editorial 93acta med indones indones j intern med • vol 51 • number 2 • april 2019 diagnostic tools for sarcopenia: can we get less expensive and accurate methods? siti setiati1,2 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 clinical epidemiology and evidence based medicine unit, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: prof. siti setiati, md., phd. division of geriatric medicine, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: s_setiati@yahoo.com. sarcopenia, as defined by the european working group on sarcopenia (ewgsop) in older people is “a progressive and generalized skeletal muscle disorder that is associated with increased likelihood of adverse outcomes including falls, fractures, physical disability, and mortality”.1 the first ewgsop and asian working group for sarcopenia used muscle mass to define sarcopenia, which is diagnosed by using dual-energy x-ray absorptiometry (dxa). however, the cut-off from several countries in asian showed different cut-off value for different age groups and bmi. in addition, not all hospitals and countries can afford dxa to be used as daily diagnostic routine for sarcopenia.2 in 2018, ewgsop made a revision regarding sarcopenia, as well as the diagnostic test and cutoff value (ewgsop2). ewgsop2 recommends using self-questionnaire, known as sarc-f as sarcopenia screening, especially in communitydwelling elderly. sarc-f consisted of 5 questions regarding patient’s perception of his or her limitations in strength, walking ability, rising from a chair, stair climbing and experiences with falls. this is more feasible to be done in countries without advanced muscle mass measurement tools. several parameters in sarcopenia are muscle strength, muscle quantity, and physical performance. in muscle strength, measuring grip strength can be done as predictor for patients’ outcomes, such as hospitalization and quality of life. for muscle quantity, the gold standards are magnetic resonance imaging (mri) and computed tomography (ct). however, since both are expensive, and the cut-off points have not been defined yet, dxa and bioelectrical impedance analysis (bia) can be a substitute. current evidence showed that dxa still does not give consistent results and not yet portable for the use in the community. on the other hand, bia measure muscle mass using the wholebody electrical conductivity and less expensive than the other tools, thus can be used in the community setting. however, there is no specific cut-off for bia especially in elderly. for physical performance, several tests can be done, such as gait speed and timed-up and go test (tug). study done by setiati, et al showed that sarc-f combined with calf and/or thigh circumference measurement can be used in community and hospital setting to make diagnosis of sarcopenia as it has high specificity value. both calf and thigh circumference measurement can be widely used in community elderly as it does not use expensive equipment and it complements to establish sarcopenia diagnosis. this research is a novel study as past studies did not combine both calf and/or thigh circumference with sarc-f. past studies used only calf or thigh circumference to complement sarc-f to establish sarcopenia. furthermore, laksmi, et al did a research siti setiati acta med indones-indones j intern med 94 to find the cut-off value of bia in comparison to dxa and found out that the sensitivity and specificity for male was 70.6% and 82.8% (bia <6.9 kg/m2) and for female was 85.7% and 97% (bia <5 kg/m2). bia is not as expensive as dxa and it can be used in community setting thus it make clinicians easier to measure muscle quantity as part of the sarcopenia. the cut-off value in the study slightly below the normal cutoff value for bia based on ewgsop, which was <7 kg/m2 for male and <5.7 kg/m2 for female. bia, even though not all hospitals have the tool, it is more feasible to be find and used compared to dxa, thus this is a promising evidence about sarcopenia diagnosis research. further research in different settings are still required regarding the external validation for both studies mentioned above to ensure the applicability of the tools in all levels of health care services, as currently there are no external validations for those tools. references 1. cruz-jentoft a, bahat g, bauer j, et al. sarcopenia: revised european consensus on definition and diagnosis. age and ageing. 2019;48:16-31. 2. chen lk, lee wj, peng ln. recent advances in sarcopenia research in asia: 2016 update from the asian working group for sarcopenia. jamda. 2016;17(767);e1-767.e7. medical illustration acute cerebellar strokes with anoxic brain injury after a cardiopulmonary arrest in sars-cov-2 patient tariq janjua1, luis r. moscote-salazar2 1 intensive care department, regions hospital, saint paul, minnesota, united states. 2 cartagena neurotrauma research group, university of cartagena, cartagena, colombia. corresponding author: luis rafael moscote-salazar, md. university of cartagena, cartagena de indias, colombia. email: mineurocirujano@ aol.com. figure 1. pa chest radiograph showing bilateral pulmonary infiltrates. figure 2. ct scan head showed diffuse low attenuation involving the bilateral basal ganglia, occipital lobes and cerebellar hemispheres. figure 3. ct scan head showed diffuse low attenuation involving the bilateral basal ganglia, occipital lobes and cerebellar hemispheres. figure 4. ct scan head showed diffuse low attenuation involving the bilateral basal ganglia, occipital lobes and cerebellar hemispheres. 177acta med indones indones j intern med • vol 52 • number 2 • april 2020 tariq janjua acta med indones-indones j intern med neurological complications from novel coronavirus is becoming more common.1,2 these patients usually have primary pulmonary problem of acute lung injury. presentation in the form of encephalitis, meningitis, guillainbarre syndrome and seizures are noted. it is also noted that sars-cov-2 has predilection for brain stem leading to patient not feeling extensive pulmonary injury. here we share another neurological presentation. a 65-year-old women of a history diabetes, active sars-cov-2 infection and mild dementia. she was at her home in quarantined state. emergency services were called for unresponsive state. on arrival patient was apneic and in cardiac arrest. it took 10 minutes for rosc after cpr and multiple doses of epinephrine. she was intubated in the emergency department. her gcs was 3t at this that stage. investigations showed lactic acidosis, profound hypoxemia and bilateral pulmonary infiltrates. (figure 1) ct scan head showed diffuse low attenuation involving the bilateral basal ganglia, occipital lobes and cerebellar hemispheres concerning for diffuse anoxic injury probably related to posterior circulation limitation. there was no early cerebral edema. (figure 2-4) she had no cough, gag and conjunctival reflexes. the pupillary light reflex was absent with fixed 2 mm pupils bilateral. with pupillometry there was minimal response with intact neurological pupil index™ (neuroptics npi -200 pupillometer, laguna hills, ca). there was no breath triggering in spontaneous mode trial even with serum lactate of 11.7 mmol/l (0.5-2.0 mmol/l). mri was not possible due to hemodynamic instability. based upon presentation, severe brain injury and severe sars-cov-2 pulmonary involvement, patient was made comfort care. this patient was thought to have secondary cardiac arrest from severe pulmonary disease. it is known that patient donot sense the impending worsening with sars-cov-2 progressive disease. since the onset of this pandemic, multiple reports have demonstrated neuroinvasion by human respiratory coronaviruses. sars-cov-2 facilitates the formation of venous and arterial thromboembolic events through multiple associated pathophysiological mechanisms. the presence of inflammatory hyper-response, hypoxia, and disseminated intravascular coagulation create the necessary conditions for the development of stroke. subclinical hypoxia has been reported as an event that is part of the initial phases, including asymptomatic.3 hypercoagubility could be the substrate for ischemic cerebrovascular events, and very high numbers of ischemic phenomena have been reported in critically ill sars-cov-2 patients of up to 31%.4 the evolution of rapid cerebellar infarction with sudden death forcing to investigate the characteristics of the invasion of the coronavirus in the brain stem, especially in the centers that control breathing. this opens a new alert scenario for patients diagnosed with coronavirus infection. references 1. li yc, bai wz, hashikawa t. the neuroinvasive potential of sars-cov2 may play a role in the respiratory failure of covid-19 patients [published online ahead of print, 2020 feb 27]. j med virol. 2020;10.1002/jmv.25728. doi:10.1002/jmv.25728. 2. conde cardona g, quintana pájaro ld, quintero marzola id, ramos villegas y, moscote salazar lr. neurotropism of sars-cov 2: mechanisms and manifestations. j neurol sci. 2020;412:116824. doi:10.1016/j.jns.2020.116824. 3. carod-artal fj. neurological complications of coronavirus and covid-19. complicaciones neurológicas por coronavirus y covid-19. rev neurol. 2020;70(9):311-22. doi:10.33588/rn.7009.2020179. 4. markus hs, brainin m. covid-19 and stroke-a global world stroke organization perspective [ p u b l i s h e d o n l i n e a h e a d o f p r i n t , 2 0 2 0 a p r 2 9 ] . i n t j s t r o k e . 2 0 2 0 ; 1 7 4 7 4 9 3 0 2 0 9 2 3 4 7 2 . doi:10.1177/1747493020923472. 178 editorial 273acta medica indonesiana the indonesian journal of internal medicine enhanced external counterpulsation in chronic heart failure: where do we stand? ryan ranitya department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. correspondence mail: department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: rranitya@gmail.com. heart failure has been known as an increasing health burden worldwide and the prevalence is expected to rise more than 23 million in 2030. chronic heart failure has characteristic of ventricular dysfunction which will cause dyspnea, fatique, and finally some limitation in functional capacity and reduced quality of life.1 recent advances in treatment of chronic heart failure may give us option of wide variety of modalities from pharmacologic and nonpharmacologic therapy with invasive and noninvasive approaches. each has its own benefit and risk. structural heart disease of heart failure indicates non reversible damage. thus, treatment will aim to prevent symptoms and improve quality of life. enhanced external counterpulsation (eecp) was a non-invasive treatment originally to reduce symptom of refractory angina.2-4 in the newest european society of cardiology (esc) guideline for management of stable coronary artery disease 2013, eecp had been approved as class iia-recommended treatment for refractory angina.5 enhanced external counterpulsation (eecp) had been reported to improve myocardial contractility, increased stroke volume, enhanced angiogenesis and developing new collateral circulation. eecp produces pulsatile blood circulation which will increase endothelial shear stress and, thus, improved endothelial function. some patients with ischemic heart disease and not eligible to have revascularization therapy due to increased risk may have recurrent angina symptom and shortness of breath. these patients are assumed to be good candidates for eecp therapy.6 actually, eecp is not a novel therapy. since almost two decades ago eecp was given to patients with chronic heart failure on top of optimal pharmacologic therapy, not only to those with concomitant refractory angina pectoris. some studies showed beneficial effect of eecp in heart failure but its efficacy is still controversial. the randomized controlled prospective evaluation of eecp in congestive heart failure (peech) trial involved 187 patients of ischemic and non-ischemic heart failure showed significant improvement in exercise tolerance but failed to show significant change in maximal oxygen uptake after six months post treatment.7 result from peech trial had been considered due to the placebo effect or training effect. the multicentre study of eecp (musteecp) and other similar studies showed that eecp is safe and effective for chronic heart failure.8-10 the data from international eecp patient registry (iepr) of 1097 patients with angina symptoms who were mostly not eligible for further revascularization therapy. although there were significant improvement in symptoms, but the incidence of major adverse cardiac event (mace) still high in the long term. it seemed that eecp could not modify disease process.11 a double-blind randomized clinical trial by rampengan et al12 in this journal tried to investigate the efficacy eecp in improving functional capacity in chronic ischemic heart failure. there were 99 patients involved and significant improvement was shown in the ryan ranitya acta med indones-indones j intern med 274 eecp group. the result is in accordance with some studies of eecp, but its efficacy in the long term remains unknown.13 the newest guidelines for management of heart failure 2013 had not yet mentioned eecp for heart failure treatment.14,15 however, it had been showed beneficial effect of eccp in selected patients specially chronic heart failure with ischemic origin or refractory angina. clinical benefit from eecp including reduced symptom, reduced rehospitalization and reduced health cost.16 will eecp be recommended for chronic heart failure in the next guideline? larger, longer and further studies on eecp in heart failure will certainly be needed. meanwhile, patients who will have most benefit of eecp therapy must be well-selected. alternative treatment options are widely open for the best therapy suitable for patients. references 1. roger vl. epidemiology of heart failure. circulation 2013; 113: 646-59. 2. kim mc, kini a, sharma sk. refractory angina pectoris: mechanism and theurapetic options. j am col cardiol 2002;39:923-34. 3. novo g, bagger jp, carta r, koutrolis g, hall r , n i h o y a n n o p o u l o s p. e n h a n c e d e x t e r n a l counterpulsation (eecp) for treatment of refractory angina pectoris. j cardiovasc med 2006;7:335-9. 4. bonetti po, barsness gw, keelan pc, et al. enhanced external counterpulsation (eecp) improves endothelial function in patients with symptomatic coronary artery disease. j am coll cardiol 2003; 41:1761-8. 5. montalescot g, sechtem u, achenbach s et al. european society of cardiology guidelines on management of stable coronary artery disease. eur heart j 2013; 34: 2949-3003. 6. feldman am, silver ma, francis gs, et al. enhanced external counterpulsation (eecp) improves exercise tolerance in patients with chronic heart failure. j am coll cardiol 2006; 48:1198-205. 7. fieldman am, silver m, francis g, lame p, parmley w. treating heart failure with eecp: design of the prospective evaluation of eecp in heart failure (peech trial). j cardiol fail 2005; 11(3): 240-5. 8. arora rr, chou tm, jain d. the multicentre study of enhanced external counterpulsation (must-eecp): effect of enhanced external counterpulsation on exercise-induced myocardial ischemia and angina episodes. j am coll cardiol 1999; 33: 1833-40. 9. urano h, ikeda h. enhanced external counterpulsation (eecp) improves exercise tolerance, reduces exerciseinduced ischemia and improves left ventricular diastolic filling in patients with coronary artery disease. j am coll cardiol 2001; 37-93-9. 10. lawson we, silver ma, hui jc, kennard ed, kelsey sf. angina patients with diastolic versus systolic heart failure demonstrate comparable immediate and oneyear benefit from enhanced external counterpulsation (eecp). j cardiol fail 2005; 11:61-6. 11. soran o, kennard ed, kfoury ag, kelsey sf, iepr investigators two year clinical outcomes after enhanced external counterpulsation (eecp) therapy in patients with refractory angina pectoris and left ventricular dysfunction (report from the international eecp patient registry). am j cardiol 2006; 97: 17-20. 12. rampengan sh, prihartono j, siagian m, immanuel s. the effect of enhanced external counterpulsation therapy and improvement of functional capacity in chf patients: a randomized clinical trial. acta med indones indones j intern med. 2015;47(4):275-82. 13. arora rr, shah ag. the role of enhanced external counterpulsation (eecp) in the treatment of angina and heart failure. can j cardiol 2007: 23(10): 779-81. 14. yancy cw, jessup mj, bokurt b et al. 2013 acc/ aha guideline for the management of heart failure. circulation 2013; 128: e240-327. 15. mcmurray jj, adamapoulos s, anker sd et al. esc guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. eu heart j 2012; 33: 1787-847. 16. m a n c h a n d a a , s o r a n o . e n h a n c e d e x t e r n a l counterpulsation (eecp) and future direction-step beyond medical management for patients with angina and heart failure. j am coll cardiol 2007;50: 1523-31. editorial 181acta medica indonesiana the indonesian journal of internal medicine challenges in screening and diagnosing frailty syndrome: which tool to be used? purwita w. laksmi department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. correspondence mail: division of geriatrics, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro no. 71 jakarta 10430, indonesia. frailty syndrome has become one of the geriatric syndromes with an increasing risk of debilitating clinical outcome.1,2 accordingly, the current treatment guidelines have been focusing in viewing frailty syndrome as an important aspect to be considered. the international diabetes federation (idf) classifies the guideline for managing the elderly with type 2 diabetes mellitus based on their functional status, whether it is functionally independent or dependent. functionally dependent group is further classified as subgroup of frail and/ or demented people.3 special consideration on older people has also been discussed as a topic on the treatment algorithm for hypertension and dyslipidemia.4,5 furthermore, the guideline published by the american college of surgeons has recommended that baseline frailty score determination as one of the important checklists for optimal preoperative assessment in geriatric patient.6 undoubtedly, physicians should have the knowledge and skill on frailty syndrome, including the methods to screen and diagnose frailty syndrome in order to improve health outcome of geriatric patients. frailty syndrome can be viewed as a clinical syndrome (phenotype) or deficits accumulation.7,8 frailty syndrome which consists of physical, psychological, and social domain, should be considered as a continuum spectrum of fit/robust, pre-frail, and frail state with dynamic transition among these spectrums over a period of time.9,10 fried et al1 hypothesize that decreases in metabolic rate, muscle strength and vo2 maximal due to sarcopenia contribute to the manifestation of physical frailty, such as exhaustion, slowness of walking speed, decreased body weight and physical activity that eventually lead to disability and dependency. this pathophysiologic approach measures clinical manifestation of frailty syndrome regardless of the etiology.1 in contrast, the index method consists of deficits which are constructed using variables originated from a cohort study aimed to determine variables that can predict morbidity and mortality. those items further consider as frailty predictors.8,11 the ideal scoring system to define frailty should be able to assess all domains of frailty syndrome and its severity, as well as easy to be conducted in daily clinical practice and able to measure the changes over time or after intervention(s). there are many scoring systems to define frailty state, but mostly are developed from phenotype concept described by fried et al in cardiovascular health study (chs) or deficits accumulation concept described by rockwood et al in canadian study of health and aging (csha). those two scoring systems have been validated in large populations.1,8,9,11 the phenotypic concept mainly focus on physical domain of frailty syndrome, while the index method usually tries to evaluate all three domains of frailty syndrome. the phenotypic approach may be easier to be conducted, while in comparison it may be challenging to implement the index method in daily clinical practice as it purwita w. laksmi acta med indones-indones j intern med 182 consists of many variables to be evaluated. in addition, deficits or co-morbidities included in the scoring system may be sustained or relatively unchanged after intervention especially in short period of time, meanwhile it is easier to measure changes in gait speed and muscle strength as the phenotypic scoring systems’ components from time to time or after certain intervention.9,11 although there has been no gold standard method to define frailty syndrome until now, de vries9 reported in his systematic review that the index method better predict clinical outcome of frailty syndrome. nevertheless, the validity and reliability of scoring systems to define frailty syndrome may vary in different populations.12 therefore, we publish the diagnostic test study of scoring system for frailty syndrome done by seto et al in this edition of acta medica indonesiana-the indonesian journal of internal medicine.this study indicates that compared to frailty index 40 item (fi 40 item) scoring system, the cardiovascular health study (chs), study of osteoporotic fracture (sof) and comprehensive geriatric assessment-based frailty index (fi-cga) scoring systems had low sensitivity (8.8-41.2%), but each scoring system had a perfect specificity (95-100%) and high positive predictive value (ppv 73.7-100%). lack of sensitivity will increase the risk of a frail state to be misdiagnosed. in general, which scoring system should be used in screening and diagnosing frailty syndrome would depend on its purpose, practicability and applicability to be implemented in certain clinical settings. however, lesson learned from the study done by seto et al13 emphasizes that individuals with a low suspicion of frailty better screened with fi 40 item, while fi-cga, sof and chs may be used in individuals with a high suspicion of frailty. it is recommended that frail individual screened using fi 40 item is further evaluated using fi-cga, sof or chs to identify intervention modalities and follow up improvement over time or after intervention. obviously this study provide new paradigm of reasoning in choosing scoring system to screen and diagnose frailty syndrome. references 1. fried lp, tangen cm, walston j, et al. frailty in older adults: evidence for a phenotype. j gerontol med sci.2001;56(3):m146-56. 2. rizzoli r, reginster jy, amal jf, et al. quality of life in sarcopenia and frailty. calcif tissue int. 2013;93(2):101-20. 3. idf working group. managing older people with type 2 diabetes. international diabetes federation: brussels. 2013. 4. james pa, oparil s, carter bl, et al. evidence-based guideline for the management of high blood pressure in adults report from the panel member appointed to the eight joint national committee (jnc 8). jama. 2014;311(5):507-20. 5. catapano al, reiner z, backer gd, et al. esc/eas guidelines for the management of dyslipidaemias the task force for the management of dyslipidaemias of the european society of cardiology (esc) and the european atherosclerosis society (eas). atherosclerosis. 2011;217:3-46. 6. chow wb, rosenthal ra, merkow rp, ko cy, esnaola nf. optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the american college of surgeons national surgical quality improvement program and the american geriatric society. j am coll surg. 2012;215(4):453-66. 7. song x, mitnitski a, rockwood k. prevalence and 10-year outcomes of frailty in older adults in relation to deficit accumulation. j am geriatr soc.2010;58:681-7. 8. r o c k w o o d k , h o g a n d b , m a c k n i g h t c . conceptualisation and measurement of frailty in elderly people. drugs aging. 2000;17:295-302. 9. de vries nm, staal jb, van ravensberg cd, hobbelen jsm, rikkert mgmo, van der sanden mwgn. outcome instruments to measure frailty: a systematic review. ageing res rev. 2011;10:104-14. 10. gill tm, gahbauer ea, allore hg, han l. transitions between frailty states among community-living older persons. arch intern med. 2006;166:418-23. 11. strandberg te, pitkala kh, tilvis rs. frailty in older people. euro ger med. 2011;2:344-55. 12. mitnitski ab, graham je, mogilner aj, rockwood k. frailty, fitness and late-life mortality in relation to chronological and biological age. bmc geriatr. 2002;2:1. 13. seto e, setiati s, laksmi pw, tamin tz. diagnostic test of a scoring system for frailty syndrome in the elderly according to cardiovascular health study, study of osteoporotic fracture and comprehensive geriatric assessment based frailty index compared with frailty index 40 items. acta med indones indones j intern med. 2015;47(3):183-7. editorial 1acta medica indonesiana the indonesian journal of internal medicine are we giving optimal dose of efavirenz? evy yunihastuti department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: evy yunihastuti, md. division of allergy and clinical immunology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: evy.yunihastuti@gmail.com. antiretroviral is one of the drugs that extensively been studied for its drug-todrug interaction. its long term used and the fact that many hiv-infected patients came in the late stage of disease make polypharmacy is unavoidable.1 efavirenz is one of antiretroviral drugs that widely used in hiv-infected patients age more than 3 years old in many countries. latest indonesian antiretroviral guidelines recommend a combination of tenofovir, lamivudine and efavirenz given orally in one daily dose as the preferred primary fixed-drug combination treatment. this recommendation is based on many evidence supporting efficacy, tolerability, price, pregnancy safety, simplicity and the availability of the drug that will support the continuing comprehensive care for hiv-infected patients in primary care level.2 since first being marketed in 1998, efavirenz has been dosed at 600 mg once a day for hivinfected adults, either as efavirenz tablet of fixed-drug combination.3 this drug often causes cns-related symptoms that sometimes persist for a long period. this side effect frequently leads to treatment discontinuation or non-adhere to the treatment. efavirenz is extensively metabolized by the cyp2b2 isoenzyme group, particularly to the 8oh-efv metabolite. it is also an autoinducer of its own metabolism via induction of cyp2b6.4 earlier study in caucasian population shown that concomitant use of rifampicin could decrease efavirenz plasma concentration up to 26%.5 therefore, it was recommended to raise the dose to 800 mg a day in patients with pre treatment bodyweight more than 50 kg. different finding was reported in south africa. study by orell, et al.6 revealed that 600 mg efavirenz still retained adequate potency when giving concomitantly with rifampicin in hiv-infected patients with active tuberculosis.6 however, combining rifampicin with other available nnrti nevirapine could decrease nevirapine plasma concentration even more.7 therefore, efavirenz is still the preferred drug to be combined with rifampicin in many guidelines.2 recently, questions have been raised about whether the dose of efavirenz could be reduced to 400 mg to lessen cns-related effect and reduce cost without interfering the effectiveness. the encore1 study first published in 2014 randomly assigned 639 antiretroviral naive patients who were starting treatment to either 400 mg or 600 mg efavirenz. about one third of participants in this study were asian. adverse events were significantly less frequent in the 400 mg group, recovery of cd4 lymphocytes was better in the 400 mg group, and proportions of patients with viral load suppression at 48 weeks were similar in both groups. hiv-infected patients with active tuberculosis were excluded in this study, hence it is unable to clarify the issue concomitant use of rifampicin with low dose efavirenz.8 however, the newest who has started to recommend the use of 400 mg efavirenz as alternative first-line regiment in combination with tenofovir and lamivudine/or emtricitabine.9 evy yunihastuti acta med indones-indones j intern med 2 t h i s r e c o m m e n d a t i o n n e e d s t o b e implemented carefully for indonesian population. study reported here by mariana, et al10 comparing hiv-infected indonesian patients starting efavirenz-based antiretroviral therapy with and without the use of rifampicin revealed that there was large proportion of patients with sub-therapeutic efavirenz concentrations even in patients not receiving rifampicin. one of the plausible reasons is the possibility of many extensive metabolizer genotype in this population. even though, in indonesia, no studies have identified the cyp2b6 enzyme activity. the impact of different therapeutic level of efavirenz to virological success can not be concluded in this study. not only because of the small sample size, but also because of various time of viral load testing in defining the virologic suppression used in this study.10 references 1. moore hn, mao l, oramasionwu cu. factors associated with polypharmacy and the prescription of multiple medications among persons living with hiv (plwh) compared to non-plwh. aids care. 2015;27(12):1443-8. 2. ministry of health ri. guidelines of antiretroviral treatment. jakarta: ministry of health ri, 2015. [cited at may 25th, 2016] available at: http:// w w w. k e b i j a k a n x a i d s i n d o n e s i a . n e t / i d / u n d u h / viewdownload/28-peraturan-pusat/645-permenkesri-no-87-tahun-2014-tentang-pedoman-pengobatanantiretroviral. 3. bristol-myers squibb. sustiva package insert. http:// packageinserts.bms.com/pi/pi_sustiva.pdf. 4. ngaimisi e, mugusi s, minzi om, et al. long-term efavirenz autoinduction and its effect on plasma exposure in hiv patients. clin pharmacol ther. 2010;88:676–84. 5. lopez-cortes lf, ruiz-valderas r, viciana p, et al. pharmacokinetic interactions between efavirenz and rifampicin in hiv-infected patients with tuberculosis. clin pharmacokinet. 2002;41:681-90. 6. orrell c, cohen k, conradie f, et al. efavirenz and rifampicin in the south african context: is there a need to dose-increase efavirenz with concurrent rifampicin therapy? antivir ther. 2011;16:527–34. 7. ribera e, pou l, lopez rm, et al. pharmacokinetic interaction between nevirapine and rifampicin in hivinfected patients with tuberculosis. j acquir immun defic synd. 2001;28:450-3. 8. encore1 study group, puls r, amin j, et al. efficacy of 400 mg efavirenz versus standard 600 mg dose in hiv-infected, antiretroviral-naive adults (encore1): a randomised, double-blind, placebo-controlled, noninferiority trial. lancet. 2014;383:1474–82. 9. world health organization. policy brief: consolidated guidelines on the use of antiretroviral drugs for treating and preventing hiv infection: what’s new. geneva: world health organization, 2015. 10. mariana n, purwantyastuti, instiaty, rusli a. efavirenz plasma concentrations and hiv viral load in hiv/ aids-tuberculosis infection patient treated with rifampicin. acta med indones-indones j intern med. 2016;48(1):10-6. 13 original article acta med indones indones j intern med • vol 53 • number 1 • january 2021 consideration of the cycle threshold values from realtime rt-pcr sars-cov-2 interpretation for the clinicians: analysis of 339 positive cases from a referral laboratory in jakarta, indonesia fera ibrahim, augustine natasha, yulia rosa saharman, andi yasmon, fithriyah, anis karuniawati, selvia ganiesa, pratiwi sudarmono department of microbiology, faculty of medicine universitas indonesia, jakarta, indonesia. corresponding author: fera ibrahim, md., phd. department of microbiology, faculty of medicine universitas indonesia. jl. pegangsaan timur no. 16, jakarta 10430, indonesia. email: r.fera@ui.ac.id. abstrak latar belakang: real-time rt-pcr (rrt-pcr) merupakan metode yang direkomendasikan oleh who untuk diagnosis covid 19. nilai cycle threshold (ct) diduga berkaitan dengan manifestasi klinis. saat ini modalitas diagnosis lain untuk deteksi kuantitatif secara molekuler dan isolasi virus belum tersedia sebagai pemeriksaan rutin. penelitian ini dilaksanakan untuk menganalisa hubungan antara nilai ct dari rrt-pcr kualitatif dengan manifestasi klinis, serta mendeskripsikan faktor-faktor yang dapat mempengaruhi hasil pemeriksaan. metode: spesimen yang dikirimkan ke laboratorium rujukan pada bulan maret sampai april 2020 dari berbagai institusi kesehatan menjadi sampel penelitian. data karakteristik pasien dan manifestasi klinis diambil dari formulir penyidikan epidemiologi yang dikirim bersama spesimen. spesimen diperiksa dengan metode rrt-pcr dan nilai ct dikumpulkan. data yang diperoleh diolah dengan uji statistik yang sesuai. hasil: dari 339 hasil positif, diperoleh 176 (52%) kasus ringan-sedang dan 163 (48%) kasus berat. wanita lebih banyak ditemukan pada kasus ringan-sedang (58%) sementara laki-laki lebih banyak pada kasus berat (60%). median usia pada kasus ringan-sedang adalah 35 tahun dan kasus berat adalah 49 tahun. terdapat hubungan antara manifestasi klinis dengan jenis kelamin (p = 0.001) dan usia (p < 0.001), tetapi tidak ditemukan hubungan antara nilai ct dengan manifestasi klinis. kesimpulan: situasi saat ini pada laboratorium rujukan dengan berbagai faktor pada pengambilan dan pemrosesan spesimen dapat mempengaruhi nilai ct yang dihasilkan. sebagai tambahan, respon imun pejamu merupakan faktor yang juga mempengaruhi tingkat keparahan penyakit, terlepas dari jumlah virus yang menginfeksi. nilai ct dari laboratorium rujukan antara pasien bergejala ringan-sedang dan berat tidak menunjukkan hubungan yang signifikan, dengan demikian interpretasi nilai ct harus dilakukan dengan hati-hati. kata kunci: sars-cov-2, cycle threshold, rrt-pcr, interpretasi klinis. abstract background: real-time rt-pcr was recommended by who for covid-19 diagnosis. the cycle threshold (ct) values were expected to have an association with clinical manifestation. however, the diagnostic modalities such as quantitative molecular detection and virus isolation were not yet available for the routine test. this study has been conducted to analyze the relationship between the ct values of qualitative rrt-pcr and the clinical manifestation and to describe the factors determining the result. methods: from march to april 2020, specimens were sent to our laboratory from different healthcare centers in jakarta. the patient’s characteristic and clinical manifestation were extracted from the specimen’s epidemiology forms. the specimens extracted and tested using fera ibrahim acta med indones-indones j intern med 14 rrt-pcr, and the ct value were collected. the data were analyzed using the appropriate statistic test. results: from 339 positive results, the mild to moderate case was 176 (52%) and the severe cases was 163 (48%). female was dominant in the mild to moderate cases (58%), while the male was prevalent in the severe cases (60%). the median age for mild to moderate case was 35 years old and severe cases was 49 years old. statistical analysis found relationship between both group with gender (p = 0.001) and age (p < 0.001), but not with the ct value. conclusion: many variables in specimen sampling and processing could affect the ct value result. in addition, the disease’s severity was depended with the host immune response, regardless the number of virus. there was suggested no significant difference between the ct values of mild-moderate and severe covid-19, and thus should not be loosely interpreted. keywords: sars-cov-2, cycle threshold, rrt-pcr, clinial interpretation. introduction real-time reverse transcriptase (rrt) pcr has been recommended by who for sars-cov-2 detection in the recent guideline.1 several studies correlated cycle threshold (ct) values with viral loads and disease severity.2,3 tom et al.4 proposed ct values to be considered in clinical decision making. however, publications from canada and singapore had different ct values cutoff for infectivity.5,6 the different result from the studies might come from the variety of approaches and methods of rrt-pcr and its ct value interpretation. the concept of ct values inversely related to viral load is very tempting, especially for managing a patient’s length of hospital stay during the pandemic. han et al. addressed their concern for publications which used ct values deliberately for viral quantification and correlated them with clinical manifestation.7 recently, many clinicians questioned the interpretation of ct values for the patient management and disease control strategy. this study has been conducted to analyze the relationship between the ct values of qualitative rrt-pcr and the clinical manifestation and to describe the factors determining the result. methods this cross-sectional study used the records in the epidemiology form of the specimens which sent to the clinical microbiology laboratory of the faculty of medicine of universitas indonesia, from 13 march to 30 april 2020. only specimens documented as the first sample with completed epidemiology form were included in this study for further analysis. specimens documented as a follow up test were excluded. the clinical manifestation, gender, and age were collected. the clinical manifestation was grouped according to the criteria from who and the national health commission of people’s republic of china.8 therefore, the clinical manifestation was grouped as the mild to moderate case and the severe case. the specimens were extracted with several methods of rna extraction (qiagen, adbio, da an, viogen, liveriver). all of the extraction kits were tested before use. the method used for sars-cov-2 detection was qualitative rrt-pcr. the reaction was shown following the commercial kit’s protocol, with n gene and orf gene as the target (da an gene, china). the ct values under 40 for each gene were regarded as a positive result. confirmatory rrt-pcr was conducted if the first reaction resulted in ct values between 38 and 40. all data were analyzed using the appropriate test. the variables collected were categorical and numerical data. the categorical variables were presented as number (percentage). the numerical variables were tested for normality and presented as mean (ci 95%, lower – upper) or median (interquartile range (iqr), number), depended on the normality result. the two categorical variables (clinical manifestation and gender) were analyzed with chi-square test. the correlation between clinical manifestation and other numerical variables (age, ct value), were assessed by one-way anova or kruskal-wallis test, as indicated from normality test. results patient characteristics were shown according to clinical manifestation in table 1. of 339 vol 53 • number 1 • january 2021 consideration of the ct values from real time rt-pcr sars-cov-2 15 positive results, the mild to moderate cases contributed to 52% of all cases. the median age of mild to moderate cases was 35 years old (iqr, 25.25) and severe cases was 49 years old (iqr,22). the specimens were received from hospitals and other health care providers such as private clinics, primary health care, and laboratories. the median ct values of all clinical manifestations were 34.7 (iqr, 5.33) for n gene and 35.4 (iqr, 5.23) for orf gene. there was an association between clinical manifestation and gender (p = 0.001). female was more frequently found in the mild to moderate cases, while the male was prevalent in the severe cases (table 1). there was a statistically significant difference of age in clinical manifestation as determined by kruskalwallis (p < 0.001). older age was dominant in the severe cases, and younger age proportion were bigger in the mild to moderate cases (table 1). statistical analysis found no difference in the ct value with the clinical manifestation (p > 0.05). discussion from jakarta specimens, age and gender were related to clinical manifestation in concordance with other studies.9,10 advanced age was reported as the risk factor for hospital admission and male sex as the risk factor for severe disease.11 regarding the ct values and the clinical manifestation, no relationship was found between both subjects. it was similar to tan et al‘s12 report, in which ct values were altered but could not be used to distinguish the disease severity. however, it was different from the previous studies by yu et al.2 and zou et al.3, suggesting the relationship between ct values and disease severity. it was possible that the latter studies were conducted in a hospital laboratory where the specimen quality were highly supervised, or the swab materials, viral transport media, and the assay reagent came from similar manufacturer. in contrast, our specimens came from more than ten different hospitals and public-health centers in jakarta. the specimens were collected at different times and stored for a while before delivery. every health center had fluctuating swab supplies from different manufacturers and had health-care workers with different level of experience in swabbing the patients. from our observation, the variation of types and volume of virus transport medium (vtm) also became noticeable with the increasing number of specimens. these uncontrolled factors could affect the specimen and determine the test results.13 in this pandemic situation, the laboratory also had unstable supply of rna extraction kits, and different methods were used in one month. this condition made a ct values from the first test was unable to be compared with the follow up test because the specimen processing was not equal. in the combination with the sampling process and transportation, each extraction kit also generated a different number of extracted rna, despite the correct methods. these factors could affect the pcr reaction and the ct value result might confuse the clinicians when they got a lower ct value from a follow up test, especially when the patient’s general condition was stable or showed no sign of infections. since some studies mentioned the correlation of infectivity with ct values,5,6 the current unstable ct value results could create doubt when the clinicians were asked to release the recovered patients from the isolation state. in addition, the agreement on a quantification unit for every type of specimen was not yet established. table 1. patients characteristics and the median ct value according to clinical manifestation. mild to moderate case severe case p value age (years old), n (%) < 10 2 (1.0) 1 (1.0) 0.000 10 – 19 15 (9.0) 4 (2.5.0) 20 – 29 44 (25.0) 17 (10.0) 30 – 39 43 (24.0) 23 (14.0) 40 – 49 23 (13.0) 37 (23.0) 50 – 59 30 (17.0) 41 (25.0) ≥ 60 19 (11.0) 40 (24.5) gender, n (%) male 74 (42.0) 98 (60.0) 0.001 female 102 (58.0) 65 (40.0) ct value (median, iqr) n gene 35 (5.41) 34.49 (5.26) 0.874 orf gene 35.54 (5.72) 35.00 (4.92) 0.841 total cases, n (%) 176 (52.0) 163 (48.0) fera ibrahim acta med indones-indones j intern med 16 for respiratory samples using flocked swab, the viral load could be normalized by volume (rna copies/ml of transport medium) or by cell number (rna copies/median number of cells).14 we also noticed since the study was conducted, several latest pcr kits also had different ct values cutoff for positive results. this condition would affect the ct values in the follow up test because of the different cutoff. furthermore, a state of emergency made most of the referral laboratories employ many inexperienced technicians. these limitations would create slight alteration of ct values between batches, in line with han et al.’s notification about the batch effect on ct values from rrt-pcr.7 besides the technical problem, the unclear onset of diseases and the pathogenesis of covid-19 also could affect the number of virus particle obtained from the patient’s body. although we already limited the specimen to the initial confirmed-specimen of the patients, currently we do not have any diagnostic tools or scoring instrument to assess whether the patients are in the early or the later stage of diseases. in addition, the diseases progressivity, the patient’s immune response, and the viral clearance are different in every individual.15 these factors could explain our result, which there was no difference of ct value between the mild to moderate case and the severe case. the limitation of this study was the short period of time to do the observation, when the situation was rapidly changing every month. our findings represented the unstable nature of the pandemic situation, hence not applicable for different situations. until this paper was made, there was no guideline in indonesia for the quantification unit and ct value standarization. there was also no current report on the correlation between ct values and infectivity from the specimens in indonesia. in addition, the variety of host immune response to sars-cov-2 infection also affected the clinical outcome. therefore, clinicians should not consider ct value results from rrt-pcr for patient management. clinical decisions should be made through comprehensive assessment of patient’s condition, other laboratory tests, and radiologic findings. conclusion ct values of rrt-pcr generated from a referral laboratory during a pandemic are not suitable as the additional data for disease control strategy, as long as the uncontrolled variables persisted. future studies may include advances in virus quantification and development of regulation to reinforce the validation of the pcr kit performance before widely used for diagnostic test. acknowledgments the authors would like to thank the indonesian ministry of research and technology/national research and innovation agency (kemenristek/ brin) for the financial support in the form of hibah pdupt (contract no. nkb-169/un2. rst/hkp.05.00/2020). conflict of interest declarations of interest: none. references 1. world health organization. laboratory testing for coronavirus disease 2019 (covid-19) in suspected human cases: interim guidance, 2 march 2020. 2. yu x, sun s, shi y, wang h, zhao r, sheng j. sarscov-2 viral load in sputum correlates with risk of covid-19 progression. critical care. 2020;24(1):170. 3. zou l, ruan f, huang m, et al. sars-cov-2 viral load in upper respiratory specimens of infected patients. new engl j med. 2020;382(12):1177-9. 4. tom mr, mina mj. to interpret the sars-cov-2 test, consider the cycle threshold value. clinical infectious diseases. 2020. 5. bullard j, dust k, funk d, et al. predicting infectious sars-cov-2 from diagnostic samples. clinical infectious diseases. 2020. 6. national centre for infectious disease. position statement from the national centre for infectious diseases and the chapter of infectious disease physicians, academy of medicine, singapore: period of infectivity to inform strategies for deisolation for covid-19 patients. https://www.ncid. sg/documents/period%20of%20infectivity%20 position%20statementv2.pdf. 2020 (accessed 24 june 2020). 7. han ms, byun j-h, cho y, rim jh. rt-pcr for sars-cov-2: quantitative versus qualitative. lancet infect dis. 2020:s1473-3099(20)30424-2. vol 53 • number 1 • january 2021 consideration of the ct values from real time rt-pcr sars-cov-2 17 8. gao z, xu y, sun c, et al. a systematic review of asymptomatic infections with covid-19. j microbiol immunol infect. 2020. 9. tian s, hu n, lou j, et al. characteristics of covid-19 infection in beijing. j infect. 2020. 10. young be, ong swx, kalimuddin s, et al. epidemiologic features and clinical course of patients infected with sars-cov-2 in singapore. j am med assoc. 2020;323(15):1488-94. 11. gottlieb m, sansom s, frankenberger c, ward e, hota b. clinical course and factors associated with hospitalization and critical illness among covid-19 patients in chicago, illinois. acad emerg med. 2020;27(10):963-73. 12. tan l, kang x, ji x, et al. validation of predictors of disease severity and outcomes in covid-19 patients: a descriptive and retrospective study. med. 2020. 13. qian m, yi q, qihua f, ming g. understanding the influencing factors of nucleic acid detection of 2019 novel coronavirus. chin j lab med. 2020;10. 14. piralla a, giardina f, rovida f, campanini g, baldanti f. cellular dna quantification in respiratory samples for the normalization of viral load: a real need? j clin virol. 2018;107:6-10. 15. carmo a, pereira-vaz j, mota v, et al. clearance and persistence of sars-cov-2 rna in patients with covid-19. j med virol. 2020;92(10):2227-31. case report 57acta med indones indones j intern med • vol 49 • number 1 • january 2017 riedel’s lobe: clinical importance of a rare variant in liver morphology juferdy kurniawan1, dewi anggraeni2, esthika dewiasty1, lutfie1 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of obstetric and gynecology, faculty of medicine universitas indonesia / ciptomangunkusumo hospital, jakarta, indonesia. corresponding author: juferdy kurniawan, md. division of hepatobiliary, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no.71 jakarta 10430, indonesia. email: juferdy.k@gmail.com. abstrak lobus riedel merupakan salah satu bentuk variasi normal pada lobus kanan hepar, yang umumnya jarang ditemukan. kami melaporkan kasus seorang perempuan berusia 38 tahun dengan temuan insidental yang tidak ditemukan melalui pemeriksaan fisis, namun dijumpai hepatomegali pada saat pemeriksaan ultrasonografi ginekologis. diagnosis lobus riedel dikuatkan dengan hasil temuan serupa pada ultrasonografi hepatobilier, mri abdomen, dan laparoskopi diagnosis. pasien kami pulangkan dan disarankan untuk menjalani pemeriksaan follow-up tiga bulan kemudian. pengetahuan pada anomali ini penting untuk dimiliki karena temuan lobus tambahan hepar tidak selalu bersifat asimtomatik seperti pada kasus pasien kami, melainkan dapat pula berkaitan dengan komplikasi klinis yang bermakna. kata kunci: lobus riedel, temuan insidental, ultrasonografi hepatobilier, mri abdomen, laparoskopi. abstract riedel’s lobe is a normal variant form of right liver lobe rarely found. here we report a case of 38 years old female with an incidental finding not revealed in physical examination, but then known to have hepatomegaly by gynecological ultrasonography. diagnosis of riedel’s lobe was strengthened by similar results on hepatobiliary ultrasonography, abdominal mri, and diagnostic laparoscopy. our patient was discharged and had follow up examination three months later. knowledge regarding this anomaly is essential to be understood because the finding of accessory liver lobe does not always remain asymptomatic as in our patient, but rather can be related to significant clinical complication. keywords: riedel’s lobe, incidental finding, hepatobiliary ultrasonography, abdominal mri, laparoscopy. introduction the liver is an internal organ with various anatomical variations, for both vascular and biliary tract structures. in spite of that, the formation of accessory liver lobe is a quite rare anomaly, with an estimated prevalence less than 1%.1-3 one of the abnormalities reported several times is the riedel’s lobe, defined as a downward tongue-like projection of the anterior edge of the right liver lobe to the right of the gallbladder.4 this variant was first published by riedel based on the result of his surgical patients with palpable right hipocondrium mass. the incidence of riedel’s lobe in general juferdy kurniawan acta med indones-indones j intern med population varies widely, from 3,3% to 14,5% depends on the diagnostic criteria and methods used.1,5 this rare morphological lobulation is relatively asymptomatic, rarely found by physical examination, and mostly found incidentally from surgery, radiological examination, endoscopic procedure, or autopsy.1,3,6,7 awareness regarding this anomaly is essential, due to the experience of several cases reporting malignancy and torsion involving the riedel’s lobe.8 we report a case of a 38-year old female with incidental finding of typical feature of riedel’s lobe unidentified by abdominal palpation. case illustration a middle-aged woman, 38 years old, came to her gynecologist with chief complaint of abdominal discomfort on the lower quadrant. the complaint was intermittent and had been experienced several times before, diagnosed with abdominal colic. the patient did not have any complaint of fever, nausea, vomitus, urination, defecation, and menstrual problems. history of trauma or previous surgical procedure was denied. there was not any similar complaint ever felt by her family member. physical examination showed stable vital signs. both abdominal and gynecological examinations failed to reveal any abnormality. gynecological ultrasonographic examination found normal endometrium (0,79 mm), uterus (6,8 x 3,74 x 6,15 mm), and both ovaries size (right 2,87 x 1,92 mm; left 2,67 x 3,6 mm), with suspicion of right ovarian mass sized 1,66 x 1,31 mm. on the same examination, hepatomegaly was incidentally found, which later was confirmed by hepatobiliary ultrasonography. (figure 1) the result showed an elongation of right liver lobe through the lower lobe of right kidney, whereas gallbladder, spleen, and pancreas appeared to be in normal condition. routine blood examination was within the normal limits, and so was the liver function test (alt/ast, bilirubin) and tumor marker of ca-125. the patient underwent whole abdomen mri examination (figure 2, figure 3) in order to identify the ovarial mass and hepatomegaly previously found. the result showed feature of inflammation on bilateral adnexa with ovarian tube and right hydrosalpinx abscess. another result found was fluid collection on douglas pouch, suspected to focal adenomyosis in the anterior side of uterine corpus. an elongation of right liver lobe to the inferior side until the lower pole of right kidney was also confirmed, corresponded to normal variation of liver called riedel’s lobe. there was not any focal lesion or pathological enhancement on both lobes of the liver, and also no abnormality found in paraaortic, bilateral parailiac, and bilateral inguinal lymph nodes. we performed pap smear procedure and the anatomical pathology examination was dominated only by squamous epithelial and glandular cells as well as leukocyte infiltration, whereas malignant tumour cells were not found. figure 1. patient’s hepatobiliary ultrasonography. noticed the elongation of right liver lobe through the lower lobe of right kidney. 58 vol 49 • number 1 • january 2017 riedel’s lobe: clinical importance of a rare variant in liver morphology human papilloma virus (hpv) genotyping with genoflow method showed negative hpv dna array dectected for either high or low risk virus. in order to obtain definitive diagnosis regarding her gynecological status, the patient t h e n u n d e r w e n t d i a g n o s t i c l a p a r o s c o p y examination. the result of examination was in accordance with the previous finding from the mri, which was ovarian tube and hydrosalpinx abscess, together with riedel’s lobe. (figure 4) based on the data of supporting examination done, it was concluded that the patient’s chief complaint was due to the abscess of internal genital organ, meanwhile the finding of hepatomegaly was actually the riedel’s lobe, a normal variant of liver morphology. the patient was dicharged from hospital and recommended to visit outpatient clinic for an evaluation three months later. discussion in spite of its complex embryological development, macroscopic abnormality of the liver is rare. the variation is usually related to morphological irregularity, but the formation of an accessory liver lobe is rather extremely rare.9 accessory liver lobes are defined as supranumerary number, composed of normal liver parenchyma in continuity directly with the original liver, by mesentery, or by a pedicle.10 figure 2. patient’s whole abdomen multiphasic mri (axial section). noticed the elongation of right liver lobe to the inferior side as high as the lower lobe of right kidney, revealing riedel lobe, a normal variant of liver. figure 3. patient’s whole abdomen multiphasic mri (coronal section). noticed the elongation of right liver lobe to the inferior side as high as the lower lobe of right kidney, revealing riedel lobe, a normal variant of liver. 59 juferdy kurniawan acta med indones-indones j intern med there are several types of accessory liver lobes classified by volume and weight, including a bulky accessory liver lobe (>31 gram, connected to the liver via a stalk of tissue or wide base in the subphrenic or perihepatic zone); a small accessory liver lobe (11-30 gram, connected to the liver via a wide base on the surface of the liver), an ectopic liver lobe (a completely separate lobe with no connection to normal liver tissue, often diagnosed as mass in the thorax or pelvic cavity);11,12 a pinpoint atopic lobe (<10 gram, most often located at the margins of the liver or even gallbladder wall).1,10,13 our patient’s variant was a bulky tipe, with a clear connection to its original liver. riedel’s lobe incidentally found in our case is a rare morphologic feature of hepatic lobulation with inferior projection of the anterior edge of 5th and 6th liver segment to the right of the gallbladder.4 in its classic form, riedel’s lobe’s functional anatomy is similar to liver in general, which receives portal, arterial, and biliary branches. this patient’s additional liver lobe elongates until the lower pole of the right kidney, just like how riedel’s lobe usually found approaching iliac fossa with “tongue like” or triangular pyramid shape.1 epidemiologically, riedel’s lobe’s prevalence is higher in women (4,5-19,4%), as in our case, than in men (2,1-6,1%).1,5,6 a radiologic series with different definition criteria noted higher incidence (31%) and close proportion between both sexes.1,7 we had this finding in a middleaged woman, but this accessory hepatic lobe has been reported in infants as young as 2 months of age as well as in patients presenting late in 79 years old, predominantly in adult or elderly.7,14 the etiology of riedel’s lobe in our patient could be either congenital or acquired. the congenital origin of accessory liver lobe is associated with an excessive disembrioplasic anomaly in the development of a hepatic bud.1,6,15 history of omphalocele or gastrochisis, which is also proposed to be related with supranumerary lobes, were denied by our patient.2,3,14 despite of that fact, we were not able to exclude the congenital possibility because its rare occurence correlated to an autosomal recessive gene with a very low frequency in population.13 however, our patient also had an acquired risk factor for occurence of riedel lobe, due to intrapelvic inflammatory condition of gynecologic adnexitis and abscess.3,6,7 therefore, the occurence of riedel’s lobe in this case can be attributed to combination of congenital anomaly and the impact of inflammation experienced several times before. the existence of riedel’s lobe actually can be presented with minor symptoms of acute or reccurent abdominal discomfort, nausea, constipation, or bloating caused by extrinsic compression or episode of torsion.1,13,16 not the least of these arises from the fact that most patients are asymptomatic, even though they have hepatomegaly.6 this is the usual pattern of incidental finding as reported in most case reports, just like our case in which no clinically significant symptoms occured. similar results from patient’s hepatobiliary ultrasonography, abdominal mri, and diagnostic laparoscopy strengthen the diagnosis of riedel’s lobe as a cause of hepatomegaly in our case. the diagnosis is usually established by imaging techniques, for instance ultrasonography with or without doppler examination, abdominal ct scan, abdominal mri, scintigraphy, and arteriographic modalities. 5,6,8 diagnostic laparoscopy was performed a role as a definitive diagnostic method as there was still doubt from the previous radiological examination performed. the laparoscopic examination was able to present a clear visualization of the liver and thus conservative treatment could be figure 4. patient’s laparoscopy examination. noticed the elongation of segment 6 liver to the inferior side through the lower lobe of right kidney. 60 vol 49 • number 1 • january 2017 riedel’s lobe: clinical importance of a rare variant in liver morphology preferred as only normal tissue found.10 as a normal variant, our patient’s riedel’s lobe is usually associated with good prognosis, considering early-stage diagnosis and the lack of clinical complications. knowledge and awareness of its possibility is essential, as it does not always remain clinically latent. approximately 20-30 cases related to its mechanical complication, particularly about torsion of hepatic lobe with pedicle, have already been reported.2,3,7 moreover, bleeding, rupture, and extrinsic compression of the stomach have been described.1,10 other data we need to be aware is the case of malignancy arising in riedel’s lobe, for example hepatocellular carcinoma or metastatic lesion.8,17 the incidence estimated to range between 0.2-4.2% for tumors arise only in the accessory liver lobe.1,8 fortunately, none of those manifested in our case. asymptomatic or uncomplicated riedel’s lobe usually does not need any special treatment, moreover to non peduncular one.13 surgical treatment, with or without cholecystectomy, can be considered in the case of the hypertrophic parencyma in case of torsion with noisy clinical presentation, metastatic lesion, or liver hydatide cysts of the riedel’s lobe.6,7 some other literatures suggested that resection be done more often because malignancy of riedel’s lobe is sometimes difficult to be differentiated with only imaging procedure and the confirmation of diagnosis can only be made after histopathological examination following resection or by laparoscopic.4,7 taking into account that no significant complication or suspicion of malignancy was found, we decided that the patient could be discharged and recommended to visit outpatient clinic for an evaluation three months later. our choice went along with the report from savopoulos, et al., in which the author still recommended that the asymptomatic patients still needed to do a follow up and monitoring several months after the diagnosis was made.5 conclusion riedel’s lobe is a normal variant form of liver which is rare. the diagnosis is usually established incidentally upon radiological examination, surgery, or autopsy. this case mostly has good prognosis, but follow up examination is still recommended for the uncomplicated case without surgical treatment. acknowledgments we would like to thank department of obstetry and gynecology, and also department of radiology of faculty of medicine universitas indonesia cipto mangunkusumo hospital, for the contributions of diagnosis establishment and implementation of patient’s management. references 1. glennison m, salloum c, lim c, et al. accessory liver lobes: anatomical description and clinical implications. jour visc surg. 2014;151:451-5. 2. umehara m, sugai m, kudo d, hakamada k, sasaki m, munakata h. torsion of an accessory lobe of the liver in a child: report of a case. surg today. 2009;39:80-2. 3. salisbury m, yi ce, merianos dj, sapra a, anselmo dm. laparoscopic resection of a torsed accesory hepatic lobe: case report and literature review. j ped surg case reports. 2013;1:214-7. 4. zamfir r, brasoveanu v, boros m, herlea v, popescu i. hepatocellular carcinoma in riedel’s lobe. chirurgia. 2008;103(1):121-3. 5. savopoulos c, kakaletsis n, kaiafa g, iliadis f, fountzila ak, hatzitolios ai. riedel’s lobe of the liver: a case report. medicine. 2015;94(3):1-3. 6. popescu i, zamfir r, brasoveanu v, boros m, herlea v. a rare indication for liver resection. chirurgia. 2005; 100(1):75-8. 7. hundal rs, ali j, korsten ma, khan am. torsion and infarction of an acessory liver lobe. j gastroenterol. 2006;44:1223-6. 8. huo l, feng r, zhuang h, li f. hepatocellular carcinoma in an accesory lobe of the liver revealed by 11c-acetate pet with a negative finding on fdg imaging. clin nucl med. 2012;37:393-5. 9. jain m, shukla l, jain s. a rare case with multiple variatons of liver and associated arteries. int j anat res. 2014;2(2):410-2. 10. sommariva a, pasquali s, stramare r, montesco mc, tropea s, rossi cr. laparoscopic diagnosis and treatment of a twisted accessory liver lobe. crsls mis. 2014;00170:1-5. 11. han s,soylu l. accessory liver lobe in the left thoracic cavity. ann thoarc surg. 2009;87:1933-4. 12. yi w, liao j, guo zw, hua cj, yong h, ming cj. accessory lobe of right liver mimicking a pulmonary tumor in an adult male. ann thorac surg. 2010;89:e910. 13. wang c, cheng l, zhang z, et al. accessory lobes of 61 juferdy kurniawan acta med indones-indones j intern med the liver: a report of 3 cases and review of the literature. intract rare dis res. 2012;1(2):86-91. 14. jambhekar k, pandey t, kaushik c, shah hr. intermittent torsion of accessory hepatic lobe: an unusual cause of recurrent right upper quadrant pain. indian j radiol imaging. 2010;20(2):135-7. 15. vinnakota s, jayasree n. a new insight into the morphology of the human liver: a cadaveric study. isrn anatomy 2013;article id 689654: 1-6. 16. ladurner r, brandacher g, mark w, et al. complete hepatic ischemia due to torsion of a large accessory liver lobe: first case to require transplantation. transplant international. 2005;18:467-9. 17. pryakhin a, yukhimets s, chernomortseva e, gesase ap. accessory lobes, accessory fissures, and prominent papillary process of the liver. anatomy j africa. 2015;4(2):611-6. 62 case report 330 acta medica indonesiana the indonesian journal of internal medicine adult necrotising enterocolitis: a rare entity mahesh gupta1, subhash goyal1, milan verma1, rekha goyal2 1 department of surgery, m.m. institute of medical sciences and research, mullana, (distt ambala), haryana, india. 2 department of radiodiagnosis, m.m. institute of medical sciences and research, mullana, (distt ambala), haryana, india. correspondence mail: dr mahesh gupta. dept of surgery m.m. institute of medical sciences and research, mullana, (distt -ambala) pin code – 133203, haryana, india. email: gm982003@yahoo.co.in. abstrak dilaporkan sebuah kasus enterokolitis nekrotikans pada orang dewasa yang dialami oleh seorang wanita dewasa, yang sebelumnya didiagnosis menderita obstruksi usus. pada laparotomi eksploratif, penyebab mekanik tidak ditemukan meskipun sebagian besar usus halus, sekum dan kolon asendens proksimal sudah mengalami gangren yang diselingi oleh beberapa bagian normal. reseksi usus yang terkena gangren tersebut dilakukan dan diikuti oleh yeyunostomi dan kolostomi transversal. sayangnya, pasien tidak mampu bertahan hidup pasca pembedahan. enterokolitis nekrotikans pada orang dewasa dapat menyerupai obstruksi usus, baik secara klinis maupun radiologis dan intervensi medis dan intervensi bedah diindikasikan segera pada kasus-kasus yang mencurigakan walaupun prognosisnya ternyata buruk. kata kunci: enterokolitis nekrotikans pada orang dewasa, iskemia mesenterika non-oklusif, usus yang mengalami gangren. abstract a case of adult necrotising enterocolitis in an adult female whom diagnosed with intestinal obstruction was reported. on exploratory laparotomy, the mechanical caused was not found although major part of small bowel, caecum and proximal ascending colon were gangrenous along with intervening normal parts. resection of affected bowel was performed followed by jejunostomy and transverse colostomy. unfortunately, the patient not survive in the postoperative periods. adult necrotising enterocolitis may mimic intestinal obstruction clinically or radiologically and prompt medical and surgical intervention is indicated in doubtful cases although it carries a poor prognosis. key words: adult necrotizing enterocolitis, non-occlusive mesenteric ischemia, gangrenous bowel. introduction adult necrotizing enterocolitis (anec) and non occlusive mesenteric ischemia (nomi) are rare causes of acute abdomen.1,2 necrotising enterocolitis usually affects children and only few cases have been described in adults. accurate preoperative diagnosis is often difficult in these cases. it is characterized by diffuse ulceration and necrosis of the distal small bowel and the colon. the surgical options in advanced cases in both these diseases are minimal and the prognosis is poor. we report one such case of necrotising vol 46 • number 4 • october 2014 adult necrotizing enterocolitis: a rare entity enterocolitis in an adult female with a fatal outcome after surgery. case illustration a 45-year-old female, presented with acute abdominal pain, vomiting and abdominal distension of one day duration and clinical features suggestive of intestinal obstruction and hypovolemic shock. four days prior to her current presentation she passed dark loose stools. her past medical history was significant for paraumblical hernioplasty two years ago. at the time of admission, pulse was 130 beats/min, blood pressure was 86/50 mmhg, and respiratory rate was 36/min with cold extremities. total leucocyte count was 39,0000/cu mm and creatinine 2.39 mg%. a plain erect abdominal radiograph revealed multiple air-fluid levels, thereby suggesting strangulation following obstruction of the intestines most likely due to adhesions from her previous surgery. she was taken to operation theatre for surgical treatment of her intestinal obstruction. during exploratory laparotomy, foul smelling dark coloured fluid was found along with gangrene of large part of small intestine, cecum and the proximal part of the ascending colonwith intervening normal gut. (figure 1). there was no evidence of adhesions or any other evidence of mechanical obstruction. a right hemicolectomy with resection of major part of small bowel was performed leaving approximately one feet of proximal jejunum (figure 2). the jejunum was brought out as jejunostomy and the proximal end of the transverse colon was brought out as colostomy through the same opening. unfortunately patient could not survive in the postoperative period. histopathological examination revealed a nonspecific picture of infarction necrosis of the bowel wall. discussion the exact cause of anec is not known. various theories include infection with certain bacteria and viruses, inflammatory mediators, circulatory disturbances leading to hypoxic injury with release of oxygen free radicals and loss of the bowel’s cellular integrity. this mechanism is similar to bowel necrosis occurring in non occlusive mesenteric ischemia (nomi).3-5 mesenteric vasoconstriction leads to gut hypoperfusion and intestinal necrosis, with bacterial translocation as the secondary event. however the primary etiology of anec seems to be different from neonatal necrotizing enterocolitis (nnec). in children due to poor development of defence systems, an initial infective insult seems to be the cause of intestinal necrosis than the primary vascular cause as seen in anec or nomi.6 radiological and laboratory data are seldom helpful in diagnosing this entity. findings on x-ray of these patients may show dilated bowel loops with multiple air-fluid levels are non specific. the common findings in anec at laparotomy include dilated and thickened loops of bowel with segments of necrosis often separated by segments of normal bowel (skip lesions) which are usually absent in nomi.7,8 histological examination is figure 1. intraoperative picture showing gangrene of major part of small bowel and caecum. figure 2. specimen of right hemicolectomy showing gangrenous caecum and proximal ascending colon 331 mahesh gupta acta med indones-indones j intern med characterized by pathological features such as an intestinal necrosis beginning in the mucosa, without obstruction of the mesenteric vessels. management is both medical and surgical. medical management attempts at producing local vasodilatation whenever possible and surgical resection of the affected intestinal segment. in many cases the diagnosis is made during exploratory laparotomy. however, in advanced cases surgical options are limited.9 late complications include short bowel syndrome and malnutrition in case patients survive after surgical resection. conclusion there is strong correlation between the vascular and infective events occurring in the mechanism of massive bowel necrosis in anec. the clinical and radiological findings, laboratory investigations, histopathology features might be non-specific in advanced disease. a high index of suspicion is necessary in making a diagnosis although it carries a very poor prognosis. references 1. howard tj, plaskon la, wiebke ea, et al. nonocclusive mesenteric ischemia remains a diagnostic dilemma. am j surg. 1996;171:405-8. 2. lahmiti s, aboussad a. neonatal necrotizing enterocolitis. scientific world j. 2011;22(11):655-6. 3. schnabl kl, van aerde je, thomson ab, clandinin mt. necrotizing enterocolitis: a multifactorial disease with no cure. world j gastroenterol. 2008;14:2142-61. 4. reinus jf, brandt lj, boley sj. ischemic diseases of the bowel. gastroenterol clin north am. 1990;19:319-43. 5. acosta s, ogren m, sternby nh, berqvist d, björck m. fatal nonocclusive mesenteric ischemia: populationbased incidence and risk factors. j intern med. 2006;259:305-13. 6. walsh mc, kleigman rm. necrotizing enterocolitis: treatment based on staging criteria. pediatr clin north am. 1986;33:179-201. 7. smerud m, johnson cd, stephens dh. diagnosis of bowel infarction: a comparison of plain films and ct scans in 23 cases. ajr am j roentgenol. 1990;154:99103. 8. bakal cw, sprayregen s, wolf el. radiology in intestinal ischaemia. angiographic diagnosis and management. surg clin north am. 1992;72:125-41. 9. boley sj, sprayregans, siegelmanss, veith fj. initial results from an aggressive roentgenological and surgical approach to acute mesenteric ischaemia. surgery. 1977;82:848-55. 332 288 acta med indones indones j intern med • vol 54 • number 2 • april 2022 case report pontine infarct as initial presentation of catastrophic antiphospholipid syndrome in systemic lupus erythematous rathika rajah1, rizna a. cader2* 1 department of medicine, universiti kebangsaan malaysia (ukm) medical centre, cheras, kuala lumpur, malaysia. 2 nephrology unit, department of medicine, ukm medical centre, kuala lumpur, malaysia * corresponding author: rizna abdul cader, md. consultant nephrologist. nephrology unit, department of medicine, universiti kebangsaan malaysia medical centre, jalan yaacob latif, 56000 cheras, kuala lumpur, malaysia. email: rizna_c@hotmail.com. abstract antiphospholipid syndrome (apls) is an autoimmune condition which commonly manifests as an arterial or venous thrombosis affecting medium to large vessels, with the presence of antiphospholipid antibodies. apls can be a primary disease by itself, or secondary to other autoimmune diseases, such as systemic lupus erythematosus (sle). catastrophic apls is a rare but a fatal sequelae of apls, affecting up to three or more organs, and progresses rapidly with a high mortality rate. we report a case of catastrophic apls in a young woman with underlying sle who presented to us with multiple cranial nerve palsies due to bilateral pontine infarct, and eventually developed deep vein thrombosis and pulmonary embolism during the course of the illness. she was treated with high dose corticosteroids and intravenous cyclophosphamide with biochemical improvement. in this case report, we would like to highlight the fact that our patient had bilateral pontine infarcts as the initial presentation, with no inciting events and antiphospholipid antibodies were negative during the acute illness. keywords: antiphospholipid syndrome, catastrophic apls, infarct, thrombosis, cyclophosphamide introduction antiphospholipid syndrome (apls) was first described in 1983 by graham hughes, in which there will be a single arterial or venous thrombosis as a result of an occlusion of the medium to large vessels with the presence of antiphospholipid antibodies.1 apls is a hypercoaguable state that predominantly affects females with a mean age of 37 years.2 it can either stand on its own as primary apls, or associated with other autoimmune conditions, primarily sle. anticardiolipin antibodies (acl) and lupus anticoagulant antibodies (la) are seen in a significant amount in patients with sle, which then contributes to the formation of apls. catastrophic apls is a life threatening, rare variant of apls seen in less than 1% of apls.3 it progresses rapidly to cause diffuse small vessel ischemia due to the presence of micro-thromboses, in contrary to apls. the four most commonly affected organs are renal (71% 89%), followed by cerebral (62%), lungs (45% 64%) and cardiac (45% 51%).4,5 diagnosing catastrophic apls is rather challenging and often be blinded by other differential diagnoses, especially disseminated intravascular coagulopathy (divc) and thrombotic thrombocytopenic purpura (ttp). the diagnostic criteria include a history of apls or persistent positive antibodies in two occasions six weeks apart, with three or more organs affected, symptoms onset within a week and biopsy proven micro-thrombosis. a definite catastrophic apls requires all four criteria to be vol 54 • number 2 • april 2022 pontine infarct as initial presentation of catastrophic antiphospholipid 289 fulfilled, whereas a probable catastrophic apls requires three out of four criteria.6 many reviews have reported catastrophic apls to have a mortality rate as high as 44%, and patients usually succumb due to cerebral involvement, cardiac cause and infection. a combination of anticoagulant, corticosteroids and plasma exchange was thought improve outcomes, while the use of intravenous cyclophosphamide was not proven to be beneficial.3 case illustration we report a case of a 28-year-old lady, single, nulliparous, who was diagnosed to have sle with musculoskeletal and hematological involvement at a private hospital in 2017 where she presented with anaemic symptoms and fever. she first presented to our institution in 2018 with relapsed sle and lupus nephritis (ln). renal biopsy showed diffuse proliferative lupus nephritis (isn/rps ln class iv). she was then treated with intravenous methylprednisolone and subsequently induced with mycophenolate mofetil (mmf) and cyclosporin a (csa). however, she never achieved complete remission (normal renal function and albumin, but persistent proteinuria of 3g/day). renal biopsy was repeated in june 2019 and showed the presence of focal proliferative lupus nephritis (isn/rps ln class iii). she was once again treated with intravenous methylprednisolone and scheduled for intravenous cyclophosphamide. two weeks later, she presented with complaints of left eye ptosis, preceded with three days of fever and cough which had resolved. she denied having any constitutional symptoms, recent trauma or surgery. upon examination, she was comfortable, orientated and not septic looking. she was neither hypertensive nor febrile with bp being 140/83. both pupils were equal and reactive. she had a partial ptosis over the left eye. there was limited adduction of the left eye, whereas on the right eye, the adduction and abduction were both limited. she also had right facial lower motor neuron weakness. other examinations were unremarkable. her full blood count showed normochromic normocytic anaemia, with thrombocytopenia (hb 9.3 g/dl; platelet 106 x 109/l). peripheral blood film showed no evidence of haemolysis. the coagulation profile was normal. there were no biochemical or radiological evidence of infection (wbc 4.4 x 109/l; crp 0.95 mg/l; blood c&s showed no growth; chest x-ray clear lung fields). her renal function was normal throughout admission, but had a heavy proteinuria of 6g/day. serum albumin was 26. urine full examination and microscopic examination (ufeme) showed protein of 4+ and blood 5+. her antinuclear antibody (ana if) was positive, 1:640 homogenous. but, her antiphospholipid antibodies were tested to be negative (we do not have a prior antiphospholipid antibody tests done). her serum complement c3 and c4 levels were low. patient was subjected for contrast enhanced computerized tomography (ct) scan and mri/mra brain. both were suggestive of bilateral pontine infarct, with no meningeal enhancement or dural venous thrombosis. she was empirically started on intravenous antibiotics. she was also given intravenous methylprednisolone 250mg once daily for three days, followed by oral prednisolone. we decided to continue the second cycle of intravenous cyclophosphamide during this period for her active lupus nephritis. during the 5 th day of admission, she complained of shortness of breath. further workup showed the presence of extensive left lower limb deep vein thrombosis and bilateral acute pulmonary embolism. with regards to her rapidly progressing thrombotic symptoms involving three major organs (brain, renal and lungs), she was deemed to have probable catastrophic apls. patient was started with low molecular weight heparin (lmwh) in ward and switched to warfarin upon discharge. during her clinic follow up for further cyclophosphamide doses, we did see a significant biochemical improvement (proteinuria), but remained to have residual neurological symptoms. discussion the hallmark of catastrophic apls includes the presence of antiphospholipid antibodies, thrombocytopenia, anaemia, and prolonged rathika rajah acta med indones-indones j intern med 290 clotting time as opposed to the absence of haemolytic picture in the blood film. thrombotic storm, is an alternative diagnosis that presents in a similar manner, whereby the thrombotic events occur rapidly without a triggering factor diagnosed based on clinical grounds.7 both conditions keep physicians on the ball in events of patient progressing into definite catastrophic apls, requiring aggressive treatment with corticosteroid and immunosuppressants. the nervous system is the second most commonly affected organ in catastrophic apls after the renal system. the dual pathology of thrombotic damage and antibodies induced oxidative stress contributes to the formation of infarction. they vary in terms of distribution of lesion (central or peripheral) and phenotype due to genetic predisposition or individual susceptibility. with middle cerebral artery territory being the most common affected site, pontine infarcts are said to be the least commonly affected area involving less than 10% of individuals.8 catastrophic apls can also present with non-thrombotic features such as headache, seizures, neuropsychiatric symptoms and movement disorders. asherson et al,4 reported that almost half of the patients with catastrophic apls will have a preceding event mainly infection, followed by trauma, surgery, malignancy or obstetric condition, none of which were seen in our case. epstein bar virus (ebv) and cytomegalovirus (cmv) infections are closely linked to catastrophic apls. catastrophic apls leads to immune activation, then systemic inflammatory response syndrome and small vessel thrombosis. the presence of antiphospholipid antibodies with thrombosis is needed to define apls and catastrophic apls, portraying the importance of these antibodies in the pathogenesis of the disease. the most commonly seen antibodies are acl igg and la, 83% and 82% respectively. but, there have been cases reported where the antibodies were only positive two months later. 9,10 it can be explained by the fact that the antibodies can be falsely negative due to the antibody consumption by a larger thrombus size during the acute period and become positive shortly after. it is also postulated that these antibodies are occasionally directed to some other antigens and creating a complex that cannot be tested using the conventional method. therefore, it is wise to repeat the test later on.10,11 it is not known to when is the best time to repeat the test. as mentioned above, catastrophic apls mostly affects the kidney causing a rise in serum creatinine, proteinuria of more than 6g/ day and severe hypertension. be it definite or probable catastrophic apls, the standard treatment regime includes anticoagulant plus corticosteroids plus plasma exchange with or without intravenous immunoglobulin.12 this is to treat the precipitating factor and thrombotic event, thus further suppressing the cytokines released during the acute period. few reports have suggested that the use of cyclophosphamide during the acute period does not confer a better prognosis.12 but for some physicians, high dose corticosteroids together with cyclophosphamide had been the preferred initial choice of treatment. on the other hand, rituximab, an anti-cd20 monoclonal antibody used in hematological malignancies, has been widely studied in catastrophic apls. catastrophic apls and hematological malignancies often have the same blood picture, which is anaemia, thrombocytopenia or thrombotic micro-angiopathies. hence, the use of rituximab in catastrophic apls with haematological involvement has shown to be equally effective. rituximab has also been proven to be beneficial in patients with renal and cardiac involvement.13 besides being a poor prognostic factor for catastrophic apls, the co-existence of active sle and apls with both pulmonary and renal involvement confers a higher rate of relapse. age of more than 36 years and the presence of antinuclear antibodies and lupus anticoagulant also have an added value to cause relapse.14 with regards to our patient, a normal clotting time and fibrinogen level excludes divc, whereas the absence of haemolysis with a background of thrombocytopenia excludes ttp. the onset of symptoms was within days and progressed to involve three major organs (renal, vol 54 • number 2 • april 2022 pontine infarct as initial presentation of catastrophic antiphospholipid 291 cerebral and lungs) but the antiphospholipid antibodies were tested to be negative. we regarded her as having probable catastrophic apls, as any further delay in aggressive treatment could cause a detrimental effect. the decision to continue the cyclophosphamide instead of plasma exchange or giving intravenous immunoglobulin was made as she was having active lupus nephritis which did not respond to mmf. and, as to whether rituximab can lead to neurological improvement, it is still unknown as there is lack of trials in this aspect. it is imperative for us to follow her up closely to repeat her antiphospholipid antibodies and be watchful for relapse. conclusion catastrophic apls can have various clinical and biochemical presentations. the diagnosis criteria is a useful guide, but high index of suspicion and early initiation of treatment is needed to prevent any unwanted complications. references 1. koike t. antiphospholipid syndrome: 30 years and our contribution. int j rheum dis. 2015;18(2):233-41. 2. nayer a, ortega lm. catastrophic antiphospholipid syndrome: a clinical review. j nephropathol. 2014;3(1):9. 3. bucciarelli s, espinosa g, cervera r, erkan d, gómez‐puerta ja, ramos‐casals m, font j, asherson ra. mortality in the catastrophic antiphospholipid syndrome: causes of death and prognostic factors in a series of 250 patients. arthritis & rheumatism. 2006;54(8):2568-76. 4. asherson ra. multiorgan failure and antiphospholipid antibodies: the catastrophic antiphospholipid ( a s h e r s o n ’s ) s y n d r o m e . i m m u n o b i o l o g y. 2005;210(10):727-33. 5. asherson ra, cervera r, de groot pg, erkan d, boffa mc, piette jc, khamashta ma, shoenfeld y. catastrophic antiphospholipid syndrome registry project group. catastrophic antiphospholipid syndrome: international consensus statement on classification criteria and treatment guidelines. lupus. 2003;12(7):530-4. 6. aguiar cl, erkan d. catastrophic antiphospholipid syndrome: how to diagnose a rare but highly fatal disease. therapeutic advances in musculoskeletal disease. 2013;5(6):305-14. 7. ortel tl, kitchens cs, erkan d, et al. clinical causes and treatment of the thrombotic storm. expert review of hematology. 2012;5(6):653-9. 8. fleetwood t, cantello r, comi c. antiphospholipid syndrome and the neurologist: from pathogenesis to therapy. frontiers neurol. 2018;9. 9. mull es, aranez v, pierce d, rothman i, abdul-aziz r. newly diagnosed systemic lupus erythematosus: atypical presentation with focal seizures and longstanding lymphadenopathy. jcr: journal of clinical rheumatology. 2019;25(7):e109-13. 10. miret c, cervera r, reverter jc, et al. antiphospholipid syndrome without antiphospholipid antibodies at the time of the thrombotic event: transient’seronegative’a ntiphospholipid syndrome?. clinical and experimental rheumatology. 1997;15(5):541-4. 11. drenkard c, sanchez-guerrero j, alarcon-segovia d. fall in antiphospholipid antibody at time of thromboocclusive episodes in systemic lupus erythematosus. journal rheumatol. 1989;16(5):614-7. 12. cervera r, rodríguez-pintó i, colafrancesco s, et al. 14th international congress on antiphospholipid a n t i b o d i e s t a s k f o r c e r e p o r t o n c a t a s t r o p h i c antiphospholipid syndrome. autoimmunity rev. 2014;13(7):699-707. 13. elagib em, eltahir ni, adam me, mahmoud zi, yousif hh. catastrophic antiphospholipid syndrome in combination with sle treated by rituximab: a case report and literature review. lupus: open access. 2019;4:137. 14. bucciarelli s, erkan d, espinosa g, cervera r. catastrophic antiphospholipid syndrome: treatment, prognosis, and the risk of relapse. clinical reviews allergy & immunology. 2009;36(2-3):80-4. 603acta med indones indones j intern med • vol 54 • number 4 • october 2022 case report additional chromosomal abnormalities in chronic myeloid leukemia patient treated with first-line tyrosine kinase inhibitor therapy: good or poor prognosis? wulyo rajabto, noviana joenputri* division of hematology and medical oncology, department of internal medicine, faculty of medicine universitas indonesia – dr. cipto mangunkusumo general hospital, jakarta, indonesia. * corresponding author : noviana joenputri, md. division of hematology and medical oncology, department of internal medicine, faculty of medicine universitas indonesia – dr. cipto mangunkusumo general hospital. jl. salemba raya no. 6, jakarta 10430, indonesia. email: noviana.joenputri@gmail.com. abstract a 33-year-old male came to policlinic of hematology-medical oncology dr. cipto mangunkusumo general hospital for routine control of chronic myeloid leukemia (cml) treatment. he was treated with imatinib mesylate (im) for two years. at the beginning of therapy, he showed good treatment response. however, after two years of treatment, he lost complete hematological response (chr) occured and major molecular response (mmr) was not achieved. this demonstrated drug resistance even with good compliance. evaluation of therapy through cytogenetic karyotype testing showed complex additional chromosomal abnormalities (aca) in addition to the philadelphia chromosome (ph). tyrosine kinase inhibitor (tki) therapy in this type of patients should be replaced with other alternative tkis. a mutation profiling test is needed to determine alternative tki. monitoring in the treatment of cml patients is very important. the presence of aca indicates disease progression and poor prognosis. time to change therapy in cml patients must be done appropriately based on the results of hematological, molecular, and cytogenetic testing. keywords: chronic myeloid leukemia (cml), additional chromosomal abnormalities, drug resistance introduction chronic myeloid leukemia (cml) is a hematopoietic stem cell disorder caused by translocation t(9;22)(q34;q11) that results in a philadelphia chromosome (ph).1 when first diagnosed, most cml patients (90-95%) are in chronic phase.1,2 the onset age of cml patients in asia is lower than in western countries.3 proportion of ph(+)/bcr-abl(+) chronic phase (cp) cml patients in dr. cipto mangunkusumo general hospital is 90%.4 cml treatment has changed dramatically in the last decade. imatinib and nilotinib are tyrosine kinase inhibitors (tkis) which are commercially used for treatment of cml patients in indonesia. treatment with tki results in 8595% overall survival after five years.5 imatinib mesylate (im) is the first tki approved to treat cml-cp patients. im competitively inhibits adenosine triphosphate (atp) attachment sites on bcr-abl oncoprotein, thus inhibiting phosphorylation of proteins involved in cell signal transduction. this efficiently inhibits bcr-abl kinase, however, it also blocks platelet-derived growth factor (pdgf) receptors and kit tyrosine kinase.5 we expected that cml patients who were treated with tki to have prolonged survival which is similar to normal people. however, patients with cml responded differently to wulyo rajabto acta med indones-indones j intern med 604 tki. we are reporting a case of a cml patient who showed disease progression after being treated with first-line im therapy and showed additional chromosomal abnormalities (aca) from cytogenetic testing. case illustration a 33-year-old male visited polyclinic of hematology-medical oncology dr. cipto mangunkusumo general hospital for his routine check-up of cml treatment. at the time of the visit, he had no complaints. he had been treated with oral im 1 x 400 mg/day for two years. he had good compliance in taking his medication and did not take any other drugs. he had no history of any other diseases. he regularly came to policlinic of hematology-medical oncology for a check-up and to get im. physical examination did not show splenomegaly. after two years of im therapy, laboratory testing revealed an increase in white blood cell (wbc) count to 91,140/ul (normal range: 4000-11,000/ ul), platelet (plt) count to 1,761,000/ul (normal range: 150,000-400,000/ul), basophil to 9% (normal range: 0-2%), myeloblast 1% (normal: no immature cells). quantitative bcr-abl was 63% is. bone marrow aspiration revealed a hypercellular morphology with m:e ratio 6.5:1 and expansion of granulopoiesis with 5.5% of blast cells. on his first visit two years ago, he complained of feeling nauseous and bloated. vital signs were normal. physical examination indicated anemia in both eyes conjunctiva and massive splenomegaly (schuffner 8). there was neither hepatomegaly nor any other abnormal findings. the result of blood test revealed anemia with hemoglobin (hb) count of 5.9 g/dl (normal range: 13.2-17.3 g/ dl), leukocytosis with wbc count of 251,030/ ul, normal plt value of 186,000/ul, basophil 1%, promyelocytes 1%, myeloblast 3%, and myelocytes 1%. he underwent bone marrow aspiration testing. qualitative bcr-abl testing was positive. based on history, splenomegaly, peripheral blood, bone marrow aspiration, and bcr-abl testing, we established the diagnosis of cml-cp. sokal score was 1.3 points and eutos score was 87 points. discussion our patient was a 33-year old male who came to policlinic of hematology-medical oncology dr. cipto mangunkusumo general hospital with cml diagnosis who was treated with im since two years ago. he routinely came for control of his im treatment and had no complaints. we evaluated the treatment response of cml patients regularly. response to tki therapy is determined by the measurement of hematologic (normalization of peripheral blood counts), cytogenetic (decrease in the number of ph-positive metaphases using bone marrow cytogenetics), and molecular responses (decrease in the amount of bcr-abl chimeric mrna using qpcr). the goal of tki therapy is to achieve a complete hematologic response (chr) within three months, a complete cytogenetic response (ccyr) and major molecular response (mmr) within 12 to 18 months after first-line tki therapy and to prevent disease progression to accelerated or blastic phase or cml.5,6 since patients with cml on tki are expected to live just like normal people, surrogate markers of outcome are important. achieving a deeper response faster is associated with better outcome.7 this patient achieved chr within three months after he started taking im and continued the treatment until two years with good compliance. after two years of treatment, his peripheral blood counts revealed leukocytosis, thrombocytosis, basophilia, and the presence of immature cells. quantitative bcr-abl was 63% is. thus, the patient loss of chr and did not achieve mmr after 24 months of imatinib therapy while he had no symptoms. we should evaluate patient compliance and drug interaction. in this patient, he had good compliance and did not take any other medications. patients with disease that is resistant to primary treatment with imatinib should be treated with bosutinib, dasatinib, or nilotinib in the second-line setting.6 we performed bone marrow aspiration and, despite the two-year treatment with im, the bone marrow still showed hypercellular morphology and expansion of granulopoiesis with 5.5% of blast cells (figure 1). cytogenetic analysis showed complex additional chromosomal abnormalities (aca) such as 41,y,-x,-11,-16,vol 54 • number 4 • october 2022 additional chromosomal abnormalities in chronic myeloid leukemia 605 17,-18[1]/44,xy,-17,-20[2]/45,xy,18[1]/45, xy,ob(13;22)(q10;q10),22[1]/46,xy,t(9;22) (934;q11)[2]/46,xy[6], while ph was still there (figure 2). ideally, we also need to perform bcr-abl mutation profiling to guide the selection of alternative tki.5-7 however, we have a limitation in performing mutation profiling due to lack of facilities. cytogenetic monitoring should be performed by analysis of marrow cell metaphases, reporting the proportion of ph+ metaphases with 20 metaphases analyzed minimally. the cytogenetic response is defined as complete (ccyr) with 0% ph+ metaphases, partial (pcyr) with 1%-35% ph+ metaphases, minor with 36%-65% ph+ metaphases, minimal with 66%-95% ph+ metaphases, and none if >95% ph+ metaphases.5 our patient did not achieve cytogenetic response at all at 2 years of treatment with im, even the cytogenetic also showed additional chromosome abnormalities which indicate a warning to treatment response. figure 1. morphology of bone marrow after 2 years on imatinib mesylate treatment. figure 2. cytogenetic testing after 2 years on imatinib treatment wulyo rajabto acta med indones-indones j intern med 606 the emergence of additional chromosomal abnormalities (acas) in ph (+)/ bcr-abl (+) cml, known as clonal evolution, is an indicator of multistep disease progression. it is a reflection of genetic instability that characterizes disease evolution in cml.8,9 beside for diagnosis, cytogenetics is an important tool for prognosis after treatment with tki. frequently, acas are found in ph+ cells and interfere with the progression of cml. acas increase in the advanced stage, from 30% in accelerated phase to 80% in blastic crisis. acas are related to poor prognosis, with a lower rate of treatment response with imatinib.10,11 we believe that acas in our patient is a hallmark of poor prognosis to treatment with imatinib, even acas also a sign of progression into an accelerated phase of cml so that we should change imatinib to the second generation tkis, such as nilotinib, dasatinib, or bosutinib, or even ponatinib. there is a general consensus that patients who fail after imatinib should change without hesitation to either nilotinib or dasatinib. the choice should be guided by the mutation profile, if relevant, the comorbidities of the patient, the side effects of the drugs, and the availability of the drugs. the presence of bcr-abl mutations is a way to guide to which one of tkis should the clinician choose as a second-line treatment after imatinib failure. direct sequencing of dna after qrt-pcr is most often used by clinicians to identify specific mutations in the bcr-abl kinase domain. in a survey of bcr-abl mutations in 386 cml subjects, branford and colleagues identified specific mutations, which conferred significant resistance to nilotinib (e255k/v, y253h, and f359c/v) and dasatinib (v299l and f317l). ponatinib is the only approved tki that binds to the t315i bcr-abl mutant protein.11-15 conclusion treatment monitoring in cml management is very important. the presence of acas is a sign of disease progression and poor prognosis. we need to properly decide when to change to alternative therapy based on hematology, molecular and cytogenetic testing. references 1. hehlmann r, hochhaus a, baccarani m. chronic myeloid leukaemia. lancet. 2007;370(9584):342-50. 2. hoffmann vs, baccarani m, hasford j, et al. treatment and outcome of 2904 cml patients from the eutos population-based registry. leukemia. 2017;31(3):593. 3. au wy, caguoia pb, chuah c, et al. chronic myeloid leukemia in asia. int j hematol. 2009;89:14–23. 4. rajabto w, reksodiputro ah, tadjoedin h, harimurti k. hubungan gambaran klinis dan laboratorium hematologis antara leukemia granulositik kronik ph(+)/bcr-abl(+) dengan bentuk kelainan ph/ bcr-abl lainnya. jurnal penyakit dalam indonesia. 2018;5(1):11-6. 5. hochhaus a, saussele s, rosti g, et al. chronic myeloid leukemia: esmo clinical practice guidelines for diagnosis, treatment, and follow up. ann oncol. 2017;28 (suppl 4):iv41-iv51. 6. radich jp, deininger m, abboud cn, et al. chronic myeloid leukemia, version 1.2019, nccn clinical practice guidelines in oncology. j nat comprehensive cancer network. 2018;16(9):1108-35. 7. jabbour e, kantarjian h. chronic myeloid leukemia. chronic myeloid leukemia: 2018 update on diagnosis, therapy, and monitoring. am j hematol 2018;93:44259. 8. crisan am, coriu d, arion c, colita a, jardan c. the impact of additional cytogenetic abnormalities at diagnosis and during therapy with tki in cml. j med and life. 2015;8(4):502-8. 9. chandran rk, geetha n, sakthivel km, et al. impact of additional chromosome abberation on the disease progression of chronic myeloid leukemia. front. oncol. 2019;9(88):1-12. 10. dorfman le, floriani ma, oliveira tmrdr, et al. the role of cytogenetics and molecular biology in the diagnosis, treatment, and monitoring of patients with chronic myeloid leukemia. j pras pathol med lab. 2018;54(2);83-91. 11. shah j. the importance of hematologic, cytogenetic, and molecular testing and mutational analysis in chronic myeloid leukemia. jcso 2014;121:179-87. 12. vigil ce, griffiths ea, wang eswetzler m. interpretation of cytogenetic and molecular results in patients treated for cml. blood rev. 2011;25(3):13946. 13. hughes t, white d. which tki? an embarrassment of riches for chronic myeloid leukemia patients. hematology 2013:168-75. 14. bitencourt r, zalcberg i, louro id. imatinib resistance: a review of alternative inhibitors in chronic myeloid leukemia. rev bras hematol hemoter. 2011;33(6):470-5. 15. bhamidipati p, kantarjian h, cortes j, cornelison am, jabbour e. management of imatinib-resistant patients with chronic myeloid leukemia. ther adv hematol 2013;4(2): 103-17. 315acta med indones indones j intern med • vol 53 • number 3 • july 2021 case report atypical exanthem as cutaneous manifestation related to covid-19 at a primary healthcare facility prasetyadi mawardi1, danu yuliarta1, waode nuraida2 1 department of dermatology and venereology, faculty of medicine, sebelas maret university/dr. moewardi general hospital, surakarta, central java, indonesia. 2 badak baru primary health care, kutai kartanegara, east kalimantan, indonesia. corresponding author: prasetyadi mawardi, md., phd. department of dermatology and venereology, faculty of medicine, sebelas maret university/dr. moewardi general hospital, jl. kol. sutarto 132 jebres surakarta 57126, indonesia. email: prasetyadimawardi@gmail.com; prasetyadi_m@staff.uns.ac.id. abstrak infeksi penyakit coronavirus (covid-19) menyerang struktur mukosa saluran pernapasan, terutama mukosa bronkial dan sel imun. perubahan kulit dan manifestasi terkait infeksi covid-19 tetap tidak dipahami dengan jelas. manifestasi kulit terkait covid-19 telah dilaporkan. pasien kami menunjukkan eksantema kulit atipikal di kakinya tanpa kelainan lain yang ditemukan. kami menggunakan azitromisin oral 500 mg, deksametason 0,5 mg, vitamin c 100 mg, dan parasetamol 500 mg, yang tersedia di puskesmas badak baru. exanthem telah membaik setelah 10 hari pengobatan. kata kunci: manifestasi kulit atipikal, covid-19, exanthem, perawatan kesehatan primer. abstract coronavirus disease (covid-19) infection attacks the mucosal structures of the respiratory tract, especially the bronchial mucosa and immune cells. the skin changes and manifestations related to covid-19 infection remain not clearly understood. cutaneous manifestations related to covid-19 had been reported. our patient manifested atypical cutaneous exanthem on her legs, with no other abnormalities found. we used oral azithromycin 500 mg, dexamethasone 0.5 mg, vitamin c 100 mg, and paracetamol 500 mg, which are available at badak baru primary health care. the exanthem has improved after 10 days of treatment. keywords: atypical cutaneous manifestation, covid-19, exanthem, primary health care. introduction the first cases of coronavirus disease (covid-19) were found in wuhan, china. the world health organization reported that the outbreak was caused by a new type of coronavirus called covid-19 on february 11, 2020.1 covid-19 is a public health emergency characterized by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) or acute respiratory distress syndrome (ards).2 covid-19 infection attacks the mucosal structures of the respiratory tract, especially the bronchial mucosa and immune cells as evidenced by the histopathological findings in biopsy specimens from various organs such as the lungs, heart, kidneys, spleen, or bone marrow. however, sars-cov-2 symptoms are unpredictable; each person exhibits various symptoms that are different from others, which making difficult to establish a certain diagnosis.3 several prasetyadi mawardi acta med indones-indones j intern med 316 dermatologists found cutaneous manifestations such as rash, urticaria, chicken pox-like eruptions, transient livedo reticularis, chilblain lesions, and erythema multiformes.4,5 however, cutaneous manifestations related to covid-19 infection remain not clearly understood whether they were caused by the infection or treatment reaction.3,6 case illustration a 30-year-old female patient visited the badak baru primary health care and presented with rashes on her lower legs since 3 days prior (figure 1). a week before the rash emerged, the patient complained of a mild fever, cold, cough, sore throat, and discomfort when swallowing. the patient denied any history of drug consumption. her vital signs were normal. the physical examination exhibited symmetrical exanthem on both lower legs. the laboratory finding showed reactive antibody covid-19 test and positive pcr swab covid-19 test. however, the physician did not conduct histopathological examination of the skin due to high risk virus transmission and limited facilities. the patient was diagnosed with exanthematous rash related to covid-19. she was treated with oral azithromycin 500 mg once a day for 10 days, oral dexamethasone 0.5 mg twice a day (four tablets in the morning and two tablets in the afternoon) for 5 days and then tapered to two tablets daily in the morning and two tablets daily in the afternoon for 5 days, oral vitamin c 100 mg 3 times a day for 10 days, and paracetamol 500 mg as needed for high fever. moreover, patient self-isolated for 10–14 days. on the 10th day of the treatment, the evaluation exhibited improvement in cutaneous manifestation (figure 2). no other abnormalities were found. 7 88 figure 1: lesion on lower leg: exanthem upon admission. figure 2: both lower legs: atypical exanthem 10 days after admission. figure 3: lower leg atypical exanthem after 14 days. vol 53 • number 3 • july 2021 atypical exanthem as cutaneous manifestation related to covid-19 317 discussion c u t a n e o u s m a n i f e s t a t i o n r e l a t e d t o covid-19 was first reported by recalcati, who examined 148 confirmed covid-19positive patients who were hospitalized at lecco hospital, lombardi, italy. of the 148 patients, it turned out that 60 patients have received previous therapy so they were excluded from observation. the most common types of skin disorder were erythematous rash (77.8%), extensive urticaria (16.7%) and varicella-like vesicles (5.5%).7 our patient had atypical exanthem on both lower legs. an exanthem is defined as a manifestation of infection of the skin or a reddening reaction of an inflammatory process related to the adverse effects of systemic drug use.8 casas et al. classified cutaneous manifestation with covid-19: pseudo chilblain, urticarial eruption, vesicular eruption, and maculopapular eruption.9 according to garcia, viral exanthem is classified into three types, namely, classic or typical viral, atypical, and paraviral exanthem. the six classic types of rashes are measles, rubella, scarlet fever, exanthem subitum, erythema infectiosum, and varicella.10 viral infection is preceded by a very complicated viral infection, both at the time of binding of the virus by certain human receptors, through different stages until new virion are released outside. initial viral infection is stochastic, depending on human exposures to the virus; it may cause systemic infection or complete elimination of the virus by antibodies due to minimal exposure to the virus. although the pathobiology of cutaneous manifestation related to covid-19 is not well understood, exanthem is common in viral infections. on the basis of the cells that are likely infected, covid-19 can be divided into three phases that correspond to different clinical stages of the disease: asymptomatic state (initial 1–2 days of infection), upper airway and conducting airway response (next few days), and then progression to ards with hypoxia, ground glass infiltrates. the 20% of confirmed covid-19 patients can progress to the third stage, and approximately 80% of infected patients have asymptomatic and mild diseases.11 therapy using oral azithromycin 500 mg, dexamethasone 0.5 mg, vitamin c 100 mg, and paracetamol 500 mg for high fever and selfisolation for 10–14 days was recommended. these medications are available at badak baru primary health care (puskesmas). on the 10th day, the patient came to the primary health care (puskesmas) with fading rashes on both her legs (figure 2). no other abnormalities were found. the exanthem has improved after 14 and 40 days (figures 3 and 4). the anti-microbial azithromycin has immunomodulatory and antiinflammatory effects.12 oral dexamethasone is also given as an anti-inflammatory drug. dexamethasone inhibits the expression of inflammatory mediators by macrophages and other cells and is used in the treatment of many immune-mediated inflammatory diseases. dexamethasone has a long-lasting action and higher anti-inflammatory and lower mineralocorticoid effects.13 meanwhile, oral vitamin c is indicated to increase the potentiation of anti-inflammatory drugs. limitations limitations in this case report include the use of minimal facilities and equipment such as a camera that is not available in our public health facility. atypical manifestations can be misdiagnosed in cases of covid-19. figure 4: improvement after 40 days. prasetyadi mawardi acta med indones-indones j intern med 318 conclusion besides respiratory problems, the sarscov-2 virus manifested multi-organ symptoms with each person having different manifestations, including those on the skin. comprehensive identification by conducting a complex history and physical examination is useful in treating sars-cov-2 infection. we showed the rare manifestations, which cutaneous manifestations might be related to immunity. declaration of patient consent the authors certify that they obtained all appropriate patient consent forms. in the form, the patient has given her consent for her images and other clinical information to be reported in a journal. the patient has understood that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. conflicts of interest there is no conflict of interest. references 1. who. coronavirus disease 2019 (covid-19) situation report 59. accessed april 10, 2020. https:// www.who.int/docs/default-source/coronaviruse/ situation-reports/20200319-sitrep-59-covid-19.pdf 2. zhu n, zhang d, wang w, et al. a novel coronavirus from patients with pneumonia in china, 2019. n engl j med. 2020;382(8):727-33. 3. iancu gm, solomon a, birlutiu v. viral exanthema as manifestation of sars-cov-2 infection: a case report. medicine (baltimore). 2020;99(35):e21810. 4. richardson s, hirsch js, narasimhan m, et al. presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with covid-19 in the new york city area. jama. 2020;323(20):2052-9. 5. gisondi p, piaserico s, bordin c, et al. cutaneous m a n i f e s t a t i o n s o f s a r s c o v2 i n f e c t i o n : a clinical update. j eur acad dermatol venereol. 2020;34(11):2499-504. 6. yao x, li t, he z, et al. histopathological study of new coronavirus pneumonia (covid-19) in three patients. chinese j pathol. 2020;49. 7. recalcati s. cutaneous manifestations in covid-19: a first perspective. j eur acad dermatol venereol. 2020;34(5):e212-3. 8. drago f, rampini p, rampini e, et al. atypical exanthems: morphology and laboratory investigations may lead to an aetiological diagnosis in about 70% of cases. br j dermatol. 2002;147(2):255-60. 9. casas cg, catal a, hernández gc, et al. classification of the cutaneous manifestations of covid-19: a rapid prospective nationwide consensus study in spain with 375 cases. br j dermatol. 2020;183(1):71-7. 10. garcia jjg. differential diagnosis of viral exanthemas. open vaccine j. 2010;3:65-8. 11. mason rj. pathogenesis of covid-19 from a cell biology perspective. eur respir j. 2020;55(4):9-11. 12. pradhan s, madke b, kabra p, et al. anti-inflammatory and immunomodulatory effects of antibiotics and their use in dermatology. indian j dermatol. 2016;61(5):46981. 13. newton r. molecular mechanism of glucocorticoid action : what is important?. thorax. 2000;55:603-13. 28 acta med indones indones j intern med • vol 54 • number 1 • january 2022 original article abstract background: the need of palliative care is increasing, but it is not all achievable. it is necessary to identify palliative patients in order to provide the proper care according to the needs of the patients. cipto mangunkusumo hospital has been making the identification using a palliative-patient screening questionnaire, but no performance assessment has been carried out on the screening tool. this study aimed to evaluate the performance of the screening-tool questionnaire used on palliative-care patients at cipto mangunkusumo hospital in order to assess the need of palliative-care consultation and to find out the optimal cut-off point of palliative care screening tools. methods: the design of this study is cross-sectional and was conducted at cipto mangunkusumo national central public hospital in july – october 2019. the sampling was collected by consecutive sampling. the reliability test was performed by the intraclass correlation coefficient (icc). the internal consistency was measured by the cronbach’s-alpha coefficient. the criterion-validity test was run by an evaluation using the pearson test. results: there were 64 subjects collected, the largest age group was 51-70 years (50%). cancer was the main disease found in most of the subjects (56 people / 87.5%). the most common comorbidity was kidney disease (11 people). the most common palliative score distribution was 6 (15 people). the average score was 7.51. the mortality rate at the hospital was 51.6%, 33 patients from a total of 64 patients. from the palliative score distribution curve, the auc value was 0.687 with a 95% ci (0.557-0.818). the optimal cut-off point was 8. all patients were palliative according to expert opinion based on who criteria. conclusion: the performance of this tool is sufficient to screen palliative patients in a terminal and complex condition, but requires improvements to screen for patients who need early palliative care. the optimal cut-off point to determine the limit of consultation on palliative patients is found at score 8. keywords: palliative care, performance, screening questionnaire, optimal cut-off point. palliative screening tools to identify palliative care consultation at tertiary hospital rudi putranto1, ratih arianita agung2, cosphiadi irawan3, czeresna heriawan soejono4, hamzah shatri1* 1 division of psychosomatic and palliative care, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 trainee of department of internal medicine, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 3 division of hematology and medical oncology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 4 division of geriatrics, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. * corresponding author: hamzah shatri, md. division of psychosomatic and palliative care, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jalan diponegoro no. 71. jakarta 10430, indonesia. email: hshatri@yahoo.com; psikosomatik@yahoo.com. vol 54 • number 1 • january 2022 palliative screening tools to identify palliative care consultation 29 introduction palliative care is an approach of care which aims to prevent and reduce various types of pain – physical, psychological, social, or spiritual – suffered by patients with life-threatening diseases.1 the number of patients who are at risk of developing such conditions, such as patients with cardiovascular disease, cancer, chronic obstructive pulmonary disease, aids, and diabetes, continues to increase every year.1 there are more than 20 million people worldwide who need palliative care in the last years of their lives, but there are only 14% of them who receive palliative care.2 a study reports that palliative-care units require fewer resources and shorter patientcare duration than the general care; therefore, they are more cost effective.3,4 another report suggests that palliative care results in the same survival level as the general care, improvement in symptoms, and more satisfaction in the patients and their families.5 the identification of palliative patients using screening tools can increase the number of patients referred to palliative care.6,7 these tools can be used on various care backgrounds and patients, such as in the emergency unit, the intensive care unit (icu), cancer patients, geriatric patients, etc. nevertheless, given the varying patient characteristics in each health facility, further evidence-based validity and standardization are required for the use of palliative-care assessment tools in every health care facility. cipto mangunkusumo national central public hospital (cmh) has been developing screening tools adapted from other screening tools with modifications since 2015, but until now its performance has not been assessed. the aim of the research is to develop a more reliable and valid palliative-patient screening tool for use at cmh. methods the research method used in this study is a cross-sectional study. the research was conducted by collecting data from cmh medical records and started from july to october 2019 until the required data were met. the sampling technique was carried out using the consecutive sampling method. research inclusion criteria include: adult patients, over 18 years of age with progressive chronic disease; recipients of palliative team consultation; and, patient with complete data in the medical records. the exclusion criteria in this research include patiens with incomplete medical records. the researchers also sought opinion from two experts to assess whether a patient was categorized as palliative/non-palliative or terminal/non-terminal. the subjects of this research were doctors and nurses who filled out the medical records of inpatients. the researchers informed the research objectives and asked the consent to conduct the research. the research data processing was carried out using the spss24.0 computer program. the normality test was run using the shapirowilk method. if the data distribution is normal (p=>0.05), a parametric test will be conducted using the pearson correlation test. if the distribution is not normal (p=0.05), then a non-parametric test will be conducted using the spearman correlation test. the internal consistency was assessed by calculating the cronbach’s-alpha coefficient. ethics this research was granted clearance from the committee for medical research ethics, faculty of medicine – universitas indonesia (panitia etik penelitian kedokteran fakultas kedokteran universitas indonesia) number: ket-828/un2. f1/etik/ppm.00.02/2019. results there were 64 palliative patients.three patients were excluded because of incompleted data. patient data were consulted to the palliative team consisting of 2 experts in the palliative field, which results in 64 palliative patients, as shown in figure 1. the overall research subjects were dominated by the age group of 51-70 years old (50%), while the age group of 18-30 years old had the lowest number of participants, i.e. 35 male patients (54.69%) and 29 female patients (45.31%). cancer was the primary disease found in most of the patients (56 people – 87.5%), followed by patients rudi putranto acta med indones-indones j intern med 30 who suffer from a chronic heart disease (4 people – 6.3%), advanced copd (1 person – 1.6%), and 3 people were consulted with other main diagnoses, namely ards (2 people) and hepatic cirrhosis (1 person), as shown in table 1. table 1. characteristics of research subjects characteristics n=64 age, n (%) 18-30 5 (7.8) 31-50 16 (25.0) 51-70 32 (50.0) >70 11 (17.2) sex, n (%) male 35 (54.7) female 29 (45.3) screener, n (%) doctors 61 (95.3) nurses 3 (4.7) primary diseases cancer (recurrent/metastases) 56 (87.5) advanced copd 1 (1.6) stroke 0 chronic kidney disease 0 coronary heart disease 4 (6.3) hiv/aids 0 congenital disease 0 comorbid diseases chronic heart disease 7 (10.9) moderate kidney disease 11 (17.19) moderate copd 4 (6.3) congestive heart failure 6 (9.4) other conditions/complications 15 (23.4) functional fully active, able to perform activities without obstacles. 1 (1.6) there are obstacles in strenuous activities but able to walk and perform light activities, such as house chores and light office work 1 (1.6) able to walk, perform self-care activities, but not able to perform all activities more than 50% of waking hours 3 (4.7) able to perform limited self-care activities, spend more time in bed or wheelchair, more than 50% of waking hours 24 (37.5) not able to perform self-care activities; spend most of the time in bed. harsh condition / disable. 35 (54.6) other criteria will not undergo curative treatment 44 (68.7) in severe-disease conditions and choose not to continue with the therapy 16 (25.0) untreated pain more than 48 hours 12 (18.7) have uncontrollable symptoms (e.g. nausea and vomiting) 14 (21.9) have a psychosocial and spiritual condition that needs attention 10 (15.6) frequent visit to the emergency unit / hospitalized (> 1x/ month for the same diagnosis) 12 (18.7) more than once of the same diagnosis within 30 days 13 (20.3) undergo long treatment without any significant progress (10 days). 19 (29.7) undergo long treatment at the icu without any progress (> 2 weeks) 5 (7.8) gastrointestinal cancer was the most found disease (31.3%), while infection was the most frequent comorbid disease (17.2%). there were 23.4% patients treated due to infection. there were 8 people (12.5%) suffering from depression, and 21 people (32.8%) with malnutrition. the most used painkiller was opiate (28.1%), while the use of paracetamol was 10.9%. one patient (1.6%) received psychopharmacotherapy and psychotherapy. the highest palliative performance score was 40% (15 patients). distribution of palliative score of screening tools at cipto mangunkusumo hospital table 2 describes the distribution of the palliative score collected during the research. the average score is 7.51. the mortalities of the patients at the hospital were 33 patients (51.6%) out of the total 64 patients. table 2. distribution of palliative score and mortalities at the hospital palliative score live (n=30) die (n=34) 4 2 (6.7) 0 (0.0) 5 1 (3.3) 2 (5.9) 6 10 (33.3) 5 (14.7) 7 6 (20.0) 4 (11.8) 8 6 (20.0) 8 (23.5) 9 3 (10.0) 8 (23.5) 10 2 (6.7) 6 (17.6) 11 0 (0.0) 1 (2.9) patient referred to palliative care team (n=67) inclusion patient (n=64) the result of the consultation of two palliative expert (n=64) exclusion patient (n=3) figure 1. study flow diagram. vol 54 • number 1 • january 2022 palliative screening tools to identify palliative care consultation 31 from the palliative score distribution curve, it is found that this tool is able to distinguish life and death, with an auc value of 0.687 and 95% ik (0.557-0.818) with moderate correlation. table 3. sensitivity and specificity score sensitivity specificity 4 1.000 0.00 5 1.000 0.07 6 0.939 0.10 7 0.758 0.43 8 0.636 0.63 9 0.424 0.83 10 0.212 0.93 11 0.029 1.00 the optimal cut-off point to determine the limit of consultation on palliative patients is found at score 8. validity and reliability based on the validity test that has been completed, 4 domains have varying validity, while the reliability test has a cronbach’s alpha value of 0.560 from 4 domains, which means it has low reliability (<0.70). the corrected item – total correlation value shows that domain iii and iv are above 0.3. table 4. corrected item – total correlation value average scale when items deleted variation scale when items deleted corrected item total correlation cronbach’s alpha when items deleted domain i domain ii domain iii domain iv 12.92 14.38 12.64 12.78 9.184 9.889 8.520 6.110 0.224 0.250 0.356 0.438 0.588 0.630 0.540 0.425 table 5. validity and reliability of each domain domain r p domain i 0.289 0.021 domain ii 0.175 0.167 domain iii 0.425 <0.001 domain iv 0.736 <0.001 the criteria domain has the best correlation compared to the other domains, while the comorbidity domain has no correlation. expert opinion from the table 6, it is indicated that all patients are palliative patients and more than 95% are patients in a terminal condition. table 6. results of consultations with experts in the palliative field researcher 1 researcher 2 palliative 64 (100) 64 (100) non-palliative 0 (0) 0 (0) terminal 62 (96.9) 61 (95.3) non-terminal 2 (3.1) 3 (4.7) discussion the participants involved in this research were dominated by those aged 51-70 years old, while those aged 18-30 years old were in a group with the lowest number of participants (7.8 %). this shows that in general, the patients who receive palliative care by the palliative team at cmh are elderly, which is in accordance with the research at cmh on 300 palliative patients between 2016 and 2018 where 43.7% of the patients were aged 50-70 years old.8 data from who in 2011 indicates that 20.4 million people need palliative care, 69% of whom are aged above 60 years old, 25% are aged 15-59 years old. cancer is the most common condition found in the participants involved in this research. early and continuous palliative care should be given to cancer patients.8,9 different types of cancer play a role in the difference of the improvement in the quality of life of the patients but do not affect the patient’s survival rate.8 the characteristics of other primary diseases that are commonly found in this research are acute heart failure and advance copd. chf and copd are the two main causes of chronic conditions. chf, particularly, is the main cause figure 2. distribution of palliative score rudi putranto acta med indones-indones j intern med 32 of death worldwide while copd is projected to increase to be the third highest cause by 2030.4 in this research, there were 12 patients with untreated pain for more than 48 hours. the incidence of pain in palliative, progressive patients and patients with cancer was high, with 90% of them suffering from advanced-stage cancer. 10 this untreated pain was experienced by 43% of patients with obstacles from receiving treatments is commonly found in asia.11 morphine is an effective analgesic used in the pain treatment for patients with cancer.12 pain was not the most common complaint in this research because cmh demonstrates good adequacy in dealing with pain, in accordance with the research conducted at cmh on 258 patients who consulted for palliative care in 2016-2018, 175 (61,4%) patients complained of pain, and it was found that 87,5% of them received adequate pain treatment.13 performance of palliative screening tools at cmh based on the validity test, 4 domains had varying validity. the r of domains of primary disease, comorbid disease, and other criteria is more than 0.2641; therefore, domains i, iii, and iv are valid. the domain of other criteria has the highest correlation that is 0.736, while the domain of comorbid disease has no correlation. according to fabrigar et al., the low correlation value indicates that there is only a small variation as a result of the sample being too homogenous, so it is possible to fail in identifying the number of factors that actually exist.14 the consistency of the measuring instruments measures what needs or should be measured. the reliability test in this research has a cronbach’s alpha value of 0.560 from 4 domains. other reliability results are seen by showing the value of alpha if deleted item and the value of corrected item-total correlation. if the value of corrected item-total correlation ≥ 0.3, it is evident that the items contained in the subscale measure the constructs in the subscale.15 in this research, the domains of functional status and other criteria has the value of corrected itemtotal correlation ≥ 0.3, which is 0.356 and 0.438. therefore, it can be stated that such items are able to measure patients that should be consulted to the palliative team. the validity and reliability in this research is satisfactory, but improvements are required in the domains of primary and comorbid disease. the identification process is a stage in overcoming multi-layered and complex problems. these problems may reduce the level of success in early palliative care within the hospital.15 the effectiveness of palliative care is indicated by patients who have been identified with positive quality of life towards the end of treatments.16 the sooner a patient is detected in need of palliative care, the sooner the needs of the treatments fulfilled, which will impact the patient’s quality of life. patients who need early identification are no longer patients who are expected to die, but patients who are at risk of deteriorating conditions and terminal conditions are more likely to receive proactive assessment and treatment plans from health workers. as a tool in assessing a patient’s condition, palliative-care screening tools must have assessment contents which are valid, applicable, easy to understand, and acceptable to the users, health workers and patients, as well as easy to analyze and interpret. in this research, the optimal cut-off point of the palliative score is 8. however, as a screening tool, the cut-off point of 6 can also be considered. in this research, the cut-off point is higher than the original score, which is 8. a report in taiwan using a similar screening tool shows that the auc value for all cut-off points is 0.84 – 0.88. based on the youden’s index, the optimal cutoff point value for 14 days are 2.16 therefore, palliative care in taiwan can be given earlier due to the lower cut-off point, which is 2. this is in line with the suggestion that palliative care should be initiated earlier. several influencing factors to the cut-off point are the knowledge and skills of experts in filling out the screening tools, the type of hospital, whether it is primary, secondary, tertiary, the distribution of patient characteristic, and hospital policy. the medical personnel knowledge on when to consult with the palliative team also plays an important role, where there has to be conformity on when to consult and the understanding on palliative self-care. vol 54 • number 1 • january 2022 palliative screening tools to identify palliative care consultation 33 hospital policy greatly influences the coverage of palliative services. with good support from hospital management, it is expected that a policy on palliative care will be regulated and led with clear governance, leadership, and management/operation that can guide the implementation of palliative care at a hospital, so they are able to provide comprehensive and holistic palliative services. this also applies to the screening of palliative patients. this palliative screening tools is suitable to be applied at hospitals that treat patients with terminal conditions, at tertiary hospitals. however, it is not necessarily applicable to primary and secondary health services. suggestion for further studies are: research with larger samples and a more even distribution of primary and comorbid diseases, dissemination of information to health workers on when to consult with the palliative team and on the screening tools, and further development of this screening tool. study limitation even this is the first study in indonesia to assess the performance of palliative screening, limitations include: • the patients admitted to the hospital were already in severe/terminal conditions. • this research took samples from a tertiary hospital, where the majority of the patients were patients with complex and terminal conditions; therefore, it is necessary to develop other tools which are able to reach all levels of health services. • there was an uneven distribution of primary and comorbid diseases. there were no samples from patients diagnosed with hiv/ aids, stroke, chronic kidney disease, or congenital abnormalities. • the absence of proper standards in assessing palliative-need services can also result in the differences in consultation time with the palliative team. • there are differences in the perception and the understanding of officers in filling out the palliative-screening sheet. conclusion this palliative screening tool is sufficient to assess palliative patients in terminal and complex conditions, while to assess patients who need early palliative care, it still requires improvements. the optimal cut-off point to refer to the palliative team in this research was 8. acknowledgments i would like to thank to dean of faculty of medicine and rector of universitas indonesia for support and grant, pitta a no:nkb-0400/ un2.r3.1/hkp.05.00/2019 references 1. who. planning and implementing palliative care services: a guide for programme managers. geneva: 2016. 2. wpca. global atlas of palliative care at the end of life. 2014. 3. putranto r, mudjaddid e, shatri h, adli m. development and challenges of palliative care in indonesia: role of psychosomatic medicine. biopsychosoc med. 2017;11 (1):29. 4. isenberg sr, lu c, mcquade j. economic evaluation of a hospitalbased palliative care program. j oncol pract. 2017;13 (5):e408–20. 5. meier de. increased access to palliative care and hospice services: opportunities to improve value in health care. milbank q. 2011;89 (3):343–80. 6. lauren cd, karen m, jenifer dc, riddhi s, julia hd. content validation of advanced illness criteria of a palliative care screening tool. j palliative med. 2018;20 (20):1–5. 7. weissman de, meier de. identifying patients in need of a palliative care assessment in the hospital setting. j palliative med. 2011;14 (1):17–23. 8. shatri h, putranto r, irawan c, adli m, elita d. characteristics of palliative patients, insights of patients and families, and the impact of estimated survival time on therapy decisions. 2019;51 (2):151–7. 9. ferrell br, temel js, temin s, et al. integration of palliative care into standard oncology care : american society of clinical oncology clinical practice guideline update. j clin oncol. 2019;35 (1). 10. liz gwyther ek. wpca policy statement on defining palliative care. w pall care alliance. 2011:1–6. 11. sholjakova m, durnev v, kartalov a, kuzmanovska, b. pain relief as an integral part of the palliative care. macedonian j med sci. 2018;6 (4):739–41. rudi putranto acta med indones-indones j intern med 34 12. chen ch, tang st, chen ch. meta-analysis of cultural differences in western and asian patient-perceived carriers to managing cancer pain. palliat med. 2012; 26 (3):206–21. 13. shatri h, agung ra, abdullah v, et al. factors related to pain management adequacy in patients receiving palliative care: data from a tertiary hospital in indonesia. med j indones. 2020;399–402. 14. fabrigar l, robert c, duane t, ej. evaluating the use of exploratory factor analysis in psychological reseach. psychol methods. 1999;4 (3):272–99. 15. dahlan s. penelitian diagnostik, validitas dan reliabilitas: dasar-dasar teoritis dan aplikasi dengan program spss dan stata. 2 edition. jakarta: epidemiologi indonesia; 2018. p. 173-5. 16. wang ssc, huang cm, feng rc, wu yl, huang sj. validation of a concise screening tool for the identification of palliative care needs among inpatients: a prospective study in hospital setting. j formosan med assoc. 2019;118 (5):883–90. 300 original article acta medica indonesiana the indonesian journal of internal medicine short-term survival of acute respiratory distress syndrome patients at a single tertiary referral centre in indonesia zulkifli amin, hasna afifah, chrispian o. mamudi department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia corresponding author: zulkifli amin, md., phd., fccp, finasim. division of respirology and critical care internal medicine, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl diponegoro no. 71, jakarta 10430, indonesia. email: zulkifliamin52@gmail.com. abstrak tujuan: mengetahui kesintasan jangka pendek dalam 28 hari pada pasien acute respiratory distress syndrome (ards). metode: studi retrospektif dilakukan di rumah sakit pusat rujukan tersier di jakarta, indonesia. pada studi ini, digunakan data rekam medis yang diambil selama 10 bulan, yaitu oktober 2015 hingga agustus 2016. keluaran primer studi ini adalah kesintasan jangka pendek selama 28 hari terhitung sejak pasien didiagnosis sebagai ards. hasil yang didapatkan kemudian dianalisis menggunakan kaplan-meier dan analisis multivariat cox regresi. hasil: studi ini mendapatkan 101 pasien ards dalam periode 10 bulan. kesintasan keseluruhan selama 28 hari adalah 47.5% dan nilai median adalah 10 hari (95% ci 2.47 – 17.52). kesintasan pada pasien ards cenderung menurun signifikan pada minggu pertama setelah didiagnosis ards. hal itu menunjukkan mortalitas tertinggi terjadi pada minggu pertama. skor apache ii >20 menunjukkan hr 2.45 (95% ci 1.404.28) dan derajat ards moderat-berat menunjukkan hr 2.27 (95% ci 1.25-4.12). kesimpulan: kesintasan jangka pendek di negara berkembang seperti indonesia masih rendah dan manajemen yang optimal pada awal dari minggu pertama pada pasien ards akan memperbaiki tingkat kesintasan. kata kunci: sindrom distres pernapasan akut, kesintasan, negara berkembang abstract aim: to identify the 28-day short-term survival rate in patients with acute respiratory distress syndrome (ards). methods: this is a retrospective cohort study conducted at a tertiary referral hospital in jakarta, indonesia. we conducted the study for 10 months and data was extracted from medical records between october 2015 and august 2016. the primary end point of the study was 28-day short-term survival rate using the initial date of ards diagnosis as the index time. overall survival rate was analyzed using kaplan-meier test and multivariate cox regression analysis. results: there were 101 ards subjects during 10 months of study. the overall rate of 28-day survival was 47.5% and the median time of survival was 10 days (95% ci 2.47–17.52). the survival rate in ards patients was reduced significantly at the first week after the diagnosis of ards was made, which indicated that the highest mortality occured in the first week. subjects with apache ii score of >20 had a hazard ratio (hr) of 2.45 (95% ci 1.40-4.28) and those with moderate-severe of ards had hr of 2.27 (95% ci 1.25-4.12). conclusion: the short-term survival rate of ards in developing countries including indonesia is still low and early management with optimal treatment provided within the first week may improve the survival rate. keywords: ards, survival, developing countries. vol 48 • number 4 • october 2016 short-term survival of ards patients at a single tertiary referreal centre 301 introduction acute respiratory distress syndrome (ards) is an intense inflammation of lung that may lead to life-threatening condition. patients are usually treated with supportive ventilation.1-3 ards has been well studied by many developed countries,4-6 and mortality has been reduced to up to 30%. nevertherless, the survival rate remains moderate to low in developing countries including indonesia. it may be due to some major problems such as limited access to hospitals, lack of facilities and ards is under-diagnosed by most clinicians. early identification based on the knowledge of short-term survival rate of ards may help clinicans in acute care setting to predict earlier prognosis and provide help for appropriate and prompt treatment. clinicians should be more aware about the best time to provide supportive care or perform careful observation for ards patients, particularly the underdiagnosed case. our data is limited on this issue.7 therefore, the burden of ards remains underreported in indonesia. moreover, most published studies in asian developing countries still use the old criteria of aecc (american-european consensus conference) definition, which would now be obsolete. to our knowledge, our study is the first study using new criteria of berlin definition in indonesia. we hope that our study could be a trigger to improve the management of ards and may provide an insight about the burden of ards and consequently; therefore, any deterioration can be prevented earlier. methods study design and population a retrospective cohort study was conducted at cipto mangunkusumo general hospital, a national referral hospital in jakarta, indonesia. we enrolled all adult patients aged 18 years and older who were admitted to the hospital with a diagnosis of ards as documented on their medical records. the study was conducted in 10 months, i.e. between october 2015 and august 2016. diagnosis of ards was defined using the criteria of berlin definition. the definition of ards in berlin criteria was characterized by the following key components: there was acute onset over 1 week or less following any identified clinical event; de novo respiratory symptoms or worsening of previous respiratory symptoms; bilateral opacities detected on chest x-ray or ct, which may not be fully explained by pleural effusions; respiratory failure, which must not be fully explained by cardiac failure or fluid overload. the ards was categorized as being mild (200 mmhg <pao2/fio2 ≤300 mmhg with peep ≥5 cmh2o), moderate (100 mmhg <pao2/fio2 ≤200 mmhg with peep ≥5 cmh2o), and severe (pao2/fio2 ≤100 mmhg with peep ≥5 cmh2o).8 primary and secondary endpoints the primary endpoint of our study was the 28-day short-term survival rate using the initial date of hospital admission as the index time. secondary endpoint included factors (apache ii score, severity) that might affect the survival. those variables were classified as dichotomous variables. our study has been approved by ethic committe of faculty of medicine university of indonesia, registration number: 998/un2.f1/ etik/2015. informed consent to the sujects was not requested since our study was observational and we followed the routine practice in our setting. sample size short-term survival rate as the primary end point of our study was used to calculate sample size. we used the survival rate obtained from a previous large-scale study conducted by bellani g, et al6 as a baseline. the study included 50 countries over 5 continents and the 28-day survival rate showed by that study was 60.4%.6 the confidence level was set at 95% and the precision of predicted survival rate was set at 15% in 28 days since there might be different survival rate between developed and developing countries. the minimum sample size, which should be obtained in our study was 91 patients. a 10% dropout rate was anticipated; thus, a minimum sample size of 101 subjects was determined. zulkifli amin acta med indones-indones j intern med 302 statistical analysis we used spss 20.0 (chicago, usa) to analyse the data. dichotomous variables were presented as number or percentage. the overall survival was analyzed using kaplan meier test and the date of first hospital admission day was determined as the index date. we presented the result of overall survival rate in percentage, the median time of survival in days and the specific time when most patients had faster deterioration. we also performed mulivariate cox regression analysis to examine survival time with variables included in the model and the results were reported with their corresponding hazard ratio and 95% ci. we considered p-value of less than 0.05 as significantly different. results there were 101 subjects participated in our study. important clinical characteristics related to ards were shown table 1. mean age was 52.7±17.2 years. out of 101 subjects, 45 (45.5%) subjects aged less than 60 years and 55 (54.4%) subjects aged over 60 years. there was a slight male dominance. approximately 83% patients had ards risk factors such as extrapulmonary sepsis and pneumonia. as many as 63.4% patients had apache ii score of less than 20 and the rest had score of more than 20. survival rate the overall 28-day survival was 47.5% and median time of survival was 10 days (95% ci 2.47–17.52). the survival rate was more likely to have a significant drop in the first week compared to the following weeks. almost 50% patients died in the first week. it indicated that the highest mortality in ards patients occured in the first week. the survival of ards patient with mild, moderate, and severe grade were 63.6%, 38.9%, and 28.6%, respectively. the median of survival time for mild, moderate and severe were 21, 5, and 3 days. table 1. main characteristics of patients with ards parameters n (%) survivors, n (%) non-survivors, n (%) age ≥60 years old 55 (54.4) 25 (45.4) 30 (55.6) <60 years old 46 (45.6) 23 (50) 23 (50) gender male 48 (47.5) 26 (54.2) 22 (45.8) female 53 (52.5) 22 (41.5) 31 (58.5) apache ii <20 66 (65.3) 37 (56.1) 29 (43.9) >20 35 (34.7) 11 (31.4) 24 (68.6) severity mild 44 (43.5) 28 (63.6) 16 (36.4) moderate 36 (35.7) 14 (38.9) 22 (61.1) severe 21 (20.8) 6 (28.6) 15 (71.4) gas exchange, first day of ards pao2/fio2 ratio [(median min-max)], mmhg 221 (41-612) 142 (53-624) paco2 [(median minmax)], mmhg 31.4 (17.3-77.10) 32.6 (1-73) ph [(median min-max)] 7.43 (7.14-7.61) 7.43(7.03-7.61) vol 48 • number 4 • october 2016 short-term survival of ards patients at a single tertiary referreal centre 303 discussion the survival rate of ards patients remains low and varies widely. most studies have reported that the mortality rate ranges from 30 to 60%.9,24 the overall survival of ards patients table 2. cox regression analysis of ards patients variables hazard ratio 95% ci p-value apache ii 2.45 1.40-4.28 .002 severity 2.27 1.25-4.12 .007 mild vs moderatesevere figure 1. the overall 28-day survival rate since the first diagnosis of ards. figure 2. kaplan-meier survival analysis of 28-day survival rate according to severity of ards. the survival was lower for those with moderate-severe ards compared to those with mild ards (p = 0.004, log-rank test). in the lung-protective ventilation era has shown an increasing trend. a recent large-scale study conducted by bellani et al,6 which was performed in 50 countries across 5 continents, showed that the survival rate has reached 60.4% (95% ci 58,762,2). mansur a et al10 showed that the 28-day survival rate among ards caucasian patients is over 65%; furthermore, the survival rate in mildmoderate grade patients is even higher, which is more than 85%. however, there are limited studies conducted in asia on survival of ards, especially in developing countries. a previous small-sized study conducted in a single tertiary care center in pakistan showed that the 28-day of survival rate is 44%.11 a large retrospective study in taiwan between 1997 and 2011 showed that the overall in-hospital mortality rate was 57.8% and the rate was decreased from 59.7% to 47.5% in 2011 (p<0.001).12 in our study, the survival rate is similar to most studies conducted in asia, especially in lower-middle-income countries. (table 3) compared to the mortality rate of ards patients in a highor upper-middle-income countries such singapore, china and japan, the mortality rate is higher in the lower-middle income countries.13 a study conducted by lew t et al in singapore showed that mortality at 28 days for their entire cohort was 10.1% and for icu death, the rate was 37%. a japanese study by endo s et al showed that the 30-day mortality rate of acute lung injury (ali) and ards were 21.6% and 20.5%, respectively.14 moreover, the hospital mortality rate in iceland decreased by 1% per year, i.e. from 50% in 1988-1992 to 33% in 2006-2010.15 ards mortality rate is still high in many developing countries where the facilities for intensive care and assisted ventilation are not widely available. there is a need to provide intensive care that is accessible and affordable to patients. a study conducted in singapore by lew et al13 also showed that the in-hospital mortality rate is the lowest (33.5%) in young patients (age 18-29 years) and the highest (68.2%) in the elderly patients (>80 years, p<0.001). patients who died during hospitalization are older and zulkifli amin acta med indones-indones j intern med 304 predominantly male. moreover, there is a lower mortality rate of ards patients at younger age (36%) as shown by a study conducted in india.16 in our study, almost 50% of our patients are <60 years old and the mortality rate is similar between young and elderly patients. some studies have shown that the age distribution of ards patients are variable. a small sample study in a rural area of india shows that the mortality among ards patients are 36.4% and it is possibly due to different baseline characteristics compared to other studies as the study included younger age of subjects and tropical disease.16 however, several asian studies have demonstrated that most subjects are at younger age and elderly age is usually associated with the increased risk of death.11,12,14,16,17 as we have known, the mortality rate in patients with ards is similar for both genders, either male or female, and many studies have reported various results.12,18,19 further investigations should be conducted by assesing the sex hormone level or sex-specific gene polymorphism in asian races related to ards risk. mortality rate is found to be higher with greater ards severity.6,10 the berlin definition has a better classification to predict mortality compared to the old definition of aecc. major studies including our findings have been consistent with the berlin classification. moreover, lower apache ii scores and higher baseline ratio of pao2 to fraction of inspired oxygen are associated with earlier recovery.11,13,15,16 our findings are also consistent with the results of previous studies. apache ii score still can serve as the ‘gold standar’ to predict the deterioration in ards. however, many parameters should be included in the score and applying the score every 24-48 hours is not practical to many settings in the middle-income countries. a new score with fewer parameters, but having similar capacity as apache ii score is urgently needed, especially in our country. many studies have also shown that the highest mortality among ards patients is found within the first week after the diagnosis of ards is made.10,16,20 however, a study conducted in singapore reveals that the highest mortality among sars-associated ards patients is found after the patients spending 7 days in icu due to late complications.11 different etiologies of ards may affect the survival rate found in those studies. classifying the etiologies would be useful to provide information whether a certain etiology can contribute to a higher risk of ards deterioration. some measures may prevent the development of ards including prompt resuscitation within 6 hours, early administration of effective antimicrobials and appropriate control of source of infection.21 optimal management and careful observation in ards patients within the first week of their hospitalization would prevent further deterioration and ultimately, it can decrease the table 3. comparison the mortality/survival rate of ards from various studies among developing countries in asia studies countries mortality/survival rate criteria hartini, et al7 indonesia study in a tertiary care hospital, the overall mortality rate of mechanically ventilated patients was 65.7%. aecc sharif n, et al11 pakistan study in a single tertiary care center, the 28-day survival rate was 44%. aecc george t, et al16 india study in a rural-urban hospital, the overall mortality rate was 36.6%. patients were dominated with younger age and tropical infection. aecc varghese gm, et al22 india study in a university teaching hospital, the overall mortality rate of ards patients with scrub typhus was 67.9% not mentioned bhadade rr, et al23 india study in a tertiary care hospital, the overall mortality was 57%. patients were dominated with younger age and tropical infection. aecc singh g, et al24 india study in a tertiary care hospital, the overall mortality in those with ards admitted to surgical intensive care unit was 41.8%. aecc vol 48 • number 4 • october 2016 short-term survival of ards patients at a single tertiary referreal centre 305 mortality rate and complications. a previous study conducted by sharif n et al showed that high apache ii score, sepsis, multiorgan failure, refractory shock, and refractory hypoxemia are the leading causes of death in ards patients.11 results of our study are consistent with their findings regarding the fact that the apache ii score did affect the mortality rate and in our study, our subjects were also predominated by sepsis and pneumonia. we admit that there are some limitations of our study since it was a retrospective design with a single center setting. nevertheless, our focus is on the overall survival rate among ards patients found in our setting and our study is the first study reporting the actual condition in indonesia. further studies are required and preferably to be performed in multicenter settings with a higher power of study. classifying ards based on the specific etiology and conducting a large-scale epidemiological study may be beneficial to raise the awareness of this devastating clinical syndrome in developing world. conclusion our study demonstrates that the short-term survival rate of ards is 47.5%. there is equal distribution of age, gender and sepsis among survivors and non survivors. high apache ii score and severe grade are associated with high mortality. earlier optimal management provided in the first week may increase the survival rate of ards patiens. the overall survival rate of ards patients in the era of lung-protective ventilation has been improved over time either in highor low-middle income countries. however, lower survival rate is found in lower-middle income countries. it may be related to disparity in facilities and resource, which causes the identification of ards cases and management of ards treatment to less optimal than high-income countries since in those countries, ards guideline have been routinely applied. references 1. fanelli v, vlachou a, ghannadian s, simonetti u, slutsky as, zhang h. acute respiratory distress syndrome: a new definition, current and future theraupetic options. j thorac dis. 2013;5(3):328-34. 2. sud s, sud m, frierich j, et al. high frequency oscillation patients with acute lung injury and acute respiratory distress syndrome (ards): systematic review and meta-analysis. bmj. 2010;340:c2327. pubmed pmid: 20483951. 3. udobi k, childs e, touijer k. acute respiratory distress syndrome. am fam physician. 2003;67(2):315-22. 4. gattinoni l, caironi p, cressoni m, et al. lung recruitment in patients with the acute respiratory distress syndrome. n engl j med. 2006;354:1775–86. 5. wiedemann hp, wheeler ap, bernard gr, et al. comparison of two fluid-management strategies in acute lung injury. n engl j med. 2006;354:2564–75. 6. bellani g, laffey j, pham t, et al. epidemiology patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. jama. 2016;315(8):788-800. 7. hartini k, amin z, pitoyo cw, rumende cm. faktorfaktor yang mempengaruhi mortalitas pasien ards di rumah sakit cipto mangunkusumo jakarta. ina j chest crit and emer med. 2014;1:21-6. 8. the ards definition task force. acute respiratory distress syndrome: the berlin fefinition. jama. 2012;307:2526-33. 9. phua j, stewart te, ferguson nd. acute respiratory distress syndrome 40 years later: time to revisit its definition. crit care med. 2008;36(10):2912–21. 10. mansur a, steinau m, popov af, et al. impact of statin therapy on mortality in patients with sepsis-associated acute respiratory distress syndrome (ards) depends on ards severity: a prospective observational cohort study. bmc med. 2015;13:128. 11. sharif n, irfan m, hussain j, khan j. factors associated within 28 days in-hospital mortality of patients with acute respiratory disstress syndrome. biomed res int [internet]. 2013 jun [cited 2016 may 1];2013:[about 5 p]. available from: http://www.hindawi.com/journals/ bmri/2013/564547/ 12. chen w, chen y, tsai c, chen sc, lin m, ware l, chen c. incidence and outcome of acute respiratory distress syndrome: a nationwide registry-based study in taiwan, 1997 to 2011. medicine. 2015;94(43):e1849. pubmed pmid: 26512593 13. lew tk, kwek t, tai d, et al. acute respiratory distress syndrome in critically ill patients with severe acute respiratory syndrome. jama. 2003;290(3):374-80. 14. endo s, shibata s, sato n, et al. a prospective cohort study of ali/ards in the tohoku district of japan (second report). j anesth. 2010;24(3):351-8. 15. sigurdsson mi, sigvaldason k, gunnarsson ts, moller a, sigurdsson gh. acute respiratory distress syndrome: nationwide change in incidence, treatment and mortality over 23 years. acta anaesthesiol scand. 2013;57(1):37-45. 16. george t, viswanathan ss, karnam ah, abraham zulkifli amin acta med indones-indones j intern med 306 g. etiology and outcomes of ards in a rural-urban fringe hospital of south india. crit care res pract. [internet]. 2014 [cited 2016 may 1];2014:[about 7 p]. available from: http://www.hindawi.com/journals/ ccrp/2014/181593/ 17. liu x, xu y, zhang r, et al. survival predictors for severe ards patients treated with extracorporeal membrane oxygenation: a retrospective study in china. plos one. [internet]. 2016 jun [cited 2016 aug 1];11(6):[about 14 p]. available from:http://journals. plos.org/plosone/article/asset?id=10.1371%2fjournal. pone.0158061.pdf 18. bakowitz m, bruns b, mccunn m. acute lung injury and the acute respiratory distress syndrome in the injured patient. scand j trauma resusc emerg med. 2012;20:54. 19. sheu c, zhai r, su l, et al. christiani. sexspecific association of epidermal growth factor gene polymorphisms with acute respiratory distress syndrome. c. eur respir j. 2009;33(3):543-50. 20. adamzik m, frey u, sixt s, knemeyer l, beiderlinden m, peters j, siffert w. ace i/d but not agt (-6)a/g polymorphism is a risk factor for mortality in ards. eur respir j. 2007;29:482-8. 21. rittayamai n, brochard l. recent advences in mechanical ventilation in patients with acute respiratory distress syndrome. eur respir rev. 2015;24:132-40. 22. varghese gm, trowbridge p, janardhanan j, et al. clinical profile and improving mortality trend of scrub typhus in south india. int j infect dis. 2014;23:39-43. 23. bhadade rr, de souza ra, harde mj, khot a. clinical characteristics and outcomes of patients wih acute lung injury and ards. j postgrad med. 2011;57:286-90. 24. singh g, gladdy g, chandy tt, sen n. incidence and outcome of acue lung injury and acute respiratory distress syndrome in the surgical intensive care unit. indian j crit care med. 2014;18(10):659-65. medical illustration thyroid abscess as a clinical manifestation of papillary thyroid carcinoma tri juli edi tarigan1*, marina epriliawati2 1 division of endocrinology and metabolism, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 2 division of endocrinology and metabolism, department of internal medicine, fatmawati general hospital, jakarta, indonesia. * corresponding author: tri juli edi tarigan, md., phd. division of endocrinology and metabolism, department of internal medicine, faculty of medicine universitas indonesia dr. cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: tri.judi@ui.ac.id. figure 1. lateral view of the neck in a patient with a thyroid abscess at the left lower pole figure 2. computed tomography imaging of the neck figure 3. anterior view of the neck in a patient with a thyroid abscess at the left lower pole figure 4. neck ultrasound 138 acta med indones indones j intern med • vol 54 • number 1 • january 2022 vol 54 • number 1 • january 2022 thyroid abscess as a clinical manifestation of papillary thyroid 139 thyroid abscess is a relatively uncommon condition. it accounts for less than 1% of all thyroid diseases and less than 0.7% of surgical pathology in the thyroid gland. the thyroid gland has protective factors, including high iodine content that acts as a bacterial effect, well-developed capsule, adequate lymphatic drainage, a plentiful blood supply, and hydrogen peroxide production within the gland, which inhibits infection development in the thyroid tissue. predisposing factors that may increase the susceptibility of the thyroid gland to infection include pyriformis sinus fistulae, thyroid nodule or cancer, or immunocompromised patients. around 5-10% of the population is estimated to have a palpable nodule, but with ultrasound, it could increase to 50-60% and approximately 5% of the detected nodules are malignant. therefore, a thorough examination of the thyroid nodule is essential in order to rule out thyroid cancer. usually, thyroid cancer is present with a mass. however, it is rare for thyroid cancer to present with a thyroid cyst or thyroid abscess, even with infection symptoms. numerous reports indicate that females with a pre-existing thyroid nodule had a higher incidence of thyroid abscesses. although thyroid abscesses are uncommon, they can result in significant morbidity and mortality. therefore, once a thyroid abscess is diagnosed, aggressive management should be initiated to avoid dangerous complications. the majority of thyroid abscesses are successfully treated with a combination of antibiotics and surgery. percutaneous drainage and intracavitary antibiotic injection are conservative and is a less invasive alternative management strategy. a 50-year-old woman presented with a 7-day history of an enlarged, painful, and warm neck mass resulting in swallowing difficulty, as well as a high fever and headache. she had no history of upper respiratory tract infection or neck trauma but had previously been diagnosed with a thyroid nodule a year prior without being treated. she was found critically ill with a temperature of 380c and a heart rate of 100 beats per minute. other vital signs were within normal limits. her left anterolateral neck was swollen (10x10x5cm), warm and tender, and was reddish. due to neck tenderness, cervical lymphadenopathy was difficult to assess. the white blood cell count was 16,800/ul with an elevated neutrophil count (78%), esr of 120 mm/h (0-20), procalcitonin of 0.09 ng/ml (<0.05), and quantitative crp of 86.0 mg/l (<5.0). tshs were within the normal range (0.580 uiu/ml, reference 0.270-4.200), free t4 was 1.390 ng/dl (reference 0.930-1.700), random blood glucose was 161 mg/dl (<140), electrolytes were normal, and both anti-hiv and hbsag were non-reactive. chest x-ray revealed a soft tissue mass in the left inferior neck, displacing the trachea to the right between the c6 and t1 levels. a computed tomography scan of the neck revealed a 7.2x5.4x7.1cm cystic lesion in the left lobe with a thick wall, dislodging the glottis and trachea to the right and extending inferiorly to the supraclavicular, consistent with a left thyroid abscess. the patient was diagnosed with thyroid abscess and treated with ceftriaxone at a dose of 2 grams per day and metronidazole for 500 mg three times daily. neck sonography revealed a cystic lesion in the left lobe, surrounded by a thick wall and contain a ruptured lateral capsule. ultrasound-guided aspiration of this lesion was performed for diagnostic purposes and to alleviate pain; 100 cc of thick yellow-brown liquid was aspirated from the lesion. following aspiration, the cavity was twice injected with 50 cc of metronidazole. the patient was scheduled for left isthmolobectomy due to pus expanding into the tissue from a ruptured capsule. histopathological examination revealed that the specimen was composed primarily of thyroid tissue that had partially formed a cyst cavity. granulation tissue lined with necrotic tissue and inflammatory cells formed the cyst wall. the pericystical area contained thyroid tissue with epithelium-lined follicles with round nuclei, clear chromatin, and nuclear groove. this finding confirmed the presence of a thyroid abscess associated with a follicular variant of papillary thyroid carcinoma with no extrathyroidal extension. all symptoms were relieved following surgery on the eighth day of admission, including the neck tenderness that was the patient’s chief tri juli edi tarigan acta med indones-indones j intern med 140 complaint. the wbc count was reduced to 7,950/ul in the laboratory, and no bacteria were detected in blood culture or fluid specimens. she was then discharged and prescribed ampicillin sulbactam 375 mg twice daily for three days. thyroid abscesses are uncommon, even in patients with compromised host defenses.1-3 it is more common in women aged 20-40 and affects the left lobe more than the right.3-5 it accounts for less than 1% of all thyroid diseases and less than 0.7% of surgical pathology in the thyroid gland.1-3 it is even more uncommon to see thyroid carcinoma presenting as thyroid abscess. the patient is a 50-year-old woman who has had an untreated thyroid nodule for a year. the patient was then admitted to the hospital with acute symptoms of an enlarged, painful, and warm mass on the left side of the neck that caused difficulty swallowing and was accompanied by a high fever and headache. at first, we suspected it purely as an infection of thyroid abscess. she had no history or laboratory evidence of respiratory infection or immunodeficiency; however, she had a history of thyroid nodule since a year ago. the patient’s initial laboratory test results revealed an elevated wbc count of 16,800/ul, an elevated neutrophil count (78 %), esr of 120 mm/h, and crp of 86.0 mg/l, but normal tsh and free t4 levels. it is common to see increased non-specific markers of infection such as leukocyte and esr with normal thyroid function tests. however, hyperthyroidism or hypothyroidism may be present in some cases of thyroid abscess.3,4,9 ultrasound and computed tomography (ct) scans are highly sensitive for the detection of abscess collection.9 ultrasound examinations provide sufficient information about intraor extra-thyroid abscesses, solid or mixed lesions, and the thyroid gland’s echostructure and vascular flow. a ct scan can be used to pinpoint the abscess’s location and any adjacent organs or structures.4 when a pyriform sinus fistula is suspected, barium swallow has a high sensitivity for detecting it. this test, however, should be done after the infection has been resolved.8 in our case, the ct scan revealed the abscess and its relationship to neighboring structures. it revealed a cystic lesion in the left lobe measuring 7.2x5.4x7.1cm with a thick wall, dislodging the glottis and trachea to the right and extending inferiorly to the supraclavicular, consistent with a left thyroid abscess. at the same time, neck sonography revealed a cystic lesion in the left lobe that was encased in a thick wall and contained a ruptured lateral capsule. although the incidence is rare, thyroid abscesses may lead to significant morbidity and mortality, especially if left untreated. thyroid storm, airway obstruction due to laryngeal oedema or tracheal compression, tracheal and esophageal perforation, descending necrotizing mediastinitis, internal jugular vein thrombosis, and generalized sepsis are all severe complications of thyroid abscess that can occur at any time.7,9,11 fna (fine needle aspiration) is a minimally invasive procedure that can be used to diagnose a thyroid abscess, differentiate benign from malignant thyroid nodules, and obtain culture specimens of the causative organism. thus, a more targeted antibiotic therapy can be prescribed.4,10 staphylococcus aureus is the most frequently implicated causative organism in thyroid abscesses. however, other organisms, such as oropharyngeal anaerobes or gram-negative aerobes, are also involved.7 mycobacterium tuberculosis, candida albicans, and brucellosis, all of which are mixed flora, have been reported occasionally.3,4,8,12 as a result, this should be considered when initiating empiric antibiotic therapy in the absence of a culture result.9 as no organism grew in the culture of blood and fluid specimens in this patient, antibiotics were given empirically in combination with percutaneous drainage and intracavitary antibiotic injection to resolve the symptoms. however, because the thyroid capsule has ruptured and the abscess has spread to adjacent tissue, the isthmolobectomy procedure is necessary in this case. surgical intervention and dual antimicrobial therapy were used to resolve the thyroid abscess. histological examination confirmed thyroid abscess with a follicular variant of papillary thyroid carcinoma without extrathyroidal extension. the management of a thyroid abscess is appropriate systemic antibiotics and abscess drainage. aspiration of the abscess may resolve vol 54 • number 1 • january 2022 thyroid abscess as a clinical manifestation of papillary thyroid 141 in cases with small abscesses, although a larger one will need partial or total thyroidectomy.7,11 percutaneous image-guided drainage of thyroid abscesses with catheter irrigation and intracavitary antibiotics also have been reported as conservative management. yeow, et al. recommended needle aspiration drainage for small lesions (<3 cm) and catheter drainage for lesions larger than 3 cm or with the involvement of thyroid or parotid gland. percutaneous needle drainage was performed twice in each case and antibiotics were injected inside the cavity after pus evacuation and rinsing the lesions with 0.02% chlorhexidine gluconate.5 in the presence of underlying pathology such as the pyriformis sinus tract, operative management is recommended to achieve definite control and prevent a recurrence.9 we presented a rare case of thyroid cancer presenting as thyroid abscess. a year before, the patient was diagnosed with an unevaluated thyroid nodule, which could be a malignant lesion, while benign or malignant nodule is a risk factor of thyroid abscess. the patient was initially planned to be treated conservatively by intravenous and intracavitary antibiotic injections. ultrasound-guided aspiration was conducted for diagnostic and to relieve pain. however, surgical intervention was needed due to the rupture of the capsule and the expansion of the abscess to the surrounding tissue. the histopathological findings from the surgery confirmed thyroid abscess with a follicular variant of papillary thyroid carcinoma. in this case report, this rare finding (cancer presenting as an abscess) explained that physicians must be aware of thyroid abscess in acute tender neck swelling, as it may present as thyroid cancer. references 1. yedla n, pirela d, manzano a, et al. thyroid abscess: challenges in diagnosis and management. j invest med high impact case rep. 2018;6:1–3. 2. h o ff m a n n c j , b r o w n t t. t h y r o i d f u n c t i o n abnormalities in hiv-infected patients. clin infect dis. 2007;45(4):488–94. 3. akdemir z, karaman e, akdeniz h, et al. giant thyroid abscess related to postpartum brucella infection. case rep infect dis. 2015;2015:1–3. 4. ghaemi n, sayedi j, bagheri s. acute suppurative thyroiditis with thyroid abscess: a case report and review of the literature. iran j otorhinolaryngol. 2014;26(74):51–5. 5. ilyin a, zhelonkina n, severskaya n, romanko s. nonsurgical management of thyroid abscess with sonographically guided fine needle aspiration. j clin ultrasound. 2007;35(1):333–7. 6. nguyen qt, lee ej, huang mg, et al. diagnosis and treatment of patients with thyroid cancer. res article am health drugs ben. 2015;8(1):30-40. 7. brown j, nguyen hh, cohen sh. a pain in the neck: thyroid abscess. am j med [internet]. 2014;127(3):e5. 8. stavreas np, amanatidou cd, hatzimanolis eg, et al. thyroid abscess due to a mixed anaerobic infection with fusobacterium mortiferum. j clin microbiol. 2005;43(12):6202–4. 9. cawich so, hassranah d, naraynsingh v. idiopathic thyroid abscess. int j surg case rep [internet]. 2014;5(8):484–6. available from: http://dx.doi. org/10.1016/j.ijscr.2014.05.019 10. lu y, zhang j, liang x, hu m, zheng r, li l. efficacy of fine-needle aspiration cytology for a thyroid abscess in children: two case reports. exp ther med. 2015;9(3):860–2. 11. kale su, kumar a, david vc. thyroid abscess an acute emergency. eur arch oto-rhino-laryngology. 2004;261(8):456–8. 12. raza t, nm k. gi microbiome in thyroid abscess. 2017;2(1):2017. 70 acta med indones indones j intern med • vol 55 • number 1 • january 2023 case report giant left ventricular pseudoaneurysm in a 79-year-old female patient: diagnostic and management nina solomakhina1, alexey lishuta 1*, ekaterina gladysheva1, anna dementeva2 1department of hospital-based therapy, i.m. sechenov first moscow state medical university (sechenov university), sklifosovsky institute for clinical medicine, moscow, russian federation. 2 veterans affairs hospital 1, moscow, russian federation. *corresponding author: alexey lishuta, md. department of hospital-based therapy, i.m. sechenov first moscow state medical university (sechenov university), sklifosovsky institute for clinical medicine, 18-2 trubetskaya str., moscow 119991, russian federation. email: abstract left ventricular pseudoaneurysm is a rare but dangerous complication, which occurs in the early post myocardial infarction period. small pseudoaneurysms are not fatal, while large ones cause death due to sudden rupture and cardiac tamponade if surgery is not performed on time. as left ventricular pseudoaneurysm is uncommon in population, only few case reports were found in the published literature. in this article, we present a case of left ventricular pseudoaneurysm in a 79-year-old female patient after a silent posterolateral myocardial infarction, which increased to gigantic size for 3 months and was diagnosed accidentally by transthoracic echocardiography. since the patient refused surgical treatment, the difficulties in deciding on the management of the patient based on a review of the literature is described. the main goal of this case is to describe the 6-month survival rate of a 79-year-old female patient with left ventricular pseudoaneurysm after silent posterolateral myocardial infarction despite refusal of surgical treatment and extremely low adherence to drug treatment due to cognitive impairment. key words: left ventricular pseudoaneurysm, echocardiography, diagnosis, prognosis. introduction myocardial ruptures include left ventricular free wall rupture and internal ruptures of interventricular septum and papillary muscles, the latter being the most severe and potentially fatal complications developing in the early post myocardial infarction (mi) period.1-3 some left ventricular free wall ruptures may be subacute, in this case the myocardial rupture is small and sometimes closed by partially thrombosed hematoma “sealed” to the pericardium. it means that the thrombus, hematoma, and pericardium cover the rupture, thus forming a false aneurism or pseudoaneurysm of the left ventricle.2,3 pathologically, in pseudoaneurysm, there is a small narrow canal (isthmus) which connects the left ventricular cavity with a massive aneurysmal sac containing blood, clots, and only pericardial fibrous elements – no myocardial tissue.4 macroscopically, the rupture is linear or arched, with transmural localization, edges are irregular, the site of rupture is jagged.5 left ventricular pseudoaneurysm is a very rare complication of mi2,3 and develop in less than 0.1% of all patients with mi.6 postmortem examination of 303 patients who died of mi revealed no left ventricular pseudoaneurysmrelated deaths.5 it is known, that only small pseudoaneurysms are compatible with life, but with large ones and absence of timely surgical vol 55 • number 1 • january 2023 giant left ventricular pseudoaneurysm in a 79-year-old female patient 71 treatment patients die because of spontaneous rupture and tamponade development.2,3 as a rule, reports in the existing literature describe small left ventricular pseudoaneurysms. in this article, we report a case of a giant left ventricular pseudoaneurysm in a 79-year-old female patient after posterolateral silent mi, who refused surgical treatment. case illustration a 79-year-old patient female was urgently admitted to a cardiology unit with breathlessness on mild exertion, increasing in supine position (at night the patient takes the sitting position), swelling of lower extremities (shins and feet), and weakness. history taking was complicated by patient’s marked cognitive impairments. the patient lived alone and had no relatives. the medical records showed that she had been suffering from arterial hypertension for a long period of time, over the past 3 months her blood pressure persisted but was not higher than 110/70 mm hg. the patient had paroxysmal atrial fibrillation for 5 years. three years ago she suffered an acute cerebrovascular event which triggered progressive memory loss. two years ago, the patient developed angina pectoris iii functional class. coronary angiography findings revealed circumflex artery stenosis, stenting was performed. meanwhile echocardiography showed that local left ventricular contractility was normal. adherence to drug regimen was poor (ramipril, bisoprolol, atorvastatin, clopidogrel, aspirin, warfarin were taken irregularly, dosage instructions were not followed). blood pressure and heart rate were not monitored. the patient noticed the deterioration of her condition 3 months prior to admission, when she suddenly felt weakness when she was at home. then she developed signs of left heart failure (hf) (breathlessness on mild exertion increasing in supine position), and was hospitalized. echocardiography showed the left ventricular wall with depressed myocardial contractility in posterolateral segment, the rupture of the basal segments with forming pseudoaneurysm with size 6.2x2.5 cm, and volume about 62 ml. coronary angiography reveals 70% restenosis in the stent of the circumflex artery. surgical treatment was recommended, but the patient refused it and was discharged with recommendation to add loop diuretic (furosemide, 20 mg and spironolactone, 50 mg on a once-daily basis) to her therapy. over the next three months, the patient’s c o n d i t i o n p r o g r e s s i v e l y d e t e r i o r a t e d ; manifestations of right ventricular heart failure (swollen lower legs and feet) supervened, and she had to be hospitalized. on admission, the patient’s condition is of moderate severity (nyha class iii); due to shortness of breath, she is lying with the head of the bed raised. the respiratory rate is 24 per minute. auscultation revealed weak breath sounds, moist rales over the lower lateral divisions of the lungs on both sides. heart sounds are muffled; the rhythm is regular; systolic murmur is heard at the apex and at the base of the xiphoid process of the sternum, diastolic murmur at the left lower sternal border (3rd-4th intercostal space). the heart rate is 92 bpm. bp is 100/70 mmhg. the abdomen is soft and non-tender. the liver is enlarged and 3 cm below the costal margin, tender on palpation. swollen thighs, shins, and feet. complete blood count and basic metabolic panel revealed no significant changes. however, nt-probnp was increased to 2450 pg/ml, serum creatinine was increased to 140 μmol/l. electrocardiogram (ecg) showed scarring of posterolateral wall. (figure 1) chest x-ray showed signs of venous congestion and left-sided hydrothorax (figure 2 a,b). two-dimensional echocardiography findings revealed dyskinesia of the basal posterolateral and mid posterolateral left ventricular segments, hypokinesia of the lower basal and mid segments of the left ventricular, and hypokinesia of its anterolateral basal and mid segments. at the basal level of the posterolateral wall, there is a defect (wall rupture) up to 1.9 cm, communicating with a cavity with size 6.1x9.4 cm, volume about 315 ml. (pseudoaneurysm). the cavity of pseudoaneurysm demonstrates spontaneous echo contrast and mural thrombi (figure 3a, b). colour doppler echocardiography showed blood flow pattern “to-and-fro” between two cavities: circulation from the left ventricular through the isthmus to the cavity of pseudoaneurysm and nina solomakhina acta med indones-indones j intern med 72 figure 1. electrocardiogram sinus rhythm. qr waves in leads ii, iii, avf, avl, v5, v6, and symmetric inversion of t wave in leads i, avl, v5 and v6. figure 2. chest x-ray. а. frontal view. b. left lateral view. on the left, there is a homogeneous shadow with an upper indistinct border at the level of rib iv anterior segment (arrow), due to effusion mainly in the anterior sinus. vol 55 • number 1 • january 2023 giant left ventricular pseudoaneurysm in a 79-year-old female patient 73 backflow from the cavity of pseudoaneurysm through the isthmus to the left ventricular cavity (figure 4 a, b). there were also revealed: diastolic dysfunction of the left ventricular of the restrictive type, a decrease in the ejection fraction up to 40%, an increase in pulmonary hypertension up to 55 mm hg, dilation of the inferior vena cava up to 2.3 cm, which collapsed on inspiration less than 50%. colour doppler echocardiography showed moderately severe mitral, aortic and tricuspid regurgitations (figure 5a, b). 7 figure 3. a. echocardiogram in the parasternal long axis view and scheme. thinning and wall rupture – a defect in the posterolateral left ventricular wall (arrow) through which the left ventricular communicates with the pseudoaneurysm. b. echocardiogram in the apical four chamber position and scheme. mural thrombi in the pseudoaneurysm cavity (arrows). figure 4. a. color doppler echocardiography and scheme. in the projection of the defect, the blue flow indicates cardiac shunt from the left ventricular through the isthmus into the pseudoaneurysm cavity (arrow). b. color doppler mapping and scheme. in the projection of the defect, the red flow indicates blood return from the pseudoaneurysm cavity through the isthmus into the left ventricular cavity (arrow). figure 5. a. color doppler echocardiography and scheme. apical five-chamber position. turbulent flow in the left atrium during systole reaching the upper wall of the left atrium. the stream of mitral regurgitation is variegated (arrow). b. colour doppler echocardiography and scheme. apical five-chamber position. turbulent flow in the left ventricular outflow tract and cavity. the stream of aortic regurgitation is colored red (arrow). abbreviations: pseudoaneurysm (pa), left ventricle (lv), right ventricle (rv), left atrium (la), right atrium (ra). nina solomakhina acta med indones-indones j intern med 74 the patient flatly refused to be further examined and operated and was discharged to be followed up by a cardiologist with recommendations to continue drug therapy: ramipril 2.5 mg daily, bisoprolol 5 mg/day, atorvastatin 20 mg qd, rivaroxaban 20 mg, furosemide 20 mg and veroshpiron 50 mg orally on a once-daily basis. however, three months later, the patient died with symptoms of progressive hf up to functional class iy (nyha) in another hospital. discussion i n l e f t v e n t r i c u l a r p s e u d o a n e u r y s m , myocardial rupture develops slowly for several hours or even days7 and progresses from endocardium to pericardium.8 blood continually oozes to the pericardium through a small defect in the left ventricular wall causing local inflammation and “de novo” pericardial adhesions.8 in addition, myocardial rupture may be contained by existing pericardial adhesions.2 the above described mechanism clearly explains how the patient’s posterolateral silent mi resulted in left ventricular pseudoaneurysm, which prevented rapid cardiac tamponade followed by patient’s death. due to lack of medical documentation, the date of mi and how long pseudoaneurysm developed are not known. having studied incomplete medical record of the patient, we suppose that it happened 3 months prior to admission, when being in stable condition, the patient felt worse and developed acute left hf and paroxysmal dyspnea with no previous attacks of angina pectoris, which could prompt her to seek medical attention earlier. the literature describes a case of left ventricular pseudoaneurysm development as a result of transmural mi without preceding angina within 5 months, with hf also being the main clinical manifestation.9 according to the literature, the time interval between mi and the diagnosis of pseudoaneurysm is from 1 to 11 months,8 and the median time from mi to diagnosis of pseudoaneurysm is 3.9 months.10 we also suppose that the initial rupture of the left ventricular wall was small. however, later due to the continuous blood flow to the cavity of pseudoaneurysm, its volume increased to 315 ml. it significantly exceeded volume of the left ventricular, which cavity, due to the constant flow of blood into the pseudoaneurysm cavity decreased to 80 ml. decreased blood flow resulted in spontaneous echo contrast and massive thrombus formations on the aneurysmal sac walls which are the major risks for a thromboembolic event.1,11 based on literature, the most common localization of both left ventricular free wall ruptures, and true left ventricular aneurysms is the anterior wall of the left ventricular.5 this results from frequent atherosclerosis of the left anterior descending artery,1,8 while 78.6 % of left ventricular pseudoaneurysms8 develop in posterolateral mi as a result of circumflex artery thrombosis.7,8,12 an explanation for the greater prevalence of pseudoaneurysms in the posterolateral left ventricular wall, as compared to the anterior wall, is that anterior wall ruptures always have a vivid clinical picture, a fulminant course with the development of tamponade and do not have time to confine themselves to pericardial adhesions.8 furthermore, the patient had the majority of the known risk factors for both, left ventricular rupture – female gender, age over 65, uncontrolled arterial hypertension, history of prior cerebrovascular event, and for pseudoaneurysm – silent posterolateral mi, transmural lesion and the wall thinning at the site of mi.1,7,13,14 clinical manifestations following pseudoaneurysm development were the signs of congestive hf, i.e. were not specific and could not alert the clinicians to possible left ventricular pseudoaneurysm. other authors also pay attention to the non-specificity of clinical manifestations and physical examination data.8,15,16 chest x-ray in terms of exclusion or confirmation of pseudoaneurysm, as in this case, is often not informative (a non-informative method).1,16 it should be noted that the ecg was not very informative either, since with such a gross damage to the left ventricular wall, instead of qr waves in leads ii, iii, avf, avl, v5, and v6, one should expect the presence of qs or qrs, which would confirm transmural damage to the myocardium of the posterolateral left ventricular vol 55 • number 1 • january 2023 giant left ventricular pseudoaneurysm in a 79-year-old female patient 75 wall. other authors also draw attention to the lack of marked ecg changes in the development of left ventricular pseudoaneurysm due to posterolateral mi,12,17 in contrast to anterior left ventricular wall ruptures, which make the ecg highly informative.14 it is obvious that in this case, like in the most cases described in literature, left ventricular pseudoaneurysm was diagnosed accidentally by echocardiography in mi, congestive hf, rhythm disturbances, and thromboembolism.2,8,9,12 therefore nowadays, echocardiography as a widely available, noninvasive and informative diagnostic method has become the method of choice for early diagnosing of left ventricular pseudoaneurysm.1,2,12,13,16,18 of course, in diagnostically complex cases, as well as in preparation for surgery may require the additional carrying out of other, but more expensive, imaging techniques: magnetic resonance imaging, multispiral computed tomography or ventriculography. since left ventricular pseudoaneurysm is a very rare condition, there is no randomized controlled study, to guide a management strategy. the information on surgically treated and untreated left ventricular pseudoaneurysms is not structured, and based on retrospective analysis of single cases.13 no large studies comparing the results of surgical and drug treatment of left ventricular pseudoaneurysms have been conducted. according to the current management s t r a t e g y, p a t i e n t s w i t h l e f t v e n t r i c u l a r pseudoaneurysm require surgical intervention if pseudoaneurysm is large, acute (less than 3 months), and localized in the anterior wall of the left ventricular.1,8,13 unlike true aneurysms, in which the wall is intact but fibrous and thin, the wall of pseudoaneurysms contains only pericardium and thrombus3,4 and no endocardial or myocardial tissue.1,13 it explains a high risk of rupture and tamponade formation, which accounts for 30-45%.3 such ruptures are very unpredictable in terms of onset and development. however, postoperative mortality is also high (35.7%)8 because postoperative outcome is influenced by such factors as stage of hf, mi size, patient’s overall heath and comorbidities. moreover, surgical treatment is not always limited to pseudoaneurysm resection and closure of ventricular defect. some cases require mitral valve replacement or coronary bypass surgery,8 which makes risks of poor outcome even higher. meanwhile, some authors1,10,11,13 believe that poor prognosis for such patients is more likely to be linked to progressive hf and thromboembolic complications, but not to a possible fatal rupture. having observed the patients with pseudoaneurysm for four years, t.c. yeo et al.10 show that not all pseudoaneurysms have a high risk of rupture. varvarigos n. et al.1 suggest that small (up to 3 cm) chronic asymptomatic aneurysms which are not prone to increase may be treated only medically. moreno r. et al.11 think that the long-term prognosis for patients with post mi left ventricular pseudoaneurysms is relatively good, with low risk of fatal ruptures, which should be considered while choosing surgical intervention as the main treatment strategy. díaz-navarro r. and nihoyannopoulos p.18 also it’s believed that despite the fact that surgical treatment is the method of choice to avoid the risk of fatal myocardial rupture, the long-term results of medical treatment of patients with left ventricular pseudoaneurysm appear to be relatively favorable. however, when surgery is an absolute indication but the patient’s prognosis is quite poor, decisionmaking process for a clinician is very difficult and even counter-intuitive, especially if a patient refuses surgery. in published literature, there are cases which describe patients who refused surgical intervention in spite of having absolute indications and bad prognosis, medical treatment remained the only option for them.1,2 it is necessary to note that after diagnosis, such patients were successfully receiving medical treatment for 41 and 2 years,2 their condition being stable. roa-castro v.h. et al.2 suggest that the long survival of such patients is due to dense pericardial adhesions. varvarigos n. et al.1 believe medical therapy to be the only optimal treatment for high-risk patients refusing surgery. hulten e.a. et al.13 also think that for patients with chronic pseudoaneurysm (more than 3 months) who have high risk for surgical intervention “conservative management may be nina solomakhina acta med indones-indones j intern med 76 prudent”. taking into account the above information, the opinions of cardiologists and cardiac surgeons on the management of this patient were divided. those who insisted on surgical treatment argued their position with high risk of pseudoaneurysm rupture and an equally high risk of thromboembolic complications, and those who proposed conservative management of the patient, with extremely high risk of surgical intervention (advanced age, low ejection fraction, presence of severe concomitant pathology: a previous stroke). nevertheless, the patient was offered surgery which she denied (twice, including previous hospitalization). next 3 months, as well as 3 previous months, the patient treatment was conservative. conclusion the case we report proves that left ventricular pseudoaneurysms have non-specific clinical presentation even if they are giant and have a rough wall defect. they are often diagnosed accidentally by echocardiography after the pseudoaneurysm has already been formed. therefore, when examining patients with echocardiography, primarily with congestive heart failure, who have had posterolateral mi, it should be recommended to be alert to exclude left ventricular pseudoaneurysm, especially if the patient is a female, older adults and senile, with arterial hypertension and a history of acute cerebrovascular accident. as the patient with the giant left ventricular pseudoaneurysm, massive thrombi formation, and unsatisfactory compliance to treatment did not develop the two major complications – thromboembolism and wall rupture which could have inevitably led to sudden and rapid death, this case proves that medical treatment can be the method of choice in patients with left ventricular pseudoaneurysm. although the survival period was limited to only 6 months, it could definitely have increased with the patient’s better compliance to treatment. this is especially important for older patients who refuse surgical treatment or for patients with an extremely high risk of surgical treatment, when conservative treatment is forced to become the only method. funding the article was written as part of the employment of the authors by sechenov university. acknowledgments the authors wish to acknowledge the contribution of dmitrii dementev in preparing figures for this article. ethical statement the research work done for preparing rare the clinical case was approved by the interuniversity ethics committee. references 1. varvarigos n, koletsis e, zafiropoulos a, et al. a case of left ventricular pseudoaneurysm with long survival and congestive heart failure as first presentation. case report and review of the literature. med sci monit. 2005;11(11):69-73. pmid: 16258404. 2. roa-castro vh, molina-bello e, valenzuela-suárez h, et al. survival after left ventricular free wall rupture in an elderly woman with acute myocardial infarction treated only medically. case rep vasc med. 2012;2012:728602. doi:10.1155/2012/728602. 3. helmy ta, nicholson wj, lick s, et al contained myocardial rupture: a variant linking complete and incomplete rupture heart. 2005;91:e13. doi:10.1136/ hrt.2004.048082. 4. davies mj. ischaemic ventricular aneurysms: true or false? heart. 1988;60(2):95-97. doi: 10.1136 / hrt.60.2.95 5. rudakova le, rakhmatullov fk, bondarenko la, fatkabrarov mf, fatkabrarova am. retrospective analysis of myocardial rupture cases in patients with acute myocardial infarction. russian j cardiol. 2010;(4):10-14 (in russ.). doi:10.15829/1560-40712010-4. 6. hoey dr, kravitz j, vanderbeek pb, et al. left ventricular pseudoaneurysm causing myocardial i n f a r c t i o n a n d c e r e b r o v a s c u l a r a c c i d e n t . j emerg med. 2005;28(4):431-5. doi:10.1016/j. jemermed.2004.12.013. 7. frances c, romero a, grady d. left ventricular pseudoaneurysm. am coll cardiol. 1998;32(3):557561. doi:10.1016/s0735-1097 (98)00290-3. 8. eren e, bozbuga n, toker me, et al. surgical treatment of post-infarction left ventricular pseudoaneurysm. a two-decade experience. texas heart inst j. 2007;34(1):47-51. pmid: 17420793. 9. kadin r, fellat n, doghmi n, et al. giant left ventricular false aneurysme revealing a silent vol 55 • number 1 • january 2023 giant left ventricular pseudoaneurysm in a 79-year-old female patient 77 myocardial infarction. ann cardiol angeiol (paris). 2020;69(3):144-7 (in french). doi:10.1016/j. ancard.2019.08.014. 10. yeo tc, malouf jf, oh jk, et al. clinical profile and outcome in 52 patients with cardiac pseudoaneurysm. a n n a l s i n t e r n a l m e d i c i n e . 1 9 9 8 ; 1 2 8 ( 4 ) : 2 9 9 . doi:10.7326 / 0003-4819-128-4-199802150-00010. 11. moreno r, gordillo e, zamorano j, et al. long term outcome of patients with postinfarction left ventricular pseudoaneurysm. heart. 2003;89(10):1144-1146. doi:10.1136/heart.89.10.1144. 12. sheikh wr, sehgal p, verma a, et al. left ventricular pseudoaneurysm post myocardial infarction int j crit illn inj sci. 2019;9(1):43-45. doi:10.4103/ijciis. ijciis_42_18. 13. hulten ea, blankstein r. pseudoaneurysms of the heart. circulation. 2012;125(15):1920-1925. doi:10.1161/circulationaha.111.043984. 14. zeltyn-abramov em, radzevich ae. external cardiac breaks in the acute period of myocardial infarction: clinical and instrumental predictors. russian journal of cardiology. 2010;2(82):10-13 (in russ.). doi:10.15829/1560-4071-2010-2. 15. alapati l, chitwood wr, cahill j, et al. left ventricular pseudoaneurysm: a case report and review of the literature. world j clin cases. 2014;2(4):90-93. doi:10.12998/wjcc.v2.i4.90. 16. contuzzi r, gatto l, patti g, et al. giant left ventricular pseudoaneurysm complicating an acute myocardial infarction in patient with previous cardiac surgery: a case report journal of cardiovascular m e d i c i n e . 2 0 0 9 ; 1 0 ( 1 ) : 8 1 4 . d o i : 1 0 . 2 4 5 9 / jcm.0b013e32831a98e6. 17. katkova la, furman nv, dolotovskaya pv, et al. chronic heart failure due to the formation of a giant pseudoaneurysm of the left ventricle after a painless myocardial infarction in a patient with type 2 diabetes. kardiologiia. 2016;56(9):92-6 (in russ.). doi:10.18565/cardio.2016.9.92-96. 18. díaz-navarro r, nihoyannopoulos p. post-myocardial infarction left ventricular pseudoaneurysm diagnosed incidentally by echocardiography. echo res pract. 2017;4(4):k37-k40. doi:10.1530/erp-17-0035. 35 original article acta medica indonesiana the indonesian journal of internal medicine antifungal susceptibility testing in hiv/aids patients: a comparison between automated machine and manual method erni j. nelwan1, evi indrasanti2, robert sinto1, farida nurchaida2, rustadi sosrosumihardjo2 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of clinical pathology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: erni j. nelwan, md. division of tropical and infectious disease, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: ejnelwan@yahoo.com. abstrak tujuan: untuk mengevaluasi kinerja vitek2 compact mesin (biomerieux inc ver 04,02, prancis) mengacu pada metode manual untuk menguji kepekaan ketahanan candida pada pasien hiv/aids. metode: kami melakukan uji perbandingan hasil pemeriksaan sensitifitas obat anti-jamur antara vitek2 compact machine (biomerieux inc. ver 04.02, france) dengan metode manual. kesepakatan kategorik antara hasil pemeriksaan dengan kedua metode tersebut dinilai sesuai dengan kriteria yang telah disepakati. kami juga melakukan pengukuran waktu yang diperlukan untuk mendapatkan hasil dengan menggunakan kedua metode. hasil: terdapat 137 isolat candida yang terdiri atas 8 spesies candida dengan c. albicans dan c. glabrata sebagai spesies yang terbanyak pertama (56,2%) dan kedua (15,3%), secara berturutan. sebanyak 2,6% c. albicans resisten terhadap flukonazol pada pemeriksaan dengan metode manual namun tidak ditemukan resistensi terhadap flukonazol pada pemeriksaan dengan mesin vitek2. seluruh spesies c. krusei resisten terhadap flukonazol pada pemeriksaan dengan kedua metode tersebut. pola resistensi c. glabrata terhadap flukonazol, vorikonazol, amfoterisin b secara berturut sebanyak 52,4%, 23,8%, 23,8% pada pemeriksaan dengan metode manual dibandingkan 9,5%, 9,5%, 4,8% pada mesin vitek2. waktu yang diperlukan untuk mendapatkan hasil uji dengan menggunakan mesin vitek2 lebih singkat dibandingkan metode manual. kesimpulan: terdapat kesepakatan kategorik yang baik antara hasil pemeriksaan dengan metode manual dan mesin vitek2, kecuali pada spesies c. glabrata. waktu yang diperlukan untuk mendapatkan hasil uji dengan menggunakan mesin vitek2 lebih singkat dibandingkan metode manual. kata kunci: uji kepekaan anti-jamur, metode otomatis, metode manual, hiv. abstract aim: to evaluate the performance of vitek2 compact machine (biomerieux inc. ver 04.02, france) in reference to manual methods for susceptibility test for candida resistance among hiv/aids patients. methods: a comparison study to evaluate vitek2 compact machine (biomerieux inc. ver 04.02, france) in reference to manual methods for susceptibility test for candida resistance among hiv/aids patient was done. categorical agreement between manual disc diffusion and vitek2 machine was calculated using predefined criteria. time to susceptibility result for automated and manual methods were measured. results: there were 137 candida isolates comprising eight candida species with c.albicans and c. glabrata as the first (56.2%) erni j. nelwan acta med indones-indones j intern med 36 introduction during the last few decades, fungal infections due to candida species is increasing, mostly among immunocompromised patients including hiv/aids.1 oropharyngeal candidiasis is the most common site of infection with the prevalence of as much as 80-95% in hiv/aids patients.2,3 as a consequence of this, the use of antifungal in this population has also increased. the treatment guidelines for candidiasis include the administration of nystatin, azol derivates such as fluconazole, voriconazole, itraconazole or ketoconazole and amphotericin b. 4 in many cases, candida infection is often treated empirically; this practice may further lead to the frequent use of antifungal drugs in the clinic. there is a need to understand the pattern of susceptibility to antifungal drugs since a decrease of sensitivity to candida species was reported from several studies.3,5 the use of conventional test for drug sensitivity with manual diffusion has already been routinely performed in the clinic. however, this method needs media preparation, antifungal discs and more time consumption for the final result. the availability of a rapidly provided automated method and ready to use media could yield faster results. the vitek2 system (biomérieux inc. ver 04.02, france) is an automated bacterial identification and susceptibility testing system that uses fluorescence-based technology. 6 the availability of vitek2 compact machine (biomerieux) in our institution was used initially to identify bacteria pathogens only. previous studies showed that this system could give reliable identification and susceptibility results with pure bacterial cultures.7-9 a comparison study to evaluate the performance of vitek2 compact machine (biomerieux inc. ver 04.02, france) in reference to manual methods for susceptibility test for candida resistance among hiv/aids patients was done. methods one hundred and thirty seven candida isolates were included in the study. candida species were identified using chromogenic media (chromagar, france). we classified yeast species according to the colour of each colony: green colonies were identified as c. albicans; blue colours were regarded as c. tropicalis, pink and purple as c. krusei, and light white-purple as c. parapsilosis or c. glabrata. purification was conducted according to standard method. (rex, jh-no 38) after being purified, isolates were plated onto sabourraud dextrose agar (sda) for further identification with vitek2 machine (biomerieux inc. ver 04.02, france). vitek2 machine identification was based on biochemical reaction and measured the capacity of using source of carbon, nitrogen and enzymatic activity of vitek2 using yst reagent (biomerieux, france). sensitivity tests with the manual disc method was conducted by measuring the diameter of inhibition zone according to clsi m 44-a2, using three types of antifungal discs, fluconazole 25 µg (oxoid, uk), voriconazole 1 µg (oxoid, uk), and amphotericin 20 µg (liofilchem, italy). for vitek2 machine, sensitivity test was based on turbidimetry using reagent card ast (biomerieux, france) consisted of antifungal such as fluconazole (diluted to 1, 4, 8, 16 mg/l), voriconazole (diluted to 0.5, 1, 4, 8 mg/l) and and second (15.3%) most common species, respectively. for fluconazole drug, among the c. albicans, 2.6% was found resistant on manual disc diffusion methods and no resistant was determined by vitek2 machine; whereas 100% c. krusei was identified as resistant on both methods. resistant patterns for c. glabrata to fluconazole, voriconazole and amphotericin b were 52.4%, 23.8%, 23.8% vs. 9.5%, 9.5%, 4.8% respectively between manual diffusion disc methods and vitek2 machine. time to susceptibility result for automated methods compared to vitex2 machine was shorter for all candida species. conclusion: there is a good categorical agreement between manual disc diffusion and vitek2 machine, except for c. glabrata for measuring the antifungal resistant. time to susceptibility result for automated methods is shorter for all candida species. keywords: antifungal susceptibility test, automated test, hiv, manual test. vol 48 • number 1 • january 2016 antifungal susceptibility testing in hiv/aids patients 37 amphotericin b (diluted to 1, 4, 8, 16 mg/l). categorical agreement was classified as sensitive, intermediate/sdd and resistant after matching two different methods using manual diffusion method as a reference. discordance between two methods was concluded as error in interpretation and categorized as very major error (vme) if found resistant on the automatic methods and sensitive on the manual methods. major error (mae) was concluded if found sensitive on the automatic methods and resistant on the manual methods. minor error (mie) was classified if sdd/i was found in the automatic method while sensitive/resistant in the manual method or the other way around.6 candida albicans atcc 14053 (canada, usa) was used as a quality control (qc) standard strain for identification. c. parapsilosis atcc 22019 (canada, usa) was used as qc for sensitivity test. antifungal disc and card ast for vitek2 were tested with atcc strains for seven times, before the tests were conducted. these procedures were repeated after the tests have been perfomed twenty times. results for identification test, both methods were comparable with control strains c. albicans atcc 14053 (canada, usa) as recommended by clsi m35-a and vitek2 manual. for sensitivity test, vitek2 machine was comparable with c. parapsilosis atcc 22019 (canada, usa). the results were compared by entering data on excel sheets and statistical calculations were made and recorded. there were 137 candida isolates comprising eight candida species with c. albicans as the most common species (56.2%) and c. glabrata as the second most common species (15.3%) (table 1). for evaluation of resistance pattern, the c. famata and c. magnoliae were excluded because vitek2 machine was not designed to detect these species. for fluconazole drug, among the c. albicans, 2.6% was found resistant on manual diffusion methods and no resistant was determined by vitek2; whereas 100% resistant was identified for c. krusei on both methods. resistance pattern for c. glabrata to fluconazole, voriconazole and amphotericin b was (52.4%, table 1. distribution of candida isolates (n=137) species n (%) c. albicans 77 (56.2) c. glabrata 21 (15.3) c. tropicalis 19 (13.9) c. krusei 9 (6.7) c. parapsilosis 5 (3.6) c. dubliniensis 4 (2.9) c. famata 1 (0.76) c. magnolia 1 (0.76) 23.8%, 23.8% vs. 9.5%, 9.5%, 4.8%) between manual disc diffusion method and vitek2 machine. detail on resistance pattern was shown in table 2. error interpretation between manual diffusion and vitek2 for 77 isolates of c. albicans to fluconazole found four (5.2%) mie and three (3.8%) mae; 3 (3.8%) mae and 3 (3.8%) mie to voriconazole and one (1.2%) vme to amphotericin b. total categorical agreement for c. albicans to fluconazole, voriconazole and amphotericin b was 90.9%, 92.2% and 98.7% respectively. for c. glabrata error interpretation among 21 isolates to fluconazole 9 (42.8%) mie and 8 (38.1%) mae, voriconazole 5 (23.8%) mae and 1 (4.7%) mie; to amphotericin b 2 (9.5%) mae and 2 (2.9%) mie. total categorical agreement for c. glabrata to fluconazole, voriconazole and amphotericin b was 19.1%, 71.4% and 80.9%. of 19 isolates of c. tropicalis error interpretation to fluconazole and voriconazole 1 (5.26%) mie and 1 (5.26%) mae and 1 (5.26%) mie and 2 (10.5%) mie for amphotericin b. total categorical agreement was 89.5% for each studied drugs. the five isolates of c. parapsilosis for error interpretation resulted in 1 (20%) mie only for amphotericin b, hence resulted in total categorical agreement of 100% for fluconazole, 100% for voriconazole and 80% for amphotericin b. among the 4 isolates of c. dubliniensis the error interpretation was found 1 (25%) mie to fluconazole only with total categorical agreement of 75% to fluconazole, 100% to voriconazole and 100% to amphotericin b. total error interpretation to all candida species between manual disc diffusion and vitek2 for fluconazole showed no vme, 8.89% erni j. nelwan acta med indones-indones j intern med 38 mae and 11.11% mie. voriconazole reported no vme, 6.67% mae and 4.44% mie. among the amphotericin b 1.46% vme, 2.22% mae and 5.18% mie were found (figure 1). time to susceptibility result for manual method was 24 h for c. albicans, c. dubliniensis and c. tropicalis; and 48 hours for c. glabrata, c. krusei and c. parapsilosis. using vitek2, the average time to susceptibility result for c. albicans was 13.25 hours, c. glabrata 12.75 h, c. dubliniensis 14.75, c. tropicalis 12.25 h, c. parapsilosis 16.75 h, and c. krusei 18.75 h. discussion the majority of candida species that were included in our study was c. albicans, in resemblance with other reports of epidemiology of candida infection in hiv/aids patients.5,10,11 the cathegorical agreement between two methods as presented in table 2 showed that there was no vme for fluconazole and voriconazole. very major error for amphotericin b was 1.46%, lower than the acceptable threshold allowed by fda, i.e. 1.5%. major errors for fluconazole, voriconazole and amphotericin b were 8.89%, 6.67%, 2.22% respectively. only amphotericin b met the fda acceptable threshold for major error, i.e. 3%. in addition, the minor errors for fluconazole, voriconazole and amphotericin b were 11.11%, 4.44%, 5.18%, respectively. only voriconazole met the fda acceptable threshold for minor error, i.e. 5%. there was a good categorical agreement between manual disc diffusion and vitek2, except for c. glabrata (table 3). this good figure 1. total error interpretation (%) to all candida species between manual disc diffusion and vitek2 table 2. error and categorical agreement of manual diffusion and vitek2 machine candida species antifungal resistant (%) vme mae mie ca (%)vitek2 machine manual diffusion s i/sdd r s i/sdd r c. albicans (77) fca 97.4 2.6 0 94.8 2.6 2.6 0 3 4 90.9 vor 97.4 1.3 1.3 96.1 1.3 2.6 0 3 3 92.2 amb 97.4 0 2.6 100 0 0 1 0 0 98.7 c. glabrata (21) fca 80.9 9.5 9.5 14.3 33.3 52.4 0 8 9 19.1 vor 90.5 0 9.5 66.7 9.5 23.8 0 5 1 71.4 amb 90.5 4.8 4.8 56.7 19.5 23.8 0 2 2 81 c. tropicalis (19) fca 100 0 0 89.5 5.3 5.3 0 1 1 89.5 vor 100 0 0 89.5 5.3 5.3 0 1 1 89.5 amb 100 0 0 94.7 0 5.3 0 0 2 89.5 c. krusei (9) fca 0 0 100 0 0 100 0 0 0 100 vor 100 0 0 88.9 11.1 0 0 0 1 88.9 amb 66.7 22.2 11.1 44.4 44.4 11.1 1 1 2 55.6 c. parapsilosis (5) fca 100 0 0 100 0 0 0 0 0 100 vor 100 0 0 100 0 0 0 0 0 100 amb 80 20 0 80 0 20 0 0 1 80 c. dubliniensis (4) fca 100 0 0 75 25 0 0 0 1 75 vor 100 0 0 100 0 0 0 0 0 100 amb 75 25 0 75 25 0 0 0 0 100 vme = very major error; mae = major error; mie = minor error; ca = categorical agreement; s = sensitive; i/sdd = intermediate/ susceptible dose dependent; r = resistant; fca = fluconazole; vor = voriconazole; amb = amphotericin b vol 48 • number 1 • january 2016 antifungal susceptibility testing in hiv/aids patients 39 table 3. categorical agreement for c. albicans of manual diffusion and vitek2 machine in other studies. study no. of isolate antifungal methods resistance (%) ca (%) population pfaller, 200712 198 fca vitek2 1.5 all candida specimens bmd 1.5 99.5 vor vitek2 1.5 bmd 1.5 99 bargoeis, 200913 84 fca vitek2 1.2 microdilution clsi 1.2 100 candidemia etest 1.2 100 vor vitek2 0 bmd 0 100 etest 0 100 ca = categorical agreement; fca = fluconazole; vor = voriconazole; amb = amphotericin b; bmd = broth microdilution; clsi = clinical & laboratory standards institute table 4. categorical agreement for c. glabrata of manual diffusion and vitek2 machine in other studies study no. of isolate antifungal methods ca (%) population pfaller, 200314 235 fca bmd all candida specimensetest (48 hours) 52.3 manual disk (24 hours) 64.7 vor bmd etest (48 hours) 94.8 manual disk (24 hours) 97.4 alexander, 200715 38 fca bmd candidemia etest (24 hours) 55 sensititre 34 vor bmd etest (24 hours) 76 sensititre 87 bourgeois, 200913 56 fca vitek2 candidemia microdilution clsi 78.6 etest (48 hours) 23.2 vor vitek2 microdilution clsi 87.5 etest (48 hours) 51.8 ca = categorical agreement; fca = fluconazole; vor = voriconazole; amb = amphotericin b; bmd = broth microdilution; clsi = clinical & laboratory standards institute categorical agreement for c. albicans species and fair categorical agreement for c. glabrata were similar with the result from previous studies as shown in table 4. the major contributors of categorical disagreement for c. glabrata were mae and mie, with no vme. from the previous studies, the hypothesis for c. glabrata categorical disagreement was the presence of heteroresistance or selection within the specimen which further resulted in the presence of subpopulation resistance of the less sensitive group.12-14 the latter will be found as a less clear zone during manual disc diffusion technical examination. the manual disc diffusion test could provide more accurate results for measuring resistance in homogeneous specimen erni j. nelwan acta med indones-indones j intern med 40 of c. glabrata.15 using microdilution principles, vitek2 provides antifungal and microcuvet in one ready-used kit. resistance test can be done easily because the reagent and media have been standardized by the manufacturer. a lot of samples can be tested at a single time point; thus with a shorter time to susceptibility result compared with standard method; this method is suitable to be used in laboratory with high workload. however, this is not the fastest method available for having timely result.16 apart from the advantages in terms of cost analysis and applicability, manual method needs a meticulous expertise, especially in the interpretation of less clear zone during examination. conclusion the result of this study can be used as a scientific justification for clinicians to perform antifungal specificity test for the majority of candida species in hiv/aids patients with automated method (vitek2), except for c. glabrata, due to its good categorical agreement compared to manual method. references 1. l o c h a r t s r , d i e k e m a d j , p f a l l e r m a . t h e epidemiology of fungal infection. clinical mycology. churchill livingstone: elsevier; 2009. p. 1-12. 2. tong k, murtagh k, lau c, selfeldin r. the impact of esophageal candidiasis on hospital charges and costs across patient subgroups. curr med res. 2008;24:16774. 3. enwuru ca, ogunledun a, idika n, et al. fluconazole resistant opportunistic oro-pharyngeal candida and non-candida yeast-like isolates from hiv infected patients attending arv clinics in lagos, nigeria. african health sciences. 2008;8:142-8. 4. pappas pg, rex kh, sobel jd, et al. guidelines for treatment of candidiasis. clin infect dis. 2004;38:16189. 5. badiee p, alborzi a, davarpanah ma, shakiba e. distributions and antifungal susceptibility of candida species from mucosal sites in hiv positive patients. arch iran med. 2010;13:282-7. 6. pfaller ma, diekema dj, procop gw, rinaldi mg. multicenter comparison of the vitek2 antifungal susceptibility test with the clsi broth microdilution reference method for testing amphotericin b, flucytosine, and voriconazole against candida spp. j clin microbiol. 2007;45:3522-8. 7. barry al, pfaller ma, brown sd, et al. quality control limits for broth microdilution susceptibility tests of ten antifungal agents. j clin microbiol. 2000;28:3457–9. 8. chen yc, chang sc, luh kt, hsieh wc. stable susceptibility of candida bloodstream isolates to fluconazole despite increasing use during the past 10 years. j antimicrob chemother. 2002;52:71–7. 9. espinel-ingroff a, barchiesi f, cuenca-estrella c, et al. comparison of visual 24-hour and spectrophotometric 48-hour mics to clsi reference microdilution mics of fluconazole, itraconazole, posaconazole, and voriconazole for candida spp.: a collaborative study. j clin microbiol. 2005;43:4535–40. 10. magaldi s, mata s, hartung c, verde g, deibis l, roldan y. in vitro susceptibility of 137 candida sp. isolates from hiv positive patient to several antiungal drugs. mycopathologia. 2000;149:63-8. 11. hamza ojm, matee min, moshi mj, simon enm, mugusi f, mikx fhm. species distribution in vitro antifungal susceptibility of oral yeast isolates from tanzanian hiv infected patient with primary and recurrent oropharyngeal candidiasis. bmc microbiol. 2008;8:1-9. 12. pfaller ma, diekema dj, gibbs dl, et al. results f r o m t h e a rt e m i s d i s k g l o b a l a n t i f u n g a l surveillance study, 1997 to 2005: an 8.5-year analysis of susceptibilities of candida species and other yeast species to fluconazole and voriconazole determined by clsi standardized disk diffusion testing. j clin microbiol. 2007;45:1735-45. 13. bourgeois n, dehandschoewercker l, bertout s, bousquet pj, rispail p, lachaud l. antifungal susceptibility of 205 candida spp. isolated primarily during invasive candidiasis and comparison of the vitek2 system with the clsi broth microdilution and etest methods. j clin microbiol. 2010;48:154–61. 14. pfaller ma, diekema dj, boyken l, messer sa, tendolkar s, hollis rj. evaluation of the etest and disk diffusion methods for determining susceptibilities of 235 bloodstream isolates of candida glabrata to fluconazole and voriconazole. j clin microbiol. 2003;41:1875–80. 15. alexander bd, byrne tc, smith kl, hanson ke, anstrom kj. comparative evaluation of etest and sensititre yeast one panels against the clinical and laboratory standards institute m27-a2 reference broth microdilution method for testing candida susceptibility to seven antifungal agents. j clin microbiol. 2007;45:698–6. 16. junkinsa ad, arbefeville ss, howard wj, richter ss. comparison of bd phoenix ap workflow with vitek2. j clin microbiol. 2010:48;1929-31. 254 acta med indones indones j intern med • vol 53 • number 3 • july 2021 original article abstrak latar belakang: sklerosis sistemik (ssc) merupakan penyakit autoimun sistemik yang mengenai jaringan ikat multisistem dan salah satu penyebab terjadinya interstitial lung disease (ild). modified rodnan’s skin score (mrss) merupakan pemeriksaan standar baku emas yang bersifat semikuantitatif, non-invasif untuk mengukur fibrosis kulit pada ssc. kelainan fibrosis paru pada ssc terutama berbentuk ild merupakan penyebab mortalitas terbanyak dan seringkali terlambat dalam diagnosis. pemeriksaan baku emas untuk menilai morfologi ild adalah dengan high resolution computed tomogaphy (hrct) scan thoraks, namun ketersediaannya masih sangat terbatas. derajat fibrosis kulit berdasarkan mrss pada ssc dapat memprediksi adanya ild pada beberapa penelitian, namun belum banyak diteliti di indonesia. tujuan penelitian ini untuk mengetahui hubungan morfologi ild berdasarkan hrct scan thoraks dengan derajat fibrosis kulit berdasarkan mrss pada sklerosis sistemik. metode: penelitian ini merupakan penelitian observasional analitik retrospektif dengan desain cross sectional. subjek penelitian ini adalah pasien sklerosis sistemik yang memiliki data hasil pemeriksaan mrss dan hrct scan thoraks sejak juli 2019 hingga maret 2020. analisis statistik yang menggunakan uji korelasi spearman’s. hasil: terdapat 42 subjek penelitian, terdiri dari 41 perempuan (97.6%) dan satu laki-laki (2.4%) dengan rerata usia 41.29±12.045 tahun dengan rentang usia dari 19 tahun hingga 60 tahun. hasil uji korelasi berdasarkan spearman’s terdapat korelasi sedang dengan r= 0,429 yang bermakna (p = 0.005) antara skor morfologi ild dengan nilai mrss. kesimpulan: terdapat korelasi sedang yang bermakna antara skor morfologi interstitial lung disease berdasarkan hrct thoraks dengan derajat fibrosis kulit berdasarkan modified rodnan’s skin score pada sklerosis sistemik. kata kunci: high-resolution computed tomography chest, interstitial lung disease, modified rodnan’s skin score, sklerosis sistemik. abstract background: systemic sclerosis (ssc) is a systemic autoimmune disease multiorgan/multisystem involvement. modified rodnan’s skin score (mrss) is a gold standard for measuring skin fibrosis in c o r r e l a t i o n b e t w e e n i n t e r s t i t i a l l u n g d i s e a s e morphology scores based on high-resolution computed tomography chest and skin fibrosis degree based on modified rodnan’s skin score on systemic sclerosis irma hassan hikmat1, suci s. ramdhini1, hari soekersi1, sumartini dewi2,3 1 department of radiology, faculty of medicine, universitas padjadjaran, hasan sadikin hospital, bandung, indonesia. 2 division of rheumatology, department of internal medicine, hasan sadikin hospital, bandung, indonesia. 3 immunology study center, faculty of medicine, universitas padjadjaran, bandung, indonesia. corresponding author: sumartini dewi, md. division of rheumatology, department of internal medicine, immunology study center, faculty of medicine, universitas padjadjaran. jl. eijkman no. 38, bandung 40161, indonesia. email: sumartini.dewi@unpad.ac.id vol 53 • number 3 • july 2021 correlation between interstial lung disease morphology scores 255 introduction systemic sclerosis (ssc) is a systemic autoimmune disease affecting multisystem connective tissue and one of the causes of interstitial lung disease (ild).1,2 the number of patients with systemic sclerosis continues to increase and has the potential for increased morbidity and mortality due to visceral organ fibrosis.3,4 data on the incidence and prevalence of systemic sclerosis in indonesia are not yet available. however, the number continues to increase and has the potential to become a severe and life-threatening disease. systemic sclerosis is the third most common disease in rheumatology polyclinic of rsup dr. hasan sadikin bandung, after systemic lupus erythematosus (sle) and rheumatoid arthritis (ra). in 2019, there were 100 systemic sclerosis patients (7%) of the total patients visiting the rheumatology polyclinic. the survey was conducted in 2015 2016 by the rheumatology division, department of internal medicine, faculty of medicine, padjadjaran university (unpad) bandung at dr. hasan sadikin bandung, and there were 24 (42.1%) patients who had involvement of pulmonary fibrosis.1,3 in ssc, lung involvement may include pulmonary fibrosis or a groundglass opacity image on a high-resolution computed tomography (hrct) chest scan with a forced vital capacity (fvc) value of less than 80% and a forced expiratory volume/fvc ratio of more than 80%.5,6 ild is the leading cause of morbidity and mortality in systemic sclerosis patients up to 40% within ten years after disease onset.7 matsuda et al.5 in 2019 stated that there is an association between mrss and organ involvement; higher mrss significantly increased the prevalence of ssc-related ild. a study by deepa et al.6 in india in 2016 revealed that rodnan’s score was significantly associated with severe lung involvement. likewise, a study by cottrell et al.7 in 2014 mentioned that the incidence of moderate to severe restrictive lung disease (rld) was associated with an increase in skin sclerosis scores. these evidences refer that mrss (modified rodnan’s skin score) can be used as an alternative marker of lung involvement in systemic sclerosis. mrss is a semi-quantitative, non-invasive gold standard examination to measure skin fibrosis in ssc. in ssc, pulmonary fibrosis disorder, especially ild, is the most common cause of mortality and lattermost diagnosed. chest x-ray is not specific for ild. the gold standard examination for assessing ild morphology is the high-resolution computed tomography (hrct) chest scan, but its availability is still very limited. the degree of skin fibrosis based on mrss on ssc can predict the presence of ild shown in ssc. in ssc, lung fibrosis disorders, especially interstitial lung disease (ild), are the leading cause of mortality and often late in diagnosis. high-resolution computed tomography (hrct) chest scan is a gold standard for evaluating ild morphology, but its availability is limited. the degree of skin fibrosis based on mrss in ssc can predict the presence of ild in several studies but has not been widely studied in indonesia. this study aimed to determine the relationship of the ild morphology based on thoracic hrct scan with the degree of skin fibrosis based on mrss in ssc. methods: this study is a retrospective analytic observational study with a cross-sectional design. the subjects of this study are ssc patients who had data of mrss and hrct chest scan from july 2019 to march 2020. statistical analysis uses spearman’s correlation test. results: there were 42 study subjects, consisting of 41 women (97.6%) and one man (2.4%) with an average age of 39.50 years old (age range of 19 years to 60 years old). correlation test results based on spearman’s show a moderate correlation between the morphological score of ild with mrss with r = 0.429, which is significant (p = 0.005). conclusion: there is a significant moderate correlation between the morphological scores of ild based on hrct chest and the degree of skin fibrosis based on mrss in ssc. keywords: high-resolution computed tomography chest, interstitial lung disease, modified rodnan’s skin score, systemic sclerosis. irma hassan hikmat acta med indones-indones j intern med 256 several studies, but it has not been widely studied in indonesia. research on the morphological relationship between ild and mrss has never been conducted in indonesia. it is expected that this study would increase the evidence regarding mrss scoring to predict the presence of ild; hence the management of complications of systemic sclerosis will be more effective. methods this research is an observational analytic correlation study with a cross-sectional model, using retrospective data. this study measures the relationship between risk factors and their outcome. the risk factors and outcomes were observed once and at the same time. the subjects of this study were systemic sclerosis patients who met the 2013 acr/eular criteria and visited the rheumatology department of internal medicine at dr. hasan sadikin bandung from july 2019 to march 2020. this study has received ethical approval from the research ethics committee of the faculty of medicine, padjadjaran university, and dr. hasan sadikin bandung with a letter of ethics number lb.02.01/x.65/73/2020. subjects the inclusion criteria for the subjects of this study were subjects aged 18-60 years old diagnosed with systemic sclerosis, who have completed data on the degree of skin fibrosis based on mrss and spirometry results of restrictive lung abnormalities. subjects with restrictive lung disease due to autoimmune diseases other than systemic sclerosis and subject with tuberculosis and malignancy were excluded from our study. mrss and ild evaluation the range of mrss values is 0 51. the standard value is achieved by transforming mrss values into an interval scale with the following formula: transformation value 100 = (actual value lowest actual value)/value range x 100. the hrct chest examinations utilize t h e m u l t i d e t e c t o r c t / m d c t 1 2 8 s l i c e (hitachi scenaria se-128 –slice, hitachi healthcare), which produce digital imaging and communication in medicine (dicom) data. the ild morphological score was obtained from the analysis of hrct imaging based on the warrick semi-quantitative method. the total score based on the parenchymal lesion pathology and the extent of the lesion ranged from 0 to 30.45.54. degree of severity include mild (<8), moderate (8-15), and severe (> 15). statistical analysis statistical analysis was conducted to assess the correlation between the ild morphological score based on chest hrct and the pulmonary fibrosis score based on mrss on systemic sclerosis patients. spearmen correlation was used to determine the correlation between numerical and ordinal data. interpretation of hypothesis test results was based on correlation strength, correlation direction, and p-value: correlation strength (r) based on guillford’s criterion (1956): 0.0 <0.2 = very weak; 0.2 <0.4 = weak; 0.4 <0.7 = moderate; 0.7 <0.9 = strong; 0.9 -1.0 = very strong. results the study subjects were 42 patients who met the inclusion and exclusion criteria as described in figure 1. subject diagnosed with systemic sclerosis and have completed data on mrss and restrictive lung abnormalities (n=43) one subject was older than 60 year old (n=1) subject met inclusion and exclusion criteria (n=42) assesment of skin fibrosis (mrss) and ild score based on hrct thorax data analysis figure 1. patient flow chart. table 1 shows a total of 42 study subjects consisting of 41 women (97.6%) and one male (2.4%) with an average age of 39.5 years old and age range of 19 to 60 years old. the median duration of disease was three years with the range from 1 to 13 years. most initial symptoms were presented as skin fibrosis in vol 53 • number 3 • july 2021 correlation between interstial lung disease morphology scores 257 38 (90.5%) subjects. previous chest x-ray results were normal in 23 (55%) subjects, bronchopneumonia in 9 (21.4%) subjects, and bronchitis in 3 (7.1%) subjects, respectively. only one (2.4%) patient was described as ild. after hrct chest was performed, the ground glass opacities were found in all study subjects, septal or subpleural lines in 40 (95.2%) subjects, irregular pleural margins in 32 (76.2%) subjects, honeycombing in 23 (54.8%) subjects, and subpleural cysts in 19 (45.2%) subjects. table 2 shows an overview of the ild m o r p h o l o g i c a l s c o r e , i l d , a n d m r s s morphological categories. the ild morphological score has a median of 18.00 with a range of 6.0027.00, consisting of 4 (9.5%) mild subjects, 11 (26.2%) moderate) subjects and 27 (64.3%) severe subjects. mrss has a mean of 18.93 (sd 8.247). table 2. ild morphological score, ild and mrss morphological categories. variables n=42 ild morphological score median 18.00 range (min-max) 6.00-27.00 ild morphological category, n (%) mild 4 (9.5) moderate 11 (26.2) severe 27 (64.3) mrss mean (sd) 18.93 (8.247) note: categorical data are presented with number/ frequency and percentage, while numeric data are presented with mean, median, standard deviation, and range. table 3. analysis of the correlation between ild morphological score and mrss variables correlation r p-value correlation between skor morphological ild score and mrss value spearman 0.429 0.005** note: p-value significance <0.05. sign ** indicates statistically significant or significant a. r: correlation coefficient. table 3 shows the spearman’s correlation test between the ild morphological score and mrss obtaining a p-value of 0.005 (p-value <0.05) and an r-value of 0.429 (guilford’s criteria). r-value > 0.40 (<0.70) indicates a moderate correlation between the ild morphological score and the mrss score. mrss value towards ild morphological score shows a positive trend (figure 2), which is explained by an increase in the mrss value yet followed by an increase of ild morphological score. discussion the results of this study show that the female distribution was more than male, i.e. 41 (97.6%) women and one (2.4%) man, with the median age of 39.5 years old. this is consistent with research by vinent et al, denton et al. and budiman et al. stating that systemic sclerosis patients are dominated by women compared to male patients, with the most frequent range in patients at age 25-55 years.1-3 table 1. subject characteristic. variables n=42 sex, n (%) male 1(2.4) female 41(97.6) age median 39.50 range (min-max) 19.00-60.00 duration of disease (years) median 3.00 range (min-max) 1.00-13.00 initial symptoms, n (%) skin fibrosis 38 (90.5) raynaud’s phenomenon 4 (9.5) chest x-ray, n (%) normal 23 (54.8) bronchopneumonia 9 (21.4) bronchitis 3 (7.1) pneumonia 2 (4.8) inactive pulmonary tb 2 (4.8) pleura thickening 1 (2.4) active pulmonary tb 1 (2.4) interstitial lung disease 1 (2.4) morphology of ild, n (%) ground glass opacities 42 (100) irregular pleural margin 32 (76.2) septal or subpleural lines 40 (95.2) honeycombing 23 (54.8) subpleural cyst 19 (45.2) note: categorical data are presented with number/ frequency and percentage, while numeric data are presented with mean, median, standard deviation, and range. irma hassan hikmat acta med indones-indones j intern med 258 chest x-ray examination obtained normal results in 23 (55%) study subjects, whereas the others (45%) suggested bronchopneumonia disorders, bronchitis features, pneumonia, old pulmonary tuberculosis, pleural thickening, active pulmonary tuberculosis, and ild. in ssc, patients with early symptoms of pulmonary involvement may have normal chest x-rays, but this does not eliminate the possibility of ild. the ground-glass image is predominantly found in the basal lung area and can only be assessed in 25-44% of ssc patients.8,9 this chest x-rays imaging was described previously as bronchopneumonia, bronchitis, pneumonia, and pulmonary tuberculosis. in this study, all subjects with the mild to severe category had ground-glass opacities m o r p h o l o g y b e c a u s e o f i n c r e a s e d l u n g attenuation. this is consistent with research by deepa et al. in 2016 in the italian population, explaining that the initial changes of the ild process were alveolitis which featured ground-glass opacity, septal/subpleural lines, and irregular pleural margins as a result of the thickening of the interstitial intralobular tissue. the subsequent process is fibrosis which gives a honeycombing and subpleural cyst morphology. histologically, ild in ssc includes non-specific interstitial pneumonia (nsip) with more inflammatory features and less fibrosis, usual interstitial pneumonia (uip) characterized by fibrosis and scarring, as well as a combination of both.6,10,11,12 in addition, table 4 explains the value of the mrss with a mean of 18.93 (sd 8.247), where is different from the research by by matsuda et al.5 with a mean of 9.9 (sd 8.9) and deepa et al.6 with a mean of 29.9 (sd 7.13). correlation between ild morphological score and mrss value. our study revealed that there was a moderately significant correlation between ild morphological scores based on chest hrct and the degree of skin fibrosis based on mrss. our results are in line with matsuda et al.5 in 2019 in the japanese population that stated higher mrss was associated with the presence of ild in ssc (p <0.05). deepa et al.6 in 2016 in the indian population stated that rodnan’s score was significantly associated with severe lung involvement (p = 0.031). cottrell et al.7 in 2014 showed that in the united states population patients with higher skin fibrosis scores may develop to moderate to severe restrictive pulmonary involvement (p <0.001). the strong correlation between skin fibrosis and pulmonary fibrosis as ild in ssc patients may be affected by similarities in the pathophysiology of skin and lung involvement in ssc, namely the presence of inflammatory cell invasion in the early stages and proliferation accompanied by degeneration of collagen fibers in the late stages of the disease.8 a similar study by wu et al.13 in 2018 used a large european scleroderma trial and research (eustar) database, multicenter and prospective study to assess the association of increased skin fibrosis with organ involvement and increased mortality in diffuse ssc patients. figure 2. correlation between ild morphological score and mrss value. 0 10 20 30 40 50 0 5 10 15 20 25 30 m r ss score of morfologi ild vol 53 • number 3 • july 2021 correlation between interstial lung disease morphology scores 259 out of 1021 subjects, 78 subjects had increased skin fibrosis within one year of observation. the study found that the increase in skin fibrosis in one year was associated with decreased lung function (p = 0.004) and a worse survival rate (p = 0.063); hence it can be confirmed that mrss is an alternative marker for diffuse ssc.13 a study by wangkaew et al.14 in 2016 in the thai population showed a correlation between changes in hrct and changes in clinical variables such as fvc, mrss, erythrocyte sedimentation rate (esr), and changes & spo2 in the early phase of ssc patients. on the other hand, a study by yani et al.15 in 2019 concluded there is no correlation between serum krebs von den lungen (kl-6) levels with fvc and mrss value of subjects with both restrictive lung disease and diffuse type systemic sclerosis. the kl-6 is a serum biomarker that is produced by alveolar pneumocytes whenever there is a fibrogenesis activity in the lungs. this study used the cohort method involving 31 subjects who underwent hrct chest examination at the beginning and observation for the next 12 months, then calculated the hrct score based on ild morphology. the hrct score was found to be a useful and sensitive method for assessing disease progression in ssc-related ilds (r = −0.38, p <0.05). however, our study did not reflect the initial incidence of ild in ssc patients. ssc patients who were sent for hrct scan with suspected ild were already undergoing modification therapy for anti rheumatic drugs (dmard)/ conventional immunosuppressants with different doses and duration of therapy. there was no initial data on the chest hrct examination when the patient was diagnosed with ssc; therefore, the chest hrct examination during the study did not reflect the changes that occurred. further cohort research with the completed hrct dan mrss baseline data is required in ssc patients for early detection of ild and evaluating changes over a period of time. conclusion t h e r e w a s a m o d e r a t e l y s i g n i f i c a n t correlation between the ild morphological score based on hrct chest and the degree of skin fibrosis based on modified rodnan’s skin score on systemic sclerosis. acknowledgments ih, ss, hs, and sd conceived and designed the study. ss acquired the data. all authors contributed to the writing of the manuscript. this study was funded by universitas padjadjaran internal grant. references 1. vincent v, dewi s, wachjudi r. correlation between serum procollagen type 1 n-terminal propeptide level with modified rodnan’s skin score in systemic sclerosis patients. indonesian journal of rheumatology. 2018;9. 2. denton c, khanna d. systemic sclerosis. www. thelancet.com. 2017;390. 3. budiman a, dewi s, prananta m. clinical manifestation and laboratory finding of sclerosis systemic patient in dr. hasan sadikin general hospital bandung a descriptive quantitative study. indonesian journal of rheumatology. 2018;10(1). 4. domsic rt, rodriguez-reyna t, lucas m, fertig n, medsger ta, jr. skin thickness progression rate: a predictor of mortality and early internal organ involvement in diffuse scleroderma. ann rheum dis. 2011 jan;70(1):104-9. 5. matsuda km, yoshizaki a, kuzumi a, fukasawa t, ebata s, miura s, et al. skin thickness score as a surrogate marker of organ involvements in systemic sclerosis: a retrospective observational study. arthritis res ther. 2019 may 28;21(1):129. 6. deepa as, rachel rp, ramchandran p, devaraj u, arnold sa, shobha v, et al. pulmonary involvement in systemic sclerosis: a clinical profile. lung india. 2016 mar-apr;33(2):144-7. 7. cottrell t, robert a wise, wigley frm, boin3 f. the degree of skin involvement identifies distinct lung disease outcomes and survival in systemic sclerosis. ann rheum dis 2014. 2014;73:1060–1066. 8. peroš-golubičić t. scleroderma and lung. interstitial lung disease (clinical focus). jaypee brothers medical publishers; 2011 9. strollo d, goldin j. imaging lung disease in systemic sclerosis. current rheumatology reports. 2010;12(2):156-61. 10. caron m, hoa s, hudson m, schwartzman k, steele r. pulmonary function tests as outcomes for systemic sclerosis interstitial lung disease. european respiratory review. 2018;27(148):170102. 11. veraldi kl, hsu e, feghali-bostwick ca. pathogenesis of pulmonary fibrosis in systemic sclerosis: lessons from interstitial lung disease. current rheumatology reports. 2010;12(1):19-25. irma hassan hikmat acta med indones-indones j intern med 260 12. hussein k, shaaban lh, mohamed e. correlation of high-resolution ct patterns with pulmonary function tests in patients with interstitial lung diseases. egyptian journal of chest diseases and tuberculosis. 2016;65(3):681-8. 13. wu w, jordan s, graf n, de oliveira pena j, curran j, allanore y, et al. progressive skin fibrosis is associated with a decline in lung function and worse survival in patients with diffuse cutaneous systemic sclerosis in the european scleroderma trials and research (eustar) cohort. ann rheum dis. 2019 may;78(5):648-56. 14. wangkaew s, euathrongchit j, wattanawittawas p, kasitanon n. correlation of delta high-resolution computed tomography (hrct) score with delta clinical variables in early systemic sclerosis (ssc) patients. quant imaging med surg. 2016 aug;6(4):38190. 15. yani h, dewi s, rahmadi ar. correlation between serum krebs von den lungen-6 levels with forced vital capacity and modified rodnan skin score of patients with restrictive lung disease in diffusetype systemic sclerosis. indonesioan journal of rheumatology. 2019;11(2):145-17. 114 original article acta medica indonesiana the indonesian journal of internal medicine pain reduction after laser acupuncture treatment in geriatric patients with knee osteoarthritis: a randomized controlled trial d w i r . helianthi 1, chr i stina simadibrata 1, adining sih sr ilestar i 1, edy r. wahyudi2, rudy hidayat2 1 department of medical acupuncture, faculty of medicine universitas indonesia, jakarta, indonesia. 2 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: dwi rachma helianthi, md. department of medical acupuncture, faculty of medicine universitas indonesia. jl. diponegoro 71, jakarta 10430, indonesia. email: dokter_emma@yahoo.com. abstrak tujuan: membandingkan efektivitas laserpunktur aktif dengan plasebo dalam menurunkan intensitas nyeri dan perbaikan fungsional pada pasien geriatri dengan osteoartritis (oa) genu. metode: uji klinis acak dengan kontrol tersamar ganda dilakukan pada pasien geriatri dengan oa genu di poliklinik akupunktur medik, poliklinik geriatri terpadu serta poliklinik reumatologi rs. cipto mangunkusumo, jakarta, periode mei 2015 – oktober 2015. enam puluh dua pasien oa genu secara acak dibagi menjadi dua kelompok: kelompok laserpunktur aktif atau kelompok laserpunktur plasebo. intervensi menggunakan laser gallium aluminium arsenida pada titik st35 dubi, st36 zusanli, sp9 yinlingquan, gb34 yanglingquan dan ex le 4 neixiyan, pada lutut yang terdiagnosis oa selama 10 sesi terapi, dua kali seminggu. visual analogue scale (vas) dan indeks lequesne digunakan untuk mengukur keluaran penelitian yang dinilai pada saat sebelum perlakuan, setelah 4 sesi, setelah 9 sesi dan 2 minggu pasca perlakuan dihentikan. hasil: terdapat perbaikan luaran vas yang bermakna pada kelompok laserpunktur aktif dibandingkan dengan kelompok laserpunktur plasebo pada penilaian setelah 4 sesi (beda rerata 0,39; p<0,001), setelah 9 sesi (beda rerata 37,48; p<0,001) dan 2 minggu pasca perlakuan dihentikan (beda rerata 39,15; p<0,001). terdapat perbaikan keluaran indeks lequesne yang bermakna pada kelompok laserpunktur aktif dibandingkan dengan kelompok laserpunktur plasebo pada penilaian setelah 4 sesi (beda rerata 4,68; p<0,001), setelah 9 sesi (beda rerata 5,90; p<0,001) dan 2 minggu pasca perlakuan dihentikan (beda rerata 6,48; p<0,001). kesimpulan: laserpunktur aktif efektif dalam menurunkan intensitas nyeri. kata kunci: osteoartritis genu; laserpunktur; vas; indeks lequesne. abstract aim: to compare the effectiveness of active laser acupuncture with placebo on reducing pain intensity and improving functional outcome in geriatric patients with knee osteoarthritis (oa). methods: a double-blind randomized controlled trial was conducted in geriatrics with knee oa at medical acupuncture outpatient clinic, integrated geriatric outpatient clinic, rheumatology outpatient clinic of cipto mangunkusumo hospital, jakarta, during may to october 2015. sixty two patients with knee oa were randomly assigned into two groups: active laser acupuncture group or placebo laser acupuncture group. interventions were carried out using a gallium aluminum arsenide laser device at the st35 dubi, st36 zusanli, sp9 yinlingquan, gb34 yanglingquan and ex le 4 neixiyan acupuncture points on the affected knee for ten sessions of treatment, vol 48 • number 2 • april 2016 pain reduction after laser acupuncture treatment in geriatric patients 115 i.e. twice a week. patients were assessed using a visual analogue scale (vas) and lequesne index at baseline, after four sessions, after nine sessions and at 2 weeks after the treatment had been stopped. results: the vas scores were significantly improved in the active laser acupuncture group compared to the placebo group. the evaluation of vas scores was carried out after four treatment sessions (mean difference: 0.39; p<0.001), after nine treatment sessions (mean difference: 37.48; p<0.001) and at 2 weeks post intervention (mean difference: 39.15; p<0.001). the evaluation also showed significant improvement of lequesne index after four treatment sessions (mean difference: 4.68; p<0.001), after nine treatment sessions (mean difference: 5.90; p<0.001) and at 2 weeks post intervention (mean difference: 6.48; p<0.001). conclusion: active laser acupuncture is effective in reducing pain. keywords: knee osteoarthritis, laser acupuncture, vas, lequesne index. introduction knee osteoarthritis (oa) is the most common form of arthritis and a leading cause of impaired mobility in elderly. the prevalence of knee oa with the longer life expectancy.1 in indonesia, there are 5% of people age older than 65 years old and it is estimated to increase up to 10.6% of population by the year 2035, which will become a burden.2 there is currently no available diseasemodifying therapy for knee oa. non-steroidal anti inflammatory drugs (nsaids) are used for patients with knee oa, but they only reduce knee pain with a tendency of inducing gastrointestinal bleeding.3,4 moreover, the population of elderly also has co-morbidities, which may lead to increased side effects due to drug interactions. recently, there is an increasing number of studies that investigate the efficacy of acupuncture for knee oa (koa). moreover, a systematical review by osteoarthritis research international society (oarsi) has stated that acupuncture may have a symptomatic benefit in patients with knee oa.5 acupuncture itself is a technique involving fine needle and using current knowledge of anatomy, physiology and pathology and the principles of evidence-based medicine.6 acupuncture has several techniques, while one of the most popular is laser acupuncture. this non-invasive technique has a positive effect on degenerative process at neurovascular bundle on the acupuncture points (acupoints) and has almost no complications or side effects.7 there are only three published studies, which have investigated the efficacy of laser acupuncture on koa with conflicting results.8-10 those studies had many important factors that affect effectiveness of laser acupuncture including the wavelength, treatment duration, dosage and the number of acupoints. variations in those factors make it difficult to conclude.11 in our study, we only performed laser acupuncture without exercise or any other interventions. therefore, the results could be more objective that they were the outcomes of laser acupuncture treatment. none of published studies has the same protocol as ours. our study investigated the efficacy of laser acupuncture applied to acupoints in geriatrics with knee oa by comparing the outcomes between the placebo laser group and the active laser group. methods we conducted a double-blind randomized controlled trial in geriatric patients with knee osteoarthritis who visited the geriatric outpatient clinic, acupuncture outpatient clinic and rheumatology outpatient clinic at cipto mangunkusumo hospital, jakarta, indonesia from may 2015 to october 2015. subjects the sample size was calculated using formula of mean difference with type i error of 5% and type ii error of 20%. based on the experiences from previous studies, we defined the minimum difference of reduction as clinically significant when there was 30 mm of difference with 3.49 standard deviation.8,12 the minimum total subjects needed were 28 patients for each group. however, we decided to dwi r. helianthi acta med indones-indones j intern med 116 collect 31 samples for each group to anticipate the 10% lost. we included patients aged more than 60 years old who had been diagnosed with grade 2 and grade 3 knee osteoarthritis based on the kellgren-lawrence grading scale, either unilateral or bilateral and who also had average pain intensity of more than 40 on a 100-mm visual analogue scale (vas). we excluded patients who had a previous knee replacement surgery, consumed opioids as well as the patients who had a previous corticosteroid intraarticular injection in the last 4 months or those with hyaluronic acid intrarticular injection in the last 6 months or local-oral nsaids medication in the last 3 days or topical capsaicin treatment prior to study entry. patients who received tens, ultrasound or laser therapy in the previous 2 weeks or those with conditions of laser treatment contraindication (cancer, infections with high fever, untreated epilepsy, acute solaris dermatitis, increased photoallergic responsiveness, congestive heart failure) as well as those with conditions that would interfere outcome measures (e.g. psychotic, moderatesevere cognitive impairment) were excluded. patients were allowed to take acetaminophen as required for severe pain (with a maximum dose of 4 g/day). all of the participants had given written informed consent. the participants were considered drop out when they missed two consecutive treatment sessions. randomization b e f o r e c o m m e n c i n g t h e s t u d y, a randomization list was created using a computer generated table containing random numbers. both investigator and participants did not know whether laser acupuncture active treatment or placebo treatment was being administered. only the researcher and her assistant had the code to determine which treatment was given. both groups used the same laser device and the same study site. participant blinding was optimized by using eye mask and headset during treatment session so that participant could not see the red light from laser device and also could not hear the sound from laser device. laser acupuncture and lequesne index our study used a single-probe gallium aluminum arsenide laser device (handylaser trion rj-laser®, waldkirch, germany) with 50 mw output power and 25 mw/cm2 power density. the device produces an infrared laser with a wavelength of 785 nm. probe and laser device were checked before starting the laser acupuncture treatment. laser acupuncture was performed at the acupuncture points of st35 dubi, st36 zusanli, sp9 yinlingquan, gb34 yanglingquan and ex-le-4 neixiyan. a laserpuncture dose of 4 joule was carried out for 80 seconds at each point. the treatment was given twice a week as many as 10 sessions. the same procedures were applied in placebo group but the device was inactive. in both groups, patients were not allowed to see the red light that came out from the instrument and they were also not allowed to hear the sound from device; therefore, they wore eye mask before wearing a protective goggle and also headset. vas was measured at the baseline, after four treatment sessions, after nine treatment sessions and at 2 weeks post intervention. the investigator asked participants to rate their pain on a horizontal 100-mm line, “no pain” on the left and “worst pain possible” on the right.12 participants marked a line to represent their pain level. lequesne index has been developed as an interview format and consists of three aspects: pain, maximum distance walked and activities of daily living. the score for pain contains five questions for each scale and ranges from 0 (no pain or functional limitation) to 2 (pain at rest). the maximum distance walked aspect is graded from 0 = unlimited to 6 = less than 100 m. the score was upgraded one point if the participant used one walking stick or two point if participant used two walking sticks or crutches. the activities of daily living aspect is graded from 0 = no limitation; 0.5 = able with mild limitation; 1 = able with moderate limitation; 1.5 = able with severe limitation; 2 = unable. lequesne index directly aggregates symptoms and function, which results in a single global index score ranging from 0 to 24.13 vol 48 • number 2 • april 2016 pain reduction after laser acupuncture treatment in geriatric patients 117 ethics the study protocol has been approved by the research ethics committee of the faculty of medicine, university of indonesia – cipto mangunkusumo hospital (345/un2.f1/ etik/2015). statistical analysis statistical analysis was performed using spss version 20.0 (ibm corp., new york, usa). a student t-test was applied when the variables were numerical data with normal distribution. a ”per-protocol” analysis was used in this study. results fifty nine of 62 eligible participants completed the study. one participant from the laser acupuncture active group was unable to complete the protocol because of having cerebrovascular accident. two participants from the placebo laser group refused to complete the protocol because they felt no improvement after 2 sessions (figure 1). the demographic and baseline clinical characteristics of the groups were similar (table 1). vas scores showed a statistically significant improvement for the active laser acupuncture group after four sessions of treatment (mean difference 0.39, 95% ci 0.20 to 0.58, p<0.001), after nine-treatment sessions (mean difference 37.48, 95% ci 29.05 to 49.50, p<0.001) and at 2 weeks post intervention (mean difference 39.15, 95% ci 31.14 to 47.16, p<0.001) compared to the placebo group (table 2 and figure 2). on the contrary, vas scores showed no statistically significant improvement for the placebo laser group at all assessment periods (p=0.48). these eligible participants (n = 62) random allocation active laser acupuncture group placebo laser acupuncture group vas and lequesne index ( n = 31) vas and lequesne index ( n = 31) vas and lequesne index ( n = 30) vas and lequesne index ( n = 29) vas and lequesne index ( n = 30) vas and lequesne index ( n = 29) baseline after 4 sessions after 9 sessions data analysis (n = 59) vas and lequesne index ( n = 30) vas and lequesne index ( n = 29) 2 weeks post intervention drop out (n = 1) drop out (n = 2) figure 1. a flow chart of study protocol dwi r. helianthi acta med indones-indones j intern med 118 table 1. baseline characteristics between groups characteristics all subjects (n=59) active laser acupuncture group (n=30) placebo laser acupuncture group (n=29) age (years), mean (sd) 69 (5) 69 (6.0) 68 (5.0) gender (n) male 17 12 5 female 42 18 24 body mass index (kg/m2), mean (sd) 26.1 (4.3) 25.8 (4.3) 26.3 (4.3) grade of oa grade 2 23 14 9 grade 3 36 16 20 visual analogue scale (mm), mean (sd) 57.2 (11.9) 60.2 (12.2) 54.1 (10.8) lequesne index, mean (sd) 10.8 (4.3) 10.7 (5.0) 11.0 (3.6) acetaminophen medication (n) had medication 29 14 15 no medication 30 16 14 table 2. changes in vas and lequesne index between groups characteristics active laser acupuncture group (n = 30) placebo laser acupuncture group (n = 29) mean difference (95% ci) p value δ vas1 1.36 (0.27) 0.97 (0.30) 0.39 (0.20 to 0.58) <0.001 δ vas2 41.1 (15.3) 3.6 (17.0) 37.48 (29.05 to 49.50) <0.001 δ vas3 40.5 (14.8) 1.3 (6.0) 39.15 (31.14 to 47.16) <0.001 δ lequesne 1 3.7 (2.4) -1.0 (3.7) 4.68 (3.07 to 6.29) <0.001 δ lequesne 2 5.2 (3.9) -0.7(4.2) 5.90 (3.78 to 8.02) <0.001 δ lequesne 3 5.3 (4.5) -1.2 (3.7) 6.48 (4.34 to 8.46) <0.001 δ vas1: changes in vas between baseline and the fourth treatment session; δ vas2: changes in vas between baseline and the ninth treatment sessions; δ vas3: changes in vas between baseline and at 2 weeks post intervention; δ lequesne 1: changes in lequesne index between baseline and the fourth treatment session; δlequesne 2: changes in lequesne index between baseline and ninth treatment sessions; δ lequesne 3: changes in lequesne index between baseline and at 2 weeks post intervention improvements were clinically significant for the active laser acupuncture group after nine sessions of treatment and at 2 weeks post intervention. similar to the vas scores, the lequesne index was improved significantly after four sessions of treatment (mean difference 4.68, 95% ci 3.07 to 6.29, p<0.001), after nine-treatment sessions (mean difference 5.90, 95% ci 3.78 to 8.02, p<0.001) and at 2 weeks post intervention (mean difference 6.48, 95% ci 4.34 to 8.46, p < 0.001) compared to the placebo group (table 2 and figure 3). there was no statistically significant improvement of lequesne index for the placebo laser group at all assessment periods (p=0.89). discussion our study found that the laser acupuncture treatment has a beneficial effect on reducing pain intensity and improving functional outcome in patients with knee oa. infrared light with 785 nm wave length was used as it provides deeper penetration compared to the visible red light.7 the dose was given based on consideration vol 48 • number 2 • april 2016 pain reduction after laser acupuncture treatment in geriatric patients 119 of minimum dose as defined by walt for knee oa.14 the treatment intervention was performed in 10 sessions twice a week; therefore, it can be applied for outpatient clinic units. yurtkuran et al8 conducted a clinical trial to investigate the effects and minimum effective dose of laser acupuncture in knee oa and to determine whether it is superior to placebo treatment. their study used a laser device with 904-nm low-level laser irradiation, 10 mw/ laser acupuncture active group laser acupuncture placebo group figure 2. mean visual analogue scores. assessments were made at baseline, after four sessions, nine sessions and at 2 weeks post intervention. laser acupuncture active group laser acupuncture placebo group figure 3. mean lequesne index. assessments were made at baseline, after four sessions, nine sessions and at 2 weeks post intervention. dwi r. helianthi acta med indones-indones j intern med 120 cm2 power density, 4 mw output power and 0.4 cm2 spot size. acupuncture point of sp9 was irradiated for 120-sec (0.48 j) treatment time per session for the laser and placebo groups. the patients in both groups had treatment as many as 10 sessions with an interval of 5 days per week. the patients in both groups were also given 10 sets of isometric exercises and active range of motion exercises for knee every day. the result showed that there is an improvement of knee swelling as shown by better knee circumference measurement in the laser group compared to the placebo group at the 2nd week.8 our study showed a statistically significant difference on vas after four sessions, nine sessions and at 2 weeks post intervention between two groups. vas improvement was shown clinically significant after nine sessions (41.1 mm) and at 2 weeks post intervention (40.5 mm) in the laser acupuncture active group. similar result has also been shown for lequesne index. our results are different from the study conducted by yurtkuran et al. the difference may be due to lower laser doses. the dose may be too low as walt has set 4 joules as the minimum dose for koa.14 in addition, power density also plays an important role. yurtkuran et al8 used a laser device with a power density of 10mw/ cm2. the power density may be too low to be able to induce mast cell degranulation, which is important to stimulate the acupuncture point.15 al rashoud et al10 conducted a clinical trial to evaluate the efficacy of laser acupuncture when applied to five acupuncture points combined with exercise. the study use lower dose and power density. the number of acupuncture points and also therapy sessions used in the study are similar with our study. the study demonstrated a significant reduction of pain level in laser acupuncture active group and placebo group at the 9th session and 6 months post intervention.10 pain reduction can occur through several mechanisms. low level laser therapy has biostimulation effects, which increase cell proliferation and migration, particularly fibroblasts. it also can cause modulation of cytokines, growth factors and inflammatory m e d i a t o r s a s w e l l a s i m p r o v i n g t i s s u e oxygenation.16 bjordal et al stated that lowintensity laser therapy modulates inflammation by decreasing the levels of biochemical markers (pge2. m-rna cox-2. il1β. and tnfα), the influx of neutrophils, oxidative stress and edema.17 serra et al18 found that the analgesia effect of laser acupuncture comes from the release of opioid through the migration of immune cells releasing local beta endorphins. brosseau et al19 also suggested that laser acupuncture can disrupt sensory input to the central nervous system as a result of the increased activity of the na k pump and therefore, it increases the pain threshold. laser acupuncture with minimal power density of 20 w/cm2 can cause needle-equivalent acupuncture effects.15 moreover, laser irradiation will stimulate peripheral drg neurons and mast cells. stimulation of the peripheral drg neurons will inhibit pain transmission to central nervous system.20 laser irradiation will cause mast cell degranulation and release of histamine, which has been known to have the effect of stimulating the aβ and non nociceptive c fibers that play a role in the inhibition of pain.20,21 a systematic review indicates that infrared laser light irradiation has some effects on aδ and c nociceptive nerve fibers including direct inhibition of nerve conduction and reduced pain intensity. the laser irradiation can also increase serotonin level in the cns and decrease bradykinin activities.22 side effects such as infection and shock are not found. pain was once reported by 17 of 30 subjects (56.67%) in the laser acupuncture active group, i.e. after they had the first two or three sessions. however, the complaint was not reported in subsequent sessions. there were no previous studies reported similar issues. the pain may be experienced due to the accumulated effects of histamine release by mast cell degranulation, which was triggered by laser irradiation.15 the limitation of our study is the shortterm follow-up period and therefore, we do not know when exactly the laserpuncture effect will diminish. vol 48 • number 2 • april 2016 pain reduction after laser acupuncture treatment in geriatric patients 121 conclusion laser acupuncture has a more effective effect on reducing vas and lequesne index in the elderly patients with koa compared to placebo treatment. larger sample size or longer follow-up period are still necessary for further studies to evaluate more effect on the efficacy of the treatment modality. references 1. woolf ad, pfleger b. burden of major musculoskeletal condition. bulletin who. 2003;(81):646-56. 2. badan pusat statistik. proyeksi penduduk indonesia 2010-2035. jakarta: badan pusat statistik; 2013 [cited2015]. available from: http://www.bps.go.id/ hasil_publikasi/proyeksi_penduduk_2010_2035/ i n d e x 3 . p h p ? p u b = p r o y e k s i % 2 0 p e n d u d u k % 2 0 i n d o n e s i a % 2 0 ( i n d o n e s i a % 2 0 p o p u l a t i o n % 2 0 projection)%202010%20-%202035. 3. towheed te ml, judd mg, catton m, hochberg mc, wells g. acetaminophen for osteoarthritis. cochrane database systematic rev. 2006;(1):1-3. 4. richmond j, hunter d, irrgang j, et al. treatment of osteoarthritis of the knee (nonarthroplasty). j am acad orthop surg. 2009;17(9):591-600. 5. zhang w, moskowitz rw, nuki g, et al. oarsi recommendations for the management of hip and knee osteoarthritis. part ii: oarsi evidence-based. expert consensus guidelines. osteoarthritis cartilage. 2008;16(2):137–62. 6. white a. western medical acupuncture a definition. acupunct med. 2009;27:33-5. 7. kreisel v. weber m. a practical handbook laser acupuncture successful treatment concept. germany: fuchtenbusch verlag; 2012. p. 10-29. 8. yurtkuran m. alp a. konur s. ozcakir s. bingol u. laser acupuncture in knee osteoarthritis: a double blind, randomized controlled study. photomed laser surg. 2007;25(1):14-20. 9. shen x, zhao l, ding g, et al. effect of combined laser acupuncture on knee osteoarthritis: a pilot study. lasers med sci. 2009;(24):129-36. 10. al-rashoud as. abboud rj. wang w. wigderowitz c. efficacy of low-level laser therapy applied at acupuncture points in knee osteoarthritis: a randomised double-blind comparative trial. physiotherapy. 2014;(100):242-8. 11. litscher g. opitz g. technical parameters for laser acupuncture to elicit peripheral and central effects: state-of-the-art and short guidelines based on results from the medical university of graz, the german academy of acupuncture. and the scientific literature. evidence-based complemen alt med. 2012;2012:1-5. 12. lee js, hobden e, stiell ig, wells ga. clinically important change in the visual analog scale after adequate pain control. acad emerg med. 2003;10:1128-30. 13. osteoarthritis research society international. index of severity for osteoarthritis of the hip by lequesne et al. 2013. 14. world association of laser therapy. walt recommendation dosage for laser. 2010. 15. schikora d. laserneedle acupuncture: a critical review and recent results. med acupunct. 2008;20(1):37-42. 16. vamanan jn. mechanisms of low level light therapy in acupuncture laser acupuncture. harvard; 2010. 17. bjordal jm la, klovning a, slordal l. non-steroidal anti-inflammatory drugs. including cyclo-oxygenase-2 inhibitors, in osteoarthritic knee pain: meta-analysis of randomised placebo controlled trials. bmj. 2004;329(7478):1-6. 18. serra ap. ashmawi ha. influence of naloxone and methysergide on the analgesic effects of low-level laser in an experimental pain model. rev bras anestesiol. 2010;3(60):302-10. 19. brosseau l, welch v, wells ga, et al. low level laser therapy (classes i, ii, and iii) for treating osteoarthritis. cochrane database syst rev. 2004;(3):1-64. 20. wang l, hu l, grygorczyk r, shen x, schwan w. modulation of extracellular atp content of mast cells and drg neurons by irradiation: studies on underlying mechanism of low-level-laser therapy. mediator inflamm. 2014:1-10. 21. quah-smith i, williams ma, lundeberg t, suo c, sachdev p. differential brain effects of laser and needle acupuncture at lr8 using functional mri. acupunct med. 2013;31:282–9. 22. chow r, armati p, laakso e-l, bjordal jm, baxter gd. inhibitory effects of laser irradiation on peripheral mammalian nerves and relevance to analgesic effects: a systematic review. photomed laser surg. 2011;29:365–81. case report 129acta medica indonesiana the indonesian journal of internal medicine obstructive jaundice as a complication of macrocystic serous cystadenoma of the pancreas hendra koncoro, i komang w. d. putra, i dewa n. wibawa department of internal medicine, faculty of medicine, university of udayana sanglah hospital, denpasar, bali, indonesia. corresponding author: hendra koncoro, md. division of gastroentero-hepatology, department of internal medicine, faculty of medicine, university of udayana sanglah hospital. jl. sanglah, denpasar 80114, bali, indonesia. email: hendra_koncoro@ yahoo.com. abstrak kistadenoma serosa makrokistik merupakan tumor pankreas yang jarang dijumpai dan umumnya jinak. pada laporan kasus ini, dilaporkan wanita berusia 40 tahun yang didiagnosis kistadenoma serosa makrokistik dengan keluhan ikterus obstruktif. lesi kistik pada bagian caput dan corpus pankreas ditunjukkan dengan ct abdomen. aspirasi kista pankreas intraoperatif menyingkirkan neoplasma kistik musinosa yang memiliki potensi ganas. sitologi cairan kista pankreas menunjukkan bahan amorf basofilik yang disimpulkan sebagai lesi kistik jinak. drainase internal dilakukan alih-alih reseksi pankreas yang menunjukkan hasil yang baik. obstruksi bilier merupakan komplikasi yang jarang dijumpai pada kistadenoma serosa. kasus ini menggambarkan tampilan klinis tidak lazim dari kistadenoma serosa makrokistik. kata kunci: kistadenoma serosa makrokistik, pankreas, ikterus obstruktif. abstract macrocystic serous cystadenoma is an unusual and essentially benign pancreatic tumor. herein, we report on a 40-year-old woman diagnosed with macrocystic serous cystadenoma who presented with obstructive jaundice. a cystic lesion in the head and body of the pancreas was revealed by abdominal computed tomography. intraoperative pancreatic cyst aspiration ruled out mucinous cystic neoplasm which has a malignant potential. the pancreatic cyst fluid cytology was basophilic amorph materials concluded as benign cystic lesion. internal drainage was performed instead of pancreatic resection which showed good outcome. biliary obstruction is a rare complication of serous cystadenoma. this case describes an unusual clinical presentation of macrocystic serous cystadenoma. keywords: macrocystic serous cystadenoma, pancreas, obstructive jaundice. introduction cystic neoplasms of the pancreas are uncommon, representing approximately 1015% of all pancreatic cystic lesions and account for 1% of pancreatic malignancy.1,2 in 1978, compagno and oertel issued an histopathologic classification of cystic neoplasms of the pancreas identifying two different types of cyst. the first type is serous cystadenoma (sca) with benign behavior.3 mucinous cystic neoplasms of the pancreas are the other type of lesions and possess the more frequent ability to transform into malignant condition.4 previously, sca were also known as microcystic adenomas. however, 130 hendra koncoro acta med indones-indones j intern med in 1992 lewandrowski et al reported a variant coined as macrocystic sca.5 the macrocystic subtype of sca has been reported only on rare occasions.5-7 preoperative diagnosis of macrocystic sca by physical examination and radiologic studies is difficult.7,8 the imaging of a macrocystic sca may resemble a pseudocyst or a mucinous cystadenoma.7-9 thus, it is often difficult to make a correct diagnosis. biliary obstruction is a rare complication of sca and only a few cases have been reported.10 we herein report a case of pancreatic sca causing obstructive jaundice, which we treated successfully by an internal drainage procedure. case illustration a 40-year-old balinese female who had suffered from jaundice since mid-january 2012, was hospitalized in our department on february 9, 2012. the complaint was accompanied by intense itching, dark urine and fatigue. she reported anorexia with waxing and waning upper abdominal pain for about 1 year. abdominal pain was felt on her epigastrium and not penetrated to her back. the patient had no history of alcohol consumption nor abdominal trauma. physical examination revealed the following: height 165 cm; body weight 55 kg; body temperature 37.2°c; blood pressure 120/84 mmhg. her skin and conjunctiva were jaundiced. there was upper abdominal mass palpable sized 8 x 9 cm. there was no ascites or leg edema. blood and biochemical test on admission showed the following abnormalities: white blood cells 9800/mm3; total bilirubin 11.85 mg/dl; direct bilirubin 11.55 mg/dl; amylase 145 u/l; alkaline phosphatase 706 u/l; gamma-glutamyl transferase 349 iu/l; aspartate aminotransferase 69,7 iu/l; alanine aminotransferase 113.9 iu/l. the serum tumor markers, carcinoembryogenic antigen (cea) and carbohydrate antigen (ca) 19-9 were not elevated. abdominal ultrasonography (us) showed dilation of the intrahepatic bile duct and common bile duct (cbd) and multiple hypoechoic mass in the pancreas (figure 1). an abdominal ct scan showed multiple well-defined hypodense cystic lesion of pancreas with the largest cyst sized 6.7 x 9 cm. gallbladder enlargement was also shown (figure 2). these findings were highly suggestive of pancreatic cystic lesion causing stenosis of the cbd and obstructive jaundice. swelling of the pancreatic cysts around the cbd had caused severe stenosis and sludge of bile had formed, resulting in obstructive jaundice. figure 1. transabdominal ultrasonography revealed pancreatic cysts. figure 2. abdominal ct (axial section) with contrast showing multiple well-defined hypodense, cystic lesion in the pancreas. l a p a r o t o m y s h o w e d a m u l t i c y s t i c tumor arising from the head and body of the pancreas, with no evidence of metastatic disease. intraoperative pancreatic cyst aspiration 131 vol 48 • number 2 • april 2016 obstructive jaundice as a complication of macrocystic sorous cystadenoma was performed and caused them to shrink and improved the compressive effect on choledochal duct. internal drainage was done by cystojejunostomy. aspiration revealed a clear watery fluid. microscopically, pancreatic cyst fluid cytology was basophilic amorph material without any mucinous columnar epithelial cells concluded as benign cystic lesion (figure 4). therefore, the tumor was diagnosed to be a macrocystic serous cystadenoma of the pancreas. the postoperative course was uneventful. at last follow-up 1 year post-operatively, the patient is doing well without clinical or radiographic evidence of recurrent disease. classified cystic neoplasms of pancreas as serous cystadenomas and mucinous cystic neoplasms.3,4 sca of the pancreas is an uncommon and essentially benign tumor. it consists of a predominantly microcystic architecture lined by a layer of cuboidal epithelium with rounded and uniform nuclei, and clear cytoplasm containing a large amount of glycogen.3 sca has macrocystic variant which consists of six cysts or less with diameter sized more than 2 cm (unilocular, oligocystic).5 pancreatic macrocystic sca has to be differentiated with other pancreatic cystic lesions such as pseudocysts or mucinous cystic neoplasms.1 cysts in other sites need to be explored to rule out the possibility of von hippel lindau disease.11 it is important to establish a correct diagnosis before surgery so that appropriate surgical management can be done.9 however, it seems difficult to make the distinction by imaging studies preoperatively, and almost all cases are diagnosed after surgery by histologic examination.12 borgne reviewed 389 cases of cystadenoma of the pancreas based on their imaging findings and concluded that correct diagnosis of macrocystic sca by preoperative imaging was only 20%.13 lewandrowski et al also found that the radiological features of their 5 cases of macrocystic sca were indistinguishable from those of mucinous cystic neoplasms, and when unilocular, could be confused with pseudocysts.5 pseudocyst may be diagnosed by a history of pancreatitis with unilocular cyst appearance on computed tomography scan and typical fluid cyst analysis.12,14 sca also had to be differentiated from mucinous cystic neoplasms. mucinous cystic neoplasms should always be resected due to tendency towards malignancy. management of sca was not as radical as mucinous cystic neoplasms since sca were considered to be tumors with no potential for malignant transformation. multilocular cyst and pancreatic cyst fluid analysis which showed no inflammatory cells and low amylase content were common occurrences in sca and mucinous cystic neoplasms. differences between both type of cysts are viscosity and cytologic analysis of figure 3. findings on ct (coronal section). gallbladder seen greatly distended and multiple cystic lesion in the pancreas. figure 4. basophilic amorph materials concluded as benign cystic lesions. discussion pancreatic cystic lesions contribute to 10% of all pancreatic cysts.2,3 in 1978, compagno et al.4 132 hendra koncoro acta med indones-indones j intern med cyst fluid. the cyst fluids of mucinous cystic neoplasms were mucoid and viscous on gross inspection with cytologic preparations showed mucinous columnar epithelial cells with high content of mucin.12,14-16 in our case, from clinical appearance there was jaundice with recurrent abdominal pain without history of pancreatitis and mass in epigastrium. radiologic findings showed well-defined multiple hypodens cystic lesions in pancreas with largest cyst sized 6.7 x 9 cm. clinical appearance and radiologic findings supported the diagnosis of a pancreatic cystic lesion. pseudocysts may be ruled out due to negative findings of abdominal pain which penetrated to back typical of pancreatitis with radiologic findings of multilocular cysts. therefore, diagnosis may be tighten into pancreatic cystic lesion with differential diagnosis of macrocystic sca and mucinous cystic neoplasm. laparatomy was done on this patient followed by intraoperative pancreatic cyst fluid aspiration. aspiration caused the cysts to shrink and relieved the compressive effect on the choledochal duct. pancreatic cyst aspiration showed clear fluid with watery consistency. intraoperative diagnosis lead to possibility of macrocystic sca, therefore pancreatic resection was not done in this case. pancreatic resection carries a much higher risk of complications and mortality especially in centers with low experience with pancreatic surgery.17,18 if pseudocysts or sca are considered, often other modalities are better than resection.15 therefore, we performed the cyst aspiration, did internal drainage and continued with cystojejunostomy. the histologic examination showed neither malignant cells nor mucinous epithelial cells which concluded the findings as sca. amylase content and tumor marker of the fluid was not done due to limited facilities. low level of fluid amylase, ca 19-9, and cea might confirm the diagnosis of sca.14,16,17 neither clinical findings of cystic swelling nor obstructive jaundice have been found by radiology or laboratory data for more than 1 year follow-up. cyst aspiration followed by internal drainage may be a better palliative option for treating benign compressive tumors such as macrocystic sca of the pancreas causing obstructive jaundice since chances of malignancy in sca are no more than 1%.19,20 watanabe described a case of macrocystic sca causing obstructive jaundice successfully managed by cystic fenestration. no recurrence of sca has been detected in that case for more than 2 years since the cystic fenestration.19 conclusion we reported a case of rare presentation of biliary obstruction caused by pancreatic serous cystadenoma. although very rare, serous macrocystic adenoma might appear with complication of obstructive jaundice and has to be taken into consideration in differential diagnosis of cystic lesions of the pancreas. the patient had surgical treatment to perform treated surgically, underwent cyst aspiration and internal drainage (cystojejunostomy) without resection of the pancreas. the patient had a great improvement during follow-up after the surgery. references 1. sharma a. tumors of the pancreas. in: greenberger nj, blumberg rs, burakoff r, eds. current diagnosis and treatment gastroenterology, hepatology, and endoscopy. new york: mcgraw-hill; 2009. p. 310-20. 2. ros pr, hamrick-turner je, chiechi mv, ros lh, gallego p, burton ss. cystic masses of the pancreas. radio graph. 1992;12:673-86. 3. compagno j, oertel je. microcystic adenomas of the pancreas (glycogen-rich cystadenomas). a clinicopathologic study of 34 cases. am j clin pathol. 1978;69:289-98. 4. compagno j, oertel j. mucinous cystic neoplasms of the pancreas with overt and latent malignancy ( c y s t a d e n o c a r c i n o m a a n d c y s t a d e n o m a ) : a clinicopathologic study of 41 cases. am j clin pathol. 1978;69:573-80. 5. lewandrowski k, warshaw a, compton c. macrocystic serous cystadenoma of the pancreas. a morphologic variant differing from microcystic adenoma. hum pathol. 1992;23:871-5. 6. egawa n, maillet b, schroder s, mukai k, kloppel g. serous oligocystic and ill-demarcated adenoma of the pancreas: a variant of serous cystic adenoma. virchows arch. 1994;424:13-7. 7. gouhiri m, soyer p, barbagelatta m, rymer r. macrocystic serous cystadenoma of the pancreas: ct and endosonographic features. abdom imaging. 1999;24(1):72-4. 8. khadaroo r, knetman n, joy s, nguyen gk. macrocystic serous adenoma of the pancreas. pathol 133 vol 48 • number 2 • april 2016 obstructive jaundice as a complication of macrocystic sorous cystadenoma res pract. 2002;198:485-8. 9. hsieh yy, hsueh s, chen rj, hsueh c. macrocystic serous cystadenoma of the pancreas in a young patient resembling a pseudocyst: case report and literature review. chang gung med j. 2003;26(8):602-6. 10. horaguchi j, fujita n, kobayashi g, noda y, kimura k, ito k, et al. serous cystadenoma of the pancreas associated with obstructive jaundice. j gastroenterol. 2003;38(5):501-6. 11. jakhere sg, yeragi b, jain dg. von hippel lindau (vhl) disease: magnetic resonance imaging spectrum in a single patient. acta med indones. 2012;44(4):324-6. 12. bhutani ms, gupta v, gusha s, gheonea di, safloiu a. pancreatic cyst fluid analysis – a review. j gastrointestinal liver dis. 2011;20:175-80. 13. le borgne j, de calan l, partensky c. cystadenoma and cystadenocarcinomas of the pancreas: a multiinstutional retrospective study of 398 cases. ann surg. 1999;230:152-61. 14. lewandrowski kb, southern jf, pins mr, compton cc, warshaw al. cyst fluid analysis in the differential diagnosis of pancreatic cysts. ann surg. 2003;217(1):41-7. 15. park wg. screening for pancreatic cancer: what can cyst fluid analysis tell us? f1000 med rep. 2011;3:3. 16. ng dz, goh bk, tham eh, young sm, ooi ll. cystic neoplasms of the pancreas: current diagnostic modalities and management. ann acad med sing. 2009;38:251-9. 17. goldsmith jd. cystic neoplasms of the pancreas. am j clin pathol. 2003;119(1):s3-16. 18. pyke cm, van heerden ja, colby tv, sarr mg, weaver al. the spectrum of serous cystadenoma of the pancreas: clinical, pathologic, and surgical aspects. ann surg. 1992;215(2):132-9. 19. watanabe h, ohtsubo k, yamaguchi y, mouri h, motoo y, noto m, et al. successful cystic fenestration for macrocystic serous cystadenoma of the pancreas causing obstructive jaundice: report of a case. surg today. 2006;36(1)89-93. 20. tseng jf, warshaw al, sahani dv, lauwers gy, rattner dw, castillo cf. serous cystadenoma of the pancreas:tumor growth rates and recommendations for treatment. ann surg. 2005;242:413-21. 41 original article acta medica indonesiana the indonesian journal of internal medicine use of pleural fluid interferon-gamma enzyme-linked immunospot assay in the diagnosis of pleural tuberculosis tika adilistya1, dalima a.w. astrawinata1, ujainah z. nasir2 1 department of clinical pathology, cipto mangunkusumo hospital, jakarta, indonesia. 2 department of internal medicine, cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: tika adilistya, md. department of clinical pathology, cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: dr.adilistya@gmail.com. abstrak tujuan: untuk melakukan penilaian terhadap uji diagnostik pemeriksaan interferon-gamma release assay (igra) metode enzyme-linked immunospot (elispot), yaitu t-spot.tb, untuk deteksi tb pleura menggunakan spesimen sel mononuklear (mn) cairan pleura. metode: sebanyak 48 pasien efusi pleura terduga tb dengan karakteristik cairan pleura eksudatif berdasarkan kriteria light dan dominasi sel mn lebih dari 50% dilakukan pemeriksaan t-spot.tb, biakan tb media cair mycobacterial growth indicator tube (mgit), dan aktivitas adenosine deaminase (ada) cairan pleura. penyebab lain efusi pleura seperti gagal jantung, gagal ginjal, sirosis hati, dan keganasan telah disingkirkan. hasil: sebanyak 39 dari 48 subjek (81,25%) menderita tb pleura berdasarkan biakan mgit positif dan/atau ada lebih dari 40 u/l. dari jumlah tersebut seluruhnya positif untuk t-spot.tb. hasil uji diagnostik igra elispot untuk diagnosis tb pleura adalah sensitivitas 100%, spesifisitas 88,89%, nilai prediksi positif 97,5%, dan nilai prediksi negatif 100%. kesimpulan: igra elispot menggunakan specimen cairan pleura merupakan metode diagnostik yang cepat dan reliabel sehingga bermanfaat untuk diagnosis tb pleura khususnya pada daerah endemis tb. kata kunci: interferon-γ release assay, elispot, tuberkulosis pleura. abstract aim: to evaluate the diagnostic value of an interferon-gamma release assay (igra) with enzyme-linked immunospot (elispot) method, t-spot.tb, in the diagnosis of pleural tb using pleural fluid mononuclear cells (pfmc). methods: forty-eight subjects, presumed to have pleural tb with exudative pleural effusion by light’s criteria, dominated by mononuclear cells, had their pleural fluid specimen tested with t-spot. tb, mycobacterial growth indicator tube (mgit) culture, and adenosine deaminase (ada) activity. other causes of pleural effusion such as heart failure, renal failure, hepatic cirrhosis, and malignancy were excluded. results: the sensitivity, specificity, positive predictive value, and negative predictive value of the igra elispot assay using pfmc for the diagnosis of pleural tb were 100%, 88.89%, 97.5%, and 100%, respectively. conclusion: igra with elispot method performed on pfmc is useful for a rapid and reliable diagnosis of pleural tb in clinical practice, especially in area with high tb burden. keywords: interferon-γ release assay, elispot, pleural tuberculosis. tika adilistya acta med indones-indones j intern med 42 introduction tuberculosis (tb) remains one of the leading causes of mortality in the world. although tb is typically a disease of the lungs, which serves both as port of entry and also as the major site of disease manifestation, mycobacterium tuberculosis has the ability to disseminate to various extrapulmonary sites. tuberculous pleurisy, or pleural tb, is the second most common manifestation of extrapulmonary tb and a common cause of pleural effusion in endemic tb areas. to date, diagnosis of pleural tb relies on either insensitive (acid fast bacilli smears), unspecific (cell count, biochemical levels), or time consuming (culture) methods often leading to defer initiation of therapy. the paucity of bacilli in pleural fluid leads to low sensitivity of direct bacillary detection such as ziehl-neelsen staining, culture, and also pcr.1-3 therefore, a rapid, accurate diagnostic test is urgently needed for pleural tuberculosis. in the late 1990s, many studies about the m. tuberculosis genome have led to the identification of tb specific antigens. among all antigens, early secretory antigenic target with 6 kda molecular weight (esat-6) and culture filtrate protein with 10 kda molecular weight (cfp10), which appear exclusively in m. tuberculosis, are the most immunodominant and also virulency determinant of mycobacteria. other mycobacteria, such as m. bovis in bacillus calmette-guerin vaccine and most environmental nontuberculous mycobacteria do not have these specific antigens therefore the use of esat-6 and cfp10 are beneficial for tb detection because it is more sensitive and specific.4 during active tb, antigen-specific t lymphocytes clonally proliferate and are recruited to the site of active infection. those cells will release more interferon-gamma (ifn-γ) cytokine after rechallenge with tb specific antigens in vitro. in pleural tb, more cd4+ t lymphocyte subgroups are found in the pleural fluid than in peripheral blood, and also the level of ifn-γ secreted by t lymphocytes in pleural fluid are more than the level of ifn-γ in peripheral blood.5 until now, the commercial platforms of igra are only validated for blood samples. based on facts that more antigen-specific t lymphocytes are found in pleural fluid than those in peripheral blood, we were interested in evaluating the clinical utility of an m. tuberculosis antigenspecific ifn-γ using enzyme-linked immunospot (elispot) method, performed on pleural fluid mononuclear cells (pfmc), for the diagnosis of pleural tb in a setting with high incidence of tb disease. methods a diagnostic study was performed in which 48 consecutive patients with presumed tb pleural effusion were enrolled at cipto mangunkusumo hospital from may to september 2015. the study was approved by the ethical committee of cipto mangunkusumo hospital/faculty of medicine universitas indonesia. subjects inclusion criteria were patients aged more than 18 years old with suspected pleural effusion based on clinical symptoms and ultrasound examination, with no history of antituberculosis medication in the last 6 months. patients with heart failure, renal failure, hepatic cirrhosis, and malignancy were excluded. written informed consents were obtained from all the subjects. sample size was 48 subjects, determined using diagnostic test sampling formula. pleural fluid tb culture and ada activity were used as the gold standard in this diagnostic study. based on who guidelines of extrapulmonary tb management, microscopic examination is the gold standard for diagnostic. but it has limitations since the sensitivity is very low. so we combined with pleural fluid ada activity to overcome this. in clinical practice in our centre, as indonesia is a high tb burden country, when a clinically suspected pleural tb patients has elevated pleural fluid ada activity and other causes of false elevation have been excluded, they will be treated with antituberculosis although tb culture is negative. one hundred millilitres (75-125 ml) of pleural fluid was aspirated. first tube (25 ml) was for routine pleural fluid analysis such as white blood cell (wbc) count, mononuclear (mn) cell vol 48 • number 1 • january 2016 use of pleural fluid interferon-gamma enzyme-linked immunospot assay 43 count, protein and ldh levels). determination of exudate was based on light’s criteria (fluid/ serum protein ratio >0.5, fluid/serum ldh ratio >0.6, and ldh >2/3 upper limit of normal serum ldh).6-7 if the results were not exudate, subjects would be excluded from the study. if the results were exudate, subsequent steps were ada activity measurement, elispot, and mgit culture. white blood cells count was performed using sysmex xe-2100. mn cell count was performed using wright stained cytocentrifuged slide which is presently considered as the “gold standard” for body fluid differential counting.the elispot assay and mgit culture was performed within 2 hours after the collection of pleural fluid. pfmc elispot assay the elispot kit (t-spot.tb; oxford immunotec ltd, oxford, uk) was performed according to the manufacturer’s instruction with some modifications in order to have an adequate and good quality of pleural fluid mononuclear cells (pfmc). the sample preparation needs pleural fluid volumes of 50 ml to 100 ml. volumes of 100 ml are more likely to provide sufficient cells although 50 ml are normally sufficient. samples should be stored at room temperature or 2-8°c. they should not be frozen. pleural fluid is transferred to a 50-ml falcon tube and centrifuged at 465 g for 15 minutes at room temperature. after centrifugation, check if there is a good cell pellet at the bottom of the tube. pipette the supernatant carefully to ensure that there is no loss of cells. if the pellet is small, centrifugation can be repeated. if the pellet is contaminated with red blood cells, then carry out a “hypertonic shock” as follows. resuspend the pellet in 2 ml sterile or distilled water and incubate for 50-60 seconds. to restore the normal osmolarity, add 2x pbs to the suspension. after that, dilute the suspension with 1x pbs or rpmi medium to 20-30 ml and centrifuge the suspension again at 465 g for 15 minutes. if the pleural fluid is contaminated with many red blood cells, a density gradient centrifugation similar to the density gradient centrifugation used in the standard t-spot.tb test can be performed, such as the ficoll procedure and leucosep method. if the contamination of the pellet with red blood cells is low, resuspend the pellet in one ml of rpmi using a pipette and make up to 20-30 m, then centrifuge again at 465 g for 15 minutes, remove supernatant carefully. after that, resuspend the pellet in 0,7 ml aim-v medium and process the t-spot.tb test according to the manufacturer’s instruction for peripheral blood mononuclear cells (pbmc).t-spot.tb uses two tb specific antigens: esat-6 and cfp10. panel a contains esat-6 and panel b contains cfp10. the response of stimulated cultures was considered positive when the test well (panel a or panel b) contained at least six more spots and had twice the number of spots shown in the control well. the background number of spots in negative control wells was below 10 spots per well in all patients.8 tb culture using mycobacterial growth indicator tube twenty five millilitres of pleural fluid was centrifuged at 3500 g for 15 minutes. the pellet was treated with an equal volume of naoh 4% for 15 minutes at room temperature and neutralized with sterile phosphate buffer. the suspension was inoculated for isolation of acid fast bacilli by culture in mgit (bd bactec mgit 960 system). determination of ada activity in pleural fluid adenosine deaminase (ada) activity levels were detected using an ada measurement kit with enzymatic colorimetric method (mindray bio-medical electronics, shenzhen, china) by following the manufacturer’s instructions. statistical analysis data results were analyzed by using ms excel for mac 2011 and ibm spss statistics ver. 23.0. normality of data was analyzed using kolmogorov-smirnov and shapiro-wilk analysis. the difference between two groups was analyzed by using unpaired t test or mannwhitney test (age, cell count, biochemistry levels, number of spots, ada) and chi square (gender). statistical significance defined as p value <0.05. diagnostic values such as sensitivity, specificity, positive predictive value (ppv), and negative predictive value (npv) were counted from 2x2 table. positive mgit culture and/or ada activity >40 u/l were used as the gold standard of pleural tb. tika adilistya acta med indones-indones j intern med 44 results of the 48 patients with presumed pleural tb, with mean age of 49 years (range 19–80 years), 39 patients were confirmed as pleural tb based on positive mgit culture and/or ada activity >40 u/l as the gold standard. characteristics of both groups can be seen in table 1. based on the gold standard, patients can be divided into two groups: pleural tb (39 patients) and non pleural tb (9 patients). the median proportion of cell count in pleural effusion fluid was 1530 cells/µl (range 80–64 680 cells/µl) in the group of patients with confirmed pleural tb and 672.2 (sd 388.3) cells/ µl in the group of patients with no pleural tb. the median proportion of mn cell count was 1203 cells/µl (range 64–58 212 cells/µl) in the pleural tb group and 546 (sd 307.8) cells in no pleural tb group. both of cell count and mn cell count were statistically different between two groups. pleural fluid protein, pleural fluid ldh, fluid/serum protein ratio, and fluid/serum ldh ratio between two groups were not statistically different. of the 39 patients in pleural tb group, all of them (100%) were positive for t-spot.tb (table 1). the median spot of (panel a – negative control) was 38 (4–314) spots and (panel b – negative control) was 27 (0–328) spots. these table 1. clinical and laboratory characteristics of the patients characteristics pleural tb (n=39) non pleural tb (n=9) age (years), mean (sd) 44.9 (16.5) 51.1 (18.4) gender (male/female) 18/21 7/2 unilateral effusion on ultrasound 37 4 wbc count (/µl) 1530 (80 – 64.680)** 672.2 (388.3)* mn count (/µl) 1203 (64 – 58.212)** 546 (307.8)* fluid protein (g/dl), mean (sd) 4.7 (0.95) 4.4 (0.71) protein ratio, mean (sd) 0.67 (0.11) 0.64 (0.07) fluid ldh (u/l) 613 (212 – 51,413)** 647.8 (395.25)* ldh ratio, median (range) 1.24 (0.59 – 28.28) 0.79 (0.6 – 3.58) t-spot.tb panel a – negative control (spot) 38 (4 – 314)** -2 (1 – 12)** panel b – negative control (spot) 27 (0 – 328)** 1.8 (4.7)* ada (u/l) 87.6 (48.9 – 461.5)** 17.95 (10.17)* * mean (sd), ** median (range) tabel 2. 2x2 table of diagnostic test gold standard total positive negative t-spot.tb positive 39 1 40 negative 0 8 8 total 39 9 48 results were statistically different with the results in non pleural tb group with p-value <0.001. the median levels of ada were significantly higher in pleural tb group than in non pleural tb group as shown in table 1. from table 2, sensitivity, specificity, ppv, npv, lr+, and lrof t-spot.tb using pfmc for the diagnosis of pleural tb are 100% (95% ci 90.97-100%), 88.89% (95% ci 51.75-99.72%), 97.5% (86.84-99.94%), 100% (63.06-100%), 9 (1.42 – 57.12), and 0, respectively. discussion because tb disease can be difficult to diagnose, igra such as t-spot.tb has recently become popular as supportive diagnostic method for tb. however, igra cannot distinguish between active and latent tb infection (ltbi) or healed tb if performed on peripheral blood samples. in patients with pulmonary affection, bronchoalveolar cells but not pbmcs showed reactivity towards mycobacterial antigens. thus, vol 48 • number 1 • january 2016 use of pleural fluid interferon-gamma enzyme-linked immunospot assay 45 it is suggestive that whilst only a small number of antigen-specific t cells are found in peripheral circulation, highly activated, antigen-specific effector t cells accumulate at disease site and rapidly produce th-1-type cytokines.5 however, recently it was demonstrated that enumeration of mtb-specific mononuclear cells from the site of the infection by elispot can distinguish between active tb, ltbi, or other disease with a high diagnostic sensitivity and specificity. in smear-negative pulmonary tb, the mean numbers of esat-6 and cfp10 spots in lung mononuclear cells were 9.6and 7.9-fold higher than in pbmcs. in a smaller study on pleural tb where only esat-6 antigen was used, the mean number of esat-6 spots in pfmc was 15-fold higher than in pbmcs.8 in the present study, the possibility of a reliable and rapid diagnosis of pleural tb using a commercially available mtb-specific elispot in a routine clinical practice was further evaluated. average age of subjects in this study was 49 years (range 19 – 80 years). it is similar with an epidemiological analysis from the united states with the mean age of 7549 patients was 49 years. epidemiologically, pleural tb predominates in men with an overall male-to-female ratio of 2:1.9 in this study, the number of male subjects was slightly more than the number of female subjects. of 48 patients, 39 patients (81.25%) were diagnosed as having pleural tb, based on positive mgit culture and/or ada activity more than 40 u/l. the median/mean of pleural fluid wbc count was 1530 cells/µl in pleural tb group and 672 cells/µl in non pleural tb group (table 1). both of them are statistically different. in tb infection, cells, especially antigen-specific t cells, are recruited and clonally expand at the site of infection.5 this causes an increase in wbc count. the median/mean of mn cells count was 1203 cells/µl in pleural tb group and 546 cells/µl in non pleural tb group, and both groups are statistically significant. although neutrophils may be the predominant cells in the pleural cavity in the initial stage, t lymphocytes predominate thereafter. the compartmentalized inflammatory process increases the permeability of pleural capillaries. along with impaired lymphatic clearance due to parietal pleural involvement, this leads to pleural fluid formation and accumulation.9 protein as inflammatory products is accumulated in pleural fluid. a pleural fluid protein concentration greater than 5 g/dl is found in 70% patients.9 the enzyme lactat dehydrogenase (ldh) is found in the cells of many body tissues, especiallly heart, liver, lungs, brain, and skeletal muscle. when disease or injury affects the cells containing ldh, the cells lyse and ldh is spilled, causes an increase in ldh activity in pleural tb effusion.10 in this research, pleural fluid protein, fluid/serum protein ratio, pleural fluid ldh, and fluid/ serum ldh ratio were not statistically different between two groups. this is particularly because in this research we only include patient with exudative pleural fluid based on light’s criteria. the elispot assay was positive in all 39 patients (100%) with pleural tb. in pleural tb patients, the number of immunospots in the pleural fluid elispot assay was much higher than the number of immunospots in non pleural tb patients. the median value in pleural tb group was 38 for the esat-6 antigen (range 4–314) and 27 for the cfp10 antigen (range 0–328) (table 1). the median value of immunospots in non pleural tb group was -2 for esat-6 antigen (range 1–12) and 1.8 (sd 4.7) spots for cfp10 antigen. both groups showed significantly difference with p-value of <0.001. this is because the number of antigen-specific t cells in pleural tb is higher and these cells secrete more ifn-γ when stimulated. a false-positive result of pleural fluid elispot was obtained for one patient, probably due to the non-specific ifn-γ present in the effusion before m. tuberculosis antigen stimulation which trapped at the bottom of the well immediately after the fluid was added.11 furthermore, esat-6 and cfp10 are absent from all bcg strains and from non-tuberculous mycobacteria with the exception of m. kansasii, m. szulgai, and m. marinum.12 in the diagnosis of pleural tb, ada activity is highly sensitive, simple, speed, and relatively cheap. they cause the widespread implementation and routine utilization of this assay. in this research, ada activity was higher in pleural tb group than in non pleural tb group tika adilistya acta med indones-indones j intern med 46 with p-value of <0.001 (table 1). increased ada activity in pleural tb is due largely to increased activity of the ada isoenzyme ada-2, together with the fact that only cells in which ada-2 has been found are monocyte and macrophage. stimulation of those cells by live phagocytosed microorganisms will cause cells to release ada.4,8 in this research, the sensitivity, specificity, positive predictive value, and negative predictive value of the igra elispot assay using pfmc for the diagnosis of pleural tb were 100%, 88.89%, 97.5%, and 100%, respectively.a meta-analysis of 19 studies showed that pooled sensitivity and pooled specificity for the pleural fluid igra assay were 72% (95% ci, 55% 84%) and 78% (95% ci, 65% 87%), respectively.13 as sensitivity of t-spot.tb was 100%, theoretically this test is appropriate for screening purpose. as specificity of t-spot.tb was only 88.89%, positive test results should always be furtherly evaluated with caution because there is a chance of 11.11% of false positive. as ppv of t-spot.tb was 97.5%, if a patient with presumptive pleural tb gets positive result, the chance of this patient to be really sick is 97.5%. as npv of t-spot.tb was 100%, negative result of patients with presumptive pleural tb always ruled out a diagnosis of active pleural tb. there are some limitations involved in the use of igra in the diagnosis of pleural tb using pleural fluid specimen. first, the t-spot.tb assay is validated for pbmc sample therefore the cut-off level for pbmc is well defined while the cut-off level for pfmc sample has not yet been defined. several previous reports have used various cut-off levels derived in heterogeneous settings, this must be a problem in routine clinical practice. a large, comparative study is required to determine the appropriate cut-off levels for positivity, and this may be different in areas with a low or high incidence of tb. second, pleural tb could only be confirmed by tb culture in less than half of cases (data not shown). however, we have implemented a strict exclusion criteria. in our clinical practice, considering that our country has a high tb-burden setting, presumptive pleural tb patients with exudative pleural fluid, high ada activity, with other common causes of pleural effusion (liver failure, kidney failure, malignancy, congestive heart failure) are already excluded, will be given tb therapy although they have negative tb culture. conclusion the igra elispot assay, t-spot. tb,using pleural fluid samples showed a high diagnostic accuracy for diagnosing pleural tb in a high burden setting of tb infection. it suggests that t-spot.tb assay may be an adjunctive but useful method in the diagnosis of pleural tb. acknowledgments the research was financially supported by ciptomangunkusumo hospital research grant 2015. references 1. kang jy, rhee ck, kang nh, kim js, yoon hk, song js. clinical utility of two interferon-gamma release assays on pleural fluid for the diagnosis of tuberculous pleurisy. tuberc respir dis. 2012;73:143-50. 2. liao m, yang q, zhang j, et al. gamma interferon immunospot assay for pleural effusion mononuclear cells for diagnosis of tuberculous pleurisy. clin vaccine immunol. 2014;21(3):347-53. 3. reuter h. pleural effusion and empyema in adult tuberculosis. in: schaaf hs, zumla ai, grange jm, et al, eds. tuberculosis, a comprehensive clinical reference. 1st ed. london: elsevier saunders; 2009. p. 342-50. 4. abdallah am, gey van pittius nc, champion pa, et al. type vii secretion—mycobacteria show the way. nat rev microbiol. 2007;5(11):883-91. 5. nemeth j, winkler hm, zwick rh, et al. recruitment of mycobacterium tuberculosis specific cd4+ t cells to the site of infection for diagnosis of active tuberculosis. j intern med. 2009;265(1):163-8. 6. light rw. diagnostic principles in pleural disease. eur respir j. 1997;10:476-81. 7. light rw. update on tuberculous pleural effusion. respirology. 2010;15:451-8. 8. losi m, bossink a, codecasa l, et al. use of a t-cell interferon-gamma release assays for the diagnosis of tuberculous pleurisy. eurrespir j. 2007;30(6):1173-9. 9. porcel jm. tuberculous pleural effusion. lung. 2009;187:263-70. 10. pagana kd, pagana tj. mosby’s manual of diagnostic and laboratory test. 5th ed. st. louis: elsevier mosby; 2014. p. 329-30. 11. lee ln, chou ch, wang jy, et al. enzyme-linked immunospot assay for interferon-gamma in the diagnosis of tuberculous pleurisy. clin microbiol vol 48 • number 1 • january 2016 use of pleural fluid interferon-gamma enzyme-linked immunospot assay 47 infect. 2009;15(2):173-9. 12. anonymous. t-spot®.tb, an aid in the diagnosis of tuberculosis infection, 96-well plate format. [package insert]. oxon: oxford immunotec; 2007. 13. aggarwal an, agarwal r, gupta d, dhooria s, behera d. interferon gamma release assays for diagnosis of pleural tuberculosis: a systematic review and metaanalysis. j clin microbiol. 2015;53(8):2451-9. 360 original article acta med indones indones j intern med • vol 52 • number 4 • october 2020 sexual dysfunction reduction in female patients with chronic kidney disease undergoing continuous ambulatory peritoneal dialysis gede wirya k. duarsa1, yenny kandarini2, luciana3, ida b. p. pramana1, g e d e wi r a t a 4, pa n d e ma d e w. ti r t a y a s a 1, i wa y a n yu d i a n a 1, kadek b. santosa1, anak agung gde oka1 1 department of urology, faculty of medicine universitas udayana sanglah hospital, denpasar, bali, indonesia. 2 department of internal medicine, faculty of medicine universitas udayana sanglah hospital, denpasar, bali, indonesia. 3 department of surgery, faculty of medicine universitas udayana sanglah hospital, denpasar, bali, indonesia. 4 department of anatomy, faculty of medicine universitas udayana sanglah hospital, denpasar, bali, indonesia. corresponding author: gede wirya kusuma duarsa, md. department of urology, faculty of medicine universitas udayana sanglah hospital jl. p.b. sudirman, denpasar, bali 80232, indonesia. email: gwkduarsa@yahoo.com. abstrak latar belakang: penyakit ginjal kronis (pgk) merupakan masalah kesehatan utama di dunia. salah satu pengobatan kunci untuk pasien pgk stadium akhir dilakukan dengan terapi dialisis seperti continuous ambulatory peritoneal dialysis (capd). penelitian ini bertujuan untuk mengetahui perbedaan kejadian disfungsi seksual pada wanita dengan pgk oleh capd. metode: penelitian ini merupakan penelitian observasional analitik multisenter dengan sampel wanita sebelum dan sesudah capd. dilakukan antara november 2018 januari 2019 dengan 26 responden perempuan. mereka dinilai menggunakan kuesioner indeks fungsi seksual wanita (fsfi) pada pra-capd dan pasca-capd. hasil: hasil skor fsfi sebelum capd adalah 32,77 (sb 19,72) dan setelah capd adalah 48,88 (sb 20,29). analisis perbedaan skor fsfi sebelum dan sesudah capd menunjukkan bahwa terdapat perbedaan yang signifikan (p = 0,003). kesimpulan: wanita pgk yang menjalani capd mengalami peningkatan skor fsfi dibandingkan sebelum capd. dengan demikian, penggunaan capd dapat dilihat untuk mengurangi disfungsi seksual dan meningkatkan kualitas hidup wanita dengan pgk. kata kunci: indeks fungsi seksual wanita, disfungsi seksual, terapi dialisis, penyakit ginjal stadium akhir. abstract background: chronic kidney disease (ckd) is a major worldwide health problem. one key treatment for endstage ckd patients is dialysis therapy such as continuous ambulatory peritoneal dialysis (capd). this study aimed to find out the differences in the incidence of sexual dysfunction in women with ckd by capd. methods: this study was a multicenter observational analytic study design in female samples before capd and after capd. it was conducted between november 2018 january 2019 with 26 female respondents. they were assessed using the female sexual function index (fsfi) questionnaire at pre-capd and post-capd. results: the results of the fsfi score before capd were 32.77 (sd 19.72) and after capd was 48.88 (sd 20.29). analysis of differences in fsfi scores before and after capd demonstrates that there was a significant difference (p = 0.003). conclusion: women with ckd who underwent capd, had an increase in fsfi scores compared to before capd. thus, the use of capd can be seen to reduce sexual dysfunction and therefore improve the quality of life of women with ckd. keywords: female sexual function index, sexual dysfunction, dialysis therapy, end-stage renal disease. vol 52 • number 4 • october 2020 sexual dysfunction reduction in female patients with ckd 361 introduction chronic kidney disease (ckd) is still a major health problem for people around the world. the prevalence of ckd varies from country to country. population-based health surveys in europe report a 10.2% prevalence of ckd in norway.1 treatment for end-stage ckd patients is carried out by administering dialysis therapy such as hemodialysis (hd) and peritoneal dialysis aimed at maintaining the quality of life of patients. hd is the third choice of renal replacement therapy after kidney transplantation and peritoneal dialysis. besides hd, the use of peritoneal dialysis has also increased sharply. a large cohort in canada with patient respondents using peritoneal dialysis showed an increase in patient life expectancy. during 2012, the mortality rates for continuous ambulatory peritoneal dialysis (capd) and hd were almost the same, 1.55 and 1.60 per 1,000 patients. this is due to better infection control and the application of vascular access and the use of cardioprotective drugs.2 in 2017 according to the indonesia renal registry (irr), there were 30,831 new patients, and 77,892 active patients. the number of ckd patients who received capd therapy in december 2017 was 1,737, and the proportion between hd and capd patients were 98% and 2%, respectively.3 dependence on hd and capd can cause changes in the lives of ckd patients. changes that will occur in patients undergoing hemodialysis i n c l u d e p h y s i c a l c h a n g e s , p s y c h o s o c i a l changes, and financial changes. various studies from diverse geographical and socio-cultural backgrounds show similar problems globally. sexual dysfunction in women is a multifactorial problem that requires a valid and structured diagnostic instrument. one of the instruments to evaluate female sexual function is the female sexual function index (fsfi) questionnaire. this questionnaire can be used as a tool to detect early sexual dysfunction disorders in ckd women so that management can be undertaken earlier.4 a meta-analysis conducted by stripolli et al.5 suggested that 84% of women undergoing dialysis experience sexual dysfunction using the fsfi questionnaire. sexual dysfunction very often occurs in around 60-70% of women with ckd, especially those who use dialysis therapy.6 in italy in 2012, santos et al.7 stated that the prevalence of sexual dysfunction in women undergoing hemodialysis had reached 84%. based on the evidence above, we aimed at finding out the differences in the incidence of sexual dysfunction in women with ckd by capd. methods this study was a multicenter observational comparative study in both the division of nephrology, department of internal medicine, medical faculty, universitas udayana, sanglah general hospital, denpasar, bali, and the department of the kidney and hypertension, renal health hospital ny. r.a. habibie bandung. the study was conducted prospectively starting in november 2018 and running until january 2019. this research has been approved by the research ethical committee of medical faculty universitas udayana and sanglah general hospital no 2655/un 14.2.2.vii.14/ lp/2018. the inclusion criteria were female patients with ckd ranging in age from 17 years to 65 years, who performed capd for at least 3 months. patients who met the inclusion criteria were assessed using fsfi questionnaire at precapd and post-capd. the fsfi or female sexual function index is a short questionnaire that describes a woman’s sexual function in order to assess the domain of sexual function which includes sexual arousal, desire, orgasm, satisfaction, pain, lubrication, and was given to patients who met the inclusion criteria. this questionnaire has been examined by two groups of researchers in america, and validated and published in the journal of sex and marital therapy in 2000.8 descriptive statistical analysis aims to describe the characteristics of research subjects and describe research variables. numerical data scale variables are described using mean, median and standard deviation, while categorical data scale variables are described using relative frequency. the results of the descriptive statistical analysis are illustrated in a single table. bivariate gede w.k. duarsa acta med indones-indones j intern med 362 analysis was used to determine differences in fsfi scores before and after capd. before the bivariate analysis was performed, the data was tested for normality using kolmogorov-smirnov, and data homogeneity was assessed by the levene test. if the data was found to be normally distributed then a paired t-test was performed. if the data was not normally distributed then the wilcoxon sign rank test was performed. results the study involved 26 female respondents with ckd, who underwent capd for at least 3 months in sanglah general hospital denpasar and rskg ny. r.a. habibie bandung (table 1). the mean age of respondents was 43.65 (sd 9.96) years. respondents have a good body mass index, lipid profile, and blood sugar. the mean capd duration was 4.4 (sd 2.4) years and ckd duration was 5.3 (sd 2.5) years. determine the difference between the fsfi score before the capd and after the capd (table 2). the results of the analysis contained different fsfi scores before and after capd (p = 0.003). discussion a study by hansson and watnick2 stated that the prevalence of peritoneal dialysis use increased by 9.7% among ckd patients. this increase was due to more cost-effective financing compared to hd. the availability of proper and functioning peritoneum is very important for the success of treatment in peritoneal dialysis. sinnakirouchenan and holley9 also stated that quality of life was better in capd, especially at the beginning of dialysis. in this study, the mean bmi, blood pressure, blood sugar levels, and lipid profile of respondents were still within normal limits. esposito et al.’s10 research, examining the relationship between obesity and sexual function in women who use the fsfi score, found that there is an inverse relationship between bmi and fsfi scores, where a high bmi is found to have a low fsfi score. in addition, the condition of hypertension was found to cause sexual dysfunction in 42.1% of women.11 saraswati and funistera’s research,12 highlighted that sexual dysfunction in women with diabetes was significantly higher than in the control group (27% and 15%, p = 0.04). women with diabetes generally have more dysfunction in sexual interests / desires, lust, lubrication, and orgasm, than women without diabetes. research by esposito et al.13 found a positive association of hdl cholesterol levels with fsfi scores. in addition, women with hyperlipidaemia have a higher prevalence of sexual dysfunction. the results showed that there was a significant difference when comparing the fsfi score before the capd was performed with the fsfi score table 1. characteristics of respondents undergoing capd. variables n ages mean (sd), years old 43.65 (9.96) bmi mean (sd), kg/m2 21.9 (5.19) systolic blood pressure mean (sd), mmhg 136.15 (22.15) diastolic blood pressure mean (sd), mmhg 86.54 (10.56) blood sugar mean (sd), mg/dl 114.4 (27.4) total cholesterol mean (sd), mg/dl 195.1 (52.04) ldl mean (sd), mg/dl 120.7 (49.4) hdl mean (sd), mg/dl 45.5 (12.28) triglyceride mean (sd), mg/dl 170.5 (88.13) capd duration mean (sd), years 4.4 (2.4) ckd duration mean (sd), years 5.3 (2.5) menopause period, n (%) yes 14 (53.00) non 12 (47.00) fsfi score before capd mean (sd) 32.77 (19.72) fsfi score after capd mean (sd) 48.88 (20.29) bmi: body mass index, ldl: low density lipoprotein, hdl: high density lipoprotein, fsfi: female sexual function index, sd: standard deviation. when analysing the fsfi score before and after the capd, it was noted that there was an increase in the mean score after the capd. the wilcoxon sign rank test was then performed to table 2. difference between fsfi score before and after capd. variables mean rank p value fsfi score after capd treatment < fsfi score before capd 10.2 0.003 fsfi score after capd treatment > fsfi score before capd 13.7 vol 52 • number 4 • october 2020 sexual dysfunction reduction in female patients with ckd 363 after the capd was performed, (p = 0.003). endocrine abnormalities in women with ckd primarily decrease estrogen production causing vaginal dryness and dyspareunia, which can contribute to decreased sexual function. about 65% of women who have hd report sexual dysfunction problems and up to 40% report that they no longer have sexual relations. so, it can be concluded that although infertility in women with kidney disease, especially as a result of abnormal endocrine function, causes anovulation, lack of sexual activity can also contribute to the low rate of pregnancy in these women.14 lowstarovikz’s research in asdifard,15 mentions that the sexual problems of women undergoing hd are disorders of sexual arousal and failure to orgasm. the main problems suffered by ckd women are lack of sexual desire, decreased vaginal lubrication, failure of orgasm, vaginism, and dyspareunia and infertility. depression, anxiety and sleep disorders are among the factors related to the sexual function of women undergoing hd.16 based on a multinational study, crosssectional analysis has evaluated potential associations for each domain, but only one of them conducted an analysis that was adjusted for demographic and clinical characteristics. older age, hypertriglyceridemia and higher scores on the beck depression inventory (bdi) scale for assessment of depression symptoms were associated with lower scores in each sexual dimension of women on hemodialysis. the presence of depression was associated with worse lubrication and pain scores (mean difference for depressed versus non-depressed women, respectively) while women who had experienced a previous cardiovascular event reported higher pain scores. in conclusion, women in hemodialysis reported scores consistent with marked low sexual functioning across a range of domains; the low functioning appeared to be associated with a comorbidity.17 francois and bargman16 stated that capd is an effective kidney replacement strategy for patients suffering from end-stage renal disease. capd offers patient survival comparable to or better than regular hd in maintaining residual kidney function, empowering patient autonomy, and reducing financial burdens. in patients with cardio renal syndrome and uncontrolled fluid status, it can reduce the level of hospitalization and duration. scientific reports demonstrate that research aimed to compare health-related quality of life (hrqol) over time in patients initiating hemodialysis (hd) or peritoneal dialysis (pd). hrqol was assessed 3, 12, and 24 months after the start of dialysis. the adjusted three-month scores of patients on pd showed better hrqol in eight end-stage renal disease (esrd), three physical component summary domains and one mental component summary domain, compared with patients on hd. both patients on hd and pd experienced significant decreases in different hrqol domains over two years and the degree of changes in hrqol over time was not different between dialysis modality. however, the scores of three domains (effects of kidney disease, burden of kidney disease, and dialysis staff encouragement, all p < 0.05) and two other esrd domains (sexual function and dialysis staff encouragement, all p < 0.05) were still higher in patients on pd compared with patients on hd at one and two years after initiation of dialysis, respectively. pd shows better hrqol during the initial period after dialysis even after adjusting for clinical and socioeconomic characteristics, and the effect lasts up to two years. patients on pd were bothered less by the burden of esrd, symptoms, and pain, and were able to continue their jobs more compared with those on hd. these results can be explained by the fundamental differences in dialysis method between hd and pd. further, patients receiving pd maintained social interaction and social support more actively, had more satisfaction with dialysis staff encouragement, and ultimately felt better general physical health and emotional wellbeing compared with those undergoing hd. the results of a longitudinal follow-up revealed that patients on hd had more problems with sexual function and sleep, as well as experiencing decreased patient satisfaction over time since beginning dialysis.18 loss of clearance in ckd leads to accumulation of waste products from metabolism that increase to potentially damaging concentrations and gede w.k. duarsa acta med indones-indones j intern med 364 thereby become uremic toxins. in esrd, potentially noxious metabolites may increase >10-fold, particularly preceding a dialysis session. among classes of uremic toxins are catabolic and degradation products of essential nutrients and cofactors. although similar in structure to their precursor but nonfunctional, uremic toxins may have a potentially damaging function as antimetabolites. the inhibition of transketolase was reversible, although the identity of the inhibitor was difficult to discern. the inhibitor was of low molecular weight and was initially considered to be guanidinosuccinic acid. low levels of guanidinosuccinic acid in the plasma of patients with decreased red blood cell transketolase activity, a lack of correlation of guanidinosuccinic acid concentration to inhibition of transketolase activity, and the failure of guanidinosuccinic acid to inhibit transketolase activity in red blood cells ex vivo suggested that other compounds are likely involved. disturbance of levels of pentose phosphate pathway metabolites in peripheral nerves in vivo regulated by transketolase activity and recovery of this by hemodialysis (hd) indicated reversible inhibition of transketolase. transketolase activity was also decreased in patients with capd. this occurred in the presence of normal levels of plasma thiamine and red blood cell tpp. the mechanism of reversible inhibition of transketolase in renal failure has remained unresolved for more than 40 years.19 conclusion sexual dysfunction in women with ckd is quite high. in ckd women who underwent capd, had an increase in fsfi scores compared to those before capd. thus, the use of capd can be seen to reduce sexual dysfunction and can improve the quality of life of women with ckd. authorship all authors state that they meet the current icmje criteria for authorship. conceptualization, g.w.k.d.; methodology, g.w.k.d., and g.w.; investigation, k.b.s., i.w.y., p.m.w.t., and a.a.g.o.; writing – original draft, l.; writing – review & editing, g.w.k.d., i.b.p.p., and g.w.; supervision and resources, g.w.k.d., and i.b.p.p.; data curation, l., and y.k.; formal analysis, g.w. declaration of competing interest the authors state that they do not have any competing interests with regard to this research. references 1. hwang sj, tsai jc, chen hc. epidemiology, impact and preventive care of chronic kidney disease in taiwan. nephrology (carlton). 2010;15:3-9. 2. hansson jh, watnick s. core curriculum in nephrology update on peritoneal dialysis: core curriculum 2016. am j kidney dis. 2016;67:151-64. 3. indonesian renal registry. 10th report of indonesian renal registry. 2017. 4. rehman ku, asif mahmood m, sheikh ss, sultan t, khan ma. the female sexual function index (fsfi): translation, validation, and cross-cultural adaptation of an urdu version “fsfi-u”. sex med. 2015;3:244-50. 5. strippoli gf, vecchio m, palmer s, et al. collaborative depression and sexual dysfunction (cds) in hemodialysis working group. sexual dysfunction in women with esrd requiring hemodialysis. clin j am soc nephrol. 2012;7:974-81. 6. kim jh, doo sw, yang wj, et al. association between the hemodialysis adequacy and sexual dysfunction in chronic renal failure: a preliminary study. bmc urology. 2014;14:4. 7. santos pr, capote jr jr, cavalcanti ju, et al. quality of life among women with sexual dysfunction undergoing hemodialysis: a cross-sectional observational study. health qual life outcomes. 2012;10:103. 8. rosen r, brown c, heiman j, et al. the female sexual function index (fsfi): a multidimensional selfreport instrument for the assessment of female sexual function. j sex marital ther. 2000;26:191-208. 9. sinnakirouchenan r, holley jl. peritoneal dialysis versus hemodialysis: risks, benefits and access issues. adv chronic kidney dis. 2011;18:428-32. 10. esposito k, maiorino mi, bellastella g, giugliano f, romano m, giugliano d. determinants of female sexual dysfunction in type 2 diabetes. int j impot res. 2010;22:179-84. 11. levin rj, both s, georgiadis j, kukkonen t, park k, yang cc. the physiology of female sexual function and the pathophysiology of female sexual dysfunction (committee 13a). j sex med. 2016;13:733-59. 12. saraswati mr, funistera ss. disfungsi seksual pada wanita penderita diabetes melitus tipe 2. j peny dalam. 2011;12:92-7. 13. e sposito k , c iotola m, maiorino mi, et al. hyperlipidemia and sexual function in premenopausal women. j sex med. 2009;6:1696-1703. vol 52 • number 4 • october 2020 sexual dysfunction reduction in female patients with ckd 365 14. anantharaman p, schmidt rj. sexual function in chronic kidney disease. adv chronic kidney dis. 2007;14:119-25. 15. asdifard f, mohamadi sz, heidari tbb. sexual function of women with chronic renal failure undergoing hemodialysis and factors related to it. iran j crit care nurs. 2013;5:204-13. 16. françois k, bargman jm. evaluating the benefits of home-based peritoneal dialysis. int j nephrol renovasc dis. 2014;7:447-55. 17. saglimbene v, natale p, palmer s, et al. the prevalence and correlates of low sexual functioning in women on hemodialysis: a multinational, cross-sectional study. plos one 2017; 12(6); 1-12. 18. jung hy, jeon y, park y, et al. better quality of life of peritoneal dialysis compared to hemodialysis over a two-year period after dialysis initiation. scientific reports. 2019-9:10266;1-1. 19. fang z, jinit m, attia a, et al. the uremic toxin oxythiamine causes functional thiamine deficiency in end-stage renal disease by inhibiting transketolase activity. 2016-8;396-403. 320 original article acta medica indonesiana the indonesian journal of internal medicine plasma sodium in relation with the extracellular fluid volume in chronic hemodialysis patients parlindungan siregar department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. correspondence mail: division of nephrology and hypertension, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta, indonesia. email: sparlindungan@yahoo.com. abstrak tujuan: memperoleh hubungan sebab akibat antara perubahan kadar natrium dalam plasma dan meningkatnya volume cairan ekstraselular pada pascahemodialisis dan prahemodialisis jadual dialisis berikutnya atau kadar natrium dalam plasma berfungsi sebagai prediktor volume cairan ekstraselular. metode: penelitian ini mengikutsertakan 40 subjek yang dipilih secara acak dari 247 pasien hemodialisis di unit hemodialisis, divisi nefrologi dan hipertensi, departemen penyakit dalam, fakultas kedokteran universitas indonesia – rs cipto mangunkusumo yang memenuhi kriteria inklusi dan eksklusi. dilakukan pemeriksaan kadar natrium dalam plasma, berat badan pascahemodialisis dan prahemodialisis jadual dialisis berikutnya. hasil: tidak ada perbedaan kadar natrium plasma yang bermakna antara pascahemodialisis dan prahemodialisis pada jadual dialisis berikutnya. meskipun demikian, terdapat perbedaan berat badan yang cukup berarti antara pascahemodialisis dan prahemodialisis pada jadual dialisis berikutnya (p=0,0000). pada analisis regresi yang dilakukan untuk meneliti hubungan antara perbedaan kadar natrium prahemodialisis dikurangi dengan kadar natrium pasca-hemodialisis sebelumnya (y) dan perbedaan berat badan prahemodialisis dikurangi dengan berat badan pasca-hemodialisis sebelumnya, ditemukan hubungan sebab akibat yang bermakna dengan rumus regresi berupa y = 2,205 + 0,937 x. kesimpulan: kadar natrium plasma pada pasien hemodialisis kronik dapat dipakai sebagai prediktor volume cairan tubuh atau volume cairan ekstraselular. di setiap unit dialisis, pertambahan berat badan yang dianjurkan untuk pasien adalah 2,5 kg-2.9 kg agar dapat mencegah penurunan kadar natrium dalam plasma yang bermakna, yang dapat berujung pada kematian. kata kunci: kadar natrium dalam plasma, pertambahan berat badan, hemodialisis. abstract aim: to obtain a causal relationship between changes in plasma sodium levels and increased extracellular fluid volume between post-hemodialysis and pre-hemodialysis on the following day or plasma sodium serves as a predictor of extracellular fluid volume. methods: the study was conducted on 40 subjects randomly selected from the 247 chronic hemodialysis patients in hemodialysis unit of nephrology and hypertension division, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital that met the inclusion and exclusion criteria. their plasma sodium levels, post-hemodialysis weight and prehemodialysis weight on the following day were examined. results: there was no significant difference in the plasma sodium levels between post-hemodialysis and pre-hemodialysis on the following day. however, there was a considerable differences between post-hemodialysis weight and pre-hemodialysis weight on the following day (p = 0.0000). in regression analysis that were conducted on the relationship between the difference in prehemodialysis sodium levels subtracted by previous post-hemodiaysis sodium levels (y) and the difference in vol 46 • number 4 • october 2014 plasma sodium as a predictor of extracellular fluid volume 321 introduction sodium is the major cation in the extracellular fluid, as well as the main determinant of solute effective plasma osmolality and tonicity. in the state of hyponatremia, the plasma osmolality /tonicity will decrease, while the opposite situation occurs in the state of hypernatremia. furthermore, increase of water volume in the extracellular fluid will cause a decrease in osmolality or hyponatremia, while hypernatremia or increased plasma osmolality occurs in the opposite situation. under normal renal urine concentrating function, an increase or decrease in plasma osmolality will increase or decrease the secretion of adh (antidiuretic hormone) from the hypothalamus into the blood, causing increase or decrease water reabsorption in the renal collecting ducts in order to restore plasma osmolality to normal direction. similarly, an increase or decrease in extracellular fluid volume will affect the carotid baroreceptors, right atrium/ventricle, and renal afferent artery, aimed to increase or decrease sodium excretion via the kidney collecting ducts in order to restore plasma volume/extracellular fluid to the normal condition.1-3 in stage 5 of chronic kidney disease (ckd), nephron function has decreased considerably. therefore, the osmotic regulation that affects the plasma osmolality through the influence of adh as well as volume regulation that control the sodium excretion through the influence of baroreceptors could not function normally anymore. 4-6 consequently, in ckd stage 5, extracellular fluid osmolality is strongly influenced by changes in the water volume of the extracellular fluid. fluctuations in the sodium levels of the extracellular fluid or plasma in stage ckd 5 is only affected by the rise or fall of the fluid volume.7 serum sodium is strongly correlated with residual renal function (rrf), hyponatremia being associated with lower rrf.8 intradialytic weight gain (iwg) or increase in extracellular fluid volume is correlated with several nutritional and dialytic variables and with parameters that predict survival in hd patients.9 increase in extracellular fluid volume is always occurs in patients undergoing chronic hemodialysis. in their investigation, mc causland fr et all found that the pre-dialysis serum sodium concentration appears to be unaffected by the dialysate sodium concentration in maintenance hemodialysis.10 extracellular fluid volume assessment is one of the parameters in succeeding the hemodialysis (hd) program for patients. clinically, weightgaining during inter-hemodialyisis is an indicator of extracellular fluid volume expansion. in the management of chronic hd patients, the determination of dry weight is necessary in order to prevent the incidence of pulmonary edema due to excess extracellular fluid and reducing cardiovascular complications. determination of dry weight as well as maintain its stability is important in the management of patients in hemodialysis. research conducted by waikar ss et al.11,12, concluded that the lower the sodium levels in pre-hemodialysis, and in the hospitalized patiens, the higher the mortality rate. this suggests that in patients in chronic hemodialysis, normal sodium levels need to be maintained to avoid an increase in mortality rate. prediction of the amount of extracellular fluid volume based on plasma sodium levels become very important, because then we can determine either the increase in extracellular fluid volume or how much weight is gained compare to dry weight of the patient to prevent hyponatremia during subsequent hemodialysis. pre-hemodialysis weight subtractted by previous post-hemodialysis weight (x), a significant causal relationship was found with the regression formula of y = 2.205 + 0.937 x. conclusion: plasma sodium levels in chronic hemodialysis patients can be used as predictors of body fluid volume or extracellular fluid volume. at each dialysis unit, the recommended weight gain for the patients are 2.5 kg-2.9 kg, in order to prevent a significant decrease in plasma sodium levels that could lead to mortality. key words: plasma sodium, weight gain, hemodialysis. parlindungan siregar acta med indones-indones j intern med 322 therefore, the purpose of this research is to determine plasma sodium levels in relation to the of extracellular fluid volume in chronic hemodialysis patients. methods interventional study was conducted to compare the post-hemodialysis body-weight and blood sodium level with the following day pre-hemodialysis body-weight and blood sodium level in chronic hemodialysis patient population at cipto mangunkusumo hospital, jakarta, indonesia. sampling for the study subjects were done by simple random sampling, using a random number table. chosen patients were then selected again according to the inclusion and exclusion criteria. patients that has undergone more than 3 months hemodialysis were included, while those who either suffer from diabetes mellitus or have random blood glucose level of more than 200 mg/dl were excluded. sample size determination was preceded by doing a research pilot on 35 chronic hemodialysis patients in dialysis unit of siloam hospital lippo-village tangerang. the sample size in this study was calculated with the formula for the two pairing groups and the formula for the correlation coefficient. a total sample of 40 subjects was obtained. subjects weighing done during post and pre-hemodialysis in the following day using the same type of scales for all subjects. sampling for examination of post-hemodialysis sodium level was done at the end of hemodialysis after blood flow (qb) was lowered to 50 ml/min for 10 minutes. sampling for examination of prehemodialysis sodium level was done during the insertion of vascular access for hemodialysis. statistical analysis was done using spss statistics 17 with setting of determining the difference between mean of post-hemodialysis sodium plasma and the mean of following pre-hemodialysis plasma sodium level, as well as the difference between the mean of post-hemodialysis weight and the mean of following pre-hemodialysis weight (comparative numerical variables of two pairing groups. paired t-test is done in normal distribution, while the wilcoxon test is done if the distribution is not normal). linear correlation/regression between the amount of weight gain (difference between pre-hemodialyisis weight and post-hemodialysis weight on the previous hemodialysis) and the difference in pre-hemodialysis plasma sodium levels subtracted by previous post hemodialysis plasma sodium levels were also calculated. the ethics committee of the faculty of medicine, universitas indonesia has given the approval for this study. results there are 40 subjects who participated in this study consisted of 21 men and 19 women, with mean age of 46.15±14.94 years. the mean post-hemodialysis plasma sodium was 137.20±2.17 meq/l, and mean of following day pre-hemodialysis plasma sodium was 137.53±3.15 meq/l. there was no significant difference between the mean of posthemodialysis and subsequent pre-hemodialysis sodium levels (p=0.54). (figure 1) the mean post-hemodialysis weight was 54.52±11.49 kg, while mean of following pre-hemodialysis weight was 57.20±11.66 kg. there was a significant difference between the mean post-hemodialysis and subsequent prehemodialysis weight (p=0.0000). (figure 2) p=0.54 post hd pre hd m e a n s o d iu m p la s m a ( m e q /l ) figure 1. mean sodium level in post-hemodialysis and prehemodialysis in the next session. there was a significant weak correlation between the difference in sodium level of pre-hemodialysis subtracted by previous posthemodialysis and the difference in the weight of pre-hemodialysis subtracted by previous postvol 46 • number 4 • october 2014 plasma sodium as a predictor of extracellular fluid volume 323 diffuse, the rest of the data was not segregated (figure 3). discussion based on the regression formula obtained in this study, in order to prevent a decrease in sodium levels from post-hemodialysis to pre-hemodialysis on the following day, the acceptable weight gain for each hemodialysis is of 2.35 kg. {y = 2.205 + (0.937 x 2.35) = 0}. in this study, it turns out that there was no significant difference between plasma sodium levels in post-hemodialysis and pre-hemodialysis on the next session. with the increase in extracellular fluid volume that was seen in the subsequent hemodialysis weight gain between 2.5 kg and 2.9 kg, a considerable decrease in plasma sodium levels were not found. this is understandable because the increase of weight between 2.5 kg and 2.9 kg, will lead to a decrease of plasma sodium levels between 0.14 meq/l and 0.5 meq/l, which is a not significant decrease. for example, to reduce about 10 meq/l of plasma sodium in the next session of hemodialysis, an increase in extracellular fluid volume of 8.32 liters or weight gain of 8.32 kg are required if the regression formula obtained in this study is used (10 = 2.205 + 0.937. 8,32). in analysis which was conducted from the regression calculation, about 14.4% of the regression model y function can be explained by factor x (r square = 0.144). if it is observed from this side, only 14.4% of change in plasma sodium levels are caused by an increase in extracellular fluid volume. this is most likely due to the addition of extracellular fluid volume or a weight gain of about 2.35 kg in the subsequent pre-hemodialysis (according to the calculation above, the addition of 2.35 kg does not lead to changes in sodium levels from post-hemodialysis to pre-hemodialalysis in the next session). from calculation of regression anova table, a value of f = 6.405 > (fα,1,n-2 = f0, 05.1.674 = 4.08) was found, showing the regression model of y = 2.205 + 0.937 x, which was relatively satisfying. based on this anova table analysis, this regression model can still be applied eventhough there were still some weaknesses listed above.13 hemodialysis (r=0.37, p=0.019). from calculation of regression between the difference in weight of pre-hemodialysis subtracted by previous post-hemodialysis and the difference in sodium level of pre-hemodialysis subtracted by previous post-hemodialysis a formula y= 2.205 + 0.937 x was obtained, and the r square was equivalent to 0.144. difference in sodium level of pre-hemodialysis subtracted by previous post-hemodialysis acts as dependent variable y, while the difference in weight of pre-hemodialysis subtracted by previous posthemodialysis acted as independent variable x. in the regression curve, it revealed that the data tend to follow a linear pattern. although somewhat p=0.0000 post hd pre hd m e a n w e ig h t (k g ) figure 2. mean weight in post-hemodialysis and prehemodialysis in the next session. difference in pre-post sodium level difference in weight figure 3. regression curve of difference in sodium level of pre-hemodialysis subtracted by previous post-hemodialysis and the difference in the weight of pre-hemodialysis subtracted by previous post-hemodialysis. parlindungan siregar acta med indones-indones j intern med 324 conclusion plasma sodium levels can be used as a predictor of extracellular fluid volume in patients on hemodialysis. there is a relationship between changes in plasma sodium levels in the next session of hemodialysis. in chronic hemodialysis patients are recommended to have interhemodialysis weight gain, of 2.5 kg 2.9 kg, in order to prevent decreased plasma sodium levels which will lead to increased mortality. references 1. darwis d, moenadjat y, nur bm, et al. gangguan keseimbangan air-elektrolit dan asam-basa. fisiologi, patofisiologi, diagnosis dan tatalaksana. 2nd ed. jakarta: upk-pkb, fakultas kedokteran universitas indonesia; 2008. 2. halperin ml, kamel ks, goldstein mb. fluid, electrolyte, and acid-base physiology. a problem-based approach. 4th ed. philadelphia: saunders-elsevier; 2010. 3. rose bd, post tw. volume regulation versus osmoregulation. in: basow ds, waltham ma, ed. 2012. 4. yeh bpy, tomko dj, stacy wk, et al. factor influencing sodium and water excretion in uremic man. kidney int. 1975;7:103-10. 5. cherney dz, zevallos g, oreopoulos d, halperin ml. a physiological analysis of hyponatremia: implications for patients on peritoneal dialysis. perit dial int 2001;21:7-13. 6. zevallos g, oreopoulos d, halperin ml. hyponatremia in patients undergoing capd: role of water gain and/ or malnutrition. perit dial int. 2001;21:72-6. 7. hecking m, kainz a, horl wh, et al. sodium setpoint and sodiumgradient: influence on plasma sodium change and weight gain. am j nephrol. 2011;33:39-48. 8. dimitriadis c, sekercioglu n, pipili c, oreopoulos dg, bargman jm. hyponatremia in peritoneal dialysis: epidemiology in a single center and correlation with clinical and biochemical parameters. perit dial int. 2013 may 1. [epub ahead of print]. 9. kimmel pl, varela mp, peterson ra, et al. interdialytic weight gain and survival in hemodialysis patients: effects of duration of esrd and diabetes mellitus. kidney int. 2000;57(3):1141–51. 10. mc causland fr, steven m. brunelli sm, waikar ss. dialysate sodium, serum sodium and mortality in maintenance hemodialysis. nephrol dial transplant. 2012;27:1613–18. 11. waikar ss, curhan gc, brunelli sm. mortality associated with low serum sodium concentra tion in maintenance hemodialysis. am j med. 2011;124:7784. 12. waikar ss, mount db, curhan gc. mortality after hospitalization with mild, moderate, and severe hyponatremia. am j med. 2009;122:857-65. 13. pramesti g. panduan lengkap spss 13.0 dalam mengolah data statistik. jakarta: pt elex media komputindo kelompok gramedia; 2006. case report 82 acta med indones indones j intern med • vol 53 • number 1 • january 2021 the ‘great imitator’: a case of covid-19 presenting with encephalitis and acute coronary syndrome guntur darmawan1,2,3, samadhi tulus makmud4 1 department of internal medicine, faculty of medicine, krida wacana christian university, jakarta, indonesia. 2 department of internal medicine, sumber waras general hospital, jakarta, indonesia. 3 department of internal medicine, faculty of medicine, universitas padjadjaran, bandung, indonesia. 4 department of neurology, sumber waras general hospital, jakarta, indonesia. corresponding author: guntur darmawan, md. department of internal medicine, faculty of medicine, krida wacana christian university. jl. arjuna utara no. 6, jakarta 11470, indonesia. email: guntur.darmawan@ukrida.ac.id. abstrak meskipun manifestasi tipikal coronavirus disease-19 (covid-19) adalah gejala saluran nafas, covid-19 dapat memiliki tampilan awal klinis gejala ekstra-pulmonal. kami melaporkan satu kasus menarik covid-19 pada pasien perempuan dengan gejala awal gangguan sistem saraf pusat dan infark miokardial. keterlibatan multiorgan pada infeksi covid-19 memungkinkan presentasi klinis atipikal yang mungkin terabaikan oleh klinisi. kata kunci: covid-19, manifestasi ekstra-pulmonal, infark miokard akut, kejang, kehilangan kesadaran. abstract although typically patients with coronavirus disease-19 (covid-19) have pulmonary symptoms atypical cases can occasionally present with extra-pulmonary symptoms. we report an interesting case of covid-19 female patient presenting with combination of central nervous system disorder and acute myocardial infarct as initial manifestation. multiorgan involvement in covid-19 might lead to multiple atypical presentation which could be overlooked by the physician. keywords: covid-19, extra-pulmonary manifestation, acute myocardial infarct, seizure, loss of consciousness. introduction coronavirus disease-19 (covid-19) has rapidly emerged as global pandemic and public health emergency. as it is officially named severe acute respiratory syndrome coronavirus 2 (sars-cov-2) by the international committee on taxonomy of viruses, clinical manifestation of covid-19 is mostly characterized by respiratory symptoms.1 however, several extrapulmonary symptoms have been reported as first clinical manifestation in covid-19 patient.2,3 here, we report a covid-19 patient having combination of central nervous system disorder and acute coronary syndrome as initial manifestations. case illustration a 41-year-old indonesian female presented to our institution due to loss of consciousness after a generalized seizure episode lasting for minutes within an hour prior to admission. she experienced episodes of headache, chest discomfort, shortness of breath and fever since the day before admission. no cough, sore throat, anosmia, or gastrointestinal symptoms were noted. past medical history was unremarkable vol 53 • number 1 • january 2021 the ‘great imitator’: a case of covid-19 presenting except hypertension for 1.5 year, treated with ramipril 5 mg/day. she did not smoke, drink alcohol, or use any illicit drug. she had just finished her menstruation 2 days prior to admission. she worked as an online-based motorcycle-taxi driver and had no history of travelling out of the city. on admission, the patient was comatose with initial blood pressure was 180/100 mmhg, heart rate was 110 beats/ minute, respiratory rate of 28 times/minute and body temperature was 390c. there was no cardiac murmur, no respiratory crackles or wheezes, and no rashes at general physical examination. her pupil was isochor with positive light reflects bilaterally. neck stiffness was absent. laboratory examination showed anemia (hemoglobin 6.1 g/dl, hematocrit 21.7%), thrombocytosis (742,000/µl) and leukocytosis (36,900/µl; differential count showing 94% neutrophil and 3% lymphocyte). peripheral blood smear demonstrated microcytic hypochromic anemia, leukocytosis with toxic granulation, neutrophilia, lymphocytopenia, and thrombocytosis with no morphology abnormality. serum electrolyte were low for potassium, calcium, and magnesium (1.6 mmol/l, 0.88 mmol/l, and 1.3 mg/dl respectively). c-reactive protein was normal, igm and igg anti sars-cov-2 results were nonreactive. urinary examination was unremarkable. patient’s serum troponin i level was elevated (1.43 ng/ml; normal value: 0.00-0.02 ng/ml). electrocardiogram revealed sinus rhythm with giant t wave inversion at v2-4. (figure 1) chest x-ray showed no pulmonary abnormality and brain ct was normal with no sign of edema, hemorrhage, or space occupying lesion. a provisional diagnosis of sepsis, encephalitis, nonst elevation myocardial infarct was made. patient was intubated and treated with continuous iv heparin, aspirin, clopidogrel, nitrate, bisoprolol, ramipril, statin, levofloxacin, ceftriaxone, dexamethasone, acyclovir, and correction of electrolyte. we also transfused packed red blood cells. bed side echocardiography examination demonstrated hypokinetic at mid-apical anterior, anteroseptal, and diastolic dysfunction. additional serum magnesium examination revealed hypomagnesemia (1.3 mg/dl) so that magnesium sulphate infusion was started. gram stain of bronchial sputum showed gram-negative bacilli and neither acid-fast bacilli nor potassium hydroxide 10% examinations was present. on day-3 of admission, the high-grade fever episodes were still persisted. repeat laboratory showed hemoglobin 10.1 g/dl, hematocrit 34.4%, leucocyte 31,500/µl, thrombocytes 742,000/µl, and anti-hiv was non-reactive. we then decided to shift the antibiotic to meropenem. lumbar fluid examination at day 4 of admission was positive for both nonne and pandy reaction with slight increase of glucose (100.3 mg/dl). blood culture revealed no growth of microorganism and bronchial sputum culture yielded acinetobacter calcoaceticus, susceptible to meropenem. nonetheless, the patient’s condition did not improve with continuous highgrade fever episodes until day-5 of admission. we then planned to perform tracheostomy. a repeat pre-operative rapid covid-19 was unexpectedly reactive; therefore, we performed nasopharyngeal swab test for polymerase chain reaction (pcr) to detect the presence of sarsfigure 1. electrocardiogram: giant t wave inversion at v2-4. 83 guntur darmawan acta med indones-indones j intern med cov-2 and transferred the patient to isolation room. unfortunately, the patient was rapidly deteriorated and eventually succumbed in the following day while still awaiting the pcr swab examination result. two days later, pcr swab examination revealed positive for covid-19. discussion covid-19 can manifest as various signs and symptoms, acting as great imitator. while most people are familiar with the hallmark respiratory symptoms of covid-19—cough, fever, dyspnea, -covid-19 might present with extra-pulmonary problems such as a c u t e c o r o n a r y s y n d r o m e , n e u r o l o g i c a l illness, electrolyte abnormalities. 4-6 our case interestingly demonstrated an atypical combination of central neurological and c a r d i a c s y m p t o m s w i t h n o r e s p i r a t o r y symptom as presenting clinical symptoms. of which, covid-19 was initially overlooked. a review by lai summarized prevalence o f e x t r a p u l m o n a r y m a n i f e s t a t i o n s i n patient with covid-19, including acute c a r d i a c i n j u r y m a n i f e s t a t i o n ( 8 1 2 % ) , impaired consciousness (7.5%), and seizure (0.5%).5 moreover, less studies specifically r e p o r t e d e x t r a p u l m o n a r y s y m p t o m s a s initial presentation of covid-19 patient. a case series by bangalore reported 10 of 18 confirmed covid-19 patients with myocardial injury had st-segment elevation as initial presentation to hospital in new york.7 to a lesser extent, central nervous system manifestation such as encephalitis, seizure have been reported in minority of cases.8,9 the exact pathophysiology behind these manifestations are still under thorough investigation. it is proposed that angiotensinc o n v e r t i n g e n z y m e 2 ( a c e 2 ) m e d i a t e d d i r e c t v i r a l t o x i c i t y, t i s s u e i n j u r y, a n d dysregulation of immune responses underlie these features.10,11 moreover, the leukocytosis in our case hid the presence of viral infection; normal initial crp level and chest x-ray blunted clinical awareness of covid-19. thus, covid-19 pcr examination was not performed initially during admission or lumbar fluid examination. yet, our patient had a high neutrophile to lymphocyte ratio, which is a risk factor for disease severity.12 o u r p a t i e n t a l s o d e v e l o p e d e l e c t r o l y t e imbalance, which might be due to ace2mediated renal loss in covid-19.13 hypertension was the only comorbid in our patient. several studies described the presence of hypertension in 15-30% of covid-19 patients, which might associate with disease severity and mortality.14,15 in addition, our patient took ramipril as her maintenance drug. although it was hypothesized that ace inhibitor linked with increase of ace2 expression and complication from covid-19, r e c e n t e v i d e n c e d o e s n o t s u p p o r t t h i s deleterious hypothesis and discontinuation of ace inhibitor treatment.16,17 during family interview, neither her family nor neighbor were known to have history of covid-19; however, her occupation might risk her for acquiring covid-19 infection. furthermore, our case delivered some important messages. cautious interpretation of laboratory result is needed in interpreting rapid antibody serology result. as described by peeling et. al., igm antibody of covid-19 started to be detectable within 5 to 10 days after the onset of clinical symptoms and closely followed by igg antibody.18 initial non-reactive serology rapid antibody test and “normal” chest x-ray could not exclude sars-cov-2 infection. clinical correlation and serial observation are essential in raising clinical suspicion and deciding to undergo pcr swab confirmatory examination. it is important that in the pandemic era, clinicians are aware of the possibility of covid-19 even in the absence of respiratory symptoms. as shown in our case, covid-19 patients could rapidly deteriorated and diagnosis was established after the patient died. hence, unawareness resulted in delayed testing, diagnosis, treatment, and prevention of transmission. conclusion t h i s c a s e u n d e r l i n e d m u l t i s y s t e m involvement of covid-19 infection. it is necessary for clinician to early recognize 84 vol 53 • number 1 • january 2021 the ‘great imitator’: a case of covid-19 presenting extra-pulmonary symptoms of covid-19 infection since covid-19 might act as great masquerader. acknowledgments the authors thank eko b. prasetyo, md, fonny m. tedjo, md, debora nurhadi, md, lukman jauhari, md, ferry, md, ivy jesslyn, md, siska marianna, md, desy trisnawati, md, antony yaputra, md for valuable contribution to this article conflict of interest none ethical statement informed consent was obtained from patient’s family prior to the publication of this case. references 1. del rio c, malani pn. covid-19—new insights on a rapidly changing epidemic. jama. 2020;323(14):133940. 2. fischer q, darmon a, ducrocq g, feldman l. case report of anterior st-elevation myocardial infarction in a patient with coronavirus disease-2019. eur heart j case reports. 2020;4:1-5. 3. sohal s, mossammat mj. covid-19 presenting with seizures. idcases. 2020(20):e00782. 4. asadi-pooya aa, simani l. central nervous system manifestations of covid-19: a systematic review. j neurol sci. 2020(413):116832. 5. lai c-c, ko w-c, lee p-i, jean s-s, hsueh p-r. extra-respiratory manifestations of covid-19. int j antimicrob agents. 2020;56(2):106024. 6. bansal m. reviews: cardiovascular disease and covid-19. diabetes metab syndr. 2020;14:247-50. 7. bangalore s, sharma a, slotwiner a, et al. st-segment elevation in patients with covid-19—a case series. nejm. 2020;382:2478-80. 8. anand p, al-faraj a, sader e, et al. seizure as the presenting symptom of covid-19: a retrospective case series. 2020;112:107335. 9. moriguchi t, harii n, goto j, et al. a first case of meningitis/encephalitis associated with sarscoronavirus-2. int j infect dis. 2020;94:55-8. 10. g u p t a a , m a d h a v a n m v, s e h g a l k , e t a l . extrapulmonary manifestations of covid-19. nat med. 2020;26(7):1017-32. 11. zheng ki, feng g, liu w-y, targher g, byrne cd, zheng m-h. extrapulmonary complications of covid-19: a multisystem disease? j med virol. 2020:1-13. 12. kong m, zhang h, cao x, mao x, lu z. higher level of neutrophil-to-lymphocyte is associated with severe covid-19. epidemiol infect. 2020;148:e139. 13. lippi g, south am, henry bm. electrolyte imbalances in patients with severe coronavirus disease 2019 (covid-19). ann clin biochem. 2020;57(3):262-5. 14. lippi g, wong j, henry bm. hypertension and its severity or mortality in coronavirus disease 2019 (covid-19): a pooled analysis. arch intern med. 2020;130(4):304-9. 15. singh ak, gupta r, misra a. comorbidities in covid-19: outcomes in hypertensive cohort and controversies with renin angiotensin system blockers. diabetes metab syndr. 2020;14(4):283-7. 16. fosbøl el, butt jh, østergaard l, et al. association of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use with covid-19 diagnosis and mortality. jama. 2020;324(2):168-77. 17. kreutz r, algharably eae-h, azizi m, et al. hypertension, the renin–angiotensin system, and the risk of lower respiratory tract infections and lung injury: implications for covid-19: european society of hypertension covid-19 task force review of evidence. cardiovasc res. 2020;116(10):1688-99. 18. peeling rw, wedderburn cj, garcia pj, et al. serology testing in the covid-19 pandemic response. lancet infect dis. 2020;20(9):e245-e9. 85 editorial 1acta med indones indones j intern med • vol 52 • number 1 • january 2020 diagnosing covid-19: “did we miss anything?” moses m. asaf1, eric d. tenda1,2 1 division of respirology and critical care, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 national heart and lung institute, imperial college london, united kingdom. corresponding author: eric daniel tenda, md. national heart and lung institute, imperial college london. south kensington campus, london, greater london sw7 2az, united kingdom. email: ericdanieltenda@yahoo.com. in late 2019, a mass of patients showing symptoms of a pneumonia-like disease of unknown origin emerged in wuhan, china. little did the world know it was the prelude of what would be a devastating pandemic. samples were collected from these patients and the use of unbiased sequencing and subsequent isolation of the pathogen using human airway epithelial cells led to the discovery of a novel coronavirus, named 2019-ncov by the world health organization (who) and severe acute respiratory syndrome coronavirus-2 (sarscov-2) by the international committee on taxonomy of viruses.1,2 the disease caused by this virus is officially called the coronavirus disease 2019 (covid-19). coronaviruses are enveloped rna viruses that are spherical in shape with bulbous surface projections.1,3 currently, there are six known species of coronavirus that can cause various systemic diseases in humans.1 two of the six species of coronaviruses – severe acute respiratory syndrome coronavirus (sarscov) and the middle east respiratory syndrome coronavirus (mers-cov) – originated from animals and have caused outbreaks in the past with relatively high mortality rates.4 sars-cov and mers-cov have been shown to possess the potential to cause severe and potentially fatal respiratory tract infections.5 sars-cov-2 is a highly transmissible beta-coronavirus that could infect humans by binding into the angiotensin-converting enzyme 2 (ace2) receptor, the same receptor as sarscov.5 the genome sequence of sars-cov-2 has been found to share 79.5% identity to sars-cov and is 96.2% identical to a strain of bat cov, raising the suspicion that bats may be the natural host and reservoir of sars-cov-2.5 pangolin is the most likely intermediate host of sars-cov-2 between bats and humans, based on preliminary data.2 from the discovery of sars-cov-2 in late 2019 until january 24, 2020, there had been 830 confirmed cases of covid-19 in nine countries with 26 fatalities.6 since then, the virus has been spreading aggressively on a global scale, and the number of cases has grown exponentially. by march 12, 2020, 116 countries had been affected, and 118,000 confirmed cases had been reported.7 in march 28, 2020, the johns hopkins coronavirus research center database had confirmed a total of 615,519 cases of covid-19 in 177 countries with 28,717 fatalities. covid-19 primarily manifests as an acute respiratory infectious disease, as shown by the clinical findings several recent studies have found. generally, the most common symptoms found in covid-19 patients include fever, dry cough, fatigue, expectoration, and malaise, with gastrointestinal symptoms such as diarrhea occurring infrequently or sporadically throughout the illness.8-10 though not yet welldocumented, li et al.11 have suggested that ocular manifestations such as unilateral or bilateral conjunctivitis are still a possibility in covid-19, moses m. asaf acta med indones-indones j intern med 2 based on a previous report in wuhan, where a healthcare worker donning full protective gear except goggles was infected, with unilateral conjunctivitis preceding the onset of illness. the spectrum of disease severity in covid-19 varies from asymptomatic, mild, moderate, to severe and critical. in severe cases, covid-19 patients could develop acute respiratory distress syndrome (ards), respiratory failure, sepsis, multiple organ failure, and death.5,10 ards commonly develops on day 8 to 12 from the onset of illness.9,10 recent studies have reported that white blood cell (wbc) count tends to be normal in most patients, though some experience a minor decrease in wbc.5,10 decreased total lymphocyte or lymphocytopenia is a common occurrence.8,9 increased coagulation activity marked by elevated d-dimer concentrations were also common, but significant elevation of greater than 1 mcg/ml is associated with poor prognosis.8,10,12 generally, marked alteration of coagulation parameters increase the risk of disseminated intravascular coagulation (dic) and could subsequently lead to a poor patient outcome that results in death. procalcitonin is an inflammatory marker that is not usually substantially increased in covid-19 patients, and a gradual increase in concentration could indicate a bacterial superinfection or a superimposed bacterial infection.13 however, another inflammatory marker, c-reactive protein (crp), has generally been shown to increase and is directly proportional to disease severity and poor prognosis.14,15 other laboratory predictors of poor outcome include a higher sequential organ failure assessment (sofa) score, which encompasses the respiratory (pao2/fio2), coagulation (platelets), cardiovascular (mean arterial pressure), hepatic (bilirubin), neurological (glasgow comma scale), and renal (creatinine) systems, increased lactate dehydrogenase, and increased cardiac troponin.10,13 as of march 2, 2020, the who’s interim guidance on laboratory testing for covid-19 still recommends the use of nucleic acid amplification tests (naat), such as reverse-transcriptase polymerase chain reaction (rt-pcr), to screen suspect cases.16 the specimens recommended to be collected are upper respiratory materials (nasopharyngeal and oropharyngeal swab) and/or lower respiratory materials (sputum/ endotracheal aspirate/bronchoalveolar lavage).16 however, recent radiological studies concerning the remarkable sensitivity of chest computed tomography (ct) scan in diagnosing covid-19 patients raises the question on whether or not chest ct should be a staple modality in diagnosing covid-19.17,18 studies by fang et al.17 and ai et al.18 have found the sensitivity of chest ct in diagnosing covid-19 to be 98% and 97% respectively. subsequently, a subgroup of patients in the study of ai et al.18 showed positive chest ct scans prior or within 6 days of the initial positive rt-pcr results. chest ct has even been shown to be a reliable screening tool in asymptomatic patients, as shown by the study of shi et al.19, substantiating the suggestion that asymptomatic patients could develop abnormalities in chest ct prior to the onset of symptoms. patients with ncp generally show signs of bilateral subpleural ground-glass opacity, consolidation, and sometimes accompanied by the thickening of the interlobular septum often called a “crazy paving stone-like” pattern.19,20 several other studies also support the notion of using chest ct as a screening tool in subjects with negative rt-pcr results suspected with covid-19 infection based on their exposure history and/or clinical symptoms.17,18 rt-pcr is still a reliable diagnostic tool, although there are some factors that may compromise the efficiency. those factors include improper sampling technique, varying detection rate due to different manufacturers, low viral load, and imperfect development of nucleic acid detection technology.17 overall, in the context of a rapidly needed emergency disease control like covid-19, physicians should adjust and utilize their arsenal of diagnostic tools to find the balance between swiftness and accuracy, and chest ct might help to find that balance. another radiological modality as a possible screening or diagnostic tool for covid-19 is the lung ultrasound (lus). in lus, covid-19 is characterized by a patchy distribution of subpleural consolidation with associated areas of white lung.21 lus may be useful in healthcare facilities that may not have sophisticated vol 52 • number 1 • january 2020 diagnosing covid-19: “did we miss anything?” 3 radiological or laboratory equipment necessary to diagnose covid-19, as ultrasound devices are commonly more readily available than ct and rt-pcr test kits, especially in primary and secondary healthcare facilities. lus may be useful in the emergency room setting and in monitoring disease progression in icu patients using a ventilator, as the mobility of these patients are usually very limited and performing radiological examinations such as ct scan would be extremely difficult. lus is also safer in terms of radiation exposure compared to ct and should be considered as a viable option in children suspected with covid-19. nonetheless, it should be noted that lus is heavily dependent on a skilled operator, and different operators might have different interpretations based on their subjectivity. lus operators should also be equipped with proper personal protective equipment (ppe) as they are in close proximity with suspected patients while conducting examinations. recently, the united states (us) food and drug administration (fda) has given an emergency use authorization (eua) to abbott laboratories for the use of their product called the abbott id now covid-19 test that runs on abbott’s id now™ platform. this lightweight and portable assay device is claimed to be “fastest available molecular point-of-care test for novel coronavirus”, and can deliver positive results in a mere five minutes and negative results in 13 minutes by targeting the rdrp gene of the virus. if this claim is substantiated and could perform with high sensitivity and specificity, this product could significantly help healthcare workers in diagnosing covid-19, which subsequently would enhance response time for management and isolation, and overall help lessens the spread of covid-19. abbott laboratories is expected to produce around 5 million tests in april, and deliver another 50,000 tests per day. if successful, the use of this rapid immunoassay test in the us could serve as a precedent for screening programs in other countries, including indonesia. g i v e n t h e s e a r e w h a t w e c u r r e n t l y comprehend about covid-19, it is imperative for each physician on the frontlines to equip themselves with the latest diagnostic proficiency in order to tackle this challenge in an efficient manner. as different physicians in different healthcare facilities face different circumstances, the use of adaptive and structured diagnostic method is essential in identifying the most appropriate management strategy, preventing poor prognosis and outcome, and overall help reduces the spread of covid-19. another issue worth addressing that could supplement efficient diagnosis in facing this challenge includes infrastructural improvements such as the establishment of an accessible realtime and transparent icu information network between healthcare facilities where laboratory and radiological results could be accessed securely, and the establishment of adequate numbers of contemporary laboratories that could efficiently run rt-pcr tests in a designated region. qualified healthcare workers should also be distributed evenly with sustainable working hours and sufficient equipment to ensure patient safety and their well-being. understandably, addressing these issues will require sophisticated planning and execution will not be straightforward, but problem identification is always the first step in resolving any challenge. references 1. zhu n, zhang d, wang w, et al. a novel coronavirus from patients with pneumonia in china, 2019. n engl j med. 2020;382(8):727-33. 2. del rio c, malani pn. covid-19-new insights on a rapidly changing epidemic. jama. 2020. 3. goldsmith cs, tatti km, ksiazek tg, et al. ultrastructural characterization of sars coronavirus. emerg infect dis. 2004;10(2):320. 4. cui j, li f, shi zl. origin and evolution of pathogenic coronaviruses. nat rev microbiol. 2019;17(3):181-92. 5. guo yr, cao qd, hong zs, et al. the origin, transmission and clinical therapies on coronavirus disease 2019 (covid-19) outbreak an update on the status. mil med res. 2020;7(1):11. 6. munster vj, koopmans m, van doremalen n, van riel d, de wit e. a novel coronavirus emerging in china — key questions for impact assessment. new engl j med. 2020;382(8):692-4. 7. hoseinpour dehkordi a, alizadeh m, derakhshan p, babazadeh p, jahandideh a. understanding epidemic data and statistics: a case study of covid-19. arxiv. 2020:arxiv: 2003.06933. 8. guan wj, ni zy, hu y, et al. clinical characteristics of coronavirus disease 2019 in china. n engl j med. moses m. asaf acta med indones-indones j intern med 4 2020. 9. wang d, hu b, hu c, et al. clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china. jama. 2020;323(11):1061-9. 10. zhou f, yu t, du r, et al. clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study. lancet. 2020;395:1054–62. 11. li j-po, lam dsc, chen y, ting dsw. novel coronavirus disease 2019 (covid-19): the importance of recognising possible early ocular manifestation and using protective eyewear. bmj publishing group ltd; 2020. 12. tang n, li d, wang x, sun z. abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. j thromb haemost. 2020;18:844–7. 13. lippi g, plebani m. laboratory abnormalities in patients with covid-2019 infection. clin chem lab med. 2020. 14. chen n, zhou m, dong x, et al. epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study. lancet. 2020;395(10223):507-13. 15. zhang jj, dong x, cao yy, et al. clinical characteristics of 140 patients infected with sars-cov-2 in wuhan, china. allergy. 2020;00:1–12. 16. organization wh. laboratory testing for coronavirus disease 2019 (covid-19) in suspected human cases: interim guidance, 2 march 2020. world health organization; 2020. 17. fang y, zhang h, xie j, et al. sensitivity of chest ct for covid-19: comparison to rt-pcr. radiology. 2020:200432. 18. ai t, yang z, hou h, et al. correlation of chest ct and rt-pcr testing in coronavirus disease 2019 (covid-19) in china: a report of 1014 cases. radiology. 2020:200642. 19. shi h, han x, jiang n, et al. radiological findings from 81 patients with covid-19 pneumonia in wuhan, china: a descriptive study. lancet infect dis. 2020;20(4):425-34. 20. zhao x, liu b, yu y, et al. the characteristics and clinical value of chest ct images of novel coronavirus pneumonia. clin radiol. 2020;75(5):335-40. 21. soldati g, smargiassi a, inchingolo r, et al. is there a role for lung ultrasound during the covid-19 pandemic? j ultrasound med. 2020. 292 original article acta medica indonesiana the indonesian journal of internal medicine qt interval prolongation associated with amiodarone use in cipto mangunkusumo hospital, jakarta nafrialdi1, theresia g. kurniawan1, arini setiawati1, lukman h. makmun2 1 department of pharmacology, faculty of medicine universitas indonesia, jakarta, indonesia. 2 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. correspondence mail: department of pharmacology, faculty of medicine universitas indonesia. jl. salemba 6 jakarta 10430, indonesia. email: nafrialdi@yahoo.com. abstrak tujuan: mempelajari kejadian perpanjangan interval qtc pada pemakaian amiodaron di rscm dan faktor yang mempengaruhinya. metode: penelitian deskriptif retrospektif dilakukan berdasarkan rekam medik pasien yang dirawat di iccu rscm tahun 2004-2011. penelitian dilakukan pada 4 kelompok pasien yaitu (1) kelompok yang menggunakan amiodaron dan obat lain yang menyebabkan perpanjangan interval qtc; (2) kelompok yang menggunakan amiodaron dengan obat-obat lain yang tidak menyebabkan perpanjangan interval qtc; (3) kelompok yang menggunakan obat selain amiodaron yang memperpanjang interval qtc dan (4) kelompok kontrol (tidak menggunakan amiodaron atau obat lain yang memperpanjang interval qtc). perubahan interval qtc (dqtc) selama perawatan dalam satu kelompok dianalisis dengan uji t berpasangan atau wilcoxon. perbandingan dqtc antar kelompok dianalisis dengan uji kruskal wallis. pengaruh faktor lain (jenis kelamin, umur, gagal jantung, fungsi hati dan elektrolit) terhadap kejadian perpanjangan interval qtc dianalisis dengan menggunakan regresi multipel. hasil: perpanjangan interval qtc pada kelompok 1, 2, dan 3 secara berturut-turut adalah 65,5%, 63,3%, 56,6% yang berbeda bermakna dibandingkan kelompok kontrol (24,4%, p <0,05). tidak terdapat potensiasi perpanjangan interval qtc bila amiodaron dikombinasi dengan obat lain yang menyebabkan perpanjangan qt. hipernatremia dan hipertensi merupakan faktor risiko terjadinya perpanjangan interval qtc. terdapat kematian pada kelompok 1, 2, dan 3 masing-masing 3, 4, dan 4 pasien, sedangkan pada kelompok 4 tidak terdapat kematian. kesimpulan: perpanjangan interval qtc secara bermakna terjadi pada pemakaian amiodaron dan beberapa obat yang menyebabkan perpanjangan interval qt, namun tidak terjadi potensiasi bila kedua kelompok obat digunakan bersamaan. hipernatremia dan hipertensi memberikan kontribusi pada perpanjangan interval qtc. kata kunci: amiodaron, anti-aritmia, interval qtc. abstract aim: to evaluate the incidence of qtc interval prolongation associated with the use of amiodarone, as well as factors that influence its occurrence. methods: this was a descriptive retrospective study conducted from november 2010 until december 2011 using medical record of patients at iccu cipto mangunkusumo hospital from 2004-2011. four groups of patients were included: (1) patients receiving amiodarone and other drugs causing which can cause qtc prolongation, (2) patients receiving amiodarone and other drug not causing qtc prolongation, (3) patients receiving drugs which can cause causing qtc prolongation, (4) patients not receiving amiodarone, nor other drugs which can cause causing qtc prolongation (served as control group). difference of qtc interval within the same group was analyzed with paired t-test or wilcoxon matched-pairs test. between vol 46 • number 4 • october 2014 qt interval prolongation associated with amiodarone use 293 groups comparison were performed with kruskal wallis test. the influence of other factors (sex, age, heart failure, liver disorder, electrolyte imbalance) on qtc prolongation was analyzed using multiple regression. results: qtc interval prolongation in groups 1, 2, and 3 were respectively 65.5%, 63.3%, 56.6%, which were significantly different from control group (24.4%); hypernatremia and hypertension were revealed as significant risk factor for qtc prolongation. mortality occurred in 3, 4, and 4 patients in group 1, 2, and 3 respectively, and none in group 4. conclusion: qtc interval prolongation occurred in association with amiodarone and other drugs known to prolong qtc interval. hypernatremia and hypertension were shown as significant influencing factor of qtc interval prolongation. key words: amiodarone, antiarrhythmia, qtc interval. introduction a m i o d a r o n e i s a w i d e s p e c t r u m antiarrhythmic drug which shows very good activity against various types of arrhythmias including atrial flutter and fibrillation, as well as arrhythmias of ventricular origin. it has a good pharmacologic profile, and represents the most widely used antiarrhythmia.1 beside its good pharmacologic profile, amiodarone possesses a potentially dangerous adverse effect, i.e qt interval prolongation which can lead to torsade des pointes or polymorphic ventricular arrhythmia, which may end with ventricular fibrillation and sudden death.2,3 qt interval is defined as the time needed by the ventricle to perform complete depolarization and repolarization.1,2 some drugs are known to induce qt interval prolongation by inhibiting outward current of potassium ion, which lead to prolongation of myocardial repolarization. some drugs in the group of antiarrhythmic drugs, antidepressants, antipsychotics such as haloperidol, and some antibiotics such as quinolones, azithromycin, and metronidazole, are known to cause qt interval prolongation.4-6 some patients admitted to intensive cardiac care unit known to have various types of arrhythmia and need antiarrhythmic drugs, including amiodarone. some of them also received concomitant drugs causing qt interval prolongation. however, publication on the incidence of qt interval prolongation in this group of patients in indonesia is still lacking. in the present study, we aimed to evaluate the incidence of qtc interval prolongation in patients receiving amiodarone and other drugs which can cause qt prolongation at intensive cardiac care unit of cipto mangunkusumo hospital, jakarta. role of other factors such as gender, electrolyte imbalance, presence of heart failure and liver disorder in the occurrence of qt interval prolongation was also evaluated. methods this was a descriptive retrospective study conducted using secondary data from medical record of patients hospitalized in the intensive cardiac care unit (iccu) of cipto mangunkusumo hospital, jakarta during the period of 2004 to 2011. all patients aged between 16-65 years were included in this study, while those with incomplete or unreadable ecg data were excluded. a total of 200 samples were planned, but only 176 samples were eligible for analysis. the protocol of this study has been approved by research ethics committee of the faculty of medicine universitas indonesia. the patients were classified into 4 groups according to the drugs they received. group i received amiodarone and other drugs causing qt prolongation; group ii received amodarone and other drug(s) not causing qt prolongation; group iii received other drugs causing qt prolongation, without amiodarone; and group iv received neither amiodarone, nor drugs causing qt prolongation. since qt interval is inversely correlated with heart rate, thus, it is presented as corrected qt interval (qtc). the correction formula used in this study is based on bazett equation where qtc = qt/(rr).7 during this study, qt interval prolongation is defined as qtc more than 450 ms, or the increase of more than 30% from baseline value, and lead ii was taken as reference of qt interval calculation.6 nafrialdi acta med indones-indones j intern med 294 data analysis demographic data as well as laboratory results were reported descriptively. the difference of qtc interval (dqtc) between baseline and the longest qtc during hospitalization within one group was analyzed by using paired t-test or wilcoxon matched-pair test. percentage of difference between groups were analyzed by using kruskal wallis test. influence of other factors such as gender, age, presence of heart failure, serum electrolyte on qt prolongation was analyzed by multiple regression with backward approach. mortality in each group was presented descriptively. results a total of 176 data have been collected comprising of group i (29 patients), ii (49 patients), iii (53 patients), and iv (45 patients). table 1 shows distribution of patients according to gender, age, cardiac diseases, serum electrolyte, and liver function. table 1. demographic data and distribution of cardiac diseases, serum electrolyte, and liver dysfunction of study subjects variables group total n (%) i ii iii iv n (%) n (%) n (%) n (%) gender: male 20 (69) 33 (67) 33 (62) 28 (62) 114 (65) female 9 (31) 16 (33) 20 (38) 17 (38) 62 (35) age: years (sd) 58 (10) 51 (12) 53 (7) 52 (7) 53 (9) range 30 69 25 69 32-65 36-65 25-69 cardiac disease: uap 2 (6,8) 8 (16,3) 14 (26,4) 10 (22,2) 34 (19,3) nstemi 9 (31) 6 (12,2) 17 (32) 15 (33,3) 47 (26,7) stemi 11 (37,9) 18 (36,7) 16 (30,2) 15 (33,3) 60 (34,1) heart failure: yes 18 (62) 23 (47) 31 (58) 9 (20) 81 (46) no 11 (38) 26 (53) 22 (42) 36 (80) 95 (54) serum electrolyte: hypokalemia 5 (17.2) 5 (9.4) 14 (26.34) 4 (8.9) 28 (15.9) normokalemia 23 (79.3) 40 (81.6) 37 (69.8) 39 (86.7) 139 (78.9) hypernatremia 5 (17.2) 7 (13.2) 6 (11.3) 4 (8.9) 22 (12.5) normonatremia 23 (79.3) 40 (75.5) 45 (84.9) 38 (54.4) 146 (82.9) liver function: high sgpt 3 (10.3) 5 (10.2) 5 (9.4) 5 (11.1) 18 (10.2) normo sgpt 21 (72.4) 35 (71.4) 38 (71.6) 32 (71.1) 126 (71.6) hf : heart failure, uap: unstable angina pectoris, nstemi: non st-elevated myocardial infarction, stemi: st elevated myocardial infarction table 2 shows baseline qtc interval and prolonged qtc interval of subjects in all groups. a significant increase of qtc interval can be seen in all group. however, the first three groups has about the same magnitude of qtc prolongation, while the group iv which did not received neither amiodarone, nor drug causing prolonged qt, showed a significantly lower qtc prolongation. (figure 1) beside the magnitude of qtc prolongation, it can be seen that the proportion of patients having qtc interval prolongation was also significantly lower in group iv (table 3). table 4 shows that azithromycin was the most frequent drug causing prolonged qt received by the subjects. qtc prolongation was vol 46 • number 4 • october 2014 qt interval prolongation associated with amiodarone use 295 slightly less in group receiving azithromycin compared with amiodarone or combination of amiodarone and azithromycin, but this different was not significant. other drugs (metronidazole and haloperidol) are used in much less frequency. table 2. comparison of baseline and prolonged values of qtc interval in each group baseline qtc ms (sd) prolonged qtc ms (sd) p group i 434.8 (57.1) 478.4 (81.5) 0.001 group ii 446.9 (72.4) 497.6 (108.7) 0.008 group iii 464.8 (75.2) 515.40 (71.7) 0.001 group iv 454.3 (51.1) 468.4 (55.4) 0.008 tabel 3. proportion of patients experiencing qtc interval prolongation in the four groups prolonged qtc n (%) normal qtc n (%) total n group i 19 (65.5) 10 (34.5) 29 group ii 31 (63.3) 18 (36.7) 49 group iii 30 (56.6) 23 (43.4) 53 group iv 11 (24.4)* 34 (75.6) 45 total 91 (51.7) 85 (48.3) 176 * p<0.05 vs group i, ii, iii figure 1. magnitude of changes of qtc interval in all groups during hospitalization at the iccu table 4. influence of concomitant drug(s) on the occurrence of qtc prolongation main drug concomitant drug (n) qtc prolongation n (%) group i (n = 29) amiodarone azithromycin (25) 16 (64) metronidazol (2) 2 (100) haloperidol (2) 1 (50) group ii (n = 49) amiodarone 31 (63.3) group iii (n =53) azithromycin (45) 24 (52) metronidazol (7) 5 (71) haloperidol (1) 1 (100) group iv (n = 45) 11 (24.4) influence of some risks factors on the occurrence of qtc prolongation result of multiple regression shows that among several factors dialyzed, hypernatremia, lung disease, and hypertension have significant influence on the occurrence of qtc interval prolongation (table 5). tabel 5. multiple regression of the influence of risks factors on the occurrence of qtc interval prolongation risk factors b (slope) p gender 0,040 0.911 heart failure 0,201 0.569 hypokalemia -0,321 0.490 liver disease 0,358 0.488 hypernatremia 1,264 0.019 arrhytmia -0,034 0,928 lung disease -0,644 0,039 hypertension 0,830 0,009 discussion a m i o d a r o n e b e l o n g s t o c l a s s i i i antiarrhythmic drugs which shares the property of all other classes of antiarrhythmic drugs. this drug is considered the most frequently used antiarrhythmic agent owing to its broad spectrum of action that make it effective in many types of arrhythmias. on one hand, it has a good clinical profile, with relatively low incidence of adverse effects if used by respecting specific prcautions and contraindications such as liver and thyroid dysfunctions. on the other hand, it ms 60 50 40 30 20 10 0 i ii iii iv groups * p<0.05 vs. gr i, ii, iii nafrialdi acta med indones-indones j intern med 296 also has the potential of inducing arrhythmias, one of which is qt interval prolongation that can lead to serious polymorphic ventricular arrhythmia or torsade de pointes (tdp).8 this type of arrhythmia is related to the mechanisms of action of amiodarone by blocking potassium channel and causes prolongation of ventricular repolarization and the refractory period, -leading to qt-interval prolongation.9 beside amiodarone, some other drugs are also reported to have the potential to cause qt prolongation, such as azythromycin, haloperidol, metronidazole, cisapride, erythromyin, clozapine, etc. adverse drug reaction advisory committee (adrac 2005) of australia,10 reported 140 cases of qtc prolongation and/or torsade de pointes. seven of them were fatal. the most frequently implicated drugs in these reports are sotalol, cisapride, clozapine, amiodarone and erythromycin. in the present study, we found significant frequent of qt interval prolongation in the group receiving amiodarone or other drug causing qt prolongation, either alone or in combination. it is interesting to note, that there was no further potentiation of qt interval prolongation if amiodarone was used in combination with other qt prolongation inducer drugs. this finding is different from that of samarendra et al,11 who reported the potentiation of qt prolongation if two groups of drugs are combined. explanation of this different result is not clear, but it might be due to the influence of different cadiovascular background and the small sample size. azithromycin is a macrolide antibiotic that frequently used to treat pneumonia. it is known that patients with severe clinical conditions are prone to contract nosocomial infection or hospital associated pneumonia in which combination of antibiotics is recommended. however, in the last several years, some reports emerged on the increase of qt prolongation associated with azythromycin.12-14 in the present study, azithromycin is the most frequent drug causing qt prolongation used by the patients, and most of them experienced qt interval prolongation. this finding is consistent with a cohort study conducted by ray et al. on more than three hundreds patients taking azithromycin.15 the authors found that the risk of cardiovascular death was significantly higher in patients taking azithromycin compared to those taking amoxicillin, or those taking no antibiotic, but comparable with levofloxacin.16 besides concomitant drugs, we have also evaluated some other influencing factors of qt prolongation. among these factors, hypernatremia, lung disease, and hypertension were found to have significant influence on the occurrence of qt interval prolongation. other study by moreno et al.,16 (2011) also reported that hypernatremia was associated with qt interval prolongation, while gender, serum potassium level, and liver or kidney function did not show significant influence. on theorethical point of view, hypokalemia can induce arrhythmia, since low extracellular potassium level decreases ikr,4 an effect that is likely to contribute to qt interval prolongation. however, in this study, as well as in that of moreno,16 hypokalemia was not related with qt prolongation. on the contrary, some literatures reported that hypokalemia is an important risk factor of tdp development.4,6 explanation of this contradictory findings of hypokalemia and hypernatremia on the occurrence of qt prolongation is not well understood. the fact is sodium and potassium ions compete for access to extracellular binding sites on ikr channel and sodium is a potent blocker of this current. it can be speculated this competition might explain the occurrence of qtc prolongation in this study. concerning the influence of gender, strambabadiale et al., (1997) reported that female gender may play determinant role in the occurrence of qt interval prolongation.17 it is suggested that sex steroid hormones may have differential influences on ventricular repolarization, since the tendency of prolonged qt interval in female is only observed after puberty. concerning mortality, we observed mortality in groups receiving amiodarone or other drugs causing prolonged qt, alone or in combination. among all mortalities, 3 was caused by sudden cardiac death, 4 due to cardiogenic shock, and others were due to pneumonia and septic shock. the role of qt interval prolongation in these mortalities could not be concluded, since vol 46 • number 4 • october 2014 qt interval prolongation associated with amiodarone use 297 it occurred shortly after hospital admission. thus, the severe heart attack seemed to be more possible as the cause of death. in this study, no cases of severe arrhythmia, such as torsade des pointes, was observed. indeed, amiodarone frequently prolonged qt interval, but the incidence of torsade de pointes was reported to be low.6 with small sample size in our study, the probability to find the tdp was thus very low. conclusion from this study, we concluded that the use of amiodarone in cipto mangunkusumo hospital was associated with a high incidence of qt interval prolongation, but no serious arrhythmia was observed. the use of other drugs causing qt prolongation resulted in similar incidence of qt interval prolongation. no potentiation effect was found when these two drugs were used in combination. hypernatremia was shown as contributing factor to qtc interval prolongation. references 1. hume jr, grant ao. agents used in cardiac arrhythmias. in: katzung bg, ed. basic and clinical pharmacology. 10th ed. boston: mcgraw hill; 2007. p. 211-35. 2. yap yg, camm aj. drug induced qt prolongation and torsades de pointes. heart. 2003;89(11):1363–72. 3. nachimuthu s, assar md, schussler jm. drug-induced qt interval prolongation. mechanisms and clinical management. ther adv in drug safe. 2012;3(5):241-53. 4. kannankeril p, roden dm, darbar d. drug-induced long qt syndrome. pharmacol rev. 2010;62:760-81. 5. tips from other journals. drug-induced prolongation of the qt interval. am fam physician. 2005;71(1):164-6. 6. roden dm. drug-induced prolongation of the qt interval. n engl j med. 2004;350:1013-22. 7. u.s. department of health and human services food and drug administration. guidence for industry: e 14 clinical evaluation of qt/ qtc interval prolongation and proarrhytmic potential for non-antiarrhytmic drugs. ich;2005. 8. tips from other journals. drug-induced prolongation of the qt interval. am fam physician. 2005;71:164-6. 9. shantsila e, watson t, yh lip g. drug-induced qtinterval prolongation and proarrhythmic risk in the treatment of atrial arrhythmias. europace (2007) 9 (suppl 4): iv37-iv44. doi: 10.1093/europace/eum169 10. department of health and aging, therapeutic goods administration, australian government. australian adv drug react bull. 2005;24(6):1-2. 11. smarendra p, kumari s, evans sj, et al. qt p r o l o n g a t i o n a s s o c i a t e d w i t h a z i t h r o m y c i n / amiodarone combination. pacing clin electrophysiol. 2001;24:1572-4. 12. rao ga, mann jr, shoaibi a, et al. azithromycin and levofloxacin use and increased risk of cardiac arrhythmia and death. ann fam med. 2014;12(2):1217. doi:10.1370/afm.1601. available at: http://www. annfammed.org. (retrieved sept 24, 2014) 13. lowes r. azithromycin poses fatal cardiac risk, fda warns. medscape med news. march 12, 2013. available at: http://www.medscape.com/ viewarticle/780660. (retrieved sept 24, 2014) 14. nachimuthu s, assar md, schussler jm. drug-induced qt interval prolongation. mechanisms and clinical management. ther adv in drug safe. 2012;3(5):241-53. 15. ray wa, murray kt, hall k, arbogast pg, stein m. azithromycin and the risk of cardiovascular death. n engl j med. 2012;366:1881-90. 16. moreno jd, clancy ce. pathophysiology of the cardiac late na current and its potential as a drug target. 2012;52(3):608-19. doi: 10.1016/j.yjmcc.2011.12.003. 17. stramba-badiale m, locati eh, martinelli a, courville j, schwartz pj. gender and the relationship between ventricular repolarization and cardiac cycle length during 24-h holter recordings. eur heart j. 1997;18(6):1000-6. 307acta med indones indones j intern med • vol 54 • number 2 • april 2022 review article quality of life in patients with renal failure undergoing hemodialysis haerani rasyid1*, hasyim kasim1, st. rabiul zatalia1, jerry sampebuntu2 1 division of nephrology and hypertension, department of internal medicine, faculty of medicine, hasanuddin university – dr. wahidin sudirohusodo hospital, makassar, indonesia. 2 department of internal medicine, faculty of medicine, hasanuddin university – dr. wahidin sudirohusodo hospital, makassar, indonesia. *corresponding author: prof. haerani rasyid, md, phd. division of nephrology and hypertension, department of internal medicine, faculty of medicine, hasanuddin university – dr. wahidin sudirohusodo hospital. jl. perintis kemerdekaan no.10, makassar, 90245, south sulawesi, indonesia. email: haeraniabdurasyid@yahoo.com. abstract a good quality of life is one of the many indicators that determine the success of hemodialysis (hd) therapy. factors that significantly affect the quality of life of patients with renal failure who undergo hd include sociodemographic condition, mental state (depression), severity of kidney disease, accompanying disorders, hd duration, non-adherence towards prescribed medication and nutritional problems. among said factors, the metabolic and nutritional disorder commonly known as protein energy wasting (pew), plays an important role in the clinical course of renal failure patients. the aim of nutrition management in patients with renal failure is to slow down the progression of kidney disease, improve quality of life, and reduce cardiovascular morbidity and mortality. keywords: quality of life, renal failure, hemodialysis. introduction the rising prevalence of chronic kidney disease (ckd) has led to an increase in the number of patients requiring hemodialysis (hd). the global burden of disease data in 2010 reported that ckd rose from the 27th leading cause of death globally in the year 1990 to become the 18th in 2010.1 renal failure is a clinical condition characterized by an irreversible reduction of renal function, resulting in the inability to maintain biochemical homeostasis and accumulation of body fluids and waste products if one only relies on the help of conservative treatments. hence, this condition requires renal replacement therapy (rrt) in the form of either dialysis or kidney transplantation.2 based on the 2016 indonesian renal registry (irr), 98% of renal failure patients undergo hd therapy and 2% undergo peritoneal dialysis (pd) therapy.1 hemodialysis can be defined as a process of exchanging the composition of blood solutes using a solution of dialysate (dialysis fluid). it can also be described as a process of separating, filtering, or cleaning of blood through a semipermeable membrane which is performed on patients with both acute and chronic impaired renal function.2 the frequency of hd varies depending on the remaining kidney function, although on average a patient undergoes hd three times a week, with a duration of three to four hours per treatment. besides the time intensive nature, hd also poses physiological, psychological, and socioeconomic issues that haerani rasyid acta med indones-indones j intern med 308 impacts not only the patient but also the caregiver and society in general. collectively, these effects will impacts the quality of life of renal failure patients undergoing hd.2.3 the concept of quality of life definition the quality of life of an individual cannot be determined for certain due to its subjectivity, and only the person in question will be able to assess it.4 the world health organization quality of life (whoqol) group states that quality of life is an individual’s perception of their position in life, in the cultural context and value system in which the individual lives, and in correlation with personal goals, expectations, standards and desires. this is a concept, which coalesces with the various ways one can reach adequate levels of physical and psychological state, functional independence, social relations, and bond with the surrounding environment.4,5 there are two basic components of quality of life, namely subjectivity and multidimensionality. subjectivity means that the quality of life can only be determined from the point of view of the individual, and hence can only be known by direct query towards said individual. meanwhile, the multidimensionality of quality of life refers to the way that it is viewed from multiple aspects within an individual’s life, including biological/ physical, social, and environmental. polinsky (2000) concluded that a person’s quality of life is measured by considering the physical, psychological, social and the disease state or condition.4 the scope of quality of life based on a questionnaire developed by the who, there are five general areas of assessment used in the measurement of quality of life, which includes physical health, psychological health, degree of independence, social relationships and the individual’s relationship with the environment. these five quality of life indicators are described in detail below.4 1. physical health: general health, protein energy malnutrition (pem), pain, energy and vitality, sexual activity, sleep and rest. 2. psychological health: ways of thinking, learning, memory and concentration. 3. level of independence: mobility, daily activities, communication, work ability. 4. social relationship: social relations, social support. 5. environment: security, home environment, job satisfaction. renal failure patients response to hemodialysis chronic kidney disease (ckd) negatively affects the physical and biopsychosocial aspects of the lives of in dividuals with the disease, thereby affec ting the quality of life (qol) of patients and their families.6 since chronic diseases have an impact on health-related quality of life (hrqol), this has become a key outcome measure in disease management. patients with end stage renal disease (esrd) require rrt in the form of dialysis or a kidney transplant. kidney transplantation may offer a nearly normal life and is considered the optimum treatment for eligible patients. alternative dialysis modalities are hd and pd.7 the initial response towards hd is generally favorable because the patient deems the intervention as something that can help overcome disease. however, varying response was reported among patients with acute kidney disease who received hd as part of emergency care.8 when the onset of renal failure is in the adaptive phase, several studies reported that there are 3 stages of adaptation to dialysis, which includes: 8 1. the honeymoon period. this phase is the initial response towards hd, starting from for the first few weeks until the next 6 months. usually during this phase, improvement in physical and psychological conditions appear followed by the emergence of hope and confidence to achieve recovery. during the honeymoon period, patients tend to respond positively to the healthcare providers involved. 2. disenchantment and discouragement period this period is marked by a decrease in self-confidence and hope for recovery. this vol 54 • number 2 • april 2022 quality of life in patients with renal failure undergoing hemodialysis 309 period lasts for 3 12 months. this phase arises due to boredom from the the inability to carry out everyday activities and the necessity to periodically undergo hd. during this time, the patient will experience prolonged sadness and hopelessness. 3. long-term adaptation period during this period, patients become more accepting of their own limitations as well as the complications they experience while undergoing hd. although patients may still experience occasional depressive episodes, they are eventually able to adapt especially with support from their surrounding environment. in reality, not all patients will experience these three phases, and it is common for each individual to go through different experiences. other psychological issues that may arise among patients undergoing hd include depression, dementia or delirium, anxiety, sexual function disorders and socioeconomic problems.9 factors that influence the quality o f l i f e o f pat i e n t s w i t h r e n a l failure who undergo hemodialysis sociodemographic factors several studies have shown that social demographic factors such as age, gender, ethnicity, economic status, marital status, and employment status are related to a person’s quality of life. in general, the physical domain of quality of life will deteriorate as the patient gets older. differences in treatment outcome expectations and the ability to accept or adapt towards deteriorating health status can also explain the differences in quality of life between older and younger patients. older patients tend to be more accepting of their health condition and consider it a consequence of aging.10 race also affects the quality of life of patients who undergo hd. some studies report that european patient groups report better physical and mental health compared to asian patients. african-american patients who undergo hd report better quality of life compared to caucasian, hispanic and asian patients.10 several studies have reported that lower socioeconomic and education status are associated with lower quality of life among hd patients, wherein employed patients have been shown to have a better quality of life.11,12 female patients with renal failure who undergo hd have a lower quality of life. likewise, married patients report higher quality of life compared to patients those who are not married. 11,12 clinical factors several studies on hd patients have identified clinical and biochemical markers related to the quality of life of patients, particularly towards the physical dimension. 10,11 1. hemoglobin: as a marker of anemia that often accompanies renal disease, hemoglobin level is strongly related to the physical function and well-being of the patient. increased hemoglobin levels after treatment and erythropoietin therapy have been known to improve energy, stamina and patient participation in everyday activities. 2. protein energy malnutrition (pem): the prevalence of renal failure patients receiving hd therapy is increasing. various attempts have been made to inhibit the progression of ckd. one of the factors that can hinder ckd progression is to implement a therapeutic diet during the pre-dialysis stage. on the other hand, ckd patients often suffer from nutritional disorders, which are a common comorbidity in renal disease. among the multiple risk factors found in ckd, metabolic and nutritional disorders commonly known as pem plays an important role in the course of ckd patients. the pathogenesis of pem in ckd is multifactorial. 3. comorbidity of hd patients: increase in the number of comorbid conditions (e.g., cardiovascular disease, peripheral vascular disease, hypertension and diabetes) exerts a negative influence on the physical quality of life domain of and may also affect the emotional domain of quality of life. psychosocial factors psychological factors are related to the quality of life and mortality rates of hd patients, most notable among which are depression, the patient’s perception of their disease, and the haerani rasyid acta med indones-indones j intern med 310 amount of social support that they receive. anxiety disorders have also been found to be associated with lower quality of life. assessment of depression in patients undergoing hd is quite difficult because of the similarities between somatic depression symptoms with symptoms of kidney failure and the side effects of kidney replacement therapy. several studies have proven a decrease in quality of life and increased mortality rates among hd patients with depression.10,11 social support, either from the patient’s family or healthcare providers, plays an important role in improving the quality of life. patients who received adequate social support from both their family and healthcare provider have reported a better quality of life.10,11 coping strategies hold an important role in determining the quality of life of hd patients. kidney disease and hd are traumatic experiences that cause stress to patients and their families thereby reducing quality of life. inability to adapt or cope with the situation will reduce the quality of life for hd patients. 10,13 efforts to improve the quality of life of patients with renal failure who undergo hemodialysis resolving anemia extensive studies and articles that investigate anemia among renal failure patients have come to similar conclusions. a systematic study by leaf and goldfarb concluded that erythropoietin therapy in a study using sf-36, showed a dramatic improvement in physical symptoms, vitality, energy, and performance. it also found a small improvement in social functioning and mental health, and an improvement in emotional health. optimal improvement was found when hemoglobin levels ranges around 10-12 g/ dl.10,14,15 resolving malnutrition nutritional status assessment, monitoring, and intervention are components that play a crucial role in the management of patients with ckd. adequate nutritional therapy is very important in the long-term management of ckd patients. the increasing prevalence of renal failure has led to improved awareness throughout the world to further enhance strategies to inhibit the progression of ckd. the approach of nutritional therapy in pre-dialysis ckd is one of the strategies that aim to inhibit ckd progression. the approach generally focuses on the intake of protein, salt, potassium, calcium, phosphorus, alkaline derivates, oxalate, citrate, uric acid and water.16 the goal of nutrition management in cases of protein-energy wasting (pew) is to fulfill optimal nutrient intake (carbohydrates, protein fats and micronutrients) which are expected to improve the nutritional status of patients. for decades, protein restriction has been the basic regime for ckd in the pre-dialysis stage. this restriction allows an intake of <0.6-0.8 gram/ kg/day in which 50% of the protein source is expected to come from proteins with high biological value. this protein restriction must be accompanied by adequate calorie intake of 30-35 kcal/kg/day. the dietary regime is expected to prevent the occurrence of pew in the pre-dialysis stage. when the patient has undergone dialysis, the amount of protein intake must be modified from <0.6-0.8 gram/ kg/day to 1.2-1.5 grams/kg/day, depending on the patient’s dialysis modality.17 besides meeting the needs of protein and calories, fulfillment of other nutrients must also be considered using the following recommendations: 1) adequate fat intake, especially unsaturated fats; 2) recommended sodium intake is 2-3 grams/day; 3) recommended potassium intake is 2-4 grams/day; 4) fluid requirements must be regulated individually referring to the daily mandatory requirements of 1,000 ml/day (+ urine volume); 5) the need for micronutrients in the form of folic acid (1 mg/day), vitamin b6 (10-20 mg/day), vitamin c (30-60 mg/day), vitamin b1 (0.5-1.5 mg/day), and vitamin e 800 iu.17 resolving depression various treatment regimens have been reported to treat depression in patients with chronic kidney disease. anti-depressant medications have been used and the results have been reported to significantly improve symptoms vol 54 • number 2 • april 2022 quality of life in patients with renal failure undergoing hemodialysis 311 of depression. however, overcoming depression pharmacologically is often contradictory for various reasons.10 assessing sexual function studies have reported the correlation between sexual dysfunction and other quality of life parameters, such as various mental and physical components. recent studies have shown that in men with mild to moderate depression, improvement of erectile dysfunction is associated with significant improvement of depression symptoms and quality of life.10 resolving stress stress in patients with kidney disease may become a burden. there are various stressors that affect the lives of hd patients. these stressors may include the impact of the disease on the overall body function, nutritional problems, unemployment, financial difficulties, time constraints, mood fluctuations, functional limitations, and fear of physical disability and death.10 providing social support social support has been shown to correlate with a variety of domains including symptoms of depression, the patient’s perception of disease, life satisfaction, and overall quality of life of patients. marital and family problems are generally observed in patients with end stage renal disease and may have a negative impact on the individual. active support from the community also includes spiritual involvement.10 clinical application of quality of life in patients with renal failure who undergo hemodialysis assessing quality of life in patients who undergo hemodialysis assessing quality of life, in addition to more objective clinical indicators, is now increasingly applied given the numerous questions on its effectiveness and suitability. the centers for disease control and prevention (cdc) in usa recommends measuring quality of life to help determine the burden of preventable disease, based on its correlation with risk factors. measuring quality of life will help monitor the progress towards achieving health goals.18 in nephrology, evaluating the quality of life involves determining the efficiency and effectivity of various forms of kidney replacement therapy (e.g., hd and peritoneal dialysis), in addition to evaluating the efficiency and effectiveness of various treatments that are applied to patients with renal failure (e.g., recombinant human erythropoietin therapy). various disease-specific and domain-specific assessment tools have been used to assess quality of life in patients undergoing hemodialysis. disease-specific assessment tools include quality of life index-d (qli-d), kidney disease quality of life short form (kdqolsf), kidney disease questionnaire (kdq), renal quality of life profile (rqlp), choice health experience questionnaire (cheq) and renal dependent individualized quality of life questionnaire. domain-specific assessment tools include barthel index of disability (bi) and mcgill pain questionnaire (mpq).18 jesus nm et al (2018) who measured the qol of individuals with ckd and compare the qol scores of patients with ckd to the scores of disease-free individuals to find factors as sociated with better qol. the whoqol-bref scores of patients with ckd on hemodialysis were lower than the scores observed in the control group. only the scores in the physical and psychological domains were statistically different between the case and control groups. the variables that more significantly affected the qol of individuals with ckd on hemodialysis were having a spouse, the number of comorbidities, under going hemodialysis at a public clinic, more years of schooling, older age, living with more persons in the household, and longer hemodialysis sessions.6 pratiwi dt et al (2019) at their study who determined the determinants quality of life among 200 hemodialysis patients in the hd unit dr. hardjono hospital, ponorogo, east java, in april 2019 using the kidney disease quality of life (kdqol) sf-36 questionnaire showed age, gender, education, type of financing, family income, stress, frequency of hemo-dialysis, level of physical dependence, comorbidity, and social group affect the quality of life of hd patients.19 haerani rasyid acta med indones-indones j intern med 312 assist in decision-making on patient management there are some studies compare the hrqol of hd and capd patients. surendra nk et al (2019) who measured the health utilities and identified socio-demographic and clinical factors associated with hrqol for hd and continuous ambulatory peritoneal dialysis (capd) of 141 patients (77 hd and 64 capd) in malaysia, showed that capd patients had a higher utility index score than hd patients but this was not statistically significant.7 jung hy et al (2019) who compared hrqol over time in 989 patients starting hd or pd showed both patients on hd and pd experienced significant decreases in different hrqol domains over two years and the degree of changes in hrqol over time was not different between dialysis modality. however, the scores of three (effects of kidney disease, burden of kidney disease, and dialysis staff encouragement, all p < 0.05) and two (sexual function and dialysis staff encouragement, all p < 0.05) esrd domains were still higher in patients on pd compared with patients on hd at one and two years after initiation of dialysis, respectively. pd shows better hrqol during the initial period after dialysis even after adjusting for clinical and socioeconomic characteristics, and the effect lasts up to two years.20 the largest impact that quality of life poses on clinical practice is towards decision-making processes regarding administration of hd. patients with renal failure are faced with various treatment options which must be decided on, such as when to start hd, acceptable hd modalities, the decision on kidney transplantation, and etc. if no medical contraindications are present, these decisions are made based on personal preference while considering the patient and family condition, and the patient’s quality of life to treatment options.2117 conclusion a good quality of life is one of the several indicators of hd therapy success. the factors that affect the quality of life among renal failure patients who undergo hd include sociodemographic factors, mental factors (depression), severity of kidney disease, accompanying disorders, hd duration, non-adherence to prescribed medications and nutritional problems. all are important comorbidities in kidney disease. among said risk factors, the metabolic and nutritional disorder commonly known as protein energy wasting (pew) plays a crucial role in the course of renal failure patients. nutrition management in patients with renal failure aims to not only slow down the progression of kidney disease, but to also improve quality of life and reduce cardiovascular morbidity and mortality. references 1. kemenkes ri. cegah dan kendalikan penyakit ginjal dengan cerdik dan patuh [online]. (updated on 7 march 2018). www.depkes.go.id/article/view/18030700007/ cegah-dan-kendalikan-penyakit-ginjal-dengan-cerdikdan-patuh.html [accessed on 5 september 2018]. 2. suhardjono. hemodialisis; prinsip dasar dan pemakaian kliniknya. buku ajar ilmu penyakit dalam. 6th ed. jakarta: interna publishing; 2014. p. 2194. 3. nkf-kdigo. kdigo 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. isn. 2013; 3(1):1–163. 4. gerasimoula k, lefkothea l, maria l, et al. quality of life in hemodialisis patients. materia socio-medica. 2015;27(5):305. 5. mollaoglu m. quality of life in patients undergoing hemodialysis. in hemodialysis 2013. intech. 6. jesus nm, de souza gf, mendes-rodrigues c, de almeida neto op, rodrigues ddm, cunha cm. quality of life of individuals with chronic kidney disease on dialysis. braz. j. nephrol. 2019;41(3):36474. 7. surendra nk , abdul manaf mr, hooi ls, et al. health related quality of life of dialysis patients in malaysia: haemodialysis versus continuous ambulatory peritoneal dialysis. bmc nephrology. 2019;20(151):1-10. 8. theofilou p. outcomes assessment in end‐stage kidney disease—measurements and applications in clinical practice. bentham science publishers. 2014. 9. finkelstein fo, wuerth d, finkelstein sh. health related quality of life and the ckd patient: challenges for the nephrology community. kidney international. 2009;76(9):946-52. 10. kallenbach jz. review of hemodialysis for nurses and dialysis personnel. elsevier health sciences; 2015. 11. desnauli e, nursalam n, efendi f. indikator kualitas hidup pasien gagal ginjal kronis yang menjalani hemodialisa berdasarkan strategi koping. jurnal ners. 2017;6(2):187-91. 12. soponaru c, bojian a, iorga m. stress, coping mechanisms and quality of life in hemodialysis patients. archives of medical science-civilization vol 54 • number 2 • april 2022 quality of life in patients with renal failure undergoing hemodialysis 313 diseases. 2016;1(1):16-23. 13. jaar bg, chang a, plantinga l. can we improve quality of life of patients on dialysis? clinical journal of the american society of nephrology. 2013;8(1):1-4. 14. chen ss, al mawed s, unruh m. health-related quality of life in end-stage renal disease patients: how often should we ask and what do we do with the answer?. blood purification. 2016;41(1-3):218-24. 15. maglakelidze n, pantsulaia t, tchokhonelidze i, et al. a. assessment of health-related quality of life in renal transplant recipients and dialysis patients. transplantation proceed. 2011;43(1):376-9. 16. rasyid h. pengaturan nutrisi pada pasien penyakit ginjal kronik: fokus diet rendah protein. national congress xii and annual scientific meeting 2014 indonesia society of nephrology. 2014;221-7. 17. rasyid h. manajemen protein energy wasting pada gagal ginjal; tantangan dalam menurunkan angka morbiditas dan mortalitas pasien dialisis. disampaikan pada pidato penerimaan jabatan profesor dalam bidang ilmu penyakit dalam fakultas kedokteran universitas hasanuddin. 2017. p. 7-14. 18. mollaoglu m. quality of life in patients undergoing hemodialysis. cumhuriyet university, health sciences faculty, turkey. 2013:829-33. 19. pratiwi dt, tamtomo dg, suryono a. determinants of the quality of life for hemodialysis patients. indonesian journal of medicine. 2019;4(2):145-54. 20. jung hy, jeon y, park y, et al. better quality of life of peritoneal dialysis compared to hemodialysis over a two-year period after dialysis initiation. available at: www.nature.com/scientificreports. 2019. 21. spiegel bm, melmed g, robbins s, et al. biomarkers and health-related quality of life in end-stage renal disease: a systematic review. clinical journal of the american society of nephrology. 2008;3(6):1759-68. 39 original article acta med indones indones j intern med • vol 52 • number 1 • january 2020 three years survival of elderly cancer patients in indonesia: do we need a different approach? noorwati sutandyo1, sri a. kurniawati1, nia n. siregar1, nina k. sari2 1 department of hematology – medical oncology, dharmais cancer hospital, jakarta, indonesia. 2 dharmais cancer hospital, jakarta, indonesia. corresponding author: noorwati sutandyo, md., phd. department of hematology-medical oncology, dharmais cancer hospital. jl. letjen. s. parman kav. 84-86, slipi, jakarta 11420, indonesia. email: noorwatis3@yahoo.com, noorwatisoetandyo@ gmail.com. abstrak latar belakang: jumlah populasi usia lanjut semakin meningkat di indonesia. di lain sisi, prevalensi kanker pada pasien usia lanjut juga meningkat. akan tetapi, studi mengenai faktor klinis terkait kesintasan pasien kanker usia lanjut masih terbatas. studi ini bertujuan untuk mengevaluasi kesintasan pasien kanker usia lanjut dan faktorfaktor terkait. metode: studi ini adalah kohort retrospektif. subyek adalah pasien kanker usia lanjut berusia > 60 tahun yang berobat pada tahun 2013 – 2015 di rs kanker dharmais. data diambil dari rekam medis, terdiri dari jenis kelamin, usia, jenis kanker, stadium, status performa ecog, indeks massa tubuh, charlson comorbidity index, dan jenis terapi. analisis kesintasan menggunakan analisis cox regression untuk mengidentifikasi faktor prognostik independen. hasil: sejumlah 249 pasien dilibatkan dalam studi; median usia adalah 66 tahun dengan rentang usia 60 – 85 tahun. jenis kanker terbanyak adalah paru, diikuti dengan payudara, kolorektal dan ginekologi. median waktu kesintasan adalah 24 bulan. analisis multivariat dilakukan dengan stratifikasi berdasarkan jenis kelamin. kanker stadium lanjut (iii-iv) adalah variabel yang bermakna pada kelompok perempuan (hazard ratio [hr] 2.72; 95% confidence interval [ci] 1.53–4.80; p = 0.001), sedangkan status performa (ecog 2 – 4) merupakan faktor risiko pada kelompok laki-laki (hr 1.82; 95% ci 1.01–3.24; p = 0.04). kesimpulan: kesintasan pasien kanker usia lanjut dipengaruhi berbagai faktor prognostik tradisional. kanker stadium lanjut merupakan faktor prognostik bermakna pada perempuan, sedangkan status performa merupakan faktor prognostik pada laki-laki. kata kunci: usia lanjut, kanker, kesintasan. abstract background: the number of elderly people in indonesia is increasing. additionally, cancer prevalence among older patients is also increasing. however, studies assessing clinical factors associated with the survival of elderly patients with cancer are still lacking. this study aimed to investigate the survival of geriatric patients with cancer and associated factors. methods: this was a retrospective cohort study. subjects were geriatric patients with cancer aged >60 years, enrolled between 2013 and 2015 in dharmais cancer hospital. data were retrieved from medical records and consisted of gender, age, cancer type, stage, eastern cooperative oncology group (ecog) performance status (ps), body mass index (bmi), charlson comorbidity index, and type of treatment. cox regression analysis was used to identify independent prognostic factors for survival. results: a total of 249 patients were enrolled, with a median age of 66 (60–85) years. the most common cancer was of the lung, followed by breast, colorectal, and uterine cervical cancers. the median survival time was 24 months. cox multivariate analysis was performed by gender stratification. advanced stage cancer (iii-iv) was identified as the risk factor for mortality in female patients (hazard ratio [hr] 2.72; 95% confidence interval [ci] 1.53–4.80; p = 0.001), noorwati sutandyo acta med indones-indones j intern med 40 while poor performance status (ecog 2 – 4) was the risk factor in male group (hr 1.82; 95% ci 1.01–3.24; p = 0.04). conclusion: the survival of elderly patients with cancer is affected by traditional prognostic factors. advanced cancer stage was significant independent prognostic factor in female patients, while poor performance status was significant in male patients. keywords: elderly patients, cancer, survival. introduction the number of elderly people (aged 60 years and above) is increasing rapidly in indonesia. approximately 8.97% (23.4 million) of elderly people were estimated in the country in 2017, a percentage that is expected to increase to 15% in 2035.1 on the other hand, the prevalence of non-communicable diseases associated with aging − including cancer − is also increasing. among western populations, and the median age of diagnosis of common cancers, such as breast, colon, and prostate, is mostly above 60 years.2 this demographic change carries the challenge of managing cancer in elderly patients and led to the emergence of geriatric oncology.3 a major issue in the management of elderly patients with cancer is the intensity of optimal treatment. elderly patients are a heterogeneous group and little information is available regarding their ability to tolerate the toxicity of certain anticancer regimens.4 a study found that elderly patients are submitted to less surgery, more frequent single-agent hormonal treatment, and less adjuvant systemic treatment compared with younger patients. moreover, elderly patients have shorter relative survival than their younger counterparts.5 although developments in medicine and socioeconomics have reduced the mortality associated with other conditions, cancer death remains high. the cancer mortality rate is also higher in older than in younger patients. the agebased cancer mortality for patients over 65 years (1,068/100,000) is higher than that of younger patients (67/100,000). these data showed that the cancer mortality rate was 16 times higher in advanced age than in younger ages. more than 70% of mortality related to solid cancers, such as prostate, bladder, colon, uterus, pancreas, stomach, rectum, and lung, occurs in patients over 65 years of age.6 another study by bourdel et al.7 found that 1-year mortality rate in elderly patients with cancer older than 70 years was 43.89%. recent data from indonesia showed that the cancer prevalence increased from 1.4‰ in 2013 to 1.8‰ in 2018.8 together with the increasing life expectancy, geriatric patient management will soon be a new challenge for medical professionals. however, appropriate training and clinical geriatric oncology practice are still limited in asian countries, including indonesia.9 the increasing prevalence of cancer and elderly patients, along with the high associated mortality rate, argue in favor of more geriatric oncology research. until now, studies investigating factors associated with the survival of elderly patients with cancer in indonesia were lacking. therefore, this study aimed to evaluate the survival of elderly patients with cancer and associated factors. methods this was a retrospective cohort study included patients from dharmais cancer hospital (dch), in jakarta. elderly patients between january 2013 and december 2015 were enrolled based on medical record assessments. the elderly were defined as patients aged >60 years, based on world health organization criteria for developing countries.10 this study was approved by the dch ethical committee on april 4, 2018, with the ethical clearance number 048/kepk/iv/2018. clinical assessment clinical data were obtained from patients’ medical records and included age at diagnosis, performance status (ps), comorbidities, type of cancer, histopathology, stage at diagnosis, and type of treatment. the clinical outcome assessed was 3-year survival, defined as the time between the date of diagnosis and death from any cause. vol 52 • number 1 • january 2020 three years survival of elderly cancer patients in indonesia 41 patients were censored if they were lost to follow-up (observed until december 31, 2018). criteria for nutritional status based on the body mass index (bmi) criteria for the asian population, patients were classified according to nutritional status as underweight (bmi <18.5 kg/m2), normalweighted (bmi= 18.5–22.9 kg/m2), overweight (bmi = 23.0–24.5 kg/m2), and obese (bmi >25.0 kg/m2).11 comorbidities were assessed using the charlson comorbidity index (cci) as the total number of non-cancer chronic conditions.12 performance status was assessed based on the eastern cooperative oncology group (ecog) ps, scored from 0 to 4.13 statistical analysis demographic and clinical variables were descriptively presented. differences in overall survival between subgroups were calculated using the kaplan–meier survival analysis.14 the log-rank test was used to evaluate the equality of survival distributions across different subgroups; a p value <0.05 was considered statistically significant. the cox proportional hazards model was developed to identify independent prognostic factors for overall survival, and expressed as the hazard ratio (hr) and corresponding 95% confidence interval (ci).15 statistical analyses were performed using stata version 12.0 for windows pc. results a total of 249 patients were enrolled in this study, 60% of which were female. the patients’ median age was 66 years, ranging from 60 to 85 years. a total of 233 solid and 16 blood/lymphoid tumors were identified. the most common solid cancer was of the lung, followed by breast, colorectal, and uterine cervical cancers. most patients were diagnosed at advanced stages (iii or iv). other clinical characteristics are shown in table 1. survival analysis a total of 173 deaths were recorded during the study period. the median 3-year survival was 24.00 (21.24–26.76) months (figure 1). the highest mortality was found among patients with lung cancer (84.8%), followed by table 1. characteristics of study subjects (n = 249) variables n (%) gender (n, %) male 100 (40.2) female 149 (59.8) educational level <12 years (finished high school or less) 190 (76.3) >12 years (graduate and postgraduate) 59 (23.7) nutritional status underweight 39 (15.7) normal weight 89 (35.7) overweight 49 (19.7) obesity class i 52 (20.9) obesity class ii 20 (8.0) anatomical origin of primary tumor lung 66 (26.5) breast 64 (25.7) gastrointestinal 37 (14.9) gynecological 37 (14.9) blood and lymphoid 16 (6.4) urological 15 (6.0) head and neck 11 (4.4) skin 2 (0.8) neurological 1 (0.4) stage (n, %) i–ii 55 (22.1) iii–iv 194 (77.9) comorbidity cci 0 – 1 204 (81.9) cci 2 – 4 45 (18.1) ecog ps 0 – 1 192 (77.1) 2 – 4 57 (22.9) figure 1. kaplan-meier survival curves of 3-years overall survival. noorwati sutandyo acta med indones-indones j intern med 42 those with head and neck cancers (27.3%), and digestive cancers (27.0%). univariate analysis found that older age (>75 years old), underweight (bmi <18.5 kg/m2), poor performance status, advanced stage disease and single treatment significantly associated with lower overall survival (table 2). kaplan-meier curve for each significant variable was shown in figure 2 – figure 7. table 2. univariate analysis variables hr (95% ci) p male 1.40 (1.04-1.89) 0.029 age >75 years 1.57 (1.05-2.34) 0.028 bmi <18.5 kg/m2 1.64 (1.11-2.42) 0.013 ecog ps 2-4 1.63 (1.16-2.30) 0.005 stage iii-iv 2.97 (1.89-4.65) <0.001 single treatment 1.35 (0.99-1.84) 0.05 cci 0.89 (0.45-1.74) 0.73 figure 2. kaplan-meier survival curves of 3-years overall survival based on sex. all data were treated as closed cohort with 36 months observation. after data management and categorizing all independent variables, it was found that gender did not meet the cox proportional assumptions. therefore, multivariate analysis with cox regression was carried out by gender stratification. all variables with p<0.20 in univariate analysis were conducted to univariate and multivariate analysis in each group. advanced stage cancer (iii-iv) was identified as the risk factor for mortality in female patients (hazard ratio [hr] 2.72; 95% figure 3. kaplan-meier survival curves of 3-years overall survival based on age group. figure 4. kaplan-meier survival curves of 3-years overall survival based on bmi group. figure 5. kaplan-meier survival curves of 3-years overall survival based on performance status group. vol 52 • number 1 • january 2020 three years survival of elderly cancer patients in indonesia 43 confidence interval [ci] 1.53–4.80; p = 0.001) (table 4), while poor performance status (ecog 2 – 4) was the risk factor in male group (hr 1.82; 95% ci 1.01–3.24; p = 0.04) (table 6). discussion geriatric oncology is a new field of medical research in indonesia, and this study was a preliminary assessment of prognostic factors affecting the survival of elderly patients with cancer. in this study, cancer staging was not merely the prognostic factor assessed. other important variables like age, nutritional status (represented by bmi) and performance status were also assessed. aging is a complex process. pre-treatment condition of elderly patients is very important to be assessed before giving any treatment.16 assessing psychosocial aspect such as level of education, family support, and psychomental state are also necessary. a recent systematic review found that advanced age, low income, low socioeconomic status, presence of comorbidities, advanced stage at diagnosis, and poor tumor grade were associated with lower survival.17 however, since this was a retrospective study and psychosocial assessment was not routinely done, we did not do further analysis. figure 6. kaplan-meier survival curves of 3-years overall survival based on treatment group. figure 7. kaplan-meier survival curves of 3-years overall survival based on disease stage. table 3. univariate analysis in female patients (n=149) variables hr (95% ci) p age >75 years 1.74 (1.00-3.03) 0.048 bmi <18.5 kg/m2 2.10 (1.22-3.60) 0.007 ecog ps 2-4 1.58 (1.00-2.51) 0.049 stage iii-iv 3.19 (1.83-5.55) <0.001 single treatment 1.49 (0.99-2.24) 0.05 cci 1.49 (0.60-3.69) 0.41 table 4. cox proportional hazard model in female patients (n=149) variables multivariate hr (95% ci) p age >75 years 1.49 (0.82-2.69) 0.19 bmi <18.5 kg/m2 1.57 (0.87-2.81) 0.13 ecog ps 2-4 1.42 (0.88-2.27) 0.15 stage iii-iv 2.72 (1.53-4.80) 0.001 multiple treatments 1.51 (0.99-2.29) 0.05 table 5. univariate analysis in male patients (n=100) variables hr (95% ci) p age >75 years 1.51 (0.72-3.14) 0.27 bmi <18.5 kg/m2 1.29 (0.74-2.25) 0.37 ecog ps 2-4 1.86 (1.08-3.17) 0.02 stage iii-iv 2.07 (0.95-4.51) 0.07 multiple treatments 0.96 (0.59-1.55) 0.86 cci 0.51 (0.19-1.40) 0.19 table 6. cox proportional hazard model in male patients (n=100) variables multivariate hr (95% ci) p age >75 years 1.64 (0.77-3.50) 0.19 bmi <18.5 kg/m2 1.13 (0.62-2.05) 0.68 ecog ps 2-4 1.82 (1.01-3.24) 0.04 stage iii-iv 2.16 (0.98-4.73) 0.05 multiple treatments 1.06 (-.65-1.74) 0.81 noorwati sutandyo acta med indones-indones j intern med 44 age is one of the traditional factors that is commonly related to mortality in cancer. however, multivariate analysis in this study failed to find significant association between age and survival in cancer patients. this findings showed that chronological age has limitation in evaluating patient’s physiological function, health and aging status, therefor it is not always significantly associated with mortality. nowadays, biological age (estimated by biomarkers) is famously known as the “real age” which can reflect health status with aging. further studies of elderly using biological age are needed. sex is an important factor in pathogenesis, diagnosis, and prognosis in many diseases, including cancer. several studies showed that female gender was associated with longer survival.17,18 our study found that female had better survival than male. however, gender did not meet cox proportional hazard assumption in further analysis. a study by cook et al.19 found that sex-related cancer disparities are more strongly related to etiology than prognosis. the ps (karnofsky or ecog) is traditionally used to assess the functional status in elderly patients with cancer and determines their ability to tolerate anticancer treatments. in the last few decades, the comprehensive geriatric assessment (cga) has been added to geriatric oncology practice to evaluate the tolerability of the elderly before receiving chemotherapy. cga also indicated that elderly patients with cancer have numerous health problems associated with survival, such as functional impairment, malnutrition, and comorbidities.4 growing evidence demonstrates that cga can predict mortality in elderly patients with cancer.20 however, as cga is not used in our hospital, we were unable to evaluate certain aspects of geriatric patients, as social functioning, activities of daily living, and psychological function. univariate analysis showed that subjects with worse ps (ecog 2 – 4) had lower os compared to subjecta with better ps. in gender-stratified multivariate analysis of this study, ecog 2 – 4 was also associated with mortality. in general geriatric population, functional status have been found to be a predictor of survival.21 for elderly with cancer, performance status may affect the ability and respond to treatment. patients with poor performance status are associated with increased risk of treatment toxicity and poor outcomes compared to patients with better performance status.22 the correlation between cancer stage and survival has been widely investigated. as expected, survival in advanced stage cancer is lower than early stage.23 a study in breast cancer patients showed that advanced stage were associated with higher mortality.24 his similar finding was found in this study. in multivariate analysis, advanced stage cancer was associated with lower survival, especially in female group. in certain types of cancer that are more common in men such as prostate cancer and hodgkin’s lymphoma, stage does not significantly affect the decrease in survival.23 this can be the reason of insignificant association between cancer stage and survival in male group. nutritional status is an important prognostic factor in elderly patients. the bmi is one of several methods to measure the nutritional status. in elderly people, reduced weight or bmi is a complex condition resulting from reduced dietary intake, loss of muscle mass (sarcopenia), and cachexia due to cancer, with potential prognostic implications.25 undernutrition can be found in 66% of elderly patients with cancer.26 low bmi and weight loss are associated with an increased risk of death in the elderly population.27 severe malnutrition has been associated with poor prognosis in colorectal cancer.28 in the current study, patients with undernutrition status had lower survival (figure 4). however, multivariate analysis failed to show prognostic role of bmi, suggesting that it was a confounding factor, affected by more advanced stage and related to poor ps. however, the use of bmi as a single nutritional status measure has a major drawback, since it cannot accurately reflect muscle mass or adiposity. in line with this finding, a study among elderly people aged ≥70 years without cancer found that obesity was inversely associated with mortality.29 another study among patients with non-metastatic colorectal cancer showed that low muscle mass, high adiposity, or both were associated with worse survival, with the lowest vol 52 • number 1 • january 2020 three years survival of elderly cancer patients in indonesia 45 risk of mortality found for bmi between 25 and <30 kg/m2. in ct scan, patients in this subgroup seemed to have adequate muscle mass and low fat.30 this could be the reason why patients with low bmi had poor survival outcomes. the treatment of elderly patients with cancer remains a challenge due to the complexity of organ function decline, comorbidities, impairments, and social factors.31 the toxicity of anticancer therapies is potentially higher in elderly patients,32 but evidence is limited as most clinical trials have not enrolled elderly patients. in this study, the net effect of multimodal treatment compared with single treatment was investigated and failed to show significant association with survival. single treatment with a cytotoxic agent is usually recommended for elderly patients with advanced disease. however, several studies showed different results. study by thiels et al.33 found that multimodality treatment in elderly patients with stage iii rectal cancer resulted in better outcomes. another study by coate et al.34 also showed that multimodality treatment in elderly cancer patients could provide better outcomes if given to fit-elderly and for curative goals. based on the current results, the authors encourage adequate management of nutrition in elderly patients with cancer. geriatric oncology team should also involve nutritionists in management of nutrition for elderly cancer patients. whenever feasible, exercise should also be advised to increase muscle mass and reduce fat. further studies are required to elucidate the optimal weight and body composition able to tolerate multiple treatments and produce better clinical outcomes. contrary to current beliefs, multiple treatments with optimal regimens can be offered to this patient population, as the elderly are still responsive to anticancer treatment. significant association between cancer stage and survival emphasizes the importance of early detection. this study has some limitations. first, it had a retrospective design, based on medical record data. therefore, the clinical data retrieved were limited and no further assessments could be performed regarding other characteristics of geriatric patients. however, some important prognostic factors could still be assessed and used for analysis. second, all patients were included and a specific cancer type was not evaluated. it is possible that survival time is affected by tumor type, as observed in lung cancer, which has the highest mortality rate. further studies with prospective design using cga are needed. conclusion the survival of elderly patients with cancer is affected by traditional prognostic factors. advanced cancer stage was significant independent prognostic factor in female patients, while poor performance status was significant in male patients. acknowledgments the authors would like to thank enago (www.enago.com) for the english language review. conflict of interest: the authors report no conflict of interest regarding this study. funding resources this research did not receive any specific grant from funding agencies in the public, commercial or not for profit sectors. references 1. statistics indonesia (badan pusat statistik). statistics of aging population 2017. jakarta: badan pusat statistik, 2018. 2. arnold m, karim-kos he, coebergh jw, et al. recent trends in incidence of five common cancers in 26 european countries since 1988: analysis of the european cancer observatory. eur j cancer. 2015;51:1164–87. 3. terret c. management and geriatric assessment of cancer in the elderly. expert rev anticancer ther. 2004:4(3):469–75. 4. caillet p, laurent m, bastuji-garin s, et al. optimal management of elderly cancer patients: usefulness of the comprehensive geriatric assessment. clin interv aging. 2014;9:1645–60. 5. bastiaannet e, liefers gj, de craen ajm, et al. breast cancer in elderly compared to younger patients in the netherlands: stage at diagnosis, treatment and survival in 127,805 unselected patients. breast cancer res treat. 2010;124(3):801–7. noorwati sutandyo acta med indones-indones j intern med 46 6. berger na, savvides p, koroukian sm, et al. cancer in the elderly. trans am clin climatol assoc. 2006;117:147 – 55. 7. bourdel-marchasson, diallo a, bellera c, et al. one-year mortality in older patients with cancer: development and external validation of an mna-based prognostic score. plos one. 2016;11(2):e0148523. 8. ministry of health. riset kesehatan dasar (basic health research). national institute for health research and development, ministry of health, republic of indonesia: jakarta, 2018. downloaded from: http:// www.depkes.go.id/resources/download/info-terkini/ materi_rakorpop_2018/hasil%20riskesdas%202018. pdf. last 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1958;53:457–81. 15. cox dr. regression models and life-tables. j royal stat soci series b, stat methodol. 1972;34:187–220. 16. loh kp, soto-perez-de-celis e, hsu t, et al. what every oncologist should know about geriatric assessment for older patients with cancer: young international society of geriatric oncology position paper. j oncol pract. 2018;14(2):85 – 94. 17. galvin, delva f, helmer c, et al. sociodemographic, socioeconomic, and clinical determinants of survival in patients with cancer: a systematic review of the literature focused on the elderly. j geriatr oncol. 2018;9(1):6–14. 18. jung kw, park s, shin a, et al. do female cancer patients display better survival rate compared with males? analysis of the korean national registry data, 2005 – 2009. plos one. 2012;7(13): e52457. 19. cook mb, mcglynn ka, devesa ss, freedman nd, anderson wf. sex disparities in cancer mortality and survival. cancer epidemiol biomarkers prev. 2011; 20(8):1629 – 37. 20. extermann m, hurria a. 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soubeyran p, bourdel-marchasson i. undernutrition in elderly patients with cancer: target for diagnosis and intervention. crit rev oncol hematol. 2008;67(3):243– 54. 27. newman ab, yanez d, harris t, duxbury a, enright pl, fried lp, for the cardiovascular study research group. weight change in old age and its association with mortality. j am geriatr soc. 2001;49:1309–18. 28. barao k, cavagnari mav, fucuta ps, forones nm. association between nutrition status and survival in elderly patients with colorectal cancer. nutr clin pract. 2017;32(5):658–63. 29. stenholm s, mehta nk, elo it, heliovaara m, koskinen s, aromaa a. obesity and muscle strength as long-term determinants of all-cause mortality – a 33 year follow-up of the mini finland health examination. int j obes (lond). 2014;38:1126–32. 30. caan bj, meyerhardt ja, kroenke ch, et al. explaining the obesity paradox: the association between body composition and colorectal cancer survival (c-scans study). cancer epidemiol biomarkers 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kurniati2, florence low2, ras a. riza2 1 department of physiology, faculty of medicine universitas indonesia, jakarta, indonesia. 2 faculty of medicine universitas indonesia, jakarta, indonesia. correspondence mail: department of physiology, faculty of medicine universitas indonesia. jl. salemba 6, jakarta 10430, indonesia. email: minarma2001@yahoo.com. abstrak tujuan: menentukan efektivitas dari renal sympathetic – nerve ablation dibandingkan dengan penggunaan kombinasi obat anti hipertensi dalam menurunkan hipertensi resisten. metode: pencarian literatur secara terstruktur dilakukan dengan menggunakan pubmed sesuai dengan pertanyaan klinis. pemilihan artikel dilakukan berdasarkan kriteria inklusi dan eksklusi. lima artikel yang terpilih kemudian dinilai kualitasnya dengan kriteria yang mencakup validity, importance dan applicability. hasil: salah satu studi menunjukan tidak efektifnya denervasi renal terhadap penurunan tekanan darah pada pasien dengan hipertensi resisten, namun ke empat studi lainnya menunjukan hasil yang signifikan. kesimpulan: literatur yang memiliki tingkat bukti yang paling tinggi menunjukan bahwa tidak ada hubungan antara prosedur renal-sympathetic nerve ablation dan penurunan tekanan darah. namun, masih ada kelemahan metodologi yang mungkin mempengaruhi hasil sehingga harus dilakukan studi selanjutnya. kata kunci: denervasi renal, hipertensi resisten. abstract aim: to determine whether the renal sympathetic – nerve ablation method is more effective compared to multiple anti – hypertensive drug among patients with resistant hypertension. methods: a search was conducted on pubmed. the selection of title and abstract was conducted using inclusion and exclusion criteria, which led to five relevant articles. the selected studies were critically appraised for its validity, importance and applicability. results: one of studies showed that renal denervation is not effectively reduced blood pressure in patients with resistant hypertension; nevertheless other studies showed significant results. conclusion: literature with strongest evidence showed that there is no relationship between renal sympathetic-nerve ablation procedure and reduction of blood pressure. however, as there is still some methodological flaw on the literature, we recommend doing another study that may find the appropriate results. key words: renal denervation, resistant hypertension. minarma siagian acta med indones-indones j intern med introduction the increasing rate of the aging population in indonesia leads to an increase in the number of hypertensive patients. in clinical practice, it is estimated that 10% of hypertensive patients are suffering from resistant hypertension. resistant hypertension is defined as systolic blood pressure that is higher than 140 mmhg even though they consume three maximally tolerated antihypertensive medication class, including diuretics at an appropriate dose.1 there are many complications of resistant hypertension such as left ventricular hypertrophy, increased incidence of retinal hemorrhage and kidney damages.2 pharmacological treatment for resistant hypertension is currently available. however, the effectiveness of pharmacological treatment for resistant hypertension is low.3 many failure of this pharmacological therapy is mainly attributed to low-adherence of pharmacological therapy. in which patient do not realize the seriousness of this asymptomatic disease and do not consume anti-hypertensive drug routinely.3 new approach in form of therapeutic intervention may be needed. renal denervation is based on a hypothesis that essential hypertension is caused by an elevated rate of norephinephrine spillover, the number of norepinephrine that is not taken by neuronal uptake and distributed to general circulation.4 the first proof-of-concept experiment involving ablation of sympathetic nerve was done by schlaich in 2009. this experiment reduced blood pressure from 161/107 mmhg to 127.81 mmhg.5 case illustration a 57 years old man came to our clinic for a general medical check up. he did not have an any complaints. however, during physical examination we found that his blood pressure is 152/94. from his medical records, he has consumed three different hypertensive drugs: captopril 25 mg 3 times a day, hydrochlorothiazine 25 mg twice a day and amlodipine 10 mg once a day. at first, we thought that this patient has a compliance problem. however, his wife reassured us that he was compliant in consuming his anti-hypertensive drugs. having heard renal denervation procedure that can reduce blood pressure in patient with resistant hypertension, we were wondering whether this procedure can be done in patient. clinical question in a population with resistant hypertension, does renal sympathetic-nerve ablation effective in reducing blood pressure compared to people that only get combinedanti-hypertensive drugs? methods a search of pubmed® was performed on may 29th, 2014 using the key words “renal denervation”, “resistant hypertension”, “treatment” with its synonyms and related terms. (figure 1) a search cochrane® was also attempted using the same key words. the results were not included since only 2 articles were found, which were already on the pubmed® list. search strategy, results, the inclusion and exclusion criteria are shown in the flowchart. they were articles on clinical trials, systematic reviews, published within 5 years, and performed on humans. after literature selection, critical appraisal was done using several aspect based on center of evidence-based medicine, university of oxford for therapy study (table 1 and table 2). results this evidence-based case report will review the effectiveness of renal denervation in reducing blood pressure of patients with resistant hypertension. the primary endpoint was reduction of blood pressure compared to baseline at 6 months follow-up. from the search criteria mentioned above, 13 journals met the inclusion and exclusion criteria. through further selection process, five studies, which included two rcts, two cohorts, and one systematic review, were eligible for this evidence-based case report. all included trials were appraised for its validity and relevance (table 1 and table 2). the summary of all included studies are depicted in table 3. four articles discussed populations with resistant hypertension while ott et al investigated patients with moderate-resistant hypertension. 342 vol 46 • number 4 • october 2014 effectiveness of renal denervation for treatment of resistant hypertension online database searching using key words “renal denervation”, “resistant hypertension”, and “treatment” 359 articles found from pubmed 38 articles found 13 fulltext studies assessed for eligibility 11 studies assessed for validation 5 studies included 26 of records were excluded 1 article is excluded due to trial is still ongoing 6 articles excluded addition of filters clinical trial systematic review published within 5 years study on human screening from title and abstract figure 1. flow chart of search strategy table 1. critical appraisal of the 10 studies based on criteria by centre of evidence medicine university of oxford articles year validity relevance st ud y de si gn nu m be r of pa tie nt s ra nd om iz at io n si m ila ri ty tr ea tm en t & co nt ro l bl in di ng co m pa ra bl e tr ea tm en t in te nt io n to tr ea t do m ai n de te rm in an t m ea su re m en t of o ut co m e le ve ls o f ev id en ce * bhatt et al6 2014 rct 535 + + + + + + + + 2 krum et al7 2014 cohort 88 + + + 3 ott et al8 2013 cohort 54 + + + + 3 esler et al9 2010 rct 106 + + + + + + 2 + stated clearly in the article; not being done; ? not stated clearly; * levels of evidence based on the oxford center of evidence based medicine 2011 table 2. critical appraisal of a systematic review authors validity level of evidencepico appropriate searching relevant study included quality assessment of trials heterogenity davis et al10 + + + + + 3 based on the literature, resistant hypertension is defined as systolic blood pressure of at least 160 mmhg, to be taking maximally tolerated doses, one of which had to be a diuretic at an optimum dose, while moderate-resistant hypertension is defined as office bp ≥140/90 mmhg and <160/100 mmhg with at least 3 anti-hypertensive drugs, including a diuretic, in adequate dose.6-10 studies by bhatt et al, esler et al, ott et al, and davis et al had a follow-up period for 6 months, whereas krum et al assessed the trials for 36 months. 343 minarma siagian acta med indones-indones j intern med table 3. results of all studies author primary endpoint result summary bhatt et al6 reduction of blood pressure compared with baseline at 6 months decrease in sbp* of -14.13±23.93 mmhg in the denervation group compared to -11.74 25.94 mmhg in the sham procedure group, p = 0.26 between those group. change in 24-hour ambulatory sbp was -6.75±15.11 mmhg in the denervation group compared to -4.79±17.25 mmhg in sham-procedure group. p = 0.98 reduction of blood pressure after 6 months post-renal denervation in this study is neither clinically significant nor statistically significant. krum et al8 reduction of blood pressure from baseline within 36 months mean reduction (95% ci) in systolic and diastolic blood pressure from baseline, p=0.01: • 1 month g sbp: -18.9 (-22.1 to -15.7) mmhg, dbp* -9.4 (-11.4 to -7.4) mmhg. • 6 months g sbp: -22.0 (-25.7 to -18.4) mmhg, dbp -10.2 (-12.4 to -7.9) mmhg. • 12 months g sbp: -26.5 (-30.2 to -22.8) mmhg, dbp -13.5 (-15.9 to -11.1) mmhg. • 24 months g sbp: -28.9 (-33.5 to -24.4) mmhg, dbp -14.0 (-16.9 to -11.1) mmhg. • 36 months g sbp: -32.0 (-35.7 to -28.2) mmhg, dbp -14.4 (-16.9 to -11.9) mmhg significant reduction of blood pressure of blood pressure within 36 months. ott et al8 blood pressure reduction in moderate hypertension patient after 6 months post renal denervation therapy 1. office bp • at baseline in 54 patients: systolic (151 ± 6 mmhg), diastolic (83 ± 11 mmhg) • three months post rdn: systolic (146 ± 23 mmhg, p = 0.164), diastolic (79 ± 12 mmhg, p = 0.011) • six months post rdn: systolic (138 ± 21 mmhg, p < 0.001); diastolic (75 ± 11 mmhg, p < 0.001) 2. 24-h abpm (n = 36) • at baseline: systolic (151 ± 5 mmhg); diastolic (84 ± 10 mmhg) • three months post rdn: systolic (142 ± 20 mmhg, p = 0.012); diastolic (79 ± 11 mmhg, p = 0.003) • six months post rdn: systolic (133 ± 19 mmhg, p < 0.001); diastolic (75 ±11 mmhg, p < 0.001) significant reduction of office and 24 – h ambulatory bp in patients with moderate treatment of resistant hypertension after 6 months post rdn. esler et al16 reduction of blood pressure compared to non treated patient with baseline at 6 months 1. 3 months: therapy group g office bp was reduced from baseline by 32/12 mm hg (sd 23/11, p<0•0001). control group g office bp was reduced from baseline by 1/0 mm hg [21/10], p=0•77 systolic and p=0•83 diastolic) 2. 6 months: reduction of sbp at least 10 mmhg in therapy group (84%) compared to control group (35%) (p<0•0001) reduction of blood pressure of blood pressure after 6 months. this randomised controlled trial is statistically significant davis et al10 reduction of blood pressure in controlled and uncontrolled studies at 6 months 1. 12 studies included: 4 controlled studies, uncontrolled studies 2. ma* of controlled study showed significant decrease in both systolic and diastolic blood pressure (sbp and dbp): mean difference of sbp at 3 month follow-up g -20.82 (95%ci -26.41, -15.24). mean difference of sbp at 6 month follow-up g -28.90 (95%ci -37.20, -20.60) 3. ma of uncontrolled studies also showed significant decrease in both sbp and dbp: mean difference of sbp at 3 month followup g -22.79 (95%ci -26.83, -18.76). mean difference of sbp at 6 month follow-up g -25.01 (95%ci -29.92, -20.09) renal denervation therapy resulted in substantial reduction in mean bp at 6 months in patient with resistant hypertension *abbreviations: abpm (ambulatory blood pressure monitoring); sbp (systolic blood pressure); dbp (diastolic blood pressure); ma (meta analysis) 344 vol 46 • number 4 • october 2014 effectiveness of renal denervation for treatment of resistant hypertension study by bhatt showed no significant reduction of blood pressure in post renal denervation therapy, however, other studies concluded the contrary results.6-10 discussion since the inception of renal denervation, this method has been hailed as a novel way to combat resistant hypertension.4 it is a relatively new finding, in which proof of concept study was done in 2009 by schlach.5 even though it is a relatively new study, as many as 4 rct and cohort studies and one systematic reviews (table 2) were found in this topic. this may be caused by high prevalence and morbidity that may be caused by resistant hypertension.2 from five studies that we analyzed in this ebcr, we found two cohorts and one rct that found that renal denervation procedure effectively reduce both systolic and diastolic blood pressure. the reduction of systolic blood pressure ranged from 10 mmhg to 32 mmhg.7,8 whereas the reduction of diastolic blood were more modest ranged from 10 mmhg to 17 mmhg.7,11 two studies showed decreased blood pressure of >10mmhg however both these studies were more aimed at the safety hence limited number of participant and heterogeneity and no randomization performed.12,13 one study that begs to differ from the consensus is done by bhatt et al.6 this study found renal denervation did not significantly reduced blood pressure. the different conclusions between these studies were explained by superior methods that were applied by bhatt et al.6 this study has the most number of patients, which were 535. in this study, we found randomization between treatment and control groups, which are lacking in all other studies. in addition, bhatt et al used sham procedure as control in this study.6 even though many researchers consider sham surgery as unethical, it is found to be more effective in testing effectiveness of procedure by performing randomized comparison.14 there are several reasons that may explain the results of the clinical trial that is conduced by bhatt et al.15 the first explanation is that renal denervation may not be effective in human. as mentioned before, this study is the most rigorous study that have been conducted in analyzing the efficacy of renal denervation. there may be regression-to-the-mean phenomenon that can be observed in this large sample.16 the second possible explanation is the lack of statistical power in this trial. this study’s sample size is calculated based on previous study that may have overestimated clinical effect of renal denervation. this overestimation may be possible because of different baseline characteristics with other studies that have been discussed in this article: in bhatt et al paper, the baseline hypertension in this study is 159.1 mmhg in denervation group and 159.5 mmhg in sham group. different from other studies that have baseline blood pressure of 180 mmhg in other studies. there is evidence that renal denervation is much more effective in higher baseline blood pressure.16 the third reason is doubt that the procedure can be performed effectively in bhatt et al trial. in this paper, it is stated that there are 88 centers of study with 535 patients participated in this trial.15 as in the supplementary section of the study it is said that all of the cardiothoracic surgeon that participated in this trial have no previous experience in doing renal denervation.15,16 it is likely that this procedure were not done properly. moreover, there are no tools to assess whether renal nerve destructions has already happened. the fourth reason is the high consumption rate of vasodilators in this study.16,17 vasodilators are found to be a predictor for non-response in renal denervation procedure.17 for the patient in case illustration, we cannot yet recommend renal denervation to solve his persistent high blood pressure. even though all of the studies were conducted in patients with similar characteristics to the case: high blood pressure that is resistant with at least three drugs that includes thiazide, the lack of single conclusion between these studies prevent us to recommend this procedure. moreover, the study that has different results was superior in term of methodology. in addition, safety of this procedure and long-term effect of renal denervation procedure on kidney function must be also considered. even though individual trials have explored safety profile of renal denervation procedure. a more 345 minarma siagian acta med indones-indones j intern med robust systematic review must be implemented to find the definitive results.18 currently, renal denervation is available at the national cardiovascular center, harapan kita and hasan sadikin hospital, bandung. however, it is not yet available to the general public. so, we do not know the economical cost of this procedure in indonesia. an analysis by geisler et al on the cost-effectiveness of renal denervation procedure may give us some glimpse on the cost of renal denervation.19 in the analysis, the cost of renal-denervation procedure costs rp 150.000.000,00 (assuming that 1 us$=rp 12,000,00) compared to rp 10,416,000,00 of yearly combined antihypertensive drugs. according to the economic model, the cost of this procedure is us$ 3,071 per quality-adjustedlife year.19 this expensive procedure may limit the applicability of this procedure in indonesian society. we should also consider genetic variations that may influence the results. a study by dimsdale et al found that there’s a significant racial difference between race and it’s vascular response to norepinephrine. in this study, we found that blacks are more sensitive to autonomic nervous system changes compared to whites.20 no study has found the comparison of autonomic changes in asian population compared to white which is the subject of this research. however, as study from asian-american showed that ace inhibitor is less effective compared to calcium channel blocker, renal denervation may be less effective in asian population compared to white.21 conclusion in conclusion, results of studies concerning the practice of renal denervation on patient with resistant hypertension are inconclusive. randomized trials with large number of participants with intention-to-treat analysis of data will be required before an evidence-based recommendation can be provided on the benefits of this procedure. recommendation as there’s still conflicting results on the efficacy of renal denervation procedure we should conduct other randomized controlled trials. the trial that we recommend should be: • has experienced operator, which at least have done twenty renal denervation procedure • has clear method to measure success of renal denervation procedure • baseline in lower range of blood pressure: 150-160 mmhg • revise calculation of sample size • reduce the consumption of vasodilator drug in the treatment group references 1. sarafidis pa, georgianos p, bakris gl. resistant hypertension: its identification and epidemiology. nat rev nephrol. 2013;9(1):51-8. 2. cuspidi c, magga g, sampireri l, et al. high prevalence of cardiac and extracardiac target organ damage in refractory hypertension. j hypertens. 2001;19(11):2063-70. 3. pantelis a, bakris g. resistant hypertension: an overview of evaluation and treatment. j am coll cardiol. 2008;52(22):1749-57. 4. schlaich mp, lambert e, kaye dm, et al. sympathetic augmentation in hypertension: role of nerve firing, norepinephrine reuptake, and angiotensin neuromodulation. hypertension. 2004;43(2):169-75. 5. schlaich mp, sobotka pa, krum h, lambert e, esler md. renal sympathetic-nerve ablation for uncontrolled hypertension. new engl j med. 2009;361(9):932-4. pubmed pmid: 19710497. 6. bhatt dl, kandzari de, o’neill ww, et al. a controlled trial of renal denervation for resistant hypertension. new engl j med. 2014;370(15):1393401. pubmed pmid: 24678939. epub 2014/04/01. eng. 7. krum h, schlaich mp, sobotka pa, et al. percutaneous renal denervation in patients with treatment-resistant hypertension: final 3-year report of the symplicity htn-1 study. lancet. 2014;383(9917):622-9. pubmed pmid: 24210779. epub 2013/11/12. eng. 8. ott c, mahfoud f, schmid a, et al. renal denervation in moderate treatment-resistant hypertension. j am coll cardiol. 2013;62(20):1880-6. pubmed pmid: 23850901. epub 2013/07/16. eng. 9. esler md, krum h, sobotka pa, schlaich mp, schmieder re, bohm m. renal sympathetic denervation in patients with treatment-resistant hypertension (the symplicity htn-2 trial): a randomised controlled trial. lancet. 2010;376(9756):1903-9. pubmed pmid: 21093036. epub 2010/11/26. eng. 346 vol 46 • number 4 • october 2014 effectiveness of renal denervation for treatment of resistant hypertension 10. davis m, filion k, zhang d, et al. effectiveness of renal denervation therapy for resistant hypertension. j am coll cardiol. 2013;62(3):231-41. 11. worthley sg, tsioufis cp, worthley mi, et al. safety and efficacy of a multi-electrode renal sympathetic denervation system in resistant hypertension: the enlightn i trial. eur heart j. 2013;34(28):2132-40. pubmed pmid: 23782649. pubmed central pmcid: 3717311. epub 2013/06/21. eng. 12. ormiston ja, watson t, van pelt n, et al. renal denervation for resistant hypertension using an irrigated radiofrequency balloon: 12-month results from the renal hypertension ablation system (rhas) trial. euro soc cardiol. 2013;9(1):70-4. pubmed pmid: 23685297. epub 2013/05/21. eng. 13. damascelli b, patelli g, ticha v, et al. catheterbased radiofrequency renal sympathetic denervation for resistant hypertension. j vasc inter radiol. 2013;24(5):632-9. pubmed pmid: 23622036. epub 2013/04/30. eng. 14. kim s, frank s, holloway r, zimmerman c, wilson r, kleburtz k. science and ethics of sham surgery: a survey of parkinson disease clinical researchers. arch neurol. 2005;62(9):1367-0. 15. bhatt dl, kandzari de, o’neill ww, et al. a controlled trial of renal denervation for resistant hypertension. new engl j med. 2014;370(15):1393401. pubmed pmid: 24678939. 16. lüscher tf, mahfoud f. renal nerve ablation after symplicity htn-3: confused at the higher level? euro heart j. 2014. 17. laurent s, schlaich mp, esler m. new drugs, procedures, and devices for hypertension. lancet. 2012;380:591-600. 18. krum h, schlaich mp, whitbourn r, et al. catheterbased renal sympathetic denervation for resistant hypertension: a multicentre safety and proof-ofprinciple cohort study. lancet. 2009;373(9671):127581. 19. geisler b, egan b, cohen j, et al. cost-effectiveness and clinical effectiveness of catheter-based renal denervation for resistant hypertension. j am coll cardiol. 2012;60(14):1271-7. 20. dimsdale je, graham rm, ziegler mg, zusman rm, berry cc. age, race, diagnosis, and sodium effects on the pressor response to infused norepinephrine. hypertension. 1987;10(6):564-9. 21. jamerson k, dequattro v. the impact of ethnicity on response to antihypertensive therapy. am j med. 1996;101(3 suppl 1):22s-32s. 347 47 original article acta med indones indones j intern med • vol 52 • number 1 • january 2020 global longitudinal strain (gls) in elderly and its associated factors mohamad s. azizi, sally a. nasution, siti setiati, hamzah shatri department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: mohamad syahrir azizi, md. division of cardiology, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: dr.syahrir@gmail.com. abstrak latar belakang: penyakit kardiovaskular sangat umum dan bisa berakibat fatal pada pasien usia lanjut. hal ini sering diawali oleh disfungsi sistolik ventrikel kiri (lvsd) asimptomatik atau subklinis. deteksi dini lvsd dapat mengurangi morbiditas dan mortalitas akibat penyakit kardiovaskular. salah satu metode yang digunakan dalam deteksi dini lvsd adalah penilaian global longitudinal strain (gls). penelitian ini bertujuan untuk menentukan nilai rerata faktor gls dan terkait gls. metode: penelitian cross-sectional dilakukan di antara pasien usia lanjut berusia >60 tahun di poliklinik geriatri dan kardiologi, departemen ilmu penyakit dalam, rs cipto mangunkusumo. data diperoleh dengan menggunakan metode wawancara, rekam medis, dan pemeriksaan ekokardiografi transthoracic. variabel usia, frailty, hipertensi, penyakit arteri koroner, dislipidemia, dan diabetes mellitus dianalisis sebagai faktor penentu penurunan gls. analisis univariat dilakukan untuk setiap variabel. analisis bivariat dilakukan dengan menggunakan uji chi-square dengan signifikansi p<0,25 dan interval kepercayaan (ci) 95%, dan analisis multivariat menggunakan uji regresi logistik. hasil: sebanyak 194 pasien dirawat sesuai dengan kriteria penelitian, usia rerata 66 tahun. proporsi wanita adalah 60,8%. studi ini mengungkapkan bahwa faktor penentu dengan p<0,25 adalah frailty, hipertensi, dislipidemia, dan diabetes mellitus, dengan analisis multivariat frailty memperoleh nilai or 2,002 (95% ci 1,042-3,925) dan diabetes mellitus memiliki or 2,8278 (95% ci) 1.033–5.025). kesimpulan: nilai rerata gls pada orang tua adalah -21,6% (nilai minimum -5,3% dan nilai maksimum 29,9%). faktor-faktor yang mempengaruhi penurunan gls adalah frailty dan diabetes mellitus. kata kunci: global longitudinal strain (gls), disfungsi sistolik ventrikel kiri (lvsd), frailty. abstract background: cardiovascular disease is very common and can be fatal in elderly patients. it is often preceded by asymptomatic or subclinical left ventricular systolic dysfunction (lvsd). early detection of lvsd can reduce morbidity and mortality due to cardiovascular disease. one method used in the early detection of lvsd is an assessment of global longitudinal strain (gls). this study aimed to determine the mean value of gls and glsrelated factors. methods: this cross-sectional study was conducted among elderly patients aged > 60 years in the geriatric and cardiology clinic, internal medicine, cmh hospital. data were obtained from interviews, medical records, and transthoracic echocardiography examination. the variables of age, frailty, hypertension, coronary artery disease, dyslipidemia, and diabetes mellitus were analyzed as the determinants of a decrease in gls. univariate analysis was conducted for each variable. bivariate analysis was conducted using the chisquare test with a significance level of p<0.25 and confidence interval (ci) of 95%, and multivariate analysis used a logistic regression test. results: a total of 194 patients were admitted according to the study criteria, with mohamad s. azizi acta med indones-indones j intern med 48 a mean age of 66 years. the proportion of women was 60.8%. the study revealed that the determinants with p<0.25 are frailty, hypertension, dyslipidemia, and diabetes mellitus, with multivariate analysis frailty having an or of 2.002 (95% ci 1.042–3.925) and diabetes mellitus having an or of 2.278 (95% ci 1.033–5.025). conclusion: the mean value of gls among the elderly was -21.6% (minimum value -5.3% and maximum value 29.9%). the factors that influence the decrease of gls are frailty and diabetes mellitus. keywords: global longitudinal strain (gls), left ventricular systolic dysfunction (lvsd), frailty. introduction cardiovascular disease is very common and potentially fatal in elderly patients. heart failure is the end stage of all cardiovascular diseases and is often preceded by asymptomatic or subclinical left ventricular systolic dysfunction (lvsd).1,2 subclinical lvsd is lvsd without the signs and symptoms of heart failure detected by global longitudinal strain (gls).3 it can be classified as stage a and b heart failure according to the american college of cardiology/american heart association 2013.4 the early detection of lvsd prior to it developing into heart failure can reduce morbidity and mortality due to cardiovascular diseases.5 subclinical lvsd management is currently controversial as it is a new event that requires further research and adjustment to the stage of heart failure obtained.6 lvsd can be diagnosed by measuring the left ventricular ejection fraction (lvef), which progressively decreases with age. however, lvef examination is not sensitive to subclinical lvsd assessment.7,8 one potential early detection method that can be carried out is to measure echocardiography using the speckle tracking echocardiography (ste) method. using this ste method, the strain ability of the heart muscle can be assessed by evaluating gls. a decrease in gls is generally caused by a change in left ventricular geometry with or without any accompanying damage to or decrease in the left ventricular function. gls is thus able to provide an early assessment of changes in the left ventricular systolic function when lvef is still within normal limits.9-11 other factors that may affect a decrease in gls values are changes in left ventricular geometry associated with various comorbidities: (1) type 2 diabetes mellitus presents a 2.26 times greater risk of a decrease in gls compared to patients without type 2 diabetes mellitus; (2) hypertension is closely related to a decrease in gls. patients that have been hypertensive for more than 10 years have a 3.51 times greater risk of a decrease in gls, while patients with uncontrolled hypertension are at a 3.55 times greater risk of a decrease in gls; (3) dyslipidemia presents a 2.26 times greater risk of a decrease in gls compared to patients without dyslipidemia.10,11 dyslipidemia is a single major risk factor of coronary artery disease (cad). cad also affects a decrease in gls.12 a study by liou et al. found that gls can be used to detect cad in symptomatic patients.13 the management of various risk factors and diseases will inhibit the process of the disease becoming symptomatic heart failure.12 cardiovascular dysfunction plays an important role in the development of frailty. frailty is a condition in which there is an increased susceptibility to stressors that causes multisystem dysregulation. it is influenced by age and is associated with a high risk of physical dysfunction and increased mortality in the elderly.14 a study by russo et al.15 found that black ethnicity was associated with a greater degree of subclinical lvsd by gls than for other race-ethnic groups. other study, meanwhile, have shown the existence of reference ranges based on age, gender, and ethnicity. the data for the research were gathered from africans, americans, asians, australians, and those of middle eastern and pacific descent. however, based on the research, indonesian data is not yet known.16 we sought to investigate the relationship between gls, elderly and its comorbidities. methods this is an observational study with a crosssectional design with the aim of adding data on gls in elderly patients and its related factors. the vol 52 • number 1 • january 2020 global longitudinal strain (gls) in elderly and its associated factors 49 data were collected from elderly patients aged > 60 years old in the geriatric and cardiology clinic, internal medicine, cmh hospital. data were obtained from interviews, medical records, and transthoracic echocardiography examinations, using the consecutive sampling method, from december 2018 to april 2019. this study was approved by the ethics committee, faculty of medicine, universitas indonesia, with ethical approval no. 1212/un2.f1/etik/2018. registered patients at the geriatric and cardiology clinic aged >60 years old who met the inclusion criteria of having one of the comorbidities needed in this study were included. the comorbidities for inclusion were hypertension, cad, dyslipidemia, and diabetes mellitus. meanwhile, any patients who had symptomatic heart disease, were involved in drug research, had pulmonary diseases and kidney disorders (stage 4 and 5 chronic kidney disease), had arrhythmia, had poor echo window, and who were unwilling to take part in the study were excluded. the subjects were given oral and written explanations regarding the study and were asked to sign an informed consent form. frailty was determined based on a questionnaire comprising a 40-item frailty index. echocardiography was carried out by one operator (msa), with two operators (san, lr) who already had the echocardiography examination certification providing confirmation of the post-processing data. the results were recorded and analyzed. data analysis a data normality test was conducted using the kolmogorov-smirnov test. the variables of age, frailty, hypertension, coronary artery disease, dyslipidemia, and diabetes mellitus were analyzed as the determinants of a decrease in gls. univariate analysis was carried out in respect of each variable. bivariate analysis was undertaken using a chi-square test with a significance level of p<0.25 and confidence interval (ci) of 95%, and multivariate analysis was carried out using a logistic regression test. results from a total of 203 patients who met the inclusion criteria, 9 were excluded owing to the presence of arrhythmia and poor echo window, which resulted in 194 research subjects meeting the criteria for analysis in this study. these 194 patients consisted of 76 males (38.2%) and 118 females (60.8%). the median age in this study is 66 years, with a range of 60–90 years old. a total of 184 patients (94.8%) have lvef within normal limits, and 10 patients (5.2%) have decreased lvef. the gls assessment shows that 135 patients (69.6%) are within normal limits, while 57 patients (29.4%) have decreased gls. some of the patients with normal lvef have decreased gls. frailty was present for 85 patients (43.8%), with non-frailty present in 109 patients (56.2%). in this study, 34 patients have cad (17.5%), 149 have hypertension (76.8%), 105 have dyslipidemia (54.1%), and 44 patients have diabetes mellitus (22.7%). from the echocardiography results, the measurements of interventricular thickness enddiastole (ivsd), left ventricular dimension end-diastole (lvdd), and left ventricular posterior wall (lvpw) have average values of 1.26 cm, 4.39 cm, and 1.07 cm, respectively. the measurements of left atrial end-systolic volume index (lavi) and e/a display average values of 28.40 ml/m2 and 0.80, respectively. the table 1. characteristic of subjects characteristics n (%) gender, n (%) women 118 (60.8) age, median (min-max) 66 (60-90) young-old, n (%) 161 (83.0) lvef, median (min-max) 66 (24.7 82.2) normal (≥ 55 %), n (%) 184 (94.8) gls, median (min-max) 21,6 (5.3 29.9) normal (≥ -20 %), n (%) 135 (69.6) frailty index, median (minmax) 0.22 (0.03-0.9) frailty (≥0,24), n (%) 85 (43.8) cad, n (%) yes 34 (17.5) hypertension, n (%) yes 149 (76.8) dyslipidemia, n (%) yes 105 (54.1) diabetes mellitus, n (%) yes 44 (22.7) mohamad s. azizi acta med indones-indones j intern med 50 measurements of ejection fraction 4-chamber (ef4c), ejection fraction biplane (efbp), global longitudinal strain (gls) and tricuspid annular plane systolic excursion (tapse) have average values of 65.45%, 65.03%, -21.60%, and 28.40%, respectively. from the bivariate analysis, this study revealed some determinants that have p<0.25; these are frailty, hypertension, dyslipidemia, and diabetes mellitus. the multivariate analysis shows that frailty has an or of 2.002 (95% ci 1.042–3.925) and diabetes mellitus has an or of 2.278 (95% ci 1.033–5.025). discussion the patients in this study were predominantly female, with a proportion of 60.8% compared to the males. a study by bendiab et al.17 reported no significant difference between males and females on gls changes. the age range of the patients in this study was 60–90 years old with a median age of 66 years. this age range is not in accordance with various studies from all over the world. nadruz et al.8, in a study using subjects with an average age of 75.6 (sd 5.0) years old, stated that elderly patients with frailty had a greater decrease in gls. in addition, hung et al.7 used subjects with an average age of 76 (sd 5) years in their study about the relationship between table 2. characteristics of echocardiographic features of research subjects characteristics value frailty non frailty aorta diameter, cm (median) 2.50 (2.10-3.70) 2.50 2.50 left atrium, cm (mean) 3.56 (3.39-3.73) 3.43 3.46 e-point septal separation, cm (median) 0.50 (0.20-1.40) 0.60 0.50 rv dimension end-diastole, cm (median) 1.97 (1.31-3.21) 1.97 2.01 iv thickness end-diastole, cm (mean) 1.26 (1.20-1.32) 1.23 1.22 lv dimension end-diastole, cm (mean) 4.39 (4.24-4.54) 4.29 4.49 lv posterior wall, cm (median) 1.07 (0.74-1.94) 1.06 1.00 lv dimension end-systole, cm (mean) 2.53 (2.41-2.64) 2.54 2.68 fractional shortening, % (median) 42.36 (16.80-52.70) 41.4 41.3 ef teich, % (median) 75.00 (35.20-84.00) 72.7 74.15 relative wall thickness (median) 0.50 (0.30-0.80) 0.50 0.40 lv mass index, g/m2 (mean) 110.50 (106.42-121.30) 111.69 113.54 pulmonary acceleration time, ms (mean) 120.41 (114.05-126.76) 114.58 116.0 ef 4-chamber, % (median) 65.45 (24.70-82.20) 66.70 65.6 ef biplane, % (median) 65.03 (25.30-77.60) 66.50 65.2 gls, % (median) -21.60 (-5.30 -29.90) -20.80 -22 tv d-e excursion, cm (mean) 2.48 (2.37-2.57) 2.43 2.38 la end-systolic volume index, ml/m2 (mean) 28.40 (25.28-31.51) 28.12 27.23 ivc expiration, cm (mean) 1.52 (1.45-1.57) 1.54 1.48 ivc inspiration, cm (median) 0.68 (0.0-1.77) 0.69 0.69 stroke volume, ml (mean) 62.98 (57.94-68.03) 61.25 65.66 cardiac output, l/min (median) 4.30 (2.50-10.20) 4.2 4.35 doppler data e, cm/s (mean) 76.65 (71.22-82.07) 73.67 76.69 a, cm/s (mean) 86.84 (81.68-92.01) 91.33 93.36 e/a (median) 0.80 (0.50-2.90) 0.70 0.80 e’ medial, cm/s (mean) 6.87 (6.35-7.38) 6.47 7.81 e’ lateral, cm/s (mean) 8.82 (8.20-9.44) 8.31 9.33 e/e’ (mean) 8.58 (8.01-9.15) 8.62 8.81 vol 52 • number 1 • january 2020 global longitudinal strain (gls) in elderly and its associated factors 51 age and sex and left ventricular remodeling. the differentiation in this study is that the younger ages were different from those in overseas studies. according to 2017 data from the united nations, life expectancy in indonesia falls within the range 65–69 years. the results of the echocardiography measurements from ivsd, lvdd, and lvpw illustrate a thickening of the left ventricular wall, with the dimensions being within normal limits for geriatric patients. the lavi and e/a measurements illustrate early onset of diastolic dysfunction in geriatric patients with e/a ≥ 0.80, with lavi within normal limits. the patients’ measurements of ef4c, efbp, gls, and tapse are within normal limits. the lvef measurement data show that 94.8% of the patients have normal lvef, while 5.2% of the patients have decreased lvef. the gls measurement data show that 69.6% of the patients have normal gls, while 30.4% of patients have decreased gls. this reveals that 26.6% of patients with normal lvef have decreased gls. this is in line with a study by yancy et al.2, which stated that there are elderly patients who have decreased gls with normal lvef. in this study, it was also found that a decrease in gls has a sensitivity of 100%, a specificity of 73.4%, and a positive predictive value of 100% compared to the decrease in lvef. plana et al.18 stated that a decrease in gls can predict subclinical lvsd before structural changes in the left ventricular and a decrease in lvef, with high values for sensitivity, specificity, positive predictive value, and negative predictive value (65–96%, 73–95%, 50–83%, and 89–97%). in this study, based on bivariate analysis, age was not associated with a decrease in gls. table 3. bivariate analysis for gls deteminants variables gls total pr (95% ci) p value decreased (n,%) normal (n,%) frailty frailty 31 (36.5) 54 (63.5) 85 1.728 1.092-2.735 0.018 non-frailty 23 (21.1) 86 (78.9) 109 usia old-old 6 (18.2) 27 (81.8) 33 0.610 0.285-1.306 0.174 young-old 48 (29.8) 113 (70.2) 161 hypertension yes 36 (24.2) 113 (75.8) 149 0.604 0.382-0.954 0.038 no 18 (40.0) 27 (60.0) 45 dm yes 17 (38.6) 27 (61.4) 44 1.566 0.983-2.495 0.069 no 37 (24.7) 113 (75.3) 150 cad yes 8 (23.5) 26 (76.5) 34 0.818 0.426-1.573 0.675 no 46 (28.7) 114 (71.2) 160 dyslipidemia yes 23 (21.9) 82 (78.1) 105 0.629 0.397-0.996 0.045 no 31 (34.8) 58 (65.2) 89 table 4. multivariate analysis for gls determinants b coefficient standard error wald (forward) value p (sig.) or 95% ci frailty 0.704 0.338 4.332 0.037 2.002 1.042–3.925 dm 0.824 0.404 4.164 0.041 2.278 1.033-5.025 mohamad s. azizi acta med indones-indones j intern med 52 with a pr of 2.880 and a p value of 0.289 (95% ci 0.443–18.749). statistically, the age variable was not suitable to be continued to multivariate analysis due to the p value ≥0.25, although we did continue to multivariate analysis because it was clinically meaningful. this finding differs from that in a study by hung et al.7, which stated that age should show a significant difference in terms of the decrease in gls. hung et al.7 reported a decrease in gls of 0.39–0.19% per decade. the value of gls decreases every decade. in this study, the average gls value for patients aged 60–70 years (n:141) was -21.08% (-7.4% – -29.9%), for patients aged 71–80 years (n:43) it was -20.76% (-5.3% – -29.5%), while for patients aged 81–90 years (n:10) it was -22.88% (-16.8% – -26.20%). the higher average value for the oldest group may be due to the low number of subjects, which totaled only 10 patients. this study showed a statistically significant relationship between frailty and a decrease in gls, with an or of 2.002 and a p value of 0.037 (95% ik 1.042–3.925). this shows that patients with frailty have a 2.002 times greater risk of a decrease in gls than non-frail patients. seto et al.14 stated that cardiovascular dysfunction plays an important role in the development of frailty, which is the condition of being frail. the incidence of frailty increases with age, female gender, african-american race, low education and income, poor health, and the presence of chronic comorbid diseases and disability. some of the subjects in this study have diseases such as hypertension, diabetes mellitus, coronary heart disease, and dyslipidemia. pathophysiologically, frail elderly patients can display sarcopenia and weakness of limbs, resulting in a decrease in body activity, including for the cardiovascular system.19 a significant decrease in gls has been shown in elderly patients without risk factors for cardiovascular disease, with a value of -20.9 (sd 1.9) %.2 elderly patients with frailty reported a greater decrease in gls (22%) compared to the non-frail (12%).8 from the bivariate analysis, 24.2% of the patients with hypertension show a decrease in gls, with a pr of 0.604 and a p value of 0.038 (95% ci 0.382–0.954). furthermore, multivariate analysis was carried out by logistic regression, although a p value of ≥0.05 meant it could not proceed to the multivariate final stage. this shows that hypertension is statistically not related to a decrease in gls. however, this is not in accordance with a study by bendiab et al.17, which stated that hypertension is closely related to a decrease in gls. hypertensive patients with a duration of more than 10 years have a 3.51 times greater risk of a decrease in gls, while patients with uncontrolled hypertension have a 3.55 times greater risk of a decrease in gls. this difference is likely to be due to the majority of the subjects in this study being hypertensive patients undergoing routine treatment. in this study, the average duration of hypertension is 8.6 years. most of the patients were using a combination therapy of several drugs, with amlodipine being the most used drug. the mean blood pressure of the subjects was 133/81 mmhg, thus indicating that the subjects had controlled hypertension. the echocardiographic characteristics did not show a change in the structure due to severe hypertension, which could have produced a decrease in gls values. this study succeeded in revealing elements that were in accordance with the existing research on the relationship between diabetes mellitus and decreased gls. patients with diabetes mellitus have a 2.278 times greater risk of experiencing a decrease in gls than patients without diabetes mellitus, with a p value of 0.041 (95% ci 1.033–5.025). these results indicate that diabetes mellitus is the most influential factor in decreasing gls compared to the other studied factors. this finding is in accordance with that of mahalle et al.10, who found that patients with diabetes mellitus have a 2.26 times greater risk of a decrease in gls compared to patients without diabetes mellitus. pathophysiologically, on the theoretical framework, diabetes mellitus causes a decrease in gls in terms of macroangiopathy (coronary arteries) and microangiopathy (nonischemic cardiomyopathy). diabetes mellitus and atherosclerosis-related cardiovascular events are also associated with comorbidities such as obesity, hypertension, and dyslipidemia. diabetic cardiomyopathy is associated with an increase in adipocytes to release leptin and resistin, which vol 52 • number 1 • january 2020 global longitudinal strain (gls) in elderly and its associated factors 53 causes a direct change in cardiac structure, the occurrence of hypertrophy, and fibrosis.20 ammirati et al.1 stated that cad can cause a decrease in gls due to systolic dysfunction resulting from permanent damage from myocytes that turn into nonfunctional fibrotic tissue or dysfunctional myocytes. however, this study has shown different results. from the bivariate analysis, it was found that 23.5% of the patients with cad had a decrease in gls, with a pr of 0.818 and a p value of 0.675 (95% ci 0.426–1.573). the analysis was continued to multivariate analysis despite the p value ≥0.25 because cad is an important parameter toward a decrease in gls. this study also shows that there is no statistical relationship between cad and decreased gls. the results of this study are different from those of prior studies as the cad diagnoses were established based only on the patients’ medical records and not by the gold standard of an angiographic examination. this allows for a false negative on the incidence of cad. based on esc 2013 guidelines, patients with age ≥60 years, male and female, with or without symptoms have a pretest probability of intermediate risk that requires further evaluation using a stress test to diagnose the presence or absence of cad.21 gls itself is a significantly strong predictor of stenosis in stable cad with a mean value of -17% and an or of 1.25 per 1% reduction in gls.22 according to mahalle et al.10 and miller et al.11, patients with dyslipidemia have a 2.26 times greater risk of a decrease in gls, compared to patients without dyslipidemia. however, those studies are contrary to our finding. from the multivariate analysis, it was found that there is a statistically significant relationship between dyslipidemia and decreased gls, with an or of 0.401 and a p value of 0.011 (95% ci 0.199–0.808). this indicates that dyslipidemia is a protective factor against a decrease in gls. other studies have shown that gls has a negative correlation with several risk factors, one of which is dyslipidemia, especially in children.23 vitarelli et al.24 stated that children and young adults with dyslipidemia have more severe left ventricular disorders characterized by a decrease in gls. the study used subjects with a mean age of 10.48 (sd 3.42). this significant difference is probably due to the characteristics of the subjects from different studies, especially with regard to the age and history of dyslipidemia. the subjects of this study were selected based only on their medical records, with no cholesterol check performed alongside the echocardiography examination. conclusion from this study, the mean value of gls in elderly is -21.6% (minimum value -5.3% and maximum value 29.9%). the factors that influence the decrease of gls are frailty and diabetes mellitus. references 1. ammirati e, rimoldi oe, camici pg. is there evidence supporting coronary revascularization in patients with left ventricular systolic dysfunction? circ j. 2011;75: 3–10. 2. yancy cw, jessup m, bozkurt b, et al. accf/ aha guideline for the management of heart failure: executive summary. j am col cardiol. 2013;128: 1810–52. 3. cioffi g, viapiana o, ognibeni f, et al. prognostic role of subclinical left ventricular systolic dysfunction evaluated by speckle-tracking echocardiography in rheumatoid arthritis. j am soc echocardiogr. 2017;30: 602–11. 4. ayoub am, keddeas vw, ali ya, et al. subclinical lv dysfunction detection using speckle tracking echocardiography in hypertensive patients with preserved lv ejection fraction. clin med insights cardiol. 2016;10:85–90. 5. leng s, chen x, mao g. frailty syndrome: an overview. clin interv aging. 2014;9:433–41. 6. wang tj, levy d, benjamin ej, et al. the epidemiology of ‘asymptomatic’ left ventricular systolic dysfunction: implications for screening. ann intern med. 2003;138: 907–16. 7. hung c-l, goncalves a, shah am, et al. age and gender-related influences on left ventricular mechanics in elderly individuals free of prevalent heart failure: the atherosclerosis risk in communities study. circ cardiovasc imaging. 2017;10:784–90. 8. nadruz w, kitzman d, windham bg, et al. cardiovascular dysfunction and frailty among older adults in the community: the aric study. j gerontol a biol sci med sci. 2017;72:958–64. 9. holland dj, marwick th, haluska ba, et al. subclinical lv dysfunction and 10-year outcomes in type 2 diabetes mellitus. heart. 2015;101:1061–6. mohamad s. azizi acta med indones-indones j intern med 54 10. mahalle n, garg m, naik s, et al. study of pattern of dyslipidemia and its correlation with cardiovascular risk factors in patients with proven coronary artery disease. indian j endocrinol metab. 2014;18:48–55. 11. miller m. dyslipidemia and cardiovascular risk: the importance of early prevention. q j med. 2009;102: 657–67. 12. russo c, jin z, elkind msv, et al. prevalence and prognostic value of subclinical left ventricular systolic dysfunction by global longitudinal strain in a community-based cohort. eur j hear fail. 2014;16: 1301–9. 13. liou k, negishi k, ho s, et al. detection of obstructive coronary artery disease using peak systolic global longitudinal strain derived by two-dimensional speckle-tracking: a systematic review and metaanalysis. j am soc echocardiogr. 2016;29:724–35. 14. seto e, setiati s, laksmi pw, et al. diagnostic test of a scoring system for frailty syndrome in the elderly according to cardiovascular health study, study of osteoporotic fracture and comprehensive geriatric assessment based frailty index compared with frailty index 40 items. acta med indones-indones j intern med. 2015;47:183–7. 15. russo c, jin z, homma s, et al. race-ethnic differences in subclinical left ventricular systolic dysfunction by global longitudinal strain: a community-based cohort study. am hear j. 2015;169:721–6. 16. poppe k. a meta-analysis of echocardiographic measurements of the left heart for the development of normative reference ranges in a large international cohort: the echonormal study. eur hear j. 2014;15:341–8. 17. soufi taleb bendiab n, meziane-tani a, ouabdesselam s, et al. factors associated with global longitudinal strain decline in hypertensive patients with normal left ventricular ejection fraction. eur j prev cardiol. 2017; 24:1463–72. 18. plana jc, galderisi m, barac a, et al. expert consensus for multimodality imaging evaluation of adult patients during and after cancer therapy: a report from the american society of echocardiography and the european association of cardiovascular imaging. eur heart j cardiovasc imaging. 2014;27:911–9. 19. setiati s, kedokteran p, indonesia d. geriatric medicine, sarcopenia, frailty and geriatric quality of life: future challenge in education, research and medical service in indonesia. ejki. 2013;1:234–42. 20. leon bm. diabetes and cardiovascular disease: epidemiology, biological mechanisms, treatment recommendations and future research. world j diabetes. 2015;6:1246. 21. montalescot g, sechtem u, achenbach s, et al. guidelines on the management of stable coronary artery disease. eur hear j. 2013;34:2949–3003. 22. biering-sørensen t, hoffmann s, mogelvang r, et al. myocardial strain analysis by 2-dimensional speckle tracking echocardiography improves diagnostics of coronary artery stenosis in stable angina pectoris. circ cardiovasc imaging. 2014;7:58–65. 23. zhang p, li d, su y, et al. assessment of myocardial strain in children with risk factors for atherosclerosis with use of 3d speckle tracking echocardiography. echocardiography. 2018;35:487–93. 24. vitarelli a, martino f, capotosto l, et al. early myocardial deformation changes in hypercholesterolemic and obese children and adolescents: a 2d and 3d speckle tracking echocardiography study. med (united states). 2014;93:1–10. case report 155acta med indones indones j intern med • vol 52 • number 2 • april 2020 a family cluster of coronavirus disease (covid-19) infection with different clinical manifestations soedarsono department of pulmonology and respiratory medicine, faculty of medicine universitas airlangga, surabaya, indonesia. corresponding author: soedarsono, md., phd. department of pulmonology and respiratory medicine, faculty of medicine universitas airlangga. jl. mayjen prof. dr. moestopo no. 6-8 surabaya 60131, indonesia. email: ssoedarsono@gmail.com. abstrak coronavirus disease 2019 (covid-19) yang disebabkan oleh severe acute respiratory syndrome coronavirus 2 (sars-cov-2) oleh who telah dinyatakan sebagai pandemi global. selama pandemi, kecurigaan infeksi covid-19 adalah pada pasien yang menunjukkan gejala klinis covid-19. beberapa gejala klinis covid-19 yang baru dikenal telah dilaporkan baru-baru ini. hal ini menyebabkan kesulitan untuk mengidentifikasi covid-19 hanya berdasarkan gejala klinis. real-time reverse transcriptase-polymerase chain reaction (rt-pcr) mutlak diperlukan untuk menegakkan diagnosis. kami melaporkan satu keluarga yang terinfeksi covid-19 dengan manifestasi klinis yang berbeda satu sama lain. kasus klaster dalam keluarga ini menunjukkan potensi penularan covid-19 pada orang yang awalnya tidak memiliki gejala tetapi pada perjalanan penyakitnya menunjukkan gejala karena periode inkubasi yang bervariasi antara 5-14 hari. orang tanpa gejala ini tetap berpotensi untuk menularkan virus. laporan kasus ini menguraikan temuan epidemiologis, klinis, radiologis, laboratorium, dan berbagai manifestasi klinis yang berbeda dalam satu keluarga dengan covid-19 di indonesia. covid-19 ditularkan dari orang yang tidak menunjukkan gejala pada masa inkubasi. kata kunci: covid-19, sars-cov-2, gejala klinis, orang tanpa gejala. abstract coronavirus disease 2019 (covid-19) caused by severe acute respiratory syndrome coronavirus 2 (sarscov-2) had been declared as a global pandemic by who. during the pandemic, a suspicion of covid-19 infection could be found on patients presented with clinical symptoms of covid-19. however, several new clinical symptoms of covid-19 had also been reported recently. this caused difficulties to identify covid-19 based on the clinical symptoms only. real-time reverse transcriptase-polymerase chain reaction (rt-pcr) was absolutely needed to determine the correct diagnosis. we report a family cluster of covid-19 with different clinical manifestations to show a potential covid-19 transmission in person who has no symptoms initially but may develop symptoms later as the incubation period varies from 5-14 days. this asymptomatic person remains potential to transmit the virus. this report describes the epidemiological, clinical, radiological, laboratory findings, and different clinical manifestation of a family cluster of covid-19 case in indonesia. covid-19 was transmitted from asymptomatic person in the incubation period. keywords: covid-19, sars-cov-2, clinical manifestation, asymptomatic person. 156 soedarsono acta med indones-indones j intern med introduction coronavirus disease 2019 (covid-19) was caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2), which first found in wuhan, china and had been declared as a global pandemic by the world health organization (who) on 11 march 2020.1-4 the common clinical symptoms and laboratory findings caused by this covid-19 infection were fever, dry cough, dizziness, headache, sore throat, rhinorrhea, chest pain, dyspnea, myalgia, malaise, arthralgia, fatigue, sputum production, anorexia, diarrhea, nausea, and vomiting. recently, anosmia (loss of smell sense) and ageusia (loss of taste sense) had been reported as the symptoms of confirmed covid-19 patients in the previous studies.5,6 generally, laboratory findings showed normal range of wbc count, reduced lymphocyte count, and elevated c-reactive protein level. radiological manifestation of covid-19 were patchy ground glass opacity with or without consolidation involving multiple lobes, mainly in the peripheral zone, accompanied by halo sign, vascular thickening, crazy paving pattern, or air bronchogram sign.7-10 however, several new clinical symptoms of covid-19 had also been reported recently. this caused difficulties to identify covid-19 based only the clinical symptoms. a better understanding of diagnosis and transmission of covid-19 are needed. this report describes the epidemiological, clinical, radiological, laboratory findings, and different clinical manifestation of a family cluster of covid-19 case in indonesia. april 2020 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 patient 1 (father) dry cough, nasal congestion, dyspnea patient 2 (daughter) dry cough, nasal congestion patient 3 (mother) patient 4 (son) contacted with and take care of patient 1 boxes filled with yellow are the dates of close contacted; boxes filled with orange are the dates of symptoms. visited a private doctor visited a private doctor accompanied patient 1 and 2 to visit a hospital x-ray positive started admitted in isolation room visited a hospital x-ray positive started admitted in isolation room visited a hospital x-ray positive started self-isolation rt-pcr positive rt-pcr positive rt-pcr positive rt-pcr positive anosmia and ageusia figure 1. clinical timeline of symptoms’ onset of a family cluster and their contacts. 157 vol 52 • number 2 • april 2020 a family cluster of covid-19 infection with different clinical manifestations case illustration these case histories began when patient 2 (daughter of patient 1 and patient 3) initially presented with dry cough and nasal congestion since 4th april 2020 (symptoms’ onset/illness day 1). then, patient 1 (father) became unwell and developed dry cough and nasal congestion on 6th april 2020 (2 days after the symptoms’ onset of patient 2). patient 3 (mother) presented no symptom. patient 4 (son of patient 1 and patient 3) presented very mild symptoms in only 1 day and recovered on 11th april 2020. clinical timeline of symptoms’ onset was presented in figure 1. this family lived closely in a particular neighborhood. patient 1, 2, and 3 lived together in one house, while patient 4 lived in the different house and frequently came to his parents’ house, especially when patient 1 felt sick. patient 2 has not worked for a long time before this pandemic. patient 2 also stated that she stayed home along this pandemic. patient 3 was a housewife with no activity outside. patient 1 was a worker who also routinely attended religious activities in mosque even in this pandemic time. this was a risk factor of covid-19 infection and the patient was suspected and considered as indexed case. patient 1 was a 58 year old man presented with dry cough and nasal congestion since 6th april 2020 (symptoms’ onset). this patient had no co-morbid, but he was a smoker. he visited a private doctor on 7th april 2020 and chest x-ray examination showed infiltrate on basal of the right lung (figure 2). on 9th april 2020, he visited our hospital and second chest x-ray on the same day showed bilateral infiltrate on both of the lung (figure 2). he was directly hospitalized in isolation room. at presentation, laboratory examination showed elevated c-reactive protein (crp) to 92.7 mg/l and low lymphocyte to 22.06% (table 1). on the following day, dyspnea was occurred and his 3rd chest x-ray on 10th april 2020 showed progressive infiltrate in sub pleural and basal of both of lungs (chest x-ray developed/ progressed into more severe). the following lab examination showed reduced lymphocyte to 19.40%. he was prescribed antibiotic of levofloxacin iv, antipyretic, antitusive, vitamin c supplement and oxygenation. he was tested positive for sarscov-2 by real-time reverse transcriptasepolymerase chain reaction (rt-pcr) assay on 11th april 2020. after confirmed as covid-19 positive, this patient received chroloquine 2 times a day, 400 mg as an antiviral. laboratory examination showed reduced lymphocyte to 11.93% on 17th april 2020. secondary bacterial infection got worse and levofloxacin was changed to cephalosporin. bacterial culture was not evaluated due to cost limitation. the three times of rt-pcr evaluation every 5 days remained positive, while clinical condition which had been worsen in the previous days, was improved now. the following evaluation of rt-pcr showed negative for sars-cov-2 and patient was in good condition. patient 2 was a 34 year old woman (daughter of patient 1 and patient 3) presented with dry cough and nasal congestion since 4 april 2020. he visited a private doctor on 7th april 2020 then visited a hospital with patient 1 due to persistent symptoms on 9th april 2020. she was prescribed symptomatic drugs. laboratory examination showed normal percentage of lymphocyte to 38.89% (table 1). chest x-ray showed pulmonary nodule infiltrate in the right paracardial (figure 2). she started self-isolation on 9th april 2020 and was tested using rt-pcr assay on 14th april 2020. the rt-pcr assay test showed a positive result for covid-19. she received symptomatic drugs without antiviral. all symptoms were improved and she was recovered. rt-pcr test was negative for covid-19 on 17th april 2020. patient 3 was a 63 year old woman (mother of patient 2 and patient 4) presented no symptom. this patient had co-morbid of type 2 diabetes mellitus (t2dm). on 9th april 2020, she accompanied patient 1 and patient 2 to a hospital, under the instruction of doctor, she was recommended to get a chest x-ray due to abnormal chest x-ray results found in patient 1 and patient 2. her chest x-ray showed infiltrate bilateral in the basal of both of the lungs (figure 2). laboratory examination showed low lymphocyte to 22.76% (table 1). she was then admitted to the isolation room (triage) on the same day and was prescribed 158 soedarsono acta med indones-indones j intern med table 1. summary of clinical features and laboratory results of the family cluster infected with covid-19, at presentation. patient 1 (father) patient 2 (daughter) patient 3 (mother) patient 4 (son) age (years) 58 34 63 30 sex man woman woman man occupation retired unemployed housewife employee co-morbid type 2 diabetes mellitus fever body temperature (0c) 38.2 37,4 36.4 na cough + + + (dry) (dry) (dry) dyspnea headache myalgia sore throat nasal congestion + + fatigue anosmia + ageusia + gastrointestinal symptoms (diarrhea) chest x-ray infiltrates + + + isolation room (triage) + + self-isolation + + white blood cell (10^3/ul) 11.66 6.28 6.65 na normal range 3.8-10.6 (↑) lymphocyte (%) 22.06 36.89 22.76 na normal range 25-40 (↓) (↓) hemoglobin (g/dl) 15.84 14.31 14.59 na normal range 13.2-17.3 sodium (na) (mmol/l) 120.80 na na na normal range 125-147 potassium (k) (mmol/l) 3.50 na na na normal range 3.5-5.0 chloride (cl) (mmol/l) 99.60 na na na normal range 95-105 glucose (md/dl) 126 na 199 na normal range <145 blood urea nitrogen (mg/dl) 13.1 na na na normal range 10-20 creatinine (mg/dl) 0.82 na na na normal range 0.62-1.10 sgot/ ast (u/l) 82 75 na na normal range 0-50 (↑) (↑) sgpt/alt (u/l) 51 69 na na normal range 0-50 (↑) (↑) c-reactive protein (mg/l) 92.7 na na na normal range <6 (↑) na=not available; +=positive (yes); -=negative (no); ↑=above normal range; ↓=below normal range. 159 vol 52 • number 2 • april 2020 a family cluster of covid-19 infection with different clinical manifestations b1 b2 b3 c1 c2 c3 d1 a1 a2 a3 a4 a5 figure 1. chest radiograph of all patients. a. patient 1; b. patient 2; c. patient 3; d. patient 4; a1. 7th april 2020; a2. 9th april 2020; a3. 10th april 2020; a4. 20th april 2020; a5. 1st may 2020; b1. 7th april 3030; b2. 9th april 2020; b3. 17th april 2020; c1. 9th april 2020; c2; 14th april 2020; c3. 20th april 2020; d1. 10th april 2020). 160 soedarsono acta med indones-indones j intern med only multivitamins. the rt-pcr test showed positive for sars-cov-2 on 11th april 2020. chest x-ray examination on the 5th day of hospitalization showed improvement. on the 6th day, patients asked to be discharged from hospital and start her self-isolation at home. she still had no symptoms until she was tested negative for covid-19, 3 weeks away from the first rt-pcr test. patient 4 was a 30 year old man (son of patient 1 and patient 3). this patient stated that he had implemented both social and physical distancing, hand hygiene, and wear mask when he was outside his house. he frequently visited and looked after patient 1 (father), since patient 1 felt sick. he also stated that he was in close contact with patient 1. chest x-ray on 10th april 2020 showed normal lungs (figure 2). on 11th april 2020, he reported very mild symptoms such as anosmia and ageusia in a very short time which lasted only one day and recovered on the same day. he was tested positive for covid-19 on 17th april 2020. due to very mild symptoms, he started self-isolation at home. he was not prescribed any drugs and finished his 14 days of self-isolation. he was later tested negative for covid-19, 3 weeks after the first rt-pcr test. discussion this family cluster of covid-19 showed that infection caused by sars-cov-2 can present with different clinical manifestations. patient 1, as suspected of indexed case, had no symptoms initially but developed symptoms later on. he also had a progressive severity of disease but then improved and recovered in one month. while patient 2 who was most likely transmitted by patient 1, initially showed symptoms of dry cough and nasal congestion then recovered in a short time. patient 3 had no symptoms, while patient 4 only presented with ageusia and anosmia in just a day and recovered. chest x-ray of patient 1, 2, and 3 showed abnormalities, while chest x-ray of patient 4 showed normal lungs. rt-pcr of all patients also showed positive for covid-19. these findings indicated that covid-19 can be transmitted by asymptomatic carriers during the incubation period. a study in china also reported the transmission of covid-19 from asymptomatic carriers during the incubation period in a familial cluster.11 approximately 80% of infected individuals remain asymptomatic or present only with minor symptoms, whereas 15% become moderately to severely ill with cough and shortness of breath, and 5% require intensive care. elderly people with underlying diseases, such as cardiovascular disease, diabetes mellitus, hypertension, chronic respiratory disease and malignancies, are at greater risk of developing severe covid-19.12 covid-19 can affect all groups of ages and asymptomatic infection has been well described. in the large chinese report, 2% of infections were in individuals below 20 years old. similarly, in south korea, 6.3% of nearly 8000 infections were in those younger than 20 years old. pneumonia is the most frequent serious manifestation of infection, characterized primarily by fever, cough, dyspnea. there are no specific clinical features that can differentiate covid-19 from other viral respiratory infections.10 patient 1, as the indexed case, was in more severe condition and hospitalized for around 1 month due to persistent clinical manifestation, heavier dyspnea, followed by extendedly worsening of serial chest x-ray and a secondary bacterial infection from laboratory examination. patient 3 had no symptoms but she was hospitalized for a week and was discharged for self-isolation, despite the remained positive result of rt-pcr. this was according to the guideline in indonesia which allows covid-19 patients with rt-pcr positive to implement self-isolation if the symptoms are very mild and patients are in good condition. patient 2 and 4 started self-isolation for 14 days after confirmed for covid-19. this was due to very mild symptoms of those patients. self-isolation was done under supervision and monitored by surabaya local public health authorities. antiviral was only given to patient 1, following the policy of hospital, which antiviral was only given to patient with moderate to severe symptoms of disease. patients with mild symptoms were treated with symptomatic drugs. patient 1 was known as an active smoker. smoking is a risk factor for many respiratory 161 vol 52 • number 2 • april 2020 a family cluster of covid-19 infection with different clinical manifestations infections, and could also trigger disease progression in those infected.13 previous studied have shown that smokers are more likely to contract influenza and exhibit more severe symptoms than nonsmokers.14 smoking was reported to be a risk factor for middle east respiratory syndrome coronavirus (mers-cov) infection and associated with high mortality.15 the mechanisms in which smoking increases the risk of worsening pneumonia include altered airway architecture, inhibition of airway cilliary clearance and reduced immune function.14 the proportion of patients with severe symptoms was 21.2% among current smokers and 42.9% among past smokers, which was higher compared with those who had never smoked (14.5%). only 4.7% of those who had never smoked developed critical outcomes.8 co-morbidities such as cardiovascular disease, diabetes mellitus, chronic lung disease, hypertension and malignancies are believed to increase the risk of mortality.10 although in this family cluster, patient 3 had a co-morbidity of type 2 diabetes mellitus (t2dm) and presented with no symptoms. she was hospitalized and recovered in less than a week. this finding showed that patient with t2dm also had chance to recover from covid-19. there were some uncompleted data such as laboratory examination including procalcitonin due to the expensive cost of some examinations, which was not covered by the government because the hospital was not a referral hospital for covid-19. conclusion physicians should be aware and raise suspicion on asymptomatic person who has no symptoms initially but may develop symptoms later because this asymptomatic person was able to transmit the virus. diagnosis of covid-19 should not only on clinical manifestations. radiological and laboratory testing should be used in the diagnosis and rt-pcr was absolutely needed to confirm covid-19. conflict of interest we are exempt from ethical approval from the second islamic hospital surabaya institutional review board as it is not required in our hospital for a case report. acknowledgments author thanks to mayta rithmala, m.d. and nurses of outpatient clinic and ward room of the second islamic hospital surabaya. references 1. world health organization. novel coronavirus – china. http://www.who.int/csr/don/12-january-2020novel-coronavirus-china/en/. 12 january 2020. 2. huang c, wang y, li x, et al. clinical features of patients infected with 2019 novel coronavirus in wuhan, china. lancet. 2020. https://doi.org/10.1016/ s0140-6736(20)30183-5. 3. world health organization director-general’s opening remarks at the media briefing on covid-19. march 2020. 4. world health organization. naming the coronavirus disease (covid-19) and the virus that causes it. https://www.who.int/emergencies/diseases/novelcoronavirus-2019/technical-guidance/naming-thecoronavirus-disease-(covid-2019)-and-the-virus-thatcauses-it (accessed mar 24, 2020). 5. russel b, moss c, rigg a, hopkins c, papa s, van hemelrijck. anosmia and ageusia are emerging as symptoms in patients with covid-19: what does the current evidence say?. ecancer. 2020; 14: ed98. https:// doi.org/10.3332/ecancer.2020.ed98. 6. benezit f, turnier p, declerck c, et al. utility of hyposmia and hypogeusia for the diagnosis of covid-19. lancet infect dis. 2020. https://doi. org/10.1016/s1473-3099(20)30297-8. 7. yang x, xu j, shu h, et al. clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, retrospective, observational study. lancet respir med. 2020. https://doi.org/10.1016/s2213-2600(20)300795. 8. guan w, ni z, hu y, et al. clinical characteristics of coronavirus disease 2019 in china. n engl j med. 2020. https://doi.org/10.1056/nejmoa2002032; pmid: 32109013; epub ahead of press. 9. han r, huang l, jiang h, dong j, peng h, zhang d. early clinical and ct manifestation of coronavirus disease 2019 (covid-19) pneumonia. am j roentgenol. 2020;215:1-6. 10. i n t e r n a t i o n a l p u l m o n o l o g i t s ’s c o n s e n s u s o n covid-19: 2nd edition. 2020. india. 11. ye f, xu s, rong z, et al. delivery of infection from asymptomatic carriers of covid-19 in a familial cluster. int j infect dis. 2020;94:133-8. 12. komiyama m, hasegawa k. smoking cessation as a public health measure to limit the coronavirus disease 162 soedarsono acta med indones-indones j intern med 2019 pandemic. 2020;15:e16. https://doi.org/10.15420/ ecr.2020.11. 13. groskreutz dj, monick mm, babor ec, et al. cigarette smoke alters respiratory syncytial virus-induced apoptosis and replication. am j respir cell mol biol 2009;41:189–98. https://doi.org/10.1165/rcmb.20080131oc; pmid: 19131644. 14. arcavi l, benowitz nl. cigarette smoking and infection. arch intern med. 2004;164:2206–16. https://doi.org/10.1001/archinte.164.20.2206; pmid: 15534156. 15. park je, jung s, kim a, park je. mers transmission and risk factors: a systematic review. bmc public health 2018;18:574. https://doi.org/10.1186/s12889018-5484-8; pmid: 29716568. 202 acta med indones indones j intern med • vol 53 • number 2 • april 2021 case report a beneficial bipolar hemiarthroplasty on a centenarian in one developing country komang agung irianto1,2, novira widajanti1,2, eko julianto2, swan ien2, ronald t. m. panggabean2, yudhistira p kloping1 1 faculty of medicine, airlangga university – dr. soetomo hospital, surabaya, indonesia. 2 surabaya orthopedic and traumatology hospital, surabaya, indonesia. corresponding author: komang agung irianto s, md. faculty of medicine airlangga university dr. soetomo general hospital. jl. prof. dr. moestopo 6-8, surabaya 60115, indonesia. email: komang168@yahoo.com. abstrak fraktur pinggul geriatri sering terjadi, namun operasi pada pasien berusia 100 tahun jarang terjadi di indonesia. kami melaporkan artroplasti pada wanita 100 tahun dengan fraktur panggul kanan dan fraktur colles kanan yang menguntungkannya tiga tahun hidup aktif dan berkualitas. meskipun usianya sangat lanjut, pasien cukup mandiri, aktif, dan mobilitasnya baik. oleh karena itu perencanaan pra-operasi dan rehabilitasi paska-operasi yang cermat disusun oleh tim geriatri medis dan non-medis yang komprehensif. hemiarthroplasty bipolar tanpa semen cukup sempurna untuk patah tulang pinggul di bawah anestesi regional sementara patah tulang colles dikelola dengan reduksi tertutup dan plesteran. rehabilitasi dimulai pada hari ke-2 dan dilanjutkan beberapa minggu setelah pulang. pasien dapat bertahan hidup dan sehat sampai setelah 3 tahun operasi. pembedahan bermanfaat bagi pasien berusia 100 tahun; demi kepentingan terbaik mobilitas dan kualitas hidup pasien. usia saja tidak boleh membatasi keputusan pembedahan selama semua komorbiditas dikendalikan oleh tim geriatri medis dan non-medis yang komprehensif. kata kunci: cementless bipolar hemiarthroplasty, fraktur pinggul, usia lanjut, pembedahan. abstract geriatric hip fractures are common; however, surgery on a 100-year-old patient is rare in indonesia. we report arthroplasty in 100-year-old woman with right hip fracture and right colles fracture; which benefits her a three year of active and qualified life. despite her age, the patient was quite independent, active, and mobile beforehand. hence a meticulous preoperative planning and post-operative rehabilitation were structured by a comprehensive medic and non-medic geriatric team. cementless bipolar hemiarthroplasty was perfectly sufficient for the hip fracture under regional anesthesia while the colles fracture was managed with a close reduction and plastering. rehabilitation was started on day-2 and continued weeks after discharge. the patient is still alive and well 3 years after the surgery. surgery is beneficial for the 100-year-old patient; it is in the best interests of the patient’s mobility and quality of life. age alone should not limit a surgical decision as long as all comorbidities are controlled by a comprehensive medic and non-medic geriatric team. keywords: cementless bipolar hemiarthroplasty, hip fracture, elderly, surgery. vol 53 • number 2 • april 2021 a beneficial bipolar hemiarthroplasty on a centenarian 203 introduction indonesia is a developing asian country where there are only few 100 years old patients with hip fracture undergoing a surgery. the uncommonness of the cases was shown by the lack of reported data. from the socio-cultural point of view, there’s little to no reasons that medical decisions such as surgery should be performed on a very old patient. the number of hip fractures among the elderly is expected to surpass 6 million by the year 2050 worldwide.1,2 geriatric hip fracture is highly burdening; not only is it a major morbidity, many of them never fully recover.3-5 instead, hip fracture is one of the major problems in the very old patient due to bedridden worsening factors.4,5 by immaculate planning management, the sooner the surgery performed, the sooner patient back to usual active life, and skip the morbidity.5,6 when a 100-year old woman, who was still healthy and active, tripped and needed a major surgery, several medical and non-medical preparations should be convened. quality of life of the patient is one of the most important things to consider in planning a treatment management.5,6 our report discusses the benefit of surgery on a geriatric patient with a hip fracture contrary to the local socio-cultural beliefs that may prevent this medical procedure from being performed. this case report has been reported in line with the scare criteria.7 case illustration a 100-year-old woman (indonesian woman of chinese descent), height 1.42 m, weight 39 kg, asa ii, and body mass index of 19.3 kg/ m2) was admitted in er after a domestic fall on september 2013. patient was compos mentis; her heart rate was 80 bpm and blood pressure were 150/80 mmhg. patient had a history of mild hypertension and was on medication without hyperlipidemia, diabetes, nor cardiac arrhythmia. she was able to do daily activities independently before admission. patient felt pain on the right hip and wrist, both regions were swollen, deformed and had limitation of motion. the neurovascular and mental status were good. there were no other complaints associated with this injury. x-ray of the hip lesion showed fracture of the trochanter of the right femur (ao classification 31-a1) and colles fracture of the right wrist. chest x-ray was normal, but ecg revealed minor mitral regurgitation. laboratory tests displayed within normal hematology value, insignificant liver and renal function, and all electrolytes were within normal value. the thorough preparation involved a medic and paramedic incorporating team to convince the patient and the family about the benefits and the risks of the surgery and the necessary lengthy rehabilitation. despite the commonly-perceived notoriety and the notion that doing surgery on a very old patient may potentially be useless and dangerous, the patient herself was willing to be mobile and able to enjoy her life again. the geriatric team prepared the informed consent form, explained and discussed the necessities and all possible risk factors of the treatment planning, the surgical procedure and anesthetic technique with the patient and the family. treatment planning, bipolar arthroplasty for right hip fracture, closed reduction and plastering for the right colles fracture. skin traction for the hip was applied one day before the surgery. the preoperative and postoperative x-ray(s) of the right wrist and hip are depicted in figure 1 and 2, respectively. figure 1. colles fracture. (a) right colles fracture before reduction (b) after reduction in circulair cast. komang agung irianto acta med indones-indones j intern med 204 preoperative medication, the existent antihypertensive medication (amlodipine 5 mg p.o. o.d), celecoxib 40 mg i.v. o.d for analgesic and ceftriaxone 2 mg i.v. o.d. as prophylactic antibiotics. surgery was performed under regional anesthesia (epidural anesthesia) using marcaine 0.5%. cementless bipolar hemiarthroplasty was inserted by the moore’s posterior approach in lateral decubitus position. the trochanter mayor was fixated using wire. there was no prosthesis instability nor leg length discrepancy, which were checked while in the or immediately after the surgery. the surgery took 120 minutes with 400 ml blood loss and a drain was inserted for 2 days evaluation. hemoglobin post-surgery was 9.5 gr%; transfusion was not needed. from the recovery room, patient was admitted in icu for overnight observation. post-operative medication, the prophylactic antibiotic ceftriaxone 1 g i.v. t.i.d. for 2 days. analgesic was changed to tramadol 50 mg i.v. b.i.d. other medications were amlodipine 5 mg p.o. o.d., citicoline 500 mg p.o. t.i.d., omeprazole 20 mg i.v. b.i.d. for two days, and alprazolam 1 mg p.o. o.d. prn. on the second day (day 1 post-surgery), patient was transferred to the ward. some insignificant predictable complications occurred, such as constipation, sleeping difficulties, and delirium due to dementia drugs. gradual mobilization was started by the physiotherapy team. patient was put on half sitting position while leaning on the head of the bed with limited range of motion (rom) of the hip joint. the rehabilitation program for active and passive movement was held twice a day. post-operative blood from drain was 180 ml, became minimal to less than 30 ml, and the drain was off by 2x24 hours post-surgery. hemoglobin on day 2 postsurgery was 10.5 gr%. on the fourth day of post-surgery, the patient was encouraged to sit and increase her hip joint rom. on the fifth day, the patient was trained to sit on the bedside and transferred to a chair or wheelchair. the rehabilitation process was done gradually by log-rolling, sitting-standing, and partial weight bearing walking using u walker. the clinical photo of patient’s rehabilitation process is depicted in figure 3. on the sixth day, the patient was discharged as scheduled owing to the good and significant recovery as well as the mobility progression. the distal perfusion and rom evaluation of the colles fracture were good with minimal vas score (1-2). the plastering of the colles fracture was kept for 5 days and then was changed into skin tight before discharge. all surgical-related medications were discontinued upon discharge. the patient’s care-giver was her youngest daughter who stayed with her. the care-giver was taught to clean the wound areas and keep the rehabilitation program twice a day. figure 2. hip fracture. (a) x-ray of right fracture pertrochanter hip. (b) x-ray after bipolar arthroplasty and sanar wire augmentation. vol 53 • number 2 • april 2021 a beneficial bipolar hemiarthroplasty on a centenarian 205 follow-ups were scheduled on the 2nd week for wound care and physiotherapy evaluation. surgical wound was healed without any sign of skin inflammation. the vas for hip and wrist was minimal (1-2). physiotherapy was continued as scheduled. four weeks post-surgery, the hip joint was functioning well; good rom without pain. the wrist was clinically union, well-functioning and the patient could hold the walker without pain; but the wrist x-ray showed minimal calluses and revealed shortening of the radial bone. the wrist cast was removed, and the patient felt fine. a rehabilitation physiotherapy program was continued to improve the range of motion of the wrist and the patient was also asked to continue mobilization with walker at home until 6-8 weeks. a recent interview (2nd march 2017) with the patients’ family revealed that the patient was still mobile and active until two years post-surgery (2015) without any complications. however, in the last years (2016-2017), her dementia and cataract worsened, which affected her activity; yet, she was otherwise in good health regarding her hip-related condition. discussion hip fractures are very common among elderly patients due to osteoporosis and multiple associated diseases.6 this type of fracture increases the risk of morbidity and mortality among the elderly.2,3 elderly people are frail, disabled and dependent.8-10 among the elderly, severe disability after acute hospitalization is most commonly caused by falls and hip fracture.10,11 in this case there are some comorbidities that were managed by the geriatric medical team. the meticulous pre-operative planning and postoperative rehabilitation as one medical decision were structured to minimize post-operative complications.5,6,8 regardless of the age, the patient was quite independent, active and mobile before the fracture; hence a comprehensive management incorporating the veracious surgical and anesthesia technique, the exact implant selecting, and immediate post-operative rehabilitation was taken into consideration. people aged 90 years old or older are prone to suffer traumatic injuries that would cause hip fractures requiring care and rehabilitation. furthermore, this age is associated with increased mortality and worse chance of functional recovery.12 even though the risks of complication are high, a study by domenico et al. showed that patients 90 years of age or older with hip fracture achieved a surprisingly good postoperative outcome and returned home after rehabilitation.13 in this case, the patient had a positive outcome due to a multidisciplinary approach and comprehensive care of the patient before, during, and after the surgery. in the absence of routine follow-up, complications after a hip hemiarthroplasty are frequently present; most of them require surgical reintervention.14 cementless bipolar hemiarthroplasty was performed through moore’s posterior approach. cementless type of prosthesis was chosen to decrease blood loss during operation. it also has a lower dislocation rate; therefore, the rehabilitation process could be done swiftly without limitations and with a lower risk of pulmonary embolism due to prosthetics.8 the austin-moore hemiarthroplasty has been used for more than 60 years and is frequently performed for dependent elderly patients.15 a dc.b. figure 3. (a) (b) sequences of rehabilitation 2nd after surgery, (c) 3rd day after operation, (d) 4 years after surgery. komang agung irianto acta med indones-indones j intern med 206 the result of the study conducted by lin et al.14 suggested that elderly patients who receive bipolar hemiarthroplasty may have a better rate of survival compared to those who receive unipolar hemiarthroplasty.15 some studies suggest that cemented prosthesis could reduce postoperative thigh pain, aseptic loosening, and the incidence of periprosthetic fracture.16,17 however, uncemented prostheses are believed by some surgeons to be able to eliminate cementrelated complications and mortality and , shorten surgery time, thus reducing complications that may arise after the surgery.18,19 the colles fracture was managed by a closed reduction and plastering to decrease the surgery time. plastering would be changed into skin tight cast one week later, which then would be continued for four weeks, when there’s a sign of clinical healing. unstable distal radius fractures (colles fracture) can be treated with closed reduction and cast application in low-demand elderly patients to avoid risks and complications of surgery.20 although there was malunion (4 weeks postoperative in x-ray perspective), but the wrist itself is in good function and painless when the patient held her walker. the geriatric medic and non-medic team are very important; they are required to assess medical problems, to minimize risk of complications that may arise before, during, and after the surgery. the geriatric team was also involved since the first time in delivering informed consent and in discussing the non-medical issues as well. based on the research results provided by domenico et.al., a comprehensive geriatric assessment combined with a good multidisciplinary approach could provide a positive outcome for the elderly.13 the short-term outcome of surgical management for asian nonagenarian with hip fractures is favorable in selected patients.21 the positive post-operative condition of the patient was also due to the comprehensive rehabilitation management during recovery, and the utmost supports from the family to keep the patient mobile and active, irrespective of her age. this case is reported to inspire medical professionals in asian developing countries that performing surgery on an elderly patient is possible, or even mandatory as long as the case is devoid of absolute contraindications. a good and comprehensive geriatric team is a must. conclusion performing a bipolar hemiarthroplasty in a previously healthy, active, and mobile 100year-old patient with hip fracture is a highly recommended medical decision. age alone should not limit a surgical decision as long as all comorbidities are controlled, and complications are prevented by a comprehensive medic and non-medic geriatric team. references 1. dhanwal dk, dennison em, harvey nc, cooper c. epidemiology of hip fracture: worldwide geographic variation. indian j orthop. 2011;45(1):15. 2. kannus p, parkkari j, sievänen h, heinonen a, vuori i, järvinen m. epidemiology of hip fractures. bone. 1996;18(1):s57-63. 3. wolinsky fd, fitzgerald jf, stump te. the effect of hip fracture on mortality, hospitalization, and functional status: a prospective study. am j public health. 1997;87(3):398-403. 4. bentler se, liu l, obrizan m, et al. the aftermath of hip fracture: discharge placement, functional status change, and mortality. am j epidemiol. 2009; 170(10):1290-9. 5. gill tm, allore hg, holford tr, guo z. hospitalization, restricted activity, and the development of disability among older persons. jama. 2004;292(17):2115-24. 6. boyd cm, xue ql, simpson cf, guralnik jm, fried lp. frailty, hospitalization, and progression of disability in a cohort of disabled older women. am j med. 2005;118(11):1225-31. 7. agha ra, fowler aj, saetta a, barai i, rajmohan s, orgill dp and the scare group. the scare statement: consensus-based surgical case report guidelines. int j surg. 2016;34:180-6. 8. daabiss m. american society of anaesthesiologists physical status classification. indian j anaesth. 2011; 55(2):111. 9. lunney jr, lynn j, foley dj, lipson s, guralnik jm. patterns of functional decline at the end of life. jama. 2003;289(18):2387-92. 10. arinzon z, fidelman z, zuta a, peisakh a, berner yn. functional recovery after hip fracture in old-old elderly patients. arc gerontol geriatr. 2005;40(3):327-36. 11. intiso d, di rienzo f, grimaldi g, et al. survival and functional outcome in patients 90 years of age or older after hip fracture. age ageing. 2009;38(5):619-22. 12. imbelloni le, lima u, pedrosa fk. successful anesthesia and hip surgery in a 107 year-old patient. am j case rep. 2014;15:308. vol 53 • number 2 • april 2021 a beneficial bipolar hemiarthroplasty on a centenarian 207 13. chaplin vk, matharu gs, knebel rw. complications following hemiarthroplasty for displaced intracapsular femoral neck fractures in the absence of routine followup. ann r coll surg engl. 2013;95(4):271-4. 14. lin cc, huang sc, ou yk, et al. survival of patients aged over 80 years after austin-moore hemiarthroplasty and bipolar hemiarthroplasty for femoral neck fractures. asian j surg. 2012;35(2):626. 15. lo wh, chen wm, huang ck, chen th, chiu fy, chen cm. bateman bipolar hemiarthroplasty for displaced intracapsular femoral neck fractures uncemented versus cemented. clin orthop res. 1994; 302:75-82. 16. khan r, macdowell a, crossman p, datta a, jallali n, arch b, keene g. cemented or uncemented hemiarthroplasty for displaced intracapsular femoral neck fractures. int orthop. 2002;26(4):229-32. 17. lennox ia, mclauchlan j. comparing the mortality and morbidity of cemented and uncemente d hemiarthroplasties. injury. 1993;24(3):185-6. 18. parvizi j, ereth mh, lewallen dg. thirty-day mortality following hip arthroplasty for acute fracture. jbjs. 2004;86(9):1983-8. 19. killic a, ozkaya u, kobucuoglu y, sokucu s, basilgan s. the results of non surgical treatment for unstable distal radius fractures in elderly patients. acta orthop traumatol turc. 2009;43(3):229-34. 20. lin wt, chao cm, liu hc, li yj, lee wj, lai cc. short-term outcomes of hip fractures in patients aged 90 years old and over receiving surgical intervention. plos one. 2015;10(5):e0125496. 149acta med indones indones j intern med • vol 53 • number 2 • april 2021 original article abstrak latar belakang: penyakit ginjal diabetik (pgd) sebagai penyebab utama penyakit ginjal tahap akhir (pgta), merupakan komplikasi dari diabetes mellitus (dm). salah satu kondisi yang menjadi faktor risiko pgd yaitu defisiensi vitamin d, dimana polimorfisme reseptor vitamin d (vdr) disinyalir memiliki peran. studi ini bertujuan untuk melihat adanya hubungan antara polimorfisme reseptor vitamin d (vdr) terhadap pgd, dan faktor yang memengaruhi hubungan tersebut. metode: studi dilakukan secara potong lintang pada pasien dm tipe 2 di poliklinik penyakit dalam rsupn dr. cipto mangunkusumo, jakarta dengan rentang waktu november 2014 – maret 2015. subjek yang memenuhi kriteria penelitian dilakukan pengumpulan data berupa karakteristik subjek, pemeriksaan fisik, dan pemeriksaan darah (polimorfisme bsmi gen reseptor vitamin d). pasien dengan penyakit akut dan berat dieksklusikan dari studi. selanjutnya dilakukan analisis secara bivariat dan multivariat antar variabel. hasil: dari 93 subjek penelitian, didapatkan 42 (45.2%) subjek tanpa pgd dan 51 (54.8%) subjek dengan pgd. sebagian besar subjek memiliki genotip bb yaitu sebesar 89.2%, serta tidak ada subjek yang memiliki genotip bb. sebagian besar subjek memiliki alel b, yakni sebesar 55.4%. tidak terdapat hubungan yang berbeda bermakna antara polimorfisme bsmi gen reseptor vitamin d dengan pgd (or = 1.243; ci 95% 0.334-4.621; p = 0.751). kesimpulan: genotip bb pada polimorfisme bsmi didapatkan sebesar 89.2% dan genotip bb sebesar 10.8%. sebagian besar subjek memiliki alel b, yakni sebesar 55.4%. tidak ditemukan adanya hubungan bermakna antara polimorfisme bsmi gen reseptor vitamin d dengan pgd. durasi dm lebih dari lima tahun memengaruhi hubungan antara kedua variabel tersebut. kata kunci: polimorfisme, bsmi, gen reseptor vitamin d, penyakit ginjal diabetik, ras indonesia-malay. abstract background: diabetic kidney disease (dkd), as a common cause of end-stage renal disease (esrd), is a chronic complication of diabetes mellitus (dm). it has been established that vitamin d deficiency is one of dkd risk factors, which may be related to vitamin d receptor (vdr) polymorphisms. this study aimed to analyze the association between vdr polymorphisms and dkd in indonesian population, also risk factors that influence it. methods: a cross-sectional study was conducted in type 2 dm patients who visited internal medicine outpatient clinic at dr. cipto mangunkusumo hospital, jakarta, from november 2014 until march 2015. data collection association of bsmi polymorphisms in the vitamin d receptor gene among indonesian population with diabetic kidney disease pringgodigdo nugroho1,2, aida lydia1, suhardjono1, kuntjoro harimurti2 1 division of nephrology and hypertension, department of internal medicine, faculty of medicine, universitas indonesia—dr cipto mangunkusumo hospital, jakarta, indonesia. 2 clinical epidemiology unit, department of internal medicine, faculty of medicine, universitas indonesia—dr cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: aida lydia, md, phd. division of nephrology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: aidalydia@gmail.com pringgodigdo nugroho acta med indones-indones j intern med 150 introduction diabetic kidney disease (dkd) is a common cause of end-stage renal disease (esrd). data from the indonesian renal registry (2011) revealed that the 25% etiology of patients who have undergone hemodialysis is dkd.1 factors that are associated with dkd include blood glucose control, hypertension, dyslipidemia, duration of diabetes mellitus (dm), high body mass index, age, sex, ethnicity, vitamin d deficiency, high-sodium diet, high-protein diet, and smoking.2–7 vitamin d has an anti-calcium effect by inhibiting the renin-transcription process, angiotensin ii, the renal-inflammation process, and albumin excretion. it also prevents podocyte damage, glomerulosclerosis, and transformation from kidney epithelial cells into mesenchymal cells.8 current studies on the association between vitamin d deficiency and dkd are still controversial. those controversial results may be related to genetic factors, which are vitamin d receptor (vdr) polymorphisms. the vdr polymorphism is affected by the cdx2, apai, bsmi, foki, and taqi genes, whereas the asian population is mostly affected by apai, foki, and cdx2.9 several studies have reported the association between bsmi polymorphisms in the vitamin d receptor gene and dkd in various populations. zhang et al. (2012) study revealed an association between bsmi polymorphisms in the vitamin d receptor gene and dkd in han chinese population, while vedralova et al. (2012) study in caucasians showed the opposite result.10,11 however, the association between bsmi polymorphism in the vitamin d receptor gene and dkd has not been investigated in the indonesian population. based on the current evidence, we aimed to analyze the association between bsml polymorphism in the vitamin d receptor gene and dkd particularly in indonesian population. in terms of secondary objective, we aimed to investigate other risk factors that influence the association between main variables. by knowing the potential risk factor of bsmi polymorphism in the vitamin d receptor gene, it is hoped that the number of cases and morbidity of dkd can be prevented. methods a cross-sectional study was conducted t o u n d e r s t a n d t h e a s s o c i a t i o n o f b s m i polymorphisms in the vitamin d receptor gene with dkd among the indonesian–malay race. the subjects of this study were patients who came to the internal medicine outpatient clinic, dr. cipto mangunkusumo hospital, jakarta, from november 2014 until march 2015. the inclusion criteria were patients with type-2 dm, of indonesian–malay population, who signed the informed consent form. patients with urinary tract infection or fever, who were pregnant or in their menstrual period, had undergone hemodialysis or peritoneal dialysis, had used nonsteroid anti-inflammatory drugs (nsaids), and postexercise were excluded. this study has been approved by the ethical committee includes characteristics of subjects and laboratory examination, including bsmi polymorphisms in the vitamin d receptor gene. patients with acute and severe disease were excluded from the study. bivariate and multivariate analyses were done. results: of 93 dm subjects, 42 (45.2%) subjects were without dkd and 51 (54.8%) subjects had dkd. most of the subjects had the bb genotype (89.2%), with no subject having the bb genotype. the proportions of the b and b alleles were 44.6% and 55.4%, respectively. there is no association between bsmi polymorphisms in the vitamin d receptor gene and dkd (or = 1.243; ci 95% 0.334-4.621; p value = 0.751). conclusion: the profile of bsmi polymorphisms in the vitamin d receptor gene in the indonesian population were genotypes bb (89.2%) and bb (10.8%). there was no association between bsmi polymorphisms in the vitamin d receptor gene and dkd. duration of dm more than five years influenced the association between those variables. keywords: polymorphisms, bsmi, vitamin d receptor (vdr) gene, diabetic kidney disease, indonesian– malay race. vol 53 • number 2 • april 2021 association of bsml polymorphisms in the vitamin d receptor gene 151 of faculty of medicine universitas indonesia (reference no. 756/un2.f1/etik/2014). d a t a c o l l e c t i o n i n c l u d e d s u b j e c t s ’ characteristics, physical examination, and laboratory examination, including bsmi polymorphisms in the vitamin d receptor gene. 5 ml of venous blood was collected in a non-fasting state and added to an edtaanticoagulated container. bsmi polymorphisms were measured using polymerase chain reaction with high resolution melt analysis. since the diabetic kidney disease was defined from albuminuria, the mid-stream random urine was collected in a urine collector. albuminuria was measured using nyocacard u-albumin with sandwich immunometric assay technique. the data were then analyzed by spss v.16. participants’ characteristics were reported in percentages for categorical data, mean (standard deviation), or median (range) for continuous data. a chi square test was used to analyze the association between bsmi polymorphisms in the vitamin d receptor gene and dkd. also, logistic regression analysis was performed to investigate the role of other risk factors that influence the association between bsmi polymorphisms in the vitamin d receptor gene and dkd. bivariate and multivariate analyses were presented with confidence interval 95% and considered statistically significant if the p value was <0.05. results 93 subjects were recruited for the present study. there were 51 subjects (54.8%) with dkd and 42 subjects (45.2%) without dkd. the characteristics of the subjects, which include demography and laboratory examination results, are presented in table 1. table 1. characteristics of the subjects. dkd (n = 51) without dkd (n = 42) sex, n (%) male 28 (66.7) 14 (33.3) female 23 (45.1) 28 (54.9) age, median (range) 61 (46-73) 61.5 (45–85) body mass index (kg/ m2), mean (sd) 26.08 (3.93) 25.40 (3.84) duration of dm, n (%) > 5 years 39 (63.9) 22 (36.1) ≤ 5 years 12 (37.5) 20 (62.5) systolic bp (mmhg), median (range) 137 (88–180) 130 (98–173) diastolic bp (mmhg), median (range) 74 (52–100) 75 (51–94) egfr (ml/min/1.73 m2), mean (sd) 43.46 (22.46) 73.51 (23.23) urea (mg/dl), median (range) 39 (17–145) 25.5 (13–54) creatinine (mg/dl), median (range) 1.5 (0.7–9.6) 0.9 (0.6–1.9) fasting blood glucose mg/dl), median (range) 133 (79–365) 121.5 (75–285) 2-hours postprandial blood glucose (mg/ dl), median (range) 199 (60–521) 180.5 (80–479) hba1c (%), median (range) 7.5 (5.4–11.1) 7.2 (5.9–11.4) total cholesterol (mg/ dl), mean (sd) 187.35 (44.66) 175.48 (35.34) triglyceride (mg/dl), median (range) 115.5 (30–447) 95.5 (52–272) hdl cholesterol (mg/ dl), mean (sd) 50.57 (18.77) 53.57 (12.76) ldl cholesterol (mg/ dl), mean (sd) 117.88 (40.46) 108.00 (29.47) dkd: diabetic kidney disease; dm: diabetes mellitus; bp: blood pressure. the proportion of genotype and allele of bsmi polymorphisms in vitamin d receptor gene are presented in table 2. the majority of the subjects had the bb genotype (89.2%), and no subject had the bb genotype. the percentage of the b allele was 55.4%. table 2. genotype and allele of the subjects. frequency n (%) genotype bb 83 (89.2) bb 10 (10.8) allele b 83 (44.6) b 103 (55.4) association of bsmi polymorphisms in vitamin d receptor gene with dkd there is no association between bsmi polymorphisms in the vitamin d receptor gene and dkd (or = 1.234; ci 95% 0.334– 4.621; p = 0.75). there is also no significant association between allele b or allele b on bsmi polymorphisms in the vitamin d receptor gene and dkd (or = 1.043; ci 95% 0.584–1.866; p = 0.89). (table 3 and table 4). pringgodigdo nugroho acta med indones-indones j intern med 152 risk factors of dkd several factors have significant associations table 3. association of bsmi polymorphisms in vitamin d receptor gene with dkd. dkd n (%) without dkd n (%) total n (%) or 95% confidence interval min max bb 46 (55.4) 37 (44.6) 83 (100) 1.243 0.334 4.621 bb 5 (50) 5 (50) 10 (100) table 4. association between b allele of bsmi polymorphisms in vitamin d receptor gene and dkd. dkd n (%) without dkd n (%) total n (%) or 95% confidence interval min max b 46 (55.4) 37 (44.6) 83 (100) 1.043 0.584 1.866 b 56 (54.4) 47 (45.6) 103 (100) table 5. risk factors of dkd. dkd n (%) without dkd n (%) or 95% confidence interval min max genotype bb 46 (55.4) 37 (44.6) 1.243 0.334 4.621 bb 5 (50) 5 (50) duration of dm > 5 years 39 (63.9) 22 (36.1) 2.955 1.218 7.167 ≤ 5 years 12 (37.5) 20 (62.5) body mass index overweight and obese 40 (59.7) 27 (40.3) 2.020 0.806 5.062 normal 11 (42.3) 5 (57.7) blood pressure hypertension 48 (62.3) 29 (37.7) 7.172 1.883 27.319 without hypertension 3 (18.8) 13 (81.2) blood glucose control uncontrolled 40 (55.6) 32 (44.4) 1.023 0.378 2.769 controlled 11 (55) 9 (45) dyslipidemia dyslipidemia 28 (57.1) 21 (42.9) 1.217 0.537 2.760 without dyslipidemia 23 (52.3) 21 (47.7) blood pressure control uncontrolled 23 (62.2) 14 (37.8) 1.643 0.705 3.829 controlled 28 (50) 28 (50) kidney function egfr < 60 41 (75.9) 13 (24.1) 9.146 3.531 23.690 egfr ≥ 60 10 (25.6) 29 (74.4) with dkd, such as duration of dm being more than five years (p value = 0.015), blood vol 53 • number 2 • april 2021 association of bsml polymorphisms in the vitamin d receptor gene 153 pressure (p value = 0.001), and kidney function (p value < 0.001). from logistic regression analysis, confounding factors had effects on the association between bsmi polymorphisms in the vitamin d receptor gene and dkd with crude or of 1.243 (95% ci 0.334–4.621) and adjusted or of 1.410 (95% ci 0.335–2.296). duration of dm being more than five years influenced the association of bsmi polymorphisms in the vitamin d receptor gene and dkd. the results are presented in table 5 and table 6. table 6. crude or and adjusted or genotype as risk factor of dkd and effect from other risk factors or 95% ci genotype bb crude or: 1.243 0.334–4.621 adjusted (+) egfr 1.137 0.248–5.216 8.5% (+) hypertension 1.058 0.219–5.121 6.9% (+) duration of dm 1.449 0.278–7.551 37% (+) body mass index 1.525 0.283–8.217 5.2% (+) bp control 1.410 0.260–7.652 7.5% discussion the studied participants were type-2 dm patients who came to the internal medicine outpatient clinic, dr. cipto mangunkusumo hospital, jakarta. most of the subjects were female with ages ranging from 45 to 85 years old. dewi et al.12 study and indra et al.13 study showed similar participants; most of their subjects were female. the duration of dm of most subjects was more than five years (65.6%), and most subjects had comorbidities, such as hypertension, elevated body mass index, and dyslipidemia. these findings resembled indra et al.13 study, which had 82.8% patients with hypertension and most of them with more than five years’ duration of dm. insulin resistance in type-2 dm patients causes an increase in angiotensin ii, inflammatory mediator release, which causes endothelial damage, and hyperglycemia, which increases sodium reabsorption in renal tubules. hence, plasma volume will increase, which leads to hypertension.14 even though hypertension was the major comorbidity among type-2 dm patients in this study, the median blood pressure in both groups was less than 140/90 mmhg, since 81.7% of subjects had already taken antihypertensive drugs such as ace inhibitors or arbs. more than half of the participants belonged to the dkd group (54.8%). this finding was related to the higher number of patients with comorbidities such as hypertension, dyslipidemia, overweight, poor glycemic control (hba1c median = 7.45), and more than five years of dm. a total of 82.8% subjects had a higher body mass index, with a mean of 26.08 from the dkd group and 25.40 from the non-dkd group. it was found that obesity leads to oxidative stress conditions, which cause endothelial damage and decrease adiponectin levels. such conditions result in renal podocyte damage.15 most subjects with dkd had an estimated glomerular filtration rate (egfr) of less than 60 ml/min/1.73 m2 (75.9%). albuminuria in dkd causes reduced renal function by triggering chemokine expression and activating complements of renal tubules, which cause infiltration of inflammatory cells in interstitial and fibrogenesis. in the end, reduced renal function may have resulted in an esrd state.16 based on the results of this study, 10.8% of the subjects had the bb genotype, 89.2% had the bb genotype, and none had the bb genotype. there were 44.6% subjects with the b allele and 55.4% with the b allele. this result was different from zhang et al.10 study, which showed the majority of the bb genotype among the participants. on the other hand, vedralova et al.11 showed the bb genotype for most of the patients. based on these previous studies, it can be concluded that genotype differences are influenced by race. indonesian native citizens, most of whom come from the malay race, are different from han chinese, who belong to the mongoloid race, and are also different from the caucasian race. data suggested an elevated number of dkd among bb genotypes (adjusted or 1.410), but the confidence interval was above 1 (ci 95% 0.260–7.652). this result contradicted zhang et al. (2012),10 who revealed a significant correlation between bsmi polymorphisms in the vitamin d receptor gene and dkd among han pringgodigdo nugroho acta med indones-indones j intern med 154 chinese population. b e s i d e s b s m i , v i t a m i n d r e c e p t o r p o l y m o r p h i s m w a s i n f l u e n c e d b y o t h e r investigated genes, such as taqi, apai, and foki. zhang et al.10 study conducted among han chinese population stated that there is no association between apai polymorphisms in the vitamin d receptor gene and dkd in the same population. a study from arababadi et al. (2010) found that there was no significant association between apai and taqi polymorphisms and dkd. arababadi et al. (2010) found that vitamin d receptor gene polymorphisms have an association with dm, but not with dkd.17 vedralova et al.11 also found that the vitamin d receptor-gene polymorphism that has an association with dkd is foki. in the case of the separation of alleles b and b, no significant association was found between the b allele of bsmi polymorphisms in the vitamin d receptor gene and dkd (p value = 0.89). this result was different from zhang et al.10 study, which found that allele b has a significant association with dkd among han chinese population. according to logistic regression analysis, more than five years’ duration of dm has the greatest influence on the association of bsmi polymorphisms in the vitamin d receptor gene and dkd. another study also reported that a longer duration of dm increases the prevalence of dkd and increases the proteinuria.18 to the best of our knowledge, this is the first study to analyze the proportion and association of bsmi polymorphisms in vitamin d receptors with dkd in the indonesian–malay race. this study provides a preliminary understanding of vitamin d receptor-gene polymorphisms and the influence of genetic factors in the therapeutic response of dkd. however, this study lacks the measurement of both vitamin d and vitamin d receptor levels of the subjects which might affect the association between variables. hence, there were several confounding factors affecting the association between the bsmi gene-receptor vitamin d and dkd. also, this study analyzed only the association of the bsmi gene as one of the vitamin d receptor-gene polymorphisms. therefore, this study was not able to describe the entirety of vitamin d receptor-gene polymorphisms. this still warrants further studies. conclusion the profiles of bsmi polymorphisms in the vitamin d receptor gene in the indonesian– malay race were genotypes bb (89.2%) and bb (10.8%). there was no association between bsmi polymorphisms in the vitamin d receptor gene and dkd, which might be due to the influence of genetic factors among different populations. in addition, the duration of dm being more than five years influenced the association between those variables. funding the study was financially supported by the universitas indonesia research grant. conflict of interest the authors declare no conflict of interest references 1. perhimpunan nefrologi indonesia. report of indonesian renal registry. jakarta; 2011. 2. ramachandran a, snehalatha c, shetty as, et al. trends in prevalence of diabetes in asian countries. world j diabetes. 2012;3(6):110. 3. zhao h, thomas g, leung w, et al. an update on the management of nephropathy in type 2 diabetes. j chin med assoc. 2003;66(11):627–36. 4. tseng ch. lipid abnormalities associated with urinary albumin excretion rate in taiwanese type 2 diabetic patients. kidney int. 2005;67(4):1547–53. 5. vedovato m, lepore g, coracina a, et al. effect of sodium intake on blood pressure and albuminuria in type 2 diabetic patients: the role of insulin resistance. diabetologia. 2004;47(2):300–3. 6. dullaart r, beusekamp b, meijer s, et al. longterm effects of protein-restricted diet on albuminuria and renal function in iddm patients without clinical nephropathy and hypertension. diab care. 1993;16(2):483–92. 7. abbasi ma, abro a, sheikh m. smoking is related to albumin excretion in type 2 diabetes mellitus. pak j physiol. 2006;2(2):45–8. 8. koroshi a, idrizi a. renoprotective effects of vitamin d and renin-angiotensin system. hippokratia. 2011;15(4):308–11. 9. bid h, konwar r, aggarwal c, et al. vitamin d receptor (foki, bsmi and taqi) gene polymorphisms and type 2 diabetes mellitus: a north indian study. vol 53 • number 2 • april 2021 association of bsml polymorphisms in the vitamin d receptor gene 155 indian j med sci. 2009;63(5):187–94. 10. zhang h, wang j, yi b, et al. bsmi polymorphisms in vitamin d receptor gene are associated with diabetic nephropathy in type 2 diabetes in the han chinese population. gene. 2012;495(2):183–8. 11. vedralová m, kotrbova-kozak a, železníková v, et al. polymorphisms in the vitamin d receptor gene and parathyroid hormone gene in the development and progression of diabetes mellitus and its chronic complications, diabetic nephropathy and non-diabetic renal disease. kidney blood press res. 2012;36(1):1–9. 12. dewi k. penurunan fungsi ginjal pada pasien dm tipe 2 di poliklinik endokrin metabolik rsupn cipto mangunkusumo. university of indonesia; 2007. 13. indra ta. asosiasi antara status vitamin d (25[oh]d) dengan albuminuria pada pasien diabetes melitus tipe 2. university of indonesia; 2013. 14. giunti s, barit d, cooper me. mechanisms of diabetic nephropathy: role of hypertension. hypertension. 2006;48(4):519–26. 15. bayliss g, weinrauch la, d’elia ja. pathophysiology of obesity-related renal dysfunction contributes to diabetic nephropathy. curr diab rep. 2012;12(4):440– 6. 16. abbate m, zoja c, remuzzi g. how does proteinuria cause progressive renal damage? j am soc nephrol. 2006;17(11):2974–84. 17. nosratabadi r, arababadi m, salehabad v, et al. polymorphisms within exon 9 but not intron 8 of the vitamin d receptor are associated with the nephropathic complication of type‐2 diabetes. int j immunogenet. 2010;37(6):493–7. 18. inassi j, vijayalakshmy r. role of duration of diabetes in the development of nephropathy in type 2 diabetic patients. natl j med res. 2013;3(1):8–11. 55 original article acta med indones indones j intern med • vol 52 • number 1 • january 2020 pregnancy profile and infant outcomes among hiv infected women who delivered in cipto mangunkusumo hospital ju ni t a in d ar t i 1, ev y yu ni h a s t u t i 2, ni a ku r ni at i 1, b e l l a ap r i l i a 1, danang t. pamungkas1, ariel t. chiprion1, mega a. ginting1, saiful rizal1, citra dewi1, lieke handayani1 1 department of obstetrics and gynecology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: junita indarti, md. department of obstetrics and gynecology, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no 71, jakarta 10430, indonesia. email: junita_indarti@yahoo.com. abstrak latar belakang: infeksi hiv pada kehamilan merupakan masalah besar untuk masa depan bangsa. virus ini dapat ditularkan ke bayi melalui kehamilan, persalinan dan selama menyusui yang memerlukan deteksi dan intervensi dini. tujuan dari penelitian ini adalah untuk menggambarkan proses pencegahan penularan di antara pasien kami. metode: ini adalah studi kohort retrospektif penularan vertikal hiv. kriteria inklusi adalah wanita hamil dengan infeksi hiv yang menjalani perawatan antenatal di rumah sakit cipto mangunkusumo dari januari 2013 hingga desember 2018. data diambil dari rekam medis, registrasi hiv dan hasil laboratorium. data yang dimasukkan adalah demografi, risiko infeksi, data obstetri, cara persalinan, riwayat arv, riwayat laboratorium pada ibu dan bayi. data disajikan sebagai data deskriptif. hasil: terdapat 138 wanita hamil hiv dimasukkan sebagai subyek penelitian. sebagian besar wanita berusia 25-29 tahun (39,85%), sebagai ibu rumah tangga (41,30%), dengan riwayat lebih dari satu pasangan seksual (50,73%). subjek sebagian besar multigravida (77,5%), kunjungan pertama ke rscm pada trimester ketiga (98,6%), dengan riwayat perawatan antenatal >4 kali (48,6%), janin tunggal (99,3%), dan disampaikan oleh c-section (84,1%) . diagnosis hiv dilakukan selama kehamilan (73,53%), dan sudah memakai antiretroviral (arv) selama lebih dari 6 bulan (50,7%). didapatkan data cd4 pada 78% peserta (24% peserta dengan <200 sel/ml) dan 84% data viral load (36% dengan viral load >200). sekitar 72,5% bayi yang lahir dengan berat lahir 2500-3500g. hampir semua bayi menerima profilaksis arv (97,9%) dan pemberian susu formula. pcr hiv diperiksa pada 16 bayi pada usia 6 minggu dan pada13 bayi di usia 6 bulan. ada 1 bayi dengan hasil viral load >400 yang segera merujuk ke klinik hiv pediatrik. analisis bivariat menunjukkan korelasi yang signifikan antara konsumsi arv ibu dan hasil bayi saat lahir (p=0,05). tingkat cd4 ibu tidak berkorelasi secara signifikan dengan status virologi neonatal (p=0,12). kesimpulan: diagnosis hiv pada wanita hamil adalah penting, karena pemberian arv pada awal kehamilan secara signifikan mengurangi penularan vertikal. protokol profilaksis arv penting untuk mencegah infeksi hiv pada bayi. kata kunci: hiv dalam kehamilan, luaran obstetrik, luaran bayi. abstract background: hiv infection in pregnancy is a big concern for the future of our nation. the virus can be transmitted to the baby through pregnancy, childbirth and during breastfeeding which rendering to early detection and intervention. the aim of this study was to describe the transmission prevention cascade among our patient. methods: junita indarti acta med indones-indones j intern med 56 introduction human immunodeficiency virus (hiv)/ acquired immune deficiency syndrome (aids) is one of the world’s growing and increasing health problems. as many as 36.7 million people live with hiv with 1.5 million deaths due to aids based on data until the end of 2015.1 the incidence pregnant women with hiv in asia was around 77,000 in the end of 2015.2 in indonesia, the total number of pregnant women living with hiv was 2955 in 2018. hiv infection in pregnancy has become the most common problem in some developing countries. it has major implication for the management of pregnancy and birth.3,4 the program to prevent transmission of hiv infection from mother to child (pmtct) in indonesia has included hiv screening as one of the standard examinations during antenatal care which widely applied in the last 5 year.5 there were more than 15 million pregnant women with hiv infection in developing countries and more than 500,000 infected babies born hiv every year. based on previous studies, it was found that 2.5% of 21,103 pregnant women diagnosed with hiv positive in 2011 in indonesia.6 interventions to prevent hiv transmission from mother to infant are needed so as not to increase the number of hiv-infected children. possible interventions are achieveable by preventing hiv infection in women-child-bearing age, managing pregnant women with hiv infection with antiretroviral (arv) to achieve reduction of viral load, minimizing fetal exposure to blood and body fluids during delivery, and optimizing the health of neonates born to mothers with hiv infection. this study is about pregnant women with hiv infection and the outcomes on infants in tertiary referral hospital. methods this was a restrospective cohort study. the population of the study were all pregnant and in labor women with hiv infection at rsupn cipto mangunkusumo jakarta from january 2013 up to december 2018. the inclusion criteria was pregnant women with hiv infection who have antenatal care, delivery and follow up in cipto mangunkusumo hospital. total sampling was used. this study has been approved by the ethical committee of faculty of medicine universitas indonesia (reference number: 0035/un2.f1/etik/2019). typically patients referred to our hospital due to their obstetric problem and/or their hiv status. the obstetric care coordinated with hiv integrated service especially for hiv and comorbidity and arv treatment. once the this was a retrospective cohort study of hiv vertical transmission. the inclusion criteria was pregnant women with hiv infection who have antenatal care in cipto mangunkusumo hospital from january 2013 up to december 2018. data was retrieved from medical record, hiv registry and laboratory results. the included data were demographic, risk of infection, obstetrical data, mode of delivery, arv history, laboratory history in mother and infant. data was presented as descriptive. results: there was 138 hiv pregnant women included as study subjects. most women were at 25-29 years old (39.85%), as housewife (41.30%), with history of more than one sexual partners (50.73%). the subjects was mostly multigravida (77.5%), first visit to rscm in third trimester (98.6%), with history of antenatal care >4 times (48.6%), singleton fetus (99.3%), and delivered by c-section (84.1%). hiv diagnosis was done during pregnancy (73.53%), and already on antiretroviral (arv) for more than 6 months (50.7%). there was 78% subjects with cd4 (24% subjects with <200 cells/ml) and 84% with viral load data (36% with viral load >200 copies/ul). around 72.5% infants born with birth weight 2500-3500g. almost all infant received arv prophylaxis (97.9%) and formula feeding. pcr hiv was examined on 16 infant on 6 weeks of age and and 13 on 6 month age. there was 1 infant with viral load results >400 copies/ml which immediately refered to pediatric hiv clinic. bivariate analysis showed significant correlation between maternal arv consumption and infant result at birth (p=0.05). maternal cd4 level was not significantly correlate with neonatal virology status (p=0.12). conclusion: hiv diagnosis in pregnant women is important, since arv administration on early pregnancy significantly reduce vertical transmission. arv prophylaxis protocols is important to prevent hiv infection on infant. keywords: hiv in pregnancy, obstetric outcome, infant outcome. vol 52 • number 1 • january 2020 pregnancy profile and infant outcomes among hiv infected women 57 table 1. distribution of maternal characteristics (20132018) (n=138). characteristic of subjects n (%) age of subjects < 20 years 10 (7.2) 20-35 years 108 (78.3) >35 years 20 (14.5) employment housewife 58 (42.0) employee 24 (17.4) entrepreneur 8 (5.8) no data 48 (34.8) number of marriage one 65 (47.1) more than one 70 (50.7) unmarried 1 (0.7) no data 2 (1.5) gravida 1 31 (22.5) ≥2 107 (77.5) gestational age at delivery trimester 2 2 (1.4) trimester 3 136 (98.6) fetus singleton 137 (99.3) multi fetus 1 (0.7) history of ante natal care no data 45 (32.6) anc 1-3 times 26 (18.8) anc ≥ 4 times 67 (48.6) delivery method vaginal delivery 22 (15.9) cesarean section 116 (84.1) intrapartum complications premature rupture of membrane 34 (24.7) preeclampsia 8 (5.8) no complication 96 (69.5) patients gave birth to their infants, they will be followed up in obstetry clinic and pediatric clinic. most of the time they use our service up to 6 month and they transferred back to other health care near their home. infant diagnosis was a challenge since it was not part of pmtct service covered by government until 2017. data was retrieved from medical record, hiv registry and laboratory results. maternal demographic status including age, education, employment, and number of sexual partner. the obstetric status including the parity, gestational age at admission, number of fetus, frequency of antenatal care, and delivery method. hiv status of mother including known hiv status before pregnancy, arv consumption, cd4 level, viral load level, and the present of opportunistic infection. status of the baby including birth weight, use of arv prophylaxis, and infant result which was determined by at least 2 pcr rna results on 6-8 weeks of age and on 6 month of age. collected data was presented as distribution and di s played in tables as number and percentages. results there was a total of 138 subjects who were under cipto mangunkusumo hospital care from january 2013 to december 2018. demographic data shows that most women were at 20-35 years old (n=108, 78.3%). fifty-eight pregnant women work as housewife (42%), 24 subjects (17.4%) work as employee and 8 subjects (5.8%) work as entrepreneur. seventy subjects (50.7%) were on second or more marriage, 65 subjects (47.1%) married one time only, and one pregnant woman has no marriage status. number of sexual partners was not available since it was not part of data collected on medical record. on the obstetric status, most subjects have a history of multigravida more than 2 (n=107, 77.5%). they usually came at third trimester (n=136, 98.6%), with singleton fetus (n=137, 99.3%), already have anc more than 4 times (n=67, 48.6%), and delivered by c-section (n=116, 84.1%). detailed data on distribution of maternal obstetric status can be seen on table 1. almost all (93%) diagnosed prenatally (40%) and intranatal (83 cases, 53%). did not received hiv diagnosis prenatally. ten subjects (7.3%) were diagnosed during delivery which were seen as diagnosis missed opportunity. however around 51% subjects had already on arv for more than 6 months while the rest were less than 6 months. there were 10 subjects with opportunistic condition. according to hiv-who disease stage 3-4, there was 5 with lung tuberculosis, 3 with oral candidiasis, and 1 with cmv infection. junita indarti acta med indones-indones j intern med 58 on the other hand, there was 1 patient with molluscum contagiosum which categorized as hivwho disease stage 1-2. there were 10 subjects with co-infection, consisted of 8 with hepatitis (b or c) and 2 subjects with condyloma acuminate. unfortunately, data of maternal cd4 and viral load were mostly (78% and 84%) unavailable. distribution of maternal hiv status can be seen on table 2. baby with viral load above 40 copies/ml. at 6 months of age, viral load on all the babies were undetected. distribution of baby status can be seen on table 3 and 4. table 2. distribution of hiv status of the mother (2013 – 2018) (n=138) characteristic of subjects n (%) hiv diagnosis before pregnancy 83 (60.1) during pregnancy 45 (32.6) at delivery 10 (7.3) mother’s arv no arv 32 (23.2) arv <6 months 26 (18.8) arv >6 months 70 (50.7) n/a 10 (7.3) the last cd4 level < 200sel/ul 8 (5.8) 200-500 sel/ul 20 (14.5) ≥ 500sel/ul 2 (1.5) n/a 108 (78.2) the last viral load level < 50 copies/ml 14 (10.2) 50-400 copies/ml 2 (1.4) 401-1000 copies/ml 0 (0.0) >1000 copies/ml 6 (4.3) n/a 116 (84.1) who hiv stage stage 1-2 129 (93.4) stage 3-4 9 (6.6) table 3. description and outcome of baby (2013-2018) (n=138) characteristic of subjects n (%) birth weight < 1000 g 1 (0.7) 1000 to <1500 g 3 (2.2) 1500 to <2500 g 24 (17.4) 2500 to <3500 g 100 (72.5) ≥ 3500 g 10 (7.2) baby’s arv no data 3 (2.2) yes 135 (97.8) no 0 (0.0) table 4. baby’s viral load examination (2016-2018) (n=66). variables n (%) baby’s vl examination at 6 weeks no data 42 (63.6) undetected 23 (35.0) detected (> 40 copies/ml) 1 (1.4) baby’s vl examination at 6 months no data 49 (74.2) undetected 17 (25.8) detected (> 40 copies/ml) 0 (0.0) most babies born with birth weight 25003500 gr (n=100; 72.5%) and received arv prophylaxis (n=135; 98%). there was small number of pregnancy with hiv during 2013-2018; it was 1.4% in 2013, 1.3% in 2014, 1.1% in 2015, 1.6% in 2016, 1.3% in 2017, and 1.5% in 2018 among all pregnant patients in cipto mangunkusumo hospital. unfortunately we do not have infant data from 2013-2015. therefore, we analyzed 66 infants result only from 2016-2018. there were 24 babies with viral load results at 6 weeks and 1 bivariate analysis revealed no significant correlation between maternal arv consumption and neonatal virology result at 6 weeks (p=0.077) and at 6 months (p=0.795). maternal cd4 level was not significantly correlate with neonatal virology status at 6 weeks (p=0.784) and 6 months (p=0.671). discussion this is the first study that try to explain the cascade of hiv transmission from mother to child who use care from intranatal through post natal in cipto mangunkusumo hospital. during study time there was 138 pregnant patients with hiv, which use obstetry care in rscm. they were mostly at 20-24 years old, which is similar to any hiv worldwide epidemy.1,2 according to unaids, there was approximately 36.7 million vol 52 • number 1 • january 2020 pregnancy profile and infant outcomes among hiv infected women 59 people infected with hiv, among which 26% of new infections occured in women aged 15-25 years old. women education plays an important risk in hiv infection, according to who that woman has less access to education and lack of employment opportunity have higher probability for hiv infection.2 around 50.8% women who live with hiv in usa were also not graduate from high school.3 unfortunately there was no data on subjects education in our study. the majority of our subjects were housewife (41.3%). this is similar with study on 109 patients with hiv, which 17% were women; 45% were unemployed.4 history of more than one sexual partner (50.73%) reflected in our data in which more than half were on their second marriage. this finding was similar with data from a research in russia, among 758 hiv cases there were 73.9% with multi partners.5 marital relationships does not translate into less risk of hiv infection. yang in cambodia, shown that hiv transmission within marital relationships have increased, this was transmission from hiv-positive men to their hiv-negative spouses. plausible factors influencing inter-spousal hiv transmission were a hierarchical male dominated society, husbands’ involvement with sex workers, cultural values concerning the ideal khmer woman and unprotected sex between an hiv infected husband and his uninfected wife.6 our study presented a higher distribution of multigravidity (77.5%), similar to a larger study in malawi with 87.3% (2426) with >2 pregnancies. compared with another study, a surveillance study in the united kingdom and ireland showed 65.7% (n:144 ) multigravidity.7,8 this numbers were associated with conception rates, which were influenced by sexual activity, procreational intent, fertility, and access to and use of contraception. a higher rate of conception rate, likely reflecting on perceived improvement in hiv treatment and vertical transmission risk. in our study, 99.3% of our subjects were pregnant with single fetus. this result is comparable with other studies. kreitchmann r et al in a cohort study in latin america and the caribbean shows 96.7% (n=1483) single fetus pregnancy.6 from another study, lower transmission rates area also seen in twin’s deliveries compared with single deliveries, with twice as likely not to be infected than single born infant (or = 0.5% ci 0.378-0.85 p=0.007), based on study by nkenfou cn et al.9 it is speculated that more care is given in multiple pregnancies. this occurs in their study, that more women with multiple pregnancy underwent prevention of mother-to-child transmission than women with single pregnancy (p=0.02).9 however a more recent study concludes that twin pregnancies had lower risk of hiv transmission, provided that the mother is on highly active antiretroviral therapy (haart) or has received effective arv treatment in the antenatal period.10,11 our study shows sufficient anc visits (48.6%). anc can be a media to ensure that pregnant mothers received arv to their hiv condition, as a prophylaxis to mother-tochild transmission. mothers who did not take prophylaxis during anc were three times more likely to transmit hiv to their children compared to those who took the prophylaxis during anc. (aor: 3.1; 95% ci: 1.3, 0.9). lack of prophylaxis may increase viral load and its chance to transmit hiv to their children. anc visits itself were not statistically significant.12 our study shows higher number of anc visits (>4 anc visits, 48.6%, n: 67), though not significantly higher compared to less anc visits number. a study by unaids in 2013 showed that 54% pregnant women in low and middle-income countries did not had routine hiv tests during anc, which is an important step to prevent hiv transmission.13 therefore, in indonesia itself, there was a low coverage of pregnant women living with hiv accessing antiretroviral medicines. even so there is an increase from 9% in 2010 to 21% in 2016.2 which may explain, even though the hiv mothers conducts frequent anc visits, it is not a guarantee to receiving hiv prophylaxis. delivery method in our study were dominated by cesarean section (84.1%, n:116), similar to a study in a tertiary care in india 91.5% mothers delivered by cesarean sections.13 the mothers were counseled about the benefits and risks of the junita indarti acta med indones-indones j intern med 60 delivery types. the majority opted for cesarean delivery to prevent perinatal transmission.14 however, the total number of cesarean delivery among pregnant women with hiv in japan and korea relatively small with 9 pregnant women in japan for 3 years and 15 pregnant women for 12 years. in this study, hiv status of patients (53%) was unknown before pregnancy. this is because the hiv test has not been carried out simultaneously for screening before pregnancy in indonesia. data from unaids obtained in 2016, around 40% of individuals living with hiv globally do not know their hiv status.2 in 2013, 54% of pregnant women in lowand middle-income countries did not get an hiv test done.15 costa et al.16 reported routine hiv screening during pregnancy was effective and recommended for preventing universal mother-infant transmission (p <0.001). but in reality many hospitals and primary health care have not implemented the program hiv screening in pregnant women is an effort to detect hiv in pregnant women. as there was only 50.7% patients having arv more than 6 months though almost 93% patients was diagnosed hiv before and after pregnancy, we assumed that diagnosis of hiv was not early in pregnancy or if done early did not automatically followed by having arv. ten patients (7.3%) also was diagnosed at delivery that translated as failure of hiv screening before pregnancy (as premarital screening) and during pregnancy (as 1st trimester screening). this could be a failure of a national program for 1st trimester screening for hiv infection in indonesia. this could occur also because there was a not financial coverage for hiv infection screening.17 our finding shows that art was given more than 6 months before delivery (50%). this is similar with previous research at the haji adam malik general hospital medan in 2012-2016 based on the duration of antiretroviral (arv) use, the highest was found in the duration of >1 year as many as 44 people (97.8%) and followed by a duration of <6 months as many as 1 person (2.2%). then hiv / aids pregnant women with duration of 6-12 months antiretroviral use and hiv / aids pregnant women who have never taken antiretroviral drugs each have the same number of respondents as many as 0 people (0%).18 one consideration is to allow pregnant patients with hiv, among others, if the immune system is good enough, cd4 above 500.19 in a previous study at the medan malik haji general hospital in medan 2012-2016, it was found that hiv / aids pregnant women with a cd4 count <350 / mm were 22 people (48.9%). in hiv / aids pregnant women with a cd4 count of >350 / mm3 as many as 17 people (37.8%), and in medical records that have no data obtained as many as 6 people (13.3%).18 other studies at midwifery poly sanglah hospital denpasar, july 2013 june 2014, there were 25 patients who had cd4 > 200 cells / mm3 (59.5%).10 in the study in rscm in 2013-2018, it was found that hiv / aids pregnant women with a cd4 count < 200 cell/ul were 8 people (8%). in hiv/ aids pregnant women with a cd4 count of 200-500 cell/ul were 20 people (14%). in hiv/ aids pregnant women with a cd4 count of >500 cell/ul were 2 cases (1%) and 108 cases (78%) cannot be counted. considerations to allow pregnant people with hiv include: if the immune system is good enough, viral load is minimal / undetectable (less than 1000 copies / ml).9 in this study, patients with viral load level <50 copies / ml were recorded as many as 14 patients (10%), viral load level 50-400 copies / ml as many as 2 patients (1%), and not counted as many as 116 (84%). in our study, opportunistic infections occurred only in 20 patients (14%). hiv / aids is characterized as a severe immunosuppressive disease that is often associated with opportunistic infections.11 previous research at the dr. wahidin sudirohusodo hospital in makassar during may 2011 april 2012 shows that out of 172 cases of hiv-aids, 121 people (70%) suffered from opportunistic infections.12 the incidence of non-opportunistic infections is lower than the incidence of opportunistic infections at cipto mangunkusumo hospital, jakarta. in our study, 72.5% babies were born with birth weight 2500-3500 gr. this result is similar with the study by ahmudu.21 in nigeria, which found that 81% babies born from hiv positive vol 52 • number 1 • january 2020 pregnancy profile and infant outcomes among hiv infected women 61 mothers have birth weight more than 2500 gr. based on study by european collaborative study,22 neither birth weight and height was associated with hiv infection status in neonates. arv prophylaxis was administered on 135 babies (97.8%). there was no available data on 3 babies (2.2%), which could be because the babies were premature with neonatal problems that prohibited oral intake in the first 72 hour. according to our protocol, arv prophylaxis is mandatory to all babies born from mother with hiv infection. this protocol is similar to who recommendation that a short duration of antiretroviral prophylaxis (for 4-6 weeks) is indicated for infant born to hiv infected women receiving art, to further reduce peripartum and postpartum hiv transmission, in addition to the protection received from the mother’s arv regimen.2 regardless of infant feeding choice, infant prophylaxis provides added protection from early postpartum transmission, particularly in situations where women have started art late in pregnancy, have less than optional adherence to art and have not achieved full viral suppression. through this study, we also found there was 1 baby with positive viral load at 6 weeks age and no baby with positive viral load at 6 months age. this success story was consistent with who recommendation about hiv prophylaxis for babies delivered by mother with hiv infection.2 bivariate analysis showed that antiretroviral therapy during pregnancy was associated with neonatal virology status even though with not significant result statistically. this result similar with meta-analysis from cochrane.23 a regimen combining triple antiretrovirals is most effective for preventing transmission of hiv from mothers to babies. short courses of antiretroviral drugs are also effective for reducing mother-to-child transmission of hiv and are not associated with any safety concerns in the short-term. conclusion hiv screening in pregnant women is important and should be performed prenatally or during early pregnancy, in order to apply arv prevention in mother, safe infant delivery, prophylaxis arv in infant and negative transmission results which we showed in this study. our study showed that in those with completed data, prevention of transmission hiv can be done successfully. support to completeness of pmtct should be part of program covered by government. conflict of interest there is no conflict of interest in this article references 1. cdc. hiv/aids surveillance report. united states: department of health and human services, 2009. 2. unaids. global statistics 2015 2016 [cited 2019 16 january]. available from: http://www.unaids.org/sites/ default/files/media_asset/unaids_factsheet_en.pdf 3. finger jl, clum ga, trent me, ellen jm. desire for pregnancy and risk behavior in young hiv-positive women. aids patient care stds. 2012;26(3):173-80. 4. vitry-henry l, penalba c, beguinot b, dschamps f. relationship between work and hiv/aids status. occup med. 1999;49(2):115-6. 5. attanasio l, kozhimannil k, kjerulff k. women’s preference for vaginal birth after a first delivery by cesarean. birth. 2018 (jul 27). 6. boatin a, schlotheuber a, hosseinpoor a. within country inequalities in caesarean section rates: observational study of 72 low and middle income countries. bmj. 2018;360(k55). 7. kyaw k, oo m, kyaw n, phyo k, aung t, mya t. low mother-to-child hiv transmission rate but high loss-to-follow-up among mothers and babies in mandalay, myanmar; a cohort study. plos one. 2017;12(9):e0184426. 8. charurat m, datong p, matawal b, a ajene a, blattner w, abimiku a. timing and determinants of mother-tochild transmission of hiv in nigeria. int j gynaecol obstet. 2009;106(1):8-13. 9. nkenfou n, temgoua e, ndzi e, mekue l, ngoufack m, dambaya b. maternal age, infant age, feeding options, single/multiple pregnancy, type of twin sets and mother-to-child transmission of hiv. j trop pedia. 2018;0:1-7. 10. eriksson j, kaiantie e, osmond c, et al. boys live dangerously in the womb. am j hum biol. 2010;22:330-5. 11. makunyane l, moodley j, titus m. hiv transmission in twin pregnancy: maternal and perinatal outcomes. s afr j infect dis. 2017;32(2):54-6. 12. beyene g, dadi l, mogas s. determinants of hiv infection among children born to mothers on prevention of mother to child transmission program of hiv in addis ababa, ethiopia: a case control study. bmc infect dis. 2018;18:327. 13. unaids. the gap report-join united nations junita indarti acta med indones-indones j intern med 62 programme on hiv/aids 2014 [cited 2019 16 january]. available from: http://www.unaids.org/ sites/default/files/media_asset/unaids_gap_report_ en.pdf. 14. acog. labor and delivery management of women with human immunodeficiency virus infection. j obstet gynaecol. 2018;132:e131-37. 15. unaids. the gap report-join united nations programme on hiv/aids 2014 [cited 2019 16 january]. available from: http://www.unaids.org/ sites/default/files/media_asset/unaids_gap_report_ en.pdf. 16. costa z, machado g, avelino m, et al. prevalence and risk factors for hepatitis c and hiv-1 infections among pregnant women in central brazil. bmc infect dis. 2009;9:116. 17. money d, tulloch k, boucoiran i, caddy s. guidelines for the care of pregnant women living with hiv and interventions to reduce perinatal transmission. j obstet gynaecol can. 2014;36(8 esuppl a):s1-s46. 18. tan mk. karakteristik ibu hamil dengan hiv/aids di rumah sakit umum pusat haji adam malik medan tahun 2012-2016. j usu. 2017;2(5). 19. depkes ri. modul pelatihan pencegahan penularan hivdari ibu ke bayi. 2008. 20. suherlim r. karakteristik penderita hiv pada ibu hamil di klinik prevention mother to child transmission (pmtct) poli kebidanan rsup sanglah denpasar periode juli 2013 – juni 2014. jurnal mahasiswa pspd fk universitas tanjungpura. 2015;1(3). 21. suhalmi d, savira m, krisnadi sr. pencegahan dan penatalaksanaan infeksi hiv pada kehamilan. majalah kedokteran bandung. 2009. 22. zainul aa. gambaran faktor risiko kejadian hivaids pada usia produktif di puskesmas jumpandang baru dan rsup dr. wahidin sudirohusodo makassar periode 2011-2012 (tidak dipublikasi): universitas islam negeri alaudin; 2012. 23. siegfried n, van der merwe l, brocklehurst p, sint tt. antiretrovirals for reducing the risk of mother-to-child transmission of hiv infection. cochrane database of systematic reviews. 2011;7. art. no.: cd003510. doi: 10.1002/14651858.cd003510.pub3. 124 acta med indones indones j intern med • vol 54 • number 1 • january 2022 case report sight-threatening condition in severe thyroid eye disease: how we should manage yunia irawati1,2*, dewi m. juhrie2, carennia paramita1, darmayanti siswoyo2, hernawita suharko2, laurentius aswin pramono3,4 1 plastic and reconstructive surgery division, department of ophthalmology, faculty of medicine universitas indonesia, jakarta, indonesia. 2 orbital and oculoplastic service, jec eye hospitals and clinics, jakarta, indonesia. 3 internal medicine service, jec eye hospitals and clinics, jakarta, indonesia. 4 department of public health and nutrition, school of medicine and health sciences atma jaya catholic university of indonesia, jakarta, indonesia. * corresponding author: yunia irawati, md. plastic and reconstructive surgery division, department of ophthalmology, faculty of medicine universitas indonesia dr. cipto mangunkusumo hospital, jakarta, indonesia. jec eye hospitals and clinics, jakarta, indonesia. jl. kimia no. 8, central jakarta, dki jakarta, 10430, indonesia. email: yunia_irawati@yahoo.com. abstract thyroid eye disease (ted) is an autoimmune disorder that is associated with thyroid gland dysfunction which causes muscle and orbital fat enlargement. this case report is aimed to present a case of sight-threatening ted and how we should manage this condition. we present a case of patient with chief complaint of vision loss and prominent eyes for 5 months prior to the visit to our eye hospital. patient had sought advice from an ophthalmologist and internist. ted was eventually diagnosed 2 months after consulted with an ophthalmologist in the rural area. according to eugogo guidelines, ted with sight-threatening condition should be treated with glucocorticoid iv 500-1000 mg for 3 days consecutively. although the patient was already given steroid injection for the initial treatment, the dosage was inadequate. after the inflammation process was reduced, the patient was reluctant to have an orbital decompression that was suggested. hence, ted progressed continuously besides sight-threatening complications arising. he indeed underwent fat decompression and tarsorrhaphy as eyelid surgery to prevent corneal exposure. in follow-up, both visual acuity and corneal improvement were finally achieved. in the management of ted, collaboration between ophthalmologist and internist, who may be specialized in endocrinology, is imperative. they should be able to manage ted promptly and correctly, hence sight-threatening and other complications can be prevented and satisfactory results are achieved. fat decompression should be considered as a good help to improve visual acuity nevertheless orbital decompression cannot be done. keywords: grave’s disease, thyroid eye disease, dysthyroid optic neuropathy, orbital decompression, fat decompression. vol 54 • number 1 • january 2022 sight-threatening condition in severe thyroid eye diasease 125 introduction graves’ disease is an autoimmune disease that leads to a generalized overactivity of the entire thyroid gland (hyperthyroidism). it is the most common cause of hyperthyroidism in the united states. generally occurring in patients with hyperthyroidism, sometimes thyroidassociated ophthalmopathy or thyroid eye disease (ted) occurs in patients with euthyroid or hypothyroid chronic autoimmune thyroiditis. the condition has an annual adjusted incidence rate of 16 women and 3 men per 100.000 population.1 ted is an autoimmune disorder that is associated with thyroid gland dysfunction which causes muscle and orbital fat enlargement. ted generally accompanies graves hyperthyroidism where the course of eye disease does not always parallel with the activity of thyroid gland. the onset of ted can precede, together, or after the onset of hyperthyroidism.2-5 ted pathophysiology is complex and the treatment has not fully focused on the pathogenesis of the disease. although the majority of ted cases are mild, around 3-7% of patients develop vision-threatening complications such as corneal damage or dysthyroid optic neuropathy (don). the strategy for handling this disease consists of various methods such as medical therapy, surgery, and radiotherapy.4-6 the ability of ophthalmologists and internists to diagnose and assess the activity and severity of this disease correctly is expected to help determine the right treatment for patients. in an active ted, proper handling can improve vision, appearance, and quality of life. therefore, ted is a challenge for ophthalmologists and internists both in diagnosis and appropriate management.4-6 this case report discussed severe ted with corneal damage and don. eventually, ted was diagnosed, yet the treatment given was not according to guidelines, so the patient was deteriorating and in high risk of losing his sight. case illustration a 64-year-old male was referred to our eye hospital presented with complaint of vision loss, protrusion and soreness on both eyes. five months prior, he complained of redness, swelling, and blurred vision. there was no other sign of systemic infection, previous illness, and family illness. all of these conditions lead his first-seen-ophthalmologist to diagnose his red eyes with an eye infection. two months later, he went to an internist with a complaint of trembling, sweating, weight loss, heart palpitations, and sleep deprivation. there was no data about physical examination because he was seeking the internist in another hospital in rural area. the laboratory tests supported the diagnosis of hyperthyroidism and type two diabetes mellitus because he has high level of total t3 (5.15 ng/ ml), high level of total t4 (20,7 mg/dl) and low level of tshs (<0,02 miu/ml). there was no data on blood glucose level. he was a heavy-smoker although he had already been advised to quit smoking. the patient was given thiamazole 3x10 mg, glimepiride 1x2 mg, and univoxy® 1x1 tablet per day from the internist. one month later, both of his eyes became protruded. right eye (re) was blind and left eye (le) was otherwise normal. clinically suspected with pseudotumors, the doctor evaluated him with orbital computed tomography (ct) scan, but neither retrobulbar nor pseudotumor was found. this patient was then referred to ophthalmologist at another hospital in urban area. one month later, he felt his le vision began to be blurred. orbital ct-scan depicted an orbital muscle enlargement with a coke-bottle sign and proptosis in both eyes, hence the patient was eventually diagnosed with ted and received steroid injections twelve times for three days (divided doses of steroid) of hospitalization consecutively from the first ophthalmologist. (figure 1) the patient did not remember the dosage of steroid injection that was given by the ophthalmologist. in spite of the inflammation process that was subsided, one week later, swelling of both eyes became recurrent and the visual acuity of his le got worsened until he lost his vision. the laboratory tests revealed a hypothyroid condition with low ft4 (0.28 ng/dl), high tshs (28.834 miu/ml) and low total t3 (0.46 ng/ml). hence, the internist in the second hospital reduced the dosage of thiamazole to 1x10 mg. this patient did not have a regular schedule of follow up for thyroid and diabetes mellitus. yunia irawati acta med indones-indones j intern med 126 the patient came to our eye hospital. on examination, there was no light perception (nlp) for the re and light perception (lp) for the le. he has 30º exotropia. both eye movements were -4 in all directions (fixed eyeball). there were proptosis, edema on upper and lower eyelids, retraction of upper and lower eyelids, lagophthalmos, severe chemosis, and caruncular edema in both eyes. corneal ulceration in the re and corneal infiltrate in the le were also recognized. pupillary light reflexes were reduced for both eyes, so relative afferent pupillary defect (rapd) was difficult to be assessed. cataract could also be identified in both eyes. the result of hertel exophthalmometers on each eye was 25 mm. diabetes mellitus was again confirmed by laboratory tests with high level of hba1c (ngsp 6.4% and ifcc 46 mmol/mol). at the same time, his hypothyroidism condition was supported by laboratory tests such as low ft3 (1.55 pg/ml), low ft4 (0.68 ng/dl), high tshs (0.375 miu/ml), low total t3 (0,51 ng/ml), low total t4 (4,49 mg/dl), high trab (15,74 iu/l), and low anti-tpo (<0.5 iu/ml). based on all manifestations and work-up studies, this patient had complex problems due to the complications of grave’s disease, such as bilateral proptosis, re corneal ulcer, le exposure keratitis, bilateral dysthyroid optic neuropathy (don), and bilateral immature cataracts. he was hospitalized and treated with methylprednisolone intravenous (iv) 500 mg for three consecutive days, chloramphenicol eye ointment 3 times/day, citicoline 2x500 mg, mecobalamin 2x500 µg, gatifloxacin eye drops every 3 hours, and solcoseryl® eye gel every hour. after the methylprednisolone iv administration, patient’s blood glucose level increased to 355 mg/ dl indeed. he was given insulin (lantus 1x14 unit and novorapid 3x10 unit) and thiamazole 1x10 mg from the internist. his le vision was improved to 2/60 on his fourth day of hospitalization. however, he still had don and at high risk for corneal perforations on both eyes, hence he was suggested to undergo an orbital decompression. as he was being reluctant to proceed, he underwent fat decompression and blepharorrhaphy. the procedures included chemosis incision, eyelid fat removal, upper and lower blepharotomy, amniotic membrane transplant, bandage contact lenses, and blepharorrhaphy. two consecutive days after the surgery, he was given an infusion of 250 mg mp per day. the blepharorrhaphy was then released after 3 days. central corneas were healed but left scars at the inferior corneas of both eyes. during hospitalization, intraocular pressures (iop) were high (20.7 mmhg for re and 34.3 mmhg for le). he was given latanoprost-timolol maleate eye drops 2 times/day, acetazolamide 3 x 250 mg, potassium l-aspartate 3 times/day, calcium-vitamin d3 2 x/day, acetylsalicylic acid 2 x 160 mg, tobramycin-dexamethasone eye drops 1 x/day, gatifloxacin 4 x/day, solcoseryl® 4 x/day, selenium 1 tablet/day, vitamin c 500 mg iv, ciprofloxacin 2 x 500 mg and mefenamic acid 2 x 500 mg. on the 11th day of hospitalization, his eye movements improved to -3 in all directions for both eyes and his dosage of methylprednisolone was increased to 500 mg. he was finally allowed to go home on the 12th day of hospitalization. (figure 2, figure 3) figure 1. axial, sagittal, and coronal ct-scan showed proptosis and extraocular muscles enlargement (coke-bottle sign). vol 54 • number 1 • january 2022 sight-threatening condition in severe thyroid eye diasease 127 on the last visit, his eye pain was alleviated, vision of the re remained nlp and vision of the le improved to 0.1. exotropia improved to 15º and both eye movements were improved in all directions as well. in spite of eyelid oedema, caruncular oedema and conjunctival chemosis that were still found, his eyes were generally improved compared to the initial condition. rapd was positive in the re. ishihara test for the le showed total colour blindness. (figure 4) discussion the assessment recommended by the 2018 european thyroid association (eta) guidelines for suspected grave’s hyperthyroidism is thyroidstimulating hormone (tsh), free t3 (ft3), free t4 (ft4), tsh receptor antibodies (trab), and thyroid gland ultrasound examination. tshs should be used as an initial screening test because it has the highest sensitivity and specificity for evaluating suspected grave’s hyperthyroidism. 4 figure 3. perimetry of the le demonstrated a visual field defect. figure 2. a) before surgery, there were eyelid retraction on the re and chemosis on both eyes; b) eye condition after fat decompression and blepharorrhaphy was released. chemosis was gradually diminished but caruncular oedema was still recognized. on the le, eyelid oedema was slowly subsided. 4 figure 3. perimetry of the le demonstrated a visual field defect. yunia irawati acta med indones-indones j intern med 128 serum tsh levels are more sensitive than thyroid hormone (t3, t4) tests for assessing thyroid hormone excess. diagnostic accuracy improves when both serum tshs and ft4 are assessed at the initial evaluation. trab measurements are also sensitive and specific in evaluating suspected grave’s hyperthyroidism. trab is a specific biomarker for the extrathyroidal manifestations of grave’s disease and correlates with ted activity and severity.7-10 in grave’s hyperthyroidism, 30-50% of patients will have ocular involvement. in one-third of ted cases, symptoms and signs appear altogether with hyperthyroidism. diagnosis of ted is made when 2 of the following 3 signs are present: (1) typical orbital signs (1 or more of the following): unilateral/ bilateral eyelid retraction with typical temporal flares (with/without lagophthalmos), unilateral/ bilateral proptosis, restrictive strabismus, compressive optic neuropathy, eyelid oedema/ erythema, or caruncular oedema/chemosis; (2) immune-related thyroid dysfunction (1 or more of the following): grave’s hyperthyroidism, hashimoto thyroiditis, or presence of thyroid antibodies without a coexisting dysthyroid state (tsh-receptor antibodies, thyroidbinding inhibitory immunoglobulins/tbii, thyroid-stimulating immunoglobulins/tsi, figure 4. a) corneal ulcer on the re; b) corneal infiltrate was seen on the le; c) corneal leucoma (improvement on the re); d) corneal nebula (improvement on the le). anti microsomal antibody); (3) radiographic evidence of ted (enlargement of 1 or more of the following): inferior/medial/superior/lateral rectus muscle or levator palpebral muscle.1-3 in this patient, the diagnosis of ted was made based on ophthalmology examination, laboratory tests, and orbital ct-scan findings. orbital ct-scan of this patient demonstrated an extraocular muscle enlargement with tendon sparing and optic nerve compression at the orbital apex.11,12 prior ophthalmologists were unable to recognize the disease despite all orbital signs, laboratory findings and ct-scan that supported the diagnosis of ted. as a result, the patient did not get the proper treatment immediately. even after the patient was eventually diagnosed with ted, he was not given an appropriate treatment according to the european group on grave’s orbitopathy (eugogo) guidelines. this patient had a poor prognosis because of several risk factors of ted including old age, smoking habits, and diabetes mellitus. furthermore, the patient came to us when he already had don. therefore, these conditions deteriorated and lead his eyes to a severe sightthreatening ted consequently. in the age of 64 years old, he was considered as in the peak incidence of ted (age 45-49 years old and at 65-69 years old in men). don generally vol 54 • number 1 • january 2022 sight-threatening condition in severe thyroid eye diasease 129 occurs at older ages (over age 60 years old).2,13 hyperthyroid patient who smokes is five times higher to suffer from ted and will suffer more severe form than non-smokers. the risk of ted in an active smoker is related to the number of cigarettes smoked per day which causes the progression of ted. smokers have a poor response to immunosuppressant therapy, hence, the patient should be advised to taper and stop smoking.2,5,6 diabetes mellitus (dm) is also an important risk factor for the occurrence of don. the incidence of don in patient with dm is greater (15-35%) than without dm (34%) due to vasculopathy. visual improvement is not significant in don, smoker and diabetic patients.4,5,14 in accordance to eugogo guidelines and italian consensus, the priorities in ted cases are prompt correction of thyroid dysfunction and stable maintenance of euthyroidism, smoking cessation, conservative therapy for eyes, and assessing the activity and severity of ted. based on 7/7 clinical activity score (cas), the patient was indicated as an active ted.2,4,6,15 it is imperative to determine ted activity because high-dose glucocorticoid is only effective in an active phase. severity assessment is also important to decide whether it is worth running the risk of high-dose glucocorticoid or it is preferable to limit the therapeutic intervention to local and preventive measures.3,6,7according to eugogo guidelines, the severity of ted in this case is categorized as sight-threatening (very severe) ted due to corneal damage and don in both eyes. both of these conditions are emergencies that must be treated immediately.4,6,7 until the third day of hospitalization, even though the patient already received an infusion of methylprednisolone 500 mg/day for 3 consecutive days, both eyes were still protruded, eyelids were still retracted, and lagophthalmos were still present. thus, the risk for corneal perforation in both eyes was still inevitable. we decided to do chemosis incision and fat decompression, blepharotomy, amniotic membrane transplant for corneal ulceration, bandage contact lenses, and partial blepharorrhaphy in both eyes. this appears in line with eugogo recommendations that stated severe corneal exposure should be treated immediately, medically or with surgery, to avoid corneal perforation. after blepharorrhaphy was released, both corneas were healed and the vision of the le could finally improve. in this case, methylprednisolone iv was continued until the second week with total of 3 grams. vision of the re did not improve but vision of the le improved from lp to 2/60. the pupillary light reflexes of both eyes were still decreased, so don has not been resolved. therefore, it was required to do orbital decompression surgery for the le. instead, the patient was reluctant to undergo such surgery. we decided to continue giving methylprednisolone iv, corresponding to eugogo guidelines for severe ted treatment (infusion of methylprednisolone 500 mg/ week for 6 weeks, followed by infusion of methylprednisolone 250 mg/week for 6 weeks, with the total limit should not exceed 8 grams).6 on the last day of treatment, re vision remained nlp and le vision improved to 0.1. surgery for ted is not advised until a euthyroid state is maintained and it has been in the stable phase for at least 6-9 months. exceptions include don or corneal damage, in which cases urgent surgical intervention is warranted.18,19 studies from kahaly et al and vaphiades et al revealed case series of 3 patients who had don with nlp vision and onset of 5 days to 3 months, showed a return of vison following orbital decompression surgery suggesting that axonal death may be delayed by months after total nerve function loss. orbital decompression surgery may still be effective in reversing compressive optic neuropathy in patients with nlp vision of up to 3 months.7,20 the ted course is conceptualized by the rundle’s curve. ted consists of 2 phases, the inflammatory/active phase which lasts for 6-24 months, followed by the inactive phase where fibrotic changes occur.4-6 ted treatment during the active phase aims to reduce the immune and inflammatory reactions and to limit destructive consequences. in our case, the active phase had occurred 5 months before the patient was treated with methylprednisolone infusion. referring to rundle’s curve, it was more difficult to shift this yunia irawati acta med indones-indones j intern med 130 disease to be inactive. therefore, ted is indeed a challenge for ophthalmologists and internists, both in the diagnosis and management. it is crucial to be able to diagnose ted immediately because early initiation of therapy lead to a better prognosis.4,5,6 conclusion the ability to diagnose ted promptly and manage this disease correctly is importantly needed to prevent sight-threatening complications and to achieve satisfying results. a collaboration between internist, who may be subspecialized in endocrinology, and ophthalmologist should be established to control and treat the associated systemic disease. conflict of interest the authors have no conflict of interest to declare. references 1. bahn rs. grave’s ophthalmopathy. n engl j med 2010;362:762-38. 2. fay a, dolman pj, bahn rs, kazim m. diseases and disorders of the orbit and ocular adnexa. thyroid eye disease. boston: elsevier; 2016.p.219-34. 3. foster ja, carter kd, durairaj vd, kavanagh mc, korn bs, nelson cc, et al. orbit, eyelids, and lacrimal system. orbital inflammatory and infectious disorder. in: cantor lb, rapuano cj, cioffi ga. american academy of ophthalmology section 7. san fransisco: leo; 2012.p.47-55. 4. barrio-barrio j, sabater al, bonet-farriol e, velazquezvilloria a, galofre jc. graves’ ophthalmopathy: visa versus eugogo classification, assessment, and management. j ophthalmol 2015;15:1-12. 5. nair ag, desai st. an algorithmic approach in the diagnosis and management of thyroid eye disease. j clin ophthalmol res 2015;3(2):113-9. 6. bartalena l, baldeschi l, boboridis k, et al. the 2016 european thyroid association/european group on graves’ orbitopathy guidelines for the management of graves’ orbitopathy. eur thyroid j 2016;5:9-26. 7. kahaly gj, bartalena l, hegedus l, leenhardt l, poppe k, pearce sh. 2018 european thyroid association guideline for the management of graves’ hyperthyroidism. eur thyroid j 2018;7:167-86. 8. lantz m, planck t, asman p, hallengren b. increased trab and/ or low anti-tpo titers at diagnosis of graves’ disease are associated with an increased risk of developing ophthalmopathy after onset. exp clin endocrinol diabetes 2014;122:113-7. 9. bartalena l. grave’s orbitopathy: imperfect treatments for a rare disease. eur thyroid j 2013;2:259-69. 10. katsuyama t, takeda m, otsuka f, et al. rapid progression of grave’s ophthalmopathy despite the administration of thiamazole. int med 2013;52:231720. 11. yen mt. imaging in thyroid ophthalmopathy [internet]. usa: medscape [updated 2016 jan 13; cited 2018 nov 22]. available from: https://emedicine.medscape.com/ article/383412-overview. 12. penne rb, rapuano cj. wills eye hospital – color atlas and synopsis of clinical ophthalmology. thyroid eye disease; china: wolters kluwer. 2018.p.166-71. 13. wiersinga wm, kahaly agj. graves’ orbitopathy. a multidisciplinary approach – questions and answers: management of very severe graves’ orbitopathy (dysthyroid optic neuropathy and corneal breakdown). switzerland: karger; 2010.p.159-66. 14. wiersinga wm. graves’ orbitopathy: management of difficult cases. indian j endocr metab 2012;16(2):1502. 15. pinto cn. current protocol for the management of thyroid eye disease. dos times [internet]. india: management protocol oculoplasty [updated 2015 apr 10; cited 2018 nov 22]. available from: http://www. dos-times.org/pulsar9088/20150507173851069.pdf. 16. american academy of ophthalmology. tarsorrhaphy [internet]. usa: american academy of ophthalmology [updated 2018; cited 2018 nov 22]. available from: https://www.aao.org/bcscsnippetdetail. aspx?id=3c2b27d8-c930-4a31-8036-9ce3dcebaf61. 17. rajak s, rajak j, selva d. performing tarsorrhaphy. community eye health j 2015;28(89):10-1. 18. palace mr. perioperative management of thyroid dysfunction. health serv insights 2017;1-5. 19. mercandetti m. orbital decompression for graves’ disease [internet]. usa: medscape [updated 2018 oct 19; cited 2018 dec 2]. available from: https:// emedicine.medscape.com/article/878672-overview. 20. vaphiades m. graves’-related blindness reversible with decompression surgery [internet]. usa: american academy of ophthalmology [updated 2014 mar 24; cited 2018 dec 3]. available from: https:// www.aao.org/editors-choice/orbital-decompressioncompressive-optic-neuropathy. case report 375acta med indones indones j intern med • vol 52 • number 4 • october 2020 misleading diagnosis of radiological imaging of covid-19 pneumonia during pandemic era: risk on the existence of cmv infection ceva w. pitoyo1, i putu e. k. wijaya1, vally wulani2, anindita k. wiraputri1, michael a. romulo1 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of radiology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: ceva wicaksono pitoyo, md., msc. division of respirology and critical care internal medicine, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: cevawpitoyo@gmail.com. abstrak coronavirus disease 2019 (covid-19) adalah sebuah penyakit pernapasan akut yang sangat menular akibat virus severe acute respiratory syndrome coronavirus-2 (sars-cov-2). presentasi klinis covid-19 antara lain demam, batuk non-produktif dan sesak napas. meskipun diagnosis ditegakkan dengan mendeteksi ribonucleic acid (rna) virus melalui metode reverse transcription-polymerase chain reaction (rt-pcr), ct scan memiliki peranan penting dalam deteksi dan tatalaksana covid-19 terutama pada daerah yang prevalensinya tinggi. ct scan memiliki sensitivitas yang tinggi, namun spesifisitasnya rendah karena gambaran pneumonia covid-19 seperti ground glass opacities (ggo) dan konsolidasi juga dimiliki oleh berbagai penyakit lain, salah satunya adalah infeksi sitomegalovirus (cmv). tujuan laporan kasus ini adalah untuk meningkatkan kewaspadaan terhadap penyakit lain yang memiliki gambaran radiologis yang serupa dengan covid-19, terutama pada pasien dengan imunodefisiensi yang rentan terhadap infeksi virus seperti infeksi cmv agar keterlambatan penanganan penyakit dapat dicegah. kata kunci: respiratory medicine, radiologi, ilmu penyakit dalam. abstract coronavirus disease 2019 (covid-19) is an acute respiratory disease which rapidly disseminated due to severe acute respiratory syndrome coronavirus-2 (sars-cov-2) virus. clinical presentations of covid-19 are fever, non-productive cough, and dyspnea. although the diagnosis establishment is done by detecting the viral ribonucleic acid (rna) through reverse transcription-polymerase chain reaction (rt-pcr) method, ct scan has an important role in detection and treatment of covid-19 especially in high prevalence regions. chest ct scan has high sensitivity yet low specificity because there are a lot of other pathological spectrums that also present features of covid-19 such as ground glass opacities (ggo) and consolidation, one of them is cmv infection. the objective of this case report is to raise vigilance towards other diseases that have radiological image similarities with covid-19, especially in the immunocompromised patients who are susceptible to viral infections like cmv infection so that the delay in the disease treatment can be prevented. keywords: respiratory medicine, radiology, internal medicine. 376 ceva w. pitoyo acta med indones-indones j intern med introduction coronavirus disease 2019 (covid-19) is an acute respiratory disease which rapidly disseminated due to severe acute respiratory syndrome coronavirus-2 (sars-cov-2), a virus that originated from the coronaviridae family. covid-19 should be suspected if the patient has a history of respiratory tract symptoms such as fever, cough, runny nose, sore throat accompanied by a history of travel to a country or a region with local transmission; or a history of contact with probable case or covid-19 confirmed case. covid-19 is diagnosed by detecting ribonucleic acid (rna) virus from reverse transcription-polymerase chain reaction (rt-pcr) method.1,2 several literatures revealed that chest ct scan has an important role in early detection and treatment of covid-19.1,3,4 chest ct scan findings in the early course of covid-19 is ground-glass opacity (ggo) with or without consolidation in the posterior and peripheral part of the lung, but in the later course of the disease, consolidation, reticular opacity, crazypaving pattern, reversed halo sign and vascular enlargement are more often found. ggo is defined by a hazy opacity that blurs the bronchial structure or vessels beneath.1 chest ct scan has high sensitivity but also low specificity because there are a lot of other pathological spectrums which can cause similar radiological findings in covid-19 including ggo, consolidation, interlobular septal thickening and reticular opacities. those findings are often found in viral/bacterial/fungal pneumonia, interstitial lung disease, pneumonitis due to hypersensitivity, and even lung edema.1,5 therefore, in this covid-19 pandemic era, we should not forget other diseases that can cause similar presentations of covid-19 pneumonia on chest ct scan. in this article, 3 cases of cytomegalovirus (cmv) pneumonia with similar chest ct scan findings to covid-19 pneumonia were reported. case illustration patient i a 66 year old woman came to the hospital on march 26th 2020 with a difficulty of breathing since 2 weeks prior to admission. the patient has a history of diabetes mellitus (dm) type 2, hypertension, ischemic stroke and permanent pacemaker (ppm) insertion due to sick sinus syndrome. the physical examination obtained blood pressure (bp) 152/89 mmhg, pulse 74 beats per minute, respiratory rate (rr) 22 times per minute, and body temperature 36°c. laboratory examination showed an elevated c-reactive protein (crp) 115.1 mg/dl (table 1). the chest x-ray showed bilateral infiltrates with pleural effusion in the left lung. the patient was given meropenem 1 g i.v. t.i.d, rivaroxaban 10 mg p.o. o.d., adalat oros 30 mg p.o. o.d., atorvastatin 10 mg p.o. o.d. thoracocentesis was performed on the patient and then the obtained pleural fluid was checked for culture examination, cytology, and adenosine deaminase (ada). on the 3rd day of care, the patient felt strenuous shortness of breath and o2 saturation table 1. clinical data of the case. patient i patient ii patient iii sex female female male age (years) 66 60 63 comorbidities dm, hypertension, ischemic stroke, ppm insertion due to sick sinus syndrome sle, heart failure vasculitis, hypertension chief complaint during admission shortness of breath shortness of breath fever chest x-ray bilateral infiltrates with left pleural effusion bilateral infiltrates and cardiomegaly bilateral diffuse consolidation chest ct scan bilateral diffuse ground glass opacities and consolidation in the left lung consolidation in the left lung bilateral ground glass opacities, consolidation, reticular opacities and pleural effusion 377 vol 52 • number 4 • october 2020 misleading diagnosis of radiological imaging of covid-19 pneumonia dropped to 83-88%. the patient was suspected for worsening pneumonia due to tb. levofloxacin 1 x 750 mg iv was then added to the treatment list. chest ct scan was also performed on the patient with a result of diffuse ggo in both sides of the lungs and consolidation in the left lung (figure 1). a week prior to hospitalization. the patient also complained feeling of nausea and vomit. there were no cough and fever. the patient has a history of valvular heart disease since 2010. the patient has also been suffering from systemic lupus erythematosus (sle) since 2017. prednison 3 mg p.o. t.i.w., hydroxychloroquine 200 mg p.o. o.d. and mycophenolic acid 180 mg p.o. b.i.d. has been routinely consumed for the past 1 year. physical examination obtained bp 70/40 mmhg, pulse 150 bpm irregular, rr 34 times per minute, o2 saturation 98.5%. from chest examination, bilateral wet coarse rhonchi was acquired. laboratory examination showed lymphopenia of 0.57 x 109/l, nlr of 13.5, elevated crp of 13.5 mg/l, elevated procalcitonin of 0.51 ng/ml. chest x-ray revealed infiltrates in both sides of lungs and cardiomegaly (figure 2). chest ct scan was also performed on patient with a result of consolidation in the left lung (figure 3). figure 1. ct scan showed bilateral diffuse ggo and consolidation in the left lung. on the 5th day, the patient’s condition did not get any better, therefore the patient was suspected for covid-19 based on the ct scan result. the patient was planned for rapid serological test for sars-cov-2 antibody and oropharyngeal swab twice. rapid serological test was non reactive. other examinations such as ada resulted in 8 iu/l, culture examination found no microorganism and pleural fluid cytology found no malignancy. due to hypotension with a systolic pressure of 70 mmhg on the 8th day of care, the patient was moved to icu. the patient was given some additional drugs: hydroxychloroquine 400 mg p.o. b.i.d., n-acetylcysteine 1200 mg i.v. o.d., meropenem was stopped and replaced by tigecycline 100 mg i.v. o.d. loading dose then 50 mg i.v. b.i.d. from the 1st and 2nd oropharyngeal result which came out on the 13th day, sars-cov-2 was found negative and from the blood pcr test for cmv dna, it was found positive with cmv count of 7.3 x 103 copies/ml. subsequently, hydroxychloroquine was stopped and the patient began to be treated with ganciclovir 250 mg i.v. b.i.d. unfortunately, the patient passed away on the next day. patient ii a 60 year old woman came to the hospital on april 28th 2020 with shortness of breath since figure 2. infiltrates in both sides of lungs and cardiomegaly revealed on chest x-ray. figure 3. consolidation in the left lungs from chest ct scan. 378 ceva w. pitoyo acta med indones-indones j intern med initial diagnoses of the patient were a suspected case of covid-19, cardiogenic shock, heart failure, atrial fibrillation with normal ventricular response (af-nvr) and sle. the patient was given dobutamine drip 3 mg/kgbw/ hour, ceftriaxone 2 g i.v. o.d., azithromycin 500 mg p.o. o.d., warfarin sodium 2 mg p.o. o.d., bisoprolol 5 mg p.o. o.d., digoxin 0.125 mg p.o. o.d., methylprednisolone 4 mg p.o. o.d., and allopurinol 100 mg p.o. o.d. rapid serological test for sars-cov-2 antibody was non reactive. rt-pcr swab was done 3 times and all the results were negative. on the 11th day, igg anti-cmv was checked and the result was 691.3 u/ml. on the 21st day, cmv dna resulted in 1.06 x 104 copies/ml. on the 25th day, the patient’s condition was getting better and then discharged for ambulatory care. patient iii the third patient is a 63 year old man who came to the hospital on july 3rd 2020. the patient complained about fever since 3 days prior to admission, along with shortness of breath and worsening cough since a day beforehand. the patient was referred from another hospital which located 700 km from our hospital due to suspicion of pulmonary embolism and sepsis caused by complicated urinary tract infection (uti). the patient had already been catheterized upon arrival. the patient did not experience any dizziness, headache, chest pain, epigastric pain, nausea and vomitus. the patient has a history of vasculitis and asthma that occasionally occurs in the past 2 years. the patient also has a history of hypertension. the patient routinely consumes hydroxychloroquine 200 mg p.o. o.d, imidapril 10 mg p.o. o.d., and amlodipine 10 mg p.o. o.d. the patient had been treated with methylprednisolone for vasculitis but it had already been stopped since 8 months before admission. the patient has allergies on several drugs including levofloxacin, ciprofloxacin, cefadroxil, cefixime and mefenamic acid. the patient also has contrast allergy and seafood allergy. in the previous hospital, the patient had already been given nebulization of salbutamol, furosemide 40 mg i.v. o.d., enoxaparin natrium 0.6 u i.v. o.d., fondaparinux 2.5 mg s.c. o.d., and meropenem 1 g i.v. o.d. from the physical examination, several datas were obtained. the bp was 151/87 mmhg, pulse 95 beats per minute regular, rr 20 times per table 2. laboratory examination results. laboratory results (normal value) patient i patient ii patient iii hemoglobin (g/dl, 11.5-15) 12.4 8.4 11.8 thrombocyte (x 109/l, 150-350) 153 199 291 wbc count (x 109/l, 3.5-9.5) 10.5 9.7 25.7 neutrophil (x 109/l, 1.8-6.3) 7.41 7.7 19.8 lymphocyte (x 109/l, 1.1-3.2) 2.27 0.57 1.25 neutrophil lymphocyte ratio 3.2 13.5 15.84 crp (mg/l, 0-5) 121 17.34 108.9 procalcitonin (ng/ml, 0-0.05) 0.02 0.51 4.02 igm anti cmv (<0.7 u/ml) 0.2 igg anti cmv (<0.5 u/ml) 691.3 pcr dna cmv positive, 7.3 x 103 copies/ml positive, 1.06 x 104 copies/ml positive, 9.5 x 103 copies/ml ph (7.35-7.45) 7.37 7.43 pco2 (35-45 mmhg) 50 24.3 po2 (80-100 mmhg) 110 216.5 hco3(22-26 mmhg) 27.9 16.5 so2 97.1 98.5 rapid serological test sars-cov-2 non reactive non reactive non reactive rt-pcr swab sars-cov-2 negative negative negative 379 vol 52 • number 4 • october 2020 misleading diagnosis of radiological imaging of covid-19 pneumonia minute, pulse oxymetry 95%. minimal rhonchi on the left lung was found from chest examination. laboratory examination showed leukocytosis of 25.7 x 103 /mm3, lymphocyte count of 1.25 x 109 /l (normal), nlr of 15.84, elevated crp of 108.9 mg/dl, elevated procalcitonin of 4.02 ng/ ml. chest x-ray showed diffuse consolidation in both sides of the lungs (figure 4). ct scan revealed ggo, consolidation and reticular opacities in both sides of the lungs, along with bilateral pleural effusion (figure 5). mg i.v. b.i.d. while being treated in the ward, several drugs were added to the treatment list: n-acetylcysteine 5 g i.v. o.d., fluconazole 150 mg i.v. o.d., fondaparinux 2.5 mg s.c. o.d, hydroxychloroquine 200 mg p.o. o.d., imidapril 10 mg p.o. o.d., and amlodipine 5 mg p.o. o.d. on the 2nd day of care, the patient felt strenuous shortness of breath and o2 saturation dropped to 92-93%. in this covid-19 pandemic era, this kind of situation leads to suspicion of covid-19 thus the patient was tested for rapid serological test for sars-cov-2 antibody, nasopharyngeal and oropharyngeal swab. from the previous hospital, rapid serological test had already been done twice which both resulted in non reactive. on the 2nd day of care in our hospital, rapid serological test showed non reactive for sars-cov-2 antibody. rt-pcr examination on nasopharyngeal and oropharyngeal swabs came out negative on the 4th day of care. on the next day, several laboratory examinations were carried out to search for the pneumonia etiology, one of them was cmv dna examination with pcr method. on the 6th day of care, the result turned out to be positive. a couple days later, the result of quantitative pcr examination for cmv dna was obtained and the cmv count was 9.5 x 103 copies/ml. hence, the patient was given ganciclovir with the loading dose of 250 mg i.v. b.i.d. and the maintenance dose of 250 mg i.v. o.d.. the patient’s condition improved and the patient was discharged on the 16th day for ambulatory care. discussion covid-19 pneumonia is a novel acute respiratory disease which has been disseminated rapidly and has similar clinical presentations to other viral pneumonias.6 epidemiologically, covid-19 often happens in male about 40-60 years old with history of residing or travelling into the area of epidemic. in other hand, viral pneumonia often occurs in children, rarely found in adults or in the communities and its prevalence also spikes in the certain season. the occurrence of viral pneumonia depends on the virulence of the virus, transmission route, age and the host’s immunological status.7 figure 4. diffuse consolidation of both lungs found in chest x-ray. figure 5. ct scan showed ggo, consolidation and reticular opacities in both sides of the lungs. when the patient was admitted to the ward, the patient was diagnosed with bacterial pneumonia with differential diagnosis of fungal and viral pneumonia, along with leukocytoclastic vasculitis and controlled hypertension. the patient was given paracetamol 1 g i.v. t.i.d. prn., meropenem 1 g i.v. t.i.d., methylprednisolone 62.5 mg i.v. o.d., nebulization of salbutamol : budesonide 1:1 ml b.i.d, and esomeprazole 40 380 ceva w. pitoyo acta med indones-indones j intern med covid-19 clinical manifestations are mainly fever, non-productive coughs and shortness of breath.6,8 those symptoms are similar to viral pneumonia symptoms in general including coughs, dyspnea, fever and pleuritic chest pain. coughs in viral pneumonia are mainly non-productive, but if there were sputum production, the sputum would be scant and watery in contrast to bacterial pneumonia that presents with mucopurulent sputum.6 clinical presentations of viral pneumonia alone may not distinguish the specific cause of the viral pneumonia. nevertheless, covid-19 has some symptoms that are rarely found in other viral pneumonia such as anosmia, dysgeusia and gastrointestinal symptoms.9,10 laboratory findings that are often found in covid-19 are normal or low white blood cell (wbc) count, lymphopenia, elevated crp, elevated lactate dehydrogenase (ldh), and elevated erythrocyte sedimentation rate (esr).7,8 in viral pneumonia, wbc count may increased, normal or decreased, but increased wbc count is often associated with bacterial pneumonia. elevated crp is also found in viral pneumonia even though it is not a sensitive nor specific finding.11 similar to clinical presentations, general parameters that are measured in the laboratory such as complete blood count and differential count cannot differentiate the specific cause of pneumonia, but can only raise the tendency of the cause of infection whether if it is viral or bacterial. because of that, specific laboratory examinations must be conducted to detect the specific cause of pneumonia. radiological features of covid-19 found in chest ct scan are multiple and bilateral ggo with or without consolidation in the posterior, basal and peripheral part of the lungs. other finding which is often found after ggo and consolidation is reticular opacities that appear due to a complex network of interlobular and intralobular septal thickening. crazy paving pattern, reversed halo sign and air bronchogram are also found in chest ct scan. the features that are rarely seen in covid-19 are widespread ggo, lymphadenopathy and pleural effusion.1,5 rt-pcr examination is a specific laboratory examination that has to be conducted on covid-19 suspected patients because it is the gold standard in covid-19 diagnosis establishment,1 but it requires a lot of time –a day or even more— in order to get the result especially in the early of pandemic.7 during covid-19 pandemic era, chest ct scan has a vital role in diagnosing covid-19 and monitoring the patient’s clinical course.1,3 ggo, one of the most often radiological finding of covid-19, appears on the chest ct scan in the early course of the disease (0-4 days after the symptom onset).12 the existence of that finding in high risk patients may raise the suspicion and vigilance towards covid-19.3 according to the multinational consensus statement from the fleischner society,13 chest ct scan is indicated if the patient presents with moderate to severe covid-19 symptoms regardless of the rt-pcr result. asymptomatic patients or patients with mild symptoms are not indicated for chest ct scan examination. if the chest ct scan resulted in suggestive of covid-19, that patient must be admitted, isolated, and the rt-pcr examination must be performed in order to establish the diagnosis.7,13,14 based on the systematic review done by böger b et al,2 chest ct scan has high sensitivity about 89.8% to 93.7% (mean = 91.9%), in contrast to its low specificity around 21.0% to 29.5% (mean = 25.1%). low specificity of chest ct scan is caused by the ct scan features of covid-19 that are also found in other lung diseases, ranging from pneumonia caused by virus, bacteria, fungi, pneumonitis caused by hypersensitivity, to lung edema.5 in imaging diagnosis, covid-19 is hardly distinguishable from its differential diagnoses particularly viral pneumonia.7 because of that, it is important to identify viruses that can also cause the radiological features of covid-19 pneumonia. several viruses that can produce radiological features of covid-19 such as ggo and consolidation are cmv, adenovirus, herpes s i m p l e x v i r u s ( h s v ) , i n f l u e n z a v i r u s , parainfluenza virus, human meta-pneumovirus (hmpv), coronavirus, and respiratory syncytial virus (rsv). nevertheless, those viruses show some radiological findings that are useful in differential diagnosis. in general, rsv shows 381 vol 52 • number 4 • october 2020 misleading diagnosis of radiological imaging of covid-19 pneumonia centrilobular nodules and area of consolidation which often distributed asymmetrically. ggo caused by adenovirus can be distributed in the lobular manner. parainfluenza virus and hmpv can produce some centrilobular nodules with thickening bronchial walls. influenza virus often shows nodule and tree in bud opacities. ggo due to hsv and cmv are involving >75% of lung area. coronaviruses that are causing the severe acute respiratory syndrome (sars) and the middle east respiratory syndrome (mers) can produce ggo, consolidation, septal thickening and air bronchogram that are similar to covid-19. however, reversed halo sign has never been reported in sars and mers cases. the lung abnormalities in sars are more often unifocal.1,5 cmv is the main cause of morbidity in patients with immunodeficiency which occurs due to hiv or non-hiv such as autoimmune disease and post transplantation. cmv infection can happen in various organs particularly the eyes, gi tract, liver and lungs. cmv infection in lungs has similar clinical manifestations as covid-19, there are fever, non-productive cough and shortness of breath. in contrast to covid-19, the cmv infection only occurs in immunocompromised patients due to its opportunistic nature.15 ct imaging of cmv pneumonia are mainly bilateral ggo and consolidation along with poorly defined small centrilobular nodules. thickened interlobular septum and pleural effusion are also found often.16 centrilobular nodule image and pleural effusion are the features that distinguish cmv pneumonia from covid-19. the diagnosis of cmv pneumonia is established by using polymerase chain reaction (pcr) method.15 in the case illustrations above, the first and the second patient had shortness of breath whereas the third patient had fever and shortness of breath. it is needed to be noted that all of the reported patients had comorbidities; the first patient had the ppm implantation done, the second and the third patient had autoimmune disease. these patients were included in the group that had a high risk of covid-19 and all of them came to the hospital with symptoms that match the clinical presentation of covid-19, consequently they were suspected as covid-19 cases. chest ct scan result of patient i and iii showed bilateral ggo and consolidation, while the patient ii only showed unilateral consolidation. these results represent pneumonia suggestive of covid-19. in further development, rapid serological test showed a non-reactive result for sars-cov-2 antibody and oropharyngeal swab rt-pcr examination resulted in negative for sars-cov-2. soon after, a few follow up examinations were performed to evaluate the cause of pneumonia. one of them was cmv dna examination which turned out to be positive in all cases. diagnosis establishment for other diseases besides covid-19 in these cases were slow. during the covid-19 pandemic, it is important to suspect a case when the ct imaging showed the features of covid-19. however, the consideration of the patient’s history of travel/epidemiology, clinical manifestations, and performing swab rt-pcr are needed by clinicians to establish the diagnosis.2,7,13 in this case report, all cases were initially suspected of covid-19 because those patients were high risk of covid-19 and all of them came with symptoms that match the clinical presentation of covid-19, supported with their ct findings of pneumonia suggestive of covid-19. eventually, the cause of the disease in all of the reported cases was cmv. hence, it is needed to be considered for clinicians to think about other differential diagnoses and to do further examinations to search for the disease etiology as soon as possible in order to achieve faster diagnosis establishment. therefore, in specific conditions where other viral infections may occur such as in immunocompromised or transplant patients suspicion towards non-covid-19 diseases must be properly considered. conclusion while facing the covid-19 pandemic, chest ct scan has an important role in covid-19 detection due to its high sensitivity. however, chest ct scan has low specificity for covid-19 because of several other diseases that have similar radiological features. this case report describes 3 cases of pneumonia cmv with 382 ceva w. pitoyo acta med indones-indones j intern med clinical presentations and chest ct scan results that resemble the clinical and radiological features of covid-19. therefore, we should not forget that other diseases may have similar radiological finding to covid-19, especially in specific conditions such as immunocompromised patients, transplant patients or patients with comorbidities so that the delay in the treatment of other diseases including cmv does not occur. references 1. carotti m, salaffi f, sarzi-puttini p, et al. chest ct features of coronavirus disease 2019 (covid-19) pneumonia: key points for radiologists. radiol med [internet]. 2020;125(7):636-46. available from: https:// link.springer.com/article/10.1007/s11547-020-012374 doi: 10.1007/s11547-020-01237-4. 2. böger b, fachi mm, vilhena ro, cobre af, tonin fs, pontarolo r. systematic review with meta-analysis of the accuracy of diagnostic tests for covid-19. am j infect control [internet]. 2020;s0196-6553(20)30693-3. available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/pmc7350782/ doi:10.1016/j.ajic.2020.07.011. 3. tenda ed, yulianti m, asaf mm, et al. the importance of chest ct scan in covid-19. acta med indones. 2020;52(1):68-73. 4. ai t, yang z, hou h, et al. correlation of chest ct and rt-pcr testing for coronavirus disease 2019 (covid-19) in china: a report of 1.014 cases. radiology [internet]. 2020;296(2):e32-e40. available from: https://pubmed.ncbi.nlm.nih.gov/32101510/ doi: 10.1148/radiol.2020200642. 5. parekh m, donuru a, balasubramanya r, kapur s. review of the chest ct differential diagnosis of ground-glass opacities in the covid era. radiology [internet]. 2020;202504. available from: https:// pubs.rsna.org/doi/10.1148/radiol.2020202504 doi: 10.1148/radiol.2020202504. 6. darden d, hawkins r, larson, s, iovine, n, prough, d, efron p. the clinical presentation and immunology of viral pneumonia and implications for management of coronavirus disease 2019. crit care explore [internet]. 2020;2(4):e01-e09. available from: https://journals. lww.com/ccejournal/fulltext/2020/ 04000/the_ clinical_presentation_and_immunology_of_viral.17. aspx doi: 10.1097/cce .0000000000000109. 7. dai wc, zhang hw, yu j, et al. ct imaging and differential diagnosis of covid-19. can assoc radiol j [internet]. 2020;71(2):195-200. available from: https://pubmed.ncbi.nlm.nih.gov/32129670/ doi:10.1177/0846537120913033. 8. rodriguez-morales aj, cardona-ospina ja, gutiérrezocampo e, et al. clinical, laboratory and imaging features of covid-19: a systematic review and meta-analysis. travel med infect dis [internet]. 2020;34:101623. available from: https://pubmed. ncbi.nlm.nih.gov/32179124/ doi :10.1016/j. tmaid.2020.101623. 9. meng x, deng y, dai z, meng z. covid-19 and anosmia: a review based on up-to-date knowledge. am j otolaryngol [internet]. 2020;41(5):102581. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc7265845/ doi:10.1016/j.amjoto.2020.102581. 10. cheung ks, hung ifn, chan ppy, et al. gastrointestinal manifestations of sars-cov-2 infection and virus load in fecal samples from a hong kong cohort: systematic review and meta-analysis. gastroenterology [internet]. 2020;159(1):81-95. available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/pmc719 4936/ doi:10.1053/j.gastro.2020.03.065. 11. freeman am, leigh, jr tr. viral pneumonia. [updated 2020 jul 10]. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2020 jan [cited 2020 sep 13]. available from: https://www.ncbi.nlm.nih.gov/ books/nbk513286/. 12. pan f, ye t, sun p, gui s, liang b, li l, et al. time course of lung changes at chest ct during recovery from coronavirus disease 2019 (covid-19). radiology [internet]. 2020;295(3):715-21. available from: https:// pubs.rsna.org/doi/10.1148/radiol.2020200370 doi: 10.1148/radiol.2020200370. 13. rubin gd, ryerson cj, haramati lb, et al. the role of chest imaging in patient management during the covid-19 pandemic: a multinational consensus statement from the fleischner society. radiology [internet]. 2020;296(1):172-80. available from: https://pubs.rsna.org/doi/10.1148/radiol.2020201365 doi:10.1148/radiol.2020201365. 14. nair a, rodrigues j, hare s, et al. a british society of thoracic imaging statement: considerations in designing local imaging diagnostic algorithms for the covid-19 pandemic. clinical radiology [internet]. 2020;75(5):329-34. available from: https://www.clinicalradiologyonline .net/article/ s0009-9260(20)30096-9/fulltext doi:10.1016/j. crad.2020.03.008. 15. smith, cb. cytomegalovirus pneumonia. chest. 1989;95(3):182s–187s. doi: 10.1378/chest.95.3_ supplement.182s. 16. moon jh, kim ea, lee ks, kim ts, jung kj, song jh. cytomegalovirus pneumonia: high-resolution ct findings in ten non-aids immunocompromised patients. korean j radiol [internet]. 2000;1(2):73-8. available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/pmc2718167/ doi:10.3348/kjr.2000.1.2.73. 331acta med indones indones j intern med • vol 53 • number 3 • july 2021 review article risk factor, diagnosis, and current treatment of h. pylori infection in indonesia: a literature review rizani p. iman1, tiroy junita1, rinaldo i. rachman1, ari f. syam2 1 faculty of medicine universitas indonesia, jakarta, indonesia. 2 division of gastroenterology, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: prof. ari fahrial syam, md., phd. division of gastroenterology, dept. of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: ari_syam@hotmail.com. abstrak infeksi helicobacter pylori (h. pylori) di indonesia merupakan suatu masalah yang telah berkembang, meskipun prevalensi di indonesia dilaporkan lebih rendah dibanding negara asean dan asia lainnya. dominasi jenis bakteri h. pylori dengan virulensi genotipe yang lebih lemah di indonesia diduga menjadi penyebab rendahnya prevalensi infeksi tersebut serta kanker gaster sebagai komplikasinya. walaupun pemeriksaan endoskopi masih menjadi alat utama untuk mengevaluasi status mukosa gaster pada pasien yang terinfeksi h. pylori, infeksi h. pylori sendiri dapat secara sederhana didiagnosis menggunakan strategi test-and-treat, terutama pada daerah dengan sumber daya terbatas. beberapa temuan menunjukkan angka resistensi terhadap berbagai antibiotik yang tinggi di banyak daerah dan etnik indonesia, di mana hal tersebut mengindikasikan bahwa pengobatan menggunakan triple therapy regimen tidak dapat diaplikasikan terhadap semua populasi secara keseluruhan. pengobatan infeksi h. pylori sebaiknya didasarkan terhadap pola resistensi pada area tersebut, dan regimen menggunakan antibiotik jenis baru seperti furazolidone, rifabutin, dan sitafloxacin dapat dipertibangkan sebagai terapi potensial untuk mengeradikasi infeksi tersebut. untuk menentukan pendekatan yang paling adekuat, studi multisenter menggunakan sampel yang lebih besar penting untuk dilakukan. kata kunci: faktor risiko, diagnosis, penatalaksanaan terkini, infeksi, helicobacter pylori. abstract helicobacter pylori (h. pylori) infection has become an emerging problem in indonesia despite its relatively low prevalence as opposed to other southeast asian and asian countries. strains containing less virulent genotypes predominantly found in indonesia is suggested to be the rationale for why the disease prevalence, as well as its gastric cancer complication, remain inferior in respect of neighboring counterparts. although endoscopic evaluation is still necessary to determine the gastric mucosal status of those infected with h. pylori, the infection itself can be easily diagnosed with test-and-treat strategy especially in areas with limited resources. several findings revealed high rates of antibiotic resistance varying among indonesian regions and ethnicities, suggesting that triple therapy regimen may not be suitable for all populations. whereas treatment should be based on the pattern of resistance in respective regions, novel regimens involving furazolidone, rifabutin, and sitafloxacin are proposed as potential drugs of choice to eradicate h. pylori infection. in order to determine the adequate approach for h. pylori infection in indonesia, further multicenter studies involving larger sample size should be conducted. keywords: risk factor, diagnosis, current treatment, infection, helicobacter pylori. rizani p. iman acta med indones-indones j intern med 332 introduction indonesia is one of the most populous countries in the world. indonesia is unique in that its land mass is formed of an archipelago consisting of more than 1,000 ethnicities and even more sub-ethnic groups. helicobacter pylori (h. pylori) infection has been an emerging problem in indonesia with a prevalence of 22.1% reported by syam et al.1 globally, 4.4 billion people are infected with h. pylori.2 the prevalence of h. pylori infection in indonesia is relatively low compared with that of other countries in southeast asia and asia. in developing countries, the prevalence of h. pylori infection ranges from 85% to 90%; however, this figure is significantly lower in developed countries, ranging between 30% and 50%.3,4 for instance, the united arab emirates has an overall prevalence of 41%.5 in southern asia, pakistan and india have the highest h. pylori infection prevalence—81% and 63.5%, respectively. in line with the low prevalence of h. pylori infection, indonesia has only the fifth highest incidence of gastric cancer among southeast asian countries, reported as 3,014 cases per year according to globocan 2018.6 in contrast to neighboring countries, vietnam ranks first, with 17,527 new cases of gastric cancer per year.6 china leads asia in term of gastric cancer incidence, with 456,124 cases per year. southeast asia in general has a gastric cancer incidence of 8.2 per 100,000 and 4.1 per 100,000 per year for men and women, respectively. these relatively high numbers are only less than a third of those in east asia (the highest in the world).7 these data spark the question: “is the low prevalence of gastric cancer in indonesia due to the low prevalence of h. pylori infection?”. etiopathogenesis and risk factors the low prevalence of h. pylori infection remains a point of curiosity. initially, the prevalence of h. pylori in indonesia was expected to be as high as in other developing asian countries, as sanitation infrastructures are not yet well constructed. several studies have assessed the risk factors of h. pylori infection in indonesia. a study by goto et al. showed that the risk factors significantly associated with h. pylori infection are infrequent hand washing before meals (or 4.10; 95% ci: 1.15-14.6), cucumber intake more than once a week (or 6.61; 95% ci: 1.87-23.3), chicken intake more than once a week (or 1.40; 95% ci: 0.434.56), and former and current alcohol drinking (or 61.9; 95% ci: 1.67-2300.8).8 on the other hand, drinking soy milk more than once a week decreased the risk with marginal significance (or 0.10; 95% ci: 0.01-0.97). the buginese and batak ethnicities were shown to have a higher risk of h. pylori infection than the javanese, as buginese and bataknese eat using their fingers more frequently.8 drinking tap water instead of mineral water is also a risk factor for h. pylori infection.9 the same risk factors are also seen in the united arab emirates.5 with regard to ethnicity, a study conducted by syam et al. assessing the prevalence of h. pylori on the five largest islands of indonesia revealed much interesting data. they found differences in the prevalence of h. pylori infection between ethnicities, hence establishing ethnicity as an independent risk factor for h. pylori infection. the papuan, batak, and buginese ethnicities had a higher risk of developing h. pylori infection than the javanese, dayak, and chinese ethnicities.10 ethnicity is also a risk factor for h. pylori infection in the united arab emirates (p < 0.001). khoder et al. showed that people of african descent have a significantly higher prevalence than those of asian or arab ethnicity. among asians, indians have the highest prevalence of h. pylori infection, followed by the people of pakistan and the philippines.5 there is an ongoing debate over whether or not psychological stress is a risk factor for h. pylori infection. the idea is that psychological stress provokes gastric acid secretion, increasing the level of aggressive factors and inhibiting protective factor of the gastric mucosa. these conditions facilitate infection of the stomach by h. pylori. a study by darwin et al. in padang showed that psychological stress appears to have no correlation with the expression of il-6 in the gastric mucous of patients with functional dyspepsia. however, there is evidence of increasing activity of h. pylori in patients with increased psychological stress.11 vol 53 • number 3 • july 2021 risk factor, diagnosis, and current treatment of helicobacter pylori infection 333 h. pylori can manifest as a broad spectrum of clinical symptoms and diseases ranging from peptic ulcer to gastric cancer and from bloating to dyspepsia. a cross-sectional study in medan conducted by siregar et al. involving 80 patients with gastritis showed that serum tnf-α and vegf levels were significantly increased in the h. pylori-infected group, but there were no significant differences in serum levels of il-8 between h. pylori-positive and negative groups. high levels of tnf-α were associated with a severe degree of chronic inflammation, high levels of il-8 were associated with severe degree of chronic inflammation and neutrophil infiltration, and high levels of vegf were associated with a severe degree of premalignant gastric lesion.12 one of the clinical manifestations of h. pylori infection is gastroesophageal reflux disease (gerd). it was suggested that there is a parallel association of increasing gerd incidence with decreasing h. pylori infection prevalence in asia. miftahussurur et al. conducted a study involving 104 dyspeptic patients evaluated by endoscopy in indonesia. this study found a high prevalence of gerd in areas with a low h. pylori prevalence, although the association could not be measured due to an insufficient number of cases.12 peptic ulcer disease is still a significant health burden, despite decreasing rates of h. pylori infection due to eradication therapy. in indonesia the prevalence of h. pylori infection in peptic ulcer disease is 90%-100%. peptic ulcer disease itself can be differentiated into duodenal and gastric ulcer disease. h. pylori plays a role in those two ulcer locations. the location of h. pylori infection determines whether gastric acid secretion will be upor downregulated, based on the inflammatory zone. untreated h. pylori infection may lead to gastric cancer, as h. pylori is classified as a class 1 carcinogen in humans. however, the risk of malignancy depends on the virulence factor of h. pylori.13 a n i n t e r e s t i n g p o i n t c o n c e r n i n g t h e prevalence of gastric cancer in indonesia is that it is relatively low compared with other asian countries. a multicenter study conducted by miftahussurur et al. in java, papua, sulawesi, borneo, and sumatera showed that virulence factors of genotypes presenting in h. pylori strains were suggested to contribute to the low rate of gastric cancer in indonesia. their study revealed the genetic profile of h. pylori in indonesia. of the strains examined, 97.7% possessed the caga gene, 60.5% of which were east-asian-type caga, while 20.9% were western-type-caga. in all, 18.6% were of the novel abb type, most of which were obtained from papuan subjects. patients infected with east-asian-type-caga strains possessing a 6-bp deletion showed significantly lower inflammation and atrophy scores in the corpus area than those with strains expressing the western-type caga. these findings suggest that the low incidence of gastric cancer in indonesia may also be due to less virulent genotypes in the predominant strains.10 variations in h. pylori strains affect the prevalence of gastric cancer within a country. hspeasia isolates among chinese people appear linked to a higher incidence than hpasia2 or hpeurope strains, found among indians and malays.7 h. pylori vaca and caga genes are associated with higher virulence, whereas vascular endothelial growth factor (vegf) is one important marker for neo-angiogenesis. siregar et al. conducted a study in medan and concluded that an increased level of vegf is correlated with h. pylori infection and its virulence status. there was a significant rise in serum levels of vegf in h. pylori-infected patients compared with those without infection. moreover, cagapositive strains of h. pylori also showed significantly higher vegf levels than cag-a negative strains.14 diagnosis of h. pylori infection several studies were performed in indonesia to identify other diagnostic tools and biomarkers and to compare them with the urea breath test (ubt) and endoscopic evaluation, for the diagnosis of h. pylori infection in the indonesian population. budyono et al.15 conducted a cross-sectional study from november 2016 to march 2017 to analyze the association between the severity of dyspepsia, measured with a modified glasgow dyspepsia severity score (gdss) questionnaire, rizani p. iman acta med indones-indones j intern med 334 and h. pylori infection, measured with 14c ubt examination. there was a significant difference in gdss scores between h. pylorinegative and positive patients. however, clinical assessment failed to show a significant difference in severity between the two groups (gdss of 3.06 in positive and gdss of 1.67 negative, out of 10). therefore, it is difficult to recommend modified gdss as a substitute for the current examination method, as it has a sensitivity of 41.6% and specificity of 85.5%, taking ubt as the gold standard. h. pylori eradication should be considered in patients with a modified gdss score of 4 and above if there is no better examination available. nurdin et al.16 conducted a study to investigate h. pylori detection in gastric biopsy. they compared immunohistochemistry and giemsa staining for the detection of h. pylori in active chronic gastritis. the giemsa sensitivity test performed upon immunohistochemistry showed a sensitivity value of 65% and a specificity value of 100%. immunohistochemistry staining in active chronic gastritis was more sensitive than giemsa, particularly in detecting coccoid-shaped bacteria. as for the use of serology in h. pylori infection, miftahussurur et al. found than an elisa test for h. pylori infection had sensitivity of 66.7% and specificity of 97.2%, compared with immunohistochemistry as the gold standard. this showed the low accuracy of the elisa kit when used in an indonesia population.17 other studies attempted to generate markers that could be used to evaluate gastric mucosal status in patients with h. pylori infection. miftahussurur et al. studied the use of serum pepsinogen (pgs) as a non-invasive method to determine gastric mucosal status, in order to favor areas in indonesia in which gastrointestinal endoscopy is unavailable. pg levels were determined using the pg elisa kit. the samples were then classified according to the abc method as follows: h. pylori-negative/ pg-negative (group a), h. pylori-positive/ pg-negative (group b), h. pylori-positive/ pg-positive (group c), and h. pylori-negative/ pg-positive (group d). h. pylori (+) patients had significantly higher pg ii levels and lower pg i/pg ii ratios than h. pylori (-) patients. the prevalence of chronic and atrophic gastritis was also significantly higher in h. pylori (+) patients. pg levels can be useful to determine chronic gastritis but have modest sensitivity for atrophic gastritis in indonesia.17 a cross-sectional study conducted by dairi et al. aimed to determine serum malondialdehyde (mda) levels in patients with h. pylori (+) gastritis. h. pylori infection produces reactive oxygen species (ros), whereas ros itself are an important factor for the development of gastritis. h. pylori infection also causes recruitment of neutrophils and macrophages, which in turn increase free radicals. this oxidative stress causes tissue damage that can be measured by mda, the product of lipid peroxidase. the mean mda level in h. pylori (+) patients was 1.58, whereas in h. pylori (-) it was 1.19, with p = 0.013 for the difference. there is still no normal value of mda that can be used as standard, as it can be affected by age, enzyme activities, antioxidant supplements, diseases, and environmental factors.18 from a study using a survey of 26 experts from nine southeast asian countries (cambodia, indonesia, laos, malaysia, myanmar, the philippines, singapore, thailand, and vietnam), the rapid urease test (rut) was the most common method used to diagnose h. pylori infection, followed by ubt. most southeast asian countries used a test-and-treat strategy for patients with dyspepsia without alarming symptoms, except laos and the philippines. in these cases, stool antigen and urea breath tests were commonly used. among health centers and regions in the same countries, there were significantly different proportions of patients with findings of endoscopic gastritis who underwent rut and histological evaluation.19 complications of h. pylori infection colonization with h. pylori is known to increase the risk of certain diseases, such as duodenal ulcer, gastric ulcer, non-cardiac gastric carcinoma, b-cell lymphoma, and possibly thrombocytopenic purpura. a case-control study was conducted by darnindro et al. between june 2014 and august 2014 in jakarta with 69 vol 53 • number 3 • july 2021 risk factor, diagnosis, and current treatment of helicobacter pylori infection 335 cases and 71 controls using medical record and histopathology evaluation. h. pylori infection can cause atrophy and metaplasia of the gastric mucosa. according to histopathological findings, active chronic gastritis was found in 62.3% of h. pylori (+) patients, compared with only 12.7% of h. pylori (-) patients (or = 11.31; 95% ci: 4.86-26.7). mild and moderate atrophy was higher among h. pylori (+) patients, though the difference was not statistically significant (p = 0.09). the frequency of gastric mucosal metaplasia was found to be higher in h. pylori (+) patients (10.1% vs 1.4%; p = 0.03).20 increased metaplasia in the h. pylori (+) population was also observed by tenggara et al. of 1127 patients who underwent endoscopy between 2001 and 2011 in north jakarta, metaplasia was found in 3.31% of h. pylori (-) patients and 9.23% of h. pylori (+) patients. only 7 patients had gastric malignancies, and all of them were h. pylori (-). they concluded that there was an association between metaplasia and h. pylori infection. however, there was no association between gastric malignancy and h. pylori infection.21 according to quach et al., the prevalence of gastric cancer is the highest in vietnam (17/100.000) and the lowest in indonesia (1/100.000). in indonesia, ethnicities including c h i n e s e , b a t a k n e s e , a n d m i n a h a s a n e s e were considered as high-risk factors for the development of gastric cancer. in most southeast asian countries, a familial history of gastric cancer and precancerous gastric lesions were considered risk factors for gastric cancer development.20 it was suggested that h. pylori infection decreases the risk of gastroesophageal reflux disease and its complications, including barret’s esophagus, adenocarcinoma of the esophagus, and gastric cardia. a study conducted by miftahussurur et al. in surabaya involved 104 patients with dyspeptic syndrome in indonesia between october 2015 and november 2015 who underwent endoscopic evaluation. gerd was diagnosed by endoscopic evaluation, and patients were asked to complete gerd-q questionnaires. the presence of h. pylori strains was identified on the basis of histology, culture, and immunohistochemistry. of all patients, 53.8% were confirmed to have gerd. only two patients (1.9%) were diagnosed as h. pylori positive, although both were also diagnosed with gerd. in conclusion, this study found a high prevalence of gerd in areas with a low h. pylori prevalence, although the association could not be measured due to an insufficient number of cases.12 current treatment modalities for h. pylori infection the currently available guidelines for dyspepsia with h. pylori infection management in indonesia by syam et al. (2017) recommend a minimum 7-day course of either triple or quadruple therapy for the first-line regimen, d e p e n d i n g o n t h e r a t e o f r e s i s t a n c e t o clarithromycin in the affected area.22 the combination of a proton pump inhibitor (ppi), such as rabeprazole, lansoprazole, omeprazole, pantoprazole, or esomeprazole, to reduce gastric acid production and antibiotics effective against h. pylori is reported to be beneficial to eradicate the infection. triple therapy with ppi, amoxicillin, and clarithromycin/metronidazole remains the treatment of choice in areas with a rate of resistance of less than 20% to clarithromycin.21 meanwhile, those residing in areas with high resistance to clarithromycin are suggested to undergo a culture and resistance test with samples isolated from an endoscopic specimen, or a molecular test directly through gastric biopsy, prior to treatment initiation. a quadruple therapy comprising bismuth subsalicylate, ppi, metronidazole, and tetracycline is recommended in such areas. under circumstances where bismuth is not available, the same regimen can still be used without including bismuth. when the first-line clarithromycin-based regimen fails, bismuth quadruple or triple therapy with ppi, levofloxacin, and amoxicillin are favorable as the second-line treatment, whereas in areas with high resistance to clarithromycin, the ppi-levofloxacin-amoxicillin regimen may be the first line of treatment.22 a confirmation test needs to be conducted within at least 4 weeks after each treatment rizani p. iman acta med indones-indones j intern med 336 course.22 a ubt or h. pylori stool antigen monoclonal test can be beneficial to identify any treatment failure. antibiotic resistance in h. pylori infection the high prevalence of clarithromycin-, levofloxacin-, and metronidazole-resistant h. pylori remains a burden of many asia-pacific countries, as reported in a meta-analysis by kuo et al.22 among many other reasons, such as genetic polymorphisms and patient compliance, antibiotic resistance has been proposed as a major factor contributing to the low eradication rate of h. pylori infection after standard therapy.24 therefore, in h. pylori management in asean: the bangkok consensus report, mahachai et al. recommend that the first-line regimen should be customized for each region in accordance with its antibiotic resistance pattern.25 miftahussurur et al.26 conducted a prospective study to evaluate resistance rates from august 2012 to november 2015 involving 849 adult dyspeptic patients who underwent endoscopy examinations in 11 cities spreading across the five largest islands of indonesia. among them, 77 strains of h. pylori were isolated to undergo sensitivity assays for metronidazole, clarithromycin, levofloxacin, amoxicillin, and tetracycline. there were high rates of antibiotic resistance to metronidazole and levofloxacin (46.8% and 31.2%, respectively), whereas a lower prevalence of resistance to clarithromycin (9.1%), amoxicillin (5.2%), and tetracycline (2.5%) were observed. the patterns of resistance were also found to vary significantly among several ethnicities and regions. the highest rate of resistance to levofloxacin was found in java (50%) and sumatera (44.4%), while sumatera also showed a significantly higher rate of metronidazole resistance (88.9%) than other islands. of all ethnic groups, ambonese were associated with significantly higher rates of metronidazole and tetracycline resistance compared with others. moreover, high levels of clarithromycin resistance were also observed in ambonese, chinese, and balinese. only strains isolated from dayak individuals were found to be sensitive to all antibiotics. the study suggested that standard triple therapy based on metronidazole and levofloxacin may not be effective at eradicating h. pylori infection in indonesia. to i n v e s t i g a t e t h i s m a t t e r f u r t h e r, miftahussurur et al.26 initiated a follow-up study where a total of 105 strains isolated from 1,039 dyspeptic subjects from august 2012 to february 2016 were analyzed in order to investigate possible alternative regimens for h. pylori infection in indonesian regions with high rates of metronidazole and levofloxacin resistance. sensitivity to five alternative antibiotics comprising rifaximin, rifabutin, furazolidone, garenoxacin, and sitafloxacin were assessed in this study. it was revealed that all strains were sensitive to rifabutin, furazolidone, and sitafloxacin. a mild rate of resistance to garenoxacin was found, whereas those treated with rifaximin showed a much higher rate (6.7% and 38.9% respectively). the resistance rates to both drugs were found to be the highest in java. garenoxacin resistance was found neither in bali, kalimantan, and timor nor in those belonging to ambonese, balinese, dayak, javanese, minahasanese, and timor ethnic groups. in contrast, rifaximin resistance was found to be evenly distributed among all ethnicities. the study suggested that alternative therapies with furazolidone, rifabutin, and sitafloxacin might be considered as the treatment of choice to eradicate h. pylori in indonesian regions with metronidazole and levofloxacin, as well as clarithromycin resistance. in an attempt to identify the virulence factors that might contribute to the high prevalence of antibiotic-resistant h. pylori strains in indonesia, genetic sequencing assays were conducted in both studies. an association between h. pylori resistance to several antibiotics and their genotypes were then discovered.26,27 tetracycline-resistant h. pylori was shown to be significantly associated with caga-positive strains, whereas those with genetic expression of vaca were associated with rifaximin resistance. conclusion the prevalence of h. pylori infection in indonesia is relatively low in comparison with vol 53 • number 3 • july 2021 risk factor, diagnosis, and current treatment of helicobacter pylori infection 337 other southeast asian and asian countries, as is the incidence of gastric cancer. we suggest that this phenomenon is due to east-asian-type-caga strains as a predominant strain in indonesia that possesses a 6-bp deletion, resulting in less virulent disease. in areas with limited resources, the test-and-treat strategy is preferred to diagnose dyspeptic patients without alarming symptoms. to date in indonesia, there is still no noninvasive examination proven to be significantly valuable for evaluating gastric mucosal status in h. pylori infected patients. triple therapy remains the mainstay of treatment in areas of low resistance rates to clarithromycin, while a ppi-levofloxacin-amoxicillin regimen should be used in high-resistance areas. however, the indonesian population also has high resistance rate to levofloxacin, especially in the regions of java and sumatera. therefore, in these cases, furazolidone, rifabutin, and sitafloxacin might be considered as drugs of choice to eradicate h. pylori. a multicenter study involving a large number of samples should be conducted to determine the optimal h. pylori treatment regimen in indonesia. references: 1. syam af, miftahussurur m, makmun d, et al. risk factors and prevalence of helicobacter pylori in five largest islands of indonesia: a preliminary study. plos one;10(11):e0140186. 2. hooi jky, lai wy, ng wk, et al. global prevalence of helicobacter pylori infection: systematic review and meta-analysis. gastroenterology. 2017;153:420–9. 3. world gastroenterology. world gastroenterology organisation global guideline: helicobacter pylori in developing countries. j clin gastroenterol. 2011; 45:383–8. 4. burucoa c, axon a. epidemiology of helicobacter pylori infection. helicobacter. 2017;22 (1). 5. khoder g, muhammad js, mahmoud i, soliman ssm, burucoa c. prevalence of helicobacter pylori and its associated factors among healthy asymptomatic residents in the united arab emirates. pathogens. 2019;8(44);1-14. 6. globocan indonesia: estimated age-standardized incidence and mortality rates: both sexes. [internet] 2012 [cited 2016 jan 20]. available from: www. http:// globocan.iarc.fr/ pages/fact_sheets_population.aspx 7. gheelim, lim kg, palayan k. a review of gastric cancer research in malaysia. asian pacific j cancer prevent. 2019;20(1):5. 8. goto y, syam af, darnindro n, puspita hapsari fc. risk factors for and prevalence of helicobacter pylori infection among healthy inhabitants in northern jakarta, indonesia. asian pac j cancer prev. 2016;17(9):4469-75. 9. darnindro n, syam af, fauzi a, rumende cm. seroprevalence and socio-demographic factors of helicobacter pylori infection in patients with dyspepsia in kalibaru primary health care north jakarta. acta med indones. 2015;47(4):297–303. 10. miftahussurur m, syam af, makmun d, et al. helicobacter pylori virulence genes in the five largest islands of indonesia. gut pathogens. 2015;7(1):26. 11. darwin e, murni aw, nurdin ae. the eff darwin e, murni aw, nurdin ae. the effect of psychological stress on mucosal il-6 and helicobacter pylori activity in functional dyspepsia. acta medica indonesiana. 2017 apr;49(2):99-104. 12. miftahussurur m, doohan d, nusi ia, et al. gastroesophageal reflux disease in an area with low helicobacter pylori infection prevalence. plos one. 2018;13(11):e0205644. 13. koncoro h, wibawa idn. peptic ulcer disease different pathogenesis of duodenal and gastric ulcer. indones j gastroenterol hepatol digest endosc. 2015;16(3);17982. 14. siregar ga, halim s, sitepu rr. serum tnf-α, il-8, vegf levels in helicobacter pylori infection and their association with degree of gastritis. acta medica indonesiana. 2015;47(2). 15. budyono c, widita h, herardi r, syam af. association between severity of dyspepsia and urea breath test results in patients with positive helicobacter pylori serology. indones j gastroenterol hepatol digest endosc. 2016;19(2);79-82. 16. nurdin w, krisnuhoni e, kusmardi. comparison of helicobacter pylori detection using immunohistochemistry and giemsa and its association with morphological changes in active chronic gastritis. indones j gastroenterol hepatol digest endosc. 2016;17(1);21-7. 17. miftahussurur m, nusi ia, akil f, et al, adi p. gastric mucosal status in populations with a low prevalence of helicobacter pylori in indonesia. plos one. 2017;12(5):e0176203. 18. dairi l, siregar a, sungkar t. the comparison of serum malondialdehyde level between h. pylori positive and h. pylori negative gastritis patients. indones j gastroenterol hepatol digest endosc. 2018;19(1);3-6. 19. quach dt, vilaichone r, vu kv, yamaoka y, sugano k, mahachai v. helicobacter pylori infection and related gastrointestinal diseases in southeast asian countries: an expert opinion. asian pac j cancer prev. 2018;19 (12):3565-9. 20. darnindro n, syam af, handjari dr, makmun d. gastric mucosa atrophy and metaplasia in patient with rizani p. iman acta med indones-indones j intern med 338 helicobacter pylori infection. indones j gastroenterol hepatol digest endosc. 2015;16(1);13-6. 21. tenggara r, irawan vr. the association between metaplasia and gastric malignancy with helicobacter pylori infection. indones j gastroenterol hepatol digest endosc. 2017;18(2);94-7. 22. syam af, simadibrata m, makmun d, abdullah m, fauzi a, renaldi k, maulahela h, utari ap. national consensus on management of dyspepsia and helicobacter pylori infection. acta medica indonesiana. 2017;49(3):279. 23. kuo yt, liou jm, el-omar em, et al. primary antibiotic resistance in helicobacter pylori in the asiapacific region: a systematic review and meta-analysis. lancet gastroenterol hepatol. 2017;2(10):707-15. 24. vilaichone rk, quach dt, yamaoka y, sugano k, mahachai v. prevalence and pattern of antibiotic resistant strains of helicobacter pylori infection in asean. asian pacific j cancer prevent. 2018;19(5):1411. 25. mahachai v, vilaichone rk, pittayanon r, et al. helicobacter pylori management in asean: the bangkok consensus report. j gastroenterol hepatol. 2018;33(1):37-56. 26. miftahussurur m, syam af, nusi ia, et al. surveillance of helicobacter pylori antibiotic susceptibility in indonesia: different resistance types among regions and with novel genetic mutations. plos one. 2016;11(12):e0166199. 27. miftahussurur m, waskito la, syam af, et al. alternative eradication regimens for helicobacter pylori infection in indonesian regions with high metronidazole and levofloxacin resistance. infection and drug resistance. 2019;12:345-58. 147 original article acta med indones indones j intern med • vol 52 • number 2 • april 2020 the difference in the cyclin d1 expression in advanced stage nasopharyngeal cancer based on treatment response: a retrospective cohort study cosphiadi irawan1, rahmat cahyanur1, lisnawati2, murdani abdullah1, reyhan e. yunus3 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 departement of pathological anatomy, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 3 department of radiology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: rahmat cahyanur, md. division of hematology and medical oncology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: rahmat.cahyanur01@ui.ac.id. abstrak latar belakang: kanker nasofaring (knf) merupakan kanker leher kepala terbanyak di indonesia (28,4%). sebagian kasus (18,9%) terdiagnosis pada stadium lanjut. kemoterapi memainkan peranan penting pada kasus stadium lanjut. akan tetapi, pasien dengan stadium yang sama dapat memiliki respon pengobatan yang berbeda, karena adanya perbedaan karakteristik biologi molekular. cyclin d1 adalah suatu protein yang berperan dalam siklus sel yang akan mempercepat proliferasi. penelitian ini menilai ekspresi cyclin d1 serta hubungannya dengan respon pengobatan. metode: penelitian ini menggunakan disain kohort retrospektif pada pasien knf stadium lanjut yang mendapatkan kemoterapi di rscm pada kurun waktu 2015-2018. pewarnaan imunohistokimia cyclin d1 menggunakan antibodi monoklonal cyclin d1 novocastratm dengan teknik pengambilan antigen suhu tinggi. penilaian ekspresi dilakukan dengan menggunakan h-skor. respons pengobatan ditinjau ulang berdasarkan kriteria recist 1.1. hasil: terdapat 15 subjek (48,4%) dengan ekspresi cyclin d1 positif. peneliti menemukan ekspresi cyclin d1 positif lebih banyak pada subjek yang respon terhadap kemoterapi (66,7% vs. 33,3%, p = 0,032). rerata h-skor antara kelompok respons dan tidak respons juga memiliki perbedaan bermakna (116,24 sd57,80 vs. 77,97 sd45,27, p = 0,048). kesimpulan: penelitian ini menunjukkan ekspresi cyclin d1 berhubungan dengan respon pengobatan yang baik pada pasien knf. kata kunci: cyclin d1, kanker nasofaring, respon pengobatan. abstract background: nasopharyngeal cancer (npc) is the most common type of head and neck cancer in indonesia (28.4%). reports showed that 18.9% of cases came with advanced stage. chemotherapy play important role in advanced stage. however, patients with the same stage of the disease may have different treatment response, likely due to the different tumor biological characteristics. cyclin d1 is a protein involved in the cell cycle, which will stimulate proliferation. this study aimed to examine the proportion of cyclin d1 in npc and its association with treatment response. methods: a retrospective cohort study was conducted on advanced npc patients that underwent chemotherapy at cipto mangunkusumo hospital from 2015 until 2018. cyclin d1 cosphiadi irawan acta med indones-indones j intern med 148 immunohistochemistry staining was done by antigen retrieval methods using the cyclin d1 novocastratm monoclonal antibody. the cyclin d1 expression was evaluated with h-score. treatment response was reviewed based on the recist 1.1 criteria. results: fifteen subjects (48.4%) had a positive expression of cyclin d1. higher proportion of cyclin d1 positive was found in responsive group compare with non-responsive group (66.7% vs. 33.3%, p = 0.032). statistically significant difference in mean h-score was observed between the subjects who responded and those who did not respond (116.24 sd57.80 vs. 77.97 sd45.27, p = 0.048). conclusion: this study suggests that a higher expression of cyclin d1 is associated with a good treatment response in npc patients. keywords: cyclin d1, nasopharyngeal cancer, treatment response. introduction nasopharyngeal cancer (npc) is the most common type of head and neck cancer in indonesia (28.4% cases). in 2012–2015, there were 878 npc patients at cipto mangunkusumo general hospital.1 the incidence of npc is about 12,000 cases/year. npc is mostly diagnosed in the locally advanced and advanced stages of the disease (30.1% and 18.9%).1 treatment of this stage is chemotherapy and radiotherapy.2 the stage of the disease and the lymph nodes’ involvement are some factors proven associated with patient survival.1,3 however, patients with the same stage of the disease exhibited different results in terms of disease progression, treatment response, and recurrence rate, likely due to the different characteristics of molecular biology that are not included in stage determination.4 cyclin d1 is a protein involved in cell cycle progression from the g1 to the s phase. it is encoded by the ccnd1 gene located in chromosome 11q13. 5 it binds to cdk 4/6, activating rb protein. the transcription factor e2f will be released from rb protein, obliterating its repressive trait against cyclin e transcription. the upregulation of cyclin e will be followed by binding between cyclin e and cdk 2, initiating the s phase.6 therefore, the overexpression of cyclin d1 will shorten phase g1 of the cell cycle.4 the overexpression of cyclin d1 has been found in many cancers, but studies regarding the association between the expression level of cyclin d1 and chemotherapy response, until now, have shown a different results. some studies reported that npc7 and bladder cancer8,9 with an overexpression of cyclin d1 have a better response to induction chemotherapy with cisplatin. meanwhile, other studies of germ cell tumors,10 pancreatic cancer,11 and head and neck cancer10 give an opposite results. in indonesia, data concerning the cyclin d1 expression in npc do not yet exist. therefore, in this study, we examine the proportion of cyclin d1 in npc and its association with treatment response. methods this retrospective cohort study included all npc patients at cipto mangunkusumo general hospital from 2015 until 2018. patient data were collected based on medical records. the inclusion criteria were: an age greater than 18 years, histopathological results showing npc, diagnosis as stage iv b npc, completion of six series of cisplatin–fluorouracil (5fu) chemotherapy or discontinuation after three cycles due to progressive disease in treatment. patients with incomplete medical records, with incomplete treatment, and whose chemotherapy schedule was delayed more than 21 days or their imaging evaluation was not done in eight weeks post-chemotherapy were excluded from this study. the response to treatment was reviewed based on the response evaluation criteria in solid tumors (recist) 1.1 criteria by staff of the radiology department of the faculty of medicine, universitas indonesia/ cipto mangunkusumo general hospital. the immunohistochemistry examination was conducted in the department of pathological anatomy of the faculty of medicine, universitas indonesia/cipto mangunkusumo general hospital. a paraffin block of advanced npc patients that matched the inclusion criteria and not vol 52 • number 2 • april 2020 the difference in the cyclin d1 expression in advanced stage nasopharyngeal 149 the exclusion criteria were reviewed using h e m a t o x y l i n a n d e o s i n ( h & e ) s t a i n i n g to ensure the results of histopathological examination showed npc. then, cyclin d1 immunohistochemistry staining was carried out at room temperature (25°c) by antigen retrieval methods using the cyclin d1 novocastratm monoclonal antibody. the staining was read together with a supervisor using an olympus microscope. each preparation was chosen for 10 locations that were considered representations of the preparation (figure 1). each was assessed using the h-score method by using the imagej 1.50i application. the sample size was calculated using a comparison of the two means test formula, and we obtained a minimum sample size of 16 subjects in each group. the data will be recorded in the case record form and then entered into the spss program version 23. the unpaired t-test or mann– whitney analysis was performed to determine the mean difference between the two groups, depending on the data distribution. then, a cut-off score was determined to divide the expression of cyclin d1 into positive or negative; thus, the mean difference of each group could be determined. the study was conducted under ethical clearance no. 1224/un2.f1/etik/2018 from ethical commission faculty of medicine university of indonesia. results out of 84 registered subjects with npc, 34 subjects’ data were incomplete and they did not undergo complete treatment, having an incomplete initial imaging examination, delayed chemotherapy for more than three weeks, or not come back for treatment. nineteen of the rest 50 subjects were excluded because their paraffin block could not be found. finally, 31 subjects were included in the study. clinical characteristics of subjects the clinical characteristics of the subjects, including demographic data, clinical profiles, and treatment responses, are shown in table 1. the majority of subjects were men and they lived outside jakarta. the chief complaint of the subjects was mostly a mass in the neck (58.1%). the mean age of the subjects when diagnosed was 44.87 years. in this study, majority of the subjects had complained the symptoms for >6 months before definitive diagnosis was established (64.5%). who-iii was the most common histopathological finding (93.6%). more than half of the subjects had t4 and n3 disease (64.5 and 54.8%, respectively). bone is the most common organ affected by metastasis. most subjects only have one metalocation. six subjects had metastases in more than one organ, three subjects had metastases in the bone and lung, and two subjects had metastases in the bone and liver. as well, one subject had metastasis locations in the bones, liver, and lungs. in addition, there was one subject with a meta-location on the skin. all study subjects received a chemotherapy regimen using cisplatin–5fu at the first administration. patients who experienced figure 1. results of cyclin d1 immunohistochemical examination. (a) immunohistochemical features of subjects with positive cyclin d1 expression. (b) immunohistochemical features of subjects with negative cyclin d1 expression. cosphiadi irawan acta med indones-indones j intern med 150 decreased kidney function (egfr <60 ml/ min/1.73 m2) during treatment were given carboplatin in place of cisplatin. distribution of subjects based on treatment response based on the treatment response using the recist 1.1 criteria, 1 subject with had complete response, 13 subjects partial response, 9 subjects had a stable disease, and 8 subjects had a progressive disease. based on the treatment response, the subjects were divided into two groups: respond (partial and complete response) and not respond (stable disease or progressive disease). fourteen subjects (45.2%) were classified as respond and 16 subjects (54.8%) did not respond. c y c l i n d 1 e x p r e s s i o n a n d tr e a t m e n t response the assessment was carried out by assessing the percentage of cells that had the cyclin d1 expression and the degree of intensity of the cyclin d1 expression compared to positive controls (figure 1). an assessment of the cyclin d1 expression used the h-score method. after obtaining the h-score for all subjects, the cutoff value was determined using the (receiver operating characteristic) roc curve of the entire study sample. from 31 subjects, we reported 15 subjects with positive cyclin d1 expression. this study reported that higher proportion of cyclin d1 positive was noted in respond group compared with not respond (66.7% vs. 33.3%, p = 0.032). the mean h-score also significantly different between respond and non-respond (116.24 (sd 57.80) vs. 77.97 (sd 45.27), p<0.05). discussion this study included homogeneous subjects of stage iv b npc patients. however, patients with the same stage had different responses to the treatment and recurrence rate.3,12 based on the clinical conditions, most also had the same characteristics; for example, all subjects had a good performance status or either 0 (80.6%) or 1 (19.4%), because the requirement to get a combination chemotherapy is a good performance status (0 or 1). recondo et al.13 table 1. clinical characteristics of the subjects. subjects characteristics n (%) age, mean (sd) 44.87 (13.964) gender, male 27 (87.1) performance status (ecog) 0 25 (80.6) 1 6 (19.4) domicile jakarta 11 (35.5) outside jakarta 20 (64.5) smoking habit 11 (35.5) duration of chief complaint >6 months 20 (64.5) ≤6 months 11 (35.5) signs and symptoms mass in the neck 29 (93.5) olfactory disturbance 21 (67.7) visual disturbance 13 (41.9) ear disturbance 17 (54.8) neurology symptoms 3 (9.7) pain 20 (64.5) histopathology who-i 1 (3.2) who-ii 1 (3.2) who-iii 29 (93.6) stage t t2 7 (22.6) t3 4 (12.9) t4 20 (64.5) stage n n0 1 (3.2) n1 1 (3.2) n2 12 (38.7) n3 17 (54.8) metastasis location liver 3 (9.7) lung 7 (22.6) bone 28 (90.3) amount of metastasis 1 location 25 (80.7) >1 location 6 (19.3) comorbidity hypertension 1 (3.2) diabetes mellitus 1 (3.2) heart disease 0 (0.0) renal disease 0 (0.0) number of cycle cisplatin used cisplatin <4x 3 (9.6) cisplatin ≥4x 27 (90.4) vol 52 • number 2 • april 2020 the difference in the cyclin d1 expression in advanced stage nasopharyngeal 151 reported that a performance status of 0 or 1 is related to a good response to treatment. the presence of other comorbidities that could affect the patient’s condition, such as diabetes mellitus and hypertension, were assessed. the subjects of this study mostly (93.6%) did not have comorbidities. subjects in this study mostly lived outside jakarta (64.5%), which reflected that this study not only described patients living in jakarta, but it also described patients from various regions. this was possible because cipto mangunkusumo hospital is a national referral center with adequate facilities for the management of npc, especially diagnostic facilities (mri) and treatment (radiotherapy). the majority of subjects were men (87.1%) and the average age of the subjects at the time of diagnosis was 44.87 years. this was in accordance with the literature and previous research in indonesia, that cases of npc were dominated by men.14 adham et al.15 reported that men were 2.4 times more likely to have npc than women. hayati et al.1 also reported in 2017 that men (73.8%) were more likely than women to be diagnosed with npc, with a median age at diagnosis of 46 years. most of the subjects came after the chief complaint lasted more than six months. jayalie et al.16 conducted a study of npc patients in cipto mangunkusumo general hospital and reported that more than half of the subjects had a complaint duration of six months or less before a diagnosis was made. it differs from this study because in this study, the subjects included were patients with the stage of metastasis. in this stage, the duration of complaints was longer than in the lower stage.16 the chief complaint that brought them to a health facility was a mass in the neck, and other complaints included a nasal disorder (nasal congestion, nosebleeds) and impaired vision (double vision, decreased vision), similar to the results of jayalie et al.16 in this study, the location of metastasis in most subjects (90.3%) was the bone, followed by the lungs and liver. this is in accordance with the literature, which states that bone is the most common metastatic location in npc.17,18 in this study, some subjects experienced a decline in kidney function (egfr <60 ml/ min/1.73 m2), so cisplatin was replaced with carboplatin. cisplatin is the main choice in patients with head and neck cancers, but its toxicity to the kidney limits its use. several studies have shown that carboplatin in head and neck cancers, including npc, exhibits the same efficacy. a non-inferiority study in thailand involving 206 locally advanced stage npc patients reported the same efficacy between cisplatin and carboplatin in concurrent or adjuvant administration.19 kua et al.20 reported that the response rate of carboplatin did not differ from that of cisplatin. based on these data, the use of carboplatin is not inferior to the use of cisplatin as an alternative for individuals with renal impairment. proportion of the cyclin d1 expression in this study, most subjects (48.4%) had a positive cyclin d1 expression. studies that assessed the cyclin d1 expression in npc are limited. various studies in the west included the categorization of npc into squamous neck and head cell carcinoma. the results of this study show a higher expression than previous publications abroad, which showed that 30–50% of cases had a cyclin d1 expression.4 this study showed similar result. hwang et al.21 also reported that the expression of cyclin d1 in npc patients who experienced recurrence was 66%. the increase in the cyclin expression in cancer can be caused by the amplification of the ccnd1 gene, the translocation of the ccnd1 gene (t11.14) (q13; q32), or a cyclin d1 protein degradation defect.22 most of the increase in the cyclin d1 expression is caused by ccnd1 gene amplification. increasing the ccnd1 gene promoter plays a role in amplification, such as of nf-κb, pi3k-akt, egfr, and the β-cateninlef1 pathway.23 an increased expression of cyclin d1 in cancer can be stimulated by various growth factors. a study on prostate cancer showed that an excessive expression of egfr would cause an increase in the number of mrna and cyclin d1 protein. breast cancer that has the her2 expression will also be associated with an increase in the cyclin d1 expression.23 the cosphiadi irawan acta med indones-indones j intern med 152 expression of lmp1 due to an ebv infection in nasopharyngeal squamous cells will be followed by the expression and phosphorylation of egfr. in npc, 60–90% of cases have the egfr expression. this was followed by the upregulation of the cyclin d1 gene promoter through an increase in heterodimer c-jun/jun b.24 the high proportion of metastatic npc subjects who have the cyclin d1 expression provides an opportunity for drugs to work on the cyclin d-cdk4/6 pathway to inhibit tumor proliferation. until now, the study of cdk 4/6 inhibitors in npc has been limited. hsu et al.25 conducted a palbociclib administration test in animals with amplified ccnd1 gene npc, showing the effect of inhibiting tumor growth and reducing ebv titers. jiao et al.26 provided a case report on npc patients with pulmonary metastasis and an excess amplification of cdk 4/6 who were given palbociclib, and they showed a partial response after 6 months of treatment. they triggered further research regarding the use of palbociclib in advanced npc patients. c y c l i n d 1 e x p r e s s i o n a n d tr e a t m e n t response the group of subjects who responded to treatment had a higher proportion of the cyclin d1 expression than the group of subjects who did not respond. this is contrary to the previous studies of noel et al10 and biliran et al11, which states that the cyclin d1 expression is higher in npc patients who do not respond compared to those who do respond to treatment. nonetheless, these results are supported by several other studies. in vitro study of akervall et al.27 showed that the mean concentration inhibiting growth of 50% of the cells (id50) was lower in cell lines with higher cyclin d1 expression. seiler et al.8 conducted a study on bladder cancer and reported that the cyclin d1 expression in the lymph nodes demonstrated a good response to platin-based chemotherapy compared to a group of subjects who had a negative/weak cyclin d1 expression. the paradoxical effect of cyclin d1 on dna repair several studies explain the ambiguous/ paradoxical effect of cyclin d1. different types of cancer cells can influence the different roles of cyclin d1 in response to the administration of cytostatic drugs, although the mechanism underlying these responses is still unknown.28 a highly excessive expression of cyclin d1 is reported to cause chromosomal instability in some cancers (breast, neck, head cancer) because they are forced to enter the s phase immediately, obstructing the dna repair process.22 an excessive expression of cyclin d1 also can trigger an excessive expression of protein in the dna repair process. the excessive stimulation of rad51 will cause toxicity to dna, causing a disruption to the dna repair mechanism and dna instability.22 richardson et al.29 reported that an excessive rad51 expression would lead to genome instability due to aneuploid chromosome formation and changes to the chromosome arrangement. some reports identify differences in the cyclin d1 response to the degree of dna damage. severe dna damage, such as due to chemotherapy or high-dose radiation, will be followed by a sharp decrease in cyclin d1 levels, which will prevent cells from entering the s phase. this will cause cells to stop proliferation and die. meanwhile, the low degree of dna damage is not enough to decrease cyclin d1 levels sharply, so the cell continues to divide. with low-grade dna damage, cyclin d1 will be found in the cell nucleus, and it has a role in dna repair activity. in addition, cyclin d1 will activate the expression of the dna repair protein, rad51.22 myklebust et al.30 also reported that an increase in the cyclin d1a and d1b isoforms had a different response to 5-fluorouracil. in the study, it was reported that the expression of the cyclin d1a isoform in colorectal cancer subjects receiving 5-fluorouracil responded better to treatment than subjects with the cyclin d1b expression. this can occur because of an imbalance between the ability of dna repair and synthesis.23 strengths and limitations of research this study is the first to assess the cyclin d1 expression, specifically in cases of metastatic npc in indonesia. informations obtained from this study can be a further basis for our understanding of the cyclin d1 pathway in the biology process of npc. this study has a limitation in that until vol 52 • number 2 • april 2020 the difference in the cyclin d1 expression in advanced stage nasopharyngeal 153 now, the cut-off value to determine the cyclin d1 expression as positive has not been agreed upon in the international community. conclusion cyclin d1 positive were expressed in half of advanced npc subjects (48.4%). there are significant mean differences in the cyclin d1 expression between the group of subjects who responded compared with who did not respond to platinum 5fu (p = 0.048). further studies are needed to clarify the paradoxical effects of cyclin d1 in npc focusing the mechanism that explaining this finding. studies still needed before cyclin d1 could be widely used as predictor for chemotherapy response in advanced npc. conflict of interest the authors declare that there is no conflict of interest concerning the publication of this paper. acknowledgments this work is supported by hibah pitta 2018 funded by drpm universitas indonesia no.2060/un2.r3.1/hkp.05.00/2018. references 1. faisal hh. analisis kesintasan dan faktor yang berperan pada pasien kanker nasofaring di departemen tht rsupn dr. cipto mangunkusumo [thesis]. [jakarta]: universitas indonesia; 2017. 2. wildeman ma, fles r, herdini c, indrasari rs, vincent ad, tjokronagoro m, et al. primary treatment results of nasopharyngeal carcinoma (npc) in yogyakarta, indonesia. plos one. 2013;8(5):e63706. 3. ren y, qiu h, yuan y, et al. evaluation of 7th edition of ajcc staging system for nasopharyngeal carcinoma. j cancer. 2017;8(9):1665–72. 4. dhingra v, verma j, misra v, srivastav s, hasan f. evaluation of cyclin d1 expression in head and neck squamous cell carcinoma. j clin diagn res. 2017;11(2):ec01–ec4. 5. gioacchini fm, alicandri-ciufelli m, kaleci s, magliulo g, presutti l, re m. the prognostic value of cyclin d1 expression in head and neck squamous cell carcinoma. eur arch otorhinolaryngol. 2016;273(4):801–9. 6. li y, barbash o, diehl ja. regulation of the cell cycle. in: mendelsohn j, gray jw, howley pm, israel ma, thompson cb, editors. the molecular basis of cancer. philadelphia: elsevier; 2015. p. 165–78. 7. akervall j, brun e, dictor m, wennerberg j. cyclin d1 overexpression versus response to induction chemotherapy in squamous cell carcinoma of the head and neck--preliminary report. acta oncol. 2001;40(4):505–11. 8. seiler r, thalmann gn, rotzer d, perren a, fleischmann a. ccnd1/cyclind1 status in metastasizing bladder cancer: a prognosticator and predictor o f c h e m o t h e r a p e u t i c r e s p o n s e . m o d p a t h o l . 2014;27(1):87–95. 9. ngo bt, felthaus j, hein m, et al. monitoring bortezomib therapy in multiple myeloma: screening of cyclin d1, d2, and d3 via reliable real-time polymerase chain reaction and association with clinicopathological features and outcome. leuk lymphoma. 2010;51(9):1632–42. 10. noel ee, yeste-velasco m, mao x, et al. the association of ccnd1 overexpression and cisplatin resistance in testicular germ cell tumors and other cancers. am j pathol. 2010;176(6):2607–15. 11. biliran h, jr., wang y, banerjee s, et al. overexpression of cyclin d1 promotes tumor cell growth and confers resistance to cisplatin-mediated apoptosis in an elastase-myc transgene-expressing pancreatic tumor cell line. clin cancer res. 2005;11(16):6075–86. 12. american joint committee on cancer. 8th edition implementation project 2018 [internet]. [cited 2018 15 october]. available from: https://cancerstaging. org/8thedimplementation/pages/default.aspx. 13. recondo g, armand jp, tellez-bernal e, et al. recurrent and/or metastatic head and neck squamous cell carcinoma: a clinical, univariate and multivariate analysis of response and survival with cisplatin-based chemotherapy. laryngoscope. 1991;101(5):494–501. 14. wei wi, sham js. nasopharyngeal carcinoma. lancet. 2005;365(9476):2041–54. 15. adham m, kurniawan an, muhtadi ai, et al. nasopharyngeal carcinoma in indonesia: epidemiology, incidence, signs, and symptoms at presentation. chin j cancer. 2012;31(4):185–96. 16. jayalie vf, paramitha ms, jessica, et al. profile of nasopharyngeal carcinoma in cipto mangunkusumo national hospital, 2010. ejki. 2016;4(3):156–62. 17. shen l, dong j, li s, et al. m1 stage subdivision and treatment outcome of patients with bone-only metastasis of nasopharyngeal carcinoma. oncologist. 2015;20(3):291–8. 18. chan j, pilch b, kuo t, wenig b, lee a. tumours of the nasopharynx. in: barnes l, eveson jw, reichart p, sidransky d, editors. world health organization pathology and genetics of head and neck tumours. lyon: iarc press; 2005. p. 83–97. 19. chitapanarux i, lorvidhaya v, kamnerdsupaphon p, et al. chemoradiation comparing cisplatin versus carboplatin in locally advanced nasopharyngeal cancer: randomised, non-inferiority, open trial. eur j cancer. 2007;43(9):1399–406. cosphiadi irawan acta med indones-indones j intern med 154 20. kua vf, ismail f, phua vce, aslan nm. carboplatin/5fluorouracil as an alternative to cisplatin/5-fluorouracil for metastatic and recurrent head and neck squamous cell carcinoma and nasopharyngeal carcinoma. asian pac j cancer prev. 2013;14(2):1121–6. 21. hwang cf, cho cl, huang cc, et al. loss of cyclin d1 and p16 expression correlates with local recurrence in nasopharyngeal carcinoma following radiotherapy. ann oncol. 2002;13(8):1246–51. 22. jirawatnotai s, sittithumcharee g. paradoxical roles of cyclin d1 in dna stability. dna repair (amst). 2016;42:56–62. 23. qie s, diehl ja. cyclin d1, cancer progression, and opportunities in cancer treatment. j mol med (berl). 2016;94(12):1313–26. 24. xu y, shi y, yuan q, et al. epstein-barr virus encoded lmp1 regulates cyclin d1 promoter activity by nuclear egfr and stat3 in cne1 cells. j exp clin cancer res. 2013;32:90. 25. hsu c-l, lui k-w, chi l-m, et al. integrated genomic analyses in pdx model reveal a cyclin-dependent kinase inhibitor palbociclib as a novel candidate drug for nasopharyngeal carcinoma. j exp clin cancer res. 2018;37(1):233. 26. jiao x-d, liu k, qin b-d, et al. palbociclib for the treatment of metastatic nasopharyngeal carcinoma with cdk4 amplification: a case report. jco precis oncol. 2019;(3):1–4. 27. akervall j, kurnit dm, adams m, et al. overexpression of cyclin d1 correlates with sensitivity to cisplatin in squamous cell carcinoma cell lines of the head and neck. acta otolaryngol. 2004;124(7):851–7. 28. sun y, luo d, liao dj. cyclind1 protein plays different roles in modulating chemoresponses in mcf7 and mdamb231 cells. j carcinog. 2012;11:12. 29. richardson c, stark jm, ommundsen m, jasin m. rad51 overexpression promotes alternative doublestrand break repair pathways and genome instability. oncogene. 2004;23(2):546–53. 30. myklebust mp, li z, tran th, et al. expression of cyclin d1a and d1b as predictive factors for treatment response in colorectal cancer. br j cancer. 2012;107(10):1684–91. 14 original article acta med indones indones j intern med • vol 52 • number 1 • january 2020 identia registry: incidence of deep vein thrombosis in medically ill subjects at high risk in indonesia: a prospective study karmel l. tambunan1, johan kurnianda2, catharina suharti3, shinta o. wardhani4, lugyanti sukrisman5, noorwati sutandyo6, ni made r.a. rena7, nusirwan acang8, andi f. benyamin9, m. d. prenggono10, dairon gatot11, trinugroho h. fadjari12, j. pandelaki13 1 department of internal medicine, cikini hospital and universitas indonesia, jakarta, indonesia. 2 department of internal medicine, faculty of medicine universitas gadjah mada dr. sardjito hospital, yogyakarta, indonesia. 3 department of internal medicine, faculty of medicine, diponegoro university dr. kariadi hospital, semarang, indonesia. 4 department of internal medicine, faculty of medicine, brawijaya university dr. saiful anwar hospital, malang, indonesia. 5 department of internal medicine, faculty of medicine universitas indonesia dr. cipto mangunkusumo hospital, jakarta, indonesia. 6 department of internal medicine, faculty of medicine universitas indonesia dharmais cancer hospital, jakarta, indonesia. 7 department of internal medicine, faculty of medicine, udayana university sanglah hospital, denpasar indonesia. 8 department of internal medicine, faculty of medicine, andalas university dr. m. djamil general hospital, padang, indonesia. 9 department of internal medicine, faculty of medicine, hasanuddin university hospital, makassar, indonesia. 10 department of internal medicine, faculty of medicine, lambung mangkurat university ulin hospital, banjarmasin, indonesia. 11 department of internal medicine, faculty of medicine, sumatera utara university h. adam malik hospital, medan, indonesia. 12 department of internal medicine, faculty of medicine, padjadjaran university dr. hasan sadikin hospital, bandung, indonesia. 13 department of radiology, faculty of medicine universitas indonesia dr. cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: catharina suharti, md., phd. division of hematology medical oncology, department of internal medicine, faculty of medicine, diponegoro university dr. kariadi hospital. jl. dr. sutomo no. 16, semarang, indonesia. email: catharina.suharti@yahoo.com. abstrak latar belakang: pasien rawat inap dengan penyakit medis berisiko terjadinya trombosis vena dalam (tvd) dan akibatnya terjadi peningkatan risiko mortalitas. di indonesia, terdapat disparitas fasilitas pelayanan medis dan terbatasnya data insidens tvd di negara beragam etnisitas dan geografi yang unik dengan populasi yang besar ini. maka, kami mengeksplorasi insidens tvd dan skor wells rerata pada pasien rawat inap dengan vol 52 • number 1 • january 2020 identia registry: incidence of deep vein thrombosis in medically ill subjects 15 penyakit medis yang berisiko tinggi. metode: pada studi registri multisenter, prospektif, observasional di indonesia, subyek (usia > 40 tahun) dengan penyakit medis akut (seperti kanker, infeksi akut, atau penyakit respiratori berat) dan tirah baring total selama > 3 hari diikutsertakan dalam studi ini antara januari 2016 dan november 2017. data mengenai riwayat penyakit, skor wells, diagnosis tvd dengan compression ultrasonography (cus) diambil. insidens tvd dianalisa pada kelompok eligible dan evaluable. data dianalisa menggunakan metode deskriptif. hasil: dari 360 subyek, 334 dianalisa sebagai kelompok eligible. compression ultrasonography tidak dapat dilakukan pada 26 subyek. sehingga, 308 subyek yang menyelesaikan prosedur studi dianalisa sebagai kelompok evaluable. etnis jawa merupakan etnis terbanyak pada kelompok eligible dan obesitas merupakan riwayat medis tersering. secara keseluruhan, insidens tvd pada kelompok eligible dan evaluable sebesar masing – masing 37,1% dan 40,3%. skor wells rerata (sb) sebesar 3 (1,20) dan durasi tirah baring rerata selama 9 (6,89) hari. kesimpulan: studi ini menemukan insidens tvd yang tinggi pada pasien penyakit medis di indonesia dan memberikan masukan baru mengenai kewaspadaan tvd di indonesia. kata kunci: trombosis vena dalam, insidens, penyakit medis. abstract background: medically ill hospitalized patients are at risk of deep vein thrombosis (dvt) and consequentially have high chances of mortality. in indonesia, there is disparity in healthcare facility and data on incidence of dvt in this multi-ethnic, geographically unique country with large population are limited. hence, we determined the incidence of dvt and evaluated mean wells score among medically ill hospitalized persons at increased risk. methods: in this multicenter, prospective, observational registry in indonesia, subjects (age >40 years) with acute medical illness (like cancer, acute infection, or severe respiratory disease) confined to bed for >3 days were enrolled between january 2016 and november 2017. data for medical history, wells score, and dvt diagnosis with compression ultrasonography (cus) were recorded. dvt incidence was analyzed in eligible and evaluable groups. data were analyzed by descriptive method. results: out of 360 subjects enrolled, 334 were included in the eligible group for analyses. cus could not be performed in 26 subjects. thus, 308 subjects who completed the study were included in the evaluable group. javanese were predominant in the eligible group and obesity was the most common medical history at presentation. overall, incidence of dvt in eligible and evaluable patients was 37.1% and 40.3%, respectively. mean (sd) wells score and bedridden days were 3 (1.20) and 9 (6.89), respectively. conclusion: this study indicated that the incidence of dvt is high in medically ill patients in indonesia and will provide new insights and awareness about dvt in indonesia. keywords: deep vein thrombosis, incidence, medically ill. introduction venous thromboembolism (vte) is a common cause of preventable morbidity and mortality in medically ill patients1, and deep vein thrombosis (dvt) with pulmonary embolism (pe) is associated with high mortality rate.2 the frequency of dvt without prophylaxis varies from 10% to 26%. pe is accountable for up to 10% in-hospital mortality, and 75% of fatal pe cases occur in medically ill patients.3 owing to the lack of robust literature on asian population, it was earlier believed that the incidence of vte was higher in the caucasian population.4 however, recent literature shows that asian countries account for considerable global vte-related burden and in terms of incidence, it is comparable to the west. the incidence of vte in asia is significant and rising among hospitalized medically ill patients.5 population-wide estimates of annual vte rates in three asian countries: korea, taiwan, and hong kong, range from 15% to 20% of the level recorded in the western countries.6 deep vein thrombosis can occur without symptoms, and affected patients may have minimal or atypical symptoms; even patients without thrombotic disorders may present clinical features suggestive of dvt. only 25% karmel l. tambunan acta med indones-indones j intern med 16 of those with dvt symptoms have a confirmed diagnosis of dvt on objective testing.7 the wells scoring system is a clinical model widely used to assess the risk of dvt or pe in medically ill patients.8,9 the american college of chest physicians guidelines recommend initial testing with compression ultrasonography (cus) for moderate and high pretest probability of the firsttime dvt of the lower extremity, especially if the patients have a comorbid condition associated with elevated d-dimer levels and are likely to have a false-positive result.10 one of the major challenges in medically ill patients at risk of vte is significant underutilization of thromboprophylaxis.11-13 in asia, underutilization of thromboprophylaxis is attributed to the notion that the incidence of vte in asians is lower than that in caucasians.5 a prospective disease registry in indonesia documents underutilization of anticoagulants in acute medically ill patients at the risk of vte.14 therefore, understanding the true incidence of vte in asian countries could improve the rate of vte thromboprophylaxis in clinical practice. indonesia, a geographically unique country with large multi-ethnic population, has disparate healthcare facilities.15 to the best of our knowledge, no national-level data are available on dvt incidence in medically ill patients at high risk in indonesia to help physicians evaluate and develop or adopt a standard-of-care for the benefit of patients with dvt. hence, we conducted the identia registry to determine the incidence of dvt and evaluate the mean of wells score among hospitalized medically ill patients at increased risk. methods identia was a multicenter prospective observational study conducted in indonesia between january 2016 and november 2017. the study duration for each patient was approximately 1–3 days, with either 1 or 2 visits depending on the wells score of the patient. patients with wells score ≥2 had two mandatory visits: first a baseline visit and second within 3 days for cus to confirm dvt. the study was conducted as per the guiding principles detailed in the 18th world medical assembly (declaration of helsinki, 1964) and its subsequent amendments, the guidelines for good epidemiology practice (us and european), and the applicable local regulations. this study has been approved by the ethical committee of faculty of medicine, diponegoro university kariadi hospital, semarang (reference number: 346/ec/fk-rsdk/2015). subjects considering the incidence of dvt to be 15%3 and assuming a dropout rate of 15%, 360 patients were required to ensure 95% confidence interval. this would allow a minimum of 306 evaluable patients from 12 centers (1 private general hospital, 10 government general hospitals, and 1 cancer hospital) across indonesia. the number and geographic distribution of centers and the number of patients included in this study were representative of the population in indonesia. inclusion and exclusion criteria patients, >40 years of age; with acute illness such as heart failure new york heart association class iii or iv, severe respiratory disease, stroke, acute infections, or cancer; completely immobilized and confined to bed for >3 days, willing to sign the informed consent; were included. patients, with a history of coagulation disorders (e.g., hemophilia, antiphospholipid syndrome, von willebrand’s disease, and thrombophilia); suffering from thrombocytopenia (platelet count <50000/µl on the day of signing informed consent); had undergone surgery; or had received antithrombotic drugs; or if pregnant; were excluded. data collection and analysis at visit 1 (baseline visit): the informed consent was obtained, the eligibility criteria assessed, and the patient’s demographic data, reason for hospitalization, signs and symptoms of dvt, and wells score were recorded. at visit 2 (baseline visit–day 3): the signs and symptoms of dvt and diagnosis of dvt based on cus were recorded. the diagnosis of dvt was confirmed if one or more of the following criteria were observed during the cus examination: lack of complete compressibility of vein; visualization of intraluminal thrombus with complete or partial vol 52 • number 1 • january 2020 identia registry: incidence of deep vein thrombosis in medically ill subjects 17 obstruction of the vein lumen; distention of the vein compared to the adjacent artery; abnormal venous doppler signals, i.e., continuous nonphasic flow, reduced or absent flow with distal augmentation, or no obtainable signal; and continuous, non-phasic flow in common femoral vein (cfv) unilaterally, with phasic flow in contralateral cfv, suggesting iliac vein outflow obstruction, i.e., dvt of extrinsic compression.16 all radiologists who performed the cus in this study were briefed to standardize the examination process. patients who were eligible for visit 2, but could not complete the cus examination and for whom no endpoint data were available, were considered as dropouts. patients were stratified into two risk categories: “dvt likely” if the wells score was ≥2 and “dvt unlikely” if the wells score was <2. dvt was confirmed if the pretest probability was intermediate or high, and the cus result was positive; when the clinical suspicion was low, and the cus result was negative, presence of dvt was ruled out. statistical analysis incidence of dvt was estimated in the eligible and evaluable patient groups. eligible group consisted of all patients who enrolled in the registry. evaluable group consisted of all patients who provided informed consent and completed visit 1 but did not qualify for visit 2; or those who qualified for visit 2 and completed cus. quantitative variables were presented using descriptive statistics, while qualitative variables were summarized using frequencies and percentages. statistical analyses were performed using sas (version 9.4; sas institute inc., cary, nc, united states). all data were analyzed in an explorative manner. data were summarized using mean, median, standard deviation (sd), and range for continuous parameters; and counts and percentages for categorical parameters. results of the 360 patients enrolled, 26 were not eligible. among 334 eligible patients, cus was not performed in 26 at visit 2 (due to patient’s limitations or for other reasons), and hence were excluded from the evaluable group (n=308). (figure 1) eligible n=334 evaluable n=308 enrolled n=360 ineligible n=26 dropout n=26 figure 1. subject disposition table 1. demographic information and baseline characteristics variables eligible subjects(n=334) age (year) mean (sd) 60.00 (11.34) median (min, max) 59 (40.0, 96.0) gender, n (%) men 153 (45.81) women 181 (54.19) height (cm) n 325 mean (sd) 159.00 (8.05) weight (kg) n 317 mean (sd) 53.00 (12.86) bmi n 317 mean (sd) 21.00 (4.27) ethnicity, n (%) javanese 171 (51.20) bataknese 29 (8.68) balinese 22 (6.59) minangkabau 22 (6.59) chinese 20 (5.99) sundanese 16 (4.79) banjarnese 11 (3.29) buginese 8 (2.40) betawi 7 (2.10) makassar 7 (2.10) malay 5 (1.50) other*, n (%) 16 (4.79) past medical history, n (%) obesity 14 (4.2) hormone therapy 7 (2.1) history of previous venous thromboembolism 2 (0.6) varicose vein 1 (0.3) karmel l. tambunan acta med indones-indones j intern med 18 the study comprised 45.81% (n=153) men and 54.19% (n=181) women; the mean (sd) age was 60.00 (11.34) years (table 1). javanese (n=171; 51.20%) was the major ethnic group followed by bataknese (n=29; 8.68%). the most common past medical history was obesity (n=14; 4.2%), and the most common acute illness was cancer (table 1). incidence of dvt and mean of wells score compression ultrasonograpgy (cus) was performed in 268 (80.2% of eligible and 87.0% of evaluable population) patients with wells score ≥2. overall, 124 subjects had confirmed dvt (37.1% of eligible and 40.3% of evaluable table 1. demographic information and baseline characteristics variables eligible subjects(n=334) diagnosis of medically ill subjects (n=334)** cancer 217 acute infection 154 severe respiratory disease 24 stroke 19 heart failure nyha class iii/iv 13 bmi, body mass index; max, maximum; min, minimum; n, total number of subjects; n, total number of eligible subjects; sd, standard deviation. other*=manado, palembang, flores, melanesia, ambonese, dayak, irian jaya, mongondow, ternate, toraja. **each subject probably had more than 1 diagnosis. table 2. incidence of dvt according to acute illnesses in eligible population diagnosis (eligible subjects, n=334) dvt (n=124) without dvt (n=184) dropouts (n=26) cancer 92 104 21 acute infection 50 91 13 severe respiratory disease 5 19 0 stroke 7 11 1 heart failure nyha class iii/iv 4 7 2 each subject probably had more than 1 diagnosis population). most patients with dvt had either cancer or acute infection (table 2). the mean (sd) wells score was similar among the two groups: 3 (1.20) for eligible and 3 (1.18) for the evaluable group. a wells score of 2 was most commonly noted among patients (144 [43.1%] in the eligible group and 132 [42.9%] patients in the evaluable group). the highest wells score of 7 was noted in 2 (0.6%) patients from the eligible and in 1 (0.3%) patient in the evaluable group (table 3). data on incidence of dvt when stratified by wells score, indicated a probable trend with increasing dvt incidence with a corresponding increase in wells score 2 to 5 (table 4). duration of immobilization and incidence of dvt in eligible group during hospitalization, patients were immobile for a minimum of 2 days and a maximum of 38 days. the average duration of the patients’ confinement to the hospital bed table 3. two-level dvt wells score in the evaluable group evaluable (n=308) wells score n 308 mean (sd) 3.00 (1.18) median (min, max) 2 (1.0, 7.0) clinical probability simplified score, n (%) dvt likely (wells score ≥2) 268 (87.0) dvt unlikely (wells score <2) 40 (13.0) wells score, n (%) 1 40 (13.0) 2 132 (42.9) 3 80 (26.0) 4 30 (9.7) 5 18 (5.8) 6 7 (2.3) 7 1 (0.3) dvt, deep vein thrombosis; max, maximum; min, minimum; n, total number of patients; n, total number of evaluable patients; sd, standard deviation vol 52 • number 1 • january 2020 identia registry: incidence of deep vein thrombosis in medically ill subjects 19 was 9 (sd 6.89) days. majority of the patients were immobile for 4 days and the incidence of dvt among those patients was 40.2% (35/87) (table 5). signs and symptoms of dvt at visit 1 and visit 2 in eligible group overall, 40.1% (n/n=134/334) and 34.3% (n/n=37/108) patients at visit 1 and visit 2, respectively, had at least 1 sign or symptom of dvt. at both the visits, the most common sign and symptom was pitting edema confined to the symptomatic leg. other common signs and symptoms noted at both the visits were entire leg swelling, calf swelling of at least 3 cm larger than asymptomatic side, localized tenderness or pain along the distribution of deep venous system, erythema of the symptomatic leg, and collateral superficial veins (non-varicose) (table 6). signs and symptoms of dvt and cus results in eligible group out of 124 patients with positive cus, 50 (40.3%) did not have any sign and symptom of dvt. on the other hand, out of 144 (43.1%) patients with negative cus, 45 (31.3%) had signs and symptoms of dvt. correlation between past medical history and dvt incidence in eligible group there was no statistically significant correlation between the past medical history and the incidence of dvt. the incidence of dvt was 6.5% (8/124) in subjects with history of obesity (table 7). table 4. incidence of dvt among patients with wells score ≥2 wells score dvt incidence among medically ill patients at increased risk eligible=294 evaluable=268 n n (%) n n (%) 2 144 42 (29.2) 132 42 (31.8) 3 86 39 (45.3) 80 39 (48.8) 4 34 21 (61.8) 30 21 (70.0) 5 20 16 (80.0) 18 16 (88.9) 6 8 5 (62.5) 7 5 (71.4) 7 2 1 (50.0) 1 1 (100.0) overall 294 124 (37.1) 268 124 (40.3) dvt, deep vein thrombosis; n, total number of patients with incidence; n, total number of patients in each category. incidence rate: number of patients whose wells score was ≥2 and cus result was positive divided by the number of available patients in each category. percentage will be calculated from total number of patients available in each category as denominator. correlation between past medical history and wells score in eligible group there was no statistically significant correlation between the past medical history and the wells score. of the 294 patients, who had wells score ≥2, 13 (4.4%) patients had a history of obesity, while obesity was present in only 1 (2.5%) of the 40 patients from the wells score 1 group. overall, patients with medical history were mostly found in wells score ≥2 group than in the wells score 1 group (table 8). discussion this study showed a high incidence of dvt among medically ill patients in indonesia who are immobile (confined to bed for >3 days) and at an increased risk of vte. in another study, vte developed in 11% of patients who were at high risk of thrombosis and did not receive thromboprophylaxis.11 the incidence of dvt was 40.3% and is relatively higher than that reported in a recent systematic literature review including several asian countries.6 this finding might be explained by inclusion of high-risk medically ill patients. cancer, congestive heart failure, chronic obstructive pulmonary disease are some of the known high risk factors associated with dvt.17 other factors, such as high number of patients with wells score 2 or more, relatively older patients (mean age: 60 years), long duration of immobilization (mean duration of confinement to bed: 9 days), and the criteria of diagnosis using cus may have also karmel l. tambunan acta med indones-indones j intern med 20 contributed to the high incidence of dvt. the criteria for high-risk dvt used in the inclusion criteria of this registry is in line with the padua scoring system, a validated risk assessment model to identify subjects at potential risk of vte. reduced mobility for >3 days and acute medical condition are the 2 factors incorporated in this registry from the padua model to categorize high-risk subjects.11 in this study, the wells scoring system is used to assess the probability of dvt, and cus was performed for diagnosing dvt, whereas, the d-dimer test was not performed as it is considered to have a high negative predictive value and is useful in ruling out dvt. the mean wells score in our study is consistent with the result of a similar hospital-based prospective study that reported a score of 3.58 in subjects with clinical suspicion of dvt.18 the diagnosis of dvt was positive in both eligible and evaluable groups and there was an indication of corresponding increase in dvt with increasing wells score. this trend was similar to the linear trend observed between incidence of dvt and wells score in an earlier study that assessed the risk of dvt in patients with trauma, indicating that wells score is a valid pretest tool for risk stratification of dvt.19 a strong association between immobility and risk of venous thrombosis has been widely reported.20,21 confinement to bed for >3 days is one of the risk factors for acute dvt.22 in this study, the mean duration of confinement to bed during hospitalization was 9 days. most of the patients had an immobilization period of 4 days, and the incidence of dvt among these patients was >40%, signifying the risk status. the most common signs and symptoms observed in this registry were pitting edema and swelling in the entire symptomatic leg; both are established clinical variables to assess the probability of dvt.23 in the eligible group in our study, out of 124 patients with positive cus, 59.7% had signs and symptoms of dvt, while the remaining 40.3% showed no signs and symptoms. an earlier study reported 36.4% confirmed cases among those having signs and symptoms of dvt assessed by duplex ultrasonography.24 in our study, out of 144 eligible patients with negative cus, 31.3% had signs and symptoms of dvt. this could be suggestive of other clinical conditions having similar signs and symptoms. in general, wells table 5. duration of immobilization in current hospitalization and incidence of dvt (eligible group) duration of immobilization (days) dvt incidence among medically ill patients at increased risk eligible n=334 n (%) 2 3 2 (66.7) 3 9 4 (44.4) 4 87 35 (40.2) 5 43 14 (32.6) 6 28 8 (28.6) 7 17 5 (29.4) 8 18 5 (27.8) 9 27 8 (29.6) 10 8 2 (25.0) 11 9 5 (55.6) 12 13 6 (46.2) 13 10 3 (30.0) 14 9 4 (44.4) 15 5 1 (20.0) 16 6 3 (50.0) 17 3 1 (33.3) 18 2 0 (0) 19 5 2 (40.0) 20 3 2 (66.7) 21 4 1 (25.0) 22 3 2 (66.7) 23 3 2 (66.7) 24 1 0 25 5 4 (80.0) 26 1 0 (0) 28 1 0 (0) 30 4 1 (25.0) 31 1 0 32 2 1 (50.0) 33 1 1 (100.0) 34 1 1 (100.0) 36 1 0 (0) 38 1 1 (100.0) total 334 124 (37.1) dvt, deep vein thrombosis; n: total number of patients with incidence; n, total number of patients having duration of immobilization (days). incidence rate: number of patients whose wells score was ≥2 and cus result was positive divided by the number of available patients in each category. vol 52 • number 1 • january 2020 identia registry: incidence of deep vein thrombosis in medically ill subjects 21 score of >2 can help predict patients who are at increased probability of dvt, especially if doppler ultrasonography (usg) is not available. patients with wells score >2 and a positive result on doppler usg should receive treatment. hence, patients with signs and symptoms should be further diagnosed with doppler usg since there are several other diseases with similar signs and symptoms of dvt. among the risk factors associated with dvt in medically ill patients, a previous history of vte is one of the strongest predictors.25 the risk of dvt also substantially increases among patients diagnosed with varicose veins26 and in those exposed to hormonal therapy.27 in addition, evidence suggests that subjects with obesity (body mass index [bmi] ≥30 kg/m2) are at 2-fold higher risk of developing dvt than subjects without obesity.28 in this study, there was no statistically significant correlation between the past medical history and the wells score or dvt incidence. the very low number of patients with table 6. details of signs and symptoms of dvt at visit 1 and visit 2 (eligible group) eligible (n=334) visit 1 visit 2 the subject was not eligible for visit 2*, n (%) 40 (12.0) the subject was eligible for visit 2 as per all enrolled/evaluable population,* n (%) 294 (88.0) visit 2 was not performed on the same day of visit 1 108 (36.7) visit 2 performed on the same day of visit 1 170 (57.8) not done 15 (5.1) missing† 1 (0.3) total no. of subjects with any sign/symptom,‡ n (%) 134 (40.1) 37 (34.3) total no. of subjects without any sign/symptom,‡ n (%) 200 (59.9) 71 (65.7) pitting edema confined to the symptomatic leg, n (%) yes 97 (29.0) 30 (10.2) no 237 (71.0) 78 (26.5) entire leg swelling, n (%) yes 84 (25.15) 24 (8.2) no 250 (74.85) 84 (28.6) calf swelling at least 3 cm larger than asymptomatic side, n (%) yes 35 (10.48) 9 (3.1) no 299 (89.52) 99 (33.7) localized tenderness or pain along the distribution of deep venous system, n (%) yes 29 (8.68) 10 (3.4) no 305 (91.32) 98 (33.3) erythema of the symptomatic leg, n (%) yes 11 (3.3) 3 (1.0) no 323 (96.7) 105 (35.7) collateral superficial veins (non-varicose), n (%) yes 2 (0.6) 2 (0.7) no 332 (99.4) 106 (36.1) cyanosis of the symptomatic leg, n (%) yes 2 (0.6) 0 (0) no 332 (99.4) 108 (36.7) n, total number of patients; n, total number of patients in eligible/evaluable group. *percentage was calculated based on eligible/evaluable group. †no data on sign and symptoms of dvt at visit 2. ‡percentage was calculated based on patients for whom visit 2 was not performed on the same day of visit 1. details of signs and symptoms of dvt to be filled if visit 1 and visit 2 were not performed on the same day. karmel l. tambunan acta med indones-indones j intern med 22 a past medical history in this registry makes it difficult to establish an association with occurrence of dvt. limitations in this study, cus was used for detection of dvt, which is an effective and noninvasive procedure, but may not be superior to contrast venography. though regarded as a gold standard, contrast venography has inherent risks and limitations and is not routinely used and not widely available in indonesia. for subjects with wells score 2 or more but with negative finding on cus, no serial cus examination was performed during the study. there might be a high possibility of increased number of dvt cases being detected if cus was performed more than once in this population. table 7. correlation between past medical history and dvt incidence (eligible group*) dvt (n=124) without dvt (n=144) p-value obesity, n (%) yes 8 (6.5) 4 (2.8) 0.2352 no 116 (93.5) 140 (97.2) hormone therapy, n (%) yes 3 (2.4) 4 (2.8) 1.0000 no 121 (97.6) 140 (97.2) history of previous venous thromboembolism, n (%) yes 2 (1.6) 0 (0) 0.2131 no 122 (98.4) 144 (100.0) varicose vein, n (%) yes 0 (0) 0(0) 0.2131 no 124 (100.0) 144 (100.0) dvt, deep vein thrombosis; n, total number of patients; n, total number of eligible patients. percentage was calculated from total number of patients available in each category. p-value was computed using chi-square/fisher test to check the difference of past medical history among dvt incidences. *data were missing for 26 eligible patients, which meant that these subjects were eligible for visit 2, but visit 2 was not performed for some reason. table 8. correlation between past medical history and wells score (eligible group) wells score 1 (n=40) wells score ≥2 (n=294) p-value obesity, n (%) yes 1 (2.5) 13 (4.4) 1.0000 no 39 (97.5) 281 (95.6) varicose vein, n (%) yes 1 (2.5) 0 (0) 0.1198 no 39 (97.5) 294 (100.0) hormone therapy, n (%) yes 0(0) 7 (2.4) 1.0000 no 40 (100.0) 287 (97.6) history of previous venous thromboembolism, n (%) yes 0 (0) 2 (0.7) 1.0000 no 40 (100.0) 292 (99.3) n, total number of patients; n, total number of eligible patients. percentage was calculated from total number of patients available in each category. p-value was computed using chi-square/fisher test to check the association between past medical history among wells scores. vol 52 • number 1 • january 2020 identia registry: incidence of deep vein thrombosis in medically ill subjects 23 conclusion identia registry, to the best of our knowledge, is the first of its kind study to determine the incidence of dvt among medically ill patients at an increased risk of dvt in indonesia. in this study, wells score together with cus was used for diagnosing dvt; the high incidence reported herewith indicates that dvt is common among medically ill patients at risk of vte in indonesia. these findings would help increase awareness on the risk of dvt among healthcare professionals and facilitate the use of appropriate prophylaxis necessary to prevent death and other vte-related complications among medically ill patients hospitalized in indonesia. addendum k. l. tambunan is the national coordinator and principle investigator of the study. j. pandelaki did data acquisition and briefed all radiologists involved in this study regarding the study-specific procedures (doppler usg). all remaining authors are principal investigators in the study. all authors were responsible for the interpretation of analyses and critical revision of the manuscript. acknowledgments this study was funded by sanofi. the authors would like to thank the study participants, their family and caregivers who were involved in this study. editorial support in the preparation of this publication was provided by apcer life sciences and paid for by sanofi. editorial support in the preparation of this publication was also provided by anahita gouri and rohan mitra of sanofi, india. the authors, individually and collectively are responsible for all content and editorial decisions and received no payment from sanofi directly or indirectly (through a third party) related to the development/presentation of this publication. data sharing statements qualified researchers may request access to patient level data and related study documents including the clinical study report, study protocol with any amendments, blank case report form, statistical analysis plan, and dataset specifications. patient level data will be anonymized and study documents will be redacted to protect the privacy of trial subjects. further details on sanofi’s data sharing criteria, eligible studies, and process for requesting access can be found at: https://www. clinicalstudydatarequest.com. conflict of interests all authors report personal fees and nonfinancial support from sanofi indonesia during the conduct of the study. dr. tambunan reports personal fees from boehringer ingelheim outside the submitted work. dr. suharti reports personal fees and non-financial support from bayer, indonesia outside the submitted work. dr. benyamin reports personal fees and nonfinancial support from dexa medica outside the submitted work. references 1. streiff mb, lau bd. thromboprophylaxis in nonsurgical patients. hematology am soc hematol educ program. 2012;2012:631-7. 2. tapson vf. acute pulmonary embolism. n engl j med. 2008;358:1037–52. 3. turpie ag, leizorovicz a. prevention of venous thromboembolism in medically ill patients: a clinical update. postgrad med j. 2006;82:806-9. 4. w h i t e r h . t h e e p i d e m i o l o g y o f v e n o u s thromboembolism. circulation. 2003;107:14-8. 5. liew nc, chang yh, choi g, et al. asian venous thromboembolism guidelines: prevention of venous thromboembolism. int angiol. 2012;31:501-16. 6. lee lh, gallus a, jindal r, wang c, wu cc. incidence of venous thromboembolism in asian populations: a systematic review. thromb haemost. 2017;117(12):2243-60. 7. hirsh j, lee ay. how we diagnose and treat deep vein thrombosis. blood. 2002;99(9):3102–10. 8. wells ps, hirsh j, anderson dr, lensing aw, foster g, kearon c, weitz j, d’ovidio r, cogo a, prandoni p. accuracy of clinical assessment of deep-vein thrombosis. lancet. 1995;345:1326–30. 9. wells ps, ginsberg js, anderson dr, et al. use of a clinical model for safe management of patients with suspected pulmonary embolism. ann intern med. 1998;129:997–1005. 10. guyatt gh, akl ea, crowther m, schünemann hj, gutterman dd, lewis sz. introduction to the ninth edition: antithrombotic therapy and prevention of thrombosis. 9th ed. american college karmel l. tambunan acta med indones-indones j intern med 24 of chest physicians evidence-based clinical practice guidelines. chest. 2012;141:48s–52s. 11. barbar s, noventa f, rossetto v, ferrari a, brandolin b, perlati m, de bon e, tormene d, pagnan a, prandoni p. a risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the padua prediction score. j thromb haemost. 2010;8:2450–7. 12. goldhaber sz, tapson vf; dvt free steering committee. a prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. am j cardiol. 2004;93:259–62. 13. tapson vf, decousus h, pini m, chong bh, froehlich jb, monreal m, spyropoulos ac, merli gj, zotz rb, bergmann jf, pavanello r, turpie ag, nakamura m, piovella f, kakkar ak, spencer fa, fitzgerald g, anderson fa jr; improve investigators. venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: findings from the international medical prevention registry on venous thromboembolism. chest. 2007;132:936–45. 14. atmakusuma td1, tambunan kl, sukrisman l, et al. underutilization of anticoagulant for venous thromboembolism prophylaxis in three hospitals in jakarta. acta med indones. 2015;47:136-45. 15. mahendradhata y, trisnantoro l, listyadewi s, soewondo p, marthias t, harimurti p, prawira j (‎2017)‎. the republic of indonesia health system review, health systems in transition. vol-7 no.1. who regional office for south-east asia. http://www.who. int/iris/handle/10665/254716. 16. zwiebel wj, pellerito js. introduction to vascular ultrasonography. 5th ed. philadelphia, pa: elsevier saunders; 2005. p. 456. 17. g o l d h a b e r s z . r i s k f a c t o r s f o r v e n o u s thromboembolism. j am coll cardiol. 2010;56:1-7. 18. karmacharya rm, batajoo h, shakya yr, pradhan s. applicability of wells’ criteria for diagnosis of deep vein thrombosis in lower extremities at dhulikhel hospital, kathmandu university hospital. ind j vasc endovas surg. 2017;4:173–5. 19. modi s, deisler r, gozel k, reicks p, irwin e, brunsvold m, banton k, beilman gj. wells criteria for dvt is a reliable clinical tool to assess the risk of deep venous thrombosis in trauma patients. world j emerg surg. 2016;11:24. 20. engbers mj, blom jw, cushman m, rosendaal fr, van hylckama vlieg a. the contribution of immobility risk factors to the incidence of venous thrombosis in an older population. j thromb haemost. 2014;12:290–6. 21. farzamnia h, rabiei k, sadeghi m, roghani f. the predictive factors of recurrent deep vein thrombosis. arya atheroscler j. 2011;7:123–8. 22. kyrle pa, eichinger s. deep vein thrombosis. lancet. 2005;365(9465):1163–74. 23. wells ps, owen c, doucette s, fergusson d, tran h. does this patient have deep vein thrombosis? jama. 2006;295:199–207. 24. baroncini lav, frança gj, de oliveira a, et al. correlation of clinical features with the risk of lower limb deep vein thrombosis assessed by duplex ultrasound. j vasc bras. 2013;12:118–22. 25. mahan ce, fisher md, mills rm, fields le, stephenson jj, fu ac, spyropoulos ac. thromboprophylaxis patterns, risk factors, and outcomes of care in the medically ill patient population. thromb res. 2013;132:520–6. 26. chang sl, huang yl, lee mc, et al. association of varicose veins with incident venous thromboembolism and peripheral artery disease. jama. 2018;319:807– 17. 27. barros mv, arancibia ae, costa ap, bueno fb, martins ma, magalhães mc, silva jl, bastos md. incremental value of hormonal therapy for deep vein thrombosis prediction: an adjusted wells score for women. blood coagul fibrinolysis. 2016;27:328 33. 28. stein pd, beemath a, olson re. obesity as a risk factor in venous thromboembolism. am j med. 2005;118(9):978–80. 99 original article acta medica indonesiana the indonesian journal of internal medicine early realignment versus delayed urethroplasty in management of pelvic fracture urethral injury: a meta-analysis rama firmanto, gampo a. irdam, irfan wahyudi department of urology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: gampo a. irdam, md. department of urology, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: gampoai@gmail.com. abstrak tujuan: evaluasi kejadian striktur uretra sebagai parameter keberhasilan penatalaksanaan pfui melalui tindakan early realignment (er), dibandingkan dengan tindakan delayed urethroplasty (du). komplikasi jangka panjang berupa disfungsi ereksi dan inkontinensia dari kedua tindakan tersebut juga akan dievaluasi. metode: penelusuran literatur online bersumber dari pubmed, embase, cochrane, dan google scholar. insiden striktur dievaluasi dari seluruh studi pada kelompok er dan du. striktur uretra ditegakkan dari gejala penyakit berupa keluhan obstruksi yang dirasakan pasien, pemeriksaan uretroskopi, uroflowmetri, dan residu urin post berkemih yang ditunjang dengan pemeriksaan uretrografi yang dilakukan secara berkala. pasien dinilai tidak terjadi striktur bila tidak diperlukannnya lagi tindakan dilatasi uretra atau uretrotomi lanjutan. penilaian inkontinensia didapatkan dari keluhan subjektif pasien. fungsi ereksi dinilai secara subjektif, menurunnya derajat tumesen, berkurangnya durasi ereksi, kegagalan penetrasi dinilai sebagai kejadian disfungsi ereksi. data yang didapat diolah sebagai data dikotomi dengan menghitung risk ratio dengan menggunakan review manager 5.1. hasil: lima studi telaah dimasukkan dalam meta-analisis. angka kejadian striktur uretra secara statistik lebih rendah bermakna pada kelompok tindakan early realignment (rr=0,70, 95% ci 0,50-0,99, p<0,05). tidak terdapat perbedaan yang bermakna secara statistik di antara kedua kelompok tindakan terhadap angka kejadian disfungsi ereksi (rr=0,72, 95% ci 0,39-1,34) ataupun angka kejadian inkontinensia (rr=0,74, 95% ci 0,36-1,51). kesimpulan: early realignment menurunkan angka terjadinya striktur pada penanganan pfui dibandingkan dengan metode delayed urethroplasty. untuk komplikasi yaitu disfungsi ereksi dan inkontinensia tidak ada perbedaan yang bermakna pada kedua metode. kata kunci: cedera uretra, fraktur pelvis, early realignment, delayed urethroplasty. abstract aim: this meta-analysis study will evaluate the incidence of urethral stricture as a successfull parameter in the management of pfui through early realignment, compared with delayed urethroplasty. long-term complications such as erectile dysfunction and incontinence on both methods will also be evaluated. methods: online literature was sourced from pubmed, embase, cochrane, and google scholar. the incidence of stricture was evaluated from the entire study group of er and du. stricture of the urethra is diagnosed by the symptoms such as the obstruction that felt by the patient, uroflowmetry examination, and urine residual post micturition that supported by urethrography examination at regular interval. in some cases the incidence of stricture also diagnosed by urethroscopy. the patient is assessed as not having stricture when it is no longer needed to do rama firmanto acta med indones-indones j intern med 100 urethral dilatation or advanced urethrotomy. the rate of incontinence was assessed subjectively from the patient’s complaints. the erectile function assessed subjectively; decreased of tumesen’s degree, reduced the duration of erection, and penetration failure diagnosed as erection dysfunction. the data were processed as dichotomy data to calculate the risk ratio using review manager 5.1. results: five relevant literatures reviewed in this study. the incidence of urethral strictures are statistically significant lower in early realignment group (rr=0.70, 95% ci 0.50-0.99, p<0.05). there were no statistically significant differences between both treatment groups on the incidence of erectile dysfunction (rr=0.72, 95% ci 0.39-1.34) nor the incidence of incontinence (rr=0.74, 95% ci 0.36-1.51). conclusion: early realignment decrease the occurrence of stricture on pfui treatment compared to delayed urethroplasty method. between the two methos, the complications such as erectile dysfunction and incontinence; however, there was no significant difference. keywords: urethra injury, pelvic fracture, early realignment, delayed urethroplasty. introduction pelvic fracture urethral injury (pfui) is a disorder in urology often found in pelvic trauma, with an incidence ranging from1.6% to 25%.1 the disorder is often caused by high-velocity injury associated with pelvic ring disruption.2 the pelvic fractures indicate a considerable strength in the lower abdominal area/pelvis. this energy can be transferred to the internal organs in the pelvic cavity including the lower urinary tract. physical compression occurs and the prostate is forced into the perineal membrane, causing stretching of the urethra, and can be followed by rupture of the posterior urethra.3 pfui can lead to complications such as urethral stricture, urinary incontinence, and erectile dysfunction; which causes long-term impairment for the patient.4 pfui management until todays is still matter of controversy. in the beginning, the early realignment (er) in the form of primary suturing/ open urethra realignment is the best management for pfui. in correlation with the limited mobilization of patients in pelvic fractures and the high incidence of complications caused delayed urethroplasty (du) with cystostomy diversion be preferred. advancement in endoscopic techniques lead to early realignment through endoscopic (primary endoscopic realignmentper) became an alternative management with good results. this meta-analysis study will evaluate the incidence of urethral stricture as a success parameter management of pfui through early realignment, compared with delayed urethroplasty. long-term complications such as erectile dysfunction and incontinence on both methods will also be evaluated. all articles included in this study involve a retrospective cohort studies. methods eligibility criteria all articles included in this study were published in international journals with english language within the last fifteen years. only studies with management of pfui through early realignment, compared with delayed urethroplasty were included. furthermore, the outcome measures in this study were the longterm complications such as urethral stricture, erectile dysfunction and incontinence. information sources online literatures sourced from pubmed, embase, cochrane, and google scholar. keywords used mesh words “pelvic fracture urethral injury” or “pfui” and “management” o r “ e a r l y r e a l i g n m e n t ” o r “ d e l a y e d urethroplasty”. the last literature search was on october 2015. search the search terms of the study used the picos formula. related articles of relevant literatures were also searched thoroughly. study selection inclusion criteria of the study use the picos formula as presented in table 1. exclusion criteria are non-english studies, studies with non-pfui patients, and studies vol 48 • number 2 • april 2016 early realignment versus delayed urethroplasty 101 that classified as ‘review article’, ‘systematic review’, ‘meta-analysis’, and ‘case report’ which does not compare early realignment and delayed urethroplasty. furthermore, the inclusion and exclusion of this meta-analysis study illustrated schematically using prisma flow diagram as shown in figure 1. 598 literatures, 459 literatures were excluded. subsequently, 139 literatures are reviewed as a reference, to identify the literatures that fulfil the inclusion criteria of the study. however, after reviewing the full manuscript, the authors found 134 literatures classified as exclusion criteria. therefore, the final results of literature searches identified five relevant literatures will be reviewed in this study (figure 1). participants and intervention based on the five relevant literatures, the numbers of samples obtained are 393 patients with pfui. total patients with pelvic fracture urethral injury (pfui) that had a good handling of early realignment (er) are 177 patients and 216 patients treated with delayed urethroplasty (du). comparison all of the five relevant literatures are showed the incidence of urethral stricture between patients treated with early realignment (er) and delayed urethroplasty (du) (figure 2). however, only three studies compared the incidence of erectile dysfunction (figure 3) and incidence of urinary incontinence in patient with early realignment (er) and delayed urethroplasty (du) (figure 4). outcome stricture of the urethra is diagnosed by symptoms such as obstruction that felt by the patient, uroflowmetry examination, and urine residual post micturition that supported by urethrography examination which is done regularly. in some cases the incidence of stricture is also diagnosed by urethroscopy. the patient is assessed as not having stricture when is no longer needed urethral dilatation or advanced urethrotomy. the rate of incontinence assessed subjectively from the patient’s complaints. the erectile function assessed subjectively; decreased of tumesen’s degree, reduced the duration of erection, and penetration failure diagnosed as erection dysfunction.1-6 realignment openly conducted in a way to insert a retrograde catheter through the external meatus to identify the urethra rupture in distal section. other catheter inserted into the proximal urethra through the bladder to identify the table 1. picos: study criteria patients patients with pelvic fracture urethral injury interventions realignment comparisons early realignment versus delayed urethroplasty outcome urethral stricture, erectile dysfunction, incontinence study design retrospective cohort study records identified in pubmed (n=598) records after screening the irrelevant titles and abstracts (n=459) records reviewed for reference (n=139) records excluded (n=134) studies included (n=5) records identified in embase, cochrane records identified in google scholar figure 1. schematic flow search data collection process the data of the study were processed after reviewing the full manuscripts. statistical analysis the data of the study were processed as dichotomy data. to calculate the dichotomy data, this study are using the risk ratio (rr) and test i2 for assessed the heterogeneity (low (25%-50%), moderate (50%-75%) and high (>75%)). in this study, statistical analysis was performed using review manager 5.1. results study selection during literature searches, the authors have identified 598 relevant literatures. after screening through the titles and abstracts of the rama firmanto acta med indones-indones j intern med 102 proximal end of the rupture. the ends of both catheters are connected to create realignment.7-11 in these studies, early realignment is done in the first 14 days after the incident of pfui. for partial urethral injury, folley catheter insertion is slowly performed in one time trial.8-10 endoscopic realignment (primary endoscopic realignmentper) was also performed in two studies.9,10 urethral catheter on hold for 3-8 weeks, until the result of urethrogram peri-catheter showing the normal conditions of urethra marked by the absence of extravasation of contrast.7-11 in the group of delayed urethroplasty, cystostomy performed followed by definitive treatment 3-6 months after pfui. post-treatment, the catheter was hold for 2-4 weeks, until the result of urethrogram peri-catheter showed healing. the incidence of urethral strictures are statistically significant lower in early realignment group (rr=0.70, 95% ci 0.50-0.99, p<0.05). test i2 for heterogeneity was applied to the studies reviewed in the incidence of urethral stricture and get 0%. forest plots formed of five research studies in the meta-analysis. forest plot looks symmetrical collected, which shows a lack of bias publications. the incidence of erectile dysfunction after treatment is assessed from three studies (figure 3). there were no statistically significant differences between both treatment groups on the incidence of erectile dysfunction (rr=0.72, 95% ci 0.39-1.34). ci=confidence interval; er=early realignment; du=delayed urethroplasty figure 2. meta-analysis of the incidence of urethral stricture ci=confidence interval; er=early realignment; du=delayed urethroplasty figure 3. meta-analysis of the incidence of erectile dysfunction vol 48 • number 2 • april 2016 early realignment versus delayed urethroplasty 103 the incidence of incontinence after treatment assessed from three studies (figure 4). there were no statistically significant differences between both treatment groups on the incidence of incontinence (rr = 0.74, 95% ci 0.36-1.51). discussion urethral injury is commonly caused by blunt trauma to the pelvis in men. besides causing urethral strictures, the injury can cause long-term complications, such as incontinence and erectile dysfunction, which can certainly be an emotional stressor for the patient. management of pfui until today is still a matter of controversy; between early realignment and delayed repair.12,13 the aim of pfui management is not to prevent stricture but to ensure that the strictures that occur can be handled easily.9 early realignment was first introduced by ormond and cothran in 1934. the purpose of the early realignment is to pull down the proximal urethra properly/parallel to the distal side so that healing process will occur with minimal strictures.5 treatment with early realignment can be done when the patient’s condition is stable and life-threatening injuries have been treated.6 in patients with vascular injury or other abnormalities that require exploration in the pelvic cavity, prostatourethral severe dislocation, or laceration of the neck of the bladder; early realignment could minimizes the problems that will occur next.9 e a r l y r e a l i g n m e n t m e t h o d i n r e c e n t decades becomes easier with advances in urology endoscopy technique.5 the benefits of endoscopy are less bleeding, reduced period of hospitalization, and reduce the possibility of stricture.12 other studies show that early realignment using endoscopic techniques may reduce the frequency of advanced urethrotomy procedures which provides a great advantage in the management of the complications and costs.14 there are several endoscope methods of choice for pfui management with good results. some studies support the use of flexible cystoscopy after failing catheter insertion. cystoscopy, either rigid or flexible, can be performed simultaneously through cystostomy and through the urethra; to facilitate the process of realignment.15 the success rate of realignment using endoscopy is very good, which is 72100%.5,16-18 the success rate will be increased in accordance with the increasing number of the operator’s experience.19,20 c y s t o s t o m y d e l a y e d u r e t h r o p l a s t y introduced by johansson in sweden in 1953. in this method, the only emergency action that has done is urinary diversion through the installation of cystostomy, without exploration of urethral injury. the stricture cannot be avoided and will be treated electively several months later.7 the benefits of delayed repair is that urinary diversion is easily done, optimizing the patient’s general condition; and management of other injuries that are more life-threatening. exploration of the urethra in the acute phase of injury is difficult and high risk of failure, and lost a lot of blood, thus delayed repair is an option.7,9 ci=confidence interval; er=early realignment; du=delayed urethroplasty figure 4. meta-analysis of the incidence of urinary incontinence rama firmanto acta med indones-indones j intern med 104 delayed urethral repair is indicated when the rupture is not complete, the separation of the urethra is minimal, critical condition of unstable patients, and there is no facility that support or in the absence of an experienced surgeon.21 the disadvantage of this method is the need to wear a suprapubic tube for a long time, which would cause discomfort to the patient.12 when comparing the success of these two methods, the degree of incontinence and erectile dysfunction were also compared. in this metaanalysis, the incidence of urinary incontinence and erectile dysfunction between the two treatment groups showed a similar relative. this shows that both incidences are caused by the initial injury, not a complication after-treatment. erectile dysfunction of pfui can be caused by vasculogenic factors and neurogenic factors. stief et al explain that impotence occurs after pelvic trauma is due to the damage of the autonomic plexus and erigentes nerve as a result of the displacement of the prostate.22 armenakas et al.23 evaluated the impotent patient with disruption of the prostate pars membranous before done the reconstruction using mri pelvis and ultrasound duplex; and it shows that 80% cases of erectile dysfunction is caused by vasculogenic.erectile dysfunction caused by abnormal blood vessels can be treated by penile revascularization.24 husmann et al reported that there was no significant difference in the degree of incontinence in patients treated with early realignment and delayed urethroplasty.12 in the final analysis the results are dependent on the type of the injury and the quality improvements are made. s t u d i e s i n c l u d e d i n t h i s s t u d y a r e retrospective. despite the retrospective study’s relatively low evidence, the authors chose to include the studies because it is good to get the information needed as well as a foundation for further research. another weakness of this study is a limitation of the authors in finding studies that were not published. conclusion early realignment decreases the occurrence of stricture on pfui treatment, compared to the delayed urethroplasty method. furthermore, about the complications such as erectile dysfunction and incontinence; there was no significant difference in these two methods. hence, the advances in endoscopic urology technique will increase the success of the early realignment method and reduce the cost. references 1. barret k. primary realignment vs suprapubic cystostomy for the management of pelvic fracture associated urethral injuries: a systematic review and meta-analysis. urol. 2014;83:924-9. 2. mediana e, rodjani a, wahyudi i. one-year evaluation of overall urethral stricture management using questionnaires and uroflowmetry. indones j urol. 2014;21(2):1-7. 3. hampson la, mcaninch jw, breyer bn. male urethral strictures and their management. nature rev urol. 2014;11(1):43-50. 4. anger jt, buckley jc, santucci ra, elliott sp, saigal cs. trends in stricture management among male medicare beneficiaries: underuse of urethroplasty? urol. 2011;77(2):481. 5. hadjizacharia. evaluation of immediate endoscopic realignment as a treatment modality for traumatic urethral injuries. j trauma. 2008;64(6):1443-9;1449-50. 6. asci r, sarikaya s, buyukalpelli r, et al. voiding and sexual dysfunction after pelvic fracture urethral injuries treated with either initial cystostomy and delayed urethroplasty or immediate primary urethral realignment. scand j urol nephrol. 1999;33:228-33. 7. qu y, zhang w, sun n, et al. immediate or delayed repair of pelvic fracture urethral disruption defects in young boys: twenty years of comparative experience. chin med j (engl). 2014;127(19):3418-22. 8. onen a, ozturk h, kaya m, otcu s. long-term outcome posterior urethral rupture in boys: a comparison of different surgical modalities. urol. 2005;65(6):1202-7. 9. ku jh, jeon ys, kim me, et al. comparison of long term results according to the primary mode of management and type of injury for posterior urethral injuries. urol int. 2002;69:227-32. 10. ku j, kim me, jeon ys, lee nk, park yh. management of bulbous urethral disruption by blunt external trauma: the sooner, the better? urol. 2002;60:579–83. 11. balkan e, kilic n, dogruyol h. the effectiveness of early primary realignment in children with posterior urethral injury. int j urol. 2005;12:62–6. 12. husmann da, wilson wt, boone tb, allen td. prostatomembranous urethral disruptions: management by suprapubic cystostomy and delayed urethroplasty. j urol. 1990;144(1):76-8. 13. hagedorn jc et al. pelvic-fracture urethral injury in vol 48 • number 2 • april 2016 early realignment versus delayed urethroplasty 105 children. arab association of urology (2015) 13, 37–42 14. chang pc, hsu yc, shee jj, et al. early endoscopic primary realignment decreases stricture formation and reduces medical costs in traumatic complete posterior urethral disruptions in a 2 year follow up. chang gung med j. 2011;34:179-185. 15. santucci ra, joyce gf, wise m. male urethral stricture disease. j urol. 2007;177(5):1667-74. 16. leddy ls, vanni aj, wessells h, voelzke bb. outcomes of endoscopic realignment of pelvic fracture associated urethral injuries at a level 1 trauma center. j urol. 2012;188:174–8. 17. kim fj, pompeo a, sehrt d, et al. early effectiveness of endoscopic posterior urethra primary alignment. j trauma acute care surg. 2013;75:189–94. 18. herschorn s, thijssen a, radomski sb. the value of immediate or early catheterization of the traumatized posterior urethra. j urol. 1992;148:1428–31. 19. olapade-olaopa eo, atalabi om, adekanye ao, adebayo sa, onawola ka. early endoscopic realignment of traumatic anterior and posterior urethral disruptions under caudal anaesthesia – a 5year review. int j clin prac. 2010;64:6–12. 20. olapade-olaopa eo, adebayo sa, atalabi om, popoola aa, ogunmodede ia, enabulele uf. rigid retrograde endoscopy under regional anaesthesia. a novel technique for the early realignment of traumatic posterior urethral disruption. afr j med med sci 2002;31:277–80. 21. koraitim mm et al. effect of early realignment on length and delayed repair of postpelvic fracture urethral injury. urology 79: 912–916, 2012 22. stief cg, pohlemann t, hagemann j, schlote n, truss m, tscherne h, et al. etiology of erectile dysfunction after pelvic trauma. eur urol 1998; 31(suppl 1): 12(a48). 23. armenakas na, mcaninch jw, lue tf, dixon cm, hricak h. post-traumatic impotence: magnetic reso nance imaging and duplex ultrasound in diagnosis and management. j urol 1993; 149 (part 2): 1272–6. 24. matthews la, herbener te, seftel ad. impotence associated with blunt pelvic and perineal trauma: penile revascularization as a treatment option. semin urol 1995; 13: 66–72. 505acta med indones indones j intern med • vol 53 • number 4 • october 2021 clinical practice the comparison of point prevalence survey (pps) and gyssens flowchart approach on antimicrobial use surveillance in indonesian national referral hospital erni juwita nelwan1,2,3, helio guterres4,5, adeline pasaribu1, sharifah shakinah1,2, ralalicia limato6,7, djoko widodo1 1 division of tropical and infectious disease, department of internal medicine, faculty of medicine universitas indonesia, jakarta, indonesia 2 infection and immunology research cluster, indonesian medical research institute faculty of medicine universitas indonesia, jakarta, indonesia 3 member of antimicrobial resistance control cipto mangunkusumo hospital, jakarta, indonesia 4 department of internal medicine, faculty of medicine universitas indonesia, jakarta, indonesia 5 department of internal medicine, hospital nacional guido valadares, dili, timor leste 6 eijkman-oxford clinical research unit (eocru), jakarta, indonesia 7 centre for tropical medicine and global health, nuffield department of medicine, university of oxford, oxford, uk * corresponding author: erni juwita nelwan, md., phd. division of tropical and infectious disease, department of internal medicine, faculty of medicine universitas indonesia – dr. cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: erni.juwita@ui.ac.id. abstract the antimicrobial resistance (amr) rate in indonesia is steadily rising, despite the existing national action plan in 2014. in line with the global action plan on amr, proper surveillance on antimicrobial usage and resistance are needed. at present, antimicrobial surveillance (ams) data in indonesia is heterogeneous, fragmented, and localized. the common method of antimicrobial surveillance (ams) in referral hospitals is by implementing gyssens flowchart during antimicrobial resistance control program committee clinical rounds. however, the recent method of ams with point prevalence survey (pps) offers many advantages include its concise and simple protocol, large data collection, shorter required time, comprehensive data outcomes, real-time data, and standardized parameters. in low-middle income countries such as indonesia with its restricted resources in ams, pps is superior compared to the ‘traditional’ hospital clinical round in generating representative and homogenous outcomes that can be compared to data from other centers worldwide. keywords: antimicrobial, point prevalence survey, gyssens flowchart, indonesia. introduction indonesia, the fourth most populous country in the world, underwent a rapid increase in infectious diseases and antimicrobial usage (amu) up to 54-84%, therefore potentiating rise in antimicrobial resistance (amr).1–6 despite the existing national action plan toward amr in 2014, the amr rate in indonesia remained high4,5 and caused an increase in mortality, length of hospital stays, and hence costs of hospitalization. furthermore, the imbalance of newer antimicrobial invention was lagging erni juwita nelwan acta med indones-indones j intern med 506 effectiveness of convalescent plasma therapy in treating covid-19 behind intense microbial mutation.7,8 consistent with the 2011 jaipur declaration9 which aimed to tackle amr, in 2015, world health assembly adopted the global action plan on antimicrobial resistance, which concentrated on global surveillance and research.10 numbers of regional surveillance programs had been undergone mostly in high-income countries (hics), such as the central asian and eastern european surveillance of antimicrobial resistance (caesar)11, european point prevalence survey by european centre for disease prevention and control (ecdc)12, european antimicrobial resistance surveillance network (ears-net)13, and latin american antimicrobial resistance surveillance network (relavra)14. regardless of the success of data collection over years, these networks had a variety of standards for methods, data-sharing, and coordination at local and global levels. therefore in 2015, world health organization (who) established global antimicrobial resistance surveillance system (glass)15 and consequently global point prevalence survey (global-pps) which encompassed over 80 participating countries and more than 800 participating hospitals.16 unfortunately, amu surveillance data in indonesia are heterogeneous, fragmented, sporadic, with most only performed by referral hospitals and did not connect to the national network.2 this data was commonly obtained by implementing gyssens flowchart17, either through antimicrobial resistance control program (program pengendalian resitensi antimikroba/ ppra) committee clinical rounds or incidental antimicrobial audit researches.4,18–22 the recently popular surveillance method by pps offers a simpler method and a more thorough data collection on amu and amr, thus guided local and national asp.23,24 overseas studies were familiar with pps3,12,24–26 however indonesia had only carried out one antimicrobial surveillance research up to now.27 this review aims to observe the comparison of gyssens flowchart application to pps for amu surveillance method in indonesian national referral hospital. m e t h o d o f a n t i m i c r o b i a l surveillance in indonesia regulation on antimicrobial resistance control program in indonesia was authorized in 2015, which mainly focused on microbial resistance and antimicrobial surveillance.28 it recommended the extraction of antimicrobial quantity data from medical or pharmacy records and quality data from antimicrobial usage form. data was analyzed afterward using gyssens flowchart by antimicrobial resistance control program panelists during the clinical round. any disagreement on antimicrobial assessment will be discussed among panelists, consisted of infectious disease specialists, pharmacologists, clinical microbiologists, clinical pathologists, therapy-pharmacists, clinical pharmacists, nurses, attending physician, and infection prevention control (ipc) members.28–30 this method of surveillance was widely implemented in referral hospitals, one of which was cipto mangunkusumo national referral hospital in jakarta. the clinical round was usually performed weekly among all clinical departments proposing one or two complicated clinical cases. these cases were discussed for 2-3 hours by panelists who examined the quality of antimicrobial prescribing with gyssens flowchart. the outcomes of the analysis were commonly formed as an assessment of antimicrobial conformity with the clinical case and also further recommendations toward the patient. recently in 2020, pps on antimicrobial prescribing was also performed in cipto mangunkusumo hospital.31 data collection from patients on antimicrobial consumption was completed in 12 days by five field enumerators. enumerators were medical doctors or hospital staff who received one-day training in data collection guidelines.5 as different from the previous method, pps succeeded in gathering a larger amount of data from 244 patients who were on antimicrobial consumption. the outcomes of this pps were characteristics of adult inpatients, antibiotic usage profile, and microbial resistance profile. vol 53 • number 4 • october 2021 the comparison of point prevalence survey (pps) and gyssens flowchart 507 gyssens flowchart criterion on the antimicrobial prescribing quality audit was developed by kunin, et al. in 1973. this criterion was applied and performed by infectious disease specialists, and then further evolved and modified by other authors throughout time. in 1992, gyssens flowchart was developed to assess the quality of individual antimicrobial prescriptions. the flowchart is read from top to bottom to evaluate the process outcome (figure 1).32 gyssens flowchart was ideally performed by experts handling authoritative criteria or comparison of agreement with local, national, or international guidelines or standards. the outcomes measurements were explained in terms: data not sufficient, not indicated, not appropriate (efficacy, toxicity, cost, broadness of spectrum), not appropriate in the duration of treatment, not appropriate in dosage (dose, dose interval, administration, and not appropriate in timing (too late/ early). to conclude this, experts evaluation was needed.32 moreover, gyssens flowchart was commonly assessed retrospectively, hence missing medical record data was common.33 point prevalence survey (pps) point prevalence survey is a cross-sectional study that identifies a number of people with figure 1. gyssens flowchart. erni juwita nelwan acta med indones-indones j intern med 508 effectiveness of convalescent plasma therapy in treating covid-19 disease or condition at one point in time.34 one widely known protocol by global pps who performed data collection by retrieving information at ward level (as the denominator) and patient level (as the numerator) within 4 weeks. the departments involved in the survey were grouped into the medical and surgical adult department, adult intensive care units (icus), pediatric and neonatal department. each ward will be alternately assessed in only one day. a multidisciplinary team will collect the data at 8 a.m. from all inpatients admitted on the ward and on the consumption of antimicrobial agents.35 point prevalence survey gave snapshot realtime data on basic information from medical records and associated patient documentations. the included data were the type of ward and available beds, the number of admissions and antimicrobial consumption, patient’s characteristics (age, body mass index, gender), biomarkers, culture (blood, urine, wound, sputum), antimicrobial data (include duration, start and stop date, indication, route, diagnosis, frequency, guideline compliance, review date, type of treatment), and any additional variables due to research preference. accordingly, pps was able to summarize quantitative and qualitative data on the prevalence of amu, types of infection by sites and by location (community, hospital), and also quality indicators of antimicrobial, within a short duration of the study.35,36 figure 2 shows the concise flowchart of pps. prevalence surveys on infections had been published since the 1970s in italy and sweden.37,38 hereinafter, the surveillance methods evolved into pps on infection and related antimicrobial consumption.39 within a decade, national pps had been vastly implemented in hics.26,40–43 recently, pps has been the latest trend in antimicrobial surveillance, not only because it allowed a thorough extraction of data, but also was able to generate uniform and comparable outcomes among one study to another, especially in the availability of global pps protocol by who.24,26,44 in years, lmics such as indonesia struggled with data collection and analysis on antimicrobial consumption, due to the high workload and level of resources needed for regular monitoring. pps proposed a simpler method, therefore it could be repeatedly performed to maintain sustainability in surveillance.26 the first pps in indonesia was studied by limato, et al.27 and was published in 2021. p o i n t p r e va l e n c e s u r v e y ( p p s ) versus gyssens flowchart based on multicenter surveys in six referral hospitals in jakarta27, we observed that pps was a concise yet comprehensive method for antimicrobial surveillance in referral hospitals in indonesia. the key of pps method was in its study protocol which was easy and simple to be performed, even by general practitioners.26,35 in comparison, hospital clinical rounds used gyssens flowchart that had to be discussed among a group of multi-department experts, consequently demand bigger effort and resources.32 point prevalence survey method was also capable of gathering a large database within a brief duration of the study. surveys in two large teaching and referral hospitals in jakarta were completed within only 12 days, respectively. in total, the duration of surveys in six referral hospitals was 40 days, conducted by 3 – 5 field enumerators, and comprised of 993 patients on antibiotics. in general, every enumerator took approximately 20-25 minutes for respective patients and was responsible for 6 – 8 patient’s data every day.27 this method of antibiotic audit resulted in faster and larger data collection compared to gyssens flowchart implementation during clinical rounds, which was only able data collection on ward level: at 8 a.m, enumerator browse data on all inpatients in one ward. thereafter, enumerator screen all inpatiens who consume antimicrobial based on the list of drugs for respective patients. data collection on patient level: data on patients who consume antimicrobial at present were recorded. data on ward and patient level were collected in only one day. another data collection in other ward will be perform in another day figure 2. flowchart of point prevalence survey (pps) method vol 53 • number 4 • october 2021 the comparison of point prevalence survey (pps) and gyssens flowchart 509 to evaluate approximately 11-12 cases in 90 days. the outcome data in pps was also comprehensive, in which it included patients’ baseline characteristics, the profile of antibiotic use (prevalence, type, purpose, indication), the profile of culture and resistance, and also the presence and compliance to clinical pathway among a group of patients.35,36 an alike data was not available from clinical rounds with gyssens flowchart practice, albeit clinical rounds were able to analyze most complex cases compared to pps. the outcomes of clinical rounds were also usually limited to the quality analysis of antibiotic prescribing which was specific for certain cases.32 another superiority of pps over gyssens flowchart was its homogeneity in study outcomes. in the presence of standardized protocol by who35 and global-pps36, many countries all over the world performed pps by referring to these protocols, hence the outcomes of pps were able to be accumulated and compared from one another centers.26 in contrast, antibiotic audit data from clinical rounds were usually fewer and heterogenous among centers, therefore outcomes collection and comparison were difficult. in addition to that, unlike pps which collected real-time data, an antibiotic audit by clinical round evaluated retrospective data, therefore increased concern on missing outcomes.18,19,33,45,46 on top of that, pps was appropriate for continuous surveillance in lmics, including indonesia, in consideration of its simple, repeatable, relatively low-cost practice, yet resulted in comprehensive data.47 one study in makassar stated that lack of manpower specialized in antimicrobial surveillance was the principal obstacle in asp, therefore pps supposedly ideal to overcome it.30 table 1 shows differences in antimicrobial audit between pps dan gyssens flowchart. conclusion point prevalence survey was an appropriate method for antimicrobial prescribing audit and surveillance in lmic such as indonesia. audit with pps offered a concise and simple method, yet resulted in comprehensive data on quantity and quality of antimicrobial use. this method was also superior compared to the ‘traditional’ hospital clinical round in generating representative and homogenous outcomes that can be compared to data from other centers worldwide. based on our analysis, we emphasize the importance of routine antimicrobial surveillance with pps method at referral hospitals in indonesia. the data from pps had been proven useful for many institutions and countries, therefore it is time for indonesia to perform adequate antimicrobial surveillance. references 1. klein ey, van boeckel tp, martinez em, et al. global increase and geographic convergence in antibiotic consumption between 2000 and 2015. proc natl acad sci usa. 2018;115(15):e3463–70. 2. parathon h, kuntaman k, widiastoety th, et al. progress towards antimicrobial resistance containment and control in indonesia. bmj. 2017;358:31–5. 3. ansari f, erntell m, goossens h, davey p. the european surveillance of antimicrobial consumption (esac) point-prevalence survey of antibacterial use in 20 european hospitals in 2006. clin infect dis. 2009;49(10):1496–504. 4. hadi u, duerink do, lestari es, nagelkerke nj, keuter m, huis d. audit of antibiotic prescribing in two governmental teaching hospitals in indonesia. clin table 1. comparison of point prevalence survey and gyssens flowchart. point prevalence survey gyssens flowchart concise and simple protocol study can be applied by trained general practitioners large data collection within a brief duration required time for data collection of one case/ patient was approximately 15-20 minutes outcomes of quantitative and qualitative data were available (included antimicrobial quality indicators) standardized protocols were available, therefore data on outcomes were mostly homogenous analysis of real-time data require discussion from multi-department experts: infectious disease specialists, pharmacologists, clinical microbiologists, clinical pathologists, therapypharmacists, clinical 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of antimicrobial use and healthcare-associated infections in belgian acute care hospitals: results of the globalpps and ecdc-pps 2017. antimicrob resist infect control. 2020;9(1):1–13. 25. porto apm, goossens h, versporten a, costa sf. global point prevalence survey of antimicrobial consumption in brazilian hospitals. j hosp infect. 2020;104(2):165–71. 26. frenette c, sperlea d, german gj, afra k, boswell j, chang s, et al. the 2017 global point prevalence survey of antimicrobial consumption and resistance in canadian hospitals. antimicrob resist infect control. 2020;9(1):1–9. 27. limato r, nelwan ej, mudia m, brabander j de, guterres h, enty e, et al. a multicentre point prevalence survey of patterns and quality of antibiotic prescribing in indonesian hospitals. 2021; 28. kementerian kesehatan indonesia. peraturan menteri kesehatan republik indonesia nomor 8 tahun 2015 tentang program pengendalian resistensi antimikroba di rumah sakit. 2015; available from: www.bphn.go.id 29. tambunan t. kebijakan pengendalian resistensi antimikroba. 2019;4–7. available from: http:// parceiro.vitalatman.com.br/cgi-bin/content/view. php?data=kebijakan_pengendalian_resistensi_antim ikroba&filetype=pdf&id=3e98db39a5ab9e39f94acd 5e9f47c5c2 30. rukmini, siahaan s, sari id. analisis implementasi kebijakan program pengendalian (studi kasus di rsup dr . wahidin sudirohisudo, makassar). bul penelit sist vol 53 • number 4 • october 2021 the comparison of point prevalence survey (pps) and gyssens flowchart 511 40. gharbi m, doerholt k, vergnano s, et al. using a simple point-prevalence survey to define appropriate antibiotic prescribing in hospitalised children across the uk. bmj open. 2016;6(11):1–8. 41. xie d shuang, xiang l li, li r, hu q, luo q qin, xiong w. a multicenter point-prevalence survey of antibiotic use in 13 chinese hospitals. j infect public health [internet]. 2015;8(1):55–61. available from: http://dx.doi.org/10.1016/j.jiph.2014.07.001 42. goossens h, ferech m, vander stichele 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health organization. antimicrobial stewardship programmes in health-care facilities in lowand middle-income countries: a who practical toolkit [internet]. vol. 1, jac-antimicrobial resistance. 2019. available from: https://academic.oup.com/jac/articleabstract/30/5/724/849889?redirectedfrom=fulltext kesehat. 2019;22(2 april 2019):106–16. 31. guterres h. point prevalence survey penggunaan antibiotik pada pasien dewasa rawat inap di rsupn cipto mangunkusumo. thesis. universitas indonesia; 2020. 32. gyssens ic. audits for monitoring the quality of antimicrobial prescriptions. antibiot policies theory pract. 2005;197–226. 33. katarnida ss, murniati d, katar y. evaluasi penggunaan antibiotik secara kualitatif di rs penyakit infeksi sulianti saroso, jakarta. sari pediatr. 2016;15(6):369. 34. centers for disease control and prevention. introduction to public health surveillance [internet]. 2021 [cited 2021 mar 15]. available from: https:// www.cdc.gov/training/publichealth101/surveillance. html?cdc_aa_refval=https%3a%2f%2fwww. cdc.gov%2fpublichealth101%2fsurveillance. html#:~:text=public health surveillance is “the,health surveillance systems and methods. 35. world health organization (who). who methodology for point prevalence survey on antibiotic use in hospitals. 2018; available from: http://apps.who.int/iris 36. goossens h. protocol: global point prevalence survey of antimicrobial consumption and resistance. 2020;(may):2–10. 37. moro m, stazi m, marasca g, greco d, zampieri a. national prevalence survey of hospital-acquired infections in italy, 1983. j hosp infect. 1988;8:72–85. 38. bernander s, hambraeus a, myrback k, nystrom b, sundelof bo. prevalence of hospital-associated infections in five swedish hospitals in november 1975. scand j infect dis. 1978;10(november 1975):66–70. 39. vincent jl, bihari dj, suter pm, et al. the prevalence of nosocomial infection in intensive care units in europe: results of the european prevalence of infection in intensive care (epic) study. jama j am med assoc. 1995;274(8):639–44. 311 original article acta med indones indones j intern med • vol 51 • number 4 • october 2019 effect of oral n-acetylcysteine supplementation on the immunity system in patients with acute myocardial infarction trisulo wasyanto, ahmad yasa’, akhmad jalaludinsyah department of cardiology and vascular medicine, faculty of medicine, sebelas maret university dr. moewardi hospital, surakarta, indonesia. corresponding author: trisulo wasyanto, md, ph.d. department of cardiology and vascular medicine, faculty of medicine, sebelas maret university dr. moewardi hospital, surakarta. jl. kolonel sutarto 132 surakarta 57126, indonesia. email: trisulo.wasyanto@gmail.com. abstrak latar belakang: inflamasi, stres oksidatif dan fibrosis memegang peran penting setelah terjadinya infark miokard akut (ima). biomarker inflamasi yang banyak dipelajari pada penyakit kardiovaskular adalah c-reactive protein. ada bukti bahwa myeloperoksidase (mpo) dan galectin-3 (gal-3) memegang peran penting pada sistem imun tubuh saat terjadi ima. penelitian ini bertujuan untuk melihat efek pemberian terapi tambahan n-acetylcystein (nac) secara oral 600 mg 3 kali sehari selama 3 hari terhadap sistem imun pasien ima. metode: penelitian eksperimental acak, tersamar tunggal dengan metoda predan post-test. dilakukan di rumah sakit dr. moewardi surakarta, dari bulan mei hingga agustus 2018. tiga puluh dua pasien ima dengan elevasi segmen st (stemi) yang mendapat terapi fibrinolitik masuk penelitian: 17 pasien mendapat terapi standar ditambah nac 600 mg per oral setiap 8 jam selama 3 hari dan 15 pasien mendapat terapi standar sebagai kontrol. kadar high sensitivity c-reaktif protein (hscrp), mpo, dan galectin-3 dari kedua kelompok diperiksa saat masuk dan setelah 72 jam perawatan. hasil: kadar hscrp, mpo, dan gal-3 pada kelompok nac dan kontrol pada saat admisi tidak berbeda bermakna, sedangkan kadar antar kelompok pasca 72 jam pemberian nac didapatkan perbedaan yang bermakna dengan nilai p untuk kadar hscrp, mpo, dan gal-3 sebesar 0,0001, 0,001, dan 0,017. pada kelompok nac saat admisi dan pasca 72 jam, didapatkan perbedaan kadar hscrp, mpo, dan gal-3 yang bermakna dengan nilai p secara berurutan 0,0001, 0,0001 dan 0,0001; sedangkan pada kelompok kontrol tidak didapatkan perbedaan ini. terdapat perbedaan kadar hscrp, mpo, dan gal-3 yang bermakna antara kelompok nac dan kelompok kontrol (nilai p secara berurutan adalah 0,011, 0,022 dan 0,014). kesimpulan: pemberian terapi tambahan nac 600 mg oral tiap 8 jam selama 72 jam dapat menurunkan kadar hscrp, mpo, dan gal-3 pada pasien ima yang mendapatkan terapi fibrinolitik. hasil penelitian ini akan memberikan pilihan terapi tambahan untuk pengelolaan pasien ima yang lebih baik. kata kunci: infark miokard akut, n-acetylcystein, sistem imun. abstract background: inflammation, oxidative stress, and fibrosis play important roles after an acute myocardial infarction (ami) event. the most studied inflammatory biomarker in cardiovascular disease is c-reactive protein (crp). it has been demonstrated that myeloperoxidase (mpo) and galectin-3 (gal-3) have some essential roles on immune system when an ami event occurs. we aimed to determine the effect of oral n-acetylcysteine (nac) supplementation at the dose of 600 mg 3 times daily for 3 consecutive days on the immune system of ami patients. methods: our randomized single-blinded experimental study using preand post-treatment evaluations was performed at dr. moewardi hospital, indonesia, from may to august 2018. thirty-two patients with ami and trisulo wasyanto acta med indones-indones j intern med 312 st segment elevation (stemi) who received fibrinolytic therapy were included. there were 17 patients received standard therapy plus 600 mg oral nac supplementation every 8 h for 3 days and 15 patients received standard therapy, which served as the control group. high-sensitivity c-reactive protein (hscrp), mpo, and gal-3 levels of both groups were evaluated at admission and after 72 h receiving treatment. results: hscrp, mpo, and gal-3 levels between nac and control groups at admission were not significantly different; while intergroup differences after 72 h of nac supplementation were significant (p values of hscrp, mpo, and gal-3 levels were 0.0001, 0.001, and 0.017, respectively). furthermore, in the nac group, hscrp, mpo, and gal-3 levels at 72 h after treatment were significantly different from the corresponding levels at admission (p values: 0.0001, 0.0001, and 0.0001, respectively); the control group did not show these differences. there were also significant intergroup differences between the nac and control groups regarding hscrp, mpo, and gal-3 levels (p values: 0.011, 0.022, and 0.014, respectively). conclusion: oral supplementation of 600 mg nac every 8 h for 72 h can reduce hscrp, mpo, and gal-3 levels in ami patients receiving fibrinolytic therapy. results of our study will provide more options for supplementation therapy to improve management of ima patients. keywords: acute myocardial infarction, n-acetylcysteine, immune system. introduction coronary heart disease (chd) is the leading cause of death worldwide.1 in the united states, the incidence of acute myocardial infarction (ami) with st segment elevation (stemi) decreases; while the incidence of ami without st segment elevation (nstemi) remains constant or slightly increases.2 in indonesia, deaths from cardiovascular disease are increasing every year and cardiovascular disease has become the most common cause of death.3 inflammation is an important factor in the development of atherosclerosis and subsequent cardiovascular events. continuous inflammation increases the likelihood of erosion or rupture of atherosclerotic lesions. the most studied inflammatory biomarker in cardiovascular disease is c-reactive protein (crp), an acutephase protein, which is produced mainly by hepatocytes under the influence of cytokines such as interleukin (il)-6 and tumour necrosis factoralpha (tnf-α).4 several studies have found that serum crp levels can predict the risk of recurrent acute cardiovascular events in hospitals5 or 30day or long-term mortality in cases of stemi.6 the pathogenesis of ami is influenced by systemic and local process on myocardial plaque and inflammation. various types of leukocytes play an important role in local inflammatory processes and trigger plaque rupture, one of them is known as polymorphonuclear (pmn) neutrophils.7 pmn neutrophils play important roles in the innate and acquired immune systems. they accumulate in the inflammatory area and contribute to host endurance, regulation of the inflammatory process, and tissue injury. one important component of pmn neutrophils is myeloperoxidase (mpo).8 mpo is a member of a subfamily of peroxidases; it is mostly expressed in immune cells such as pmn cells, lymphocytes, monocytes, and other macrophages and cells. it is stored in the cytoplasmic membrane and binds to azurophilic granules. the mechanism of neutrophil degranulation is thought to be related to oxidative stress. mpo is involved in the production of reactive oxygen species (ros) and other free radicals via a peroxidase or halogenation cycle. mpo is a strong oxidant, and if its levels are low and controlled, it is toxic to microorganisms and plays an important role in the immune system. however, if presents in excess and uncontrolled, mpo can cause host cell damage.9 current evidence suggests that galectin plays an important role in acute and chronic inflammatory responses, as well as other diverse pathological processes.10 galectin-3 (gal-3) is expressed by almost all types of immune cells and inflammation, through constitutive and induction processes. it is a lectin that binds to β-galactoside and plays a major role in the development of cardiac fibrosis in conditions of excessive pressure (pressure overload), neuro-endocrine activation, and hypertension. vol 51 • number 4 • october 2019 effect of oral n-acetylcysteine supplementation on the immunity system 313 however, its role in remodelling after ami has not received enough attention.11 in this study, we aimed to determine the effect of oral nac supplementation at the dose of 600 mg 3 times daily for 3 consecutive days on the immune system of ami patients who also were treated with fibrinolytics. methods our study was a randomized, singleblinded study involving preand post-treatment evaluations. the study was conducted at dr. moewardi general hospital, surakarta, from may to august 2018. this study has been approved by the ethics committee of dr. moewardi hospital/medical faculty of sebelas maret university in surakarta with a reference number 536/iv/hrec/2018 on may 16th, 2018. population and samples the study was conducted in 32 stemi patients who received fibrinolytic therapy and underwent treatment at icvcu dr. moewardi surakarta, central java using consecutive sampling method. there were 17 patients in the n-acetylcysteine (nac) group and 15 patients in the control group. study variables the independent variable in this study was nac and the dependent variables were levels of high-sensitivity c-reactive protein (hscrp), mpo, and gal-3. the patients received effervescent nac tablets (600 mg; fuimucil®, zambon switzerland ltd) thrice a day for 3 days. the inclusion criteria for this study were stemi patients with symptoms who arrived at the hospital within 12 h and received fibrinolytic drugs, patients aged 18-75 years, and patients who had no absolute contraindications for fibrinolytic drugs. the exclusion criteria were patients with a history of acute coronary syndrome (acs) or chronic heart failure, valvular heart disease, chronic renal failure, liver cirrhosis, chronic inflammatory disease or malignancy, an acute infection or sepsis, and stroke. study instrumentation intravenous blood (volume: 4 ml) was collected before and at 72 h after nac administration. levels of hscrp, mpo, and gal-3 were determined using elisa by prodia laboratory. data analysis data was presented in the form of mean and standard deviation. spss version 22.0 for windows was used for data analysis and the significant level was set at p < 0.05. to determine the mean difference before and after treatment in each groups, dependent sample t-test was used if data distribution was normal and wilcoxon was used if data distribution was not. mean difference between the two groups and mean difference between changes (delta) before and after treatment in the treatment and control groups, the independent samples t-test was performed if the data distribution was normal and mann-whitney test was performed if the data distribution was not normal. results the basic characteristics of the patients are presented in table 1. intergroup differences were not significant between the nac and control groups. at admission, the levels of hscrp, mpo, and gal-3 in the nac and control groups were not significantly different; however, intergroup differences in the levels were significant after 72 h of nac administration (p values: 0.0001, 0.001, and 0.017, respectively) (table 2). in the nac group, the levels of hscrp, mpo, and gal-3 at 72 h after nac treatment were significantly different from the corresponding pre-treatment levels (p values: 0.0001, 0.0001, and 0.0001, respectively). such differences were not found in the control group (table 3). in addition, there were significant intergroup differences regarding the changes in hscrp, mpo, and gal-3 levels (p values: 0.011, 0.022, and 0.014, respectively) (table 4). discussion this study was an experimental study with preand post-treatment evaluations that aimed to determine the effect of nac 600 mg supplementary therapy administered orally 3 trisulo wasyanto acta med indones-indones j intern med 314 times a day for 3 days on hscrp, mpo, and gal-3 levels in stemi patients who received fibrinolytic therapy. effect of n-acetylcysteine on hscrp inflammation associated with chd and ami triggers the formation of atheroma plaques in the coronary arteries. one parameter to assess the degree of inflammation in ami is the measurement of crp, an acute-phase protein produced mainly by hepatocytes under the table 1. basic characteristics variables nac group (n = 17) control group (n = 15) demographic characteristic sex, n (%) male 16 (94.1) 12 (80.0) female 1 (5.9) 3 (20.0) age (years), mean (sd) 55.24 (10.19) 58.27 (8.07) risk factors, n (%) hypertension 12 (70.6) 10 (66.7) smoking 13 (76.5) 9 (60.0) diabetes mellitus 5 (29.4) 1 (6.7) clinical condition, mean (sd) onset (h) 4.82 (2.63) 4.80 (2.65) systolic blood pressure (mmhg) 136.71 (24.39) 132.20 (28.39) diastolic blood pressure (mmhg) 84.47 (17.57) 81.00 (18.68) heart rate (times/ min) 75.33 (19.09) 78.00 (11.93) killip i class n, (%) 13 (76.5) 10 (66.7) killip ii-iv class n, (%) 4 (23.5) 5 (33.3) anterior stemi n, (%) 11 (64.7) 8 (53.3) non-anterior stemi n, (%) 6 (35.3) 7 (46.7) laboratory parameters, mean (sd) haemoglobin (gr/dl) 13.75 (1.80) 13.59 (1.81) egfr (ml/min/1.73 m) 64.40 (26.09) 72.13 (29.97) ldl (mg/dl) 125.59 (33.41) 137.80 (83.90) triglycerides (mg/dl) 193.88 (149.46) 113.47 (46.69) therapy fibrinolytic therapy, n (%) success 2 (11.8) 4 (26.7) failure 15 (88.2) 11 (73.3) ace-i/arb n, (%) 15(88.2) 14(93.3) beta blocker n, (%) 12(70.6) 14(93.3) table 2. changes of biomarker levels in both groups parameters nac group control p value hscrp, median (range) admission 76.80 (10.80-270.60) 114.50 (18.10-300.00) 0.089 72 h 14.90 (3.60-266.80) 151.50 (42.50-285.20) 0.0001 mpo, mean (sd) admission 162.91 (79.42) 168.34 (79.42) 0.825 72 h 112.76 (57.28) 180.40 (69.03) 0.001 gal-3, mean (sd) admission 13.92 (4.49) 12.70 (3.94) 0.427 72 h 8.40 (2.55) 11.21 (3.70) 0.017 data are presented as mean (standard deviation), except in the case of hscrp, which is expressed as [median (min-max)]. hscrp: high-sensitivity c-reactive protein; mpo: myeloperoxidase; gal-3: galectin-3. table 3. changes of biomarker levels in both groups parameters nac group at admission at 72 h p value hscrp 76.80 (10.80-270.60) 14.90 (3.60-266.80) 0.0001 mpo 162.92 (57.29) 112.76 (37.50) 0.0001 gal-3 13.92 (4.49) 8.41 (2.55) 0.0001 parameters control group at admission at 72 h p value hscrp 114.50 (18.60-300.00) 151.50 (42.50-285.20) 0.910 mpo 168.35 (79.42) 180.41 (69.04) 0.674 gal-3 12.71 (3.95) 11.22 (3.71) 0.310 data are presented as mean (standard deviation), except in the case of hscrp, which is expressed as [median (min-max)]. hscrp: high-sensitivity c-reactive protein; mpo: myeloperoxidase; gal-3: galectin-3. influence of proinflammatory cytokines such as interleukin (il)-6 and tumour necrosis factoralpha (tnf -α).4 several studies have shown that serum crp levels can predict the risk of recurrent acute cardiovascular events in hospitals5 or 30day or long-term mortality in stemi patients.6 in our study, hscrp levels, as a marker of inflammation, were affected by oral nac supplementation. our finding is consistent with the theory that nac has anti-inflammatory properties. induction of the proinflammatory transcription factors activator protein-1 (ap-1) and nuclear factor-κb (nf-κb) is inhibited by vol 51 • number 4 • october 2019 effect of oral n-acetylcysteine supplementation on the immunity system 315 nac. these transcription factors are induced in response to oxidative stress, thus supporting the argument that the anti-inflammatory properties of nac are due to its mechanism of action as an antioxidant.12 various studies have also shown that nac supplementation can inhibit various inflammatory markers such as tnf-α, il-6, il-3, hscrp, and c3, and soluble intercellular adhesion molecule (sicam). it has been proven that nac can also reduce ischemia of reperfusion, arrhythmia injury, and expansion of infarction. fibrinolytic agents used in ami patients can cause reperfusion injury with marked myocardial manifestations, arrhythmias, myocardial damage, and expansion of infarct size. nac in combination with streptokinase significantly reduces oxidative stress and improves ventricular function in patients with myocardial infarction.13 effect of n-acetylcysteine on myeloperoxidase oxidative stress and inflammation play an important role in the pathogenesis of chd, which can cause ami. in ami with elevation of st segment (ami est), neutrophil breakdown (degradation) occurs after neutrophil activation. neutrophils contain granules that have mediators that play a role in delivering inflammatory signals. the granules consist of vesicles, azurophilic granules, and specific granules.7,14 azurophilic granules consist of mpo, which is the largest protein in neutrophils. mpo is a strong oxidant, forming reactive oxidants and other free radicals through the peroxidase cycle or through a halogenization cycle depending on the availability of the substrate. in the peroxidase cycle, mpo activation occurs through the interaction of mpo with h2o2 to form h2o. 7,9 nadph oxidase is the main enzyme in neutrophils involved in the formation of ros. the enzyme catalyses the reaction; therefore, the reaction is called respiratory burst or oxidative burst.14 activation of mpo through halogenation involves halid (cl-) and pseudohalid substrates such as thiocyanate/scn-. this reaction causes the formation of hypochloric acid (hocl-) and hypotonic acid (hoscn-). the formation of reactive oxidants and other free radicals through the peroxidase cycle or through the halogenization cycle depends on the availability of the substrate.9 b a s e d o n t h e e ff e c t o f m p o o n t h e inflammatory response and oxidative stress, mpo inhibition strategies become therapeutic target. one agent that can inhibit mpo activity is nac. this study shows mpo levels can be affected by oral nac supplementation. nac is a novel tripeptide that works as an antioxidant agent in various inflammatory pathways. it works optimally on hydroxyl radicals, hypochloric acid, and hydrogen peroxide. nac inhibits the respiratory burst reaction in mpo activation, and can also reduce the formation of hypochlorous acid (hocl) in mpo activation. it plays a role in stimulating antioxidant enzymes that reduce mpo activation.15 the results of our study are the same as those of the naciam trial conducted by pasupathy et al.16 in 2017, which studied a high-dose intravenous nac supplementation combined with a low-dose intravenous nitroglycerin therapy. in the naciam trial, the levels of mpo, malondialdehyde (mda), and syndecan-1 were determined. the study showed that mpo was significantly correlated to the amount of myocardium that can be saved by administering nac and nitroglycerin therapy. furthermore, mpo and other oxidative enzymes can be targeted in the pathogenesis of cardiovascular and inflammatory diseases. in our study, we analysed mpo levels after nac supplementation in the treatment and control groups. there were table 4. comparison of changes in biomarker levels of both groups parameters nac group control group p value hscrp -25.10 [(-108)-(-1.80)] -5.50 [(-77)-253] 0.011 mpo -50.15 (46.62) 12.06 (108.65) 0.022 gal-3 -5.51 (3.06) -1.49 (5.49) 0.014 data are presented as mean (standard deviation), except in the case of hscrp, which is expressed as [median (minmax)]. hscrp: high-sensitivity c-reactive protein; mpo: myeloperoxidase; gal-3: galectin-3. trisulo wasyanto acta med indones-indones j intern med 316 increased mpo levels in the treatment group. mpo levels in nac-treated patients tend to decrease. effect of n-acetylcysteine on galectin-3 gal-3 is secreted by activated macrophages and modulates several physiological and pathological processes, including inflammation and fibrosis. it directly induces fibroblasts to proliferate and deposit type i collagen in the extracellular matrix.17,18 remodelling after myocardial infarction is due to an acute loss of the myocardium, which causes structural and biomechanical changes in an effort to maintain cardiac function. fibrosis is important in this process, including in the initial phase and after ami.18 in a study by van der velde et al.19 in which 247 stemi patients underwent primary percutaneous coronary intervention (pci), gal-3, as a fibrosis biomarker after ami, could be used to predict left ventricular ejection fraction and infarct area after 4 months. since gal-3 has an important role in the pathophysiology of adverse cardiac remodelling and could be an independent predictor of heart failure after ami, it can be hypothesized that a therapy that can inhibit gal3 may affect the development of heart failure in patients with ami.19 tr a n s f o r m i n g g r o w t h f a c t o rβ i s a n important mediator in the remodelling process.20 differentiation and activation of fibroblasts into myofibroblasts by inflammatory cytokines, such as tgf-β, starting with the entry of cells including macrophages, is the first step in the process of fibrogenesis. gal-3 plays a role in this process when macrophages and tgf-β induce activation of myofibroblasts; however, recruitment of macrophages and expression of tgf-β do not depend on gal-3.11 our study findings indicate that oral nac supplementation can affect gal-3 levels. results of our study are consistent with those of a study conducted by talasaz et al.21 evaluating the effect of nac on cardiac remodelling based on matrix metallopeptidase (mmp)-9 and mmp-2 levels in 98 ami patients. in the group of patients who received additional oral nac therapy, mmp-9 and mmp-2 levels were significantly lower than the levels in the placebo group (p = 0.014 and p = 0.045, respectively). talasaz et al.21 aimed to determine the effects of nac on pro-fibrotic cytokines, tgf-β and tnf-α in ami patients. they concluded that nac supplementation can prevent an increase in tgf-β levels compared to that in patients who were not treated with nac and that tgf-β is strongly associated with left ventricular ejection fraction, and therefore, its antagonism may be important in preventing remodelling. the reduction in gal-3 levels by nac supplementation can be explained by an indirect inhibitory mechanism through nac’s role as an antioxidant and anti-inflammatory agent. nac, a direct antioxidant, is a ros scavenger, but its main role as a therapeutic antioxidant agent is attributable to its role as a precursor of cysteine in the synthesis of glutathione. the role of nac in inhibiting inflammation involves the inhibition of the induction of ap-1 and nf-κb proinflammatory transcription factors. these transcription factors are induced in response to oxidative stress.22 conclusion oral nac supplementation at the dose of 600 mg 3 times daily for 3 days can reduce levels of hscrp, mpo, and gal-3 in ami patients receiving fibrinolytic therapy. the findings of this study will provide a therapeutic option for the successful management of patients with ami. conflict of interests the authors report no conflicts of interest associated with this work. references 1. hartley a, marshall dc, salciccioli jd, et al. trends in mortality from ischemic heart disease and cerebrovascular disease in europe: 1980 to 2009. circulation. 2016;133(20):1916–26. 2. mozaffarian d, benjamin ej, go as, et al. heart disease and stroke statistics 2015 update: a report from the american heart association. circulation. 2015;131(4):e29–322. 3. dharma s, juzar da, firdaus i, et al. acute myocardial infarction system of care in the third world. neth heart j. 2012;20(6):254–9. 4. kushner i. the phenomenon of the acute phase response. ann n y acad sci. 1982;389:39–48. vol 51 • number 4 • october 2019 effect of oral n-acetylcysteine supplementation on the immunity system 317 5. tomoda h, aoki n. prognostic value of c-reactive protein levels within six hours after the onset of acute myocardial infarction. am heart j. 2000;140:324–8. 6. makrygiannis ss, ampartzidou os, zairis mn, et al. prognostic usefulness of serial c-reactive protein measurements in st-elevation acute myocardial infarction. am j cardiol. 2013;111:26–30. 7. carbone f. pathophysiological role of neutrophils in acute myocardial infarction. thromb haemost. 2013; 110(3):501–14. 8. arnhold j, flemmig j. human myeloperoxidase in innate and acquired immunity. arch biochem biophys. 2010;500(1):92–106. 9. khan a, alsahli ma, rahmani ah. myeloperoxidase as an active disease biomarker: recent biochemical and pathological perspectives. med sci. 2018;6(2):e33. 10. liu ft, yang r, hsu dk. galectine in acute and chronic inflammation. ann n y acad sci. 2012; 1253:80–91. 11. yu l. the role of galectin-3 in cardiac remodeling and fibrogenesis. groningen: 2012. p. 152. 12. r a d o m s k a l e ś n i e w s k a d m , s k o p i ñ s k i p. n-acetylcysteine as an anti-oxidant and antiinflammatory drug and its some clinical applications. centr eur j immunol. 2012;37(1):57-66. 13. yesilbursa d, serdar a, senturk t, et al. effect of n-acetylcysteine on oxidative stress and ventricular function in patients with myocardial infarction. heart vessels. 2006;21:33–7. 14. teng n, maghzal gj, thalib j, et al. the roles of myeloperoxidase in coronary artery disease and its potential implication in plaque rupture. redox rep. 2017;22(2):51–73. 15. kilciksiz s, demirel c, erdal n, et al. the effect of n-acetylcystein on biomarkers for radiation-induced oxidative damage in a rat model. acta med okayama. 2008;62(6);403–9. 16. pasupathy s, tavella r, grover s, et al. early use of n-acetylcysteine (nac) with nitrate therapy in patients undergoing primary percutaneous coronary intervention for st-segment elevation myocardial infarction reduces myocardial infarct size (the naciam trial). circulation. 2017;136(10):894-903. 17. yang ry, rabinovich ga, liu ft. galectins: structure, function and therapeutic potential. expert rev mol med. 2008;10:e17. 18. sharma uc, mosleh w, chaudhari mr, et al. myocardial and serum galectin-3 expression dynamics marks post-myocardial infarction cardiac remodeling. heart lug circ. 2016;26(7):736–45. 19. van der velde ar, lexis cph, meijers wc, et al. galectin-3 and sst2 in prediction of left ventricular ejection fraction after myocardial infarction. clin chim acta. 2016;452:50–7. 20. talasaz ah, khalili h, jenab y, et al. n-acetylcysteine effects on transforming growth factor-β and tumor necrosis factor-a serum levels as pro-fibrotic and inflammatory biomarkers in patients following stsegment elevation myocardial infarction. drugs r d. 2013;13:199–205. 21. talasaz ah, khalili h, fahimi f, et al. effects of n-acetylcysteine on the cardiac remodeling biomarkers and major adverse events following acute myocardial infarction: a randomized clinical trial. am j cardiovasc drugs. 2014;14:51–61. 22. ibanez b, james s, agewall s, et al. 2017 esc guidelines for the management of acute myocardial infarction in patients presenting with st-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with st-segment elevation of the european society of cardiology (esc). eur heart j. 2018;39:119–77. 283 original article acta medica indonesiana the indonesian journal of internal medicine the effect of rational emotive behavior therapy (rebt) on antiretroviral therapeutic adherence and mental health in women infected with hiv/aids surilena1, r. irawati ismail2, irwanto3, zubairi djoerban4, budi utomo5, sabarinah5, iwan5, arwin a.p. akip6 1 department of psychiatry, faculty of medicine, atma jaya catholic university of indonesia, jakarta, indonesia. 2 department of psychiatry, faculty of medicine universitas indonesia, jakarta, indonesia. 3 department of psychology, faculty of psychology, atma jaya catholic university of indonesia, jakarta, indonesia. 4 department of internal medicine, faculty of medicine, universitas indonesia, jakarta, indonesia. 5 department of public health, faculty of public health, universitas indonesia, depok, indonesia. 6 department of pediatric, faculty of medicine, universitas indonesia, jakarta, indonesia. correspondence mail: department of psychiatry, faculty of medicine, atma jaya catholic university of indonesia. jl. pluit raya 2, jakarta 14440, indonesia. email: surilenahasan@yahoo.co.id, surilena@atmajaya.ac.id. abstrak tujuan: mengetahui efektifitas terapi berbasis perilaku emosi rasional (berbasis rebt) terhadap perbaikan kesehatan mental dan kepatuhan terapi anti retroviral (art) pada perempuan yang terinfeksi hiv/aids (odha perempuan). metode: penelitian ini merupakan uji klinis, randomisasi, tersamar tunggal, pada odha perempuan yang berobat jalan di pokdiksus aids rs cipto mangunkusumo dan unit diagnostik terpadu aids rs dharmais, oktober 2011-maret 2012. hasil alokasi acak (randominasi blok) pada 160 odha perempuan didapatkan kelompok intervesi berbasis rebt (n=80) dan kelompok kontrol (n=80). kelompok intervensi mendapat intervensi berbasis rebt 8 sesi/minggu yaitu 6 sesi/minggu terapi individual dan 2 sesi/minggu terapi kelompok. instrumen yang digunakan kuesioner demografi, kepatuhan art (self report dan hitung pil), kesehatan mental (srq-20). data dianalisis dengan kai kuadrat, generalized linear model, generalized estimating equations. hasil: 148 responden yang dianalisis yaitu kelompok intervensi berbasis rebt (n=72) dan kontrol (n=76) dengan rerata usia 33-34 tahun. setelah 8 minggu intervensi berbasis rebt, ada perbaikan (peningkatan) rerata skor kepatuhan laporan diri (self report) dibandingkan dengan kelompok kontrol (100%; 95% ci 83,3-96,7 v.s. 84%; 95% ci 77,5-87,8) dan perbaikan (penurunan) rerata skor srq-20 pada kelompok intervensi berbasis rebt dibandingkan dengan kelompok kontrol (2,9; 95% ci 2,7-13,0 v.s. 5,4; 95% ci: 5,0 13,6). kepatuhan art berdasarkan titer viral load (vl) tidak dianalisis pada kedua kelompok karena mayoritas proporsi titer vl tidak terdeteksi (<400 copies/ml). analisis glm menunjukkan penurunan rerata skor srq-20 dan peningkatan rerata skor kepatuhan art (self report) kelompok intervensi berbasis rebt lebih signifikan (p<0.000) daripada kelompok kontrol pada minggu 8. analisis gee menunjukkan penurunan 1 poin srq-20 akan meningkatkan kepatuhan art (self report) sebesar 0,722 poin dan statistik korelasi bermakna (p<0,00). kesimpulan: setelah 8 minggu intervensi berbasis rebt pada odha perempuan, penurunan rerata skor srq20 berpengaruh terhadap peningkatan rerata skor kepatuhan art pada kelompok intervensi dibanding kontrol. kata kunci: kepatuhan art, hiv/aids, perempuan, kesehatan mental, rebt. surilena acta med indones-indones j intern med 284 abstract aim: to identify the effectiveness of rational-emotive-behavior-based therapy (rebt-based therapy) on improved mental health and antiretroviral (art) therapeutic adherence in women infected with hiv/aids (female subjects with hiv/aids). methods: a randomized and single-blinded clinical trial in women infected with hiv/aids who had their treatment at the outpatient clinic of pokdiksus aids rscm and at the aids comprehensive diagnostic unit of dharmais hospital was conducted between october 2011 and march 2012. a block randomization of 160 female subjects with aids was performed that resulted in a rebt-based treatment group (n=80) and a control group (n=80). the treatment group received rebt-based intervention of 8 sessions weekly including 6 individual-therapeutic sessions/week and 2 group-therapeutic sessions /week. instruments used in the study were questionnaires on demography, art adherence (measured by self report and pill count), and mental health (srq-20). data were analyzed using chi-square test, generalized linear model, and generalized estimating equations. results: there were 148 respondents analyzed including in the rebt-based group (n=72) and in the control group (n=76) with mean age of 33-34 years. after 8 weeks of rebt-based intervention, there was improved (increased) mean value of the self-reported adherence score (self-report) compared to control group (100%; ci 95%,83.3-96.7 vs. 84%; ci 95%,77.5-87.8) and improved (decreased) srq-20 mean score in rebt-based treatment group compared to control group (2.9; ci 95%, 2.7-13.0 vs. 5.4; ci 95%: 5.0.-13.6). art adherence based on viral load titer was not analyzed in both group since most of vl titer were undetected (<400 copies/ml). glm analysis showed decreased srq-20 mean score and increased mean value of self-reported art adherence (self-report) in the rebt-based treatment group, which were more significant (p<0.000) than control group on the 8th week. gee analysis showed that 1 point decrement of srq-20 would increase self-reported art adherence as much as 0.722 point and the correlation was statistically significant (p<0.00). conclusion: after 8 weeks of rebtbased intervention to female subjects with hiv/aids, there is a decrease of srq-20 mean score which may result in increased art adherence mean score in the treatment group compared to the control. key words: art adherence, hiv/aids, women, mental health, rebt. introduction the global report on aids epidemic (unaids report, 2012) showed that there are 34 million people with hiv/aids worldwide and 50% among them are women. the number of women infected with hiv/aids are increasing each year along with the increase in number of men doing unsafe sex, who eventually will transmit hiv/aids to their sexual partner or their spouse.1 minister of health of indonesia reported that in 2010, there were 406,600 people with hiv/aids (42% women) and it was predicted that there would be 813,720 people with hiv/ aids in 2014 (55% women).2 the psychosocial burden of housewives infected with hiv/aids is larger than their physical burden. psychosocial burden will extremely affect their survival and may cause emotional and mental health problem, which may lead to mental emotional disorder and poor medication adherence.3,4 a study (2008) demonstrated that 45% of people with hiv/aids who experienced depression would have poor medication adherence compared to 25% of those who did not.5 antiretroviral therapy must be continued lifelong and adherence is necessary. high adherence, >95% in taking arv medication is required to reduce the viral load to target level.6 hiv/aids management has not only been focused on physical problem, but also on psychosocial effects.7 rational-emotive-behaviorbased interventional therapy (rebt-based) is a form of psychotherapy using a structured, directed, and objective cognitive modification. it is oriented on “here and now” problems. this intervention aims to help women living with hiv/aids to identify and manage their irrational perception and beliefs in various situation, events, experiences, or problems they may encounter, particularly problems associated with hiv/aids infection; thus, they will be able to reach optimal self-realization, to build confidence and to develop vol 46 • number 4 • october 2014 the effect of rebt on antiretroviral therapeutic adherence and mental health 285 rational behavior and emotion, i.e. mental health and art adherence.8,9 this study was conducted to evaluate the effect of rebt-based intervention on art adherence in those infected with hiv/ aids, especially women who got hiv/aids through their spouse/regular partner. methods an explanatory, randomized, single-blinded clinical trial was conducted on women infected with hiv/aids who visited the outpatient clinic of pokdiksus aids at cipto mangunkusumo hospital and aids comprehensive diagnostic unit at dharmais hospital between october 2011 and march 2012. the inclusion criteria were women infected with hiv/aids through their partner/husband, were aged 17 years or older, literate in indonesian language or able to read and write and without history of substance/ alcohol dependency or abuse. sample size was determined using two proportion formula, with an assumption that art adherence changes as much as 20% after rebt intervention and to anticipate 10% drop out, we obtained a sample size of 160 respondents. furthermore, a block randomization was performed in 160 women living with hiv/aids and we found a rebtbased treatment group (n=80) and a control group (n=80), i.e. 40 subjects in each group at the aids pokdisus cipto mangunkusumo hospital and aids comprehensive diagnostic unit dharmais hospital. on the next phase, an assistant investigator provided two sealed envelopes to be chosen by respondents. if the respondent chose an envelope with letter a on it, then she would be categorized into the control group, and those who got envelope with letter b would be included in rebt-based treatment group. respondents in the control group subsequently filled in the srq-20 questionnaire, self-reported art adherence and underwent viral load titer examination on the first session/first week. meanwhile, respondents in the rebt-based treatment group were escorted by the assistant investigator to a consultation room for receiving rebt-based intervention provided by the principal investigator who was in charge on the first session/first week. the investigators tried to minimize and prevent drop out or loss of follow-up w by providing transportation fee of idr 15,000.00 for each session of treatment, building a good rapport since the first therapy session, scheduling the next meeting session and reminding the subjects for the next appointment using sms or phone call three days and one day before the next appointment. drop out or loss follow-up subjects were not included in the ontreatment analysis. the rebt-based intervention was conducted by the investigator herself for all respondents in the rebt-based treatment group both at cipto mangunkusumo hospital and dharmais hospital. rebt-based intervention consisted of 8 sessions/week including 6 sessions of individual therapy/week and 2 sessions of group therapy/ week. the respondents filled in questionnaires on demography (session 1), art adherence (measured by self-report and pill count) on session 1 – 8, and mental health (srq-20) as well as underwent viral load titer examination on session 1 and 8; while respondents in the control group filled in questionnaires on demography (session 1), art adherence (measured by selfreport), srq-20 and underwent viral load titer examination (session 1 and 8). instruments used were questionnaires on demography, art adherence, and mental health (srq-20). statistical analysis in this study, an analysis was performed using two group t-test and chi square between rebt-based treatment group and control group to identify comparability of basic variables.10,11 furthermore, a multivariable analysis was performed using (1) glm (general linear model) repeated measure to identify any differences in improvement tendency: (a) srq-20 mean score between rebt-based treatment group and control group on the 1st and 8th week; (b) art adherence mean score between rebt-based treatment group and control group on the 1st to 8th week; (c) risk factors that were assumed to modify rebt effects on art adherence; (2) gee (generalized estimating equations) to identify changes and role of srq-20 mean score on art adherence using self-report between rebt-based treatment group and control group on the 1st week and 8th week.12,13 statistical analysis was done using spss software program version 17.0. surilena acta med indones-indones j intern med 286 results subject characteristics in this study, there were 8 subjects in the rebt-based treatment group who were not included in the analysis (6 subjects were loss to follow-up, 2 subjects were drop-out on the second or third session) and 4 subjects in the control group were loss to follow-up on the second session. therefore, 148 subjects were analyzed, i.e. those in rebt-based treatment group (n=72) and control group (n=76). mean age of subjects in the rebt-based treatment group and control group were comparable, i.e. 33-34 years of age. the majority of subjects in rebtbased treatment group and control group had the following characteristics: married (91.6%93.4%), high school graduates (72.2%-59.2%), working women (43%-35.5%), moderate income families 58.3%-52.6%), duration of hiv/aids table 1. socio-demographic characteristics, hiv/aids infection and medication in rebt-based treatment group and control group prior to the intervention characteristics intervention p based rebt (n=72) control (n=76) sociodemographic status age (mean ± sd) 33 (6.5) 34 (19.2) 0.551 education level (%) high 10 (13.9%) 11 (14.5%) 0.174 moderate 52 (72.2%) 45(59.2%) low 10 (13.9%) 20 (26.3%) occupation (%) working 31 (43.0%) 27 (35.5%) 0.413 not working 41 (57.0%) 49 (64.5%) marital status (%) married 66 (91.6%) 71 (93.4%) 0.263 unmarried 6 (8.4%) 5 (6.6%) socioeconomic status (%) moderate 42 (58.3%) 40 (52.6%) 0,111 low 30 (41.7%) 36 (47.7%) hiv/aids infection duration of infection (%) <5 years 52 (72.2%) 50 (65.8%) 0.736 >5 years 20 (27.8%) 26 (34.2%) hiv stadium (%) asymptomatic (1) 22 (30.5%) 18 (23.7%) 0.656 mild (2) 40 (55.5%) 42 (55.3%) moderate (3) 10 (13.9%) 16 (21.0%) medication duration of art treatment (%) <2 years 40 (54.0%) 42 (55.3%) 0.874 >2 years 32 (46.2%) 34 (44.7%) side effects of art (%) absent 28 (38.9%) 40 (52.6%) 0.026* present 44 (61.1%) 36 (47.4%) art regimen (%) 3-type art 67 (93.1%) 73 (96.1%) 0.468 2-type art 5 (6.90%) 3 ( 3.90%) p*= levels of significance for changes were varied based on the self-report measured in the rebt-based treatment group and the control group vol 46 • number 4 • october 2014 the effect of rebt on antiretroviral therapeutic adherence and mental health 287 infection <5 years (72.2%-65.8%), hiv stage ii (55.5%-55.3%), duration of art therapy <2 years (54%-55.3%), and using 3 types of art (93.1%-96.1%). (table 1) pre-intervention analysis showed that there were comparable characteristics on sociodemographic issues, hiv/aids infection and medication between the rebt-based treatment group and the control group, except for the side effects variable (p>0.05). side effects between rebt-based treatment group and control group were not comparable (p=0.026), in which the subjects in the treatment group had more side effects (61.1%) than the control group (47.4%). (table 1) it indicates that randomization design in the rebt-based treatment group and the control group for evaluating the side effects variable was not successful. therefore, the variable of side effect should be controlled statistically with multivariate analysis. characteristics of art adherence in this study, art adherence in the rebtbased treatment group was measured by the self-report and pill count on the 1st up to 8th week as well as by viral load titer examination on the 1st and 8th week. post-intervention analysis showed that the mean score of self-reported adherence between the rebt-based treatment group and the control group on the first week were comparable (74%: ci95%, 69.0-75.3) v.s. (77 %: ci 95%, 71.8-80.3) and on the following weeks, there were improved (increased) mean score of self-report in the rebt-based treatment group compared to the control group (p=0.000). the mean score of pill-count adherence in rebtbased treatment group was 88% on the first week and was improved (increased) with time on the following weeks. both self-report and pill-count art adherence in the rebt-based treatment group had reached optimal art adherence (>95%) on the 5th week. art adherence based on viral load (vl) titer could not be analyzed due to lack of variation of vl titer proportion (most subjects on both groups had undetected vl titer; <400 copies/ml) on the 1st and 8th week. these characteristics are described in table 2. characteristics of emotional mental health chi square analysis showed that there was a significantly greater decrease of srq-20 mean score in the rebt-based treatment group on the 8th week than the control group (p=0.000). the proportion of respondents who had positive psychopathology (score >6) on the first week was comparable between the rebt-based treatment group and the control group, i.e. 58.8%-60%. however, after receiving the intervention, on the 8th week we found that there were more subjects with negative psychopathology in the rebtbased treatment group (score <5), which were 78.8% compared to 45.5% in the control group. the more commonly found psychopathologies were depression (66%) and anxiety disorder (34%). (table 2) multivariate analysis the general linier model (glm) repeated measure analysis showed that there was a significantly greater decrease of srq-20 means score in the rebt-based treatment group than the control group on the 8th week (p=0.000) (figure 1) and there was also a significantly greater decrease of self-reported art adherence mean score in the rebt-based treatment group on the 4th and 8th week compared to the control group (p=0.000). (figure 2) the results of glm analysis also showed that socio-demographic risk factors, hiv/aids infection (duration of illness, stage of infection), medication (duration of art, art side effects, and art regiments) did not have significant effect on modifying the effect of rebt-based intervention on art adherence (p<0.05). generalized estimating equations (gee) analysis showed that the equal regression of self-reported art adherence on the first week was 79.71–0.722*; srq-20 on the 8th weeks were 96.35-0.722*srq, which means that 1 point decrease of srq will increase art adherence as much as 0.722 point. the results of analysis showed a significant correlation between decreased srq-20 mean score and the increased mean score of self-reported art after the intervention in both the rebt-based treatment group and control group (p=0.000). (table 3) surilena acta med indones-indones j intern med 288 table 2. characteristics of irrational beliefs, mental health, and art adherence in the rebt-based treatment group and the control group characteristics rebt (n= 72) control (n=76) p mean (%) mean of 95% confidence interval mean (%) mean of 95% confidence interval art adherence self report week 1 74.0 69.0-75.3 77.0 71.8-80.3 week 2 84.0 week 3 90.0 week 4 94.0 81.4-92.7 79.0 77.5-87.8 week 5 100.0* week 6 100.0 week 7 100.0 0.000* week 8 100.0 83.3-96.7 84.0 77.5-87.8 pill count week 1 88.0 85.4-90.0 week 2 90.0 80.0-90.2 week 3 93.0 82.4-93.0 week 4 95.0 83.6-95.2 week 5 99.0 82.7-95.6 week 6 100.0 83.2-96.6 0.000* week 7 100.0 82.7-96.3 week 8 100.0 83.8-96.9 viral load titer week 1 undetected 92.5 95.0 detected 7.5 5.0 week 8 undetected 87.5 93.9 detected 2.5 1.2 drop out 10.0 5.0 mental health (srq-20) week 1 negative psychopathology (≤5) 40.0 41.3 0.000* positive psychopathology (≥6) 60.0 58.8 week 8 negative psychopathology (≤5) 78.8 45.0 positive psychopathology (≥6) 21.3 55.0 ci= confidence interval on 95% mean p*= levels of significance for changes were varied based on the self-report measured in the rebt-based treatment group and the control group discussion this study is a clinical trial, which was c o n d u c t e d t o p r o v i d e e v i d e n c e s o n t h e effectiveness of rebt-based intervention on art adherence and mental health in women living with hiv/aids who visited the outpatient clinic of pokdiksus aids at cipto mangunkusumo hospital and aids comprehensive diagnostic unit at dharmais hospital. although the study was conducted only at two health care sites of vol 46 • number 4 • october 2014 the effect of rebt on antiretroviral therapeutic adherence and mental health 289 art clinics, i.e. at cipto mangunkusumo and dharmais hospital, but both hospitals were health referral centers providing antiretroviral therapy for people with hiv/aids in indonesia; thus the results of our study can be generalized to be applied in indonesia. limitation of this study includes our inability to have all respondents receiving therapeutic session each week since most of them have to work and could not afford transportation cost. in order to get the subjects to be able to participate and attend each sessions, the investigator did some measures including providing transportation incentives of idr 15,000.for respondents in both groups – the rebt-based treatment group and the control group (for each session), building good rapport since the first session of therapy, explaining about the aim and benefit of the study that could be obtained by the respondents after participating in the study, especially for those in rebt-based treatment group. also, subjects and the investigator determined and made appointment for next meetings, the investigator also reminded subjects to come for the next session through sms or phone calls three days or one day previously. the measures to minimalize study limitation were quite successful since only 8 out of 160 subjects were drop out in the rebtbased treatment group (6 respondents were loss to follow-up, 2 respondents were drop-out on second or third session) and 4 respondents were loss to follow-up in the control group on the second group. thus, there were 148 subjects analyzed in this study including all women who got infected by hiv/aids from their regular sexual partner/ spouse and without any history of drug/substance abuse. unaids (2010) estimated that there are more than 90% of 1.7 million women living with hiv/aids in asia actually got the infection from their partner/spouse.1 in indonesia, it is predicted that the number of women infected with hiv/aids will be increasing. ministry of health republic of indonesia (2011) stated that the numbers of housewives infected with hiv will increase each year; while the number of commercial sex worker infected with hiv is declining. it is assumed that it is resluted from transmitted hiv infection from their partner/ spouse who have high-risk behavior.2 this study demonstrated that before intervention (first week/first session) there were 60% respondents with positive psychopathology in both groups. most subjects described their various thoughts and beliefs such as that they had no future, would not be able to be cured although treated with antiretroviral (arv), would not be able to have a long life, would not be able to care 8 6 4 2 1 2 srq e s ti m a te d m a rg in a l m e a n s rebt conventional estimated marginal means of measure 1 figure 1. improved mental health (srq-20) mean score between rebt-based treatment group and control group 100.00 95.00 90.00 85.00 80.00 75.00 70.00 1 4 8 visit (weekly) rebt conventional s e lf r e p o rt figure 2. improved self-reported art adherence mean score between rebt-based treatment group and control group table 3. changes of srq-20 mean score and art adherence on gee analysis in rebt-based treatment group and control group parameters b se 95% ci p intercept 79.713 1.9257 75.939-83.487 .000 week 8 16.636 1.5905 13.519-19.753 .000 week 1 0a . . . srq-20 -.722 .2074 -1.128--.315 .001 ci=confidence interval; se=standard error; b=coefficient surilena acta med indones-indones j intern med 290 for their children, or they were having punishment from god, feeling guilty for transmitting the virus to their children, feeling helpless due to the illness, feeling being rejected or isolated from family or environment if their hiv status were known. a study (2007), which was conducted at the john hopkins hiv clinic reported that 54% women infected with hiv/aids were also diagnosed with psychopathologies including 20% suffered from severe depression, 18% with adjustment disorder, and 74% with substance abuse disorder.14 another study also reported that greater depression disorder was found in women infected with hiv/aids compared to those without hiv/aids infection. mental emotional disorders, especially depression in people infected with hiv/aids may affect medication adherence and resulting in poor adherence to therapy.15 our study also showed a significantly greater improvement on srq-20 mean score in rebtbased treatment group compared to control group on the 8th week. it indicates that rebt-based intervention is effective to help women with hiv/aids to manage their irrational belief and change it into rational belief against various situations, events, experiences or problems they encountered; thus, these women could achieve optimal self-realization, build self-esteem, and able to develop rational and healthy emotion, i.e. mentally healthy condition.8,9 raffy (2008) demonstrated that people with hiv/aids who had irrational belief usually have emotional mental disorders such as depression, which are characterized by the feeling of helplessness, no life purposes, reluctant to take medication, and belief that they will die soon.16 the results of our study also showed that there was increased mean score of self-reported and pill-count art adherence and it has reached optimal adherence (>95%) on the fifth week after receiving the rebt-based intervention therapy. these suggest that the eight-week sessions of rebt-based intervention therapeutic modules could be reduced or given into five-week sessions. therefore, further studies on rebtbased intervention therapy of five-week sessions should be conducted. arv adherence assessment based on pill-count was only performed in the rebt-based treatment group since the assessment of art adherence on conventional therapy is only based on self-report and viral load titer examination; while the art adherence based on viral load titer could not be analyzed since viral load titer of most respondents was undetected (<400 copies/ml) in both groups on the first and eight week. it may be probably due to several issues, such as most subjects had received art ≤6 months – 2 years and the study was conducted in hiv/aids referral center hospitals that received referral from various central and peripheral art health care units in indonesia. a study (2010) in 102 women infected with hiv showed that approximately 69 women had undetected virus titer in their blood after 6 months of treatment.17 centers for disease control and prevention (cdc) suggested that undetected viral load can be reached after 6 months of art therapy.6 this study showed significant correlation between decreased srq-20 mean score and increased mean score of self-reported art adherence after rebt-based intervention. it indicates that rebt-based intervention could improve and change irrational and negative perception, behavior and attitude of women living with aids, especially about art therapy that they have received into a rational and logic perception and belief; thus, those women are able to improve their self-esteem and motivation on medication adherence. another study (2008) showed that people living with hiv/aids who have negative and irrational perception and belief show mental emotional disorders such as depression, which is manifested as feeling of despair, pessimistic, helplessness, feeling of losing purpose of life, feeling that there is no use of taking any medication and believing that they will die soon.18 pence (2009) suggested that irrational thought and belief may affect the condition of people living with hiv/aids either by cognitive, affective or conative aspect. pence also suggested that depression may become a predictor of low art adherence, increased highrisk sexual behavior, failure of art therapy, and faster hiv syndrome manifestation and higher mortality rate. people living with hiv/aids who vol 46 • number 4 • october 2014 the effect of rebt on antiretroviral therapeutic adherence and mental health 291 have depression are likely to get hiv-treatment (art) adherence problems of two folds greater compared to those without depression.16,19 therefore, early detection and prompt treatment for mental emotional health problems in women living with hiv/aids are essential to prevent further deterioration on physical and mental health as well as their quality of life. conclusion after 8 weeks of rebt-based intervention in women living with hiv/aids, a decrease of srq-20 mean score may affect increased mean score of art adherence in the treatment group compared to control group. rebt-based intervention is recommended to be given in central and rural art health care units, especially for mental health service in order to achieve optimal physical and mental health and optimal art adherence (>95%) as well as to reach the target of getting to zero policy, i.e. zero new hiv infection and zero aids related death, particularly in women infected with hiv/aids. references 1. unaids. strategic plan 2010-2012. the coalition of asia pasific regional networks on hiv/aids. 2010. 2. perez r, bano rj. health-related quality of life of patients with hiv: impact of sociodemografic, clinical and psychosocial factors. qual life res. 2005;14:1301-10. 3. folkman. stress and coping caregiving partners of women with aids. psy clin north am. 2000;17:35-52. 4. aasha km, sreoshi g. the impact of hiv/aids on women care givers in situations of poverty: policy issues. the united nations development fund for women. am j psychol. 2008;18:267-79. 5. aditya bj. kerentanan perempuan terhadap hiv/ aids. j perempuan. 2008; 43:7-21. 6. who. antiretroviral therapy for hiv infection in adult and adolescents towards universal access. recommendations for a public health approach. 2010 revision. 7. mazzafero ke. murray pz. depression, stress, and social support as predictors of hiv/aids in young women. j adolescent health. 2009;39:337-44. 8. ellis a. discomfortanxiety: a new cognitive behavioural construct. j psychol. 2003;8:233-9. 9. surilena. effect of rational emotive behaviour based therapy on antiretroviral therapy adherence in hiv-positive women. disertasi. program doktor. universitas indonesia. fakultas kedokteran. agustus 2012. 10. puspenogoro hd, wirya ign, pudjiadi ah, bisanto j. uji diagnostik dalam dasar-dasar metodologi penelitian klinis. 2nd ed. jakarta: sagung seto; 2002. p. 55-6. 11. kenneth fs, douglas a. the consort statement: revised recommendations for improving the quality of reports. jama. 2001;18:1-12. 12. nelder j, wedderburn w. generalized linear models. j royal stat soc, series a. 1998;135:370–84. 13. bryek as, raudenbush sw. application of hierarchical linear models to assessing change. psychol bulletin. 1999;101:147–58. 14. felix fw, caroline g. highly active antiretroviral therapy adherence. its determinants in selected regions in indonesia. amj indones. 2011;20:1021-33. 15. jaquet a, ekouevi dk, et al. health-related quality of life in french people living with hiv in hiv. aids. 2007;21(suppl1):s19-27. 16. claude am, elizabeth bc. the role of psychosocial and family factors in adherence to antiretroviral treatment in human immunodeficiency virus infected children. pediatr infect dis j. 2004;23:1035–41. 17. chesney ma, i ckovics jr, chambers db, et al. self report adherence to antiretroviral medications among participants in hiv clinical trials: the aactg adherence instruments. patients care committee & adherence working group of the outcomes committee of the adult aids clinical trial group (aactg). aids care. 2000;12(3):255-66. 18. filho lf, nogueira sa, machado es, et al. factors associated with lack of antiretroviral adherence among adolescents in a reference centre in rio de jeneiro, brazil. aids patient care stds. 2008;19(10):685-8. 19. abera k, gedif t, mariam t. quality of life of people living with hiv/aids and in highly active antiretroviral therapy in ethiopia. aids care. 2010:9(1):31-40. 467acta med indones indones j intern med • vol 54 • number 3 • july 2022 review article aquaretics use in acute decompensated heart failure (adhf) patients: a literature review norman sukmadi1*, kevin surya1, arif sejati2 1 faculty of medicine and health sciences, atma jaya catholic university, jakarta, indonesia. 2 department of internal medicine, cardiovascular consultant, faculty of medicine and health sciences, atma jaya catholic university atma jaya hospital, jakarta, indonesia. *corresponding author: norman sukmadi, md. faculty of medicine and health sciences, atma jaya catholic university, jakarta, indonesia. jalan pluit raya no. 2, jakarta, indonesia, 14440. email: sukmadi279@gmail.com. introduction heart failure is a global pandemic, with a rapidly increasing prevalence, affecting at least 26 million people worldwide.1 in the united states of america, the american heart association (aha) estimated that, between 2013 and 2016, around 6.2 million people suffered from heart failure. this number is projected to increase in 2030, with an increased prevalence rate of 46% from the available data in 2012, more than 8 million patients will have heart failure. this burden of disease will increase from 30.7 billion us dollars in 2012 to 69.8 billion us dollars in 2030.2 generally, acute heart failure (ahf) is defined as a rapid onset or worsening of heart failure signs and symptoms that need urgent medical treatment. ahf may present as a first occurrence (de novo), or more frequently, due to acute decompensation of chronic heart failure, commonly known as acute decompensated heart failure (adhf).3 more than 1 million hospitalizations per year in the united states is due to adhf; thus, this condition is the main reason for hospitalization in patients aged 65 or more.4 adhf causes a heavy financial burden on the healthcare system, most of which are closely related to hospitalization. the in-hospital mortality rate of adhf is around 4-7%; the 3-month post-discharge mortality rate is around 7-11%, and the 1-year post-discharge mortality rate is 36%. according to studies in the united states, the length of hospitalization is around four days, and in europe, it can be around 6-11 days. despite this long-standing burden, only a few steps were achieved within the last couple of years in medical treatment for adhf.5 the management of adhf was written by the european society of cardiology (esc) in abstract this is a literature review of the use of aquaretic in patients with acute decompensated heart failure (adhf), including the physiologic function of vasopressin and its mechanism of action in heart failure patients, and aquaretic drugs with their respective risks and benefits. vasopressin is one of several hormones that can cause hyponatremia and worsen congestion in adhf patients. aquaretics are a class of drugs that have an antagonistic effect on vasopressin receptors, especially v2r. aquaretics use in adhf patients can provide relief for congestive symptoms with no serious adverse effects. in-depth additional understanding regarding aquaretics may be useful for clinical judgments in treating adhf patients. keywords: acute decompensated heart failure (adhf), aquaretics. norman sukmadi acta med indones-indones j intern med 468 v2r receptors are g-protein-coupled receptors (gpcr) found in the basolateral plasma membrane in the collecting duct. vasopressin bound to this receptor will increase water absorption by regulating aquaporin-2 (aqp2).12 aqp-2 plays a crucial role in regulating shortand long-term water permeability in the collecting duct. short-term regulation results in increased water permeability 5 to 30 minutes after vasopressin concentration increases, while the long-term regulation happens when vasopressin level increases within days, causing increased aqp2 levels in cells.13 v3r correlates with the secretion of acth by binding the receptors in the anterior pituitary.14 table 1 describes the vasopressin receptor’s physiological effects. vasopressin in heart failure vasopressin levels will increase in heart failure patients as the functional severity of the disease increases.15 the increase in vasopressin is modulated by three mechanisms: the osmoreceptor, the baroreceptor, and the renin-angiotensin-aldosterone system (ras). vasopressin production is primarily regulated by the osmoreceptors in the hypothalamus; a 1-2% decrease in plasma osmolality will suppress vasopressin level so that maximal aquaresis is achieved. heart failure patients have a decreased cardiac output that causes lower arterial filling, leading to baroreceptor activation in the carotid sinus, aortic arch, and left ventricle. this pathway has a lower sensitivity in regulating vasopressin but is much more potent in heart failure patients. on the other hand, the ras system regulates the vasopressin by direct secretion of the hormone angiotensin ii.16 the increase in vasopressin leads to lower excretion of water and, thus, causes 2016 and the american college of cardiology foundation (accf) in conjunction with the aha in 2013. however, aquaretic (vasopressin receptor antagonist) use was only considered in patients with volume overload and severe resistant hyponatremia.3,6 one of the pathophysiologies in heart failure patients is an increased level of vasopressin. through the activation of the v1 pathway, there is an increase in peripheral resistance and pulmonary capillary wedge pressure (pcwp), whereas stroke volume and cardiac output decrease.7 vasopressin receptor antagonist drugs bind three receptors, v1r that affects vasoconstriction, v2r that has a role in water reabsorption, and v3r that affects the adrenocorticotropic hormone.8 this literature review highlights the mechanism, benefits, risks, and use of aquaretics in adhf patients. physiology of vasopressin vasopressin, or antidiuretic hormone (adh), is a hormone secreted in the hypothalamus and stored in the posterior pituitary. this hormone has several roles in controlling the body’s osmotic balance, blood pressure regulation, sodium homeostasis, and kidney function.9 these v receptors can be classified into v1 vascular (v1r), v2 renal (v2r), v3 pituitary (v3r), dan oxytocin (otr) subtypes.10 v1r receptors are found in vascular smooth muscles and result in vasoconstriction by increasing the intracellular calcium levels. v1r receptors are also found in the brain, testes, liver, and renal medulla; however, the function is still unknown. platelets are known to express v1r receptors, which facilitate thrombosis; however, there is varying platelet aggregation response in different individuals.11 table 1. physiologic function of vasopressin receptor.11–14 vasopressin receptor location physiologic function v1r vascular smooth muscle (mainly), thrombocyte, brain, testicles, liver, cardiomyocyte, and kidney medulla vasoconstriction (mainly), gluconeogenesis, and thrombocyte aggregation v2r collecting duct of the kidney increasing water reabsorption through aqp2 v3r anterior pituitary gland secreting acth vol 54 • number 3 • july 2022 aquaretics use in acute decompensated heart failure (adhf) 469 hyponatremia. water retention will exacerbate congestion in heart failure patients, while hyponatremia independently correlates with increased mortality. chronically, this process will cause heart remodeling.17 (figure 1) pharmacology of aquaretics aquaretics are a class of drugs that induces water excretion without electrolyte excretion. this group of drugs refers to vasopressin receptor antagonists, especially v2 receptor antagonist.19 peptide vasopressin receptor antagonists have been developed since 1960; however, their efficacy is low. peptide antagonists lose their antagonistic effects and become agonists when administered chronically and can only be given parenterally. vaptan is a non-peptide vasopressin receptor antagonist that is orally active.20 table 2 shows the available aquaretics. conivaptan is a type of vaptan with affinity to v1 and v2 receptors, with dose-dependent effects. conivaptan is approved by the food and drug administration (fda) for its hyponatremia usage with an intravenous dose of 40-80 mg/ day. however, this is not recommended for heart failure patients because no significant difference in the effect found when applied in the patients compared to placebo.21 lixivaptan is an orally active vasopressin receptor antagonist with non-peptide and v2 receptor-selective (100:1 with v1) characteristics. similar to conivaptan, the potency of aquaresis in lixivaptan is also dose-dependent.22 currently, this drug is undergoing phase 3 clinical trials in patients with autosomal dominant polycystic kidney disease (adpkd).23 mozavaptan (opc-21268) is a selective v2 receptor antagonist (10:1 with v1), which can be given parenterally. the aquaretic effect from mozavaptan is dose-dependent (0,017-1 mg/kg) and still has its effect after two hours. when administered in high doses (0,75-1 mg/ kg), its aquaretic effect has the same potency as 20 mg furosemide.21 mozavaptan is only used in japan, and its clinical indication is for the inappropriate secretion of antidiuretic hormone in paraneoplastic syndrome.20 satavaptan is an orally active and highly selective v2 receptor antagonist (112:1 with v1).24 satavaptan has a long half-life and can be table 2. aquaretics type available.20 receptor antagonist type examples v1/v2 conivaptan v2 lixivaptan mozavaptan satavaptan tolvaptan figure 1. role of vasopressin in heart failure. norman sukmadi acta med indones-indones j intern med 470 given once daily with a 5-50 mg/day dose. this drug is metabolized in the liver and eliminated with the feces.20 tolvaptan is a type of aquaretic with high selectivity to the v2 receptor (29:1 with v1) and has no biologic activity with v3. around 40% of oral tolvaptan dose will be reabsorbed, with maximal concentration achieved in 2-4 hours (not affected by foods). dosing of tolvaptan starts from 15 mg once daily, and may only be increased after 24 hours until a maximum dose of 60 mg/day.25 tolvaptan is one of the few drugs accepted by the fda for the treatment in hyponatremia in siadh, heart failure, and liver failure patients because of its safety and efficacy. on the contrary, other vaptans are still under clinical trials or have already been rejected because of its safety and efficacy.26 benefits and uses decompensation in adhf patients occurs due to increased sympathetic nervous system activation, adh, and renin-angiotensinaldosterone (raas). these neurohormonal activations cause upregulation in the raas and intrarenal vasoconstriction, thus increasing sodium and water retention. diuretics such as furosemide, metolazone, and spironolactone have become one of the mainstay therapies for adhf patients. aquaretics are added to increase fluid and osmotic balance by inhibiting water retention without affecting the electrolytes in adhf patients.27 efficacy most patients hospitalized for adhf are complaining about their symptoms due to volume overload (congestion). decongestion through diuresis is one of the primary treatment in these patients, and some parameters such as weight loss, and urine output could be attributed as objective parameters to assess the efficacy. activ trial, a randomized clinical trial (rct) done by gheorghiade et al. compared three doses of tolvaptan (30 mg, 60 mg, and 90 mg) with placebo. patients aged 18 years and older with decompensated heart failure with stable hemodynamic were included. tolvaptan was useful in weight loss on day one and significantly provided relief for congestive symptoms. an increase in sodium level was found in patients with a tolvaptan regimen, while a small decrease was found in patients with a placebo regimen. tolvaptan used in adjunction to standard therapies such as potassium-sparing diuretics will allow greater diuresis independent of the dose.28 this greater diuresis effect is reflected by one of the symptoms which is dyspnea. a metaanalysis from luo et al, stated add‐on tolvaptan was shown to be more effective in relieving short‐term dyspnea than traditional diuretics alone (rr = 1.12 [1.05‐1.18]). in addition to relieving dyspnea, tolvaptan as an add-on therapy was also more effective at reducing edema and body weight, as well as urine output (rr = 1.08 [1.02-1.15], md = -0.82 [-0.94 – 0.71], md = 0.49 [0.39 – 9.60] respectively).29 this finding is similar with meta-analysis from ma, et al, which included 7 rct with 937 patients showed that tolvaptan as an adjuvant therapy may reduce body weight and increase sodium levels in adhf patients significantly.30 in contrast, tactics-hf by felker, et al showed that, despite of greater weight loss and net fluid loss in the tolvaptan arm compared in placebo, but dyspnea relief by likert scale was similar between these 2 arms at 8 hour and 24 hour (p: 0.59, and 0.80 respectively). these 2 arms were received standardized loop diuretic which consist of iv furosemide equivalent to their total daily oral outpatient dose (low dose arm in dose study). these findings may represent that despite net fluid loss is higher, time is needed for distribution of fluid out of the extravascular spaces into the circulation. median length of stay was similar in both groups (5 days), and other clinical endpoints such as post-discharge outcome in 30 days was similar.31 konstam, et al has similar finding in his rct, which tolvaptan has rapid and persistent weight loss, but not associated with improvement in dyspnea at first 8 – 24 hours (assessed with likert dyspnea scores), but at day 3 dyspnea reduction was greater and significant in tolvaptan arm.32 these findings suggest that further research is needed to develop more strategies for decongestion in patients with adhf. vol 54 • number 3 • july 2022 aquaretics use in acute decompensated heart failure (adhf) 471 loop diuretic is the mainstay therapy for congestion in patients with adhf and tolvaptan add-on has shown great efficacy to relieve the congestion, but tolvaptan has been studied as monotherapy in patient with adhf. aquaahf, a randomized pilot study conducted by ng et al, evaluating tolvaptan as monotherapy (30 mg oral, daily) in patients with hf that required hospitalization for decongestive therapy with hyponatremia compared to loop diuretics (5mg/h iv). this study showed that urine output, and net fluid balance were better in the furosemide group, but did not have significant differences in median between groups. renal function is also better in the furosemide group, but not statistically significant. oral tolvaptan monotherapy was associated with similar diuresis compared with iv furosemide, but not superior.33 larger studies are needed to further address this finding. diuretic resistance (dr) is a common challenge in treating adhf patients. patients with such condition are commonly treated with a combination of diuretic regiments. current guidelines recommend adding a second diuretic such as thiazide, but it has limited data for the recommendation. cox et al, conducted a trial to compare the combination of diuretic strategies, 5mg oral metolazone twice daily vs 500 mg iv chlorothiazide twice daily vs 30mg tolvaptan daily, concomitantly with high-dose iv furosemide. this study showed that, tolvaptan has similar results in term of weight loss with other diuretic, but only tolvaptan was associated with an improved urine output-based diuretic efficiency, and smaller decreases in serum sodium and chloride compared to others.34 renal properties patients that require more diuretic agents are linked to worsening renal function (wrf), this finding makes researchers conduct some study. although the impact of renal function during adhf is less defined, there have been some studies conducted to clear things up. a rct conducted by kimura et al, which compared addition of early tolvaptan administering (24 hours) to fixed furosemide dose (20mg/day) with furosemide that dosed up to 30mg/day, had significantly wrf and natrium serum level. a kaplan-meier analysis for survival free of cardiac death, or readmission for heart failure during the 90 days after discharge was done. event free rate was significantly lower in the persistent wrf (p-wrf) subgroup, and the incidence of p-wrf was significantly lower in the tolvaptan group.35 this renoprotective benefit of tolvaptan as add-on therapy is also observed by yamamoto et al, in their retrospective study. changes in serum creatinine (cr) was significantly increased in the non-tolvaptan group (+0.2 mg/dl vs -0.1 mg/ dl), and the changes of gfr was significantly decreased in non-tolvaptan group ( -2.7 ml/ min/1.73m2 vs +1.4 ml/min/1.73m2). the wrf rate in the tolvaptan group was significantly lower (2.5% vs 15.4%) especially in the heart failure with preserved ejection fraction (hfpef) patients. when multiple logistic regression performed for analyzing the predictors of wrf, tolvaptan also found to be an independent factor for reducing wrf (or: 0.14 [0.02-0.98]).36 these similar results also found by kin et al, tolvaptan add-on therapy had lower incidence of wrf (8.5% vs 24%), and tolvaptan add-on therapy was an independent factor of preventing wrf.37 but these results were varied, felker et al in his study showed that wrf was more frequent in tolvaptan arm than in placebo arm (39% vs 27%).31 wang c, et al showed in their meta-analysis that tolvaptan decreased the rate of wrf compared with furosemide. tolvaptan could also elevate the sodium level as fast as 2 days, indicating that tolvaptan was more suitable for adhf with hyponatremia.38 long-term effect konstam et al. conducted a trial that included patients aged 18 years or older with reduced left ventricular ejection fraction, nyha iii/ iv symptoms, and hospitalization caused by adhf. the patients were randomized to receive a placebo or 30 mg/day tolvaptan (standard therapy was given to both groups). in the short term, when added to standard therapy, tolvaptan showed improved signs and symptoms of adhf with no severe adverse reactions.39 in the long term, tolvaptan was non-inferior for mortality compared to standard therapy (kaplan meier analysis for mortality is 25% in the tolvaptan group and 26% in the placebo group, and death norman sukmadi acta med indones-indones j intern med 472 from cardiovascular causes or first hospitalization is 42% and 40.2%, respectively). 40 wang c et al. also showed that tolvaptan was not inferior in mortality and prevented rehospitalization compared to conventional therapy, but a subgroup analysis showed that more than 15mg/ day of tolvaptan had the highest probability of achieving the best efficacy in preventing mortality and rehospitalization.41 however in asian population, nakao et al. in his meta-analysis showed that, compared to the conventional therapy tolvaptan as add-on therapy did not show to improve long-term mortality and hf readmission in japanese patients with hf. (or: 1.02 [0.69 – 1.52], and or: 0.73 [0.24 – 2.22] respectively). 42 cardiac remodeling prevention is one of the hypotheses that encourages the possible beneficial use of tolvaptan. udelson et al. conducted an rct to examine the effects of tolvaptan on changes in the left ventricular volume over time. there were no significant changes in the left ventricular end-diastolic volume (lvedv) after one year of observation.43 however, since this study was only conducted in stable hf patients, more studies are needed to confirm the cardiac remodeling effect of vaptans in patients after hospitalization due to adhf. cost effectiveness cost is one of the topics currently being considered and studied thoroughly. dasta et al. conducted a study in 2018 that analyzed data from the hyponatremia registry (hnr), a multicenter and global observational study of management of hospitalized patients with euvolemic or hypovolemic hyponatremia. seven hundred sixty-two patients, who were hospitalized because of heart failure, were analyzed. the data showed that patients administered with tolvaptan had a shorter hospitalization duration than patients with water restriction only (4 vs 6 days). additionally, the average cost of 15 mg and 30 mg was compared with the average cost of hospitalization per day in the united states. tolvaptan use was estimated to be 2295 usd cheaper than only water restriction regimen. however, the weakness of this study was only relying on data taken from hnr, which might present with input errors. furthermore, the sample characteristics cannot be determined as in an experimental study. the cost of hospitalization is different in each country; therefore, this research cannot be used as an international reference.44 general usage of vaptans tolvaptan is used once daily orally with flexible titration. the starting dose is 15 mg/day and can be titrated to 30 mg/day after at least 24 hours and up to 60mg/day. during the initiation and titration, clinicians should frequently monitor the electrolytes and volume. tolvaptan is contraindicated in patients with hypovolemic hyponatremia, anuria, hypersensitivity, concomitant use of potent cyp3a inhibitors, urgent need to raise serum sodium acutely, and inability to respond to thirst. chronic use of tolvaptan can cause liver injury; thus, tolvaptan should not be given for more than 30 days to minimize the risks. patients with cirrhosis should be monitored carefully as gi bleeding may occur.45 vra use has been mentioned before in the 2013 accf/aha guidelines for patients h o s p i t a l i z e d w i t h v o l u m e o v e r l o a d a n d severe hyponatremia and with a iib class of recommendation and a b level of evidence.6 on the other hand, the 2016 esc guidelines also stated that vra, such as tolvaptan, can treat patients with volume overload and resistant hyponatremia, but did not state the class of recommendation nor the level of evidence.3 these guidelines should be updated because newer evidence showed that fda-approved vaptan such as tolvaptan could be used as an adjuvant therapy to standard therapy (loop diuretic and/or mra) to lower the use of more loop diuretics. this is important because higher doses of loop diuretics may worsen the renal function, and the addition of vra provides better relief of congestive symptoms and stable serum sodium levels. vra can still be used in patients with adhf without hyponatremia, but adhf patients with hyponatremia may get the most benefit.30,35,41,46 risks the use of vasopressin receptor antagonists can cause some side effects, such as thirst, vol 54 • number 3 • july 2022 aquaretics use in acute decompensated heart failure (adhf) 473 pollakiuria, and dry mouth. thirst is found in 29% of patients and may become a problem if the patients increase their fluid intake.44 in the administration of conivaptan, 9.8% of patients experienced a rapid correction of serum sodium (>12 meq/l/day) with no neurological symptom drawbacks especially the central pontine myelinolysis (cpm).48 tolvaptan use is safe and only has some minor adverse reactions. an rct found that 39.2% of patients complained of thirstiness, but these side effects were not prominent if the drugs were only given for 7-14 days. other studies also reported that thirst was only felt mostly during the first three days.49,50 some case reports demonstrated that tolvaptan use in the elderly may cause liver damage.51 the risk of liver damage in patients with adpkd is well known. in an rct of 961 patients, 1.5% of patients stopped the drug due to liver dysfunction, 4% of patients had a significant improvement in liver function, and 0.9% of patients had an increase in bilirubin.52 however, no studies have reported liver damage in patients with ahf, especially adhf. a retrospective study by fujioka et al found that although the continuous use of tolvaptan after discharge did not affect mid-term cardiac events of hf overall, it may be associated with increased cardiac events in the subgroup with preserved renal function. the exact cause was not determined, but the author argued that thirst, a side effect of tolvaptan, might have increased water intake after discharge. this result suggested that the use of tolvaptan might need to be limited to in-hospital management of adhf.53 in laboratory animals, conivaptan exerted fetopathic effects at doses that were less than the therapeutic dose. this delayed labor in rats at doses that were equivalent to their therapeutic doses. thus, conivaptan has been considered in pregnancy category c by the fda. another thing to consider is that the administration of conivaptan can increase plasma concentrations of midazolam, simvastatin, digoxin, and amlodipine. conivaptan is a potent inhibitor of cytochrome p450 3a4 (cyp3a4), leading to serious drug-drug interactions. tolvaptan has less potential for drug-drug interactions. coadministration of conivaptan with potent inhibitors of (cyp3a4), such as ketoconazole, itraconazole, clarithromycin, ritonavir, and indinavir is contraindicated. due to this drawback, an oral preparation of conivaptan has not been developed.47 there have been efforts to develop novel vasopressin antagonists, one of which is the highly v2 selective lixivaptan. the balance trial, an rct designed to evaluate the effect of lixivaptan in adhf, reported a statistically significant but modest increase in sodium concentration. however, there was an unusually high number of deaths early in the lixivaptan group for unclear reasons – 15 patients in the first ten days of treatment versus four in the placebo group. this raised concerns about the safety of lixivaptan use in patients hospitalized with adhf. thus, on september 13, 2012, the fda voted unanimously against recommending lixivaptan for the treatment of hypervolemic hyponatremia.54 conclusion the use of aquaretics in patients with heart failure is well known in scientific writing, but this has only focused on the short-term, long-term, and the safety of their use. the use of aquaretics, especially tolvaptan, with a starting dose from 15 mg/day titrated up to 60mg/day may lead to good outcomes as adjuvant therapy in reducing symptoms from congestion such as shortness of breath, and objective parameters such as weight reduction, and in correcting hyponatremia. this use of the drug is non-inferior in terms of mortality compared to standard therapy. clinicians need to investigate more on aquaretics to provide the best therapy for adhf patients. references 1. savarese g, lund lh. global public health burden of heart failure. card fail rev. 2017;3(1):7–11. 2. heart disease and stroke statistics—2020 update: a report from the american heart association. circulation [internet]. 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indonesian society of respirology, jakarta, indonesia. 2 department of parasitology, faculty of medicine universitas indonesia, jakarta, indonesia. 3 siena clinical: academic research organization, jakarta, indonesia. 4 regional public hospital of pasar rebo, jakarta, indonesia. 5 regional public hospital of ciracas, jakarta, indonesia. 6 provincial health office of special capital region of jakarta, jakarta, indonesia. 7 department of pulmonology and respiratory medicine, faculty of medicine universitas indonesia, persahabatan hospital, jakarta, indonesia. corresponding author: anna rozaliyani, md., phd. indonesian society of respirology. jl. cipinang baru bunder no.19, cipinang, jakarta 13340, indonesia. email: annaroza1110@gmail.com. abstrak latar belakang: penyakit coronavirus 2019 adalah penyakit sistem pernapasan yang baru saja muncul dan menjadi pandemi. indonesia mengalami peningkatan jumlah kasus yang cukup drastis tetapi data lokal terkait hal ini masih jarang didapatkan. metode: analisis dalam riset ini menggunakan data rekapitulasi penelusuran epidemiologi (pe) yang dikeluarkan oleh pemerintah daerah khusus ibukota jakarta dari 2 maret hingga 27 april 2020. hasil: dari total 4.052 pasien, 381 (9,4%) pasien meninggal. analisis multivariabel menunjukkan bahwa kematian berhubungan dengan usia tua (odds ratio [or] 1,03; 95% confidence interval [ci] 1,02, 1,05, peningkatan usia per tahun; p<0,001), sesak napas (or 4,83; 95% ci 3,20, 7,29; p <0,001), pneumonia (or 2,46; 95%ci 1,56, 3,88; p<0,001), dan riwayat hipertensi (or 1,86; 95%ci 1,24, 2,78; p=0,003). angka kematian tertinggi terjadi pada 6 april 2020 dan menurun di beberapa pekan selanjutnya, setelah pembatasan sosial berskala besar diberlakukan. kesimpulan: usia tua, sesak napas, pneumonia, dan riwayat hipertensi berhubugan dengan risiko kematian. mortalitas tergolong tinggi tetapi mungkin dapat dikurangi dengan pembatasan interaksi sosial. kata kunci: covid-19, kematian, indonesia, jakarta, karakteristik pasien. abstract background: coronavirus disease 2019 is an emerging respiratory disease that is now a pandemic. indonesia is experiencing a rapid surge of cases but the local data are scarce. methods: this is an analysis using data from the ongoing recapitulation of epidemiological surveillance (es) by the provincial health office of jakarta from march 2nd to april 27th 2020. we evaluated demographic and clinical characteristics of all confirmed cases in association with death. results: of the 4,052 patients, 381 (9.4%) patients were deceased. multivariable analysis showed that death was associated with older age (odds ratio [or] 1.03; 95% confidence interval [ci] 1.02, 1.05, per year increase; p<0.001), dyspnea (or 4.83; 95% ci 3.20, 7.29; p<0.001), pneumonia (or 2.46; 95%ci 1.56, 3.88; p<0.001), and pre-existing hypertension (or 1.86; 95% ci 1.24, 2.78; p=0.003). death was vol 52 • number 3 • july 2020 factors associated with death in covid-19 patients in jakarta, indonesia 247 highest in the week of april 6th 2020 and declined in the subsequent weeks, after a large-scale social restriction commenced. conclusion: older age, dyspnea, pneumonia, and pre-existing hypertension were associated with death. mortality was high, but may be reduced by lockdown. keywords: covid-19, death, indonesia, jakarta, patient characteristics. introduction coronavirus disease 19, or widely known as covid-19 is a new emerging respiratory disease that can cause respiratory failure due to severe pneumonia.1 this viral infection was first reported in december 2019 in wuhan, china and suspected to be transmitted through zoonotic origin, followed by human to human transmission.2 by may 22nd 2020, a total of 4,993,470 confirmed cases have been reported globally and the disease has spread rapidly throughout at least 215 countries, including indonesia.3 the first two cases in indonesia were identified in west java province on march 2nd 2020.4 thenceforth, the number of covid-19 cases in the country increased remarkably, reaching 20,796 confirmed cases on april 22nd 2020. at the time of preparing this manuscript, the number of covid-19 cases and mortality rates in indonesia are still increasing and the end of the epidemic is still uncertain.5,6 published reports on the epidemiology and clinical characteristics of covid-19 cases from indonesia are scarce. high-quality evidence is important for understanding the disease, improving the quality of care of patients and could serve as a basis for policy making. in this study, we analyze demographic and clinical parameters associated with the mortality of laboratory-confirmed cases with covid-19 in dki jakarta, indonesia. methods this is a retrospective cohort study using data from the ongoing recapitulation of epidemiological surveillance (es) conducted by the provincial health office of capital special region of jakarta (dinas kesehatan/ dinkes provinsi dki jakarta). the laboratory-confirmed patients are defined as patients with a positive result on real-time reverse transcription polymerase chain reaction (rt-pcr) for the presence of sars-cov-2 in either the nasal or pharyngeal swab specimens, irrespective of the clinical signs and symptoms. all confirmed cases of covid-19 in jakarta between march 2nd 2020 and april 29th 2020 were included in the analysis. this study was approved by the ethics committee of faculty of medicine university of indonesia (no: ket-506/ un2.f1/etik/ppm.00.02/2020). data collection data were collected using epidemiological surveillance (penyelidikan epidemiologi/pe) forms which were distributed to all healthcare facilities in the province, including all public primary care centres (puskesmas) and public and private hospitals. doctors or nurses who provided care for patients suspected with covid-19 infection were obliged to fill in the pe. the pe forms were later being submitted to dinkes provinsi dki jakarta. the pe form consists of questions related to patient demographic characteristics and clinical information. signs and symptoms that were asked in the questionnaire included body temperature and the presence of fever, cough, cold, sore throat, dyspnea, chills, headache, malaise, myalgia, nausea and emesis, abdominal pain and diarrhea. other conditions and comorbidities that were asked included the presence history of diabetes, heart disease, hypertension, malignancy, immunologic disorder, chronic kidney failure, chronic liver failure, and chronic obstructive pulmonary disease (copd). in case patients were hospitalized, the start and end date of hospitalization were recorded together with whether there was admission to the intensive care unit (icu), intubation performed, and the use of extracorporeal membrane oxygenation (ecmo) machine. the end date of hospitalization was also recorded and data about the clinical outcomes were collected. anna rozaliyani acta med indones-indones j intern med 248 age was classified into 5 groups; 0-9 years, 10-19 years, 20-49 years, 50-69 years, and older than 70 years. patient’s address was classified into 6 groups; including 5 areas of jakarta (south, west, east, north, and central) and outside jakarta if patients had non-jakarta address. within subjects with available data of body temperature, we categorized them into 4 groups (<37oc, 37.3–38oc, 38.1– 39oc, and >39oc). the time from the onset of the symptoms to nasal and/or throat swab tests were used as a proxy for patient’s access to a health facility with a shorter number represents better access. outcome measures death was considered as the main outcome in this study. all deaths that occurred after the diagnosis of covid-19 were considered to be the consequence of the infection. this clinical outcome was followed up until april 29th 2020. data analysis patients’ demographic information and clinical characteristics were tabulated for descriptive purposes. all these variables were considered as potential predictors of death during the follow-up time. univariable regression was first performed to evaluate the unadjusted relation between each predictor and the occurrence of death. we selected the statistically significant predictors from the univariable analysis and evaluated them using multivariable logistic regression. results are expressed as odds ratios (ors) with 95% confidence intervals (cis) and corresponding p values. statistical significance was considered to be a 2-sided p value <0.05. all analyses were performed using spss version 25.0 for mac (spss inc., chicago, il, usa). results of the 4,052 covid-19 patients included in the study, 381 (9.4%) patients were deceased, while 3670 (90.6%) patients survived (table 1). among the surviving patients, 412 (11.2%) patients were cured, 2,012 (54.8%) patients were still hospitalised, and 1,246 (33.6%) patients were in self-isolation. table 1 shows the demographic and clinical characteristics of the study population in total and separately for those who died and those who survived. the mean age of the patients was 45.8 years. the majority of the patients were from age groups of 20 to 49 years and 50 to 69 years (51.2% and 37.6% respectively, from the total population). those who died were significantly older than those who survived. similarly, analysis by age groups also showed significant differences in the risk of death with more patients in the 50 to 69 years and older than 70 years groups dying. there were more male patients in the total population and among those who died. the majority of the patients had non-jakarta addresses and death rates were significantly different depending on the area where they lived. among all the comorbidities, hypertension was revealed to be the most common disease reported (18.3%), followed by diabetes (11.1%), heart disease (6.9%), and copd (5.6%). among 800 patients with the non-missing data on the existence of all comorbidities, 83.6% were reported to having at least one comorbidity. the proportion of patients with hypertension, diabetes, heart disease, and renal diseases were significantly higher in those who died. cough (61.0%), fever (53.0%), malaise (32.4%) and dyspnea (30.2%) were the most commonly reported symptoms, while pneumonia occurred in 41.1% of patients. the proportion of patients with these symptoms and pneumonia was also significantly higher among those who died. within 655 patients with reported body temperature, the majority had a body temperature between 37.3 – 38.0oc. the mean duration between symptom onset and swab test in the total population was 7 days (sd 6.0) and was significantly different between those who died and those who survived (9.9 days vs 8 days, p < 0.001). the following procedures were also more common in those who died as compared to those who survived; icu admission (20 [16.0%] vs 17 [1.2%], p < 0.001), intubation (17 [13.8%] vs 11 [0.8%], p < 0.001), and ecmo (7 [5.9%] vs 4 [0.3%], p < 0.001). in table 2, we show that in the univariable analysis, older age, being older than 70 years, male, residing in central or south jakarta, having symptoms of cough, fever, malaise, dyspnea, vol 52 • number 3 • july 2020 factors associated with death in covid-19 patients in jakarta, indonesia 249 table 1. baseline characteristics of the patients. characteristics total (n=4052) death yes (n=381) no (n=3670) age (n=3986) 45.8 (16.3) 58.2 (14.3) 44.5 (15.9) age group 0 to 9 years 47 (1.2) 4 (1.1) 43 (1.2) 10 to 19 years 133 (3.3) 2 (0.5) 131 (3.6) 20 to 49 years 2040 (51.2) 69 (18.4) 1971 (54.6) 50 to 69 years 1497 (37.6) 220 (58.5) 1277 (35.4) older than 70 years 269 (6.8) 81 (21.5) 188 (5.2) sex (n=4043), male 2169 (53.5) 256 (67.5) 1913 (52.2) registered address (n=3657) west jakarta 571 (14.1) 51 (13.4) 520 (14.2) central jakarta 554 (13.7) 57 (15.0) 497 (13.5) south jakarta 627 (15.5) 88 (23.1) 539 (14.7) east jakarta 666 (16.4) 81 (21.3) 585 (16.0) north jakarta 459 (11.3) 41 (10.8) 418 (11.4) outside jakarta 1161 (28.7) 63 (16.5) 1098 (30.0) citizenship (n=4051) indonesian 3915 (96.6) 374 (98.2) 3541 (96.5) foreigner 136 (3.4) 7 (1.8) 129 (3.5) symptoms cough (n=2258) 1377 (61.0) 184 (81.8) 1193 (58.7) fever (n=2242) 1189 (53.0) 167 (74.6) 1022 (50.6) malaise (n=2123) 688 (32.4) 115 (57.2) 573 (29.8) dyspnea (n=2255) 682 (30.2) 167 (74.2) 515 (25.4) headache (n=2128) 483 (22.7) 61 (30.5) 422 (21.9) nausea/emesis (n=2058) 434 (21.1) 57 (29.7) 377 (20.2) sore throat (n=2256) 508 (22.5) 71 (31.7) 437 (21.5) cold/runny nose (n=2255) 507 (22.5) 49 (21.7) 458 (22.6) myalgia (n=2087) 360 (17.2) 41 (21.2) 319 (16.8) chills (n=2081) 231 (11.1) 40 (20.6) 191 (10.1) abdominal pain (n=2069) 145 (7.0) 19 (9.9) 126 (6.7) diarrhea (n=2126) 170 (8.0) 21 (10.6) 149 (7.7) pneumonia (n=2077) 853 (41.1) 182 (81.6) 671 (36.2) temperature (n=655) < 37.3 oc 194 (29.6) 14 (16.7) 180 (31.5) 37.3 – 38.0 oc 273 (41.7) 37 (44.0) 236 (41.3) 38.1 – 39.0 oc 158 (24.1) 26 (31.0) 132 (23.1) >39.0 oc 30 (4.6) 7 (8.3) 23 (4.0) existing comorbidity (n=800) 669 (83.6) 153 (92.7) 516 (81.3) comorbidities hypertension (n=2131) 390 (18.3) 106 (47.5) 284 (14.9) copd (n=2229) 125 (5.6) 14 (6.2) 111 (5.5) diabetes (n=2131) 236 (11.1) 66 (29.5) 170 (8.9) heart disease (n=2131) 148 (6.9) 49 (22.0) 99 (5.2) renal disease (n=2129) 37 (0.9) 19 (8.5) 18 (0.9) malignancy (n=2131) 8 (0.2) 2 (0.9) 6 (0.3) immunological disorder (n=2132) 14 (0.3) 4 (1.8) 10 (0.5) liver failure (n=2126) 5 (0.1) 2 (0.9) 3 (0.2) obesity 5 (0.1) 0 (0.0) 5 (3.2) values are means with standard deviations in for continuous variables and n (%) for frequencies. in case skewed data (*), the median with the interquartile range is presented. copd = chronic obstructive pulmonary disease. anna rozaliyani acta med indones-indones j intern med 250 table 2. factors associated with death in patients with laboratory confirmed covid-19 variable univariable multivariable or (95% ci) p-value or (95% ci) p-value age 1.06 (1.05; 1.07) <0.001 1.03 (1.02; 1.05) <0.001 age group 0 to 9 years reference 10 to 19 years 0.16 (0.03; 0.93) 0.041 20 to 49 years 0.38 (0.13; 1.08) 0.069 50 to 69 years 1.85 (0.66; 5.21) 0.243 older than 70 years 4.63 (1.61; 13.33) 0.004 sex, male 1.91 (1.52; 2.39) <0.001 1.17 (0.80, 1.70) 0.42 registered address west jakarta 1.17 (0.79, 1.74) 0.44 1.03 (0.54, 1.97) 0.92 central jakarta 1.67 (1.16, 2.40) 0.006 0.87 (0.47, 1.61) 0.66 south jakarta 1.41 (0.98, 2.04) 0.07 0.99 (0.53, 1.82) 0.96 east jakarta 1.00 (0.65, 1.54) 1.00 1.04 (0.54, 1.98) 0.92 north jakarta 0.59 (0.40, 0.86) 0.006 0.93 (0.49, 1.79) 0.83 outside jakarta reference reference citizenship, foreigner 0.51 (0.24; 1.11) 0.09 symptoms cough 3.16 (2.23; 4.48) <0.001 1.01 (0.62; 1.63) 0.98 fever 2.86 (2.09; 3.91) <0.001 1.26 (0.83; 1.93) 0.28 malaise 3.15 (2.34; 4.23) <0.001 1.04 (0.67; 1.59) 0.88 dyspnea 8.47 (6.18; 11.61) <0.001 4.83 (3.20; 7.29) <0.001 headache 1.57 (1.14; 2.16) 0.006 1.09 (0.71; 1.67) 0.71 nausea/emesis 1.67 (1.20; 2.32) 0.002 0.79 (0.52; 1.21) 0.28 sore throat 1.69 (1.25; 2.29) 0.001 1.00 (0.66; 1.51) 0.98 cold/runny nose 0.95 (0.68; 1.32) 0.95 myalgia 1.33 (0.92; 1.92) 0.13 chills 2.31 (1.58; 3.37) <0.001 1.02 (0.62; 1.69) 0.95 abdominal pain 1.53 (0.92; 2.53) 0.10 diarrhea 1.41 (0.87; 2.28) 0.16 pneumonia 7.83 (5.05; 11.13) <0.001 2.46 (1.56; 3.88) <0.001 temperature < 37.3 oc reference 37.3 – 38.0 oc 2.12 (1.06; 3.84)) 0.03 38.1 – 39.0 oc 2.53 (1.27; 5.04) 0.008 >39.0 oc 3.92 (1.43; 10.70) 0.008 existing comorbidity, yes 2.94 (1.58; 5.47) 0.001 comorbidity hypertension 5.18 (3.87; 6.93) <0.001 1.86 (1.24; 2.78) 0.003 copd 1.12 (0.63; 1.99) 0.70 diabetes 4.27 (3.08; 5.92) <0.001 1.26 (0.80; 1.98) 0.32 heart disease 5.15 (3.53; 7.50) <0.001 1.43 (0.85; 2.41) 0.18 renal disease 9.77 (5.05; 18.91) <0.001 2.42 (0.99; 5.95) 0.06 malignancy 2.87 (0.58; 14.30) 0.20 immunological disorder 3.47 (1.08; 11.15) 0.04 2.63 (0.44; 15.77) 0.29 liver failure 5.76 (0.96; 34.66) 0.06 obesity a data are presented as or from (univariable or multivariable) logistic regression coefficients with 95% confidence intervals for every oneunit increase in the predictor or for positive predictor. copd = chronic obstructive pulmonary disease. athe number of cases was too small to enable analysis. vol 52 • number 3 • july 2020 factors associated with death in covid-19 patients in jakarta, indonesia 251 headache, nausea/emesis, sore throat, chills, and pneumonia were significantly associated with a higher risk of death. deaths were also more likely with higher body temperature, pre-existing comorbidities (mainly hypertension, diabetes, heart disease, renal disease, and immunological disorder). when all significant demographic and clinical characteristics (p < 0.05) were included in the multivariable analysis, we show that most associations between these characteristics and the occurrence of deaths became non-significant. the characteristics which remained significantly associated with higher mortality were older age (or 1.03, one year increment), dyspnea (or 4.83), evidence of pneumonia (or 2.46), and pre-existing hypertension (or 1.86). based on the total number of deaths and confirmed cases, the case fatality rate (cfr) in jakarta was estimated to be 9.4%. the number of confirmed cases and death due to covid-19 showed an increased surge during the observation period. the weekly number of new confirmed cases was consistently increasing during the observation period (figure 1). the weekly number of deaths, on the other hand, reached its peak in the week of april 6th 2020 and dropped in the following weeks. this is as shown in figure 2 where the slope becomes less steep in the following weeks after april 6th 2020. discussion in the present study we provided evidence suggesting that among laboratory-confirmed cases of covid-19 in jakarta, the odds of death were greater if patients were older, had dyspnea, pneumonia, and pre-existing hypertension. to the best of our knowledge, this is the figure 1. weekly cumulative number of covid-19 cases in jakarta, indonesia. figure 2. weekly cumulative number of deaths in patients with covid-19 in jakarta, indonesia. anna rozaliyani acta med indones-indones j intern med 252 first and largest analysis using epidemiological surveillance data to assess risk factors for mortality in laboratory-confirmed covid-19 patients in indonesia. the study population was comprised of people living in the epicenter of local transmissions, the urban setting of jakarta and its surrounding area (jabodetabek) with relatively good access to the healthcare facility. in terms of time, this study captured the initial phase of the epidemic in indonesia (within 2 months after the first case of covid-19 in indonesia was reported). the data comprising the entire population with laboratory confirmed covid-19 in the area were included in the analysis. our finding that older age was related with higher mortality in covid-19 patients is in concordance with several previous studies.7,8 mortality was higher by 10% per year increase in these studies as compared to 3% in the present study. this difference might be attributed to the fact that only adult patients were included in the previous study. our finding also confirms previous studies that showed significant increased risk of death in patients aged >65 years.9,10 due to impaired immune response, older patients tend to have a more serious condition and poorer response to treatments. pneumonia and dyspnea (shortness of breath) have been reported to be associated with death in the previous studies.11,12 the latter was associated with the occurrence of acute respiratory distress syndrome (ards) in covid-19 patients.8 in addition, an earlier study also revealed that early onset of dyspnea may be a marker of poor prognosis.11 these findings are also supported by a meta-analysis which suggested that patients with dyspnea showed worse clinical outcomes.12 in the present study a total of 41% patients were reported with pneumonia and 30% had dyspnea. the proportions are higher than in china where less than 20% confirmed cases had pneumonia and only 14% had dyspnea.13 this study revealed pre-existing hypertension was independently associated with mortality in covid-19 patients in jakarta. earlier studies also reported that hypertension was the most common underlying disease of the covid-19 patients, especially in fatal cases.8,11,14 disruption of the renin-angiotensin system may explain this phenomenon.15 it is postulated that pre-existing cardiovascular disease, including hypertension, contributes to the occurrence of pneumonia and fatal symptoms in covid-19.16 our analysis showed that covid-19 patients with preexisting hypertension have an approximately 2-fold risk of death as compared to patients without. this is relatively comparable to the increased risk of developing severe covid-19 (or:2.92) estimated by a large meta-analysis from china.17 the unadjusted analyses showed that diabetes increased risk of death in covid-19 patients but this association became non-significant after adjustment for other characteristics (age, sex, symptoms, and other comorbidities). this finding suggests that diabetes itself may not have direct implication on infection severity, but rather present coexisting with other worsening factors such as older age and hypertension. this is in line with previous studies which showed no significant association between diabetes and mortality of covid-19 patients when other factors such as age, sex, other comorbidities were taken into account in the analyses.18,19 we showed a case fatality rate (cfr) of 9.4% in our study population, which was among the highest in the world. this rate leads among countries in southeast asia, higher than in wuhan, china (4.3% of confirmed cases) and is almost twice the global mortality rate of 5.97%.20,21 the high cfr in our population might partially be explained by the limited capacity of pcr testing which resulted in serious underreporting.22 it is estimated that only 0.03 tests were done daily per thousand people.20 patients with more pronounced symptoms and therefore a more severe condition were more likely to seek help and therefore had better access to pcr tests. nonetheless, the high cfr might also reflect poorer healthcare capacity in responding to the epidemic. data from the provincial health office of special capital region of jakarta revealed the death cases during february 2020 were 5792 people, markedly increased from january 2020 (3072 deaths).23 this might indicate undetected deaths related to covid-19 before the first case was diagnosed in indonesia. vol 52 • number 3 • july 2020 factors associated with death in covid-19 patients in jakarta, indonesia 253 about one third of patients in this study had a registered address outside jakarta. this finding might indicate the urban problem of jakarta and public health problems. many people possibly work and live in jakarta while still maintaining their “outside jakarta” address on their id card. additionally, people who live in the surrounding areas near jakarta might prefer to go to jakarta when seeking medical services. therefore, basing the calculation of healthcare services demand solely on the number of jakarta inhabitants would result in serious overestimation of jakarta’s preparedness for the pandemic. a large-scale social restriction (pembatasan sosial berskala besar or psbb) has been imposed in jakarta since april 10th 2020.24 the psbb in jakarta seems to create an impact in reducing the curve slope of both the cumulative number of confirmed cases and the number of deaths (figure 1 and 2). the number of weekly new confirmed cases dropped to 651 patients in the period between april 20th and april 26th 2020, 10 days after psbb was applied. this number was lower than in the previous weeks and in the early days of psbb (833 patients between april 6th – april 13th 2020). in line with this, the number of weekly death cases dropped to 25 patients in the period between april 20th and april 26th 2020. this number was lower than in the previous weeks and in the early days of psbb (82 patients between 6 april – 13 april 2020). these results are preliminary but indicate the effectiveness of the large-scale social restriction in controlling the spread and mitigating the catastrophe of covid-19. the mathematical modeling suggested that quarantine, school closure and social distancing had an impact in the reduction of covid-19 cases.25,26 india, which adopted early social distancing and social lockdown had lower mortality (3%) due to covid-19 compared to spain (12%) and france (19.9%).3,27 australia experienced success in decreasing the rate of covid-19 cases together with low mortality rate (1.4% per 10 may 2020) as an impact of international travel restrictions and social distancing.28 this study has several limitations. first, no data were available regarding the diagnostic and treatment received by the patients. diagnostic and therapeutic measures, notably, may have a significant role in modifying the clinical course of the disease and its outcomes. laboratory and radiologic findings may provide insights into the course of the disease and severity of the condition. in the absence of such information, interpretation of our findings needs to be done with caution. secondly, some information in the pe form was missing because it was left empty by the interviewer. proper training of the healthcare providers might increase the quality of the pe form database. conclusion we identified older age, dyspnea, pneumonia, and pre-existing hypertension as predictors for mortality among the laboratory confirmed cases of covid-19 in dki jakarta, indonesia. the mortality rate was high at 9.4%. the research has also shown the apparent beneficial impact of psbb in reducing the spread of covid-19. acknowledgments we gratefully acknowledge the provincial health office of special capital region of jakarta for providing the database of epidemiological surveillance as the source of this study. references 1. ceraolo c, giorgi fm. genomic variance of the 2019 ncov coronavirus. med virol. 2020;92(5):522–8. 2. li q, guan x, wu p, et al. early transmission dynamics in wuhan, china, of novel coronavirus–infected pneumonia. n engl j med. 2020;382(13):1199–207. 3. world health organization. coronavirus disease (covid-19) situation report 22 may 2020. (may):1– 18. https://www.who.int/docs/default-source/ coronaviruse/situation-reports/20200522-covid-19sitrep-123.pdf?sfvrsn=5ad1bc3_4. 4. ministry of health republic of indonesia. dua pasien positif covid-19 dirawat di rspi sulianti saroso. https://www.kemkes.go.id/article/view/20030200009/ dua-pasien-positif-covid-19-dirawat-di-rspi-suliantisaroso.html (2020, accessed may 25, 2020). 5. setiati s, azwar mk. covid-19 and indonesia. acta med indones. 2020;52(1):84–9. 6. ministry of health republic of indonesia. situasi terkini perkembangan novel coronavirus (covid-19) 22 mei 2020. https://covid19.kemkes.go.id/situasiinfeksi-emerging/info-corona-virus/situasi-terkinianna rozaliyani acta med indones-indones j intern med 254 perkembangan-coronavirus-disease-covid-19-23mei-2020/#.xsve9ghkjiu (2020). 7. zhou f, yu t, du r, et al. clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study. lancet. 2020;395(10229):1054–62. 8. wu c, chen x, cai y, et al. risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in wuhan, china. jama intern med. 2020;e1–e10. 9. du r, liang l, yang c, et al. predictors of mortality for patients with covid-19 pneumonia caused by sarscov-2 : a prospective cohort study. eur respir j. 2020;56(1):1–8. 10. yang x, yu y, xu j, et al. clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, retrospective , observational study. lancet respir med. 2020;8(5):475–81. 11. du y, tu l, zhu p, et al. clinical features of 85 fatal cases of covid-19 from wuhan: a retrospective observational study. am j respir crit care med. 2020;201(11):1372–9. 12. zheng z, peng f, xu b, et al. risk factors of critical & mortal covid-19 cases: a systematic literature review and meta-analysis. j infect. 2020;81(2):e16– e25. 13. wu z, jennifer m. characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china summary of a report of 72 314 cases from the chinese center for disease control and prevention. jama. 2020;323(13):1239– 42. 14. chen n, zhou m, dong x, et al. epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study. lancet. 2020;395(10223):p507-513. 15. hanff tc, harhay mo, brown ts, cohen jb, mohareb am. is there an association between covid-19 mortality and the renin-angiotensin system? a call for epidemiologic investigations. clin infect dis. 2020;71(15):870–4. 16. zheng y-y, ma y-t, zhang j-y, xie x. covid-19 and the cardiovascular system. nat rev cardiol. 2020;17(5):259–60. 17. wang x, fang x, cai z, et al. comorbid chronic diseases and acute organ injuries are strongly correlated with disease severity and mortality among covid-19 patients: a systemic review and metaanalysis. am assoc adv sci. 2020;1–16. 18. docherty ab, harrison em, green ca, et al. features of 20 133 uk patients in hospital with covid-19 using the isaric who clinical characterisation protocol: prospective observational cohort study. bmj. 2020;369(m1985):1–12. 19. petrilli cm, jones sa, yang j, et al. factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in new york city: prospective cohort study. bmj. 2020;369(m1966):1–15. 20. h a s e l l j , m a t h i e u e , b e l t e k i a n d , e t a l . coronavirus (covid-19) testing statistics and research. https://ourworldindata.org/coronavirustesting#indonesiaaccessed (2020). 21. wang d, hu b, hu c, et al. clinical characteristics of 138 hospitalized patients with 2019 novel coronavirusinfected pneumonia in wuhan, china. j am med assoc. 2020;323(11):1061–9. 22. ji y, ma z, peppelenbosch mp, pan q. potential association between covid-19 mortality and health care resource availability. lancet glob heal. 2020;8(4):e480. 23. statistical unit special capital region of jakarta. pelaporan kematian periode januari-desember 2019 dan januari-april 2020 di provinsi dki jakarta. http:// statistik.jakarta.go.id/pelaporan-kematian-periodejanuari-desember-2019-dan-januari-april-2020-diprovinsi-dki-jakarta/ (2020). 24. provincial health office of special capital region of jakarta. poin penting psbb di dki jakarta. (april): https://corona.jakarta.go.id/id/publikasi (2020). 25. lewnard j, co n. scientific and ethical basis for social-distancing interventions against covid-19. lancet infect dis. 2020;20(6):631–3. 26. stein ra. covid-19 and rationally layered social distancing. int j clin pract. 2020;14(00):e13501. 27. paital b, das k, kumar s. science of the total environment inter nation social lockdown versus medical care against covid-19, a mild environmental insight with special reference to india. sci total environ. 2020;728(138914):1–18. 28. covid-19 national incident room surveillance team. covid-19, australia: epidemiology report 15. 2020. p. 1–26. clinical practice 76 acta medica indonesiana the indonesian journal of internal medicine nocturnal hypertension: neglected issue in comprehensive hypertension management andi kristanto1, randy adiwinata1, silvia suminto1, benny n. kurniawan1, finna christianty1, robert sinto2 1 faculty of medicine, atmajaya catholic university of indonesia, jakarta, indonesia. 2 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: robert sinto, md. department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: rsinto@yahoo.com, andi_kris@hotmail.com. abstrak irama sirkadian dalam tubuh, mempengaruhi variasi tekanan darah baik pada siang dan malam hari, sehingga didapatkan pola tekanan darah yang berbeda. hipertensi nokturnal adalah peningkatan tekanan darah >120/70 mmhg pada malam hari akibat terganggunya irama sirkadian, dan berkaitan dengan peningkatan kejadian kardiovaskular, serebrovaskular, serta mortalitas pada pasien hipertensi. hipertensi nokturnal dan perubahan pola penurunan tekanan darah, hanya dapat diketahui dengan cara melakukan pemeriksaan tekanan darah secara kontinyu selama 24 jam yang dikenal sebagai ambulatory blood pressure measurement (abpm). kronoterapi, menjadi salah satu strategi dalam menangani pasien dengan hipertensi nokturnal, yaitu dengan meminum obat anti hipertensi pada malam hari untuk mendapatkan penurunan tekanan darah yang sesuai irama sirkadian untuk meningkatkan kontrol tekanan darah. kata kunci: hipertensi nokturnal, pengukuran tekanan darah ambulatori, non-dipping, kronoterapi. abstract the body circardian rhythm affects blood pressure variability at day and night, therefore blood pressure at day and night might be different. nocturnal hypertension is defined as increase of blood pressure >120/70mmhg at night, which is caused by disturbed circadian rhythm, and associated with higher cardiovascular and cerebrovascular events also mortality in hypertensive patients. nocturnal hypertension and declining blood pressure pattern, can only be detected by continuous examination for 24 hours, also known as ambulatory blood pressure measurement (abpm). chronotherapy, has become a strategy for managing the hypertensive nocturnal patients, by taking hypertensive medication at night to obtain normal blood pressure decrease in accordance with the normal circadian rhythm and, improving blood pressure control. keywords: nocturnal hypertension, ambulatory blood pressure measurement, non-dipping, chronotherapy. vol 48 • number 1 • january 2016 nocturnal hypertension 77 introduction hypertension has been for long time well studied as one of the major cardiovascular disease risk factor, thus hypertension treatment in controlling blood pressure is important to prevent cardiovascular disease progression.1 however, the diagnosis of nocturnal hypertension tend to be missed although it is an important predictor of all cause mortality and/or cardiovascular mortality.2 lack of awareness with hypertension cause patients to measure their blood pressure only during hospital visit. this factor contributed to the limited use of ambulatory blood pressure measurement (abpm), and the possibility of nocturnal hypertension became overlooked.3 in this review, we described the definition, epidemiology, pathophysiology, clinical significance, diagnosis, and anti hypertension management of nocturnal hypertension. definition hypertension is a major independent risk factor for the development of cardiovascular disease, and its variation at day or night of the blood pressure depends on circadian rhythm, which is associated with interaction of sympathetic nervous system and reninangiotensin systems.4 this blood pressure variation phenomenon consist of dipping, extreme dipping, non dipping and riser or reverse dipping. dipping phenomenon is defined as a decrease in systolic nighttime blood pressure 1020% from daytime blood pressure and occurs as normal physiologic changes. the term “extreme dipping” is used when nighttime blood pressure decrease more than 20%. meanwhile, in non dipping pattern, the decrease in blood pressure is only approximately 0-10% and the increase in blood pressure at night is called reverse dipping or riser. the latter pattern (non dipping and reverse dipping/riser) were associated with nocturnal hypertension. nocturnal hypertension is defined as increase of blood pressure >120/70 mmhg at night.5-7 epidemiology as discussed above, the blood pressure changes at night was a physiologic changes that occurs in healthy individual. however, these changes did not occur in some people. the non dipping pattern was found higher in chinese, japanese, and south africans compared in western and eastern europeans with the prevalence of 10.9% vs. 6.0%. the higher sodium and lower potassium intake among asian than other population might be contribute to it.8 in a cohort study of spanish society of hypertension ambulatory blood pressure monitoring registry reported that from 42,947 hypertensive patients, there were 50.2% untreated patients and 40% treated patients had dipping pattern. at the same time, there were also 35% untreated patients and 40% treated patients had non dipping pattern.9 non dipping pattern was associated with more severe target organ damage from chronic kidney disease (ckd), cardiovascular and cerebrovascular disease induced by hypertension.10 non dippers were more prevalent in individuals with ckd and diabetic patients. liu et al11 found that non dipping phenomenon was commonly found in patients undergoing hemodialysis with the prevalence up to 70%. the possible mechanism is due to an inadequate blood pressure as a consequence of baroreflex or autonomic dysfunction in ckd patients, thus maintaining more adequate hemodialysis in these patients is needed to decrease cardiovascular complications. also, in a study conducted by cuspidi et al, found that non dipping prevalence was higher in hypertensive diabetic subjects than in hypertensive nondiabetic subjects after 24 hours ambulatory blood pressure monitoring. renal hemodynamics, blood flow distribution, and plasma volume are thought to be affected by hyperglycemia state in diabetic patients.12,13 pat h o p h y s i o l o g y o f n o c t u r n a l hypertension many factors were postulated in disrupting the circadian rhythm, which in turn lead to attenuation of nocturnal blood pressure lowering phenomenon. the causes of abnormal circadian rhythm of blood pressure can be divided to hormonal metabolic factors and external factors such as smoking or aging. some disease are implicated in the disruption, such as diabetes andi kristanto acta med indones-indones j intern med 78 mellitus, metabolic syndrome, chronic kidney disease, and obstructive sleep apnea (osa).14 in this paper, we described the two most reported mechanisms of nocturnal hypertension, which were imbalance of nocturnal autonomic nervous system and limited sodium metabolism by kidneys. imbalance of nocturnal autonomic nervous system activation in physiologic state, blood pressure levels is fluctuated along the day with peak in early morning and low during sleeping. circadian rhythm is one of the contributors of the fluctuation which controlled from suprachiasmatic nuclei (scn) of the anterior hypothalamus. circadian rhythm mainly influenced by autonomic nervous system.15 in general, autonomic nervous system composed of sympathetic and parasympathetic nerves, which keep in balance to maintain physiologic state. over dominance of sympathetic activation was postulated as the cause of nocturnal hypertension and attenuated the blood pressure dipping. vardhan et al reported that, patients with obstructive sleep apnea (osa) were having higher catecholamines plasma and urinary levels compared with control. this findings were correlated with hypertension in patient with osa.16 nielsen et al17, found that low degree of blood pressure dipping were related to sustained adrenergic activity which reflected by higher noradrenaline level and lead to decreased the peripheral vasodilatation capacity. doxazosin, an alpha-1 adrenergic blocker drug, will effectively block the sympatethics activity which in turn lower the blood pressure while sleeping.18 these studies showed that non dipping phenomenon is caused by sympatethics system over activity. limited sodium metabolism kidneys have a role in maintaining blood pressure, regulated by renin-angiotensinaldosteron system and influenced by circadian rhythm. non dipping patients are thought to be related with impaired capacity of kidneys to excrete sodium during daytime or increased tubular sodium reabsorption which was commonly caused by hyperaldosteronism.19 this theory was supported by data that the prevalence of non-dipper was increased in patient with low glomerular filtration rate (gfr).20 wang et al21 reported among 540 chinese ckd patients, total of 21.9% patients were riser, 36.1% patients were dipper, and 42% of patients were non-dipper.21 however, increased daily salt intake also found to be related with nocturnal hypertension. kidneys will compensate high sodium intake by enhancing natriuresis during the night. thus, blood pressure will remain elevated until kidneys succeed in reducing excess sodium.22,23 clinical implications of nocturnal hypertension nocturnal hypertension phenomenon results in several clinical implications that have to be taken into consideration to predict complications and approach strategy to treat every individual with hypertension. there have been many studies conducted about circadian patterns and its clinical implications, especially those associated with cardiovascular, cerebrovascular, and renal diseases. fagard et al24, mentioned that cardiovascular complication in subject with non dipping circadian pattern is higher compared to subjects with dipping pattern. this statement is also supported by one of the studies that showed increasing 10 mmhg of nighttime systolic blood pressure would rise 35% possibility of cardiovascular risk in diabetic population.25 the negative effect of cardiac function was described by verdecchia et al26. that non dipping group had greater risk of left ventricular hypertrophy (lvh) compared with dipping group. groups with dipping circadian pattern had lvh risk at about 4%, while the risk of group with non dipping pattern increased to 15%. the thickening of carotid intima (>0.8 mm) also found higher in non dipping pattern than dipping, that will lead to atherosclerosis. opera study showed on their population based cohort study of 900 middle aged individuals, that mean carotid intima media thickness were higher in non-dipper (90 mm) compared to dipper (80 mm).27 the association between carotid intima thickening and atherosclerosis plaque formation is supported by salvetti et al28. the results of ultrasonography showed that thickening of carotid intima and formation of plaque presence were 55% and 56% respectively in uncontrolled vol 48 • number 1 • january 2016 nocturnal hypertension 79 hypertensive patients with non dipping circadian pattern, whereas in dipping circadian pattern were 24% and 33% respectively. persons who have high blood pressure in the night, which includes reverse dipping and non dipping had an increased risk of intracerebral hemorrhage (ich). sun et al6, found that probability of silent ich in non dipping and reverse dipping group was 50.8%. meanwhile, tsivgoluis et al conducted a research on patients with ich, and found that 74.4% of the patients with ich were non dippers, while 43.8% of the patients were dippers.29 another study by ma et al30 showed, that several subjects with non dipping pattern had silent cerebral infarct. non dipping are associated with lacunar cerebral infarct eventwhich may leads to decline in verbal memory function.31 kidney failure was also considered as another important clinical implication of the non dipping circadian pattern, reflected by presence of microalbuminuria and decreasing gfr. kastarinen et al did a research of renal function on 460 subjects where 18.7% of the study population were non dipper. the mean egfr of non dippers in this study were significantly lower compared with a mean egfr in dipper patients.32 meanwhile, afsar et al33 compared patterns of non dipping and 24 hour urinary albumin excretion (uae) in 158 hypertensive patients (104 dippers; 54 non dippers). among patients in the non dipper group, 17 patients had microalbuminuria, while only 9 patients in dipper group had microalbuminuria (p<0.0001). the median uae of dipper group was significantly lower (5.25 mg/day) when compared with non dipper group (23 mg/day). significance of ambulatory blood pressure monitoring in non dipping hypertensive patient there are several modalities of measuring blood pressure, which is divided into two categories, the clinic based measurement (auscultatory method, oscillometric method) and non clinic-based measurement (home blood pressure monitoring, abpm).34 abpm itself has gained popularity as an alternative to traditional method for measuring blood pressure in clinical setting.35 in the abpm technique, the patient wears a portable blood pressure measuring device for a certain period (usually 24 h). this periodically measures blood pressure (every 15–30 min during the day and every 30–60 min overnight) automatically and may provide information of blood pressure during normal daytime activities and importantly during sleep.36,37 the term ‘nocturnal hypertension’ or ‘non dipping’ pattern as described in above section become an important phenomenon to be considered by all clinicians and it can only be identified by 24 hour abpm or other methods of recording the sleep blood pressure.38,39 many studies compared abpm and clinicbased measurement and concluded that abpm is more superior in predicting cardiovascular event or other prognostic factor. abpm may also reduce the incidence of white-coat effect and masked hypertension that were not detected in clinic-based measurement, and also predict allcause mortality especially due to cardiovascular event than awake or clinic blood pressure.24,34,40 the results of the study showed that patients with an absence of normal dipping has higher mortality than the dipping one. the pattern of dipping that was detected will add clinical predictive information and further reinforcing the use of ambulatory monitoring in patient management. 40 therefore, importance of nocturnal hypertension or ‘non dipping pattern’ of blood pressure strengthens the need for 24 hours abpm. t h e i m p r o v e d s t r a t e g y i n hypertension management standard treatment of hypertension nowadays, there are many different classes of antihypetensive drugs, such as diuretics, angiotensin-converting enzyme (ace) inhibitor, angiotensin ii-receptor-blockers (arbs), β-blocker, and calcium antagonist, that have been used for the intitiation and maintenance of antihypertensive treatment. generally, a long-acting antihypertensive drug with 24 hours duration is used as a initial standard treatment of hypertensive patients in order to maintain blood pressure variability and adherence to therapy.41,42 andi kristanto acta med indones-indones j intern med 80 however, antihypertensive drugs used once daily are rarely effective from the morning dosing until the following morning. many of the hypertensive patients, especially non dipper patients on standard antihypertensive drugs still have raised blood pressure on the morning. it is because the effect of antihypertensive drugs on the diurnal variation of blood pressure, depends not only on the mechanism of action of the drugs, but also on the time of administration, and the pharmacokinetics and pharmacodymamics of the drug.43 in this regard, choosing the optimal timing for drug administration, especially a single dose antihypertensive drug, such as several kind of ace inhibitor, arb, or calcium antagonist should be considered. also, we have discussed that the blood pressure (bp) is regulated by many different systems and its activity vary throughout the day. as drugs are developed that selectively block these systems, the reduction on the bp may not be consistent over 24 hours.4,44 chronotherapy: improving the hypertension management chronotherapy is defined as administering drug while considering the optimal dosing time in purpose to enhance drugeffectiveness and tolerance. in hypertension, chronotherapy defined as taking hypertensive medication at night to obtain normal bp decrease in line with circadian rhythms, reduce the morbidity and mortality.45,46 t h e m a p e c s t u d y c o m p a r e d t h e administration time between morning dose (taking all prescribed drugs in the morning) and bedtime doses (taking more than one drug at bedtime), and concluded that after a mean follow up of 5.6 years in 2156 subjects, the bedtime dose achieved better overall bp control. also, subjects taking more than one drug at bedtime showed significantly lower relative risk of total cardiovascular disease events, compared to those taking all drugs in the morning. the prevalence of non-dipping significantly reduced in those receiving medication in the bedtime (34% vs. 62%) and higher prevalence of controlled ambulatory bp (62% vs. 53%).45 the possibility to achieve better bp control using telmisartan administered at bedtime was assessed in a study, in which telmisartan 80 mg given in 215 patients randomized to take the drug in the morning or bedtime. after 12 weeks of treatment, the reduction of bp was similar for both groups. however, subjects taking bedtime dose had reduced prevalence for non-dipper by 76%, without loss in 24 hour efficacy of telmisartan.47 similar results were found in other studies, in which olmesartan or valsartan taken at night provided 24 hours bp reduction while improving nocturnal bp fall more significantly than morning dosing, thus reducing the prevalence of non dipper.48,49 t h e u s e o f c h r o n o t h e r a p y i n o t h e r hypertensive drugs regimens had shown similar beneficial effects. bedtime dosing of ramipril in at least two different studies were found to be effective in achieving nocturnal bp regulation.50,51 the role of chronotherapy in nifedipine gits (gastrointestinal-therapeuticsystem) formulation and amlodipine as calcium channel blocker class drugs also showed greater reduction of 24-hours abpm and greater bp reduction at night compared with morning dosing.52,53 a chronotherapy trial using combination antihypertensive drug also has been conducted by hermida et al54, using valsartan/amlodipine combination in 203 hypertensive subjects, and resulted that bp-lowering efficacy was highest when both antihypertensive drugs ingested at bedtime, compared to both ingested on awakening, or either of the drugs ingested on awakening and the other at bedtime. moreover, chronotherapy was found to have useful effect in treatment of resistant hypertension. in a study of 250 patients with resistant hypertension that received three hypertensive drugs, ambulatory bp reduced by 9.4/6.0 mmhg when one of the drugs was administered at bed time. the percentage of dippers increased from 16% to 57% after 12 weeks of administering one drug at bedtime.55 conclusion as conclusion, identifying the nocturnal hypertension as well dipping or non dipping status of patients are important for aiding the decision on the necessity of chronotherapy, withdrawal vol 48 • number 1 • january 2016 nocturnal hypertension 81 or reduction of unnecessary medication, and monitoring hypertension treatment. taking the antihypertensive medication in the night significantly improves the dipping pattern of hypertensive patient, thus chronotherapy is a improved strategy in hypertension management. references 1. maraj i, makaryus jn, ashkar a, et al. hypertension management in the high cardiovascular risk population. int j hyper. 2013:1-7. 2. friedman o, logan ag. can nocturnal hypertension predict cardiovascular risk? integr blood press control. 2009;2:25–37. 3. li y, wang jg. isolated nocturnal hypertension: a disease masked in the dark. hypertension. 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abdel-monem badawi yousif3, awni alshurafa1, fateen ata1 1 department of medicine, hamad general hospital, doha, qatar. 2 department of medicine, al khor hospital, doha, qatar. 3 department of pharmacy, hamad general hospital, doha, qatar. corresponding author: fahmi yousef khan, md. consultant, department of medicine/hamad general hospital. assistant professor of clinical medicine weill cornel medical university, qatar. p.o.box: 3050, doha, qatar. email: fakhanqal@gmail.com. abstrak latar belakang: beberapa penelitian telah melaporkan acute kidney injury (aki) terkait piperacillintazobactam (taz/pipc) dengan berbagai frekuensi. tujuan dari penelitian ini adalah menentukan frekuensi aki terkait taz/pipc di antara pasien kami dan untuk mengidentifikasi faktor risiko pada entitas klinis. metode: penelitian potong lintang retrospektif ini dilakukan di rumah sakit umum hamad; melibatkan pasien dewasa yang dirawat dari januari 2017 hingga desember 2017. hasil: terdapat 917 pasien yang diikutsetakan, di antaranya 635 (69,25%) laki-laki dan 282 (30,75%) perempuan. usia rerata pasien adalah 52 (sb 19) tahun, dan 98 (10,7%) pasien didiagnosis dengan aki. para pasien dengan aki secara signifikan lebih tua daripada tanpa aki [59,71 (sb 19,79) versus 51,06 (sb 18,67); p <0,001]. setelah inisiasi taz/pipc, rerata kadar kreatinin pada kelompok aki lebih tinggi dibandingkan rerata kadar kreatinin pada kelompok non-aki, [158,91 (sb 81,93) berbanding 66,78 (sb 21,42); p<001]. rerata waktu timbulnya aki setelah inisiasi pipc/taz adalah 4,46 (sb 3,20) (1-12 hari). aki secara signifikan terkait dengan albumin serum rata-rata rendah (p<0,001), gula darah puasa rerata tinggi (p<0,001), penyakit arteri koroner (p<0,001), gagal jantung (p<0,001), penyakit hati (p=0,047), diabetes melitus (p=0,021) dan hipertensi (p<0,001). angka mortalitas di rumah sakit secara signifikan lebih tinggi pada kelompok aki [38,78% berbanding 5,13% pada kelompok non-aki; p<0,001], dan hanya usia lanjut dan gagal jantung yang ditemukan sebagai faktor risiko independen untuk aki terkait taz/pipc. kesimpulan: taz/pipc secara signifikan berhubungan dengan aki. usia lanjut dan gagal jantung diidentifikasi sebagai faktor risiko independen untuk aki terkait taz/pipc. kata kunci: acute kidney injury, piperacillin/tazobactam, usia lanjut, gagal jantung. abstract background: several studies have been reported piperacillin-tazobactam (taz / pipc)-associated aki with various frequencies. the aim of this study was to determine the frequency of taz/pipcassociated aki among our patients and to identify the risk factors for this clinical entity. methods: this retrospective cross-sectional study was conducted at hamad general hospital; it involved adult patients who were admitted from january 2017 to december 2017. results: we involved 917 patients, of whom 635 (69.25%) were males and 282 (30.75%) were females. the mean age of the patients was 52 (sd 19) years, and 98 (10.7%) patients were diagnosed with aki. the patients with aki were significantly older than without aki [59.71 (sd 19.79) versus 51.06 (sd 18.67); p <0.001]. after taz/pipc initiation, the mean creatinine level in the aki group was higher than the vol 53 • number 2 • april 2021 frequency of acute kidney injury in patient receiving piperacillin-tazobactam 157 introduction the combination piperacillin-tazobactam (taz/pipc) is a commonly prescribed empirical therapy for patients with healthcare-associated infections, as it provides coverage against both methicillin-sensitive staphylococcus aureus (mssa) and pseudomonas aeruginosa.1 common adverse effects include headache, trouble sleeping, itching, skin rash, nausea, leucopenia, neutropenia, constipation, and diarrhea.1 serious adverse effects include clostridioides difficile infection and allergic reactions including anaphylaxis may occur.2,3 acute kidney injury (aki) as an adverse effect of taz/pipc has been mentioned in several reports with varying frequencies. the proposed mechanisms for taz/pipc induced aki include acute interstitial nephritis or toxic effects on the renal tubule.4-5 during our practice, we noted that many patients developed aki after using taz /pipc; however, the frequency of this complication in our hospital is unknown. this study was designed to determine the frequency of aki due to taz/ pipc among our patients and to identify the risk factors for taz/pipc-associated aki. methods this retrospective analytical cross-sectional study was conducted at hamad general hospital (hgh), which is a tertiary center that covers all specialties except for hematology-oncology and obstetrics. this study involved adult patients who were admitted to hgh from january 1, 2017 to december 31, 2017 and received piperacillintazobactam at a dose of 4.5 g intravenously every eight hours daily. inclusion and exclusion criteria eligible subjects were adults of 18 years of age or more, who were admitted to hgh from january 1, 2017 to december 31, 2017, and received piperacillin-tazobactam at a dose of 4.5 g intravenously every eight hours daily. patients younger than 18 years old and patients who had a baseline serum creatinine level of >1.2 mg/dl (106 mcmol/l) [3] or receiving renal replacement therapy at the time of the initiation of treatment, were excluded. moreover, patients who had recent administration of contrast agents also were excluded. source of data and data collection the list of the patients who received taz/ pipc from january 1, 2017 to december 31, 2017 was obtained from the pharmacy electronic records at hgh. then the electronic medical records (cerner system) of all patients were screened for inclusion purposes and the records of the eligible patients were reviewed to obtain demographic data, laboratory data (baseline serum creatinine, serum creatinine after receiving taz/pipc, fasting blood glucose and serum albumin), comorbidities (hypertension, cad, dm, copd, pad, heart failure, liver disease, active cancer), concomitant drugs (nsaids, ace/arb, vancomycin, acyclovir, diuretics), type of infection and the outcome. outcomes the primary outcome of our study was acute kidney injury (aki), which was defined according to the kdigo (kidney disease: improving global outcomes) criteria, [6] as an increase in serum creatinine level by 50% or higher from baseline or by 0.3 mg/dl (26.5 μmol/l) or higher within 2 hospital days or mean creatinine level in the non-aki group, [158.91 (sd 81.93) versus 66.78 (sd 21.42); p<001]. the mean time of onset of aki after pipc/taz initiation was 4.46 (sd 3.20) (1-12 days). aki was significantly associated with low mean serum albumin (p<0.001), high mean fasting blood glucose (p<0.001), coronary artery diseases (p<0.001), heart failure (p<0.001), liver diseases (p=0.047), diabetes mellitus (p=0.021) and hypertension (p<0.001). the in-hospital mortality was significantly higher in the aki group [38.78% versus 5.13% in the non-aki group; p<0.001], and only advanced age and heart failure were found as independent risk factors for taz/pipc-associated aki. conclusion: taz/pipc was significantly associated with aki. advanced age and heart failure were identified as independent risk factors for taz/pipc-associated aki. keywords: acute kidney injury, piperacillin/tazobactam, advanced age, heart failure. fahmi yousef khan acta med indones-indones j intern med 158 fewer. the secondary outcome was in-hospital mortality, which was defined as all deaths occurring during the hospital stay. data analysis results were expressed as mean ± sd. after the demonstration of a normal distribution, two-tailed unpaired student’s t-tests and the mann-whitney test were used to compare the distribution of quantitative variables and the χ2 tests and fisher’s test for categorical variables. variables that showed significant association in bivariate analysis (p<0.05) were entered into multivariate analysis to identify the independent risk factors of aki at p<0.05. ethical approval the ethical approval for this study was obtained from the medical research committee (mrc) at hamad medical corporation (hmc). the reference to the approved proposal was mrc-01-18-065. according to the mrc, a waiver of informed consent is not required for any retrospective study and all data/samples were fully anonymized by the principal investigator and other team members before being accessed by others including the biostatistician, journal and readers. results during the study period, we retrospectively identified 2540 patients who received taz/ pipc, of which 917 fulfilled the inclusion criteria and became the subject of this study as illustrated in figure 1. the electronic medical records of all eligible patients were fetched and reviewed. of the 917 patients, there were 635 (69.25%) males and 282 (30.75%) females. the mean age of the patients was 52 sd 19 (range:18-90 years) and 98 (10.7%) patients were found to have acute kidney injury (aki). table 1 describes the demographic and clinical data of the cohort of this study. a comparison between aki and non-aki groups the patients with aki were significantly older than without aki [59.71 (sd 19.79) vs 51.06 (sd 18.67); p <0.001]. after taz/pipc initiation, the mean creatinine level in the aki group was higher than the mean creatinine level in the non-aki group, [158.91 (sd 81.93) versus 66.78 (sd 21.42); p<001]. the mean time of onset of aki after pipc/taz initiation was 4.46 (sd 3.20) (1-12 days). aki was significantly associated with low mean serum albumin (p<0.001), high mean fasting blood glucose (p<0.001), coronary artery diseases (p<0.001), heart failure (p<0.001), liver diseases (p=0.047), diabetes mellitus (p=0.021) and hypertension (p<0.001). the in-hospital mortality was table 1. demographic and clinical characteristics of the patients involved in this study. characteristics number (%) / mean (sd) sex, n (%) female 282 (30.75) male 635 (69.25) age (years), mean (sd) 51.98 (18.97) bmi, mean (sd) 27.04 (6.73) nationalities, n (%) non-qatari 640 (69.79) qatari 277 (30.21) cad, n (%) 130 (14.18) pad, n (%) 36 (3.93) copd, n (%) 39 (4.25) heart failure, n (%) 63 (6.87) liver disease, n (%) 53 (5.79) dm, n (%) 378 (41.22) hypertension, n (%) 360 (39.3) active cancer, n (%) 107 (11.67) hematology cancer, n (%) 24 (2.62) nsaid, n (%) 142 (15.49) acei/arb, n (%) 181 (19.74) vancomycin, n (%) 100 (10.91) acyclovir, n (%) 20 (2.18) diuretics, n (%) 169 (18.43) pneumonia, n (%) 406 (44.27) endocarditis, n (%) 1 (0.11) febrile neutropenia, n (%) 24 (2.62) urinary tract, n (%) 96 (10.47) abdominal infection, n (%) 181 (19.74) musculoskeletal, n (%) 107 (11.67) septicemia, n (%) 183 (19.98) others, n (%) 131 (14.3) aki, n (%) 98 (10.7) baseline creatinine, mean (sd) 69.50 (17.75) creatinine after taz/pipc initiation, mean (sd) 76.63 (43.93) duration of taz/pipc therapy, mean (sd) 6.13 (4.17) duration of taz/pipc until aki, mean (sd) 4.46 (3.20) albumin, mean (sd) 27.38 (6.46) fasting blood glucose, mean (sd) 7.58 (3.53) aki duration, mean (sd) 10.93 (18.73) renal replacement therapy, n (%) 17 (1.9) in-hospital mortality, n (%) 80 (8.72) vol 53 • number 2 • april 2021 frequency of acute kidney injury in patient receiving piperacillin-tazobactam 159 significantly higher in the aki group [38.78% versus 5.13% in the non-aki group; p<0.001]. table 2 summarizes the conditions associated with aki in this study. the outcomes and the independent risk factors for aki the in-hospital mortality was 80 (8.72%). table 3 describes the outcomes of the cohort of this study. after adjusting the relationship to include many variables, and by using conditional multiple logistic regression analysis, only advanced age (adjusted or=0.96, 95% ci = 0.93-1.00, p= 0.03) and heart failure (adjusted or=3.8, 95%ci=1.16-12.54, p=0.02) were found to be independent risk factors for aki (table 4). discussion taz / pipc is one of the most commonly used antibiotics in our hospital. its effectiveness is attributed to its ability to cover broad-spectrum gram-negative microorganisms and anaerobic agents. at the time of introduction to our hospital, it was an unrestricted antibiotic that allowed any physician to prescribe the antibiotic indefinitely. table 2. comparison between aki group and non-aki group in relation to demographic, clinical characterestics of patients involved in this study. characteristics total (n=917) aki negative (n=819) aki positive (n=98) p-value age, mean (sd) 51.98 (18.97) 51.06 (18.67) 59.71 (19.79) <0.001 male, n (%) 635 (69.25) 573 (69.96) 62 (63.27) 0.174 qatari, n (%) 277 (30.21) 242 (29.55) 35 (35.71) 0.209 bmi, mean (sd) 27.04 (6.73) 26.89 (6.62) 28.29 (7.45) 0.051 baseline creatinine, mean (sd) 69.50 (17.75) 67.84 (17.20) 83.33 (16.29) <0.001 creatinine after taz/pipc initiation 76.63 (43.93) 66.78 (21.42) 158.91 (81.93) <0.001 duration of taz/pipc, mean (sd) 6.13 (4.17) 6.07 (4.24) 6.75 (3.53) 0.268 albumin, mean (sd) 27.29 (6.99) 27.60 (6.98) 24.75 (6.59) <0.001 fasting blood glucose, mean (sd) 7.58 (3.53) 7.4 (3.37) 9.07 (4.38) <0.001 coronary artery disease (cad), n (%) 130 (14.18) 103 (12.58) 27 (27.55) <0.001 peripheral artery disease (pad), n (%) 36 (3.93) 31 (3.79) 5 (5.1) 0.526 copd, n (%) 39 (4.25) 35 (4.27) 4 (4.08) 0.929 heart failure, n (%) 63 (6.87) 41 (5.01) 22 (22.45) <0.001 liver disease, n (%) 53 (5.79) 43 (5.26) 10 (10.2) 0.047 diabetes mellitus, n (%) 378 (41.22) 327 (39.93) 51 (52.04) 0.021 hypertension, n (%) 360 (39.3) 302 (36.92) 58 (59.18) <0.001 active cancer, n (%) 107 (11.67) 92 (11.23) 15 (15.31) 0.235 hematology cancer, n (%) 24 (2.62) 19 (2.32) 5 (5.1) 0.103 nsaid, n (%) 142 (15.49) 131 (16.0) 11 (11.22) 0.217 acei/arb, n (%) 181 (19.74) 159 (19.41) 22 (22.45) 0.476 vancomycin, n (%) 100 (10.91) 79 (9.65) 21 (21.43) <0.001 acyclovir, n (%) 20 (2.18) 19 (2.32) 1 (1.02) 0.405 diuretics, n (%) 169 (18.43) 121 (14.77) 48 (48.98) <0.001 pneumonia, n (%) 406 (44.27) 348 (42.49) 58 (59.18) 0.002 endocarditis, n (%) 1 (0.11) 1 (0.12) 0 (0) 0.729 febrile neutropenia, n (%) 24 (2.62) 22 (2.69) 2 (2.04) 0.705 urinary tract, n (%) 96 (10.47) 84 (10.26) 12 (12.24) 0.543 abdominal infection, n (%) 181 (19.74) 174 (21.25) 7 (7.14) 0.001 musculoskeletal, n (%) 107 (11.67) 98 (11.97) 9 (9.18) 0.418 septicemia, n (%) 183 (19.98) 152 (18.58) 31 (31.63) 0.002 in-hospital mortality, n (%) 80 (8.72) 42 (5.13) 38 (38.78) <0.001 table 3. outcomes of the cohort of this study. outcomes n (%) creatinine after taz/pipc initiation, mean (sd) 76.63 (43.93) aki, n (%) 98 (10.7) aki duration, mean (sd) 10.93 (18.73) renal replacement therapy, n (%) 17 (1.9) in-hospital mortality, n (%) 80 (8.72) fahmi yousef khan acta med indones-indones j intern med 160 think our results will support the efforts of the stewardship program designers to restrict the use of this antibiotic in hmc to avoid unwanted side effects such as aki that results from the judicious use of this antibiotic. regardless of the characteristics of the population analyzed and the criteria used to diagnose aki, taz / pipc-associated aki has been reported by several authors with various frequencies; the estimated frequency varies between 7.8 and 38.5% of cases.3-9 in our study, the frequency of taz/pipc-associated aki was 10.7% of cases, which falls within the international range. taz/pipc is often co-administered with vancomycin to cover methicillin-resistant gram-positive organisms in various infections such as catheter-related bloodstream infections. it has recently been reported that patients receiving a combination of vancomycin and taz / pipc had a relatively high aki level compared to patients receiving vancomycin alone.3,4,10-13 although our study was not designed to compare between patients who used vancomycin in combination with taz/pipc and patients who received taz/pipc alone, the number of patients who received vancomycin in the aki group was significantly higher than the patient in the non-aki group [21 (21.43%) vs. 79 (9.65%); p<0.001], which is in keeping with the above studies. based on this finding, patients receiving a combination of vancomycin and taz table 4. results of multivariate analysis of predictors of aki. variables adjusted or p value age 0.96 (0.93-1.00) 0.038 baseline creatinine 0.98 (0.96-1.01) 0.214 creatinine after taz/ pipc initiation 1.03 (1.00-1.06) 0.079 albumin 1.00 (0.94-1.06) 0.951 fasting blood glucose 0.96 (0.86-1.07) 0.474 cad 1.51 (0.51-4.48) 0.460 heart failure 3.80 (1.16-12.45) 0.027 liver disease 1.54 (0.40-5.89) 0.531 diabetes mellitus 0.36 (0.12-1.08) 0.069 hypertension 1.57 (0.49-4.98) 0.447 vancomycin 0.47 (0.14-1.58) 0.219 diuretics 0.63 (0.25-1.62) 0.342 pneumonia 1.48 (0.62-3.52) 0.371 abdominal infection 0.35 (0.09-1.35) 0.128 septicemia 2.49 (0.94-6.59) 0.065 in-hospital mortality 1.56 (0.47-5.19) 0.467 12 total number of patients assessed for eligibility (n=2540) excluded patients: 1623 � younger than 18 years = 594 � baseline serum creatinine level of >1.2 mg/dl = 703 � receiving renal replacement therapy at the time of the initiation of treatment = 300 � contrast agents = 26 patients enrolled (n= 917) patients with aki [n=98 (10.7%)] patients without aki [n=819 (89.3)] figure 1. a flow chart of patients recruitment in this study however, because of its high prescription volume and rising expenses1, a restriction decision has been made in the last three years till present, in an attempt to monitor and control the judicious use of this antibiotic. as part of a stewardship program in hamad medical corporation (hmc), taz/pipc was placed on a 48-hour restriction, therefore, any physician could order the antibiotic, but each order would be given a 48-hour stop date, after which it is subjected to a review by an infectious disease physician. to our knowledge, this is the first study to report taz/pipc-associated aki among patients treated in hamad general hospital, qatar. we vol 53 • number 2 • april 2021 frequency of acute kidney injury in patient receiving piperacillin-tazobactam 161 / pipc should, therefore, be closely monitored for the development of aki and it would be better if they were switched to a less nephrotoxic regimen. moreover, we found that the aki group used more diuretics than the non-aki group [48 (48.98%) vs. 121 (14.77%); p<0.001], which is contrary to a report by rutter et al.4 the exact mechanism of aki in these patients is unclear. however, this finding indicates that we should use taz/pipc cautiously in patients under diuretics. of note, the duration of taz/pipc use was significantly longer in the aki group than in the non-aki group [7.44 (sd 6.09) vs. 6.04 (sd 4.24); p=0.004], which coincide with other reports in the literature.14 therefore, we support the stewardship program recommendation on the restriction of taz/pipc, as this step will shorten the duration of exposure of the patients to this drug. our study also showed a significant association between aki and many variables such as low serum albumin, diabetes mellitus, coronary artery disease, liver disease, pneumonia, abdomen infection, sepsis and hypertension. in critically ill patients with sepsis, aki is a recognized clinical entity; in one study,15 it was found in 66% of patients admitted to the intensive care unit. in such a case, aki may be a consequence of the sepsis itself or of therapeutic interventions that include drugs like vancomycin and taz/ pip, or the dual effect of both. in the same context, jensen et al. observed that in patients with sepsis-related renal dysfunction, exposure to taz/ pip is associated with a lower rate of improvement in glomerular filtration rate (gfr) compared to other antibiotics and that the kidney function improves rapidly after stopping this medication.16 given this finding, let us conclude that patients with sepsis are more susceptible to aki if they receive taz/ pip. further prospective rcts are needed to confirm this observation. however, it is advisable to look for effective strategies to reduce nephrotoxicity in this group of patients. suggested strategies include avoiding dehydration and co-administration of other nephrotoxic agents. other actions include close monitoring of renal function, early and repeated reevaluations of empirical antibiotic therapy with appropriate alterations, and the use of alternatives to taz/pip such as cefepime or an antipseudomonal carbapenem.17 on the other hand, the reason for the significant association between aki and hypertension in patients receiving taz/pip is unclear, however, it could be attributed to the pre-existing hypertensive renal disease. interestingly, we only found advanced age and heart failure to be associated significantly with aki in both bivariate and multivariate analyses. the association of advanced age and heart failure with aki in patients receiving taz/ pipc could be explained by the fact that heart failure and advanced age cause reduced renal blood flow13,14 that may aggravate tubular injury related to taz/pipc, by limiting oxygen and nutrient availability and facilitating oxidative stress. we, therefore, recommend caution when using taz/ pipc in patients with advanced age and heart failure who should be closely monitored for the development of aki. to our knowledge, this is the first clinical study to report heart failure as an independent risk factor for aki associated with taz/pipc administration. a noteworthy finding of this study is that the in-hospital mortality was higher in aki patients compared to non-aki patients [38 (38.78%) vs. 24 (5.13%); p = 0.02], which is consistent with emerging evidence suggesting that there are higher in-hospital mortality rates with even smaller changes in serum creatinine level.18 however, the impact of tiz/pip-associated aki on mortality is unclear due to the lack of information and the paucity of studies. our study has several limitations. first, it was a retrospective study that did not allow us to study in detail many variables, such as the reason for the prolonged use of taz/ pipc in some patients in our study over a period of up to 42 days. moreover, we did not have detailed information about other medications used during the study period. second, we have excluded patients under the age of 18 years. as a result, we missed the opportunity to estimate the prevalence of taz/ pipc-induced aki among different groups in our hospital. third, we did not have the facilities to measure taz/ pipc levels to assess whether patients with aki had higher fahmi yousef khan acta med indones-indones j intern med 162 taz/ pipc blood levels or not. fourth, this was a hospital-based study, despite the large sample size, therefore, the results may not be applicable to other hospitals. conclusion we found that taz/pipc was associated with aki and that co-administration of taz/ pipc with vancomycin or diuretics resulted in a high rate of aki compared to patients receiving taz/pipc alone. advanced age and heart failure have been identified as independent risk factors for taz/pipc-induced aki that should be targeted to prevent aki and improve patient outcomes. we, therefore, recommend baseline evaluation and continuous monitoring of renal function in high-risk patients receiving taz/ pipc therapy. conflict of interest there is no conflict of interest. funding the authors received no specific funding for this work. references 1. khan fy, elhiday a, khudair if, et al. evaluation of the use of piperacillin/tazobactam (tazocin) at hamad general hospital, qatar: are there unjustified prescriptions? infect drug resist. 2012;5:17-21. 2. k h a n f y, a b u k h a t t a b m , a n a n d d , e t a l . epidemiological features of clostridium difficile infection among inpatients at hamad general hospital in the state of qatar, 2006-2009. travel med infect dis. 2012;10(4):179-85. 3. karino s, kaye ks, navalkele b, et al. epidemiology of acute kidney injury among patients receiving c o n c o m i t a n t va n c o m y c i n a n d p i p e r a c i l l i n tazobactam: opportunities for antimicrobial s t e w a r d s h i p . a n t i m i c r o b a g e n t s c h e m o t h e r. 2016;60(6):3743–50. 4. rutter wc, burgess dr, talbert jc, burgess ds. acute kidney injury in patients treated with vancomycin and piperacillin-tazobactam: a retrospective cohort analysis. j hosp med. 2017;12(2):77–82. doi:10.12788/ jhm.2684. 5. morimoto t, nagashima h, morimoto y, tokuyama s. frequency of acute kidney injury caused by tazobactam/ piperacillin in patients with pneumonia and chronic kidney disease: a retrospective observational study. yakugaku zasshi. 2017;137(9):1129-36. 6. kidney international supplements. kidney disease: improving global outcomes (kdigo). kdigo clinical practice guideline for acute kidney injury. http://www.kdigo.org/clinical_practice_guidelines/ pdf/kdigo%20aki%20guideline.pdf. published march 2012. accessed july 11, 2019. 7. mccormick h, tomaka n, baggett s, et al. comparison of acute renal injury associated with intermittent and extended infusion piperacillin/tazobactam. am j health syst pharm. american society of healthsystem pharmacists; 2015;72 (11 suppl 1):s25–30. 8. kadomura s, takekuma y, sato y, sumi m, kawamoto k, itoh t, sugawara m. higher incidence of acute kidney injury in patients treated with piperacillin/ tazobactam than in patients treated with cefepime: a single-center retrospective cohort study. j pharm health care sci. 2019;5:13. 9. karino f, miura k, fuchita h, et al. efficacy and safety of piperacillin/tazobactam versus biapenem in late elderly patients with nursingand healthcare-associated pneumonia. j infect chemother. 2013;19(5):909–15. 10. c arreno j, smiraglia t, h unter c , tobin e , lomaestro b. comparative incidence and excess risk of acute kidney injury in hospitalised patients receiving vancomycin and piperacillin/tazobactam in combination or as monotherapy. int j antimicrob agents. 2018;52(5):643-50. 11. kim t, kandiah s, patel m, et al. risk factors for kidney injury during vancomycin and piperacillin/ tazobactam administration, including increased odds of injury with combination therapy. bmc res notes. 2015;8:579. 12. lecleir lk, pettit rs. piperacillin-tazobactam versus cefepime incidence of acute kidney injury in combination with vancomycin and tobramycin in pediatric cystic fibrosis patients. pediatr pulmonol. 2017;52(8):1000-5. 13. luther mk, timbrook tt, caffrey ar, dosa d, lodise tp, laplante kl. vancomycin plus piperacillintazobactam and acute kidney injury in adults: a systematic review and meta-analysis. crit care med. 2018;46(1):12-20. 14. lorenz ma, moenster rp, linneman tw. effect of piperacillin/tazobactam restriction on usage and rates of acute renal failure. j med microbiol. 2016;65(2):195-9. 15. wang he, muntner p, chertow gm, warnock dg. acute kidney injury and mortality in hospitalized patients. am j nephrol. 2012;35:349–55. 16. jensen ju, hein l, lundgren b, et al. procalcitonin and survival study (pass) group. kidney failure related to broad-spectrum antibiotics in critically ill patients: secondary end point results from a 1200 patient randomised trial. bmj open. 2012;2:e000635. 17. watkins rr, deresinski s. increasing evidence of the nephrotoxicity of piperacillin/tazobactam and vancomycin combination therapy: what is the clinician vol 53 • number 2 • april 2021 frequency of acute kidney injury in patient receiving piperacillin-tazobactam 163 to do? clin infect dis. 2017;65(12):2137-43. 18. chertow gm, burdick e, honour m, bonventre jv, bates dw. acute kidney injury, mortality, length of stay, and costs in hospitalized patients. j am soc nephrol. 2005;16(11):3365-70. 326 original article acta med indones indones j intern med • vol 52 • number 4 • october 2020 the association between peripheral th17, th1, il-17, and ifn-γ levels and tace response in patients with unresectable hepatocellular carcinoma with or without cirrhosis irsan hasan1, rino a. gani1, laurentius a. lesmana1, siti b. kresno2, jacub pandelaki3, suhendro suwarto1 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of clinical pathology, dharmais cancer hospital, jakarta, indonesia. 3 department of radiology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: irsan hasan, md., phd. division of hepatobiliary, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jalan diponegoro no. 71, jakarta 10430, indonesia. email: irsan_h@yahoo.com. abstrak latar belakang: sel th17, yang memiliki kemampuan memproduksi il-17, dilaporkan memiliki efek pro-tumor dan anti-tumor. sel th1 diketahui dapat mengeliminasi sel tumor melalui ifn-γ yang dihasilkannya. kemoembolisasi transarterial (tace) merupakan pilihan terapi untuk pasien karsinoma sel hati (ksh) yang tidak dapat dilakukan reseksi. penelitian ini bertujuan untuk menentukan hubungan antara kadar th1, th17, il-17, dan ifn-γ pada sirkulasi perifer dengan respons tace pada pasien ksh sirotik maupun non-sirotik yang pertama kali menjalani tace. metode: penelitian ini menggunakan desain studi kohort prospektif yang dilakukan di rumah sakit cipto mangunkusumo dan beberapa rumah sakit jejaring dari juni 2015 hingga januari 2019. pasien ksh dengan atau tanpa sirosis hati yang memenuhi kriteria inklusi diikutsertakan dalam penelitian ini. pengambilan sampel darah dilakukan sesaat sebelum tace dan 30 hari setelah tace. sel th1 dan th17 dianalisis menggunakan flowcytometry, sedangkan sitokin il-17 dan ifn-γ diperiksa menggunakan metode elisa. respons terhadap tace dinilai menggunakan mrecist. hasil: sebanyak 41 pasien ksh diikutsertakan dalam penelitian ini. berdasarkan kriteria mrecist, 12 pasien dinilai sebagai kelompok respons (respons komplet dan parsial) dan 29 pasien dinilai sebagai kelompok nonrespons (lesi stabil dan progresif). kadar th1 dan th17 meningkat secara bermakna setelah tace pada kelompok respons. di sisi lain, kadar il-17 dan ifn-γ menurun setelah tace pada kedua kelompok, walaupun tidak bermakna secara statistik. yang menarik, pada kelompok respons didapatkan peningkatan signifikan pada kadar sel t yang mengekspresikan baik ifn-γ maupun il-17 pada permukaannya, yaitu sel sel t cd4+/ifn-γ+/il-17+. kesimpulan: peningkatan kadar sel th1, th17, dan sel t cd4+/ifn-γ+/ il-17+ ditemukan pada pasien ksh dengan respons komplit atau parsial terhadap tace. kata kunci: karsinoma sel hati, kemoembolisasi transarterial, th1, th17. abstract background: th17 cells, a subset of cd4+ t cells with the capacity to produce il-17, were reported to have pro-tumor and anti-tumor effects. th1 cells are known for their capacity to eliminate tumor cells by producing ifn-γ. transarterial chemoembolization (tace) is a treatment of choice for patients with unresectable hepatocellular carcinoma (hcc). therefore, this study aimed to determine the association between peripheral vol 52 • number 4 • october 2020 the association between peripheral th17, th1, il-17, and ifn-g levels 327 th17, th1, il-17, and ifn-γ levels and tace response in patients with unresectable hcc with or without cirrhosis. methods: a prospective cohort study was conducted in cipto mangunkusumo hospital and several affiliated hospitals from june 2015 to january 2019. hcc patients with or without cirrhosis who met the inclusion criteria were included in this study. blood samples were obtained immediately before tace and 30 days after tace. th1 and th17 cells were analyzed by flowcytometry, while il-17 and ifn-γ were examined with elisa method. tace response was assessed with mrecist. results: forty-one hcc patients were enrolled in this study. according to mrecist, 12 patients were assessed as response group (complete and partial response) and 29 patients were assessed as nonresponse group (stable and progressive disease). levels of th1 and th17 increased significantly after tace in the response group. on the other hand, il-17 and ifn-γ decreased after tace in both groups, although not statistically significant. interestingly, in the response group, a significant increase was found in the number of t cells subset showing both ifn-γ and il-17 markers on their surfaces, i.e. cd4+/ifn-γ+/il-17+ t cells. conclusion: increased circulating th1, th17, and cd4+/ifn-γ+/il-17+ t cells were observed in hcc patients with complete or partial response to tace. keywords: hepatocellular carcinoma, th1, th17, transarterial chemoembolization. introduction hepatocellular carcinoma (hcc) is the fourth leading cause of cancer-related deaths globally and a major health problem in southeast asia,1 including indonesia. nearly 85% of hcc patients were diagnosed in the intermediate or advanced stage, when curative treatment is no longer eligible.2 in the intermediate stage, transarterial chemoembolization (tace) is the recommended treatment modality for hcc patients with good performance status and preserved liver function.3 however, the outcome of tace is not satisfactory with reported 3-year overall survival (os) rate as low as 10-40%.4 t h e i m m u n e c e l l s i n t h e t u m o r microenvironment play important role in modulating liver fibrosis, hepatocarcinogenesis, tumor invasion, and metastasis.5 t helper 17 (th17) cells, are among the many immune cells that play a major role in tumor microenvironment by producing proinflammatory cytokines capable of promoting or inhibiting tumor growth.6 several studies reported that high levels of th17 cells, either in peripheral blood or intratumoral, were associated with poor prognosis of hcc.7–9 these findings were supported by the negative correlation of increased intratumoral interleukin-17 (il-17), one of the cytokines that is secreted by th17, with survival rate.10 on the other hand, liao et al11 found that increased circulating th17 level 30 days after tace was associated with better os and time-to-progression (ttp) in stage iii hcc patients. these results are representative of th17 controversies in hcc. meanwhile, th1 cells are known for their anti-tumor effect through ifn-γ production.12 yan et al.13 reported that high ratio of th17/th1 in peripheral blood was associated with poor prognosis in hcc patients and emphasized the role of th1 in tumor elimination. to date, data on the association between th17, th1, il-17, and ifn-γ levels and response to tace are limited. most studies only reported the effects of th17 or il-17 on survival. therefore, this study aims to determine the association of peripheral th17, th1, il-17, and ifn-γ levels and tace response in patients with unresectable hcc with or without cirrhosis. methods study design and patient selection a prospective cohort study was conducted on hcc patients who were hospitalized to undergo tace procedure in cipto mangunkusumo national general hospital, premier jatinegara hospital, and metropolitan medical centre hospital between june 2015 and january 2019. diagnosis of hcc was based on the criteria published by the indonesian association for the study of the liver.14 tumor staging was based on the barcelona clinic liver cancer (bclc) staging system.15 irsan hasan acta med indones-indones j intern med 328 inclusion criteria were unresectable hcc patients with or without cirrhosis who were admitted for their first tace procedures. all patients who were willing to participate in this study were asked to sign informed consent forms. hcc patients with contraindications for tace (child-pugh class c liver cirrhosis, diffuse multiple liver nodules, extrahepatic metastasis, and presence of intrahepatic arteriovenous fistula), history of autoimmune disease, positive anti-hiv serology, and/or history of consuming sorafenib during the study period, were excluded from this study. information about demographic data, baseline laboratory, and blood examination for levels of th17, th1, il-17 and ifn-γ before and 30 days after tace were obtained. response of tace was evaluated 30 days after tace. the level of peripheral th17, th1, il-17, and ifn-γ before and 30-days after tace were evaluated in overall general samples and in two comparison subgroup (response vs nonresponse). tace procedure and evaluation of tace response conventional tace (ctace) procedures were performed by interventional radiology specialists and team. tumor blood vessels and tumor-supplying arteries were identified by hepatic arteriography. the combination of doxorubicin and lipiodol was used to perform chemoembolization, with dose being adjusted to tumor size, liver function, and tumor vascularization. this was followed by embolization with gelatin sponge particle (gelfoam; phamarcia-upjohn, kalamazoo, mi) until stasis in the tumor-feeding arteries. three-phase abdominal ct or mri was performed 30 days after tace procedure. tace response was assessed with the modified response evaluation criteria in solid tumors (mrecist).16 complete response (cr) and partial response (pr) were classified into “response group”, meanwhile stable disease (sd) and progressive disease (pd) were classified into “nonresponse group”. blood collection and peripheral blood mononuclear cell isolation (pbmc) 20 ml of blood sample was obtained from hcc patients (immediately before tace and 30 days after tace procedure). blood sample collection was postponed until seven days if patient had symptoms of sepsis. for the examination of th17 and th1, pbmc were isolated from fresh edta whole blood by ficoll density gradient centrifugation. the aliquot of plasma was stored at temperature -800c for il17 and ifn-γ analysis. th1 and th17 flowcytometry analysis pbmc were stained with the following antibodies: percp/cyanine5.5 anti-human cd4, pe anti-human il-17a, and fitc anti-human ifn-gamma (bd biosciences). sorted cells were stimulated with pma/ionomycin (sigmaaldrich), stained with surface markers, fixed with stain buffer and bd cytofix fixation buffer. cells were permeabilized with bd perm/wash buffer and finally stained with anti-il-17a and anti-ifn-gamma. data were acquired using facscanto flowcytometer bd biosciences. th1 and th17 cells were identified as cd4 subsets expressing intracellular ifn-γ and il17a, respectively. cd4+/ifn-γ+/il-17t cells only expressed ifn-γ, meanwhile cd4+/ ifn-γ-/ il-17+ t cells only expressed il-17a and cd4+/ ifn-γ+/il-17+ t cells expressed both ifn-γ and il-17a. il-17 and ifn-γ cytokine analysis plasma cytokine levels of il-17 and ifn-γ were analyzed using the sandwich enzymelinked immune-sorbent assay (elisa) technique with human il-17 elisa (elabscience e-el-h0105) and human ifn-γ elisa (elabscience e-el-h0108) kit according to the manufacturer’s instructions. statistical analysis all data were analyzed using statistical software. continuous variables were presented as mean (standard deviation) if data were normally distributed and median (range) if data were not normally distributed. shapiro-wilk test was conducted to assess for normality of data distribution. categorical variables were presented as frequency (proportion). statistical analysis of paired samples, i.e. before and 30-days after tace, within two subgroups (response vs. non-response) were determined using paired t-test if the data was normally vol 52 • number 4 • october 2020 the association between peripheral th17, th1, il-17, and ifn-g levels 329 distributed or wilcoxon signed-rank test if the data was not normally distributed. the paired parameters was considered significant if the p-value was less than 0.05. statement of ethics this study protocol has been approved by the ethics committee of faculty of medicine universitas indonesia (ref. no. 546/un2.f1/ etik/2015). all subjects who participated in this study signed written informed consents. results baseline characteristics majority of subjects in this study were male with mean age of 54.14 (sd 12.18) years. chronic hbv infection was the most common etiology. most of the patients had liver function of class a or b based on the child-pugh classification. demographic and laboratory baseline characteristics of the study population is shown in table 1. peripheral th17, th1, il-17, and ifn-γ levels before and 30 days after tace in the response group, th17 and th1 levels were significantly elevated after tace. in the non-response group, only the cd4+/ifn-γ+/ il-17t cells level was significantly elevated (p = 0.042). levels of il-17 and ifn-γ were decreased in both groups after tace, but were not statistically significant (table 2). interestingly, in the response group, a significant increase was found in the number of t cells subset showing both ifn-γ and il-17 markers on their surfaces, i.e. cd4+/ifn-γ+/il-17+ t cells. in the response groupd, afp level and tumor size were also significantly reduced. discussion in the past decade, the role of th17 and il-17 in tumor immunity has been widely studied in various types of tumors, such as breast cancer,17 ovarian cancer,18 myeloma,19 melanoma,20 and hepatocellular carcinoma.9,11 the results are conflicting and most studies only focus on the role of th17 in tumor growth and survival.21 considering the fact that the immune system has substantial contributions in tumor development, any treatment modality would undoubtedly cause inflammatory reaction in tumor site and; thus, affect the immune system, as well. however, studies that focused on the association between the immune system, especially th17 cells, and response to treatment, are very limited. tumor response is the assessment of treatment efficacy. studying the association between tumor response table 1. demographic and laboratory baseline characteristics of study population. baseline characteristics values demographic characteristics sex, n (%) female 9 (22) male 32 (78) age, mean (sd) 54.41 (12.18) etiology, n (%) hepatitis b 35 (85.4) hepatitis c 6 (14.6) child pugh class, n (%) a 34 (82.9) b 7 (17.1) c 0 (0) laboratory characteristics hemoglobin, mean (sd) (g/dl) 12.43 (1.95) white blood cells (wbc) count, median (range) (x103 cells/μl) 5.9 (2.42–16.1) platelet count, median (range) (x103 cells/μl) 205 (74–686) ast, median (range) (u/l) 46 (18–190) alt, median (range) (u/l) 29 (9–454) albumin, mean (sd) (mg/dl)) 3.57 (0.51) levels of th17, th1, il-17 and ifn-γ cd4, mean (sd) (%) 23.98 (14.02) th17, median (range) (%) 38.0 (12.2–90.1) th1, median (range) (%) 8.9 (1.8–31.5) il-17, median (range), (pg/ml) 326.94 (136.44–683.78) ifn-γ, median (range), (pg/ml) 80.00 (58.96–245.47) hcc: hepatocellular carcinoma, sd: standard deviation a s t: a s p a r t a t e a m i n o t r a n s f e r a s e , a lt: a l a n i n e aminotransferase, hcc: hepatocellular carcinoma, cd4: cluster of differentiation 4, ifn-γ: interferon-γ, il-17: interleukin-17, , th1: t helper 1, th17: t helper 17 irsan hasan acta med indones-indones j intern med 330 and immune system should be considered in the era of precision medicine. this study showed that significantly elevated levels of peripheral th17 and th1 cells were found in hcc patients with complete or partial response to tace. the elevation of th17 levels in patients with complete or partial response to tace was in contrary with the findings that high levels of th17 cells, either in peripheral blood or intratumoral, were associated with poor prognosis of hcc.7–9 interestingly, in patients with partial or complete respons to tace, there was a significant increase in the number of t cells subset showing both ifn-γ and il-17 markers on their surfaces, i.e. cd4+/ifn-γ+/il-17+ t cells. we suggest that the source of elevated th17 and th1 cells was the increase in th17/th1-like cells. in line with our results, liao et al11 reported that highest os and ttp were observed in high th17 with high ifn-γ+il-17+ group. th17 cells had unique capacity to transform themselves into th17/th1-like cells that produce both il-17 and ifn-γ. plasticity of th17 cells in the hcc milieu is determined by the local environment. th17 cells are derived from cd4+ cells in the presence of tgf-β, il-6, il-1β, and are maintained long-term in the presence of il-21 and il-23.22 these th17 cells are unstable and are readily converted into th17/th1-like cells in the presence of il-12 or il-23 and in the absence or low amount of tgf-β, whereas high level of tgf-β preserved a th17 phenotype.23 tgf-β is a growth factor excessively expressed in tumor cells and secreted by tumor associated macrophages (tams).24 tgf-β can induce the expression of angiogenic factors by macrophages25 or dendritic cells26 in hypoxic condition. furthermore, tgf-β increases vascular endothelial growth factor (vegf) mrna in an ap-1/hif-1 (activator protein-1/ hypoxia-inducible factor-1) dependent mechanism and may potentiate the hypoxic response.27 in patients with small tumor volume (less than 7 cm), perfect embolization of the whole tumor could be achieved and thus expression of tgf-β by tumor cells reduced significantly after tace. on the other hand, if the tumor is not perfectly embolized, expression of tgf-β remains high. in line with this, there is a dynamic relationship between hif-1α and vegf levels in patients undergoing tace. immediately after tace, there is also an increase in il-6, as described by kim et al.28 reflecting acutetable 2. levels of th17, th1, il-17 and ifn-γ before and after tace. parameters response (n=12) nonresponse (n=29) before tace after tace p before tace after tace p cd4, mean (sd) 21.93 (13.90) 20.30 (9.69) *0.690 24.82 (14.23) 22.31 (12.92) *0.380 th17, mean (sd) 39.72 (17.15) 50.43 (21.76) *0.04 43.87 (22.91) 44.18 (11.75) *0.927 th1, median (range) 9.4 (1.8 – 25.5) 11.75 (2.9–34.3) †0.037 8.9 (2.2–31.5) 9.5 (2.5–26.4) †0.665 cd4+/ifn-γ+/il-17(%), median (range) 0.1 (0.0–1.3) 0.2 (0.0–4.0) †0.096 0.1 (0.0–1.1) 0.2 (0.0–4.8) †0.042 cd4+/ifn-γ-/il-17+ (%), mean (sd) 29.15 (12) 36.15 (15.67) *0.079 32.57 (15.54) 34.66 (8.56) *0.398 cd4+/ifn-γ+/il-17+ (%), median (range) 9.3 (1.7–24.2) 11.5 (2.9–34.3) †0.041 8.9 (2.1–30.5) 9.2 (2.3–24.4) †0.531 il-17 (pg/ml), median (range) 325.64 (136.4–577.2) 225.42 (163.56–551.19) †0.388 326.94 (144.8–683.8) 241.81 (136.7–662.5) †0.157 ifn-γ (pg/ml), median (range) 79.23 (60.06–223.48) 71.25 (59.43–208.46) †0.695 80.00 (58.96–245.47) 77.30 (49.77–219.21) †0.256 afp (ng/ml), median (range) 274.4 (2.4–12.147) 19.9 (1.3–646.98) †0.012 311.1 (2.3–716,780) 400 (2.18–400,000) †0.903 largest tumor diameter (cm), mean (sb) 7.29 (2.60) 4.68 (3.58) *0.001 11.38 (4.66) 11.42 (5.04) *0.916 *t-test dependent, †wilcoxon testafp: alpha fetoprotein, cd4: cluster of differentiation 4, hcc: hepatocellular carcinoma, ifn-γ: interferon-γ, il-17: interleukin-17, tace: transarterial chemoembolization, th1: t helper 1, th17: t helper 17 vol 52 • number 4 • october 2020 the association between peripheral th17, th1, il-17, and ifn-g levels 331 phase responses and partly associated with post-treatment hepatitis. il-6 and tgf-β1 promote differentiation of th17 cells from naïve t cells29,30 by inducing transcription factors orphan nuclear receptors, retinoid-related orphan receptor (ror)γt, and rorα.31,32 il-23 is needed for the expansion and survival of th17 lineage and for maintaining its phenotype.33 an in vitro study showed that absence of tgf-β, il-12 and il-23 cytokines promotes differentiation of th17 toward th17/th1-like cells with suppressed il17 and enhanced ifn-γ production.34 in accordance with our results, we suggest that patients with complete or partial response after tace had high levels of il-6 with low expression of tgf-β in their tumor microenvironment, which supported the differentiation of th17 into th17/th1-like cells. these th17/th1-like cells were detected as cd4 t cells showing both ifn-γ and il-17 markers on their surfaces. th17/th1like cells are known to be capable of producing ifn-γ with less il-17a,35 thus promoting antitumor effect. at low concentrations, tgf-β with il-6 and il-21 promote il-23r expression, favoring th17 cell differentiation from naïve cd4 t cells.36,37 this is also in accordance with our results, which shows that th17 cells increased significantly in patients with complete or partial response (table 2). to our surprise, there is a significant elevation of cd4+/ifn-γ+/il-17t cells, expressing only ifn-γ, in non-response group. the most destructive antitumor response is known to come from th1.38,39 in the absence of th1 cells or their cytokines, it is difficult for immune cells to eradicate tumor cells. a strong antigenic interaction with apc is needed to maintain th1 response. death of tumor cells have strong immunostimulatoric activity for activation and maturation of apc, which become a strong signal for th1 activation and differentiation.40 thermal ablation in hcc can also stimulate apc maturation.41 however, after chronic specific antigen exposure, t cell lymphocyte could fall into functional hyporesponsiveness and fail to destroy cancer cells.42,43 in our study, we could not determine whether elevation of th1 cells was accompanied with good functional potential or not. il-17, one of the cytokines secreted by th17 cells, was found lower after tace in both response and nonresponse group but not statistically significant. wu et al.44 reported that tumor size > 5 cm and higher baseline serum il-17 had higher risk of early hcc recurrence in patients who underwent liver resection. the presence of th17 in remnant liver tissue was expected to stimulate cytokine associated with tumor progression. another study also reported that increased expression of intratumoral il-17 and il-17 re were associated with lower survival rate. only kim et al.28 reported the changes of serum il-17 levels in hcc patients after tace. the levels of il-17a decreased over time until statistically significant compared to baseline levels in two months after tace. however, this study did not analyze the reduction of serum il17 with therapy outcome or os. ifn-γ secreted by th1 cells was also lower after tace in both groups with p-value > 0.05. kim et al.28 did not report changes of ifn-γ after tace procedure. the decrease in il-17 and ifn-γ was expected to be associated with the nature of cytokines. cytokines are only secreted in the presence of ongoing inflammation. kim et al.28 showed that the concentration of serum il-6 increased 3 days after tace and reached baseline seven days after tace. this finding showed that inflammation due to tace lasted for seven days. the decrease in levels of il-17 and ifn-γ 30 days after tace occurred because the cytokines were not actively secreted into peripheral blood as a result of reduction in inflammation. only cells secreting these cytokines could be detected. finally, our data suggest that tumor size and completeness of embolization play a major part in determining immune response after tace. tumor expression of tgf-β, hypoxia, and inflammatory cytokines produced after tace, were all important factors that determine differentiation of th17 cells into favourable th17/th1-like cells which have antitumor phenotype. to the best of our knowledge, this is the first study that determines plasticity of th17 in response to tace. irsan hasan acta med indones-indones j intern med 332 conclusion hcc patients with complete or partial response to tace had a significant increase of peripheral th1, th17, and cd4+/ifn-γ+/il-17+ t cells levels. acknowledgments and affiliations we would like to thank ms. anugrah dwi handayu; ms. gita aprilicia; imelda maria loho, md; lutfie, md; jordan sardjan, md; and steven zulkifly, md. this study was partially supported by pitta research grant from universitas indonesia. references 1. bray f, ferlay j, soerjomataram i, siegel rl, torre la, jemal a. global cancer statistics 2018: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 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www.pnas.org/content/112/22/7061.abstract. 36. korn t, bettelli e, gao w, et al. il-21 initiates an alternative pathway to induce proinflammatory th17 cells. nature. 2007;448(7152):484–7. 37. zhou l, ivanov ii, spolski r, et al. il-6 programs th-17 cell differentiation by promoting sequential engagement of the il-21 and il-23 pathways. nat immunol. 2007;8(9):967–74. 38. ikeda h, old lj, schreiber rd. the roles of ifnγ in protection against tumor development and cancer immunoediting. cytokine growth factor rev. 2002;13(2):95–109. 39. wong sbj, bos r, sherman la. tumor-specific cd4+ t cells render the tumor environment permissive for infiltration by low-avidity cd8+ t cells. j immunol. 2008;180(5):3122–31. 40. akbulut gd, özkazanç d, esendağli g. th1 cells in cancer-associated inflammation. turkish j biol. 2017;41(1):20–30. 41. zerbini a, pilli m, fagnoni f, et al. increased immunostimulatory activity conferred to antigenpresenting cells by exposure to antigen extract from hepatocellular carcinoma after radiofrequency thermal ablation. j immunother. 2008;31(3):271–82. 42. vignali da, collison lw, workman cj. how regulatory t cells work. nat rev immunol. 2008;8(7):523–32. 43. speiser de, utzschneider dt, oberle sg, münz c. t cell differentiation in chronic infection and cancer: functional adaptation or exhaustion? nat rev immunol. 2014;1–7. 44. wu j, du j, liu l, et al. elevated pretherapy serum il17 in primary hepatocellular carcinoma patients correlate to increased risk of early recurrence after curative hepatectomy. plos one. 2012;7(12):1–9. editorial 87acta medica indonesiana the indonesian journal of internal medicine aspirin resistance and its importance aru w. sudoyo department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. correspondence mail: division of haematology and medical oncology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: arusudoyo@gmail.com. the use of salicylates (popularly known as aspirin or asa) is well established for the secondary prevention of cardiovascular disease. however, there are reportedly a numer of patients who suffered repeat cardiovascular events despite being given aspirin “prophylaxis”, and uncertainty prevails on whether or not this is due to an inherent inability of aspirin to sufficiently modify platelet activity or are there other mechanisms involved. coined as “aspirin resistance”, the condition warrants attention as an ineffective prophylaxis may lead to unexpected morbidity and subsequent disappointment.1 therefore, it is important that patients who do not benefit from aspirin prophylaxis are identified. in indonesia, a country with the fourth largest population in the world, with cerebrovascular disease as the top killer, the problem becomes more relevant as even a small percentage of the population goes a long way. however, several issues will have to be addressed: firstly, resistance (or sensitivity, for that matter) tests will have to take into account polymorphisms and ethnic characteristic – based on local population data; secondly, the test will have to be relatively simple and easy, covering a wide spectrum of health facilities.2 the report by kurniawan, et al.3, a crosssectional study with the aim of obtaining the prevalence of asa resistance utilizing the platelet function test, is an endeavour that merits a place in this editorial. it is simple but important as there has not yet been a descriptive study in indonesia – for such a large population – that takes on a problem as relevant as this. further studies will have to follow in its wake, and a lot more data are needed to identify and stratify the indonesian population. but we have to start somewhere and this article is a good start. aspirin resistance, as a phenomenon, is real. it is a phenomenon that – in a number of metaanalyses – affects between 15 to 25 percent of the population, with a higher incidence in stroke patients. it has clinical consequences that burden the public health system, and addressing the issues involved will be a big contribution to the practice of medicine. references 1. alberts mj. platelet function testing for aspirin resistance is reasonable to do. stroke. 2010;41:2400-1. 2. shen h, herzog w, drolet m, et al. aspirin resistance in healthy drug-naive men versus women (from the heredity and penotype intervention heart study). am j cardiol. 2009;104:606-12. 3. kurniawan m, harris s, hermawan d, prihartono j. evaluating resistance to acetyl salicylic acid using platelet function test in patients with ischemic stroke at cipto mangunkusumo hospital. acta med indonesindones j intern med. 2015;47(2):88-94. editorial 1acta medica indonesiana the indonesian journal of internal medicine bacteria fight back, also in indonesia! pratiwi sudarmono department of microbiology, faculty of medicine, university of indonesia – cipto mangunkusumo hospital. jl. pegangsaan timur 16, jakarta pusat 10320, indonesia. correspondence mail: pratiwi.pudjilestari@ui.ac.id. get an inf ection, take an antibiotic. that simple, sensible, and often life-saving intervention, repeated myriad times, has triggered an ever-escalating war between humans and microbes—a war the microbes seem to be winning.1 almost as soon as penicillin was introduced in 1942, bacteria started to develop resistance. now, many common bacteria have acquired resistance to multiple antibiotics, making some infections extraordinarily difficult to treat.1,2 antibiotic resistance is the ability of a microorganism to withstand the effects of an antibiotic. in indonesia, antibiotics can be purchased even without a doctor’s prescription. now, as bacterial resistance to antibiotic are increasing, the potency of an antibiotic to eradicate pathogenic bacteria seems to be decreasing, not very long after a new antibiotic is available in the market. generally, the development of resistant bacteria to antibiotics happen spontaneously or because of a pressure of inappropriate antibiotic use in clinical practice. in indonesia, the absence of antibiotic regulation to be used in human as well as animal health is also believed to have contributed to the rapidly increasing incidence of multidrug resistant bacteria. the antibiotic resistant bacteria has become a serious problem especially for patients hospitalized in intensive care units. more than 40% of the budget for drugs is allocated for antibiotics, and once the causative bacteria develops resistance to antibiotics, the case fatality rate of the infections increases. data on antibiotic resistance pattern from several hospital isolates in indonesia showed an increase in resistance rates, not only in gram negative bacteria such as pseudomonas aeruginosa, enterobacteriaceae, klebsiella peumoniae and acinetobacter baumanii, but also in gram positive bacteria such as staphylococcus aureus. isolation of methicillin resistant staphylococcus aureus (mrsa) which is more resistant to antibiotics from the beta-lactam group are also reported in several hospitals. although there is no report on the isolation of mrsa from the community, the existence of this super bug is an indicator that nonrational use of antibiotic in indonesia is highly practiced. antibiotic resistant bacteria is also the major problem for patient care in the intensive care unit. the problem is dramatically increased whenever the causative bacteria is a multidrug resistant bacteria, meaning that the bacteria isolated from patients are resistant to more than one category of antibiotics, such as resistant to beta-lactam groups of antibiotics, at the same time also resistant to fluoroquinolones or aminoglycosides. multidrug resistant bacteria such as pseudomonas aeruginosa and klebsiella pneumonia, were also isolated from icu of fatmawati hospital, jakarta. most of them were resistant both to third generation cephalosporin and fluoroquinolones.3 these resistant bacteria are categorized in a group called extended spectrum beta-lactamase producing bacteria (esbl), which show a multidrug resistant bacteria mainly to beta lactam antibiotics. the increase of esbls in indonesia has been proven by clinical microbiology laboratories, among others as reported by karuniawati a, et al.4 molecular epidemiology studies of antibiotic resistant pathogens in indonesia are very rare, and this study conducted on clinical isolates from intensive care unit of cipto mangunkusumo hospital in 2011 showed that the prevalence of carbapenem resistant gram negative pathogens are increased in enterobacteriaceae 27.6%, p s e u d o m o n a s a e r u g i n o s a 2 1 . 9 % a n d i n acinetobacter baumanii 50.5%. using such molecular epidemiology technique applied to antibiotic resistant strain isolated in hospital, a certain common genes among isolates can be pratiwi sudarmono acta med indones-indones j intern med 2 determined. the data obtained from molecular epidemiology study will be very useful for the development of an antibiotic guideline for physician working in that specific hospital. this evidence based hospital guidelines to treat infections in hospital will improve the quality of hospital prescription for antibiotics delivered by the clinicians. saharman yr and lestari dc,5 present an interesting data on a simple modified hodge test method to detect the existence of carbapenemase.5 the result shows the high prevalence of esbls in hospital isolates in jakarta. this result shows similar pattern with results obtained from the similar surveillance conducted in other parts of indonesia. a total of 300 esbl-producing isolates have been collected in 2010 from three other teaching hospitals, i.e. in semarang, malang and surabaya, with three most prevalent esbl producers being escherichia coli, klebsiella pneumoniae, and enterobacter spp.6 routine examination and surveillance for hospital’s bug should be conducted more often. this shows the important role of a clinical microbiology experts working together with other clinicians in hospital. to look for those superbugs mentioned above and to limit the spreading of hospital acquired infections, a robust and efficient clinical microbiology laboratory should be established in hospital. given the alarming problems of antibiotic resistant bacteria in hospital setting, we should look into the quality of antimicrobial drug prescription in hospital. j.w.m. van der meer6 mentioned in his very interesting publication that even in the netherlands where both antibiotic consumption and antibiotic resistant bacteria are low, the antimicrobial prescription is not optimal. in his survey, 15% of antibiotic therapy in surgical and internal medicine wards are not adequate. the major problem of an inappropriate prescribing is due to insufficient education about infectious diseases and antimicrobial therapy.7 adjustment of the initial antimicrobial therapy based on the clinical microbiology result and clinical course is one of the most relevant steps in antimicrobial prescribing, since it is clearly diminishes the selection pressure to microorganisms in hospital. many physicians who prescribed antibiotic, does not even understand if their appropriate or inappropriate prescription can have an impact on bacterial resistance development. a reasonable and evidence based antibiotic guidance is one tool toward good antibiotic prescription. a clear antibiotic guidance in hospitals should be able to identify specific antibiotic use for oral versus parenteral therapy, combination versus single drug therapy and guidelines in changing between one antibiotic to other antibiotic whenever necessary. a continuous effort in hospital surveillance, infection control and clinical audits must be conducted as a routine hospital management to fight against the development of antibiotic resistant pathogens. references 1. roberts l, simpsons s. deadly defiance. science. 2008;321(5887):355. 2. vincent jl, rello j, marshall j, et al. international study of the prevalence and outcomes of infection in intensive care units. jama. 2009;302(21):2323-9. 3. radji m, fauziah s, aribinuko n. antibiotic sensitivity pattern of bacterial pathogens in the intensive care unit of fatmawati hospital, indonesia. asian pacific j trop biomed. 2011;1(1):39-42. doi: 10.1016/s22211691(11)60065-8. 4. karuniawati a, saharman ys, lestari dc. gene resistance characteristics of carbapenem resistant enterobacteriaceae, pseudomonas aeryginosa and acinetobacter baumanii in icu ward of dr. cipto mangunkusumo hospital in 2011. in press. 5. saharman yr, lestari dc. phenotype characterization of enterobacteriacea multi-drug resistant antibiotic producing beta–lactamase enzyme in intensive care unit (icu) at cipto mangunkumo hospital in 2011. acta med indones-indones j int med. 2013;45(1):11-6. 6. van der meer jwm, gyssens jc. quality of antimicrobial prescription in hospital. clin microbiol infect. 2001;7(suppl. 6):s12–s15. 7. kuntaman, santoso s, wahjono h, et al. pola sensitivitas bakteri penghasil extended spectrum beta lactamase terhadap enam antibiotik yang biasa dipergunakan pada pengobatan di klinik. j indones med assoc. 2011;61(12):482-6. medical illustration discordance between clinical status and chest x-ray (cxr) in covid-19 patient with asymptomatic transmission in jakarta erlina burhan1, heidy agustin1, agus d. susanto1, ibrahim dharmawan2, markus meyer2, rita rogayah1 1 department of pulmonology, faculty of medicine universitas indonesia persahabatan hospital, jakarta, indonesia. 2 faculty of medicine universitas indonesia, jakarta, indonesia. corresponding author: erlina burhan, md., phd. department of pulmonology, faculty of medicine universitas indonesia persahabatan hospital. jl. persahabatan raya no.1 jakarta 13230, indonesia. email: erlina_burhan@yahoo.com. figure 1. series of cxrs starting from day 1 up to 7 of hospitalization. cxrs at day 1 (1), day 3 (2), day 4 (3), day 5 (4), day 6 (5), and at day 7 of hospitalization (6), each. according to the cxrs, the patient’s pneumonia and infiltration improved. coronavirus disease 2019 (covid-19) symptoms are highly various in each patient. patients with covid-19 may show severe symptoms with severe pneumonia and ards, mild symptoms resembling simple upper respiration tract infection, or even completely asymptomatic.1 few are known about the natural progression of covid-19 and whether its pneumonia follow the pattern of pneumonia caused by other microorganism. chest x-ray (cxr) is an affordable and simple radiology modality routinely used to monitor patient with 297acta med indones indones j intern med • vol 52 • number 3 • july 2020 erlina burhan acta med indones-indones j intern med covid-19. it is not known whether cxr is useful for monitoring covid-19 patient. male, 55 years-old, mr. f, experienced symptoms of respiratory disease. on the first day of symptoms, the patient developed fever of 38 oc, gradually followed by dry cough and sore throat. on day 7 of symptoms, patient experienced mild dyspnea. the patient underwent cxr leading to the diagnosis of severe pneumonia. hence, the patient was admitted to emergency room at department of pulmonology of the persahabatan hospital, jakarta, on day 8 of symptoms (day 1 of hospitalization). the patient had no history of contact with confirmed or presumed covid-19 patients, nor any known travel history. patient’s wife had close contact to confirmed covid-19 patients. the wife was reported to be healthy with no symptoms. however, she refused to be tested for covid-19. during 8 days of hospitalization, the patient received cxr daily. (figure 1) there was a gradual improvement of lung lesion seen on cxr starting from the first day of hospitalization. however, patient clinically deteriorate and suffered from severe dyspnea on the fourth day of hospitalization. the patient required oxygen therapy delivered through high flow nasal canule and optiflow. in addition, the patient was treated with oseltamivir 2 x 75 mg, chloroquin 2 x 500 mg, levofloxacin 1 x 750 mg, vitamin c 2 x 1000 mg, vitamin b1 1 x 100 mg, vitamin b6 1 x 100 mg, and vitamin b12 1 x 200 mcg. the patient was discharged after 15 days of hospitalization following two negative rt-pcr covid-19 tests. it is important to note that covid-19 symptoms are highly variable. patients may show severe or mild symptoms, or just be asymptomatic.2 ye, et al.2 reported about case series including a familial cluster with asymptomatic transmission. in our study, patient never had contact with covid-19 patient. in this case, wife might acted as asymptomatic carrier for our patient. cxr finding in this patient does not correlate well with improvement of clinical condition. on the day 8 of symptoms (day 1 of hospitalization), cxr showed a wide bilateral infiltrate. however, patient only experienced mild dyspnea. cxr was conducted on the first day of hospitalization and started improving on day 2 and the following day. however, the patient continued to clinically deteriorate as well as developed severe dyspnea requiring higher level of oxygen therapy on day 4 of hospitalization. this discordance between cxr finding and clinical status may be caused by cytokine storm leading to acute respiratory distress syndrome (ards).3 it may also caused by fibrosis formation that develop at the late stage of covid-19 infection.4 asymptomatic transmission is possible in covid-19. clinician attending covid-19 patient must rely on monitoring the clinical presentation of the patient and not solely on cxr improvement. acknowledgments covid19 commando team persahabatan general hospital references 1. q&a on coronaviruses (covid-19) [internet]. [cited 2020 apr 3]. available from: https://www.who.int/ news-room/q-a-detail/q-a-coronaviruses. 2. ye f, xu s, rong z, et al. delivery of infection from asymptomatic carriers of covid-19 in a familial cluster. int j infect dis. 2020 may;94:133–8. 3. xie p, ma w, tang h, liu d. severe covid-19: a review of recent progress with a look toward the future. front public health. 2020;8:189. 4. ye z, zhang y, wang y, huang z, song b. chest ct manifestations of new coronavirus disease 2019 (covid-19): a pictorial review. eur radiol. 2020;19:1–9. 298 456 acta med indones indones j intern med • vol 54 • number 3 • july 2022 case report high dose oestrogen in life threatening obscure gastrointestinal bleeding tee meng kang, khairul najmi muhammad nawawi, ngiu chai soon, deborah chew chia hsin, raja affendi raja ali, wong zhiqin* gastroenterology unit, department of medicine, faculty of medicine, universiti kebangsaan malaysia medical centre, kuala lumpur, malaysia. *corresponding author: wong zhiqin, md. senior consultant gastroenterologist & hepatologist. gastroenterology unit, department of medicine, faculty of medicine, universiti kebangsaan malaysia medical centre. jalan yaacob latif, bandar tun razak, 56000 cheras, kuala lumpur, malaysia. email: wzhiqin@ppukm.ukm.edu.my. abstract obscure gastrointestinal bleeding is defined as recurrent or persistent gastrointestinal bleeding in the setting of normal upper and lower endoscopies. there are reported use of numerous pharmacological agents to halt the bleeding, including oestrogen. we report a case of middle age gentleman with multiple comorbidities, presented with life threatening gastrointestinal bleeding. he underwent bidirectional endoscopies and mesenteric angiogram, but failed to localise the bleeding. red blood cell scintigraphy showed numerous bleeding points in small and large bowels. a 5-day oral high dose oestrogen was prescribed in view of difficulty to manage the bleeding, in which the hemostasis was ultimately achieved. keywords: angiodysplasia, hormonal therapy, oestrogen, obscure gastrointestinal bleeding. introduction obscure gastrointestinal bleeding (ogib) is defined as recurrent or persistent gastrointestinal bleeding in the setting of normal upper and lower endoscopies. it can manifest as overt bleeding with visible passage of blood or occult bleeding which manifest as iron deficiency anaemia or positive faecal occult blood test.1 it usually arises from small bowel with varying nature, ranging from angiodysplasia, dieulafoy lesion to meckel’s diverticulum. despite the advancement of small bowel endoscopy and video capsule endoscopy, 25% of patients may still have unidentifiable source of bleeding.1 besides, despite identification of source of bleeding, some of these patients may not be amenable for therapeutic endoscopic or surgical intervention due to severe comorbidities. in this group of patients, medical therapy may be considered to ameliorate the bleeding. case illustration a 63-year-old gentleman presented to us with a 3 days history of haematemesis and melaena. he was on double antiplatelet agents from recent myocardial infarction and coronary angioplasty. other comorbidities included end stage renal failure, hypertension, dyslipidemia, and noncirrhotic chronic hepatitis c. on examination, vital signs were unremarkable and per rectal examination revealed stale melaena. laboratory investigations showed haemoglobin of 7.4 g/ dl and platelet of 220 x 109/l, with normal coagulation profile. antiplatelet agents were withheld, and he was started on intravenous bolus esomeprazole 8 0 m g f o l l o w e d b y 8 m g / h o u r i n f u s i o n . two units red blood cells were transfused. oesophagogastroduodenoscopy (ogd) showed forrest 2c ulcer at prepyloric region, however no varices and active bleeding was seen. on vol 54 • number 3 • july 2022 high dose oestrogen in life threatening obscure gastrointestinal bleeding 457 the next day, he still passing out melaena. repeated ogd was unremarkable. subsequent computed tomography of mesenteric angiogram (cta) failed to show any evidence of arterial bleeding. colonoscopy was performed and showed oedematous ileocaecal valve with right sided diverticulosis, without active bleeding. intubation into the terminal ileum was failed due to the oedema. video capsule endoscopy was deemed not feasible due to concern of trapped capsule. he was managed conservatively with blood transfusion until the day 7 of admission, when he developed another melaena with hypovolemic shock, requiring fluid/blood resuscitation and vasopressor. after initial stabilization, cta was repeated but reported as unremarkable. thus, he underwent a tc-99m-red blood cell scan which eventually showed multiple bleeding sites arising from the distal duodenum, proximal jejunum and colonic hepatic flexure. deep push enteroscopy was performed on the same occasion, but only showed pooling of blood, with no source of active bleeding. surgical opinion was sought but he was deemed unsuitable for any surgical intervention due to poor functional cardiac status. in view of ongoing bleeding episode, he was started on high dose oral conjugated oestrogen 12.5 mg daily for 5 days after counselled on possible thrombotic risk with no further antiplatelet therapy. after the initiation of oestrogen, he had no more bleeding episode, and haemoglobin remained stable with no further blood transfusion requirement. he was discharged well with haemoglobin of 10.5 g/ dl. up to 150 days after initiation of oestrogen, no further bleeding episode or thrombotic event was noted. discussion hormonal therapy was initially explored by harrison in 1982 after observing few case series of epistasis improvement in patients with hht during pregnancy and puerperium.2 the mechanism of action of hormonal therapy is not well understood. oestrogen and progesterone receptors have been detected in telangiectatic lesions in patients with hereditary haemorrhagic telangiectasia (hht), and the hormone-receptor binding improved endothelial integrity in patients with hht. in animal model, oestrogen was found to improve the vascular stasis within the mesenteric microcirculation and decreased mucosal blood flow. in patients on hemodialysis, oestrogens shorten bleeding time by the reduction of endothelial prostacyclin production.3 hormonal therapy has been reported in several case reports and controlled/uncontrolled studies of gastrointestinal angiodysplasias or ogib.4-6 the results, however, were conflicting. in a study of 43 patients with ogib who were treated with hormonal therapy, rebleeding was effectively stopped in 38 patients (follow-up of a mean time of 535 days).7 however, two controlled studies on angiodysplasia bleeding did not demonstrate any benefit. both studies had small number of sample and with lower dose of oestrogen used. this discrepancy suggest that dosing of oestrogen may play a role.8,9 overall, the effectiveness of hormonal therapy remains unclear, except for the treatment of hht, von willebrand disease, chronic kidney failure and gastric antral vascular ectasia.10 its utilization in ogib should be of last therapeutic resort. the treatment with oestrogen is not without risk, which includes thrombosis, gynecomastia, breast tenderness, fluid retention, heart failure, and vaginal bleeding in females.7 in our patient, he had achieved hemostasis despite having multiple bleeding sites after 5 days of high dose conjugated oestrogen. spontaneous resolution of the bleeding could be argued due to the cessation of antiplatelet. however, in this gentleman, he still experienced ogib despite the antiplatelet therapy being stopped for more than 9 days. conclusion despite lack of convincing clinical data, we believe that hormonal therapy especially oestrogen at higher dose, remains one of the pharmacological therapy options in patient with difficult to manage ogib. conflict of interest authors declare there is no conflict of interest. tee meng kang acta med indones-indones j intern med 458 references 1. asge standards of practice committee, fisher l, lee krinsky m, et al. the role of endoscopy in the management of obscure gi bleeding. gastrointest endosc. 2010;72:471-9. 2. harrison df. use of estrogen in treatment of familial hemorrhagic telangiectasia. laryngoscope. 1982;92:314-20. 3. zuckerman gr, prakash c, askin mp, et al. aga technical review: evaluation and management of occult and obscure gastrointestinal bleeding. gastroenterol. 2000;118:201-21. 4. b r o n n e r m h , p a t e m b , c u n n i n g h a m j t, e t al. estrogenprogesterone therapy for bleeding gastrointestinal telangiectasias in chronic renal failure. an uncontrolled trial. ann intern med. 1986;105:371–4. 5. van cutsem e, rutgeerts p, vantrappen g. treatment of bleeding gastrointestinal vascular malformations with oestrogen-progesterone. lancet. 1990;335:953–5. 6. van cutsem e, rutgeerts p, coremans g, et al. doseresponse study of hormonal therapy in bleeding gastrointestinal vascular malformations (abstr). gastroenterology. 1993;104:a286. 7. barkin js, ross bs. medical therapy for chronic gastrointestinal bleeding of obscure origin. am j gastroenterol. 1998;93:1250-4. 8. lewis b, salomon p, rivera-macmurray s, et al. does hormonal therapy have any benefit for bleeding angiodysplasia? j clin gastroenterol. 1992;15:99–103. 9. junquera f, feu f, papo m, et al. a multicenter, randomized, clinical trial of hormonal therapy in the prevention of rebleeding from gastrointestinal angiodysplasia. gastroenterol. 2001;121:1073-9. 10. apostolopoulos p, liatsos c, gralnek im, et al. evaluation of capsule endoscopy in active, mild-tomoderate, overt, obscure gi bleeding. gastrointest endosc. 2007;66:1174-81. case report 332 acta med indones indones j intern med • vol 50 • number 4 • october 2018 acute appendicitis in a patient with systemic lupus erythematosus hendra gunawan, awalia, joewono soeroso department of internal medicine, faculty of medicine, airlangga university dr. soetomo hospital, surabaya, indonesia. corresponding author: prof. joewono soeroso, md., phd. department of internal medicine, faculty of medicine, airlangga university dr. soetomo hospital. jl. mayjen prof. dr. moestopo 4-6, surabaya 60132, indonesia. email: joewono.soeroso4@gmail.com.. abstrak lupus eritematosus sistemik (les) adalah suatu penyakit autoimun kronis eksaserbatif dengan manifestasi klinis yang sangat beragam. manifestasi gastrointestinal merupakan manifestasi yang sering dijumpai namun dapat terjadi efek masking oleh karena penggunaan obat-obatan untuk mengontrol penyakitnya seperti obat anti-inflamasi non-steroid (oains) dan kortikosteroid. appendisitis akut merupakan salah satu penyebab nyeri abdomen pada penderita les. patofisiologi appendisitis akut dapat terjadi primer oleh aktivitas penyakitnya maupun sekunder oleh sebab lain. membedakan etiologi appendisitis akut perlu dilakukan untuk memberikan tatalaksana yang komprehensif pada penderita dengan les. kata kunci: lupus eritematosus sistemik (les), appendisitis akut, nyeri abdomen. abstract systemic lupus erythematosus (sle) is a chronic excacerbative autoimmune disease with wide clinical spectrum. gastrointestinal manifestasion is a frequent clinical manifestasion seen in sle. management with glucocorticoid and non-steroid anti-inflammatory drugs (nsaid) can mask the gastrointestinal symptoms in patient with sle. one of the etiologies of gastrointestinal manifestations in sle is acute appendicitis. patients with acute appendicitis usually have abdominal pain as its chief complaint. the pathophysiology of acute appendicitis can occur primarily from sle and secondary from other causes eg: infection, inflammation, etc. when a sle patient has acute appendicitis as its initial assessment, determining its etiology is pivotal to give comprehensive management and preventing life-threatening complications. keywords: systemic lupus erythematosus (sle), acute appendicitis, abdominal pain. introduction systemic lupus erythematosus (sle) is a chronic exacerbative autoimmune disease, with a wide clinical spectrum as its clinical manifestasions.1 gastrointestional manifestations is a frequent clinical manifestation in sle patient though not as common as lupus nephritis. william osler stated that gastrointestinal manifestations in sle patient can mimic a lot of abdominal abnormalities. the clinical spectrum is very wide, ranging from simple abdominal pain, nausea vomiting to acute abdomen. the prevalence of abdominal pain, nausea, and vomiting is 50%, whereas acute abdomen can be seen in 8-40% patient with active sle.2,3 acute abdomen is a serious clinical condition that needs surgical intervention. its presentation can manifest as acute or insidious abdominal pain vol 50 • number 4 • october 2018 acute appendicitis in patient with systemic lupus erythematosus due to masking effect of using non-steroid anti inflammatory drugs (nsaid) and glucocorticoid as a medication for symptom relief or underlying disease. gastrointestinal vasculitis can lead to life threatening ischemia, perforation, and infarction.2-4 surgical intervention should be considered when there is possibility of bowel perforation. the prevalence of acute appendicitis in sle patient with abdominal pain is 4.2%.5 the initial presentation of sle patient with acute appendicitis can be abdominal pain, nausea, and vomiting, therefore it is very similar with gastrointestinal vasculitis. the etiology of acute appendicitis can be classified into primary from sle and secondary from other causes.6 we reported a case of secondary acute appendicitis in patient with sle. case illustration a 30-year old woman was brought into the emergency department due to abdominal pain in right lower quadrant. the pain occurred since 14 days before admission. it was sudden, continuous, getting steadily worse, and referred into stomach. she also complained of nausea, vomiting. there was shortness of breath since 2 days before admission that limited her household activities. she had had a history of lupus nephritis since 15 years ago, routinely visited rheumatology outpatient clinic. her last medication was methylprednisolone 4 mg tid, omeprazole 20 mg bid, and calcium tablets. on physical examination, her general appearance was weak, blood pressure 90/70 mmhg, respiratory was 24 times per minute, vas 5, and body temperature was 38.50c. there were anemia and alopecia. rhonchi were found in both sides of lung. abdomen was slightly distended, the point of pain was at mcburney site. there were rovsing sign, psoas sign, and rebound tenderness, without defence musculaire, darm contour, nor darm steifung. blood test showed hemoglobin levels 9.2 g/dl, leukocytes 7,030 cells/mm3, neutrophil 88.2%, albumin 2.72 g/dl, random plasma glucose 89 mg/dl, bun 14 mg/dl, creatinine serum 0.75 mg/dl, crp 82.93 mg/dl, aptt 36.3 seconds (control 26.2 seconds), ppt 11.8 seconds (control 10.8 seconds), hbsag rapid test (-), esr 18, c3 59.5 mg/dl, c4 39.1 mg/dl, potassium 3.2 mmol/l. chest x-ray showed paracardial infiltrate. abdominal usg revealed edematous appendix with diameter of 10.1 mm. donut sign, and probe tenderness at mcburney site (figure 1) without the presence of extraluminal fluid. her initial assessment was sle, acute appendicitis, s. cap, sepsis, and hypokalemia. she was consulted to surgery department but refused to have surgical intervention. she was given intravenous methylprednisolone 1 mg/kgbw, ceftriaxone 1 gram intravenous bid and metronidazole 500 mg tid as empirical antibiotics for sepsis, oral ksr for hypokalemia, and nebulization. proper education was given to patient and her family about the risk and benefit of surgical appendectomy. figure 1. the usg examination of the patient showed donut sign and outer to outer diameter ±10.1 mm abdominal pain became steadily worse until the 6th day of admission, her vas was 7. she finally agreed to have appendectomy. the surgery succeeded with perioperative intravenous methylprednisolone was given before surgical procedure. the pathology examination of appendix revealed intact mucosa, the presence of faeces without fecalith. microscopic examination revealed infiltration of neutrophils, lymphocytes, and plasma cells in lamina propria of the appendix without vasculitis in the appendix nor periappendicular tissue (figure 2). her abdominal pain was relieved after appendectomy and she was discharged 3 days post surgery. 333 hendra gunawan acta med indones-indones j intern med discussion acute appendicitis’ prevalence is 4,2% among patients with sle that presents with abdominal pain.7 the diagnosis of our case was made based on history taking, physical diagnostic, and radiographic evaluation. the history taking which revealed abdominal pain in lower right quadrant with nausea, vomitting, and shortness of breath. pain at mcburney site along with rovsing sign, psoas sign, and rebound tenderness were found in physical examination. ultrasonography examination revealed a donut sign, with diameter of appendix approximately 10,1 mm, and tenderness with probe at mcburney site.4,8,9 acute appendicitis in patients with sle has 2 distinctive mechanisms. the first mechanism is from the underlying disease. acute appendicitis in patient with sle can be the complication of gastrointestinal vasculitis. cellini reported that gastrointestinal vasculitis in periappendicular tissue caused ischemia. ischemia of appendix enhances bacterial proliferation. the underlying mechanism in secondary acute appendicitis is obstruction of the appendix lumen. obstruction of appendix lumen will increase intraluminal pressure and trigger ischemia of the appendix. careful history taking and physical diagnosis should be carried out in order to determine the etiology of acute appendicitis.2,3,10 patients with acute appendicitis due to lupus vasculitis will present with gastrointestinal manifestasions such as abdominal pain, bloating, nausea, vomiting, along with manifestasions in other organs such as musculoskeletal, lupus nephritis, or hematology. abdominal muscle guarding, rebound tenderness, pain at mcburney site, rovsing sign, and psoas sign are the most prominent finding in physical examination. laboratory findings of patient with acute appendicitis due to vasculitis revealed the sle in active state such as decreased c3 and c4, elevated esr or the presence of serology marker. pathology examination will reveal the appearance of small vessel vasculitis and large vessel vasculitis in periappendicular tissue without intramular inflammation of the appendix tissue. cellini stated that small vessel vasculitis was evident by transmural infiltration of lymphocytes. large vessel vasculitis was characterized by the presence of neutrophil infiltration and endothelialitis. secondary acute appendicitis was characterized by the presence of suppurative appendicitis, appendicitis gangrenosum, and periappendicitis. suppuratis appendicitis was evident by the infitration of neutrophil on lamina propria of the appendix.4,10 there were no signs of vasculitis in periappendicular tissue in our case, therefore we concluded that her acute appendicitis was a secondary process. (figure 3) figure 2. the microscopic examination of appendix of the patient. figure 3. the periappendicular tissue microscopic view. left: the periappendicular tissue of the appendicitis showed no vasculitis. right: detailed view of the periappendicular artery showed no vasculitis. the management of acute appendicitis are conservative and surgical treatment. defining the etiology of acute appendicitis is important to give proper treatment in sle patients with acute appendicitis as its initial presentation. pulse dose of glucocorticoid along with cyclophosphamide might be given when vasculitis were suspected as the underlying mechanism of acute appendicitis.11 334 vol 50 • number 4 • october 2018 acute appendicitis in patient with systemic lupus erythematosus methylprednisolone 1-2 mg/kgbw/day might be given for 24-48 hours since there were numerous reports of successfull treatment of gastrointestinal vasculitis with high dose intravenous methylprednisolone. patient with gastrointestinal vasculitis should respond to steroid therapy within 12-48 hours. surgical treatment may be necessary if the patient’s symptoms do not improve in 48 hours or the signs of perforation, large bowel ischemia, or acute abdomen present.9 the combination of ceftriaxone and metronidazole can be given when intra abdominal infection is suspected. ceftriaxone and metronidazole are the preferred combination because of its activity against aerob and anaerob bacteria. early laparotomy within 48 hours is critical to improve the prognosis in patient with gastrointestinal vasculitis.2,9,12 intravenous methylprednisolone was given to our case with dose 1 mg/kgbw while we evaluated the activity of her sle by requesting c3, c4, and esr. patient and her family refused any surgical intervention initially. there were no improvement in clinical condition after 48 hours with intravenous methylprednisolone. the presence of pain at mcburney site was found until 6th day of hospital care. there was no sign of active disease state nor flare found in this patient, seen by her c3, c4, and esr level were 59,5 mg/ dl, 39,1 mg/dl, and 18 respectively. surgical intervention was performed in 7th day of hospital care. the pathology examination revealed appendix with intact mucosa, with the presence of faeces without fecalith. microcopically, infiltration of lymphocytes, plasma cell, and neutrophils were found in appendix without the presence of vasculitis in periappendicular tissue (figure 2 and 3). thus, we assumed that her acute appendicitis was not related to gastrointestinal vasculitis conclusion a case report of sle patient with acute appendicitis that was not related with her underlying disease activity. acute appendicitis clinical manifestasions can mimic any other g a s t r o i n t e s t i n a l m a n i f e s t a s i o n s i n s l e patient. when patient present with clinical manifestasions of acute appendicitis, the possibility of gastrointestinal vasculitis and secondary cause should be considered. accurate history taking, physical examination, laboratory, and radiographic examination are useful to define the etiology of acute appendicitis in order to give comprehensive management in sle patient with acute appendicitis. references 1. merrill jt, buyon jp, utset t. a 2014 update on the management of patients with systemic lupus erythematosus. seminars in arthritis and rheumatism. 2014;44(2):e1-e2. 2. tian x-p, zhang x. gastrointestinal involvement in systemic lupus erythematosus: insight into pathogenesis, diagnosis and treatment. world j gastroenterol. 2010;16(24):2971-7. 3. daruwala c, mercogliano g, harder tp. gastrointestinal manifestasions of systemic lupus erythematosus and scleroderma. clin med: gastroenterol. 2009;2:7-12. 4. cellini c, hoda sa, spigland n. lupus-associated vasculitis manifesting as acute appendicitis in a 16 year old girl. pediatric rheumatol. 2008;6(10):1-3. 5. al-hakeem ms, mcmillen ma. evaluation of abdominal pain in systemic lupus erythematosus. american j surg. 1998;176(1):291-4. 6. yuan s, lian f, chen d, et al. clinical features and associated factors of abdominal pain in systemic lupus erythematosus. j rheumatol. 2013;40(12):2015-22. 7. sultan sm, ioannou y, isenberg d. a review of gastrointestinal manifestations of systemic lupus erythematosus. rheumatol. 1999;38(2):917-32. 8. parks na, schroeppel tj. update on imaging for acute appendicitis. surg clin north am. 2011;91(1):141-54. 9. anoosh. f, shariff r, ambujakshan d, et al. acute abdomen as initial presentation in a patient with systemic lupus erythematosus. am j case rep. 2009;10(3):55-8. 10. carr nj. the pathology of acute appendicitis. annals diag pathol. 2000;4(1):46-58. 11. indonesia rheumatology association. diagnosis dan pengelolaan lupus eritematosus sistemik. 1st edition. jakarta: indonesia rheumatology assoc; 2011. p. 17. 12. solomkin js, mazuski je, rodvold ka, et al. diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the surgical infection society and the infectious diseases society of america. clin infect dis. 2008;50(4):133-64. 335 164 acta med indones indones j intern med • vol 53 • number 2 • april 2021 original article abstrak latar belakang: world health organization (who) memperkirakan angka kejadian dm tipe 2 di indonesia sebesar 21.3 juta jiwa pada tahun 2030. diabetes melitus mempunyai komplikasi kronis. salah satu komplikasi kronis adalah terjadinya neuropati perifer. untuk mengetahui terjadinya neuropati, pemeriksaan fisik yang direkomendasikan adalah menilai neuropathy disability score (nds). haemoglobin a1c (hba1c) adalah glycated haemoglobin yang digunakan untuk menilai status kadar gula dalam 2 atau 3 bulan terakhir. hubungan antara hba1c dengan derajat keparahan neuropati dm dilakukan dengan pemeriksaan elektrodiagnostik menunjukkan bahwa peningkatan kadar hba1c dan usia menjadi prediktor utama terjadinya neuropati dm namun pemeriksaan elektrodiagnostik mahal. untuk itu diperlukan penelitian untuk mengetahui hubungan antara kadar hba1c dengan nds sehingga morbiditas neuropati dm dapat diminimalisir. penelitian ini bertujuan untuk mengetahui hubungan antara derajat keparahan neuropati diabetes yang diukur dengan neuropathy disability score dengan nilai hba1c pada penderita diabetes melitus tipe 2. metode: penelitian analitik korelatif dengan metode cross sectional. setiap penderita dm yang memenuhi kriteria inklusi dan eksklusi dimasukkan sampai jumlah sampel terpenuhi. data yang terkumpul dianalisis dengan uji korelasi spearman. hasil: didapatkan 56 subyek penelitian. rerata usia 59.55 (sb 9.48) dengan 57.1% berjenis kelamin wanita, median lamanya menderita dm 5.5 tahun. median nilai skor nds sebesar 7.5 dan median nilai hba1c sebesar 8.65. analisa korelasi spearman menunjukkan koefisien korelasi sebesar 0.487 dengan nilai p=0.000. kesimpulan: terdapat hubungan antara kadar hba1c dengan derajat keparahan neuropati pada pasien dm tipe 2. kata kunci: haemoglobin a1c, neuropati, diabetes melitus. abstract background: world health organization (who) estimates the incidence of type 2 diabetes in indonesia would increase to 21.3 million in 2030. diabetes has a chronic complications, including peripheral neuropathy. the degree of neuropathy was assessed through the neuropathy disability score (nds). in contrast, haemoglobin a1c is glycated haemoglobin used to monitor the glucose levels of diabetic patients in the last 2 or 3 months. the relationship between hba1c and diabetic neuropathy carried out by electrodiagnosis showed that hba1c and age were the main predictors of diabetic neuropathy. however, electrodiagnosis is still considered costly. research is needed to determine the relationship between hba1c and nds to reduce morbidity. this study aims to determine the relationship between the severity of diabetic neuropathy as measured by nds with hba1c the correlation between hba1c and neuropathy disability score in type 2 diabetes ilsa hunaifi1, i gusti ngurah ommy agustriadi2, i gede yasa asmara2, catharina budyono2 1 department of neurology, faculty of medicine, university of mataram west nusa tenggara general hospital, ntb, indonesia. 2 department of internal medicine, faculty of medicine, university of mataram west nusa tenggara general hospital, ntb, indonesia. corresponding author: ilsa hunaifi, md. department of neurology, faculty of medicine, university of mataram-west nusa tenggara general hospital. jl. prabu rangkasari, dasan cermen, mataram, ntb 83232, indonesia. email: ilsahunaifi@unram.ac.id. vol 53 • number 2 • april 2021 the correlation between hba1c and neuropathy disability score 165 level in type 2 diabetes. methods: this cross-sectional study involved correlation analysis.. the collected data were analyzed with the spearman correlation test. results: approximately 56 diabetic patients were involved in this study. patients were recruited from the internal medicine outpatient ward from the west nusa tenggara general hospital. the mean age was 59.55 (sd 9.48) with 57.1% female; the median duration of diabetes was 5.5 years. the median nds score is 7.5 and the median hba1c value is 8.65. spearman correlation analysis shows a correlation coefficient of 0.487 with a value of p = 0.000 conclusion: there is a relationship between hba1c level and the severity of diabetic neuropathy in type 2 dm. keywords: haemoglobin a1c, neuropathy, diabetes mellitus. introduction based on the international diabetes federation, 425 million people would suffer from diabetes mellitus (dm) by 2045. in a developing country, including indonesia, it is predicted that 4 out of 5 have diabetes.1 according to the basic health research conducted by the ministry of health indonesia in 2013, dm is the 4th most non-communicable disease after cancer in indonesia. furthermore, in west nusa tenggara, the estimated number of people having dm is 0.9% of the total population.2 diabetes is a metabolic disease with an abnormal hyperglycemic index that occurs due to abnormal insulin secretion, insulin action, or combined. dm type 2 has several classic symptoms, including polyuria, polydipsia, polyphagia, and weight loss. dm diagnosis requires several laboratory examinations: fasting blood glucose level, 2 hours after postprandial blood glucose level, and haemoglobin a1c (hba1c). 3 diabetes mellitus has several acute and chronic complications that may affect various organs and cause morbidity and mortality. chronic complications are categorized into vascular (microvascular and macrovascular) and non-vascular complications. microvascular complications include neuropathy, nephropathy, and retinopathy, whereas macrovascular complications include cerebrovascular, coronary heart disease, and peripheral arterial disease.4 dm neuropathy affects 50% of people with both type 1 and type 2 dm. diabetic neuropathy can be in the form of polyneuropathy, mononeuropathy, or autonomic neuropathy. the occurrence of neuropathy is related to the duration of dm and control of blood glucose. the most type of neuropathy is distal symmetric polyneuropathy and the most common symptoms are such sensory disorders as hyperesthesia, paresthesia, and dysesthesia.4 to identify the complications of neuropathy in diabetes, it is necessary to screen and then stratify for the degree of neuropathy. screening the occurrence of neuropathy is conducted through a series of questions to patients to find out whether there is neuropathy. a series of physical examinations such as the neuropathy disability score (nds) can be used to determine the degree of neuropathy so that complications can be prevented. nds include pinprick examination, achilles reflex examination, temperature, and vibration perception on patients.5,6 nds examination is performed on both sides and a score ≥ 6 points are considered abnormal.6 haemoglobin a1c (hba1c) is glycated haemoglobin used to monitor the status of glucose levels in the previous 2 or 3 months. recommendation from the american diabetes association (ada), hba1c levels must be maintained at 7% in all diabetics patients. hba1c levels above 7% increase the risk of complications, especially microvascular complications. koening and colleagues first reported the relationship between hba1c and blood glucose control in uncontrolled diabetic patients. many studies indicate an association between hba1c and diabetes complications. however, few studies have focused on hba1c levels with diabetic polyneuropathy.7 early detection of diabetes polyneuropathy can prevent morbidity. neuropathy disability score (nds) has been widely accepted and validated as an assessment tool to identify the presence of diabetic neuropathy.8 the relationship between hba1c and the severity of diabetic neuropathy is ilsa hunaifi acta med indones-indones j intern med 166 done by electrodiagnosis examination, showing that increased hba1c levels and age are the main predictors of diabetes neuropathy.9 the electrodiagnosis examination is a sophisticated examination and not all hospitals in low resource settings have this device so that validated physical testing is needed to establish the severity of the diabetic neuropathy.9 for this reason, research is required to explore the correlations between hba1c and the severity of diabetic neuropathy as assessed by the neuropathy disability score (nds) among diabetes mellitus patients. methods this cross-sectional study was conducted from march to august 2019 with criteria of type 2 diabetes mellitus who experienced neuropathy symptoms selected by examining neuropathy symptom scores. patients were recruited from the internal medicine outpatients ward of west nusa tenggara general hospital. patients who experience symptoms of neuropathy were examined for neuropathy disability scores and hba1c levels. neuropathy disability scores include vibration sensation with a 128 hz tuning fork, temperature sensation with a cold tuning fork, pinprick examinations, and achilles reflex examinations on both sides of the body (table 1). the maximum nds score is 10 and the abnormal score is ≥ 6.6 table 1. neuropathy disability score (nds).6 nds items description vibration sensation (128 hz tuning fork) 0 = present, 1 = reduced/absent per side temperature sensation (cold tuning fork) 0 = present, 1 = reduced/absent per side pin-prick 0 = present, 1 = reduced/absent per side ankle reflex 0 = present, 1 = present with reinforcement, 2 = absent per side this study has been approved by the ethical committee of mataram university (reference number 41/un18.f7/etik/2019). in this study, a minimum sample of 51 patients was determined and sampling was carried out by the method according to the case that came sequentially (sampling from consecutive admission) until a predetermined sample size was reached. data were analyzed through the pearson correlation test or spearman if the requirements for the pearson correlation test were not obtained. all data were analyzed using spss version 22.0. results fifty-six individuals met the criteria of this study, see table 2. the mean age of the study subjects was 59.55 (sd 9.48) years. the youngest patient was 43 years old and the oldest was 79 years old. demographic data of research subject are shown in table 2. table 2. baseline characteristic (n: 56). characteristic value p age (years), mean (sd) 59.55 (9.48) 0.757 sex, n male female 24 32 0.396 type of therapy, n medical insulin others 36 15 5 length of diabetes, mean (sd) 6.95 (5.07) 0.238 nds value, mean (sd) 6.77 (2.55) hba1c value, mean (sd) 9.13 (2.36) the correlation between nds values and hba1c levels was tested with the spearman correlation test because the data were not normally distributed even though the data transformation was done. from the spearman correlation test results obtained a correlation coefficient of 0.487 with a value of p = 0.000 (table 3) table 3. correlation of hba1c with nds. variable coefficient correlation p n nds vs hba1c + 0,487 0,000 56 spearman correlation test discussion research subjects were predominantly female. this was similar to the previous study in china showing that dm in women was mostly found in rural area and male in urban areas.10 based on age, the mean age of study subjects was 59.55 (sd 9.48) years. the cdc (centers for disease control and prevention) report shows the average age of dm sufferers was 53.8 years vol 53 • number 2 • april 2021 the correlation between hba1c and neuropathy disability score 167 in 1997 and 54.2 years in 2011. furthermore, previous studies reported that the average age of dm in hong kong was 52 years and in china was 40-59 years.10 patients with dm for more than five years have a higher risk of neuropathy. the results of this study indicate that the median duration of dm is 5.5 years. reports in the united kingdom (uk), dm neuropathy, occurs in 36% of people with diabetes for more than ten years compared with people with diabetes less than five years and nerve denervation damage increases with the length of dm.11 various scores were developed to assess the degree of neuropathy in people with dm. one of the score that are often used is nds (neuropathy disability score). the median value of nds in the study was 7.5. nds assesses achilles reflexes, vibration sensations, prick pin tests, and temperature sensations on both feet with a maximum score of 10 where a score of 6 or more indicates a severe degree of neuropathy. data reports in the uk show that 50% of people with dm show neuropathy symptoms and 7% have diabetic foot after 1 year.12 this study aims to find the relationship between dm neuropathy severity by measuring the nds scale with hba1c levels. spearman correlation analysis results show there is a significant relationship between hba1c and nds. this indicates that the higher the hba1c value in patients with type 2 dm, the higher the nds value was. in other words, the higher the hba1c level, the higher the severity of the neuropathy. zilliox et al.11 research showed that nds values in dm neuropathies were 6.26 (sd 0.34). the electrodiagnosis examination found in patients with large fiber neuropathy showed a heavier nds value compared to patients with small fiber neuropathy [(7.23 (sd 0.91) vs 4.77 (sd 0.53)]. the research of stem et al.12 showed that complications of dm (neuropathy, retinopathy, or nephropathy) occur in patients with hba1c 8.5 (sd 1.5). the higher levels of hba1c will further accelerate and worsen the complications of neuropathy. control of glucose levels is very important to prevent and decrease the complications from dm. high levels of hba1c have associated with high microvascular complications in people with dm. limitations of this study were hba1c was only evaluated once and electrodiagnosis examination was not performed as a gold standard to determine the severity of neuropathy. conclusion hba1c level is related to the severity of neuropathy in patients with type 2 diabetes. the higher the hba1c value, the higher the neuropathy disability score. monitoring of hba1c level is crucial to prevent further complications of dm both in the nervous system and in other organs. acknowledgments we thank the language center university of mataram for proofreading the manuscript. conflict of interest the author declares no conflict of interest. references 1. international diabetes federation, idf diabetes atlas 8ed, 2017, www.idf.org, accessed oct 14, 2019 2. departemen kesehatan republik indonesia, riset kesehatan dasar, 2013, www.depkes.go.id. accessed oct 14, 2019. 3. perkeni, konsensus pengelolaan dan pencegahan diabetes melitus tipe 2 di indonesia, 2006, www. pbperkeni.or.id, accessed oct 14, 2019. 4. powers ac. diabetes mellitus. in: fauci as, kasper dl, longo dl, et al (ed). harrisons principle of internal medicine. 17th ed. new york: mc graw-hill medical, 2015. p. 2275-304. 5. boulton ajm, vinik ai, arezzo jc, et al. diabetic neuropathies. diabetes care. 2005;28;956-62. 6. yang z, chen r, zhang y, et al. scoring systems to screen for diabetic peripheral neuropathy (protocol). cochrane database of systemic reviews. 2014;3:1-31. 7. lee wj, jang s, lee sh, lee hs. correlation between the severity of diabetic peripheral polyneuropathy and glycosylated hemoglobin levels: a quantitative study. ann rehabil med. 2016;40 (2):263-70. 8. meijer jwg, sonderen e, blaauwwikel ee, et al. diabetic neuropathy examination. diabetes care. 2000;23;750-3. 9. yuan h, li x, wan g, et al. type 2 diabetes epidemic in east asia: a 35-year systematic trend analysis.onco target. 2018;9(6):6718-27. 10. nisar mu, asad a, waqas a, et al. association of diabetic neuropathy with duration of type 2 diabetes ilsa hunaifi acta med indones-indones j intern med 168 and glycemic control. cureus. 2015;7(8):e302. 11. zilliox la, ruby sa, singh s, zhan m, russell jw. clinical neuropathy scale in neuropathy associated with impaired glucose tolerance. j diabetes complication. 2015;29(3):372-7. 12. stem ms, blachley ts, shtein rm, herman wh, gardner tw, stein jd. impact of diagnosing diabetic complications on future haemoglobin a1c levels. j diabetes complication. 2016;30(2):323-8. 78 acta med indones indones j intern med • vol 55 • number 1 • january 2023 case report cefepime induced encephalopathy in a non-dialysis dependent chronic kidney disease patient: a case report giritharan muniandy1, lydia kamaruzaman2, tan hui jan3, rozita mohd2, theepa neesam mariamutu2, fong voon ken2, pau kiew beng4, ruslinda mustafar2* 1 department of medicine, faculty of medicine, universiti kebangsaan malaysia. 2 nephrology unit, department of medicine, faculty of medicine, universiti kebangsaan malaysia. 3 neurology unit, department of medicine, faculty of medicine, universiti kebangsaan malaysia. 4 department of pharmacy, hospital canselor tuanku muhriz, universiti kebangsaan malaysia. * corresponding author: ruslinda mustafar. nephrology unit, department of medicine, national university of malaysia medical centre. jalan yaacob latif, bandar tun razak, cheras, 56000, kuala lumpur, malaysia. email: ruslinda.m@gmail.com. abstract cefepime is a frequently used fourth-generation cephalosporin antibiotic for a wide variety of infections. toxic levels of this drug can cause neurological complications. the most common neurological adverse event of cefepime is headache and lightheadedness. here, we presented a case of cefepime induced encephalopathy in a 57-year-old female patient with acute on chronic kidney disease. with an accurate diagnosis that requires a high index of clinical suspicion, prompt management was instituted. she had full resolution of symptoms following discontinuation of the medication and also emergent dialysis. keywords: cefepime, encephalopathy, chronic kidney disease. introduction cefepime has a broad antibacterial spectrum covering aerobic for gram-positive and gramnegative bacteria including pseudomonas.1 cefepime was recommended for a wide array of infections such as hospital-acquired pneumonia, febrile neutropenic sepsis as well as soft tissue and intra-abdominal infections.2 the neurotoxic effects of cefepime was first reported in 1999 and the most common being headache and lightheadedness.3,4 these symptoms are often associated with decreased cefepime clearance in the setting of reduced glomerular filtration rate and increased central nervous system penetration secondary to blood-brain barrier dysfunction.5 these adverse events are mostly seen in patients who are on renal replacement therapy. it is rarely seen in patients not requiring dialysis. in 2002, the food and drug administration (fda) adjusted the labelling to account for increased risk of seizures, encephalopathy and myoclonus, especially in the setting of renal impairment.6 case illustration a 57-year-old female with stage iiib chronic kidney disease (ckd) secondary to diabetes mellitus (baseline creatinine of 137 µmol/l), hypertension and dyslipidemia presented with a one-week history of fever, reduced oral intake, nausea lower abdominal pain and acute urinary retention. on examination, she was alert with blood pressure of 138/90 mmhg, pulse rate 98 beats per minute and febrile at 38oc. vol 55 • number 1 • january 2023 cefepime induced encephalopathy in a non-dialysis dependent 79 abdominal examination revealed a distended bladder. therefore emergent catheterization was done. her blood glucose was 8mmol/l, and urinalysis had leukocyte of 3+. her renal function test showed raised creatinine level to 246 µmol/l with urea of 11.7 mmol/l, she had no leukocytosis but raised serum c-reactive protein of 5.4mg/dl. she was diagnosed and treated for urinary tract infection and emprically started on intravenous ceftriaxone 2gm once daily. ultrasound of urinary tracts showed grossly distended urinary bladder with bilateral hydronephrosis and hydroureter. on day 3, her urine and blood cultures both grew enterobacter species beta-lactamase group 1, sensitive to cefepime only. her antibiotic was escalated to intravenous (iv) cefepime 500mg twice daily. her renal function was at 267 µmol/l, with an estimated glomerular filtration rate (egfr) of 16mls/min/1.73m2. after three days of iv cefepime, she was noted to be disoriented and had incoherent speech. her conscious level was fluctuating with glasgow coma scale ranging from 13/15 to 14/15. capillary plasma glucose was 8mmol/l, other electrolyte parameters and ct brain were all normal. her neurological manifestations coincide with the initiation of iv cefepime; thus, the possibility of cefepime induced encephalopathy (cie) was entertained. electroencephalogram (eeg) showed mild to moderate cerebral disturbance by virtue of excessive theta activity with triphasic waves in keeping with metabolic encephalopathy. the eeg images are as below (figure 1). therefore, based on clinical manifestations and eeg findings, she was diagnosed with cie. cefepime was withheld, and she underwent two sessions of hemodialysis (hd) lasting 4 hours each which saw a tremendous improvement in her clinical condition with normal orientation and speech. the antibiotic was switched to iv meropenem for another 5 days after stopping the cefepime. her repeated blood and urine cultures were negative and she was allowed to be discharged home. as expected, her renal functions also returned to the baseline (figure 2). discussion cefepime is a widely used antibiotic in the settings of sepsis and acutely ill. it is a 4th generation cephalosporin with a broad antibacterial spectrum covering aerobic grampositive and gram-negative bacteria including pseudomonas.1 it is mainly excreted via the kidneys with 85% unchanged in the urine and the body metabolizes the remainder to n-methylpyrrolidine, a 7epimer isomer.1 approximately 10% of serum cefepime is able to pass through the blood-brain barrier; however in the setting of decreased egfr, this can increase up to 45%.5 treatment with a cephalosporin may also induce endotoxin release which generates cytokines liberation such as tumor necrosis factorα (tnfα). tnf-α seems to mediate septic encephalopathy.7 alternatively, in an animal study, cephalosporin’s may decrease γ-aminobutyric acid (gaba) release from nerve figure 1. eeg showing encephalopathic disturbances with triphasic waveform. giritharan muniandy acta med indones-indones j intern med 80 terminals, increase excitatory amino acid release, and exert a competitive antagonism towards gaba.8 in the settings of acute on chronic kidney disease, the clearance of cefepime is delayed, and in our patient, the blood brain barrier is further compromised due to the underlying bacteremia that can further potentiate risk of encephalopathy. in patients with end-stage renal disease (esrd), there are multiple evidence and reports of non-convulsive status-epilepticus and metabolic encephalopathy associated with cefepime.3 the eeg in these patients shows paroxysmal activity or sharp triphasic waves which are pathognomonic of cie.9-11 cefepime was also found to have significant adverse effects despite renal dose adjustments.12 two metaanalysis studies measured all-cause mortality. the first study was in 2006, where it evaluated antibiotic treatment for neutropenic fever with 33 trials showing higher allcause mortality after 30 days with cefepime when compared to other β-lactams.13 a second study by rugate et al. in 2013 evaluated 100 patients from the intensive care unit setting for neurotoxicity and found 15 patients likely to have cie, and 7 patients were found to be definite. four patients out of these 7 had their cefepime dose adjusted for their renal function but still experienced adverse effects.12 the diagnosis of cie in these studies was made via eeg and also based on clinical features. a case series by the u.s. food and drug administration (fda) in 2012 also showed the varying occurrence of cie in patients from different age group and renal status.14 measurement of serum cefepime to predict the neurotoxicity has also been studied. some early reports suggested neurotoxicity can be expected when the serum level exceeds 22mg/l and the level needed for harm ranges from 2.1 to 18.5 mg/l.15 some recent prospective studies in 2017 have suggested neurotoxicity associated with cefepime at concentrations exceeding 35mg/l.16 the facility to measure serum cefepime level is not readily available in our setting; therefore, we need to have a high index of suspicion based on the clinical manifestations and eeg findings. apart from the toxic threshold of cefepime concentration, other factors that cause alteration in the blood-brain barrier such as inflammatory conditions, severe sepsis, toxins, metabolic disorder; together with an underlying renal dysfunction has the likelihood to contribute to its neurotoxic potential. in patients with normal renal function, cefepime is eliminated in more than 80% of cases by urine, with a half-life of 2-2.5 hours. in a patient with renal failure and creatinine clearance <10ml/min, the half-life of cefepime is 5 times higher from 2.3 to 13.5 hours and sometimes even up to 22 hours.17 cefepime is dialyzable and up to 70% of a given dose can be removed during a 3-hour hemodialysis session.18 haemodialysis therapy has been found to give a good prognosis in patients with cie. chatellier et al. reported a series of five cases, all treated with urgent haemodialysis, with full recovery in four cases. delay in diagnosis in the fifth case could be the reason for the patient’s 35 0 30 0 trend of creatinine ( µ mol/ l) / urea ( mmol/ l) 311 280 24 6 26 7 249 19 320 0 15 0 10 0 13 7 13 7 5. 1 11. 7 14 9. 4 12 10 8. 6 7. 1 baseline day 1 day 2 day 3 (started on cefepime) day 5 (onset of cie) day 6 (post day 7 (post hd x 1) hd x 2) day 14 (discharge) creatinine urea figure 2. trend of serum creatinine and urea. vol 55 • number 1 • january 2023 cefepime induced encephalopathy in a non-dialysis dependent 81 death.18 haemodialysis seems to be favourable because of its rapid action to clear the drug from circulation. a good understanding of the clinical course and manifestations of cie may facilitate earlier identification and prompt treatment.19 however, symptoms may be delayed with a median onset of 4 days after the initiation of the drug. (table 1) even though neurotoxicity with cefepime is most commonly occurs when inappropriate doses are administered to patients with renal dysfunction, there are new and emerging evidence that indicate neurotoxicity can happen in patients receiving proper dose adjustments and also in those with normal renal function.20 the use of alternative antibiotics should be considered for those patients who are at risk of neurotoxicity, at the same time recognizing the potentials emergence of antibiotic resistance. if substituting the antibiotics is not a choice, close clinical monitoring is warranted. symptoms of cie can be delayed and progressive, but clinical improvement usually is seen following drug cessation, treatment of epileptiform activity and also drug removal via hemodialysis. in this case, we illustrated the development of cie in a patient with acute on ckd. however, despite adequate dose adjustment, our patient developed clinical features of cie after three days of therapy. with a prompt diagnosis of cie, immediate withdrawal of the drug and urgent hemodialysis showed good clinical outcome for this lady. conclusion recognising cefepime as a source of neurotoxicity can be a challenge given the clinical picture is often clouded by accompanying causes of encephalopathy such as metabolic disturbances, infection, uraemia, and hepatic encephalopathy. for this reason, a heightened index of suspicion is required when treating patients with or without renal impairments, even when cefepime dose is appropriately adjusted. references 1. burgess sv, mabasa vh, chow i, ensom mh. evaluating outcomes of alternative dosing strategies for cefepime: a qualitative systematic review. ann pharmacother. 2015;49(3):311-22. 2. bazan ja, martin si, kaye km. newer beta-lactam antibiotics: doripenem, ceftobiprole, ceftaroline, and cefepime. the medical clinics of north america. 2011;95(4):743-60, viii. 3. wong km, chan wk, chan yh, li cs. cefepimerelated neurotoxicity in a haemodialysis patient. nephrol dial transplant. 1999;14(9):2265-6. 4. neu hc. safety of cefepime: a new extendedspectrum parenteral cephalosporin. am j med. 1996;100(6a):68s-75s. 5. durand-maugard c, lemaire-hurtel as, graschampel v, et al. blood and csf monitoring of cefepime-induced neurotoxicity: nine case reports. j antimicrobial chemother. 2012;67(5):1297-9. 6. fda drug safety communication: cefepime and risk of seizure in patients not receiving dosage adjustments for kidney impairment. 2012. 7. eggers v, fugener k, hein ov, et al. antibiotic mediated release of tumour necrosis factor alpha and norharman in patients with hospital-acquired pneumonia and septic encephalopathy. intensive care medicine. 2004;30(8):1544-51. 8. desarro a, ammendola d, zappala m, grasso s, desarro gb. relationship between structure and convulsant properties of some beta-lactam antibiotics following intracerebroventricular microinjection in rats. antimicrob agents ch. 1995;39(1):232-7. 9. jallon p, fankhauser l, du pasquier r, et al. severe but reversible encephalopathy associated with cefepime. neurophysiologie clinique clinical neurophysiology. 2000;30(6):383-6. 10. martinez-rodriguez je, barriga fj, santamaria j, et al. nonconvulsive status epilepticus associated with cephalosporins in patients with renal failure. am j table 1. clinical characteristics and recommended treatment for cie. risk factors signs and symptoms eeg characteristics treatment renal dysfunction critical illness altered bbb older age drug overdose altered mental status reduced consciousness confusion myoclonus aphasia seizures triphasic waves multifocal sharp waves non-convulsive se generalised slowing myoclonic se drug’s discontinuation haemodialysis benzodiazepine* eeg: electroencephalography, bbb: blood-brain barrier, se: status epilepticus. *for eeg abnormalities/seizure activity associated with toxicity giritharan muniandy acta med indones-indones j intern med 82 med. 2001;111(2):115-9. 11. g r i l l m f, m a g a n t i r . c e p h a l o s p o r i n induced neurotoxicity: clinical manifestations, potential pathogenic mechanisms, and the role of electroencephalographic monitoring. a nn pharmacother. 2008;42(12):1843-50. 12. fugate je, kalimullah ea, hocker se, clark s l , wi j d i c k s e f, r a b i n s t e i n a a . c e f e p i m e neurotoxicity in the intensive care unit: a cause of severe, underappreciated encephalopathy. crit care. 2013;17(6):r264. 13. paul m, yahav d, fraser a, leibovici l. empirical antibiotic monotherapy for febrile neutropenia: systematic review and meta-analysis of randomized controlled trials. j antimicrobial chemother. 2006;57(2):176-89. 14. song jc. cefepime: fda drug safety communication on non-convulsive status epilepticus risk. infectious disease (alert). 2012. 15. lamoth f, buclin t, pascual a, et al. high cefepime plasma concentrations and neurological toxicity in febrile neutropenic patients with mild impairment of renal function. antimicrob agents chemother. 2010;54(10):4360-7. 16. huwyler t, lenggenhager l, abbas m, et al. cefepime plasma concentrations and clinical toxicity: a retrospective cohort study. clinical microbiology infection. 2017;23(7):454-9. 17. sonck j, laureys g, verbeelen d. the neurotoxicity and safety of treatment with cefepime in patients with renal failure. nephrol dial transplant. 2008;23(3):96670. 18. chatellier d, jourdain m, mangalaboyi j, et al. cefepimeinduced neurotoxicity: an underestimated complication of antibiotherapy in patients with acute renal failure. intensive care medicine. 2002;28(2):2147. 19. payne le, gagnon dj, riker rr, et al. cefepimeinduced neurotoxicity: a systematic review. crit care. 2017;21(1):276. 20. gangireddy vg, mitchell lc, coleman t. cefepime n e u r o t o x i c i t y d e s p i t e r e n a l a d j u s t e d d o s i n g . scandinavian j infect dis. 2011;43(10):827-9. 25 original article acta med indones indones j intern med • vol 52 • number 1 • january 2020 comparative effectiveness of tuberculosis treatment daily versus intermittent regimen in indonesian tb-dm patients: real world patient database study angelina siane1, purwantyastuti ascobat2, instiaty2, heidy agustin3 1 clinical pharmacology specialist program, faculty of medicine universitas indonesia, jakarta, indonesia. 2 department of pharmacology and therapeutics, faculty of medicine universitas indonesia, jakarta, indonesia. 3 department of pulmonology and respiratory medicine, faculty of medicine universitas indonesia, jakarta, indonesia. corresponding author: prof. purwantyastuti ascobat, md., phd. department of pharmacology and therapeutics, faculty of medicine universitas indonesia. jl. salemba 6, jakarta 10430, indonesia. email: purwanty2703@yahoo.com. abstrak latar belakang: diabetes melitus (dm) meningkatkan risiko terjadinya tb aktif sebesar tiga kali; saat ini belum ada strategi pengobatan yang spesifik untuk pasien tuberkulosis-dm (tb-dm). panduan who 2017 tidak lagi merekomendasikan pemberian obat secara intermiten pada pengobatan tb fase lanjutan karena tingginya risiko kegagalan, relaps, dan resistensi obat dibandingkan dengan pemberian setiap hari. penelitian ini bertujuan untuk membandingkan efektivitas pengobatan fase lanjutan dengan kedua cara pemberian tersebut, dalam hal respons klinik dan konversi sputum, pada pasien tb-dm. metode: studi kohort retrospektif menggunakan rekam medik pasien rawat jalan rumah sakit pesahabatan, jakarta mulai 1 januari 2015 hingga 31 desember 2018. kriteria inklusi adalah semua pasien tb-dm berusia >18 tahun tanpa hiv dengan pemeriksaan sputum positif pada saat diagnosis, yang mendapat pengobatan kategori 1 dan telah memasuki fase lanjutan. hasil: sebanyak 72 pasien memenuhi kriteri inklusi (75% laki-laki and 88.8% setidaknya memiliki hasil pemeriksaan sputum 1+ pada saat diagnosis). tiga puluh subyek belum mengalami konversi pada awal pengobatan fase lanjutan. pada akhir fase lanjutan, 44.2% pada kelompok intermiten dan 41.4% pada kelompok pengobatan setiap hari dinyatakan sembuh. tujuh subyek mengalami efek samping; tetapi terdapat banyak pasien putus obat dan tidak dapat dijelaskan penyebab putus obat terkait dengan efek samping atau tidak. kesimpulan: tidak didapatkan perbedaan dalam profil konversi sputum dan keberhasilan pengobatan tb kategori 1-dm fase lanjutan antara pemberian intermiten dan setiap hari pada pasien diabetes. kata kunci: tb-dm, diabetes melitus, fase lanjutan, pengobatan intermiten, pengobatan setiap hari, keberhasilan pengobatan. abstract background: diabetes mellitus (dm) increases the risk of active tb by three times; there is no specific treatment strategy for tuberculosis-dm (tb-dm) patients. the 2017 who guidelines no longer recommended an intermittent regimen in the advanced phase of tb treatment due to higher risk of failure, relapse, and drug resistance compared to the daily regimen. this study aims to compare the effectiveness of treatment, in terms of clinical response and sputum conversion, of tb-dm patients in the advanced phase between the two-treatment delivery schedules. methods: a retrospective cohort study from the medical records of patients from 1 january 2015 to 31 december 2018 at persahabatan hospital, jakarta. the inclusion criteria are tb-dm patients aged >18 years with non-reactive hiv test, who have entered the advanced phase of category 1 tb treatment with smear positive at the time of diagnosis. results: a total of 72 patients met the inclusion criteria. (75% male and 88.8% angelina siane acta med indones-indones j intern med 26 introduction tuberculosis (tb) is the largest cause of morbidity and mortality among infectious diseases in the world.1 in 2017, 10 million people worldwide suffered from tb and 1.7 million people are estimated to have latent tb infection and at risk of developing active tb disease during their lifetime. indonesia has the third highest number of tb cases in the world.2 early diagnosis and adequate therapy of tb patients are the primary treatment strategies.3 diabetes mellitus (dm) increases the risk of active tb by three times,4 and pulmonary tb is the 9th most frequent complication in dm.5 the prevalence of tb-dm in southeast asia is 14% and 14.8% in indonesia.6 a systematic review revealed that tb prevalence in dm patients is around 1.7–36% and dm prevalence in tb patients is around 1.9–35%.7 patients with hba1c ≥7% have 2.5 times greater risk of developing tb compared to those with hba1c ≤7%.8 good glycemic control can reduce the risk of developing tb in dm patients.9 the risk of death, treatment failure, and relapse is very high in tb-dm patients.10,11 the risk of death is around 6.5–6.7 times higher in tb-dm patients.12 blood glucose management of dm patients in chronic inflammatory state is extremely difficult, while tb is a chronic inflammatory disease.13 recent research found that tb worsens glycemic control in dm patients, and failure of tb treatment in dm patients increases by 69% and risk of relapse four times.14 an optimal treatment strategy for tb-dm patients has not been found, and there is no scientific evidence supporting the difference in regimens between tb only and tb-dm patients.13 based on 2011 who guidelines, tb-dm management is the same as non-dm. in the intensive phase, four antituberculosis drugs (rifampicin, isoniazid, pyrazinamide, and ethambutol) are given daily for two months, followed by an advanced phase, in which two antituberculosis drugs (rifampicin and isoniazid) are given daily or intermittently three times a week for four months when blood sugar is well controlled, or it will be extended to seven months when blood sugar is poorly controlled.15 in 2017, world health organization (who) no longer recommended intermittent treatment in advanced phase. this was supported by a systematic review of intermittent therapeutic regimens in 2009; randomized control trials show that intermittent treatment has a higher risk of failure, relapse, and drug resistance compared to daily treatment.16 t b i s d i a g n o s e d b a s e d o n s p u t u m examination,3 which is also used for assessing treatment success. sputum examination is usually performed at the end of the 2nd, 4th, and 5th month. the treatment of tb patient is considered unsuccessful if the sputum conversion is not achieved by the end of the fifth month of therapy.17 no study in indonesia has been conducted to compare the outcome of advanced phase treatment in tb-dm patients between intermittent and daily regimens. this study aims to compare the effectiveness of treatment in terms of clinical response and sputum conversion of tb-dm patients in the advanced phase between the two-treatment delivery schedules. methods this cohort retrospective study was conducted at persahabatan hospital, jakarta. data was taken had at least 1+ smear results at the time of diagnosis). thirty subjects still have positive smear at the beginning of the advance phase of treatment. after the advanced phase, 44.2% in the intermittent and 41.4% in the daily group were cured or having sputum conversion. seven subjects had side effects; but there were lots of dropouts and it is unclear whether they dropped because of side effects or not. conclusion: there is no difference between sputum conversion profile and treatment success in advanced phase tb-dm treatment category 1 between the daily and intermittent regimen.ly for diabetic patients. keywords: tb-dm, diabetes mellitus, advanced phase, intermittent treatment, daily treatment, treatment success. vol 52 • number 1 • january 2020 comparative effectiveness of tuberculosis treatment daily 27 from all the medical records of tb-dm patients receiving category 1 tb treatment in the period of 1 january 2015 to 31 december 2018. the study secured ethical approval from the research ethics committee of persahabatan hospital. the inclusion criteria were tb-dm patients aged >18 years who had entered the advanced phase of tb treatment category 1 (2rhze/4rh or 2rhze/4r3h3) with smear positive at the beginning of tb treatment and non-reactive hiv test. the cohort were followed from the start of the adavanced phase up to the end of the treatment period. data collected from the patients medical records, were analyzed comparing patients that had received the intermittent regimen using fixed dose combination (fdc) of three times a week and the ones that had received daily regimen using individual tablets. the dosage given was in accordance with the indonesian guideline. this study observed the documented end results of treatment at the end of each patients advance phase. statistical tests were performed using spss 20.0 and the method used to compare the results of treatment of the two groups (proportion of success) was x2 test. this study has been approved by the ethical committee of persahabatan hospital (reference number 25/kepk-rsupp/04/2019). results from 704 medical records of patient who registered as tb-dm patients from january 1, 2015 until december 31, 2018, 134 patients had entered the advanced phase of tb treatment category 1. from those 134 patients, only 72 patients met the inclusion criteria. table 1 presents the basic characteristics of these 72 patients. fifty-four subjects (75%) were male, 68.1% were in the age group 46–65 , 76.4% had body weight 40–60 kg, and 64 patients had at least 1+ smear results (88.9%). thirty patients (41.7%) did not reach conversion at the end of the intensive phase of treatment (table 2). for seven table 1. basic characteristics (n = 72) intermittently thrice a week (n = 43) n (%) daily (n = 29) n (%) total n (%) sex male 31 (72.1) 23 (79.3) 54 (75.0) female 12 (27.9) 6 (20.7) 18 (25.0) age group 18–25 years 0 1 (3.4) 1 (1.4) 26–45 years 9 (20.9) 9 (31.0) 18 (25.0) 46–65 years 30 (69.8) 19 (65.5) 49 (68.1) >65 years 4 (9.3) 0 4 (5.6) body weight <40 kg 1 (2.3) 1 (3.4) 2 (2.8) 40–60 kg 31 (72.1) 24 (82.8) 55 (76.4) >60 kg 11 (25.6) 4 (13.8) 15 (20.8) smear 1–9 bar 5 (11.6) 3 (10.3) 8 (11.1) 1 positive 13 (30.2) 11 (37.9) 24 (33.3) 2 positive 12 (28.0) 6 (20.7) 18 (25.0) 3 positive 13 (30.2) 9 (31.0) 22 (30.6) table 2. sputum conversion at the beginning of advance phase (n = 72) sputum conversion intermittently thrice a week (n = 43) n (%) daily (n = 29) n (%) total n (%) p value conversion 26 (60.5) 16 (55.2) 42 (58.3) 0.276 no conversion 17 (39.5) 13 (44.8) 30 (41.7) angelina siane acta med indones-indones j intern med 28 patients, conversion happened at the end of the 3rd month, and 12 patients dropped out before conversion. after the advanced phase, thirtyone subjects were cured (table 3), 19 (44.2%) in the intermittent group and 12 (41.4%) in the daily group. lost to follow up were similar for both groups (46.5% vs. 51.7%). seven subjects had side effects (table 4), 6 in the intermittent (14%) and 1 in the daily treatment (4%); but there were a lot of dropouts without information and it remained unclear whether they dropped out because of side effects or not. discussion in this study, the number of male subjects in both groups was greater than female subjects (75% vs 25%). this result is consistent with who’s 2018 global report data which states that in 2017, the majority of tb patients were male,2 and the 2017 international diabetes federation, which reported that dm mostly occurs in males.18 the largest number of subjects were aged 46–65 years (68.1%) with body weight between 40–60 kg (76.4%), sputum examination results at least 1+ (88.8%), and 30 patients (41.7%) remain positive at the end of the intensive phase. the results is consistent with riza et al.13 who found that patients with tb-dm were mostly elderly, with a higher body mass index, and positive examination results, which usually remained positive at the end of the 2nd month of the intensive phase treatment.13 conversely, har ashish jinda et al.19 found that 32.7% remained positive at the end of the 4th week. success rate, failure, and dropouts were comparable in both groups. this differs from who’s statement that the intermittent thrice a week regimen entails a higher risk of failure compared to the daily regimen.16 success rate in the intermittent group was only 44.2%, which differs from the treatment success observed in mexico, 71.35%;11 and treatment success in the daily group was only 41.4%, which differs from cameroon’s 90%.20 failure of treatment occurred in three patients, one in the intermittent group and two in the daily group. one in the daily group failed due to reversion at the end of the 5th month, and the others failed due to delayed sputum conversion until the end of 5th month of treatment, and their sputum culture results showed monoresistance to inh. this is in contrast to argita et al.’s21 study: tb patients with isoniazid monoresistance have the same response to sputum conversion and treatment results as patients who are sensitive to all tuberculosis drugs. these results were in accordance with the ministry of health of the republic of indonesia’s report: the results of tb treatment in dm patients had a greater number of failures due to delayed sputum conversion.22 thirtyeight subjects were dropouts, 12 of them dropouts since they entered table 4. adverse effect (n = 72) adverse effect intermittently thrice a week (n = 43) n (%) daily (n = 29) n (%) total n (%) p value no 37 (86.0) 28 (96.6) 65 (90.3) 0.219 itching 1 (2.3) 0 1 (1.4) tingling 3 (7) 0 3 (4.2) joint paint 2 (4.7) 0 2 (2.8) nausea 0 1 (3.4) 1 (1.4) table 3. treatment result (n = 72) treatment result intermittently thrice a week (n = 43) n (%) daily (n = 29) n (%) total n (%) p value cure 19 (44.2) 12 (41.4) 31 (43.1) 0.634 lost to follow up 23 (53.5) 15 (51.7) 38 (51.7) failed 1 (2.3) 2 (6.9) 3 (4.2) vol 52 • number 1 • january 2020 comparative effectiveness of tuberculosis treatment daily 29 the advanced phase and their follow up could not be performed. these results were similar with mi feng ling et al.’s, that tb-dm patients have higher dropouts rate.23 seven patients experienced side effects, mostly in the intermittent group (six vs. one). this result is different from pranab kumar mandal et al.’s which reported more side effects in the daily treatment group.24 strengths and limitations of the study the strength of this study is that this is the first study comparing real world data of indonesian tb-dm patients, assessing effectiveness and side effects of category 1 tb treatment at advanced phase between intermittent, thrice a week, and daily regimens. the data in this study was taken from the patients’ medical record, and the large number of lost to follow up patients make it impossible to get the picture of these patients response. there were not enough patients to meet the number of samples needed in this study, eventhough we have included all eligible tb-dm patients, with the consequence of lower power of the study. conclusion treatment effectiveness in terms of clinical response and sputum conversion between intermittent group (three times a week), and daily treatment group during advanced phase in tb-dm patients were comparable. conflict of interest the authors declare that they have no conflict of interest. references 1. tuberculosis (tb). data and statistics. available at: https://www.cdc.gov/tb/statistics/default.htm. accessed august 28th, 2018. 2. global tuberculosis report 2018. geneva: world health organization. 2018. 3. gunda dw, nkandala i, kavishe ga, kilonzo sb, kabangila r, mpondo bc. prevalence and risk factors of delayed sputum conversion among patients treated for smear positive ptb in northwestern rural tanzania: a retrospective cohort study. j trop med. 2017;2017:5352906. 4. dooley ke, chaisson re. tuberculosis and diabetes mellitus: convergence of two epidemics. lancet infect dis. 2009;9(12):737-46. 5. sidibe eh. main complications of diabetes mellitus in africa. ann med interne (paris). 2000;151(8):624-8. 6. alisjahbana b, sahiratmadja e, nelwan ej, et al. the effect of type 2 diabetes mellitus on the presentation and treatment response of pulmonary tuberculosis. clin infect dis. 2007;45(4):428-35. 7. jeon cy, harries ad, baker ma, et al. bi-directional screening for tuberculosis and diabetes: a systematic review. trop med int health. 2010;15(11):1300-14. 8. leung cc, lam th, chan wm, et al. diabetic control and risk of tuberculosis: a cohort study. am j epidemiol. 2008;167(12):1486-94. 9. lee ph, fu h, lai tc, chiang cy, chan cc, lin hh. glycemic control and the risk of tuberculosis: a cohort study. plos med. 2016;13(8):e1002072. 10. baker ma, harries ad, jeon cy, et al. the impact of diabetes on tuberculosis treatment outcomes: a systematic review. bmc med. 2011;9:81. 11. jimenez-corona me, cruz-hervert lp, garcia-garcia l, et al. association of diabetes and tuberculosis: impact on treatment and post-treatment outcomes. thorax. 2013;68(3):214-20. 12. dooley k, tang t, golub je, dorman se, cronin w. impact of diabetes mellitus on treatment outcomes of patients with active tuberculosis. am j trop med hyg. 2009;80(4):634-9. 13. riza al, pearson f, ugarte-gil c, et al. clinical management of concurrent diabetes and tuberculosis and the implications for patient services. lancet diabetes endocrinol. 2014;2(9):740-53. 14. faurholt-jepsen d, range n, praygod g, et al. the role of diabetes co-morbidity for tuberculosis treatment outcomes: a prospective cohort study from mwanza, tanzania. bmc infectious diseases. 2012;12:165. 15. isbaniyah f, thabrani z, soepandi pz, et al. pedoman diagnosis & penatalaksanaan tuberkulosis di indonesia (konsensus tb). jakarta: perhimpunan dokter paru indonesia. 2011. 16. guidelines for treatment of drug-susceptible tuberculosis and patient care. 2017 update. geneva: world health organization. 2017. 17. azarkar z, sharifzadeh g, ebrahimzadeh a, olumi s. time to sputum smear conversion in smear-positive pulmonary tuberculosis patients and factors for delayed conversion. iran j med sci. 2016;41(1):44-7. 18. cho nh, kirigia j, mbanya jc, et al. idf diabetes atlas – 8th edition. in: karuranga s, fernandes jdr, huang y, malanda b, eds. international diabetes federation. 2017. 19. jinda ha, bhatt b, malik js. a study on the smear conversion time and its associated factors in sputum positive category i tuberculosis dots cases in district rohtak, haryana. sch j app med sci. 2015;3(9d):3391-9. 20. fonkeng ls, ali im, noubom m, et al. prevalence, predictors and treatment outcome of type 2 diabetes angelina siane acta med indones-indones j intern med 30 among newly diagnosed sputum positive pulmonary tuberculosis patients in western cameroon. j infect dis epidemiol. 2017;3(2):1-13. 21. salindri ad, sales rf, dimiceli l, schechter mc, kempker rr, magee mj. isoniazid monoresistance and rate of culture conversion among patients in the state of georgia with confirmed tuberculosis, 20092014. ann am thorac soc. 2018;15(3):331-40. 22. konsensus pengelolaan tuberkulosis dan diabetes melitus (tb-dm) di indonesia. jakarta: kementerian kesehatan ri direktorat jenderal pengendalian penyakit dan penyehatan lingkungan, direktorat pengendalian penyakit tidak menular. 2015. 23. mi f, tan s, liang l, harries ad, et al. diabetes mellitus and tuberculosis: pattern of tuberculosis, two-month smear conversion and treatment outcomes in guangzhou, china. trop med int health. 2013;18(11):1379-85. 24. mandal pk, mandal a, bhattacharyya sk. comparing the daily versus the intermittent regimens of the antitubercular chemotherapy in the initial intensive phase in non-hiv, sputum positive, pulmonary tuberculosis patients. j clin diagn res. 2013;7(2):292-5. case report 314 acta medica indonesiana the indonesian journal of internal medicine transcatheter closure of patent ductus arteriosus in adolescents and adults: a case series sukman t. putra, mulyadi m. djer, nikmah s. idris, sudigdo sastroasmoro department of pediatrics, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: sukman tulus putra, md., phd, facc. department of pediatrics and child health, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. salemba 6 jakarta 10430, indonesia. email: sukmanputra@yahoo.com. abstrak dalam kurun waktu 11 tahun antara 1januari 2005 sampai 31 desember 20015 sebanyak 18 kasus pda pada anak remaja dan dewasa dilakukan penutupan pda dengan alat amplatzer duct occluder (ado). terdapat 9 kasus anak remaja yang berumur antara 14-18 tahun dan 9 orang dewasa yang berumur di atas 18 tahun dengan umur yang tertua 46 tahun. sebelum pelaksanaan tindakan, dilakukan pemeriksaan klinis, ekg dan foto toraks serta ekokardiografi transtorakal untuk konfirmasi diagnostik pda. prosedur implantasi ado dilakukan dengan anastesi umum pada remaja dan anestesi lokal dan sedasi pada pasien dewasa. ukuran diameter pda berkisar antara 1,6 mm-11,1 mm. berdasarkan klasifikasi kritchenko terdiri dari 15 pda tipe a1 dan 3 kasus tipe a2. flow rati oantara sirkulasi pulmonal dan sirkulasi sistemik berkisar antara 1,1–5,9. waktu pelaksanaan prosedur berkisar antara 60-189 menit dengan waktu florsokopi antara 7,1-77,3 menit. tekanan rata-rata pada arteri pulmonalis berkisar antara 22-63 mmhg dengan tekanan tertinggi sebesar 63 mmhg terdapat pada 2 kasus (no 12 dan 13). segera setelah prosedur tindakan menujukkan penutupan total pada 14 kasus dan pada 4 kasus terdapat pirau residual minimal pada gambaran angiografi yang kemungkinan disebabkan kebocoron sementara melalui sela-sela device. dalam 24 jam pertama setelah tindakan ditemukan penutupan total pada semua kasus (100%) dan hasil tersebut ditemukan sampai 1 bulan dan 6 bulan setelah tindakan. selama kurun waktu tersebut tidak ditemukan sisa pirau (residual shunts) dan komplikasi berarti lainnya seperti embolisasi device atau rekanalisasi pada duktus. hasil studi seri kasus ini ini menunjukkan bahwa penutupan pda dengan prosedur transkateter menggunakan ado pada pasien remaja dan dewasa dalam jangka pendek sangat baik dan efektif serta tidak ada komplikasi yang berarti. namundemikian masih diperlukan pemantauan jangka panjang untuk menilai efektivitas dan keamanan prosedur ini. kata kunci: penutupan transkateter, duktus arteriosus persisten, remaja, dewasa, amplatzer duct occluder (ado). abstract during 11 years period from january 2005 to december 2015 there were 18 adolescent and adult patients who underwent transcatheter closure of pda using pda amplatzer duct occluder (ado). there were 9 cases with age of 14 to 18 years and 9 cases with age of more than 18 years where the oldest case was 46 years old. two cases were male and 16 cases were female. prior to procedures, clinical assessment, ecg, chest x-ray and transthoracic echocardiography (tte) were performed to confirm the diagnosis of pda. the procedures of device implantation was performed under conscious sedation in adults and using general anesthesia in adolescents. the size of pda ranged from 1.6 mm to 11.1 mm. based on kritchenko classification, the type of pda were vol 48 • number 4 • october 2016 transcatheter closure of patent ductus arteriosus in adolescents and adults 15 type a1 and 3type a2. flow ratio between pulmonary to systemic circulation was between 1.1 and 5.9. the procedure time ranged from 60-189 minutes and the fluoroscopic time 7.1-77.3 minutes. the pa pressure ranged from 22 to 63 mmhg. immediate results after procedures as seen in angiography showed complete closure in 14 cases and smoky residual shunt or minimal residual shunts in 4 cases, which probably due to the temporary leaking through the devices. in 24 hours, complete closure was achieved in all cases (100%) and continued until 1months. at 6 month follow up, there was no residual shunts detected and also there was no significant complications, such as device embolization or recanalization. this case series suggest that transcatheter closure of pda in adolescents and adults using amplatzer duct occluder (ado) is effective and has excellent resultswithout significant complication. however, long-term follow up is required to assess long term efficacy and safety. keywords: transcatheter closure, patent ductusarteriosus, adolescent, adult, amplatzer duct occluder. introduction patent ductus arteriosus (pda) is vascular structure that connects the left pulmonary artery near its origin to the descending aorta. this structure is important during fetal life and in fullterm infants, about 90% closes spontaneously the 48 hours of life. pda is considered a congenital heart defect if there is persistent patency beyond the third month of life in full term infants.1 in infants and children, pda can be associated with various congenital heart disease like asd or vsd, but in adults, it is usually an isolated lesion. the incidence of pda is approximately 1 per 2000 live birth, accounting for 5-10% of congenital heart diseases.2 most of the pda were detected and treated in infancy and childhood. however, in the developing world, some cases could be detected very late in the adolescence or even in adulthood due to the lack of resources and access to cardiac centers. the clinical significance of pda depends l a rg e l y o n t h e s i z e a n d t h e u n d e r l y i n g cardiovascular status and co-morbidities of the patient. the pda may be “silent” with no evidence of clinical symptoms (asymptomatic). the silent pda is detected incidentally by primary care physician during other examination, in which the echocardiography was done for different reasons. the anatomy of pda in adults may differ from children due to calcification or aneurysm, which may cause challenges in performing transcatheter closure of pda and, therefore, a surgery is required. however, it has been reported that transcatheter closure of the pda in adults may be safe and effective but data is very limited.3 the mortality rate of untreated pda in adults is 1.8% per year.4 there are also some additional complications, such as lv overload, pulmonary hypertension, infective endocarditis, calcification, aneurysm and rarely rupture.5 here we presented a case series on the short-term results of transcatheter closure of pda in 18 adolescents and adults which consists of complete closure and complications from the years of 2005 to 2015. case illustration during 11 years period from 2005 until 2015, there were 18 of adolescents and adults undergoing transcatheter closure of pda using ado. there were 9 adolescents between 14 and 18 years of age, while the remaining 9 patients were adults, among whom the oldest case was 46 years old. most of the patients were female (table 1). the size of pda ranged from 1.6 mm to 11.1 mm. based on kritchenko classification, the type of pda were 14 of a1 type and 3 of a2 type. flow ratio between pulmonary to systemic circulations ranged from 1.1 to 5.9. the procedure time was 60-189 minutes and the fluoroscopic time was 7.1-77.3 minutes. the range of pa pressure was 22-63 mmhg, in which the highest occurred in patient no. 12 and 13. transcatheter closure of pda procedure t h i s c a s e s t u d y w a s p e r f o r m e d retrospectively by reviewing the medical records of 18 adolescents and adults (2 male and 16 female) patients admitted between 2005 315 sukman t. putra acta med indones-indones j intern med table 1. hemodynamic data and immediate results of transcatheter closue of pda using ado pts no. sex/ age year device w (kg) pda size type fr ft pt comp. immediate result pa sys pa dias pa mean 1 f/20 2006 ado i 46.0 4.0 a1 3.2 7.1 71 nil complete closure 58 17 37 2 f/14 2007 ado i 54.5 3.35 a2 1.1 12.8 68 nil complete closure 22 12 8 3 f/18 2008 ado i 42.0 3.00 a1 2.2 43.3 125 nil complete closure 26 17 21 4 f/23 2008 ado i 48.0 5.67 a1 1.8 9.3 60 nil smoky residual shunt 30 18 24 5 f/15 2009 ado i 38.0 6.00 a2 2.9 33.6 170 nil smoky residual shunt 67 35 49 6 m/14 2009 ado i 43.0 7.00 a1 4.9 17.0 80 nil complete closure 58 33 42 7 f/37 2010 ado i 49.0 4.00 a1 3.0 38.3 120 nil complete closure 22 9 15 8 f/14 2010 ado i 23.0 2.60 a2 3.5 13.6 150 nil smoky residual shunt 40 25 33 9 f/18 2012 ado i 55.0 5,6. a1 1.2 22.1 133 nil complete closure 48 27 37 10 m/15 2012 ado i 33.0 6.02 a1 5.9 19.4 69 nil complete closure 60 30 42 11 f/18 2012 ado i 49.0 8.00 a1 1.9 17.1 68 nil complete closure 45 10 27 12 f/23 2012 ado i 47.0 6.0.0 a1 2.5 14.0 70 nil smoky residual shunt 83 46 63 13 f/17 2013 ado i 10.0 8.00 a1 3.2 17.8 120 nil complete closure 90 36 63 14 f/16 2013 ado i 43.0 10.00 a1 2.3 11.0 60 nil complete closure 74 42 57 15 f/39 2013 ado i 42.0 11.30 a1 1.4 77.3 189 nil complete closure 30 14 26 16 f/20 2015 ado i 53.0 6.50 a1 2.5 8.1 70 nil complete closure 40 15 32 17 f/15 2014 ado i 40.0 4.20 a1 2.0 12.0 60 nil complete closure 38 15 30 18 f/46 2014 ado i 61.5 6.96 a1 1.4 22.2 99 nil complete closure 61 32 49 w: weight; fr: flow ratio; ft: flouroscopy time; pt: procedure time; pa: pulmonary artery; comp: complication. and 2015 at integrated cardiovascular center (pjt), dr. cipto mangunkusumo hospital jakarta. prior to the intervention procedures, clinical assessment, ecg, chest x-ray, and trans-thoracic echocardiography (tte) were performed to confirm the diagnosis of pda. the procedures of the device implantation were performed under conscious sedation in adults and with general anesthesia in adolescents. a single dose of intravenous antibiotic is administered (cephalosporin) 30 mg/kg bw (max 1 gram) 30 minutes before the catheterization and two subsequent doses at 8 and 16 hours after the procedure. a 100 international unit (iu)/ kg (maximum 5000 iu) of sodium heparin were administered after insertion of catheter at the femoral artery. the right and left heart catheterization was performed and an aortogram with true lateral position was made to visualize the size and shape of the duct and to assess the minimum diameter, diameter of the aortic ampulla and the length of the duct (figure 1). we used amplatzer ductal occluder (ado i ) device, in which the size chosed was at least 2 mm larger 316 vol 48 • number 4 • october 2016 transcatheter closure of patent ductus arteriosus in adolescents and adults than narrowest diameter of the duct. the device then was immersed into saline solution. after the device was screwed to the tip of the delivery cable, it was then loaded into the delivery catheter and the whole system is immersed into saline again (figure 2). after this, the device was introduced and advanced through the sheath into the descending aorta by fluoroscopy guidance, and then the retention disk was deployed in the descending aorta. the sheath and the retention disk were pulled back firmly into the ampulla of the duct. at this position the rest of device was deployed by holding the delivery cable of the device while pulling back the delivery sheath. to confirm the correct position of the device, an aortogram was performed soon afterward, to ensure the retention disk sitting on the rim of the ductal ampulla and not obstructing the descending aorta. the device could be replaced by another device of different size as necessary. if everything is correct and the position of the device is stable, the device can be released by rotating the delivery cable in the anticlockwise direction. device profile all of our patients had their pda closed by ado i. the ado (aga medical corporation, golden valley, mn) is a self-expanding and selfcentering device made from 0.0004 (0.1mm) to 0.0005 inch nitinol wire mesh. it is mushroomshaped with a low profile and consist of a flat retention disk and a cylindrical main body, into which polyester fibers are sewn (figure 1). ado has a retention disk which is 4 mm larger than the main body which itself has a conical structure. the delivery system consists of a delivery cable, a mullin-type sheath, loader and a pin vise. the size of the device used will be at least 2 mm larger than the size the narrowest diameter of the duct. at the end of the procedures, the arterial and venous catheter were removed and the compression of the groin was done to achieve the hemostasis. follow up echocardiogram was performed 24 hour post-procedure. the aim of repeating the echo was to demonstrate the orientation of the device (its relation to descending aorta and the branches of pulmonary arteries, and to visualize the degree of residual shunting. a chest x-ray in anterior/posterior and lateral projections was done prior to discharge. further clinical follow up and echocardiography were undertaken at 24 hours, 1 months, and 6 months after the procedures. follow-up the immediate results after procedures as shown by angiography were complete closure in 14 patients and smoky residual or minimal residual shunts in 4 patients,which was probably due to temporary leak through the device. at 24 hour follow up after the procedure, complete closure was achieved in all patients and persisted at 1 month follow up. the follow up after 6 months, there was no residual shunt detected and no significant complications occured, such as device embolization or recanalization. discussion transcatheter closure of pda has been performed worldwide since the first percutaneous closure of pda by porstman in 1967.6 there were figure 1. amplatzer duct occluder (ado) figure 2. angiography before and after implantation of ado (before released) 317 sukman t. putra acta med indones-indones j intern med various kind of duct occluder available, such as rashkind occluder, gianturco coils, lifetech device, and ado as the most commonly used device. the ado is an expandable device that has been used in many centers with excellent results since early 2000. bilkis et.al reported the safety and efficacy of closing the pda using ado in 209 patients, particularly in symptomatic infants and small children with relatively large pda.3 most pda are closed during infancy or childhood, when there were significant clinical symptoms and signs, which causes hemodynamic disturbances with left atrial and ventricle volume overload and pulmonary hypertension. djer mm et.al reported good results of pda closure using devices, mostly with ado, with success rate of 97.3% in the period of 11 years.7 in adults, pda is usually “silent” with no clinical symptoms or asymptomatic, which is detected incidentally during routine physical examination or echocardiography for other purposes. therefore, the treatment of pda in adults remains controversial.5 pda closure by surgical intervention has been the “gold standard” since 1939, especially for a large pda.8,9 however, in adults, surgical closure has some challenges and difficulties due to duct calcification, aneurysm, and other related comorbidities such as coronary atherosclerosis and renal diseases. therefore, transcatheter closure of pda in adults and adolescents is an alternative to surgery with good results. wilson et.al (1993) reported effective results of pda closure in adults and children.10hong et al (2002) reported 36 out of 37 patients (97%) had successful ado placement.11 in our study of 18 patients, 9 were adolescents and 9 were adults; all of them had succesful ado placement. immediately after the procedures, complete closure was achieved in 14 of 18 patients, whereas the remaining four had minimal or “smoky” residual shunts. however, all of the patients had complete closure after 1 month and 6 months. there were no residual shunts at 6 month follow up. mean pulmonary artery pressure increased in 7 of 18 patients, of whom all were adults. the pa pressure ranged between 42–63 mmhg was reversible to the administration of 100% oxygen with good results after pda closure. transcatheter closure of pda in adults with severe pulmonary artery hypertension seemed to be feasible, effective and safe as reported previously.13 in general, pda transcatheter closure has been proven to be effective with excellent results, but there were several reported complications, such as embolization, narrowing of lpa, or aortic obstruction.12 in general, the complications of transcatheter closure of pda is very low both in children and adult patients.14 the occurrence of embolization rate varies from 0% and 3.1%.12,15 in our study, no device embolization occurred at all, which was probably related to careful case and device selections. there was no other complications observed in this study and the overall succesful rate was high. a previous study reported an overall success rate of 98.1% among 69 adults undergoing percutaneous pda closure.16 conclusion our study showed that transcatheter closure of pda in adolescents and adults is effective and safe with excellent results in short-term follow up. no serious complications such as endocarditis ordevice embolization in the 6 month follow up. however, a long-term follow up is needed. references 1. forsey jt, elamsry qa, martin rp. patent arterial duct. orphanet j rare dis. 2009;4:17. 2. mitchell sc, korones sb, berendes hw. congenital heart disease in 56.109 births. incidence and natural history. circulation.1971;43:323-32. 3. bilkis aa, alwi m, hasri s, et al. the amplatzer duct occluder: experience in 209 patients. j am coll cardiol. 2001;37:258-61. 4. campbell m. natural history of patent ductus arteriosus. br heart j. 1968;30:4-13. 5. i n g l e s s i s i , l a n n d z b e rg m j . i n t e r v e n t i o n a l catheterization in adult congenital heart disease. circulation. 2007;115:1622-33. 6. portsmann w, wierny l, warnke h, et al. catheter closure of patent ductus arteriosus: 62 cases treated without thoracotomy. radiol clin north am. 1971;9:203-18. 7. djer mm, saputro dd, putra st, idris ns. transcatheter closure of patent ductus arteriosus: 11 years of clinical experiences in cipto mangunkusumo hospital, jakarta, indonesia. pediatr cardiol. 2015;36:1070-4. 318 vol 48 • number 4 • october 2016 transcatheter closure of patent ductus arteriosus in adolescents and adults 8. fischer g, stiech j, uebing a, et al. transcatheter closure of persistent ductus arteriosus in infants using the amplazer duct occluder. heart. 2001;86:444-7. 9. gross re, hubbard jp. surgical ligation of patent ductus arteriosus. repostt first successful case. jama. 1939;112:729-73. 10. wilson nj, neutze jm, mawson jb, calder al. transacetheter closure of patent ductus arteriosus in children and adults. n z med j. 1993;106:299-301. 11. hong te, hellenbrand we, hijazi zm. transcatheter closure of patent ductus arteriosus in adults using the amplatzer duct occlude: initial results and follow up. indian heart j. 2002;54(4):384-9. 12. jang gy, son cs, lee jw, lee jy, kim sj. complications after transcatheter closure of patent ductus arteriosus. j korean med sci. 2007;22:484-90. 13. zhang cj, huang yg, huang xs, huang t, huang wh, xia cl, mo yj. transcatheter closure of large patent ductus arteriosus with severe pulmonary artery hypertension in adults: immediate and two year followup results. chin med j (engl). 2012:125(21):3844-50. 14. yu ml, huang xm, wang jf, qin yw, zhao xx, zheng x. safety and efficacy of transcatheter closure of large patent ductus arteriosus in adults with selfexpandable occlude. heart vessels. 2009;24:440-5. 15. azhar as, abd el-azim aa, habb hs. transcatheter closure of patent ductus arteriosus: evaluating the effect of the learning curve on the outcome. ann pediatr cardiol. 2009;2:36-40. 16. behjati-ardakani m, rafiei m, behjati-ardakani a, vafaeenasab m, sarebanhassanabadi m. longterm results of transcatheter closure of patent ductusarteriosus in adolesecents and adults with amplatzer duct occluder. north am j med sci. 2015;7:208-11. 319 3acta med indones indones j intern med • vol 54 • number 1 • january 2022 original article abstract background: sulfonylureas (sus) have been widely used in many countries for t2dm treatment. gliclazide is one of the sus with the lowest risk of hypoglycemia; however, the safety and effectiveness of gliclazide mr during ramadan has not yet been reported in indonesia. this study aimed to assess safety, efficacy, and tolerability of gliclazide modified release (mr) during ramadan fasting. methods: the study was a part of dia-ramadan study, a prospective observational study with subjects of t2dm patients aged >18 years, who had either controlled or sub-optimally controlled blood glucose level, performed ramadan fasting. subjects had been treated with gliclazide mr for at least 90 days prior the study, and were examined for their body mass index (bmi), fasting plasma glucose (fpg) and hba1c levels 6 to 8 weeks before ramadan (v0) and 4 to 6 weeks after the end of ramadan (v1). results: out of 198 subjects participating in the study, there were only two subjects (1.0%) who reported symptomatic hes (either confirmed or not confirmed) and no severe hes had been reported. there were no significant changes in hba1c and fpg levels (p>0.05). interestingly, there was a reduction of bodyweight (-0.4kg) from preto post-ramadan (p < 0.001). almost no subjects reported discontinuation of gliclazide mr throughout the entire study; however, there was one subject who reported a change of diabetic treatment into diet only. conclusion: gliclazide mr is safe, well tolerated and can maintain glycemic control effectively for indonesian patients with t2dm who perform ramadan fasting. keywords: type 2 dm, gliclazide mr, ramadan, indonesia. indonesia dia-ramadan study: a real-life, prospective and observational of gliclazide mr in type-2 diabetes patients during ramadan fasting soebagijo adi soelistijo1, andi makbul aman2*, hendra zufry3, agung pranoto1, achmad rudijanto4, mohamed hassanien5 on behalf of the dia-ramadan study investigators in indonesia 1 department of internal medicine, faculty of medicine, airlangga university dr. soetomo hospital, surabaya, indonesia 2 department of internal medicine, faculty of medicine, hasanuddin university wahidin sudirohusodo hospital, makassar, indonesia 3 department of internal medicine, faculty of medicine, syah kuala university zainoel abidin hospital, aceh, indonesia 4 department of internal medicine, faculty of medicine, brawijaya university dr. saiful anwar hospital, malang, indonesia 5 department of endocrinology, dubai hospital, dubai, united arab emirates. *corresponding author: andi makbul aman, md. department of internal medicine, faculty of medicine, hasanuddin university wahidin sudirohusodo hospital, makassar, indonesia. email: makbul_aman@yahoo.com. soebagio adi soelistijo acta med indones-indones j intern med 4 introduction indonesia, as a country with the largest muslim population, has been projected with having 238 million of muslim population in 2010.1 with a prevalence of diabetes mellitus (dm) of 10.9% by year 2018, indonesia has been ranked as a country with the seventh largest diabetes population in the world.2,3 fasting during the holy month of ramadan is an important event for muslims and considered as one of the five pillars of islam. fasting for a long period could potentially affect the metabolic state of diabetes patients, including hypoglycemia, hyperglycemia, ketoacidosis, dehydration and increasing risk of complications.4 patients in indonesia fast for one month during ramadan with at least 13 to 14 hours of fasting per day.5 there is no consensus about the most appropriate oral antidiabetic (oad) agents for patients with t2dm to use during ramadan.6 sulfonylureas (sus) remain the most commonly used oad after metformin in indonesia.7 it is well known that sus were associated with a higher risk of hypoglycemia, which has raised some concerns about their use during ramadan. several studies demonstrate that many patients with t2dm may continue to use second-generation sus and fast safely during ramadan.6,8 several randomised clinical trial (rct) studies showed that gliclazide has lower risk of hypoglycaemia, even during fasting ramadan, compared with other sus. a newer formulation, modified release (mr) of gliclazide showed a lower risk of hypoglycemia, even during a fasting period when compared with other sus.6,9,11 the effectiveness and safety of gliclazide mr has not been studied during ramadan in a real-life setting. the indonesia-diaramadan study, is a part of global-diaramadan study, which is conducted across countries in the middle east, africa, south, and south-east asia. to our knowledge, our study represents the first real-life study of gliclazide mr in patients with t2dm who perform fasting during ramadan. the aim of our study was to assess safety (based on hes), efficacy (based on hba1c changes), and tolerability of gliclazide mr in indonesian muslims with controlled or suboptimal controlled t2dm (hba1c < 9%) during ramadan fasting. methods dia-ramadan was a prospective and observational study conducted at 64 sites in 9 countries across the middle east, africa and asia (bangladesh, egypt, india, indonesia, kuwait, malaysia, pakistan, saudi arabia and united arab emirates). seven cities in indonesia involved in this study were jakarta, surabaya, yogyakarta, makassar, aceh, solo, and malang. the inclusion criteria were: subjects > 18 years of age with t2dm, body mass index (bmi) of ≥23 and <30 kg/m2, controlled or sub-optimally controlled t2dm (hba1c <9%); treated with gliclazide mr for at least 90 days prior to the initiation of the study (inclusion visit), either as monotherapy or in combination with any other diabetes treatment except insulin; experienced with self-monitoring of blood glucose (using blood glucose meter); subjects were willing to perform full (30 days) fast during ramadan in 2019. the study was conducted from mid-march 2019 to end of august 2019. the overall treatment duration consisted of pre-ramadan period (6 to 8 weeks prior to the ramadan), the ramadan period (4.5 weeks), and post-ramadan period (4 to 6 weeks after ramadan) (figure 1). during the first inclusion visit (v0), patient’s demographic data, hba1c and fasting plasma glucose (fpg) levels and body weight data were collected. each patient was provided with a diary at v0 for recording the following events: (1) any changes in their recommended oral antidiabetic therapy; (2) any hypoglycemia-related symptoms experienced during the study; (3) any other adverse events (aes) occurred during the study. ethics this study was approved by ethical committee of health research ethics committee (hrec) faculty of medicine, brawijaya university (reference no. 013/ec/kepk/01/ 2019). study assessment gliclazide mr was taken orally once daily at breakfast according to the summary of product vol 54 • number 1 • january 2022 indonesia dia-ramadan study 5 characteristics (smpc) until the beginning of ramadan. during ramadan11, subjects were advised by their physician to take their gliclazide mr at iftar time (i.e., the post-sunset meal). dose adjustment was based on direction of the investigator according to routine practice and local guidelines, if applicable. during the study, subjects continued receiving concomitant treatments for comorbid conditions. outcome variables the primary endpoint of the study was the proportion of subjects with at least one symptomatic hypoglycemia event (he), either suggestive or confirmed by a measured glucose concentration of ≤ 70 mg/dl. symptomatic hypoglycemia was defined as the presence of at least one of the following symptoms: sweating, pallor, tremor, intense hunger, pounding heart, visual disturbance, drowsiness, weakness, dizziness, cognitive impairment, unexplained behavior or mood change, confusion, headache; without or with a measurement of blood glucose. severe hypoglycemia was defined as reported severe cognitive impairment requiring thirdparty assistance for recovery.12,13 secondary endpoints included changes of the following: hba1c and fpg levels as well as body weight between v0 and v1; the proportion of subjects with at least one confirmed he (asymptomatic or symptomatic); the proportion of subjects with at least one he of any type. any he was defined as symptomatic hypoglycemia (confirmed or not) or confirmed asymptomatic hypoglycemia (asymptomatic with a measured glucose concentration of ≤ 70 mg/dl). statistical analysis two-sided statistical tests (paired t-test or wilcoxon signed rank test) were applied with type i error (alpha), which was set at 5%. the wilcoxon signed rank test was applied in cases of strong violation of normality. statistical analyses were performed by aixial (boulognebillancourt, france). analyses were conducted using sas software, version 9.4 or higher (sas institute, north carolina, usa). the values presented as means ± standard deviation unless specified otherwise. results patient recruitment out of a total of 212 recruited patients, 198 patients were included in the final analysis set. fourteen patients were excluded from the final analysis for reasons including noncompliance with inclusion/exclusion criteria and withdrawal of consent. of the 198 patients examined at the inclusion visit (v0), 183 (92.4%) completed the study by attending the end of study visit (v1). the majority of patients who withdrew from the study did so due to non-medical reasons. among 198 patients, 91 were male (46%) and 107 were female (54%), with average fasting day was 28.7 days. contributing cities were jakarta [24%], surabaya [21%], yogyakarta [17%], makassar [16%], aceh [10%], solo [7%], and malang [5%]). all subjects were included in the final analysis set. figure 1. diaramadan study protocol soebagio adi soelistijo acta med indones-indones j intern med 6 baseline patterns of antidiabetic medication use of 198 patients, 84 patients were using gliclazide mr as monotherapy (42.4%) and 114 patients were using gliclazide mr in combination with other antidiabetic agents (figure 2). the mean daily dose of gliclazide mr was 65 mg. no dose modification in gliclazide mr treatment was observed during the study. safety and tolerability hypoglycemia event under gliclazide mr treatment during ramadan fasting in indonesia was very low; there were only two subjects (1%) experiencing at least one hypoglycemia episode during the period of fasting, i.e., one subject (0.5%) with symptomatic hypoglycemia and one patient (0.5%) with confirmed hypoglycemia. no subjects reported severe hypoglycemia. adverse effects (other than hes) the most commonly reported aes in the study were vertigo and gastrointestinal disorders. in clinical experiences, gliclazide mr does not cause vertigo and gastro-intestinal symptoms but we cannot confirm whether these vertigo and gastro-intestinal complaints are related to medication or fasting. no subjects experienced any drug-related aes during the study. tolerability during the study period, there was only one subject who discontinued the gliclazide mr treatment and changed it with lifestyle modification according doctor’s advice. our results showed that gliclazide was well tolerated by almost all subjects. efficacy hba1c and fpg levels were examined at visits v0 and v1 (figure 3a). there was no significant change of hba1c and fpg (p>0.05) levels between both study visits. there were increased number of subjects with hba1c level of table 1. baseline characteristics variable mean (sd) gender (%) male female age (years) diabetes durations diabetes treatment gliclazide mr (monotherapy) gliclazide mr + 1 other oad gliclazide mr + 2 others oad comorbid conditions (%) arterial hypertension dyslipidemia established cardiovascular disease diabetic neuropathy diabetic nephropathy diabetic retinopathy diabetic foot duration of fasting (days) laboratory values hba1c, (%) fpg, (mg/dl) serum creatinine, (mg/dl) 91 (46) 107 (54) 57.4 (8.2) 3.9 (3.9) 84 (42.4) 84 (42.4) 30 (15.2) 76 (38.4) 84 (42.4) 10 (5.1) 9 (4.5) 2 (1.0) 1 (0.5) 1 (0.5) 28.7 (3.5) 7.4 (0.9) 134.5 (42.4) 0.91 (1.02) fpg, fasting plasma glucose; oad, oral anti diabetic; hba1c, glycated hemoglobin; sd, standard deviation figure 2. antidiabetic treatment at baseline (v0). dpp4, dipeptidyl peptidase 4 inhibitor; glp1 ra, glucagon-like peptide-1 receptor agonist; mr, modified release; sglt2i, sodium-glucose cotransporter 2 inhibitor; tzd, thiazolidinedione. vol 54 • number 1 • january 2022 indonesia dia-ramadan study 7 hemoglobin; sd, standard deviation. body weight significant reductions in body weight (0.4 kg) were recorded between visits v0 and v1 (p < 0.001) (figure 4). <7.5% from 99 to 109 subjects and from 0 to 13 subjects with hba1c >9%, indicating that there was improved glycemic control in 10 subjects and worsened in 13 subjects. (figure 3b). (hba1c [n = 182] and fpg [n = 182] at v1). fpg, fasting plasma glucose; hba1c, glycated figure 3. hba1c and fpg levels at v0 and v1. (a) mean hba1c and fpg levels at v0 and v1. (b) proportion of patients within specified hba1c range at v0 and v1. figure 4. mean body weight at v0 and v1. (n = 184). sd, standard deviation. soebagio adi soelistijo acta med indones-indones j intern med 8 the ultimate goal of diabetes treatment during ramadan is to sustain glycemic control during fasting period with low risk of hypoglycemia in patients with t2dm17. our results presented here show that gliclazide-treated patients experienced a stable level of hba1c and fpg as well as a significant reduction of body weight between study visits. as no dose changes were reported during the study, patients treated with gliclazide mr can therefore continue with pre-ramadan dosing levels during fasting. there was a higher proportion of patients having an hba1c value ≥9% at v1 versus v0 (6.6%) compared to diaramadan global study.18 this different result could be related to change of meal composition during ramadan since there was no report of any change in diabetic treatment except one subject reporting discontinuation of gliclazide mr and dietary change only during the study period. our study has several limitations, including the biases that are typically associated with non-comparative observational study designs. in addition, the study enrolled patients were already receiving gliclazide mr at stable doses for 90 days prior to the inclusion visit. this suggests that the study drug was well tolerated in these patients. other relevant biases include underreporting of adverse events and hypoglycemic episodes, particularly those that were self-reported in patients’ diaries, as well as recall bias. at visit v0, patients were advised about changes required to the timing of their gliclazide mr dose during the month of ramadan according to current idf-dar guidelines at the discretion of the treating physician. results of our study show real-life evidences gathered by the investigators according to their standard clinical practice. treatment adherence to gliclazide mr during ramadan in indonesia is high (98.8%). majority of patients (92.4%) who attended the inclusion visit (v0) also attended the end-of study visit (v1), and only a few data were missing considering the observational nature of the study. conclusion in indonesian population, gliclazide mr either as monotherapy or combinations with other oads has been shown to be an effective, safe and discussion sulfonylureas have been extensively used as treatment of type-2 diabetes for nearly 70 years.14 the most common choice for second-line therapy in patients who require additional glucoselowering during metformin monotherapy were sus and dpp-4is.15 to our knowledge, dia-ramadan is the first real-life observational study assessing the efficacy and safety of gliclazide mr 60 mg in patients with controlled or sub-optimally controlled t2dm during ramadan fasting. in line with the results from previous observational studies, gliclazide (ir or mr) showed a lower incidence of hes compared with other sus in this study. a large observational study evaluating the incidence of hes in patients with t2dm treated with glipizide, glimepiride, gliclazide (ir or mr), or glibenclamide showed that 14% of those treated with gliclazide experienced at least one symptomatic he during ramadan, which was notably lower than values reported for other sus (glipizide [27.6%], glibenclamide [25.6%] and glimepiride [16.8%]).16 the reduced rate of hes with gliclazide compared with other sus could be explained by differences in its pharmacokinetic and pharmacodynamics properties, mechanism of action and insulin excretion profile.sulfonilureas stimulate secretion of insulin from pancreatic β-cells via a blockade of atp-sensitive k-channels (katp), resulting in membrane depolarisation, calcium influx and insulin release. while glibenclamide provides irreversible inhibition of the kir6.2/sur1 katp channel, inhibition by gliclazide is rapidly reversible. a previous study examining hypoglycemia in patients with t2dm receiving sitagliptin or an su during ramadan showed that incidence of hypoglycaemia was similar between sitagliptin and gliclazide. the proportion who reported symptomatic hes in sitagliptin group was 6.7% compared with 6.6% of patients treated with gliclazide mr.6 additionally, the proportion of patients treated with gliclazide mr with at least one symptomatic he during ramadan was reported to be as low as 1.8% in one study (compared with glibenclamide [5.2%] and glimepiride [9.1%]).10 vol 54 • number 1 • january 2022 indonesia dia-ramadan study 9 well-tolerated treatment in patients with t2dm who perform fasting during ramadan with a consistently low incidence of hypoglycemia, whilst maintaining glycemic control. acknowledgments the study was supported by servier (servier affaires medicales). we acknowledge the kind contribution of all the investigators, staff, and patients at the participating sites from the dia-ramadan study. the following are also dia-ramadan study investigators in indonesia: benny santosa, bowo pramono, budi santoso, eva nia m, fatimah eliana, fx suharnadi, himawan sanusi, ida ayu khsanti, laksmi sasiarini, m robikhul, rulli rosandi, sony wibisono. references 1. pew researcher center. the future of the global muslim population. projections for 2010-2030. washington: pew research center. 2011. 2. indonesian ministry of health. survey kesehatan rumah tangga (skrt) 2018. balitbangkes depkes 2018. 3. international diabetes federation., idf diabetes atlas. brussels, belgium. 2017. 4. lee jy, wong cp, tan css, nasir nh, lee swh. type 2 diabetes patient’s perspective on ramadan fasting: a qualitative study. bmj open diab res care. 2017;5:e000365. 5. iskandar wj, handjaja ct, salama n, anasy n, ardianto mf, kusumadewi d. evidence-based case report: acute diabetic complication risks of ramadan fasting in type 2 diabetics. acta med indones-indones j intern med. 2013;45(3):235-39. 6. al sifri s, basiounny a, echtay a, al omari m, harmanboehm i, kaddaha g, et al. the incidence of hypoglycaemia in muslim patients with type 2 diabetes treated with sitagliptin or a sulphonylurea during ramadan: a randomised trial. int j clin pract. 2011;65:1132–40. 7. cholil ar, lindarto d, pemayun tgd, wisnu w, kumala p, puteri hhs. diabcare asia 2012: diabetes management, control, and complications in patients with type 2 diabetes in indonesia. med j indones. 2019;28(1):47-56. 8. al-arouj m, hassoun aa, medlej r, pathan mf, shaltout i, chawla ms, et al. the effect of vildagliptin relative to sulphonylureas in muslim patients with type 2 diabetes fasting during ramadan: the virtue study. int j clin pract. 2013;67:957–63. 9. aravind sr, ismail sb, balamurugan r, gupta jb, wadhwa t, loh sm, et al. hypoglycemia in patients with type 2 diabetes from india and malaysia treated with sitagliptin or a sulfonylurea during ramadan: a randomized, pragmatic study. curr med res opin. 2012;28:1289–96. 10. hassanein m, abdallah k, schweizer a. a doubleblind, randomized trial, including frequent patientphysician contacts and ramadan-focused advice, assessing vildagliptin and gliclazide in patients with type 2 diabetes fasting during ramadan: the steadfast study. vasc health risk manag. 2014;10:319–26. 11. hassanein m, al-arouj m, hamdy o, bebakar wmw, jabbar a, al-madani a, et al. diabetes and ramadan: practical guidelines. diabetes res clin pract. 2017;126:303–16. 12. perkeni. pedoman pengelolaan dan pencegahan diabetes melitus tipe 2 dewasa di indonesia 2019. jakarta: pb perkeni. 2019. 13. international hypoglycemia study group. glucose concentrations of less than 3.0 mmol/l (54 mg/dl) should be reported in clinical trials: a joint position statement of the american diabetes association and the european association for the study of diabetes. diab care. 2017;40:155–7. 14. sola d, rossi l, schianca gpc, maffioli p, bigliocca m, mella r. sulfonylureas and their use in clinical practice. arch med sci. 2015;11(4):840–8. 15. montvida o, shaw j, atherton jj, stringer f, paul sk. long-term trends in antidiabetes drug usage in the us: real-world evidence in patients newly diagnosed with type 2 diabetes. diab care. 2018;41(1):69–78. 16. aravind sr, al tayeb k, ismail sb, shehadeh n, kaddaha g, liu r, et al. hypoglycaemia in sulphonylurea-treated subjects with type 2 diabetes u n d e rg o i n g r a m a d a n f a s t i n g : a f i v e c o u n t r y observational study. curr med res opin. 2011;27:1237– 42. 17. ibrahim m, abu al magd m, annabi a, assaad-khalil s, ba-essa em, fahdil i et al. recommendations for management of diabetes during ramadan: update 2015. bmj open diabetes res care. 2015;3:e000108. 18. hassanein m, al sifri s, shaikh s, raza sa, akram j, pranoto a et al. a real-world study in patients with type 2 diabetes mellitus treated with gliclazide modifiedrelease during fasting: dia-ramadan. diabetes res clin pract. 2020;163:108154. 107acta med indones indones j intern med • vol 54 • number 1 • january 2022 case report possible cases of sars-cov-2 reinfection in pekanbaru, indonesia rahmat azhari kemal1*, dewi anggraini2 1 department of medical biology, faculty of medicine universitas riau, pekanbaru, riau, indonesia. 2 department of microbiology, faculty of medicine universitas riau, pekanbaru, riau, indonesia. *corresponding author: rahmat azhari kemal, md. department of medical biology, faculty of medicine universitas riau. jl. diponegoro no.1, pekanbaru, riau 28133, indonesia. email: rahmat.azharikemal@lecturer.unri.ac.id abstract confirmed and possible reinfection cases of sars-cov-2 have been reported from various countries. here we present two cases of possible sars-cov-2 reinfection in pekanbaru, indonesia. a 26 years old female and a 27 years old male healthcare workers were first confirmed by pcr with high ct-value (>35) while presenting no or mild symptoms, respectively. in more than one month since the last negative test results, both patients developed typical covid-19 symptoms; fever and anosmia. rt-pcr results for sars-cov-2 were positive with ct-value less than 30. the timeframe between 1st and 2nd episode, negative test result between episodes, and epidemiological risk factor strengthened the possibility of reinfection. however, we did not have whole genome sequence (wgs) or viral viability data to further confirm reinfection with different viable virus. the requirement of viral wgs data to confirm true reinfection cases calls for investment in whole genome sequencing platform in public health laboratories. we encourage standardized definition of sars-cov-2 reinfection case in order to be able to investigate and observe such cases. keywords: covid-19, indonesia, reinfection, sars-cov-2 introduction s e v e r e a c u t e r e s p i r a t o r y s y n d r o m e coronavirus 2 (sars-cov-2) has caused the worldwide coronavirus disease 2019 (covid-19) pandemic since early 2020. while the medical and scientific community have speedily studied the virus, there are still many things to learn, including the possibility of reinfection. investigation and observation of reinfection cases could provide better understanding on immunity to sars-cov-2.1 currently, at least there have been 4 cases supported by whole genome sequencing (wgs) data to confirm reinfection with geneticallydistinct virus.2–5 there are also several other possible reinfection cases without wgs data. 6–9 to the best of our knowledge, there are no published reinfection cases from indonesia. we present two cases of immunocompetent, young persons that indicated the possibility of sars-cov-2 reinfection from pekanbaru city, riau province, indonesia. case illustration case 1 the timeline of case #1 is summarized on figure 1. a 26-years old female healthcare worker was tested on august 4th, 2020 as part of contact tracing. one of her flat-mates was confirmed positive for sars-cov-2. the initial case was also a healthcare worker in the same hospital. last shift of case #1 in the hospital was a night shift on august 3rd, 2020. nasorahmat azhari kemal acta med indones-indones j intern med 108 oropharyngeal sample was taken on august 4th with positive result for sars-cov-2 (ct-value of 35.50 rdrp) using allplex™ 2019-ncov assay (seegene, south korea). the patient did not have any complaints, and her lab results such as routine hematology (table 1), blood gas analysis, and chest x-ray were within normal range. the patient was admitted to the hospital for isolation purpose on august 6th – 11th and remained asymptomatic. the patient was prescribed azythromicin, oseltamivir, paracetamol, omeprazole, acetylcystein, and vitamin d. case #1 was tested negative twice on august 9th and 11th, thus declared to be recovered. the case 1 was tested on august 23rd, 2020 as another part of contact tracing while still presented no symptoms. the result of nasooropharyngeal swab came back negative using standard m ncov real-time detection kit (sd biosensor, south korea). on november 3rd, case 1 developed fever, cough, sneezing, and anosmia. the patient was on duty as nurse in covid-19 icu. therefore, the patient’s naso-oropharyngeal swab sample was taken in influenza-like illness unit on november 4th. the rt-pcr (sd biosensor, south korea) result was positive for sars-cov-2 with ct-value of 22.19 (orf1ab) and 21.78 (e). the patient was further hospitalized. laboratory test showed neutropenia and lymphocytosis (table 1) while chest x-ray was within normal limits. the patient had no comorbidities. the patient was prescribed levofloxacin, dexamethasone, enoxaparine, favipiravir, acetylcysteine, vitamin d, vitamin b, and curcuma. table 1. routine hematology result from first and second covid-19 episode of case #1. parameter first covid-19 episode second covid-19 episode reference hemoglobin (g/dl) 13.1 13.8 11.7 – 15.5 hematocryte (%) 38.9 39.9 35 – 47 erythrocyte (mio/µl) 4.66 4.88 3.8 – 5.2 mcv (fl) 83.5 81.8 79 – 99 mch (pg) 28.1 28.3 27 – 31 mchc (g/dl) 33.7 34.6 33 – 37 leucocyte (mio/µl) 9.3 5.8 4.8 – 10.8 basophil (%) 0 0 0 – 1 eusinophil (%) 1 1 2 – 4 neutrophil (%) 58 39 50 – 70 lymphocyte (%) 36 53 25 – 40 monocyte (%) 5 7 2 – 8 thrombocyte (mio/µl) 269 240 150 – 440 absolute lymphocyte (mio/µl) 3.32 3.08 1 – 4 neutrophil-lymphocte ratio 1.61 0.74 < 3.13 c-reactive protein 1.12 n/a <5 d-dimer n/a 159.53 <500 figure 1. timeline of case #1 vol 54 • number 1 • january 2022 possible cases of sars-cov-2 reinfection in pekanbaru, indonesia 109 the patient was followed up on november 10th and 14th. both came back positive, with ct-value of 33.78 (orf1ab) & 31.66 (e gene) for the first follow-up and 35.29 (orf1ab) and 33.82 (e gene) for the second follow-up. after symptom resolution, patient was discharged on november 16th with positive sars-cov-2 rt-pcr result of ct-value 34.85 (orf1ab) and 35.19 (e). all three follow-ups used the same rt-pcr kit (sd biosensor, south korea). on november 18th, her naso-oropharyngeal swab was tested negative for sars-cov-2 rna (gb sars-cov-2 real-time rt-pcr, gbc, taiwan). case 2 the timeline of case 2 is summarized on figure 2. a 27-years old male self-reported malaise on september 15th, 2020. the patient’s naso-oropharyngeal swab was tested for sarscov-2 on september 18th using diaplexq™ novel coronavirus (2019-ncov) detection kit (solgent, south korea) resulting in positive result with ct-value of 38.62 (orf1a) and 38.08 (n). the same sample was re-extracted and retested using the same kit, resulting in same positive result (36.90 orf1a, 36.74 n). his blood parameter and chest x-ray were within normal range, thus the patient conducted selfisolation at home. the patient had paracetamol, omeprazole, vitamin c, vitamin d, zinc, azythromicin, oseltamivir. the patient reported going out for lunch with 3 people on september 10th. his contacts were additionally tested on september 19th. two of them were negative, but one contact was tested positive (37.12 orf1a, 37.70 n, diaplexq™ kit). the contact reported sorethroat and cough starting on september 12th. additional contact tracing from the abovementioned contact found another positive contact. the patient case #2 was followed up on september 21st using the same test kit and his naso-oropharyngeal swab was tested negative. the patient continued self-isolation for additional 1 week. however, when tested for antibody using standard q covid-19 igm/igg combo test kit (sd biosensor, south korea) on october 26th, the patient was nonreactive for both igm and igg. the patient had no history of immunocompromised and was not taking any immunosuppressive drugs. the case #2 travelled inter-province on october 31st evening by car with a driver and figure 2. timeline of case #2 (blue) and of his contacts, friend (red), father (purple), and mother (green). rdt-ab: rapid antibody test rahmat azhari kemal acta med indones-indones j intern med 110 arrived on november 1st morning to attend a family function. in the same morning, the patient’s father developed fever and did not attend the family function. the father’s nasopharyngeal swab was tested for sarscov-2 (mbiocov-19, biofarma, indonesia) on november 2nd with positive result (32.01 orf1b, 35.21 rdrp). the patient’s mother, who attended the family function on november 1st, developed fever on november 6th. her nasopharyngeal swab was tested for sars-cov-2 (standard m, sd biosensor, south korea) on november 9th with positive result (27.54 orf1ab, 28.38 e). nasopharyngeal swab was taken from case #2 for sars-cov-2 testing on november 11th morning as part of contact tracing while reporting no symptoms. however later in the evening, the patient developed fever (37.8°c) which on the following day reached 38.8°c. on november 13th, the sars-cov-2 test result came back positive (28.39 orf1ab, 26.39 e, standard m kit). chest x-ray and blood analysis were not performed. the patient conducted selfisolation at home. the patient had paracetamol, omeprazole, vitamin c, vitamin d, zinc, azythromicin, oseltamivir. on november 16th the patient started to develop anosmia. the case #2’s father was tested negative on november 10th and 11th, the mother was tested negative on november 16th and 20th, and the case #2 himself was tested negative on november 23rd and 25th. all follow-up tests were conducted on nasopharyngeal swab sample using standard m kit (sd biosensor, south korea). the table 2. possibility of reinfection based on cdc (2020) and yahav (2020) criteria definition criteria case #1 case #2 us cdc (2020) suspected reinfection characteristic clinical symptoms on 2nd episode + fever, cough, sneezing, anosmia fever, anosmia rt-pcr of 2nd episode ct < 33 22.19 (orf1ab), 21.78 (e) 28.39 (orf), 26.39 (e) timeframe from 1st episode ≥45 days 92 days 56 days close-contact + n/a + viral rna sequence different strain n/a n/a yahav et al. (2020) confirmed reinfection true 1st episode ct value < 35 35.50 (rdrp) 38.62 (orf1a) 38.08 (n) same specimen retested: 36.90 (orf1a) 36.74 (n) characteristic clinical symptoms on 2nd episode + + + rt-pcr of 2nd episode ct < 35 + + negative test between 1st and 2nd episode at least 1, ideally 2 3 1 viral culture / subgenomic rna* + n/a n/a timeframe from 1st episode >90 days† 92 days 56 days‡ viral rna sequence different strain n/a n/a clinical reinfection characteristic clinical symptoms on 2nd episode + + + rt-pcr (ct < 35) + + + viral culture / subgenomic rnaa + n/a n/a epidemiological risk factor + + + * optional to provide evidence of replicating virus.† could be <90 days if recovery proven by negative pcr tests and current known covid-19 exposure.‡ had one negative rt-pcr after 1st episode and close-contact with two laboratory-confirmed covid-19 cases before 2nd episode. vol 54 • number 1 • january 2022 possible cases of sars-cov-2 reinfection in pekanbaru, indonesia 111 table 3. summary of several sars-cov-2 reinfection reports cases sex age (years) 1st episode (rt-pcr) 2nd episode (rt-pcr) timeframe (days) negative test between episodes epidemiological risk faktor viral rna sequence pekanbaru case 1 f 26 asymptomatic 35.50 (rdrp) symptomatic 22.19 (orf1ab) 21.78 (e) 92 3 healthcare worker n/a pekanbaru case 2 m 27 mild 38.62 (orf1a) 38.08 (n) worse 28.39 (orf) 26.39 (e) 56 1 close-contact n/a hong kong (2) m 33 mild (positive) asymptomatic 26.69 142 2 travel abroad different clade usa (3) m 25 mild 35.24 hospitalized 35.31 48 2 n/a same clade, genetically distinct belgium (4) f 51 mild 25.6 (n1) 27.2 (n2) milder 32.6 (n1) 33.2 (n2) 93 n/a n/a different clade ecuador (5) m 46 mild 36.85 (orf3) worse 30.82 (n) 63 1 n/a different clade uk (6) m 25 mild (negative, reactive antibody) milder (positive) >90 close-contact n/a usa (7) m 82 hospitalized (positive) hospitalized (positive, high ctvalue) 55 2 n/a n/a bangladesh (8) m 40 mild (positive) mild (positive) 53 1 healthcare worker / contact n/a israel (9) f 20 mild (positive) asymptomatic (positive) ~90 2 close-contact n/a case #2 was tested on december 4th for using covid-19 igm/igg combo test kit (sd biosensor, south korea), resulting in igg strong reactivity and igm weak reactivity. in most reported reinfection cases (table 3), the first positive results were mainly asymptomatic or mildly symptomatic with high ct-value and followed by nonreactive antibody test. our case #2 was nonreactive for both igm and igg within 6 weeks after the first, mildly symptomatic infection. to the extent of our knowledge, case #2 had neither immunocompromised nor immunosuppressed condition which was shown by the presence of igg after the second, symptomatic infection. sensitivity and specificity of the rapid antibody test kit could play a factor. however, it could also be due to lower antibody response in mild cases compared to more severe cases.12–13 studies regarding antibody against sars-cov-2 and its persistence have also been contradictory. several studies showed waning response while others showed lasting immunity. non-hospitalised patients have been shown to have more rapid decline of antibody titer.12 ibarrondo et al. showed declining antibody with half-life of 36 days.14 jeewandara et al. also showed that 4 out of 13 mild covid-19 patients had no detectable neutralizing antibody (nab) at 40 days since illness onset.13 on the other hand, choe et al. showed that antibody against sars-cov-2 was still present at 8 months after asymptomatic or mild covid-19.15 rodda et al. showed that not only antibody but also both memory b and memory t cell persisted at least 3 months after mild sars-cov-2 infection.16 it is important to note that in both choe et al. and rodda et al. not all mild patients had seropositivity, with only 85% and 69.0-91.4%, respectively.15–16 another possible factor for reinfection is the low viral load rahmat azhari kemal acta med indones-indones j intern med 112 during the first episode. kim et al. showed in ferret model, lower viral load in the first episode resulted in lower nab titer which correlated to reinfection when challenged with heterologous virus three weeks after primary infection.17 in both of our cases, low viral load (indicated by high ct-value) during the first episode and low antibody titer (showed by nonreactive rapid antibody test of case #2) might had left them susceptible to reinfection after more than 45 days or 7 weeks from primary infection. our case report also highlights important p u b l i c h e a l t h m e s s a g e s . o u r c a s e s h a d considerably easier testing access therefore could be tested while presenting no or mild symptoms. it is possible that we are missing many reinfection cases with asymptomatic or mild sars-cov-2 infections due to limited access to testing. widespread testing and data management might enable us to observe more possible sars-cov-2 reinfection cases. the current national report system, new all record, has continuous data per personal id number therefore it could be utilized to observe possible reinfection cases. additionally, investment in wgs platform, especially automated platform will surely be beneficial to confirm reinfection cases during current covid-19 pandemic. adaptation of routine whole genome sequencing in public health laboratory will support epidemiological analysis to detect, monitor, and control circulating or emerging pathogens in indonesia.18–19 lastly, as shown by our case report, natural infection might result in varied immune response due to the varied viral load. we will require safe and effective vaccines as well as robust vaccination program to achieve herd immunity against sars-cov-2. conclusion we presented two possible sars-cov-2 reinfection cases from pekanbaru, indonesia. both cases mostly fulfilled us cdc criteria for suspected reinfection, namely presence of typical clinical covid-19 on 2nd episode, rt-pcr with ct-value of less than 33 on 2nd episode, as well as timeframe of more than 45 days between 1st and 2nd episode. one of the cases, case #2, had close-contact while case #1 had epidemiological risk factor as healthcare worker. however, in both cases, no viral rna sequences or viral viability data were obtained. both data are relatively laborious to obtain and not routinely conducted in public health laboratories, hindering many to observe and report (possible) reinfection cases. as reinfection cases could provide better understanding on immunity to sars-cov-2, definition and criteria of sarscov-2 reinfection case are needed to capture and observe such cases. combination of reinfection criteria from cdc10 and yahav et al.11 could be adapted. additionally, in order to fulfill the requirement of wgs data, investment in routine use of automated whole genome sequencing platform in public health laboratories is needed. acknowledgments figures were designed by fajri marindra siregar. we thank members of biomolecular laboratory for insightful discussion regarding this case report. references 1. iwasaki a. what reinfection means for covid-19. lancet infect dis. 2020; (published online oct 12, 2020). doi: 10.1016/s1473-3099(20)30783-0 2. to kkw, hung ifn, ip jd, et al. 2020. covid-19 re-infection by a phylogenetically distinct sarscoronavirus-2 strain confirmed by whole genome sequencing. clin infect dis. 2020; (published online aug 25, 2020). doi:10.1093/cid/ciaa1275 3. tillett rl, sevinsky jr, hartley pd, et al. genomic evidence for reinfection with sars-cov-2: a case study. lancet infect dis. 2020;(published online oct 12, 2020). doi: 10.1016/s1473-3099(20)30764-7 4. van elslande j, vermeersch p, vandervoort k, et al. symptomatic sars-cov-2 reinfection by a phylogenetically distinct strain. clin infect dis. 2020; (published online sep 5, 2020). doi: 10.1093/cid/ ciaa1330 5. prado-vivar b, becerra-wong m, guadalupe jj, et al. covid-19 re-infection by a phylogenetically distinct sars-cov-2 variant, first confirmed event in south america. ssrn. 2020; (published online sep 8, 2020) [preprint]. doi: 10.2139/ssrn.3686174 6. west j, everden s, nikitas n. a case of covid-19 reinfection in the uk. clin med dec. 2020. doi: 10.7861/clinmed.2020-0912. 7. duggan nm, ludy sm, shannon cb, reisner at, vol 54 • number 1 • january 2022 possible cases of sars-cov-2 reinfection in pekanbaru, indonesia 113 wilcox sr. is novel coronavirus 2019 reinfection possible? interpreting dynamic sars-cov-2 test results. am j emerg med. 2021; (published online jul 4, 2020). doi: 10.1016/j.ajem.2020.06.079 8. akram l, khan mhur, iqbal, akram a. a case report of recurrent covid-19 infection of a physician in bangladesh: re-infection or persistence infection? bangladesh j infect dis. 2020;7(suppl 2):s57-s60. doi: 10.3329/bjid.v7i00.50164 9. nachmias v, fusman r, mann s, koren g. the first case of documented covid-19 reinfection in israel. idcases 2020; 22: e00970. doi: 10.1016/j.idcr.2020. 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indones j intern med • vol 50 • number 2 • april 2018 the coexistence of systemic lupus erythematosus and psoriasis: is it possible? hendra gunawan, awalia, joewono soeroso department of internal medicine, faculty of medicine, airlangga university dr. soetomo hospital, surabaya, indonesia corresponding author: prof. joewono soeroso, md., m.sc, phd. division of rheumatology, department of internal medicine, faculty of medicine, airlangga university dr. soetomo hospital. jl. mayjen. prof. dr. moestopo 4-6, surabaya 60132, indonesia. email: joewono.soeroso4@gmail.com; sylvester.gunawan@gmail.com. abstrak lupus eritematosus sistemik (les) adalah penyakit autoimun kronik eksaserbatif dengan manifestasi klinis yang beragam. psoriasis vulgaris adalah penyakit kulit yang menyerang 1-3% dari populasi. patofisiologi mengenai tumpang tindihnya penyakit tersebut belum sepenuhnya diketahui. hal ini menyebabkan adanya tantangan tersendiri dalam tatalaksana kedua penyakit tersebut. dua orang laki-laki dengan les dan psoriasis vulgaris dilaporkan dengan manifestasi klinis eritroderma berulang dengan fotosensitif. perbaikan klinis dicapai setelah terapi kombinasi metilprednisolon dengan metotrexat. adanya les yang tumpang tindih psoriasis vulgaris merupakan suatu fenomena klinis yang langka. hubungan kedua penyakit tersebut dapat berupa saling mendahului atau tumpang tindih pada suatu waktu yang sama dan memiliki hubungan dengan adanya antiro/ssa. adanya tumpang tindih dari dua penyakit tersebut memberikan paradigma baru dalam patofisiologi, diagnosis, dan tatalaksana di masa mendatang. kata kunci: lupus eritematosus sistemik, psoriasis vulgaris, psoriatic artritis, overlap syndrome. abstract systemic lupus erythematosus (sle) is a chronic autoimmune disease with various clinical disorders and frequent exacerbations. psoriasis vulgaris is a common skin disorder which affect 1-3% of general populations. the pathophysiology regarding the coexistence of these diseases is not fully understood. therapeutic challenges arise since the treatment one of these diseases may aggravate the other. we reported two cases of sle with psoriasis vulgaris with clinical manifestations as recurrent erythroderma with photosensitivity. improvement in clinical condition was observed after treating the patients with methylprednisolone combined with methotrexate. the coexistence sle and psoriasis are considered very rare. the presence of this overlap syndrome may precede one another or occur simultaneously and is closely related with the presence of anti-ro/ssa. thus, it raises new challenge regarding its relationships, diagnosis, therapeutic, and management. keywords: systemic lupus erythematosus, psoriasis vulgaris, psoriatic arthritis, overlap syndrome. 145 vol 50 • number 2 • april 2018 the coexistence of sle and psoriasis: is it possible? introduction systemic lupus erythematosus (sle) is a chronic exacerbative autoimmune disease with various clinical disorders. cutaneous manifestations are frequent in sle, as much as 70-80% patients develop skin lesions during the disease progression and approximately 20% of sle patients have skin lesions as initial presentation. cutaneous manifestations in sle can be divided into acute, subacute, and chronic cutaneous lupus erythematosus (ccle). the most common cutaneous manifestations are malar rash, photosensitivity, discoid lesions, and alopecia. other manifestations such as raynaud phenomenon, livido reticularis, panniculitis, bullous lesions, vasculitic purpura, and urticaria may be related but not specific to sle.1,2 subacute cutaneous lupus erythematosus (scle) distribution is more extensive than chronic cutaneous lupus erythematosus. scle also has the tendency to spare the face with minimal or no scarring. the most common types are papulosquamous and annular polycyclic lesion. other scle presentations such as erythroderma, erythema multiforme, toxic epidermal necrolysis like lesion (rowell syndrome), and generalized poikiloderma are uncommon and considered as rare type of scle.3,4 majority of patients with scle are associated with anti-ro antibodies but only 50% of patients meet criteria for sle. patients with scle usually have mild systemic symptoms with arthritis and myalgia are the most common symptom. other more severe symptoms such as lupus vasculitis, cns lupus, and nephritis are scarce and only occur in less than 10%.2 psoriasis vulgaris is a skin disease which a ff e c t s a p p r o x i m a t e l y 1 3 % i n g e n e r a l population.5 it is a chronic inflammatory skin disease. inflammatory arthritis is a common clinical manifestation in psoriasis patient, approximately affecting 25% psoriasis pasien. it affects both men and women equally and at the age of 30-50 years old. psoriatic arthritis (psa) is a seronegative spondyloarthritis due to the potential of axial joint involvement and enthesitis as its pathogenesis. the presentation is variable and can range from mild to debilitating, erosive arthropaty.6 the coexistence of sle and psa is very rare with a prevalence of 0.6%.7 psoriasis generally precedes the sle. phototherapy which is common management in patient with psoriasis may act as a trigger for sle. common problems are diagnostic problem and therapeutic management as sle is a seropositive arthritis while psa is a seronegative arthritis, and hydroxychloroquin as well as systemic corticosteroids may exacerbate psoriasis.8 therefore, we reported a case series of patients with psoriatic-like skin lesion presenting as erythroderma. case illustration case 1 a 45-year-old male came into the emergency department with persistent scaling and redness of the skin. history taking revealed persistent scaling and redness of the skin had occurred since 7 months before. scaling of the skin was preceded by redness, and skin eruptions in extensor area of extremities. history of taking antibiotics, non-steroid anti-inflammatory drugs, and pain killer drugs was not reported. there were no constitutional symptoms like fever, fatigue, nausea, shortness of breath, vomiting, and weight loss. he was anxious about his medical condition and had insomnia since 2 months before. joint pain was felt on both hands, fingers, and knees. previous medication history revealed the presence of psoriasis vulgaris based on skin biopsy which did not improve with methotrexate 15 mgs weekly, type 2 diabetes mellitus with insulin, and depression. he worked as an officer in a construction company and had a history of photosensitivity with sun exposure. family histories of psoriasis and connective tissue diseases were negative. physical examination revealed a fully alert with normal, vital signs, thorax, and abdominal examinations. extremities examinations revealed the presence of joint swelling without tenderness in pip and dip i-ii-iii-iv-v, as well as bilateral knees. erythroderma presenting as generalized maculae with squamae was evident in ≥10% of his body surface area (bsa) (figure 1). psoriatic nail was evident in fingers and toes. laboratorium parameter showed hemoglobin 146 hendra gunawan acta med indones-indones j intern med 13.5 g/dl, leukocytes 13.14 µ/l, neutrophils 62.3%, platelets 345 µ/l, albumin 2.86 g/dl, fasting glucose level 200 mg/dl, 2-hours post prandial glucose level 315 mg/dl, and low level of potassium 3.0 meq/l. renal and liver function tests are within normal limit. immunology parameter revealed ana test was positive 1:151.4, ana profile showed the presence of anti ro/ssa (ro-52 recombinant), rheumatoid factor, and igm anti mcv. radiology examination revealed seagull appearance in pip and dip joints in both sides of hands (figure 2), degenerative disease of the spine without sacroilitis. skin biopsy revealed the presence of elongated rete ridges, parakeratosis, acanthosis concurrent with psoriasis. his dermatology life quality index (dlqi) score was 24. systemic lupus erythematosus (sle) and psoriatic arthritis were diagnosed in this patient based on slicc criteria which showed the presence of depression, skin lesion, skin rash (erythroderma), arthritis, along with the presence of ana and anti ro/ssa as the immunology criteria, sle and psoriatic arthritis were assessed in this patient. pulse dose of 500 mg methylprednisolone was administered in 3 days, methotrexate 15 mg po/weekly along with folic acid supplementation and basal bolus insulin regimen. intravenous methylprednisolone was tapered to 1 mg/kgbw after pulse dose. scaling of the skin was improved there was no new episode of scaling, and joint pain was improved by the 6th day after pulse dose of methylprednisolone. he was discharged from hospital with methylprednisolone, methotrexate, basal bolus insulin, and education about his current condition. case 2 a 79-year-old male came into emergency department with scaling of the skin since 3 days ago. he had a history of generalized erythematous lesion 3 weeks before admission. scaling of the skin was preceded with redness and itch in all areas of his body. constitutional symptoms like fever, dyspnea, and joint pain was reported. joint pain in both knees, fingers, and toes were reported since 4 months ago. morning stiffness were also felt for 40 minutes. history of photosensitivity, recurrent painless oral thrush since 6 months ago were reported. there was no history of weight loss, nausea, vomiting, nor diarrhea. skin biopsy revealed the presence of psoriasis vulgaris. he is a retired clerk, with 9 children spent his time mostly by gardening. there was no family history of autoimmune nor metabolic diseases. figure 1. physical appearance of the patient. the right side showed the presence of psoriatic nail with erythematous maculae and squamae. figure 2. the presence of seagull-like appearance showed the evidence of psoriatic arthritis in both hands figure 3. the presence of generalized erythroderma in this patient 147 vol 50 • number 2 • april 2018 the coexistence of sle and psoriasis: is it possible? physical examination revealed the presence of edema in bilateral pretibial. dermatological examination revealed the presence of auspitz’s sign and erythroderma in ≥10% bsa (figure 3). laboratory parameter showed hemoglobin 11.5 g/dl, leukocytes 8,500 µ/l, neutrophils 45%, eosinophils 11.9%, lymphocytes 51%, platelets 42,000 µ/l, albumin 2.9 g/dl, crp 80 mg/dl, ast 44 iu/l, and alt 65 iu/l. his ana-if revealed the nucleoplasm speckled pattern ≥1:1000, cytoplasmic homogenous 1:100, whereas anti ro/ssa was negative. bilateral knee x-ray examinations revealed the presence of bilateral entesopathy (figure 4) and gull wing appearance in both pip ii-iiiiv-v. his dlqi score was 7. based on his age, the presence of, skin rash, thrombocytopenia, arthritis, photosensitivity, and ana-if, sle was assessed in this patient. therefore, sle + psoriatic polycyclic plaques. other forms, such as erythroderma, erythema multiforme-like lesions, and generalized-poikiloderma may occur and regarded as a rare type of scle.3 the presence of scle is closely associated with the presence of anti-ro/ssa.9 the key mechanism in sle is the production of autoantibodies which are produced by polyclonal b cell activation or autoantigen directed immune stimulation. several factors such as genetic, environmental, and hormonal factors are the trigger of sle.10 the presence psa is approximately 25% in patients with psoriasis. it is characterized by stiffness, pain, swelling, and tenderness of the joints as well as surrounding areas, such as ligaments and tendons. it affects both male and female equally and typically presents at the age of 30 to 50 years. the presence of cutaneous symptoms usually precedes the onset of psa. it is considered as a seronegative spondyloarthritis. the clinical manifestasions ranges from mild arthritis to severe, debilitating, and erosive arthropathy.6,11 imaging examinations such as conventional radiography, computed tomography, magneting resonance, skeletal scintigraphy, positron emission tomography, and fluoroscopic optical imaging are helpful in making diagnosis, evaluating, and monitoring disease progression. conventional radiography may reveal the combination of destructive changes such as erosions, tuft resorption, and osteolysis with bone proliferation including periostitis, ankulosis, spur formation, as well as non-marginal syndesmophytes. though less sensitive than the others, conventional radiography remains highly specific compared to ct in detection of joint erosions.12 the etiology and pathogenesis of psoriasis are not yet understood, but it is thought to be a multifactorial disease comprises of genetic disposition and environmentalrisk factors which act as trigger factors, such as stress, trauma, infections, and drugs. psoriasis shares both immunologic and genetic risk factors with other autoimmune diseases such as rheumatoid arthritis (ra) and sle. the role of novel cd4 t effector cells (th17) plays an important role in autoimmune inflammatory response. the main cytokines secreted by th17 is il-6, il-17, ilfigure 4. the presence of entesopathy bilateral. arthritis was assessed in this patient. supportive treatment was given due to recent pneumonia and older age. intravenous methylprednisolone 1 mg/kgbw was administered for 7 days and methotrexate 10 mg/weekly. upon treatment, symptoms were gradually improved including no new rash, increased platelets (68,000 µ/l) and he was discharged after 10 days of hospitalization. discussion subacute cutaneous lupus erythematosus clinical manifestations occurred mostly in females. its lesions present with erythematous macules and papules that evolve into scaly papulosquamous (psoriasiform) or annular/ 148 hendra gunawan acta med indones-indones j intern med 21, and il-22. keratinocytes hyperproliferation is induced by il-21 and il-22. thus, the current postulate that in a genetically predisposed an unknown stimulus are needed on epidermal keratinocytes to produced tumor necrosis factor (tnf)-a, interferon (ifn)-a, and ifn-g. these mediators will activate dendritic cells and induce the differentiation of naïve t cells into th1 and th17 which would migrate to skin, acting as antigen presenting cells and releasing cytokines, such as tnf-a, ifn-g, il-23, il-22, and il17. those cytokines induced proliferation of keratinocytes and alter their maturation, resulting the epidermal hyperproliferation, together with inflammatory t cell infiltration are the fundamental basis psoriatic lesions.10 the presence of sle and psoriasis itself is very rare. the association between these two disease is not yet fully understood even though there should be the trigger that induce the development of both diseases.13 it is known that t cells play a central role in the development of psoriasis whereas b cells do in sle. this fact leads to the view that superantigens might be the common mediator, but it is known that alterations of th17 may occur in both diseases. the presence of il-17 and il-23, cytokines which are produced by th17 subset play a role to the renal damage in sle patients.10 the onset of both diseases might precede one another or occur simultaneously in a person. patients with overlap syndrome of sle and psoriasis have an increased risk for photosensitivity which was evident in both cases.5,13 the presence of sle and psoriasis raises question about how to diagnose both diseases. the coexistence of these diseases is associated to ana and anti-ro/ssa (52-recombinant). cozzani et al.14, reported that ana was present in 98% sle patients and 57% psoriasis patients. anti-ro/ssa’s presence were reported in psoriasis and sle. silvy et al.15, reported that anti-ro/ssa was present in 3 out of 200 psoriasis cases, whereas johnson et al, reported its prevalence was 2% in biologically agent naïve psoriatic arthritis patients. anti-ro/ssa’s presence was also reported in sle patients. cozzani et al.14, reported its prevalence was 80% in scle patients, another report by lopez-longo et al.16, showed that anti-ro/ssa was detected in 88% patients with scle.9,14-17 though antibodies to ro/ssa was pivotal in the diagnosis of sle and psoriasis, some cases reported with this overlap syndrome reported the absence of antibody to ro/ssa antibody. thus, detailed medical history taking, including the history of previous medication, photosensitivity, and other constitutional symptoms must be done meticulously.10 histologic examination, serology, and immunofluorescence test (lupus band test) are useful to search for the deposit of immunoglobulin and complement components in dermoepidermal junction which is seen in sle patients. the most frequent immunoglobulin class deposited is igm, seen in 90% of lesional skin biopsies. it is helpful in diagnosing scle or chronic lupus cutaneous from other type of sle since it is only positive in skin lesion. the disadvantages are the presence of antibody is found in 60-100% biopsy samples and its wide range of sensitivity (10.5-78.9%) as well as specificity (47.8-97.8%) depending on the criteria used.18,19 we thought there was a strong indication to perform lupus band test to confirm sle diagnosis in both cases, but we could not do that due to lack of equipment. therefore, we diagnosed scle in case 1 based on refractory erythroderma which was unresponsive to psoriasis medication. thrombocytopenia can be found in psoriasis patient after receiving anti-tnf therapy, and case 2 was naïve to psoriasis medication.20 therefore, based on his age, thrombocytopenia, arthritis, photosensitivity, and ana test, we diagnosed this patient with sle and psoriasis. the coexistence of these diseases raises question about the management to control both diseases simultaneously. the control of sle requires the administration of systemic corticosteroid, especially in sle with renal or central nervous system involvement. failure in corticosteroid tapering may induce rebound flare of psoriasis or psoriatic erythroderma. phototherapy though favorable for psoriasis in most cases must be put into consideration as it can trigger sle flare. antimalarial agents which widely used in cutaneous and joints manifestations may aggravate or precipitate 149 vol 50 • number 2 • april 2018 the coexistence of sle and psoriasis: is it possible? psoriasis. patients with cutaneous sle who develops psoriasis after the administration of antimalarial agents should be evaluated for the possibility of drug-induced psoriasis.10,13 biologic agents, like etanercept or infliximab may be used to control psoriasis but its adverse effect such as anti-tnfa induced lupus (atil) must be considered. though reversible through withdrawal of therapy, the clinical manifestations may involve renal and central nervous system. systemic corticosteroids or immunosuppressants often needed to control moderate-to-severe psoriasis. moderate-to-severe psoriasis is defined as the presence of skin lesion >10% bsa and dlqi score >10. glucocorticoid pulse is indicated in severe psoriasis.21,22 methotrexate is the only agent that is known successfully treating the coexistence of these diseases. in our cases both patients were administered systemic corticosteroids.10 we administered pulse dose of 500 mg intravenous methylprednisolone in case 1 because of the severe psoriasis which presented as recurrent generalized erythroderma in ≥10% of his bsa and dlqi score was 25. we did not administer pulse dose of corticosteroids to case 2 because he was an elderly patient and the history of recent infection. therefore, we used intravenous methylprednisolone 1 mg/ kgbw with close monitoring to the platelet counts. methotrexate was given to both cases. the clinical condition of case 1 improved dramatically after pulse dose of corticosteroids and methotrexate 15 mg/weekly. there was no new rash and he could resume his daily activities. patient in case 2 had a worse prognosis because of his age and many comorbid factors, such as history of infection in previous hospital admission. conclusion it has been reported a case series of coexistence of sle and psoriasis with erythroderma as its manifestation. the coexistence of both diseases is rare and poses new challenge in discovering its relationships, therapeutical management, and education. the presence of this overlap syndrome may precede one another or occur simultaneously and is closely related with the presence of anti-ro/ssa. lupus band test is helpful to search for immune complex deposition in skin lesion. therapeutic challenges occur in which suppression of sle activity with corticosteroids or antimalarial agents may aggravate or precipitate psoriasis and phototherapy or biologic agents may trigger sle flare. thus, proper history taking should be performed in order to diagnose this rare phenomenon and giving comprehensive managements are key to suppress the acitivities of both diseases. competing interest the authors declare that there is no conflict of competing interest regarding the publication of this article. acknowledgments we acknowledge poernomo boedi setiawan, dr. sp.pd-kgeh as the head of internal medicine department of airlangga university for giving us permission to manage and write this case report. we also acknowledge all staffs in our department for the support given to us. references 1. cojocaru m, cojocaru im, silosi i, doina c. manifestations of systemic lupus erythematosus. j clin med. 2011;6(4):330-6. 2. okon lg, werth vp. cutaneous lupus erythematosys: diagnosis and treatment. best pract res clin rheumatol. 2013;27(3):391-404. 3. mutasim df. severe subacute cutaneous lupus e r y t h e m a t o s u s p r e s e n t i n g w i t h g e n e r a l i z e d erythroderma and bullae. j am acad dermatol. 2003;48(2):947-9. 4. pai v, naveen k, athanikar s, dinesh u, reshme p, divyashree r. subacute cutaneous lupus erythematosus presenting as erythroderma. indian j dermatol. 2014;59(6):634-8. 5. avriel a, zeller l, flusser d, abu shakra m, halevy s, sukenik s. coexistence of psoriatic arthritis and systemic lupus erythematosus. israel med assoc j. 2007;9(2):48-9. 6. lloyd p, ryan c, menter a. psoriatic arthritis: an update. arthritis. 2012:1-7. 7. dubois e. lupus-specific skin disease. dubois’ lupus erythematosus. 2nd edition. in: wallace dj, hahn bh, eds. los angeles: university of southern california press; 1974. p. 559-64. 8. berthelot c, nash j, duvic m. coexistent psoriasis 150 hendra gunawan acta med indones-indones j intern med and lupus erythematosus treated with alefacept. am j clin dermatol. 2007;8(1):47-50. 9. kuhn a, sontheimer r, ruzicka t. clinical manifestations of cutaneous lupus erythematosus. cutaneous lupus erythematosus. first edition. in: kuhn a, lehmann p, ruzicka t, eds. heidelberg: springerverlag berlin. 2005. 10. cuesta ml, i b. connective tissue diseases and psoriasis. actas dermo-sifiliograficas. 2011;102(7):487-97. 11. boehncke w, qureshi a, merola j, et al. diagnosing and treating psoriatic arthritis: an update. british j dermatol. 2014;170(1):772-86. 12. aleo e, migone s, prono v, barbieri f, garlaschi g, cimmino ma. imaging techniques in psoriatic arthritis: update 2012−2014 on current status and future prospects. j rheumatol. 2015;93(1):53-6. 13. pramatarov k, tsankov n. association of cutanous lupus erythematosus with other dermatological diseases. cutaneous lupus erythematosus. first edition. in: kuhn a, lehmann p, ruzicka t, eds. heidelberg: springer-verlag berlin; 2005. 14. cozzani e, drosera m, gasparini g, parodi a. serology of lupus erythematosus: correlation between immunopathological features and clinical aspects. autoimmune diseases. 2014;1:1-13. 15. silvy f, bertin d, bardin n, et al. antinuclear antibodies in patients with psoriatic arthritis treated or not with biologics. plos one. 2015;10(7):e0134218. 16. lopez-longo f, monteagudo i, gonzalez c, grau r, carreno l. systemic lupus erythematosus: clinical expression and anti-ro/ss&mdash; a response in patients with and without lesions of subacute cutaneous lupus erythematosus. lupus. 1997;6:32-9. 17. johnson s, schentag c, gladman d. autoantibodies in biological agent naive patients with psoriatic arthritis. annals rheum dis. 2005;64:770-2. 18. meurer m. immunopathology of cutaneous lupus erythematosus. cutaneous lupus erythematosus. first edition. in: kuhn a, lehmann p, ruzicka t, eds. heidelberg: springer-verlag berlin; 2005. 19. reich a, marcinow k, birula-bialynicki r. the lupus band test in systemic lupus erythematosus patients. ther clin risk manag. 2011;7:27-32. 20. balato n, gallo l, gaudiello f, chiurazzi f, ayala f. transient and reversible thrombocytopenia in a psoriatic patient treated with etanercept. j dermatological treatment. 2010;21:117-8. 21. mrowietz u, kragballe k, reich k, et al. definition of treatment goals for moderate to severe psoriasis: a european consensus. arch dermatol res. 2011;303:110. 22. sinha a, bagga a. pulse steroid therapy. indian j ped. 2008;75(1):1057-66. 331 original article acta med indones indones j intern med • vol 51 • number 4 • october 2019 intact glycocalyx of intestinal mucosa in intraabdominal infection: an investigation using blood group antigen toar j. m. lalisang1, mohamad sadikin2, ridho a. syaiful1, novi s. hardiany2, yefta moenadjat1 1 department of surgery, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of biochemistry and molecular biology. faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: toar jm lalisang, md, phd. department of surgery, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: toar.m@ui.ac.id. abstrak latar belakang: glikokaliks usus berperan pada patogenesis translokasi bakteri penyebab sepsis yang berasal dari infeksi intraabdomen. kondisi ini rentan terjadi pada golongan darah tertentu. namun, sejauh ini belum diketahui hubungan antara glikokaliks usus pada golongan darah tertentu dengan infeksi intraabdomen. penelitian ini bertujuan mengetahui kondisi glikokaliks usus pada sepsis intraabdomen pada golongan darah tertentu. metode: penelitian deskriptif melibatkan subjek infeksi intraabdomen yang menjalani laparotomi. sampel berupa spesimen usus. dilakukan pengukuran ekspresi glikokaliks usus dengan metode elisa menggunakan antigen golongan darah (a dan b). data ekspresi pada sekretor dianalisis menggunakan uji kolmogorov–smirnov dilanjutkan dengan komparasi parametrik menggunakan anova dan uji–t. hasil: terdapat 32 subjek dengan infeksi intraabdomen yang diteliti pada studi ini. seluruhnya berstatus sekretor serta mengeskpresikan antigen a dan b dengan kuat. tidak ada perbedaan antara infeksi intraabdomen dengan komplikasi maupun tanpa komplikasi. golongan darah o merupakan golongan darah yang dominan pada subjek (43,8%). eschericia coli merupakan mikroba yang paling sering didapatkan (61,3%). kesimpulan: penelitian ini menunjukkan tidak terjadi kerusakan glikokaliks pada usus pasien sepsis akibat infeksi intraabdomen. kata kunci: glikokaliks, infeksi intraabdomen, golongan darah. abstract background: intestinal glycocalyx plays a role in bacterial translocation as the pathogenesis sepsis derived from intra-abdominal infections that vulnerable in certain blood types. however, the link between intestinal glycocalyx in specific types of blood groups and abdominal infections remains unknown. this study aims to find out the condition of intestinal glycocalyx in certain blood types with intraabdominal sepsis. methods: descriptive study involved subjects with intraabdominal infections who underwent laparotomy. samples are in the form of intestinal specimens. the measurement of intestinal glycocalyx proceeded by the elisa method using blood group antigens (a and b). expression data on the secretors were analyzed using the kolmogorov – smirnov test followed by parametric comparisons using anova and t-tests. results: there were 32 subjects with intra-abdominal infections studied in this study. all of them are secretors and express a and b antigens strongly. we found no difference between intraabdominal infections in those with complications or without complications. blood type o is a predominant blood type found (43.8%). escherichia coli is the most commonly found microbe in the culture (61.3%). conclusion: this study shows there is no disrupted intestinal glycocalyx of sepsis patients caused by intraabdominal infection. keywords: glycocalyx, intraabdominal infection, blood type. toar j.m. lalisang acta med indones-indones j intern med 332 introduction i n t h e p a t h o g e n e s i s o f g u t d e r i v e d (abdominal) sepsis (recently attributed to intraabdominal infection), there are two main problems encountered and addressed in the clinical practice. the first issue is the phenomenon of bacterial translocation. intraabdominal infection following gut perforation (or, complicated intraabdominal infections, ciai) is a logical consequence. however, in the non–perforated viscus (non-complicated intraabdominal infections, or simply intraabdominal infections, iai) – known as bacterial translocation – remains a mystery that needs more evidence.1–3 recent studies showed that disrupted tight junctions that play an essential role in maintaining the intestinal mucosal barrier is responsible for the translocation. the second issue is sepsis that identified in patients with blood type o of the abo blood typing system. studies showed that blood group o is prone to a particular disease while the other blood group not. our preliminary study showed that sepsis develops in subjects with blood group o comprise of 46.69% out of 213 subjects diagnosed as complicated intraabdominal infections. in contrast, blood type a was 24.66%, and blood group b 26.87%.4 the phenomenon may clearly describe through the better knowledge of identified blood type antigen in the tissues other than blood cells (namely, secretor), using the blood typing system of the non–abo system. the essential secretor of the blood type is glycocalyx of the gastrointestinal tract, as well as intestinal mucosa. glycocalyx has a core peptide that binds the amino acid residues to the host’s glycans. 5 the core peptide comprises either glycosylation–o that binds oxygen or glycosylation–n that binds other amino acids. the core peptide is found differently in each blood group.6 this distinctive characteristic leads to different susceptibility to certain conditions, including sepsis.7 while disintegrated endothelial glycocalyx paralleled to endothelial dysfunction found in sepsis, the course of intestinal glycocalyx remains unclear. to find out the answer, we investigated the glycocalyx in the intestinal mucosa in specific blood types in those diagnosed as intraabdominal infection (both in iai and ciai). methods the investigation proceeded in intestinal and blood specimens taken from subjects who diagnosed with an intraabdominal infection that underwent a surgical procedure in 2017. the diagnosis based on the findings: sepsis syndrome with gi perforation (ciai) and with no perforation (iai). primary peritonitis, particularly abdominal tuberculosis, and those who are not the candidate for gut resection, and pediatrics excluded. the subjects enrolled consecutively as he/she agreed to be enrolled and signed the consent. the subjects’ characteristics, namely, age, gender, and diagnosis recorded. blood specimens taken for some tests, particularly blood typing and peripheral blood count. intraoperatively, gut specimens taken for investigation purposes — the samples subjected to mucin analysis for the expression of antigen a and b of blood group and bacterial culture to find out the microbial pattern. intestinal mucosa scraped and subjected to the investigation for the concentration of protein in glycocalyx. for elisa purposes, we used anti a serum (blood group a antigen monoclonal antibody, human, thermo fisher, catalog he– 193) and anti b serum (blood group b antigen monoclonal antibody, human, thermo fisher, catalog 89–f) and secondary antibody goat anti–mouse igg (h+l) secondary antibody, hrp (thermo fisher, catalog 31430). antigen expression on elisa expressed in % intensity with reference of abo blood group (transferase a, alpha 1–3–n–acetylgalactosaminyltransferase; transferase b, alpha 1–3–galactosyltransferase) of a homosapiens is 0.472813 (data glycocalyx gene set).8 data descriptively presented in two categories i.e., subjects with perforation and those not. the analysis preceded with a distribution test for numerical one using kolmogorov smirnov, a normal distribution defined as p-value >0.05. binary data expressed in mean (sd) and categorical data presented in the table describing the frequency in percentage. statistical analysis proceeded using a parametric compare of two means, namely anova and non–parametric t-test. vol 51 • number 4 • october 2019 intact glycocalyx of intestinal mucosa in intraabdominal infection 333 the committee of ethics faculty of medicine, universitas indonesia approved the study no.104/un.f1/etik/2017 and the permission to conduct a study from research bureau of dr. cipto mangunkusumo general hospital no.lb.02.01/x.2/66/2017. results thirty–two subjects met the criteria enrolled in the study. all subjects treated empirically using intravenous aminoglycoside (namely gentamycin sulfate 80 mg b.i.d.) and metronidazole 1,500 mg b.i.d. subjects’ characteristics presented in table 1. found was escherichia coli (19 subjects, 61.3%), klebsiella pneumonia (5 subjects, 15.2%), pseudomonas aeruginosa (2 subjects, 6.1%) bacteroides fragilis (2 subjects, 6.1%), and acinetobacter (1 subject, 3%). besides, candida albicans also found (2 subjects, 6.1%). bacterial growth on the disc found in both ciai (11 subjects, 35.48%) and iai (21 subjects, 67.74%). the difference between the two groups showing p = 0.119 ci 95% (-0.373-3.145). table 1. subjects’ characteristics in the study (n = 32) demographic characteristics total gender*, n (%) males 18 (56.2) females 14 (43.8) age (mean (sd)), years 52.3 (12.7) blood type*, n (%) a 10 (31.2) b 8 (25.0) ab 0 (0.0) o 14 (43.8) blood tests, mean (sd), cells/mm3 leukocytes 15,223 (5,702) platelet 343,748 (163,634) in the pathology point of view, gi infection, and the bowel obstruction found of most. the abdominal pathology both of gi– and non–gi origin presented in table 2. bacterial culture (n = 31) were monomicrobial (7 subjects, 22.6%) and polymicrobial (24 subjects, 77.4%) with the commonest bacteria table 2. intraabdominal pathology in the study (n = 32) abdominal pathology n (%) gi origin 29 (90.6) gut perforation (ciai) 11 (34.4) perforated appendicitis, perforated ileum, and perforated colon non– perforation (iai) 21 (65.6) gi obstruction non–gi origin 3 (9.4) perforated uterus pelvic abscess table 3. expression of antigen a and antigen b in the study (n = 32) antigen expression p value normal 0.472813 (glycocalyx gene set) antigen a, mean (sd) 2.33 (1.374) 0.467 antigen b, mean (sd) 1.77 (1.334) on the study of antigen expression (n = 32), namely antigen a (using anti–a serum) and antigen b (using anti–b serum), all subjects (100%) expressed both antigens; denoting all subjects were the secretors. in the study, we found both antigen a and b were strongly expressed in most subjects (n = 32); indicating the oligosaccharide complex constructing the glycans was intact. using anova test proceeded to find out the difference between ciai (n = 11) and iai group (n = 21), we found p = 0.130 for antigen a and p = 0.250 for antigen b; although box–whisker plot graphic showing the antigen expression in ciai group a little bit stronger than those of iai subjects (figure 1). using independent samples test, we found there was no significant correlation of antigen a and b with ciai and iai; there’s no significant difference found. table 4. antigen expression between ciai and iai group n mean (sd) p value antigen a ciai 11 1.5435 (0.59473) 0.130 iai 21 1.2928 (0.32272) antigen b ciai 11 1.4246 (0.45230) 0.250 iai 21 1.2775 (0.26075) toar j.m. lalisang acta med indones-indones j intern med 334 discussion the important findings in the study never been reported. firstly, strong expression of antigen means an intact glycocalyx found both in iai group (representing the theory of bacterial translocation) and perforated group as well. secondly, using immune enzyme method we were unable to identify tissue blood type, but the secretor. in the study we found the dominant blood type in intraabdominal infection was blood type o, and the dominant bacteria found to translocated escherichia coli, which is the commensal bacteria in the gi. a study showed disrupted endothelial glycocalyx in sepsis, which identified through an investigation under hematoxylin-eosin stained specimens.9,10 there is plenty of research that showed disrupted endothelial glycocalyx in sepsis, including those correlated to the fluid management in sepsis.10 however, the intestinal glycocalyx has distinctive characteristics to endothelial. the mucin domain of the glycocalyx integrates with the deeper mucus layer on the mucosal surface and interacts with the bacterial residence, i.e., commensal bacteria. this deeper mucus layer contains mucin (produce of goblet cells), and antimicrobial peptide (produce of paneth cells), together with commensal bacteria, protects against pathogenic bacteria.11 it is known that the peptidoglycans of the glycocalyx consist of core peptides where the amino acids residues bound to glycans in two types, namely oxygen–linked glycosides (or, o–glycosylation) or n–glycosides (or, n–glycosylation) which are found differently in each blood type.12 this specific characteristic leading to different susceptibility to a certain disease,13 including sepsis. glycans are the contact site of microbes to the host cell, and the microbes take the energy required for metabolic activity, to grow and develop.7 the interaction between microbes and host proceeds in glycans that linked to o (namely, o–linked glycans)12 that contact to lectins in bacteria (hemagglutinins, ligands, adhesins).14 the secrets (enzymes) released by the bacteria were able to modify glycosylated glycans in the mucin bound the ligands, and uptake and utilizes glucose for the microbial metabolic purposes. the interaction between microbes and mucus layers allowing a prolonged colonization.15 normally, those of pathogenic remain in the superficial layer. however, changes in the luminal atmosphere such as antibiotics let the pathogenic invades the deeper layer.16,17 the flagella, the representative of microbial virulence contact to the glycocalyx. this contact is leading to disruption of glycocalyx results in a defect of signals transducing to the epithelial cell-tocell junctions. the molecules of the junction found disassembled, and the barrier is no longer maintained; formerly attributed to intestinal hyperpermeability. the micro molecules may migrate across the barrier.18,19 the above paragraphs explain the bacterial translocation focused on bacterial virulence, as many studies do. however, to date, the figure 1. box–whisker plot graphic showing antigen expression in iai and ciai group. it is shown that the expression in the ciai group is slightly stronger than iai even though outliers were found in both of groups; statistically, this difference was not significant. vol 51 • number 4 • october 2019 intact glycocalyx of intestinal mucosa in intraabdominal infection 335 pathophysiology of bacterial translocation remains unclear. most believe it as a phenomenon rather than a true pathology.20 in addition to limited study focused on the exact mechanism of bacterial translocation that remain scanty, studies on intraabdominal sepsis continue focused on the virulence of various bacteria, the microbial resistance, and the effort to find out the superior antibiotic.21 one may have difficulty to explain how the bacteria may spread across the barrier with an intact glycocalyx. there was a thought that glycocalyx of the intestinal mucosa in those of blood type o recognizes the antigens of the intestinal microbes let the microbes crossing the mucosal barrier with no host’s immune response. whereas, when the antigen is not recognized, then the inflammatory response may lead to an excessive one, as found in the sepsis, which is destructive. to this thinking, we carried out the study focused on blood types approach. glycans associated o referred to the structure rolled as the secretor of blood types. both of antigen a and antigen b expressed on glycocalyx of intestinal mucosa of the secretor and blood group ab. otherwise, these antigens not expressed in non–secretor and blood group o.22 the critical thinking is to distinguish blood group o to the non–secretor in non–expressed antigens; however, a more evidence is required. our findings showed these antigens expressed in all subjects (100%) denoting all these subjects were the secretor, while the previous study showed only 70% of the population.23,24 theoretically, the carbohydrate-based antigens that have been identified as histo–blood group antigens (hbga), blood group abh and lewis antigen also expressed in red blood cells are also expressed in other cells.25 those other cells attributed as the secretor. known secretors are the epithelium and endothelium. all epithelium throughout the body is the secretor, except the epithelium covering the cerebrospinal fluid. the last-mentioned epithelium found in the form of soluble oligosaccharides. various pathogens use histo–blood groups antigen to be attached to the host cells. studies show that this pathogen– hbga relationship promotes the different antigens currently known.24,25 each individual has a variety of active glycosyltransferases. this variation is leading to a different oligosaccharide expression in the tissue. among the epithelial of rolled as the secretors, mucin–coated glycocalyx in the gi epithelium known to be the most hbga contained hbga. the study of marionneau (2000) showed that the h antigen in the blood group abh, which is a characteristic possessed by blood group o (of the abo blood group system), might change antigen a or b antigen through the role of glycosyltransferases a or b. abh and antigen precursors were able to let fucosylated of glcnac (glycans) and forming lewis antigen. fucosyltransferase secretor/ fut2 (small intestines) will be added resembling fucose secretor. this enzyme found in the secretors.26 in this study, all subjects were the secretor and exposed to intraabdominal infection. the infection was proven by the evidence of growing escherichia coli (61.3%) in culture media taken from the peritoneum; beyond the lumen. this evidence, however, should be elaborated and critically appraised. firstly, this finding did not eliminate the possibility that those of non–secretor is free from a potential to have an intraabdominal infection, because there were all the secretor has no control in this study. secondly, those with blood o type were not the only ones who experienced intraabdominal infection, even though those with o type were found dominant (43.8%). investigation using this immune enzyme method is different from the current qualitative procedure using hemagglutination to identify blood type in tissues (i.e., secretors). 8,27 the technique is quite challenging. despite encountering optimation procedures that took plenty of time, detection of the antigen expression referred to challenging one, because any value regarding the standard threshold should be obtained and set as the reference point.8 a total of thirty–two subjects showing a strong expression (mean 1.374 and 1.77 for antigen a and b, respectively) or in another word 2.9 times (antigen a) and 3.7 times (antigen b) to normal. the small-sized and inequality of samples was the limitation of the study; good candidates unwilling to be enrolled in the study; no resection indicated was the characteristic of problems toar j.m. lalisang acta med indones-indones j intern med 336 in surgical research. other limitations in this study, including 1) the blood group test that not carried out simultaneously, even though the same serum used; thus, might lead to a bias. 2) the study on saliva using the same antigen, which proposed early, was found unable to be proceeded due to constraining. finally, no study on histomorphology carried out. on the other hand, the authors believe that this study, which focused on glycocalyx on the intestinal mucosa, has not been ever studied, expected to encourage future studies. conclusion in intraabdominal infection, the glycocalyx was intact showing bacterial translocation without disrupting the barrier. however, the link with blood type could not be explained in this study. conflict of interest the authors declare no conflict of interest. acknowledgments a great appreciation for the director of cipto mangunkusumo general hospital for operational grant 2017. references 1. sartelli m, catena f, abu-zidan f, ansaloni l, biffl wl, bormeester ma, et al. management of intra-abdominal infections: recommendations by the wses 2016 consensus conference. world j surg. 2017:12(22)1-31. 2. macfie j. current status of bacterial translocation as a cause of surgical sepsis. br med bull. 2004;71:1-11. 3. deitch ea. bacterial translocation or lymphatic drainage of toxic products from the gut: what is important in human beings? surgery. 2002;131(3):241-4. 4. robby rdk, moenadjat y. correlation between blood types and intraabdominal infection: a preliminary study. new ropanasuri j surg. 2018;3(1):175-8. 5. moran ap, gupta a, joshi l. sweet-talk: role of host glycosylation in bacterial pathogenesis of the gastrointestinal tract. gut. 2011;60(10):1412-25. 6. johansson mev, sjövall h, hansson gc. the gastrointestinal mucus system in health and disease. nat rev gastroenterol hepatol. 2013;10(6):352-61. 7. cooling l. blood groups in infection and host susceptibility. clin microbiol rev. 2015;28(3):801-70. 8. rouillard ad, gundersen gw, fernandez nf, et al. the harmonizome: a collection of processed datasets gathered to serve and mine knowledge about genes and proteins. database (oxford). 2016;2016:1-16. 9. ushiyama a, kataoka h, iijima t. glycocalyx and its involvement in clinical pathophysiologies. j intensive care. 2016;4(1):1-11. 10. song jw, zullo ja, liveris d, dragovich m, zhang xf, goligorsky ms. therapeutic restoration of endothelial glycocalyx in sepsis. j pharmacol exp ther. 2017;361(1):115-21. 11. van putten jpm, strijbis k. transmembrane mucins: signaling receptors at the intersection of inflammation and cancer. j innate immun. 2017;9(3):281-99. 12. johansson mev, sjövall h, hansson gc. the gastrointestinal mucus system in health and disease. nat rev gastroenterol hepatol. 2013;10(6):352-61. 13. johansson me v, ambort d, pelaseyed t, et al. composition and functional role of the mucus layers in the intestine. cell mol life sci. 2011;68(22):3635-41. 14. nizet v, varki a, aebi m. chapter 37 microbial lectins: hemagglutinins, adhesins, and toxins. essentials of glycobiology. vol 037. ncbi bookshelf. new york: a service of the national library of medicine, national institutes of health; 2017. p. 1-13. 15. rasko da, rosovitz mj, myers gsa, et al. the pangenome structure of escherichia coli: comparative genomic analysis of e. coli commensal and pathogenic isolates. j bacteriol. 2008;190(20):6881-93. 16. ianiro g, tilg h, gasbarrini a. antibiotics as deep modulators of gut microbiota: between good and evil. gut. 2016;65(11):1906-15. 17. becattini s, taur y, pamer eg. antibiotic-induced changes in the intestinal microbiota and disease. trends mol med. 2016;22(6):458-78. 18. rescigno m. the intestinal epithelial barrier in the control of homeostasis and immunity. trends immunol. 2011;32(6):256-64. 19. rescigno m. mucosal immunology and bacterial handling in the intestine. best pract res clin gastroenterol. 2013;27(1):17-24. 20. munster am, smith-meek m, dickerson c, et al. translocation: incidental phenomenon or true pathology? ann surg. 1993;218(3):321-7. 21. soop m, carlson gl. recent developments in the surgical management of complex intra-abdominal infection. br j surg. 2017:104:e65–e74. 22. jaff ms. higher frequency of secretor phenotype in o blood group its benefits in prevention and/or treatment of some diseases. int j nanomedicine. 2010;5(1):901-5. 23. saboor m, ullah a, qamar k, mir a, moinuddin. frequency of abh secretors and non secretors: a cross sectional study in karachi. pakistan j med sci. 2014;30(1):189-93. 24. santosh tv, sivaprasad pvm, sithara ms, swetha pr, terence bc. association of blood group antigen secretor status and diseases of the gastrointestinal tract. j dent med sci. 2016;15(12):102-4. vol 51 • number 4 • october 2019 intact glycocalyx of intestinal mucosa in intraabdominal infection 337 25. heggelund je, varrot a, imberty a, krengel u. histoblood group antigens as mediators of infections. curr opin struct biol. 2017;44:190-200. 26. marionneau s, cailleau-thomas a, rocher j, et al. abh and lewis histo-blood group antigens, a model for the meaning of oligosaccharide diversity in the face of a changing world. biochimie. 2001;83(7):565-73. 27. quraishy n, sapatnekar s. advances in blood typing. adv clin chem. 2016;77:221-69. case report 56 acta medica indonesiana the indonesian journal of internal medicine hemoperitoneum caused by spontaneous rupture of hepatocellular carcinoma nata p. hardjo lugito, andree kurniawan, rizki yaruntradhani, andhika rachman department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. correspondence mail: department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: nata_pratama_hl@yahoo.com. abstrak kami melaporkan seorang pasien pria berusia 46 tahun yang datang ke unit gawat darurat dengan keluhan utama nyeri perut 1 hari sebelum masuk rumah sakit. tidak ada riwayat trauma abdomen. pasien sering mengeluhkan gangguan perut dalam 5 tahun terakhir. pada pemeriksaan fisik, tampak penurunan kesadaran, syok, konjungtiva pucat, distensi abdomen disertai nyeri di seluruh abdomen pada pemeriksaan palpasi dan tidak ditemukan bising usus. pemeriksaan laboratorium menunjukkan anemia, leukositosis, kadar amilase dan lipase normal. pemeriksaan. fast (focus assissted sonography on trauma) menunjukkan adanya asites masif. pasien menjalani laparotomi eksplorasi dan kemudian ditemukan darah pada rongga abdomen, hepar bernodul dan tumor hepar dengan perdarahan aktif. selama dirawat di rumah sakit, pasien mengalami pemulihan dan kemudian pasien pulang. pada kasus abdomen akut, ruptur spontan karsinoma hepatoselular/hepatocellular carcinoma (hcc) merupakan salah satu diagnosis banding yang perlu dipertimbangkan mengingat tingginya insidens hcc di asia tenggara, khususnya di indonesia. konfirmasi diagnosis pada kasus peritonitis umum membutuhkan pemeriksaan ct scan abdomen dan ultrasonografi untuk menyingkirkan kemungkinan ruptur hcc. kata kunci: hemoperitoneum, ruptur karsinoma hepatoselular. abstract we are reporting a male, 46 years old came to emergency unit with a chief complaint of abdominal tenderness since 1 day prior to admission. no history of abdominal trauma. he often felt abdominal discomfort for the last 5 years. physical examination revealed decreased consciousness, shock, pale conjungtiva, distended abdomen, with tenderness of the whole abdomen on palpation, and no bowel movement. laboratory examination found anemia, leucocytosis, normal amilase and lipase. fast (focus assissted sonography on trauma) found massive ascites. patient underwent cito laparotomic exploration that found blood on abdominal cavity, nodular liver, and actively bleeding tumour of liver. during hospitalization, patient recovered and discharged. in the case of acute abdomen, spontaneous ruptured hepatocellular carcinoma (hcc) is one of differential diagnosis, considering high incidence of hcc in south east asia, especially indonesia. confirming diagnosis of generalized peritonitis requires abdominal ct scan and ultrasonography, to rule out ruptured hcc. key words: hemoperitoneum, ruptured hepatocellular carcinoma. vol 47 • number 1 • january 2015 hemoperitoneum caused by spontaneous rupture of hepatocellular carcinoma introduction hepatocellular carcinoma (hcc), previously known as hepatoma is the most common primary liver malignancy in africa and asia pacific, with the incidence of 20 to 30 cases per 100,000 person year and higher in south east asia.1 spontaneous rupture is acute complication with high mortality rate. its incidence reached 8 – 26% in asia and 3% in united kingdom.1,2 mean age of patients with ruptured was 75 – 79 years old.1 diagnosis was made based on symptoms and signs, imaging examination and bloody ascites fluid. imaging examination of choice is abdominal ct scan strengthen with doppler ultrasonography, but with low sensitivity. management of ruptured hcc are resuscitation of hypovolemic shock, bleeding control and management of hcc.1,2 there are many methods of bleeding control, but patients with poor condition are not suitable to these methods, making artery embolization as an effective and safe choice until the patients are stable to undergo surgery or radiofrequency ablation to manage ruptured hcc.2 this case report is about male, 46 years old admitted to emergency unit of cipto mangunkusumo hospital with symptom of abdominal tenderness and sign of acute abdomen since 1 day prior to admission, that was suspected generalized peritonitis caused by perforated viscous (stomach) with hypovolemic shock. laparotomic exploration found 3000 cc of blood within abdominal cavity with liver that was nodular and a tumour that bled actively. a packing dressing was installed on the tumour. patient’s condition was recovered during hospitalization. case illustration male, 46 years old came to emergency unit of cipto mangunkusumo hospital with a chief complaint of abdominal tenderness 1 day prior to admission. tenderness was continuous, increased with movement and getting worse. two days prior to admission he felt epigastric discomfort that worsen and spread to the whole abdomen. patient felt nausea but did not vomit, nor experienced diarrhea, but he could not defecate since 2 days prior to admission. he did not have fever, no history of abdominal trauma. he often felt abdominal discomfort for the last 5 years, there was no history of analgesic drugs nor herbal medicines. physical examination revealed somnolent consciousness, blood pressure of 80/50 mmhg, pulse 110 per minute, weak, reguler, breathing 40 per minute, temprature 36°c. conjungtiva was pale. abdomen was distended, with no venectation; there was tenderness of the whole abdomen on palpation, with no bowel movement. on rectal toucher sphingter tonus was good, ampula was not collapsed, smooth mucosae, no mass, and there was faeces ongloves with no blood. no palmar erythema on extremities. laboratory examination found hemoglobine 8.7 g/dl, hematocrite 25%, leucocyte 20,200/ μl, platelet 130,000/μl. urea 29 mg/dl, creatinine 2.8 mg/dl. sgot 35 iu/l, sgpt 14 iu/l, albumine 3.5 g/l, blood glucose 465 mg/dl, sodium 139 meq/l, potassium 3.1 meq/l, chloride 104 meq/l. amilase 24 mg/ dl, lipase 26 mg/dl. on blood gas analysis ph 7.291, pco2 21.2 mmhg, po2 157.1 mmhg, hco310.3 meq/l, saturation o2 99.2%. pt 14.5 seconds (12.5 seconds), aptt 42.4 seconds (31.1 seconds), fibrinogen 128 mg/ dl, d-dimer 0.1. chest radiology was normal. fast (focus assissted sonography on trauma) ultrasonography found a large amount of free fluid on di hepatorenal and splenorenal space, between intestine and perivesical space, with no debris nor fibrin within the fluid suggesting of massive ascites. based on data collection, the diagnosis was general peritonitis suspected caused by perforated viscous (stomach) with hypovolemic shock. patient undergone cito laparotomic exploration. when peritoneum was incised, there was blood on abdominal cavity of about 3,000 cc. on exploration, the liver was nodular on segmen 3, 4, 7 with active bleeding from tumour on segmen 1. packing dressing was installed on the tumour because bleeding did not stop with stitching. on the next day patient was relaparotomized to remove the packing. at that time, bleedinbg had stopped. post operation, patient was admitted to icu (intensive care unit) for 8 days. after patient 57 nata p. hardjo lugito acta med indones-indones j intern med recovered and stable, he was moved to internal medicine ward and prepared to discharge from hospital. discussion hepatocellular carcinoma (hcc) is the most common primary liver malignancy in africa and asia pacific. 1 cholangiohepatocellular carcinoma (chh) is a seldom variant that histologically resembles hcc and cholangiocarcinoma. chh behaviour resembles hcc but tends to be more aggressive and more advanced on diagnosis. spontaneous rupture was not rare and usually happened without warning with fatal consequences.1 spontaneous rupture is acute complication with high mortality rate. mechanisms of spontaneous rupture was not clear. some hypothesis stated the role of rapid growth of the tumour, venous hypertension, trauma or compression by diaphragm that related to breathing movement, coagulopathy and thrombocytopenia.2 rapid growth caused the tumour to exceed vascular supply, causing necrosis with intra tumour bleeding. hcc is a vascular tumour with its main supply from hepatic artery, causing high intra tumour pressure that can dissect. the bridging of hepatic capsule caused intra peritoneal bleeding. this is the most common excepted hypothesis at present. venous hypertension, invasion or thrombosis, coagulopathy and thrombocytopenia increased risk of rupture. other factors that contributed was the large size of tumour, locatied peripherally and extra hepatic extension.2,3 rupture of tumour within the liver can be asymptomatic or causing pain, on the other hand peripherally located tumour caused hemoperitoneum with peritonitis and hemodynamic instability.2 a study by bassi et el. found that tumor size did not correlate with severity of the hemoperitoneum.4 this patient had multiple tumour with high possibility of necrosis and were located peripherally. coagulopathy and thrombocytopenia seems to play minor role in this patient. diagnosis of ruptured hcc was made based on symptoms and signs, imaging examination and bloody ascites fluid. main symptoms was abdominal tenderness, acute blood loss and shock. other symptoms and signs were distended abdomen, hypotension, abdominal tenderness and tachycardia. imaging examination of choice was abdominal ct scan. but sensitivity of imaging was still low, a study showed ct scan and ultrasonography can only diagnose 13% ruptured hcc patients. the use of ultrasonography can increased sensitivity. the presence of ascites, extravasation of contrast and tumour contour defect support ruptured hcc. enucleated sign on helical ct scan was more specific of ruptured hcc. bloody ascites diagnosed with paracentesis, but not routinely done. bloody ascites occured on 33% hcc patients without rupture, possibly caused by oozing bleeding due to portal hypertension. on acute hemoperitoneum, erythrocyte count can exceed 1 x 106/mm3 with hematocryte exceeding 3%.1,2 this patient only undergone fast (focus assissted sonography on trauma) ultrasonography that found massive ascites. no symptoms, signs nor history of chronic liver disease nor hcc found, making it difficult to choose imaging modality to confirm etiology figure 1. hepatocellular carcinoma nodules on segmen 1 found intraoperative 58 vol 47 • number 1 • january 2015 hemoperitoneum caused by spontaneous rupture of hepatocellular carcinoma of peritonitis. the etiology of peritonitis was found on laparotomic exploration, which is hemoperitoneum caused by ruptured hcc. m a n a g e m e n t o f r u p t u r e d h c c a r e resuscitation of hypovolemic shock, bleeding control and management of hcc.1,2 in 1960– 1980, resection with tumour excision was the main method. there were many procedures such as perihepatic packing, plication of bleeding tumour with suture, alcohol injection, hepatic artery ligation and liver resection. patients with poor condition are not suitable for these methods. artery embolization as an effective and safe choice until patients stabilized to undergone surgery or radiofrequency ablation to manage ruptured hcc.2 transarterial embolization (tae) is a palliative procedure that was done when liver function was compromised such as child pugh c or multifocal or bilobar hcc. radiofrequency ablation can also be done to manage ruptured hcc.2 other study concludes that any lesion should be considered for surgery if a low-risk curative resection is possible in a child a-b patient, if necessary and possible this intervention may be delayed.4 figure 2 describe algorythm of management patient with spontaneous ruptured hcc.6,7 this patient undergone perihepatic packing dressing because the rupture was found on laparotomy, instead of tae. survival time and survival rate in patient with ruptured hcc was short. a study compared management with tae and conservative therapy showed survival time of 244.8 days vs. 13.1 days. survival rate with conservative therapy on day 7 was 59.4%; day 14 was 37.5%; day 30 was 6.3%; and with tae on 3 months was 56.3%; 12 months 23.4%; 24 months 15.6%. factors related to short term mortality (less than 3 weeks) were poor liver function and incompatibility to tae therapy. in patients with tae therapy that survived, independent factor of long term survival (more than 3 weeks) was tumour size smaller than 7 cm.7 patients with spontaneous ruptured hcc hemodynamically stable acute treatment and triage conservative treatment: stabilization close monitoring correct coagulopathy hemodynamically unstable resuscitation hemostasis procedure hemostasis assessment of liver function staging of hcc staged liver researction for resectable hcc palliative treatment tae expertise available portal vein patient reasonable liver function open surgery perihepatic packing suture plication alcohol injection hal emergeny liver resection small and easily accessible tumor noncarrhotic liver figure 2. management algorhythm of spontaneous rupture of hcc.6 59 nata p. hardjo lugito acta med indones-indones j intern med conclusion this case report a male, 46 years old with generalized peritonitis suspected caused by perforated viscous (stomach) with complication of hypovolemic shock. after laparotomic explaration, blood was found within abdominal cavity, from bleeding tumour on segmen 1 and nodular liver on segmen 3, 4, and 7, indicating a spontaneous ruptured hcc. packing dressing was done, continued with packing removal on the next days. after laparotomy patient recovered and discharged in good condition. in the case of acute abdomen, spontaneous ruptured hcc was one of differential diagnosis, considering high incidence of hcc in south east asia, especially indonesia. confirmation diagnosis of generalized peritonitis requires abdominal ct scan and ultrasonography, making a more precise diagnosis and management. references 1. paracha sj, jalihal a, telisinghe pu, chong vh. haemoperitoneum secondary to spontaneous rupture of liver tumour. brunei int med j. 2011;7(3):181-5. 2. b u c z k o w s k i a j , k i m p t w, h o s g , e t . a l . m u l t i d i s c i p l i n a r y m a n a g e m e n t o f r u p t u r e d hepatocellular carcinoma. j gastrointest surg. 2006;10:379-86. 3. reso a, ball cg, sutherland fr, bathe o, dixon e. rupture and intra-peritoneal bleeding of a hepatocellular carcinoma after a transarterial chemoembolization procedure: a case report. cases j. 2009;2:68-70. 4. bassi n, caratozzolo e, bonariol l, et al. management of ruptured hepatocellular carcinoma: implications for therapy. world j gastroenterol. 2010;16(10):1221-5. 5. keller d, capozza t, gable e. ruptured hepatoma with hemorrhagic ascites. clin gastroenterol hepatol. 2009;7:32-41. 6. l a i e c h , l a u w y. s p o n t a n e o u s r u p t u r e o f hepatocellular carcinoma. a systematic review. arch surg. 2006;141:191-8. 7. kirikoshi h, saito s, yoneda m, et al. outcomes and factors influencing survival in cirrhotic cases with spontaneous rupture of hepatocellular carcinoma: a multicenter study. bmc gastroenterol. 2009;9:29. 60 review article 413acta med indones indones j intern med • vol 52 • number 4 • october 2020 kidney hyperfiltration after nephrectomy: a mechanism to restore kidney function in living donors maruhum bonar h. marbun, endang susalit department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: maruhum bonar h. marbun, md., phd. division of nephrology, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: mbhmarbun@gmail.com. abstrak transplantasi ginjal donor hidup (ldkt) adalah pengobatan pilihan untuk pasien dengan penyakit ginjal tahap akhir (esrd). hingga saat ini, penelitian yang melaporkan dampak nefrektomi pada donor ginjal yang masih hidup terhadap fungsi ginjal mereka di masa depan masih terbatas. sebagian besar donor hidup menjalani pemulihan fungsi ginjal setelah nefrektomi karena kemampuan ginjal yang tersisa untuk mengkompensasi kehilangan nefron melalui hiperfiltrasi adaptif. namun, hiperfiltrasi dapat gagal dan menjadi maladaptif, menyebabkan penurunan fungsi ginjal pendonor dan meningkatkan risiko penyakit ginjal kronis (pgk) dalam jangka panjang. hiperfiltrasi disebabkan oleh peningkatan aliran darah ginjal dan hipertrofi glomerulus. kedua kondisi tersebut diatur oleh berbagai faktor. hiperfiltrasi adaptif pada fase awal setelah nefrektomi mungkin memainkan peran penting dalam menentukan fungsi ginjal jangka panjang, namun faktor yang mempengaruhi proses tersebut masih belum jelas. hiperfiltrasi juga dapat dipengaruhi oleh karakteristik donor seperti usia, indeks massa tubuh (imt), keluarga yang berhubungan dengan penerima, kekakuan arteri dan tekanan intrabdominal intraoperatif. diperlukan studi lebih lanjut untuk memahami mekanisme hiperfiltrasi agar pusat transplantasi ginjal dapat mengantisipasi kegagalannya dan efek merugikan dari nefrektomi di masa mendatang. kata kunci: hiperfiltrasi, fungsi ginjal, transplantasi ginjal, donor hidup, nefrektomi. abstract living donor kidney transplantation (ldkt) is the treatment of choice for patients with end stage renal disease (esrd). up to now, the studies reporting the impact of nephrectomy in living kidney donors to their future kidney function were limited. most living donors undergo recovery of kidney function after nephrectomy owing to remnant kidneys’ capability to compensate nephron loss through adaptive hyperfiltration. however, hyperfiltration may fail and turn out to be maladaptive, causing deterioration of donors’ kidney function and increasing risk of chronic kidney disease (ckd) in long term. hyperfiltration is caused by increased in kidney blood flow and glomerular hypertrophy. both conditions are regulated by various factors. the adaptive hyperfiltration in the early phase after nephrectomy may play important role in determining long term kidney function, but factors affecting the process are still unclear. hyperfiltration may also be influenced by donors’ characteristics such as age, body mass index (bmi), family related to the recipient, arterial stiffness and intraoperative intrabdominal pressure. further study to understand the mechanism of hyperfiltration is needed so that kidney transplant centers could anticipate its failure and the detrimental effects of nephrectomy in the future. keywords: hyperfiltration, kidney function, kidney transplantation, living donor, nephrectomy. maruhum bonar h. marbun acta med indones-indones j intern med 414 introduction living donor kidney transplantation (ldkt) is the treatment of choice for patients with end stage renal disease (esrd). compared to dialysis, ldkt is associated with lower mortality and better quality of life.1,2 while there are concerns regarding long-term risks to donors, living kidney donation is generally safe. moreover, most studies have reported that there is no increased risk for esrd in donors compared to general population. it may occur owing to the capability of remnant kidney to compensate kidney loss through an adaptive process called hyperfiltration.3 hyperfiltration allows donors’ post-nephrectomy glomerular filtration rate (gfr) to increase up to 60-70% of baseline value despite 50% nephrons loss due to the procedure.1 the exact mechanism by which hyperfiltration occurs is not fully understood; however, it is widely suspected that hyperfiltration is caused by an increase in kidney blood flow and glomerular hypertrophy.4 increase in kidney blood flow is a physiologic hemodynamic response to maintain homeostasis, which is regulated by various mediators.5 glomerular hypertrophy increases filtration surface area, which in turn improves gfr. post-nephrectomy glomerular hypertrophy is stimulated by various growth factors, including insulin-like growth factor 1 (igf-1) and vascular endothelial growth factor (vegf).6 hyperfiltration, however, is not always able to restore kidney function and protect donors from chronic kidney disease (ckd). studies have reported deterioration of gfr to <60 ml/ min/1.73 m2 in 40-55% donors, six months after nephrectomy.1,7 this may result from impairment in either blood flow or hypertrophy. lower post-nephrectomy gfr is associated with older age, obesity, family history of ckd and arterial stiffness.8-11 it is important to understand the mechanism of hyperfiltration so that all kidney transplant centers could anticipate its failure and the detrimental effects of nephrectomy. a d a p t i v e a n d m a l a d a p t i v e hyperfiltration hyperfiltration occurs after nephrectomy as remnant kidney attempts to maintain kidney function in spite of nephron loss. hyperfiltration is usually an adaptive process aiming to make amends for declining filtration rate without causing any harmful effects. previous studies have reported that adaptive hyperfiltration is influenced predominantly by increase in kidney blood flow and glomerular hypertrophy, rather than by increase in glomerular capillary pressure.4 nevertheless, hyperfiltration could also bring about detrimental effects. while inadequate hyperfiltration would lead to insufficient kidney function, excessive hyperfiltration may also lead to failure in maintaining kidney function. excessive hyperfiltration forces kidney to work more vigorously as well as causes podocyte damage and proteinuria.5 although excessive hyperfiltration tend to occur after a more aggressive procedure such as 5/6 nephrectomy, it is possible that similar process takes place after unilateral nephrectomy causing reduction of gfr in the long term.12 this circumstance, in which hyperfiltration causes more harm rather than benefits, is termed maladaptive hyperfiltration. increased in kidney blood flow increased in kidney blood flow is mediated by regulation of vascular pressure and resistance. various mediators are involved in the process including nitric oxide (no) being one of the most essential. no is released by macula densa causes vascular relaxation through series of reaction involving guanylate cyclase and cyclic guanosine monophosphate (cgmp). the modulation of tubuloglomerular feedback starts immediately after nephrectomy, mostly during the first two days.13 accordingly, resistive index (ri), a parameter of kidney blood flow, increases significantly two days after nephrectomy. increased in kidney blood flow improves kidney oxygen supply, preventing ischemicreperfusion injury in spite of nephrectomyrelated disruption of perfusion. when kidney blood flow does not increase adequately after nephrectomy, inadequate oxygen supply forces kidney cells to carry out anaerobic metabolism. anaerobic metabolism produces a lesser amount of adenosine triphosphate (atp) and accumulation of lactic acid. this may alter vol 52 • number 4 • october 2020 kidney hyperfiltration after nephrectomy 415 stability of lysosome membrane, causing leakage of hydrolase, which damages cell structure. impaired na/k/atpase pump allows more sodium to enter the cell, leading to cellular edema and hydrolysis.14 kidney blood flow stabilizes one week after nephrectomy, which is possibly associated with decreased kidney response to no after seven days.13 accordingly, ri returns to baseline value. such decline of ri is mainly observed in smaller, more distal vessels such as arcuate arteries. smaller arteries may provide better portrayal of changes occurring in glomerular as they are located closely. decline of ri throughout this period appears to be an essential part of adaptive hyperfiltration as donors with ri remaining elevated have lower gfr on the following days. excessive increase in kidney blood flow produces high pressure on capillary wall. podocyte injury is caused by transmitted shear stress.5 structural damage of podocyte leads to loss of negative charge needed to prevent albumin passing through filtration slit. albuminuria increases kidney workload and may cause kidney function decline in the long term. glomerular hypertrophy the process of glomerular hypertrophy begins as early as four days after nephrectomy. glomerular hypertrophy is induced by various growth factors including vegf, insulin-like growth factor 1 (igf-1) and epidermal growth factor (egf). igf-1 is known to stimulate release of vegf. vegf promotes proliferation of glomerular endothelial cells, which expands filtration surface area and hence, increasing gfr.6 vegf is secreted by podocytes and tubular epithelial cells to primary urine. before acting on its receptors on endothelial cells, vegf need to undergo back-filtration across glomerular capillary wall by diffusion and electrokinetic model.12 endothelial glycocalyx layer, including heparan sulfate proteoglycan, provides assistance to the process.15 vegf then lodges capillary lumen, increasing capillary pressure and hence, further promoting hyperfiltration.16 it is important to note that the surge of vegf beyond a certain level is possibly harmful. excessive proliferation of glomerulus widens podocyte diaphragm slit and opens fenestrae, causing albuminuria. prolonged albuminuria injures tubular cells, lowering kidney function in the long term.16 ischemic-reperfusion injury nephrectomy may cause ischemic-reperfusion injury, which would reduce kidney function in the long term. hyperfiltration may paradoxically cause tissue hypoxia as it increases kidney oxygen demand. toll-like receptor (tlr4) is a part of innate immunity involved in the pathophysiology of ischemic-reperfusion injury. when ischemicreperfusion injury occurs, tubular epithelial cells release tlr ligands called high motility group box 1 (hmgb-1). tlr4 would bind with hmgb-1 and induces nuclear factor kappa-lightchain-enhancer of activated b cells (nf-kb). nf-kb would in turn stimulates recruitment of inflammatory cells and release proinflammatory cytokines and chemokines, including tumor necrosis factor-a (tnf-a). tnf-a would later activate e-selectin, a glycoprotein expressed on the surface of endothelial cells.17 e s e l e c t i n m e d i a t e s r e c r u i t m e n t o f polymorphonuclears (pmn) from the circulation. when activated by proinflammatory stimulus, pmn releases reactive oxygen species (ros) through a specific process termed respiratory burst, mediated by nadph oxidase. ros damages glomerular filtration barrier by disrupting podocyte diaphragm slit and effacing foot processes. this structural disruption of podocytes would lead to albuminuria. ros also washes away glycocalyx, a protective layer on the surface of endothelial glomerular cells. e-selectin also causes pmn to undergo degranulation and release lysozymes and neutrophil gelatinase-associated lipocalin (ngal).18 age many studies of the general population have reported the association between aging and kidney function. older donors are believed to be at higher risk of ckd and slower recovery after nephrectomy. various pathologic conditions could develop as someone ages, as well as normal physiologic changes including decreased maruhum bonar h. marbun acta med indones-indones j intern med 416 kidney responsiveness to vasodilators and vasoconstrictors. it may alter remnant kidney’s ability to increase blood flow—an essential factor of adaptive hyperfiltration. lower compliance of kidney vessels also impedes glomerular hypertrophy rendering inadequate hyperfiltration.11 age-related glomerulosclerosis reduces number of functional nephrons and further reducing gfr.19 despite evidence of age-related decline in kidney function, toyoda et al reported no significant difference of post-nephrectomy gfr between older and younger donors. intense monitoring may aid on preventing deterioration of kidney function in older donors after nephrectomy.20 body mass index (bmi) bmi is widely known as a risk factor for several diseases including ckd. aside from its association with hypertension and diabetes mellitus—two common etiologies of ckd, obesity itself causes several functional changes of kidney collectively termed obesityrelated glomerulopathy. it is characterized by hyperfiltration and increased kidney blood flow to accommodate higher metabolic demand. obese individuals are in low-grade chronic inflammatory state that renders them vulnerable to kidney damages. this inflammatory process involves adipokines such as leptin, adiponectin and also macrophages infiltration. hormonal activities stimulate activation of proinflammatory cytokines. obesity is also associated with an increase of oxidative stress and endothelial dysfunction.21,22 nephrectomy aggravates these preexisting conditions, forcing kidney to work excessively and further impairing its function. family history of ckd previous studies of general population have reported that individuals with family history of ckd are at higher risk to acquire the same condition. skrunes et al have reported that the relative risk of esrd in individuals with a firstdegree relative with esrd is 7.2. when esrd caused by hereditary etiologies is excluded, the relative risk is 3.7.23 in donor population, several studies have reported similar results. donors with family history of ckd show lower gfr after nephrectomy.24 family history of ckd is associated with low nephron endowment at birth, a known risk factor to ckd.25 nevertheless, association between family history and risk of ckd should not be attributed only to genetic factor. environmental factor must also be considered as family members usually live in the same household; therefore, exposures to factors causing ckd could affect all family members.23 arterial stiffness arterial stiffness is marked by elevated pulse wave velocity (pwv). in donor population, higher pwv is associated with lower hyperfiltration after nephrectomy.9 contraction of the left ventricle during systole pushes blood to the arterial system in a pulsatile manner. the pulsatile waves are propagated through the arterial system from central to peripheral arteries. when this wave encounters disjunction along the arterial tree, it partly reflects backward to the aorta. stiffer arteries propagate this backward wave more quickly leading to increased vascular pressure during systole.26 normal arteries are capable of changing pulsatile flow from intermittent left ventricle ejection into a continuous flow needed to perfuse tissues and organs; therefore, reducing pressure transmitted to distal vascular walls. when arteries become stiff as a consequence of aging or other conditions, they lost this ability, causing vascular walls to receive higher pressure. kidney microvasculature is particularly susceptible to pressure-related damage. kidney microcirculation is characterized by low resistance and low wave reflections, rendering higher pulsatile energy transmission to the glomerulus and ultimately vascular damage. myogenic properties of the afferent arteriole and tubule-glomerular feedback mechanism allow autoregulation of kidney blood flow despite increased transmission of pulsatile pressure to the glomerulus. this protective mechanism, however, may fail and it leads to reduction of kidney function.26 vol 52 • number 4 • october 2020 kidney hyperfiltration after nephrectomy 417 r e d li n e : m a la d a ti v e h y p e rf il tr a ti o n b lu e li n e : a d a p ti v e h y p e rf il tr a ti o n in c re a s e d in tr a a b d o m in a l p re ss u re h e m o d y n a m ic d is tu rb a n c e in tr a o p e ra ti v e p o st o p e ra ti v e a ff e re n t v a so d il a ti o n n e p h ro n d a m a g e ? s y st e m ic a rt e ri a l st if fn e s s o b e si ty b lo o d fl o w � n e p h ro n lo ss g f r ? n o � m a c u la d e n sa k id n e y is c h e m ia k id n e y b lo o d fl o w � e n d o th e li a l v e g f � g lo m e ru la r h y p e rt ro p h y a n g io g e n e si s in c re a s e o f n f -? b e -s e le c ti n p m n l y so z y m e b lo c k i? b o p e n e d fe n e st ra e in c re a s e o f p e rm e a b il it y r e d u c e d k id n e y fu n c ti o n in c re a s e d in tr a g lo m e ru la r p re ss u re p ro in fl a m m a to ry c y to k in e s: il -1 , il -6 , t n f -� a d e q u a te a t p a d e q u a te so d iu m p u m p r e d u c e d in tr a c e ll u la r e d e m a r e d u c e d o n c o si s in c re a s e d o x y g e n a ti o n a e ro b ic m e ta b o li s m r e v e rs ib le k id n e y fu n c ti o n d a m a g e d ia p h ra g m sl it s r o s � c e n tr a l a d ip o c y te s p ro x im a l tu b u le in ju ry : n g a l , k im -1 s c le ro si s n e c ro ti c p o d o c y te a lb u m in u ri a l o ss o f p o d o c y te s’ n e g a ti v e c h a rg e r e la te d d o n o r a g e d a m a g e p o d o c y te g ly c o p ro te in h y p e rf il tr a ti o n e n d o th e li a l g ly c o c a ly x la y e r (e g l ): h e p a ra n su lf a te h m g b -1 b in d s w it h t l r -4 (t u b u la r e p it h e li a l c e ll ) v e g f g e n e tr a n s c ri p ti o n l iv in g d o n o r k id n e y t ra n sp la n ta ti o n fi gu re 1 . s ch em e th at il lu st ra te s fa ct or s re la te d to k id ne y fu nc tio n af te r ne ph re ct om y. maruhum bonar h. marbun acta med indones-indones j intern med 418 i n c r e a s e d i n t r a o p e r a t i v e intraabdominal pressure laparoscopic nephrectomy may increase intraoperative intraabdominal pressure by causing pneumoperitoneum. increased intraabdominal pressure surpassing 20 mmhg may lead to circulation problem. kidney is greatly affected elevation of intraabdominal pressure as it reduces kidney blood flow. high pressure in the abdominal cavity may also directly compress kidney parenchyma, which causes ischemia and later injury. cranially-displaced diaphragm compresses the heart that may lead to reduced cardiac output, which in turn cause decrease in kidney blood flow.27,28 conclusion after nephrectomy, living donors undergo hyperfiltration to compensate for nephron loss. mechanisms of adaptive hyperfiltration involve an increase in kidney blood flow and glomerular hypertrophy. donors’ characteristics such as age, bmi, family history of ckd, arterial stiffness and intraoperative intrabdominal pressure may influence kidney function after nephrectomy. factors affecting restoration of kidney function in the early phase after nephrectomy is still unclear. the mechanism related to kidney function after nephrectomy of living donor is illustrated in scheme below. references 1. choi k, yang s, joo d, et al., editors. clinical assessment of renal function stabilization after living donor nephrectomy. transplantation proceedings. elsevier; 2012. 2. tonelli m, wiebe n, knoll g, et al. systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes. 2011;11(10):2093-109. 3. mueller tf, luyckx vajjotason. the natural history of residual renal function in transplant donors. 2012;23(9):1462-6. 4. lenihan cr, busque s, derby g, blouch k, myers bd, tan jc. longitudinal study of living kidney donor glomerular dynamics after nephrectomy. j clin invest. 2015;125(3):1311-8. 5. srivastava t, celsi ge, sharma m, et al. fluid flow shear stress over podocytes is increased in the solitary kidney. 2014;29(1):65-72. 6. chen z, fang j, li g, et al., editors. compensatory changes in the retained kidney after nephrectomy in a living related donor. transplantation proceedings. elsevier; 2012. 7. kwon h, kim d, jang h, et al., editors. predictive factors of renal adaptation after nephrectomy in kidney donors. transplantation proceedings. elsevier; 2017. 8. muzaale ad, massie ab, wang m-c, et al. risk of end-stage renal disease following live kidney donation. 2014;311(6):579-86. 9. fesler p, mourad g, du cailar g, ribstein j, mimran ajajop-rp. arterial stiffness: an independent determinant of adaptive glomerular hyperfiltration after kidney donation. 2015;308(6):f567-f71. 10. nogueira jm, weir mr, jacobs s, breault d, klassen d, evans da, et al. a study of renal outcomes in obese living kidney donors. 2010;90(9):993-9. 11. jeon hg, lee sr, joo dj, oh yt, kim ms, kim ys, et al. predictors of kidney volume change and delayed kidney function recovery after donor nephrectomy. 2010;184(3):1057-63. 12. kuppe c, rohlfs w, grepl m, schulte k, veron d, elger m, et al. inverse correlation between vascular endothelial growth factor back-filtration and capillary filtration pressures. 2018;33(9):1514-25. 13. sigmon dh, gonzalez-feldman e, cavasin ma, d’anna lp, beierwaltes whjjotason. role of nitric oxide in the renal hemodynamic response to unilateral nephrectomy. 2004;15(6):1413-20. 14. chatauret n, badet l, barrou b, hauet tjpeu. ischemia-reperfusion: from cell biology to acute kidney injury. 2014;24:s4-s12. 15. gengrinovitch s, berman b, david g, witte l, neufeld g, ron djjobc. glypican-1 is a vegf165 binding proteoglycan that acts as an extracellular chaperone for vegf165. 1999;274(16):10816-22. 16. schrijvers bf, flyvbjerg a, tilton rg, rasch r, lameire nh, de vriese asjnen. pathophysiological role of vascular endothelial growth factor in the remnant kidney. 2005;101(1):e9-e15. 17. wu h, chen g, wyburn kr, yin j, bertolino p, eris jm, et al. tlr4 activation mediates kidney ischemia/ reperfusion injury. 2007;117(10):2847-59. 18. ma y, yabluchanskiy a, lindsey mljf, repair t. neutrophil roles in left ventricular remodeling following myocardial infarction. 2013;6(1):11. 19. denic a, mathew j, lerman lo, lieske jc, larson jj, alexander mp, et al. single-nephron glomerular filtration rate in healthy adults. 2017;376(24):2349-57. 20. toyoda m, yamanaga s, kawabata c, et al., editors. long-term safety of living kidney donors aged 60 and older. transplantation proceedings. elsevier; 2014. 21. suneja m, kumar abjjocc. obesity and perioperative acute kidney injury: a focused review. 2014;29(4):694. e1-e6. 22. mascali a, franzese o, nistico s, et al. obesity and kidney disease: beyond the hyperfiltration. london, england: sage publications; 2016. 23. s k r u n e s r , s v a r s t a d e , r e i s æ t e r av, vi k s e vol 52 • number 4 • october 2020 kidney hyperfiltration after nephrectomy 419 bejcjotason. familial clustering of esrd in the norwegian population. 2014;9(10):1692-700. 24. mjøen g, hallan s, hartmann a, et al. long-term risks for kidney donors. 2014;86(1):162-7. 25. elsherbiny he, alexander mp, kremers wk, et al. nephron hypertrophy and glomerulosclerosis and their association with kidney function and risk factors among living kidney donors. 2014;9(11):1892-902. 26. i georgianos p, a sarafidis p, n lasaridis ajcvp. arterial stiffness: a novel cardiovascular risk factor in kidney disease patients. 2015;13(2):229-38. 27. armaly z, abassi zjain. deleterious effects of increased intra-abdominal pressure on kidney function. 2014;2014. 28. cheatham mljsjot, resuscitation, medicine e. abdominal compartment syndrome: pathophysiology and definitions. 2009;17(1):10. 3 original article acta medica indonesiana the indonesian journal of internal medicine the differences between interleukin-6 and c-reactive protein levels among adult patients of dengue infection with and without plasma leakage eppy1, suhendro2, leonard nainggolan2, cleopas m. rumende2 1 subspeciality educational program in internal medicine, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: suhendro, md., phd. division of tropical and infectious disease, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: dreppysppd@yahoo.com. abstrak tujuan: mengetahui perbedaan kadar il-6 dan protein c reaktif antara kelompok infeksi dengue dengan dan tanpa kebocoran plasma. metode: penelitian potong lintang terhadap penderita infeksi dengue yang dirawat di rs cipto mangunkusomo dan rs persahabatan antara 1 maret 2014 1 april 2015 dengan menganalisis perbedaan kadar il-6 dan protein c reaktif pada hari ke-3 dan ke-5 demam antara kedua kelompok, maupun pada tiap kelompok. kadar il-6 dan protein c reaktif pada kedua kelompok dianalisis menggunakan uji t tidak berpasangan atau mann-whitney, dan pada masing-masing kelompok dianalisis dengan uji t berpasangan atau wilcoxon. hasil: sampel yang diteliti terdiri atas 24 orang dengan kebocoran plasma dan 20 orang tanpa kebocoran plasma. kadar il-6 pada kelompok dengan dan tanpa kebocoran plasma pada hari ke-3 dan ke-5 demam adalah 8,56 (1,85-96,15) vs. 3,80 (1,94-81,93) pg/ml (p=0,069) dan 4,30 (1,60-70,28) vs. 2,76 (1,26-11,67) pg/ml (p=0,025), sedangkan untuk protein c reaktif adalah 10,1 (4,3-36,5) vs. 6,8 (3,0-21,6) mg/l (p=0,014) dan 5,0 (2,0-20,1) vs. 2,9 (0,19,9) mg/l (p=0,048). kadar il-6 hari ke-3 dan ke-5 demam pada kelompok dengan dan tanpa kebocoran plasma adalah 8,56 (1,85-96,15) vs. 4,30 (1,60-70,28) pg/ml (p=0,037) dan 3,80 (1,94-81,93) vs. 2,76 (1,26-11,67) pg/ml (p=0,005). kadar protein c reaktif hari ke-3 dan ke-5 demam pada kelompok dengan dan tanpa kebocoran plasma adalah 10,1 (4,3-36,5) vs. 5,0 (2,0-20,1) mg/l (p=0,0001) dan 6,8 (0,3-21,6) vs. 2,9 (0,1-9,9) mg/l (p=0,0001). kesimpulan: pada hari ke-3 demam kadar il-6 tidak berbeda antara kedua kelompok, sedangkan pada hari ke-5 demam, kadar il-6 lebih tinggi pada kelompok dengan kebocoran plasma. kadar protein c reaktif hari ke-3 dan ke-5 demam lebih tinggi pada kelompok dengan kebocoran plasma. kadar il-6 dan protein c reaktif kedua kelompok lebih tinggi pada hari ke-3 dibandingkan hari ke-5 demam. kata kunci: interleukin-6, protein c reaktif, dengue, kebocoran plasma. abstract aim: to determine the differences in il-6 and crp levels among groups of dengue infection patients with and without plasma leakage. methods: a cross-sectional study was conducted in adult patients with dengue infection who were treated at cipto mangunkusumo and persahabatan hospital between 1 march 2014 and 1 april 2015. the study analyzed differences in il-6 and crp levels on the 3rd and 5th day of fever in both groups, as well as differences in each group. interleukin-6 and crp levels in both groups, was analyzed using unpaired t-test or mannwhitney and in each group, the data was subsequently analyzed using paired t-test or wilcoxon test. results: the eppy acta med indones-indones j intern med 4 samples of study consisted of 24 subjects with plasma leakage and 20 subjects without plasma leakage. the level of il-6 for groups with and without plasma leakage for the 3rd and the 5th day of fever were 8.56 (1.85-96.15) vs. 3.80 (1.94-81.93) pg/ml (p=0.069) and 4.30 (1.60-70.28) vs. 2.76 (1.26-11.67) pg/ml (p=0.025), respectively; while for crp level, there were 10.1 (4.3-36.5) vs 6.8 (3.0-21.6) mg/l (p=0.014) and 5.0 (2.0-20.1) vs 2.9 (0.19.9) mg/l (p=0.048). the level of il-6 on the 3rd and the 5th day of fever in the group with and without plasma leakage were 8.56 (1.85-96.15) vs. 4.30 (1.60-70.28) pg/ml (p=0.037) and 3.80 (1.94-81.93) vs. 2.76 (1.26-11.67) pg/ml (p=0.005). the level of crp on the 3rd and 5th day of fever in the group with and without plasma leakage were 10.1 (4.3-36.5) vs. 5.0 (2.0-20.1) mg/l (p=0.0001) and 6.8 (0.3-21.6) vs. 2.9 (0.1-9.9) mg/l (p=0.0001). conclusion: there was no difference in il-6 level on the 3rd day of fever between the two groups; while on the 5th day of fever, the il-6 level was higher in the group with plasma leakage. the level of crp on the 3rd and the 5th day of fever were higher in the group with plasma leakage. the levels of il-6 and crp on the 3rd day of fever were higher than the levels on the 5th day of fever in both groups. keywords: interleukin-6, c-reactive protein, dengue, plasma leakage. introduction until now, dengue infection still is an important health problem, either worldwide1 or in indonesia.2 dengue fever (df) and dengue hemorrhagic fever (dhf) are the most common manifestations of dengue infection. df is a mild feature of the disease without plasma leakage; while dhf is a form of severe disease, accompanied by plasma leakage in critical phase.3 plasma leakage in dhf may include increased hematocrit, hypoalbuminemia as well as serous effusion in the pleural, pericardial and peritoneal cavities.4,5 poor treatment will cause dengue shock syndrome (dss) and its mortality rate worldwide is still relatively high, i.e. 5-30%.6 according to the immunopathogenesis theory, plasma leakage in dhf/dss is a result of cytokine storm reaction or multiplication of cytokine production in the vascular endothelium.7,8 the theory is supported by some studies in children,9-12 which reported an association between increased levels of tumor necrosis factor (tnf)-α, interleukin (il)-1β and interleukin (il)-6 with plasma leakage in dhf/ dss patients. those three pro-inflammatory cytokines also serve as endogenous pyrogen, which will have increased levels in each process of acute inflammation and can induce synthesis of various acute phase proteins such as c-reactive protein (crp).13 the crp itself is a systemic inflammatory marker that is commonly used in daily clinical practice and has been acknowledged as one of many inflammatory variables.13,14 in adults, few studies have been conducted on the pathophysiology of cytokine storm reaction. for clinical application, il-6 is the most relevant to be studied among those three pro-inflammatory cytokines as it is the main inducer of c-reactive protein synthesis.13 until now, no study has been conducted in adult patients to compare the levels of il-6 and crp between groups of dengue infection with and without plasma leakage in order to identify the correlation between acute inflammatory process and the development of plasma leakage. moreover, the temporal pattern of il-6 and crp production associated with cytokine storm reaction in dengue infection has not been known either. therefore, serial measurements of il-6 and crp levels in febrile and critical phases should be performed since the il-6 and crp can also increase due to secondary bacterial infection. in daily practice, we still can find a relatively high incidence of antibiotic treatment for patients with dengue infection due to a great concern on secondary infection caused by bacterial translocation from the intestinal lumen into the circulation.4,15,16 the peak of febrile phase is on the 3rd day of fever; while critical phase usually occurs on the 5th day of fever.17 theoretically, the cytokine storm reaction in dengue infection occurs during febrile phase and will resolve in critical phase.7,8 the theory should be confirmed further through clinical studies in adult patients with dengue infection. the aim of our study was to determine differences in the levels of il-6 and crp among groups of dengue infection with and without plasma leakage. vol 48 • number 1 • january 2016 the differences between il-6 and crp levels among adult patients of dengue 5 methods the present study was a cross-sectional study using secondary data from medical records and case report form (crf) of adult patients with dengue infection who were hospitalized in cipto mangunkusumo and persahabatan hospital between 1 march 2014 and 1 april 2015. secondary data collection was performed in may – june 2015. the inclusion criteria were patients with dengue infection who came to the hospital with ≤3-day fever, aged ≥14 years and did not receive antibiotic treatment during hospitalization; while the exclusion criteria were pregnancy, patients with comorbidities (hypertension, diabetes mellitus, cardiovascular disease, liver cirrhosis, malnutrition with hypoalbuminemia, pulmonary edema, ards, other infectious disease, inflammatory disease, m a l i g n a n c y, p a t i e n t s w i t h l e u k o c y t o s i s and or neutrophilia), patients who were on corticosteroid and immunosuppressant treatment and incomplete data. samples were obtained in our study by consecutive sampling. sample size was determined using estimation formula of sample size for different mean value of 2 unpaired groups. for il-6 variable, the minimal sample size for each group was 22 subjects with a total sample size of 44 subjects; while for crp variable, the minimal sample size for each group was 18 subjects and the total sample size was 36 subjects. based on both calculations, we took the greatest minimal sample size in order to achieve the study goal, i.e. 44 subjects. our study used secondary data and therefore, informed consent was not necessary. ethical approval was issued by the ethics committee for medical research, faculty of medicine, university of indonesia with a reference number of 443/un2.f1/etik/2015; however, all data used for the purpose of the study were kept confidential. data collection secondary data collected from medical record and crf were basic data (age, sex, diagnosis, length of hospitalization), data obtained from history taking (duration of fever, bleeding manifestation), data from physical examination (vital signs, bleeding manifestation, pleural effusion, ascites), data from laboratory workup (hemoglobin, hematocrit, leukocytes, platelet count, albumin, il-6 and crp levels), as well as data from usg examination (pulmonary and abdominal usg). il-6 examination was performed by elisa method using quantikine reagent (r&d systems, inc); while the examination of crp was done by immunoturbidimetry method using cobas integra instrument and crphs latex (roche) reagent. the subjects were considered as having dengue infection when they had 2-7 days of fever and were ns1 positive. plasma leakage was defined when there was pleural effusion or ascites confirmed by pulmonary and abdominal usg. statistical analysis the collected data was filled into the subject form. next, the data was tabulated into dummy table, which was consistent with the aim of the study and subsequently the data was edited and coded. afterwards, the data was documented into a computerized magnetic disc and was processed by a personal computer using spss 22.0 software. the subject characteristic data was presented descriptively. data of il-6 and crp levels in both groups were analyzed with shapiro-wilk test to evaluate their distribution and unpaired student t-test or mann-whitney test were used to compare between groups. data of il-6 and crp levels on the 3rd and 5th day of fever in each group were analyzed using paired student t-test or wilcoxon test. differences between both groups were considered significant when the p<0.05. results the number of subjects participated in the study were 44 subjects. subject characteristics are presented in table 1. mean age of the subjects in both groups could be categorized into young adults with a proportion of male and female as many as 50% respectively. on the 3rd and 5th day of fever, we found that the mean hemoglobin and hematocrit levels for both groups were still within normal limit; while the mean leukocyte and platelet counts were lower than normal values. on the 3rd day of fever, we found that the eppy acta med indones-indones j intern med 6 mean albumin levels for both groups were also still within normal limits, but on the 5th day of fever, the value was below normal limits for the group with plasma leakage; while for the group without plasma leakage, the value was still within normal limit. delta of hematocrit and albumin levels was calculated based on differences of values on the 3rd and 5th day of fever. the mean delta of hematocrit levels in both groups was found less than 10%; while the mean delta of albumin levels for the group with plasma leakage was more than 0.5 g/dl and for the group without plasma leakage was less than 0.5 g/dl. the levels of il-6 on the 3rd day of fever was not different between the group with and without plasma leakage (p>0.05); while on the 5th day of fever, it was higher than the group with plasma leakage than the group without plasma leakage (p<0.05). crp levels on the 3rd and 5th day were higher in the group with plasma leakage compared to the group without plasma leakage (p<0.05). (table 2) the levels of il-6 in the groups with and without plasma leakage were higher on the 3rd day of fever than on the 5th day of fever in both groups (p<0.05). crp levels were found higher on the 3rd day compared to the 5th day of fever in both groups (p< 0.05). (table 3) table 1. subject characteristics characteristics with plasma leakage (n=24) without plasma leakage (n=20) age (year), mean (sd) 23.7 (8.4) 24.3 (6.5) sex (male), n (%) 13 (54.2) 8 (40) hemoglobin level (g/dl), mean (sd) the 3rd day 14.3 (2.0) 13.4 (1.3) the 4th day 13.9 (2.0) 13.3 (1.6) hematocrit (%), mean (sd) the 3rd day 40.5 (4.9) 39.1 (3.0) the 5th day 39.8 (5.6) 9.5 (4.1) leukocytes (103/µl), mean (sd) the 3rd day 3.37 (1.61) 3.02 (1.63) the 5th day 4.53 (2.08) 3.56 (1.51) platelets (103/µl), mean (sd) the 3rd day 92.83 (30.89) 109.30 (31.47) the 5th day 4.88 (22.34) 60.00 (22.88) albumin level (g/dl), mean (sd) the 3rd day 3.81 (0.26) 3.78 (0.25) the 5th day 3.30 (0.39) 3.50 (0.30) delta hematokrit (%), mean (sd) 10.96 (6.59) 7.09 (4.37) delta albumin (g/dl), mean (sd) 0.55 (0.33) 0.31 (0.26) table 2. differences in interleukin-6 and crp levels in groups of dengue infection with and without plasma leakage variables with plasma leakage (n=24) without plasma leakage (n=20) p* il-6 level (pg/ml), median (range) the 3rd day 8.56 (1.85-96.15) 3.80 (1.94-81.93) 0.069* the 5th day 4.30 (1.60-70.28) 2.76 (1.26-11.67) 0.025* crp level (mg/l), median (range) the 3rd day 10.1 (4.3-36.5) 6.8 (3.0-21.6) 0.014* the 5th day 5.0 (2.0-20.1) 2.9 (0.1-9.9) 0.048* * mann-whitney test table 3. the levels of interleukin-6 and crp on the 3rd and the 5th day of fever variables on the 3rd day (n=44) on the 5th day (n=44) p* il-6 level (pg/ml), median (range) with plasma leakage 8.56 (1.85-96.15) 4.30 (1.60-70.28) 0.037* without plasma leakage 3.80 (1.94-81.93) 2.76 (1.26-11.67) 0.005* crp level (mg/l), median (range) with plasma leakage 10.1 (4.3-36.5) 5.0 (2.0-20.1) 0.0001* without plasma leakage 6.8 (0.3-21.6) 2.9 (0.1-9.9) 0.0001* * wilcoxon test discussion the mean age of subjects in both groups is still included in the group of young age, which is consistent with a study conducted by bhaskar et al.4 in few last decades, there are epidemiological changes of dengue infection in indonesia, i.e. there are a higher number of dengue infection cases in the age group over 15 years of age.15 vol 48 • number 1 • january 2016 the differences between il-6 and crp levels among adult patients of dengue 7 similar data has also been shown by other asian countries such as singapore, which in 1990-1996 demonstrated the highest morbidity rate in the 15-34 years age group and bangladesh which during the epidemic dengue in 2000 found the highest proportion cases in the 18-33 years age group.18 the proportion between male and female subjects in our study is similar, which is consistent with reports from malaysia and south america.18 the mean hemoglobin levels and hematocrit on the 3rd and 5th day in both groups were still within normal limit, which is consistent with the study conducted by priyadarshini et al.19 the absence of hemoconcentration in our study is probably due to fluid intervention during early treatment. leukopenia has occurred on the 3rd day of fever in both groups. in dengue infection, leukopenia usually o c c u r s e a r l i e r t h a n t h r o m b o c y t o p e n i a . 1 thrombocytopenia had been identified on the 3rd day of fever in both groups and it was getting more severe on the 5th day of fever. thrombocytopenia commonly occurs in df and is always found in dhf/dss.1 in the group with plasma leakage, we found that the mean albumin levels on the 5th day of fever was lower than normal. it is consistent with the theory that plasma leakage of dhf occurs during the critical phase, which is characterized by albumin loss to the extravascular space due to increased capillary permeability.20 it was found that the mean of delta albumin in the group with plasma leakage was more than 0.5 g/dl. it is consistent with the who criteria1 on the markers of plasma leakage in dhf patients. in our study, there was no difference of il-6 levels between both groups on the 3rd day of fever; while on the 5th day of fever, there was a higher levels of il-6 in the group with plasma leakage compared to the group without plasma leakage. various results of previous studies show different findings due to different range of study design, time set for sample collection and different population of patients and clinical classification. priyadarshini et al19 found higher il-6 levels in dhf group compared to the df group. kumar et al21 and mangione et al12 found that the il-6 levels in the dhf group was not different from the levels in the df group. results of our study showed that il-6 may have role in the development of plasma leakage in dengue infection. however, the effect of various other factors that has not been studies should also be considered including the cytokines and other inflammatory mediators, cellular and humoral immune factors, virus virulence and susceptibility of host genetic.22 the crp levels on the 3rd and 5th day of fever was found higher in the group with plasma leakage compared to the group without plasma leakage. it indicates that there is more severe inflammatory process in the group with plasma leakage, either in the febrile or critical phase. however, differences in crp levels between both groups on the 3rd day of fever were not accompanied by different il-6 levels. it may occur since there is still an effect of tnf-α and il-1β on crp synthesis in the liver during the febrile phase. the results of our study have confirmed the pathophysiology of the cytokine storm in dengue infection of adult patients. it is obvious that the cytokine storm reaction occurs in the febrile phase and it is resolved during the critical phase with an impact of plasma leakage in critical phase. according to guabiraba et al.23, there is cytokine storm with high levels of pro-inflammatory cytokines in dhf/dss patients, which will be followed by activation of coagulation system, acute phase proteins, soluble receptor and other inflammatory mediators with end results of endothelial activation, vascular leakage, which are accompanied by bleeding and shock.23 our study also found that il-6 levels on the 3rd day was higher than on the 5th day of fever, both in the group with and without plasma leakage. it indicates that during the critical phase, the inflammatory process has been resolved in both groups. however, the il-6 levels on the 5th day of fever was still higher in the group with plasma leakage compared to the group without plasma leakage. it demonstrates that il-6 released during the febrile phase has equal strength in both groups, but the recovery process in the group with plasma leakage was slower; therefore, during the critical phase, we found eppy acta med indones-indones j intern med 8 higher il-6 levels compared to the group without plasma leakage. according to chaturvedi et al.5, if there is a shift of cytokine response to th2 cytokines in dengue infection, which is characterized by a very high il-6 production, then plasma leakage will occur. consistent with various previous studies, crp levels were found higher on the 3rd day compared to the 5th day of fever in both groups. nascimento et al.24 reported that in the dfh and df groups, there are higher levels of crp than the healthy control. kumar et al.21 found that during the febrile phase, the crp levels in dhf and df groups are higher than the control group; while during the critical phase it is not different from the control. it indicates that there is more severe inflammatory process in dengue infection during the febrile phase compared to the critical phase. crp is one of acute phase proteins that will have increasing levels when inflammation occurs. in systemic viral infection, increased crp levels may also occur.13 during the febrile phase in dengue infection, there will be viremia that can induce acute inflammatory process, which is accompanied by increased crp levels.3,9 it is consistent with the basic function of crp, i.e. to control inflammation, clearance stimulation of damaged cells and tissue component and to initiate the repair function.25 different crp levels on the 3rd and 5th day of fever in both groups probably happened due to inflammatory reaction on the dengue virus itself, instead of secondary bacterial infection since we found reduced crp levels on the 5th day of fever in both groups and during hospitalization, no subjects had received antibiotic treatment. the limitation of our study that can affect the results is that we did not measure the levels of cytokines that induce synthesis of other crps, i.e. the tnf-α and il-1β. in addition, the usg examination also did not measure other parameters for plasma leakage, which are thickening of gall bladder wall and pericardial effusion; therefore, there is a possibility of undetected plasma leakage in our study. although we used secondary data, but there is small possibility of recall bias in our study since the subjects with incomplete data has been excluded from our study. the possibility of inaccurate measurement on duration of fever is also small because all of medical records in accessible population have been completed with crf compiled by an experienced clinical team. moreover, the usg examination to detect the presence of pleural effusion and ascites was performed by an experienced usg expert to avoid the inter-observer bias. results of our study can be applied in larger populations by evaluating generalizations. external validity of our study was relatively good since the subjects were recruited by consecutive sampling for approximately a year; therefore, we believe that it may represent all cases of dengue infection all year long. the second external validity of our study was also relatively good since the characteristics of patients with dengue infection who were hospitalized in both hospitals were not different from the dengue infection patients of other hospitals. based on the above mentioned explanation, we suggest that the generalization of our study results can be done for adult patients with dengue infection who are hospitalized in all hospitals. conclusion on the 3rd day of fever, the il-6 levels were not different between the group of adult dengue infection patients with and without plasma leakage; while on the 5th of fever, the il-6 levels were higher in the group with plasma leakage. the levels of il-6 and crp in both groups were higher on the 3rd day compared to the 5th day of fever. the clinical application of our study is that measurements of crp levels can support the management of adult patients with dengue infection through increasing awareness on the development of plasma leakage. references 1. who. comprehensive guidelines for prevention and control of dengue and dengue haemorrhagic fever. revised and expanded edition: world health organization, regional office for south-east asia; 2011. 2. brito caa, albuquerque mdfmp, lucena-silva n. plasma leakage detection in severe dengue: when serum albumin quantification plays a role? rev soc bras med trop. 2007;40(2):220-3. vol 48 • number 1 • january 2016 the differences between il-6 and crp levels among adult patients of dengue 9 3. tdr/who. dengue: guidelines for diagnosis, treatment, prevention and control. geneva: world health organization; 2009. 4. bhaskar me, moorthy s, kumar ns, arthur p. dengue haemorrhagic fever among adults--an observational study in chennai, south india. indian j med res. 2010;132:738-40. 5. chaturvedi uc, agarwal r, elbishbishi ea, mustafa as. cytokine cascade in dengue hemorrhagic fever: implications for pathogenesis. fems immunol med microbiol. 2000;28(3):183-8. 6. dalrymple na, mackow er. endothelial cells elicit immune-enhancing responses to dengue virus infection. j virol. 2012;86(12):6408-15. 7. costa vv, fagundes ct, souza dg, teixeira mm. inflammatory and innate immune responses in dengue infection: protection versus disease induction. am j pathol. 2013;182(6):1950-61. 8. basu a, chaturvedi uc. vascular endothelium: the battlefield of dengue viruses. fems immunol med microbiol. 2008;53:287-299. 9. juffrie m, meer gm, hack ce, et al. inflammatory mediators in dengue virus infection in children: interleukin-6 and its relation to c-reactive protein and secretory phospholipase a2. am j trop med hyg. 2001;65(1):70-5. 10. restrepo bn, isaza dm, salazar cl, ramirez r, ospina m, alvarez lg. serum levels of interleukin-6, tumor necrosis factor-alpha and interferon-gama in infants with and without dengue. rev soc bras med trop. 2008;41(1):6-10. 11. suharti c, van gorp ecm, dolmans wmv, et al. cytokine patterns during dengue shock syndrome. eur cytokine net. 2003;14(3):172-7. 12. mangione jn, huy nt, lan nt, et al. the association of cytokines with severe dengue in children. trop med health. 2014;42(4):137-44. 13. prasad k. c-reactive protein (crp)-lowering agents. cardiovasc drug rev. 2006;24(1):33-50. 14. dellinger rp, levy mm, rhodes a, et al. surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. crit care med. 2013;41(2):580-637. 15. citraresmi e, hadinegoro sr, akib aa. diagnosis dan tata laksana demam berdarah dengue pada kejadian luar biasa tahun 2004 di enam rumah sakit di jakarta. sari pediatri. 2007;8(3):8-14. 16. van de weg ca, pannuti cs, de araujo es, et al. microbial translocation is associated with extensive immune activation in dengue virus infected patients with severe disease. plos negl trop dis. 2013;7(5):e2236. 17. suwandono a, kosasih h, nurhayati, et al. four dengue virus serotypes found circulating during an outbreak of dengue fever and dengue haemorrhagic fever in jakarta, indonesia, during 2004. trans r soc trop med hyg. 2006;100(9):855-62. 18. guha-sapir d, schimmer b. dengue fever: new paradigms for a changing epide-miology. emerg themes epidemiol. 2005;2(1):1. 19. priyadarshini d, gadia rr, tripathy a, et al. clinical findings and pro-inflammatory cytokines in dengue patients in western india: a facility-based study. plos one. 2010;5(1):e8709. 20. srikiatkhachorn a. plasma leakage in dengue haemorrhagic fever. thromb haemost. 2009; 102(6):1042-9. 21. kumar y, liang c, bo z, rajapakse jc, ooi ee, tannenbaum sr. serum proteome and cytokine analysis in a longitudinal cohort of adults with primary dengue infection reveals predictive markers of dhf. plos negl trop dis. 2012;6(11):e1887. 22. whitehorn j, simmons cp. the pathogenesis of dengue. vaccine. 2011;29(42):7221-8. 23. guabiraba r, ryffel b. dengue virus infection: current concepts in immune mecha-nisms and lessons from murine models. immunol. 2014;141(2):143-56. 24. nascimento ej, silva am, cordeiro mt, et al. alternative complement pathway deregulation is correlated with dengue severity. plos one. 2009; 4(8):e6782. 25. biro a, rovo z, papp d, et al. studies on the interactions between c-reactive protein and complement proteins. immunol. 2007;121(1):40-50. special article 84 acta med indones indones j intern med • vol 52 • number 1 • january 2020 covid-19 and indonesia siti setiati1, muhammad k. azwar2 1 department of internal medicine – clinical epidemiology and evidence-based medicine, cipto mangunkusumo hospital – faculty of medicine universitas indonesia, jakarta, indonesia. 2 faculty of medicine, universitas indonesia, jakarta, indonesia. corresponding author: prof. siti setiati, md., phd. department of internal medicine – clinical epidemiology and evidence-based medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: khifzhon@gmail.com, s_setiati@yahoo.com. abstrak pandemi infeksi virus corona 2019 (covid-19) adalah masalah yang sedang dihadapi di lebih dari 200 negara di dunia. indonesia juga terkena dampak buruk dari covid-19 di mana tingkat kematiannya mencapai 8.9% pada akhir maret 2020. ketidaksiapan layanan kesehatan dan langkah besar yang diambil oleh pemerintah mungkin dapat diubah untuk memberantas infeksi ini. dianjurkan bagi indonesia untuk memperketat himbauan untuk diam di rumah, menurunkan penyebaran penyakit dengan karantina wilayah dalam skala besar, meningkatkan pelayanan kesehatan, serta meningkatkan ketersediaan alat pelindung diri (apd). penting bagi negara untuk menurunkan epidemic peak agar tidak membuat negara kewalahan dengan cara mengkarantina individu dengan riwayat kontak dengan kasus covid-19. karantina wilayah/ lockdown juga dapat meningkatkan doubling time epidemi secara signifikan. kebutuhan pelayanan kesehatan akan mengalami peningkatan seiring dengan melonjaknya jumlah kasus. hal ini menggarisbawahi pentingnya melindungi tenaga kesehatan dari risiko infeksi. penelitian ilmiah di indonesia juga krusial untuk memberikan anjuran yang berhubungan dengan kasus covid-19. kata kunci: covid-19, sars-cov-2, coronavirus, indonesia. abstract coronavirus disease 2019 (covid-19) pandemic is an ongoing problem in more than 200 countries in the world. indonesia has been greatly affected by covid-19 with case fatality rate (cfr) being 8.9% in the end of march 2020. we have some room for improvement related to the unreadingess of healthcare facility and the major steps taken by the government. it is suggested that the country should have stricter stay-at-home notice, suppress the spread by imposing lockdown on a large scale, improve healthcare service, and increase the availability of personal protective equipments (ppe). it is important to avoid an epidemic peak that potentially overwhelms healthcare service by quarantining the case contacts. lockdown may prolong the epidemic doubling time significantly. demand of health system is likely to grow since the number of covid-19 case is likely to rise. effective procedures for protecting medical staff from infection are essential. scientific research in indonesia is also crucial to provide suggestion and recommendation pertinent to covid-19. keywords: covid-19, sars-cov-2, coronavirus, indonesia. vol 52 • number 1 • january 2020 covid-19 and indonesia introduction coronavirus disease 2019 (covid-19) pandemic is an ongoing problem in more than 200 countries in the world.1 covid-19 has been identified as the cause of an outbreak of infectious respiratory disease in wuhan, people’s republic of china.2 as of 31 march 2020, there were 719,758 confirmed cases worldwide. the number of deaths related to covid-19 also reached 33,673 worldwide. the pandemic has resulted in a rapid surge in research in response to the condition.1 indonesia has also been hit badly by sarscov-2 infection. this article will highlight the situation, the measures taken, and the steps suggested in indonesia from medical point of view. situation in indonesia by 31 march 2020, there have been 1,528 confirmed covid-19 cases in indonesia and 136 deaths related to the disease. the nation’s case fatality rate (cfr) is also much higher than that of people’s republic of china (8.9% vs 4%).3 indonesia’s healthcare facility is not ready to face covid-19 yet. massive preparation should have been taken seriously at the beginning of disease spread in the people’s republic of china.4 professor joseph wu warned all parties as early as january 2020 in the lancet. at that moment, the author stated that 2019-ncov could be about to become a global epidemic. he also suggested that preparedness plans should be readied by ensuring the supply of drugs, personal protective equipment (ppe) as well as human resources needed to face the global outbreak.5 according to the latest data of the ministry of health of indonesia, there are only 309,100 hospital beds in indonesia, with most of them being located on java island. on top of that, there are less than 6,000 intensive care unit (icu) beds nationwide. the number appears much, but in fact, indonesia only had 2.7 icu beds per 100,000 people and thus the country ranked among the lowest in asia.6 in addition, mechanical ventilator is not widely available in rural settings and there is a shortage of protective gear for healthcare workers. mass screening was chosen by the state palace to be implemented in march 2020. in the end of march 2020, indonesia’s president finally decided to implement large-scale social restriction / pembatasan sosial berskala besar in cities and provinces, instead of regional quarantine. regional quarantine is one of four types of health quarantine according to 2018 health quarantine law. the government also emphasises the need to stay at home for all indonesian citizens. to date, regional quarantine is applicable only to neighbourhood / rukun tetangga (rt) or villages.7 a lockdown scenario was initially prepared in jakarta and west java in march 2020. however, the capital city dropped the plan following the rejection from the central government and the greater jakarta transportation agency.8 suggested step: stricter stay-athome notice based on 16 studies, when it is applied with high level of compliance (>70%), quarantining of exposed persons is effective to slow down the transmission of disease during an influenza pandemic.9 by quarantining only half of all case contacts over a period of one month prior to the epidemic peak, the epidemic peak will occur 1 week later. not only can the action delay the peak, it can also decrease the case number during epidemic peak by 25%.10 it is important to avoid an epidemic peak that potentially overwhelms healthcare service.11 during the current pandemic, individuals may have unintentional close contact with people with covid-19 in public. this is partly due to the presence of several asymptomatic and presymptomatic sars-cov-2 infection.12 it is estimated that 80% of people with covid-19 only have mild or asymptomatic disease.11 the government may work together with religious leaders, traditional leaders, police officers, and/or indonesian national armed forces to make voluntary plus mandated quarantine successful. masks and ppe should also be provided for the officers. although voluntary isolation at home may be a more feasible social distancing plan,10 not everyone complies with the stay-at-home notice. pandemic plans should consider how to facilitate social distancing 85 siti setiati acta med indones-indones j intern med measure. in severe pandemics, more drastic social distancing measure might be needed.10 stricter stay-at-home notice may lead to less mass gathering in public, too. a systematic review of 45 studies showed that acute respiratory infection is the commonest disease spread through mass gathering, including festival and religious events.13 stricter policy may adopt a law from other parts of the world, for instance, individuals breaking social distancing guidelines are given fines and possible jail time. in new south wales, australia, individual and corporations will be hit with fines of aud 1,000 and aud 5,000, respectively. covid-19 social distancing breach could also lead to 6 months of imprisonment under existing enforcement powers.14 suggested step: suppressing the spread through lockdown lockdown does not eradicate the viral infection in patients with the disease, but it suppresses the disease spread. if the government locked down certain region, no journeys would be allowed in or out of the region. a study showed that lockdown may have positive impact on the spread of covid-19. after imposing lockdown in wuhan, china, the doubling time increases significantly from 2 days (95% confidence interval, ci): 1.9-2.6) to 4 days (95% ci: 3.54.3). the doubling time became even longer after additional alteration in testing and diagnostic methods (19.3 days [95% ci: 15.1-26.3]).15 the travel restriction also had beneficial effect on an international scale. after imposing lockdown, the number of imported case worldwide dropped by 80% until mid february 2020.16 “we consider the social distancing measures taken as of today as insufficient, and we believe that additional and more restrictive measures should be taken immediately, as it is already happening in other countries across the world.” so wrote more than 500 academic signatories in the world.17 however, indonesian government has decided only to implement cityand province-level large-scale social restriction.7 this is contrary to the steps taken by ghana. the authorities of the developing country imposed lockdown on the greater accra and kumansi metropolitan area in the end of march 2020 in response to the concern about covid-19. the president of ghana stated, “we know how to bring the economy back to life. what we do not know is how to bring people back to life.” the director-general of world health organization (who) found the presidential statement powerful.18 it is crucial to respect the welfare of all people affected by certain law. who directorgeneral emphasised that closing down of certain region means that the government should secure the need of individuals who have to work on a daily basis to win the bread. the need of the citizens who lost their income and in desperate need of sanitation and food should also be taken into account.19 it may be unlikely for the government to cover the daily needs of the affected individuals nationwide. donation from affluent indonesians could be an option to help the citizens in need. the estimated number of wealthy citizens in indonesia from world wealth report 2019 was 129,000.20 donation appears to be a promising solution to help the country hand in hand. this is potentially achievable seeing that indonesia topped the caf world giving index in 2018 among all countries in the world. indonesians have a high tendency to help strangers, to volunteer and give financial aid.21 s u g g e s t e d s t e p : i m p r o v i n g healthcare service the executive director of who health emergencies programme suggested indonesia to have a comprehensive strategy including the strengthening of health system. demand of health system is likely to grow since the number of covid-19 case is likely to rise.19 estimates suggest that 14% and 6% of people with covid-19 have severe disease and critical illness, respectively.9 availability of hospital bed as well as mechanical ventilation facility have to be prepared for the worst case. indonesia may learn from the outbreak of ebola virus disease. the deaths from other causes became higher due to the deaths of healthcare workers and the saturated healthcare system.11 not only is the goal successful treatment, it 86 vol 52 • number 1 • january 2020 covid-19 and indonesia should also be a better ability to chase after the virus and to diagnose. who director-general stated that any movement restriction or stayat-home notice must be accompanied by the ability to detect suspect cases followed by the isolation of confirmed cases.19 mass screening decided by indonesian government may be the correct step to take, because a majority of covid-19 cases are only mildly symptomatic or asymptomatic. symptom-based control alone may not be adequate unless the cases are only lightly infectious.11 in western medicine, physicians practise according to evidence-based medicine. several medications have been introduced and reported as beneficial in the treatment of covid-19, but most studies are based on small sample size. there are ongoing clinical trials to assess the safety and efficacy of covid-19 vaccine as well as treatment.4 however, it may take a long time to obtain final study result. majority of studies were published in english language (89.2%) and conducted by chinese scholars (67.7%).2 sars-cov-2 is relatively new compared to other coronavirus and local research has yet to be conducted. the current lack of access to the government’s data pertinent to covid-19 results in the absence of scientlific research in this topic in indonesia. the access is crucial for doctors and scientists, so that statistical analysis of the data may bring about suggestion and recommendation for the prevention of covid-19, early detection as well as the patient-centred treatment. the simplest study may describe the condition statistically. on the other hand, study results may also allow early detection as well as deterioration of the disease during the pandemic in this country. s u g g e s t e d s t e p : i n c r e a s i n g availability of personal protective equipment (ppe) ppe is the uniform of modern warfare to eradicate covid-19. higher number of health personnel must be accompanied by the availability of ppe. scientific evidence recommended the use of standard surgical mask in non-aerosol-generating procedures, although evidence was not done in the case of covid-19. the usage of mask should be enhanced by personal hygiene and the usage of gown and goggles for optimum protection.22 supply disruption helpline and email address help with queries regarding ppe in the uk. national health service (nhs) uk stated that it supported the provision of ppe 24 hours a day and 7 days a week. masks and hand sanitizers were distributed rapidly as the demand keeps rising. protective equipments were also delivered to care homes, hospices, community pharmacy, general practitioner practice, and dental practice.23 the deaths of healthcare workers became a problem during the covid-19 pandemic. doctors also threaten to stop working due to the lack of ppe.24 once a front-line staff are contracting the disease, the staff may in turn harm the next patient. this indicates that effective procedures for protecting staff from the infection are essential.12 once ppe is available, healthcare staff requires training regarding its usage. all the protective measures are important so that the workers feel safe whilst working. conclusion indonesia has been hit badly by covid-19 with cfr being 8.9% in the end of march 2020. we have some room for improvement related to the unreadingess of healthcare facility and the major steps taken by the government. it is suggested that the country should have stricter stay-at-home notice, suppress the spread through lockdown, improve healthcare service, and increase the availability of ppe. scientific research in indonesia about covid-19 is crucial to provide suggestion and recommendation for the disease prevention, early detection, as well as the patient-centred treatment. acknowledgments the authors would like to thank all the healthcare workers fighting together during the covid-19 pandemic. we thank the almighty god for reasons too numerous to mention. 87 siti setiati acta med indones-indones j intern med references 1. world health organization. coronavirus disease (covid-19) situation dashboard [internet]. geneva, ch: world health organization; 2020 [updated 2020 mar 31; cited 2020 mar 31]. available from: https:// experience.arcgis.com/experience/685d0ace521648f8 a5beeeee1b9125cd. 2. adhikari sp, meng s, wu yj, et al. epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (covid-19) during the early outbreak period: a scoping review. infect dis poverty. 2020;9(1):29. doi: 10.1186/s40249-02000646-x. 3. kementerian kesehatan republik indonesia. info infeksi emerging kementerian kesehatan ri [internet]. jakarta, id: kementerian kesehatan republik indonesia; 2020 [cited 2020 mar 31]. available from: https://covid19.kemkes.go.id/. 4. horton r. offline: covid-19 and the nhs—“a national scandal”. lancet. 2020;395(10229):p1022. doi: 10.1016/s0140-6736(20)30727-3. 5. wu jt, leung k, leung gm. nowcasting and forecasting the potential domestic and international spread of the 2019-ncov outbreak originating in wuhan, china: a modelling study. lancet. 2020;395(10225):p689-697. doi: 10.1016/s01406736(20)30260-9. 6. phua j, faruq mo, kulkarni ap, redjeki is, detleuxay k, mendsaikhan n, sann kk, shrestha br, hashmi m, palo je, haniffa r, wang c, hashemian smr, konkayev a, mat nor mb, patjanasoontorn b, nafees kmk, ling l, nishimura m, al bahrani mj, arabi y, lim cm, fang wf, for the asian analysis of bed capacity in critical care (abc) study investigators, and the asian critical care clinical trials group. critical care bed capacity in asian countries and regions. criti care med. 2020; online first. doi: 10.1097/ccm.0000000000004222. 7. putra pms. menko pmk: jokowi setujui aturan karantina wilayah di tingkat daerah. liputan 6 [internet]. 2020 mar 30 [cited 2020 mar 31]. available from: https://www.liputan6.com/news/read/4214913/ menko-pmk-jokowi-setujui-aturan-karantina-wilayahdi-tingkat-daerah. 8. gobiano mi, ghaliya g. turf war undermines c o v i d 1 9 f i g h t i n i n d o n e s i a . t h e j a k a r t a post [internet]. 2020 apr 1 [cited 2020 apr 1]. available from: https://www.thejakartapost.com/ news/2020/04/01/turf-war-undermines-covid-19-fightindonesia-government-jokowi-anies.html. 9. fong mw, gao h, wong jy, xiao j, shiu eyc, ryu s, cowling bj. nonpharmaceutical measures for pandemic influenza in nonhealthcare settings-social distancing measures. emerg infect dis. 2020;26(5). doi: 10.3201/eid2605.190995. 10. rashid h, ridda i, king c, begun m, tekin h, wood jg, booy r. evidence compendium and advice on social distancing and other related measures for response to an influenza pandemic. paediatr respir rev. 2015;16(2):119-26. doi: 10.1016/j. prrv.2014.01.003. 11. anderson rm, heesterbeek h, klinkenberg d, hollingsworth td. how will country-based mitigation measures influence the course of the covid-19 epidemic?. lancet. 2020;395(10228):p931-934. doi: 10.1016/s0140-6736(20)30567-5. 12. yuen ks, ye zw, fung sy, chan cp, jin dy. sarscov-2 and covid-19: the most important research questions. cell biosci. 2020;10:40. doi: 10.1186/ s13578-020-00404-4. 13. karami m, doosti-irani a, ardalan a, et al. public health threats in mass gatherings: a systematic review. disaster med public health prep. 2019;13 (5-6):103546. 14. thomas s, nguyen k. coronavirus social distancing breaches could lead to fines and jail time, nsw police announces. abc news [internet]. 2020 mar 25 [cited 2020 mar 31]. available from: https://www.abc.net. au/news/2020-03-25/nsw-police-will-fine-breachesfor-coronavirus-social-distancing/12089732. 15. lau h, khosrawipour v, kocbach p, mikolajczyk a, schubert j, bania j, khosrawipour t. the positive impact of lockdown in wuhan on containing the covid-19 outbreak in china. j travel med. 2020 mar 17. pii: taaa037. doi: 10.1093/jtm/taaa037. 16. chinazzi m, davis jt, ajelli m, et al. the effect of travel restrictions on the spread of the 2019 novel coronavirus (covid-19) outbreak. science. 2020 mar 6. pii: eaba9757. doi: 10.1126/science.aba9757. 17. mahtani kr, heneghan c, aronson jk. what is the evidence for social distancing during global pandemics? a rapid summary of current knowledge [internet]. oxford, uk: oxford covid-19 evidence service; 2020 [updated 2020 mar 19; cited 2020 mar 31]. available from: https://www.cebm.net/what-isthe-evidence-for-social-distancing-during-globalpandemics-a-rapid-summary-of-current-knowledge/. 18. president akufo-addo earns international plaudits for his profound coronavirus quote. ghana web [internet]. 2002 mar 30 [cited 2020 mar 31]. available from: https://www.ghanaweb.com/ghanahomepage/ n e w s a r c h i v e / p r e s i d e n t a k u f o a d d o e a r n s international-plaudits-for-his-profound-coronavirusquote-908848. 19. world health organization (who). live from who headquarters coronavirus covid-19 daily press briefing 30 march 2020 [video file]. 2020 mar 30 [cited 2020 mar 31]. available from: https://www.youtube. com/watch?v=2v3vlw14nbm 20. capgemini. world wealth report 2019 [internet]. 2019 [cited 2020 mar 31]. available from: https:// w o r l d w e a l t h r e p o r t . c o m / w p c o n t e n t / u p l o a d s / sites/7/2019/07/world-wealth-report-2019.pdf. 21. charities aid foundation. caf world giving index 2018: 88 vol 52 • number 1 • january 2020 covid-19 and indonesia a global view of giving trends [internet]. 2018 [cited 2020 mar 31]. available from: https://www.cafonline. org/docs/default-source/about-us-publications/ caf_wgi2018_report_webnopw_2379a_261018.pdf 22. greenhalgh t, chan xh, khunti k, et al. what is the efficacy of standard face masks compared to respirator masks in preventing covid-type respiratory illnesses in primary care staff? [internet]. oxford, uk: oxford covid-19 evidence service; 2020 [updated 2020 mar 24; cited 2020 mar 31]. available from: https:// www.cebm.net/covid-19/what-is-the-efficacy-ofstandard-face-masks-compared-to-respirator-masksin-preventing-covid-type-respiratory-illnesses-inprimary-care-staff/. 23. national health service uk. guidance on supply and use of personal protective equipment (ppe). united kingdom: national health service uk; 2020 [cited 2020 mar 31]. available from: https://www.england. nhs.uk/coronavirus/publication/guidance-supply-useof-ppe/. 24. the guardian. doctors threaten to quit nhs over shortage of protective. the guardian [internet]; 2020 mar 24 [cited 2020 mar 25]. available from: https:// www.theguardian.com/world/2020/mar/24/doctorsthreaten-to-quit-over-protective-equipment-shortage. 89 editorial 83acta medica indonesiana the indonesian journal of internal medicine impact of frailty on cardiovascular disease (and the other way around) esthika dewiasty department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: esthika dewiasty, md., msc. division of geriatrics, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: edewiasty@gmail.com. cardiovascular disesase has been identified as the most frequent cause of death, while frailty has been identified as one of geriatric giants characterized by decreased physiological reserves and increased vulnerability.1 despite of aggressive treatment for cardiovascular diseases such as invasive methods,frail patients who undergo these procedures tend to experience undesirable effects compared to non frail patients.2 as the population of elderly patiens worldwide is growing larger, these issues lead to major health problems that we have to overcome. a s s o c i a t i o n b e t w e e n f r a i l t y a n d cardiovascular disease is still debatable. cardiovascular disease accelerates frailty. on the other hand, frail patients have higher risk of cardiac mortality and major cardiac events due to their complex health status.2 however, by doing good risk prediction and assessment, interventional treatment can be performed safely in selected older patients.3 to date, only a few studies have been conducted to investigate relationship between these two major health problems in elderly. therefore, in this edition we highlight a study which investigate association between frailty and major adverse cardiac events in patients who underwent invasive intervention. further researches are still needed to establish evidences between these two geriatric major health problems. references 1. ekerstad n, swahn e, janzon m, et al. frailty is independently associated with short-term outcomes for elderly patients with non-st segment elevation myocardial infarction. circulation. 2011;124(22):2397404. 2. singh m, rihal cs, lennon rj, et al. outcomes in octogenarians undergoing percutaneous coronary interventions. circ cardiovasc qual outcomes. 2011;4:496-502. 3. lo dky, chan ck, wong jt, et al. outcomes in octogenarians undergoing percutaneous coronary interventions. asian j gerontol geriatr. 2011;6:7-13. 366 original article acta med indones indones j intern med • vol 52 • number 4 • october 2020 the dominance of crf01_ae and the emergence of drug resistance mutations among antiretroviral therapyexperienced, hiv-1-infected individuals in medan, indonesia dw i w. indr iati 1,2, adiana m. witaning r um 2, m. qu shai yunif iar 2, siti q. khairunisa2, shuhei ueda2,3, tomohiro kotaki3, nasronudin2,4, masanori kameoka3 1 department of health, faculty of vocational studies, universitas airlangga, surabaya, indonesia. 2 indonesia-japan collaborative research centre for emerging and re-emerging infectious diseases, institute of tropical disease, universitas airlangga, surabaya, indonesia. 3 department of public health, kobe university graduate school of health sciences, hyogo, japan. 4 faculty of medicine, universitas airlangga, surabaya, indonesia. corresponding author: masanori kameoka. department of public health, kobe university graduate school of health sciences, 7-10-2 tomogaoka, suma-ku, kobe, hyogo 654-0142, japan. email: mkameoka@port.kobe-u.ac.jp. abstrak latar belakang: infeksi human immunodeficiency virus tipe 1 (hiv-1) adalah ancaman kesehatan masyarakat yang serius di seluruh dunia. medan merupakan salah satu kota besar di indonesia dengan prevalensi infeksi hiv-1 yang tinggi; namun, penelitian yang terbatas untuk mendeteksi peredaran subtipe hiv-1 di medan. selain itu, faktor serius yang dapat berimplikasi pada pengobatan orang yang terinfeksi hiv-1 adalah munculnya mutasi yang resisten terhadap obat. oleh karena itu, informasi tentang infeksi hiv-1 penting untuk meningkatkan pengobatan bagi individu yang terinfeksi. metode: enam puluh tujuh orang yang berpengalaman dengan terapi antiretroviral, orang yang terinfeksi hiv-1 diikutsertakan pada penelitian ini. gen hiv-1 pol yang mengkode protease (gen pr) dan reverse transcriptase (gen rt), serta gen env dan gag, diamplifikasi dari dna yang berasal dari sampel darah tepi. subtipe hiv-1 dilakukan untuk mempelajari subtipe hiv-1 dominan yang beredar di wilayah tersebut. selain itu, munculnya mutasi yang resisten terhadap obat dianalisis berdasarkan pedoman yang diterbitkan oleh international antiviral society-united states of america (ias-usa). hasil: subtipe hiv-1 yang dominan ditemukan di medan adalah crf01_ae (77,6%). selain itu, subtipe dan virus rekombinan lain seperti rekombinan pada crf01_ae dan subtipe b (12,2%), subtipe b (4,1%), dan crf02_ag (4,1%) juga ditemukan. mutasi utama terkait resistensi obat ditemukan pada 21,6% (8/37) gen rt dan 3,1% (1/32) gen pr yang diteliti. kesimpulan: penelitian ini menunjukkan bahwa subtipe dominan yang ditemukan pada orang yang berpengalaman dengan art, orang yang terinfeksi hiv yang tinggal di medan adalah crf01_ae. munculnya mutasi yang resisten terhadap obat dalam gen rt dan pr menunjukkan pentingnya memantau prevalensi mutasi yang resisten terhadap obat di antara orang yang terinfeksi hiv-1 di medan. kata kunci: hiv-1, crf01_ae, terapi antiretroviral, resistensi obat, medan. abstract background: human immunodeficiency virus type 1 (hiv-1) infection is a serious public health threat worldwide. medan is one example of big cities in indonesia with a high prevalence of hiv-1 infection; however, quite a limited study had conducted for detecting the circulation of hiv-1 subtypes in medan. in addition, a serious vol 52 • number 4 • october 2020 the dominance of crf01_ae and the emergence of drug resistance 367 factor that can implicate the treatment of hiv-1-infected individuals is the emergence of drug resistance mutations. thus, the information on hiv-1 infection is important to improve the treatment for infected individuals. methods: sixty-seven antiretroviral therapy-experienced, hiv-1-infected individuals were recruited for this study. hiv-1 pol genes encoding protease (pr genes) and reverse transcriptase (rt gene), as well as env and gag genes, were amplified from dna derived from peripheral blood samples. hiv-1 subtyping was conducted to study the dominant hiv-1 subtype circulating in the region. in addition, the emergence of drug resistance mutations was analyzed based on the guidelines published by the international antiviral society-united states of america (ias-usa). results: the dominant hiv-1 subtype found in medan was crf01_ae (77.6%). in addition, another subtype and recombinant viruses such as recombinants between crf01_ae and subtype b (12.2%), subtype b (4.1%), and crf02_ag (4.1%) were also found. drug resistance-associated major mutations were found in 21.6% (8/37) of rt genes and 3.1% (1/32) of pr genes studied. conclusion: our study showed that the dominant subtype found in art-experienced, hiv-1-infected individuals residing in medan was crf01_ae. the emergence of drug resistance mutations in rt and pr genes indicated the importance to monitor the prevalence of drug resistance mutations among hiv-1-infected individuals in medan. keywords: hiv-1, crf01_ae, antiretroviral therapy, drug resistance, medan. introduction the number of reported hiv-1-infected cases in indonesia has increased in the last decade, 2010-2018 with the highest number reported in 2016-2018. the data from the ministry of health showed that, in 2017, there were 48,300 hiv-1 infection cases. meanwhile in 2018, the number dropped to 46.659 cases. in north sumatera, the number of reported hiv-1 infection in 2017 and 2018 was 1,891 and 1,999 cases, respectively, and it was ranked seventh in the number of hiv-1-infected individuals among provinces in indonesia.1 since medan is the capital city of north sumatera province, it is important to study the hiv-1 infection in this city. h i v1 i n f e c t i o n w a s s u c c e s s f u l l y suppressed by the antiretroviral therapy (art). recommended first-line regimens by who in 2019 are dolutegravir (dtg) in combination with a nucleoside reverse transcriptase (rt) inhibitor (nrti) backbone, and efavirenz (efv) in combination with an nrti backbone as the alternative first-line regimen for hivinfected adult. for infants and children, who recommends raltegravir (ral)-based regimen.2 the first-line art regimens recommended by the indonesian ministry of health are tenofovir (tdf), lamivudine (3tc) or emtricitabine (ftc) with efavirenz (efv). alternative firstline regimens which can be applied for hiv-1 infected individuals are 1). zidovudine (azt), 3tc with efv or nevirapine (nvp); and 2). tdf, 3tc or ftc with nvp. recently, the prevalence of drug resistance has increased among individuals on art in indonesia.3,4 this drug resistance can decrease the efficacy of art. meanwhile, it is known that there are two types of drug resistance which acquired drug resistance and transmitted drug resistance (tdr), and tdr is believed to have greater impact on art.5 the prevalence of drug resistance mutations was also found in surabaya and maumere, indonesia, in our previous studies.6,7 thus, it is important to monitor the effectiveness of art and prevalence of drug resistance mutations in other cities in indonesia. we aimed to monitor the prevalence of drug resistance mutations among hiv-1-infected individuals on art. in addition, to reveal the prevalence of drug resistance mutations, molecular epidemiological study to determine the dominant hiv-1 subtype is also needed. a dominant hiv-1 subtype in indonesia is crf01_ae8; however, it cannot rule out the emergence of other subtypes in medan since the information on prevalent hiv-1 subtype is quite scarce in this region. methods sixty seven hiv-1-infected individuals on art (33 male and 34 female, the mean age of 31 years old) were recruited from vct dwi w. indriati acta med indones-indones j intern med 368 program in community health centers in padang bulan medan, north sumatera, indonesia. ten milliliters of ethylenediaminetetraacetic acid (edta)-anticoagulated peripheral blood samples were collected from participants using bd vacutainer®cpt (bd bioscience, san jose, usa) in july 2017. peripheral blood mononuclear cells (pbmc) were isolated using density gradient centrifugation with histopaque (sigma aldrich, usa). after centrifugation at 2,000rpm for 20 minutes, blood samples were separated into plasma, pbmc and red blood cells. after the centrifugation, thin layer ring or buffy coat containing pbmc was formed. dna was extracted from pbmc using the qiaamp dna mini kit (qiagen, hilden, germany). this study was conducted with an approval from the ethics committees of universitas airlangga and kobe university graduate school of medicine. all study participants were requested to sign an informed consent prior to sample calculation. all participants agreed to provide blood samples for this study. polymerase chain reaction (pcr) and sequence analysis the partial fragments of viral pol gene encoding protease (pr gene) and rt (rt gene), as well as gag and env genes, were amplified from dna extracted from pbmc samples by a nested pcr using ex taq (takara bio, shiga, japan) and the following primers. for the amplification of rt gene, the primers for the first pcr were rt1l, 5’-atgatagggggaattggaggttt-3’ [corresponding to nucleotide (nt) 2388 to 2410 of a hiv-1 reference strain, hxb2 (genbank accession no. k03455)] and gpr2m, 5’-ggactaca gtcyacttgtccatg-3’ (nt 4402 to 4380), and the primers for the nested pcr were rt7l, 5’-gacctac acctgtcaacataattgg-3’ ( n t 2 4 8 5 t o 2 5 0 9 ) a n d g p r 3 l , 5’-ttaaaatcactarccattgytctcc-3’ (nt 4309 to 4285). for the amplification of pr gene, the primers for the first pcr were pro5f, 5’-agaaattgcagggcccctaggaa-3’ ( n t 2 0 2 2 t o 2 0 4 4 ) a n d d r p r 0 2 l , 5’-tatggattttcaggcccaatttttga-3’ (nt 2716 t o 2691) , and the pr imer s for nested pcr were pro5f and drpr06, 5 ’ a c t t t t g g g c c at c c at t c c 3 ’ ( n t 2 6 11 t o 2 5 9 2 ) . t h e v i r a l e n v g e n e w a s a m p l i f i e d b y n e s t e d p c r w i t h t h e p r i m e r s m 5 , 5 ’ c c a at t c c c ata c at tat t g t g c c c c a g c t g g 3 ’ ( n t 6 8 5 8 to 6889), and m10, 5’-ccaattgtccct c atat c t c c t c c t c c a g g 3 ’ ( n t 7 6 6 1 to 7632), in the first round, and m3,5’gtcagcacagtacaatgiacacatgg-3’ (nt 6948 to 6973), and m8, 5’-tccttccatggga ggggcatacattgc-3’ (nt 7547 to 7521), in the second round. the viral gag gene was amplified by nested pcr with the primers h1g777, 5’-tcacctagaactttgaatgcatggg-3’ ( n t 1 2 3 1 t o 1 2 5 5 ) , a n d h 1 p 2 0 2 , 5 ’ c t a a t a c t g t a t c a t c t g c t g c t c c t g t3 ’ ( n t 2 3 5 2 t o 2 3 2 5 ) , i n t h e f i r s t r o u n d , a n d h 1 g a g 1 5 8 4 , 5 ’ a a a g at g g ata at c c t g g g 3 ’ ( n t 1577 to 1595), and g17, 5’-tccacatttc caacagcccttttt-3’ (nt 2040 to 2017), in the second round. pcr products were then visualized by ethidium bromide staining under uv light following 1.5% agarose gel electrophoresis. all successfully amplified samples for pr, rt, gag and env genes were then subjected to sequencing analysis using the bigdye terminator v3.1 cycle sequencing kit (applied biosystems, foster city, ca, usa) with an abi prism 3500 xl genetic analyzer following purification step using exosap-it (thermofisher scientific, waltham, usa). sequencing data were then assembled and aligned using genetyx version 10 software (genetyx, tokyo, japan). as the results, the sequencing data of 32 pr genes (297-bp), the n-terminus of 37 rt genes (762-bp), 34 env genes spanning c2-v3 region of gp120 (389bp) and 28 gag genes encoding a part of gag p24 (382-bp) were obtained from 67 blood samples. the nucleotide sequences of these pr, rt, gag and env genes have been deposited in the genbank database under accession numbers mt163520-mt163650. hiv-1 subtyping and the detection of drug resistance mutations hiv-1 subtyping was carried out using the recombinant identification program (rip), available at the website of the hiv sequence database (www.hiv.lanl.gov/). in addition, vol 52 • number 4 • october 2020 the dominance of crf01_ae and the emergence of drug resistance 369 neighbor-joining (nj) trees with a kimura two-parameter model were constructed using mega6.2 software13 with bootstrap values (1,000 replicates) as comparison with those results analyzed with rip. viral subtyping was carried out based on the successfully sequenced pr, rt, env and gag genes, and if there were an incompatibility in the subtype or crf among the pr, rt, gag and env genes, the viral gene was considered to be a recombinant form of hiv-1. drug resistance-associated mutations were studied according to the international antiviral society-united states (ias-usa) report.9 we analyzed drug resistance-associated mutations on rt and pr genes which were the targets of the first line and the second line art regimens in indonesia, respectively. results medan is one of the big cities in indonesia. the majority of hiv-1-infected individuals were batak and javanese. hiv transmission in medan was spread dominantly through sexual intercourse while most (82.8%) study participants were married (table 1). all study participants had experienced art more than a year. they were treated with the first line art regimen as it is suggested for primary treatment by ministry of health in accordance with who regulations. crf01_ae was the dominant hiv-1 subtype found in medan hiv-1 subtypes detected among hiv-1infected individuals in medan were crf01_ae (41 samples), recombinants between crf01_ae and subtype b (6 samples), crf02_ag (2 samples), and subtype b (2 samples) (figure 1). the result showed that the dominant hiv-1 subtype in medan was crf01_ae, indicating that the dominant subtype found in this region was similar to that in other regions in indonesia. since its first appearance in 1990s,10 crf01_ae has been continuously found as a dominant subtype in indonesia. crf01_ae was found in 3 individuals with idu, 4 wives with heterosexual transmission from husband with idu, 17 individuals with heterosexual transmission, 13 homosexual individuals (men who have sex with men or msm), 6 pediatric patients transmitted from mother, and an individual with blood transfusion. recombinants between crf01_ae and subtype b as well as crf02_ag were found among individuals with heterosexual transmission. in addition, subtype b was found in msm and individuals with heterosexual transmission. major and minor drug resistance mutations detected in rt genes most study participants were on art with first-line regimens, azt, 3tc and nvp/efv; or tdf, 3tc and nvp/efv. drug resistance mutations were detected among 9 out of 37 table 1. general characteristic of hiv-1-infected individuals in medan. characteristics value (n=67) age, mean (sd), years 31.0 (10.8) gender, n (%) male 33 (49.3) female 34 (50.8) marital status, n (%) married 48 (82.8) single (divorced/widowed) 10 (17.2) ethnic group, n (%) batak 26 (38.8) malay 5 (7.5) javanese 23 (34.3) chinese 5 (7.5) dayak 1 (1.5) indian 1 (1.5) karo 1 (1.5) mandailing 1 (1.5) minang 2 (3.0) nias 2 (3.0) transmission risk category, n (%) heterosexual 34 (50.8) injecting drug use (idu) 7 (23.9) men having sex with men 16 (23.9) mother to child transmission (mtct) 8 (12.0) blood transfusion 2 (3.0) types of art used, n (%) azt+3tc+nvp 24 (35.8) azt+3tc+efv 10 (14.9) tdf+3tc+efv 21 (31.3) tdf+3tc+nvp 10 (14.9) duration of art, n (%) < 1 year 3 (4.5) 1 – 3 years 24 (35.8) > 3 years 40 (59.7) dwi w. indriati acta med indones-indones j intern med 370 figure 1. phylogenetic tree analysis of hiv-1 rt, pr, env, and gag genes derived from infected individuals residing in medan, indonesia. phylogenetic trees were constructed for the hiv-1 rt (a), pr (b), env (c), and gag genes newly sequenced in the present study (d). the corresponding viral genes of reference hiv-1 strains representing subtypes a1, a2, b, c, d, and g as well as crf01_ae (01_ae), crf02_ag (02_ag), crf15_01b (15_01b), crf33_01b (33_01b), and crf34_01b (34_01b) were included in the analyses (shown in bold letters). sequence ids are presented as a genbank accession number, sample id, or the id of the reference hiv-1 strain, and the subtype or crf of the reference strain (shown in parentheses) in that order. bootstrap values were shown if they were >70. individuals (24.3%) on long-term art. major drug resistance mutations detected in rt genes were e138g (33.3%), k103n (22.2%), and m184v (22.2%). meanwhile, minor drug resistance mutations detected in rt genes were v106i (33.3%), v90i (11.1%) and v179d (11.1%) (table 2). a major and several minor drug resistance mutations were detected in pr genes protease inhibitor is used for the second-line regimens in combination with 2 nrti drugs in indonesia; however, no study participants in the present study were on art with protease inhibitor. therefore, drug resistance mutations vol 52 • number 4 • october 2020 the dominance of crf01_ae and the emergence of drug resistance 371 figure 1. phylogenetic tree analysis of hiv-1 rt, pr, env, and gag genes derived from infected individuals residing in medan, indonesia. phylogenetic trees were constructed for the hiv-1 rt (a), pr (b), env (c), and gag genes newly sequenced in the present study (d). the corresponding viral genes of reference hiv-1 strains representing subtypes a1, a2, b, c, d, and g as well as crf01_ae (01_ae), crf02_ag (02_ag), crf15_01b (15_01b), crf33_01b (33_01b), and crf34_01b (34_01b) were included in the analyses (shown in bold letters). sequence ids are presented as a genbank accession number, sample id, or the id of the reference hiv-1 strain, and the subtype or crf of the reference strain (shown in parentheses) in that order. bootstrap values were shown if they were >70. in pr genes were studied to find tdr in this study. a major drug resistance mutation, i50v, was found in pr gene from a study participant. this major mutation is correlated with the resistance to darunavir/ritonavir (drv/r), lopinavir/ritonavir (lpv/r), and fosamprenavir/ ritonavir (table 3). in addition, 12 minor drug resistance mutations were detected. especially, minor mutations, m36i/k, h69k and l89m/i/v, were detected in all samples (table 3). discussion the dominant hiv-1 subtype, crf01_ae prevalent in medan, was consistently detected in jakarta, bali, east java, west nusa tenggara and other parts of indonesia in previous dwi w. indriati acta med indones-indones j intern med 372 table 2. genotypic characteristics and drug resistance mutations detected in rt genes derived from 9 individuals on art in medan. sample subtype* art status drug resistance mutations** drug resistance nrtis nnrtis med 11 crf02_ag*** 3tc, azt, efv v90i etr med 12 crf01_ae tdf 3tc, efv v106i dor, etr med 17 crf01_ae 3tc, azt, nvp a62v**** k65r m184v k103n e138g abc, ftc, 3tc tdf, ddi, d4t, efv, nvp, rpv, etr med19 crf01_ae 3tc, azt, efv e138g etr, rpv med 25 crf01_ae tdf, 3tc, nvp e138a etr, rpv med 42 crf01_ae tdf, 3tc, efv k103n v106i efv, nvp, dor, etr med 46 crf01_ae tdf, 3tc, nvp v106i dor, etr med 48 crf01_ae 3tc, azt, nvp e138g v179d etr, rpv med 65 crf01_ae 3tc, azt, nvp m184v y181c abc, ftc, 3tc, efv, etr, nvp, rpv * the subtype of rt genes was assigned based on rip and phylogenetic analyses. **the determination of drug resistance mutations was based on the guidelines published by the international antiviral society-united states (ias-usa). ***recombinants crf02_ag ****the letter written in bold was showing major mutation. table 3. genotypic characteristics and drug resistance mutations detected in pr genes derived from 32 individuals on art in medan. mutation* frequency (%) all (n=32) crf01_ae** (n=30) crf02_ ag*** (n=2) l10i/v 4 (12.5) 4 (13.3) 0 (0) g16e 6 (18.8) 6 (20.0) 0 (0) k20r/i 23 (71.9) 22 (73.3) 1 (50.0) m36i/k 32 (100) 32 (100) 0 (0) i50v**** 1 (3.1) 1 (3.3) 0 (0) i62v 5 (15.6) 5 (16.7) 0 (0) l63p 5 (15.6) 3 (10.0) 2 (100) i64v 1 (3.1) 0 (0) 0 (0) h69k 32 (100) 30 (100) 2 (100) v77i 10 (31.3) 10 (33.3) 0 (0) v82i 2 (6.3) 2 (6.7) 0 (0) l89m/i/v 32 (100) 30 (100) 2 (100) i93l/m 5 (15.6) 4 (13.3) 1 (50.0) *the determination of drug resistance mutations was based on the guidelines published by the international antiviral society united states (ias-usa). ** the subtype of pr genes was assigned based on rip and phylogenetic analyses. *** recombinants crf02_ag ****the letter written in bold was showing major mutation. studies.6,11–14 different transmission routes could account for the transmission of different hiv-1 subtypes. previous studies by merati et al,14 20128 showed that crf01_ae was more frequently found among individuals with idu rather than individuals with other transmission routes in indonesia. in contrast, subtype b were more frequently found among individuals with the heterosexual transmission. however, interestingly in our results, recombinant viruses containing crf01_ae gene fragment, rather than b subtype, were frequently detected among individuals with the heterosexual transmission. our results were also in accordance with our previous results showing that crf01_ae were frequently detected among female sex workers.15 another recombinant form, crf02_ag, was found in this study. interestingly, the emergence of crf02_ag was also detected in other parts of indonesia in recent studies.16–18 crf02_ag was first detected from frozen serum samples collected in the democratic republic of the congo (former zaire) in 1976.19 similarity could be found between crf01_ae and crf02_ag throughout their genome, and both of them were rapidly and largely transmitted by heterosexual transmission.20 however, its appearance in indonesia needs to be further studied in order to reveal its role in the hiv-1 epidemic in indonesia. vol 52 • number 4 • october 2020 the dominance of crf01_ae and the emergence of drug resistance 373 among the hiv-1 subtype, the difference in cellular tropism or coreceptor usage, ccr5 (r5) and cxcr4 (x4), was reported,21,22 and it was related to hiv-1 pathogenesis. studies on coreceptor usage have been extensively conducted on hiv-1 subtype b and c, but not for other subtypes and crfs. therefore, further researches are required on subtypes and recombinants detected in this study. generally, r5 viruses were detected over the entire course of disease progression after hiv-1 infection while x4 viruses were usually found in the late stage of disease progression. x4 vir uses were found in the late stage of disease progression for most hiv-1 subtypes except subtype c. the switch in coreceptor usage between r5 and x4 was correlated with faster cd4+-t cell decline and rapid development to aids.23–25 acquired drug resistance mutations were detected in rt genes (24.32%). this number was consistent with those in our previous results in bali, maumere, and kepulauan riau.6,13,17 drug resistance mutations among individuals on art have been detected in many other asian countries such as nepal26 and china.27 major drug resistance mutations found in rt genes were correlated with the resistance against first-line regimens of art in indonesia. drug resistance mutations against nucleoside rt inhibitors (nrtis), abc, ftc, 3tc, and tdf were detected in 2 out of 9 individuals while the mutations against non-nucleoside rt inhibitors (nnrtis), etr, rvp, efv, and nvp were detected among 9 all individuals. artexperienced individuals failing first-line art regimen were subjected to second-line regimens, which is tdf or azt, 3tc or ftc with lpv/r. although no study participants were on art with protease inhibitors, we investigated drug resistance mutations in pr genes as tdr. a major drug mutation, i50v, was detected in a pr gene. the emergence of tdr potentially compromises second-line art regimens in indonesia; thus, we believe it is important to continue monitoring the appearance of tdr in pr genes in a future study. minor drug resistance mutations detected in pr genes were m36i, h69k, and l89i. those mutations were associated with natural polymorphisms detected among crf01_ae viruses.28 conclusion the dominant hiv-1 subtype found in medan, south sumatera, was crf01_ae. several other subtypes and recombinant viruses including crf02_ag were also detected. in addition, antiretroviral drug resistance mutations were observed in rt and pr genes. resistance mutations against rt inhibitors were found in 24.3% of art-experienced individuals. we also detected a major mutation in a pr gene (3.1%). our results suggest the importance of continuous surveillance studies on hiv-1 subtypes and drug resistance mutations among art-experienced individuals. references 1. ri dpkk. laporan perkembangan hiv aids dan pims di indonesia. 2018. available from http://icjr.or.id/data/wp-content/uploads/2019/08/ penanggulangan-hiv-dalam-ancaman-r-kuhp.pdf. 2. world health organization (who). update of first and second line antiretroviral regimens. who. 2019. available from https://apps.who.int/iris/bitstream/ handle/10665/325892/who-cds-hiv-19.15-eng. pdf?ua=1. 3. hong sy, nachega jb, kelley k, et al. the global status of hiv drug resistance: clinical and public-health approaches for detection, treatment and prevention. infect disord drug targets. 2011;11(2):124–33. 4. hosseinipour mc, gupta rk, van zyl g, et al. emergence of hiv drug resistance during firstand second-line antiretroviral therapy in resource-limited settings. j infect dis. 2013;207 suppl 2:s49–56. 5. takuva s, louwagie g, zuma k, et al. durability of first line antiretroviral therapy: reasons and predictive factors for modifications in a swaziland cohort. j antivirals antiretrovir. 2012;4(1):014–20. 6. indriati dw, kotaki t, khairunisa sq, et al. appearance of drug resistance mutations among the dominant hiv-1 subtype, crf01_ae in maumere, indonesia. curr hiv res. 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et al. hiv-1 entry cofactor: functional cdna cloning of a seventransmembrane, g protein-coupled receptor. science. 1996;272(5263):872–7. 23. koot m, keet ip, vos ah, et al. prognostic value of hiv-1 syncytium-inducing phenotype for rate of cd4+ cell depletion and progression to aids. ann intern med. 1993;118(9):681–8. 24. karlsson a, parsmyr k, sandstrom e, et al. mt-2 cell tropism as prognostic marker for disease progression in human immunodeficiency virus type 1 infection. j clin microbiol. 1994;32(2):364–70. 25. esbjörnsson j, månsson f, martínez-arias w, et al. frequent cxcr4 tropism of hiv-1 subtype a and crf02_ag during late-stage disease indication of an evolving epidemic in west africa. retrovirology. 2010;7:1–13. 26. bhusal n, sutthent r, horthongkham n, et al. prevalence of hiv-1 subtypes and antiretroviral drug resistance mutations in nepal. curr hiv res. 2016;14(6):517-24. 27. luo xl, mo ld, su gs, et al. incidence and types of hiv-1 drug resistance mutation among patients failing first-line antiretroviral therapy. j pharmacol sci. 2019;139(4):275–9. 28. iemwimangsa n, pasomsub e, sukasem c, et al. surveillance of hiv-1 drug-resistance mutations in thailand from 1999 to 2014. southeast asian j trop med public health. 2017;48(2):271–81. 52 original article acta med indones indones j intern med • vol 53 • number 1 • january 2021 clinical evaluation of hiv/aids patients on antiretroviral therapy using hiv symptoms index: a reliability and applicability evaluation using indonesian language khalid m. shidiq1, erni j. nelwan2, evy yunihastuti3, kuntjoro harimurti4, herdiman t. pohan2 1 department of internal medicine, faculty of medicine universitas indonesia-cipto mangunkusumo hospital, jakarta, indonesia. 2 division of tropical and infectious disease, department of internal medicine, faculty of medicine universitas indonesia-cipto mangunkusumo hospital, jakarta, indonesia. 3 allergy and immunology division, department of internal medicine, faculty of medicine universitas indonesiacipto mangunkusumo hospital, jakarta, indonesia. 4 board of fellow, center for clinical epidemiology and evidence-based medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: erni j. nelwan, md, phd. division of tropical and infectious disease, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: ejnelwan@yahoo.com. abstrak latar belakang: hiv/ aids merupakan penyakit kronis seumur hidup dengan spektrum klinis yang luas yang dapat menurunkan kualitas hidup. pengukuran gejala obyektif penting karena berhubungan dengan kepatuhan pengobatan dan progresivitas penyakit. saat ini, tidak ada alat klinis yang tersedia untuk mengevaluasi gejala infeksi hiv dan efek samping pengobatan untuk pengaturan rawat jalan. penelitian ini bertujuan untuk menilai keandalan indeks gejala hiv versi indonesia untuk mengukur gejala pasien hiv/ aids, dan menggunakannya untuk menilai profil gejala mereka. metode: penelitian cross sectional pada pasien rawat jalan penderita hiv / aids (n = 87) yang direkrut di poliklinik hiv rsud cipto mangunkusumo periode september-november 2018. indeks gejala hiv terdiri dari 20 item evaluasi somatik, psikis, dan kombinasi keduanya. gejala, dan ‘adaptasi bahasanya ke bahasa indonesia dilakukan dengan metode beaton dan guillemin. reliabilitas indeks gejala hiv versi indonesia diuji dengan analisis koefisien alpha cronbach, dan validitas internal diuji dengan analisis multitrait scaling sebelum digunakan untuk profil pola gejala pasien hiv/ aids. hasil: indeks gejala hiv versi indonesia dapat diandalkan (cronbach alpha 0.76) dan valid (korelasi multitrait> 0.4) untuk mengukur gejala pasien hiv/ aids. gejala yang paling umum adalah kelelahan (55,7%), diikuti insomnia (43,3%), pusing dan pusing (42,3%), masalah kulit (42,3%), dan nyeri, mati rasa, atau kesemutan pada tangan atau kaki (39,2%) . kesimpulan: indeks gejala hiv versi indonesia dapat diandalkan dan valid untuk mengukur gejala penderita hiv / aids secara obyektif. kata kunci: gejala, hiv/aids, evaluasi klinis. abstract background: hiv/aids is a chronic, lifelong disease with a wide clinical spectrum which could decrease the quality of life. objective symptoms measurement is important because it is correlated to treatment adherence vol 53 • number 1 • january 2021 clinical evaluation of hiv/aids patients on antiretroviral therapy 53 and progressivity of the disease. currently, there is no clinical tool available to evaluate symptoms of hiv infection and the treatment’s side effect for the outpatient setting. this study aimed is to assess the reliability of the indonesian version of hiv symptom index for measuring symptoms of hiv/aids patients, and use it for assessment of their symptom profile. methods: this is a cross sectional study in outpatient hiv/aids subjects (n=87) recruited in cipto mangunkusumo hospital’s hiv clinic from september-november 2018. the hiv symptom index consisted of 20 items evaluating somatic, psychologic, and the combination of both symptoms, and its’ language adaptation to indonesian was done with beaton and guillemin method. reliability of the indonesian version of hiv symptom index was tested by alpha cronbach’s a coefficient analysis, and the internal validity was tested with multitrait scaling analysis before being used to profile the symptom pattern of hiv/ aids patients. results: indonesian version of hiv symptom index is reliable (cronbach alpha 0.76) and valid (multitrait correlation >0.4) for measuring symptoms of hiv/aids patients. the most common symptom is fatigue (55.7%), followed by insomnia (43.3%), dizziness and lightheadedness (42.3%), skin problems (42.3%), and pain, numbness, or tingling in the hands or feet (39.2%). conclusion: indonesian version of hiv symptom index is reliable and valid to measure symptoms of hiv/aids patiens objectively. keywords: symptom, hiv/aids, clinical evaluation. introduction hiv/aids infection is a global epidemic disease with increasing burden. despite the decreasing mortality due to antiretroviral (arv) therapy, hiv/aids is still a fifth leading cause of morbidity and disability.1,2 hiv has a wide clinical spectrum, and since it’s a chronic disease with no total cure yet possible, symptoms and quality of life are very important to attend to.3,4 arv therapy has a big impact on the clinical presentation of hiv patients. clinical improvement after arv therapy may decrease patient’s symptoms, but adverse effects of arv may cause new symptoms.4,5 these clinically stable patients could still deal with chronic, not severe symptoms on a daily basis either caused by the hiv related problems or side effects of the therapies. these symptoms in a long term might be causing disturbance in patient’s life, since symptoms of hiv patients are correlated with adherence to therapy, depression, and possibly the quality of life.1,5 it is important to detect symptoms accurately in such patients, and to monitor the progress objectively in a routine evaluation.6-8 thus a tool that is more sensitive and measurable than a routine anamnesis by a doctor is needed.7,8 in this study we used hiv symptom index developed by justice et al,5 because it is a simple, self-reported questionnaire that was developed by comparing and improving several tools, and only took no longer than 5 minutes to finish. methods the ethical committee of the faculty of medicine universitas indonesia cipto mangunkusumo hospital has given their approval for this study (no. 0850/un2.f1/etik/ 2018). this cross-sectional study used random sampling method from hiv clinic’s enrollment sequence to include hiv/ aids patients aged 18 years and over who had received arv therapy for at least 6 months who came to seek treatment at upt hiv rscm in august to september 2018. patients who were not able to read or write, do not understand indonesian, use anti-anxiety drugs, anti-depressants, and psychotropic drugs, and those whose medical history is incomplete are excluded from the study. a self-reported hiv index symptoms consisted of 20 questions. language adaptation from the original english version into indonesian was done with beaton and guillemin method. this research is broadly divided into preanalysis and analysis stages. the pre-analysis stage includes the process of language and cultural adaptation and the final stage, namely the reliability test and validity of the hiv symptom index. reliability was assessed by the test-retest test with a 14-day interval and internal consistency was analyzed using cronbach’s alpha coefficient. reliability is rated as adequate if it is > 0.70 and optimal if > 0.80. construct validity was assessed by a multitrait scaling analysis that assessed khalid m. shidiq acta med indones-indones j intern med 54 convergence and discrimination from validity. convergence is said to be significant if> 0.40 and discrimination is said to be meaningful if the correlation coefficient between items and domains is higher than other domains. next the tested questionnaire was given to a larger sample.9,10 the results of filling out the hiv symptom index questionnaire were presented descriptively to obtain symptomatic profiles of hiv patients. data analysis was carried out using the spss program. data on socio-demographic, clinical characteristics and health-related quality of life are described using descriptive statistical methods. validity test for the hiv symptom index questionnaire was carried out using a multitrait scaling approach, whereas reliability testing with interclass correlation coefficient (icc). we calculated the reliability of the questionnaire following the retest method by assessing the correlation coefficient of the first and eighth day hiv symptom index questionnaire. further reliability analysis was done by calculating the internal consistency of the questionnaire by calculating the cronbach α.9,10 descriptions of symptoms of hiv patients are delivered in the form of frequency of symptoms (presentation of each symptom) and total score. the total score is calculated by summing the numbers of each symptom (0 = no symptoms, 1 = no disturbing symptoms, 2 = there are symptoms that are a little annoying, 3 = there are disturbing symptoms, 4 = there are very disturbing symptoms), with a minimum score of 0 and maximum 80.5 hiv symptoms are compared between patients with male and female gender, cd4 above 350 and below 350, detectable and undetectable viral load , and line 1 and line 2 arv therapy. results of the 155 randomized subjects, 48 subjects did not meet the inclusion / exclusion criteria. the remaining 107 patients were subjected to a preanalysis of 20 patients and subjects analyzed by 87 patients. a valid and reliable questionnaire was used to assess symptoms in 87 hiv patients with characteristics as in table 1. language and culture adaptation in the pre analysis of language and culture adaptation, the final language and cultural adaptation of the hiv index symptoms questionnaire into indonesian. (table 2) tests for the reliability and validity of the hiv symptom index questionnaire was done on 20 subjects with good results (cronbach alpha > 0.7). results can be seen in table 3. test the reliability and validity of the hiv symptom index the internal validity test of the hiv symptom index shows a good correlation (r> 0.4) between each item with a domain score, and an optimal correlation (r> 0.8) between domain scores and total scores. results can be seen in table 4. table 1. characterictics of study subjects. variables, n (%) frequency (n = 87) gender man 64 ( 73,6 ) woman 23 (26.4 ) age, average (sd) 38.91 ( 8.63 ) education low 10 (11.5 ) middle class 40 (46.0 ) high 37 (42.5 ) income < regional minimum wage 30 (345) > regional minimum wage 57 (65.5) marital status married 45 (51.7) unmarried 42 (48.3) cd4 , mean (sd) 464.80 (320.23) hospitalization in 3 months yes 5 (5.7) no 82 (94.3) viral load detected undetected no data 18 (20.68) 40 (45.97) 29 (33.33) arv therapy 1st line 2nd line(with a protease inhibitor) 77 (88.5) 10 (11.5) risk factors for transmission syringes 34 (39.1) homosexual 17 (19.5) free sex (heterosexual) 31 (35.6) do not know 2 (2.3) no answer 3 (3.4) vol 53 • number 1 • january 2021 clinical evaluation of hiv/aids patients on antiretroviral therapy 55 table 2. indonesian version of hiv symptom index. indeks simtom hiv nama pasien usia nomer rekam medis tanggal nomer protokol kode instruksi : jawablah pertanyaan berikut dengan membubuhkan tanda centrang (√) pada jawaban yang dianggap paling tepat. a. pertanyaan-pertanyaan di bawah ini berkaitan dengan simtom/keluhan-keluhan yang pernah saudara alami dalam 4 minggu terakhir. mohon berikan tanda centang (√) pada lingkaran yang paling sesuai selama saudara mengalami masing-masing keluhan tersebut. (pilih salah satu √) saya tidak memiliki keluhan ini saya memiliki keluhan ini dan keluhan ini tidak mengganggu saya sedikit mengganggu saya mengganggu saya sangat mengganggu saya 1 kelelahan atau kurang energi?      0 1 2 3 4 2 demam, menggigil, atau berkeringat?      0 1 2 3 4 3 pusing atau kliyengan?      0 1 2 3 4 4 nyeri, mati rasa, atau kesemutan di tangan atau kaki?      0 1 2 3 4 5 kesulitan mengingat?      0 1 2 3 4 6 mual atau muntah?      0 1 2 3 4 7 diare atau sulit buang air besar?      0 1 2 3 4 8 merasa sedih, putus asa, atau depresi?      0 1 2 3 4 9 merasa cemas atau gelisah?      0 1 2 3 4 10 tidak bisa tidur atau mudah terbangun?      0 1 2 3 4 11 masalah pada kulit, seperti kemerahan, kering, atau gatal-gatal?      0 1 2 3 4 12 batuk-batuk atau sulit bernafas?      0 1 2 3 4 13 sakit kepala?      0 1 2 3 4 14 hilang nafsu makkan atau perubahan cita rasa makanan yang dikonsumsi?      0 1 2 3 4 khalid m. shidiq acta med indones-indones j intern med 56 (pilih salah satu √) saya tidak memiliki keluhan ini saya memiliki keluhan ini dan keluhan ini tidak mengganggu saya sedikit mengganggu saya mengganggu saya sangat mengganggu saya 15 perut kembung, nyeri perut, atau gas dalam lambung?      0 1 2 3 4 16 nyeri pada otot atau tulang/sendi?      0 1 2 3 4 17 masalah seksual, seperti kehilangan hasrat, impoten, atau sulit mencapai kepuasan seksual      0 1 2 3 4 18 perubahan bentuk tubuh seperti penumpukan lemak atau bertambah berat badan?      0 1 2 3 4 19 berat badan menurun atau menjadi kurus?      0 1 2 3 4 20 rambut rontok atau kusam?      0 1 2 3 4 profile of symptoms of hiv patients symptoms of hiv patients as measured by the hiv symptom index can be seen in table 5. the five symptoms most experienced by subjects were fatigue (55.7%), dizziness / keliyengan (43.3%), sleep disorders (43.3%), skin problems (42.3%), and pain, numbness , or tingling in the hands and feet (39.2%). the most moderate-to-severe symptoms (score 3-4) were the skin disorders (13.4%), dizziness (10.3%) and headaches (10.3%). the most disturbing symptoms with the most intensity are hair loss table 4. internal validity test results. internal validity test correlation coefficient p mental domain total score 0.871 <0.001 physical domain total score 0.865 <0.001 or dullness (6.2%), headache (5.2%) and skin problems (5.2%). discussion average of subject’s ages is 38.78 years, and male sex proportion is 72,9%. these findings are comparable to data from the republic of indonesia ministry of health in 2018, where the highest presentation of hiv infection was at the age of 25-49 years at 70.2%, and proportion of male to female hiv sufferers are 2: 1.11 interesting data can be seen in the patient’s income and education status. 67.1% of the subjects had income above the regional minimum wage, and 88.3% of the subjects had a secondary education level. this is quite different from other studies which show that patients with low education levels tend to have a higher risk of experiencing hiv. even the research by nokes et al illustrates that 75% of hiv sufferers in their study did not have jobs.12,13 most risk factors for hiv transmission are through needles (39.1%), followed by h e t e r o s e x u a l ( 3 5 . 6 % ) a n d h o m o s e x u a l s (19.5%). this finding is in contrast with the table 3. reliability test results with cronbach alpha. cronbach alpha mental domains 0.842 physical domains 0.878 mental domain / physical-total score 0.760 vol 53 • number 1 • january 2021 clinical evaluation of hiv/aids patients on antiretroviral therapy 57 table 5. symptoms of subjects based on hiv symptom index. symptoms symptoms severity (n = 8 7) * 0 1 2 3 4 fatigue or loss of energy, n (%) fever, chills, or sweating, n (%) dizziness or lightheadedness, n (%) pain, numbness or tingling, n (%) trouble remembering, n (%) nausea or vomiting, n (%) diarrhea or loose bowel movement, n (%) sad, down, or depressed, n (%) nervous or anxious, n (%) difficulty falling or staying asleep, n (%) skin problems, n (%) cough or difficulty breathing, n (%) headache, n (%) loss of appetite, n (%) bloating, pain or gas in stomach n (%) muscle aches or joint pain, n (%) sexual problems, n (%) body shape changes, n (%) weight loss or wasting, n (%) hair loss or changes, n (%) 43 (44.3) 82 (84.5) 55 (56,7) 59 (60.8) 61 (62,9) 77 (79.4) 76 (78.4) 73 (75.3) 66 (68.0) 55 (56,7) 56 (57.7) 77 (79.4) 60 (61,9) 74 (76.3) 67 (69,1) 63 (64,9) 69 (71,1) 64 (66.0) 72 (74.2) 72 (74.2) 22 (22,7) 10 (10.3) 18 (18,6) 17 (17,5) 23 (23,7) 12 (124) 17 (17,5) 13 (13.4) 13 (14.4) 22 (22,7) 17 (17,5) 12 (12.4) 15 (15,5) 13 (13.4) 17 (17,5) 16 (16,5) 10 (10.3) 20 (20,6) 14 (14.4) 12 (12.4) 22 (24,7) 2 (2,1) 12 (12.4) 12 (12.4) 8 (8.2) 3 (3,1) 4 (4,1) 8 (8.2) 12 (12.4) 11 (11,3) 11 (11,3) 3 (3,1) 12 (12.4) 4 (4,1) 8 (8.2) 12 (12.4) 14 (4,4) 7 (7.2) 5 (5,2) 6 (6.2) 6 (6.2) 2 (2,1) 6 (6.2) 7 (7.2) 4 (4,1) 3 (3,1) 0 1 (1,0) 2 (2,1) 5 (5,2) 8 (8.2) 1 (1.0 5 (5,2) 3 (3,1) 3 (3,1) 3 (3,1) 4 (4,1) 4 (4,1) 2 (2,1) 1 (1,0) 2 (2,1) 1 (1,0) 4 (4,1) 2 (2,1) 1 (1,0) 2 (2,1) 0 2 (2,1) 3 (3,1) 4 (4,1) 5 (5,2) 4 (4,1) 5 (5,2) 3 (3,1) 2 (2,1) 3 (3,1) 0 2 (2,1) 4 (4,1) 6 (6.2) * the severity of symptoms is expressed on a scale: 0 = no symptoms 1 = has symptoms but does not interfere 2 = has symptoms and is a little annoying 3 = having symptoms and disturbing 4 = has symptoms and is very disturbing report of the indonesian ministry of health in 2018 where the use of non-sterile syringes was only 8.6% of the risk factors for hiv infection, and the majority were heterosexual (70.2%).11 this study was intended for outpatients who had received arv therapy, the majority of the study subjects (71%) were at the who clinical stage 1. this was in accordance with the cd4 value where 74.7% of the study subjects had cd4 levels above 200. most ( 79.32%) research subjects also had undetectable levels of viral load. the hiv symptom index questionnaire detects more symptoms in patients than routine evaluation with history taking. by filling out the questionnaire 90.8% of patients had at least one complaint, albeit not disturbing. with history taking, only 20.6% of patients had complaints. this finding is in accordance with a previous study by justice et al in 1999, where symptomatic surveys filled by patients were more sensitive than symptom surveys asked by health workers.7,8 several factors can explain these findings, the first routine evaluation by the doctor uses more open questions, while on the questionnaire every important symptom is asked in private.second, during interviews with doctors, patients cannot remember and convey all the symptoms they experience, not only when they meet with a doctor but daily complaints that are felt at home, especially if the complaints felt by patients are relatively mild or do not interfere with daily activities. third, doctors tend to ignore complaints that are not considered important, and some doctors still have a discriminatory feeling towards people with hiv who tend to underestimate some of the patient’s complaints because they think the patient deserves the the symptoms and condition.7,8,13,14 based on clinical symptoms obtained from the indonesian version of hiv symptom index, 5 khalid m. shidiq acta med indones-indones j intern med 58 most common symptoms were fatigue (55.7%), sleep disturbances (43.3%), dizziness (42.3%), skin problems (42.3%), and pain, numbness or tingling in the hands or feet (39.2%). among these symptoms the most disturbing intensity was skin problems (13.4%), dizziness (10.3%), and headache (10.3%). these complaints can be caused by various mechanisms. fatigue can be caused by direct hiv infection, opportunistic infections, malnutrition, depression, or side effects of arv drugs. dizziness can be caused by encephalitis, hiv infection, or arv side effects. sleep disorders can be caused by depression, anxiety, encephalopathy, or arv side effects. skin problems can be caused by hiv infection, opportunistic infections, malnutrition, or sexually transmitted diseases. pain, numbness, tingling can be caused by hiv infection, arv side effects or tb treatment, diabetes mellitus, aging, alcohol consumption.15-18 if further analyzed, opportunistic infections were only experienced by 11.34% of patients, mostly only candidiasis, and all patients had received appropriate therapy. patients with tb treatment were only 9%, and had received vitamin b6 supplements. encephalitis is only experienced by 3.4% of patients. hiv infection in more than 70% of patients has improved, cd4 values of less than 200 are only found in 25.3% of patients, and viral load is still detected in only 20.58% of patients. sad/depressed complaints were only experienced by 24.7% of patients, anxiety was only experienced by 32% of patients and 14.4% did not interfere. based on these data, it is likely that these complaints were caused by side effects of arv drugs.17 fatigue can be caused by the use of zidovudine and efavirenz, sleep disturbances and dizziness can be caused by efavirenz, emtricitabine, indinavir, dolutegavir.17,18 pain, numbness and tingling can be caused by the use of zidovudine and lamivudine.17 the few complaints that the patients complained were fever (15.5%), cough (20.6%), nausea (21.6%), diarrhea (21.6%). symptoms of fever, cough, and diarrhea are most often caused by opportunistic infections, because the subjects in this study had received arv therapy and therapy for opportunistic diseases, those complaints appeared less. this has similarities with the first study using hiv symptom index by justice et al, in which the most common symptoms and the most disturbing are fatigue, pain, and muscle pain.5 in this study there were several symptoms that showed a large enough difference between men and women. in men there are more complaints of fever, cough, and diarrhea. these symptoms are mostly caused by opportunistic infections. in addition, in men also more complaints of weight loss and loss of appetite, which may be caused by hiv-related symptoms. the cause of these findings is the difference in pathogenesis and immunological response to hiv infection between men and women. in women, activation of cd8 + t lymphocyte cells is higher than that of men, besides that the expression of interferon is also higher in women. women tend to have lower levels of hiv viral load in the early phase of infection.19 women are more likely to have viral control phenotypes than men.19 a meta-analysis by hongbo jiang et al.20 also showed that women were less likely to experience advance case of hiv infection and late presentation than men. responses to arv therapy differ between sexes, where women tend to experience better cd4 cell gains.20in addition, more men smoke cigarettes, which may increase coughing complaints. in women there are more complaints of disorders of the hair, skin problems, body shape disorders. these complaints are more experienced by women, perhaps because psychologically women are more concerned with their appearance.19 in addition, women also complain more about dizziness, headache, and joint pain. one that might cause this is the pain threshold in women is lower than that of men. the difference was not due to differences in clinical stage, cd4 level, viral load, or arv therapy, in the two groups there was no significant difference (p> 0.05). conclusion patients with detectable viral load had a higher percentage of complaints on all symptoms compared to the group of patients with an undetectable viral load. this is consistent with the pathophysiology of hiv/ aids where viral load usually becomes undetectable as the treatment progresses and the patient’s cd4 vol 53 • number 1 • january 2021 clinical evaluation of hiv/aids patients on antiretroviral therapy 59 increases. similar results were obtained by the studies of justice et al and muhammad et al who showed symptoms and patients’ quality of life was worse in patients who had a detectable viral load. 9,10 indonesian version of hiv symptom index is reliable and valid to measure symptoms of hiv/aids patients. most frequent symptoms are fatigue or weakness, dizziness or lightheadedness, insomnia, skin problems, and pain, numbness, or tingling in the hands or feet. further investigation should provide better solution for those symptoms in terms of causality. references 1. ortblad kf, lozano r, murray cjl. the burden of hiv: insights from the global burden of disease study 2010. aids. 2013;27(13):2003–17. 2. who 2014. who the top 10 causes of death . fact sheet n°310 (updated may 2014). 2014. available on: http://www.who.int/mediacentre/factsheets/ fs310/en/ pada 10 oktober 2017. 3. world health organization. prevalence of hiv among adults aged 15-49 (%). 2013. available on: http://www. who.int/gho/hiv/epidemic_status/ prevalence/en/ pada 10 oktober 2017. 4. unaids. global aids update 2016. world health organization . 2016; march:422. available on: http:// www.unaids.org/sites/default/files/ media_asset/ unaids_gap_report_en.pdf pada 15 oktober 2017 5. justice ac, holmes w, gifford al, et al. development and validation of a self-completed hiv symptom index. j clin epidemiol. 2001;54-12.1. 6. whalen cc, antani m, carey j, landefeld cs. an index of symptoms for infection with human immunodeficiency virus: reliability and validity. j clin epidemiol. 1994;47(5):537–46. 7. justice ac, chang ch, rabeneck l, zackin r. clinical importance of provider-reported hiv symptoms compared with patient-report. med care. 2001;39(4):397–408. 8. justice ac, rabeneck l, hays rd, wu aw, bozzette sa, group oc of the act. sensitivity, specificity, reliability, and clinical validity of provider-reported symptoms: a comparison with self-reported symptoms. j acquir immune defic syndr. 1999;21: p. 126–33. 9. sastroasmoro s, ismael s. dasar-dasar metodologi penelitian klinis. jakarta: sagung seto; 2011. p. 25–32. 10. muhammad nn, shatri h, djoerban z, abdullah m. validity and reability test of indonesian version of world health the quality of life patients with hiv/ aids uji kesahihan dan keandalan kuesioner world health organization quality of life-hiv bref dalam bahasa indonesia untuk mengukur kualitas hidup pa. j penyakit dalam indones. 2017;4(3):112–8. 11. ditjen p2p kementrian kesehatan ri. laporan situasi perkembangan hiv-aids dan pims di indonesia 2018. jakarta: dirjen p2p kemenkes; 2018. p. 1. 12. nokes km, kendrew j, rappaport a, jordan d, rivera l. development of an hiv educational needs assessment tool. j assoc nurses aids care. 1997;8(6):46–51. 13. murri r, fantoni m, borgo c del, visona r, barracco a, zambelli a. determinants of health-related quality of life in hiv-infected patients. aids care. 2010;15:4:581–90. 14. kilbourne am, justice ac, rollman bl, et al. clinical importance of hiv and depressive symptoms among veterans with hiv infection. j gen intern med. 2002;17(7):512–20. 15. maartens g, celum c, lewin sr. hiv infection: epidemiology, pathogenesis, treatment, and prevention. lancet. 2014;384(9939):258–71. 16. agustriadi o, sutha ib. aspek pulmonologis infeksi oportunistik pada infeksi hiv/aids. j peny dalam. 2008;9(3):233–44. 17. carr a, cooper da. adverse effects of antiretroviral therapy. lancet. 2000;356(9239):1423–30. 18. ammassari a, murri r, pezzotti p, et al. self-reported symptoms and medication side-effects influence adherence to highly active antiretroviral therary in persons with hiv infection. vol. 28, jaids. 2001. 445–9. 19. scully ep. sex differences in hiv infection. curr hiv/ aids rep. 2018;15(2):136-46. 20. jiang h, yin j, fan j, zhang z, liu l, nie s. gender difference in advance hiv disease and late presentation according to european consensus definition. sci rep. 2015: 5 (1453). 102 original article acta med indones indones j intern med • vol 52 • number 2 • april 2020 the role of acute hyperglycemia on the risk of malignant arrhythmia in acute myocardial infarction patients: a study of myocardial damage, ion channel changes and inflammatory factors sally a. nasution1, idrus alwi1, imam subekti1, m. yamin1, suhendro1, kuntjoro harimurti1,2, suzanna immanuel3, abdul majid4, esther elizabeth5, chairul n. azali6 1 department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 2 center of clinical epidemiology and evidence based medicine (ceebm), faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 3 department of clinical pathology, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 4 siloam dhirga surya hospital, medan, indonesia. 5 faculty of medicine, diponegoro university, semarang, indonesia. 6 faculty of medicine, university of north sumatera, medan, indonesia. corresponding author: sally aman nasution, md, phd. division of cardiology, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: sallynasution@gmail.com. abstrak latar belakang: infark miokard akut (ima) sering kali diikuti oleh hiperglikemia. sampai saat ini, belum ada penelitian terkait peran kerusakan miokard, perubahan saluran ion dan peningkatan respons inflamasi sebagai patomekanisme aritmia ganas akibat hiperglikemia pada pasien ima. tujuan penelitian ini untuk mengetahui pengaruh hiperglikemia akut pada kejadian aritmia ganas, troponin i, vlp, galur ekokardiografi, perubahan saluran ion (camkii) dan hscrp. penelitian ini juga bertujuan untuk menilai efek troponin i, vlp, gls, camkii dan hscrp pada terjadinya aritmia ganas pada pasien ima dengan hiperglikemia akut. metode: studi potong lintang diikuti oleh studi kohort dilakukan pada pasien ima yang dirawat di iccu rs cipto mangunkusumo jakarta selama periode november 2018 hingga mei 2019. pasien dengan infeksi parah dan mengalami aritmia ganas tidak diikutsertakan dalam penelitian ini. terjadinya aritmia ganas sebagai hasil utama dari penelitian ini dan tingkat camkii dinilai pada hari kelima pengobatan. pasien yang meninggal sebelum hari kelima pengobatan karena penyebab selain aritmia ganas dikeluarkan dari analisis. hubungan antara hiperglikemia akut dengan vlp dan kejadian aritmia ganas dianalisis melalui uji chi-square, sedangkan perbedaan antara troponin i, gls, camkii dan hscrp, berdasarkan status hiperglikemia pasien, dianalisis oleh uji u mann-whitney. hasil: total 110 pasien dilibatkan dalam penelitian ini. dua pasien meninggal pada hari ketiga pengamatan karena aritmia ganas. tidak ditemukan hubungan bermakna antara hiperglikemia akut pada ima dan aritmia ganas (rr=1,38, 95% ci 0,503,77). ada perbedaan tingkat camkii pada hari-1 dan hari-5 antara mereka yang mengalami arrhytmia ganas dan mereka yang tidak (p-value untuk perbedaan masing-masing adalah 0,03 dan 0,01. pada kelompok hiperglikemia akut, ada ada perbedaan tingkat camkii hari ke-5 antara vlp positif dan negatif (p=0,03). kesimpulan: tahap awal ima menyebabkan kerusakan miokard yang lebih dominan, dibandingkan dengan faktor metabolik. pada tahap ima berikutnya, hiperglikemia akut meningkatkan ros dan aktivasi perubahan saluran vol 52 • number 2 • april 2020 the role of acute hyperglycemia on the risk of malignant arrhythmia in ami 103 ion yang dijelaskan oleh camkii. perubahan ini menghasilkan remodeling elektrofisiologis jantung, seperti yang terlihat pada gambar vlp pada sa-ecg. kata kunci: hiperglikemia akut, infark miokard akut (ima), camkii, hscrp, aritmia ganas, vlp. abstract background: acute myocardial infarction (ami) is often followed by hyperglycemia. to date, there is no study that examine the role of myocardial damage, ion channel changes and increased inflammatory response as a pathomechanism of malignant arrhythmias due to hyperglycemia in ami patients. the aim of this study is to determine the effect of acute hyperglycemia on the occurence of malignant arrhythmias, troponin i, vlp, echocardiographic strain, ion channel changes (camkii) and hscrp. this study also aims to assess the effect of troponin i, vlp, gls, camkii and hscrp on the occurence of malignant arrhythmias in ami patients with acute hyperglycemia. methods: a cross-sectional study followed by a cohort study was conducted on ami patients treated at iccu cipto mangunkusumo hospital jakarta during november 2018 to may 2019 period. patients with severe infections and who had experienced malignant arrhythmias at admission were excluded from the study. the occurence of malignant arrhythmias as the main outcome of this study and camkii level were assessed on the fifth day of treatment. patients who died before the fifth day of treatment due to causes other than malignant arrhythmias were excluded from analysis. the association between acute hyperglycemia with vlp and the occurence of malignant arrhythmias was analyzed through a chi-square test, whereas the differences between troponin i, gls, camkii and hscrp, based on the hyperglycemia status of the patient, were analyzed by mann-whitney u test. results: a total of 110 patients were included in the study. two patients died on the third day of observation due to malignant arrhythmias. no significant relationship was found between acute hyperglycemia in ami and malignant arrhythmias (rr = 1,38, 95%ci 0.50−3.77). there were differences of camkii level on day-1 and day-5 between those who were experienced malignant arrhytmia and those who were not (p-value for differences are 0,03 and 0,01, respectively. in the acute hyperglycemia group, there was difference of camkii day-5 levels between positive and negative vlp (p = 0.03). conclusion: it was concluded that the inititial stage of ami causes more dominant myocardial damage, as compared to metabolic factors. in the next stage of ami, acute hyperglycemia increases ros and the activation of ion channel changes described by camkii. this change results in electrophysiological remodeling of the heart, as seen in the vlp image on sa-ecg. keywords: acute hyperglycemia, ami, camkii, hscrp, malignant arrhythmias, vlp. introduction acute myocardial infarction (ami) is often followed by various cardiac complications such as atrial and ventricular arrhythmias, haemodynamic disorders, conduction disorders, heart failure, ventricular aneurysms and myocardial rupture. cardiac complications that can result in sudden cardiac death (scd) are malignant ventricular arrhythmias like ventricular fibrillation (vf), persistent ventricular tachycardia (ventricular tachycardia, vt) and non persistent ventricular tachycardia (non-sustained ventricular vt). in severe stress such as acute myocardial infarction (ami), the body often demonstrates an increase in blood glucose levels at the time of hospital admission, also called acute hyperglycemia. acute hyperglycemia responses are mediated by the activation of the sympathetic nervous system and the hypothalamic-pituitary axis, which stimulates the release of catecholamines and cortisol. as a result, an increasing process of gluconeogenesis, glycogenolysis and lipolysis occurs. in iccu cipto mangunkusumo hospital, jakarta, the prevalence of acute hyperglycemia (plasma glucose >140 mg/dl) in acs cases has been reported to reach 50.4%.1 patients with ami and hyperglycemia at admission will have myocardial dysfunction as showed by electrophysiological remodeling, as well as a disruption to left ventricular systolic function. myocardial damage and dysfunction will trigger higher malignant ventricular arrhythmias. myocardial dysfunction can be assessed through several examinations, namely sally a. nasution acta med indones-indones j intern med 104 electrocardiographic features such as signal averaged electrocardiography (sa-ecg) and echocardiographic strain. sa-ecg examination is a holter ecg examination that can assess the electrophysiological function of the cardiac muscle in 15−20 minutes described by ventricular late potential (vlp). several studies have shown that myocardial damage in ami may vary as functional impairment or electrophysiological remodeling which results in impairment of cardiac electrical conductivity and at risk of arrhythmias especially malignant arrhythmias that will increase the risk of sudden cardiac death.2,3 echocardiographic strain examination can be assessed through a global longitudinal strain (gls). gls is more sensitive than an examination of the left ventricular ejection fraction (lvef), which is usually conducted during routine echocardiographic examinations. in ami there will be some cellular alteration in ion channels, especially calcium, which can cause complications, especially malignant arrhythmias. when myocardial lesions occur, they increase levels of reactive oxygen species (ros) and activate ca2+/calmodulin-dependent protein kinase ii (camkii), a protein enzyme classified as serine/threonine kinase that plays a role in several human physiological processes in the heart and brain.4 the process of autophosphorylation, glycosylation and oxidation will increase camkii levels and increase the risk of malignant arrhythmias through changes in the calcium ion channel.5 ami consists of a series of inflammatory processes that increase inflammatory markers. this study found that several inflammatory markers, which increased at the time of ami including hscrp, il-6, tnf-a were associated with more frequent and severe complications.6 levels of hscrp are also increased in hyperglycemia due to acute stress, which then increases the risk of malignant arrhythmias.7,8 however, studies have not been conducted as to whether increasing hscrp as an inflammatory marker plays a role in the mechanism of malignant arrhythmias in ami patients with acute hyperglycemia. thus, we conducted this study to determine the role of acute hyperglycemia against the risk of malignant arrhythmias, and the related processes: myocardial damage and dysfunction, cardiac electrophysiological remodeling, ion channel changes and inflammatory response. methods we conducted a cross sectional followed by a prospective cohort study in ami (nstemi and stemi) patients who were consecutively sampled from november 2018 to may 2019 at iccu of cipto mangunkusumo hospital, jakarta. those with severe infection and malignant arrhythmias at hospital admission were excluded from the study. one patient in this study died before the fifth day of treatment from causes other than a malignant arrhythmia. this study has ben approved by the ethics committee of faculty of medicine universitas indonesia (reference no. 1093/un2.f1/etik/2018). definition of study variables acute hyperglycemia is defined by a blood glucose level >140 mg/dl at initial patient admission. blood glucose, troponin, hscrp, and camkii levels were obtained from blood samples and measured at the cipto mangunkusumo hospital clinical pathology laboratory. ventricular late potential (vlp) and echocardiographic strain (gls) were obtained from examination of saeg and echocardiographic performed at iccu. saecg is an electrocardiogram that show cardiac electrophysiology remodeling by evaluating vlp. ventricular late potentials were considered positive when ≥ 2 of the following criteria were fulfilled: qrstt > 120 ms, las40 > 40 ms, and rms40 < 25 uv. echocardiographic strain is a strain changes in myocardium contraction that showed with echocardiography. blood glucose, troponin, hscrp, saecg and gls levels were assessed on the first day of treatment. camkii was assessed on the first and fifth days of treatment. malignant arrhythmia which are non sustained ventricular tachycardia, ventricular tachycardia and ventricular fibrillation is observed 24 hours in electrocardiogram monitor during five days treatment at iccu. data analysis a data normality test was conducted using the kolgomorov-smirnov test. data was analyzed vol 52 • number 2 • april 2020 the role of acute hyperglycemia on the risk of malignant arrhythmia in ami 105 table 1. characteristics of the study population at baseline. characteristics total subject (n = 110) acute hyperglycemia (n = 65) normoglycemia (n = 45) gender, male n (%) 88 (80) 51 (78.5) 37 (82.2) age (years), mean (sd) 57.38 (10) 57.83 (9.83) 56.73 (10.9) risk factor, n (%) diabetes mellitus 44 (40) 35 (53.8) 9 (20) dyslipidemia 57 (51.8) 37 (56.9) 20 (44.4) hypertension 62 (56.4) 38 (58.5) 24 (53.3) obesity 13 (11.8) 11 (16.9) 2 (4.4) smoker 73 (66.4) 40 (61.5) 33 (73.3) history of coronary heart disease 21 (19.1) 16 (24.6) 5 (11.1) history of revascularization 14 (12.7) 12 (18.5) 2 (4.4) stroke 9 (8.2) 6 (9.2) 3 (6.7) number of risk factor, n (%) 1 risk factor 21 (19.1) 8 (12.3) 13 (28.9) 2 risk factor 34 (30.9) 16 (24.6) 18 (40) ≥ 3 risk factor 55 (50.0) 41 (63.1) 14 (31.1) ami, stemi n (%) 70 (63.6) 40 (61.5) 30 (66.7) grace score, median (interquartile range) 113.5 (48) 116.5 (48) 110.5 (47) killip classification, n (%) class 1 50 (46.7) 28 (44.4) 22 (50) class 2 23 (21.5) 14 (22.2) 9 (20.5) class 3 20 (18.7) 11 (17.5) 9 (20.5) class 4 14 (13.1) 10 (15.9) 4 (9.1) cardiac marker troponin i, pg/ml, median (interquartile range) 6954 (57562.8) 3617.7 (70947.9) 8380 (42279.3) cardiac troponin i normal, < 30 pg/ml, n (%) 2 (1.8) 2 (3.1) 0 (0) elevated, > 30 pg/ml, n (%) 108 (98.2) 63 (96.9) 45 (100) echocardiography ejection fraction, %, mean (sd) 45.7 (13.7) 46 (14.3) 47 (13.1) systolic function, n (%) preserved, ≥ 50% 47 (42.7) 29 (44.6) 18 (40) low, < 50% 63 (57.3) 36 (55.4) 27 (60) diastolic function normal, n (%) 11 (11.5) 7 (12.3) 4 (10.3) impaired relaxation, n (%) 40 (41.7) 24 (42.1) 16 (41.0) pseudonormal, n (%) 38 (39.6) 20 (35.1) 18 (46.2) restrictive, n (%) 7 (7.3) 6 (10.5) 1 (2.6) rbg, mg/dl, median (interquartile range) 149.5(81.3) 191.1 (115.5) 119 (20.8) normoglycemia, < 140 mg/dl, n (%) 45 (40.9) acute hyperglycemia, > 140 mg/dl, n (%) 65 (59.1) fpg, mg/dl, median (interquartile range), n = 100 118 (52.7) 133 (90.2) 99 (34.25) ppg, mg/dl, median (interquartile range), n = 90 136.5 (99.75) 167 (106) 108 (45.5) hba1c, %, median (interquartile range), n = 104 5.8 (1.38) 6.4 (2.8) 5.4 (0.5) normal, < 6,5%, n (%) 71 (68.3) 32 (51.6) 39 (92.9) diabetes mellitus ≥ 6,5%, n (%) 33 (31.7) 30 (48.4) 3 (7.1) ami = acute myocardial infarction; stemi = st segment elevation myocardial infarction; nstemi = non-st segment elevation myocardial infarction; grace = the global registry of acute coronary events; rbg = random blood glucose; fpg = fasting plasma glucose; ppg = post prandial glucose; sd = standard deviation. sally a. nasution acta med indones-indones j intern med 106 using a chi-square, mann whitney u-test and independent t-tests. the correlation between acute hyperglycemia with vlp and the occurence of malignant arrhythmias was analyzed by chisquare test, whereas troponin i, gls, camkii and hscrp based on the hyperglycemia status were tested by t-test of mann-whitney test. results there were 110 patients consisting of 88 males (80%) and 22 females (20%). the average age was 38 years old with the youngest being 29 years old and the oldest being 83 years old. (table 1) from this study, the common risk factor was smoking, with 73 patients (66.4%) reported as smokers. the median grace score was 113.5 and the common killip score was class 1 killip (46.7%). the subject of this study was also divided into two groups – the acute hyperglychemia group (> 140 mg/dl), with 65 subjects, and the normoglycemia group (< 140 mg/dl), with 45 subjects. the median troponin value was 3617.7 in the acute hyperglycemia group and 8380 in the normoglycemia group. the average ejection fraction in this study was 45.7%. there were ten patients (15.4%) who had malignant arrhythmias in the acute hyperglycemia group and five patients (11.1%) who had malignant arrhythmias in the normoglycemia group. there is no significant difference between acute hyperglycemia and malignant arrhythmia (rr 1.38, 95% ci 0.50−3.77, p = 0.52). ami patients with acute hyperglycemia have a higher risk of malignant arrhythmias compared to those with normoglycemia based on electrophysiology remodeling described by vlp based on a saecg assessment (rr = 2.3, 95% ci 0.59−7.25, p = 0.25). there is no sigficiant difference between acute hyperglycemia in ami patients on troponin i, gls, camkii day one and five and hscrp and patients in the normoglycemia group. (table 2) there is a tropinin i level difference between malignant and no malignant arrhythmia in ami patients within the normoglycemia group. this difference is not seen within acute hyperglycemia patients. (table 3) there are also differences of camkii, as marker of calcium ion channel changes, between ami patients with and without malignant arrhytmia on day-1 and day 5. subgroup analysis showed that the differences also seen on normoglycemia patients on day 5. (table 4) there is an increase risk of malignant arrhythmia in ima patients with cardiac electrophysiology remodeling (vlp positive) tabel 2. relationship of acute hyperglycemia on troponin i, gls, camkii day 1, camkii day 5, and hscrp levels. variables rbg status p acute hyperglycemia, n = 65 normoglycemia, n = 45 troponin i, pg/ml, median (iqr) 3617.7 (70947.9) 8380 (42279.3) 0.56* gls, mean (sd) 11.65 (4.14) 11.44 (4.69) 0.81** camkii 1, ng/ml, median (iqr) 0.24 (0.52) 0.19 (0.25) 0.09* camkii 5, ng/ml, median (iqr) 0.19 (0.3) 0.15 (0.32) 0.25* hscrp, ng/ml, median (iqr) 18.88 (103) 13.66 (48) 0.59* gls = global longitudinal strain; camkii 1 = calcium/calmodulin-dependent protein kinase type ii day 1; camkii 5 = calcium/calmodulin-dependent protein kinase type ii day 5; hscrp = high sensitivity c-reactive protein; rbg = random blood glucose; sd = standard deviation. *mann-whitney test. **independent t test. table 3. differences in troponin i levels between malignant arrhythmia and non-malignant arrhythmia in acute hyperglycemia group and normoglycemia blood glucose status troponin i, pg/ml, median (interquartile range) p malignant arrhythmia no malignant arrhythmias acute hyperglycemia, n = 65 4534.55 (100537.5) 3617.7 (66330.8) 0.44* normoglycemia, n = 45 83473.5 (334657.5) 7921.95 (31036.0) 0.04* total, n = 100 7579.7 (159586.7) 5471 (46840.2) 0.10* *mann-whitney test vol 52 • number 2 • april 2020 the role of acute hyperglycemia on the risk of malignant arrhythmia in ami 107 compared to vlp negative, but this increase not statistically significant. the increase is seen only in patients with acute hyperglycemia. (table 5) there is no differences of global longitudinal strain (gls) and inflammatory marker (hscrp) between ami patients with and without malignant arrhythmia. analysis of ion channel changes on the first day (camkii day one) through electrophysiological remodeling showed no significant difference in all subjects, including the acute hyperglycemia and normoglycemia table 5. the associations between electrophysiological remodeling with the occurrence of malignant arrhythmia in acute hyperglycemia group and normoglycemia. blood glucose status cardiac electrophysiology remodeling malignant arrhythmia no malignant arrhythmia rr (ci 95%) p value acute hyperglycemia (n = 65) vlp positive. n (%) 3 (33.3) 6 (66.7) 2.64 (0.84-8.46) 0.09* vlp negative. n (%) 7 (12.5) 49 (87.5) normoglycemia (n = 45) vlp positive. n (%) 0 (0.0) 4 (100.0) 1* vlp negative. n (%) 5 (12.2) 36 (87.8) total (n = 110) vlp positive. n (%) 3 (25.0) 9 (75.0) 2.04 (0.67-6.21) 0.21* vlp negative. n (%) 12 (12.2) 86 (87.8) vlp = ventricular late potential; rr = risk ratio; ci = confidence interval. * chi-square test table 6. the differences of ion channel changes between positive and negative vlp in patients with acute hyperglycemia group and normoglycemia blood glucose status collection day camkii, ng/ml, median (interquartile range) p value positive vlp negative vlp acute hyperglycemia (n = 65) day-1 0.27 (0.41) 0.23 (0.55) 0.56* day-5 0.40 (0.55) 0.18 (0.26) 0.03* normoglycemia (n = 45) day-1 0.23 (0.00) 0.18 (0.24) 0.98* day-5 0.31 (0.00) 0.15 (0.31) 0.98* total (n = 110) day-1 0.27 (0.38) 0.22 (0.34) 0.44* day-5 0.32 (0.41) 0.18 (0.29) 0.05* camkii = calcium/calmodulin-dependent protein kinase type ii; vlp = ventricular late potential. * mann-whitney test. groups. however, there was a significant difference between camkii day five with electrophysiological remodeling in the acute hyperglycemia group (p = 0.03). (table 6) discussion to our knowledge, this is the first study exploring the risk of malignant arrhythmia in hyperglycemia through multiple mechanisms in setting of ami. out of 110 ami patients included in this study, the common risk factors found table 4. differences in camkii levels between malignant arrhythmia and non-malignant arrhythmia with camkii in acute hyperglycemia group and normoglycemia blood gluce status collection day camkii, ng/ml, median (interquartile range) pmalignant arrhythmia no malignant arrhythmia acute hyperglycemia day-1 0.33 (0.53) 0.23 (0.48) 0.13* n = 65 day-5 0.28 (0.32) 0.18 (0.29) 0.20* normoglycemia day-1 0.40 (0.82) 0.18 (0.23) 0.20* n = 45 day-5 0.53 (0.63) 0.15 (0.33) 0.02* total day-1 0.40 (0.52) 0.22 (0.32) 0.03* n = 110 day-5 0.33 (0.50) 0.17 (0.27) 0.01* camkii = calcium/calmodulin-dependent protein kinase type ii. * mann-whitney test sally a. nasution acta med indones-indones j intern med 108 were smoking (66.4%), hypertension (56.4%), dyslipidemia (51.8%) and diabetes mellitus (40%). this result was consistent with previous studies in terms of the common risk factors for ami which are smoking, hypertension, low physical activity and dyslipidemia.3 this study showed that the median troponin i level in all subjects was 6945 pg/ml, 3617.7 pg/ml in acute hyperglycemia group and 8380 pg/ml in normoglycemia group. this study found there is no association between hyperglycemia status on admission and the occurrence of malignant arrhythmia, which is not conform with results from previous studies.1,9 further analysis showed that in ami patients with acute hyperglycemia there is risk increase electrophysiological remodeling compared to those who normoglycemi on admission, although not statistically significant. electrophysiologic remodeling (represent by vlp examination) is a marker for increasing risk of malignant arrhythmia. myocardial infarction results in electrophysiological remodelling caused by excessive myocardial structural changes generates inhomogeneous electrical impulses conduction within myocardial structure leads to arrhythmia.10 there is no previous study explored the risk of malignant arrhythmia in hyperglycemia patients using vlp assessment, which is a sensitive parameter to detect the risk for malignant arrhythmia. eventhough our results did not attaint statistically significant, but the estimation risk (relative risk 2.3) is clinically important. we suggest this association is not signifficant because inadequate sample sizes. we found that in normoglycemic patients, there is a significant difference of tropinin i level between those who are develop malignant arrhytmia and not. this difference was not seen in acute hyperglycemic grup as well as in total group. this may occur because median levels of troponin i in the normoglycemia group were almost three times higher than in the. acute hyperglycemia group there was no previous study which have been explored this phenomenon, we suggest further research about the correlation between the extent of infarct lesion and malignant arrhytmia. these results explain that the influence of myocardial damage is very dominant in the early phase of ami compared to metabolic factors which is blood glucose status (acute hyperglycemia or normoglycemia). another mechanism studied is the role of ion channel changes, represent by camkii level, on the development of malignant arrhythmia in ami patients with hyperglycemia. we found there are significant differences of camkii level between malignant arrhytmia and no malignant arrhythmia patients, both in first day of and fifth day after admission. further analysis showed that the differences specially found in normoglycemic patients on fifth day after admission. based on this result, we suggest that metabolic factors are not the main cause of malignant arrhythmias in the early phase of ami. cellular influences, including ion channel changes, seems consistently statistically significant as a dominant factor in the mechanism of malignant arrhythmias. the results show that on the first day, a prominent factor was myocardial damage, in which there was a very high increase in troponin i levels even in the ami with normoglycemia population. metabolic factors described by random blood glucose will affect in the following days, and the results were statistically significant on the fifth day of examination. there are three processes that occur simultaneously during the pathomechanism of malignant arrhythmia during ami. first, myocardial damage occurs and appears dominant in the early phase of ami. this theoretically may result in malignant arrhythmias through several processes. second, changes occur in intracellular calcium ions, which activate camkii and subsequently cause electrophysiological remodeling of the myocardial surface, affecting the action potential and influencing proarithmic. third, ami increases the stress hormones glucocorticoid and catecholamine, which trigger acute hyperglycemia and increase the production of reactive oxygen species (ros) that activate camkii via ros camkii. these changes result in electrophysiological remodeling of the heart on the surface as seen in the vlp during the sa-ecg examination which will eventually trigger the occurrence of malignant arrhythmias. (figure 1) vol 52 • number 2 • april 2020 the role of acute hyperglycemia on the risk of malignant arrhythmia in ami 109 conclusion this study showed that there was no relationship between acute hyperglycemia in ami patients and malignant arrhythmias, myocardial damage, electrophysiological remodeling, left ventricular dysfunction, ion channel changes and inflammatory processes compared to ami patients without acute hyperglycemia.there was no relationship between myocardial damage, cardiac electrophysiological remodeling, left ventricular dysfunction and inflammatory process in ima, and acute hyperglycemia in the occurrence of malignant arrhythmias. there were differences between ion channel changes described by camkii day one and five, and the occurrence of malignant arrhytmias. however, camkii day one is not enough to predict the occurrence of malignant arrhythmias in ami patients with acute hyperglycemia. there were also differences between ion channel changes described by camkii day five and electrophysiological remodeling, which is a risk for malignant arrhythmias. these differences were statistically significant in the acute hyperglycemia group. references 1. zein afm, nasution sa, purnamasari d, mansjoer a. the influence of hyperglycemia at admission on in-hospital arrhythmia patients with acute coronary syndrome. acta med indones. 2015;47(4). 2. underwood d, jaeger f, simmons t, editors. the effect of varying filter techniques on late potential parameters of signal averaged electrocardiographic records. [1991] proceedings computers in cardiology; 1991: ieee. 3. eryol nk, topsakal r, oguzhan a, et al. is the change of late potential over time related to enzyme levels? ichemic burden in acute myocardial infarction. j annals noninvasive electrocardiol. 2002;7(3):242-6. 4. zhang p. camkii: the molecular villain that aggravates cardiovascular disease. j experimental ther med. 2017;13(3):815-20. 5. erickson jr, pereira l, wang l, et al. diabetic hyperglycaemia activates camkii and arrhythmias by o-linked glycosylation. j nature. 2013;502(7471):372. 6. marfella r, siniscalchi m, esposito k, et al. effects of stress hyperglycemia on acute myocardial infarction: role of inflammatory immune process in functional cardiac outcome. j diabetes care. 2003;26(11):312935. 7. mountantonakis s, deo r. biomarkers in atrial fibrillation, ventricular arrhythmias, and sudden cardiac death. j cardiovascular therapeutics. 2012;30(2):e74-e80. 8. empana j-p, jouven x, canouï-poitrine f, et al. c-reactive protein, interleukin 6, fibrinogen and risk of sudden death in european middle-aged men: the prime study. j arteriosclerosis thromb vasc biol. 2010;30(10):2047-52. 9. angeli f, reboldi g, poltronieri c, et al. hyperglycemia in acute coronary syndromes: from mechanisms to prognostic implications. j ther advan cardiovascular dis. 2015;9(6):412-24. figure 1. mechanisms of arrhytmia in acute myocardial infarction and the role of acute hyperglycemia. sally a. nasution acta med indones-indones j intern med 110 10. kaneko h, anzai t, naito k, et al. role of ischemic preconditioning and inflammatory response in the development of malignant ventricular arrhythmias after reperfused st-elevation myocardial infarction. j cardiac failure. 2009;15(9):775-81. 28 original article acta medica indonesiana the indonesian journal of internal medicine comparison of asymmetric dimethylarginine levels between stages three, four, and five non-dialysis of chronic kidney disease tri p. asmarawati, widodo, m. thaha, aditiawardana, nunuk mardiana, ardityo r. ardhany, artaria tjempakasari, djoko santoso, pranawa, chandra irwanadi department of internal medicine, faculty of medicine, airlangga university, surabaya, indonesia. corresponding author: m. thaha, prof, md, phd. department of internal medicine, faculty of medicine, airlangga university. jl. mayjen. prof. dr. moestopo 6-8, surabaya 60131, indonesia. email: tripudyasmarawati@gmail.com, mochthaha@yahoo.com. abstrak tujuan: mengetahui perbandingan kadar asymmetric dimethylarginine (adma) antar-stadium 3, 4, dan 5 pasien penyakit ginjal kronik (pgk) non-dialisis di rsud dr. soetomo surabaya. metode: penelitian potong lintang dilakukan di instalasi rawat jalan ginjal dan hipertensi rsud dr. soetomo mulai bulan januari-februari 2015. stadium pgk ditentukan berdasarkan rumus perkiraan lfg menurut rumus mdrd 4 variabel. analisis statistik perbedaan kadar adma ketiga kelompok subyek menggunakan uji anova satu arah. hasil: sebanyak 75 subyek, terdiri atas masing-masing 25 pasien pgk stadium 3, 4, dan 5 non-dialisis. umur rerata pasien pgk stadium 3, stadium 4, dan stadium 5 non-dialisis masing-masing 57,12 tahun, 54,80 tahun, dan 53,68 tahun. rerata kadar adma pada kelompok stadium 3 adalah 0,62 (0,11) iu/ml, kelompok stadium 4 adalah 0,72 (0,16) iu/ml, dan kelompok stadium 5 adalah 0,73 (0,18) iu/ml. terdapat perbedaan kadar adma secara bermakna (p=0,04) antar-stadium pgk, dengan perbedaan terbesar pada perbandingan kelompok stadium 3 dan 5. kesimpulan: terdapat perbedaan kadar adma yang bermakna antar-stadium pgk dan semakin tinggi pada stadium pgk yang lebih tinggi. kata kunci: penyakit ginjal kronis, asymmetric dimethylarginine (adma), penyakit kardiovaskular. abstract aim: to determine the differences of adma level between stages 3, 4, and 5 non-dialysis of chronic kidney disease (ckd) patients at outpatient nephrology clinic, dr. soetomo hospital. methods: a cross-sectional study was conducted on stage 3, 4, and 5 non-dialysis ckd patients at outpatient nephrology clinic, dr. soetomo hospital, surabaya from january to february 2015. stages of ckd were determined based on gfr estimation according to 4-variable mdrd formula. statistical analysis of differences in the levels of adma in three subject groups use one-way anova test. results: seventy-five patients were included in the study. each group consisted of 25 patients stage 3, 4, and, 5 non-dialysis patients. mean age of stage 3, stage 4, and stage 5 non-dialysis ckd patients were respectively 57.12 years, 54.80 years and 53.68 years. the mean levels of adma in stage 3, stage 4, and 5 were 0.62 (0.11) iu/ml, 0.72 (0.16) iu/ml, and 0.73 (0.18) iu/ml respectively. analysis of the differences between the groups showed significant differences in adma levels (p=0.04), with the highest difference between stage 3 and stage 5. conclusion: comparison of adma levels showed significant differences between ckd stages and the level tends to be higher along with increase severity of ckd stages. keywords: chronic kidney disease, asymmetric dimethylarginine (adma), cardiovascular disease. vol 48 • number 1 • january 2016 comparison of asymmetric dimethylarginine levels 29 introduction c a r d i o v a s c u l a r d i s e a s e ( c v d ) a n d atherosclerotic complications are the most important causes of morbidity and mortality in patients with chronic kidney disease (ckd).1 some evidences of association between renal dysfunction and cardiovascular complications was first discovered in dialysis population, where the incidence of cardiovascular mortality was very high. it was also found in subjects with less severe impaired renal function.2 traditional risk factors and non-traditional risk factors such as inflammation, oxidative stress, endothelial dysfunction, coronary artery calcification, hyperhomocysteinemia, and immunosuppressants have been associated with accelerated atherosclerosis. coronary artery disease (cad) is one of the primary types of cvd in patients with ckd. atypical presentation of cad in patients with ckd often leads to delay in diagnosis and treatment. the diagnostic value of baseline ecg is often limited by non-specific changes due to left ventricular hypertrophy and electrolyte disturbances. furthermore, the outcomes of cad are poorer in patients with ckd than non-ckd counterparts.3 endothelial dysfunction is common in ckd patients. it is due to the reduced bioavailability of nitric oxide (no). nitric oxide has a protective role for the cardiovascular system because it inhibits vascular muscle cell proliferation, platelet aggregability, and the adhesion of monocytes to the endothelium. asymmetrical dimethylarginine (adma) is an endogenous inhibitor of endothelial nitric oxide synthase (enos) which may contribute to endothelial dysfunction and may participate actively in development of atherogenesis in patients with end-stage renal disease. adma is in part excreted by the kidney, but this compound is mainly disposed by transformation into citrulline, a reaction driven by the enzyme diethyl-diaminohydrolase (ddah). diethyldiaminohydrolase is present within the endothelial cells and is very sensitive to oxidative stress. oxidative stress is pervasive in esrd, therefore, high adma in this condition may be the expression of the high rate of generation of oxidants.4 studies have demonstrated that high adma is strongly associated with well established risk markers such as increased intima-media thickness in the carotid arteries and concentric left ventricular hypertrophy.5-8 adma predicts death and cardiovascular complications independently of other risk factors in end-stage renal disease (esrd) patients.9 therefore, measuring the plasma adma level may be important to determined the cardiovascular risk in patient with ckd and manage the atherosclerotic complication earlier. previous researches showed that in patients with mild to moderate ckd, adma level is inversely correlated with glomerular filtration rate (gfr) and is a strong predictor for the progression towards esrd and death in ckd patients underwent coronary angiography.9,10 study performed by kielstein et al.11 meanwhile showed that plasma level of adma are not correlated with gfr. another study showed that mean plasma adma levels were not significantly different in renal patients with normal gfr and mild reduction of gfr but were significantly higher with more advanced stages of renal failure.12 however, most of the previous studies performed also in ckd patient with cvd comorbidity and traditional risk factors whereas the elevation of adma level might be related to the cvd rather than the severity of ckd. the previous studies also did not analyze the differences of the adma level according to the ckd stages. an estimated gfr below 60 ml/min/1.73 m2 is a risk factor for both new and recurrent cardiovascular disease in the general population and in people at increased risk for cardiovascular disease. in these patients, cardiovascular morbidity is more common than progression to kidney failure.13 we conducted this study to determine and analyze the differences of the adma level in ckd patient with gfr less than 60 ml/min/1.73 m2. comparing the differences of adma level between stages of ckd especially in moderate to advanced stage could provide us information about which stadium should undergo early intensive evaluation and treatment of risk factors for cardiovascular disease. methods cross-sectional study was conducted to examine adma levels at various ckd stages tri pudy asmarawati acta med indones-indones j intern med 30 at outpatient nephrology clinic, dr. soetomo hospital, surabaya. data collection was done from january to march 2015. the inclusion criteria were patients with ckd stage 3, 4, and 5 non-dialysis aged 21-65 years, and agreed to participate in the study. the exclusion criterias were subjects with cigarette smoking, poorly controlled diabetes mellitus, uncontrolled hypertension, history of cardiovascular disease, multiple organ failure, presence of hepatic dysfunction, pregnant, and on antioxidant use since these condition influenced the adma level. we determined the sampel size by equation for unpaired numerical analytical study and the result was 25 in each group, so that the total sample in three groups comprised of 75 patients.14 sampling was done using retrieval technique with consecutive sampling system. ckd stage classification was based on nfkkdoqi guidelines in 2002 and the determination of the estimated glomerular filtration rate (egfr) use the 4-variables modification of diet in renal disease (mdrd) formula.15 patients with ckd stages 1 and 2 were not included because these groups were difficult to find in nephrology outpatient clinic. non-dialysis stage 5 ckd patients in this study were patients with egfr<15 ml/min/m2 but not yet experiencing symptoms of uremia. determination of adma use adma elisa kit made by standardized laboratory. concentration in the plasma was determined in units of µmol/l.16 based on internal studies in healthy subjects, the average levels of adma was 0.45 µmol/l. normal adma level ranges was average serum/plasma ± 2 sd = 0.45 ± 0.19 µmol/l.17 all of the subjects who met the inclusion and exclusion criteria were recorded for demography and clinical characteristics which include age, gender, body mass index, blood pressure, history of antihypertensives (ace-inhibitor, arb) medications, and antidiabetic drugs (metformin, thiazolidinediones, insulin). venous blood sampling was performed on each subject for examination of adma levels, bun, and serum creatinine. all data collected were then analyzed with a statistical test to determine differences in adma levels between the three groups of samples. data processing was done by the program r version 3.2.18,19 the data were analyzed with descriptive statistics and presented in the form of a frequency distribution table. statistical analysis of adma levels differences among the three groups of subjects used one-way anova test when data distribution was normal and data variance was the same as well. post hoc analysis is conducted when the result of anova showed significant differences between at least two groups to determine the magnitude of the differences between each group.14 results the total number of samples in this study were 75 patients with ckd who were divided into 3 groups of stages, each consist of 25 patients. demographic and clinical characteristics of the subjects are shown in table 1. the mean age of the study subjects was 55.20 (8.16) years. parameters of hemoglobin and albumin showed that the higher the ckd stage of the patients, the lower the average value obtained. table 2 shows the average levels of adma between stage groups. post hoc analysis are shown in table 3, in which there is the highest difference in stages 3 and 5, while the lowest difference was in stage 4 and 5. discussion ckd has become recognised as a key independent risk factor for cvd. it is now increasingly apparent that individuals are more likely to die from cardiovascular disease than to develop esrd. initial evidence indicating a relationship between renal dysfunction and adverse cardiovascular events become apparent in those on dialysis, where the number of cvd deaths was found to be raised.20 furthermore, cvd in ckd patients, as the major cause of death, cannot be entirely explained by the traditional cardiovascular risk factors. it has been hypothesized that this excessive risk can be attributed, at least in part, to endothelial dysfunction and reduced bioavailability of nitric oxide (no), which might play a pivotal role in the initiation and progression of atherosclerosis and might be a potential link between cardiovascular disease and ckd.9 vol 48 • number 1 • january 2016 comparison of asymmetric dimethylarginine levels 31 table 1. demography and clinical characteristics of the subjects characteristics stage 3 (n=25) stage 4 (n=25) stage 5 non-dialysis (n=25) age (years), mean (sd) 57.12 (5.40) 54.80 (7.14) 53.68 (10.89) sex (male), n (%) 16 (64.0) 8 (32.0) 11 (44.0) ckd causes, n (%) dm 6 (24.0) 10 (40.0) 10 (40.0) non-dm 19 (76.0) 15 (60.0) 15 (60.0) proteinuria degree, n (%) +1 16 (64.0) 13 (52.0) 3 (12.0) +2 7 (28.0) 8 (32.0) 11 (44.0) +3 1 (4.0) 2 (8.0) 6 (24.0) +4 1 (4.0) 2 (8.0) 5 (20.0) estimated gfr (ml/min/1.73m2), mean (sd) 40.34 (7.45) 22.22 (3.84) 10.55 (3.21) serum creatinine (mg/dl), median (range) 1.73 (1.20-2.40) 2.68 (1.90-3.70) 5.79 (3.30-15.50) albumin (g/l), mean (sd) 4.54 (0.35) 4.23 (0.45) 4.09 (0.49) haemoglobin (g/dl), mean (sd) 12.92 (1.96) 11.30 (2.02) 10.13 (1.50) dm, n (%) insulin use 0 (0.0) 3 (33.3) 5 (50.0) tiazolidindion use 0 (0.0) 2 (20.0) 1 (10.0) metformin use 0 (0.0) 0 (0.0) 0 (0.0) random blood glucose (mg/dl), mean (sd) 109.88 (34.45) 107.92 (29.44) 116.36 (32.37) hypertension, n (%) acei/arb use 11 (44.0) 11 (44.0) 12 (48.0) non ht/ non acei/arb 14 (56.0) 14 (56.0) 13 (52.0) systolic bp (mmhg), mean (sd) 133.16 (14.52) 131.44 (16.32) 139.72 (13.12) diastolic bp (mmhg), mean (sd) 80.04 (9.45) 75.68 (10.36) 74.48 (11.21) dyslipidemia, n (%) statin use 8 (32.0) 10 (40.0) 4 (16.0) non-dyslipidemia/ non-statin 17 (68.0) 15 (60.0) 21 (84.0) ldl (mg/dl), mean (sd) 102.28 (28.71) 109.08 (29.48) 93.32 (28.23) table 2. adma level between ckd stages ckd groups total mean (sd) p value stage 3 25 0.63 (0.11) 0.04 stage 4 25 0.72 (0.16) stage 5 25 0.73 (0.18) table 3. results of post-hoc analysis mean difference min max p value stage 4 vs 3 0.09 -0.01 0.19 0.10 stage 5 vs 3 0.10 -0.00 0.20 0.06 stage 4 vs 5 0.01 -0.09 0.11 0.97 asymmetric dimethylarginine is inhibitor of endothelial nos. in those with esrd, adma has been independently associated with the intima-media thickness of the carotid artery and may predict its progression during a one-year follow-up period.4,6 in a cohort of hemodialysis patients, scientists found that plasma adma may be a strong and independent risk factor of total mortality and cardiovascular outcome.20 asymmetric dimethylarginine is thought to be significantly associated with the oxidative stress process through its inhibition of no, and thus leading to endothelial dysfunction and vascular damageand plays a major role in potentiating atherosclerosis.4 asymmetric dimethylarginine levels are markedly elevated in renal impairment. several prospective studies showed association between adma and ckd progression. each 0.1 µmol/l increase of adma may increase 47% progression tri pudy asmarawati acta med indones-indones j intern med 32 of ckd.12 a study in patients with type 1 diabetes and overt diabetic nephropathy showed that an adma level higher than the median was associated with a faster yearly decline in gff and a greater risk of developing esrd over a median follow-up of 11.3 years.21 a study in patients with type 2 diabetes (with normoalbuminuria or microalbuminuria) followed up over 5.2 years reported progression of diabetic nephropathy to a more advanced stage.22 patients with adma levels above the median had a 2.7-fold higher risk of disease progression. together, these studies provide strong evidence that increased adma levels are associated with progression of ckd.23 no is synthesized by stereospecic oxidation of the terminal guanidino nitrogen of the amino acid l-arginine by the action of nos. no synthesis can be selectively inhibited by competitive blockade of the nos active site with guanidino-substituted analogues of l-arginine such as adma. adma is released from proteins that have been post-translationally methylated, and subsequently hydrolysed. these proteins are largely found in the nucleolus and appear to be involved in rna processing and transcriptional control. there are two types of enzymes that methylate arginine residues: protein arginine methyl-transferase type i (prmt i) forms adma and lnma, whereas prmt ii forms symmetric dimethylarginine (sdma), that is a stereoisomer of adma, which has no direct inhibitory effect on nos. adma is renally excreted to some extent, but the major metabolic pathway is degradation by the enzyme ddah, which hydrolyses adma to dimethylamine and l-citrulline. there are two isoforms of ddah: ddah i is predominately found intissues that express neuronal nos, whereas ddah ii is predominately found in tissues expressing endothelial nos. the increased adma levels that inhibit nos resulting in decreased no levels, which has major adverse consequences for the kidney and might lead to progression of ckd.24-26 genetic predisposition factors are associated with increased adma in ckd. dimethylarginine dimethylaminohydrolase-2 gene variations and pmrt-1 gene polymorphism are associated with adma levels in hemodialysis patients.27 the decline in ddah-2 enzyme activity may inhibit adma metabolism and pmrt-1 increased activity will lead to increased production of adma, so both have a role in the increase of adma in ckd.28 altough adma level was found to be elevated in ckd, the correlation between adma level and gfr showed conflicting results. in this study it was found that there was a significant difference in the levels of adma between ckd stages, with the lowest level in ckd stage 3 and the highest level was in ckd stage 5 (p=0.04). post hoc analysis showed that the highest difference between two groups was found in the comparison of ckd stages 3 and 5, while the least difference was in the comparison between ckd stage 4 and 5. a study conducted by ronden ra et al29 examined the decline in renal clearance and increased plasma adma levels in hypertensive subjects with mild to moderate renal insufficiency. the results of this study showed similar trends with our study, but the adma level for egfr group 30-59 was lower than adma level in group stages 3 and 4 in our study. the difference is probably because the subjects included in ronden’s study were hypertensive patients, instead of ckd patients as in our study. another explanation is that there is difference in adma measurement methods. another study conducted by eloot, et al which aims to determine whether the value of egfr describes uremic toxins, including adma concentrations, at various stages of ckd, also showed similar results with our research.30 previous studies showed that in patients with mild to advanced ckd, adma level is inversely correlated with gfr and it is a strong predictor for the progression towards esrd and death.9,10 a study conducted by kielstein et al.11 showed that levels of adma increased independently of renal function in patients with ckd and did not correlate with gfr. other studies in patients with mild to moderate kidney disease (gfr 30-90) indicates that the decline in gfr is associated with increased adma levels, but decrease in clearance of plasma adma is not associated with increased adma levels.29 our study results showed that there was narrow differences of adma level in ckd stage 4 and 5 while in ckd vol 48 • number 1 • january 2016 comparison of asymmetric dimethylarginine levels 33 stage 3 and 4 had wider differences. this suggest that adma level started to increased in patient with mild to moderate ckd and reach the highest level in esrd. however, in advanced ckd the elevation are not always correlate with gfr. this also suggest that there may be other mechanisms besides the influence of gfr that plays a role in adma accumulation in ckd. however, our study has several limitations. the staging of ckd was based on estimated gfr instead of measured gfr and conducted only in one time measurement. we did not involve all ckd stages in our study, so that the pattern of adma accumulation in all stages could not be analyzed. the causes of ckd was only distinguished by dm and non-dm, whereas other causes of ckd, such as stones, infections, and autoimmune diseases, were not detailed. some confounding variables were obtained only from very subjective history taking. conclusion the mean level of adma in group stages 3, 4 and 5 were respectively 0,63 µmol/l, 0.72 µmol/l and 0.73 µmol/l. there were differences in adma level between ckd stages and adma levels increase along with the higher stage of ckd. the greatest increase in adma levels was between ckd stage 3 and stage 4, so that any attempt to reduce cardiovascular complications should be done at the time or before it reaches stage 3. references 1. amaresan ms. cardiovascular disease in chronic kidney disease. indian j nephrol. 2005;15:1-7. 2. schiffrin el, lipman ml, mann jfe. chronic kidney disease: effects on the cardiovascular system. circulation. 2007;116:85-97. 3. cai q, mukku vk, ahmad m. coronary artery disease in patients with chronic kidney disease: a clinical update. currcardiol rev. 2013;9:331-9. 4. landim mbp, casella filho a, chagas acp. asymmetric dimethylarginine (adma) and endothelial dysfunction: implications for atherogenesis. clinics. 2009;64(5):471-8. 5. miyazaki h, matsuoka h, cooke jp, usui m, ueda s, okuda s, imaizumi t. endogenous nitric oxide synthase inhibitor: a novel marker of atherosclerosis. circulation. 1999;99:1141-6 6. zoccali c, benedetto fa, maas r, mallamaci f, tripepi g, malatino ls, böger r. creed investigators: asymmetric dimethylarginine, c-reactive protein, and carotid intima-media thickness in end-stage renal disease. j am soc nephrol. 2002;13:490-6. 7. alsagaff my, thaha m, aminuddin m, yogiarto r m , yo g i a n t o r o m , to m i n o y. a s y m m e t r i c dimethylarginine: a novel cardiovascular risk factor in end-stage renal disease. j intern med res. 2012; 40:340-9. 8. selcoki y, aydin m, ikizek m, armutcu f, eryonucu b, kanbay m. association between asymmetric dimethylarginine and the severity of coronary artery disease in patients with chronic kidney disease. turk neph dial transpl. 2011;20(1):58-64. 9. lu tm, chung my, lin cc, hsu cp, lin sj. asymmetric dimethylarginine and clinical outcome in chronic kidney disease. clin j am socnephrol. 2011; 6:1566-72. 10. ravani p, tripepi g, malberti f, testa s, mallamaci f, zoccali c. asymmetric dimethylarginine predicts progression to dialysis and death in patients with chronic kidney disease: a competing risks modeling approach. am j soc nephrol. 2005; 24:2449-55. 11. kielstein jt, boger rh, bode-boger sm, frolich jc, haller h, ritz e, fliser. marked increase of asymmetric dimethylarginine in patients with incipient primary chronic renal disease. j am soc nephrol. 2002;13: 170–6. 12. fliser d, kronenberg ft, morath kj, bode-boger c, haller h. asymmetric dimethylarginine and progression of chronic kidney disease: the mild to moderate kidney disease study. j am soc nephrol. 2005;16:2456-61. 13. sarnak mj, levey as, schoolwerth ac, et al. kidney disease as a risk factor for development of cardiovascular disease: a statement from the american heart association councils on kidney in cardiovascular disease, high blood pressure research, clinical cardiology, and epidemiology andprevention. hypertension 2003;42:1050-65. 14. rosner b. fundamentals of biostatistics. 7th ed. boston: brooks/cole, cengage learning; 2010. p. 222. 15. kidney disease improving global outcome. kdigo clinical practice guideline for evaluation and management of ckd. kidney int. 2012;3(1). 16. blackwell s. the biochemistry, measurement and current clinical significance of asymmetric dimethylarginine. ann clin biochem. 2010;47:17-28. 17. schulze f, wesemann r, schwedhelm e, et al. determination of asymmetric dimethylarginine (adma) using a novel elisa assay. clin chem lab med. 2004;42(12):1377–83. 18. kanda y. investigation of the freely available easyto-use software ‘ezr’ for medical statistics. bone marrow transplant. 2013;48:452–8. 19. fox j, valat mb. getting started with the r commander. 2014. tri pudy asmarawati acta med indones-indones j intern med 34 20. zoccali c, bode-böger s, mallamaci f, et al. plasma concentration of asymmetrical dimethylarginine and mortality in patients with end-stage renal disease: a prospective study. lancet. 2001;358:2113-7. 21. lajer m. plasma concentration of asymmetric dimethylarginine (adma) predicts cardiovascular morbidity and mortality in type 1 diabetic patients with diabetic nephropathy. diabetes care. 2007;31:747–52. 22. hanai k. asymmetric dimethylarginine is closely associated with the development and progression of nephropathy in patients with type 2 diabetes. nephrol dial transpl. 2009;24:1884–8. 23. kronenberg f. emerging risk factors and markers of chronic kidney disease progression. nat rev nephrol. 2009;5:677-89. 24. kielstein jt, frolich jc, haller h, fliser d. adma (asymmetric dimethylarginine): an atherosclerotic disease mediating agent in patients with renal disease? nephrol dial transplant. 2001;16:1742-5. 25. schwedhelm e, böger rh. the role of symmetric and asymmetric dimethylarginine in renal disease. nat rev nephrol. 2011;7:275–85. 26. ueda s, yamagishi si, okuda s. new pathways to renal damage: role of adma in retarding renal disease proression. j nephrol. 2010;23(4):377-86. 27. thaha m, yusuf m, yogiarto rm, yogiantoro m, handayani r. polymorphism of ddah2 gene and its association with adma level in ckd-5d patients. j nephrol. 2013;3:75-81. 28. thaha m, nilamsari wp, yusuf m, amin m. profile of prmt-1 gene polymorphism in hemodialysis patients with increased adma level. acta med indones. 2014;46(2):97-103. 29. ronden ra, houben ajhm, teerlink t, et al. reduced renal plasma clearance does not explain increased plasma asymmetric dimethylarginine in hypertensive subjects with mild to moderate renal insufficiency. am j physiol renal physiol. 2012;303:149-56. 30. eloot s, schepers e, barreto dv, et al. estimated glomerular filtration rate is a poor predictor of concentration for a broad rangge of uremic toxins. clin j am soc nephrol. 2011;6:1266-73. review article 139acta medica indonesiana the indonesian journal of internal medicine new paradigm in treating cancer: right on target noorwati sutandyo department of internal medicine, faculty of medicine universitas indonesia, dharmais cancer center, jakarta, indonesia. corresponding address: division of hematology and medical oncology, department of internal medicine, dharmais cancer center. jl. let. jend. s. parman kav. 84-86, jakarta, indonesia. email: noorwatis3@yahoo.com. abstrak prevalensi kanker meningkat setiap tahun dan sekarang kanker merupakan penyebab kematian ketiga tertinggi di negara-negara berkembang. terapi antikanker yang efektif dapat memperpanjang hidup dan memperbaiki kualitas hidup pasien. terapi target adalah suatu modalitas terapeutik baru yang tertuju pada molekul-molekul spesifik dalam sel-sel kanker dan memutus jalur-jalur pensinyalan abnormal yang terlibat dalam karsinogenesis. oleh karena terapi target tidak menyerang sel-sel normal, efek sampingnya dianggap lebih rendah dibandingkan kemoterapi. lebih dari 15 jenis obat telah disetujui penggunaannya pada berbagai kanker manusia. obat-obatan tersebut secara garis besar dapat digolongkan menjadi inhibitor tirosin kinase dan antibodi monoklonal. tinjauan pustaka ini akan difokuskan pada obat-obatan yang paling sering digunakan dari kedua kelompok tersebut. kata kunci: antibodi monoklonal, inhibitor tirosin kinase, terapi antikanker, terapi target. abstract cancer prevalence is increasing every year and now cancer is the third highest cause of death in developing countries. effective anticancer treatment can prolong life and improve the patient’s quality of life. targeted therapy is a new therapeutic modality which targets specific molecules in the cancer cell and disrupts dysregulated signaling pathways involved in carcinogenesis. since targeted therapy does not attack normal cells, its side effects are considered low compared to chemotherapy. more than 15 drugs have been approved for treatment in various human cancers. these drugs can largely be grouped into tyrosine kinase inhibitors and monoclonal antibodies. this review will focus on the most common agents within both groups. keywords: anticancer therapy, monoclonal antibodies, targeted therapy, tyrosine kinase inhibitors. introduction cancer treatment remains challenging today because conventional treatments such as chemotherapy, radiation and surgery do not always results in complete disease control or prolonged survival. cancer kills one in two people in high-income countries and one in three people in low-to-middle-income countries.1 therefore, researchers are still looking for agents that can effectively kill cancer cells without affecting normal cells. one of the widely studied therapeutic modalities is targeted therapy, a type of treatment that uses drugs or other substances to identify and attack specific types of cancer cells with less harm to normal cells.2 there are two broad categories of targeted therapy: small molecules (molecular weight +500 dalton) and monoclonal noorwati sutandyo acta med indones-indones j intern med 140 antibodies (molecular weight +150.000 dalton). small molecules are protein kinase inhibitors, usually tyrosine kinase inhibitors, (i.e. those names ending with -nib) that can penetrate membrane cell and interact with targeted protein enzyme and modulate enzymatic activities. monoclonal antibodies (i.e. those names ending with mab) are large molecules that bind specific antigens on the cell surface, such as growth factor receptors. the mechanism of targeted therapy is by interfering signaling cascades that control cell proliferation, survival, invasion and apoptosis. in contrast to chemotherapy that also kills normal cells; targeted therapy attacks cancer cells indirectly by identifying potential targets that play a role in cancer. since targeted therapy only affects cancer cells, its side effects are considered less than chemotherapy. it can be tailored to individual needs, depends on the presence or absence of the specific target molecules; thus, it may require specific test before starting the treatment. currently, there are many kinds of targeted therapy for use in various cancers. this review will focus only on some agents that are frequently used in common cancers. small molecules protein kinases are enzymes that are involved in phosphorylation and transfer of a phosphate group from adenosine 3 phosphates (atp) to tyrosine, serine or threonine residues. there are two broad categories of protein kinase, i.e.: • receptor tyrosine kinase (rtk): egfr, pdgfr, fgfr, ir • non-receptor tyrosine kinase (nrtk): src, abl, fak, jak rtk have many domains for extracellular ligand. after binding to a specific ligand, a signal will pass the cell membrane and the tyrosine kinase will be activated. agents that block the activation of rtk are called tyrosine kinase inhibitors (tkis). the nrtk acts in a similar fashion, but beside of the tyrosine kinase domain, it has additional domains such as serine/threonine kinase domain. this review will focus in tyrosine kinase inhibitors only. tyrosine kinase proteins are enzymes that catalyze the transfer of phosphate polypeptide of atp to a target protein. the active form of the enzyme causes an increase in growth and cell proliferation, induces anti-apoptotic effects, induce angiogenesis and metastasis, and resistance to other therapies. 3 active autophosphorylation of the tyrosine kinase domain occurs in the cytoplasm and activate the downstream cascade like the ras-raf pathway, mitogen-activated protein kinase (mapk), phosphatidylinositol 3-kinase pathway (pi3k), signal transducers and activators of transcription (stat) pathway, and protein kinase c.4 initiation of pi3k signaling would then inhibit the phosphatase and tensin homolog (pten) tumor suppressor gene signaling pathway.5 cancer cells have several mechanisms that may cause dysregulation of tyrosine kinase. mutations can occur and may increase the expression of tyrosine kinase receptor or ligand such as breast cancer with positive her2 receptor.3 tyrosine kinase inhibitors are metabolized by cytochrome p450 enzymes and work on targets inside the cell, so that the components can fit easily into the cells.6,7 this therapy usually blocks the action of the enzyme on the target protein.8 several agents in this group are the epidermal growth factor receptor (egfr), vascular endothelial growth factor (vegf), and bcr-abl tyrosine kinase inhibitors. ligand binding to the extracellular domain of the tyrosine kinase receptor causes dimerization that consequence in autophosphorylation and activation of the intracellular kinase d o m a i n . i t l e a d s t o t h e r e c r u i t m e n t o f enzymes (phosphoinositide 3-kinase (pi3k)), phospholipase cγ1 (plcγ1), src and signal transducer, activator of transcription 3 (stat3) and adaptor molecules, and activation of downstream signaling pathways. the signaling pathways regulate a various array of processes including transcription, translation, metabolism, cell proliferation, survival, differentiation and motility. gene mutations or overexpression can trigger unregulated activation of receptor tyrosine kinases, leading to deregulation of downstream signaling pathways that can ultimately cause malignant proliferative disorders.9 vol 48 • number 2 • april 2016 new paradigm in treating cancer: right on target 141 epidermal growth factor receptors (egfr) signaling egfr family of receptors called her tyrosine kinase family consists of 1-4 erbb oncogene encoded erb. small molecules that inhibit egfr are gefitinib, erlotinib, and lapatinib. they act by blocking the phosphorylation of egfr dimerization, thereby inhibiting protein signaling. gefitinib and erlotinib are reversible egfr inhibitors that compete with atp for binding to catalysis pouch. gefitinib inhibits the activity of cyclin-dependent kinases, inhibits tumor angiogenesis, and arrest the cell cycle. mutation of egfr in exon 19-21 needs to be confirmed before starting treatment.10 lapatinib irreversibly inhibits egfr, her2, and akt pathways. this therapy has a broader spectrum and a smaller resistance than other types of anti-egfr.11 drug similars to lapatinib is neratinib. neratinib inhibit dimerisation egfrher4 or egfrher2.12 afatinib also irreversibly inhibits human her2 and egfr kinases. afatinib does not active only against egfr mutations as first line, like erlotinib or gefitinib, but also against those not sensitive to these standard therapies.13 canertinib is an anti-egfr that is irreversible and has anti-tumor activity with a broad spectrum effects. however, not all mutations in egfr are sensitive to anti-egfr therapy.14 in addition, egfr is also present in normal epithelial cells (skin and mucosa); therefore, inhibition of the egfr may trigger side effects in the skin and gastrointestinal system.7,15 vascular endothelial growth factor (vegf) and vegf receptor (vegfr) signaling the vegf family consists of vegf-a, vegf-b, vegf-c, vegf-d, vegf-e, placenta growth factor (plgf) and three receptors, namely vegf receptor (vegfr) 1, 2 and 3.16 vegf-a and vegfr-2 are expressed in all malignant tumors.17 vegfs work on vascular endothelial cells by inducing vascular permeability, resulting in deposition of fibrin in the extracellular matrix that triggers cell proliferation and migration. the interaction of vegf with its receptors leads to endothelial cell proliferation and new blood vessel formation in in vitro models of angiogenesis.15 sorafenib is a small molecule that inhibits several targets, i.e. vegfr 1-3, pdgf-h receptor serine threonine kinase and raf-1. the drug works through the raf-mapk signaling pathway, which plays a role in arresting cell proliferation and tumorigenesis. a proven efficacy has been shown in hepatocellular and renal cell carcinomas.18 sunitinib is also small molecule with multiple targets. it is the oral form of the receptor protein against several vegfrr 1-3, pdgf-h receptor, and others. bcr-abl tyrosine kinase inhibitors imatinib mesylate is a targeted therapy for bcr-abl protein. mutations on bcr-abl gene may cause dysregulation of intracellular signaling, leading to increased cell proliferation and anti-apoptosis of hematopoietic cells.19 imatinib also inhibits c-kit mutation in mast cell of chronic myelogenous leukemia (cml) and acute myeloid leukemia (aml) patients and also inhibit platelet-derived growth factor receptor (pdgfr) tyrosine kinases that play a role in gastrointestinal stromal tumors (gist).3 monoclonal antibodies monoclonal antibodies are used on the target cell surface, such as excessive antigen expressed on tumor cells. antibodies do not kill cells directly, but through other mechanism in the body’s immune system or by initiating signaling pathways in target cells.8 monoclonal antibodies recognize antigens on the surface of cancer cells, called the target. it works in four ways: 1) monoclonal antibody bound to antigen activates complement components, leading to opsonization of cancer cells by phagocytic cells expressing complement receptors, direct lysis of tumor cells and inflammation with recruitment of inflammatory cells. 2) monoclonal antibody binds to activating fc receptors on the effector cells, leading to antibody-dependent cellular cytotoxicity (adcc) or release of cytokines. 3) monoclonal antibody binds to inhibitory fc receptors (or to both activation and inhibitory fc receptors), inhibiting effector cell activation. 4) monoclonal antibody binds directly to growth factor receptors noorwati sutandyo acta med indones-indones j intern med 142 or other signaling molecules on the cancer cell, leading to cell death.20 egfr antibody cetuximab is a monoclonal egfr antibody that plays a role in blocking the proliferation, invasion, and migration especially in solid tumors, such is colon cancer and head and neck cancer. increased egfr expression showed poor prognosis.21 cetuximab inhibits the binding of ligands egf and transforming growth factor-alpha (tgfα) with egfr and inhibits the activation of receptor tyrosine kinase-induced ligand.22 in addition, cetuximab inhibits homodimerization, heterodimerization between egfr and her2, egfr downstream signaling through the mapk pathway and akt. cetuximab induces apoptosis and inhibits neovascularization. before treating metastatic colon cancer with cetuximab, it should be confirmed that there is no mutation of k-ras gene.23 cell proliferation through an increase in pten activity. trastuzumab can stop cell proliferation by arresting at g1 phase. trastuzumab increases the body’s immune response through the working of natural killer (nk) cells, which induces cell lysis. trastuzumab decreases angiogenesis and it is widely used for breast cancer with her-2 positive 3 (strongly positive).12 vegf and vegfr monoclonal antibodies therapy includes n e u t r a l i z i n g a n t i b o d i e s t o v e g f ( e . g . bevacizumab) or its receptor, vegfr (e.g. ramucirumab). antibody to vegf neutralized vegf after it is secreted from the tumor cells. bevacizumab is an example of humanized monoclonal antibody that inhibits new vessel growth, regresses a newly formed tumor vasculature, alters vascular function and tumor blood flow, and acts on tumor cells directly. it is used in combination with standard chemotherapy for metastatic colon cancer. it has been approved for use in certain lung cancers, renal cancers, ovarian cancers, and glioblastoma multiforme of the brain.24 cluster of differentiation (cd) antibodies that attack the cell surface markers cd20, cd33, and cd52 on lymphoma and leukemia are the first discovered targeted therapy. chimeric anti-cd20 monoclonal antibody (rituximab) works by inducing adcc and cdc that inhibits cell proliferation and stimulates apoptosis. adcc stimulate nk cells to produce interferon-γ (ifnγ) which have anti-tumor effects and can activate immune cells.25 positive cd20 is a prerequisite for the administration of rituximab. common treatment side effects include infection (31%), headache (19%), nausea (23%), vomiting (10%), and others. rituximab can induce fever, thrombocytopenia, bronchospasm, hypoxemia, and others. alemtuzumab is a specific targeted therapy against cd52. alemtuzumab induce apoptosis and through cdc directly. side effects include infection, anemia, thrombocytopenia and myocardial infarction.26 brentuximab vedotin is used in the treatment of non-hodgkin’s lymphoma with cd30 positive.26 ligand egfr pi3k akt mtor jak stat ras raf erf survival proliferation figure 2. egfr signaling pathway her2/neu antibody her2 is a transmembrane receptor with tyrosine kinase activity. the first monoclonal antibody that blocks her2 is trastuzumab.12 it acts by binding to her2 thereby preventing growth signaling pathways to occur. in addition, trastuzumab inhibits intracellular signaling pathways through mapk and pi3k.12 mapk pathways play a role in tumor cell proliferation, whereas pi3k inhibits apoptosis by triggering and activating akt phosphorylation. trastuzumab inhibits the pi3k pathway and vol 48 • number 2 • april 2016 new paradigm in treating cancer: right on target 143 other targets mechanistic of rapamycin (mtor) inhibitor the mechanistic (formerly mammalian) target of rapamycin (mtor) is a serinethreonine kinase that is a member of the phosphatidylinositol kinase-related kinase (pikk) family of kinases (9).27 it presents in two multiprotein complexes (mtorc1 and mtorc2). it has broad antitumor effects such as arresting cell cycle, angiogenesis, and apoptosis. mtor is a protein complex composed of two mtorc1 and mtorc2. pi3k activation would trigger catalyzing phosphoinositide-3,4,5-tri-phosphate (pip3), then activate akt that becomes active mtorc1. the mtorc2 is directly activated by pip3. these mutations will lead to growth, anti-apoptosis, and cell proliferation.28 key molecular factors activate the pi3k/ akt/mtor pathway in either endothelial or cancer cells 3. in addition to effects reported in cancer cells, mtor inhibitors might also act as anti-angiogenic agents by intercepting the vegf and pdgf signaling cascades.29 conclusion cancer is a disease of intracellular signaling dysregulation leading to uncontrolled cell proliferation. targeted therapy is a new treatment modality which can directly disrupt the growth signaling pathway, either by inhibiting enzymatic activity (such as tyrosine kinase inhibitor) or by blocking cell surface receptors with monoclonal antibodies. targeted therapy has an important role in cancer therapy because it has minimal side effects and higher efficacy compared to chemotherapy. however, resistance against targeted therapy can occur and the high cost may also be a problem. references 1. world health organization global health observatory data repository, mortality and global health estimates 2012. 2. nci dictionary of cancer terms. available at: http:// www.cancer.gov/ publications/dictionaries/cancerterms?cdrid=270742. 3. krause ds, van etten ra. tyrosine kinases as targets for cancer therapy. n engl j med. 2005;353(2):172-87. 4. marshall j. clinical implications of the mechanism of epidermal growth factor receptor inhibitors. cancer. 2006;107(6):1207-18. 5. sartore-bianchi a, martini m, molinari f, et al. pik3ca mutations in colorectal cancer are associated with clinical resistance to egfr-targeted monoclonal antibodies. cancer res. 2009;69(5):1851-7. 6. schetter aj, nguyen gh, bowman ed, et al. association of inflammation-related and microrna gene expression with cancer-specific mortality of colon adenocarcinoma. clin cancer res. 2009;15(18):5878-87. 7. g e r b e r h p, f e r r a r a n . p h a r m a c o l o g y a n d pharmacodynamics of bevacizumab as monotherapy or in combination with cytotoxic therapy in preclinical studies. cancer res. 2005;65(3):671-80. 8. abramson r. overview of targeted therapies for cancer2014. downloaded from: http://www. mycancergenome.org/content/other/molecularmedicine/overview-of-targeted-therapies-for-cancer. last access: august 8, 2014. 9. grimminger f, schermuly rt, ghofrani ha. targeting non-malignant disorders with tyrosine kinase inhibitors. nat rev drug discov. 2010;9:956-70. 10. haber da, bell dw, sordella r, et al. molecular targeted therapy of lung cancer: egfr mutations and response to egfr inhibitors. cold spring harb symp quant biol. 2005;70:419-26. 11. verma s, miles d, gianni l, et al. trastuzumab emtansine for her2-positive advanced breast cancer. n engl j med. 2012;367:1783-91. 12. hubalek m, brunner c, mattha k, marth c. resistance to her2-targeted therapy: mechanisms of trastuzumab resistance and possible strategies to overcome unresponsiveness to treatment. wien med wochenschr. 2010;160:506-12. 13. minkovsky n, berezov a. bibw-2992, a dual receptor tyrosine kinase inhibitor for the treatment of solid tumors. curr opin investig drugs. 2008;9:1336-46. 14. kancha rk, von bubnoff n, peschel c, duyster j. functional analysis of epidermal growth factor receptor (egfr) mutations and potential implications for egfr targeted therapy. clin cancer res. 2009;15:460-7. 15. agero al, dusza sw, benvenuto-andrade c, busam kj, myskowski p, halpern ac. dermatologic side effects associated with the epidermal growth factor receptor inhibitors. j am acad dermatol. 2006;55:65770. 16. hicklin dj, ellis lm. role of the vascular endothelial growth factor pathway in tumor growth and angiogenesis. j clin oncol. 2005;23:1011-27. 17. sitohy b, nagy ja, dvorak hf. anti-vegf/vegfr therapy for cancer: reassessing the target. cancer res. 2012;72:1909-14. 18. rini bi. vascular endothelial growth factor-targeted therapy in renal cell carcinoma: current status and future directions. clin cancer res. 2007;13:1098-106. noorwati sutandyo acta med indones-indones j intern med 144 19. arora a, scholar em. role of tyrosine kinase inhibitors in cancer therapy. j pharmacol exp ther. 2005;315:971-9. 20. houghton an, scheinberg da. monoclonal antibody therapies-a ‘constant’ threat to cancer. nat med. 2000;:373-4. 21. hirsch fr, varella-garcia m, cappuzzo f. predictive value of egfr and her2 overexpression in advanced non-small-cell lung cancer. oncogene. 2009;28 suppl 1:s32-7. 22. ayyappan s, prabhakar d, sharma n. epidermal growth factor receptor (egfr)-targeted therapies in esophagogastric cancer. anticancer res. 2013;33:413955. 23. zhang j, ji j, yuan f, ma t, ye zb, yu yy, et al. egfrblockade by antibody cetuximab inhibits the growth of human gastric cancer xenograft in nude mice and its possible mechanism. zhonghua zhong liu za zhi [chinese j oncology]. 2009;31:85-9. 24. ellis lm. mechanisms of action of bevacizumab as a component of therapy for metastatic colorectal cancer. semin oncol. 2006;33(5 suppl 10):s1-7. 25. weiner gj. rituximab: mechanism of action. semin hematol. 2010;47(2):115-23. 26. scott am, wolchok jd, old lj. antibody therapy of cancer. nat rev cancer. 2012;12:278-87. 27. engelman ja. targeting pi3k signalling in cancer: opportunities, challenges and limitations. nat rev cancer. 2009;9:550-62. 28. dufour m, dormond-meuwly a, demartines n, dormond o. targeting the mammalian target of rapamycin (mtor) in cancer therapy: lessons from past and future perspectives. cancers (basel). 2011;3:2478-500. 29. faivre s, kroemer g, raymond e. current development of mtor inhibitors as anticancer agents. nat rev drug discov. 2006;5:671-88. clinical practice 364 acta med indones indones j intern med • vol 51 • number 4 • october 2019 practical guidelines management of graves ophthalmopathy imam subekti1, pradana soewondo1, suharko soebardi1, budiman darmowidjojo1, dante s. harbuwono1, dyah purnamasari1, tri j. e. tarigan1, wismandari wisnu1, dicky l. tahapary1, farid kurniawan1, m. sidik2, syntia nusanti2, salmarezka dewiputri2, hernawita suharko2, gusti g. suardana2, indrati suroyo3, vally wulani3, alvita d. siswoyo4, soehartati gondhowiardjo5, henry kodrat5 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of ophthalmology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 3 department of radiology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 4 department of radiology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 5 department of radiotherapy, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: prof. imam subekti, md., phd. division of endocrinology and metabolism, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430. indonesia. email: imam.subekti@ui.ac.id. abstrak oftalmopati graves merupakan manifestasi ekstra-tiroid yang paling sering dijumpai pada pasien dengan penyakit graves, yang didasari oleh kondisi inflamasi dan autoimun pada jaringan orbital. panduan praktis ini dibuat oleh tim dengan anggota yang terdiri dari berbagai disiplin ilmu, dan diharapkan dapat memberikan panduan untuk pendekatan diagnosis dan tatalaksana oftalmopati graves dalam praktek klinik sehari-hari untuk meningkatkan mutu pelayanan dan hasil pengobatan pada pasien. kata kunci: oftalmopati graves, diagnosis, tata laksana. abtract graves’ ophthalmopathy is the most common extra-thyroid manifestation in patients with graves’ disease, based on inflammatory and autoimmune conditions in orbital tissue. this practical guideline was formed by a multidiciplinary team, and is intended to provide guidance for diagnosis and management of graves’ ophthalmopathy in daily clinical practice to improve quality of care and treatment outcome. keywords: graves’ ophthalmopathy, diagnosis, management. vol 51 • number 4 • october 2019 practical guidelines management of graves ophtalmopathy 365 introduction graves’ ophthalmopathy (go) is one of the most common extra-thyroid manifestation of graves’ disease. clinically visible manifestation of go can be observed in approximately 25-50% of patients with graves’ disease.1 however, when computed-tomography (ct) scan or orbital magnetic resonance imaging (mri) was performed, go can be detected in almost 90% of the patients.2 according to cipto mangunkusumo national general hospital, jakarta, indonesia in 2004, prevalence of graves’ disease in all patients with thyroid symptoms was 21%. about 32% of which presented with clinically visible eye abnormalities.3 a study by subekti et al. at cipto mangunkusumo national general hospital, diagnosis of go was made in 37.3% of patients coming to the hospital with clinical eye abnormalities and 83.6% of patients through orbital ct scans.4 in go treatment, there is no guarantee that the eye abnormalities will improve along with the improvement of thyrotoxicosis. go management was often not optimal because of the unstandardized parameters. therefore, in order to achieve the desired treatment results, management of go must include a comprehensive assessment of the clinical activity and severity of go as well as the quality of life of patients.1 this practical guide is intended to provide guidance for primary care physicians/ doctors, specialists (internal medicine, eye, radiology, nuclear medicine, radiotherapy, surgery, etc.), specialist-consultants (endocrinology and metabolism consultants, eye consultants, radiology consultants, nuclear medicine consultants, etc.), and related healthcare providers in the diagnosis and management of go in order to improve quality of care and treatment outcomes. definition g r a v e s o p h t h a l m o p a t h y ( g o ) i s a n inflammatory eye disease in the orbita, including its consequences, which are associated with autoimmune thyroid disease.5 pathogenesis genetic, environmental, and endogenous factors can change the characteristic of the tsh receptor, which causes b lymphocytes to produce antibodies against the tsh receptor (tshr-ab). the tshr-ab binds to the tsh receptor which causes hyperthyroidism leading to thyrotoxicosis as well as thyroid follicle cell hyperplasia leading to the development of goitre. tshr-ab also binds to tsh receptor in adipocytes and orbital fibroblast, thus initiates the secretion of proinflammatory cytokines by t cells and glycosaminoglycans (gag) by fibroblasts. proinflammatory cytokines can cause fibrosis, while accumulation of gag contributes to the increase of volume of extraocular muscle, connective tissue, and orbital adipocytes. risk factor table 1 showed risk factors for go based on the american thyroid association (ata) 2016.5 table 1. go risk factor5 risk factor comments amenable to intervention age advanced age, have a higher risk for severe go no gender go is more frequent in women, but more severe in men no genetic highest prevalence of go in caucasians, lowest in asians. immunomodulatory genes likely involved no mechanical factors orbital lateral wall angle is wider in go patients no tshr-ab predicts go risk and treatment response no smoking increases go progression and decreases treatment efficacy yes thyroid dysfunction need for expeditious control of hyperthyroidism then prevention of hypothyroidism post graves disease therapy. yes radioactive iodine (rai) therapy risk is additive to smoking; increased with preexistent and active go; preventable by glucocorticoids 6–12 weeks post rai. yes imam subekti acta med indones-indones j intern med 366 diagnosis clinical features the diagnosis of go is established by the presence of ocular signs and symptoms. the ocular symptoms of go are gritty sensation in the eyes, pressure or pain in the eyes (30%), double vision (17%), lacrimation/ photophobia (15-20%), and blurred vision (7.5%). the ocular signs of go are conjunctival and eyelid edema, proptosis or exophthalmus, eyelid retraction (>90%), lid lag (50%), restrictive extraocular myopathy (40%), and optic nerve dysfunction (5%). other clinical features incluseds pretibial myxedema (4%), acropachy (1%), and myasthenia gravis (<1%). in graves’ disease with typical eye abnormalities, diagnosis can be made without orbital imaging. some ocular features of go can be seen on appendix 1 (www.actamedindones.org/index.php/ijim/ article/view/1062/pdf_append). imaging imaging modalities in go are orbital ct scans and mri. orbital imaging is done to evaluate: (1) non-characteristic/ asymmetrical eye abnormalities; (2) involvement/ compression of optic nerves; and (3) orbital structures in preparation for decompression and rehabilitation surgeries. orbital ct scan is not routinely performed in mild go, unless there is complaint of diplopia or suspicion of other retroorbital abnormalities. orbital imaging plays an important role in the differential diagnosis and interdisciplinary management of go patients. extraocular muscle thickening has been found through ct scan in mild go (grade 0 in nospecs classification).2 classification go classification is based on clinical activity score and degree of severity. clinical activity and severity assessment are tools to choose the appropriate treatment options. clinical activity is clinical symptoms and signs that addresses the degree of inflammation. it is assessed using clinical activity score (cas), which consists of active and inactive go. degree of severity is clinical features of the eye associated with changes in anatomical structure, risk of sight-threatening go, and quality of life. it is assessed using eugogo (european group on graves’ orbitopathy) criteria, which consists of mild, moderate-tosevere, and very severe go. assessment criteria can be seen in table 2 and table 3. d a t a o b t a i n e d f r o m t h e n o s p e c s examination is then used to determine the severity of go based on eugogo criteria. management every go patient needs to undergo a t r e a t m e n t p r o g r a m i n o r d e r t o a c h i e v e euthyroidism, smoking cessation, and local eye table 2. go clinical activity score (cas)1 cas first examination, point 1-7: 1. spontaneous retrobulbar pain 2. pain on attempted upward or downward gaze 3. swelling of eyelids 4. redness of eyelids 5. redness of conjunctiva 6. swelling of conjunctiva (chemosis) 7. swelling of caruncle or plica monitoring after 1-3 months, point 8-10: 8. increase in measured proptosis >2 mm 9. decrease in eye movement limit of >8o any direction 10. decrease in visual acuity equal to 1 snellen chart line note: *active go = cas ≥3/7 in fisrt examination or >4/10 on monitoring *inactive go = cas <3/7 in first examination or ≤4/10 on monitoring vol 51 • number 4 • october 2019 practical guidelines management of graves ophtalmopathy 367 care. patients with mild go that can be controlled with antithyroid drugs and local lubricants do not need to be referred to specialists. all go patients with hyperthyroidism are treated to achieve euthyroidism by reducing either the synthesis of thyroid hormone through antithyroid drugs or the amount of thyroid tissue through radioactive iodine or total thyroidectomy. patients with hyperthyroidism who get radioctive iodine treatment and show risk factors for go or patients with mild active go can be given glucocorticod prophylaxis.6 approach in go management includes n o n p h a r m a c o l o g i c a l , p h a r m a c o l o g i c a l , rehabilitative surgery, and radiotherapy, based on the assessment of clinical activity and degree of severity (figure 1). table 3. go degree of severity with nospecs1 no signs or symptoms (degree of severity 0) only signs, no symptoms (degree of severity 1) lid aperture (distance between lid margins in mm with patient looking in primary position, sitting relaxed, with distant fixation) soft tissue involvement (degree of severity 2) swelling/redness of the eyes proptosis (degree of severity 3) exophthalmos (in mm: using the same hertel exophthalmometer and same intercanthal distance for an individual patient) extraocular muscle involvement (degree of severity 4) eye muscle ductions in degrees; subjective diplopia score: intermittent (diplopia when tired or first awakening); inconstant (diplopia at extremes of gaze); constant (continuous diplopia in primary or reading position). corneal involvement (degree of severity 5) absent/ punctuate keratopathy, ulcer sight loss (optiv nerve involvement) (degree of severity 6) best-corrected visual acuity, color vision, optic disk, relative afferent papillary defect, visual fields (if optic nerve compression is suspected) table 4. assessment of go severity based on eugogo1 mild go mild go manifestations have a minimum impact on the daily life. it usually appears in one or more of the following signs: minor lid retraction (<2 mm) mild soft-tissue involvement exophtalmos <3 mm above normal for race and gender (women 18 mm, men 20 mm) no or intermittent diplopia corneal exposure responsive to lubricants moderate-to-severe go patients without sight-threatening go with sufficient impact on the daily life, who need immunosuppression (if go is active) or surgical intervention (if inactive). two or more of the following sign usually appear: lid retraction (≥2 mm) moderate or severe soft-tissue involvement exophtalmos ≥3 mm above normal for race and gender (women 18 mm, men 20 mm) inconstant or constant diplopia very severe go (sight-threatening) patients with dysthyroid optic neuropathy (don) or sight-threatening corneal breakdown. rare cases: eyeball subluxation, severe form of "frozen eye", choroidal folds, postural visual darkening. imam subekti acta med indones-indones j intern med 368 topical eye care dry eyes are treated with preservative-free artificial tear eye drops with osmoprotective agents and long-acting analgesics. if needed, it can be used several times a day to protect the surface and epithelium of the eyes and to control eye symptoms in the early stage of the disease. in the later stage, gel or ointment can be used, especially at night.1,7 elevating the head and and closing the eyes using eye-tape at night can help prevent nocturnal corneal dryness.8 mild diplopia can be controlled with the use of prisms.8 in addition, protective googles can also be used to keep the eyes from foreign objects. pharmacological therapy, rehabilitative surgery, and radiotherapy the choice of pharmacological therapy, rehabilitative surgery, and radiotherapy are based on clinical activity and degree of severity. glucocorticoids are the first choice on pharmacological therapy that can be given for clinically active go. glucocorticoids can be administered through oral, intravenous, or local route. local administration of glucocorticoids through subconjunctival or retrobulbar injection is not recommended due to the risk of trauma and unproven effectiveness. intravenous glucocorticoids have showed better response and improvement in clinical activity compared with oral administration. some contraindications of methylprednisolone as part of go therapy are (1) history of viral hepatitis (evidence of recent viral hepatitis); (2) significant liver dysfunction; (3) severe cardiovascular morbidity; (4) uncontrolled hypertension; (5) psychiatric disorders; and (6) uncontrolled diabetes.8,9 proton pump inhibitors can be administered along with glucocorticoids to prevent peptic ulcers, and bone protection may be required, especially in patients high-risk for osteoporosis. side effects of high-dose oral glucocorticoids include cataracts, peptic ulcer, prolonged suppression of adrenal function, cushing’s syndrome, hypertension, diabetes, osteoporosis, reactivation of chronic disease (such as tuberculosis), infection, and psychosis.8 if intravenous glucocorticoid administration is not possible, oral prednisone can be given for 12 weeks, with initial dose of 0.2 gram/day, gradually tappered down to and 0.01 gram/week (cumulative dose of 4 grams).10,11 t h e r e a r e s e v e r a l a l t e r n a t i v e s t o glucocorticoids that are extensively studied, such as rituximab, anti-interleukin-6 (il-6) tocilizumab receptor, and anti-insulin growth factor 1 receptor (igf-1r) teprotumumab.12 rituximab is a second-line therapy that can be given to moderate-to-severe active go who fail the initial therapy or show glucocorticoids resistance.13 tocilizumab is associated with ocular improvement, such as increase in visual acuity and decrease in intraocular pressure.14 * : refer to specialists ** : refer to endocrinology and metabolism or eye consultants *** : refer to eye consultants # : if available. figure 1. management of go1 vol 51 • number 4 • october 2019 practical guidelines management of graves ophtalmopathy 369 teprotumumab is a new immunosuppresive agents which can effectively reduce proptosis and improve clinical activity of go.15 mild go in mild go, the focus is to give a topical eye protection and control of the risk factors. when the impact of go on quality of life exceeds the risk of therapy, intravenous glucocorticoids as immunosuppressive agents can be given to active go and rehabilitative surgery for inactive go. treatment of mild go begins with observation and, if available, twice-daily selenium 100 mg for 6 months in order to improve eye symptoms and quality of life, as well as to prevent the progression of go. in a controlled clinical trial, no side effects of selenium were shown in go. selenium is less effective in mild chronic inactive go, thus if needed, rehabilitative surgery is more recommended.1 moderate-to-severe active go high-dose systemic glucocorticoids are the first line of moderate-to-severe active go. intravenous glucocorticoids show 70-80% effectiveness, while oral administration only 50%. in addition, intravenous glucocorticoids show better tolerance than oral. moderate-to-severe active go management and steps after 4 weeks of treatment can be seen in figure 2.1,7 methylprednisolone is given as much as 500 mg/day for 3 consecutive days, repeated every week for 4 weeks, so that the cumulative dose of 6 grams is obtained. glucocorticoid therapy as first line is generally effective for moderateto-severe active go. if there is a partial or inadequate response to glucocorticoids, there are several therapeutic options: 1. second course intravenous glucocorticoids if the patients show good tolerance in first course of glucocorticoids, but does not exceed 8 gram cumulative dose in the second course of administration 2. combination of oral glucocorticoids and orbital radiotherapy • orbital radiotherapy shows potential to provide a synergistic effect along with oral glucocorticoids. • cumulative dose 20 gy per eye divided into 10 daily doses given over a period of 2 weeks, or a dose of 1 gy per week for a period of 20 weeks, which has the same effectiveness and better tolerance.1 • m i l d t r a n s i e n t e x a c e r b a t i o n o f ocular symptoms might occur and can be controlled with low-dose oral glucocorticoids. • contraindications to radiotherapy in go are history of retinopathy and/or uncontrolled diabetes. • radiotherapy can be done using ct scanbased technique, such as 3-dimensional conformal radiotherapy (3dcrt), intensity modulated radiotherapy figure 2. moderate-to-severe active go treatment1 imam subekti acta med indones-indones j intern med 370 (imrt), or volumetric modulated arc radiotherapy (vmat). 3. combination of oral glucocorticoids and cyclosporine • prednisone 100 mg/day gradually tappered down for 3 months, given in single or combination with cyclosporine with initial dose of 5 mg/kg/day for 12 months. combination therapy is associated with better ocular outcome and lower rate of recurrence, or • prednisone with initial dose of 60 mg/day with/or cyclosporine with initial dose of 7.5 mg/kg/day for 12 weeks. as many as 60% of patients who did not respond to single therapy show better response to combination therapy. 4. rituximab • rituximab 1,000 mg given twice in two weeks, or rituximab 100 mg followed by injection of 500 mg single dose. • side effects can be prevented by antihistamine premedication and 100 mg hydrocortisone. side effects of periorbital edema and inflammation can also occur. 5. other therapies • periocular triamcinolone injection 20 mg/week for 4 consecutive weeks show decrease in diplopia and the size of the extraocular muscle in newly active go without local or systemic side effects. • subconjunctival triamcinolone injection is effective in reducing swelling and mild retraction of the eyelids in new onset of go, with transient elevation in iop.1 • if symptoms relapse after glucocorticoid doses tappered down or there is no clinical improvement after glucocorticoid administration, bromocriptine 1.257.5 mg/day gradually increased can be considered for 3-10 months single or in with glucocorticoid.1–5 • methotrexate is an alternative in case of glucocorticoid side effects, either 7.5-15 mg/week orally or 20 mg by subcutaneous injection.7,8 choice of therapy mentioned above can be considered as second-line therapy. however, the choice of therapy should be decided together in a multidisciplinary manner, taking into account the advantages and disadvantages for patients from various aspects. moderate-to-severe inactive go rehabilitative surgery is recommended in patients with go who have significant altered visual function or quality of life after go become inactive for at least 6 months. if more than one procedure of rehabilitative surgery is needed, the sequence of procedures is performed, namely decompression surgery, strabismus surgery, then periorbital and eyelids cosmetic surgery, since the prior procedure affect the latter. a. orbital decompression surgery. orbital decompression surgery is indicated in severe and persistent proptosis, especially if there is an inadequate response to glucocorticoid therapy and or orbital radiotherapy and if there is keratitis, and optic neuropathy due to suppression of the optic nerve.8 decompression surgery aims to reduce intraocular pressure, reduce exophthalmus, eyelids retraction, pain, reduce strabismus, and improve blurred vision due to orbital microvasculopathy and optic nerve. b. strabismus surgery. strabismus surgery aims to improve diplopia. this surgery is needed because extraocular muscle involvement often does not respond to drug therapy and worsens after orbital decompression surgery. c. periorbital and eyelids cosmetic surgery. this surgery aims to repair the eyelids. retraction of the upper and lower eyelids is a combination of the inflammatory and fibrotic process, adrenergic stimulation, as well as vertical rectus muscle restriction. in addition, exophthalmus also increases eyelids aperture. very severe go very severe go caused by dysthyroid optic neuropathy (don) and or exposure to the cornea or corneal damage is an emergency that requires immediate treatment. eyeball subluxation can occur through the traction of the optic nerve with/ without corneal damage. first-line therapy in don is intravenous g l u c o c o r t i c o i d s , f o r e x a m p l e s i n g l e vol 51 • number 4 • october 2019 practical guidelines management of graves ophtalmopathy 371 methylprednisolone 500-1,000 mg for 3 consecutive days or intervals a day for 1 week. if the response is not good or there is deterioration in visual function, decompression surgery needs to be performed.1 monitoring initial response can predict a long-term response to glucocorticoid therapy. things to consider in monitoring: 1. glucocorticoids should not be used for more than 12 weeks with cumulative dose of methylprednisolone not exceeding 8 grams. 2. blood glucose, liver function, and blood pressure should be controlled every month during therapy. 3. after cessation of glucocorticoids, it is necessary to monitor orbital vascular congestion that resembles active go images, such as eyelid edema, eyelid or conjunctival redness, and chemosis, especially in patients with longer duration of illness.1,7 quality of life assessment go management should be done through a “centered” approach to patients, which includes the effects of the disease and therapeutic effects on quality of life and psychosocial aspects of the patient (appendix 1). references 1. bartalena l, baldeschi l, boboridis k, et al. the 2016 european thyroid association/european group on graves’ orbitopathy guidelines for the management of graves’ orbitopathy. eur thyroid j. 2016;5:9–26. 2. kartono d. korelasi antara ketebalan otot ekstraokular pada ct scan orbita dengan derajat oftalmopati graves. fkui. jakarta; 2017. 3. subekti i. diagnosis dan pengelolaan oftalmopati graves. jakarta endocrinology meeting. jakarta: divisi metabolik endokrinologi, departemen ilmu penyakit dalam fkui/rscm; 2008. p. 30–5. 4. subekti i. hubungan tsh receptor antibody, thyroid stimulating antibody, dan thyroid blocking antibody dengan aktivitas klinis dan derajat keparahan oftalmopati graves. fakultas kedokteran universitas indonesia. jakarta.; 2011. 5. ross ds, burch hb, cooper ds, et al. 2016 american thyroid association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. thyroid. 2016;26(10):1343–421. 6. kahaly gj, bartalena l, hegedüs l, leenhardt l, poppe k, pearce sh. 2018 european thyroid association guideline for the management of graves’ hyperthyroidism. eur thyroid j. 2018;7:167–86. 7. bahn rs, burch hb, cooper ds, et al. hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the american thyroid association and american association of clinical endocrinologists. endocr pr. 2011;21(6):593–646. 8. bartalena l, marcocci c, pinchera a. treating severe graves’ ophthalmopathy. baillieres clin endocrinol metab. 1997;11(3):521–36. 9. tu x, dong y, zhang h, su q. corticosteroids for graves’ ophthalmopathy: systematic review and metaanalysis. 2018;2018. 10. kahaly gj, pitz s, hommel g, dittmar m. randomized, single blind trial of intravenous versus oral steroid monotherapy in graves’ orbitopathy. j clin endocrinol metab. 2005;90(9):5234– 40. 11. bartalena l, baldeschi l, dickinson a, et al. consensus statement of the european group on graves ’ orbitopathy ( eugogo ) on management of go. eur j endocrinol. 2008;158:273–85. 12. wiersinga wm. advances in treatment of active, moderate-to-severe graves’ ophthalmopathy. lancet diabetes endocrinol. 2017;5(2):134–42. 13. stan mn, salvi m. rituximab therapy for graves’ orbitopathy – lessons from randomized control trials. eur j endocrinol. 2017;176(2):r101-9. 14. atienza-mateo b, v.calvo-río, martín-varillas jl, demetrio-pablo r. anti-il6-receptor tocilizumab in graves orbitopathy. multicenter study of 29 patients. sci abstr. 2018;sat0601:1153–4. 15. fleming jc, dailey ra, tang ra, et al. teprotumumab for thyroid-associated ophthalmopathy. n engl j med. 2017;376(18):1748-61. 469acta med indones indones j intern med • vol 53 • number 4 • october 2021 case report xanthogranulomatous pyelonephritis with pyonephrosis and renal abscess in a young adult: a consequence of neglected urinary tract infection leading to nephrectomy ali ariyono1, maria f. pudjohartono1, thomas rikl1, hanggoro t. rinonce1*, hadi irawiraman2, yulita pundewi setyorini3, daisy tumedia3 1 department of anatomical pathology, faculty of medicine, public health, and nursing, universitas gadjah mada dr. sardjito hospital, yogyakarta, indonesia. 2 department of anatomical pathology, faculty of medicine, mulawarman university, samarinda, indonesia. 3 department of anatomical pathology, dr. kanujoso djatiwibowo hospital, balikpapan, indonesia. *corresponding author: hanggoro tri rinonce, md, phd. department of anatomical pathology, faculty of medicine, public health, and nursing, universitas gadjah mada. radiopoetro building, 4th floor, farmako street, sekip utara, sinduadi, mlati, sleman, yogyakarta 55281, indonesia. email: hanggoro_rinonce@ugm.ac.id. abstract xanthogranulomatous pyelonephritis (xgp) is a rare form of chronic pyelonephritis, which is challenging to diagnose because its clinical presentation mimics other entities and is commonly associated with a history of urinary tract obstruction. we report a case of xgp in a young adult without nephrolithiasis and urinary tract obstruction. a 23-year-old woman presented with intermittent abdominal pain in the right upper quadrant persisting for the last ten months. the pain was dull, poorly localized, and started spreading to the right back, right shoulder, and right thigh in the last three months. other complaints included fever, chills, pain during urination, and nausea. the patient had a history of infrequent urination, recurrent urinary tract infections (utis), and a low fluid intake. a physical examination revealed that the patient had right upper quadrant abdominal tenderness and right costovertebral angle tenderness. laboratory findings showed leukocytosis and neutrophilia. the radiological examination revealed a round mass in the superior pole of the right kidney with mixed cystic and solid components, and a well-defined margin. it further enlarged from 4.5 cm to 10.6 cm in diameter in three months. the urologist performed a total right nephrectomy. the histopathological examination showed xgp with renal abscess. proteus mirabilis was identified from the pus specimen culture. xgp should be considered in the diagnosis of patients having chronic uti presented with or without the findings of urinary tract obstruction. keywords: xanthogranulomatous pyelonephritis, pyonephrosis, renal abscess, urinary tract infection, nephrectomy. introduction xanthogranulomatous pyelonephritis (xgp) is a rare form of chronic pyelonephritis, which has a challenging diagnosis because of its resemblance to other renal pathologies. xgp is a rare entity that accounts for only 0.6% of histologically documented cases of chronic pyelonephritis.1 women are predominantly affected (the male-to-female ratio ranges between 0.5 and 0.6), usually in mid-life years (40–50 years).2,3 this chronic destructive granulomatous inflammation of renal parenchyma often results in a complete loss of function in the affected kidney. ali ariyono acta med indones-indones j intern med 470 the exact etiology of xgp is still yet to be discovered, but it appears to be multifactorial. two of the most common risk factors are urinary tract obstruction and infection, with obstruction playing a major role in pathogenesis.4 the most common cause of obstruction is nephrolithiasis, which is present in 90% of xgp cases.2,3 other causes include ureterolithiasis, ureteral stenosis, pyelo-ureteral junction abnormalities, and pyeloureteral duplicities. xgp is also associated with recurrent urinary infections, with common pathogens such as escherichia coli and proteus mirabilis. the difficulty of diagnosing xgp arises from the fact that it may closely mimic other diseases of the kidney. this nature has earned xgp the title of “the great imitator”.5 the findings in xgp are often difficult to distinguish from pyonephrosis, renal abscess, renal tuberculosis, and renal cell carcinoma by the clinical symptoms, physical examination, and radiological findings.6 the diagnosis is only confirmed by pathological examination after nephrectomy. we present an unusual case of xgp in a young adult without urinary obstruction and nephrolithiasis. the case was complicated by pyonephrosis and renal abscess caused by proteus mirabilis, which further led to nephrectomy. a pathological examination confirmed xgp after total nephrectomy. case illustration a 23-year-old woman presented with intermittent abdominal pain in the right upper quadrant persisting for the last ten months. the pain was dull and poorly localized, with a score of 8 out of 10 on the numerical rating scale. the abdominal pain started spreading to the right back, right shoulder, and right thigh from the past three months. the patient also complained of fever, chills, pain during urination, and nausea. there were no complaints of darker or turbid urine. the medical history was significant for untreated recurrent urinary tract infections (uti) for the last three years. she said that she rarely drank water in the last five years, only consuming around 400 ml a day. she denied any history of drug use, sexual activity, and urine catheter usage. she usually changed underwear twice a day and kept the genital area clean. the physical examination revealed that the patient had normal vital signs, right upper abdominal tenderness, and right costovertebral angle tenderness. complete blood counts showed leukocytosis (12.05 × 103/μl) and neutrophilia (76.8% neutrophils). urea and creatinine blood levels were within normal limit, 18 mg/dl and 0.52 mg/dl respectively. the estimated glomerular filtration rate (egfr) was 133 ml/min/1.73 m2. other laboratory tests were also within the normal range. an ultrasound examination revealed a round mass, 4.5 cm in diameter, in the superior pole of the right kidney with cystic and solid components, and well-defined margins (figure 1). three months later, a computed tomography scan of the abdomen showed a cystic mass measuring 10.6 × 8 × 7.72 cm in the superior pole of the right kidney suppressing the pelvicocalyceal system, accompanied by perirenal fat obliteration and lymphadenopathy (figure 2). the patient was diagnosed with a kidney mass. therefore, a urologist performed a total nephrectomy because of the non-functional kidney. surprisingly, the kidney was found to be enlarged and contained approximately 200 figure 1. ultrasonography of the right kidney showed a round, well-defined, mixed cystic and solid mass with a diameter of 4.5 cm in the superior pole of the right kidney vol 53 • number 4 • october 2021 xanthogranulomatous pyelonephritis with pyonephrosis 471 ml of pus intraoperatively. the histopathological examination revealed the granulomatous i n f l a m m a t i o n o f t h e r e n a l p a r e n c h y m a comprising many xanthomatous histiocytes with foamy cytoplasm and multinucleated giant cells surrounded by lymphocytes, areas of hemorrhage, and necrosis with numerous neutrophil infiltrations, thereby indicating xgp with renal abscess (figure 3). cultures from the pus showed proteus mirabilis infection without any antibiotic resistance. the patient was treated with parenteral ceftriaxone and metronidazole postoperatively. the patient was followed up thrice after the nephrectomy. the patient was discharged from the hospital one week after the surgery, when the operation wound was already dry; however, there was still a feeling of pain in the wound area. one week after the first followup, the pain had lessened and the wound edges appeared to have fused on inspection. three months after the surgery, the surgical wound had healed completely and the patient did not have symptoms of any kind. follow-up of renal function test showed normal results (blood urea 26 mg/dl, blood creatinine 0.8 mg/dl, and egfr 103 ml/min/1.73 m2). discussion the diagnosis of xgp is rare and challenging because of its non-specific clinical symptoms, laboratory, and radiologic findings. this condition typically occurs in middle-aged women and is mainly linked to urinary obstruction. however, the patient described in the presented case was a 23-year-old woman without any evidence of underlying urinary obstructions, thus presenting a potential diagnostic pitfall. epidemiologically, xanthogranulomatous pyelonephritis is seldom found in a young, otherwise healthy adult. an xgp case in a young adult has been reported previously but it was in the presence of a staghorn calculi.7 the absence of urinary obstruction further makes the occurrence of xgp more unlikely in the previously described patient. ultrasonography and ct scans did not find nephrolithiasis or ureterolithiasis. no anatomical abnormalities were observed from radiology and intraoperative assessment. despite the low possibility, xgp was confirmed in the patient. similar conditions have also been reported in other case reports where xgp was confirmed by the histopathologic examination in patients who did not have a history of urinary tract obstruction.8,9 the only related risk factor found in the aforementioned patient was recurrent and chronic urinary infections. xgp can arise as a complication of chronic urinary infections.2 figure 2. a contrast abdominal ct scan in the transverse plane (upper) and coronal plane (lower) showed a kidney mass measuring 7.72 × 8 × 10.6 cm in the superior pole of the right kidney suppressing the pelvico-calyceal system with perirenal fat obliteration and lymphadenopathy figure 3. histopathologic examination showed: (a) granulomatous inflammation of the renal parenchyma, xanthomatous histiocytes with foamy cytoplasm, and areas of hemorrhage and necrosis, indicating xanthogranulomatous pyelonephritis with renal abscess (hematoxylin and eosin (he) stain, 40x). higher magnification showed (b) xanthomatous histiocytes (he, 400x), (c) foreign bodytype histiocytic giant cells (he, 400x), and (d) collection of inflammation cell infiltrate, dominated by neutrophils with few lymphocytes, plasma cells, and histiocytes (he, 400x). ali ariyono acta med indones-indones j intern med 472 the recurrence and chronicity of the urinary infections could occur from the patient’s low fluid intake and infrequent urination. drinking less than 1.5 l of total fluid daily is associated with more frequent urinary infections in women.10 adequate treatment and related lifestyle changes can prevent complications from a urinary infection. the management of xgp depends on the extent of the disease. the current treatment of choice for diffuse xgp is surgical intervention. if xgp is found in the earlier stages with a smaller lesion size, then antibiotics can be attempted as an initial treatment.6 the diffuse xgp in the patient had resulted in a non-functioning kidney; hence, the urologist decided treatment with nephrectomy. an early recognition and management of recurrent utis and the xgp itself might have prevented the necessity of nephrectomy in the described patient. conclusion xgp is a rare type of chronic pyelonephritis, whose diagnosis is challenging preoperatively. the described patient was quite atypical as she was a young adult with no evidence of urinary obstruction. the only risk factor found in the patient was recurrent utis. clinicians should still consider xgp in patients with recurrent utis in all ages, even without the presence of risk factors. an early diagnosis and treatment of the utis and xgp could prevent unnecessary morbidity caused by nephrectomy. acknowledgments no author of this case report has any conflicts of interest. we received no financial support for collecting data and writing this case report. references 1. dell’aprovitola n, guarino s, del vecchio w, et al. xanthogranulomatous pyelonephritis mimicking a renal cell carcinoma: a unique and challenging case. acta radiol short reports. 2014;3(1):1-4. 2. i c h a o u i h , s a a d i a , c h a k r o u n m , e t a l . xanthogranulomatous pyelonephritis in adults: clinical, biological, radiological and therapeutic main findings in diffuse and focal forms. about 42 cases. tunis med. 2018;96(8):495–500. 3. k u n d u r , b a l i y a n a , d h i n g r a h , e t a l . clinicopathological spectrum of xanthogranulomatous pyelonephritis. indian j nephrol. 2019;29(2):111–5. 4. g u p t a s , a r a y a c e , d h a r n i d h a r k a v r . xanthogranulomatous pyelonephritis in pediatric patients: case report and review of literature. j pediatr urol. 2010;6(4):355–8. 5. chlif m, chakroun m, ben rhouma s, et al. xanthogranulomatous pyelonephritis presenting as a pseudotumour. can urol assoc j. 2016;10(1–2):36. 6. kim sw, yoon bi, ha us, et al. xanthogranulomatous pyelonephritis: clinical experience with 21 cases. j infect chemother. 2013;19(6):1221–4. 7. morales c, opazo v, bassa c, et al. xanthogranulomatous pyelonephritis: a case report. urol case reports. 2018;19(1):65–6. 8. e l a b i a d y, d e h a y n i y, q a r r o a , e t a l . xantogranulomatous pyelonephritis: the missed diagnosis. int j surg case rep. 2016;18:21-3. 9. el-asmar jm, ghanem r, ghandour r, et al. postpartum xanthogranulomatous pyelonephritis: a case report. case reports in women’s health. 2019;22:e00112. 10. hooton tm, vecchio m, iroz a, et al. effect of increased daily water intake in premenopausal women with recurrent urinary tract infections: a randomized clinical trial. jama intern med. 2018;178(11):1509– 15. case report 252 acta med indones indones j intern med • vol 51 • number 4 • october 2019 a case report on cholestatic jaundice secondary to adverse effect of phaleria macrocarpa (mahkota dewa) muhammad f. a. rahim1, alvin o. payus2 1 department of internal medicine, universiti kebangsaan malaysia medical centre (ukmmc), kuala lumpur, malaysia. 2 faculty of medicine and health science, universiti malaysia sabah (ums), kota kinabalu, sabah, malaysia. corresponding author: alvin oliver payus, mrcp. faculty of medicine and health science, universiti malaysia sabah (ums). jalan ums, 88400. kota kinabalu, sabah, malaysia. email: dralvinpayus@ums.edu.my. abstrak cedera hati kolestatik yang diinduksi obat dapat menimbulkan kesulitan diagnostik yang merupakan daftar panjang penyebab potensial berkaitan dengan ketidak-lengkapan resep atau obat yang dijual bebas, seperti obat herbal dan obat phaleria macrocarpa, atau lebih dikenal sebagai ‘mahkota dewa’ oleh penduduk lokal di asia tenggara. ekstrak tanaman obat ini telah semakin digunakan untuk pengobatan tradisional berbagai penyakit. kami melaporkan kasus seorang pria muda yang tidak memiliki penyakit medis mengalami pola kerusakan hati kolestatik yang disebabkan oleh konsumsi kronis phaleria macrocarpa. tujuan dari laporan kasus ini adalah untuk membagikan efek samping yang tidak umum dari penggunaan produk tradisional ini, mungkin pernah dilaporkan sebagai efek yang tidak diketahui. keywords: drug induced cholestatic liver injury, kolestasis, phaleria macrocarpa, asia. abstract drug induced cholestatic liver injury can posed a great diagnostic difficulty as a result of its long nonexhaustive list of potential offending causes which can be either prescribed or over-the-counter medications, such as medicinal herbs and remedies. phaleria macrocarpa, or more commonly known as the ‘god’s crown’ by the local people of south east asia, is not listed as one of the causes. this medicinal plant extract has been increasingly used for traditional treatment for various ailments. here, we report a case of a young man who has no known medical illness presented with cholestatic pattern of liver injury which caused by chronic ingestion of phaleria macrocarpa. the objective of this case report is to share the uncommon side effect of taking this traditional product which may have been under-reported due to the unknown effect. keywords: drug induced cholestatic liver injury, cholestasis, phaleria macrocarpa, asia. introduction ‘mahkota dewa’ which literally translated as the ‘god’s crown’ is the other name for phaleria macrocarpa in south east asia. it has been increasingly used as a traditional medicinal product for various conditions for the past few years.1 most literatures available tried to explore the potential benefit of the product,2 but very few that study the adverse effect of taking it for long term. here, we report a rather uncommon or may have been under-reported adverse effect of the phaleria macrocarpa extract product which causes cholestatic jaundice. to the best of our knowledge, this is the first article that reported a vol 51 • number 4 • october 2019 a case report on cholestatic jaundice secondary case of a cholestatic jaundice that occur as a side effect of taking phaleria macrocarpa. case illustration a 35-year old man who works as a car mechanic and has no known medical illness was referred for further evaluation of progressively deepening jaundice and on and off body pruritus with corresponding abnormal liver enzymes over period of one month. he denied any fever, abdominal pain, vomiting nor altered bowel habit. he abhors alcohol consumption and does not smoke cigarette. he also was not taking any regular prescribed or over-the-counter medications. there was no significant history to suggest metabolic syndrome. on further questioning, the patient actually has been taking the extract of phaleria macrocarpa over period of one year in the form of premixed coffee. he mentioned that the intention of this ingestion was merely for supplementary purpose as he was told that the product is liver protective. on examination, he has lean body built with the body mass index of 22, and appears overtly jaundice. otherwise, he was not pale and there were no signs of acute liver failure nor any stigmata of chronic liver disease. his abdomen was soft and not tender, and there was no palpable mass nor organomegaly. examination of the iris reveal no kayser–fleischer rings seen, and there was no cerebellar sign found as well. initial blood investigations were taken at that time and shows his liver function was in cholestatic pattern with predominant conjugated hyperbilirubinemia (table 1). table 1 showed hyperbilirubinemia with apparent cholestatic pattern of liver injury as evidence of raised alkaline phosphatase. apart from a mildly raised total white count, all other parameters from full blood count and renal function are within normal ranges. aetiologic work-up for various infective causes of cholestasis like viral hepatitis, cytomegalovirus, hiv and epstein–barr virus were negative. autoimmune profiles were also screened and came back negative. later he was subjected to ultrasound with doppler scan of the abdomen which show normal liver size and echogenicity and no biliary tree dilatation (figure 1 and 2). he also did a complimentary endoscopic hepatobiliary ultrasound and a computed tomography imaging of the abdomen which revealed no radiological evidence of biliary obstruction and no corresponding biliary tree dilatation. the liver size and echogenicity were reported as normal. subsequently, liver biopsy was done and revealed moderate intrahepatic cholestasis with mild hepatocellular injury. the perivenular and centrilobular region exhibit cholestasis with bile plugs in dilated canaliculi, bile in hepatocytes and kupffer cells. there was occasional steatosis but the absence of hepatocyte ballooning and mallory-denk bodies make fatty liver infiltrates less likely. there was no active cirrhosis, no lymphoplasmacytic portal inflammation or no interface hepatitis which is classical of autoimmune hepatitis. all in all, liver biopsy has concluded that intrahepatic cholestasis was suggesting of outflow obstruction, making drug induced liver injury a top diagnostic priority (figure 3 and 4). as the patient was not taking any regular medications both prescribed and over-the-counter, it was concluded that the cholestatic jaundice was induced by phaleria macrocarpa extract in premixed coffee. he was managed conservatively with regular oral ursodeoxycholic acid 250 mg there times daily and also oral chlorphenamine 4mg as needed for the pruritus. he was discharged well and was follow up in the clinic for regular liver function monitoring, which has been normalized after withdrawal from taking the plant extract. table 1. the initial blood investigation. blood parameters result normal range haemoglobin 13.7 g/dl 12 – 18 g/dl platelet 375 x 109/l 150 – 400 x 109/l white blood cell 12.9 x 109/l 4.0 – 11.0 x 109/l albumin 32 g/l 35 – 50 g/l alkaline phosphatase 270 u/l 50 – 150 u/l alanine transaminase 56 u/l 5 – 35 u/l total bilirubin 472 μmol/l 0 – 13 μmol/l creatinine 83 μmol/l 60 – 120 μmol/l sodium 135 mmol/l 135 – 150 mmol/l potassium 3.6 mmol/l 3.5 – 5.0 mmol/l urea 3.2 mmol/l 1.7 – 8.0 mmol/l 253 muhammad f.a. rahim acta med indones-indones j intern med figure 1. ultrasound of the hepatobiliary system which shows no focal lesion, and normal liver size and echogenicity in both right and left lobe. figure 2. colour doppler ultrasound of the portal system which shows patent portal vein with normal doppler flow. figure 3. this photomicrograph shows mild inflammation of the portal tracts without evidence of bile duct injury or proliferation and no interface hepatitis. figure 4. image showing evident perivenular marked cholestasis, with bile plugs within dilated canaliculi. discussion phaleria macrocarpa or fondly known as ‘mahkota dewa’ in the south east asia region which literally translated as the god’s crown, is ubiquitous in the region especially in malaysia and indonesia. it is a complete tree which encompasses stem, leaves, flowers and the distinctive fiery red fruit, and can grow as high as 18 meters in height.1 in the recent years, this plant has become an emerging popular medicinal plant among malaysian and indonesian. it is believed that the plant has medicinal properties to treat various ailments such as cancer, impotency, hemorrhoids, diabetes mellitus, just to name a few. faried et al. said that natural antioxidant 254 vol 51 • number 4 • october 2019 a case report on cholestatic jaundice secondary gallic acid extracted from phaleria macrocarpa is believed to be a potential anticancer compound without denying the fact that in depth in vivo studies any needed to support.2 on top of that, there are several other literatures have described the extract as being able to lower post-prandial hyperglycemia in animal model.3,4 the plant was also said to have a hepatoprotective effect5 and was proven in a study on a rat model by sundari et al.6 on the contrary, there is very limited literature that evaluate the nature of the possible adverse effect of the plant extract. one study reported that the extract is believed to cause oral ulcers.7 here, we report a case of a cholestatic jaundice that was induced by taking phaleria macrocarpa extracts in a premixed coffee and has resolved spontaneously upon withdrawal from the supplement. as there is no single test that can directly pinpoint a diagnosis of drug induced liver injury currently, drug history plays a pivotal role in identifying the cause. this is done by simply enquiring the use of both prescribed and over-the counter medications which include vitamin and medicinal plant for remedies and herbal supplements.8 in this case report, our patient who was physically fit young man with no known medical illness has only positive history of taking phaleria macrocarpa extract contained premixed coffee. however, a thorough work-up was done in order to rule out other more common causes of cholestatic jaundice, especially other possible drug that may have induced the liver injury, before the conclusion of phaleria macrocarpa as the cause was made. conclusion this case report served to share an uncommon case of cholestatic jaundice secondary to phaleria macrocarpa, which may have been underreported. as the product has been increasingly used in this part of the world, more studies are warranted in order to evaluate the hazardous effect of this plant extracts. however, the authors would like to emphasize systematic and stepwise evaluation should always be undertaken to rule out other more common causes of jaundice and liver injury. acknowledgments the authors would like to thank the patient for giving his consent and cooperation in relation to the writing of this case report. the author would also like to thank the director general of ministry of health of malaysia for his permission to publish this article. conflict of interest there are no conflict of interest and financial support for this article. references 1. altaf r, asmawi mz, dewa a, sadikun a, umar mi. phytochemistry and medicinal properties of phaleria macrocarpa (scheff.) boerl. extracts. pharmaco rev. 2013;7(13):73. 2. faried a, kurnia d, faried ls, usman n, miyazaki t, kato h, kuwano h. anticancer effects of gallic acid isolated from indonesian herbal medicine, phaleria macrocarpa (scheff.) boerl, on human cancer cell lines. int j oncol. 2007;30(3):605-13. 3. sugiwati s, kardono l, bintang m. a-glucosidase inhibitory activity and hypoglycemic effect of phaleria macrocarpa fruit pericarp extracts by oral administration to rats. j appl sci. 2006;6:2312-6. 4. triastuti a, park hj, choi jw. phaleria macrocarpa suppress nephropathy by increasing renal antioxidant enzyme activity in alloxan-induced diabetic rats. natural prod sci. 2009;15(3):167-72. 5. zhang yb, xu xj, liu hm. chemical constituents from mahkota dewa. j asian natural prod res. 2006;8(1-2):119-23. 6. sundari n, soetikno v, louisa m, wardhani bw, tjandrawinata rr. protective effect of phaleria macrocarpa water extract (proliverenol) against carbon tetrachloride-induced liver fibrosis in rats: role of tnf-α and tgf-β1. j toxicol. 2018;2018. 7. yosie a, effendy ma, sifzizul tm, habsah m. antibacterial, radical-scavenging activities and cytotoxicity properties of phaleria macrocarpa (scheff.) boerl. leaves in hepg2 cell lines. int j phar sci res. 2011;2(7):1693. 8. sundaram v, björnsson es. drug‐induced cholestasis. hepatol comm. 2017;1(8):726-35. 255 261acta med indones indones j intern med • vol 53 • number 3 • july 2021 original article association of polymorphisms in c-reactive protein (crp) promoter -821 a>g, -390 c>a/t, and plasma interferon-α (ifn-α) with plasma crp level in javanese systemic lupus erythematosus (sle) patients awalia1, harianto notopuro2, joewono soeroso1 1 division of rheumatology, department of internal medicine, faculty of medicine, universitas airlangga dr. soetomo academic general hospital, surabaya, indonesia. 2 department of biochemistry, faculty of medicine, universitas airlangga surabaya, indonesia. corresponding author: awalia, md. division of rheumatology, department of internal medicine, faculty of medicine, universitas airlangga dr. soetomo academic general hospital, surabaya, indonesia. jl. prof. dr. moestopo 47 surabaya, 60132, indonesia. email: awalia_nov74@yahoo.com. abstrak latar belakang: sebagai reaktan fase akut, crp diperlukan untuk membersihkan sel apoptosis dan kompleks imun pada sle. crp yang tidak responsif ini mungkin disebabkan oleh variasi genetik dan ifn-α yang melimpah yang dapat menghambat sekresi crp. penelitian ini bertujuan untuk menganalisis hubungan polimorfisme nukleotida tunggal (snp) pada promotor crp dan ifn-α plasma dengan kadar crp pada pasien sle di jawa. kami juga menganalisis hubungan snp ini dengan sle. metode: empat puluh sle dan 40 pasien spondyloarthritis (sebagai kontrol) dimasukkan. subjek sle menjalani pemeriksaan laboratorium rutin, kadar crp, ifn-α serum, dan sekuensing dna untuk mendeteksi snp pada promotor crp. kelompok kontrol hanya menjalani sekuensing dna. hasil: median usia pasien sle adalah 31,5 tahun. skor rata-rata slam adalah 8,5. usia rata-rata kelompok kontrol adalah 39 tahun. crp rata-rata 5,19 sb 2,69 mg / l, ifn-plasma median adalah 46,02 pg/ml. tidak ada perbedaan signifikan snp di crp -821 (rs2794521) atau -390 (rs3091244) antara sle dan kontrol. snp baru ditemukan pada crp -456 a>g pada 5 pasien sle, tetapi tidak ada pada kontrol. snp ini akan meningkatkan risiko sle 2.143 kali lipat. ada korelasi negatif sedang antara tingkat ifn-α dan crp plasma. regresi linier hanya menunjukkan tingkat ifn-α (tidak juga dengan snp) berkorelasi dengan crp serum. kesimpulan: ifn-α plasma berhubungan dengan kadar crp. tidak ada hubungan snp di crp -821, -390, dan -456 dengan level crp. snp crp -456 a>g akan meningkatkan risiko sle dengan rasio odds 2.143. kata kunci: promotor crp, interferon-α, kadar crp, lupus eritematosus sistemik, manusia, penyakit. abstract background: as an acute-phase reactant, crp is needed to clear apoptotic cells and immune complexes in sle. this unresponsive crp may be caused by genetic variation and abundant ifn-α that might inhibit crp secretion. this study aims to analyze the association of single nucleotide polymorphisms (snp) in crp promoter and plasma ifn-α with crp level in javanese sle patients. we also analyzed the association of these snps with sle. methods: forty sle and 40 spondyloarthritis (as control) patients were included. sle subjects underwent routine laboratory test, crp level, serum ifn-α, and dna sequencing to detect snps in crp promoter. the control group only underwent dna sequencing. results: the median age of sle patients was 31.5 years. the median slam score was 8.5. the median age of the control group was 39 years. the average crp was 5.19 sd awalia acta med indones-indones j intern med 262 2.69 mg/l, median plasma ifn-α was 46.02 pg/ml. there was no significant difference of snps in crp -821 (rs2794521) or -390 (rs3091244) between sle and control. new snp was found in crp -456 a>g in 5 sle patients, but none in controls. this snp would increase sle risk 2.143 times. there was a moderate negative correlation between ifn-α level and plasma crp. linear regression only showed ifn-α level (not either snp) correlated with serum crp. conclusion: plasma ifn-α correlates with crp level. there was no association of snps in crp -821, -390, and -456 with crp level. snp crp -456 a>g would increase the risk of sle with an odds ratio of 2.143. keywords: crp promoter, interferon-α, crp level, systemic lupus erythematosus, human, health. introduction c-reactive protein (crp) is an acute-phase reactant that increases during inflammation due to il-6 stimulation. its function is to clear apoptotic cells, increase phagocytosis, and release inflammatory cytokines. therefore, it is used as a biomarker for infection, atherosclerosis, inflammation, and autoimmune process. unlike other autoimmune diseases, crp level in sle is normal or slightly elevated despite high disease activity and abundant il-6 unless there is a bacterial infection. low crp level may cause inadequate apoptotic cells clearance, and this uneliminated product will induce immune reaction by producing autoantibodies, forming immune complex deposited in tissues and cause further inflammation cascade. indeed, protective effects of crp in the disease process have been demonstrated in animal models of lupus.1–3 there are three hypotheses as to why crp is unresponsive in sle: variation of crp gene, the anti-crp antibody that binds crp, and ifn, inhibiting crp hepatocytes’ crp secretion. there are currently no studies elucidating which factor was more dominant.1,4 there are several studies in various population showing crp gene polymorphisms related to sle and crp level. snps in promoter crp -390 (or 1440, rs3091244) and -821 (or 1009, rs2794521) are those showing correlation with sle and crp level in korean, filipino, and afro-american population.5–7 these snps have never been studied in our population (javanese ethnic in the indonesian population). the anti-crp antibody is often found in sle, but its relation with plasma crp level is doubted lately. it is said that anti-crp correlates with sle activity but not with crp level. when produced by hepatocytes, crp is in pentamer form (nativecrp). in a special condition like inflammation, it will dissociate into monomer crp (mcrp) in the tissues that is more functional biologically. serum anti-crp is an antibody against mcrp. on the other hand, measured plasma crp is pentameric crp.4,8,9 in viral infection and sle, we find a high level of ifn-α so it is presumed that ifn-α may inhibit crp production by hepatocytes.2,4,10 this study aims to analyze the association of snps in promoter crp and plasma ifn-α level with crp level in javanese sle patients. methods the sample size was determined using the formula for linear regression study. previous study in the philippines showed β-coefficient = 0.45 for snps correlation with plasma crp level. therefore, we included 40 sle patients as sample group, and 40 spondyloarthritis (spa) patients as control. spa patients were used as control because like other autoinflammmatory disorders, in severe spa patients we generally would see an increase of plasma crp level. all sle patients came to either the rheumatology outpatient clinic for routine control or admitted to the hospital ward due to sle flares. we included all spa patients from the rheumatology outpatient clinic. all of the patients were from dr. soetomo academic general hospital surabaya, indonesia. diagnosis of sle was made using acr classification criteria for sle 2019.11,12 demographic data and clinical manifestation were obtained from history taking, physical examination, and medical record. slam (systemic lupus activity measurement) and sledai (sle disease activity index) were vol 53 • number 3 • july 2021 association of polymorphisms in c-reactive protein (crp) 263 used to measure the sle disease activity score. blood samples blood samples were taken from sle subjects to check cbc, esr, crp, complement c3, c4 level and other routine laboratory tests for sle. all of the examinations were done at clinical pathology laboratory at dr. soetomo academic general hospital surabaya. crp level was measured using the immunoturbidimetry method with an upper normal limit level was 5 mg/l. complement c3 and c4 level were measured using radial immunodiffusion technique, and the normal limit for c3 was 90-180 mg/dl and for c4 was 9-36 mg/dl. plasma samples were stored at -800c to measure ifn-α level until elisa was performed. elisa kit was human ifn alpha elisa kit invitrogen bms216/bms216ten. upon completing a sample assay using the kit protocol, absorbance was determined at 450 nm on microplate reader: imark (biorad). both sle subjects and control underwent dna sequencing to detect snps in crp promoter through dna isolation from peripheral blood mononuclear cells (pbmc). pcr machine was perkin elmer pj 2000, qia quick gel extraction kit (qiagen, cat.no 28704) was used for dna purification. the forward and reverse primer is shown in figure 1. numbering system of snps in this study was based on genbank accession number af449713.13 ethics this study had received approval from the ethics committee of dr. soetomo academic general hospital with ethical clearance number 1014/kepk/iii/2019 dated march 8, 2019. statistical analysis spss.21 was used for data analysis. firstly, data distribution was tested. if homogenous, pearson correlation was used, and if not, the spearman correlation test was used to analyze the association between snps crp -390, -821, plasma ifn-α level and plasma crp level. genotypes of promoter crp were also compared between sle and the control group using the mann-whitney test. then multivariate analysis using linear regression was done to analyze the association of some independent variables (snps, ifn-α) with plasma crp level. results forty javanese sle patients (26 from the rheumatology outpatient clinic, 14 patients from the internal medicine ward) and 40 javanese spa patients from the outpatient clinic were included in this study from august 2019 to february 2020. diagnosis of sle was made based on sle classification criteria from acr 2019, and diagnosis of spa was based on asas classification criteria 2010 [11,12]. all patients with median age were 31,5 years old (range 18-59) for the sle group and 39 years old for the control group (range 21-60). clinical characteristic of sle subjects is shown in table 1. laboratory result of sle patients is revealed in table 2. positive pcr result as crp gene amplification with suitable primer on several sle subjects can figure 1. forward and reverse primer. awalia acta med indones-indones j intern med 264 table 1. clinical characteristic of subjects clinical manifestation median number (%) duration of illness (months) 23 body mass index underweight normal overweight 23.19 4 (10) 22 (55) 14 (35) skin and mucosa manifestation malar rash discoid rash oral ulcer hair loss photosensitivity 9 (22,5) 6 (15) 4 (10) 17 (42.5) 1 (2.5) musculoskeletal manifestation arthritis muscle pain fatigue panniculitis 22(55) 2 (5) 2 (5) 2 (5) lung manifestation 2 (5) heart manifestation heart failure hypertension 2 (5) 2 (5) serositis 5 (12.5) nephritis 13 (32.5) neuropsychiatric 2 (5) slam score mild (<7) moderate (7-20) severe (20) 8.5 (0-26) 16 (40) 21 (52.5) 3 (7.5) sledai mild (1-5) moderate (6-10) severe (>10) 2 (0-28) 28 (70) 3 (7.5) 9 (22.5) table 2. laboratory characteristic of subjects. laboratory examination mean (sd) median number (%) positive anti ds-dna 13 (32,5) hematology hb (g/dl) anemia leukocytes (x103/ml) leukopenia lymphocyte lymphopenia thrombocyte thrombocytopenia 10.78 (2.92) 8.92 (4.68) 252,150 (144.462) 1715 22 (55%) 5 (12.5) 17 (42.5) 11 (27.5) serum complement c3 low (<90 mg/dl) c4 low (<9 mg/dl) 88.41 (44.28) 20.76 (12.22) 16 (40) 7 (17.5) esr (mm/h) high (>20mm/h) 24 (6-155) 26 (65) c-reactive protein (mg/l) 5.19 ± 2.69 (0.5-9.8) ifn-α (pg/ml) 46.02 (16.43-177.96) be seen in figure 2. it shows dna ribbon with 865 bp nucleotides. figure 2. crp gene electrophoresis showing dna ribbon 865 bp. during dna sequencing, we found a new snp in promoter crp -456 a>g (nucleotide 1374 from the front). to our knowledge, this snp has never been reported in any publication before. five sle patients had the snp, but none in the control group. this snp would increase sle risk 2.143 times compared to wildtype. genotype and allele distribution of crp gene in both groups are shown in table 3 and table 4. since shapiro-wilk test showed p<0.05 for ifn-α level, spearman correlation test was used. it revealed a significant association between plasma ifn-α and crp level (p=0.003 and r= -0.455 (moderate negative correlation). spearman test also showed a moderate positive correlation between plasma ifn-α level and sle disease activity (slam score) with p=0.001 and r=0.568 and with sledai p=0.004 and r=0.440. there was no significant association between vol 53 • number 3 • july 2021 association of polymorphisms in c-reactive protein (crp) 265 crp level and sle disease activity (p=0.903). neither of the snps showed a significant correlation with plasma crp level (p>0.05). all of the variables showed in table 5 related to plasma crp level. linear regression study also revealed only ifn-α correlated with plasma crp level multivariately, as shown in table 6, with mathematic model was crp = 6.910 – 0.025 ifnα. discussion baseline characteristics of the subjects involved in this study were slightly different than the south korean and phillipine cohort, but based on the sample size formula for a minimal patient number for linear regression study, 40 subjects were sufficient. other studies also used normal subjects as control, but in this study, we used another autoinflammatory rheumatic disease as the control because there was increasing crp in high disease activity spa patients.5,7 the mean crp level in this study was 5.19 (sd 2.69) mg/l (range 0.5-9.8 mg/l), a little higher than other studies such as in mexico with a mean crp was 1.46 mg/l (0.5-4.77 mg/l) and the philippines with 1.5 mg/l.7,14 this might be because sle subjects were from the outpatient clinic and those admitted at the hospital due to flare. all the patients from other study were from the outpatient clinic only (a stable condition with remission or low disease activity). there was no association found in this study between snps at -821 nor -390 with sle or plasma crp level. kim et al.5 showed a significant difference of snp -390 between table 3. genotype distribution of crp gene in sle group and control location genotype sle group (%) control (%) p -821 aa (wildtype) ag gg 22 (55) 15 (37.5) 3 (7.5) 21 (52.5) 18 (45) 1 (2.5) p = 0.996 * -390 cc (wildtype) ca ct aa 26 (65) 7 (17.5) 5 (12.5) 2 (5) 29 (72.5) 6 (15) 5 (12.5) 0 p = 0.387 * -456 aa (wildtype) gg 35 (87.5) 5 (12.5) 40 (100) 0 p = 0.027 ** (or 2.143) * not significant with mann-whitney test (p>0.05) ** significant difference with fisher exact test (p<0.05) table 4. allele distribution of crp gene in sle group and control. location allele sle group (%) control (%) p -821 a g 59 (73.75) 21 (26.25) 60 (75) 20 (25) p=0.856* -390 c t a 64 (80) 5 (6.3) 11 (13.8) 69 (86.3) 5 (6.3) 6 (7.5) p=0.436** -456 a g 70 (87.5) 10 (12.5) 80 (100) 0 p = 0.001*** * not significant with chi-square test (p>0.05) ** not significant with mann-whitney test (p>0.05) *** significant difference with fisher exact test (p<0.05) table 5. correlation of each variable with plasma crp level. variables plasma crp level snp at promoter crp -821 p=0.546* snp at promoter crp -390 p=0.711* snp promoter crp -456 p=0.161* plasma interferon-α p=0.003** r= -0.455 * not significant with spearman test ** significant spearman test table 6. linear regression analysis for this study. variables β b p ifn-α -0.025 -0.421 0.005 snp -456 -0.956 -0.119 0.439 constanta 6.910 0.001 awalia acta med indones-indones j intern med 266 the sle group and control (p=0.033), but not snp -821. a study by kim et al. also revealed a correlation between snp -390 (not for snp -821) with plasma crp level (p=0.03). a more extensive study in the philippines showed a moderate correlation between snp -390 with plasma crp level (β-coefficient = 0.45), but not for snp promoter crp -821.5,7 a usa study involving the caucasian race only showed a significant correlation between snp -390 promoter crp with plasma crp level (p=0.012), but not for snp -821. other studies in the usa also showed a significant difference between the sle group and control for snp -390 with or 1.43 (p=0.001).6,15 studies in china and taiwan involving healthy subjects showed a correlation between snp promoter crp -821 (not crp -390) with plasma basal crp level.16 new snp on promoter crp -456 (1374) was found in this study, and none of those studies reported this snp before. snp promoter crp -456 a>g had a significant difference between the sle group and controls with or 2.143, but it did not correlate with plasma crp level. hepatocytes synthesize crp molecules as a response to il-6 during inflammation. in viral infection and sle flare, plasma crp is normal though there is increasing in il-6. it is caused by abundant ifn-α during sle flare and viral infection. all subtypes of ifn-α can inhibit crp promoter gene activity. this inhibition depends on the dose and is mediated by type-i ifn receptors. the ifn-α-dependent inhibition of crp promoter activity was confirmed by studies of crp secretion in primary human hepatocytes. il-1β–induced crp secretion was inhibited by 49.2%, and il-6–induced secretion was inhibited by 51.5%, whereas the inhibition induced by il-1β plus il-6 was moderate (21.1%). after preincubation of ifn-α for 6 hours, there is suppression of promoter activity despite stimulation of il-6 and il-1β. crp itself also may inhibit the production of ifn-α by pdc induced by the immune complex. as of writing, there is no study directly compares serum ifn-α and crp level. a study by enocsson et al.2 showed inhibition of the transcription process in crp promoter during crp synthesis by hepatocytes.2,4,8 this study directly correlated plasma ifn-α level with plasma crp level, and it showed moderate correlation in both bivariate and multivariate analysis. in a longitudinal study, it is reported that there is increasing of ifn-α in active sle patient serum. plasma ifn-α level also correlates with sledai score. there is also increasing ifn-α gene expression in active sle patients, and there is a significant difference in sledai scores between patients with high and low plasma ifn-α level (p=0.0038). direct measurement of plasma ifn-α has shown more accurate and specific than ifn-α signature.17–19 all type i ifn will increase during sle flare related to higher disease activity. ifn signature gene expression is also high in severe organ disturbance in lupuslike nephritis or neuropsychiatry.20,21 our study also showed a moderate positive correlation between ifn-α and disease activity in sle patients. conclusion this study showed the correlation between plasma ifn-α with crp level in both bivariate and multivariate analysis. there was a new snp found in this study at crp promoter -456 a>g. there was no association of snps in promoter crp -821, -390, and -456 with crp level, but snp promoter crp -456 a>g would increase the risk of sle (or 2.143). acknowledgments we thank all the sle patients at dr. soetomo academic general hospital surabaya who had participated in this study. conflict of interest there is no conflict of interest in this study. references 1. batuca j, delgado alves j. c-reactive protein in systemic lupus erythematosus. autoimmunity. 2009;42(4):282–5. 2. e n o c s s o n h , g u l l s t r a n d b , e l o r a n t a m l , e t al. c-reactive protein levels in systemic lupus erythematosus are 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villamin c, vyse tj. genetic determinants of basal c-reactive protein expression in filipino systemic lupus erythematosus families. genes immun. 2008;9(2):153–60. 8. enocsson h, sjöwall c, kastbom a, et al. association of serum c-reactive protein levels with lupus disease activity in the absence of measurable interferon-α and a c-reactive protein gene variant. arthritis rheumatol. 2014;66(6):1568–73. 9. li qy, li hy, fu g, yu f, wu y, zhao mh. autoantibodies against c-reactive protein influence complement activation and clinical course in lupus nephritis. j am soc nephrol. 2017;28(10):3044–54. 10. mahajan a, herrmann m, muñoz le. clearance deficiency and cell death pathways: a model for the pathogenesis of sle. front immunol. 2016;7:1–12. 11. fanouriakis a, tziolos n, bertsias g, boumpas dt. update in the diagnosis and management of systemic lupus erythematosus. ann rheum dis. 2021;80(1):14–25. 12. aringer m, costenbader k, daikh d, et al. 2019 european league against 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arthritis res ther. 2019;21(1):1–11. 360 acta med indones indones j intern med • vol 53 • number 3 • july 2021 clinical practice anemia in inflammatory bowel disease: a neglected issue in comprehensive inflammatory bowel disease management randy adiwinata1, andrea livina1, bradley jimmy waleleng2, harlinda haroen3, linda rotty3, fandy gosal2, luciana rotty2, cecilia hendratta3, pearla lasut3, jeanne winarta2, andrew waleleng2, marcellus simadibrata4 1 department of internal medicine, faculty of medicine, universitas sam ratulangi/prof. dr. r. d. kandou hospital, manado, indonesia 2division of gastroenterology-hepatology, department of internal medicine, faculty of medicine, universitas sam ratulangi/prof. dr. r. d. kandou hospital, manado, indonesia 3division of hematology and medical oncology, department of internal medicine, faculty of medicine, universitas sam ratulangi/prof. dr. r. d. kandou hospital, manado, indonesia 4division of gastroenterology, department of internal medicine, faculty of medicine, universitas indonesia, cipto mangunkusumo hospital, jakarta, indonesia corresponding author: bradley jimmy waleleng, md. division of gastroenterology-hepatology, department of internal medicine, faculty of medicine universitas sam ratulangi prof. dr. r. d. kandou hospital, manado 95115, indonesia. email: walelengbradley@gmail.com abstrak anemia merupakan komplikasi ekstraintestinal tersering dari inflammatory bowel disease (ibd) dan berkorelasi signifikan dengan berbagai keluaran penyakit yang lebih buruk seperti angka rawat inap, angka relaps, kebutuhan tindakan pembedahan yang lebih tinggi, dan kualitas hidup yang lebih rendah. prevalensi anemia pada pasien ibd dilaporkan bervariasi, akan tetapi diperkirakan berkisar antara 8,8% hingga 74%. meskipun tingginya prevalensi tersebut, hingga saat ini masih terdapat kesenjangan antara protokol skrining dan pengobatan anemia pada praktik klinis sehari-hari. sehingga dapat disimpulkan bahwa anemia pada ibd merupakan suatu komplikasi ibd yang bersifat signifikan dan perlu ditatalaksana secara komprehensif namun seringkali dikesampingkan. anemia pada ibd dapat disebabkan oleh berbagai faktor, dengan anemia defisiensi besi sebagai etiologi tersering. manajemen komprehensif anemia pada ibd mencakup skrining aktif, evaluasi dari etiologi, tatalaksana holistik, dan monitoring. optimalisasi terapi ibd juga merupakan hal penting karena akan berkontribusi pada perbaikan kondisi anemia. pendekatan dan kolaborasi multidisiplin diperlukan untuk memberikan pelayanan pasien ibd dengan lebih baik. kata kunci: anemia, inflammatory bowel disease, kolitis ulseratif, penyakit crohn. abstract anemia is the most common extraintestinal inflammatory bowel disease (ibd) manifestations and is significantly correlated with several adverse impacts such as higher hospitalization rate, relapse rate, surgical intervention requirement, and low quality of life. the prevalence of anemia in ibd patients is greatly varied between reports, with an estimated prevalence of 8.8% to 74%. however, studies showed there were still gaps in the screening protocol and anemia treatment in daily practice. anemia in ibd tends to be an overlooked complication of significance and must be adequately addressed. anemia in ibd may be caused by interplay of vol 53 • number 3 • july 2021 anemia in ibd: a neglected issue in comprehensive ibd management 361 introduction inflammatory bowel disease (ibd), which consists of ulcerative colitis (uc) and crohn’s disease (cd), is characterized by chronic inflammation of the gastrointestinal tract. pathogenesis of ibd is multifactorial and is generally thought of as an interaction of genetic, environmental, host immunological factors, and intestinal microbiota.1 prolonged inflammation in ibd patients may cause several intestinal and extraintestinal complications, with anemia being the most common extraintestinal complication. anemia in ibd patients can be caused by complex interactions of all factors such as iron deficiency, persistent inflammation, blood loss due to gastrointestinal bleeding during ibd flare, folate and vitamin b12 deficiency, and the side effects of drugs. therefore, a complete evaluation and stepwise diagnostic approach of anemia in ibd should be implemented, as many factors may interplay as the cause of anemia.2 many studies showed the significant impact of anemia on decreased quality of life of ibd patients. anemia is also associated with higher rates of hospitalization and prolonged hospital length of stay.3 while practitioners generally recognize the significant adverse impact of anemia in ibd; a study showed there were still gaps in the screening protocol and anemia treatment in daily practice.3,4 therefore, anemia in ibd tends to be an overlooked yet significant complication which needs to be adequately addressed.3 the burden of anemia in ibd patients the prevalence of anemia in ibd patients is greatly varied between reports. anemia is recognized as the most common extraintestinal manifestation of ibd.5 the prevalence was estimated to be between 8.8 to as high as 74%; it greatly depends on subgroup ibd patients being studied. a study in a brazil outpatient clinic consisting of 100 uc patients and 100 cd patients reported the prevalence of anemia of 21%. they found no significant difference between the anemia prevalence of uc and cd patients (18% vs. 24%). iron deficiency anemia (ida) being the most common etiology of anemia (6% in uc and 10% in cd), followed by anemia of chronic disease (acd), which represented 6% of both groups.4 a large fiveyear cohort study in the united states involving 1821 ibd patients (1077 cd, 744 uc) showed that the prevalence of anemia was 50.1% (cd: 53.3% vs. uc 44.7%). several risk factors were analyzed, which showed that disease severity was closely related to anemia.6 meta-analysis by filmann et al.7 in 2014 revealed that the prevalence of anemia in ibd cases in europe to be 27% in the cd group and 21% in the uc group. further analysis showed that anemia was associated with the usage of ibd-specific medications and disease activity status. patients who were treated with ibd-specific drugs (odds ratio 1.54) and patients with active disease (odds ratio 2.72) were more likely to have anemia. this meta-analysis also showed that uc patients were less likely to experience anemia than cd patients (odds ratio 0.77). assessment of iron status among anemic patients revealed that more than 50% were iron deficient. a large multicenter study (ecco-epicom study) evaluating 1871 newly diagnosed patients, including 686 cd patients, 1021 uc patients, and 164 unclassified ibd did follow up monitoring for one year. the prevalence of anemia at diagnosis was higher among cd patients than uc patients (44% vs. 31%) in western european countries. during one-year follow-up, they found that 49% of cd and 39% of uc patients experienced at least one episode of anemia. further analysis regarding the type of anemia found ida approximately 12-17%, acd several factors, with iron deficiency anemia being the most common etiology. comprehensive management of anemia in ibd should consist of active screening, evaluation of the etiology, holistic treatment, and follow-up monitoring. optimization of ibd therapy should be emphasized because it also may improve the anemic condition. a multidisciplinary approach and collaboration are needed to ensure better ibd care. keywords: anemia, inflammatory bowel disease, ulcerative colitis, crohn disease. randy adiwinata acta med indones-indones j intern med 362 10-27%, and mixed causes in 23-31%.8 a study done in an asian country, namely india, showed that anemia was found in more than half of uc patients even in clinical remission, with ida being the most common finding.9 another long-term cohort study of ibd patients in turkey showed that anemia was detected in 548 (58.2%) patients, from the total of 941 ibd patients. they also found that anemia was more prevalent among female and cd patients. age of the ibd disease was highly correlated with anemia, with an incidence rate calculated as 103.45 per 1,000 patient-years. this finding showed that anemia incidence in ibd might present upon presentation and correlated with the ibd disease course.10 impact of anemia in ibd patients m a n y s t u d i e s s h o w e d t h a t a n e m i a significantly affects patients’ quality of life and may be associated with a more severe ibd course. anemia may affect the productivity of patients due to fatigue, affecting emotional and also cognitive functioning. anemia in ibd is also implicated with more healthcare resources utilization and higher medical cost burden.11 a study showed that anemia therapy might lead to quality of life (qol) improvement in ibd patients.12 a five-year-longitudinal analysis performed by koutroubakis et al. involving 410 ibd patients (245 cd, 165 uc) showed that the prevalence of anemia was 37.1%, and ibd patients with anemia required more health care, had lower qol, and was associated with more severe disease activity. further analysis also showed that persistent or recurrent anemia for three or more years was significantly associated with more frequent hospitalizations, health care related visits, and surgeries for ibd.6 therefore, more aggressive management of anemia in ibd patients should be emphasized. analysis of 15,761 patients ibd by michailidou et al. found that more than half were having anemia, and anemia was strongly correlated with increased risk for an emergency operation and sepsis. anemia was also served as a predictor for severe morbidity and increased length of stay.13 pathophysiology anemia in ibd may result from multiple factors, with iron deficiency becoming the most common cause.4 interplay of multiple factors may occur, such as iron deficiency, vitamin deficiency, chronic inflammation, diet, micronutrient malabsorption, surgical history, disease activity, medications being used, ibd location and duration, and gastrointestinal bleeding (either visible or occult bleeding). many journals stated that anemia in ibd is a model of combination between iron deficiency and chronic inflammation.2 iron deficiency anemia in ibd iron deficiency anemia may be caused by absolute or functional iron deficiency. absolute iron deficiency is defined as severely reduced or absence of iron stores in the body. functional iron deficiency state is defined as adequate body iron stores but insufficient iron availability for incorporation into erythroid precursors; these findings are commonly caused by elevated hepcidin levels.14 dietary iron is absorbed mainly in the duodenum and proximal jejunum, with approximately 2 mg of iron absorbed daily. approximately 1-2 mg iron daily is mainly lost from skin desquamation, shedding of intestinal epithelial cells, and blood loss. absorbed iron will be bound to transferrin, an iron transport protein, transported in circulation and delivered to bone marrow as primary resources for erythropoiesis. old red blood cells will be phagocytized by macrophages and recycled for new red blood cells. excess iron will be bound to a storage protein called apoferritin, forming ferritin.15,16 hepcidin also plays significant roles in systemic iron regulation. high hepcidin levels may inhibit intestinal iron absorption, macrophage iron recycling and inhibit erythropoiesis.17 the iron deficiency state in ibd patients may be caused by chronic gastrointestinal bleeding or blood loss during ibd flare episodes, therefore contributing to negative iron balance. inflammation lesion located at duodenum or proximal jejunum caused by cd may contribute to further iron absorption impairment. also notably, strict dietary restrictions may also contribute to the development of iron deficiency anemia due vol 53 • number 3 • july 2021 anemia in ibd: a neglected issue in comprehensive ibd management 363 to low intake. iron metabolism may also be impaired in chronic inflammation state due to the ibd condition. elevated proinflammatory cytokines may impair the transportation of iron for erythropoiesis from iron stores to bone marrow, which is reflected in adequate ferritin levels but low transferrin saturation levels.16,18 anemia of chronic disease in ibd i b d c o n d i t i o n r e s u l t i n g i n c h r o n i c inflammation state does not only occur locally in the intestinal mucosal but also as chronic systemic inflammation. a study showed that ibd patients had elevated circulating levels of proinflammatory cytokines and chemokines also related to local intestinal inflammation and tissue damage.19 a study from antunes et al. showed that higher c-reactive level protein (crp) levels were found among anemic ibd patients and increased crp by each 1 mg/l increased the risk for anemia.4 elevated inflammatory cytokines may result in the suppression of erythropoiesis. interleukin 1 (il-1) and tumor necrosis factor (tnf) inhibit the response of bone marrow to anemia by reducing erythropoietin production. interleukin 6 (il-6) increased hepcidin production, therefore inhibiting the iron absorption and transportation of iron from iron storage.17,18,20 chronic inflammatory conditions also shorten erythrocyte survival, which is mainly caused by increased activation of macrophage and increased erythrocyte destruction rate in the reticuloendothelial system.20 erythropoietin and ibd erythropoietin (epo), the primary regulator of erythropoiesis, a hormone secreted by the kidney, has blunted response in chronic i n f l a m m a t o r y c o n d i t i o n s s u c h a s i b d . inflammatory cytokines also may impair the production of epo. some studies showed higher epo levels among ibd patients, possibly due to part of the compensation to the anemic condition. however, the elevated production may still be inadequate according to anemia condition, which is termed relative epo deficiency.21 the role of epo stimulating agent (esa) usage in anemia ibd management may be beneficial when ibd patients had been adequately repleted but still had anemia, possibly due to epo deficiency. esa was used to overcome this problem.22 ibd drug-induced anemia c o m m o n i b d m e d i c a t i o n s s u c h a s sulfasalazine, azathioprine, or 6-mercaptopurine have a side effect of myelosuppression which manifests as anemia, leucopenia, thrombocytopenia, or pancytopenia. the incidence of bone marrow suppression due to thiopurines and azathioprine are reported ranging from 2-5% and 2-4%, respectively.23 micronutrient deficiency and anemia patients with ibd are at higher risk for malnutrition and especially micronutrient deficiency. this condition may be related to the malabsorptive condition caused by ibd, persistent inflammation, chronic gastrointestinal bleeding post-surgery, and decreased oral intake. deficiency of iron, folate, and vitamin b12 may also lead to anemia. a study by park et al.24 showed that 39% of ibd patients had either folate, vitamin b12, or 25-oh-vitamin d deficiency.study by huang et al.25 showed the prevalence of vitamin b12 deficiency was 14.9% and folate deficiency was 13.3%. vitamin b12 and folate deficiency may lead to the development of macrocytic anemia. diagnostic approach the basic understanding of interpreting laboratory results of anemia workup is essential for diagnosing anemia in ibd. sometimes, it may be challenging to determine the actual cause of anemia in ibd due to overlapping anemia mechanisms and contributing factors.26 world health organization (who) defined the hemoglobin (hb) cut-off for anemia in the general population as lower than 12 g/dl for women, lower than 11 g/dl for pregnant women, and lower than 13 g/dl for men. several studies and consensus by european crohn’s and colitis organisation (ecco) used the same hb cut-off for anemia diagnosis in ibd.27 ecco recommended anemia workup should be commenced whenever hemoglobin level was below normal. history taking should be done carefully, consisting of questions regarding the history of disease activity, recent gastrointestinal bleeding, medication being taken, dietary randy adiwinata acta med indones-indones j intern med 364 history, anemia symptoms, occupation, travel and family history, menstruation cycle, alcohol consumption, history of bleeding disorders, or excessive bruising, and surgical history. a comprehensive physical examination is warranted to find the sign of anemia, bleeding disorder, organomegaly, and tumor.27,28 ecco differentiated anemia laboratory workup into two categories, basic and extensive workup. basic workup was determined as the minimum examination in order to evaluate t h e c a u s e o f a n e m i a i n i b d . m i n i m u m workup includes hb, red blood cell count, mean corpuscular volume (mcv), mean corpuscular hemoglobin (mch) and mean corpuscular hemoglobin concentration (mchc), reticulocytes count/production index, red cell distribution width (rdw), different blood cell count, serum ferritin, transferrin saturation, crp concentration, reticulocyte count, thrombocyte count, and leucocyte count. extensive workup is warranted to further determine the cause of ibd anemia after basic examination, including serum concentrations of vitamin b12, folic acid, haptoglobin, the percentage of hypochromic red cells, reticulocyte hemoglobin, lactate dehydrogenase, soluble transferrin receptor, creatinine, and urea. ecco recommended having hematological consultation if the cause of anemia is still unknown despite extensive workup.27 interpretation of anemia laboratory workup result may begin from the interpretation of mcv and mch to categorize the type of anemia into microcytic/normocytic/macrocytic anemia. a common anemia diagnosis algorithm may be applied in evaluating anemia in ibd (figure 1). microcytic anemia in ibd may have resulted from iron deficiency and chronic disease. normocytic anemia may have resulted from chronic disease or other hematological disorders. macrocytic anemia may be related to folate acid and vitamin b12 deficiency due to malabsorption or strict dietary restriction, ibd drugs usage such as azathioprine, 6-mercaptopurine, sulfasalazine.27 reticulocyte count may represent the erythropoiesis compensation response due to low hb level. low reticulocyte count may indicate inappropriate erythropoiesis condition, which occurred in ida whilst high reticulocyte count may be related to the hemolytic process. reticulocyte production index (rpi) is more useful than absolute reticulocyte count. rpi can easily be calculated using the formula: reticulocyte percent x hematocrit/45 x 1/ correction factor.26,29 rdw is reflecting the broadness of erythrocyte size distribution or anisocytosis.30 high rdw value is found among patients with ida.31 disease activity and inflammation degree in ibd related to crp level. high crp levels may indicating ongoing inflammation process that may inhibit the erythropoiesis in ibd patients.4 platelet and white blood cell count is helpful to determine whether the anemia was part of pancytopenia or not. pancytopenia may be caused by bone marrow failures such as aplastic anemia, myelodysplastic anemia, or other hematological malignancies.32 iron studies iron studies are mandatory for evaluating the iron status of anemic ibd patients, which is most commonly caused by iron deficiency. ferritin is a laboratory examination to evaluate body iron storage. while low ferritin serum level is a marker of functional iron deficiency, ferritin is also categorized as an acute phase reactant protein, which may be elevated in inflammatory conditions such as ibd. therefore, interpretation of ferritin should be made carefully, as the measured serum ferritin in inflammatory conditions may not be well correlated with the actual iron storage condition.26,33 ecco recommended using ferritin cut-off level of 30 mg/l to be used in diagnosing iron deficiency anemia in ibd and using the cut-off level of 100 mg/l if the ibd patients are in an active inflammatory condition.27 transferrin is a glycosylated protein that functions as a transport for iron to the usage and storage sites. transferrin saturation (tsat) is reflecting the percentage of binding sites on all transferrin molecules occupied with iron molecules. tsat is simply calculated by dividing iron serum with total ironbinding capacity (tibd). a low level of tsat is consistent with the iron deficiency condition. therefore, tsat is a helpful marker for the diagnosis of ida. however, transferrin may be vol 53 • number 3 • july 2021 anemia in ibd: a neglected issue in comprehensive ibd management 365 figure 1. approach to anemia screening and evaluation in ibd patients26,27,32 downregulated in inflammation conditions.26,34 soluble transferrin receptors (stfr), a novel biomarker for iron studies, is found to be unaffected by inflammation condition or concomitant chronic disease. therefore, it may serve to be a valuable diagnostic tools to differentiate iron deficiency and chronic disease anemia, especially ibd. further studies are needed to validate the reference range in ibd.31,35,36 according to ecco in their european consensus on the diagnosis and management of randy adiwinata acta med indones-indones j intern med 366 iron deficiency and anemia in ibd, diagnostic criteria for ida should be differentiated according to the status of inflammation of ibd patients. in non-active ibd patients who are defined as having no active clinical symptoms (diarrhea, hematochezia), no active endoscopic inflammation lesions, and no elevation of inflammatory biochemical marker (crp, wbc); serum ferritin <30 mg/l may be indicative for ida. while serum ferritin < 100 mg/l cut-off should be used if there is active inflammation. anemia of chronic disease in ibd can be diagnosed if there is biochemical or clinical evidence of active inflammation and ferritin level > 100 mg/l and tsat < 20%. a ferritin level of 30-100 mg/l may indicate the presence of a combination between ida and acd.26,27 management management of anemia in ibd patients should be comprehensive and targeted to the underlying etiology, as outlined above. the stabilization of the ibd disease course, in conjunction with dietary regulation, should be optimized. all patients with ibd should be actively screened for anemia. screening of anemia can be employed every 6-12 months for patients in remission and every three months in active ibd patients.26 management of ida ecco recommended that ida should be treated with iron supplementation in all ibd patients. the goal of treatment should be normalization of the hb value and restore iron stores. ecco recommended hb improvement should be at least 2 gr/dl within four weeks of treatment.27 i r o n s u p p l e m e n t a t i o n m a y b e g i v e n orally or intravenously. ecco recommends intravenous iron supplementation as the firstline treatment, especially in patients with active ibd, documented previous oral iron intolerance, hb below 10 gr/dl, and patients in esa therapy. however, in some developing countries, this recommendation may not be applicable due to the higher cost of the intravenous iron regimen, required administration by a healthcare professional, and required close monitoring due to the possibility for iron overload and anaphylactic reactions. intravenous iron has some advantages over oral supplementation, especially in ibd patients, which is faster repletion of iron stores and effective even with impaired intestinal absorption. on the other hand, oral iron supplementation becomes a more feasible option for developing countries, as iron supplementation is inexpensive and can be selfadministered by the patients at home. several issues are related to the oral iron supplementation in ibd patients, which may create issues in attaining hb goal and maintaining patient compliance, such as the impaired intestinal absorption and gastrointestinal side effects (abdominal pain, nausea, constipation).27,28 oral iron supplementation was also found to cause gut bacterial diversity shifting in ibd patients.37 real-world data from germany, including more than 1000 ibd patients with ida, showed that ibd patients who received intravenous iron supplementation had less hospitalization rate and lower total healthcare costs than patients receiving oral iron.38 the safety and effectiveness of oral iron supplementation in ibd patients have been shown by several studies. therefore, oral iron supplementation is still recommended by ecco for inactive ibd, no history of previous oral iron intolerance, and patient with mild anemia (hb 11.0-11.0 gr/dl for nonpregnant women and 11.0-12.9 gr/dl in men).26,27 several newer oral and intravenous iron supplementation have been developed in order to minimize gastrointestinal side effects and anaphylactic reaction. it is also noted that oral iron side effects are dose-dependent.28 ecco recommended no more than 100 mg elemental iron per day should be given in patients with ibd. estimation of iron needs may be based on baseline hb and body weight. for patients with hb 10-13 gr/ dl the estimated total iron need is 1000 mg and 1500 mg, respectively for bodyweight <70 kg and >70 kg. for patients with hb 7-10 gr/dl and body weight < 70 kg required 1500 mg total iron, while patients with similar hb and body weight >70 kg required 2000 mg.27,39 list of oral and intravenous iron supplementation can be seen in table 1.28,40 b l o o d t r a n s f u s i o n i s g e n e r a l l y n o t vol 53 • number 3 • july 2021 anemia in ibd: a neglected issue in comprehensive ibd management 367 recommended for first-line treatment of ida due to several possible side effects. a blood transfusion may be given for patients with active bleeding with unstable hemodynamics, critical anemia (hb <7 gr/dl), having significant cardiovascular comorbidity, which warrants a higher hemoglobin level. packed red cell transfusion should be considered as temporary management only in iron deficiency anemia management. the hemoglobin threshold for initiating blood transfusion may vary between healthcare facilities.26, 28,41 esa usage in managing anemia in ibd still require further studies. the non-optimal response of hb normalization after iron correction therapy may indicate concurrent acd. esa should be given after restoration of iron level. possible risks of esa administration in ibd patients are the risk of venous thromboembolism and the possibility of the response of epo receptors that may be expressed in several malignant cells.26 ecco recommended esa initiation for patients with acd with an insufficient response to iron correction and after optimization of ibd therapy. hemoglobin target with esa therapy should not higher than 12 g/dl.27 monitoring of ida treatment should be performed every three months for at least a year after correction and periodically 6 and 12 months after. recurrent anemia after correction warrants further evaluation as it may indicate persistent intestinal disease activity. maintenance therapy may be needed in order to maintain the adequacy of iron stores and hb. iron supplementation can be resumed if the ferritin level was lower than 100 mg/l.26,28 summary of ida management in ibd patients can be seen in figure 2. management of non-iron deficiency anemia dietary supplementation with cobalamin and folic acid should be given to correct whenever folate and vitamin b12 deficiency is present. correction of malnutrition may be needed. guidelines from the asian working group regarding diet and inflammatory bowel disease, published in 2019 or practical guidance of clinical nutrition in ibd by the european society for clinical nutrition and metabolism, may be used as dietary guidance.42,43 optimization of ibd treatment in order to reduce inflammation or to achieve remission should be emphasized, as high inflammatory cytokines level may inhibit erythropoiesis, leading to refractory acd. drug-induced anemia such as azathioprine and 6-mercaptopurine may be managed by switching to other drugs if possible or to have the dose adjusted. cooperation with a hematologist may be required in managing anemia in ibd. other causes of non-iron deficiency anemia should be evaluated and excluded, such as infections and malignancies, and managed concomitantly.27 conclusion anemia in ibd is often a neglected health issue in ibd management. anemia in ibd is highly correlated with a worse prognosis and lower quality of life. active screening of anemia table 1. list of oral and intravenous iron preparations28,40 preparations elemental iron (mg) dose oral ferrous sulfate 65 325 mg tid ferrous gluconate 36 300 mg tid ferrous fumarate 33 100 mg tid iron polysaccharide complex 150 150 mg tid carbonyl iron 50 50 mg bid intravenous iron sucrose iron dextran ferric gluconate ferumoxytol sodium ferric gluconate complex 100-200 mg over 2-5 minutes or infusion over 15 minutes 100 mg over 2 minutes 125 mg over 10 minutes 510 mg over 15 minutes 62.5-125 mg over 1 hour ferric carboxymaltose 750 mg over 15 minutes randy adiwinata acta med indones-indones j intern med 368 in ibd, structured evaluation, comprehensive management, and multidisciplinary collaboration are needed. references 1. guan q. a comprehensive review and update on the pathogenesis of inflammatory bowel disease. j immunol res. 2019;2019. 2. weiss g, gasche c. pathogenesis and treatment of anemia in inflammatory bowel disease. haematologica. 2010;95(2):175–8. 3. qureshi t, peter nt, wang r, et al. improving anemia in inflammatory bowel disease: impact of the anemia care pathway. dig dis sci. 2019;64(8):2124–31. 4. antunes cvda, neto aeh, nascimento crda, et al. anemia in inflammatory bowel disease outpatients: prevalence, risk factors, and etiology. biomed res int. 2015;2015. 5. mücke v, mücke mm, raine t, et al. diagnosis and treatment of anemia in patients with inflammatory bowel disease. ann gastroenterol. 2017;30(1):15–22. 6. koutroubakis ie, ramos-rivers c, regueiro m, et al. five-year period prevalence and characteristics figure 2. management of iron deficiency anemia in ibd patients26,27 figure 2. management of iron deficiency anemia in ibd patients 26,27 vol 53 • number 3 • july 2021 anemia in ibd: a neglected issue in comprehensive ibd management 369 of anemia in a large us inflammatory bowel disease cohort. j clin gastroenterol. 2016;50(8):638–43. 7. filmann n, rey j, schneeweiss s, et al. prevalence of anemia in inflammatory bowel diseases in european countries: a systematic review and individual patient data meta-analysis. inflamm bowel dis. 2014;20(5):936–45. 8. burisch j, vegh z, katsanos kh, et al. occurrence of anaemia in the first year of inflammatory bowel disease in a european population-based inception cohort-an ecco-epicom study. j crohn’s colitis. 2017;11(10):1213–22. 9. chaubal a, pandey v, choksi d, et al. anemia in patients with ulcerative colitis in remission: a study from western india. indian j gastroenterol. 2017;36(5):361–5. 10. atuʇ ö, kani ht, banzragch m, et al. incidence rate of anemia in inflammatory bowel diseases. turkish j gastroenterol. 2016;27(2):143–8. 11. parra rs, feitosa mr, ferreira s, et al. anemia and iron deficiency in inflammatory bowel disease patients in a referral center in brazil: prevalence and risk factors. arq gastroenterol. 2020;57(3):272–7. 12. wells cw, lewis s, barton jr, et al. effects of changes in hemoglobin level on quality of life and cognitive function in inflammatory bowel disease patients. inflamm bowel dis. 2006;12(2):123–30. 13. michailidou m, nfonsam vn. preoperative anemia and outcomes in patients undergoing surgery for inflammatory bowel disease. am j surg. 2018;215(1):78–81. 14. gafter-gvili a, schechter a, rozen-zvi b. iron deficiency anemia in chronic kidney disease. acta haematol. 2019;142(1):44–50. 15. wallace df. the regulation of iron absorption and homeostasis. clin biochem rev. 2016;37(2):51–62. 16. gasche c. anemia in ibd: the overlooked villain. inflamm bowel dis. 2000;6(2):142–50. 17. pagani a, nai a, silvestri l, et al. hepcidin and anemia: a tight relationship. front physiol. 2019;10:1294. 18. kaitha s, bashir m, ali t. iron deficiency anemia in inflammatory bowel disease. world j gastrointest pathophysiol. 2015;6(3):62. 19. singh up, singh np, murphy ea, et al. chemokine and cytokine levels in inflammatory bowel disease patients. cytokine. 2016;77:44–9. 20. nemeth e, ganz t. anemia of inflammation. hematol oncol clin north am. 2014;28(4):671–81. 21. tsiolakidou g, koutroubakis ie. stimulating erythropoiesis in inflammatory bowel disease associated anemia. world j gastroenterol. 2007;13(36):4798–806. 22. christodoulou dk, tsianos ev. anemia in inflammatory bowel disease the role of recombinant human erythropoietin. eur j intern med. 2000;11(4):222–7. 23. mclean lp, cross rk. adverse events in ibd: to stop or continue immune suppressant and biologic treatment. expert rev gastroenterol hepatol. 2014;8(3):223–40. 24. park ye, park sj, park jj, et al. incidence and risk factors of micronutrient deficiency in patients with ibd and intestinal behçet’s disease: folate, vitamin b12, 25-oh-vitamin d, and ferritin. bmc gastroenterol. 2021;21(1):1–9. 25. huang s, ma j, zhu m, et al. status of serum vitamin b12 and folate in patients with inflammatory bowel disease in china. intest res. 2017;15(1):103–8. 26. niepel d, klag t, malek np, et al. practical guidance for the management of iron deficiency in patients with inflammatory bowel disease. therap adv gastroenterol. 2018;11:1756284818769074. 27. dignass au, gasche c, bettenworth d, et al. european consensus on the diagnosis and management of iron deficiency and anaemia in inflammatory bowel diseases. j crohn’s colitis. 2015;9(3):211–22. 28. jimenez k, kulnigg-dabsch s, gasche c. management of iron deficiency anemia. gastroenterol hepatol. 2015;11(4):241–50. 29. buttarello m. laboratory diagnosis of anemia: are the old and new red cell parameters useful in classification and treatment, how? int j lab hematol. 2016;38:123–32. 30. fava c, cattazzo f, hu z-d, et al. the role of red blood cell distribution width (rdw) in cardiovascular risk assessment: useful or hype? ann transl med. 2019;7(20):581–581. 31. oustamanolakis p, koutroubakis ie, kouroumalis ea. diagnosing anemia in inflammatory bowel disease: beyond the established markers. j crohn’s colitis. 2011;5(5):381–91. 32. gnanaraj j, parnes a, francis cw, et al. approach to pancytopenia: diagnostic algorithm for clinical hematologists. blood rev. 2018;32(5):361–7. 33. dignass a, farrag k, stein j. limitations of serum ferritin in diagnosing iron deficiency in inflammatory conditions. int j chronic dis. 2018;2018:1–11. 34. pfeiffer cm, looker ac. laboratory methodologies for indicators of iron status: strengths, limitations, and analytical challenges. am j clin nutr. 2017;106(suppl 6):1606s-1614s. 35. peng yy, uprichard j. ferritin and iron studies in anaemia and chronic disease. ann clin biochem. 2017;54(1):43–8. 36. abitbol v, borderie d, polin v, et al. diagnosis of iron deficiency in inflammatory bowel disease by transferrin receptor-ferritin index. med (united states). 2015;94(26). 37. lee t, clavel t, smirnov k, et al. oral versus intravenous iron replacement therapy distinctly alters the gut microbiota and metabolome in patients with ibd. gut. 2016;66(5):863–71. 38. stein j, haas js, ong sh, et al. oral versus intravenous iron therapy in patients with inflammatory bowel disease and iron deficiency with and without anemia randy adiwinata acta med indones-indones j intern med 370 in germany a real-world evidence analysis. clin outcomes res. 2018;10:93–103. 39. avnit t, bieber a, steinmetz t, et al. treatment of anemia in inflammatory bowel diseasesystematic review and meta-analysis. plos one. 2013;8(12):e75540. 40. pergola pe, fishbane s, ganz t. novel oral iron therapies for iron deficiency anemia in chronic kidney disease. adv chronic kidney dis. 2019;26(4):272–91. 41. cotter j, baldaia c, ferreira m, et al. diagnosis and treatment of iron-deficiency anemia in gastrointestinal bleeding: a systematic review. world j gastroenterol. 2020;26(45):7242–57. 42. sood a, ahuja v, kedia s, et al. diet and inflammatory bowel disease: the asian working group guidelines. indian j gastroenterol. 2019;38(3):220–46. 43. bischoff sc, escher j, hébuterne x, et al. espen practical guideline: clinical nutrition in inflammatory bowel disease. clin nutr. 2020;39(3):632–53. special article 179acta med indones indones j intern med • vol 52 • number 2 • april 2020 mass panic disaster management in covid-19 pandemic hamzah shatri1,2, edward faisal1, rudi putranto1 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of epidemiology, cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: edward faisal, md. division of psychosomatic and palliative, faculty of medicine universitas indonesia cipto mangunkusumo hospital . jl. diponegoro no. 71, jakarta 10430, indonesia. email: efaisal.psikopaliatif@yahoo. com, psikosomatik@yahoo.com. abstrak pandemi infeksi virus corona 2019 (covid-19) terjadi dalam waktu singkat. situasi ini adalah bencana tidak terduga. pengobatan yang belum pasti untuk infeksi virus ini meningkatkan kecemasan berlebihan. kecemasan ini tdak hanya terjadi pada satu orang saja tapi pada sebagian besar orang sehingga menyebabkan panik massal. panik massal adalah masalah serius yang harus segera diidentifikasi dan ditatalaksana. manajemen panik massal akan dapat menurunkan insiden covid-19. kata kunci: panik massal, kecemasan, manajemen, bencana, covid-19. abstract coronavirus disease (covid-19) pandemic occurred abruptly. it is an unexpected disaster. uncertain treatment for this viral infection increases excessive anxiety, which does not occur only in one person but also in majority of people; therefore, it can create mass panic. mass panic is a serious problem that must be immediately identified and managed. mass panic management will reduce covid-19 incidence. keywords: mass panic, anxiety, management, disaster, covid-19. introduction covid-19 pandemic occurs very quickly.1, 2 the centers of disease control and prevention (cdc) fact sheet describes that bad rumors, fear and anxiety about covid-19 have already happened. the pandemic is a false alarm for someone who already had anxious personalities and anxiety can occur in any individual of all age groups. this condition is a strong trigger for someone who has a desire not to be infected, especially for those who already had a history of anxiety. coughlin, et al.3 suggest that anxiety and depression have been known to be associated with various viral infections. the mildest disorder of anxiety is hypochondriasis; while disorder with the most rapid exacerbation is panic attack. behavioral response, which is associated with the fear of coronavirus infection today, is similar to fear-related behavior of ebola virus pandemic, which had occurred in west africa previously. behavior and action collectively occurs as a response to perceived threat or actual exposure to events that have the potential to cause trauma. in this case, it is the fear-related behavior on covid-19. every individual may have a significant contribution in accelerating the virus transmission and similar condition also applies to the ebola epidemic. o’leary et al.4 have demonstrated that there is discriminatory hamzah shatri acta med indones-indones j intern med attitude and 95% survivors of ebola have experienced stigma. such fear is not only limited to layman but also health workers. some asymptomatic layman may have panic behavior and this situation may be catastrophic in the context of preventing the rapid spread of covid-19. fear and anxiety about covid-19 can be overwhelming and even stressful.5 psychological symptoms related to covid-19 that have been observed at population level are anxietydriven panic buying and paranoia about attending community events. people who have been prevented from accessing their training institutions, workplaces, homes, respectively, are expected to have developed abnormal psychological symptoms. the abnormal psychological symptoms may occur because of stress, lack of autonomy and increasing concerns about income and job insecurity, etc. another concern may include the impacts of the isolation, which can induce fear and panic in the community. furthermore, the fear may be possibly more harmful than the covid-19 infection itself.6 one of major problems found in this pandemic is mass panic. mass panic is a crowd problem, which is the opposite of collective resilience. there is a need for good management on mass panic. people will suffer more because of ‘behavioral and emotional responses’ than ‘physical injuries’.7 according to gøtzsche in bmj, we are all the victim of mass panic due to covid-19.8 people in hong kong, singapore, indonesia, and japan have the worst responses to the contagious covid-19 infection. they are so afraid that it induces them to perform bulk buying.9 bulk buying is one of the signs of mass panic. further management should be done, which includes mass behavioral treatment. definition and epidemiology negative emotion and reaction can impact a large group of people; therefore, it may lead to serious consequences, which are group insecurity, anxiety, worry or fear. it may also lead to distress and worsen a threatening or harmful situation. the phenomenon has been described as “herding behavior”, a type of irrational behavior that often leads to dangerous overcrowding and impaired escape. the transition of experience from individual psychology to mass psychology could happen due to herding behavior. herding behavior is the result of social contagion. destructive actions may result from an individual’s high stress level and inability to make decisions. loss of social identity within a group, loss of personal space, high crowd density, severe external crises or emergencies and high emotional arousal are described as non-adaptive crowd behaviors. social attachment could delay or boost incident mass panic.10,11 there are three common levels of distress, which are anxiety, fear, and panic.10 in addition to fear, the bodily sensation of physical pressure caused by close contact with other people and being confined in a limited space also has the potential to cause panic. panic-related emotions and panic behavior may affect decisionmaking and causes consequent human behavior changes.10 the terms “irrationality” and “herding”, which associated with “panic” are ubiquitous in the crowd dynamics. all of these terms are used for describing human escape behaviour.12 crowd behaviors in emergencies and disasters are divided into two categories: (1) those that are assumed to have a default of psychological vulnerability and (2) those that have emphasized psychosocial resilience. panic typically means loss of behavioral control, rather than selfishness and mental disorder.7 panic can affect evacuation efficiency, in both beneficial or detrimental ways.12 meanwhile, mass panic is defined as dysfunctional behavior, delusory beliefs and social pathology. in mass panic, the crowd becomes irrational and it is likely to be associated with the ‘contagion’ of emotion. two and more people may share the same beliefs related to covid-19-associated symptoms. an irrational response is often subtle in a mass emergency situation and it may have dangerous effects. the people’s ability to remain calm and react logically to the situation is blurred because of their fear and anxiety. in contrast, collective resilience is an emphasis on the people’s collective capacity for recovering 180 vol 52 • number 2 • april 2020 mass panic disaster management in covid-19 pandemic and continuing to function through shared social and psychological resources.7 there are some unique factors associated with mass panic that should be considered for management, including environmental factors, human factors and policy factors.10 risk factors, clinical features and outcome the cognition, behavior, emotion and previous experience can directly impact the outcomes of this pandemic. the pandemic is one of emergency situations and human beings may respond to it with negative psychological feelings such as stress, panic and altered decision-making patterns. non-adaptive behaviors such as panic behavior and crowd behavior may also be observed. apart from the psychological impacts, human behavior can lead to serious physical consequence such as injuries or deaths. there are three stages psychological reaction in emergency situation:10 1. the pre-impact phase, which contains the threat stage and warning stage. 2. the impact phase. 3. post-impact phase, which contain the recoil stage, rescue stage, and post-traumatic stage. the pre-impact phase and impact phase are viewed as pre-movement process. ignoring or denying the situations and being apathetic to the upcoming danger are common findings in this early phase. human behavior in the pre-movement process are collecting information about the situation, collecting important belongings, and choosing an optimal way to saving own life. the most important determinants of human behavior are risk perception and decision-making. decision-making process in this pandemic is typically conducted under time pressure. the immediate consequences of threat are stress, anxiety, and arousal.10 clinical manifestations in crowd may not be identified exactly, but they are more easily observed in individuals. due to lack of evidence about clinical manifestations in crowd, the risk of mass panic can be assessed based on environmental and situational cues. a few cues that can use for identifying mass pathologies are: (1) perception of an urgent and immediate threat to someone and/or their family; (2) belief that overprotection in situations is possible, even in the reality it may not; and (3) feelings of helplessness, especially when others are not willing or not able to help. at individual level, amidst the pandemic, the manifestations of psychological problems may include anxiety, depression, and post traumatic disorder syndrome.6 there are general psychological clinical manifestations during an infectious disease outbreak:5 • fear and worry about their own health and relatives. • changes in sleep or eating patterns. • difficulty sleeping or concentrating. • worsening of chronic health problems. • excessive crying or irritation. • excessive worry or sadness. • unhealthy eating or sleeping habits. • difficulty with attention and concentration. • avoidance of activities enjoyed in the past. • unexplained headaches or body pain. • increased use of alcohol, tobacco, or other drugs. in certain situation, particularly after being released from a quarantine, one could experience psychological disturbances and the clinical manifestations include:5 • mixed emotions, including relief after quarantine • fear and worry about your own health and the health of your relatives • stress from the experience of monitoring yourself or being monitored by others for signs and symptoms of covid-19 • sadness, anger, or frustration because friends or loved ones have unfounded fears of contracting the disease from having a contact with you, even though you have been confirmed as non-contagious • guilt about not being able to perform normal work or parenting duties during quarantine • other emotional or mental health changes mass panic management self-isolation and quarantine are the best way to reduce the spread of covid-19, which also include screening for non-specific 181 hamzah shatri acta med indones-indones j intern med covid-19 symptoms and reporting absence of transmission. compulsory physical distancing, hand hygiene, and mass masking are successful way to eliminate covid-19 transmission.13-15 stigmatization can be removed by using mask in public area. the recent recommendation for mass masking is included for asymptomatic subjects in public places. mass masking as a public health intervention may reduce the virus transmission to other healthy people from asymptomatic infected people. while encouraging people to use mask, there is a problem of global shortage of medical mask supply. mass mask panic have made people rush in buying mask (panic buying) for protected their self and family. hong kong and italy had the same problem about panic mask buying; however, the craze has gone about more than 30 days.13 now, the world health organization are neither against nor recommending the use of non-medical mask (e.g. cotton fabric) to reduce covid-19 transmission.14,15 medical masks and their technical specifications are designed specifically for the protection of health-care workers and it is not intended for layman.13-15 the facts are there are a lot of people in the community have misused the medical equipment as they feel having greater protection when they use medical masks, which is also used by medical officers. it is one of signs that mass panic has already happened. people continue to use medical-grade mask although they are aware that there will be a lack of supply of self protection device for medical officers. currently, there is insufficient supply of personal protective equipment due to panic buying and stockpiling.16 at this point, governments must prepare to handle mass panic and explore other sustainable alternatives to protect civilians as well as reaching for effective source control in community settings. health authorities need to respond fast and make quick decision in order to stop mass panic and make advance preparations to avoid confusion and chaos in the anticipated challenges ahead. the pandemic covid-19 in our lives has been traumatic enough to constitute a crisis and the stress levels are nearly unmanageable. such crises include being diagnosed with a probable covid-19 infection or having personal contact with covid-19 patient; however, events of lesser severity may also constitute a crisis.17 respond to covid-19 depends on personal background, which is different among the community. everyone may have different reaction to stressful situation. there are some stress coping mechanisms that someone in the community can do to make him/her feel stronger to face the stressful event. those who already have preexisting mental health conditions should continue their medication and always be aware of new or worsening symptoms. the most important thing that can we do to reduce panic, anxiety, and fear are taking care of yourself, friends, and family. the community becomes stronger when there are people with good stress coping ability who can influence the others with positive attitudes.5 things to do when facing crises are focuses on the important issues, find support, lessen the stress response, process our feeling, take care of our body, and be patient towards ourself.17 first of all, the people who is going to selfisolation or quarantine need to understand about the disease; therefore, he/she will do the isolation voluntarily without stressful thoughts.18 for community sake, things that we can do to support psychological coping mechanism are: 5,9,17-21 • doing daily routine activities. such as maintaining daily sleep cycle and having normal eating habit. • planning daily timetable for sustaining mental and physical health. • trying to notice and limit anxiety triggers such as information or news from unknown and untrustworthy source. • avoiding or taking breaks from using gadgets, watching, reading, or listening to news stories, including social media, especially listening to the news about the pandemic repeatedly. do not using gadgets during meal time, when you are in a social situation, before bedtime or in the bathroom. set time limits for how long you would like to spend on your phone. information overload due to global connectivity has made propensity to disruption and the people could not distinguish the fact from hoax. • avoiding replicate and broadcast negative news. 182 vol 52 • number 2 • april 2020 mass panic disaster management in covid-19 pandemic • taking care of your body. • doing exercise regularly. • doing some meditation such as yoga. • if you feel bored or you are stuck in your negative mind do take deep breaths, stretch, or meditate. • eating healthy food and well-balanced meals. • getting enough sleep. • doing your hobbies. • doing communication with distant family members or you friends with video call option. • avoiding alcohol, smoking, and drugs abuse. covid-19 affects people in the community as well as those who are in quarantine and people being released from quarantine. during quarantine, people can still perform their daily activity similar to activities they have in the community in order to reduce their stress. however, different situation may occur for those who have released from quarantine as they may experience stigma and fear-associated discrimination from others in their community. to overcome such situation, firstly we have to stay healthy and maintaining positive energy to live a fulfilling life of becoming real healthy people.5 another way to reduce the impact of the pandemic is using telemental health consultation, which is one of the easiest ways to treat mass mental health problem as it is feasible and affordable. treatment protocols should address both of physiological and psychological needs. since psychological treatment and support may diminish the burden of comorbid mental health conditions, thus it may the wellbeing of people with mental health issues. another challenge is to provide mental health services during isolation. telemental health services (ths), which is carried out through videoconference, e-mail, telephone, or smartphone apps, can help people in isolation and those who are at high risk for covid-19 including clinicians on the frontline, patients diagnosed with covid-19 and their families, policemen, and security guards. ths can maintain psychological well-being and can help them to cope in acute and post-acute condition. the services include counseling, supervision, training, as well as psychoeducation. ths can fill the needs of those in rural and remote area during this situation. communication is one of basic needs during isolation. simple communication methods should be used more extensively to share information about symptoms of burnout, depression, anxiety, and ptsd during covid-19. the aims of doing this are to offer cognitive and/or relaxation skills, to deal with minor symptoms and to encourage access to online self-help programs. ths can be used to monitor symptoms and also to provide support when needed.6 conclusion in every situation, positive thinking is the right method for reaching healthy life. with this, every individual can avoid panic, anxiety, and fear. mass panic can also be avoided by performing prevention and promotion measures on psychological and physical problems during the pandemic. further study should be conducted to identify the problem further and provide proper management. currently, studies on mass panic issue are ongoing in indonesia. references 1. kampf g, todt d, pfaender s, steinmann e. persistance of coronavirus on inanimate surfaces and their inactivation with biocidal agents. j hospital infect. 2020;104:e251. 2. wu z, mcgoogan j, m. characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china summary of a report of 72,314 cases from the chinese center for disease control and prevention. jama. 2020:e1-4. 3. coughlin ss. anxiety and depression: linkages with viral diseases. public health rev. 2012;34:1-13. 4. o’leary a, jalloh mf, neria y. fear and culture: contextualising mental health impact of the 2014–2016 ebola epidemic in west africa. bmj glob health. 2018;3:000924. 5. center for disease control and prevention. coronavirus disease 2019 (covid-19): daily life & coping. usa: u.s. departement of health & human services; 2020 [cited 2020 april 1, 2020]. available from: https://www.cdc.gov/coronavirus/2019-ncov/dailylife-coping/managing-stress-anxiety.html. 6. zhou x, snoswell cl, harding le, et al. the role of telehealth in reducing the mental health burden from covid-19. telemed j e health. 2020:1-3. 7. drury j, novelli d, stott c. representing crowd behaviour in emergency planning guidance: ‘mass 183 hamzah shatri acta med indones-indones j intern med panic’ or collective resilience? resilience. 2013;1:1837. 8. gøtzsche pc. covid-19: are we the victims of mass panic? bmj. 2020;368:m800. 9. peckham r. the covid-19 outbreak has shown we need strategies to manage panic during epidemics2020 april 11, 2020 [cited 2020 february 21, 2020]. available from: https://blogs.bmj.com/bmj/2020/02/21/robertpeckham-covid-19-outbreak-need-strategiesmanage-panic-epidemics/. 10. cheng y, liu d, chen j, namilae s, thropp j, seong y. human behavior under emergency and its simulation modeling: a review. ijhfms. 2019:313-25. 11. gantt p, gantt r. disaster psychology dispelling the myths of panic. prof saf. 2012;57:42-9. 12. haghani m, cristiani m, bode nwf, boltes m, corbett a. panic, irrationality, and herding: three ambiguous terms in crowd dynamics research. j adv transport. 2019(9267643):1-58. 13. leung cc, lam th, cheng kk. mass masking in the covid-19 epidemic: people need guidance. lancet. 2020;395(10228):945. 14. world health organization. advice on the use of masks in the context of covid-19 2020 april 9, 2020 [cited 2020 april 6, 2020]:[1-5 pp.]. available from: https:// www.who.int/publications-detail/advice-on-the-useof-masks-in-the-community-during-home-care-andin-healthcare-settings-in-the-context-of-the-novelcoronavirus-(2019-ncov)-outbreak. 15. world health organization. advice on the use of masks the community, during home care and in health care settings in the context of the novel coronavirus (2019ncov) outbreak2020 april 9, 2020 [cited 2020 january 29, 2020]:[1-2 pp.]. available from: https://www.who. int/docs/default-source/documents/advice-on-the-useof-masks-2019-ncov.pdf. 16. world health organization. rational use of personal protective equipment for coronavirus disease 2019 (covid-19) 2020 april 9, 2020 [cited 2020 february 27, 2020]:[1-7 pp.]. available from: https://apps.who. int/iris/bitstream/handle/10665/331215/who-2019ncov-ipcppe_use-2020.1-eng.pdf. 17. scott e. tips on how to cope with a crisis or trauma 2020 april 7, 2020 [cited 2019 november 10, 2019]. available from: https://www.verywellmind.com/copewith-a-crisis-or-trauma-3144525. 18. brooks sk, webster rk, smith le, et al. the psychological impact of quarantine and how to reduce it: rapid review of the evidence. lancet. 2020;395:91220. 19. gould wr. the hidden stressors of technology you should be aware of 2020 april 7, 2020 [cited 2020 february, 2020]. available from: https:// www.verywellmind.com/the-hidden-stressors-oftechnology-4783960. 20. world health organization. mental health and psychosocial considerations during covid-19 outbreak. 2020. 21. whalley m, kaur h. guide uk english living with worry and anxiety amidst global uncertainty. uk: psychology tools limited; 2020 [cited 2020. available from: https://www.psychologytools.com/ resource/ living-with-worry-and-anxiety-amidstglobal-uncertainty. 184 125 original article acta med indones indones j intern med • vol 52 • number 2 • april 2020 the influence of new-onset atrial fibrillation after coronary artery bypass grafting on three-year survival rasco s. sihombing1, muhadi2, arif mansjoer2, ikhwan rinaldi3 1 department of internal medicine, medical faculty of universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia 2 division of cardiology, department of internal medicine, medical faculty of universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 3 clinical epidemiology unit, department of internal medicine, medical faculty of universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: arif mansjoer, md. division of cardiology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: arif.mansjoer@gmail.com. abstrak latar belakang: fibrilasi atrium (fa) awitan dini pascabedah pintas arteri koroner (bpak) merupakan salah satu komplikasi pascaoperasi yang sering terjadi. aritmia ini merupakan fenomena sementara dan mayoritas pasien akan mengalami konversi ke irama sinus saat dipulangkan. meskipun bersifat sementara, fa awitan baru pasca-bpak berpotensi mengalami rekurensi sehingga meningkatkan risiko mortalitas jangka panjang. penelitian ini bertujuan untuk mengetahui peran fa awitan baru pasca-bpak dalam mempengaruhi kesintasan tiga tahun. metode: studi kohort retrospektif menggunakan analisis kesintasan yang meneliti 196 pasien yang menjalani bpak di rumah sakit cipto mangunkusumo sejak januari 2012 sampai desember 2015. eksklusi dilakukan pada pasien dengan riwayat fa sebelum operasi, menjalani operasi tanpa mesin pintas jantung-paru, dan yang meninggal dalam 30 hari pascaoperasi. subyek penelitian dibagi menjadi 2 kelompok berdasarkan ada tidaknya fa awitan baru pasca-bpak dan kemudian ditelusuri status kematiannya dalam tiga tahun sejak operasi. kurva kaplan-meier digunakan untuk menilai kesintasan tiga tahun dan dilakukan uji regresi cox sebagai uji multivariat terhadap variabel perancu untuk mendapatkan nilai adjusted hazard ratio (hr). hasil: sebanyak 29,59% pasien mengalami fa awitan baru pasca-bpak. mortalitas tiga tahun pasien yang mengalami fa awitan baru pasca-bpak baru lebih tinggi (15,52% vs 3,62%) dan secara signifikan menurunkan kesintasan tiga tahun (p=0,008; hr 4,42; ik 95% 1,49-13,2). pada analisis multivariat, fa awitan dini pasca-bpak merupakan faktor independen penurunan kesintasan tiga tahun (adjusted hr 4,04; ik 95% 1,34-12,14). kesimpulan: fa awitan baru pasca-bpak secara independen menurunkan kesintasan tiga tahun. kata kunci: awitan baru, bedah pintas arteri koroner, fibrilasi atrium, kesintasan. abstract background: new-onset atrial fibrillation after coronary artery bypass grafting (cabg) is a common postoperative complication. this arrhytmia considered as temporary phenomenon which the majority are converted back to sinus rhytm when the patients discharged from the hospital. despite its transience, those arrhytmia can recur and increasing the long term mortality. this study aims to determine the role of new-onset atrial fibrillation after cabg in three year survival. methods: retrospective cohort study using survival analysis of patients who underwent coronary artery bypass grafting since january 2012 to december 2015 at cipto mangunkusumo hospital. patients with atrial fibrillation before surgery, who had surgery without cardiopulmonary bypass machine, and who died rasco s. sihombing acta med indones-indones j intern med 126 in 30 days after surgery are excluded. subjects are divided into two category based of the presence of new-onset atrial fibrillation after cabg and the mortality status is followed up until 3 years post-surgery. the kaplan-meier curve is used to determine the three-year survival of the patients who had new-onset atrial fibrillation after cabg and cox regression test used as multivariate analysis with confounding variables in order to get adjusted hazard ratio (hr). results: new-onset atrial fibrillation after-cabg occurred in 29,59% patients. patients with new-onset atrial fibrillation after cabg have higher three-year mortality (15,52% vs 3,62%) and significantly decreases three-year survival (p=0,008; hr 4,42; 95% ci 1,49-13,2). in multivariate analysis, new-onset atrial fibrillation after cabg is an independent factor of the three-year survival decline (adjusted hr 4,04; 95% ci; 1,34-12,14). conclusion: new-onset atrial fibrillation after cabg independently decreases three-year survival. keywords: atrial fibrillation, coronary artery bypass grafting, new-onset, survival. introduction coronary artery bypass grafting (cabg) is one of methods of revascularization therapy in coronary artery disease (cad). despite its decline in past decade accompanied by the increasing numbers of percutaneous coronary intervention, cabg still considered better in certain conditions to prolong patients’ survival. in united states, about 400.000 operations performed anually.1 older age accompanied by increasing comorbidites of candidates of cabg contributed to difficulties in preventing postoperative complications. one of the complication is postoperative arrhytmia which is dominated by new-onset atrial fibrillation (af). the incidence of new-onset af can reach 40% and can be doubled if the procedure combined with the valve surgery.2,3 majority of new-onset af occurred in four days postoperatively and already converted back to sinus rhytm when the patients discharged.4 because of its characteristics, newonset af after cabg often considered to have no important clinical consequenses.5 meta-analysis reported by phan et al shows the influence of new-onset af after cabg to the increasing risk of in-hospital complications and 30-days mortality. patients with new-onset af after cabg has lower survival in 1,5, and 10 years.6 the excel study (evaluation of xience versus coronary artery bypass surgery for effectiveness of left main revascularization) concluded that new-onset af after cabg is an independent predictor of three-year mortality with hazard ratio (hr) 3,02 (p=0,0006, ci 95% 1,6-5,7).7 the af rhytm of patients with history of new-onset af after cabg can recur in longterm period. using the most sensitive detector, af recurrence in that group can reach 60,9% in 2 years postoperatively. majority of those recurent cases are asymptomatic.8 those conditions are related with increasing mortality through cardiac death, fatal stroke, and fatal arrhytmia caused by anti-arrhytmic drugs.9 the influence of new-onset af after cabg to long-term mortality had never been published in indonesia. several studies abroad can not be just generalized because some characteristics differences. patients who underwent cabg in indonesia are younger and have better left ventricular ejection fraction.10,11 several preoperative factors that can influence survival of patients after cabg are patients aged 60 years old and over, the presence of diabetes mellitus (dm), chronic obstructive pulmonary disease (copd)12, renal dysfunction (estimated glomerular filtration rate <60 ml/minute/m2)13, and low ejection fraction (<40%).14 the aim of this study is to determine the role of new-onset atrial af after cabg on threeyear survival so can affect the evaluation and management and resulting in positive impact to patients’ survival. methods this is a retrospective cohort study with survival analysis to study the role of newonset af after cabg on three-year survival. the minimum sample size in this study was 248 patients. new-onset af after cabg is defined as af rhythm occurred for the first time vol 52 • number 2 • april 2020 the influence of new-onset atrial fibrilation on after coronary artery bypass 127 postoperatively, with or without symptoms, and documented in hospital care or in ≤30 days if the patients are discharged. this study has been approved by the ethics committee of the faculty of medicine universitas indonesia (reference no. 1007/un2.f1/etik/2018). this study analyzed the secondary data with inclusion criteria as follows : patients ≥18 years old who underwent cabg (single or combined with valve surgery) at cipto mangunkusumo hospital since january 2012 to december 2015, and subjects with complete data of heart rhytm in hospital care postoperatively. exclusion criteria as follows: subjects with history of af before surgery, subjects operated without cardiopulmonary bypass machine, and patients who died in 30 days postoperatively. subjects then divided into the group with and without new-onset af after cabg. in three years since the surgery date, all cause mortality status will be searched. the subjects will be censored if the mortality status unknown or still alive in three years after surgery. the studied variable and confounding preoperative variables (aged 60 years old and over, dm, copd, renal dysfunction, low ejection fraction) will be analyzed using proportional hazard test. variables which fullfill proportional hazard assumption are included in bivariate analysis and then variables with the p value<0,25 will be analyzed in multivariate analysis using cox regression. stata 15.0 was used to analyze the data. results among 196 subjects in this study (table 1), 58 subjects (29.59%) had history of new onset af after cabg. the characteristics of the groups based on the presence of new-onset af after cabg can be seen in table 2. the most common episode of new-onset af on occurred at operative day and 87.9% cases are converted back to sinus rhytm in ≤24 hours. intravenous amiodarone is the most common therapy given in treating new-onset af after cabg. in this study, the three years mortality status of 14 patients (7.14%) are unknown. patients with history of new-onset af after cabg has higher mortality rate (15.52% vs 3.62%). the table 1. characteristics of subjects. variables description (n = 196) age, years mean (sd) 58.05 (8.24) age ≥60 years old n (%) 94 (47.96) male n (%) 163 (83.16) body mass index, kg/m2 (mean, sd) 25.03 (3.64) ejection fraction, % (mean, sd) 54.14 (14.99) low ejection fraction n (%) 37 (18.88) diabetes mellitus n (%) 75 (38.27) renal dysfunction n (%) 38 (19.39) cad three-vessel disease n (%) 177 (90.31) left main disease n (%) 79 (40.31) combination with valve surgery n (%) 34 (17.35) new-onset af after cabg n (%) 58 (29.59) left atrial enlargement n (%) 45 (22.96) diastolic dysfunction n (%) 93 (47.45) copd n (%) 4 (2.04) smoking n (%) 90 (45.92) euroscore additive (median, minmax) 3 (0-16) beta-blocker usage n (%) 179 (91.33) cpb time, minutes (median, min-max) 121 (54-353) aortic cross clamp time, minutes (median, min-max) 92 (32-199) three-year survival curve between groups of patients with and without new-onset af can be seen in figure 1. new-onset af after cabg, age 60 years old and over, and dm fullfilled proportonal hazard assumption and then analyzed with cox regression. bivariate analysis is shown in table 3. it is concluded that new-onset af after cabg is the only significant factor influencing the three-year mortality with hr 4.42 (ci 95%) 1.4913.2). multivariate analysis with confounding variables resulted in adjusted hr 4.04 (ci 95% 1.34-12.14) as shown in table 4. discussion the mean age of this study is 58,05 years old. the result is almost similar with the prior study which was held in indonesia,10 although is younger when compared with several studies abroad.9,12 the mean of fraction ejection in this study is 54,11%, which is better if compared with abroad studies.9,12 the incidence of new-onset af after cabg in this study is 29.59%, in range of the reported before.2 the variation in number rasco s. sihombing acta med indones-indones j intern med 128 of incidence caused by different definition of new-onset af after cabg which has not been agreed, especially about the minimum duration. new-onset af after cabg most often occurred at operative day (32.8%) which is related with ischemia, and postoperative day-2 (24.1%) which is influenced by inflammatory response and oxidative stress after using of cardiopulmonary bypass machine.15 majority of cases of af are ended in first 24 hours after surgery because most of patients have normal left atrial diameter and ejection fraction. it is known that the greater the change of heart’s structure, the more likely af become persistent.5 table 2. subjects’ characteristics based on the presence of new-onset af after cabg. variables new-onset af after cabg yes (n=58) no (n=138) age ≥60 years old n (%) 33 (56.9) 61 (44.2) male n (%) 46 (79.31) 117 (84.78) body mass index, kg/m2 mean (sd) 24.84 (3.56) 25.08 (3.68) low ejection fraction n (%) 12 (20.92) 29 (21.01) diastolic dysfunction n (%) 27 (46.55) 66 (47.83) left atrial enlargement n (%) 18 (31.03) 27 (19.57) copd n (%) 1 (1.72) 3 (2.17) diabetes mellitus n (%) 25 (43.1) 50 (36.23) renal dysfunction n (%) 10 (17.24) 28 (20.29) smoking n (%) 23 (39.66) 67 (48.55) cad three-vessel disease n (%) 53 (91.38) 124 (89.86) left main disease n (%) 23 (39.66) 56 (40.58) beta blocker usage n (%) 54 (93.1) 125 (90.58) combination with valve surgery n (%) 12 (20.69) 23 (16.67) cpb time (minutes), median (min-max) 128,5 (69-284) 118 (54-353) aortic cross clamp time (minutes), median (min-max) 93 (52-199) 90.5 (32-186) potassium correction n (%) 48 (82.76) 98 (71.01) magnesium correction n (%) 25 (43.1) 33 (23.91) anticoagulant when discharged n (%) 14 (24.14) 22 (15.94) euroscore additive (median, min-max) 3 (0-13) 3 (0-16) three-year mortality n (%) yes 9 (15.52) 5 (3.62) unknown 3 (5.17) 11 (7.97) table 3. influence of new-onset af after cabg, age ≥60 years old, and diabetes mellitus to three-year survival. variables hazard ratio ci 95% p value new-onset af after cabg 4.42 1.49-13.2 0.008 age ≥60 years old 1.95 0.65-5.8 0.23 diabetes mellitus 2.38 0.82-6.86 0.11 table 4. hazard ratio of new-onset af after cabg. variables hazard ratio (ci 95%) crude hr new-onset af after cabg 4.42(1.49-13.2) adjusted hr dm 4.23 (1.42-12.66) age ≥60 years old 4.04 (1.34-12.14) in this study, the group with new-onset af after cabg has older age. it is reported in prior study in indonesia that age is the only significant factor which can increase the incidence of newonset af after cabg.10 more patients with vol 52 • number 2 • april 2020 the influence of new-onset atrial fibrilation on after coronary artery bypass 129 new-onset af after cabg sent home with anticoagulant therapy, although the indications mosly as part of postoperative valve surgery management. proportion of renal dysfunction is smaller in the group of new-onset af after cabg. that result can be influenced by the exclusion of patients with 30 days postoperative mortality which also consists of more patients with renal dysfunction. we do not get median survival data because this study is limited in three-years observation. mariscalco et al.9 reported the median survival of patients with new-onset af after cabg can reach seven years. the influence of new-onset af after cabg to survival in this study is consistent with prior studies which resulting the value of or 3.4 (p=0.018, ci 95% 1.58-7.45)12 and hr 3.02 (p=0.0006, ci 95% 1.6-5.7).7 in contrast to other studies, the preoperative ejection fraction is not proven to influence the survival. there are no myocardial viability data in these patients that can make the improvement of ejection fraction after cabg still possible. we also can not find the significant association between variable of age ≥60 year old to the survival. that can be caused by characteristics difference which is influenced by the patients with age of ≥70 years old. those patients may have significantly lowe survival compared to younger groups. nicolini et al.11 in their study had proportion of patients with age of ≥70 years old reaching 24.9% while in this study just only 6.12%. patients with history of new-onset af after cabg usually have severe comorbidities which can increase the possibility to die earlier.9 despite of that possibility, new-onset af after cabg can also thought to have direct association with long-term mortality. this is shown by consistent association although the characteristics between the groups are matched.9,12 causal relationship between new-onset af and mortality in this study can be assessed by hill’s criteria which shown strength of association, consistency, spesificity, temporality, biological gradient, biological plausibility, and analogy. like paroxysmal af in general population, new-onset af after cabg over time can cause electrophysiological remodelling which can end to progressivity or death. the strength of this study was the difference of study subjects, which were reported younger and had better ejection fraction than prior studies abroad. the exclusion of 30-day mortality is crucial to evaluate the direct role of new-onset af after cabg to long-term mortality. the 30-day mortality is agreed as surgery-related mortality, which may not be directly related to af itself. although the minimum sample in this study cannot be achieved, the power of study is 96.7% which is good. the limitation of this study is the using of figure 1. kaplan-meier curve of survival analysis between patients with and without new-onset af after cabg. rasco s. sihombing acta med indones-indones j intern med 130 secondary data which negates the measurement control that can make the paroxysmal af cannot be detected. another limitation is we cannot get the information about patient’s cause of death. conclusion new onset af after cabg independently decreases three-year survival, so it necessary to make careful evaluation about the possibility of af recurence in patients with history of new-onset af after cabg that can be related to increasing of long-term mortality. further prospective study using more sensitive af detector is needed to evaluate the role of newonset af in long-term mortality. references 1. alexander jh, smith pk. coronary-artery bypass grafting. n engl j med. 2016;374(20):1954-64. 2. dunning j, treasure t, versteegh m, nashef sam, et al. guidelines on the prevention and management of de novo af after cardiac and thoracic surgery. eur j cardiothorac surg. 2006;30(6):852-72. 3. bessissow a, khan j, devereaux j, et al. postoperative af in non-cardiac and cardiac surgery: an overview. j thromb haemost.2015;13(1):s304–s31. 4. maesen b, nijs j, maessen j, allessie m, schotten u. post-operative af: a maze of mechanisms. europace. 2012;14(2):159–74. 5. ehlert fa, narula dd, steinberg js. risk factors for the development of postoperative af. in: steinberg js, editor. af after cardiac surgery. massachusetts: kluwer academic publishers; 2000. p. 51-80. 6. phan k, ha ksk, phan s, medi c, thomas sp, yan td. new-onset af following coronary bypass surgery predicts long-term mortality: a systematic review and meta-analysis. eur j cardiothorac surg. 2015;48(6):817-24. 7. kosmidou i, chen s, kappetein p, et al. new-onset af after pci or cabg for left main disease. j am coll cardiol. 2018;71(7):739-48. 8. el-chami m, merchant f, smith p, et al. management of new-onset postoperative af utilizing insertable cardiac monitor technology to observe recurrence of af (monitor-af). pacing clin electrophysiol. 2016;39(10):1083-89. 9. mariscalco g, klersy c, zanobini m, et al. af after isolated coronary surgery affects late survival. circulation. 2008;118(16):1612-18. 10. hadis h, yunadi y, idham i. insidens dan faktor risiko fibrilasi atrium pasca bedah pintas arteri koroner. j kardiol indones. 2010;31:16-25. 11. nicolini f, fortuna d, contini ga, et al. the impact of age on clinical outcomes of coronary artery bypass grafting: long-term results of a real-world registry. biomed research international;2017:1-11. available in https://doi.org/10.1155/2017/9829487 12. villareal rp, hariharan r, liu bc, et al. postoperastive af and mortality after coronary artery bypass surgery. j am coll cardiol. 2004;43(5):742-48. 13. hillis gs, croal bl, buchan kg, et al. renal function and outcome from coronary artery bypass grafting. circulation. 2006;113(8):1056-62. 14. hillis gs, zehr kj, williams aw, et al. outcome of patients with low ejection fraction undergoing coronary artery bypass grafting. circulation. 2006;114[suppl i]:i-414–i-419. 15. melby sj, george jf, picone dj, et al. a time-related parametric risk factor analysis for postoperative af after heart surgery. j thorac cardiov surg. 2015;149(3):886-92. 118 original article acta med indones indones j intern med • vol 52 • number 2 • april 2020 influence of micronutrient consumption by tuberculosis patients on the sputum conversion rate: a systematic review and meta-analysis study putri b. machmud1, ratna djuwita1, dwi gayatri1, nurul khairani2, wahyu k. y. putra3, sudarto ronoatmodjo1 1 department of epidemiology, faculty of public health universitas indonesia, depok, indonesia. 2 department of public health, stikes tri mandiri sakti, bengkulu province, indonesia. 3 department of nutrition, faculty of public health universitas indonesia, depok, indonesia. corresponding author: putri bungsu machmud. department of epidemiology, faculty of public health universitas indonesia. kampus baru ui depok, kota depok 16424, indonesia. email: putri.bungsu10@ui.ac.id. abstrak latar belakang: penyakit menular merupakan salah satu tantangan kesehatan global di dunia, termasuk penyakit tuberkulosis (tbc). beberapa faktor secara signifikan terkait dengan peningkatan keberhasilan pengobatan, termasuk lamanya pengobatan atau kepatuhan pengobatan, menggunakan lebih dari tiga obat sensitif, rejimen individual, dan berat badan yang terkait dengan mikronutrien. metode: tinjauan sistematis dan studi metaanalisis dari uji coba kontrol secara acak yang dilaporkan oleh item pelaporan pilihan untuk tinjauan sistematis dan meta-analisis. sumber data primer adalah publikasi online, terdiri dari tiga basis data, yang berlangganan oleh universitas indonesia, yaitu proquest, ebsco cinahl, ebsco dentistry. risiko bias dinilai menggunakan alat risiko bias cochrane, dan data dianalisis menggunakan review manager 2015. hasil: terdapat delapan studi yang relevan. ada perbedaan efek yang signifikan antara kelompok intervensi dibandingkan kelompok kontrol (atau kelompok plasebo). rr dari estimasi yang dikumpulkan adalah 1,12 (95% ci: 1,06 1,18) dengan studi heterogenitas 36%. sementara itu, kutub yang dihitung berdasarkan jenis mikronutrien dari tujuh penelitian menunjukkan tidak ada perbedaan konversi dahak antara vitamin d dan kelompok plasebo (rr-1,05, 95% ci 0,99-1,12) dengan studi heterogenitas 0% dan hasil yang signifikan tampak di antara intervensi zinc dan retinol (rr = 1.21, 95% ci 1,09 1,35) dengan studi heterogenitas 40%. kesimpulan: intervensi mikronutrien selama pengobatan tb memiliki efek positif terhadap konversi sputum di antara pasien. zinc dan retinol mempengaruhi konversi dahak sedangkan vitamin d tidak. kata kunci: tuberkulosis, penyakit menular, konsumsi mikronutrien, konversi dahak. abstract background: infectious disease is one of the global health challenge in the world, including tuberculosis. some factors significantly associated with increased treatment success, including the duration of treatment or treatment compliance, use more than three sensitive drugs, individualized regimen, and weight-related to micronutrient. methods: a systematic review and meta-analysis study of randomized control trial studies conducted and reported by preferred reporting items for systematic reviews and meta-analyses. the primary data source was online publications, consist of three bases data, which subscribed by universitas indonesia, they are proquest, ebsco cinahl, ebsco dentistry. risk of bias was assessed using the cochrane risk-of-bias tool, and data were analyzed using review manager 2015. results: there were eight full paper rates as relevant studies. there was a significant difference of effect among the intervention group compared the control group (or placebo group). rr of the pooled vol 52 • number 2 • april 2020 influence of micronutrient consumption by tb patients 119 introduction infectious diseases, including tuberculosis, are a global health challenge. according to the world health organization (who), there were an estimated 1.3 million tuberculosis deaths in 2017.1 this was a marked increase in the number of reported cases in 2014 and 2015 (300,000 and 430.000 cases, respectively).2,3 globally, the total incidence of new tb cases was 133 per 100,000 population in 2017.4 according to targets set by the who, using the 2015 figure as a baseline, there needs to be a 90% reduction in the absolute number of tb deaths and an 80% reduction in the tb incidence rate.1 the first step in ending the global tb epidemic is the treatment of all people with tb, including drug-resistant tb, and patient support.1 although tb treatment is lengthy and expensive, previous studies reported highly successful outcomes in several countries where comprehensive treatment programs were initiated.1-3 several studies showed that treatment regimens were successful in more than 60% of tb cases.1-3 factors significantly associated with successful treatment outcomes included the treatment duration and treatment compliance, use of more than three sensitive drugs, use of fluoroquinolones, individualized treatment regimens, micronutrients, and patient weight.4-7 a previous study reported that plasma retinol concentrations of patients were significantly associated with their body mass indexes8-10 several studies suggested that tb programs should consider the use of various interventions, including supplementation with micronutrients, in conjunction with anti-tb treatment.11-13 micronutrients, such as vitamin d, modulate inflammatory and immune responses to tb and mediate the induction of the antimicrobial peptide cathelicidin.14 previous research suggested that deficiency of 25-hydroxyvitamin d and single nucleotide polymorphisms in the vitamin d receptor gene may increase the risk of tb and decrease culture conversion rates in drugsusceptible tb.14 this systematic review and meta-analysis aimed to investigate the influence of micronutrient consumption on sputum conversion rate among tb patients and to identify optimum micronutrient levels during tb treatment. methods this review study was performed according to the preferred reporting items for systematic review and meta-analysis (8).15,16 the study was registered in the prospero database. a metaanalysis study conducted by using preferred reporting items for systematic reviews and metaanalyses. participants the study population consisted of 1,311 tb patients who received anti-tb treatment as part of a government program based on who guidelines. patients receiving treatment as part of non-government programs or from private health facilities were also included. the population comprised adult male or female patients newly diagnosed with tb and patients with a history of treatment failure or default. patients with/without comorbidities (e.g., hiv infection and diabetes) were also included. intervention and comparator the study intervention was micronutrient supplementation with any or a combination of the following micronutrients during antitb treatment: selenium, potassium, albumin, vitamin a, vitamin d, vitamin e, zinc, and iron. the comparator was tb patients or non-tb patients who did not consume any additional estimate was 1.12 (95% ci: 1.06 1.18) with heterogeneity study 36%. while, the poled calculated based on type of micronutrient from seven studies showed there was no difference of sputum conversion between vitamin d and placebo group (rr=1.05, 95% ci 0.99 – 1.12) with heterogeneity study 0% and a significant result seems among zinc and retinol intervention (rr=1.21, 95% ci 1.09 – 1.35) with heterogeneity study 40%. conclusion: micronutrient intervention during tuberculosis treatment has a positive effect toward to sputum conversion among patient. zinc and retinol influence sputum conversion while vitamin d did not. keywords: tuberculosis, infectious disease, micronutrient consumption, sputum conversion. putri b. machmud acta med indones-indones j intern med 120 micronutrients or consumed lower doses than those in the intervention group. outcome the primary outcome was treatment success, as determined by the sputum conversion rate. inclusion criteria this systematic review included primary studies published worldwide in the last ten years. tb treatment programs were in place decades ago in several countries and also for the first study related to outcome among patients. information sources this systematic review included only primary studies published in english or bahasa. the primary data source was online publications deposited in three databases that was subscribed by universitas indonesia : proquest, medline, ebsco cinahl and ebsco dentistry. the review included only full-text papers with free access and analytical (randomized controlled trials [rcts] and non-rcts) studies. search methods/strategy in the search strategy, we used synonyms of picot-related terms. we also conducted a search using the following mesh terms and keywords: micronutrient, selenium, potassium, albumin, vitamin a, vitamin d, vitamin e, zinc, iron, tuberculosis, rct, patient(s), and adult. pb and a librarian at the university of indonesia with experience of performing literature searches conducted the searches. study selection at the start of the review, pb screened duplicate titles using endnote software. next, all six authors (pb, rd, wk, nk, dg, and sr) assessed the relevance of the titles and abstracts. we excluded all primary studies that did not include details on methodology contained fewer than five patients and had a patient response rate of less than 50%. we also excluded other systematic review studies and meta-analysis studies. data collection process pb extracted the selected studies, together with their titles and abstracts, in tabular format and then entered the data into microsoft excel spreadsheets. three authors (rd, dg, and sr) then checked the accuracy of the selected data. the data extraction consisted of the origin of the study (i.e. country where the research was conducted), authors and publication year of the study, journal name, study population, study design, sample size, comorbidities (e.g. hiv infection and diabetes), history of tb, intervention (type and strategy), and outcome. risk of bias in individual studies all the authors assessed the quality of the studies, including the risk of bias in each research. to evaluate the risk of bias, they used the rating and scoring cochrane risk of bias tool for rcts. using this tool, they rated the quality of the studies as good, fair, or poor. the disagreement was resolved by discussion and consultation with an expert in the field. summary measures there were eight similar exposure and outcome categorizations. thus, a meta-analysis was conducted. the analyzed to obtain a pooled estimate of risk ratio (rr) and its 95% table 1. inclusion criteria. population, intervention, comparator, outcome; timeframe (picot) inclusion criteria participants adult patients newly diagnosed with multi-drug resistant tb and patients with a history of treatment failure, default, or drop-out receiving tb treatment in public or private hospitals/clinics intervention micronutrient supplementation, including selenium, potassium, albumin, vitamin a, vitamin d, vitamin e, zinc, and iron in partial doses, single, or combination doses comparator no micronutrient supplementation or supplementation with lower doses than those in an intervention group outcome sputum conversion and time to sputum conversion timeframe studies published in the last ten years (2008–2018) setting all countries and facility-based or community-based interventions vol 52 • number 2 • april 2020 influence of micronutrient consumption by tb patients 121 confidence interval (ci). data processing was performed used revman software of a fixedeffect model to obtain the pooled estimate of rr, with its 95% ci and heterogeneity. results of 704 studies identified through the search of the literature, 657 relevant studies were from proquest, and the others were from ebsco cinahl and ebsco dentistry. we excluded one study due to duplication and excluded 618 studies after screening the titles. we excluded 41 studies because the abstracts were not relevant to the present study, and we excluded two studies because the full paper was not open access. thus, 42 studies were subjected to a full review. of these, we excluded observational research studies (n=14), review articles (n=4), in vitro studies (n=4), studies with different primary outcomes (n=11), and ongoing studies (n=1). figure 1 presents information on the study selection process. study characteristics of the eight full-text papers included in the present study, the publication years were as follows: 2003 (n=1), 2004 (n=1), 2005 (n=2), 2009 (n=2), 2013 (n=1), and 2015 (n=1). regarding location, two of the studies were conducted in pakistan, and the others were performed in mexico, india, nigeria, the uk, indonesia, and tbilisi. all the studies used an rct design, and four of the studies were double-blinded rcts. based on the type of micronutrient, the interventions in the eight studies consisted of vitamin d (n=4), zinc and retinol (n=3), and a local food supplement (n=1). risk of bias within the studies table 2 presents the results for the risk of bias in the eight selected studies, with the risk assessed using the cochrane risk of bias tool studies. using this tool, we rated five of the eight studies as good quality, two of the studies as fair quality, and one study as poor quality. results of individual studies as shown in figure 2, there was a significant difference in the sputum conversion rate in the intervention group as compared with that in the control group, depending on micronutrient supplementation. the rr of the pooled estimate was 1.12 (95% ci: 1.06, 1.18), with a heterogeneity of 36%. figure 3 shows the combined estimates based on the type of micronutrient. in seven of the eight studies, we separated micronutrient supplementation into two categories: 1) vitamin d; 2) zinc and retinol. the results revealed no difference in the sputum conversion rate between the intervention group and control group (rr = 1.05, 95% ci: 0.99, 1.12), with a heterogeneity of 0%. in contrast, there was a significant difference in the sputum conversion rate between the intervention group that received supplementation with zinc and retinol versus that in the control group (rr = 1.21, 95% ci: 1.09, 1.35), with the heterogeneity of 40%. figure 1. prisma chart. putri b. machmud acta med indones-indones j intern med 122 discussion this study investigated the influence of micronutrient supplementation on sputum conversion among tb patients. in the eight included studies, there was a significant difference in a treatment outcome, as reflected by sputum conversion of the intervention group (micronutrient supplementation group) as compared with that of the group that received no intervention. regarding the type of micronutrient, zinc, and retinol, supplementation had a statistically significant effect on sputum conversion. this was likely due to the role of retinol as a metabolite of vitamin a, the concentration of which is affected by the inflammatory status of the patient.26 the table 2. a descriptive summary of the eight studies. source study year country sample size study design micronutrient afzal et al. (11) 201817 2015 pakistan 120 120 vitamin d armijos et al. (12)18 2005 mexico 39 39 zinc and retinol jahnavi, 201019 2005 india 100 100 food supplement lawson, 201021 2003 nigeria 350 350 zinc and retinol martineau, 201322 2013 uk 126 126 vitamin d pakasi, 201023 2004 indonesia 300 300 zinc and retinol salahuddin, 201324 2009 pakistan 259 259 vitamin d tukvadze, 201525 2009 tbilisi 199 199 vitamin d table 3. risk of bias in randomized and stepped wedge studies. no component a fz al , 2 01 8 a rm ijo s, 2 01 0 la w so n, 2 01 0 ja hn av i, 20 10 m ar tin ea u, 2 01 3 p ak as i, 20 10 s al ah ud di n, 20 10 tu kv ad ze , 2 01 5 1 random sequence generation (selection bias) + + + + + + + + 2 allocation concealment (selection bias) ? + + + + + + + 3 blinding of participants and high-risk open-label research (performance bias) + + + + + + + 4 blinding of outcome assessment (detection bias) ? + + + ? + + 5 incomplete outcome data (attrition bias) ? + + + + + + + 6 selective reporting (reporting bias) + + + + + + + + 7 other bias ? ? ? ? ? note: high risk of bias: -; low risk of bias: +; unclear:? figure 2. pooled micronutrient consumption and sputum conversion. vol 52 • number 2 • april 2020 influence of micronutrient consumption by tb patients 123 findings of the present study are in contrast to those of a previous study, which found no difference in the rates of sputum conversion or radiographic improvements among tb patients receiving zinc or zinc plus retinol supplements as compared with those of patients receiving placebos.21 in the present study, vitamin d did not influence the treatment outcome. this finding is in accordance with that of previous research on vitamin d3.27 however, there is a wealth of observational epidemiological evidence linking vitamin d deficiency to an increased risk of reactivation disease, and many studies have suggested that vitamin d supplementation can be considered as combination therapy in patients with pulmonary tb.28-29 data are lacking in regards to daily dietary consumption of vitamin d, zinc, and retinol. there were several limitations to this study. first, it included a search of studies in only three databases (proquest, ebsco cinahl, and ebsco dentistry). second, the study included only open-access papers, with the result that two articles were excluded. third, the search was limited to only english and bahasa language studies, therefore excluding potentially relevant items in other languages. in terms of strengths, the selected databases are representative of studies in health science. also, this review included only original research and excluded grey literature or previous meta-analysis studies. figure 3. effect of pooled micronutrient consumption on sputum conversion based on the type of micronutrient. conclusion micronutrient supplementation during tb treatment had a positive effect on sputum conversion of tb patients. zinc and retinol influenced sputum conversion, whereas vitamin d did not. conflict of interest the authors declare that they have no competing 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with reduced rate of sputum culture conversion in multidrug-resistant tuberculosis patient in south africa. plos one. 2017;12(7):1-11. 15. shamseer l, moher d, clarke m, et al. preferred reporting items for systematic review and meta-analysis protocols (8) 2015 statement. bmj. 2015;349:1-25. 16. wells g, shea b, o’conell d, et al. the newcastleottawa scale (nos) for the quality of nonrandomized studies in meta-analysis canada: www.ohri.ca; 2014. 17. afzal a, rathore r, butt nf, randhawa fa. efficacy of vitamin d supplementation in achieving an early sputum conversion in smear-positive pulmonary tuberculosis. pakistan j med sci quarter. 2018;34(10):849-54. 18. armijos rx, weigel mm, chacon r, flores l, campos a. adjunctive micronutrient supplementation for pulmonary tuberculosis. salud publica de mexico. 2010;52(9):185-9. 19. jahnavi g, sudha c. randomised controlled trial of food supplementation in patients with newly diagnosed tuberculosis and wasting. singapore med. 2010;51(12):957-62. 20. lawson l, thacher td, yassin ma, et al. randomized controlled trial of zinc and vitamin a as con-adjuvants for the treatment of pulmonary tuberculosis. trop med int health. 2010;15(12):1481-90. 21. martineau ar. old wine in new bottles: vitamin d in the treatment and prevention of tuberculosis. the proceedings of the nutrition society. 2012;71(1):84-9. 22. pakasi ta, karyadi e, suratih nmd, et al. zinc and vitamin a supplementation fails to reduce sputum conversion time in severely malnourished pulmonary tuberculosis patients in indonesia. nutritional j. 2010;9(41):1-10. 23. masood ki, rottenberg me, salahuddin n, et al. expression of m. tuberculosis-induced suppressor of cytokine signaling (socs) 1, socs3, foxp3 and secretion of il-6 associates with differing clinical severity of tuberculosis. bmc infect dis. 2013;13:13. 24. tukvadze n, sanikidze e, kipiani m, et al. high-dose vitamin d3 in adults with pulmonary tuberculosis: a double-blind, randomized controlled trial. am j clin nutr. 2015;102:1059-69. 25. qrafli m, kari ke, aguenaou h, bourkadi je, sadki k, mzibri me. low plasma vitamin a concentration is associated with tuberculosis in moroccan population: a preliminary case-control study. bmc res notes. 2017;10:1-6. 26. ganmaa d, munkhzul b, fawzi w, et al. high-dose vitamin d3 during tuberculosis treatment in mongolia: a randomized controlled trial. am j resp crit care med. 2017;196(5):628-37. 27. wu h-x, xiong x-f, zhu m, wei j, zhuo k-q, cheng d-y. effects of vitamin d supplementation on the outcomes of patients with pulmonary tuberculosis: a systematic review and meta-analysis. bmc pulmonary med. 2018;18(108). 28. skodric-trifunovic v, blanka a, stjepanovic mi, et al. the health benefits of vitamin d relevant for tuberculosis. j med biochem. 2014;33:301-6. editorial 193acta med indones indones j intern med • vol 52 • number 3 • july 2020 covid-19 in indonesia: where are we? iwan ariawan1,2, hafizah jusril1,2 1 faculty of public health, universitas indonesia, depok, indonesia 2 reconstra utama integra, jakarta, indonesia. corresponding author: iwan ariawan, md., msph. faculty of public health universitas indonesia. ui campus depok 16424, indonesia. email: iariawan@ui.ac.id. in-country that has 265 million population1 and carrying a double burden due to changing pattern of morbidity, mortality and disability2, a prompt and effective disease control should be unarguable. by 3.5 months since the 1st case officially confirmed, indonesia recorded more than 1000 new cases daily. the national trend shows no sign of decrease as 19 september 2020 the report sets a new mark of 4000 new cases in a day.3 earlier this month, president jokowi affirms the national fatality (of detected positive cases) is above the global average.4 matching to decentralized governance, reported transmissions and responses on controlling it is observed varied across the regions. t h e c o n c e p t o f c o n t r o l l i n g d i s e a s e transmission relies on contacts suppression; and on the longer end, relies on vaccinations. as 27 september 2020, no vaccine is approved for use in the general population. until then, countries should implement early, widespread, and strict disease mitigation strategies. while much remains to be learned on covid-19, global evidence assert at least three strategies at the population level contributes to flatten the curve: mobility restriction, testing and isolation and rigorous contact-tracing.5-9 at the individual level, strict compliance on practising preventive behaviours: physical distancing, mask-wearing and proper handwashing, could reduce risk of infection.8,10 while many are struggling, some countries that have achieved low incidence of covid-19 exhibit exemplary disease surveillance and health information system. here in indonesia, both are works in progress; challenging the much-needed evidence-based actions. as such, how exactly indonesia works on suppressing this unprecedented pandemic gain us costly lessons learned. notably, the health information system must be strengthened to record disease discourse from contact to an outcome. reliable, quality and timely information system are unquestionably pivotal. this might sound obvious, but the fact that many covid-19 are asymptomatic11 and some would develop symptoms on the estimate of 2-14 days12 makes a substantial number of transmissions could go undetected; especially for countries that test only the symptomatic. some epidemiologists suggest indonesia does not yet have an epidemic curve, and the notion might not be baseless. analysis of covid-19 data shows testing delay between three to seven days13 implying report of positive cases is not a timely reflection of actual disease transmission on the field. for indonesia that is constrained by its limited testing capacity, delays or mistakes in disease control would be devastating, if not, catastrophic. indonesia is not on entire absences of actions, but the epidemic calls for more. the central government called for social distancing two weeks after the first case confirmed and regulation on the large scale social distancing (pembatasan sosial berskala besar/ psbb) that restrict non-essential population mobility is enacted by april 2020. the provincial government can declare psbb upon central government approval. the capital, dki jakarta, was first to act on school and business closures iwan ariawan acta med indones-indones j intern med 194 on mid-march then went full psbb on 10 april 2020. such mobility restrictions were found effective on suppressing transmission, the covid-19 effective reproduction number (rt) decreased from 2.0 in april 2020 to 1.2 in june 2020 when at least half population complying to staying at home.13-15 the rt steadily increased by june 2020 when it’s relaxed.13 understandably, mobility restriction is not feasible for the long run, but wuhan showcased an uncontrolled epidemic is damaging and traumatic for personnel, community and system. acknowledging strict and long term psbb is no longer a viable option, indonesia must outpace the transmission with other interventions. as mentioned, suppressing covid-19 transmissions demands population involvement to comply and be discipline on proven effective preventive behaviours: physical distancing, proper mask-wearing and handwashing with soap.8,10 to our knowledge, there is no systematic measurement of preventive measures coverages in the population. some telephone-based and online surveys reported high coverage of face mask use. nevertheless, direct interview of preventive measures tends to have social desirability bias.16 our model indicates only high coverage of preventive measures compliance coupled with high coverage of testing, tracing and isolation would result in a decrease on rt.14 similar to the documentation on preventive behaviours, there is no periodic information of these three indicators yet. s u c h l i m i t a t i o n o n s u r v e i l l a n c e a n d information system intensifies needs on indonesia health systems strengthening. recent evidence outlines test, tracing and isolation are effective in suppressing covid-19 transmission.8,17,18 minimizing testing and tracing delay, less than four days with coverage of 80% close contacts could prevent and reduce onwards transmission.18 the evidence base for tracing delay and tracing ratio in indonesia is hindered by limited of data. but the frail disease surveillance and detected reporting delays implies testing delay remains an issue, and contact tracing is inadequate. no or weak contact tracing would let the chain of transmission free and undetected; opening possibility of transmission would grow exponentially.19 that we need to more is indisputable. the vaccine is not a magic bullet; it is a long-term control measure and should be a complete series of careful and precise examinations. indonesia will also likely require high coverage of vaccination to achieve herd immunity. at present, if there is no significant improvement in the coverage of preventive measures in the population and disease surveillance system, our hospital will be overwhelmed, and case fatality will be devastating. references 1. badan pusat statistik. statistik indonesia 2019. jakarta: badan pusat statistik; 2019. 2. mboi n, murty surbakti i, trihandini i, et al. on the road to universal health care in indonesia, 1990&#x2013;2016: a systematic analysis for the global burden of disease study 2016. lancet. 2018; 392 (10147):581-91. 3. satuan tugas penanganan covid-19. perkembangan kasus terkonfirmasi positif covid-19 per-hari. 2020. https://covid19.go.id/peta-sebaran2020). 4. muthiariny d. jokowi admits indonesia’s covid-19 fatality rate higher than global average. tempo. 2020 2 september 2020. 5. bayham j, fenichel ep. impact of school closures for covid-19 on the us health-care workforce and net mortality: a modelling study. lancet publ health. 2020; 5(5): e271-e8. 6. lau h, khosrawipour v, kocbach p, et al. the positive impact of lockdown in wuhan on containing the covid-19 outbreak in china. j travel med. 2020; 27(3). 7. ferguson n, laydon d, nedjati gilani g, et al. report 9: impact of non-pharmaceutical interventions (npis) to reduce covid19 mortality and healthcare demand. 2020. 8. kucharski aj, klepac p, conlan ajk, et al. effectiveness of isolation, testing, contact tracing, and physical distancing on reducing transmission of sars-cov-2 in different settings: a mathematical modelling study. lancet infect dis. 2020. 9. bi q, wu y, mei s, et al. epidemiology and transmission of covid-19 in 391 cases and 1286 of their close contacts in shenzhen, china: a retrospective cohort study. lancet infect dis. 2020. 10. chu dk, akl ea, duda s, et al. physical distancing, face masks, and eye protection to prevent person-toperson transmission of sars-cov-2 and covid-19: a systematic review and meta-analysis. lancet. 2020; 395(10242):1973-87. 11. li r, pei s, chen b, et al. substantial undocumented infection facilitates the rapid dissemination of novel vol 52 • number 3 • july 2020 covid-19 in indonesia: where are we? 195 coronavirus (sars-cov2). science 2020. 12. world health organization. coronavirus disease 2019 (covid-19) situation report – 73. world health organization; 2020. 13. ariawan i, riono p, farid mn, jusril h, wahyuningsih w. covid-19 di provinsi dki jakarta. jakarta indonesia; 2020. 14. ariawan i, riono p, farid mn, jusril h. an epidemiologic model for covid-19 post-psbb in indonesia. jakarta: fkm ui, 2020. 15. ariawan i, riono p, farid mn, jusril h. pembatasan sosial di indonesia: apakah ada dampaknya terhadap epidemi covid-19? jakarta; 2020. 16. phillips dl, clancy kj. some effects of “social desirability” in survey studies. am j sociol. 1972; 77(5):921-40. 17. cheng h-y, jian s-w, liu d-p, et al. contact tracing assessment of covid-19 transmission dynamics in taiwan and risk at different exposure periods before and after symptom onset. jama intern med. 2020. 18. kretzschmar me, rozhnova g, bootsma mcj, van boven m, van de wijgert jhhm, bonten mjm. impact of delays on effectiveness of contact tracing strategies for covid-19: a modelling study. lancet publ health. 2020;5(8):e452-e9. 19. macintyre cr. case isolation, contact tracing, and physical distancing are pillars of covid-19 pandemic control, not optional choices. lancet infect dis. 2020; 20(10):1105-6. clinical practice 78 acta medica indonesiana the indonesian journal of internal medicine management of hypertension in pregnancy nurike s. mudjari, nur samsu department of internal medicine, faculty of medicine, university of brawijaya saiful anwar hospital, malang, indonesia. correspondence mail: department of internal medicine, faculty of medicine, university of brawijaya saiful anwar hospital. jl. jaksa agung suprapto no. 2, malang 65111, indonesia. email: nurike_k@yahoo.com. abstrak mortalitas maternal akibat hipertensi mencapai 16% bila dibandingkan dengan penyebab lain seperti sepsis, perdarahan maupun abortus. ibu hamil dengan hipertensi berpotensi mengalami sejumlah komplikasi antara lain koagulasi intravaskular diseminata (kid), perdarahan otak, gangguan fungsi hati, dan gagal ginjal akut. sedangkan pada janin dapat berakibat pertumbuhan janin terhambat, prematuritas dan mortalitas perinatal. hipertensi pada kehamilan perlu ditatalaksana dengan baik agar dapat menurunkan angka morbiditas serta mortalitas ibu dan janin, yaitu dengan menghindarkan ibu dari resiko peningkatan tekanan darah, mencegah perkembangan penyakit dan mencegah timbulnya kejang dan pertimbangan terminasi kehamilan jika ibu atau janin dalam keadaan bahaya. kata kunci: tekanan darah, hipertensi, eklamsia, preeklamsia, ibu hamil, gestasional. abstract hypertension-related maternal mortality reaches 16% when it is compared to other causes of maternal mortality such as sepsis, bleeding or abortus. pregnant women with hypertension disorder are at increased risk for experiencing numerous complications including disseminated intravascular coagulation (dic), cerebral hemorrhage, liver dysfunction and acute renal failure; while to the fetus, it may cause intrauterine growth retardation, prematurity and perinatal mortality. hypertension in pregnancy should be managed appropriately to reduce maternal and fetal morbidity and mortality rate, i.e. by preventing women from getting the risks of increased blood pressure, preventing disease progression and preventing the development of seizure and considering termination of pregnancy in lifethreatening situation for maternal and fetal health. key words: blood pressure, hypertension, eclampsia, preeclampsia, pregnant women, gestational. introduction the prevalence of pregnancy-related hypertension in well-developed countries varies between 10-20% and it is the most important cause of maternal and fetal morbidity and mortality.1 currently, maternal mortality due to hypertension reaches 16% in addition to other causes such as sepsis, bleeding or abortus.2 pregnant women with hypertension are at increased risk for experiencing numerous complications such as disseminated intravascular coagulation (dic), cerebral hemorrhage, liver dysfunction and acute renal failure; while to the fetus, it may cause intrauterine growth retardation, prematurity and perinatal mortality.3 pathogenesis of preeclampsia (pe) is quite complex involving genetic, immunologic and environmental factors. the development of pe vol 47 • number 1 • january 2015 management of hypertension in pregnancy 79 is categorized into 2 stages including abnormal placentation and maternal syndrome.4 the classification of hypertension in pregnancy that has been commonly used is the one proposed by the national high blood pressure education program working group on hypertension in pregnancy (nhbpep), in which hypertension is defined as blood pressure that is ≥140/90 mmhg.5 numerous problems may develop on the management of hypertension in pregnancy including indication of treatment, target blood pressure that should be achieved, maternal and fetal side effects of antihypertensive drugs.6 observational studies in patients with mild chronic hypertension demonstrate that the risk of pregnancies are: preeclampsia (l025%), abruptio (0.7-l.0%), premature birth less than 37 weeks (12-34%) and intrauterine fetal growth (8-16%). the risk increases in severe chronic hypertension during the first trimester since the risk of experiencing preeclampsia increases up to 50%. to the fetus, hypertension causes increased risk of intrauterine growth retardation, prematurity and intrauterine death. moreover, common risks of hypertension such as heart failure, encephalopathy, retinopathy, cerebral hemorrhage and acute renal failure may also occur. however, it should be noted that the benefit of hypertension treatment during pregnancy depends on the severity of the disease. physiologically, blood pressure begins to fall inn the second trimester, which may reach mean blood pressure of 15 mmhg lower than the systolic blood pressure before the third trimester of pregnancy. the fall occurs either in subjects with normal blood pressure (normotension) or those with chronic hypertension. hemodynamical changes, altered renal anatomy and physiology and body adaptation that occur during pregnancy cause early detection can be difficult.7 altered renal anatomy and function during pregnancy the changes that occur during pregnancy include increased kidney size of ±1 cm, increased kidney volume by 30% and physiological hydronephrosis that appears until 12 weeks post-partum. in addition, the physiological changes that occur during pregnancy include systemic vasodilation characterized by a significant reduction in systolic blood pressure (sbp) ≥10 mmhg due to local mediators such as prostacyclin and nitric oxide (no), in which the lowest blood pressure is reached at the gestational age of 22-24 weeks. this condition causes body adaptation by increasing the secretion of reninangiotensin aldosterone (raa) that may lead to vasoconstriction, volume and plasma retention, as well as potassium excretion in the urine. at the same time, to protect the mother and fetus of an excessive increase in the raa, the body will increase the resistance to the effects of angiotensin ii with a reduced amount of angiotensin ii receptor accompanied by the production of prostacyclin and no. at 28 weeks gestation, blood pressure began to rise while still under the blood pressure before pregnancy. increase in renal plasma flow (rpf) and glomerular filtration rate (gfr) may reach 45% and experienced a peak in the first trimester which causes a decrease in serum creatinine to a range of 0.5 0.8 mg/dl.4 current definition of hypertension is the one used by the national high blood pressure education program working group on hypertension in pregnancy (nhbpep), i.e. a blood pressure ≥140/90 mmhg or dbp ≥90 mm hg, or an increase in sbp ≥30 mmhg and/ or dbp >15 mmhg from the previous measurement, which is measured twice with an interval between measurement of ≥6 hours.8 ideal blood pressure measurement is recommended to be performed at home or known as the ambulatory blood pressure monitoring (abpm) and the pulse wave analysis (pwa) measurement.9,10 some literatures differentiate blood pressure based on blood pressure levels, namely mild hypertension for sbp between 140-159 mmhg or dbp between 99-109 mmhg. hypertension is considered to be severe when the sbp ≥160 mmhg or dbp ≥110 mmhg.4,11-13 the purpose of nhbpep classification is to differentiate preeclampsia from eclampsia of other hypertensive disorders in pregnancy since both preeclampsia and eclampsia have a poor prognosis on maternal and fetal morbidity and mortality.14 the diagnosis criteria of hypertensive disorder in pregnancy are as follows:14,15 nurike s. mudjari acta med indones-indones j intern med 80 chronic hypertension chronic hypertension is defined as sbp ≥140 mmhg or dbp ≥90 mmhg that is observable before pregnancy or before the 20th week of gestation. it can be found at the gestational age of >20 weeks or persist in 12 weeks postpartum. the incidence of chronic hypertension is estimated 1-5% of pregnancies depending on age and ethnicity/race. recent reports reported that the incidence occurs on afro-american race and it is 1% for other races. gestational hypertension it is a hypertension characterized by sbp ≥140 mmhg or dbp ≥ 90 mmhg that develops for the first time at the gestational age of ≥ 20 weeks, without proteinuria or any signs and symptoms of preeclampsia; usually the blood pressure back to normal in 42 days post partum. patients with gestational hypertension are at risk of having hypertension in their next pregnancy and it can develop into preeclampsia. preclampsia a. minimal criteria. when there is sbp ≥140 mmhg or dbp ≥90 mmhg at >20 weeks of gestation, along with proteinuria ≥300 mg/24 hour or ≥ +1 on dipstick urinalysis or protein: creatinine ratio in the urine ≥0.3. b. additional criteria that support the diagnosis. blood pressure ≥160/110 mmhg, proteinuria 2.0 g/24 hour or ≥ +2 on dipstick urinalysis, creatinine serum level of >1.2 mg/ dl, platelet count <100,000, microangiopathy hemolysis, increased transaminase serum level, headache, cerebral or other visual disorders. preeclampsia itself can be classified into 2 categories, namely mild preeclampsia and severe preeclampsia. mild preeclampsia is the preeclampsia with sbp <160 mmhg or dbp 90-<110 mmhg. it is called severe preeclampsia when we found one of the following signs in the patients: sbp ≥160 mmhg and dbp ≥110 mmhg, proteinuria ≥5 g/24 hours or 4+ on dipstick urinalysis, creatinine serum level >1.2 mg/dl, microangiopathy hemolysis, oliguria, cyanosis and pulmonary edema, increased transaminase serum level, other cerebral or visual disorders, persistent epigastric pain, platelet counts <100,000 cells/mm; increased liver enzymes (alanin aminotransferase (alt) or aspartate aminotransferase (ast); hemolysis – which is best known as the hellp syndrome. eclampsia when there is any unexplainable seizure in a woman who had preeclampsia. preeclampsia superimposed on chronic hypertension the possibility of chronic hypertension becomes preeclampsia/eclampsia is 1530%.16,17 we should suspect for superimposed preeclampsia when we find out the following symptoms and laboratory abnormalities: a sharp increase of blood pressure (>160/110 mmhg), severe proteinuria (or 2 gram/day), a sudden increase of blood pressure after a period of controlled blood pressure and increased serum creatinine level over 1.2 mg/dl. the management of preeclampsia superimposed on chronic hypertension is similar with the general management of preeclampsia. nagay et al.18 observed phenotypic changes in the cells of smooth muscle afferent artery of the renal glomerulus in patients with chronic hypertension who also experienced preeclampsia. by immunohistochemistry, they demonstrated the occurrence of reduced contractile protein (antimonoclonal smooth miscle cell myosin heavy chain isoform antibodies = sm2) in afferent glomerular arteries of patients with preeclampsia superimposed on chronic hypertension.18,19 diagnosis of preeclampsia preeclampsia is characterized by hypertension which occurs at >20 gestation, along with proteinuria and the symptoms resolve after birth. proteinuria is defined as the excretion of protein in the urine of ≥300 mg/24 hour, or protein: creatinine ratio ≥0.3, or when there is a persistent protein finding of 30 mg/dl on random urinalysis (+1 on dipstick urinalysis). preeclampsia occurs in 6% of pregnancies, usually primigravida. moreover, preeclampsia is classified as mild and severe preeclampsia, in which both should be managed differently.14 the following factors increase the risk of preeclampsia: vol 47 • number 1 • january 2015 management of hypertension in pregnancy 81 1. risk factors associated with the male partner, such as: primigravida, primipaternity, age of extremes (too young or too old for pregnancy), male partner who had married a woman and the woman became pregnant and had preeclampsia, limited exposure to sperm, insemination donor and oocyte donor. 2. risk factors associated with past medical history and family history of the disease, such as: history of previous preeclampsia, c h r o n i c h y p e r t e n s i o n , r e n a l d i s e a s e , obes ity, gestational diabetes, type-1 dm, antiphospholipid antibodies and hyperhomocysteinemia 3. risk factors associated with pregnancy, such as: mola hydatidosa, multiple pregnancies, urinary tract infection in pregnancy, hydrops fetalis. platelet count). measurements of ast, alt and ldh enzymes are performed in order to identify liver involvement. urinalysis is necessary to identify proteinuria or to quantify the amount of protein excretion in the 24-hour urine. creatinine serum level is measured to identify renal function in pregnancy and usually decreased level can be found. the measurement of uric acid should be considered since elevated uric acid level is usually used as a marker of preeclampsia severity. ecg test is necessary in patients with chronic hypertension; while for pregnancies without hypertension, the measurement of blood glucose and urine culture are also necessary. laboratory investigation for patients with hypertension in pregnancy include: hemoglobin and hematocrit level, platelet count, sgot/ sgpt, ldh serum level, protein urine (24-hour urine collection), urinalysis, uric acid, and serum creatinine level.20 if new hypertension develops during pregnancy in women who are previously healthy or in those who are at high risk for preeclampsia, an evaluation of short-term hospitalization is necessary to distinguish primary hypertension from the secondary hypertension using diagnostic procedure and subsequently determine the classification of hypertension in pregnancy as well as execute appropriate treatment. the assessment of target organ damage includes left ventricular hypertrophy, retinopathy and renal disease. some authors suggest adrenal ultrasonography and measurement of metanephrine and noremetanephrine in the urine for all pregnant women when their hypertension is caused by pheochromocytoma that may appear asymptomatic and may be fatal if the diagnosis can not be made before birth.21 usg is useful to determine gestational age, fetal development and fetal heart rate. any abnormality in doppler assessment of uterine artery and fetal artery as well as the venous doppler is useful as a predictor of preeclampsia development and perinatal outcomes.10 management of hypertension in pregnancy the aim of managing hypertension in pregnancy is to reduce fetal and maternal tabel 1. diagnostic criteria for severe preeclampsia4,14 symptoms • central nervous system disorders such as blurred vision or severe headache • stretched liver capsule that causes pain signs • sbp ≥160 mmhg or dbp ≥110 mmhg • stroke • intrauterine growth retardation (iugr) • pulmonary edema • cortical blindness laboratory findings • proteinuria >5 g/day • oliguria <500 ml/ day and /or creatinine serum level ≥1.2 mg/dl • hellp syndrome • liver damage with transaminase serum level ≥ 2x of normal range • platelet count <100.000/mm3 • coagulopathy, elongated prothrombin time or low fibrinogen blood level. laboratory investigation in addition to blood pressure monitoring, laboratory investigation is also necessary to monitor any changes in blood, kidney and liver that may affect fetal and maternal prognosis. the recommended laboratory investigations to monitor patients with hypertension in their pregnancies are hb or ht to observe the possibility of hemoconcentration that support the diagnosis of gestational hypertension. a very low platelet count can be found in hellp syndrome (hemolysis, elevated liver enzyme levels and low nurike s. mudjari acta med indones-indones j intern med 82 morbidity and mortality, i.e. by preventing women from getting the risks of increased blood pressure, preventing disease progression and preventing the development of seizure and considering termination of pregnancy if the mother or fetus has a life-threatening situation. the management of pregnancy with hypertension can be seen in table 2. in preeclampsia, the hypertension resolves to normal condition after birth. however, before birth, this condition is unfavorable for the fetus. therefore, although it carries a certain degree of risk, conservative treatment is preferable by waiting to the best situation when the baby can be born in a better condition. when the range of systolic blood pressure is 140-160 or the diastolic blood pressure is 9099 mmhg, non-pharmacologic treatment can be administered. short-term hospitalization is useful for establishing diagnosis and excluding the possibility of preeclampsia. the management depends on clinical condition, the severity of hypertension, gestational age, maternal and fetal risks. it may include close monitoring, physical activity restriction, bed rest on the left side. for this condition, a normal diet without salt restriction is recommended. pharmacological treatment the administration of antihypertensive agents should be adjusted individually with the risks and benefits for pregnant women. there are still debates on when starting antihypertensive therapy and on the target blood pressure that should be achieved. severe hypertension (bp ≥160/100 mmhg) increases cerebrovascular risks and therefore, antihypertensive agents should be administered.6 however, the use of these agents for mild and moderate hypertension is still controversial. some studies show that the use of antihypertensive agents in mild hypertension can reduce the risk of developing severe hypertension; however, there is no difference regarding the development of preeclampsia, neonatal death, premature birth and low birth weight (lbw) infants.22,23 the national high blood pressure education program working group on hypertension in pregnancy (nhbpep) recommends the administration of antihypertensive agents for sbp ≥150-160 mmhg or dbp >100-110 mmhg or when there is target organ damage, such as left ventricular hypertrophy or reduced renal function. the desired target blood pressure is sbp <140150 mmhg and dbp <90-100 mmhg table 2. management of pregnancy with gestational hypertension12 degree of hypertension mild hypertension (140/90 to 149/99 mmhg) moderate hypertension (150/100 to 159/109 mmhg) severe hypertension (160/110 mmhg or higher) admit to hospital no no yes (until blood pressure is 159/109 mmhg or lower) treat no with oral labetalol as firstline treatment to keep: with oral labetalol as firstline treatment to keep: • diastolic blood pressure between 80-100 mmhg • systolic blood pressure less than 150 mmhg • diastolic blood pressure between 80-100 mmhg • systolic blood pressure less than 150 mmhg measure blood pressure not more than once a week at least twice a week at least four times a day test for proteinuria at each visit using automated reagent-strip reading device or urinary protein creatinine ratio at each visit using automated reagent-strip reading device or urinary protein creatinine ratio daily using automated reagent-strip reading device or urinary protein creatinine ratio blood tests only those for routine antenatal care test kidney function electrolytes full blood count, transaminases bilirubin do not carry out further blood tests if no proteinuria at subsequent visits test at presentation and then monitor weekly: kidney function electrolytes full blood count, transaminases bilirubin vol 47 • number 1 • january 2015 management of hypertension in pregnancy 83 or mean arterial pressure (map) <105-125 mmhg. there has not been any definitive and complete data on the safety of target therapy for blood pressure treatment in pregnant women with hypertension.10,24 in patients with chronic hypertension who are being pregnant and having high blood pressure, their previous treatment should be continued. however, in those with slightly high blood pressure, the treatment must be given with caution and dose reduction should be employed whenever necessary. based on data of some studies, it has been demonstrated that the use of antihypertensive agents for mild hypertension may reduce the development of severe hypertension, but show no difference on the development of preeclampsia, neonatal death, premature birth and low birth weight (lbw) infants.22,23 extremely low blood pressure may develop risk of reduced utero-placental perfusion, which may disrupt fetal development. however, there has not been sufficient convincing evidence on the benefit of mild hypertension treatment in pregnancy since the number of studied cases is still very low and therefore, it is not enough to demonstrate the benefit of reduced obstetric complication rate. systolic blood pressure of more than 170 or diastolic blood pressure higher than 110 mmhg in pregnant woman must be considered as a medical emergency and the patient is suggested to have hospital care. a patient with such condition must have her blood pressure reduced as soon as possible. many doctors do not give any drug until the limit of diastolic blood pressure reaches >105-110 mmhg or when the systolic blood pressure has reached 160 mmhg, a limit in which complication of cerebral hemorrhage usually takes place. however, in some conditions, the limit is not so accurate considering that the previous diastolic pressure is less than 75 mmhg. in gestational hypertension (without proteinuria), the limit of blood pressure that calls for treatment usually is above 140 mmhg systolic blood pressure or 80 mmhg diastolic blood pressure. in those who have hypertension and proteinuria or who have symptoms or who have signs of target organ damage (chronic hypertension), the drugs can be given to achieve the normal blood pressure. there are 2 types of antihypertensive drugs, namely for acute or emergency situation, which usually needs parenteral or oral treatment. table 3. management of pregnancy with preeclampsia12 degree of hypertension mild hypertension (140/90 to 149/99 mmhg) moderate hypertension (150/100 to 159/109 mmhg) severe hypertension (160/110 mmhg or higher) admit to hospital yes yes yes treat no with oral labetalol as firstline treatment to keep: with oral labetalol as firstline treatment to keep: • diastolic blood pressure between 80-100 mmhg • systolic blood pressure less than 150 mmhg • diastolic blood pressure between 80-100 mmhg • systolic blood pressure less than 150 mmhg measure blood pressure at least four times a day at least four times a day more than four times a day, depending on clinical circumstances test for proteinuria do not repeat quantification of proteinuria do not repeat quantification of proteinuria do not repeat quantification of proteinuria blood tests monitor using the following tests twice a week: kidney function, electrolytes, full blood count, transaminases, bilirubin monitor using the following tests three times a week: kidney function, electrolytes, full blood count, transaminases, bilirubin monitor using the following tests three times a week: kidney function, electrolytes, full blood count, transaminases, bilirubin nurike s. mudjari acta med indones-indones j intern med 84 tabel 4. antihypertensive drugs in pregnancy antihypertensive drugs explanation βadrenergic agonist dosing: 0.75-3 g/day divided in 3 doses (tid) methyldopa (risk factor: b) is the first-line antihypertensive drug in pregnancy side effects: dysrhythmia, weakness, sedation, depression, reduced mental stability, dry mouth, decrease in libido, parkinsonism, and hyperprolactinemia, increased serum transaminase level and hemolytic anemia calcium channel antagonists nifedipine (risk factor: c) is a second-line drug dosing: 30 mg-120 mg/day with extended-release formulation short-acting nifedipine may cause maternal hypotension and fetal distress; therefore it is not recommended. the administration of mgso4 in pregnant women who had received ccb may cause severe hypotension and neuromuscular blockade verapamil (risk factor: c) effective and safe for preventing tachycardia effect caused by the β mimetic and relaxation effect on uterine muscle tissues vasodilator hydralazine (risk factor: c) is an arterial vasodilator, which is often used in pregnancy due to its minimum hypotension effect. dosing: 75150 mg/ day, divided in 3 doses side effects: lupoid-like syndrome, thrombocytopenia in newborns βadrenenoceptor antagonists labetolol (risk factor: c) is a combination of alpha and beta adrenoceptor antagonist with vasodilation effect, can reduce blood pressure without lowering uteroplacental blood flow. no side effect of inhibited fetal growth or hypoglycemia in newborns dosing 200 mg – 2.5 gram/day, divided in 2 doses. atenolol (risk factor: c) is likely to have side effect of lbw infants; therefore, it should be avoided in early pregnancy. diuretics the use of diuretics as antihypertensive drugs is permitted only if it has been used for a long period of time before pregnancy. loop diuretics, particularly furosemide (risk factor: c) is indicated for severe heart failure, pulmonary edema or oliguria and if there is a risk of hyperbilirubinemia in newborns. the use of hct (hydrochlorothiazide) (b) may cause side effects of neonatal thrombocytopenia, jaundice, maternal pancreatitis, hypokalemia, hyponatremia, in which some studies show that the side effect is similar with those who do not receive diuretic treatment. dosing: hct 12.5-50 mg/day spironolactone is contraindicated for pregnancy due to its antiandrogenic effect as observed in animal experimental studies. ace inhibitor and angiotensin ii receptor (arb) antagonists risk factor: c on the 1st trimester and d on the 2nd and 3rd trimester it has risks of oligohydroamnion, intrauterine growth retardation, pulmonary hypoplasia, contracture of joints, neonatal renal failure, hypotension it carries potential risk for any woman who is planning a pregnancy the parenteral drugs include intravenous injection of abetalol, hydralazine and calcium antagonists. methyldopa 250 mg twice daily can be increased up to maximal 4 gram daily. labetalol can be given 100 mg twice daily and maximum 400 mg daily. atenolol, a beta blocker, which no effect of alpha blocker is associated with reduced placental and fetal blood flow during the birth when it is given starting from the early pregnancy. labetalol, an alpha and beta blocker, can maintain uteroplacental blood flow in maximal condition. a beta blocker drug used for mild hypertension may increase the risk of having small-for-gestational-age infants (with a relative risk of 1.35 on 95% confidence interval), a risk that is not higher compared to other antihypertensive drugs. more experiences have been found on using calcium antagonists, which have been proven relatively safe for pregnancy. longacting nifedipine (maximum dose of 120 mg/ day) and non-dihydropiridin, i.e. verapamil can vol 47 • number 1 • january 2015 management of hypertension in pregnancy 85 be given. however, fda does not accept fastacting nifedipine as a treatment for emergency hypertension as well as the sub-lingual treatment as some evidences have demonstrated that the treatment may cause excessive reduction in blood pressure. it can be concluded from studies on treatment of hypertension in pregnancy that the selection of antihypertensive treatment should depend on experiences and knowledge of doctor who is treating the patient, particularly in terms of the maternal and fetal effect of the drug. although there is no clinical study that provides any evidence of how much reduction in blood pressure is considered to be optimal, many have suggested a target systolic blood pressure of 140-150 mmhg and diastolic blood pressure of 90-100 mmhg. in pregnant women who have experienced target organ damage, it is suggested to reduce the blood pressure to less than 140/90 mmhg until it reaches 120 and 80 mmhg. i n d i c at i o n f o r o u t pat i e n t a n d hospital management according to bcrcp obstetric guideline 11 hypertension in pregnancy 2006, the following are indications for outpatient and hospital management of hypertension in pregnancy:3 1. indications for outpatient assessment: sbp <140 mmhg and dbp <90 mmhg, proteinuria ≤1+ on dipstick urinalyisis on one occasion, no target organ damage and normal platelet counts. weekly office visits. 2. indications to consider hospitalization. sbp ≥140 mmhg and/or dbp ≥90 mmhg, repeated proteinuria >1+, creatinine >30 mg/mmol, hyperuricemia, platelet count <100,000, any adverse features, ultrasound evidence of oligohydroamnios or inadequate fetal growth. 3. indication for conservative management and termination of pregnancy indication for conservative management: • gestational age < 34 weeks • s table and wellcontr olled blood pressurel (sbp <160 mmhg/ dbp <110 mmhg) with atwo antihypertensive agents on submaximal dose • platelet count ≥100,000 • proteinuria ≤2+ on dipstick (<1 g/day) • good fetal condition (on usg, stress test) indication for termination of pregnancy: • gestational age >34 weeks • severe or refractory hypertension >24 hours • pulmonary edema • refractory renal failure • t h r o m b o c y t o p e n i a , w o r s e n i n g coagulopathy • eclampsia with neuroprogressive symptoms • progressive reduction of liver function • placental rupture • fetal distress • evidences of iugr or hydramnion post partum hypertension hypertension may develop after birth with a peak on the 3rd – 6th day due to mobilization of extracellular fluid that occur during pregnancy and a continuation of hypertension in pregnancy. the risks of developing post partum hypertension may arise in pregnancy with preeclampsia, premature birth, multipara women with a high level of uric acid and blood urea nitrogen (bun). some literatures explain that severe hypertension, which occurs both during pregnancy and after birth, should be treated. methyldopa should be avoided after birth due to a risk of post-natal depression. the common first-line agents are atenolol, nifedipin or ace inhibitor whenever other antihypertensive agents are necessary. antihypertensive treatment for preeclampsia lasts for approximately 2 weeks; while for gestational hypertension, it lasts less than a week. preeclampsia is a risk factor for post-partum thromboemboli; while other risk factors include obesity, bed rest of >4 days after birth and caesarian section. prevention of thromboemboli should be considered unless it is proven to be ineffective.15,25 conclusion a pregnant mother with hypertension has potential risks to have some complications, such as: disseminated intravascular coagulation nurike s. mudjari acta med indones-indones j intern med 86 (dic), cerebral hemorrhage, liver dysfunction and acute renal failure. moreover, for the fetus, it may cause intrauterine fetal growth retardation, prematurity and perinatal mortality. the β-adrenergic agonist, namely methyldopa (risk factor: b) is the first-line antihypertensive drug in pregnancy. although there is no clinical study that provides any evidence of how much reduction in blood pressure is considered to be optimal, many have suggested a target systolic blood pressure of 140-150 mmhg and diastolic blood pressure of 90-100 mmhg. in pregnant women who have experienced target organ damage, it is suggested to reduce the blood pressure to less than 140/90 mmhg until it reaches 120 and 80 mmhg. references 1. umans jg. hypertension in pregnancy. in: lip gyh, hall je, eds. new york: mosby elsevier; 2007. p. 6679. 2. khan ks, woddyla d, say l, et al. who analysis of causes of maternal death: a systematitic review. lancet. 2006;367:1066. 3. bcrcp obstretric guidelines 11 hypertension in pregnancy (www.rcp.gov.bc.ca), 2006. 4. kaplan nm. hypertensive with pregnancy and the pill. in: kaplan nm, victor rg, eds. clinical hypertension. 10th ed. lippincot williams & willkins. 2010;15:41130. 5. brown ma. diagnosis and classification of preeclamsia and other hypertensive disorders of pregnancy. in: belfort ma, thornton s, saade gr, eds. hypertension in pregnancy. 1st ed. new york: marcel dekker; 2002. p. 1-16. 6. folic m, folic n, varjacic m, jocovjevic m, jancovic s. antihypertensive drug therapy for hypertensive disorders in pregnancy. asta med medicin. 2008;47(3): 65-72. 7. mccarthy fg, kenny lc. hypertension in pregnancy. curr obs & gynecol. 2009;16(3):315-20. 8. levine rj, ewel mg, hauth jc, et al. should definition of preeklamsia include a rise in diastolic blood pressure of >90 mmhg in association with proteinuria? am j obstet gynecol. 2000;183:787-92. 9. feldman d. ambulatory blood pressure during pregnancy. in: white wb, ed. clinical hypertension and vascular disease. humama press inc. 2007;15: 369-87. 10. chichel ls, breborowicz gh, tykarski a. treatment of arterial hypertension in pregnancy. arch perina med. 2007;13(2):7-16. 11. nice guidelines. hypertension in pregnancy: the management of hypertensive disorders during pregnancy. 2009. available online: www.nice.org.uk. 12. nice guidelines. hypertension in pregnancy: the management of hypertensive disorders during pregnancy. 2010. available online: www.nice.org.uk. 13. ferris th. hypertension and preeclamsia. medical complication during pregnancy. in: burrow gn, ferris tf, eds. 4th eds. philadelphia: w.b. sounders co.; 1995. p. 1-22. 14. cunningham fg. pregnancy hypertension. in: william o, ed. 23rd ed. new york: mcgraw hill co.; 2010. p. 706b-756b. 15. working group report on high blood pressure in pregnancy. j clin hyper. 2001;3(2):75-88. 16. august p, lindheimer md. chronic hypertension. in: lindheimer md, roberts jm, cunningham fg, eds. chesley’s hypertensive disorders in pregnancy. 2 nd ed. stanford: appleton & lange; 2009. p. 60533. 17. gibson p, carson m. hypertension and pregnancy. 2002. available online: http//www.e.medicine. specialties.com. 18. nagay y. renal vascular walls in patient preeclamsia. am j kidney dis. 2001;37(4):728-35. 19. parlindungan s. hypertensi pada kehamilan. simposium penatalaksanaan kedaruratan di bidang ilmu penyakit dalam ii. jakarta: pusat penerbitan ilmu penyakit dalam fkui/rs cipto mangunkusumo; 2002. p. 117-26. 20. chifkova r. hypertension in pregnancy. in: mancia g, grassi g, kjeldesen se, eds. manual of hypertension of european society of hypertension. 1st ed. london: informa healthcare; 2008. p. 281-7. 21. rossi gp, seccia tm, pessina ac. clinical use of laboratory test for identification of secondary form of arterial hypertension. crit rev clin lab sci. 2007;44:1-85. 22. abalos e, duley l, steyn d, henderson-smart d. antihypertensive drugs therapy for mild to moderate hypertension during pregnancy. cochrane database syst rev. cd002252; 2007. 23. von dadelszen p, magee la. antihypertensive drug therapy for hypertensive in pregnancy preeclamsia. clin obstet gynecol. 2005;48:441-59. 24. william k. hypertension in pregnancy. british columbia reproductive care program; 2000. 25. jogc guidelines. diagnosis, evaluation and management of the hypertensive disorders of pregnancy: treatment of hypertensive disorder of pregnancy. jogc. 2008;32:s34-s35. 290 original article acta med indones indones j intern med • vol 51 • number 4 • october 2019 plasma concentrations of adiponectin in patients with coronary artery disease and coronary slow flow muhammad diah1, aznan lelo2, dharma lindarto3, zulfikri mukhtar4 1 faculty of medicine, universitas sumatera utara, medan, indonesia. 2 department of pharmacology, faculty of medicine universitas sumatera utara, medan, indonesia. 3 department of internal medicine, faculty of medicine universitas sumatera utara, medan, indonesia. 4 department of cardiology, faculty of medicine universitas sumatera utara, medan, indonesia. corresponding author: muhammad diah, md., phd. faculty of medicine, universitas sumatera utara. jl. dr. mansyur no. 5, medan, indonesia. email: diah6262@gmail.com. abstrak latar belakang: adiponektin, hormon yang disekresikan oleh adiposit yang berperan pada homeostasis energi dan memiliki efek antiinflamasi, antioksidan, endothelium serta efek protektif terhadap endotelium dan miokard dengan fungsi regulasi yang positif terhadap mikrosirkulasi koroner. meskipun secara fisiologis peran adiponektin masih belum diketahui secara pasti,namun adiponektin berperan pada proses inflamasi atau metabolisme lipid, yang berkontribusi terhadapa proses aterosklerosis. pada studi ini, kami melakukan evaluasi kadar konsentrasi adiponektin pada pasien cad, aliran darah lambat dan subjek sehat. metode: penelitian ini dilakukan dengan design cross-sectional yang melibatkan 30 pasien cad, 30 pasien scf dan 30 pasien subjek sehat dari desember 2017-februari 2018 di rsud dr. zainoel abidin, banda aceh, indonesia. kadar plasma adiponektin di ukur dengan menggunakan alat immunosorbent enzyme-linked (elisa) sesuai dengan spesifikasi alat. hasil: terdapat hasil yang signifikan bermakna secara statistik di antara subjek cad, scf dan subjek sehat dalam hal usia, jenis kelamin, tekanan darah sistolik, kolesterol total, trigliserida dan kreatinin dengan p<0,001. rerata kadar konsentrasi adiponektin pada pasien cad secara signifikan menunjukkan nilainy yang lebih rendah dibandingkan pasien dengan scf dan subjek sehat (cad 3,40 (0,87) μg/ml; scf 4,58 (2,32) μg/ml; subyek sehat 5,65 (4,87) μg/ml; p<0,001). kesimpulan: penelitian ini menunjukkan kadar plasma adiponektin yang rendah merupakan molekul penting yang berhubungan dengan aterosklerosis. kadar plasma adiponektin mungkin berhubungan dengan peran terjadinya patofisiologi dari penyakit kardiovaskular baik pasien cad dan csf. kata kunci: adiponektin, penyakit arteri koroner, aliran darah lambat. abstract background: adiponectin, an adipocyte-secreted hormone involved in energy homeostasis, has broad anti-inflammatory, antioxidant, and endotheliumand myocardial-protective effects, together with a potentially positive regulatory function in coronary microcirculation. although the physiological role of adiponectin has not yet been fully elucidated, it may well be involved in the regulation of many of the inflammatory processes or lipid metabolisms that contribute to atherosclerosis. in this study we investigate the plasma concentration of adiponectin in patients with coronary artery disease (cad), those with coronary slow flow (csf) and in healthy subjects. methods: this study was conducted according to a cross-sectional design involving 30 cad, 30 csf, and 30 healthy subjects. these subjects were sourced from the dr. zainoel abidin center hospital, banda aceh, indonesia, between december 2017 and february 2018. the plasma concentration of adiponectin was measured using enzyme-linked immunosorbent assay (elisa) according to the manufacturer’s specifications. vol 51 • number 4 • october 2019 plasma concentrations of adiponectin in patients with cad 291 results: there were statistically significant differences at p<0.001 between the cad, csf, and healthy-subject groups in terms of age, sex, systolic blood pressure, total cholesterol, triglycerides, and creatinine. mean plasma concentrations of adiponectin in patients with cad were significantly lower than in patients with csf and in healthy subjects (cad: 3.40 (0.87) μg/ml; csf: 4.58 (2.32) μg/ml; healthy subjects: 5.65 (4.87) μg/ml; p<0.001). conclusion: the findings suggest that low plasma adiponectin concentration is associated with atherosclerosis. plasma concentrations of adiponectin may be related to the pathophysiology role of cardiovascular disease in both cad and csf patients. keywords: adiponectin, coronary artery disease, coronary slow flow. introduction adiponectin is one of the most intensively discussed secretion products of white fat cells, having been increasingly implicated in the pathogenesis of atherosclerosis and insulin resistance.1 a previous study detected adiponectin in catheter-injured vascular walls of rats but not in intact vascular walls. separate studies have shown that plasma adiponectin accumulates in the subendothelial space of the vascular wall at an early phase of catheter injury and that it can be detected around macrophages in the injured human aorta at the site of a thrombus.2,3 d a t a o n t h e p r o s p e c t i v e i m p a c t o f adiponectin plasma-concentration determination in cardiovascular disease in humans are evolving. several clinical studies have demonstrated a strong association between low plasma adiponectin levels and coronary artery disease (cad). in addition, decreased adiponectin concentrations have been shown to be implicated in the pathogenesis of cardiovascular risk as being related to endothelial dysfunction. despite these advances in understanding, the exact relationship between plasma concentrations of adiponectin and cad remains unclear in clinical practice.4 in this study, we focus particularly on the plasma concentration of adiponectin in patients with cad, csf, and in healthy subjects. methods this cross-sectional study was conducted between december 2017 and february 2018 in the division of cardiology, internal medicine department, faculty of medicine, university of syiah kuala, banda aceh and the cardiac catheterization laboratory, dr. zainoel abidin hospital, banda aceh. patients aged >26 years were consecutively recruited into one of three groups: cad, csf, and healthy subjects. all study participants had been referred for coronary angiography because of exertional chest pain suggestive of stable angina pectoris. exclusion criteria were the presence of total stenosis of coronary arteries, patients who had undergone coronary artery bypass graft, and healthy subjects with significant comorbidity, including hypertension, diabetes mellitus, the use of antiinflammatory drugs other than aspirin, renal and/or hepatic dysfunction, bmi >22.9 kg/m2 or <18.5 kg/m2, smoking, and alcohol consumption. the study has been approved by the ethical review committee of the medical faculty of universitas sumatera utara, medan, indonesia; reference number 476/tgl/kepk fk usursup ham/2017 on september 14, 2017 and all subjects provided informed consent for the study. laboratory measurement venous blood was drawn from all subjects after an overnight fast. routine hematology, total cholesterol, high-density lipoprotein (hdl) cholesterol, triglycerides, glucose, urea, and creatinine levels were measured using conventional methods. the concentration of adiponectin (μg/ml) was measured using enzymelinked immunosorbent assay (elisa) according to the manufacturer’s specifications (r&d systems). coronary angiography coronary angiography was performed using the standard judkins technique. a contrast agent was injected manually during coronary angiography (6–10 ml of contrast agent at each position using right and left, and cranial and caudal angulations). coronary angiography recordings were taken at the left anterior oblique, cranial and muhammad diah acta med indones-indones j intern med 292 right anterior oblique, and caudal and horizontal positions. all angiographic examinations were conducted by two cardiologists who were blind to the clinical characteristics of the patients. they assessed the flow in coronary arteries using the thrombolysis in myocardial infarction (timi) frame-count method described by gibson et al.5 timi frame count was calculated from the difference between the first and last frames. since the distance between proximal and distal bifurcation in the left anterior descending (lad) coronary artery is longer than in other coronary arteries, lad timi frame count is significantly higher than those of the right coronary artery (rca) and the circumflex (cx) artery. the cutoff values in respect of length for normal visualization of coronary arteries were 36.2 (sd 2.6) frames for the lad, 22.2 (sd 4.1) frames for the left cx (lcx), and 20.4 (sd 3) frames for the rca. the corrected cutoff value for the lad coronary artery was 21.1 (sd 1.5) frames. all participants with a corrected timi frame count greater than the two standard deviations of the published range for the particular vessel were considered as having csf. the mean timi frame count for each patient and control subject was calculated by dividing the sum of the timi frame count for lad, lcx, and rca by 3. statistical analysis continuous variables are presented as mean (standard deviation) and categorical variables are presented as n (%) prevalence. conformity to normal distribution of the continuous variables was examined using the shapiro–wilk test. according to data distribution and number of groups, a parametric (analysis of variance [anova], t test) or nonparametric (kruskal– wallis, mann–whitney) test was then performed. post hoc comparisons were performed with the appropriate test for data distribution. the pearson’s or spearman correlation test was used for evaluation of the correlation between variables. a value of p<0.05 was considered statistically significant. table 1. demographic and clinical characteristics of the subjects in the three groups variables cad (n = 30) csf (n = 30) healthy subjects (n = 30) age (years), median (range) 55 (37–65) 52 (37–65) 35 ( 27–51) sex-male, n (%) 29 (96.0) 10 (33.0) 17 (56.0) bmi (kg/m2), median (range) 23.7 (21.6–29.0) 22.7 (18.1–31.2) 23.2 (18.5–25.1) sbp (mmhg), median (range) 130 (112–152) 126.50 (109–147) 116.50 (107–128) dbp (mmhg), mean (sd) 84.30 (7.13) 84.93 (9.63) 78.10 (8.84) hemoglobin (g/dl), median (range) 14.2 (10.1–17.1) 13.2 (8.7–16.6) 13.2 (11.6–17.5) hematocrit (%), mean (sd) 42.17 (4.93) 39.90 (4.85) 39.93 (3.44) wbc (ul), median (range) 8350 (5900–14,900) 8700 (4600–16,600) 7700 (4500–10,100) platelets (103/ul), mean (sd) 263.4 (59.4) 270.7 (74.2) 278.1 (65.2) neutrophil-lymphocyte count ratio, median (range) 1.6 (0.8–19) 1.3 (0.8–5.1) 1.3 (0.8–1.7) total cholesterol (mg/dl), median (range) 198 (112–461) 194 (127–336) 149 (90–198) ldl cholesterol (mg/dl), mean (sd) 50.4 (18.31) 49 (17.7) 64.8 (14.5) hdl cholesterol (mg/dl), median (range) 121.5 (30–225) 129 (50–252) 111 (62–156) triglyceride (mg/dl), median (range) 143.5 (88–231) 106 (55–373) 94 (21–129) urea (mg/dl), mean (sd) 30.9 (11.03) 23.8 (6.62) 23.3 (5.20) creatinin (mg/dl), median (range) 1.0 (0.6–1.6) 0.8 (0.6–1.3) 0.7 (0.5–1.0) fasting glucose (mg/dl), median (range) 101 (71–218) 109 (89–154) 98 (82–117) 2 hours post-prandial glucose (mg/dl), median (range) 129 (100–226) 133 (103–226) 126 (97–176) data presented as mean (sd) or n (%) prevalence. nonparametric tests were used and the medians of these data are presented: body mass index (bmi); systolic blood pressure (sbp); diastolic blood pressure (dbp); white blood count (wbc); low-density lipoprotein (ldl); high-density lipoprotein (hdl). vol 51 • number 4 • october 2019 plasma concentrations of adiponectin in patients with cad 293 table 2. baseline characteristics of timi frame counts for angiographic data of patients with cad and csf timi frame cad (n = 30) csf (n = 30) p value rca (frame), mean (sd) 28.07 (8.82) 26.83 (3.87) 0.486 lcx (frame), mean (sd) 34.4 (10.34) 28.37 (2.76) 0.003 lad (frame), mean (sd) 47.27 (10.11) 42.37 (7.77) 0.04 ctfc lad (frame), mean (sd) 27.8 (5.9) 24.67 (4.8) 0.029 ctfc (frame), mean (sd) 30.13 (7.94) 26.83 (3.553) 0.042 target vessel, n (%) rca 22 (73.3) 28 (93.3) 0.038 lcx 4 (66.6) 25 (83.3) 0.136 lad 26 (86.6) 25 (83.3) 0.718 right coronary artery (rca); left circumflex artery (lcx); left anterior descending artery (lad); corrected thrombolysis in myocardial infarction (ctfc). table 3. between-group comparison of adiponectin level in cad, csf, and healthy subjects mean (sd) median (min-max) 95% confidence interval p value cad (n = 30) 3.40 (0.87) 3.35 (1.48–4.95) 2.99–3.81 < 0.001 csf (n = 30) 4.58 (2.32) 4.15 (1.63–9.99) 3.50–5.67 healthy subjects (30) 5.65 (4.87) 4.87 (3.27–9.45) 4.80–6.50 kruskal–wallis analysis, a post hoc mann–whitney test showed healthy vs. csf p = 0.045; healthy vs. cad p<0.001; and cad vs. csf p = 0.157 results the study included 90 subjects: 30 patients with cad (the cad group); 30 patients with only coronary slow flow (the csf group) and 30 healthy subjects. demographic and clinical characteristics of the patients are summarized in table 1. based on the clinical data, there was a statistically significant difference (at p<0.001) between the cad, csf, and healthy-subject groups in terms of age, sex, and sbp. using another correlation analysis, total cholesterol, serum triglycerides, and creatinine were also significantly higher in subjects with cad compared to both subjects with csf and healthy subjects (p<0.001). the baseline characteristics of the timi frame counts for cad, csf, and healthy subjects are shown in table 2. the corrected timi frame counts for rca and mean corrected thrombolysis in myocardial infarction (ctfc) were significantly higher in patients with csf than in those with cad (123.10 (sd 27.89) vs. 105.85 (sd 20.27), p = 0.034; 91.85 (sd 12.56) vs. 83.75 (sd 13.64), p=0.006, respectively) and the most common target vessel in the csf group was rca (93.3%, p = 0.038) for all three coronary arteries. mean plasma adiponectin concentrations were found to be significantly lower in the cad and csf subjects than in the healthy subjects (3.40 (0.87) μg/ml; 4.58 (2.32) μg/ml; and 5.65 (4.87) μg/ml, respectively; p<0.001) discussion the objective of the study was to investigate whether the plasma levels of adiponectin differed between subjects. the study demonstrated that the plasma levels of adiponectin differed significantly between groups of patients with cad, csf, and healthy subjects. cad, also known as ischemic heart disease or coronary heart disease, has become one of the major causes of death worldwide. atherosclerosis, which is the main cause of cad, is an inflammatory process involving the vascular wall cells and activation of markers of inflammation such as monocytes, t lymphocytes, pro-inflammatory cytokines, chemoattractant cytokines (chemokines), and growth factors.6 vessel-wall inflammation is a central feature in the initiation, progression, and terminal stages of atherosclerosis, leading to plaque, rupture, and thrombosis, and many systemic markers of muhammad diah acta med indones-indones j intern med 294 inflammation have been investigated and linked to the prediction of future cardiovascular events and to identification of patients at risk.7,8 during the last decade, much interest has been focused on adiponectin as an important modulator of inflammatory response during the initiation and progression of atherosclerosis in the vascular wall.9 adiponectin is a collagen-like protein produced specifically by adipose tissue that is abundantly present in the circulation. a recent report concluded that plasma adiponectin concentrations were related to the severity of coronary atherosclerosis, although the difference fell short of significance, in that adiponectin concentrations decreased as the number of significantly narrowed coronary arteries increased.10 in vitro and in vivo studies have reported that circulating adiponectin shows multiple protective effects on the vascular endothelium by inhibiting various crucial steps in the atherosclerotic process. adiponectin has been shown to attenuate monocyte attachment to endothelial cells by reducing adhesion-molecule expression, suppressing macrophage-to-foam cell transformation, and decreasing proliferation and migration of vascular smooth-muscle cells.11-13 in our study, we found significantly differences in the levels of plasma serum adiponectin between the three groups, with the level being lowest in the cad group. however, plasma concentration of adiponectin has been differently reported by lim et al.14, whose study showed that adiponectin concentrations did not correlate with coronary atheroma or coronary stenosis scores. in the literature, there are a number of clinical reports identifying the crucial role of endothelial dysfunction in the pathogenesis of csf. selcuk et al.9 showed that plasma adiponectin concentrations were significantly decreased in patients with csf compared to those with normal coronary flow. it has been suggested that loss of the anti-inflammatory effects of adiponectin and increased endothelial expression of proinflammatory factors directly contribute to endothelial dysfunction by allowing vascular proinflammatory reactions to occur more readily.15 in this mechanism, decreased concentrations of circulating adiponectin may be attributed to impaired endothelial function resulting from slow-flow-induced vascular damage that gives rise to the accumulation of adipocytokine in the vessel wall.16 our study showed that plasma concentration of adiponectin was lower in patients with csf than in healthy subjects. our study had some limitations. first, the number of participants was relatively low. second, the patients did not undergo intravascular ultrasonography (ivus) to detect atherosclerotic figure 1. comparison of plasma concentrations of adiponectin in patients with cad, csf and healthy subjects vol 51 • number 4 • october 2019 plasma concentrations of adiponectin in patients with cad 295 changes in the coronary arteries. finally, we did not measure the inflammatory indicators as supporting evidence for the mechanisms of pathophysiology in cardiovascular disease. conclusion the results of this study show that plasma adiponectin is an important molecule associated with atherosclerosis, and, for the data obtained, the level of adiponectin is lowest in the cad group. these findings may have important implications for understanding the physiopathologic role of cardiovascular disease in both cad and csf patients and therefore for the development of therapeutic strategies. conflict of interest the authors have declared no financial conflicts of interest. references 1. schnabel r, messow cm, lubos e, et al. association of adiponectin with adverse outcome in coronary artery disease patients: results from the athero gene study. eur heart j. 2008;29:649–57. 2. okamoto y, arita y, nishida m, et al. an adipocytederived plasma protein, adiponectin, adheres to injured vascular walls. horm metab res. 2000;32:47–50. 3. ouchi n, kihara s, arita y, et al. adipocytederived plasma protein, adiponectin, suppresses lipid accumulation and class a scavenger receptor expression in human monocyte-derived macrophages. circulation. 2001;103:1057–63. 4. hashimoto n, kanda j, nakamura t, et al. association of hypoadiponectinemia in men with early onset of coronary heart disease and multiple coronary artery stenoses. metabolism. 2006;55:1653–7. 5. gibson cm, cannon cp, daley wl, et al. timi frame count: a quantitative method of assessing coronary artery flow. circulation. 1996:93;879–88. 6. hua xp, zhang xd, kwong jsw, zeng xt, zhang zj, wei wl. tumor necrosis factor-alpha g-238apolymorphism and coronary artery disease risk: a meta-analysis of 4,222 patients and 4,832 controls. ther clin risk manag. 2015;11:1429–36. 7. razi mm, abdali n, asif sm, azharuddin m. association of inflammatory cytokines/biomarkers with acute coronary syndrome and its correlation with severity and hospital outcome. j clin prev cardiol. 2017;6:44–9. 8. rosenson rs, koenig w. utility of inflammatory markers in the management of coronary artery disease. am j cardiol. 2003;92(suppl):10i–18i. 9. selcuk h, selcuk mt, temizhan a, et al. decreased plasma concentrations of adiponectin in patients with slow coronary flow. heart vessels. 2009;24:1–7. 10. nakamura y, shimada k, fukuda d, et al. implications of plasma concentrations of adiponectin in patients with coronary artery disease. heart. 2004;90:528–33. 11. ouchi n, kihara s, arita y, et al. adiponectin, an adipocyte-derived plasma protein, inhibits endothelial nf-kappab signaling through a camp-dependent pathway. circulation. 2000;102:1296–301. 12. ouchi n, kihara s, arita y, et al. adipocytederived plasma protein, adiponectin, suppresses lipid accumulation and class a scavenger receptor expression in human monocyte-derived macrophages. circulation. 2001;103:1057–63. 13. matsuda m, shimomura i, sata m, et al. role of adiponectin in preventing vascular stenosis. the missing link of adipo-vascular axis. j biol chem. 2002;277:37487–91. 14. lim hs, tayebjee mh, tan kt, patel jv, macfadyen rj, lip gyh. serum adiponectin in coronary heart disease: ethnic differences and relation to coronary artery disease severity. heart. 2005;91:1605–06. 15. ouchi n, kihara s, funahashi t, matsuzawa y, walsh k. obesity, adiponectin and vascular inflammatory disease. curr opin lipidol. 2003;14:561–6. 16. okamoto y, arita y, nishida m, et al. an adipocyte derived plasma protein, adiponectin, adheres to injured vascular walls. horm metab res. 2000;32:47–50. 5 original article acta med indones indones j intern med • vol 52 • number 1 • january 2020 sarcopenia and frailty profile in the elderly community of surabaya: a descriptive study novira widajanti1, jusri ichwani1, rwahita s. dharmanta2, hadiq firdausi1, yudha haryono3, erikavitri yulianti4, stefanus g. kandinata5, meilia wulandari5, rastita widyasari5, viranti a. adyanita5, nuri i. hapsanti5, diar m. wardana5, titin kr i sti ana 5, d r iy arkara 5, he mma wahy u d a 5, s arah yunara 5, kholidatul husna5 1 department of internal medicine, faculty of medicine universitas airlangga dr. soetomo hospital, surabaya, indonesia. 2 department of physical medicine and rehabilitation, faculty of medicine universitas airlangga dr. soetomo hospital, surabaya, indonesia. 3 department of neurology, faculty of medicine universitas airlangga dr. soetomo hospital, surabaya, indonesia. 4 department of psychiatry, faculty of medicine universitas airlangga dr. soetomo hospital, surabaya, indonesia. 5 faculty of medicine universitas airlangga, surabaya, indonesia. corresponding author: novira widajanti, md. department of internal medicine, faculty of medicine universitas airlangga – dr. soetomo hospital, surabaya. jl. mayjen prof. dr. moestopo 47, surabaya 60131, indonesia. email: novirawidajanti@fk.unair. ac.id. abstrak latar belakang: sarkopenia dan frailty merupakan salah satu penyebab hilangnya mobilitas, disabilitas, gangguan neuromuskular, dan sindroma kegagalan homeostatik dengan kelainan gaya berjalan dan keseimbangan pada usia lanjut. hal ini berkontribusi terhadap peningkatan angka jatuh dan patah (fall and fractures) sekaligus meningkatan hospitalisasi, imobilisasi, bahkan mortalitas. jumlah populasi usia lanjut dengan sarkopenia dan frailty diperkirakan meningkat di seluruh dunia, sehingga studi mengenai angka prevalensi sarkopenia dan frailty secara nasional sangat penting dilakukan sebagai dasar studi selanjutnya. metode: penelitian ini merupakan penelitian deskriptif dengan menggunakan data primer dari komunitas usia lanjut di surabaya melalui posyandu lanjut usia. data biopsikososial, penurunan berat badan, kelelahan, dan aktivitas fisik didapat melalui wawancara, sedangkan kekuatan genggam tangan, massa otot, dan performa fisik (kecepatan berjalan) diukur melalui instrumen. hasil: tiga ratus delapan subjek terkualifikasi untuk penelitian. rerata usia subjek adalah 63 (60–100) tahun dengan 74,7% subjek berjenis kelamin perempuan. prevalensi sarkopenia pada usia lanjut di surabaya sebesar 41,8% (laki-laki 13,9%, perempuan 27,9%). prevalensi frailty secara umum adalah 36,7% (laki-laki 5,2%, perempuan 31,5%). kesimpulan: prevalensi sarkopenia dan frailty pada populasi usia lanjut di komunitas tergolong tinggi. hasil penelitian ini diharapkan dapat menjadi awal dari penelitian berikutnya, terutama dalam menentukan cutoff sarkopenia yang sesuai dengan sosiodemografi indonesia. kata kunci: sarkopenia, frailty, usia lanjut, komunitas, profil. abstract background: sarcopenia and frailty cause immobility, disability, neuromuscular disorders, and homeostatic balance failure syndrome, characterized by gait and balance abnormalities in the elderly, and an increasing novira widajanti acta med indones-indones j intern med 6 prevalence worldwide. this further contributes to the elevated incidence of falls and fractures, hospitalization, immobilization, and even mortality, hence, a national-level study was conducted on the prevalence rates of sarcopenia and frailty in the elderly. methods: this descriptive study used primary data of elderly people (n = 308) in surabaya, indonesia. furthermore, the biopsychosocial data, weight loss, fatigue, and physical activity measurements were obtained through interviews, while handgrip strength, muscle mass, and physical performance (walking speed) were evaluated using instruments. results: the median age of the subjects was 63 years (60–100 years), and 230 (74.7%) were women. in addition the prevalence rate of sarcopenia was 41.8% (in 86 [27.9%] women), while the prevalence rate of frailty was 36.7% (in 16 [5.2%] men and 97 [31.5%] women). conclusion: the prevalence of sarcopenia and frailty in the elderly is significantly high, thus, it is expected that this study results are used as a basis for subsequent research, especially to determine the sarcopenia cut-off, in accordance with indonesian sociodemography. keywords: sarcopenia, frailty, elderly, community, profile. introduction sarcopenia is more often used as the subject of research compared to frailty, despite of the fact that they have been studied together for a long time.1 meanwhile, the absence of optimal treatment is known to cause loss of muscle strength, which further contributes to immobility, neuromuscular disorders, homeostatic balance failure syndrome,2 as well as walking and stability disturbance.3 these occurrences tend to increase the risk of fall and fractures in the elderly,4-6 which ultimately leads to sarcopenia and frailty. according to the european working group on sarcopenia in older people (ewgsop) and the asian working group for sarcopenia (awgs), the prevalence of sarcopenia in healthy adults aged ≥60 years is approximately 10% (95% confidence interval [ci] = 8%–12%) in men and 11% (95% ci = 8%–13%) in women.7 a 2016 study in bandung, west java, indonesia, on 229 participants showed a 7.4% prevalence in men and 1.7% in women on the basis of awgs parameters.7 a systematic review8 of 31 studies on people aged ≥65 years showed a frailty incidence of 4%–17% (9.9% on average), while a study by setiati et al.9 (2013) on 270 elderly people in the outpatient department of dr. cipto mangunkusumo hospital, jakarta recorded 27.4%. in addition, women are two times more likely to be frail, and the prevalence significantly increases in people aged >80 years.10 currently, there is a lack of national data regarding the prevalence of sarcopenia and frailty in indonesia, especially in surabaya. also, agreements have not been investigated on the instruments and cut-offs of sarcopenia. therefore, the aim of this study is to determine the prevalence of sarcopenia and frailty as a basis for subsequent research. methods this is a cross-sectional, observational, descriptive study, where primary data were obtained using interviews and questionnaires. also, specific instruments were used to measure sarcopenia and frailty amongst the elderly in posyandu lansia in surabaya. study setting data were collected between december 2017 and march 2018 from five clinics, part of five health centers in surabaya, which were puskesmas tambak rejo, sememi, menur, perak timur, and putat jaya. study population and sampling method the study population comprised the elderly aged ≥60 years. cluster random sampling was used. one health center from each of the five administrative regions in surabaya was randomly selected for data collection. the elderly selected for the study encompassed those who were recorded in the clinics, were willing and able to fill out information on the informed consent sheets, cooperative and capable of undergoing several tests. furthermore, those with severe cardiovascular or respiration problems, a history of pacemakers utility, and incomplete vol 52 • number 1 • january 2020 sarcopenia and frailty profile in the elderly community of surabaya 7 checkpoints were excluded. the study was conducted under ethical clearance no. 273/ec/kepk/fkua/2017. study instruments t h e g e n e r a l c h a r a c t e r i s t i c s o f t h e subjects were obtained using questionnaires. biopsychosocial profiles, including the comorbidity index, nutritional status, cognitive status, mental status, and functional status, were assessed using the charlson comorbidity index (cci), the cumulative illness rating scale (cirs), the mini nutritional assessment (mna) questionnaire, the abbreviated mental test (amt), the mini-mental state examination (mmse), the geriatric depression scale (gds), the barthel activity of daily living (adl) scale, and lawton’s instrumental activity of daily living (iadl). in addition, sarcopenia was measured on the basis of the following awgs11 parameters: (i) muscle mass, which was evaluated using the bioelectrical impedance analysis omron karada scan model hbf-362 (omron corporation, kyoto, japan) by adopting the cut-off 2sd-derived from 40 subjects of non-sarcopenic young adults as controls12 (men, 6.1 kg/m2; women, 3.05 kg/m2); (ii) hand grip strength was measured using the tkk 5001 grip a hand dynamometer in triplicate, and the best value was collected; and (iii) walking speed was calculated using the gait speed test, where each subject was requested to walk in a straight line for 6 meters, and the time was recorded using a stopwatch. to determine the degree of sarcopenia, the subjects were divided into the following groups: severe sarcopenia on instances of low muscle mass, hand grip strength, and gait speed; and sarcopenia if the muscle mass was low and the hand grip strength or gait speed was low; presarcopenia if only the muscle mass was low; and normal if all parameters were normal.13 based on the cardiovascular health study (chs) scale3 the measurement for frailty involved using the following items: unintentional weight loss, weakness with cut-off according to the body mass index, fatigue, slow gait speed, and low physical activity (measured using the physical activity scale for the elderly). furthermore, the subjects were divided into groups as follows: frailty if three of five criteria were met, prefrailty if one or two were attained, and fit if none was met. statistical analysis data collected were processed using spss statistics ver. 17.0 (ibm corporation, armonk, ny, usa) for windows (microsoft corporation redmond, wa, usa). the categorical variables were presented in frequencies and percentages, while the continuous variables were presented according to their distributions. furthermore, table 1. general characteristics of the subjects in this study characteristics n (%) sex male 78 (25.3) female 230 (74.7) marital status married 178 (57.8) widow/widower 117 (38.0) divorced 7 (2.3) single 6 (1.9) education no schooling 48 (15.6) some primary 42 (13.6) completed primary 98 (31.8) junior high school 63 (20.5) high school 42 (13.6) associate’s degree 7 (2.3) bachelor’s degree 8 (2.6) monthly income (in millions rupiahs) <1.5 234 (75.9) 1.5–3 55 (17.9) >3 19 (6.2) financial dependency independent 69 (22.4) partially dependent 55 (17.9) wholly dependent 160 (51.9) pension 24 (7.8) walker use no 295 (95.8) yes 13 (4.2) regular exercise no 106 (34.4) yes 202 (65.6) history of falls in the last year no 270 (87.7) yes 38 (12.3) novira widajanti acta med indones-indones j intern med 8 continuous variables with normal distributions were presented as mean (standard deviation), while those without were displayed as median (minimum-maximum). results from december 2017 to march 2018, a total of 320 elderly were screened for the study, where none exhibited severe cardiovascular or respiration problems, and history of utilizing pacemakers. however, about 12 participants were unable to complete the checkpoints, and thus excluded from the study. out of the 308 total subjects, 230 (74.7%) were women, with a median age of 63 (60–100) years, and table 1 shows other general characteristics. the median comorbidity score based on the cci was 4.00 (2–10). the median 10-year survival rate was 0.53 (0.00–0.90). based on the cirs, the three most frequent comorbidities were musculoskeletal disorders (mild: n = 187 [60.7%]; moderate: n = 23 [7.5%]), hypertension, and sensory system disorders. based on the lawton’s iadl tool, the median functional status score was 6.00 (1–8) for men and 8.00 (0–8) for women, and table 2 shows other biopsychosocial profiles of the subjects. the median value for hand grip strength was 29.00 kg (15.00–44.00 kg) and 18.50 kg (6.00–29.00 kg) for men and women. the median gait speed for men was 0.78 m/s (0.30–1.32 m/s); whereas the mean gait speed for women was 0.70 (sd 0.20) m/s. in addition, the mean muscle mass for men was 4.89 (sd 1.30) kg/ m2; while the median muscle mass for women was 3.08 (1.33–5.52) kg/m2. table 3 shows the distribution of all three sarcopenia parameters. table 2. biopsychosocial profile of the subjects in this study variables n (%) amt severe mental impairment 5 (1.6) mild-moderate mental impairment 22 (7.1) normal 281 (91.2) mmse severe cognitive impairment 12 (3.9) mild cognitive impairment 53 (17.2) normal 243 (78.9) gds normal 305 (99.0) depressive 3 (1.0) nutritional status normal 216 (70.1) at risk of malnutrition 81 (26.3) malnourished 11 (3.6) barthel adl partially dependent 4 (1.3) minimally dependent 94 (30.5) totally independent 210 (68.2) amt, abbreviated mental test; mmse, mini-mental state examination; gds, geriatric depression scale; adl, activity of daily living. table 3. distribution of sarcopenia parameters variables male n (%) female n (%) hand grip strength low 27 (8.8) 101 (32.8) normal 51 (16.6) 129 (41.9) gait speed low 42 (13.6) 162 (52.6) normal 36 (11.7) 68 (22) muscle mass low 66 (21.4) 109 (35.4) normal 12 (3.9) 121 (39.3) the prevalence rate was 41.8%, where 43 (13.9%) men and 86 (27.9%) women were sarcopenic, and 63 (20.4%) of the subjects exhibited severe symptoms. on the basis of the chs scale, the prevalence rate of frailty was 36.7%, of which 16 (5.2%) were men and 97 (31.5%) were women, with details shown in table 4. discussion sarcopenia is defined as low muscle mass with low hand grip strength or low gait speed.11 furthermore, its prevalence rate in asia (2008)14 was 6%–23% and 8%–22% in men and women, respectively, with the lowest prevalence was found in hong kong (12.3% in men and 7.6% in women) and korea (6.3% in men and 4.1% in women).15 conversely, the highest incidence is recorded in taiwan (23.6% in men and 18.6% in women)14 and japan (21.8% in men and 22.1% in women).16 vol 52 • number 1 • january 2020 sarcopenia and frailty profile in the elderly community of surabaya 9 specifically, this study records a prevalence of 13.9% in men and 27.9% in women, which is much higher than the studies conducted in bandung, reported based on the cut-off recommended by the awgs of 9.1% (7.4% in men and 1.7% in women) and 40.6% (20.1% in men and 20.5% in women) based on the cut-off from taiwan’s population.7 the subjects in this study had a much lower mean muscle mass for both men and women, compared to the research in bandung, with the women in both exhibiting relatively lower values. a study by pongchaiyakul et al17 in thailand showed a higher prevalence of sarcopenia, based on the assessment of low relative skeletal muscle mass only, both in men and women, which were 35.33% and 34.74% respectively. in addition, living in the city had the strongest association with low skeletal muscle index with an odds ratio (or) of 17.26 (sd 7.12) in men and 8.62 (sd 2.74) in women. living in the biggest metropolitan city in the province, the people of surabaya tend to have a more sedentary lifestyle. this contributes to the development of sarcopenia, asides from the factor associated with age, which were from the factors associated with activities and nutrition.17-18 similar results were established in a study of brazilian elderly women conducted by mazocco et al.19, which demonstrated a higher vulnerability in those living in urban areas (or = 9.561). in addition, less sun exposure, more diet high in fats and refined carbohydrates, and also low fiber intake are other possible reasons for the high prevalence.17 about 86 (27.9%) women studied were sarcopenic, which is much higher than in men (13.9%). this is in line with a study of suburbdwelling older chinese in 2016, recording a higher occurrence in women than men, of 11.5% and 6.4% respectively. according to the study, the higher bmi in men was identified as a protective factor against sarcopenia.20 also, menopause is capable of changing body composition and fat distribution, consequently the composition of fat-free body mass in women declines with increasing body weight, fat mass, and central fat deposition. this is characterized by the tendency to exhibit decreased muscle mass,21 and a higher incidence of sarcopenia. interesting results were reported for the muscle mass values, as categorized in table 3, which was low for the majority of men (n = 66 [21.4%]), and normal for most women (n = 121 [39.3%]). according to roubenoff, men tend to experience a more significant decrease in muscle mass as a result of the declining growth hormone and testosterone levels.22 hence, some studies reported a relatively higher prevalence in men.14-15 malnutrition was associated with the development of sarcopenia.18,23-25 on the basis of the mna questionnaire, 81 (26.3%) subjects in this study were classified to be at risk of malnutrition and 11 (3.6%) were malnourished. the prevalence of malnutrition was lower (1.2%) in iran, where the prevalence of sarcopenia was 20.8%.23 lower prevalence of sarcopenia was also identified in a study among communitydwelling elderly in taiwan (6.8%), where the prevalence of abnormal nutritional status (both at risk and already malnourished) was only 5.1%.24 in addition, malnourished individuals tend to lack nutritional factors like protein, vitamin d, calcium, and the acid-base balance of a diet, which plays a role in maintaining muscle mass and muscle strength, as well as physical performance,18 necessary in the diagnosis of table 4. distribution of frailty parameters based on the chs scale. variables male n (%) female n (%) weight loss no 69 (22.4) 205 (66.6) yes 9 (2.9) 25 (8.1) hand grip weakness no 75 (24.4) 128 (41.6) yes 3 (1) 102 (33.1) fatigue no 57 (18.5) 159 (51.6) yes 21 (6.8) 71 (23) slow gait speed no 29 (9.4) 29 (9.4) yes 49 (15.9) 201 (65.3) low levels of physical activity no 35 (11.4) 95 (30.8) yes 43 (14) 135 (43.8) chs, cardiovascular health study. novira widajanti acta med indones-indones j intern med 10 sarcopenia. meanwhile, the other possible explanation is because malnourished people demonstrate reduced muscle protein synthesis.25 frailty the prevalence rate of frailty in the present study was 5.2% in men and 31.5% in women. overall, the prevalence of frailty was 36.7%. the prevalence rate of frailty according to the chs in the elderly aged >=65 years is 7%, reaching 30% in those aged >=80 years.3 lower results were found in a study by setiati et al.26 recording a prevalence of 25.2%, where nutritional and functional status, as well as age were considered as essential factors. despite the relatively older mean age (74.2%) recorded,26 the proportion of individuals at risk and those already malnourished was lower than the values reported in the present study of 24.6% and 2.5% respectively. however, it is also noted that setiati et al.26 recruited the subjects from the hospital, of which some were referred from primary health care and smaller hospitals. this consequently leads to differences in the prevalence of frailty in comparison with other elderly individuals in the indonesian population. another study by setiati et al.9 (2013), reported on the frailty prevalence rate of 27.4% in 270 elderly individuals of an outpatient setting, while 71.1% was recorded for prefrailty. women are known to be at a two times higher risk of being frail compared to men.10 this phenomenon is possibly explained through various mechanisms, including the fact that women exhibit lower hand grip strength than men, with a mean value of 18.5 kg and 29 kg, respectively. this is due to the fact that women possess greater fat mass,21 and the relatively higher vulnerable to fatigue. specifically, fatigue is defined on the basis of two items identified in the center for epidemiologic studies depression scale (ces-d) questionnaire: • i find it difficult to start activities as usual. • i feel the need for extra effort to start the activity. using similar definition, vestergaard et al.27 reported a 15% and 29% prevalence rate of fatigue in men and women, respectively in italy. also, using reduced energy as the definition, tolea et al.28 reported the experience in 12% of men and 22% of women. comparably, women tend to exhibit a slightly lower speed, due to the variation in anthropometric size and lifestyles.28 among the elderly, lenardt et al.29 (2013) reported men as more physically active. there was higher prevalence of frailty among women in the present study than men (31.5% vs. 5.2%). a study by rensa et al.30 reported a 24% proportion in women, with report of a relatively older median age (67 years old). however, the b-adl was lower in the present study, which according to rensa et al,30 was associated with the frailty syndrome in elderly. the prevalence further increases significantly in individuals >80 years of age,10 as cellular m e t a b o l i s m a n d p h y s i o l o g i c a l f u n c t i o n progressively decreases over time. in addition, the musculoskeletal system is also affected by sarcopenia, characterized by the reduced muscle strength, mobility, balance, and tolerance for activities, subsequently increasing the risk of falls and physical inactivity.31 weight loss results in reduced fat mass, muscle mass, and bone.32 furthermore, low muscle mass is one of the factors associated with the decline in gait speed and weakness of hand grip in sarcopenia,33 hence the overlapping relationship with frailty.34 in addition, low muscle mass is also associated with fatigue.35 according to newman36 (2005), about 15%–20% of the elderly experience weight loss, which is defined as a loss of >=5 kg (or >5%) of the initial body weight for 5–10 years. this prevalence increases in high-risk populations, encompassing community-dwelling elderly, and it is also associated with advanced age, presence of disability, comorbidity, hospital admission history, low level of education, cognitive impairment, smoking, death of a partner, and low initial body weight.27 conversely, physical activities are affected by both physiological and external factors, including opportunities, gender-related sociocultural values, motivation, and choices.37 health problems are risk factors for a decreased functional status, creating limitations for the elderly, which results in complications and the emergence of new problems.38 therefore, the presence of physical vol 52 • number 1 • january 2020 sarcopenia and frailty profile in the elderly community of surabaya 11 activity is an indicator of independence in daily life, which contributes towards the reduction and control of cardiovascular and ischemic heart disease.39 there was an association between cognition and frailty,40-41 which was better illustrated as a cycle as frailty increases the risk of future cognitive decline and conversely cognitive impairment increases the risk of frailty.41 a systematic review on 10 cross-sectional studies and 9 longitudinal studies reported that cognitive impairment was more prevalent in frail elderly.40 this result is in line with the present study, where most (75%) of the elderly with severe cognitive impairment were frail and 54.7% of those with mild cognitive impairment were frail. (table 5). young adults as the reference for the diagnosis of sarcopenia. moreover, according to the authors’ knowledge, the present study is the first multicenter study in indonesia which has nearly complete sarcopenia and frailty profile in the elderly. this study is expected to be a basis for subsequent research. conclusion the prevalence rates of sarcopenia and frailty in the elderly population of surabaya are high. however, the results obtained differ from other previous research perfomed in several cities of indonesia, hence an agreement on the instruments and cut-offs is required in the determination of sarcopenia. acknowledgments the author is grateful to the heads of the tambak rejo community, menur, sememi, perak timur, and putat jaya health center, as well as the supervised posyandu, posyandu lansia cadres in each, and all parties involved in ensuring the successful completion of this research. this study was funded by dr. soetomo hospital, surabaya research program. references 1. bauer jm, sieber cc. sarcopenia and frailty: a clinician’s controversial point of view. exp gerontol. 2008;43(7):674-8. doi: 10.1016/j.exger.2008.03.007. pmid 18440743. 2. vetta f, ronzoni s, taglieri g, et al. the impact of malnutrition on the quality of life in the elderly. clin nutr. 1999;18(5):259-67. doi: 10.1054/clnu.1999.0060. pmid 10601532. 3. dutta c. significance of sarcopenia in the elderly. j nutr. 1997;127(5 suppl.):992s-3s. doi: 10.1093/ jn/127.5.992s. pmid 9164281. 4. fried lp, tangen cm, walston j, et al. cardiovascular health study collaborative research group: frailty in older adults. j gerontol a. 2001;56(3):m146-57. doi: 10.1093/gerona/56.3.m146. 5. moulias r, meaume s, raynaud-simon a. sarcopenia, hypermetabolism, and aging. z gerontol geriatr. 1999;32(6):425-32. doi: 10.1007/s003910050140. pmid 10654381. 6. vanitallie tb. frailty in the elderly: contributions of sarcopenia and visceral protein depletion. metabolism. 2003;52(10 suppl.):22-6. doi: 10.1016/s00260495(03)00297-x. pmid 14577059. 7. vitriana, defi ir, irawan gn, et al. prevalensi table 5. frequency of cognitive impairment among fit, prefrail, and frail elderly. cognitive function fit n (%) prefrail n (%) frail n (%) severe cognitive impairment 0 (0) 3 (25) 9 (75) mild cognitive impairment 1 (1.9) 23 (43.4) 29 (54.7) normal 18 (7.4) 150 (61.7) 75 (30.9) among other instruments, the frailty criteria proposed by fried et al.8, using the data from chs, remains the most frequently used,40,42 and was shown to demonstrate a good predictive validity for adverse health outcomes in various populations.42 however, there are some studies suggested the inclusion of cognition as a frailty component,41-42 as impairments in both physical and cognitive function contribute to the risk of functional decline in elderly. there were some limitations in the present study. first, the subjects were needed to undergo several tests to measure each components of sarcopenia and frailty. this could lead to fatigue which could affect the outcomes. to overcome this, all subjects were given time to eat and do ice-breaking in the middle of the tests. second, all subjects despite exhibiting cognitive impairment were included in the present study, although some informations were collected from the care giver, not the subjects themselves. one of the strength in this study is the mean muscle mass measurement of non-sarcopenic novira widajanti acta med indones-indones j intern med 12 sarkopenia pada lansia di komunitas (community dwelling) berdasarkan dua nilai cut-off parameter diagnosis. mkb. 2016;48(3):164-70. doi: 10.15395/ mkb.v48n3.417. 8. fried lp, walston j. frailty and failure to thrive. in: hazzard wr, blass jp, ettinger wh jr, halter jb, ouslander j, editors. principles of geriatric medicine and gerontology. 5th ed. vol. 1. new york: mcgrawhill; 2003. p. 1487-502. 9. setiati s, seto e, sumantri s. frailty profile of elderly outpatient in cipto mangunkusumo hospital, jakarta. 2013 10. morley je, von haehling s, anker sd, vellas b. from sarcopenia to frailty: a road less traveled. j cachexia sarcopenia muscle. 2014;5(1):5-8. doi: 10.1007/ s13539-014-0132-3. pmid 24526568. 11. ogawa s, yakabe m, akishita m. age related sarkopenia and its pathophysiological bases. inflam regen. 2016;36:17. doi: 10.1186/s41232-016-0022-5. pmid 29259690. 12. chen lk, liu lk, woo j, et al. sarcopenia in asia: consensus report of the asian working group for sarcopenia. j am med dir assoc. 2014;15(2):95-101. doi: 10.1016/j.jamda.2013.11.025. pmid 24461239. 13. cruz-jentoft aj, baeyens jp, bauer jm, et al. sarcopenia: european consensus on definition and diagnosis: report of the european working group on sarcopenia in older people. age ageing. 2010;39(4):412-23. doi: 10.1093/ageing/afq034. pmid 20392703. 14. chien my, huang ty, wu yt. prevalence of sarcopenia estimated using a bioelectrical impedance analysis prediction equation in community-dwelling elderly people in taiwan. j am geriatr soc. 2008;56(9):17105. doi: 10.1111/j.1532-5415.2008.01854.x. pmid 18691288. 15. lau em, lynn hs, woo jw, et al. prevalence of and risk factors for sarcopenia in elderly chinese men and women. j gerontol a biol sci med sci. 2005;60(2):213-6. doi: 10.1093/gerona/60.2.213. pmid 15814865. 16. yamada m, nishiguchi s, fukutani n, et al. prevalence of sarcopenia in community-dwelling japanese older adults. j am med dir assoc. 2013;14(12):911-5. doi: 10.1016/j.jamda.2013.08.015. pmid 24094646. 17. pongchaiyakul c, limpawattana p, kotruchin p, rajatanavin r. prevalence of sarcopenia and associated factors among thai population. j bone mineral metabolism. 2013;31(3):346–50. doi:10.1007/s00774013-0422-4. 18. beaudart c, sanchez-rodriguez d, locquet m, reginster j-y, lengelé l, bruyère o. malnutrition as a strong predictor of the onset of sarcopenia. nutrients. 2019;11(12):2883. doi:10.3390/nu11122883. 19. mazocco l, gonzalez mc, barbosa-silva tg, chagas p. sarcopenia in brazilian rural and urban elderly women: is there any difference? nutrition. 2019;58:120-4. doi:10.1016/j.nut.2018.06.017. 20. han p, kang l, guo q, wang j, zhang w, shen s, niu k. prevalence and factors associated with sarcopenia in suburb-dwelling older chinese using the asian working group for sarcopenia definition. j gerontology series a: biol sci med sci. 2015;71(4): 529–35. doi:10.1093/gerona/glv108. 21. dehghan m, merchant at. is bioelectrical impedance accurate for use in large epidemiological studies? nutr j. 2008;7(1):26. doi: 10.1186/1475-2891-7-26. pmid 18778488. 22. roubenoff r, hughes va. sarcopenia: current concepts. j gerontol a biol sci med sci. 2000;55(12):m716-24. doi: 10.1093/gerona/55.12.m716. pmid 11129393. 23. nasimi n, dabbaghmanesh mh, sohrabi z. nutritional status and body fat mass: determinants of sarcopenia in community-dwelling older adults. exp gerontol. 2019;122:67-73. doi:10.1016/j.exger.2019.04.009. 24. kuo y-h, wang t-f, liu l-k, lee w-j, peng l-n, chen l-k. epidemiology of sarcopenia and factors associated with it among community-dwelling older adults in taiwan. am j med sci. doi:10.1016/j. amjms.2018.11.008. 25. hai s, cao l, wang h, zhou j, liu p, yang y, dong b. association between sarcopenia and nutritional status and physical activity among community-dwelling chinese adults aged 60 years and older. geriatrics gerontol int. 2017;17(11):1959–66. doi:10.1111/ ggi.13001. 26. setiati s, laksmi pw, aryana i, et al. frailty state among indonesian elderly: prevalence, associated factors, and frailty state transition. bmc geriatrics. 2019;19(1). doi:10.1186/s12877-019-1198-8 27. vestergaard s, nayfield sg, patel kv, et al. fatigue in a representative population of older persons and its association with functional impairment, functional limitation, and disability. j gerontol a biol sci med sci. 2009;64(1):76-82. doi: 10.1093/gerona/gln017. pmid 19176328. 28. tolea mi, costa pt, terracciano a, et al. sexspecific correlates of walking speed in a wide ageranged population. j gerontol s b psychol soc sci. 2010;65b(2):174-84. 29. lenardt mh, sousa jr, carneiro nhk, et al. physical activity of older adults and factors associated with pre-frailty. acta paul enferm. 2013;26(3):269-75. doi: 10.1590/s0103-21002013000300011. 30. rensa r, setiati s, laksmi pw, rinaldi i. factors associated with physical frailty in elderly women with low socioeconomic status in urban communities: a c r o s s s e c t i o n a l s t u d y. a c t a m e d i n d o n e s . 2019;51(3):220-229. pmid: 31699945 31. silva ta, frisoli junior a, pinheiro mm, et al. sarcopenia and aging: etiological aspects and therapeutic options. rev bras reumatol. 2013;46(6):391-7. 32. h u o y r , s u r i y a a r a c h c h i p, g o m e z f, e t a l . comprehensive nutritional status in sarcoosteoporotic vol 52 • number 1 • january 2020 sarcopenia and frailty profile in the elderly community of surabaya 13 older fallers. j nutr health aging. 2015;19(4):474-80. doi: 10.1007/s12603-014-0543-z. pmid 25809813. 33. masanes f, rojano i, luque x, et al. cut-off points for muscle mass–not grip strength or gait speed-determine variations in sarcopenia prevalence. j nutr health aging. 2017;21:825-9. 34. molina-garrido mj, guillén-ponce c, fernández-félix bm. relationship between sarcopenia and frailty in a spanish cancer in the elderly unit: the oncosarco project. j am med dir assoc. 2016;17(8):760-1. doi: 10.1016/j.jamda.2016.04.025. pmid 27287932. 35. de groot cp, perdigao al, deurenberg p. longitudinal changes in anthropometric characteristics of elderly europeans. seneca investigators. eur j clin nutr. 1996;50;suppl 2:s9-15. pmid 8841780. 36. newman ab, lee js, visser m, et al. weight change and the conservation of lean mass in old age: the health, aging and body composition study. am j clin nutr. 2005;82(4):872-8; quiz 915. doi: 10.1093/ ajcn/82.4.872. pmid 16210719. 37. costa tb, neri al. indicators of physical activity and frailty in the elderly: data from the fibra study in campinas, são paulo state, brazil. cad saúde publ. 2001;27(8):1537-50. 38. rodrigues rap, scudeller pg, pedrazzi ec, et al. morbidity and interference in seniors’ functional ability. acta paul enferm. 2008;21(4):643-8. doi: 10.1590/s0103-21002008000400017. 39. pereira jc, barreto sm, passos vm. the profile of cardiovascular health of elderly brazilian people needs to improve: a population-based study. arq bras cardiol. 2008;91(1):1-10. doi: 10.1590/s0066782x2008001300001. pmid 18660938. 40. brigola ag, rossetti es, santos br. dos neri al, zazzetta ms, inouye k, pavarini sci. relationship between cognition and frailty in elderly: a systematic review. dementia neuropsychol. 2015;9(2):110–9. doi:10.1590/1980-57642015dn92000005. 41. sternberg sa, schwartz aw, karunananthan s, bergman h, mark clarfield a. the identification of frailty: a systematic literature review. j the american geriatrics society. 2011;59(11):2129–38. doi:10.1111 /j.1532-5415.2011.03597. 42. ávila-funes ja, pina-escudero sd, aguilar-navarro s, gutierrez-robledo lm, ruiz-arregui l, amieva h. cognitive impairment and low physical activity are the components of frailty more strongly associated with disability. j nutr health aging. 2011;15(8):683–89. doi:10.1007/s12603-011-0111-8. medical illustration giant recurrence pituitary adenoma after three times transphenoidal removal surgery, one craniotomy procedure, and 30 doses of external radiotherapy laurentius a. pramono1,2, em yunir1, tri juli e. tarigan1, syntia nusanti3, renindra a. aman4, indrati suroyo5 1 department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 2 department of public health and nutrition, school of medicine and health sciences universitas katolik indonesia atma jaya – department of internal medicine st carolus hospital, jakarta, indonesia. 3 department of ophthalmology, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 4 department of neurosurgery, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 5 department of radiology, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: em yunir, md., phd. division of endocrinology and metabolism, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: l_aswin@hotmail.com figure 1. dynamic pituitary mri revealed giant recurrence pituitary adenoma after four times surgery and 30 doses of external radiotherapy. 221acta med indones indones j intern med • vol 53 • number 2 • april 2021 laurentius a pramono acta med indones-indones j intern med 222 this is a case of 42nd year-old woman with history of sight loss in her both eyes. she experienced headache and visual field decrease gradually since 2014. after several laboratory and imaging examinations, from her dynamic pituitary magnetic resonance imaging (mri), it is concluded that she had a giant adenoma of the pituitary gland which compressed to her optic chiasm. from her pituitary laboratory hormone panel, it is revealed that the tumor is a nonfunctioning pituitary adenoma. from the neuroophthalmology (campimetry) examinations, she had papillae atrophy in her both eyes and also bilateral temporal hemianopia. the patient underwent transphenoidal removal surgery in june 2016, followed by laboratory and imaging evaluations afterward. the surgery was repeated three times due to recurrence detected by headache and worsening visual field and imaging; in november 2006 and april 2017 (both transphenoidal removal surgery) and the last surgery was done in november 2019 with craniotomy removal surgery techniques. all of the histopathology of the pituitary gland is benign pituitary adenoma. since the pituitary mass still reside and recur, pituitary team decided to radiate the recurrence pituitary adenoma with 30 doses of external beam radiotherapy (ebrt) at the department of oncology radiation in march 2020. after 30 doses of external radiation, from the hormonal examinations, the morning cortisol serum was 0.9 mcg/dl (normal 3.7 – 19.4 mcg/dl) and adrenocorticotrophic hormone (acth) was < 0.1 pg/ml (normal 7.2 – 63.3 pg/ml), indicate that she had a secondary adrenal insufficiency. this condition was treated by substitution of oral steroid. other pituitary figure 2. campimetry assessment revealed bilateral temporal hemianopia. vol 53 • number 2 • april 2021 giant recurrence pituatary adenoma after three times transphenoidal 223 hormones i.e. luteinizing hormone (lh), follicle stimulating hormone (fsh), thyroid stimulating hormone (tsh) were at the normal range. right now, the patient still complaining for her visual field loss, but no severe or extraordinary headache was perceived. dynamic pituitary magnetic resonance imaging (mri) 6 months and 1 year after external radiotherapy revealed that the size of the tumor is growing larger than before. pituitary mri explained there is a solid mass (size 6.4 x 6.3 x 4.2 cm) in axial and extra-axial of sella and parasella region, filled the sphenoidal sinus to left spatial and exert to surrounding intracranial structures. this condition is diagnosed with recurrence giant pituitary adenoma after four times surgery and optimal dose of external radiotherapy. it is a very rare, difficult, yet challenging case to resolve. prevalence of pituitary tumors is 80-100 cases per 100,000 with incidence 4 new cases in 100,000 each year. generally, pituitary tumors are common and easily treated by surgery and medical treatments. but, a small subset of pituitary tumors is classified as aggressive based on resistance to medical treatment and multiple recurrences despite standard therapies such as surgery, pharmacology, and external radiotherapy.1 at least 50% of surgically resected non-functioning pituitary adenomas will recur.2 about 30% of patients will show tumor regrowth 0.4-37 years after surgery. the risk of progression is higher in the case of residual tumor and extrasella region.1 our patient experienced recurrence detected by sign and symptom of worsening of her visual field and by the evaluation of imaging study (mri) which done every 6 months after surgery. after four times of surgery (one of which by craniotomy procedure) and 30 doses of external radiotherapy, the tumor still regrowth in a not so long-time evaluation. there are some options for recurrence and aggressive non-functioning pituitary adenoma, such as surgery revision, external radiotherapy, and medical treatments. surgical revision is eventually needed in 30-50% of non-functioning pituitary adenomas after surgery.3 however, this is not an option for our patient because we have done four removal surgeries before. external radiotherapy may look a good option since the efficacy is doubtless and late radiotherapy seems as effective as early treatment for local control.3 but again, our patient has undergone 30 doses of radiotherapy last year. so, in our pituitary team meeting, panel experts suggest the patient will not undergo surgery and external radiotherapy anymore. medical and palliative therapy is the treatment of choice at this point. clinical practice guidelines from european society for endocrinology (ese) has published recommendations for medical treatments for aggressive and recurrence pituitary adenoma. they recommend the use of temozolomide as first line chemotherapy. the standard dose regimen is 150-200 mg/m2 for 5 consecutive days every 28 days. first evaluation of treatment response must be done after 3 cycles.1 if radiological progression is demonstrated, temozolomide treatment should be ceased. it has been suggested to examine mgmt status by immunohistochemistry by an expert neuropathologist. low expression of mgmt content in immunohistochemistry correlate with more positive response to temozolomide.4 however, a trial of temozolomide may be considered in patients with high mgmt expression. combination of temozolomide and other chemotherapy drugs such as capecitabine, thalidomide, and bevacizumab is also being reported in case reports, but the efficacy is still need to study further.1 a n o t h e r d r u g w h i c h c a n b e u s e d i s cabergoline, a dopamine agonist usually used for treating prolactinoma. in difficult and recurrence pituitary tumors, cabergoline can be an option.3 recently, researcher have conducted a randomized clinical trial which showed cabergoline as an effective drug for treating residual non-functioning pituitary adenoma. cabergoline shows 70% efficacy for shrinking non-functioning pituitary adenomas.5 since medical treatment was the only option for our patient at this point, we give cabergoline and plan to carry out immunohistochemistry (mgmt staining) for the patient as a requirement for our patient to get temozolomide from our national health insurance. laurentius a pramono acta med indones-indones j intern med 224 references 1. raverot g, burman p, mccormack a, et al. european society of endocrinology clinical practice guidelines for the management of aggressive pituitary tumours and carcinomas. eur j endocrinol. 2018;178:g1-24. 2. delgado-lopez pd, pi-barrio j, duenas-polo mt, gordon-bolanos mc. recurrent non-functioning pituitary adenomas: a review on the new pathological classification, management guidelines and treatment options. clin transl oncol. 2018;20(10):1233-45. 3. hayhurst c, taylor pn, lansdown aj, palaniappan n, rees da, davies js. current perspectives on recurrent pituitary adenoma: the role and timing of surgery vs adjuvant treatment. clin endocrinol (oxf). 2020;92(2):89-97. 4. kontogeorgos g, thodou e. is mgmt the best marker to predict response of temozolomide in aggressive pituitary tumors? alternative markers and prospective treatment modalities. hormones (athens). 2019;18(4):333-7. 5. lin s, zhang a, zhang x, wu zb. treatment of pituitary and other tumours with cabergoline: new mechanisms and potential broader applications. neuroendocrinology. 2020;110(6):477-88. 298 original article acta medica indonesiana the indonesian journal of internal medicine effective dose and adverse effects of maintenance bacillus calmette-gue´rin in intermediate and high risk non-muscle invasive bladder cancer: a meta-analysis of randomized clinical trial ari astram1, adianti khadijah1, prahara yuri2, ahmad zulfan2, chaidir a. mochtar1, r. danarto2, rainy umbas1, agus rizal a.h. hamid1, 1 department of urology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of surgery, faculty of medicine universitas gadjah mada dr. sardjito hospital, yogyakarta, indonesia. correspondence mail: agus rizal ah hamid, md. department of urology, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, po box 1086, indonesia. email: rizalhamid.urology@gmail.com. abstrak tujuan: mengevaluasi dosis efektif dan efek samping pemberian bcg. metode: dilakukan pencarian publikasi uji klinis acak di medline dan cochrane sebelum oktober 2013. penelitian yang berkaitan dengan pemberian bcg setelah tur dan pemantauannya pada pasien kanker kandung kemih non-otot invasif (kkknio) dengan risiko sedang dan tinggi dimasukkan sebagai kriteria inklusi. kriteria eksklusi meliputi pasien kkknio risiko rendah, pemberian bcg dengan dosis lain dan kanker buli infasif otot. hasil: studi meta-analisis 6 uji klinis yang meliputi 2719 pasien kkknio risiko sedang-tinggi menunjukkan angka kekambuhan setelah pemberian dosis penuh (81 mg), dosis rendah (27 mg) dan dosis sangat rendah (13,5 mg) berturut-turut 33,3%, 34,7%, dan 30%. meta analisis (2175 pasien), dosis bcg 81 mg menghasilkan hasil yang lebih baik dari dosis 27 mg dalam mengurangi kekambuhan tumor (rr 0,86; 95% ci 0,77-0,96, i2 = 0% dan p=0,008). meta-analisis (544 pasien), efektivitas dosis rendah dinilai lebih tinggi dibandingkan dengan dosis sangat rendah (rr 0,66; 95% ci 0,49-0,89, i2 = 8,8% dan p=0,006). efek samping sistemik terjadi pada 25% dosis tinggi, 28,5% dosis rendah, dan 15,5% dosis sangat rendah. dosis rendah dinilai superior terhadap dosis penuh pada efek samping sistemik (p=0,000) namun tidak terhadap efek samping lokal (p=0,137) pada 2 meta analisis (1816 pasien). kesimpulan: dosis penuh bcg memiliki hasil superior dalam hal menurunkan angka kekambuhan kkknio dibandingkan dengan dosis rendah atau sangat rendah. tidak ada perbedaan bermakna antara dosis terhadap efek samping lokal. namun, dosis penuh memiliki angka efek samping sistemik yang lebih tinggi dibandingkan dengan dosis rendah dan sangat rendah. kata kunci: bacillus calmette-gue´rin, dosis dan efek samping, kanker kandung kemih non-otot invasif (kkknio). abstract aim: to evaluate the effective dose and adverse effects of bcg doses. methods: we searched published rcts in medline and cochrane database before october 2013. article using maintenance bcg after tur in intermediate-high risk non-muscle invasive bladder cancer (nmibc) and followed for effectiveness, local and systemic side effect are included. low risk patients, other dose and mibc were excluded. results: metavol 46 • number 4 • october 2014 effective dose and adverse effects of maintenance bacillus calmette-guerin 299 analysis of 6 clinical trials involving 2719 intermediate-high risk nmibc patients showed recurrence rate in full dose (81 mg), low dose (27 mg) and very low dose (13.5 mg) were 33.3%, 34.7% and 30%, respectively. meta-analysis of 2175 patients, 81 mg bcg was found to be superior to 27 mg in reducing tumour recurrences (rr 0.86; 95% ci 0.77-0.96, i2 = 0% and p=0.008). meta-analysis of 544 patients, the effectiveness reducing tumour recurrences in 27 mg bcg was found to be superior to 13,5 bcg (rr 0.66; 95% ci 0.49-0.89, i2 = 8.8% and p=0.006). systemic side effects were happened in 25%, 28.5%, and 15.5% in the doses 81.27 and 13.5 mg bcg, respectively. low dose was superior to full dose in affecting systemic side effect (p=0,000) but no difference in affecting local side effect (p=0.137) in the meta-analysis of 1816 patients in 2 clinical trials. conclusion: full dose bcg had superior outcome to reduce recurrences compared to low dose and very low dose. there were no significant differences between each dose in local side effect. however full dose regimen has higher systemic side effect compared to low and very low dose. key words: bacillus calmette-gue´rin, dose and adverse effect, non-muscle invasive bladder cancer (nmibc). introduction non muscle invasive bladder cancer is characterized by a high risk of recurrence and progression to a muscle invasive disease.1 the individual estimated risk of recurrence and progression can be calculated by using t h e r i s k s c o r e i n t r o d u c e d b y e u r o p e a n organisation of research and treatment of cancer (eortc) risk table or a simplified risk group classification.2,3 intravesical instillation of bacilus calmette-guerin ( bcg ) is the most effective adjuvant therapy after transurethral resection of intermediate or high risk superficial bladder tumours and recommended as the first line treatment for patients with carcinoma in situ.2,4,5 in the intermediate and high risk patients, the protective effect of long term therapy bcg are more pronounced compared with chemotherapy.6,7 since the introduction of bcg in the mid 1970s for the treatment and prophylaxis of superficial bladder tcc, it has become the biological response modifier of choice for tumours at high risk of recurrence and progression.8 several randomised trials and meta-analyses published threafter suggested that maintenance bcg instillations during 1-3 years is superior to both chemotherapy and induction bcg alone in reducing recurrences and even progression to muscle-invasive disease.3,7,9-11 morales et al mentioned that induction bcg instilation performed every 6 week and aditional bcg instilation reduce recurrence but optimal duration of maintenance instilation remains controversial.9,12,13 based on several metaanalysis, the eau guidelines recommend at least 1 year of maintenance. bcg can produce either local or systemic adverse effects such as bacterial or chemical cystitis, dysuria, frequency, hematuria, granuloma prostatitis, epididymitis, urethral obstruction and contracted bladder, fever, influenza like symptoms include general malaise and chills, lung infection, liver toxicity and sepsis. the occurrence of adverse effects is one of the main reasons why urologist try to avoid the use of bcg, particulary in intermediate-risk patients, for whom chemotherapeutic agents are often prescribed. bcg efficacy and toxicity are dosedependent and the problem lies in finding a very low bcg dose that is effective and has low toxicity. a reduction in side effects might be achieved in several different ways, for example, by reducing the bcg dose, administration of the antituberculosis drug inh,6,14 antibiotic ofloxacin,15 or by reducing its dose. however, the optimal duration of maintenance instillation remains controversial.4,8,16 by the late 1980s, two groups were trying lower doses than normal in an attempt to decrease the frequency and intensity of adverse reactions but the lack of agreement among these studies induced the spainish urological club for oncological treatment (cueto: club urologico espanol de tratamiento oncologico) to undertake a study to ascertain the therapeutic value and toxic effect of a three-fold lower dose of bcg compared with the standard dose.17,18 the aim of this study is to find effective ari astram acta med indones-indones j intern med 300 dose and evaluate dose related local as well as systemic side effects of bcg. methods review questions and study protocols the proposed questions aimed to be answered by our study are what is the effective dose and what are the side effects of maintenance bcg in intermediate and high risk non-muscle invasive bladder cancer? this meta-analysis are conducted under guidance of quality of reporting of meta-analysis (quorom) statements. literatures search we searched literatures in medline and cochrane database before october 2013 using systematic searching strategy with keywords “dose and side effect”, “intermediate and high”, “non-muscle invasive bladder cancer”, “bacillus calmette-guerin”. only english language papers were included in this study. eligibility criteria this meta-analysis is performed based on published randomized controlled trials. inclusion criterias were: a). publication which use single bcg instilation with full dose (81 mg), low dose (27 mg) and very low dose (13.5 mg) after transurethral resection, b). patient with moderate and high risk nmibc, c). follow up for local side effects (bacterial or chemical cystitis, frequency, hematuria, granulomatous prostatitis, epididimytis, ureteral obstruction and scar tissue in bladder) and systemic side effects (fever more than 39ºc, influenza like symptoms such as chill and malaise, bcg induced lung infection, liver toxicity and sepsis induced bcg). exclusion criterias were: a). low risk nmibc patient, b). other dose of bcg, c). invassive bladder cancer. data extraction and statistical analysis data extracted from each trial consisted of sample size, mean follow up duration, bcg doses consisted of full dose (81 mg), low dose (27 mg) and very low dose (13.5 mg), regimen of bcg therapy, local and systemic side effect of each dose. statistical analysis using fixed effects model or random effects model with mantzel haenzel methods to calculate relative risk and 95% confidence interval and compared every dose given. authors assessed the heterogeneity by calculating the i2 statistic (low (25%50%), moderate (50%-75%) and high (>75%). all analysis performed using stata statistical software version 12.0 (statacorp). results from 429 publications authors selected 20 publications. there are only 6 randomized controlled trial (rct) which were feasible for further meta-analysis (figure 1). meta-analysis from 6 rct from 2719 patients with intermediate and high risk non muscle invasive bladder cancer patients, the recurrence rate for full dose (81 mg), low dose (27 mg) and very low dose (13.5 mg ) was 33.3% (374/1120), 27.5% (365/1323) and 30% (83/276) (table 1). 429 published publications are identified and screened 20 publications retrieved for more detailed evaluation 6 potentially appropriate rcts to be include in meta-analysis 409 published publications are excluded 14 publications excluded because did not meet detailed inclusion criteria figure 1. literature searching meta-analysis from 4 rct which compared full dose (81 mg) bcg (with the mean follow up 77,3 months) and low dose (27 mg) (mean follow up 70 months ) in 2175 patients found that full dose of bcg was superior over low dose in reducing reccurence nmibc 33.3% and 38.5% respectively (rr 0.86; 95% ci 0.77-0.96, i2 = 0% and p=0.008). (figure 2) the results of two rct with 544 nmibc patient with moderate and high risk patients, comparing effectivity of low dose bcg (268 patient with mean follow up 58.2 months) and very low dose bcg (276 patient with mean follow up 58.5 months) to reduce reccurence rates found that low dose bcg was superior than very low dose (rr 0.66; 95%ci 0.49-0.89, i2 = 8.8% and p=0.006). about 20.1% patients with low dose vol 46 • number 4 • october 2014 effective dose and adverse effects of maintenance bacillus calmette-guerin 301 table 1. recurrence rate in clinical trial compared full dose bcg with low dose bcg as nmibc therapy study year inclusion criteria therapy regimen dose p n total full dose n/n mean followup low dose n/n mean followup odden j et al1 2013 pt1g3or multipel pta–t1, grade 1–3 bladder urothelial carcinoma once a week for 6 week, after that every 3 week on 3, 6, 12, and 18 month 0.045 1355 276/677 85.2 mo 311/678 85.2 mo martinez ja et al8 2002 ta, t1, dan tis bladder cancer once a week for 6 week, after that every 2 week for 6 times 0.58 499 29/252 69 mo 33/247 69 mo semper m et al19 2010 carcinoma insitu (cis) bladder every 3 week at 3, 6, 12, and 18 month >0,05 138 34/93 76 mo 34/93 55 mo unda m et al20 2009 ta-t1 giii and or carcinoma insitu (cis) bladder every 3 week on 3, 6, 12, and 18 month >0.05 183 35/98 79 mo 35/98 71 mo total 2175 374/1120 77.3 mo 406/1055 70 mo table 2. recurrence rate in clinical trials compared low dose with very low dose bcg in nmibc therapy study year inclusion criteria therapy regimen dose p total n low dose n/n mean followup very low dose n/n mean followup ojea a et al4 2007 tag2 and t1g12 bladder cancer once a week for 6 weeks, continue every 2 week for 12 weeks 0.517 281 38/142 53.7 mo 50/139 61.2 mo march n et al21 2002 t1g1-2 bladder cancer once every 6 week,continue every 2 week for 12 weeks 0.58 263 16/126 62.7 mo 33/137 55.9 mo total 544 54/268 58.2 mo 83/276 58.5 mo figure 2. forest plot reccurence rate full dose compared with low dose of bcg. ari astram acta med indones-indones j intern med 302 bcg experience reccurence compare with 30% patient with very low dose bcg. (figure 3) in meta-analysis from 4 rct with total 2360 moderate-high risk nmibc patient, incidence local side effect after full dose, low dose and very low dose bcg instilation were 59.3% (537/905), 60.0% (708/1179), and 63.7% (176/276). systemic side effects occured in 25.4% (230/905), 28.5% (337/1179), and 15.5% (43/276) respectively.(table 3 and 4) in meta-analysis with 1816 patient, there was no significant difference in local side effect (p=0.137), but low dose was better to reduce systemic side effect (p=0.000). in meta-analysis with 544 patient given low dose and very low dose bcg also had no significant difference figure 3. forest plot reccurence rate in low dose patient compared with very low dose of bcg table 3. study compared side effect full dose and low dose bcg in nmibc therapy study year inclusion criteria therapy regimen local side effect systemic side effect n total full dose n/n low dose n/n n total full dose n/n low dose n/n brausi m et al22 2013 pt1g3 or multiple pta– t1, grade 1–3 urothelial bladder cancer once a week for 6 weeks, continue every 3 weeks in 3,6,12 and 18 month 1316 412/657 414/659 1316 192/657 211/659 martinez ja et al8 2002 ta, t1, dan tis bladder cancer once a week for 6 weeks, continue every 2 weeks for 6 times 500 125/248 168/252 500 38/248 89/252 total 1816 537/905 528/911 1816 230/905 300/911 table 4. study compared side effect low dose and very low dose bcg in nmibc therapy study year inclusion criteria therapy regimen local side effect systemic side effect n total low dose n/n very low dose n/n n total low dose n/n very low dose n/n ojea a et al4 2007 tag2 dan t1g1-2 bladder cancer once every 6 week, continue every 2 weeks for 12 weeks 281 93/142 89/139 281 16/142 15/139 march n et al21 2002 t1g1-2 bladder cancer once a weeks for 6 weekss, continue every 2 weeks for 12 weeks 263 87/126 87/137 263 21/126 28/137 total 544 180/268 176/276 544 37/268 43/276 vol 46 • number 4 • october 2014 effective dose and adverse effects of maintenance bacillus calmette-guerin 303 (p=0.400) and (p=0.600) (figure 4 and 5). discussion over 35 years ago, morales et al published the first study on the use of intravesical bcg immunotherapy for nmibc.22 efficacy of bcg instillation does not seem to be increased significantly when combined with intradermal bcg vaccination simultaneously.21 since then, several meta-analysis have shown that adjuvant intravesical treatment reduces nmibc recurrency. the choice between adjuvant intravesical tratments, namely chemotherapy or bcg immunotherapy, depends on the risk that needs to be reduced : recurrence or progressive. intravesical instillation of bcg reduces the risk of recurrence and delays the time to reccurence compared with transurethral alone or other drugs given intravesically. however the mechanism is not completely understood. the japanese groups suggest that cytokines play an important role in the effector mechanism of bcg, especially interleukin-2 (il-2) that can be used to monitor the reaction of a patient to bcg.23 this can be used to classify responders and non responders to bcg and tailored bcg schedule and doses.24 based on meta-analysis, maintenance bcg schedule was found to be essential in preventing progression.25 despite this advantages, bcg is not free from complications such as bacterial or chemical cystitis, dysuria, frequency, hematuria, granuloma prostatitis, epididymitis, urethral obstruction and contracted bladder, fever, influenza like symptoms include general malaise and chills, lung infection, liver toxicity and sepsis. a clinical trial by ojea et al. and march et al., on 544 moderate-high risk nmibc patients found that low dose bcg was more effective and significantly reduce recurrence compared to very low dose. oden et al., martinez et al., semper et al., and unda et al., who compare full dose with low dose in 2175 patient found that full dose seems better in reducing the reccurence of tumor. figure 4. forest plot local side effect of full dose, low dose and very low dose bcg ari astram acta med indones-indones j intern med 304 the mechanisms by which bcg leads to the development of infectious complications is not fully understood. one explanation is its action as an immunotherapeutic agent on helper t cell cytokine profile known as the “th1 response”.26 considerable debate exists about whether infectious complications due to bcg represent a hypersensitivity reaction or ongoing active infection. the hypersensitivity hypothesis gained early attention based upon the presence of granulomas and the absence of recoverable organisms. in a number of case reports, acidfast bacilli have not been demonstrated and organisms have not grown despite a high clinical suspicion of bcg infection.27,28 a response to glucocorticoids, administered along with antituberculous drugs, has also supported the notion of a hypersensitivity response. the fastidious growth nature of bcg in culture and a doubling time of 24 to 48 hours contribute to the difficulty in its isolation. it should be emphasized that >95% of patients tolerated bcg without significant morbidity. most of symptoms associated with bcg immunotherapy are a result of immune stimulation that is required to effectively eradicate cancer cells. these symptoms include urinary frequency and burning, mild malaise and low grade fever.29 local side effect includes bacterial or chemical cystitis, dysuria, frequency, haematuria, granulomatous prostatitis, epididymitis, urethral obstruction and contracted bladder. the most common local side effect was drug induced cystitis, manifested as iritative voiding with negative urine culture and hematuria that resolves in 48 hours without the need to stop bcg instilation.30-32 systemic side effects include fever (>39oc), influenza like symptoms, including general malaise and chills, bcg induced lung infection, liver toxicity, and sepsis. figure 5. forest plot systemic side effect of full dose, low dose and very low dose bcg vol 46 • number 4 • october 2014 effective dose and adverse effects of maintenance bacillus calmette-guerin 305 even, rare severe systemic reaction of bcg can be found due to active infection with immune response, such as systemic granulomatous disease with high fever that can progressed into multi organ failure. onset of the symptoms can be months until years after last instilation. this phenomenon may be due to the prescence of bcg for long time in body. skin rash, atralgia and arthritis were classified as possible allergic reactions. fever, which occurred predominantly in bcg-sensitised patients, was the only factor in a multivariate analysis significantly related to a decreased recurrence rate and increased toxicity. drug related life threatening side effect such as septic bcg could be occurred due to systemic bcg absorption.30 maintenance bcg has been suggested by many authors as the treatment of choice for patients with high risk superficial bladder cancer or carcinoma insitu.25,28 this is reflected in various guidelines on non muscle invassive bladder cancer that include bcg as first line adjuvant therapy after transurethral resection in high risk patient.2,5 the widely accepted maintenance schedule is based on southwest oncology group regimen, starting with series of six weekly induction followed by three weekly instilation at 3 months and then every 6 months for 3 year.9 european association of urology guidelines recommend at least 1 year of bcg maintenance therapy.2 however, the side effects make urologists reluctant to administer bcg to their patient when the disease is not high risk. thus, it is important to decrease bcg toxicity while maintaining its efficacy. there are some ways to overcome the bcg side effects such as administration of isoniazid 300 mg daily or dose reduction. patient with evidence of bcg infection such as epididimytis, hepatitis or symptomatic prostatitis are treated with isoniazid plus rifampin 600 mg daily. in eortc trial in which intravesical epirubicin, bcg and bcg plus isoniazid were compared in 957 patients. isoniazid does not seem to reduce the side effects of bcg. the most dangerous complication of bcg is systemic septic and/ or hypersensitivity reaction, characterized by chills, fever, hypotension, and progressive multi organ failure but the incidence of this event is very low 0.4%.29 in 2012, brausi21 compared side effects of low dose (27 mg) with full dose (81 mg) of maintenance bcg and concluded no significant difference in toxicity was detected according to dose (one-third dose vs full dose) or duration of treatment. a randomized prospective trial comparing a standard full dose (81 mg) of intravesical bcg with a reduced dose (27 mg) in superficial bladder cancer showed the proportion of patient with no toxicity, either local or systemic, was significantly higher in the reduced dose than in stnadard dose.8 the difference in severe systemic toxicity were not significant, indeed 4.4% of patient in the reduce dose group and 3.6% in the standard dose. neither life – threatening episodes nor sepsis were reported for either group. there is a report of granulomatous epididimytis and simultanoeus polyneuropathy in reduced dose patient, but whether it was caused by bcg is unclear. a randomized prospective trial comparing adjuvant therapy for intermediate risk superficial bladder cancer between one-third dose, full dose bcg and mitomycin c concludes the disease free interval was significantly longer after treatment with bcg 27 mg and the number of recurrence was lower in bcg 27 mg than in 30 mg mitomycin c group. this study suggests that the minimum effective dose of bcg is one third of the standard dose. one sixth of standard dose is not indicated as adjuvant treatment for superficial bladder cancer of intermediate risk because it has the same efficacy as mitomycin c 30 mg but is more toxic. in fact, the toxicity level of one sixth of the standard dose is similar to that observed with one third of the standard dose.4 march21 in his study compared 30 mg mmc with 27 mg and 13.5 mg bcg as adjuvant therapy in medium and low risk superficial bladder cancer. the recurrent rate was lower in 27 mg bcg group but the time to recurrence also higher in this group. no significant difference between other groups, and there were no significant difference in adverse effect between the two bcg treatment groups. ari astram acta med indones-indones j intern med 306 conclusion full dose (81 mg) of bcg showed slightly superior effect in reducing recurrences compared to low and very low dose in moderate–high risk non muscle invasive bladder cancer following transurethral resection. low dose bcg had less systemic side effect compared to full dose, however it had no difference in all doses regimen for local side effects. bcg instilation in moderate-high risk nmibc patient should be considered as primary therapy in indonesia. references 1. oddens j, brausi m, sylvester r, et al. final result of an eortc – gu cancers group randomized study of maintenance bacillus calmette – guerin in intermediate – and high risk ta, t1 papilary carcinoma of the urinary bladder : one-third dose versus full dose and 1 year versus 3 years of maintenance. eur urol. 2013;63:462-72. 2. brausi m, witjes ja, lamm d, et al. a review of current guidelines and best practie recommendation for the management of non-musclinvasive baldder cancer by the international bladder cancer groups. j urol. 2011;186:2158-67. 3. sylvester rj, van der meijden ap, oosterlinck w, et al. predicting recurrence and progression in individual atients with stage ta t1 bladder cancer using eortc risk tables: a combined analysis of 2596 patients from seven eortc trials. eur urol. 2006;49:466–77. 4. ojea a, nogueira jl, solsona e, et al. cueto group (club urolo´ gico espan˜ol de tratamiento oncolo´ gico). a multicentre, randomized prospective trial comparing three intravesical adjuvant therapies for intermediate-risk superficial bladder cancer: low-dose bacillus calmette-guerin (27 mg) versus very low-dose bacillus calmetteguerin (13.5 mg) vs mitomycin c. eur urol. 2007;52:1398–406. 5. babjuk m, oosterlinck w, sylvester r, et al. european association of urology (eau). eau guidelines on non-muscle-invasive urothelial carcinoma of bladder; the 2011 update. eur urol. 2011;59:997-1008. 6. sylvester rj, brausi ma, kirkels wj, et al. long –term efficacy result of eortc genito-urinary group randomized phase 3 study 30911 comparing intravesical instillations of epirubicin, bacillus calmette guerin and bacillus galmette guerin plus isoniazid in patient with intermediate and high risk stage tat1 urothelial carcinoma of the bladder. eur urol. 2010;57:766-73. 7. malmstrom pu, sylvester rj, crawford de, et al. an individual patient data meta-analysis of the long term outcome of randomised studies comparing intravesical mitomycin c versus bacillus calmette guerin for non-muscle-invasice bladder cancer. eur urol. 2009;56:247-56. 8. martı´nez-pin˜eiro ja, flores n, isorna s, et al. cueto (club urolo´ gico espan˜ol de tratamiento oncolo´ gico). long-term follow-up of a randomized prospective trial comparing a standard 81 mg dose of intravesical bacillus calmette-guerin with a reduced dose of 27 mg in superficial bladder cancer. bju int. 2002;89:671–7. 9. lamm dl, blumenstein ba, crissman jd, et a l . m a i n t e n a n c e b a c i l l u s c a l m e t t e g u e ´ r i n immunotherapy for recurrent ta, t1 and carcinoma in situ transitional cell carcinoma of the bladder: a randomized southwest oncology group study. j urol. 2000;163:1124–9. 10. bohle a, bock pr. intravesical bacillus calmetteguerin versus mitomycin c in superficial bladder cancer: formal meta-analysis of comparative studies on tumour progression. urology. 2004;63:682–6. 11. bohle a, jocham d, bock pr. intravesical bacillus calmette-guerin versus mitomycin c for superficial bladder cancer: a formal meta-analysis of comparative studies on recurrence and toxicity. j urol. 2003;169:90– 5. 12. hinotsu s, akaza h, naito s, et al. maintenance therapy with bacillus calmette-gue´ rin connaught strain clearly prolongs recurrence-free survival following transurethral resection of bladder tumour for non–muscle-invasive bladder cancer. bju int. 2011;108:187–95. 13. kavoussi lr, torrence rj, gillen dp, et al. results of 6 weekly intravesical bacillus calmette-gue´ rin instillations on the treatment of superficial bladder tumors. j urol. 1988;139:935–40. 14. van der meijden ap, brausi m, zambon v, kirkels w, de balincourt c, sylvester r, members of the eortc genito-urinary group. intravesical instillation of epirubicin, bacillus calmette-guerin and bacillus calmette-guerin plus isoniazid for intermediate and high risk ta, t1 papillary carcinoma of the bladder: a european organization for research and treatment of cancer genito-urinary group randomized phase iii trial. j urol. 2001;166:476–81. 15. vegt pd, van der meijden ap, sylvester r, brausi m, ho¨ ltl w, de balincourt c. does isoniazid reduce side effects of intravesical bacillus calmette-guerin therapy in superficial bladder cancer? interim results of eortc protocol 30911. j urol. 1997;157:1246–9. 16. colombel m, saint f, chopin d, malavaud b, nicolas l, rischmann p. the effect of ofloxacin on bacillus calmette-guerin induced toxicity in patients with superficial bladder cancer: results of a randomized, prospective, double-blind, placebo controlled multicenter study. j urol. 2006;176:935–9. 17. rintala e, jauhiainen k, alfthan o et al. mitomycin c and bcg in intravesical chemotherapy and vol 46 • number 4 • october 2014 effective dose and adverse effects of maintenance bacillus calmette-guerin 307 immunotherapy of superficial bladder cancer. in: debruyne f, denis l, van der meijden apm, eds, eortc genito-urinary group monograph 6: bcg in superficial bladder cancer. new york: alan r liss 1989. p. 271–4. 18. pagano f, bassi p, milani c et al. low-dose bcg pasteur strain in the treatment of superficial bladder cancer: preliminary results. in: debruyne f, denis l, van der meijden apm, eds, eortc genito-urinary group monograph 6: bcg in superficial bladder cancer. new york: alan r liss; 1989. p. 256–61. 19. semper m, jarabo r, solsona e, fernandez j, dorrego jm et al. treatment of carcinoma in situ of the bladder associated or not associated to non-muscle invasive transitional carcinoma using two different bcg doses: the standard or onethird dose. a five year follow-up. eur urol supp. 2010;9:91. 20. unda m, madero r, solsona e, gomez jm, martinespineiro ja, ojea a. long-term follow up of the effectiveness of standard dose bcg (81 mg. connaught strain) comparing with a three fold reduce dose (27 mg.) in high risk non muscle invasive bladder cancer. cueto group. eur urol supp. 2009;8:284. 21. march n, solsona e, unda m, ojea a et al. a multicenter and randomized prospective study comparing three intravesical therapies, two with bacillus calmette-gue´rin immunotherapy and one with mitomycin-c chemotherapy in medium and low risk superficial bladder tumours. eur urol supp. 2002;1:101. 22. brausi m.a, oddens j.r, sylvester r.j, bono a.v, et.al. bacillus calmette-guerin: one third dose versus full dose and one year versus three years of maintenance. final result of an eortc gu cancers group randomized trial in non muscle invasive bladder cancer. eur urol. 2013;63(3):462-72. 23. morales a, eidinger d, bruce aw. intracavitary bacillus calmette-guerin in the treatment of superficial bladder tumors. j urol. 1976;116:180–3. 24. luftenegger w, ackermann dk, futterlieb a, et al. intravesical versus intravesical plus intradermal bacillus calmette-gue´ rin: a prospective randomized study in patients with recurrent superficial bladder tumors. j urol. 1996;155:483–7. 25. van rhijn bwg, burger m, lotan y, et al. recurrence and progression of disease in non–muscle-invasive bladder cancer: from epidemiology to treatment strategy. eur urol. 2009;56:430–42. 26. shintani y, sawada y, inagaki t, kohjimoto y, uekado y, shinka t. intravesical instillation therapy with bacillus calmette-gue´rin for superficial bladder cancer: study of the mechanism of bacillus calmettegue´rin immunotherapy. int j urol. 2007;14:140–6. 27. saint f, kurth n, maille p, et al. urinary il-2 assay for monitoring intravesical bacillus calmette-gue´rin response of superficial bladder cancer during induction course and maintenance therapy. int j cancer. 2003;107: 434–40. 28. sylvester rj, van der meijden ap, lamm dl. intravesical bacillus calmette-guerin reduces the risk of progression in patients with superficial bladder cancer: a meta-analysis of the published results of randomized clinical trials. j urol. 2002;168:1964–70. 29. mitropoulos dn. novel insights into the mechanism of action of intravesical immunomodulators. in vivo. 2005;19:611. 30. case records of the massachusetts general hospital. weekly clinicopathological exercises. case 29-1998. a 57-year-old man with fever and jaundice after intravesical instillation of bacille calmette-guérin for bladder cancer. n engl j med. 1998;339:831. 31. elkabani m, greene jn, vincent al, et al. disseminated mycobacterium bovis after intravesicular bacillus calmette-gue’rin treatments for bladder cancer. cancer control. 2000;7:476. 32. lamm d. efficacy and safety of bacillecalmette guerin immunotherapy in superficial bladder cancer. clinical infect disease. 2000;31:s86-90. case report 134 acta medica indonesiana the indonesian journal of internal medicine chemotherapy-induced spontaneous pneumothorax: case series een hendarsih, trinugroho h. fadjari, amaylia oehadian department of internal medicine, hasan sadikin hospital, bandung, indonesia. corresponding author: een hendarsih, md. division of hematology and medical oncology, department of internal medicine, hasan sadikin hospital. jl. pasteur no. 38, bandung, indonesia. email: hendarsih_een@hotmail.com. abstrak kami laporkan 2 orang pasien dengan limfoma dan rabdomiosarkoma dengan metastasis paru yang mengalami pneumotoraks spontan setelah kemoterapi. kasus 1, seorang pria berusia 43 tahun, datang dengan keluhan sesak napas 10 hari sebelum masuk rumah sakit. tidak ada riwayat trauma atau terapi tuberkulosis sebelumnya. tiga minggu sebelumnya pasien mendapat kemoterapi chop siklus pertama untuk limfoma non hodgkin’s stadium ii be. pada foto toraks didapatkan adanya pneumotoraks kanan. setelah mendapat terapi dengan pemasangan chest tube thoracotomy (ctt) selama 1 bulan, pasien mengalami perbaikan dan kemoterapi dilanjutkan tanpa komplikasi lebih lanjut. kasus 2, seorang pria 35 tahun datang dengan keluhan sesak napas dan nyeri dada pada hari keempat setelah kemoterapi sistemik siklus kedua untuk rabdomiosarkoma stadium iv (metastasis paru) dengan doksorubisin, ifosfamid, mesna, dan dacarbazin. foto toraks memperlihatkan adanya hidropneumotoraks bilateral. setelah terapi dengan pemasangan ctt selama 2 minggu, pasien mengalami perbaikan dan kemoterapi dilanjutkan tanpa komplikasi lebih lanjut. mekanisme pneumotoraks yang terjadi setelah kemoterapi belum jelas diketahui. terdapat beberapa hipotesis di antaranya: 1). pecahnya bula subpleura setelah kemoterapi; 2). pecahnya bula emfisematosa pada bagian paru yang mengembang akibat obstruksi parsial oleh tumor; 3). tumor lisis atau nekrosis akibat efek sitotoksik kemoterapi yang secara langsung menimbulkan pembentukan fistula. pada pasien dengan keluhan sesak napas dan nyeri dada mendadak yang terjadi setelah kemoterapi tumor yang bersifat kemosensitif, perlu dipikirkan kemungkinan terjadinya pneumotoraks spontan. penatalaksanaannya adalah dengan reekspansi paru. pneumotoraks yang diinduksi kemoterapi seharusnya dikelola sebagai kegawatdaruratan onkologi. kata kunci: pneumotoraks spontan, kemoterapi, tumor kemosensitif, kegawatdaruratan onkologi. abstract we present 2 patients who developed spontaneous pneumothorax (sp) following rapid regression of lymphoma and rhabdomyosarcoma with lung metastases. case 1, a 43-year old man was admitted to our hospital with dyspnea 10 days before admission. he denied any recent trauma or previous treatment for lung tuberculosis. three weeks prior to admission, he received first cycle of chop for non-hodgkin’s lymphoma stage ii be. chest x-ray consistent with right pneumothorax. after treatment with chest tube drainage for about 1 month, the patient recovered and chemotherapy could be continued without further complications. case 2, a 35year old man was admitted to other hospital with dyspnea and chest pain on day 4 after second cycle of systemic combined chemotherapy for rhabdomyosarcoma stage iv (lung metastases) with doxorubicin, ifosfamide, mesna, and dacarbazine. chest x-ray showed hydropneumothorax on right and left lung. after treatment with chest tube drainage about 2 weeks, the patient recovered and chemotherapy could be continued without further complications. the mechanism of pneumothorax following chemotherapy is not clearly understood yet, however, several vol 48 • number 2 • april 2016 chemotherapy-induced spontaneous pneumothorax hypotheses have been considered: 1) the rupture of a subpleural bulla after chemotherapy; 2) the rupture of an emphysematous bulla in an over expanded portion of the lung which is partially obstructed by a neoplasm; 3) tumor lyses or necrosis due to cytotoxic chemotherapy directly induces the formation of fistula. dyspnea and chest pain suddenly appear during successful chemotherapy for metastatic chemosensitive tumors should alert the physician to the possibility of sp. the treatment is directed toward lung re-expansion. chemotherapy induced pneumothorax should be considered as oncologic emergency. keywords: spontaneous pneumothorax, chemotherapy, chemosensitive tumors, oncologic emergency. introduction chemotherapy is one of the modalities of cancer treatments. the principal obstacles to the clinical efficacy of chemotherapy has been toxicity to the normal tissue of the body especially rapidly growing cells.1 many side effects of chemotherapy are predictable, depending on the drugs in the regimen, and can be prevented or easily diagnosed and managed effectively without causing substantial morbidity. many of these can cause unpredictable and rare side-effects, occurring in fewer than 1% of patients, which can develop as immediate lifethreatening illnesses.2 nowadays, spontaneous pneumothorax (sp) caused by chemotherapy has been reported sporadically. sp is generally observed in healthy young men, as a result of rupture of apical and/or subpleural blebs. pneumothorax can also occur secondary to a variety of pulmonary disorders such as chronic obstructive pulmonary disease (copd), pneumoconiosis, diffuse interstitial fibrosis, and infection diseases. iatrogenic factors are continuous positive pressure ventilation, closed-chest cardiac massage, and tracheostomy.3 although sp is a well known complication of primary lung cancer and metastatic lung disease, it is a rare complication of chemotherapy, with a reported incidence of less than 1%, and is commonly associated with chemosensitive tumours such as germcell tumours, lymphomas, and sarcomas and rarely with lung and gynaecological malignant disease.4-5 pneumothorax seems to occur 2–7 days after chemotherapy treatment and can be unilateral or bilateral.2 these complications should be kept in mind in order to avoid further sequelae. a search for the presence of intrapleural pathology by a thorough clinical and radiological evaluation should be made in all patients with unexplained dyspnea and chest pain after received chemotherapy. clinicians should be aware that spontaneous pneumothorax may be one of the manifestation of chemotherapy’s side effect. case illustration herein, we present 2 patients who developed sp following rapid regression of lymphoma and rhabdomyosarcoma with lung metastasis. case 1: a 43-year old man was admitted to our hospital with complaints of dyspnea and productive cough 10 days before admission. there were no history of fever, nor recent trauma or previous treatment for lung tuberculosis. three weeks prior to admission, he received first cycle of chop for non-hodgkin’s lymphoma stage ii be. he had tachypnea and tachycardia. on physical examination, we found left tracheal deviation, pulmonary examination revealed right sided hypersonor percussion notes and diminished breath sound on auscultation. his chest x-ray was consistent with right pneumothorax (figure 1). chest x-ray before chemotherapy was within normal limit (figure 2). mycobacterium tuberculosis was not detected in his sputum. we did not perform a chest computed tomography (ct) scan for evaluated lung involvement from lymphoma due to financial problem. according to british thoracic society ( b t s ) p l e u r a l d i s e a s e g u i d e l i n e 2 0 1 0 , patients with primary sp or secondary sp and significant breathlessness associated with any size of pneumothorax should undergo active intervention.6 in this patient, we inserted chest tube thoracotomy (ctt) in emergency room. 135 een hendarsih acta med indones-indones j intern med second cycle of chemotherapy was postponed. after treatment with chest tube drainage about 1 month and chemical pleurodesis was attempted using tetracycline, the patient recovered and chemotherapy could be continued without further complications. case 2 : a 35year old man was admitted to other hospital with dyspnea and chest pain on day 4 after second cycle of systemic combined chemotherapy for rhabdomyosarcoma of the upper left thigh stage iv (lung metastases) with doxorubicin, ifosfamide, mesna, and dacarbazine. there was no history of fever and no reducing dyspnea at rest. he had tachypnea and tachycardia. on physical examination, we found hypersonor on percussion and reduced vesicular breath sound on the both chest walls, without tracheal deviation. his chest x-ray showed hydropneumothorax on right and left lung (figure 3). based on bts pleural disease guideline 2010,6 we inserted ctt on bilateral hemithorax in emergency room. chest x-ray 24 hours after ctt insertion showed complete lung reexpansion (figure 4). after treatment with a chest tube drainage for about 2 weeks and chemical pleurodesis was attempted using tetracycline, the patient recovered and chemotherapy could be continued without further complications. figure 1. chest x-ray consistent with right pneumothorax. figure 2. chest x-ray before chemotherapy figure 3. chest x-ray on admission figure 4. chest x-ray performed 24 hours after insertion chest tube discussion sp in primary pulmonary neoplasm or lung metastases is very rare. however, sp seems to occur more often in patients with metastases from sarcomas, especially osteogenic sarcoma, than in patients with primary lung carcinoma.7 136 vol 48 • number 2 • april 2016 chemotherapy-induced spontaneous pneumothorax conversely, sporadic case reports describe sp due to lung metastases from teratomas, wilms’ tumors, melanomas, carcinomas of the kidney and pancreas, gynecologic malignancies, lymphomas, choriocarcinomas, and lymphangiomatosis.5,7 the mechanism of pneumothorax following chemotherapy is not clearly understood yet, however, several hypotheses have been considered:4-5,7-10 1) the rupture of a subpleural bulla after chemotherapy; or growing nodules can cause a check-valve effect, with subsequent overdistension of the alveoli, leading to the release of air into the interstitial tissues and eventual rup¬ture of a subpleural bleb 2) the rupture of an emphysematous bulla in an over expanded portion of the lung which is partially obstructed by a neoplasm; 3) tumor lyses or necrosis due to cytotoxic chemotherapy directly induces the formation of fistula. when small airways are narrowed by cancer invasion they act as a check valve, causing air trapping and dilation of distal alveolar spaces and eventual rupture. bronchopleural fistula can be caused by either direct tumor invasion or develop secondary to necrosis of a peripheral tumor from effective chemotherapy, or spontaneous vascular occlusion within the tumor itself. direct invasion of the pleura by tumor is also a possible mechanism though relatively uncommon.11 pneumothorax following radiation therapy and following bleomycin lung have been described. it is also possible that tumour invasion and disruption of the visceral pleura and of peripheral bronchioles might produce slow air leakage resulting in small clinically silent pneumothorax.4 lee proposed the temporal relationship between the use of combination chemotherapy and the development of pneumothorax as a consideration of chemotherapeutic’s side effects. for example, doxorubicin was the chemotherapeutic agent most likely to impair the wound healing with tissue repair, and may consequently predispose patients with pulmonary metastasis or underlying lung lesions to pneumothorax.12-13 in case 1, the pathogenesis of the sp may have involved the rupture of an emphysematous bulla in an over expanded portion of the lung which is partially obstructed by a neoplasm or tumor lyses or necrosis due to cytotoxic chemotherapy directly induces the formation of fistula. the mechanism of rupture of a subpleural bulla after chemotherapy is ruled out because patient is no-affected by copd according his medical history and he denied any recent trauma or previous treatment for lung tuberculosis. the rupture of an emphysematous bulla in an over expanded portion of the lung which is partially obstructed by a neoplasm mechanism is likely but ct scan and bronchoscopy not be done. the likelihood of tumor lyses or necrosis due to cytotoxic chemotherapy directly induces the formation of fistula mechanism is strengthened by responsiveness of the tumor to cytotoxic chemotherapy. this type of complication is not unique, as rapid shrinkage of abdominal lymphoma which is known to lead to perforation of the bowel in some patients.5 based on the mechanisms of the sp, it was always associated with lung involvement,8 but in present case, lung involvement not be evaluated. in case 2, the pathogenesis of the sp may have involved in the rupture of an emphysematous bulla in an over expanded portion of the lung which is partially obstructed by a neoplasm mechanism. our patient is a non smoker, has no previous history of sp and is not manipulated in any way, so attachment of the rupture of a subpleural bulla after chemotherapy mechanism is ruled out. the tumor lyses or necrosis due to directly induced formation of fistula mechanism of cytotoxic chemotherapy is unlikely, because chest x-ray showed no improvement of lung metastases after chemotherapy. the possibility mechanism of rupture of an emphysematous bulla in an over expanded portion of the lung which is partially obstructed by a neoplasm is more likely. however, we did not performed chest ct scan and bronchoscopy to confirm this. in both cases, doxorubicin was included in the cytotoxic regimen, however it is difficult to relate its direct effect on pneumothorax.12 we assumed that pneumothorax in our patients were triggered by the chemotherapy. t h e t r e a t m e n t o f s p s e c o n d a r y t o chemotherapy is directed toward lung reexpansion. a closed chest tube is usually unable to prevent recurrence of pneumothorax in such patient and ctt alone results on only partial 137 een hendarsih acta med indones-indones j intern med re-expansion of the lung.5,14 if an experienced thoracic surgeon is not available or in case patient refuses an operation or the operative risk is too high, chemical pleurodesis by instillation of a pleural irritant into the thoracic drain or by under local anaesthesia is an alternative to invasive surgical treatment.3,6 the report of the effectiveness of chemical pleurodesis in primary sp is well documented. in both our cases, chemical pleurodesis with tetracycline successfully results in lung re-expansion. this treatment was effective and at three months follow-up, both the patients have no recurrence of pneumothorax. conclusion sudden dyspnea and chest pain appearing d u r i n g c h e m o t h e r a p y f o r m e t a s t a t i c chemosensitive tumors should alert the physician to the possibility of sp. the treatment is directed toward lung re-expansion. chemical pleurodesis via chest tube may be an effective treatment strategy of pneumothorax. we suggest that chemotherapy-induced sp should be included in oncologic emergencies and require our awareness. references 1. devita vt jr, chu e. principles of medical oncology. in: devita, hellman, rosenberg, eds. cancer: principles and practice of oncology. 8 th ed. new york: lippincot williams & wilkins; 2008. p. 337-42. 2. morgan c, tillett t, braybrooke j, et al. management of uncommon chemotherapy-induced emergencies. lancet oncol. 2011;12:806–14. 3. van schil pe, hendriks jm, de maeseneer mg, et al. current management of spontaneous pneumothorax. monaldi arch chest dis. 2005;63:204-12. 4. fehr m, von moos r, furrer m, cathomas r. spontaneous pneumothorax during chemotherapy: a case report. onkol. 2010;33:527–30. 5. fiorelli a, vicidomini g, napolitano f, et al. spontaneous pneumothorax after chemotherapy for sarcoma with lung metastases: case report and consideration of pathogenesis. j thorac dis. 2011;3:138-40. 6. macduff a, arnold a, harvey j. on behalf of the bts pleural disease guideline group. management of spontaneous pneumothorax: british thoracic society pleural disease guideline 2010. thorax. 2010;65(suppl 2):18-31. 7. maniwa t, nakagawa k, isaka m, et al. institutional report thoracic oncologic. pneumothorax associated with treatment for pulmonary malignancy. interact cardiovasc thorac surg. 2011;13:257-61. 8. s r i n i v a s s , va r a d h a c h a r y g . s p o n t a n e o u s pneumothorax in malignancy: a case report and review of the literature. ann oncol. 2000;11:887-9. 9. mori m, nakagawa m, fujikawa t, et al. simultaneous bilateral spontaneous pneumothorax observed during the administration of gefitinib for lung adenocarcinoma with multiple lung metastases. intern med. 2005;44: 862-4. 10. zhang y, yang h, zhao m, et al. bilateral pneumothorax after bevacizumab-containing chemotherapy in fibrosarcoma. j thorac dis. 2012;4:229-31. 11. ahmed sa. spontaneous bilateral pneumothorax in a patient with metastatic synovial sarcoma while under chemotherapy. transl lung cancer res. 2012;1:28991. 12. lee ch, park uk, nah dy, won ks. bilateral spontaneous pneumothorax during cytotoxic chemotherapy for angosarcoma of the scalp: a case report. j korean med sci. 2003;18:277-80. 13. kelly e, mhurchu en, sukor s, et al. chemotherapya s s o c i a t e d r e c u r r e n t p n e u m o t h o r a c e s i n lymphangioleiomyomatosis. respir care. 2010;55: 1491-4. 14. nam hs, lee hj, kim ms, et al. erlotinib-related spontaneous pneumothorax in patient with primary lung cancer. tuberc respir dis. 2010;69:465-8. 138 medical illustration cushing’s syndrome: a large adenoma of adrenal gland m. adi soedarso1, k. hery nugroho2, erik prabowo1, devia e. listiana3, danu soesilowati4, a. gunawan santoso5 1 department of surgery, faculty of medicine, diponegoro university dr. kariadi hospital, semarang, indonesia. 2 department of internal medicine, faculty of medicine, diponegoro university dr. kariadi hospital, semarang, indonesia. 3 department of radiology, faculty of medicine, diponegoro university dr. kariadi hospital, semarang, indonesia. 4 department of pathology anatomy, faculty of medicine, diponegoro university dr. kariadi hospital, semarang, indonesia. 5 department of anesthesia, faculty of medicine, diponegoro university dr. kariadi hospital, semarang, indonesia. corresponding author: m. adi soedarso, md. division of urology, department of surgery, faculty of medicine, diponegoro university dr. kariadi hospital. jl. dr. soetomo no. 16, semarang, indonesia. email: drsoedarso@gmail.com. figure 1. msct noted large adenoma, mri hypothalamus hypophise normal. large resected adrenal compare with large kidney basin (right). figure 2. left: trocar optic, working element. right, laparoscopic view. figure 3. a). proliferation of polygonal cells with oval round, clear cytoplasm to eosinophilic, normochromatic, prominent nucleololi. no visible mitosis or malignant signs. b). no visible infiltration to the capsule, angioinvasion. figure 4. striae in abdomen, axilla thins. noted removal site and trocar scar 75acta med indones indones j intern med • vol 51 • number 1 • january 2019 m. adi soedarso acta med indones-indones j intern med adrenal adenomas are found in approximately 10-15% of cases of cushing’s syndrome.1 it can be either acth-dependent (pituitary adenoma or acth independent (extra pituitary adenoma). multidisciplinary approach: endocrine manipulation, surgery, specific anesthetic procedure is needed in management of this case.2,3 a 20-year old man was admitted for evaluation of cushing’s syndrome. he presented with a history of headache, fatique, mood disorder, hypertension (blood pressure 170/120 mmhg), moon face, buffalo hump, striae rubrae. cortisol serum laboratory increased 33.53 µgr/ dl (normal range: 3.09 – 16.6µgr/dl). abdominal ct scan showed a right adrenal mass diameter 10.53 x 6.83 cm, with calcified and necrotized area. levels of acth < 5 pg/ml (normal range : 6 – 50 pg/ml), absence hypothalamus pituitary defect in brain mri angiography lead the primary site on adrenal. patient was given ketoconazole 600 mg daily to treat hypercortisolemia. the patient underwent laparoscopic right adrenalectomy. preparation of hydrocortisone 100 mg during anesthesiasurgery to prevent occurrence of adrenal crisis. patient position was lld, 11 mm trocar port with 0, 30 degree optic, 2 port 5mm was used for working element. harmonic ultrasoundshear was used for dissection, hemolock clip to control vascular. right subcostal incision make to remove adrenal gland. ebl 1000 cc, close monitoring in icu ward. hydrocortison was continued 5 days after surgery. ventilatory support removed in 2 day after surgery. on the fifth day condition stable without signs of adrenal crisis, and the patient sent to elective ward. the pathology report revealed a cushing adenoma of adrenal gland. on the fifth day after surgical intervention, postoperative cortisol levels at 12 µgr/dl. on seventh day, surgical wound healing was well with minimum dose nsaid orally. striae thining, ginecomastia, buffalo neck, moon face was reduced. the patient was regularly followed up at endocrine division, department of internal medicine. moon face have been eliminated, no striae and good mood condition. blood pressure was 130/ 70 mmhg (without antihypertensive drugs) and cortisol serum was 4.52 µgr/dl and independent from steroid medication. multidisciplinary approach including endocrine treatment, prevention adrenal crisis and laparoscopic adrenalectomy procedure have good result for cushing’s syndrome due to adenoma of adrenal gland. references 1. nieman lk, bilier bm, finding jw. the diagnosis of cushing’s syndrome: an endocrine society clinical practice guideline. j clin endocrinol metab. 2008: 93:1526-40. 2. castinetti f, guignat l, giraud p, et al. ketoconazole in cushing’s disease: is it worth a try? j clin endocrinol metab. 2014;99:1623. 3. aggarwl s,yadav s sharma ap, sethi v. laparoscopic bilateral transperitoneal adrenalectomy for cushing’s syndrome: surgical challenges and lessons learnt. surglaparosc endosc percutan tech. 2013;23(3):324-8. 76 review article 74 acta med indones indones j intern med • vol 52 • number 1 • january 2020 hyperkalemia associated with angiotensin converting enzyme inhibitor or angiotensin receptor blockers in chronic kidney disease yudi h. oktaviono, novia kusumawardhani department of cardiology and vascular medicine, faculty of medicine, airlangga university, surabaya, indonesia. corresponding author: yudi her oktaviono, md, phd. department of cardiology and vascular medicine, faculty of medicine airlangga university. jl. mayjen prof. dr. moestopo 6-8, surabaya 60131, indonesia. email: yhoktaviono@yahoo.com. abstrak inhibisi dari renin – angiotensin – aldosteron system (raas) merupakan strategi kunci untuk mengatasi hipertensi pada penyakit jantung dan ginjal. namun, penghambat raas (penghambat enzim konversi angiotensin, penghambat reseptor angiotensin, penghambat reseptor aldosteron, dan penghambat renin) meningkatkan resiko hiperkalemia (kadar kalium serum > 5.5 mmol/l). hal ini menimbulkan tantangan karena kelompok pasien dengan hiperkalemia ini membutuhkan terapi khusus. pertimbangan untuk menginisiasi acei atau arb dengan melihat estimasi laju filtrasi glomerulus, konsentrasi kalium basal dan melihat asupan kalium yang berlebihan, suplemen atau obat yang dapat meningkatkan kalium menjadi penting. pemeriksaan kalium setelah inisiasi terapi dapat mencegah terjadinya hiperkalemia. bila hiperkalemia terjadi, pengenalan terhadap disritmia kardiak dan terapi antagonis dari efek potassium terhadap jantung, meredistribusi kalium ke dalam sel, dan mengeluarkan kelebihan kalium perlu segera dilakukan. pengetahuan dan kewaspadaan serta monitoring akan pemberian acei dan arb terutama pada gagal ginjal kronis dapat meminimalisiasi kejadian hiperkalemia. kata kunci: hiperkalemia, penghambat enzim konversi angiotensin, penghambat reseptor angiotensin, gagal ginjal kronis. abstract inhibition of the renin-angiotensin-aldosterone system (raas) is a key strategy in treating hypertension in cardiovascular and renal diseases. however, raas inhibitors (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, aldosterone receptor antagonists, and direct renin inhibitors) increase the risk of hyperkalemia (serum potassium >5.5 mmol/l). this poses a therapeutic challenge because these patient groups comprise in whom the drugs are therapeutically indicated. important considerations when initiating acei or arb therapy include obtaining an estimate of glomerular filtration rate and a baseline serum potassium concentration, as well as assessing whether the patient has excessive potassium intake from diet, supplements, or drugs that can also increase serum potassium. serum potassium monitoring shortly after initiation of therapy can assist in preventing hyperkalemia. if hyperkalemia does develop, prompt recognition of cardiac dysrhythmias and effective treatment to antagonize the cardiac effects of potassium, redistribute potassium into cells, and remove excess potassium from the body is important. understanding the mechanism of action and monitoring of acei and arb coupled with judicious drug use and clinical vigilance can minimize the risk to the patient of developing hyperkalemia. keywords: hyperkalemia, angiotensin converting enzyme inhibitor, angiotensin receptor blocker, chronic kidney disesase. vol 52 • number 1 • january 2020 hyperkalemia associated with angiotensin converting enzyme inhibitor 75 introduction angiotensin-converting enzyme inhibitors (acei) and angiotensin receptor blockers (arb) are used to lower blood pressure, treat heart failure, decrease cardiovascular morbidity and death after myocardial infarction, blunt progression of renal disease in non diabetic patients with chronic kidney disease (ckd), and slow renal disease progression in patients with type 2 diabetes.1 aceis and arbs have shown efficacy in decreasing proteinuria, and slowing the progression of diabetic nephropathy. their use, however, is sometimes complicated by hyperkalemia that may necessitate their discontinuation.2 the use of acei/arb in patients with advanced renal disease may be complicated by hyperkalemia because of decreased urinary potassium excretion from impaired glomerular filtration and/or a decline in aldosterone levels. the extent of renal impairment, the coadministration of drugs inhibiting kaliuresis and/or diabetes may also modulate serum potassium excretion in these patients.3 hyperkalemia occurs in up to 10% of hospitalized patients, with 10% of those patients (i.e., up to 1% of hospitalized patients) having serum potassium greater than or equal to 6 mmol/l.4 acei/arb therapy is considered a contributing cause in 10% to 38% of hospitalized hyperkalemia cases.5 in ambulatory practice, a c e i / a r b t h e r a p y a l s o c o n t r i b u t e s t o hyperkalemia in up to 10% of patients3,6 with about 1% of patients with diabetes experiencing serious hyperkalemia.4 furthermore, acei/arb therapy is implicated in hyperkalemia in as many as 6% of patients enrolled in clinical trials.7 in stockholm creatinine measurements (scream) project with potassium monitoring in the year following ace-i or arb initiation (n=52 996) potassium >5 mmol/l occurred in 5.6% (n=2977), potassium >5.5 mmol/l occurred in 1.7% (n=924), and potassium >6 mmol/l occurred in 0.63% (n=334). hyperkalemia occurred much more frequently among people with lower egfr. for example, among people with egfr <30 ml/min per 1.73 m2, new users of acei or arb therapy had a 55% and 29% 1-year occurrence of potassium >5 and >5.5 mmol/l, respectively.8 concern about the limit of hyperkalemia after initiation of acei or arb become important but the guideline which monitoring of potassium still unclear. hyperkalemia with use of acei or arb in chronic kidney disease will futher discuss. classification hyperkalemia can be classified according to serum potassium into mild (5.5–6.5 mmol/l), moderate (6.5–7.5 mmol/ l) and severe (>7.5 mmol/l) hyperkalemia. hyperkalemia not only rarely associated with symptoms, occasionally patients complain of palpitations, nausea, muscle pain, or paresthesia but also life threatening complications.9 ckd is defined as kidney damage or glomerular filtration rate (gfr) <60 ml/min/1.73 m2 for 3 months or more, irrespective of cause. kidney damage in many kidney diseases can be ascertained by the presence of albuminuria, defined as albumin-to-creatinine ratio >30 mg/g in two of three spot urine specimens. gfr can be estimated from calibrated serum creatinine and estimating equations, such as the modification of diet in renal disease (mdrd) study equation or the cockcroft-gault formula 10. ckd could be classified according to severity, diagnosis, treatment and prognosis (table 1). pathophysiology the renin – angiotensin aldosterone system (raas) is a well known regulator of blood pressure (bp) and determinant of target organ damage. it controls fluid and electrolyte balance through coordinated effects on the heart, blood vessels, and kidneys.11 ace (also known as kininase ii) is a relatively non-selective dipeptidyl carboxypeptidase that accepts various substrates, including angiotensin i and bradykinin. ace catalyses the hydrolysis of bradykinin to inactive products and converts the inactive decapeptide angiotensin i to the biologically active octapeptide angiotensin ii.12 angiotensin ii is the main effector of the raas and exerts its vasoconstrictor effect predominantly on the postglomerular arterioles, thereby increasing the glomerular hydraulic yudi h. oktaviono acta med indones-indones j intern med 76 pressure and the ultrafiltration of plasma proteins, effects that may contribute to the onset and progression of chronic renal damage.11 angiotensin ii elevates blood pressure by various mechanisms, including direct vasoconstriction, potentiation of the activity of the sympathetic nervous system at both central and peripheral levels, stimulation of aldosterone synthesis and release with consequent sodium and fluid retention by the kidney, and stimulation of arginine vasopressin release. renin secretion is influenced by intra and extra renal factors such as low renal perfusion pressure, β-adrenergic stimulation, prostaglandins, angiotensin ii, potassium, and sodium. decreased sodium and chloride delivery to the distal tubule stimulate renin release. renin acts on angiotensinogen in the blood to form angiotensin i, which is converted by angiotensinconverting enzyme (ace) to angiotensin ii. angiotensin ii stimulates the release of aldosterone from zona glomerulosa cells in the adrenal cortex. aldosterone secretion is also influenced by plasma potassium. angiotensin ii and potassium act synergistically on aldosterone release. aldosterone directly affects kidney potassium handling. potassium secretion in the collecting duct is regulated primarily by serum aldosterone concentrations and the amount of sodium delivered to the distal nephron. aldosterone binds to a receptor in collecting duct cells and stimulates sodium reabsorption across the luminal membrane through a sodium channel. as sodium is reabsorbed, the lumen becomes more electronegative and provides a favorable environment for potassium secretion through a potassium channel.7 drugs acting on the raas include agents that inhibit renin synthesis and release; that is, the direct renin inhibitors and b-adrenoceptor blockers, the ace inhibitors, the arbs, the aldosterone-receptor antagonists (aras) and a new class of combined ace and neutral endopeptidase (nep) inhibitors, called the vasopeptidase inhibitors (vpis). a total of 17 ace inhibitors have been developed for clinical use, and many have been approved for the treatment of hypertension, heart failure, diabetic nephropathy and/or left ventricular dysfunction. all ace inhibitors act by binding to the active site of ace and interfering with the ability of the enzyme to bind to and cleave its substrates, angiotensin i and bradykinin. these compounds proved to be highly successful in the treatment of hypertension and related target-organ damage, including left ventricular hypertrophy, heart failure and post myocardial infarction left ventricular remodelling renal insufficiency and diabetes with proteinuria. the arbs are non-peptide compounds that specifically block the binding of angiotensin ii to the at1 receptor by occupying the space among table 1. classification of chronic kidney disease stage description classification by severity classification by treatmentgfr ml/min/1.73 m2 related terms 1 kidney damage with normal or  gfr > 90 albuminuria, proteinuria, hematuria t if kidney transplant recipient 2 kidney damage with mild  gfr 60-89 albuminuria, proteinuria, hematuria 3 moderate  gfr 30-59 chronic renal insufficiency, early renal insufficiency 4 severe  gfr 15-29 chronic renal insufficiency, late renal insufficiency, pre-esrd 5 kidney failure < 15 (or dialysis) renal failure, uremia, endstage renal disease d if dialysis (hemodialysis, peritoneal dialysis) vol 52 • number 1 • january 2020 hyperkalemia associated with angiotensin converting enzyme inhibitor 77 the seven transmembrane helices of the receptor protein, and interacting with the amino-acid residues in this region of the receptor molecule. they do not interact with at2 receptors. arb administration indirectly activates the at2 receptor by blocking feedback inhibition of renin release and thereby activating the raas cascade and causing more angiotensin ii to be generated, and shunting the angiotensin ii so generated from at1 to at2 receptors.12 under normal circumstances, there is an inverse relationship between the plasma aldosterone concentration and the delivery of sodium to the distal nephron so that potassium excretion remains independent of changes in extracellular fluid volume. under conditions of decreased renal perfusion, aldosterone concentrations increase. at the same time, the proximal absorption of sodium and water increases, and as a result, their distal delivery decreases. renal potassium excretion remains fairly constant under these conditions, since the stimulatory effect of increased aldosterone is counterbalanced by the decreased delivery of filtrate to the distal nephron. mild to moderate reductions in renal perfusion typically do not cause the distal delivery of sodium to fall to a level that impairs potassium secretion sufficiently to result in clinically significant hyperkalemia. in most patients with untreated congestive heart failure, the serum potassium concentration is normal or at the high end of the normal range as long as the impairment in cardiac function and renal perfusion is not severe. when such patients are treated with ace inhibitors or angiotensin-receptor blockers, the fall in the circulating aldosterone concentration typically will be counterbalanced by increased distal delivery of sodium so that the serum potassium concentration remains stable. the increase in the distal delivery of sodium is due to the afterload-reducing effects of these drugs, which cause an improvement in cardiac output and renal perfusion. the reduction in angiotensin ii concentration plays an important role in decreasing proximal sodium reabsorption. in addition, most patients are treated with loop diuretics, which further enhance the delivery of sodium to the collecting duct. when renal perfusion becomes more severely reduced, as in intractable congestive heart failure, proximal reabsorption can become so intense that very little sodium escapes into the distal nephron. despite increased concentrations of aldosterone, the lack of availability of sodium can begin to impair renal potassium secretion. to the extent that cardiac output and renal perfusion become refractory to the afterload-reducing effects of ace inhibitors or angiotensin-receptor blockers, the risk of hyperkalemia increases. in this setting, these drugs may also cause the serum creatinine concentration to rise owing to reductions in intraglomerular pressure that are no longer offset by increases in glomerular perfusion.7 management the risk of severe complications and the urgency for treatment of hyperkalemia is determined by individual patient conditions including presenting symptoms, overall hemodynamic status, kidney function, underlying medical conditions, patient medications, rapidity of potassium rise, serum potassium level, acidbase status, ecg findings, and so on.13 the initial approach to such a patient is to determine the specific risk of hyperkalemia by accurately assessing the level of renal function (table 2).7 in patients with chronic kidney disease, the level of renal function should not be the sole criterion for deciding whether use of these drugs should be initiated or continued. when they are used in patients with severe reductions in the glomerular filtration rate (i.e., those with rates below 30 ml per minute), close monitoring is required. withholding these drugs solely on the basis of the level of renal function will unnecessarily deprive many patients of the cardiovascular benefit that they otherwise would have received, particularly since numerous steps can be taken to minimize the risk of hyperkalemia. patients should follow a low-potassium diet with specific counseling against the use of salt substitutes that contain potassium. diuretics are particularly effective in minimizing hyperkalemia. diuretics enhance the excretion of potassium in the kidney by increasing the delivery of sodium to the collecting duct. in patients with an estimated yudi h. oktaviono acta med indones-indones j intern med 78 glomerular filtration rate that is 30 ml per minute or higher, thiazide diuretics can be used, but in patients with more severe renal insufficiency, loop diuretics are required.7 in patients with chronic kidney disease and metabolic acidosis, the administration of sodium bicarbonate is an effective strategy to minimize increases in the serum potassium concentration.14 if treatment with an ace inhibitor or an angiotensin-receptor blocker is to be initiated, it is best to begin with low doses. the serum potassium concentration should be checked within one week after the drug has been started. if the potassium concentration is normal, then the dose of the drug can be titrated upward. with each increase in the dose, the serum potassium concentration should be measured again one week later.15 if the serum potassium concentration is 5.6 mmol per liter or higher despite the precautions described above, then such drugs may need to be avoided. particular attention should be given to patients with underlying disturbances of cardiac conduction, since even mild degrees of hyperkalemia can precipitate heart block.7 however, typical electrocardiography (ecg) changes in a patient with hyperkalemia, increases the urgency for treatment. the ‘‘classic’’ ecg changes associated with hyperkalemia are well described. the earliest changes, often beginning with levels above 6.5 meq/l, are ‘‘peaked,’’ or ‘‘tented’’ t-waves, which are most prominent in the precordial leads. with further rise in serum levels, there is diminished cardiac excitability manifested by flattening of the p-wave, pr interval lengthening, and the eventual disappearance of the pwave. the qrs duration becomes prolonged, progressing to a ‘‘sine wave’’ appearance, and finally ending in ventricular asystole or fibrillation with levels 8 to 10 mmol/l.13 conclusion acei and arb are effective therapeutic agents but can cause mild to life threatening hyperkalemia particularly in chronic kidney disease. to minimize the risk of hyperkalemia in patients initiate acei or arb, filtration glomerular rate and serum potassium level must be estimated, drug that interfere in renal potassium secretion, potassium intake, supplements should be evaluated. if hyperkalemia occur, definitive treatment such as prevention of cardiac dysrhythmia and remove excess of potassium from the body can optimize the outcome. references 1. raebel ma. hyperkalemia associated with use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. cardiovascular ther. 2012;30:e156-66. table 2. approach to patients at risk for hyperkalemia caused by inhibitors of the renin–angiotensin–aldosterone system. estimate glomerular filtration rate to assess specific risk of hyperkalemia whenever possible, discontinue drugs that interfere in renal potassium secretion, inquire about use of herbal preparations, and discontinue nonsteroidal antiinflammatory drugs, including selective cyclooxygenase-2 inhibitors prescribe low-potassium diet; inquire about use of salt substitutes that contain potassium prescribe thiazide or loop diuretics (loop diuretics necessary when estimated glomerular filtration rate is <30 ml/min) prescribe sodium bicarbonate to correct metabolic acidosis in patients with chronic kidney disease: 1 or 2 650-mg tablets twice a day (each tablet contains 8 meq of sodium bicarbonate) or 1/2–1 tsp of baking soda daily (25–50 meq of sodium bicarbonate) initiate therapy with low-dose ace inhibitor or angiotensin-receptor blocker measure potassium 1 week after initiating therapy or after increasing dose of drug if potassium increases to ≤5.5 mmol/liter, decrease dose of drug; if patient is taking some combination of an ace inhibitor, an angiotensin-receptor blocker, and an aldosterone-receptor blocker, discontinue one and recheck potassium the dose of spironolactone should not exceed 25 mg daily when used with an ace inhibitor or angiotensin-receptor blocker; this combination of drugs should be avoided when the glomerular filtration rate is <30 ml/min if potassium is >5.5 mmol/liter despite steps described above, discontinue drugs vol 52 • number 1 • january 2020 hyperkalemia associated with angiotensin converting enzyme inhibitor 79 2. sadjadi sa, mcmillan ji, jaipaul n, blakely p, hline ss. a comparative study of the prevalence of hyperkalemia with the use of angiotensin-converting enzyme inhibitors versus angiotensin receptor blockers. ther clin risk manag. 2009;5:547-52. 3. maddirala s, khan a, vincent a, lau k. effect of angiotensin converting enzyme inhibitors and angiotensin receptor blockers on serum potassium levels and renal function in ambulatory outpatients: risk factors analysis. am j medical sciences. 2008; 336:330-5. 4. raebel ma, ross c, xu s, et al. diabetes and drug-associated hyperkalemia: effect of potassium monitoring. j general intern med. 2010;25:326-33. 5. ahuja ts, freeman d, jr., mahnken jd, agraharkar m, siddiqui m, memon a. predictors of the development of hyperkalemia in patients using angiotensinconverting enzyme inhibitors. am j nephrol. 2000; 20:268-72. 6. johnson es, weinstein jr, thorp ml, et al. predicting the risk of hyperkalemia in patients with chronic kidney disease starting lisinopril. pharmacoepidemiol drug safety. 2010;19:266-72. 7. palmer bf. managing hyperkalemia caused by inhibitors of the renin-angiotensin-aldosterone system. new engl j med. 2004;351:585-92. 8. bandak g, sang y, gasparini a, et al. hyperkalemia after initiating renin-angiotensin system blockade: the stockholm creatinine measurements (scream) project. j am heart assoc. 2017;6. 9. lehnhardt a, kemper mj. pathogenesis, diagnosis and management of hyperkalemia. pediatric nephrol. 2011;26:377-84. 10. levey as, eckardt ku, tsukamoto y, et al. definition and classification of chronic kidney disease: a position statement from kidney disease: improving global outcomes (kdigo). kidney int. 2005;67:2089-100. 11. remuzzi g, perico n, macia m, ruggenenti p. the role of renin-angiotensin-aldosterone system in the progression of chronic kidney disease. kidney int suppl. 2005:s57-65. 12. zaman ma, oparil s, calhoun da. drugs targeting the renin-angiotensin-aldosterone system. nature rev drug discovery. 2002;1:621-36. 13. schaefer tj and wolford rw. disorders of potassium. emergency medicine clinics of north america. 2005; 23:723-47. 14. wilmer wa, rovin bh, hebert cj, et al. management of glomerular proteinuria: a commentary. j am soc nephrol. 2003;14:3217-32. 15. perazella ma. drug-induced hyperkalemia: old culprits and new offenders. am j med. 2000;109:30714. 339acta med indones indones j intern med • vol 53 • number 3 • july 2021 review article lung transplantation as a way to escape pneumonia in patients with covid-19: lessons from ards and influenza reyhaneh shams khozani1, dorsa shekouh2, sayyed amirreza hosseini3, mehrnush saghab torbati4, mahsa noorian5, reyhaneh rabiei6, qazal mohseni3, hossein rostami rad3, shakiba shaterzadeh bojd7, parastoo hosseini8, arina ansari9, kimia godazandeh10, niloofar deravi7* 1 department of medical biotechnology, venom and biotherapeutics molecules lab, pasteur institute of iran, tehran, iran. 2 student research committee, school of medicine, shiraz university of medical sciences, shiraz, iran. 3 student research committee, school of medicine, mazandaran university of medical sciences, sari, iran. 4 student research committee, school of medicine, zahedan azad university of medical sciences, zahedan, iran. 5 student research committee, school of medicine, hamadan university of medical science, hamadan, iran. 6 student research committee, school of medicine, arak university of medical sciences, arak, iran. 7 student research committee, school of medicine, shahid beheshti university of medical sciences, tehran, iran. 8 department of virology, school of public health, tehran university of medical sciences, tehran, iran. 9 student research committee, school of medicine, north khorasan university of medical sciences, bojnurd, iran. 10 ucl medical school, uk. corresponding author: niloofar deravi, md. sbums, arabi ave, daneshjoo blvd, velenjak, tehran 19839-63113, iran. e-mail: niloofarderavi@sbmu.ac.ir abstrak pada masa kini, coronavirus, yang disebut sebagai severe acute respiratory syndrome coronavirus 2 (sarscov-2), virus yang mengancam jiwa dengan tingkat kematian yang tinggi (4,2%) dan belum ada pengobatan absolut, pada akhirnya dapat mengakibatkan sindrom gangguan pernafasan akut (ards). ards adalah salah satu komplikasi fatal, ditandai dengan infiltrasi paru dan hipoksemia berat. kondisi ini dapat berkembang dari peradangan paru primer yang disebabkan oleh berbagai virus, terutama virus influenza, beberapa patogen manusia yang paling umum. karena itu, banyak penelitian mengeksplorasi beberapa pendekatan untuk pengobatan ards. transplantasi paru telah diklaim sebagai obat yang efisien untuk ards dan influenza parah, yang juga dapat untuk mengobati komplikasi paru kritis pada sars-cov-2. sepengetahuan kami, baru pertama kali studi untuk meninjau semua data yang tersedia tentang kemampuan transplantasi paru pada pengobatan pasien kritis dengan ards, influenza, dan sars-cov-2. kata kunci: sars-cov-2, covid-19, ards, influenza, lung transplantation. abstract in this era, the novel coronavirus, referred to as severe acute respiratory syndrome coronavirus 2 (sarscov-2), a life-threatening virus with a high mortality rate (4.2%) and with no absolute treatment as of yet, may ultimately result in acute respiratory distress syndrome (ards). ards is one of the fatal complications, highlighted by pulmonary infiltration and severe hypoxemia. this condition can be developed from primary lung inflammation caused by various viruses, particularly influenza viruses, some of the most common human pathogens. due to this reyhaneh shams khozani acta med indones-indones j intern med 340 introduction the latest danger against global health is the current outbreak of the respiratory disease that was given the name coronavirus disease 2019 (covid-19). the first cases of covid-19 were reported in december 2019. this coronavirus was structurally related to the virus responsible for severe acute respiratory syndrome (sars).1, 2 an experimental antiviral medication, remdesivir, received emergency use authorization by the us food and drug administration in 2020 for patients afflicted with severe covid-19.3 in addition, chloroquine and hydroxychloroquine were considered, as for decades they served as useful medications in prevention and treatment of chronic inflammatory diseases, including rheumatoid arthritis (ra).4 despite their use in the treatment of viral respiratory infections, no strongly established evidence was found for the effectiveness of chloroquine/hydroxychloroquine medication on sars or middle east respiratory syndrome (mers).5 in the lineup for new, more efficacious medical approaches, lung transplantation (lt) is receiving more attention. lt is preferred for patients with end-stage lung related diseases or severe respiratory insufficiency. also, bilateral lung recipients showed a higher survival rate.6,7 lt, as the only therapy for end-stage ards, provided the final choice for these patients to avoid death. therefore, patients with irreversible pulmonary fibrosis, like post-covid-19 ards, can be analyzed carefully for the possibility of a lt. in the lancet section for respiratory medicine, lang et al.8 provided a comprehensive report of a 44-year-old patient with covid-19-associated ards, who underwent a pre-treatment transplant assessment process and was successfully treated with lt. in addition, for patients with persistent lung failure following covid-19, in whom many weeks of supportive measures in the intensive care unit (icu) has not shown any significant improvement, lt was offered as a choice of treatment. although this treatment is lifesaving, the true impact of lt in the acute cases of covid-19 may have little consideration.9 according to the data and hypothesis that lt can be a beneficial treatment of ards and influenza, its potential for curing end-stage covid-19 patients should be assessed further. in this review, to the best of our knowledge for the first time we aimed to gather available data about the efficacy of lt in patients with respiratory diseases ards, influenza, and covid-19 to achieve a better perspective of this treatment in these patients. considerations in a covid-19 patient evaluation for lt eligibility lt has been suggested as the savior treatment for selected covid-19 patients present with persistent pulmonary disease despite several weeks or months of hospitalization in icu.10 there are ten considerations that should be taken into account during a covid-19 patient evaluation for lt candidacy. first, patients must not be older than 65, as cases of older patients showed poorer outcomes. second, candidates for surgery must have single -organ dysfunction only. third, adequate time must be considered for recovery.11 fourth, there must be radiological documentation of refractory lung disease. fifth, the patient must be informed and able to discuss about transplantation. they should understand the impact of surgery on their quality of life. sixth, patients must receive adequate physical health care while on the waiting list, because of better outcomes in such cases.12,13 seventh, patients should be eligible for standard transplantation criteria such as sufficient body-mass index and absence of other notable comorbidities, including severe heart disease.14 eighth, the patient’s recent sarsissue, many studies explored several approaches for ards treatment. lung transplantation has been claimed as an efficient cure for severe ards and influenza, which can also be offered for treating critical lung complications of sars-cov-2. thereupon, to the best of our knowledge for the first time, we aimed to review all available data about capability of lung transplantation for the treatment of critically ill patients with ards, influenza, and sars-cov-2. keywords: sars-cov-2, covid-19, ards, influenza, lung transplantation. vol 53 • number 3 • july 2021 lung transplantation as a way to escape pneumonia in patients 341 cov-2 polymerase chain reaction (pcr) result should be negative. based on observations made so far, the post-surgery fatality rate is remarkably higher for patients tested positive for infectious diseases, even in asymptomatic cases.15 ninth, the surgical center should be qualified in performing high-risk surgeries, as this type of surgery on ards patients with extracorporeal membrane oxygenation (ecmo) support is one of the highest-risk and most complicated procedures.16 tenth, a wide donor pool should be accessible to qualified surgical centers to maximize survival chance of patients on the waiting-list. this will retain fair and impartial organ donor allocation and provide life-saving organ transplantation for cases that have the greatest chance of survival.17 therefore, with ecmo support and fulfilling the aforementioned criteria, lt can be helpful in selected cases with severe, serious respiratory failure secondary to ards and covid-19. lt for covid-19-associated ards in pcr-positive patients although a large proportion of patients with covid-19 develop asymptomatic or mild disease, about 10% transfer to icu as a result of ards.18,19 mortality rates of up to 60% have been reported for these patients.20,21 lang et al.8 reported the first case of lt for a confirmed sars-cov-2 patient, a 44-year-old female patient with symptoms of cough and fever and nothing remarkable in her past medical history, except mild psoriatic arthritis which was treated previously, and a diagnosis of idiopathic cd4 lymphocytopenia with no clinical significance. according to the comprehensive examination and interdisciplinary discussions, the patient’s lungs had no potential for recovery and based on following considerations, transplantation was approved: (1) negative viral culture and high real-time polymerase chain reaction (rt-pcr) ct values, (2) more than one month after the onset of sars-cov-2 infection, (3) no available alternative procedure, (4) a young patient with a single-organ failure, (5) a pre-septic condition originated from the patient‘s lungs, and (6) no other obvious barriers for long-term recovery. a sequential bilateral lt was carried out, the patient was transferred to the icu in a stable condition, and was proned in order to improve the gas exchange and to decrease the pressure on the lower lobes of the lungs. standard triple immunosuppression therapy was performed, and due to the fact that the patient was highly presensitized, six additional treatment patterns of immune-absorption were done and antithymocyte globulin was provided. regardless of the success of this procedure it is necessary to mention that most covid-19 patients admitted to the icu are older than the maximum age limit for transplantation or have other comorbidities that might not allow physicians to consider lt. this case report suggests that lt should be included in the therapeutic methods for covid-19 positive patients with covid-19-related ards. however, the applied criteria for patient selection and timing of lt still need to be validated in further studies. p r ea n d p o s t-o p e r at i v e m e n ta l assessment and intervention for lt in elderly covid-19 patients lyu et al.22 reported the postoperative mental status of two elderly covid-19 patients in china who had no history of psychiatric disorders prior to the covid-19 infection. the first patient, a 66-year-old woman without any history of chronic disease, underwent a bilateral lt and her status was observed for 28 days thereafter. she had developed symptoms such as restlessness and confusion 27 days before surgery which lasted for 7 days. after achieving full consciousness 8 days after surgery, only psychological supportive treatments were administered to enhance her mood and sedatives such as zolpidem (10 mg/ day) and olanzapine (5 mg/day) were prescribed to treat her insomnia. the mental status of the second patient, a 70-year-old man with a 5-year history of hypertension and a 10-year history of diabetes, was observed for 21 days. consciousness was fully recovered 6 days after the lt surgery and similar to the first patient, sedatives were prescribed to treat episodes of insomnia. by the time the observation period was over, no sign of any mental disturbance was declared. muscle rehabilitation training started in both patients 10 days after operation. in regard reyhaneh shams khozani acta med indones-indones j intern med 342 of these data, providing intensive supportive care may avoid post operation acute brain dysfunction in covid-19 patients. co v i d 1 9 a n d i m m u n e r e s p o n s e s before and after lt a few covid-19 patients were diagnosed with more severe conditions, including acute lung injury (ali) and ards. as previously mentioned, lt may be a beneficial method to protect patients from covid-19-related ards.8,10 however, to attain safer outcomes, perioperative immune reactions of patients should be evaluated. the recent report by yan et al.20 surveyed the immune system reactions and the remnants of sars-cov-2 nucleic acids in two clinical cases before and after lt, including the very first case of lt for covid-19 globally. they described two severely ill covid-19 patients (group 1: a 58-year-old male with covid-19-related ali and ards) and (group 2: a 73-year-old male with covid-19associated multiple organ failure and ards). both cases were admitted for lt, in order to be preserved from end-stage complications of covid-19, in particular, ards. whole blood lymphocytes, immunocytes (t, b, and nk cells), blood cytokines, and ag-definite igms and iggs of hospitalized covid-19 patients were assessed. the number of lymphocytes in these cases remained below the standard amount before and after lt (<1.1×109/l). the levels of blood immunocyte subclass cd3+ cd45+ t were under 60% and a decrease of cd8+ t cells was observed (p < 0.01). furthermore, together with viral replication, the il-6 and il-10 ranges in plasma overstepped the maximum limit of normal values. total concentrations of cytokine il-10, il-4, il-6, ifn-γ, and tnf-α in a severe period of disease were considerably higher compared to the convalescence period. these findings display weak humoral and cellular immune reactions in patients infected with covid-19. in pathological analyses, the results of the second patient illustrated vague mature cd3+ cells in tissues and large-scale fibrosis and mucosal necrosis in the bronchioles, and the number of iga+ cells in epithelial cells declined in both lung lobes. residual covid-19 in the lungs could be the main cause for the positive test result and mild symptoms in recovered sarscov-2 patients, despite antiviral therapy. after the lt operation in severely ill covid-19 patients (without antiviral treatments), there were no signs of covid-19 infection in the transplanted lungs and no indication of residual covid-19 nucleic acids observed on ct scans. also, the humoral immune response was found to be negative. moreover, according to tabary et al.23, covid-19 is extremely devastating to the immune system, leading to the decrease of splenic t and b cell population as a result of necrosis and apoptosis. this may explain the incompetence of the immune system to protect the lungs from sars-cov-2. lt for elderly patients with severe covid-19 pneumonia according to some studies, sars-cov-2 might result in irreversible loss of respiratory function in end-stage covid-19 elderly patients.24-26 the international society for heart and lung transplantation (ishlt) mentioned that lt is considered to be an efficient treatment for end-stage chronic lung disease.27-29 however, it is not recommended for patients with positive viral rna tests since the ubiquitous virus may damage the transplanted lungs.8,30 thus, the viral rna test should be negative at least twice before surgery and the specimen tested should be extracted via sputum and bronchoalveolar lavage (bal). han et al.31 speculated that some factors such as blood transfusion or long-term medication, with high-doses of immunomodulators such as thymallfasin, may be associated with early acute rejection. however, up to now, there hasn’t been enough evidence to prove that irreversible lung injury may progress in sars-cov-2 lung infection patients. two patients with end-stage covid-19 pneumonia who underwent lt were studied.31 the first case was a 66-year-old woman diagnosed with covid-19, who received medication as well as convalescent plasma therapy, but showed no improvement in her declining respiratory condition. afterwards, the patient was tested for vol 53 • number 3 • july 2021 lung transplantation as a way to escape pneumonia in patients 343 sars-cov-2, and due to negative result (despite her “white lung” radiographs) she was enlisted for lt. there were no detectable signs of pleural effusion after surgery, but the oxygenation index started to decrease. there were some complications pointing towards acute rejection, but after one dose of steroid pulse therapy, the patient’s oxygen saturation rapidly improved and the chest x-ray became clearer. the other case was a 70-year-old man diagnosed with covid-19, with progressive decline in his condition, despite receiving medication. his lungs in his most recent chest x-ray were described as a blurry x-ray furthermore, after testing negative on the sarscov-2 nucleic acid tests, lt was performed. outcomes were virtually the same as the first patient: demonstrating clear chest x-rays with no evidence of pleural effusion and residual covid-19 in the lungs.31 based on this study, lt could be an efficient intervention for end-stage covid-19 patients when using medication, internal medicine guidelines, and mechanical ventilation (mv), where ecmo cannot ameliorate the lungs’ deteriorating condition. lt for progressive covid-19 related pulmonary fibrosis lt could be a potential life-saving procedure for patients with currently non-resolving covid-19.32,33 however, concerns limiting transplantation include recurrence of covid-19 (or superinfecting pathogens associated with viral pneumonia), infection of the allograft, technical challenges imposed via virus-mediated injury to the patient’s lung, and possible risk of allograft infection with ventilator-associated pathogens causing pneumonia. severe covid-19 related damage to pulmonary vessels and pleura could create practical barriers to transplantation, and severe deconditioning due to long-term mv together with sedation and blockade of neuromuscular function. there remains a lack of adequate evidence about the possibility of lung recovery after severe covid-19 pneumonia, and whether it results in better long-term outcomes than lt.32 in this regard, bharat et al.32 reported the first results of two successful lt surgeries in patients diagnosed with nonresolving sarscov-2 associated ards at the united states. comparing the histology of explanted native lungs compared to the lungs of patients who expired from sars-cov-2 demonstrated some evidence of severe fibrosis in the former. the results of single molecule fluorescence in-situ hybridization (smfish) for detecting covid-19 rna strands did not detect recurrent covid-19 infection in the allograft. therefore, lt may be the only choice for saving these patients.32 their study reported a case of a female in her 20s diagnosed with sarscov-2 showing the symptoms of severe and treatment-resistant hypoxemia despite different interventions (such as endotracheal tube placement and mv), with the level of oxygen in her blood progressively decreasing. thus, she was listed for lt and later underwent the bilateral lt surgery. post-operative care included the patient’s current medication regime in addition to immunosuppressants. as well as her neurocognitive state, her muscular strength and endurance improved quickly following the transplantation. two months after surgery, the patient was discharged home with oxygen saturation values of over 98% and was able to perform daily activities on her own.32 another case of a man in his 60s diagnosed with sarscov-2, who also suffered from comorbid conditions, including recurrent pseudomonas aeruginosa pneumonia and hemothorax, was reported. despite attempting different treatment approaches, no improvement in lung compliance and oxygen saturation was seen, therefore he was listed for lt. despite the similarity between his first two independent intraoperative assessments, unexpected complexity was reported because of colliquative necrosis following covid-19 related pseudomonas aeruginosa pneumonia. thirty days after transplantation surgery, the patient respired on room air with oxygen saturations above 97%, and his status, including consciousness and muscular strength, improved over time, under the care of rehabilitation services.32 moreover, according to the findings of this study, the lungs of both patients infected with sars-cov-2 were edematous and their reyhaneh shams khozani acta med indones-indones j intern med 344 weight had significantly increased. explanted lungs of both patients showed presence of pleural thickness and adherence, along with large bacterial cavities associated with necrosis. these bacteria were detected through pcr assay in bal samples of the postoperative cultures. in addition, regions of diffuse alveolar hemorrhage, acute bronchopneumonia due to secondary bacterial infection, and uncommon micro thrombi were observed in the lungs of both cases. lack of matrix organization was seen in the biopsies of patients who expired from severe sarscov-2 pneumonia as well as in the sections of lung explants from patients who underwent transplantation.32 lessons from lt treatment for ards patients according to american-european consensus conference (aecc), ards is the acute onset of decreasing oxygen levels in the blood, with bilateral intrusions on chest x-ray, without any evidence of left atrial hypertension.34 complications are seen as a result of sepsis, trauma, and pneumonia, although some patients may also have extra-pulmonary complications.30 coronaviruses that are highly pathogenic to humans such as sars-cov, mers-cov, and sars-cov-2 have different symptoms, but one of the most important side effects is ali or ards, which can even lead to death.35 in patients with covid-19, a phenomenon called cytokine storm is observed, which is also associated with lung damage, in which inflammatory cytokines are secreted in large quantities.36 the exact mechanism of ards in covid-19 patients is not known, but the abundant secretion of cytokines that induce inflammation such as il-6, il-1, and tnf-α may play an important role.37-40 due to the critical condition of patients with ards, multiple studies were conducted on the effectiveness of various therapeutic interventions, including lt. chang et al.41, in a retrospective study, identified 305 patients with ards, including 14 patients with an average age of 39 (sd 11) years and 8 females with no underlying disease. however, there were only 3 patients with underlying diseases, all of whom were utilizing mv. most of these patients were candidates for lt, the first major cause of ards in these patients being accidental inhalation of humidifier disinfectant and the second being pneumonia. the results of this study demonstrated that although lt may be able to lengthen the survival time of ards patients, it is in fact the final therapeutic option. more importantly, physicians should pay close attention to the reversibility of patients’ lung function. in another study conducted by brichon et al.42 a 32-year-old woman with acute myeloid leukemia was first treated with chemotherapy and autologous bone marrow transplantation, and three months later received ruminant interleukin 2 (ll-2). since the patient developed ards 4 days after receiving ruminant ll-2, mv was required. although many efforts were made to treat the patient, her condition worsened, and lt was performed as a final resort. after 11 months of follow-up, it was found that the patient was in good condition. therefore, in this study, it was suggested that lt can be a suitable method in some patients with ards. according to the promising results obtained from these studies, the use of lt for the treatment of patients with ards can be concluded, and it was anticipated that lt may be useful in the treatment of patients with covid-19 who have ards. lessons from lt treatment for influenza patients invasive pulmonary aspergillosis (ipa) is an uncommon disease presented in pediatric cases with impaired immune systems. however, it may also develop secondary to severe influenza a pneumonia in adults who were previously healthy. while fatality and morbidity rate reported among children is high, patients are commonly given antifungal medication for ipa prior to radiologic and clinical resolution. in addition, ecmo, also known as extracorporeal life support (ecls), is gradually developing as a promising treatment especially in patients with intense respiratory failure. bates et al.43 reported a critical care unit admission for a 15-yearold case with respiratory distress induced by influenza a subtype h3. due to his rapidly deteriorating condition, mv was required for vol 53 • number 3 • july 2021 lung transplantation as a way to escape pneumonia in patients 345 him. furthermore, the growth of aspergillus fumigatus led to increased serum galactomannan, and despite the administration of antifungal medications, bilateral intensive pulmonary necrosis developed. afterwards, he received veno-venous ecmo (vv-ecmo) support. since multiple organ failure markedly lowered his chance of recovery, he was eligible for lung transplant. thereby, the patient underwent successful bilateral lt operation after his medical support changed to a right ventricular assist device (rvad) and oxygenator. 40 days later, he was discharged in a stable condition. influenza a virus subtype h1n1 provokes a broad range of clinical syndromes, including self-limited illness and worst of all, ards.44 in fact, influenza a is capable of rapid progression to ards and pulmonary fibrosis. pulmonary fibrosis secondary to influenza a pneumonia may cause lung dysfunction, however it rarely warrants lt.45,46 nonetheless, an established invaluable treatment for ards called ecmo is a bridging option for pulmonary transplantation, although its long-term usage is a highly controversial topic. generally, influenza a is a communicable disease which presents with the same respiratory and gastrointestinal symptoms as covid-19. to name a few: cough, fever, vomiting and diarrhea (particularly in pediatric patients). manifestations vary from mild to severe, meaning some patients might show no symptoms while some might struggle with an irreversible stage of disease.47 also, dr. lisa maragakis pointed out more similarities in addition to what has just been cited. both infectious viruses can be easily transmitted during their incubation period, however, this period is much longer in covid-19. moreover, pneumonia may develop secondary to these infections. medications commonly administered are antiviral drugs, not antibiotics. if both diseases progress into more severe stages, hospitalization and assisted ventilation may be required.48 in the following, few cases infected with different subtypes of influenza virus who eventually recovered due to lt will be reviewed. qi wang et al. reported a successfully performed bilateral lt in a 45-year-old man with h1n1induced ards and progressive fibrosis who had received ecmo for the last 45 days before the operation.49 his hospitalization and treatment processes are described below: with no underlying lung disease, his only symptoms were cough and fever. as h1n1 pneumonia was diagnosed, he received oseltamivir. evidence of bilateral pulmonary infiltration confirmed ards indicating the need for ventilation and ecmo. also, tracheostomy along with continuous antibiotic therapy was used. despite experiencing subsequent septic episodes, the h1n1 test result was negative, thus several antibiotics were administered. even with immediate treatment measures for pulmonary fibrosis, the lungs were continuing to deteriorate. therefore, he was included in the list of urgent recipients of lt and after about one week, a suitable 16-year-old donor free of infection was available. ultimately, bilateral lt was operated successfully. on the first day after the operation, there was no longer a need for ecmo, on the 4th-day the ventilator was withdrawn, and on the 15th-day non-invasive ventilation via tracheostomy tube was stopped. despite postoperative complications, including empyema, right ventricular (rv) failure, acute dysfunction of the liver and kidney, he recovered and was discharged 65 days later. after seven months, his condition was well and he could live independently, but he had signs of slightly reduced lung capacity plus elevated blood creatinine due to anti-rejection drugs.2 influenza 1 a severe respiratory illness associated with h1n1 virus, was identified in march 2009 in mexico.50 rapid viral testing and pcr, with broad range of sensitivity, were used to detect this virus. al aklabi et al.2 reported a case of a 50-year-old man who suffered from chronic obstructive pulmonary disease and end stage lung disease due to α1-antitrypsin deficiency. he was hospitalized and listed for bilateral lt, but 48 hours after the injection of latent h1n1 virus vaccine, he displayed non-specific symptoms such as malaise and myalgia. a nasopharyngeal swab was taken for pcr testing, then following the positive test result and ishlt recommendations51,52, oseltamivir was started. reyhaneh shams khozani acta med indones-indones j intern med 346 after transplantation, two samples of bal from the transplanted lung happened to be positive for h1n1 virus, resulting in antiviral and antirejection therapy prescription based on regular protocols which previously resulted in promising outcomes. finally, he was discharged home in a good condition 21 days after the operation. thus, it can be concluded that lt can be successful in pandemic periods if careful clinical evaluation sand laboratory screenings are performed on both donors and recipients. influenza 2 patients with suppressed immune system are at high risk for developing severe influenza a (h1n1) disease. d. p. mason et al.53 reported a case of 65-year-old man who suffered from end-stage interstitial lung disease and was admitted for unilateral transplantation. before his operation, the recipient complained of a mild sore throat with no fever, malaise, and rhinorrhea, and had a normal chest x-ray. rt-pcr for influenza was positive 17 days after original nasopharyngeal swab; however postoperative bal cultures were negative for both allograft and native lungs. 4 hours after transplantation he became agitated due to a body temperature of 40.0°c thus oseltamivir (tamiflu) was started empirically. during 48 hours, he developed worsening hypoxemia and increasing consolidation of the allograft. he received peramivir after consideration of the high risk of renal insufficiency, disseminated intravascular coagulation and interrupted limb ischemia. seventy-two hours after starting peramivir, he began to recover dramatically and chest x-rays gradually cleared. despite these positive outcomes, the overall prognosis was assessed as poor and he died 22 days after the operation. this case report shows the important lasting threat of influenza h1n1 for patients who receive thoracic organ transplants, especially unilateral lt because of the airborne nature of the pathogen. therefore, recommendations of ishlt should be taken seriously: avoidance of contact with symptomatic individuals, vaccination of all h1n1 influenza patients listed for transplantation, and recipients who show even subtle signs and symptoms of upper respiratory infection or unusual infectious symptoms should be swabbed for h1n1, scheduling surgery only when results are available.51 f e v e r, s h o r t n e s s o f b r e a t h , c o u g h , expectoration, as well as laboratory tests, such as lymphopenia and an increased level of c-reactive protein are similar both influenza and covid-19.54 so it can be hypothesized that due to success in lt in influenza, the use of lt in covid-19 cases may be useful too, but caution should be exercised when selecting patients, ensuring that they meet 10-item criteria (previously mentioned), including a negative rtpcr test before the operating in both the donor and recipient, due to high risk of severe infection. conclusion despite, a large number of efforts to find treatments for critically ill patients with covid-19 in the medical world, there is no effective treatment for end-stage sars-cov-2 infected patients. moreover, conventional antiviral therapies may not be beneficial and some patients experience the end-stage acute respiratory syndrome. lt provided the potential effectiveness for the treatment of these patients and rescued them from death. since sarscov-2 has similarities to the flu and ards, and a number of articles have recently begun to examine the positive effect of lt on the treatment of covid-19. therefore, this review aimed to collect all the data on this subject, gaining experiences from ards and the flu for lt. satisfactory results after lt in improving the general condition have arisen the researcher’s efforts to find a better method for the treatment of acute respiratory syndrome covid-19. this review shows that lt could be used when medical treatments consisting of ventilation and ecom could not modify the lung action., and could be a promising choice. conflicts of interest there is no conflict of interest on this article. references 1. fauci as, lane hc, redfield rr. covid-19— navigating the uncharted. mass medical soc. 2020. 2. al aklabi mm, weinkauf jg, humar a, ghorpade vol 53 • number 3 • july 2021 lung transplantation as a way to escape pneumonia in patients 347 n. successful bilateral lung transplantation in a patient with end-stage lung disease and positive novel influenza virus (h1n1). j heart lung transplant. 2010;29(8):898-9. 3. mccreary ek, angus dc. efficacy of remdesivir in covid-19. jama. 2020;324(11):1041-2. 4. ben-zvi i, kivity s, 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2019-related pulmonary fibrosis. chin med j (engl). 2020;133(12):1390-6. 11. luyt c-e, combes a, becquemin m-h, et al. longterm outcomes of pandemic 2009 influenza a (h1n1)associated severe ards. chest. 2012;142(3):583-92. 12. benazzo a, schwarz s, frommlet f, et al. twenty-year experience with extracorporeal life support as bridge to lung transplantation. j thoracic cardiovasc surg. 2019;157(6):2515-25. e10. 13. hoetzenecker k, donahoe l, yeung jc, et al. extracorporeal life support as a bridge to lung transplantation–experience of a high-volume transplant center. j thoracic cardiovasc surg. 2018;155(3):131628. e1. 14. weill d, benden c, corris pa, et al. a consensus document for the selection of lung transplant candidates: 2014--an update from the pulmonary transplantation council of the international society for heart and lung transplantation. j heart lung transplant. 2015;34(1):1-15. 15. doglietto f, vezzoli m, gheza f, et al. factors associated with surgical mortality and 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in lung transplantation over the past decade. eur respir rev. 2020;29(157). reyhaneh shams khozani acta med indones-indones j intern med 348 34. ranieri vm, rubenfeld gd, thompson bt, et al. acute respiratory distress syndrome: the berlin definition. jama. 2012;307(23):2526-33. 35. quan c, li c, ma h, li y, zhang h. immunopathogenesis of coronavirus-induced acute respiratory distress syndrome (ards): potential infection-associated hemophagocytic lymphohistiocytosis. clin microbiol rev. 2020;34(1). 36. ragab d, salah eldin h, taeimah m, khattab r, salem r. the covid-19 cytokine storm; what we know so far. front immunol. 2020;11:1446. 37. huang c, wang y, li x, et al. clinical features of patients infected with 2019 novel coronavirus in wuhan, china. lancet. 2020;395(10223):497-506. 38. chen n, zhou m, dong x, et al. epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study. lancet. 2020;395(10223):507-13. 39. lai cc, shih tp, ko wc, tang hj, hsueh pr. severe acute respiratory syndrome coronavirus 2 (sarscov-2) and coronavirus disease-2019 (covid-19): the epidemic and the challenges. int j antimicrob agents. 2020;55(3):105924. 40. cron rq, behrens em. cytokine storm syndrome. 2019. 41. chang y, lee so, shim ts, et al. lung transplantation as a therapeutic option in acute respiratory distress syndrome. transplantation. 2018;102(5):829-37. 42. brichon py, barnoud d, pison c, perez i, guignier m. double lung transplantation for adult respiratory distress syndrome after recombinant interleukin 2. chest. 1993;104(2):609-10. 43. bates ar, hanot j, carroll a, muhieldin a, anton n, lequier l. a pediatric case of prolonged extracorporeal support and successful lung transplantation following invasive pulmonary aspergillosis and influenza infection. d51 pediatric cases ii: american thoracic society; 2016. p. a7249-a. 44. influenza wcotwcocaop. clinical aspects of pandemic 2009 influenza a (h1n1) virus infection. new engl j med. 2010;362(18):1708-19. 45. shieh w-j, blau dm, denison am, et al. 2009 pandemic influenza a (h1n1): pathology and pathogenesis of 100 fatal cases in the united states. the american journal of pathology. 2010;177(1):16675. 46. weill d, benden c, corris pa, et al. a consensus document for the selection of lung transplant candidates: 2014—an update from the pulmonary transplantation council of the international society for heart and lung transplantation. elsevier; 2015. 47. organization wh. coronavirus disease (covid-19): similarities and differences with influenza 2020. 48. lisa lockerd maragakis md, m.p.h. coronavirus disease 2019 vs.the flu 2020 [available from: http:// www.who.int/westernp. 49. wang q, pan s, zhang s, shen g, huang m, wu m. lung transplantation in pulmonary fibrosis secondary to influenza a pneumonia. annals thoracic surg. 2019;108(4):e233-e5. 50. perez-padilla r dlr-zd, ponce de leon s, et al. pneumonia and respiratory failure from swine-origin influenza a (h1n1) in mexico. n engl j med. 2009;361:680-9. 51. danziger-isakov la, husain s, mooney ml, hannan mm. the novel 2009 h1n1 influenza virus pandemic: unique considerations for programs in cardiothoracic transplantation. j heart lung transplant. 2009;28(12):1341-7. 52. hajjar la, schout d, galas fr, et al. guidelines on management of human infection with the novel virus influenza a (h1n1)--a report from the hospital das clínicas of the university of são paulo. clinics (sao paulo). 2009;64(10):1015-24. 53. m a s o n d p, m u r t h y s c , yu n j j , e t a l . l u n g transplantation in a recipient with novel 2009 h1n1 influenza: lessons learned. thorac cardiovasc surg. 2011;59(2):126-7. 54. yin z, kang z, yang d, ding s, luo h, xiao e. a comparison of clinical and chest ct findings in patients with influenza a (h1n1) virus infection and coronavirus disease (covid-19). ajr am j roentgenol. 2020;215(5):1065-71. 282 acta med indones indones j intern med • vol 53 • number 3 • july 2021 original article the relationship between folic acid and vitamin b12 serum levels with high sensitivity c-reactive protein and homocysteine in chronic hemodialysis patients: a cross-sectional study aida lydia1, dimas priantono 2, kuntjoro harimurti3 , idrus alwi4 1 division of nephrology and hypertension, department of internal medicine, faculty of medicine, universitas indonesia cipto mangunkusumo national hospital, jakarta, indonesia. 2 department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo national hospital, jakarta, indonesia. 3 clinical epidemiology unit, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo national hospital, jakarta, indonesia. 4 division of cardiology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo national hospital, jakarta, indonesia. corresponding author: aida lydia, md., phd. division of nephrology and hypertension, department of internal medicine, faculty of medicine, universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: aidalydia@gmail.com. abstrak latar belakang: pemberian suplementasi asam folat (af) dan vitamin b12 pada pasien pgk, telah secara rutin diresepkan untuk menurunkan kadar homosistein dan peradangan pada pasien pgk. akan tetapi, belum banyak penelitian mengenai hubungan kadar asam folat dan vitamin b12 pada pasien yang menjalani hemodialisis dua kali seminggu. penelitian ini bertujuan untuk menilai kadar folat serum dan b12 pada pasien hemodialisis kronis dan hubungannya dengan kadar homosistein dan hscrp dalam darah. metode: studi ini merupakan studi potong lintang yang mengikutsertakan suluruh pasien hemodialisis rutin dua kali seminggu di rs cipto mangunkusomo, jakarta,indonesia. sampel untuk pengukuran kadar asam folat, vitamin b12, homosistein, dan hscrp diambil dari sampel darah predialisis. subjek yang memiliki kondisi medis yang mempengaruhi hasil pemeriksaan dikeluarkan dari penelitian ini. korelasi antar variabel dianalisis menggunakan uji korelasi spearman. hasil: delapan puluh subjek diikutsertakan dalam penelitian ini. pada subjek yang tidak mendapatkan suplementasi asam folat [26 (32.5%)] dan suplementasi vitamin b12 [16 (20.0%)], hanya 3,85% subjek memiliki kadar asam folat yang rendah dan tidak ada subjek yang memiliki kadar vitamin b12 yang rendah. didapatkan adanya korelasi negatif sedang antara asam folat serum dan kadar homosistein (p≤0,001; r = -0,42) dan korelasi lemah antara vitamin b12 serum dan kadar homosistein (p = 0,009; r = -0,29). pada subjek dengan risiko kardiovaskular tinggi (crp> 3, n = 49), terdapat korelasi negatif sedang antara asam folat serum dan kadar homosistein (p≤0.001; r = -0.561) dan korelasi negatif yang lemah antara vitamin b12 dan homosistein (p = 0,018; r = -0,338). kesimpulan: kadar vitamin b12 dan asam folat berhubungan negative dengan kadar homosistein, terutama pada kelompok dengan risiko kardiovaskular risiko tinggi. kata kunci: asam folat, vitamin b12, kardiovaskular, mortalitas, morbiditas, hscrp, penyakit ginjal kronis, hemodialisis. vol 53 • number 3 • july 2021 the relationship between folic acid and vitamin b12 serum levels 283 introduction chronic kidney disease (ckd) is a resourcedraining condition with poor outcomes.1 the spectrum of ckd ranges from early to end-stage kidney disease (eskd), which needs kidney replacement therapy (krt). the indonesian renal registry and indonesian ministry of health data showed that 25 million indonesians are affected by ckd, and hemodialysis is the most common krt modality among this population.2-3 chronic kidney disease patients have a 16 to 30-fold higher mortality compared to the general population.4,5 the most common cause of death in ckd patients is cardiovascular disease (cvd), which comprises 37% of all causes of mortality.6 homocysteine is an independent risk factor for cvd. studies have shown that homocysteine-lowering therapy could decrease cardiovascular mortality and morbidity in ckd patients.7,8 folic acid has an essential role in homocysteine methylation, while vitamin b12 acts as a coenzyme in the process. theoretically, supplementation of those two could lower the homocysteine level.9,10 c-reactive protein (crp) is also a good predictor for mortality.11 a small increase in serum crp level could be detected by high-sensitivity crp (hs-crp) assays.12 high serum hscrp has been correlated with inflammation and major adverse cardiovascular events (mace).13 in chronic hemodialysis patients, folic acid and vitamin b12 are two of the most routinely prescribed drug “cocktails”; however, until now, there is unclear evidence for folic acid and vitamin b12 deficiency in chronic hemodialysis patients. this practice is based on the theory that folic acid and vitamin b12 deficiency will occur in ckd. studies in predialysis patients (i.e., ckd stage 1-4) by hassan et al. in 201514 showed that folic acid deficiency increases along with kidney disease progression. in hemodialysis patients, the folic acid deficiency could be worse. folic acid is a water-soluble nutrient with low molecular weight material. therefore, it can be removed during the dialysis session and worsen the deficiency. most of the published studies have demonstrated the relationship between folic acid level and all-cause mortality in hemodialysis population. however, those studies could not conclude whether supplementation of folic acid and vitamin b12 could decrease serum homocysteine level, hscrp, or cardiovascular events, and most of them observe the relationship in predialysis patients or thrice-weekly hemodialysis patients.7-10 15-23 there abstract background: folic acid (fa) and vitamin b12 treatment have been routinely prescribed to lower serum homocysteine levels and to reduce inflammation. however, no study has been conducted to determine serum folic acid (sfa) and vitamin b12 (b12) levels in patients who have twice-weekly hemodialysis. the aim of our study was to assess serum folate and b12 levels in chronic hemodialysis patients and their relationship with hscrp and homocysteine levels. methods: our study was a cross-sectional study involving patients who had twice-weekly hemodialysis in dr cipto mangunkusumo national hospital jakarta, indonesia. predialysis blood samples were taken to measure sfa, b12, homocysteine and hscrp levels. patients with medical conditions affecting the assays were excluded. spearman correlation was used to compare variables. results: eighty subjects were enrolled in this study. among those without folic acid and vitamin b-12 supplementation, only 3.85% of subjects had low folic acid levels, and none had low vitamin b12 levels. a moderate negative correlation between serum folic acid and homocysteine level (p≤0.001; r=-0.42) and a weak correlation between serum vitamin b12 and homocysteine level (p=0.009; r=-0.29) was found. among the high-risk cardiovascular group (crp>3, n=49), there is a moderate negative correlation between serum folic acid and homocysteine level (p≤0.001; r=-0.561) and a weak negative correlation between vitamin b12 and homocysteine level (p=0.018; r=-0.338). conclusions: there is a significant negative correlation between serum vitamin b12 and folic acid with homocysteine levels, especially in high-risk cardiovascular group. keywords: folic acid, vitamin b12, cardiovascular, mortality, morbidity, hscrp, ckd, chronic hemodialysis. aida lydia acta med indones-indones j intern med 284 has not been any study involving twice-weekly dialysis patients, which are the most common type of hemodialysis patients in indonesia. in indonesia, the national health insurance only reimburses three-weekly dialysis for a highly selected group of patients. the differences in dialysis frequency, high-flux vs. low flux dialyzers, and patient characteristics creates a demand for this kind of study. this study aims to give insight into whether folic acid and vitamin b12, a routinely prescribed supplementation, had a significant relationship with hscrp and homocysteine, markers for a poor outcome in a twice-weekly hemodialysis population. our study aimed to assess the level of folic acid and vitamin b12 and their relationship to hscrp and homocysteine levels in twice-weekly hemodialysis patients. methods we performed a cross-sectional study at the hemodialysis unit in cipto mangunkusumo national hospital, jakarta, indonesia, involving adult patients aged 18 years or older. the patients had been diagnosed with ckd and had undergone twice-weekly chronic hemodialysis for at least three months. we excluded patients with severe acute illness, malignancies, autoimmune disease, tuberculosis infection, exposure to immunosuppressive treatments, and gastrointestinal tract surgery history that could impair folic acid/vitamin b12 absorption. informed consent was requested from each eligible subject for the willingness to participate in the study. using sample size formula for correlation analysis, with alpha 0.05 and power of 80%, the minimum sample size needed for this study was 62 subjects.24 the ethical clearance was obtained from the research ethics committee faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta. demographic and clinical data data collection was done from august 2019 to october 2019. the patients’ demographic characteristics and clinical data were collected through interviews and examination, as well as from electronic or paper-based medical records provided at the hemodialysis unit. folic acid (eclia/ electrochemiluminescence i m m u n o a s s a y ) , v i t a m i n b 1 2 ( c m i a / chemiluminescent microparticle immunoassay), and homocysteine (cmia) assays were performed at the prodia laboratory, jakarta, indonesia (iso 9001 and iso 15189 certification). serum hscrp (immunoturbidimetry) and other laboratory assays were carried out at the department of clinical pathology laboratory, cipto mangunkusumo national hospital. statistical analysis patients’ baseline data, such as demographic data, clinical data, and laboratory measurements, were summarized as numerical and nominal values accordingly. mean and standard deviations or median and interquartile ranges were used appropriately for each parameter. spearman correlation was used to evaluate the correlation between folic acid/b12 levels and homocysteine/ hscrp levels. a p-value of <0.05 was considered as statistically significant. results we screened 90 subjects. after applying inclusion and exclusion criteria, 80 subjects were included (figure 1). table 1 summarized the baseline characteristics of the subjects. as summarized in table 1, the mean age of subjects in our study was 52 (standard deviation 12.5) years. we had an almost equal number of male and female participants (38 number of twice daily hd patients screened n=90 subject fulfilling inclusion criteria n=89 subject with exclusion criteria n=9 subject included in this study n=80 figure 1. flow diagram vol 53 • number 3 • july 2021 the relationship between folic acid and vitamin b12 serum levels 285 and 42 subjects, respectively). the median duration of ckd diagnosis was 6.5 years, with a median duration of hemodialysis treatment of 5 years. the most prevalent cause of ckd was hypertension. r e s u l t s o f f o l i c a c i d , v i t a m i n b 1 2 , homocysteine and hscrp assays can be seen in table 2. normal-high b12 and folic acid levels show in 98.75% and 95% patients, respectively. without folic acid supplementation, only 3.85% of subjects had low folic acid levels, and none of the non-vitamin b12 supplemented group had low vitamin b12 levels. about 61.3% of the subjects had high hscrp levels. meanwhile, high homocysteine was found in 75% of subjects and in 93.75% of subjects who have not received vitamin b12 supplementation. a m o n g s u b j e c t s g i v e n f o l i c a c i d supplementations, high hscrp was found in 61% of subjects, while 68.5% of subjects had high homocysteine levels. meanwhile, in subjects who were not given folic acid supplementation, table 1. characteristics of subjects variables (n=80) result age (years), mean (sd) 52.03 (sd 12.46) sex (n,%) male female 38 (47.5) 42 (52.5) duration of ckd diagnosis (years), median (iqr) 6.5 (6.75) duration of hemodialysis treatment (years), median (iqr) 5 (6.75) duration of hemodialysis (hours/session), median (iqr) 5 (0) qb (ml/min), median (iqr) 280 (50) qd (ml/min) 500 ultrafiltration volume (ml), median (iqr) 3,700 (1,500) kt/v, mean (sd) 1.81 (0.36) weekly folate supplementation (mg/week), median (iqr) 35 (105) no supplementation (n,%) 26 (32.5) 35 mg/week (n,%) 21 (26.3) 70 mg/week (n,%) 8 (10.0) 105 mg/week (n,%) 25 (31.3) weekly vitamin b12 supplementation (mcg/week), median (iqr) 1,050 (4,650) no supplementation (n,%) 17 (21.3) oral (n,%) 42 (52.5) parenteral (n,%) 9 (11.3) oral+parenteral (n,%) 12 (15) bmi (kg/m2), mean (sd) 25.06 (4.68) cause of ckd (n,%) hypertension 31 (38.8) hypertension and diabetes 22 (27.5) glomerulonephritis 9 (11.3) kidney stones 5 (6.3) diabetes 3 (3.8) polycystic kidney disease 3 (3.8) preecclampsia 2 (2.5) nephrotoxic agents 2 (2.5) others 2 (2.5) undetermined 1 (1.3) sd, standard deviation; iqr, interquartile range; ckd, chronic kidney disease; bmi, body mass index aida lydia acta med indones-indones j intern med 286 high hscrp was found in 61% of subjects, and high homocysteine was found in 75% of subjects. furthermore, in subjects given vitamin b12 supplementation, high hscrp was found in 60.94% of subjects, while high homocysteine was found in 70.31%. in subjects who were not given vitamin b12 supplementation, high hscrp was found in 62.5% of subjects, and high homocysteine was found in 93.8% of subjects. we found a moderately negative correlation between serum folic acid and homocysteine level (p ≤0.001; r=-0.4228) and a weak correlation between serum vitamin b12 and homocysteine level (p=0.009; r=-0.2905) (table 3); however, no correlation was found between folic acid and vitamin b12 with hscrp levels. we performed subgroup analysis according to the subject hscrp level to determine the high-risk group’s correlation (hscrp >3 mg/l, n=49). there is no difference found in folic acid, vitamin b12 and homocysteine levels between group (p>0.05) (table 4). however, in high risk group, stronger correlations were observed both in serum folic acid (r=-0.561, p p ≤0.001) and vitamin b12 (r=-0.338, p=0.018) with homocysteine level. but, no correlations were observed between vitamin b12 and folic acid with hscrp levels (table 5). discussion most of our subjects had high folic acid and vitamin b12 levels. even in those without supplementation, 96.16% of subjects had normal-high folic acid, and 100% had normalhigh vitamin b12 levels. a study by fehrmantable 2. folic acid, vitamin b12, homocysteine and hs crp measurement results variables (n=80) total folic acid supplementation n (%) p-value vitamin b12 supplementation n (%) p-value no 26 (32.5%) yes 54 (67.5%) no 16 (20.0%) yes 64 (80.0%) folic acid ng/ml (median; iqr) 18.04 (36.89) 11.65 (6.71) 27.92 (56.36) 0.001* 12.18 (6.59) 24.61 (54.9) 0.006* low (n,%) 4 (5) 1 (3.85) 3 (5.56) 0.001* 0 (0) 4 (6.25) 0.003* normal (n,%) 35 (43.8) 22 (84.62) 13 (24.07) 14 (87.50) 21 (32.81) high (n,%) 41 (51.2) 3 (11.54) 38 (70.37) 2 (12.50) 39 (60.94) vitamin b12 pg/ml (median; iqr) 1,695 (58,286.5) 1,149.5 (3,303) 1,817.5 (145.227) 0.049* 1,017.5 (1,224) 1,817.5 (130,152.5) 0.023* low (n,%) 1 (1.25) 1 (3.85) 0 (0) 0.192 0 (0) 1 (1.56) 0.246 normal (n,%) 22 (27.5) 9 (34.62) 13 (24.07) 7 (43.75) 15 (23.44) high (n,%) 57 (71.25) 16 (61.54) 41 (75.93) 9 (56.25) 48 (75.0) homocysteine μmol/l (median; iqr) 20.85 (11.45) 22 (13.8) 20.35 (11.6) 0.122 22 (13.05) 20.7 (12.45) 0.324 low (n,%) 0 (0) 0 (0) 0 (0) 0.054 0 (0) 0 (0) 0.053 normal (n,%) 20 (25) 3 (11.54) 17 (31.48) 1 (6.25) 19 (29.69) high (n,%) 60 (75) 23 (88.46) 37 (68.52) 15 (93.75) 45 (70.31) hscrp mg/l (median; iqr) 4.7 (12.63) 4.1 (7) 4.9 (13.7) 0.801 7.4 (11.85) 4.3 (12.2) 0.923 <1,0 (n,%) 8 (10) 2 (7.69) 6 (11.11) 0.878 2 (12.50) 6 (9.38) 0.892 1,0-3,0 (n,%) 23 (28.7) 8 (30.77) 15 (27.78) 4 (25.0) 19 (29.69) >3,0 (n,%) 49 (61.3) 16 (61.54) 33 (61.11) 10 (62.5) 39 (60.94) hscrp, high-sensitivity c reactive protein (hscrp); iqr, interquartile range; *) p < 0.05. table 3. correlation between folic acid and vitamin b12 to hscrp and homocysteine level variables r p-value folic acid and hscrp -0.0535 0.637 folic acid and homocysteine -0.4228 0.001* vitamin b12 and hscrp -0.1443 0.202 vitamin b12 dan homocysteine -0.2905 0.009* hscrp, high-sensitivity c reactive protein; *) p<0.05. vol 53 • number 3 • july 2021 the relationship between folic acid and vitamin b12 serum levels 287 table 4. folic acid, vitamin b12 and homocysteine comparisson between cardiovascular risk group. variables (n=80) total cardiovascular risk p-valuehigh 49 (6.13%) low 31 (38.7%) folic acid ng/ml (median; iqr) 18.04 (36.89) 17 (39.01) 18.85 (28.52) 0.976 low (n,%) 4 (5%) 3 (75.00%) 1 (25.00%) 0.785 normal (n,%) 35 (43.8%) 22 (62.86%) 13 (37.14%) high (n,%) 41 (51.2%) 24 (58.54%) 17 (41.46%) vitamin b12 pg/ml (median; iqr) 1,695 (58,286.5) 1,446 (50,495) 1,918 (168,218) 0.388 low (n,%) 1 (1.25%) 0 (0%) 1 (100.00%) 0.352 normal (n,%) 22 (27.5%) 15 (68.18%) 7 (31.82%) high (n,%) 57 (71.25%) 34 (59.65%) 23 (40.35%) homocysteine μmol/l (median; iqr) 20.85 (11.45) 20.7 (10.5) 22.2 (11.3) 0.122 low (n,%) 0 (0%) 0 (0%) 0 (0%) 0.895 normal (n,%) 20 (25%) 12 (60.00%) 8 (40.00%) high (n,%) 60 (75%) 37 (61.67%) 23 (38.33%) iqr, interquartile range. table 5. subgroup analysis in subjects according to high sensitivity c-reactive protein. variables hscrp<3.0 n=31 (38.75%) hscrp>3.0 n=49 (61.25%) r p-value r p-value folic acid and hscrp -0.141 0.439 -0,059 0,686 folic acid and homocysteine -0.250 0.175 -0,561 <0,001* vitamin b12 and hscrp -0.445 0.012* 0,014 0,925 vitamin b12 dan homocysteine -0.205 0.269 -0,338 0,018* hscrp, high-sensitivity c reactive protein; *) p<0.05. ekhol et al.25 in 2008 also demonstrated a high level of vitamin b12 in the dialysis population. many things can contribute to the elevated levels of vitamin b12 in hemodialysis patients. first, the high dose (5,000 mcg/session) of intradialytic parenteral vitamin b12 and oral vitamin b12 supplementation among the dialysis population can not be removed by dialysis. vitamin b12 (c63h88con14o14p) has a molecular weight of 1,355 daltons.26-27 this molecule is categorized as middle molecules (500-15,000 daltons) alongside insulin and ß-2 microglobulin and therefore, it can not be removed by dialyzer.27 second, folic acid and vitamin b12 could be deposited in the body for an extended period (1-1.5 years for folic acid and 3-5 years for vitamin b12). third, in chronic kidney disease, the production of transcobalamin ii is decreased. transcobalamin ii protein functions as a vitamin b12 transporter in the small intestine.28 therefore, vitamin b12 uptake by tissues is reduced.10,29 elevated levels of hscrp in the majority (61.3%) of the subjects are closely related to a chronic inflammatory state. this marker was chosen because of its consistency with cardiovascular risk, comparable with systolic blood pressure and total cholesterol.30 a study by bazeley et al. in chronic kidney disease patients in 10 countries showed an increase in hscrp related to increased mortality.11 large cardiovascular studies, such as the jupiter study, have shown that hscrp >2mg/l is a strong indication of therapy, and a marked decrease in cardiovascular risk was observed after therapy.30 we also found that hyperhomocysteinemia is prevalent i n m o s t h e m o d i a l y s i s p a t i e n t s ( 7 5 % ) . hyperhomocysteinemia is proven to be related to arterial thrombosis and atherosclerosis. a study by pastore et al. 31 showed that hyperhomocysteinemia occurs in more than aida lydia acta med indones-indones j intern med 288 90% of dialysis patients. we found that folic acid and vitamin b12 level was negatively correlated with homocysteine level, which is consistent with the results of a study conducted by nand et al., who had such evaluation in the non-hemodialysis ckd population.7 in the subgroup analysis, we found a moderate correlation of folic acid and homocysteine in the group of patients with hscrp levels of > 3.0 mg/dl. we also found a mild correlation between vitamin b12 and homocysteine levels. this phenomenon could describe the protective effect that could only be seen in high-risk patients. our study also showed that vitamin b12 level and hscrp was negatively correlated in low-risk patients. there is speculation that some microelements decrease during inflammation. however, a previous study reported that inflammation has no impact on the level of vitamin b12.31. there is also inconsistency in the results between the two groups. in the low-risk group, there was negative correlation, while the high-risk group, had positive correlation even though not statistically significant. selection bias in this study is unlikely to occur because the inclusion and exclusion criteria were appropriate and consistently applied in this study. likewise, with information bias and measurement bias, those biases are unlikely to occur in this study because the data and parameters studied were measured directly and obtained from medical records. theoretically, we did not find potential confounders in the relationship between the variables studied. therefore, we did not perform multivariate analysis. however, we identified a modifier effect in cardiovascular risk, which we then performed subgroup analysis. there is a possibility that our findings were found by chance. this may be due to the relatively small sample size. moreover, we did not measure the duration of folic acid and vitamin b12 supplementation and the variation in folic acid and vitamin b12 supplementation and intake among patients. further research is needed to confirm these findings, and a randomized controlled trial study is recommended to see biological plausibility and time relationship. despite the above limitations, our study is the first study in indonesia assessing the serum folic acid and vitamin b12 levels in the ckd population and their relationship with homocysteine and hscrp levels. we had an 88.88% response rate which means our study can be implemented to our eligible population. however, generalization to all ckd patients needs cautions since we only included patients with stable conditions and had no comorbidity nor other conditions that can affect folic acid and b12 absorptions. in addition, we studied patients with ckd who underwent twice-weekly hemodialysis while previous studies were mostly done in thrice-weekly hemodialysis patients. we suggest conducting randomized, double-blind clinical trials to compare the benefits of each treatment. conclusion in conclusion, there is a negative correlation between serum vitamin b12 and folic acid with homocysteine levels. moreover, in a high cardiovascular risk subject, we found stronger correlations between folic acid and homocysteine levels and also vitamin b12 and homocysteine levels. our findings suggest that supplementation of fa and vitamin b12 might more give benefit in high risk cardiovascular (hscrp>3) hemodialysis patients conflict of interest the authors declare that there is no conflict of interest regarding the publication of this paper funding statement universitas indonesia funded this study for the research grant under the pitta (internationally indexed publication for ui student’s thesis) program. references 1. xu x, qin x, li y, et al. efficacy of folic acid therapy on the progression of chronic kidney disease: the renal substudy of the china stroke primary prevention trial. jama 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hyperhomocysteinaemia in chronic kidney disease and effect of supplementation of folic acid and vitamin b12 on cardiovascular mortality. jiacm 2013;14(1):33-36. 8. tamadon mr, jamshidi l, soliemani a, et al. effect of different doses of folic acid on serum homocysteine level in patients on hemodialysis. iran j kidney dis 2011;5(2):93-96. 9. qin x, huo y, langman cb, et al. folic acid therapy and cardiovascular disease in esrd or advanced chronic kidney disease: a meta-analysis. clin j am soc nephrol 2011;6(3):482-8. doi: 10.2215/cjn.05310610 10. amini m, khosravi m, baradaran hr, et al. vitamin b12 supplementation in end stage renal disease: a systematic review. mjiri 2015;29(167):1-8. 11. bazeley j, bieber b, li y, et al. c-reactive protein and prediction of 1-year mortality in prevalent hemodialysis patients. clin j am soc nephrol 2011;6(10):2452-61. doi: 10.2215/cjn.00710111 12. li y, zhong x, cheng g, et al. hs-crp and allcause, cardiovascular, and cancer mortality risk: a meta-analysis. atherosclerosis 2017;259:75-82. doi: 10.1016/j.atherosclerosis.2017.02.003 13. hwang yc, morrow da, cannon cp, et al. highsensitivity c-reactive protein, low-density lipoprotein cholesterol and cardiovascular outcomes in patients with type 2 diabetes in the examine (examination of cardiovascular outcomes with alogliptin versus standard of care) trial. diabetes obes metab 2018;20(3):654-59. doi: 10.1111/dom.13136 14. hassan k. association of low potassium diet and folic acid deficiency in patients with ckd. ther clin risk manag 2015;11:821-7. doi: 10.2147/tcrm.s83751 15. jamison rl, hartigan p, kaufman js, et al. effect of homocysteine lowering on mortality and vascular disease in advanced chronic kidney disease and end-stage renal disease: a randomized controlled trial. jama 2007;298(10):1163-70. doi: 10.1001/ jama.298.10.1163 16. jardine mj, kang a, zoungas s, et al. the effect of folic acid based homocysteine lowering on cardiovascular events in people with kidney disease: systematic review and meta-analysis. bmj 2012;344:e3533. doi: 10.1136/bmj.e3533 17. wrone em. randomized trial of folic acid for prevention of cardiovascular events in end-stage renal disease. journal of the american society of nephrology 2004;15(2):420-26. doi: 10.1097/01. asn.0000110181.64655.6c 18. chang ty, chou kj, tseng cf, et al. effects of folic acid and vitamin b complex on serum c-reactive protein and albumin levels in stable hemodialysis patients. curr med res opin 2007;23(8):1879-86. doi: 10.1185/030079907x218077 19. heinz j, kropf s, domrose u, et al. b vitamins and the risk of total mortality and cardiovascular disease in end-stage renal disease: results of a randomized controlled trial. circulation 2010;121(12):1432-8. doi: 10.1161/circulationaha.109.904672 20. righetti m, serbelloni p, milani s, et al. homocysteinelowering vitamin b treatment decreases cardiovascular events in hemodialysis patients. blood purif 2006;24(4):379-86. doi: 10.1159/000093680 21. righetti m, ferrario g, milani s, et al. effects of folic acid treatment on homocysteine levels and vascular disease in hemodialysis patients. med sci monit 2003;9(4):37-42. 22. vianna aca, mocelin aj, matsuo t, et al. uremic hyperhomocysteinemia: a randomized trial of folate treatment for the prevention of cardiovascular events. hemodial int 2007;11(2):210-16. doi: doi:10.1111/ j.1542-4758.2007.00171.x 23. trimarchi h, schiel a, freixas e, et al. randomized trial of methylcobalamin and folate effects on homocysteine in hemodialysis patients. nephron 2002;91:58-63. 24. hulley sb, cummings sr, browner ws, grady d, newman tb. designing clinical research : an epidemiologic approach. 4th ed. philadelphia, pa: lippincott williams & wilkins; 2013. appendix 6c, page 79 25. fehrman-ekholm i, lotsander a, logan k, et al. concentrations of vitamin c, vitamin b12 and folic acid in patients treated with hemodialysis and on-line hemodiafiltration or hemofiltration. scand j urol nephrol 2008;42(1):74-80. doi: 10.1080/00365590701514266 26. information ncfb. vitamin b12, cid=25102581. pubchem database, 2019. 27. azar a, canaud b. hemodialysis system. in: azar at, ed. modelling and control of dialysis systems. berlin: springer-verlag 2013:99-166. 28. clase cm, ki v, holden rm. water-soluble vitamins in people with low glomerular filtration rate or on dialysis: a review. semin dial 2013;26(5):546-67. doi: 10.1111/sdi.12099 29. soohoo m, ahmadi sf, qader h, et al. association of serum vitamin b12 and folate with mortality in incident aida lydia acta med indones-indones j intern med 290 hemodialysis patients. nephrol dial transplant 2017;32(6):1024-32. doi: 10.1093/ndt/gfw090 30. yousuf o, mohanty bd, martin ss, et al. highsensitivity c-reactive protein and cardiovascular disease: a resolute belief or an elusive link? j am coll cardiol 2013;62(5):397-408. doi: 10.1016/j. jacc.2013.05.016 31. pastore a, angelis sd, casciani s, et al. effects of folic acid bfore and after vitamin b12 on plasma homocysteine concentrations in hemodialysis patients with known mthfr genotypes. clin chem 2006;52(1):145-48. 621acta med indones indones j intern med • vol 54 • number 4 • october 2022 case report the application of coronary contrast emptying time in diagnosing coronary slow flow phenomenon: a serial case report yudhie tanta1*, ali ghanie1, taufik indrajaya1, erwin sukandi1, imran saleh1, ziske maritska2 1 division of cardiovascular, department of internal medicine, faculty of medicine universitas sriwijaya dr. mohammad hoesin hospital, palembang, indonesia. 2 department of biology medicine, faculty of medicine universitas sriwijaya, palembang, indonesia. *corresponding author: yudhie tanta, md. division of cardiovascular, department of internal medicine, faculty of medicine universitas sriwijaya dr. mohammad hoesin hospital. jl. jend. sudirman km 3,5 palembang 30126, indonesia. email: tanta7an7a@yahoo.com abstract the coronary slow flow phenomenon doesn’t achieve as much attention as its counterpart coronary arterial disease because it is considered a rather benign entity. but now it is proven that coronary slow flow phenomenon can also manifest as an acute coronary syndrome, myocardial ischemia, malignant arrhythmia, and even sudden cardiac death. this entity is usually diagnosed from coronary angiography study when a delayed coronary contrast filling time is found without the presence of significant epicardial narrowing of the related arteries. but, in our center’s years of experience, we frequently found cases in which myocardial ischemia or infarction was suggested or proven clinically, on the other hand, angiography study showed no significant epicardial coronary artery narrowing neither delayed coronary contrast filling time. furthermore, we observed that this group of patients exhibited a rather prolonged coronary contrast emptying time instead. in this serial case report, we presented some of our cases where microvascular disorders were suspected. we demonstrated that not all coronary contrast filling times in ischemic or infarction-related arteries were prolonged, on the other hand, prolongation of coronary contrast emptying time showed a more consistent result. keywords: coronary slow flow phenomenon, microvascular disorder, myocardial ischemia, myocardial infarction. introduction traditionally, the coronary slow flow p h e n o m e n o n is a n a n g i o g r a p h i c e n t i t y characterized by delayed contrast filling of distal coronary arteries without significant stenotic lesions. non-significant stenotic lesion defined as a stenotic lesion with less than 40% lumen diameter reduction.1 delayed contrast filling was commonly diagnosed either with gibson’s or timi method. based on gibson criteria, diagnosis of a delayed contrast filling is when the total frame count from the moment contrast entered the proximal of the related coronary artery until it reached the distal end exceeds 27 frames, with 30 frames/second angiographic frame speed. meanwhile, lad needs a correction factor, where the total frame count should be divided by 1.5. whereas with timi criteria, yudhie tanta acta med indones-indones j intern med 622 a delayed contrast filling is diagnosed when the time from the moment contrast entered the proximal of the related coronary artery until it reached the distal end takes more than three heartbeats. other methods for measuring coronary blood flow velocity, such as the one that gibson proposed using guidewire and kelly clamps, were not commonly used.2,3,4 years of experience in our center showed frequently found cases that do not fit the delayed filling time criteria by gibson’s or timi method but with clear myocardial ischemic or infarction evidence. the current method for diagnosing coronary slow flow phenomenon based on measuring contrast filling time can only detect this abnormality in its intermediate and late form. thus, we propose coronary contrast emptying time measurement as a marker to diagnose coronary slow flow phenomenon in the earlier stage. we define coronary contrast-emptying time as the period that starts when it entered the related artery until its complete emptying with prolonged emptying time is more than 3 seconds (45 frames with 15 frames/second angiographic frame speed or 90 frames with 30 frames/second angiographic frame speed). in this serial case report, we presented coronary slow flow phenomenon cases in our center. we demonstrate the measurement of coronary contrast emptying time and its comparison to gibson’s method for diagnosing coronary slow flow phenomenon. here, we presented four patients whom we suspected to have myocardial ischemia or infarction episodes. case illustration the first case was a 35-year-old woman. she has no previous history of chest pain, neither history of diabetes or hypertension. she was complaining of squeezing chest pain started 2 hours before admission. on anamnesis, she informed that her father died after collapsing suddenly. the patient hemodynamic was stable. the ecg recording showed an st elevation in septal and lateral leads. further echocardiography examination showed a hypokinetic movement of basal and mid anteroseptal with a 45% ejection fraction. there was no significant coronary lesion found during a coronary angiography study. the study showed filling time of lad was 26,6 total frame count (with a picture-taking speed of 30 frames per second), which is within range. however, the coronary contrast emptying time was prolonged, with a total of 136 frame counts (with the picture-taking speed of 30 frames per second). meanwhile, the filling time of lcx was within the recommended filling time limit (26 total frame counts). however, coronary contrast emptying time was prolonged, which was 110 total frame count. filling time in rca was 38 total frame count, which is also longer. coronary contrast emptying time of rca was 132 total frame count, showing another prolonged duration. the second case was a 34 years old male who came to our clinic with chest discomfort on performing moderate activities. he also complained of having some palpitation episodes and get fatigued while performing daily activities. fixed splitting of second heart sound was present. otherwise, the physical examination findings were unremarkable. the ecg recordings showed a first-degree av block with interchanging morphology between complete and incomplete rbbb. cardiac mri showed dilatation of theright atrium and right ventricle with mild tricuspid regurgitation, whereas left ventricle structure and function showed no abnormalities. there was no significant coronary lesion found during a coronary angiography study. the study showed a total of 20 frame counts of lad, which is normal. yet coronary contrast emptying time was prolonged, with a total of 92 frame counts. the filling time of lcx was prolonged as well, with a total of 32 frame counts. coronary contrast emptying time was 92 total frame count, which also showed a prolonged duration. furthermore, the filling time and coronary contrast emptying time of rca show an increment, with 46 frame counts and 178 total frame counts, respectively. the third case was a 41 years old male. he was referred to our hospital with retrosternal chest pain starting 7 hours before admission. the patient was a smoker and had a history of dyslipidemia before, with other physical examinations showing normal findings. the vol 54 • number 4 • october 2022 the application of coronary contrast emptying time 623 electrocardiography examination showed a marked st elevation on inferior leads. the patient then underwent a fibrinolytic procedure successfully. echocardiography showed concentric left ventricular hypertrophy with preserved systolic function. there was no significant coronary lesion found during a coronary angiography study. the study showed filling time of lad was 32 total frame counts, which showed a prolonged filling time. coronary contrast emptying time was longer, with 104 frame counts. the filling time of lcx was good, with 26 total frame counts. however, the coronary contrast emptying time was 104 frame counts, which showed a prolonged duration. filling time in rca was also good, with 24 frame counts. coronary contrast emptying time of rca was 150 total frame count, which showed a marked prolonged duration. the fourth case was a 45 years old female who came to our hospital with the typical chest pain symptoms, induced by moderate activities such as walking 100 meters or climbing stairs, but further relieved with short rest. the patient has a history of hypertension for four years, which she consumed amlodipine 5 mg daily. physical examinations on the patients show no remarkable findings. the electrocardiography displayed a complete lbbb with stelevation on avr. meanwhile, the echocardiography showed left ventricular hypertrophy with a 63% ejection fraction, with no segmental wall motion abnormalities. there was no significant coronary lesion found in the coronary angiography study. its filling time was 24 total frame counts. nevertheless, its coronary contrast emptying time was 108 total frame count, which fulfilled our criteria as prolonged contrast emptying duration. although the coronary contrast emptying time increased to 96 frame counts, the filling time of lcx was good, with a total of 26 frame counts. filling time in rca was 32 total frame counts, which showed a prolonged duration. coronary contrast emptying time of rca was 110 total frame count, which is long. discussion we proposed several postulates to explain why measuring the coronary emptying time as a whole is critical in assessing coronary microvascular disorders and not just coronary filling time. classically, there are two compartments of coronary vasculature, which are epicardial coronary arteries and microvascular. there are three subcategories for microvascular, which are arteriole, periarteriole, and capillary beds. in normal conditions, arteriole contributes to 25% of total blood flow resistance in the coronary vasculature, arteriole contributes to 55% of total resistance, while the rest comes from capillary beds. several different factors play roles in regulating microvascular tones.5 endothelial and neural factors, mainly induced by the shear stress of the vascular wall, regulate periarteriole and large-arteriole tones. meanwhile, the myogenic factors and physical factors control the medium-sized arteriole tones. take, for example, the presence of extravascular compression and increased intraventricular enddiastolic pressure. metabolic factors, on the other hand, regulate the small-sized arteriole tones. while we have a predominant mechanism for controlling resistance on each part of the microvascular compartment, this is more like a continuum than a clear-cut separation.5 table 1. summary of myocardial ischemia/infarction in each patient, with coronary filling time dan emptying time measurements patient evidence suggesting myocardial ischemia/infarction coronary filling time coronary emptying time lad lcx rca lad lcx rca 35 years old woman anterolateral st elevation hypokinetic wall motion of anteroseptal lv wall on echo 26.6 26 38 136 110 132 34 years old male palpitation and fatigueness 1st degree av block with rbbb 20 32 46 92 92 178 41 years old male inferior st elevation 32 26 24 104 104 150 45 years old female typical chest pain complete lbbb 24 26 32 108 96 110 yudhie tanta acta med indones-indones j intern med 624 in coronary angiography study, the first compartment blood and contrast entered after occupying epicardial arteries is arterioleslarge arterioles compartment. when the blood can not enter the arterioles-large arterioles compartment, the coronary angiography contrast will also face difficulties in occupying epicardial space, known as the delayed filling time in the slow coronary flow phenomenon. endothelial dysfunction and subclinical atherosclerosis are widely accepted. they are also the most studied etiologies for the slow coronary flow phenomenon. cin and colleagues on their study with intravascular ultrasound found a diffuse intimal thickening and widespread calcification with no luminal irregularities observed from coronary angiography in patients with coronary slow flow phenomenon. in other study, pekdemir and colleagues also found increased endothelin-1 concentration in coronary slow flow patient during rapid atrial pacing compared to patient without coronary slow flow phenomenon. these entities will affect primary, large arterioles, and also a proportion of medium-sized arterioles. so our first suggestion is that a milder but more diffuse form will cause difficulties of blood entering the ‘medium-sized arterioles’ compartment on coronary angiography study, which in turn will cause difficulty for contrast entering the ‘prearteriolelarge arteriole’ compartment. rather than delayed contrast filling, this phenomenon will manifest more as delayed contrast emptying.6,7,8 several factors theoretically might contribute to microvascular disturbance but are not as extensively studied. those factors are the physical factors, myogenic and metabolic factors. since they mainly affect medium to small-sized arterioles resistance, these factors will cause delayed contrast emptying rather than filling in coronary angiography. it further lays the foundation for the second suggestion where physical factors like left ventricular hypertrophy and myocardial fibrosis could contribute to coronary microvascular disorders incidence. furthermore, it manifests as delayed contrast emptying time rather than filling time on coronary angiography.8 although we emphasize the contrast emptying time aspect of the microvascular disorder, its measurement should not be separated from contrast filling time measurement. the reason is that we accept that endothelial dysfunction and subclinical atherosclerosis are the main risk factors for the slow coronary flow phenomenon until now. moreover, these compartments previously described are a continuum rather than separate compartments. thus, we propose new criteria for diagnosing slow coronary flow phenomenon with coronary contrast emptying time, which counts from the first time the contrast entering the related epicardial arteries until it fully empties from that artery. this process will take no more than three seconds. epicardial coronary stenosis can have a direct impact on coronary filling time. its presence consequently excludes the diagnosis of coronary slow flow phenomenon by gibson’s criteria. ramakrishnan and his colleagues from their observational study concluded that dyslipidemia, hypertension, and smoking are strongly associated to coronary slow flow phenomenon incidence. since they have relatively the same risk factors, these two entities can be present in one patient at once. patel and colleagues demonstrated the presence of these two entities at once on her study by measuring myocardial perfusion at rest and stress with quantitative positron emission tomography. that is why we also propose that in the significantly narrowed epicardial coronary artery, prolongation of coronary emptying time with a normal-filling time could indicate a presence of microvascular disorder in conjunction with epicardial stenosis.9,10 different operators lead to the variability of contrast injection duration, and it will cause bias without using an automatic contrast injector device. thus we proposed the contrast injection duration to be 1 to 1,5 seconds for three cc contrast each shot. conclusion we propose that measurement of epicardial contrast duration might serve as a better marker in terms of sensitivity than measurement of contrast filling time. vol 54 • number 4 • october 2022 the application of coronary contrast emptying time 625 references 1. wang x, nie sp. the coronary slow flow phenomenon: characteristics, mechanisms, and implications. cardiovasc diagn ther, 2011;1(1):37-43. 2. beltrame jf. defining the coronary slow flow phenomenon. circulation journal. 2012;76(4);818-20. 3. gibson cm. timi frame count: a quantitative method of assessing coronary artery flow. circulation. 1996; 93(5):879-88. 4. gibson cm, dodge jt, goel m, et al. angioplasty guidewire velocity: a new simple method to calculate absolute coronary blood velocity and flow. am j cardiol. 1997;80:1536-39. 5. hermann j. coronary microvascular dysfunction in the clinical setting: from mystery to reality. european heart journal. 2012;33:2771-81. 6. cin vg. diffuse intimal thickening of coronary arteries in slow coronary flow. jpn heart j. 2003;44;907-19. 7. pekdemir h, et al. elevated plasma endothelin-1 levels in coronary sinus during rapid right atrial pacing in patients with slow coronary flow. int j cardiol. 2004; 97:3541. 8. vijayan s, barmby ds, pearson ir, davies ag, wheatcroft sb, sivananthan m. assessing coronary blood flow physiology in the cardiac catheterisation laboratory. curr cardiol rev. 2017;13(3):232–43. 9. ramakrisnan sn, et al. coronary slow flow phenomenon (csfp). assessment of the role of endothelial dysfunction. journal of the american college of cardiology. 2016;67 (16):550-1. 10. patel mb, bui lp, kirkeeide rl, gould kl. imaging microvascular dysfunction and mechanisms for female-male differences in cad. jacc cardiovasc imaging. 2016;9(4):465–82. 206 original article acta med indones indones j intern med • vol 52 • number 3 • july 2020 test, trace, and treatment strategy to control covid-19 infection among hospital staff in a covid-19 referral hospital in indonesia rakhmad hidayat1,2, nurul aini2, azizah fitriana n. ilmi3, faiza azzahroh3, astuti giantini1,2 1 faculty of medicine universitas indonesia, jakarta, indonesia. 2 work unit, universitas indonesia hospital, universitas indonesia, depok, indonesia 3 internal researcher, universitas indonesia hospital, depok, indonesia. corresponding author: rakhmad hidayat, md. universitas indonesia hospital, universitas indonesia. pondok cina 16424, depok, indonesia. email: rhidayat.md@gmail.com, rhidayat81@ui.ac.id, rakhmad.hidayat@rs.ui.ac.id. abstrak latar belakang: infeksi covid-19 disebabkan oleh virus korona baru. salah satu strategi yang paling banyak digunakan untuk mengendalikan penyebaran covid-19 adalah 3t (test, trace, and treatment). penelitian ini bertujuan untuk mengevaluasi strategi 3t pengendalian infeksi covid-19 di rumah sakit rujukan covid-19 depok, jawa barat, indonesia. metode: penelitian potong lintang yang dilakukan di rs universitas indonesia. penelitian dilakukan pada bulan juni 2020 dengan 742 partisipan (anggota staf) menggunakan data sekunder hasil uji polymerase chain reaction (pcr). kami menyajikan data dalam bentuk deskriptif dan melakukan analisis bivariat menggunakan uji chi-square/ fischer untuk data kategorikal. hasil: hasil tes pcr positif pada 83 (11,1%) peserta, dengan rasio kasus per penelusuran 1:24 dan 1:2 masing-masing pada fase pelacakan pertama dan ketiga. grafik kasus covid-19 untuk peserta menurun seiring dengan penerapan strategi 3t. tingkat positif pada pelacakan tahap pertama adalah 20% dan menurun menjadi 5% pada pelacakan tahap ketiga. staf dengan hasil tes yang dikonfirmasi positif disarankan untuk mengisolasi diri mereka sendiri (rumah sakit atau isolasi sendiri). isolasi rumah sakit ditemukan terkait dengan durasi konversi tes pcr (p<0,001). kesimpulan: strategi 3t efektif untuk mengendalikan penyebaran covid-19. penerapan strategi ini harus dilakukan bersamaan dengan kewaspadaan kesehatan lainnya untuk mengurangi risiko penyebaran infeksi. keywords: strategi 3t, covid-19, tes pcr, rs. universitas indonesia. abstract background: covid-19 infection is caused by a novel coronavirus. one of the most used strategies that can be used to control the spread of covid-19 is the 3t (test, trace, and treatment) strategy. this study aimed to evaluate the 3t strategy to control covid-19 infection in a covid-19 referral hospital in depok, west java, indonesia. methods: this is a cross-sectional study conducted at the university of indonesia hospital. the study was conducted in june 2020 with 742 participants (staff members) using secondary data from polymerase chain reaction (pcr) test results. we presented data in the descriptive form and performed bivariate analysis using the chi-square/fischer test for categorical data. results: the pcr test results were positive in 83 (11.1%) participants, with a case-per-tracing ratio of 1:24 and 1:2 in the first and third phases of tracing, respectively. the covid-19 case graph for the participants decreased along with the implementation of the 3t strategy. the positivity rate in the first phase of tracing was 20% and decreased to 5% in the third phase of tracing. staff with vol 52 • number 3 • july 2020 test, trace, and treatment strategy to control covid-19 infection 207 introduction covid-19 is a respiratory infection caused by the novel coronavirus or sars-cov-2. it originated in the animal and seafood market of hubei province, china in december 2019.1 according to the world health organization (who), covid-19 affected 219 countries, infected 16,558,289 people, and caused 656,093 deaths.2 indonesia is one of the countries with the highest infection rates. data from the indonesian ministry of health showed that as of july 29, 2020, there were 104,432 covid-19 confirmed cases in indonesia and 4,975 deaths.3 depok is a suburban city located near jakarta and at risk of being the center of infection due to high mobility and a higher number of covid-19 cases in neighboring cities. on july 29, 2020, there were 1,172 confirmed cases and 45 deaths in depok.4 to increase the diagnostic capacity of close contacts of confirmed covid-19 patients and people or patients under surveillance, the government of depok allocated 3,600 additional polymerase chain reaction (pcr) tests for depok residents. the university of indonesia hospital was appointed to perform these additional pcr tests. hospital staff are susceptible to infection in this pandemic due to their close contact with infected patients. for example, in the early covid-19 pandemic, it was found that 1.1% of health workers in tertiary hospitals in wuhan, china were confirmed to be positive for sarscov-2.5 similar findings were also observed in indonesia. in june 2020, 75 health workers were confirmed cases in east java, of whom 12 were medical residents.6 in late may 2020, depok general hospital was forcibly closed because 27 staff members were found to be positive for sars-cov-2.7 the university of indonesia hospital is one of the referral hospitals of covid-19 in depok and dealing with similar situations. therefore, the university of indonesia hospital must devise a way that not only focuses on controlling infection transmission, but also mitigates the risk of becoming an infection epicenter. one of the most used strategies that can be used to control covid-19 spread is the test, trace, and treatment (3t) strategy. this strategy is designed to control the infection chain of the disease by identification of covid-19 cases using laboratory tests, tracing close contacts of confirmed cases, and advising them to isolate to prevent further spread of infection.8 this article discusses the implementation of a 3t strategy to control the spread of infection among the staff of university of indonesia hospital. methods a cross-sectional design was used in this study. the study was conducted at the university of indonesia hospital in june 2020. the data were collected from the secondary data from the pcr test results of the staff members of the hospital. a total of 742 participants were included in this study. all participants included the hospital staff of university of indonesia hospital (health workers and non-health workers). we present data in the descriptive form and performed bivariate analysis using the chi-square or fischer test for categorical data. the ethical committee of universitas indonesia hospital approved this study (reference no. 002/skpe/kko/2020/00). t h e u n i v e r s i t a s i n d o n e s i a h o s p i t a l conducted pcr testing during june 19-23, 2020. pcr tests were carried out on staff members who were registered and screened through electronic forms provided by the universitas indonesia hospital. the registration form included identity, screening for symptoms, contact history, risk of transmission, comorbid diseases, history of the disease, and a history of previous pcr testing. occupational safety and health department of the university of indonesia hospital conducted contact tracing for the patients or hospital staff confirmed positive test results were advised to isolate themselves (hospital or self-isolation). hospital isolation was found to be associated with the duration of pcr test conversion (p<0.001). conclusion: the 3t strategy is effective for controlling the spread of covid-19. the strategy should be implemented simultaneously with other health precautions to reduce the risk of spreading infection. keywords: 3t strategy, covid-19, pcr test, universitas indonesia hospital. rakhmad hidayat acta med indones-indones j intern med 208 with a positive pcr test result. individuals who had contact with a covid-19 case were tested by pcr. if the pcr test results are positive, the patient must be isolated. this isolation could be performed at a hospital or self-isolation at home. tracing is carried out based on three levels of contact tracing, namely high risk, medium risk and low risk. included in the high risk criteria are people who have had direct contact with a positive covid-19 patient with a distance of less than one meter, more than fifteen minutes, without using personal protective equipment, or using inadequate personal protective equipment. the medium risk category is people who have direct contact with patients under surveillance who have not been confirmed positive for covid-19 with a distance of less than one meter, more than fifteen minutes, without using personal protective equipment, or using inadequate personal protective equipment. meanwhile, the low risk category is people who have direct contact with patients under surveillance or people under surveillance who have not been confirmed positive for covid-19 with a distance of less than one meter, more than fifteen minutes, using personal protective equipment according to standards. for people in the high risk category, a swab test will be carried out the following day. it is attempted to finish the results of the swab on the same day to determine the next tracing. results pcr testing was performed for 742 hospital staff members consisting of 154 staff members in the testing phase and 557 in the tracing phase (figure 1). of all pcr tests, 83 staff members tested positive for covid-19 (11.1%). the occupational health and safety, department of the universitas indonesia hospital traced staff members who tested positive. the criterion for identification of close contact was: close contact with covid-19 confirmed patient within 2 meters for a minimum of 15 minutes. those who were found positive were advised to isolate themselves. the staff could choose between selfisolation and hospital isolation, and participants who self-isolated at home were asked to fill out the monitoring form. figure 1 shows the decline of positive cases found using pcr tests performed at the figure 1. pcr test results among universitas indonesia hospital staff. vol 52 • number 3 • july 2020 test, trace, and treatment strategy to control covid-19 infection 209 university of indonesia hospital. the positivity rate of the pcr test in the testing phase was 7,8% (confidence interval [ci] 95%; 0,04−0,12). the secondary attack rate was the number of cases that occurred among close contacts who were traced. secondary attack rate among hospital staff from tracing one declined with time, 20.1% (ci 95%; 0.15−0.25) to 3.7% (ci 95%; 0.02−0.06) and 5.3% (ci 95%; -0,05−0,15). the secondary attack rate of all 588 close contacts was 12.1% (ci 95%; 0,09−0,15) (71 cases per 588 close contacts). it was higher than the attack rate found in the testing phase (12,1% vs. 7,8%). testing detection of covid-19 infection among the staff of the university of indonesia hospital was achieved using a pcr test for 154 members (health workers and non-health workers), who were routinely tested. health workers consisted of doctors and nurses. data regarding demographic characteristics of the pcr test are presented in table 1. statistical analysis showed no significant associations among variables (p >0.05). tracing tracing was carried out for confirmed covid-19 positive cases by monitoring their interactions with families or colleagues. the confirmed positive staff filled in the contact history form and reported their condition to their manager and occupational health and safety team. furthermore, the close contacts of the confirmed positive cases were tested by pcr. if the contacts were found positive, tracing would continue until there were no positive cases left at the university of indonesia hospital. tracing were done 3 times, namely tracing 1, 2 and 3. starting with 12 positive cases in the testing phase, 298 pcr tests were performed for their close contacts (clusters); thus, the trace per case ratio was 1:24 (tracing 1). from 298 cases, 60 new positive cases were detected (positivity rate 20,1%) and were retraced to find 271 new close contacts (case per trace ratio 1:4) in tracing 2. from 271 cases, 10 new positive cases were found and retraced (positivity rate 3.7%). the last, 19 close contacts were identified from previous cases (1:2) and we successfully detected only 1 new positive case in tracing 3 (positivity rate 5.3%). the infection rate of health workers from the testing phase to tracing increased compared to that of non-health workers (7 vs. 5 times), although the secondary attack rate in health workers was lower than that in nonhealth workers (10.5% vs. 13.5%). we found a statistically significant association between age and pcr results, but found no similar results in other variables (table 2). treatment positive cases of covid-19 among the staff of the university of indonesia hospital were isolated or quarantined to stop the spread of the infection. comfort and psychological reassurance were provided for the patients and the people surrounding them. the university of indonesia hospital provided two options for isolation: hospital isolation or self-isolation at home. self-isolation was for two weeks, whereas in hospital isolation, patients could be discharged after they consecutively tested negative twice table 1. demographic data of pcr test in the universitas indonesia hospital variables positive (%) negative (%) total attack rate (%)(ci 95%) p value age <30 years 5 (41.7) 93 (62.8) 98 5 (0.01-0.09) 0.122* ≥30 years 7 (58.3) 49 (34.5) 56 13 (0.04-0.22) sex male 4 (33.3) 47 (33.1) 51 8 (0.01-0.15) 1.000* female 8 (66.7) 95 (66.9) 103 8 (0.03-0.13) occupation health worker 4 (33.3) 19 (13.4) 23 17 (0.02-0.32) 0.083* doctor 2 (16.7) 10 (7.0) 12 nurse 1 (8.3) 9 (6.3) 10 midwife 1 (8.3) 0 (0) 1 non health worker 8 (66.7) 123 (86.6) 131 6 (0.02-0.10) rakhmad hidayat acta med indones-indones j intern med 210 by pcr, and were declared as fit to work by an occupational doctor. during isolation, staff could do their work from home by complying with health protocols. of the 83 positive staff members, 44 stayed at the hospital for isolation, and 39 were isolated at home. the average length of stay for hospital isolation was 8 days, with 25 as the longest. ages of the staff members ranged from 19 to 57 years, with an average age of 29 years (table 3). the average duration for the pcr test to become negative in two consecutive tests was 12 days. one staff member hospitalized at the universitas indonesia hospital have not reached negative conversion leading to exclusion from the study. table 4 shows the association between conversion duration and type of isolation and age. the type of isolation was correlated with the duration of conversion. besides isolation, there were several measures to control infection in the hospital cluster. this was done by implementing a special protocol related to covid-19; using appropriate self-protection equipment for those who had direct contact with covid-19 patients, obligatory mask for all staff in the hospital, body temperature checking, promoting hand hygiene by providing hand sanitizer and soap supply, management of the working area by limiting the number of staff members in one room, physical distancing, and ensuring healthy air circulation. discussion prevention of the spread of infection is a major goal in controlling covid-19. the who has recommended the identification of cases, contact tracing, and isolation for individuals table 2. demographic data of tracing phase variables tracing 1 (n) tracing 2 (n) tracing 3 (n) total (n) p value secondary attack rate (%) 95% ci + + + + age <30 year 36 141 6 218 0 17 42 376 0.018* 10.0 0.07-0.13 > 30 year 24 97 4 43 1 1 29 141 17.1 0.11-0.23 sex male 23 94 4 78 0 9 27 181 0.618* 13.0 0.08-0.18 female 37 144 6 183 1 9 44 336 11.6 0.08-0.15 occupation health worker 22 82 8 161 0 12 30 255 0.264* 10.5 0.07-0.14 non38 156 2 100 1 6 41 262 13.5 0.10-0.17 total (n) 60 238 10 261 1 18 71 517 12.1 0.09-0.15 *statistical analysis using chi-square test table 3. age, length of stay and duration of conversion. mean (sd) min max age (n=83), year 29.4 (7.4) 19 57 length of stay (n=44), day 8.7 (3.59) 3 25 duration of conversion (n=82), day 12.0 (4.00) 3 28 self-isolation (n=39), day 13.8 (4.23) 7 28 hospital isolation (n=43), day 10.41 (2.99) 6 19 table 4. association of age, isolation types, and duration of conversion variables duration of conversion (n=82) p value <14 days >14 days isolation self-isolation 18 (32.1) 21 (53.8) 0.000* hospital isolation 38 (67.9) 5 (19.2) age <30 years 35 (62.5) 11 (42.3) 0.086* ≥ 30 years 21 (37.5) 15 (57.7) *statistical analysis using chi-square test vol 52 • number 3 • july 2020 test, trace, and treatment strategy to control covid-19 infection 211 with covid-19. one strategy that can be used to prevent the spread is the 3t (test, trace, and treatment) strategy, which has proven to be able to control covid-19 outbreaks in several countries, such as south korea, singapore, and scotland.9 the implementation of the 3t strategy in scotland started with pcr testing on patients, health workers, and social workers. if a positive test result was found on examination, tracing would be carried out by the national contact tracing service to identify those who had close contact with the confirmed case, including everyone who had a contact history of being within 2 meters for 15 minutes or more. people who had close contact with confirmed cases were contacted by the national contact tracing service to identify the symptoms and advised to self-isolate for 14 days if they were asymptomatic. however, if the person showed symptoms of covid-19, then tracing would continue to identify a history of close contact with that person.10 moreover, tracing conducted in south korea and singapore was also through the gps on cell phones, transaction history, and cctv recordings in public areas.9 covid-19 testing should be done in all the hospital staff, and not only limited to the public. a report by imperial college london states that routine weekly pcr tests can identify asymptomatic or mild symptom cases and become the basis for tracing people who have close contact with the confirmed cases.11 routine pcr testing of health workers and risk groups helped to reduce the rate of virus transmission by 25%-33%, higher than isolation alone.12 contact tracing should be done by considering the individual-level variation in transmission. the higher the transmission variation, the more people will have to undergo an examination. the who has recommended that 10-30 examinations should be performed for each confirmed case. indonesia has also implemented this recommendation by conducting 20-30 examinations in the confirmed cases. this tracking has been implemented in several cities in indonesia, such as dki jakarta and surabaya. the depok government has set 3600 pcr tests dedicated to examining health workers in depok, including the university of indonesia hospital.11 therefore, as referral hospitals of covid-19 in depok, the university of indonesia hospital conducted a mass pcr test for the staff, followed by tracing and isolation to ensure safety from covid-19 infection. pcr test from mass swab test found 12 positive cases from 154 people (7.8%). because of that, contact tracing was carried out and resulted in the hospital having to do more swab tests with a ratio of 1:24 (out of 12 positive cases, the next swab test was 298). from 298 people, 60 (20.1%) were confirmed cases which later resulted in more contact tracing. then for second tracing from 60 positive cases resulted in 271 contact tracing with a trace per case ratio 1: 4 and found 10 positive cases (3.7%). from 10 positive cases, the third contact trace to 19 people and only found 1 positive case. all test conducted by the university of indonesia hospital was able to detect 83 (11.2%) confirmed cases from four examination periods and a total of 742 staff examined, namely the testing phase, tracing 1, tracing 2, and tracing 3. tracing of close contact from the first 12 cases in the testing phase was able to detect 60 new cases with a trace per case ratio of 1:24. in the next tracing, new case findings decreased to 1 new case per 4 close contacts and 3rd trace was 1:2. the ratio reduction indicates that the need for tracing will be higher in the first tracing cluster and lower if the cluster has been treated. when compared to mass swab tests, the result of first tracing shows the important role of tracing over mass swabs, 20.1% compared to 7.8 % (positivity rate of mass swab test) or 12.3% (positivity rate of indonesia in july 25, 2020). this shows a positive rate of contact tracing almost three times than a mass swab (20.1% compared to 7.8%). this percentage is higher than that observed in china where the infection rate of the hospital staff was 1.1%.5 focusing on contact tracing is crucial in indonesia, where financial condition and pcr test price are not favorable. in the future, mass swabs are not specifically required, and if they are done, they should be done based on cluster sampling followed by tracing. because mass pcr tests conducted on 5% of the population per week were estimated to reduce transmission by 2%.13 meanwhile from tracing we can conduct until 12% of the population. the higher number rakhmad hidayat acta med indones-indones j intern med 212 of cases in the university of indonesia hospital could be caused by close contact between staff and confirmed cases. the staff members of the university of indonesia hospital with positive results on the pcr test were asked to isolate. the implementation of the tracing and isolation strategies can reduce transmission of covid-19 (47%-64%) better than isolation strategies alone (29-37%).13 according to the who guidelines, confirmed and suspected cases must be isolated in health facilities to prevent the spread of coronavirus. if the number of health facilities is inadequate, isolation is prioritized for individuals with poor prognosis, such as aged >60 years and having a comorbid disease. patients with mild or asymptomatic symptoms can self-isolate at home or other non-health facilities, such as hotels or stadiums, by implementing standard health precautions.14 the indonesian ministry of health has also established guidelines for patients undergoing independent isolation: the patient is placed in a separate room that is well ventilated; both patients and families caring for patients will use masks; patient will restrict movement and sharing the same room with family members; patient will use separate cutlery; patient will sleep separately from family members or use a different bed; one healthy caretaker will take care of the patient; family members must wash their hands after every contact with the patient or the patient’s environment. patients undergoing self-isolation need daily monitoring, including identification of symptoms, such as fever, colds, sore throat, shortness of breath, and other complaints, such as mental health and psychosocial support.15 the university of indonesia hospital chose hospital isolation because it can reduce risk community transmission even though it involves a higher cost than self-isolation. about 42% of staff infected with covid-19 chose to self-isolate at home, whereas others chose hospital isolation. 21 patients (53.8%) who did self-isolation at home converted swab test result in more than 14 days, the remaining 18 patients (32.1%) converted in less than 14 days. meanwhile, 38 patients (67.9%) isolated in hospital converted in less than 14 days. five patients (19.2%) who were isolated in hospital converted in more than 14 days. a significant difference in the conversion time (less than 14 days and more than 14 days) from the staff was in self-isolation and hospital isolation. hospital isolation can also reduce the stigma of covid-19 infection. social stigma and discrimination can been experienced by infected patients, their families, health workers, and other frontline officers who have treated covid-19 patients. thus, it is important to consider socio-psychological impacts, such as stigma and discrimination in each phase of the covid-19 emergency response. reasonable attention must be given to assist in the integration of people affected by covid-19.16 this study found that the infection rate in health workers was lower than that in nonhealth workers. lai, et al.5 also found a similar result in a study, where infection rates among front-liner hospital staff were lower than in the non-front liners. many factors may lead to lower infection rates, such as self-protection, equipment availability, usage, and compliance with health precaution protocols. conclusion test, trace, and treatment (3t) strategy is a strategy to eliminate the spread of covid-19 in the hospital environment. this strategy could be used to control covid-19 infection because the infection rate of the hospital staff was quite high (11%). case identification of covid-19 should be followed by contact tracing. in one confirmed case, 24 additional tests were needed. the staff members who were confirmed positive were isolated. the random test is still applied but the sample does not need to include all staff due to the high cost. we recommend samples to be taken on a random basis per-unit or perprofession. from this randomized test, if some positive people are found, contact tracing is necessary. pcr test results must be obtained within 24 hours, so that people who are being tracked are not isolated for too long while waiting for the results and services at the hospital do not have to be closed. tracing was carried out until positive covid-19 results were no longer found. 3t strategy implementation should be performed simultaneously with other health protocols to vol 52 • number 3 • july 2020 test, trace, and treatment strategy to control covid-19 infection 213 reduce the risk of infection spreading, such as hand hygiene, physical distancing, and working space management. references 1. wang d, hu b, hu c, et al. clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in wuhan, china. jama. 2020;323:1061–9. 2. who. who coronavirus disease (covid-19) dashboard. 2020;available from: https://covid19.who. int/. 3. covid-19 gtpp. peta sebaran | gugus tugas percepatan penanganan covid-19 [internet]. covid19.go.id [cited 2020 jul 20]; available from: https://covid19.go.id/peta-sebaran. 4. kota depok i covid-19 [internet]. [cited 2020 jul 20];available from: https://ccc-19.depok.go.id/. 5. lai x, wang m, qin c, et al. coronavirus disease 2019 (covid-2019) infection among health care workers and implications for prevention measures in a tertiary hospital in wuhan, china. jama netw open 2020;3:e209666. 6. safutra i. 75 tenaga kesehatan di jatim positif korona [internet]. 2020 [cited 2020 jul 14];available from: https://www.jawapos.com/surabaya/20/06/2020/75tenaga-kesehatan-di-jatim-positif-korona/. 7. yandiputra ar. perawat positif corona, rsud depok tutup sementara metro tempo.co [internet]. 2020 [cited 2020 jul 16];available from: https://metro. tempo.co/read/1345168/perawat-positif-corona-rsuddepok-tutup-sementara. 8. testing, tracing, and when to lift restrictions: who’s latest advice [internet]. un news2020 [cited 2020 jul 20];available from: https://news.un.org/en/ story/2020/04/1061642. 9. lucy h. testing for covid-19: a way to lift confinement restrictions. 2020;21. 10. scottish government. covid-19 – test, trace, isolate, support: a public health approach to maintaining low levels of community transmission of covid-19 in scotland. 2020. 11. rivett l, sridhar s, sparkes d, et al. screening of healthcare workers for sars-cov-2 highlights the role of asymptomatic carriage in covid-19 transmission. elife 2020;9:e58728. 12. grassly n, pons salort m, parker e, et al. report 16: role of testing in covid-19 control [internet]. imperial college london; 2020 [cited 2020 jul 14]. available from: http://spiral.imperial.ac.uk/ handle/10044/1/78439 13. kucharski aj, klepac p, conlan ajk, et al. effectiveness of isolation, testing, contact tracing, and physical distancing on reducing transmission of sars-cov-2 in different settings: a mathematical modelling study. lancet infect dis [internet] 2020 [cited 2020 jul 16];0. available from: https://www.thelancet.com/journals/ laninf/article/piis1473-3099(20)30457-6/abstract. 14. world health organization. considerations in the investigation of cases and clusters of covid-19: interim guidance [internet]. 2020 [cited 2020 jul 14];available from: https://apps.who.int/iris/ handle/10665/331668. 15. kementerian kesehatan republik indonesia. keputusan menteri kesehatan republik indonesia nomor hk.01.07/menkes/413/2020 tentang pedoman pencegahan dan pengendalian coronavirus disease 2019 (covid-19). 16. inter-agency standing committee. catatan tentang aspek kesehatan jiwa dan psikososial wabah covid-19 versi 1.0 [internet]. available from: https:// www.who.int/docs/default-source/searo/indonesia/ covid19/catatan-tentang-aspek-kesehatan-jiwa-danpsikososial-wabah-covid-19-feb-2020-indonesian. pdf?sfvrsn=ebae5645_2. 31 original article acta med indones indones j intern med • vol 53 • number 1 • january 2021 modifiable risk factors for dementia in indonesia’s urban population muhammad k. azwar,1 siti setiati2 1 faculty of medicine universitas indonesia, jakarta, indonesia. 2 department of internal medicine – clinical epidemiology and evidence-based medicine unit, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: prof. siti setiati, md., phd. division of geriatric, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no.71, jakarta 10430, indonesia. email: s_setiati@yahoo. com; khifzhon@gmail.com. abstrak latar belakang: indonesia merupakan satu dari sepuluh negara di dunia yang diestimasi memiliki jumlah kasus demensia melebihi satu juta orang. jumlah penduduk lansia di perkotaan indonesia sudah melebihi jumlah lansia yang tinggal di pedesaan, namun indonesia masih kekurangan data yang dapat mewakili populasi dominan tersebut tentang faktor risiko demensia yang dapat dimodifikasi. pencegahan demensia penting dilakukan. studi ini mengidentifikasi faktor risiko demensia yang dapat dimodifikasi pada populasi perkotaan di indonesia. metode: penelitian kasus-kontrol ini menggunakan data 5 tahun rumah sakit umum pusat nasional dengan melacak kembali buku rekam medis individu berusia 60 tahun ke atas di klinik rawat jalan geriatri hingga data kunjungan pertama. analisis statistik bivariat serta multivariat digunakan untuk mengontrol faktor perancu dengan tepat. subanalisis dilakukan untuk demensia vaskular. hasil: data 345 pasien menunjukkan bahwa faktor risiko demensia yang dapat dimodifikasi adalah riwayat merokok (adjusted or 2.860, 95% ci 1.5595.246), riwayat penurunan pendengaran (adjusted or 7.962, 95% ci 3.534-17.941), riwayat depresi (adjusted or 12.473, 95% ci 2.533-61.417), hipertensi (adjusted or 1.751, 95% ci 1.006-3.048), dan diabetes melitus (adjusted or 2.561, 95% ci 1.482-4.425). pasien demensia memiliki median durasi diabetes melitus lebih lama (12 tahun) dibanding lansia tanpa demensia (9 tahun). kondisi underweight atau tingkat pendidikan rendah sendirinya tidak berhubungan dengan demensia di perkotaan. faktor risiko demensia vaskular mirip dengan demensia pada umumnya. kesimpulan: pada populasi perkotaan di indonesia, faktor risiko demensia yang dapat dimodifikasi adalah riwayat merokok, penurunan pendengaran, depresi, hipertensi, dan diabetes melitus. kata kunci: faktor risiko, demensia, indonesia, perkotaan, jakarta. abstract background: indonesia is one of ten countries in the world with estimated number of dementia case exceeding a million. the number of elderly population living in indonesian cities has exceeded the number in rural areas, but the country lacks data representing the urban population better related to modifiable risk factors for dementia, prevention of which is crucial. we aimed to identify the modifiable risk factors for dementia in indonesia’s urban population. methods: this case-control study used five-year data in indonesia’s national general hospital by tracing back medical record books of individuals aged 60 years and above in geriatric medicine outpatient clinic to the first hospital visit. statistical analyses included bivariate and multivariate analyses to adjust for confounding factors appropriately. results: data from 345 patients suggested that the significant risk factors for dementia were history of smoking (adjusted or 2.860, 95% ci 1.559-5.246), history muhammad khifzhon azwar acta med indones-indones j intern med 32 of hearing loss (adjusted or 7.962, 95% ci 3.534-17.941), history of depression (adjusted or 12.473, 95% ci 2.533-61.417), hypertension (adjusted or 1.751, 95% ci 1.006-3.048), and diabetes mellitus (adjusted or 2.561, 95% ci 1.482-4.425). dementia patients had longer median duration of diabetes mellitus (12 years) than elderly without dementia (9 years) before the diagnosis of dementia. single point late-life underweight condition and low educational attainment were not associated with dementia in indonesia’s urban setting. the risk factors for vascular dementia were largely similar to those of dementia. conclusion: in indonesian urban population, history of smoking, hearing loss, depression, hypertension, and diabetes mellitus are associated with dementia. keywords: risk factor, dementia, indonesia, urban, city, jakarta. introduction the greatest challenge for social care and healthcare worldwide in the 21st century is dementia. prevention is currently better than cure for dementia.1 asia pacific region in general has the fastest growing population of dementia patients in the world.2 indonesia is one of ten countries in the world with estimated number of dementia case exceeding a million.3 the number of population of older people nationwide in 2020 reached approximately 27.08 million (9.99% of total population)4 and accounts for about twofifths of the total elderly population in southeast asia.3 previous local study in yogyakarta, indonesia reported several risk factors associated with dementia with most of the subjects residing in rural areas.5 in fact, the number of urban population in indonesia exceeded that of rural community.6 there is also paucity of data representing the urban community of indonesia better. indonesia is seldom involved in multinational studies related to dementia. studies in highincome,1 as well as other lowand middleincome countries, have analyzed the relationship between several modifiable risk factors (abnormal body mass index [bmi], low educational attainment, history of smoking, hearing loss, hypertension and diabetes mellitus [dm]) and dementia.7 the aforementioned risk factors may also confound each other’s link with dementia.8–25 therefore, a local study about alterable risk factors for dementia in urban settlement with appropriate adjustment for potential confounders is needed. we aimed to identify the modifiable risk factors for dementia in indonesia’s urban setting, by utilizing data from the national general hospital in jakarta, the capital city of indonesia. the center is a favorable study location due to its variability of patient characteristics to estimate and represent the real condition of population well. the study variables were latelife underweight condition, low educational attainment, history of smoking, history of hearing loss, hypertension, and dm. as vascular dementia was among the commonest type of dementia in previous study of indonesia’s geriatric medicine outpatients.26 subanalysis was also done to identify the modifiable risk factors for vascular dementia. methods data source we investigated the effect relationship of the modifiable risk factors and dementia in indonesian clinical cohort of patient with and without dementia. a hospital-based case-control study design was conducted in indonesia’s national general hospital, cipto mangunkusumo hospital (rscm) using five-year data between january 2014 and december 2018. we selected the centre due to its variable characteristics of patient to estimate and represent the real condition of population well. ethical approval was granted by the ethics committee of the faculty of medicine, universitas indonesia (protocol number 20-03-0384). we included all prevalent dementia cases in this study. patients in control group attended the same outpatient service with no history of dementia and were selected with simple random sampling technique. we included patients 60 years of age and older, and excluded patients with incomplete medical record. we manually opened medical record books of patients in vol 52 • number 4 • october 2020 modifiable risk factors for dementia in indonesia’s urban population 33 outpatient geriatric medicine clinic to obtain the information by tracing back to the first hospital visit of each patient. such data collection method was an attempt to avoid potential bias from possible mistake in data input to the underdeveloped electronic health record system. in addition, we verified the diagnoses by rereading the subjective and objective findings in the care plans of each patient. we collected data related to body mass index, educational attainment, history of smoking, history of hearing loss, hypertension, and dm. we also documented the durations of hypertension and dm up until the diagnosis of dementia or simply the duration until 1 march 2020 for the control group. the durations were based on local hospital data and memory recall during history taking. dementia and depression diagnoses were made by physician as per diagnostic and statistical manual of mental disorders iv (dsm iv) and indonesia’s own guideline pedoman penggolongan dan diagnosis gangguan jiwa iii (ppdgj iii). the suspected type of dementia was based on clinical judgement by physicians and supported by appropriate diagnostic tool (e.g. brain mri), without post-mortem brain study. we considered late-life body mass index as underweight if it was <18.5 kg/m2. low educational attainment was defined as history of primary school completion only or no formal education at all. smoking was obtained by selfreport and classified as the presence or absence of history of smoking. history of hearing loss was recorded as yes or no, depending on diagnosis made by physicians. the diagnoses of hypertension and dm were made on the basis of joint national committee 7 (jnc 7) criteria and american diabetes association (ada) 2010 criteria, respectively. statistical methods sample size calculation relied on the formula for case-control study.27 we expected the number of individuals in control group to be twice as many as in case groups. p1 was the proportion of dementia elderly exposed to hypertension (0.72),26 whereas p2 was 0.478.28 the minimum number of sample in dementia group was 62. data were finally obtained from 115 patients with dementia and 230 patients without dementia. we analyzed the data utilising ibm® spss® statistics version 20 involving bivariate and multivariate analyses. the crude or of each variable was appropriately adjusted for other study variables in multivariate analysis. we provided subanalysis result to identify the role of the potential risk factors for vascular dementia. we considered p-value < 0.05 as statistically significant. results we collected data from 345 subjects. the characteristics of study participants are shown in table 1. nearly half of all subjects were 70-79 years old (47.0%). a majority of older people completed senior high school education (40.9%). most of all older people had bmi of 18.5 kg/ m2 or higher (86.1%). among all subjects, 20%, 11.9%, 58.3%, and 32.8% had history of smoking, hearing loss, hypertension, and dm, respectively. only 4.9% of elderly had history of depression. table 1. characteristics of subjects (n = 345). characteristics all subjects (n = 345) n % age 60-69 years 103 29.9 70-79 years 162 47.0 80 years and older 80 23.2 sex male 190 55.1 female 155 44.9 body mass index ≥18.5 kg/m2 297 86.1 underweight (<18.5 kg/m2) 48 13.9 last completed formal education no formal education 19 5.5 primary school 58 16.8 junior high school 34 9.9 senior high school 141 40.9 higher education 93 27.0 history of smoking 69 20.0 history of hearing loss 41 11.9 history of depression 17 4.9 hypertension 201 58.3 diabetes mellitus 113 32.8 muhammad khifzhon azwar acta med indones-indones j intern med 34 among dementia patients (n=115), the most common types of dementia were vascular dementia (54.8%) and alzheimer’s disease (17.4%). among all dementia patients, 2.6% and 1.7% were diagnosed with dementia with lewy bodies and frontotemporal dementia, respectively. on the other hand, 23.5% of patient’s dementia type remained unspecified. a majority of patient (70.4%) was diagnosed with dementia for the first time when they were 70 years old or older. forty percent dementia patients completed higher education and 74.8% of dementia patients had high educational attainment. the numbers of participant in each variable, bivariate, and multivariate analysis results related to dementia in general are shown in table 2, whereas it is shown in table 3 for vascular dementia. most dementia patients in the city had normal bmi, high educational attainment, and without the history of smoking, hearing loss, as well as depression. a majority of dementia patients had late-life hypertension (70.4%), whereas the proportions of dementia patient with and without documented dm were similar (47.8% vs 52.2%). likewise, similar proportions were also seen in vascular dementia patients, except much higher proportion of vascular dementia patients had latelife hypertension (82.5%). the median (range) duration of hypertension was 7 years (1.47 years) in control group, whereas it was 6 years (0.36 years) in dementia patients. in control group and dementia group, the durations of dm were 9 years (1.47 years) and 12 years (0.37 years), respectively. table 2. crude odds ratio (or) and adjusted or of modifiable risk factors for dementia. variables patient without dementia (n= 230) n (%) patient with dementia (n=115) n (%) crude or (95% ci) p value of crude or adjusted or (95% ci)a p value of adjusted or body mass index 0.190≥18.5 kg/m2 200 (87) 97 (84.3) 1.237 (0.657-2.329) 0.510 1.608 (0.791-3.271)underweight (<18.5 kg/m2) 30 (13) 18 (15.7) educational attainment high educational attainment 183 (79.6) 86 (74.8) 1.313 (0.774-2.228) 0.313 1.272 (0.690-2.342) 0.440 low educational attainment 47 (20.4) 29 (25.2) history of smoking no history of smoking 196 (71) 80 (69.6) 2.522 (1.471-4.323) 0.001 2.860 (1.559-5.246) 0.001documented smoking history 34 (49.3) 35 (30.4) history of hearing loss no history of hearing loss 220 (95.7) 84 (73) 8.119 (3.813-17.288) <0.001 7.962 (3.534-17.941) <0.001documented history of hearing loss 10 (4.3) 31 (27) history of depression no history of depression 228 (99.1) 100 (87) 17.100 (3.838-76.180) <0.001 12.473 (2.533-61.417) 0.002documented history of depression 2 (0.9) 15 (13) hypertension no hypertension 110 (47.8) 34 (29.6) 2.184 (1.356-3.518) 0.001 1.751 (1.006-3.048) 0.048 late-life hypertension 120 (52.2) 81 (70.4) diabetes mellitus no diabetes mellitus 172 (74.8) 60 (52.2) 2.718 (1.696-4.357) <0.001 2.561 (1.482-4.425) <0.001documented diabetes mellitus 58 (25.2) 55 (47.8) a mutually adjusted odds ratios (with 95% confidence intervals) derived from logistic regression model which included all of other variables for which results are presented. vol 52 • number 4 • october 2020 modifiable risk factors for dementia in indonesia’s urban population 35 the crude odds ratio (or) and adjusted or of the risk factors for dementia were shown in table 2. results showed that history of smoking (adjusted or 2.860, 95% ci 1.559-5.246), history of hearing loss (adjusted or 7.962, 95% ci 3.534-17.941), history of depression (adjusted or 12.473, 95% ci 2.533-61.417), hypertension (adjusted or 1.751, 95% ci 1.0063.048), and dm (adjusted or 2.561, 95% ci 1.482-4.425) were significant modifiable risk factors for dementia. in contrast, underweight (adjusted or 1.608, 95% ci 0.791-3.271) and low educational attainment (adjusted or 1.272, 95% ci 0.690-2.342) were not significant risk factors for dementia in this study. similarly, significant risk factors for vascular dementia were also history of smoking, hearing loss, depression, hypertension, and dm. (table 3) the adjusted or of hypertension (adjusted or 3.305, 95% ci 1.576-6.931) as a risk factor for vascular dementia was higher than for dementia in general, whereas the role of depression as a risk factor for vascular dementia was insignificant. discussion the most common type of dementia in this study was vascular dementia. the modifiable risk factors for dementia in indonesia’s urban population are history of smoking, hearing loss, depression, hypertension, and dm. in this study, the role of underweight state or low educational attainment as the risk factor for dementia was not significant. longer median duration of dm was seen in dementia patients (12 years) than in elderly without dementia (9 years). in this study, we identified risk factors similar to those found in studies in high1 and low-income countries,7 except the findings related to body mass index and low educational level. we found table 3. crude odds ratio (or) and adjusted or of modifiable risk factors for vascular dementia. variables patient without vascular dementia (n= 282) n (%) patient with vascular dementia (n=63) n (%) crude or (95% ci) p value of crude or adjusted or (95% ci)a p value of adjusted or body mass index ≥18.5 kg/m2 242 (85.8) 55 (87.3) 0.880 (0.390-1.985) 0.758 1.240 (0.506-3.042) 0.638 underweight (<18.5 kg/m2) 40 (14.2) 8 (12.7) educational attainment high educational attainment 222 (78.7) 47 (74.6) 1.260 (0.668-2.377) 0.476 1.162 (0.569-2.373) 0.679 low educational attainment 60 (21.3) 16 (21.1) history of smoking no history of smoking 235 (85.3) 41 (65.1) 2.683 (1.465-4.915) 0.001 2.922 (1.478-5.778) 0.002 documented smoking history 47 (16.7) 22 (34.9) history of hearing loss no history of hearing loss 259 (91.8) 45 (71.4) 4.504 (2.252-9.010) <0.001 4.262 (1.942-9.350) <0.001documented history of hearing loss 23 (8.2) 18 (28.6) history of depression no history of depression 273 (96.8) 55 (87.3) 4.412 (1.63111.939) 0.003 2.303 (0.715-7.419) 0.162documented history of depression 9 (3.2) 8 (12.7) hypertension no hypertension 133 (47.2) 11 (17.5) 4.220 (2.114-8.423) <0.001 3.305 (1.576-6.931) 0.002 late-life hypertension 149 (52.8) 52 (82.5) diabetes mellitus no diabetes mellitus 204 (72.3) 28 (44.4) 3.269 (1.865-5.731) <0.001 2.882 (1.528-5.434) 0.001documented diabetes mellitus 78 (27.7) 35 (55.6) a mutually adjusted odds ratios (with 95% confidence intervals) derived from logistic regression model which included all of other variables for which results are presented. muhammad khifzhon azwar acta med indones-indones j intern med 36 that dementia patients were not more likely to have late-life underweight condition (adjusted or 1.608, 95% ci 0.791-3.271). the result of subanalysis for vascular dementia also suggested similar finding. this is contrary to the results of a longitudinal study conducted by fitzpatrick and colleagues, including the evidence that people with late-life underweight condition had higher risk of dementia (hr 1.62, 95% ci 1.02-2.64).29 this finding may suggest less contribution of single measurement of bmi in increasing the risk of dementia in indonesian urban population aged 60 years and above. rather than single measurement, lifetime trends in weight may improve the prediction. monitoring of bmi is thus needed, seeing that bmi loss is a marker of incipient dementia.30 the odds of low educational attainment among dementia patients are similar to the odds among controls (adjusted or 1.272, 95% ci 0.690-2.342). likewise, the result of subanalysis for vascular dementia also suggested insignificant role of low educational attainment in early life as an alterable risk factor. in contrast, a cross-sectional study in indonesia with most of the subjects residing in rural area reported inverse association between dementia and educational level.5 our study showed that almost half of the dementia patients in our urban population completed higher education. in addition, jakarta has the highest net enrolment ratio of senior and junior high school among other provinces. earlier study in jakarta also showed no significant relationship between educational level and memory impairment among elderly with normal mini-mental state examination (mmse) result.31 in another urban setting in manado, indonesia, there was also no correlation between educational level and dementia.32 the findings in the indonesian cities collectively suggest that people in the city regardless of their educational attainment may also develop dementia, whilst other risk factors may be more prominent. years of schooling might not represent the quality of education, which is possibly a more important factor.33 on the other hand, we hypothesised that the result of this study may be affected by presumed underdetection of dementia in urban population with low educational level. there is limited data to support this conjecture and researchers have yet to analyse the associated risk factors for underdetection of dementia in indonesia, owing to the fact that different income may partly affect the detection of dementia in different countries. for instance, low levels of education, occupational class and income in china are strongly associated with greater risk for having undetected dementia.34 dementia patients are nearly three times more likely to have a history of smoking (adjusted or 2.860, 95% ci 1.559-5.246). similar result was seen for vascular dementia. cigarette smoke contains neurotoxins increasing the risk for dementia.35 the proportion of elderly with history of smoking in indonesia’s urban population was 22.54%,36 similar to the finding in this study (20%). the link between smoking and dementia may also be due to the relationship between smoking and cardiovascular diseases.1 smoking increases fibrinogen levels, induces hypercoagulable state, and results in oxidative damage. the risk of cardiovascular pathology is lowered as smoking cessation reduces oxidative stress and inflammatory markers. in asian population, a prolonged period of smoking cessation (≥ 4 years) is beneficial to lower the risk of dementia.37 nevertheless, not smoking increases health in ageing as well as life expectancy.1 strategy regarding the prevention and cessation of smoking should be emphasised in all age groups. in this study, hearing loss was not divided into central and peripheral impairment. hearing loss itself may lead to depression or social disengagement. furthermore, it may cause alterations in the brain through the cognitive load of the vulnerable brain. microvascular pathology and older age heighten the risk of peripheral hearing loss and dementia, which may confound the association between the two.1 however, even after adjustment for potential confounders in this study, the odds of having hearing loss among dementia patients were significantly higher than controls (adjusted or 7.962, 95% ci 3.534-17.941), whereas the adjusted or was lower in terms of vascular dementia (adjusted or 4.262, 95% ci 1.942-9.350). preliminary vol 52 • number 4 • october 2020 modifiable risk factors for dementia in indonesia’s urban population 37 result of other study suggested that mitigation of the risk of dementia from hearing loss can be achieved by hearing aid.7 however, in the case of central hearing loss, hearing aid does not improve hearing. thus, central hearing loss is unlikely to be modifiable since comprehension of speech in noise is impaired due to noncochlear pathology. nevertheless, the relationship between depression and dementia can be bidirectional, since alzheimer’s disease may affect central auditory area. thus, hearing loss could be a prodromal symptom of the dementia as well.1 we suggest an association between history of depression and dementia (adjusted or 12.473, 95% ci 2.533-61.417). a systematic review suggested a link between depressive mood and air pollution, noise pollution, lack of green areas, as well as poor housing quality 38, which are all common in indonesian urban setting. a cohort study suggested that only 10 years prior to the incidence of dementia that depression is more common in elderly with dementia than those without dementia. the risk of dementia is increased through the impact on stress hormones, hippocampal volume, and neuronal growth factor.39 similar to hearing loss, the association between the cognitive decline and depressive symptoms may also be bidirectional. in regards to the effort to lower the risk of dementia, the effect of antidepressants remains controversial.1 interestingly, depression is not a significant risk factor for vascular dementia (adjusted or 2.303,95% ci 0.715-7.419). we hypothesised that depression may occur later in vascular dementia, instead of being an independent variable prior to vascular dementia. one study suggested that depressive symptoms were more prevalent in patients with vascular dementia compared to alzheimer’s disease. in addition, the depressive symptoms may also be more severe in vascular dementia patients.40 the odds of having hypertension is almost two times higher among dementia patients than controls (adjusted or 1.751, 95% ci 1.0063.048). on the other hand, the odds of having hypertension is 3.3 times higher among vascular dementia patients than controls in this study (adjusted or 3.305, 95% ci 1.576-6.931). the median duration of hypertension was 7 years in control group, whereas it was only 6 years in dementia patients. the duration may be affected by recall bias. in general, both the detection of hypertension and the blood pressure control are protective against later-life cognitive decline.41 fortunately, the awareness and treatment of hypertension in indonesia’s urban population is already higher than in rural parts. indonesia’s communitybased integrated coaching posts may contribute to the community participation in the early detection of hypertension.42 the issue in asian countries is that not many people are aware of the relationship between hypertension and dementia / cognitive impairment.41 blood pressure control can be achieved by combining pharmacological and non-pharmacological approach.43 among all antihypertensives, angiostensin receptor blockers (arbs)44 and calcium channel blockers (ccbs)45 have a more pronounced protective effect to reduce the risk of dementia. older people with hypertension may not meet the target of recommended physical activity for young adults, thus functional capacity and preferences of each individual should be considered. lifestyle changes that are recommended to patients with hypertension in general, including dietary salt restriction, dietary approaches to stop hypertension (dash) diet, may be detrimental to older people.43 ambulatory adults with hypertension may benefit from treatment with a goal of sbp <120 mm hg to reduce the risk of mild cognitive impairment (mci) significantly in comparison with antihypertensive drug treatment with higher goal sbp (>140 mm hg) (hr 0.81, 95% ci 0.69-0.95).46 however, the relationship in studies conducted in older adults was variable. although at least a trial of elderly patients showed no significant difference in dementia incidence between antihypertensive treatment and placebo groups, the result of meta-analysis of trials favoured treatment (hr 0.87, 95% ci 0.76-1.00, p = 0.045).47 a recent meta-analysis of cohort studies showed that antihypertensive drug in older people is associated with reduced risk for dementia (rr 0.86, 95% ci 0.75-0.99, p = 0.033), but not with the risk for cognitive muhammad khifzhon azwar acta med indones-indones j intern med 38 impairment, cognitive decline and alzheimer’s disease.48 despite the controversial results regarding the beneficial effect of antihypertensive drugs on the reduction of dementia risk, we still emphasise the importance of antihypertensive treatment in all patients with hypertension. the reasons include the potential damage of the brain in cases of hypertension. hypertension is associated with incidence of stroke. once stroke occurs, there is sixfold higher risk of developing dementia at 5 years. stroke may have impact on the white matter and hippocampus, leading to post-stroke cognitive impairment.41 a systematic review and metaregression analysis showed that antihypertensive treatment lowered the risk for disabling or fatal stroke (rr 0.71, 95% ci 0.59-0.85, p < 0.001) as well as the risk for recurrent stroke (rr 0.73, 95% ci 0.62-0.87, p < 0.001).49 stroke prevention is crucial, since it is a risk factor for dementia. in fact, blood pressure variability in asian older adults is still an issue. diurnal blood pressure variation is associated with silent cerebrovascular damage and may lead to the development of dementia in the form of alzheimer’s disease. strict nocturnal blood pressure control has a neuroprotective effect on the brain to prevent the incidence of dementia.41. a multicentre study in lowand middle-income countries not involving indonesia suggested hypertension and hearing loss as initial targets for dementia prevention strategies. the prevention potential of the modifiable risk factors for dementia in those countries is even greater than in high-income countries.7 the odds of having dm among dementia patients in general and vascular dementia patients are nearly three times higher than controls (adjusted or for dementia 2.561, 95% ci 1.482-4.425; adjusted or for vascular dementia 2.882, 95% ci 1.528-5.434). in controls and dementia group, the median duration of dm were 9 years (range 1, 47 years) and 12 years (range 0, 37 years), respectively. diabetes has adverse effects seen from vascular, degenerative and metabolic point of view. atherosclerosis and cerebrovascular diseases may result in vascular dementia, whereas altered insulin metabolism, impaired amyloid clearance, and p-tau play role in the development of alzheimer’s disease.50 peripheral insulin anomalies lead to lower production of brain insulin causing impairment in amyloid clearance. from metabolic point of view, high blood sugar level and inflammatory state in diabetic patients also impair cognition.1 oxidative stress, advanced glycation end product (age), and glucose toxicity are all involved in the pathophysiology of the newly proposed type of dementia, namely diabetes-related dementia. patients with diabetes-related dementia are characterised by less severe medial temporal lobe atrophy and less word recall impairment, but patients may have impaired executive function and attention. patients with this type of dementia is typically old with long duration of diabetes, high haemoglobin a1c, high frequency of insulin therapy, and low frequency of apolipoprotein e4 carrier.50 interestingly, a 24-week randomised controlled trial analysing the oral hypoglycaemic drug rosiglitazone in older people did not show beneficial effect of the treatment on the reduction of dementia risk.51 another commonly prescribed drug for diabetic patient, statin, is also ineffective for the risk reduction in the elderly.52 to date, we believe that our study is the only primary observational study taking account data related to various reported multiple risk factors at once to identify the modifiable risk factors for dementia in indonesia’s urban setting. we also avoided overadjustment and under-adjustment for potential confounders. however, we acknowledge the limitations of this study. first, wide confidence interval is an issue in mainly two study variables (history of hearing loss and depression). second, the study result might be affected by presumed underdetection of dementia in city dwellers with low educational attainment. third, we only took account one-time bmi measurement for the analysis. fourth, we have not incorporated other potential risk factors in our study, including low social contact, physical inactivity, living near major roads, and alcohol consumption. to overcome the limitations, studies should have larger sample size and follow up the changes of study variables. moreover, future studies have yet to elaborate more on other potential risk vol 52 • number 4 • october 2020 modifiable risk factors for dementia in indonesia’s urban population 39 factors for dementia, as well as the potential risk factors for underdetection of dementia. improved detection of dementia may bring about higher reliability of study result. conclusion the odds of having either hypertension, dm, history of smoking, hearing loss, or depression are significantly higher among dementia patients in indonesia’s urban population than controls. the role of underweight state or low educational attainment as the risk factor for dementia was not significant. the study result provides information to physicians and patients for the detection of modifiable risk factors before the occurrence of dementia. prolonged smoking cessation (≥4 years), hearing aid, and antihypertensive drugs (angiostensin receptor blockers and calcium channel blockers) may be beneficial for the significant reduction of dementia risk. acknowledgments we thank the almighty god for reasons too numerous to mention. we also thank rahmi istanti and christy magdalena simanjuntak for their precious help in statistical analysis and careful article checking, respectively. the authors declare that there is no conflict of interest regarding the publication of this paper. the authors received no financial support for the research, authorship, and/or publication of this article. references 1. livingston g, sommerlad a, orgeta v, et al. dementia prevention, intervention, and care. lancet. 2017;390(10113):2673–734. 2. alzheimer’s disease international. world alzheimer report 2019: attitudes to dementia. london, uk; 2019. 3. prince m, wimo a, guerchet m, et al. world alzheimer report 2015—the global impact of dementia: an analysis of prevalence, incidence, cost and trends. london, uk; 2015. 4. direktorat kesehatan keluarga direktoral jenderal kesehatan masyarakat kementerian kesehatan ri. panduan pelayanan kesehatan lanjut usia pada era pandemi covid-19. jakarta: kementerian kesehatan ri; 2020. 5. suriastini n, turana y, supraptilah b, wicaksono t, mulyanto e. prevalence and risk factors of dementia and caregiver’s knowledge of the early symptoms of alzheimer’s disease. aging med healthc. 2020;11(2):60–6. 6. world bank world development indicators. rural population (% of total population) indonesia. 7. mukadam n, sommerlad a, huntley j, livingston g. population attributable fractions for risk factors for dementia in low-income and middle-income countries: an analysis using cross-sectional survey data. lancet glob heal. 2019;7(5):e596–603. 8. andreoulakis e, hyphantis t, kandylis d, iacovides a. depression in diabetes mellitus: a comprehensive review. hippokratia. 2012;16(3):205–14. 9. gao k, shi x, wang w. the life-course impact of smoking on hypertension, myocardial infarction and respiratory diseases. sci rep. 2017;7(1):4330. 10. garcía-fabela l, melano-carranza e, aguilar-navarro s, garcía-lara jma, gutiérrez-robledo lm, ávilafunes ja. hypertension as a risk factor for developing depressive symptoms among community-dwelling elders. rev investig clin. 2009;61(4):274–80. 11. jonas bs, franks p, ingram dd. are symptoms of anxiety and depression risk factors for hypertension? longitudinal evidence from the national health and nutrition examination survey i epidemiologic follow-up study. arch fam med. 1997. 12. agarwal s, mishra a, jagade m, kasbekar v, nagle sk. effects of hypertension on hearing. indian j otolaryngol head neck surg. 2013;65(s3):614–8. 13. yikawe ss, iseh kr, sabir aa, inoh mi, solomon jh, aliyu n. cardiovascular risk factors and hearing loss among adults in a tertiary center of northwestern nigeria. world j otorhinolaryngol head neck surg. 2018. 14. croll ph, voortman t, vernooij mw, et al. the association between obesity, diet quality and hearing loss in older adults. aging (albany ny). 2019;11(1):48–62. 15. kim sy, kim h-j, park e-k, joe j, sim s, choi hg. severe hearing impairment and risk of depression: a national cohort study. malmierca ms, editor. plos one. 2017;12(6):e0179973. 16. mener dj, betz j, genther dj, chen d, lin fr. hearing loss and depression in older adults. j am geriatr soc. 2013;61(9):1627–9. 17. mozaffari m, tajik a, ariaei n, ali ehyaii f, behnam h. diabetes mellitus and sensorineural hearing loss among non-elderly people. east mediterr heal j. 2010 sep;16(9):947–52. 18. maddatu j, anderson-baucum e, evans-molina c. smoking and the risk of type 2 diabetes. translational research. 2017. 19. piirtola m, jelenkovic a, latvala a, et al. association of current and former smoking with body mass index: a study of smoking discordant twin pairs from 21 twin cohorts. remuzzi g, editor. plos one. 2018;13(7):e0200140. 20. flensborg-madsen t, bay von scholten m, flachs muhammad khifzhon azwar acta med indones-indones j intern med 40 em, mortensen el, prescott e, tolstrup js. tobacco smoking as a risk factor for depression. a 26-year population-based follow-up study. j psychiatr res. 2011 feb;45(2):143–9. 21. yun c, wang z, gao j, et al. prevalence and social risk factors for hearing impairment in chinese children—a national survey. int j environ res public health. 2017;14(1):88. 22. kiely dk, gross al, kim dh, lipsitz la. the association of educational attainment and sbp among older community-living adults. j hypertens. 2012;30(8):1518–25. 23. sacerdote c, ricceri f, rolandsson o, et al. lower educational level is a predictor of incident type 2 diabetes in european countries: the epic-interact study. int j epidemiol. 2012;41(4):1162–73. 24. cohen ak, rai m, rehkopf dh, abrams b. educational attainment and obesity: a systematic review. obes rev. 2013;14(12):989–1005. 25. mezuk b, eaton ww, golden sh, ding y. the influence of educational attainment on depression and risk of type 2 diabetes. am j public health. 2008;98(8):1480–5. 26. azwar mk, setiati s. the clinical profile of dementia in indonesia’s national general hospital. the 11th iagg asia/oceania regional congress program book. iagg asia oceania; 2019. 27. ariawan i. besar dan metode sampel pada penelitian kesehatan. 1st ed. depok, id: jurusan biostatistik dan kependudukan fakultas kesehatan masyarakat, universitas indonesia; 1998. 28. febianora m, achmad c. trends in population blood pressure and prevalence, awareness, treatment, and control of hypertension among middle aged and elderly in rural area of riau archipelago, indonesia from 2007 to 2015. j hypertens. 2015;33:e25. 29. fitzpatrick al, kuller lh, lopez ol, et al. midlife and late-life obesity and the risk of dementia. arch neurol. 2009. 30. atti ar, palmer k, volpato s, winblad b, de ronchi d, fratiglioni l. late-life body mass index and dementia incidence: nine-year follow-up data from the kungsholmen project. j am geriatr soc. 2008;56(1):111–6. 31. turana y, handajani ys, widjaja nt. association between apoe ε4 genotype and memory impairment in elderly with normal global cognitive assessment. diagnostics. 2015;5(4):615–23. 32. setiawan d, bidjuni h, karundeng m. hubungan tingkat pendidikan dengan kejadian demensia pada lansia di balai penyantunan lanjut usia senja cerah paniki kecamatan mapanget manado. j keperawatan unsrat. 2014;2(2):1–7. 33. rawtaer i, gao q, nyunt msz, et al. psychosocial risk and protective factors and incident mild cognitive impairment and dementia in community dwelling elderly: findings from the singapore longitudinal ageing study. anstey k, editor. j alzheimer’s dis. 2017;57(2):603–11. 34. lang l, clifford a, wei l, et al. prevalence and determinants of undetected dementia in the community: a systematic literature review and a meta-analysis. bmj open. 2017;7(2):e011146. 35. swan ge, lessov-schlaggar cn. the effects of tobacco smoke and nicotine on cognition and the brain. neuropsychology review. 2007. 36. indonesia kkr. analisis lansia di indonesia. jakarta, id: kementerian kesehatan republik indonesia; 2017. p. 7–8. 37. choi d, choi s, park s. effect of smoking cessation on the risk of dementia: a longitudinal study. ann clin transl neurol. 2018;5(10):1192–9. 38. lecic-tosevski d. is urban living good for mental health? curr opin psychiatry. 2019;32(3):204–9. 39. alexopoulos gs. vascular disease, depression, and dementia. j am geriatric soc. 2003. 40. luchsinger ja, honig ls, tang mx, devanand dp. depressive symptoms, vascular risk factors, and alzheimer’s disease. int j geriatr psychiatry. 2008. 41. turana y, tengkawan j, chia yc, et al. hypertension and dementia: a comprehensive review from the hope asia network. j clin hypertens. 2019;21(8):1091–8. 42. peltzer k, pengpid s. the prevalence and social determinants of hypertension among adults in indonesia: a cross-sectional population-based national survey. int j hypertens. 2018;2018(3):1–9. 43. benetos a, petrovic m, strandberg t. hypertension management in older and frail older patients. circ res. 2019;124(7):1045–60. 44. chiu w-c, ho w-c, lin m-h, et al. angiotension receptor blockers reduce the risk of dementia. j hypertens. 2014;32(4):938–47. 45. hwang d, kim s, choi h, et al. calcium-channel blockers and dementia risk in older adults – national health insurance service – senior cohort (2002–2013). circ j. 2016. 46. williamson jd, pajewski nm, auchus ap, et al. effect of intensive vs standard blood pressure control on probable dementia. jama. 2019;321(6):553. 47. peters r, beckett n, forette f, et al. incident dementia and blood pressure lowering in the hypertension in the very elderly trial cognitive function assessment (hyvet-cog): a double-blind, placebo controlled trial. lancet neurol. 2008;7(8):683–9. 48. xu g, bai f, lin x, et al. association between antihypertensive drug use and the incidence of cognitive decline and dementia: a meta-analysis of prospective cohort studies. biomed res int. 2017;2017(11):1–11. 49. katsanos ah, filippatou a, manios e, et al. blood pressure reduction and secondary stroke prevention. hypertension. 2017;69(1):171–9. 50. hanyu h. diabetes-related dementia. advances in experimental medicine and biology. 2019. p. 147–60. vol 52 • number 4 • october 2020 modifiable risk factors for dementia in indonesia’s urban population 41 51. gold m, alderton c, zvartau-hind m, et al. rosiglitazone monotherapy in mild-to-moderate alzheimer’s disease: results from a randomized, double-blind, placebo-controlled phase iii study. dement geriatr cogn disord. 2010. 52. mcguinness b, craig d, bullock r, passmore p. statins for the prevention of dementia. cochrane database of systematic reviews. 2016. p. cd003160. 1acta med indones indones j intern med • vol 54 • number 1 • january 2022 editorial urease, gastric bacteria and gastritis marcellus simadibrata kolopaking* division of gastroenterology, department of internal medicine, faculty medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. * corresponding author: prof. marcellus simadibrata kolopaking, md., phd. division of gastroenterology, department of internal medicine, faculty medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: prof.marcellus.s@gmail.com. urease is an enzyme produced by diverse bacterial species including normal flora, non pathogens, and pathogens such as proteus mirabilis, staphylococcus saprophyticus, klebsiella pneumonia, citrobacter freundii, enterobacter cloacae helicobacter spp and helicobacter pylori.1-4 urease is central in helicobacter pylori metabolism and virulence, important for colonization in the gastric mucosa.1 urease catalyzes the hydrolysis of urea to ammonia and carbamate. this ammonia product can be examined by urease biopsy test and urea breath test such as 14c-urea breath test or 13c-urea breath test.1 previously, the urea breath test was intended to detect an increase in ammonia which is a urease product in the gastric mucosa produced by pathogenic gastric bacteria, such as helicobacter pylori, etc.1-7 acute and chronic gastritis caused by infection with these pathogenic bacteria infection turned out to be positive on urea breath test.8-11 indirectly, the results of the urea breath test are also related to the presence of inflammation in acute and chronic gastritis, regardless of whether the cause is helicobacter pylori or other ureaseproducing pathogenic bacteria.7,8 the use of the urea breath test indirectly in diagnosing acute and chronic gastritis should be studied further. the use of the urea breath test is indeed very important to assist health services in countries and regions with limited endoscopic facilities, especially developing countries. we know that the prevalence of helicobacter pylori infection in causing acute and chronic gastritis by examination of urea breath test in indonesia is not too high, ranging from 2-11.2%.5 so that is why more studies on non-helicobacter pylori producing urease pathogens are needed, which can appear as a false positive urea breath test. miftahussurur m et al.5 in their research on 95 dyspeptic patients at soetomo hospital surabaya indonesia found that the urease levels of positive patients with acute and chronic gastritis were higher than negative patients (p = 0.001, r = 0.353; p <0.0001, r = 0.433). the auc values of 14c-ubt for detecting acute, chronic, and atrophic gastritis were 0.889, 0.632 and 0.544, respectively. they concluded that 14c-ubt is an adequate diagnostic modality to predict acute or chronic gastritis but not atrophic gastritis. references 1. urease – helicobacter pylori –ncbi bookshelf. cited 11 february 2022. 2. lee a, o’rourke j. gastric bacteria other than helicobacter pylori. gastroenterol clin north am. 1993;22(1):21-42. 3. de groote d, van doorn lj, van den bulck k, et.al. detection of non-pylori helicobacter species in “helicobacter heilmannii”-infected humans. helicobacter. 2005;10(5):398-406. 4. osaki t, mabe k, hanawa t, kamiya s. ureasepositive bacteria in the stomach induce a falsepositive reaction in a urea breath test for diagnosis of helicobacter pylori infection. j med microbiol. 2008;57(7):814–9. 5. miftahussurur m, shiota s, suzuki r, et al. identification marcellus simadibrata kolopaking acta med indones-indones j intern med 2 of helicobacter pylori infection in symptomatic patients in surabaya, indonesia, using five diagnostic tests. epidemiology & infection.2015;143(5):986 96 . 6. dore mp, pes gm, bassotti g, usai-sattap . dyspepsia: when and how to test for helicobacter pylori infection. gastroenterol res practice. 2016. article id 8463614, 9 pages http://dx.doi.org/10.1155/2016/8463614. 7. diego mora d, arioli s. microbial urease in health and disease. plos pathogens. 2014;10(12): e1004472:1-4. 8. hernandez a. acute gastritis. available from url:// https://www.osmosis.org/answers/acute-gastritis. cited 11 february 2022. 9. cleveland clinic. gastritis. available from url://https:// my.clevelandclinic.org/health/diseases/10349-gastritis. cited 11 february 2022. 10. drug genius. gastritis diagnosis. available from url:// https://druggenius.com/diagnosis/gastritis/. cited 22 february 2022. 11. bmj best practice. gastritis. available from url:// https://bestpractice.bmj.com/topics/en-us/816. cited 11 february 2022. 233acta med indones indones j intern med • vol 53 • number 2 • april 2021 clinical practice the management of pulmonary fibrosis in covid-19 cleopas martin rumende, erwin c. susanto, truely p. sitorus division of respirology and critical care, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: cleopas martin rumende, md, phd. division of respirology and critical care, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: rumende_martin@yahoo.com. abstrak fibrosis paru pasca infeksi covid-19 dapat terjadi akibat komplikasi ards yang ditandai dengan adanya kegagalan re-epitelisasi alveolar, aktifasi fibroblast, akumulasi kolagen dan matriks ekstraseluler lain secara berlebihan sehingga menyebabkan kelainan arsitektur paru. ada beberapa faktor risiko untuk terjadinya fibrosis paru pasca-covid yaitu usia lanjut, riwayat ards, penggunaan ventilator mekanik yang dapat menyebabkan terjadinya injury paru, riwayat merokok dan konsumsi alkohol. diagnosis fibrosis paru pasca-covid ditegakkan berdasarkan gejala klinis dan gambaran karakteristik kelainan ct scan paru. hingga saat ini belum ada terapi definitif untuk fibrosis paru pasca-covid, namun beberapa obat antifibrosis dapat dipertimbangkan untuk diberikan. selain terapi medika mentosa, rehabilitasi paru dan terapi oksigen jangka panjang juga harus merupakan bagian dalam tatalaksana komprehensif fibrosis paru pasca-covid-19. kata kunci: fibrosis paru, covid-19. abstract pulmonary fibrosis due to covid-19 is recognized as sequel of ards characterized by failed alveolar reepithelization, fibroblast activation, excessive collagen deposition and other extracellular matrix components that disrupt the normal lung architecture. there are risk factor for pulmonary fibrosis namely advanced age, severe ards infection, mechanical ventilation due to ventilator-induced lung injury, smoking and chronic alcoholism. diagnosis of post-covid pulmonary fibrosis can be made by clinical symptoms and characteristic finding from lung ct scan. to date, there is no definitive treatment for post-inflammatory pulmonary fibrosis after covid-19 infection, however some of antifibrotic therapies may be considered. beside medical treatment, pulmonary rehabilitation program and long-term oxygen treatment should be included as part of comprehensive treatment for pulmonary fibrosis due to covid-19. keywords: pulmonary fibrosis, covid-19. introduction the novel coronavirus disease (covid-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2), has generated huge concern for high mortality and lack of specific and effective treatment. the most critically ill patients in the context of sarscov-2 infection may develop acute respiratory distress syndrome (ards). it has been found that 40% of patients with covid-19 develop ards, and 20% of ards cases are severe.1 pulmonary fibrosis is recognised as sequel of ards characterized by failed alveolar reepithelization, fibroblast activation, excessive cleopas martin rumende acta med indones-indones j intern med 234 collagen deposition and other extracellular matrix (ecm) components that disrupt the normal lung architecture. excessive depotition of ecm is therefore central to the process of lung fibrosis. it manifests as an irregular interlobar septal thickening and reticular pattern with traction bronchiectasis on chest ct scan.2 the prevalence of post-covid 19 fibrosis will become apparent with time, but early analysis from patients with covid-19 on hospital discharge suggest that more than a third of recovered patients develop fibrotic abnormalities. a study of italian covid-19 pandemic survivors found that as many as 45% patients still complained of dyspnea at follow up visit conducted a mean of 60 days after the initial onset of the symptom. a follow-up study by zhao et al.3 of pulmonary function and radiology in 55 covid-19 survivors 3 months after recovery showed that 71% had residual ct abnormalities, including evidence of interstitial thickening in 27%. abnormal lung function has also been identified at the time of discharge from the hospital and after 2 weeks later in up to 47% cases. restrictive ventilatory defects is the most common abnormality of lung function seen in about 25% of cases. the pulmonary function abnormalities being worse in those with severe acute infection. follow up of cohorts of post-covid survivors are already underway at several centers to determine weather fibrosis changes on ct scan are persist or gradually improved or even worsen with the passage of time. this has implications not only for patient prognosis but also for treatment. antifibrotic may have an important role in patients with progressive lung fibrosis (figure 1).3 compared with the last ct scan before discharge, the abnormalities (including focal/ multiple ggo, consolidation, interlobular septal thickening, subpleural lines and irregular lines) in lung are gradually absorbed in the first and second follow-ups after discharge. the lung lesion of 64.7% discharged patients were fully absorbed after 4-week follow-up. it indicates reversible lung tissue damage of covid-19 cases. it also suggest that the prognosis of non-severe patients is favourable, and clinical intervention should be conducted to prevent the worsening of covid-19 patients.1 r i s k f a c t o r s f o r p u l m o n a r y fibrosis in sars-cov-2 the factors mediating a profibrotic response to sars-cov-2 virus are not fully known, but from some studies suggest that age, severity of illness, use of mechanical ventilation, smoking and chronic alcoholism may contribute.2,4 age. pulmonary fibrosis is reported more often in patients with advance age. the median age for diagnosis is 65 years, and it rarely occurs before 50 years. in a follow-up study, advance age correlated with the risk of developing pulmonary fibrosis at 6 months after discharge. the exact reason for this association is unknown; however, older patient are more susceptible to both sars and mers similar to sars-cov-2 infection and more likely to have severe symptoms.2,4 illness severity. according to world health organization, 80% of sars-cov-2 infection are mild, 14% develop severe symptoms, and 6% will become critically ill. factors associated with increased diseases severity include comorbidities such as hypertension, diabetes and coronary artery disease. laboratory findings of lymphopenia and elevated lactate dehydrogenase (ldh) correlate with increased disease severity. serum ldh level has been used as marker of disease severity following acute lung injury. it is an indicator of pulmonary tissue destruction and correlate with the risk of mortality. the extent of lung injury and inflammatory respons correlate with the extent of fibroblastic response required to repair the injury. peaked ldh level was found to significantly correlate with the risk of pulmonary fibrosis following mersfigure 1. the natural history of post-covid pulmonary fibrosis will be one of three possible course. vol 53 • number 2 • april 2021 the management of pulmonary fibrosis in covid-19 235 cov infection. similarly, a follow-up study at 6 months after discharge in sars patients show a significant relation between elevated levels of ldh during acute illness and an increased risk of developing pulmonary fibrosis.2 length of icu stay and mechanical ventilation. icu care is required in 5-12% of covid-19 patients, with the criteria for icu admission varying from one region to another. while disease severity is closely related to the length of icu stay, mechanical ventilation poses an additional risk of ventilator-induced lung injury (vili). ventilator-induced lung injury is an acute lung injury arising from or exacerbated by mechanical ventilation. abnormalities of pressure or volume setting underlie this injury leading to release of proinflamatory mediators, worsening acute lung injury and increased mortality or pulmonary fibrosis in survivors. in a follow-up study of 27 patients who had mechanical ventilation for ards, 110-267 days after extubation, 23 patients (85%) had pulmonary fibrosis with a significant relationship to the duration of pressure-controlled inverseratio ventilation.2 smoking. smoking has been linked to the pathogenesis of various lung disease such as emphysema, chronic bronchitis and pulmonary fibrosis. smoking is associated with chronic oxidative stress, increased expression of inflammatory cytokine and interstitial lung fibrosis. the injury associated with smoking continues even after cessation. a systemic review shows that smokers were 1.4 times more likely to have severe symptoms of covid-19 and 2.4 times more likely to need icu admission and mechanical ventilation or die compared to nonsmokers.2 chronic alcoholism. chronic alcoholism has been cited a predisposing factor for severe respiratory infection. alcohol abuse is associated with recurrent pneumonia due to gastric aspiration. there is also evidence of additional injury to the lung in chronic alcoholism. chronic alcoholism may cause glutathione depletion, chronic oxidative stress, inflammation and induction of tgf-? in the lung, thereby increasing the risk of acute lung injury and pulmonary fibrosis.2 pathogenesis although ards seems to be the main predictor of pulmonary fibrosis in covid-19, several studies showed that covid induced ards is different from the classical ards. result from ct scan finding in many cases are also not suggestive of classical ards. therefore mechanism of pulmonary fibrosis in covid-19 is different from that of idiopathic pulmonary fibrosis (ipf), especially with pathological findings pointing to alveolar epithelial cells being the site of injury and not the endothelial cells.1 based on pathological pattern of pulmonary fibrosis, the clinical process of covid-19 patients can be divided into three stages (figure 2).5 the first stage: the sars-cov-2 has just invaded the upper respiratory tract. patients figure 2. pathological pattern of pulmonary fibrosis caused by covid-19. cleopas martin rumende acta med indones-indones j intern med 236 often have only cough, fatique and sore throat. from the imaging there is no manifestation of pneumonia. if the patient’s immunity are strong enough at this time, it can be self-limited. the second stages: the stages of acute inflammatory reaction. patients usually have fever, obvious respiratory tract symptoms (shortness of breath, dyspnea) and other symptom such as diarrhea. at this stage there are large number of inflammatory cells infiltrated in the lung and pneumonia could be seen in pulmonary tomography imaging. there is also a small number of fibroblast and myofibroblasts proliferate to repair damages alveolar epithelial cells (mainly type ii alveolar epithelial cells). the third stage: the late stage of inflammation or recovery stage. with the improvement of the disease, pulmonary inflammation gradually decreased. however, due to the necrosis and shedding of abundant alveolar epithelial cells in previous stage, the human body initiate damage repair mechanisms through myofibroblast proliferation and extracellular matrix aggregation and finally the pulmonary fibrosis will occur. it is worth noted that the second and third stages often have no strict boundaries, and often develop simultaneously.5 the mechanisms by which sars-cov-2 infection cause pulmonary fibrosis are not fully understood. most of study suggest that cytokine (espescially transforming growth factor-b/ tgb-b), fibroblast, angiotensin converting enzyme 2, ventilator induced-lung injury (vili) and oxygen toxicity have an important role for developing of pulmonary fibrosis in covid-19 (figure 3).2,6 cytokine and fibroblast. the alveolar wall has three components: the alveolar epithelium w i t h i t s b a s e m e n t m e m b r a n e , c a p i l l a r y endothelium with a basement membrane and an interstitium containing fibroblast, collagen fibrils, elastic fiber and macrophages. pulmonary fibrosis usually occurs as a consequence of severe assault of the lung that cause alveolar wall injury. it occur as a result of dysregulation in one or more of the phases of wound healing: injury, inflammation and repair. sars-cov-2 can be act as inciting factor for alveolar wall injury. fibroblasts as the effector cells in fibroproliferation are found in the alveolar interstitium. following alveolar injury, fibroblast migration to site of injury is stimulated by fibroblast growth factor (fgf), platelet-derived growth factor (pdgf), tgf-b and chemokines. fibroblast proliferate and differentiate in to myofibroblast under the influence of vascular endothelial growth factor (vegf), pdgf, tgf-b and il-1. fibroblast synthesize collagen, fibronectin and extracellular matrix (ecm) ground substance. in addition, mediators of repair process such as vegf and tgf-b are secreted by myofibroblast. myofibroblast produce denser but more disorganized ecm than fibroblast and persist longer at the site of injury. tansforming growth factor-b is multifunctional cytokine playing a key role in the process of tissue repair following injury. importance source of tgf-b including granule of platelets and macrophage. transforming growth factor-b is figure 3. postulated mechanism of sars-cov2 induced pulmonary fibrosis stressing the pivotal role of angiotensin 2. vol 53 • number 2 • april 2021 the management of pulmonary fibrosis in covid-19 237 predominantly expressesd in the pathogenesis of pulmonary fibrosis because it stimulates extracellular matrix formation namely collagen, fibronectin, elastic fibres and ground substance. transforming growth factor-b has fibrogenic potential by stimulating fibroblast migration and proliferation, inducing collagen and fibronectin deposition and inhibiting ecm degradation by matrix metalloproteinases. the stimulation of ecm deposition and inhibition of breakdown is fundamental to excessive accumulation of scar tissue in fibrosis. platelet-derived growth factor are potent stimuli for migration and proliferation of fibroblast and has been reported as one of growth factors playing a key role in pulmonary fibrosis.2,6 a n g i o t e n s i n c o n v e r t i n g e n z i m e 2 . moleculer basis of progression to pulmonary fibrosis in covid-19 is still unclear, but is believed to be multifactorial. the role of reninangiotensin system has also been looked at with great interest as the high-affinity binding between the sars-cov-2 viral spike protein and the angiotensin-converting enzyme-2 (ace2) receptor. interaction between sars-cov-2 and ace2 receptor has been shown to down regulate the level of the ace2 receptor. angiotensinconverting enzyme-2 have protective role in lung fibrosis. the decreased ace-2 expression in turn leads to high angiotensin 2 (ang ii) level. ang ii is a potent vasoconstrictive peptide directly involved in development of inflammation and fibrosis. in addition to its role in regulating blood pressure, ang ii plays a pivotal role in fibrotic process signaling cellular and molecular events that lead to the development of abberant wound healing and pulmonary fibrosis. these include production of pro-inflamatory cytokines such as il-6 and il-8, production of reactive oxygen species among infected alveolar cells and activation of tgf-b which in turn leads to proliferation, migration and differentiation of fibroblasts to myofibroblasts with resultant deposition of collagen and fibronectin.2,6 oxygen toxicity and vili. the role two iatrogenic factors potentially contributing to the fibrosis encountered in survivor of severe covid-19 pneumonia are oxygen toxicity and ventilator induced lung injury (vili). patients who develop post-covid lung fibrosis are invariably those who are more sick with extensive, bilateral lung involvement, hence are more likely to required high oxygen concentration. high oxygen concentration on the other side; may result in heightened production of oxygen-derived free radicals which can damage the pulmonary epithelium. the sickest patients with ards from covi-19 pneumonia are also more likely to require prolonged mechanical ventilation, often with generation of high plateau pressures in attempts to ventilate the stiff, noncompliant lungs. the role of mechanical stress as an inciting factor for lung injury is also well recognized and it is likely that vili may also contribute to the pulmonary fibrosis.2,6 clinical manifestations pulmonary fibrosis presents with the following symptoms : dry cough, fatique and dyspnea. furthermore physical condition of the patients may deteriorates, accompanied by reducing of their body weight. therefore, the quality of life patients suffering from this disorder are systematically regresses.6 knowledge of the natural evolution of lung abnormalities in covid-19 may help the clinician to determine the stage of disease and indistinguishing them from potential complications when evaluating chest ct examinations. roughly four stages of covid-19 at chest ct scan have been described : (a) early stage (0-5 days after symptom onset), which characterized by either normal findings or mainly ground-glass opacities; (b) progresive stage (5-8 days after symptom onset), which is characterized by increased ground-glass opacities and crazy-paving appearance;(c) peak stage (9-13 days after symptom onset) which is characterized by progressive consolidation and (d) late stage (?14 days after symptom onset), which is characterized by a gradual decrease of consolidation and ground-glass opacities, while signs of pulmonary fibrosis may appear. pulmonary fibrosis signs consisting of parenchymal bands, architectural distorsion and traction bronchiectasis (figure 4). it should be noted that the temporal evolution and extend of lung abnormalities are heterogenous among different patients, dependent on the severity of cleopas martin rumende acta med indones-indones j intern med 238 the disease.7 previous studies highlight that duration of disease is an important determinant for developing of post-ards pulmonary fibrosis. this study showed that 4% of patients with a disease duration of less than 1 week, 24% of patients with a disease duration of between weeks 1 and 3, and 61% of patients with a disease duration of greater than 3 weeks, developed fibrosis.1 diagnosis the diagnosis of pulmonary fibrosis requires integration of clinical symptoms and radiologic information and history of severe ards due to covid-19. clinical symptoms of pulmonary fibrosis consisting of dry cough, fatique and dyspnea.6 lung ct scan finding from pulmonary fibrosis consisting of parenchymal bands, architectural distorsion and traction bronchiectasis.7 although there is no specific finding from laboratory testing, tgf-b and vegf may increase as a marker of pulmonary fibrosis. management until now there is no specific therapy to handle post-inflammatory pulmonary fibrosis due to covid-19 infection. several studies are on going to determine an effective treatment for this chronic complication. while ards seems to be the main cause of pulmonary fibrosis in covid-19, the pathogenesis of ards caused by sars-cov-2 is different from the typical ards. some therapies may be considered for reducing the fibrosis process in lung after covi19 infection namely pirfenidone, nintedanib and mesenchymal stem cells.8,-11. based on who guideline for clinical management of covid-19, treatment with antifibrotic agent should be in context of clinical trial. therefore for the legal aspect, outside of clinical trial all of these antifibrotic drugs should be given as investigational therapeutics based on the following criteria : no proven effective treatment exist, preliminary data from serial cases reports support the efficacy and safety of these drugs, treatments has been suggested by qualified scientific advisory committee on the basis of a favourable risk-benefit analysis, appropriately qualified ethich committee have approved such use, the patients informed consent is obtained and the results are documented and shared in timely manner with the wider medical and scientific community.12 pirfenidone. pirfenidone is a pyridone that is 2-pyridone substituted at positions 1 and 5 by phenyl and methyl groups respectively. pirfenidone has both antifibrotic and antiinflamatory properties and is able to mitigate the proliferation of fibroblast and production of protein and cytokines associated with fibrosis. it also mitigates the accumulation of extracellular matrix in response to cytokine growth factors such as tgf-β and pdgf. pirfenidone can be administered as a monotherapy or combined with anti-inflammatory drug, il-1 or il-6 inhibitor which will exhibit a synergy effect in reducing its complication. the efficacy of pirfenidone has yet to be determined. pirfenidone is given according to the principle of gradual increase in drug dose. the first week of treatment is 267 figure 4. natural evolution from ground-glass opacities to multifocal organizing consolidation. vol 53 • number 2 • april 2021 the management of pulmonary fibrosis in covid-19 239 mg three times daily; second week of treatment is 534 mg three times daily, the third week and after is 801 mg three times daily (taking it with meal). pirfenidone is given for 4 weeks or more, depent on the clinical respons. pirfenidone can be associated with hepatotoxicity, whereas liver dysfunction is common in patients infected with sars-cov-2. evaluation of liver and kidney function is necessary especially in patients with risk of liver and kidney damage (glomerular filtration rate of less than 30 ml/min per 1·73 m²).8-11 nintedanib. nintedanib act as tyrosine kinase inhibitor that works on the receptors for fgf, pdgf, vegf and on non-receptor kinases results in a broad inhibitory activity on the downstream signalling cascades of fibroblasts and myofibroblasts and potentially also on cells involved in angiogenesis in the lung. dose for nintedanib is 150 mg twice daily for 12 months, in addition to standard of care. similar to pirfenidone, it should be taken with food. nintedanib also relates to liver and kidney damage, therefore closely monitored for these organ function should be performed. if necessary the dose of nintedanib can be reduced to 100 mg twice daily to prevent occurring of the liver and kidney injury.7,9 mesenchymal stem cells (mscs). stem cells are the cells with a specific function with the ability of self-renewal, possess varied potency and differentiate into multilineages. stem cell therapy has proven itself to be one of the most promising therapeutic approaches that provide opportunities to treat several diseases that were considered incurable like in post-covid-19 pulmonary fibrosis. mesenchymal stem cell therapy is preferred over other therapeutic strategies because they are free of ethical and social issues, they have a high proliferation rate and a low invasive nature. mesenchymal cells are harvested from various sources, including adipose tissues, dental pulp, bone marrow, umbilical cord, fetal liver, various adult tissues (such as the infrapatellar fat pad, abdominal fat pad) and tissues associated with neonates (placenta, wharton’s jelly, cord blood, and amniotic fluid)).13-19 i n f e c t i o n o f c o v i d 1 9 t r i g g e r s a n exaggerated immune reaction in the body by producing large amounts of various inflammatory factors including several cytokines, chemokines and immune reactive cells. the mscs therapy might prevent the triggering of cytokine storm by the activated immune system, and the reparative properties of the stem cells might promote endogenous repair. mesenchymal stem cells when intravenously injected will lead to some part of the population getting entrapped in the lungs. the pulmonary micro-environment could be recovered with the help of these mscs, thus protecting the alveolar epithelial cells. hence, pulmonary fibrosis of the lungs could be prevented, which may lead to curing covid-19 caused pneumonia. in the multiple disease condition, the immunomodulatory effects will be responsible for improved function after mscs infusion. a variety of paracrine factors are secreted by these cells. these paracrine factors interact with the immune cells, eventually leading to immunomodulation. the vigorous anti-inflammatory activities of mscs will actually be responsible for improvements after their infusion in covid-19 patients.11-19 in the guidelines for quality control and preclinical study of stem cell preparations (trial), indications for stem cell therapy in covid-19 include severe or critical illness from covid-19-related pneumonia. mesenchymal stem cells can be given via intravenous injection or intravenous cell infusion with dosage 1 × 106 cells/kg. the dose can be repeated for 3 times with 5 days interval. intravenous injection of mscs may produce a first-order lung effect, which leads to significant cell retention in the lungs, thus providing an advantage for lung tissue repair in covid-19.14, 16 respiratory support breathing exercise. about 80% of the work of breathing is done by the diaphragm. after illness or general deconditioning, the breathing pattern may be altered, with reduced diaphragmatic movement and greater use of neck and shoulder accessory muscles. this results in shallow breathing, increasing fatigue and breathlessness, and higher energy expenditure. the “breathing control” technique is aimed at cleopas martin rumende acta med indones-indones j intern med 240 normalizing breathing patterns and increasing the efficiency of the respiratory muscles (including the diaphragm) resulting in less energy expenditure, less airway irritation, reduced fatigue and improvement in breathlessness. the patient should sit in a supported position and breathe in and out slowly, preferably in through the nose and out through the mouth, while relaxing the chest and shoulders and allowing the tummy to rise. they should aim for an inspiration to expiration ratio of 1:2. this technique can be used frequently throughout the day, in 5-10 minute bursts (or longer if helpful).20 pulmonary rehabilitation. many patients are still recovering spontaneously in the first six weeks after acute covi-19 infection and do not generally require fast-track entry into a pulmonary rehabilitation programme. those who have had significant respiratory illness may benefit from pulmonary rehabilitation, defined as “a multidisciplinary intervention based on personalised evaluation and treatment which includes, but is not limited to, exercise training, education, and behavioural modification designed to improve the physical and psychological condition of people with respiratory disease.” in the context of covid-19, rehabilitation is being delivered by various virtual models, including video linked classes and home education booklets with additional telephone support.20 pulse oximetry self monitoring. hypoxia may reflect impaired oxygen diffusion and is a recognized feature of covid-19. it may be asymptomatic or symptomatic. oxygen saturation probes (pulse oxymeters) have been used as part of a package of care for patietns with covid-19. patients should be provided with pulse oxymeter and an observasional diary and given instructions for how to perform self monitoring. this would be a daily reading taken on a clean, warm finger without nail polish, after resting for 20 minutes; the device should be left to stabilize and the highest reading obtained should be recorded. the target range for oxygen saturation as 94-98% and a level of 92% or below as requiring supplementary oxygen (unless the patients is in chronic respiratory failure. normal assessment without red flag, an oxygen saturation of 96% or above and the absence of desaturation on exertional test is very reassuring. oxymeter readings persistenly in the 94-95% range or below require assessment and further investigation. appropriate adjusments should be made for patients with lung disease and knownin whom the range of 88-92% is considered acceptable.20 conclusion severe acute respiratory tract infection due to covid-19 infection is an extremely serious disease. one of the complications of respiratory system infection is pulmonary fibrosis, leading to permanent disability. diagnosis of pulmonary fibrosis can be made based on history of suffering from severe ards, following by clinical symptoms and characteristic pattern of pulmonary fibrosis from ct scan finding. there are few options available for its treatment. the most important factor in limiting pulmonary fibrosis is timely antiviral treatment and elimination of the causative agent. there is no fully definitive treatment for post-inflammatory pulmonary fibrosis after covid-19 infection. antifibrotic therapies may be considered consisting of pirfenidone, nintedanib and mscs. beside medical treatment, pulmonary rehabilitation program and longterm oxygen treatment should be included as part of comprehensive treatment for pulmonary fibrosis due to covid-19. references 1. rai dk, sharma p, kumar r. post covid-19 pulmonary fibrosis is it reversible? indian j tuberculosis. https:// doi.otg/10.1016/j.ijb.2020.11.003. 2. ojo as, balogun sa, williams ot, ojo os. pulmonary fibrosis in covid-19 survivors: predictive factors and risk reduction strategies. pulmonary medicine. https:// doi.org/10.1155/2020/6175964. 3. udwadia zf, koul pa, richeldi l. post covid-19 lung fibrosis: the tsunami that will follow the earthquake. indian chest society. http://doi:10.4103/ lungindia.lungindia_818_20. 4. mcdonald lt. healing after covid-19: are survivors at risk for pulmonary fibrosis? am j physiol lung cell mol physiol. 2021:320:l257-65. 5. zhang c, wu z, li jw, et al. discharge may not be the end of treatment: pay attention to pulmonary fibrosis caused by severe covid-19. j med virol. 2021;93: 1378-86. 6. lechowicz k, drozdzal s, machaj f, et al. covid-19: vol 53 • number 2 • april 2021 the management of pulmonary fibrosis in covid-19 241 the potential treatment of pulmonary fibrosis associated with sars-cov-2 infection. j clin med. 2020;9:2-20. 7. kwee tc, kwee rm. chest ct scan in covid-19: what the radiologist needs to know. https://doi. org/10.1148/rg.2020200159. 8. al mamun sm, jahan r, islam qt, nazrin t, shajalal k. rationale of using common antifibrotic therapy in post covid pulmonary fibrosis. j medicine. 2021; 22:46-50. 9. seifirad s. pirfenidone: a novel hypothetical treatment for covid-19. https://doi.org/10.1016/j. mehy.2020.110005. 10. george pm, wells au, jenkins rg. pulmonary fibrosis and covid-19: the potential role for antifibrotic therapy. https://doi.org/10.1016/s22132600(20)30225-3. 11. vitiello a, pelliccia c, ferrara f. covid-19 patients with pulmonary fibrotic tissue: clinical pharmacological rational of antifibrotic therapy. sn comphrehensive clinical medicine. 2020;2:1709-12. 12. clinical management of covid-19: living guidance. who/2019-ncov/clinical/2021.1. 13. qin h, zhao a. mesenchymal stem cell therapy for acute respiratory distress syndrome: from basic to clinics. protein cell. 2020;11:707-22. 14. li z, niu s, guo b, et al. stem cell therapy for covid-19, ards and pulmonary fibrosis. cell proliferation. 2020;53:e12939. 15. can a, coskun h. the rationale of using mesenchymal stem cells in patients with covid-19-related acute respiratory distress syndrome: what to expect. stem cells transl med. 2020;1–16. 16. esquivel d, mishra r, soni p, et al. stem cells therapy as a possible therapeutic option in treating covid-19 patients. stem cell rev and rep. 2020;17:144-52. 17. li c, zhao h, wang b. challenges for mesenchymal stem cell-based therapy for covid-19. drug design, development and therapy. 2020;14:3995–4001. 18. shetty r, murugeswari p, chakrabarty k, et al. stem cell therapy in coronavirus disease 2019: current evidence and future potential. cytotherapy. https://doi. org/10.1016/j.jcyt.2020.11.001. 19. eiro n, cabrera jr, fraile m, costa l, vizoso fj. the coronavirus pandemic (sars-cov-2): new problems demand new solutions, the alternative of mesenchymal (stem) stromal cells. front cell dev biol. doi: 10.3389/ fcell. 2020.00645. 20. greenhalgh t, knight m, a’court c, buxton m, husain l. management of post-acute covid-19 in primary care. bmj. 2020;370:3026. http://dxdoi.org/10.1136/ bmj.m3026. 438 acta med indones indones j intern med • vol 54 • number 3 • july 2022 case report acute limb ischemia due to arterial thrombosis in a patient with covid-19 pneumonia: a case report renata primasari1, yetti hernaningsih2, hartono kahar2, bramantono3 1clinical pathology specialization program, faculty of medicine universitas airlangga, surabaya, indonesia. 2division of hematology, department of clinical pathology, faculty of medicine universitas airlangga, dr. soetomo hospital, surabaya, indonesia. 3division of tropical and infectious diseases, department of internal medicine, faculty of medicine universitas airlangga, dr. soetomo hospital, surabaya, indonesia. corresponding author: yetti hernaningsih, md, clinical pathologist (consultant of hematology), phd. department of clinical pathology, faculty of medicine universitas airlangga – dr. soetomo hospital. jl. mayjen prof. dr. moestopo no. 6-8, surabaya 60285, indonesia. email: yetti-h@fk.unair.ac.id abstract the covid-19 pandemic has caused more than 4 million deaths worldwide to date. during the course of the covid-19 pandemic, thrombotic complications due to hypercoagulable state have emerged as an important issue. acute limb ischemia is one of emergency cases in vascular disease caused by a sudden decrease in arterial limbs perfusion. here, we report a 53-year-old male patient with severe covid-19 and a history of uncontrolled type 2 diabetes mellitus (t2dm) who developed extensive arterial thrombosis and limb ischemia despite being on therapeutic-dose anticoagulation, requiring surgical intervention. right and left leg open thrombectomy was performed at day 7 after admission due to the excruciating pain and the worsening of the limb conditions. the patient was transferred to intensive care unit in emergency room because of the unstable hemodynamic and passed away a few hours after the surgery. for critically ill patients with covid-19, special attention should be paid to abnormal coagulation dysfunction and microcirculatory disorders. keywords: acute limb ischemia, ali, covid-19, diabetes mellitus, hypercoagulable state. introduction the respiratory disease from coronavirus disease 2019 (covid-19) has caused over 230 million confirmed infections globally, including indonesia, with over 4 million deaths as of september 2021.1 extra-pulmonary complications of covid-19 are increasingly reported in the literature, including hypercoagulable state and thromboembolic events.2 acute limb ischemia is one of emergency cases in vascular disease caused by a sudden decrease in arterial limbs perfusion. patients with hypercoagulation state are at risk of arterial thrombosis. the decision of surgical intervention must be determined quickly in patients with hypercoagulation state due to the clinical outcome. many studies had shown an overall increase in mortality and amputation rate in hospitals.3 we described a case of acute limb ischemia due to arterial thrombosis associated with hypercoagulable state in a patient with covid‐19 pneumonia. the aim of this report is to report our first experience managing such case from a clinicopathological conference. vol 54 • number 3 • july 2022 acute limb ischemia due to arterial thrombosis 439 case illustration a 53-year-old male patient with past medical history of uncontrolled type 2 diabetes mellitus and hypertension came to dr. soetomo general hospital in surabaya, indonesia during covid-19 pandemic with shortness of breath and anosmia since 3 days before admission. since 8 days before admission, he had experienced occasional dry cough and fever. retroorbital pain, headache, and skin rash were absent. he had no problem with passing urine and bowel movement. there was history of close contact with his confirmed covid-19 wife and son. history of covid-19 vaccination was denied. in the emergency room, he was alert. temperature was 38oc, pulse 102 bpm, blood pressure 153/70 mmhg, respiratory rate 30 times/ min, and pulse oximeter 86% saturation with 3 lpm nasal canulla supplemental oxygen. the chest, abdomen, and remainder of the physical examination was normal. he had a weight of 75 kg, height of 170 cm, and calculated body mass index (bmi) of 25.9%. laboratory results revealed an elevated random blood glucose (294 mg/dl), elevated aspartate aminotransferase (89 u/l), elevated alanine aminotransferase (53 u/l), and elevated d-dimer (1,094 ng/ ml). kidney function tests were normal (blood urea nitrogen 9 mg/dl and serum creatinine 0.71 mg/dl). the sars-cov-2 real time pcr examination showed positive results. chest x-ray revealed bilateral pneumonia. the patient was transferred to the isolation ward (day 2 of treatment) for further evaluation and treatment. he was given intravenous fluid with nacl 0.9%, oxygen supplementation 6 lpm, remdesivir 200 mg i.v q.d, lovenox 40mg s.c b.i.d, novorapid 12 unit s.c t.i.d, lantus 26 unit s.c q.d, dexamethasone 6 mg i.v q.d, amlodipine 5 mg p.o. q.d, n-acetylcysteine 600 mg p.o. b.i.d and curcuma 20 mg p.o. b.i.d. on the second day in isolation ward (day 3 of treatment), laboratory results showed neutrophilia (74%), lymphocytopenia (16%), elevated d-dimer (1,760 ng/ml), elevated random blood glucose (369 mg/dl), elevated hba1c (12.3%), elevated crp (14.5 mg/dl), and elevated ferritin (5,346 ng/ml). liver function tests remain abnormal. he also underwent plasma il-6 level test and an increase in il-6 with a value of 11.04 pg/ml was found. blood gas analysis showed a metabolic acidosis condition. on the fourth day in isolation ward (day 5 of treatment), he developed bluish discoloration and worsening pain in both legs (figure 1). his lower extremities were swollen and bluish in color, cold to the touch, and had a peripheral oxygen saturation of 75% (right foot) and 70% (left foot). the pulse of the right and left femoral artery, tibialis posterior artery, and dorsalis pedis artery were unpalpable bilaterally. he also still complained of difficulty breathing despite oxygen supplementation. laboratory tests showed leukocytosis, with leukocyte value of 19,060 accompanied by increased neutrophil lymphocyte ratio of 14.6 and elevated procalcitonin (3.78 ng/ml). random blood glucose, liver function tests, and ferritin remain high. d-dimer was extremely elevated with d-dimer value of 336,600 ng/ml. t h r o m b o e l a s t o g r a p h y ( t e g ) a s s a y was performed in this patient and the result showed increased coagulation activity, normal fibrinogen activity, normal platelet activity, and adequate fibrinolytic activity. teg suggest hypercoagulability (enzymatic) factor (figure 2). he was consulted to the thoracic and vascular surgery department for thrombectomy. preoperative doppler ultrasound was performed and showing thrombosis of left and right superficial femoral artery (figure 3). based on the examination, the patient was diagnosed with acute limb injury with modified rutherford classification iib. an emergency revascularization figure 1. showed ischemia in the patient’s limbs on september 1st, 2021 renata primasari acta med indones-indones j intern med 440 with open thrombectomy procedure was suggested. however, the procedure was delayed due to the concern of the patient and his family. oxygen supplementation was changed to 30 lpm high flow nasal canulla, anticoagulant was changed to heparin 5000 unit i.v. o.d and heparin 24.000 unit i.v. q.d, antibiotic cefoperazone sulbactam 1 gram i.v. q.i.d was added. on the fifth day in isolation ward (day 6 of treatment), he presented with hematuria. laboratory results showed prolonged pt (26.8 seconds) and aptt (97.1 seconds). heparin was stopped due to hematuria and the preparation of thrombectomy procedure. chest x-ray showed bilateral pneumonia with decreased infiltrates. he underwent a thrombectomy on september 3rd, 2021. preoperative laboratory results revealed a decrease in the value of pt (11.9 seconds), aptt (24.8) and d dimer (23,990 ng/ml) compared to the previous day. open thrombectomy procedure using fogarty catheter was performed and thrombus of length 43 cm from the left leg and 40 cm from the right leg were removed (figure 4). post-operative evaluation was performed and the pulse of the right and left femoral artery, popliteal artery, tibialis posterior artery and dorsalis pedis artery were palpable bilaterally. he was transferred to intensive care unit in emergency room after the procedure because of figure 2. thromboelastography (teg) assay suggest a hypercoagulability (enzymatic) factor. figure 3. doppler ultrasonography of left lower limbs on september 1st, 2021 at dr. soetomo hospital surabaya indicated the presence of thrombus from left superficial femoral artery (filling>50% lumen). vol 54 • number 3 • july 2022 acute limb ischemia due to arterial thrombosis 441 unstable hemodynamics. he was still intubated and placed on a ventilator. laboratory results revealed normochromic normocytic anemia (hb 6.6 g/dl), leucocytosis (27.050/µl), thrombocytopenia (139,000/µl), hyperkalemia (6.5 mmol/l), hypocalcemia (8.1 mmol/l) and elevated lactic acid (9 mmol/l). kidney function tests were abnormal (blood urea nitrogen 34 mg/dl and serum creatinine 1.7 mg/dl) and liver function tests were extremely elevated (aspartate aminotransferase 470 u/l alanine aminotransferase 783 u/l). blood gas analysis showed worsening metabolic acidosis. examination of serum ketones and urine ketones was not performed so that the possibility of diabetic ketoacidosis could not be ruled out. chest x-ray showed bilateral pneumonia with increased infiltrates (the history of patient’s chest x-ray results during hospitalization is shown in figure 5). the patient passed away few hours after thrombectomy procedure. discussion in this case, we presented an unusual case of covid-19 infection with an initial stable period and a rapid deterioration leading to icu admission, and eventual demise due to extensive arterial thrombosis. as described by recent studies, patients with covid-19 have an increased risk of both venous and arterial thrombotic events.4,5 the pathophysiology is complex and not yet fully understood. previous study mentioned the symptoms of acute limb ischemia are as following: pain, numbness, paresthesia, coldness, and irreversible purpura at extremities.6 in this case, the patient showed clinical symptoms in the form of pain, paresthesia and bluish rash accompanied by legs that were cold to touch. s e v e r a l s t u d i e s i n d i c a t e t h a t s e v e r e covid-19 infections are associated with higher d-dimer levels, reflecting a more pronounced hypercoagulable state.7,8 in this case, the patient had an increased level of d-dimer (336,600 ng/ ml). the thromboelastography assay results confirmed the hypercoagulable state in this patient. based on the clinical conditions, it can be presumed that the hypercoagulation state with clinical ischemia in this patient signified severe illness and required close monitoring and appropriate early intervention management. sars-cov-2 directly attacks vascular endothelial cells and activates the coagulation cascade after causing endothelial injury. this pathologic insult is suggested to result in excessive cytokine release and storm from activating of widespread coagulation factors while inhibiting fibrinolysis causing extensive thrombosis similar to disseminated intravascular coagulation. il-6 is a key factor in sars-cov-2 induced inflammatory storm. while il-6 can stimulate the liver to synthesize fibrinogen and thrombopoietin, it also upregulates the expression of vascular endothelial growth factor to disrupt the stability of vascular barrier and figure 4. thrombus obtained from the total thrombectomy with a length of 40 cm and 43 cm (from right and left femoral artery respectively) figure 5. an overview of the development of chest x-ray during hospitalization from august 27, 2021 to september 3, 2021. a. showed a bilateral pneumonia. b. showed the improvement of patient’s chest x-ray on september 2, 2021. c. showed the worsening of patient’s chest x-ray on september 3, 2021. renata primasari acta med indones-indones j intern med 442 stimulate monocytes to express more tissue factors, thereby activating the extrinsic pathway of coagulation.9 these coagulation abnormalities along with elevated d-dimers are likely indicators for higher mortality predisposing the patients to a variety of ischemic and thrombotic events.8 this patient had the history of uncontrolled type 2 diabetes mellitus. during hospitalization there was elevated random blood glucose (470 mg/dl) and hba1c (12.3%). a study by calvisi et al. showed diabetes, hyperglycemia and glycemic variability were strong risk factors for the development of thromboembolic complications in covid-19 patients. diabetes was associated with both inflammation and coagulopathy (elevated c reactive protein and d-dimer levels, mild prolongation of the prothrombin time and decreased antithrombin iii), suggesting that a hyperglycaemia-related amplification of the pathobiological mechanisms of immunothrombosis could be responsible of the increased thrombotic risk.10 covid-19 is a disease that can trigger hypercoagulable conditions, so that it can increase the incidence of ali in patients with a history of t2dm. viral infiltration causes a process of cell disruption, leading to a disseminated intravascular coagulopathy (dic)–like clinical feature, in which d-dimer breakdown products and fibrin/ fibrinogen are significantly increased, and microvascular microthrombi are formed.11 i n t h i s c a s e , t h e p a t i e n t u n d e r w e n t thrombectomy. thrombectomy was indicated in accordance to this patient stage being rutherford stage iib. 12 according to the guideline, grade iib ali should undergo an emergency revascularization procedure within 6 h after the diagnosis has been made.13 unfortunately, the procedure was delayed due to the concern of the patient and his family. prolonged ischemia can cause muscle cell liquefactive necrosis and k+ ion, myoglobin, creatine kinase, lactic acid, and superoxide accumulation in the affected limb. these metabolites perfuse throughout the body upon revascularization and cause hyperkalemia, arrhythmia, pulmonary edema, metabolic acidosis, and myoglobinuria, and in severe cases, it can cause sudden death from heart and renal failure. the so-called ischemia– reperfusion injury is a severe complication that determines prognosis after the revascularization of ali.6 this ischemia–reperfusion injury could be the cause of death in this patient as we found hyperkalemia, worsening metabolic acidosis, elevated kidney test results, and elevated lactic acid after the thrombectomy procedure. open surgical techniques have been preferred because time to reperfusion is rapid especially when faced with class iib ali. early operative intervention, however, result in considerable risk of perioperative mortality. despite advances in resuscitative care, reports state mortality rates as high as 20% in patients undergoing operative revascularization for ali. 14 a combined approach of mechanical and pharmacologic catheter-based techniques are becoming more prevalent as an alternative to more invasive and open surgical approaches that typically incur a higher morbidity and mortality, especially in patients with comorbidities.13 studies showed that intraoperative hyperglycemia will result in postoperative infections, cardiovascular and cerebrovascular accident, cognitive dysfunction, and other poor outcomes in diabetic patients. effective glycemic management in patients with diabetes can improve their surgical outcomes.15 several studies suggested that elevated aminotransferases is associated with higher mortality in covid-19.16,17 multiple hypotheses such as direct viral cytotoxicity through ace-2, drug-induced liver injury, immune-mediated damage, and passive congestion have been proposed.18 the liver function tests of this patient were high upon the admission and got extremely elevated after the thrombectomy procedure. systemic organ ischemia and hypoxia would occur in diabetic patients due to microvascular disorder. related research shows that severe hypoxia results in increased metabolic activity of transaminases and bilirubin metabolism disorders in the hepatocytes, and even liver necrosis.19 operative blood loss, ischemia, and stress will aggravate the state of systemic organ ischemia and may be the reason for the further transaminase increase in the diabetic patients postoperatively. vol 54 • number 3 • july 2022 acute limb ischemia due to arterial thrombosis 443 conclusion ali accompanied with covid-19 and type 2 diabetes mellitus is a complex case. it requires comprehensive covid-19 treatment, good management of glycemic control and i m m e d i a t e s a l v a g e l i m b t r e a t m e n t . t h e ischemia–reperfusion injury can be a cause of death in covid-19 patients with limb ischemia undergoing thrombectomy. the prognosis for ali with covid-19 and t2dm is worse than in other patients and most cases ended with death. further studies is needed to establish the optimal management of ali with covid-19 and t2dm. references 1. john hopkins university and medicine. johns hopkins coronavirus resource center covid-19 data in motion [internet]. 2021. available from: https:// coronavirus.jhu.edu/covid-19-daily-video%0ahttps:// coronavirus.jhu.edu/ 2. levi m, thachil j, iba t, levy jh. coagulation abnormalities and thrombosis in patients with covid-19. lancet haematol. 2020;7(6):e438–40. 3. aboyans v, ricco jb, bartelink mlel, et al. 2017 esc guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the european society for vascular surgery (esvs). eur heart j. 2018;39(9):763–816. 4. nowroozpoor a, bank ma, jafari d. limb ischemia due to extensive arterial thrombosis in the absence of venous occlusion as an unusual complication of critical illness from covid-19. case reports acute med. 2021;4(1):23–31. 5. dias lm, martins j, castro r, mesquita a. multiple arterial thrombosis in a patient with covid-19. bmj case rep. 2021;14(6):2–3. 6. mcnally mm, univers j. acute limb ischemia. surg clin north am. 2018;98(5):1081–96. 7. yu hh, qin c, chen m, wang w, tian ds. d-dimer level is associated with the severity of covid-19. thromb res [internet]. 2020;195(april):219–25. available from: https://doi.org/10.1016/j.thromres.2020.07.047 8. zhou f, yu t, du r, et al. clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study. lancet. 2020;395(10229):1054–62. available from: http:// dx.doi.org/10.1016/s0140-6736(20)30566-3 9. zhou y, fu b, zheng x, wang d, zhao c. severe pulmonary syndrome patients of a new coronavirus. biorxiv prepr. 2020;(february). available from: https://doi.org/10.1101/2020.02.12.945576 10. c a l v i s i s l , r a m i r e z g a , s c a v i n i m , e t a l . thromboembolism risk is higher among patients with diabetes and covid-19 and is associated to poor clinical outcome. medrxiv. 2021;2021.04.17.21255540. av a i l a b l e f r o m : h t t p : / / m e d r x i v. o rg / c o n t e n t / early/2021/04/20/2021.04.17.21255540.abstract 11. kichloo a, dettloff k, aljadah m, et al. covid-19 and hypercoagulability: a review. clin appl thromb. 2020;26. 12. olinic d-m, stanek a, tătaru d-a, homorodean c, olinic m. acute limb ischemia: an update on diagnosis and management. j clin med. 2019;8(8):1215. 13. björck m, earnshaw jj, acosta s, et al. editor’s choice – european society for vascular surgery (esvs) 2020 clinical practice guidelines on the management of acute limb ischaemia. eur j vasc endovasc surg. 2020;59(2):173–218. available from: https://doi. org/10.1016/j.ejvs.2019.09.006 14. lind b, morcos o, ferral h, et al. endovascular strategies in the management of acute limb ischemia. vasc spec int. 2019;35(1):4–9. 15. wang j, chen k, li x, et al. postoperative adverse e v e n t s i n p a t i e n t s w i t h d i a b e t e s u n d e rg o i n g orthopedic and general surgery. med (united states). 2019;98(14):1–7. 16. pozzobon fm, perazzo h, bozza fa, rodrigues rs, de mello perez r, chindamo mc. liver injury predicts overall mortality in severe covid-19: a prospective multicenter study in brazil. hepatol int. 2021;15(2):493–501. available from: https://doi. org/10.1007/s12072-021-10141-6 17. taramasso l, vena a, bovis f, et al. higher mortality and intensive care unit admissions in covid-19 patients with liver enzyme elevations. microorganisms. 2020;8(12):1–12. 18. boregowda u, aloysius mm, perisetti a, gajendran m, bansal p, goyal h. serum activity of liver enzymes is associated with higher mortality in covid-19: a systematic review and meta-analysis. front med. 2020;7(july):1–10. 19. wang t, fontenot rd, soni mg, bucci tj, mehendale hm. enhanced hepatotoxicity and toxic outcome of thioacetamide in streptozotocin-induced diabetic rats. toxicol appl pharmacol. 2000;166(2):92–100. medical illustration primary central nervous system lymphoma in an immunocompetent young adult patient: a rare case aisyah wirdah1, norman djamaludin2, mediarty syahrir2, yenny dian andayani2, mita andriani1, yunni diansari3 1department of internal medicine, faculty of medicine universitas sriwijaya mohammad hoesin general hospital, palembang, indonesia. 2medical hematology oncology division, department of internal medicine, faculty of medicine, universitas sriwijaya mohammad hoesin general hospital, palembang, indonesia. 3division of neuro oncology, department of neurology, faculty of medicine universitas sriwijaya mohammad hoesin general hospital, palembang, indonesia. corresponding author: aisyah wirdah, md. department of internal medicine, faculty of medicine universitas sriwijaya mohammad hoesin general hospital. jl. dr. muhammad ali, sekip jaya, kota palembang, sumatera selatan 30114, indonesia. email: aisyahwirdah297@gmail.com. a) b) c) d) e) figure 1. pathological anatomy. a) hematoxylin & eosin a pcnsl biopsy basal ganglia. b). cd 20 positive. c). cd 45 positive. d). cd 3 negative. e). ki 67+90-95% high grade. 107acta med indones indones j intern med • vol 55 • number 1 • january 2023 aisyah wirdah acta med indones-indones j intern med 108 primary cns lymphoma (pcnsl) is a rare form aggressive extra nodal non-hodgkin lymphoma (nhl) that comprising 1-2% of the primary brain tumors that develops in the brain, spinal cord, eye or leptomeningeal area without evidence of systemic involvement.1 the overall incidence of pcnsl with immunocompetent patients is only 0.47/100,000 year in pcnsl. approximately 10-20% of patients had ocular involvement and around one third had multifocal neurological disease. overall long-term survival rate was only 20-40%, this is because the management of pcnsl is limited by ability of the drug due to cross the blood brain barrier (bbb). we present a b-cell central nervous system lymphoma in an immunocompetent patient who responded to chemotherapy.2 a 35-year-old man presented to our hospital with sudden change in mental status since 4 hours before admission. he was experiencing headache and blurred of vision within 3 months and have episode seizure. on examination, figure 3. brain mri patients after 2 cycle chemotherapy. glasgow coma scale (gcs) e2m1v aphasia. the patient was found to have right hemiparesis with bilateral papilloedema. visual acuity of both eyes was no light perception (nlp). the other physical exam was normal. laboratory tests hb 10.7 g/dl, ldh 446 u/l, and d-dimer 3.21 ug/ml. rubella igg 76.9, cmv ig g 245.6 and, hsv igg and igm negative, hiv test nonreactive, toxoplasma igg and toxoplasma igm negative, hbsag and hcv test negative. brain mri and mri stereoscopy: lobulated mass size 7.08 cm x 4.75 cm at the left caudate nucleus and left lateral periventricular area. choline/naa ratio: 5-9, choline/creatine ratio 6-11 suggestive of malignancy, possibly lymphoma. whole spine mri showed bulging intervertebral disc at the level of c4-c5. chest and abdomen ctscan result was normal. bone survey result was normal, electroencephalogram (eeg) suggested epileptiform discharges of left temporal area. cerebrospinal fluid: showed gliosis and suspected malignancy. the patient underwent figure 2. brain mri patients before chemotherapy. vol 55 • number 1 • january 2023 primary central nervous system lymphoma 109 ventriculoperitoneal shunt (vp shunt) due to obstructive hydrocephalus and craniotomy. pathology biopsy and immunohistochemistry (ihc) of basal ganglia revealed a diffuse large b cell lymphoma (nhl) non-germinal center, cd 20 +, ki 67 95% (high grade), cd 45 +, cd 3 -, bcl6 +, mum 1+. for this patient, we started induction therapy with rmp regimens (rituximab 375 mg/m2, day 1, 15 and 29, high dose methotrexate (hdmtx) 3000 mg/m2 day 2, 16 and 30, and procarbazine 60 mg/m2 day 3-12) due to the unavailability of procarbazine in town, we decided to change it with dacarbazine 375 mg/m2 days 3, 17 and 31), dexamethasone 5 mg/6 hours, and low dose whole brain radiotherapy (wbrt). pcnsl is a rare form aggressive extra nodal nhl, especially in immunocompetent patient. in this particular case of patients high dose methotrexate chemotherapy has achieved high respond especially for this patient that showed gcs e4m5v6 and recovery neurological deficit after 2 cycle chemotherapy. references 1. portnow lj, baehring j. central nervous system cancers. nccn clinical practice guidelines in oncology. version 2.2021. 2. rubenstein jl, gupta nk, mannis gn, lamarre ak, treseler p. how i treat cns lymphomas. b l o o d . 2 0 1 3 ; 1 2 2 : 2 3 1 8 – 3 0 . d o i : 1 0 . 1 1 8 2 / blood-2013-06-453084 347acta med indones indones j intern med • vol 54 • number 3 • july 2022 editorial the vascular access related infections: have we anticipated them adequately? erni juwita nelwan* division of tropical and infectious diseases, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. *corresponding author: erni juwita nelwan, md., phd. division of tropical and infectious diseases, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. salemba raya 6, jakarta 10430, indonesia. email: erni.juwita@ui.ac.id. t h e n u m b e r o f p a t i e n t s i n n e e d o f haemodialysis (hd) is increasing from time to time. in 2018, the indonesian renal registry documented more than 130,000 active patients from 651 registered hd centres. twenty percent are diabetic patients with end-stage renal disease (esdr) equal to 8,633 patients.1 diabetes mellitus accounts for 2% of all diabetes cases in the age of 15 year-old and above.2 hence, the increasing need for hd is inevitable and is parallel with the need for vascular access procedures. one of the major problems that occurs with vascular access is the risk of infection. among hd patients, mortality and morbidity are predominantly associated with infection; about one-fifth as a cause of hospital admissions, one-fourth of the infection-related admissions are due to infection of vascular access. in addition, patients on hd are hospitalized more frequently compared to other illnesses. therefore, information on the magnitude of the problems needs to be well understood.3 susilo et.al,4 reported around 40% of patients with temporary vascular access had an infection. data is limited and might be also underestimated. the definition of vascular access-related infection needs to be carefully classified. the infection site can be classified as: (1) exit site infection, inflammation confined around the skin area at the catheter exit site and not involving the cuff if the catheter is tunneled; (2) the infection of the tunnel, inflammation along the subcutaneous tunnel whereby exudate can be drained to the exit site; and (3) bloodstream infection, with positive blood culture.5 an agreed upon and unified definition is mandatory for clinical use and research. challenges for clinicians even start from determining the incidence due to different views on the reporting of such instances, whether the occurrence of infection should be reported as per dialysis session or rate per-patient-day or per-catheter-day. this heterogeneity makes the general picture of the problem needs to be carefully analyzed.6,7 u n f o r t u n a t e l y, t h e a v a i l a b l e s t u d i e s examining risk factors for vascular accessassociated infection are scarce and mostly collected with substandard methodology.3 susilo et al.4 found that female gender, anemia, duration of catheter use, and diabetes mellitus are risk factors for temporary vascular access related infection. however, the vascular access type is also an important factor contributing to bloodstream infection.4,6 it is to be highlighted that the study of susilo et al.4 may represent the population of a referral hospital for hd, yet as a reader it is worth noting that heterogeneity among centres and populations should be acknowledged. information is needed on the clinical impact of transient vascular access-related infections such as mortality, which has not been described in this report. a comprehensive in-depth review and further research of these studies are crucial erni juwita nelwan acta med indones-indones j intern med 348 for a greater level of understanding for the cause of infection and therefore inform effective early detection and prevention strategies to reduce morbidity and mortality among haemodialysis patients, especially at-risk patients. references 1. indonesian renal registry. (2018). 11 th report of indonesian renal registry 2018. http://www. indonesianrenalregistry.org/ 2. badan penelitian dan pengembangan kesehatan. laporan nasional riskesdas 2018-badan penelitian dan pengembangan kesehatan. jakarta: lembaga penerbit badan penelitian dan pengembangan kesehatan; 2019. 3. menegueti mg, betoni nc, bellissimo-rodrigues f, romão ea. central venous catheter-related infections in patients receiving short-term hemodialysis therapy: incidence, associated factors, and microbiological aspects. revista da sociedade brasileira de medicina tropical. 2017;50(6):783–7. https://doi. org/10.1590/0037-8682-0438-2017 4. susilo a, suryana kd, nugroho p, muhadi, alodia b, nainggolan l. risk factors for temporary vascular access infection in patients with end-stage renal disease undergoing hemodialysis in cipto mangunkusumo hospital. acta med indones indones j intern med. 2022;54(3):356-64. 5. lok ce, huber ts, lee t, et al. kdoqi clinical practice guideline for vascular access: 2019 update. american journal of kidney diseases. 2020;75(4): s1–s164. 6. basri ns, patrianef p. infection of double lumen catheter as hemodialysis access. the new ropanasuri journal of surgery. 2017;2(1):25–8. https://doi. org/10.7454/nrjs.v2i1.18 7. miller lm, clark e, dipchand c, et al. hemodialysis tunneled catheter-related infections. canadian journal of kidney health and disease. 2016;3(1). https://doi. org/10.1177/2054358116669129 editorial 167acta medica indonesiana the indonesian journal of internal medicine fasting can prevent various chronic diseases ari fahrial syam department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: ari fahrial syam, md., phd. division of gastroenterology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: ari_syam@hotmail.com. the national social economy survey (susenas) in 2004 shows that there are increased risk factors for coronary heart disease and stroke among indonesian people. the survey indicates that unhealthy life style is also increasing in indonesia, which includes smoking habit, lack of physical activities, unbalanced diet, obesity, low fiber diet/less fruit and vegetables in diet, high calorie and salty diet and high-animal fat diet. such conditions must be anticipated by all of us. ramadhan fasting for muslims is an opportunity to fix the condition of unhealthy lifestyle.1 why fasting can snap out the unhealthy lifestyle? ramadhan fasting that has been practiced by muslims is a condition, which medically has been known as ‘prolonged intermittent fasting’. fasting is a diet management, which alter the eating habit of 3 times daily into 2 times daily with a 14-hour interval period between meals, i.e. avoid eating and drinking starting from sahur (pre-dawn meal) until iftar (the evening meal when muslims break their daily ramadhan fast at sunset). by reducing the diet intake, the calorie and fat intake are also reduced. the low fat intake will also lower cholesterol intake. when an individual is practicing a good fasting, his/her laboratory parameters will be improved. total cholesterol and triglycerides level will be reduced including the bad cholesterol (ldl), which also will be reduced. the uric acid level should also be reduced; likewise for individuals with high blood glucose level, their blood glucose level will be within the normal limits. various studies on fasting individuals have reported reduced ldl and increased hdl levels, which obviously bring positive effects on prevention of cardiovascular diseases.2 a s t u d y w a s c o n d u c t e d i n c i p t o mangunkusumo hospital (rscm) jakarta, indonesia in 43 healthy subjects (medical personnel) who practiced ramadan fasting in 2013. the study included several examinations, i.e. a complete examination of body composition using special instruments (gaia 359 plus (jawon medical, south korea)), anthropometric examination and an analysis on daily dietary intake. the examinations were carried out on the first day of ramadan, on the 28th day and 4-5 week after the ramadan fasting. study subjects were free to have their usual meal when they fast and there was no limitation for physical activity. they performed their usual professional work as doctors, nurses and nutritional experts.3 the study then reveals that apparently during the ramadan, there was reduced weight and altered body composition except for the body protein mass. similar result was also found for waist to hip circumference ration, which was also reduced. it is interesting that the calorie intake actually did not change on the first and last days of fasting. however, activities related to religious services were increased such as increased activities of taraweeh and sunnah prayers. it means that there is increased energy expenditure during ramadan. it may result in ari f. syam acta med indones-indones j intern med 168 reduced body fat although the individual may still have the same amount of dietary intake. in fact, the dietary intake can be reduced during ramadhan, which will certainly bring better effect on health.3 during ramadhan fasting, a smoker actually should be able to reduce the amount of his/her cigarette consumption as smoking breaks the fast. smokers should be able to hold themselves not to smoke for 14 hours. after breaking the fast to the time of sahur, smokers also must perform obligatory prayers, taraweh prayers and they also need to sleep; therefore, during the fasting, it is certain that the smokers will automatically reduce the amount of cigarette they consume. when performing ramadhan fasting, daily activities are still carried out and in fact, sleeping all day long with fasting as an excuse is not recommended, either based on medical or religious point of views. during the ramadhan fasting, in addition to the obligatory prayers, those who exercise the ramadhan fasting are suggested to practice additional sunnah prayers including the night prayers, which contain taraweeh prayers with 11 raka’at (movements and words performed while offering prayers) or some of the prayers come with 23 raka’at. vegetables and fruit consumption is recommended when breaking a fast. the recommended menu for breaking a fast includes fruit juice and kurma (dried date palm fruit) and it is still recommended to have vegetables intake when breaking a fast and when having a sahur. fruits and vegetables contain high fiber, mineral, vitamin, anti-oxidant and complex carbohydrates; while nuts even contain vegetable protein. finally, by fasting, we can manage our eating habit, reduce carbohydrate and fat consumption, reduce the amount of cigarettes for smokers, still performing activity and increase fruits and vegetables intake. the serial of these healthy activities will make our body healthy and keep away various degenerative diseases such as stroke, heart diseases and obesity. using this rationale, it can be said that ramadhan fasting can also improve diseases caused by lifestyles, particularly the diseases in gastroenterology such as gerd diseases. patients with functional dyspepsia will get better during ramadhan fasting compared to when they are not having ramadhan fasting. ultimately, a muslim is expected to appreciate the health lessons offered during ramadhan months. references 1. sadeghirad b, motaghipisheh, kolahdooz f, zahdi mj, haghdoost. islamic fasting and weight loss: a systematic review and meta-analysis. public health nut. 2014;17(2):396–406. 2. azizi f. islamic fasting and health. ann nutr metab. 2010;56:273–82. 3. syam af, sobur cs, abdullah m, makmun d. ramadan fasting decreases body fat but not protein mass. int j endocrinol metab. 2016;14(1):e29687. 423acta med indones indones j intern med • vol 53 • number 4 • october 2021 original article the effect of physical activity on social isolation in elderly sri sunarti1,4*, khonsaa a. h. subagyo2, tita hariyanti3, achmad rudijanto4, retty ratnawati5, setyawati soeharto6, maryunani7 1 doctoral program in medical sciences, faculty of medicine universitas brawijaya, malang, indonesia. 2 faculty of medicine universitas brawijaya, malang, indonesia. 3 department of public health, faculty of medicine universitas brawijaya, malang, indonesia. 4 department of internal medicine, faculty of medicine universitas brawijaya, malang, indonesia. 5 departement of physiology, faculty of medicine universitas brawijaya, malang, indonesia. 6 departement of pharmacology, faculty of medicine universitas brawijaya, malang, indonesia. 7 faculty of economics and business universitas brawijaya, malang, indonesia. *corresponding author: sri sunarti, md. doctoral program in medical science, faculty of medicine universitas brawijaya. jl. veteran, malang 65145, indonesia. email: sri_sunarti.fk@ub.ac.id abstract background: elderly people who have poor social relationships have a higher risk of death than those who have strong social networks. loneliness and social isolation are associated with an increased risk of coronary heart disease and stroke. physical activity can reduce social isolation, diverting feelings of loneliness by socializing with other people and expanding social networks by participating in the community. this study aimed to determine the effect of physical activity on social isolation in the elderly. methods: a cross-sectional study was conducted to 181 respondents. the data is collected through interviewing respondents with the international physical activity questionnaire (ipaq) and social isolation questionnaires. the data was then analyzed descriptively and calculated using fisher’s exact test. setting: ardirejo and panggungrejo villages, kepanjen district, malang regency. results: based on the fisher’s exact between physical activity and social isolation results were obtained p-value 0.000 (pr = 23.407; 95% ci = 3,117-175,800). conclusion: there is a significant relationship between physical activity and social isolation in the elderly in the community. keywords: social isolation, the elderly, physical activity, social interaction. introduction the aging process causes various problems. one of the health problems experienced by elderly persons is a psychological problem, loneliness.1 the national council on aging and older people reports that the prevalence of elderly people in america who feel loneliness is 62%.2. in indonesia, the percentage of elderly who experience slight loneliness is 69%, there were 11% having moderate loneliness and 2% having severe loneliness, and 16% others did not experience loneliness. the loneliness felt by the elderly is generally caused by a lack of social interaction and attention from the surrounding environment.3 this is a triggering factor for depression and other related symptoms, especially in the geriatric population.4 social isolation refers to situations when an individual does not have a sense of belonging to socialize, has no involvement with other people, has a minimal number of social contacts, and unable to have quality relationships.5 the occurrence of social isolation can be a potential issue of emotional or psychological symptoms.6 sri sunarti acta med indones-indones j intern med 424 elderly who have poor social relationships have a higher risk of death compared to elderly who have strong social networks. it was also found that loneliness and social isolation are associated with an increased risk of coronary heart disease and stroke.7 interventions to overcome social isolation in the elderly should focus on improving social relationships and interactions. physical activity is known to reduce the social isolation in adults.9 based on a qualitative study conducted by robins [2016], elderly people believe that physical activity interventions conducted in groups can help them meet other people, expand their social networks, and help maintain their health by participating in the community. thus avoiding social isolation being one of the most effective ways to improve psychosocial health.8 currently, there are various physical training programs and exercises for the elderly.9 these programs include; daily active life program, physical fitness improvement program, strength improvement, and walking activities.10 these activities are low-cost alternatives to physical activities that are easy to implement in the elderly community. this can also be done in urban and rural areas.4 based on arahaf’s study [2017], shown 64.2% of the elderly in malang city can do physical activity independently and 35.8% feel dependence on family members in doing physical activities in daily life[11]. other data revealed that elder people at malang city have low level physical activity or inactive (35,4%), minimally activity (52,8%), and high activity (11,8%).12 physical activity, especially regular exercise, is a non-pharmacological therapy that can be used as an intervention in preventing social isolation and managing loneliness in the elderly.13 based on this information, the researcher wanted to know the association of the physical activity to the prevention of social isolation in the geriatric population. methods this is a cross-sectional study among elderly people who came to posyandu lansia (community-based integrated service center for older adults) in ardirejo and panggungrejo villages, kepanjen district, malang regency. measurement the research instrument used was the physical activity questionnaire from ipaq (international physical activity questionnaire), which categorized physical activity into two levels: light and moderate to vigorous physical activity. ipaq questionnaires have been validated in 14 centers in 12 countries that have been internationally standardized with more than adequate level of validity (r=0.40) and reliability (0.70-0.87).14 result from indonesian version of the ipaq questionnaires had small but significant correlation with physical activity recall (r=0.28).15 social isolation questionnaire was taken from the handbook of geriatric assessment 5th edition. the questionnaire consists of 10 questions, with the answer “yes” or “no” to each question. if the answer “yes” ≥ 5, then the participant is declared positive to experiencing social isolation.16 the author examined the validity and reability for social isolation questionaire. validity and reliability were measured using the product moment technique. the criteria for selecting items are based on the total item correlation value, generally using a total item coefficient 0.02 because the number of respondents is 50 (r=0.2). in the social isolation measurement questionnaire, the validity coefficient moves from 0.258 to 0.0727, except for item no. 7 which has a validity coefficient of -0.053 and a cornbach’s alpha value of 0.775. item no. 7 will still be used for data collection by researchers, because it is considered not to affect other items. the standardized protocols for data collection, including validity and reliability, can minimize inter-observer variability. ethics approval and consent to participate all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. this study was reviewed and approved by the research ethics universitas brawijaya malang no.100/ec/kepk/04/2020. vol 53 • number 4 • october 2021 the effect of physical activity on social isolation in elderly 425 statistical analysis data analysis includes descriptive analysis and hypothesis testing. in the descriptive analysis, categorical scale data, such as the level of physical activity (light and moderate to vigorous), were expressed as a frequency distribution. hypothesis testing in data analysis uses an association test to determine the relationship between the independent and dependent variables. the association test used is fisher’s exact test. the confidence interval states the magnitude of the independent variable’s influence on the dependent variable, and the p-value is considered significant if the p-value is <0.05. data analysis was performed using spss 25. results based on table 1, it is known that from 181 respondents, the most respondents were elderly aged 60-70 years, which was 126 elderly (69.61%). proportion of males and females in the elderly respondents were 21.54% (n=39) and 78.46% (n=142), respectively. the characteristics of respondents based on occupation were mostly as housewives, 93 elderly (51.4%). the highest level of education was primary school, with 75 elderly (41.4%). according to table 2, it can be seen that most of the elderly have a moderate level of physical activity, which was 93 elderly (51.38%). in table 3, it is known that social isolation occurred in 34 elderly (18.78%). table 4 shows the results of the fisher’s exact test are obtained with significance or p value = 0.000. so that if the p value <0.05, there is a significant correlation between physical activity and social isolation in the elderly. regarding to the calculations obtained from table 5, it is known that the odds ratio between the level of light and moderate physical activity on the social isolation in the elderly is 23.407 (or = 23.407; 95% ci = 3.117-175.800). it showed that the elderly with light physical activity levels are 23 times more likely to experience social isolation than the elderly who have moderate and vigorous physical activity levels. discussion in this study, it was found the most respondents who did physical activity was elderly aged 60-70 years old and the least was the elderly aged 91-100 years. according to data from badan pusat statistik (bps), the percentage of elderly in indonesia is dominated by young elderly (aged 60-69 years) 63.82%, the rest are middle elderly and the older elderly people.14 according to sharkey (2011) a person at the age of 60 and has retired, has more time to increase activity, although it can decrease with age.15 the figure 1. flowchart participant recruitment 542 452 sri sunarti acta med indones-indones j intern med 426 perform physical activity.16 the gender of respondents was dominated by women, which was 142 (78.46%) elderly, and the largest proportion had an occupation of being a housewife with 93 (51.4%) elderly. demographically, women have a higher life expectancy20 and women who are mother figures for their children and have maternal innate responsibilities where they are fully responsible for their family’s condition and themselves, especially in the health aspect (housewives).18 i n a d d i t i o n , t h e o t h e r r e s p o n d e n t s ’ occupations involves vigorous physical activity, such as 5 labourers, 8 farmers, 6 drivers, and 1 stockbreeder. only 5 out of 181 respondents are jobless. this is in line with research conducted by noni ejw and katrin r (2008) which states that having job as farmers/laborers, tea pickers, and factory workers require vigorous physical activity.19 workers who use skills over physical strength tend to involve lower levels of physical activity.20 the heavier the activity, the more energy required to carry out these activities.21 in this study, the elderly who work as housewives generally have moderate to vigorous physical activity levels. this is in accordance with the previous theory which states that in general women have the responsibility to cook, clean table 1. distribution of respondents’ frequency characteristics (n=181). respondents’ characteristics frequency [f] percentages [%] age 60-70 126 69.61% 71-80 48 26.52% 81-90 6 3.32% 91-100 1 0.55% gender male 39 21,54% female 142 78,46% occupation housewife 93 51,4% retired employee 36 19,9% private employee 9 5% entrepreneur 14 7,7% driver/taxibiker/ pedicab driver 6 3,3% labor 5 2,8% farmer stockbreeder 8 1 4,4% 0,5% freelancer 4 2,2% unemployed 5 2,8% level of education unschoolers had not finished primary education elementary school junior high school senior high school bachelor 4 14 75 33 37 18 2,2% 7,8% 41,4% 18,3% 20,4% 9,9% (source: primary data, 2020) table 2. distribution of elderly physical activity frequency. no. level of physical activity frequency [f] percentage [%] 1 light 26 14.37% 2 moderate to vigorous 155 85.63% total 181 100% (source: primary data, 2020) table 3. distribution of elderly sosial isolation frequency no. incidence of social isolation frequency [f] percentage [%] 1 social isolation 34 18.78 2 normal 147 81.22 total 181 100 (source: primary data, 2020) table 4. cross tab between light and moderate to vigorous physical activity levels on the incidence of social isolation in the elderly social isolation physical activity normal social isolation light 61 1 moderate vigorous 87 32 total 148 33 table 5. fisher’s exact test, prevalence ratio calculation between light, moderate to vigorous physical activity levels on social isolation in the elderly. no. incidence of social isolation frequency [f] percentage [%] 1 social isolation 34 18.78% 2 normal 147 81.22% total 181 100% (source: primary data, 2020) older they get, the lower the physical activity will be performed, this is due to a decrease in the strength level caused by comorbidities suffered by the elderly, thus it prevented the elderly to vol 53 • number 4 • october 2021 the effect of physical activity on social isolation in elderly 427 the house, doing errands, and do all activities that require a lot of walking, bending, standing, and lifting, thus when accumulated, the activity level of housewives are included in the category of moderate to vigorous physical activity levels. since housewives do not accrue occupational physical activity or work-related commuting activity, housewives does engage in domestic activities, and may have additional child care or home care activity compared to employed women.22 by engaging in light to vigorous intensity physical activity for many hours during the day, housewives may achieve the same volume of activity as employed woman who engage in more short-term moderate to vigorous physical activity, but also spend more time sedentary.23,24 based on educational background, it can be seen that the majority of the elderly in ardirejo and panggungrejo village have a fairly low level of education, which is elementary school education. this was shown by 75 (41.4%) of 181 respondents only completed having their primary education. from these data, it was found that the physical activity of the elderly in panggungrejo and ardirejo villages had more moderate to vigorous physical activities than light physical activities. the results of this data are in accordance with research conducted by cheah yk and poh bk (2014) which states that the higher a person’s education level, the lower the level of their physical activity.23 physical activities of the elderly in ardirejo and panggungrejo villages, kepanjen district, malang regency according to the level of physical activity, 155 (88.05%) elderly had moderate to vigorous physical activity levels and 26 (14.37%) elderly had low activity levels. a systematic review of research articles on physical activity in elderly population around the world in 2000-2012 showed that physical activity is consistently associated with functional capacity, overall quality of life, autonomy, past, present, and future activities, death, relationship intimacy, mental health, vitality, and psychological conditions.24 a high level of physical activity reduces the risk of mortality in the elderly. the elderly who were physically active at a moderate level of 150 minutes per week experienced a mortality reduction by 30% compared to those who were less active. the greatest benefit from physical activity is obtained by those aged 60 years and above.25 previous studies have shown that subjects with moderate to vigorous levels of physical activity are associated with good quality of life and good mental health.30–32 social isolation of the elderly in ardirejo and panggungrejo villages, kepanjen district, malang regency in this study, it was found that social isolation only occurred in 34 (18.78%) of the elderly in panggungrejo and ardirejo villages. social isolation is defined as the termination of real relationship with society, groups and communities. in fact, it is defined as the weakness of social relationship and friendship, as well as correlation with formal and informal groups.26 in tehran of iran, the proportion of elderly people in the population was 7.5% and it is known that 62% of the elderly of that proportion experienced social isolation. it shows the expansion of extensive social isolation in tehran.27 if it is reviewed with frequency distribution of physical activity data, it can be seen that the physical activity of the elderly in the two villages has moderate to vigorous activity levels. in accordance with the research hypothesis that the higher the physical activity performed by a person, the higher the reduction of the occurrence of social isolation. this is also in line with research conducted by robins (2016) which explains group physical activity is known to reduce the occurrence of social isolation in adults.8 elderly who live in a supportive environment for physical activity has lower risk of social isolation.28 the effect of physical activity on social isolation in the elderly in this study, it was found that the elderly in ardirejo and panggungrejo villages had a fairly high level of activity. it can be seen from the data that there are more elderly who have moderate to vigorous physical activity than light physical activity. physical activity level was related to the level of social isolation that occurs in the two villages. the percentage of elderly with social isolation was only 18.78% sri sunarti acta med indones-indones j intern med 428 in the two villages. it could be due to the high level of physical activity of the elderly in the two villages. after doing the fisher’s exact test, there was a significant correlation (p value <0.05) with the p value between the level of physical activity and social isolation in the elderly being 0.000 (pr = 23.407; 95% ci = 3.117-175.800). the results of this study is in line with research conducted by robins that physical activity was significantly associated with social isolation with an odds ratio of 1.03 (ci 1.01-1.04, p-value 0.002).9 intervals that are very wide (3.117-175.800) indicate that we have little knowledge about the result, and that further information is needed. it shows that there is an effect of physical activity on the occurrence of social isolation in the elderly where the higher the level of physical activity, the lower the incidence of social isolation. this is in line with one of previous studies which states that social isolation is associated with sedentary behaviour, mild, and moderate levels of physical activity. these findings are consistent with the possible role of physical activity in health risks toward social isolation. although not large, there still seem to be difference in physical activity between the daily life of more isolated individuals and those who are not. these differences will accumulate as the time goes by and contribute to an increased likelihood of chronic disease and disability in the elderly.29 physical activity is one of the most effective ways to improve health in populations and psychosocial health.30 old elderly can avoid the occurrence of health problems associated with social isolation by participating in social interactions that are held regularly by communities or institutions.31 voluntary activities such as social service performed by older adults provide better mental health and physical function also reduce the risk of death.32–34 regular exercise can improve cardiovascular, metabolic, endocrine, and psychological health. support from others is an effective way to reduce the negative effects of loneliness for the elderly to stay active.13 currently, there are various physical exercise programs and sports for the elderly with the aim of reducing social isolation and its various consequences.9 these programs include; daily active life program, physical fitness improvement, strengthening exercises, and walking activities.10 in line with the research explored by,35 compared to other forms of treatment therapy of social isolation (e.g mindfulness therapy, art, and craft therapy), physical activity intervention, especially in small groups (up to eight to nine people), can assist in building friendly and trusting relationships between participants. some intervention consist of aerobic exercise training in small group, that allow the participants to interact each other.35 mechanism of physical activity can affect social isolation through loneliness reduction models, stress reduction and increased social support during activities. physical activities can increase peripheral social networking during friendly conversation between participants.36 beside that, enjoyable forms of physical activities generate happiness and bring positive emotions, which in turn could be related to loneliness reduction as shown in longitudinal study by newall.37 in the group, elderlies can share interest and goals, which in turn strengthening the social interaction and promote well-being.38 confounding factors affecting association between social isolation and physical activity firstly, poor physical health, limits capacity for physical activity and is associated with social isolation and loneliness (coyle and dugan, 2012). second, problem with modality and impairment in activities of daily living (adls) may restrict social interaction and associated with depression in elderlies.39 socioeconomic status partly explains links between social isolation/ loneliness, disease risk, and mortality.40,41 an association between social isolation and physical activity could be secondary to any of these factors. the relation between physical activity and social isolation is a vicious cycle. poor physical activity will reduce physical fitness and limit social interaction. in the other side, lack of social interaction can pomote loneliness and induce depression, which interferes with motivation to be physically active. vol 53 • number 4 • october 2021 the effect of physical activity on social isolation in elderly 429 there are limitations of this study. in this research the willingness elderly to participate was low. this study has not performed multivariate analysis, because the data did not fulfill the basic requirements for independent variables of at least having 0.05 the principle of factor analysis is the correlation between variables. this may lead future research to evaluate deeply. in addition, the better way to estimate the level of physical activity is with qualitative measures, such as accelerometer-based measurements rather than self-reported results.29 changes in norms with age and disability of what constitutes vigorous activity, cognitive and recall problem can limit the accuracy of self-reports in older age. future research may need to address the limitations above for better elucidation of the association. implications for the field of medicine this research is expected to be an alternative method to prevent and reduce the occurrence of social isolation in the elderly through increased physical activity, especially physical activity in groups or in a community. we also hope that this research can give insight into the effect of physical activity on the management of loneliness, physical health and psychological health improvement in the elderly. conclusion there is a significant correlation between physical activity and social isolation in the elderly. the vigorous the physical activity, the lower the occurrence of social isolation in the elderly. acknowledgments this paper and the research behind it would not have been possible without the exceptional support of my promotor professor achmad rudijanto and my co-promotor retty ratnawati md, setyawati soeharto md, and professor maryunani. their enthusiasm, knowledge and exacting attention to detail have been an inspiration and kept my work on track from my first encounter with this manuscript to the final draft of this paper. funding source the author’s received no financial support for the research, authorship, and/or publication of this article. references 1. narulita. manajemen sehat lansia. jakarta: pustaka belajar; 2013. 2. damayanti y, sukmono ac. perbedaan tingkat kesepian lansia yang tinggal di panti werdha dan di rumah bersama keluarga. jurnal ilmiah keperawatan. 2013;8(1):1–10. 3. kementrian kesehatan ri. buletin jendela data dan informasi kesehatan. kementrian kesehatan ri. 2013. 4. ogundiran oo. social isolation in the 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koesnoe, md. division of allergy and clinical immunology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: koesno.sukamto.md@gmail.com. abstract in 2020, a new type of coronavirus (sars-cov-2) whose disease is called coronavirus disease 2019 (covid-19) has been reported. this virus was first discovered in wuhan, china and has infected 90,308 people per march 2, 2020. as of the end of october 2020, more than 40 million people have been infected, with the death toll reaching 1,150,000 worldwide. apart from respiratory tract infections, patients infected with this virus may exhibit other symptoms, such as diarrhea, abdominal pain, nausea, or vomiting. this means that the virus can be found in feces and anus, hence the anal swab can be used as a diagnostic tool for covid-19 infection. the results of the specimen test show that the sensitivity of the nasopharyngeal swab positive detection rate is the highest and remains the gold standard for diagnosis. this sensitivity can also be influenced by the course of the disease that can infect the gastrointestinal tract so that anal pcr is performed for the diagnosis to detect the covid-19 virus in patients. keywords: coronavirus; covid-19, pneumonia, gastrointestinal disease, anal swab. introduction the coronavirus disease (covid-19) has spread widely in china and more than 190 other countries around the world. in 2020, more than 40 million people have been infected, with the death toll reaching 1,150,000 worldwide.1.2 apart from respiratory tract infections, patients infected with this virus may exhibit other symptoms, such as diarrhea, abdominal pain, nausea, or vomiting.3,4 on march 20, 2020, who declared covid-19 a pandemic.5 as of march 24, 2021, there were 166,860,081 confirmed cases and 3,459,966 deaths worldwide. in indonesia, 18,388 positive cases of covid-19 and 142,952 deaths have been reported.6,7 covid-19 can be diagnosed by assessing patients’ clinical condition as well as x-ray results of the lungs, and then confirmed using a pcr test.8 pcr examination with nasopharyngeal and oropharyngeal swabs is the gold standard for diagnosing covid-19.9 in some cases not detected by pcr test, anal swab pcr test can be done as an alternative.10 the following is a case report of anal swabs at a covid-19 referral hospital. anal swab was chosen as an evaluation for patients with gastrointestinal symptoms who also have covid-19 symptoms. anal swab is chosen to evaluate patients if the results of the nasopharyngeal swab are negative. sukamto koesnoe acta med indones-indones j intern med 452 case illustration case 1 the patient is a female patient aged 81 years who had black stools for a week, with the onset of black stools 3-4 times a day and the most severe being in the last two days. previously, the patient had a medical check-up at hga hospital and had received a prc transfusion, with laboratory results of hb 8.9, wbc 5,900, 171,000, and hb 9.3 when examined in the er. the patient had no comorbidities. an examination was carried out in the er with the results as follows: blood pressure 122/77 mmhg, hr 83 beats/minute, respiratory rate 19x/minute, temperature 36.8° celsius; the patient was diagnosed with probable covid-19. an anal swab was performed (21/05/2020) with negative result and this was confirmed by pcr test. the results of the nasopharyngeal and oropharyngeal swabs (02/06/2020) were both negative. in addition, a chest x-ray was taken, showing a minimal infiltrate in the right lung and suggestive of pneumonia. case 2 a 59-year-old female patient presented with complaints of black stools for four days, congestion (+), heartburn (+), stomach feels full, and weight loss of 13 kg in a year. the patient did not experience fever, cough, runny nose, sore throat, and impaired smell. the patient was previously diagnosed with pulmonary tb and had been treated with antitubercular medications & sida since april 2020, but not yet received arv treatment. history of ht, dm, heart disease, and asthma was denied. no drug allergies. an examination in the er obtained the following results: blood pressure 114-72 mmhg; hr 87-95 beats/minute, strong; crt <2 seconds. several swabs were carried out with the results as follows: anal swab (4/06/2020): negative; anal swab (21/05/2020): negative; anal swab pcr test (31/05/2020): negative; and nasopharyngeal and oropharyngeal swabs pcr test (10/06/ 2020): negative. in addition, a chest x-ray was taken (18/05/2020), showing pneumonia with differential diagnosis of pulmonary tuberculosis. meanwhile, heart size was within normal limits. the patient was diagnosed with probable covid-19. case 3 a 50-year-old male patient came with a complaint of fever for ten days, with the highest temperature of 39.3°c. the patient had taken paracetamol and undergone temperature therapy at home. cough (+), runny nose (-), phlegm difficult to come out, drinking water > 1.5 liters/day. urine not overflowing, dripping table 1. case illustration. no. case 1 case 2 case 3 1. primary diagnosis probable covid-19 probable covid-19 covid-19 ards 2. secondary diagnosis anemia ec melena anemia ec melena & chronic disease septic shock hypertension 3. pcr test nasopharyngeal and oropharyngeal swabs (25/05/2020): negative nasopharyngeal and oropharyngeal swabs (04/06/2020): negative nasopharyngeal and oropharyngeal swabs (10/06/2020): negative 4. anal swab anal swab (21/05/2020): negative anal swab (31/05/2020): negative anal swab (4/06/2020): negative anal swab (29/04/2020): positive sars-cov-2 5. roentgen infiltration and consolidation infiltration and consolidation infiltration and consolidation 6. electrocardiogram normal normal normal 7. ct scan ground glass opacity vol 54 • number 3 • july 2022 anal swab in covid-19 patients 453 with diarrhea for two days, frequency >5x/ day. decreased appetite. examination in the er obtained results as follows: systolic blood pressure: 106 mmhg, diastolic bp: 59 mmhg, respiratory rate: 40x/minute, temperature: 37.8° c, weight: 96.40 kg, height: 170 cm, hr: 91 beats/minute. a chest x-ray was taken with the results of suprahilal, perihilar, and pericardial infiltrates of both lungs, dd/pneumonia, and pulmonary edema. furthermore, an anal swab was performed on 29/04/20; the result was positive for sars-cov-2. therefore, the patient was diagnosed with covid-19 ards. discussion based on the results of biopsies of gastric, duodenal, and rectal epithelial cells, sars-cov-2 has been shown to infect the gastrointestinal tract. this virus can be detected in feces; in 23% of patients, it was still found in feces even though it was not detected in respiratory samples.11 this is in line with the third case of this case report which tested positive on anal swab. the collection was carried out at the time of onset, i.e., on the 3rd-7th day from hospital admission. this fact strengthens the suspicion of the possibility of fecal-oral transmission. in addition to being found in fecal specimens, the sars-cov-2 virus can also be identified using an anal or rectal swab. upon further evaluation, the rectal swab ranks second in the positive detection rate. the pathogenesis of sars-cov-2 remains unusual, but it is suspected that it is not much different from the more widely known sarscov pathogenesis. in humans, sars-cov-2 primarily infects cells in the airways lining the alveoli. protein s is reported to be a significant determinant in viral entry into host cells. the entry of sars-cov into cells begins with the fusion of the viral membrane with the plasma membrane of the cells. in such cases, an increase in cd38+hla-dr+ t cells (activated t cells), especially cd8 t cells, was observed on the 7th9th days of the nasopharyngeal and oropharyngeal swab examinations.12-14 regarding the first and second cases in this report, the results of the swabs were negative since the time of collection had already passed the incubation period of the virus in the oropharynx. however, the adverse effects were associated with other supporting examinations such as laboratory results and chest x-ray results. both patients of these cases had pneumonia, thus being categorized as probable cases. there was an increase in antibody-secreting cells (ascs) and cold blood t follicular helper (tfh) cells on the 7th day; this onset occurred before symptoms. a progressive increase in sars-cov-2 igm/igg was also found from the 7th day to 20th day in the gastrointestinal tract.15 in the third case, the time of collection was influenced by the onset and the availability of reagents at the referral hospital. the change in sensitivity persisted for up to 7 days after symptoms relieved. in the humoral immune response, igm and igg are formed against sars-cov. igm against sarscov is lost by the end of the 12th week, while igg can persist in the long term. the results of a prior study on patients recovered from sars show that cd4+ and cd8+ memory t cells were specific for sars-cov after four years, but their numbers decreased.16 figure 3. result showing signs of worsening pneumonia. figure 2. result showing signs of worsening pneumonia figure 1. result showing signs of worsening pneumoniafigure 1. result showing signs of worsening pneumonia. sukamto koesnoe acta med indones-indones j intern med 454 this case report collected various specimens from covid-19 patients with the course of disease of 7 to 30 days, including specimens taken from nasopharyngeal and anal swabs, saliva, blood, and urine. pcr was used for nucleic acid detection and absolute counting of these specimens. meanwhile, elisa test was performed to detect anti-n igm/igg and antis-rbd igg in serum samples of the patients.17 the results of the tests on nucleic acid specimens showed the highest positive detection rate for nasopharyngeal swabs at 7-20 days and the highest average number of virus was found in the oropharyngeal swabs. case reports indicate that viral infections can enter the gastrointestinal tract. in the advanced stages of the disease, the virus can be detected on anal swabs, and the results remain positive even after nasopharyngeal swabs show negative results. this phenomenon, and the relatively high positive detection rate of anal swabs, reached 24% at the 14th–20th days. a previous study has found that the positive detection rate of saliva specimens is high, up to 61.5%. in addition, the study proved that viral nucleic acids were detectable in posterior oropharyngeal saliva specimens.18 a better percentage of favorable agreement was observed in samples obtained within seven days of symptom onset. nevertheless, the positive detection rate of saliva specimens in the study was only 16%, which presumably related to the sampling method. false-negative results on virological tests can occur due to the poor quality of collection or specimen management, specimen collections in the early stage of infection, or technical difficulties in the laboratory. therefore, a negative result does not rule out the possibility of sars-cov-2 infection, especially in patients with a high index of suspicion. this is also in connection with the availability of reagents as well as the day of specimen collection. c o l l e c t i o n a n d t r a n s p o r t a t i o n o f nasopharyngeal swabs, anal swabs, saliva, blood, and urine specimens were stored at 4° c until use. the sampling methods are as follows: 1. nasopharyngeal swab 2. anal swab 3. saliva the results of this case study show that the nasopharyngeal swab is the best method for detecting sars-cov-2. adverse effects occurred in the first and second cases because the samples were taken at intervals of 10 days and 11 days after the onset of symptoms. meanwhile, the third case tested positive on anal swab since the sampling was carried out at the beginning of the course of disease, namely on the 3rd and 7th days. this is also influenced by the method used to take the specimen, the availability of reagents, and the form of tube transportation. furthermore, the results of this study also suggest that nucleic acid testing for recovered patients should be carried out on nasopharyngeal swabs and other specimens to obtain a more accurate diagnosis of complete recovery from coronavirus infection when using nasopharyngeal and oropharyngeal swabs. conclusion in these three cases, anal swab was carried out with gastrointestinal patients who also suspected with covid-19. in cases with positive anal swab results, positive results were found after 10 days of symptoms (early phase) faster than the previous case study which shown that positive results for anal swabs shown after 14-20 days of symptoms (late phase). references 1. wu f, zhao s, yu b, et al. a new coronavirus associated with human respiratory disease in china. nature. 2020;579:265−9. table 2. nasopharynx oropharynx intestine anal incubation 69 days 7-14 days 7-10 days 7-10 days detection presentation 16 % 61.5 % 16%61.5 % 23%-24 % 23%-24 % vol 54 • number 3 • july 2022 anal swab in covid-19 patients 455 2. wrapp d, wang n, corbett ks, et al. cryo-em structure of the 2019-ncov spike in the prefusion conformation. science. 2020;367(6483):1260−3. 3. azwar mk, kirana f, kurniawan a, handayani s, setiati s. gastrointestinal presentation in covid-19 in indonesia: a case report. acta med indones. 2020;52(1):63−7. 4. song y, liu p, shi xl, et al. sars-cov-2 induced d i a r r h o e a a s o n s e t s y m p t o m i n p a t i e n t w i t h covid-19. gut. 2020 jun;69(6):1143-4. doi: 10.1136/ gutjnl-2020-320891. 5. world health organization. who director-general’s opening remarks at the media briefing on covid-19 11 march 2020 [internet]. 2020 [updated 2020 march 11]. available from: https://www.who.int/dg/speeches/ detail/who-director-general-s-opening-remarks-at-themedia-briefing-on-covid-19---11march-2020. 6. world health organization. situation report – 42 [internet]. 2020 [updated 2020 march 02; cited 2020 march 15]. available from: https:// www.who.int/docs/default-source/ coronaviruse/ situation-reports/20200302-sitrep-42-covid-19. pdf?sfvrsn=224c1add_2. 7. kementerian kesehatan republik indonesia. info infeksi emerging kementerian kesehatan ri [internet]. 2020 [updated 2020 march 30; cited 2020 march 31]. available from: https:// infeksiemerging. kemkes.go.id/. 8. rousan, l.a., elobeid, e., karrar, m. et al. chest x-ray findings and temporal lung changes in patients with covid-19 pneumonia. bmc pulm med. 2020;20:245. https://doi.org/10.1186/s12890-020-01286-5. 9. teymouri m, mollazadeh s, mortazavi h, et al. recent advances and challenges of rt-pcr tests for the diagnosis of covid-19. pathol res pract. 2021;221:153443. doi:10.1016/j.prp.2021.153443. 10. abdullah m, sudrajat dg, muzellina vn, et al. the value of anal swab rt-pcr for covid-19 diagnosis in adult indonesian patients. bmj open gastroenterol. 2021;8:e000590. doi: 10.1136/ bmjgast-2020-000590. 11. parasa s, desai m, thoguluva chandrasekar v, et al. prevalence of gastrointestinal symptoms and fecal viral shedding in patients with coronavirus disease 2019: a systematic review and meta-analysis. jama netw open. 2020;3(6):e2011335. published 2020 jun 1. doi:10.1001/jamanetworkopen.2020.11335. 12. harrison ag, lin t, wang p. mechanisms of sarscov-2 transmission and pathogenesis. trends immunol. 2020;41(12):1100-15. doi: 10.1016/j. it.2020.10.004. epub 2020 oct 14. pmid: 33132005; pmcid: pmc7556779. 13. gu j, korteweg c. pathology and pathogenesis of severe acute respiratory syndrome. am j p a t h o l . 2 0 0 7 ; 1 7 0 ( 4 ) : 11 3 6 4 7 . d o i : 1 0 . 2 3 5 3 / ajpath.2007.061088. pmid: 17392154; pmcid: pmc1829448. 14. li x, geng m, peng y, meng l, lu s. molecular immune pathogenesis and diagnosis of covid-19. j pharm anal. 2020;10(2):102-8. doi: 10.1016/j. jpha.2020.03.001. epub 2020 mar 5. pmid: 32282863; pmcid: pmc7104082. 15. boppana s, qin k, files jk, russell rm, stoltz r, bibollet-ruche f, bansal a, erdmann n, hahn bh, goepfert pa. sars-cov-2-specific circulating t follicular helper cells correlate with neutralizing antibodies and increase during early convalescence. plos pathog. 2021;17(7):e1009761. doi: 10.1371/ journal.ppat.1009761. pmid: 34270631; pmcid: pmc8318272. 16. peng y, mentzer aj, liu g, et al. broad and strong memory cd4+ and cd8+ t cells induced by sarscov-2 in uk convalescent individuals following covid-19. nat immunol. 2020;21:1336–45. https:// doi.org/10.1038/s41590-020-0782-6. 17. li l, tan c, zeng j, et al. analysis of viral load in different specimen types and serum antibody levels of covid-19 patients. j transl med. 2021;19(1):30. doi: 10.1186/s12967-020-02693-2. pmid: 33413461; pmcid: pmc7790347. 18. cheuk s, wong y, tse h, et al. posterior oropharyngeal saliva for the detection of sars-cov-2. clin infect dis. 2020. https://doi.org/10.1093/cid/ciaa797. case report 221acta medica indonesiana the indonesian journal of internal medicine a 44-year-old man with waldenstrom macroglobulinemia and bilateral maxillary sinusitis shinta o. wardhani, herman b. trianto, muhammad anshory department of internal medicine, faculty of medicine, university of brawijaya saiful anwar hospital, malang, indonesia. corresponding author: shinta o. wardhani, md. division of hematology and medical oncology, department of internal medicine, faculty of medicine, university of brawijaya – dr. saiful anwar hospital. jl. jaksa agung suprapto no.2, malang 61351, indonesia. email: shinta_ow@yahoo.com. abstrak waldenstrom macroglobulinemia adalah penyakit kelainan limpoproliferatif yang bersifat kronik dan indolen dengan karakteristik adanya igm makroglobulin yang tinggi, peningkatan viskositas serum, dan infiltrasi limfoplasmasitik pada sumsum tulang. manifestasi klinis terjadi karena adanya igm paraprotein dan infiltrasi sel limfoplasmasitik maligna pada sumsum tulang dan jaringan yang lain. telah dilaporkan laki-laki dengan waldenstrom macroglobulinemia dan sinusitis maksillaris bilateral, diberikan terapi simptomatik dan antibiotik untuk sinusitis, transfusi ffp dan prc untuk memperbaiki kondisi umumnya, dan kemoterapi regimen chop sebagai terapi definitifnya. kata kunci: waldenstrom macroglobulinemia, monoclonal gammopathy, chop. abstract waldenstrom macroglobulinemia is a chronic, indolent, lymphoproliferative disorder, which is characterized by the presence of a high macroglobulin (igm) level, elevated serum viscosity, and the presence of a lymphoplasmacytic infiltrate in the bone marrow. clinical manifestations may be found due to the presence of igm paraprotein and malignant lymphoplasmacytic cell infiltration of the bone marrow and other tissues. we reported a case of male patient with waldenstrom macroglobulinemia and bilateral maxillary sinusitis. he had received symptomatic and antibiotic treatment for his sinusitis, ffp and prc transfusion to improve his general condition and chemotherapy with chop regimen as definitive treatment. keywords: waldenstrom macroglobulinemia, monoclonal gammopathy, chop. introduction waldenstrom macroglobulinemia (wm), one of the malignant monoclonal gammopathies, is a chronic, indolent, lymphoproliferative disorder.1 wm is currently classified by the revised european american lymphoma (real) and world health organization (who) systems as a lymphoplasmacytic lymphoma.2 waldenstrom macroglobulinemia is a relatively rare condition with 1500 cases diagnosed per year in us accounting for approximately 2% of hematologic malignancies. in uk, the annual incidence of this disease is 10.3 per million. it is common in elderly individuals, i.e. among 7th – 8th decade of life with median about 65 years and a slight male predominance.3-5 shinta o. wardhani acta med indones-indones j intern med case illustration a 44-year-old male patient came to hospital with general weakness since 1 month ago, which had been worsened since 2 weeks ago. he also complained of tension-type headache, especially in the front head and in his left cheek, there was smelly odor from his nose with purulent-greenish discharge from his left nose and his throat. he also suffered from sorethroat and nasal blockage. previously, he complained about intermittent nasal discharge and sneezing, especially when he was exposed to cold weather. he had toothache of his left upper third molar since 1 year ago with intermittent pain, but since 1 month ago, he started to feel pain again and the pain did not subside. he experienced weight loss since 3 months ago without any change of eating habit. in the past 1 week, he started to feel tingling sensation on his right forefoot. the patient had already visited ent specialist and dentist. he was told that he has maxillary sinusitis and pulp gangrene. he received pain killer as well as antibiotics, but because his hemoglobin level was low, he was referred to an internist and subsequently was advised to be referred to saiful anwar general hospital due to a suspicion of aplastic anemia. he is a married man with 2 children, and works as a farmer. physical examination revealed blood pressure of 120/80mmhg, pulse rate of 82 beats/ minute, respiratory rate of 18x/minute, axillary temperature of 36.70c, anemic conjunctiva, left maxillary tenderness, bilateral edema of medial conchae with bilateral purulent discharge from the medial meatus, hyperemic pharynx with multiple granulae, pulp gangrene on the left upper m3, traube space dullness; while others findings were within normal limit. laboratory tests showed a hemoglobin level of 6.80 g/dl, leukocyte count of 3,700/ µl, hematocrit of 21.50%, platelet count of 110,000/µl, (diff count 0/0.3/0/47.8/40.5/10). blood smear examination showed anisocytosis normochromic anemia indicating reduced leukocytes and platelets. the blood smear also showed giant platelets. his serum albumin level was 3.16 g/dl with globulin level of 8.21 g/dl, total protein of 11.49 g/dl and positive result of fobt with prolonged hemostatic function result. his serum electrolyte, renal function test, liver function test, ldh, bilirubin and urinalysis were within normal range. waters’ view sinus x-ray showed that there was acute on chronic maxillary sinusitis on his left sinus, chronic maxillary sinusitis on his right sinus and rhinitis. abdominal usg revealed splenomegaly. protein electrophoresis was carried out 3 days later with a result indicating a monoclonal gammopathy and his bone marrow puncture showed infiltration with 80% cells consist of lymphocytes, plasmacytoid, and plasma cells. we concluded that the diagnosis of the patient was suspected waldenstrom macroglobulinemia and immunofixation is needed to confirm the diagnosis. bone marrow immunohistochemistry revealed negative result for cd20; while the immunofixation showed positive result for monoclonal igm lambda and serum immunohistochemistry showed no positive dominant markers. unfortunately, the amount of samples obtained from bone marrow aspiration was too little for immunohistochemistry assay and therefore, the result only showed for the cd 20. patient was diagnosed with waldenstrom macroglobulinemia, hypoalbuminemia, acute on chronic maxillary sinusitis on left sinus, chronic maxillary sinusitis on right sinus and rhinitis. he received high calories high protein meal 2100 kcal/day, 20 drops/minute of ivfd of normal saline (0.9% nacl solution), prc transfusion 2 packs/day until his hb >10 g/dl, 400 mg intravenous ciprofloxacin twice daily, 625 mg amoxycillin-clavulanic acid three times daily, 50 mg natrium diclofenac twice daily, pseudoephedrine hcl 60 mg/tripolidine hcl 2.5 g twice daily, 2 tablets of vit b6/b12 three times daily and 1000 µg folic acid daily. on day 3, the patient was hospitalized. he had dark tarry stool, his fobt result was positive and he had prolonged hemostatic function. he received ffp transfusion of 4 packs/day afterward. he also received short wave diathermi 6x to relieve his maxillary pain. during therapy, his condition was improved with hb level of more than 10 g/dl; his weakness, headache and nasal discharge subsided gradually. 222 vol 48 • number 3 • july 2016 a 44-year-old man with waldenstrom macroglobulinemia he was scheduled for chemotherapy with 6 series of chop regimen (cyclophosphamide, doxorubicin, vincristin, prednison) with 21 days cycles and showed good response to the treatment. that can contribute to peripheral neuropathy, and immunologically related lupus anticoagulant activity.2 the differences between wm and multiple myeloma (mm) are wm does not cause bone lesions or hypercalcemia, the size of the igm paraprotein results in little renal excretion, and only ~20% of patients excrete light chains. therefore, renal disease is not common.the light chain isotype is kappa in 80% of the cases. patients present with insidious weakness, fatigue, anorexia, weight loss and recurrent infections, bleeding diasthesis, visual disturbances, and neurologic symptoms such as peripheral neuropathy, dizziness, headache, and transient paresis.6 physical examination reveals adenopathy and hepatosplenomegaly; while ophthalmoscopic examination may reveal vascular segmentation and dilatation of the retinal veins, which is a characteristic sign of hyperviscosity. periorbital mass resulting from infiltration into retro-orbital structures and the lacrimal gland have been described, thus it may cause proptosis and occular nerve palsies. purpura and other hemorrhagic manifestations could be found due to interference of macroglobulin with hemostatic factors as well as platelet function. patients may have a normocytic, normochromic anemia with rouleaux formation and positive coombs test. anemia is caused by plasma hemodilution, decreased life span of erythrocyte, blood loss due to bleeding, and bone marrow failure. malignant lymphocytes are usually present in the peripheral blood. about 10% of macroglobulins are cryoglobulins. these are pure m components and are not the mixed cryoglobulins seen in rheumatoid arthritis and other autoimmune diseases. mixed cryoglobulins are composed of igm or iga complexed with igg, for which they are specific. in both cases, raynaud’s phenomenon and serious vascular symptoms precipitated by the cold may occur.6 some of signs and symptoms, but not all, can be found in this patient. general symptoms such as weakness, weight loss, fatigue, and recurrent infections could be caused by anemia, leukopenia and netropenia, or by malignancy itself. tingling sensation on his right forefoot figure 1. bone marrow aspiration showing infiltration of lymphocyte, plasmacytoid and plasma cells discussion waldenstrom macroglobulinemia is a malignant disease of b cells that appear to be a hybrid of lymphocytes and plasma cells. these cells characteristically secrete an igm paraprotein and many clinical manifestations of the disease are related to this macroglobulin.5 clinical manifestations of this disorder result from 2 important factors. the first factor is the secretion of the igm paraprotein that may lead to hyperviscosity and vascular complications because of physical, chemical, and immunologic properties of the paraprotein. m o n o c l o n a l i g m c a u s e s h y p e r v i s c o s i t y syndrome, cryoglobulinemia types 1 and 2, coagulation abnormalities, sensorimotor peripheral neuropathy, cold agglutinin disease and anemia, primary amiloidosis, and tissue deposition of amorphous igm in the skin, gi tract, kidneys, and other organs. the second factor is neoplastic lymphoplasmacytic cells that infiltrate the bone marrow, spleen, and lymph nodes. less commonly, these cells can infiltrate the liver, lungs, gi tract, kidneys, skin, eyes, and cns. infiltration of these organs causes numerous clinical symptoms and signs. occasionally, igm paraprotein has rheumatoid factor activity, antimyelin activity 223 shinta o. wardhani acta med indones-indones j intern med could be caused by peripheral neuropathy due to igm secretion, but it still need to be confirmed by further examination such as enmg, since his neurological examinations revealed normal results. melena was suspected due to prolonged results on hemostatic function tests, which were associated with alteration of macroglobulin. splenomegaly found in this patient is consistent with wm characteristics. other positive findings were related to sinusitis. our patient was found accidentally with primary complaints related to sinusitis, as mentioned in literature, that the disease is indolent and sometimes the complaints are found accidentally during medical check up or due to complications.2,3,6 according to literatures, no definite etiology has existed for waldenstrom macroglobulinemia. environmental (works with pesticides, paint, metal, woods, textile, asbestos, and gasoline industries, radiation), race (afro-america), gender (male), age (old age), familial, genetic, and viral factors have been reported as some of precipitating factors. igm monoclonal gammopathies of undetermined significance (mgus) are considered the precursors of waldenstrom macroglobulinemia. hepatitis c, hepatitis g, and human herpes virus 8 have been implicated, but no strong data has supported a causative link between these viruses and waldenstrom macroglobulinemia. our patient is male and at middle age, which has no family history of malignancies and the only possible risk factor was the environmental factor, i.e. pesticides exposure since he works as a farmer.7,8 waldenstrom macroglobulinemia can be identified by the abovementioned signs and symptoms as well as results of several additional examinations such as complete blood count, blood smear, hemostatic function, esr, igm monoclonal serum, lymph node histology (if any), and bone marrow examination. diagnosis waldenstrom macroglobulinemia is characteritized by (1) serum igm monoclonal level was more than 15 g/dl; (2) biopsy of bone marrow showed pleomorphic infiltrations by small lymphocytes, plasma cells, plasmacytoid cells, mast cells, and hystiocytes. trephine biopsy may showed nodular form, which i n d i c a t e s b e t t e r p r o g n o s i s c o m p a r e d t o diffuse infiltration; (3) increased erythrocyte sedimentation rate; lymphocytosis with some of them were plasmacytoid; and (4) lymph node histology revealed covered sinus architecture with disappeared folicular pattern combined with similar cellular infiltration found in bone marrow.9 splenic marginal zone lymphoma (smzl) and other lymphoproliferative disordes can be distinguished from wm based on their clinical signs and symptoms, immunophenotypic and molecular cytogenetic.10,11 our patient showed vague signs and symptoms and therefore, at first, we suspected that the diagnosis was aplastic anemia. his complete blood count (cbc) revealed pancytopenia with lymphocytosis, which might be related to bone marrow failure due to cell infiltration, inversed ratio of albumin and globulin indicating the predominance of globulin protein, which was related to increasing amount of gammaglobulin in circulation. these findings suggested that the pancytopenia could also be caused by gammopathies, including multiple myeloma, waldenstrom macroglobulinemia, poem syndrome, heavychain disease, amiloidosis, or evenbenign monoclonal gammopathy. results of protein electrophoresis supported the possibility of gammopathies since it demonstrated monoclonal gammopathy and the results of bone marrow biopsy exactly showed the same histology described for waldenstrom macroglobulinemia. furthermore, the diagnosis is highly suspected because the results showed that the igm monoclonal was igm monoclonal lambda. however, immunophenotyping/ immunohistochemistry and molecular cytogenetic examination had not been performed in our patient due to lack of bma samples. the examination was only performed for cd20, which showed negative results; while the immunohistochemistry of serum showed no positive dominant markers. however, the clinical symptoms were quite obvious and we could distinguish between mm and wm since there was no bone or renal involvement in our patient. moreover, there was also different morphology of cells in bone marrow. thus, our patient has met the diagnostic criteria for waldenstrom 224 vol 48 • number 3 • july 2016 a 44-year-old man with waldenstrom macroglobulinemia macroglobulinemia.11 hyperviscosity syndrome should be suspected only in patients who have a serum viscosity greater than 4. plasma exchange is an accepted treatment approach for hyperviscosity, but it should be considered as a temporary measure until systemic chemotherapy can be initiated, which can successfully downsize the tumor mass and igm level. patients with wm and associated hyperviscosity may need emergency treatment, i.e. paraprotein reduction using plasmapheresis. about 2 to 3 plasma exchanges are required to reduce the igm levels by 30%-60%. this measure is absolutely necessary, particularly before starting a rituximab-containing regimen because rituximab has been known to cause a flare reaction in patients with wm-associated hyperviscosity.12,13 our patients received supportive treatment to correct anemia, bleeding and sinusitis infection. plasmapharesis could not be performed due to lack of facilities although the hyperviscosity syndrome was suspected. the patient had headache, which is debatable, but he had prolonged test results on hemostatic function, which is mainly caused by interference related to wm. moreover, densitometry to confirm the diagnosis also could not be performed due to lack of facilities. autologous stem cell transplantation is still not available in this hospital. many factors must be considered when deciding the best treatment approach for the patient, including age, comorbidities, cytopenias, hyperviscosity, neuropathy, and organ dysfunction. for initial management of asymptomatic or smoldering disease, observation without treatment is recommended. asymptomatic or smoldering disease is defined as a disorder with hemoglobin level of over 11 g/dl, a platelet count of more than 100 x 109/l and an absence of neuropathy, hyperviscosity or wm-associated hemolytic anemia or constitutional symptoms.13 in initial treatment of non-bulky symptomatic disease, single-agent rituximab therapy should be considered. nonbulky symptomatic disease is characterized by wm-associated neuropathy, anemia or cytopenias, low-volume nodal disease and asymptomatic splenomegaly. bulky symptomatic disease is characterized by bulky adenopathy, symptomatic splenomegaly, cytopenias, hyperviscosity, neuropathy, or constitutional symptoms, which is considered to be a match for our patient (splenomegaly, cytopenia, hyperviscosity, and neuropathy).13 t h e c o m b i n a t i o n o f c h o p r e g i m e n (cyclophosphamide, doxorubicin, vincristine, and prednisone) and rituximab (chop-r) has been tested in patients with wm. the response rate in the chop-r was 94% compared to 69% in the chop.14 the role of maintenance therapy in patients with wm/lpl remains controversial, as there are no prospective trials demonstrating any benefit. however, many centers extrapolate the indolent lymphoma data and would consider rituximab maintenance in patients who show response to a rituximab-containing induction regimen. many of the regimens listed above, which are not used as initial therapy, can be considered as a salvage approach. in addition, many centers recommend retreatment with the initial regimen if there is a durable remission (lasting >2 years) and the treatment was well tolerated. other salvage approaches include alemtuzumab, bortezomib/ rituximab, everolimus, ofatumumab, autologous and allogeneic transplantation.13 when considering initial and salvage therapies for patients who may eventually be considered for autologous transplant, exposure to stem cell damaging agents such as alkylating agents and purine analogs should be avoided. because many of the standard regimens do contain alkylating agents and purine analogs, many centers recommend either collecting stems cells early to be sequestered for a later transplant or not waiting later than the second or third chemosensitive salvage before considering autologous transplantation.13 while some allogenic transplantation has demonstrated very durable remissions, transplant-related mortality remains very high. approaches that use reduced intensity conditioning regimens appear promising, with durable remissions and reduced transplantrelated mortality. allogenic transplantation has demonstrated durable remissions with much lower transplant-related mortality but it should be considered only in younger patients with highly 225 shinta o. wardhani acta med indones-indones j intern med refractory disease or as part of a clinical trial.13 the use of radioimmunotherapy such as iodine 131i-tositumomab radioimmunotherapy in wm has been limited since the high level of bone marrow involvement limits their use. however, case reports have shown that these therapies may be effective in patients with wm who have <25% bone marrow involvement.14 the development of novel agents (proteosome inhibitor, immunomodulatory agents, monoclonal antibodies and blocking protein, signalling pathways inhibitor) and stemcell sparing agents has been prioritized in the treatment of wm.14 according to this recommendation, chop-r is quite a good choice with overall survival rate of 94%. nevertheless,our patient has health insurance coverage for rituximab treatment, but the coverage can be given only if his cd20 is positive. the negative result of cd20 has prevented our patient to have rituximab treatment. we considered to give 6 series of chop regimens with 21 cycles as the treatment that could be fully covered by his insurance with good overall survival rate. factors associated with poor prognosis in patients with wm include advanced age, high β2-microglobulin, cytopenias, low albumin, and organomegaly. age, hemoglobin concentration, serum albumin level, and β2-microglobulin are identified as the predominant outcome predictors. an international prognostic scoring system (wm-ipss) has been presented as a staging system for survival for symptomatic patients who are in need of therapy. the parameters used to stratify the risk were in our patient were age over 65 years, β2-microglobulin level of greater than 3 mg/l, monoclonal protein level of greater than 70 g/l, hemoglobin of less than 11.5 g/dl, and platelet count of less than 100 × 109/l. low risk is defined as the presence of fewer than 1 adverse characteristic, except age; while high risk is defined as the presence of more than 2 adverse characteristics; therefore, patients with 2 adverse characteristics or older than 65 years have intermediate risk. other prognostic markers, which have been considered in current studies are the serum free light chain and serum soluble cd27. our patient had hb of less than 11.5 g/dl, but other factors such as β2 microglobulin level and quantitative igm level were not measured yet due to lack of facilities, thus we could not justify his prognosis.14 conclusion we reported a 44-year-old male with waldenstrom macroglobulinemia and bilateral maxillary sinusitis with improved general condition. he has received therapy for sinusitis and chemotherapy with chop regimen afterward. references 1. vogt rf, marti ge. overview of monoclonal gammopathies of undetermined significance. br j haematol. 2007;139(5):687-9. 2. pasricha sr, juneja sk, westerman da, came na. bone-marrow plasma cell burden correlates with igm paraprotein concentration in waldenstrom macroglobulinemia. j clin pathol. 2012;64(6):520-3. 3. wang h, chen y, li f, et al. temporal and geographic variations of waldenstrom macroglobulinemia incidence: a large population-based study. cancer. 2011;2. 4. menke mn, feke gt, mcmeel jw, treon sp. 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in: sudoyo aw, setiyohadi b, alwi i, et al. jakarta: interna publishing; 2006. p. 749-54. 10. theml h, diem h, haferlach t. color atlas of hematology. 2nd edition. new york: thieme; 2004. 11. nccn guidelines. waldenstrom’s macroglobulinemia/ lymphoplasmacytic lymphoma. version 1.2012 january 20, 2012. national comprehensive cancer network. 226 vol 48 • number 3 • july 2016 a 44-year-old man with waldenstrom macroglobulinemia available at http://www.nccn.org/professionals/ physician_gls/pdf/waldenstroms.pdf. accessed june 20, 2013. 12. ghobrial im, fonseca r, greipp pr, blood e, rue m, vesole dh. initial immunoglobulin m ‘flare’ after rituximab therapy in patients diagnosed with waldenstrom macroglobulinemia: an eastern cooperative oncology group study. cancer. 2004;101(11):2593-8. 13. tuscano, joseph m. waldenstrom macroglobulinemia treatment protocols. medscape. available at http:// emedicine.medscape.com/article/2057687-overview. accessed june 20, 2013. 14. lelau, xavier, aldo m. roccaro, et al. waldenstrom macroglobulinemia. nih public access. 2012. available at http://www.ncbi.nlm.nih.gov/pmc/articles/ pmc3133633. accessed june 20, 2013. 227 275 original article acta medica indonesiana the indonesian journal of internal medicine the effect of enhanced external counterpulsation therapy and improvement of functional capacity in chronic heart failure patients: a randomized clinical trial starry h. rampengan1, joedo prihartono2, minarma siagian3, suzanna immanuel4 1 departement of cardiology and vascular medicine, faculty of medicine, university sam ratulangi, manado, indonesia. 2 departement of community medicine, faculty of medicine universitas indonesia, jakarta, indonesia. 3 departement of physiology, faculty of medicine universitas indonesia, jakarta, indonesia. 4 departement of clinical pathology, faculty of medicine universitas indonesia, jakarta, indonesia. correspondence mail: departement of cardiology and vascular medicine, faculty of medicine, university sam ratulangi. jl. hasanuddin no. 95, bitung-karang ria, tuminting, manado, north sulawesi 95237, indonesia. email: starry8888@yahoo.com. abstrak tujuan: untuk mengevaluasi efektivitas terapi enhanced external counterpulsation (eecp) dalam memperbaiki kapasitas fungsional pasien gagal jantung kronik (gjk). metode: uji klinik acak tersamar ganda dilakukan terhadap 99 pasien gjk yang menjalani terapi eecp di klinik jantung jade, manado pada periode waktu januari 2014-juni 2015. pasien dibagi menjadi 2 kelompok dimana 49 pasien mendapatkan terapi sham eecp dan 50 pasien mendapatkan terapi eecp. semua pasien gjk dilakukan latihan jalan 6 menit (lj6m) sebelum dan sesudah menjalani terapi eecp. hasil: karakterisitik dasar pasien gjk tidak ditemukan adanya perbedaaan bermakna antara kedua kelompok. hasil lj6m sebelum terapi pada kelompok sham eecp ditemukan 30 pasien (61,2%) dengan jarak tempuh <300 meter sedangkan pada kelompok yang dilakukan terapi eecp sebesar 34 pasien (68%), p=0,24. pasca terapi eecp ditemukan 33 pasien (67,3%) dengan jarak tempuh <300 meter pada kelompok sham eecp, sedangkan pada kelompok terapi eecp hanya 1 pasien (2%), p<0,01. jarak tempuh pada kelompok sham sebelum terapi adalah 252,65 (sd 97,55) meter dan pada kelompok eecp 243,65 (sd 86,96) meter; p=0,18. pada kelompok eecp jarak tempuh lj6m sebelum dilakukan terapi adalah sebesar 256,88 (sd 85,56) meter dan sesudah terapi eecp jarak tempuhnya menjadi sebesar 449,46 (sd 92,08) meter; p<0,01. kesimpulan: terapi eecp efektif dalam memperbaiki kapasitas fungsional pada pasien gjk. kata kunci: gagal jantung kronis, latihan jalan 6 menit, terapi enhanced external counterpulsation. abstract aim: to investigate the efficacy of enhanced external counterpulsation (eecp) therapy to improve functional capacity in patients with chronic heart failure (chf). methods: a double-blind random clinical trial was performed in 99 patients with chf who had received eecp therapy at jade cardiovascular clinic, manado, north sulawesi, indonesia between january 2014 and june 2015. subjects were categorized into 2 groups, i.e. 49 subjects had sham eecp therapy and 50 subjects had eecp therapy. all subjects performed six-minute walking test (6mwt) before and after receiving eecp therapy. results: there was no significant difference between both groups regarding the basic characteristics of patients with chf. the 6mwt result before eecp therapy showed that there were 30 patients (61.2%) with walk distance of <300 meter in the sham eecp group; while starry h. rampengan acta med indones-indones j intern med 276 introduction heart failure is still a major health problem. the incidence of heart failure is increasing from 1.5-4% to 6.7-9.9% in developing countries.1-3 in patients with chronic heart failure (chf), there is a reduced left ventricular ejection fraction (lvef), cardiomegaly, and increased left ventricular end diastolic pressure (lvedp), which will produce clinical manifestations such as short of breath (dyspnea), fatigue, insomnia, easily awake due to shortness of breath that result in limited daily physical activity and impair the functional capacity of patients.3-6 in patients with chf, functional capacity is a method to evaluate patient’s ability to perform daily activity, which can be measured by performing six-minute walking test (6mwt). the 6mwt is a simple test, which is easily performed and it is usually utilized to evaluate functional exercise capacity, walking capacity and the effectiveness of treatment in patients with chf.4-9 various treatment methods have been performed to increase survival and improve quality of life for patients with chronic heart disease. one of those various methods that have been applied recently in the last decade is enhanced external counterpulsation (eecp) therapy. the therapy is used to improve contractility of myocardium and increase stroke volume in addition to its angiogenesis and atherogenesis effect as well as developing new collateral circulation. enhanced external counterpulsation is a treatment of choice for patients with chf who still have symptoms of fatigue after receiving optimal pharmacological treatment and for those who are not eligible for having revascularization treatment.10-14 some studies show that eecp treatment does not provide significant improvement effect on increased left ventricular ejection fraction or on exercise tolerance; however, some studies on the effects of eecp therapy have recently provided evidence about its beneficial effect for patients with angina pectoris and heart failure.10-12,15-17 however, there is very limited data about eecp studies on chronic heart failure. the 6mwt was performed to evaluate their functional capacity. our study was aimed to evaluate the effectiveness of eecp treatment to improve functional capacity in patients with chf. methods our study was designed to evaluate functional capacity using six-minute walking test in patients with chf, on those who had received eecp therapy or who only had sham eecp therapy. the study was conducted at the jade cardiovascular clinic, manado, north sulawesi, indonesia between january 2014 and june 2015. the target population in our study was all patients with chronic heart failure; while the study population was patients with chronic heart failure who had treatment at the jade cardiovascular clinic, manado siloam hospital, manado adventist hospital and prof. dr. r.d. kandou general hospital, manado. the subjects of our study were all patients with chf who were eligible as well as those who had met the inclusion criteria and who were willing to participate in our study. the inclusion criteria of our study were patients with: 1) age between 25 and 79 years; 2) mild to moderate symptomatic chronic heart failure (nyha functional class i-ii) with the following etiology: ischemic heart disease, hypertension heart disease, coronary heart in the group receiving eecp therapy, we found 34 patients (68%); p=0.24. post-eecp therapy, there were 33 patients (67.3%) with walk distance of <300 meters in eecp sham group; while in the group receiving eecp alone, there was only 1 patient (2%); p <0.01.the 6mwt walk distance in sham group before eecp therapy was 252.65 (sd 97.55) meters and it was 243.65 (sd 86.96) meters following the eecp therapy; p=0.18. in eecp group, the 6mwt walk distance before therapy was 256.88 (sd 85.56) meters and after eecp therapy the walk distance was 449.46 (sd 92.08) meters; p<0.01. conclusion: eecp therapy is effective to improve functional capacity in patients with chf. key words: chronic heart failure, six-minute walk test, enhanced external counterpulsation (eecp) therapy. vol 47 • number 4 • october 2015 the effect of eecp therapy and improvement of functional capacity in chf 277 disease or acute coronary syndrome; 3) certain echocardiography result, i.e. the difference between end diastolic volume and end systolic volume divided with end diastolic volume was <40%; 4) chronic heart disease who had received standard therapy according to the heart failure national guideline for at least one month before participating in our study; 5) willingness to participate in the study and signed the informed consent form. the exclusion criteria were those with:11,15,16 1) severe heart valve damage; 2) acute coronary syndrome at least <6 weeks prior to the study; 3) major arrhythmia that significantly can interfere the eecp instrument such as atrial fibrillation, extra systole of more than six times per minute; 4) heart catheterization <2 weeks prior to the study; 5) history of bypass surgery <3 months and history of coronary stent implant less than 6 months prior to the study and peripartum cardiomyopathy; 6) implantable cardioverter defibrillator instrument; 7) pregnancy and breastfeeding; 8) intermittent claudication; 9) uncontrolled blood pressure of >180/110 mmhg; 10) deep vein thrombosis, thrombophlebitis, pulmonary embolism or aortic aneurysm; 11) other medical, legal or social condition that may affect the patients’ judgment in giving their informed consent or when participating the study. the drop out criteria were patients who did not complete eecp/sham eecp therapy either with or without reason including those who had cardiovascular or severe side effect as well as those who had lost their interest in our study. intervention the eecp instrument consists of 3 pairs of pneumatic cuff, which were applied to lower extremities. the patients were treated for 1 hour daily for a total of 36 sessions in 7 weeks. three sets of pneumatic cuff were applied to calves, lower and upper thigh and were sequentially inflated during the diastolic phase of the heart. furthermore, an external pressure of 300 mmhg was applied during the diastolic phase for subjects in eecp therapy group; while those in sham eecp group only had 75 mmhg, enough to preserve the appearance and feel of an eecp application, but insufficient to alter measurably the patient’s blood pressure. all patients then performed the six-minute walking test. the test was conducted as indoor test in a straight corridor which had 30 meters length as recommended by the american thoracic society (ats) guideline. sample size number of needed samples was calculated using statistical formula based on the difference of walking distance in six minutes between patients with and without eecp intervention. confidence interval of 95% and statistical power of 80% were applied in the sample size calculation. based on our previous clinical experience, the estimated standard deviation of walking distance was 90 meters and the minimal expected significant difference between both groups after intervention was 50 meters, thus the needed sample size is 50 subjects for each group. there were 158 patients who had received optimal medical treatment were included in our study and after having screening test, 46 patients were excluded as 15 patients were not willing to participate in our study and 31 patients did not meet the inclusion criteria. the patients subsequently underwent further tests and filled the form about basic characteristics data for population study such as demography, risk factors for coronary heart disease, laboratory data on blood glucose and cholesterol level as well as echocardiography and medication. randomization and blind our study was a double blind randomized clinical trial, in which the evaluator did not know about the category of subject groups. we did not know whether the patients with chf were in the group receiving eecp or sham eecp therapy. block randomization using concealed envelopes was then performed and the subjects were categorized into 2 groups, i.e. there were 56 patients in the sham eecp group and other 56 patients in the eecp therapy group. the study participants were recruited by the participating cardiologists following the study protocol. the test was carried out by 2 specific clinical nurses at the jade cardiovascular clinic. during the treatment period, 7 patients were excluded from the sham eecp group; consisted of 4 patients that were dropped out since they could not complete the study, and 3 patients had cardiovascular starry h. rampengan acta med indones-indones j intern med 278 adverse events (rehospitalized); while in the eecp group, we found 6 patients who were not able to continue the study including 3 dropped out patients, 1 patient who had lost his interest to continue the study and 2 patients who had cardiovascular events (rehospitalized). there were 49 patients who completed eecp treatment in sham group and there were 50 patients in eecp group. afterwards, all patients performed the six-minute walking test. statistical analysis statistical analysis was performed for all outcomes including primary, secondary and safety outcomes. data were processed using mean value (standard deviation) and were tested with unpaired mean difference (median). in order to evaluate the difference between eecp and sham eecp data, unpaired student t-test was used when the data in both groups showed normal distribution; when it did not show normal distribution, a mann-whitney ranks test was used. alpha of 5% was used in interpreting statistical significance. the data of our study was analyzed using a computer software program of spss version 22.0. study protocol patients with chf who were in stable condition of nyha functional class i and ii and who had received optimal treatment for coronary heart disease, including beta blocker, nitrate, aspirin and statin performed six-minute walking test and filled in the who-5 questionnaires. they were then randomly selected to receive eecp treatment or non-eecp treatment (i.e. only receiving optimal sham therapy to imitate eecp treatment). an evaluation was subsequently conducted in 6 weeks following the eecp treatment, both for eecp and sham eecp group by performing the six-minute walking test. our study was conducted in keeping with helsinki declaration and was supported by ethical clearance. the ethical clearance was issued by ethic committee of faculty of medicine, university of sam ratulangi, manado with registration number 014.01.06/11.2/018/2014. all patients were obliged to sign informed consent before participating in our study. results the study was conducted between january 2014 and june 2015. figure 1 shows a flow chart for participants in the study. outcome measures of 6mwt were collected at baseline and after eecp therapy. based on the results of our study, we found that most of chf patients in both groups were male and they were most frequently at the age of 55-65 years. from the basic characteristic data of patients, we did not find significant difference between those in eecp group and those in sham eecp group as presented in table 1. table 2 shows that there was no significant difference of pre-treatment six-minute walking test results between sham eecp and eecp group either for walking distance of <300 meters chf patients (158) unwilling (15) not eligible (31) eligible (112) eecp group (56) sham group (56) completed (50) dropped out (6) dropped out (7) completed (49) figure 1. the participants’ flow diagram vol 47 • number 4 • october 2015 the effect of eecp therapy and improvement of functional capacity in chf 279 distance in eecp group in which 98% subjects had significant statistical rate for walk distance of >300 meters (p<0.01); while in sham eecp group, we found no significant difference when compared to pre-eecp treatment. there was no significant difference of the six-minute walking test results in the sham eecp group between before and after treatment (252.65 [sd 97.55] vs. 243.65 [sd 86.96]; p=0.18). however, there was a significant increased result of six-minute walking test in eecp group (256.88 [sd 85.56] vs. 449.46 [sd 92.08]; p<0.01) as we can see in table 3. delta analysis after and before eecp of both group also shows significantly different (-9 [sd 67.68] vs 192.58 [sd 87.45]; p<0.05). discussion the mechanism of action for eecp in alleviating symptoms of chronic angina has not been fully understood; however, the hemodynamic effect of eecp is basically the same with intra-aortic balloon pump (iabp), i.e. by reducing afterload and increasing coronary perfusion pressure through diastolic pressure in aortic root. at the initial phase of left ventricular diastolic, the sets of pneumatic cuff were subsequently inflated and applied to the calves, upper and lower thigh-one at a time. the inflated cuffs will cause arterial and venous compression of the lower extremities and pump the blood to superior part of the body, both to the aortic root table 1. descriptive baseline characteristics of the study population characteristics pre sham group (n= 49) pre eecp group (n= 50) demographic age (year),mean (sd) 62.43 (12.06) 60.54 (8.6) gender (male), n (%) 38 (77.6) 36 (72.0) weight (kg),mean (sd) 61.8 (11.74) 58.5 (12.02) height (cm),mean (sd) 162,6 (8.92) 160.4 (8.69) bmi (kg/m2),mean (sd) 23.67 (3.48) 23.06 (4.10) cardiovascular risk factor dyslipidemia, n (%) 34 (69.4) 34 (68.0) hypertension, n (%) 35 (70.1) 35 (71.4) smoking, n (%) 16 (32.7) 20 (49.0) diabetes mellitus,n (%) 13 (26.5) 14 (28.0) family predisposition, n (%) 14 (28.6) 8 (16.0) blood parameters fasting glucose (mg/dl), mean (sd) 109.41 (42.52) 95.54 (32.60) hba1c, n (%) 6.83 (1.81) 6.18 (2.05) total cholesterol (mg/dl), mean (sd) 218.33 (74.16) 210.08 (49.61) ldl cholesterol (mg/dl), mean (sd) 160.12 (33.94) 157.86 (49.16) hdl cholesterol (mg/dl), mean (sd) 33.76 (8.46) 38.50 (8.18) triglycerides (mg/dl), mean (sd) 134.59 (82.84) 133.06 (71.09) echocardiography findings lvedd (mm),mean (sd) 61.89 (9.18) 63.54 (8.66) lvesd (mm),mean (sd) 50.47 (8.65) 51.96 (8.14) lvef (%), mean (sd) 32.69 (3.82) 31.88 (3.95) medications aspirin, n (%) 48 (97.9) 48 (96.0) statin, n (%) 48 (97.9) 49 (98.0) b-blocker, n (%) 40 (81.6) 41 (82.0) ace inhibitors/arb, n (%) 44 (89.8) 45 (90.0) nitrates, n (%) 41 (83.7) 43 (86.0) exercise tolerance 6 mwt (m), mean (sd) 252.65 (97.55) 256.88 (85.56) lvedd = left ventricular end diastolic diameter; lvesd = left ventricular end-systolic diameters;lvef = left ventricular ejection fraction; ldl = low density lipoprotein table 2. comparison of 6 mwt distance between sham eecp group and eecp group before and after eecp therapy variables 6 mwt distance ρ value≤300 m >300 m before intervention, n (%) sham group (n=49) 30 (61.2) 19 (38.8) 0.24* eecp group (n=50) 34 (68.0) 16 (32.0) after intervention, n (%) sham group (n=49) 33 (67.3) 16 (32.7) <0.01* eecp group (n=50) 1 (2.0) 49 (98.0) *chi square test (61.2% vs. 68.0%) or for walk distance of >300 meters (38.8% vs. 32.0%); p=0.24. table 2 also shows results on post-six-minute walking test and we found significant increased walking starry h. rampengan acta med indones-indones j intern med 280 and cava vein. the blood pumping may produce increased aortic diastolic pressure, which may push strong and oxygen-rich blood toward the heart and increasing the perfusion pressure of coronary artery.11,12 in chronic heart failure, reduced vascular shear stress occurs persistently, which may worsen endothelial dysfunction. the eecp will produce pulsatile blood circulation, which will increase endothelial shear stress (ess) leading to improved endothelial function, reduced proinflammatory cytokines, lower macrophage accumulation and complement activation and reduced vascular inflammation.17 in general, the mechanism of action of eecp is to reduce afterload and lower myocardial oxygen demand. eecp increases coronary blood flow and promotes myocardial collateralization through the development of collateral blood vessels, arteriogenesis and angiogenesis. increased blood flow and ess can improve endothelial function, vasodilatation and myocardial perfusion.11 recently, there are studies about eecp therapy in patients with heart failure, which demonstrate that the therapy is beneficial in improving exercise capacity, quality of life and functional status with a small number of side effects. a study by michaels et al evaluated the advantages of eecp on aortic, intracoronary and left ventricular hemodynamic with left heart catheterization. the study concludes that eecp has the same effect with iabp. eecp has also been known as a procedure to increase venous return and contributes to increased cardiac output without any increase in heart rate. michael et al found that increased preload during eecp has a balance effect on reduced afterload, which gives neutral effect on myocardial efficiency.18 masuda et al19 demonstrate that eecp may induce the release of angiogenesis factors. anp and bnp levels were found lower after eecp therapy and no (nitrite oxide) level was higher during rest. masuda et al19 show that there is improved coronary vasodilatation and myocardial perfusion following the eecp therapy. the peech (prospective evaluation of eecp in heart failure) study in patients with heart failure (class ii and iii nyha classification) indicate that eecp therapy can increase exercise duration, improve nyha functional status and quality of life.16 results of “must-eecp” (multicenter study of enhanced external counterpulsation) show that eecp therapy is safe and effective for patients with chronic heart failure.20 in our study, six-minute walking test performed in all patients after they completed the eecp/ sham eecp treatment. the six-minute walking test is an indicator and predictor for health and physical ability status. according to the american thoracic society (ats), six-minute walking test is able to measure various capacity level, such as the capacity of cardiovascular and respiratory system, hemodynamic changes, systemic and peripheral circulation as well as neuromuscular metabolism.21 the six-minute walking test in our study showed high significance difference (table 2 and 3) between eecp group and sham eecp group at the end of our observation (p<0.01). the increased walking distance of six-minute test found in patients who had received routine eecp therapy indicates that there is increased functional capacity. improved functional capacity post-eecp is associated with a significant and persistent increase of exercise capacity through increased oxygen uptake, increased tolerance and better exercise duration.11,15,22 in our study, there were 49 patients (98%) who could have >300 m walking distance following the eecp therapy table 3. comparison of 6 mwt distance between sham eecp group and eecp group before and after eecp therapy variables before after d analysis after before 6 mwt distance, mean (sd) sham group 252.65 (97.55) 243.65 (86.96) -9 (67.68) eecp group 256.88 (85.56) 449.46 (92.08) 192.58 (87.45)* *mann whitney rank test; # p<0.01 vol 47 • number 4 • october 2015 the effect of eecp therapy and improvement of functional capacity in chf 281 compared to those in sham eecp group (32.7%) as seen in table 2. eecp therapy is similar to a physical exercise and gives effects as if we are running since it increases blood flow and shear stress of arterial muscular layer in the lower extremities. continuous movement will increase no release from endothelial cells and produce vasodilatation. increased no release in coronary artery during eecp therapy has been correlated to improve reservoir of coronary blood flow and endothelial function associated with increased myocardial perfusion and exercise tolerance. another study has also demonstrated that eecp therapy increases no release to improve peripheral endothelial function and vasorelaxation of the smooth muscle.23 improved endothelial function is associated with improved heart function and symptoms experienced by the patient.24 increased walking distance in six-minute walking test (>300 m) in eecp group indicates improved functional capacity in patients with heart failure. this result has been proved in our study as seen in table 3. there is improvement of walking distance in eecp group compare with sham group. it was shown that there is a significant difference of delta analysis after and before eecp between two groups. a study by o’connor et al25 for patients with chronic heart failure who also underwent six-minute walking test also demonstrated a great improvement of walking distance after physical exercise in 3-month observation. a number of patients demonstrated peak increase of oxygen uptake.25,26 improved functional capacity as shown by increased walking distance of six-minute walking test is a beneficial eecp effect and it contributes to lower cardiovascular incidence, less recurrent hospitalization and lower mortality rate of patients with chf. this study has limitation due to the fact that some of participants from both groups had to be dropped out of the study. however, despite its limitation, the findings of this study could be generalized for chf patients with nyha class i-ii that can be improved their functional capacity using eecp treatment. conclusion eecp therapy is safe and effective. it brings beneficial effects on improved quality of life in patients with chronic heart failure as demonstrated by increased walking distance in six-minute walking test. acknowledgments we thanks to prof. sarwono waspadji, md, sppd-kemd; inneke sirowanto, md and all jade cardiovascular clinic staff (miss stevi dungir, miss sheren lalenoh, mrs catleen kawulusan, ns asty abubakar, ns stevianty lumombo, ns richo rumfaan, ns susianty mapalulo, ns sukarni areros) for support during the research. references 1. ribeiro acm, mann ge, de meirelles lr, moss mb, matsuura, brunini tmc. the role of exercise on l-arginine nitric oxide pathway in chronic heart failure. open biochem j. 2009;3:55-65. 2. siswanto bb. peramal kematian dan rawat ulang gagal jantung. jakarta: fakultas kedokteran universitas indonesia; 2006. p. 1-2. 3. aukrust p, gullestad l, ueland t, damas j, yndestad a. 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external counterpulsation. circulation. 2002;106:1237-42. 19. masuda d, nohara r, hirai t, et al. enhanced external counterpulsation improved myocardial perfusion and coronary flow reserve in patients with chronic stable angina; evaluation by (13) n-ammonia positron emission tomography. eur heart j. 2001;22:1451-8. 20. arora r, chou t, jain d, et al. the multicenter study of enhanced external counterpulsation (musteecp): effect of eecp on exercised induced myocardial ischemia and angina episodes. jacc. 1999;33(7);1834-40. 21. adnan r, mckellar s, appukutty m, et al. efficacy of six minute walk test on cardiac rehabilitation program. aust j basic appl sci. 2011;5(9):1740-46. 22. przywara-chowaniec b, gawlikowski m, kuczaj a, et al. enhanced external counterpulsation in patients with advanced ischemic cardiomyopathy. acta physica polonica a. 2012;122(5):866-9. 23. nichols ww, estrada jc, braith rw, et al. enhanced external counterpulsation treatment improves arterial wall properties and wave reflection characteristics in patients with refractory angina. j am coll cardiol. 2006;48:1208-14. 24. arora rr, shah ag. the role of enhanced external counterpulsation in the treatment of angina and heart failure. can j cardiol. 2007;23(10):779-81. 25. o’connor cm, whellan dj, lee kl. efficacy and safety of exercise training in patients with chronic heart failure. jama. 2009;301(14):1439-50. 26. abbottsmith cw, chung es, varricchione t, et al. enhanced external counterpulsation improves exercise duration and peak oxygen consumption in older patients with heart failure: a subgroup analysis of the peech trial. chf. 2006;12:307-11. case report 158 acta med indones indones j intern med • vol 51 • number 2 • april 2019 adult-onset still’s disease as a differential diagnosis in prolonged fever: diagnosis and treatment experience felix f. widjaja1, diah martina1, soroy lardo2, suryo a. k. wibowo1 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of internal medicine, indonesia army central hospital gatot soebroto, jakarta, indonesia. corresponding author: suryo anggoro kusumo wibowo, md. division of rheumatology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: dr.suryoipd@gmail.com; felixfw@gmail.com. abstrak adult onset still’s disease merupakan penyakit sistemik jarang yang melibatkan berbagai organ serta menyerupai penyakit lain seperti infeksi, penyakit autoimun dan juga keganasan. diagnosis dan pengobatan belum terlalu baik karena penyakit ini jarang. meskipun demikian, sudah terdapat beberapa kriteria diagnosis yang dapat membantu. kami memaparkan suatu kasus, pria berusia 36 tahun datang dengan demam tinggi terus menerus yang pertama kali dianggap sebagai infeksi. pasien juga mengalami nyeri sendi pergelangan tangan dan lutut unilateral disertai ruam makulopapular. pemeriksaan laboratorium menunjukkan leukosit tinggi dengan hitung jenis netrofil polimorfonuklear tinggi, trombosit tinggi, feritin tinggi, dan berbagai penanda infeksi negatif (antibodi tifoid, prokalsitonin, malaria, kultur darah, kultur urin, igm pneumonia, asto, tes sifilis, antihiv, hbsag, antihcv dan sebagainya). rontgen dada, rontgen sendi, ultrasonografi, dan ekokardiografi menunjukkan hasil normal. pasien ini kemudian didiagnosis adult onset still’s disease dan diberikan metilprednisolon intravena dan demam hilang dalam tiga hari. enam bulan kemudian pasien mengeluhkan nyeri sendi dan diberikan metrotreksat, kemudian nyeri membaik. kata kunci: adult onset still’s disease, demam berkepanjangan, diagnosis, penatalaksanaan. abstract adult onset still’s disease is a rare systemic disease that may involve many organs and may mimick many disease such as infection, autoimmune disease, and also malignancy. the diagnostic approach and treatment strategies have not been well established due to its rarity; however, there are some diagnostic criteria that may help. we present a case of 36-year old man who experienced high prolonged fever which firstly thought as infection. he also had unilateral wrist and knee joint pain and maculopapular rash. laboratory examination showed high leukocytes count with elevated polymorphonuclear neutrophil count, high platelet count, high ferritin levels, and negative results of many infection markers (typhoid antibody, procalcitonin, malaria test, blood culture, urine culture, igm pneumonia, asto, syphilis test, antihiv, hbsag, antihcv, etc). chest x-ray, joint x-ray, ultrasonography, and echocardiography showed normal result. the patient was then diagnosed with adult-onset still’s disease and received intravenous methylprednisolone and the fever was disappeared in 3 days. six months later the arthralgia appeared again, methotrexate was administered and the pain was then relieved. keywords: adult onset still’s disease, prolonged fever, diagnosis, treatment. 159 vol 51 • number 2 • april 2019 adult-onset still’s disease as a differential diagnosis in prolonged fever introduction adult-onset still’s disease (aosd) is a rare rheumatic disease which involves systemic inflammation in young adults.1 the disease may be tricky to diagnose and can be mistakenly thought as infectious disease. fever with high levels of leukocytosis, a hallmark of aosd, may also suggest the diagnosis of infection. therefore, aosd should also be included in the differential diagnosis of prolonged fever or fever of unknown origin.2 aosd is a complex autoinflammatory disorder.3 it could not be included as pure autoinflammatory disease that affect mostly in innate immune system; meanwhile it may be triggered by autoimmune.4 thus, it is not an autoinflammatory nor autoimmune disease, but it has been put in the middle of autoinflammatory and autoimmune disease.3 the difficulty in the diagnosis of aosd may lead to mistreatment and in further context, it can make both patients and physicians become desperate since the true cause of the fever remains unknown due to the wide spectrum of the clinical features.5 the estimated incidence of aosd from the literature ranges from 0.16 to 0.44 per 100,000 persons worldwide.3,6 the main characteristics of aosd are triad of high spiking fever, salmon-colored skin rash, and joint pain.4,5 viral infection may cause similar clinical picture of rash called viral exanthem with different characteristics. hence, aosd is still a diagnosis of exclusion and a definitive diagnosis should only be made after we rule out infection, autoimmune disease, and malignancy.4 in this article, we present a patient with aosd that at first was wrongly thought as typhoid fever. the symptom of arthralgia may disappear by itself and may relapse, which reduces patient’s quality of life. we would also like to share our treatment strategies and good treatment response of our patient. case illustration a 36-year-old man came to our hospital because of fever for a week before hospital admission. he felt higher grade of fever at night with duration of three to five hours and felt better after taking acetaminophen. he also experienced joint pain on his right shoulder and then the pain was spreading to right knee. it was also heavier when the joint was moved. there was no other complaint and the patient had no history of other illness. on physical examination, we found increased body temperature at night and it reached 40°c, but then for the rest of the day the temperature returned to normal. there was no palpable lymph node enlargement . in the affected joint, there was tenderness and limited range of motion with no swollen joint and redness. physical examination of other organs revealed normal results. in the early days of hospital admission, the laboratory examination revealed leukocytosis, high levels of platelet counts, and high levels of erythrocyte sedimentation rate (esr). the liver and renal function as well as glucose levels were normal. examinations on rheumatoid factor, asto, and urinalysis showed normal results. results of radiographic examinations of the chest, left and right knee joint were normal (figure 1). infection was firstly suspected as the source of the fever since the patient had fever accompanied with leukocytosis; however, the source of infection was assumed to be unknown. third-generation of cephalosporin antibiotic was given as empiric treatment along with acetaminophen. figure 1. x-ray examination of thorax and right knee at admission showed no abnormality. on the fourth day, the patient’s leukocyte count was still high, crp levels was high, typhoid antibody test revealed negative results and procalcitonin levels was normal; but the fever still persisted. blood culture was performed and the antibiotic treatment was continued. urinalysis and feces analysis was repeated and 160 felix f. widjaja acta med indones-indones j intern med the results were normal. new rash was found on his back and it was consulted to dermatologist and he was diagnosed as viral exanthema. the patient was given topical corticosteroid. on the seventh day, crp was still high and plaletet count was elevated again. evaluations on the possibility of hepatitis b, hepatitis c, and hiv infection revealed negative results. there was new joint pain on the patient’s left wrist without any visible swollen joint. diclofenac at a dose of 25 mg twice daily was given and the pain was relieved. the rash on his back resolved (figure 2). results of malaria test were also negative. abdominal ultrasonography revealed no abnormality. blood culture showed negative result on ninth day. gamma-glutamyl transpeptidase levels was 140u/l, alt/ast levels were high (425/274 u/l). examinations on ss-a, ss-b, rnp, sm, scl-70, jo 1 also showed negative results. echocardiography was also normal. urine culture also showed negative result. evaluations on anca and igm m. pneumoniae also revealed negative results. in the second month, the patient underwent bone marrow aspiration and showed normal morphologic findings with no suggestive result for any primary marrow disorder. in that center, this patient was treated with low dose corticosteroid but the patients had only consumed it for three months because he felt better and decided to stop the medication himself. fever was only felt once over two months period after the first injection of methylprednisolone was given. table 1 shows results of the laboratory examinations till the second month. in the third month, he started to complain of bilateral wrist joint pain, but the pain had a good response to nsaid treatment. in the sixth month, the patient came back to our center and the pain had got much better, but it still relapsed occasionally. at this time, the laboratory examination revealed following results: leukocyte count of 8990 cells/µl, platelet count of 492000 cells/µl, esr of 34 mm/hour, crp levels of 44.5 mg/l, ferritin levels of 442 ng/ml. the radiographic examination also showed no abnormality (figure 4). considering his condition, methotrexate was given at the dose of 7.5 mg weekly to overcome his joint pain and he had good response to the treatment. after two a b figure 2. rash at the back two days after administration of topical corticosteroid (a). rash completely dissolved after four days administration (b). on the tenth day, there was a new rash on lower trunk (figure 3). after we had ruled out several infections, aosd was suspected. ferritin levels was high (>1200 ng/ml) and ana was negative. serum iron and tibc were normal. thus, we gave intravenous methylprednisolone at the dose of 62.5 mg daily (approximately 1mg/kgbb/day) and we found that the duration of fever was shorter. after three days, the fever disappeared. leukocyte and platelet counts were within normal limit. t h e p a t i e n t t h e n u n d e r w e n t a n o t h e r examination outside of our center for seeking a second opinion. additional laboratory examinations such as syphilis antibody, anti ccp, antibody o tsutsugamushi, igm chingkungunya, and igm leptospira revealed negative results and free t4, tsh were within normal limit. figure 3. salmon skin rash at back thigh. 161 vol 51 • number 2 • april 2019 adult-onset still’s disease as a differential diagnosis in prolonged fever to patients with prolonged fever and fever of unknown origin may help us in considering aosd.2 there are some criteria that can be used to establish the diagnosis of aosd: cush criteria,7 yamaguchi criteria,8 and fautrel criteria.9 the criteria can be seen in table 2. our patient has fulfilled the cush diagnostic criteria of aosd (fever of >39°c, arthralgia, negative rhematoid factor, negative ana, salmoncolored skin rash, and leukocytosis of >15,000 cells/mm3). the later findings of high ast/alt levels may also be ruled in the yamaguchi criteria. although we did not examine glycocylated ferritin levels of our patient, but he also fulfilled the fautrel criteria (major criteria: spiking fever ≥39°c, arthralgia, transient erythema, pmn ≥80%; minor criteria: maculpapular rash, leukocytes >10,000 cells/µl). spiking fever means very high temperature at evening and becomes normal in the morning.10 it is a typical symptom of aosd that had been found in our patient. moreover, the rash found in our patient was transient, which was suggestive of aosd (figure 2).6 our patient also had a unique macular salmon-colored rash, which involved common area (trunk and limbs).3,11 acute rheumatic fever as differential diagnosis should be kept in mind when dealing with patient complaining fever and arthralgia. using the revised jones criteria,12 this patient had fulfilled one major criterion (migratory polyarthralgia) and two minor criteria (fever and abnormality of esr and/or crp). although it often happens in children, but there is a case report of 45-year-old woman with acute rheumatic fever.13 our patient had negative results of asto and blood culture examinations figure 4. x-ray of wrist joint showed no abnormality. table 1. laboratory examination d-1 d-3 d-5 d-7 d-9 d-10 d-15 d-16 d-19 d-40 hb (g/dl) 14.8 12.7 13 12.5 12.2 12.3 12.2 12.9 11.7 leukocyte count (cells/µl) 27420 20440 20760 21060 16940 20490 10080 7130 20300 neutrophil 87% 87% 90% 93% 53% 89% lymphocyte 8% 8% 6% 5% 19% 8% platelet (1000cells/µl) 462 387 410 448 440 437 350 323 640 esr (mm/hour) 92 64 82 100 crp (mg/l) 318 348 47.9 167.5 156.4 pct (ng/ml) 0.24 0.28 0.14 hb: hemoglobin; esr: erythrocyte sedimentation rate; crp: c-reactive protein; pct: procalcitonin; d: day weeks of treatment, the joint pain got better and his ferritin levels became 216 ng/ml with crp levels of 14.7mg/l and esr of 25 mm/hour. discussion aosd mainly occurs in young adults with a peak incidence in subjects at thirties age group as our patient who was at his 41 years of age; however, it also may occur in older age up to 83 years.3 the rare incidence made this disease is often mistakenly regarded as other disease. it has been stated that woman predominates aosd.3,6 there are four clues that can help us in diagnosing the disease: spiking fever, neutrophilic leukocytosis, joint pain, and salmonpink-colored maculopapular rash.6 approach 162 felix f. widjaja acta med indones-indones j intern med and his echocardiography revealed no evidence of carditis. procalcitonin (pct) measurement may help to differentiate bacterial infection. patients with aosd usually have extremely high crp levels and high leukocyte count with low pct, which similar to our findings in our patient. the same features can also be seen in patients with crystal arthritis or in malignancy. in patients with malaria, pct may increase significantly; while in those with tuberculosis, their pct may be normal. unfortunately, endocarditis may also give normal pct value; therefore, normal pct measurement could not be used to exclude acute rheumatic fever, but it can rule out the possibility of systemic bacterial infection.14 high ferritin is also a hallmark for the diagnosis of aosd. it is also suggested for evaluating prolonged fever when there is no clue for specific diagnosis.2 ferritin with a cut-off of five times normal value is suggestive of aosd with specificity (41 to 46%).3 glycocylated ferritin (gf) is said to be more specific; and therefore, fautrel put it as one of the diagnostic criteria. gf ≤ 20% has higher specificity of 64% and when it is combined with hyperferritinemia, the specificity becomes 84%.6 high ferritin is also related with macrophage activation syndrome (mas) associated with aosd; therefore, it should be addressed cautiosly.1 meanwhile, serum vitamin b12 levels may also be a marker for mas in aosd.15 this patient had ferritin levels of at least three times normal limit. such findings may occur due to the limited capacity of the laboratory that could only report result of ferritin levels of more than 1200 ng/ml. unfortunately, the glycocylated ferritin and vitamin b12 levels could not be performed in this patient due to limited facility. patient with higher ferritin has worse prognosis.16 a literature review has suggested that patients with high ferritin levels (20,000 ng/ ml) had worse outcome than those with lower levels (4100 ng/ml); however, it may return to normal levels.5 moreover, ferritin measurement may also be used to monitor treatment response and it may be normal in patients with remission,17 which was shown in this patient, in which he had table 2. some criteria of adult-onset still’s disease criteria cush7 yamaguchi8 fautrel9 major fever >39°c arhtralgias and/or arthritis rf titer <1:80 ana titer <1:100 fever ≥39°c lasting ≥1 week arthralgia lasting ≥2 weeks typical skin rash leukocytosis ≥10,000/mm3 with pmn ≥80% spiking fever ≥39°c arthralgia transient erythema pharyngitis pmn ≥ 80% glycocylated ferritin ≤20% minor leukocytosis (>15,000 cells/mm3) juvenile rheumatoid arthritis rash serositis (pleuritis or pericarditis) evidence of res involvement pharyngitis or sore throat liver enzyme abnormalities (aminotransferase) negative for rf or ana maculopapular rash leukocytosis ≥10,000/mm3 exclusion criteria none absence of infection, especially sepsis and epstein-barr viral infection absence of malignant diseases, especially lymphomas absence of inflammatory disease, especially polyarteritis nodosa none diagnosis four major criteria with two minor criteria at least five criteria, including two major criteria and no exclusion criteria four major criteria or three major and two minor criteria sensitivity none 96.2% 80.6% specificity none 92.1% 98.5% rf: rheumatoid factor; ana: antinuclear antibody; res: reticuloendothelial system (hepatomegaly, splenomegaly, generalized lymphadenopathy); pmn: polymorphonuclear neutrophil; typical rash: maculopapular, non-pruritic, salmonpink rash with concomitant fever spikes 163 vol 51 • number 2 • april 2019 adult-onset still’s disease as a differential diagnosis in prolonged fever lower ferritin when the fever subsided. since the diagnosis of aosd should be made by exclusion, 18f-fdg pet/ct, pet scanner may aid the diagnosis to exclude lymphoma, tuberculosis, or sarcoidosis and increased uptake is found in patients with arthritis.18 unfortunately, pet scan was not performed to this patient due to limited facilities. aosd may be treated with aspirin, nsaids, corticosteroids, dmards (methrotrexate, azathrioprine, naproxen, mycofenolate mofetyl, intravenous immunoglobulin), biologic agents (tnf-inhibitor (infliximab, etanercept), anti b-cell agents, il-1 receptor antagonist (anankira), anti-il-6 receptor monoclonal antibody.17 several reviews have recommended that the main treatment of aosd is corticosteroid.3,6,19 the dose should be at 0.5-1mg/kg/day and intravenous administration will give quick result within a couple of hours or a few days.3,6 in this patient, the fever resolved only in three days after corticosteroid treatment had been initiated. the treatment should be given at the dose of 0.5-1mg/ kg/day for 4 to 6 weeks and then tappered off.3 unfortunately, this patients did not comply with the prescription. three months after stopping corticosteroid treatment, he felt a joint pain again and when he got back to our center, corticosteroid was given for the induction again plus low dose of methrotrexate as the second line treatment.6 as the patient got another joint pain, dmard may be used for refractory period in addition to the combination of nsaids and prednisone. it was used to suppress joint destruction and methotrexate at the dose of 7.5 mg/week could lower the use of steroid, which provides successful outcome for at least a year.17 methotrexate also works systemically as aosd is a systemic disease. another study has reported that methotrexate at the dose of 7.5 to 17.5 mg/week can control aosd in more than 60% patients who are steroid-dependent. the presence of abnormal liver enyzme levels should not be a contraindication for methotrexate treatment, but the patients should be monitored closely.3 another dmards that may be used in aosd, but with lower success are cyclosporine a, hydroxychloroquine, azathioprine, cyclophosphamide, penicillamine, and gold.17 biological agents may become an option for refractory aosd.4,6,17,19 unfortunately, there is no uniform definition for refractory aosd; therefore, when considering biological agents, the treatment should be individualized for each patient and depends on clinical experience of each center. conclusion aosd is a rare rheumatic disease with the triad classical symptoms of high-spiking fever, salmon-colored skin rash, and joint pain. aosd should be considered in the differential diagnosis of prolonged fever or fever of unknown origin. the diagnosis is mainly diagnosis of exclusion; however, high ferritin levels may aid the diagnosis. the treatment is mainly steroid and dmard, as well as methotrexate whenever necessary. references 1. ruscitti p, cipriani p, di benedetto p, et al. increased levels of h-ferritin and its imbalance with l-ferritin, in bone marrow and liver of patients with adult onset still’s disease, developing macrophage activation syndrome, correlate with the severity of the disease. autoimmun rev. 2015;14:429-37. 2. hersch ec, oh rc. prolonged febrile illness and fever of unknown origin in adults. am fam physician. 2014;90:91-6. 3. gerfaud-valentin m, jamilloux y, iwaz j, seve p. adult-onset still’s disease. autoimmun rev. 2014;13:708-22. 4. maria at, le quellec a, jorgensen c, touitou i, riviere s, guilpain p. adult onset still’s disease (aosd) in the era of biologic therapies: dichotomous view for cytokine and clinical expressions. autoimmun rev. 2014;13:1149-59. 5. narula n, narula t, abril a. seizing the clinical presentation in adult onset still’s disease. an extensive literature review. autoimmun rev. 2015;14:472-7. 6. fautrel b. adult-onset still disease. best pract res clin rheumatol. 2008;22:773-92. 7. cush jj, medsger ta, jr., christy wc, herbert dc, cooperstein la. adult-onset still’s disease. clinical course and outcome. arthritis rheum. 1987;30:186-94. 8. yamaguchi m, ohta a, tsunematsu t, et al. preliminary criteria for classification of adult still’s disease. j rheumatol. 1992;19:424-30. 9. fautrel b, zing e, golmard jl, et al. proposal for a new set of classification criteria for adult-onset still disease. medicine (baltimore). 2002;81:194-200. 164 felix f. widjaja acta med indones-indones j intern med 10. bywaters eg. still’s disease in the adult. ann rheum dis. 1971;30:121-33. 11. mahroum n, mahagna h, amital h. diagnosis and classification of adult still’s disease. j autoimmun. 2014;48-49:34-7. 12. gewitz mh, baltimore rs, tani ly, et al. revision of the jones criteria for the diagnosis of acute rheumatic fever in the era of doppler echocardiography: a scientific statement from the american heart association. circulation. 2015;131:1806-18. 13. oba y, watanabe h, nishimura y, et al. a case of adult-onset acute rheumatic fever with longlasting atrioventricular block requiring permanent pacemaker implantation. int heart j. 2015;56:664-7. 14. delevaux i, andre m, colombier m, et al. can procalcitonin measurement help in differentiating between bacterial infection and other kinds of inflammatory processes? ann rheum dis. 2003;62:33740. 15. kalyoncu u, buyukasik y, akdogan a, et al. increased serum vitamin b12 levels are associated with adultonset still’s disease with reactive macrophage activation syndrome. joint bone spine. 2010;77:131-4. 16. colina m, zucchini w, ciancio g, orzincolo c, trotta f, govoni m. the evolution of adult-onset still disease: an observational and comparative study in a cohort of 76 italian patients. semin arthritis rheum. 2011;41:279-85. 17. efthimiou p, georgy s. pathogenesis and management of adult-onset still’s disease. semin arthritis rheum. 2006;36:144-52. 18. roy sg, karunanithi s, dhull vs, bal c, kumar r. (1)(8)f-fdg pet/ct aids the diagnosis of adult onset still’s disease in a patient with fever of unknown origin. rev esp med nucl imagen mol. 2014;33:392-3. 19. pouchot j, arlet jb. biological treatment in adultonset still’s disease. best pract res clin rheumatol. 2012;26:477-87. 184 original article acta medica indonesiana the indonesian journal of internal medicine effects of pipemidic acid, phenazopyridine hcl and sodium diclofenac on pain perception following endoscopic urological surgery: double-blinded randomized-controlled trial prahara yuri1, zulfikar ali2, nur rasyid1, ponco birowo1 1 department of surgery, faculty of medicine universitas indonesia, jakarta, indonesia. 2 department of surgery, kardinah hospital, tegal, central java, indonesia. corresponding author: ponco birowo, md, phd. division of urology, department of surgery, faculty of medicine universitas indonesia. jl. diponegoro no. 71, jakarta 10430, indonesia. email: ponco.birowo@gmail.com. abstrak tujuan: untuk mengevaluasi efek analgesik, efek samping, dan keamanan dari obat setelah prosedur endoskopi di bidang urologi. metode: 80 pasien yang menjalani operasi endoskopi di rumah sakit kardinah, tegal sejak juni sampai juli 2015 dibagi jadi empat kelompok. kelompok eksperimental diberikan analgesik selama 4 hari, (a) asam pipemidat 400 mg bid, atau (b) phenazopyridine 200 mb tid, atau (c) diklofenak 50 mg bid, dan (d) plasebo tid. efek analgesik dinilai dengan visual analog scale (vas). hubungan antar variabel dinilai dengan menggunakan cramers v dan kruskall wallis. hasil: prosedur endoskopi urologi terdiri dari 30 pasien menjalani urs, 6 pasien litotripsi, 17 pasien turp, 24 pasien pengangkatan dj stent, dan 3 pasien sistoskopi. rerata usia kelompok a, b, c, dan d adalah 50.1 (13.7), 50.7 (14.8), 49.1 (13.4), dan 49.6 (14.3) tahun, dan rerata lama followup adalah 7 hari. nilai vas dari seluruh kelompok eksperimental lebih rendah dari kelompok kontrol pada hari pertama sampai hari ke tujuh setelah prosedur endoskopi (p<0.05). pada kelompok eksperimental, tidak terdapat perbedaan antara kelompok b dan c (p>0.05). kelompok a memperlihatkan efek analgesik yang lebih baik daripada b dan c (p<0.05). tidak didapatkan efek samping yang serius pada seluruh kasus. kesimpulan: penggunaan analgesik oral efektif untuk meredakan nyeri setelah operasi endoskopi di bidang urologi. asam pipemidat memiliki efek analgesik yang superior. kata kunci: asam pipemidat, phenazopyridine, diklofenak, endoskopik , visual analog scale. abstract aim: to evaluate the analgesic effect, the side effects and the safety of analgesics following endoscopic urological procedure. methods: eighty patients who underwent endoscopic urological surgery at kardinah hospital, tegal from june to july 2015 were divided into four groups. the experimental group was administered analgesic for 4 days pipemidic acid (a) 400 mg bid, or phenazopyridine (b) 200 mg tid, or sodium diclofenac (c) 50 mg bid and the control (d) group was administered placebo tid for 4 days. the analgesic effects were assessed using visual analog scale (vas). association between variables was assessed using cramers v and kruskall wallis. results: the endoscopic urological procedures consisted of 30 patients for urs, 6 patients for lithotripsy, 17 patients for turp, 24 patients for removal jj stent and 3 patients for cystoscopy. the mean age of group a, b, c and d (control) was 50.1 (13.7), 50.7 (14.8), 49.1 (13.4), and 49.6 (14.3) years, respectively, and follow-up period was 7 days. the vas score in all experimental groups was less than control group on day 1 to 7 following endoscopic urological procedures (p<0.05). in the experimental group, there was no vol 48 • number 3 • july 2016 effects of pipemidic acid, phenazopyridine hcl and sodium diclofenac 185 difference between groups b and c (p>0.05). group a demonstrated a more favourable analgesic effect than b and c (p<0.05). no serious side effects were detected in any of the cases. conclusion: we conclude that oral analgesics are effective for pain relief following endoscopic urological surgery. pipemidic acid was found to have a superior analgesic effect than phenazopyridine hcl and sodium diclofenac. keywords: pipemidic acid, phenazopyridine, sodium diclofenac, endoscopic urology, visual analog scale. introduction pain is a common symptom following endoscopic urological surgery, and the need for effective pain management is a major concern. in general, regional or local anaesthesia demonstrates distinct advantages and disadvantages in terms of postoperative morbidity.1,2 therefore, general or regional anesthesia has been replaced by opioids, sedatives, non-steroidal anti-inflammatory drugs (nsiads), and topical anesthetics for pain management.3,4 the ideal postoperative analgesic treatment should provide rapid and effective pain relief, offer a low incidence of adverse effects and result in a minimal impact on organ systems with no significant interaction with other pharmacological agents.1 the mechanism of acute pain following endoscopic urological surgery remains unclear. acute postoperative pain is mainly associated with the operation itself and the duration of operation time.5 until now, many urologists have not yet studied the outcome of acute post-operative pain which the patients perceive as a serious problem and which accompanies most postoperative complications.5 in addition to nsaids, there are several drugs known as anti-microbial and uroseptic that have an analgesic effect, such as phenazopyridine hcl and pipemidic acid.6–8 based on the degree of pain, urological procedures, such as extracorporeal shock wave lithotripsy (eswl), endoscopic urological surgery (transurethral, endoscopic percutaneous) and trans-vaginal surgery are still included in the category of mild pain following surgery.9 phenazopyridine relieves pain associated with bladder spasms and postoperative ureteral stent or in-dwelling urinary catheter discomfort.4,6 pipemidic acid is an anti-microbial group that is used as a urinary antiseptic and reduces pain caused by an acute tract infection.7,10,11 the analgesic effect of pipemidic acid following endoscopic urological surgery is controversial and, to date, there are no relevant study reports to support the claim. the analgesic effect might be caused by optimization of a pipemidic acid autotaxin inhibitor.12–15 non-steroidal antiinflammatory drugs (nsaids) are commonly used for their potent antipyretic and analgesic effects. these drugs reduce pain following surgery by preventing synthesis and release of prostaglandins at the site of surgical trauma by inhibition of cyclo-oxygenase-2 (cox-2).1 the clinical indication and analgetic effect of pipemidic acid, phenazopyridine and sodium dicofenac remain unclear. the purpose of this prospective, randomized study was to compare the effectiveness of analgesia and side-effects of pipemidic acid, phenazopyridine hcl and sodium diclofenac for postoperative analgesia following endoscopic urological surgery. methods study design this study was a prospective, randomized, double-blind, placebo-controlled trial. the study compared the analgesic effects following endoscopic urological surgery. pain perception was assessed from the first day until the seventh day following surgery. analgesic drugs were administered for 4 days following surgery. the analgesic effects were assessed using the visual analog scale (vas). the eligibility criteria of subject was age ≥17 years old who underwent endoscopic urological surgery, such as transurethral resection transurethral of prostate (turp), ureterorenoscopy (urs), lithotripsy of bladder stone, removal double-j stent and cystoscopy. no history was presented of psychotic mental illness, organic psychiatric conditions and other mental illnesses, of severe pain-induced illnesses and malignancy. the prahara yuri acta med indones-indones j intern med 186 patient underwent open surgery conversion after exclusion of endoscopic urological surgery. the study was initiated after obtaining the approval of the institutional ethics committee kardinah hospital. ref: 071/008/2015. intervention the patients who underwent endoscopic urological surgery (transurethral resection of prostate (turp), lithotripsy of bladder stone, ureterorenoscopy (urs), removal jj stent and cystoscopy) at kardinah hospital, tegal from june 2015 to july 2015 were divided into four groups. the experimental groups (a, b and c) consisted of 20 patients in each group while the control group (d) consisted of 20 patients. the experimental group was administered antibiotics, anticoagulant and analgetic medication. in group a, patients were administered pipemidic acid 400 mg bid for 4 days. in group b, patients were administered phenazopyridine 200 mg tid for 4 days. in group c, 50 mg of sodium diclofenac was applied twice a day for 4 days. control group d was administered antibiotics, anticoagulant and placebo medication tid for 4 days. all groups were randomized by block random system. all patients were remained consistant for the duration of this study. the analgesic effects were assessed using the visual analog scale (vas). statistical analysis age, gender, day of catheterization, operation time, hospitalization, patient satisfaction, adverse events, patient complaints and vas scale for each patient were recorded. statistical analysis was recorded using one way anova, kruskal wallis; cramers v, mann u whitney, and results were compared between the four groups. a p value of less than 0.05 was considered to be statistically significant. results patients characteristics are summarized in table 1. the average age of the 80 patients (50 males and 30 females) was 49.9 (13.8) years old. the endoscopic urological procedures included 30 patients for urs, 6 patients for lithotripsy of bladder stone, 17 patients for turp, 24 patients for removal jj stent and 3 patients for cystoscopy. (figure 1) the overall postoperative vas scale following endoscopic urological surgery was summarized in table 2 and 3. table 1. subject’s characteristics variables overall pipemidic acid phenazopyridine hcl sodium diclofenac placebo age, mean (sd) 49.9 (13.8) 50.1 (13.7) 50.7 (14.8) 49.1 (13.4) 49.6 (14.3) day(s) of catheterization, mean (sd) 1.4 (1.5) 1.3 (1.5) 1.4 (1.5) 1.5 (1.5) 1.4 (1.5) operation time, mean (sd) 33.5 (21.6) 33.3 (25) 35.1 (21.2) 34 (21) 31.5 (20.1) hospitalization, mean (sd) 1.5 (1.5) 1.4 (1.5) 1.5 (1.7) 1.6 (1.5) 1.5 (1.5) diagnosis, n (%) ureteral stone 29 (36.3) 7 (35) 7 (35) 8 (40) 7 (35) ureteral stenosis 1 (1.3) 0 (0) 1 (5) 0 (0) 0 (0) bladder stone 6 (7.5) 2 (10) 1 (5) 1 (5) 1 (5) benign prostate hyperplasia (bph) 17 (21.3) 4 (20) 4 (20) 5 (25) 4 (20) jj stent in situ 24 (30) 7 (35) 6 (30) 5 (25) 6 (30) voiding dysfunction 3 (3.8) 0 (0) 1 (5) 1 (5) 1 (5) gender, n (%) male 50 (62.5) 12 (60) 11 (55) 14 (70) 13 (65) female 30 (37.5) 8 (40) 9 (45) 6 (30) 7 (35) vol 48 • number 3 • july 2016 effects of pipemidic acid, phenazopyridine hcl and sodium diclofenac 187 table 1. subject’s characteristics variables overall pipemidic acid phenazopyridine hcl sodium diclofenac placebo management, n (%) urs/lithotripsy 36 (45) 9 (45) 9 (45) 9 (45) 9 (45) turp 17 (21.3) 4 (20) 4 (20) 5 (25) 4 (20) dj stent removal/ cystoscopy 27 (33.7) 7 (35) 7 (35) 6 (30) 7 (35) catheterization, n (%) yes 56 (70) 13 (65) 14 (70) 15 (75) 14 (70) no 24 (30) 7 (35) 6 (30) 5 (25) 6 (30) jj stent insertion, n (%) yes 14 (17.5) 3 (15) 3 (15) 4 (20) 4 (20) no 66 (82.5) 17 (85) 17 (85) 16 (20) 16 (20) patient satisfaction, n (%) yes 69 (86.3) 20 (100) 19 (95) 18 (90) 13 (65) no 11 (13.7) 0 (0) 1 (5) 2 (10) 7 (35) urinalysis, mean (sd) ph 5.9 (0.8) 5.8 (0.7) 5.8 (0.7) 6.3 (0.9) 6 (0.6) specific gravity 1.01 (0.007) 1.013 (0.006) 1.015 (0.008) 1.016 (0.008) 1.015 (0.007) erithrocituria, n (%) yes 58 (72.5) 14 (70) 13 (65) 16 (80) 15 (75) no 22 (27.5) 6 (30) 7 (35) 4 (20) 5 (25) leucocyturia, n (%) yes 63 (78.8) 17 (85) 17 (85) 14 (70) 15 (75) no 17 (21.2) 3 (15) 3 (15) 6 (30) 5 (25) 80 patients who underwent endoscopic urology surgery (30 patients urs, 6 patients lithotripsy, 17 patients turp, 24 patients removal jj stent and 3 patients cystoscopy). randomization, double blind 20 were assigned to be grup a (sodium diclofecnac 50 mg bid) no lost follow 20 were included in analysis 20 were assigned to be grup b (pipemidic acid 400 mg bid) no lost follow 20 were included in analysis 20 were assigned to be grup c (phenazopyri dine hcl 200 mg tid) no lost follow up 20 were included in analysis 20 were assigned to be grup a (placebo tid) no lost follow up 20 were included in analysis figure 1. consort flow diagram of the current randomized controlled trial prahara yuri acta med indones-indones j intern med 188 the comparison of median age of groups 1, 2, 3 and 4 were 50.1, 50.7, 49.1 and 49.6 years, respectively, compared with 44.98 years in group 2 (p=0.05). leukocyturia was found in 17 patients in group 1, 17 patients in group 2, 14 patients in group 3 and 15 patients in group 4 (p=0.57). the most common diagnosis was ureteral stones in 29 patients. catheterization and double-j stent insertion were undertaken in 56 and 14 patients, respectively. decrease of vas scale following endoscopic urological surgery was statistically significant from day one until day seven (p<0.05). however, if we compare the various methods of endoscopic urological surgery, the decrease of vas scale was only statistically significant on day one (p=0.014), but not statistically significant during the other days (p>0.05). in the experimental group, there was no difference between group b and c (p>0.05). group a demonstrated a better analgesic effect than b and c (p<0.05). (table 5 and figure 2) no serious side effects were detected in any of the cases (table 4). eleven patients complained of severe acute postoperative pain with vas 7-10 (one patient in group 1, 3 patients in group 2, 3 patients in group 3 and 4 patients in group 4). this was optimally controlled with ketoprofen 50 mg suppositories of non-steroidal anti-inflammatory drugs (nsaids). discussion major advancements have been made in recent times in urological treatments which constituted the majority of urological conditions. in the past, treatment involved mainly invasive procedures. in recent years, non-invasive procedures, such as endourological surgery, have been made available.5 pain management is a common and complex issue for the urologist. unrelieved pain is a major medical problem. in the end of the 1990s, the physiological and psychological consequences of acute and chronic pain became well-recognized16, and pain management during transurethral procedures is now well established.1,2 however, many urologists have not yet studied the relief of acute postoperative pain following endoscopic table 2. postoperative vas score for all endoscopic urological surgeries post operative overall, mean (sd) pipemidic acid, mean (sd) phenazopyridine hcl, mean (sd) sodium diclofenac, mean (sd) placebo, mean (sd) p value day 1 5.3 (2.6) 3.2 (1.8) 5.9 (2.2) 5.4 (2.8) 6.7 (2.2) <0.001 day 2 4.1 (2.2) 2.5 (1.8) 4.4 (1.4) 4.0 (2.5) 5.6 91.9) <0.001 day 3 3.0 (1.9) 1.6 (1.6) 3.2 (1.2) 3.0 (2.2) 4.4 (1.7) <0.001 day 4 2.4 (1.9) 1.3 (1.5) 2.4 (1.6) 2.5 (1.9) 3.6 (1.7) 0.001 day 5 1.9 (2.0) 0.9 (1.4) 2.1 (1.8) 2.4 (2.5) 2.7 (1.9) 0.013 day 6 1.6 (1.9) 0.5 (0.8) 1.8 (1.8) 2.0 (2.5) 2.1 (1.9) 0.014 day 7 1.3 (1.8) 0.3 (2.5) 1.5 (1.5) 1.6 (2.5) 1.8 (1.8) 0.006 table 3. postoperative vas score based on endoscopic urological surgery postoperative turp urs/lithotripsy dj stent removal/cystoscopy p day 1 6.9 (2.5) 5.1 (2.4) 4.5 (2.6) 0.014 day 2 4.7 (2.2) 4.4 (2.3) 3.4 (2.0) 0.134 day 3 3.5 (1.8) 3.3 (1.9) 2.4 (1.9) 0.162 day 4 2.4 (1.4) 2.8 (1.9) 1.9 (1.9) 0.241 day 5 2.0 (1.7) 2.3 (2.2) 1.6 (1.9) 0.318 day 6 1.8 (1.6) 1.8 (2.1) 1.2 (2.0) 0.242 day 7 1.1 (1.4) 1.5 (1.8) 1.2 (2.0) 0.566 vol 48 • number 3 • july 2016 effects of pipemidic acid, phenazopyridine hcl and sodium diclofenac 189 table 4. most frequent adverse events and patient complaints overall pipemidic acid phenazopyridine hcl sodium diclofenac placebo additional analgetic, n (%) 11 (13.8) 1 (5) 3 (15) 3 (15) 4 (20) fever, n (%) 5 (6.3) 1 (5) 1 (5) 1 (5) 2 (10) nausea, n (%) 24 (30) 4 (20) 6 (30) 6 (30) 8 (40) vomitus, n (%) 6 (7.5) 0 (0) 1 (5) 2 (10) 3 (15) abdominal discomfort, n (%) 14 (17.5) 0 (0) 4 (20) 3 (15) 7 (35) skin rash, n (%) 1 (1.3) 0 (0) 0 (0) 0 (0) 1 (5) table 5. post hoc analysis p value for vas score day 1 day 2 day 3 day 4 day 5 day 6 day 7 pipemidic acid phenazopyridine hcl <0.001 0.001 0.003 0.031 0.017 0.011 0.002 sodium diclofenac 0.01 0.046 0.036 0.039 0.018 0.023 0.042 placebo <0.001 <0.001 <0.001 <0.001 0.002 0.001 0.001 phenazopyridine hcl sodium diclofenac 0.415 0.592 0.782 1 0.923 0.966 0.53 placebo 0.198 0.044 0.012 0.022 0.275 0.526 0.571 sodium diclofenac placebo 0.103 0.044 0.035 0.049 0.481 0.529 0.299 � overall � pipemidic acid phenazopyridine hcl sodium diclofenac placebo � � � figure 1. pain scale changes on the visual analog scale (vas) – (p<0.05) urological surgery. the goal of pain management after endoscopic treatments is to relieve pain and, keep the side effects to a minimum at the same time.17 pain induced by endoscopic treatments is not the result of tissue injury alone and indeed has no significant effect. cystoscopy usually causes pain due to preoperative anxiety and postoperative patients often suffer a urinary tract irritation following surgery.4 however, in tur-p, the resected adenoma cannot be rationally associated with pain induction, since the major causes of tur-p pain are bladder spasms, catheter-related pain and capsule offense.1,6 an in-dwelling prahara yuri acta med indones-indones j intern med 190 urinary catheter is a foreign body positioned in the bladder and can often cause severe pain and discomfort and impair the quality of life of the patient. the presence of a urinary catheter can trigger the bladder muscle to go into spasm in an effort to expel the catheter. this spasm leads to cramping lower abdominal pain. the placement of ureteral stent following ureteroscopy remains a common practice. stents have been routinely placed to facilitate passage of residual stone fragments, prevent ureteral stricture formation and renal colic secondary to ureteral edema. unfortunately, ureteral stenting continues to result in significant patient morbidity, including flank pain, lower abdominal or loin discomfort, urinary urgency, urinary frequency, hematuria, infection, encrustation and migration. it has been reported that 38% to 80% of patients experience stent-related symptoms. to address this problem, modifications in ureteral stent design have been used, including self-retaining designs, softer biomaterials, dual durometer stents, reduced caliber configurations, biostable materials and biodegradable stents.18 postoperative ureteral stent discomfort may be resolved by these modifications.6 current approaches for the management of catheterization/ureteral, stent-related pain/ discomfort include the use of non-steroidal anti-inflammatory medications, oral narcotics, oral anticholinergic medications (oxybutynin or tolterodine), drug-eluting/coated stents, and/ or oral local anesthetics (phenazopyridine). the efficacy of these medications in the treatment of pain/discomfort needs to be clarified and they are prescribed based mainly on intuition and assumption of good clinical practice.18 the analgesic effect of pipemidic acid still requires further clarification and remains a controversial matter. no study to date has compared the analgesic effect of pipemidic acid, phenazopyridin and nsaid following endoscopic urological treatments. the clinical indication of phenazopyridine remains unclear. it has been used clinically in conditions with increased bladder sensation, such as cystitis and bladder pain syndrome/interstitial cystitis. phenazopyridine (2,6-diamino-3[phenyl-azo]pyridine) hydrochloride has been used clinically as a local anesthetic/analgesic to provide symptomatic relief of pain in certain conditions, such as cystitis and urethritis. in addition, this drug is being used as a therapeutic option in patients with chronic bladder pain syndrome/interstitial cystitis (bps/ic), and also hydrodistention, amitriptyline or pentosan polysulfate sodium. but there is little information available to date on the mode of action of the drug, i.e. influence to the sensory mechanisms, which have been referred to in the afferent functions in the rat.19 phenazopyridine hcl is effective for early acute pain relief following cystoscopy4, management of postoperative ureteral stent discomfort,6,18 and catheterization discomfort.6 nsaids for analgesia after surgery is a controversial matter, due to increased risk of post-operative bleeding by inhibition of the other isoforms of cyclo-oxygenase, causing antiplatelet activity.1 diclofenac sodium is an nsaid. nsaids are effective analgesics without the undesirable side effects associated with opioids, such as sedation, respiratory depression, nausea and vomiting. they inhibit the synthesis and the release of prostaglandins at the site of surgical trauma by inhibition of cyclo-oxygenase-2 (cox-2), which responsible for pain, fever and vasodilatation in response to trauma.17 nsaids are known to decrease the incidence of bladder spasms through the reduction of the amount of prostaglandins released. moreover, nsaids may help reduce postoperative edema, resulting in successful early catheter removal.1 in a further study, non-steroidal anti-inflammatory drugs have demonstrated strong antimicrobial properties when tested against a large number of gram-positive and gram-negative bacteria. the mic range was from 50-200 ìg/ml in most of the cases and recorded even lower in some instances. diclofenac is suggested to possess the capacity to treat urinary tract infections caused by drug-resistant e. coli strains.20 p i p e m i d i c a c i d ( h p pa ) , 8 e t h y l 5 , 8-dihydro-5-oxo-2-(1-piperazinyl)-pyrido[2,3-d] pyrimidine-6carboxylic acid, is a therapeutic agent for urinary tract infections due to its antibacterial activity against gram-negative, and some gram-positive bacteria.7,8,10,11,13,21 the vol 48 • number 3 • july 2016 effects of pipemidic acid, phenazopyridine hcl and sodium diclofenac 191 analgesic effect of pipemidic acid remains unclear and association with optimalization of pipemidic acid autotaxin inhibitor has been reported.12 the ectoenzyme autotaxin (atx) possesses lysophospholipase d phosphodiesterase and, to a lesser extent, nucleotide pyrophosphatase activities. in 1992, the atx protein was purified and characterized from melanoma cell-conditioned medium, after which it was assigned to the nucleotide pyrophosphatase phosphodiesterase subfamily of alkaline phosphatases based on sequence homology.22 subsequently, atx was shown to be the lysophospholipase d enzyme responsible for synthesis of the bioactive lipid lysophosphatidic acid (lpa) in vivo.12 recent work has shown that atx plays a critical role in normal human development and disease. atx has been linked to cancer progression, multiple sclerosis, obesity, diabetes, alzheimer’s disease and chronic pain through the production of lpa.12,22 one study reports a convenient diversification strategy to generate structure-activity relationship (sar) data in the hope of better understanding atx inhibitor recognition, and in identifying more potent analogs. in this study, the derivatization of pipemidic acid with commercially available isothiocyanate building blocks was identified as a facile route to a range of analogs of compound 1 bearing various substituents on the phenylthiourea motif.12 lysophosphatidylcholine (lpc, lysolecithin) is an important cell signaling molecule among lysophospholipids. it is a major plasma lipid component that transports fatty acids and choline to tissues, and is produced under physiological and pathological conditions.14 recent reports suggest that lpc modulates pain signaling. lpc treatment of the aphenous or sciatic nerve– induced neuropathic pain, such as mechanical allodynia and thermal hyperalgesia, as well as demyelination and up-regulation of pain-related proteins in the dorsal root ganglion (drg). however, the molecular mechanisms underlying lpc-induced neuropathic pain-like symptoms remain to be determined.15 more recently, a study reported that intrathecal (i.t.) injection of lysophosphatidic acid (lpa) induces mechanical allodynia and thermal hyperalgesia, as well as demyelination of dorsal root and upregulation of pain-related proteins in the drg and spinal cord via the lpa1 receptor.14 autotaxin (atx), is responsible for the conversion of lpc to lpa, and is abundantly expressed in central and peripheral nerve tissues, especially in cerebrospinal fluids.14,15,23 this study had several limitations. first, this study had fewer sample in randomization and the study population was limited in rural hospital in central java. further research is necessary to develop medications, improve design or modifications in surgical techniques that may effectively treat and/or prevent painrelated endoscopic treatment. this investigation provides a sound foundation for future studies to assess the ability of oral agents to reduce pain following endoscopic urological surgery. conclusion the study suggests that pipemidic acid, phenazopyridine hcl and sodium diclofenac, as oral analgesics, have been proven effective for pain relief following endoscopic urological surgery without inducing any side effects. pipemidic acid has been found to have more superior analgesic effect than phenazopyridine hcl and sodium diclofenac. references 1. kara c, resorlu b, cicekbilek i, et al. analgesic efficacy and safety of nonsteroidal anti-inflammatory drugs after transurethral resection of prostate. int braz j urol. 2010;36(1):49–54. 2. tyritzis si, stravodimos kg, vasileiou i, et al. spinal versus general anaesthesia in postoperative pain management during transurethral procedures. isrn urol. 2011;1–6. 3. liu j, zang y-j. comparative study between three analgesic agents for the pain management during extracorporeal shock wave lithotripsy. urol j. 2013;10(3):942–5. 4. kim tn, chung mk. a randomized, prospective, p l a c e b o / c o n t r o l l e d s t u d y f o r t h e e f f e c t o f phenazopyridine hcl on pain perception following cystoscopy. korean j urol. 2006;47(1):97–100. 5. ahn st, kim jh, park jy, et al. acute postoperative pain after ureteroscopic removal of stone: incidence and risk factors. korean j urol. 2012;53(1):34–9. 6. gupta, op, aggarwal k. role of phenazopyridine in urinary tract infections. indian j clin pract. 2012;22(9):437–42. prahara yuri acta med indones-indones j intern med 192 7. meyer ec, schoeman hs. a comparative study of pipemidic acid and nitrofurantoin in the treatment of uncomplicated urinary tract infections. south african med j. 1987;72:663–5. 8. shimizu m, nakamura s, takase y, et al. pipemidic acid: absorption, distribution, and excretion. antimicrobial agents chemother. 1975;7(4):441–6. 9. borda ap, fonteyne v, papaioannou eg. pain management and palliative care. eur assoc urol guidel. 2014;1–95. 10. kamran ma, ali s, khattak kn. therapeutic evaluation of pipemidic acid (r-urexin) in urinary tract infection. a preliminary report. j pak med assoc. 1984;34(8):235–8. 11. shimizu m, takase y, nakamura s, et al. pipemidic acid : its activities against various experimental infections. antimicroblal agents chemother. 1976;9(4):569–74. 12. hoeglund ab, bostic he, howard al, et al. optimization of a pipemidic acid autotaxin inhibitor. j med chem. 2010;53(3):1056–66. 13. iacovino r, rapuano f, caso jv, et al. β-cyclodextrin inclusion complex to improve physicochemical properties of pipemidic acid: characterization and bioactivity evaluation. int j mol sci. 2013;14(7):13022– 41. 14. i n o u e m , x i e w, m a t s u s h i t a y, e t a l . lysophosphatidylcholine induces neuropathic pain through an action of autotaxin to generate lysophosphatidic acid. neuroscience. 2008;152(2):296– 8. 15. inoue m, ma l, aoki j, et al. autotaxin, a synthetic enzyme of lysophosphatidic acid (lpa), mediates the induction of nerve-injured neuropathic pain. mol pain. 2008;4:6. 16. pace j, jaeger m, nickel jc, et al. pain management in urology training : a national survey of senior residents. can urol assoc j. 2013;7(11-12):456–61. 17. yesil s, polat f, ozturk u, et al. effect of different analgesics on pain relief during extracorporeal shock wave lithotripsy. hippokratia. 2014;18(2):107–9. 18. norris rd, sur rl, springhart wp, et al. a prospective, randomized, double-blinded placebo-controlled comparison of extended release oxybutynin versus phenazopyridine for the management of postoperative ureteral stent discomfort. urology. 2008;71(5):792–5. 19. siegel s, noblett k, mangel j, et al. results of a prospective, randomized , multicenter study evaluating sacral neuromodulation with interstim therapy compared to standard medical therapy at 6 monts in subjects with mild symptoms of overactive bladder. neurourol urodyn. 2015;34(3):224–30. 20. mazumdar k, dutta nk, dastidar sg, et al. diclofenac in the management of e. coli urinary tract infections. in vivo (brooklyn). 2006;20:613–20. 21. joux f, lebaron p. ecological implications of an improved direct viable count method for aquatic bacteria. appl environ microbiol. 1997;63(9):3643–7. 22. parrill al, baker dl. autotaxin inhibitors: a perspective on initial medicinal chemistry efforts. expert opin ther pat. 2011;20(12):1619–25. 23. inoue m, ma l, aoki j, et al. simultaneous stimulation of spinal nk1 and nmda receptors produces lpc which undergoes atx-mediated conversion to lpa, an initiator of neuropathic pain. j neurochem. 2008;107(6):1556–65. 219acta med indones indones j intern med • vol 55 • number 2 • april 2023 review article pulmonary artery wedge pressure formula using echocardiography finding lukman h. makmun1, telly kamelia2*, prasandhya astagiri yusuf3 1division of cardioloy, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2division of respirology and critical care medicine, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 3department of medical physics, faculty of medicine universitas indonesia, jakarta, indonesia. *corresponding author: telly kamelia, md., phd. division of respirology and critical care medicine, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: tellykamelia99@gmail.com. abstract this study aims to introduce a new formula for pulmonary artery wedge pressure (pawp) derived from the pathophysiology of velocity a (va) waves. the current formula is the the nagueh formula. left ventricular (lv) filling is described as a velocity a (va) wave. the va wave represents the filling rate of the end-diastolic blood phase from the left atrium (la) to the lv which can be determined on echocardiography. left ventricular end diastolic pressure (lvedp) is equivalent to la pressure and is also equivalent to pawp. the gold standard method for obtaining pawp values is right heart catheterization. by measuring the va waves in the bloodstream, a new pawp formula is obtained, and the pawp examination can be validated in research and can be compared with several other pawp formulas that are currently the world’s standard formula for calculating pulmonary artery wedge pressure (pawp). the new pawp formula is obtained from the conversion of the va wave. this formula could be validated further in research and used in clinical practice. keywords: velocity a wave (va wave), pulmonary artery wedge pressure (pawp) formula. introduction pulmonary arterial wedge pressure (pawp) is between 4 to 12 mmhg. it is used to asses for severity of mitral stenosis (ms), to differentiate between cardiogenic and non-cardiogenic pulmonary edema, and to confirm the diagnosis of pulmonary hypertension (ph).1 pawp is a critical component of the hemodynamic evaluation, as the sole parameter to define precapillary ph (pcph) from ph due to left heart disease.2 the gold standard method to assess the functionality of the pulmonary circulation is by right heart catheterization (rhc), which measures pulmonary vascular pressures using fluid-filled swan-ganz catheter and pulmonary flow thermodilution or the fick principle. pawp is acceptable as estimate of left atrial pressure (lap) or left ventricular end diastolic pressure (lvedp).3 the current formula to calculate pawp is the nagueh formula. it uses the measurements of e wave velocity and early diastolic velocity of mitral annulus (ea) during doppler tissue imaging. these velocities reflect the shortening and lengthening of the myocardial fibers along a longitudinal plane, with each corner of the annulus being influenced more by the adjacent lukman h. makmun acta med indones-indones j intern med 220 left ventricle (lv) wall. it demonstrated that the ratio of the transmitral e velocity to ea (i.e., the e/ea ratio) is related significantly with pawp. 4 on doppler echocardiographic examination, lv filling is described as a velocity a (va) wave. the va wave represents the filling rate of the end-diastolic blood phase from the la to the lv, and is also equivalent to pawp. by measuring the va waves in the bloodstream, a new pawp formula is obtained. calculation of conversion of va value to pawp value (pc), equivalent to pla pla or pressure on the la area stereometrically caused by the suppression of the blood volume contained in the la in the end diastolic phase. the amount of pressure in the la area is calculated using the formula: pressure (pla) = force (f) / area on which the force act (a) or: pla = f / a……………………..1). f = force ……..in n (newton). w (weight) = m x g; w = or f (n). w = weight (n); m = mass (kg); g = gravitational field strength = 9,8 m/sec2 1 n = 1 kg. 1 m/sec2 = 1 kg.m/sec2 1 dn (dyne) = 1 g cm/sec2 1 n = 103 .g. 102 cm/ sec2 = 105 gcm/sec2 1 n = 105 dn. by using the formula for kinetic energy: e = ½ mv2 …………………2). e = energy; m = mass; v = velocity. then combined with this formula: e = f x d ……………………3) e = energy; f = force; d = distance thus becoming: f x d = ½ mv2 f = ½ mv2 / d ………….4) f = m x g. thus: m x g = ½ mv2 / d or d = v2 / 2 g …………….…5) pressure formula: pla = f / a …………..1) = m g / a ………….6). calculation of la volume in the end diastolic phase: referring to the heart on atlas netter, mitral cross section > la basic cross section h = height from apex, lv peak to la base h1 = distance from apex – mitral cross section d = distance = distance from la base – mitral cross section. r = pseudo “la basic cross section” radius (look at the image) r1 = mitral cross section radius. r2 = “pseudo” cross radius at la level based on the comparison count in the heart image on atlas of human anatomy: h1 = 2/3 h; d = 1/3 h; r1 = 2/3r; r = r1 + 2 r2 or: r2 = ½ (r – r1) = ½ (r – 2/3r) = 1/6 r. based on the comparison calculation in the heart image on atlas of human anatomy, the shape from basic to apex is more like a tube, so the general volume formula is: v = π r2 h v (volume) la = π r2h – π r1 2 h1 – 2 (π r2 2 d) v = π (r2h – r1 2 h1 – 2. r2 2 d) v = π (r2h – r1 2. 2/3 h – 2. r2 2 1/3h) = πh (r2 – 2/3 r1 2 – 2/3. r2 2) = πh {r2 – 2/3(r1 2+r2 2)} = πh {r2 – 2/3(4/9r2+ 1/36r2)} = πh (r2 – 2/3x17/36r2) = πh. 37/54 r2 or = 37/54 πh r2 ……………7) formula: mass = volume x density m = v x d. m = mass; v = volume from formula 7); d = blood density = 1,060 g/cm3. m = 37/54 πh r2 x d. = 37/54 πh r2d gram (cgs unit) ………….8) vol 55 • number 2 • april 2023 pulmonary artery wedge pressure formula 221 figure 1. comparison of anatomical and schematics drawing of a heart.5 a = la space surface area la area approximation = the total conical wall area with side length s approximately equal to length h, minus the conical wall area “lv” and minus the area of 2 “pseudo” small cone sections at the base. area of 1 full circle with radius = s, is = πs2 area of a section with angle α at the center = α/ 360 πs2 r/h = tg ½ α. based on the calculation of the ratio of r and h on the heart image in atlas netter: r = 6 cm, h = 10 cm  tg ½ α.= 0,6 tg 300 =0,58. thus 1/2 α = 300 or angle α = 600 la half area = ½ a 1/2 a = α/ 360 πs2 α/360 π s1 2 – 2 x (1/2α)/360 π s2 2. = α/360 π (s2 s1 2 – s2 2); length s approximately = h = α/360 π (h2 – h1 2 – d2) = α/360 π (h2 – 4/9 h 2 – 1/9 h2) = π α/360. 4/9 h2 the total surface area of la = a = 2x . 4/9 π α/360 h2 = 8/9 π 60/360 h2 = 4/27 πh2 cm2 ………………..……9). pressure on la pla = m. g / a from formula 6) = 37/54 πh r2 d. g / 4/27 πh2 from formula 8) and 9) = 37/8 d r2 . g h / h2 = 37/8 (r/h)2 d g. 3d ;…………..see also formula 5).: h = 3d and d = v2 /2 g = 37/8 (r/h)2 d. g. 3 x v2 /2 g d = 1,060 g/cm3, g = gravitational field strength r/h = tg 1/2 α; α= 600; 1/2 α = 300  tg 300 = 0,58. pla = 111/16. 0,58 2 . 1,060 . x v2. pla = 2,47 v 2 g/cm.sec2 ………………10) 1 pa = 1 n/ 1 m 2. (pa = pascal) = 1 kgm/sec2 / 1 m2 =1 kg/m sec2 = 10 g/cm sec2 1 mmhg = 133,3 pa atau 1 pa = 0.0075 mmhg pla = 2,47 va 2 g/ cm.sec2 = 0,247. va 2 pa (pascal) = 0,247 va 2 x 0,0075 mmhg or: pla = 18,525. 10 -4 x va 2 mmhg cgs  va units must be in cm/s = 18,525. 10-4. 104 x va 2 mmhg va value in m/s pla = 18,525 va 2 mmhg…….( va in m/s) …… formula 11. lukman h. makmun acta med indones-indones j intern med 222 example: if va = 0,7 m/s pla = 18,525 x 0,7 2 mmhg. = 9,1 mmhg one of the clinical benefits is in treating acute heart failure, according to the nohria method with wet and cold data, other than cardiac output, pc (pulmonary capillary) or pawp pressure is required. conclusion the new pawp formula has advantages over the nagueh formula, where the new formula uses blood flow while the nagueh formula uses tissue imaging. this formula can enrich the knowledge, especially in the field of cardiology. it is recommended that this formula be validated with right heart catheterization using swanganz catheter, to compare its advantages and disadvantages over the nagueh formula. acknowledgments this pawp formula has been registered to the indonesian copyright service (haki) by lukman h. makmun (reg. no.ec00202297063, november 30, 2022). references 1. nair r, lamaa n. pulmonary capillary wedge pressure. statpearls [internet]. 2022 apr 21; available from: https://www.ncbi.nlm.nih.gov/books/nbk557748/ 2. viray mc, bonno el, gabrielle nd, et al. role of pulmonary artery wedge pressure saturation during right heart catheterization: a prospective study. circ heart fail [internet]. 2020;660–2. available from: https://www.ahajournals.org/doi/abs/10.1161/ circheartfailure.120.007981 3. naeije r. physiology of the pulmonary circulation and the right heart. curr hypertens rep. 2013;15(6):623– 31. 4. nagueh sf, middleton kj, kopelen ha, zoghbi wa, quiñones ma. doppler tissue imaging: a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. j am coll cardiol. 1997;30(6):1527–33. 5. netter fh. netter atlas of human anatomy. 7th edition. philadelphia, pa: elsevier health sciences; 2019. 432 acta med indones indones j intern med • vol 53 • number 4 • october 2021 original article the association between plasma mirna-21 levels with overall 1-year survival rate of breast cancer patients at various stages pradana zaky romadhon,1,2,3 ami ashariati prayoga,1,2,3 siprianus ugroseno yudho bintoro,1,3 muhammad noor diansyah,1,2,3 putu niken amrita,1,3 merlyna savitri,1,3 choirina windradi2 1 department of internal medicine, airlangga university, faculty of medicine, surabaya, indonesia 2 universitas airlangga hospital, surabaya, indonesia 3 dr. soetomo general teaching hospital, surabaya, indonesia corresponding author: ami ashariati prayoga, md. department of internal medicine, faculty of medicine airlangga university – dr. soetomo hospital. jl. mayjen prof. dr. soetomo 6 – 8, surabaya, indonesia. email: amiashariati@yahoo.com. abstract background: mirna 21 exhibits an increased expression in breast cancer (bc). however, its relationship with the 1-year survival of breast cancer patients is still disputable and under serious discussion. methods: cohort prospective study involving 49 breast cancer patients was done, comprising 26 in early stage and 23 in end-stage. we evaluated mirna-21 values and observed its association with mortality within 1 year. results: in general, there was a correlation between the increase in mirna-21 levels and the mortality rate of breast cancer patients (r = 0.651; p <0.05). in the early stages, the increase in mirna-21 values was not associated with breast cancer mortality (r= 0.25; p=0.218), but in the later stages, we found that the increase in mirna-21 had a correlation with mortality (r=0.866; p=<0, 05). in advanced stage, high level of mirna-21 had high asscociation with mortality rate (hr 17,27 95%ci 7,37-40,69). conclusion: the increase in mirna-21 values is associated with the 1-year survival of breast cancer patients. keywords: mirna-21, breast cancer, mortality rate, survival, health. introduction breast cancer has been noticed as a worldwide health issue with an increasing prevalence in the world with a high mortality rate. based on globocan data (global cancer statistics) 2018, breast cancer ranks first in the incidence of cancer in women with the number of new cases worldwide of 2,088,849 people (24.2%) with a mortality rate of 626,679 people (15%), of which half of the new cases and mortality cases found in asia.1 indonesia came with the data revealing that breast cancer is the second most common malignancy after cervical cancer with a prevalence of 0.5 percent and an estimated number of cases of 61,682 patients, where the highest incidence is found in the central java, followed by east java, west java and dki jakarta.2 data on one-year, five-year and ten-year survival rates in breast cancer patients aged 15 to 99 years during the period 2013-2017 in the uk were found to be 95.8%, 85% and 75.9%, respectively, where plans of action are somewhat still needed in increasing breast cancer survival rates.3 the examination of minimally invasive circulating biomarkers offers new hope to diagnose breast cancer, monitor progression, vol 53 • number 4 • october 2021 the association between plasm mirna-21 levels 433 determine prognosis and predict response to treatment, which is a vital part of strategies to reduce breast cancer morbidity and mortality. several conventional circulating biomarkers that are known and used in monitoring and assessing breast cancer progression are carcinoembryonic antigen (cea) and carbohydrate antigens (ca) such as (ca15-3). however, the sensitivity values of the biomarkers cea and ca 15-3 are relatively low, around 22% and 15%, respectively. due to the low sensitivity of existing biomarkers, new minimally invasive biomarkers with better sensitivity and specificity are required to monitor breast cancer progression.4-6 the discovery of microrna (mirna) in the last decade has unfolded new opportunities for the detection and prognostication of breast cancer. the advantages of mirna in the oncogenesis process include various expression patterns associated with the type of cancer, easy detection in biopsies, fine stability in blood and other body fluids, especially in blood, plasma, serum, and saliva so that mirnas can be used as promising biomarkers.7,8 dysregulation in mirna genes in the form of mutations, deletions, translocations, increased expression, or decreased expression can trigger biological changes in cells, and is believed to have an important role in cancer development.9 several literature studies have shown that mirna-21 has increased expression in breast cancer. mirna-21 targets that have been identified are tumor suppressor tropomyosin 1 (tpm1), timp3, reck cdc25a network of p53, pdcd4, pten, and maspin. mirna-21 overexpression correlates with specific breast cancer biopathological features, such as advanced tumor stage, lymph node metastases, and poor patient survival, suggesting that mirna-21 may serve as a molecular prognostic biomarker for breast cancer progression. high mirna-21 expression had a negative impact on overall survival and recurrence-free survival in breast cancer.10 several studies that have been conducted regarding the relationship of mirna-21 with breast cancer prognosis had contradictory results. the meta-analysis by wang et al.11 on the association of mirna-21 expression with breast cancer prognosis identified 10 studies involving 1,439 cases, showing that high mirna-21 expression predicted poor overall survival and disease-free survival and low relapse-free survival in breast cancer patients.11 study of khanbashi et al. (2015) on 27 locally-advanced breast cancer patients, radojicic et al. (2011) on 49 triple-negative breast cancer patients, and qian et al. (2009) on 344 breast cancer patients, showed that the results of the analysis of serum and tissue mirna-21 expression were not correlated with overall survival and disease-free survival.12-14 according to the fact that there are contradicting results among several previous studies, further analysis is considered necessary to apply mirna-21 as a prognostic factor for breast cancer. this study aims to determine the relationship between circulating mirna 21 levels and overall 1-year survival in breast cancer, where the circulating mirna-21 parameter used is blood plasma which is more stable and different from previous studies using serum or tissue. methods this is a cohort-retrospective study which was conducted at the oncology hematology outpatient clinic, airlangga university hospital, surabaya, starting from november 2019 through november 2020. participants taking a part in the study were those who met all of the following criteria: female patients aged 18 and above; breast cancer patients who have not received chemotherapy and radiotherapy; and are willingly involved in the study by signing an informed consent form. participants who were excluded from the study were patients who met one or more of the following criteria: breast cancer patients with terminal conditions (ecog2, karnofsky, score 50%), patients with a history of other malignancy in the last 5 years, and patients with comorbid diseases such as copd, heart failure, chronic kidney disease, liver cirrhosis and diabetes mellitus that are not under control. data were obtained from history taking, physical examination and additional examination. the expressed value of circulating plasma mirna-21 in the blood plasma of breast cancer pradana zaky romadhon acta med indones-indones j intern med 434 patients is measured using the quantitative real time polymerase chain reaction (qrt-pcr) method. the hsa-mir-16-5p lna pcr primer set was used as an endogenous control and a qrtpcr process was used to calculate the expression value of circulating mirna-21. blood samples withdrawal were carried out by the surabaya prodia laboratories and then sent for storage and processing at the jakarta prodia laboratory. samples for mirna21 examination was gained from 10 cc venous blood of deceased and healthy patients. centrifugation was carried out at 3000 rpm for 5 minutes to separate the serum and then sent and stored in a container with a temperature of -80c until rna was able to be extracted. total rna extraction, including small rna, was performed by the qiagen mirneasy serum/plasma kit according to the protocol of the product supplier. the mirna-21 reverse transcription technique used taqman tm microrna reverse transcription kit (applied biosystem) and mirna-21 specific stem-loop primer (applied biosystem, assay) for mirna-21 reverse transcription (rt) reaction. rt primers for small nuclear mirna-16 (applied biosystem) were used as endogenous controls. ethics approval this study has been approved by the research ethics committee of universitas airlangga hospital (no: 164/kep/2019). statistical analysis the sample size in this study was calculated by the formula of correlative analytic sample. furthermore, the number of samples required was approximately 37 patients, but our study obtained 49, consisting of 26 patients with early-stage breast cancer and 23 advanced-stage patients. statistical analysis was carried out using spss version 24.0. (chicago, il, usa). statistical analysis to determine the correlation of the two variables used the pearson statistical test if the data distribution was normal, otherwise, spearman test was used. the correlation test results are interpreted based on the p value, the strength of the correlation and the direction of the correlation. results the characteristics of 49 breast cancer patients are presented in table 1. of the 49 breast cancer patients, 26 patients were in the early stages, consisting of 5 at stage 1 and 21 at stage 2. meanwhile, of 23 patients with breast cancer in the advanced stage, 11 at stage 3 while 12 at stage 4. table 1. characteristics of breast cancer patients. variables n % age (mean/sd) 51.95 10.21 stage early (n,%): 26 53.06 1a 4 8.16 1b 1 2.04 2a 9 18.37 2b 12 24.49 advanced (n,%): 23 46.94 3a 3 6.12 3b 5 10.20 3c 3 6.12 4 12 24.49 menarche premenopause 25 51.02 menopause 24 48.98 comorbid ht 13 26.53 dm 5 10.20 thallasemia 1 2.04 chemotherapy adjuvan 23 46.94 neoadjuvan 14 28.57 palliative 12 24.49 performance status (ecog) 0 32 65.31 1 15 30.61 2 2 4.08 estrogen receptor neg 14 28.57 pos 23 46.94 progesteron receptor neg 19 38.78 pos 18 36.73 human epidermal growth factor receptor (her-2) neg 17 34.69 pos 1 4 8.16 pos 2 4 8.16 pos 3 11 22.45 ki67 (mean) 50% vol 53 • number 4 • october 2021 the association between plasm mirna-21 levels 435 vital sign systolic pressure (mean, sd) 128.38 15.09 diastolic pressure (mean,sd) 78.14 9.59 pulse (mean, sd) 85.88 8.64 respiration rate (mean, sd) 19.08 1 temperature (mean,sd) 36.19 0.91 physical status: height (cm) 152.84 4.88 weight (kg) 57.03 11.18 body surface area (bsa/m2) 1.51 0.16 laboratory hb (g/dl) (mean, sd) 12.24 1.28 wbc (103/l) (mean, sd) 7.75 2.62 plt (103/l) (mean, sd) 344.16 100.01 ast (u/l) (mean, sd) 26.57 16.7 alt (u/l) (mean, sd) 28.35 29.83 basal urea nitrogen (mg/l) (mean, sd) 10.77 4.12 creatinine (mg/l)(mean, sd) 0.69 0.17 mirna-21 6 5.35 cea 5.63 6.74 ca 15-3 68.62 141.95 outcome: life (n,%) 36 73.47 death (n,%) 13 26.53 based on the breast cancer stages, the number of pre-menopausal patients were dominantly found (57.69%) in the early stages compared to the menopausal ones, while at an advanced stage, menopausal patients were more frequent than premenopausal ones (56.52%). hypertension seemed to be the first-ranked comorbidity both in the early and advanced stage patients. mirna, cea, and ca 15-3 values in advanced stages had higher mean values. there were 2 deaths in the early stage, while in the late stage there were 11 deaths. eleven cases of death at an advanced stage consisted of 3 cases of death at stage 3 (1 in case 3a and 2 in case 3b) and 8 cases of death occurred at stage 4. overall the increase in mirna-21 values correlated with the death of breast cancer patients (r = 0.651 ; p<0.05). nonetheless, in the early stages, the increase in mirna-21 did not show any correlation (r = 0.25; p = 0.218). otherwise, mirna-21 was correlated with death in the advanced stages (r = 0.866; p = <0.05). (table 2). tabel 2. the comparison between early and advanced stage and the association between death and mirna-21 in breast cancer patients. stage overall (n=49) early (n=26) advance (n=23) menarche menopause 11 42.31 13 56.52 24 48.98 premenopause 15 57.69 10 43.48 25 51.02 comorbid ht 9 34.62 4 17.39 13 26.53 dm 2 7.69 3 13.04 5 10.2 thalasemia 1 3.85 0 0.00 1 2.04 ca mammae marker mirna-21 (mean,sd) 4.57 2.83 7.62 6.94 6 5.35 cea (mean, sd) 3.43 3.09 8.12 8.73 5.63 6.74 ca 15-3 (mean, sd) 17.60 4.66 128.91 3.52 68.62 142 outcome life (n,%) 24 92.31 12 52.17 36 73.47 death (n,%) 2 7.69 11 47.83 13 26.53 correlation with mortality rate mirna-21 (r; pvalue) 0.25 0.218 0.866 <0.05 0.651 <0.05 pradana zaky romadhon acta med indones-indones j intern med 436 as seen on figure 1, it appears that in the advanced and early stages, the mean mirna figure 2. graphic survival mrna-21 level in 1 year values were lower in the surviving patients and higher in the deceased patients. figure 1. vol 53 • number 4 • october 2021 the association between plasm mirna-21 levels 437 according to figure 2, it appears that low level of mirna21 indicates better survival which is statistically significant (p<0.05). meanwhile, high levels of mirna21 represented a statistically significant acceleration of death within 1 year in all cases, particularly in advanced stages (hr 5.5; 95%ci (3.2-9.46); hr 17.27; 95% ci : 7.33-40.69). discussion the mean age of the subjects was 51.95 ± 10.21 years, with the youngest being 29 years and the oldest being 73. this is in line with a study conducted by elghourory et al., (2018) on the evaluation of mirna-21 as a prognostic marker in breast cancer in 50 breast cancer patients with a mean age of 53.4 ± 9.9 years, also with a study by cuk et al. (2013) who examined circulating plasma mirna-21 as a marker for early detection of breast cancer in 127 breast cancer patients with a mean age of 56.6 years.15, 16 age somewhat is the major risk of breast cancer, in addition to reproductive factors, heredity and lifestyle factors, because the incidence of breast cancer is strongly associated with the increasing age. data in 2016 in the united states about 99% of breast cancers were reported at the age of over 40 years, so it is highly recommended to screen women aged 40 and over.17, 18 recent research data showed that in east asian and southeast asian, the breast cancer was more commonly found in the younger women than in the older ones. factors that influence this trend are “westernization” which includes dietary changes (high fat, low vegetables) and environmental factors (physical inactivity, smoking, alcoholism) in the last two decades in asian countries.19 in this study, according to the menarche status, 25 patients were the premenopausal women (51.02%), while 24 were the at the menopause stage (48.97%). this was supported by several previous studies where the percentage of the pre-menopausal group was higher than the menopausal one, such as by dong et al., (2014) (54.16% and 45.84%), elghourory et al. (2018) (64% and 36%). meanwhile, another study by papadaki et al. (2018) on circulating mirna-21 as a predictive factor for recurrence in 133 breast cancer patients, stated that the proportion of those being pre-menopausal subjects were 42.9% (n=57), while menopausal ones were 57.1% (n= 76).15, 20 reproductive factors such as menstrual history (early menarche, late menopause) are one of the risk factors for breast cancer. every one year delay in menopause has been shown to elevate the risk of breast cancer by 3%, while every one year delaying menarche has been shown to reduce the it by 5%. 17, 18 in this study, the percentage of pre-menopause patients was slightly higher than the menopause group, which differred from the european study. this condition is in accordance with the age factor of breast cancer patients in asia who tend to be younger than european and american countries. reproductive factors also play a role because asian women today tend to delay the birth of children, limit the number of children and rarely breastfeed. all of those factors elevate the tendency of breast cancer incidence at a younger age. menarche status in the two groups of subjects in this study was homogeneous, so the relative risk for breast cancer did not differ. of all 49 research subjects, 5 were at the stage 1 (10,2%), 21 were at the stage 2 (42,85%), 10 were at the stage 3 (20,40%), and 13 were at the stage 4 (26,53%). this is congruent with a study by gao et al. (2013) comparing mirna-21 with cea and ca 15-3 in 89 breast cancer patients, which obtained 23.59% stage 1 (n=21), 31.46% stage 2 (n=28), 10.11% stage 3 (n=9), and 34.83% stage 4 (n=31) patients.5 research by zhang et al. (2016) revealed that stage 1 was 10.4% (n=11), stage 2 was 40.5% (n=43), stage 3 was 30.2% (n=32), and stage 4 was 18, 9% (n=20).8 while fattah et al. (2018) stated that 20% (n=6) were at, 30% at stage 2 (n=9), 23.33% table 3. one year survival breast cancer according mirna21 level mrna21 one year survival low mrna high mirna hr 95% ci hr 95% ci overall 0.18 0.11-0.31 5.5 3.2-9.46 early stadium 0.766 0.33-1.8 1.31 0.55-3.07 advance stdium 0.058 0.03-0.14 17.27 7.33-40.69 pradana zaky romadhon acta med indones-indones j intern med 438 at stage 3 (n=7), and 26.66% at stage 4 (n=8).21 the subjects at stage 1 of breast cancer were at the smallest proportion, while the stage 4 group is second largest proportion. in contrast to other studies, this was due to the fact that breast cancer patients in indonesia often come at an advanced stage and rarely check themselves routinely for early detection. the results of this study obtained circulating plasma mirna-21 expression values using the 2-δδct formula to calculate relative gene expression in samples using the quantitative real time polymerase chain reaction (qrtpcr). the calculation of ct (cycle threshold of the fluorescence cycle sample from the qrtpcr product) was obtained from the difference between ct of the breast cancer group and ct of the control group. the calculation of ct was obtained from the qrt-pcr value results of mirna-21 as the expression of the gene under study minus the value of the qrt-pcr mirna-16 (hsa-mir-16-5p lna pcr primer set) as the expression of endogenous control genes that were not affected in the study. t h e m e a n e x p r e s s i o n o f c i r c u l a t i n g plasma mirna-21 in the breast cancer group was 6.00±5.35 with a median of 4.43 (minmax:1.11-32.22). according to the clinical stage in the breast cancer group, the mean was 4.31 +0.97 and the median was 4.75 (min-max: 2.885.35) at stage 1, 4.62 ±3.13 and the median was 3.68. (min-max: 1.18-11.79) at stage 2, 5.40 ± 4.27 and median 3.83 (min-max: 1.11-14.12) at stage 3, and 9.32 ± 8.21 and median 5.77 (minmax: 3.18-32.22) at stage 4. in line with fattah et al. (2018), it was found that the expression of circulating mirna-21 in the stage 1 breast cancer group was 1.6 (1.2-1.9), at stage 2 it was 2.6 (2.3-3.0), at stage 2 it was 2.6 (2.3-3.0). 3 was 3.5 (3.2-4.8), and in stage 4 it was 7.4 (5.9-8.7) (p= < 0.001).22 this result was also in accordance with the research of abdulhussain et al. (2017) who examined the relationship between serum and tissue mirna-21 levels with pdcd4 expression in breast cancer patients in iraq, where circulating mirna-21 in the stage 1 breast cancer group was 0.3±0.29, stage 2 was 3.4±0.35, stage 3 was 3.57±0.44 and stage 4 was 4.26.23 the measurement of circulating plasma mirna-21 levels was performed using the qrt-pcr technique. the sample was obtained from venous blood since the levels were more stable than those from breast tumor tissue. blood plasma was more preferred than serum due to the occurrence of erythrocyte hemolysis during the blood coagulation process which releases mirna. blood plasma was stable in an rnase-rich environment in the bloodstream, in high and low temperature changes, in high and low ph conditions, in repeated freezingthawing processes, and in long-term storage.24, 25 mirnas were protected by microparticles such as exosomes or bound to the ago2 protein which was part of the rna-induced silencing complex. this study used the hsa-mirna-16-5p lna pcr primer set as an endogenous control and carried out a duplicate process in the qrtpcr process to further improve the accuracy of circulating mirna-21 expression values. this study used mirna-16 as an endogenous control, which was consistently expressed in all study groups and was not affected by breast cancer status, and this is also consistent with several studies using mirna-16 as a cancer normalizer.21 in the breast cancer group, higher mirna-21 levels are detected due to over-expression (up regulation) of the mir-21 gene which further escalates the release of mir-21 in the circulation and acts on several tumor suppressor genes such as p53 network and cdc25a which manage cell proliferation; tpm1, timp, reck which have roles in cell invasion and metastases; and pten, pdcd4, fasl which regulate apoptosis. the whole process of increasing mirna-21 expression and inhibition of tumor suppressor genes would trigger breast cancer. mirnas expression in the breast cancer group significantly increased as the stage got more advanced. the positive interrelation of mirna-21 and 155 exosomal plasma and tissue mirnas signify the role of these mirna cargoes in tumor metastasis and explain the invasiveness of cancer cells through the activation of timp3/ mirna-21 expression. survival is one of the benchmarks in assessing the mortality and morbidity rate of a vol 53 • number 4 • october 2021 the association between plasm mirna-21 levels 439 disease in an area, and the survival rate is related to risk factors as well as treatment and prevention plans. in recent years, the mortality rate for breast cancer had down-trended in developed countries. in indonesia, despite relatively-low survival rate of breast cancer patients, early diagnostic tool and more advanced treatment modalities are currently under the development. the results of the 1-year overall survival evaluation in 49 breast cancer patients in this study showed that 36 patients lived (73.46%) while 13 patients (26.54%) died. based on the clinical stage, in stage 1 all (100%) survived, 19 (90.47%) did at stage 2, 7 (70%) at stage 3, and 5 at stage 4 (38.46%). the overall 1-year survival rate for breast cancer patients based on research data in england, denmark and china was 95.8%, 94.4% and 94.91%, respectively. research data in china also showed that the overall 1-year survival rate when assessed based on clinical stage, the survival rate will decrease in more advanced stage. in this study, the overall 1-survival rate were lower than the data in england, denmark and china, possibly because breast cancer patients in indonesia often come at an advanced stage so that the therapy might not be optimal, then affected the survival rate. this was supported by the data from the indonesian ministry of health where the cancer survival rate in indonesia was still low, and research data from noorwati et al. (2020) on cancer patients at dharmais cancer hospital stating 77.9% of patients were in stage 3 and stage 4.2 enhanced expression of mirna-21 in breast tissue is significantly associated with tumor size, histopathological grade, lymph node involvement, tumor invasion to the vasculature and lymphatic flow, visceral metastases, and advanced stage. increased mirna-21 expression is also associated with a lower response to therapy and a poorer breast cancer prognosis. this fact is consistent with the oncogenic role of mirna-21 during proliferation, invasion, metastasis, and inhibition of apoptosis of cancer cells. mirna-21 targets that have been identified were tumor suppressor tropomyosin 1 (tpm1), timp3, reck cdc25a network of p53, pdcd4, pten, and maspin. mirna-21 overexpression correlates with specific breast cancer biopathological features, such as advanced tumor stage, lymph node metastases, and poor patient survival, suggesting that mirna-21 may act as a molecular prognostic biomarker for breast cancer progression. the relationship between circulating mirna-21 plasma expression levels and overall 1-year survival of breast cancer in this study was found to have a strong, negative correlation between circulating mirna-21 plasma expression and overall 1-year survival of breast cancer (r of 0,-651, p-value <0.05). the negative or opposite direction of the correlation means that the higher the expression of circulating mirna-21 plasma, the lower the overall 1-year survival. further statistical analysis shown in the kaplan-meier graph revealed that high mirna-21 expression when compared to low mirna-21 expression had a hazard ratio value of 5.5 with p <0.05. the research of yan et al., (2008) showed that mirna-21 expression was significantly associated with poor prognosis in breast cancer patients (p<0.001), with a hazard ratio value of 5.476.10 the research of papadaki et al., (2018) stated that circulating mirna-21 was significantly correlated with overall survival (p=0.033), with a hazard ratio value of 2.884.26 while the research by dong et al., (2014) showed that mirna-21 was significantly associated with overall survival (p=0.0107), with a hazard ratio value of 2.32.20 nevertheless, this study had a number of weaknesses. the research subjects were not homogeneously distributed among stages, that might cause bias. the follow-up monitoring time took only a year; thus it was not able to conclude patients’ survival in a longer period. in addition, this study also did not observe other survival metrics such as recurrence period or disease-free survival. this study also did not explore other factors that influence survival such as tumor histopathological profile or hormone receptor status, and only one type of mirna was assessed. conclusion our principal finding is that overexpression of mir-21, one of the most significantly altered pradana zaky romadhon acta med indones-indones j intern med 440 mirnas in bc, is associated with progression and poor prognosis of the patients. although the precise molecular mechanism surrounding mirna-21 upregulation requires further clarification, our data indicate that mirna-21 may be a good candidate as a molecular prognostic marker. future study on the role of mirna-21 in bc progression will no doubt add to the knowledge of this nascent field. conflict of interests the authors have no relevant conflict of interest. acknowledgments we thank to universitas airlangga hospital for supporting the study. references 1. bray f, ferlay j, soerjomataram i, siegel rl, torre la, jemal a. global cancer statistics 2018: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. ca: a cancer j clin. 2018;68(6):394-424. 2. kemenkes. kementrian kesehatan ri: ‘situasi penyakit kanker indonesia’2015. 3. uk. office of national statistics: cancer survival by stage at diagnosis for england 2019. available from: https://www.gov.uk/government/statistics/ cancer-survival-in-england-for-patients-diagnosedbetween-2014-and-2018-and-followed-up-until-2019/ cancer-survival-in-england-for-patients-diagnosedbetween-2014-and-2018-and-followed-up-to-2019. 4. uehara m, kinoshita t, hojo t, akashi-tanaka s, iwamoto e, fukutomi t. long-term prognostic study of carcinoembryonic antigen (cea) and carbohydrate antigen 15-3 (ca 15-3) in breast cancer. international j clin oncol. 2008;13(5):447-51. 5. gao j, zhang q. clinical significance of serum mir-21 in breast cancer compared with ca153 and cea. 2013. 6. stieber p, nagel d, blankenburg i, et al. diagnostic efficacy of ca 15-3 and cea in the early detection of metastatic breast cancer—a retrospective analysis of kinetics on 743 breast cancer patients. clin chim acta. 2015;448:228-31. 7. mar-aguilar f, mendoza-ramírez ja, malagónsantiago i, et al. serum circulating microrna profiling for identification of potential breast cancer biomarkers. dis markers. 2013;34(3):163-9. 8. zhang j, jiang c, shi x, yu h, lin h, peng y. diagnostic value of circulating mir-155, mir-21, and mir-10b as promising biomarkers in human breast cancer. int j clin experiment pathol. 2016;9(10):10258-65. 9. kayani m, kayani ma, malik fa, faryal r. role of mirnas in breast cancer. asian pac j cancer prev. 2011;12(12):3175-80. 10. yan lx, huang xf, shao q, et al. microrna mir-21 overexpression in human breast cancer is associated with advanced clinical stage, lymph node metastasis and patient poor prognosis. rna. 2008;14(11):2348-60. 11. wang g, wang l, sun s, wu j, wang q. quantitative measurement of serum microrna-21 expression in relation to breast cancer metastasis in chinese females. annals lab med. 2015;35(2):226-32. 12. qian b, katsaros d, lu l, et al. high mir-21 expression in breast cancer associated with poor disease-free survival in early stage disease and high tgf-β1. breast cancer res treat. 2008;117(1):131-40. 13. radojicic j, zaravinos a, vrekoussis t, kafousi m, spandidos da, stathopoulos en. microrna expression analysis in triple-negative (er, pr and her2/neu) breast cancer. cell cycle. 2011;10(3):50717. 14. aboussekhra a, al-khanbashi m, caramuta s, et al. tissue and serum mirna profile in locally advanced breast cancer (labc) in response to neoadjuvant chemotherapy (nac) treatment. plos one. 2016;11(4):e0152032. 15. elghoroury ea, eldine hg, kamel sa, et al. evaluation of mirna-21 and mirna let-7 as prognostic markers in patients with breast cancer. clin breast cancer. 2018;18(4):e721-e6. 16. cuk k, zucknick m, heil j, et al. circulating micrornas in plasma as early detection markers for breast cancer. int j cancer. 2013;132(7):1602-12. 17. shah r. pathogenesis, prevention, diagnosis and treatment of breast cancer. world j clin oncol. 2014;5(3):283. 18. sun y-s, zhao z, yang z-n, et al. risk factors and preventions of breast cancer. int j biol sci. 2017;13(11):1387-97. 19. lin c-h, yap ys, lee k-h, et al. contrasting epidemiology and clinicopathology of female breast cancer in asians vs the us population. jnci: journal of the national cancer institute. 2019;111(12):1298-306. 20. dong g, liang x, wang d, et al. high expression of mir-21 in triple-negative breast cancers was correlated with a poor prognosis and promoted tumor cell in vitro proliferation. med oncol. 2014;31(7). 21. fattah h, mahmoud n, elzoghby d, matar m, el shaer i. clinical utility of circulating microrna-21 in breast cancer. egyptian j hosp med. 2018;71(4):2950-5. 22. sakr hi, khowailed aa, al-fakharany rs, abdelfattah ds, taha aa. serum uric acid level as a predictive biomarker of gestational hypertension severity; a prospective observational case-control study. reviews on recent clinical trials. 2020;15(3):22739. 23. abdulhussain mm, hasan na, hussain ag. interrelation of the circulating and tissue microrna-21 vol 53 • number 4 • october 2021 the association between plasm mirna-21 levels 441 with tissue pdcd4 expression and the invasiveness of iraqi female breast tumors. indian j clin biochem. 2017. 24. mitchell ps, parkin rk, kroh em, et al. circulating micrornas as stable blood-based markers for cancer detection. proceedings of the national academy of sciences. 2008;105(30):10513-8. 25. kim y-k. extracellular micrornas as biomarkers in human disease. chonnam med j. 2015;51(2):51. 26. papadaki c, stratigos m, markakis g, et al. circulating micrornas in the early prediction of disease recurrence in primary breast cancer. breast cancer res. 2018;20(1). 385acta med indones indones j intern med • vol 53 • number 4 • october 2021 original article abstract aim: to summarize the prognosis of corona virus disease 2019 (covid-19) patients with elevated troponin and n-terminal pro brain natriuretic peptide (nt-probnp) levels and demonstrate the involvement of myocardial injury as a complication in covid-19. methods: a systematic literature search was performed using several databases (pubmed, medline, proquest and scopus ) for studies published up to august 2020. observational studies about the mortality outcome of covid-19 patients who experienced cardiac injury, as defined by the elevation of serum levels of troponin, brain natriuretic peptide (bnp), with nt-probnp or only bnp or only nt-probnp, were included. in addition, a critical appraisal was conducted for all included studies using the critical appraisal for prognostic studies checklist published by the centre for evidence-based medicine by the university of oxford. results: seven retrospective observational studies fulfilled the inclusion criteria. this study found that there is a higher risk of death in covid 19 patients with higher levels of troponin and nt-probnp, indicating the importance of these biomarkers as determinant factors to predict in-hospital deaths. conclusion: based on the analysis, elevation of troponin and nt-probnp levels plays an essential role in determining the patient prognosis because it is shown to be associated with in-hospital mortality. this also supports the involvement of myocardial injury as a prominent fatal complication in covid-19. keywords: covid-19, myocardial injury, troponin, bnp, nt-probnp, prognostic factors. elevation of cardiac biomarkers in covid-19 as a major determinant for mortality: a systematic review tracy anabella hermansyah1, eka ginanjar2*, valerie hirsy putri3 1 faculty of medicine universitas indonesia, jakarta, indonesia. 2 division of cardiovascular, department of internal medicine faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 3 bunda general hospital, jakarta, indonesia. *corresponding author: eka ginanjar, md. department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia, email: ekaginanjar.md@gmail.com. introduction in early 2020, a pandemic state was reported in relation to the coronavirus disease-2019 (covid-19), a novel strand of severe acute respiratory syndrome coronavirus-2 (sarscov-2). 1,2 by august 21, 2020, the global number of confirmed cases had reached more than 4 million, with over 780,000 deaths having occurred in 213 different countries.3 although the major complication of covid-19 infection is respiratory failure, there have been reports of myocardial injury defined by elevated biomarker values in patients, with troponin i as the main biomarker used.1,48 the use of troponin i is based on its unique regulatory protein encoded by a specific gene that is only found in the myocardium, making it a fundamental aspect to clinically define the diagnosis of myocardial injury.9-10 other biomarkers, such as troponin t (tnt), brain natriuretic peptide (bnp), and n-terminal brain natriuretic peptide (nt-probnp), are also used to further support the determination of any myocardial damage.11 tracy anabella hermansyah acta med indones-indones j intern med 386 to date, the most plausible cause of the myocardial injury found in covid-19 is the presence of ace2 receptors in the myocardium; these receptors allow the binding of sarscov2 structural protein, leading to a direct viral infection of the heart. furthermore, infectionmediated vasculitis by covid-19 may also contribute to causing direct myocardial injury because of the ace2 receptor expressions in the arterial and venous endothelial cells. both events may lead to an indirect immunological response resulting in a hypersensitivity reaction, which manifests as the myocardial injury and dysfunction seen in covid-19. such occurrences often lead to a fatal outcome.1 many studies have found that intensive care unit (icu) admissions and in-hospital mortality may also be associated with elevated biomarkers, further supporting the essential determinant factor of patients’ prognosis in clinical settings.12 thus, many clinicians have drawn their attention to the role of troponin and nt-probnp elevation in determining the prognosis of patients with covid-19. methods as a foundation for performing an extensive literature search, this study chose a relevant clinical question using a patients/intervention/ comparison/outcome (pico) model to define suitable terms for use in the search. the chosen terms derived from the following question: could the elevation of troponin and bnp/nt-probnp determine the prognosis of patients with covid-19 myocardial injury? the selected keywords comprised of p (patients), i (intervention) and o (outcome), whereas c (comparison) was not considered as the main focus and therefore, excluded (table 1). we used the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines for this review. a literature search was performed using four databases (pubmed, medline, proquest and scopus) from april 24 to august 26, 2020, using a combination of medical subject headings (mesh) terms based on the pico keywords derived from the clinical question (table 2). only longitudinal cohort studies or randomized controlled trials that observed death as the main outcome for covid-19 patients with elevated nt-probnp and/or troponin were included in this study. table 1. pico. patient (p) intervention (i) comparison (c) outcome (o) covid-19 myocardial injury patients elevation of troponin and bnp/ntpro-bnp mortality/death case bnp/ntprobnp, brain natriuretic protein/n-terminal pro brain natriuretic peptide ;covid-19, coronavirus disease 2019; table 2. literature search strategy. database search terms hits pubmed ((((("covid-19"[title/abstract]) or (coronavirus[title/abstract])) and (myocardial injury [title/abstract]) and ((troponin[title/abstract]) or (bnp [title/abstract]) or (nt-probnp[title/abstract])) and (mortality [title/abstract]) 178 proquest ((covid-19) or (coronavirus)) and (myocardial injury) and ((troponin)) or (bnp) or (nt-probnp)) and (mortality) 45 scopus ((covid-19) or (coronavirus)) and (myocardial injury) and ((troponin)) or (bnp) or (nt-probnp)) and (mortality) 17 medline ((covid-19) or (coronavirus)) and (myocardial injury) and ((troponin)) or (bnp) or (nt-probnp)) and (mortality) 215 total 455 vol 53 • number 4 • october 2021 elevation of cardiac biomarkers in covid-19 387 critical appraisal a critical appraisal was conducted thoroughly by the author for all included studies using the critical appraisal for prognostic studies checklist published by the university of oxford (www. cebm.net). any uncertainties for inappropriate topics was then consulted to the second reviewer. study design, patient demographics, value changes in troponin and bnp and/or nt-probnp value, mortality rate, risk ratio/odd ratio, hazard ratios and other outcomes from adjusted statistical (if stated) were extracted from the included studies for further analysis. results search selection a total of 455 papers were identified from the four databases. after the deduplication process, 450 different papers were screened based on their titles and abstracts (figure 1). as a result, 216 articles were excluded from the initial screening, leaving 234 articles to undergo a full review and further selection process. seven articles were selected as the final sample for this study. a summary of the selection process according to the prisma statement can be seen in the prisma diagram on figure 1.13 the characteristics of the baseline study can be seen in table 3. all chosen studies varied from a single-center or multicenter observational cohort and observed the relationship between the elevation of myocardial biomarkers of covid-19 patients and the mortality outcome. zhou et al14., chen et al.15, and stefanini et al.16 focused on the association of patients’ clinical outcomes with troponin and nt-probnp as myocardial markers. guo et al.17, gao et al.18, zhang et al.19, and shi et al.20 included other myocardial injury biomarkers, such as creatinine kinase myocardial band (ckmb), myohemoglobin, or myoglobin. these studies underwent critical appraisal as presented in table 4. id e n ti fi c a ti o n in c lu d e d lig ib ili ty s c re e n in g (n=7) figure 1. prisma flow diagram of search and selection process tracy anabella hermansyah acta med indones-indones j intern med 388 ta bl e 3. c ha ra ct er is tic o f i nc lu de d st ud ie s a ut ho r in st itu tio n/ c ou nt ry s tu dy c on du ct ed d es ig n in cl us io n c ri te ri a e xc lu si on c ri te ri a p ar tic ip an ts m yo ca rd ia l bi om ar ke r te st ed o th er b io m ar ke r te st ed p ri m ar y en dp oi nt s s ec on da ry en dp oi nt (s ) r es ul ts zh ou e t a l ji ny in ta n h os pi ta l an d w uh an p ul m on ar y h os pi ta l (w uh an , c hi na r et ro sp ec tiv e c oh or t s tu dy c on fir m ed c o v id -1 9 in pa tie nt s w ho d ie d or di sc ha rg ed be tw ee n 29 th d ec 2 01 9 an d 31 st j an 2 02 0 n on c o v id -1 9 in pa tie nt s, p at ie nt s w ith ou t ac ce ss ib le m ed ic al re co rd s 19 1 p at ie nt s h sct ni w hi te b lo od c el l, ly m ph oc yt e co un t, h ae m og lo bi n, p la te le t co un t, a lb um in , a lt , c re at in in e, l ac ta te de hy dr og en as e, c re at in in e ki na se , se ru m fe rr iti n, il 6, p ro ca lc ito ni n, , p ro th ro m bi n tim e, ddi m er d ea th , d is ch ar ge d n /a h sct ni : 3. 0 pg /m l s ur vi vo r (5 4/ 19 1) v s 22 .2 pg /m l no n su rv iv or (1 37 /1 91 ) o r h sct ni 8 0. 07 (c i 10 .3 4 – 62 0. 36 ) g uo e t a l s ev en th h os pi ta l o f w uh an c ity , c hi na r et ro sp ec tiv e c oh or t s tu dy c on fir m ed c o v id -1 9 in pa tie nt s w ho d ie d or di sc ha rg ed be tw ee n 23 rd ja n 20 20 a nd 23 rd f eb 2 02 0 c o v id -1 9 in pa tie nt s w ith ou t a co m pl et e m ed ic al re co rd 18 7 p at ie nt s tr op on in t , c k m b fr ac tio n, m yo gl ob in , n tpr ob n p w hi te b lo od c el l, ly m ph oc yt e co un t, n eu tro ph il, a lb um in , a lt , c re at in in e, a m in ot ra ns fe ra se (a la ni ne , a sp ar ta te ), hs c r p, g lo bu lin , p ro ca lc ito ni n, p ro th ro m bi n tim e, ddi m er , a p tt , c ho le st er ol (t ot al , tri gl yc er id e, h d l, l d l) , s er um p ot as si um , s er um c al ci um d ea th , d is ch ar ge d n /a m or ta lit y in n or m al t nt (1 2[ 8. 9% ]) vs e le va te d tn t (3 1[ 59 .6 % ]) [p <0 .0 01 ] b ot h tn t an d n tpr ob n p le ve ls in cr ea se d si gn ifi ca nt ly d ur in g th e co ur se o f h is pi ta liz at io n in th os e w ho u lti m at el y di ed [p <0 .0 01 ], bu t n o su ch d yg na m ic c ha ng es in th os e bi om ar ke rs w er e ev id en t i n su rv iv or s s hi e t a l r en m in h os pi ta l of w uh an u ni ve rs it r et ro sp ec tiv e c oh or t s tu dy c on fir m ed c o v id -1 9 in pa tie nt s be tw ee n 20 th ja n 20 20 a nd 10 th f eb 2 02 0 c o v id -1 9 in pa tie nt s w ith ou t ca rd ia c bi om ar ke rs da ta 41 6 p at ie nt s h sct ni , n tpr ob n p, c k m b , n t pr ob n p, m yo he m og lo bi n le uk oc yt e, ly m ph oc yt e, p la te le t, e ry th ro cy te , h ae m og lo bi n, c -r ea ct iv e pr ot ei n, p ro ca lc ito ni n, c re at in in e, a m in ot ra ns fe ra se (a la ni ne , a sp ar ta te ), s er um p ot as si um , s er um c al ci um d ea th , di sc ha rg ed , re m ai ne d in ho sp ita l n /a h sct ni : ca rd ia c in ju ry (0 .1 9[ 0. 08 -1 .1 2] p< 0. 00 1) v s w ith ou t (< 0. 00 6) [< 0. 00 60. 00 9] p< 0. 00 1] d ea th o f p at ie nt w ith ca rd ia c in ju ry (4 2/ 82 ) vs w ith ou t ( 15 /3 34 ) [p <0 .0 01 ] vol 53 • number 4 • october 2021 elevation of cardiac biomarkers in covid-19 389 d is ch ar ge d pa tie nt s w ith c ar di ac in ju ry (2 /8 2) vs w ith ou t ( 38 /3 34 ) [p <0 .0 01 ] p at ie nt re m ai ne d in th e ho sp ita l w ith c ar di ac in ju ry (3 8/ 82 ) v s w ith ou t (2 81 /3 34 ) [ p< 0. 00 1] c he n et a l to ng ji h os pi ta l, w uh an , c hi na r et ro sp ec tiv e c oh or t s tu dy c on fir m ed c o v id -1 9 cr iti ca lly il l in pa tie nt s be tw ee n 13 th ja n 20 20 a nd 28 th f eb 2 02 0 n ot sp ec ifi ed 27 4 p at ie nt s h stn i, n tpr ob n p w hi te b lo od c el l co un t, n eu tro ph il, ly m ph oc yt e, m on oc yt e, p la te le t, h ae m og lo bi n, c -r ea ct iv e pr ot ei n, p ro ca lc ito ni n, c re at in in e, a m in ot ra ns fe ra se (a la ni ne , a sp ar ta te ), to ta l b ili ru bi n, a lk al in e ph os ph at as e, ga m m a gl ut am yl tra ns pe pt id as e, tr ig ly ce rid es , s er um po ta ss iu m , s er um c al ci um , b lo od u re a n itr og en , c re at in e k in as e, l ac ta te de hy dr og en as e, p ro th ro m bi n tim e, ac tiv at ed p ar tia l th ro m bo pl as tin e tim e, d -d im er , f er rit in , er yt hr oc yt e, th yr oi d st im ul at in g ho rm on e, fre e tri io do th yr ox in e, fre e th yr ox in , im m un og lo bu lin (a ,g ,m ), c 3, c 4, il -1 b , il -1 re ce pt or , i l-6 , i l-8 , il10 , t um or n ec ro si s fa ct or a lp ha , u rin ar y pr ot ei n, u rin ar y o cc ul t bl oo d d ea th , r ec ov er ed n /a e le va te d h stn i i n de ce as ed p at ie nt s (6 8/ 94 [7 2% ]) vs re co ve re d pa tie nt s 15 /1 09 [1 4% ] e le va te d n tpr ob n p in de ce as ed p at ie nt s( 68 /8 0 [8 5% ]) vs re co ve re d pa tie nt s (1 7/ 93 [1 8% ]) tracy anabella hermansyah acta med indones-indones j intern med 390 g ao e t a l h ub ei g en er al h os pi ta l, c hi na r et ro sp ec tiv e o bs er va tio na l s tu dy c o v id -1 9 pa tie nt s w ith s ev er e co nd iti on s (r es pi ra to ry ra te ≥ 3 0/ m in o r r es t ox yh em og lo bi n sa tu ra tio n (s p o 2) ≤ 93 % or o xy ge na tio n in de x (a rte ria l ox yg en te ns io n/ in sp ire d ox yg en fra ct io n, p ao 2/ fi o 2) ≤ 30 0 m m h g) p at ie nt s la ck in g n tpr ob n p re su lts , p at ie nt s w ith st ro ke , ac ut e m yo ca rd ia l in fa rc tio n, m al ig na nt tu m or , a nd pr eg na nc y 54 pa rti ci pa nt s n -te rm in al pr ob -ty pe na tri ur et ic pe pt id e (n tpr ob n p ), h ig h se ns iti ve tro po ni n i ( h stn i), c re at in in e ki na se m yo ca rd ia l b an d (c k m b ) m yo ha em og lo bi n, u re a, c re at in in e, w hi te b lo od ce ll co un t, ly m ph oc yt e, c r p, p ro ca lc ito ni n d ea th , su rv iv ed n /a n tpr ob n p a re a un de r th e cu rv e (a u c ) f or in ho sp ita l m or ta lit y w as 0 .9 09 (9 5% c i 0 .7 99 –0 .9 70 , p < 0. 00 1) . us in g th e cu t-o ff 8 8. 64 p g/ m l zh an g et a l w uh an n o. 1 h os pi ta l, c hi na r et ro sp ec tiv e o bs er va tio na l s tu dy c on fir m ed o r s us pe ct ed c o v id -1 9 in pa tie nt s ad m itt ed be tw ee n 25 th d ec 2 01 9 an d 15 th f eb 20 20 , w ho un de rw en t h sct ni te st w ith in 48 h ou rs a fte r ad m is si on n on c o v id -1 9 in pa tie nt s, di d no t un de rg o hs -c tn i w ith in 4 8 ho ur s af te r ad m is si on 48 p at ie nt s h ig h se ns iti ve tro po ni n i ( h sct ni ), c re at in in e ki na se m yo ca rd ia l b an d (c k m b ) w hi te b lo od c el l co un t, ly m ph oc yt e co un t, n eu tro ph il, h ae m og lo bi n, p la te le t, th ro m bo cy te c re at in in e ki na se , a m in ot ra ns fe ra se (a la ni ne , as pr at at e) , l ac ta te de hy dr og en as e, se ru m c re at in in e, c r p, fi br og en , d -d im er d ea th , su rv iv ed d is ch ar ge d, tr an sf er re d m or ta lit y: p at ie nt s w ith el ev at ed h sct ni 7 6. 9% vs n or m al h sct ni 2 0% [p <0 .0 01 ] s te fa ni ni et a l h um an ita s c lin ic al a nd r es ea rc h h os pi ta l (r oz za no -m ila n, lo m ba rd y, it al y) r et ro sp ec tiv e o bs er va tio na l s tu dy co nfi rm ed c o v id -1 9 pa tie nt s w ith av ai la bl e da ta on c ar di ac bi om ar ke rs n o ex cl us io ns w er e ap pl ie d 39 7 pa tie nt s h ig hse ns iti vi ty tro po ni n i ( hs tn i), b -ty pe na tri ur et ic pe pt id e (b n p ) d -d im er , f ib rin og en , c r p, il -6 , f er rit in , c re at in in e, w hi te c el l co un t, n eu tro ph ils , ly m ph oc yt es , p la te le t ba se lin e, h ae m og lo bi n ba se lin e, p ro ca lc ito ni n, a lt , a lp , t ot al b ili ru bi n ba se lin e, p t ra tio ba se lin e, p tt ra tio ba se lin e, in r b as el in e n /a al l-c au se m or ta lit y ad m is si on in in te si ve ca re u ni t (ic u ), ac ut e re sp ira to ry di st re ss sy nd ro m e (a r d s ) an d sh oc k m or ta lit y ra te : el ev at ed hs -t ni (2 2. 5% , o r 4 .3 5 [9 5% c i 1. 72 11 .0 4] ) v s el ev at ed b n p (3 3. 9% , o r 7 .3 7, vol 53 • number 4 • october 2021 elevation of cardiac biomarkers in covid-19 391 [9 5% c i 3. 53 to 16 .7 5] ) vs b ot h (5 5. 6% , o r 1 8. 75 , [9 5% c i 9. 32 to 37 .7 1] ) v s w ith ou t el ev at ed ca rd ia c bi om ar ke rs (6 .2 5% ). a lp , a lk al in e ph os ph at as e; a lt , a la ni ne a m in ot ra ns fe ra se ; a r d s , a cu te r es pi ra to ry d is tre ss s yn dr om e; c i, c on fid en ce in te rv al ; c k m b , c re at in in e ki na se -m yo ca rd ia l b an d; c o v id -1 9, c or on av iru s d is ea se 2 01 9; c r p, c -r ea ct iv e p ro te in ; h sct ni , h ig h se ns iti vi ty c ar di ac tr op on in i; in r , i nt er na tio na l n or m al iz ed r at io ; i c u , i nt en si ve c ar e u ni t; il , i nt er le uk in ; n tpr ob n p, n -te rm in al p ro b ra in n at riu re tic p ep tid e; o r , o dd s r at io ; n /a , n ot a pp lic ab le ; p t, p to th ro m bi n ti m e; p tt , p ar tia l p ro th ro m bi n tim e; t nt , t ro po ni n t. tracy anabella hermansyah acta med indones-indones j intern med 392 ta bl e 4. c ri tic al a pp ra is al o f t he in cl ud ed s tu di es u si ng p ro gn os is s tu di es q ue st io nn ai re o f o xf or d c e e b m c ri te ri a s hi e t a l ( 20 20 ) g uo e t a l (2 02 0) zh an g et a l (2 02 0) zh ou e t a l (2 02 0) g ao e t a l ( 20 20 ) c he n et a l (2 02 0) s te fa ni ni e t a l (2 02 0) v a l i d i t y w as th e de fin ed re pr es en ta tiv e sa m pl e of p at ie nt s as se m bl ed a t a co m m on (u su al ly e ar ly ) p oi nt in th e co ur se o f th ei r di se as e ye s. r ec ru ite d pa rti ci pa nt s w er e pa tie nt s co nfi rm ed w ith c o v id 1 9 ac co rd in g to w h o in te rim g ui da nc e an d or ig in at ed fr om w uh an ye s. r ec ru ite d pa rti ci pa nt s w er e pa tie nt s co nfi rm ed w ith c o v id 19 a cc or di ng to w h o in te rim gu id an ce a nd or ig in at ed fro m w uh an u nc le ar . r ec ru ite d pa rti ci pa nt s w er e pa tie nt s su sp ec te d an d co nfi rm ed w ith c o v id 1 9 ac co rd in g to w h o in te rim g ui da nc e an d or ig in at ed fr om w uh an . a ll pa tie nt s w ho un de rw en t h sct ni te st w ith in 4 8 ho ur s af te r ad m is si on w er e in cl ud ed ye s. r ec ru ite d pa rti ci pa nt s w er e pa tie nt s co nfi rm ed w ith c o v id 1 9 ac co rd in g to w h o in te rim gu id an ce a nd or ig in at ed fr om w uh an ye s. r ec ru ite d pa rti ci pa nt s w er e pa tie nt s co nfi rm ed w ith c o v id 1 9 ac co rd in g to w h o in te rim g ui da nc e an d or ig in at ed fr om w uh an ye s. r ec ru ite d pa rti ci pa nt s w er e pa tie nt s co nfi rm ed w ith c o v id 1 9 ac co rd in g to g ui da nc e fo r c or on a v iru s di se as e 20 19 by th e na tio na l h ea lth co m m is si on o f c hi na an d or ig in at ed fr om w uh an ye s. y es . r ec ru ite d pa rti ci pa nt s w er e pa tie nt s co nfi rm ed w ith c o v id 1 9 ac co rd in g to w h o in te rim gu id an ce a nd or ig in at ed fr om ita ly w as p at ie nt fo llo w up s uffi ci en tly lo ng an d co m pl et e ye s ye s ye s ye s n o. b io m ar ke rs w er e on ly c ol le ct ed o n a si ng le te st a t a dm is si on ye s ye s w er e ou tc om e cr ite ri a ei th er ob je ct iv e or a pp lie d in a ‘b lin d’ fa sh io n? u nc le ar u nc le ar u nc le ar u nc le ar ye s u nc le ar u nc le ar if su bg ro up s w ith di ffe re nt p ro gn os es ar e id en tifi ed , di d ad ju st m en t fo r im po rt an t pr og no st ic fa ct or s ta ke p la ce ? ye s. a ge , co m or bi di tie s, cr ea tin in e le ve ls a nd pr ob n p w er e ta ke n ac co un t i nt o th e an al ys is n o ye s. a ge , s po 2, s er um cr ea tin in e, a nd d -d im er va lu e w er e ta ke n ac co un t in to th e an al ys is n o ye s. s ex , a ge , hy pe rte ns io n, c or on ar y he ar t d is ea se , m yo gl ob in , c k -m b , tro po ni n i, ur ea , cr ea tin in e, w hi te b lo od ce ll, ly m ph oc yt e an d pr oc al ci to ni n is ta ke n ac co un t i nt o th e an al ys is n o ye s. a ge , ly m ph oc yt e co un ts a nd d -d im er el ev at io n w er e ta ke n ac co un t i nt o th e an al ys is vol 53 • number 4 • october 2021 elevation of cardiac biomarkers in covid-19 393 i m p o r t a n c e w ha t w er e th e re su lts ? m or ta lit y ra te w as 51 .2 % a m on g pa tie nt s w ith c ar di ac in ju ry . m or ta lit y ra te w as 5 9. 6% am on g pa tie nt s w ith c ar di ac in ju ry . m or ta lit y ra te w as 7 6. 9% am on g pa tie nt s w ith ca rd ia c in ju ry . u ni va ria te o r of in -h os pi ta l de at h w ith el ev at io n of hs -c tn i v al ue 80 .0 7 th e a u c fo r i nho sp ita l de at h w as 0 .9 09 m or ta lit y ra te w as 72 % a nd 8 5% in pa tie nt s w ith in cr ea se d tro po ni n an d n tpr ob n p c on ce nt ra tio ns co ns ec ut iv el y th e a u c fo r a llca us e m or ta lit y pr ed ic to r i s 0. 93 8 h ow p re ci se a re th e pr og no st ic es tim at es ? h r o f d ea th ti m e fro m s ym pt om o ns et w as 4 .2 6 [9 5% c i, 1. 92 -9 .4 9] h r o f d ea th ti m e fro m a dm is si on to st ud y en d po in t 3 .4 1 [9 5% c i, 1. 62 -7 .1 6] u nc le ar (n o c i w as st at ed ) h r o f d ea th in e le va tio n of hs -c tn i v al ue 1 0. 9 [9 5% c i, 1. 28 -9 2. 93 ] 95 % c i, 10 .3 462 0. 36 95 % c i, 0. 79 -0 .9 7 u nc le ar (n o c i w as st at ed ) 95 % c i 1 .0 6 to 9. 93 a p p l i c a b i l i t y c an i ap pl y th is va lid , i m po rt an t ev id en ce a bo ut pr og no si s to m y pa tie nt ? ye s ye s ye s ye s ye s ye s ye s tracy anabella hermansyah acta med indones-indones j intern med 394 u s i n g a m u l t i v a r i a b l e a d j u s t e d c o x proportional hazard regression model, shi et al.21 reported a hazard ratio of death of 3.4 in patients with cardiac injury (95% confidence interval [ci], 1.62–7.16). zhang et al.19 reported a hazard ratio of death among patients with highsensitivity cardiac troponin i (hs-ctni) elevation of 10.902 (95% ci, 1.279–92.927). zhou et al.14 calculated the odds ratio of death in covid-19 patients with elevated hs-ctni levels with a univariate regression analysis, and they reported a value of 80.07 (95% ci, 10.34–620.36).19 guo et al.17 reported a higher mortality rate in patients with elevated serum troponin t levels (59.6%) than in those with normal levels (8.9%).. a single-center study conducted by gao et al.18 stated there is a significantly higher mortality rate in covid-19 patients with high nt-probnp compared with those with lower values (with a cut-off of 88.64 pg/ml); shown by the area under the curve (auc) value of 0.909 (95% ci, 0.799–0.97) and hazard ratio of 1.373 (95% ci, 1.118–1.586, p<0.001) after adjusting for other risk factors (i.e sex, age, hypertension, coronary heart disease, myoglobin, ckmb, hs-tni, urea and creatinine value. both chen et al.15 and stefanini et al.16 reported higher concentrations of hs-ctni (78% and 22.5%, respectively) and nt-probnp markers (85% and 33.9%, respectively) in deceased patients compared with those who survived. in deceased patients (85% and 33.9%, respectively) compared to those who survived.15 discussion the world health organization (who) declared covid-19 a global pandemic in early 2020.2 this novel strain of coronavirus disease has various clinical manifestations: it can be asymptomatic in some people or result in a severe condition, with acute respiratory distress syndrome (ards) or other organ failures, in others.3 recent reports have shown evidence of myocardial injury involvement in covid-19 patients, supported by the finding of elevated biomarkers, abnormal echocardiograph, and electrocardiograph in some hospitalized patients.1-2,,6 outcomes of patients with such conditions are often undesirable, and there is a high association with death.1,6 the finding of this study suggests that a higher risk of death can be found in covid-19 patients with elevated cardiac biomarkers, consistent with previous reviews on the risk of mortality outcomes from covid-19, especially for troponin i and bnp.14,17,19-20. shi et al. reported a higher mortality rate in patients with higher levels of hs-ctni (42/82) compared with those without such elevated levels (15/334).11 this result was also in concordance with zhang et al.’s finding, where the mortality rate was higher (up to 76.9%) among patients with hs-ctni elevation compared with those without such biomarker elevation (20%).20 zhou et al. reported a similar finding of a higher chance of death in patients with elevated hs-ctni levels, using a specific cutoff of 28 pg/ml.14 this supports the hypothesis of myocardial injury involvement in covid-19 related to sars-cov-2 structural s protein that binds to the ace2 receptor of the myocardium, leading to possible cardiac injury and immune reactions throughout the body. hs-ctni has mainly been used to determine troponin levels in many studies. only guo et al. used a slightly different biomarker component, tnt, to assess patients’ troponin levels. although this biomarker is less specific to define myocardial injury as a whole, other biomarkers of myocardial damage were also significantly elevated (ckmb, myoglobin, nt-probnp), providing supporting evidence of myocardial injury in patients.17 moreover, this study showed similar results to other studies that used hs-ctni, underlining that the elevation of any troponin increases patients’ risk of death. the complex mechanism of the clinical manifestation and limited information regarding disease progression indicate the need for other biomarkers to be considered when assessing patients’ prognoses. gao et al.18 reported that procalcitonin and white blood cells also make a significant contribution to predicting inhospital deaths. stefanini et al.15 and chen et al.16 reported that the values of nt-probnp and bnp were also shown to be increased in accordance with the elevation of troponin levels. this highlighted the essential need for further investigation of biomarkers’ roles in myocardial vol 53 • number 4 • october 2021 elevation of cardiac biomarkers in covid-19 395 injury in covid-19 patients and the associated prognoses, which should be conducted with better quality controls. only gao et al.18 included a bias control for the outcome analysis in the studies in this review, but an insufficient patient follow-up process was employed. all the other studies did not clearly state whether they were using blind assessment for the patients outcome or not. blinding is crucial because unblinded investigators may search more aggressively for outcomes in people with known elevated cardiac biomarkers. deciding on the underlying factors of mortality is a bit more complicated in patients with systematic diseases and requires blinding of the risk factors to ensure that it is unbiased. moreover, guo et al17, chen et al15, zhou et al14 did not make any adjustment for other prognostic factors so it may pose a significant threat to the validity of the study. limitation the study the sources we used in this systematic review have potential bias and flaws due to the limited time and resources in this pandemic condition. pre-prints articles were also used due to the as-yet limited information regarding covid-19. however, the author only included studies with relevant information. under current pandemic circumstances, we believe our study may be beneficial to the medical society and general public. conclusion although limited, there is evidence of higher mortality rate in covid-19 patients with elevated troponin and nt-probnp levels. our findings highlight the importance of evaluating myocardial injury biomarkers, especially in terms of the early analysis of troponin and ntprobnp levels. this may guide clinicians in considering the required preventive measures against further deterioration in patients’ condition and avoiding fatal outcomes. references 1. atri d, siddiqi hk, lang j, nauffal v, morrow da, bohula ea. covid-19 for the cardiologist: a current review of the virology, clinical epidemiology, cardiac and other clinical manifestations and potential therapeutic strategies. jacc: basic to translational science. 2020. doi: https://doi.org/10.1016/j. jacbts.2020.04.002. 2. mason rj. pathogenesis of covid-19 from a cell biology perspective. eur respir j. 2020;55(4):2000607. published 2020 apr 16. doi:10.1183/13993003.006072020 3. who. coronavirus disease 2019 (covid-19) situation report – 97. geneva, switzerland. who; 2020. accessed at 26/04/2020. cited from https:// www.who.int/docs/default-source/coronaviruse/ situation-reports/20200426-sitrep-97-covid-19. pdf?sfvrsn=d1c3e800_6 4. zeng jh, liu yx, yuan j, et al. first case of covid-19 complicated with fulminant myocarditis: a case report and insights [published online ahead of print, 2020 apr 10]. infection. 2020;1‐5. doi:10.1007/s15010020-01424-5 5. rizzo p, vieceli dalla sega f, fortini f, marracino l, rapezzi c, ferrari r. covid-19 in the heart and the lungs: could we «notch» the inflammatory storm?. basic res cardiol. 2020;115(3):31. published 2020 apr 9. doi:10.1007/s00395-020-0791-5 6. zheng y., ma y., zhang j, et al. covid-19 and the cardiovascular system. nat rev cardiol. 2020;17:259– 60 (2020). https://doi.org/10.1038/s41569-020-0360-5 7. hua a, o’gallagher k, sado d, byrne j. lifethreatening cardiac tamponade complicating myopericarditis in covid-19 [published online ahead of print, 2020 mar 30]. eur heart j. 2020;ehaa253. doi:10.1093/eurheartj/ehaa253 8. hu h, ma f,wei x, fang y. coronavirus fulminant myocarditis treated with glucocorticoid and human immunoglobulin, european heart journal. 2020, ehaa190. https://doi.org/10.1093/eurheartj/ehaa190 9. gao et al. role of troponin i proteolysis in the pathogenesis of stunned myocardium. aha j. 2020;80(3):393-9. https://doi.org/10.1161/01. res.0000435855.49359.47 10. sharma s, jackson pg, makan j. cardiac troponins. j clin pathol. 2004;57(10):1025‐6. doi:10.1136/ jcp.2003.015420 11. babapoor-farrokhran s, gill d, walker j, rasekhi rt, bozorgnia b, amanullah a. myocardial injury and covid-19: possible mechanisms. life sci. 2020;253:117723. doi:10.1016/j.lfs.2020.117723 12. c l e r k i n k j , f r i e d j a , r a i k h e l k a r j , e t a l . c o r o n a v i r u s d i s e a s e 2 0 1 9 ( c o v i d 1 9 ) a n d cardiovascular disease [published online ahead of print, 2020 mar 21]. circulation. 2020;10.1161/ circulationaha.120.046941. 13. liberati a, altman dg, tetzlaff j, et al. the prisma statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. plos med. 2009;6(7):e1000100. doi:10.1371/journal. pmed.1000100 tracy anabella hermansyah acta med indones-indones j intern med 396 14. zhou f, yu t, du r, et al. clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study [published correction appears in lancet. 2020;395(10229):1038] [published correction appears in lancet. 2020 mar 15. chen tao, wu di, chen huilong, et al. clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. bmj. 2020; 368 16. stefanini, et al. early detection of elevated cardiac biomarkers to optimise risk stratification in patients with covid-19. heart. 2020;106:1512–8. 17. guo t, fan y, chen m, et al. cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (covid-19) [published online ahead of print, 2020 mar 27]. jama cardiol. 2020;e201017. doi:10.1001/jamacardio.2020.1017 18. gao l., jiang d., wen x, et al. prognostic value of nt-probnp in patients with severe covid-19. respir res. 2020;21:83. https://doi.org/10.1186/s12931-02001352-w 19. zhang, et al. myocardial injury is associated with in-hospital mortality of confirmed or suspected covid-19 in wuhan, china: a single center retrospective cohort study 20. preprint medrxiv. 2020. doi: https://doi.org/10.1101/ 2020.03.21.20040121. 21. shi s, qin m, shen b, et al. association of cardiac injury with mortality in hospitalized patients with covid-19 in wuhan, china. jama cardiol. published online march 25, 2020. doi:10.1001/jamacardio.2020.0950 19acta med indones indones j intern med • vol 54 • number 1 • january 2022 original article correlation of moxifloxacin concentration, c-reactive protein, and inflammatory cytokines on qtc interval in rifampicin-resistant tuberculosis patients treated with shorter regimens tutik kusmiati1,2, ni made mertaniasih3*, johanes nugroho eko putranto4, budi suprapti5, nadya luthfah4, soedarsono2, winariani koesoemoprodjo2, aryani prawita sari2 1 doctoral program of medical science, faculty of medicine universitas airlangga, surabaya, indonesia. 2 department of pulmonology and respiratory medicine, faculty of medicine universitas airlangga, surabaya, indonesia. 3 department of clinical microbiology, faculty of medicine universitas airlangga, surabaya, indonesia. 4 department of cardiology and vascular medicine, faculty of medicine universitas airlangga, surabaya, indonesia. 5 department of clinical pharmacy, faculty of pharmacy universitas airlangga, surabaya, indonesia. *corresponding author: ni made mertaniasih, md. department of clinical microbiology, faculty of medicine universitas airlangga. jl. mayjen prof. dr. moestopo no. 47, surabaya, indonesia. email: nmademertaniasih@gmail.com. abstract background: drug-resistant tuberculosis (dr-tb) is a global health concern. qtc prolongation is a serious adverse effect in dr-tb patients receiving a shorter regimen. this study aimed to evaluate the correlation of moxifloxacin concentration, crp, and inflammatory cytokines with qtc interval in dr-tb patients treated with a shorter regimen. methods: this study was performed in 2 groups of rifampicin-resistant (rr-tb) patients receiving shorter regimens. correlation for all variables was analyzed. results: crp, il-1β, and qtc baseline showed significant differences between 45 rr-tb patients on intensive phase and continuation phase with p-value of <0.001, 0.040, and <0.001, respectively. tnf-α and il-6 between rr-tb patients on intensive phase and continuation phase showed no significant difference with p=0.530 and 0.477, respectively. crp, tnf-α, il-1 β, and il-6 did not correlate with qtc interval in intensive phase (p=0.226, 0.281, 0.509, and 0.886, respectively), and also in continuation phase (0.805, 0.865, 0.406, 0.586, respectively). at 2 hours after taking the 48th-dose, moxifloxacin concentration did not correlate with qtc interval, both in intensive phase (p=0.576) and in continuation phase (p=0.691). at 1 hour before taking the 72nd-hour dose, moxifloxacin concentration also did not correlate with qtc interval in intensive phase (p=0.531) and continuation phase (p=0.209). conclusion: moxifloxacin concentration, crp, and inflammatory cytokines did not correlate with qtc interval in rr-tb patients treated with shorter regimens. the use of moxifloxacin is safe but should be routinely monitored and considered the presence of other risk factors for qtc prolongation in rr-tb patients who received shorter regimens. keywords: drug-resistant tuberculosis, shorter treatment regimen, qtc interval. tutik kusmiati acta med indones-indones j intern med 20 introduction tuberculosis (tb) caused by mycobacterium tuberculosis strains resistant to anti-tb drugs is becoming a global health concern with an increasing number of cases. world health organization (who) reported 465,000 cases of drug-resistant tuberculosis (dr-tb) in 2020 with a treatment success rate of 57%. indonesia currently ranks 5th for countries with high dr-tb cases with a treatment success rate of less than 50%, due to the high mortality rate and loss to follow-up.1 in 2016, the who recommended a standardized shorter regimen off 9-12 months to treat multidrug-resistant/rifampicin-resistant (mdr/rr-tb) patients with a specific inclusion criteria.2 indonesia started to implement the shorter regimen in 2017.3 however, not all mdr/rr-tb patients were treated with shorter regimens until the end of treatment and 16/224 (7%) of patients switched their regimens from shorter regimen to individual regimens due to the presence of prolonged qt.4 another study reported the incidence of increased qtc interval of >30 ms in 21/98 (21.4%) and >60 ms in 10/98 (10.2%) of dr-tb patients who received shorter regimens.5 interval qt prolongation is a serious adverse effect and can potentially cause torsade de pointes (tdp) and sudden cardiac death.6 moxifloxacin is one of the components of shorter regimen and is often criticized for its higher risk of qtc interval prolongation and tdp.[4,6] according to the national program, moxifloxacin was given in 400 mg, 600 mg, or 800 mg dosages based on body weight.3 inflammatory activation due to systemic inflammation was indicated as a new potential cause of acquired long qt syndrome via cytokine-mediated changes in cardiomyocyte ion channels.7 impaired expression and or function of several cardiac ion channels was affected by systemically or locally released inflammatory cytokines (mainly tnf-α, il1, and il-6), resulting in a decrease of k+ currents and or an increase of ical. cardiac or systemic inflammation promotes qtc-interval prolongation via cytokine-mediated effects, and this may increase sudden cardiac death risk.8 c-reactive protein (crp) is one of the acute phase proteins that increases during systemic inflammation.9,10 it is also commonly used as a prognostic marker in tb.11 elevated crp serum level is a strong independent predictor of heart disease and cardiovascular disease in asymptomatic individuals.9,10 xie et al. (2015) suggested that crp may directly or indirectly influence qtc interval via influencing the expression of k+ channel interaction protein 2 (kchip2) and formation of transient outward potassium current (ito.f) density of cardiomyocytes.12 p r o l o n g a t i o n o f q tc i n t e r v a l i s usually asymptomatic and requires routine electrocardiography (ecg) monitoring during treatment using qt-prolonging drug.2,13 hence, it is very important to thoroughly assess dr-tb patients before attributing qtc prolongation solely due to anti-tb drugs.14 although several studies have reported qt prolongation in drtb, the correlation of inflammatory markers and qtc interval is still rarely being studied. in this study, we aimed to evaluate the correlation of moxifloxacin concentration, crp, and inflammatory cytokines with qtc interval in dr-tb patients treated with shorter regimen. methods an observational analytic study with consecutive sampling was conducted from september 2019 to february 2020 in dr. soetomo hospital surabaya, one of east indonesia tb referral hospitals. study subjects were rr pulmonary tb patients based on the genexpert examinations with age 18 to 65 years old who will start the intensive phase and who are on the continuation phase of shorter treatment regimens. rr-tb patients with baseline qtc >500 ms, potassium <3.5 mmol/l, magnesium <1.7 mmol/l, calcium <8.5 mmol/l, creatinine clearance <30 cc/m, aspartate aminotransferase alanine aminotransferase (ast-alt) >5x upper limit normal (uln), body mass index (bmi) <18 kg/m2, on anti-arrhythmia therapy, antidepressant therapy, with bradycardia, anti-fungal treatment (azoles), erythromycin therapy, and phenytoin therapy were excluded from this study. vol 54 • number 1 • january 2022 correlation of moxifloxacin concentratin, c-reactive protein 21 the respondents were given an explanation of the research and publications to be carried out. all respondents information is kept confidential and only used for research purposes. after getting an explanation, the respondent is allowed to refuse the study or resign in the middle of the study. the respondents gave their written consent and permission for publication of the letters and to participate in the research. we confirm that all the research meets the ethical guidelines and in accordance with the declaration of helsinki. ethics an informed consent was signed by all participants and the ethics committee of dr. soetomo hospital with ethical clearance number 1444/kepk/viii/2019 on august 23rd, 2019. operational definition rifampicin-resistant tuberculosis (rr-tb) was defined as the results of mycobacterium tuberculosis detected with rifampicin resistance based on genexpert mtb/rif.15 rr-tb patients in intensive phase were defined as rr-tb patients who are eligible for shorter regimens and will start intensive phase of treatment. rr-tb patients in continuation phase were defined as rr-tb patients who have completed the intensive phase (4-6 months), i.e. those who have sputum smear conversion after the 4th, 5th, or 6th month. shorter regimens were as recommended by the who in 2016 and the national program in 2019, consisted of 4-6 km – mfx – eto(pro) – hhigh dose – cfz – e – z / 5 mfx – cfz – e – z for 9-11 months.2,16 electrocardiography (ecg) was defined as a 12-lead surface heart recording using an ecg machine. the qt interval is that portion of the ecg that begins at the start of the qrs complex and ends at the termination of the t wave. the qtc referred to the corrected qt interval using the fredericia formula.14 the changes of qtc (δqtc) referred to the difference between the qt interval at baseline and the qt interval at 2 hours after taking the 48th-hour dose, and 1 hour before taking the 72nd-hour dose. concentration of moxifloxacin blood samples were collected and put into heparin tubes at 2 hours after taking the 48th-hour dose and 1 hour before taking the 72nd-hour dose. blood samples were centrifuged and the plasma was stored in the deep freezer with a temperature of -800 c. the moxifloxacin concentration was measured by a validated method using highperformance liquid chromatography (hplc). the separation of moxifloxacin from the plasma matrix using protein precipitation, followed by measurements using the waters hplc alliance e2695 with a detector of waters 2998 photodiode array (pda). 240 µl of acetonitrile solution (100%) was added to the 200 µl of plasma sample. the sample was then vortexed for 1 minute and centrifuged at a speed of 10,000 g for 5 minutes. a total of 200 µl of supernatant was put into the vial and injected into the hplc with an injection volume of 10 µl. separation using a sunfiretm c18 column (4.6 x 100 mm, 5 µm; waters, ireland). the mobile phase consisted of 0.4% tea in aquabides with a ph of ±3 and 100% of acetonitrile (75%:25% (v/v)). the flow rate is 1 ml/min and the pda detector was set at a wavelength of 296 nm. accuracy for standard concentration curves is between 95.5% to 103.4%, depends on the standard concentration level. the coefficient of variation for intraand inter-assay was less than 7.2% for the range from 0.204 to 10,200µg / ml. the lowest limit value which can be quantified was 0.204 µg/ml. measurement of crp levels venous blood samples from each subject were collected into heparin tubes. serum was separated by centrifugation at 3,000 rpm for 5 minutes and stored at 40 c for 24 hours for the analysis.9 crp levels were determined by an immunoturbidimetric assay using siemens dimension clinical chemistry system for quantitative determination of crp in serum and plasma. this instrument automatically calculates and prints the concentration of crp in [mg/l] mg/dl. analytical measurement range was 0.5250.0 mg/l or 0.05-25.00 mg/dl. measurement of inflammatory cytokines levels samples of venous blood with an amount of 5 cc were taken from each patient and put into edta serum tubes. all samples were stored in a deep freezer with a temperature of -800 c. after tutik kusmiati acta med indones-indones j intern med 22 the samples had sufficient amounts, all samples were put at room temperature for 2 hours or at 40 c for a night. the samples were centrifuged for 15 minutes to separate the blood plasma and serum. the cytokines levels were measured using the elisa method with a kit of elabsiences. qtc interval measurement qt interval was measured automatically using ecg machine merc blt e30 (guangdong biolight meditech, germany, 2017) at baseline before treatment, 2 hours after taking the 48thhour dose, and 1 hour before taking the 72nd-hour dose. heart rate-corrected qt (qtc) interval was calculated using fredericia formula,[14] manually by cardiologists. data analysis and ethical statement the data obtained in this study were presented as tables and graphics. data were analyzed using spss 21.0 software (ibm corp., armonk, ny, usa). p-value <0.05 was considered as significant statistically. this study was conducted in accordance with the declaration of helsinki. an informed consent was signed by all participants. this study was approved by the ethics committee of dr. soetomo hospital with ethical clearance number 1444/kepk/viii/2019 on august 23rd, 2019. results this study included 29 rr-tb patients on intensive phase and 16 rr-tb patients on continuation phase of shorter regimens. the clinical symptoms found in this study were cough, fever, chest pain, haemoptysis, weight loss, night sweats, dyspnea at rest, and dyspnea during activity. table 1 showed that the clinical symptoms of rr-tb patients improved in continuation phase, but there is no significant difference between the reported symptoms in intensive phase and continuation phase. albumin, crp, il-1β, qtc baseline, and qtc at 2 hours after the 48th dose showed significant differences between rr-tb patients on intensive phase and continuation phase with p = 0.002, <0.001, 0.040, <0.001, and 0.026, respectively. while tnf-α, il-6, moxifloxacin concentration at 2 hours after the 48th dose, moxifloxacin concentration and qtc at 1 hour before 72nd dose between rr-tb patients on intensive phase and continuation phase showed no significant difference with p = 0.530, 0.477, 0.686, 0.610, and 0.325. this was presented in table 1. table 2 showed that crp, tnf-α, il-1β, and il-6 did not correlate with qtc interval in intensive phase with p = 0.226, 0.281, 0.509, and 0.886, respectively. crp, tnf-α, il-1β, and il-6 also did not correlate with qtc interval in continuation phase with p = 0.805, 0.865, 0.406, and 0.586, respectively. this result indicated that inflammatory markers could not predict qtc interval in our study. at 2 hours after the 48th dose, it was known that moxifloxacin concentration did not correlate with qtc interval and δqtc, both in intensive phase (p = 0.576 and 0.415) and continuation phase (p = 0.691 and 0.353). at 1 hour before the 72ndhour dose, moxifloxacin concentration also did not correlate with qtc interval and δqtc in intensive phase with p = 0.531 and 0.813, and in continuation phase with p = 0.209 and 0.464, as presented in table 3. scatter plot in figure 1 showed that the distribution of crp, tnf-α, il-1β, and il-6 did not correlate with qtc interval. levels of crp, tnf-α, il-1β, and il-6 are overlapping between intensive and continuation phases, while qtc interval showed an increased in continuation phase. t h e d i s t r i b u t i o n o f m o x i f l o x a c i n concentration and qtc interval at 2 hours after taking the 48th-hour dose and 1 hour before taking the 72nd-hour dose did not form a specific pattern as presented in figure 2. this scatter plot showed that moxifloxacin concentration did not correlate with qtc interval, as the results of correlation analysis in table 3. discussion multidrug-resistant/rifampicin-resistant tb (mdr/rr-tb) is an emerging threat to tb control, with clinical presentation of patients with mdr/rr-tb being identical to that of patients with drug-susceptible disease.[17] all patients with rr-tb in this study were symptomatic, most commonly with cough (66.7% in intensive phase and 33.3% in continuation phase), other symptoms including fever, chest pain, vol 54 • number 1 • january 2022 correlation of moxifloxacin concentratin, c-reactive protein 23 table 1. characteristics of study subjects characteristics rr-tb on start of intensive phase (n=29) rr-tb on start of continuation phase (n=16) p-value age (years)* 37 (18-62) 44 (19-56) 0.569 sex** women men 13 (59%) 16 (70%) 9 (41%) 7 (30%) 0.673 bmi (m/kg2)* 20.4 (18.03-28.65) 19.06 (18.26-27.68) 0.530 diabetes mellitus** 14 (73.7%) 5 (26.3%) 0.429 cough** 28 (66.7%) 14 (33.3%) 0.285 fever** 12 (75%) 4 (25%) 0.272 chest pain** 6 (100%) 0 (0%) 0.075 haemoptysis** 9 (64.3%) 5 (35.7%) 1.000 weight loss** 14 (60.9%) 9 (39.1%) 0.608 night sweats** 10 (71.4%) 4 (28.6%) 0.738 dyspnea at rest** 3 (60%) 2 (40%) 1.000 dyspnea during activity** 7 (70%) 3 (30%) 1.000 potassium (mmol/l)*** 4.3 ± 0.45 3.96 ± 0.4 0.019 calcium mg/dl)*** 9.03 ±0.46 8.67 ± 0.2 0.001 albumin*** 3.43 ± 0.28 3.65 ± 0.14 0.002 crp (mg/dl)* 1.5 (0.2-10.9) 0.15 (0.1-0.6) <0.001 tnf-α (pg/ml)* 6.8 (0.13-36.22) 4.79 (0-43.34) 0.530 il-1β (pg/ml)* 20.13 (2.23-708.7) 7.42 (0.6-113.47) 0.040 il-6 (pg/ml)* 43.17 (10.14-1076) 40.61 (4.47-113.99) 0.477 qtc baseline(ms)*** 417.28 ± 31.2 455.94 ± 16.6 <0.001 moxifloxacin ** 600 800 17 (60.8%) 12 (70.6%) 11 (39.2%) 5 (29.4%) 0.727 moxy conc (48+2) (µg/ml)*** 4.3 ± 2.32 4.61 ± 2.54 0.686 qtc 48+2 (ms)*** 444.38 ± 31.25 467.94 ± 35.7 0.026 ∆qtc (48+2)-baseline (ms)* 20 ((-17) – (81)) 2.5 ((-44) – (115)) 0.036 moxy conc (72-1) (µg/ml)* 1.01 (0.01 – 3.27) 0.91 (0.01 – 1.61) 0.610 qtc 72-1 (ms)* 448 (386-518) 447 (428-524) 0.325 ∆qtc (48+2) (72-1) (ms)* 0 ((-75) – (60)) 7.5 ((-77) – (52)) 0.122 * median (min-max) using mann-whitney test; ** chi-square; ***mean ± standard deviation using t-test; bmi = body mass index. table 2. correlation analysis at baseline using pearson or spearman-rho test intensive phase qtc baseline continuation phase qtc baseline r p r p crp (mg/dl) -0.232 0.226 crp (mg/dl) 0.067 0.805 tnf-α (pg/ml) 0.207 0.281 tnf-α (pg/ml) 0.046 0.865 il-1β (pg/ml) 0.128 0.509 il-1β (pg/ml) -0.223 0.406 il-6 (pg/ml) -0.028 0.886 il-6 (pg/ml) -0.147 0.586 r: correlation coefficient; p: sig. (2-tailed). table 3. correlation analysis at 2 hours after the 48th dose and at 1 hour before the 72ndhour dose moxi conc at 48+2 moxi conc at 72-1 intensive phase qtc at 48+2 r -0.108 qtc at 72-1 r 0.121 p 0.576 p 0.531 ∆qtc ((48+2) – baseline)) r -0.157 ∆qtc ((48+2) – (72-1)) r -0.046 p 0.415 p 0.813 continuation phase qtc at 48+2 r 0.108 qtc at 72-1 r -0.332 p 0.691 p 0.209 ∆qtc ((48+2) – baseline)) r 0.249 ∆qtc ((48+2) – (72-1)) r -0.197 p 0.353 p 0.464 correlation analysis using pearson or spearman-rho test; r: correlation coefficient; p: sig. (2-tailed). tutik kusmiati acta med indones-indones j intern med 24 haemoptysis, weight loss, night sweats, dyspnea at rest, and dyspnea during activity. a study in 93 mdr-tb patients by brode et al. (2015) also reported productive cough as the most common symptoms in mdr-tb, followed by weight loss, malaise, fever, haemoptysis, night sweats, and chest pain.18 the symptoms were more often reported in intensive phase, then improved in continuation phase (table 1), as the intensive phase of rr-tb treatment aimed to significantly decrease the bacillary burden. the improved symptoms may results from the decreased bacillary burden and the decreased inflammation (inflammation caused by mycobacterium tuberculosis infection) after intensive phase of treatment. interval qtc prolongation is a serious effect and is often reported in dr-tb patients treated with shorter regimens. moxifloxacin is considered as a qt-prolonging drug and is often criticized to cause qtc prolongation in dr-tb patients.1,6 moreover, qt prolongation related to inflammatory factors also has been widely reported, as has been known that inflammation occurs as a response to injury, lipid peroxidation, and infection, including tb infection.26 in this study, rr-tb patients on intensive phase of shorter regimen have a higher level of crp, tnf-α, il-1β, and il-6 levels, compared to those in continuation phase. crp and il-1β, and qtc baseline were significantly different between rr-tb patients on intensive phase and continuation phase with p-value of <0.001, 0.040, and <0.001, respectively. while tnf-α and il-6 figure 1. scatter plot of inflammatory cytokines (tnf-α, il-1β, and il-6), c-reactive protein, and baseline of qtc interval in rr-tb patients. vol 54 • number 1 • january 2022 correlation of moxifloxacin concentratin, c-reactive protein 25 between rr-tb patients on intensive phase and continuation phase showed no significant difference with p = 0.530 and 0.477, respectively (table 1). a higher level of inflammatory biomarkers in intensive phase showed that the inflammation due to mycobacterium tuberculosis infection was still high because the patients have just received dr-tb treatment, while patients on continuation phase have been treated for a few months and have experienced sputum conversion which indicated decreased inflammation in lung tissue. pulmonary tb infection ellicits an inflammatory process in lung tissue, which is correlated with crp levels changes,27 and induction of inflammatory cytokines to regulate immune system.25 this immune process depends on th1-cell activity, including tnf-α. il-1β directly kills mycobacterium tuberculosis in macrophages. il-6 is a requirement in host resistance to infection. ifn-γ , tnf-α , il-12.28 at baseline examination, qtc interval in continuation phase was found higher than intensive phase (table 1), while correlation analysis in table 2 showed that crp, tnf-α, il-1β, and il-6 did not correlate with qtc interval in intensive phase and continuation phase. this was different from previous studies that reported a correlation between inflammation marker and qtc prolongation. crp levels were found higher and correlated with qtc prolongation in hypertensive and rheumatoid arthritis patients.21-23 other studies reported increased tnf-α in elderly general population, elevated il-6 levels in patients who experienced tdp, and higher levels of il-1β in patients with connective tissue diseases, all being risk factors for long qtc intervals. t h e c o r r e l a t i o n b e t w e e n c r p a n d cardiovascular risk is through systemic inflammation. inflammatory cytokines such as tnf-α, il-6, and il-1 act directly on cardiomyocyte ion channels expression and function, and may represent a risk factor for qtc prolongation.7 another study found that il-6 negatively affected cardiomyocyte ion channel function and increased risk for qt prolongation, suggesting that patients with high levels of il-6 should receive routine ecg and counseling if other qtc prolonging risk factors are present. systemic inflammation promotes qtc-interval prolongation via cytokine-mediated effects. released inflammatory cytokines are able to directly affect the expression and/or function of several cardiac ion channels, resulting in a decrease of k+ current and/or an increase of calcium current. while in this present study, it was shown that inflammation due to dr-tb infection did not correlate with qtc interval (table 2). another factor was considered for acquiring qtc prolongation, and moxifloxacin as a component in the standardized shorter regimen was suspected to induce qtc prolongation. the mechanism of drug-induced qt prolongation is due to blockage of the human ether a-go-go gene (herg) that is responsible for the inward potassium rectifier (ikr) repolarizing current. [31-33] our study showed that at 2 hours after the 48th dose, moxifloxacin concentration did not correlate with qtc interval, both in intensive and continuation phases. at 1 hour before the 72ndhour dose, moxifloxacin also did not affect qtc interval in intensive and continuation phases (table 3). yoon et al. (2017) also revealed the safe use of moxifloxacin on qtc changes in dr-tb patients. moxifloxacin at the dosage of 400, 600, or 800 mg does not correlate with the qtc interval. moxifloxacin is relatively safe, and the prolongation caused by moxifloxacin is considered minimal or moderate, but should be carefully monitored when other risk factors are present. qt prolongation is usually asymptomatic and requires routine ecg monitoring during qt drug use, to ensure the safe use of moxifloxacin and prevent serious adverse effects which can be life-threatening. conclusion o u r s t u d y f o u n d t h a t m o x i f l o x a c i n concentration, crp, and inflammatory cytokines did not correlate with qtc interval in dr-tb patients treated with shorter regimens. the use of moxifloxacin is safe but should be routinely monitored and considered the presence of other risk factors for qtc prolongation in dr-tb patients received shorter regimens. tutik kusmiati acta med indones-indones j intern med 26 acknowledgments the authors would like to thank mrs. atika, m.sc., who helped us in statistical analysis. conflict of interests the authors report no conflicts of interest in this work. references 1. world health organization. global tuberculosis report. geneva: world health organization; 2020. 2. world health organization. who treatment guidelines for drug-resistant tuberculosis: 2016 update. geneva: world health organization; 2016. 3. indonesian ministry of health. technical guideline for drug-resistant tuberculosis treatment with shorter regimens in health care facility. jakarta: indonesian ministry of health; 2017. 4. soedarsono s, kusmiati t, wulaningrum pa, et al. factors cause of switching shorter regimen to longer regimen in multidrug-resistant/ rifampicin-resistant tuberculosis treated patients in dr. soetomo hospital surabaya, indonesia. indian j med forensic med toxicol 2021; 15: 1589-1595. 5. kusmiati t, mertaniasih nm, putranto jn, et al. factors that contribute to the qtc interval prolongation in drtb patients on str regimen. indian j med forensic med toxicol 2020; 15: 1618-1625. 6. khan f, ismail m, khan q, ali z. moxifloxacininduced qt interval prolongation and torsades de pointes: a narrative review. expert opin drug saf 2018; 17(10). https://doi.org/10.1080/14740338.201 8.1520837. 7. lazzerini pe, laghi-pasini f, bertolozzi i, morozzi g, lorenzini s, simpatico a, et al. systemic inflammation as a novel qt-prolonging risk factor in patients with torsades de pointes. heart (british cardiac society) 2017; 103 (22):1821-1829. doi:10.1136/ heartjnl-2016-311079. 8. lazzerini pe, capecchi pl, el‐ sherif n, pasini fl, boutjdir m. emerging arrhythmic risk of autoimmune and inflammatory cardiac channelopathies. j am heart assoc 2018; 7: e010595. doi: 10.1161/ jaha.118.010595. 9. kim e, joo s, kim j, ahn j, kim j, et al. association between c-reactive protein and qtc interval in middleaged men and women. eur j epidemiol 2006; 21(9): 653–659. 10. sproston nr, ashworth. role of c-reactive protein at sites of inflammation and infection. front immunol 2018; 9: 754. 11. pansey p, shukla s, acharya s. serum c-reactive protien (crp) a dependent prognostic marker in pulmonary tuberculosis. international journal of contemporary medical research 2017;4(10):21112114. 12. xie y, mai jt, wang f, lin yq, yuan wl, luo ns, fang mc, wang jf, chen yx. effects of c-reactive protein on k+ channel interaction protein 2 in cardiomyocytes. am j trans res 2015; 7(5): 922-931. 13. yoon hy, jo kw, nam gb, shim ts. clinical significance of qt-prolonging drug use in patients with mdr-tb or ntm disease. int j tuberc lung dis 2017; 21(9): 996-1001. 14. united states agency for international development. guide for qtc monitoring and management of drugresistant tb patients with qt-prolonging agents. new york: usaid; 2018. 15. indonesian ministry of health. technical guideline for programmatic management of drug resistant tuberculosis. jakarta: indonesian ministry of health; 2014. 16. indonesian ministry of health. guidelines for drugresistant tuberculosis management in health care facility. jakarta: indonesian ministry of health; 2019. 17. weyer k. multidrug-resistant tuberculosis. cme 2005; 23(2): 74-84. 18. brode sk, varadi r, mcnamee j, malek n, stewart s, jamieson fb, et al. can respir j 2015; 22(2): 97-102. 19. migliori gb, tiberi s, zumla a, petersen e, chakaya jm, wejse c, et al. mdr/xdr-tb management of patients and contacts: challenges facing the new decade. the 2020 clinical update by the global tuberculosis network. int j infect dis 2020; 92s: s15-s25. 20. kusmiati t, suci yd, dewi kp, et al. qtc interval prolongation in drug resistant tuberculosis patients treated with shorter treatment regimens. med leg j update 2021; 21: 1208-1215. 21. chang kt, shu hs, chu cy, lee wh, hsu pc, du hm, et al. association between c-reactive protein, corrected qt interval and presence of qt prolongation in hypertensive patients. kaohsiung journal of medical sciences 2014; 30: 310-5. 22. kobayashi h, kobayashi y, yokoe i, kitamura n, nishiwaki a, takei m, et al. heart rate–corrected qt interval duration in rheumatoid arthritis and its reduction with treatment with the interleukin 6 inhibitor tocilizumab. j rheumatol 2018;45:1620-7. 23. panoulas vf, toms te, douglas km, sandoo a, metsios gs, kalinoglou as, et al. prolonged qtc interval predicts all-cause mortality in patients with rheumatoid arthritis: an association driven by high inflammatory burden. rheumatology 2014;53:131-7. 24. medenwald d., kors ja, loppnow h, thiery j, kluttig a, nuding s, et al. inflammation and prolonged qt time: results from the cardiovascular disease, living and ageing in halle (carla) study. plos one 2014; 9(4):e95994. 25. pisoni cn, reina s, arakaki d, eimon a, carrizo c, borda e. elevated il-1beta levels in anti-ro/ssa connective tissue diseases patients with prolonged vol 54 • number 1 • january 2022 correlation of moxifloxacin concentratin, c-reactive protein 27 corrected qtc interval. clin exp rheumatol 2015; 33(5): 715–20. 26. willerson jt, ridker pm. inflammation as a cardiovascular risk factor. circulation 2004; 109[suppl ii]:ii-2–ii-10.). 27. soedarsono s, subiantoro mc. changes of crp serum levels in pulmonary tb patients with afb smear-positive sputum before and two months after receiving anti-tuberculosis drug treatment. indian j tuberc 2019; 66: 134-8. 28. romero-adrian tb, leal-montiel j, fernandez g, valecillo a. role of cytokines and other factors involved in the mycobacterium tuberculosis infection. world j immunol 2015; 5(1): 16-50. 29. chandrashekara s. c reactive protein: an inflammatory marker with specific role in physiology, pathology, and diagnosis. ijrci 2014; 2(s1): sr3. doi: 10.15305/ijrci/v2is1/117. 30. aromolaran as, srivastava u, ali a, chahine m, lazaro d, el-sherif n, et al. interleukin-6 inhibition of herg underlies risk for acquired long qt in cardiac and systemic inflammation. plos one 2018; 13(12): e0208321. https://doi.org/10.1371/journal. pone.0208321. 31. wa t s o n k j , g o r c z y c a w p, u m l a n d j , e t a l . pharmacokinetic–pharmacodynamic modelling of the effect of moxifloxacin on qtc prolongation in telemetered cynomolgus monkeys. j pharmacol toxicol methods 2011; 63: 304-313. 32. nachimutu s, assar md, schussler jm. drug-induced qt interval prolongation: mechanisms and clinical management. ther adv drug saf 2012; 3: 241-253. 33. cubeddu, l. drug-induced inhibition and trafficking disruption of ion channels: pathogenesis of qt abnormalities and drug-induced fatal arrhythmias. curr cardiol rev 2016; 12: 141-154. 226 acta med indones indones j intern med • vol 55 • number 2 • april 2023 special article sleep problem in post covid-19 patient, its impact on quality of life and current management: an evidence-based of case report hamzah shatri1,2, rizka zainudin1, yanuar ardani1, edward faisal1, rudi putranto1 1 division of psychosomatic and palliative, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo national hospital, jakarta, indonesia. 2 clinical epidemiology unit, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo national hospital, jakarta, indonesia. *corresponding author: hamzah shatri, md., phd. psychosomatic and palliative division, department of internal medicine, faculty medicine universitas indonesia cipto mangunkusumo national hospital. jl diponegoro no. 71, jakarta 10430, indonesia. email: hshatri@yahoo.com; psikosomatik.paliatif@gmail.com. abstract background: covid-19 is a global health problem that affects both physical and psychological aspect of patients. sleep problems were experienced by many patients during the acute phase of after covid-19 recovery. it affects patient’s quality of life and required comprehensive management. this evidence-based case report aims to study the effect of sleep disturbance on quality of life and what is the appropriate management in post covid-19 patients. methods: searching were conducted in pubmed, cohcrane, ebsco according to clinical questions. study was selected based on inclusion and exclusion criteria, then it was critically appraised. results: high score on the insomnia severity index and the pittsburgh sleep quality index were found to be associated with quality of life. cognitive behavioural therapy is currently the best evidence-based treatment in patient during and after covid-19. conclusion: sleep disturbance is a problem that many post covid-19 patient face and cbt can improve their quality of life. keywords: sleep problem, post covid-19, quality of life, cognitive behavioural therapy. introduction covid-19 pandemic became a worldwide devastating health issue starting in december 2019 in china and then gradually was a global health problem. the world health organization (who) on march 2020 has declared the novel coronavirus (covid-19) outbreak a global pandemic and the world should be more aggressive in facing this infection.1 as of march 2022, globally there have been more than 400 billion confirmed cases of covid-19, including 6 billion death. in indonesia there have been more than 5 billion cases and around 150,000 death.2 covid-19 has double weapon on physical and mental domains of health. along with its high infectivity and fatality rates, covid-19 has caused universal psychosocial impact by causing mass hysteria, economic burden, and financial losses, social curfew and ambiguity about the future.3 furthermore, quarantine leading to emergence of fearful reaction, stressful condition, significant anxiety and sleep disorder among general population.4 study showed that mental health problems, such as depression, anxiety, insomnia and post-traumatic stress disorder (ptsd), dramatically increased after covid-9 pandemic.4 vol 55 • number 2 • april 2023 sleep problem in post covid-19 patient, its impact on quality of life 227 sleep is an important biological mechanism for maintaining homeostasis and quality of life. sleep problems negatively affected the immune response by their effect on circadian rhythm of the body. ptsd after recovery from covid-19 have been correlated to sleep problems, high anxiety level and depressive manifestations, also quality of life of front liner workers and patients was extremely burdened during the post recovery period.4 clinical question a female patient, 40 years old, came to the psychosomatic clinic with complaints of sleeping problem since last month. the patient said that it was difficult to start sleeping and woke up several times during the night. one month ago the patient had a covid-19 infection and was hospitalized because she had oxygen desaturation up to 90% (room air). since then, the patient was afraid due to her history of shortness of breath and still remembered several times saw other patients died because of covid-19 when hospitalized. at this time there were no complaints of shortness of breath, cough, and fever. the patient is a housewife and does not have any children. the patient’s husband is a bus driver. there was no previous history of psychiatric disorders or sleep disturbances. methods a comprehensive literature searching was conducted on march 6 th 2022 to answer the question mentioned by exploring several online databases such as pubmed, cochrane library, and ebsco. the keyword used are “sleep disorder”, “sleep problem”, insomnia, “post covid”, “after covid, and “quality of life” combined with boolean operator “and” and “or” were used. articles obtained were screened according to predetermined selection criteria. the articles were selected based on inclusion and exclusion criteria. the inclusion criteria included: (1) research articles including metaanalyses, systematic reviews, randomized c o n t r o l l e d t r i a l s , o b s e r v a t i o n a l s t u d i e s , quantitative studies, qualitative studies, and mixed method studies evaluating sleep problem or sleep disorder or insomnia ; (2) post covid-19 or after covid-19 population; (3) determining quality of life on different domain. the exclusion criteria are case series, case reports, review articles, and other studies which were reported in language other than english and not relevant to pico. after meeting the inclusion and exclusion criteria, every article will be assessed for its validity, importance, and applicability by using the critical appraisal worksheet available from centre of evidence-based medicine (ceebm) university of oxford in accordance to the type of article obtained. level of evidence of each article would be classified according to the oxford central for evidence-based medicine classification. there were 5 articles obtained after searching through online data base. the queries are described in table 1. after screening through titles and abstracts, we filtered one article that suited the formulated clinical question and pico. screening and reviewing processes based on the inclusion and exclusion criteria were done. after further full-text reading, there were one article found to be matched to answer the clinical question. flowchart of the searching strategy is presented in figure 1. table 1. queries used to conduct literature searching in journal databases. journal database keywords hits screened pubmed/ medline (((("sleep disorder") or ("sleep problem")) or (insomnia) and (y_5[filter])) and (("post covid") or ("after covid") and (y_5[filter]))) and ("quality of life") 5 1 cochrane library sleep disorder or sleep problem or insomnia and post covid or after covid and quality of life (word variations have been searched) 0 0 ebsco sleep disorder or sleep problem or insomnia and post covid or after covid and quality of life 0 0 hamzah shatri acta med indones-indones j intern med 228 results the study that included to be appraised is a single centre cross sectional observational study by samir el sayed et.al.5 summary of the article is presented in table 2. critical appraisal of the study is presented in table 3. discussion apart from its physical burden, covid-19 has enormous psychosocial impact. disease itself multiplied by forced quarantine, “infodemic” spread via different platforms of social media and bad experience in having covid-19 may cause mental distress such as anxiety, depression, and ptsd.3,5 sleep disorder is one of the psychiatric problems that arise during and post covid-19 patient6. covid-19 insomnia is manifested by lack of sleep at night, sleepiness during the day and increase needs for naps. it occurs due to disrupted circadian rhythm during isolation and increased cytokine due to infection that interfere both non-rem and rem sleep.6 this study found that there were sleep problem in post covid-19 patient based on isi and psqi assessment. based on isi, 133 (26%) and 27 (5.4%) subjects had moderate articles identified through database searching (n=5) articles excluded based on exlcusion criteria (n=4) articles screened (n=1) full articles assessed for eligibility (n=1) full articles aexcluded (n=0) studies included (n=1)in c lu d e d e li g ib il it y s c re e n in g id e n ti fi c a ti o n figure 1. flow diagram of literature searching. table 2. summary of articles used in this study. reference studydesign subjects determinants inclusion criteria exclusion criteria outcomes level of evidence el sayed et al.5 cross sectional study 500 subjects sleep problem (insomnia severity index (isi) and pittsburgh sleep quality index (psqi)) (1) age ranged from 18 to 60 years; (2) must have two negative pcr test for covid 19 within one month after recovery (1) primary language other than english; (2) patients with well-known psychiatric disorders and under effect of psychotropic medication different domains of quality of life (qol) 2c vol 55 • number 2 • april 2023 sleep problem in post covid-19 patient, its impact on quality of life 229 and severe clinical insomnia. regarding global psqi, based on 7 components, sum of this score was 15+4 which indicates a disturbed quality of sleep. other study also found high score of psqi in the post covid-19 patients with persistent anxiety, depressive disorder and sleep quality insufficiency conducted in medical staff. there were also case series that said some patients will have worsening in subjective sleep quality and problems, including sleep latency and daytime function in 85% patient who recovered from covid-19 and were re-evaluated in 8 weeks after discharge.4 there were also association between sociodemographic data and severity of insomnia which there was a significantly positive correlation between age, female gender, single of marital status, days after recovery from covid 19, physical functioning, role limitation due to physical health, role limitation due to emotional problems, general health and global psqi.4 this study found a statistically significant positive association between isi and different domains of qol scale sf 36 including physical health, role restriction because of physical health, role limitation due to emotional burdens and general wellbeing which in parallel with the result of the study concluded impaired quality of life (qol) independently related to high anxiety score, severe depressive manifestations, poorer quality of sleep and insomnia problem.4 cognitive behavioral therapy is the best evidence-based treatment for patient during and after covid-19 infection. medication may be considered for patients with severe depressive or anxiety disorder as well. multicomponent interventions include a comprehensive history, sleep diary highlighting potential behavioral changes, addressing dysfunctional beliefs, and use of stimulus control, sleep restriction and various relaxation methods based on patient and therapist preference.7 the european cbt-i academy offered to: 1) follow natural sleep rhythm on a set schedule; 2) address worry and stress by using diaries and conversations; 3) use the bed only for sleep (and sex); 4) share feelings via social media; 5) avoid devices in the 1–2 h before bed; 6) engage in safe, enjoyable activities; 6) follow healthy habits such as regular exercise, no eating in the 2–3 h before bed, seek natural light in the morning and then evening dim light; and 7) relax before bedtime, e.g. reading a book, yoga, etc.7 however, pharmacological treatment is still preferred and used in non-severe cases because, in some cases, cbt is not effective and not applicable. for acute anxiety in post covid-19 patients, short acting benzodiazepine could be used. ssri and snri, venlafaxine is the first choice. after remission, the drug should be continued at least several months to prevent relapse. on the other hand, patient post covid-19 with general anxiety disorder (gad) could use ssri and snris as the first choice and pregabalin as the second drug choice. other drug that can be used are buspirone and hydroxyzine. table 3. critical appraisal of cross-sectional study based on criteria by center of evidence-based medicine. article: el sayed et al.5 1. did the study address a clearly focused question / issue? yes. 2. is the research method (study design) appropriate for answering the research question? yes. 3. is the method of selection of the subjects (employees, teams, divisions, organizations) clearly described? yes. 4. could the way the sample was obtained introduce (selection) bias? yes. 5. was the sample of subjects representative with regard to the population to which the findings will be referred? no 6. was the sample size based on pre-study considerations of statistical power? yes 7. was a satisfactory response rate achieved? unclear 8. are the measurements (questionnaires) likely to be valid and reliable? yes 9. was the statistical significance assessed? yes 10. are confidence intervals given for the main results? yes 11. could there be confounding factors that haven’t been accounted for? yes 12. can the results be applied to your organization? yes hamzah shatri acta med indones-indones j intern med 230 benzodiazepine used only for long treatment therapy if the other drugs or cbt were failed.8,6 overall, the use of anti-insomnia drugs in covid-19 patients must be very careful and need more attention since there were broad spectrum of the symptoms and patient’s comorbidity. caution and close monitoring were needed if anti-insomnia drugs were used together with covid-19 drugs because of its risk and interaction.6 sleep related strategies of melatonin and sedating psychotropic medications have been suggested as potentially beneficial in infected covid-19 patients. the use of melatonin in covid-19 patients is recommended as an adjuvant therapy. exogenous administration of melatonin up to 10 mg have modestly improved the sleep of icu patients.7 besides its increasing sleep parameters, it also had anti-inflamatory and immunomodulatory effect. the essential role of circadian sleep rhythm in the deterioration of sleep quality during and post covid-19 and the lack of melatonin on respiratory drive indicate that melatonin has potential effect for sleep disturbance related covid-19. melatonin may also increase the efficacy of covid-19 vaccination. the high safety profile and its antisars-cov-2 effects make this drugs preferred for treating sleep disturbace in covid-19 patient.9 benzodiazepine can be used judiciously in anxious patients with covid-19 to provide symptom relief. the lowest possible dose of alprazolam or lorazepam is recommended up to 4 times daily and should be continued at the lowest daily dose to avoid benzodiazepine withdrawal-induced delirium. second option include gabapentin, anti-convulsant gaba analogue. with both of these medications, sedation is minimal and there is no major respiratory depression.10 conclusion management of sleep during and after covid-19 is challenged and need to be more analyzed to get and effective therapeutic intervention. this ebcr revealed high score of insomnia and sleep disturbances during the recovery period of covid-19 infection, and these problems have implications in quality of life which must be managed during this critical era of covid-19. references 1. cucinotta d, vanelli m. who declares covid-19 a pandemic. acta biomed [internet]. 2020 [cited 2022 mar 8];91(1):157–60. available from: https://pubmed. ncbi.nlm.nih.gov/32191675/ 2. who coronavirus (covid-19) dashboard | who coronavirus (covid-19) dashboard with vaccination data [internet]. 2022 [cited 2022 mar 8]. available from: https://covid19.who.int/ 3. dubey s, biswas p, ghosh r, et al. psychosocial impact of covid-19. diabetes metab syndr [internet]. 2020 sep 1 [cited 2022 mar 8];14(5):779–88. available from: https://pubmed.ncbi.nlm.nih.gov/32526627/ 4. el sayed s, gomaa s, shokry d, kabil a, eissa a. sleep in post-covid-19 recovery period and its impact on different domains of quality of life. egypt j neurol psychiatry neurosurg [internet]. 2021 dec 1 [cited 2022 mar 8];57(1). available from: https:// pubmed.ncbi.nlm.nih.gov/34924750/ 5. choi eph, hui bph, wan eyf. depression and anxiety in hong kong during covid-19. int j environ res public health [internet]. 2020 may 5 [cited 2022 mar 8];17(10). available from: https://pubmed.ncbi. nlm.nih.gov/32466251/ 6. saputra bd, levita j, mustarichie r. efficacy, safety, and drug. drug interactions for insomnia therapy in covid-19 patients. j multidiscip healthc [internet]. 2022 jan 21 [cited 2022 mar 8];15:137–52. available from: https://www.dovepress.com/efficacy-safety-anddrugdrug-interactions-for-insomnia-therapy-in-covipeer-reviewed-fulltext-article-jmdh 7. becker pm. overview of sleep management during covid-19. sleep med [internet]. 2021 [cited 2022 mar 8]; available from: /pmc/articles/pmc8106485/ 8. maramis mm. pandemi covid-19 dan ansietas. in: sutrisno, kalalo rt, andrianto, editors. covid-19 dan problematika kesehatan mental. surabaya: ikatan dokter indonesia wilayah jawa timur; 2021. p. 73–104. 9. wichniak a, kania a, siemiński m, cubała wj. melatonin as a potential adjuvant treatment for covid-19 beyond sleep disorders. int j mol sci [internet]. 2021 aug 2 [cited 2022 mar 8];22(16). available from: https://pubmed.ncbi.nlm.nih. gov/34445329/ 10. khawam e, khouli h, pozuelo l. treating acute anxiety in patients with covid-19. cleve clin j med [internet]. 2020 may 14 [cited 2022 mar 8];87(5):1–4. available from: https://www.ccjm.org/content/ early/2020/05/12/ccjm.87a.ccc016. 26 acta med indones indones j intern med • vol 55 • number 1 • january 2023 original article abstract background: sarcopenia is associated with worse outcomes in maintenance hemodialysis (mhd) patients. differences in criteria and methods used to diagnose sarcopenia, results in a wide range of prevalence. factors associated with sarcopenia in mhd have not been well-studied. this study aimed to investigate the prevalence and factors associated with sarcopenia in the mhd population. methods: observational cross-sectional study was done with 96 mhd patients aged ≥18 years old, with dialysis vintage ≥120 days at cipto mangunkusumo hospital march-may 2022. descriptive, bivariate, and logistic regression analysis were done to find sarcopenia’s prevalence and association with simplify creatinine index (sci), type 2 diabetes (dm), interleukin-6 (il-6), nutritional status, physical activity, and phosphate serum level. asian working group for sarcopenia (awgs) 2019 criteria used to diagnose sarcopenia, hand grip strength (hgs) to identify muscle strength, bioimpedance spectroscopy (bis) to calculate muscle mass, and 6-meter walk test to evaluate physical performance. results: the prevalence of sarcopenia was 54.2%. factors with a significant association in bivariate analysis were phosphate serum level (p=0.008), sci (p=0.005) and low physical activity (international physical activity questionnaire) (p-0.006). logistic regression analysis found higher phosphate serum level and high physical activity protective of sarcopenia (or 0.677;ci95% 0.493-0.93 and or 0.313;ci95% 0.130-0.755 respectively). conclusion: the prevalence of sarcopenia in the mhd population was 54.2%. phosphate serum level, sci, and physical activity were significantly correlated with sarcopenia. both high phosphate level and high physical activity were protective against sarcopenia. key words: maintenance hemodialysis, awgs 2019, sarcopenia. factors associated with sarcopenia in maintenance hemodialysis patients: a cross-sectional study ria jauwerissa1, maruhum bonar marbun1*, pringgodigdo nugroho1, ikhwan rinaldi2, suhardjono1, hamzah shatri3, purwita wijaya laksmi4, irsan hasan5 1 division of nephrology and hypertension, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 2 division of hematology and oncology, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 3 division of psychosomatic, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 4 division of geriatric, department of internal medicine, faculty of medicine universitas indonesia, jakarta, indonesia. 5 division of gastroentero-hepatology, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. *corresponding author: maruhum bonar h. marbun, md. division of nephrology and hypertension, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: ria.jauwerissa@gmail.com; mbhmarbun@gmail.com. vol 55 • number 1 • january 2023 factors associated with sarcopenia in maintenance hd patients 27 introduction sarcopenia is associated with worsened clinical and nutritional outcomes and is an independent predictor of morbidities and mortality in a maintenance hemodialysis patient.1 the prevalence of sarcopenia in patients with chronic kidney disease (ckd) population ranges between 4%-68% depending on guidelines, tools, and methods used to identify each variables to define sarcopenia. the prevalence in the dialysis population is found at an average of 37%.2 sarcopenia in chronic kidney disease (ckd) is called uremic sarcopenia.3 low physical activity and negative protein balance because of prolonged uremic milieu, chronic inflammation, insulin resistance, hormonal imbalance, malnutrition, vitamin d deficiency, and oxidative stress were proposed to play a role in uremic sarcopenia.4 to date, there has been no studies in indonesian mhd population using awgs 2019 criteria. this study aimed to find the prevalence of sarcopenia using awgs 2019 criteria and factors associated with sarcopenia in maintenance hemodialysis (mhd) populations. methods study design, setting, participants, and sample size we conducted a cross-sectional study at cipto mangunkusumo hospital jakarta from march to may 2022. sampling was done consecutively, inclusion criteria were patients aged ≥ 18 years with dialysis vintage ≥120 days. we excluded hospitalized patients, as well as subjects who were unable to follow procedure, amputated, or refused to join. the sample size of this study was 96. ethics this study was approved by the ethical committee of faculty of medicine universitas indonesia (ref. no. ket-175/un2.f1/etik/ ppm.00.02/2022). variables and data sources data from medical records were age, dialysis duration, diabetes history, hypertension, angiotensin converting enzyme (ace) inhibitor/angiotensin receptor blocker (arb) use, and phosphate binder use. physical activities were evaluate using the international physical activity questionnaire (ipaq), while nutritional status was evaluated using the subjective global assessment (sga). laboratory examinations taken before the dialysis session for interleukin-6 (il-6) level, calcium ion level, haemoglobin, and albumin serum. simplify creatinine index (sci) assessed with single pool kt/v (spkt/v). body composition data for muscle mass calculation was obtained from body composition monitor (fresenius) and appendicular muscle mass was calculated using the formula by lin et al.5 hand grip strength measurement by jamar hand dynamometer used to identify muscle strength and physical performance was evaluated with 6-meters walk test. we defined sarcopenia based on the criteria suggested by awgs in 2019. statistical methods we analyzed the data using spss version 20, involving descriptive analysis to find the prevalence of sarcopenia, bivariate analysis by independent t-test and chi-square to determine the association between phosphate serum level, diabetes, il-6, physical activity, sci, and nutritional status with sarcopenia. p<0.05 was considered statistically significant. variables with p<0.25 were then analysed with logistic regression (predictive analysis). results the prevalence of this study was 54.2%, with characteristics as shown in table 1. ria jauwerissa acta med indones-indones j intern med 28 table 1. characteristics of the subject. variables frequencies (%) mean (sd)/median (range) sex male female 48 (50.0) 48 (50.0) age (year) 50.82 (14.9) dialysis vintage (month) 48 (24-96) nutritional status sga a sga b 89 (92.7) 7 (7.3) diabetes mellitus yes no 30 (31.3) 66 (68.8) international physical activity questionnaire (ipaq) light activity moderate activity 58 (60.4) 38 (39.6) hypertension yes no 75 (78.1) 21 (21.9) angiotensin-converting enzyme inhibitor/ angiotensin receptor blocker (acei/arb) use yes no 36 (3.5) 60 (62.5) calcium carbonate (caco3) use yes no 57 (59.4) 39 (40.6) early referral yes no 18 (18.8) 78 (81.3) simplify creatinine index (sci)(mg/kg/day) 23.02 (3.59) interleukin-6 (pg/ml) 5.53 (3.93-10.52) single pool (sp) kt/v 2.02 (1.76-2.33) phosphate serum (mg/dl) 4.08 (1.45) creatinine serum (mg/dl) 11.99 (3.77) ion calcium (mmol/l) 1.13(1.08-1.21) hemoglobin (g/dl) 9.30 (1.38) albumin (g/dl) 3.93 (0.38) body mass index (kg/m2) 23.07 (4.91) fat mass (kg) 14.15 (9.23-21.30) lean tissue mass (kg) 35.35 (30.57-41.80) appendicular skeletal muscle mass (asm) (kg/m2) male female 4.92 (0.84) 3.76 (0.79) hand grip strength (kg) male female 24 (20-30) 18 (12-20) vol 55 • number 1 • january 2023 factors associated with sarcopenia in maintenance hd patients 29 independent t-test analysis showed a significant difference in mean phosphate serum level (p=0.008) and simplify creatinine index (p=0.005). the chi-square analysis of physical activity (using ipaq score) (p=0.006) was significantly associated with sarcopenia (table 2). researchers elaborated analysis with a predictive model using variables with p<0.25 and found higher phosphate serum levels (or 0.677, p=0.016) and higher physical activity (or 0.313, p=0.01) were protective of and significantly correlated with sarcopenia in mhd population (table 3). discussion muscle loss is a common finding in ckd patients, especially in the hemodialysis patients. the prevalence of sarcopenia is greatly influenced by the variability of diagnostic criteria and patient characteristics. sarcopenia in the mhd population’s prevalence from various studies ranges from 4-68%.6,7 the prevalence of sarcopenia in this study population was 54.2%. this study is the first in indonesia that used awgs 2019 criteria to diagnose sarcopenia. researchers use bio-impedance spectroscopy (bis) to assess appendicular skeletal mass (asm), hand grip strength (hgs) to assess muscle strength, and 6-meters walk test to evaluate physical performance. the examinations were done before hemodialysis session on the non-av-shunt arm. the etiologic factors that contribute to muscle loss in hemodialysis are diverse and can be grouped into factors that contribute to increased protein degradation (reduced energy and protein intake, inflammation, insulin resistance, metabolic acidosis, vitamin d deficiency, and oxidative stress) and factors that related to decreasing protein synthesis (loss of amino acid and protein during dialysis, reduced regenerative stimulus, hormonal derangements, sedentary lifestyle, ageing).8 table 2. association of sci, type 2 dm, il-6, nutritional status, physical activity with sarcopenia. variables sarcopenia p yes no phosphate serum level, mean (sd) 3.73 (sd 1.18) 4.5 (sd 1.63) 0.008 simplify creatinine index (sci), mean (sd) 22.09 (sd 3.56) 24.12 (sd 3.35) 0.005 type 2 dm, n (%) yes 20 (66.7) 10 (33.3) 0.095 no 32 (48.5) 34 (51.5) il6, n (%) normal 33 (56.9) 25 (43.1) 0.507 above normal level 19 (50.0) 19 (50.0) nutritional status, n (%) sga a 46 (51.7) 43 (48.3) 0.120* sga b 6 (85.7) 1 (14.3) ipaq, n (%) light activity 38 (65.5) 20 (34.5) 0.006 moderate activity 14 (36.8) 24 (63.2) table 3. multivariate analysis logistic regression. variables b se z p 1 phosphate serum 0.390 0.162 2.407 0.016 2 physical activity 1.162 0.449 2.588 0.010 3 constant -3400 0.962 3.534 <0.001 ria jauwerissa acta med indones-indones j intern med 30 impaired muscle regeneration also often develops in ckd patients, proven by reduced cell activation and expression of myogenic regulatory factors (a negative regulator of skeletal muscle mass).9 furthermore, there is increased catabolism in ckd due to the accumulation of uremic toxins, chronic inflammation, insulin resistance, hormonal imbalance, malnutrition, vitamin d deficiency, oxidative stress, and increased ubiquitination.4 emerging evidence addressed an association between phosphate and muscle function, but only a little attention focused on this issue.10 high phosphate concentrations are associated with an increased incidence of cardiovascular complications and mortality in ckd patients, h e n c e d i e t a r y a n d p h a r m a c o t h e r a p e u t i c interventions aimed to reduce phosphate serum level.11 however, a meta-analysis study by block et al12 found significant increases in the relative risk of death in lower phosphate serum concentrations (<4.0 mg/dl). bivariate analysis in this study showed a significant association between the lower level of phosphate serum with sarcopenia and accordance with the following study by umakanthan, et al13, ren, et al14, and cai, et al15. the findings suggested that a high protein diet also contained high phosphate, and patient in the uremic milieu usually lost their appetite or even has anorexia. reduced energy and protein intake will lower phosphate serum levels, causing malnutrition, catabolic protein condition, and sarcopenia. another mechanism that could explain hypophosphatemia in sarcopenia is that inorganic phosphate also plays a role in cell membrane, energy production, and transduction signal in all body cells.16 study by pesta et al.17 in animal showed that genetically and diet-induced hypophosphatemic mice has a decreasing muscle atp synthesis rate.18 this study also found a significant correlation between simplify creatinine index (sci) with sarcopenia (p=0.005). this finding also followed canaud, et al19 study which stated that sci is a reliable and inexpensive marker of muscle metabolism and can be used as a nutritional and skeletal muscle marker in the dialysis population. yamamoto, et al20 found that sci’s long term predictive value was comparable with hand grip strength and walking speed. in this study, physical activity was analysed with ipaq and had a significant correlation with sarcopenia in this study (p=0.006). regolisti, et al21 stated that low physical activity was commonly found in mhd populations and related to muscle disuse which could further cause loss of muscle mass and eventually sarcopenia. limited physical activity during hemodialysis session and lethargic feelings that are often felt by mhd populations reduce their activity time. this study did not find a significant correlation between dmt2 and sarcopenia in the mhd population (p=0.095); nevertheless, 66.7% of dmt2 participants in this study were diagnosed with sarcopenia. this finding was following giglio, et al1, hoppe, et al22, and visser, et al23. this could be explained by the fact that both diabetes and ckd present with chronic inflammation that could disrupt muscle metabolism in the long term. nutritional status was assessed with sga as recommended by kdoqi. the majority of samples in this study (92.7%) have good nutritional status (sga a). macedo, et al24 found that 51.2% of samples in the non-sarcopenia group suffered from malnutrition. vettoretti, et al25 also found no significant correlation between sarcopenia and malnutrition and stated that both were different domains of nutrition abnormalities. similar finding was also found in ren, et al’s study.14 the inflammation factor (using il-6 as a marker) did not meet the significance’s requirement in this study (0.507). many studies found similar results using the same or different markers.1,14,26,27 this could explained by the fact that inflammation in mhd population are increase in an episodic manner and do not picture the chronic conditions state of the patient. the logistic regression analysis showed the ideal model to detect sarcopenia, where higher phosphate level and high physical activity were both protective factors to prevent sarcopenia (or 0.677;ci95% 0.493-0.93 and or 0.313;ci95% 0.130-0.755 respectively). this study presented the recent data about the prevalence of sarcopenia in mhd populations vol 55 • number 1 • january 2023 factors associated with sarcopenia in maintenance hd patients 31 in indonesia using awgs 2019 criteria with variables that are proposed to play a role in the pathogenesis of sarcopenia. this study’s high prevalence of sarcopenia implies the necessity to address and treat sarcopenia in the clinical setting. variables used in this study was objective and easily retrieved in hemodialysis centers to diagnose sarcopenia in mhd patient, so the reproducibility of this study was good. this study was cross sectional, so the causal relationship between variables was not achieved. this study did not include the role of hormones like ghrelin and angiotensin. bias potentials from this study required considerations were glucocorticoid use and hgs examination in the non-av shunt arm, which could be the nondominant arm. factors that were not significant in logistic regression analysis might reach significance in larger samples study; hence the follow-up study is encouraged. conclusion the prevalence of sarcopenia in the mhd population in cipto mangunkusumo hospital was 54.2%. this study’s factors significantly associated with sarcopenia were phosphate serum level, sci, and physical activity. logistic regression analysis showed that higher phosphate serum level and high physical activity were protective against sarcopenia in the mhd population. on the basis of these findings, it seems prudent to suggest that early detection of sarcopenia is crucial in mhd populations, and by increasing physical activity and a better control of phosphate serum level could prevent this condition. author’s contribution rj designed the study, collected the data, performed data analysis, and drafted the original manuscript. mbm and pn participated in designing the study and revised the manuscript. ir helped in data analysis and revising the manuscript. s, hs, pwl, and ih participated in revised the manuscript. all authors read and approved the final manuscript. acknowledgments the authors would like to thank the hemodialysis team in cipto mangunkusumo hospital for the help in collecting the data. references 1. giglio j, kamimura ma, lamarca f, rodrigues j, santin f, avesani cm. association of sarcopenia with nutritional parameters, quality of life, hospitalization, and mortality rates of elderly patients on hemodialysis. j ren nutr. 2018;28(3):197-207. 2. kim j-k, choi s, choi m, et al. prevalence of and factors associated with sarcopenia in elderly patients with end-stage renal disease. clinical nutrition (edinburgh, scotland). 2013;33. 3. sato e, mori t, mishima e, et al. metabolic alterations by indoxyl sulfate in skeletal muscle induce uremic sarcopenia in chronic kidney disease. scientific reports. 2016;6(1):36618. 4. avin kg, moorthi rn. bone is not alone: the effects of skeletal muscle dysfunction in chronic kidney disease. curr osteoporos rep. 2015;13(3):173-9. 5. lin ty, wu my, chen hs, hung sc, lim ps. development and validation of a multifrequency bioimpedance spectroscopy equation to predict appendicular skeletal muscle mass in hemodialysis patients. clinical nutrition. 2021;40(5):3288-95. 6. da silva mzc, vogt bp, reis n, caramori jct. update of the european consensus on sarcopenia: what has changed in diagnosis and prevalence in peritoneal dialysis? eur j clin nutr. 2019;73(8):1209-11. 7. matsuzawa r, yamamoto s, suzuki y, et al. the clinical applicability of ultrasound technique for diagnosis of sarcopenia in hemodialysis patients. clinical nutrition. 2021;40(3):1161-7. 8. sabatino a, cuppari l, stenvinkel p, lindholm b, avesani cm. sarcopenia in chronic kidney disease: what have we learned so far? j nephrol. 2020. 9. avin kg, chen nx, organ jm, et al. skeletal muscle regeneration and oxidative stress are altered in chronic kidney disease. plos one. 2016;11(8):e0159411. 10. chen yy, kao tw, chou cw, et al. exploring the link between serum phosphate levels and low muscle strength, dynapenia, and sarcopenia. scientific reports. 2018;8(1):3573. 11. vervloet mg, sezer s, massy za, johansson l, cozzolino m, fouque d. the role of phosphate in kidney disease. nat rev nephrol. 2017;13(1):27-38. 12. block ga, klassen ps, lazarus jm, ofsthun n, lowrie eg, chertow gm. mineral metabolism, mortality, and morbidity in maintenance hemodialysis. journal of the american society of nephrology. 2004;15(8):2208-18. 13. umakanthan m, li jw, sud k, et al. prevalence and factors associated with sarcopenia in patients on maintenance dialysis in australia a single centre, cross-sectional study. nutrients. 2021;13(9). ria jauwerissa acta med indones-indones j intern med 32 14. ren h, gong d, jia f, xu b, liu z. sarcopenia in patients undergoing maintenance hemodialysis: incidence rate, risk factors and its effect on survival risk. renal failure. 2016;38(3):364-71. 15. cai g, ying j, pan m, lang x, yu w, zhang q. development of risk prediction nomogram for sarcopenia in patients receiving maintenance hemodialysis. research square; 2022. 16. berndt t, kumar r. phosphatonins and the regulation of phosphate homeostasis. annu rev physiol. 2007;69:341-59. 17. pesta dh. hypophosphatemia promotes lower rates of muscle atp synthesis. faseb j. 2016;30. 18. bartali b, semba rd, araujo ab. klotho, fgf21 and fgf23: novel pathways to musculoskeletal health? j frailty aging. 2013;2. 19. canaud b, ye x, usvyat l, et al. clinical and predictive value of simplified creatinine index used as muscle mass surrogate in end-stage kidney disease haemodialysis patients—results from the international monitoring dialysis outcome initiative. nephrology dialysis transplantation. 2020;35(12):2161-71. 20. yamamoto s, matsuzawa r, hoshi k, et al. modified creatinine index and clinical outcomes of hemodialysis patients: an indicator of sarcopenia? j renal nutr. 2021;31(4):370-9. 21. regolisti g, maggiore u, sabatino a, et al. interaction of healthcare staff’s attitude with barriers to physical activity in hemodialysis patients: a quantitative assessment. plos one. 2018;13(4):e0196313. 22. hoppe k, schwermer k, dopierała m, et al. can overnutrition lead to wasting? the paradox of diabetes mellitus in end-stage renal disease treated with maintenance hemodialysis. nutrients. 2022;14(2). 23. visser wj, egmond a, timman r, severs d, hoorn ej. risk factors for muscle loss in hemodialysis patients with high comorbidity. nutrients. 2020;12(9). 24. macedo c, amaral tf, rodrigues j, santin f, avesani cm. malnutrition and sarcopenia combined increases the risk for mortality in older adults on hemodialysis. frontiers in nutrition. 2021;8. 25. vettoretti s, caldiroli l, armelloni s, ferrari c, cesari m, messa p. sarcopenia is associated with malnutrition but not with systemic inflammation in older persons with advanced ckd. nutrients. 2019;11(6). 26. beberashvili i, sinuani i, azar a, et al. il-6 levels, nutritional status, and mortality in prevalent hemodialysis patients. clin j am soc nephrol. 2011;6(9):2253-63. 27. johansen kl, dalrymple ls, delgado c, et al. association between body composition and frailty among prevalent hemodialysis patients: a us renal data system special study. j am soc nephrol. 2014;25(2):381-9. 207 original article acta medica indonesiana the indonesian journal of internal medicine hiv patients drop out in indonesia: associated factors and potential productivity loss adiatma ym. siregar1, pipit pitriyan1, rudi wisaksana2 1 department of economics, center for economics and development studies, faculty of economics and business, padjadjaran university, bandung, indonesia. 2 department of internal medicine, hasan sadikin hospital faculty of medicine, padjadjaran university, bandung, indonesia. corresponding author: dr. adiatma ym. siregar. center for economics and development studies, faculty of economics and business, padjadjaran university. jl. cimandiri no.8, citarum, bandung 40115, indonesia. email: adiatma.siregar@unpad. ac.id. abstrak tujuan: meneliti tentang faktor-faktor yang berhubungan dengan probabilitas drop out yang lebih tinggi bagi pasien hiv, dan potensi produktifitas yang hilang akibat drop out tersebut. metode: kami menganalisis data dari 658 pasien hiv dari sebuah database di sebuah rumah sakit rujukan utama di kota bandung, jawa barat, indonesia dari tahun 2007-2013. pertama, kami menggunakan metode analisis regresi probit dan mengikutsertakan, antara lain, variabel berikut: status pasien (aktif atau drop out), cd4 cell count, tb dan infeksi oportunistik (io), status bekerja, jenis kelamin, pengalaman sebagai penasun, dan dukungan dari keluarga dan peers. kedua, kami menggunakan data tingkat drop out dari database kami dan tingkat penurunan cd 4 cell count dari studi lain untuk mengestimasi produktifitas yang hilang akibat drop out. hasil: cd4 cell count yang rendah diasosiaikan dengan probabilitas drop out yang lebih tinggi. dukungan dari peers, hidup bersama keluarga, dan menderita tb diasosiasikan dengan probabilitas drop out yang lebih rendah. produktifitas yang hilang pada tingkat nasional akibat drop out (dank arena tingkat cd 4 cell count yang menurun) dapat mencapai us$365 juta (menggunakan upah rata-rata). kesimpulan: pertama, karena tingkat cd 4 cell count yang rendah diasosiasikan dengan probabilitas drop out yang lebih tinggi,kami merekomendasikan (untuk mengoptimasikan) pemberian arv dini pada tingkat cd 4 cell count yang lebih tinggi, melibatkan pemberian layanan hiv di tingkat komunitas. kedua, dukungan keluarga dan peer harus diperkuat untuk mendukung kesuksesan dari perawatan hiv. ketiga, drop out dari layanan art akan menyebabkan hilangnya produktifitas yang cukup besar. kata kunci: hiv, sosial-ekonomi, terapi antiretroviral, indonesia, drop out. abstract aim: this study reported various factors associated with a higher probability of hiv patients drop out, and potential productivity loss due to hiv patients drop out. methods: we analyzed data of 658 hiv patients from a database in a main referral hospital in bandung city, west java, indonesia from 2007 to 2013. first, we utilized probit regression analysis and included, among others, the following variables: patients’ status (active or drop out), cd4 cell count, tb and opportunistic infection (oi), work status, sex, history of injecting drugs, and support from family and peers. second, we used the drop out data from our database and cd 4 cell count decline rate from another study to estimate the productivity loss due to hiv patients drop out. results: lower cd4 cell count was associated with a higher probability of drop out. support from family/peers, living with family, and diagnosed with tb were associated with lower probability of drop out. the productivity loss at national adiatma ym. siregar acta med indones-indones j intern med 208 level due to treatment drop out (consequently, due to cd4 cell count decline) can reach us$365 million (using average wage). conclusion: first, as lower cd 4 cell count was associated with higher probability of drop out, we recommend (to optimize) early arv initiation at a higher cd 4 cell count, involving scaling up hiv service at the community level. second, family/peer support should be further emphasized to further ensure treatment success. third, dropping out from art will result in a relatively large productivity loss. keywords: hiv, socio-economic, antiretroviral therapy, indonesia, drop out. introduction indonesia is experiencing a fast increase in hiv prevalence (estimated <0.1% in 2001 to 0.4% in 2012)1 and a change in the hiv epidemic whereas it was previously concentrated within the intravenous drug users (idus) and their couples, and now it moves to general population. the percentage of hiv transmission through injecting drug use decreased from 53% in 20012005 to 34% in 2011, while the heterosexual transmission rose from 37% to 71% within the same period.2 indonesia’s response to the epidemic have started since the first domestic case was detected which included the continuing support for care and treatment programs.2,3 in accordance, the need for antiretroviral therapy (art) was expected to reach around 87,000 patients in 2014.4 although the availability of art in indonesia is increasing2, drop out rate is still a significant issue.5–7 in a more specific context, this phenomenon is apparent in a clinic within a main referral hospital in west java. although this clinic has been successful in increasing the quality of hiv-care and reducing mortality rate, it is still facing challenges in reducing a high dropout rate, which is only slightly lower than the national estimate.6,8 this is crucial as the success of art will increase quality of life (qol), productivity, and physical and emotional health.9–11 these factors in the end will influence the survival of patients.12 given the importance of hiv patients drop out, there is an urgency to answer the following questions: 1) what are the factors influencing the hiv patients drop out rate in indonesia?, and 2) what is the potential economic impact? there has been a number of studies trying to pinpoint the reasons underlining treatment drop out or non-adherence. some local studies suspected socio-economic factors as possible causes13,14, while others suspected psycho-social and biomedical factors5,7,15, or simply patients’ error (e.g. forget to take medication).16 these factors have also been explored by international studies.17–21 the results were varied from all of these studies, and required further confirmation to apply in a specific context. understanding the factors influencing dropout rate will provide valuable input in providing better service and policy input.6 the research on economic impact of drop out, on the other hand, still limited. this is a very important point for indonesia since hiv patients drop out is still a problem. t h i s s t u d y a n a l y z e d t h e p a t i e n t s ’ socioeconomic, demographic, and clinical characteristics, and explored whether these characteristics were associated with the higher/ lower probability of hiv patients drop out. this study also estimated the economic impact of drop out in terms of productivity loss. this study was unique for four reasons. first, to our knowledge, studies exploring the factors causing hiv patients dropouts in indonesia is limited. second, our study utilizes data from a large number of patients’ medical record as a part of a larger cohort database owned by the clinic, providing a lot of valuable information otherwise unattainable. third, the clinic in our study is utilized by patients from all over the province (and in some cases beyond the province), which gives it a pivotal role in providing evidence for policy making. fourth, this study estimates the productivity loss as the impact of drop out to provide evidence for policy makers. methods study setting and study population the study was conducted in bandung, at an hiv/aids clinic in the largest public referral vol 48 • number 3 • july 2016 hiv patients drop out in indonesia 209 and teaching hospital in west java province (43 million inhabitants). the clinic is visited by high risk group of patients and the general population, and deliver hiv-related services such as voluntary counseling and testing, art, and sexually transmitted infections services. the clinic operates at full capacity because it is among the few clinics that deliver art in bandung. the clinic generates its own revenues through government, hospital, and private funding. the art-related services are free, except for hospitalization and the registration fee. data collection and analysis we utilized the database of a clinic within a main referral hospital in bandung city, west java, indonesia (2007-2013). out of the data of 8,184 hiv patients, we only included the data of 658 patients due to incomplete data set. we extracted data related to four categories: patient’s current status, socioeconomic, demographic, and clinical characteristics. the detailed variables list from each category is presented in table 1. we used microsoft excel 2013 and stata 13 for data cleaning and analysis. we utilized probit regression analysis to determine the influence of each factor. we only used the patients’ clinic id number throughout the analysis, and none of patients’ personal identification is used. we also combined our dropout rate data and the cd4 decline rate from another study within the same clinic to estimate the productivity loss due to drop out from hiv treatment. we estimated the length of time it took for the cd4 cell count of patients who drop out to reach approximately 50 cells/mm3 (assuming that they do not seek any treatment after they drop out). we assumed that patients can no longer be productive afterwards due to the onset of various opportunistic infections as patients with cd4 cell count lower than 100 cells/mm3 was considered to experience immunological failure.23 the productivity loss was then measured by the loss of income from the moment patients reach the cd4 cell count of 50 cells/mm3 until the end of productive age using microsoft excel 2013. we used average and minimum wage from a publication by ilo24, and we assumed the productive age of 15-64 years as stated by bureau of statistics of indonesia table 1. list of variables variable list definition type patient status (dependent variable) 0 = active, 1= drop out dummy socioeconomic characteristics age absolute continuous sex 0 = female, 1= male dummy employment status 0 = unemployed, students, housewife, 1 = employed dummy education 0 = primary school/no education, 1 = junior high, 2 = senior high, 3 = university/college ordered dummy marital status 0 = not married/divorced/widowed, 1 = married dummy have children 0 = no children, 1 = have children dummy social insurance membership 0 = not on social insurance, 1 = on social insurance dummy live with family 0 = not live with family, 1 = live with family dummy support from family/peers 0 = not satisfied, 1 = satisfied dummy demographic characteristics place of stay 0 = live in bandung city, 1 = live outside bandung city dummy clinical characteristics cd4 cell count 0 = >349 cells/mm3, 1 = 150-349 cells/mm3, 2 = 50-149 cells/ mm3, 3 = 0-49 cells/mm3 ordered dummy oi 0 = not infected by oi, 1 = infected by oi dummy idu history 0 = no history, 1 = with history dummy tb history 0 = no history, 1 = with history dummy length of treatment 0 = less than 1 year, 1 = more than 1 year dummy adiatma ym. siregar acta med indones-indones j intern med 210 (bps). lastly, we used the discount rate of 3%25, and the exchange rate of rp13,230/1us$.26 we then combined the estimation of productivity loss per person to the whole number of (estimated) drop out patients at the clinic and at national level. table 2 summarizes the indicators used in the productivity loss analysis. the estimation of patients undergoing art and drop out rate at national level were taken from spiritia.8 results table 3 summarizes patient characteristics based on factors presented in table 1. most patients are at their productive age, and mostly are male, employed, and receive secondary or tertiary education. more than a half of patients are married and have children. almost all of patients are living with their family and satisfied with peer support. most patients visit the clinic for the first time with higher than 50 cells/mm3 cd4 cell count, and around 60% of the patients have idu history. table 2. productivity loss calculation indicators items values average cd 4 cell count, drop out patients (95% c.i) 123 (91–155) number of drop out hiv patients male/female 55 female 29 national male** 9,510 national female** 2,506 monthly wage24 minimum us$ 97.38 average us$ 144.91 productive age 15 – 64 years (50 years) time length for cd 4 cell count to reach approximately 50 cells/mm3 after dropout* idu 3.42 years non idu 3.67 years idu*** idu male*** dropout rate clinic rate 12.77% national rate8 17.90% unemployment rate clinic rate (male)*** 36.36% national rate8 6.10% 27 female labor participation rate clinic rate*** 31.03% national rate8 51% 27 exchange rate26 rp 13,230/us$ discount rate25 3% * calculated based on results from meijerink et al.22 ** estimated based on spiritia8 *** from drop out patients table 3. patient characteristics (n=658) variable list values patients who drop out 84 (12.77%) socioeconomic characteristics mean of age (95% c.i) 30 (29.7 – 30.6) male 443 (67.33%) employed 425 (64.59%) education (secondary and tertiary) 635 (96.50%) marital status (married) 393 (59.73%) have children 402 (61.09%) have social insurance membership 87 (13.22%) live with family 585 (88.81%) satisfied with support from family/peers 625 (94.98%) demographic characteristics place of stay (live outside bandung city) 236 (35.87%) clinical characteristics cd4 cell count (<50 cells/mm3) 213 (32.37%) oi 166 (25.23%) idu history 394 (59.88%) tb history 163 (24.77%) length of treatment (>1 year) 583 (88.60%) factors associated with drop out figure 1 presents the marginal effect of the probit regression result. from the factors associated with higher probability of drop out (and significant at 90%, 95%, or 99% c.i), we found that patients with under than 50 cells/mm3 cd4 cell count had 8.7% higher probability of drop out compared with patients with higher than 349 cells/mm3 cd4 cell count. this percentage decreased as we move up the cd 4 cell count groups. from the factors associated with lower probability of dropping out (and significant at vol 48 • number 3 • july 2016 hiv patients drop out in indonesia 211 90%, 95%, or 99% c.i), we found that patients who lived with family have 10.2% lower probability of drop out compared with patients who did not. patients who were satisfied with support from family/peers, had 8.8% lower probability of dropping out, compared to those who were not satisfied. patients who lived outside bandung city, and patients who were diagnosed with tb were associated with lower probability of drop out compared to their counterparts. those who have been undergoing treatment for more than 1 year had a lower probability of dropping out compared to those who were undergoing the treatment for less than one year. impact of drop out on productivity loss table 4 presents the productivity loss at the clinic level and at national level. using clinic dropout rate, the estimated productivity loss over remaining productive lifetime for patients visiting clinic can reach us$18 million. projecting the clinic dropout rate into the number of hiv patients on arv at national level, the estimated productivity loss over remaining productive lifetime can reach us$191 million. using the national dropout rate, these numbers can rise to us$365 million. figure 1. the econometric analysis result using probit regression, presented by the marginal effect results for each variables table 4. estimated productivity loss over remaining productive lifetime (us$) items amount per person (based on clinic estimate) high estimate* 34,226 low estimate** 23,001 clinic estimation high estimate* 18,607,499 low estimate** 12,504,956 national estimation using clinic indicators high estimate* 191,054,269 low estimate** 128,395,829 using national indicators (except for % of idu) high estimate* 365,041,113 low estimate** 245,321,691 *using average wage, ** using minimum wage discussion this study has two aims. first it analyzes the factors associated with hiv patients dropout in the clinic. second, it estimates the impact of hiv patients dropout on productivity loss over remaining productive lifetime at the clinic and adiatma ym. siregar acta med indones-indones j intern med 212 national level. based on these objectives, five observations can be made. first, as higher cd 4 cell count are associated with lower probability of drop out, in line with a study by blutinger et al.21 in india, optimizing early arv initiation at higher cd 4 cell count is warranted. the benefit of potential costs saving by providing early art has been discussed in other studies28–31, and our study adds that it may also reduce the probability of dropout. one of the potential scale up sites are the community clinics, since patients are taking hiv test at this type of clinic at a much higher cd4 cell count compared to those visiting hospitals.32 in addition, accessing hiv service at the community level will reduce patients’ costs and increase adherence of art.5,28,33,34 however, the potential budget impact of scaling up and providing early art35,36, and the required community staff capacity37 should be carefully assessed. given the current prevalence rate of indonesian hiv epidemic (0.5% for adults age 15-49)38, it seems that scaling up art at the community should be conducted at areas with high prevalence setting 39,40 to have a large impact. second, our results show that living with family and peer support is significantly associated with lower probability of hiv patients dropout. another study from indonesia and some studies from other countries also have similar finding.15,17,19,20,41,42 thus, it is clear that family/ peer support should be further enhanced to ensure treatment success in the long run. finding the correct scheme to enhance family/peer support should be done carefully as not all schemes may work (e.g. use of pager).43 on the other hand, interventions such as text messaging, self-forming group of patients, modified directly observed therapy (mdot), are able to support art adherence.44–47 indonesia should start to either adopt (or modify if necessary) these already proven interventions or come with a breakthrough approach to improve the current family/peer support for hiv patients. third, as patients with tb history is associated with lower probability of drop out, it is a plausible idea to integrate tb and hiv treatment. studies have shown that this integration have a positive impact on patients and community48–50, and models from lowand middle-income countries are available.51 however, the infrastructures and the capacity of health care workers, need to be enhanced for this integration to work.51,52 fortunately, this kind of integrated tb/hiv models are also increasing in indonesia2, leading to more efficient service deliveries. therefore, consistent monitoring and evaluation of this scheme is required to produce an even more efficient and better quality hiv/ tb integrated services. fourth, our study shows that patients with longer than a year length of treatment are associated with lower probability of drop out. this has an important implication because if we are able to reduce drop out rate and keep patients within the treatment, it will lead to an even lower probability of drop out rate, creating a continuous effect. fifth, the costs of productivity loss over remaining productive lifetime due to dropout can be high. in our case, it can reach us$365 million: 0.042% of our gross domestic product (gdp) in 201353 or 1.36% of total health expenditure in the same period.54 we need to compare this productivity loss to the costs of treatment if patients are staying in the program. based on the study by siregar et al.28, the cost of treating a patient with arv is approximately us$1,200 per patient per year for patients with cd4 cell count lower than 50 cells/mm3 (this cost decreases as the cd4 cell count increases). multiplying this amount with the number of drop out patients at national level (using clinic dropout rate and the discount rate of 3%) for the rest of their life years (subtracting life expectancy55 with the age of drop out in the clinic) results in us$301 million, lower than the productivity loss. thus, it seems that keeping patients within the treatment program is less costly compared to losing them. in addition, the art provides other benefits aside of treating hiv patients. it also acts as a prevention measure for hiv epidemic56,57 and will most likely prevent spending more costs. furthermore, bear in mind that our productivity loss calculation is based only on productivity approach using average and minimum wage. as such, in showing the potential economic impact of hiv patients dropout, we have forgone vol 48 • number 3 • july 2016 hiv patients drop out in indonesia 213 other important values such as those stemming from loss of/reduced quality of life, costs to family members, hospitalization costs, oi treatment costs, possible line 2 art costs, and indirect costs. therefore, we believe the actual economic impact of dropout should be much higher. however, we need to take into account the currently low health budget of indonesia if we want to provide art to all hiv patients.58 in addition to our main observations, an important finding, although it is not statistically significant, should be carefully noted. our analysis shows that higher education is related with higher probability of drop out. this is the opposite of the results by schilkowsky et al.20, waldrop-valverde et al.59, and unge et al.42. we suggest to explore this finding further as it has an important implication. if indeed a higher education is associated with higher probability of dropout, then a specific intervention should be designed to target patients with higher education as more than 90% of the patients in our study belong to this group. on the other note, the history of drug use, surprisingly, does not seem to have a significant influence on the drop out rate. this is supported by another study in the clinic13, although international studies show otherwise.59,60 this warrants further investigations since idus still hold a crucial role in the indonesian hiv epidemic. study limitation there are several limitations in our study. first, the analysis on factors associated with hiv patients drop out is specific to the clinic that we studied, although similar results are found in some other local and international studies. other clinics in indonesia, however, may have different patterns. therefore, applying the same study in more clinics in different settings in indonesia (e.g. region, culture, religion, and politics) may yield more varied result and may enrich the discussion. second, we assume that the drop out patients will not join other art program at other clinics and that they will not seek treatment afterwards. of course this may not be true to all patients, as some may visit other clinics to obtain art once their disease has become more severe and they feel the need for treatment. a more detailed analysis following patients who drop out may provide further insight on the potential economic impact of hiv patients drop out. third, there are much incomplete data set per person in our database, cutting our observation from 8,184 to 658 patients. this, will have implication on our results, and having better dataset may have improved our findings. regardless, given the current number of observation, we have managed to show the significant factors that influence the probability of hiv patients dropout, adding information for the clinic managers and/or policy makers in designing appropriate policy. fourth, our productivity loss calculation is based only on productivity approach using average and minimum wage. we believe actual economic impact of drop out should be much higher as we forgone important values such as loss of/reduced quality of life, costs to family members, and hospitalization costs. however, the purpose of our productivity loss analysis is to show the potential economic impact due to the drop out at its most basic state. our study has shown this and clarifies that this amount can only be higher if it is further calculated. conclusion controlling drop out rate is crucial as the success of art will increase qol, productivity, and physical and emotional health which influences the survival of patients. this study has shown that higher cd 4 cell count, satisfied with family/peer support, have been in treatment longer than a year, and have tb history are associated with lower probability of hiv patients dropout. we have also presented the severity of dropout in terms of its consequences on productivity loss. the estimated productivity loss over productive lifetime due to dropout can reach us$312 million for idu and us$306 million for non-idu at national level. we recommend to optimize early art, family/peer support, and tb/hiv service integration to reduce drop out rate and reduce its economic impact. adiatma ym. siregar acta med indones-indones j intern med 214 acknowledgments we would like to thank all of teratai clinic staff (hasan sadikin hospital) for their contribution in providing the available data for analysis. this research was financially supported by universitas padjadjaran. authors declare no conflict of interest. references 1 unaids. global report: unaids report on the global aids epidemic 2013. 2013. 2 national aids commission (nac). republic of indonesia country report on the follow up to the declaration of commitment on hiv/aids (ungass), reporting period 2010-2011. 2012. 3 coordinating minister for people’s welfare/chair of the national aids commission government of indonesia. indonesian national aids strategy. 1994. 4 ministry of health of indonesia. mathematic model of hiv epidemic in indonesia. 2008. http://spiritia.or.id/ doc/model0814.pdf. 5 haroen h, 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prevention programs in lowand middle-income countries. science. 2006; 311:1474–6. 32 siregar aym, komarudin d, wisaksana r, van crevel r, baltussen r. costs and outcomes of vct delivery models in the context of scaling up services in indonesia. trop med int heal. 2011;16:193–9. 33 portelli ms, tenni b, kounnavong s, chanthivilay p. barriers to and facilitators of adherence to antiretroviral therapy among people living with hiv in lao pdr: a qualitative study. asia pac j public health. 2012;53. doi:10.1177/1010539512442082. 34 brinkhof mwg, pujades-rodriguez m, egger m. mortality of patients lost to follow-up in antiretroviral treatment programmes in resource-limited settings: systematic review and meta-analysis. plos one. 2009; 4:e5790. 35 kitajima t, kobayashi y, chaipah w, sato h, chadbunchachai w, thuennadee r. costs of medical services for patients with hiv/aids in khon kaen, thailand. aids. 2003;17:2375–81. 36 afriandi i, aditama ty, mustikawati d, oktavia m, alisjahbana b, riono p. hiv and injecting drug use in indonesia: epidemiology and national response. acta med indones-indones j intern med. 2009;41 (suppl 1):75–8. 37 curran j, debas h, arya m, knobler s, pray l. scaling up treatment for the global aids pandemic: challenges and opportunities. washington: the national academies press; 2005. 38 unaids. hiv and aids estimates (2013) indonesia. 2015. http://www.unaids.org/en/regionscountries/ countries/indonesia (accessed june 27, 2015). 39 nelwan ej, crevel r van, alisjahbana b, indrati ak, dwiyana rf. human immunodeficiency virus, hepatitis b and hepatitis c in an indonesian prison: prevalence, risk factors and implications of hiv screening. trop med int heal. 2010;15:1491–8. 40 world health organization. scaling up hiv/aids care: service delivery & human resources perspectives. 2004. 41 nachega jb, knowlton ar, deluca a, et al. treatment supporter to improve adherence to antiretroviral therapy in hiv-infected south african adults. a qualitative study. j acquir immune defic syndr. 2006; 43 (suppl 1):s127–33. 42 unge c, södergård b, marrone g, et al. long-term adherence to antiretroviral treatment and program drop-out in a high-risk urban setting in sub-saharan africa: a prospective cohort study. plos one. 2010; 5. doi:10.1371/journal.pone.0013613. 43 simoni jm, huh d, frick pa, et al. peer support and pager messaging to promote antiretroviral modifying therapy in seattle: a randomized controlled trial. j acquir immune defic syndr. 2009;52:465–73. 44 finitsis dj, pellowski j a., johnson bt. text message intervention designs to promote adherence to antiretroviral therapy (art): a meta-analysis of randomized controlled trials. plos one. 2014;9. doi:10.1371/journal.pone.0088166. 45 decroo t, telfer b, biot m, et al. distribution of antiretroviral treatment through self-forming groups of patients in tete province, mozambique. jaids j acquir immune defic syndr. 2011;56:e39–44. 46 bärnighausen t, chaiyachati k, chimbindi n, peoples a, haberer j, newell m-l. interventions to increase antiretroviral adherence in sub-saharan africa: a systematic review of evaluation studies. lancet infect dis. 2011;11:942–51. 47 pearson cr, micek ma, simoni jm, et al. randomized control trial of peer-delivered, modified directly observed therapy for haart in mozambique. jaids j acquir immune defic syndr. 2007;46:238–44. 48 ikeda jm, lópez tellez ca, hudes es, et al. impact of integrating hiv and tb care and treatment in a regional tuberculosis hospital in rural guatemala. aids behav 2014;18. doi:10.1007/s10461-013-0595-9. 49 coetzee d, hilderbrand k, goemaere e, matthys f, boelaert m. integrating tuberculosis and hiv care in the primary care setting in south africa. trop med int health. 2004;9:a11–5. 50 abdool karim ss, naidoo k, grobler a, et al. integration of antiretroviral therapy with tuberculosis treatment. new engl j med. 2011;365:1492–501. 51 legido-quigley h, montgomery cm, khan p, et al. integrating tuberculosis and hiv services in lowand middle-income countries: a systematic review. trop med int heal. 2013;18:199–211. 52 mahendradhata y, ahmad ra, lefèvre p, boelaert m, van der stuyft p. barriers for introducing hiv testing among tuberculosis patients in jogjakarta, indonesia: a qualitative study. bmc public health. 2008;8:385. 53 world bank. gdp (current us$) world development indicators. 2015. http://data.worldbank.org/indicator/ ny.gdp.mktp.cd (accessed june 30, 2015). 54 world bank. health expenditure, total (% of gdp) world development indicators. 2015. http://data. worldbank.org/indicator/sh.xpd.totl.zs (accessed adiatma ym. siregar acta med indones-indones j intern med 216 june 30, 2015). 55 the world bank. life expectancy at birth, total (years). 2015. http://data.worldbank.org/indicator/sp.dyn. le00.in/countries/id-4e-xn?display=default (accessed aug 3, 2015). 56 cohen ms, chen yq, mccauley m, et al. prevention of hiv-1 infection with early antiretroviral therapy. n engl j med. 2011;365:493–505. 57 mathers bm, degenhardt l, ali h, et al. hiv prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage. lancet. 2010;375:1014–28. 58 the world bank. indonesia’s health sector review: overview. 2010. 59 waldrop-valverde d, jones dl, weiss s, kumar m, metsch l. the effects of low literacy and cognitive impairment on medication adherence in hiv-positive injecting drug users. aids care. 2008;20:1202–10. 60 braitstein p, brinkhof mwg, dabis f, et al. mortality of hiv-1-infected patients in the first year of antiretroviral therapy: comparison between low-income and highincome countries. lancet. 2006;367:817–24. 356 acta med indones indones j intern med • vol 54 • number 3 • july 2022 original article risk factors for temporary vascular access infection in patients with end-stage renal disease undergoing hemodialysis in cipto mangunkusumo hospital adityo susilo1*, kresna dharma suryana2, pringgodigdo nugroho3, muhadi4, beryl alodia5, leonard nainggolan1 1division of tropical and infectious diseases, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 3 division of nephrology and hypertension, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 4 division of cardiology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 5 faculty of medicine universitas indonesia, jakarta, indonesia. *corresponding author: adityo susilo, md. division of tropical and infectious diseases, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: aditsilo@gmail.com. abstract background: temporary vascular access is used to provide adequate hemodialysis for patients who are initiating dialysis or are awaiting maturation of a more permanent vascular access. however, infection is one of the most frequent complications of using temporary vascular access and is the second leading cause of death in patients undergoing hemodialysis after cardiovascular events. there has been no research on the risk factors for the incidence of infection in patients using temporary vascular access in indonesia. methods: this is a retrospective cohort study utilizing secondary data from medical records of 318 subjects aged 18 years and older with end-stage renal disease and undergoing hemodialysis using temporary vascular access at cipto mangunkusumo hospital. results: temporary vascular access infection was found in 125 of 318 subjects (39.3%). the risk factors of temporary vascular catheter infection in the multivariate analysis were females (or 1.731; 95% ci 1.050-2.854; p=0.032), low hemoglobin levels (or 2.293; 95% ci 1.353-3.885; p=0.002), presence of diabetes mellitus (or 2.962; 95% ci 1.704-5.149; p<0.001) and duration of catheter insertion (or 5.322; 95% ci 1.871-15-135; p=0.002). the association between ferritin and catheter insertion site was not analyzed as a risk factor because it was not performed in all subjects. conclusion: the incidence of infection in patients with end -stage renal disease undergoing hemodialysis using temporary vascular access at cipto mangunkusumo hospital was 39.3%. female gender, low hemoglobin level, diabetes mellitus, and duration of catheter insertion were risk factors for temporary vascular access infection. keywords: risk factors, temporary vascular access infection, end-stage renal disease, chronic kidney disease, hemodialysis. vol 54 • number 3 • july 2022 risk factors for temporary vascular access infection in patients 357 introduction chronic kidney disease (ckd) is a complex condition characterized by decreased kidney function. patients diagnosed with ckd can survive with the help of renal replacement therapy, one of which is dialysis. based on the 2016 nkf-kdoqi guidelines regarding ckd, the recommended management for ckd patients includes dialysis through vascular access for hemodialysis. the usage number of hemodialysis catheters as vascular access increases linearly coinciding with the increase in new hemodialysis patients.1 a common complication that can occur after installing hemodialysis access is infection. three factors known to influence the occurrence of bacteremia in hemodialysis patients are patient immunity, bacterial virulence, and hemodialysis procedures. infections after hemodialysis catheter insertion can cause various complications such as local infection at the exit-site to hemodynamic instability, changes in mental status, and death. patients undergoing hemodialysis through temporary access have a 2-3 times greater risk of infection and death than those using permanent access.2 to date, there have been no studies in indonesia that explored the risk factors predisposing patients to infection after temporary vascular access placement. by understanding the risk factors associated with infection after hemodialysis catheter insertion, further actions can be undertaken to control the source of infection to reduce the percentage of post-catheter insertion infections in hemodialysis patients. methods a retrospective analysis was conducted on ckd patients undergoing hemodialysis in cipto mangunkusumo hospital, jakarta, indonesia from january 2015 until the required sample size was met. the inclusion criteria for the study were adult ckd patients (aged ≥ 18 years) who underwent hemodialysis with temporary vascular access, either in the femoral, internal jugular, or subclavian vein, and presented with infection. patients with an infection prior to being diagnosed with an infection related to the insertion of a temporary catheter or infection outside the catheter insertion site, patients with missing data in the medical record, and patients using immunosuppressive drugs or were under medications that decreased the immune system, were excluded from the study. t h e d a t a r e t r i e v e d i n c l u d e p a t i e n t characteristics such as age, gender, hemoglobin level, albumin level, duration of catheter use, presence of diabetes mellitus, hypertension, heart failure and malignancy, catheter insertion location, culture results, and antibiotics used to treat the infection. the outcome of this study was the incidence of temporary vascular access infection. ethical clearance the ethical clearance was issued by the ethics committee of the faculty of medicine, universitas indonesia/cipto mangunkusumo hospital, with approval number ket-1227/un2. f1/etik/ppm.00.02/2020. statistical analysis t h e s t a t i s t i c a l a n a l y s e s w e r e d o n e electronically using the spss software. data regarding the baseline clinical characteristics of research subjects were presented in tables. categorical data were presented in percentages. bivariate analysis was performed using the chisquare test for nominal variables. in the bivariate analysis of nominal variables, if the chi-square test conditions were not satisfied, fisher’s exact test or kolmogorov-smirnov test was used instead. all the bivariate outcome variables with a p<0.25 were included in the multivariate analysis using logistic regression. results from 2607 patients with ckd in need of hemodialysis found in the hospital database, a total of 318 patients were included in this study. the reason for the exclusion of the subjects were patients with an infection before being diagnosed with an infection related to the insertion of a temporary catheter or infection outside the catheter insertion site, incomplete or missing data of patients in the medical record, and patients using immunosuppressive drugs (figure 1). the characteristics of the included and excluded subjects undergoing hemodialysis with adityo susilo acta med indones-indones j intern med 358 temporary non-tunneled vascular access were not significantly different (table 1). overall, the included subjects had a mean age of 51.7 years, 160 were males, and 158 were females. the ckd patients with infection had a median age of 54 years (iqr 41-46 years), while those not infected had a median age of 55 years (iqr 46-63 years). comorbid conditions such as hypoalbuminemia 2607 records of ckd patients in need of hemodialysis in dr. cipto mangunkusumo hospital (2015-2020) 318 met the inclusion criteria 193 non-infectious patients 125 infectious patients 747 patients who had an infection before being diagnosed with a temporary vascular access infection 1403 incomplete medical records data regarding the variables examined in this study 139 patients did not return for postoperative vascular access control figure 1. flow diagram showing the patient selection. table 1. characteristic comparison of the included and excluded groups. variables data included (318) excluded (2289) age (years), median (iqr) 55 (43-62) 53 (42-61) age, n (%) > 60 years 92 (28,9) 602 (26,4) < 60 years 22 (71,1) 1682 (73,6) gender, n (%) male 160 (50,3) 1155 (50,7) female 158 (49,7) 1125 (49,3) hemoglobin level, n (%) < 10 g/dl 102 (32,1) 965 (44,2) ≥ 10 g/dl 216 (67,9) 1217 (55,8) albumin, n (%) hypoalbuminemia (< 3.50 mg/dl) 193 (64,8) 858 (68,0) normoalbuminemia (> 3.50 mg/dl) 105 (35,2) 403 (32,0) ferritin, n (%) low risk infection (< 3822 µg/l) 108 (100,0) 689 (100,0) high risk infection (> 3822 µg/l) 0 (0,0) 0 (0,0) duration of catheter use, n (%) ≥ 30 days 83 (26,3) 364 (26,0) < 30 days 233 (73,7) 1034 (74,0) urea, median (iqr) 162,5 (111,63-213) 141,8 (105,4-183,0) creatinine, median (iqr) 7,89 (5,56-10,90) 7,10 (4,9-10,90) egfr, median (iqr) 7,85 (5,02-13,0) 8,4 (5,85-11,10) vol 54 • number 3 • july 2022 risk factors for temporary vascular access infection in patients 359 table 2. clinical characteristics of research subjects. variables total age (years), median (iqr) age, n (%) > 60 years 101 (31.8) < 60 years 217 (68.2) gender, n (%) male 160 (50.3) female 158 (49.7) hemoglobin level, n (%) < 10 g/dl 101 (31.8) ≥ 10 g/dl 217 (68.2) albumin, n (%) hypoalbuminemia (< 3.50 mg/dl) 193 (64.8) normoalbuminemia (> 3.50 mg/dl) 105 (35.2) random plasma glucose, n (%) dm (> 200 mg/dl) 206 (64.8) non-dm (< 200 mg/dl) 112 (35.2) duration of catheter use, n (%) ≥ 30 days 21 (6.6) < 30 days 295 (93.4) hypertension, n (%) yes 204 (64.2) no 114 (35.8) heart failure, n (%) yes 32 (10.1) no 286 (89.9) malignancy, n (%) yes 25 (7.9) no 292 (92.1) location of catheter use, n (%) femoral vein 183 (57.9) jugular vein 128 (40.5) subclavian vein 5 (1.6) urea, median (iqr) 162.5 (111.63-213) creatininea, median (iqr) 7.89 (5.56-10.9) blood culture no bacterial growth was found 61 (31.9) not done 130 (68.1) were found in 64.8% of subjects, followed by diabetes (64.8%), hypertension (64.2%), anemia (31.8%), heart failure (10.1%), and malignancy (7.9%) (table 2). vascular access was installed in the femoral vein in 57.9% of subjects, the jugular vein in 40.5% of subjects, and the subclavian vein in only 1.6% of subjects. evaluation of ferritin, procalcitonin (pct), and lactate levels was only performed in patients with infection, so they were not used as comparisons. ferritin levels <1000 ug/l were found in 108 infected subjects, and procalcitonin levels >1.5 were found in 24 infected subjects. in addition, lactate levels >2 were found in 102 infected subjects. culture examinations were not performed on 130 subjects. of the 188 subjects who had undergone culture examination, 61 samples did not show any bacterial growth, which could be due to the improper sampling technique and the timing of sampling, which could only be done after the subjects had received antibiotics. furthermore, the most widely used antibiotics to treat transient vascular access infections were cefixime (53.2%), meropenem (10.6%), cefepime (6.4%), levofloxacin (6.4%), and ceftriaxone (6.4%). based on the bivariate analysis, age was adityo susilo acta med indones-indones j intern med 360 not a risk factor for infection (rr 0.938, 95%ci 0.696-1.266, p=0.675) (table 3). discussion despite the benefits of providing adequate hemodialysis for patients initiating dialysis or awaiting permanent access, temporary vascular access has a higher risk of infection. temporary vascular access infection is the second leading cause of mortality after cardiovascular events.3 the incidence of catheter-related bloodstream infection ranges between 0.6 and 6.5 episodes per 1000 catheter days.4 the pathogens use two main routes to reach the bloodstream: the extraluminal and intraluminal pathways. regardless of the route used, after entering the bloodstream, the organisms can attach directly to the surface of the vascular access or become incorporated in the fibrin sheath that envelops the catheter and usually forms within 24 hours of catheter insertion. adherence of organisms to the surface of the catheter initiates the formation of biofilms that are highly resistant to antibiotics. therefore, it is clear that the most critical step in the treatment of catheter-related bloodstream infection (crbsi) is preventing the attachment of microorganisms to the catheter and the formation of a biofilm. the first preventive step is to identify risk factors for infection, including gender, anemia, diabetes mellitus, duration of catheter use, old age, ferritin, hypoalbuminemia, and catheter insertion location.4,5 several studies have shown that men have higher risks than women for developing catheterrelated infections. borges prr et al showed that 65% of subjects with infection were males.6 this was different from the results obtained from our study, where females had more infections (57.6%; or 1.731; 95%ci 1.050-2.854; p=0.032) (table 4). this could happen since most of the female subjects in our study had more comorbidities and worse general condition when they first initiated hemodialysis. anemia is common in patients with chronic renal failure due to the shortened life span of red blood cells caused by hemolysis, folic acid deficiency, and bone marrow suppression by excess uremic substances, which further table 3. the comparison between independent variables with the proportion of temporary vascular access infection. variables infection rr (95% ci) p yes no age, n (%) > 60 years 38 (37.6) 63 (62.4) 0.938 (0.696-1.266) 0.675 < 60 years 87 (40.1) 130 (59.9) gender, n (%) female 72 (45.6) 86 (54.4) 1.376 (1.041-1.817) 0.023 male 53 (33.1) 107 (66.9) anemia, n (%) yes 53 (52.5) 48 (47.5) 1.582 (1.214-2.061) 0.001 no 72 (33.2) 145 (66.8) hypoalbuminemia, n (%) yes 87 (45.1) 106 (54.9) 1.246 (0.925-1.678) 0.138 no 38 (36.2) 67 (63.8) diabetes mellitus, n (%) yes 95 (46.1) 111 (53.9) 1.722 (1.226-2.419) 0.001 no 30 (26.8) 82 (73.2) duration of catheter use, n (%) ≥ 30 days 15 (71.4) 6 (28.6) 1.951 (1.432-2.358) 0.002 < 30 days 108 (36.6) 187 (63.4) location of catheter use, n (%) femoral vein 72 (39.3) 111 (60.7) 4.728 (0.331-67.589) 0.252 jugular vein 53 (41.4) 75 (58.6) 4.977 (0.347-71.274) 0.257 subclavian vein 0 (0,.0) 5 (100.0) comparator vol 54 • number 3 • july 2022 risk factors for temporary vascular access infection in patients 361 causes failure of erythropoietin production and decreased red blood cell production. additionally, iron deficiency is known to play a role in causing anemia in chronic renal failure patients. iron is an essential element in the immune process. iron deficiency can cause impaired phagocyte function and increase the risk of infection and death from infection.7 based on the results of a study by wang k et al. involving 865 subjects, low hemoglobin levels were a significant risk factor for the incidence of infection (or 2,276; 95%ci 1,0101-4,749; p=0.012) [8]. these results support the findings in our study where infection occurred in 52.5% of subjects who had anemia and 33.2% in subjects who did not have anemia (or 2.293; 95%ci 1.353-3.885; p=0.002). diabetes causes immune system disorders, including decreased humoral and cellular immunity, which play a role in the pathogenesis of crbsi. diabetes causes decreased mobility of polymorphonuclear cells, chemotactic and phagocytic functions, and impaired adherence function, also decreased the number of t lymphocytes, especially cd4, which decreases the cd4:cd8 ratio. grothe et al showed that diabetic patients in hypertonic conditions had a 22% greater chance of catheter infections. menegueti et al reported the result of a casecontrol study indicating that diabetes mellitus was a risk factor for catheter infection (or 2.651; p<0.001). another study by sahli et al. also proved that diabetes significantly increases a person’s risk of crbsi.4,8,9 similarly, a retrospective cohort study by çaylan r et al. found that diabetes mellitus was associated with infection (or 2.20; 95%ci 1-4.82; p=0.049).10 this was in line with the results obtained from this study; 76% of the infected subjects were diabetic (or 2.962; 95%ci 1.704-5.149; p<0.001). generally, the recommended duration of catheter use is <21 days, but the 30-day limit was used in this study.11 napalkov et al. reported that most temporary vascular access infections occurred within the first 90 days, with an incidence rate of 5.1 per 1000 catheter days. the risk of infection was also higher as the duration of use increased, going up to 3.3 times in a period >90 days.8 meanwhile, borges prr et al. found that an average catheter infection occurred after 9 days of use.6 these results were supported by oliver mj et al.12 through his research which showed the possibility of bacteremia on the first day of catheter insertion was 1.9% and significantly increased to 13.4% on the second day. this indicated an association between the increased risk of crbsi and the duration of catheter use. similar results were obtained from our study, where there were 71.4% of subjects using catheters >30 days developing an infection (or 5.322; 95%ci 1.871-15.135; p<0.002), compared to 63.4% of patients using catheter <30 days who did not have an infection. there are changes in non-specific systems that happen due to aging that facilitates the invasion of pathogenic organisms into the mucosal tissue. increase in the plasma concentration of il-6, il-1, and tumor necrosis factor-alpha (tnf-α) in the elderly was also shown to be a predictor of functional disability and mortality and causes continuous stimulation of the immune system, resulting in a subclinical inflammatory state or what is known as inflamm-aging. the aging process also impacts the specific immune system, causing a decrease in the number of t and b lymphocytes.13 our analysis showed no statistically significant correlation between age >60 years and infection. this could be because the mean age in all groups with temporary vascular access was 51.7 years, and 68.2% of the infectious subjects were aged <60 years old. similar results were table 4. multivariate analysis variables or (95% ci) p gender: female 1.731 (1.050-2.854) 0.032 anemia 2.293 (1.353-3.885) 0.002 diabetes mellitus 2.962 (1.704-5.149) <0.001 duration of catheter use > 30 days 5.322 (1.871-15.135) 0.002 adityo susilo acta med indones-indones j intern med 362 found by the study of borges prr et al where age was not a significant risk factor for infection.6 ferritin indicates the amount of iron stored in the body. a high ferritin level in the serum shows high iron content in the body. ckd patients undergoing dialysis therapy generally have iron overload caused by the body’s increased need for red blood cells, so they need to be given iron intravenously, with or without red blood cell transfusions. simultaneously, excess iron can cause damage to neutrophils and t cell function. ferritin protects the body during infection by limiting the availability of iron used by pathogens for multiplication and colony formation. a study by seifert et al showed an increased incidence of bacterial infection in hemodialysis patients with ferritin levels ranging from 10012000 ng/ml compared to patients with serum ferritin levels ranging from 10-220 ng/ml (p<0.01).7 another prospective study reported a 2.92 times greater risk in patients undergoing hemodialysis with ferritin levels >1000 ng/ml than those with ferritin levels <1000 ng/ml.14 the relationship between ferritin levels and the risk of infection in this study could not be analyzed further because a ferritin examination was not performed on every subject undergoing hemodialysis. hypoalbuminemia is common in patients undergoing dialysis. inadequate nutrition is associated with impaired immunity, increasing the likelihood of becoming infected.15 lukowsky et al reported that one-third of deaths within the first 90 days in patients undergoing hemodialysis was associated with hypoalbuminemia. the multivariate analysis emphasized that albumin levels <33 g/dl were an independent predictor of catheter infection. a case-control study conducted by adeniyi oa, et al.16 found that serum albumin levels before treatment in subjects with vascular access infection were in the range of 2.4 ± 0.6 g/dl, while for the group of subjects who did not have an infection, had an albumin value of 3.2 ± 0.6 g/dl (p<0.0001). another study by darma et al also showed an increased risk of catheter-associated bacteremia in patients with hypoalbuminemia (p<0.008).17,18 in addition, similar findings were also shown by demirci et al,3 where low albumin levels were an independent predictor of the occurrence of crbsi (or 0.119, 95% ci 0.019-0.756, p=0.024).15 our study was consistent with the results, where 69.6% of subjects with hypoalbuminemia had an infection, while only 30.4% of subjects were infected in the group with a normal albumin level. the location of catheter insertion could also impact the incidence of infection. insertion of temporary cvc to the femoral vein is associated with a higher risk of infection. sahli et al reported that the incidence of infection in cvc installed in the femoral vein is 8.8 per 1000 catheter days. meanwhile, the subclavian vein has the lowest risk of infection, despite a higher risk of stenosis. thus, the internal jugular vein is preferred for hemodialysis.4,19 this risk of stenosis was also the exact reason for not preferring the subclavian vein as a cvc insertion site at cipto mangunkusumo hospital; hence the correlation between the catheter insertion location and the risk of infection in our study could not be analyzed further. kdoqi recommended that health workers who come into contact with catheters must use clean or sterile masks and gloves. liquids that can be used to clean the exit sites are 2% chlorhexidine and 70% alcohol or 10% povidoneiodine liquid. several studies and meta-analyses have shown that chlorhexidine is superior to alcohol and povidone-iodine. technical implementation of exit-site maintenance at cipto mangunkusumo hospital has also used 2% chlorhexidine.5 the use of topical antibiotics at the exit site has been associated with a 75-93% reduced risk of cvc-associated bacteremia. one of the recommended topical antibiotics, which are used in cipto mangunkusumo hospital, is mupirocin. in addition, antimicrobial lock prophylaxis has been shown to reduce the risk of cvc-related bacteremia. antimicrobial lock combination prophylaxis, which is currently being used at cipto mangunkusumo hospital, is gentamicin 40 mg and heparin 2000 units. this use was in line with the international society of nephrology recommendations: gentamicin 5 mg/ml + heparin 5000 u/ml. overall, this could vol 54 • number 3 • july 2022 risk factors for temporary vascular access infection in patients 363 cause a low incidence of cvc infection in cipto mangunkusumo hospital.5 our study has several limitations. first, this study was a retrospective study that relied on medical record data; thus, it may not fully reflect the patient’s condition if there were improper or incomplete documentation in the medical record. second, data collection was only done in one hospital; therefore, the results obtained may not represent the results from other hospitals. third, we did not assess the comorbid factors of each subject before temporary vascular access insertion, which could inherently affect the patient’s susceptibility to infection. conclusion the proportion of temporary vascular access infections at the cipto mangunkusumo hospital was 39.3%. the significant risk factors for temporary vascular access infection were female gender, diabetes mellitus, low hemoglobin level, and the duration of catheter use >30 days. we recommend that ferritin examination be performed routinely in all patients with temporary vascular access, regardless of the infection status. blood cultures should be examined twice, with samples from peripheral veins and hemodialysis catheters taken before administration of antimicrobial therapy and observed for 48 hours of incubation. culture studies should be performed after excluding other possible infection causes in patients with fever. more research should be carried out, preferably using a prospective design, to assess the actual condition of the patient better and to be able to follow the patient’s course of disease continuously. lastly, further research should pay more attention to the characteristics and proportions of each of the subjects involved to show more accurate results and reduce the possibility of bias. acknowledgments we would like to express our gratitude to our advisors: chyntia olivia maurine jasirwan, suryo anggoro kusumo wibowo, dicky levenus tahapary, leonard nainggolan, and rr. dyah purnamasari sulistianingsih who gave us constructive inputs throughout this project. funding the authors did not receive support from any organization for the submitted work. author contributions all authors contributed to the study’s conception and design. material preparation, data collection, and analysis were performed by kresna dharma suryana. the first draft of the manuscript was written by kresna dharma suryana, and all authors commented on previous versions of the manuscript. all authors read and approved the final manuscript. references 1. national kidney foundation. update of the kdoqi tm clinical practice guideline for hemodialysis adequacy; 2015. 2. collins aj, foley rn, chavers b, et al. us renal data system 2011 annual data report. am j kidney dis. 2012;59(1):a7. 3. demirci r, sahtiyanci b, bakan a, akyuz o. the predictors of catheter-related bloodstream infections in patients undergoing hemodialysis: a single center experience. j vasc access. 2021;112972982199883. 4. sahli f, feidjel r, laalaoui r. hemodialysis catheterrelated infection: rates, risk factors and pathogens. j infect public. 2017;10(4):403-8. 5. lok c, mokrzycki m. prevention and management of catheter-related infection in hemodialysis patients. ki. 2011;79(6):587-98. 6. borges prr, bedendo j. risk factors associated with temporary catheter-related infection in patients on dialysis treatment. text context nurs. 2015;24(3):680-5. 7. seifert a, herrath d, schaefer k. iron overload, but not treatment with desferrioxamine favours the development of septicemia in patients on maintenance hemodialysis. q j med. 1987;65(248):1015-24. 8. knezevic v, djurdjevic-mirkovic t, bozic d, et al. risk factors for catheter-related infections in patients on hemodialysis. vojnosanit pregl. 2018;75(2):159-66. 9. menegueti mg , betoni nc, bellissimo-rodrigues f, romão ea. central venous catheter-related infections in patients receiving short-term hemodialysis therapy: incidence, associated factors, and microbiological aspects. rev soc bras med trop. 2017;50(6):7837. 10. çaylan r, yilmaz g, sözen ee, aydin k, köksali. incidence and risk factors for bloodstream infections stemming from temporary hemodialysis catheters. turk j med sci. 2010;40(6):835-41. 11. bream p. update on insertion and complications of adityo susilo acta med indones-indones j intern med 364 central venous catheters for hemodialysis. semin intervent radiol. 2016;33(01):31-8. 12. oliver m, callery s, thorpe k, schwab s, churchill d. risk of bacteremia from temporary hemodialysis catheters by site of insertion and duration of use: a prospective study. ki. 2000;58(6):2543-5. 13. setiati s, rizka a. imunosenesens. in: setiati s, alwi i, sudoyo aw, et al, eds. buku ajar ilmu penyakit dalam. 3rd edition. jakarta: interna publishing; 2014. p. 3680-5. 14. boelaert jr, daneels rf, schurgers ml, matthys eg, gordts bz. iron overload in haemodialysis patients increases the risk of bacteraemia: a prospective study. nephrol dial transplant. 1990;5:130-4. 15. kernan k, carcillo j. hyperferritinemia and inflammation. int immunol. 2017;29(9):401-9. 16. adeniyi oa, tzamaloukas ah. relation between access-related infection and preinfection serum albumin concentration in patients on chronic hemodialysis. hemodial int. 2003;7(4):304-10. 17. miller lm, clark e, dipchand c, et al. hemodialysis tunneled catheter-related infections. can j kidney heal dis. 2016;3:1-11. 18. trianto, semadi n, widiana g. faktor risiko infeksi kateter hemodialisis double lumen non-tunneled. j ilmu kedokteran. 2014;46:25-30. 19. lafrance j, rahme e, lelorier j, iqbal s. vascular access-related infections: definitions, incidence rates, and risk factors. am j kidney dis. 2008;52(5):982-93. 524 acta med indones indones j intern med • vol 54 • number 4 • october 2022 original article abstract background: colorectal cancer is a type of cancer that begins in the colon and/or rectum tissue. natural killer (nk) cells play a critical role in the first line of defense against infection and tumors, as well as in autoimmunity and hypersensitivity reactions. nk cells also play a role in regulating tumor cell growth and metastasis. the number and percentage of activated natural killer cells have been determined in patients with colorectal cancer and benign lesion. methods: this was a cross-sectional observational analytic study. the number and percentage of activated nk cells in peripheral blood were determined using the flow cytometry method in 50 samples from patients who underwent colonoscopy and obtained a mass as evidenced by histopathological examination. results: among the 50 samples, 24 samples included in the colorectal cancer group and 26 samples from benign lesion group. the mean number of nk cells in colorectal cancer was 161.71 ± 62.666 cells/µl, benign lesion was 553.92 ± 269.173 cells/µl. the mean percentage of activated nk cells in colorectal cancer was 2.82 ± 1.19%, benign lesion was 5.10 ± 2.48%. there was a significant difference in the number of nk cells and the percentage of activated nk cells between colorectal cancer and benign lesion patients (p = 0.000). conclusion: the number and activity of nk cells decreases in patients with colorectal cancer. keywords: the number of nk cells, percentage of activated nk cells, colorectal cancer, cancer. lower number and percentage of activated natural killer cells in colorectal cancer patients amie vidyani1*, iswan abbas nusi1, ulfa kholili1, poernomo b. setiawan1, herry purbayu1, titong sugihartono1, ummi maimunah1, budi widodo1, husin thamrin1, muhammad miftahussurur1,2 1 division of gastro entero-hepatolog y, depar tment of internal medicine, fac ulty of medicine universitas airlangga dr. soetomo hospital, surabaya, indonesia. 2 institute of tropical disease, universitas airlangga, surabaya, indonesia. * corresponding author: amie vidyani, md. division of gastroentero-hepatology, department of internal medicine, faculty of medicine universitas airlangga dr. soetomo hosptial. jl. mayjen prof. dr. moestopo 47, surabaya 60131, indonesia. email: amie.vidyani@fk.unair.ac.id. introduction colorectal cancer is a type of cancer that begins in the colon and/or rectum tissue. recently the incidence of colorectal cancer has been increasing in both western and developing countries. colorectal cancer is the third most common type of cancer worldwide, the second leading cause of death from cancer, and the leading cause of death from gastrointestinal cancer.1 colorectal cancer is the third most common type of cancer and the third leading cause of death in men and women in the united states, according to the american cancer society. in 2018, 19,113 men (11.9% of new cancer cases) and 10904 women (5.8% of new cancer cases) were diagnosed with colorectal cancer in the world.2 data in dr. soetomo surabaya hospital, indonesia, recorded as many as 852 patients diagnosed with colorectal cancer from 1 january 2012 to 31 december 2017. other data obtained were 201 patients were recorded as having colorectal tumors at the gastroenterovol 54 • number 4 • october 2022 lower number and percentage of activated natural killer cells 525 hepatology center dr. soetomo hospital from june 2013 to may 2015. the risk of developing colorectal cancer can be associated with aging, poor dietary habits, lack of exercise, smoking, and obesity.3 in general, it is stated that the development of colorectal cancer is an interaction of various factors, namely environment and genetics. natural killer (nk) cells are a type of large granular lymphocyte with a distinctive morphology that participates in innate immunity. nk cells play a role in the early stages of infection and tumor defense and may also play a role in autoimmunity and hypersensitivity reactions. nk cells protect the body by killing specific cells and secreting chemokines and cytokines (innate immune system), as well as assisting other immune cells in eliminating the targeted cells (adaptive immune system). nk cell functions are regulated by two types of receptors, namely receptor activation, and inhibition.4 nk cells are the primary cells in cancer immune surveillance. the role of nk cells in colorectal cancer can predict the occurrence of postoperative recurrence and metastases. a previous study shows that the number of nk cells is related to the life expectancy of people with colorectal cancer.5 the decrease in nk cell activity was not associated with the cancer staging, is associated with a lower life expectancy.4 colorectal cancer was tenfold more likely to develop in patients with low nk cell activity.6 the incidence of colorectal cancer is increasing in developing countries such as indonesia. a recent study compared patients at high risk of colorectal cancer, specifically those over the age of 40 who had colonoscopy.6 this study compares the number and percentage of activated natural killer cells in colorectal cancer patients and benign lesion patients based on this description. methods the method used was observational analytic with a cross-sectional design. the population of this study was all patients who underwent colonoscopy at dr. soetomo hospital, surabaya, east java, indonesia. the study sample was patients who met the inclusion and exclusion criteria, and had a mass taken in colonoscopy which was proven by histopathological examination. the inclusion criteria were consenting to participate in the study with informed consent, aged 20-60 years and not undergoing anticancer treatment, including surgery and chemotherapy. while the exclusion criteria were patients who are not pregnant and not currently using contraception, currently has no active bacterial or viral infection, had hepatitis b or c infection, had a history of using corticosteroids and immunosuppressants for the past six months, had autoimmune diseases (rheumatoid arthritis, multiple sclerosis, systemic lupus erythematosus, kidney disease), intestinal inflammation including crohn’s disease, type 1 diabetes, guillain barre syndrome), currently has no active tb or a history of hiv infection. the number of subjects was obtained after calculating the minimum sample size using the formula unpaired numerical analytic. the number of samples was obtained with 24 colorectal cancer samples and 26 benign lesion samples. colorectal cancer patients are patients whose masses are suspected of malignancy originating from the colon and/or rectum on colonoscopy examination, as well as evidenced by histopathological examination, and benign lesion patients are patients who do not show a mass suspected of malignancy (polyps, internal and external hemorrhoids, normal) as evidenced by histopathological examination. this study has approved by the ethics committee of dr. soetomo hospital (ref. no. 2028/kepk/ vii/2020). the research location was the gastroenteroh e p a t o l o g y c e n t e r, i n t e r n a l m e d i c i n e department/smf at dr. soetomo hospital, surabaya, east java, indonesia. samples were taken in the period july 2020 to february 2021. sampling was done by consecutive sampling until the sample size was met. this research was conducted by taking the peripheral blood of the research subject to check the number and percentage of activated nk cells using the flow cytometry method. after conducting research and obtaining the desired data, the data were collected and analyzed using spss version 25 software. amie vidyani acta med indones-indones j intern med 526 results based on the 50 subjects obtained, 26 subjects had colorectal cancer and 24 subjects had benign lesion. based on the age profile, the mean age of the subjects for colorectal cancer was 44 years while for benign lesion it was 49 years as shown in table 1. most of the subjects (57.69%) were female in the benign lesion group (15 people), and most 75% were male in the colorectal cancer group (18 people). characteristics of the research subject’s laboratory examination from a total of 50 research subjects, 24 subjects had colorectal cancer, and 26 subjects had benign lesion. as can be seen in table 2 shows that the average hb value in the benign lesion was higher than the colorectal cancer group. the average value is not more significant. leukocyte levels in benign lesion subjects were higher (10353.46 cells/µl) than in the colorectal cancer group. at the same time, the platelet level was higher (371037.50 cells/µl) in the colorectal cancer group. lymphocyte levels were greater (2110.77 cells/µl) in the benign lesion group. the mean serum glutamic oxaloacetic transaminase (sgot) was 30.09 mg/dl for the colorectal cancer group. mean serum glutamic pyruvic transaminase (sgpt) level 34.50 mg/ dl for benign lesion. the average blood urea nitrogen (bun) level was 7.07 mg/dl for the colorectal cancer group. the average albumin level in the colorectal cancer group was 3.55 g/dl. examination of the serum creatinine (sk) test showed the mean sk level for the benign lesion group was 3.32 mg/dl. the average na level for the colorectal cancer group was 135.79, while the average k level in the benign lesion group was 4.05. distribution of colorectal cancer and benign lesion based on histopathological type the results of this study found that the most frequent histopathological types found in the colorectal cancer group was adenocarcinoma (36%), followed by carcinoma well differentiated (12%). while for the benign lesion group, nonspecific chronic colitis was most frequent (28%), table 1. demographic characteristics. characteristics colorectalcancer benign lesion p-value n = 24 n = 26 age (years) mean ± sd 44.83 ± 12.11 49.35 ± 10.94 0.540 median 46.0 54.0 gender women (%) 25 57.69 0.019 men (%) 75 42.30 body massa index (kg/m2) mean ± sd 25.754 ± 0.84 22.096 ± 3.07 0.034 median 25.60 21.75 ethnicity javanese (%) 79.17 76.92 0.957 madura (%) 12.5 15.38 tionghoa (%) 8.33 7.7 symptoms hematochezia (%) 29.17 38.46 diarrhea (%) 29.17 23.07 constipation (%) 8.33 3.85 0.821 abdominal pain (%) 33.33 34.62 vol 54 • number 4 • october 2022 lower number and percentage of activated natural killer cells 527 followed by non-specific chronic colitis with mild dysplasia (12%), and active chronic colitis (12%). number of nk cells in colorectal cancer and benign lesion group the mean number of nk cells in the colorectal cancer group was 161.71 ± 62.66 cells/µl, which was greater than the average number of nk cells in the benign lesion group, which was 553.92 ± 269.17 cells/µl. the lowest number of nk cells in the colorectal cancer group was 25, while the highest number was table 2. characteristics of the research subject's laboratory examination. laboratory parameters colorectal cancer n=24 benign lesion n=26 p-value hemoglobin (g/dl) mean ± sd 12.27 ± 2.10 12.85 ± 2.21 0.565 median 12.65 12.85 leukocytes (cell/µl) mean ± sd 9618.67 ± 5994.57 10353.46 ±12677.35 0.432 median 8385.00 6755.00 platelets (cell/µl) mean ± sd 371037.50 ± 193426.06 326938.46 ± 135021.05 0.352 median 4.20 4.20 lymphocytes (cell/µl) mean ± sd 1147.50 ± 449.44 2110.77 ± 635.13 0.069 median 1090.00 2300.00 sgot mean ± sd 30.09 ± 27.26 27.46 ± 17.75 0.191 median 20.500 24.500 sgp-t mean ± sd 31.15 ± 17.71 34.50 ± 21.11 0.651 median 28.00 28.00 bun mean ± sd 7.07 ± 3.41 6.19 ± 2.35 0.652 median 6.00 6.00 albumin mean ± sd 3.55 ± 0.69 2.90 ± 0.94 0.232 median 3.70 2.80 sc mean ± sd 2.47 ± 2.12 3.32 ± 2.67 0.321 median 1.3200 1.3200 na mean ± sd 135.79 ± 6.70 131.08 ± 24.60 0.363 median 135.00 134.50 k mean ± sd 3.99 ± 0.49 4.05 ± 0.35 0.390 *sgot : serum glutamic oxaloacetic transaminase sgp-t : serum glutamic pyruvic transaminase sc : serum creatinine na : natrium k : kalium table 3. histopathological classification. variables n (%) colorectal cancer adenocarcinoma carcinoma well differentiated 18 (36) 6 (12) benign lesion non-specific chronic colitis non-specific chronic colitis with mild dysplasia active chronic colitis 14 (28) 6 (12) 6 (12) total (100) amie vidyani acta med indones-indones j intern med 528 244. the lowest number of nk cells in the benign lesion group was 272, while the highest number was 1095. the range of minimum and maximum values in both groups was also quite large, as indicated by the very high standard deviation of 62.66 in the colorectal cancer group and 269.17 in the benign lesion group. comparative analysis of the number of nk cells in patients with colorectal cancer and benign lesion patients were performed using the mann whitney’s test. the analysis results show a significant difference between the number of nk cells in patients with colorectal cancer and benign lesion (p-value 0.000). percentage of activated nk cells in colorectal cancer and benign lesion group the average percentage of activated nk cells in the colorectal cancer group is 2.82 ± 1.19%, which is smaller than the benign lesion group with 5.10 ± 2.48%. the lowest percentage of activated nk cells was 0.92, and the highest was 4.67 in the colorectal cancer group, while the lowest percentage of nk cells in the benign lesion group was 1.23, and the highest was 11.44. the range of minimum and maximum values in both groups was also quite large, as indicated by the high standard deviation values, namely 1.19 in patients with colorectal cancer and 2.48 in patients without colorectal cancer. the analysis results show a significant difference between the percentage of activated nk cells in patients with colorectal cancer and benign lesion with a p-value of 0.000. discussion colorectal cancer group is a patient whose mass is suspected of malignancy originating from the colon and/or rectum on colonoscopy e x a m i n a t i o n , a s w e l l a s e v i d e n c e d b y histopathological examination.1 the number and activity of natural killer cells (nk cells) decreased in patients with colorectal cancer in this study. nk cells are effector lymphocytes of the innate immune system that regulate the growth and spread of several types of tumors. nk cells are a promising cell type for adoptive immunotherapy. transplantation of tumorinfiltrating lymphocytes has demonstrated some remarkable responses in patients with metastatic melanoma.7 although nk cells have a limited ability to infiltrate the colorectal cancer microenvironment, a subpopulation of colorectal cancer patients had lesions that are sufficiently infiltrated with nk cells for statistical analysis. nk cell infiltration was previously detected in approximately 30% of colorectal tumor specimens. notably, nk cell infiltration was not found to be associated with disease progression.8 following a 5-year follow-up, the beneficial effect of nk cell-t cell cooperation on the clinical course of colorectal cancer is diminished. the mechanism underlying this phenomenon is obscure. one could hypothesize that tumorinfiltrating nk cells lose their helper function over time as a result of altered activities induced by cancer cells via a variety of mechanisms. these include indoleamine 2,3-dioxygenase (ido) and prostaglandin e2 (pge2) production by malignant cells, metalloproteinases (mmps), transforming growth factor b1 (tgfb1), and integrin b2 production by malignant cells (itgb2, also known as lfa1).9 another study found that the mean age of patients with colorectal cancer was 42 years.10 most colorectal cancer sufferers are at the age of 40-49 years. other studies mostly found colorectal cancer at the age of over 40 years. the age of 40 years is when the diagnosis of colorectal cancer begins to increase sharply.11 in this study the colorectal cancer group was also found to be at an average age of 44 years. this situation may occur due to the slow metabolic process, inactivity, and more frequent food consumption. as many as 70% of colorectal cancer cases are sporadically caused by poor lifestyle, such as a diet low in fiber and fruits, excessive red meat and saturated fat consumption, lack of physical activity, alcohol consumption, and smoking.12 based on gender, the proportion of female subjects in the benign lesion group significantlt larger than that the colorectal cancer group. as for the colorectal cancer group, there was a significantly higher proportion of males. in most studies, colorectal cancer were mostly found in male patients. the incidence of colorectal cancer in men is related vol 54 • number 4 • october 2022 lower number and percentage of activated natural killer cells 529 to the level of the hormone estradiol, which in normal amounts, functions in spermatogenesis and fertility. however, excessive amounts of estradiol will inhibit the secretion of gonadotropin proteins such as luteinizing hormone (lh), further reducing testosterone secretion. a high amount of testosterone is associated with a reduced risk of colorectal cancer.13 another study discovered that the majority of colorectal cancer patients had an overweight bmi. obesity causes hormone accumulation, increased insulin levels, and insulin-like growth factor-1 (igf-1), triggering tumor growth regulators, impaired immune response, and oxidative stress, thus triggering colorectal carcinoma.14 based on ethnicity, the proportion of subjects with javanese ethnicity in the colorectal cancer group was more significant than the benign lesion group. another study found colorectal cancer patients of javanese ethnicity. the ethnic groups chosen for this study are critical because they will influence cancer treatment strategies, cancer prevention strategies, early detection, and appropriate treatment.15 ethnic variations in the risk of colorectal cancer should affect r e s u l t s if adjusted for known or suspected risk factors and environmental exposures.16 although there was no statistically significant difference in the number of nk cells in the peripheral blood of healthy donors and colorectal cancer patients, the colorectal cancer group had 10.10 cells/l in the cd45+ cd56+ cell population. whereas in healthy donors, the results were 12.3 cells/µl.17 increased loss of cd16 expression via release could explain the increase in the frequency of the cd56-dimmed cd16 population. cd16 release can also be induced by activating nk cells with cytokines such as il-2, il-15, and il-18, tnf, or target cells (such as tumor cells). many of these cytokines are increased in the blood of patients with colorectal cancer. when nk cells are activated via cd16 or nkg2d signaling, the adam17 metalloprotease, which also cleaves cd16 in nk cells, is increased.18 the increase in cd56+cd16 + nk cell counts in colorectal cancer patients is statistically significant. cd16 is a low-affinity fcriii that recognizes antibody-coated targets and signals antibodydependent cytotoxicity (adcc). cd16 binds specifically to the fc moiety of igg antibodies on the surface of coated cells and induces degranulation of intracellular granules, resulting in the death of infected or tumor cells.19 nkg2d expression was significantly downregulated in nk cells isolated from patients with colorectal cancer. the decreased expression of nkg2d may be associated with the suppression of nk cell activity in colorectal cancer.20 nkg2d is required for nk cell activation, and decreased nkg2d expression may result in decreased nk cell activity in patients with colorectal cancer. in colorectal cancer patients, the nkg2 pathway can be used to inhibit nk cell-mediated antitumor immune responses. the imbalanced expression of nkg2a and nkg2d may contribute to the suppression of nk cell activity in colorectal cancer patients, thereby allowing tumor cells to escape nk-mediated lysis. numerous cytokines, including il-2, il-12, il-15, and ifn-, can increase nkg2 expression and nk cell-mediated cytotoxicity. due to the decreased level of nkg2d expression in colorectal cancer patients, which may be related to nk cell suppression, tumor cells can evade nk cell control via the nkg2 pathway.21 conclusion a significant difference was found between the number and percentage of activated nk cells in colorectal and benign lesion patients. conflict of interest the authors declare that they have no conflicting interests. references 1. granados-romero jj, valderrama-treviño ai, contreras-flores eh, et al. colorectal cancer: a review. int j res med sci. 2017;5(11):4667. 2. gandomani hs, yousefi sm, aghajani m, et al. colorectal cancer in the world: incidence, mortality and risk factors. biomed res ther. 2017;4(10):1656. 3. schreuders eh, ruco a, rabeneck l, et al. colorectal cancer screening: a global overview of existing programmes. gut. 2015;64(10):1637–49. 4. paul s, lal g. the molecular mechanism of natural killer cells function and its importance in cancer immunotherapy. front immunol. 2017;8. amie vidyani acta med indones-indones j intern med 530 5. tang yp, xie mz, li kz, li jl, cai zm, hu bl. prognostic value of peripheral blood natural killer cells in colorectal cancer. bmc gastroenterol. 2020;20(1):1–11. 6. jobin g, rodriguez-suarez r, betito k. association between natural killer cell activity and colorectal cancer in high-risk subjects undergoing colonoscopy. gastroenterol. 2017;153(4):980–7. available from: http://dx.doi.org/10.1053/j.gastro.2017.06.009 7. mordoh j, levy em, roberti mp. natural killer cells in human cancer: from biological functions to clinical applications. j biomed biotechnol. 2011;2011. 8. sconocchia g, eppenberger s, spagnoli gc, et al. nk cells and t cells cooperate during the clinical course of colorectal cancer. oncoimmunology. 2014;3(8):1–6. 9. desbois m, rusakiewicz s, locher c, zitvogel l, chaput n. natural killer cells in non-hematopoietic malignancies. front immunol. 2012;3:1–12. 10. dozois ej, boardman la, suwanthanma w, et al. young-onset colorectal cancer in patients with no known genetic predisposition: can we increase early recognition and improve outcome? medicine (baltimore). 2008;87(5):259–63. 11. khosama y. faktor risiko kanker kolorektal. cermin dunia kedokt. 2015;42(11):829–32. 12. binefa g, rodríguez-moranta f, teule à, medinahayas m. colorectal cancer: from prevention to personalized medicine. world j gastroenterol. 2014;20(22):6786–808. 13. lin jh, zhang sm, rexrode km, et al. association between sex hormones and colorectal cancer risk in men and women. clin gastroenterol hepatol. 2013;11(4):419–24. 14. johnson it, lund ek. review article: nutrition, obesity and colorectal cancer. aliment pharmacol ther. 2007;26(2):161–81. 15. sudoyo aw, hernowo b, krisnuhoni e, reksodiputro ah, hardjodisastro d, sinuraya es. colorectal cancer among young native indonesians: a clinicopathological and molecular assessment on microsatellite instability. med j indones. 2010;19(4):245–51. 16. ollberding nj, nomura amy, wilkens lr, henderson be, kolonel ln. racial/ethnic differences in colorectal cancer risk: the multiethnic cohort study. int j cancer. 2011;129(8):1899–906. 17. yunusova nv, stakheyeva mn, molchanov sv, et al. functional activity of natural killer cells in biological fluids in patients with colorectal and ovarian cancers. cent eur j immunol. 2018;43(1):26–32. 18. yamaguchi m, okamura s, yamaji t, et al. plasma cytokine levels and the presence of colorectal cancer. plos one. 2019;14(3):1–13. 19. leibson pj. signal transduction during natural killer cell activation: inside the mind of a killer. immunity. 1997;6(6):655–61. 20. shen y, wang q, qi y, et al. peripheral foxp3+ regulatory t cells and natural killer group 2, member d expression levels in natural killer cells of patients with colorectal cancer. mol med rep. 2014;10(2):977–82. 21. shen y, lu c, tian w, wang l, cui b, jiao y, et al. possible association of decreased nkg2d expression levels and suppression of the activity of natural killer cells in patients with colorectal cancer. int j oncol. 2012;40(4):1285–9. 647acta med indones indones j intern med • vol 54 • number 4 • october 2022 special article revisiting the overlooked infection: rickettsioses lie khie chen1,2*, erni juwita nelwan1,2, adeline pasaribu1, sharifah shakinah1, robert sinto1,2, leonard nainggolan1,2 1division of tropical and infectious disease, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 2member of antimicrobial stewardship committee, cipto mangunkusumo hospital, jakarta, indonesia. * corresponding author: lie khie chen, md., phd. division of tropical and infectious disease, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: drkhiechen@gmail.com. abstract the prevalence of human rickettsioses cases in indonesia is unknown and could probably be underestimated. the high prevalence of seropositive rickettsia sp. was reported in small mammals (as vectors) and humans. in indonesia, a recent study in patients with acute fever revealed that the prevalence of rickettsioses is 10%. many cases of rickettsioses were often misdiagnosed with dengue fever, enteric fever, or leptospirosis due to their overlapping clinical manifestation. the limitation of point of care testing in indonesia hindered the adequacy of diagnosis confirmation. appropriate empirical or definitive treatment with macrolide, mainly doxycycline, is preferable compared to other broad-spectrum antibiotics, such as cephalosporin or quinolones. moreover, when left untreated, rickettsioses may deteriorate progressively to fatal outcomes, such as meningitis, sepsis, and even death. the awareness of health care practitioners, the availability of confirmatory rapid diagnostic tests and adequate treatment choices are important in eradicating this disease. keywords: infection, rickettsioses, tropical disease. introduction rickettsial diseases are a group of diseases caused by a genus of obligately intracellular, gram-negative coccobacilli and short bacilli, and non-spore-forming bacteria.1,2 the family of rickettsiaceae as the etiology of rickettsial diseases were originally classified into six genera, i.e., rickettsia, ehrlichia, anaplasma, neorickettsia, candidatus neoehrlichia, and wolbachia1. however, based on the antigenic and genetic data, it was further classified as rickettsia spp. and orientia, spp. these species are traditionally divided into three rickettsioses disease groups, i.e., spotted fever group (sfg), typhus group and scrub typhus group.3,4 the acute presentations of rickettsioses are often similar during the first 5 days, i.e., fever, headache, myalgia, nausea, vomiting and cough. it is usually first presented as a fever that may subside without further clinical evolution or it may also evolve along one or more principal clinical lines, i.e., macular or maculopapular rash, eschar, vesicular rash, pneumonitis, meningoencephalitis, and even sepsis and toxic shock syndromes with hypotension and multiorgan failure.1,2 regardless of its potentially fatal outcomes, rickettsioses are often misdiagnosed in daily clinical practice because the initial signs and symptoms of the disease may overlap with other acute febrile illnesses clinical features, such as dengue fever, leptospirosis, or enteric fever disease.5,6 establishing a definitive diagnosis is also challenging as it requires more time to lie khie chen acta med indones-indones j intern med 648 examine serum samples during the acute and convalescent phases, whereas, the disease course may deteriorate rapidly if they are not promptly treated.1,2,4,7 definition and clinical features rickettsioses were firstly described as exanthematic typhus in 1760, followed by the first report of scrub typhus in 1879 and the discovery of a pathogen for rocky mountain spotted fever (rmsf) by howard taylor ricketts, whose name underlies the etymology of the disease.1,8,9 in indonesia, the term typhus (as included in rickettsioses) or “tifus” (in indonesian language) is commonly mistaken as typhoid fever or enteric fever which is caused by salmonella, sp. and has a fecal-oral transmission.10 the earliest definition of the term “typhus” is difficult to be determined since it was applied to a broad range of infectious diseases before the 20th century. the new era of rickettsiology had been fastened by the discovery of typhus diagnostic test which was able to identify epidemic typhus caused by rickettsia spp. and orientia spp. with the rapid invention of antibiotics, however, the widespread epidemic could be suppressed and nowadays the prevalence rate of the infection has decreased.9 centers for disease control and prevention (cdc) categorized rickettsial diseases as travelrelated infectious diseases, in which all travellers from endemic areas are at risk of acquiring rickettsial infections. since most rickettsial diseases incubate for 5-14 days, tourists may not experience symptoms during their trip and onset may coincide with their return home or within a week after returning.11 the lists of endemic areas are diverse, for example, rmsf is endemic in south-central united states, canada, mexico, and south america; scrub typhus in asia, australia, pacific; murine typhus spreads worldwide; and mediterranean spotted fever in southern europe, africa and asia.1,2,7 table 1 summarizes the groups of rickettsioses and their features. situation in indonesia the epidemiology data of rickettsioses vary according to geographic distribution and seasonal activities of tick vectors and vertebrate hosts, in addition to the human behaviors that increase the risk of tick exposure, tick attachment, and subsequent infection.7 the exact prevalence of these diseases is often underestimated since the establishment of definitive diagnosis is still limited. a study held in 1995 on rickettsial disease risk revealed that indonesia was an endemic area for murine typhus, scrub typhus, and q fever, whereas other typhus and sfg endemicity were unknown.10 evidence of rickettsial diseases or table 1. group of rickettsioses and their clinical features.1,2,11 disease* organism transmission incubation (days) duration (days) rash % eschar % lymphadenopathy a spotted fever group (sfg) rocky mountain spotted fever r. rickettsii tick 2-14 2-10 90% <1 + flea-borne spotted fever r. felis flea 8-16 8-16 80 15 rickettsialpox r. akari mite bite 10-17 3-11 100 90 +++ mediterranean spotted fever r. conori tick bite 5-7 7-14 97 50 + typhus group murine typhus r. typhi flea feces 8-16 9-18 80 none epidemic typhus r. prowazekii louse feces, fleas, lice 7-14 10-18 80 none scrub typhus group scrub typhus orientia tsutsugamushi mite bite 9-18 6-21 50 35 +++ *the diseases are not limited to what is listed on the table, however, it conveys the list of the most common diseases. a ++++, severe; +++, marked; ++, moderate; +, present in a small proportion of cases; —, not a noted feature. vol 54 • number 4 • october 2022 revisiting the overlooked infection: rickettsioses 649 rickettsioses in indonesia have been described since the early 1900s in western indonesia (sumatra and java) to eastern indonesia (papua)10,12–14 several cases of underdiagnosed yet fatal clinical features of rickettsioses also had been reported among travellers returning from indonesia.15,16 another study on ectoparasite and small mammals in indonesia also showed a high rate of typhus group rickettsiae-specific antibodies, which indicated the high risk for rickettsia infection and the existence of various hosts and vectors across the country.14,17 this data indicated the potential rickettsioses endemicity in indonesia. in the last decade, many studies have highlighted the importance of rickettsioses as one important differential diagnosis of fever.5,6,18–21 in 2020, observational research showed that rickettsioses were the third most prevalent cause of acute febrile illness in indonesia. all the cases were misdiagnosed by the standard of care examination.6 furthermore, rickettsioses were also the third most common cause of sepsis in a multinational study held in southeast asia, therefore, our awareness of this disease is mandatory.22 t h e e m e r g i n g p r o b l e m o f rickettsioses in indonesia in the upcoming text, we will elaborate on the emerging problem of rickettsioses in indonesia. 1. undiscovered facts that rickettsiosis cases are prevalent during 2013-2016, the indonesia r e s e a r c h p a r t n e r s h i p o n i n f e c t i o u s disease (ina-respond) conducted an observational cohort study (acute fever requiring hospitalization/afire) on acute febrile illness at eight tertiary healthcare facilities in indonesia. among 1,488 enrolled subjects with fever and 1,003 pediatric and adult subjects with identified etiology of disease, rickettsioses ranked as the third most prevalent infection (103 subjects, 10.3%), following dengue and typhoid fever.6 the confirmed rickettsioses were established by one of these examinations: enzyme-linked immunosorbent assay (elisa) and/or indirect immunofluorescence assay (ifa) for serology examination, followed by polymerase chain reaction (pcr) of bacterial dna 17-kd outer membrane protein (17-kd omp) gene of rickettsia sp., 47-kd omp gene of o. tsutsugamushi, and 743-bp sequence of rickettsia sp. ompb gene.5 in this study, igg of r. typhi was detected among 30.8% of total subjects, followed by igg detection of spotted fever and o. tsutsugamushi. although mere single serology detection is not sufficient in diagnosing rickettsioses, this high rate of seropositivity reflects the high exposure of rickettsia, spp. in indonesia, which is higher13,23–26 or similar12 compared to the previous studies. one systematic review by wangdi et al.20 studied undifferentiated febrile illness cases in south and southeast asia and revealed that the prevalence of rickettsioses reached 4%, which comprised of scrub typhus, murine typhus, and spotted fever disease. compared to this systematic review, data on the prevalence of rickettsioses in indonesia is significantly higher and demands further attention. rickettsioses are also one of the most common etiologies of community-acquired sepsis from a multinational multicentre observational study in southeast asian countries, including indonesia, together with dengue and leptospiral infection. the prevalence rate of rickettsioses as the cause of sepsis and severe sepsis reached 6%, comprised of r. typhi, o. tsutsugamushi, and spotted fever group.22 although these studies showed that the prevalence of rickettsioses was high, all identified cases were initially suspected as leptospirosis, typhoid fever, chikungunya, or dengue fever – none were diagnosed as rickettsioses.22 this data may also portray the unawareness of healthcare practitioners to suspect rickettsioses in the first instance on a patient with acute febrile illness. by reflecting on the rate of misdiagnosis of this disease, healthcare providers need to be conscious and thorough in diagnosing acute febrile illness, and hence can consider rickettsioses as a differential diagnosis. lie khie chen acta med indones-indones j intern med 650 2. inadequacy of diagnostic modalities one of the possible reasons why rickettsioses was often misdiagnosed a s a n o t h e r d i s e a s e w a s b e c a u s e t h e accompanying symptoms of rickettsioses, such as fever, nausea, headache, vomiting, lethargy, anorexia, arthralgia, myalgia, chills, and epigastric pain, may overlap with dengue, typhoid, and leptospiral infection.1,2 the afire study showed that rickettsioses mostly affected gastrointestinal, lower respiratory tract and systemic organs, and therefore, its manifestation is similar to other differential diagnoses. signs and symptoms are also often not specific for rickettsioses, as the rickettsia triad (fever, headache, and rash) were only developed in 10% of subjects.5,6 on 815 adult patients with community-acquired sepsis, rickettsioses were presented as acute respiratory infection, acute systemic infection, acute diarrhea and acute central nervous system (cns) infection which overlapped with symptoms of influenza, rhinovirus, hantavirus, leptospirosis, s. aureus infection, dengue fever, e. coli infection, streptococcus, spp. infection, and other bacterial infection.22 a pr esumptive clinical diagnosis of rickettsioses can be confirmed by immunohistochemical (ihc) assays in tissue, detection of antibodies by ifa with concomitant seroconversion or a fourfold or greater rise in antibody titre between acute and convalescent samples, or pcr of blood or tissue.1,2,4 whilst having high diagnostic value, those examinations are not widely available as point-of-care testing (poct), expensive, and may cause a delay in empirical treatment (e.g., waiting for the serum convalescent testing). detection of antibody and antigen for rickettsioses in indonesia is still limited for research purposes. the isolation of rickettsia, spp. requires suitable techniques and must be handled as highly pathogenic in a biosafety level 3 laboratory, hence its use for prompt diagnosis is also limited.4 this lack of diagnostic modalities is concerning because rickettsioses are most misdiagnosed and potentially lethal, even though they are an easily treatable disease.6 in the afire study, less than 50% of microbial etiologies were identified by standard-of-care testing, 23.6% were identified by ina-respond laboratory, w h i l e t h e r e m a i n i n g 3 2 . 5 % w e r e unidentified. rickettsia spp. (r. typhi and r. felis) is one of three infectious etiologies which was not captured by standard-ofcare examinations.5 the previous studies and data highlight the need for a better and more widely accessible poct for rickettsioses, preferably based on antigen detection over antibody response to be able to rapidly diagnose and treat rickettsioses. 3. choice of therapy is widely available and simple, however, the administration is often delayed macrolide, mainly doxycycline, is the drug of choice for the treatment of all tickborne rickettsial diseases in patients of all ages. it should be initiated immediately in persons suggestive of rickettsioses without waiting for the confirmatory laboratory examination. the drug is given orally or intravenously at a dose of 100 mg twice daily (adult) or 2.2 mg/kg of body weight twice daily (children), until at least 3 days after fever subsides and the patient is clinically improved.7 prior to hospitalization, many patients with rickettsioses have already consumed a n t i b i o t i c s , i n c l u d i n g a m o x i c i l l i n , cefadroxil, cotrimoxazole, or cefixime – none of which are the empiric treatment for rickettsioses.6 during hospitalization, b r o a d s p e c t r u m a n t i b i o t i c s , s u c h a s ceftriaxone and ciprofloxacin, are effective empiric treatments; however, the routine broad-spectrum administration should be discouraged in the context of antimicrobial stewardship. in cases of acute fever unresponsive to empirical treatment of other acute febrile illnesses, administration of doxycycline should be considered. vol 54 • number 4 • october 2022 revisiting the overlooked infection: rickettsioses 651 4. f a t a l c a s e s ( s e p s i s , m o r t a l i t y ) i n rickettsioses the spectrum of rickettsioses varies from self-limited febrile illnesses to the involvement of cns, liver, lung, and even death. among rickettsioses, r. prowazeki and r. typhi are known to be able to survive for an extended period outside the reservoir or vector and they are extremely infectious. due to their high level of infectivity and severe illness after inhalation, r. prowazekii, r. rickettsii, r. typhi, r. conorii, and coxiella burneti are known for bioterrorism threats.2,5,19,27 according to the afire study, the overall mortality of patients with acute febrile illnesses reached 5.9% and the most common microbiologic etiologies included r. typhi, with mortality rate of 6.8%, markedly higher than the previous studies.5,6 a study in australia also observed that among 135 cases, 13% required icu admission, mostly caused by spotted fever group and scrub typhus.28,29 another study in india reported a higher fatality rate of 12.2% with evidence of acute respiratory distress syndrome and aseptic meningitis among patients. one retrospective study on acute meningoencephalitis patients also identified rickettsia sp. on cerebrospinal fluid examination, depicting the wide variety of its clinical manifestations. in fact, this underdiagnosed disease can lead to fatal outcomes even though the empirical treatment with doxycycline is relatively simple and widely available. an improvement in presumptive and confirmed diagnosis is important, as it will lead to more appropriate management and reduction of fatal cases and death. conclusion rickettsioses are a group of diseases that are common in indonesia but often overlooked as a differential diagnosis of acute febrile illness. previous studies have demonstrated that rickettsioses are often misdiagnosed as dengue fever, leptospirosis, typhoid fever, and chikungunya due to some possible reasons, i.e., unspecific and overlapping signs and symptoms with other diseases, inadequate modalities of point of care examination to establish the confirmed diagnosis, and unfamiliarity of health care providers and system in suspecting rickettsioses on patients with acute febrile illness. therefore, awareness and understanding of the diseases, the adequate point of care diagnosis modalities, and treatment of rickettsioses in indonesia need to be established to reduce morbidity and mortality. competing interests the authors declared no conflict of interest. references 1. raoult d. introduction to rickettsioses, ehrlichioses, and anaplasmoses. in: bennett je, dolin r, blaser mj, editors. mandell, douglas, and bennett’s principles and practice of infectious diseases. 9th ed. philadelphia: elsevier, inc; 2020. p. 2344–8. 2. walker d, dumler j, blanton l, et al. rickettsial diseases. in: jameson jl, kasper dl, longo dl, fauci as, hauser sl, loscalzo j, editors. harrison’s principles of internal medicine. 20th ed. philadelphia: mcgraw hill education; 2018. p. 1303–5. 3. raoult d, 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mmwr recomm reports. 2016;65(2):1–44. 8. paris dh, kelly dj, fuerst pa, et al. a brief history of the major rickettsioses in the asia–australia–pacific region: a capstone review for the special issue of tmid. trop med infect dis. 2020;5(4):165. 9. quintal d. historical aspects of the rickettsioses. clin dermatol. 1996;14(3):237–42. lie khie chen acta med indones-indones j intern med 652 10. richards al, rahardjo e, soeatmadji dw, et al. rickettsial diseases: risk for indonesia. bul penelit kesehat. 1995;23(3 sept). 11. nicholson wl, paddock cd. rickettsial diseases (including spotted fever & typhus fever rickettsioses, scrub typhus, anaplasmosis, and ehrlichioses) [internet]. 2019 [cited 2021 nov 17]. available from: https://wwwnc.cdc.gov/travel/yellowbook/2020/ travel-related-infectious-diseases/rickettsial-includingspotted-fever-and-typhus-fever-rickettsioses-scrubtyphus-anaplasmosis-and-ehr 12. richards al, soeatmadji dw, widodo ma, et al. seroepidemiologic evidence for murine and scrub typhus in malang, indonesia. am j trop med hyg. 1997;57(1):91–5. available from: https://www.ajtmh. org/view/journals/tpmd/57/1/article-p91.xml 13. richards al, ratiwayanto s, rahardjo e, et al. serologic evidence of infection with ehrlichiae and spotted fever group rickettsiae among residents of gag island, indonesia. am j trop med hyg. 2003;68(4):480–4. 14. barbara ka, farzeli a, ibrahim in, et al. rickettsial infections of fleas collected from small mammals on four islands in indonesia. j med entomol. 2010;47(6):1173–8. 15. takeshita n, imoto k, ando s, et al. murine typhus in two travelers returning from bali, indonesia: an underdiagnosed disease. j travel med. 2010;17(5):356–8. 16. stockdale aj, weekes mp, kiely b, at al. case report: severe typhus group rickettsiosis complicated by pulmonary edema in a returning traveler from indonesia. am j trop med hyg. 2011;85(6):1121–3. 17. widjaja s, williams m, winoto i, et al. geographical assessment of rickettsioses in indonesia. vector-borne zoonotic dis. 2016;16(1):20–5. 18. chrispal a, boorugu h, gopinath kg, et al. scrub typhus: an unrecognized threat in south india clinical profile and predictors of mortality. trop doct. 2010;40:129–33. 19. biswal m, krishnamoorthi s, bisht k, et al. rickettsial diseases: not uncommon causes of acute febrile illness in india. trop med infect dis. 2020;5(2). 20. wangdi k, kasturiaratchi k, nery sv, et al. diversity of infectious aetiologies of acute undifferentiated febrile illnesses in south and southeast asia: a systematic review. bmc infect dis. 2019;19(1):1–17. 21. tam pyi, obaro sk, storch g. challenges in the etiology and diagnosis of acute febrile illness in children in lowand middleincome countries. j pediatric infect dis soc. 2016;5(2):190–205. 22. sudarmono p, aman at, arif m, et al. causes and outcomes of sepsis in southeast asia: a multinational multicentre cross-sectional study. lancet glob heal. 2017;5(2):e157–67. 23. suttinont c, losuwanaluk k, niwatayakul k, et al. causes of acute, undifferentiated, febrile illness in rural thailand: results of a prospective observational study. ann trop med parasitol. 2006;100(4):363–70. 24. phongmany s, rolain jm, phetsouvanh r, et al. rickettsial infections and fever, vientiane, laos. emerg infect dis. 2006;12(2):256–62. 25. gordon smith ce, van peenen pfd, koesharjono c, et al. antibodies against murine typhus in sera from indonesians. trans r soc trop med hyg. 1977;71(4):297–9. available from: https://doi. org/10.1016/0035-9203(77)90103-1 26. dennis dt, hadi tr, brown rj, et al. a survey of scrub and murine typhus in the ancol section of jakarta, indonesia. southeast asian j trop med public health. 1981;12(4):574–80. 27. suputtamongkol y, suttinont c, niwatayakul k, et al. epidemiology and clinical aspects of rickettsioses in thailand. ann n y acad sci. 2009;1166:172–9. 28. stewart aga, smith s, binotto e, et al. the epidemiology and clinical features of rickettsial diseases in north queensland, australia: implications for patient identification and management. plos negl trop dis. 2019;13(7). 29. mawuntu ahp, johar e, anggraeni r, et al. rickettsia felis identified in two fatal cases of acute meningoencephalitis. plos negl trop dis. 2020;14(2):1–10. available from: http://dx.doi. org/10.1371/journal.pntd.0007893 medical illustration pulmonary embolism in hospitalized patient with coronavirus disease 2019 (covid-19) wulyo rajabto1, dimas priantono1*, rahmad mulyadi2 1 division of hematology-medical oncology, department of internal medicine, faculty of medicine universitas indonesia dr. cipto mangunkusumo general hospital, jakarta, indonesia. 2 division of interventional radiology department of radiology, faculty of medicine universitas indonesia dr. cipto mangunkusumo general hospital, jakarta, indonesia. * corresponding author: dimas priantono, md. division of hematology-medical oncology, department of internal medicine, faculty of medicine universitas indonesia dr. cipto mangunkusumo general hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email:dimas.priantono@gmail.com. coronavirus disease 2019 (covid-19) pandemic has affected healthcare policy globally more than ever. for the first time, a global pandemic was studied meticulously by scientists and clinicians worldwide. the virus was initially considered to be a respiratory disease. meanwhile, several discoveries have been made, including the impact of this infectious disease on coagulation. early studies showed that patients with covid-19 had elevated d-dimer levels.1 these findings were confirmed by autopsies which showed thrombosis in various sites in patients that died from covid-19.1 thrombosis occurs in up to one-third of hospitalized patients with covid-19,2 it happens at many sites by the diffuse activation of coagulation cascade. furthermore, pulmonary embolism have been reported to be the most dangerous thrombotic event which greatly increases mortality in covid-19.2 however, the diagnosis of this condition i s f r e q u e n t l y o v e r l o o k e d . p u l m o n a r y angiogram or computed tomography (ct) pulmonary angiogram is often difficult to obtain, meanwhile, echocardiogram and electrocardiogram might show pathognomonic abnormalities suggesting pulmonary embolism but lack sensitivity and specificity. therefore, the demonstration of intraluminal filling defect by ct pulmonary angiogram or fluoroscopic pulmonary angiogram is considered the gold standard of diagnosis. figure 1. (a) and (b) ct-pulmonary angiography showed intra-luminary hypodense lesion in posterior and basal segment of right pulmonary artery suggesting pulmonary embolism. 493acta med indones indones j intern med • vol 53 • number 4 • october 2021 wulyo rajabto acta med indones-indones j intern med 494 a 54-year-old male was presented to the emergency department and complained of worsening dyspnea associated with fever and cough 9 days before admission. the nasopharyngeal and oropharyngeal sars-cov-2 polymerase chain reaction (pcr) swab test was performed and the result was positive. the patient was hospitalized at covid-19 isolation intensive care unit (icu) with ventilatory support due to acute respiratory distress syndrome (ards) for 9 days. fortunately, a good clinical response was achieved without endotracheal intubation and mechanical ventilation, i.e., good chest x-ray response without duplex pneumonia, and tested negative to the nasopharyngeal and oropharyngeal pcr swabs. afterwards, the patient was transferred to non-covid-19 icu and later to the general ward after 3 days. however, in the inpatient ward, a sudden incidence of dyspnea, cough, and nervousness were observed. on physical examination, the patient was alert but moderately ill, blood pressure was 140/90 mmhg, heart rate 110x/ minute, respiratory rate 20x/ minute, and afebrile. furthermore, peripheral o2 saturation was 90% and improved to 98% with 15 l/ minute oxygen supplementation via non-rebreathing mask, while the laboratory values include hb 14.5 g/dl, white blood cells (wbc) 9,810 cells/ ml, and platelets 276,000 cells/ml. liver and renal function tests were within normal limits as well as random blood glucose and electrolytes. d-dimer was extremely elevated to 14,150 ng/ ml (reference value: <500 ng/ml), while chest x-ray imaging showed no infiltrates in both lungs. a doppler ultrasound was performed on both extremities and the result indicated chronic venous insufficiency, while ct-pulmonary angiography showed intra-luminary hypodense lesion in the posterior and basal segment of right pulmonary artery. the diagnosis of postsevere covid-19 pneumonia-ards pulmonary embolism was established. low molecular weight heparin (lmwh): enoxaparin 6,000 iu (0.6 ml) bid was administered subcutaneously to the patient. after 10 days, the clinical condition improved, the patient was discharged with direct oral anticoagulant rivaroxaban 15 mg bid for 21 days and 20 mg qd for 3-6 months. hospitalized patients with covid-19 are at high risk of thromboembolic complications such as deep vein thrombosis (dvt) and pulmonary embolism (pe).3 a systematic review and metaanalysis by suh, et al4 reported that pooled incidence rates of pe and dvt in patients with covid-19 were 16.5% (95%ci: 11.6-22.9) and 14.8% (95%ci: 8.5-24.5) respectively. incidence of pe was higher in patients admitted to the icu i.e. 24.7% (95% ci: 18.6-32.1) compared to 10.5% (95% ci: 5.1-20.2) in patients admitted to the general ward.4 about two centuries ago, german physician rudolph ludwig karl virchow described 3 factors that contribute to thrombosis namely endothelial vessel wall injury, venous stasis, and hypercoagulability widely known as the “virchow’s triad”.5 the primary function of the endothelium is maintenance of nonturbulent blood flow with homeostatic mechanisms to prevent thrombosis.6 meanwhile, viral particles of the sars-cov-2 virus penetrate the cells through the binding of spike-like protein (s-protein) with the angiotensin-converting enzyme 2 (ace2) receptor. the ace2 receptor for sars-cov-2 is also present in endothelial cells. this endothelial invasion by sars-cov-2 leads to endothelial dysfunction and activates coagulation cascade, thereby contributing to thrombosis.7 furthermore, immobilization due to dyspnea and hypoxia induces thrombosis due to venous stasis and increasing blood viscosity.8 meanwhile, covid-19-related hypercoagulable state and thrombotic complications are usually due to the increased thrombo-inflammation secondary to infection. this leads to severe hemostatic instability as typically seen in septic patients which promotes coagulation. other complications include weakening of anticoagulation and fibrinolysis.9 pulmonary embolism is a part of venous thromboembolism together with deep vein thrombosis (dvt).10 as described above, covid-19 hypercoagulable state leads to activation of the coagulation cascade. this process occurs throughout systemic circulation. in a classic case of pulmonary embolism, about 70% of patients have lower extremity vol 53 • number 4 • october 2021 pulmonary embolism in hospitalized patient with coronavirus 495 dvt.10 however, in this study, lower extremity ultrasound did not find any evidence of dvt. the pathophysiology of hypercoagulation in covid-19 differs from classic cascade activation caused by other infections. given that pulmonary i n v o l v e m e n t i s c o m m o n i n c o v i d 1 9 , researchers have postulated a hypothesis on the pathogenesis of this coagulation process, which is termed pulmonary intravascular coagulation (pic).11 in the pic process, the binding of sarscov-2 to ace 2 receptor on type ii pneumocytes and endothelium increases procoagulant activity and activates the coagulation cascade.11 this mechanism is assumed to be responsible for the formation of microthrombi in the lung capillaries. this process continues and promotes systemic coagulation. the thrombus produced travel through the systemic circulation and clog the pulmonary artery. several available modalities are used to diagnose pulmonary embolism. point of care testing such as electrocardiography and bedside echocardiography aid pulmonary embolism diagnosis. however, these techniques lack sensitivity and specificity.10 the classic mcginn white (s1q3t3) pattern occurs rarely. the electrocardiogram is useful in exploring the possibility of other differential diagnoses such as acute myocardial infarction and pericarditis.10 similarly, echocardiography is used to evaluate indirect signs of pulmonary embolism. the thrombus is rarely demonstrated in the echocardiogram. lung scintigraphy or ventilation-perfusion scan was used extensively in patients suspected of pulmonary embolism. however, perfusion defects might also be caused by other pathologies such as lung consolidation, fibrosis, and malignancy. in this covid-19 pandemic era, ct pulmonary angiography is a versatile modality. aside from being used to diagnose or exclude pulmonary angiography, the lung window also provides information on the extent of damage caused by covid-19 to the lungs i.e., the amount of ground glass opacities. this modality also provides information on consolidation, tumors, and pleural diseases. in acutely ill patients at general wards, initial treatment with lmwh have advantages in terms of minimal drug–drug interactions and risk of rapid clinical deterioration compared to oral treatment. current guidelines by the international society of thrombosis and hemostasis (isth) suggest lmwh for thromboembolism prophylaxis in hospitalized covid-19 patients.12 this is due to the simplicity in administration and low risk of drug-drug interaction. in cases of acute vte, anticoagulants are given in therapeutic doses. in this study, the patient was treated with enoxaparin 6.000 iu (0.6 ml) bid subcutaneously. direct oral anti coagulants (doacs) provide advantages over vitamin k antagonists (vkas), especially in the post-hospital setting, because it is safer, and does not require routine monitoring. nevertheless, in hospitalized covid-19 patients, doac is not recommended due to potential drug-drug interaction with antivirals.13 furthermore, vte in covid-19 patients is induced by a reversible risk factor, therefore, a treatment duration of 3 months is advised. an initial lmwh. enoxaparin 0.6 ml was administered twice daily to the patient and then rivaroxaban after discharge for 3 months.14 rivaroxaban and other doacs are considered safe after discharge given that the patient had already finished the prescribed antibiotics and antivirals. covid-19 is often accompanied by thromboembolic complications. meanwhile, pulmonary embolism occurs in covid-19 patients without dvt. based on the results, parenteral anticoagulant followed by doac is the mainstay of treatment in covid-19 coagulopathy. references 1. al-samkari h, karp leaf rs, dzik wh, et al. covid-19 and coagulation: bleeding and thrombotic manifestations of sars-cov-2 infection. blood. 2020;136(4):489-500. 2. loo j, spittle da, newnham m. covid-19, immunothrombosis and venous thromboembolism: biological mechanisms. thorax. 2021;76(4):412-20. 3. cuker a, tseng ek, nieuwlaat r, et al. american society of hematology 2021 guidelines on the use of anticoagulation for thromboprophylaxis in patients with covid-19. blood adv. 2021;5(3):872-88. 4. suh yj, hong h, ohana m, et al. pulmonary embolism and deep vein thrombosis in covid-19: a systematic review and meta-analysis. radiology wulyo rajabto acta med indones-indones j intern med 496 2021;298(2):e70-e80. 5. mehta jl, calcaterra g, bassareo pp. covid-19, thromboembolic risk, and virchow’s triad: lesson from the past. clin cardiol. 2020;43(12):1362-7. 6. gąsecka a, borovac ja, guerreiro ra, et al. thrombotic complications in patients with covid-19: pathophysiological mechanisms, diagnosis, and treatment. cardiovasc drugs ther. 2021;35(2):215-29. 7. ahmed s, zimba o, gasparyan ay. thrombosis in coronavirus disease 2019 (covid-19) through the prism of virchow’s triad. clinical rheumatology. 2020;39(9):2529-43. 8. sakr y, giovini m, leone m, et al. pulmonary embolism in patients with coronavirus disease-2019 (covid-19) pneumonia: a narrative review. annals of intensive care. 2020;10(1):124. 9. ozsu s, gunay e, konstantinides sv. a review of venous thromboembolism in covid-19: a clinical perspective. clin respir j. 2021;15(5):506-12. 10. r i e d e l m . a c u t e p u l m o n a r y e m b o l i s m 1 : pathophysiology, clinical presentation, and diagnosis. heart. 2001;85(2):229-40. 11. belen-apak fb, sarıalioğlu f. pulmonary intravascular coagulation in covid-19: possible pathogenesis and recommendations on anticoagulant/thrombolytic therapy. j thromb thrombol. 2020;50(2):278-80. 12. thachil j, tang n, gando s, et al. isth interim guidance on recognition and management of coagulopathy in covid-19. j thromb haemost. 2020. 13. hashemi a, madhavan mv, bikdeli b. pharmacotherapy for prevention and management of thrombosis in covid-19. seminars in thrombosis and hemostasis. 2020;46(7):789-95. 14. flaczyk a, rosovsky rp, reed ct, bankheadkendall bk, bittner ea, chang mg. comparison of published guidelines for management of coagulopathy and thrombosis in critically ill patients with covid 19: implications for clinical practice and future investigations. crit care. 2020;24(1):559. 567acta med indones indones j intern med • vol 54 • number 4 • october 2022 original article diagnostic performance of mac-2-binding protein glycosylation isomer (m2bpgi), compared to transient elastography to assess liver stiffness in treatment naïve chronic hepatitis c patients andri sanityoso sulaiman*, irsan hasan, cosmas rinaldi a. lesmana, juferdy kurniawan, chyntia olivia maurine jasirwan, saut nababan, kemal f. kalista, rachmadianti s. hanifa, desti rachmani, rino alvani gani division of hepatobiliary, department of internal medicine, faculty of medicine universitas indonesia dr. cipto mangunkusumo general hospital, jakarta, indonesia. * corresponding author: andri sanityoso sulaiman, md., phd. division of hepatobiliary, department of internal medicine, faculty of medicine, universitas indonesia, dr. cipto mangunkusumo national general hospital. jl. salemba raya no 6, jakarta 10430, indonesia. email: andri_sani@yahoo.com; andri.sanityoso@ui.ac.id; hepato.ui@gmail.com abstract background: liver fibrosis is an essential factor in the management of hepatitis c virus infection. its assessment is crucial in decision-making regarding the therapeutic decisions, and the patients’ follow up. however, the established liver measurement methods have several limitations. therefore, this study aims to assess the role of mac-2-binding protein glycosylation isomer (m2bpgi) as a novel biomarker to measure liver stiffness in treatment naïve chronic hepatitis c indonesian patients. methods: this study used a crosssectional design to determine the correlation between serum m2bpgi and the degree of liver stiffness, transient elastrography, and differences in serum m2bpgi levels in chronic hepatitis c patients. serum m2bpgi level and transient elastography results were evaluated in 56 chronic hepatitis c patients and 48 healthy controls. pearson correlation analysis was conducted to find the correlation between the level of m2bpgi and transient elastography result. roc analysis was conducted to find the optimum cut-off to assess fibrosis’s degree among chronic hepatitis c patients. results: the level of serum m2bpgi and transient elastography result was strongly correlated with the median level of serum m2bpgi. it was also significantly higher among chronic hepatitis c patients than among healthy controls (r: 0.708, p<0.001; 0.590 coi vs. 4.130 coi, p<0.001). among the chronic hepatitis c patients, the median serum of m2bpgi increased according to the degree of liver fibrosis: 1.500 coi (f0-f1), 2.985 coi (f2-f3) and 8.785 coi (≥f4). the optimum cut-off value for diagnosing significant fibrosis (f2-f3) was 1.820 coi (auc: 90.8%) and for diagnosing cirrhosis (≥f4) was 3.770 coi (auc: 89.3%). conclusion: serum m2bpgi was a reliable diagnostic tool for identifying liver fibrosis in indonesian patients with chronic hepatitis c. keywords: chronic hepatitis c, mac-2-binding protein glycosylation isomer, transient elastography. introduction chronic hepatitis c remains a global burden of disease due to its high prevalence. it is estimated that around 177.5 million adults (2.5% of the total global population) live with hcv infection.1 in indonesia, the prevalence of anti-hcv is 2.5% of the total population. this data shows an increase by 0.4% from the andri sanityoso sulaiman acta med indones-indones j intern med 568 previous survey conducted in 2007.2 moreover, nearly 400 thousand people die annually from the complication of hcv infection, such as liver cirrhosis, hepatic decompensation, or hepatocellular carcinoma.3 in clinical practice, the quantification of liver fibrosis in patients with chronic hepatitis c is crucial in decision making regarding the start of therapeutic regimens and the adequate follow up of the patients. according to the current clinical practice guidelines, chronic hepatitis c treatment is recommended when significant fibrosis is present.4 for those detected to have liver cirrhosis, the treatment duration will be prolonged up to 6 months, and regular screening for complications and hepatocellular carcinoma surveillance must be initiated.4,5 moreover, the fibrosis stage is also found to be the main predictive factors of complication once the virus is eradicated. therefore, fibrosis regression has become a new surrogate goal of hepatitis c virus infection therapy.6 the gold standard for assessing the degree of liver fibrosis is a liver biopsy. however, due to its invasive method, it could lead to some potential complications. a previous study found that around 6% of complications were observed from 1806 biopsy procedures in which 75% of these patients reported moderate and severe pain, while 33% of the others underwent prolonged hospital observation or surgical intervention due to excessive bleeding.7 furthermore, errors in sampling and interpretation are often found in biopsy procedures. consequently, many clinicians prefer to use non-invasive approaches.8 several non-invasive approaches have been used in assessing liver fibrosis in chronic hepatitis c patients. one of the commonly used non-invasive modalities that have been highly validated is transient elastography (te). it works to quantify the mechanical responses of liver tissues through a shear-wave velocity produced by a piston. however, the generated mechanical waves diffuse in nonviscous liquids. hence, te could not be used in patients with ascites condition.9 in addition, the assessment of liver fibrosis through biomarkers has also been widely used. some methods are considered as a “direct” method since they are directly involved in the cellular matrix accumulation process. on the other hand, several biomarkers are considered an “indirect” method because they could only portray the epiphenomena associated with the fibrogenesis process.10 one commonly used indirect biomarker for assessing liver fibrosis is ast to platelet ratio index (apri). its diagnostic performance has been extensively evaluated and consistently depicted more robust positive diagnostic performance when assessing advanced fibrosis and cirrhosis. however, since it is an indirect biomarker to evaluate liver fibrosis, its application will also need adjustment according to the specific condition of the patients.10 mac-2-binding protein glycosylation isomer (m2bpgi) was recently found to be an alternative serum for detecting liver fibrosis. acting as a juxtracrine messenger sent by hepatic stellate cells (hscs) to kupffer cells during liver fibrosis enables it to depict the liver fibrosis progression directly.11 previous studies have confirmed that m2bpgi was useful to measure liver fibrosis in several conditions, such as hepatitis b or c infection, autoimmune hepatitis, biliary atresia, primary biliary cirrhosis, and non-alcoholic fatty liver (nafld).12–16 furthermore, a metaanalysis study also found that m2bpgi could be a reliable predictor for determining the stage of liver fibrosis.12 however, another study also found that the value of m2bpgi might be different according to the etiology of the liver fibrosis, even when the stage of liver fibrosis is similar. for instance, the level of m2bpgi among non-alcoholic steatohepatitis (nash) tends to be lower than those in chronic hepatitis c or b infection with the same degree of liver fibrosis.13 given this uniqueness and the lack of research on the role of serum m2bpgi in assessing liver fibrosis in treatment naïve chronic hepatitis c patients in the indonesian population, this study aims to find the correlation of m2bpgi level with the fibrosis measurement by using transient elastography, measure the cut-off point to assess significant fibrosis and cirrhosis, and evaluate its diagnostic performance on hepatitis c chronic patients in these population. vol 54 • number 4 • october 2022 diagnostic performance of mac-2-binding protein glycosylation isomer 569 methods this study used a cross-sectional design to determine the correlation between serum m2bpgi and the degree of liver stiffness, transient elastrography, and differences in serum m2bpgi levels in chronic hepatitis c patients. and, based on the minimum sample calculation for differences of two means. patients 56 treatment naïve chronic hepatitis c patients in one of the national general hospital in jakarta were recruited for the study. inclusion criteria were: age >18 years old with hepatitis c. exclusion criteria were: (i) diagnosed with hepatitis b, hiv, or hcc, (ii) had a history of hepatitis c treatment. furthermore, 48 healthy controls were also recruited as a comparison group. the ethics committee at the faculty of medicine universitas indonesia approved the study with the number of approval letter: 85/ un2.f1/etik/2019. informed consent was collected from each participant before the data collection process. liver stiffness measurement liver stiffness measurement was assessed using fibro scan®, and the result was used as the reference standard. a skilled full physician performed the assessment of lsm after the measurement of serum m2bpgi on the same day. the median of ten lsm values was used as the final score. significant fibrosis was defined as of lsm ≥8 kpa, while cirrhosis was defined as the level of lsm ≥12 kpa. moreover, probe xl was used to assess liver fibrosis among obese patients. serum m2bpgi measurement m2bpgi level was assessed through a lectin-antibody sandwich immunoassay using the hiscl-5000 immune analyzer (sysmex corporation, hyogo, japan). the blood sample was taken before the measurement of lsm measurement. the final value of m2bpgi was obtained by using the following equation: cut off index (coi) = ([m2bpgi]sample – [m2bpgi]nc)/([m2bpgi]pc-[m2bpgi]nc) in which [m2bpgi]sample is the m2bpgi found in the serum sample, pc is a positive control, and nc is the negative control. the positive control was used as the calibration solution preliminarily standardized, which provided a cut off value of 1.0. the result of m2bpgi level is automatically calculated by the instrument.17 statistical analysis c o r r e l a t i o n b e t w e e n l i v e r s t i ff n e s s measurement and serum m2bpgi level was analyzed using pearson correlation. differences between numeric variables were assessed by using independent t-test analysis for the parametric data and mann-whitney u test for the nonparametric data. optimal serum m2bpgi cut off value was evaluated by performing roc and auc analysis based on the optimal sensitivity, specificity, positive predictive value (ppv), and negative predictive value (npv). results baseline clinical characteristic of patients the baseline of the study participants is shown in table 1. the enrolled patients in the table 1. baseline characteristic. characteristic cases (n = 56) control (n=48) p value sex (m/f) 33/23 22/26 >0.05 lsm, kpa, median (range) 14.35 (3.0 – 75.0) 5.1 (3.5 – 8.7) <0.001 fibrosis stage (f0-f1/ f2-f3 /≥f4) 14/8/34 47/1/0 <0.001 alt f0-f1 51.6 ± 30.2 f2-f3 67.5 ± 45.3 ≥f4 63.1 ± 53.9 ast f0-f1, mean ± sd 42.5 ± 21.9 f2-f3 mean ± sd 52.0 ± 15.5 ≥f4, mean ± sd 65.3 ± 39.7 m2bpgi, coi, median (range) 4.13 (0.72 – 26.00) 0.59 (0.23 – 1.27) <0.001 andri sanityoso sulaiman acta med indones-indones j intern med 570 case group were dominated by male participants (59%), while the control group was dominated by female participants (54%). in the hepatitis c infected group, the median of liver stiffness measurement (lsm) was significantly higher than the healthy control group (14.3 kpa vs. 5.1 kpa, p<0.001). most of the hepatitis c group were in the cirrhosis stage (≥f4), accounting for 60% of the total participant in the case group. moreover, the m2bpgi level also differed significantly between the case and control groups (4.13 coi vs. 0.59 coi, p<0.001). correlation between m2bpgi and liver stiffness measurement in treatment naïve chronic hepatitis c patients based on the pearson correlation analysis, the level of serum m2bpgi was found to have a strong positive correlation with the liver stiffness measurement by transient elastography (r=0.708, p<0.001) (figure 1a). moreover, the median level of serum m2bpgi increased significantly according to the severity of liver fibrosis stages as 1.50 coi for f0-f1, 2.985 coi for significant fibrosis (f2-f3) and 8.785 coi for cirrhosis (≥f4). the analysis also showed that the level of m2bpgi between healthy control and f0-f1 hepatitis c group differed significantly (0.585 coi vs 1.500 coi, p<0.001) (figure 1b). cut-off values of serum m2bpgi to detect significant fibrosis and cirrhosis roc analysis was carried out to evaluate the diagnostic performance of serum m2bpgi to evaluate significant liver fibrosis and cirrhosis. the aucs were 0.908 (95%ci: 0.807 – 1.000) for evaluating significant fibrosis and 0.893 (95%ci: 0.806 – 0.980) for evaluating cirrhosis (figure 2). a b figure 1. a) correlation of log10 serum m2bpgi with log10 liver stiffness measurement by transient elastography. b) the difference of median level of serum m2bpgi across fibrosis stages. a b figure 2. roc graphs of serum m2bpgi for evaluating a. significant fibrosis and b. cirrhosis vol 54 • number 4 • october 2022 diagnostic performance of mac-2-binding protein glycosylation isomer 571 the optimal cut-off value for diagnosing significant fibrosis and cirrhosis were 1.820 coi and 3.770 coi, respectively. the sensitivity, specificity, negative predictive value, and positive predictive value for each cut-off were presented in table 2. discussion hepatitis c virus infection could progress to numerous extra-hepatic manifestations and affect the achievement of svr. however, due to its high cost, not all patients infected with the virus would undergo therapy. in this case, liver fibrosis measurement is essential in the decision-making to start treatment and determine the patients’ adequate follow-up.6 furthermore, the fibrosis stage has also been a primary predictive factor of complications after eradicating the virus.18 the gold standard for assessing liver fibrosis is a liver biopsy. however, it has several limitations, such as the risk of tremendous side effects due to its invasive nature and the possibility of sampling bias also inter-observer variability7,19 several non-invasive modalities have been developed to overcome this barrier, such as transient elastography, which is accessible, accurate, and safe for patients. it has also been widely investigated and validated; therefore, it is also recognized as the liver biopsy’s surrogate modality.20 in this study, it was found that the level of serum mac-2-binding protein glycosylation isomer (m2bpgi) in treatment naïve chronic hepatitis c patients had a strong positive correlation with liver stiffness measurement by using transient elastography (r=0.708, p<0.001). moreover, the level of serum m2bpgi tended to increase according to the severity of liver stiffness stages (figures 1a-b). these findings were in line with the previous study, which also found that serum m2bpgi was positively correlated with transient elastography (rho=0.504, p<0.001).17 moreover, a significant difference of serum m2bpgi level was found between the treatment naïve chronic hepatitis c groups and healthy control (4.13 coi vs. 0.59, p<0.001). a previous study has suggested that m2bpgi is sent by the hepatic stellate cells (hscs) as a juxtracrineacting messenger to kuppfer cells during the occurrence of liver fibrosis. hence, the alteration of serum m2bpgi between healthy control and chronic hepatitis c patients could demonstrate the progression of liver fibrosis which occurs among the chronic hepatitis c patients.11 roc analysis also showed an excellent diagnostic accuracy for detecting significant fibrosis (auc: 0.908) and cirrhosis (auc: 0.893) using the cut-off levels of 1.820 coi and 3.770 coi, respectively, with high sensitivity and specificity, especially for significant fibrosis (table 2). hence, this marker could be reliable for screening, distinguishing patients with significant liver fibrosis from those who do not. although the roc, sensitivity, and specificity of serum m2bpgi for diagnosing cirrhosis was found lower than for diagnosing significant fibrosis, the result was still considered to be satisfying. there are several limitations to this study. firstly, there was no liver biopsy assessment, which could lead to bias, especially when the liver stiffness measurement falls into the grey area. secondly, based on the previous studies, it was stated that the specificity of m2bpgi could be an issue due to the influence of other medical conditions, such as acute liver injury and adenocarcinoma (21,22). however, this study also excluded participants who had been diagnosed with hepatitis b virus infection and hepatocellular carcinoma. therefore, the bias could be minimized. moreover, best to our knowledge, this is the first study about the role of m2bpgi in detecting liver fibrosis in indonesian patients who have treatment naïve chronic hepatitis c. table 2. diagnostic performance of serum m2bpgi for evaluating significant fibrosis and cirrhosis. fibrosis stages cutoff auc sen spe npv ppv significant fibrosis (≥f2) 1.820 0.908 (0.807 – 1.000) 0.93 0.86 0.80 0.95 cirrhosis (≥f4) 3.770 0.893 (0.806 – 0.980) 0.82 0.91 0.77 0.93 andri sanityoso sulaiman acta med indones-indones j intern med 572 conclusion serum m2bpgi was strongly positively correlated with liver stiffness measurement and high diagnostic performance to assess significant fibrosis and cirrhosis. thus, the level of serum m2bpgi could be a simple and reliable diagnostic modality for evaluating liver fibrosis in treatment naïve indonesian patients with chronic hepatitis c conditions. conflict of interest andri sanityoso sulaiman received research grant from the ministry of health, republic of indonesia and sysmex indonesia company. the funders had no role in the design of the study, in the collection, analysis, interpretation of data, in writing the manuscript, or in the decision to publish the result. funding this study was supported by the ministry of health of republic indonesia through health science and technology research grant (no: hk.03.01/1/994/2020) and by the sysmex indonesia (no:pea0006/mkt/esi/xi/2019) author contributions ass proposed, designed, and conducted the study. ih, cral, jk, comj, sn, and kfk performed the research. rsh, dr collected and analyzed the data. ass wrote the draft of the manuscript. rag reviewed the manuscript. ass was the research coordinator. acknowledgments the author would like to thank the national institute of health research and development, the indonesia ministry of health, and sysmex indonesia for funding the study. furthermore, the authors would also like to send gratitude to raysha afiff, pertiwi puji lestari, and dwi handayu from the hepatobiliary division, faculty of medicine universitas indonesia for their excellent technical assistance on sample collection and processing. references 1. petruzziello a, marigliano s, loquercio g, cozzolino a, cacciapuoti 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2017;52(2):245–52. 15. umemura t, joshita s, sekiguchi t, et al. serum wisteria floribunda agglutinin-positive mac-2-binding protein level predicts liver fibrosis and prognosis in primary biliary cirrhosis. am j gastroenterol. 2015;110(6):857–64. 16. abe m, miyake t, kuno a, et al. association between wisteria floribunda agglutinin-positive mac-2 binding protein and the fibrosis stage of non-alcoholic fatty liver disease. j gastroenterol. 2015;50(7):776–84. 17. xu h, kong w, liu l, et al. accuracy of m2bpgi, compared with fibro scan®, in analysis of liver fibrosis in patients with hepatitis c. bmc gastroenterol. 2017;17(1):62. 18. aasld/idsa hcv guidance panel. hepatitis c guidance: aasld-idsa recommendations for testing, managing, and treating adults infected with hepatitis c virus. hepatol baltim md. 2015;62(3):932–54. 19. regev a, berho m, jeffers lj, et al. sampling error and intraobserver variation in liver biopsy in patients with chronic hcv infection. am j gastroenterol. 2002;97(10):2614–8. 20. mak l-y, wong dk-h, seto w-k, et al. correlation of serum mac-2-binding protein glycosylation isomer (m2bpgi) and liver stiffness in chronic hepatitis b infection. hepatol int. 2019;13(2):148–56. 21. morio k, imamura m, daijo k, et al. wisteria floribunda agglutinin positive mac-2-binding protein level increases in patients with acute liver injury. j gastroenterol. 2017;52(12):1252–7. 22. waragai y, suzuki r, takagi t, et al. clinical significance of serum wisteria floribunda agglutininpositive mac-2 binding protein in pancreatic ductal adenocarcinoma. pancreatol off j int assoc pancreatol iap al. 2016;16(6):1044–50. 60 original article acta med indones indones j intern med • vol 53 • number 1 • january 2021 polypharmacy and drug use pattern among indonesian elderly patients visiting emergency unit czeresna h. soejono, aulia rizka division of geriatric, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: czeresna heriawan soejono, md., phd. division of geriatric, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: ch.soejono@gmail.com. abstrak latar belakang: polifarmasi merupakan masalah kesehatan besar bagi pasien usia lanjut terkait dengan risiko morbiditas karena interaksi obat dan efek simpang obat. profil polifarmasi di unit gawat darurat pada pasien usia lanjut belum banyak diketahui. penelitian ini bertujuan mengetahui prevalensi polifarmasi di igd dan faktor yang memengaruhinya. metode: studi potong lintang antara juli hingga desember 2018 pada ugd rs cipto mangunkusumo jakarta indonesia, melibatkan seluruh pasien berusia lanjut. dilakukan evaluasi pola penggunaan obat menggunakan sistem atc dan dicari hubungan antara polifarmasi dengan jenis kelamin, usia dan jumlah komorbid. hasil: 475 pasien usia lanjut mengunjungi ugd (54,8% laki-laki dengan rerata usia 67.69 (sd 6.58) tahun. polifarmasi didapatkan pada 57.6% subyek. obat yang paling banyak digunakan adalah obat untuk saluran cerna dan gangguan metabolisme, diikuti dengan suplementasi darah, obat kardiovaskular dan antibiotika. jumlah komorbid berhubungan dengan polifarmasi namun tidak dengan jenis kelamin dan usia. kesimpulan: polifarmasi pada usia lanjut banyak ditemukan dan membutuhkan perhatian khusus dari klinisi. kata kunci: polifarmasi, geriatri, unit kegawatdaruratan, obat. abstract background: polypharmacy is a major concern for elderly patients, as it links to high morbidity related to drug interaction and adverse drug effects. not much is known about profile of polypharmacy among elderly subjects visiting emergency department (ed) for acute conditions. methods: a cross sectional study conducted between july to december 2018 in ed of cipto mangunkusumo hospital jakarta indonesia. all elderly patients admitted to ed were included. we evaluated drug use pattern using atc system along with the association between polypharmacy with sex, age and number of comorbidities. results: 475 geriatric patients visited eu 247 subjects were male (54.8%; mean age 67.69 (sd 6.58) years old). polypharmacy was found in 57.6% subjects. the most frequently used of drug was that of alimentary tract and metabolism pharmacologic group, followed by drugs related to blood and blood forming organs, cardiovascular system, and anti-infectives for systemic use. sex and age were not associated with polypharmacy, while more than 3 comorbidities was associated with polypharmacy. conclusion: polypharmacy is prevalent among elderly visiting ed in indonesia, requiring special attention from clinician to evaluate each drug and interaction among the drugs used. keywords: polypharmacy, geriatric, emergency unit, drug. vol 53 • number 1 • january 2021 polypharmacy and drug use pattern among indonesian elderly patients introduction the number of elderly people in indonesia will reach 28.283.200 in 2030 (9,6% of total population). strident increase will be seen in 2045 whereas it will comprise 19.7% of total population or 43,370,400 people.1 disease accumulation in this particular group will put them in the risk of polypharmacy. polypharmacy due to multiple pathology is of great importance as it has something to do with supply chain management especially in regards to the huge amount of drugs procurement; which in turn affects financial aspect.2,3 drug pattern usage data of geriatric patients with polypharmacy are very scarce in indonesia; not to mention its risk factors that play important role. it is very crucial to have this data in health facility. it will help managing medication availability and at the same time evaluate drug usage for better planning and quality of care. polypharmacy also increases the risk of adverse event and occurrence of drug interactions. ageing itself plays an important role in the development of side effects due to drug accumulation. lipophilic substance will have broader volume distribution as the increase of body fat in elderly. hydrophilic agents with higher protein affinity will have higher free concentration in the plasma as hypoalbuminemia is frequent among geriatric patients. decrease drug metabolism with reduction in glomerular filtration will increase drug toxicity due to accumulation.4 emergency department (ed) is a starting point of drug usage for some patients including geriatric patients. drug reconciliation process often missed as patients come in acute condition that required more attention; thus geriatric patients have a greater risk of polypharmacy. over or under prescription leading to iatrogenic diseases might frequently occur in ed where time limitation is a major concern for the clinicians. not much is known about the drug pattern used by geriatric patients visiting eu and factors related with the polypharmacy. aim of this research was to identify drug pattern in geriatric patients admitted in eu with polypharmacy along with related factors that might contribute to its occurrence. methods a cross sectional study was conducted from july – december 2018) at emergency department (ed) of cipto mangunkusumo hospital (rscm) jakarta, a national referral hospital in indonesia. study population were all elderly patients consecutively admitted to ed, due to acute or acute on chronic condition.5 measurement and data collection presenting symptoms, major diagnosis, comorbidities, patients’ medications (active substance), sex, and age were recorded. active substances were classified using anatomical therapeutic chemical (atc) system. all information were collected from the patients’ medical records. two independent physicians reviews the drugs used by the patients for the purpose of the study. age was grouped in two: 60 – 69 years and > 70 years.6 presenting symptoms, major diagnosis, and comorbidities were reported as absolute number as well as percentage. one major diagnosis might be accompanied by more than one comorbidities. according to atc system, the most commonly used medications were then categorized towards three classifications: low (prescribed < 10%), moderate (between 10 – 40%), and high (> 40%). we define polypharmacy as using 5 or more drugs. statistical analysis data were analyzed using statistical package for social sciences (spss), version 24.0. spearman test was used to see the correlation between age and number of drugs, as well as age and number of diagnosis (comorbidities) if the data were normally distributed.. for the same reason, mann-whitney test was used to analyze the correlation between categorical data and number of drugs. ethical approval this study was part of epidemiological study of elderly patients visiting ed of cipto mangunkusumo hospital. this study was approved by faculty of medicine university of indonesia medical ethics committee (0859/ un2.f1/etik/2018). 61 czeresna h. soejono acta med indones-indones j intern med results during july – december 2018 there were 475 elderly patients visited eu rscm; 24 patients did not receive any medications; resulting 451 patients receiving active substances (table 1). two hundred and four were female (45.2%; mean age 69.17 (sd 8.01) years old); 247 subjects were male (54.8%; mean age 67.69 (sd 6.58) years old). number of age group 60-69 years, >70 years, were 287 subjects and 164 subjects, respectively. from 451 subjects, 2494 active substances were identified; whereby 1,639 medications, and 855 medications, were identified being given to those in age group of 60-69 years, and >70 years, respectively. two hundred and sixty subjects (57.6%) were recorded as having polypharmacy. presenting symptoms of respiratory, gastrointestinal, neurological system, pain, and fatigue predominate the chief complaint, as seen in table 2. malignancies, infection, cardiovascular diseases, digestive diseases, and metabolic encephalopathy were the top five main diagnosis with variety of comorbidities especially anemia, hypertension, arthritis, renal disease, and t2dm (type 2 diabetes mellitus). the most frequent substance being used were sodium chloride solution, followed by paracetamol, ranitidine, ceftriaxone, and omeprazole. besides ranitidine and omeprazole, propulsive and sucralfate were also quite frequent being prescribed for gastrointestinal problem. ceftriaxone and levofloxacine were the most frequent anti-infective agent being used for combating infection. (table 3) most frequent medications were quite the same between two age groups (60 – 69 years and > 70 years) as seen in table 4. the highest number was alimentary tract and metabolism table 2. primary complaint, main diagnosis, and most frequent comorbidity in emergency unit. characteristic (n = 451) n (%) primary complaint respiratory system gastrointestinal system neurology pain fatigue trauma cardiology skin and musculoskeletal reproduction and urinary system fever bleeding 91 (20.2) 66 (14.6) 66 (14.6) 61 (13.5) 51 (11.4) 31 (6.9) 26 (5.8) 16 (3.5) 15 (3.3) 15 (3.3) 13 (2.9) main diagnosis malignancy infection hemodynamic, cardiac disease, vascular digestive disease metabolic encephalopathy neurologic disease skin and musculoskeletal disease hematologic disease urinary tract disease respiratory disease 106 (23.5) 70 (15.5) 67 (14.8) 51 (11.4) 49 (10.8) 37 (8.3) 24 (5.3) 18 (3.9) 17 (3.8) 12 (2.7) comorbidity* anemia hipertention arthritis renal disease t2dm electrolyte imbalance hypoalbuminemia cancer pneumonia stroke 309 (65.6) 301 (63.9) 241 (51.2) 214 (45.5) 185 (39.3) 176 (37.4) 138 (29.3) 137 (29.1) 125 (26.5) 93 (19.8) *one main diagnosis could have several comorbidities table 3. top active substances prescribed to study participants. no name atc code frequency percentage 1 nacl b05cb 255 10.22 2 paracetamol n02be 150 6.01 3 ranitidine a02ba 148 5.93 4 ceftriaxone j01dd 142 5.69 5 omeprazole a02bc 96 3.85 6 nac r05cb 86 3.65 7 propulsives a03fa 75 3.01 8 amlodipine c08ca 70 2.81 9 hmg coa red inh c10aa 59 2.37 10 ace inh c09aa 56 2.25 11 levofloxacine j01ma 50 2.00 12 sucralfate a02bx 49 1.96 13 corticosteroids s02ba 31 1.24 14 mefenamic acid m01ag 22 0.88 15 diet form v06dc 19 0.76 name of substances: in any concentration or dosage atc code: anatomical therapeutic chemical code nac: n-acetyl cysteine hmg coa red inh: hydroxymethylglutaryl-coenzyme a reductase inhibitor ace inh: angiotensin-converting enzyme inhibitor diet form: diet formulation for therapy of obesity (carbohydrates) table 1. characteristics of subjects (n = 451). characteristics n (%) sex male female 247 (54.8) 204 (45.2) age 60-69 years old > 70 years old 287 (63.6) 164 (36.4) polypharmacy yes (number of drugs > 5) no (number of drugs < 5) 260 (57.6) 191 (42.4) 62 vol 53 • number 1 • january 2021 polypharmacy and drug use pattern among indonesian elderly patients table 4. distribution of active substances according to pharmacologic group in study participants conferring to age group. pharmacologic group 60-69 years >=70 years total male n = 164 female n = 123 male n = 83 female n = 81 male n = 247 female n = 204 overall n = 451 a = alimentary tract and metabolism 227 181 95 113 322 294 616 b = blood and blood forming organs 193 138 80 108 273 246 519 c = cardiovascular system 172 99 66 65 238 164 402 d = dermatologicals 4 9 4 0 8 9 17 g = genito urinary system and sex hormones 4 4 3 2 7 6 13 h = systemic hormonal preparations, excl. sex hormones and insulins 3 10 4 0 7 10 17 j = anti-infectives for systemic use 140 96 60 84 200 180 380 l = antineoplastic and immunomodulating agents 1 3 0 0 1 3 4 m = musculo-skeletal system 20 14 6 14 26 28 54 n = nervous system 90 66 47 23 137 89 226 r = respiratory system 61 42 27 31 88 73 161 s = sensory organs 32 10 10 2 42 12 54 v = various 12 8 5 6 17 14 31 table 5. association between number of drug used and sex. men (n=247) women (n=204) p-value number of drugs (median [min-max]) 5 (1-14) 5 (1-14) 0.885* *mann-whitney test (non-parametric test was used as data distribution was not normal). pharmacologic group, followed by blood and blood forming organs, cardiovascular system, and antiinfectives for systemic use. there was no correlation between age group and number of drugs being used (r=-0.076, p=0.107). there was neither any association between sex and number of drugs used (table 5). significant association were neither seen between sex or age group with the existance of polypharmacy (table 6). the mode as well as the median number of chronic diseases were three. higher proportion of polypharmacy was seen in patients with more than three chronic diseases, whereas patient with three or less chronic diseases was more likely to have no polypharmacy (p 0.000; or 2.554 [1.724 – 3.783]). there was neither seen any correlation between age group and number of chronic diseases (r=-0.056, p=0.237). the complete pattern of drugs used according atc grouping were seen in table 7. the result will be described further according to the frequency of their usage. firstly, from alimentary and metabolism (616 prescriptions [20.89%]), h2 receptor antagonist ranitidine was the most frequent medication prescribed (148 or 5.93%); followed by proton pump inhibitor (96 or 3.85%), propulsive (75 or 3.01%), and insulin (46 or 1.84%). secondly, from blood and blood forming organs (519 prescriptions [20.81%]), normal saline was the most frequent substance prescribed (255 or 10.22%); followed by platelet aggregation inhibitor (120 or 4.81%), amino-acids solutions (39 or 1.56%), and heparin group (28 or 1.12%). thirdly, from cardiovascular system (402 prescriptions [16.12%]), dihydropyridine derivatives (selective calcium channel blocker) was the most frequent medication prescribed (70 or 2.81%); followed by lipid modifying agents i.e. hmg coa reductase inhibitors (59 or 2.37%), ace inhibitors (56 or 2.25%), beta 63 czeresna h. soejono acta med indones-indones j intern med table 6. association between sex, age group, and number of chronic diseases and number of drugs used. polypharmacy (n=260) not polypharmacy (n=191) p-value or (95% ci) sex male female 146 (56.2) 114 (43.8) 101 (52.9) 90 (47.1) 0.490 1.141 (0.784-1.661) age > 70 60-69 90 (34.6) 170 (65.4) 74 (38.7) 117 (61.3) 0.368 0.837 (0.568 – 1.233) number of chronic diseases > 3 < 3 137 (52.7) 123 (47.3) 58 (30.4) 133 (69.6) 0.000 2.554 (1.724 – 3.783) blocking agents (55 or 2.21%), and sulfonamide diuretic (51 or 2.04%). fourthly, from the anti-infectives for systemic use (380 prescriptions [15.24%]), third generation cephalosporins was the most frequent medications prescribed (142 or 5.69%), followed by fluoroquinolones (50 or 2.00%), macrolides (40 or 1. 64%), other beta-lactam antibacterials (36 or 1.44%), and extended spectrum penicillins (28 or 1.12%). the fifth, from the nervous system (226 prescription [9.06%]), analgesic antipyretics anilides was the most frequent substance prescribed (150 or 6.01%), followed by opioids phenylpiperidine derivatives (12 or 0.48%), opioid alkaloids (11 or 0.44%), and benzodiazepine derivatives (10 or 0.40%). number six, from the respiratory system (161 prescription [6.46%]), mucolytics (n-acetyl cysteine) was the most frequent substance prescribed (86 or 3.65%). discussion in this study population, the percentage of male (54.8%) and female (45.2%) subjects were equally distributed. al ameri (2014) and tan (2019) reported the same gender percentage of polypharmacy.5,7 in indonesian general population, elderly female population is higher than the male.8 the difference in this observation was probably due to the fact that the study population was derived from elderly with acute illnesses that should be treated in an emergency setting whereby the possibility of having such an emergency clinical presentation was similar between these two gender groups.9 the percentage of those age group of 60 – 69 years was higher than age group > 70 years; this observation was different from those who were admitted for inpatient whereby the older old (> 70 years) was higher than the younger ones.8 those who were more severely ill will be hospitalized while those lesser sick who were usually younger will be discharged from ed and visit the outpatient clinic the next days of follow up.9 the prevalence of polypharmacy was 57.6% with the most frequent active substances were: normal saline, ranitidine, paracetamol, ceftriaxone, and omeprazole. those active substances were concordance with the most frequent diagnosis (malignancy, infection, hemodynamic disturbances, digestive system) and/ or primary complaints (respiratory symptoms, gastrointestinal, neurology, and pain) of the subjects. this observation was quite the same as observed by santalucia et al (2015) whereby the usage of alimentary tract and metabolism class, blood and blood forming organs system , cardiovascular system, and nervous system pharmacological class were predominant.10 tan (2019) reported a lower percentage of polypharmacy (14.5%) among community-dwelling elderly, while gupta (2018) and al ameri (2014) reported higher prevalence of polypharmacy of geriatric patients in hospital setting i.e 60.9% and 89.0% respectively.5,9 elderly patients in the community represents those with less severe cases with less co-morbidity, while those in hospitals were 64 vol 53 • number 1 • january 2021 polypharmacy and drug use pattern among indonesian elderly patients ta bl e 7. d ru g u til iz at io n p at te rn (a lim en ta ry t ra ct a nd m et ab ol is m ) d ru g u til iz at io n pa tte rn (% ) le ve l 1 n % le ve l 2 n % le ve l 3 n % le ve l 4 n % a = a lim en ta ry tra ct a nd m et ab ol is m 61 6 20 .8 9% a 01 :s to m at ol og ic al pr ep ar at io ns 3 0. 12 % a 01 a :s to m at ol og ic al pr ep ar at io ns 3 0. 12 % a 01 a b :c ar ie s pr op hy la ct ic ag en ts 3 0. 12 % a 02 :d ru gs fo r a ci d re la te d di so rd er s 29 3 11 .7 5% a 02 b :d ru gs fo r p ep tic ul ce r a nd g as tro oe so ph ag ea l r efl ux di se as e (g e r d ) 29 3 11 .7 5% a 02 b a :h 2re ce pt or an ta go ni st s 14 8 5. 93 % a 03 :d ru gs fo r f un ct io na l ga st ro in te st in al d is or de rs 79 3. 17 % a 03 b :b el la do nn a an d de riv at iv es , p la in 4 0. 16 % a 02 b c :p ro to n pu m p in hi bi to rs 96 3. 85 % a 04 :a nt ie m et ic s an d an tin au se an ts 2 0. 08 % a 03 f: p ro pu ls iv es 75 3. 01 % a 02 b x :o th er d ru gs fo r p ep tic ul ce r a nd g as tro -o es op ha ge al re flu x di se as e (g e r d ) 49 1. 96 % a 05 :b ile a nd li ve r t he ra py 2 0. 08 % a 04 a :a nt ie m et ic s an d an tin au se an ts 2 0. 08 % a 03 b a :b el la do nn a al ka lo id s, te rti ar y am in es 3 0. 12 % a 06 d ru gs fo r c on st ip at io n 54 2. 17 % a 05 a :b ile th er ap y 2 0. 08 % a 03 b b :b el la do nn a al ka lo id s, se m is yn th et ic , q ua te rn ar y am m on iu m c om po un ds 1 0. 04 % a 07 :a nt id ia rr he al s, in te st in al an tii nfl am at or y/ an tii nf ec tiv e ag en ts 10 0. 40 % a 06 a :d ru gs fo r co ns tip at io n 54 2. 17 % a 03 fa :p ro pu ls iv es 75 3. 01 % a 10 :d ru gs u se d in d ia be te s 80 3. 21 % a 07 a :in te st in al an tii nf ec tiv es 2 0. 08 % a 04 a a :s er ot on in (5 h t3 ) an ta go ni st s 2 0. 08 % a 11 :v ita m in s 15 0. 60 % a 07 b :in te st in al a ds or be nt s 5 0. 20 % a 05 a a :b ile a ci ds a nd de riv at iv es 2 0. 08 % a 12 :m in er al s up pl em en ts 79 3. 17 % a 07 d :a nt ip ro pu ls iv es 2 0. 08 % a 06 a b :c on ta ct la xa tiv es 29 1. 16 % a 07 e :in te st in al an tii nfl am m at or y ag en ts 1 0. 04 % a 06 a d :o sm ot ic al ly a ct in g la xa tiv es 25 1. 00 % a 10 a :in su lin s an d an al og ue s 64 2. 57 % a 07 a a :a nt ib io tic s 2 0. 08 % 65 czeresna h. soejono acta med indones-indones j intern med a 10 b :b lo od g lu co se lo w er in g dr ug s, e xc l. in su lin s 16 0. 64 % a 07 b c :o th er in te st in al ad so rb en ts 5 0. 20 % a 11 c :v ita m in a a nd d , i nc l. co m bi na tio ns o f t he tw o 1 0. 04 % a 07 d a :a nt ip ro pu ls iv es 2 0. 08 % a 11 d :v ita m in b 1, p la in a nd in c om bi na tio n w ith v ita m in b 6 an d b 12 1 0. 04 % a 07 e c :a m in os al ic yl ic a ci d an d si m ila r a ge nt s 1 0. 04 % a 11 e :v ita m in b -c om pl ex , in cl . c om bi na tio ns 3 0. 12 % a 10 a b :in su lin s an d an al og ue s fo r i nj ec tio n, fa st -a ct in g 46 1. 84 % a 11 g :a sc or bi c ac id (v ita m in c ), in cl . co m bi na tio ns 3 0. 12 % a 10 a d :in su lin s an d an al og ue s fo r i nj ec tio n, in te rm ed ia te o r lo ng -a ct in g co m bi ne d w ith fa st -a ct in g 5 0. 20 % a 11 h :o th er p la in v ita m in pr ep ar at io ns 7 0. 28 % a 10 a e :in su lin s an d an al og ue s fo r i nj ec tio n, lo ng -a ct in g 13 0. 52 % a 12 a :c al ci um 34 1. 36 % a 10 b a :b ig ua ni de s 7 0. 28 % a 12 b :p ot as si um 31 1. 24 % a 10 b b :b ig ua ni de s 9 0. 36 % a 12 c :o th er m in er al su pp le m en ts 14 0. 56 % a 11 c c :v ita m in d a nd an al og ue s 1 0. 04 % a 11 d a :v ita m in b 1, p la in 1 0. 04 % a 11 e a :v ita m in b -c om pl ex , pl ai n 3 0. 12 % a 11 g a :a sc or bi c ac id (v ita m in c ), pl ai n 3 0. 12 % a 11 h a :o th er p la in v ita m in pr ep ar at io ns 7 0. 28 % a 12 a a :c al ci um 34 1. 36 % a 12 b a :p ot as si um 31 1. 24 % a 12 c a :s od iu m 11 0. 44 % a 12 c b :z in c 1 0. 04 % a 12 c c :m ag ne si um 2 0. 08 % 66 vol 53 • number 1 • january 2021 polypharmacy and drug use pattern among indonesian elderly patients b = b lo od a nd bl oo d fo rm in g or ga ns 51 9 20 .8 1% b 01 :a nt ith ro m bo tic a ge nt s 15 0 b 01 a :a nt ith ro m bo tic ag en ts 15 0 6. 01 % b 01 a a :v ita m in k a nt ag on is ts 1 0. 04 % b 02 :a nt ih em or rh ag ic s 56 b 02 a :a nt ifi br in ol yt ic s 39 1. 56 % b 01 a b :h ep ar in g ro up 28 1. 12 % b 03 :a nt ia ne m ic p re pa ra tio ns 12 b 02 b :v ita m in k a nd o th er he m os ta tic s 17 0. 68 % b 01 a c :p la te le t a gg re ga tio n in hi bi to rs e xc l. he pa rin 12 0 4. 81 % b 05 :b lo od s ub st itu te s an d pe rfu si on s ol ut io ns 30 1 b 03 b :v ita m in b 12 a nd fo lic a ci d 12 0. 48 % b 01 a d :e nz ym es 1 0. 04 % b 05 a :b lo od a nd re la te d pr od uc ts 18 0. 72 % b 02 a a :a m in o ac id s 39 1. 56 % b 05 b :i. v. s ol ut io ns 16 0. 64 % b 02 b a :v ita m in k 17 0. 68 % b 05 c :ir rig at in g so lu tio ns 26 3 10 .5 5% b 03 b a :v ita m in b 12 (c ya no co ba la m in a nd an al og ue s) 5 0. 20 % b 05 x :i. v. s ol ut io n ad di tiv es 4 0. 16 % b 03 b b :f ol ic a ci d an d de riv at iv es 7 0. 28 % b 05 a a :b lo od s ub st itu te s an d pl as m a pr ot ei n fra ct io ns 12 0. 48 % b 05 a x :o th er b lo od p ro du ct s 6 0. 24 % b 05 b a :s ol ut io ns fo r p ar en te ra l nu tri tio n 2 0. 08 % b 05 b b :s ol ut io ns a ffe ct in g th e el ec tro ly te b al an ce 13 0. 52 % b 05 b c :s ol ut io ns p ro du ci ng os m ot ic d iu re si s 1 0. 04 % b 05 c b :s al t s ol ut io ns 25 5 10 .2 2% b 05 c x :o th er ir rig at in g so lu tio ns 8 0. 32 % b 05 x a :e le ct ro ly te s ol ut io ns 4 0. 16 % c = c ar di ov as cu la r sy st em 40 2 16 .1 2% c 01 :c ar di ac th er ap y 45 1. 80 % c 01 a :c ar di ac g ly co si de s 8 0. 32 % c 01 a a :d ig ita lis g ly co si de s 8 0. 32 % c 02 :a nt ih yp er te ns iv es 12 0. 48 % c 01 c :c ar di ac s tim ul an ts ex cl . c ar di ac g ly co si de s 12 0. 48 % c 01 c a :a dr en er gi c an d do pa m in er gi c ag en ts 12 0. 48 % 67 czeresna h. soejono acta med indones-indones j intern med c 03 :d iu re tic s 57 2. 29 % c 01 d :v as od ila to rs u se d in ca rd ia c di se as es 24 0. 96 % c 01 d a :o rg an ic n itr at es 24 0. 96 % c 07 :b et a bl oc ki ng a ge nt s 61 2. 45 % c 01 e :o th er c ar di ac pr ep ar at io ns 1 0. 04 % c 01 e b :o th er c ar di ac pr ep ar at io ns 1 0. 04 % c 08 :c al ci um c ha nn el bl oc ke rs 70 2. 81 % c 02 a :a nt ia dr en er gi c ag en ts , c en tra lly a ct in g 12 0. 48 % c 02 a c :im id az ol in e re ce pt or ag on is ts 12 0. 48 % c 09 :a ge nt s ac tin g on th e re ni nan gi ot en si n sy st em 97 3. 89 % c 03 a :l ow -c ei lin g di ur et ic s, th ia zi de s 2 0. 08 % c 03 a a :t hi az id es , p la in 2 0. 08 % c 10 :l ip id m od ify in g ag en ts 60 2. 41 % c 03 c :h ig hce ili ng d iu re tic s 51 2. 04 % c 03 c a :s ul fo na m id es , p la in 51 2. 04 % c 03 d :p ot as si um -s pa rin g ag en ts 4 0. 16 % c 03 d a :a ld os te ro ne an ta go ni st s 4 0. 16 % c 07 a :b et a bl oc ki ng a ge nt s 61 2. 45 % c 07 a a :b et a bl oc ki ng a ge nt s, no nse le ct iv e 2 0. 08 % c 08 c :s el ec tiv e ca lc iu m ch an ne l b lo ck er s w ith m ai nl y va sc ul ar e ffe ct s 69 2. 77 % c 07 a b :b et a bl oc ki ng a ge nt s, se le ct iv e 55 2. 21 % c 08 d :s el ec tiv e ca lc iu m ch an ne l b lo ck er s w ith di re ct c ar di ac e ffe ct s 1 0. 04 % c 07 a g :a lp ha a nd b et a bl oc ki ng a ge nt s 4 0. 16 % c 09 a :a c e in hi bi to rs , p la in 56 2. 25 % c 08 c a :d ih yd ro py rid in e de riv at iv es 70 2. 81 % c 09 c :a ng io te ns in ii re ce pt or b lo ck er s (a r b s) , pl ai n 41 1. 64 % c 08 d b :b en zo th ia ze pi ne de riv at iv es 1 0. 04 % c 10 a :l ip id m od ify in g ag en ts , p la in 60 2. 41 % c 09 a a :a c e in hi bi to rs , p la in 56 2. 25 % c 09 c a :a ng io te ns in ii re ce pt or bl oc ke rs (a r b s) , p la in 41 1. 64 % c 10 a a :h m g c oa re du ct as e in hi bi to rs 59 2. 37 % 68 vol 53 • number 1 • january 2021 polypharmacy and drug use pattern among indonesian elderly patients c 10 a b :f ib ra te s 1 0. 04 % d = d er m at ol og ic al s 17 0. 68 % d 02 :e m ol lie nt s an d pr ot ec tiv es 1 0. 04 % d 02 a :e m ol lie nt s an d pr ot ec tiv es 1 0. 04 % d 02 a x :o th er e m ol lie nt s an d pr ot ec tiv es 1 0. 04 % d 04 :a nt ip ru rit ic s, in cl , an tih is ta m in es , a ne st he tic s, et c. 13 0. 52 % d 04 a :a nt ip ru rit ic s, in cl . a nt ih is ta m in es , an es th et ic s, e tc . 13 0. 52 % d 04 a a :a nt ih is ta m in es fo r to pi ca l u se 13 0. 52 % d 06 :a nt ib io tic s an d ch em ot he ra pe ut ic s fo r de rm at ol og ic al u se 2 0. 08 % d 06 a :a nt ib io tic s fo r t op ic al us e 2 0. 08 % d 06 a x :o th er a nt ib io tic s fo r to pi ca l u se 2 0. 08 % d 07 :c or tic os te ro id s, de rm at ol og ic al p re pa ra tio ns 1 0. 04 % d 07 x :c or tic os te ro id s, ot he r c om bi na tio ns 1 0. 04 % d 07 x a :c or tic os te ro id s, w ea k, ot he r c om bi na tio ns 1 0. 04 % g = g en ito u rin ar y sy st em a nd s ex ho rm on es 13 0. 52 % g 01 :g yn ec ol og ic al an tii nf ec tiv es a nd a nt is ep tic s 10 0. 40 % g 01 a :a nt iin fe ct iv es an d an tis ep tic s, e xc l. co m bi na tio ns w ith co rti co st er oi ds 10 0. 40 % g 01 a f: im id az ol e de riv at iv es 10 0. 40 % g 04 :u ro lo gi ca ls 3 0. 12 % g 04 b :u ro lo gi ca ls 1 0. 04 % g 04 b e :d ru gs u se d in e re ct ile dy sf un ct io n 1 0. 04 % g 04 c :d ru gs u se d in b en ig n pr os ta tic hy pe rtr op hy 2 0. 08 % g 04 c a :a lp ha -a dr en or ec ep to r an ta go ni st s 2 0. 08 % h = s ys te m ic ho rm on al pr ep ar at io ns , e xc l. se x ho rm on es a nd in su lin s 17 0. 68 % h 01 :p itu ita ry a nd hy po th al am ic h or m on es a nd an al og ue s 3 0. 12 % h 01 c :h yp ot ha la m ic ho rm on es 3 0. 12 % h 01 c b :s om at os ta tin a nd an al og ue s 3 0. 12 % h 02 :c or tic os te ro id s fo r sy st em ic u se 10 0. 40 % h 02 a :c or tic os te ro id s fo r sy st em ic u se , p la in 10 0. 40 % h 02 a b :g lu co co rti co id s 10 0. 40 % h 03 :t hy ro id th er ap y 4 0. 16 % h 03 a :t hy ro id p re pa ra tio ns 2 0. 08 % h 03 a a :t hy ro id h or m on es 2 0. 08 % h 03 b :a nt ith yr oi d pr ep ar at io ns 2 0. 08 % h 03 b a :t hi ou ra ci ls 2 0. 08 % j = a nt iin fe ct iv es fo r s ys te m ic u se 38 0 15 .2 4% j0 1: a nt ib ac te ria ls fo r sy st em ic u se 34 4 13 .7 9% j0 1b :a m ph en ic ol s 5 0. 20 % j0 1b a :a m ph en ic ol s 5 0. 20 % j0 2: a nt im yc ot ic s fo r sy st em ic u se 2 0. 08 % j0 1c :b et ala ct am an tib ac te ria ls , p en ic ill in s 44 1. 76 % j0 1c a :p en ic ill in s w ith ex te nd ed s pe ct ru m 28 1. 12 % 69 czeresna h. soejono acta med indones-indones j intern med j0 4: a nt im yc ob ac te ria ls 28 1. 12 % j0 1d :o th er b et ala ct am an tib ac te ria ls 18 8 7. 54 % j0 1c e :b et ala ct am as e se ns iti ve p en ic ill in s 1 0. 04 % j0 5: a nt iv ira ls fo r s ys te m ic us e 1 0. 04 % j0 1f :m ac ro lid es , lin co sa m id es a nd st re pt og ra m in s 42 1. 68 % j0 1c r :c om bi na tio ns o f pe ni ci lli ns , i nc l. be ta -la ct am as e in hi bi to rs 15 0. 60 % j0 6: im m un e se ra a nd im m un og lo bu lin s 4 0. 16 % j0 1g :a m in og ly co si de an tib ac te ria ls 5 0. 20 % j0 1d b :f irs t-g en er at io n ce ph al os po rin s 3 0. 12 % j0 1m :q ui no lo ne an tib ac te ria ls 50 2. 00 % j0 1d d :t hi rd -g en er at io n ce ph al os po rin s 14 2 5. 69 % j0 1r :c om bi na tio ns o f an tib ac te ria ls 9 0. 36 % j0 1d e 36 1. 44 % j0 1x :o th er a nt ib ac te ria ls 1 0. 04 % j0 1d h :c ar ba pe ne m s 7 0. 28 % j0 2a :a nt im yc ot ic s fo r sy st em ic u se 2 0. 08 % j0 1f a :m ac ro lid es 41 1. 64 % j0 4a :d ru gs fo r t re at m en t of tu be rc ul os is 28 1. 12 % j0 1f f: li nc os am id es 1 0. 04 % j0 5a :d ire ct a ct in g an tiv ira ls 1 0. 04 % j0 1g b :o th er a m in og ly co si de s 5 0. 20 % j0 6a :im m un e se ra 1 0. 04 % j0 1m a :f lu or oq ui no lo ne s 50 2. 00 % j0 6b :im m un og lo bu lin s 3 0. 12 % j0 1r a :c om bi na tio ns o f an tib ac te ria ls 9 0. 36 % j0 1x x :o th er a nt ib ac te ria ls 1 0. 04 % j0 2a b :im id az ol e de riv at iv es 1 0. 04 % j0 2a c :t ria zo le d er iv at iv es 1 0. 04 % j0 4a b :a nt ib io tic s 8 0. 32 % j0 4a k :o th er d ru gs fo r tre at m en t o f t ub er cu lo si s 12 0. 48 % j0 4a m :c om bi na tio ns o f d ru gs fo r t re at m en t o f t ub er cu lo si s 8 0. 32 % j0 5a b :n uc le os id es a nd nu cl eo tid es e xc l. re ve rs e tra ns cr ip ta se in hi bi to rs 1 0. 04 % 70 vol 53 • number 1 • january 2021 polypharmacy and drug use pattern among indonesian elderly patients j0 6a a :im m un e se ra 1 0. 04 % j0 6b b :s pe ci fic im m un og lo bu lin s 3 0. 12 % l = a nt in eo pl as tic an d im m un om od ul at in g ag en ts 4 0. 16 % l0 1: a nt in eo pl as tic a ge nt s 1 0. 04 % l0 1x :o th er a nt in eo pl as tic ag en ts 1 0. 04 % l0 1x x :o th er a nt in eo pl as tic ag en ts 1 0. 04 % l0 3: im m un os tim ul an ts 1 0. 04 % l0 3a : i m m un os tim ul an ts 1 0. 04 % l0 3a a :c ol on y st im ul at in g fa ct or s 1 0. 04 % l0 4: im m un os up pr es sa nt s 2 0. 08 % l0 4a :im m un os up pr es sa nt s 2 0. 08 % l0 4a a :s el ec tiv e im m un os up pr es sa nt s 1 0. 04 % l0 4a x :o th er im m un os up pr es sa nt s 1 0. 04 % m = m us cu lo sk el et al s ys te m 54 2. 17 % m 01 :a nt iin fla m m at or y an d an tir he um at ic p ro du ct s 34 1. 36 % m 01 a : a nt iin fla m m at or y an d an tir he um at ic pr od uc ts , n on -s te ro id s 34 1. 36 % m 01 a b :a ce tic a ci d de riv at iv es an d re la te d su bs ta nc es 10 0. 40 % m 02 :t op ic al p ro du ct s fo r jo in t a nd m us cu la r p ai n 1 0. 04 % m 02 a :t op ic al p ro du ct s fo r jo in t a nd m us cu la r p ai n 1 0. 04 % m 01 a e :p ro pi on ic a ci d de riv at iv es 2 0. 08 % m 03 :m us cl e re la xa nt s 2 0. 08 % m 03 a :m us cl e re la xa nt s, pe rip he ra lly a ct in g ag en ts 2 0. 08 % m 01 a g :f en am at es 22 0. 88 % m 04 :a nt ig ou t p re pa ra tio ns 17 0. 68 % m 04 a :a nt ig ou t pr ep ar at io ns 17 0. 68 % m 02 a a :a nt iin fla m m at or y pr ep ar at io ns , n on -s te ro id s fo r to pi ca l u se 1 0. 04 % m 03 a c :o th er q ua te rn ar y am m on iu m c om po un ds 2 0. 08 % m 04 a a :p re pa ra tio ns in hi bi tin g ur ic a ci d pr od uc tio n 16 0. 64 % m 04 a c :p re pa ra tio ns w ith n o eff ec t o n ur ic a ci d m et ab ol is m 1 0. 04 % n = n er vo us sy st em 22 6 9. 06 % n 01 :a ne st he tic s 2 0. 08 % n 01 a :a ne st he tic s, g en er al 1 0. 04 % n 01 a x :o th er g en er al an es th et ic s 1 0. 04 % n 02 :a na lg es ic s 17 9 7. 18 % n 01 b :a ne st he tic s, lo ca l 1 0. 04 % n 01 b b :a m id es 1 0. 04 % n 03 :a nt ie pi le pt ic s 13 0. 52 % n 02 a :o pi oi ds 29 1. 16 % n 02 a a :n at ur al o pi um a lk al oi ds 11 0. 44 % 71 czeresna h. soejono acta med indones-indones j intern med n 04 :a nt i-p ar ki ns on d ru gs 4 0. 16 % n 02 b :o th er a na lg es ic s an d an tip yr et ic s 15 0 6. 01 % n 02 a b :p he ny lp ip er id in e de riv at iv es 12 0. 48 % n 05 :p sy ch ol ep tic s 17 0. 68 % n 03 a :a nt ie pi le pt ic s 13 0. 52 % n 02 a x :o th er o pi oi ds 6 0. 24 % n 06 :p sy ch oa na le pt ic s 7 0. 28 % n 04 a :a nt ic ho lin er gi c ag en ts 2 0. 08 % n 02 b e :a ni lid es 15 0 6. 01 % n 07 :o th er n er vo us s ys te m dr ug s 4 0. 16 % n 04 b :d op am in er gi c ag en ts 2 0. 08 % n 03 a b :h yd an to in d er iv at iv es 2 0. 08 % n 05 a :a nt ip sy ch ot ic s 5 0. 20 % n 03 a e :b en zo di az ep in e de riv at iv es 1 0. 04 % n 05 b :a nx io ly tic s 10 0. 40 % n 03 a f: c ar bo xa m id e de riv at iv es 1 0. 04 % n 05 c :h yp no tic s an d se da tiv es 2 0. 08 % n 03 a g :f at ty a ci d de riv at iv es 4 0. 16 % n 06 a :a nt id ep re ss an ts 3 0. 12 % n 03 a x :o th er a nt ie pi le pt ic s 5 0. 20 % n 06 d :a nt i-d em en tia d ru gs 4 0. 16 % n 04 a a :t er tia ry a m in es 2 0. 08 % n 07 c :a nt iv er tig o pr ep ar at io ns 4 0. 16 % n 04 b a :d op a an d do pa de riv at iv es 2 0. 08 % n 05 a d :b ut yr op he no ne de riv at iv es 3 0. 12 % n 05 a x :o th er a nt ip sy ch ot ic s 2 0. 08 % n 05 b a :b en zo di az ep in e de riv at iv es 10 0. 40 % n 05 c d :b en zo di az ep in e de riv at iv es 2 0. 08 % n 06 a a :n on -s el ec tiv e m on oa m in e re up ta ke in hi bi to rs 2 0. 08 % n 06 a b :s el ec tiv e se ro to ni n re up ta ke in hi bi to rs 1 0. 04 % n 06 d a :a nt ic ho lin es te ra se s 4 0. 16 % n 07 c a :a nt iv er tig o pr ep ar at io ns 4 0. 16 % 72 vol 53 • number 1 • january 2021 polypharmacy and drug use pattern among indonesian elderly patients r = r es pi ra to ry sy st em 16 1 6. 46 % r 01 :n as al p re pa ra tio ns 14 0. 56 % r 01 a :d ec on ge st an ts a nd ot he r n as al p re pa ra tio ns fo r t op ic al u se 14 0. 56 % r 01 a d :c or tic os te ro id s 14 0. 56 % r 03 :d ru gs fo r o bs tru ct iv e ai rw ay d is ea se s 57 2. 29 % r 03 a :a dr en er gi cs , in ha la nt s 56 2. 25 % r 03 a c :s el ec tiv e be ta -2 ad re no re ce pt or a go ni st s 19 0. 76 % r 05 :c ou gh a nd c ol d pr ep ar at io ns 90 3. 61 % r 03 b :o th er d ru gs fo r o bs tru ct iv e ai rw ay di se as es , i nh al an ts 1 0. 04 % r 03 a l: a dr en er gi cs in c om bi na tio n w ith an tic ho lin er gi cs in cl . tri pl e co m bi na tio ns w ith co rti co st er oi ds 37 1. 48 % r 05 c :e xp ec to ra nt s, e xc l. co m bi na tio ns w ith c ou gh su pp re ss an ts 87 3. 49 % r 03 b a :g lu co co rti co id s 1 0. 04 % r 05 d :c ou gh su pp re ss an ts , e xc l. co m bi na tio ns w ith ex pe ct or an ts 3 0. 12 % r 05 c b :m uc ol yt ic s 86 3. 45 % r 05 d a :o pi um a lk al oi ds a nd de riv at iv es 3 0. 12 % s = s en so ry or ga ns 54 2. 2% s 01 :o ph th al m ol og ic al s 23 0. 92 % s 01 a :a nt iin fe ct iv es 15 0. 60 % s 01 a a :a nt ib io tic s 5 0. 20 % s 02 :o to lo gi ca ls 31 1. 24 % s 01 e :a nt ig la uc om a pr ep ar at io ns a nd m io tic s 7 0. 28 % s 01 a e :f lu or oq ui no lo ne s 8 0. 32 % s 01 x :o th er op ht ha lm ol og ic al s 1 0. 04 % s 01 e c :c ar bo ni c an hy dr as e in hi bi to rs 3 0. 12 % s 02 b :c or tic os te ro id s 31 1. 24 % s 01 e d :b et a bl oc ki ng a ge nt s 4 0. 16 % s 01 fa :a nt ic ho lin er gi cs 2 0. 08 % s 01 x a :o th er op ht ha lm ol og ic al s 1 0. 04 % s 02 b a :c or tic os te ro id s 31 1. 24 % v = v ar io us 31 1. 24 % v 03 :a ll ot he r t he ra pe ut ic pr od uc ts 12 0. 48 % v 03 a :a ll ot he r t he ra pe ut ic pr od uc ts 12 0. 48 % v 03 a e :d ru gs fo r t re at m en t of h yp er ka le m ia a nd hy pe rp ho sp ha te m ia 12 0. 48 % v 06 :g en er al n ut rie nt s 19 0. 76 % v 06 d :d ie t f or m ul at io ns fo r tre at m en t o f o be si ty 19 0. 76 % v 06 d c :c ar bo hy dr at es 19 0. 76 % n ot e: a p at ie nt m ay b e pr es cr ib ed o ne o r m or e th an o ne d ru g fr om le ve l 2 , l ev el 3 an d le ve l 4 c at eg or ie s p er ce nt ag es g iv en w ith r es pe ct to th e to ta l s am pl e si ze o f t he p at ie nt 73 czeresna h. soejono acta med indones-indones j intern med more severely ill with higher number of comorbidities.11 patients with higher number of co-morbidity will have higher risk of multiple medications. special consideration should be given to the use of ranitidine for gastrointestinal symptom and diagnosis in digestive system. it was prescribed as much as 33.0% of all medications (the highest number of drug) whereas sheth (2020) also found the same observation that ranitidine was the most common medication prescribed in tertiary hospital.12 from geriatrics point of view of h2 receptor antagonist class, this drug has potentially serious side effect for the elderly, namely confusion, hallucination, and arrhythmia.13,14 as the clearance of this drug becomes slower in geriatric population compared to the young ones (0.58 sd 0.19 ml/hr vs 1.11 sd 0.12 ml/hr, p<0.0002); the elimination of half life is longer in elderly than the young ones (4.66 sd 1.23 hr vs 2.50 sd 0.75 hr, p<0.01), and the reached maximum concentration in elderly is higher than in younger patients (1647.7 [1332.0 – 2079.0] ng/ml vs 573.7 [419.2 – 905.7] ng/ml, p<0.01) made this aged population was likely to have this risk of side effects.15 clinicians as well as the management has to be aware of this situation in planning for the gastrointestinal medications. omeprazole that was also prescribed quite often in this observation might provide better option. evaluating the connection between most frequent drugs being prescribed (normal saline, ranitidine, paracetamol, ceftriaxone, o m e p r a z o l e , a n d a m l o d i p i n e ) w i t h t h e prevalence of diagnosis (malignancies, infection, hemodynamic disturbances, digestive diseases) or presenting symptoms (respiratory complaints, gastrointestinal symptoms, neurological, pain, fatigue), the drug pattern being used was still coherent. kurt (2019) reported a slightly different distribution of diseases among those with polypharmacy attending family medicine outpatient clinic; hypertension (71.66%), diabetes mellitus (40.00%), hyperlipidemia (31.25%), depression (18.75%), and hypothyroidism (17.91%) were the top five diagnosis; cancer was in number six (8.75%).16 this variation was due to the difference in disease pattern at outpatient clinic compare to that of in inpatient hospital wards.17 in this observation, it was found that there was no distribution differences of drugs being prescribed according to sex or age group. santalucia et al.10 reported the similar result, although more drugs were given to men compared to women (5.38 sd 3.0 vs 5.08 sd 2.8; p<0.0030). morgan18 also found similar result, although the community dwelling elderly women were at 16% higher odds of receiving inappropriate prescriptions than men (adjusted or 1.16, 95% ci 1.12-1.210. the trend of polypharmacy according to age group was not found in this report as well.10,19 the older the patients become does not necessarily mean they have to use more medications. the median number of chronic diseases per patient in this research was three; subjects then grouped as having more than three diseases (higher level of multimorbidity) and three or less than three diseases (lower level of multimorbidity). there was a significant difference between these two groups in regard to the occurance of polypharmacy. percentage of those with polypharmacy in the first group was higher than the second group (52.7% vs 30.4%) and the percentage of those without polypharmacy was higher in the second group than the first group (69.6% vs 47.3%), p: 0.000; or 2.554 (95% ci 1.724-3.783). the same finding were reported by kurt16 and ramos17. kurt16 reported that the older the subjects were the more likely they had higher ratio of chronic diseases per age group which was concordance with the number of medications. while ramos17 observed, also those with history of hospitalization in the previous year were more likely to have > five drugs at the same time, compare to those without history of prior hospitalization (32% [95% ci 27.7;37.7 vs 16.3 [95% ci 15.0-17.8]). it was as expected that those with higher number of chronic diseases were more likely to have more medications and had higher risk of being hospitalized due to acute insult. as a whole, the top ten list of medication (nacl, paracetamol, ranitidine, ceftriaxone, omeprazole, n-acetyl cysteine, propulsive, amlodipine, hmg coa reductase inhibitor, 74 vol 53 • number 1 • january 2021 polypharmacy and drug use pattern among indonesian elderly patients ace inhibitor) were coherent with the top ten list of diagnosis (malignancies, infections, cardiovascular, hemodynamic disturbances, digestive diseases, metabolic encephalopathy, neurologic diseases, musculoskeletal and skin diseases, hematologic diseases) or ten most frequent primary complaints (respiratory system, gastrointestinal system, neurology, pain, fatigue, trauma, cardiology, musculoskeletal and skin, reproduction and urinary system, fever). in a more detailed perspective while malignancies was number one diagnosis but it did not necessarily put cytotoxic drugs (chemotherapy agents) as the most frequent medications that should be prescribed. it was expected that not all malignancy cases in ed will be treated with chemotherapy; but treating dehydration or provide vascular access were essential. malignancy cases often come to ed due to pain of fever secondary from infection that also need antibiotics and or paracetamol. in this observation, it was also found that (table 3) diet formulation for the treatment of obesity prescribed in ed which actually was not essential for emergency situation; clinicians should be aware of this and be advised not to execute unnecessary non-emergency medications in an emergency unit. conclusion the prevalence of polypharmacy was 57.6%; percentage of polypharmacy were equally distributed between women and men, as well as between younger and older age groups. the most frequent drugs used were sodium chloride, followed by paracetamol, ranitidine, ceftriaxone, omeprazole, nac, propulsive, amlodipine, hmg coa reductase inhibitor, and ace inhibitor. the presence of polypharmacy in those with > 3 diseases was significantly higher than those with < 3 chronic diseases. the most frequently prescribed medications were concordant with the most common diagnosis and or primary complaints, despite the concern regarding the use of ranitidine and diet formulation for the treatment of obesity in the emergency department. acknowledgments special thank you to rahmi istanti, skm, mars and dr. yulian huningkor for your help in preparation and tidy up up the data. conflict of interest authors declare no conflict of interest. references 1. bappenas, bps, unfpa. proyeksi penduduk indonesia (indonesia population projection) 2015 2045. hasil supas 2015. jakarta: bappenas; agustus 2018. 2. van seben r, smorenburg sm, buurman bm. a qualitative study of patient-centered goal-setting in geriatric rehabilitation: patient and professional perspectives. clinical rehabilitation. 2019; 33(1):128– 40. 3. morandi a, bellelli g, vasilevskis ee. predictors of rehospitalization among elderly patients admitted to a rehabilitation hospital: the role of polypharmacy, functional status and length of stay. j am med dir assoc. 2013;14(10):761–7. 4. petronic m, gnjidic d, tommelein e, boussery k. pharmacotherapy, in learning geriatric medicine. in: roller-wirnsberger r, singler k, polidori mc, editors. switzerland: springer international publishing; 2018. p. 219-26. 5. tan yw, suppiah s, bautista mac, malhotra r. polypharmacy among community-dwelling elderly in singapore: prevalence, risk factors and association with medication non-adherence. proceeding of singapore healthcare. 2019;28(4):224-31. 6. peraturan menteri kesehatan nomor 79/ 2014 tentang penyelenggaraan pelayanan geriatri di rumah sakit. sekretariat jenderal kementerian kesehatan republik indonesia, jakarta, 2014. 7. al ameri mn, makramalla e, albur u, kumar a, rao p. prevalence of polypharmacy in the elderly: implications of age, gender, co-morbiditiesand drug interactions. soj pharm pharm sci. 2014;1(3):1-7. 8. statistik penduduk lanjut usia 2020. badan pusat s t a t i s t i k r e p u b l i k i n d o n e s i a . n o . p u b l i k a s i 04220.2005. katalog 4104001. jakarta. 2020. 9. gupta r, malhotra a, malhotra p. a study on polypharmacy among elderly medicine in-patients of a tertiary care teaching hospital of north india. national j of physiology. pharmacy and pharmacology. 2018;8(9):1297-301. 10. santalucia p, franchi c, djade cd, et al. gender difference in drug use in hospitalized elderly patients. european j of int med. 2015;26:483-90. 11. badawy na, labeeb sa, alsamdan mf, alazemi bf. prevalence and risk of polypharmacy among community-dwelling, elderly kuwaiti patients. med 75 czeresna h. soejono acta med indones-indones j intern med princ pract. 2020; 29:166-73. 12. sheth ar, dave rb, rana d, sheth d. comparison of the extend and prevalence of prescription of potentially inappropriate medications prescribed to geriatric age group residing in old-age homes versus those receiving care from tertiary care hospital using beers criteria. perspect clin res. 2020;11(4):144-9. 13. rudolph jl, marcantonio er. delirium. in: duthie eh, katz pr, malone ml., eds. practice of geriatrics. 4th edition. philadelphia: saunders elsevier; 2007. p. 341. 14. bowker lk, price jd, shah ks, smith sc. oxford handbook of geriatric medicine. 3rd edition. londong, uk: oxford; 2018. p. 235. 15. pérez g, olguin hj, pérez a, lares-asseff i. effect of age on the pharmacokinetics of ranitidine in healthy mexican volunteers. proc west pharmacol soc. 2005; 48:84-8. 16. kurt m, akdeniz m, kavukcu e. assessment of comorbidity and use of prescription and nonprescription drugs in patients over 65 years attending family medicine outpatient clinic. gerontology and geriatric medicine. 2019;5:1-7. 17. ramos lr, tavares nul, bertoldi ad, et al. polypharmacy and polymorbidity in older adults in brazil: a public health challenge. rev saúde pública. 2016;50(suppl2):9s. 18. morgan sg, weymann d, pratt b, smolina k, gladstone ej, raymond c, mintzes b. sex diffences in the risk of receiving potentially inappropriate prescriptions among older adults. age and ageing. 2016;45:535-42. 19. orlando v, mucherino s, guarino i, guerriro f, trama u, menditto e. gender differences in medication use: a drug utilization study based on real world data. int. j. environ res public health. 2020;17(3926):1-10. 76 case report 63acta med indones indones j intern med • vol 51 • number 1 • january 2019 immunohistochemical staining on an excision biopsy specimen as a diagnostic modality for rare idiopathic hepatocellular adenoma: a case report juferdy kurniawan1,2, andri sanityoso1,2, toar j.m lalisang1,3, ening krisnuhoni1,4, sahat matondang1,5, abirianty p. araminta1, lutfie1 1 national hepatopancreatobiliary center, jakarta, indonesia. 2 department of internal medicine, faculty of medicine universitas indonesia, jakarta, indonesia. 3 department of surgery, faculty of medicine universitas indonesia, jakarta, indonesia. 4 department of pathology anatomy, faculty of medicine universitas indonesia, jakarta, indonesia. 5 department of radiology, faculty of medicine universitas indonesia, jakarta, indonesia. corresponding author: juferdy kurniawan, md. division of hepatobiliary, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71 jakarta 10430, indonesia. email: juferdy.k@ gmail.com. abstrak adenoma hepatoselular merupakan tumor jinak hati yang sangat jarang, dengan predominasi pada wanita usia muda. estimasi insidens 3-4 kasus per 1.000.000 populasi setiap tahunnya menjadikan kondisi ini memiliki tantangan diagnostik tersendiri. melalui naskah ini kami melaporkan seorang wanita berusia 30 tahun dengan adenoma hepatoselular tanpa faktor risiko klasik. rangkaian metode diagnostik telah dikerjakan untuk dapat menegakkan diagnosis dan hanya biopsi eksisi dari reseksi segmental yang menunjukkan kemaknaan nilai diagnostik. kasus ini mengilustrasikan peran dari pulasan imunohistokimia pada biopsi eksisi sebagai modalitas diagnostik terbaik untuk adenoma hepatoselular, sekaligus sebagai modalitas terapeutik untuk mencegah transformasi keganasan. kata kunci: adenoma hati, tumor jinak hati, diagnosis, penanda imunohistokimia, reseksi. abstract hepatocellular adenoma is an extremely rare benign tumor of the liver which predominantly in young women. its rare incidence with estimated 3-4 cases per 1.000.000 annually makes it a diagnostic challenge. here we present a 30-year-old female patient with hepatocellular adenoma without classic risk factors. a series of work up tools have been performed in order to diagnose the condition. none but excision biopsy from segmental resection had been showed to increase diagnostic confidence. this case illustrates the role of immunohistochemical staining from excision biopsy as the best diagnostic modality of hepatocellular adenoma as well as therapeutic modality to prevent malignant transformation. keywords: liver adenoma, benign liver tumor, diagnosis, immunohistochemical marker, resection. juferdy kurniawan acta med indones-indones j intern med introduction hepatocellular adenoma (hca), also known as hepatic adenoma, are rare, benign, hormonal induced hepatic tumors. commonly found in childbearing-aged women, hca has been strongly correlated with the use of oral contraceptives.1 incidence of hca is approximately 1/1.000.000 in women without history of oral contraceptives compare to 3040/1.000.000 in long-term users.2,3 nevertheless, the mechanism of estrogen-induced hca is not completely understood. other etiologies inducing the development of hca include longterm use of anabolic androgenic steroids and glycogen storage diseases.4 the clinical presentation of hepatic adenomas varies widely. about 25-50% patients with hepatic adenomas reported with pain in the right upper quadrant or epigastric region. lesions may be palpable or incidentally found during abdominal imaging study for other study. bordeaux classification of hepatic adenomas is currently being evaluated. the classification consists of hepatocyte nuclear factor 1α-inactivated hca (hnf1α hca 30-35%), β cateninmutated hca (β-cat hca 10-15%), inflammatory hca (50%), and a subgroup of less than 10% that remains unclassified.5 basically, hca is diagnosis made by excluding other differential diagnosis. serological test are performed to exclude other possible diagnosis. serum aminotransferase levels may be mildly elevated due to the mass effect of the tumor. most patients with hepatic adenoma have normal range of serum alpha-fetoprotein (afp). an elevation in afp levels is correlated with primary carcinoma or malignant transformation of adenoma. radiologic findings are nondiagnostic because the mass commonly found in solitary and well demarcated lesion. advances in contrast-enhanced mri and contrast-enhanced ultrasonography may be helpful to distinguish hepatic adenoma and possibly determined bordeaux classification subtypes.6 immunohistochemistry may be performed to further characterize lesion under the new bordeaux classification while results of histologic evaluation with liver biopsy are nondiagnostic and insensitive.5 the prognostic for hepatic adenoma is not well established. while complete resolution is uncommon, the risk of malignant transformation still remains even after oral contraceptive or steroid use has been discontinued. all symptomatic tumors should be resected. asymptomatic adenomas smaller than 5 cm in size may be managed with close monitoring.7 case illustration a 30-year-old female was referred with abdominal pain in the right upper quadrant over the preceding one year. the pain was described as localized, episodic, and non-triggered by food or activity. she had not complained of nausea, vomit, dark-colored stool urine, black stool, abdominal enlargement, bloating or weight loss. she could still carry on daily activity without restriction. she had no history of jaundice, blood transfusions, hepatitis, excessive alcohol consumption, or long-term oral contraception. clinical examination revealed no abnormalities, no abdominal palpable mass found. laboratory tests were within normal limits. tests for hepatitis b surface antigen and hepatitis c antibodies were all non-reactive. serum tumor markers (afp, cea, ca 19-9, ca 125) were all within normal range. multiphase abdominal multi slice computed tomography (msct) showed a focal mass in right lobe liver, segment 5, with size of 6.3 cm x 5.2 cm x 5 cm. the mass was shown as iso-hypodense lesion with slight enhancement in arterial phase, followed by heterogeneous enhancement in portovenous phase and contrast washed out in delayed phase (figure 1). the ct findings suggested hepatocellular carcinoma with differential diagnosis of adenoma, adenocarcinoma. liver core biopsy was then performed to ensure the diagnosis. core biopsy findings suggested liver adenoma with differential diagnosis hepatocellular carcinoma grade 1. immunohystochemical staining was performed following core biopsy, with findings of positive granular cytoplasm with expression of glypican 3, complete expression of cd 34, positive expression of cd10, and less than 5% of expression of ki67 (figure 2). the findings suggested hepatocellular carcinoma grade 1. 64 vol 51 • number 1 • january 2019 immunohistochemical staining on excision biopsy specimen as diagnostic the patient underwent open laparotomy. medial laparotomy incision from xiphoid process to two fingers below umbilicus, passing through cutis, sub cutis, and linea alba. intraoperative ultrasonography (usg) was performed and showed solid lesion of 3 x 3 x 3 cm in hepatic segment v. tumor resection margins were determined with the use of usg guidance. liver mobilization began by releasing the liver from the falciform ligament, coronary ligament, and triangular ligament. hepatoduodenal ligament was identified and released from surrounding tissues at right hepatic artery, right portal vein and common bile duct using pringle maneuver. to treat the lesion, hepatectomy of segment v was performed. the specimen was brown-black colored, spongy, measuring 10 x 7 x 4.5 cm. the mass itself measured 7 x 6 x 3 cm, yellow-brown colored, firm and tender. a 2.5 x 2 x 1.5 cm hollow with inner irregular surface was shown in division of the mass (figure 3). microscopic examination showed tumor tissues with partly poor-circumscribed edges. neovascularization was also seen. tumor cells showed hepatocytes differentiation consists of trabecular tissue of 2-4 cells/field in depth, common uniform nucleated tumor cells, some with vivid nucleolus, and mitosis was hardly found (figure 4). microscopic examination showed the lesion was hepatocellular adenoma. the specimen was consulted and sent to groningen, netherlands and new york, usa, of which both confirmed the diagnosis was hepatocellular adenoma. mutation examination revealed it was inactivated hepatocellular adenoma through evaluation of hnf-1α. figure 1. multiphase abdominal msct of the patient (clockwise from top left): non-contrast, arterial phase, venous phase, delayed phase. figure 2. histopathology finding and immunohistochemical staining on core biopsy specimen (clockwise from top left): stained with hematoxylin & eosin (h&e), cd34, glypican-3, and ki67. figure 3. macroscopic specimen of liver mass. figure 4. h&e staining on excision biopsy specimen showing hepatocellular adenoma characterized by sinusoidal dilatation and cluster of small arteries surrounded by inflammation. no signs of liver failure were shown after surgery. the patient was discharged one week 65 juferdy kurniawan acta med indones-indones j intern med after surgery. the patient was advised for followup ultrasound examination six months after the operation. discussion the differential diagnosis of benign liver cell tumors requires understanding of the clinical, radiological, and pathological features of the liver lesions. a detailed history, physical examinations, hepatic tests, imaging, and histopathological studies are necessary for precise diagnosis. there are several points of approach for the lesion which may be beneficial as the clues of establishing hca diagnosis, differentiating it with focal nodular hyperplasia (fnh) or hepatocellular carcinoma (hcc). patients with liver adenomatosis range in age from 12 to 75 years, with a mean age of 34 years.8 eighty-eight percent of them are women, as well as those with fnh (80-90%), meanwhile hcc predominates in men.9 patients diagnosed with hca are typically young women with longstanding oral contraceptive use or with history of glycogen storage diseases.9 in the present case, the diagnosis is difficult to be determined and distinguished from other possible diagnosis due to absence of classic risk factors from neither hca nor hcc (viral, alcoholic, metabolic syndrome) and fnh (local or systemic vascular anomalies). hca typically occurs in noncirrhotic livers.8 however, a recent case of hca was observed in a hepatitis b virus or alcoholicassociated cirrhotic liver.10 the majority of the tumors are in the size range of 5 to 15 cm at the time diagnosis, but they can be < 0,5 or > 30 cm. clinical presentation is usually related to the size of the tumors, with size of ≥ 5 cm tend to be more likely simptomatic, presented with acute abdominal pain (43%) and hemorrhagic complications (46%).8 several diagnostic modalities have been performed. unlike in hcc, both hca and fnh were usually presented with normal function liver test results and no or minimal elevation in serum tumor markers, such as α-fetoprotein.10 although the laboratory test results in our case appeared within normal range, hepatocellular carcinoma was suggested from radiologic findings. radiological findings for hca are similar with those in hcc or fnh. adenomas are sharply marginated (85%), nonlobulated (95%), sometimes encapsulated (30%), and rarely calcified (10%), demonstrated with homogenous or nearly homogenous enhancement in 80% of cases.11 while most of adenomas were presented in a single mass that may contain area of fat or hemorrhage, we have found none in our case. also, the accurate differentation of the hca lesion often can be better interpreted with magnetic resonance imaging (mri) or contrast enhanced ultrasonography (ceus).8,9 s e v e r a l p r i m a r y h e p a t i c t u m o r s , including hcc, fnh and hca, are classified as hypervascular tumors, on the basis of helical multiphasic ct observations and pathophysiology, and therefore a confident preoperative diagnosis of hca are difficult based on the radiologic observations.12,13 fnh usually comes with diagnostic pointer of central scar with centrifugal or eccentric enhancement,8 whereas well-differentiated hcc is usually large, heterogenous, and lobulated, with large, central, or eccentric scars and radiating fibrous septa, calcifications (40-68%), as well as abdominal lymphadenopathy (65%).11 distinction between hca and hcc are obviously of paramount clinical importance in determining appropriate therapy and assessing prognosis, unless often can usually be achieved only on histologic grounds. we found that the histopathology examination of core biopsy from our patient indicated benign lesion. the later immunohistochemical staining with glypican 3, cd34, cd10 and ki67 of core biopsy specimen indicated hcc lesion. however, distinguishing hca from well-differentiated hcc can be extremely challenging when the diagnostic material is a small needle biopsy.8 nonetheless, the efficacy of percutaneous liver biopsy is limited with preoperative accuracy about 50%.13,14 conservative treatment was the initial treatment for hca < 5 cm in diameter. a tumor size ≥ 5 cm and abdominal complaints, as found in our case, were major criteria for surgical resection. among all hcas, 9% may transform into hcc with risk factors including male sex, 66 vol 51 • number 1 • january 2019 immunohistochemical staining on excision biopsy specimen as diagnostic androgen use, size ≥ 5 cm, and ß-catenin-mutated hca. in these complicated cases, early surgical removal may improve patient outcomes.15 as an alternative, several reports also demonstrated the efficacy of radiofrequency ablation (rfa), especially in cases not amenable to surgery or in patients who would require major hepatic resection otherwise.16 our patient was then decided to undergone surgery with hepatectomy for diagnostic and therapeutic purpose. immunohistochemical examination of glutamine synthetase, beta-catenin, serum amyloid a and c-reactive protein, and liver fatty-acid binding protein on surgical specimen determined the lesion as of non-inflammatory hca or specifically hnf-1α hca. among all hcas, the hnf-1α hca is the least aggressive subtype with almost no risk for the development of malignancy. conclusion as illustrated in this case, similar findings of hca and well-differentiated hcc as well as fnh in radiologic findings can be a challenge in distinguishing the diagnosis. because management of these tumors is different, confident preoperative diagnosis is essential. although documented in low statistic number, hca could occur in individual without classic risk factor. atypical features such as heterogeneous enhancement should be evaluated with additional imaging, such as mri; or biopsy; even surgical resection. in such cases, all possible diagnosis must be excluded. resection and histopathology examination remains the best modality in diagnosing hca, as well as therapeutic option to exclude malignant neoplasm. acknowledgments we thank professor annette s.h.gouw, md, phd from university medical centre, groningen, netherlands and professor swan n thung, md, faasld from mount sinai hospital, new york for the consultation on histopathology and immunohistochemical staining on surgical resection. references 1. c h a n g c y, h e r n a n d e z p r e r a j c , r o a y a i e s , schwartz m, thung sn. changing epidemiology of hepatocellular adenoma in the united states: review of the literature. int j hepatol 2013. article id 604860. doi:10.1155/2013/604860. 2. rooks jb, ory hw, ishak kg, et al. epidemiology of hepatocellular adenoma: the role of oral contraceptive use. jama.1979;242(7):644-8. 3. soe kl, soe m, gluud c. liver pathology associated with the use of anabolic-androgenic steroids. liver 1992;12:73. 4. curry mp, afdhal nh. hepatic adenoma. in: chopra, sanjiv, eds. up to date. retrieved may 12, 2015, from http://www.uptodate.com/home. 5. bioulac-sage p, balabaud c, zucman-rossi j. subtype classification of hepatocellular adenoma. dig surg. 2010;27(1):39-45. 6. van aalten sm, thomeer mg, terkivatan t, et al. hepatocellular adenomas: correlation of mr imaging findings with pathologic subtype classification. radiology. 2011;261(1):172-81. 7. geller s, petrovic l. benign tumors and tumor-like conditions. biopsy interpretation of the liver. 3rd ed. philadelphia: williams and wilkins, 2003. p. 281-304. 8. kahn me, french s, wang hl. hepatocellular adenoma: morphological and molecular variants and distinction from well-differentiated hepatocellular carcinoma. pathol case rev. 2009;14:13-20. 9. palladino e, sommacale d, siboni r, et al. focal nodular hyperplasia and hepatocellular adenomas: what is new in 2013? int j hepatobiliary pancreat dis. 2014;4:15-25. 10. dhingra s. update on the new classification of hepatic adenomas: clinical, molecular, and pathologic characteristics. arch pathol lab med. 2014;138:1090-7. 11. grazioli l, federle mp, brancatelli g, ichikawa t, olivetti l, blachar a. hepatic adenomas: imaging and pathologic findings. radiographics. 2001;21:877-94. 12. ichikawa t, federie mp, grazioli l, nalesnik m. hepatocellular adenoma: multiphasic ct and histopathologic findings in 25 patients. radiology. 2000;214(3):861-8. 13. charny ck, jarnagin wr, schwartz lh, et al. management of 155 patients with benign liver tumors. br j surg. 2001;88:808-13. 14. van der windt dj, kok nf, hussain sm, et al. caseoriented approach to the management of hepatocellular adenoma. br j surg. 2006;93:1495-502. 15. margolskee e, bao f, gonzalez ak, et al. hepatocellular adenoma classification: a comparative evaluation of immuno-histochemistry and targeted mutational analysis. diag pathol. 2016;11:27. 16. aalten sm, vledder mg, terkivatan t, man ra, leertouwer t, ijzermans jn. safety and efficacy of radiofrequency ablation for hepatocellular carcinoma. j vasc intervent radiol. 2011;22(6):787-93. 67 165acta med indones indones j intern med • vol 55 • number 2 • april 2023 original article abstract background: the arrhythmia-specific questionnaire in tachycardia and arrhythmia (asta) was developed in sweden using english which may pose cultural and language barriers for indonesian patients. as such, we aimed to translate the original asta into indonesian, then assess its validity and reliability. methods: translation of the asta from english to indonesian was done using forward and backward translation. the final version was then validated with the short form-36 (sf-36) questionnaire. test-retest reliability study was done in a 7-14day interval. results: the indonesian version of asta was deemed acceptable by a panel of researchers with cronbach’s α of 0.816 and intraclass correlation coefficient (icc) ranging from 0.856-0.983. in a comparison to the sf-36, the medication utilization domain was poorly correlated with role limitations due to physical health (r:0.384; p<0.01) and pain (r:-0.317; p<0.05). the arrhythmia-specific symptoms domain was poorly correlated with role limitations due to emotional problems (r:0.271; p<0.05). in addition, the health-related quality of life (hrqol) domain was poorly correlated with role limitations due to physical health (r:0.359; p<0.01) and emotional problems (r:0.348; p<0.01), also total sf-36 score (r:-0.367; p<0.01). the asta total score was poorly correlated with role limitations due to physical health (r:0.37; p<0.01), and emotional problems (r:0.376; p<0.01), also total sf-36 score (r:-0.331; p<0.01). conclusion: the indonesian version of asta has good internal and external validity as well as good reliability. both the physical and mental domains of asta are correlated with role limitations due to emotional problems and sf-36 total score. keywords: atrial fibrillation, reliability, validity, quality of life. validity and reliability studies of the indonesian version of arrhythmia-specific questionnaire in tachycardia and arrhythmia (asta) muhammad yamin1*, simon salim1, siti setiati2, angga pramudita pudianto1, putri zulmiyusrini3, alexander edo tondas4, dono antono1, eka ginanjar1, arif mansjoer1, m. syahrir azizi1, annisa puspitasari nachrowi1, rubiana sukardi5, idrus alwi1 1division of cardiology, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 2division of geriatric, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 3department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 4department of cardiology and vascular medicine, mohammad hoesin general hospital, palembang, indonesia. 5integrated cardiac centre – cipto mangunkusumo hospital, jakarta, indonesia corresponding author: muhammad yamin, md. division of cardiology, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: muhyam511@ gmail.com. muhammad yamin acta med indones-indones j intern med 166 introduction the most common form of tachyarrhythmia is atrial fibrillation (af), which is found in 2-4% of the world’s population. the prevalence increases with age.1 morillo et al. reported that af is the most common type of arrhythmia found in clinical practice, as well as a significant global burden, closely followed by comorbidities which increase disability and mortality rates. as a chronic condition, af leads to healthcare and medication utilization which increases the economic burden on individuals, as well as nations. the burden of af is also related to complications, such as stroke, in which onethird of cases have af.2 taheri et al. reported a gradual decrease in af patients qol due to psychosocial distress and hemodynamic instability, which induces dyspnea, palpitations, and fatigue. increased risk of heart failure, myocardial infarction, venous thromboembolism, and stroke, as well as increased hospitalization length of stay also play a role in qol reduction.3,4 jones et al. reported that patients with af experienced major lifestyle changes after diagnosis, including role limitations and need for health services, which may decrease qol in the family or caregivers.4 vintila et al. reported that qol is lower in permanent af compared to persistent and paroxysmal af.5 qol evaluations can be used to determine management strategy and treatment success in clinical practice.6 in addition to objective parameters such as ecg and echocardiography, patient-reported outcomes (pros) should be considered in order to assess patient welfare. however, the majority of pros questionnaires for the arrhythmia population were designed exclusively for af.7 the arrhythmia-specific questionnaire in tachycardia and arrhythmia (asta) was the first questionnaire developed to evaluate arrhythmia-specific symptoms and qol in patients with different types of arrhythmia, including af.1 asta was first introduced in sweden in the english language, which may pose language and cultural barriers to indonesians.7 as such, we aimed to translate asta into indonesian and analyze the reliability and validity of this indonesian version of asta. methods we conducted this cross-sectional study in march april 2022. the inclusion criteria of this study were patients diagnosed with af according to their medical records, aged >18 years, and fluent in the indonesian language. patients with a history of cardiac surgery or hospitalization due to acute or severe chronic conditions within the previous 30 days, physical handicap, or mental or psychiatric disorders were excluded. the european heart rhythm association ( e h r a ) s c o r e a n d d u r a t i o n o f a f w a s recorded during history taking. other general characteristics (gender, age, highest education level attained, and marital status) and clinical characteristics (ejection fraction/ef in the previous 3 months, as well as af etiology and type) were taken from medical records. the asta and short form-36 (sf-36) questionnaires were filled independently in two stages, as the test and retest, respectively. the retest was taken 7-14 days after the test. this study was approved by the health research ethics committee, faculty of medicine universitas indonesia, cipto mangunkusomo hospital, with approval number ket-/054/un2. f1/etik/ppm.00.02/2021. translation we conducted this study in two phases. the first phase was translation and cultural adaptation of asta from the original english to indonesian. the translation process was conducted after obtaining permission from walfridsson et al., the original authors of asta. the second phase was assessment of the reliability and validity of the indonesian version of asta. the translation and cultural adaptation of asta was done in several steps. first, forward translation from english to indonesian was conducted by 2 translators: one medical and one non-medical translator. both translators were certified and experienced in translation and interpretation. after the translation process, they discussed and combined their translations into the indonesian synthesis translation. this version then underwent backward translation (indonesian to english) performed by two native english speakers vol 55 • number 2 • april 2023 validity and reliability studies of the indonesian version of arrhythmia 167 who both had nearly ten years of experience in interpreting and translating between english and indonesian. both backward translations were compared to the original version of asta. any differences were reviewed by the research team before the prefinal questionnaire was distributed to participants. this questionnaire was first pretested by 30 participants, then edited based on patient feedback, forming the final questionnaire. the final questionnaire was then used for the second phase. questionnaire the asta consists of 3 parts: the medication utilization domain consisting of 2 questions, the arrhythmia-specific symptoms consisting of 8 questions, and hrqol consisting of 13 questions. the first part evaluates the most recent episode of symptoms and medication utilization. the second part evaluates symptom burden, including the average duration, longest duration, frequency, symptoms, precipitating factors, and severity scale of arrhythmia. the scale has a 4-point range from 0 (not relevant) to 3 (yes, a lot). a lower score indicates milder symptoms of arrhythmia. the third part of asta (hrqol) consists of 7 questions referring to the physical domain and 6 questions referring to the mental domain. each hrqol question also has a 4-point scale, from 0 (not relevant) to 3 (yes, a lot). a lower score indicates better qol related to tachyarrhythmia.8 data analysis we analyzed the data using spss statistics 26.0 software and are presented in tables. general and clinical characteristics are presented as frequency and percentage. we performed normality test using kolmogorov-smirnov test (n>50). normally distributed data (p>0.05) were analyzed by pearson’s test, while non-normally distributed data (p<0.05) were analyzed by spearman’s test. the asta score was first converted to a 0-100 scale and reversed as needed to balance the scores between questions. we assessed the reliability using test-retest reliability analysis, resulting in cronbach’s α and intraclass correlation coefficient (icc) between the first test and the retest. cronbach’s α values were interpreted as low (<0.6), acceptable (0.60.8), or very good internal consistency (>0.8).9 icc values were considered to have poor (<0.5), moderate (0.5-<0.75), good (0.75-<0.9), or excellent (>0.9) reliability.10 the validity test was conducted using bivariate correlation analysis of the inter-item correlation and total score. analyses of each domain in asta and sf36, as well as clinical parameters were done to evaluate the concordance between the two questionnaires. the degrees of correlation were defined as very low (r:0.00-0.199), low (r:0.200.399), moderate (r:0.400.599), high (r:0.600.799), and very high (r:0.80-1.00). results general and clinical characteristics in the second phase, 60 participants were recruited. most participants were elderly (31.67%), male (53.33%), and had ef >50% (76.67%), as shown in table 1. the prevalence of af increased with age. the almost half of participants (40%) were not troubled by af symptoms. more than half (53.33%) of our subjects were diagnosed with valvular disease based on echocardiography. table 1. general and clinical characteristics. characteristics (n=60) % gender male 32 53.33 female 28 46.67 age group in years <40 5 8.33 41-50 8 13.33 51-60 17 28.33 61-70 19 31.67 >70 11 18.33 education primary or less 6 10.00 junior high 6 10.00 senior high 22 36.67 university 26 43.33 marital status single 6 10.00 married 50 83.33 widow/widower 4 6.67 ehra i 4 6.67 iia 24 40.00 iib 18 30.00 iii 12 20.00 iv 2 3.33 muhammad yamin acta med indones-indones j intern med 168 ejection fraction (%) <40 5 8.33 40-49 9 15.00 >50 46 76.67 duration of diagnosis <1 year 2 3.33 1-5 years 50 83.33 >5 years 8 13.33 af etiology valvular 32 53.33 non-valvular 28 46.67 af type paroxysmal 11 18.33 persistent 9 15.00 longstanding persistent 2 3.33 permanent 36 60.00 reliability and validity of the indonesian version of asta indonesian version of asta had a very good internal consistency as suggested by cronbach’s α of 0.816 (table 2). the icc values for each domain were more than 0.33 (r: 0.856-0.983; p<0.01). the medication utilization domain, arrhythmia-specific symptoms domain, and hrqol domain were all reliable, based on cronbach’s α values (0.629-0.789; p<0.01). based on total score correlation, our version of asta was considered to be valid (p<0.01). the medication utilization domain had a low correlation with total asta score (r: 0.378; p<0.01). the arrhythmia-specific symptoms domain was moderately correlated with total hrqol domain (r: 0.491; p<0.01) and highly correlated with total asta score (r: 0.721; p<0.01). the hrqol domain was very highly correlated with total asta score (r: 0.934; p<0.01). correlation between the indonesian version of asta and sf-36 the analysis of our version of asta and sf-36 as the gold standard is shown in table 3. the medication utilization domain was poorly correlated with role limitations due to physical table 2. reliability and validity of indonesia version of asta. correlations variables medication utilization arrythmia-specific symptoms domain hrqol domain total score icc d1 and d8-14 cronbach’s α total medication utilization domain 1 0.039 0.232 0.378** 0.949** 0.789** si_1 0.982** 0.022 0.245 0.378** 0.942** si_2 0.558** 0.092 0.124 0.342** 0.953** total arrythmiaspecific symptoms 0.039 1 0.491** 0.721** 0.944** 0.629** domain sii_1 -0.11 0.146 -0.441* -0.389** 0.901** sii_2 -0.044 0.093 -0.388** -0.349** 0.915** sii_3 -0.662** 0.047 -0.431** -0.420** 0.929** sii_5 -0.043 0.412** 0.128 0.332** 0.951** sii_6a 0.116 0.383** 0.422** 0.462** 0.955** sii_6b -0.025 0.485** 0.631** 0.619** 0.871** sii_6c 0.241 0.699** 0.381** 0.573** 0.977** sii_6d 0.225 0.466** 0.556** 0.609** 0.966** sii_6e 0.378** 0.514** 0.604** 0.691** 0.872** sii_6f 0.418** 0.451** 0.529** 0.623** 0.868** sii_6g 0.046 0.607** 0.466** 0.561** 0.962** sii_6h 0.085 0.609** 0.418** 0.535** 0.910** sii_6i 0.216 0.501** 0.542** 0.610** 0.970** sii_7 0.095 -0.09 -0.482** -0.384** 0.956** sii_8 0.01 0.451** -0.016 0.346** 0.913** total hrqol 0.232 0.491** 1 0.934** 0.973** 0.766** * significant correlation in α = 0.05 (2-tailed) ** significant correlation in α = 0.01 (2-tailed) vol 55 • number 2 • april 2023 validity and reliability studies of the indonesian version of arrhythmia 169 health (r: 0.384; p<0.01) and pain (r: -0.317; p<0.05). arrhythmia-specific symptoms domain was poorly correlated with role limitations due to emotional problems (r: 0.271; p<0.05). hrqol domain was poorly correlated with role limitations due to physical health (r: 0.359; p<0.01), role limitations due to emotional problems (r: 0.348; p<0.01), and total sf-36 score (r: -0.367; p<0.01). the total score of the indonesian version of asta was poorly correlated with role limitations due to physical health (r: 0.37; p<0.01), role limitations due to emotional problems (r: 0.376; p<0.01), and total sf36 score (r: -0.331; p<0.01). the lower total score of the hrqol domain and total asta (better qol) was correlated with higher sf-36 score. the physical hrqol domain was poorly correlated with role limitations due to emotional problems (r: 0.342; p<0.01) and moderately correlated with total sf-36 score (r: -0.456; p<0.01). while mental hrqol domain was moderately correlated with role limitations due to emotional problems (r: 0.492; p<0.01) and total score (r: -0.512; p<0.01) as shown in table 4. this poor correlation indicates that these domains are useful for assessing different aspects of a patient’s life, such as the physical or emotional, with little overlap, as they were devised to do. table 3. analysis of the indonesian version of asta and sf-36. domain variables medication utilization domain arrythmiaspecific symptoms domain hrqol domain total score physical functioning 0.056 0.114 0.146 0.156 role limitations due to physical health 0.384** 0.113 0.359** 0.370** role limitattions due to emotional problems 0.225 0.271* 0.348** 0.376** energy/fatigue 0.065 -0.081 0.040 0.012 emotional wellbeing 0.183 -0.031 0.024 0.042 social functioning 0.108 0.112 -0.003 0.060 pain -0.317* -0.199 -0.167 -0.254 general health 0.097 -0.098 -0.020 -0.031 total score -0.188 -0.043 -0.367** -0.331** all data were analyzed using pearson’s test * significant correlation in α = 0.05 (2-tailed) ** significant correlation in α = 0.01 (2-tailed) table 4. analysis of the hrqol domain of the indonesian version of asta and sf-36. domain variables hrqol domain(physical) hrqol domain (mental) physical functioning 0.229 0.006 role limitations due to physical health 0.202 0.080 role limitations due to emotional problems 0.342** 0.492** energy/fatigue 0.031 0.044 emotional well-being 0.023 0.021 social functioning 0.076 -0.097 pain -0.129 -0.184 general health 0.000 -0.041 total score -0.456** -0.512** all data were analyzed using pearson’s test * significant correlation in α = 0.05 (2-tailed) ** significant correlation in α = 0.01 (2-tailed) muhammad yamin acta med indones-indones j intern med 170 correlation between the indonesian version of asta, ejection fraction and ehra there were no correlations between medication utilization domain, arrhythmia specific symptoms domain, hrqol domain, or asta total score and other clinical parameters such as ef and ehra in our study. discussion af symptoms are the main reason for hospital admission, although rienstra et al. reported that 15-30% of af is asymptomatic. af may present as palpitations, chest discomfort, and reduced exercise capacity. approximately two-thirds of af patients who visit the emergency department end up hospitalized.11 the cronbach’s α of our indonesian version of asta was slightly lower (0.816) than the brazilian version (0.88) or the swedish version (0.91). the cronbach’s α in the physical domain was lower in our study than in the swedish version (0.87 vs. 0.89, respectively), while the cronbach’s α in the mental domain was higher in our study (0.86 vs 0.79, respectively). the difference may have been due to our smaller sample size (60 participants) compared to the brazilian (172 participants) and swedish (185 participants) versions.1,8 our icc ranged from 0.856 to 0.983, which was considered to be good or excellent reliability. between the test and retest of 7-14 days, there were no major changes in af patient symptoms. this finding was supported by lindberg et al., who stated that af is a chronic lifelong condition which requires regular medical control. prevention of complications, such as stroke, and routine medical treatment demand regular clinic visits, diet and alcohol restriction, and regular evaluation of bleeding or drug interactions.12 in our study, higher sf-36 score (better qol) was poorly correlated with lower asta total score (r: -0.331; p<0.01) and moderately correlated with the physical hrqol domain (r: -0.456; p<0.01). higher hrqol domain score was also significantly correlated with inability to perform daily activities due to both physical health (r:0.359; p<0.01) and emotional problems (r: 0.348; p<0.01). barbaglia et al. stated that disability has become an important component of disease burden, with cardiovascular disease contributing to one of nine disability-causing health conditions.13 these limitations might be caused by af symptoms such as lack of energy (92%), dyspnea (76%), and palpitations (70%) due to lack of atrial contraction and irregular diastole leading to decreased stroke volume, cardiac output, and blood pressure.14,15 concomitant diseases such as coronary artery disease (35.6%), heart failure (12.7%), and thyroid disease (7.6%) may contribute to both physical and emotional limitations.14 rienstra et al. reported that more than half of af patients present with reduced exercise capacity, with shortness of breath as the main complaint. rapid ventricular rate and atrioventricular dyssynchrony impair diastolic filling, which may result in cardiac output reduction. diastolic dysfunction also increases left ventricular pressure, which may predispose patients to development of subclinical pulmonary edema. rapid atrial rate and changes in cardiac pressure give rise to structural changes, which lead to worsening af symptoms and reduced physical capacity.11 however, there was no correlation between any asta domains and ef in our study, which might have been due to the small sample size. psychological complications of af may be exacerbated by lack of social understanding, feeling isolated, and inadequate social support, which result in frustration and a feeling of helplessness.16 in our study, the arrhythmiaspecific symptoms domain (r:0.271; p<0.05) and hrqol domain (r:0.348; p<0.01) were poorly correlated with role limitations due to emotional problems. kupper et al. reported an elevation of anxiety (35%) and depression (20%) prevalence in af patients in relation to chronic use of medication, drug side effects, fear of worsening symptoms, symptom emergence during activity, and planned intervention to control symptoms.14 gayman et al. reported that pain, physical limitations, chronic stress, and daily social discriminations were all correlated with daily activity limitation.17 ironically, lampert et al. also reported that anger and stress increased the risk of af due to sympathetic nerve system activation.18 vol 55 • number 2 • april 2023 validity and reliability studies of the indonesian version of arrhythmia 171 ef and ehra score were not significantly correlated with any asta domain. these parameters were correlated with physical functioning and exercise tolerance. both physical and mental domains affect total asta score in our study. however, mental domain has a stronger affects the total score.19 the limitation of this study was the small sample size, which may have affected the degree of statistical significance. conclusion the indonesian version of asta has good internal and external validity as well as good reliability to evaluate the qol of individuals with af. the indonesian version of asta can be used to assess qol changes over time, as severity and treatment evaluations. both the physical and mental domains of asta are correlated with role limitations due to emotional problems and sf-36 total score. references 1. cannavan pms, cannavan fps, walfridsson u, lopes mhbm. translation and validation of the arrhythmiaspecific questionnaire in tachycardia and arrhythmia (asta) to the brazilian context: an instrument focusing on arrhythmia symptoms. cardiol res pract. 2020;2020:1–7. 2. morillo ca, banerjee a, perel p, wood d, jouven x. atrial fibrillation: the current epidemic. j geriatr cardiol. 2017;14(3):195–203. 3. taheri l, poorgholami f, zare a, jahromi mk. quality of life in patients with atrial fibrillation: an intervention. nurs crit care. 2020;15(6):7–11. 4. jones j, stanbury m, haynes s, et al. importance and assessment of quality of life in symptomatic permanent atrial fibrillation: patient focus groups from the rateaf trial. cardiol. 2020;145(10):666–75. 5. vintila a, stanciu a, horumba m, vintila v, lupusoru m, gurghean a. impact of atrial fibrillation on quality of life. j hypertens. 2019;37(june):2019. 6. kotecha d, ahmed a, calvert m, lencioni m, terwee cb, lane da. patientreported outcomes for quality of life assessment in atrial fibrillation: a systematic review of measurement properties. plos one. 2016;11(11):1–13. 7. walfridsson u, arestedt k, stromberg a. development and validation of a new arrhythmia-specific questionnaire in tachycardia and arrhythmia (asta) with focus on symptom burden. health qual life outcomes. 2012;10:1–10. 8. walfridsson u, stromberg a, arestedt k. development and validation of an arrhythmia-specific scale in tachycardia and arrhythmia with focus on healthrelated quality of life. j cardiovasc nurs. 2015;30(2):98–108. 9. daud kam, khidzir nz, ismail ar, abdullah fa. validity and reliability of instrument to measure social media skills among small and medium entrepreneurs at pengkalan datu river. int j dev sustain. 2018;7(3):1026–37. 10. han x. on statistical measures for data quality evaluation. j geogr inf syst. 2020;12(03):178–87. 11. rienstra m, lubitz sa, mahida s, et al. symptoms and functional status of patients with atrial fibrillation: state of the art and future research opportunities. circulation. 2012;125(23):2933–43. 12. lindberg t, sanmartin berglund j, elmståhl s, bohman dm. older individuals’ need for knowledge and follow-up about their chronic atrial fibrillation, lifelong medical treatment and medical controls. scand j caring sci. 2017;31(4):1022–30. 13. barbaglia g, adroher nd, vilagut g, et al. health conditions and role limitation in three european regions: a public-health perspective. gac sanit. sespas; 2017;31(1):2–10. 14. kupper n, van den broek kc, widdershoven j, denollet j. subjectively reported symptoms in patients with persistent atrial fibrillation and emotional distress. front psychol. 2013;4(april):1–9. 15. carlisle ma, fudim m, devore ad, piccini jp. heart failure and atrial fibrillation, like fire and fury. jacc hear fail. 2019;7(6):447–56. 16. hilow h, whibley d, l.kratz a, ghanbar h. a focus group study to inform design of a symptom management intervention for adults with atrial fibrillation author links open overlay panel. cardiovasc digit heal j. 2021;2(5):246–55. 17. gayman md, turner rj, cui m. physical limitations and depressive symptoms: exploring the nature of the association. journals gerontol ser b psychol sci soc sci. 2008;63(4):219–28. 18. lampert r, burg mm, jamner ld, dziura j, brandt c, li f. effect of beta-blockers on triggering of symptomatic atrial fibrillation by anger or stress. heart rhythm. 2019;16(8):1167–73. 19. bekfani t, nisser j, derlien s, et al. psychosocial factors, mental health, and coordination capacity in patients with heart failure with preserved ejection fraction compared with heart failure with reduced ejection fraction. esc hear fail. 2021;8(4):3268–78. 62 acta med indones indones j intern med • vol 54 • number 1 • january 2022 original article identification of the immune subtype among muscleinvasive bladder cancer patients by multiple datasets khyber shinwari1, 6, zihao chen2, guojun liu3*, lu chen4, mikhail a. bolkov5, irina a. tuzankina5, valery a. chereshnev5 1 department of immunochemistry, institute of chemical engineering, ural federal university, ekaterinburg 620000, russia. 2 school of chinese medicine, the chinese university of hong kong, hong kong, china. 3 school of life science and technology, inner mongolia university of science and technology, baotou 014010, china. 4 the first affiliated hospital, baotou medical college, baotou, china. 5 institute of immunology and physiology of the ural branch of the russian academy of sciences, yekaterinburg, russia. 6 faculty of education, department biology, nangrahar university, nangrahar, afghanistan. *corresponding author: guojun liu, md., phd. school of life science and technology, inner mongolia university of science and technology, baotou 014010, china. email: gjliu0325@gmail.com. abstract background: immunotherapies including pd-1/pd-l1 antibodies have been approved for the treatment of muscle-invasive bladder cancer (mibc) patients. however, immunotherapies could only be beneficial for about 20% mibc patients. thus, identification of the immune subtype is becoming increasingly important. this study aimed to explore the immune subtype by analyzing the gene expression profiles. methods: a total of 6 datasets including (gse13507, gse31684, gse32548, gse32894, gse69795, and tcga-blca) were downloaded. the gene expression profiles from different datasets were combined since the batch effects were removed. we performed unsupervised clustering analysis to identify the immune subtype by the combined gene expression profiles. the tumor-infiltration levels of 22 immune cells, immune scores, and tumor purity were calculated, and the survival analysis was performed to investigate the prognosis difference between immune subtypes. the enriched pathways for each immune subtype were obtained. results: we identified four novel immune subtypes (referred to s1, s2, s3, and s4) among mibc patients. we found that s1 was enriched in immune scores had the best prognosis. in contrast, s3 was poor in immune scores and had the worst prognosis. subtype s1, s2, s3, and s4 were enriched in immune-related pathways, extracellular matrix-related pathways, metabolismrelated pathways, and cancer-related pathways, respectively. conclusion: the current study suggests that the immune subtypes based on gene expression profiles could contribute to select the appropriate mibc patient for immunotherapies. keywords: molecular subtype, immunotherapy, mibc, immunotype, tmb, bioinformatics. vol 54 • number 1 • january 2022 identification of the immune subtype 63 introduction bladder cancer (bc) is the most common genitourinary cancer of the urinary tract.1,2. a quarter of blca patients have muscleinvasive bladder cancer (mibc), which has a higher risk of metastasis, or cancer cells migrating to regional pelvic lymph nodes and/or visceral regions, making the disease incurable.3 muscle-invasive bladder cancer (nmibc) and non-muscle-invasive bladder cancer (nibc) are the two kinds of bc (mibc). around a quarter of bc patients will develop mibc, and more than half of mibc patients will experience relapse and metastasis.4 radial cystectomy (rc) plus neoadjuvant cisplatin-based chemotherapy (nac) is the standard first-line multimodal treatment for mibc patients, however roughly 60% of mibc patients do not exhibit a significant therapeutic response.5 furthermore, because of its toxicity, many people are unable or unwilling to accept cisplatin treatment.6 the five-year survival rate for mibc patients is as low as 50%.7 there is also an urgent need for new treatment drugs. immunotherapies, particularly immune checkpoint blockade (pd-1/pd-l1), have recently been licensed, improving the prognosis of mibc patients significantly.8 the practical use of immunotherapy, however, may be limited because only 20% of mibc patients respond to treatment.9 tumor-infiltrating t cells.10 pd-l1/ pd-1 levels,11 highly microsatellite instability (msi-h),12 tumor mutational burden (tmb),13 and intestinal microbiota.14 have all been found to be good indicators of immunotherapy efficacy. these potential markers were frequently unstable because numerous genes and pathways were involved in tumor immune evasion.15 in the checkmate025 research, for example, responses to nivolumab (pd-1 antibody) exhibited no correlation with pd-l1 level, and patients with a high level of pd-l1 had a worse prognosis.15 as a result, immunological subtypes established by clustering samples based on big genes from many datasets could be a good predictor of immunotherapy success. according to multiple research,16 patients with high tumor pd-l1 levels had better treatment response rates and lived longer. til density, especially cd8+ t cells, is a strong positive prognostic indicator, and immunotherapy works in part by reactivating a preexisting tumor immune response.17 tmb stands for the amount of somatic mutations per million bases,18 and tumor cells with a high tmb are more likely to generate neoantigens, which can be identified by t cells and trigger an antitumor response.19 in 22 different tumor types, attempts to identify pd-1 antibody responders by combining tmb and tumor-infiltrating t cells have recently been published.20 apart from these biomarkers, other studies have advocated molecular subtype as a distinct technique for identifying immunotherapy candidates.21–23 based on rna expression profiling, individuals with mibc can be categorized into luminal and basal subtypes, with the basal subtype being more connected with the epithelial-mesenchymal transition (emt), immune-related pathways, and worse prognosis than the luminal subtype.24–26 however, more study is needed to confirm the role of molecular subtypes in predicting the therapeutic response of mibc patients to immunotherapy. in the age of precision immunotherapy, it’s crucial to create an immunotype model that can predict immunotherapy response rates and identify mediators that are key determinants. models and biomarkers could be utilized to influence immunotherapy response, adapt cancer treatment, cut costs, and avoid immune-related side effects. in the current study, 683 samples from six separate cohorts were used to generate immunological subgroups. s1 was shown to have the best prognosis of the four immunological subtypes studied. subtypes s1, s2, s3, and s4 were all enriched in immune-related, extracellular matrix-related, metabolism-related, and cancerrelated pathways. overall, our findings may aid researchers in better understanding the diversity of mibc patients and identifying those who will benefit from immunotherapy. methods t h e e x p r e s s i o n m a t r i x a n d c l i n i c a l information of 6 bladder cancer datasets including gse13507 (62 mibc and 103 nmibc samples),27 gse31684 (66 mibc and 27 nmibc khyber shinwari acta med indones-indones j intern med 64 samples),28 gse32548 (38 mibc samples and 93 nmibc samples),29 gse32894 (93 mibc and 215 nmibc samples),30 gse69795 (20 mibc samples and 18 nmibc samples),31 and tcga-blca (404 mibc and 4 nmibc samples)32 were downloaded. by using the sva software33 on the information from nmibc and mibc, these 6 datasets were merged into a single dataset, and batch effects were removed. batch effects in datasets were detected using principal component analysis (pca). identification of immune subtypes the gene list and 736 immune-related genes were obtained from the gene expression omnibus (geo) under the entry ‘gpl25507’. the ‘consensusclusterplus’ program34 used mibc expression profiles of immune-related genes to identify the immunological subtype. the k-means technique was used to produce consensus clustering with 1,000 re-samplings. survival analysis and calculation of immune cell proportions to estimate survival distributions for each subtype, the overall survival data from these six datasets were merged, and kaplan–meier survival curves were displayed. using the survival package in r, we did a log-rank test to see if differences between immune subtypes were significant. the cibersort algorithm was used with 1000 permutations to compute immune cell proportions (such as b cells, dendritic cells, macrophages, neutrophils, nk cells, cd4+ t cells, and cd8+ t cells) against each sample. using the estimate package, the estimate method36 was used to determine immune scores, stromal scores, and tumor purity, and the kruskal–wallis test was chosen to compare the differences. functional enrichment analysis of immune subtypes subtype-specific pathways were discovered for each subtype by comparing samples from that subtype to the remaining samples using the gsea approach. false discovery rate (fdr) 0.05 was used as the limit for subtypespecific pathways. the ‘fgsea’ program was used to analyze differentially expressed genes among diffuse glioma subtypes using the kyoto encyclopedia of genes and genomes (kegg) database. results removing the batch effects among datasets the “sva” program was used to normalize and remove batch effects from six datasets: gse13507, gse31684, gse32548, gse32894, gse69795, and tcga-blca. before the batch effect was abolished, mibc samples were mixed with nmibc samples, and samples from other datasets were clearly segregated (figures 1a-b). on the other hand, the pca plot demonstrated that mibc samples were segregated from nmibc samples, and samples from different datasets were mixed (figures 1c-d). the batch effects in six datasets were removed as a result of these findings. after batch effects were removed, the “sva” software produced the combined expression profiles of these six datasets. mibc samples from the integrated expression profiles (a total of 683 samples) were kept for further study. identification of the mibc immune subtypes mibc immune subtypes were identified using an expression matrix of 736 immunerelated genes derived from merged expression data. to identify the distinct subtypes (k = 2, 3, 4, 5, and 6) among 683 mibc samples, we used the ‘consensusclusterplus’ program. based on the cdf curves and delta plots, the optimal division (k = 4) was chosen as the optimal number of clusters (figure 2a-b). the heatmap’s boundary remained pretty clear-cut at k = 4 (figure 2c), indicating that the sample cluster was stable and robust. table 1 summarizes the distribution of immune subtypes among datasets. we discovered substantial prognostic differences among the identified immunological subtypes using the previously described classification (log-rank test, p= 0.012, figure 2d). subtype 1 (s1) patients had a longer median survival time (67.3 months) than subtype 2 (s2) patients (35.9 months), subtype 3 (s3) patients (30.9 months), and subtype 4 (s4) patients (median survival: 30.9 months) (median survival: 16.9 months). overall, we discovered four mibc immunological subgroups that were linked to vol 54 • number 1 • january 2022 identification of the immune subtype 65 clinical outcomes based on gene expression profiles. correlation of mibc immune subtypes with tumor-infiltrating immune cells the cibersort technique was used to calculate tumor-infiltrating immune cells, and it revealed variances in immune cells among mibc immune subtypes (figure 3). (1) cd8 t cells, m1 macrophages, m2 macrophages, monocytes, and memory cd4 t cells were all greater in s1 samples. (2) in naive b cells and m0 macrophages, s2 samples were greater. (3) resting nk cells, naive t cells, and eosinophils were all greater in s3 samples. (4) in resting dendritic cells, active mast cells, and neutrophils, s4 samples were greater. correlation of mibc immune subtypes with immune scores and molecular subtypes the immune subtypes’ immunological scores, stromal scores, and tumor purity were calculated using the estimate technique. immune and stromal scores were found to be figure 1. the normalization and batch effect removal from six datasets. (a) pca plot illustrated the cluster of the samples by nmibc/mibc before batch effect removal. (b) pca plot illustrated the cluster of the samples by datasets before batch effect removal. (c) pca plot illustrated the cluster of the samples by nmibc/mibc after batch effect removal. (d) pca plot illustrated the cluster of the samples by datasets after batch effect removal. dataset s1 n=149 s2 n=198 s3 n=195 s4 n=141 gse13507 3 (2.01%) 20 (10.1%) 31 (15.9%) 8 (5.67%) gse31684 12 (8.05%) 18 (9.09%) 24 (12.3%) 12 (8.51%) gse32548 6 (4.03%) 13 (6.57%) 14 (7.18%) 5 (3.55%) gse32894 28 (18.8%) 21 (10.6%) 15 (7.69%) 29 (20.6%) gse69795 0 (0.00%) 8 (4.04%) 9 (4.62%) 3 (2.13%) tcga-blca 100 (67.1%) 118 (59.6%) 102 (52.3%) 84 (59.6%) subtype table 1. the distribution of immune subtypes among datasets. khyber shinwari acta med indones-indones j intern med 66 figure 2. identification of mibc immune subtypes. (a) the cumulative distribution function (cdf) curves in consensus cluster analysis. (b) delta area plots in in consensus cluster analysis. consensus scores for different subtype numbers (k = 2 to 6) are presented. (c) the heatmap illustrating the consensus matrix at k = 4. (d) survival analysis of mibc immune subtypes. the log-rank test was conducted to determine the significance of the differences. figure 3. immune characteristics of four mibc immune subtypes. the heatmap showing the abundance of immune-cell populations calculated by cebersort. vol 54 • number 1 • january 2022 identification of the immune subtype 67 highest in s1, and lowest in s4 (immune scores: s1 > s4 > s2 > s3; stromal scores: s1 > s2 > s4 > s3). however, these immunological subtypes’ tumor purity was in reverse order: (s3 > s4 > s2 > s1) (figure 4a-c). s1 (basal, n:80, p:82 percent ; luminal, n:17, p:18 percent ) and s4 (basal, n:70, p:83 percent ; luminal, n:14, p:17 percent ) had different distributions of basal and luminal subtypes than s2 (basal, n:43, p:36 percent ; luminal, n:75, p:64 percent ) and s3 (basal (figure 4d). it’s worth noting that the basal and luminal subtype information was only accessible in the minc samples from the tcga-blca dataset. subtype-specific signaling pathways among immune subtypes gsea analysis were used to uncover signaling pathways unique to the immunological subtypes observed (figures 5a, b). immunerelated pathways including cytokine-cytokine receptor interaction and antigen processing and presentation were found to be overrepresented in subtype s1. subtype s2 was shown to be particularly rich in extracellular matrix-related pathways such as cell adhesion molecules ( c a m s ) a n d va s c u l a r s m o o t h m u s c l e contraction. subtypes s3 and s4 were found to be associated with metabolism-related pathways (metabolism of xenobiotics by cytochrome p450, linoleic acid metabolism, and fatty acid metabolism) and cancer-related pathways (pathways in cancer and cell cycle). overall, we were effective in identifying immunological subtype characteristic signaling pathways. discussion there are two major molecular subgroups among mibc patients, namely the basal and luminal subtypes, according to studies.37,38 because it is associated with a more aggressive figure 4. the correlation of stromal scores, immune scores, tumor purity, and molecular subtypes with the identified immune subtype. (a-c) evaluation of stromal scores, immune scores, and tumor purity for the four immune subtypes by kruskal-wallis test. (d) the distribution of molecular subtypes (basal and luminal subtype) in the four immune subtypes. khyber shinwari acta med indones-indones j intern med 68 phenotype and a higher risk of distant metastasis than the luminal subtype, the basal subtype has gotten a lot of attention.38 although significant progress has been made in the mibc molecular subtype, more study into the mibc immunological subtype is required. the identification of immunological subtypes is becoming increasingly important since it may aid in the selection of suitable candidates for immunotherapies. tmb, which is independent of pd-l1 expression, is a powerful predictor of tumor behavior and immunotherapy response in patients with small-cell lung cancer.39 on the other hand, tmb criteria for predicting response in a variety of different malignancies aren’t well established.40 apart from limited correlation research, the mechanism by which tmb predicts immunotherapy sensitivity is mainly unknown.34 furthermore, molecular subtypes may provide additional information for predicting immunotherapy response. the basal and luminal subtypes are derived from separate progenitor cells, according to various studies, and the basal subtype has a higher orr in immunotherapy treatment.09,41,42 immunotype a patients exhibited the best orr and had the most immunological checkpoints, tmb, and cd8+ t cells, indicating that immunotherapy was highly recommended for them. it’s because immunotype a corresponds to previously identified “hot tumors”.43 patients with immunotype b exhibited a lower orr, a lower level of immunological checkpoints and cd8+ t cells, and a moderate number of tmb. more research is needed to establish if this tendency is analogous to “cold tumors,” which are characterized by insufficient t cell priming (low tumor mutational load, poor antigen presentation, and intrinsic t cell death insensitivity).43–45 to increase t cell responses and turn cold tumors into “hot tumors,” treatment techniques include cancer stem cell (csc) vaccination or adoptive t cell transfer.43, 46 immunotype c patients, on the other hand, had the lowest orr. they had strong immunological checkpoints, intermediate cd8+ t cells, and low tmb, implying that immunotherapy may not be suited for this patient population. ttn, tp53, kmt2d, muc16, arid1a, kdm6a, and syne1) were identified as cancer risk genes after they were found to be changed often among three immunotypes. seven more genes are as important: pik3ca, rb1, fgfr3, kmt2c, macf1, ryr2, and ep300. three immunotypes have varied mutation rates for these genes, allowing for a more thorough and comprehensive understanding of mibc immunotype mutation rates. individual genes figure 5. bubble plots for 5 enriched kegg pathways with the lowest p.value in each immune subtype. (a) the plot of kegg pathways. (b) the annotation of kegg pathways. vol 54 • number 1 • january 2022 identification of the immune subtype 69 in a co-expression network are less stable than modules because the overall function of a module can be maintained when individual gene expression can be replaced by other genes with similar redundant functions [02]. network analysis revealed eight hub genes for the mibc immunotype-related module (acta2, acta1, col1a1, col1a2, col5a1, dcn, sparc, vim). the disease stage-related hub gene involvement of col1a1, col1a2, and col5a1 was previously discovered by another group,47 which is compatible with our findings. multiple datasets should be used to find the robust immune subtype among mibc patients. when merging disparate datasets, the batch effect will be a key stumbling block for researchers. fortunately, ‘sva’ package33 has been shown the ability to remove the batch effect in studies.48,49 according to the pca results, the batch effect was successfully removed. because we analyzed 683 samples from six separate cohorts, the four immunological subgroups we discovered may be more robust than a single dataset. among the four immune subtypes, s1 received the highest immunological and stromal evaluations, whereas s3 had the lowest. the estimate approach did not produce the same findings as the cibersort approach. s1 has a lot of cd8 t cells, m1 macrophages, m2 macrophages, monocytes, and memory cd4 t cells. as a result, s1 patients should receive immunotherapy, but s3 patients should not. based on the distribution of immunological scores and molecular subtypes in these four immune subtypes, we could determine that 1) s1 was the basal subtype with more immune cells and s4 was the basal subtype with fewer immune cells. 2) tumor cells were lower and higher in the luminal subtypes s2 and s3, respectively. conclusion finally, the findings of this study improved immunological subtype research in mibc samples by identifying four immune subtypes with varying immunological scores. immune subsets revealed may aid doctors in deciding on treatment for mibc patients. these findings will pave the way for new immunotherapy approaches in the future. conflict of interests the authors declare that there is no conflict of interest regarding the publication of this article. acknowledgments the work was carried out within the framework of research at the institute of immunology and physiology, ural branch of the russian academy of sciences, project number aaaa-a21-121012090091-6. references 1. siegel rl, miller kd, jemal a. cancer statistics 2020. ca cancer j clin. 2020; 70:7-30. 2. chen z, liu g, et al. a co-expression network for differentially expressed genes in bladder cancer and a risk score model for predicting survival. hereditas. 2019;156:24. 3. kim j, akbani r, creighton cj, et al. invasive bladder cancer: genomic insights and therapeutic promise. clin cancer res. 2015;21:4514-24. 4. b o g n a r z , f e k e t e k , a n t u s c , e t a l . 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muscleinvasive bladder cancer subtypes. front genet. 2018; 9:422. 38. choi w, czerniak b, ochoa a, et al. intrinsic basal and luminal subtypes of muscle-invasive bladder cancer. nat rev urol. 2014;1:400-10. 39. boumber y. tumor mutational burden (tmb) as a biomarker of response to immunotherapy in small cell lung cancer. j thorac dis. 2018;10:4689-93. 40. chan ta, yarchoan m, jaffee e, et al. development of tumor mutation burden as an immunotherapy biomarker: utility for the oncology clinic. ann oncol. 2019;30:44-56. 41. choi w, porten s, kim s, et al. identification of distinct basal and luminal subtypes of muscle-invasive bladder cancer with different sensitivities to frontline chemotherapy. cancer cell. 2014;25:152-65. 42. dadhania v, zhang m, zhang l, et al. meta-analysis of the luminal and basal subtypes of bladder cancer and the identification of signature immunohistochemical markers for clinical use. ebio med. 2016;12:105-17. vol 54 • number 1 • january 2022 identification of the immune subtype 71 43. galon j, bruni d. approaches to treat immune hot, altered and cold tumours with combination immunotherapies. nat rev drug discov. 2019; 18:197-218. 44. camus m, tosolini m, mlecnik b, et al. coordination of intratumoral immune reaction and human colorectal cancer recurrence. cancer res. 2009;69:2685-93. 45. sanmamed mf, chen l. a paradigm shift in cancer immunotherapy: from enhancement to normalization. cell. 2018;175:313-26. 46. shi x, zhang x, li j, et al. pd-1 blockade enhances the antitumor efficacy of gm-csf surface-modified bladder cancer stem cells vaccine. int j cancer. 2018; 142:2106-17. 47. di y, chen d, yu w, yan l. bladder cancer stageassociated hub genes revealed by wgcna coexpression network analysis. hereditas. 2019;156:7. 48. tan tz, rouanne m, tan kt, huang ry, thiery jp. molecular subtypes of urothelial bladder cancer: results from a meta-cohort analysis of 2411 tumors. eur urol. 2019;75:423-32. 49. a b b a s a g h a b a b a z a d e h f, l i q , f r i d l e y b l . comparison of normalization approaches for gene expression studies completed with high-throughput sequencing. plos one. 2018;13:e0206312. 42 acta med indones indones j intern med • vol 54 • number 1 • january 2022 original article urease levels and gastritis stage in dyspeptic patients muhammad miftahussurur1,2,3*, chyntia dewi maharani putri1, titong sugihartono1, ari fahrial syam4, herry purbayu1, diah priyantini5, hartono kahar6, yudith annisa ayu rezkitha2,7, iswan abbas nusi1, poernomo boedi setiawan1, ummi maimunah1, langgeng agung waskito2, ulfa kholili1, budi widodo1, amie vidyani1, husin thamrin1, gontar a. siregar8, reny i’tishom9, tomohisa uchida10, yoshio yamaoka1,3 1 division of gastroentero-hepatology, department of internal medicine, faculty of medicine-dr. soetomo teaching hospital, universitas airlangga, surabaya 60286, indonesia 2 helicobacter pylori and microbiota study group institute of tropical disease, universitas airlangga, surabaya 60115, indonesia 3 department of environmental and preventive medicine, oita university faculty of medicine, yufu 879-5593, japan 4 division of gastroenterology, department of internal medicine, faculty of medicine, university of indonesia, jakarta 10430, indonesia 5 faculty of nursing, universitas airlangga, surabaya 60115, indonesia 6 department of clinical pathology, faculty of medicine-dr. soetomo teaching hospital, universitas airlangga, surabaya 60131, indonesia 7 faculty of medicine, muhammadiyah university of surabaya, surabaya 60113, indonesia 8 division of gastroentero-hepatology, department of internal medicine, faculty of medicine, north sumatra university, medan, 20115, indonesia 9 department of medical biology, faculty of medicine, universitas airlangga, surabaya 60131, indonesia 10 department of molecular pathology, oita university faculty of medicine, yufu 879-5593, japan corresponding author: muhammad miftahussurur, md., ph.d. division of gastroentero-hepatology, department of internal medicine, faculty of medicine universitas airlangga dr. soetomo hospital. jalan mayjend prof. dr. moestopo no. 6-8 surabaya, surabaya 60286, indonesia. e-mail: muhammad-m@fk.unair.ac.id. abstract background: dyspepsia is a frequent main symptom of inpatients and outpatients scenario in indonesia. however, the number of endoscopy facilities are still low, thus the use of non-invasive method to detect gastritis is necessary. we measured the relationship between urease levels and the stage of gastritis in dyspeptic adult patients. methods: a cross-sectional study included outpatient dyspepsia patient from november 2018 to february 2019. we examined 14c-urea breath test (ubt) and determined the stage of gastritis based on the updated sydney system classification. results: the urease level of acute and chronic gastritis positive patients were higher than negative patients (p = 0.001, r = 0.353; p <0.0001, r = 0.433, respectively). the auc value of 14c-ubt to detect acute, chronic, and atrophic gastritis are 0.889, 0.632 and 0.544, respectively. the best cut-off points of 14c-ubt to predict acute gastritis was ≥26.50δ‰ with sensitivity and specificity being 88.89% and 63.95%, respectively. whereas the best cut-off points for chronic gastritis was ≥34.50δ‰ with 82.89% sensitivity, 63.16% specificity. as for atrophic gastritis, it showed very low auc value, hence it is not a sufficient test modality to predict atrophic gastritis cases. conclusion: 14c-ubt is sufficient for predicting acute or chronic gastritis but not for atrophic gastritis. keywords: dyspepsia, gastritis severity, urea breath test, cancer. vol 54 • number 1 • january 2022 urease levels and gastric stage in dyspeptic patients 43 introduction dyspepsia is the most common gastrointestinal symptom in clinical practice.1approximately 44.7% patients with dyspepsia had gastritis or duodenitis diagnosed by endoscopic examination in indonesia.2 dyspepsia might be caused by two factors, infection and non-infection. infection is mostly caused by helicobacter pylori, whereas non-infection might be caused by stress, diet habits, hormonal factors and other functional factors.3 detection of h. pylori infection could be performed by many ways, such as histological examination, stool antigen test, anti h. pylori antibody and urea breath test (ubt).4 gastritis, especially atrophic gastritis is the common contributing factor for gastric cancer.5 inflammation of the gastric mucosa may cause loss of glands that will eventually be replaced by intestinal-type epithelial cells, which is considered as a low-grade dysplasia.6 this dysplastic tissue then become intestinal type gastric cancer as the end result of progressive changes in the gastric mucosa.7 mechanism of gastritis induced by urease enzyme activity remains unclear. urea and urease may increase mucosal damage due to increased ammonia level in the gastric mucosa.8 a study in mice given ammonia showed an increase in the number of inflammatory cells induced by chronic gastritis, suggesting a significant relationship between ammonia levels and gastritis.9 another study in patients with dyspepsia confirmed that ammonia levels were significantly associated with the severity of gastritis.10 in addition, peptic ulcer patients had significantly higher urease level than patients without peptic ulcers.11 it is suspected that there are urease-producing bacteria, including pathogens other than h. pylori which cause chronic gastritis in areas with low prevalence of h. pylori such as indonesia. ubt is a non-invasive method to detect h. pylori which relied on the fact that h. pylori secretes urease enzyme which converts urea into ammonia and carbon dioxide.12,13 the ubt is a reliable method to detect h. pylori and performed based on the ability of h. pylori to break down urea, which is absorbed from the stomach and eliminated in exhalation.14 if the isotope is detected in the breath, the test is positive, suggesting h. pylori presence in the stomach.15 the amount of urease activity, detected by value from ubt may reflect the h. pylori bacterial load in the stomach.16 indeed, ubt is mainly used for detecting h. pylori, but since there are other bacteria that has urease activity, such as proteus mirabilis, citrobacter freundii, klebsiella pneumoniae, enterobacter cloacae and staphylococcus aureus).17 however, the end point of urease activity is producing ammonia, a toxic substance for the stomach. therefore, ubt may have potential usage and become a non-invasive alternative diagnostic modality to detect ureaserelated gastritis. indonesia is a multi-ethnic country with over 267 million people living in more than seventeen thousand islands with regional disparities in health service quality.18 dyspepsia and gastritis are included in the top 10 diseases and is common in inpatients and outpatients clinics of indonesia. however, the number of endoscopy experts in indonesia is lacking and the number of endoscopy centers is still low.19 recently, 14c-ubt, a non-invasive method with simple, less expensive, accurate and easy handling is massively used in clinical practice. this study aimed to determine relationship between urease levels with the severity of gastritis in dyspeptic patients. methods we conducted a cross sectional study from november 2018 to february 2019 in dr. soetomo teaching hospital, surabaya, indonesia. ninety five dyspeptic patients aged 18 to 70 years old were included in this study. we excluded patients receiving antibiotics and bismuth drugs 4 weeks prior to examination, proton pump inhibitor 2 weeks prior to examination, patients with history of gastric surgery, bleeding gastrointestinal tract within 4 weeks, impaired kidney diseases, liver cirrhosis, diabetes mellitus, gut malignancy, history of smoking and alcohol consumption, history of nsaid consumption and patients with endoscopy contraindication. we collected demographics data and dietary habits by questionnaire. one day before endoscopy, all patients were examined by 14c-ubt (heliprobe, stockholm, muhammad miftahhussurur acta med indones-indones j intern med 44 sweden) using 14c-urea (250 uci, amersham) reconstituted with 25 ml of sterile distilled water. subjects were fasted for at least six hours prior to the test. they removed false teeth (if present), and cleansed their mouth with antiseptic solution such as thymol, salol, menthol, saccharin, fuchsin, water and ethanol. a baseline breath sample was collected and identified as time 0. then, they swallowed 5 uci of 14c-urea dissolved in 20 ml of water. breath samples were collected at 5, 10, 15, 20 and 30 minutes. patients were instructed to blow through tubing attached to a safety trap into a scintillation vial containing 2.5 ml of 400 mm hyamine (sigma) in methanol with 15 mg/l thymolphthalein (blue alkaline color). they had to blow until the solution became colorless indicating the collection of 1 mmol of co2. once the breath samples had been collected, scintillation fluid (10 ml-5.5 g ppo/0.2g popop of 2:1 v/v toluene/triton-x) was added to the vial; counting proceeded for 5 minutes per vial, and the results were expressed as cpm/mmol co2. counting efficiency of the beckman ls 100c was 93%. endoscopy and biopsy were performed on the next day. experienced endoscopists collected single biopsy samples from corpus and antrum of the gaster for histological examination. patients with evidence of activity or inflammation in the antrum or corpus upon histological examination were considered positive for gastritis. the severity of gastritis is determined by histological examination based on the updated sydney system classification.20 informed consent was obtained from all participants, and the protocol was approved by the ethics committee of dr. soetomo teaching hospital (surabaya, indonesia). statistical analysis statistical analysis is done using the spss statistical software package version 23 (spss, inc., chicago, il, usa). correlation analysis used spearman’s signed rank test because the distribution data was abnormal. correlation coefficient considered with r and significant analysis with p value was <0.05. in addition, to determine the cut-off point of ubt examination we used receiver operating characteristic (roc) analysis for showing area under curve (auc) then we calculated the sensitivity and specificity from the determined cut-off point. results demographical characteristics of patients the total study population was 95 consecutive dyspeptic patients (52 female and 43 male; age range 20-65 years). female patients had a higher proportion of chronic and atrophic gastritis (4/52, 7.7%; and 15/52, 28.8%, respectively, table 1), however statistically insignificant (p = 0.130). age group of >60 years old had a more acute gastritis than other age groups (6/21, 28.6%, p = 0.018). christian (5/20, 25.0%) and buddhist (1/3, 33.3%) patients had higher association with acute gastritis (p = 0.038). however, there was no association between marital status, job, income, education and ethnics with prevalence of gastritis (all p >0.05). the amount of resident 1–4 people had higher proportion in acute and chronic gastritis (7/71, 9.9%, p = 0.049 and 15/71, 21.1%, p = table 1. demographical characteristic of respondents demographical characteristic n acute gastritis chronic gastritis atrophic gastritis sex male female 43 52 5 (11.6) 4 (7.7) 6 (14.0) 13 (25.0) 9 (20.9) 15 (28.8) age 20-29 years old 30-39 years old 40-49 years old 50-59 years old >60 years old 4 9 31 30 21 0 (0.0) 0 (0.0) 2 (6.5) 1 (3.3) 6 (28.6)* 1 (25) 0 (0.0) 5 (16.1) 5 (16.1) 8 (38.1) 2 (50.0)* 0 (0.0) 4 (12.9) 10 (33.3) 8 (38.1) marital status married single 87 8 9 (10.3) 0 (0.0) 18 (20.7) 1 (12.5) 21 (24.1) 3 (37.5) vol 54 • number 1 • january 2022 urease levels and gastric stage in dyspeptic patients 45 0.031, respectively, table 2), but only tended in atrophic gastritis (19/71, 26.8%, p = 0.094). the frequency of eating with hand had association with acute, chronic and atrophic gastritis (p = 0.026, p = 0.045 and p = 0.036, respectively). smokers had higher prevalence of acute gastritis than non-smokers (5/22, 22.7% vs. 4/73, 5.5%, p = 0.015). source of water, alcohol drinker, hand washing after toilet use and before eating did not influence prevalence of gastritis (all p >0.05). among 95 subjects, 19 (26.3%) frequently consumed analgesics and had association with acute gastritis (p = 0.005, table 3). in addition, anxiolytic users had a higher acute gastritis rather than non-users (5/26, 19.2% vs. 4/69, 5.8%, p = 0.045). the most six common symptoms in acute, chronic and atrophic gastritis were epigastric pain (9/92, 9.8%; 14/92, 20.3%; 23/92, 24.2%, respectively), easy to feel full when consuming food or drink (8/64, 12.5%; 16/64, 25.0%; 17/64, 26.6%, respectively), nausea (6/64, 9.4%; 12/64, 18.8%; 15/64, 23.4%, respectively), feeling bloated (6/69, 8.7%; 14/69, 20.3%; 16/69, 23.2%, respectively), heart burn (4/46, 8.7%; 8/46, 17.4%; 13/46, 28.3%, respectively) and vomiting (7/72, 9.7%; 14/72, 19.4%; 16/72, 22.2%, respectively), but there was no significant association between all symptoms with gastritis (all p >0.05). there were three most comon diseases from endoscopy including erosive gastritis (20/95, 21.1%), gastroesophageal reflux disease (18/95, 18.9%) and superficial gastritis (13/95, 13.7%). the prevalence of h. pylori-positive subjects in this study was very low (4/48, 8.3%). when we used the cut-off point of ubt from manual job civil servant housewife employee doctor teacher student retired farmer 5 35 42 1 2 2 2 6 0 (0.0) 2 (5.7) 5 (11.9) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (2.1) 0 (0.0) 7 (20.0) 8 (19.0) 0 (0.0) 1 (50.0) 0 (0.0) 1 (50.0) 2 (33.3) 1 (20.0) 9 (25.7) 11 (26.2) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 3 (50.0) income under minimum regional income** upper minimum regional income** 69 26 6 (8.7) 3 (11.5) 15 (21.7) 4 (15.4) 16 (23.2) 8 (30.8) religion buddhism hindu moeslim catholic christian 3 2 65 5 20 1 (33.3)* 0 (0.0) 3 (4.6) 0 (0.0) 5 (25.0) 1 (33.3) 0 (0.0) 10 (15.4) 1 (20.0) 7 (35.0) 1 (33.3) 0 (0.0) 13 (20.0) 2 (40.0) 8 (40.0) education not educated elementary school junior high school senior high school diploma bachelor master 1 9 13 43 2 25 2 0 (0.0) 1 (11.1) 2 (15.4) 2 (4.7) 0 (0.0) 4 (16.0) 0 (0.0) 0 (0.0) 2 (22.2) 5 (38.5) 7 (16.3) 0 (0.0) 5 (20.0) 0 (0.0) 0 (0.0) 2 (22.2) 7 (53.8) 8 (18.6) 1 (50.0) 6 (24.0) 0 (0.0) ethnic ambon bataknese javanese madura sunda tioghoa alas balinese padang pak pak 2 22 49 4 1 11 1 3 1 1 0 (0.0) 5 (22.7) 2 (4.1) 0 (0.0) 0 (0.0) 2 (18.2) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 6 (27.3) 9 (18.4) 0 (0.0) 0 (0.0) 4 (36.4) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (50.0) 7 (31.8) 10 (20.4) 1 (25.0) 0 (0.0) 5 (45.5) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) * p <0.05 with chi-square analysis ** usd 272 currency on march 2020 muhammad miftahhussurur acta med indones-indones j intern med 46 table 3. medical status of subjects medical status n acute gastritis chronic gastritis atrophic gastritis symptom bloated yes no epigastric pain yes no heart burn yes no nausea yes no vomiting yes no easy to fill yes no 69 26 92 3 46 49 64 31 23 72 64 31 6 (8.7) 3 (11.5) 9 (9.8) 0 (0.0) 4 (8.7) 5 (10.2) 6 (9.4) 3 (9.7) 2 (8.7) 7 (9.7) 8 (12.5) 1 (3.2) 14 (20.3) 5 (19.2) 18 (19.6) 1 (33.3) 8 (17.4) 11 (22.4) 12 (18.8) 7 (22.6) 5 (21.7) 14 (19.4) 16 (25.0) 3 (9.7) 16 (23.2) 8 (30.8) 23 (24.2) 1 (33.3) 13 (28.3) 11 (22.4) 15 (23.4) 9 (29.0) 8 (34.8) 16 (22.2) 17 (26.6) 7 (22.6) proton pump inhibitor yes no 4 91 1 (25.0) 8 (8.8) 2 (50.0) 17 (18.7) 1 (25.0) 23 (25.3) antibiotics yes no 11 84 2 (18.2) 7 (8.3) 4 (36.4) 15 (17.9) 2 (18.2) 22 (26.2) table 2. health behavior of subjects health behavior n acute gastritis chronic gastritis atrophic gastritis resident in one house 1 – 4 people 5 and more people 71 24 7 (9.9)* 2 (8.3) 15 (21.1)* 4 (16.7) 19 (26.8) 5 (20.8) source of water well new mineral water refill mineral water boiled water 8 14 48 25 0 (0.0) 1 (7.1) 4 (8.3) 4 (16.0) 0 (0.0) 1 (7.1) 11 (22.9) 7 (28.0) 1 (12.5) 3 (21.4) 14 (29.2) 6 (24.0) hand wash after toilet never rarely sometimes often always 1 6 9 25 54 0 (0.0) 0 (0.0) 1 (11.1) 2 (8.0) 6 (11.1) 0 (0.0) 1 (16.7) 3 (33.3) 2 (8.0) 13 (24.1) 0 (0.0) 2 (33.3) 3 (33.3) 6 (24.0) 13 (24.1) hand wash before eat never rarely sometimes often always 1 3 13 35 43 0 (0.0) 0 (0.0) 2 (15.4) 3 (8.6) 4 (9.3) 0 (0.0) 0 (0.0) 3 (23.1) 5 (14.3) 11 (25.6) 0 (0.0) 1 (33.3) 3 (23.1) 10 (28.6) 10 (23.3) eating with hand never rarely sometimes often always 7 24 31 20 13 1 (14.3) 3 (12.5) 0 (0.0) 1 (5.0) 4 (30.8)* 1 (14.3) 8 (33.3) 2 (6.5) 3 (15.0) 5 (38.5)* 2 (28.5) 7 (29.2) 6 (19.4) 4 (20.0) 5 (38.5)* smoking yes no 22 73 5 (22.7)* 4 (5.5) 5 (22.7) 14 (19.2) 4 (18.2) 20 (27.4) alcohol yes no 21 74 4 (19.0) 5 (6.8) 5 (23.8) 14 (18.9) 5 (23.8) 19 (25.7) * p <0.05 with chi-square analysis vol 54 • number 1 • january 2022 urease levels and gastric stage in dyspeptic patients 47 instruction (50.00), there was no correlation between diseases and positivity of h. pylori. urease levels and stage of gastritis based on the gastritis stage, we observed a significant trend of increasing ubt level with both degree of acute and chronic antral gastritis (r= 0.366 and r= 0.404, respectively; both p < 0.001) (figure 1). however, we could not find correlation between degree of both atrophic gastritis and intestinal metaplasia in antrum. as for in the corpus, we only could find a significant analgesic yes no 19 76 5 (26.3)* 4 (5.3)* 5 (26.3) 14 (18.4) 4 (21.1) 20 (26.3) anti-anxiety yes no 26 69 5 (19.2)* 4 (5.8)* 6 (23.1) 13 (18.8) 7 (26.9) 17 (24.6) * p <0.05 with chi-square analysis correlation between corporal atrophy and ubt level (r= 0.270, p=0.036). the others histological parameter (acute gastritis, chronic gastritis and intestinal metaplasia) did not show a significant association (all p > 0.05). we validated the accuracy of 14c-ubt to predict acute gastritis. acute gastritis is expressed as a neutrophil infiltration ≥1 on the gastric mucosa. the auc of the urea levels compared with acute gastritis with auc score was 0.889 (95% ci = 0.729 – 0.950) (figure figure 1. association between urease levels with the degree of gastritis in each stage. muhammad miftahhussurur acta med indones-indones j intern med 48 2). the best cut-off point was ≥26.50 δ‰ with sensitivity of 88.89%, specificity of 63.95%, positive predictive value (ppv) of 71.15%, negative predictive value (npv) of 85.20%, positive likelihood ratio of 2.47, negative likelihood ratio of 0.17 and accuracy of 76.42%. i n a d d i t i o n , w e a l s o d e t e r m i n e t h e performance of 14c-ubt for detecting chronic gastritis. ubt level yielded an auc score of 0.632 (95% ci = 0.592 – 0.883) (figure 3). the best cut-off point was ≥34.50 δ‰ with sensitivity, specificity, ppv, npv, positive likelihood ratio and negative likelihood ratio being 82.89%, 63.16%, 78.69%, 69.23%, 3.69, and 0.44, respectively with overall 73.03% accuracy. the validation examination for atrophic gastritis showed a very low auc score of 0.544 (95% ci = 0.396 – 692). therefore, it is not sufficient for determining the best cut-off. as for the accuracy of the 14c ubt for intestinal metaplasia was not measured because there were only 2 positive cases. discussion we confirmed the accuracy of 14c-ubt to predict severity of gastritis but not for atrophic gastritis. the cut-off point 14c-ubt to measure acute and chronic gastritis were higher than atrophic gastritis. this result is in agreement with a previous study which showed that the ubt value was correlated to gastric cancer and was significantly lower than that for gastritis, duodenal ulcer, or gastric ulcer in h. pyloripositive patients.21,22 they also found a low ubt value were associated with the risk of gastric cancer, similar with this study where the cutoff points in atrophic was lower than acute or chronic gastritis.16 urease level has better sensitivity in acute and chronic gastritis than atrophic gastritis due to the difference in h. pylori colonization bacterial load. extensive gastric mucosal atrophy may decrease colonization by h. pylori and produce a low ubt value.4,23 in addition, ubt value is mainly influenced by h. pylori colonization which lead to increasing neutrophil infiltration, therefore it contribute to the higher association between acute gastritis rather than the atrophic gastritis.24,25 however, indonesia has a low prevalence of h. pylori infection.26 in this study, we also confirmed that figure 2. the urea levels compared with acute gastritis with auc score. figure 3. urease activity level compared to chronic gastritis resulted auc score. vol 54 • number 1 • january 2022 urease levels and gastric stage in dyspeptic patients 49 the prevalence of h. pylori infection was very low, suggesting in indonesian cases generally the bacteria do not have a major influence on clinical outcomes27, especially in ethnic groups with low prevalence of h. pylori. therefore, due to dyspepsia and gastritis being one of the top 10 diseases in indonesia, non-h. pylori urease-producing bacteria might a major role causing gastritis. non-h. pylori bacteria such as non-h. pylori helicobacter spp., mycobacterium spp., staphylococcus spp, proteus mirabilis, citrobacter freundii, klebsiella pneumoniae, and enterobacter cloacae. could produce urease enzyme.17,25 sufficient sensitivity but low specificity of 14c-ubt for determining acute gastritis, suggests that 14c-ubt has sufficient ability to screen for acute gastritis, but low specificity indicates ubt test was not a good diagnostic method.28,29 thus, other modalities, either invasive or non-invasive to determine gastritis is necessary. there were options for non-invasive diagnostic method that had potential determining the gastritis status, such as serum pepsinogen level. serum pepsinogen had been well recognized as a noninvasive screening option for early stages of gastric cancer. combination of serum pepsinogen and anti-h. pylori antibody, miki and co-workers had established a stratification method for gastric cancer risk.30 that method had been applied and showed promising results in several populations, including in indonesia.31,32 therefore, serum pepsinogen might be still become the best noninvasive methods to measure severity of gastritis, especially in indonesia.33 urease exposure can cause an inflammatory reaction by producing reactive oxygen species and inducing the expression of inducible nosynthesizing enzyme.34 urease can also give a toxic effect indirectly by producing ammonia, a product of urea hydrolysis.16 the presence of ammonia in the stomach can cause hypoxia in gastric tissue by increasing intracellular and intra mitochondrial ph. ammonia also interferes with the activity of tricarboxylic acid which can reduce atp synthesis so that it interferes with cell migration and cell proliferation which can inhibit repair of the gastric epithelium. this activity causes the activation of the danger associated molecular pattern (damp) that recognized by the pattern recognition receptor and activate monocytes and neutrophils and the recruitment of inflammatory cells, such as il-1, il-8 and tnf-αv.35 in addition to inducing the release of proinflammatory cytokines, ammonia can also enter the g cell nucleus easily and bind the gene-regulating gastrin unit so that it can activate expression and enhance gastrin formation.36 that mechanism might be a responsible way explaining observed gastritis in the high ammonia individuals. based on demographic characteristics, age group of >60 years old had higher acute gastritis prevalence than other age groups because ageing reductes of mucous cells in the gastric mucosa of elderly, which is associated with a decreasing prostaglandin concentration.26 the research finding also stated smokers had higher prevalence of acute gastritis than non-smokers, and it is in agreement with other studies.15 smokers have higher cases in gastritis because the gaster produce higher amounts of acid than in non-smokers. female patients were found to have higher prevalence of chronic and atrophic gastritis, but it is statistically insignificant. some authors support a small contribution of sex differences where there is predominance in h. pylori related outcomes in males, including gastric cancer. there were several limitations in this current study, first it had a very low sample number and was only collected in one center. in addition, there was no healthy individuals that were included in the population. therefore, interpretation warrants caution since it may not represent the whole indonesian population. our study did not have any information regarding h. pylori status which might be considered as a main factor affecting the value of 14c-ubt, since urease is currently believed to mainly come from bacterial infection; therefore, the association between ubt and gastritis might be affected by h. pylori. this condition is needed a careful consideration. conclusion our study showed ubt has a sufficient potential for predicting acute and chronic antral muhammad miftahhussurur acta med indones-indones j intern med 50 gastritis with a good value of sensitivity. as for other gastritis parameters, ubt showed not a good choice for predicting those stages. the ubt mainly used for determining h. pylori infection; therefore, the involvement of h. pylori infection in the development of gastritis still need to be carefully considered. conflict of interest the authors declare no potential conflicts of interests. references 1. suzuki h, moayyedi p. helicobacter pylori infection in functional dyspepsia. nat rev gastroenterol hepatol. 2013;10(3):168–74. 2. oling m, odongo j, kituuka o, galukande m. prevalence of helicobacter pylori in dyspeptic patients at a tertiary hospital in a low resource setting surgery. bmc res notes. 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suppl 2:2–9. 20. hassan tm, al-najjar s, al-zahrani i, alanazi fb, alotibi m. helicobacter pylori chronic gastritis updated sydney grading in relation to endoscopic findings and h. pylori igg antibody: diagnostic methods . j microsc ultrastruct. 2016;4(4):167. 21. de re v, orzes e, canzonieri v, et al. pepsinogens to distinguish patients with gastric intestinal metaplasia and helicobacter pylori infection among populations at risk for gastric cancer. clin transl gastroenterol. 2016;7(7). 22. tanaka t, mulyadi ik, moestikaningsih, et al. rare helicobacter pylori infection may explain low stomach cancer incidence: ecological observations in bali, indonesia. asian pacific j cancer prev. 2016;17(3):979–84. 23. miftahussurur m. noninvasive helicobacter pylori diagnostic methods in indonesia. vol. 14. gut and liver. editorial office of gut and liver; 2020. p. 553–9. 24. ivashkin vt, kasoev sg, stepanov ev. analysis of the isotopic composition of exhaled air by the diode laser spectroscopy 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multivariate statistical apportionment of specific polycyclic aromatic hydrocarbons. nucl instruments methods phys res sect b beam interact with mater atoms. 1997;123(1– 4):475–86. 30. miki k, morita m, sasajima m, hoshina r, kanda e, urita y. usefulness of gastric cancer screening using the serum pepsinogen test method. am j gastroenterol. 2003;98(4):735–9. 31. tong y, wu y, song z, yu y, yu x. the potential value of serum pepsinogen for the diagnosis of atrophic gastritis among the health check-up populations in china: a diagnostic clinical research. bmc gastroenterol. 2017;17(1):88. 32. miftahussurur m, agung waskito l, aftab h, et al. serum pepsinogens as a gastric cancer and gastritis biomarker in south and southeast asian populations. plos one. 2020;15(4). 33. agkoc m, dursun h, albayrak f, et al. usefulness of serum pepsinogen levels as a screening test for atrophic gastritis and gastric cancer. eurasian j med. 2010;42(1):15–8. 34. uski o, jalava pi, happo ms, et al. effect of fuel zinc content on toxicological responses of particulate matter from pellet combustion in vitro. sci total environ. 2015;511:331–40. 35. kwiecien s, jasnos k, magierowski m, et al. lipid peroxidation, reactive oxygen species and antioxidative factors in the pathogenesis of gastric mucosal lesions and mechanism of protection against oxidative stress induced gastric injury. j physiol pharmacol. 2014;65(5):613–22. 36. harada y, harada y, elly c, et al. transcription factors foxo3a and foxo1 couple the e3 ligase cbl-b to the induction of foxp3 expression in induced regulatory t cells. j exp med. 2010;207(7):1381–91. 231acta med indones indones j intern med • vol 55 • number 2 • april 2023 clinical practice current diagnostic and treatment approach of clostridioides difficile infection bella yunita1, achmad fauzi2* 1 department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 2 division of gastroenterology, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. *corresponding author: achmad fauzi, md. division of gastroenterology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 70. jakarta 10430, indonesia. email: bellaaabellss@ gmail.com abstract c. difficile infection is related to wide spectrum of disease, from self-limiting diarrhea to fulminant disease that can cause toxic megacolon or pseudo-membrane colitis. difficult approach to diagnose this disease is also problem. c. difficile infection is diagnosed when diarrhea occurred in high risk patient with positive result of gdh or naat test that was confirmed by positive result of toxin test. nevertheless, there is limited choice of treatment in indonesia. thus, the main priority of c. difficile infection in indonesia is associated with its prevention, by implementing standard precaution and use of rational antimicrobial. keywords: c. difficile infection, colitis, diagnosis, diarrhea, treatment. introduction clostridioides difficile (c. difficile) infection causes wide spectrum of disease; it may cause self-limiting diarrhea to severe and fulminant infection such as pseudo-membrane colitis and toxic megacolon. several risk factors are reported to contribute for this infection: older age, history of hospitalization, people who lived in healthcare facilities, or history of antimicrobial use.1 c. difficile infection is defined as c. difficile colonization that causes diarrhea, with positive result of c. difficile toxins or toxigenic c. difficile is detected from feces specimen, or pseudomembrane colitis found by colonoscopy and/or histopathology examination. in the patient with risk factors and experienced diarrhea 3 times/ day, this patient should undergo c. difficile examination.2-3 nevertheless, prevalence of community acquired c. difficile infection increased, because it can also occurred in patient without prior history hospitalization.4 in the united states, c. difficile infection is associated with 15,000-30,000 deaths/year, while in indonesia, studies related to c. difficile infection is limited.1,4 c. difficile infection is often undetected in indonesia, yet higher use of over the counter (otc) antimicrobial in indonesia can lead to higher prevalence of c. difficile infection. study from collins, et al (2017) that was conducted in hospital located in central java reported positive glutamate dehydrogenase (gdh) results in 20.6% patients with detected toxins in 5.6% patients. from culture, toxigenic c. difficile was detected in 10.9% and nontoxigenic was detected in 10.6%. other results from this study: ribotype 017 was detected in 24.3%, non-toxigenic qx 224 in 9.5%, and qx 238 and qx 108 was detected in 8.1%. this bella yunita acta med indones-indones j intern med 232 prevalence was higher than in neighbor countries such as australia (7%), singapore (7-11%), and malaysia (13.7%).1 because high prevalence of c. difficile infection and difficult diagnostic and treatment approach of this disease, this review article intend to explain current diagnostic and treatment approach of c. difficile infection. clostridioides difficile virology c. difficile is gram positive rod, anaerobic bacteria that produces pathogenic spores for gut.4-6 transmission of c. difficile infection occurred as fecal-oral transmission. once the c. difficile spores infected stomach, this spores can not be disintegrated even when exposed to acid secretion of stomach. the bacteria then enters small gut, and exposed to bile acid that can induce vegetative state of this bacteria. prior exposure to antimicrobial decreased number of normal flora of the gut, thus induce colonization of c. difficile in colon. this colonization then produces c. difficile toxins.5,6 c. difficile toxins inhibits polymerization of actin from host cell and then causes cell death. in colon, this bacteria produces spores that will exit with feces. c. difficile is reported can withstand heat and ethanol based disinfectant.5 there are three types of toxins produced by c. difficile bacteria, toxin a, toxin b, and cdt. toxin a is enterotoxin, while toxin b is cytotoxin, thus both of these toxins play the role to impair gut mucosa and acute inflammation that causes colitis and diarrhea as the main clinical manifestation.1,4 the third toxin, cdt, which is a binary toxin is rarely detected in host cell, yet it is associated with inflammation and water loss from colon.1,7 host immunity to fight the toxin is associated with severity of clinical manifestation and recurrent infection. risk factors for c. difficile consist of history of hospitalization, history of antimicrobial use (clindamycin, cephalosporin, carbapenem, fluoroquinolone, and monobactam), and older age. study from smilings, et al.8 (2014) reported that antimicrobial that is associated with c. difficile infection are third generation cephalosporin (or 3.2; 95% ci 1.8-5.71), clindamycin (or 2.9; 95% ci 2-4), forth generation cephalosporin (or 2.14; 95% ci 1.3-3.52), carbapenem (or 1.8; 95% ci 1.32.7), cotrimoxazole (or 1.8; 95% ci 1.3-2.7), and fluoroquinolone (or 1.7; 95% ci 1.2-2.4). other risk factors are inflammatory bowel disease (ibd), heart disease, chronic kidney disease, and white race.3 table 1 explains clinical characteristic of c. difficile infection.4 once c. difficile enters the body, it causes innate immune system by four virulence factor, tcda/tcdb (or toxin a and toxin b), flagellin, protein a (slpa), and pg fragment. all of this virulence factor then inducing production of nuclear factor κβ (nf-κβ) and ap-1 protein to release chemokine and pro-inflammatory cytokine.7 c. difficile infection is different from c. difficile colonization. toxigenic c. difficile always consists of toxin b and usually consists of toxin a. nontoxigenic c. difficile does not cause infection. nevertheless, toxigenic strain of c. difficile can cause colonization in asymptomatic patient. for diagnosing c. difficile infection, we need to obsereve diarrhea as clinical manifestation of c. difficile infection with positive result of toxin a and/or toxin b from feces specimen.1 d i a g n o s t i c a p p r o a c h a n d classification active infection of c. difficile is marked by new onset of 3 times/day diarrhea with unknown cause. other clinical manifestation that can occur table 1. clinical characteristic of c. difficile infection.4 characteristic hospital-acquired community-acquired recurrent age (median) 72 50-51 56-75 risk factors prior use of antimicrobial, ppi, ibd prior use of antimicrobial, heart disease, ckd, ibd older age, female, ckd, ibd, prior use of corticosteroid, immunocompromised strain 078, 106 ribotype 002, 020, 014, 015, 027, 078, 106 ribotype 027 30-day mortality rate 10.6% 3-17% 7.8-9.3% vol 55 • number 2 • april 2023 current diagnostic and treatment approach of clostridioides difficile 233 is fever, nausea and vomiting, and abdominal pain. every patient with flare of ibd and diarrhea as clinical manifestation is recommended to undergo c. difficile examination. normal result of colonoscopy and histopathology excludes c. difficile infection in patient with diarrhea.3 table 1 explains clinical manifestation of c. difficile infection.6 patient with clinical manifestation of c. difficile infection (diarrhea ≥ 3 times/day) should undergo c. difficile examination. c. difficile examination consists of gdh or naat examination. negative results excludes c. difficile infection, yet if the result is positive it means the patient is recommended to undergo toxin examination. naat or gdh examination alone can not distinguish c. difficile infection from c. difficile colonization. repeat examination within 7 days in the same diarrhea episode and in asymptomatic patient are not recommended.2 table 3 explains choices for diagnostic examination with each sensitivity and specificity.3 picture 1 explains algorithm for diagnosing c. difficile infection.3 table 2. clinical manifestation of c. difficile infection.6 spectrum of disease diarrhea other symptoms physical examination colonoscopy and other finding asymptomatic carrier none none normal normal simple antibiotic associated diarrhea mild absent usually normal normal early colitis profuse nausea, anorexia low grade fever, with/ without mild abdominal tenderness nonspecific patchy erythema pseudo-membranous colitis profuse nausea, malaise, abdominal discomfort fever (sometimes high); abdominal distension and tenderness pseudo-membrane (raised yellow plaque), leukocytosis (> 50,000/µl) with shift to the left pattern fulminant colitis usually profuse and sever, may be absent in ileus or toxic megacolon nausea, abdominal discomfort toxic appearance, high fever, abdominal distension, tenderness and peritoneal sign endoscopy is contraindicated in severely ill patient, leukemoid reaction, radiographic may show colonic dilatation, mucosa; thickening or perforation table 3. choices for diagnostic examination of c. difficile infection.3 examination sensitivity specificity ppv npv comment toxigenic culture 94 99 detect toxigenic strain not differentiate colonization from active infection glutamate dehydrogenase (gdh) 94-96 90-96 34-38 100 not differentiate toxigenic and non-toxigenic strain not differentiate colonization from active infection cell cytotoxicity neutralization assay (ccna) 93 98 detect free toxin b differentiate colonization from active infection nucleic acid amplification testing (naat) 95-96 94-98 46 100 gene detection for toxin b not differentiate colonization from active infection enzyme immunoassay (eia) toxin a and toxin b 57-83 99 69-81 99 detect free toxin differentiate colonization from active infection bella yunita acta med indones-indones j intern med 234 classification of c. difficile infection consists of severe disease, fulminant disease, and recurrent disease. severe c. difficile infection is characterized by leucocyte ≥ 15,000/ml or scr > 1.5 mg/dl. from post hoc analysis of rct study, it was reported that leukocytosis (rr 2.29; 95% ci 1.63-3.21) and renal failure (rr 2.52; 95% ci 1.82-3.5) that occurred in c. difficile infection were associated with failure of fidaxomicin and vancomycin therapy.9 other definition of severe disease comes from european society of clinical microbiology and infectious diseases (escmid), which defines severe c. difficile infection as infection with fever > 38.5oc, leukocytosis with leucocyte count of > 15,000/ ml, and rise in scr > 50% above baseline.10 fulminant c. difficile infection is characterized by criteria of severe disease and hypotension or shock or ileus or toxic megacolon. fulminant disease is associated with needs of colectomy, increased risk of mortality after procedure, or increased risk of death. other predictor for poor prognosis includes hypoalbuminemia, eosinophilia, fecal calprotectin > 2,000 mg/g, and fever > 38.5oc. hypoalbuminemia is marker of protein loss in the condition of colopathy and host defense mechanism to bind toxin a or b, thus it promotes proteolytic formation to gut epithelial and avoid cytotoxic effect of infection.3 recurrent infection is characterized as recurrent episode of diarrhea with positive result of confirmation test (naat or eia) within 8-12 weeks after initial treatment of c. difficile infection. outcome of recurrent infection divides into 2 categories: clinical recover (no diarrhea episode and no recurrent diarrhea) and bacteriologic recover (clinical recover and negative result from feces test).3 primary and secondary prevention prevention of c. difficile infection includes standard precautions such as use of gloves (handschoen) and gown, wash hands with water and soap and implementation of hand hygiene for health workers, family, or caregiver who treat c. difficile infection patients.2-3 other primary prevention of c. difficile infection includes rational use of antimicrobial.6 patient with c. difficile infection room and bathroom should be separated with other patient, until 48 hours after diarrhea resolved. asymptomatic patient is carrier of c. difficile infection, yet this group of patient does not have to be isolated from other patient.2,5 probiotic (living microorganism figure 1. diagnostic algorithm for c. difficile infection.3 vol 55 • number 2 • april 2023 current diagnostic and treatment approach of clostridioides difficile 235 with good effect for health, due to colonization of this microorganism is related to inhibition of pathogenic microorganism, modulation of immune system, and protect gut mucosa integrity) is not recommended as primary and secondary prophylaxis for c. difficile infection.3 fecal microbiota transplantation (fmt), a new prevention approach of c. difficile infection, is recommended to prevent recurrent infection. gut has normal flora that can inhibits or as competitor for pathogenic microorganism. in patient with proliferation of c. difficile, reduced number of normal gut flora is observed; thus fmt is thought to be a better option to increase number of normal gut flora that comes from healthy person.11 fmt is administered during colonoscopy procedure or by capsule. both of this administration of fmt is not different statistically from studies, but if it can not be done other approach is by enema administration. from rct study, enema administration of fmt is not different statistically with placebo, thus it is better if fmt was administered by capsule or colonoscopy. enema fmt can be considered in children with c. difficile infection. repeat dose of fmt can be given 8 weeks after the first dose.3 adverse effect of fmt administration is abdominal cramp, bloating, abdominal pain, nausea, diarrhea, constipation, and sub-febrile fever. risk of other pathogenic infection is also observed with fmt administration. from study, it was reported that bacteremia from extended spectrum beta lactamases (esbl) escherichia coli can occur in fmt administration. fmt administration can also causes perforation, gastrointestinal bleeding, and sedation complication. failure of fmt is defined as recurrent diarrhea with positive result of c. difficile. administration of fmt from colonoscopy procedure or antimicrobial can be given in this situation.3 donor candidate for fmt should be screened from hiv, hepatitis a, b, and c, viral, bacterial, and parasite infection.11 medical treatment for prevention of c. difficile infection consists of antimicrobial use or bezlotoxumab (bez). oral vancomycin with the dose of 125 mg daily can be offered in patient who is not fmt candidate, relapse after fmt administration, or high risk of recurrent c. difficile infection. this approach can be offered in older patient (age ≥ 65 years old) or immunocompromised patient.3 bez is monoclonal antibody that can bind with toxin b of c. difficile and can inhibit the toxin from attachment to gastrointestinal cell thus it can prevent colon cell damage. bez should be considered in older age (age ≥ 65 years old) with other criteria that consists of severe infection, immunocompromised patient, or recurrent infection of c. difficile within 6 months. bez should be used with caution in patient with heart failure or other heart comorbid. bez is administer in the dose of 10 mg/kg/day in 60 minutes, antibody can be detected 3 months after administration.3,12 management based on newest guidelines from american college of gastroenterology (acg) 2021, management of c. difficile infection with antimicrobial consists of • initial treatment for non-severe infection: oral vancomycin 125 mg q.d.s. or oral fidaxomicin 200 mg b.i.d. for 10 days • initial treatment for low risk and non-severe infection: oral metronidazole 500 mg t.i.d. for 10 days • initial treatment for severe infection: oral vancomycin 125 mg q.d. or oral fidaxomicin 200 mg b.i.d. for 10 days • fulminant disease: fluid resuscitation followed by oral vancomycin 500 mg q.d.s. within 48-72 hours, or in combination with intravenous metronidazole 500 mg t.i.d.. fmt should be considered in patient that refractory from antimicrobial therapy and poor candidate of surgery procedure • ileus patient: enema vancomycin 500 mg q.d.s. ibd patient: oral vancomycin 125 mg q.d.s. for 14 days • immunocompromised patient: vancomycin or fidaxomicin as antimicrobial • pregnant or lactation: vancomycin as antimicrobial3 ta b l e 4 e x p l a i n s a n t i m i c r o b i a l recommendation from infectious disease society of america (idsa) 2021.12 bella yunita acta med indones-indones j intern med 236 fidaxomicin is superior to prevent recurrent c. difficile infection, followed by vancomycin, and then metronidazole. low risk patient (younger patient with less comorbid) can be treated with metronidazole; this treatment is also cost-effective in this group of patient. other antimicrobial that is studied for c. difficile infection treatment are teicoplanin, nitazoxanide, surotomycin, cadazolid, and ridinilazole.3,13,14 other approach of antibody based therapy that has been studied for treatment of c. difficile infection beside bez, included intravenous immunoglobulin (ivig). yet, current study regarding use of ivig in c. difficile infection is not associated with improve mortality, colectomy, and hospital duration.13 antimotility agent such as loperamide without antimicrobial administration in fulminant disease is not recommended, due to trapped of c. difficile toxin can increase risk of toxic megacolon. if the patient is already in antimicrobial therapy, antimotility treatment can be considered. table 4. antimicrobial recommendation from infectious disease society of america (idsa) 202112 clinical manifestation recommended treatment comments initial episode preferred: oral fidaxomicin 200 mg b.i.d. for 10 days alternative: oral vancomycin 125 mg q.d.s. for 10 days alternative for non-severe disease: oral metronidazole 500 t.i.d. 10-14 days non-severe disease: leucocyte < 15,000/µl and scr < 1.5 mg/dl first recurrent disease preferred: oral fidaxomicin 200 mg b.i.d. for 10 days or 200 mg b.i.d. for 5 days followed by once every other day for 20 days alternative: oral vancomycin 125 mg q.d.s. for 10 days or in tapered and pulsed regimen adjunctive: intravenous bez 10 mg/kg during antimicrobial administration if metronidazole is given in the first treatment, consider oral vancomycin tapered/pulsed vancomycin regimen: 125 mg q.d.s. for 10-14 days, followed by 125 mg b.i.d. for 7 days, 125 mg o.d. for 7 days, then every 2-3 days for 2-8 weeks second or subsequent recurrent disease oral fidaxomicin 200 mg b.i.d. for 10 days or 200 mg b.i.d. for 5 days followed by once every other day for 20 days oral vancomycin in tapered and pulsed regimen oral vancomycin 125 mg q.d.s. for 10 days followed by rifaximin 125 mg t.i.d. for 20 days fmt adjunctive: intravenous bez 10 mg/kg during antimicrobial administration antimicrobial should be offered first then fmt fulminant infection oral or ngt administration of vancomycin 500 mg q.d.s. combination with intravenous metronidazole 500 mg t.i.d. should be considered in ileus patient rectal instillation of vancomycin in ileus patient fulminant: hypotension or shock, ileus, toxic megacolon cholestyramine is not recommended as c. difficile infection treatment, moreover in patient with vancomycin administration due to drug interaction between this two drugs. high fiber diet should be considered in c. difficile infection, because it can increase gut microbiota and reduce c. difficile.3 fulminant c. difficile infection should be treated in multidisciplinary approach, involving gastroenterologist, infection specialty, critical care, and surgeon. supportive treatment with fluid resuscitation is administered with the target of normal urine output (0.5-1 ml/kg/ hour) and renal function. antimicrobial is recommended with option and dose as previously stated. in ileus patient, enema vancomycin is recommended, due to more effective delivery of treatment compared to oral administration of drug. combination with metronidazole should be considered, because metronidazole has greater delivery to colon in ileus patient compared to oral vancomycin.3 vol 55 • number 2 • april 2023 current diagnostic and treatment approach of clostridioides difficile 237 surgery should be done with colectomy and end ileostomy and stapled rectal stump or diverting loop ileostomy with colon lavage and intraluminal vancomycin for 10 days. surgery is recommended in patient with fulminant disease and followed by toxic megacolon, ischemia, or perforation of the gut. fmt is also recommended in fulminant or severe infection, with colonoscopy approach, especially in pseudo-membrane disease. fmt can be administered 3-5 days until loss of pseudo-membrane. fmt administration is also associated with reduce risk of colectomy and sepsis. recurrent infection should be treated with different antimicrobial with initial therapy. for patient with vancomycin and metronidazole as initial therapy, for recurrent infection this patient should be treated with fidaxomicin. metronidazole is not recommended in recurrent infection. anti-secretory agent such as proton pump inhibitor (ppi) should be continued once it is started.3 patients with ibd exposed to higher risk of c. difficile infection due to corticosteroid and biological agent (infliximab, adalimumab) exposure, more comorbid, hospitalization history and repeat visit to hospital to control their disease. c. difficile infection in ibd increase risk of colectomy. in patient with ibd, oral vancomycin 4 x 125 mf should be given of minimal 14 days. in flare ibd, immunosuppressive agent should not be stopped, yet if the symptom does not improve after c. difficile infection treatment, escalation of immunosuppressive agent should be considered.3 in special population such as lactating or pregnant women, vancomycin is antimicrobial of choice, because higher risk of failure with metronidazole therapy. fidaxomicin should be avoided in lactating or pregnant women, while fmt should be avoided in pregnancy. vancomycin is not transferred in breast milk, thus it is safe to give to lactating women. immunocompromised patient can be given vancomycin or fidaxomicin. in immunocompromised patient, c. difficile is easier to occur, with high risk of severe and recurrent disease. this risk increased due to history of hospitalization, neutropenia, history of antimicrobial and immunosuppressive agent. increased risk occurred in hiv patient with cd4 ≤ 50 cell/mm3 and multiple organ transplantation.3 conclusion due to high spectrum of disease, diagnostic and management approach of c. difficile infection should be noticed. for patient with high risk of this infection (older age, history of hospitalization, history of antimicrobial use) that experience diarrhea 3 times/day, gdh or naat test should be conducted. negative result defined negative c. difficile infection, while positive result should be confirmed with toxin detection. if the toxin detection is positive, thus the patient is diagnosed with c. difficile infection. antimicrobial agent should be administered based on initial or recurrent disease, severity of disease, with fmt, bez as adjunctive treatment to prevent recurrent infection. unfortunately, choices of treatment is not much in indonesia, because the only option of antimicrobial that is available is metronidazole. thus, primary prevention by implementing standard precaution and rational use of antimicrobial should be primary priority in limited resource country. references 1. collins da, gasem mh, habibie th, et al. prevalence and molecular epidemiology of clostridium difficile infection in indonesia. new microbe and new infect. 2017;18:34-7. 2. mcdonald lc, gerding dn, johnson s, et al. clinical practice guidelines for clostridium difficile infection in adults and children: 2017 update by the infectious diseases society of america (idsa) and society of healthcare epidemiology of america (shea). clin infect dis. 2018;66:e1-48. 3. kelly cr, fischer m, allegretti jr, et al. acg clinical guidelines: prevention, diagnosis, and treatment of clostridioides difficile infections. am j gastroenterol. 2021;116:1124-47. 4. fu y, luo y, grinspan am. epidemiology of community-acquired and recurrent clostridioides difficile infection. therap adv gastroenterol. 2021;14:1-11. 5. sandhu bk, mcbride sm. clostridioides difficile. trends microbiol. 2018;26:1049-50. 6. guh ay, kutty pk. in the clinic: clostridioides difficile infection. ann intern med. 2018;169:itc49-64. 7. liwang f, sinto r. pendekatan klinis terkini infeksi clostridium difficile nosocomial. jpdi. 2021;8:104-9. 8. smilings c, riley tv. antibiotics and hospitalbella yunita acta med indones-indones j intern med 238 acquired clostridium difficile infection: update of systematic review and meta-analysis. j antimicrobe chemother. 2014;69:881-91. 9. bauer mp, hensgens mp, miller ma, et al. renal failure and leukocytosis are predictors of a complicated course of clostridium difficile infection if measured on day of diagnosis. clin infect dis. 2012;55:s149-53. 10. van prehn j, reigadas e, vogelzang eh, et al. european society of clinical microbiology and infectious diseases: 2021 update on treatment guidance document for clostridioides difficile infection in adults. clin microbiol infect. 2021;27:s1-21. 11. gupta a, khanna s. fecal microbiota transplantation. jama. 2017;318:1. 12. johnson s, lavergne v, skinner am, et al. clinical practice guideline by the infectious diseases society america (idsa) and society for healthcare epidemiology of america (shea): 2021 focused update guidelines on management of clostridioides difficile infection in adults. clin infect dis. 2021;73: e1029-44. 13. cho jm, pardi ds, khanna s. update on treatment of clostridioides difficile infection. mayo clin proc. 2020;95:758-69. 14. guery b, galperine t, barbut f. clostridioides difficile: diagnosis and treatments. bmj. 2019;366:l4609. review article 259acta med indones indones j intern med • vol 49 • number 3 • july 2017 multidiscipline care for type 2 diabetes patients: from general to asian population benedicta m. suwita1, dewi friska2, deriyan s. widjaja1, liana srisawitri2 1 faculty of medicine universitas indonesia, jakarta, indonesia. 2 community medicine department, faculty of medicine universitas indonesia, jakarta, indonesia. corresponding author: dewi friska, md. community medicine department, faculty of medicine universitas indonesia. jl. pegangsaan timur no. 16, cikini, jakarta 10320, indonesia. email: defriska@yahoo.com. abstrak tatalaksana multidisiplin didefinisikan sebagai tatalaksana yang melibatkan setidaknya satu dokter, satu perawat, dan petugas kesehatan lainnya (contohnya dietisien). tatalaksana multidisiplin dapat memberikan keuntungan, baik dalam aspek medis (misalnya meningkatkan kepatuhan berobat pasien) dan non-medis (misalnya meningkatkan efektivitas biaya dibandingkan tatalaksana konservatif). terdapat beberapa model tatalaksana multidisiplin; namun demikian, model yang paling cocok untuk tatalaksana diabetes mellitus tipe 2 belum jelas. dalam kajian ini, penulis bertujuan mengidentifikasi dan membandingkan berbagai jenis tatalaksana multidisiplin dalam menurunkan kadar hemoglobin glikosilasi (hba1c) pada pasien diabetes mellitus tipe 2, terutama pasien ras asia, karena golongan ini memiliki kecenderungan untuk mengidap diabetes mellitus tipe 2 pada derajat obesitas yang lebih rendah dan usia yang lebih muda dibandingkan kelompok ras kaukasia. penelitian mengenai tatalaksana multidisiplin pada pasien diabetes mellitus tipe 2 masih terbatas, terlebih untuk pasien ras asia. studi-studi tersebut menunjukkan hasil yang bervariasi mengenai efektivitas tatalaksana multidisiplin untuk mencapai target hba1c. kunjungan tenaga medis, baik dalam sesi perorangan ataupun kelompok, tampak efektif pada populasi pasien diabetes mellitus tipe 2 secara umum dan pada ras asia. penelitian lebih lanjut masih diperlukan untuk mengetahui model tatalaksana multidisiplin mana yang paling cocok untuk pasien di wilayah tertentu dengan kebudayaan, kondisi sosial ekonomi dan fasilitas kesehatan yang beragam. kata kunci: asia, diabetes melitus tipe 2, hemoglobin glikosilasi, tatalaksana multidisiplin, tim multidisiplin. abstract multidiscipline care is defined as a care consisting of at least a physician, a nurse, and other healthcare worker (eg. dietician). multidiscipline care has generated benefits, both in medical aspects (eg. increasing patients’ compliance) and nonmedical aspects (eg. more cost-effective than conventional treatment). there are several models of multidiscpline care; however, which model is more suitable for type 2 diabetes care is not clear yet. in this review, we aimed to identify and compare multidiscipline care method for reducing glycated hemoglobin ( hba1c) levels in type 2 diabetes patients, particularly asian patients because they have greater tendency to develop type 2 diabetes at lower degrees of obesity and at younger ages than caucasian ethnic group. there were limited number of studies examining multidiscipline care for type 2 diabetes patients, moreover for asian patients. they showed mixed results on the efficacy of multidiscipline care in achieving hba1c target. healthcare personnel visit, either personal or group session, appeared effective both for general and asian t2dm patients. it needs further studies to clarify which models are most effective for practices of varying cultures, socio-economic condition, and healthcare settings. keywords: asian, type 2 diabetes mellitus, glycated hemoglobin, multidiscipline care, multidiscipline team. benedicta m. suwita acta med indones-indones j intern med 260 introduction type 2 diabetes mellitus (t2dm) is a chronic metabolic disorder which affects more than 300 million people worldwide; this number is expected to reach 438 million by 2030 for those aged between 20-70 years old.1-3 however, the proportion of those achieving optimal glycemic control is predicted to be less than half. several factors, such as non-adherence to the prescribed medications or improper administration of drugs by the patients, contribute to this failure.4-12 multidiscipline care, defined as a healthcare consisting of at least an attending physician, a nurse, and other healthcare worker (eg. dietitian), has generated positive impact on both medical and nonmedical aspects. increased treatment compliance and cost-effectiveness are some examples of its benefit. it is also associated with statistically significant reduction in hba1c level.4,13 asians have greater tendency to develop t2dm at lower degrees of obesity and at younger ages than their caucasian counterparts.14-15 asian patients also face more cultural and familal barriers in t2dm treatments. culturally meaningful food, such as white rice, has to be reduced due to its glycemic content. dietary modifications can compel patient to skip somethings in a family meal, such as sweet desserts. in some cultures which value certain staple food and sharing meals with family members, these lifestyle changes can be very unpleasant. additionally, family members can consider the patient as a burden that needs to be cared for – determining who should be the primary caregiver sometimes cannot be settled peacefully between family members, and potentially create a family conflict.16,17 there are several types of multidiscipline care, but little is known about its capability of achieving glycemic control, especially for asian patients. this review examines various multidisciplinary care models in t2dm treatment to achieve hba1c target and also provides the basics of multidiscipline approach for general practitioners. benefits of multidiscipline care collaborative, multidiscipline teams are best suited to provide care for people with chronic conditions, such as diabetes, and to facilitate patients’ self management.18 t2dm treatment includes medication, changes in diet and physical activity. patients need knowledge, motivation, training, and ongoing support to incorporate treatment regimens in their daily lives.19 for this purpose, cooperation between physicians and other health care personnels is inevitable, creating a multidiscipline team to provide all aspects of the t2dm treatment. multidiscplinary approach involves multiple contacts with different healthcare personnel, each specialized in a particular process or expertise – including nurse educators, nutritionists, pharmacists, physical trainers and podiatrists.4 tailored care that supplied culturally-appropriate diabetes selfmanagement education and treatment approach will yield better outcomes according to national institute for health and care excellence (nice) and american diabetes association (ada) guidelines.4,18,20 systematic reviews and observational studies in both developed and developing countries showed drug compliance rate among t2dm patients were poor; it could be as low as 16%. patients had numerous reasons for nonadherence, such as lack of disease knowledge and fear of medication side effects – these might be intervened effectively using multidisciplinary approach.4,10,21-23 a randomized clinical trial (rct) in t2dm patients with baseline hba1c >8% showed that multidiscipline care with pharmacist increased medical compliance and drug knowledge significantly compared to standard care.11 multidiscipline care model several multidiscipline care models will be discussed in this review: (1) telephone coaching, (2) healthcare personnel visit, and (3) combination of both. telephone coaching was done either by nurse or pharmacist its content varied between studies, but it included: introduction of nurse/ pharmacist’s role, confirmation of medical history, exploring patient’s knowledge about diabetes, identification of barriers to adherence, identification of attainable behavioral goals, and providing advice on lifestyle improvements. healthcare personnel visit was also done either vol 49 • number 3 • july 2017 multidiscipline care for type 2 diabetes patients 261 by nurse or pharmacist. intervention duration varied between studies (table 1). metaanalyses and randomized clinical trials (rct) showed mixed results on the effectivity of multidiscipline care in achieving hba1c target. healthcare personnel visit appeared effective, while telephone coaching and combined method seemed not beneficial for reducing hba1c.9, 27, 29,31-33 there were only 2 rcts specifically assessed t2dm asian patients, both showed significant reduction in glycated hemoglobin level.11,30 several rcts showed that team-based care was associated with statistically significant reductions of hba1c value.4,24 however, metaanalysis revealed mixed results. there was no significant difference in hba1c between multidiscplinary and standard approach, albeit a lower tendency of hba1c in multidiscpline group. only one meta-analysis involving 31 studies and 4263 patients showed a significant decrease in hba1c, but this benefit declined shortly after the multidiscpline care had stopped. several factors might lead to this inconsistency, for example diversity of intervention method, team composition and presence of commorbidity. intensity and duration of intervention also varied between clinical trials. all studies in these metaanalysis were conducted in western countries, mostly in the united states.25-26 telephone coaching intervention using telephone coaching showed mixed results. one rct using telephone call up to 18 sessions and total 420 minutes showed significantly lower hba1c than standard care, while other rct using up to 5 sessions and total 150 minutes had no significant hba1c difference.19,27 on the other hand, a large wellconducted rct showed that telephone coaching by pharmacist could increase drug compliance and reduce mortality risk significantly in t2dm patients receiving polypharmacy.28 currently, there was no standard for frequency and duration of telephone sessions needed to yield significant effect on achieving t2dm treatment goals. healthcare personnel visit visits by nurse or pharmacist seemed effective. in reviewed rcts, the initial visits were more frequent before treatment goal achieved (weekly to three-monthly), then less frequently afterwards (monthly to four-monthly). intervention duration varied from 6 to 24 months, but all showed a significant difference in hba1c reduction compared to standard care. these visits could be given for an individual patient or a group of patients. however, it needs to be noted that some of these rcts had small sample size, one study had only 99 subjects in total.11,29-31 in our opinion, meeting face-to-face with the patient is more effective than telephone call for table 1. summary of multidiscipline care models used in clinical studies during the last decade (2006-2016) author year country duration participant (total) multidiscipline care model hba1c reduction in multidiscipline care compared to standard care frosch, et al9 2011 united states 6 months 201 telephone coaching not significant pape, et al27 2011 united states 24 months 6 963 telephone coaching not significant chan, et al11 2012 china (hongkong) 9 months 105 healthcare personnel visit significant cohen, et al29 2011 united states 6 months 99 healthcare personnel visit (group session) significant ko, et al30 2011 china (hongkong) 24 months 205 healthcare personnel visit significant katon, et al31 2010 united states 12 months 214 healthcare personnel visit significant katon ,et al32 2012 united states 24 months 214 combination (telephone coaching and healthcare personnel visit) not significant johnson, et al33 2014 canada 12 months 1 924 combination (telephone coaching and healthcare personnel visit) not significant benedicta m. suwita acta med indones-indones j intern med 262 self-management education and support. the duration and frequency of these sessions should be planned based on patients’ characteristics, such as presence of commorbidity. for patients without psychiatric or cognitive problems, a monthly multidiscpline team visit with 15-30 minutes for each session was used. only one rct assessed t2dm patients with psychiatric commorbidity – in this study, patients with t2dm and depression were visited by trained nurses every two weeks.11,29-31 combination of telephone coaching and healthcare personnel visit combining telephone call and healthcare personnel visit appeared to be not beneficial for glycemic control. all patients involved in the studies had depression, in which depression symptoms reduced significantly, while hba1c reduction was insignificant. only one rct involving 214 patients in 14 primary clinic showed significant reduction in both hba1c and depression symptoms. however, after the intervention was stopped, hba1c target achievements quickly declined in just 6 months.32-33 it might imply that behavioral changes needed to achieve optimal glycemic control, such as medication adherence and healthy lifestyle, could not be fostered in a short amount of time. based on the effective intervention duration from reviewed rcts,11,29-31 it might need at least 6 months of multidiscipline care to achieve behavior changes that could lead to significant hba1c reduction, and at least 12 months to maintain those changes. many working patients might be unable to attend clinical visits if they were more frequent than regular physician consultation. scarcity of healthcare centres in some regions also meant that patients must travel long distance, making it more difficult to attend frequent sessions. in these situations, combining healthcare personnel visits with telephone calls could be effective to create more frequent follow-up or educational sessions. modification on the combination – steppedcare or stepwise approach – was another potential solution. in this approach, the frequency of clinical visit was tailored according to clinical outcomes. patients with worse clinical outcomes would receive more intensive multidiscipline care, and telephone sessions could be changed into face-to-face meeting sessions if their outcomes declined over-time. this way, patients could avoid unnecessary visits and receive more intensive care when truly needed. however, current ada guideline specifically recommended this stepwise multidiscipline care approach for patients with comorbid diabetes and depression, focusing on the depression symptoms management.18 group-based session recent rct using group-based session, with four to six patients in each group, significantly reduced hba1c level compared to standard care.29 additionally, patients could benefit from peer-support. current nice guideline recommended group-based programmes as preferred option.20 there’s also growing evidence for the role of community health workers, peer, or lay leaders.34-40 in our opinion, this method is particularly useful in centres with many t2dm patients and/or few healthcare providers available, as happened in many primary healthcare centres. however, t2dm patients with complication or commorbidity may need personal session tailored to individual clinical profile. multidiscipline team composition there were several multidiscipline team composition used in studies, such as primary care physician (pcp) – nurse, pcp-pharmacist, pcp-nurse-dietician, and pcp-nurse-specialist (endocrinologist or psychiatrist). intervention duration varied between studies (table 1). we found that additional team member used in clinical trials were mostly nurse or pharmacist, both had mixed results. until now, there is no study comparing the effectivity of involving nurse and pharmacist in conducting multidiscipline approach.11,19,29-33 it seemed that pharmacists were more specialized for educating patients about their medication, especially patients with multipharmacological treatment, and assisting physician in monitoring potential drug interaction. on the other hand, nurses were more specialized for educating patients about their lifestyle changes, monitoring symptoms or other clinical outcomes, and counseling—especially vol 49 • number 3 • july 2017 multidiscipline care for type 2 diabetes patients 263 for patients with commorbidity. however, in healthcare centres with limited number of healthcare personnel, choosing additional team member could be done based on their availability. collaboration with specialist is inevitable in managing complicated cases and contributes to treatment goal achievement. in one rct, collaboration between primary care physician and psychiatrist for t2dm and depressed patients led to better outcomes for both conditions.31 another rct showed that collaboration between nurse and endocrinologist for t2dm patients with chronic kidney disease (ckd) led to better diabetic and renal outcomes.30 an opencontrolled trial showed that a community-based care led by general practitioner in partnership with endocrinologist can produce more clinical and process benefits compared with a tertiary diabetes outpatient clinic.41 m u lt i d i s c i p l i n e c a r e f o r t y p e 2 diabetes asian patients studies evaluating medication adherence in asian population were limited. an observational study in malaysian primary clinics showed that only half (47%) patients were adherent.21 an rct involving 105 t2dm patients in hongkong with baseline hba1c >8% showed that team-based care with pharmacist increased medical compliance significantly compared to standard care (22.5%+13.4% vs 2.0%+5.0%, p<.001).11 it might imply that the causes of nonadherence in asian patients could be improved by multidisciplinary approach. only two rcts specifically evaluated multidiscipline care in asians for achieving glycemic target. they were conducted in hongkong, china, with relatively small samples and used healthcare personnel visits as their multidiscipline care method—both showed significant hba1c reduction. the longest follow-up duration was twentyfour months.11,30 however, these results cannot be generalized to all chinese, or to other asian ethnicity. most asian countries are developing countries, and many t2dm patients have low income. taking multiple jobs to sustain living could make patients unable to attend scheduled visits, eventhough healthcare cost was free.19 additionally, t2dm prevalence in asia increased markedly, potentially causing unbalanced healthcare providers and patients ratio. 2,14 in our opinion, mixed approach combining telephone coaching and healthcare personnel visits (individual or group sessions) may become beneficial in this situation. stepwise approach according to patient’s risk stratification is also potentially beneficial, especially for t2dm patients with depression. we found no study evaluating multidiscipline care in asian patients living in non-asian countries. this data is also important, because asians make considerable portion of overall population in many western countries. in united kingdom, for example, asians currently make 7.5% of population and will most likely increase due to incoming refugees.42-43 a small observational study in chinese-americans showed that they faced many more social and cultural barriers in t2dm management, especially for female patients. family barriers consisted of the perception that diabetes disrupted family harmony, cultural food practice, and family role/responsibilities.16-17 there was no study evaluating socio-cultural problems for t2dm management in asian ethnicities other than chinese. conclusion current evidence is few regarding how to deliver multidiscipline care specifically for t2dm asian patients. physicians and other healthcare providers should have cultural sensitivity to recognize whether t2dm management for a particular patient is culturally appropriate or not. this review cannot be used as a guide for tailoring multidiscipline care in asian population. however, it provides some insight on possible methods of multidiscipline care delivery and problems potentially encountered in treating t2dm asian patients with multidiscipline approach. in healthcare centre with high number of patients, using group session with or without telephone coaching for delivering multidiscipline care seems beneficial. benedicta m. suwita acta med indones-indones j intern med 264 limitations this systematic review has several limitations. first, there was no study comparing the efficacy between multidiscplinary care models in general or asian population. second, studies evaluating t2dm asian patients, especially with complication or commorbidity, were very few. therefore, they should be interpreted carefully and could not be extrapolated in all t2dm asian patients, with or without complication and commorbidity. third, the longest intervention duration in the studies was twentyfour months, both for general and asian population, while t2dm is a life-long disease. therefore, its true efficacy in the long haul is not clear. lastly, other t2dm treatment targets, such as blood pressure and cholesterol, were not examined. unlike type 1 diabetes management which already has a well-defined multidiscipline care (including self-management education and support) in current guidelines, there are no clear guidelines on how to tailor a multidiscipline care for type 2 diabetes patients. therefore, determining types of multidiscipline approach most effective for each of type 2 diabetes patients is a very important and interesting topic. the results from joint asia diabetes evaluation (jade) trial, which examine the effectiveness of stepwise approach with calculated risk stratification in t2dm asian patients within various asian countries will shed some light on this topic. this knowledge is necessary for family physicians all over the world, because almost all medical centres in both developing and developed countries have a considerable number of type 2 diabetes asian patients to treat. further studies need to clarify which models are most effective for practices of varying cultures, socioeconomic condition, and healthcare settings. acknowledgments the authors would like to thank evan regar, md, cipto mangunkusumo national general hospital, jakarta, indonesia for his comments and suggestions on the first version of the article; yashinta, md, sawah besar district hospital, jakarta, indonesia, and wynne oktavianne lionika, md, sawah besar district hospital, jakarta, indonesia, for reviewing the article and making valuable suggestion for revision. references 1. world health organization. diabetes: fact sheet n.312. 2015. www.who.int/mediacentre/factsheets/fs312/en/ [aceessed on december 12, 2015]. 2. world health organization. diabetes programme: facts and figures about diabetes. 2015. www.who. int/diabetes/facts/world_figures/en/ [aceessed on december 12, 2015]. 3. ramachandran a, snehalatha c, shetty as, nanditha a. trends in prevalence of diabetes in asian countries. world j diabetes. 2012;3(6):110-7. 4. so wy, chan jcn. the role of the multidiscipline team. in: holt r, cockram c, flyvbjerg a, goldstein b, eds. textbook of diabetes. 4th ed. oxford: wileyblackwell publishing. 2010:969-83. 5. guisasola fa, mavros gp, alemao ne, et al. glycemic control among patients with type 2 diabetes mellitus in seven european countries: findings from the reallife effectiveness and care patterns of diabetes management (recap-dm) study. diabetes obes metabolism. 2008;10:8-15. 6. selvin e, parrinello cm, sacks db, et al. trends in prevalence and control of diabetes in the u.s., 19881994 and 1999-2010. ann intern med. 2014;160(8): 517–25. 7. jeon jy, kim dj, ko sh, et al. current status of glycemic control of patients with diabetes in korea: the fifth korea national health and nutrition examination survey. diabetes metab j. 2014;38:197203. 8. mainous ag, diaz va, saxena s, baker r, et al. diabetes management in the usa and england: comparative analysis of national surveys. j r soc med. 2006;99:463–9. 9. dirar a, aburawi f, salih sb, et al. comparison of achievement of nice targets in type 2 diabetes in riyadh, saudi arabia and grimsby, united kingdom: an audit. j pak med assoc. 2012;62:318-21. 10. esposito k, chiodini p, bellastella g, et al. proportion of patients at hba1c target <7% with eight classes of antidiabetic drugs in type 2 diabetes: systematic review of 218 randomized controlled trials with 78 945 patients. diabetes obes metabolism. 2012;14(3): 228-33. 11. chan cw, siu sc, wong ckw, et al. a pharmacist care program: positive impact on cardiac risk in patients with type 2 diabetes. j cardiovasc pharmacol ther. 2012;17:57-64. 12. chan jc , gagliardino jj , baik sh, et al. multifaceted determinants for achieving glycemic control: the international diabetes management practice study (idmps). diab care. 2009;32:227–33. 13. gaede p, lund-andersen h, parving hh. effect of a multifactorial intervention on mortality in type 2 diabetes. n engl j med. 2008;358:580-91. vol 49 • number 3 • july 2017 multidiscipline care for type 2 diabetes patients 265 14. hu fb. globalization of diabetes: the role of diet, lifestyle, and genes. diab care. 2011;34(6):1249-57. 15. public health england. adult obesity and type2 diabetes. 2014. www.gov.uk/government/uploads/ system/uploads/attachment_data/file/338934/adult_ obesity_and_type_2_diabetes_.pdf [aceessed on december 12, 2015]. 16. chesla ca, kwan cml, chun km. cultural and family challenges to managing ttype 2 diabetes in immigrant chinese americans. diab care. 2009;32:1812–6. 17. rosland am. heisler m, choi hj, et al. family influences on self-management among functionally independent adults with diabetes or heart failure: do family members hinder as much as they help? chronic illn. 2010;6(1):22-3. 18. american diabetes association. standards of medical care in diabetes – 2015. diab care. 2015;38(suppl.1): s1–s2. 19. frosch dl, uy v, ochoa s, et al. evaluation of a behavior support intervention for patients with poorly controlled diabetes. arch intern med. 2011;171(22): 2011-7. 20. national institute for health and care excellence. type 2 diabetes in adults: management (nice guidance 28). 2015. www.nice.org.uk/guidance/ng28 [aceessed on december 12, 2015]. 21. ahmad ns, ramli a, islahudin f, et al. medication adherence in patients with type 2 diabetes mellitus treated at primary health clinics in malaysia. patient preference and adherence. 2013;7:525-30. 22. tiv m, viel jf, mauny f, et al. medication adherence in type 2 diabetes: the entred study 2007, a french population-based study. plos one. 2012;7(3):e32412. 23. garcía-pérez le, álvarez ma, dilla t, et al. adherence to therapies in patients with type 2 diabetes. diabetes ther. 2013;4:175-94. 24. shojania kg , ranji sr , mcdonald km , et al. effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta regression analysis. jama. 2006;296:427–40. 25. watson lc, amick hr, gaynes bn, et al. practicebased interventions addressing concomitant depression and chronic medical conditions in the primary care setting: a systematic review and meta-analysis. j primary care community health. 2013;4(4):294-306. 26. huang y, wei x, wu t, et al. collaborative care for patients with depression and diabetes mellitus: a systematic review and meta-analysis. bmc psychiatry. 2013;13:260-70. 27. pape ga, hunt js, butler kl, et al. team-based care approach to cholesterol management in diabetes mellitus: two-year cluster randomized controlled trial. arch intern med. 2011;171(16):1480-6. 28. wu jy, leung wy, chang s, et al. effectiveness of telephone counselling by a pharmacist in reducing mortality in patients receiving polypharmacy: randomised controlled trial. br med j. 2006;333:522. 29. cohen lb, taveira th, khatana sam, et al. pharmacist-led shared medical appointments for multiple cardiovascular risk reduction in patients with type 2 diabetes. the diabetes educator. 2011;37(6):801-12. 30. ko gtc, yeung cy, leung wys, et al. cost implication of team-based structured versus usual care for type 2 diabetic patients with chronic renal disease. hong kong med j. 2011;17(suppl 6):s9-12. 31. katon wj, lin ehb, von korff m, et al. collaborative care for patients with depression and chronic ilnesses. n engl j med. 2010;363:2611-20. 32. katon w, russo j, lin ehb, et al. cost-effectiveness of a multicondition collaborative care intervention: a randomized controlled trial. arch gen psychiatry. 2012;69(5):254-67. 33. johnson ja, sayah fa, wozniak l, et al. collaborative care versus screening and follow-up for patients with diabetes and depressive symptoms: results of a primary care-based comparative effectiveness trial. diabetes care. 2014;37:3320-6. 34. shah m, kaselitz e, heisler m. the role of community health workers in diabetes: update on current literature. curr diab rep. 2013;13:163–171. 35. heisler m, vijan s, makki f, et al. diabetes control with reciprocal peer support versus nurse care management: a randomized trial. ann intern med. 2010;153:507–15. 36. heisler m. overview of peer support models to improve diabetes self-management and clinical outcomes. diabetes spectrum. 2007;20:214–21. 37. long ja, jahnle ec, richardson dm, loewenstein g, volpp kg. peer mentoring and financial incentives to improve glucose control in african american veterans: a randomized trial. ann intern med. 2012;156:416–24. 38. moskowitz d, thom dh, hessler d, ghorob a, bodenheimer t. peer coaching to improve diabetes self-management: which patients benefit most? j gen intern med. 2013;28:938–942. 39. foster g, taylor sjc, eldridge se, ramsay j,griffiths cj. self-management education programmes by lay leaders for people with chronic conditions. cochrane database syst rev. 2007;4:cd005108. 40. siminerio l, ruppert km, gabbay ra. who can provide diabetes self-management support in primary care? findings from a randomized controlled trial. diabetes educ. 2013;39:705–13. 41. russell aw, baxter ka, askew da, et al. model of care for the management of complex type 2 diabetes managed in the community by primary care physicians with specialist support: an open controlled trial. diabet med. 2013;30:1112–21. 42. british refugee council. quarterly assylum statistics: february. 2016. www.refugeecouncil.org.uk/ assets/0003/6985/asylum_statistics_feb_2016.pdf [aceessed on april 10, 2016]. benedicta m. suwita acta med indones-indones j intern med 266 43. office for national statistics. ethinicity and national identity in england and wales. 2011. www.ons.gov.uk/peoplepopulationandcommunity/ culturalidentity/ethnicity/articles/ethnicityand nationalidentityinenglandandwales/2012-12-11 [aceessed on april 10, 2016]. 595acta med indones indones j intern med • vol 53 • number 4 • october 2021 case report the profile of covid-19 in patients with autoimmune disease: a case series zubairi djoerban1,2, muhammad alkaff2,3, dimas priantono1,2, dyah agustina waluyo2, jessica marsigit2,4, chairina azyka noor2,4, oemar ichsan2, kevin yonathan2, matdoan rifikah aisyah2,4, andy william2, uva rahmah2, wahyu permatasari2,4 1 division of hematology and medical oncology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo general hospital, jakarta, indonesia. 2 kramat 128 general hospital, jakarta, indonesia. 3 department of internal medicine, faculty of medicine universitas indonesia – persahabatan general hospital, jakarta, indonesia. 4 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo general hospital, jakarta, indonesia. *corresponding author: prof. zubairi djoerban, md., phd. hematology-oncologist consultant, internal medicine specialist, kramat 128 hospital. jl. kramat raya, jakarta 10430, indonesia. email: zubairi_djoerban@yahoo.com. abstract autoimmune diseases are known to be a risk factor for severe covid-19 infection. this is the first case series of patients with autoimmune disease suffering from covid-19 infection in jakarta, indonesia. there were 12 confirmed cases of covid-19 infection in autoimmune patients from march 2020 until february 2021. we select 5 patients in this case series. three of them had systemic lupus erythematous (sle), one of them had rheumatoid arthritis, and one of them had ankylosing spondylitis. three of them had high bsr risk stratification. most of them had used daily steroid therapy. fatigue, abdominal pain, diarrhea, and cough were the common symptoms found. none of the patients were admitted to icu, used mechanical ventilators, and all of them survived. most of the patients were prescribed anti-coagulant therapy. this first comprehensive case series can provide valuable information regarding the clinical characteristics of covid-19 infection in the indonesian autoimmune disorder patient population. keywords: autoimmune diseases, covid-19, case series, indonesia. introduction coronavirus disease-19 (covid-19) is a new global pandemic that started in wuhan, china, at the end of 2019. it is caused by a new virus known as severe acute respiratory syndrome coronavirus 2 (sars-cov-2).1 the virus is transmitted via droplets, and its spike protein (protein s) can infect the respiratory cells as it has angiotensin-converting enzyme-2 (ace-2) receptors. in addition to causing respiratory symptoms, it can also manifest in other organ systems, for example kidney injury, heart damage, and coagulation in the blood vessels. based on the latest number in indonesia, there are more than 1 million cases of covid-19 infection with mortality cases over zubairi djoerban acta med indones-indones j intern med 596 25,000 (2.9% mortality rate).2 the spectrum of severity in covid-19 is variable, ranging from asymptomatic, mild symptoms, moderate symptoms, and life-threatening conditions such as acute respiratory distress syndrome (ards) and multi-system organ failure. patients with chronic comorbid conditions have a higher risk of morbidity and mortality of covid-19.3 the severity of covid-19 is related to a combination between uncontrolled inflammation and dysfunctional lymphocyte response.4 autoimmune disease is a known risk factor for severe covid-19 infection as patients usually receive immunosuppressive therapy to control the disease.5 autoimmune disease occurs when the immune system attacks the body’s cells due to immunologic tolerance breakdown towards autoreactive immunity. it is a multifactorial disease that is usually related to genetics, environments, and infections. common examples of autoimmune disease include systemic lupus erythematosus, rheumatoid arthritis, multiple sclerosis, inflammatory bowel disease, etc.6 steroids are currently used in treating covid-19 infection, and it may have a dual effect on the patient. steroids can either exacerbate the infection or protect the host from cytokine storms resulting from the viral clearance in the early stages.7 current prevalence of the autoimmune disease in indonesia is expected to be more than 2000 patients, and the number is increasing annually, yet the exact number is still unknown.8 to o u r k n o w l e d g e , t h i s i s t h e f i r s t comprehensive case series in indonesia reporting the characteristics and clinical course of covid-19 in patients with autoimmune diseases. case illustration cases were collected retrospectively from medical records between march 2020 until february 2021. cases were confirmed by rtpcr (qrt-pcr) detection of sars-cov-2 rna through analysis of nasopharyngeal swabs. the severity of covid-19 infection was classified based on the indonesia national guideline of covid-19.9 the specific diagnosis of autoimmune diseases was made based on the revised classification criteria of the american college of rheumatology. british society of rheumatology (bsr)risk stratification was used to know whether the patient had a lowmoderate risk of covid-19 infection (score less than three) or clinically extremely vulnerable (score three or more).10 acute respiratory distress syndrome (ards) was diagnosed using berlin’s criteria.11 data was analyzed using spss software. the results were presented in percentage, mean and standard deviation if data distribution was normal or median and interquartile range if data were not normally distributed. ethical approval was obtained from director of kramat 128 hospital. informed consent was obtained from all patients for being included in the study. proxy consent occurs when an individual was provided with the legal right to make decision on behalf of another, for example in patient with altered mental status. the patients also give written inform consent for publishing their clinical records. british society of rheumatology (bsr)-risk stratification low risk high risk 41.7% 58.3% figure 1. type of autoimmune diseases figure 2. british society of rheumatology (bsr) – risk stratification. vol 54 • number 4 • october 2022 the profile of covid-19 in patients with autoimmune disease: 597 there were 60 autoimmune patients who were hospitalized between march 2020 until february 2021, with 12 confirmed cases of covid-19 infection. most of the patients (75.0%) had systemic lupus erythematosus (sle) (figure 1). based on the british society of rheumatology (bsr)risk stratification, more than 50% of the patients had low-moderate risk (figure 2). 8 out of 12 patients were categorized as moderate covid-19 infection, three as mild covid-19 infection, and only one patient without any symptoms (figure 3). as the base autoimmune diseases, one with rheumatoid arthritis, and one with ankylosing spondylosis. (table 1) case 1 female, 46 years old, had systemic lupus erythematous (sle) with hypertension and hyperthyroidism came into the er with moderate covid-19 severity. she used methylprednisolone 2x4 mg daily with bsr risk stratification categories of high. she had symptoms such as fever, chills, muscle pain, joint pain, abdominal pain, diarrhea, nausea, cough, fatigue, and dyspneu. upon hospital admission, she was hypertensive (177/96 mmhg), tachycardic (107x/minute), and feverish (37.6oc). she was given oxygen supplementation of 5 liter/minute using nasal cannule and her oxygen saturation was 98%. she had body mass index category of overweight (22.1 kg/m2). she had absolute lymphocyte count (alc) of 1317/ ul with neutrophil-lymphocyte ratio (nlr) of 1.93. she had normal d-dimer result with ground glass opacity as found in the thorax ctscan. she was treated with vitamins, intravenous remdesivir, and heparin prophylaxis dose (2x5000u). case 2 female, 46 years old, had rheumatoid arthritis (ra) with hypertension, heart disease, hyperthyroidism, and chronic kidney disease came into the er with moderate covid-19 severity. she used methylprednisolone 1x4 mg daily with sulfasalazine three times a day. she had low bsr risk stratification. she figure 3. severity percentages. table 1. patient’s characteristics. patient no. sex age autoimmune disease comorbidities autoimmune medication prednisolone equal dose (mg/ day) bsr risk stratification charlson comorbidity index length of stay covid severity 1 f 46 sle ht, thyroid glucocorticoid 10 high 0 7 moderate 2 f 46 ra ht. heart disease, thyroid, ckd glucocorticoid, sulfasalazine 5 low 5 10 moderate 3 f 36 sle heart disease, tuberculosis glucocorticoid 10 high 2 15 moderate 4 m 33 as ht, obesity none n/a low 0 0 mild 5 f 27 sle lymphadenitis tb glucocorticoid 20 high 0 8 mild we select five covid-19 patients with autoimmune diseases included in this case series. three of them had systemic lupus erythematous zubairi djoerban acta med indones-indones j intern med 598 had symptoms such as sore throat, joint pain, abdominal pain, diarrhea, cough, fatigue, and dyspneu. upon hospital admission, she was normotensive (122/75 mmhg), bradycardic (58x/minute), and her oxygen saturation was 98% in room air. she had body mass index category of overweight (22 kg/m2). she had absolute lymphocyte count (alc) of 1644/ul with neutrophil-lymphocyte ratio (nlr) of 1.15. she had normal d-dimer result with normal thorax x-ray. she was treated with vitamins and heparin prophylaxis dose (2x5000 u). case 3 female, 36 years old had systemic lupus erythematous (sle) with congestive heart failure with (ejection fraction of 55%), and hypercoagulable state came into the er with moderate covid-19 severity. she used methylprednisolone 2x4 mg, aspirin 1x80 mg, nitroglycerine 1x2.5 mg, furosemide 1x40 mg, spironolactone 1x100 mg, and diltiazem 1x200 mg. she had high bsr risk stratification. she had symptoms such as fever, headache, fatigue, ageusia, abdominal pain, nausea, vomiting, and diarrhea. upon hospital admission, she was normotensive (120/80 mmhg), heart rate was 100x/minute, and her oxygen saturation was 97% on room air. she had body mass index category of obese (28 kg/m2). she had absolute lymphocyte count (alc) of 2034/ul with neutrophil-lymphocyte ratio (nlr) of 2.03. she had increased d-dimer of 1400 with bilateral infiltrate on the thorax x-ray. she was treated with vitamins and heparin prophylaxis dose (2x5000 u). case 4 male, 33 years old had ankylosing spondylitis (as) with hypertension came into the er with mild covid-19 severity. he did not use any routine medications. he had low bsr risk stratification. he had symptoms of cough, runny nose, fatigue, muscle pain, joint pain, and diarrhea. upon hospital admission, he was hypertensive (149/94 mmhg), heart rate was 72x/minute, and her oxygen saturation was 99% on room air. he had body mass index category of obese (28 kg/m2). he had absolute lymphocyte count (alc) of 3400.3/ul with neutrophil-lymphocyte ratio (nlr) of 1.43. he had normal d-dimer result with normal thorax x-ray. he was treated with vitamins and sent to do self-isolation. case 5 female, 27 years old had systemic lupus erythematous (sle) with tuberculosis of the glands came into the er with mild covid-19 severity. she used methylprednisolone 16 mg daily. she had high bsr risk stratification. she had symptoms of fever, headache, runny nose, anosmia, ageusia, fatigue, and joint pain. upon hospital admission, she was normotensive (107/68 mmhg), heart rate was 76x/minute, and her oxygen saturation was 99% on room air. she had body mass index category of overweight (22 kg/m2). she had absolute lymphocyte count (alc) of 2125.2/ul with neutrophillymphocyte ratio (nlr) of 7.64. she had normal d-dimer result with normal thorax x-ray. she was treated with vitamins and heparin prophylaxis dose (2x5000 u). she had increased d-dimer (800) with normal thorax x-ray. she was treated with methylprednisolone high dose (2x125 mg) for 2 days due to increased disease activity and heparin continuous drip 10.000 unit/24 hour. discussion there have been several studies investigating the impact of the presence of autoimmune diseases in covid-19. below we highlighted several studies and correlating them with the results from our case series. risk of developing covid-19 autoimmune diseases have been postulated as risk factors for developing infection through the generation of autoantibody to cytokines. for example, autoantibody to ifn-γ is associated with an increased risk of tuberculosis infection.12 autoimmune disease, primarily systemic connective tissue disease such as systemic lupus erythematosus (sle), was associated with delayed type 1 interferon response. this dysfunctional interferon response could predispose to a higher risk of sars-cov-2 infection and worse outcome.13 vol 54 • number 4 • october 2022 the profile of covid-19 in patients with autoimmune disease: 599 several studies reported that patients with autoimmune diseases were at higher risk of developing covid-19 than general population. pablos jl et al. conducted a retrospective observational study from seven hospitals in spain, investigating the difference between the prevalence of pcr + covid-19 in rheumatology patients compared with matched reference populations from the same hospitals.14 the results showed that patients with chronic inflammatory diseases had higher odds of developing covid-19 (or 1.3, 95% ci 1.151.52) compared with the reference population. this higher prevalence was observed in systemic autoimmune or immune-mediated diseases, except for inflammatory arthritis or sle. besides, patients receiving biologic or targetted synthetic disease-modifying antirheumatic drugs (bdmard or tsdmard) but not conventionalsynthetic dmard (csdmard) had a higher prevalence than the reference population.14 similarly, a meta-analysis of 62 observational studies showed that patients with autoimmune diseases were at higher risk of developing covid-19 than the control patients (or 2.19; 95% ci 1.05 4.58). unlike the previous study, the sle/ sjӧgren’s syndrome/ systemic sclerosis subgroup had a higher prevalence of covid-19 than other disease subgroups. the meta-regression analysis results also showed that studies with a higher proportion of steroid use had a higher prevalence of covid-19. meanwhile, the use of dmards was not associated with increased risk.15 however, not all studies supported those results. an online survey involving 1,381 respondents with rheumatic diseases in ireland reported that the covid-19 pcr positivity rate was 0.46%, similar to general irish population positivity rate.16 similarly, a large cross-sectional study performed in italy reported no difference in the incidence of covid-19 between patients with autoimmune disease and those with no autoimmune disease.17 recommendation from european league against rheumatism (eular) also stated that so far, there had been not enough evidence that autoimmune diseases increased the risk of covid-19.18 our case series was not designed to estimate the risk of sars-cov-2 infection in autoimmune disease patients. thus, we were unable to draw any conclusion regarding the risk of infection in our patient population. our study identified 12 patients with autoimmune diseases and confirmed covid-19. although men have a higher risk of sars-cov-2 infection in the general population, most of our subjects were female because they had higher risk of developing autoimmunity. based on the bsr risk score, about half of the patients in this series were classified as low risk and the other half as high risk. two of the patients were healthcare workers. although one of them (patient no. 9) was classified as bsr low risk, they were at higher risk of sars-cov-2 exposure than the general population due to their clinical duty. clinical characteristics the most common symptom was fatigue, a non-specific symptom, followed by anorexia, fever, and cough. this finding was pretty similar to a case series in new york, where the most common symptom in the patient population of autoimmune diseases and covid-19 was fever, followed by cough and dyspnea.19 similarly, data from the german national registry for patients with rheumatic diseases and covid-19 showed that the patients’ common symptoms included cough, fever, and fatigue.19about 40% of patients in our case series experienced arthralgia, which might reflect the underlying rheumatic disease activity or disease flares triggered by sarscov-2 infection. in our case series, the most common autoimmune disease was sle, which was similar to an online survey performed by the indonesian rheumatology association where 63.6% of subjects with confirmed covid-19 in that study had sle.20 one patient in our series had asymptomatic covid-19 and was hospitalized due to other reasons. the most prevalent comorbidity in our patient population was hypertension, similar to findings from other studies.19 however, surprisingly, the prevalence of tuberculosis (tb) was relatively high in our case series (4/12 patients). three of them had pulmonary tuberculosis, while one patient had lymphadenitis tb. two of them had active pulmonary tb, and one required streptomycin injection as part of zubairi djoerban acta med indones-indones j intern med 600 the tb treatment regimen. tuberculosis in covid-19 has not been extensively reviewed. past studies about tuberculosis in sars infection showed that the sars-cov infection suppressed cellular immunity, thus causing the reactivation or new infection of m. tuberculosis.21 besides, tuberculosis patients who suffered from influenza infection had a higher risk of mortality with symptoms lasting for more than seven days. moreover, tuberculosis is an independent risk factor for hospitalization caused by influenzaassociated illness.22 a systematic review and meta-analysis investigating the relationship between tuberculosis and covid-19 by gao et al. stated that the prevalence of tuberculosis was higher in severe covid-19 patients than non-severe covid-19 patients (or=2.10; 95% ci: 0.61-7.18).22 however, this result was not statistically significant. there was still conflicting data regarding whether tuberculosis affects the mortality rate in patients with covid-19 or not. one possible mechanism is that active tuberculosis infection can increase the proinflammatory cytokines, such as ifn type i and iii, which are upregulated in both covid-19 and tuberculosis infection.23 more high-quality studies providing a clear relationship between tuberculosis and covid-19 are still needed. risk of hospitalization in patients with autoimmune diseases and covid-19 the covid-19 global rheumatology alliance (c-19 gra) is a global physicianreported registry gathering data on patients with rheumatic diseases diagnosed with covid-19. there have been several publications based on the data, which helped clarify the relationship between rheumatic diseases and the risk or clinical course of covid-19. one of the earlier publications from the c-19 gra registry investigated factors associated with increased risk of hospitalizations in autoimmune patients with covid-19. around 600 patients from 40 countries were included in the study. the study results showed that older age, comorbidities, and steroid use with a prednisolone-equivalent dose of ≥ 10 mg/day were associated with higher odds of hospitalization. neither antimalarial use (such as hydroxychloroquine) nor nsaid uses positively or negatively impacted the odds of hospitalization. in contrast, the use of bdmard or tsdmard monotherapy was associated with lower odds of hospitalization (or 0.46; 95% ci 0.22-0.93). this finding was especially true for anti-tnf, as the number of patients who used other classes of drugs was too small to draw conclusions.24 the number of patients whose age was ≥ 60 years old in our study was just one patient, and she had a mild course of covid-19. the age range of patients who had moderate covid-19 in our study was 28-59 years old. none had a severe course of covid-19. half of our patients had taken steroids with a prednisolone-equivalent dose of ≥ 10 mg/day, which was associated with a higher hospitalization rate and worse clinical outcomes. risk of mortality in patients with autoimmune diseases and covid-19 strangfeld et al. analyzed 3729 patients with rheumatic diseases from the registry to investigate factors associated with mortality in confirmed or presumptive covid-19 cases. rheumatoid arthritis was the most common rheumatic disease in the study, followed by connective tissue diseases such as sle. most patients were in remission or had low disease activity. deaths occurred in 10.5% of patients in the study, and half were hospitalized. more than half of the patients had comorbid disease, the most common being hypertension. other prevalent comorbidities include chronic lung disease, obesity, other cardiovascular diseases, and chronic kidney disease. regarding therapy for autoimmune diseases, around 40% of patients only received either csdmards, immunosuppressants, or a combination of both. in contrast, approximately 20% of patients did not receive any dmard or immunosuppressant except for steroids. almost 40% of patients were treated with steroids, whereby 10% of them received a dose exceeding >10 mg/day.25 the results of the multivariate analysis from the study revealed the following factors to be associated with increased risk of deaths: 1) age >65 years old, 2) male sex, 3) chronic lung disease, 4) presence of both cvd and hypertension, 5) patients who did not receive any dmard, 6) vol 54 • number 4 • october 2022 the profile of covid-19 in patients with autoimmune disease: 601 treatment with rituximab, 7) treatment with sulfasalazine, 8) immunosuppressants, 9) steroid treatment with a prednisolone-equivalent dose of >10 mg/ day, 10) high/ severe/ moderate disease activity. the association between increased age, male sex, and comorbidities had been established as factors that could increase the risk of covid-related mortality in other populations. high disease activity and absence of dmard being risk factors highlighted the importance of autoimmune disease control even in patients with covid. rituximab worked by depleting b-cells, which could impair immunity to covid. likewise, a high dose of steroid and immunosuppressants could cause dysfunction of the host’s immune system, leading to a more severe presentation of covid. the association with sulfasalazine was surprising, given that it was a weak immunosuppressant, but the result was consistent with studies from ibd-covid patient population. however, as the authors noted, an association was not the same as causation, and further prospective studies were needed.25 in our case series, only two patients had taken csdmard (methotrexate and sulfasalazine) while none had taken bdmard or tsdmard. most of our patients (75%) did have comorbidities that predisposed them to a higher risk of mortality, such as hypertension, cardiovascular disease, and chronic lung disease (tuberculosis). another factor that might increase mortality in our study was steroid use with a dose of ≥ 10 mg/ day. despite that, no mortality occurred in our patient population. there were several possible reasons: no patient had severe covid-19, the autoimmune disease was pretty well controlled without bdmard or tsdmard, most patients were <65 years old and were female. limitations of our study stemmed from the fact that this was a descriptive case series. thus we could not perform any statistical analysis. none of our patients in this series had severe covid-19. besides, most of our patients had sle, and patients with other types of autoimmune disorders were underrepresented. no patients in our study received bdmard or tsdmard. therefore, we could not describe the clinical characteristics in those populations. we also did not use a formal scoring system to assess the disease severity. however, although our study was only a descriptive study, our case series provide valuable information regarding the clinical characteristics of covid-19 in the indonesian autoimmune disorder patient population. to our knowledge, only one similar study focusing on indonesian autoimmune disorder patients had been published previously, and most of their subjects did not undergo pcr confirmation of covid-19.20 conversely, all of the covid-19 diagnoses in our patients were confirmed by pcr testing. conclusion this first comprehensive case series provides characteristics of autoimmune patients having positive covid-19 infection, of which study is still limited in indonesia. protecting highrisk group such as autoimmune patients are important, especially during this pandemic. data availability the data supporting the result of this article will be made available by the authors, without undue reservation. conflict of interest the authors declare that they have no competing interests. funding statement this research did not receive any specific grant from any funding agencies. acknowledgments we would like to thank kramat 128 hospital for giving the ethical permission and allowing us to collect the data. references 1. organization wh. coronavirus16 february 2021]. available from: https://www.who.int/health-topics/ coronavirus. 2. nasional. kpc-dpe. peta sebaran16 february 2021]. available from: https://covid19.go.id/peta-sebaran. 3. alharthy a, faqihi f, nasim n, et al. covid-19 in a patient with a flare of systemic lupus erythematosus: a zubairi djoerban acta med indones-indones j intern med 602 rare case-report. respiratory medicine case reports. 2020;31:101252. 4. gartshteyn y, askanase ad, schmidt nm, et al. covid-19 and systemic lupus erythematosus: a case series. the lancet rheumatology. 2020;2(8):e452-e4. 5. furer v, rondaan c, heijstek mw, et al. 2019 update of eular recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. annals of the rheumatic diseases. 2020;79(1):39-52. 6. smith da, germolec dr. introduction to immunology and autoimmunity. environmental health perspectives. 1999;107 suppl 5:661-5. 7. fung sy, yuen ks, ye zw, chan cp, jin dy. a tugof-war between severe acute respiratory syndrome coronavirus 2 and host antiviral defence: lessons from other pathogenic viruses. emerging microbes & infections. 2020;9(1):558-70. 8. ri kk. hari lupus sedunia 2018: memahami program deteksi dini penyakit lupus eritematosus sistemik (les)16 february 2021]. available from: http://p2p. kemkes.go.id/hari-lupus-sedunia-2018-memahamiprogram-deteksi-dini-penyakit-lupus-eritematosussistemik-les/. 9. pdpi, perki, papdi, perdatin, idai. pedoman tatalaksana covid-19 december 2020. 10. chattopadhyay a, mishra d, sharma v, naidu gsk, sharma a. coronavirus disease-19 and rheumatological disorders: a narrative review. indian j rheumatol. 2020;15(2):8. 11. force adt, ranieri vm, rubenfeld gd, et al. acute respiratory distress syndrome: the berlin definition. jama. 2012;307(23):2526-33. 12. maddur ms, vani j, lacroix-desmazes s, kaveri s, bayry j. autoimmunity as a predisposition for infectious diseases. plos pathogens. 2010;6(11):e1001077. 13. fernandez-ruiz r, paredes jl, niewold tb. covid-19 in patients with systemic lupus erythematosus: lessons learned from the inflammatory disease. translational research: the journal of laboratory and clinical medicine. 2020. 14. pablos jl, abasolo l, alvaro-gracia jm, et al. prevalence of hospital pcr-confirmed covid-19 cases in patients with chronic inflammatory and autoimmune rheumatic diseases. annals of the rheumatic diseases. 2020;79(9):1170-3. 15. akiyama s, hamdeh s, micic d, sakuraba a. prevalence and clinical outcomes of covid-19 in patients with autoimmune diseases: a systematic review and meta-analysis. annals of the rheumatic diseases. 2020. 16. murray k, quinn s, turk m, et al. covid-19 and rheumatic musculoskeletal disease patients: infection rates, attitudes and medication adherence in an irish population. rheumatology. 2021;60(2):902-6. 17. zen m, fuzzi e, astorri d, et al. sars-cov-2 infection in patients with autoimmune rheumatic diseases in northeast italy: a cross-sectional study on 916 patients. journal of autoimmunity. 2020;112:102502. 18. landewe rb, machado pm, kroon f, et al. eular provisional recommendations for the management of rheumatic and musculoskeletal diseases in the context of sars-cov-2. annals of the rheumatic diseases. 2020;79(7):851-8. 19. haberman r, axelrad j, chen a, et al. covid-19 in immune-mediated inflammatory diseases case series from new york. the new england journal of medicine. 2020;383(1):85-8. 20. hidayat r, isbagio h, ariane a, et al. characteristics of patients with autoimmune rheumatic disease in the era of covid-19 pandemic in indonesia. ijr. 2020;12(1):8. 21. low jg, lee cc, leo ys, low jg, lee cc, leo ys. severe acute respiratory syndrome and pulmonary tuberculosis. clinical infectious diseases. 2004;38(12):e123-5. 22. abadom tr, smith ad, tempia s, madhi sa, cohen c, cohen al. risk factors associated with hospitalisation for influenza-associated severe acute respiratory illness in south africa: a case-population study. vaccine. 2016;34(46):5649-55. 23. visca d, ong cwm, tiberi s, et al. tuberculosis and covid-19 interaction: a review of biological, clinical and public health effects. pulmonology. 2021;27(2):151-65. 24. gianfrancesco m, hyrich kl, al-adely s, et al. characteristics associated with hospitalisation for covid-19 in people with rheumatic disease: data from the covid-19 global rheumatology alliance physician-reported registry. annals of the rheumatic diseases. 2020;79(7):859-66. 25. strangfeld a, schafer m, gianfrancesco ma, et al. factors associated with covid-19-related death in people with rheumatic diseases: results from the covid-19 global rheumatology alliance physicianreported registry. annals of the rheumatic diseases. 2021. case report 55acta medica indonesiana the indonesian journal of internal medicine transcatheter coil embolization in coronary artery fistulae budi y. setianto1,2, pudya l. arshant2 1 department of cardiology and vascular medicine, gadjah mada university dr. sardjito hospital. jl. kesehatan sekip no. 1, yogyakarta, indonesia. 2 department of internal medicine, gadjah mada university dr. sardjito hospital, yogyakarta, indonesia. correspondence mail: budyuls@yahoo.com. abstrak fistula arteri koroner atau coronary artery fistulae (caf) merupakan kelainan yang jarang terjadi, sebagian besar bersifat kongenital dengan insidens sebesar 0,1% 0,2% dan insidens caf yang didapat sebesar 0,2%, sebagaimana ditunjukkan oleh angiografi koroner. caf dengan pintas aliran tinggi (high flow shunting) atau yang bersifat simtomatik harus ditangani dengan pembedahan atau teknik tertentu tanpa pembedahan seperti embolisasi dengan kumparan lintas kateter atau transcatheter coil embolization (tcce). artikel ini menyajikan suatu kasus, yakni seorang wanita berusia 63 tahun dengan keluhan utama nyeri dada sejak satu bulan yang lalu. pasien telah menjalani angiografi koroner yang menunjukkan adanya 95% penyempitan sisi proksimal arteri desenden anterior bawah atau lad (left anterior descendens) dan caf dari lad ke atrium kanan. untuk penyempitan lad sebelah proksimal telah ditangani dengan pci (percutaneous coronary intervention) dan implantasi stent bersalut obat (drug eluting stents), tetapi pasien tetap mengeluhkan nyeri dada yang dialaminya. para dokter memutuskan untuk melakukan tcee untuk menangani caf. setelah dilakukan tcee, pasien tidak lagi mengeluhkan nyeri dada dan evaluasi dengan ekg menunjukkan hasil yang normal. kata kunci: fistula arteri koroner, simtomatik, transcatheter coil embolization. abstract coronary artery fistulae (caf) is a rare anomaly, mostly with the incidence of congenital caf 0.1% 0.2% and the incidence of acquired caf 0.2% at coronary angiography. symptomatic or high flow shunting caf must be treated with surgery or non surgery approach such as transcatheter coil embolization (tcce). a women 63 years old with chief complain of chest pain since one month ago. the patient had undergone coronary angiography with conclusions as follows 95% narrowing of proximal lad (left anterior descendens) artery and caf from lad into the right atrium. whereas narrowing of proximal lad was performed pci (percutaneous coronary intervention) with the implantation of drug eluting stents, but patients still complained chest pain. caf decided to do the tcce. post tcce chest pain and ecg evaluation were within normal limits. key words: coronary artery fistulae, symptomatic, transcatheter coil embolization. introduction most coronary artery fistulae (caf) are asymptomatic, but some are symptomatic because of manifestation of coronary steal such as angina pectoris, myocardial infarction, heart failure, endocarditis, and aneurysm formation. triad diagnostic of caf is a location of abnormal murmur ‘to and fro’ corresponding persistent ductus arteriosus (pda), a left to right shunt in atrium or ventricle and turtoisity of coronary.1-3 the gold standard diagnostic of caf is coronary angiography.4,5 indications therapy of caf are asymptomatic patients with high flow shunts and the presence 56 budi y. setianto acta med indones-indones j intern med of symptoms. the goal of therapy to prevent symptom or complication.2,5-7 clinical signs related to increased morbidity and mortality. fistulae-related complications especially in elderly and mortality increases with age.8 therapy strategies of caf are divided into conservative therapy, surgical and transcatheter coil embolization (tcce). the success of surgery is quite high but the risk of cardiac arrest.1,9 tcce technique is choice of treatment because of the cost-effectiveness, and less risk compared than surgery.7,9 case ilustration a 63-year-old female patient that was treated with chief complaint of chest pain came and went since one month ago. the patient, non-obese diabetes mellitus (dm2no), hypertension and coronary artery disease, one vessel disease (cad1vd) post stenting dated january 15, 2010 with the conclusion in the following, proximal lad 95% stenosis, found the coronary artery fistulae from lad into the right atrium. other vessels are within normal limits. on physical examination there is no murmur or others abnormality. ecg finding shows ventricle extra systole (ves). the working diagnosis is observation of chest pain may caused by caf, cad-1vd post stenting, ves, hypertension and dm2no. the patient is administered by clopidogrel 75 mg twice a day, bisoprolol 5 mg once a day, valsartan 160 mg once a day, and insulin gargline 26 units subcutaneous a day. the patient underwent trancatheter coil embolization (tcce) on february 17, 2010 in the catheterization laboratory of dr. sardjito hospital, yogyakarta. the result had been installed two coil units with no residual fistulae, no chest pain anymore and no significant complications. another problem has not been controlled was hypertension, so that given additional therapy with amlodipine 5 mg once a day and patients discharged after controlled blood pressure. discussion c o r o n a r y a r t e r y f i s t u l a e ( c a f ) i s a relationship between one or more coronary arteries with a heart space or large vessel through myocardial basis, was first reported by krauss in 1865.1-3 in embryology, caf divided into congenital and acquired. congenital coronary artery fistulae caused by failure of obliteration of the sinusoids intramyocardial is due to defects in embryonic development of coronary arterial branches between the ages of 6-8 weeks of life.1,10 postulate pathophysiology of congenital caf originating from the two forms of embryologic growth disorders. based on fetal growth retardation, steinberg, dotter and baldwin divided caf into type 1 due to coronary capillary element differentiation defect and type 2 are anomalous origin of coronary arteries with concomitant inter-coronary relationship due to defect formation of a primitive septum bulb.11 approximately 0.25 to 0.4% caf associated with other congenital heart diseases such as atrial septal defect (asd), tetralogy of fallot (tof), persistent ductus arteriosus (pda), ventricular septal defect (vsd) and pulmonary atresia.8 acquired coronary artery fistulae can result from blunt or penetrating trauma, postcardiac surgery (valve replacement, transplantcoronary artery bypass, coronary angioplasty, re-post myocardial biopsy in heart transplant) and the omission of cabg through the coronary veins or complications of myocardial infarction (rare).1-3 normal anatomy of the main coronary artery has two branches of right coronary artery (rca) and left main coronary artery (lmca), which branched into left circumflex (lcx) and left anterior descendens (lad).13 normally, the two major coronary arteries from aortic sinus occur consecutively, but one or more branches of the fistulae connects directly with a heart chamber or pulmonary trunk, coronary sinus, superior vena cava or pulmonary veins showed a shortcut left-to-right. great shunts happen if caf ended up in the atrium space.14 coronary artery fistulae can arise from several parts of the three major coronary arteries. caf generally grow from the rca or lad, lcx is rarely involved. most of the caf originated from the rca or the branches (55%), 30% of the lad and 5% bilateral.2,5,15 ninety percent of the caf ended on the right side of the heart, usually on the single surface. location drainage is the most figure 1. caf from the lad into the right atrium pre and post tcce 57 vol 45 • number 1 • januari 2013 transcatheter coil embolization in coronary artery fistulae low-pressure structure, including the right of heart chamber, pulmonary artery, superior vena cava and coronary sinus. most end up in the right ventricle (45%), then the right atrium (25%), pulmonary trunk (15%), coronary sinus (7%), left atrium (5%) and left ventricle (3%).2,7,8,16 coronary artery fistulae in these patients was likely congenital because there was no history of or risk factor for acquired caf. lad coronary fistulae originated from and ended up in right atrium. lad artery as a place of origin of caf found on 30% of cases, and caf in the right atrial endings in 25% of cases. forty percent up to 55% patients with caf are asymptomatic. patients can be asymptomatic in several years, then experienced symptoms of cardiovascular disorders such as growth and development in childhood, fatigue, dyspnea, orthopnea, palpitations, angina pectoris, myocardial ischemia or infarction, stroke, congestive heart failure, chest pain atypical, subacute bacterial endocarditis or arrhythmias (such as premature ventricular contractions, atrial tachycardia, ventricular tachycardia, bundle branch block and 1st degree atrioventricular block) or sudden death.4,5,7,17 clinical presentation of the caf is influenced by age, severity of left-to-right shunt, the size and structure of relationships. in theory, caf ‘steal’ of coronary blood flow (coronary steal) from the origin of coronary artery fistulae, resulting in a decrease in coronary blood flow resulting in ischemia of the distal caf or myocardial infarction which gives the manifestation of chest pain.5,10 these alerts can be worsened by other cardiac conditions such as coronary artery disease, valve disease and myocardial hypertrophy.1 physical examination revealed no sign if there was no ischemia or myocardial infarction. the first clinical signs may include sudden death in young athletes and military personnel.18,19 most asymptomatic patients referred for unexplained angina, congestive heart failure or continuous murmur that sounded most loudly in the precordial. murmur tends to crescendo -decrescendo systolic and diastolic, but even harder on the diastolic. conversely, most continuous murmur reaches peak intensity in the second heart sound. location of continuous murmur will be heard at the entrance to the heart fistulae. if the caf entrance on the right atrium, the loudest murmur heard at the bottom along the sternal border. if caf entered the pulmonary artery or right ventricle, the loudest murmur heard at the left sternal spatium intercostal 2-3 and if it went into the left ventricle most obvious murmur near the apex. if caf is connected with the left ventricle, probably just sounded early-diastolic murmur.1,2,5,21 hallerand little describe the triad of diagnostic caf. an abnormal location of murmur "to and from" in line with the persistent ductus arteriosus, a the left to right shunt on atrial or ventricular levels and coronary artery winding (turtousity).5 chest radiography is generally within normal limits or cardiomegaly with increased vascularities, especially if there is a great left-to-right shunt.1,2,15 electrocardiography (ecg) is generally normal or ischemic changes that show the effects of ventricular volume overload or left ventricular hypertrophy left, right or both.1,2 trans thoracal echocardiography (tte) two dimensions demonstrated the large coronary artery dilatation. turbulence pattern of continuous systolic and diastolic flow describe the location of the beginning of the shunt, dilated nutrient arteries or twisting with abnormal flow patterns. shunt size are classified based on the ratio of pulmonary to systemic flow ratio (qp/qs). high-flow shunts if the ratio qp/qs >1.5. the ratio of qp/ qs in the caf typically <1.5 and rarely >2.1,17 transesophageal echocardiography (tee) with descriptions include dilatation of the heart chamber, color flow doppler jet narrowest >4 mm or descending aortic back flow.24 resolution of tee is higher because the transducer is placed in the esophagus, just behind and very close to the left atrium and thoracic aorta.4,22 treadmill test results can be positive ischemic response.16 ecg changes on the treadmill test can occur if there are other cardiovascular conditions.1 coronary angiography is the gold standard diagnosis of caf because it can accurately describe the origin, size, number and flow fistulae and presence of aneurysm. coronary angiography in congenital heart disease is the classification of the recommendations of acc/aha class i, level of evidence c.21 angiography aimed to find influence of coronary lesions on coronary hemodynamic and knowing abnormality.2,21 coronary magnetic resonance angiography (cmra), more and more used to know the anatomy of the coronary anomaly due to noninvasive, able to identify the main causes of caf and thus their minimizing radiation exposure is 58 budi y. setianto acta med indones-indones j intern med an ideal procedure.19 this patient complained recurrent chest pain though the patients were diabetic patients and post stenting one month before. chest pain was suspected because of ischemia or infarction due to coronary steal phenomenon. chest pain in patients with dm is very meaningful, because it possible existence of neuropathy. physical examination found no noisy heart. results of laboratory and others have hyperglycemia within normal limits. results of chest x-ray within normal limits and ecg demonstrated ves. therapy indication of caf is that there are clinical signs (symptomatic), mainly heart failure and asymptomatic myocardial ischemia as well as caf with high-flow shunt. the goal of therapy is to prevent the signs or complications, especially in childhood. closure of fistulae absolutely be done immediately to prevent complications.2,5-7 there are three options caf governance namely conservative, surgical and transcatheter coil embolization (tcce). conservative therapy is performed for small and asymptomatic caf. antiplatelet therapy is recommended especially at the distal caf and abnormal coronary arteries are dilated. suggested prophylactic sub-acute bacterial endocarditis due to a complication of coronary fistulae.7 definitive therapy of caf is usually needed cardiac surgery. caf surgical therapy was first performed bjork and crafoord in 1947.20 small or asymptomatic caf surgery remains controversial because of losses due to surgery.13 indications of surgery include shunt ratio >30%, signs of ischemia, pulmonary hypertension, congestive heart failure, aneurysm formation, large caf with high-flow shunt, relationships and multiple endings, the need for coronary bypass-simultaneous and social reasons.3,4,7,23 complete occlusion of fistulae after surgery achieving >95%. morbidity and mortality of surgery 0-6%, myocardial infarction <5% and risk-recurrent fistulae.1-3,7,8,14 tcce technique was first performed in 1982. this therapy is effective, safe and complete occlusion was achieved >95%. tcce successful therapy is similar to surgical therapy in patients without cardiac surgery-related morbidity due to avoid medial sternotomy and cardiopulmonary bypass. tcce purpose is occlusion of the arteries and fistulae as distal as and as close as possible to the end point to prevent the possibility of occlusion of the branches of myocardial normal. blockage of arteries that were treated at the first level of branches and reduction of shunts left-to-right so-closure of post myocardial perfusion became normal. that is too distal embolization, and if there is no significant stenosis in blood vessels, embolization may occur migration tools out fistulae and into the pulmonary circulation.2,5,6,9,24 tcce therapy is recommended during secure access to the nutrient artery, single fistulae, there are no multiple large branches, no vessels are extremely winding, narrow single-stream location and the little branches of blood vessels. despite extensive fistulae with rapid blood flow, tcce still can be done because at least supplementing, the existence of an optimal location for the main coil and attached to flow into the aneurysm location is relatively narrow and restrictive.7,9 the choice of techniques influenced the age, size of catheters that can be used, size of blood vessels that will be occluded and bend the catheter to reach the point of occlusion fistulae, and nutrient artery morphology as well as price considerations. morphology fistulae include a bend, there are at least high-flow fistulae, aneurysm dilatation of nutrient arteries and location of fistulae.2,24,25 tcce tools such as amplatzer duct occluder, microcoil and hydrocoil. tool such as the double-umbrella device amplatzer duct occluder is used on a larger caf with branches close to the location of coronary occlusion and more accurate placement. orifice occlusion in a heart chamber with the surrounding location, then elected a specific coil or double-umbrella-sized two times the diameter of orifice.6,24,25 issenberg microcoil first introduced in 1990, initially used on a smaller caf. those advantages and the catheter sheath size smaller and cheaper prices.24,25 selected microcoil diameter 20-50% larger than the largest diameter of the fistulae to prevent coil repositioning or migration. gianturco coil, independent silicon, latex balloon or a combination of coils and balloons used as embolization material. tcce tool most frequently used is the coil and is the largest type of platinum coil.7 coil delivered 2.5 fr micro-catheter and the coil is released near the meandering arteries. one or more straight 0.018-inch coil is used until there is complete obstruction and after micro-coil fixed to prevent distal migration. the advantage is to reduce the amount of coil needed to close the caf, reduce costs and time.17 microplex coil that can 59 vol 45 • number 1 • januari 2013 transcatheter coil embolization in coronary artery fistulae be controlled from larger and has a stronger shape memory than conventional coil can be like an anchor, with an additional coil to close the shunt. during the procedure, the absolute placement of the micro-catheter is as deep as possible into the fistulae and the meticulous care during coil placement.7,9 hydrocoil is a kind of hybrid-endovascular the coil material, used in large fistulae due to high-volume, low pressure due to expansion of the outer layer of a hydrophilic acrylic polymer gel which widened slowly and deployment capacity of up to nine times the volume since the first initial contact with the blood thus reducing the number of coils which needed to close fistulae or aneurysms of the aorta. for example using expandable hydrogel-coated platinum coils.17 indication of therapy in these patients because of symptomatic fistulae and ves on ecg. consideration of selection of tcce treatment modality is the age and morphology fistulae. fistulae of the lad into the right atrium with a single drainage and there is no involvement of major blood vessels. moreover, the patient is a geriatric patient with a complication of hypertension and dm2no. tcce procedure was performed on february 17, 2010. time required in this patient tcce 73 minutes. time required similar reports kabbani (2008) average 35±15 minutes.17 evaluation post coil installation, chest pain disappeared even though remains ves on ecg. complications in the post-tcce include transient ischemia on ecg, whereas atrial arrhythmia, embolization coils outside and pulmonary artery dissection post fistulae.6 re-occlusion angiography is required to view the nutrient arteries that should be closed during tcce.24 complications of caf include congestive heart failure, pulmonary hypertension, ischemia, myocardial infarction. a rare complication of ruptured aneurysms and infective endocarditis.5,7 conclusion tcce technique is the treatment choice in selected symptomatic caf patients with a high success rate, saving cost and time compared to surgery. the goal of therapy is to prevent symptoms and complications especially in elderly. clinical signs and increasing age are related to increased morbidity and mortality. references 1. cason ba, gordon hj. coronary steal caused by a coronary artery fistulae. j cardiothoracic & vascular aenesthesia. 1992;6:65-7. 2. qureshi sa. coronary arterial fistulaes. orphanet j rare dis. 2006;51:1750-2. 3. renard c, chivot c, jarry g, houpe d, remond a, leborge l. communicating bilateral coronary artery to pulmonary fistulae with aneurysm in asymtomativ patient: succesful conservative management with selective coil embolization of the aneurysm. int j cardiol. 2010. 4. osawa h, sakurada t, sasaki j, araki e. successful surgical repair of a bilateral coronary-to-pulmonary artery fistulae. ann thoracic cardiovasc surg. 2009;15:1. 5. gowda rm, vasavada bc, khan ia. coronary artery fistulaes: clinical and theurapetic considerations. int’l j cardiol. 2005;107:7-10. 6. hoffer e, materne p, henroteaux d, markov m, boland j. succesful percutaneus closure of multiple coronary artery fistulaes with coil embolization in two adults. int’l j cardiol. 2007;(122):e25-8. 7. niizeki t, daidouji h, ootaki y, kaneko k, ito m, ogume m, kubota i. trancatheter coil embolization of coronary artery fistulaes: case report. j cardiol cases. 2010;61:e1-e4. 8. ata y, turk t, bicer m, yalcin m, ata f, yavuz s. coronary arteriovenosus fistulaes in the adults: natural history and management strategies. j cardiothoracic surg. 2009;4:1-5. 9. yu-min s, jun w, gang y, yun z, yan z, zhi-qiang x. coronary arteriovenosus fistulae with giant aneurysm formation treated with percutaneus intervention. chinese medical j. 2010;123:1. 10. onorati f, mastroroberto p, bilotta m, cristodoro l, esposito a, pezzo f, renzulli a. surgical treatment of coronary-to-pulmonary fistulae: how and when? heart vessels. 2006;21:321-4. 11. steinberg i, baldwin js, dotter ct. coronary arteriovenous fistulae. j circulation. 1998;17:372-90. 12. schechter dc. the classification of coronary artery fistulaes. am heart j. 1998:281-2. 13. khan mg. heart trouble encylopedia. toronto: toddart; 1996. 14. olgunturk r, kula s, tunaoglu fs. transcatheter closure of a rare form of coronary arteriovenous fistulae. int’l j cardiol. 2006;113:261-3. 15. mehta d, redwood d, ward de. multiple bilateral coronary arterial to pulmonary artery fistulae in asymptomatic patient. int’l j cardiology. 1997;16: 96-8. 16. braden ds, o’neal kr, mcmullan mr, ebeid mr. congenital coronary arteriovenosus fistulae presenting with syncope. pediatric cardiol. 2002;23:218-20. 17. kabbani z, garcia-nielsen l, lozano ml, febles t, febles-bethencourt l, castro a. coil embolization of coronary artery fistulaes. a single-centre experience. cardiovascular revascularization medicine. 2007;9: 14-7. 60 budi y. setianto acta med indones-indones j intern med 18. angelini p. coronary artery anomalies-current clinical issues: definition, incidence, clinical relevance and treatment guidelines. texas heart j. 2002;29:271-8. 19. koenig pr, hijazi zm. congenital coronary abnormalities. uptodate 2007. version 15.1 diunduh 16 agustus 2010. 20 bjork g, crafoord c. arteriovenosus aneurysma on the pulmonary artery simulating persistent ductusarteriosus botalli. thorax. 1997;2:65. 21. scanlon pj, faxon dp, audet am, carabello b, dehmer gj, eagle ka, et al. acc/aha guidelines for coronary angiography. jacc. 1999;33(6):1-9. 22. demarla an, blanchard dg. the echocardiogram, hurst’s the heart. 9th edition. in: schlant rc, alexander rw, fuster v, eds. new york: mcgraw-hill; 1998. p. 415-7. 23. konno s, endo m. congenital coronary artery diseases. kokyu to junkan. 1993;21:378-409. 24. armsby lr, keane jf, sherwood mc, forbess jm, perry sb, lock je. management of coronary artery fistulaee: patient selection and results of transcatheter closure. j am coll cardiol. 2002;39:6. 25. sreedharan m, prasad g, barooah b, dash pk. vortex coil embolisation of coronary artery fistulae. intl j cardiol. 2004;94:323-4. 626 acta med indones indones j intern med • vol 54 • number 4 • october 2022 review article preventing thrombosis in cancer patients budi setiawan,1* eko a. pangarsa,1 damai santosa,1 ridho m. naibaho,2 rahajuningsih dharma setiabudy,3 catharina suharti1 1 division of hematology and medical oncology, department of internal medicine, faculty of medicine universitas diponegoro – dr. kariadi hospital, semarang, indonesia. 2 trainee in hematology and medical oncology, department of internal medicine, mulawarman school of medicine, parikesit hospital, and abdul wahab sjahranie hospital, samarinda, indonesia. 3 department of clinical pathology, faculty of medicine universitas indonesia, jakarta, indonesia. *corresponding author: budi setiawan, md. division of hematology and medical oncology, department of internal medicine, faculty of medicine universitas diponegoro – dr. kariadi hospital. jl. dr. soetomo no. 16, semarang, indonesia. email: boedhi_smg73@yahoo.com. abstract thromboembolism events, either venous (vte) or arterial thromboembolism (ate) remain a highly prevalent complication in cancer patients. thrombosis is a leading cause of death, contributor to significant morbidity, the reason of delayed cancer treatment, leading to increased cancer financing and expenses. both cancer and its treatment are recently found to be related to vascular inflammation through the induction of tissue factor (tf) expression and promoting a procoagulant state which triggers the activation of coagulation system. several risk factors may also coexist such as dehydration, immobilization, smoking, obesity, previous dvt, etc. even in patients with asymptomatic deep vein thrombosis (dvt), they have a three-fold increase in mortality. the high morbidity and mortality of vte raises the need for thromboprophylaxis to reduce the incidence of overt thrombosis, albeit against its possible side effects related to anticoagulant prescription. this article highlighted the clinical perspectives for thromboprophylaxis while counting on the risk stratification in a particular cancer patient. keywords: thrombosis, cancer, inflammation, thromboprophylaxis. introduction cancer is a chronic disease with a high morbidity and mortality rate despite treatment advances. however, today many patients can survive longer due to progress in early diagnosis and progress in its treatment.1 cancer has long been known to be related to thrombosis and patients are reported to have a 7-fold increased probability compared to the general population.2 studies reported that the incidence of thrombosis in patients with cancer has been increasing overtime, partly due to its increasing incidence in recent years.3 therefore, management of complications especially thrombosis during the disease course are becoming more clinically relevant. optimal strategies to manage cancerassociated thrombosis remains a major concern that challenges clinicians in daily clinical practice; due to the fact that thrombosis is a preventable complication.3,4 venous and arterial thrombosis are the already known two spectrums of thrombosis.4 venous thromboembolism (vte) represents a clinical condition whether the thrombus is developed in the venous vasculature of the lower extremities and pelvic veins, as well as visceral or splanchnic vein thrombosis. thrombus migration proximally can travel along the bloodstream. vol 54 • number 4 • october 2022 preventing thrombosis in cancer patients 627 pulmonary embolism (pe) can unexpectedly develop when the thrombus embolization occurs in the pulmonary artery or its branches which is the major cause of morbidity and mortality in patients with dvt.5 in addition to vte, arterial thromboembolism (ate), including the myocardial infarction (mci), cerebrovascular accident (cva), and peripheral arterial disease (pad) are also prevalent in patients with active cancer compared to non-cancer population.4 thrombosis events, either vte or ate, are the second-leading cause of mortality after cancer progression itself.6,7 this make cancer-associated thrombosis a clinical conditions in which relevance should be increasingly recognized both for physician and medical oncologists. this article aims to described the need for thromboprophylaxis treatment in cancer patients and how to identify those who would benefit, irrespective of the risks. the dogma that “prevention is better than cure” is not an exaggeration in terms of reducing the burden of thrombosis. the decision to prescribe anticoagulants as a prophylactic measure should be based on the risks of morbidity and mortality related to vte/ate, thrombosis recurrence, anticoagulant-related bleeding, as well as on social values and patient preferences, particularly in indonesia. t h e b u r d e n o f v t e ( a n d at e ) i n oncological practice cancer patients will experience complications during the course of their disease, which includes disease progression, infections, side effects of chemotherapy, as well as thrombosis, which is a frequently occurring complication among others.6,8 to weigh the benefits against the risks of thormboprophylaxis, clinicians need to be familiar with the burden of thrombosis in cancer patients (table 1). the decision to provide thromboprophylaxis should be based on careful assessment of the benefits, such as reduction in vte and possible arterial thromboembolism, against its harms including the side effect of bleeding from anticoagulant.7 the risk of thrombosis in cancer patients, the purpose of anticoagulation, and the consequences in this population underlines the need for clinicians to carefully assess all factors before deciding to recommend any thromboprophylactic strategies.9,10 thrombosis in cancer patients can ultimately interfere with cancer treatment, reduce the quality of life, lead to additional diagnostic tests, increase treatment cost, and prolong length of stay. patients with a history of vte have a higher risk of recurring thrombosis and an increased mortality rate.7,11 approximately 95% of blood clots originate from the proximal portion of the lower extremities. however, pulmonary embolism may also occur without prior dvt. thrombosis can occur without the presence of any symptoms, referred to as incidental thrombosis. a study conducted in dr. kariadi hospital reported the incidence of asymptomatic dvt to be 25.6% among cancer patients. without prophylaxis, pe or even fatal pe can be the initial manifestation of vte. despite that, thrombotic events in cancer patients has not gained enough attention as seen by the lack of practice of thromboprophylactic use in clinical practice, although the international4,5 and indonesian national guidelines have been published since 2018.12 table 1. thromboprophylaxis and dire consequences of thrombosis in cancer patients. ultimate goals for thromboprophylaxis prevent thrombosis reduced risk of thrombosis recurrences short-term (immediate) consequences long-term consequences morbidity caused by dvt and/or pe post-thrombotic syndrome interruption of cancer treatment chronic thromboembolic pulmonary hypertension reduced quality of life long-term bleeding risk financial consequences increased mortality abbreviations: dvt, deep vein thrombosis; pe, pulmonary embolism source: mulder fi, et al. cancers 2020, with modifications. budi setiawan acta med indones-indones j intern med 628 cancer patients have a 4to 7-fold risk of developing vte compared to non-cancer patients. according to iorga et al.,15 the prevalence of vte in patients with cancer was 15% and correlated with poor treatment outcomes. moreover, 20-30% of all vte cases occurrs in cancer patients.15,16 data from a cohort study of 21,002 inpatients in california showed that 20% (4,368 patients) of cancer patients were found to have thrombosis.16 a study in korea reported that the cumulative incidence of vte in 2 years has increased to 24.4% in patients with metastatic gastric cancer.17 a retrospective cohort study conducted in dharmais cancer hospital jakarta showed that chemotherapy is a risk factor of dvt in patients with cancer (or 5.0, p= 0.012).18 the risk of thrombosis can vary depending on the disease status. it generally increases during periods of active disease, hospitalization, tumor-directed therapy, and decreases during remission.19,20 chew et al. also reported an increased risk of vte in all types of cancer with advanced metastasis. 21 the early phases following initial diagnosis is the period with the highest risk of developing vte (figure 1), where some prothrombotic mechanisms are involved in the cat mechanism. the incidence of vte is also high in patients undergoing chemotherapy. cases of vte in cancer patients is not limited to dvt and pe, but also thrombosis in unusual sites, such as the upper extremities, cerebral veins, and splanchnic veins.22 epidemiology horsted et al.13 reported that the incidence rates of venous thrombosis in cancer patients could be stratified by the background risk of vte. the incidence among cohorts with averagerisk patients was estimated to be 13 per 1,000 person-years (95% ci: 7-23). among cohorts with high-risk characteristics, the overall incidence rate was incredibly high with 68 per 1,000 person-years (95% ci: 48-96). in terms of the type of cancer, certain cancer can interestingly be more hypercoagulable than others, such as those in the gastrointestinal tract, including gastric, esophageal, and pancreatic cancers (table 2). patients with brain and lung cancers also showed an increased risk of vte by more than ten-fold compared to the general population.14 table 2. incidence of vte among various types of cancer. type of cancer first vte per 100 person-years (95% ci) bladder 2.7 (2.4-3.0) breast 3.2 (2.9-3.4) prostate 4.4 (4.0-4.7) hematologic 4.5 (4.1-4.8) colon 6.7 (6.3-7.2) lung 10.1 (9.5-10.8) stomach 10.8 (9.5-12.3) ovary 11.9 (10.6-13.2) brain 12.1 (10.3-14.0) pancreas 14.6 (12.9-16.5) source: cohen at, et al. thromb haemost 2017. figure 1. dynamic changes in the risk of vte along the course of cancer. reproduced with permission from streiff mb. clin adv hematol oncol 2013. vol 54 • number 4 • october 2022 preventing thrombosis in cancer patients 629 risk factors for thrombosis the risk factors for thromboembolism are divided into patient characteristic risks, tumor-related risks, and therapy-related risks.22 thrombosis events in cancer patients are generally based on the interactions of each risk factor (table 3). a person with more risk factors had a greater chance of developing thrombosis. certain types of cancer have a higher incidence of thrombosis. this risk is also higher in the later stage of cancer and metastatic disease. as a concrete example, 60-70% of patients with pancreatic cancer has vte as found in autopsy.23 pathophysiology of thrombosis in cancer patients on the basis of thrombosis, there is the so-called virchow’s triad of endothelial injury, hypercoagulability, and venous stasis. cancer cells can activate coagulation pathways by direct and indirect mechanisms. the direct mechanism involves production of procoagulant factors, such as tissue factors, which is constitutively expressed by cancer cells that bind to circulating fviii and activate coagulation pathways. the indirect mechanism involves an exposure of proinflammatory cytokine stimulation in the tumor microenvironment,24 and the administration of chemotherapy also causes damage to endothelial cells, therefore triggering an inflammatory response.25,26 inflammatory stimuli from cytokines, such as tumor necrosis factor-alpha (tnf-α), interleukin (il) -1a, il-6, il-17, and il-18, as well as epidermal growth factors (egf) that mediate inflammatory responses activated through interactions with toll-like receptors (tlrs), il-1 receptors (il-1r), il-6 receptors (il-6r), and tnf receptors (tnr).26,27 in figure 2, multiple mechanism of cancer-associated thrombosis is illustrated. oncogenic met, ras, p53, or pten activation, besides promoting cancer, can also induced gene transcription involved in the hemostasis regulation such as pai-1, cox-2, and tf. tumor hypoxia also causes hif-1α overexpression that directly controls the expression of hemostasis factors through the activation of pai-1 and cox-2, or through met.25 the figure also shows that tumor-derived cytokines (il-2, tnf and vegf) can activate monocytes, platelets and endothelial cells. tumor cells adhesion molecules (p-selectin, l-selectin) can bind the inflammatory cells which activate coagulation and stimulate fibrin production. some predisposing factors can add to the overall prothrombotic phenotype in an individual cancer patients, such as obesity, diabetes, smoking habit, older age, hospitalization, surgery, central venous catheter (cvc) insertion, tumor compression stasis, ascites, and chemotherapy.8,20,22 table 3. the risk factors for cancer-associated thrombosis. patient characteristics cancer-related factors treatment-related factors biomarkers female sex site or origin of cancer hospitalization high tissue factors expression older age tumor histology cancer therapy pre-chemotherapy platelet count > 350,000/ul race (african ethnicity) advanced stage and metastatic cancer erythropoiesis-stimulating agents pre-chemotherapy wbcs > 11,000/ul common comorbidities: diabetes, obesity, previous vte, atherosclerosis, inflammation, others being in initial period after cancer diagnosis venous catheter elevated d-dimer inherited thrombophilia high levels of: plasma tissue factor soluble p-selectin c-reactive protein von willebrand factor low expression of: adamts13 gene abbreviations: vte, venous thromboembolism; wbc, white blood cells; adamts13, source: eichinger s. thromb res 2016 budi setiawan acta med indones-indones j intern med 630 the administration of chemotherapy can lead to an inflammatory condition,25 which triggers nf-κb and mapk signaling pathways to produce proinflammatory cytokines, including il-6, tnf-α, il-1, il-8, and crp.26 proinflammatory cytokines play a role in thrombus formation in cancer patients and those undergoing chemotherapy. inflammatory markers such as hs-crp is correlated with wells score and d-dimer, which can be used to predict the incidence of dvt in cancer.28 chemotherapy-induced vascular endothelial cell activation (veca) is demonstrated by increased binding of circulating endothelial cells and von willebrand factors (vwf) in the plasma.29 vwf triggers platelets adhesion, factor viii binding and transport, as well as thrombus formation.30 our study revealed that pre-chemotherapy levels of vwf:ag and adamts-13 are independent risk factors for dvt incidence among cancer patients.31 vte risk stratification in order to assess vte risk in cancer patients, various factors need to be considered. some risk models have been developed and validated. the most known is the khorana risk score which is stratified into low (score 0), intermediate (score 1-2) and high risk (score 3) based on several variables such as cancer site, platelet count, wbcs count, hemoglobin levels or use of esa, and bmi, as shown in table 4. this model had a negative predictive value of 98.5%, positive predictive value of 7.1%, sensitivity of 40%, and specificity of 88%, as reported by a cohort study of 2,701 patients which was then validated into a prospective independent cohort study of 1,365 patients.32 some variations have been published such as protech,33 conko,34 and vienna cats score,35 which elaborate other biomarkers like d-dimer and soluble p-selectin.36 the compass-cat37 and onkotev5638 models were subsequently developed, which included figure 2. multiple mechanisms in the pathophysiology of cancer-associated thrombosis. there are overlapping and interacting mechanisms that can explain the increased incidence of thrombosis (both arterial and venous thrombosis) in cancer patients. hypercoagulability is ultimately the result of intrinsic and extrinsic risk factors. reproduced with permission from varki a, blood 2007. vol 54 • number 4 • october 2022 preventing thrombosis in cancer patients 631 variables such as cardiovascular risk factors, history of vte, presence of cvc, chemotherapy or hormonal therapy, tumor stage, and platelet count. the risk of major bleeding must be considered when choosing pharmacological vte prophylaxis in cancer patients for an optimal outcome. regardless of the selection of anticoagulation, the primary contraindication to prophylactic anticoagulant are bleeding episodes.39,40 the evidence-derived improve bleeding score used 13 clinical and laboratory factors and designated a score of seven or more to identify a patient cohort (10% of the population) at a high risk of bleeding (major bleed risk), 4.1% vs. 0.4%. patients with a score of less than seven were considered at a lower risk of bleeding (table 5).41 sex and age are the fixed risk factors, while the remaining are modifiable risk factors. when deciding whether anticoagulant can be safely initiated in a prophylaxis setting, clinicians should always optimize the patient’s current clinical status. table 4. predictive models for chemotherapy-related vte in ambulatory cancer patients (khorana risk score). patient characteristics vte risk score cancer origin very high risk 2 primary brain, gastric, or pancreatic tumors high risk 1 lung, lymphoma, gynecologic, or genitourinary tumors, excluding the prostate, and myeloma low risk 0 breast, colorectal, or head and neck tumors other characteristics platelet count ≥ 350x106/ul 1 wbcs count > 11 x 103/ul 1 hemoglobin <10 g/dl or use of red blood cell growth factors 1 bmi ≥ 35 kg/m2 1 notes: low risk: 0 score; intermediate risk 1 or 2 score; high risk: 3 or higher score abbreviations: bmi: body mass index; wbc, white blood cells source: khorana aa, et al. blood 2008. table 5. improve bleeding risk score. variables bleeding risk score fixed (nonmodifiable) risk factors age ≥ 85 years 3.5 40 to 84 years 1.5 < 40 years 0 gender male 1 female 0 modifiable risk factors kidney function severe kidney impairment (gfr ≤ 30 ml/min/m2) 2.5 moderate kidney impairment (gfr 30 to 59 ml/min/m2) 1 normal kidney function (gfr ≥ 60 ml/min/m2) 0 liver function liver failure (inr ≥ 1.5) 2.5 normal liver function (inr <1.5) 0 platelets <50 x 106/ul 4 ≥50 x 106/ul 0 other factors active gastric or duodenal ulcers 4.5 prior bleeding within last 3 months 4 admission to icu or ccu 2.5 central venous catheter 2 active malignancy 2 rheumatic disease 2 notes: low risk: score <7; increased risk: score ≥7 abbreviations: inr: international normalized ratio, gfr: glomerular filtration rate, icu: intensive care unit, ccu: coronary care unit source: skeik n, westegard e. ann vasc dis 2020. budi setiawan acta med indones-indones j intern med 632 current evidence the vte prophylaxis guideline in cancer patients with anticoagulants such as unfractionated heparin (ufh), low molecular weight heparin (lmwh), direct oral anticoagulant (doac) including rivaroxaban or apixaban has been recommended by the american society of clinical oncology (asco),42 international initiative on thrombosis and cancer (itac),43 national comprehensive cancer network (nccn)44 and also the national guideline from perhimpunan trombosis hemostasis indonesia (pthi) or the indonesian society on thrombosis hemostasis (inasth).12 the results of recent clinical trials support the benefits and safety of vte prophylaxis in medical patients. these clinical trials have compared enoxaparin, dalteparin, and fondaparinux to placebo in patients with acute medical illnesses. the use of enoxaparin in the medical patients with enoxaparin (medenox) trial,45 dalteparin in the prevention of vte in immobilized patients (prevent) trial,46 fondaparinux in the arixtra for thromboembolism prevention in a medical indications study (artemis) trial, 47 and rivaroxaban in the cassini trial48 were each compared to placebo. all studies show a significant decrease in the incidence of vte. these results support the evidence-based recommendations for the use of thromboprophylaxis in clinical practice. p r i m a r y t h r o m b o p r o p h y l a x i s : choice, dose and duration r o u t i n e t h r o m b o p r o p h y l a x i s i s n o t recommended in all patients with cancer, particularly ambulatory patients. thromboprophylaxis should be offered to patients with a high risk of thrombosis, including patients with myeloma receiving thalidomide or lenalidomide, and specific strategies for patients with myeloproliferative diseases should be determined. we proposed a khorana score-based decision algorithm for thromboprophylaxis administration to cancer patients. an aggregate score of zero indicates low risk (0.8% risk of vte over the course of 4 chemotherapy cycles), score 1-2 indicates intermediate risk (1.8%) and score 3 or greater indicates high risk (7.1%). cumulative vte risk have been estimated at 17.7% in the high risk group.39 more recent publications have suggested that high risk may be reflected by a score of 2 or greater when accommodating both inpatient and outpatient cancer populations.49,50 the second mentioned was based on khorana risk score ≥2 associated with the presence of metastasis, vascular compression, and previous vte. thromboprophylaxis may be recommended in patients with a khorana score of <2 whether there were addition of other risk factors such as prior vte, known thrombophilia, or bmi >40 kg/ m2. caution should be in mind for patients with high bleeding risk, unresected tumors, impaired or fluctuating renal function, highly emetogenic chemotherapy agents limiting reliable oral intake, and drug-to-drug interactions. the proposed thromboprophylaxis chart is illustrated in figure 4. prophylaxis for medical patients:42 1. pharmacologic thromboprophylaxis is recommended for hospitalized patients with acute medical illness and reduced mobility, in the absence of bleeding and other contraindications. 2. routine pharmacologic thromboprophylaxis is not recommended in patients admitted for minor procedures or chemotherapy infusion, or in patients undergoing bone marrow transplantation. prophylaxis for cancer patients undergoing systemic chemotherapy:42,43 1. routine pharmacologic thromboprophylaxis is not recommended for all cancer outpatients. 2. high-risk cancer outpatients (khorana score of 2 or higher), can be recommended to receive thromboprophylaxis with apixaban, rivaroxaban, or low-molecular-weight heparin (lmwh) prior to starting a new chemotherapy regimen, provided that there are no significant risk factors for bleeding and in the absence of drug interactions. considerations for such therapy should be accompanied by a discussion with the patient about the relative benefits and harms, drug costs, and duration of prophylaxis. 3. patients with multiple myeloma receiving thalidomide or lenalidomide-based regimens vol 54 • number 4 • october 2022 preventing thrombosis in cancer patients 633 with chemotherapy and/or dexamethasone are recommended to receive pharmacologic thromboprophylaxis with either aspirin or lmwh for low-risk patients and lmwh for high-risk patients. prophylaxis for cancer patients undergoing surgery:42 1. all cancer patients undergoing major s u rg e r y i s r e c o m m e n d e d t o r e c e i v e pharmacologic thromboprophylaxis with either unfractionated heparin (ufh) or lmwh unless contraindicated due to active bleeding, high bleeding risk, or other contraindications. 2. mechanical prophylaxis may be added to pharmacologic thromboprophylaxis but should not be used as monotherapy for vte prevention unless pharmacologic methods are contraindicated due to active bleeding or high bleeding risk. 3. a combined regimen of pharmacologic and mechanical prophylaxis may improve efficacy, especially in high-risk patients. 4. pharmacologic thromboprophylaxis for cancer patients undergoing major surgery should be continued for at least 7 to 10 days. extended prophylaxis with lmwh for up to 4 weeks post-operatively is recommended for patients undergoing major open or laparoscopic abdominal or pelvic surgery for high-risk patients, such as those with restricted mobility, obesity, history of vte, or with other risk factors. the algorithm for thromboprophylaxis need to be individualized and the expected benefits should always outweigh the risk of bleeding. as depicted in figure 3, major surgery and hospitalization are important risk factors for vte in cancer patients. if the bleeding risk is fair or low, then primary thromboprophylaxis can be recommended. information about anticoagulant dosing for thromboprophylaxis in cancer patients are provided based information on table 7. figure 3. daily practice algorithm for individual decisions for thromboprophylaxis in cancer patients. abbrebiations: lmwh, low moeluclar weight heparin; ufh, unfractionated heparin; vte, venous thromboembolism *additional risk factors for thrombosis include: prior vte, known thrombophilia, or bmi >40 kg/m2 (see text for detail). ** doac can be considered only in non-gastrointestinal cancers budi setiawan acta med indones-indones j intern med 634 secondary prophylaxis the concept of anticoagulant therapy (with proven existing vte) can involve prolonged therapy for more than 3-6 months by noting that active cancer is a risk factor for vte, with an annual recurrence rate of 10 to 29%. considerations include: cancer type and activity, burden of disease, therapy, patient preference, immobilization, and life expectancy.51 the nccn guidelines recommends lmwh as the preferred treatment for the first 6 months, or doac (rivaroxaban) if the patient refuses to be injected or is not a candidate for subcutanoues medication for several reasons.52 t h e n e w pa r a d i g m o f c a n c e r related thromboprophylaxis despite the existence of published guidelines and studies regarding the benefits and safety of vte prophylaxis, we continue to see low adoption of such recommendations, and vte prophylaxis remains underused.53,56 the reason behind the low provision of prophylaxis in patients with high risk of vte is most often due to cost considerations,53,55,57 concerns of bleeding complications,54,56 lack of knowledge and confidence, 54 lack of awareness, 55,58 and reluctance to give daily injections of anticoagulants as prophylaxis.54 recent advances in understanding the mechanism of vte demonstrate the pivotal role of the immune system and inflammation in its pathogenesis, and show that it is an immunity and inflammation-related process rather than merely coagulation-dependent thrombosis. the above paradigm opens new ideas for further research on new therapeutic options for vte prophylaxis by inhibiting immune and inflammatory processes, instead of inhibiting the coagulation factors on the coagulation cascade directly, thereby reducing the risk of bleeding that can occur with the administration of anticoagulants as vte prophylaxis.59 currently, there is no specific guideline for arterial thrombosis in cancer patients due to the lack of specific data available. however, usual care is recommended. conclusion t h r o m b o e m b o l i s m e v e n t s r e m a i n highly prevalent in cancer patients. venous table 7. anticoagulant dosing regimens for prophylaxis in cancer patients. clinical background agent dose hospitalized cancer patients for medical reason(s) ufh 5000 u every 8 hours sq dalteparin 5000 u every 24 hours sq enoxaparin 40 mg every 24 hours sq fondaparinux 2.5 mg every 24 hours sq cancer patients undergoing surgery ufh 5000 u 2-4 hours sq preoperatively and then every 8 hours thereafter dalteparin 2500 u 2-4 hours sq preoperatively and 5000 u every 24 hours thereafter or 5000 u 2-4 sq hours preoperatively or 10-12 hours preoperatively and 5000 u every 24 hours thereafter enoxaparin 40 mg 2-4 hours sq preoperatively or 10-12 hours preoperatively and 40 mg/24 hours thereafter fondaparinux 2.5 mg every 24 hours sq beginning 6-8 hours postoperatively outpatient setting dalteparin 5000 u every 24 hours sq enoxaparin 40 mg every 24 hours sq fondaparinux 2.5 mg every 24 hours sq apixaban 2.5 mg orally every 12 hours po rivaroxaban 10 mg orally every 24 hours po abbreviations: p.o., per oral; sq, subcutaneously; ufh, unfractionated heparin source: key ns et al. j clin oncol 2019. vol 54 • number 4 • october 2022 preventing thrombosis in cancer patients 635 thromboembolism is a leading cause of death, morbidity, delayed treatment, and increased treatment cost. the high morbidity and mortality of vte raises the need for thromboprophylaxis to reduce the incidence of these clinical conditions. the administration of effective vte prophylaxis and treatment in cancer patients can improve their survival rate and quality of life. today, there are several options in medical thromboprophylaxis that include ufh, lmwh, and more recently doac also have been validated in several clinical trials involving patients with cancer. the decision to choose one anticoagulant over another was based on clinical ground, type of cancer, risk of bleeding, renal function, patient compliance, social economic religion aspects and finally, patient’s preferences. recent advances in understanding the mechanism of vte demonstrate the pivotal role of the immune system and inflammation in its pathogenesis, and show that vte is an inflammation-related process, instead of merely coagulation-dependent thrombosis. the above paradigm opens new insights for further research on new therapeutic options for vte prophylaxis by inhibiting immune and inflammatory processes, instead of inhibiting the coagulation factors on the coagulation cascade directly, thereby reducing the risk of bleeding that can occur with the administration of anticoagulants as vte prophylaxis. references 1. editorial. advancing cancer therapy. nature cancer. 2021;2:245-6. 2. blom jw, doggen cjm. osanto s, et al. malignancies, prothrombotic mutations, and the risk of venous thrombosis. jama. 2005;293:715-22. 3. american cancer society. global cancer facts & figures. 4 th edition. international agency for research on cancer. the world health organization; 2018. 4. gervaso l, dave h, khorana aa. venous and arterial thromboembolism in patients with cancer. j am college cardiol. 2021;3:173-90. 5. national institute for health and care excellence. venous thromboembolism in adults: diagnosis and management, 2013. last updated: 25 january 2021. 6. khorana aa, francis cw, culakova nm, kudered nm, lyman gh. thromboembolism is a leading cause of death in cancer patients receiving outpatient chemotherapy. j thromb haemost. 2007;5:632-4. 7. prandoni p, lensing awa, piccioli a, et al. recurrent venous thromboembolism and bleeding complications during anticoagulant treatment in patients with cancer and venous thrombosis. blood. 2002;100:3484-8. 8. suharti c. tromboemboli vena pada kanker (article in bahasa indonesia). medica hospitalia. 2013;1:143-9. 9. al-samkari h, connors jm. managing the competing risks of thrombosis, bleeding, and anticoagulation in patients with malignancy. blood adv. 2019;3:71-9. 10. m u l d e r f i , b o s c h f t m , v a n e s n . p r i m a r y thromboprophylaxis in ambulatory cancer patients : where do we stand ? cancers. 2020;12:1-17. 11. elting ls, escalante cp, cooksley c, et al. outcomes and cost of deep venous thrombosis among patients with cancer. jama. 2004;164:1653-61. 12. indonesian society of thrombosis and hemostasis. the national guideline on venous thormboembolism (in bahasa indonesia). 2018. 13. horsted f, west j, grainge mj. risk of venous thromboembolism in patients with cancer: a s y s t e m a t i c r e v i e w a n d m e t a a n a l y s i s . p l o s med. 2012;9(7):e1001275. 14. cohen at, katholing a, rietbrock s, bamber l, martinez c. epidemiology of first and recurrent venous thromboembolism in patients with active cancer a population-based cohort study. thromb haemost. 2017;117:57-65. 15. iorga ra, bratu og, marcu rd, et al. venous thromboembolism in cancer patients: still looking for answers. exp ther med. 2019;18:5026-32. 16. timp jf, braekkan sk, versteeg hh, cannegieter sc. epidemiology of cancer-associated venous thrombosis. blood. 2013;122:1712-24. 17. angchaisuksiri p. cancer-associated thrombosis in asia. thromb j. 2016;14(suppl. 1):26. 18. sutandyo n, tobing dl, kardinah. risk factors of deep vein thrombosis in cancer patients. iran j blood & cancer. 2018;10:117-23. 19. lyman gh. venous thromboembolism in the patient with cancer: focus on burden of disease and benefits of thormboprophylaxis. cancer. 2011;117:1334-9. 20. streiff mb. association between cancer types, cancer treatments, and venous thromboembolism in medical oncology patients. clin adv hematol oncol. 2013;11:349-57. 21. chew hk, wun t, harvey d, et al. incidence of venous thromboembolism and its effect on survival among patients with common cancers. arch intern med. 2006;166:458-64. 22. eichinger s. cancer associated thrombosis: risk factors and outcomes. thromb res. 2016;140:s12-s17. 23. sproul ee. carcinoma and venous thormbosis: the frequency of association of carcinoma in the body or tail of the pancreas with multiple venous thormbosis. cancer res. 1998;34:566-85. 24. karin m. nfkb as a critical link between inflammation and cancer. cold spring harb perspect biol. 2009:1: budi setiawan acta med indones-indones j intern med 636 a000141. 25. boccaccio c, paolo m. comoglio. oncogenesis, cancer and hemostasis. in: khorana aa, francis cw, eds. cancer-associated thrombosis. new york, usa: informa healthcare inc.; 2008. p. 1-15. 26. chen l, deng h, cui h, et al. inflammatory responses and inflammation-associated diseases in organs. oncotarget. 2018;9:7204-18. 27. park mh, hong jt. roles of nfκb in cancer and inflammatory diseases and their therapeutic approaches. cells. 2016;5:15. 28. setiawan b, rosalina r, pangarsa ea, santosa d, suharti c. clinical evaluation for the role of highsensitivity c-reactive protein in combination with d-dimer and wells score probability test to predict the incidence of deep vein thrombosis among cancer patients. int j gen med. 2020;13: 587-594. 29. kirwan cc, mccollum cn, mcdowell g, byrne gj. investigation of proposed mechanisms of chemotherapy-induced venous thromboembolism: endothelial cell activation and procoagulant release due to apoptosis. clin appl thromb. 2015;2:420-7. 30. sahebkar a, serban c, ursoniu s, et al., for lipid and blood pressure meta-analysis collaboration (lbpmc) group. the impact of statin therapy on plasma levels of von willebrand factor antigen. systematic review and meta-analysis of randomised placebo-controlled trials. thromb haemost. 2016;115:520-32. 31. setiawan b, permatadewi co, de samakto b, et al. von willebrand factor: antigen and adamts-13 level, but not soluble p-selectin , are risk factors for the first asymptomatic deep vein thrombosis in cancer patients undergoing chemotherapy. thromb j. 2020;18:33. 32. khorana aa, kuderer nm, culakova e, lyman gh, francis cw. development and validation of a predictive model for chemotherapy-associated thrombosis. blood. 2008;111:4902-8. 33. verso m, agnelli g, barni s, gasparini g, labianca r. a modified khorana risk assessment score for venous thromboembolism in cancer patients receiving chemotherapy : the protecht score. intern emerg med. 2012:7:291-2. 34. pelzer u, sinn m, stieler j, riess h. primäre m e d i k a m e n t ö s e t h r o m b o e m b o l i e p r o p h y l a x e bei ambulanten patienten mit fortgeschrittenem pankreaskarzinom unter chemotherapie ? dtsch med wochenschr. 2013;138:2084-8. 35. ay c, dunkler d, marosi c, et al. prediction of venous thromboembolism in cancer patients prediction of venous thromboembolism in cancer patients. blood. 2010;116:5377-82. 36. connolly gc, francis cw. cancer-associated thrombosis. hematology am soc hematol educ program. 2013;2013:684-91. 37. gerotziafas gt, taher a, abdel-razeq h, et al. a predictive score for thrombosis associated with breast, colorectal, lung, or ovarian cancer: the prospective compass – cancer-associated thrombosis study. oncologist. 2017;22:1222-31. 38. cella ca, di minno g, carlomagno c, et al. preventing venous thromboembolism in ambulatory cancer patients: the onkotev study. oncologist. 2017:22601-8. 39. chi g, goldhaber sz, kittelson jm, et al. effect of extended-duration thromboprophylaxis on veous thromboembolism and major bleeding among acutely ill hospitlaized medical patients: a bivariate analysis. j thromb haemost. 2017;15:1913-22. 40. al-shamkari h, connors jm. managing the competing risks of thrombosis, bleeding, and anticoagulation in patients with malignancy. blood adv. 2019;3:3770-9. 41. skeik n, westergard e. reccomendations for vte prophylaxis in medically ill patients. ann vasc dis. 2020;13:38-44. 42. key ns, chb mb, khorana aa, kuderer nm, bohlke k, lee ayy. venous thromboembolism prophylaxis and treatment in patients with cancer: asco clinical practice guideline update. 2019. 43. farge d, frere c, connors jm, et al. 2019 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. lancet oncol. 2019;20:e566-81. 44. khorana aa. the nccn clinical practice guidelines on venous thromboembolic disease: strategies for improveing vte prophylaxis in hospitalized cancer patients. oncologist. 2007;12:1361-70. doi:10.1634/ theoncologist.12-11-1361. 45. alikhan r, cohen at, combe s, et al. prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the medenox study. blood coagul fibronolysis. 2003;l(14):341-6. 46. leizorovicz a, cohen at, turpie agg, olsson c, vaitkus pt, goldhaber sz and for the prevent m e d i c a l t h r o m b o p r o p h y l a x i s s t u d y g r o u p . randomized, placebo-controlled trial of dalteparin for the prevention of venous thmoboembolism in acutely ill medical patients. circulation. 2004;110:874-9. 47. cohen at, davidson bl, gallus as, et al. artemis investigators. efficacy and safety of fondaparinux for the prevention of venous thromboembolism in older acute medical patients: randomised placebo controlled trial. bmj. 2006;332:325-9. 48. khorana aa, soff ga, kakkar ak, et al. rivaroxaban for thromboprophylaxis in high-risk ambulatory patients with cancer. n engl j med. 2019;380:720-8. 49. parker a, peterson e, lee ayy, et al. risk stratification for the development of venous thromboembolism in hospitalized patients with cancer. j thromb haemost. 2018;16:1321-6. 50. mulder fi, candeloro m, kamphuisen pw, et al., cat-prediction collaborators. the khorana score for prediction of venous a systematic review and metaanalysis. haematologica. 2019;104:1277-87. 51. kearon c, akl ea, ornelas j, et al. antithrombotic vol 54 • number 4 • october 2022 preventing thrombosis in cancer patients 637 therapy for vte disease: chest guideline and expert panel report. chest. 2016;149:315-52. 52. streiff mb, holmstrom b, angelini d, et al. nccn guidelines® insights: cancer-associated venous thromboembolic disease, version 2.2018. featured updates to the nccn guidelines. j natl compr canc netw. 2018;16:1289-303. 53. atmakusuma td, tambunan kl, sukrisman l, et al. underutilization of anticoagulant for venous thromboembolism prophylaxis in three hospitals in jakarta. acta medica indones. 2015;47:136-45. 54. mahe i, chidiac j, helfer h, noble s. factors influencing adherence to clinical guidelines in the management of cancer-associated thrombosis. j thromb haemost. 2016;14:2107-13. 55. bradley t, brasel kj, miller jj, pappas sg. costeffectiveness of prolonged thromboprophylaxis after cancer surgery. ann surg oncol. 2010:17:31-9. 56. figueroa r, alfonso a, lopex-picazo j, et al. insights into venous thromboembolism prevention in hospitalized cancer patients: lessons from a prospective study. plos one. 2018:13:e0200220. 57. hibbert pd, hannaford na, hooper td, et al. assessing the appropriateness of prevention and management of venous thromboembolism in australia: a cross-sectional study. bmj open. 2016;6:e008618. 58. bump gm. how complete is the evidence for thromboembolism prophylaxis in general medicine patients? a meta-analysis of randomized controlled trials. j hosp med. 2009;4:289-97. 59. budnik i, brill a. immune factors in deep vein thrombosis initiation. trends immunol. 2018;39:61023. 638 acta med indones indones j intern med • vol 54 • number 4 • october 2022 review article molnupiravir and nirmatrelvir/ritonavir: the new available antiviral options for covid-19 samuel theodorus sutanto1, robert sinto2*, adeline pasaribu2, sharifah shakinah2 1 faculty of medicine, universitas kristen krida wacana, jakarta, indonesia. 2 division of tropical and infectious diseases, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. *corresponding author: robert sinto, md. division of tropical and infectious diseases, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: robert.sinto01@ui.ac.id. abstract coronavirus disease 2019 (covid-19) is a respiratory tract disease caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2). with the complexity of multimorbidity in indonesia, it is crucial to find another line of antiviral for covid-19. this article aims to review two antivirals, molnupiravir and nirmatrelvir/ ritonavir, that have been studied extensively in treating covid-19 with promising results, and their availability in indonesia. molnupiravir and nirmatrelvir/ritonavir are two of many repurposed drugs in clinical trials, which have been reported to have a mechanism in quick clearance of sars-cov-2, reduction in viral load, and fast symptoms recovery time in phase 1 and 2 clinical trials. phase 2/3 clinical study in covid-19 patients without any indication for hospitalization showed that molnupiravir and nirmatrelvir/ritonavir significantly reduced the risk of hospitalization and death. keywords: antiviral, covid-19, molnupiravir, nirmatrelvir/ritonavir, sars-cov-2. introduction coronavirus disease 2019 (covid-19) is a respiratory tract disease caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2). up to early september 2022, the disease has caused 613 million cases and 6.5 million deaths globally.1,2 one of the strategies in eradicating covid-19 is vaccination, which has reached more than 12 billion doses administered worldwide.1 vaccination in indonesia is underway and reaching over 204 million first dose in september 2022.3 although the administration of vaccine has a widespread distribution, the incidence rate of covid-19 during this past month is still high, reaching 2,344 cases for every 100,000 people.1,2 in addition to vaccination as a preventive measure, proper and effective curative treatment is essential to decrease morbidity and mortality caused by covid-19. many studies have reported the role of covid-19 medications, such as the use of inflammatory agents, immunoglobulin, immunomodulator, convalescent plasma, or antibiotics and antivirals. we aim to highlight the role of newly repurposed antiviral agents for covid-19 treatment, molnupiravir and nirmatrelvir/ritonavir, which are available in indonesia since early 2022, but have not been widely reviewed. vol 54 • number 4 • october 2022 molnupiravir and nirmatrelvir/ritonavir: 639 covid-19 and rna dependent rna polymerase (rdrp) sars-cov-2 is a positive single-stranded ribonucleic acid (rna) coronavirus which is encapsulated by an envelope and a nucleocapsid.4 it has a 29.9-kb genome with a diameter of 50200 nm.5 the virion has many structural proteins, i.e., spike (s), envelope (e), nucleocapsid (n) and membrane (m).4,5 the s protein facilitates the binding of angiotensin-converting enzyme 2 (ace2) and the host cell membrane receptor, which then helps the fusion of virus into the host cell. inside the host cell, the replication of the viral genome occurs in cytoplasm, mediated by rna-dependent rna polymerase (rdrp) enzyme.5–7 numerous studies have focused on rdrp as a promising therapy against viral infections.5 rdrp is an important enzyme in majority of rna virus’ replication process. the enzyme is also relatively stable throughout the evolution of virus, does not have homologous structure in host cells, and has previously been studied. there is already adequate information on its structure and function. we will further discuss the drugs which mechanism of action are principally on the rdrp enzyme, i.e., molnupiravir and nirmatrelvir/ ritonavir. molnupiravir d u r i n g c o v i d 1 9 , t h e r e a r e m a n y preceding drugs which are repurposed as covid-19 therapy, such as hydroxychloroquine/ chloroquine, ivermectin, antibiotics, antivirals, antihypertensives, and immunomodulators. similar to remdesivir and favipiravir, molnupiravir works as rdrp inhibitor for transcription and replication of viral rna genome.5,8 molnupiravir works by the mechanism of “error catastrophe”, where it increases the rate of mutation in the viral genome and eventually become lethal to the virus.5 molnupiravir has a molecular formula c13h19n3o7 and its active form name is emory institute for drug development (eidd)1931-isopropyl ester (eidd-1931) or β-d-n4hydroxycytidine-5’-isopropyl ester (nhc).5,8–11 the active form is converted to nhc-triphosphate that binds to rdrp, instead of binding to cytidine and uridine triphosphates.12 the rdrp enzyme uses the nhc-triphosphate as a substrate and incorporates into the rdrp active centers to form stable complexes, leading to synthesis of mutated rna. rdrp synthesizes negative strand genomic rna (-grna) from positive strand genomic rna template. the +grna is also synthesized from m-containing rna. the m-containing rna in the -grna causes mutation in +grna, and subsequently results in mutagenesis which is lethal to the virus.11,12 the mutagenesis leads to the accumulation of deleterious errors in the genome, hence causing the inability of the virus to replicate. there is some concern that these mutations can also be produced in the host cell (mammalian dna) and therefore, increasing its potential carcinogenic and teratogenic effects. however, the concern is less likely to happen because of molnupiravir regimens are short-term (5 days).12,13 the suggested dose for patients is 800 mg (with 200 mg on each tablet) orally, twice daily for five days in mild, moderate, and severe covid-19 cases.14 for patients with comorbidity and with risk of worsening in later stages of covid-19, the national institutes of health (nih) recommended to use molnupiravir only when nirmatrelvir/ritonavir or remdesivir cannot be used. some of the comorbidities being studied are type i and ii diabetes mellitus, malignancies, cerebrovascular diseases, chronic kidney diseases, chronic liver diseases, chronic pulmonary diseases, cardiovascular diseases, and obese population.13,14 molnupiravir should be started within five days of symptoms onset.13 the contraindication of molnupiravir is pregnancy, breastfeeding, and children younger than 18 years old.13,14 there are some exception in pregnancy, when other therapies are not available, molnupiravir can be used with riskbenefit assessment and preferably beyond 10 weeks of gestation.13 clinical studies of molnupiravir the preclinical studies of molnupiravir suggested that it has broader antiviral efficacy toward sars-cov-2 compared to remdesivir. a double-blind, randomized, and placebocontrolled (dbrpc) phase 1 clinical study of samuel theodorus sutanto acta med indones-indones j intern med 640 molnupiravir reported that the drug is safe and most effective at the dose levels of 50-1600 mg, with half-life between 0.907 and 7.08 hours. the rate of absorption was low during meals, but with longer duration of exposure, the absorption rate of both the fed and unfed states was similar. another phase 1 clinical study also reported safety and tolerability of 1600 mg daily dose molnupiravir up to 5.5 days, without any serious adverse events.12 the median time needed for the active form of molnupiravir to reach maximum observed plasma concentration ranges from 1-1.75 hours. adverse events were more prevalent in the placebo arm. in both studies, the most frequently reported adverse event was headache, without any other safety concern on vital signs, electrocardiogram data, or hematological parameters.12 a phase 2 clinical study of molnupiravir reported that the dose of 800 mg twice daily had good efficacy in reducing clearance time of viral rna compared to placebo (rna negativity), with median time of 14 days versus 27 days in placebo. the most common adverse events were headache, insomnia, and increased levels of alanine aminotransferase, which were reported in both molnupiravir and placebo group.12 a phase 3 clinical study, move-out, reported that the molnupiravir reduced the risk of hospital admission and death by 50% in mild cases of covid-19; however, this study was criticized due to its inconsistencies in study method and result, implementation of the interim and primary analysis, significant differences between interim and post-interim results, and analysis of the result.15,16 bernal aj et al also reported data from move-out that molnupiravir group had a lower risk of hospitalization due to any cause or death until day 29 (table 3). there was no significant benefit to this drug in the later stage of moderate to severe covid-19. the efficacy of molnupiravir was not affected by the sars-cov-2 variant (gamma, delta, or mu), the onset time of symptoms, or the underlying risk factors.12,16 the most common adverse events in molnupiravir group were covid-19 pneumonia, diarrhea, bacterial pneumonia, and progressive covid-19.16 a dbrpc phase 3 study (move-ahead) is underway to evaluate the safety and efficacy of molnupiravir to prevent the incidence of covid-19 in non-infected adults living with an infected person. there is still lack of data on molnupiravir clinical trials in vaccinated patients, but it may have lower efficacy or no benefit on this population.13 nirmatrelvir/ritonavir another repurposed drug for covid-19 is nirmatrelvir/ritonavir, with paxlovidtm as its brand. unlike molnupiravir, this drug is not associated with the alarming possibilities of mutation induction in human dna and acceleration of the development of new virus variants. nirmatrelvir/ritonavir inhibit the main protease (mpro) and 3cl protease of sars-cov-2.7,17 mpro, which is an attractive antiviral target because it is essential in the viral replication cycle.17 study of nirmatrelvir in animals had demonstrated its activity to halt the spread of covid-19 despite the frequent mutations in the viral genomes.7 nirmatrelvir shows an effective antiviral effect against recent coronavirus mutants. working in combination with nirmatrelvir, ritonavir works as a cyp3a4 inactivator and pharmacokinetic enhancer that resulted in boosting the serum concentration of nirmatrelvir. ritonavir has also previously been used in combination with antiretroviral drugs in human immunodeficiency virus (hiv) infection.7 an interim result analysis of phase 2/3 clinical study epic-hr (evaluation of protease inhibition for covid-19 in high-risk patients) stated that this drug significantly reduced the risk of hospitalization and death in covid-19 outpatients, who have at least one comorbidity (diabetes or lung disease), with estimated risk reduction of -6.3%. during 28-day observation, 0.3% of patients in nirmatrelvir/ritonavir group were hospitalized with no mortality case, compared to 6.3% of patients in the placebo group with 12 deaths (table 3).7 the suggested dose of nirmatrelvir for patients with normal renal function is 300 mg (with 150 mg on each tablet) and ritonavir 100 mg per tablet orally, twice daily for five days, and should be initiated within five days of symptoms onset.18,19 the dose adjustment for moderate vol 54 • number 4 • october 2022 molnupiravir and nirmatrelvir/ritonavir: 641 renal impairment (estimated glomerular filtration rate (egfr) ≥ 30 to ≤ 60 ml/min) is 150 mg nirmatrelvir and 100 mg ritonavir twice daily for five days. nirmatrelvir/ritonavir is not recommended for patients with severe renal impairment (egfr) < 30 ml/min) or with severe hepatic impairment (child-pugh class c).14,18,19 nirmatrelvir/ritonavir is recommended for children 12 years old and above who weigh at least 40 kg with mild to moderate covid-19, but it is still contraindicated for children below 12 years old.14 nih stated that nirmatrelvir/ritonavir is safe to be used in pregnancy with risk-benefit assessment (medical comorbidities, body mass index, and vaccination status).19 however, there is still lack of data in indonesia regarding the safety in pregnancy, breastfeeding, and pediatric population. some adverse events of nirmatrelvir/ ritonavir are dysgeusia, diarrhea, hypertension, and myalgia, which occur in both nirmatrelvir/ ritonavir and placebo groups. the common side effects of ritonavir are nausea, vomiting, diarrhea, changes in taste, fatigue, rash, hyperlipidemia, and lipodystrophy (associated with longterm use).7,17 the drug may also interact with antiarrhythmics (amiodarone, digoxin), oral antithrombotics (apixaban, rivaroxaban, ticagrelor), statins (atorvastatin, lovastatin, simvastatin), benzodiazepines (diazepam), opioids (methadone, fentanyl), anticonvulsants (carbamazepine), neuropsychiatric drugs, and immunosuppressants; therefore, it should be administered with caution to avoid drug interactions.18 why molnupiravir and nirmatrelvir/ ritonavir essential for high-risk patient? for clinical symptoms outcome, fisher w et al reported that there are no significantly difference in patients with molnupiravir and placebo. time to resolution of covid-19 symptoms was not statistically different between participants.10 until now, there is still limited data that discuss about clinical resolutions of covid-19 symptoms, so there is a need for more studies to learn about symptoms resolutions and preventive effect of antivirals for long covid-19. many of the studies have reported clinical data, such as hospitalization rate and death. even though clinical symptoms outcome data are still lacking, lai cc et al reported that between three antiviral agents as interventions (molnupiravir, remdesivir or nirmatrelvir/ritonavir) and placebo, with the same study design (table 1 and table 2)20, showed that, nirmatrelvir/ritonavir is superior than its predecessor and molnupiravir has better outcome than placebo. high risk patients who are recognized by move-out study and cdc are people with >60 years of age, active cancer, chronic kidney disease (ckd), chronic obstructive pulmonary disease (copd), obesity (body mass index (bmi) ≥ 30 kg/m2), serious heart conditions (coronary artery diseases (cad), heart failure, cardiomyopathies), hypertension, d i a b e t e s m e l l i t u s , i m m u n o s u p p r e s s i v e diseases or immunosuppressive treatments, neurodevelopmental disorders (cerebral palsy) or other conditions that confer medical complexity (genetic or metabolic syndromes and severe congenital anomalies), and having a medicalrelated technological dependence (tracheostomy, gastrostomy).21 toussi ss et al reported that implementation of nirmatrelvir/ ritonavir in renal impairment needs dosage adjustment.22 with current limitation of high-risk patients that could be included in molnupiravir and nirmatrelvir/ ritonavir studies, there is already reduced risk of hospitalization and death. in future studies, table 1. results of the pairwise comparisons in the network meta-analysis between antiviral agents for covid-19.20 antiviral agents* nirmatrelvir plus ritonavir remdesivir molnupiravir placebo nirmatrelvir plus ritonavir 0.89 (0.17-4.69) 0.17 (0.07-0.39) 0.12 (0.06-0.24) remdesivir 1.12 (0.21-5.88) 0.19 (0.04-0.89) 0.13 (0.03-0.57) molnupiravir 5.85 (2.54-13.46) 5.22 (1.13-24.22) 0.67 (0.46-0.99) placebo 8.68 (4.15-18.17) 7.75 (1.76-34.22) 1.48 (1.01-2.18) *odds ratio and 95% confidence interval were presented with drugs on the column as the reference samuel theodorus sutanto acta med indones-indones j intern med 642 we hope that all of the high-risk patients can be included in studies and the effect of these antiviral agents can be more explored. table 2. rank probabilities for treatment by p-score.20 antiviral agents p-score* nirmatrelvir + ritonavir remdesivir molnupiravir placebo 0.8510 0.8087 0.3317 0.0086 *higher probability indicates better treatment for covid-19 table 3. summary of published phase 3 clinical trials on molnupiravir and nirmatrelvir/ritonavir. no author (year) countries population(n=patients) outcome evaluated % of outcome in both groups (drugs vs placebo) comments (if any) molnupiravir 1. fischer w, et al (2021) clinicaltrials.gov nct 04405570 multicountry n = (204) decrease in infectious virus isolation time to sars-cov-2 clearance of viral rna *infectious virus isolation day 3 : 1.9% (1/53) vs 16.7% (9/54) (p = 0.02) day 5 : 0% vs 11.1% (6/54) (p = 0.03) *time to sars-cov-2 clearance of viral rna 14 days vs 27 days (p = 0.001) randomized, double-blind, placebocontrolled trial 2. bernal aj, et al (2021) move-out clinicaltrials.gov nct 04575597 multicountry n = (1450) the risk of hospitalization or death until day 29 adverse events *the risk of hospitalization or death until day 29 7.3% (28 of 385) vs 14.1% (53 of 377) (p = 0.001) *adverse events (30.4%) 216 of 710 vs 33.0% (231 of 701) randomized, double-blind, placebocontrolled trial 3 painter wp, et al (2021) nct04392219 united kingdom n = (130) 1. number of reported adverse events 2.to determine the safety and tolerability of single and mutiple ascending doses of molnupiravir *adverse events headache (12.5% vs 18.8%) diarrhea (7.1% vs 7.1%) *single ascending doses reported adverse events (43.8% vs 35.4%) *mutiple ascending doses reported adverse events (50% vs 42.9%) randomized, double-blind, placebocontrolled trial nirmatrelvir/ritonavir 1. hammond j, et al (2022) epic-hr nct04960202 multicountry n = (2246) 1.the incidence of covid-19 related hospitalization or death by day 28 2.the incidence of adverse events *incidence of covid-19related hospitalization or death by day 28 0.77% (3 of 385) vs 7.01% (27 of 385) deaths : 0 vs 7 6.32% reduction (95% ci, -9.04 to -3.59; p<0.001; relative risk reduction, 89.1%) *adverse events : 22.6% vs 23.9% serious adverse events : 1.6% vs 6.6% adverse events leading to discontinuation : 2.1% vs 4.2% randomized, double-blind, placebocontrolled trial vol 54 • number 4 • october 2022 molnupiravir and nirmatrelvir/ritonavir: 643 m o l n u p i r av i r a n d n i r m at r e lv i r/ ritonavir availability and use in indonesia on the 13th of january 2022, the indonesian national agency of drug and food control stated that the emergency use authorization (eua) of molnupiravir has been granted.23,24 the use of molnupiravir is already registered on indonesian national agency of drug and food control. however, nirmatrelvir/ritonavir has not been granted eua yet in indonesia. regarding the availability of molnupiravir in indonesia, through www.covid19.go.id as the official website for covid-19 in indonesia, the ministry of health of the republic of indonesia reported that they have prepared 400 thousand tablets for the ongoing month since 17th of january 2022. the indonesian medical association, which includes the indonesian society of respirology, the indonesian heart association, the indonesian society of internal medicine, the indonesian society of anesthesiology and intensive therapy, and the indonesian pediatric society, has given their recommendation for use in the fourth edition of guidelines for covid-19 treatment on january 2022. conclusion there has been new insight on the use of antivirals for covid-19 treatment as molnupiravir and nirmatrelvir/ritonavir has now been made available in indonesia. despite the rising number of people who got vaccinated, antiviral treatment is still an important aspect needed to treat covid-19 infection. in indicated patients, molnupiravir and nirmatrelvir/ritonavir are expected to have a greater impact in the society, i.e., to reduce the risk of hospitalization and death than its predecessor antivirals and placebo. with promising results from preclinical, phase 1, phase 2, and phase 3 studies, both drugs are considered to be safe and tolerable without any serious adverse events. conflict of interest the authors affirm no conflict of interest in this study. acknowledgments all named authors have met the criteria for authorship, took responsibility for the integrity of the work as a whole, and have given their approval for this version to be published. references 1. john hopkins univeristy. covid-19 dashboard by the center for systems and engineering at johns hopkins university. published 2022. accessed september 21, 2022. https://www.coronavirus.jhu.edu/map.html 2. kementerian kesehatan republik indonesia. situasi terkini perkembangan coronavirus disease (covid-19). published 2022. accessed september 21, 2022. https://infeksiemerging.kemkes.go.id/situasiinfeksi-emerging/situasi-terkini-perkembangancoronavirus-disease-covid-19-08-agustus-2022 3. kementerian kesehatan republik indonesia. vaksinasi covid-19 nasional. published 2022. accessed september 21, 2022. https://vaksin.kemkes.go.id/#/ vaccines 4. drozdzal s, rosik j, lechowicz k, et al. an update on drugs with therapeutic potential for sars-cov-2 (covid-19) treatment. drug resist updat. 2021;59:127. doi:doi.org/10.1016/j.drup.2021.100794 5. hashemian smr, pourhanifeh mh, hamblin mr, shahrzad mk, mirzaei h. rdrp inhibitors and covid-19: is molnupiravir a good option? biomed pharmacother. 2022;146(january). doi:doi. org/10.1016/j.biopha.2021.112517 6. şimşek-yavuz s, komsuoğlu çelikyurt fi. an update of anti-viral treatment of covid-19. turkish j med sci. 2021;51(si1):3372-3390. doi:10.3906/sag-2106250 7. hung yp, lee jc, chiu cw, et al. oral nirmatrelvir/ ritonavir therapy for covid-19: the dawn in the dark? antibiotics. 2022;11(2):5-11. doi:10.3390/ antibiotics11020220 8. imran m, arora mk, mohammed s, et al. discovery, development, and patent trends on molnupiravir: a prospective oral treatment for covid-19. molecules. 2021;26:5795. 9. fischer w, eron jj, holman w, et al. molnupiravir, a n o r a l a n t i v i r a l t r e a t m e n t f o r c o v i d 1 9 . m e d r x i v p r e p r s e r v h e a l s c i . 2 0 2 1 : 1 3 0 . doi:10.1101/2021.06.17.21258639 10. fischer wa, eron jj, holman w, et al. a phase 2a clinical trial of molnupiravir in patients with covid-19 shows accelerated sars-cov-2 rna clearance and elimination of infectious virus. sci transl med. 2022;14(628):1-11. doi:10.1126/scitranslmed. abl7430 11. pourkarim f, pourtaghi-anvarian s, rezaee h. molnupiravir: a new candidate for covid-19 treatment. pharmacol res perspect. 2022;10(1):1-7. samuel theodorus sutanto acta med indones-indones j intern med 644 doi:10.1002/prp2.909 12. singh ak, singh a, singh r, misra a. molnupiravir in covid-19: a systematic review of literature. diabetes metab syndr clin res rev. 2021;15(6):102329. doi:10.1016/j.dsx.2021.102329 13. n a t i o n a l i n s t i t u t e s o f h e a l t h . m o l n u p i r a v i r. nih. published 2022. accessed june 4, 2022. https://www.covid19treatmentguidelines.nih.gov/ therapies/antiviral-therapy/molnupiravir/#:~:text=in nonhospitalized patients aged ≥,(paxlovid)%2c sotrovimab%2c or 14. burhan e, susanto ad, nasution sa, et al. pedoman tatalaksana covid-19. pdpi perki papdi perdatin idai; 2022. 15. thorlund k, sheldrick k, meyerowitz-katz g, singh s, hill a. making statistical sense of the molnupiravir move-out clinical trial. am j trop med hyg. 2022;106(5):1301-4. doi:10.4269/ajtmh.21-1339 16. jayk bernal a, gomes da silva mm, musungaie db, et al. molnupiravir for oral treatment of covid-19 in nonhospitalized patients. n engl j med. 2022;386(6):509-520. doi:10.1056/nejmoa2116044 17. hammond j, leister-tebbe h, gardner a, et al. oral nirmatrelvir for high-risk, nonhospitalized adults with covid-19. n engl j med. 2022;386(15):1397-408. doi:10.1056/nejmoa2118542 18. mcdonald eg, lee tc. nirmatrelvir-ritonavir for covid-19. cmaj. 2022;194(6):218. doi:10.1503/ cmaj.220081 19. national institutes of health. ritonavir-boosted nirmatrelvir (paxlovid). nih. published 2022. accessed june 4, 2022. https://www.covid19treatmentguidelines. nih.gov/therapies/antiviral-therapy/ritonavir-boostednirmatrelvir--paxlovid-/ 20. lai cc, wang yh, chen kh, chen ch, wang cy. the clinical efficacy and safety of anti-viral agents for non-hospitalized patients with covid-19: a systematic review and network meta-analysis of randomized controlled trials. viruses. 2022;14(8):1-10. doi:10.3390/v14081706 21. singh ak, singh a, singh r, misra a. an updated practical guideline on use of molnupiravir and comparison with agents having emergency use authorization for treatment of covid-19. diabetes metab syndr clin res rev. 2022;16(january):1-10. doi:doi.org/10.1016/j.dsx.2022.102396 22. toussi ss, neutel jm, navarro j, et al. pharmacokinetics of oral nirmatrelvir/ritonavir, a protease inhibitor for treatment of covid-19, in subjects with renal impairment. clin pharmacol ther. 2022;0(0):1-9. doi:10.1002/cpt.2688 23. pom b. siaran pers badan pom terbitkan emergency use authorization untuk obat molnupiravir. published 2022. accessed june 2, 2022. https:// www.pom.go.id/new/view/more/pers/636/siaranpers-badan-pom-terbitkan-emergency-useauthorization-untuk-obat-molnupiravir.html 24. kompas.com. mengenal molnupiravir dan paxlovid, obat covid-19 yang digunakan di indonesia. published 2022. accessed june 2, 2022. https://www. kompas.com/sains/read/2022/01/13/193000823/ mengenal-molnupiravir-dan-paxlovid-obat-covid-19yang-digunakan-di?page=all 172 acta med indones indones j intern med • vol 55 • number 2 • april 2023 original article vitamin d levels in pre-frail older adults and its correlation with hand grip strength noto dwimartutie1,2*, siti setiati1, tirza z. tamin3, ani retno prijanti4, alida r. harahap2, dyah purnamasari5, kuntjoro harimurti1, i dewa putu pramantara6 1division of geriatric, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2doctoral program in medical sciences, faculty of medicine universitas indonesia, jakarta, indonesia. 3division of musculoskeletal rehabilitation, department of physical medicine and rehabilitation, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 4department of biochemistry and molecular biology, faculty of medicine universitas indonesia, jakarta, indonesia. 5division of endocrinology and metabolism, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 6 division of geriatric, department of internal medicine, faculty of medicine, publich health and nursing, universitas gadjah mada, sardjito hospital, yogyakarta, indonesia. coresponding author: noto dwimartutie, md. division of geriatric, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: noto.dwimartutie@ui.ac.id. abstract background: vitamin d deficiency is frequent in older adults and associated with poor musculoskeletal function. the prevalence of pre-frailty is also high in older persons, who may proceed to a frail state. this study aimed to determine the vitamin d levels in pre-frail older adults and its correlation with hand grip strength. methods: a cross-sectional study was conducted on older adults (age > 60 years) with a pre-frail condition who were visiting the outpatient geriatric clinic at cipto mangunkusumo hospital in jakarta, indonesia. serum levels of vitamin d, measured as 25(oh)d, were determined by enzyme-linked immunosorbent assay (elisa), and hand grip strength was measured using a jamar hydraulic dynamometer. correlations between vitamin d levels and hand grip strength were evaluated by spearman’s rank correlation coefficient. multiple linear regression analysis was carried out to assess contribution of variables that influence hand grip strength. results: of 95 pre-frail older adults (mean age 70.08 ± 5.35 years), 67.4% were female, and the median vitamin d level was 17.91 (interquartile range/iqr 13.68–26.36) ng/ml. overall, 11.6% of the participants had normal vitamin d levels, whereas 34.7% and 53.7% had insufficient and deficient levels, respectively. females were more likely to have inadequacy of vitamin d than males. those with vitamin d deficiency tended to have a higher body mass index (bmi) and lower vitamin d intake than normal levels. a significant correlation between serum vitamin d levels and hand grip strength was observed (r = 0.283; p = 0.006). after adjusting for age, comorbidities, nutritional status, functional status, bmi, protein intake, and sun exposure score, regression analysis between hand grip strength and vitamin d levels gave standard coefficient beta = 0.255 (p = 0.013). conclusion: in this study, pre-frail older adults had a high proportion of deficient and insufficient vitamin d levels, and a significant correlation was found between serum vitamin d levels and hand grip strength. keywords: hand grip strength, older adults, pre-frail, vitamin d level. vol 55 • number 2 • april 2023 vitamin d levels in pre-frail older adults and its correlation 173 introduction vitamin d is a hormone that plays an important role in various organ systems, including the musculoskeletal system. vitamin d affects muscle mass by stimulating muscle cell proliferation and muscle function by exerting both genomic and non-genomic effects. vitamin d deficiency is known to cause muscle weakness.1 in older populations, many people have been found to have vitamin d deficiency. although indonesia is a tropical country with abundant sunshine, the prevalence or proportion of vitamin d deficiency in older adults is quite high.2,3 frailty is a geriatric syndrome characterized by a decrease in various organ functions that make individuals more vulnerable to stressors. decreased hand grip strength and walking speed, weight loss, fatigue, and low physical activity are phenotypes of frailty.4 older adults with a frail condition easily fall into disability conditions, require hospital care, have low quality of life and high mortality.5 vitamin d deficiency is considered to be one of the causes of sarcopenia and frailty.6,7 studies found that pre-frail conditions are more common than frail conditions in older adults.8 pre-frail seniors with vitamin d deficiency are at increased risk of frailty and mortality compared with those who are not9, which highlights the importance of maintaining good vitamin d status in pre-frail older adults to prevent deterioration into a frail condition. however, studies on the relationship between vitamin d levels and hand grip strength have reported inconsistent results. while several studies have reported an association10-14, others have found no relationship.15-19 as far as the researcher is concerned, until now, there has been no research on the vitamin d level and its correlation with hand grip strength in pre-frail older adults. therefore, this study aimed to determine vitamin d levels in older adults with a pre-frail condition and its correlation with hand grip strength. methods this cross-sectional study consecutively recruited older adults aged > 60 years who were visiting the outpatient geriatric clinic at cipto mangunkusumo hospital in jakarta, indonesia from june to august 2021. the inclusion criteria were pre-frail older adults as defined by the cardiovascular health study4, and who could understand and follow instructions. we excluded older adults who had acute medical conditions or exacerbation of previous medical conditions, who had conditions that could affect the assessment of muscle performance, such as paresis, who had cognitive impairment (abbreviated mental test score < 8), and mental status disorder/depression (geriatric depression scale score > 10), or who refused to participate. all participants provided written informed consent before the study began. ethical approval was obtained from ethical committee of the faculty of medicine universitas indonesia. the comorbidity index of each participant was evaluated using the cumulative illness rating scale (cirs) 20, nutritional status was evaluated based on the mini nutritional assessment21 which classified into normal (>24), risk of malnutrition (17-23.5) and malnutrition (<17); functional status was evaluated based on barthel’s activity of daily living (adl) index22 which classified into totally dependent (0–4), severely dependent (5–8), moderately dependent (9–11), mildly dependent (12–19), and independent (20); sarcopenia was evaluated using the sarc-f23 which classified into score > 4 (at risk of sarcopenia) and score <4; nutritional intake was evaluated using a 3-day food recall (2 working days and 1 holiday), and body mass index (bmi) was evaluated based on asia-pacific criteria.24 sun exposure was evaluated using questionnaire to assess time in sun and skin exposure25, and divided into 2 categories low (<18) and moderate-high (1956) exposure.26 all data were collected from the patient’s medical history and medical record. hand grip strength was measured three times in the dominant hand using a jamar hydraulic dynamometer and the average was taken. serum vitamin d levels (measured as 25(oh) d) were determined using the enzyme-linked immunosorbent assay technique with commercial 25-oh vitamin d reagent (euroimmun). serum vitamin d was classified into three levels: normal (> 30 ng/ml), insufficient (20–<30 ng/ml), and noto dwimartutie acta med indones-indones j intern med 174 deficient (< 20 ng/ml). the data were analysed using spss statistical package software. descriptive data were presented in the form of text and tables. subjects characteristics presented in number and percentages, mean and standard deviation if the distribution was normal, or median and interquartile range (iqr) if the distribution was not normal. pearson’s test was used for the correlation between vitamin d levels and hand grip strength if the distribution was normal, and the spearman correlation test if the distribution was not normal. multiple linear regression analysis was performed to evaluate the influence of other variables which were considered to affect hand grip strength. values of p < 0.05 were considered statistically significant. results of the 95 subjects who fulfilled the selection criteria, the mean age was 70.08 ± 5.35 years. most subjects were female (67.4%). the median overall vitamin d level was 17.91 (iqr 13.68–26.36) ng/ml. overall, 11.6% of the prefrail older adults had a normal vitamin d level, whereas most of the others had an insufficient (34.7%) or deficient (53.7%) level. most of the participants had normal nutritional status, independent functional status, obesity and no sarcopenia. subjects in the vitamin d deficient group tended to have a higher bmi and lower vitamin d intake than did those in the normal groups. hand grip strength in the subjects with normal vitamin d levels was higher than in subjects with insufficiency and deficiency. female subjects had lower serum vitamin d level [median 17.6 ng/ml (iqr 12.66-24.83)] than male [median 23.95 ng/ml (iqr 16.63-29.59)]. obesity had lowest vitamin d level [16.2 ng/ ml (iqr 12.95-24.4)] followed by overweight [20.59 ng/ml (iqr 15.82-28.01)], normal [23.28 ng/ml (iqr 15.08-29.93)] and underweight subjects (29.59 ng/ml). general characteristics of subjects and characteristic based on vitamin d status showed in table 1 and table 2. a significant positive correlation was found between vitamin d levels and hand grip strength (r = 0.283, p = 0.006) (figure 1). table 1. characteristics of the study subjects. characteristics total (n=95) age, mean (sd) 70.08 (5.04) age group, n (%) 60-69 years 40 (42.1) 70-79 years 50 (52.6) > 80 years 5 (5.3) sex, n (%) male 31 (32.6) female 64 (67.4) body mass index/ bmi (kg/m2), mean (sd) male 24.9 (3.86) female 25.8 (3.65) bmi category, n (%) underweight 1 (1.1) normal 25 (26.3) overweight 20 (21.1) obesity 49 (51.6) comorbidities, n (%) diabetes melitus 43 (45.3) hypertension 76 (80) dyslipidemia 61 (64.2) osteoarthritis 42 (44.2) coronary heart disease 20 (21.1) congestive heart disease 14 (14.7) chronic obstructive pulmonary disease 3 (3.2) osteoporosis 3 (3.2) benign prostatic hyperplasia 18 (18.9) peripheral arterial disease 3 (3.2) cirs score, n (%) < 5 24 (25.3) >5 71 (74.7) number of drugs, n (%) 0-4 19 (20) 5-10 64 (67.4) >10 11 (11.6) vitamin d supplementation, n (%) yes 29 (30.5) no 66 (69.5) sun exposure score, median (iqr) 21 (14-28) sun exposure, n (%) low exposure 40 (42.1) moderate high exposure 55 (57.9) mna score, n (%) normal (>24) 91 (95.8) risk of malnutrition (17-23.5) 4 (4.2) vol 55 • number 2 • april 2023 vitamin d levels in pre-frail older adults and its correlation 175 using linear regression analysis, after adjusting for variables age, bmi, comorbidities, protein intake, nutritional status, functional status, and sun exposure score, vitamin d levels remained significantly correlated with standard coefficient beta = 0.255 (p = 0.013). discussion the results of this study showed that in pre-frail older adults, only 11.6% had a normal vitamin d level; most had an insufficient or deficient level. this result is in line with studies barthel adl score, n (%) independent 86 (90.5) mild dependent 9 (9.5) nutritional intake, median (iqr) protein (gram) 55.6 (44.4-63.9) vitamin d (mcg) 1.6 (0.6-5.8) handgrip strength (kg), mean (sd) 23.53 (5.04) sarc-f score, n (%) < 4 77 (81.1) > 4 (risk of sarcopenia) 18 (18.9) 25(oh)d (ng/ml), median (iqr) 17.91 (13.68-26.36) table 2. subject characteristics based on vitamin d status. characteristics normal (> 30 ng/ml)(n=11) insufficiency (20-<30 ng/ ml) (n=33) deficiency (<20 ng/ml) (n=51) age, mean (sd) 69.64 (5.35) 70.64 (5.49) 69.82 (4.75) age group, n (%) 60-69 years 5 (12.5) 13 (32.5) 22 (55) 70-79 years 5 (10) 17(34) 28 (56) > 80 years 1 (20) 3 (60) 1 (20) sex, n (%) male 7 (22.6) 13 (41.9) 11 (35.5) female 4 (6.3) 20 (31.3) 40 (62.5) bmi (kg/m2), mean (sd) male 23.04 (2.88) 24.98 (3.86) 25.99 (4.28) female 23.3 (4.79) 25.34 (3.64) 26.21 (3.52) bmi category, n (%) underweight 0 1 (100) 0 normal 6 (24) 9 (36) 10 (40) overweight 3 (15) 8 (40) 9 (45) obesity 2 (4.1) 15 (30.6) 32 (65.3) cirs score, n(%) < 5 0 9 (37.5) 15 (62.5) >5 11 (15.5) 24 (33.8) 36 (50.7) number of drugs, n (%) 0-4 2 (10.5) 7 (36.8) 10 (52.6) 5-10 5 (7.8) 23 (35.9) 36 (56.3) >10 4 (36.4) 2 (18.2) 5 (45.5) vit d supplementation, n (%) yes 4 (13.8) 12 (41.4) 13 (44.8) no 7 (10.6) 21 (31.8) 38 (57.6) sun exposure, n (%) low exposure 5 (12.5) 15 (37.5) 20 (50) moderate-high exposure 6 (10.9) 18 (32.7) 31 (56.4) sun exposure score, median (iqr) 21 (9-30) 20 (12-27.5) 22 (15-28) mna score, n (%) normal (>24) 10 (11) 31 (34.1) 50 (54.9) risk of malnutrition (17-23.5) 1 (25) 2 (50) 1 (25) noto dwimartutie acta med indones-indones j intern med 176 in other tropical countries such as singapore, where 14.2% of older adults in a rehabilitation unit were found to have normal vitamin d levels.27 in indonesia, studies have shown that older adults are more likely to have inadequate vitamin d levels. a study of older adults in the pusaka jakarta community by sudarma et al.28 found that the proportion of individuals with vitamin d deficiency was 80.2%, followed by insufficiency, at 15.9%; normal vitamin d levels were found in only 4%. biben et al.3 conducted a study in west java and implemented a higher hypovitaminosis d cut-off value of < 36 ng/ ml (compared with the laboratory reference cut-off of <29.9 ng/ml) as determined based on parathyroid hormone suppression, and found that this cut-off point increased the proportion of individuals with vitamin d deficiency from 90.9% to 94.3%. our study found a higher percentage of older persons with vitamin d deficiency compared to the study by setiati et al.2 in nursing home, which found a 35% deficiency prevalence. this could be owing to variations in the settings, as our study was conducted in older persons at an outpatient clinic, who have various comorbidities that can be linked to low vitamin d levels. several factors are known to contribute to vitamin d deficiency in seniors, such as decreased vitamin d intake, increased body fat, decreased synthesis of vitamin d in the skin, a lack of outdoor activity and exposure to sunlight, and decreased kidney function1.29,30 based on the nutritional adequacy rate of older adults in indonesia31, vitamin d intake in the subjects in our study was low, even though the majority of the subjects had a good nutritional status. in our study, the majority of subjects had a low daily intake of vitamin d, in line with the findings of a systematic review on the older population in indonesia, which showed a high prevalence of low vitamin d intake.32 a lack of understanding figure 1. correlation between serum vitamin d levels and hand grip strength barthel adl score, n (%) independent 11 (12.8) 31 (36) 44 (51.2) mild dependent 0 2 (22.2) 7 (77.8) handgrip strength (kg), mean (sd) 26.87 (4.12) 24.29 (5.44) 22.31 (4.59) nutritional intake, median (iqr) protein (gram) 55.7 (44.1-65.3) 57.9 (44.6-72.5) 51.1 (44.4-62.1) vitamin d (mcg) 3.86 (1.2-6.5) 1.2 (0.5-9.95) 1.6 (0.6-5.1) sarc-f score, n (%) < 4 9 (11.7) 29 (37.7) 39 (50.6) > 4 (risk of sarcopenia) 2 (11.1) 4 (22.2) 12 (66.7) 25(oh)d (ng/ml), median(iqr) 31.33 (30.86-34.32) 25.23 (23.48-27.8) 14.04 (11.83-16.63) vol 55 • number 2 • april 2023 vitamin d levels in pre-frail older adults and its correlation 177 about balanced nutrition and inadequate income for consuming foods high in vitamin d may also lead to insufficient vitamin d intake. the higher percentage of overweight and obesity found in this study may also be contributing factors to vitamin d deficiency and/ or insufficiency. previous studies have reported an association between low vitamin d levels and high bmi and body fat percentage in older adults.33 hypothesized mechanisms underlying the association between obesity and low vitamin d levels include differences in the lifestyle of individuals with obesity, such as eating habits, sedentary lifestyle, clothing used, the presence of vitamin d storage in adipose tissue, and impaired hydroxylation in the liver.34,35 a metaanalysis found that the prevalence of vitamin d deficiency was 35% higher in obese than in eutrophic subjects (prevalence ratio 1.35; 95% confidence interval [ci], 1.21–1.5) and 24% higher in overweight subjects (prevalence ratio 1.24; 95% ci 1.14–1.34).36 according to our findings, vitamin d deficiency/insufficiency was more common in females than in males. this might be due to larger body mass index in female than male. studies reported that females tend to have lower levels of vitamin d than males.37,38 this sex difference occurs mainly because of the female behaviour of protecting themselves from sun exposure for reasons of beauty, the need for using sunscreen, and more closed dress style, especially in muslim women.38 although this study discovered that sun exposure scores were generally higher in subjects with vitamin d deficiency compared to those with normal vitamin d levels, the proportion of older adults who were vitamin d deficient remained higher than that of individuals with normal/insufficient vitamin d. this could be related to the lower vitamin d intake in the deficient group. even though subjects in this study seemed to follow indonesian ministry of health recommendation for older adults to keep sunbathing during the covid-19 pandemic,39 the possibility of ineffective vitamin d synthesis in older adults cannot be ruled out as a cause of vitamin d deficiency.40 sunlight promotes vitamin d synthesis in the skin and sun exposure is known to increase vitamin d levels. it is estimated that nearly 90% of the body’s vitamin d comes from sunlight activation through skin synthesis.40 after exposure to uvb sunlight (wavelength 290–315 nm), photolysis of 7-dehydrocholesterol (provitamin d3) in the skin transforms into previtamin d3, which is then isomerized to vitamin d3.41 setiati et al.42 reported that older adults in nursing homes who were exposed to sunlight for 25 minutes at 09:00, three times a week for 6 weeks, showed an increase in vitamin d levels from 59 to 84 nmol/l. based on a meta-analysis, frailty is associated with low vitamin d levels, where the lower the vitamin d level, the more severe the frailty status.6,43 several studies have linked vitamin d levels to a frailty component, whereas weakness, low physical activity, fatigue, and low gait speed are all associated with low vitamin d levels.44,45 individuals with these conditions tend to be physically inactive, which disturbs the balance of protein metabolism in the muscles. older populations are at risk of adverse effects due to vitamin d deficiency. inadequacy of vitamin d levels are also associated with a number of chronic diseases in addition to frailty46, but this condition can be improved. the results of the present study revealed a significant positive correlation between serum vitamin d levels and hand grip strength in older adults with a pre-frail condition. this is in line with studies on older women in the community by caniago et al.13, older outpatients by bachry et al.14, older males by kocak et al.10, and patients with hip fracture by dhanwal et al.11 however, our results differ from a population study that included korean men aged > 50 years and postmenopausal women16 and a taiwanese study of participants aged > 55 years18, which reported finding no relationship between vitamin d and hand grip strength or between vitamin d and performance on the short physical performance battery (sppb). vitamin d is known to influence skeletal muscle through both genomic and non-genomic effects. through genomic effects, vitamin d binds to the vitamin d receptor (vdr) in the cell nucleus, inducing gene transcription in myoblasts, thereby resulting in the proliferation and differentiation noto dwimartutie acta med indones-indones j intern med 178 of muscle cells. through non-genomic effects, via regulatory pathways, the calcium messenger system affects signal transduction and affects skeletal muscle contraction.1,47 to the best of our knowledge, our study is the first to evaluate the vitamin d level and its relationship with hand grip strength in older adults with a pre-frail condition in indonesia. however, because this was an observational study, no causal relationship could be investigated. further research is needed to evaluate whether vitamin d supplementation can improve physical performance in pre-frail older adults and help prevent frailty. conclusion in older adults with a pre-frail condition, proportion of vitamin d deficiency and insufficiency were high. there was positive correlation between serum vitamin d levels and hand grip strength in pre-frail older adults. acknowledgments the authors would like to thank all participants and nurses at geriatric clinic cipto mangunkusumo hospital. conflict of interest all authors have no conflict of interest. references 1. halfon m, phan o, teta d. vitamin d: a review on its effects on muscle strength, the risk of fall, and frailty. biomed res int. 2015;2015. 2. setiati s. vitamin d status among indonesian elderly women living in institutionalized care units. acta med indones. 2008;40(2):78-83. 3. biben v, defi i, nugraha g, setiabudiawan b. vitamin d status and its impact on body composition in elderly community-dwelling individuals in bandung and sumedang, west java province, indonesia. asian j epidemiology. 2017;10:63-9. 4. fried lp, tangen cm, walston j, et al. frailty in older adults: evidence for a phenotype. j gerontol a biol sci med sci. 2001;56(3):m146-56. 5. bernabei r, martone am, vetrano dl, calvani r, landi f, marzetti e. frailty, physical frailty, sarcopenia: a new conceptual model. stud health technol inform. 2014;203:78-84. 6. marcos-perez d, sanchez-flores m, proietti s, et al. low vitamin d levels and frailty status in older adults: a systematic review and meta-analysis. nutrients. 2020;12(8):1-20. 7. visser m, deeg dj, lips p, longitudinal aging study a. low vitamin d and high parathyroid hormone levels as determinants of loss of muscle strength and muscle mass (sarcopenia): the longitudinal aging study amsterdam. j clin endocrinol metab. 2003;88(12):5766-72. 8. o’caoimh r, sezgin d, o’donovan mr, et al. prevalence of frailty in 62 countries across the world: a systematic review and meta-analysis of populationlevel studies. age ageing. 2021;50(1):96-104. 9. shardell m, d’adamo c, alley de, et al. serum 25-hydroxyvitamin d, transitions between frailty states, and mortality in older adults: the invecchiare in chianti study. j am geriatr soc. 2012;60(2):256-64. 10. kocak mz, aktas g, atak b, et al. the association between vitamin d levels and handgrip strength i n e l d e r l y m e n . a c t a e n d o c r i n o l ( b u c h a r ) . 2020;16(2):263-6. 11. dhanwal dk, dharmshaktu p, gautam vk, gupta n, saxena a. hand grip strength and its correlation with vitamin d in indian patients with hip fracture. arch osteoporos. 2013;8:158. 12. mendes j, santos a, borges n, et al. vitamin d status and functional 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annweiler c, beauchet o, berrut g, et al. is there an association between serum 25-hydroxyvitamin d concentration and muscle strength among older women? results from baseline assessment of the epidos study. j nutr health aging. 2009;13(2):90-5. 18. chuang sc, chen hl, tseng wt, et al. circulating 25-hydroxyvitamin d and physical performance in older adults: a nationwide study in taiwan. am j clin nutr. 2016;104(5):1334-44. 19. vaes amm, brouwer-brolsma em, toussaint n, et vol 55 • number 2 • april 2023 vitamin d levels in pre-frail older adults and its correlation 179 al. the association between 25-hydroxyvitamin d concentration, physical performance and frailty status in older adults. eur j nutr. 2019;58(3):1173-81. 20. linn bs, linn mw, gurel l. cumulative illness rating scale. j am geriatr soc. 1968;16(5):622-6. 21. vellas b, guigoz y, garry pj, et al. the mini nutritional assessment (mna) and its use in grading the nutritional state of elderly patients. nutrition (burbank, los 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vitamin d deficiency in elderly patients admitted to an inpatient rehabilitation unit in tropical singapore. rehabil res pract. 2016;2016:9689760. 28. sudarma v hl. high skeletal muscle mass is associated with increased serum 25(oh)d levels in elderly. univ med. 2017;36:236-42. 29. meehan m, penckofer s. the role of vitamin d in the aging adult. j aging gerontol. 2014;2(2):60-71. 30. de jongh rt, van schoor nm, lips p. changes in vitamin d endocrinology during aging in adults. mol cell endocrinol. 2017;453:144-50. 31. peraturan menteri kesehatan nomor 28 tahun 2019 tentang angka kecukupan gizi yang dianjurkan untuk masyarakat indonesia. jakarta. 2019. 32. dewiasty e, agustina r, saldi srf, et al. malnutrition prevalence and nutrient intakes of indonesian community-dwelling older adults: a systematic review of observational studies. front nutr. 2022;9:780003. 33. oliai araghi s, van dijk sc, ham ac, et al. bmi and body fat mass is inversely associated with vitamin d levels in older individuals. j nutr health aging. 2015;19(10):980-5. 34. bennour i, haroun n, sicard f, mounien l, landrier jf. vitamin d and obesity/adiposity-a brief overview of recent studies. nutrients. 2022;14(10). 35. vranic l, mikolasevic i, milic s. vitamin d deficiency: consequence or cause of obesity? medicina (kaunas). 2019;55(9). 36. pereira-santos m, costa pr, assis am, santos ca, santos db. obesity and vitamin d deficiency: a systematic review and meta-analysis. obes rev. 2015;16(4):341-9. 37. kim sh, oh je, song dw, et al. the factors associated with vitamin d deficiency in community dwelling elderly in korea. nutr res pract. 2018;12(5):387-95. 38. nimitphong h, holick mf. vitamin d status and sun exposure in southeast asia. dermatoendocrinol. 2013;5(1):34-7. 39. direktorat jenderal kesehatan masyarakat. panduan pelayanan kesehatan lanjut usia pada era pandemi covid-19. jakarta: kementerian kesehatan republik indonesia; 2020. 40. holick mf. sunlight and vitamin d for bone health and prevention of autoimmune diseases, cancers, and cardiovascular disease. am j clin nutr. 2004;80(6 suppl):1678s-88s. 41. wacker m, holick mf. sunlight and vitamin d: a global perspective for health. dermatoendocrinol. 2013;5(1):51-108. 42. setiati s. pengaruh pajanan sinar ultraviolet b bersumber dari sinar matahari terhadap konsentrasi vitamin d (25(oh)d) dan hormon paratiroit pada perempuan usia lanjut indonesia. kesmas national public health journal 2008;2 (4):147-53. 43. zhou j, huang p, liu p, et al. association of vitamin d deficiency and frailty: a systematic review and metaanalysis. maturitas. 2016;94:70-6. 44. vogt s, decke s, de las heras gala t, et al. prospective association of vitamin d with frailty status and allcause mortality in older adults: results from the kora-age study. prev med. 2015;73:40-6. 45. shardell m, hicks ge, miller rr, et al. association of low vitamin d levels with the frailty syndrome in men and women. j gerontol a biol sci med sci. 2009;64(1):69-75. 46. hossein-nezhad a, holick mf. vitamin d for health: a global perspective. mayo clin proc. 2013;88(7):72055. 47. christakos s, hewison m, gardner dg, et al. vitamin d: beyond bone. ann n y acad sci. 2013;1287:45-58. case report 49acta medica indonesiana the indonesian journal of internal medicine hypertensive crises in the adolescent: evaluation of suspected renovascular hypertension indra wijaya, parlindungan siregar department of internal medicine. faculty of medicine, university of indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10431, indonesia. correspondence mail: leon_natan@yahoo.com. abstrak krisis hipertensi dapat dibagi menjadi dua kelompok, yakni hipertensi emergensi dan hipertensi urgensi. sebagian besar ahli mendefinisikan hipertensi emergensi sebagai suatu situasi yang membutuhkan penurunan tekanan darah segera dengan menggunakan obat parenteral akibat adanya ancaman kerusakan organ target yang akut dan bersifat progresif, sedangkan hipertensi urgensi merupakan suatu situasi dengan peningkatan tekanan darah yang nyata tetapi tanpa disertai gejala klinis yang berat atau kerusakan organ target yang progresif, namun tekanan darah tetap perlu diturunkan dalam hitungan jam dengan menggunakan obat oral. pasien dewasa muda dengan hipertensi perlu dicurigai mengalami hipertensi renovaskular meskipun keadaan ini dapat juga disebabkan oleh faktor lain. laporan kasus ini menyajikan suatu kasus anak laki-laki berusia 16 tahun dengan krisis hipertensi suspek hipertensi renovaskular. tekanan darahnya sebesar 240/120 mmhg saat masuk ke rumah sakit disertai retinopati hipertensi derajat iii dan didapatkan peningkatan kreatinin setelah pemberian ace-inhibitor, namun arteriografi menunjukkan hasil normal, pemeriksaan fisis lainnya dan pemeriksaan laboratorium juga menunjukkan hasil yang normal. berdasarkan hal tersebut, disimpulkan bahwa pasien menderita hipertensi esensial. oleh karena krisis hipertensi dapat muncul pada segala rentang usia, para dokter perlu mewaspadai adanya kemungkinan hipertensi renovaskular pada pasien berusia muda dengan krisis hipertensi. deteksi dini dan penanganan yang segera diperlukan untuk mencegah komplikasi akibat kerusakan organ target yang bersifat progresif. kata kunci: krisis hipertensi, dewasa muda. abstract hypertensive crises can be divided into two categories as hypertensive emergency and hypertensive urgency. most authorities have defined hypertensive emergency as a situation that requires immediate reduction in blood pressure (bp) with parenteral agents because of acute or progressive target organ damage, whereas hypertensive urgency is a situation with markedly elevated bp but without severe symptoms or progressive target organ damage, wherein the bp should be reduced within hours, often with oral agents. adolescent with hypertension should be suspected of having renovascular hypertension in spite of other causes. this case is presenting a 16-year-old boy with hypertensive crises due to suspected renovascular hypertension. his blood pressure was 240/120 at admission with hypertensive retinopathy grade iii and there was increase in creatinine after administering ace-inhibitor but his renal arteriography revealed normal, other physical examination and laboratory findings was normal. regarding these findings, the conclusion was this patient got essential hypertension. as many hypertensive crises occur in any ages, clinicians should aware the possibility of renovascular hypertension in young patients with hypertensive crises. an early detection and urgent treatment are needed to prevent the implication of progressive target organ damage. key words: hypertensive crises, adolescent. indra wijaya acta med indones-indones j intern med introduction hypertension affects more than 1 billion people worldwide and is one of the leading causes of death. among hypertension population, 70% is mild hypertension, 20% is moderate hypertension, 10% is severe hypertension, and 1% is hypertensive crises for each hypertension type. depending on the degree of blood pressure (bp) elevation and presence of end-organ damage, severe hypertension can be defined as either a hypertensive emergency or a hypertensive urgency. a hypertensive emergency is associated with acute end-organ damage and requires immediate treatment with a titratable short-acting iv antihypertensive agent. severe hypertension without acute end-organ damage is referred to as a hypertensive urgency and is usually treated with oral antihypertensive agents.1 secondary hypertension is more common in adolescent, with most cases caused by renal disease. primary or essential hypertension is more common in adolescents and has multiple risk factors, including obesity and a family history of hypertension. evaluation involves a thorough history and physical examination, laboratory tests, and specialized studies.1 case illustration a 16-year-old boy felt blurred vision in left eye without symptoms of itching, watery eyes, and eye redness within two weeks prior to admission. the ophthalmologist at cipto mangunkusumo hospital diagnosed as exudative retinal detachment with retinopathy on left eye and referred to rheumatology polyclinic to reveal any autoimmune or collagen disease, then he was referred to emergency room because of having blood pressure (bp) 240/180 mmhg. he denied any symptoms of headache, anxiety, loss of consciousness, feet edema, shortness of breath, chest pain, nosebleed, nausea and vomiting, rheumatic pain, cheek redness, photosensitivity, oral ulcers, palpitation, snoring, redness of urine, and small volume of urine. urination and defecation were normal. there were no history of head trauma, hypertension, diabetes, heart disease, renal disease, allergy, or asthma. his mother has hypertension. he was a high school student. he never smoked or consumed any drugs before. physical examination revealed the bp was 240/180 mmhg, measured in both arms and legs, heart rate 88x/mins regular beat, respiratory rate 16x/mins, and normal temperature. imt 24.2 kg/m2 (overweight). there was gallop sounds on heart auscultation, other examinations were within normal limit. laboratory results showed hemoglobin level 13.7 g/dl, white blood cell 10.100/ul (diff count: -/-/3/75/20/2), platelet count 283.000/ul, creatinine 1.2 mg/dl, albumin 4.9 u/l, normal liver function and electrolyte level. urinalysis showed proteinuria (+1) with protein excretion 556 mg/day. ecg showed lv strain. chest x-ray showed cardiomegaly with rounded shaped of left heart border. ophthalmologist diagnosed as hypertensive retinopathy os gr iii and hypertensive retinopathy od gr ii. he was diagnosed as hypertensive emergency and was given o2 3l/mins, intravenous fluid drip (ivfd) of dextrose 5%/12 hours, nicardipine 10 mg/hr, clonidine 2x0.15 mg, captopril 3x25 mg, and bisoprolol 1x5 mg. in inpatient ward, he was diagnosed as hypertension stage ii with history of hypertensive emergency and proteinuria. he was planned to undergo renal ultrasonography, renal doppler ultrasound, magnetic resonance angiography (mra), arteriography, aptt, and serial ureum/creatinin. the bp was 160/110 mmhg in all extremities with nicardipine 10 mg/hr and planning to tappering down gradually, renal diet 2100 kcals, clonidine 3x0.15 mg, captopril 3x25 mg, bisoprolol 1x5 mg. on the next day, the bp was increase to 240/170 mmhg on nicardipine 1 mg/hr, so nicardipine was increased to 2.5 mg/hr and later on to 5 mg/hr and given hydrochlorothiazide (hct) 1x25 mg and alprazolam 2x0.5 mg, on the 5th day the bp was 140/110 mmhg and nicardipine was tappering off gradually. during therapy, creatinin serial was increased from 1.2 to 1.7 and 2.2, so captopril was stopped and given amlodipine 1x10 mg. aptt test was normal, mra could not be done due to lack of facility. renal ultrasonography was normal, renal doppler ultrasound shows suspicious of right renal artery stenosis. coronary and renal arteriography was normal. he went home with clonidine 3x0.15 mg, amlodipine 1x10 mg, bisoprolol 1x5 mg, and hct 1x25 mg and should have follow up in nephrology polyclinic. 50 vol 45 • number 1 • january 2013 hypertensive crises in the adolescent discussion hypertensive emergency defined as a situation that requires immediate reduction in blood pressure (bp) with parenteral agents because of acute or progressing target organ damage.1 table 1 shows the initial evaluation of patients with a hypertensive emergency. proteinuria was 556 mg/day. the renal lesion associated with malignant hypertension consists of fibrinoid necrosis of the afferent arterioles, sometimes extending into the glomerulus, and may result in focal necrosis of the glomerular tuft. clinically, macroalbuminuria (>300 mg/d) or microalbuminuria (30–300 mg/d) are early markers of renal injury.5 aptt was normal, excluding hypercoagulable states concerning anti phospholipids syndrome. t h e r e w a s n o h y p o k a l e m i a , e x c l u d i n g hyperaldosteronism, plasma aldosterone to renin ratio was unable to be performed due to lack of facility. vanolic mandelic acid (vma) also was unable to be performed due to lack of facility, to exclude pheochromocytoma, but there were no symptoms of flushing and autonomic instability. electrocardiography (ecg) shows left ventricular hypertrophy. hypertensive heart disease (hhd) is the result of structural and functional adaptations leading to left ventricular h y p e r t r o p h y a n d d i a s t o l i c d y s f u n c t i o n . renovascular hypertension is associated with increased sympathetic neural activity leading to target organ injury, including left ventricular hypertrophy.6 chest radiography shows cardiomegaly with rounded appearance of left heart border which is the sign of left ventricular hypertrophy. renal ultrasonography shows normal interpretation. renal doppler ultrasound shows suspicious of right renal artery stenosis, the distal portion was unable to be examined because of thick peritoneal fat and presence of bowel gas. limitations of doppler ultrasound are often related to inadequate examinations, particularly in obese patients and overlying bowel gas. measuring peak systolic velocity (psv), end-diastolic velocity and the ratio of the psv in the renal artery to psv in the aorta, gives its high sensitivity and specificity to 90% and 95%.7 renal doppler ultrasound shows renal aortic velocity ratio (rar) in right renal artery 2.78 (<3.5), this ratio represents renovascular hypertension if >3.5 but at ratio of 2.78, there’s a possibility of renovascular hypertension.8 psv >200 cm/s and rar >2.0 were the flow velocity criteria utilized to indicate hemodynamically significant fibromuscular dysplasia (fmd), but it has limited specificity so most studies used rar >3.5 as accepted standard. some studies revealed that rar >3.5 table 1. initial evaluation of hypertensive emergency2 history prior diagnosis and treatment of hypertension intake of pressor agents: street drugs, sympthomimetics symptoms of cerebral, cardiac, and visual dysfunction physical examination blood pressure, funduscopy, neurologic status, cardiopulmonary status body fluid volume assessment, peripheral pulses laboratory evaluation hematocrite and blood smear, urine analysis automated chemistry: creatinine, glucose, electrolytes plasma renin activity and aldosterone (if primary aldosteronism is suspected) plasma renin activity before and 1 h after 25 mg captopril (if rvh is suspected) spot urine or plasma for metanephrine (if pheochromocytoma is suspected) chest radiograph electrocardiogram physical examination revealed bp was 240/180 mmhg with hypertensive retinopathy os gr iii and hypertensive retinopathy od gr ii. these are the signs of hypertensive emergency with eye as target organ damage. this patient had gallop sound in heart auscultation, no abdominal bruit sound was found. if cardiomegaly is present, in some patients, a third heart sound (s3 or protodiastolic gallop) is audible. about 50% of patients with renovascular hypertension have an abdominal bruit.3 laboratory examination revealed creatinine serial 1.2, 1.7, and 2.2 after given captopril 25 mg three times daily. administration of acei can reduce glomerular capillary hydrostatic pressure to cause a decrease in glomerular ultrafiltration and produces a rise in serum creatinine. filtration usually recovers rapidly after discontinuation of the offending drug. unexplained deterioration of renal function associated with an acei should raise the possibility of renovascular hypertension.4 51 indra wijaya acta med indones-indones j intern med was found in 40% and rar between 2.5-3.5 was found in 60% of patients. doopler abnormalities in mid-to-distal location and occasionally extending into primary branches, suggested renal artery fmd, but subsequent renal angiography demonstrated normal or nearly normal, rather than the classic beaded appearance.9 mra could not be done because of lack of facility and costly. mra is the screening investigation of choice for renal artery stenosis in most centers. advantages are that it is non invasive, avoids ionizing radiation, and uses a non-nephrotoxic contrast agent (gadolinium). its has high sensitivity and specificity exceeding 95%.10 arteriography shows normal coronary and renal arteriography. arteriography with contrast remains the gold standard to determine the degree and location of renal artery stenosis, however it provides no information about the functional role and the clinical significance of the lesion.11 renovascular hypertension is one of the causes of hypertensive crises, presenting between 0.2%-32% and it has been reported about 1-5% of an entire hypertensive population has renovascular hypertension.12 two most etiologies of renovascular hypertension are atherosclerosis (90%) and fmd (10%). atherosclerosis generally occurs at the proximal portion of the artery in older patients with typical cardiovascular risk factors and in the contrary, fmd occurs in the middle or distal arterial segments in younger patients.13 table 2 below shows the clinical clues for renovascular hypertension. this patient was suspected of rvh because having clinical clues which are onset of hypertension is before 30 years old, abrupt onset or worsening of hypertension, severe hypertension, worsening renal function with ace inhibitor, advanced hypertensive retinopathy, moderate proteinuria, and elevated serum creatinine. renal doppler ultrasound shows suspicious of right renal artery stenosis (rar 2,78). there are many screening tests available for detecting ra stenosis including measurement of plasma renin activity, captopril-stimulated plasma renin activity, nuclear renography, intravenous pyelography, magnetic resonance angiography (mra), renal doopler, intravascular ultrasonography (ivus), digital subtraction angiography, spiral ct imaging, and renal arteriography. the reported sensitivities and specificities range from 75% to 95%. there is no specific algorithm because a rigid diagnostic approach for every case of suspected rvh is neither possible nor advisable. a general recommendation for a diagnostic approach to patients with suspected renovascular hypertension is presented in figure 1. in some cases, it may be prudent to use a combination of studies. figure 2 is another algorithm presented for suspicious of ras. table 2. clinical clues for renovascular hypertension17 history onset of hypertension before age 30 abrupt onset or worsening of hypertension severe or resistant hypertension symptoms of atherosclerotic disease elsewhere smoker worsening renal function with ace inhibitor or arb recurrent flash pulmonary edema examination abdominal bruits, other bruits, advanced hypertensive retinopathy laboratory secondary aldosteronism: higher plasma renin, low k, low na proteinuria, usually moderate elevated serum creatinine >1.5 cm difference in kidney size on sonography cortical atrophy on ct angiography suspected etiology ? atherosclerotic disease impaired renal fibromuscular disease normal renalmoderate indexhigh index able to hold unable to holdunable to hold contrast angiography acei renography du, mra, or cta figure 1. suggested algorithm for suspected renovascular hypertension18 treatment of hypertensive crises requires immediate control of the bp to terminate ongoing end-organ damage within the first 1-2 hours with intravenous anti hypertension agent but bp should not be lower than 25% of mabp, then within 2-6 hours should be reached 160/100 mmhg or mabp 120 mmhg, then if stable we can add oral drugs and reduce bp to normal limit.1 52 vol 45 • number 1 • january 2013 hypertensive crises in the adolescent this patient had bp 160/110 mmhg with nicardipine 10 mg/h and planning to tappering down gradually to 1 mg/h and increase oral dose when we tappering down, his bp was increased to 240/170 mmhg, so we increased nicardipine dose to 2.5 mg/h and later to 5 mg/h and given hct 1x25 mg and alprazolam 2x0,5 mg. on the 5th day, his bp was 140/110 mmhg so nicardipine was tappering off and his blood pressure was stable (130/80 mmhg), oral drugs were given continually. nicardipine has 100 times more water soluble than nifedipine, and, therefore it can be administered iv, making nicardipine a titratable iv calcium channel blocker. the onset of action of iv nicardipine is between 5-10 min, with a duration of action of 15-30 min and may exceed to 4 hours. nicardipine can be given in 5-15 mg/h and increase 2.5 mg/h every 5 mins to a max of 15 mg/h. table 3 shows the iv antihypertensive medications which available in indonesia. during therapy, he was given captopril 3x25 mg and creatinin serial revealed increase of creatinine from 1.2, 1.7, and 2.2, so captopril was stopped and was given amlodipine 1x10 mg. acei is widely accepted as being superior in controlling renovascular hypertension. the major concern about acei is their potential to precipitate acute renal failure in patients with renovascular hypertension.17 this patient was concluded to have essential hypertension due to complication of chronic hypertension and normal arteriography. renal artery us/duplex *mra captopril scintigraphy unavailable or poor quality study unavailable or poor quality study + ras ras technically good study technically poor study but still with wrong poor study or with wrong + ras suspicion of ras and an indication for intervention angiography and angiography **angiography and stop angiography and techni cally poor study but s till with wrong good study no more work up mra or angiography and ras clinical suspicion clinical suspicion clinical suspicion figure 2. algorithm for suspicion of renal artery stenosis18 table 3. dosages of i.v antihypertensive medications19 drugs dosage ooa doa conidine 150 ug 6 amp/250 cc gluc 5% microdrip 30-60 min 24 hrs nitroglycerin 10-50 ug per 500 cc 2-5 min 5-10 min nicardipine 0.5-6 ug/kg/min 1-5 min 15-30 min diltiazem 5-15 ug/kg/min then 1-5 ug/kg/min 1-5 min 15-30 min nitroprussid 0.25 ug/kg/min immediate 2-3 min conclusion as many hypertensive crises occur in any ages, clinicians should remember the possibility of renovascular hypertension in young patients with hypertensive crises. an early detection and urgent treatment are needed to prevent the complications of progressive target organ damage. references 1. marik pe, joseph varon j. hypertensive crises: challenges and management. chest. 2007;131:194962. 2. kaplan nm. hypertensive crises. kaplan’s clinical hypertension. 9th ed. philadelphia: lippincott william wilkins; 2006. p. 2273-89. 3. schiffrin el. remodeling of resistance arteries in essential hypertension and effects of antihypertensive treatment. am j hypertens. 2004;17:1192-200. 4. garovic vd, textor sc. renovascular hypertension and ischemic nephropathy. circulation. 2005;112:1362-74. 53 indra wijaya acta med indones-indones j intern med 5. kotchen ta. hypertensive vascular disease. in: braunwald, fauci, kasper, hauser, longo, jameson, eds. principles of internal medicine. 17ed. new york: mcgraw-hill; 2008;241. p. 1549-62. 6. casas jp. effect of inhibitors of the renin-angiotensin system and other antihypertensive drugs on renal outcomes: systematic review and meta-analysis. lancet. 2005;366:2026. 7. radermacher j, chavan a, bleck j, et al. use of doppler ultrasonography to predict the outcome of therapy for renal-artery stenosis. n engl j med. 2001;344:410–7. 8. kawashima a, francis ir, baumgarten da, et al. renovascular hypertension. am coll radiol. 2007. 9. gowda ms, loeb al, crouse lj, kramer ph. complementary roles of color-flow duplex imaging and intravascular ultrasound in the diagnosis of renal artery fibromuscular dyslasia, should renal arteriography serve as the gold standard? jacc. 2003;41:8. 10. schoenberg so, rieger j, johannson la, et al. diagnosis of renal artery stenosis with magnetic resonance angiography: update 2003. nephrol dial transplant. 2003;18:1252-6. 11. garovic vd, kane gc, schwartz gl. renovascular hypertension: balancing the controversies in diagnosis and treatment. cleveland clinic j med. 2005;72:12. 12. derkx fh, schalekamp ma. renal artery stenosis and hypertension. lancet. 1994;344:237-9. 13. safian rd, textor sc. renal artery stenosis. nejm. 2001;344:6. 14. mclaughlin k, jardine ag, moss jg. renal artery stenosis. bmj. 2000;320:1124–7. 15. bloch mj. an evidence-based approach to diagnosing renovascular hypertension. curr cardiol rep. 2001;3:477-84. 16. chobanian av, bakris gl, black hr, et al. the seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: the jnc 7 report. jama. 2003; 289:2560–72. 17. gottam n, nanjundappa a, dieter rs. renal artery stenosis: pathophysiology and treatment. expert rev cardiovasc ther. 2009;7(11):1413-20. 54 481acta med indones indones j intern med • vol 53 • number 4 • october 2021 review article molecular mechanism of acute sarcopenia in elderly patient with covid 19 i gusti putu suka aryana1*, siti setiati2, sandra surya rini3 1 division of geriatrics, department of internal medicine, faculty of medicine udayana university – sanglah hospital, denpasar, bali, indonesia. 2 division of geriatrics, department of internal medicine – clinical epidemiology and evidence-based medicine unit, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 3 department of internal medicine, faculty of medicine udayana university – sanglah hospital, denpasar, bali, indonesia. *corresponding author: i gusti putu suka aryana, md., phd. division of geriatrics, department of internal medicine, faculty of medicine udayana university – sanglah hospital. jl. pulau tarakan no.1, denpasar 80114, bali, indonesia. email: ptsuka_aryana@unud.ac.id. abstract coronavirus disease 2019 (covid-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2). case fatality rate has been on the rise among older adults. muscle loss is a consequence of several chronic diseases (chronic sarcopenia) and recent theory also suggested that acute sarcopenia may caused by acute significant stressor such as an acute illness, surgery, infections, trauma or burns including covid-19 infection leading to further muscle loss in elderly. cytokine storm, the hallmark of covid-19 pathogenesis will induce various pro-inflammatory cytokine such as il-1 and il-6 causing acute sarcopenia by activating negative regulators like nf-κb, atrogin-1, murf-1. long standing chronic inflammation also known as inflammaging along with acute inflammation during covid-19 in elderly will cause reticulum endoplasmic and mitochondria stress activating caspase and finally increase both cytosolic and nuclear levels of aif and endog to induce acute sarcopenia. several precipitating factors shared same molecular pathway like physical inactivity and hormonal dysregulation which act through igf-1-akt-mtor pathway. physical inactivity during covid-19 infection also induced myostatin and atrogin-1/ mafbx/ murf pathway. this review provides recent research advances dealing with molecular pathway modulating muscle mass in acute sarcopenia during covid-19 infection. keywords: covid-19, acute sarcopenia, inflammation, aging. introduction coronavirus disease 2019 (covid-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (sarscov-2). it was first reported in december 2019 in wuhan, china and has spread quickly to all over the world.1 the number of confirmed covid-19 cases has reach more than 233 million worldwide and currently has mortality rate 1.71%. 2 indonesia has 4.2 million confirmed cases up to october 2021 including 142.115 total death.3 covid-19 has high mortality and morbidity in elderly patients with 38.6% death case among elderly patients in indonesia. men have higher proportion of both confirmed and death cases compared to women in elderly population.4 case fatality rate has been on the rise among older adults. according to statistical data, up to 80i gusti putu suka aryana acta med indones-indones j intern med 482 90% of deaths was mostly happened in elderly patients (≥60 years old).5 globally, elderly population is growing faster than the number of people in all younger age groups each year. in 2019, aging population have reached 703 million worldwide.6 indonesia is one of the most populated countries and its elderly population is estimated to be 25.64 million in 2019. elderly people will experience decrease of organ function such as loss of muscle strength. decrease of muscle mass and muscle function will lead to sarcopenia in elderly. sarcopenia is a syndrome characterized by loss of skeletal muscle mass and function.7 acute sarcopenia is defined as changes in muscle mass and muscle function less than 6 months due to significant stressor such as an acute illness, surgery, infections, trauma or burns.8 in covid-19 cases, acute sarcopenia was associated with increased mortality risk, longer icu admission and risk of higher mechanical ventilator.9,10,11,12,13 the combination of high inflammation, malnutrition, and immobilization in critically ill covid-19 will increase the probability of elderly developing acute sarcopenia.14 the underlying mechanism of acute sarcopenia in elderly with covid-19 is a complex process but several cellular mechanisms are thought to be involved in the acute sarcopenia pathogenesis. this review aims to understand further about the complexity of acute sarcopenia molecular pathway in elderly with covid -19, identify the contributing factors and the implications so that clinicians can try the best measures to prevent and treat this acute and long-term, disabling condition. aging, covid-19 infection, and acute sarcopenia aging is accompanied by remodeling of the immune system including decreasing immune system capability to induce antibody and cellular response to fight against infection. this phenomenon is known as imunosenescence, a multifactorial condition which influences innate and adaptive immunity, especially t-lymphocyte cells. the hallmark of immunosenescence is the reduced ability to respond to new antigens, the accumulation of memory t cells, and long standing low-grade inflammation termed as inflammaging.15 aging has been associated with chronic inflammation and increase of inflammation markers such as c-reactive protein (crp) and interleukin-6 (il-6).16 aging is also risk factor for poor outcome in covid – 19 infection. aging will cause decrease of inhaled particle clearance in respiratory tract due to diminished ciliary amount in respiratory tract. moreover aging also affects upper respiratory tract size which reduces its size especially in men and finally increase the risk of upper respiratory tract collapse.17 sars-cov-2 s spike protein plays a crucial role in binding the human cell receptor ace2 as entry point of the virus. in lung cells, by cleaving residues of angii, ace2 produces ang i-vii which reduces the inflammatory effect of angii. the spike protein of the sars-cov-2 virus causes internalization and degradation of ace2 which exacerbates lung damage. new study found that younger subjects are prone to have higher probability for covid-19 infection, whereas in elderly who has lower amount of ace2 was associated with more severe symptoms in covid-19 infection. lower expression of ace 2 does not protect against viral invasion because sars-cov-2 has a high intrinsic affinity for the ace 2 receptor. ace 2 deficiency is accompanied by viral downregulation of ace 2 causing imbalance between ace/ang ii/at1r receptors and ace 2/ angiotensin 1-7 receptors. at the lung level, such dysregulation will greatly facilitate the development of the inflammatory process and hypercoagulation resulting from the hyperactivity of ang ii.18 these phenomenon is associated with more severe alveolar damage and mechanical ventilator support.19 age is not the only factor that affects the increase of disease severity. epidemiological studies also show differences of higher incidence and mortality of covid-19 infection in men compared to women. the number of t cells and b cells decrease significantly in elderly men and there was an increase in cd8 memory effector t cells compare to women. elderly men showed an inverse cd4/cd8 ratio compared to women. the proliferative and secretory capacity of t cell cytokines also decreases more rapidly in male.17 sex hormones also play a role and explained why vol 53 • number 4 • october 2021 molecular mechanism of acute sarcopenia in elderly patient 483 men are more susceptible compared to women. research on mice have showed differences in ace2 expression according to sex. one study also reported higher expression of ace2 in female mice in comparison to male mice. sars-cov-2 uses the cell surface enzyme ace2 and the transmembrane serine protease 2 (tmprss2) for providing virus cell entry and priming. estrogen seems play as protective factor in women. estrogen receptor alpha (erα) has an effect on t cells such as th1, th2, th17, and t regulatory cells, as well as follicular helper t (tfh) cells. therefore, estrogen, stands out as a key biological factor making women’s immune system more active against the virus. estrogen also has anti inflammatory and antioxidative effect on the effectors of the renin-angiotensin system.20 on the other hand, male sex hormone might contribute to severity of covid-19 in men compared to women. tmprss2 is an androgen-mediated protein that plays a critical role in priming the virus spike proteins for entry into the host cell as one of the first steps involved in infection and its activation is dependent on androgens.21 sarcopenia is a syndrome characterized by progressive loss of muscle mass and muscle strength.7,22 the definition of sarcopenia based on the european working group on sarcopenia in older people (ewgsop) 2 is a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength with increasing risks such as physical disability, poor quality of life and death. acute sarcopenia based on ewgsop2 is defined as incident sarcopenia within six months, normally following a stressor event and if sarcopenia persists for more than six months it will be described as chronic.22 in order to diagnose acute sarcopenia, we must obtained measurements of muscle mass and muscle function either pre-illness or during early stages of an illness.8 figure 1 shows how acute sarcopenia secondary to hospitalization can lead to worsening chronic sarcopenia and this is often seen in elderly patients infected with covid-19. sarcopenia in elderly patients has implications not only when the patient is hospitalized, but also functional and physical decline after covid-19 recovery.23 figure 1. acute sarcopenia, chronic sarcopenia, healthy aging illustration.8,22 i gusti putu suka aryana acta med indones-indones j intern med 484 acute sarcopenia in elderly with covid-19 infection: predisposing and precipitating factors i n o r d e r t o e ff e c t i v e l y p r e v e n t t h e development of acute sarcopenia, it is important to know predisposing and precipitation factors. some predisposing factors play a major role on determining the outcome of acute sarcopenia in elderly with covid – 19 infection even after recovering from covid – 19 infection. predisposing factors for acute sarcopenia is a complex process in which many factors can contribute. aging is the main predisposing factor of sarcopenia, but other factors also contribute to the loss of muscle mass such as reactive oxygen species (ros). in the context of aging, increased activity of ros has been implicated in the processes underlying aging and, in all species, tissues (including skeletal muscle) of aged organisms contain increased amounts of oxidative damage to lipids, dna and proteins. aberrant ros generation and oxidative damage have been associated with many aspects of mitochondrial dysfunction in skeletal muscle aging.24 sarcopenia is an example of impaired physical function that is thought to have complex relationships with individual long‐ term conditions and multimorbidity, including bidirectional effects. many studies proved that elderly who developed sarcopenia often has multimorbidity. study conducted by richard et al, found that almost half of the sample (44.5%) had multimorbidity (two or more categories of long‐term conditions). this was more common in those with sarcopenia (64.8%) than those without (43.4%).25 since elderly are often at risk for both the development of sarcopenia and obesity, a double burden exists. obesity remains one of predisposing factors that might cause elderly prone to develop sarcopenia and makes it not very surprising that the two conditions often coexist which is known as sarcopenic obesity. an important risk factor for both sarcopenia and obesity is the lower rate of energy expenditure with age, which is a result of lower physical activity, as well as a fat free mass relatedlower basal metabolic rate, which is often seen with older age. obesity may create resistance towards anabolic stimuli, such as, growth factors, hormones, amino acids, and exercise, a phenomenon called anabolic resistance. finally, obesity is responsible for causing systemic low-grade inflammation, particularly by visceral fat, which excretes several different proinflammatory cytokines, such as il-6)and tnf-α and inflammation is also one of predisposing factor for sarcopenia as well.26 besides obesity, malnutrition was one of the remaining problem in elderly and found to be associated with sarcopenia in several populations, including hospitalized patients. the association between malnutrition and severe sarcopenia could be explained by a lower intake of key nutrients such figure 2. predisposing and precipitating factors of acute sarcopenia in elderly with covid-19 infection.22-27 vol 53 • number 4 • october 2021 molecular mechanism of acute sarcopenia in elderly patient 485 as protein, vitamin d and calcium, amongst other factors, which affects preservation of muscle mass and subsequently muscle strength and physical performance. 22,27 acute sarcopenia is usually related to an acute illness or injury, while chronic sarcopenia is likely to be associated with chronic and progressive conditions and increases the risk of mortality. long before elderly experienced critical illness, they often have chronic sarcopenia as consequence of aging. at one point, acute illnesses could worsen the degree of sarcopenia and this condition could be termed as an acute-on-chronic sarcopenia phenotype.28 some precipitating factors are playing crucial role in the accelerated development of acute on chronic sarcopenia in elderly infected with covid-19, such as altered diet during hospitalization including anosmia and ageusia, acute medical problems including covid -19 itself, immunological events such as cytokine storm which is the hallmark of covid-19 pathogenesis, vascular problems, and physical inactivity. immobilization that occurs due to covid-19 is very different from immobilization due to other diseases such as fractures, chf fc iv or severe pneumonia. elderly with covid-19 will be more susceptible to suffering from acute sarcopenia. study conducted by mayer et al found that prolonged bed rest in the elderly with covid-19 who used high-flow oxygen therapy or was treated in the icu for covid-19 reduced rectus femoris muscle mass by 18.5% on day 7 of treatment compared to the first day of hospital admission. other effects include post intensive care syndrome (pics) with symptoms of muscle weakness and some conditions, including fatigue, anxiety, depression, and sleep disturbances.29 immobilization during hospitalization and due to government policy to restrict mobilization will increase the probability of elderly getting a thrombotic event and longer bedrest. loss of muscle mass does not only start as early as the second decade of life, but it is exacerbated by muscle inactivity. t h e c o m p l e x i n t e r a c t i o n b e t w e e n predisposing and precipitating factors would lead to mitochondrial dysfunction, mitochondrial autophagy and mitochondrial biogenesis and finally causing decrease of muscle syntesis, increase of myofibral breakdown and muscle degeneration. figure 2 showed some of predisposing and precipitating factors that might contributed in elderly with acute sarcopenia. m o l e c u l a r m e c h a n i s m o f a c u t e sarcopenia in elderly with covid-19 infection elderly are known to be particularly vulnerable to the effects of the illness, with age being associated with not only mortality but may cause more severe clinical presentation leading to development of acute sarcopenia. it has now become clear that survivors of covid-19 are still at increased risk of acute sarcopenia. biological age and ros aging has many effects towards our body, including endoplasmic reticulum (er) stress caused by ros and harmful protein accumulation. mitochondria induces apoptosis via both caspase-mediated or caspase-independent pathways. initiator caspases such as caspase-8, caspase-9, caspase-12 will be activated if there is stimuli and leading to the activation of effector caspases (caspase-3, caspase-6, caspase-7) which is responsible for cellular degradation and dna fragmentation via a caspase-activated dnase (cad). the stimuli to activate pro caspase to become caspase can divided into two pathways, firstly the extrinsic apoptotic signaling that is initiated by death receptors located on the cell surface, such as the tumor necrosis factor receptor (tnf-r) and the fas receptor and intrinsic pathways of caspase activation include those triggered by the endoplasmic reticulum (er) and the mitochondrion. recently, higher fas expression on cd4 + t and cd8 + tcells has been reported in covid-19 patients than in healthy controls but it needs further study. under er stress conditions, er-specific procaspase-12 can be activated by m-calpain, leading to caspase-3 activation. along with aging, the caspase-independent apoptotic pathways are expressed more compare to younger age leading to sarcopenia.30 i gusti putu suka aryana acta med indones-indones j intern med 486 immunosenescence aging has been associated with chronic inflammation and increase of inflammation markers such as c-reactive protein (crp) and interleukin-6 (il-6) which is well known as a phenotype predictive factor for body composition change, homeostasis and immunosenescence.16 as humans age, the presence of systemic basal inflammatory mediators increases independently of acute immune challenges in a phenomenon known as inflammaging. long standing chronic inflammation has been speculated to be main contributor to immunosenescence, a term defined as overall changes to the immune system in elderly, including a reduced ability to combat new infections.31 primary goals of the innate immune system in response to a sars-cov-2 infection are (1) to initiate a local inflammatory response to activate and recruit immune cells, (2) to directly eliminate virally infected cells and (3) to prime the adaptive immune response. as in elderly, those abilities are either diminished or dysregulated. mitochondria plays a central role in the induction and regulation of programmed cell death. a study in experimental animal models has showed a proapoptotic shift in the expression pattern of bcl-2 proteins (increased bax and decreased bcl-2 levels) that was observed in muscles of aged rodents. the release of mitochondria-specific apoptotic mediators is the process of mitochondrial outer membrane permeabilization (momp). once momp has occurred, the release of apoptogenic factors stored in the mitochondrial intermembrane space ensues, initiating the series of events that result in cell death. several studies also showed that caspase-independent apoptotic pathways are activated in elderly. translocation of mitochondrial endog to the nucleus was increased in the soleus muscle of old mice. in addition, aging will increase both cytosolic and nuclear levels of aif and endog and this was was observed in the rat gastrocnemius muscle. moreover, aif gene expression progressively increased during aging in the rat plantaris muscle, and was correlated with the progression of sarcopenia. the aforementioned findings support the role of mitochondrial caspase-independent pathway of apoptosis in the pathophysiology of sarcopenia.32 hyperinflammation (cytokine storm) c o v i d 1 9 i s a n i n f e c t i o u s d i s e a s e characterized by an increase in inflammatory c y t o k i n e s k n o w n a s c y t o k i n e s t o r m s . hyperactivation of the nuclear factor kappalight-chainenhancer of activated b cells (nf-κb) pathway has been implicated in the pathogenesis of the severe/critical covid19 infection. nf-κb activation plays major role to the acute respiratory rna virus-induced cytokine storm. in humans, sars-cov-2 binds to the angiotensin-converting enzyme 2 (ace2) receptor and with the help of the cellular serine protease tmprss2 will trigger endocytosis into the host cell. within the endosomes, rna from single-stranded rna virus is known to activate the toll-like receptors tlr7 and tlr8. however, as a second major effect the activation of the tlrs can trigger—via various intermediates—the activation of ikk (iκb kinases) resulting in phosphorylation of the cytoplasmic inhibitor factor iκbα triggering its ubiquitination followed by degradation by the 26s proteasome, thereby nf-κb (a heterodimer complex consisting of protein subunits p50 and p65) is released from iκbα.nf-κb transcription factors activation promotes the gene expression of wide variety of cytokines such as il-1, il6, il-12, tnf-α, ltα, chemokines, adhesion molecules, acute phase proteins, and inducible effector enzymes. activation of nf-κb will induce the upregulation of muscle ring finger 1 (murf1), a mediator of muscle atrophy and finally result in acute sarcopenia condition.8 on the other hand, caspase-8 which was previously viewed exclusively as an apoptotic caspase, has now emerged as a master regulator of the three major cell death pathways, including apoptosis, pyroptosis, and necroptosis. some studies found that sars-cov-2 induces caspase-8 activation to trigger cell apoptosis and directly activates some inflammatory factors such as pro-il-1β. the il-1β is then secreted through the sars-cov-2-triggered necroptosis pathway. the caspase-8-mediated apoptosis activation and inflammatory responses vol 53 • number 4 • october 2021 molecular mechanism of acute sarcopenia in elderly patient 487 in infected lung epithelial cells may induce downstream immune pathogenesis in the lung tissue. in line with the phenomenon, massive infiltration of inflammatory cells, necrotic cell debris, and pulmonary interstitial fibrosis were observed in the postmortem lung sections of fatal covid-19 patients.33 the caspase-8 is an initiator caspases that will activate the effector caspase-3 which are responsible for the cellular degradation and dna fragmentation via a caspase-activated dnase (cad) and will cause acute sarcopenia. physical inactivity regional quarantine policies and activity restrictions for the purpose of reducing infection transmission also affect the mobility of patients, especially the elderly.34 bed rest is associated with decreased muscle quantity, strength and endurance. bed rest reduces muscle protein synthesis by altering expression of ubiquitin ligases (murf-1 and mafbx).27 kortebein et al. found that in 10 days of immobilization in elderly aged 67 ± 5 years, lower extremity mass was decreased by 6.3%, isokinetic strength decreased by 15.6%, ability to climb stairs decreased by 14%, and vo2 max decreased by 2%.35 the molecular mechanisms that have been implicated in the development of disuse muscle atrophy are atrogin-1/ muscle atrophy f-box (mafbx)/ muscle ring finger 1 (murf1) pathway, the igf-1-akt-mtor pathway and the myostatin pathway.8 murf1 is the only family member shown to be associated with muscle atrophy and to result in the attenuation of muscle loss when deleted. similar to murf1, mafbx expression is selective to striated muscle. regulation of murf1 and mafbx expression in skeletal muscle. skeletal muscle atrophy is induced by a number of stressors. these stressors can lead to the increase in the expression of a number of transcription factors, including the forkhead transcription factors (foxo1 and fox03a), nfκb transcription factors (p65, c-rel, relb, p52, and p50), ccaat/enhancer-binding protein-β (c/ebpβ), kruppel-like factor-15 (klf-15), and/or activation of the glucocorticoid receptor. these transcriptional mediators can bind to the promoter regions of either the murf1 or mafbx genes, leading to an increase in their expression levels within the muscle. mafbx and murf1 mrna levels rise in rodent models of immobilisation and associated with increases in proteolysis but not inhibition of protein synthesis.8 some studies has proved the importance of igf-1 expression in the maintenance of muscle mass. when binding to igf-1, igf-1 receptor (igf-1r) phosphorylates an intracellular adaptor protein insulin receptor substrate-1 (irs-1), which recruits and phosphorylates phosphoinositide 3-kinase (pi3k) followed by akt phosphorylation. the pi3k/akt pathway plays a critical role in myotube hypertrophy, and activation of akt in rat muscle prevents denervation-induced atrophy. mammalian target of rapamycin (mtor) is a downstream target of akt. the igf-1/akt/mtor pathway has been shown to be play major role in promoting muscle hypertrophy.36 immobilization is a negative regulator in igf-1/akt/mtor pathway which inhibited during disuse (unloading)-induced atrophy. igf-1 also affects protein synthesis via myostatin signalling. myostatin is a member of tgf-β family, its expression mainly from skeletal muscle, and negatively regulates muscle mass. igf-1 and myostatin counteract each other. myostatin signalling is activated by activin type ii receptors (actriia and actriib) and activin type i receptors (alk4 and alk5), leading to phosphorylation of smad proteins (smad2 and -3). smad2/3 form a complex with smad4, which is also a co-mediator of the bone morphogenic protein (bmp) signalling pathway. when myostatin expression is downregulated, smad4 becomes more available to bmp signalling and will cause muscle hypertrophy. akt activation is downregulated by actriib and balancing the activation of igf-1, myostatin, and bmp pathways are critical to maintain muscle mass.36 hormonal dysregulation after the age of 60 years, a variety of hormones that promote the growth of muscle cells, such as testosterone, growth hormone (gh), and insulin-like growth factor 1 (igf-1) are decreasing. sex steroids such as estrogen and testosterone decline with aging and contribute to i gusti putu suka aryana acta med indones-indones j intern med 488 muscle loss. testosterone blocks the production of myostatin and ros, inhibit apoptosis, potentiate myosatellite stem cells, accelerating muscle insulin growth factor-1 (igf-1) expression, regulate skeletal muscle metabolism and increase muscle protein synthesis rate and muscle mass in elderly man. igf-1 decrease by 50% by the age of 60. growth hormone (gh) decrease in aging will also lower muscle mass.37 low expression of gh/igf-1 level in elderly will cause a decrease of protein anabolism in skeletal muscle cells, which ultimately leads to changes in the structure and function of skeletal muscle cells. study conducted by ioannis ilias et al (2021) found that igf-1 was higher in covid-19 survivors compared to non-survivors (-0.96 ± 1.89 vs -2.05 ± 2.48, respectively, p=0.030) but no significant differences were noted in gh between the groups. these results suggest that there might be an association between low igf1 (and possibly gh) and poor outcome in patients with covid-19.38 igf-1 receptor (igf-1r) binds to igf-1and phosphorylates an intracellular adaptor protein insulin receptor substrate-1 (irs-1), which recruits and phosphorylates phosphoinositide 3-kinase (pi3k) followed by akt phosphorylation. the pi3k/akt pathway will induce myotube hypertrophy and activation of akt in rat muscle prevents denervation-induced atrophy. activation of akt activates mammalian target of rapamycin (mtor) and its activity is tightly regulated by amino acid availability to the cells. amino acids are necessary to build proteins, nucleic acid, glucose, and atp in the body, mtor activity is highly correlated with the anabolic or catabolic balance. the effect of akt on mtor is indirect, akt inhibits the tuberous sclerosis complex (tsc) proteins 1 and 2, which act as a gtpase activating protein (gap) to inhibit the small g protein ras homolog enriched in brain (rheb) which activates mtor signaling. mtor consist of two different protein complexes, the rapamycin-sensitive mtorc1 and the rapamycin-insensitive mtorc2. torc2 is necessary for akt phosphorylation and activation. mtorc1 phosphorylates s6 kinase (s6k), which in turn phosphorylates the ribosomal protein s6 and other factors involved in translation initiation and elongation, thus stimulating protein synthesis. the igf-1/akt/ mtor pathway is very important in promoting muscle hypertrophy. therefore, decreased level of gh/ igf-1 plays a key role in the loss of skeletal muscle mass.39 ros, reactive oxygen species; cad, caspaseactivated dnase; dna, deoxyribonucleic acid; endo g. endonuclease g; aif, apoptosisinducing factor; tnf, tumor necrosis factor; acute sarcopenia figure 3. proposed model of molecular mechanism of acute sarcopenia in elderly with covid-19 infection.8,16,30-32,36-39 vol 53 • number 4 • october 2021 molecular mechanism of acute sarcopenia in elderly patient 489 tak-1, transforming growth factor-β-activated kinase 1; mapkk, mitogen-activated protein kinase kinase; mek 1/2, mitogen-activated protein kinase; erk1/2, extracellular signalregulated kinases; pi3k, phosphoinositide 3-kinases; foxo, the forkhead box o; akt-p, phosphorylated akt; mtor, mammalian target of rapamycin; il, interleukine; nfkb, nuclear factor kappa-light-chain-enhancer of activated b cells; murf-1, muscle ring-finger protein-1. implication of acute sarcopenia in elderly with covid – 19 decreased quality of skeletal muscles is the main cause of poor quality of life, immobilization, disability, falls, fractures, hospitalization, length of stay, hospital readmission, morbidity and mortality in the elderly. hospitalization, even for a short period of time, is associated with an increased risk of nosocomial infection in sarcopenia patients and a significant decrease in muscle strength and functional capacity.37 icu admission acute sarcopenia is associated with an increased risk of icu admission and mechanical ventilation. a study conducted by giraudo et al., (2021) found muscle mass loss was a predictor of patients admitted to the icu. patients who lost muscle mass were significantly older (73.4±10 years) and with higher crp values (71.5±71).12 low muscle mass on ct scan results is associated with higher risk of icu admission and mortality.40,11 acute sarcopenia also consider as one of risk factors for difficulty in ventilator weaning.11 intensive care unit-acquired weakness (icuaw) is a well-known complication following admission to the intensive care unit (icu). most relevant risk factors that associated with icuaw is the severity of underlying critical illness and inflammation. both of these factor was present in elderly with covid – 19.8 length of stay research conducted by sousa et al., (2016) found that acute sarcopenia patients had a longer length of stay. patients with sarcopenia are less likely to return home and also have longer time in bed.31 the study by martone et al., (2017) in hospitalized patients showed that the mean time of acute sarcopenia patients in bed was 5.1 days compared to 3.2 days in non-sarcopenia patients. muscle protein synthesis is also impaired due to lack of nutrition and physical exercise.41 frailty sarcopenia and frailty are two conditions that often coexist. frailty is a multisystem organ decline characterized by an increase in the patient’s susceptibility to stressors.42 in frailty, there is a decline in the immune, metabolic, and neuromuscular systems. covid-19 virus binds to ace2 receptors present in various organs such as the lungs, heart, liver, kidneys, and intestines to enter human cells. covid-19 patients experienced organ damage where 14% had respiratory failure, 15% had heart damage, 15.7% had liver damage, and 13.7% had kidney problems. because of this organ damage, covid-19 patients are prone to becoming frail, especially in elderly patients. woolford et al., reported that covid-19 patients had a 1.4 times higher risk in becoming frail.43 frailty was significantly associated with an increase in poor outcomes, mortality and morbidity, severity of covid-19, likelihood of being admitted to the icu, mechanical ventilation, and length of stay.44 research by zhang et al., (2021) found that frailty was a predictor of mortality in covid-19 patients. the prevalence of frailty is 51%, with hr 1.99 and or 2.48.42 hewitt et al., (2020) studied frailty in covid-19 patients and they found that frailty was detected in 49.4% of patients. the 7-day mortality rate increased in frailty patients with an or of 1.22. frailty is also associated with longer treatment.45 malnutrition covid-19 affects patients of all ages, but has more severe clinical consequences in elderly patients. some factors might be associated why the elderly with covid-19 has higher chance to become malnourished. morphine that is administered to relieve pain associated with breathing and to facilitate respiration will slow gastro-intestinal transit inducing nutritional related complaints like nausea and constipation. dexamethasone in covid-patients who require oxygen therapy to improve outcome, often i gusti putu suka aryana acta med indones-indones j intern med 490 increase plasma glucose levels necessitating tailored nutrition and insulin therapy which can be a challenge in patients who are already diabetic. covid-19 has a profound negative impact on nutritional status already before admission. this is proven in several studies showing that in 22% of the patients, mainly icu patients, lost more than 5 kg extra body weight during hospital stay. it has been demonstrated that in-hospital malnutrition is associated with hospital length of stay (los), in-hospital mortality, and re-admission rate.46 covid-19 itself results in multiple nutrition-related problems such as changes in appetite, taste and energy expenditure and changes in taste that might further worsen the level of malnutrition. malnutrition and sarcopenia often coexist and develop clinically through a combination of decreased nutritional intake, weight loss, then decreased mass, muscle strength, and physical function. this syndrome is called malnutrition-sarcopenia syndrome (mss). both conditions are independently associated with morbidity, mortality, decreased quality of life, rehospitalization, length of stay, and costs.47 a study by cederholm et al. found a significant difference in mortality after discharge from home between malnourished patients compared to good nutrition at 44% versus 18% respectively.48 community studies in patients with unexpected weight loss and low body mass index (bmi) had an increased risk of death at 3 years by 1.67 times.49 a study by newman et al. found that even 5% weight loss was a significant predictor of mortality in the elderly in the community.50 malnutrition is associated with a decrease in the functional capacity of treated patients based on mini-nutritional assessment (mna) values <24.51 malnourished elderly patients were more likely to continue treatment in nursing homes compared to returning home. this condition is also accompanied by disability, use of assistive devices, loss of muscle mass, risk of metabolic disease, and increased risk of falls and fractures.47 conclusion covid-19 infection causes acute sarcopenia with various predisposing and precipitating factors such as inflammation, biological age, ros, altered diet, physical inactivity, hormonal dysregulation and many more. molecular mechanism of acute sarcopenia in elderly infected with covid-19 is a complex process involving various molecular pathways. immunosenescence, ros, and biological age cause acute sarcopenia through endoplasmic reticulum and mitochondria stress and via caspase pathway. hyperinflammation and cytokine storm requires il-6, il-1, nfkb and murf-1 to induce acute sarcopenia. igf-1 is the main pathway involved in acute sarcopenia due to hormonal dysregulation whereas physical inactivity has three different pathways to induce acute sarcopenia, they are atrogin-1/ mafbx/ murf1 pathway, the igf-1-akt-mtor pathway and the myostatin pathway. sarcopenia conditions can also worsening covid-19 infection and vice versa and leading to longer length of stay including treatment in the icu, immune dysregulation, frailty conditions, and the occurrence of malnutrition. references 1. susilo a, rumende cm, pitoyo cw, et al. coronavirus disease 2019: tinjauan literatur terkini coronavirus disease 2019. 2020;7:45–67. 2. world health organizarion. who coronavirus disease (covid-19). dashboard. [accessed 2nd october 2021]. url: https://covid19.who.int/ 3. s a t g a s p e n a n g a n a n c o v i d 1 9 . d a t a s e b a r a n . [accessed 2nd october 2021]. url: https://covid19. go.id/4. 4. muhammad khifzhon azwar, siti setiati, aulia rizka, ika fitriana, siti rizny f. saldi, eka dian safitri. clinical profile of elderly patients with covid-19 hospitalised in indonesia’s national general hospital. acta medica indonesiana 52, 199–205. 5. kang sj, jung si. age-related morbidity and mortality among patients with covid-19. infect chemother. 2020;52:154. 6. united nations. world population ageing 2019 highlights. new york: united nations (2019). 7. setiati, s., dwimartutie, n. buku ajar ilmu penyakit dalam. jilid iii. edisi vi. jakarta: interna publishing; 2014. p. 3719–27. 8. welch ck, hassan-smith za, greig cm, et al. acute sarcopenia secondary to hospitalisation an emerging condition affecting older adults. aging and disease. 2018;9:151. 9. zhang xm, et al. sarcopenia as a predictor of mortality among the critically ill in an intensive care unit: a systematic review and meta-analysis. bmc geriatr. vol 53 • number 4 • october 2021 molecular mechanism of acute sarcopenia in elderly patient 491 2021;21:339. 10. weijs p.j, et al. low skeletal muscle area is a risk factor for mortality in mechanically ventilated critically ill patients. crit care. 2014;18:r12. 11. kou hw, et al. sarcopenia is an effective predictor of difficult-to-wean and mortality among critically ill surgical patients. plos one. 2019;14:e0220699. 12. giraudo, c. et al. reduced muscle mass as predictor of intensive care unit hospitalization in covid-19 patients. plos one. 2021;16:e0253433. 13. c. f., isirdi a, brusasco c, et al. low diaphragm muscle mass predicts adverse outcome in patients hospitalized for covid-19 pneumonia. 2020. 14. welch c, greig ca, masud t, pinkney t, jackson ta. protocol for understanding acute sarcopenia: a cohort study to characterise changes in muscle quantity and physical function in older adults following hospitalisation. bmc geriatr. 2020;20:239. 15. aiello a, et al. immunosenescence and its hallmarks: how to oppose aging strategically? a review of potential options for therapeutic intervention. front. immunol. 2019;10:2247. 16. franceschi c, campisi j. chronic inflammation (inflammaging) and its potential contribution to ageassociated diseases. j gerontol series a: biol sci med sci. 2014;69:s4–s9. 17. perrotta f, et al. covid-19 and the elderly: insights into pathogenesis and clinical decision-making. aging clin exp res. 2020;32:1599–608. 18. diaz jh. hypothesis: angiotensin-converting enzyme inhibitors and angiotensin receptor blockers may increase the risk of severe covid-19. j travel med. 2020;27:taaa041. 19. baker, sa, kwok s, berry gj, montine tj. angiotensinconverting enzyme 2 (ace2) expression increases with age in patients requiring mechanical ventilation. plos one. 2021;16:e0247060. 20. rehman s, et al. immunity, sex hormones, and environmental factors as determinants of covid-19 disparity in women. front immunol. 2021;12:680845. 21. ory j, et al. understanding the complex relationship between androgens and sars-cov2. urology. 2020;144:1–3. 22. cruz-jentoft aj, et al. sarcopenia: revised european consensus on definition and diagnosis. age and ageing. 2019;48:16–31. 23. domingues r, lippi a, setz c, outeiro tf, krisko a. sars-cov-2, immunosenescence and inflammaging: partners in the covid-19 crime. aging. 2020;12:18778–89. 24. thoma a, akter-miah t, reade rl, lightfoot ap. targeting reactive oxygen species (ros) to combat the age-related loss of muscle mass and function. biogerontol. 2020;21:475–84. 25. dodds rm, granic a, robinson sm, sayer aa. sarcopenia, long‐term conditions, and multimorbidity: findings from uk biobank participants. journal of cachexia, sarcopenia and muscle. 2020;11:62–8. 26. cleasby me, jamieson pm, atherton pj. insulin resistance and sarcopenia: mechanistic links between common co-morbidities. journal of endocrinology. 2016;229:r67–r81. 27. welch c, greig c, masud t, wilson d, jackson ta. covid-19 and acute sarcopenia. aging and disease. 2020;11:1345. 28. conti p. induction of pro-inflammatory cytokines (il-1 and il-6) and lung inflammation by covid-19: anti-inflammatory strategies. j biol regul homeost agents. 2020;34:1. 29. stam h, stucki g, bickenbach j. covid-19 and post intensive care syndrome: a call for action. j rehabil med. 2020;52:jrm00044. 30. marzetti e, et al. multiple pathways to the same end: mechanisms of myonuclear apoptosis in sarcopenia of aging. sci world j. 2010;10:340–9. 31. ferrucci l, fabbri e. inflammageing: chronic inflammation in ageing, cardiovascular disease, and frailty. nat rev cardiol. 2018;15:505–22. 32. dupont-versteegden ee. apoptosis in muscle atrophy: relevance to sarcopenia. experimental gerontology. 2005;40:473–81. 33. garcía lf. immune response, inflammation, and the clinical spectrum of covid-19. front immunol. 2020;11:1441. 34. piotrowicz k, gąsowski j, michel jp, veronese n. post-covid-19 acute sarcopenia: physiopathology and management. aging clin exp res. 2021;33: 2887–98. 35. kortebein p, et al. functional impact of 10 days of bed rest in healthy older adults. j gerontol series a: biol sci med sci. 2008;63:1076–81. 36. yoshida t, delafontaine p. mechanisms of igf-1mediated regulation of skeletal muscle hypertrophy and atrophy. cells. 2020;9:1970. 37. ali am, kunugi h. physical frailty/sarcopenia as a key predisposing factor to coronavirus disease 2019 (covid-19) and its complications in older adults. biomed. 2021;1:11–40. 38. ilias i, et al. covid-19 and growth hormone/insulin-like growth factor 1: study in critically and non-critically ill patients. front endocrinol. 2021;12:644055. 39. guertin da, et al. ablation in mice of the mtorc components raptor, rictor, or mlst8 reveals that mtorc2 is required for signaling to akt-foxo and pkcα, but not s6k1. developmental cell. 2006;11:859–71. 40. schiaffino s, et al. ct-derived chest muscle metrics for outcome prediction in patients with covid-19. radiology. 2021;300:e328–e336. 41. martone am, et al. the incidence of sarcopenia among hospitalized older patients: results from the glisten study: hospitalization and risk of incident sarcopenia. journal of cachexia, sarcopenia and muscle. 2017;8: 907–14. i gusti putu suka aryana acta med indones-indones j intern med 492 42. zhang xm, et al. frailty as a predictor of mortality among patients with covid-19: a systematic review and meta-analysis. bmc geriatr. 2021;21:186. 43. woolford sj, et al. covid-19 and associations with frailty and multimorbidity: a prospective analysis of uk biobank participants. aging clin exp res. 2020;32:1897–905. 44. yang y, et al. the impact of frailty on covid-19 outcomes: a systematic review and meta-analysis of 16 cohort studies. j nutr health aging. 2021;25: 702–9. 45. hewitt j, et al. the effect of frailty on survival in patients with covid-19 (cope): a multicentre, european, observational cohort study. the lancet public health. 2020;5:e444–e451. 46. hudson l, chittams j, griffith c, compher c. malnutrition identified by academy of nutrition and dietetics/american society for parenteral and enteral nutrition is associated with more 30-day readmissions, greater hospital mortality, and longer hospital stays: a retrospective analysis of nutrition a. j parent enter nutr. 2018;42:892–7. 47. vandewoude mfj, alish cj, sauer ac, hegazi ra. malnutrition-sarcopenia syndrome: is this the future of nutrition screening and assessment for older adults? j aging res. 2012;2012:1–8. 48. cederholm t, jägren c, hellström k. outcome of protein-energy malnutrition in elderly medical patients. am j med. 1995;98:67–74. 49. locher jl, et al. body mass index, weight loss, and mortality in community-dwelling older adults. j gerontol series a: biol sci med sci. 2007;62: 1389–92. 50. newman ab, et al. weight change and the conservation of lean mass in old age: the health, aging and body composition study. am j clin nutr. 2005;82:872–8. 51. neumann sa, miller md, daniels l, crotty m. nutritional status and clinical outcomes of older patients in rehabilitation. j hum nutr diet. 2005;18: 129–36. 653acta med indones indones j intern med • vol 54 • number 4 • october 2022 clinical practice early recognition of type 2 diabetes complications and use of sglt2i in multidisciplinary approach: indonesian perspective an expert opinion aida lydia1, ketut suastika2, pranawa martosuwignjo3, roy p. sibarani4, sally aman nasution1, soebagijo adi soelistijo5* 1 department of internal medicine, faculty of medicine universitas indonesia dr cipto mangunkusumo hospital, jakarta, indonesia. 2 department of internal medicine, faculty of medicine universitas udayana sanglah hospital, denpasar, bali, indonesia. 3 indonesian society of nephrology. 4 emc hospital, sentul city, bogor, indonesia. 5 department of internal medicine, faculty of medicine universitas airlangga dr. soetomo hospital, surabaya, indonesia. *corresponding author: soebagijo adi soelistijo, md., phd. division of endocrinology, metabolic and diabetes, department of internal medicine, faculty of medicine universitas airlangga dr. soetomo hospital. jl. mayjen prof. dr. moestopo 47, surabaya, indonesia. email: soebagijoadi76@gmail.com. abstract indonesia ranks seventh with the highest number of cases of type 2 diabetes mellitus (t2dm). t2dm is associated with major undesirable complications including cardiovascular disease and chronic kidney disease. kidneys play a major role in maintaining glucose homeostasis, leading the development of sodium glucose transporter inhibitors (sglt2i). these inhibitors block renal sodium and glucose reabsorption. several cardiovascular trials proved that sglt2i have cardioprotective and renoprotective roles and have been suggested as a drug of choice in primary and secondary prevention and management of cardiorenal complications associated with t2dm. this review highlights the need for a multidisciplinary recommendation for t2dm management in indonesian population. additionally, it is vital to provide the perspective of indonesian medical experts in terms of screening, diagnosis and treatment as the outcome differs geographically. an expert panel of 6 members from indonesia was convened to review the existing literature and develop an expert-based review/ summary on this topic. members were chosen for their proficiency in diabetes, kidney disease and cardiovascular disease. the experts opined that the early use of sglt2i will be effective in preventing and minimising the progression of cardiorenal complications. moreover, a consistent multidimensional approach is necessary for improved outcomes. keywords: type 2 diabetes mellitus, sglt2i, cardiorenal complications. introduction diabetes mellitus (dm) is a metabolic condition that affects 537 million adults worldwide, with the number estimated to increase to 783 million by 2045.1 dm in indonesia is a major health problem and has been a cause of serious concern since the 1980s.2 indonesia is ranked seventh among the top 10 countries with aida lydia acta med indones-indones j intern med 654 indonesia, the most common underlying disease in ckd patients is hypertension and diabetic kidney disease.13 as per the indonesian renal registry 2019, 26% patients with ckd stage 5 patients had an etiological diagnosis of diabetic kidney disease.13,14 according to the statistics presented at ‘the 14th national congress meeting of the indonesian society of nephrology’ hypertension (35%) and diabetic nephropathy (29%) are the two key etiological variables observed in ckd 5 patients.15 the guidelines of indonesian society of endocrinology 2011, recommend diabetes screening for high-risk groups including individuals with hypertension, dyslipidaemia, coronary artery disease and obese people having sedentary lifestyle. they also recommend that, high risk individuals obtaining a negative result should be tested annually and people >45 years should be screened every 3 years.16,17 a cross sectional survey of 15,332 urban indonesians aged between 18-55 years, reported 4.6% of diabetes mellitus prevalence with instances of 1.1% previously diagnosed and 3.5% undiagnosed cases. in addition, prevalence of hypertension and dyslipidemia among previously diagnosed and undiagnosed cases was found to be 41.4% and 50%; 49.4% and 50%, respectively.18 to lessen the risk of nephropathy progression, the perkeni 2021 guidelines recommend, optimising glucose levels and hypertension control. in patients (non-pregnant) with moderate (30-299 mg/24hr) to severe albuminuria (>300/24 hr), therapy with angiotensin converting enzyme (ace) inhibitors or angiotensin ii receptor blockers with regular monitoring of serum creatinine and serum potassium levels is suggested, but not to be used as a primary prevention. furthermore, nephrologist intervention is recommended, if serum creatinine is ≥ 2.0 mg/dl, or difficulty persist in determining the etiology, management, or in advance renal failure cases.19 the intersection of diabetes, kidney disease, ascvd, and hf necessitates the emergence of diabetic treatment modalities that are both safe and effective7 and simultaneously provide primary prevention from cardiorenal complications associated with t2dm. newer glucose-lowering the highest number of diabetics.3 the prevalence of diabetes in indonesian adults (20–79 years) is estimated to be 10.7 million, increasing to 13.7 and 16.6 million by 2030 and 2045, respectively.4 according to diabcare 2008 study in indonesia, 97.5% of patients had type 2 dm (t2dm), of which 67.9% had poor glycemic control with hba1c being in the range of 8.1 ± 2.0%.5 in addition, the discover study, presented in lisbon, portugal during easd, indonesia had the highest mean hba1c levels (9.2± 2%) among other participating countries. despite the initiation of second-line therapy, the mean hba1c levels in 70% of patients were >8%.6 t2dm is the central factor in the development and progression of cvd and kidney disease, which can lead to atherosclerotic cvd (ascvd) and heart failure (hf).7,8 a review by asian experts from 9 different countries found that the prevalence of hf is approximately identical to global estimates i.e., 1% to 3%. asian hf patients were observed to spend between 5 (indonesia) to 12.5 days (taiwan) in the hospital with a 3 to 15% readmission rate within 30 days due to hf.8 a vicious circle exists between t2dm, heart failure, and kidney disease, with the prevalence of hf increasing as ckd progresses.9 a higher risk of cardiovascular disease (cvd) is associated with t2dm, which is estimated to be 1.6 to 2.6%.4 worldwide, cvd affects 32.2% of t2dm patients and it’s the leading cause of morbidity and mortality in diabetic population.10 according to a retrospective cohort study (n=1085) conducted from 2011 -2018, the incidence of cardiovascular events among the prediabetic and diabetic indonesian population was 9.7% over a six-year period. in addition, age ≥ 45 years and hypertension were the predictors of cardiovascular events.3 following the confluence of cvd and diabetes, ckd adds a layer of complexity.11 diabetic kidney disease affects 40% of the diabetic population and is the leading cause of end-stage kidney disease (eskd). the prevalence of eskd is 10 times higher in individuals with diabetes that ranges from 10% to 67%.12 comorbidities trigger a sudden decline in renal functioning of ckd patients. in vol 54 • number 4 • october 2022 early recognition of type 2 diabetes complications and use of sglt2i 655 agents have generated a possibility to influence the history of t2dm and cardiorenal complications. sodium–glucose cotransporter 2 inhibitors (sglt2i) are the new class of drugs approved for the management of t2dm. dapagliflozin, empagliflozin, canagliflozin, and ertugliflozin have been investigated in cardiovascular outcome trials (cvots) and approved by the european medicines agency and food and drug administration (fda) either as monotherapy or as an adjunct to other antidiabetic agents.20,21 sglt2i are a relatively new addition to the armament of t2dm therapeutic modalities. when evaluated in conjunction with other oral medications or insulin, all sglt2i demonstrate similar reductions in hba1c.22–25 although the short-term hba1c reduction seen with sglt2i is comparable to that attained with sulfonylureas and dipeptidyl peptidase-4 inhibitor (dpp-iv), the glycemic effect appears to be more durable with sglt2i.26,27 several meta-analyses reported improvement in glycemic control with the use of sglt2i.28,29 in addition to glycemic effects, sglt2i exerts several extra-glycemic effects, including weight loss, blood pressure reduction, lipid level regulation, cv risk reduction, renoprotective impact, and reduction in macroand micro-vascular events, as well as lowering the risk of hypoglycaemia.22 evidence in line, stating sglt2i having glycemic and extra glycemic effects, indicates that sglt2i may be used in primary and secondary prevention of cardiorenal complications in t2dm patients.20 this review emphasises on the burden o f d i a b e t e s i n i n d o n e s i a a n d t o m a k e r e c o m m e n d a t i o n s f o r e a r l y s c r e e n i n g , diagnosis, and treatment to prevent cardiorenal complications. there is need for a multidisciplinary recommendation for t2dm management in the indonesian population as there is no data regarding the official guidelines or recommendations. additionally, the objective of this review is to justify the beneficial role of sglt2i in primary and secondary prevention of cardiorenal complications associated with t2dm, wherein primary prevention is described as prevention of occurrence of cardiorenal complication and secondary prevention is to reduce the worsening of cardiorenal complication in t2dm patients. methodology the need for comprehensive review of the early recognition of t2dm complications and its prevention and management using sglt2i in indonesian population was identified by the indonesian medical specialists from various fields. an expert panel of 6 members (four from university hospitals, and two from public sector) from indonesia was convened to review the existing literature and develop an expertbased review/ summary on this topic. members were chosen for their proficiency in diabetes, kidney disease and cardiovascular disease. series of teleconferences and web-based communications were held from june to august 2021. a manuscript outline was developed, with individual sections assigned to the authors as per their expertise. all the authors had continuous access to the working document to provide input and each section was critically reviewed and revised. in preparation, an extensive literature search was conducted using key words diabetes mellitus, “type 2 diabetes” “diabetes indonesia” “chronic kidney disease”, “cardiovascular disease”, “microvascular complications”, “hba1c”, “sglt2 inhibitors”, “empa”, “dapa” and “cana” in, medline, cochrane library and science direct databases, to identify relevant articles. in addition, experts recommended articles outside the scope of formal searches, and findings from conference proceedings and relevant online data sources were also reviewed. (figure 1) a total of 68 articles were identified out of which 54 were shortlisted. a total of 52 full text articles (meta-analysis, reviews, and randomized controlled trials) published in english and in peer-reviewed and indexed journals from 2005-2021 were selected and the studies with only abstract were excluded. articles published before the start search date provided conceptual content only. aida lydia acta med indones-indones j intern med 656 discussion a m o n g s e v e r a l s g lt 2 i n h i b i t o r s , empagliflozin has the highest sglt2 receptor selectivity, and the other agents have intermediate selectivity (dapagliflozin and canagliflozin).20 the relative specificities of different sglt2i to various sglt receptors contribute to modest variances in their clinical characteristics. the mechanism of action of sglt2i is presented in figure 2.21 sglt2i and t2dm sglt2i mediates the reabsorption of 90% of filtered glucose and inhibits glucose reabsorption at the level of the proximal convoluted tubule (pct), resulting in enhanced glucosuria, osmotic diuresis, and natriuresis, thereby managing the hyperglycemia with reduced risk of hypoglycemia.30 furthermore, sglt2i have added benefits of persistent calorie reduction leading to weight loss, reduced β-cell stress, increased rate of insulin secretion, and insulin sensitivity. sequentially, all these mechanisms regulate blood glucose levels despite β cell dysfunction or insulin resistance. additionally, they are effective in advanced stages of t2dm due to their insulin-independent mechanism.21 efficacy and safety of sglt2i in t2dm patients were investigated in a systematic review and meta-analysis that included 38 trials (n=23,997). sglt2i (canagliflozin, dapagliflozin, and empagliflozin) lowered glycated hemoglobin levels (hba1c) (–0.6% to –0.9%), fasting blood glucose (fbg) (–1.1 to –1.9 mmol/l), blood pressure (bp) (systolic –4.9 to –2.8 mmhg; diastolic – 2.0 to –1.5 mmhg), and body weight (–1.6 to –2.5 kg) when compared with placebo.28 figure 1. literature search strategy. figure 2. mechanism of action of sodium glucose transporter 2 inhibitors. vol 54 • number 4 • october 2022 early recognition of type 2 diabetes complications and use of sglt2i 657 in line with the evidence, a systematic review including three trials of dapagliflozin and two each for canagliflozin and empagliflozin reported that monotherapy with sglt2i significantly improved glycemic control, induced weight loss, and reduced blood pressure. the common adverse events reported were an increase in urinary tract infections (4–9%) and genital tract infections.28 similarly, another systematic review and network meta-analysis including 39 randomized controlled trials (rcts) (n=25,468) reported that sglt2i was superior to placebo in terms of glycemic control, weight loss, and reduction of systolic and diastolic bp.31 drug intensification is often required in t2dm patients who are on stable metformin therapy. sglt2i are potential candidates for combination therapy as they have shown promising outcomes. a meta-analysis, including six rcts, compared the efficacy and safety of sglt2i with non-sglt2 combinations (glimepiride, linagliptin, sitagliptin, glipizide) as an add on to metformin treatment. the study reported that sglt2i+metformin therapy significantly reduced hba1c% more than the non-sglt2i combination after 52 weeks and as well as after 104 weeks of therapy (p<0.00001). moreover, reduction in fpg, weight, and bp was significantly more in the sglt2i group (p<0.00001) and the incidence of hypoglycemia was also reported to be lower with sglt2i.32–34 primary and secondary prevention cvots distinguished t2dm patients without established cvd (primary prevention) and patients with established cvd (secondary prevention).20 thus, it can be inferred that primary prevention is refers to preventing cardiorenal complications in diabetic patients, whereas secondary prevention refers to the diabetic patients who have experienced an acute ischemic event and to prevent the aforementioned complications from worsening. sglt2i have shown the possibility of being cardioprotective by demonstrating relative risk reduction of major adverse cardiovascular events (mace). several meta-analyses have reported in favour of sglt2i, highlighting its renoprotective and cardioprotective effects.35,36 outcome was reported as significant reduction in mace in empagliflozin and canagliflozin trials, whereas dapagliflozin showed reduction in cv mortality and hhf.7,37,38 studies determining the role of sglt2i in primary and secondary prevention are presented in table 1 and 2 [7,37–43] glycemic and extraglycemic effects of sglt2i are presented in figure 3.21 sglt2i and cvot t2dm confers a two-to-three-fold increased risk of coronary artery disease, including angina, myocardial infarction (mi), stroke, and hf in patients with or without established cardiovascular illness.30 sglt2i has demonstrated the potential of being cardioprotective by exhibiting relative risk (rr) reduction of 3 point (non-fatal stroke, non-fatal myocardial infarction and cv death)mace.7 the empagliflozin cardiovascular outcome event trial (empa-reg outcome) was the first trial to demonstrate the cv benefits of sglt2i. over a median of 3.1 years. the risk of cv and all-cause mortality reduced in the sglt2i group by 38% and 32%, respectively, with no significant difference in the risk of non-fatal heart attack or stroke. empagliflozin was also found to be effective in secondary prevention.37 similarly, declare and canvas trials have also demonstrated the cardioprotective effects of sglt2i in multiple risk populations.7,38,44 declare-timi 58, is the largest, longest and broadest sglt2i trial compared the efficacy and safety of dapagliflozin in 17,160 patients with t2dm over a median of 4.2 years. the study showed risk reduction for both the primary endpoints i.e., mace and hhf/ cv was insignificant. the renal outcome was 4.3% in dapagliflozin group vs. 5.6% in the placebo group due to the reduced rate of hospitalization for hf, regardless of the previous history of ascvd and hf.7 therefore, it can be stated that dapagliflozin has provided beneficial effects in both primary and secondary prevention.7,36,45 sglt2i and heart failure t2dm is a prevalent co-morbidity in patients with hf and a major prognostic factor in patients with established hf. chronic hf is the major cause of hospitalization in patients over 65 years, with a 10% 30-day and 50% 1-year mortality. aida lydia acta med indones-indones j intern med 658 ta bl e 1. e ffe ct o f s g lt 2 in hi bi to rs o n c ar di ov as cu la r o ut co m e c ar di ov as cu la r o ut co m es e m pa -r e g ou tc om e c a n va s d e c la r e -t im i 5 8 c r e d e n c e v e r ti s c v d a pa h f r w e e m pa gl ifl oz in v s p la ce bo c an ag lifl oz in v s p la ce bo d ap ag lifl oz in v s p la ce bo c an ag lifl oz in v s p la ce bo e ve nt s/ 10 00 pa tie nt s e rt ug lifl oz in v s p la ce bo d ap ag lifl oz in v s p la ce bo d ap ag lifl oz in v s g lu co se lo w er in g d ru gs e ve nt s/ 10 00 p at ie nt s d ea th fr om c v ca us es , n on -fa ta l m i or n on -fa ta l s tro ke h r (9 5% c i) 10 .5 % v s 12 .1 % 0. 86 (0 .7 40. 99 ) 26 .9 % v s 31 .5 % 0. 86 (0 .7 5 0 .9 7) 8. 8% v s 9. 4% 0. 93 (0 .8 4 1 .0 3) 38 .7 v s 48 .7 0. 80 (0 .6 7 0 .9 5) 11 .9 % v s 11 .9 % 0. 97 (0 .8 51. 11 ) -- --c v d ea th h r (9 5% c i) 3. 7% v s 5. 9 % 0. 62 (0 .4 9 – 0. 77 ) 11 .6 % v s 12 .8 % 0. 87 (0 .7 2 – 1. 06 ) 2. 9% v s 2. 9% 0. 98 (0 .8 2 – 1. 17 ) 19 .0 v s 24 .4 0. 78 (0 .6 1 – 1. 00 ) 6. 2% v s 6. 7% 0. 92 (0 .7 7 – 1. 11 ) 9. 6% v s 11 .5 % 0. 82 (0 .6 9 – 0. 98 ) 6. 1 vs 8 .1 0. 75 (0 .5 7 – 0. 97 ) h os pi ta liz at io n fo r he ar t f ai lu re h r (9 5% c i) 2. 7% v s 4. 1% 0 .6 5 (0 .5 0 – 0. 85 ) 5. 5% v s 8. 7 % 0. 67 (0 .5 2 – 0. 87 ) 2. 5% v s 3. 3% 0. 73 (0 .6 1 – 0. 88 ) 15 .7 v s 25 .3 0. 61 (0 .4 7 – 0. 81 ) 2. 5% v s 3. 6% 0. 70 (0 .5 4 – 0. 90 ) 9. 7% v s 13 .4 % 0. 70 (0 .5 9 – 0. 83 ) 15 .5 v s 19 .6 0. 79 (0 .6 7 – 0. 93 ) n on -fa ta l m i h r (9 5% c i) 4. 5% v s 5. 2% 0. 87 (0 .7 0 – 1. 09 ) 9. 7% v s 11 .6 % 0. 85 (0 .6 9 – 1. 05 ) 4. 6% v s 5. 1% 0. 89 (0 .7 7 – 1. 01 ) -5. 6% v s 5. 4% 1. 04 (0 .8 6 – 1. 27 ) --10 .3 v s 11 .3 0. 91 (0 .7 4 – 1. 11 n on -fa ta l s tro ke h r (9 5% c i) 3. 2% v s 2. 6% 1. 24 (0 .9 2 – 1. 67 ) 7. 1% v s 8. 4% 0. 90 (0 .7 1 – 1. 15 ) 2. 7% v s 2. 7% 1. 01 (0 .8 4 – 1. 21 ) -2. 9% v s 2. 8% 1. 00 (0 .7 6 – 1. 32 ) -- -c a n va s : c an ag lifl oz in c ar di ov as cu la r a ss es sm en t s tu dy p ro gr am ; c r e d e n c e : c an ag lifl oz in a nd r en al e ve nt s in d ia be te s w ith e st ab lis he d n ep hr op at hy c lin ic al e va lu at io n; c v d : c ar di ov as cu la r di se as e; d a pa c k d : d ap ag lifl oz in in p at ie nt s w ith c hr on ic k id ne y di se as e; d e c la r e -t im i 5 8: d ap ag lifl oz in e ffe ct o n c ar di ov as cu la r e ve nt s– th ro m bo ly si s in m yo ca rd ia l i nf ar ct io n 58 ; e m pa r e g :, e m pa gl ifl oz in c ar di ov as cu la r o ut co m e e ve nt t ria l i n ty pe 2 d ia be te s m el lit us p at ie nt s– r em ov in g e xc es s g lu co se ; v e r ti s c v : c ar di ov as cu la r o ut co m es f ol lo w in g e rtu gl ifl oz in t re at m en t in t yp e 2 d ia be te s m el lit us p ar tic ip an ts w ith v as cu la r d is ea se ; eg fr : e st im at ed g lo m er ul ar fi ltr at io n ra te ; e s k d : e nd s ta ge k id ne y di se as e; h r : h az ar d r at io vol 54 • number 4 • october 2022 early recognition of type 2 diabetes complications and use of sglt2i 659 14 figure 3. effects of sodium glucose transporter 2 inhibitors. table 2. effect of sglt2 inhibitors on kidney outcomes. renal outcomes canvas declare-timi 58 credence vertis cv dapa ckd cana vs placebo dapa vs placebo cana vs placebo ertugliflozin vs placebo dapa vs placebo renal composite outcome description 40% reduction in egfr, renal replacement therapy or renal death ≥ 40% decrease in egfr to <60 ml/ min/1.73 m2, eskd, or death from renal cause doubling of serum creatinine, eskd, renal death death form renal causes, renal replacement therapy or doubling of serum creatinine level ≥ 50% decline in egfr, eskd, renal death renal composite outcome hr (95% ci) 5.5% vs 9.0% 0.60 (0.47 – 0.77) 1.5% vs 2.8% 0.53 (0.43 – 0.66) 43.2 vs 61.2 0.70 (0.59 – 0.82) 3.2% vs 3.9% 0.81 (0.63 – 1.04) 9.2% vs 14.5% 0.61 (0.51 – 0.72) canvas: canagliflozin cardiovascular assessment study program; credence: canagliflozin and renal events in diabetes with established nephropathy clinical evaluation; cvd: cardiovascular disease; dapa ckd: dapagliflozin in patients with chronic kidney disease; declare-timi 58: dapagliflozin effect on cardiovascular events–thrombolysis in myocardial infarction 58; empa-reg:, empagliflozin cardiovascular outcome event trial in type 2 diabetes mellitus patients–removing excess glucose; vertiscv: cardiovascular outcomes following ertugliflozin treatment in type 2 diabetes mellitus participants with vascular disease; egfr: estimated glomerular filtration rate; eskd: end stage kidney disease; hr: hazard ratio. according to their ejection fraction (ef), patients with t2dm may develop three distinct types i.e., hf with reduced ef (hfref), hf with mildly reduced ef (hfmref) and hf with preserved ef (hfpef).30 a meta-analysis including six large trials of >46,000 patients with t2dm reported that sglt2i was associated with a significant reduction of hhf (hr: 0.68; 95%ci: 0.61–0.76), benefits on the risk of hhf and its related outcomes are independent of baseline ascvd and prior hf.46 further, dapa hf trial41, determined the efficacy of dapagliflozin (10 mg/ day) in 4,744 patients with symptomatic hf and reduced ef (<40%). over a median follow-up of 18.2 months, the primary outcome (worsening hf or cardiovascular death) occurred in 16.3% in the dapagliflozin group vs. 21.2% in the placebo group. only 42% had significant t2dm. the magnitude of clinical benefits of dapagliflozin on the primary outcome was similar in patients with or without t2dm and with or without ischemic heart disease.41 the emperor reduced trial,47 evaluated the efficacy of empagliflozin (10mg/ day) against placebo or indicated therapy in 3730 patients with heart failure and 40% ef. the primary outcome occurred in 19.4% in the empagliflozin group with lowered number of hhf and 24% of the placebo group.47 these observations provide a strong basis for the guidelines and recommendations supporting the use of sglt2i. sglt2i and ckd despite efforts being made to achieve optimal glycemic and blood pressure control, patients with ckd still have a high risk of progressing to eskd, highlighting the need for additional renoprotective therapies to preserve the estimated glomerular filtration rate (egfr) and prevent eskd. the renoprotective effects of sglt2i were first demonstrated in declaretimi 58 trial7, and canvas study39, although the renal outcomes reported from these studies aida lydia acta med indones-indones j intern med 660 were the secondary outcome measures.7,38 in a meta-analysis of three cvots, sglt2i reduced the composite of worsening kidney function by 45% (0.55 [0.48–0.64]), with a similar effect in those with and without ascvd.38 as per european society of cardiology guidelines, treatment with an sglt2i is recommended at egfr of 30 <90 ml/min/1.73 m2.45 t h e c r e d e n c e t r i a l 3 9, e v a l u a t e d the renoprotective effects of canagliflozin in 4,401 patients with t2dm, ckd, and macroalbuminuria. patients with egfr>30 and <90 ml/min/1.73 m2 and urine albuminto-creatinine ratio (uacr) >300–5000 mg/g and all patients receiving renin–angiotensin system blockade were included. the primary outcome risk measure was a composite of eskd, doubling of the serum creatinine level, or renal or cardiovascular deaths which was reduced by 30% in the canagliflozin group relative to the placebo group. the canagliflozin group also reported a lower risk of cardiovascular death, myocardial infarction, or stroke.39 determination of uacr may help in early recognition of renal complications. a prespecified analysis of dapa-ckd trial,48 was conducted and the primary outcome was composite of sustained decline in egfr to at least 50%, eskd, kidney-related or cv-related death. 68% of patients had t2dm, of which 14% had ckd. the relative risk of primary and secondary outcome with dapagliflozin was consistent in a patient with t2dm, diabetic kidney disease, glomerulonephritis, and ischemic or hypertensive ckd, concluding that dapagliflozin reduces the risk of major adverse kidney and cv events and all-cause mortality in diabetic and non-diabetic ckd.48 indonesian perspective the aim in formulating this paper is to emphasise the existing diabetes burden in indonesia and measures that can be taken to curb its prevalence. diabetes related consequences are devastating, and it is vital to provide the indonesian medical experts perspective with regards to screening, diagnosis, and treatment. thus, timely screening and management of the disease is critical. the root of this article signifies that t2dm care necessitates multidimensional approach including cardiology, endocrinology, and nephrology, as it unfortunately leads to cardiorenal complications affecting the community at large. for policy makers to consider: the purpose is to focus on improving primary healthcare (phc) settings in terms of diabetes prevention, screening and early intervention. enabling these adjustments will help to reduce the ongoing table 3. recommendations for sglt2 inhibitors therapy. recommendations for sglt2i american diabetes association [50] type 2 diabetes patients with established ascvd or high risk established kidney disease, or heart failuresglt2i or glp 1 r agonist with demonstrated cvd benefit is recommended as part of the glucose lowering regimen independent of hba1c and in consideration of patient specific factors asian pacific society of nephrology (2020) [50] recommends sglt2i in adult patient with type 2 diabetes and egfr ≥ 30ml/min/1.73m2, who have cvd or diabetic kidney disease european society of cardiology (esc) and european association for the study of diabetes (2019) [45] empagliflozin, canagliflozin or dapagliflozin are recommended in patients with type 2 diabetes and cvd, or at very high/high cv risk to reduce cv events empagliflozin is recommended in t2dm and cvd patients to reduce risk of death sglt2i are recommended to lower risk of hospitalization for heart failure in t2dm patients sglt2i is recommended if egfr is 30 <90ml/min/1.73 m2 and is associated with lower risk of renal endpoints kidney disease improving global outcomes (2020) [51] recommends sglt2i in treating patients with t2dm, ckd and egfr ≥ 30ml/min/1.73m2 perkeni 2021[19] recommends sglt2i for t2dm patients with ascvd/ high risk, heart failure or ckd vol 54 • number 4 • october 2022 early recognition of type 2 diabetes complications and use of sglt2i 661 t2dm prevalence and its implementation may prove beneficial given the vast number of people that visit the phc. for doctors and patients: according to american diabetes association (ada), asymptomatic adults should be screened for prediabetes and type 2 diabetes using an informal assessment of risk factors. furthermore, annual monitoring of prediabetic patients is recommended. regardless of medication, urinary acr and egfr must be assessed atleast once a year in these patients. optimal timely referral to nephrologist allows instituting preventive and therapeutic measures designed to retard progression of kidney complications, preparing kidney replacement therapy and enhance the quality of life.49 patients should be referred for evaluation by a nephrologist if they have an egfr <30 ml/ min/1.73m2 or in the condition of uncertainty in determining etiology of kidney disease, difficult management issues, and rapidly progressing kidney disease. lastly, all the patients should receive general preventive self-care education.49 according to perkeni 2021 guidelines, patients should be referred to an endocrinologist, if they are found to have dm related chronic complications such as diabetic retinopathy/ nephropathy, symptoms of unstable angina, and unresolved hyperglycaemia, persisting even after treatment i.e., fbg > 130mg/dl, post prandial blood glucose >180mg/dl or hba1c >7% with ≥3 months of therapy. it is also recommended that patients should be educated about their disease condition with the help of educational materials as a part of prevention.19 conclusion early recognition of t2dm complications and its management with appropriate therapy is the need of the hour. in line of evidence, glycemic and extraglycemic effects of sglt2i have been thoroughly characterised. they have been found to be beneficial in controlling the hba1c levels in t2dm patients. according to the facts and literature, it can be stated that sglt2i are useful in providing primary and secondary prevention of cardiovascular and kidney-related complications in t2dm patients. dapagliflozin has shown benefit for both primary and secondary prevention, whereas empagliflozin have been proven to be effective in secondary prevention, however its role in primary prevention is yet to be established. therefore, it can be suggested that the early use of sglt2i will be effective in preventing and minimising the progression of cardiorenal complications. according to experts, a coordinated and multidisciplinary management of the patient with t2dm, with earlier implementation of guidelines and clinical recommendations, are the key factors for the comprehensive diabetic care and prevention. acknowledgments we are grateful to rajni bala for medical writing assistance. conflict of interest there is no conflict of interest funding this was funded by astrazeneca, indonesia. references 1. ogurtsova k, da rocha 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2020;383(15):1413–24. 48. wheeler dc, stefánsson b v, jongs n, et al. effects of dapagliflozin on major adverse kidney and cardiovascular events in patients with diabetic and non-diabetic chronic kidney disease: a prespecified analysis from the dapa-ckd trial. lancet diabetes endocrinol. 2021;9(1):22–31. 49. association ad. diabetes care in the hospital: standards of medical care in diabetes—2020. diabetes care. 2020;43(supplement 1):s193–202. 50. care d, suppl ss. pharmacologic approaches to glycemic treatment: standards of medical care in diabetes. 2021;44(january):111–24. 51. de boer ih, caramori ml, chan jcn, et al. kdigo 2020 clinical practice guideline for diabetes management in chronic kidney disease. kidney int. 2020;98(4):s1–115. 211acta med indones indones j intern med • vol 55 • number 2 • april 2023 case report hiv-associated progressive multifocal leukoencephalopathy: a case study elsayed abed1*, ahmed farag el-adawey1,mohamed hamed rashad1, ahmed essmat1, mohammed ali1, ahmed hassan elsheshiny1, abdel-ghaffar fayed1, fathy elbaz1, mahmoud galal ahmed1, zohreh abna2, shaimaa sayed khater3 1department of neurology, faculty of medicine, al-azhar university, cairo, 11651, egypt. 2ms fellowship, department of neurology, tehran university of medical sciences, tehran, iran. 3department of neurology, faculty of medicine, ain shams university, cairo, 11566, egypt. * corresponding author: elsayed abed, md. department of neurology, faculty of medicine, al-azhar university, cairo 11651, egypt. email: elsayedabed.226@azhar.edu.eg. abstract progressive multifocal leukoencephalopathy (pml) is a rare, life-threatening, infectious, lytic, demyelinating disease that results from reactivation of the virulent jc polyomavirus (jcv) “major opportunistic infection” in immunosuppressed individuals. we reported a case of a young girl who presented with new onset focal neurological defect, evaluated, and laboratory and radiological findings in the context of a clinical setting confirmed hiv-relatedpml infection. however, remyelination does not occur, the patients may develop complications in the long term including cognitive impairment, sensory deficits, motor deficits, and disturbances in balance. we must increase our knowledge about hivrelated pml in any patient with reduced immunity and who presented with new onset neurological defect. keywords: progressive multifocal, leukoencephalopathy, jc virus, demyelinating disease. introduction progressive multifocal leukoencephalopathy (pml) is a rare, life-threatening, infectious, lytic, demyelinating disease which affects glial cells in the white matter of the central nervous system.1,2 reactivation of the virulent jc polyomavirus (jcv) “major opportunistic infection” in immunosuppressed individuals with human immunodeficiency virus (hiv) infection, post solid organ and bone marrow transplant recipients, and malignancies causes pml disease.3,4 the only known clinical manifestation results from the reactivation of dormant jc virus is pml. although the cases associated with hiv account for about 85% of the cases that have been diagnosed with pml, the clinical entity of such presentation is to be suspected in patients who present with seizures, conscious level deterioration, and focal neurologic deficits.5 here, we reported a case of pml in an hivinfected patient. case illustration a 13-year-old girl with normal perinatal and developmental history was admitted to the emergency department with the sub-acute onset of weakness of her right lower limb and deviation of mouth to the left side for one week. there was no history of seizure, headache, fever, disturbed conscious level, other cranial elsayed abed acta med indones-indones j intern med 212 nerves involvement, disequilibrium, sensory affection, or bladder disturbances. her mother reported recurrent oral infection in the previous 6 weeks. she had a history of tonsillectomy at age of three years and left side hip surgery in her first year of life. the patient is right-handed without any history of medical importance. on examination, pulse was 75 beats/min, blood pressure was 110/70 mmhg and respiratory rate was 16/min. she was confused, limited verbal fluency, right lower motor facial nerve affection, right side hemiparesis (upper limb 4/5, and lower limb 3 /5), and extensor planter response bilaterally. the rest of the examination was normal. after admission, an urgent laboratory investigation was requested and showed normal blood pictures, electrolyte levels, blood gases, and biochemistry. cerebrospinal fluid (csf) analysis revealed normal biochemistry, cytology, culture, and sensitivity. csf analysis for the virology panel was negative as well as negative for cryptococcal infection. csf was also found negative for tubercular antigen by polymerase chain reaction. the patient started supportive treatment (intravenous fluid, vitamin), and brain imaging was requested. magnetic resonance imaging (mri) of the brain showed large confluent nonenhanced, infiltrative, ill-defined, subcortical, and cortical mass lesions, involving the left hemisphere, which crosses the midline to involve the right hemisphere via the splenium of the corpus callosum. hemorrhage figure 1. mri of the patient’s brain in the course of the disease shows large confluent non-enhanced, infiltrative, ill-defined, subcortical, and cortical mass lesions, involving the left hemisphere, which crosses the midline to involve the right hemisphere via the splenium of the corpus callosum. vol 55 • number 2 • april 2023 hiv-associated progressive multifocal leukoencephalopathy 213 or necrotic region is not detected. infection of the cns was suspected, and a blood sample for toxoplasmosis and virology screen was taken. elisa for hiv-1 was positive. the absolute cd4 count was 120/μl. the possibility of pml was increased and confirmed with positive polymerase chain reaction (pcr) for jc virus in csf. given the above clinical features and investigations, the patient was diagnosed to have hiv-related pml. the patient started highly active antiretroviral therapy (haart) with prophylaxis of opportunistic infections, but she died after 1 month. discussion the incidence of pml has increased significantly since the onset of the aids epidemic in 1981 and now hiv-associated cases account for up to 85% of all cases of pml. pml is a rare, life-threatening, demyelinating disease that affects the white matter of the central nervous system caused by the jc virus.1 jc virus is a dna virus of the polyomaviridae family that remains dormant in renal tubules and could be activated when the host developed any state of depressed immunity.6 in a reduced immunity state, reactivation of the latent form of jc virus to cause active disease needs rearrangement of gene sequences in the virus dna.7 the natural course of the disease is determined primarily by the cellular immune response of the host particularly the cytotoxic t lymphocytes. in the case of reduced immunity, there was intense perivascular infiltration of immune cells, hiv antigens, and viral proteins resulting in severe, lytic demyelination. however, csf has a major role in the clearance of the virus; we can depend on an elevated level of cytotoxic t lymphocytes in csf samples of patients with suspicion of active pml.8 pml should be considered in the differential diagnosis of any patient presented with a new onset neurological defect particularly when the cd4 count was less than 200. however, the most commonly involved sites include the subcortical white matter, periventricular areas, and cerebellar peduncles, the patients may manifest with variable presentation including cognitive decline, limb or gait ataxia, long tract affection, and aphasia.7,8 moreover, the presentation of pml could mimic different cns infections clinically; toxoplasma encephalitis, primary cns lymphoma (pcnl), hiv encephalopathy, and cmv encephalitis should be strongly considered in the differential diagnosis. radiologically, pml is asymmetric, well-demarcated, and non-contrast-enhancing lesion without a mass effect, whereas both toxoplasma and pcnl present as contrast-enhancing lesions.8 routine blood tests, infectious panel, and hiv pcr testing are indicated to identify the cause of the immunosuppressed state or any comorbid condition that led to the reactivation of the jc virus. the evaluation of abnormal neurological findings in immunosuppressed patients, such as those with aids, begins with contrastenhanced imaging with either ct or mri to reveal the presence of inflammatory change and mass effect, and could help to differentiate the pml from other mimics.9 the treatment for the complete cure of pml has not been found and is guided by the efforts made to boost the adaptive immune response of the patient.10 conclusion pml is a fatal, severe, progressive, multifocal, demyelinating disease. the main goal of current therapeutic approaches is directed at prolonging survival rates. however, remyelination does not occur, the patients may develop complications in the long term including cognitive impairment, sensory deficits, motor deficits, and disturbances in balance. we must increase our knowledge about hivrelated pml in any patient with reduced immunity and who presented with new onset neurological defect. ethics approval and consent to participate this study was conducted in concordance with declaration of helsinki and the participant signed a written informed consent before being enrolled in the study. the institutional review board (irb) approval was obtained from the ethical committee of faculty of medicine, al-azhar university, cairo. the ethical code is “near-med._71 hivassociated progressive multifocal leukoencephalopathy; a elsayed abed acta med indones-indones j intern med 214 case study._000071”. conflict of interests the authors declare that they have no competing interests. funding this study was self-funded by the authors. authors’ contributions all authors participated in manuscript writing and editing. all authors have read and approved the manuscript. acknowledgments the authors would like to express their gratitude to the department of neurology, tehran university of medical sciences, tehran, iran. references 1. major eo. progressive multifocal leukoencephalopathy in patients on immunomodulatory therapies. annual review of medicine. 2010;61:35-47. 2. wüthrich c, cheng ym, joseph jt, et al. frequent i n f e c t i o n o f c e r e b e l l a r g r a n u l e c e l l n e u r o n s by polyomavirus jc in progressive multifocal leukoencephalopathy. journal of neuropathology & experimental neurology. 2009;68(1):15-25. 3. mancall el. ricahrdson epjr. progressive multifocal l e u k o e n c e p h a l o p a t h y : h i t h e r t o u n r e c o g n i z e d complication of chronic lymphatic leukemia and hodgkins disease. brain. 1958;81:93-111. 4. koralnik ij. progressive multifocal leukoencephalopathy revisited: has the disease outgrown its name? annals of neurology. 2006;60(2):162-73. 5. choudhary s, parashar mk, parashar n, ratre s. aidsrelated progressive multifocal leukoencephalopathyreally rare in india: a case report and review of literature. indian journal of sexually transmitted diseases and aids. 2018;39(1):55. 6. jensen n, eugene o, major p. a classification scheme for human polyomavirus jcv variants based on the nucleotide sequence of the noncoding regulatory region. journal of neurovirology. 2001;7(4):280-7. 7. lima ma, marzocchetti a, autissier p, et al. frequency and phenotype of jc virus-specific cd8+ t lymphocytes in the peripheral blood of patients with progressive multifocal leukoencephalopathy. journal of virology. 2007;81(7):3361-8. 8. gildenberg pl, gathe jr, jc, kim jh. stereotactic biopsy of cerebral lesions in aids. clinical infectious diseases. 2000;30(3):491-9. 9. miller rf, hall-craggs ma, costa dc, et al. magnetic resonance imaging, thallium-201 spet scanning, and laboratory analyses for discrimination of cerebral lymphoma and toxoplasmosis in aids. sexually transmitted infections. 1998;74(4):258-64. 10. clifford db, nath a, cinque p, et al. a study of mefloquine treatment for progressive multifocal leukoencephalopathy: results and exploration of predictors of pml outcomes. journal of neurovirology,. 2013;19(4):351-8. 266 acta med indones indones j intern med • vol 54 • number 2 • april 2022 original article accuracy of bedside lung ultrasound in emergency (blue) protocol to diagnose the cause of acute respiratory distress syndrome (ards): a meta-analysis oke dimas asmara1*, ceva wicaksono pitoyo1, vally wulani2, kuntjoro harimurti3, abrianty p. araminta4 1 division of pulmonology, department of internal medicine, faculty of medicine university of indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 division of thoracic imaging, department of radiology, faculty of medicine university of indonesia, jakarta, indonesia. 3 division of geriatric, department of internal medicine, faculty of medicine university of indonesia cipto mangunkusumo hospital, jakarta, indonesia. 4 departement of internal medicine, faculty of medicine university of indonesia, jakarta, indonesia. * corresponding authors: oke dimas asmara, md. division of pulmonology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. salemba raya no. 6, jakarta pusat 10430, indonesia. email: okeasmara16@gmail.com. abstract background: there is a stigma that ultrasound cannot be used to see abnormalities in the air-filled organs makes ultrasound rarely used to identify lung abnormalities. this study purpose comparing diagnostic accuracy of blue protocol with gold standard for each diagnosis causing acute respiratory failure. methods: systematic search was done in 6 databases (pubmed/medline, embase, cochrane central, scopus, ebscohost/cinahl dan proquest) and multiple grey-literature sources for cross-sectional studies. we manually extracted the data from eligible studies and calculated pooled sensitivity, pooled specificity, likelihood ratio (lr) and diagnostic odds ratio (dor). we follow prisma (preferred reporting items for systematic reviews and meta-analyses) guideline throughout these processes. results: four studies has been picked from total 509 studies involved. the results yield parameters indicating blue protocol as a reliable modality to diagnose pneumonia with pooled sensitivity 84% (95% ci, 76-89%), pooled specificity 98% (95% ci, 93-99%), lr+ 42 (95% ci, 12-147), lr0.12 (95% ci, 0.07-0.2) and dor 252 (95% ci, 81-788), respectively. it also considerably applicable to diagnose pulmonary oedema with pooled sensitivity 89% (95% ci, 81-93%), pooled specificity 94% (95% ci, 89-96%), lr+ 14 (95% ci, 8-25), lr0.165 (95% ci, 0.11-0.24), and dor 116 (95% ci, 42-320), respectively. conclusion: blue protocol has good diagnostic accuracy to diagnose pneumonia and pulmonary oedema. we recommend implementing blue protocol as a tool in evaluating cause of arf. keywords: ultrasonography, blue protocol, accuracy, respiratory failure, meta-analysis vol 54 • number 2 • april 2022 accuracy of bedside lung ultrasound in emergency (blue) protocol 267 introduction dyspnea is a common symptom and is an important sign of acute respiratory failure (arf). this condition is a life-threatening situation and it is not uncommon for patients with arf to require intensive oxygen therapy such as a mechanical ventilator. the case of arf continues to increase every year with a mortality rate reaching 37%. determining the cause of respiratory failure is an important step in the management of arf.1-3 the blue (bedside lung ultrasound in emergency) protocol is an ultrasound examination algorithm of the lung to assist in searching for the diagnosis of various lung disorders by combining various artefacts.4-9 the accuracy of the blue protocol reaches 90.5% with a duration of approximately 3 minutes, so this protocol very suitable for use in patients with arf. however, the stigma that ultrasound cannot be used to see abnormalities in the airfilled organs makes ultrasound rarely used to identify lung abnormalities.9-10 through this meta-analysis, the authors are going to assess several previous studies regarding the accuracy of the blue protocol in diagnosing pulmonary disorders. with prompt and precise diagnosis, appropriate management for the patient can also be achieved. this study aims to determine the accuracy of the blue protocol in diagnosing the causes of arf. methods search strategy a comprehensive search was carried out from six online databases namely pubmed/ medline, embase, cochrane central, scopus, ebscohost/cinahl, and proquest on 6-13 september 2020 . the search is performed with a combination of keywords based on mesh and text word combined with the boolean operator. the keywords used come from the population and index test components of the research questions that have been formulated. the keyword used from the population component is acute respiratory failure with its synonym and examples of the diagnosis of the cause of respiratory failure. the keyword used in the index test component is the blue protocol or bedside lung ultrasound in emergency. a manual search for grey-literature was carried out at various sources on september 7, 2020. the search was carried out on several portals, namely the garuda portal (indonesia ministry of research and technology portal), proquest (focus on thesis results, dissertations, scientific posters, or proceeding books), abstracts from the scientific book jakarta international chest and critical care internal medicine (jiccim) in the last 5 years, snowballing method, the repository of the library of the university of indonesia and the national library as well as the global index medicus (gim). study selection inclusion criteria are diagnostic studies with a cross-sectional design, study subject age > 18 years, and comparing the diagnostic ability of the blue protocol with the gold standard. no language or year limits were applied. exclusion criteria were studies that didn’t include data to calculate overall accuracy. the assessment of risk of bias and study quality was carried out by apa dan cwp. if there are differences of opinion regarding the selection criteria of an article, it will be resolved through consensus and reviewed by kh. the authors use the covidence® software to assist in the selection stages of articles in this meta-analysis. ethics approval and consent to participate prospero systematic review registry number: crd42020203208. blue protocol method bedside lung ultrasound examination was introduced by dr. lichtenstein in 1989 to monitor critically ill patients in icu setting. it has been widely used for detecting many lung disorders such as pleural effusion, pulmonary oedema, pneumothorax, pneumonia, and pulmonary embolism. he formulized the lung ultrasound findings into one framework called blue protocol and become one of the most important parts of point of care ultrasound (pocus). in blue protocol, patients were positioned in semi recumbent or supine position. scans were done longitudinally and evaluated based on artefacts finding on some certain anatomical landmarks. the normal oke dimas asmara acta med indones-indones j intern med 268 lung is characterized by normal a or b line with lung sliding. blue protocol also evaluate the presence of alveolar consolidation and/ or pleural effusion.10 details of the blue protocol’s component is shown in figure 1. data extraction and quality assessment data extraction was carried out independently by two researchers. basic characteristics data such as name of the principal investigator, type of study, place/country, year of publication, basic demographic characteristics of study subjects, population eligibility, eligibility of the gold standard used, sample size, characteristics of the ultrasound device, the characteristics of the ultrasound operator, duration of lung ultrasound, blinding, and comparison of outcomes from selected studies will be displayed in the form of a descriptive table. the output is written in a 2x2 table form and is displayed in terms of sensitivity and specificity. the performance of the blue protocol is displayed in the form of a receiver operating characteristic (roc) curve. assessment of the quality and risk of bias of selected studies was carried out using the quality assessment of diagnostic accuracy study 2 (quadas 2). data synthesis and statistical analysis statistical analysis on this meta-analysis was performed using revman software version 5.4 (cochrane collaboration, the nordic cochrane center, copenhagen) and stata 14. the results of data analysis are presented in the form of a forrest plot if meta-analysis can be done. heterogeneity assessed using i2 or x2 test with result of i2 <25%, 26-50%, and >50% reflecting low or insignificant, moderate, and significant heterogeneity, respectively. fixed-effect model was chosen for insignificant heterogeneity, otherwise random-effect model was used. the expected results are in the form of accuracy, sensitivity, and specificity along with the confidence interval, likelihood ratio, diagnostic odds ratio, and the area under the roc curve. the analysis was carried out in the form of an accumulation of all diagnoses and then continued with the analysis of each diagnosis. 483 studies identified through database searching 26 additional studies identified through other sources (grey-literature) 312 studies after duplicates removed 312 studies screened by title and abstract 210 studies excluded 98 studies excluded, with reasons: 46 wrong study design 22 wrong index test/intervention 10 wrong outcome 10 wrong population n = 1 wrong reference test 9 data were incomplete 102 full-text studies assessed for eligibility 5 studies included in qualitative synthesis 4 studies included in quantitative synthesis id e n ti fi c a ti o n s c re e n in g e li g ib il it y in c lu s io n figure 1. preferred reporting items for systematic reviews and meta-analyses (prisma) flow diagram for study selection vol 54 • number 2 • april 2022 accuracy of bedside lung ultrasound in emergency (blue) protocol 269 results literature search based on the systematic search carried out, a total of 509 articles were obtained and after adjusting for the eligibility criteria only 4 studies could be continued for the meta-analysis process (figure 1). study characteristics in general, these studies classified as homogenous because most of the important characteristics were almost the same such as population eligibility, the unit site of the study, blue protocol implementation, ultrasound device/specification, gold standard used, and the presented output (table 1 and 2). the unit/site used for lichtenstein, neto, and danish study is the icu whereas patel and bekgoz study takes place at the er. the icu and er has almost the same characteristics, both taking care patient with breathing problem which life-threatening cases and require immediate care. from the origin of the country of the study, the findings from this meta-analysis could represent various types of major populations in the world.11-14 the population eligibility used by the five studies is almost the same which is patients with breathing problem and admitted into the criteria of breathing failure with indication intensive care. patel’s research used population age above 12 years which is different from the other four studies which used adult population. the author had sent email correspondence on requisition for research data by patel et al. however, to the date of this report is finished, the author had not received any reply therefore the author excluded patel et al. research in both qualitative and quantitative synthesis. however, the author tried to include patel et al research in sensitivity analysis to see if its exclusion from this research would produce significant output relative to the findings of this meta-analysis. the total samples used in the 4 studies is 770 patients. there is a difference in the ultrasound operator which performs the blue protocol. in the lichtenstein, bekgoz, and danish studies, they used certified ultrasound operators with 2 years minimum experience on lung ultrasound. neto et al used ultrasound operators who had received 5 hours theoretical training and performed 10 times lung ultrasound under supervision. the probes used in the five studies have similar characteristics, they are the probes with low frequency (curvilinear and microconvex) which frequency range 2-6 mhz. low-frequency probes is the best option for lung ultrasound because it has broader and deeper exploration area than high-frequency probes.11-14. assessment of risk of bias two reviewers (o.d.a and a.p.a) evaluate the methodological quality of included studies according to quality assessment of diagnostic accuracy studies 2 (quadas-2) criteria. the assessment shown in figure 2. any discrepancies found would be resolved by consultation with the third expert reviewer (k.h). data synthesis and analysis the results of t he included studies can be seen in table 3. from all of the studies, it was found that the sensitivity of the blue protocol in diagnosing pneumonia was in the range of 83% to 97% with the combined sensitivity calculation being 84% (95% ci 76-89%). whereas the specificity of the blue protocol in diagnosing pneumonia was in the range of 86% to 100% with the combined specificity calculation was 98% (95% ci 93-99%). forest plot for pneumonia can be seen in figure 3 and summary receiving operating characteristic (sroc) curve can be seen in figure 4. the combined result of lr + is 42 (95% ci 12-147) and and lr0.12 (95% ci 0.07–0.2) respectively with dor of 252 (95% ci 81–788). in diagnosing pulmonary edema, the sensitivity of the blue protocol was found to be in the range of 76% to 94% with a combined sensitivity calculation of 89% (95% ci, 8193%). meanwhile, the specificity of the blue protocol in diagnosing pneumonia is in the range of 90% to 100% with the calculation of the combined sensitivity is 94% (95% ci, 89-96%). the combined results for lr+ were 14 (95% ci, 8-25) and lr0.165 (95% ci, 0.11-0.24), respectively, with a dor number of 116 (95% ci, 42-320). forest plot for pulmonary edema can be seen in figure 5 and summary receiving operating characteristic (sroc) curve can be seen in figure 6. oke dimas asmara acta med indones-indones j intern med 270 ta bl e 1. s tu dy c ha ra ct er is tic s. s tu dy ye ar c ou nt ry u ni t s tu dy d es ig n n um be r of p at ie nt s in cl us io n c ri te ri a m ea n a ge u ltr as ou nd o pe ra to r u ltr as ou nd d ev ic e n um be r of a re a b lin de d li ch te ns te in et a l11 20 08 fr an ce ic u c ro ss se ct io na l 26 0 ad ul t p at ie nt s w ith a cu te re sp ira to ry fa ilu re 68 in ve st ig at or s (s ev er al y ea rs o f e xp er ie nc e) m ic ro co nv ex pr ob e 5m h z (h ita ch i-4 05 ; h ita ch i m ed ic al ; to ky o, j ap an ) 6 po in ts n o, in ve st ig at or s w er e no t bl in de d to th e pa tie nt ’s c lin ic al pr es en ta tio n n et o et a l12 20 15 b ra zi l ic u c ro ss se ct io na l 37 ag e ≥ 18 y ea rs a nd ad m is si on to th e ic u fo r a r f, d efi ne d by o ne o f th e fo llo w in g: a re sp ira to ry ra te ≥ 3 0 br ea th s/ m in ; a p ao 2 ≤ 60 m m h g; a n ox yg en s at ur at io n on ro om ai r ≤ 9 0% , a s m ea su re d by pu ls e ox im et ry ; o r a c ar bo n di ox id e te ns io n (p c o 2) ≥ 45 m m h g w ith a n ar te ria l ph ≤ 7 .3 5 73 .2 n ew ly tr ai ne d op er at or s (a tte nd in g 5 ho ur s of th eo re tic al tr ai ni ng a nd p er fo rm in g 10 su pe rv is ed l u s e xa m in at io ns ) c ur vi lin ie r p ro be 35 m h z (t os hi ba to sb ee ; t os hi ba , to ky o, j ap an ) 6 po in ts ye s p at el e t a l15 20 18 in di a e r c ro ss se ct io na l 50 p at ie nt s ha vi ng a ge > 12 ye ar s, p at ie nt s an d/ or re la tiv es g iv in g in fo rm ed co ns en t, p at ie nt s of ac ut e re sp ira to ry d is tre ss re qu iri ng ic u ad m is si on w er e in cl ud ed . 59 .6 4 u ltr as ou nd w as p er fo rm ed in e m er ge nc y de pa rtm en t b y sa m e em er ge nc y ph ys ic ia n c ur vi lin ie r ( 25 m h z) a nd l in ea r pr ob e (5 -1 0 m h z) , m ic ro m ax ul tra so un d sy st em , s on os ite 6 po in ts n o b ek go z et al 13 20 19 tu rk ey e r c ro ss se ct io na l 38 3 a ll co ns ec ut iv e pa tie nt s ag ed > 18 y ea rs a dm itt ed to th e e d w ith a p rim ar y co m pl ai nt o f a cu te dy sp ne a an d w ho co ns en te d to p ar ic ip at e 65 .5 lu s w as c on du ct ed b y 5 e d p hy si ci an s w ho ha d be en p re vi ou sl y ce rti fie d by b as ic a nd ad va nc ed u s e du ca tio n an d ha d at le as t 2 ye ar s of e d a nd u s e xp er ie nc e. t he se e d p hy si ci an s w er e al so in fo rm ed b y 2 h of th eo re tic al le ct ur es re ga rd in g lu s a nd th e b lu e p ro to co l. th ey a ls o pe rfo rm ed 1 0 su pe rv is ed l u s e xa m in at io ns a cc or di ng to th e b lu e p ro to co l m ic ro co nv ex pr ob e 26 m h z (f uj ifi lm f az on e c b , j ap an ) 4 po in ts ye s d an is h et al 14 20 19 in di a ic u c ro ss se ct io na l 90 a du lt pa tie nt s ad m itt ed to m ed ic al -s ur gi c al ic u w ho h ad e vi de nc e of lu ng pa th ol og y as d em on st ra te d by a n ac ut e lu ng in ju ry (a li ) s co re o f ≥ 1 47 .6 6 th e in te ns iv is t p er fo rm in g lu s h ad > 2 ye ar s of e xp er ie nc e in p er fo rm in g lu s c ur vi lin ie r p ro be (2 -5 m h z) s on os ite m -tu rb o (f uj ifi lm s on os ite in c. , b ot he ll, w a , u s a ) 3 po in ts ye s vol 54 • number 2 • april 2022 accuracy of bedside lung ultrasound in emergency (blue) protocol 271 ta bl e 2 . g ol d s ta nd ar ds u se d in in cl ud ed s tu di es . li ch te ns te in e t a l11 n et o et a l12 p at el e t a l15 b ek go z et a l13 d an is h et a l14 p ne um on ia in fe ct io us p ro fil e, ra di ol og ic as ym m et ry , m ic ro or ga ni sm is ol at ed (b lo od , i nv as iv e te st s) , r ec ov er y w ith an tib io tic s. in cl ud ed w er e in fe ct io us , a sp ira tio n, co m m un ity , o r h os pi ta lac qu ire d pn eu m on ia . p ne um on ia c om pl ic at in g ch ro ni c re sp ira to ry d is ea se w as c la ss ifi ed a s pn eu m on ia n ot s ta te d in fe ct io us p ro fil e, ra di ol og ic as ym m et ry , m ic ro or ga ni sm is ol at ed (b lo od ), re co ve ry w ith a nt ib io tic s in fe ct io n fin di ng s, c he st x -r ay s, m ic ro or ga ni sm is ol at io n (if p os si bl e) , c t (if n ec es sa ry ) n ot s ta te d p ul m on ar y e de m a e va lu at io n of c ar di ac fu nc tio n us in g ec ho ca rd io gr ap hy , fu nc tio na l t es ts , a nd a m er ic an h ea rt a ss oc ia tio n re co m m en da tio ns n ot s ta te d c he st ra di og ra ph y, e va lu at io n of c ar di ac fu nc tio n us in g ec ho ca rd io gr ap hy , r es po nd in g to di ur et ic s el ec tro ca rd io gr ap hy , c ar di ac b io m ar ke rs ec ho ca rd io gr ap hy (b y a ca rd io lo gi st ) n ot s ta te d p ne um ot ho ra x r ad io gr ap hy (c t if ne ce ss ar y) c he st ra di og ra ph y (c t if ne ce ss ar y) c he st x -r ay s an d c t (if n ec es sa ry ) n ot s ta te d p ul m on ar y e m bo lis m h el ic al c t h el ic al c t th or ax c t an gi og ra ph y a st hm a/ c o p d a st hm a (h is to ry , r es po nd s to b ro nc ho di la to r t re at m en t) c o p d (c on di tio n de fin ed as e xa ce rb at io n of c hr on ic re sp ira to ry d is ea se w ith ou t pn eu m on ia , p ne um ot ho ra x, pu lm on ar y ed em a, p le ur is y, o r pu lm on ar y em bo lis m . c o p d w as c on fir m ed b y fu nc tio na l te st s. ) n ot s ta te d h is to ry , r es po nd s to b ro nc ho di la to r tre at m en t, ch es t r ad io gr ap hy , a nd c o p d w as c on fir m ed b y fu nc tio na l te st s h is to ry , r es pi ra to ry fu nc tio na l t es ts , a nd re sp on se s to b ro nc ho di la to r t re at m en t fo r a ll pa tie nt s h is to ry , c lin ic al e xa m in at io n, ra di og ra ph y re ad b y ra di ol og is ts , c t w he n av ai la bl e, fa vo ra bl e cl in ic al pr og re ss io n un de r t re at m en t th e fin al d ia gn os is o f t he ep is od e of a r f m ad e by th e ic u te am b ef or e pa tie nt s w er e di sc ha rg ed fr om th e ic u w as c on si de re d th e go ld s ta nd ar d fo r a ll pa tie nt s: h is to ry , c lin ic al ex am in at io n, b as ic b lo od te st s an d sp ec ifi c bl oo d in ve st ig at io ns (a rte ria l bl oo d ga s an al ys is , d -d im er ), el ec tro ca rd io gr ap hy , r ad io gr ap hy re po rti ng b y ra di ol og is ts , c t as ne ed ed , f av or ab le c lin ic al p ro gr es si on un de r t re at m en t w as fo llo w ed a lo ng w ith th e fin al c lin ic al d ia gn os is w as m ad e by a tte nd in g em er ge nc y ph ys ic ia ns (fo r 2 15 e d p at ie nt s be fo re d is ch ar ge fro m th e e d ), at te nd in g co ns ul ta nt ph ys ic ia ns (f or 1 26 h os pi ta liz ed p at ie nt s be fo re d is ch ar ge fr om th e ho sp ita l), a nd an ic u te am (f or 4 6 ic u p at ie nt s be fo re di sc ha rg e fro m th e ic u ) t ho ra x c t sc an oke dimas asmara acta med indones-indones j intern med 272 table 3. results of included studies lichtenstein et.al11 neto et.al12 patel et.al15 bekgoz et.al13 danish et.al14 sn (%) sp (%) sn (%) sp (%) sn (%) sp (%) sn (%) sp (%) sn (%) sp (%) pneumonia 89 94 88 90 94.11 93.93 82 98 75.9 100 pulmonary edema 97 95 85 87 92.3 100 87 97 83.3 88.5 pneumothorax 88 100 80 100 85 100 88.9 100 pulmonary embolism 81 100 100 100 46.2 100 asthma/ copd 89 97 67 100 85.17 88.88 96 75 table 4. the grading of recommendations assessment, development and evaluation (grade ) of each outcome16 grade recommendations for blue protocol accuracy by each outcomes grade domain pneumonia (4 crosssectional studies) pulmonary edema (4 cross-sectional studies) pneumothorax (3 crosssectional studies) pulmonary emboly (2 cross-sectional studies) asthma/copd (3 crosssectional studies) risk of bias none none none none none inconsistency none none none serious (-1) serious (-1) indirectness none none none none none imprecision none none serious (-1) serious (-1) serious (-1) publication bias none none serious (-1) serious (-1) serious (-1) certainty of evidence results sensitivity 84% 89% 71-89% 46-81% 50-98% specificity 98% 94% 100% 99-100% 69-100% high certainty (we are very confident that the true effect lies close to that of the estimate of the effect) moderate certainty (we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different) low certainty (our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect) very low certainty (we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect vol 54 • number 2 • april 2022 accuracy of bedside lung ultrasound in emergency (blue) protocol 273 fig 3. forest plot and diagnostic accuracy of blue protocol for pneumonia figure 2. quality of assessment of included studies by quadas-2 tool. figure 3. forest plot and diagnostic accuracy of blue protocol for pneumonia. oke dimas asmara acta med indones-indones j intern med 274 figure 4. summary receiving operating characteristic curve of blue protocol for pneumonia figure 5. forest plot and diagnostic accuracy of blue protocol for pulmonary edema vol 54 • number 2 • april 2022 accuracy of bedside lung ultrasound in emergency (blue) protocol 275 fig 6. summary receiving operating characteristic curve of blue protocol for pulmonary edema figure 6. summary receiving operating characteristic curve of blue protocol for pulmonary edema figure 7. forest plot and diagnostic accuracy of blue protocol for pneumothorax, pulmonary emboly, asthma/ copd oke dimas asmara acta med indones-indones j intern med 276 figure 8. area under curve (auc) blue protocol for a) pneumonia b). subgroup analysis: ultrasound operator c) subgroup analysis: number of ultrasound zone. vol 54 • number 2 • april 2022 accuracy of bedside lung ultrasound in emergency (blue) protocol 277 figure 9. area under curve (auc) blue protocol for a) pulmonary edema b) subgrup analysis: ultrasound operator c) subgroup analysis: number of ultrasound zone. oke dimas asmara acta med indones-indones j intern med 278 b’ profile pneumonia present a profileb profile pulmonary edema any a/b or c profile pneumonia lung sliding abolished a lines plus lung point without lung point venous analysis free veinsthrombosed vein pulmonary embolism stage 3 copd or asthma plaps pneumonia no plaps figure 10. blue protocol alghoritm not all studies have examined every diagnosis used by lichtenstein as the original author of the blue protocol. the sensitivity and specificity ranges of the blue protocol in pneumothorax are 71-89% and 50-98%, in pulmonary emboli it ranges from 46-81% and 100%, and in asthma/copd ranges from 5098% and 69-100%, respectively. forest plot for pneumothorax, pulmonary emboli, and asthma/ copd can be seen in figure 7. discussion several meta-analyses on the roles of lung ultrasound for diagnosing lung abnormalities had been conducted by previous researchers. the author recorded that there are at least 4 meta-analysis with lung ultrasound topics in diagnosing pneumonia. the main difference of this meta-analysis with previous study is in the population. this study enrolled all patients with breathing problems whereas the previous 4 metaanalysis studies specifically enrolled population suspected with pneumonia. during the search process, the authors found 14 original studies that discussed the accuracy of blue protocol but among them, there were 9 studies in the form of gray-literature that could not be included in the analysis because there was no complete text. another limitation is that there are studies that did not include findings of pleural effusions. the discovery of a pleural effusion may guide the diagnosis of pulmonary disorders.32-35 in addition, the intervention/index test used by those metaanalysis studies were not standardized, whereas this study specified the assessment on the accuracy of the blue protocol. however, the vol 54 • number 2 • april 2022 accuracy of bedside lung ultrasound in emergency (blue) protocol 279 accuracy of this 4 meta-analyses are nearly even with current study. the range of sensitivity and specificity of the lung ultrasound in pneumonia diagnosis by meta-analysis conducted by chavez et al. is 80-95%, ye et al., long et.al, llamasalvarez et al. is 70-96%, consecutively.7, 15-17 three of five studies analyzed by this study included the operator who didn’t know the patient’s clinical and still produce good accuracy because the ultrasound output is objective. ultrasound accuracy might be better if it is adjusted with patient’s clinical examination data. history taking and physical examination is mandatory and irreplaceable. lung ultrasound is complimentary of history taking and physical examination to enhance the physician’s diagnosis probability. a study in italy by peris et al. shows that lung ultrasound could reduce the need for thorax x-ray imaging by 26% and thorax ct scan by 47%.1, 28-31. we use grade (grading of recommendations, assessment, development and evaluations) approach to summarize our recommendations. summary of this approach for this meta-analysis is shown in table 4.36 in sensitivity analysis calculation, the author included patel et al. study and compared it to the analysis results without patel et al. the author analyzed the accuracy of pneumonia diagnosis using the 5 studies in total and obtained the aggregate sensitivity 85% (95%ci 78-90%), specificity 97% (95%ci 93-99%), lr positive 34 (95%ci 12-94%), lr negative 0.15 (95%ci 0.1-0.23%) and the dor 222 (95%ci 89-554%). these findings is not much different with the findings of the 4 studies which qualified the inclusion criteria presented in this paper.14 the sensitivity of the blue protocol for pulmonary emboli and asthma/copd has varied range from 46% to 98%. this inconsistent result might be caused by the blue protocol algorithm to diagnose lung emboli and asthma/ copd which is based on exclusion criteria and it needs to be confirmed with emboli findings in extremity’s vein. performing ultrasound on the extremity’s vein requires a skilled operator and longer ultrasound procedure. from the date, the author did not recommend lung ultrasound to screen asthma/copd or lung emboli, but if emboli was found in the vein extremities and no lung image abnormality in any case this might lead to emboli diagnosis. this is also found in pneumothorax cases which image shows the loss of lung sliding and the presence of lung point and barcode sign which is specifically found in pneumothorax.18-20 the ultrasound area used in the five studies is almost the same except in the study by danish et al. and bekgoz et al. lichtenstein et al., neto et al., and patel et al., in performing lung ultrasound at 6 points of each hemithorax, therefore, resulted 12 examined points in total. danish et al. performed lung ultrasound at 3 points of each hemithorax and the total is 6 points and bekgoz et al. performed it at 4 points and the total is 8 points of all lung areas. this variability might explain the lower sensitivity value of pneumonia and lung edema in the research by danish et al. and bekgoz et al. when compared to other researches. lung edema yield better auc value in 6 points examination of each hemithorax (figure 8 and 9). this is slightly different on pneumonia which shows that the lung ultrasound at 6 locations did not any better than 3 or 4 locations.11-15 the four studies also show that the lung ultrasound can be performed within the first 20 minutes when the patient is admitted to the intensive unit or emergency unit without any necessary interruption to the standard procedure because the duration of the examination is brief and performed beside the patient’s bed. lichtenstein et al. and bekgoz et al. only need less than 3-5 minutes, sequentially to complete the blue protocol. the lung ultrasound can be performed while other medic or paramedic doing other procedures. for any patient who needs advanced breathing support, lung ultrasound can also be performed right after the procedure without having to remove the patient to radiology unit.21-23 operator bias tends to be found in ultrasound examination. subgroup analysis with operator competence as a variable showed an experienced and certified operator yield better accuracy than newly trained operators, in both groups. however, the accuracy level of newly trained operators is considerably good in both groups. the operator in neto et al. research is a rookie doctor in lung ultrasound who received 5 hours blue oke dimas asmara acta med indones-indones j intern med 280 protocol theoretical training and performed 10 lung ultrasounds under supervision. the research shows sensitivity 85-88% and specificity 87-90% to detect lung edema and pneumonia. certain shows that the blue protocol can be learned in relatively short time by any doctor who possesses basic knowledge of ultrasound. it is feasible for any on-duty doctor in intensive or emergency unit to be trained with blue protocol to help them manage patients with acute breathing problem (figure 8 and 9). the study to assess the time needed training duration could be the subject for future research.24-27 conclusion in conclusion, the blue protocol has high sensitivity and specificity in diagnosing pneumonia and pulmonary edema. these high diagnostic accuracy values came from a good quality study based on the grade approach. the blue protocol has high specificity in diagnose pneumothorax and pulmonary embolism but with varying sensitivity. this accuracy assessment comes from a poor-quality study based on the grade approach. abbreviation blue bedside lung ultrasound in emergency arf acute respiratory failure lr likelihood ratio dor diagnostic odds ratio prisma preferred reporting items for systematic reviews and meta analyses jiccim jakarta international chest and critical care internal medicine gim global index medicus roc receiver operating characteristic quadas 2 q u a l i t y a s s e s s m e n t o f diagnostic accuracy study 2 icu intensive care unit er emergency room sroc summary receiving operating characteristic copd chronic obstructive pulmonary disease auc area under curve grade grading of recommendations, assessment, development and evaluations competing interests the authors declare that there is no competing interest. funding this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. authors’ contributions oda is the chief principle of the study and also the coordinator of the study. oda, cwp, vw conceived the idea and developed the theory and design of the study. kh help to finalize the study conception and design, verified the analytical method and supervised the analytical calculation oda and apa carried out the data collection and analyze the result. cwp and vw review the data collection and gave revision regarding interpretation of the data. oda, apa and kh made draft manuscript preparation.all authors reviewed the results and approved the final version of the manuscript. acknowledgments the authors would like to extend our sincere thanks to all the staff of internal medicine residency program, department of internal medicine faculty of medicine univesity of indonesia and other supporting parties for helping us finishing the study. it would not have been possible without their support. references 1. peris a, tutino l, zagli g, et al. the use of point-ofcare bedside lung ultrasound significantly reduces the number of radiographs and computed tomography scans in critically ill patients. anesth analg 2010;111. 2. zanobetti m, scorpiniti m, gigli c, et al. point-of-care ultrasonography for evaluation of acute dyspnea in the ed. chest. 2017;151. 3. cochi se, kempker ja, annangi s, et al. mortality trends of acute respiratory distress syndrome in the united states from 1999 to 2013. ann am thorac soc. 2016;13. vol 54 • number 2 • april 2022 accuracy of bedside lung ultrasound in emergency (blue) protocol 281 4. lichtenstein da. lung ultrasound in critically ill. ann intensive care. 2014;30. 5. leidi a, rouyer f, marti c, et al. point of care ultrasonography from the emergency department to the internal medicine ward: current trends and perspectives. intern emerg med. 2020;15. 6. silva s, biendel c, ruiz j, et al. usefulness of cardiothoracic chest ultrasound in the management of acute respiratory failure in critical care practice. chest. 2013;144. 7. chavez ma, shams n, ellington le, et al. lung ultrasound for the diagnosis of pneumonia in adults: a systematic review and meta-analysis. respir res. 2014;15. 8. volpicelli g, elbarbary m, blaivas m, et al. international evidence-based recommendations for point-of-care lung ultrasound. intensive care med. 2012;38. 9. vignon p, repessé x, vieillard-baron a, et al. critical care ultrasonography in acute respiratory failure. crit care. 2016;20. 10. lichtenstein d. lung ultrasound in acute respiratory failure an introduction to the blue-protocol. minerva anestesiol. 2009;75. 11. lichtenstein da, mezière ga. relevance of lung ultrasound in the diagnosis of acute respiratory failure the blue protocol. chest. 2008;134. 12. dexheimer neto fl, andrade jms de, raupp act, et al. diagnostic accuracy of the bedside lung ultrasound in emergency protocol for the diagnosis of acute respiratory failure in spontaneously breathing patients. j bras pneumol. 2015;41. 13. bekgoz b, kilicaslan i, bildik f, et al. blue protocol ultrasonography in emergency department patients presenting with acute dyspnea. am j emerg med. 2019;37. 14. danish m, agarwal a, goyal p, et al. diagnostic performance of 6-point lung ultrasound in icu patients: a comparison with chest x-ray and ct thorax. turkish j anaesthesiol reanim. 2019;47. 15. patel cj, bhatt hb, parikh sn, et al. bedside lung ultrasound in emergency protocol as a diagnostic tool in patients of acute respiratory distress presenting to emergency department. j emergencies trauma shock. 2018;11. 16. ye x, xiao h, chen b, et al. accuracy of lung ultrasonography versus chest radiography for the diagnosis of adult community-acquired pneumonia: review of the literature and meta-analysis. plos one. 2015;10. 17. long l, zhao h-t, zhang z-y, et al. lung ultrasound for the diagnosis of pneumonia in adults. med. 2017;96. 18. llamas-álvarez am, tenza-lozano em, latour-pérez j. accuracy of lung ultrasonography in the diagnosis of pneumonia in adults: systematic review and metaanalysis. chest. 2017;151. 19. cibinel ga, casoli g, elia f, et al. diagnostic accuracy and reproducibility of pleural and lung ultrasound in discriminating cardiogenic causes of acute dyspnea in the emergency department. intern emerg med. 2012;7. 20. lichtenstein d. novel approaches to ultrasonography of the lung and pleural space: where are we now?. breathe. 2017;13. 21. narendra dk, hess dr, sessler cn, et al. update in management of severe hypoxemic respiratory failure. chest. 2017;152. 22. xirouchaki n, kondili e, prinianakis g, et al. impact of lung ultrasound on clinical decision making in critically ill patients. intensive care med. 2014;40. 23. seyedhosseini j, bashizadeh-fakhar g, farzaneh s, et al. the impact of the blue protocol ultrasonography on the time taken to treat acute respiratory distress in the ed. am j emerg med. 2017;35. 24. seif d, perera p, mailhot t, et al. bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol. crit care res pract. 2012;2012. 25. lichtenstein da. blue-protocol and fallsprotocol: two applications of lung ultrasound in the critically ill. chest. 2015;147. 26. staub lj, mazzali biscaro rr, kaszubowski e, et al. lung ultrasound for the emergency diagnosis of pneumonia, acute heart failure, and exacerbations of chronic obstructive pulmonary disease/asthma in adults: a systematic review and meta-analysis. j emerg med. 2019;56. 27. wooten wm, shaffer let, hamilton la. bedside ultrasound versus chest radiography for detection of pulmonary edema: a prospective cohort study. j ultrasound med. 2019;38. 28. al deeb m, barbic s, featherstone r, et al. pointof-care ultrasonography for the diagnosis of acute cardiogenic pulmonary edema in patients presenting with acute dyspnea: a systematic review and metaanalysis. acad emerg med. 2014;21. 29. abdalla w, elgendy m, abdelaziz aa, et al. lung ultrasound versus chest radiography for the diagnosis of pneumothorax in critically ill patients: a prospective, single-blind study. saudi j anaesth. 2016;10. 30. lichtenstein da, mezière ga, lagoueyte jf, et al. a-lines and b-lines: lung ultrasound as a bedside tool for predicting pulmonary artery occlusion pressure in the critically ill. chest. 2009;136. 31. huang d, ma h, xiao z, et al. diagnostic value of cardiopulmonary ultrasound in elderly patients with acute respiratory distress syndrome. bmc pulm med. 2018;18. 32. ranieri vm, rubenfeld gd, thompson bt, et al. acute respiratory distress syndrome: the berlin definition. jama j am med assoc. 2012;307. 33. soldati g, demi m, demi l. ultrasound patterns of pulmonary edema. ann transl med. 2019;7. 34. saraogi a. lung ultrasound: present and future. lung oke dimas asmara acta med indones-indones j intern med 282 india. 2015;32. 35. prosen g, klemen p, strnad m, et al. combination of lung ultrasound (a comet-tail sign) and n-terminal probrain natriuretic peptide in differentiating acute heart failure from chronic obstructive pulmonary disease and asthma as cause of acute dyspnea in prehospital emergency setting. crit care. 2011;15. 36. schünemann hj, mustafa r, brozek j, et al. grade guidelines: 16. grade evidence to decision frameworks for tests in clinical practice and public health. j clin epidemiol. 2016;76. 95acta med indones indones j intern med • vol 55 • number 1 • january 2023 case report paraganglioma in the urinary bladder: a pitfall in histopathologic diagnosis jamie lim co,* maria lourdes luna goco, jeffrey santos so department of pathology, st. luke’s medical center – global city, taguig city, philippines. * corresponding author: jamie lim co, md. department of pathology, st. luke’s medical center – global city. 5th avenue, taguig, 1634, metro manila, philippines. email: bluecojamie8293@gmail.com. abstract paraganglioma of the urinary bladder is a rare neuroendocrine tumor which originates from the chromaffin tissue of the sympathetic nervous system. it only accounts for about 0.05% of all vesical tumors. bladder paraganglioma may also present with non-specific symptoms which could easily lead to misdiagnosis. in this report, emphasis on the histomorphology and immunohistochemical profile of the tumor is stressed as the morphological findings could overlap with relatively more common urothelial neoplasms. distinction from other tumors is of utter importance because of different therapeutic options. here, we present a case of a 52 year-old, filipino, male, previously diagnosed with colonic tubulovillous adenoma, presenting with dysuria and hematuria who, after undergoing ct stonogram revealed an incidental finding of a lobulated mass measuring 5.7 cm located at the anteroinferior portion of the urinary bladder wall. keywords: paraganglioma, pitfall, urinary bladder, diagnosis. introduction paraganglioma of the bladder, also called an extra-adrenal pheochromocytoma, originates from the chromaffin tissues of the sympathetic nervous system located in the detrusor muscle of the urinary bladder.1-3 the first case was reported by zimmerman in 1953.2 of the 10% of the extra-adrenal paragangliomas’, 10% are localized within the bladder which accounts for only 0.05 % of all bladder tumors.1 being a rare entity, it has a propensity to be misdiagnosed because of 1) its frequent involvement of the muscularis propia1,4-6 2) its non-specific symptoms which also occur in other tumors3-6 3) its morphology and immunohistochemistry that can mimic other tumors5,7, and 4) its rare occurrence in the bladder.1,3-6 case illustration a 52-year-old, filipino man, presented with a 7-month history of intermittent dysuria and hematuria. he had no other irritative lower urinary tract symptoms. the patient had no history of headache, palpitations, and dizziness. his medical history consisted of a history of hypertension and colonic tubulovillous adenoma diagnosed last 2018. there was no significant family history of similar disease. physical examination was unremarkable and vital signs were stable. a noncontrast axial 256-multislice ct stonogram was done which revealed an intravesical, slightly irregular to lobulated mildly hyperdense mass approximately measuring 4.7x4.4x5.7 cm. this is located at the anteroinferior portion of the urinary bladder wall, near the neck. cystoscopy revealed a large, irregularly shaped mass located at the jamie lim co acta med indones-indones j intern med 96 left anterolateral wall of the bladder and adjacent to the bladder neck. transurethral resection of the bladder tumor was subsequently done. his intraand post-operative course remained uneventful. the specimen was then submitted to the histopathology department. description of the gross specimen consisted of several cream-tan to brown-tan, irregular soft tissue fragments with an aggregate measurement of 2.0 x 2.0 x 0.7 cm. the entire specimen was submitted for processing. microscopic evaluation showed nests of oval to polygonal cells underlying an unremarkable urothelium. these cells are arranged in nested, zellballen pattern, separated by prominent fibrovascular stroma. these cells also have abundant granular, clear to amphophilic cytoplasm, uniform round to oval nuclei with regular nuclear contour. mitosis was inconspicuous and no necrosis was seen. (figure 1 and figure 2). histological differential diagnosis at this time were urothelial carcinoma, colorectal c a r c i n o m a , m a l i g n a n t m e l a n o m a , a n d paraganglioma. immunohistochemistry showed tumor cells to be positive for chromogranin, synaptophysin, and gata-3 (figure 3 to figure 5). figure 1 figure 2 figure 1. low magnification of the urinary bladder paraganglioma. 2 figure 3 figure 4 figure 5 (figure 5) high magnification of positive nuclear staining for gata-3. the tumor cells are negative for ck, ck20, cdx2, melan-a, beta-catenin, and satb2. given the morphology of the tumor and the immunohistochemical profile, a diagnosis of paraganglioma was rendered. figure 3. high magnification of positive cytoplasmic staining for chromogranin. figure 2. high magnification of the urinary bladder paraganglioma. figure 4. high magnification of positive cytoplasmic staining for synaptophysin. figure 1 figure 2 2 figure 3 figure 4 figure 5 (figure 5) high magnification of positive nuclear staining for gata-3. the tumor cells are negative for ck, ck20, cdx2, melan-a, beta-catenin, and satb2. given the morphology of the tumor and the immunohistochemical profile, a diagnosis of paraganglioma was rendered. vol 55 • number 1 • january 2023 paraganglioma in the urinary bladder 97 the tumor cells are negative for ck, ck20, cdx2, melan-a, beta-catenin, and satb2. given the morphology of the tumor and the immunohistochemical profile, a diagnosis of paraganglioma was rendered. two months after the initial procedure, the patient was admitted for a partial cystectomy. consent and clearance were secured and on the 2nd hospital day, the patient underwent the planned procedure. intraoperative finding revealed a 4.0 x 4.0 cm pedunculated tumor extruding from the left posterolateral bladder diverticulum. specimen was then submitted to the pathology department for histopathologic processing. the patient’s postoperative course was uneventful and he was then later discharged on the 6th hospital day. description of the gross specimen consisted of a tan brown to orange tan, pedunculated, firm tissue measuring 6.0 x 5.8 x 3.5 cm. cut sections show a fairly circumscribed, pink tan, soft to solid mass measuring 5.5x3x2.7 cm. representative sections were taken. microscopic evaluation showed cells showing the same histomorphology as those seen in the previous biopsy specimen. these tumor cells extend from the urothelium and eventually involve the muscularis propria (detrusor muscle). (figure 6 and figure 7) the case was signed out as paraganglioma with the tumor involving the muscularis propria (detrusor muscle) and focally extending to the urothelium. discussion about 98% of the paragangliomas are located in the abdomen, 90% of these are in the adrenal figure 6 figure 7 figure 5. high magnification of positive nuclear staining for gata-3. figure 6. low magnification of the bladder paraganglioma focally extending to the urothelium. figure 7. low magnification of the bladder paraganglioma located within the muscularis propria. jamie lim co acta med indones-indones j intern med 98 medulla and 10% of them in extra-adrenal sites.3,8 paragangliomas can occur in patients of any age, with a mean age at 43.3 years old.1 although more common in females1,9, there are studies that show that paraganglioma can also occur in males. as shown by four studies where males are affected with ages ranging from 39 to 78-yearsold, two of which are japanese.4,10-12 in a study done in japan last 2020, it was found out that both males and females are equally affected. out of 162 patients diagnosed with the tumor, 50% consisted of males.11 molecular studies of said tumor show frequent losses at 1p, 3q, and 22q and germline mutations in sdha and sdhb genes.1 paraganglioma occurs in any part of the bladder wall but has a predilection for the detrusor muscle with the most common locations being the dome and trigone of the bladder.1 the tumor can be functional (catecholamine secreting) or non-functional.1,13 clinical symptoms are related to catecholamine release. these include hypertension, headache, blurred vision, intermittent gross hematuria, and hypertensive crisis during micturition.1,4 only a minority presented with catecholamineassociated symptoms accounting to about only 13% of the total cases.4,5 while most of the cases presented with nonspecific symptoms such as painless hematuria or no symptoms at all.4,5,15 laboratory findings show elevated urine and serum catecholamine levels.13 imaging findings are important for the diagnosis as it assesses the shape, size, and location of the tumor14 which shows the bladder paraganglioma as a well-defined, solid, ovoid vascular mass located within the urinary bladder wall.13 according to p. humphrey, et al (2016), the tumor usually consists of a well circumscribed, exophytic lesion with an average size of 3.9 cm but tumor size can increase to up to of 9 cm. on histomorphology, the majority of cases consist of the cells arranged in nests, called zellballen pattern, while the remaining 20% are arranged in a diffuse pattern. they are separated by vascular network or fibrous septa.1,15 these cells are large and polygonal with abundant clear, granular, amphophilic or acidophilic cytoplasm and uniform round to ovoid nuclei. mitosis, focal hemorrhage, and necrosis are rare.1,4,16 the tumor cells can be seen located within the muscle bundles of the muscularis propria (detrusor muscle) with absence of desmoplasia.1,4,5 paragangliomas can be confirmed with positive immunostaining for neuroendocrine markers such as chromogranin and synaptophysin1,4,9, with a majority also staining for gata31,7, and s100 in sustentacular cells.1 they are negative for epithelial markers.1,4,9 because of the frequent involvement of the muscularis propria and positive staining for gata-3, a misdiagnosis of urothelial carcinoma can be given.1,4,5,7 records of fifteen patients diagnosed with paraganglioma of the urinary bladder were reviewed back in 2004. twelve of which were transurethral resection specimens while the remaining three were partial cystectomies. tumors showing nested, zellballen pattern consisted of 12 out of the 15 cases while diffuse growth pattern were seen in the remaining 3 cases. ten cases showed the tumor nests located between the muscularis propria. eleven of these cases were misdiagnosed as urothelial carcinoma and the remaining four were diagnosed as bladder tumor.5 in our case, the senior author’s previous experience as well as his paper on paragangliomas, helped in including is a differential diagnosis. as well as not readily diagnosing this as a urothelial neoplasm. urothelial carcinoma is the most common malignant neoplasm of the urinary tract with higher pathologic staging indicating the presence of muscularis propria invasion.1majority (6790%) of the tumor cells express gata3 and cytokeratin markers.1 on histomorphology, urothelial carcinoma may exhibit a nesting pattern which could mimic the nesting, zellballen pattern of the paraganglioma. however, cytologic atypia of urothelial carcinoma is usually more pronounced and there are no vascular networks surrounding the tumor cells. the tumor nests invading the muscularis propria should also exhibit a desmoplastic response.5 malignant melanoma is a neoplasm of melanocytic origin.1 as of 2021, there are only a total of 40 cases of malignant melanoma of the bladder17 reported whereas compared to paraganglioma of the urinary bladder, wherein vol 55 • number 1 • january 2023 paraganglioma in the urinary bladder 99 there were already a total of 69 reported cases just from the year 2010 to 2021 alone.18 extracutaneous melanoma is rare and consists of only 4-5% of all diagnosed melanoma with primary malignant melanoma only accounting for less than 0.2% of all melanomas.19,20 classic microscopic feature consists of large epithelioid or spindle cells containing melanin pigments. melanoma cells show positivity for s100, hmb45, and melan a.1 based from the rarity of the cases as well as the histomorphology and immunohistochemical profile of the index case, we favor a diagnosis of a paraganglioma rather than a malignant melanoma. for metastatic tumors of the bladder, majority originates from the colorectum1 with the genitourinary tract infiltrated by 3-10% of the total cases of advanced colorectal tumors.21-24 tumors that originate from this location expresses ck20, satb2, and cdx2.1,9,25 due to the presence of apc or ctnnb1 mutation, the tumor also exhibits nuclear expression of β-catenin.9 histomorphology and immunohistochemical findings of the index case does not support these findings. however, due to the patient’s aforementioned history of colonic tubulovillous adenoma, a colorectal lesion was still ruled out via immunohistochemistry. surgical resection is the common treatment modality for bladder paraganglioma.10,15,18 this includes: (1) transurethral resection of the bladder tumor (turbt) (2) partial cystectomy and (3) total cystectomy.15,18 transurethral resection of the bladder tumor (turbt) is the treatment of choice for non-functional, non-invasive lesion measuring less than 3 cm in size while partial cystectomy is done when the tumors extend into the deep layers of the detrusor muscles. the last option consists of a total cystectomy if the lesion is too large that preservation of the bladder could not be considered or if there is metastasis to the lymph nodes. long term follow up with annual measurement of catecholamine is recommended because of the increase chance of recurrence and metastasis.10,15,18 conclusion although this tumor is rare, having its own histologic and immunohistochemical features should prompt the pathologists to include it in their differential diagnosis. however, misidentification of the tumor still occurs because of its rare entity, as well as its histological features mimicking other more common urothelial neoplasms. identification and accurate diagnosis necessitate complete knowledge of the morphological, histochemical, and molecular features of this tumor in order to better differentiate it from other neoplasms. acknowledgments and affiliations we have no conflicts of interest to disclose. all authors declare that they have no conflicts of interest. references 1. humphrey p, ulbright t, reuter v, moch h. neuroendocrine tumours. who classification of tumours of the urinary system and male genital organs. essay, international agency for research on cancer. 2016. 2. z i m m e r m a n i j , b i r o n r e , m a c m a h o n h e . pheochromocytoma of the urinary bladder. new england journal of medicine. 1953;249(1):25–6. doi:10.1056/nejm195307022490106 3. ghafoor au, yousaf i, pervez r, khan ru, mir k. paraganglioma of urinary bladder: an unusual presentation. pitfalls in diagnosis and treatment. j pak med assoc. 2012;62(1):63-5. 4. saha a, saha k, sarkar n, geelani ia. paraganglioma of urinary bladder: an uncommon entity in uropathology. cureus. 2021;13(8):e17265. https://doi.org/10.7759/ cureus.17265 5. zhou m, epstein ji, young rh. paraganglioma of the urinary bladder. am j surg pathol. 2004;28(1):94–100. https://doi.org/10.1097/00000478-200401000-00011. 6. male m, ye t, tao j, chen z-qiang, peng e. differentiating nonfunctional paraganglioma of the bladder from urothelial carcinoma of the bladder: pitfalls and breakthroughs. biomed research international, 2019;1–7. https://doi.org/10.1155/2019/1097149 7. so js, epstein ji. gata3 expression in paragangliomas: a pitfall potentially leading to misdiagnosis of urothelial carcinoma. mod pathol. 2013;26(10):136570. doi: 10.1038/modpathol.2013.76. epub 2013 apr 19. pmid: 23599157. 8. manger wm, gifford rw. diagnosis in clinical and experimental pheochromocytoma. cambridge: black well science; 1996:205-332. 9. goldblum jr, lamps lw, mckenney jk, myers jl, ackerman lv, rosai j. rosai and ackerman’s surgical pathology. 2018. 10. a l z a h r a n i a a . r e c u r r e n t u r i n a r y b l a d d e r jamie lim co acta med indones-indones j intern med 100 paraganglioma. advances in urology. 2010:912125. https://doi.org/10.1155/2010/912125. 11. kurose h, ueda k, uegaki m, et al. paraganglioma of the urinary bladder: case report and literature review. iju case reports. 2020;3(5):192–5. https:// doi.org/10.1002/iju5.12185. 12. i w a m o t o g , k a w a h a r a t, ta n a b e m , e t a l . paraganglioma in the bladder: a case report. journal of medical case reports. 2017;11(1):306. https://doi. org/10.1186/s13256-017-1473-2 13. loveys fw, pushpanathan c, jackman s. urinary bladder paraganglioma. radio graphics. 2015;35(5): 1433–8. https://doi.org/10.1148/rg.2015140303. 14. li h, xie j, chen z, yang s, lai y. diagnosis and treatment of a rare tumor-bladder paraganglioma. molecular and clinical oncology. 2020;13:40. https:// doi.org/10.3892/mco.2020.2110 15. priyadarshi v, pal dk. paraganglioma of urinary bladder. urology annals. 2015;7(3):402–4. https://doi. org/10.4103/0974-7796.152058. 16. kumar v, abbas ak, aster jc. robbins and cotran pathologic basis of disease. ninth edition. philadelphia, pa: elsevier/saunders; 2015. 17. bejrananda t, sawasdee a, boonchai s, tanthanuch m. primary malignant melanoma of the bladder: a rare case report in asia and review of the literature. res rep urol. 2021;13:833-9. https://doi.org/10.2147/ rru.s345322. 18. yuan y, su z, zhu r, li x, xu g. bladder paraganglioma: three cases report and literature review. international medical case reports journal. 2021;14:765–71. https://doi.org/10.2147/imcrj. s336659. 19. snajdar e, ajo ar, rosen k, et al. primary malignant melanoma of the urinary bladder. cureus. 2021;13(3): e14067. https://doi.org/10.7759/cureus.14067. 20. karabulut yy, erdogan s, sayar h, ergen a, ertoy baydar d. primary malignant melanoma of the urinary bladder: clinical, morphological, and molecular analysis of five cases. melanoma res. 2016;26(6):61624. doi: 10.1097/cmr.0000000000000300. pmid: 27603550. 21. nerli rb, ghagane sc, ram p, shimikore ss, vinchurkar k, hiremath mb. bladder invasion in patients with advanced colorectal carcinoma. indian journal of surgical oncology. 2018;9(4):547–51. https://doi.org/10.1007/s13193-018-0788-9. 22. eldar s, kemeny mm, terz jj. extended resections for carcinoma of the colon and rectum. surg gynecol obstet. 1985;161(4):319–22. 23. kobayashi t, kamoto t, sugino y, takeuchi h, habuchi t, ogawa o. high incidence of urinary bladder involvement in carcinomas of the sigmoid and rectum: a retrospective review of 580 patients with colorectal carcinoma. j surg oncol. 2003;84(4):209–14. 24. carne pwg, frye jnr, kennedy-smith a, et al. local invasion of the bladder with colorectal cancers: surgical management and patterns of local recurrence. dis colon rectum. 2004;47(1):44–7. 25. m a g n u s s o n k , d e wi t m , b r e n n a n d j , e t al. satb2 in combination with cytokeratin 20 identifies over 95% of all colorectal carcinomas. am j surg pathol. 2011;35(7):937-48. doi: 10.1097/ pas.0b013e31821c3dae. pmid: 21677534. clinical practice 76 acta medica indonesiana the indonesian journal of internal medicine bone metastases and bone loss medical treatment in prostate cancer patients ferry safriadi department of urology, faculty of medicine, padjajaran university hasan sadikin hospital. jl. pasteur no 38 bandung, indonesia. correspondence email: safriadif@yahoo.com. abstrak kanker prostat adalah keganasan di bidang urologi yang paling sering bermetastasis ke tulang sampai 70% kasus. penyulitnya berupa nyeri hebat, fraktur patologis, sindroma kompresi tulang belakang dan hiperkalsemia. insidensi penyulit ini sekitar 46,1%, yang mengakibatkan peningkatan biaya perawatan dan memperburuk prognosis pasien. androgen deprivation therapy merupakan terapi baku kanker prostat yang telah bermetastasis. terapi ini sendiri menyebabkan osteopenia atau osteoporosis. bifosfonat merupakan obat yang paling banyak dipakai saat ini untuk terapi metastasis tulang. bifosfonat menghambat secara langsung aktifitas osteoclast dan secara tidak langsung melalui osteoblast. denosumab merupakan opsi terapi terkini pada kasus metastasis tulang dengan efikasi yang lebih baik dari asam zoledronat. efek samping denosumab sebanding dengan penggunaan bifosfonat. kata kunci: kanker prostat, metastasis tulang, bone loss, terapi. abstract prostate cancer is a malignancy in urology with the highest incidence metastasize to the bone up to 70%. the incidence of skeletal related event (sre) by 46.1% such as severe pain, pathologic fractures, spinal compression syndrome and hypercalcemia, with a consequence of higher inpatient care and worsen the patient’s prognosis. androgen deprivation therapy (adt) as a metastatic prostate cancer treatment itself causes an osteopenia or osteoporosis. bisphosphonate inhibits normal and pathologic osteoclast-mediated bone resorption by several mechanisms. denosumab is the latest treatment option in bone metastases. multi-study shows the efficacy of denosumab is better than zoledronic acid for sre prevention. adverse events between denosumab and bisphosphonate are comparable. key words: prostate cancer, bone metastases, bone loss, treatment. introduction prostate cancer is diagnosed in more than 670 000 men yearly worldwide.1.2 in the united states, an estimated 217,730 new casesin 2010, it is 28% of all cancer incidences in men.3 in developed countries, the majority of prostate cancers are found at an early stage as much as 75%, even in the u.s. by 95%. indonesian society of urologic oncology (isuo) data shows during the period 2006-2010 there wasstage 4; 490 patients (50.5%) of 971 prostate cancer patients.4 in hasan sadikin hospital in the period 2004-2010 found 57% of cases are still organ confined and locally advanced, the remaining 43% of 320 cases were advanced stage cases. fifteen percent of patients suffering from pathological fractures. prostate cancer is a malignancy in urology is the largest cause of bone metastases 65vol 45 • number 1 • january 2013 bone metastases and bone loss medical treatment on prostate cancer patients 77 75% compared to the other malignancy.5,6 complications of bone metastases=skeletal related events (sre) causes immobilization of the patient due to severe pain, pathological fractures, spinal compression syndrome and hypercalcemia.5 sre incidence about 46% in prostate cancer patientswho affects the cost of patient care and worsening prognosis. androgen deprivation therapy (adt) as the standard therapy of advanced prostate cancer caused health costs to be doubled compared without adt. adt itself, on the other hand, causes bone loss.7 this process can be termed as a cancer treatment-induced bone loss (ctibl).8 f r o m a n o t h e r s t u d y, o s t e o p e n i a w a s found in 27% of normal men and 37% in the prostate cancer patients before adt.9 after treatment with adt, whether it be orchiectomy, gonadotropinrealising hormone (gnrh) with or without antiandrogen was causing the rapid decline of bone mineral density (bmd) of approximately 4% -13% yearly.9,10 the purpose of this paper is to review the drugs used to prevent or reduce bone loss from prostate cancer metastases and adt induced bone loss. physiology and pathophysiology of bone metastases b m d i n m i d d l e l i f e w i l l d e c r e a s e approximately 0.5-1% per year.10 risk factors for osteoporosis are: hypogonadism, family history of osteoporosis, vitamin d deficiency, low calcium diet, smoking, excessive alcohol and long-term steroid use.11,12 normal bone remodeling occurs continuously regarding the shape and bone repair, which is influenced by osteclast and osteoblast.5 osteoclast and osteoblasts communicate via local paracrine factors are: receptor activator of nuclear factor κb (rank) and progenitorcell. rank receptor (rank ligand/rankl) produced by osteoblasts and progenitor cell has a central role in the communication process. rankl and rank bonding induces preosteoclast maturation to beosteoclast, which end result of bone resorption and release growth factors such as transforming growth factor β1 (tgfβ1). fibroblasts growth factor (fgf), platelet degradation growth factor (pdgf) and insulinlike growth factor (igf) stimulate the formation osteoblast.8,13 in order for bone formation and resorption remain in the balance of osteoblasts and stromal cells also produce osteoprotegerin (opg ) which serves as a diversion against the rankl receptor, so the bond does not occur rankl to rank and induction of osteoclast for apoptosis (figure 1).8 figure 1. normal bone cycle, adapted from miller k7 estrogen and androgen help to maintain bone balance. estrogen plays a role in bone remodeling by inhibiting osteoclast. androgens reduce bone resorption through aromatization of testosterone to estrogen. adt disrupts the hormonal balance which bone need.9 cancer cells metastasize through the blood or lymph will stick to the endothelial-specific bone marrow and migrate through the gaps between cells within 24 hours. cytokines are found in the bone matrix is chemoattractant for prostate cancer cells.6 factors such as bone morphogenic bone protein-4 (bmp-4) increases tumor cell adhesion to bone marrow endothelium. adhesion and extravasation of cancer cells may also be facilitated by protease-activated receptor 1 (par1). with the activation of par1, cancer cells will secrete matrix metalloproteinase (mmp). mmp causes basement membrane damage and facilitates the expansion of bone tissue invasion.6 when the process of osteolysis progresses, growth factors in the matrix such as tgfβ, igf2 is released, and causes activated osteoblasts in the area. prostate cancer cells secrete bmps, prostate specific antigen (psa), parathyroid-related hormone (pthrp) and the protease urokinase which have mitogenic effect on osteoblast (figure 2).6 psa involved in the case of predominantly osteoblastic. in addition, psa will hydrolyze igf-binding proteins that allow igf-1 to stimulate osteoblast proliferation.6 ferry safriadi acta med indones-indones j intern med 78 and osteoporosis less than -2.5.9 changes in bone density can also be measured by markers of bone metabolism. the process of formation and bone resorption can be detected from serum or urine. these markers can also be used to predict the occurrence of sre, monitoring therapeutic efficacy and prognosis. the marker can see a new bone formation such as alkaline phosphatase, osteocalcin and amino-terminal procollagen propeptides of type 1 collagen (pinp)16 or see the excess bone resorptionsuch as: n-telopeptide of type 1 collagen (ntx)12, cross-linked n-terminal telopeptides of type 1 collagen (ctx), carboxyterminal pyridinoline cross-linked telopeptide of type 1 collagen (1ctp)17 and rank. the national osteoporosis foundation (nof) recommends fracture risk assessment with the onlinewho/frax® tool (http://www.shef. ac.uk/frax/).18 treatment of bone loss calcium supplement of 1200-1500 mg/day in divided doses and vitamin d 400-800 iu/day prevents osteoporosis.12,19 estrogen administration can increase bone density and reduce the risk of fractures. oral administration increases the risk for thromboembolism; intravenous administration is recommended. another option is to use an estradiol patch, obtained from the study will be an increase of 3.6% bone density in the spine and 2.1% at the femoral neck. side effects of estrogen are:gynecodinia 71% and gynecomastia 58%.12 selective estrogen receptor modulators (serms)such as raloxifene and toremifene also protect bone resorption by binding to the estrogen receptor on osteoclast and osteoblast.19 this drug will increase bone density of about 1%. figure 2. vicious cycle of tumor growth; adapted from saad f6 adt induced bone loss a d t c a u s e s t e s t o s t e r o n e d e f i c i e n c y secondary to impaired balance due to normal bone formation and resorption resulting in increased bone resorption.9,10 bone loss of a lumbar spine about 4.6%, femoral neck 3.9%, hip 9.6%, radius 4.5% in the provision of a first year of adt.6,9 the relative risk of fracture associated with an increased dose and duration of adt administration.12 in general, the relative risk due to administration of gnrh agonist 1.21, pelvic bone fractures1.76 and spinal 1.18 compared without adts.14 morote et al. study showed that the increase in the occurrence of bone loss occurs mainly in the first year of adt administration. therefore, repeated bmd measurement should be done by the end of first-year.10,11 bone density measurement the modality that can be used to measure bone density is dual x-ray absorptiometry (dxa = densitometry) and quantitative ct-scan. however, the most often used is dxa.9,15 dxa was chosen because it can be done quickly and the x-ray dose that is lower than conventional x-rays.12 who classification considered normal bmd if t score of -1 or more, osteopenia -1 to 2.5 risk factors for fracture: adt prior fracture assess bmd: dxa t-score -2.5 (osteoporosis) < t-score -1.0 to -2.5 (osteoporosis) t-score -2.5 (osteoporosis) > ensure adequate calcium and vitamin d intake treatment of osteoporosis to prevent further fracture: biphosphonates repeat bmd after 6 to 12 months repeat bmd after 2 years figure 3. clinical algorithm for assesment and treatment of adt associated bone loss9 vol 45 • number 1 • january 2013 bone metastases and bone loss medical treatment on prostate cancer patients 79 the use of nonsteroidal antiandrogen bicalutamide 150 mg per day as a single-agent increase bmd 2.5%, it is inversely proportional to the use of luteinizing hormone-releasing hormone (lhrh) was -5.4%.20 bicalutamide is a competitive inhibitor, inhibit binding of dihydrotestosterone to androgen receptor.12 bisphosphonates is one of the most widely used today in the treatment of osteoporosis. bisphosphonates inhibits bone resorption mediated osteolaclast, so will prevent bone loss and high bone turnover. bisphosphonates effect is influenced by carbon chain r1, which having a high ability to bind calcium. carbon chains have been potential of antiresoptive.13 r2 chain modification by the addition of nitrogen would provide a stronger effect as in the zoledronic acid. zoledronic acid is more potent than clodronate 100x and etidronate1000x.13 zoledronic acid will improve the effect of tumor cell growth inhibition and cell's apoptosis with through caspase pathway.21 it also has the effect of reducing the pain caused by bone metastasis. bisphosphonates per-oral is influenced by food and coffee, and therefore, better administered intravenously. side effects of bisphosphonates such as: flu-like symptoms, acute renal failure (when given rapidly iv) and fracture of the jaw. fracture of the jaw due to bisphosphonate administration predisposesby the presence of dental problems, steroids use and trauma.8,9 denosumab is a human monoclonal antibody (igg2) developed to specifically target rank ligand; this is a new option in cases of bone metastases.22,23 it mimics the effect of endogenous opg, so denosumab will prevent the bond between rankl and its receptor (figure 4), resulting in a decrease in osteoclast activity and bone turnover.22-25 denosumab use was associated with increasedbone mineral density at multiple skeletal sitesin women receiving aromataseinhibitor therapyfor breast cancer. research shows that the denosumab better than zoledronic acid in preventing the occurrence of sre.26the adverse events of denosumab were comparable to bisphosphonate.22 conclusion skeletal complications are a major cause of morbidity formen with metastatic prostate cancer. zoledronic acidand denosumab decrease the risk of skeletal complications in men with androgenindependent prostate cancer and bone metastases. the reduction in risk of skeletal complications must be weighed against potential treatmentrelated adverse effects. references 1. mottet n, schalken ja, heidenreich a, et al. highlights on prostate cancer from urological and oncological congresses in 2007. eur urol suppl. 2008;7:460-73. 2. boyle p, severi g, giles gg. the epidemiology of prostate cancer. urol clin n am. 2003;30:209-17. 3. palvolgyi r, daskivich tj, chamle k, kwan l, litwin ms. bone scan overuse in staging of prostate cancer: an analysis of a veterans affairs cohort. urology. 2011, inpress. 4. indonesian society of urologic oncology (isuo) meeting. 2011. unpublished data. 5. rajubendra n, bolton d, lawrentschuk n. diagnosis of bone metastases in urological malignancies-an update. urology. 2010;76:789-90. 6. saad f, clarke n, colombel m. natural history and treatment of bone complications in prostate cancer. eur urol. 2006;49:429-40. 7. kupski tl, foley ka, baser o, long s, macarios d, litwin ms. health care cost associated with prostate cancer, androgen deprivation therapy and bone complications. j urol. 2007;178:1423-8. 8. miller k, stenzl a, tombal b. advances in the therapy of prostate cancer-induced bone disease: current insights and future perspectives on the rank/rankl pathways. eur urol. 2009;suppl 8:747-52. 9. eastham ja. bone health in men receiving androgen deprivation therapy for prostate cancer. j urol. 2007;177:17-24. 10. saad f, adachi jd, brown jp, et al. cancer treatmentinduced bone loss in breast and prostate cancer. j clin oncol. 2008;26:5465-76. figure 4. inhibition of osteoclast-mediated bone resorption by a rank ligand inhibitor25 ferry safriadi acta med indones-indones j intern med 80 11. morote j, orsola a, abascal jm, et al. bone mineral density changes in patients with prostate cancer during the first 2 years of androgen suppression. j urol. 2006;175:1679-83. 12. srinivas s, colocci n. bone related events in high risk prostate cancer. j urol. 2006;176:s50-4. 13. michaelson md, smith mr. biphosphonates for treatment and prevention of bone metastases. j clin oncol. 2005;23:8219-24. 14. smith mr, boyce sp, moyneur e, duh ms, raut mk, brandman j. risk of clinical fractures after gonadotropin-releasing hormone agonist therapy for prostate cancer. j urol. 2006;175:136-9. 15. higano cs. management of bone loss in men with prostate cancer. j urol. 2003;170:s56-s64. 16. jung k, miller k, wirthm, albrecht m, lein m. bone turnover markers as predictors of mortality risk in prostate cancer patients with bone metastases following treatment with zoledronic acid. eur urol. 2011;59:60412. 17. kamiya n, suzuki h, yano m, et al. implications of serum bone turnover markers in prostate cancer patients with bone metastasis. urology. 2010;75:1446-51. 18. saylor pj, kaufman ds, michaelson md, lee rj, smith mr. application of a fracture risk algorithm to men treated with androgen deprivation therapy for prostate cancer. j urol. 2010;183:2200-5. 19. israeli rs, ryan cw, jung ll. managing bone loss in men with locally advanced prostate cancer receiving androgen deprivation therapy. j urol. 2008;414-23. 20. smth mr, goode m, zietman al, mcgovern fj, lee h, finkelstein js. bicalutamide monotherapy versus leuprolide monotherapy for prostate cancer: effect on bone mineral density and body composition. j clin oncol. 2004;22:2546-53. 21. dumon jc, journe f, kheddoumi n, lagneaux l, body jj. cytostatic and apoptotic effects of biphosphonates on prostate cancer cells. eur urol. 2004;45:521-9. 22. fizazi k, bosserman l, gao g, skacel t, markus r. denosumab treatment of prostate cancer with bone metastases and increased urine n-telopeptide levels after therapy with intravenous biphosphonates: results of a randomized phase ii trial. j urol. 2009;182:50916. 23. smith mr, egerdie b, toriz nh, et al. denosumab in men receiving androgen-deprivation therapy for prostate cancer. nejm. 2009;361(8):745-56. 24. burkiewicz js, scarpace sl, bruce sp. denosumab in osteoporosis and oncology. ann pharmacother. 2009;43(9):1445-55. 25. stenzl a. rank ligand: a key role in cancer-induced bone destruction?. eur urol. 2009;suppl 8:823-8. 26. fizazi k, carducci m, smith m, et al. denosumab versus zoledronic acid for treatment of bone metastases in men with castration-resistant prostate cancer: a randomised, double-blind study. lancet. 2011; 377(9768):813-22. review article 61acta medica indonesiana the indonesian journal of internal medicine reactivation of hepatitis b virus associated with chemotherapy and immunosuppressive agent indra wijaya, irsan hasan department of internal medicine. faculty of medicine, university of indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta pusat 10430, indonesia. correspondence mail: leon_natan@yahoo.com. abstrak reaktivasi virus hepatitis b (hbv) setelah dilakukan kemoterapi dan terapi imunosupresi merupakan akibat serius yang menimbulkan mortalitas dan morbiditas yang berkaitan dengan penyakit hati. mekanisme reaktivasi hbv masih belum jelas, tetapi para ahli meyakini bahwa mekanismenya melalui penekanan respons imum sehingga dapat meningkatkan beban virus (viral load). hingga kini, belum ada kriteria diagnostik yang disepakati, namun reaktivasi hbv dapat dipastikan oleh adanya peningkatan kadar hbv-dna dalam serum. berbagai konsensus telah membahas hal ini yang meliputi pembahasan tentang jenis dan lamanya terapi analog nukleosida sebagaimana telah diketahui tidak semua pasien dengan hepatitis b kronik akan mengalami reaktivasi. saat ini, kesadaran akan reaktivasi virus hepatitis b yang samar kini semakin meningkat, khususnya di daerah endemis virus hepatitis b, termasuk indonesia yang merupakan bagian dari wilayah asia pasifik. terapi antivirus profilaksis (preempative antiviral therapy) merupakan pendekatan terbaik untuk mencegah reaktivasi hbv. kata kunci: reaktivasi virus hepatitis b, kemoterapi, imunosupresif. abstract hepatitis b virus (hbv) reactivation after chemotherapy or immunosuppressive therapy is a serious cause of liver-related morbidity and mortality. the mechanism of hbv reactivation is still unclear, but it is believed due to the suppression of immune response hence increasing the viral load. no uniform diagnostic criteria are available, hbv reactivation can be confirmed by an increase in serum hbv-dna level. there are many consensus regarding this issue, including the type and duration of nucleoside analogue therapy which need to be understood as not all chronic hepatitis b patients will lead to hbv reactivation. recently, there has been an increased awareness of reactivation of occult hepatitis b virus, especially in hepatitis b virus endemic area, including indonesia as part of asia pacific region. preempative antiviral therapy was the best approach to prevent the hbv reactivation. key words: hepatitis b virus reactivation, chemotherapy, immunosuppressive. introduction hepatitis b virus (hbv) reactivation can occur in chronic hepatitis b patient. this issue should be put into account due to serious condition that can lead to fulminant hepatitis, liver failure, and eventually death.1 the incidence is unclear, but this condition can be predicted and preventable through evaluation of risk factors, including patient with malignancy who need chemotherapy and imunosuppresant agent.1 complete hbv serology profile should be screened in patient who will undergo cytotoxic chemotherapy and immunosuppressive therapy. it has been known that preempative antiviral therapy is more effective than treatment of hbv reactivation.1 indra wijaya acta med indones-indones j intern med 62 hepatitis b virus hepatitis b virus is a double-stranded dna virus in hepadnaviridae family. hbv virion are double-shelled particles, 40 to 42 nm in diameter, with an outer lipoprotein envelope that contains three related envelope glycoproteins (surface antigens). the core contains the viral genome and a polymerase for the viral dna synthesis in infected cells.1 pathogenesis of hepatitis b host immune responses to viral antigens on infected hepatocytes are the main mechanism of hepatocellular injury.2 these responses involve both major-histocompatibility-complex (mhc) class ii–restricted, cd4+ helper t cells and mhc class i–restricted, cd8+ cytotoxic t lymphocytes. recognition reaction of antigen and antigen presenting cell (apc) can lead to either direct lysis of the infected hepatocyte or the release of interferon-γ (ifn-γ) and tnf-α, which can down-regulate viral replication in surrounding hepatocytes without direct cell killing.3 natural histroy of chronic hepatitis b infection depends on the age at the time of infection and the immune response between host immunity and viral replication. patient who failed to recover from acute infection will lead to chronic infection through 4 phase: immune tolerance, immune clearance, non-replicative, and reactivation phase.1 hbv reactivation is related to serologic profile and intensity of immunosuppressive agent.7 the pathogenesis of hbv reactivation is still unclear, for those receiving high dose or long term of corticosteroids, it maybe due to a glucocorticoid responsive element in the hbv genome that stimulates viral replication and transcriptional activity.15 the use of chemotherapy will markedly suppress the immune response hence increasing the viral load.8 epidemiology approximately 2 billion people worldwide have been infected with hbv during their lifetime, with >350 million remaining chronically infected, leading to terminal liver disease or hepatocellular carcinoma which accounts for 1 million of death annualy. approximately 45% of population are in hbv endemic area.5 hepatitis b virus reactivation hbv reactivation is a liver necroinflammation i n i n a c t i v e c a r r i e r o r r e s u l a t i o n p h a s e patient. clinical symptoms are variable from asymptomatic to liver decompensated and death.6 hbv reactivation is related to serologic profile and intensity of immunosuppressive agent.7 the pathogenesis of hbv reactivation is still unclear. the use of chemotherapy and highly immunosuppressive agent will markedly suppress the immune response hence increasing the viral load and if the agent was ceased, there will be a fast recovery of immune response and massive cytolitic of infected hepatocytes.8 hbv reactivation related to chemotherapy agent currently, there are many reports about hbv reactivation related to chemotherapy and the risk of reactivation is increasing.9 patient with hbsag (+). lymphoma patients who are hbsag (+) are noted to have a higher risk of hbv reactivation after chemotherapy, this may be related to the relatively more immunosuppressive drugs used for lymphoma and also possibly the intrinsic immunosuppressive effect of lymphoma.10 a prospective study found that ≥60% hbv reactivation occurs in hbsag (+) patient receiving cytotoxic therapy.11 intrahepatic covalently closed circular dna (cccdna) is figure 1. cellular immune responses to hepatitis b virus3 figure 2. natural history of chronic hepatitis b4 vol 45 • number 1 • january 2013 reactivation of hepatitis b virus related to chemotherapy 63 the key of viral replication and can be used for predicting hbv reactivation in hbsag (+) patient receiving chemotherapy.12 patient with hbsag (-). patient with hbsag (-), anti-hbc (+) and undetectable hbv-dna, alt and hbv-dna must be evaluated and treated with nucleoside analog despite of alt level.13 hbv reactivation in patient with hbsag (-) but anti-hbc & anti-hbs (+) and in patient with occult anti-hbc is an uncommon condition therefore it is not recommended for routine antiviral prophylaxis. this patient should be evaluated and treated if hbv-dna is detectable.6 a separate study in taiwan by chen et al. has shown that 6% of their hbsag (-) patients with b-cell lymphoma had occult hbv infection.13 in a cohort study by hui et al. of hbsag (-) hematopoietic stem cell transplant donors in hong kong, the prevalence of occult hbv infection was 15.3%.14 hbv reactivation related to immunosuppressive agent corticosteroid. hbv replication increases in the presence of corticosteroids. the peak rise in aminotransferases typically occurs 4-6 weeks after withdrawal. the mechanisms are unclear, maybe due to a glucocorticoid responsive element in the hbv genome that stimulates viral replication and transcriptional activity.15 study by cheng et al. found that a steroid-free table 1. chemotherapy agent related to hbv reactivation1 class agents associated with hbv reactivation potential hepatotoxicity alkylators cyclophosphamide vod, hepatocellular injury ifosfamide hepatocellular injury, cholestasis chlorambucil hepatocellular injury carboplatin, cisplatin hepatocellular injury, cholestasis, steatosis, peliosis antimetabolites cytarabine vod, hepatocellular injury fluorouraril hepatocellular injury gemcitabine hepatocellular injury, cholestasis mercaptopurine hepatocellular injury, cholestasis methotrexate hepatocellular injury, steatosis, fibrosis, hepatic neoplasm thioguanine vod, hepatocellular injury, nrh, peliosis antitumor antibiotics anthracyclines hepatocellular injury, vod bleomycin steatosis mitomycin c vod, steatosis actinomycin d vod, steatosis corticosteroides prednisone/dexamethasone, etc hepatomegaly (rare association) immunotherapy rituximab (anti-cd20) hepatocellular injury alemtuzumab (anti-cd52) hepatocellular injury infliximab (anti-tnf) hepatocellular injury, steatosis plant alkaloids vincristine vod, hepatocellular injury vinblastine hepatocellular injury others asparginase hepatocellular injury, steatosis procarbazine vod docetaxel hepatocellular injury etoposide hepatocellular injury fludarabine hepatocellular injury imatinib mesylate hepatocellular injury, cholestasis interferon alpha hepatocellular injury indra wijaya acta med indones-indones j intern med 64 chemotherapy regimen reduced the risk of hbv reactivation in patients with lymphoma.16 monoclonal antibody. lymphoid malignancies and immunologic conditions often includes the use of monoclonal antibodies, such as rituximab (anti-cd20) and alemtuzumab (anti-cd52) which are highly immunosuppressive.1 rituximab plus chop chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisolone) is now a standard treatment of diffuse large b-cell lymphoma (dlbcl).15 before preemptive antihbv therapy is widely used, treatment of hbsag (+) lymphoma with chop chemotherapy alone is associated with an approximately 50% risk of hbv reactivation, the risks are greater by adding rituximab.17 anti-tnf-α. flares of hepatitis have been described during treatment with anti-tnf-α agents in chronic hbv patients with rheumatoid arthritis. severe flares have also been described in association with methotrexate, particularly following its withdrawal.18 bone marrow transplantation. patient with hbsag (+) who undergo allogenic bone marrow transplant is in highly immunosuppresive condition and has higher risk of hbv reactivation (14%-50%). known risk factors are steroid used, anti-hbs (-) donor, and graft-versus-host disease.1 in graft-versus-host disease, high dose steroid or antithymocyte globulin (atg) are needed which suppress the immune system.19 immunization of hbv is recommended for donor and recipient who has never been infected by hbv.20 renal transplantation. there has been a report about declining of renal graft function in patient receiving adefovir. entecavir is drug of choice in patient urdergoing renal transplant. diagnosis currently, no uniform diagnostic criteria are available for hbv reactivation. hbv reactivation can be confirmed by an increase in serum hbvdna level to more than 1 log higher than that of the baseline, an absolute increase exceeding 6 log10 copies/ml, or serum hbv-dna turning from negative to positive. serologic evidence of chronic hbv infection would be useful. commonly, elevation of hbv-dna happens prior to elevation of transaminase. as reactivation may be transient, more frequent hbv-dna and alt monitoring will lead to a higher rate of diagnosis.10 treatment w h e n a c l i n i c a l d i a g n o s i s i s m a d e , chemotherapy and potential hepatotoxic agent must be ceased and treatment is based on antiviral and supportive care.1 lamivudine, a nucleoside analog, is an effective treatment of chronic hbv infection. the drug is active in controlling viral replication and is therefore potentially useful for the treatment of hbv reactivation. good prognosis can be estimated if lamivudine is given at the time of hbv-dna elevation.21 there is a report about the successful of emergency liver transplantation in heterologous bone marrow transplantation patient with fulminant hbv reactivation.22 figure 3. dynamics of viral load and transaminase in hbv reactivation1 prognosis hbv reactivation is related to long-term declining of liver function. eventhough some patients can have spontaneous recovery, mortality rate occurs in about 5% 40%. patient with antihbc (+) has lower risk of reactivation compared to patient with hbsag (+), but mortality rate is higher in patient with anti-hbc (+). mortality rate is still high alhough already been treated with antiviral because usually the viral load is already high and massive immune-mediated hepatocytes injury has already occured.23 prophylactic all chemotherapy and immunosuppressive candidates should be screened for hbsag and anti-hbc before receiving the treatment.1 there are currently two approaches in management vol 45 • number 1 • january 2013 reactivation of hepatitis b virus related to chemotherapy 65 of patients at risk, namely treatment of hbv reactivation when it is diagnosed, and prevention through preempative treatment prior to or upon initiation of chemotherapy.6 preempative antiviral therapy was the best approach to prevent the reactivation.11 american association for the study of liver diseases (aasld) 2009 consensus recommend prophylactic antiviral therapy for hbv carriers at the onset of chemotherapy or of a finite course of immunosuppressive therapy.24 european association for the study of the liver (easl) 2009 consensus also recommend about hbv vaccination in seronegative patient and evaluate hbv-dna level before starting chemotherapy and receiving preempative therapy along and continue to at least 12 months after chemotherapy.25 asia pacific association for the study of the liver (apasl) 2008 consensus recommend l a m i v u d i n e a s p r e e m p a t i v e t h e r a p y f o r chemotherapy candidates, starting 1 week prior to and continue to at least 12 week after chemotherapy.26 perhimpunan peneliti hepatologi indonesia (pphi) 2006 consensus also recommend l a m i v u d i n e t h e r a p y b e f o r e a d m i n i s t e r chemotherapy or immunosuppresive agent and should be continue at least 6 weeks after treatment.27 metaanalysis study by ziakas et al. reveales that in 9 trials, cumulative prevalence for hbv reactivation in prophylaxis group was 8.6% compared to 50.6% in control group. the incidence for those who did not receive prophylaxis therapy are 54.5%-100%.28 for patient receiving monoclonal antibody treatment, antiviral therapy should be given for at least 12 months because of slow immune recovery.29 hbv reactivation can be happened in those who already received lamivudine, this maybe due to drug resistency because of ymdd (tirosinmetionin-aspartat) mutant.30 others nucleoside analog like adefovir, entecavir, telbivudine, and tenofovir, can be given to those with lamivudineresistant.31 conclusion hbv reactivation is a common complication i n p a t i e n t r e c e i v i n g c h e m o t h e r a p y a n d immunosuppressive agent, therefore we should be aware regarding its serious implication. patient figure 4. screening algorithm and prophylaxis of hbv reactivation1 indra wijaya acta med indones-indones j intern med 66 with malignancy in hbv endemic area should be screened routinely for hepatitis b status before receiving cytotoxic chemotherapy. preempative therapy with nucleoside analog had significantly reduced the incidence, morbidity, and mortality of hbv reactivation. references 1. lalazar g, rund d, shouval d. screening, prevention and treatment of viral hepatitis b reactivation in patients with haematological malignancies. br j haematol. 2007;136:699–712. 2. lavanchy d. hepatitis b virus epidemiology, disease burden, treatment, and current and emerging prevention and control measure. j viral hepatitis. 2004;11:97–107. 3. ganem d, prince am. hepatitis b virus infection: natural history and clinical consequences. n engl j med. 2004;350:1118-29. 4. yim hj, lok as. natural history of chronic hepatitis b virus infection: what we knew in 1981 and what we know in 2005. hepatol. 2006;43:173–81. 5. weinbaum cm, williams i, mast ee. recommendations for identification and public health management of persons with chronic hepatitis b virus infection. mmwr recomm rep. 2008;57:1-28. 6. hoofnagle jh. reactivation of hepatitis b. hepatol. 2009;49:158-65. 7. post a, nagendra s. reactivation of hepatitis b: pathogenesis and clinical implications. curr infect dis report. 2009;11:113-9. 8. kohrt he, ouyang dl, keeffe eb. lamivudine prophylaxis for chemotherapy-induced reactivation ofchronic hepatitis b virus infection. aliment pharmacol ther. 2006;24(7):1003-16. 9. hui ck, cheung www, zhang hy, et al. rituximab increases the risk of de novo hepatitis b infection in hepatitis b surface antigen negative patients undergoing cytotoxic chemotherapy. j gastroenterol hepatol. 2006;21:73-4. 10. wang f, xu rh, han b. high incidence of hepatitis b infection in b-cell subtype nonhodgkin’s lymphoma compared with other cancers. cancer. 2007;109:1360-4. 11. kohrt he, ouyang dl, keeffe eb. systematic review: lamivudine prophylaxis for chemotherapy-induced reactivation of chronic hepatitis b virus infection. aliment pharmacol ther. 2006;24:1003-16. 12. hui ck, bowden s, jackson k. clinical significance of intrahepatic hepatitis virus covalently closed circular dna in chromic hepatitis b patients who received cytotoxic chemotherapy. blood. 2005;105:2616-7. 13. chen mh, hsiao lt, chiou tj. high prevalence of occult hepatitis b infection in patients with b-cell nonhodgkin’s lymphoma. ann hematol. 2008;87:475-80. 14. hui ck, sun j, au wy. occult hepatitis b virus infection in hematopoietic stem cell donors in a hepatitis b virus endemic area. j hepatol. 2005;42:813-9. 15. yeo w, chan tc, leung nw. hepatitis b virus reactivation in lymphoma patients with prior resolved hepatitis b undergoing anticancer therapy with or without rituximab. j clin oncol. 2009;27:605. 16. cheng al, hsiung ca, su ij. steroid-free chemotherapy decreases risk of hepatitis b virus (hbv) reactivation in hbv-carriers with lymphoma. hepatol. 2003;37:1320. 17. iannitto e, minardi v, calvaruso g. hepatitis b virus reactivation and alemtuzumab. eur j haematol. 2005;74:254-8. 18. calabrese lh, zein nn, vassilopoulos d. hepatitis b virus reactivation with immunosuppressive therapy in rheumatic diseases: assessment and preventive strategies. ann rheum dis. 2006;65:983-9. 19. ma sy, au wy, ng io. hepatic graft versus host disease after hematopoietic stem cell transplantation: clinicopathologic features and prognostic implication. transplantation. 2004;27:1252-9. 20. piekarska a, zaucha jm, hellman a. prevention of hepatitis b virus transmission from an infected stem cell donor. bone marrow transplant. 2007;40:299-400. 21. yeo w, steinberg jl, tam js. lamivudin in the treatment of hepatitis b virus reactivation during cytotoxic chemotherapy. j med virol. 1999;59:263-9. 22. au wy, lau gk, lie a. emergency living related liver transplantation for fulminant reactivation of hepatitis b virus after unrelated transplantation. clin transplant. 2003;17:121-5. 23. su wp, wen cc, hsiung ca. long term hepatic consequences of chemotherapy related hbv reactivation in lymphoma patients. world j gastroenterol. 2005;11:5283-8. 24. lok as, mcmahon bj. chronic hepatitis b: update 2009. aasld practice guideline. hepatol. 2009;50:135. 25. easl clinical practice guidelines: management of chronic hepatitis b. j hepatol. 2009;50:227-42. 26. liaw yf, leung n, kao jh, et al. asian-pasific consensus statement on the management of chronic hepatitis b: a 2008 update. hepatol int. 2008;2:263-83. 27. konsensus perhimpunan peneliti hati indonesia. panduan tata laksana infeksi hepatitis b kronik. 2006. 28. ziakas pd, karsaliakos p, mylonakis e. effect of prophylactic lamivudine for chemotherapy-associated hepatitis b reactivation in lymphoma: a meta-analysis of published clinical trials and a decision tree addressing prolonged prophylaxis and maintenance. haematol. 2009;94:998-1005. 29. hsiao lt, chiou tj, liu jm. extended lamivudine therapy against hepatitis b virus infection in hematopoietic stem cell transplant recipients. biol blood marrow transplant. 2006;12:84-94. 30. gauthier j, bourne ej, lutz mw. quantitation of hepatitis b viraemia and emergence of ymdd variants in patients with chronic hepatitis b treated with lamivudine. j infect dis. 1999;180:1757-62. 31. peters mg, han hw h, martin p. adevovir dipivoxil alone or in combination with lamivudine in patients with lamivudine-resistant chronic hepatitis b. gastroenterol. 2004;126:91-101. 101acta med indones indones j intern med • vol 55 • number 1 • january 2023 review article plasmodium ovale malaria: endemic areas in indonesia umar zein1,2*, hadiki habib1, hadyanto lim3 1dr. umar zein tropical diseases and infectious clinic, medan, indonesia. 2department of internal medicine, faculty of medicine, north sumatra islamic university, medan, indonesia. 3division of cardiovascular medicine, department of pharmacology, faculty of medicine, methodist university of indonesia, medan, indonesia. *corresponding author: prof. umar zein, md., phd. dr. umar zein tropical diseases and infectious clinic. jl. jermal 3 no. 12 medan 20227, indonesia. email: hadikihabib@gmail.com. abstract plasmodium ovale consists of two subspecies – p. ovale wallikeri and p. ovale curtisi. increased reports of imported malaria ovale in non-endemic regions and mixed infection of p. ovale with other plasmodium species suggest that p. ovale might be under-detected during routine surveillance. areas endemic with p. ovale have mostly been reported in african and western pacific countries. a recent case report in indonesia indicated that regions with p. ovale endemicity are not only distributed in lesser sunda and papua, but also in north sumatra. keywords: plasmodium ovale, indonesia, endemic area, malaria, molecular tests. introduction malaria is caused by plasmodium parasites. plasmodium can infect humans and animals, such as mammals. many factors contribute to this infectious disease in humans, such as demography, environment, population mobility, and economic and sociocultural reasons.1 malaria is a preventable and treatable infectious disease, and intensive prevention efforts in various endemic areas have reduced the burden of this disease. endemicity and vector distribution are based on environment, climate, and season among the five plasmodium species, which vary in their distribution. ovale malaria was seldom reported except in sub-saharan africa and on some islands of the western pacific.2 in 2015, 106 countries were reported as sources of malaria transmission. between 2010 and 2015, the incidence of malaria in the at-risk population (rate of new cases) was 21%. in the same period, the global mortality rate for the at-risk population was 29% in all age groups and 35% in children under 5 years.3,4 the who global technical strategy (gts) launched in 2015, which aimed to eradicate 90% of the global burden of malaria in 2030, would likely be unmet.5 therefore, programs directed at combating malaria in endemic areas should be strengthened, specifically considering the ongoing covid-19 pandemic. although p. falciparum is generally considered to cause severe disease and death, a recent meta-analysis reported that p. ovale can lead to severe illness with jaundice, anemia, and respiratory failure.6,7 thus, it is important to recognize the severity of p. ovale infection in order to prevent rare complications. diagnosis relies on molecular examination using polymerase chain reaction (pcr). published case reports have shown that all plasmodium species can cause severe malaria.8-11 malaria in indonesia is still a public health problem. malaria endemic areas in indonesia cover several provinces, including the province of north sumatra. five species of plasmodium in humans were found with different species in umar zein acta med indones-indones j intern med 102 each endemic area, and the most common was p. falciparum species. so far, ovale malaria endemic areas in indonesia have only been reported in two provinces, namely papua and east nusa tenggara.6 the limited reports of ovale malaria endemic areas in indonesia are thought to be influenced by the diagnostic methods used in the field. for malaria blood surveys in the field, a rapid diagnostic test (rdt) is always used, because it is easy, cheap, fast and does not require special skills such as microscopic examination. rdt examination can only differentiate diagnostic p. falciparum and non-p. falciparum infections (p. vivax, p. malariae, p. ovale, and p. knowlesi cannot be distinguished). to ascertain the morphology of the five plasmodium species, the gold standard is microscopic examination of thick and thin blood with good staining and the microscopic skill and experience of the examiner. other possible misdiagnostic factors for determining p. ovale species on microscopic examination are the presence of mixed infection, low parasite density, and the subspecies of p. ovale, namely p. ovale wallikeri and p. ovale curtisi which can only be distinguished by rt-pcr examination by sequencing. the discovery of one case of ovale malaria in gerunggang village, langkat regency, north sumatra province which was reported in 2017, is the basis for making this review. previously the case was diagnosed as mixed-infection with p. falciparum and p. vivax. it was not previously thought that p. ovale might be found, because malaria endemic areas in langkat regency have been reported only p. falciparum and p. vivax. after re-observation of the patient’s blood smear, and confirmed by the parasitologist, it was confirmed that the morphology found was typical for p. ovale. unfortunately, due to limited laboratory facilities, we could not proceed with rt-pcr and sequencing to determine the subspecies of p. ovale found.12 r e p o r t s o f p l a s m o d i u m o va l e malaria worldwide p. ovale was the fourth known cause of malaria before the discovery of plasmodium knowlesi in sarawak, malaysia in 2004.13,14 in 1969, lysenko and beljaev conducted a geographical analysis of published cases of ovale malaria across the western pacific countries, including india, nigeria, philippines, southern china, iraq, pakistan, new guinea, solomon island, bulgaria, columbia, venezuela, macedonia, s. epirus, iran, ussr (armenia, georgia, bashkiria), palestine, egypt, south america, duke of york island, and indonesia.15 sporadic spread and alteration trends in the prevalence of the four plasmodium species were reported, except for p. falciparum. several countries across the african continent, including ethiopia, uganda, equatorial guinea, and kenya have recorded cases with p. ovale curtisi and p. ovale wallikeri.16 an imported case of infection by two species (p. ovale and p. falciparum) in an indonesian patient working in cameroon was reported in north sumatera.17 prakash et al. reported a case of ovale malaria from assa district, india, which was initially diagnosed as vivax malaria.18 in southern bangladesh, fuchrer et al. reported the first cases of p. ovale infection with a percentage of 1.6% in 189 patients using the species-specific nested pcr technique, targeting the small subunit ribosomal rna (ssu trna) gene from 379 patient samples.19 singh et al. in 2010 reported regarding 256 patients with p. falciparum malaria who were hospitalized in central india and diagnosed microscopically; three cases (1.2%) of p. ovale malaria were detected for the first time using species-specific nested pcr with 18s rrna.20 cao et al. identified 98 cases of ovale malaria out of 1,268 malaria cases from jiangsu province, china, from 2011 to 2014, most of which were imported from subsaharan africa.21 mitchel et al. reported that p. ovale was widely distributed in the democratic republic of the congo, especially p. ovale curtisi and p. ovale wallikeri in 2013.22 lim et al. reported the first imported malaria case, which was initially diagnosed as p. vivax malaria microscopically.23 likewise, a case report from gujarat, india in 2006, showed that the parasite seemed to be p. vivax in a thick smear stained with leishman stain. however, it was revealed as p. ovale in a thin smear using standard microscopic and morphological vol 55 • number 1 • january 2023 plasmodium ovale malaria: endemic areas in indonesia 103 evaluation.2 misidentification of p. ovale can occur microscopically when the parasite density is low and other types of plasmodium infection occur concurrently. the morphology of p. ovale is similar to that of p. vivax, which can lead to an error in the estimation of the current prevalence of ovale malaria and endemic areas by species. because p. ovale possesses a hypnozoite stage in liver cells similar to that found in p. vivax, a relapsing course of infection can ensue. furthermore, both p. ovale species, p. ovale curtisi and p. ovale wallikeri, are sympatric but distinct species, based on the analysis of the msp-1 (merozoite surface protein-1) sequence in thailand.24 diversity in pocmsp-1 and powmsp-1 by the msp-1 sequences from the isolate sample resulted in a low level of sequence, suggesting that p. ovale curtisi and p. ovale wallikeri originate from a persistently low prevalence. p. ovale infections cannot be diagnosed by ssu rrna-based pcr if coinfection with other plasmodium species is present at a very low parasite density. hence, the burden of p. ovale infection could be underestimated. an imported case of ovale malaria was reported in 201125 in brazil, which was later confirmed by standard microscopy and pcr. based on the patient’s travel history, it was concluded that the parasite was in the latent hypnozoite form for a minimum of 2 years. it was difficult to ascertain the relationship between the time of exposure to the parasite and the onset of symptoms because of the relatively long incubation period of p. ovale. asymptomatic p. ovale infection is usually found in areas endemic with ovale malaria. additionally, a report 26 in senegal showed that there was no risk of fever when the parasitemia was 80–799 parasites/ml of blood. the risk of fever increased 11-fold in mixed infections or 93-fold for p. ovale when the parasite count was 800–8000 parasites/ml of blood. multiple infections of plasmodium species often occur in certain endemic areas because of the presence of several species in the same area. microscopic findings of multiple infections of p. falciparum and p. malariae in two children were reported in central african republic.27 three species were found (p. falciparum, p. malariae, and p. ovale) in real-time pcr examination of the first blood sample after treatment follow-up. p. ovale infection was still found in one child after re-examination on day 28, suggesting a delayed appearance of ovale malaria in this mixed infection. the proportion of imported cases due to p. ovale and the difference between p. ovale curtisi and p. ovale wallikeri are important. a descriptive study to analyze the prevalence, proportion, distribution, and origin of p. ovale curtisi and p. ovale wallikeri in henan province was collected from 2010 to 2017 by zhou et al.28, and their findings showed that the proportion of imported cases of p. ovale was larger than that of p. vivax. the latency period of p. ovale curtisi was significantly longer than that of p. ovale wallikeri in these two subspecies imported into china. nolder et al. 29 reported the results of pcr examination of p. ovale curtisi and p. ovale wallikeri infections in blood samples of a british traveler who had malaria. the suspected asymptomatic period between the time of diagnosis was determined, and the time of the patient entering the uk was compared between the two groups. showed that there are epidemiologically significant differences between the two cases of ovale malaria, suggesting that targeted treatment for p. falciparum may not be sufficient to reduce the malaria burden caused by p. ovale. malaria map in indonesia one of the millennium development goals (mdgs) was to eradicate malaria in 2015. this commitment was strengthened by the sustainable development goals (sdgs). in the sdgs, the malaria control program is in the third objective, namely, ensuring the health and welfare of all people, with the specific aim of ending the malaria epidemic and neglected infectious diseases by the end of the year 2030. the level of morbidity due to malaria in an area is determined by the annual parasite index (api), which is the number of malaria cases per 1,000 population in a certain country or territorial area in a year. the api in indonesia has declined since 2011, indicating the success of the malaria prevention program conducted by the central, regional, umar zein acta med indones-indones j intern med 104 community, and related partners in indonesia.4 to date, there has been no mapping of endemic areas for p. ovale malaria in indonesia. the existing mapping considers all malaria cases without specifying the plasmodium species. the existence of p. ovale malaria in indonesia from belu (east nusa tenggara) was reported by gundelfinger et al., in 1975.6 baird et al. reported 34 cases of ovale malaria infection found in 15,806 peripheral slide smear samples examined from 1973 to 1989 from various islands in indonesia. of the 514 samples, 25 were obtained from owi, irian jaya (papua). other p. ovale infection cases originated in two areas in east flores. however, there were no cases of p. ovale malaria in samples from sumatra, kalimantan, sulawesi, and java.30 reports on parasite surveys in indonesia were recorded between 1900 and 2008 at 2,366 locations with an uneven distribution of locations; 63% of the surveys were conducted in eastern indonesia, namely, maluku, east nusa tenggara, and papua. of the 16 survey locations, p. ovale was only found in east nusa tenggara province and papua province, with a prevalence of 0.003% and 0.02%, respectively.6 however, a 2017 case report revealed nonimported p. ovale mixed with p. falciparum infection in north sumatra province, which was confirmed by microscopic examination.12 the endemicity of ovale malaria in three provinces in indonesia is shown in figure 1. the distribution of p. ovale in people in indonesia is presented in table 1. figure 1. three provinces of endemic area ovale malaria in indonesia. plasmodium ovale infection has been reported in three provinces, including north sumatra, east nusa tenggara, and papua table 1. the distribution of plasmodium ovale in indonesia. province year ofsample no. site no. exams no. pf (%) no. pv (%) no. pm (%) no. po (%) north sumatra 2015 1 75 2 (0.02) 2 (0.02) 1 (1.33) east nusa tenggara 1975–2009 609 383,950 23,502 (6.1) 19,401 (5.1) 157 (0.04) 11 (0.003) papua 1929–2009 694 193,043 19,848 (10.3) 9343 (4.8) 1395 (0.7) 40 (0.02) indonesia 1900–2021 2366 1,062,259 61,415 (5.8) 52,336 (4.9) 2299 (0.2) 52 (1.36) pf, plasmodium falciparum; pv, plasmodium vivax; pm, plasmodium malariae; po, plasmodium ovale. modified from elyazar et al.6 vol 55 • number 1 • january 2023 plasmodium ovale malaria: endemic areas in indonesia 105 conclusion the mapping of malaria-endemic areas in indonesia needs to be reviewed because of the detection of various plasmodium species that have not been previously reported. the report of cases of p. ovale malaria by the current author and colleagues in north sumatra needs to be followed up by the government and related sectors to conduct a widespread blood survey with microscopic examination, followed by nested pcr confirmation. this should yield a new map of malaria-endemic areas in indonesia in general, and in north sumatra in particular. the endemicity map may provide a rational basis for future malaria management strategies. authors’ contributions all authors have helped draft the manuscript. all authors have read and approved the final manuscript. funding this research was personally funded by the author competing interests the authors declare that they have no competing interests. references 1. picot s, bienvenu al. plasmodium. 2020. available from: https://www/sciencedirect.com/science/ referenceworks/9780128012383. accessed, july, 2021. 2. marathe a, date v, shah hn, et al. plasmodium ovale – a case report from gujarat. j vect borne dis. 2006;43;206-8. 3. who malaria fact sheet. available from: http://www. who.int/mediacentre/factsheets/fs094/en/ accessed december, 2020. 4. kemkes ri (moh indonesian republic). malaria. pusdatin kementerian kesehatan republik indonesia, 2016. 5. world malaria report. 20 years of global progress and challenges. geneva: world health organization; 2020. licence: cc 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starzengruber p, swoboda p, et al. indigenous plasmodium ovale malaria in bangladesh. am j trop med hyg. 2010;83:75-8. 20. singh r, jain v, singh pp, et al. first report of detection and molecular confirmation of plasmodium ovale from severe malaria cases in central india. trop med int health. 2013;18:1416-20. 21. cao y, wang w, liu y, et al. the increasing importance of plasmodium ovale and plasmodium malariae in a malaria elimination setting: an observational study of imported cases in jiangsu province, china, 2011–2014. malar j. 2016:15:459. 22. mitchell cl, brazeau nf, keeler c. under the radar: epidemiology of plasmodium ovale in the democratic republic of the congo. j infect dis. 2021;223:1005-14. 23. lim ya, mahmud r, chew ch, et al. plasmodium ovale infection in malaysia: first imported case. malar j. 2010;9:272. 24. putaporntip c, hughes al, jongwutiwes s. low level of sequence diversity at merozoite surface protein-1 locus of plasmodium ovale curtisi and p. ovale umar zein acta med indones-indones j intern med 106 wallikeri from thai isolates. plos one. 2013;8:e58962 25. limongi je, costa dc, carvalho lh, et al. plasmodium ovale malaria in brazil: report of an imported case with a prolonged incubation period. j infect dev ctries. 2014;8:554-7. 26. faye fbk, spiegel a, tall a, et al. diagnostic criteria and risk factors for plasmodium ovale malaria. j infect dis. 2002;186:690-5. 27. bichara c, flahaut p, costa d, et al. cryptic plasmodium ovale concurrent with mixed plasmodium falciparum and plasmodium malariae infection in two children from central african republic. malar j. 2017;339:2-4. 28. zhou r, li s, zhao y, et al. characterization of plasmodium ovale spp. imported from africa to henan province, china. sci rep. 2019;9:2191. 29. nolder d, oguike mc, maxwell-scott h, et al. an observational study of malaria in british travellers: plasmodium ovale wallikeri and plasmodium ovale curtisi differ significantly in the duration of latency. bmj open 2013;3:e002711. 30. baird jk, purnomo, masbar s. plasmodium ovale in indonesia. the southeast asian journal of tropical medicine and public health.1990;21:541-4. 99 original article acta med indones indones j intern med • vol 49 • number 2 • april 2017 the effect of psychological stress on mucosal il-6 and helicobacter pylori activity in functional dyspepsia eryati darwin1, arina w. murni2, adnil e. nurdin3 1 department of histology, faculty of medicine, andalas university-m. djamil hospital, padang, indonesia. 2 department of internal medicine, faculty of medicine, andalas university-m. djamil hospital, padang, indonesia. 3 department of psychiatry, faculty of medicine, andalas university-m. djamil hospital, padang, indonesia. corresponding author: arina widya murni, md. department of internal medicine, faculty of medicine, andalas university-m. djamil hospital. jl. universitas andalas, limau manis, padang, sumatera barat 25163, indonesia. email: arina_widya_murni@yahoo.com. abstrak latar belakang: patofisiologi dispepsia fungsional masih belum bisa dipahami sepenuhnya. terdapat banyak faktor yang mempengaruhi, diantaranya gangguan motilitas gaster, hipersensitifitas viseral, infeksi helicobacter pylori (hp), stres psikologis, dan sekresi asam lambung yang berlebihan. penelitian ini bertujuan menentukan aktifitas helicobacter pylori, ekspreksi mukosa il-6, dan hubungannya dengan stres psikologis. metode: studi potong lintang dilakukan pada 40 pasien rawat jalan di rumah sakit umum m. djamil dan 2 puskesmas di padang. mereka dibagi dalam dua kelompok, dengan atau tanpa stres psikologi, yang diidentifikasi dengan menggunakan dass 42. sampel biopsi gaster dan darah perifer diambil saat esofagoduodenoskopi. metode imunohistokimia digunakan untuk menentukan ekspresi il-6 dan hp di mukosa gaster. hubungan masing-masing variabel dalam kelompok yang mengalami tekanan psikologis dan non-stres dianalisis dengan uji chi-kuadrat. hasil: penelitian ini dilakukan pada 40 penderita dispepsia fungsional dengan rerata umur 37,58±11,82 tahun. didapatkan nilai kortisol plasma berbeda bermakna di antara kedua kelompok (non-stress vs stress), bahkan kortisol pagi pada kelompok stress melebihi nilai normal. ekspresi il-6 sebagai bukti terdapat aktifitas inflamasi terlihat lebih banyak pada kelompok non stress dibandingkan dengan kelompok stress (8,25 % vs 7,25%). aktifitas helicobacter pylori terlihat meningkat pada kelompok stress, ditandai dengan terlihatnya jumlah yang menginvasi ke submukosa lebih banyak dibandingkan kelompok non-stress (11 vs. 7). kesimpulan: stres psikologis terlihat tidak berhubungan dengan il-6 pada dispepsia fungsional mukosa gaster namun terdapat bukti adanya peningkatan aktifitas helicobacter pylori. kata kunci: dispepsia fungsional, helicobacter pylori, stres psikologis, interleukin 6 (il-6). abstract background: pathophysiology of functional dyspepsia remains poorly understood. many factors such as gastric motility disorder, visceral hypersensitivity, helicobacter pylori (hp) infection, psychological stress and excessive gastric acid secretion play roles in this symptom. psychological stress may promote peptic ulcer and has an effect on ulcers-associated hp. this study aimed to determine helicobacter pylori activity and expression of mucosal il-6 and their association with psychological stress. methods: a cross-sectional study was done among 40 outpatients with dyspeptic syndromes in m. djamil general hospital and two-community health centers in padang. the subjects were divided into two groups, with and without psychological stress, which were identified using dass 42. gastric biopsy specimens and peripheral blood samples were taken while performing esophagogastroduodenoscopy. immunohistochemistry methods was used to determine the expression of il-6 eryati darwin acta med indones-indones j intern med 100 and hp in gastric mucosa. the correlation of each variable in the group experiencing psychological stress and non-stress was analyzed using chi-square test. results: there were 40 patients with functional dyspepsia with average age of 37.58 (sd 11.82) years old. the cortisol levels were significantly different between both groups (non-stress vs. stress groups); moreover, morning cortisol level in psychological stress group was higher beyond normal limit. inter-leukin-6 expression, as the evidence of inflammatory activity, seemed higher in non-stress group than the group with psychological stress (8.25% vs. 7.25%). helicobacter pylori activity was seemed to be increased in the stress group as characterized by higher numbers of invasion to the sub mucosa epithelium compared to the non-stress group (11 vs. 7 subjects). conclusion: psychological stress seems to have no correlation with il-6 in gastric mucous of patients with functional dyspepsia; however, there is an evidence of increasing activity of helicobacter pylori. key words: functional dyspepsia, helicobacter pylori, psychological stress, interleukin 6 (il-6). introduction f u n c t i o n a l d y s p e p s i a i s a d i s e a s e characterized by recurrent gastrointestinal complaints and causes the patients to seek frequent treatments. the prevalence of dyspepsia in the world ranges from 5-40% of the population and approximately 60% of them have functional dyspepsia (fd).1 a study by mahadeva and goh2 showed that there was a relatively large prevalence of functional dyspepsia in the world ranging from 10-30% and it is expected to reach 60% in the primary health care units. functional dyspepsia (fd) is a highly prevalent and heterogeneous disorder. most patients with fd complain symptoms that are related to meals intake. however, the pathophysiology of fd remains poorly understood. functional dyspepsia involves many pathogenic factors, such as gastric motility disorders, visceral hypersensitivity, psychological factors, helicobacter pylori (hp) infection, and excessive gastric acid secretion. the role of factors causing functional dyspepsia remains controversial and there are many challenges to prove the role of each factor.3,4 psychological stress may be a factor associated with fd or it could also be a precipitating factor. during stress, corticotrophin releasing factor (crf) from the hypothalamus stimulates secretion of adrenocorti-cotrophic hormone (acth) from the pituitary, which in turn releases glucocorticoids (cortisol) from the adrenal gland.5 cortisol hormone that is secreted due to psychological stress exposure will trigger gastric acid secretion (aggressive factor) and will inhibit prostaglandin (defensive factor), which has protective effect on the stomach. decrease in prostaglandin will then facilitate the damage of gastric mucous. a study by bohmelt6 demonstrated that there was a significant increase in cortisol level among patients with df compared to control group. murni7 also shows that there is a significant increase of morning corticol level in patients with df and depression. the role of h. pylori infection on the pathophysiology of fd is still being debated. activated immune response will increase inflammatory process and will then triggers the release of various mediators and chemotactic factors such as il-6, il 8, il1β, tnfα il-10 and others. the release of these factors will further cause inflammatory reaction in gastric mucous and lead to mucosal microscopic or macroscopic damage.8 helicobacter pylori is a gram-negative spiral bacterium that colonizes the gastric mucous of human, causing chronic gastritis, peptic ulcers, gastric adenocarcinoma, and mucous-associated lymphoma. despite the development of strong immune responses against hp infection in human, the bacteria are rarely eliminated from the stomach and infection is usually lifelong.9,10 infection of helicobacter pylori induces strong local immune responses in the gastric mucous of infected host. it is characterized by the recruitment of neutrophils, t and b lymphocytes, plasma cells, macrophages and dendritic cells (dcs), together with epithelial cell damage.11 innate immune system is the first-line defense against invading hp. toll-like reseptor-2 (tlr2) is a major innate receptor for the recognition of hp infection and may vol 49 • number 2 • april 2017 the effect of psychological stress on mucosal il-6 and h. pylori activity 101 cause inflammation. activation of these innate receptors led to activation of nf-κb, caspase, and interferon pathways that result in production of pro-inflammatory cytokines such as il-1β, tnf-α, il-6, mcp-1 and ifn-β. these cytokines attract acute inflammatory mediators such as neutrophils as well as lymphocytes leading to activation of the adaptive immune response.12,13 we conducted a study to strengthen the role of psychosomatic medical science on the treatment of functional disorders in everyday practice as well as providing evidence on the involvement of psychological stress factors in the pathogenesis of functional dyspepsia, so that the management of patients can be done comprehensively. the aim of our study is to provide evidence on the correlation between psychological stress and il-6 as well as the activity of helicobacter pylori in patients with gastric mucous functional dyspepsia and to determine a non-invasive and convenient diagnostic procedure that can be used in primary health care units. methods the study was a cross-sectional study using a comparative analytical observation. it was conducted in march 2016 and the participants were patients with dyspepsia syndrome at the andalas health center and padang pasir health center as well as outpatients of m. djamil general hospital. the study had been approved by the ethical committee on health research, faculty of medicine, andalas university on may 25th, 2015 with a reference number of 081/kep/ fk/2015. patient selection forty patients enrolled in this study were 18-65 years of age who had suffered dyspepsia syndrome for more than two months. there was no subjects with sign of bleeding (alarm symptoms), history of chronic disease, pregnancy, and under medication. all patients were tested for psychological stress using depression anxiety and stress scale (dass 42). esophagogastroduodenoscopy (egd) was done to determine the underlying causes of the symptoms, and mucosal tissues were taken during egd. blood cortisol serum samples were taken from patients and examined using elecysys cortisol reagent kit and electrochemiluminescence immunoassay system (eclia) on roche elecsys 1010/2010 device with modular analitycs e 170. the normal morning serum value: 4. 30 – 22.40 µg/ dl (adult, age: 18 year) and the normal evening serum value: 3. 09 – 16.66 µg/dl (adult, age: 18 year). h i s t o p a t h o l o g y a s s e s s m e n t u s i n g immunohistochemical methods immunohistochemistry of gastric tissue was taken from two sites, i.e. the antrum and fundus. once the tissue had been harvested, fixation was done using paraffin block. ihc staining process was performed to examine the expression of il-6 and h. pylori. procedure of ihc for immunohistochemistry antigen detection in tissues and cells was performed in a multi-step immunohistochemical process. the initial step was to bind the primary antibody to its specific epitope. a secondary antibody was applied to bind with the primary antibody, which was followed by an enzymelabeled polymer; or the polymer may be applied directly to bind with the primary antibody. the bound primary antibody was detected by an enzyme-mediate colorimetric reaction. statistical analysis univariat analysis was performed to observe the distribution of each variable using a computer system, which was then presented in charts and graphs. statistical analysis of the correlation between each variable in the group experiencing psychological stress and non-stress group was done using chi-square test. results the study was conducted for approximately 4 (four) months with 40 eligible subjects out of 47 patients participated. there were 20 patients who suffered dyspepsia with psychological stress and 20 patients without psychological stress. from the table 1, we can observe that the average age of patients with dyspepsia syndrome who were included in this study is of 37.58 (sd 11.82) years with a greater total number of female eryati darwin acta med indones-indones j intern med 102 patients than the male. we found that the number of patients who experienced psychological stress and non-stress were 20 subjects for each group. the level of cortisol in every sample was tested twice, i.e. in the morning and evening. there was a significant difference of cortisol level in the morning and evening obtained from both groups. the morning and evening cortisol levels were significantly different between non-stress and psychological stress group. the morning cortisol level was also higher in psychological stress group than the normal value (4.30 – 22.40µg/dl); however, the cortisol level was still in normal range in the evening (3.09 – 16.66 µg/dl). il-6 expressions were observed by counting the number of cells marked with il-6 marker which could be seen as brown-colored cells. positive cells were counted from 100 cells that existed. from the result, we found that the group without stress had greater il-6 expression than the group with psychological stress (8.25% vs. 7.25 %, p=0.00) the study also showed helicobacter pylori activity in both groups, either with psychological stress or non-psychological stress. from the table 2, we can observe that helicobacter pylori activity in non-stress group was lower compared to group with psychological stress, as demonstrated by higher number of specimens showing invasion to submucous table 1. subjects’ characteristics (n=40) variables value age (years), mean (sd) 37.58 (11.82) gender, n (%) male 14 (35.00) female 26 (65.00) psychology, n (%) non-stress 20 (50.00) stress 20 (50.00) morning cortisol, mean (sd), µg/dl non-stress 23.100 (11.041) stress 29.015 (10.395) evening cortisol, mean (sd), µg/dl non-stress 8.360 (6.519) stress 12.944 (1499.9) il-6, mean (sd) non-stress 8.25 (3.1) stress 7. 25 (3.2) table 2. difference of helicobacter pylori activity in patients with gastrointestinal mucous functional dyspepsia patients that suffered psychological stress and nonpsychological stress. helicobacter pylori activity non-stress (n) stress (n) no activity 4 3 activity limited to epithelial 9 6 activity up to sub mucous 7 11 membrane in the psychological group (11 subjects vs. 7 subjects). discussion functional dyspepsia is a disease that is commonly found in health care practices, especially in primary care. the pathophysiology is still unclear, which causes the treatment to be less optimal. the role of psychological stress and helicobacter pylori infection is referred to as one of the many other factors that cause complaints in functional dyspepsia. the aim of our study was to observe the il-6 expression and helicobacter pylori activity in patients with functional dyspepsia that suffers from psychological stress, which assumed to differ from patients without psychological stress. dyspepsia is frequently experienced by patients of productive age, in this case at average age of 37.58 (sd 11.82) years old. the average age found in our study is younger than the results of previous study obtained by murni7, which is 41.6 (sd 14.66) years old. age does play a role in one’s ability to deal with stressors in life. depression is more commonly found at a young age due to behavioral and environmental factors, which affect the ability to adapt to stressors. females are more likely to suffer from functional dyspepsia compared to male patients in our study. this is because females are assumed to have less ability to withstand stressors and this should be proven in a subsequent study. in our study, increased cortisol levels, both morning and evening levels were found in patients with functional dyspepsia who experienced psychological stress compared to those that were not experiencing psychological vol 49 • number 2 • april 2017 the effect of psychological stress on mucosal il-6 and h. pylori activity 103 stress. stressful life events can induce persistent changes in the ability of the hpa axis, that play an important role in the pathogenesis of depressive disorders. considerable evidence suggests that this vulnerability for developing psychiatric disorders is associated with changes in neurobiological systems related to stress regulation. excessive stress will cause hpa axis to be hyperactive or hypersensitive, which caus es biological vulner ability towards stressors. chronic stress, which results in increased production of catecholamines such as norepinephrine and epinephrine from the adrenal medulla and sympathetic neurons, has long been believed to adversely influence health. stress mediators are known to promote tumor development as well as progression and are associated with increased risk of heart disease and infection.14,15 the process occurs in the hippocampal that regulate hpa outflow, which may enable cortisol to partially escape negative feedback inhibition and lead to the relative increase in diurnal cortisol output. a similar dynamic operating in cells of the immune system, particularly monocytes, could diminish glucocorticoid receptors capacity to inhibit nf-κb, ap-1, and other proinflammatory transcriptional-control pathways, which in turn could result in the heightened il-6 responses to tlr stimulation.16 increased production of peripheral cytokines and other pro-inflammatory markers have been linked to psychiatric disorders such as major depressive disorder and post-traumatic stress disorder. another study found that inflammation may be an important developmental mediator linking adverse experiences in early life to poor adult physical and mental health.17 there are some significant positive correlation between indices of il-6 and age; however, no significant correlations have been found emerged for any of the il-6 measures and sex, depression symptoms, quality of life score, state anxiety, trait anxiety, or perceived stress level. cytokines such as il-6 are integral parts of the innate inflammatory response to a physical stressor (e.g. infection, inflammation). the mechanisms by which psychosocial stress initiates cytokine responses, as well as the clinical consequences of an exaggerated cytokine response to stress, remains to be determined. o u r s t u d y f o u n d t h a t p e r c e n t a g e o f il-6 in gastric mucous of fd patients with psychological stress was lower than patients without psychological stress. il-6 may play an important role in the gastric mucosal response to h. pylori infection and in the development of clinical h. pylori-related disease. the signaling pathways regulating il-6 gene expression in h. pylori infection remains largely unstudied. although many studies have shown that h. pylori infection is associated with increased il-6 production within the gastric mucosa the mechanisms involved are largely unresolved.17,18 h. pylori preferentially stimulates il-12 secretion over that of il-6 and il-10 from human dendritic cells. the relatively poor ability of h. pylori to induce il-6 and il-10 may be due to the low endotoxin activity of its lps. this explanation implies that il-12 secretion is due to a different bacterial stimulus than that causing secretion of il-6 or il-10 in the case of h. pylori.19 in our study, activity of h. pylori was shown to be higher in gastric mucous in fd patients with psychological stress. stress can impact the developmental trajectory of the intestinal barrier and has been associated with an increase in gut permeability. the effects of stress on intestinal permeability are complex and likely involve both the gut and the brain. corticotrophin releasing factor (crf) and its receptors play a key role in stress-induced gut permeability dysfunction. in response to an acute stressor, colonic paracellular permeability increases and has been associated with the development of visceral hypersensitivity and elevated central corticotropin releasing hormone (crh) expression occurred concomitantly with changes in the gut microbiota.20 the results of our study is in line with research done by murni7 that shows that histopathological description of gastric mucous are more severe in patients with functional dyspepsia that suffers depression compared to the non-depressed groups. eryati darwin acta med indones-indones j intern med 104 conclusion psychological stress is associated with expression of pro-inflammatory cytokine (il6) in patients with gastric mucous functional dyspepsia and also involved the increase in activity of helicobacter pylori. references 1. parkman hp, camilleri m, farrugia g, mc calum rw, bahrucha ae. gastroparesis and functional dyspepsia: excerpts from the aga/anms meeting, neurogastroentero motil. 2010;22:113-33. 2. mahadeva s, goh kl. epidemiology of functional dyspepsia: a global perspective. world j gastroenterol. 2006;12(17):2661-6. 3. yarandi ss, christie j. functional dyspepsia in review: pathophysiology and challenges in the diagnosis and management due to coexisting gastroesophageal reflux disease and irritable bowel syndrome. hindawi publishing corporation – gastroenterology research and practice; 2013. p. 1-8. 4. futagami s, shimpuku m, yin y, et al. pathophysiology of functional dyspepsia. nippon med sch. 2011;78 (5): 280-5. 5. bunnett nw. the stressed gut: contributions of intestinal stress peptides to inflammation and motility. pnas. 2005;102.21:740910. 6. bohmelt ah, nater urs m, franke s. basal and stimulated hpa axis activity in patient with functional gasterointestinal disorder and healthy controls. psycho medicine. 2005;67:288-94. 7. murni aw. nilai kortisol serum pada penderita sindrom dispepsia dengan gangguan psikosomatik (tesis sp1 ilmu penyakit dalam), padang; fakultas kedokteran universitas andalas; 2006. 8. cadamuro act, rossi avt, maniezzo nm, silva ae. helicobacter pylori infection: host immune response, implication on gene expresiion and micro rnas. world j gastroenterol. 2014;20(6):1424 -37. 9. akhiani aa, pappo j, kabok z, et al. protection against helicobacter pylori infection following immunization is il-12-dependent and mediated by th1 cells. j immunol. 2002;169(12):6977-84. 10. khamri1 w, walker mm, clark p, et al. helicobacter pylori stimulates dendritic cells to induce interleukin-17 expression from cd4+ t lymphocytes. infect immun. 2010;78(2):845-53. 11. ihan a, gubin m. the immune response to helicobacter pylori. food technol biotechnol. 2014;52(2);204–9. 12. peek jr., fiske c, wilson kt. role of innate immunity in helicobacter pylori-induced gastric malignancy. physiol rev. 2010;90(3):831–58. 13. moyat m, velin d. immune responses to helicobacter pylori infection. world j gastroenterol. 2014;20(19): 5583–93. 14. nillson mb, armaiz-pena g, takahashi r, et al. stress hormones regulate interleukin-6 expression by human ovarian carcinoma cells through a src-dependent mechanism. j biol chem. 2007;282:29919-26. 15. von werne baes c, martins cms, de carvalho tofoli sm, juruena mf. early life stress in depressive patients: hpa axis response to gr and mr agonist. front psychiatry. 2014;5:2. 16. park aj, collins j, blennerhassett pa, ghia je, verdu ef, bercik p, collins sm. altered colonic function and microbiota profile in a mouse model of chronic depression. neurogastroenterol motil. 2013;25(9): 733–45. 17. lu h, wu jy, kudo t, ohno t, graham dy, yamaoka y. regulation of interleukin-6 promoter activation in gastric epithelial cells infected with helicobacter pylori. mol biol cell. 2005;16(10):4954–66. 18. odenbreit s, linder s, gebert-vogel b, rieder g, moran ap, haas r. interleukin-6 induction by helicobacter pylori in human macrophages is dependent on phagocytosis. helicobacter. 2006; 11(3):196–207. 19. guiney dg, hasegawa p, cole sp. helicobacter pylori preferentially induces interleukin 12 (il-12) rather than il-6 or il-10 in human dendritic cells. infect immun. 2003;71(7):4163–6. 20. kelly jr, kennedy pj, cryan jf, dinan tg, clarke g, hyland np. breaking down the barriers: the gut microbiome, intestinal permeability and stress-related psychiatric disorders. front cell neurosci. 2015;9: 392. 169 original article acta medica indonesiana the indonesian journal of internal medicine the effects of ramadhan fasting on clinical symptoms in patients with gastroesophageal reflux disease radhiyatam mardhiyah1, dadang makmun1, ari f. syam1, siti setiati1,2 1 department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 2 clinical epidemiology and evidence-based medicine unit, cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: dadang makmun, md., phd. department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: hdmakmun@yahoo.com, ra.dhiyah@yahoo.com. abstrak tujuan: mengetahui pengaruh puasa ramadhan terhadap keluhan gerd. metode: subjek penelitian ini dikelompokkan menjadi kelompok berpuasa ramadhan (n=66) dan kelompok tidak berpuasa ramadhan (n=64). evaluasi dilakukan antara kedua kelompok tesebut, dan antara bulan ramadhan dengan di luar bulan ramadhan pada kelompok berpuasa. evaluasi dilakukan dengan menggunakan kuesioner gerd (gerd-q) dalam bahasa indonesia. hasil: pada kelompok yang berpuasa ramadhan, terdapat perbedaan median nilai gerd-q yang bermakna secara statistik (nilai p<0,01) antara bulan ramadhan dengan nilai median 0, dan di luar bulan ramadhan dengan nilai median yang meningkat menjadi 4. sementara itu, bila dilakukan analisis untuk membandingkan median nilai gerd-q antara kelompok yang berpuasa ramadhan dan tidak, juga didapatkan perbedaan yang bermakna (nilai p<0,01). kesimpulan: pada subjek yang menjalani puasa ramadhan, keluhan gerd dirasakan lebih ringan saat menjalani puasa ramadhan dibandingkan di luar bulan ramadhan. di bulan ramadhan, keluhan gerd lebih ringan dirasakan oleh subjek yang menjalani puasa ramadhan dibandingkan subjek yang tidak menjalani puasa ramadhan. kata kunci: penyakit refluks gastroesofageal, gastro-esophagealreflux disease, gerd, ramadhan. abstract aim: to determine the effects of ramadhan fasting on gerd symptoms. methods: a total of 130 gerd patients participated in this study. patients were divided into two groups, i.e. those who performed ramadhan fasting (n=66), and those who did not perform ramadhan fasting (n=64). the evaluation was done using indonesian version of gerd questionnaire (gerd-q) between the two groups, and between ramadhan month and non-ramadhan month in the ramadhan fasting group. results: there was a statistically significant difference (p<0.01) in the median of gerd-q score in ramadhan-fasting group subjects and non-ramadhan-fasting group subjects (0 vs. 4). moreover, a statistically significant difference (p<0.01) was also found in the median of gerd-q score in ramadhan-fasting group subjects and non-fasting group subjects (p<0.01). conclusion: subjects in ramadhan fasting group, gerd symptoms experienced less severe during fasting month (ramadhan) than non-fasting month. during ramadhan month, gerd symptoms were also milder in ramadhan fasting group than those in non-fasting group subjects. keywords: gastroesophageal reflux disease, gerd, ramadhan, islamic fasting. radhiyatam mardhiyah acta med indones-indones j intern med 170 introduction gastroesophageal reflux disease (gerd) is a commonly found disease in the population. a systematic review study by el-serag, et al.1 found that the prevalence of gerd is estimated to be 18.1-27.8% in north america and 2.57.8% in eastern asia and the rate was increasing in the past decades.1,2 gerd itself is defined as gastrointestinal dysfunction, in which the stomach content is refluxed periodically into the esophagus and causes disturbing symptoms.3-5 the most commonly used modalities for gerd symptoms evaluation is gerd questionnaire (gerd-q), which has been translated into multiple languages including indonesian.6-8 gerd symptoms can be induced and exacerbated by several factors such as obesity, smoking habit, alcohol consumption, intake of certain food and drinks and certain dietary pattern.9-15 these factors that affect gerd can change when one is fasting during ramadhan. by definition, fasting means withholding oneself from certain actions such as eating, drinking, smoking, having sexual intercourse, voluntary vomiting, etc. from dawn until sunset for the whole month of ramadhan. ramadhan fasting, which lasts approximately 30 days, causes physiological changes. in a study conducted by iraki et al.16 there was reduced mean of stomach ph in fasting period compared to the non-fasting period in patients who had performed ramadhan fasting over 10 days. however, during ramadhan fasting, actually the individual does not fast for the whole day as there are periodic meals. the meals are time bound, i.e. one before dawn and one after sunset; therefore, when fasting, there is a regular meal pattern. moreover, during ramadhan fasting, there is a change in smoking habit and alcohol consumption. until now, we do not know for certain about the gerd symptoms experienced by the patients during fasting. our study was aimed to identify the effects of fasting on gerd complaints. methods t h i s w a s a l o n g i t u d i n a l s t u d y w i t h consecutive sampling method. the evaluation was performed on the 4th week of ramadhan and 3 months after. our study had obtained ethical approval from the ethical committee on health research, faculty of medicine, university of indonesia number 232/un2.f1/etik/2016. subjects the inclusion criteria for this study were patients aged over 18 years old and had been diagnosed with gerd; while the exclusion criteria were those who refused to participate in the study. subjects were subsequently categorized into the fasting and non-fasting groups. gerd complaints gerd complaints were evaluated using the gerd-q, a gerd questionnaire, which consists of 6 questions and each question has 4 choices of answers with scores of 0-3 for each question. statistical analysis the study results were managed electronically using spss software (statistical product for social science)© version 16.0. paired data analysis was performed using wilcoxon test; while non-paired data was managed using mannwhitney test. data was reported in median and interquartile range since the data could not be reported as a normal distribution. results subject characteristics the study was conducted between july and october 2015 with an objective to evaluate gerd complaints during ramadhan (july 2015) and non-ramadhan period (october 2015). the subject recruitment algorithm is shown in figure 1. about 130 subjects participated in the study and 66 of them were fasting during ramadhan; while the remaining were those in the non-fasting group. most subjects in both groups were male and the median age was 53 years. in both groups, the majority of subjects were not obese and the number of obese subject was less than 10% in each groups. the most common diagnosis in both groups was non-erosive reflux disease (nerd). in the fasting group, there was a statistically significant difference on median gerd-q score vol 48 • number 3 • july 2016 the effects of ramadhan fasting on clinical symptoms in patients with gerd 171 eligible subject (n=175) inappropriate medical record number (n=9) unavailable phone number (n=15) unanswered call (n=21) study subject (n=130) having ramadhan fasting (n=66) not having ramadhan fasting (n=64) figure 1. the algorithm of subject recruitment table 1. subjects’ characteristics characteristics ramadhan fasting group (n=66) non-ramadhan fasting group (n=64) sex, male, n (%) 51 (77) 45 (71) age, median (minimum-maximum) age 53 (20-75) 53 (18-81) body mass index, n (%) non-obese 64 (97) 61 (95) obese 2 (3) 3 (5) diagnosis, n (%) nerd 38 (58) 41 (64) esophagitis a 19 (28) 13 (20) esophagitis b 8 (12) 8 (13) esophagitis c 1 (2) 2 (3) smoking habit during ramadhan, n (%) no smoking 55 (83) 44 (69) smoking 11 (17) 20 (31) smoking habit after ramadhan, n (%) no smoking 45 (68) 53 (83) smoking 21 (32) 11 (17) (p<0.01) between ramadhan with a median value of 0 (interquartil range: 0-2) and non-ramadhan period with an increased median value of 4 (interquartil range: 2.75-5.25). meanwhile, when analysis was performed to compare the median of gerd-q between the fasting and non-fasting group, there was also a significant difference (p<0.01) with median value of 0 (interquartil range: 0-2) in the ramadhan fasting group and a median value of 2 (interquartile range: 0-5) in the ramadhan non-fasting group. in our study, we had determined that the difference in gerd-q values was considered significant when the difference of gerd-q value between nonand during ramadhan period was ≥ 3. as many as 15 subjects in the fasting group had a difference on gerd-q score of more than 3 points between ramadhan (lower gerd-q scores) and non-ramadhan (higher gerd-q scores) period. however, not all subjects experienced changes of gerd-q scores between and non-ramadhan period. there were as many as 9 subjects in the fasting group who did not have altered gerd-q scores and 2 subjects actually had improved gerd-q scores in non-ramadhan period. 2 9 40 15 20 40 4 0 0 5 10 15 20 25 30 35 40 45 worse not different < 3 > 3 n u m b e r o f s u b je c t fasting non-fasting gerd-q score figure 2. comparison on the number of subjects who experienced altered gerd-q score between ramadhan fasting group and non-fasting group radhiyatam mardhiyah acta med indones-indones j intern med 172 discussion the reduction of smoking habit during ramadhan can decrease gerd complaints. however, the shortened interval between the last meal and before sleep can increase the risks of developing gerd. altered gerd-q scores during ramadhan compared to non-ramadhan period as shown in our study will give clinical implications since it can convince patients to keep doing ramadhan fasting without any harm. in the ramadhan fasting group, there was a difference on median of gerd-q scores between ramadhan and non-ramadhan period, in which the median was 0 (lower) in ramadhan period compared to the median of 4 (higher) in non-ramadhan period. the significant increase of gerd-q score in non-ramadhan period compared to ramadhan period in subjects who were in the fasting group is clinically important as it can convince patients to fast during ramadhan. meanwhile, when we carried out an analysis to compare the median of gerd-q score between fasting and non-fasting group, we found a significant difference (p<0.01) with median of 0 (lower) in the fasting group and median of 2 (higher) in the non-fasting group. the result may also convince patients with gerd that they are still able to perform ramadhan fasting. although in our study we had determined that the clinically significant altered gerd-q score discrepancy is ≥ 3, basically a decrease of one point in gerd-q score is actually significant for the patient. in the ramadhan fasting group, there was a change of gerd-q score in more than 55 subjects (83%) and 15 of them experienced a change of gerd-q score of ≥3. previous studies11-13,17-20 reported that smoking can induce gerd complaints and stop smoking can reduce gerd complaints. our study also found that there was a statistically significant difference (p<0.01) in the number of cigarettes smoked between ramadhan and non-ramadhan period as well as between fasting and nonfasting group. during ramadhan, the number of cigarettes smoked ranges from 0-6 cigarette(s) in the fasting group and 0-12 cigarette(s) in the non fasting group. however, there was an increase number of smoked cigarettes in nonramadhan month by the fasting group, which is 0-12 cigarette(s). in addition to smoking habits, another factor which correlates with gerd symptoms is eating pattern. previous studies on eating pattern demonstrated that a short interval between the last meal and sleeping is one of the most influencing factor in developing gerd.9,12,13 if someone who is fasting chooses to have a big meal after isya prayer or tarawih, then he/ she will have a closer interval between his/her last meal and sleeping. it may increase the risk of developing gerd complaint. however, in our study, we found no significant difference (p=0.179) regarding the interval between the last meal and sleeping during ramadhan and non-ramadhan period in the fasting group. insignificant difference was also found when we performed analysis in both groups (p=0.108). to confirm whether smoking is a confounding factor in improving gerd complaints during ramadhan, further analysis was carried out by including only non-smoking subjects (both in ramadhan and non-ramadhan period). by using the analysis, we again found that the difference of gerd-q score was statistically significant. therefore, it can be concluded that smoking is not the only contributing factor to the change of gerd complaints. considering that there was no previous data about the months prior to ramadhan in our study; therefore, we could not determine whether the two subjects who experienced improved gerd-q scores in non-ramadhan months were actually experienced more severe gerd complaints during ramadhan. it is possible that the gerd complaints of both subjects before ramadhan were even worse, which was getting better during ramadhan and improved more afterwards. nevertheless, our study also could not confirm the factors that lowered the gerd-q scores in both subjects in non-ramadhan month. both subjects had no difference in smoking habit between during and non-ramadhan months (both subjects were non smokers); there were also no differences in eating and sleeping habits. both subjects also did not consume any alcohol. it is possible that there is another factor that can affect the change of gerd conditions in both subjects such as psychological vol 48 • number 3 • july 2016 the effects of ramadhan fasting on clinical symptoms in patients with gerd 173 factors which has not been evaluated in our study. in our study, there was no randomization since the subjects were categorized automatically into the fasting and non-fasting group. therefore, the blinding to the intervention (in this case, the ramadhan fasting) could not be performed because the subjects were fully aware whether he/she had fasting or not. other than the difference on the intervention, subjects in both groups received equal treatment. a significant difference in gerd-q scores in the fasting group between during ramadhan and the non-ramadhan months is clinically important as it can convince patients with gerd to fast during ramadhan. our study was also conducted in gerd patients who had one whole month fasting at the outpatient clinic since most patients did not require hospitalization. however, considering the study results could not be presented in a normal distribution; therefore, the application of our results in general population must be done with great caution. our study limitation includes the absence of data prior to the ramadhan month. it may occur since our study was only aimed to compare complaints between ramadhan and non-ramadhan months. other factors that may become the limitation of our study are the absence of analysis on other factors that may affect gerd complaints such as psychological factor and the type of food consumed. nevertheless, to our knowledge, our study is the first study evaluating the effect of ramadhan fasting on gerd complaints. conclusion gerd complaints are milder in subjects who perform fasting during ramadhan than nonramadhan month. moreover, during ramadhan, gerd complaints are less severe compared to those who do not perform ramadhan fasting. acknowledgments this research was supported by pitta grants from drpm ui (directorate of research and community engagement, universitas indonesia). references 1. el-serag hb, sweet s, winchester cc, dent j. update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. gut. 2014;63(6):871-80. 2. syam af, abdullah m, rani aa. prevalence of reflux esophagitis, barret’s esophagus and esophageal cancer in indonesian people evaluation by endoscopy. canc res treat. 2003;5:83. 3. the indonesian society of gastroenterology. national consensus on the management of gastroesophageal reflux disease in indonesia. acta med indonesindones j intern med. 2014;46(3):263-71. 4. vakil n, veldhuyzen van zanten s, kahrilas p. the montreal definition and classification of gastroesophageal reflux disease (gerd) a global evidencebased consensus. am j gastroenterol. 2006;101:190020. 5. fock km, talley nj, fass r, kahrilas p. asia-pacific consensus on the management if gastroesophageal reflux disease: update. j gastroenterol hepatol. 2008;23:8-22. 6. jones r, junghard o, dent j, et al. development of the gerdq, a tool for the diagnosis and management of gastro-oesophageal reflux disease in primary care. aliment pharmacol ther. 2009;30(10):1030-8. 7. shaw m, talley n, beebe t, rockwood t, carlsson r, adlis s. initial validation of a diagnostic questionnaire for gastroesophageal reflux disease. am j gastroenterol. 2001;96:52-7. 8. simadibrata m, rani a, adi p, djumhana a, abdullah m. the gastroesophageal reflux disease questionnaire using indonesian language: a language validation survey. med j indones. 2011;20(2):125-30. 9. kang jhe, kang jy. lifestyle measures in the management of gastrooesophageal reflux disease: clinical and pathophysiological considerations. ther adv chronic dis. 2015;6(2):51-64. 10. bhatia sj, reddy dn, ghoshal uc, et al. epidemiology and symptom profile of gastroesophageal reflux in the indian population: report of the indian society of gastroenterology task force. indian j gastroenterol. 2011;30(3):118-27. 11. festi d, scaioli e, baldi f, et al. body weight, lifestyle, dietary habits and gastroesophageal reflux disease. world j gastroenterol. 2009;15(14):1690-701. 12. fujiwara y, arakawa t. epidemiology and clinical characteristics of gerd in the japanese population. j gastroenterol hepatol. 2009;44(6):518-34. 13. minatsuki c, yamamichi n, shimamoto t, et al. background factors of reflux esophagitis and nonerosive reflux disease: a cross-sectional study of 10,837 subjects in japan. plos one. 2013;8(7):e69891. 14. goh kl. gastroesophageal reflux disease in asia: a historical perspective and present challenges. j gastroenterol hepatol. 2011;26(suppl1):2-10. 15. j a r o s z m , ta r a s z e w s k a a . r i s k f a c t o r s f o r gastroesophageal reflux disease: the role of diet. prz gastroenterol. 2014;9(5):297-301. radhiyatam mardhiyah acta med indones-indones j intern med 174 16. iraki l, bogdan a, hakkou f, amrani n, abkari a, touitou y. ramadan diet restrictions modify the circadian time structure in humans. a study on plasma gastrin, insulin, glucose, and calcium and on gastric ph. j clin endocrin metabolism. 1997;82(4):1261-73. 17. minatsuki c, yamamichi n, shimamoto t, et al. background factors of reflux esophagitis and nonerosive reflux disease: a cross-sectional study of 10,837 subjects in japan. plos one. 2013;8(7):e69891. 18. sharma pk, ahuja v, madan k, gupta s, raizada a, sharma mp. prevalence, severity, and risk factors of symptomatic gastroesophageal reflux disease among employees of a large hospital in northern india. indian j gastroenterol. 2011;30(3):128-34. 19. ness-jensen e, lindam a, lagergren j, hveem k. tobacco smoking cessation and improved gastroesophageal reflux: a prospective populationbased cohort study: the hunt study. am j gastroenterol. 2014;109:171-7. 20. song jh, chung sj, lee jh, et al. relationship between gastroesophageal reflux symptoms and dietary factors in korea. j neurogastroenterol motil. 2011;17(1):5460. 210 acta med indones indones j intern med • vol 54 • number 2 • april 2022 original article similar blood glucose pattern with highest peak at minute 45 on oral glucose tolerance test despite higher fasting insulin and insulin resistance in healthy obese than non-obese subject made ratna saraswati1*, ida bagus aditya nugraha2, ketut suastika1 1division of endocrinology and metabolism, department of internal medicine, faculty of medicine udayana university sanglah hospital, denpasar, bali, indonesia. 2department of internal medicine, faculty of medicine udayana university sanglah hospital, denpasar bali, indonesia. * corresponding author: made ratna saraswati, md. division of endocrinology and metabolism, department of internal medicine, faculty of medicine udayana university sanglah hospital. jl. p.b. sudirman, kota denpasar, bali 80232, indonesia. email: ratnasaraswati@unud.ac.id abstract background: obesity increase the risk for type 2 diabetes through induction of insulin resistance. diagnosis of diabetes were based on blood glucose level. however, insulin resistance may had happened far before diagnosis itself. this study aimed to compare fasting insulin level, insulin resistance, and blood glucose pattern during oral glucose load in healthy obese and non-obese subject. methods: this semi-experimental study was conducted at department of internal medicine, sanglah hospital, denpasar. sixteen subjects in each obese and non-obese group were matched by age and sex. obesity was defined based on body mass index (bmi) of ≥25kg/m2 and waist circumference (wc) ≥80cm (female) or ≥90cm (male). the non-obese group was defined by bmi of 18-25kg/m2 and wc <80cm (female) or <90cm (male). fasting insulin level and blood glucose was measured at minute 0, 15, 30, 45, 60, 75, 90, 120 after glucose load of 75 grams. insulin resistance was calculated based on homeostasis model assessment of insulin resistance (homa-ir) with the following formula: homa-ir = (fpi×fpg)/22.5. normal glucose tolerance (ngt) and impaired glucose tolerance (igt) subject was defined by american diabetes association (ada) criteria. results: fasting insulin level in obese subjects was higher than non-obese subjects with median 12.75 (range 3.70 – 41.30) vs 3.80 (1.80 – 36.80) µu/ml, p=0.041. homa ir was also higher in obese subjects compared to non-obese subjects: 2.45 (0.70 – 8.00) vs 0.80 (0.40 – 8.50), p=0.001. fasting insulin level was correlated with bmi (r=0.559, p=0.001) and wc (r=0.633, p<0.001). a significant correlation was also detected between homa ir with bmi (r=0.528, p=0.002) and wc (r=0.600, p<0.001). blood glucose pattern in four groups: obese igt, obese ngt, non-obese igt, and non-obese ngt, were typically similar, in particular two peaks of blood glucose. the first peak was the highest blood glucose, shown in minute 45 in both obese and non-obese subjects. the second peak was lower than the first peak, found in minute 75 among ngt and minute 90 among igt subject. blood glucose level for each measurement point was consistently higher in obese than nonobese subjects. conclusion: fasting insulin level and homa-ir were higher in obese than in non-obese subjects. bmi and wc were significantly correlated with fasting insulin level and homa ir, so that high bmi and wc can be an earlier clinical sign of insulin resistance and prediabetes. pattern of blood glucose level after oral glucose load were similar with two peaks, and blood glucose consistently higher in obese compared to non-obese subjects. the highest peak of blood glucose, shown in minute 45 in both obese and non-obese subjects. keywords: blood glucose pattern, ogtt, fasting insulin, homa ir vol 54 • number 2 • april 2022 similar blood glucose pattern with highest peak at minute 45 on oral 211 introduction prevalence of diabetes is markedly increasing, along with increasing prevalence of obesity. according to the idf atlas 10th edition 2021, the number of people with diabetes in indonesia is 19.6 million, placing at the 5th rank of top 10 countries or territories for number of adults (20–79 years) with diabetes in 2021 and 2045, rising from 7th rank in 2019.1,2 the increasing rank is predictable since indonesia was at 3rd rank of top 10 countries or territories for the number of adults (20–79 years) with impaired glucose tolerance (igt) in 2019. in order to avoid burden of diabetes and its complications, preventing diabetes is important. early detection and early management of prediabetes is the key strategy to prevent diabetes. study on 3234 nondiabetic persons aged 25 or more with elevated fasting and post-load plasma glucose concentrations revealed that a lifestylemodification program with the goals of at least a 7 percent weight loss and at least 150 minutes of physical activity per week in diabetes prevention program, reduced the incidence of diabetes by 58 percent after followed for an average of 2.8 years.3 similar study on long term effect of lifestyle interventions to prevent diabetes in the china da qing diabetes prevention study enrolled 577 adults with impaired glucose tolerance showed 51% lower incidence of diabetes during the active intervention period and a 43% lower incidence over the 20 year period.4 obesity increased the risk for type 2 diabetes through induction of insulin resistance which is thought to precede the development of diabetes 10 to 15 years.5-7 the development of insulin resistance typically results in a compensatory increase in endogenous insulin production, and at the time of compensatory insulin secretion, blood sugar may remain normal while hyperinsulinemia as a consequences of insulin resistance affect the metabolism known as metabolic syndrome.8 direct measurement of insulin resistance can be done by measuring insulin-mediated glucose disposal during insulin suppression test and the gold standard is the hyperinsulinemic-euglycemic glucose clamp technique. this test is a research technique with limited clinical applicability due to impractically and expensive. some efforts have been tried to use both the fasting plasma glucose and insulin concentration to estimate of insulin-mediated glucose disposal in more practical way, and several indices have been proposed, including homeostasis model assessment insulin resistance (homa ir).9 in a study of 490 healthy nondiabetic volunteers, fasting plasma insulin concentration accounted for approximately one-third of the variability in insulin-mediated glucose disposal, and fasting plasma insulin concentration as well as homa ir was significantly correlated to the specific estimate of insulin action.10 these two approaches, measuring fasting plasma insulin level and calculating homa ir, has almost universally been used in large population-based epidemiological studies, however in clinical practice still relatively expensive and not widely available. for a clinical purpose, we need to define more practical surrogate marker of insulin resistance. there are some difficulties in early detection of diabetes and prediabetes since the symptoms may not be obvious. the available test in clinical practice as per guideline are fasting blood glucose and blood glucose two hours post oral glucose load during oral glucose tolerance test (ogtt), which may lead particular high risk patient detected as normal glucose tolerance since the peak blood glucose could not be captured. this study aims to compare the fasting insulin level, insulin resistance, and blood glucose pattern during oral glucose load in healthy subject without history of diabetes divided into obese and non-obese groups. this study defined glucose pattern in more detail during ogtt and confirmed the importance of simple measurement of obesity in clinical practice to recognize insulin resistance regardless blood sugar level. methods this semi-experimental study was conducted at department of internal medicine, sanglah hospital, denpasar. a total of 32 subjects without history of diabetes were recruited, grouped into obese and non-obese groups, matched by age and sex. age of subjects was between 20-50 made ratna saraswati acta med indones-indones j intern med 212 years (mean age 31.46 sd 4.81 years). obesity was defined based on body mass index (bmi) of ≥25kg/m2 and waist circumference (wc) ≥80cm (female) or ≥90cm (male). the non-obese group had bmi of 18-25kg/m2 and wc <80cm (female) or <90cm (male).11 subjects were instructed to fast for at least 8 and maximum 12 hours before performing the procedure. blood sample for measurement of fasting plasma glucose level and fasting insulin level were drawn in fasting state (minute 0). oral glucose load using 75 g anhydrous glucose dissolved in 250 ml water was done in no more than 5 minutes. during oral glucose tolerance test (ogtt), capillary blood glucose level were measured in several time points at minutes 0, 15, 30, 45, 60, 75, 90 and at 120 after glucose load. another blood sample was drawn at minute 120 during ogtt for plasma glucose to confirm the normal glucose tolerance (ngt), impaired glucose tolerance (igt), or diabetes categorization. fasting insulin level was measured by solid phase enzyme-labeled chemiluminescent immunometric assay, using immulite® 2000 insulin analysis system, cat. no. l2kin2 (siemens). fasting plasma glucose (fpg) and 2 hours plasma glucose (2hpg) during oral glucose tolerance test (ogtt) were measured by enzymatic hexokinase method. capillary blood glucose was measured using glucometer (accucheck®, roche) at minutes 0, 15, 30, 45, 60, 75, 90, and 120 after 75-gram glucose load. based on fpg and 2hpg during ogtt, subjects were categorized as normal, prediabetes, or diabetes. prediabetes are defined by impaired glucose tolerance (igt) and/or impaired fasting glucose (ifg). ifg is defined as fpg levels between 100-125mg/dl, and igt as 2-h pg levels between 140 and 199 mg/dl during 75-g ogtt. diabetes is defined by fpg ≥126mg/dl or 2-h pg ≥200 mg/dl during ogtt.12 insulin resistance was calculated based on homeostasis model assessment of insulin resistance (homair) with the following formula: homair = (fpi×fpg)/22.5.13 data were analyzed for normality by shapiro-wilk test, and expressed descriptively in mean ± sd for normally distributed data or in median with range for not normally distributed data. the difference of median fasting insulin and homa ir were calculated by non-parametric test. correlation between fasting insulin and homa ir with bmi and wc were measured by spearman’s rho. repeated measurement general linier model was applied to define the blood glucose pattern during ogtt. in all statistical analyses, values of p<0.05 were considered significant. t h e s t u d y a p p r o v e d b y t h e e t h i c a l committee of the faculty of medicine udayana university and sanglah hospital (no. 2145/ un.14.2/keep/2017), and authorised by the director of sanglah hospital (no. lb.02.01/ ixiv.2.2.1/34463/2017). all subjects were given information regarding this study and signed the informed consent. this study was conducted by the declaration of helsinki. results subject recruited in this study aged between 27-48 years old (mean 31.46 + 4.81), age and sex matched, each group consisted of 8 males and 8 females. based on the fpg and 2-h pg during ogtt, 4 subjects in obese group and 1 subject in non-obese group were categorized igt, none of the subjects were categorized ifg or diabetes. distribution of fasting insulin level and homa-ir were not normally distributed. thus, data for these variables was presented in median and range (table 1). fasting insulin in obese subjects was higher than non-obese subjects, median 12.75 (range 3.70 – 41.30) vs 3.80 (1.80 – 36.80) µu/ml, p=0.041. homa ir was also higher in obese subjects than non-obese subjects: 2.45 (0.70 – 8.00) vs 0.80 (0.40 – 8.50), p=0.001 (table 1). fasting insulin level was correlated with bmi (r=0.559, p=0.001) and wc (r=0.633, p<0.001). a significant correlation was also detected between homa ir with bmi (r=0.528, p=0.002) and wc (r=0.600, p<0.001). the pattern of increasing blood glucose level during ogtt was similar between obese and non-obese subjects. pattern in both groups showed two peaks. the first peak blood glucose was at minute 45 (161.31 sd 25.24 mg/dl) follow by slightly lower at minute 60, and second vol 54 • number 2 • april 2022 similar blood glucose pattern with highest peak at minute 45 on oral 213 peak was at minute 75 (155 sd 26.23 mg/dl) followed by lower level of blood glucose the minutes after (figure 1). blood glucose level for each point of measurement was consistently higher in obese than non-obese subjects. test of sphericity for the blood glucose is significant (p=0.000) so the assumption of sphericity has not been met, then tests of between subject effects was conducted using the greenhouse-geisser row which was significant (p= 0.000). since not all subjects were categorized ngt based on the fpg and 2-h pg during ogtt (4 subjects in obese group and 1 subject in non-obese group were categorized igt), the pattern of blood glucose during ogtt were further divided into four groups, obese igt, obese ngt, non-obese igt, and non-obese ngt. generally, the blood glucose pattern in igt were higher than ngt in all point minutes of examination, in both obese and non-obese groups. blood glucose pattern in these 4 groups were typically similar, showing two peaks of blood glucose level. the first peak of blood sugar was in minute 45 in all groups, the second peak among ngt subjects was found at minute 75 meanwhile among igt subjects was found delayed: at minute 90 (figure 2). table 1. characteristics of the subject. variable (unit) data distribution mean (sd) or median (range) obese n=16 non obese n=16 total n=32 age (years) 31.56 (4.76) 31.37 (5.03) 31.46 (4.81) body height (cm) 164.40 (9.89) 163.25 (10.16) 163.82 (9.88) body weight (kg) 84.74 (15.94) 59.33 (10.77) 72 (18.59) bmi (kg/m2) 31.10 (2.91) 22.15 (2.31) 26.62 (5.23) wc (cm) 97.31 (10.38) 77.62 (6.92) 87.46 (13.24) fasting insuln (µu/ml) 12.75 (3.70 – 41.30) 3.80 (1.80 – 36.80) 7.25 (1.80 – 41.30) homa ir 2.45 (0.70 – 8.00) 0.80 (0.40 – 8.50) 2.50 (0.40 – 8.50) figure 1. blood glucose level for each minute point measurement during oral glucose tolerance test (ogtt) in obese and non-obese made ratna saraswati acta med indones-indones j intern med 214 based on kruskal-wallis test, the distribution of fasting insulin across ngt or igt and obese or non-obese categorizations were significantly different (p=0.005). the median of fasting insulin level across these categories were significantly different (p=0.41) (figure 3a). similar finding was found for the distribution of homa ir between ngt or igt categories in both obese and non-obese groups (p=0.004). the median of homa ir across these categories were significantly different (p=0.001) (table 2). since there was only 1 non-obese subject with igt, the median data and range has been omitted. fasting insulin level in this subject was 1.90 µu/ml and homa ir was 0.4. one non-obese subject with ngt has outlier fasting insulin level (36.80 µu/ml) and homa ir (8.5), as shown on the figure (figure 3a and 3b). fasting insulin and homa ir were not correlated with blood glucose level at any of point measurement between minute 15 to 120. figure 2. blood glucose level for each minute point measurement during ogtt in 4 groups: obese igt, obese ngt, non-obese igt, and non-obese ngt (ogtt = oral glucose tolerance test, ngt= normal glucose tolerance, igt=impaired glucose tolerance) figure 3. median fasting insulin (a) and homa ir (b) in each group of obese igt/ngt and non-obese igt/ngt (ngt= normal glucose tolerance, igt=impaired glucose tolerance) vol 54 • number 2 • april 2022 similar blood glucose pattern with highest peak at minute 45 on oral 215 discussion obesity is a rapidly growing nutritional disorder characterized by excessive accumulation of adipose tissue. increased body weight is associated with insulin resistance and type 2 diabetes mellitus. in this study we found that obese subjects have higher fasting insulin level as well as homa ir, and both the fasting insulin level and homa ir were correlated significantly with the clinical obese parameters: bmi and wc. higher fasting insulin level and homa ir, as well as positive correlation between bmi dan wc with homa ir confirmed the hypothesis that obese subjects were more likely to have insulin resistance compared with non-obese subjects. in this study, one non-obese subject with ngt has high level of fasting insulin (36.80 µu/ ml) and homa ir (8.5), as shown on the figure (figure 3a and 3b). insulin resistance is present in the majority of patient with impaired glucose tolerance (igt) or non-insulin-dependent diabetes mellitus (niddm) and in 25% of nonobese with normal oral glucose tolerance.14 based on history, all subjects were considered to be healthy. however based on 2-hour plasma glucose during ogtt, 4 out of 16 subjects (25%) in obese group were identified as prediabetes (more specifically igt), while in non-obese group only 1 subject was categorized as such (6.3%). this finding confirmed that obese subjects were more prone to be prediabetes. blood glucose level for each point of measurement was consistently higher in obese than non-obese subjects. pattern of increasing blood glucose level during ogtt were similar between obese and non-obese subjects in which they shown 2 peaks of blood glucose level regardless of their categorization as ngt or igt. the first peak level of blood glucose level occurred in minute 45 during ogtt, followed by lower blood glucose. the second peak occurred in minute 75 among ngt subjects and a little delayed in minute 90 among igt subjects. since the number of igt subjects was low, we need further study to evaluate the pattern of blood glucose in igt subjects and evaluate the insulin response to explain this finding. fasting and 2-hour after 75 g glucose load on ogtt have been used to diagnose prediabetes and diabetes. however, evidence indicates that clinically relevant pathophysiological i n f o r m a t i o n c a n b e o b t a i n e d b y a d d i n g intermediate time-points to a standard ogtt. a population-based study of 3666 asian indians underwent a three-point (fasting, minute 30 and 120) ogtt at baseline and then followed by another ogtt after 2 years follow up, found that elevated blood glucose at minute 30 after glucose load was associated with high risk of incident diabetes, even in individuals classified as ngt by a traditional ogtt.15 another cohort study of 5861 participants without diabetes at baseline from the danish inter99 study underwent similar three point (fasting, minute 30 and 120) ogtt identified four distinct glucose patterns during the ogtt, and the pattern with elevated glucose at minute 30 was associated with increased risk of diabetes and all-cause mortality rate independent of fasting and 2 hours glucose levels.16 there is no data of minute 45 blood glucose in these particular studies. these findings alert us to define the highest peak of blood glucose during ogtt, so that we could choose the best time reflecting peak of blood glucose. in our study by doing frequent blood glucose measurement every 15 or 30 minutes (minute 0, 15, 30, 45, 60, 75, 90, 120) after glucose load on ogtt we found two peaks of the glucose pattern. compare to these two studies, instead of minute 30, we found the first peak was at minute 45, the second peak was at minute 75 among ngt subject and at tabel 2. fasting insulin and homa ir in obese and non-obese subject. group fasting insulin ((µu/ml) homa ir median range median range obese igt 14.65 7.20 – 19.60 3.20 1.60 – 4.70 ngt 12.75 3.70 – 41.30 2.45 0.70 – 8.00 non obese ngt 3.90 1.80 – 36.80 0.80 0.40 – 8.50 made ratna saraswati acta med indones-indones j intern med 216 minute 90 among igt subjects. the first peak at minute 45 was the highest. based on our finding, we conclude that considering only fasting and 2 hours glucose levels during an ogtt may not revealed the actual highest level of blood sugar. we suggest to check blood glucose at minute 45 during ogtt, in particular patient who are obese and high risk diabetes. whether the 45 minute blood glucose provide a better prediction for future diabetes need further evaluation. we suggest to follow the obese subject group and reevaluate the blood glucose and fasting insulin level after a period of time. the data would be more comprehensive and important, if we could prescribe interventions to prevent more severe insulin resistance followed by longitudinal evaluation whether such intervention could prevent prediabetes and diabetes. conclusion fasting insulin level and homa-ir were higher in obese than in non-obese subjects. the bmi and wc were significantly correlated with fasting insulin level and homa ir. since fasting insulin and homa ir were not correlated with blood glucose level during ogtt, these two simple markers of clinical obesity (high bmi and wc) should be taken as an earlier predictor of insulin resistance and prediabetes in clinical practice regardless blood glucose level. pattern of blood glucose level after oral glucose load were similar with two peaks despite higher fasting insulin and homa ir in obese than in non-obese subject. even though fasting insulin and homa ir were not correlated with blood glucose level at any of point measurement during ogtt, blood glucose consistently higher in obese compared to non-obese subjects. the highest peak blood glucose, shown in minute 45 in both obese and non-obese subjects. based on this finding, we suggest to check blood glucose at minute 45 during ogtt in particular for obese and high risk diabetes patient. authors’ contribution mrs designed the study and performed data analysis, interpreted the data, and drafted the original manuscript. iban participated in informing subject and data collection. ks helped revised the final manuscript. all authors read and approved the final manuscript. acknowledgments laboratory measurement was conducted at prodia laboratory, denpasar, and the authors would like to convey gratitude for the technical assistance provided by the laboratory. we would also like to convey our gratitude to roche for providing the glucometer (accucheck®, roche) used in capillary blood glucose measurement in this study. references 1. international diabetes federation. idf diabetes atlas, 10th edn. brussels, belgium: 2021. available at: https://www.diabetesatlas.org. downloaded: 20 december 2021 2. idf diabetes atlas. 9th edition, 2019. https:// www.diabetesatlas.org/upload/resources/2019/ idf_atlas_9th_edition_2019.pdf. downloaded: 20 december 2021. 3. knowler wc, barrett-connor e, fowler se, et al. diabetes prevention program research group. reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. n engl j med. 2002;346(6):393-403. doi: 10.1056/nejmoa012512. pmid: 11832527; pmcid: pmc1370926. 4. pendergrass m, li g, zhang p, et al. the long-term effect of lifestyle interventions to prevent diabetes in the china da qing diabetes prevention study: a 20year follow-up study. diabetes care. 2008;31:1921-2. 5. blüher m. adipose tissue dysfunction in obesity. exp clin endocrinol diabetes. 2009;117(06):241-50. doi:10.1055/s-0029-1192044. 6. ye j. mechanisms of insulin resistance in obesity. front med. 2013;7(1):14-24. doi:10.1007/s11684013-0262-6. 7. kahn bb, flier js. obesity and insulin resistance. j clin invest. 2000;106(4):473-81. doi:10.1172/ jci10842. 8. reaven g. the metabolic syndrome or the insulin resistance syndrome? different names, different concepts, and different goals. endocrinol metab clin n am. 2004;33:283–303. vol 54 • number 2 • april 2022 supportive psychotherapy for healthcare professionals 217 9. matthews dr, hosker jp, rudenski as, naylor ba, treacher df, tu rner rc. homeostasis model assessment: insulin resistance and b-cell function from fasting plasma glucose and insulin concentrations in man. diabetologia. 1985;28:412–9. 10. yeni-komshian h, carantoni m, abbasi f, reaven gm. relationship between several surrogate estimates of insulin resistance and quantification of insulinmediated glucose disposal in 490 healthy, nondiabetic volunteers. diabetes care. 2000;23:171–5. 11. world health organization. regional office for the western pacific. (‎2000)‎. the asia-pacific perspective: redefining obesity and its treatment. sydney : health communications australia. https://apps.who.int/iris/ handle/10665/206936. 12. american diabetes association. 2. classification and diagnosis of diabetes: standards of medical c a r e i n d i a b e t e s – 2 0 2 1 . d i a b e t e s c a r e . 2021;44(suppl.1):s15-s33. 13. diabetes trial units. homa calculator. the oxford centre for diabetes, endocrinology and metabolisms, university of oxford. available from: http://www.dtu. ox.ac.uk/homacalculator/. downloaded: 10 august 2020. 14. reaven gm. role of insulin resistance in human disease. diabetes. 1988;37(12):1595-607. doi:10.2337/ diab.37.12.1595. 15. hulman a, gujral up, narayan kmv, pradeepa r, mohan d, anjana rm, mohan v, færch k, witte dr. glucose patterns during the ogtt and risk of future diabetes in an urban indian population: the carrs study. diabetes res clin pract. 2017;126:192-197. doi: 10.1016/j.diabres.2017.01.009. epub 2017 feb 17. pmid: 28259008; pmcid: pmc5408861. 16. hulman a, vistisen d, glümer c, bergman m, witte dr, færch k. glucose patterns during an oral glucose tolerance test and associations with future diabetes, cardiovascular disease and all-cause mortality rate. diabetologia. 2018;61(1):101-107. doi: 10.1007/ s00125-017-4468-z. epub 2017 oct 6. pmid: 28983719. medical illustration extrapulmonary manifestations covid-19 erni j. nelwan,1* rahajeng n. tunjungputri,2 erpryta n. tetrasiwi,2 richella k. lauditta,1 leonard nainggolan1 1 division of tropical and infectious disease. department of internal medicine faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. * corresponding author: erni juwita nelwan, md., phd. division of tropical and infectious disease. department of internal medicine faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: erni.juwita@ui.ac.id. figure 1. (a). a 44 year-old-female patient with covid-19 stomatitis and (b) after recovery. (c) a 37-year-old male with covid-19 conjunctivitis and (d) after recovery. (e) a 44-year-old female with covid-19 pharyngitis. (f) a 30-year-old female with covid-19-associated atrial fibrillation. 314 acta med indones indones j intern med • vol 54 • number 2 • april 2022 vol 54 • number 2 • april 2022 extrapulmonary manifestatation covid-19 315 cardiovascular risk and neither personal nor family history of cardiovascular disease. due to complaints of fever, she underwent sarscov-2 pcr which came back positive. on day 7, she complained of sudden lightheadedness, exertional dyspnea, anxiety and palpitations and went to the emergency department. ecg was performed, showing non-rapid ventricular response atrial fibrillation (figure 1f). upon further examinations, n-terminal prohormone of brain natriuretic peptide (nt-probnp), crp, troponin i, and echocardiography were found to be normal. she was admitted for observation, and was started oral bisoprolol. ecg was evaluated the following morning and normal sinus rhythm was found. in these 4 patients, covid-19 stomatitis, conjunctivitis, pharyngitis and covid-19-associated atrial fibrillation was subsequently diagnosed, respectively. in the pandemic stage of covid-19, covid-19 screening has often been routinely performed due to the high risk of transmission.5 however, the decrease in the number of covid-19 cases may prompt physicians to perform sars-cov-2 testing based on clinical suspicion. it is imperative to consider the likelihood of covid-19 and perform sarscov-2 pcr in patients with extrapulmonary complaints that have persisting complaints despite treatment. references 1. ritchie h, mathieu e, rodés-guirao l, et al. coronavirus pandemic (covid-19). 2020. 2. elrobaa ih, new kj. covid-19: pulmonary and extra pulmonary manifestations. frontiers in public health. 2021;9. 3. g u p t a a , m a d h a v a n m v, s e h g a l k , e t a l . extrapulmonary manifestations of covid-19. nature medicine. 2020;26(7):1017-32. 4. abobaker a, raba aa, alzwi a. extrapulmonary and atypical clinical presentations of covid‐19. j medical virology. 2020;92(11):2458-64. 5. chin et, huynh bq, chapman lac, murrill m, basu s, lo nc. frequency of routine testing for coronavirus disease 2019 (covid-19) in high-risk healthcare environments to reduce outbreaks. clinical infectious diseases. 2021;73(9):e3127-e9. after being declared as a pandemic on march 11, 2020 by the world health organization, covid-19 has affected 497 million people worldwide as of 9 april 2022.1 covid-19 is a disease with a plethora of clinical manifestations, which extends to those beyond pulmonary signs and symptoms. studies that report on the clinical presentation of covid-19 rarely report specifically on cases with only extrapulmonary manifestations of covid-19.2,3 extrapulmonary clinical presentations of covid-19 without pulmonary signs and symptoms is rare, and in such cases, covid-19 is rarely suspected.4 we herewith describe four patients with extrapulmonary manifestations of covid-19, with positive sars-cov-2 pcr when the test was performed for initial patient screening. the first patient is a 44-year-old female who developed painful ulcer (figure 1a) with burning sensation at the lateral side of the tongue along with low grade fever. this symptom appeared after the initial complaints of coughing and nasal congestion subsided. she received steroid-containing mouthwash and aloclair topical. she had no complaint after 14 days. however, the tongue lesion had not recovered completely (figure 1b). the second patient is a 37-year-old male, who complained of red eyes (figure 1c) with itchiness and increased tear production for 3 days before seeing an ophthalmologist. he received anti-inflammatory topical eyedrop 6 times daily. he developed coughing and burning sensation of the throat. on day 10, due to the persistence of symptoms, pcr sars-cov-2 was performed and came back positive. the eye redness eventually subsided after 12 days of symptom onset (figure 1d). the third patient is a 44-year-old female who developed burning sensation and soreness on her throat (figure 1e) upon swallowing with fever and chills. these symptoms appear consecutively without any respiratory complaint. she received symptomatic medications, and symptoms last for a total of 7 days. her complaints were resolved after 14 days. the fourth patient is a previously healthy, 30-year-old female, with a normal weight and bmi, and without any comorbidity, 142 acta med indones indones j intern med • vol 55 • number 2 • april 2023 original article the iodine status of women of childbearing age in an iodine-repleted area: an epidemiological study in sengi village on merapi mountain area heri nugroho1*, tjokorda gde dalem pemayun1, darmono1, banundari rachmawati2 1division of endocrine-metabolism, department of internal medicine, faculty of medicine diponegoro university kariadi general hospital, semarang, indonesia. 2department of clinical pathology, faculty of medicine diponegoro university kariadi general hospital, semarang, indonesia. corresponding author: heri nugroho, md., phd. division of endocrine-metabolism, department of internal medicine, faculty of medicine diponegoro university kariadi general hospital. jl. prof mr. sunario, tembalang, semarang 50275, indonesia. email: khris_heri@yahoo.com. abstract background: the low iodine content of daily water sources and repeated volcanic eruptions are expected to affect the iodine status and thyroid hormone profile of women of childbearing age in the magelang regency. this study aimed to determine the iodine and thyroid profile among women of childbearing age. methods: we used a cross-sectional descriptive study to learn about 140 women of reproductive age living in sengi village from october 2017 to january 2018. we assessed the iodine level, dietary intake, and goitrogenic food consumption using food frequency questionnaire (ffq), urinary iodine concentration (uic), thyroid stimulating hormone (tsh) and free thyroxine (ft4), and total goiter rate (tgr). results: the median uic was 199.5 (126.0 – 264.0) µg/l. the tgr was 10.7% on palpation and 7.8% on ultrasound. the proportion of uic levels below 100µg/l was 18.5%. the mean water iodine content was 2.03 ± 4.74 μg/l. the mean salt iodine level was 28.6±13.7ppm. there were only 35% who consumed salt with adequate iodine contents, and only 19.29% consumed >150µg iodine from daily dietary intake based on ffq. the median tsh and ft4 levels were 1.72 and 1.51miu/l. conclusion: women of childbearing age in sengi village generally had adequate iodine profiles and normal thyroid hormone levels but a considerable proportion of tgr and low uic. the iodine contents within the freshwater source, table salt, and daily dietary intake were low. there are no significant association between iodine status, daily goitrogen intake, daily iodine intake and salt iodine concentration keywords: iodine profile, thyroid, women of childbearing age. introduction iodine deficiency has been one of the major public health problems around the globe.1,2 in indonesia, the national iodine deficiency disorders (idd) survey showed that 8,2% were severely endemic to idd.3 in central java, the prevalence of iodine deficiency was 24.9%, in which the magelang regency accounts for 14.3% of the total cases.3 the spectrum of idd may affect any age, and the impacts include miscarriage, stillbirth, increased perinatal morbidity and mortality, goiter, and hypothyroidism.4 children, pregnant women, and lactating women are the most vulnerable groups.4 undiagnosed idd among women of childbearing age might increase the risk of developing idd vol 55 • number 2 • april 2023 the iodine status of women of childbearing age in an iodine-repleted area 143 and/ or its devastating consequences later during pregnancy and lactating period.4,5 the world health organization (who) and the international council for control of iodine deficiency disorders (iccidd) have propagated the use of household iodized salt to manage idd.6 in 2020, 124 countries or around 88% of the world’s population have put in place regulations about mandatory salt iodination.7 in indonesia, the widely used household iodized salt is potassium iodate (kio3), with a minimum concentration of 30-80 ppm kio3. 3 the national household coverage of adequately iodized salt in indonesia is 55.1%, with higher coverage in the urban population (59.3%) than in the rural counterpart (51.4%).8 geographical conditions, such as climate, topography, and land material, greatly affect the iodine availability in the area.9 people living in the mountain area usually have a higher risk of developing idd compared to those who live in the lowland areas.10 in 2007, the soil in areas surrounding merapi mountain in central java, indonesia, was reported to possess low iodine content. sengi village is one of the villages with moderate danger; a previous study showed that the prevalence of congenital hypothyroidism was 6%, categorizing the area endemic for idd.11 women of childbearing age are one of the most vulnerable groups to suffer from idd4,5. studies from several developed and developing countries have shown that in this population, there are still areas that are iodine deficient.12–15 considering idd’s irreversible and significant maternofetal, neonatal, and offspring impact, it is essential to assess the iodine status in this population.16 therefore, this study aims to assess the iodine profile of women of childbearing age in the sengi village from 2017 to 2018. methods we conducted this cross-sectional study in magelang from october 2017 to january 2018. the population was women aged 18-45 years. the inclusion criteria were women living in the area for a minimum of 1 year who are willing to provide written informed consent to participate in this study. the exclusion criteria were pregnancy, severe sickness, having received iodine supplementation in the past year, or inability to complete the entire study. the primary outcomes were urine iodine concentration (uic), iodine concentration within the table salt consumed by the subjects, iodine concentration within the freshwater source for daily use, estimation of daily iodine intake from diet, total goiter rate (tgr), and thyroid hormones concentration including thyroid stimulating hormone (tsh) and free thyroxine (ft4). the number of samples needed to estimate the uic parameter was 140 subjects. all data were compiled, edited, tabulated, then analyzed using descriptive analysis on spss. this study protocol was approved by the ethical committee of the faculty of medicine diponegoro university and kariadi general hospital (no.676/ec/fkrsdk/xi/2017). results there were 140 subjects included in this study, of which 97.8% were native residents who had been living there for more than 24 years. the subjects’ mean age was 33 years old. the subjects’ socioeconomic status was table 1. characteristics of study population. variables n % mean + sd age (years) 33 + 8 < 20 6 4.3 21-30 54 38.6 31-40 49 35 >40 31 22.1 subvillage sengi 38 27.1 ngampel 24 17.1 candi duwur 24 17.1 gowok pos 19 13.6 gowok sabrang 13 9.3 gowok ringin 11 7.9 candi tengah 6 4.3 candi pos 5 3.6 education level uneducated 1 0.7 elementary school 56 40 junior high school 48 34.3 senior high school 34 24.3 university 1 0.7 occupation farmer 102 72.9 heri nugroho acta med indones-indones j intern med 144 mainly lower to middle income, with an average monthly income of idr 814,000 (usd 56.91). the baseline characteristics of the study subjects are presented in table 1. the mean body mass index (bmi) is 23.67+4.82 kg/m2. most subjects (89.3%) did not have enlarged thyroid glands. from the thyroid ultrasound examination, the mean thyroid volume was 12.22±13.43 cc. the tgr at sengi village was 7.8%. among 140 subjects, 37 (25.7%) had thyroid nodule(s). the median uic was 199.5 µg/l. the complete data are presented in table 2. the mean kio3 concentration within the household salt consumed by the subjects was 28.6+13.7 ppm. eighty-nine (63,6%) salt samples had lower kio3 concentration than the recommended level, and two samples (1.4%) had higher kio3 concentration than the recommended level. based on the salt type, the salt block is the most common salt used (78.6%), followed by regular grains table salt (21.4%). the freshwater iodine content based on the altitude of the water source is illustrated in figure 1. daily dietary iodine intake among the subjects was categorized as inadequate in 80.17% of subjects. the iodine profile of the freshwater source, table salt consumption, and daily iodine intake from the diet can be seen in table 3. the most commonly consumed iodinerich source was eggs (60.7%). they consumed eggs more than three times a week. the most common goitrogenic food consumed by the respondents was cabbage (37.1%). they ate it more than thrice a week. the respondents’ dietary patterns are described in table 4. the median tsh and ft4 levels were 1.72 miu/l and 1.51 miu/l. as many as 135 subjects (97.0%) had normal tsh levels, while three subjects (2.0%) had high tsh levels, and two subjects (1.0%) had low tsh levels. all subjects had normal ft4 levels. almost all (96,5%) of the subjects were euthyroid. the remaining three (2,1%) subjects had subclinical hypothyroidism, and two (1,4%) subjects had subclinical hyperthyroidism. uic is the gold standard to define iodine deficiency for a population in a region17. who housewife 20 14.3 blue collar worker 10 7.1 merchant 4 2.9 teacher 2 1.4 private employee 2 1.4 monthly income rp814.286 + 657.36 < idr 500,000 (usd34.90) 34 24.3 idr 500,000 (usd34.90 idr 1,000,000 (usd69.81) 87 62.1 idr 1,000,001 (usd34.90) – idr 2,000,000 (usd139.62) 15 10.7 > idr 2,000,000 (usd139.62) 4 2.9 duration of stay 24 + 13 < 5 years 10 7.1 5-10 years 25 17.9 >10 years 105 75 table 2. the total goiter rate and urine iodine concentration among childbearing-age women in sengi village. variables n % thyroid gland grade by palpation no palpable or visible goiter palpable goiter visible goiter 125 9 6 89.29 6.43 4.29 thyroid gland volume by ultrasound examination ≤18.6 cc >18.6 cc 129 11 92.2 7.8 uic (μg/l) <20 (severe iodine deficiency) 20-49 (moderate iodine deficiency) 50-99 (mild iodine deficiency) 100-199 (adequate iodine intake) 200-299 (excessive iodine intake) >300 (iodine-induced hyperthyroidism. thyroid autoimmune) 1 10 15 45 53 16 0.7 7.1 10.7 32.1 37.9 11.4 table 3. iodine profile and daily iodine and goitrogenic intake of childbearing women in sengi village. variable value urinary iodine concentration (mcg/l) 199.5 (126.0 – 264.0a thyroid volume (cc) 9.1 (3.5-128.3)b iodine concentration in salt (ppm) 26.5 (5.3-100.5)b daily salt consumption (gr) 2.5 (0.5-13.3)b daily iodine intake from salt (mcg/l) 74.0 (74.0-394.6)b daily iodine intake from food (mcg/l) 12.8 (0.0-100.1)b daily total iodine intake (mcgg) 91.7 (14.3-456.8)b daily goitrogen intake (mg) 1.1 (0.0-8.3)b note: amedian (interquartile range), bmedian (minimum maximum vol 55 • number 2 • april 2023 the iodine status of women of childbearing age in an iodine-repleted area 145 cut-off for idd in the adult population is when the median uic of the population is less than 100 mcg/l, and >50% of the population has uic of less than 100 μg/l or <20% of the population has uic of less than 50 mcg/l. among the women of childbearing age in sengi village, the median uic was 199.5, with 81.4% of subjects having a uic value of > 100 mcg/l. therefore, considering the uic parameter, the women of childbearing age in sengi village had adequate iodine status. as many as 10% of subjects had uic levels of 50.1 99,9 mcg/l, and 8.8% of other subjects had uic levels of <50 mcg/l. based on palpation and thyroid ultrasound, the idd prevalence from the tgr parameter was 10.7% and 7.8%. goiter prevalence in this study was 7.8% by thyroid ultrasound examination. no evaluation of either de novo/residual goiter or thyroiditis goiter was performed in this study; hence the tgr value of this study may not truly represent the idd problem in the region. therefore, based on the uic parameter, women of childbearing age in sengi village were still considered to possess adequate iodine levels. table 5 demonstrates the relationship between iodine intake from the daily consumed table salt and the uic. this study showed that those with normal uic mostly consumed salt with >40 ppm of kio3. as many as 88.9% of subjects with normal uic consumed salt with 10-40 ppm of kio3, and 8.9% consumed salt with >40 ppm of kio3. the study shows that despite the difference in iodine status based on iuc levels, there are no table 4. dietary pattern of iodine-rich and goitrogenic foods of childbearing-age women in sengi village in the last 1 month. type of food frequency ≥ 3 times/ week < 3 times/ week never n % n % n % iodine-rich foods pindang 7 5 105 75 28 20 salted fish 5 3.6 83 59.3 52 37.1 saltwater fish 2 1.4 39 27.9 99 70.7 shrimp 0 0 4 2.2 136 97.1 oyster 0 0 1 0.7 139 99.3 egg 85 60.7 48 34.3 7 5 milk 20 14.3 19 13.6 101 72.1 beef liver 0 0 3 2.1 137 97.9 spinach 24 17.1 64 45.7 52 37.1 jelly 8 5.7 88 62.9 44 31.4 goitrogenic foods cassava 30 21.4 99 70.7 11 7.9 sweet potato 29 20.7 91 65 20 14.3 mustard greens 52 37.1 70 50 18 12.9 cabbage 23 16.4 71 50.7 46 32.9 cassava leaf 21 15 79 56.4 40 28.6 table 5. the distribution of salt iodine concentration consumed by childbearing-age women in sengi village based on their urine iodine concentration level. urine iodine concentration (μg/l) salt iodine concentration <10 ppm 10-20 ppm 20.1-30 ppm 30.1-40 ppm >40 ppm n <100 0 26.9 50 11.5 11.5 26 100-199 2.2 22.2 46.7 20 8.9 45 >199 2.9 18.8 31.9 23.2 23.2 69 heri nugroho acta med indones-indones j intern med 146 significant association between daily goitrogen intake, daily iodine intake and salt iodine concentration (table 6). discussion the tgr based on the usg examination was 8.6%. it declined significantly from 20% in 2015. using the who epidemiological criteria, dukun subdistrict had been categorized as moderately endemic for idd in 2015 and became mildly deficient of iodine in 2017-2018.18 the median uic among women of reproductive age in indonesia was 189.0 mcg/l in 2013. in central java, the value was higher; 240 mcg/l. the higher provincial median uic was possibly due to several coastal regions where daily water sources contain a much higher level of iodine; hence higher uics.18 another large-scale survey involving 106,825 pregnant women in central java in 2011 showed that the median uic was 156 mcg/l, and the percentage of pregnant women with uic lower than 100 mcg/l was 33.87%. there were four districts with mild iodine deficiency found in the study mentioned above. that study further assessed that 18 neonates (0.03%) were suspected of having cretinism, and 174 (0.18%) had tgr degrees of 1 – 2.17 kusrini’s study showed that the mean uic reached 221+88 mcg/l among pregnant women in magelang. but in the general population in magelang, it was 244 + 92 mcg/l.15 this marked difference was caused by the difference in urine samples used. kusrini’s study measured both spot urine and three days 24-hour urine samples for the mean uic measurement. in our study, only spot urine samples were used. who stated that spot urine is already a reliable representation of an individual’s iodine status.19 therefore, it is conclusive that the iodine status of both women of reproductive age and pregnant women of magelang regency, including sengi village is adequate. the iodine status of this study was determined by uic instead of tgr. total goiter rate (tgr) was a reliable predictor of moderate-to-severe iodine insufficiency when endemic goiter caused by iodine shortage was common. a significant drawback of the usage of tgr is that goiter resolution takes a long time to occur after iodine intake improves. in adults, tgr may represent past idds rather than current ones. a change in the tgr may not correctly reflect the possible contribution of idds to a decline in intelligence quotient (iq) and cognitive impairment20. the who goiter rate criteria were meant to be applied to school-age children18 . there were other causes that contributes to tgr, such as residual goiters or goiters due to autoimmune thyroiditis. thus, the tgr data had to be interpreted carefully. the median tsh and ft4 levels were within the normal range (median tsh 1.72 miu/l and median ft4 1.51 miu/l), and almost all subjects in this study were categorized as euthyroid (96.5%). kusrini’s study showed an increasing trend of median tsh along with an increase in gestational age. the median tsh level for all subjects from the rural area was 1.30 miu/l. the median ft4 level in that study was 1.27 miu/l among all the subjects.15 this difference might be caused by the increased maternal thyroid hormone production during pregnancy; hence there were higher subclinical hyperthyroidism cases in that study. another cohort study reported that lower tsh and greater ft3 and ft4 concentrations were linked to lower iodine availability throughout pregnancy and postpartum. the thyroid function improves after iodine supplementation before pregnancy and throughout pregnancy21. table 6. association between iodine status, daily goitrogen intake, daily iodine intake and salt iodine concentration. iodine status daily goitrogen intakea (mg) p-value daily iodine intakea (μg) p-value salt iodine concentrationa (ppm) p-value deficient 1.09 (0.01-7.95) 87.46 (22.85-276.80) 23.25 (10.6-47.6) adequate 1.05 (0.08-8.11) 86.93 (143-253.93) 26.5 (5.3-63.5) excessive 1.09 (0-8.33) 0.981b 93.50 (16.60-456.77) 0.499b 28.6 (7.4-106.5 0.109b note: amedian (minimum maximum), bkruskal-wallis test vol 55 • number 2 • april 2023 the iodine status of women of childbearing age in an iodine-repleted area 147 who recommended the minimum daily iodine intake for non-pregnant women of reproductive age to be 150 μg. iodine can be obtained from salt, foods, and drinks. the mean iodine intake in this study was lower than the recommendation (108.4 mcg/day).1 the women of childbearing age in this study are at risk of developing idd. the average iodine concentration of household table salt in all studied samples was 28.6+13.7 ppm, and only 35% of the subjects consumed salt with adequate iodine content. it was significantly lower than kusrini’s study, in which the mean salt iodine content across both areas (rural and urban) was 40.5±20.6 ppm.22 there were seven salt brands used by the subjects; each brand displays its iodine content, except for one brand. each brand stated that the iodine content was within the recommended range (30-80 ppm). this suggested a possible reduction of iodine content in salt during packaging, storing, and/or transportation. the who reported that the iodine content in salt is reduced by 50% by the time it reaches consumers due to poor iodine quality, mishandling during packaging, poor storage conditions (high humidity and temperature), and long storage time6. iodized salt is best stored in closed storage to keep the salt dry.1,6 t h e m e a n s a l t c o n s u m p t i o n a m o n g respondents was only 3.3 g/day, much lower than the who recommendation.1,6 it might be caused by the food cooking method. the people of sengi village usually cook once daily in the morning, and the food will be eaten throughout the day. the food was cooked long before consumption, leading to several episodes of reheating before consumption, lowering the iodine content. moreover, some participants were cautious of salt usage due to the risk of developing hypertension from consuming too much salt. other than salt, iodine also can be obtained from food. from the food frequency questionnaire (ffq), the documented mean iodine consumption was 16.1 μg/ day. egg was the most frequent iodine-rich food consumed by the respondents because it is affordable and readily available at all times. saltwater fish, shrimp, and oysters are also rich in iodine, but the respondents rarely consumed them due to their high price and low availability. almost all respondents did not consume shrimp and oysters during the one-month observation. based on the ffq, the most frequent goitrogenic foods consumed by the respondents were cassava, sweet potato, mustard green, cabbage, and cassava leaf. in this study, the mean cyanide intake among respondents was 1.9 mg/ day, significantly lower than the 10 mg/ day limit set by the fao/who. this goitrogenic food often contains cyanide derivates (thiocyanate and isothiocyanate) that inhibit thyroid hormone synthesis.19 exceeding the daily cyanide intake limit might cause health complications, such as acute intoxication, chronic toxicity, neurological disorders, growth retardation, and goiter.23 although cassava and sweet potato, which contain a high level of cyanide, are frequently consumed in the sample population, the cyanide intakes of the respondents are within the standard limit. the processing method might also modify the cyanide content in goitrogenic foods. steaming and boiling cassavas, the most common processing method in sengi village were known ways to reduce the cyanide content.24 therefore, this might lower the actual cyanide consumption among respondents than predicted. no significant associations were observed between iodine status, as determined by iuc levels, and daily iodine intake, daily goitrogen intake, and salt iodine concentration in our research. these findings imply that additional factors likely play a role in influencing iodine status within this specific region. the average iodine concentration in the water of sengi village was measured at 2.03 mcg/l. nearly all participants (98.6%) consumed water with insufficient iodine content, indicating a potential heightened risk for inadequate iodine intake and the subsequent development of id) among residents in the area.the mean water iodine concentration in sengi village was 2.03 mcg/l. almost all respondents (98.6%) consumed water with poor iodine content. hypothetically, respondents had a high chance of not getting enough iodine and eventually acquiring idd. there are several limitations of this study. this study did not employ three days of 24-hour heri nugroho acta med indones-indones j intern med 148 urine collection for a more precise measurement of uic. no further laboratory examination, including thyroid peroxidase (anti-tpo), was conducted for possible autoimmune causes in the presence of goiter for any subjects examined. the non-randomized sampling method employed in this study might lead to a selection bias. conclusion in summary, women of childbearing age living in the sengi village possess adequate iodine status and normal thyroid hormones. nevertheless, the iodine content within the freshwater sources, the household table salt, and daily dietary iodine intake were still deficient. accordingly, strenuous public health intervention is required to overcome and supervise the low iodine concentration of the daily consumed salt and low dietary iodine intake.25 the lack of association between dietary iodine intake, goitrogen intake, iodine salt concentration and iodine status may suggest that other factors such as water iodine content may play a significant role. despite adequate iodine status in the population, there is a substantial tgr, which may indicates residual goiter from previous severe endemic idd, or the presence of autoimmune thyroiditis. further evaluations are needed for the exact cause of high tgr. continuous monitoring and public health intervention to optimize iodine intake from household salt and daily dietary intake are essential for eradicating idd in sengi village and magelang regency, especially for women of reproductive age. 25 further studies are required to re-evaluate the potential cause of high tgr in this area. the implementation of universal hypothyroid newborn screening in several urban areas in indonesia must be extended to areas previously or currently endemic for idd to detect, treat and prevent further disabilities. acknowledgments the authors are thankful for the technical support provided by farida from gaky laboratory. the authors acknowledge kevin gracia pratama, who provided support in editing, formatting, and translating the manuscript. references 1. world health organisation. vmnis | vitamin and mineral nutrition information system goitre as a determinant of the prevalence and severity of iodine deficiency disorders in populations background. 2014; 2. biban bg, lichiardopol c. iodine deficiency, still a global problem? curr health sci j [internet]. 2017 [cited 2023 jan 20];43(2):103. available from: /pmc/ articles/pmc6284174/ 3. badan penelitian dan pengembangan kesehatan kementrian kesehatan ri. riset kesehatan dasar 2013 [internet]. 2013 [cited 2023 jan 20]. available from: http://labdata.litbang.kemkes.go.id/images/download/ laporan/rkd/2013/laporan_riskesdas_2013_final.pdf 4. eastman cj, zimmermann mb. the iodine deficiency disorders. 2018 feb 6 [cited 2023 jan 20]; available f r o m : h t t p s : / / w w w. n c b i . n l m . n i h . g o v / b o o k s / nbk285556/ 5. niwattisaiwong s, burman kd, li-ng m. iodine deficiency: clinical implications. cleve clin j med [internet]. 2017 mar 1 [cited 2023 jan 20];84(3):236–44. available from: https://www.ccjm. org/content/84/3/236 6. world health organization. salt reduction and iodine fortification strategies in public health: report of a joint technical meeting convened by the world health organization and the george institute for global health in collaboration with the international council for the control of iodine deficiency disorders global network. 2014 [cited 2023 jan 20]; available from: www.who.int 7. z i m m e r m a n n m b , a n d e r s s o n m . g l o b a l e n d o c r i n o l o g y: g l o b a l p e r s p e c t i v e s i n endocrinology: coverage of iodized salt programs and iodine status in 2020. eur j endocrinol [internet]. 2021 jul 1 [cited 2023 jan 26];185(1):r13–21. available from: https://academic.oup.com/ejendo/article/185/1/ r13/6654349 8. knowles jm, garrett gs, gorstein j, et al. household coverage with adequately iodized salt varies greatly between countries and by residence type and socioeconomic status within countries: results from 10 national coverage surveys. j nutr [internet]. 2017 may 1 [cited 2023 jan 26];147(5):1004s-1014s. available from: https://academic.oup.com/jn/ article/147/5/1004s/4669673 9. giulia s, lea bf, carol zc, lisa m, harper sl, elizabeth cj. the effect of climatic factors on nutrients in foods: evidence from a systematic map. environmental research letters [internet]. 2020 nov 26 [cited 2023 jan 20];15(11):113002. available from: https://iopscience. iop.org/article/10.1088/1748-9326/abafd4 10. haap m, roth hj, huber t, dittmann h, wahl r. urinary iodine: comparison of a simple method for its determination in microplates with measurement by inductively-coupled plasma mass spectrometry. sci rep [internet]. 2017 jan 3 [cited 2023 jan 20];7. vol 55 • number 2 • april 2023 the iodine status of women of childbearing age in an iodine-repleted area 149 available from: /pmc/articles/pmc5206638/ 11. djokomoeljanto r. gangguan akibat kekurangan yodium (gaki) dan kelebihan yodium (ekses). semarang: badan penerbit universitas diponegoro; 2007. p. 377–424. 12. azzeh f, refaat b. iodine adequacy in reproductive age and pregnant women living in the western region of saudi arabia. bmc pregnancy childbirth [internet]. 2020 jun 22 [cited 2023 jan 26];20(1):1–12. available from: https://bmcpregnancychildbirth.biomedcentral. com/articles/10.1186/s12884-020-03057-w 13. burns k, yap c, mina a, gunton je. iodine deficiency in women of childbearing age: not bread alone? asia pac j clin nutr [internet]. 2018 jul 1 [cited 2023 jan 26];27(4):853–9. available from: https://pubmed.ncbi. nlm.nih.gov/30045431/ 14. lucchetta rc, rodriguez gini al, de andrade cavicchioli s, et al. iodine deficiency in women of childbearing age in brazil: systematic review and meta-analysis. vitae [internet]. 2021 may 18 [cited 2023 jan 26];28(2). available from: http://www.scielo. org.co/scielo.php?script=sci_arttext&pid=s012140042021000200006&lng=en&nrm=iso&tlng=en 15. panth p, guerin g, dimarco nm. a review of iodine status of women of reproductive age in the usa. biol trace elem res [internet]. 2019 mar 15 [cited 2023 jan 26];188(1):208–20. available from: https://link. springer.com/article/10.1007/s12011-018-1606-5 16. toloza fjk, motahari h, maraka s. consequences of severe iodine deficiency in pregnancy: evidence in humans. front endocrinol (lausanne). 2020;11:409. 17. hussain h, selamat r, kuay lk, et al. urinary iodine: biomarker for population iodine nutrition. biochemical testing clinical correlation and diagnosis [internet]. 2019 apr 17 [cited 2023 jan 20]; available from: https://www.intechopen.com/state.item.id 18. world health 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26];151(10):3187–96. available from: https:// academic.oup.com/jn/article/151/10/3187/6320055 22. kusrini i, farebrother j, mulyantoro dk. adequately iodized salt is an important strategy to prevent iodine insufficiency in pregnant women living in central java, indonesia. plos one [internet]. 2020 nov 1 [cited 2023 jan 20];15(11):e0242575. available from: https:// journals.plos.org/plosone/article?id=10.1371/journal. pone.0242575 23. nyirenda kk, nyirenda kk. toxicity potential of cyanogenic glycosides in edible plants. med toxicol [internet]. 2020 mar 20 [cited 2023 jan 20]; available from: https://www.intechopen.com/state.item.id 24. zhong y, xu t, wu x, et al. dietary exposure and risk assessment of cyanide via cassava consumption in chinese population. food chem. 2021;354:129405. 25. hatch-mcchesney a, lieberman hr. iodine and iodine deficiency: a comprehensive review of a re-emerging issue. nutrients 2022;14:3474 [internet]. 2022 aug 24 [cited 2023 jan 26];14(17):3474. available from: https://www.mdpi.com/2072-6643/14/17/3474/htm medical illustration skin mottling as clinical manifestation of cardiogenic shock aldo ferly*, isman firdaus division of intensive care and cardiovascular emergency, department of cardiology and vascular medicine, faculty of medicine universitas indonesia harapan kita national cardiovascular center, jakarta, indonesia. * corresponding author: aldo ferly, md. division of intensive care and cardiovascular emergency, department of cardiology and vascular medicine, faculty of medicine universitas indonesia harapan kita national cardiovascular center. jl. letjen s. parman, jakarta, indonesia. email: aldoferly_nobita@yahoo.co.id. according to van diepen et al, cardiogenic shock is defined as the inability of the heart as a result of impaired pumping function to deliver adequate amount of blood to tissues to meet resting metabolic demand.1 according to society for cardiovascular angiography and interventions (scai), the hallmarks of cardiogenic shock are hypotension and hypoperfusion which can be classified into five levels. based on scai consensus, diagnosis and classiciation of cardiogenic shock are dependent on both physical examination and biochemical markers. prompt recognition of cardinal signs of cardiogenic shock is vital in prompt and appropriate management of said patients.2 one of the more easily recognizable signs of cs is the assessment of peripheral circulation. physical examination of the peripheral is convenient, accessible and were shown to be able to differentiate the stages of shock experienced by the patients. if the patient is at the initial period of shock, there would be systemic vasoconstriction to preserve the vital organs of the patient via decreased perfusion of the tissues. persisting peripheral vasoconstriction despite stability of hemodynamics may signify worse outcomes in patients with cardiogenic shock.3 skin mottling is defined as a red-violaceous discoloration of the skin that is usually found in the lower extremity. pathophysiology of mottling skin is believed to be due to peripheral vasoconstriction of the skin. however, the exact patophysiology remain controversial: observations showed that mottling areas are figure 1. skin mottling (mottling score 2) observed in the lower extremity 645acta med indones indones j intern med • vol 54 • number 4 • october 2022 aldo ferly acta med indones-indones j intern med 646 colder than normally colored skin. assessment using nirs showed that mottled areas have lower sto2 compared to the healthy skin tissues. mottling skin were classified using mottling score in which we classified into 5 levels: score 0 found no mottling, score 1 with modest mottling area localized to the center of the knee, score 2 is moderate mottling area that does not exceed superior edge of the kneecap. score 3 mild mottling area that does not exceed middle thigh. score 4 is severe mottling area that does not exceed the fold off the groin. score 5 is extremely severe mottling area that exceeds the fold of the groin.4 coudroy et al discusses the impact on the persistence of skin mottling during hospital stay. in this study, we see that a patient assessed with septic shock had 40% skin mottling. among patient with persistent skin mottling, it is considered as an independent risk factor for in-icu mortality and also organ dysfunction.5 persistent skin mottling is a surrogate marker for poor perfusion to the peripheral tissues. a 59 years old male came to the emergency department with chief complain of dyspnea. dyspnea has worsened since 3 days before admission accompanied with dyspnea on effort, orthopnea and paroxysmal nocturnal dyspnea. in the emergency department, patient experienced cardiac arrest after defecating, leading to cardiopulmonary resuscitation for 45 minutes. administration of vasoactive drugs were done and the patient was intubated. post resucitaiton physical examination showed that the patient was sedated, with blood pressure of 72/40 (on dobutamine support). peripheral circulation examination showed cold and clammy extremities, skin mottling of the lower extremity with mottling score of 2. crt is more than 2 seconds. blood gas analysis showed severe metabolic acidosis with blood lactate of 8.1. angiographic examination were previously done on the patient during the previous admission with the results of three vessels disease with a chronic total occlusion in the left anterior descending artery. however, patient had refused further intervention regarding the coronary problems. patient also has longtsanding atrial fibrillation. patient was admitted into the intensive care unit for further management. patient was stabilized during admisison in the intensive care with inotropes, however despite the hemodynamic stablilization the skin remain mottled-regardless. patient had complicating factors in the form of pneumonia and sepsis. patient had difficulty in weaning the ventilator and died because of arrythmia complication. references 1. van diepen s, katz jn, albert nm, et al. contemporary management of cardiogenic shock: a scientific statement from the american heart association. circulation. 2017;136(16):e232–68. 2. hanson id, tagami t, mando r, et al. scai shock classification in acute myocardial infarction: insights from the national cardiogenic shock initiative. catheter cardiovasc interv. 2020;96(6):1137–42. 3. ait-oufella h, bakker j. understanding clinical signs of poor tissue perfusion during septic shock. intensive care med. 2016;42(12):2070–2. 4. jouffroy r, saade a, tourtier jp, et al. skin mottling score and capillary refill time to assess mortality of septic shock since pre-hospital setting. am j emerg med. 2019;37(4):664–71. 5. coudroy r, jamet a, frat jp, et al. incidence and impact of skin mottling over the knee and its duration on outcome in critically ill patients. intensive care med. 2015;41(3):452–9. medical illustration black fungus complicated with covid-19 in a man with underlying non-hodgkin’s lymphoma erni juwita nelwan1,2, rahajeng n. tunjungputri2, retno s. wardani3, retno wahyuningsih4 1 division of tropical and infectious disease. department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 3 department of ear, nose and throat, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 4 department of parasitology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding authors: erni juwita nelwan, md., phd. division of tropical and infectious disease. department of internal medicine faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: e.nelwan@gmail.com. covid-19 is a disease reported to suppress cellular immunity.1 this may lead to the development of opportunistic infections, among others black fungus, or mucormycosis. on the other hand, pre-existing defect in immunity may render patients susceptible to both figure 1. (a,b) the patient upon first presentation at the outpatient clinic in july 2020. (c-f) the patient after the first debridement in september 2020 during protracted hospitalization period due to his contracting covid-19. 349acta med indones indones j intern med • vol 53 • number 3 • july 2021 erni juwita nelwan acta med indones-indones j intern med 350 mucormycosis and covid-19. mucormycosis is a relatively rare fungal infection with rapid progression unless diagnosed promptly and treated adequately. urgent surgical and medical intervention is lifesaving.2 the manifestation of mucormycosis largely depends on the presence of exposure to the pathogen and the existing risk factor of the host. as black fungus is locally invasive, the majority of cases will involve tissue damage with local destruction and contiguous spread to nearby structure. we present a case of black fungus complicated with covid-19 in a man with underlying non-hodgkin’s lymphoma. a 34 year-old man initially visited the ent outpatient clinic in june 2020 due to the chief complaint of pain on the leftside base of the nose, and swelling of the left eye. the patient developed an open wound on the base of the nose which grew larger. he complained of congestion and pain on the left side of the nose, and greenish discharge from the nose every day, with irregular pattern of fever. the ct scan revealed soft tissue lesion on the anterior nasal cavity especially on the right side, which eroded the nasal bone, with the suspicion of mass or chronic infection; pansinusitis with erosion of the left ethmoid and maxillaris sinus, left nasal bone erosion with fistulation and ulceration to the left soft tissue nasal region and medial to the left orbita; as well as thickening of the cutaneous and subcutaneous tissue of the nasomaxillar region to the left inferior palpebra. nasoendoscopy revealed a fistula on the left dorsal nasal cavity and suspicion of black fungus infection. surgical and nasoendoscopic debridement was performed. as the endoscopic appearance suggest mucormycosis, and microscopic examination revealed the presence of spores and hyphae. upon culture, dematiceae (black fungus) colony growth was found. the patient was discharged after twomonth of hospitalization for wound care and diagnosis. he was planned to receive voriconazole or amphotericin b, and therefore he was re-admitted in september 2020. however, during this hospital admission the patient was found to be pcr positive for sars-cov-2 due to contract tracing from another patient in the same ward, and he was promptly moved to the covid-19 isolation ward for further management. he did not develop new covid-19 symptoms other than fever and myalgia. although the antifungal treatment was resumed in this period and initial debridement and repeat biopsy sample was taken, he did not receive timely nor extensive surgical debridement due to the logistical challenges related to his admission in the covid-19 isolation ward. the patient was discharged after 21 days in late october 2021 and negative pcr sars-cov-2 result and planned for a follow up outpatient visit. the pathology anatomy evaluation of the septal tissue obtained from nasal lesion the type nk/t-cell lymphoma although result was only available after the patient was discharged. during the covid-19 pandemic, coinfections of any viral, bacterial or fungal pathogen with sars-cov-2 is very likely. in unfortunate instances such as the case presented in this report, hospital-acquired covid-19 although did not cause additional morbidity or severe symptoms, to some extent led to suboptimal management of the fungal infection such as delaying completion of the treatment regimen or in performing extensive surgical debridement required in the management of invasive mucormycosis. additionally, the patient was only later diagnosed with nonhodgkin’s lymphoma after repeat biopsy was taken, revealing a host risk factor for invasive fungal disease and risk of deterioration in the patient. suboptimal or delayed diagnosis and treatment of non-covid-19 diseases have been reported worldwide even with effective resource allocation.3, 4 it is important to therefore to identify cases in which delay in the management of non-covid-19 disease could potentially be life-threatening or leading to disease progression and prioritize delivery of care in these patients. references 1. liu j, yang x, wang h, et al. analysis of the long-term impact on cellular immunity in covid-19-recovered individuals reveals a profound nkt cell impairment. 2021;12(2):e00085-21. 2. cornely oa, alastruey-izquierdo a, arenz d, et al. global guideline for the diagnosis and management of mucormycosis: an initiative of the european vol 53 • number 3 • july 2021 black fungus complicated with covid-19 in a man 351 confederation of medical mycology in cooperation with the mycoses study group education and research consortium. 2019;19(12):e405-e21. 3. li z, jiang y, yu y, kang qjrm, policy h. effect of covid-19 pandemic on diagnosis and treatment delays in urological disease: single-institution experience. 2021;14:895. 4. patt d, gordan l, diaz m, et al. impact of covid-19 on cancer care: how the pandemic is delaying cancer diagnosis and treatment for american seniors. 2020;4:1059-71. 326 acta med indones indones j intern med • vol 53 • number 3 • july 2021 case report covid arm after moderna booster in healthcare worker: a case report anshari saifuddin1, sukamto koesnoe1*, nia kurniati2, sondang sirait3, riesye arisanty4, evy yunihastuti1 1 division of allergy and clinical immunology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 division of allergy and clinical immunology, department of child health, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 3 department of dermatovenereology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 4 department of pathology and anatomy, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: sukamto koesnoe, md, phd. division of allergy and clinical immunology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no.71, jakarta 10430, indonesia. email: sukamtokoesnoe@gmail.com. abstrak virus sars cov-2 telah menginfeksi lebih dari 200 juta orang di seluruh dunia dan lebih 4,4 juta orang di indonesia. program vaksinasi menjadi salah satu solusi yang dicanangkan oleh berbagai negara di dunia, termasuk di indonesia, untuk mengurangi laju transmisi covid-19. platform vaksinasi yang diproduksi bermacam-macam, seperti inactivated, viral vector, mrna dan protein subunit. program vaksinasi booster dengan platform mrna (moderna) direncanakan oleh pemerintah indonesia untuk melindungi tenaga kesehatan lebih lanjut dari infeksi covid-19 khususnya varian delta. pada tulisan ini, kami membahas mengenai salah satu efek samping yang khas didapatkan dari vaksin moderna, yang disebut sebagai covid arm. kata kunci: covid arm, covid-19, booster, moderna, vaksinasi, tenaga kesehatan. abstract sars cov-2 virus has infected more than 200 million people worldwide and more than 4.4 million in indonesia. the vaccination program has become one of the solutions launched by many countries globally, including indonesia, to reduce the transmission rate of covid-19. various vaccination platforms are produced, such as inactivated, viral vector, mrna, and protein subunit. the vaccination booster program with mrna platform (moderna) was launched by the indonesian government to give better protection for health care workers, particularly from delta variant. in this case report, we discuss one of the typical side effects of moderna vaccine, which is referred to as the covid arm. keywords: covid arm, covid-19, booster, moderna, vaccination, healthcare worker. vol 53 • number 3 • july 2021 covid arm after moderna booster in healthcare worker 327 introduction sars cov-2/ coronavirus disease 2019 (covid-19) has been declared a pandemic by who since march 2020. as of august 25th 2021, more than 214 million positive cases had been reported worldwide, with more than 4.4 million deaths.1 there are more than 4 million confirmed cases in indonesia, with 128 thousand deaths.2 many countries compete to develop vaccines in order to reduce the sars-cov-2 transmission rate. indonesia launched the covid-19 vaccination program to approximately 180 million populations in february 2021. healthcare workers and first responders are among the first to get vaccinated, which reached approximately 1.7 million people.3 the vaccine schedule was two doses of inactivated vaccine (coronavac) 2 weeks apart. in july 2020, the emergence of the second wave, the majority caused by the new delta variant, raises concern, especially for healthcare workers. the mortality rate of doctors and other healthcare workers significantly increased on the second wave. it raised the idea to give a booster vaccination with an mrna vaccine platform (moderna).4 side effects that arise after moderna vaccination are varied, similar to other vaccine platforms. mild side effects are common, either local or systemic. however, from many studies, moderna has more severe local side effects than other platforms, referred to as the covid arm. we will report a covid arm case manifested early after receiving the booster. case illustration a 56 years old doctor complained that her left arm had become red, swollen, and tender post-vaccination with moderna. she received two doses of coronavac vaccine four months before without any side effects. the moderna shot was given in the evening. during the night, she suffered from pain at the site of the injection. the pain disturbed her when she laid on the left side and needed one paracetamol tablet to reduce the pain. the following morning, her temperature increased to 40.2oc. she took another tablet of paracetamol, and a few hours later, the temperature dropped to 38.9oc. she took paracetamol every four hours for the next 48 hours, with temperatures ranging between 38.6 – 39.2oc. hence, making the patient stay home and miss work. she started to feel her left arm becoming more redd and swollen. on the 3rd day, the fever broke, but she still felt lethargic. rt-pcr sars-cov-2 on the nasopharyngeal swab was negative. the upper arm started to swell, redness, and warm to the touch. her range of motion was reduced due to pain (vas 3-4). within the next two days, the swelling extended to the upper part of the lower arm, and she used surface cooling to reduce the symptoms. on the 6th-day post-vaccination, the swelling, redness, and pain were decreased, although the lower part of the upper arm and around the elbow still showed inflammation signs. the next day she used compression stocking to reduce the symptoms further. the symptoms disappeared after the 8th-day post-vaccination. she has a history of breast cancer in 2017 and underwent radical mastectomy on the right mammae. she took tamoxifen 20 mg od routinely. she has an atopic history in the form of eczema and allergic rhinitis. she also had a thalassemia trait which had not been evaluated for a long time. a skin biopsy was done to get a proper diagnosis. histological appearance in the epidermis was mild focal spongiosis with a scattered vacuolar alteration. histological appearance in the dermis was mild inflammatory infiltrate perivascular on superficial plexus, periadnexal, deep plexus, and subcutaneous fat, consisting of lymphocytes and some histiocytes with few intravascular neutrophils. eosinophils are not present. no sign of vascular wall damage. the biopsy result is consistent with delayed-type hypersensitivity that can be found in vaccine reactions. discussion covid arm is one of the side effects that rarely occurs after the administration of the moderna vaccine. symptoms usually are swelling, redness, pain, warmth, and pruritus at the location of vaccine injection. covid arm is used to explain the delayed-type hypersensitivity reaction that occurs approximately one week after using covid-19 mrna type vaccine. in one study of covid mrna type vaccine, anshari saifuddin acta med indones-indones j intern med 328 persons who received the second dose had a higher incidence of erythema than when receiving the first dose. participants that used pfizer-biontech got erythema at the injection site as much as 4.6% after the first dose and 6.5% after the second dose within seven days. participants who used moderna reported moderate to severe degree of erythema: 3.1% after the first dose and 11.9% after the second dose within seven days.6 in the third phase clinical trial of moderna report, the most common local side effect post-vaccination was pain at the injection site. delayed type reactions at the injection site (with onset in the 8th day or later) were experienced by 244 subjects (0.8%) after the first dose and 68 subjects (0.2%) after the second dose from the total of 30,420 subjects. the reactions were marked by erythema, induration, and pain that usually improved spontaneously within 4-5 days.7 in this case, the patient had signs of covid arm in the form of an erythema, swollen, and pain at the injection site appeared three days postvaccination. the symptoms of swelling, pain, and erythema began to improve spontaneously on the 4th day after the onset. she only took paracetamol for a few days post-vaccination because of the fever that arose. she did not take any antibiotics. the description of the disease course and the symptom was matched with the covid arm. skin biopsy result confirmed covid arm diagnosis. as reported in previous studies, generally covid arm appeared approximately one week after the administration of moderna vaccine.5,7 in this case, the onset of symptoms was relatively fast compared to covid arm cases in general. whether it was related to the patient’s history of receiving two doses of inactivated vaccine still needs to be investigated. with current evidence, it is still unknown how many people are experiencing the delayedtype hypersensitivity due to covid arm after the first dose and whether they have the same reaction or are even more severe after the second dose.7 in one study, patients who had symptoms after the second dose experienced symptoms with faster onset than the first dose (1-3 days). six patients did not experience recurrence of severe reaction as they have experienced at the first dose. in comparison, three patients experienced the same reaction as the first dose, and three patients experienced a lighter reaction than the first dose.8 a delayed-type hypersensitivity reaction mediated by t cell occurred due to a reaction to the vaccine component. the reaction will be selfresolving, which will not extend systemically and will not be a contraindication for the next vaccination in the future.9,10 reactions reported are against substances such as thimerosal, neomycin, aluminum, but there is no composition from those substances contained in the moderna or pfizer vaccine.11,12 pfizer and moderna have polyethylene glycol (peg2000). both vaccines also have salt, sugar, acid, and acid stabilizer.13 peg2000 was the only ingredient in these vaccines that previously known to cause delayedtype hypersensitivity reaction. further studies are needed to prove that peg2000 plays a role in the occurrence of the covid arm.14 local skin reactions after vaccination, especially if accompanied by systemic symptoms, are often incorrectly interpreted as cellulitis. differences between the covid arm with cellulitis are following. first, pruritus that is commonly found in the covid arm usually occurs within a week after vaccination. second, the symptoms improved spontaneously within 4-5 days and responded well using topical steroids or oral antihistamines.5 halperin, et al.15 define the diagnosis criteria to differentiate between cellulitis and local reaction post-vaccination. criteria for cellulitis is a reaction in the injection site with at least 3 of these symptoms: local pain, erythema, induration/swelling, and warmth. the median time from onset of cellulitis is approximately five days post-vaccination compared to delayedtype hypersensitivity reaction that occurs in 7 days or more post-vaccination. in addition to that, the role of bacteria in cellulitis, such as staphylococcus aureus or group a beta hemolytic streptococcus could be found from the injection site. the antibiotic response is one of distinction. if the patient has cellulitis and is not given antibiotics, it could cause the formation of an abscess. while in local reaction post-vaccination, the symptoms will improve vol 53 • number 3 • july 2021 covid arm after moderna booster in healthcare worker 329 spontaneously.16 the growing population that got covid-19 vaccines, particularly mrna platforms, will increase covid arm cases that consulted to primary care doctors. primary care doctors should be able to distinguish between the delayed-type hypersensitivity reaction postvaccination with other differential diagnoses, including cellulitis. in the united states, misdiagnosed cellulitis causing 50,000 – 130,000 a b c d figure 3. a). skin biopsy result (100x magnification). b). vacuolar degeneration in epidermis (400x magnification). c). mid dermis (400x magnification). d). subcutaneous (400x magnification). figure 1. clinical picture from patient’s left arm, 4 days after vaccination. figure 2. clinical picture from patient’s left arm, 5 days after vaccination. anshari saifuddin acta med indones-indones j intern med 330 individuals hospitalized and 195-515 million dollars spent every year.17 in addition, the use of antibiotics in misdiagnosed cellulitis cases could cause increased risk to antibiotic resistance and related to 9,000 nosocomial infection cases every year in the united states.16 conclusion covid arm is one of the adverse events that can occur after moderna vaccination. this side effect is self-resolving. clinicians should be able to differentiate the covid arm from other differential diagnoses, such as cellulitis. it is essential to give appropriate and effective treatment to the patients. references 1. worldometers. coronavirus cases in world. [cited 2021 august 26]. available from https://www.worldometers. info/coronavirus/ 2. kementerian komunikasi dan informatika. sebaran kasus covid-19 di indonesia. [cited 2021 august 26]. available from https://covid19.go.id/ 3. kementerian kesehatan ri. materi penanganan covid-19. kemenkes. desember 2020. 4. tim mitigasi ikatan dokter indonesia. data kematian dokter di indonesia akibat covid-19. idi. 2021 5. lingren al, austin ah, welsh k. covid arm: delayed hypersensitivity reactions to sars-cov-2 vaccines misdiagnosed as cellulitis. j primary care comm health. 2021;12:1-5 6. allergic reactions. centers for disease control and prevention. [cited 2021 august 26]. available from https://www.cdc.gov/coronavirus/2019-ncov/vaccines/ safety/allergic-reaction.html 7. baen lr, sahly e, essink b, et al. efficacy and safety of the mrna-1273 sars-cov-2 vaccine. n engl j med. 2021;384:403-16. 8. blumenthal kg, freeman ef, saff rr, et al. delayed large local reactions to mrna-1273 vaccine against sars-cov-2.n engl j med. 2021;384:1273-7. 9. kelso jm, greenhawt mj, li jt, et al. adverse reactions to vaccines practice parameter 2012 update. j allergy clin immunol. 2012;130:25-43. 10. mcneil mm, destefano f. vaccine-associated h y p e r s e n s i t i v i t y. j a l l e r g y c l i n i m m u n o l . 2018;141:463-72. 11. u.s. food and drug administration. fact sheet for recipients and caregivers. emergency use authorization (eua) of the pfizer-biontech covid-19 vaccine to prevent coronavirus disease 2019 (covid-19) in individuals 16 years of age and older [fact sheet]. [cited 2021 august 26]. available from https://www.fda.gov/ media/144414/ download#page=2 12. u.s. food and drug administration. fact sheet for recipients and caregivers. emergency use authorization (eua) of the moderna covid-19 vaccine to prevent coronavirus disease 2019 (covid-19) in individuals 18 years of age and older [fact sheet].[cited 2021 august 26]. available from https://www.fda.gov/ media/144638/ download#page=2 13. allergic reactions. centers for disease control and prevention. [cited 2021 august 26]. available from https://www.cdc.gov/coronavirus/2019-ncov/vaccines/ safety/allergicreaction.html 14. fisher aa. immediate and delayed allergic contact reactions to polyethylene glycol. contact dermatitis. 1978;4:135-8. 15. halperin s, kohl ks, gidudu j, et al. cellulitis at injection site: case definition and guidelines for collection, analysis, and presentation of immunization safety data. vaccine. 2007;25:5803-20. 16. davies hd, mcgeer a, schwartz b, et al. invasive group a streptococcal infections in ontario, canada. ontario group a streptococcal study group. n engl j med. 1996;335(8):547-54. 17. weng qy, raff ab, cohen jm, et al. costs and consequences associated with misdiagnosed lower extremity cellulitis. jama dermatol. 2017;153(2):1416. 205acta med indones indones j intern med • vol 55 • number 2 • april 2023 case report a case report of hereditary angioedema: challenges in diagnosis and management alvina widhani*, suzy maria, rifky yulian, anshari saifuddin hasibuan, sukamto koesnoe division of allergy and clinical immunology, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. *corresponding author: alvina widhani, md. division of allergy and clinical immunology, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: alvina.widhani@gmail.com. abstract hereditary angioedema (hae) is a rare autosomal dominant genetic disorder which causes bradykinin mediated angioedema. although it can be life threatening, hae may be underdiagnosed due to a lack of awareness of the disease and limited access to laboratory testing. here, we report a case of hae which was diagnosed only after the patient was referred for covid-19 vaccination even though he had been experiencing recurrent angioedema for the past 30 years. keywords: hereditary, angioedema, diagnosis, management. introduction hereditary angioedema (hae) is a genetic disorder manifests as intermittent swelling of the skin or mucosal tissue of the upper respiratory and gastrointestinal tracts which can be lifethreatening but cannot be predicted. this rare disease has autosomal dominant inheritance.1 in indonesia, there are difficulties in the diagnosis and treatment of hae. not only is awareness of the disease lacking, but there is also limited access to the laboratory test that can confirm a diagnosis and first line medication for hae management is unavailable. case illustration a 48-year-old male was referred to cipto mangunkusumo hospital for evaluation of eligibility for a covid-19 vaccination. he had a history of recurrent swelling in the face, hands, and feet (figure 1) which had been triggered by fatigue or cold weather ever since he was in senior high school. his symptoms worsen in the first 24 hours of an attack and then disappear within 3-5 days. they do not improve with an antihistamine or oral corticosteroid. during his most severe attack, he felt shortness of breath which brought him to an emergency ward. the attending doctor told him that he had airway swelling. the first attack he ever experienced was as a teenager. there has never been any urticaria or other skin lesions. the man had no history of taking an angiotensin-converting enzyme (ace) inhibitor or non-steroidal anti-inflammatory drugs (nsaids) and also no history of food or drug allergy. his mother and siblings also had histories of the same attack (figure 2). when the patient came to the outpatient clinic, his physical examination was normal. laboratory results showed a normal peripheral blood count, c4 level 4 mg/dl (10–40 mg/dl), and c1 inhibitor 4 mg/dl (21-39 mg/dl). the patient alvina widhani acta med indones-indones j intern med 206 figure 2. patient’s family tree. figure 3. after prophylaxis, the patient rarely had angioedema attack. figure 1. recurrent angioedema experienced by the patient. was assisted financially by a foundation to check for c1 inhibitor (inh) as this is not covered by the indonesia national insurance because a sample must be sent to a laboratory in the united states by a private laboratory in indonesia. we diagnosed the patient with type 1 hae. for long term prophylaxis, we have administered tranexamic acid. after he was given prophylaxis, the patient rarely had angioedema attack (figure 3). the covid-19 vaccine, coronavac, was safely administered in this patient without adverse event following vaccination. discussion prevalence of hae globally is approximately 1 in 10,000 to 1 in 50,000 people.2 even though vol 55 • number 2 • april 2023 a case report of hereditary angioedema 207 it is rare, the mortality rate from laryngeal edema is about one death for every 20 patients.3 prevalence of the disease in indonesia is unknown and possibly underdiagnosed. this case shows a patient that had symptoms for a long time before visiting our clinic for diagnostic work up. he also has family members with similar symptoms who have not planned to visit a doctor because they don’t consider it a serious problem. underdiagnosis of the disease is not only due to a lack of awareness, but there are also problems related to diagnostic tests of c1-inh and c1-inh function because samples must be sent to laboratories outside indonesia. hereditary angioedema is one of the bradykinin mediated angioedema. angioedema tissue swelling caused by regional increased in the permeability of blood vessels can be mediated by bradykinin and/or mast cell mediators including histamine.4 histamine has important role in angioedema associated with wheals, while bradykinin is the most important mediator in angioedema not associated with wheals.2 bradykinin mediated angioedema can be hereditary or acquired.4 acquired bradykinin mediated angioedema might be caused by drugs, such as ace inhibitors, angiotensin ii receptor blockers (arb), tissue plasminogen activators, neprilysin inhibitors or gliptins.2,4 ace inhibitor inhibits degradation of bradykinin. other acquired causes are lymphoma or autoimmune diseases.2 two types of hae make up the majority of hae cases. type 1 hae is caused by c1-inh deficiency which lead to decrease of c1-inh level and function. meanwhile, type 2 hae has normal or elevated c1-inh level, but low c1-inh function. type 1 and type 2 hae are caused by a mutation in gene which code c1inh (serping1). c1-inh is the main inhibitor of mannose binding lectin-associated serine protease, c1s, and c1r (complement proteases). it also inhibits contact-system proteases (coagulation factor xiia and plasma kallikrein) and plasmin, a protease which dissolves fibrin blood clot.4 mutations in serping1 gene for type 1 and type 2 hae are different. in type 1 hae, c1-inh cannot be secreted because it is misfolded. it is caused by insertion, nonsense, deletion, missense, or frameshift in serping1 gene. low c1-inh function seen in type 2 hae is caused by mutant c1-inh.8 other types of hae are the result of known or unknown mutation. they show normal c4 and c1-inh levels and functions. the mutations are mutations of the factor xii gene, angiopoietin-1 gene, plasminogen gene, kininogen 1 gene, myoferlin gene, or heparan sulfate 3-o-sulfotransferase 6 gene. deficiency or dysfunction of c1-inh cause increase of bradykinin level then it will activate bradykinin b2 receptors. this condition increases vascular permeability which manifests as angioedema.1,4 typical manifestation of hae is swelling of the lips, hands, feet, eyes, or genitals. hae attack can also cause life-threatening laryngeal edema and abdominal pain.2 the attack which can be triggered by procedure, trauma, infection, or stress, lasts for 2-5 days which can resolve without treatment.8 clinicians should suspect for type 1 or type 2 hae when they find angioedema without wheals which do not improve with antihistamine or steroid.2,4 another supporting data are onset of manifestations in childhood or adolescence, a positive family history, and prodromal signs or symptoms before swellings. to confirm the diagnosis, measurements of c4 and c1-inh level and function are needed.4 our patient had history of swelling in his lips, hands, feet, and upper air way without wheals since adolescence which was not responsive to antihistamines or corticosteroids. this manifestation, with a positive family history and low c4 and c1-inh levels, supports the diagnosis of type 1 hae in our patient. in one case report, a patient with type 1 hae can present with atypical manifestation limited to gastrointestinal system (severe abdominal pain with bowel wall oedema and colitis). the patient had a family history for hae and the laboratory work up showed low c4 level and c1q esterase inhibitor.5 clinicians should know how to manage hae patients during acute attacks and how to give prophylaxis before procedure or for long term.2,6 medications for treatment or prophylaxis that target the pathway in bradykinin mediated alvina widhani acta med indones-indones j intern med 208 angioedema include c1-inh replacement, inhibition of the bradykinin b2 receptor, and inhibition of kallikrein which decrease bradykinin production (figure 4).1,2,6,7 low or dysfunctional c1-inh can be treated with plasma-derived or recombinant c1-inh which has similar target with endogenous c1-inh. bradykinin-mediated angioedema cannot be treated with antihistamine, steroid, and epinephrine.1,4 f i r s t l i n e m e d i c a t i o n f o r l o n g t i m e prophylaxis is plasma-derived c1-inh. other choices are lanadelumab and berotralstat. lanadelumab is a fully human antiactive plasma kallikrein monoclonal antibody which can be given subcutaneously. meanwhile berotralstat is an oral plasma kallikrein inhibitor. attenuated androgens (danazol) have also been used for long-term prophylaxis, but there are dose-related side effects related to its androgenic and anabolic effects.4 the dose of danazol varies between 100 mg every other day and 200 mg three times daily (2.5-10mg/kg/d, max 600mg).4,6 due to side effects, danazol more than 200 mg daily is not recommended for long term treatment. danazol increases c1-inh produced by the liver and c1-inh messenger rna expression in circulating monocytes. it is not useful for acute attack because danazol takes 1-2 days to have effect.1 when first-line prophylactic treatment is not available and androgens are contraindicated, antifibrinolytics, such as tranexamic acid, can be used.4 antifibrinolytic inhibits plasminogen conversion to plasmin. this condition decrease activation of fxii.1 contraindications/ precautions for antifibrinolytics are high thrombotic risk, thrombophilia, or acute thrombosis. dosage of tranexamic acid is between 30 and 50 mg/kg of body weight daily, which can be divided into two or three doses with a maximum of 6 g per day.4 in the case of this study, because the firstline medication for long term prophylaxis is not available in indonesia, we chose to administer tranexamic acid rather than attenuated androgen because of its fewer side effects. we also educated the patient about the preparations he would need to do if he planned to undergo a procedure involving the upper aerodigestive tract. for preprocedural short-term prophylaxis in procedures related to the upper aerodigestive tract, the first line recommendation is intravenous plasma-derived c1-inh (pdc1inh). if intravenous pdc1-inh cannot be given, recombinant human c1-inh (rhc1-inh) can be considered. if this medication is also unavailable, fresh frozen plasma (ffp) is an alternative option. attenuated androgens (eg, danazol) can also be figure 4. bradykinin mediated angioedema pathway and treatment modalities in hereditary angioedema. c1-inh: c1 inhibitor; ace: angiotensin converting enzyme. vol 55 • number 2 • april 2023 a case report of hereditary angioedema 209 used for scheduled preprocedural prophylaxis as it is given 5 days before the procedure and 2–3 days post procedure. in the past, tranexamic acid has been used for preprocedural prophylaxis, however it is not recommended by most guideline experts.4 because first line short time prophylaxis is not available in indonesia, the alternatives are ffp and attenuated androgen. for acute attack, especially one affecting the upper airway, the treatments of choice are icatibant (bradykinin-receptor antagoninst), ecallantide (kallikrein inhibitor), and intravenous c1inh. if these first-line options are not available, solvent detergent-treated plasma (sdp) can be given for acute attack. if sdp is also not available, ffp is the alternative.4 the available treatment option in indonesia for acute attack is ffp. educating patients about hae is also an important part of hae management. although most hae attacks are unpredictable, the patient should be informed about avoiding triggers and consider long term prophylaxis. hae attacks can be triggered by trauma, estrogencontaining oral contraceptive agents, estrogen hormone replacement therapy, ace inhibitors, fatigue, menstrual cycle, febrile illness, and psychological stress. it is also important to educate family members displaying similar symptoms and encourage them to visit a doctor for hae work up. it is recommended that family members of type 1 and type 2 hae patients are screened for c4 level and c1-inh level and function because this medical condition has autosomal dominant inheritance.4 there is concern that covid 19 vaccine can trigger angioedema attack because it shows more side effects (fatigue, pain, fever) than other vaccine. study by fijen et al.9 reported that of the 111 doses of covid 19 vaccine administered, there were 11 angioedema attacks with nine attacks happened after first dose. all attacks were mild or moderate and no hospitalization or laryngeal edema. one attack happened in patient that was already given pre procedural prophylaxis with danazol. four attacks happened in patient that were taking long term prophylaxis with intravenous c1-inh. eight attacks were treated with intravenous c1-inh. in this study, covid 19 vaccine platform given were mrna1273 (moderna), bnt162b2 (pfizer-biontech), chadox1 ncov-19 (astrazeneca), and ad26. cov2-s (janssen). there were 8 attacks from 38 patients who got pfizer-biontech vaccine, 2 attacks from 10 patients with moderna vaccine, 1 attack from 6 patients with jansen vaccine, and none from 9 patients with astrazeneca vaccine. our patient got coronavac vaccine, an inactivated covid 19 vaccine, which has different platform with covid-19 vaccine given in the study by fijen et al. although our patient did not report any adverse event following vaccination, more data is needed to know whether inactivated vaccine is safer than other covid 19 vaccine platform for patient with hae. conclusion although hae is a rare genetic disease, it can be life threatening. to improve its detection and management, awareness and knowledge of physicians needs to be increased. hae might be underdiagnosed because of limited access to the required laboratory test, which is an issue that should be addressed by health care providers. until now, first line treatment and prophylaxis for hae are not available in indonesia, probably because of unknown demand due to limited detection. references 1. wilkerson rg, moellman jj. hereditary angioedema. emerg med clin north am. 2022;40:99–118. 2. jindal ak, bishnoi a, dogra s. hereditary angioedema: diagnostic algorithm and current treatment concepts. indian dermatol online j. 2021;12(6):796–804. 3. minafra fg, goncalves tr, alves tm, pinto ja. the mortality from hereditary angioedema worldwide: a review of the real-world data literature. clin rev allergy immunol. 2022; 62(1):232-9. 4. the international wao/eaaci guideline for the management of hereditary angioedema—the 2021 revision and update. world allergy organ j. 2022; 15(3):100627. 5. soni p, kumar v, alliu s, shetty v. hereditary angioedema (hae): a cause for recurrent abdominal pain. bmj case rep. 2016; 2016: bcr2016217196. 6. zafra h. hereditary angioedema: a review. wmj. 2022;121(1):48-53. 7. kaplan ap, joseph k. complement, kinins, and hereditary angioedema: mechanisms of plasma instability when c1 inhibitor is absent. clinic rev allerg immunol. 2016;51:207–15. alvina widhani acta med indones-indones j intern med 210 8. abdulkarim a, craig tj. hereditary angioedema. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2022. 9. fijen lm, levi m, cohn dm. covid-19 vaccination and the risk of swellings in patients with hereditary a n g i o e d e m a . j a l l e rg y c l i n i m m u n o l p r a c t 2021;9(11):4156-8. 476 acta med indones indones j intern med • vol 54 • number 3 • july 2022 review article colonoscopy, biomarkers, and targeted therapy in colorectal cancer rustam effendi-ys* division of gastroenterology hepatology, department of internal medicine, faculty of medicine universitas sumatera utara adam malik hospital pirngadi hospital, medan, indonesia. *corresponding author: rustam effendi-ys, md., phd. consultant gastroenterohepatologist at columbia asia hospital. jl. listrik 2a, medan 20112, indonesia. email: effendiysr@yahoo.com; rustamoreocr@gmail.com. abstract this review highlights the most versatile diagnostic test of colonoscopy for crc. it remains the gold standard diagnostic tools for crc, and to prevent crc by screening and removing the polyp or premalignant lesions. this work also provides the most promising biomarkers, which highlights the application of the novel biomarkers in conjunction with clinical and pathologic features have allowed for more individualized approaches and targeted therapy to patients with crc. crc is the third most common cancer diagnosed, and the second leading cause of cancer-related deaths worldwide. with a population totaling 273,523,621 people, indonesia has an estimated of 396,914 new cases of all cancers and 234,511 cancer-related deaths. among those cancer cases, an estimated of 34,189 new crc cases and 17,786 crc deaths occurred in 2020. most of crc cases were located in the rectum compared to those in the distal colon or proximal colon. clinical signs, symptoms and therapeutic approaches vary, depending on the stage and the location of crc. those cancer locations are different in terms of their associated molecular alterations. biomarker tests of tumor tissue from colonoscopy biopsy can help doctors to select a specific crc treatment, and the tests can be used to determine prognostic value, predictive factors and the targeted therapy. targeted therapies are recommended for advanced or mcrc patients with kras/nras/braf mutated or wild-type tumors, her2-amplified tumors, and ntrk gene fusion-positive, while immunotherapy is only offered for tumor with msi-high (dmmr) status. the biomarkers and targeting approaches against colorectal cscs are being developed and will be quite challenging. keywords: colonoscopy, colorectal cancer, biomarkers, cancer stem cells, targeted therapy. introduction there were an estimated 19.3 million new cases of all cancers and approximately 10 million cancer-related deaths worldwide in 2020. colorectal cancer (crc) is the third most common cancer, and the second leading cause of cancer deaths among all cancers worldwide, with an estimated of 1,931,590 new crc cases (10% of all cancers), and 915,880 colorectal cancer deaths (9.2% of all cancer deaths) in 2020. with a population totaling 273,523,621 people, indonesia has an estimated of 396,914 new cancer cases and 234,511 cancer-related deaths. among those cancer cases an estimated of 34,189 new crc cases (8.6% of all cancers), and 17,786 crc deaths (7.6% of all cancer deaths) occurred in 2020. other countries with increasing populations also experience similar phenomena.1-3 most of crc cases were located in the rectum (74.6%) compared to those in vol 54 • number 3 • july 2022 colonoscopy, biomarkers, and targeted therapy in colorectal cancer 477 the distal colon (18.8%) or proximal colon (6.6%).3,4 more than 50% of crc patients will develop metastasis, and approximately 25% of them present with metastasis at initial diagnosis. clinical signs and symptoms vary depending on the location and the stage of the tumor. those locations are also different in terms of their associated molecular alterations.3,4 colonoscopy and biopsy of the tumor tissue are important in crc, and it has become a very popular method for primary crc screening. it allows for early-stage cancer detection and polyps detection and removal. sporadic crcs may develop from adenomatous polyps and from sessile serrated lesions.5,6 molecular testing of crc from tumor tissues or biomarkers has important implications for the selection of treatment. the testing can also be used to determine prognostic value for molecular predictive factors and targeted therapy. cancer locations, whether the tumor is at proximal colon, distal colon or rectum, are also different in terms of their associated molecular alterations and response with chemotherapy.3,4,7-9 crc prevention most polyps identified can be managed by conventional polypectomy, and they do not pose a significant challenge for resection to an adequately skilled and trained endoscopist.10 the main endoscopic techniques that are available for removal of colon polyps, or early cancer and precancerous growths are as follows: a) polypectomy, b) endoscopic mucosal resection (emr) and c) endoscopic submucosal dissection (esd).10,11 colonoscopy is a 1-step crc screening test, and it is the most appropriate screening test and diagnosis of crc.5 with appropriate training, esd is preferred over emr as the first-line therapy for resection of colorectal polyps, without restricting to lesion greater than 20 mm and those with high suspicion of submucosal invasion.11 clinical manifestation clinical signs and symptoms vary based on the location, the tumor size and the stage of crc.3,4 crc may not cause symptoms in the early stages. if it does, the symptoms may include a change in bowel habits, such as diarrhea, constipation or a change in the consistency of the stool, and these symptoms can last for more than a few days. the change in bowel habits can also induce feeling that the bowel does not empty properly, or result in blood in the stool from the rectum (hematochezia) that is dark brown or bright red in colour, abdominal pain, cramping, bloating, feeling full, fatigue or tiredness, a decrease in appetite, unexplained iron deficiency anemia, and unexplained weight loss. crc should be classified into several subgroups defined according to tumor location, rather than as a single entity, whether at proximal, distal colon or rectum. in clinical practice, different manifestations, molecular alterations and survivals have been observed in crc patients with tumor originating from different sub-sites of the colorectum.3,4,7,12-16 tumor location plays a critical role in predicting survival. right colon cancer patients or proximal colon cancer had worse survival especially in the subgroups including stage iii or iv disease.3,4,12,14 tumors in the proximal colon or right colon rarely cause symptoms of obstruction. stool is relatively liquid as it passes through the ileocecal to the cecum and ascending colon. tumor usually forms ulceration, chronic occult bleeding, microcytic hypochromic anemia due to iron deficiency, fatigue and weight loss. stool has become more shaped as it passes through the transverse colon to the splenic flexure, descending colon and sigmoid colon (distal colon). tumor in the distal colon can interfere with the passage of stool causing symptoms of abdominal pain or cramps, altered bowel habit, decreased stool caliber, or overflowed diarrhea. in addition, it sometimes causes symptoms of obstruction and perforation. cancer located in the rectum will result in hematochezia, tenesmus, small-caliber stools due to narrowing of the rectum caused by the tumor. crcs spread to other parts of the body by direct extension into adjacent structures and metastasis through the lymphatics and blood vessels. the favoured metastatic sites of crc are lymph nodes, liver, lung, brain, bone, and peritoneum. patient with metastatic crc (mcrc) to the liver may have signs of right upper quadrant abdominal pain, rustam effendi-ys acta med indones-indones j intern med 478 ascites, jaundice, or symptoms and signs from cancer spread to the lungs. other symptoms include those from local invasion or perforation to bladder or vagina.7,1216 diagnostic evaluation physical examination physical examination findings can be very nonspecific (e.g., fatigue, weight loss) or normal, early in the course of colon cancer. the examination is performed with specific attention to the abdominal mass, especially at the right and left iliac fossa, right upper abdomen, as well as to possible metastatic lesions, including enlarged lymph nodes, hepatomegaly, and others. examination includes the use of digital rectal examination (dre). patients with proximal colon cancer, especially at the cecum may have abdominal mass, particularly at the right iliac fossa, while patients with sigmoid cancer will have palpable mass at the left iliac fossa. common signs and symptoms of emergencies due to complications of crc should be examined, such as peritonitis from perforation, or obstruction. other signs, such as jaundice, hepatomegaly, ascites, may occur with liver metastasis.7, 12-17 colonoscopy and biopsy certain screening modalities, such as colonoscopy, sigmoidoscopy, ct colonography and to a lesser extent stool-based testing, will detect advanced adenomatous polyps, whereas colonoscopy is optimal for the detection of sessile serrated lesions (ssls). endoscopic removal of polyps reduces crc incidence and crc mortality. 5 colonoscopy is regarded as the gold standard diagnostic technique for colorectal tumor detection to determine precisely the location of the tumor. pathology and biomarker test tumor biopsy remains the gold standard for initial pathologic diagnosis and molecular testing in crc. fresh tumor tissue is obtained from colorectal tumors, either by colonoscopic biopsy or surgery. the tumor is immediately fixated by using 10% formaldehyde buffering solution and made into paraffin blocks or formalin-fixed and paraffin-embedded tissues (ffpet). it is used to determine the histology of the tumor and to examine biomarker test. immunohistochemistry test (ihc) is a special staining process performed on cancer tissue. ihc is used for the detection of chromosome instability (cin), dna-mmr defect (msi status), and kras mutation status. pcr test is used for the detection of microsatellite instability (msi) and cpg island methylation phenotype (cimp).3,7,9 laboratory examination complete blood count, urinalysis, serum chemistries e.g., hepatic function panel, kidney function tests, etc. cea tests is recommended before surgical operation and follow up after operation if there is a suspicion of cancer recurrence. an increase in the concentration of cea after operation suggested of recurrence. ct scan or magnetic resonance imaging (mri) if local or systemic metastasis crc is suspected, the following radiologic studies may be obtained, such as ct scanning of the chest, abdomen and pelvis, mri or trans rectal usg (trus) for rectal cancer. diagnostic evaluation is conducted for localized staging of rectal cancer with trus: 80-95% accuracy of distinction between t1/2 vs t3 tumors. mri is high degree of accuracy for prediction of circumferential resection margin with less operator dependent, and it allows for a study of stenotic tumors and pelvic adenopathy.7,16 biomarkers in crc as targeted therapies continue to emerge in the treatment of mcrc, knowledge and implementation of predictive and prognostic biomarkers will become increasingly important to ensure the best outcomes and to limit toxicity. biomarker tests may impact selection of the most appropriate treatment strategy.3,4,7,17-19 the application of novel molecular diagnostic test may lead to an improved survival of crc patients.20 the novel markers in conjunction with clinical and pathologic features have allowed for more individualized approaches to patients with crc.21 the location, the stage of the tumor, and the result of biomarker tests can be used for vol 54 • number 3 • july 2022 colonoscopy, biomarkers, and targeted therapy in colorectal cancer 479 the assessment of the therapeutic approach. some cancer treatments, including chemo therapies and targeted therapies, may only work for patient whose crc have certain biomarkers.3,4,17,18 several biomarkers for mcrc include extended ras (kras and nras) exons 2,3, and 4 mutations, braf v600e mutation, mismatch repair (mmr) or msi and her2 (human egfr2) amplification. in addition, actionable gene fusions such as ntrk fusions or rearrangements (neurotrophic tropomyosin receptor kinases) are extremely rare but might represent a new target to improve outcomes in the setting. however, recent ngs (nextgeneration sequencing) approaches can detect all required types of genomic alterations, including amplification, fusions, and msi.18 msi is a key biomarker in crc, with crucial diagnostic, prognostic, and predictive implications.22 it is important for understanding the onset and the progression of crc that can aid in the early detection of molecular markers and risks to improve the clinical care of crc patients.23 gene mutations have the potential of disrupting several epigenetic patterns (dna methylation, histone modification, and nucleosome positioning), and those epigenetic modifications can drive genome instability and mutagenesis (a crosstalk). similarly, epigenetic inactivation of dna mmr is often associated with genome instability and increased frequency of point mutations of cancerrelated genes.24 the genes that are most commonly mutated in crc patients include apc (about 80-82% of cases), tp53 (48-59%), kras (40-50%), and pik3ca (14-18%). some biomarkers are based on the mutational status of genes (kras, nras, braf) or associated with defects in the dna mismatch repair system (dmmr). these defects are the underlying mechanism through which msi status is determined.17 kras, braf biomarker mutations in kras/nras exons 2 (codon 12 and 13), exon 3 (codon 59 and 61), and exon 4 (codons 117 and 146) are predicted due to lack of benefit for anti-egfr mab (such as cetuximab and panitumumab) treatments in mcrc. patients with ras-wild tumor who are left-sided demonstrated excellent outcomes with antiegfr-based therapy. patients with brafv600e mutations demonstrated a markedly worse prognosis than non-braf v600e patients, and a number of sub analyses of mutation appear to suggest benefit from aggressive tripletbased therapy as a frontline therapy. patients with braf v600e demonstrated a benefit in median progression free survival in the swog randomized clinical trial of vemurafenib/ irinotecan/cetuximab in the second-line setting in comparison with irinotecan/cetuximab.18,25 the braf gene is activated by mutation in 10-12% of all crc and most frequently occur in codon 600 (braf v600).17,25 apc mutations in the apc gene occur in over 70% of sporadic crcs, and they are the cause of the fap cancer predisposition syndrome. the apc protein negatively regulates wnt signaling by facilitating the targeting of the transcription factor b-catenin for ubiquitinmediated proteasomal degradation.19 apc mutation in advanced state crc had poorer overall survival. it can be used to predict the clinical outcome of crc.24 msi status and dmmr microsatellite instability (msi) status results from a deficient dna mismatch repair (dmmr) system commonly caused by the inactivation of the mmr genes (mlh1, msh2, msh6, pms2, pms1, and mlh3). msi-high (msi-h) is characterized by instability of two or more loci. msi status can be determined by two distinct methods, immunohistochemistry analyses (ihc) or pcr based on five markers panel.4,7,17,24 m s i h t u m o r s c a n b e o b s e r v e d i n approximately 15% of all crc patients. of the 15%, 12% are associated with sporadic crc, due to sporadic hypermethylation of the promoter of the mlh1 gene. the other 3% of msi tumors are associated with lynch syndrome, an inherited cancer syndrome associated with a genetic predisposition to crc.17 msi/mmr testing should be performed in all patients diagnosed with crc, and may be predicted with immunotherapy in the metastatic setting.17,18,24 rustam effendi-ys acta med indones-indones j intern med 480 crc stage ii msi-h patients have a better prognosis and no beneficial effect of 5-fu.22 this prognostic significance indicates the need to implement msi screening for all resected stage ii crc patients. msi status is less informative in stage iii patients.17 emerging data suggest that tumors with dmmr or msi-h respond better to immune check point inhibitors (icis). 17 the us fda approved pembrolizumab, a monoclonal anti-pd1 antibody, for patients with msi-h crc. additionally, nivolumab and iplimumab are approved options for refractory stage iv msi-h patients, after prior therapy with fluoropyrimidine, oxaliplatin, and irinotecanbased therapy.17,18 msi is a key biomarker in crc, with crucial diagnostic, prognostic, and predictive implications. msi-h status is associated with a better prognosis in earlystage crc and a lack of benefit from adjuvant treatment with 5-fluorouracil (5fu) in stage ii disease. msi has emerged as a predictor of sensitivity to immunotherapy-base treatment.22 pemrolizumab is only effective in mcrc patients with msi-h status.25 cimp epigenetic instability in crc is manifested as both hypermethylation of gene promoters that contain cpg island and global dna hypomethylation. aberrant dna methylation is present in essentially all crcs; however, there is a subset of crcs (approximately 20%) that has an extremely high proportion of aberrantly methylated cpg loci. this class of crcs has been characterized as having a cimp. the discovery and classification of cimp tumors have advanced our understanding of the molecular pathology of crc, but it has not yet impacted clinical care.19 cimp status seems to overlap with braf mutations and mmr status. thus, the independent prognostic value of cimp needs to be validated.17 tp53 tp53 is the most frequent somatic gene mutation, and its mutational status has been associated with a positive response to adjuvant 5-fu therapy in stage iii crc patients. further studies are necessary in order to determine the role of tp53 as a potential prognostic and predictive biomarker in crc.17 mutations in the tp53 occur in about half of all crcs, and these mutations promote the malignant transformation of adenoma. like apc, tp53 is a key tumor suppressor gene that has been extensively studied in crc, but it currently has no predictive or prognostic role in the clinical setting.19 tp53 mutations or loss of function are reported in 5075% of crc cases.23 pi3k molecular lesions in the pi3k pathway, which in crc are primarily mutations in pik3ca and loss of pten protein expression. mutations of genes in this pathway may have the potential to be used as predictive biomarkers for therapies that target the pi3k pathway, mammalian target of rapamycin (mtorc) pathway, as well as the mapk pathway. mutations in pi3k pathway genes are observed in up to 40% crc patients.19 it is difficult to evaluate the importance of pik3ca as an independent pre dictive marker as pik3ca mutations often co-occur with ras or braf mutations.17 her 2 aberration human epidermal growth factor receptor 2 or her2 (errb2) is a transmembrane receptor of the egfr family and its activation leads to cell proliferation and apoptosis inhibition. the frequency of her2 overexpression is reported to be around 5% with errb2 amplifications reported in 5.5% of mcrc.17,25 the implementation of her2 assessment in daily practice might provide useful information for guiding therapy decision.17 several studies suggest the amplifications of erbb2 negatively predict efficiency and are associated with development of resistance to anti-egfr therapy.17,18 consensus molecular subtypes in late 2016, a large consortium of groups working on crc combined their efforts and identified four molecular subtypes based on multi gene arrays, which were conserved across all examined studies. these subtypes are referred to as cms1 (msi-immune subgroup representing vol 54 • number 3 • july 2022 colonoscopy, biomarkers, and targeted therapy in colorectal cancer 481 14% of crc cases), cms2 (canonical subgroup accounting for 37% cases), cms3 (metabolic representing 13% of crc patients) and cms4 (mesenchymal representing 23% of crc cases). cms subtypes primarily show an association with clinical outcomes. the clinical impact of the identification of these subtypes remains relatively limited.17,23,25 micrornas microrna (mirnas) are considered to be exceptional biomarkers due to their involvement in multiple physiologic pathways and their stability in paraffin-embedded tissue (ffpet), which is an important factor for the translation of biomarkers into the clinics. mirnas play an important role in the regulation of intracellular processes via the post-transcriptional regulation of gene expression.17 several specific mirnas were identified as predictive or prognostic biomarkers in crc.20, 25 numerous mirnas have been reported in tumor specimens from crc patients, and several representative mirnas have been identified in tumor tissues that have prognostic value and response to anticancer drugs in crc patients.25,26 despite the numerous studies of mirnas and extensive analyses of their expression, the role and function of many individual mirnas in crc remains poorly understood.27 tumor locations the most interesting concept in crc is the impact of the primary tumor location. colon is known to have two distinct embryological origins, namely the midgut for the proximal colon and the hindgut endoderm for the distal colon. additionally, the two parts of the colon have different blood supplies, distinct microbiome populations and are associated with different biological features. proximal colon cancer shows a worse prognosis than distal colon cancer. antiegfr therapy should be limited to distal colon cancer with kras wild type.17 primary tumor location affects response to targeted therapy and is essential for the treatment selection for ras wild type mcrc.18 a study on molecular biomarker in crc based on three locations (proximal colon, distal colon and rectum) was published (effendi et al., 2013). in this study, tumor tissues of crc patients from three locations were examined by ihc and pcr test. the protein expressions were determined by ihc for apc, dmmr (mlh1, msh2, msh6, and pms2), while microsatellite instability-high (msi-h) by pcr was based on 5 markers of bat25, bat26, d2s123, d5s346, d17s250, known as bethesda panel. msi-h was considered if there were ≥ 2 of abnormal markers.4,7,24 there were differences in the characteristics of cin, mmr, and msi-h found in colorectal cancer patients based on different locations. the mlh1 protein expression negative was prominent in proximal colon cancer, msh6 in distal and rectal cancer, and apc in distal colon cancer respectively. the proportion of msi-h displayed a tendency to occur in proximal rather than in distal colon or rectal cancer. nevertheless, these findings suggest that the underlying carcinogenic pathway or molecular backgrounds differ according to the cancer locations among crc patients in this region. the crc in each location has its specific molecular characteristics.3,4,7 right colon cancer or proximal colon cancer had better outcome at stage ii in comparison with left cc, and it had better outcomes at stage i and ii in comparison with rectal cancer. in other words, right cc was associated with a relatively favourable outcome in an earlystage disease, but had an opposite outcome in regional and metastatic disease. in this case, tumor heterogeneity was considered as the main potential reason. tumor phenotypes may vary depending on the process of tumor infiltration and metastasis.14 cancer stem cells (cscs) cscs have been put forward to be one of the determining factors that contribute to intra-tumor heterogeneity and the potential implications for crc therapy.27 cscs can escape the chemotherapy and differentiate into mature cancer cells, resulting into cancer recurrence and metastasis. therefore, development of therapy targeting cscs has a therapeutic potential, and it is important to identify approaches in combination with conventional therapy for rustam effendi-ys acta med indones-indones j intern med 482 targeting and eradicating cscs.3,4,9,28-30 treatment most crc patients are treated with surgery to remove the tumor tissue, and some of the crc patients recurred. chemotherapy used as adjuvant or neoadjuvant therapy also presents several problems, in which these treatments are useless in tumor cells with chemo-resistance. despite advanced treatment strategies, crc is rarely cured completely due to recurrence. chemotherapy can only shrink tumors by killing the active tumor cells but miss the quiescent colorectal cancer stem cells (cscs). this leads to resistance and relapse, and usually includes systemic and local toxicity of chemotherapy. cscs are considered as the origin of tumorigenesis, development, metastasis and recurrence in theory.3,8,9 surgery is the primary treatment for crc, that it is limited to the colon or rectum. it aims to remove cancerous tissue of an early stage cancer, including tumors and nearby lymph nodes, preventing the cancer from spreading. in the later stages, surgery cannot stop the cancer from spreading. systemic therapies for localized and advanced crc include chemotherapy, targeted therapy, immune therapy, and a newly developed therapy. systemic therapy for crc aims to downsize the primary tumor or metastases in order to convert them to a resectable status and increase progression-free survival. chemotherapy drugs destroy cancerous cells throughout the body. it may shrink a tumor before surgery. it can also help relieve symptoms in the later stages. chemotherapy can have widespread adverse effects, as it targets both cancerous and healthy cells. targeted therapy involves taking drugs that target specific protein to slow or prevent the growth of cancer cells. the adverse effects are usually less severe than those of chemotherapy because these drugs only target specific cells. immunotherapy can have possible adverse effects include an autoimmune reaction, in which the body mistakenly attacks its own cells. if crc spreads to organ beyond the colorectal, progressing to stage 4, it is not possible to cure it. recently numerous newly developed therapies are available. other option for stage 4 crc may include: surgery to remove a blockage, radiation therapy or chemotherapy to reduce the size of tumors, pain relief, treatment for side effects of medication, and counseling. therapeutic management should involve a multidisciplinary approach that includes diagnostic accuracy, surgical technique (high quality surgery), biomarker test, optimal selection of drug treatment or procedure and informed consent.16,31-33 colon cancer a. stage i: surgery b. stage ii-iii: surgery ± adjuvant chemotherapy c. stage iv: chemotherapy ± palliative surgery. rectal cancer a. stage i: surgery (local excision) or total mesorectal excision (tme). b. stage ii-iii: neoadjuvant chemoradiation followed by resection, followed by adjuvant chemotherapy. c. stage iv: chemotherapy ± surgery. surgery is also performed if there is a perforation or blockage due to a tumor. sometimes endoscopic stent placement is required before surgery for partial obstruction due to crc.16, 31-33 chemotherapy for advanced crc and metastasis:16 a. 5-fu/leucoferin+ oxaliplatin (folfox), b. 5-fu/lv+ irinotecan (folfiri), or c. capecitabin + oxaliplatin (capeox). targeted therapy targeted therapies are recommended for patients with kras/nras/braf mutated tumors, or wild-type tumors, her2-amplified tumors and ntrk gene fusion-positive tumors. development and approval of novel targeted therapies such as monoclonal antibodies against egfr and vegf have significantly increased the median survival of crc patients with advanced or metastatic disease. monoclonal antibodies against egfr (cetuximab or panitumumab) are recommended for patients with kras/nras/braf wildvol 54 • number 3 • july 2022 colonoscopy, biomarkers, and targeted therapy in colorectal cancer 483 type tumors. there are no roles for anti egfr therapy in kras mutation crc, as well as for dual anti egfr and anti vegf combination therapy.16, 31,33-36 targeted cytotoxic drugs against colorectal cscs marker research will provide more effective therapeutic results as well as reduce resistance and recurrence.3,37,38 cr-cscs are defined with a group of cellsurface markers, such as cd44, cd133, cd24, epithelial cell adhesion molecule (epcam), lgr5, and acetaldehyde dehydrogenase (aldh). they are highly tumorigenic, aggressive, radioresistant and chemoresistance and thus are critical in the metastasis and recurrence of crc. therefore, targeting cr-cscs may become an important research direction for the future cure of crc.39,40 the biological activities of cscs are regulated by several pluripotent transcription factors, such as oct4, sox2, nanog, klf4, and myc. in addition, many intracellular signaling pathways, such as wnt, nf-kb(nuclear factor-kb), notch, hedgehog, jak-stat (janus kinase/signal transducers and activators of transcription), pi3k/akt/mtor (phosphoinositide 3-kinase/akt/mammalian target of rapamycin), tgf(transforming growth factor)/ smad, and ppar (peroxisome proliferator-activated receptor), as well as extracellular factors, such as vascular niches, hypoxia, tumor-associated macrophages (tam), cancer-associated fibroblasts, cancer-associated mesen chymal stem cells, extracellular matrix, and exosome, have been shown to be very important regulators of cscs.41 tumor microenvironment (tme), contains both cellular components with cancerous and non-cancerous cells such as stromal myofibroblast, endothelial cells, immune cells and cancer-associated fibroblast (cafs), and non-cellular components including extracellular matrix (ecm), cytokines, growth factors and extracellular vesicles. in the tumor stroma, cafs secrete the cytokines cxcl1 and cxcl2 as well as the interleukin-6, which promote angiogenesis and tumor progression.42,43 cscs reside in anatomically specialized regions of the tme, known as csc niche, which retain their properties and protect them from anticancer drugs, contributing to their enhanced resistance to treatment. tme and metabolic plasticity may also be involved in therapeutic failure by imposing selective pressures on cscs that lead to chemoresistance and cancer progression. therefore, the development of new therapies targeting cscs taking into account the tme and tumor metabolism, represents an interesting approach to overcome resistance to therapies.42, 43 cscs are thought to be responsible for tumor initiation and dissemination, drug and radiation resistance, invasive growth, metastasis, and tumor relapse. specific pheno types could be used to distinguish cscs from non-cscs. cscs are modified by the aberrant expression of several micrornas.44 thus, it is very difficult to target cr-cscs. targeting cytotoxic drugs to crcscs with the help of stem cell surface markers provides a useful method to treat crc. also, the use of inhibitors targeting drug-detoxifying enzymes, drug-efflux pumps, or transcription factors of cscs represents a novel approach to target the cscs and reduces cancer recurrence and metastasis.7, 45 immunotherapy immune checkpoint inhibitors (icis) are a type of immunotherapy often made from antibodies. icis target co-inhibitory receptors, such as ctla-4 and programmed cell death protein 1 (pd-1) on t cells and other immune cell sub populations, or their ligands, such as pd1 ligand 1 (pd-l1) on tumor cells and various immune cells. in crc, it has been shown that only patients with the subset of dmmr or msi-h tumors are likely to respond to treatment with icis.46-48 therapeutic approaches for the treatment of crc include surgery (surgical resection), local therapies for metastatic disease, a systemic therapy comprising chemotherapy, targeted therapy and immunotherapy, and palliative chemotherapy.42 surgery can be associated with neoadjuvant therapy in order to shrink tumor mass and fascilitate medical operation and/or with adjuvant therapy to limit cancer recurrence. importantly, neoadjuvant chemotherapy, possibly coupled with radiotherapy, is mainly indicated for rectal cancers.42. treatment options and rustam effendi-ys acta med indones-indones j intern med 484 recommendations depend on several factors. these factors include: the patient’s overall health, possible side effects, the type, the size and the stage of the tumor, the location of the tumor, and its mutational and mmr status, or biomarkers.42 the lines of treatment in mcrc currently involve a combination of targeted therapies that inhibit the egfr (cetuximab and panitumumab), or angiogenesis (bevacizumab, regorafenib, aflibercept, or ramucirumab), together with chemotherapy (5-fluorouracil, irinotecan, oxaliplatin, folvox, folfiri, or capeox).46 systemic therapies for localized and advanced colorectal cancer42 1. chemotherapy: 1a 5-fluorouracil (antimetabolite). 1b. capecitabine (antimetabolite). 1c irinotecan (topoisomerase inhibitor). 1d. oxaliplatin (alkylating agent). 1e trifluridine/tipiracil (nucleoside analog / thymidine phosphorylase inhibitor) [1a to 1d: recommendations for: localized and advanced tumors]. 2. targeted therapy: 2a. bevacizumab (mab anti-vegf-a). 2b. regorafenib (multikinase inhibitor targeting e.g. vegfr and braf). 2c. aflibercept. (recombinant fusion protein blocking vegf -a/b). 2d. ramucirumab (mab anti-vegfr-2. [2a to 2d: recommendations for: kras/ nras/braf mutated tumors]. 2e. cetuximab (mab anti-egfr). 2f. panitumumab (mab anti-egfr). [2e to 2f: recommendations for: kras/ nras/braf wild-type tumors] 3. immunotherapy: 3a. pembrolizumab (mab anti-pd-1). 3b. nivolumab (mab anti-pd-1) 3c. iplimumab (mab antictla-4). [3a to 3c: recommendations for: msi-high tumors]. 4. newly developed therapy. 4a. vemurafenib (braf inhibitors). 4b. dabrafenib. (braf inhibitors). 4c. encorafenib. (braf inhibitors). 4d. trametinib (mek inhibitors). 4e. binimetinib (mek inhibitors). [4a to 4e: recommendations for: braf v600e mutated tumors]. 4f. trastuzumab. (mab anti her2). 4g. pertuzumab. (mab anti her2). 4h. lapatinib. (dual her2/egfr inhibitor) [4f to 4h: recommendations for: her2 amplified tumors]. 4i. larotrectinib. (trk inhibitors) 4j. entrectinib. (trk inhibitors). [4i to 4j: recommendations for: ntrk gene fusion-positive tumors]. * monoclonal antibody anti-programmed cell death receptor-1 (mab anti-pd-1) * anti -cytotoxic t lymphocyte associated antigen -4 (antictla-4) * trktropomyosin receptor kinases. * mek-mitogen-activated kinases. * ntrkneurotrophic tropomyosin kinase. conclusion clinical signs and symptoms of crc vary, and they are related to the location of cancer whether in proximal, distal colon or rectum, the tumor size, and the stage of crc. colonoscopy is the gold standard diagnostic tools, and to prevent crc by screening and removing premalignant lesions. biomarkers will give the information on prognostic value, serving as predictive marker for the possibility of response to chemotherapy, biological target agent, immunotherapy, newly developed therapy or targeted therapy. the approved target therapy related to the markers can be used for the selection of the treatment. the more precisely targeted therapies which can selectively 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repair deficient/microsatellite instabilityhigh metastatic colorectal cancer. j clin oncol. 2018; 36(8):773-9. 193 original article acta medica indonesiana the indonesian journal of internal medicine risk factors and scoring systems for patients with candidemia at a tertiary hospital in jakarta, indonesia mursinah, fera ibrahim, mardiastuti h. wahid department of microbiology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: fera ibrahim, md, msc, phd. department of microbiology, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. pegangsaan timur 16, jakarta 10320, indonesia. email: feraib@yahoo.fr. abstrak tujuan: untuk mengidentifikasi faktor risiko kandidemia dan mengembangkan sistem skoring kandidemia yang dapat digunakan di rumah sakit cipto mangunkusumo (rscm), jakarta, indonesia. metode: studi retrospektif dengan kasus kontrol dilakukan dengan menggunakan rekam medik pasien tahun 2011-2014. semua pasien sepsis yang dirawat di rscm dengan hasil kultur darah positif candida dimasukkan sebagai kelompok kasus. kelompok kontrol yaitu semua pasien sepsis tanpa kandidemia. perbandingan kelompok kasus dengan kontrol adalah sama (1:1). hasil: dari 234 pasien yang dianalisis, faktor risiko yang bermakna pada penelitian ini yaitu lama perawatan 8-14 hari (or 3,464; 95% ci 1,458-7,800), lama perawatan lebih dari 14 hari (or 6,844; ci 3,0-15,330), sepsis berat (or 16,407; 95% ci 1,458-7,800) dan pembedahan (or 3,03; 95% ci 1,4926,152). prediktor kandidemia di rscm yaitu lama perawatan 8-14 hari (nilai 1), lama perawatan lebih dari 14 hari (nilai 2), sepsis berat (nilai 3) dan pembedahan (nilai 1) dengan nilai cut off 3,5. kesimpulan: hasil studi ini mengindikasikan bahwa sistem skoring sebagai panduan terapi empirik kandidemia dapat dikembangkan dengan menggunakan faktor risiko kandidemia dari pasien yang diidentifikasi sebagai pasien berisiko di rscm. kata kunci: kandidemia, faktor risiko, sistem skoring. abstract aim: to identify the risk factors of candidemia and to develop a scoring system that could be implemented in cipto mangunkusumo hospital (rscm), jakarta, indonesia. methods: this study was a retrospective study with case control design using the medical records of patients since 2011 to 2014. all sepsis patients hospitalized in the rscm with a positive blood culture for candida were included in this study as a case group. the control group was all of the sepsis patients without candidemia. the ratio for case and control groups was equal (1:1). results: from 234 patients who were analyzed, the risk factors that influenced the study were length of stay of 8-14 days (or 3.464; 95% ci 1.458-7.800), length of stay of more than 14 days (or 6.844; 95% ci 3.015.330), severe sepsis (or 16.407; 95% ci 1.458-7.800), and surgery (or 3.03; 95% ci 1.492-6.152). the predictors for candidemia in rscm were length of stay in hospital for 8-14 days (score 1), a length of stay ≥14 days (score 2), severe sepsis (score 3), and surgery (score 1), with a cut off score of 3.5. conclusion: the results of this study have indicated that a scoring system in order to guide an empirical treatment for candidemia can be developed by using the risk factors for candidemia from patients who have been identified as patients with risk at cipto mangunkusumo hospital. keywords: candidemia, risk factor, scoring system. mursinah acta med indones-indones j intern med 194 introduction candida species have become an important cause of nosocomial infections due to their potential cause of mortality and a prolonged hospitalization time.1 candida is the fourth most common cause of nosocomial blood stream infections in the united states with a mortality rate of more than 40%, even though adequate antifungal therapy was given. the incidence of invasive candidiasis is various in countries and it ranges between 3.4% to 5.79%.2,3 there is a shifting of the causative agents for invasive candidiasis infections from candida albicans to a non-albicans candida species.3,4 an early identification of sepsis patients who have high risk for fungal infection is challenging, because of the complexity of a patient’s condition, a low rate of success, and a long period of time in order to obtain the results for fungal culture.5 it is important to develop a tool to predict high risk patients who might develop candidemia and need an empirical antifungal therapy. a prediction system of candidemia that was based on patient’s clinical status was developed by paphitou6 and ostrosky zeichner.7 in addition, a scoring system that is now called a “candida score” was also developed and was based upon some parameters.8 a limitation of the lack clinical prediction is the possibility of a massive antifungal therapy problem that can change a local epidemiological pattern in a hospital, as well as increasing the resistance to antifungals.6,9 this study aimed at identifying the risk factors of candidemia in rscm hospital in jakarta, indonesia. it was conducted in order to develop a scoring system that is based upon the risk factors that have been identified for candidemia which can be implemented to predict the occurrence of candidemia. methods a retrospective case control study was conducted using the medical records of sepsis patients during the period of 2011 to 2014. all sepsis patients hospitalized in rscm with a positive blood culture for candida were included in the case study group. the control group were sepsis patients with a negative candidemia (a sterile culture or a bacterial growth). the ratio for case and control group was equal (1:1). for the control group, we matched the same age groups and the wards of the patients. quantitative data analyzes were presented as mean and standard deviations (sd) or as median with a maximum and minimum value. frequency was used to describe the categorical data. to obtain the risk factors for candidemia, we performed bivariate analysis. the variables with significant risk factors (p<0.25) were included in multivariate and logistic regression models. the accuracy of the scores was determined by a receiver operating curve (roc). the data was analyzed by using spss 11.5 software. an ethical clearance was obtained from the ethical committee at the faculty of medicine, university of indonesia, cipto mangunkusumo hospital, jakarta, indonesia (no. 742/un2.fi/ etik/2o14). results a total of 234 sepsis patient’s data was obtained for this study. from that number, 117 were sepsis patients with candidemia and the same amount was included as a control group. the patient’s data and bivariate analysis are presented in table 1. the results obtained have shown that the major age group of patients was 16 to 60 years (43.6%), of which 70% of them had severe sepsis and 77% had chronic diseases. the majority of the patients had neutrophils of more than 500 (85%) and 52.1% of the patients had a normal monocyte count (2%-8%). from patients who were hospitalized in icu and hcu (60.7%), the hospital length of stay was more than 14 days (43.2%) and the length of stay in icu ranged between 1-7 days (68.3%). most of patients had urinary catheter (86.3%), central venous catheter (53%) and had antimicrobial therapy administered for more than five days (77.8%). most of the patients were treated with two antimicrobial regimens. the bivariate analysis of the risk factors for candidemia showed that the variables associated with an increased risk of candidemia with p<0.25 were severe sepsis, neutrophil count <500, hospital length of stay of more than 7 days, length of stay in icu of more than 7 days, vol 48 • number 3 • july 2016 risk factors and scoring systems for patients with candidemia 195 urinary catheter, mechanical ventilator, central venous catheter, surgery, abdominal surgery, antimicrobial therapy >5 days, and a number of antimicrobials of 2 to more than 3. the multivariate analysis for candidemia risk factors are shown in table 2. it is shown that a length of stay of 8-14 days, a length of stay of more than 14 days, severe sepsis, and surgery, were associated with the development of candidemia. to develop the scoring system, we used a logistic regression model, in order to predict the relationship between the independent variables that were obtained from the multivariate analysis, with a dependent binary variable (without candidemia or with candidemia). the results are shown in table 3. in the logistic regression analysis, the results showed that the probability of a patient having candidemia would be one time, if the length of table 1. variables associated with candidemia risk factor total (n=234) n (%) sepsis with candidemia n (%) sepsis without candidemia n (%) age <1 year 27 (11.5) 13 (11.0) 14 (12.0) 1-16 years 57 (24.4) 29 (25.0) 28 (24.0) 16 to <60 year 102 (43.6) 51 (44.0) 51 (44.0) ≥60 years 48 (20.5) 24 (21.0) 24 (21.0) severe sepsis 162 (69.2) 106 (91.0) 56 (48.0) candida colonization 56 (24.0) 29 (25.0) 27 (23.0) chronic disease 156 (77.0) 77 (66.0) 79 (68.0) neutrophil count ≥500 199 (85.0) 94 (47.2) 105 (52.8.0) <500 35 (15.0) 23 (20.0) 12 (10.0) monocyte count 2-8% 122 (52.1) 61 (52.0) 61 (52.0) >8 63 (26.5) 27 (23.0) 36 (31.0) <2 49 (20.9) 29 (25.0) 20 (17.0) hospital length of stay 1-7 days 71 (30.3) 17 (15.0) 54 (47.0) 8-14 days 61 (26.1) 31 (27.0) 30 (26.0) >14 days 101 (43.2) 69 (59.0) 32 (27.0) length of stay in the icu 1-7 days 97 (68.3) 41 (73.0) 56 (87.0) 8-14 days 29 (20.4) 18 (25.0) 11 (16.0) >14 days 16 (11.3) 12 (17.0) 4 (6.0) urinary catheter 202 (86.3) 109 (93.0) 93 (80.0) immunosuppression drugs 20 (12) 14 (12.0) 6 (5.0) mechanical ventilator 96 (41) 56 (48.0) 40 (34.0) central venous catheter 124 (53) 73 (62.0) 51 (44.0) surgery 110 (47) 67 (57.0) 43 (37.0) abdominal surgery 65 (27.8) 46 (39.0) 19 (16.0) total parenteral nutrition 49 (21) 23 (20.0) 26 (22.0) antimicrobial >5 days 182 (77.8) 102 (87.0) 80 (68.0) number of antimicrobials 1 69 (29.5) 23 (27.0) 46 (34.0) 2 72 (30.8) 32 (28.0) 40 (34.0) 3 47 (20.1) 29 (25.0) 18 (15.0) >3 43 (18.4) 32 (27.0) 11 (9.0) mursinah acta med indones-indones j intern med 196 hospitalization of more than 14 days, a plus score of 3 for severe sepsis, a plus score of 1 for the surgery, a total score of 6. the accuracy of the testing depends on how well the test distinguished the groups being tested, into those with and without the disease in question. the accuracy was measured by the area under the receiver operating characteristic (roc) curve. the roc results are shown in figure 1 and table 4. with the cut off value obtained was 3.5 with 81% sensitivity and 72% specificity, the auc was 0.838; 95% ci 0.79-0.89. this result meant that the accuracy of this scoring as diagnostic test was good. this also meant that these three variables (the length of the stay in the hospital, severe sepsis and surgery) were good mediators to differentiate the patients with candidemia or without candidemia. to validate the candidemia scoring with a cut off value 3.5, the scoring was then tested with the study group and the control group. the results are shown in table 5. the results of the implementation of the scoring showed that the sensitivity was 95/117=80%, the specificity was 84/117=70%, the positive predictive value (ppv) was 95/128=74% and the negative predictive value (npv) was 84/106=79%. discussion candidemia is an uncommon case and it remains a significant concern for hospitalized patients, especially for those in the intensive care units.10 candidemia is mainly developed in critically ill patients with terminal disease and with co-existing multiple organ failures.11 table 2. multivariate analysis of the variables associated with candidemia risk factor p value or (95% ci) hospital length of stay 1-7 days ref 8-14 days 0.004 3.464 (1.458-7.800) >14 days 0.000 6.844 (3.00-15.330) length of stay in the icu 1-7 days ref 8-14 days 0.516 0.687 (0.222-2.133) >14 days 0.416 1.938 (0.394-9.545) urinary catheter 0.104 2.954 (0.802-10.890) abdominal surgery 0.095 2.641 (0.846-8.245) mechanical ventilator 0.384 1.444 (0.631-3.302) central venous catheter 0.795 1.114 (0.492-2.525) immunosuppression drugs 0.294 1.981 (0.553-7.102) antimicrobial >5 days 0.738 1.185 (0.439-3.200) number of antimicrobials 1 ref 2 0.580 1.289 (0.524-3.171) 3 0.859 0.910 (0.322-2.571) >3 0.499 1.562 (0.429-5.694) severe sepsis 0.000 16.407 (1.458-7.800) surgery 0.002 3.030 (1.492-6.152) neutrophils <500 0.066 2.729 (0.935-7.967) table 3. the calculation of the scores: variables that were selected by the logistic regression model for candidemia in the hospital variables coefficient (β) standard error wald x2 p value length of stay 8-14 days 1.263 0.431 8.598 0.003 length of stay>14 days 1.932 0.412 21.951 0.000 surgery 0.790 0.362 9.161 0.002 severe sepsis 2.819 0.431 42.880 0.000 constant -3.726 0.533 48.886 0.000 stay was between 8-14 days (score 1). it would be twice when the length of stay was more than 14 days (score 2). the score is added one time if they had surgery (score 1), and added 3 times if they had severe sepsis (score 3). the implementation of this scoring is, as follows: when patients were hospitalized for 16 days with severe sepsis and had surgery, they would have a score of 2 for a vol 48 • number 3 • july 2016 risk factors and scoring systems for patients with candidemia 197 zaoutis et al.14 surgery, especially abdominal surgery, caused an interruption in the integrity of the gastrointestinal tract mucous that caused a port of entry for the candida to pass from the lumen to the bloodstream.15 furthermore, this study has the same results as the study of leon et al.8 who developed the candida score. in fact, the score system that we have developed offers several advantages over the candida score. two variables of the candida score (severe sepsis and surgery) are used at our hospital. for an addition, one new variable, which was the hospital length of stay, was identified. this new scoring system is easy to remember, since it is only has a few variables, including severe sepsis and surgery. this type of scoring does not need to include a laboratory examination (i.e., a culture to confirm candida colonization). this has not been routinely conducted in our hospital, because it is costly and labor extensive.16 the sensitivity and the specificity of this new scoring are proposed to table 4. cut-off value for the roc curve for the candidemia scoring system in the hospital cut-off value sensitivity false positive -1.0 1.0 1.0 0.5 1.0 0.880 1.5 0.991 0.675 2.5 0.974 0.581 3.5 0.812 0.282 4.5 0.624 0.145 5.5 0.333 0.042 7.0 0.000 0.000 the age range of the patients in this study had the same results as wu et al.12 in which the patients ages were 1-88 years with a median of 40 years. in this study, 77% of the patients had chronic diseases. the presence of a chronic disease was important as a risk factor and in the management of the patients. this was because the drug interactions for antifungal should be considered in those patients with diabetes mellitus or tuberculosis, who have had therapy for their concomitant diseases.13 in the multivariate analysis, the hospital length of stay, severe sepsis and surgery, were associated with candidemia. several other risk factors that have been associated with candidemia in other studies were not associated with candidemia in the present study. in this study, candidemia was associated with a longer hospital stay, which is similar to the study of auc 0.838 95% ci 0.788-0.888 figure 1. receiver operating characteristic (roc) curve and the area under the curve (auc) power to assess the scores table 5. the scoring system with a cut-off of 3.5 when tested with the study group and the control group score sepsis with candidemia n (%) sepsis without candidemia n (%) total >3.5 95 (80.0) 33 (30.0) 128 <3.5 22 (20.0) 84 (70.0) 106 total 117 117 234 mursinah acta med indones-indones j intern med 198 be used for screening the patients who need antifungal therapy and can minimize any unnecessary treatment. the scoring system obtained in this study might be implemented in rscm, rather than candida score, but it requires further validation. the validation should be performed in a prospective study, with a selected ward, or in two different hospitals, as in the michalopoulos study.17 the limitation of this study is sample size. the sample size was quite small because candidemia is rare and the culture does not always available. since the data were from one center, it needs careful, interpretation if the results were to be implemented in other centers. the calculations for the scoring were from secondary data, so the scores that were obtained were not as accurate as the patient’s condition at the time. the strength of the study was the case control study design that could analyze important variables in a candida infection. it is necessary to record data and evaluate the health care-associated infection, especially candidemia, in all of the wards at a hospital, so that prevention can be instigated. the implementation of a scoring system is important for the reasons to start an empiric antifungal therapy. conclusion the significant risk factors associated with candidemia in this study were the hospital length of stay, severe sepsis and surgery. the new scoring system that has been developed can be implemented in order to predict those patients that might result in a possible candidemia condition, by following these criteria: a hospital stay of 8-14 days (score 1), a hospital stay of more than 14 days (score 2), severe sepsis (score 3) and surgery (score 1), with a cutoff value of 3.5. acknowledgments we would like to thank the director of cipto mangunkusumo hospital, the head of the research division of cipto mangunkusumo hospital and the head of the medical records division at cipto mangunkusumo hospital, who gave their permission to conduct this study. references 1. vincent j. international study of the prevalence and outcomes of infection in intensive care units. jama. 2009;302. 2. chander j, singla n, sidhu sk, et al. epidemiology of candida blood stream infections: experience of a tertiary care centre in north india. j infect dev ctries. 2013;7:670-5. 3. pfaller ma, diekema dj, gibbs dl, et al. results from the artemis disk global antifungal surveillance study, 1997 to 2007: a 10.5-year analysis of susceptibilities of candida species to fluconazole and voriconazole as determined by clsi standardized disk diffusion. j clin microbiol. 2010;48:1366–77. 4. pfaller ma, moet gj, messer sa, et al. candida bloodstream infections: comparison of species distributions and antifungal resistance patterns in community-onset and nosocomial isolates in the sentry antimicrobial surveillance program, 20082009. antimicrobial agent chemother. 2011;55:561-6. 5. ellepola anb, morrison cj. laboratory diagnosis of invasive candidiasis. j microbiol. 2005;43:65-84. 6. eggiman p, ostrosky-zeichner l. early antifungal strategy intervention in icu patients. curr opin crit care. 2010;16:465-9. 7. hermsen ed, zapapas mk, maiefski m, et al. validation and comparison of clinical prediction rules for invasive candidiasis in intensive care unit patients: a matched case-control study. crit care. 2011;15:r198. 8. león c, ruiz-santana s, saavedra p, et al. a bedside scoring system (“candida score”) for early antifungal treatment in nonneutropenic critically ill patients with candida colonization. crit care med. 2006;34:730-7. 9. mootsikapun p, hsueh p-r, talwar d, et al. intravenous anidulafungin followed optionally by oral voriconazole for the treatment of candidemia in asian patients: results from an open-label phase iii trial. bmc infectious diseases. 2013;13. 10. lo sm, yu ym, lee lyl, et al. overview of the shenzhen emergency medical service call pattern. world j emerg med. 2012;3. 11. shorr af, tabak yp, johannes rs, et al. candidemia on presentation to the hospital: development and validation of a risk score. crit care. 2009;13. 12. wu z, liu y, feng x, et al. candidemia: incidence rates, type of species, and risk factors at a tertiary care academic hospital in china. int j infect dis. 2014;22:4-8. 13. bruggemann rjm, alffenaar j-wc, blijlevens nma, et al. clinical relevance of the pharmacokinetic interactions of azole antifungal drugs with other coadministered agents. clin infect dis. 2009;48:1441–58. 14. zaoutis te, argon j, chu j, et al. the epidemiology and attributable outcomes of candidemia in adults and children hospitalized in the united states: a propensity analysis. clin infect dis. 2005;41:1232-9. vol 48 • number 3 • july 2016 risk factors and scoring systems for patients with candidemia 199 15. edwards je. candida species. in: mandell, douglas, bennett, eds. principles and practice of infectious diseases. philadelphia; 2010. 16. pittet d, monod m, suter pm, et al. candida colonization and subsequent infections in critically ill surgical patients. annals surg. 1994;220:751-8. 17. michalopoulos as, geroulanos s, mentzelopoulos sd. determinants of candidemia and candidemia-related death in cardiothoracic icu patients. chest. 2003; 124:2244-55. 33acta med indones indones j intern med • vol 55 • number 1 • january 2023 original article depression symptoms and inflammation in chronic functional constipation patients hamzah shatri1, edward faisal1, murdani abdullah2,3, ari fahrial syam2, amanda pitarini utari2*, virly nanda muzellina2, saskia aziza nursyirwan2, aly lamuri3 1 division of psychosomatic and palliative, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 division of gastroenterology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 3 medical technology cluster, imeri, faculty of medicine universitas indonesia, jakarta, indonesia. *corresponding author: amanda pitarini utari, md. division of gastroenterology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71 jakarta 10430, indonesia. email: amanda.pu@hotmail.com. abstract background: inflammation in chronic functional constipation (cfc) occurs systemically and has association with depressive symptoms. biomarkers of inflammation can be assessed by the neutrophil to lymphocyte ratio and platelet to lymphocyte ratio. these inflammation biomarkers are stable, cheap, and widely available. this study aimed to determine the profile and the correlations between depressive symptoms and inflammation in cfc patients. methods: this cross-sectional study involved subjects aged 18-59 years with chronic functional constipation. we use validated beck depression inventory-ii (bdi-ii) to assess depressive symptoms. we collected the data regarding complete peripheral blood examination, liver function, kidney function, electrolytes, and neutrophil-lymphocyte ratio (nlr), and platelet-lymphocyte ratio (plr). bivariate analysis with chi-square test for categorical data and t-test or anova test for numerical data. multivariate analysis used logistic regression to look at risk factors for depression with p < 0.05 as a statistical significant level. results: a total of 73 subjects with cfc were recruited with a mean age is 40.2 years, mostly women and working as housewives. proportion of depressive symptoms in cfc patients was 73.0%, including mild depression 16.4%, moderate depression 17.8%, and severe depression 28.8%. the mean nlr in non-depressive subjects was 1.8 (sd 0.7), while in depressive subjects was 1.94 (sd 0.1) (p>0.05). the mean nlr in mild depression subjects was 2.2 (sd 1.7), in moderate depression was 2.0 (sd 0.7), and in severe depression was 1.9 (sd 0.5) (p>0.05). the mean plr in non-depressive subjects was 134.3 (sd 0.1), whereas in depressive subjects it was 138.9 (sd 46.0) (p>0.05). the mean plr in mild depression subjects was 142.9 (sd 60.6), in moderate depression was 135.4 (sd 41.2), and in major depression was 139.0 (sd 37.1) (p>0.05). conclusion: this study found that cfc patients were middle-aged, mostly women and working as a housewife. in general, biomarkers of inflammation were found to be higher in depressive subjects than non-depressive subjects, although not statistically significant. keywords: chronic functional constipation, depressive symptoms, inflammation, lymphocyte to neutrophil ratio, platelet to lymphocyte ratio. hamzah shatri acta med indones-indones j intern med 34 introduction chronic functional constipation (cfc) is an often-neglected digestive tract disorder. low-grade inflammation, cell degeneration, and increased oxidative stress impair functional conditions in cfc.1,2 in vivo studies demonstrated that inflammation in mice’s colon occurred after transplanted with cfc patients feces, as suggested by gobert et al.3 food containing antigen entering the digestive tract will incite the adaptive immune system.4,5 further inflammation might play a role in various disorders or diseases involving the gastrointestinal tract and psychological factors, e.g., depressive disorders.6 one probable mechanism is dysbiosis and inflammation in cfc, which interrupt serotonin regulation in the brain, and in turn, cause behavioral disorders with depression as a particular impact.7 the presence of proinflammatory cytokines increases serotonin reuptake transporter (sert) activity in the intestine, causing serotonin decrease as a potential cause of depression.8,9 occurring distress can impair intestinal defense, increase bacterial permeability and translocation, also activate the inflammatory system.6,10 in contrast, psychological distress also activates the immune system in response to inflammation, an increase in cell movement that plays a role in immunity between blood vessels and tissues.6 the association between serotonin and serotonin transporters located in the gastrointestinal tract and inflammation has attracted the attention of researchers as to the etiology of depressive symptoms. at the same time, inflammatory markers may increase in response to depression. simple, inexpensive, and easily reproducible inflammatory parameters may include the neutrophil-lymphocyte ratio (nlr) and plateletlymphocyte ratio (plr), c-reactive protein (crp) and high sensitivity c-reactive protein (hscrp).11,12 various studies have shown that nlr and plr are in line with crp and hscrp as markers of inflammation.11–18 it is currently unclear whether local inflammation in cfc can cause systemic inflammation; and whether it is associated with depressive symptoms. for this reason, this study further examines inflammation marked by nlr and plr. methods this cross-sectional study involved 73 subjects of chronic functional constipation (cfc) subjects. diagnosis of cfc was screened using the roma iv criteria and bristol stool chart form (bscf), validated by blake et al.19 subjects willing to participate signed the informed consent filled out the validated, indonesian version (in bahasa), bdi-ii questionnaire to evaluate depressive symptoms.20 this study has been approved by the ethics committee of the faculty of medicine universitas indonesia, and all participants signed informed consent forms. b l o o d s a m p l e w a s t a k e n t o a n a l y z e peripheral blood cell count and inflammation of the neutrophile-lymphocyte ratio (nlr) and platelet-lymphocyte ratio (plr). demographic characteristics are age, gender, ethnic group, occupation, the socioeconomic level, the education level, and clinical characteristics, including cfc signs and symptoms. this study considered high socioeconomic status as those with monthly income higher than the minimum wage in jakarta. based on the educational attainment, this study grouped those attained at least a highschool diploma as highly educated. we provided depression symptom data according to bdi-ii in the form of proportion, mean, and or median. we performed bivariate analysis with chi square test for categorical data and t test or anova test for numerical data. multivariate analysis relied logistic regression to find out risk factors for depression with p < 0.05 as a significant level. pearson’s or spearman’s rho method independently assessed the correlation between nlr and plr to depressive symptoms. pearson’s or spearman’s rho method independently assessed the correlation between nlr and plr to depressive symptoms. results the mean age of the subjects in this study was 40.2 (sd 11.25) years, and almost all cfc patients were women (90.4%). a larger proportion of subjects were of betawi ethnic group (64.3%), working as house wife (78.1%), having low socioeconomic status (95.8%) and high education levels (64.5%). the three most commonly reported vol 55 • number 1 • january 2023 depression symptoms and inflammation in chronic functional constipations 35 constipation-related complaints were straining, defecate <3 times every seven days and hard stool consistency. laboratory examinations of complete peripheral blood, liver function, kidney function and electrolytes were within normal range. the proportion of depressive symptoms (73.0%) was high in cfc patients, further classified into mild depression (16.4%), moderate depression (17.8%), and severe depression (28.8%). a complete description of the subject profile, see table 1. in table 2 and 3 were the results of bivariate and multivariate analysis of factors related to depressive symptoms, respectively. the results of significant level of peripheral blood cell count, nlr and plr of cfc based on depression and without depression symptoms (table 4) and the severity level of depressive symptoms (table 5). table 1. characteristics of the study participants. profiles all (n=73) age (mean) years 40.2 (11.25) gender, n (%) female male 66 (90.4) 7 (9.6) race, n (%) betawi sunda jawa sumatra nusa tenggara n/a 47 (64.3) 3 (4.1) 11 (15.1) 7 (9.7) 2 (2.7) 3 (4.1) work, n (%) housewife. entrepreneur employees/labourers jobless 57 (78.1) 7 (9.6) 5 (6.8) 4 (5.5) socioeconomic status, n (%) low high 70 (95.8) 3 (4.2) level of education, n (%) low high 28 (38.4) 45 (61.6) sign and symptoms cfc, n (%) straining hard stool perceived incomplete evacuation of bowel movements a blocked or full sensation in the lower intestine or anus doing movements to make defecation easier (requiring tools) less than 3 bowel movements per week 67 (89.3) 60 (80.0) 48 (64.0) 38 (50.7) 20 (26.7) 64 (85.3) laboratory result (mean (sd) haemoglobin. (hb) g/dl haematocrit (ht) % leucocyte 103/µl absolute neutrophil count 103/µl absolute lymphocyte count 103/µl platelet 103/µl nlr plr ast (u/l), alt (u/l) bilirubin (mg/dl) creatinine (mg/dl) urea (mg/dl) blood glucose(mg/dl) potassium (k) sodium (na) chloride (cl) 12.97 (1.55) 38.71 (3.81) 7.67 (2.07) 4.42 (1.60) 2.49 (0.94) 318.31 (78.41) 1,90 (0.88) 137.17 (47.74) 20.84 (9.99) 20.99 (18.02) 0.50 (0.18) 0.71 (0.16) 20.68 (5.46) 98.11 (51.49) 4.18 (0.53) 139.00 (2.17) 104.66 (2.25) hamzah shatri acta med indones-indones j intern med 36 table 2. bivariate analysis of factors related depression symptoms in cfc patients. profiles no depressionn (%) depression n (%) p-value gender female 23 (34.8%) 43 (65.2%) p 0.014 male 6 (85.7%) 1 (14.3%) ethnic group betawi 18 (38.3%) 29 (61.7%) p 0.775 non-betawi 8 (34.8%) 15 (65.2%) work unemployed or housewife 23 (37.7%) 38 (62.3%) p 0.426 employee, labourer, or entrepreneur 6 (50.0%) 6 (50.0%) socioeconomic status low 27 (38.0%) 44 (62.0%) p 0.154 high 2 (100.0%) 0 (0.0%) level of education low 6 (21.4%) 22 (78.6%) p 0.012 high 29 (39.7%) 44 (60.3%) smoking yes 6 (85.7%) 1 (14.3%) p 0.014 no 23 (34.8%) 43 (65.2%) table 3. multivariate analysis of factors related depression symptoms in cfc patients profiles no depression depression p level of education low 6 (21.4%) 22 (78.6%) 0.032 high 29 (39.7%) 44 (60.3%) smoking yes 6 (85.7%) 1 (14.3%) 0.06 no 23 (34.8%) 43 (65.2%) table 4. peripheral blood cell count, nlr, and plr of cfc based on depression and without depression symptoms. profiles no depression (n =27) depression (n=46) leukocytes, mean (sd) 103/µl 7.3 (2.1) 7.9 (2.0) absolute neutrophil count, mean (sd) 103/µl 4.1 (1.4) 4.6 (1.6) absolute lymphocyte count, mean (sd) 103/µl 2.45 (0.7) 2.6 (1.1) platelets, mean (sd), 103/µl 304.6 (68.2) 326.35 (83.5) nlr, mean (sd) 1.8 (0.7) 1.94 (0.1) plr, mean (sd) 134.3 (43.9) 138.9 (46.0) note: nlr = neutrophil lymphocyte ratio; plr = platelet lymphocyte ratio; sd = standard deviation. * t-test p>0.05/ not statistically significant depression symptoms no symptoms of depression with depression 27 (37.0) 46 (73.0) depression symptoms level no symptoms of depression mild moderate severe 27 (37.0) 12 (16.4) 13 (17.8) 21 (28.8) note: alt: alanine transaminase; ast: aspartate aminotransferase nlr = neutrophil lymphocyte ratio; plr = platelet lymphocyte ratio. vol 55 • number 1 • january 2023 depression symptoms and inflammation in chronic functional constipations 37 discussion complete laboratory examination of peripheral blood, liver function, kidney function and electrolytes were within normal limits which indicated that all subjects of this study were functional disorders, thus strengthening the diagnosis of functional constipation in rome iv criteria.21 this study found that 73 subjects of cfc were middle-aged, primarily women, mostly the ethnic is betawi, working as house wife, with low socioeconomic status, and high education levels. the demographic profile in our study was similar with study conducted by mokhtar et al.22 that 240 subjects of cfc highest among female, 72.3%, non-smokers 93.6% and had lower income 89.4%. meanwhile, the total number of subjects experiencing depressive symptoms was 73.0%; with 34 % having moderate and severe depressive symptoms and only 12% having mild depressive symptoms. this result was higher than studies that have been done by mokhtar et al.22 which found 67.1% had no depressive symptoms, 32.1% experienced mild/borderline depressive symptoms and only two (0.83%) had probable a moderate-severe depressive symptoms. however mokhtar et al.22, use rome iii criteria for functional constipation and the center for epidemiologic studies depression scale revised (cesd-r) to asses depression which can make the difference. there was a bidirectional relationship b e t w e e n d e p r e s s i v e s y m p t o m s a n d gastrointestinal disorders. psychological disorders such as depression will contribute negatively to a person’s life and his/her family. poor understanding of psychological health results in bias, namely that respondents fill out a depression symptom screening questionnaire that does not match the actual situation, but this study shows that screening can find depressive symptoms faster. psychological disorders such as depression are still a stigma in society, so many do not realize they are experiencing depressive symptoms. this argument is per a qualitative study conducted by subu et al.24 in 2017, which suggested that the stigma against patients with psychological disorders in indonesia is quite apparent, preventing patients from seeking professional help. subu et al.24 also found that a person who has a psychological disorder will continue to worsen and find it difficult to access mental health services because of the ongoing stigma. a qualitative study by holis et al.25 shows that the wrong coping mechanism occurs due to the stigma against psychological disorders. according to the qualitative study of meng et al.26, it was found that dealing with distress depends on one’s psychodynamic and adaptive abilities. until now, there were no studies that measures inflammatory conditions in cfc systemically. our findings suggested no systemic involvement due to local gastrointestinal inflammation. peripheral blood cell count, nlr and plr of cfc were higher in depression than in normal conditions, but not statistically significant. the finding of this study is similar to that of study conducted by mazza mg et. al.27 who found that nlr and plr were higher in patients with mood disorders compared to healthy controls and were also not statistically significant, which means that table 5. peripheral blood cell count, nlr and plr of cfc based on the level of depression symptoms. profiles no depression(n=27) mild depression (n=11) moderate depression (n=14) severe depression (n=21) leukocytes, mean (sd), 103/µl. 7.3 (2.1) 8.1 (2.1) 7.9 (2.4) 7.7 (1.9) absolute neutrophils, mean (sd), 103/µl 4.1 (1.4) 4.9 (2.1) 4.5 (1.8) 4.50 (1.4) absolute lymphocytes, mean (sd), 103/µl 2.4 (0.7) 2.5 (0.6) 2.7 (1.7) 2.6 (0.8) platelets, mean (sd), 103/µl 304.6 (68.2) 339.2 (97.6) 311.2 (83.8) 329.7 (78.6) nlr, mean (sd) 1.8 (0.7) 2.2 (1.7) 2.0 (0.7) 1.9 (0.5) plr, mean (sd) 134.3 (43.9) 142.9 (60.6) 135.4 (41.2) 139.0 (37.1) note: nlr = neutrophil lymphocyte ratio; plr = platelet lymphocyte ratio; sd = standard deviation. hamzah shatri acta med indones-indones j intern med 38 the inflammatory condition that occurs is only local gastrointestinal tract which has no impact systemically. this study also found that nlr and plr ratio in cfc is higher than in the normal population, especially in cfc with depression.12 according to a study by singh et al.,28 there were mastocytes and eosinophil cells in the descending colon associated with irritable bowel syndrome. leukocytes, absolute neutrophils, nrl, and plr were higher in subjects with depressive symptoms than those without depression. meanwhile, the lymphocyte levels were almost equal between the two subject conditions. this finding is consistent with the study of ucar et al.29 which showed that depressed patients experienced a decreased lymphocyte response to mitogen stimulation and impaired neutrophil activity. this study also follows the study of ozturk et al.30 which showed statistically insignificant but apparent trend in inflammatory biomarker levels. although nlr and plr were not significantly correlated with depressive symptoms, there was a higher nlr and plr in depressed cfc patients compared to patients without depressive symptoms. further research should be done. this study of inflammation in depressive symptoms was confirmed by sunbul et al.,11 who explained that nrl was significantly increased in both major and very severe depressive symptoms. although subjects with major depression were not large enough in this study, the correlation test may have had less statistical power to assess significance. this study has a fairly good internal validity, so that bias in the selection can be minimized. due to the strict inclusion criteria, the number of samples obtained was not large, but still sufficient to represent the research sample to be generalized. the study location may represent urban areas in one research group to be generalized to other urban areas in indonesia. the significant factors for the incidence of depression in cfc from this study were only low education and not smoking. therefore, it is necessary to do future studies from the aetiological side of the diagnosis of depressive symptoms. other contributing factors to depressive symptoms that require further investigation are stresses in daily life, lack of social support, and a history of eating disorders.31 in depression, serotonin levels decrease because the serotonin transporter mrna and its regulatory proteins are increased. inflammatory conditions associated with free serotonin depletion are changes in inflammatory cytokines such as il-1, il-6, and tnf-α.29 conclusion this study found that cfc patients were in middle age, mostly women and working as housewives with depressive symptoms. eventhough not statistically significant, it tends that biomarker of inflammation is higher in depressive symptoms subjects than in non depressive symptoms subjects, represented by mean of nlr and plr. increasing of nlr and plr values might indicate depression. in the future, researchers are advised to reproduce similar study with a larger sample population, to analyze serum serotonin levels, other inflammatory factors, and to analyze other factors associated with depressive symptoms. acknowledgments we would like to thank universitas indonesia, which gave a grant to this study puti: nkb2198/un2.rst/hkp.05.00/2020 references 1. ilie od, ciobica a, mckenna j, doroftei b, mavroudis i. minireview on the relations between gut microflora and parkinson’s disease: further biochemical (oxidative 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2019;103:76–82. 27. mazza mg, lucchi s, tringali agm, rossetti a, botti er, clerici m. neutrophil/lymphocyte ratio and platelet/lymphocyte ratio in mood disorders: a meta-analysis. prog neuropsychopharmacol biol psychiatry. 2018;84(pt a):229-236. doi: 10.1016/j. pnpbp.2018.03.012. epub 2018 mar 10. pmid: 29535038. 28. singh m, singh v, schurman jv, colombo jm, friesen ca. the relationship between mucosal inflammatory cells, specific symptoms, and psychological functioning in youth with irritable bowel syndrome. sci rep. 2020;10(1):1–7. 29. uçar hn, eray ş, murat d. simple peripheral markers for inflammation in adolescents with major depressive disorder. psychiatry clin psychopharmacol. 2018;28(3):254–60. 30. öztürk a, sahan e, mirçik ab, deveci e, yilmaz o, kirpinar i. mean platelet volume and neutrophil to lymphocyte ratio decrease in patients with depression with antidepressant treatment. rev psiquiatr clin. 2019;46(1):9–13. 31. razzak ha, harbi a, ahli s. depression: prevalence and associated risk factors in the united arab emirates. oman med j. 2019;34(4):274–83. 180 acta med indones indones j intern med • vol 55 • number 2 • april 2023 original article the characteristic of recurrent malaria episode: an observational study in timika papua novyan lusiyana*, anggia fitria agustin department of parasitology, faculty of medicine universitas islam indonesiayogyakarta, indonesia. *corresponding author: novyan lusiyana, md., m.sc. department of parasitology, faculty of medicine universitas islam indonesia, yogyakarta, indonesia. email: 107110411@gmail.com. abstract background: people living in malaria endemic areas are at risk of suffering from the recurrent malaria episodes. the recurrent episode of malaria can be determined by various factors and will bring some serious impacts on all life aspects. this study aims to identify malaria demographics and factors associated with the recurrent episodes of malaria in timika, papua. methods: this observational study used medical record data from the naena muktipura sub-district health center, timika papua in 2020. plasmodium infection was identified based upon microscopic examination. subjects were then categorized into positive and negative malaria followed by the determination of the positivity rate. each case of malaria was traced regarding frequency, time, and type of plasmodium. the recurrent episodes of malaria were defined as plasmodium infections occurred more than once in a year. demographic data including age, sex, and ethnicity were then analyzed using chi square. results: the incidence of recurrent malaria in timika papua was 16% with the highest positivity rate occurred in june. the most recurrent episodes of malaria were 2 episodes (77.2%) in which men were more at risk (or 2.512). meanwhile, ethnicity and age were not associated with recurrent episodes. most of recurrent episodes of malaria are caused by the similar plasmodium species, particularly plasmodium falciparum (82.25%) with the shortest interval between episodes of 14 days. conclusion: malaria is mostly experienced by men, of productive age and javanese ethnicity. men were found more at risk of experiencing recurrent episodes of malaria. the identification of these demographic factors is important to issue the policies on malaria elimination and malaria transmission termination in timika, papua. keywords: malaria, epidemiological characteristic, recurrent episode, timika papua. introduction malaria still becomes a global health issue as proven by the 87 countries with malaria endemic status. southeast asia region is one of the regions with the highest number of malaria cases in the world in which indonesia becomes the country with the highest number of cases in that region.1 the high morbidity of malaria leads to the increasing health cost both for treatment and for prevention.2 one of the malaria endemic areas in indonesia is timika regency, papua province.3 timika consists of forests, beaches, swamps and has high rainfall throughout the year.4 regional characteristics and sociodemographic factors of the community have caused the local transmission of malaria to occur continuously; as a consequence, the residents in endemic areas are at risk of being infected with plasmodium more than one episode.5-7 the prevalence of recurrent episodes of malaria reaches 16%, in which the average within 5 years can reach 5-16 episodes.8,7 recurrent episodes are determined by age, sex, ethnicity, occupation and history of malaria in the family.7 vol 55 • number 2 • april 2023 the characteristic of recurrent malaria episode 181 previous study stated that the episode of malaria is not associated with an inadequate immune system, but more associated with recurrent plasmodium infection.8 this condition is mainly experienced by children and then decreases along with aging.9 children are the potential reservoir in malaria transmission.10 in which the parasitemia of children is higher than that of adult.11 it has been suggested that epidemiological characteristic could lead to caused recurrent of malaria episode, but there are yet no published data. the recurrent malaria episode can be caused by failure of malaria treatment that caused recrudescence, reinfection from mosquito bite, or reactivation of hypnozoite stadium in liver called relaps.3 this recurrent malaria can impose severe burdens not only for the people but also governments. the impact on malaria patients also varies, such as decreases work productivity and cognitive decline in school children. far, little is known about the condition of recurrent malaria episode especially in timika as a high endemic area in indonesia.3 identifying factors associated with recurrent episode of malaria, which is core indicator of this study, can give valuable information. all these factors need to be studied in depth to formulate the policies on malaria prevention efficiently. methods this observational study used medical record data at the sub-district health center of naena muktipura, timika, papua. it has received approval from the health research ethics committee of the faculty of medicine, islamic university of indonesia with number 2/ka.kom. et/70/ke/vi/2021. data collection malaria cases were found by tracing malaria examination data carried out by officers during 2020 that met the inclusion and exclusion criteria. all malaria cases between 1 january 2020 and 31 december 2020 in sub-district health center of naena muktipura, were enrolled (figure 1). totality sampling is used to determine the sample size. based on observational sample size, only 246 samples were needed, while the sample on this study was 386. the research was conducted in naena muktipura village. this village is one of the high endemic villages for malaria and there is a sub-district health center to facilitate the residents to have medical treatment malaria cases in the sub-health center were obtained through passive case detection (pcd). malaria negative and rdt examination for diagnosis malaria, incomplete medical record was also excluded. patients who examined with rdts all suspected case of malaria in naena muktipura village, timika, jan 2020-dec 2020 (n=733 malaria negative and rdt examination were excluded (n=341) all cases of malaria (n=392) cases with incomplete records excluded (n=8) all cases of malaria and complete records (n=386) single episode (n=324) multiple episode (n=62) figure 1. flowchart of patients included and excluded. novyan lusiyana acta med indones-indones j intern med 182 were excluded, so bias could result from it. the diagnosis by rdt was not analyzed because the type of rdts that used could not identify the plasmodium species. research variables the subjects of this study were all villagers showing symptoms related to malaria and were examined for malaria at the naena muktipura sub-district health center. the diagnosis of malaria was done when plasmodium sp. was found on microscopic examination as a gold standard for diagnose malaria. from the results of microscopic examination, plasmodium species (plasmodium falciparum and plasmodium vivax) can be identified. the number of malaria incidents in the same person during 2020 was defined as the recurrent episode of malaria. the incidence of malaria in one month was also recorded to calculate the positivity rate. each malaria case was continued by recording demographic data including age, sex, ethnicity, plasmodium type, and number of malaria episodes. the recurrent episodes of malaria were defined as plasmodium infections occurred more than once throughout 2020. each incident of recurrent episodes of malaria was recorded in the form of the month of infection, type of plasmodium and the distance between episodes. the interval between episodes was defined as the average number of days between recurrent episodes. statistical analysis we analyzed the data using spss and the demographic characteristics of the subject were presented in a descriptive form. the positivity rate for malaria was obtained by adding up the malaria cases in one month divided by all malaria examinations within one month in percent units.12 the correlation of the demographic characteristics of the subjects and recurrent episodes of malaria was analyzed using the chi square test. results patients’ characteristic and positivity rate of malaria in naena muktipura village in 2020 naena muktipura village was populated by1492 people. during this year, a total of 733 people were examined related to malaria and 386 (52.66%) of them confirmed malaria. the incidence of malaria in naena muktipura village in 2020 reached 25.87%. as shown in table 1, malaria in naena muktipura village was dominated by men (60.88%), in the range of 15-64 years old (64.25%) and were those as the ethnic javanese (42.49%). the highest positivity rate occurred in june, i.e., 65 cases (60.18%) and the lowest one occurred in may with 13 cases (38.23%) (table 2). table 1. characteristics of malaria demography in naena muktipura village. variables total gender, n (%) male 235 (60.88) female 151 (39.12) age (years), n (%) 0-11 4 (1.03) 1-4 31 (8.03) 5-9 36 (9.33) 10-14 55 (14.25) 15-64 248 (64.25) >64 12 (3.11) ethnic, n (%) timika 65 (16.84) java 164 (42.49) east nusa 123 (31.86) papua 9 (2.33) sulawesi 23 (5.95) sumatra 2 (0.53) table 2. positivity rate malaria in pada 2020. month malaria examination, n (%) total positive negative january 39 (52) 36 (48) 75 february 9 (47.4) 10 (52.6) 19 march 6 (54.54) 5 (45.45) 11 april 17 (42.5) 23 (57.5) 40 mei 13 (38.23) 21 (61.77) 34 june 65 (60.18) 43 (39.82) 108 july 54 (64.28) 30 (35.72) 84 august 56 (64.36) 31 (35.64) 87 september 48 (46.6) 55 (53.39) 103 october 30 (46.15) 35 (53.85) 65 november 23 (40.35) 34 (59.65) 57 december 26 (52) 24 (48) 50 total 386 (52.66) 347 (47.34) 733 correlation of risk factor and recurrent malaria in timika episodes of malaria in 2020 were dominated by single episodes of malaria by 324/386 people (83.93%), while 62 people (16.06%) experienced vol 55 • number 2 • april 2023 the characteristic of recurrent malaria episode 183 the recurrent episodes of malaria dominated by men (12.43%), aged 15-64 years (66.1%), and javanese ethnic (17.7%). as shown in table 3, the recurrent episodes of malaria in sequence from the highest number included 2-episodes (48 people; 77.42%), 3-episodes (12 people; 19.35%) and 4-episodes (2 people; 3.23%). a total of 48 people experienced 2 recurrent episodes, and the most recurrent episodes were 4 episodes within one year. a total of 21/62 children (33.87%) were children ≤15 years old, and one of them experienced 4-episodes within one year. the results of the chi square test showed that age and ethnicity were not associated with malaria episodes (p>0.05), while sex was associated with malaria episodes (p=0.004). the proportion of recurrent episodes of malaria in males was 2.51 times higher than that of females. plasmodium type in multiple episode subsequently, it was continued to analyze the types of plasmodium and multiple malaria. the plasmodium species identified in naena muktipura village were plasmodium falciparum and plasmodium vivax. plasmodium falciparum was the most common type (82.25%; n=51/62) (table 4). recurrent infections caused by the similar plasmodium species were experienced by 50% of people, most of which were caused by p. falciparum (32.26%; n=20/62), followed by p. vivax (17.74%; n=11/62), while 31/62 people (50 %) experienced recurrent infections by 2 plasmodium species. the mean time between the nearest malaria episodes was from episode 2 to episode 3 (72 days) and the shortest distance between episodes was 14 days (table 4). table 3. correlation of risk factors and recurrent malaria in timika. characteristic single episode multiple episode total p 2nd 3th 4th sex, n (%) male 187 (48.45) 34 (54.84) 12 (19.35) 2 (3.22) 235 (60.88) 0.004*; or 2.512 (1.331-4.739) female 137 (35.5) 14 (22.58) 0 0 151 (39.12) age (year), n (%) 0-0,11 3 (0.9) 0 0 0 4 (1.03) 0.763 1-4 26 (8) 5 (8.06) 0 1 (1.62) 31 (8.03) 5-9 30 (9.3) 5 (8.06) 1 (1.62) 0 36 (9.33) 10-14 46 (14.2) 5 (8.06) 4 (6.45) 0 55 (14.25) 15-64 207 (63.9) 33 (53.23) 7 (11.29) 1 (1.62) 248 (64.25) >64 12 (3.7) 0 0 0 12 (3.11) ethnic, n (%) timika 55 (84.6) 8 (12.9) 1 (1.62) 1 (1.62) 65 (16.84) 0.287 java 135 (82.3) 21 (33.87) 7 (11.29) 0 164 (42.49) nusa tenggara 102 (82.9) 19 (30.65) 3 (4.84) 1 (1.62) 123 (31.86) papua 9 (100) 0 0 0 9 (2.33) sulawesi 22 (95.7) 0 0 0 23 (5.95) sumatra 1 (50) 0 1 (1.62) 0 2 (0.53) table 4. plasmodium types and distance in malaria episodes. characteristics of malaria episode number type of plasmodium p.f p.f 18 (29.03) p.f p.f p.f 2 (3.23) p.v p.v 7 (11.29) p.v p.v p.v 4 (6.45) mix 31 (50) time transition of malaria episodes (day) episode 1 to 2 94±64,46 (14-328) episode 2 to 3 72.14±56.19 (14-214) episode 3 to 4 96.5±101.11 (25-168) plasmodium falciparum (p. f); plasmodium vivax (p. v); mix (p.f + p.v) novyan lusiyana acta med indones-indones j intern med 184 discussion the results of this study indicated that more males suffered from recurrent episodes of malaria compared to females. men were more at risk of suffering from malaria i.e. 2.51 times compared to women, as also shown in other studies.7,12,13 this might be caused by the occupation of males as a farmer in which this occupation became one of predisposition factors of the malaria incidence.14 working as a farmer has made them to work outside leading them to be more potential to have a contact with the malaria vector (anopheles sp),15 as the due to anopheles sp. activity was outdoor in nature, and exophagic feeding.16,17 this is supported with information showing that malaria transmission occurs outdoors more.16 in timika, malaria was dominated by those at productive age (64.25%) and this finding was found the same with other studies.12 most of the productive age population in endemic areas work as farmers. agricultural land in malaria endemic area is new land resulted from the forest clearing.4 the work located near forests and living near forests are one of the risks of malaria.7,18 this phenomenon was similar to what has occurred in the border of myanmarthailand where land clearing and staying in huts near fields can increase the risk of plasmodium infection.18 interestingly, the recurrent episodes of malaria were mostly experienced by people with ethnic javanese living in timika (42.49%). the results of this study are similar to those of previous studies stating that malaria was found in the immigrants more compared to the natives of iran and uganda.19,20 this might be due to the fact that most of ethnics of the immigrants have been living in timika for so long, thus they have been acculturated with the local environment and culture in timika. the population of timika consists of the natives of timika and the migrants. the indigenous timika tribe consists of kamoro and amume tribes, while the immigrant are mostly those coming from various regions in indonesia, one of which is javanese tribe.21-24 the prevalence of recurrent episodes of malaria in this study was found similar to a study in thailand where 16% of malaria cases were the recurrent episodes of malaria.7 33.87% of cases of the recurrent episodes of malaria in this study occurred in children. the results of this study are in line with other studies showing that children aged ≤ 10 years are at risk of experiencing the recurrent episodes of malaria. the risk of recurrent episodes of malaria in children will decrease along with the aging.25 this risk will recur until the 4th year after birth, while other studies mentioned at the age of 7 years.25,26 the recurrent episodes of malaria in children might be related to the modifications of the immune system, where children who often experience recurrent malaria are more at risk of again experiencing the episodes of malaria.26,27 in this study, the distance between malaria episodes was in the range of 72 to 94 days and it was more related to the type of infecting p l a s m o d i u m a n d r e p e a t e d e x p o s u r e t o plasmodium sp. not caused by the failure of immune system.7,8 in endemic areas, the recurrent episode of malaria might be associated with the relapse, recrudescent and reinfection condition of plasmodium sp.28 also, in endemic areas might occur up to 16 episodes, and the average episode per person per year might reach 5 episodes.29 plasmodium species identified in this study included p. falciparum and p. vivax. 32% of cases of recurrent episodes of malaria were caused by plasmodium falciparum. these findings were similar to those as reported by previous studies where recurrent infection of p. falciparum occurred in 64.51% cases. meanwhile, other studies have shown that recurrent episodes of malaria can also be caused by different plasmodium.7,25,30 the results of this study revealed that 50% of cases were the mixed infections that might be associated with the incidence of cerebral malaria, although in mixed infections the proportion of organ failure will be more apparent.31,32 in timika, malaria cases can be found throughout the year, but an increase in cases occurs from june to september. the increasing cases was accompanied by an increase in rainfall from june to september with the highest rainfall of 819 mm3 in june.21 high rainfall will cause areas dominated by swamps, sago forests vol 55 • number 2 • april 2023 the characteristic of recurrent malaria episode 185 and shallow ponds inundated by rainwater. these characteristics are consistent with the characteristics of the papua region where there are many stagnant waters in swamps, sago forests, shallow pools exposed to direct sunlight.4 this location is a breeding place for mosquito anopheles sp.22,23 also the existence of breeding place of anopheles sp. near forests and agricultural land, and the activity of anopheles mosquitoes, which are more active at night to suck the blood, makes malaria transmission continual.24 this research, nevertheless, also has some weaknesses. first, in this study there was no information regarding clinical manifestations of malaria cases due to limited information in medical records. this study also did not look at parasitemia as the examination carried out at the sub-district health center of naena muktipura only looked at plasmodium species followed by calculating parasitemia. patients diagnosed with malaria were also not subjected to re-evaluation of post-treatment microscopic examination. as a consequence, its relation to recurrent episodes and treatment success could not be evaluated. further research also needs to identify the conditions of submicroscopic malaria and the incidence of recurrent episodes of malaria in timika, papua. this is necessary to be able to develop malaria control policies in timika, papua. this is in line with the endeavor to break the chain of malaria transmission to reduce the morbidity will decrease and to realize the malaria elimination immediately. conclusion men are more at risk of suffering from the recurrent episodes of malaria. moreover, the incidence of recurrent malaria was more found in productive age and migrants, particularly those from javanese ethnic. these results can be of particular concern to related agencies considering that the residents suffering from the recurrent episodes might become a reservoir of malaria transmission. also, it is necessary to evaluate malaria examination to ensure the plasmodium elimination in the patient’s blood to prevent recurrence and break the chain of malaria transmission, especially in endemic areas. acknowledgments we thank all parties that contributed to the accomplishment of this research. we also express our gratitude to all staff of the sub-district health center of naena muktipura village. conflict of interest the researcher declared that there will be no conflict of interest in this research funding this research has been funded by the research grant of medical faculty, universitas islam indonesia. references 1. who. world malaria report 2021; 2021. 2. monroe a, williams na, ogoma s, et al. reflections on the 2021 world malaria report and the future of malaria control. malar j. 2022;21(1):1-6. 3. kemenkes ri. situasi terkini perkembangan program pengendalian malaria di indonesia tahun 2018; 2018. 4. bps. kabupaten mimika dalam angka 2020; 2020. 5. hasyim h, dale p, groneberg da, et al. social determinants of malaria in an endemic area of indonesia. malar j. 2019;18(1):1-11. 6. arwati h, yotopranoto s, rohmah ea, et al. submicroscopic malaria cases play role in local transmission in trenggalek district, east java province, indonesia. malar j. 2018;17(2):1-6. 7. lawpoolsri s, sattabongkot j, sirichaisinthop j, et al. epidemiological profiles of recurrent malaria episodes in an endemic area along the thailand myanmar border: a prospective cohort study. malar j. 2019;18(124):1-11. 8. rono j, färnert a, murungi l, et al. multiple clinical episodes of plasmodium falciparum malaria in a low transmission intensity setting: exposure versus immunity. bmc med. 2015;13(1):1-11. 9. eldh m, hammar u, arnot d, et al. multiplicity of asymptomatic plasmodium falciparum infections and risk of clinical malaria: a systematic review and pooled analysis of individual participant data. j infect dis. 2020;221(5):775-785. 10. walldorf ja, cohee lm, coalson je, et al. school-age children are a reservoir of malaria infection in malawi. plos one. 2015;10(7):1-13. 11. gonçalves bp, kapulu mc, sawa p, et al. examining the human infectious reservoir for plasmodium falciparum malaria in areas of differing transmission intensity. nat commun. 2017;8(1). 12. kassam na, kaaya rd, damian dj, et al. ten years of monitoring malaria trend and factors associated with malaria test positivity rates in lower moshi. malar j. 2021;20(1):1-9. novyan lusiyana acta med indones-indones 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et al. different types of anopheles breeding place in low and high malaria case areas. j kesehat masy. 2018;14(2):178-185. 24. sandy s. bionomi vektor malaria kelompok anopheles punctulatus (anopheles farauti, anopheles koliensis, anopheles punctulatus) di provinsi papua. balaba. 2014;10(01):47-52. 25. seyoum d, kifle yg, rondeau v, et al. identification of different malaria patterns due to plasmodium falciparum and plasmodium vivax in ethiopian children: a prospective cohort study. malar j. 2016;15(1):1-11. 26. valletta jj, addy jwg, reid aj, et al. individual-level variations in malaria susceptibility and acquisition of clinical protection. wellcome open res. 2021;6:22. 27. bediako y, adams r, reid aj, et al. repeated clinical malaria episodes are associated with modification of the immune system in children. bmc med. 2019;17(1):1-14. 28. white nj. determinants of relapse periodicity in plasmodium vivax malaria. malar j. 2011;10(1):297. 29. jagannathan p, muhindo mk, kakuru a, et al. increasing incidence of malaria in children despite insecticide-treated bed nets and prompt anti-malarial therapy in tororo, uganda. malar j. 2012;11(1):1. 30. camargo m, soto-de león sc, del río-ospina l, et al. micro-epidemiology of mixed-species malaria infections in a rural population living in the colombian amazon region. sci rep. 2018;8(1):1-14. 31. genton b, d’acremont v, rare l, et al. plasmodium vivax and mixed infections are associated with severe malaria in children: a prospective cohort study from papua new guinea. plos med. 2008;5(6):0881-0889. 32. kotepui m, kotepui ku, de jesus milanez g, et al. plasmodium spp. mixed infection leading to severe malaria: a systematic review and meta-analysis. sci rep. 2020;10(1):1-12. 87acta med indones indones j intern med • vol 55 • number 1 • january 2023 case report pituitary macroadenoma in a girl with male karyotype: a rare case study fatinah shahab1,2, tania tedjo minuljo3, calvin layuk allo3, dody priambada4, mahayu dewi ariani5, sultana mh faradz5* 1master in biomedical science, faculty of medicine, diponegoro university, semarang, indonesia. 2faculty of medicine, wahid hasyim university, semarang, indonesia. 3division of endocrine metabolic, departement of internal medicine, faculty of medicine, diponegoro university dr. kariadi general hospital, semarang, indonesia. 4departement of neurosurgery, faculty of medicine, diponegoro university dr. kariadi general hospital, semarang, indonesia. 5division of human genetics, center for biomedical research, faculty of medicine, diponegoro university, semarang, indonesia. * corresponding author: prof. sultana mh faradz, md, ph.d. center for biomedical research (cebior). faculty of medicine, diponegoro university. jl. prof sudarto sh no.1, tembalang, semarang 50275, indonesia. email: sultanafaradz@gmail.com. abstract macroadenoma is a tumor that typically develops in the epithelial cells of the pituitary gland. patients suffering from the condition are often asymptomatic with complaints that are caused by hormonal imbalance. therefore, chromosome analysis needs to be done to females aged >16 years presenting with amenorrhea. karyotype 46,xy is a disorder of sex development (dsd) that is caused by the complex process of gene interactions, androgen synthesis, and hormone regulation. the patient initially came to the hospital for a scheduled transsphenoidal surgery due to pituitary macroadenoma, and later complained of primary amenorrhea and atypical external genital. furthermore, physical examination of genitalia revealed mild clitoromegaly without obvious introitus vagina. laboratory testing showed elevated prolactin and testosterone level, while ultrasonography imaging revealed the absence of the uterus and ovaries. the brain magnetic resonance imaging (mri) demonstrated a pituitary adenoma, and cytogenetic analysis showed 46,xy karyotype. subsequently, hyperprolactinemia, imaging, and histopathology examination were used to confirm pituitary macroadenoma in the patient. it was assumed that the undermasculinized genitalia was caused by hormonal disorders including the deficiency of androgen action or 5-alpha-reductase enzyme. 46,xy dsd has many different symptoms, hence, clinicians need to be aware of potential multifactorial aetiologies. imaging of internal genitalia, hormonal and chromosomal analysis should be carried out to assess patients with unknown causes of the disorder. molecular analysis needs to be carried to exclude the possible gene mutation. keywords: disorder of sex development (dsd), primary amenorrhea, pituitary macroadenoma. fatinah shahab acta med indones-indones j intern med 88 introduction disorder of sex development (dsd) is a condition that is characterized by atypical development of chromosomal and gonadal/ anatomical sex organs,1-6 and it occurs in the ratio of 1: 2500-5000 live births.6,7 furthermore, it appears in various forms at different ages,8,9 and is classified into three main categories, namely 46,xydsd; 46,xx; and sex chromosome dsd.1,7,10 phenotypes of patients with 46,xy dsd range from female external genitalia to atypical male phenotype with testicular regression.4,5,11,12 the victims generally seek medical attention, which is often delayed until puberty or a later time due to the lack of breast development and/or primary amenorrhea.13 meanwhile, the underlying cause of the disorder can be attributed to gene mutations complex process, androgen synthesis disorders as well as hormone regulation. further tests, such as hormonal, imaging, and cytogenetic analysis, which complement physical examination are necessary to establish a diagnosis of the condition.2,7,14 the genetic aetiology of most cases of the disorder is heterogeneous, hence, it remains debatable whether every patient with 46,xy dsd needs to experience parallel sequencing of a wide range of genes.15 a complete family history, including pedigree and history of consanguinity, is important and need to be carefully reviewed in cases of dsd.2,7 furthermore, physical examination of secondary sex characteristics by tanner staging and a detailed assessment of external genitalia anatomy by quigley staging are the first steps for its diagnosis. laboratory evaluation for fsh and lh are needed to observe the pituitary function. loss of lh and fsh causes amenorrhea, which is characterized by hypogonadotropic hypogonadism. prolactin and testosterone level tests are also needed to confirm the diagnosis of the disease. meanwhile, elevated prolactin level is a symptom of pituitary tumor.2 laboratory testing for fsh, lh and prolactin levels help to determine the endocrine system’s role in the pathogenesis of primary amenorrhea symptoms. ultrasonography of the pelvic region is used to confirm the presence or absence of female reproductive organs as well as to locate the gonads.16 p i t u i t a r y a d e n o m a i s t h e t h i r d m o s t common brain neoplasm, and it accounts for approximately 15% of all primary brain tumors.17,18 furthermore, the increased tumor size produces many symptoms, such as headache, visual defect, olfactory dysfunctions, and various hypopituitarism manifestations. headache and visual defects are the most common symptoms that occur in 40-70% of patients. brain mri (magnetic resonance imaging), ophthalmologic monitoring, and hormone tests are needed to evaluate a pituitary tumor. however, brain mri is the most sensitive tool to assess the pituitary gland.18 primary amenorrhea has several causes, and chromosomal abnormalities are the most common cause, which account for 40% of cases.16 therefore, cytogenetic analysis needs to be performed to evaluate chromosome aberration. this is a case study of a patient who was diagnosed with primary amenorrhea and atypical external genitalia after experiencing transsphenoidal surgery to treat pituitary macroadenoma. case illustration a 43 years old woman [ii.9] was referred to dr. kariadi province referral hospital for evaluation of primary amenorrhea. the patient’s weight and height were 50 kg and 157 cm, respectively, with a body mass index of 20,28 kg/ m2. furthermore, there was no family history of the condition, as shown in figure 1. the patient also experienced visual disturbances on the right eye since the previous year, which slowly got worse. visual acuity test using snellen chart was on the right eye showed a value of 2/60 and left eye >3/60. patient also did not complain of headache. on physical examination, the patient had no female breast development, as seen in tanner stage 1, while pubic and axilla hair growth was normal, as seen in tanner stage 5. inspection of the external genitalia showed normal labia majora and minora. however, mild clitoromegaly and a small perineal opening without obvious introitus vagina were detected. there was also a 2 cm palpable mass that is similar to testes in the left side of labia majora, as shown in figure vol 55 • number 1 • january 2023 pituitary macroadenoma in a girl with male karyotype 89 2. based on an interview with the patient and family, the genital ambiguity occurred right from birth. laboratory testing revealed an elevated prolactin level of 686.83 ng/ml as well as an increased testosterone level of 85.03 ng/ml. furthermore, the patient had a normal fsh, lh, and thyroid profile with values of 16.6 miu/ml, 4.01 miu/ml, and 15,52 ρmol/l, respectively. table 1 shows the result of the hormonal assay. the pelvis ultrasound imaging showed the complete absence of internal genital organs, namely uterus and ovaries. the initial brain mri demonstrated a pituitary macroadenoma, which extends to the right parasellar (ap 2.71 cm x cc 2.81 cm x ll 2.72 cm), thereby causing an encasement on the right internal carotid artery and compression in the intracranial part of the right optic nerve and optic chiasm. however, there was no bleeding or sign of elevated intracranial pressure, as shown in figure 3. transsphenoidal surgery was performed, which revealed that the tumor was a pituitary m a c r o a d e n o m a . t h e h i s t o p a t h o l o g i c a l microscopic examination of the excised tumor also showed that the hypercellular mass contains medium cells that formed a solid structure bonded by connective tissue and blood vessels. furthermore, the pseudorossette structure contains polarized cells with elongated cell processes as well as a round or oval nucleus, mild pleomorphic, and stippled chromatin with sparsely granulated cytoplasm. the mitotic structures were difficult to locate, and there were also tumor areas with fibrosis as well as inflammation of lymphocytes, histiocytes, macrophage, cellular organization, prolonged bleeding, and cystic degeneration. however, there were no visible areas of necrosis and no sign of malignancy on the preparation. the histopathological features were consistent with pituitary macroadenoma accompanied by chronic degeneration and inflammation. table 1. hormonal profile of the patient with primary amenorrhea hormone result references range testosterone in ng/ml 85.03 10.83-56.94 fsh in miu/ml 16.6 follicular phase : 3.03-8.08 mid-cycle peak : 2.55-16.69 luteal phase : 1.38-5.47 post menopause females without hrt : 26.72-133.41 lh in miu/ml 4.01 follicular phase :1.80-11.78 mid-cycle peak : 7.59-89.08 luteal phase : 0.58-14.00 post menopause females without hrt*: 5.16-61.99 prolactin in ngml 686.83 5.18-26.53 tshs in µiu/ml 3.41 0.51-4.94 free t4 in ρmol/l 15.52 10.6-19.4 *hrt: hormone replacement therapy ii:9 i:1 i:2 ii:2 ii:3 ii:5 ii:7 ii:11ii:1 iii:1 iii:2 ii:4 ii:6 iii:3 iii:4 ii:8 iii:5 iii:6 ii:10 iii:7 menikah 5th tdk punya anak figure 1. pedigree of the family showing no family history of the same condition. circles represent females and squares represent male gender. a slash through the symbol indicates that the family member is deceased. open symbols are unaffected, while the filled circle denoted by an arrow represents the affected patient [ii.9]. fatinah shahab acta med indones-indones j intern med 90 cytogenetic examination was carried out, which indicated a male karyotype 46,xy without structural and numerical abnormalities. meanwhile, during hospitalization, the patient was monitored daily and diabetes insipidus (di) occurred 3 days after the surgery with polyuria >3 l a day. the di was transient and recovered in the first postoperative week. figure 2. physical examination of the external genitalia showed normal labia majora and minora. mild clitoromegaly was detected with a small vaginal-introital opening without obvious bulging of the hymen. a 2 cm palpable mass that is similar to testes was found in the left side of labia majora, while the pubic hair had normal growth, as seen in tanner stage 5. figure 3. brain mri on the first admission. preoperative mri revealed a pituitary adenoma, which extends to the right parasella (ap 2.71 cm x cc 2.81 cm x ll 2.72 cm) causing an encasement of the right internal carotid artery as well as compression in the intracranial part of the right optic nerve and optic chiasm. there was no bleeding or sign of elevated intracranial pressure. vol 55 • number 1 • january 2023 pituitary macroadenoma in a girl with male karyotype 91 we followed up the patient for three months after the surgery and there was no recurrence of tumor, as shown on the mri. ophthalmological examination showed right-sided visual impairment and bitemporal visual field defect. the neurological examination was normal as well as the muscle power of extremities for both sides (grade 5/5). discussion aetiology of patients with 46,xy dsd undermasculinized male is associated with e n z y m e d i s t u r b a n c e s t h a t o c c u r d u r i n g testosterone synthesis as well as androgen insensitivity syndrome, deficit of 5-alphareductase enzyme, gonadal dysgenesis, and ovotesticular dsd. meanwhile, some of the 5α-reductase deficiencies are often misdiagnosed as androgen insensitivity syndrome because they have a similar clinical phenotype, while others escape recognition completely.19,20 diagnosis of the disorder is established by assessing the patient’s family history, physical examination, hormonal analysis, imaging, and cytogenetic analysis.2,21 in this case, the diagnosis was made based on the clinical manifestations and available laboratory investigations. the symptoms of the patient include primary amenorrhea, phenotypic female external genitalia, lack of breast development, and mild clitoromegaly. meanwhile, mild clitoromegaly was found at birth but the primary amenorrhea was diagnosed late. 7% labial and/or clitoral anomalies were also observed in the patient.22 there was a small mass in the left side of the labia majora, which was similar to the shape of a testis, while on the right side, there was no palpable mass. consequently, it was assumed that the right testis was located in the inguinal or intraabdominal region. male gonads are palpable in the majority of 46,xy dsd cases depending on the location of the external genitalia.11 some of the clues used for the diagnosis of dsd in older patients include unrecognized genital ambiguity, delayed or incomplete puberty, and primary amenorrhea.16,22,23 ultrasonography imaging is an effective diagnostic tool used to identify the presence/ absence of uterus and ovaries in 46,xy dsd cases. furthermore, females with only primary amenorrhea caused by pituitary dysfunction often have a normal uterus. detailed study on the patient revealed that there was no sign of uterus and ovaries, which indicates the absence of female internal reproductive organs. lh, fsh, and tsh levels were then evaluated to assess the pituitary function, and the result showed that the patient had normal pituitary hormone levels. the 5-alpha-reductase deficiency (5ard) is a rare autosomal recessive symptom o f 4 6 , x y d s d c a u s e d b y m u t a t i o n s i n steroid 5α-reductase 2 (srd5a2).24 the deficiency was suspected in this case because of the characteristic phenotype and increased testosterone level. furthermore, testosterone cannot be converted to dihydrotestosterone (dht) at the external genitalia target cells of a patient with the condition. dht is required for normal masculinization of the external genitalia, and the patient had an elevated testosterone level of 85.03 ng/ml. meanwhile, the testosterone level ranged from 35 to 84 in other studies. diagnosis of mutation in 5α-reductase enzyme can be made by dna analysis, but it was not performed in this case. the diagnosis of 5α-reductase deficiency was assumed to be based on the patient’s clinical presentation and hormonal assay, which revealed an elevated testosterone level. furthermore, the 3 generation pedigree shows that there was no consanguinity and no other member was affected, hence, the ard was bearable. gonadal dysgenesis is characterized by a low testosterone level,19 but this current case was different. complete androgen insensitivity syndrome (cais) cases often have a history of primary amenorrhea,2 and female patients usually have a normal-looking clitoris, vaginal introitus, labia minora, and labia majora. depending on the severity of androgen resistance, the clinical features also vary with unilateral or bilateral gonads that can be located anywhere along the path of embryonic testicular descent. however, patients with cais can be distinguished by adequate breast development and x-linked pattern of inheritance.7,12,14 breast development and pubertal growth spurt are normal because testosterone was aromatized to estrogen in the circulation.2 cais causes the production of fatinah shahab acta med indones-indones j intern med 92 testosterone, but androgen action is deficient because of mutations in the androgen receptor (ar) gene. therefore, molecular sequencing of ar gene is needed to identify mutations in 9095% cases.2,15,22,25 dsd was suspected in the patient due to the presence of clitoromegaly, tanner stage 1 no breast development, and palpated gonad in the left side of labia majora, hence, clinicians are advised to perform a cytogenetic examination to determine the karyotype and gender assignment when needed. cais and gonadal dysgenesis are characterized by the presence of female external genitalia.5 meanwhile, the absence of virilization results in female–typical genitalia was strictly linked to the androgen action and ar function. both adrenal and ovarian androgens facilitate the growth of axillary and pubic hair in girls. therefore, any type of alteration along the androgen pathway can lead to impaired virilization. patients with the syndrome normally develop testes due to the presence of the sry region and they also produce testosterone whose action is not effective because of the ar gene mutation. therefore, they lack male genitalia, except for testes. the hormonal profile of cais patients is characterized by high lh and normal fsh levels, while testosterone results are typically within the normal male range but increase relatively to the female range.25 there was an elevated prolactin level in the patient due to prolactin-secreting pituitary macroadenoma. meanwhile, the adenoma accounts for 85% of tumors in the pituitary gland,26 and it affects approximately 20% of the general population.17 in this present case, brain tumor is a pituitary adenoma that was caused by hyperprolactinemia. a pituitary macroadenoma was revealed after transsphenoidal surgery, and there was a positive relationship between hyperprolactinemia and visual changes. several etiopathogenetic hypotheses have been proposed to explain brain tumors and primary amenorrhea. one of the pathological causes of hyperprolactinemia is pituitary adenoma.27 at the time of diagnosis, the patient complained of visual disturbance, which was in the form of decreased visual acuity in the right eye due to a pituitary macroadenoma that compressed the intracranial part of the right optic nerve and optic chiasm. furthermore, compression of the visual pathways causes a disturbance in the visual functions, such as a slow progressive visual loss.17 the patient developed di with polyuria >3 l a day, which was transient 72 hours after surgery, and recovered over the next couple of days. meanwhile, di, which can either be transient or permanent is a common complication that occurs after neurosurgery of the pituitary gland, specifically with the transsphenoidal approach.28,29 most cases of the disease were transient and the patient recovered within 2 weeks of post-operative.28 it is usually caused by mild-reversible injury to the pituitary stalk.29 after 3 months follow-up, mri showed that there was no recurrence of the tumor. meanwhile, the recurrence rate in patients with pituitary adenoma 4 years after surgery was 22%.17 the recovery of visual function usually correlate with time, but there was a slow improvement of the right eye in this case.17 the clinical management of 46, xy dsd patients includes prophylactic gonadectomy, which needs to be carried out due to an increased risk of gonadal malignancy.11,21 furthermore, patients with abdominal gonads have a high risk of germ-cell tumors development30 with an incidence rate of approximately 25-33%.23 another appropriate management of xy female with the disorder includes hormonal therapy and psychological counseling. 14 optimal care of the condition also requires a multidisciplinary approach.4,5,23 psychological counseling for the patient is important, specifically when they experience gender dysphoria after being diagnosed with dsd.8,12,23 the presence of female external genitalia and mild clitoromegaly since birth as well as visual disturbance that was observed lately in a single patient is a rare combination, and it indicates the possibility of a dual diagnosis. therefore, further examination is needed to determine whether the atypical genitalia and pituitary macroadenoma contributed to the disease condition. this rare coexistence of 46,xy dsd with pituitary macroadenoma was assumed to be a coincidence, hence, a case study was carried out. however, vol 55 • number 1 • january 2023 pituitary macroadenoma in a girl with male karyotype 93 there were some limitations because molecular observation was not carried out. conclusion based on the results, 46, xy dsd has many different symptoms, and this case highlighted the atypical genital and primary amenorrhea, which were caused by various factors, hence, a multidisciplinary approach was carried out. furthermore, chromosomal analysis is important to assess the genetic factor and sex assignment of patients with the disorder. hormonal problems in the central pituitary gland can also be considered in some cases. although the precise mechanism was not determined with advanced molecular analysis of 46,xy dsd in the patient, a dual diagnosis is still impossible. this case study is expected to provide valuable insight on the approach that can be used to manage the disorder. funding source this study was funded by diponegoro university wcru grant with reference no.11803/un7.6.1/pp/2021. conflict of interest the authors declare no conflict of interest. referrences 1. hughes ia, houk c, ahmed sf, lee pa, group lec. consensus statement on management of intersex disorders. arch dis child. 2006;91:554-63. 2. nordenström a. puberty in individuals with a disorder of sex development. current opinion in endocrine and metabolic research. 2020;14:42-51. 3. cools m, drop sl, wolffenbuttel kp, oosterhuis jw, looijenga lh. germ cell tumors in the intersex gonad: old paths, new directions, moving frontiers. endocr rev. 2006;27(5):468-84. 4. wisniewski ab, mazur t. 46, xy dsd with female or ambiguous external genitalia at birth due to androgen insensitivity syndrome, 5α-reductase-2 deficiency, or 17β-hydroxysteroid dehydrogenase deficiency: a review of quality of life outcomes. int j pediatr endocrinol. 2009;2009:1-7. 5. mendonca bb, domenice s, arnhold ij, costa em. 46,xy disorders of sex development (dsd). clin endocrinol (oxf). 2009;70(2):173-87. 6. kadhim mm, aboud mj. disorders of sex development: molecular versus clinical and cytogenetic studies and their correlation with diagnostic outcome and sex of rearing in a local community. jmscr. 2014;2(7):162646. 7. khanna k, sharma s, gupta dk. a clinical approach to diagnosis of ambiguous genitalia. j indian assoc pediatr surg. 2019;24(3):162-9. 8. brain ce, creighton sm, mushtaq i, et al. holistic management of dsd. best pract res clin endocrinol metab. 2010;24(2):335-54. 9. listyasari na, santosa a, juniarto az, faradz smh. multidisciplinary management of disorders of sex development in indonesia, a prototype in developing country. journal of biomedicine and translational research. 2017;3(1). 10. r k, i m, m e, m m, a e. genetic and clinical study of disorder of sex development among children and adolecents. life science journal. 2020;17(6). 11. öcal g. current concepts in disorders of sex development. j clin res ped endo 2011;3(3):105-14. 12. wisniewski ab. gender development in 46,xy dsd: influences of chromosomes, hormones, and interactions with parents and healthcare professionals. scientifica (cairo). 2012;2012:834967. 13. wisniewski ab, batista rl, costa emf, et al. management of 46,xy differences/disorders of sex development (dsd) throughout life. endocr rev. 2019;40(6):1547-72. 14. jung ej, im dh, park yh, et al. female with 46, xy karyotype. obstet gynecol sci. 2017;60(4):378-82. 15. a h m e d s f, b a s h a m b o o a , l u c a s h e r a l d a , mcelreavey k. understanding the genetic aetiology in patients with xy dsd. br med bull. 2013;106:67-89. 16. homa l, thomas s, sanfilippo j. primary amenorrhea with transverse vaginal septum and scant hematocolpos: a case report. open j pediatrics. 2012;02(01):87-91. 17. rutkowski mj, alward rm, chen r, et al. atypical pituitary adenoma: a clinicopathologic case series. j neurosurg. 2018;128(4):1058-65. 18. j a n g m k , o h e g , l e e h , k i m e h , k i m s . postoperative symptoms and quality of life in pituitary macroadenomas patients. journal of neuroscience nursing. 2020;52(1):30-6. 19. maleki n, kalantar hormozi m, iranparvar alamdari m, tavosi z. 5-alpha-reductase 2 deficiency in a woman with primary amenorrhea. case rep endocrinol. 2013;2013:631060. 20. berra m, williams el, muroni b, et al. recognition of 5alpha-reductase-2 deficiency in an adult female 46xy dsd clinic. eur j endocrinol. 2011;164(6):1019-25. 21. campbell im, yuan b, robberecht c, et al. parental somatic mosaicism is underrecognized and influences recurrence risk of genomic disorders. am j hum genet. 2014;95(2):173-82. 22. parisi ma, ramsdell la, burns mw, et al. a gender assesstment team: experience with 250 patients over a period of 25 years. genet med 2007;9(6):348-57. 23. moshiri m, chapman t, fechner py, et al. evaluation fatinah shahab acta med indones-indones j intern med 94 and management of disorder of sex development : multidisciplinary approach to complecx diagnosis. . radiographicsrsnaorg. 2012;32(6):1599-618. 24. hummadi aa, yahya ao, al-qahtani am. late diagnosis of 5-alpha-reductase type 2 deficiency in an adolescent girl with primary amenorrhoea. sultan qaboos univ med j. 2017;17(2):e218-e20. 25. lanciotti l, cofini m, leonardi a, bertozzi m, penta l, esposito s. different clinical presentations and management in complete androgen insensitivity syndrome (cais). int j environ res public health. 2019;16(7). 26. tortosa f, webb sm. novel aspects in histopathology of the pituitary gland. endocrinología, diabetes y nutrición (english ed). 2017;64(3):152-61. 27. vilar l, vilar clarice f, lyra r, freitas maria da c. pitfalls in the diagnostic evaluation of hyperprolactinemia. neuroendocrinology. 2019;109(1):7-19. 28. qari fa, abudaood ea, nasser ta. diabetes insipidus following neurosurgery at a university hospital in western saudi arabia. saudi med j. 2016;37(2):15660. 29. de vries f, lobatto dj, verstegen mjt, van furth wr, pereira am, biermasz nr. postoperative diabetes insipidus: how to define and grade this complication? pituitary. 2021;24(2):284-91. 30. looijenga lh, hersmus r, oosterhuis jw, cools m, drop sl, wolffenbuttel kp. tumor risk in disorders of sex development (dsd). best pract res clin endocrinol metab. 2007;21(3):480-95. 150 acta med indones indones j intern med • vol 55 • number 2 • april 2023 original article abstract background: the prevalence of hypovitaminosis d (hypod) in patients with type 2 diabetes mellitus (t2dm) and depression has not been documented. in addition, the risk factors are unknown. this study aimed to identify the prevalence of and risk factors for hypod in patients with t2dm who also have depression. methods: 118 patients with t2dm who visited the outpatient endocrinology clinics at cipto mangunkusumo national hospital between december 2019-september 2022 provided the clinical and demographic data for this crosssectional study, including body mass index, blood pressure, glycosylated haemoglobin (hba1c), lipid profiles, therapy, gender, age, marital status, and educational background. we used the beck depression inventory ii (bdi-ii) to evaluate depression. we used enzyme-linked immunosorbent assay kit to assess the dependent variable: serum vitamin d. we characterized serum vitamin d levels into three groups (normal, 30 ng/ml; insufficient, 20-29 ng/ml; deficient, 20 ng/ml). we also used analyses of variance to examine the anthropometric, clinical, and biochemical factors between the three groups. results: 118 subjects with t2dm. their median age was 56 years old (48, 75-60 years old), with a bdi-ii score of 17 (15-19), and a serum concentration of vitamin d. the d level was 18.3 ng/ml (9.17–29.46 ng/ml). only 21.8% of patients with t2dm and depression had sufficient levels of vitamin d. we used multivariable analysis of variance model to examine the associations between age, bdi-ii score, hba1c, and systolic and diastolic blood pressure with vitamin d level. age and bdi-ii score both had a statistically significant effect on vitamin d levels. conclusion: this cross-sectional study discovered that patients with t2dm and depression had a high prevalence (77.7%) of hypod. age and bdi-ii score both affected differences in vitamin d levels with statistical significance. keywords: hypovitaminosis d, type 2 diabetes mellitus, depression. prevalence and factors related to hypovitaminosis d in type 2 diabetes mellitus patients with depression rudi putranto1,2*, siti setiati2, martina w. nasrun3, fiastuti witjaksono4, suzanna immanuel5, imam subekti2, kuntjoro harimurti2, agus siswanto6, hamzah shatri2, suhendro suwarto2 1doctoral program in medical sciences, faculty of medicine universitas indonesia, jakarta, indonesia. 2department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 3department of psychiatry, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 4department of clinical nutrition, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 5department of clinical pathology, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 6department of internal medicine, faculty of medicine universitas gadjah mada – sardjito hospital, yogyakarta, indonesia. *corresponding author : rudi putranto, md, mph. department of internal medicine, faculty of medicine universitas indonesia. jl. diponegoro no. 71, jakarta 10430, indonesia. email: putranto.rudi09@gmail.com. vol 55 • number 2 • april 2023 prevalence and factors related to hypovitaminosis d in type 2 dm patients 151 introduction a s a g l o b a l p u b l i c h e a l t h i s s u e , hypovitaminosis d (hypod) affects people of all ages.1 some findings suggest that vitamin d has a significant role in the health of the brain, nervous system, and depression, in addition to its effects on calcium metabolism, bone, proliferation, differentiation, and immunological modulation.2 vitamin d deficiency was associated with an 8-14% increase in the prevalence of depression.3 according to cross-sectional studies,4,5 serum 25-hydroxyvitamin d or 25(oh)d concentrations and depressive symptoms have an inverse relationship. vitamin d regulates serotonin levels and vitamin d deficiency causes lower amounts of serotonin.6 low serotonin levels may contribute to the development of clinical depression.7 strong evidence has emerged recently linking hypod to the development of insulin resistance and abnormalities in insulin secretion potentially interfering with type 2 diabetes mellitus (dm).8 patients with diabetes and prediabetes were found to have lower serum levels of 25(oh)d than people with normal glucose tolerance.9,10 low serum 25(oh)d levels have been associated with an increased risk of metabolic syndrome and type 2 diabetes in epidemiologic research, which may be partially explained by a rise in fat mass.11 long-term complications of diabetes include microand macrovascular disease. according to a recent systematic review and meta-analysis, depression is connected to an increased risk of incident macroand microvascular issues, and diabetic complications are linked to an increased chance of developing depression in the future.12 a change in vitamin d homeostasis may contribute to the emergence of type 2 diabetes and hypod is directly related to depression.13,14 many studies have examined the effect of abnormal vitamin d levels and depression5,7,11,14,15 and the effect of hypod in dm.8,10,11,16,17 however, the prevalence of hypod in patients with type 2 dm and depression, and its contributing variables are still poorly understood. until now, no study has looked at factors related to hypod in patients with type 2 dm and depression. the goal of this study was to determine the prevalence of vitamin d insufficiency and deficiency in patients with type 2 dm and depression. we also investigated the factors linked to low vitamin d plasma levels. our hypotheses for age, gender, bdi-ii score, body mass index (bmi), glycosylated haemoglobin (hba1c), systolic blood pressure (sbp), diastolic blood pressure (dbp), low-density lipoprotein (ldl), high-density lipoprotein (hdl), and triglycerides (tg) were related to low vitamin d levels in patients with type 2 dm and depression. methods study design and setting this cross-sectional study used a convenience sampling technique to obtain data from patients in outpatient endocrinology clinics at the cipto mangunkusumo national hospital, jakarta, from december 2019–september 2022. patients with type 2 dm aged over 18 years were included in the study cohort. individuals with pre-existing diseases affecting vitamin d and/or calcium metabolism, such as liver or kidney disease, psychosis, skin disease, or use of highdose steroids or immunomodulators, were excluded. however, women who were nursing or pregnant were not excluded. the cohort included only participants who provided their signed informed consent. the sample size was calculated using the finding that the prevalence rate of depressive symptoms in patients with type 2 dm in jogjakarta, indonesia, was 37.9%. the level of significance was set at 0.05, the allowable error was set at 10%, the invalid questionnaire rate was set at 10%, and the minimum number of samples was 91. all study procedures and protocols were approved by the institutional ethical review board at universitas indonesia ethics committee (lb.02.01/2.6.1/0452/2022). written informed consent was obtained from all participants. data collection procedure patients with type 2 dm were identified using world health organisation/american diabetes association criteria.18 their anthropometric parameters were measured according to standard protocols and their bmi was calculated. hba1c percentages were measured in whole blood using the immunoturbidometric method. rudi putranto acta med indones-indones j intern med 152 serum vitamin d levels were measured using an elisa kit and categorized into three groups (i.e. normal, 30 ng/ml; insufficient, 20-29 ng/ ml; deficient, 20 ng/ml).19 sbp and dbp were measured using a standard sphygmomanometer while the patients were sitting. ldl, hdl, and triglyceride (tg) levels were determined with an autoanalyzer. depression was evaluated using the beck depression inventory ii (bdi-ii). each item on the scale is scored on a 4-point (0-3) likert scale, and the total result for the bdi-ii is the sum of all 21 items. the bdi-ii was analyzed using the following algorithm: depression ranges from mild (score, 14-19), moderate (20-28), to serious (29-63).20 statistical analysis t h e k o l m o g o r o v – s m i r n o v t e s t w a s performed to determine the normality of the parameters. descriptive statistics were used to provide a summary of the demographic characteristics. the arithmetic mean and standard deviation (sd) were used for continuous variables and the count and percentage for categorical variables. we used univariate analyses to compare anthropometric, clinical, and biochemical variables between the two groups (independent t-test for quantitative data and chisquare test for categorical data). for the bdi-ii score, bmi, hba1c, sbp, dbp, ldl, hdl, and tg vales were categorized into three groups (i.e. sufficient vitamin d, vitamin d insufficiency, and vitamin d deficiency) using an analysis of variance (anova) test. a p-value of < 0.05 was considered statistically significant in all analyses. to find a potential set of variables that will go into the multivariable (linear regression) model, we used the statistical methodology for variable selection using p < 0.25 in the univariable (bivariate) analysis as a threshold. results from december 2019 to september 2022, we performed screening of 170 patients with type 2 dm to obtain 118 patients with type 2 dm and depression. we then checked their vitamin d levels (figure 1). the patients’ characteristics are indicated in table 1. the median age was 56 years (48, 75-60 years) with a median bdi-ii score of 17 (15-19), while the mean serum 25(oh)d level was 18.3 ng/ml (9.17-29.46 ng/ml). table 1. subject characteristics. variables (n = 118) age (years), median (iqr) 56 (48.75-60) gender, n (%): male 33 (28) female 85 (72) educational level, n (%) uneducated 2 (1.7) primary school 7 (5.9) junior high school 10 (8.5) senior high school 64 (64.2) university/college 35 (29.7) marital status, n (%) married 94 (79.7) unmarried 8 (6.8) divorced 16 (13.6) religion, n (%) muslim 80 (67.8) catholic 4 (3.4) christian 32 (27.1) buddhist 2 (1.7) treatment, n (%) oral antidiabetic drugs (oad) only 55 (46.6) 170 patients with type 2 dm 118 outpatients with type 2 dm > 18 years old included in this study screening for depression using bdi ii take blood test for 25(oh)d lipid profile, blood pressure, and bmi analysis 52 subjects excluded from the study figure 1. study recruitment and sampling diagram. vol 55 • number 2 • april 2023 prevalence and factors related to hypovitaminosis d in type 2 dm patients 153 insulin only 14 (11.9) combination (oad + insulin) 49 (41.5) duration of type 2 diabetes mellitus < 5 years 77 (65.3%) > 5 years 41 (34.7%) with other comorbidities hypertension 59 (50%) coronary artery disease 17 (14.4%) chronic kidney disease 30 (25.4%) stroke ischaemic 7 (5.9%) dyslipidemia 78 (66.1%) diabetic retinopathy 7 (5.9%) diabetic neuropathy 30 (25.4%) diabetic ulcer 6 (5.1%) bdi-ii score, median (iqr) 17 (15-19) bmi (kg/m2), median (iqr) 25.6 (23.4-28.93) serum 25(oh)d (ng/ml), mean (sd) 18.3 (9.17-29.46) hba1c (%), median (iqr) 7.7 (6,7-9.27) sbp (mmhg), median (iqr) 135 (117-144.25) dbp (mmhg), mean (sd) 74.19 (10.32) ldl-cholesterol, median (iqr) 115.5 (96-138) hdl-cholesterol, median (iqr) 47.5 (41-55) tg, median (iqr 140 (97.75-184.5) figure 2 shows that among 118 patients, only 22% (n = 26) have a normal/sufficient vitamin d level, with 51.7% having insufficient vitamin d and 26.3% with deficient vitamin d levels. we compared the age, gender, and metabolic profiles between patients with a normal vitamin d level and those with hypod (table 2). there was a significant difference in mean hba1c (p value = 0.015) and dbp differed between groups (p-value 0.057). and no significant difference in mean of the bdi-ii score, bmi, hdl, ldl, and tg. compared with other variables, hba1c levels differed between the sufficient/normal, insufficient, and deficient groups with p = 0.015 (table 3). table 4 shows that age and hba1c have a relationship with low vitamin d levels. variables with p < 0.25 in the bivariate analysis (i.e. age, bdi-ii score, hba1c, and ldl-cholesterol) were examined further using a multivariate analysis to identify their associations with vitamin d levels. other factors were not included in this model because they did not show a significant bivariate relationship with vitamin d level. there was a statistically significant difference in vitamin d level based on age and hba1c. however, the bdi-ii score, and sbp and dbp levels did not show statistically significant differences (table 5). discussion our study found that 77.7% of patients with type 2 dm and depression had hypod. the vitamin d level in type 2 dm patients with depression sufficient 22% insufficient 26.3% deficient 51.7 figure 2. vitamin d level in type 2 dm with depression. table 2. comparing age and gender with vitamin d grades. variable sufficient (n = 26) insufficient and deficient (n = 92) p-value age in years, median (iqr) 58.5 (55-63.5) 55 (47-60) 0.014* gender, n male 8 (24.2) 25 (75.8) 0.910** female 18 (21.2) 67 (78.8) *mann–whitney u test; **chi-square test. rudi putranto acta med indones-indones j intern med 154 supplements for osteoporosis among older age groups.22 our study showed no significant difference in vitamin d levels between genders. yu et al. found that men had higher serum 25(oh)d levels than women,23 while another study found that men had a higher prevalence of vitamin d deficiency.21 lower vitamin d levels in women may be attributed to their clothing style, spending less time outside, and engaging in less physical activity than men.22 there were significant differences in age and bdi-ii scores, but no differences in hba1c, sbp, dbp, or tg levels between patients with normal and abnormal vitamin d levels. in various clinical settings, low serum 25(oh)d levels have been linked to depressive symptoms in adults.24–26 our patients with deficient vitamin d levels have a slightly higher bdi-ii score than other patients, although this was not statistically significant. lee et al. showed that there was an inverse association between 25(oh)d levels and depression.27 similarly, khan et al. also showed that depression was more common in individuals with vitamin d deficiency.25 zhao et al. showed that vitamin d deficiency was related to high hba1c levels.28 buhary et al. also showed that hba1c was inversely related to serum vitamin d levels and vitamin d supplementation will result in better blood glucose control.29 in our study, the hba1c levels were slightly higher in the deficient group than the other groups and the findings were statistically significant and supported the results median age of the group with insufficient and deficient vitamin d levels was younger than that of the patients with normal vitamin d levels. this result was similar to a previous study by al quaiz et al. that showed younger adults had a higher prevalence of vitamin d deficiency compared with older participants,21 which may be because younger patients spend more time indoors and work inside the office, where they do not get enough sunshine, while older patients often have more free time outdoors. this finding may also be due to the use of calcium and vitamin d table 3. characteristics of patients with sufficient versus insufficient and deficient vitamin d levels. variables sufficient(n = 26) insufficient (n = 61) deficient (n = 31) p-value bdi ii score, median (iqr) 17 (15-19.2) 17 (14-19) 18 (15-21) 0.072*** bmi (kg/m2), median (iqr) 25.2 (23.6-28.9) 25.6 (22.9-28.9) 26.9 (23.6-29) 0.834*** hba1c (%), median (iqr) 6.9 (6.6-7.8) 8 (6.5-9.55) 8.7 (7.5-9.8) 0.015*** sbp (mmhg), median (iqr) 135 (115.5-145) 133 (116.5-143) 138 (118-146) 0.709*** dbp (mmhg), mean 74.65 (9.3) 72.25 (10.01) 77.65 (11.04) 0.057**** ldl-cholesterol, mean 117.35 (25.3) 119.02 (33.6) 112 (30.13) 0.591**** hdl-cholesterol, median (iqr) 49 (41-64.2) 46 (40.5-52.5) 48 (41-53) 0.682*** tg, median (iqr) 130.5 (92.2-178) 125 (106-180.5) 165 (98-201) 0.399*** bdi ii, beck depression inventory ii; bmi, body mass index; sbp, systolic blood pressure; dbp, diastolic blood pressure; ldl, low-density lipoprotein; hdl, high-density lipoprotein; tg, triglycerides. ***kruskal–wallis test, ****one-way anova. table 4. relationship between of variables with vitamin d. variable r2 p-value age (years) 0.289 0.002* gender male 13.73 (6.58-29.67) 0.283** female 20.59 (10.45-29.20) bdi ii score −0.153 0.098* bmi (kg/m2) 0.000 0.998* hba1c −0.267 0.004* sbp 0.018 0.846* dbp −0.057 0.539* ldl-cholesterol 0.108 0.243* hdl-cholesterol −0.013 0.891* tg −0.105 0.259* *spearman rho; **mann–whitney u test. table 5. linear regression analysis of vitamin d status in dm type 2 patients with depression. variable unstandardized b coef. se p-value (constant) 1.317 10.954 0.905 age in years 0.567 0.165 0.001* bdi ii score −0.665 0.326 0.043* *p-value < 0.05 vol 55 • number 2 • april 2023 prevalence and factors related to hypovitaminosis d in type 2 dm patients 155 of previous studies. vitamin d deficiency was recently considered a new risk factor for causing hypertension.30,31 a systematic review and meta-analysis by he and hao showed that there was no significant difference in sbp and dbp between the control and vitamin d deficiency groups.32 vitamin d supplementation also did not lower blood pressure in a study by zhang et al.33 low serum vitamin d levels have been associated with an atherogenic lipid profile.34 chaudhuri et al. showed that vitamin d deficiency was associated with dyslipidemia in indian subjects.35 in a retrospective observational study,36 vitamin d deficiency was associated with higher ldl and lower hdl levels. however, the results of our study showed no significant difference in lipid profiles between groups. interestingly, this study found a correlation between age and lack of vitamin d in patients with type 2 dm and depression. according to a study of male and female respondents aged 50 years, oliveira et al. linked low serum 25(oh)d levels to an increased chance of depressive symptoms, especially in women. age, economic circumstances, health, habits, bodily and mental abilities, and cognitive abilities all have an impact on depressive symptoms.37 william et al. reported vitamin d deficiency in 27.8% of children aged 5 to 9 years, 35.4% of children aged 10 to 14 years, and 50.9% of children aged 15 years or older. vitamin d deficiency was significantly associated with older age, african american ethnicity, winter/ spring seasons, a higher insulin level, the total number of comorbidities, and polycystic ovary syndrome (in girls).37 a study from qatar found that subjects aged over 60 years have a 61.3% chance of depression and type 2 dm.38 a systematic review and meta-analysis showed that vitamin d supplementation may improve depression in patients with type 2 dm.39 in a recent study of prediabetic patients, the researchers found that new-onset diabetes occurred in 22.7% of adults who received vitamin d and 25% of those who received a placebo over a 3-year period, resulting in a 15% relative risk reduction. extrapolating their results to the more than 374 million prediabetic adults worldwide indicates that low-cost vitamin d supplementation could prevent the onset of diabetes in more than 10 million individuals.40 limitation the study there are a few limitations to our research findings. this cross-sectional study means that any associations may not necessarily indicate causation. we were unable to determine whether our patients’ vitamin d status varied from that of the general community because we did not include healthy controls. our findings might not be very generalizable in regions with different sun exposure patterns. conclusion this study showed that patients with type 2 dm and depression had a high prevalence of hypod (i.e. 77.7%). in addition, age and bdi-ii score were associated with low vitamin d levels. acknowledgments we are grateful for support from dr stevanie and ms utami susilawaty for editing and statistical analyses. finally, we are thankful to all the participants in this study. declaration of competing interest the authors declare that they have no competing interests or conflicts of 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2022;100014. 39. putranto r, harimurti k, setiati s, et al. the effect of vitamin d supplementation on symptoms of depression in patients with type 2 diabetes mellitus: a systematic review and meta-analysis of randomized controlled trials. acta med indones. 2022;54(4):574–84. 40. pittas ag, kawahara t, jorde r, et al. vitamin d and risk for type 2 diabetes in people with prediabetes: a systematic review and meta-analysis of individual participant data from 3 randomized clinical trials. annals of internal medicine. 2023;176(3):355–63. 110 acta med indones indones j intern med • vol 55 • number 1 • january 2023 special article timp2 and igfbp-7 as biomarkers for the diagnosis of acute kidney injury (aki) in post-operative patients: an evidence-based case report igor ian wiguna, gde n. i. bhaskara, mutiara r. a. putri, priscilla ardianto, widi atmoko faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: igor ian wiguna, md. faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. salemba raya no. 6, jakarta 10430, indonesia. email: igorwiguna@yahoo.com. abstract background: acute kidney injury (aki) is defined as a sudden reduction in kidney function which commonly occurs as a complication of major surgeries. it is traditionally diagnosed using serum creatinine elevation. aki has relatively slow kinetics that makes it unable to diagnose at an earlier more reversible stage. furthermore, previous research has shown that timp-2 and igfbp7 were urinary biomarkers to use as a diagnostic tool for aki. we aimed to compare the accuracy of timp2 and igfbp-7 to the gold standard (serum creatinine) in diagnosing aki in postoperative patients. methods: a thorough search was performed using a search strategy on embase, pubmed, and medline (ovid) using keywords according to the objective. the collected articles were critically appraised using ceebm critical appraisal tool. results: 5 studies that fulfilled the inclusion criteria were selected and evaluated. they all stated that the use of timp2 and igfbp7 could not detect aki better than the gold standard as shown in the sensitivity and specificity of the biomarkers. furthermore, the examination of aki using both biomarkers showed a sensitivity of 60-100% and specificity of 58-91%. conclusion: timp2 and igfbp7 are promising diagnostic tools for aki. however, due to the wide variation in results amongst the different studies, further research is required to ensure the credibility of this result. keywords: postoperative aki, diagnosis, timp2, igfbp7, serum creatinine level introduction acute kidney injury (aki) is defined as a sudden reduction in kidney function. it is a common complication of major surgeries resulting in a significant increase in mortality and morbidity.1 the diagnosis of aki has remained unchanged over the years and is based on the acute rise of scr and/or a decline in urine output over time. scr elevation, however, has proven to be an imperfect gold standard due to its relatively slow rise2, disabling it from detecting aki early on, during a potentially reversible stage.3 this prompts the search for potential biomarkers with comparable accuracy to scr that are able to detect aki at an earlier stage. an example is the urinary cell-cycle arrest markers, namely timp-2 and igfbp7, whose levels were found to increase following a kidney injury.4 both timp-2 and igfbp7 are urinary cell-cycle arrest markers that are secreted by the tubule cells of the kidney. they are capable of inducing g1 cell cycle arrest and differential in secretion localization can predict kidney damage. research stated that the used of both the markers simultaneously added the predictive value in diagnosing aki. nephrocheck is the brand used to diagnose both these markers simultaneously.4 the clinical and economic vol 55 • number 1 • january 2023 timp2 and igfbp-7 as biomarkers for the diagnosis of aki 111 benefits of these biomarkers in diagnosing aki have been previously evaluated in the us hospital system settings by berdugo ma, et al. currently, they have not been evaluated in the indonesian hospital setting. furthermore, studies investigating the potential use of timp-2 and igfbp7 in the diagnosis of aki compared to scr were collected and analyzed. they were also evaluated to know whether these biomarkers have enough potential to be implemented in indonesia. case illustration a 63-year-old male underwent cardiopulmonary bypass without abnormalities in a tertiary hospital in indonesia. the patient was then transferred to the general ward and monitored. laboratory tests (blood and urine) were performed, and the results did not indicate any abnormalities (serum creatinine level 1.1 mg/ dl and he was hemodynamically stable) and thus he was treated in the general ward. suspicion was made after his surgery and nephrocheck (timp2*igfbp7) was used and found that there were increasing amounts of the biomarkers. he was then admitted to intensive care unit (icu) due to suspected aki for early treatment. in icu, his blood pressure kept increasing from 140/90 to 180/110 mmhg and his scr increased to 4.7 mg/dl during 3 days after the surgery. he was then diagnosed with acute kidney injury (aki) and severe hypertension related to the surgery. clinical question do timp-2 and igfbp7 (nephrocheck) provide a good accuracy in diagnosing aki as a postoperative complication, considering its capability of early detection? methods search strategy a thorough search was performed in three databases, namely embase, medline(ovid), and pubmed, utilizing mesh terms and keywords (table 2). this made it possible to obtain studies investigating the accuracy of timp2 and igfbp7 compared to scr in diagnosing postoperative aki. furthermore, these searches were performed on october 29, 2021 as shown in figure 1. eligibility criteria studies were screened based on the following criteria, namely to investigate aki, which is defined by either an increase in scr by 0.3 mg/dl (or 26.5 lmol/l) within 48 hours or by 1.5 times baseline, which is presumed to have occurred within the prior 7 days or urine volume < 0.5 ml/kg/h for 6 hours. based on kdigo5, this involved patients in a postoperative setting older than 18 years old, whereby timp2 and igfbp7 alongside scr were measured. scr was used as the compactor because we believe that scr is still the gold standard in diagnosing aki. however, we are trying to investigate the diagnosis accuracy of timp2 and igfbp7 in diagnosing aki in early stages. studies that investigated pregnant and pediatric patients, and also did not provide full texts or utilize other languages other than english and bahasa indonesia, were excluded. study selection this was performed simultaneously by about four people carried out this process which involved passing the studies through independent screening. the titles, abstracts, and the ones that passed this phase were screened tabel 1. pico framework. patient/problem (p) intervention (i) comparison (c) outcome (o) patients who underwent surgery suspected of aki as a postoperative complication combination of timp-2 and igfbp7 (nephrocheck) serum creatinine diagnosis of postoperative aki type of clinical question diagnosis study design evidence based case report igor i. wiguna acta med indones-indones j intern med 112 table 2. search terms per database. figure 1. study selection flow chart. vol 55 • number 1 • january 2023 timp2 and igfbp-7 as biomarkers for the diagnosis of aki 113 thoroughly in each of their full texts against the eligibility criteria. a discussion between the two conflicting reviewers was also held in order to reach a consensus in cases of conflicting decisions during the study selection. however, in a situation whereby a consensus was not reached, a third reviewer would provide a final decision. covidence© was used to perform this selection in order to ensure the accuracy of the selected study. critical appraisal critical appraisal was performed using oxford cebm diagnostics critical appraisal sheet. results search results based on the search from the three databases, 47 studies were retrieved consisting of 10 duplicates (figure 1). the remaining had their title and abstract, and later the full text screened against the eligibility criteria. in the full-text screening phase, 15 studies were excluded due to the following reasons namely, 4 studies did not have a full-text version, 3 assessed different biomarkers in combination with nephrocheck, one study did not include gold standard comparison (scr), and 4 studies were excluded as it assessed pediatric population. furthermore, one study used nephrocheck as a predictor of renal recovery instead of a diagnosis of aki, another measured the incidence of aki instead of the accuracy of the diagnostic tools and one systematic review included irrelevant studies. the full-text screening phase resulted in 5 studies which were later critically appraised. critical appraisal this was performed on the selected studies and the result are summarized in table 3. it was concluded that they were valid and important for the patients. however, about three studies6–8 did not perform blinding. based on the applicability test, it was inferred that some were not applicable because the diagnostic test was not available in indonesia. in addition, 4 out of the 5 studies showed a low percentage of post-test probability. the ones that were selected aimed to determine the level of timp2, igfbp7, and scr in specific time points and compare the concentration between the biomarkers and scr as summarized in table 4. 24 hour timp2 and igfbp7 level in detecting aki all studies, except for meersch et al, measured the urinary biomarkers after 24 hours timepoint. there were different cutoff values of table 3. summary of critical appraisal results performed on the five remaining studies. igor i. wiguna acta med indones-indones j intern med 114 table 4. summary of findings in the selected studies. author patient group outcome key results comments dusse, et al. 40 patients with [timp2]*[igfb in kdigo aki 0/1: in patients underwent tavi, [timp (2016), bmc severe symptomatic p7] urine no significant rise of [timp2]*[igfbp7] urine concentration at 2]*[igfbp7] concentrations within anesthesiology aortic stenosis who underwent transapical or transaortic concentration compared to serum creatinine all times serum creatinine and egfr remained stable at all times; 24 h after surgery is associated with the onset of aki within the next 72 h. cohort study (2b) transcatheter aortic valve implantation (tavi) were included (scr) sensitivity and specificity of [timp2]*[igfb p7] (diagnostic accuracy) in kdigo aki 2/3: [timp2]*[igfbp7] increased significantly on 1st postoperative day (pod) (4.62 ± 3.14 (ng/ml)2/1000) scr elevated on pod 2 with a maximum of 1.64 ± 0.99 mg/dl [timp2]*[igfbp7] elevated as early as 24h after tavi diagnostic accuracy for [timp2]*[igfbp7] 4h after intervention was better than using serum creatinine concentration with sensitivity of 75% and specificity of 55.6% (auc 0.646). one day after tavi, [timp2]*[igfbp7] showed sensitivity of 100% and specificity for kdigo 2 / 3 (auc 0.971). within 24 hours after tavi, [timp2]*[igfbp7] showed sensitivity of 87.5% and specificity of 82.8% (auc 0.869) compared to serum creatinine concentration. [timp 2]*[igfbp7] urine concentrations show an excellent diagnostic accuracy for the prediction of severe aki requiring rrt. . oezkur, et al. (2017), kidney blood press res cohort study (2b) 148 patients undergoing elective cardiac surgery value of [timp 2*igfbp7] compared to serum creatinine (scr) 24 hours post surgery 24h post surgery measurement of [timp2]*[igfbp7] had significant result.(or 2.11, p=0.06, sensitivity 60%, specificity 69%). ppv= 57.1%, npv= 89.9% it was concluded that early detection of elevated [timp2*igfbp7] at icu admission was more likely to predict postoperative aki compared to subsequent measurements meersch et al (2014), plos one cohort study (2b 50 patients undergoing cardiac surgery biochemical value and performance of [timp-2*igfbp7] for early diagnosis of aki the first 24 h after surgery urine [timp-2]*[igfbp7] using cutoff 0.3 yielded sensitivity of 73% and specificity 58% (auc: 0.90, ci:0.79–1.00) ppv=0.66 npv=0.67, when compared to serum creatinine maximum [timp2]*[igfbp7] value was achieved at 24h 24 patients who did not develop aki showed no statistically significant increase in [timp2]*[igfbp7 urinary [timp2]*[igfbp7] serves as a sensitive and specific biomarker to diagnose aki early after cardiac surgery and to predict renal recovery. vol 55 • number 1 • january 2023 timp2 and igfbp-7 as biomarkers for the diagnosis of aki 115 pilarczyk, et al. (2015), ann intensive care 60 patients (>18 y.o.) undergoing cabg post-operative course of [timp2]*[igfbp7] and serum creatinine in patients with aki 0/1: no significant rise of urinary [timp-2]*[igfbp7] was observed at all times scr remains stable at all times urinary [timp2]*[igfbp7] (g2 cell cycle arrest iomarkers) allow earlier diagnosis of aki compared to creatinine-based definition of aki cohort study (2b) diagnosis of aki with [timp 2]*[igfbp7] on the 1st postoperative day in patients with aki 2/3: [timp-2]*{igfbp7] increased significantly 4 hrs post surgery; reached maximum level on 3rd day scr elevation observed at pod 2 pod 4, reached maximum at pod 3 & 4 accuracy of [timp-2]*[igfbp7] at aki diagnosis: sensitivity 0.80, specificity 0.81 (cut-off value 0.89); ci 0.696-1.0, p = 0.04 mayer et al (2017), journal of cardiothoraci c and vascular anesthesia 110 patients (>18 y.o.) underwent cardiac surgery urine levels of [timp2]*[igfbp7] at an early time point after surgery for prediction of aki 1 hour after the start of cpb, the levels of timp-2*igfbp7 were measured to predict postoperative aki. sensitivity and specificity were found to be 0.778 and 0.641, respectively. positive and negative predictive values were also calculated (0.156 and 0.972, respectively). urine levels of timp-2 igfbp7 are able to diagnose aki at 1 hour afe cpb. timp-2 and igfbp7 may be recommended for supplementary criteria of aki prediction. [timp2]*[igfbp7], three studies6,8,9 utilized 0.3, while pilarcyzk et al., and mayer et al., utilized 0.817 and 0.41 respectively. dusse et al., reported the best sensitivity and specificity (100% and 91%) while others6–8,10 reported different values ranging from 60% 89% and 58% 81% respectively. as for the likelihood ratio, it was manually calculated and it was found that only dusse et al., (11.1) reported a significantly favorable likelihood ratio. however, meersch et al., and oezkur et al., reported an unfavorable likelihood ratio, namely 1.74 and 1.94 respectively. discussion the diagnosis of aki is usually performed by following the diagnostic criteria of kidney disease, such as improving global outcome (kdigo) of aki 5 using creatinine elevation as the focus of the measurement. however, this diagnosis method poses limitations because of its incapability in diagnosing aki at its earliest point before the disease becomes irreversible.3 timp-2 and igfbp7 are stress markers that are rapidly secreted during kidney injuries.4 these biomarkers were used as detection methods of aki at its earliest development.9 furthermore, all studies assessed within this case report presented similar findings such as increased levels of timp-2 and igfbp7 within 24 hours of surgery. this is in line with previous findings that [timp2]*[igfbp7] accurately identified patients with increased risk of aki in an earlier time frame postoperatively.3,11,12 dusse, et al.,9 and pilarczyk, et al.,10 examined the diagnostic accuracy of [timp-2]*[igfbp7] in diagnosing aki by comparing it to the concentration of scr level in several time points. different from the other cohort studies, this study performs blinding on the investigators, which reduces information bias. however, dusse, et al., and pilarczyk et al., had a low sample size with 40 and 60 samples respectively, which was justified by their sample size calculator but risked a less representative result. in summary, both studies reported high diagnostic accuracy of [timp-2]*[igfbp7] and were the only ones whose likelihood ratio indicated that [timp 2]*[igfbp7] provided benefits in diagnosing aki. igor i. wiguna acta med indones-indones j intern med 116 mayer et al.,7 employed a larger sample size of 110 subjects to examine the diagnostic capability of [timp-2]*[igfbp7] in diagnosing aki. the samples were consecutive patients which reduced selection bias. the measurement of urinary biomarkers was performed one hour after the surgery unlike other studies (within 24 hours), which tested their early capability in diagnosing aki. however, this study poses limitations, such as being a single-center cohort and having low number of aki events which lead to limited evidence for the obtained results. in the study by meersch, et al.8 the samples were heterogeneous and had comorbidities associated with aki, and the result showed timp2 and igfbp7 performed well in predicting aki. both biomarkers had significantly higher specificity and sensitivity in diagnosing aki. however, this study had a relatively small sample size of 50 from a single center. as a result, a larger population is required to validate the result despite the statistical and clinical significance. oezkur, et al.6 had the largest sample when compared to other prospective cohort studies exploring aki diagnosis in post-cardiac surgery patients. they excluded patients with chronic kidney diseases from their sample. therefore, the use of timp2 and igfbp7 as aki diagnostic tools in these groups of patients is unknown. in summary, the sensitivity and specificity results of nephrocheck reported by the studies seemed to vary by quite a wide margin ranging from 60-100% for sensitivity and 58-91% for specificity. this indicates that the probability of a patient with aki and being tested positive was 60-100% and those without aki and tested negative was 58-91%. this variation may have occurred because the studies employed different [timp-2]*[igfbp7] cut-off values. therefore, further studies need to be carried out in order to assess the value of [timp2]*[igfbp7] in diagnosing postoperative aki, especially in determining a standardized cutoff value. the highest likelihood ratio of 11.11 was reported by dusse, et al., and this indicates that when nephrocheck was used to detect aki, the result was 11.11 times more suitable for patients suffering from this disease. furthermore, they had positive results than those that were not suffering from aki. this result is significantly higher than the lr from the other four studies included. there is a possibility of different methods and factors, including blinding, surrounding the population leading to this peculiarity. therefore, there needs to be standardized and controlled study methods to ensure the credibility of this finding. this case report posed several strengths which include the utilization of 3 renowned scientific databases to search for relevant studies. this was carried out using an independent screening process in order to ensure objectivity in the study selection process. on the other hand, the limitation of this case report was a language barrier that caused several studies to be excluded. besides this case report also did not standardize the methodology of the appraised studies. conclusion the [timp-2]*[igfbp7] value was reported to be a promising aki diagnostic tool that was able to diagnose postoperative aki earlier. however, it seemed to be significantly influenced by the degree of severity, favouring moderateto-severe aki leading to a variety of results, and more studies are required to ensure its credibility. though [timp-2]*[igfbp7] value is a promising diagnostic tool, it is not still recommended in diagnosing postoperative aki. acknowledgments and affiliations the authors are grateful to the faculty of medicine, universitas indonesia for the opportunity to conduct this report under professional guidance. references 1. prowle jr, forni lg, bell m, et al. postoperative acute kidney injury in adult non-cardiac surgery: joint consensus report of the acute disease quality initiative and perioperative quality initiative. nat rev nephrol. 2021;17(9):605–18. 2. waikar ss, betensky ra, emerson sc, bonventre jv. imperfect gold standards for kidney injury biomarker evaluation. j am soc nephrol. 2012;23(1):13–21. 3. gunnerson kj, shaw ad, chawla ls, et al. timp2•igfbp7 biomarker panel accurately predicts acute kidney injury in high-risk surgical patients. j trauma acute care surg. 2016;80(2):243–9. vol 55 • number 1 • january 2023 timp2 and igfbp-7 as biomarkers for the diagnosis of aki 117 4. esmeijer k, schoe a, ruhaak lr, et al. the predictive value of timp-2 and igfbp7 for kidney failure and 30-day mortality after elective cardiac surgery. sci rep. 2021;11(1):1071. 5. k d i g o . k d i g o i n t e r n a t i o n a l s u p p l e m e n t s . international society of nephrology. 2012; 2(1):1-141. 6. oezkur m, magyar a, thomas p, et al. timp2*igfbp7 (nephrocheck®) measurements at intensive care unit admission after cardiac surgery are predictive for acute kidney injury within 48 hours. kidney blood press res. 2017;42(3):456–67. 7. mayer t, bolliger d, scholz m, et al. urine biomarkers of tubular renal cell damage for the prediction of acute kidney injury after cardiac surgery-a pilot study. j cardiothorac vasc anesth. 2017;31(6):2072–9. 8. meersch m, schmidt c, van aken h, et al. urinary timp-2 and igfbp7 as early biomarkers of acute kidney injury and renal recovery following cardiac surgery. plos one. 2014;9(3):e93460. 9. dusse f, edayadiyil-dudásova m, thielmann m, et al. early prediction of acute kidney injury after transapical and transaortic aortic valve implantation with urinary g1 cell cycle arrest biomarkers. bmc anesthesiol. 2016;16:76. 10. pilarczyk k, edayadiyil-dudasova m, wendt d, et al. urinary [timp-2]*[igfbp7] for early prediction of acute kidney injury after coronary artery bypass surgery. ann intensive care. 2015;5(1):50. 11. gocze i, koch m, renner p, et al. urinary biomarkers timp-2 and igfbp7 early predict acute kidney injury after major surgery. plos one. 2015;10(3):e0120863. 12. vijayan a, faubel s, askenazi dj, et al. clinical use of the urine biomarker [timp-2] × [igfbp7] for acute kidney injury risk assessment. am j kidney dis. 2016;68(1):19–28. 389acta med indones indones j intern med • vol 54 • number 3 • july 2022 original article bedaquiline effect on qt interval of drugs-resistant tuberculosis patients: real world data i gusti agung ayu putu sri darmayani1, purwantyastuti ascobat1*, instiaty1, yani jane r sugiri2, neni sawitri3 1 department of pharmacology and therapeutics, faculty of medicine universitas indonesia, jakarta, indonesia. 2 dr. saiful anwar hospital, malang, indonesia. 3 dr. m. goenawan partowidigdo hospital, cisarua, bogor, indonesia. *corresponding author: prof. purwantyastuti ascobat, md., phd. department of pharmacology and therapeutics, faculty of medicine universitas indonesia. jl. salemba no. 6, jakarta 10430, indonesia. email: sdarmayani@gmail.com. abstract background: bedaquiline (bdq) is effective as part of treatment regimen for drug-resistant tuberculosis (dr-tb), but the cardiac safety profile of bdq is not fully elucidated. this study aimed to analyse the cardiac safety of bdq by examining its effect on the qt interval of dr-tb patients. methods: this is a retrospective study cohort conducted in two dr-tb referral hospitals in indonesia. the qt interval before and after therapy using bdq was measured manually and corrected using the fridericia formula (qtcf). the qt interval profile was analysed over time during bdq treatment. results: a total of 105 subjects participated in the study. the maximum mean difference (standard deviation) of qtcf after treatment with the baseline (∆qtcf) is 34,06 (52,92) ms after three months of therapy. during bdq treatment, clinically significant qtcf prolongations was observed in 37.1% subjects with neither arrhythmia nor any other adverse cardiac event occurred. the interval qt prolongation led to bdq discontinuation in 15.2% subjects temporarily and in 6.7% subjects permanently. there were seven deaths (6.7%) during the treatment. conclusion: during bdq treatment, maximum qt prolongation was observed after three months of bdq therapy. therefore, more intensive cardiac monitoring is recommended during this period and afterwards. keyword: bedaquiline, drug-resistant tuberculosis, qt interval prolongation. introduction indonesia ranks among the 30 highestranking countries in the world when it comes to the burden associated with dr-tb, with the number of new cases increasing every year. in 2020, there were 8,200 new laboratoryconfirmed dr-tb cases.1 however, dr-tb treatment is still a challenge for clinicians due to the low effectiveness and the severe and life-threatening side effects.2 these side effects may lead to additional morbidity, treatment withdrawal and even death of the patient.3 in the last 50 years, a new tb drug has been developed from a new class of antibiotic, bedaquiline (bdq). clinical trials have shown that bdq is effective in accelerating sputum conversion and improving success rate; however, bdq may cause qt interval prolongation.4 this poses a safety concern while using bdq, as it may cause polymorphic ventricular tachycardia, also known as torsades de pointes (tdp), which may lead to sudden death.5 another major concern is the long terminal half-life of bdq (up to 5.5 months) due to tissue redistribution.6 i gusti agung ayu putu sri darmayani acta med indones-indones j intern med 390 this may lead to the generation of adverse effects of bdq, including qt interval prolongation, which can last for a longer period or may even occur after the discontinuation of the drug.4 moreover, the cardiac safety profile of bdq has not been fully elucidated by existing studies due to various limitations. reports of drug-induced tdp were relatively rare, even though the drug is widely used.5 therefore, adequate data of cardiac safety of bdq must be collected from all over the world, including indonesia. the aim of this study was to analyse the effect of bdq on the qt interval of dr-tb patients in pragmatic use from two dr-tb referral hospitals in indonesia. methods this was a retrospective cohort study using real world data from patients’ medical records. it was carried out at dr. saiful anwar malang hospital (rssa) and dr. m. goenawan partowidigdo cisarua hospital (rspg) between august 2020 and october 2020. prior to its commencement, the study received ethical approval from the institutional review board in rssa (no. 400/112/k.3/302/2020; april 6th 2020). all dr-tb patients who received bdq as part of the treatment regimen were selected. the inclusion criteria were adult, aged >18 years, who were administered ecg before bdq treatment and at least one ecg afterwards. patients with unreadable ecg reports or incomplete medical records were excluded from the study. the qt intervals before and after the treatment were measured manually then were corrected to the heart rate using the fridericia formula. according to the indonesian technical guideline,7 for cardiac safety monitoring during bdq treatment, ecg should be performed on day 2 (d2), in the first week (w1) and every month until the end of bdq treatment (m1–m6). the primary outcome was the qt interval profile consisted of qtcf, the difference of qtcf after treatment with the baseline (∆qtcf) and the proportion of clinically significant qt prolongation over time during the bdq treatment. the proportion of bdq discontinuation related to adverse cardiac events was also considered as the primary outcome. according to the international harmonisation standard (ich) clinical evaluation of qt/qtc interval prolongation and proarrhytmic potential for nonantiarrhytmic drugs (e14), clinically significant qt prolongation is defined as qtcf >500 ms, ∆qtcf >60 ms, or both.8,9 however, as per who and the indonesian guideline on dr-tb management, the criteria for the discontinuation of qt-prolonging drugs, including bdq, are based on the absolute value of qtcf. the suspected drug should be interrupted for 7 to 14 days until the normal state is restored, if qtcf >500 ms in two measurements within 30-minute intervals and without cardiac symtoms.10,11 this data of discontinuation was obtained from the clinician documentation on medical records. based on formula of the mean difference between two paired groups (before and after), a minimum sample size of 66 subjects is necessary. the analysis of data was performed using spss software version 22. a t-test or wilcoxon test was used to assess the difference in continuous variables, depending on the distribution of data. results due to the ongoing covid-19 pandemic in august to october 2020, there was limited mobility between regions in addition to limited data access to the study site. therefore, it was not possible to carry out data selection as planned. data were collected in a convenient manner, with support from data enumerators at rssa. due to the limited number of dr-tb patients treated with bdq at each site, a small sample population of patients who received bdq during the study period were finally selected. a total of 105 patients met the selection criteria (figure 1). the baseline characteristics of the study subjects are presented in table 1. a total of 405 ecg reports from 105 subjects were analysed. during the six months of bdq treatment, neither arrhythmia nor any other cardiac event occurred. the values of ∆qtcf tend to increase (table 2), and its maximum values were observed after three months of the treatment (m3). the qt interval prolongation >500 ms during the treatment led to the interruption of bdq treatment in 16 of the 105 subjects. in this study, the prolongation of the qt interval was the common cause of the temporary vol 54 • number 3 • july 2022 bedaquiline effect on qt interval of drugs-resistant tuberculosis patients 391 figure 1. enrollment flowchart. table 1. baseline characteristics of the subjects. variables n (%) gender male 61 (58.1) female 44 (41.9) age in years, median (minimum – maximum) 41 (18 – 68) comorbidity, n (%) 38 (36.2) heart disease 1 kidney disease 3 subclinical hyperthyroidism 1 subclinical hypothyroidism 2 dm 31 hypertension 2 asthma 1 category of dr-tb, n (%) mdr 79 (75.2) pre-xdr 18 (17.1) xdr 8 (7.6) number of qt prolonging drugs, n (%) one drug (bdq) 2 (1.9) two drugs lfx/bdq mfx/bdq bdq/cfz 37 (35.2) 20 3 14 *the reason for switching the regiment in 11 patients: • failure of treatment (positive culture after bdq treatment): 1 patient • adverse drug reaction: a. persistence qt prolongation: 7 patients b. inverted t wave with normal qt interval: 1 patient c. renal impairment: 1 patient d. drug reaction with eosinophilia and systemic symptoms (dress syndrome): 1 patient 105 patients were evaluated for ecg analysis i gusti agung ayu putu sri darmayani acta med indones-indones j intern med 392 three drugs lfx/bdq/cfz mfx/bdq/cfz 65 (61.9) 51 14 four drugs lfx/bdq/cfz/dlm 1 (1,0) completing bdq treatment (80 doses) yes 53 (50.5) no 52 (49.5) qtcf baseline in ms, mean (sd) 414.52 (33.74) serum kalium baseline in meq/l*, mean (sd) 4.02 (0.64) dm: diabetes mellitus; dr-tb: drug resistant tuberculosis; mdr: multi-drug resistant, xdr: extensively drug resistant; bdq: bedaquiline; lfx: levofloxacin; mfx: moxifloxacin; cfz: clofazimine; dlm: delamanid; qtcf: qt corrected using fridericia formula; sd: standard deviation. *was obtained from 96 subjects. table 2. qtcf interval profile during bdq treatment. time of monitoring ∆qtcf* ms mean (sd) p value (95%ci) temporary discontinuation of bdq treatment** n/n (%) clinically significant qtcf prolongation n (%) d2 3.55 (37.60) 0.671w 1/36 (2.8) 4/36 (11.1) w1 19.76 (39.69) 0.002 (7.83 – 31.68) 1/45 (2.2) 6/45 (13.3) w2 11.70 (41.67) 0.073 (-1.13 – 24.53) 2/43 (4.6) 5/43 (11.6) m1 27.19 (45.65) <0.001 (15.50 – 38.88) 3/61 (4.9) 10/61 (16.4) m2 23.71 (37.51) <0.001 (13.94 – 33.49) 2/59 (3.4) 10/59 (16.9) m3 34.06 (52.92) <0.001 (19.33 – 48.79) 7/52 (13.5) 13 /52 (25.0) m4 22.52 (47.34) 0.003 (8.29 – 36.74) 8/45 (17.8) m5 21.23 (33.26) 0.002 (8.58 – 33.8) 5/29 (17.2) m6 23.97 (52.82) 0.011 (5.83 – 42.11) 8/35 (22.9) total 16/105 (15.2) 39/105 (37.1) d: day 2; w: week; m: month; ∆qtcf: the difference of qtcf after treatment compared with baseline; sd: standard deviation; ci: confidence interval. * the difference of qtcf after treatment with the baseline **discontinuation related to interval qt prolongation, if qtcf >500 ms9,10 discontinuation of bdq treatment (95.8%). the prolongation of qt the interval was persistent and led to the permanent discontinuation of treatment in seven subjects (6.7%). however, most subjects with a regimen containing bdq are still on treatment (70.4%). in total, there were seven deaths during the study period. discussion in this study, 53 of the 105 subjects had completed bdq treatment for six months (80 doses). however, only three subjects (2.9%) had complete ecg data for each monitoring time. even in developed countries such as the united states, monitoring during bdq treatment is a challenge. in california, only three of 37 patients (8%) had complete ecg data at each point of monitoring.12 recently, some studies have reported on the safety aspects of bdq under programmatic conditions. these studies are from various countries, including salhotra et al.13 in india (2020), gao et al.14 in china (2021), katrak et al.12 (2021) in the united states, and brust et al.15 and isralls et al.16 (2021) in south africa. the baseline characteristics of the subjects of this vol 54 • number 3 • july 2022 bedaquiline effect on qt interval of drugs-resistant tuberculosis patients 393 study are similar to that of the participants of the aforementioned studies where bdq was also used together with other qt-prolonging drugs in the dr-tb treatment regimen and the lengths of the bdq treatment varied between subjects. during the treatment with bdq, clinically significant qtcf prolongation was observed in 37.1% of the subjects. prolongation of qt and subsequent discontinuation of treatment temporarily and permanently by the clinician is in 15.2% and 6.7% subjects, respectively. salhotra et al. reported a lower proportion of clinically significant qtcf prolongation (16.3%) compared to this study. temporary discontinuation of bdq treatment due to qt prolongation in the studies of salhotra et al.13, gao et al.14, guglielmetti et al.17 and katrak et al.12 amounted to 2.9%, 4.2%, 0.77% and 11%, respectively. here, the variability effect of bdq on subjects’ qt interval from study to study is influenced by the subjects’ baseline characteristics, with various risk factors. in this study, 61.9% of the subjects were on three qt-prolonging drugs (including bdq), and 35.2% of the subjects had comorbidities related to qt interval prolongation, such as diabetes, hypertension, heart disease, kidney disease and hypothyroidism. these factors could have contributed to more cases of clinical significance in terms of qtcf prolongation as well as discontinuation of treatment. according to ich e14, the risk of tdp is associated not only with the absolute value of the qtc interval (qtcf > 500 ms) but also with ∆qtcf > 60 ms.8,9 the incidence of ventricular arrhythmia increases by 5 to 7% for every 10 ms increase in qtc value.18 the criteria for the discontinuation of treatment due to the prolongation of the qt interval may vary, depending on the level of risk and tolerance of the patient population, which is specific to the indication of the treatment.8 according to who and the indonesian technical guidelines,10,19 ∆qtcf > 60 ms is an indicator of the need to perform ecg more often and manage other risk factors.11,20 in this study, 38 subjects (36.2%) were detected with qtc > 60 ms. there were no reports of arrhythmia or other cardiovascular events in this group. a total of 24 of the 38 subjects (63.2%) continued the treatment; 17 of them completed the bdq treatment. additionally, 11 of them were also detected to have a qtc value > 500 ms; therefore, bdq treatment in these subjects was temporarily discontinued. finally, two subjects dropped out, and treatment in one subject was changed, as they experienced a failure of the bdq treatment. during bdq treatment, seven subjects (6.7%) died (appendix 1). the cause of death in one subject was not related to bdq (sepsis and respiration failure). for the remaining (6/7; 85.7%), the cause of death could not be assessed, as they died at home, as reported by their families. it is difficult to establish the causal relationship of death with the prolongation of the qtc interval without recording the ecg at the time of the incident and evaluating complete the data before death. however, death in mdrtb patients may occur due to various causes, including the progression of the tb itself, severity of comorbidities, and disease complications.21 the use of cardiac holter monitoring could be an option for recording ecg in real time, although it will be limited by the cost.22 this study contributes to the literature by reporting the cardiac safety of bdq in a systematic and complete manner. the qt interval profile was analysed over time during treatment in order to obtain a complete picture of the cardiac safety of bdq. most ecg machines can automatically calculate qtc intervals. although it may seem practical, this automatic calculation can be inadequate due to inconsistencies in terms of the correction formula and algorithm used between ecg machine manufacturers. in addition, the ecg machine is not able to identify t and u waves when the two waves overlap. the u wave appears in hypokalemic conditions, which often occurs in dr-tb patients. therefore, it is very important to identify these waves manually in order to calculate the qt interval correctly.23 this study has a few limitations. there were no assessments of the effect of genetic factors associated with qt prolongation, qt interval diurnal variation and the effect of the number of risk factors in each subject on qt-interval prolongation. in addition, the power of the study is diminished by the fact i gusti agung ayu putu sri darmayani acta med indones-indones j intern med 394 that the number of subjects in each group at each monitoring was less than the targeted minimum sample size. further cohort studies are required to evaluate the cumulative effect of qt prolongation due to the long elimination half-life of bdq. patients should be followed up with after the end of their treatment. this study could not assess this, as there was no ecg record after bdq use (after six months). furthermore, bdq concentration was not measured. conclusion maximum qt prolongations were observed mostly after three months of bdq therapy. therefore, more intensive cardiac monitoring is recommended during this period and afterwards. acknowledgments we thank the dr-tb team as well as the research and development divisions at rssa and rspg for their assistance during the data collection process. we also express our gratitude to universitas indonesia for funding this study. references 1. world health organization (who). who global tuberculosis report. world health organization; 2021. 2. brigden g, hewison c, varaine f. new developments in the treatment of drug-resistant tuberculosis: clinical utility of bedaquiline and delamanid. infect drug resist. 2015;8:367-78. 3. halleux cm, falzon d, merle c, et al. the world health organization global adsm database: generating evidence on the safety of new treatment regimens for drug-resistant tuberculosis. eur respir j. 2018;51:1-5. 4. cohen k, maartens g. a safety evaluation of bedaquiline for the treatment of multi-drug resistant tuberculosis. expert opin drug saf. 2019;18:875-82. 5. pontali e, sotgiu g, tiberi s, d’ambrosio l, centis r, migliori gb. cardiac safety of bedaquiline: a systematic and critical analysis of the evidence. eur respir j. 2017;50. 6. ema. summary of product characteristics of sirturo (bedaquiline 100 mg tablet); 2014. 7. international conference on harmonisation (ich). the clinical evaluation of qt/qtc interval prolongation and proarrhythmic potential for non-antiarrhythmic drugs (e14). 2005;version 4 (may). 8. international conference on harmonisation (ich). e14 clinical evaluation of qt/qtc interval prolongation and proarrhythmic potential for non antiarrhythmic drugs questions and answers (r3). 2017;(june):1-15. 9. world health organization. companion handbook to the who guidelines for the programmatic management of drug-resistant tuberculosis; 2014. 10. kementerian kesehatan republik indonesia. panduan pelayanan tuberkulosis resistan obat untuk fasilitas pelayanan kesehatan; 2018. 11. pym as, diacon ah, tang sj, et al. bedaquiline in the treatment of multidrugand extensively drug resistant tuberculosis. eur respir j. 2016;47(2):564-74. 12. katrak s, lowenthal p, shen r, true l, henry l, barry p. bedaquiline for multidrug-resistant tuberculosis and qtc prolongation in california. j clin tuberc other mycobact dis. 2021;23:1-6. 13. salhotra vs, sachdeva ks, kshirsagar n, et al. effectiveness and safety of bedaquiline under conditional access program for treatment of drugresistant tuberculosis in india: an interim analysis. indian j tuberc. 2020;67:29-37. 14. gao jt, du j, wu gh, et al. bedaquiline containing regimens in patients with pulmonary multidrug resistant tuberculosis in china: focus on the safety. infect dis poverty. 2021:1-10 15. brust jcm, gandhi nr, wasserman s, et al. effectiveness and cardiac safety of bedaquiline-based therapy for drug-resistant tuberculosis: a prospective cohort study. infect dis soc am. 2020:1-18. 16. isralls s, baisley k, ngam e, grant ad, millard j. qt interval prolongation in people treated with bedaquiline for drug-resistant tuberculosis under programmatic conditions: a retrospective cohort study. open forum infect dis. 2021;8:1-10. 17. guglielmetti l, tiberi s, burman m, et al. qt prolongation and cardiac toxicity of new tuberculosis drugs in europe: a tuberculosis network european trialsgroup (tbnet) study. eur respir j. 2018;52:10-3. 18. lester rm, paglialunga s, johnson ia. qt assessment in early drug development: the long and the short of it. int j mol sci. 2019;20(6). 19. kementrian kesehatan republik indonesia. petunjuk teknis penatalaksanaan tuberkulosis resistan obat di indonesia; 2020. 20. direktorat jenderal pencegahan dan pengendalian penyakit kementerian kesehatan. petunjuk teknis penatalaksanaan tuberkulosis resistan obat di indonesia; 2020. 21. pontali e, sotgiu g, tiberi s, d’ambrosio l, centis r, migliori gb. cardiac safety of bedaquiline: a systematic and critical analysis of the evidence. eur respir j. 2017;50(5). 22. harausz e, cox h, rich m, mitnick cd, zimetbaum p, furin j. qtc prolongation and treatment of multidrug-resistant tuberculosis. int j tuberc lung dis. 2015;19:385-91. 23. dravniece g, edwards c, gebhard a, et al. guide for qtc monitoring and management of drug-resistant tb patients with qt-prolonging agents. 5th ed. kncv tuberculosis foundation usaid; 2018. vol 54 • number 3 • july 2022 bedaquiline effect on qt interval of drugs-resistant tuberculosis patients 395 a pp en di x 1. c lin ic al d at a of s ub je ct s w ho d ie d du ri ng d r -t b t re at m en t w ith r eg im en t c on ta in in g b ed aq ui lin e s ub je ct co de s ex /a ge (i n ye ar ) w ei gh t (k g) c om or bi di ty d r -t b ca te -g or y d r -t b re gi m en t c lin ic al in fo rm at io n p er io d of de at h c au se o f de at h q t in te rv al d ur in g th er ap y s up po rti ng d at a 05 m al e/ 59 59 d m o n in su lin p re -x d r lf x/ b dq / c fz /h /z /e / b 6 d is co nt in ue d of b d q in m 4 du e to de cr ea si ng li ve r f un ct io n (s g o t/ s g p t 77 5/ 33 7) m 5 u nk no w n q tc f (m s) : m 2: 4 54 ,5 7 m 3: 4 46 ,2 9 m 4: 4 70 ,9 1 ∆q tc f (m s) : m 2: -2 9, 98 m 3: -3 8, 56 m 4: -1 3, 94 s er um k al iu m (m e q/ l) : m 2: 3 ,2 m 3: 3 ,6 eg fr : m 3: 8 3 m l/m in 09 fe m al e/ 36 56 d m o n in su lin x d r lf x/ b dq / ln z/ c s/ e to /h /z /e / b 6 h ad re ce iv ed fu ll do se (8 0 do se s) m 7 r es pi ra to ry fa ilu re an d se ps is q tc f (m s) : w 1: 4 31 ,2 7 w 2: 4 22 ,8 1 m 1: 4 64 ,1 6 m 3: 4 47 ,6 8 m 5: 4 66 ,6 4 m 6: 4 21 ,4 7 ∆q tc f (m s) : w 1: -3 9, 64 w 2: -4 8, 10 m 1: -6 ,7 5 m 3: -2 3, 23 m 5: -4 ,2 7 m 6: 49 ,4 4 s er um k al iu m (m e q/ l) : m 1: 4 ,0 m 3: 4 ,0 m 5: 3 ,9 m 6: 3 ,5 eg fr : 1 19 m l/ m in 23 fe m al e/ 25 42 m d r lf x/ b dq / ln z/ c fz / c s/ b 6 o n da y 5, l nz w as s w itc h to e d ue to an em ia . h ow ev er , b d q w as c on tin ue d. tr ea tm en t d ur at io n: 2 5 da ys d 25 u nk no w n o n d 2: q tc f: 43 4, 24 m s ∆q tc f: 5 0, 2 m s n o su bs eq ue nt e c g d at a. o n da y 5, th e h b su bj ec t w as 6, 6 m g/ dl 25 m al e/ 28 48 p re -x d r b dq /l nz / c fz /e to /e / b 6 to ta l t re at m en t d ur at io n: 1 5 w ee ks m 4 u nk no w n q tc f (m s) : m 1: 4 03 ,1 1 m 2: 4 28 ,3 4 ∆q tc f (m s) : m 1: 0 ,0 0 m 2: 2 5, 23 n o su bs eq ue nt e c g d at a. s er um k al iu m : m 1: 3 ,5 m 2: 3 ,4 eg fr : m 2: 8 1, 8 m l/ m in i gusti agung ayu putu sri darmayani acta med indones-indones j intern med 396 a pp en di x 1. c lin ic al d at a of s ub je ct s w ho d ie d du ri ng d r -t b t re at m en t w ith r eg im en t c on ta in in g b ed aq ui lin e s ub je ct co de s ex /a ge (i n ye ar ) w ei gh t (k g) c om or bi di ty d r -t b ca te -g or y d r -t b re gi m en t c lin ic al in fo rm at io n p er io d of de at h c au se o f de at h q t in te rv al d ur in g th er ap y s up po rti ng d at a 27 m al e/ 67 52 m d r lf x/ b dq / c fz /e to /h / z/ e d is co nt in ua tio n fo r 1 w ee k on d ay 4 o f th er ap y du e to p ro lo ng at io n of th e q t in te rv al . t he b d q th en w as c on tin ue d, c fz w as re pl ac ed w ith c s. o n m 2, s ub je ct e xp er ie nc in g hy po ka le m ia , b ut th e q t in te rv al is n ot pr ol on ge d. a t t ha t t im e, th e hy po ka le m ia w as c or re ct ed . 2 w ee ks af te r t he la st v is it fo r m on ito rin g on m 2. u nk no w n o n m 2: q tc f: 4 46 m s ∆q tc f: 2 8, 26 n o su bs eq ue nt e c g d at a. s er um k al iu m (m e q/ l) : m 2: 2 ,7 4 eg fr : m 2: 66 m l/m in 83 fe m al e/ 22 30 m d r lf x/ b dq / c fz /c s/ d lm d is co nt in ua tio n fo r 1 w ee k on m 1 an d m 4 du e to q t in te rv al p ro lo ng at io n an d ex tre m e ta ch yc ar di a (1 30 b ea ts p er m in ut e) . o n m 5, b d q w as d is co nt in ue d. m 7 u nk no w n q tc f (m s) : w 2: 3 95 ,4 2 m 1: 5 05 ,3 6 m 2: 4 36 ,7 6 m 4: 4 00 ,3 6 ∆q tc f (m s) : w 2: 1 9, 93 m 1: 6 1, 27 m 2: 2 9, 89 m 4: 24 ,8 7 n o su bs eq ue nt e c g d at a. s er um k al iu m (m e q/ l) : m 1: 4 ,4 m 2: 5 ,2 m 4: 4 ,3 eg fr : m 6: 9 8 m l/m in 93 fe m al e/ 33 33 m d r lf x/ b dq / c fz /c s/ e to p at ie nt s w ith a h is to ry o f h yd ro pn eu m ot ho ra x pr io r t re at m en t. o n m 2, th e su bj ec t w as e xp er ie nc in g an a sy m to m at ic p ro lo ng at io n of th e q t in te rv al (q tc b 5 82 m s) a nd t in ve rs io n in v 2 – v 5. b d q tr ea tm en t w as d is co nt in ue d, b ut th e pa tie nt d id no t c om e fo r c on tro l a w ee k af te r t he di sc on tin ua tio n. m 3 u nk no w n o n m 2: q tc f: 4 36 ,7 6 m s ∆q tc f: 8 3, 98 m s n o su bs eq ue nt e c g d at a. () d : d ay 2 ; w : w ee k; m : m on th ; d m : d ia be te s m el lit us ; d r -t b : d ru g r es is ta nt t ub er cu lo si s; m d r : m ul tid ru g re si st an t, x d r : e xt en si ve ly d ru g r es is ta nt ; b d q : b ed aq ui lin e; b 6: p yr id ox in e; lf x: le vo flo xa ci n; m fx : m ox ifl ox ac in ; c fz : c lo fa zi m in e; c s: c yc lo se rin e; d lm : d el am an id ; e to : e th io na m id e; e : e th am bu to l; h : i so ni az id ; z : p yr az in am id e; q tc b : i nt er va l q t co rr ec tio n us in g b az et t’s fo rm ul a; q tc f: in te rv al q t co rr ec tio n us in g fr id er ic ia ’s fo rm ul a; ∆ q tc f: th e di ffe re nc e of q tc f af te r t re at m en t c om pa re d w ith b as el in e; m s: m ill i s ec on d; m l/m in : m ill ili tre /m in ut e; eg fr : e st im at io n of g lo m er ul ar f ilt ra tio n r at e; m e q : m ill i e qu iv al en t. 585acta med indones indones j intern med • vol 54 • number 4 • october 2022 original article long-term use of omeprazole: effect on haematological and biochemical parameters hadeel s. al ali1*, azza sajid jabbar2, nadheerah f. neamah2, nawal khalil ibrahim3 1 department of physiology, al-zahraa college of medicine, university of basrah, basrah, iraq. 2 department of pharmacology and toxicology, college of pharmacy, university of basrah, basrah, iraq. 3 department of physiology, college of medicine, university of basrah, basrah, iraq. * corresponding author: hadeel s. al ali, md. department of physiology, al-zahraa college of medicine, university of basrah, basrah, iraq. email: hadeelsalman@uobasrah.edu.iq. abstract background: long-term use of proton pump inhibitors (ppis) is believed to have various potential adverse events. omeprazole is a part of ppis most commonly prescribed worldwide; it irreversibly binds to h+-k+ atpase enzyme system in the gastric parietal cells to reduce secretion of h+ ions into the lumen of stomach. the main objective of the current work is to assess the adverse effects of omeprazole medication on certain haematological and biochemical parameters in patients who were on treatment for one year and more. methods: we conducted a comparative cross-sectional study between october 2021 and march 2022. a total of 90 participants of both sexes were enrolled in this study, aged between 25-58 years. the participants were categorized into two groups: 40 patients on long-term omeprazole medication (40 mg) as a patients group and 50 healthy subjects as a healthy group who did not use omeprazole. complete blood count and biochemical parameters were measured for both groups. results: patients of a group 1 had remarkable significant reductions in the number of red blood cells (rbcs) (p<0.001) and the indices. omeprazole elevated the cholesterol level (p<0.001) and triglyceride (p<0.001) as well as low-density lipoprotein (p<0.01). however, no impact was found with high-density lipoprotein (hdl) (p>0.05). alkaline phosphatase (alkp) (p<0.001) and aspartate aminotransferase (asat) (p<0.01) levels were elevated in long-term patients treated with omeprazole. in contrast, no significant change was found in the level of alanine aminotransferase (alat) (p>0.05). creatinine level (p<0.001) and nitrogen blood urea (p<0.0001) were significantly increased in patients group treated with omeprazole medication. the results also showed that group 1 had a high significant decline in serum ferritin (p<0.0001), vitamin d3 (p<0.01) and calcium levels (p<0.001) than that of healthy group. conclusion: prolonged use of omeprazole might result in adverse effect on hematological profile, particularly rbcs and their indices leading to develop anemia in patients on this medication. furthermore, it might result in disturbances in biochemical profile, levels of minerals and vitamins as consequences of affected absorption. keywords: omeprazole, blood count, hypocalcemia, vitamin d, kidney function, cholesterol, triglyceride. hadeel s. al ali acta med indones-indones j intern med 586 introduction omeprazole is a member of substituted benzimidazoles class, that inhibits protons pump of the gastric parietal cells.1 it inhibits gastric secretion by inhibiting the enzyme h+k+ atpase that is responsible for gastric acid production.2 omeprazole is used to manage and treat several conditions where the gastric acid inhibition can be very beneficial, including gastric ulcers, peptic ulcer, gastroesophageal reflux disease, erosive esophagitis, zollingerellison syndrome. it is superior to conventional therapies as well as it is used as over the counter drug in uncomplicated heartburn.3 side effects are rare when the drug is taken short-term. the probable common side effects include headaches, vomiting or diarrhea stomach upset, and constipation. while the serious side effects are very rare, they include liver problems, joints pain due to subacute cutaneous lupus erythematosus due to long term use and allergic reaction. other signs of long-term use may include a decrease in the levels of magnesium in the blood after taking omeprazole for more than 3 months. taking omeprazole for more than a year may increase the chances to develop other side effects such as bone fractures, gastrointestinal infections and vitamin b12 deficiency.4 furthermore, it has been found that long-term proton pump inhibitors (ppis) treatment may affect haematological indices.5 the change in gastric acidity may also affect the intestinal absorptive ability of microelement nutrients in a way that could result in iron deficiency and a decrease in the concentration of zinc, selenium and copper. impact of proton pump inhibitors on these important trace elements may reduce their antioxidant activity in the body. however, a previous study has indicated the necessity for further studies about the role of ppi in reducing certain body parameters. the common therapeutic uses of omeprazole for a wide spectrum of gastric-related health problems, being an over the counter treatment and the development of certain negative health indicators in the patients who were on long-term treatment, is the rationale for the objective of the current work, which is to elucidate the adverse influences of omeprazole medication on certain haematological and biochemical findings in patients who were on treatment for one year and more. methods study population and plan of work a comparative cross-sectional study was conducted between october 2021 and march 2022 in basrah city, iraq. a total of 90 participants of both sexes aged between 25-58 years were involved in the study. they were categorized into two groups: 40 patients on long-term omeprazole medication (40 mg), as patients group 1 and 50 individuals as healthy group who were healthy and did not take any medications, including omeprazole. patients were received and interviewed in an outpatient clinic and selected according to certain criteria. the omeprazole duration medication was one year and more. the study design was reviewed and approved by the ethics committee of the al-zahraa college of medicine, university of basrah, iraq. the aim of the research was explained for all participants before enrolling in the study and written consents were obtained. the work complied with the declaration of helsinki ethical principles. initially required information of all participants were obtained using a questionnaire form. collection of samples 5 ml of venous blood were drawn from each participant enrolled in this study, 2 ml of blood was collected in anticoagulated test tube with ethylenediaminetetraacetic acid (edta). the rest of blood sample was collected immediately in a gel plain tube in order to prepare serum for performing further tests. haematological and biochemical profiles were performed in a private laboratory. clinical biochemical analyzes clinical biochemical tests were done including lipid profile, alkaline phosphatase (alkp), alanine aminotransferase (alat), aspartate aminotransferase (asat), total bilirubin (tbil), direct (dbil) and indirect bilirubin (idbil) as well as urea and creatinine. serum samples were analysed by fully automated chemistry analyser smart 150 (gento tek, usa). vol 54 • number 4 • october 2022 long-term use of omeprazole: effect on haematological 587 determination of vitamin d3 levels sera from total patients and healthy c o n t r o l s u b j e c t s w e r e i n v e s t i g a t e d t o m e a s u r e l e v e l s o f s e r u m c i r c u l a t i n g 25-hydroxycholecalciferol(25[oh]d) using mini vidas (biomerieux, france). quantitative measurement of ferritin ferritin level was estimated for all participants by an enzyme-linked immunosorbent serologic assay (elisa) in accordance with instructions provided by the manufacturer (pointe scientific inc, usa). serum calcium assay the serum levels of total calcium were measured for both groups using high resolution inductively coupled plasma mass spectrometry icp-ms (element 2, thermo scientific, germany). normal range of serum calcium levels in adult is 8.5-10.5 mg/dl. complete blood count (cbc) test haematological indices were measured using 2 ml anti-coagulated blood, including red blood cells (rbcs) count, haemoglobin (hgb) concentration (g/dl), mean cell volume (mcv), mean cell haemoglobin (mch), mean cell haemoglobin concentration (mchc), total count and differential count (neutrophils, monocytes and lymphocytes) of white blood cells, platelets (plts) count and mean platelet volume (mpv). blood sample was immediately analysed after collection by emerald haematology system (abbott, usa). statistical analyzes collected data were inputted in an excel spreadsheet for all participants. then, differences between the two groups were assessed using an unpaired t-test. this comparison was carried out through graphpad software (version 8, software inc, united states). p-values (<0.05) were used to indicate statistical significance. all values in the tables are presented as mean±sd. results analysis of data to compare between the two groups of the study patients on long-term omeprazole and healthy group revealed several variations in haematological indices, despite no significant variation in mean age, gender percentage, body mass index (bmi) and healthy status as clarified in table 1. statistical analyses have found no variations (p>0.05) in wbc count (7.86±2.67 vs. 8.96±2.79 ×10 9/l), neutrophils % (57.04±12.84 vs. 52.53±13.61), monocytes % (9.11±1.76 vs. 8.83±2.34) and lymphocytes % (33.39±11.57 vs. 37.23±12.08) between patients group and healthy group, as illustrated in table 2. on the other hand, significant reductions were seen in red blood cell count (4.15±0.76 vs. 4.55±0.92 ×1012/l; p<0.001); hgb concentration (10.13±1.95 vs. 12.38±1.72 g/dl, p<0.001); mcv (78.71±10.29 vs. 85.83±12.75 fl, p<0.01); mch (24.39±2.80 vs. 27.32±2.48 pg, p<0.001); and mchc (30.79±2.90 vs. 31.98±1.70 g/dl, p<0.05) in patients group compared to healthy table 1. general characteristics of the studied groups. parameters patients group (n = 40) healthy group (n = 50) p-value females% 17 (42.5%) 22 (44%) ns males% 23 (57.5%) 28 (56%) age (years) (26-58) (25-55) (mean ± sd) 42.05±9.57 40.75±8.03 ns weight (kg) 88.14±2.07 85.71±2.03 ns bmi (kg/m2) 31.25±5.91 29.62±6.55 ns comorbidities diabetes mellitus n/a hypertension n/a hyperlipidemia n/a other diseases n/a *significance at level <0.05. ns: non-significant differences. hadeel s. al ali acta med indones-indones j intern med 588 group. the t-test also did not show any significant changes (p>0.05) in platelets count and mpv values between patients group and healthy group (304.40±70.74 vs. 272.90±83.67 ×109/l; 9.27±1.30 vs. 8.98±1.27 fl, respectively). regarding biochemical parameters, it has been found that the long-term use could exert a variation in certain parameters. in serum cholesterol levels, we found a significant elevation (p<0.001) in the levels of total cholesterol in patients group (225.45±23.48 mg/dl) in comparison to healthy group (182.69±39.15 mg/dl), alongside significant elevation (p<0.001) of triglyceride levels in patients group (215.46±35.98 mg/dl) compared to healthy group (158.81±48.16 mg/ dl). analysis of lipoprotein parameters such as direct low-density lipoprotein (dldl) and very low-density lipoprotein (vldl) showed significant increases (p<0.01) in patients group (152.60±34.82; 47.96±14.73 mg/dl), compared to healthy group (120.92±24.46; 33.20±8.62 mg/dl). however, there were no significant differences (p>0.05) between the two groups in high-density lipoprotein (hdl), as seen in table 3. table 2. comparison of haematological parameters between patients group and healthy group. parameters patients group (n = 40) healthy group (n = 50) p-value wbcs (×109/l) 7.86±2.67 8.96±2.79 ns neutrophils (%) 57.04±12.84 52.53±13.61 ns monocytes (%) 9.11±1.76 8.83±2.34 ns lymphocytes (%) 33.39±11.57 37.23±12.08 ns rbcs (×1012/l) 4.15±0.76 4.55±0.92 <0.001* hgb (g/dl) 10.13±1.95 12.38±1.72 <0.001* mcv (fl) 78.71±10.29 85.83±12.75 <0.01* mch (pg) 24.39±2.80 27.32±2.48 <0.001* mchc (g/dl) 30.79±2.90 31.98±1.70 <0.05* plts (×109/l) 304.40±70.74 272.90±83.67 ns mpv (fl) 9.27±1.30 8.98±1.27 ns *significance at level <0.05. data are presented as mean±sd. ns: non-significant differences. table 3. comparison of biochemical parameters between patients group and healthy group. parameters patients group (n = 40) healthy group (n = 50) p-value cholesterol (mg/dl) 225.45±23.48 182.69±39.15 <0.001* triglyceride (mg/dl) 215.46±35.98 158.81±48.16 <0.001* hdl (mg/dl) 46.10±14.73 50.57±19.05 ns dldl (mg/dl) 152.60±34.82 120.92±24.46 <0.01* vldl (mg/dl) 47.96±14.73 33.20±8.62 <0.01* alkp (u/l) 87.23±8.37 72.47±15.89 <0.001* alat (u/l) 27.62±14.76 23.54±26.87 ns asat (u/l) 23.32±4.74 14.73±6.29 <0.01* ferritin (mg/dl) 18.19±16.19 69.85±53.70 <0.0001* creatinine (mg/dl) 1.39±0.45 0.78±0.25 <0.001* urea (mg/dl) 45.75±14.22 26.27±14.77 <0.0001* vitamin d3 (ng/ml) 17.30±11.14 25.02±13.47 <0.01* s. calcium (mg/dl) 7.81±0.86 9.30±1.78 <0.001* tbil (mg/dl) 1.23±1.17 0.89±0.32 ns dbil (mg/dl) 0.35±1.00 0.26±0.83 ns idbil (mg/dl) 0.47±0.23 0.45±1.62 ns *significance at level <0.05. data are presented as mean±sd. hdl: high-density lipoprotein; dldl: direct low-density lipoprotein; vldl, very low-density lipoprotein; s. calcium: serum calcium; ns: non-significant differences. vol 54 • number 4 • october 2022 long-term use of omeprazole: effect on haematological 589 indicators of liver functions were also compared between the groups (table 3). significant increases in alkp (p<0.001) and asat (p<0.01) levels were detected in patients group (87.23±8.37; 23.32±4.74 u/l) compared to healthy group (72.47±15.89, 14.73±6.29 u/l). whereas, no significant change (p>0.05) in alat level (u/l) was found. renal function parameters were compared between patient and healthy groups. as shown in table 3, creatinine level was significantly increased (p<0.001) in patients group (1.39±0.45 mg/dl) in comparison to healthy group (0.78±0.25 mg/dl). likewise, significant differences (p<0.0001) were observed in levels of blood urea between patients group (45.75±14.22 mg/dl) and healthy group (26.27±14.77 mg/dl). moreover, patients group had significantly lower (p<0.0001) serum levels of ferritin (18.19±16.19 mg/dl) than healthy group ( 6 9 . 8 5 ± 5 3 . 7 0 m g / d l ) . s e r u m c a l c i u m concentration in long-term patients group (7.81±0.86 mg/dl) was lower (p<0.001) than healthy group (9.30±1.78 mg/dl). similarly, a significant decline in the levels of vitamin d3 (p<0.01) was found in patients group (17.30±11.14 ng/ml) compared to healthy group (25.02±13.47 ng/ml) as illustrated in table 3. no significant changes were noticed between the groups in the levels of tbil, dbil and idbil (1.23±1.17 vs. 0.89±0.32 mg/dl, p>0.05; 0.35±1.00 vs. 0.26±0.83 mg/dl, p>0.05; 0.47±0.23 vs. 0.45±1.62 mg/dl, p>0.05, respectively) (table 3). discussion over recent years, the focusing on the adverse effects of using ppi medications for long-term therapy has gained increasing concerns. omeprazole is commonly used for treating multiple acid-dependent gastrointestinal disorders. the present study was planned to detect the adverse effects of prolonged use of omeprazole on haematological and biochemical parameters. the result of this study demonstrated that omeprazole might interfere with the blood profile in patients with long-term treatment. in order to reveal if long term omeprazole use may exert an adverse effect on hematological indices or not, blood test was performed for 40 outpatients who were on omeprazole medication and visited a private clinic. we found that the means of rbcs and hgb in these patients as well as other rbc indices were significantly lower than those in healthy group. these findings are similar to what were reported by previous studies.6,7 a retrospective cohort study has examined the impact of ppis use on haematological indices among individual patients who received ppi medications for over 1 year. the study revealed a significant reduction in values of haemoglobin, haematocrit and mean corpuscular volume and suggested that the chronic use of ppis may cause iron mineral deficiency, long-term therapy may reduce absorption of non-heme iron.8 another study conducted in a group of patients using ppi medications for long-term period, kaczmarczyk et al. showed that using of ppis might cause a reduction in the number of rbcs and levels of hgb and some serum micronutrients. this suggested that prolonged use of ppis might give rise to iron deficiency anemia.7 iron absorption usually occurs in the proximal small intestine, and this process is facilitated by gastric acid secretion which is necessary to convert the iron mineral from ferric state to ferrous state.9 two biological mechanisms have been put forward that chronic use of ppis causes anemia. one of these mechanisms is the suppression of absorption of iron in the small intestine is due to inhibition of h+-k+ atpase and increase the ph of stomach.10 the another mechanism contributes in the development of anemia is the suppression of absorption of vitamin b12, food-bound vitamin b12 is liberated in the acidic medium and is bound to the glycoprotein haptocorrin for readily absorption in the ileum.11 proton pump inhibiters are powerful agents that inhibit production of gastric acid, a reduction in gastric acid production as a result of ppis use may influence the absorption of minerals and vitamins in the gastrointestinal tract. a consequence of iron and vitamin b12 deficiency is anemia.6 means of mcv, mch and mchc were low in patients group in compare to healthy group. it is likely that these patients developed iron deficiency anemia because omeprazole may suppress secretion of gastric acid and thence hadeel s. al ali acta med indones-indones j intern med 590 inhibit absorption of iron minerals. numbers of white blood cells in patients group were not significantly affected by chronic use of omeprazole medication in comparison to healthy group. omeprazole medication demonstrated a non-significant reduction in the number of wbc. although, this result differed from some published studies,7,12 it was consistent with those of other studies.13,14 we also found no statistical variation between the groups in the numbers of platelets. our results did not show any reduction in the numbers of the platelets due to use of omeprazole. literature data regarding the influence of ppis on platelet numbers are conflicting. the present findings seem to be consistent with other researches which found no differences in the numbers of platelets between ppis user and control group as well as having platelet counts which were within normal range in ppis user.7,13 on the other hand, only one case report has described the role of omeprazole medication in inducing thrombocytopenia.15 a few number of studies over the past two decades have demonstrated thrombocytopenia with various types of ppis therapy.6,16,17 suppression of gastric acid secretion is linked with alterations in the digestion process of dietary lipids. it has been demonstrated that using omeprazole result in increased lipid absorption. process of lipid absorption is associated with the underlying mechanism gastric acidity suppression resulting from using omeprazole, thereby increasing the lipolytic activities of gastric juices that lead to increased absorption of lipid in the small intestine.18 proton pump inhibitors might be involved in metabolism of cholesterol.19,20 this fact may explain the findings of the current study, cholesterol level is significantly increased in patients with longterm use of omeprazole medication compared to healthy group, alongside significant elevation in triglyceride plasma level and ldl in patients group. these results are consistent with what were reported by other researches.21-24 plasma concentration of minerals must be maintained within stable range, so that cellular metabolism processes can work properly. our results showed that plasma concentration of calcium decreased in patients with longterm treatment of omeprazole. this finding is consistent with reduction in intestinal calcium absorption.25-27 acidic environment is necessary for absorption of intestinal calcium mineral, as this process is inhibited by omeprazole intake via blocking the gastric h+-k+ atpase enzyme system that is located in the apical membrane of stomach parietal cells, which cause achlorhydia. maintenance low gastric acid reduces lipolysis which is essential for calcium absorption in the gastrointestinal region and hence reduced absorption of calcium mineral in the gut causing hypocalcemia. additionally, dietary protein increases the intestinal calcium solubility and absorption efficiency.28,29 hypocalcemia possibly mediates cardiovascular adverse events of omeprazole. it has been shown that hypocalcemia was observed in patients with long-term treatment of ppi.30,31 it may cause life-threating arrhythmias and heart failure. hypocalcemia is usually accompanied with hypomagnesemia and both these mineral abnormalities can give rise to cardiovascular instability.32,33 measurement of liver function biomarkers revealed a marked raised in serum asat and alkp levels in patients group compared to healthy group, with no significant changes in alat and bilirubin levels, visible in table 3. aminotransferases and alkaline phosphatase are enzymes that exist primarily in the hepatic parenchymal cell. increased levels of these enzymes in the bloodstream are indicators of tissue damage of the liver.34 a case study illustrated that liver clinical markers including serum level of asat, alat and γ-glutamyl transferase of old age patient suffering from gastroesophageal reflux disease receiving omeprazole (20 mg) and ranitidine were increased. however, levels of these enzymes were decreased and returned to normal values after cessation of omeprazole and replaced by herbal products as well as regulation of diet.35 recently, effect of ppis treatment on possible complication and prognosis in liver cirrhosis patient without acute-on chronic liver failure has been investigated. each of asat and alat significantly decreased in patients with liver cirrhosis in comparison to the group who did not receive ppis. also, there was no significant vol 54 • number 4 • october 2022 long-term use of omeprazole: effect on haematological 591 change in bilirubin level between these two groups.14 although, there were significant changes in the levels of asat and alkp between patients group and healthy group, these changes in the concentrations of these enzymes were within normal limits. in the current study, significant elevations in serum creatinine and blood urea concentrations in patients group were observed in comparison to the healthy group. similar findings were observed in previous researches as well. deterioration of kidney function tests was demonstrated in users of ppis compared to nonusers with marked elevation of serum creatinine and blood urea levels.36,37 decreased serum creatinine clearance is not associated with h2-receptor blockers and other ppi nonusers.37 despite of the results, these clinical markers are not optimal for detecting kidney diseases, as they are often used to find out whether patients have developed kidney diseases or not. reduction of glomerular filtration rate leads to accumulation of nitrogen waste products in circulation, evidenced by abnormal increase in serum creatinine and blood urea levels.38 the precise mechanisms between ppis and adverse kidney outcomes are unclear.37 our results contradict those of mélo and colleagues which found that level of serum creatinine did not change, while blood urea level was decreased in group treated with omeprazole compared with control group.21 omeprazole may be associated with development of kidney diseases by increasing levels of serum creatinine and blood urea. we found a significant decline in vitamin d3 in patients group compared to the healthy group. interestingly, this result is the first finding demonstrating the role of long term omeprazole use in causing vitamin d deficiency. it is well known that vitamin d plays a significant role in homeostasis of calcium through regulating calcium absorption from the gastrointestinal tract, therefore, it maintains serum level of calcium within normal range.39 it has been found that vitamin d insufficiency could contribute to the development of secondary hyperparathyroidism, osteoporosis, and in elderly, reduced muscle strength. this category of people is more likely to be at risk of bone fracture due to reduced mineral density.40 although, the main mechanism underlying the relation between long-term use of ppis and increased of bone fracture risk is still unclear, several studies have focused on two possible mechanisms. one of these mechanisms focuses on serum calcium homeostasis. calcium ion is insoluble in an alkaline environment. acidic ph is mandatory for dissolution of calcium salts to be absorbable in the small intestine.41 blockage of h+-k+ atpase by ppis renders the stomach parietal cells incapable to secrete gastric acid thereby increasing risk of bone fractures.42 moreover, hypergasterinemia induced by ppis can give rise to hyperparathyroidism, and consequently, increased rate of bone resorption.43,44 the other possible mechanism of clinical fracture induced by using ppis focuses on the cells of the bone, particularly the osteoclasts.45 ppis directly affect metabolism of bone via inhibition of vacuolar h+-atpase, specific proton pumps that are located on the cell membrane of osteoclasts.46 these pumps are responsible to create acidic environment for bone resorption. bone matrix resorption occurs at the convoluted ruffled border membrane of osteoclasts by lowering the ph.47 it has been indicated by a previous clinical article about the necessity of calcium and vitamin d intake by elderly who were treated with longterm ppis, especially with high-doses.48 we also found a significant reduction in the levels of serum ferritin in patients group treated with omeprazole medication in comparison to healthy group. this finding is matched with those observed in earlier studies. in an open label prospective study on 250 adult participants, administration of ppis (omeprazole, esomeprazole, lansoprazole or pantoprazole) for one year resulted in significant reduction in iron body stores (levels of ferritin).49 on the other hand, in an early study, it was reported that serum ferritin levels were decreased in 3 of 34 patients with esophageal reflux due to use of omeprazole medication continuously over a long-term period. the study suggests that ferritin shortage seldom occurs, even when using of ppis for long-term period.50 the results may indicate that decreased absorption of iron in the gastrointestinal tract is due to use omeprazole medication, therefore, it hadeel s. al ali acta med indones-indones j intern med 592 may reduce levels of serum ferritin and storage of iron as ferritin in the body tissues. low levels of serum ferritin may be clinically indicative of iron deficiency anemia. although the study has successfully demonstrated the impact of long-term use of omeprazole on blood parameters, it has certain limitations in terms of lack of information particularly the relation between ppis use and vitamin d. another limitation is the relatively small number of the enrolled patients. additionally, levels of serum iron were not investigated, a biomarker of iron deficiency which might have also confirm the results of the current study beside measurement of serum ferritin levels. conclusion in this study, the objective was to assess the effect of long term omeprazole medication on blood parameters. omeprazole is very effective in controling gastric acid secretion. accumulating data suggest that long-term use of omeprazole may lead to a reduction in the numbers of circulating rbcs and their indices, ultimately leading to anemia. we have demonstrated for the first time that long-term use of omeprazole causes vitamin d deficiency. low level of vitamin d is due to inhibited production of gastric acid which is necessary for calcium mineral absorption, consequently resulting in hypocalcemia. both hypocalcemia and hypomagnesemia may affect the cardiovascular system, therefore, levels of serum magnesium should also be measured to evaluate any abnormality in the serum mineral levels and their relation with cardiovascular health. omeprazole may be associated with development of kidney functional disorders, therefore, physicians should be cautious when prescribing ppis because of their adverse effects. a further study with higher number of enrolled patients could assess the various long-term adverse effects of omeprazole medication on the organ systems by performing comprehensive blood and biochemical tests. conflicts of interest the authors declare no conflicts of interest in this work. references 1. shin jm, sachs g. pharmacology of proton pump inhibitors. curr gastroenterol rep. 2008;10(6):528-34. 2. shin jm, munson k, vagin o, sachs g. the gastric hk-atpase: structure, function, and inhibition. pflügers archiv-european j physiol. 2009;457(3):60922. 3. kinoshita y, ishimura n, ishihara s. advantages and disadvantages of long-term proton pump inhibitor use. j neurogastroenterol motility. 2018;24(2):182. 4. galdo ja. long-term consequences of chronic proton pump inhibitor use. us pharm. 2013;38(12):38-42. 5. sharma n, chau wy, dobruskin l. effect of long-term proton pump inhibitor therapy on hemoglobin and serum iron levels after sleeve gastrectomy. surgery for obesity related diseases. 2019;15(10):1682-9. 6. shikata t, sasaki n, ueda m, et al. use of proton pump inhibitors is associated with anemia in cardiovascular outpatients. circulation. 2014:cj-14-0582. 7. 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overprescription of proton pump inhibitors and their relation with recurrent community aquired infections in outpatient refilled prescriptions of chronic diseases patients. eur sci j. 2016;12(6). 13. ribeiro rht, ribeiro fa, silva rpm, bortolini mjs, garrote-filho mds, penha-silva n. depression, hematologic parameters, and blood levels of vitamin b12 in patients with laryngopharyngeal reflux under use of proton pump inhibitors. clin med insights: ear, nose and throat. 2019;12:1-7. vol 54 • number 4 • october 2022 long-term use of omeprazole: effect on haematological 593 14. sun s, ye w, zhao r, et al. proton pump inhibitor therapy does not affect prognosis of cirrhosis patients with acute decompensation and acute-on-chronic liver failure: a single-center prospective study. frontiers in medicine. 2021;8. 15. mukherjee s, jana t, pan j-j. adverse effects of proton pump inhibitors on platelet count: a case report and review of the literature. case reports gastrointestinal medicine. 2018;2018. 16. dotan e, katz r, bratcher j, et al. the prevalence of pantoprazole associated thrombocytopenia in a community hospital. expert opinion on pharmacotherapy. 2007;8(13):2025-8. 17. binnetoğlu e, akbal e, şen h, et al. pantoprazoleinduced thrombocytopenia in patients with upper gastrointestinal bleeding. platelets. 2015;26(1):10-2. 18. bijvelds mj, bronsveld i, havinga r, sinaasappel m, de jonge hr, verkade hj. fat absorption in cystic fibrosis mice is impeded by defective lipolysis and post-lipolytic events. am j physiol-gastrointestinal liver physiol. 2005;288(4):g646-g653. 19. namazi m, sharifian m. the potential anti‐xanthoma and anti‐atherosclerotic effects of proton pump inhibitors. clin pharm ther. 2008;33(6):579-80. 20. cronican aa, fitz nf, pham t, et al. proton pump inhibitor lansoprazole is a nuclear liver x receptor agonist. biochemical pharmacology. 2010;79(9):13106. 21. mélo skm, santiago ta, de lima duarte t, et al. a proton-pump inhibitor modifies the concentration of digestion biomarkers in healthy horses. j equine veterinary science. 2014;34(11-12):1318-23. 22. aamir k, arain aa, tunio ag, rasheed k, soomro ua, memon ra. do ppis affect serum lipids? a pilot study in rabbit model. indo am j pharm sci. 2019;6(2):3060-3. 23. abdullah e, dhiaa s, saleh k, merkhan m. effect of esomeprazole on lipid profile in patients with peptic ulcer. pharmacia. 2021;68:613. 24. wakabayashi t, hosohata k, oyama s, et al. association between a low dose of proton pump inhibitors and kidney function decline in elderly hypertensive patients: a retrospective observational study. j int med res. 2021;49(4):1-8. 25. hardy p, sechet a, hottelart c, et al. inhibition of gastric secretion by omeprazole and efficiency of calcium carbonate on the control of hyperphosphatemia in patients on chronic hemodialysis. artificial organs. 1998;22(7):569-73. 26. graziani g, badalamenti s, como g, et al. calcium and phosphate plasma levels in dialysis patients after dietary ca-p overload. nephron. 2002;91(3):474-9. 27. o’connell mb, madden dm, murray am, heaney rp, kerzner lj. effects of proton pump inhibitors on calcium carbonate absorption in women: a randomized crossover trial. am j med. 2005;118(7):778-81. 28. liamis g, milionis hj, elisaf m. a review of druginduced hypocalcemia. j bone mineral metabolism. 2009;27(6):635-42. 29. milman s, epstein ej. proton pump inhibitori n d u c e d h y p o c a l c e m i c s e i z u r e i n a p a t i e n t with hypoparathyroidism. endocrine practice. 2011;17(1):104-7. 30. p e r a z e l l a m a . p r o t o n p u m p i n h i b i t o r s a n d hypomagnesemia: a rare but serious complication. kidney int. 2013;83(4):553-6. 31. toh jwt, ong e, wilson r. hypomagnesaemia associated with long-term use of proton pump inhibitors. gastroenterol report. 2015;3(3):243-53. 32. william jh, danziger j. magnesium deficiency and proton‐pump inhibitor use: a clinical review. j clin pharmacol. 2016;56(6):660-8. 33. cundy t, dissanayake a. severe hypomagnesaemia in long‐term users of proton‐pump inhibitors. clin endocrinol. 2008;69(2):338-41. 34. pettersson j, hindorf u, persson p, et al. muscular exercise can cause highly pathological liver function tests in healthy men. british j clin pharmacol. 2008;65(2):253-9. 35. elmahdy mf, almater jm. omeprazole induced increase in liver markers-a case report. j clin diag res. 2019;13(10). 36. avinash a, patil n, kunder sk, et al. a retrospective study to assess the effect of proton pump inhibitors on renal profile in a south indian hospital. j clin diag res. 2017;11(4):fc09-fc12. 37. sowjanya g, amulya k, priyanka r, et al. a prospective observational study on the association of the renal disease with the use of proton pump inhibitors in a tertiary care hospital. indian j pharm pract. 2019;12(2):97. 38. prakash j, gupta t, prakash s, rathore s. acute kidney injury in patients with human immunodeficiency virus infection. indian j nephrol. 2015;25(2):86. 39. autier p, boniol m, pizot c, mullie p. vitamin d status and ill health: a systematic review. lancet diab endocrinol. 2014;2(1):76-89. 40. francis r, aspray t, fraser w, et al. vitamin d and bone health: a practical clinical guideline for patient management. national osteoporosis society. 2013;1. 41. wagner sc. proton pump inhibitors and bone health: what the orthopaedic surgeon needs to know. jbjs reviews. 2018;6(12):e6. 42. yu l-y, sun l-n, zhang x-h, et al. a review of the novel application and potential adverse effects of proton pump inhibitors. advances in therapy. 2017;34(5):1070-86. 43. xu j, cheng t, feng h, pavlos n, zheng mh. structure and function of v-atpases in osteoclasts: potential therapeutic targets for the treatment of osteolysis. histology histopathol. 2007:443-54. 44. yang y-x. chronic proton pump inihibitor therapy and calcium metabolism. current gastroenterol reports. 2012;14(6):473-9. hadeel s. al ali acta med indones-indones j intern med 594 45. brisebois s, merati a, giliberto jp. proton pump inhibitors: review of reported risks and controversies. l a r y n g o s c o p e i n v e s t i g a t i v e o t o l a r y n g o l o g y. 2018;3(6):457-62. 46. jo y, park e, ahn sb, et al. a proton pump inhibitor’s effect on bone metabolism mediated by osteoclast action in old age: a prospective randomized study. gut liver. 2015;9(5):607. 47. roodman gd. cell biology of the osteoclast. experimental hematology. 1999;27(8):1229-41. 48. teramura-grönblad m, hosia-randell h, muurinen s, pitkala k. use of proton-pump inhibitors and their associated risks among frail elderly nursing home residents. scandinavian journal of primary health care. 2010;28(3):154-9. 49. qorraj-bytyqi h, hoxha r, sadiku s, et al. proton pump inhibitors intake and iron and vitamin b12 status: a prospective comparative study with a follow up of 12 months. open access macedonian j med. 2018;6(3):442. 50. koop h, bachem mg. serum iron, ferritin, and vitamin b12 during prolonged omeprazole therapy. j clin gastroenterol. 1992;14(4):288-92. special article 69acta medica indonesiana the indonesian journal of internal medicine coronary artery sequel of kawasaki disease in adulthood, a concern for internists and cardiologists anggoro b. hartopo1,2, budi y. setianto1,2 1 department of cardiology and vascular medicine, faculty of medicine, gadjah mada university – sardjito hospital. jl. kesehatan no.1 sekip, yogyakarta 55284, indonesia. 2 department of internal medicine, faculty of medicine, gadjah mada university – sardjito hospital. yogyakarta 55284, indonesia. correspondence mail: anggorobudih@yahoo.com. abstrak dewasa muda yang mengalami kejadian jantung akut (acute cardiac event) seperti sindrom koroner akut, aritmia yang terkait dengan iskemia dan kematian mendadak, seringkali tidak diketahui penyebabnya dan juga tidak mempunyai faktor risiko yang bermakna. vaskulitis koroner akibat penyakit kawasaki turut berperan sebagai faktor risiko pada populasi dewasa muda dan menimbulkan kejadian koroner akut. penyakit kawasaki terutama menyerang di masa kanak-kanak, menyebabkan vaskulitis arteri koroner dan hal ini menjadi perhatian utama karena menimbulkan aneurisma dan stenosis di kemudian hari. penyakit kawasaki bersifat swa-sirna atau dapat sembuh dengan sendirinya, sehingga penderita penyakit ini di masa kanak-kanak dapat bertahan hingga masa dewasa. bertambah cepatnya proses aterosklerosis koroner yang terjadi pada lesi yang terkait dengan penyakit kawasaki pada dewasa muda serta sindrom koroner akut dan kematian mendadak yang menyertai pada populasi ini merupakan dampak buruk dan gejala sisa yang sangat memprihatinkan dari penyakit ini. diharapkan, para ahli penyakit dalam dan kardiologi dewasa dapat mengenali gejala sisa ini dan menyediakan layanan yang lebih baik bagi para pasien. kata kunci: penyakit kawasaki, aneurisma koroner, aterosklerosis. abstract young adults suffered from acute cardiac event, such as acute coronary syndrome, ischemic-associated arrhythmia and sudden death, are frequently encountered without known etiology and significant risk factors. coronary vasculitis due to kawasaki disease contributes to be a risk factor in young adult population to develop acute coronary event. afflicted predominantly during childhood, kawasaki disease gives rise to vasculitis of coronary artery which becomes major concern since it leads to coronary aneurysm and stenosis. self-limited nature of kawasaki disease make those suffered in childhood survive into adult life. accelerated coronary atherosclerosis in the kawasaki disease-related lesion occurring in young adult and subsequent acute coronary syndrome and sudden death in this population are devastating impacts of the sequel of kawasaki disease. it is expected that internists and adult cardiologists become familiar with this sequel and provide better care for the patients. key words: kawasaki disease, coronary aneurysm, atherosclerosis. anggoro b. hartopo acta med indones-indones j intern med introduction doctor tomisaku kawasaki, a japanese pediatrician, first reported the new syndrome occurring in 50 japanese children between 1961 and 1967.1 this syndrome is known as kawasaki disease or kawasaki syndrome.1 kawasaki disease currently becomes the most common acquired heart disease in children among developed countries, especially in japan, where its incidence is ten times higher than it is in western countries.2 there is a predilection towards asian population, although the syndrome occurs in all other races as well.3,4 initially, this disease is thought to be a pediatric problem, because its self-limited nature. after populational study involving long term follow-up of children affected with kawasaki disease, the natural history of this disease becomes apparent that it will cause sequel in adult life.2,3 the natural history of kawasaki disease before the era of intravenous immunoglobulin is as follows: 1) approximately 20%-25% of children developed coronary artery aneurysms as a sequel of coronary artery vasculitis, (2) patients who developed coronary artery aneurysms during acute phase, 20% will progress to coronary artery stenosis and (3) myocardial ischemia and infarction, even sudden cardiac death, is potentially occur in relatively young age, which need treatment such as percutaneous coronary intervention, coronary artery bypass grafting, and even cardiac transplantation.3 as children with acute phase of kawasaki disease mostly survived, the sequel of coronary lesion will develop in adult life. accelerated coronary atherosclerosis occurring in relatively young age is contributed mainly by kawasaki disease sequel, which leads to acute coronary syndrome and sudden death in this population. while pediatricians care children with acute phase of kawasaki disease, internists and adult cardiologists may care these patients in adult life. sometimes their childhood medical history of kawasaki disease was not documented, even undiagnosed. thus, understanding the sequel of this disease in adult life is of paramount important for internists and adult cardiologists. this review provides an information regarding sequel of kawasaki disease which affect coronary artery in adult life. kawasaki disease in childhood kawasaki disease is an acute systemic inflammatory disease involving multiple organs and tissues, with coronary artery vasculitis is the most clinically significant feature.4 this disease is a self-limited syndrome.3-5 kawasaki disease developed over first ten days of febrile illness and than steadily disappear in most children, even without specific therapy.6 children with age between 6 months and 5 years were predominate age groups susceptible for kawasaki disease.3,5,6 fever for at least five days’ duration, with at least four of the following five clinical features: 1). polymorphous exanthema (but not petechial, bullous, or vesicular lesions); 2). bilateral nonexudative conjunctival injection; 3). changes in lips and oral cavity (but not discrete oral lesions or exudates); 4). changes in the extremities, including erythema or indurative oedema, and later (in the second week of illness) membranous desquamation starting around the nail bed; 5). cervical lymphadenopathy, often unilateral and large. children who meet the above criteria are diagnosed with complete kawasaki disease. since there is no specific diagnostic tool for kawasaki disease, clinical diagnostic criteria must be examined carefully to avoid misdiagnosis. incomplete or atypical form of kawasaki disease is diagnosed if children in suspicion do not meet the above criteria. this term is used for children with fever at least five days and at least two of the above criteria without other explainable illness and laboratory examination revealed systemic inflammation (high level of c reactive protein or erythrocyte sedimentation rate).6 incomplete (atypical) kawasaki disease often suffers from coronary artery abnormality seen on echocardiography.5,6 along with clinical features which appear sequentially, laboratory examination reveals following features during 7-10 days of disease:6 1). rutin haematology: elevated leukocyte count with neutrophilia (at least 50% of cases), progressive anaemia (usually normocytic and normochromic), increased platelet count (peak in the second or third week of illness). 2). urinalysis: urinary sediment may contain increased numbers of leukocytes without bacteruria; 3). acute phase 70 vol 45 • number 1 • january 2013 coronary artery sequel of kawasaki disease in adulthood proteins: elevated c reactive protein (>35mg/l in 80%of cases), erythrocyte sedimentation rate (>60 mm/h in 60% of cases); 4). blood chemistry: low serum sodium, low serum protein and albumin, elevated liver enzymes (specifically alanine aminotranferase), and abnormal blood lipid profile; 5). cerebrospinal fluid: pleocytosis, usually lymphocytic with normal protein and glucose. systemic vasculitis frequently developed in kawasaki disease, with coronary artery can be severely affected. thus cardiac examination must be completed as part of examination. electrocardiography and echocardiography examinations are mandatory.6 electrocardiography. sinus tachycardia with decreased qrs voltages, flattened t waves, and prolonged qtc intervals. these features are almost always reversible. heart block may occur. in untreated large coronary artery aneurysms, electrocardiography may show signs of myocardial infarction as a result of coronary thrombosis. echocardiography. decreased left ventricular function, mitral regurgitation, and pericardial effusion may be seen. coronary artery dilatation could be observed starting an average of 9-10 days after onset of fever and occurs in 30-50% of cases. c a r d i a c i n v o l v e m e n t c o n s t i t u t e o f myocarditis, pericarditis with pericardial effusion and valvulitis. pericarditis and small pericardial effusions will resolve spontaneously without sequel in almost all of the patients.7 valvulitis in acute phase of kawasaki disease develops in 2% of patients, most commonly in the mitral valve which will become scarring and incompetence.8 early myocardial involvement always resolves completely and does not necessarily associate with coronary artery involvement. long-term myocardial contractility and function measured by echocardiography is normal.9 kawasaki disease in adulthood kawasaki disease is rarely seen in infant aged less than 6 months and in adults, which supports the existence of an infectious agent for which maternal immunity is protective during infant and protective immunity development during adult life.10 although very rare, several case reports showed that acute phase of kawasaki disease occurred in adult patients.11 similar to that in children, no specific diagnostic tool is available for acute kawasaki disease in adulthood, thus clinician relies on meticulous findings of clinical diagnostic criteria. kawasaki disease in adulthood mimics several diseases with fever, cutaneous rash, mucosal involvement and cervical lymphadenopathy, such as scarlet fever, still's disease, systemic lupus erythematosus, meningococcemia, staphylococcal scalded-skin syndrome, stevensjohnson syndrome, and several viral rash fever.11 the clinical diagnostic criteria for kawasaki disease in adulthood are similar to those of in the children. the presence of coronary artery aneurysm and sequel after acute kawasaki disease in adulthood are unknown, since long term follow-up data unavailable. treatment of kawasaki disease intravenous immunoglobulin randomized controlled trials have shown that a single infusion of 2 g/kg of intravenous immunoglobulin given 5-10 days after the onset of fever eliminates fever in 85-90% of children within 36 hours and significantly reduces the risk of coronary artery aneurysms.12 reduction of coronary artery aneurysm was achieved until 3.8% after the use of high-dose immunoglobulin therapy.13 aspirin aspirin has been used in the treatment of kawasaki disease due to its antiinflammatory effect at high doses and antiplatelet effect at low dose, however it does not decrease the incidence of coronary artery coronary abnormalities.12 during the acute phase of disease, aspirin is given at a dose 30 to 50 mg/kg divided into three doses afterward followed by 3 to 5 mg/kg once daily after recovery.13 this combination has an additive antiinflammatory effect.12 for children in whom aneurysms of the coronary arteries have been diagnosed, aspirin in an antiplatelet dose is continued on a daily basis as long as aneurysms persist and echocardiography examination is needed to evaluate the aneurysms.5,9 the goal of this therapy is to prevent thrombosis and the myointimal proliferation that leads to coronary stenosis.14 71 anggoro b. hartopo acta med indones-indones j intern med corticosteroids before the era of intravenous immunoglobulin, a high incidence of coronary artery aneurysms was encountered in children with kawasaki disease treated with corticosteroids as primary therapy. randomized, controlled studies showed conflicting results of the use of corticosteroids for the primary treatment of kawasaki disease.13 pulse corticosteroid did not add beneficial effect beyond standard therapy, i.e intravenous immunoglobulin and aspirin15, however, methylprednisolon 30 mg/ kg daily for 3 days is recommended if there is no response to the second cycle of intravenous immunoglobulin infusion.6 in contrast to other systemic vasculitis, which usually respond to corticosteroids, kawasaki disease vasculitis did not response well with corticosteroid.15 coronary aneurysms in kawasaki disease the incidence of coronary aneurysm as a sequel of kawasaki disease was 16.7% in year of 1983, at the time before intravenous immunoglobulin given as standard treatment, and was rapidly decreased to 3.8% in 2007 as the use of high-dose immnunoglobulin therapy emerging.13 mild diffuse dilatation of coronary arteries arises in 30-50% of acute kawasaki disease children and begins approximately ten days from onset of febrile illness.12,16 in the majority of cases, this mild dilatation is transitory and will regress within six to eight weeks of febrile onset9, the term called transient coronary dilatation.13 persistent coronary aneurysms in the recovery phase or afterward are considered sequel of kawasaki disease.12,13 echocardiography examination during this time is an important tool to assess the coronary lesion and follow-up until recovery phase, around 30 day, is necessary for those with coronary lesion.13 coronary artery vasculitis occurs during acute kawasaki disease which features as endothelial cell swelling and subendothelial edema as well as mononuclear cells infiltration in coronary wall.17 internal elastic lamina is subsequently disrupted and myointimal proliferation within discrete area occurs.17 medial layer release matrix metalloprotease and vascular smooth muscle cell become necrotic and replace by fibrosis and calcification.18 imbalance between matrix metaloprotease and its tissue inhibitor may cause excessive fibrosis and aneurysms.19 coronary aneurysms in kawasaki disease can be divided based on its diameter:13 (1) small aneurysms (internal diameter ≤4 mm), (2) medium aneurysms (internal diameter 4–8 mm) and (3) giant aneurysms (internal diameter >8 mm). small aneurysms tend to undergo resolution and rarely progress to stenotic or thrombotic lesions.19 meanwhile, medium and giant aneurysms associated with thrombus occlusion on aneurysm site and even rupture of aneurysms, although wide range of remodeling processes occurs.13,20 in the late acute phase and early recovery phase of kawasaki disease, coronary artery lesions undergo dynamic alteration and wide range of remodeling.2,13,20 the prognosis of coronary artery aneurysms from kawasaki disease is as follows: (1) regression: regression of coronary artery aneurysms has been reported to occur in 50% to 67% of vessels with coronary aneurysms. this regression usually occurs within 1 to 2 years after onset. typical aneurysms which tend to regress are small or medium aneurysms, fusiform aneurysm and distal coronary segment aneurysms.21 despite completely regress, such patients still need follow-up because coronary artery stenosis, coronary diastolic dysfunction and intimal hyperplasia may develop which lead to juvenile arteriosclerosis and myocardial ischemia.13 (2) occlusion: coronary artery occlusion develops early in less than 1% of cases, typically in giant aneurysms.20 total coronary occlusion can develop acute myocardial infarction which greatly contributes to mortality of kawasaki disease in children. occlusion of aneurysms can occur because of flow stagnation and the sudden reduction of shear stress in the aneurysm.22 occlusion happen in early phase can be caused by jelly-like extracellular matrix which formed plug in the vasculitis site or thrombus plug in aneurysms.23 intimal fibroblastic proliferation with superimposed thrombosis has also been observed. 24 (3) occlusion with recanalization: recanalization of coronary occlusion is typical of kawasaki disease and give rise to neovascularization and collateral flow which rescue myocardia from infarcted.22 about 15% of kawasaki disease develops this recanalization or segmental stenosis which frequently (about 90%) occurs in right coronary artery.13 (4) localized stenosis: localized stenosis develops in about 10% in acute kawasaki 72 vol 45 • number 1 • january 2013 coronary artery sequel of kawasaki disease in adulthood disease.20 most of the localized stenosis occurs in the inlet and/or outlet of aneurysms, the site of high shear stress.22 shear stress promotes endothelial cell injury which induces intimal thickening and muscular proliferation lead to stenosis. during the period of up to 10 to 21 years after onset, localized stenosis of more than 75% vessel diameter develop in 4.7 to 12% of patients with coronary artery lesions and mainly occurs in the proximal segment of left anterior descending artery.13 in the late phase of disease, several years after acute phase subsided, coronary aneurysms will undergo regression, rupture, extention, c a l c i f i c a t i o n , o c c l u s i o n , o c c l u s i o n w i t h recanalization or collateral vessels and localized stenosis.20 active remodeling of coronary artery lesions of kawasaki disease are still taking place many years later, characterized by coronary artery intimal proliferation and various degrees of angiogenesis which were evident in autopsy pathology.23 regression of coronary artery aneurysms may be because of true healing or masquerading by intimal proliferation and thrombus organization, or arterial wall contraction due to scar formation which narrow coronary lumen.3 intravascular ultrasound study in the regressed coronary aneurysms shows marked symmetrical or asymmetrical myointimal thickening25 and plaque area with various degrees of fibrous, fibrofatty changes, superficial dense calcium, and necrotic core components.26 fibrous scar formation or calcification possibly develops in aneurysms years later.23 arterial wall calcification in the site of aneurysms or former aneurysms are pathognomonic sign of kawasaki disease in later life.18 in a report of japanese young adults 20 years later after acute phase of kawasaki disease, 94% of those with aneurysms at least 6 mm in internal diameter during the sub acute phase of the illness had calcification observed by electron beam computed tomography.27 calcification of kawasaki disease differs from that of atherosclerotic calcification which tends to be localized in the pre-existing aneurysms site not diffuse calcification. calcification in kawasaki disease reflected the degree of acute vasculitis and subsequent intimal proliferation which localized in proximal coronary segment and rarely involve the small branches and peripheral coronary arteries.28 localized proximal coronary calcification can be detected with cardiac x-ray and may help identify patients with kawasaki disease.28 coronary artery lesions characteristic of kawasaki disease observed in adult life include giant aneurysms, coronary artery calcification, segmental stenosis with recanalization after thrombotic occlusion and aneurysms involving the left coronary artery bifurcation.28 angiography finding shows that coronary artery lesions of kawasaki disease usually involve the proximal segments of the major branches, left anterior descending and right coronary arteries, and tend to be localized.29 this nature consequently contributes to high possibility to develop acute coronary syndrome once the lesions become significant stenotic or thrombus occlusion. besides coronary artery aneurysms and stenosis, coronary artery of kawasaki disease shows various degree of coronary artery dysfunction. dilatation capacity, endothelial dependent or endothelial independent, and coronary-myocardial blood flow reserve are impaired, even in those with angiographycaly normal coronary artery.18 carotid artery intimal medial thickness (imt) is increased in patients affected with kawasaki disease, especially in those with coronary artery aneurysms.30 decreases of arterial compliance and distensibility, increases in aortic root size, increases in myocardial fibrosis, and alterations in the coronary artery microvasculature have been reported, although in relatively small population.7 persistence of vascular inflammation and increased oxidative stress was observed.31 the clinical consequence of these findings is undetermined for patients without coronary artery lesion, although for those with persistent or regressed aneurysms, these findings indicate an increased risk of accelerated atherosclerosis, ventricular dysrhythmias, and ischemic cardiomyopathy.7 progressive localized stenosis at the site of regressed aneurysm is often observed in the late phase of kawasaki disease. even an angiographically normal coronary artery may developed intimal thickening, leading to accelerated atherosclerosis and premature cardiac events.30 coronary arteries of kawasaki disease patients predispose to accelerated atherosclerosis and contribute to coronary heart disease in relatively young ages.13,18,21 73 anggoro b. hartopo acta med indones-indones j intern med acute coronary syndrome in adult with sequel of kawasaki disease the growing number of adults with coronary artery lesions caused by kawasaki disease is expected after 40 years passed since first description of this disease. some of them have been diagnosed with kawasaki disease in the childhood and survive into adult life, some others not known until unexpected cardiac event occurs. acute coronary syndrome occurring in adults affected with kawasaki disease’s coronary artery lesions happen at a younger age than acute coronary syndrome in the general population. other cardiovascular risk factors in this population were lower than common atherosclerotic acute coronary syndrome.29 in the kawasaki disease patients, the specific nature of the kawasaki disease-related lesions seems to strongly influence the onset of acute coronary syndrome rather than the atherosclerotic risk factors.29 accelerated atherosclerosis in affected coronary artery is responsible for development acute coronary syndrome. atherosclerosis of patient affected with kawasaki disease greatly differ histologically from that of common atherosclerosis.13,18 autopsy result of patients who died late after kawasaki disease revealed calcified aneurysms, myointimal proliferation, and organizing thrombus in the coronary arteries with recanalization, whereas lipid-laden macrophages and cholesterol crystals, the hallmarks of common atherosclerosis were lack.32 this young adult population with no known previous cardiovascular history and a few cardiovascular risk factors may present with angina pectoris, myocardial infarction, ischemiainduced arrhythmia, or even sudden death.18,21 coronary angiography should be done early and the finding of the coronary arteries with proximal aneurysms with or without calcification followed by an angiographically normal distal segment should prompt anamnesis about history of kawasaki disease in childhood.18,33 tsuda et al.29 evaluated 50 cases of acute coronary syndrome in adult patients affected with kawasaki disease. they found that giant calcified aneurysms in the proximal part of the major branches of coronary artery were the most common culprit lesions. thrombus formation within the aneurysm precipitated the development of acute coronary syndrome. they also suggested that even if the aneurysms underwent regression, the risk of acute coronary syndrome remains in adult life of kawasaki disease. jcs working group13 recommend that kawasaki disease patients with angina pectoris, myocardial infarction, heart failure, or severe arrhythmia in adult life should be followed in the same way as patients with such conditions associated with etiologies other than kawasaki disease. it is advised that patients should be evaluated with noninvasive techniques, such as exercise ecg, exercise or pharmacological stress myocardial scintigraphy, holter ecg, echocardiography, magnetic resonance coronary angiography (mrca) or multislice 3d-computed tomography (mdct) coronary angiography, 3 to 4 times each year and coronary arteriography as appropriate. conclusion young adults suffered from acute cardiac event, such as acute coronary syndrome, ischemic-associated arrhythmia and sudden death, are frequently encountered without known etiology. coronary vasculitis due to kawasaki disease contributes to be a risk factor in young adult population to develop acute coronary event. sequel of kawasaki disease of childhood is rarely recognized by internist and adult cardiologists due to lack of information in childhood medical history or undiagnosed kawasaki disease. better understanding of the natural history of kawasaki disease sequel, in particular coronary artery lesions, is necessary to detect those at risk and prevent further complication. references 1. kawasaki t. kawasaki disease. cardiol young. 1991;1:184-199. 2. nakamura y, yashiro m, uehara r, oki i, watanabe m, yanagawa h. epidemiologic features of kawasaki disease in japan: results from the nationwide survey in 2005–2006. j epidemiol. 2008;18:167–72. 3. rozo jc, jefferies jl, eidem bw, cook pj. kawasaki disease in the adult. a case report and review of the literature. tex heart inst j. 2004;31:160-4. 4. burns jc, kushner hi, bastian jf, et al. kawasaki disease: a brief history. pediatrics. 2000;106:e27. 5. burns jc, glade mp. kawasaki syndrome. lancet. 2004;364:533–44. 6. harnden a, takahashi m, burgner d. kawasaki disease. bmj. 2009;338:b1514. 7. mccrindle bw. kawasaki disease: a childhood disease with important consequences into adulthood. circulation. 2009;120:6-8. 74 vol 45 • number 1 • january 2013 coronary artery sequel of kawasaki disease in adulthood 8. akagi t, kato h, inoue o, sato n, imamura k. valvular heart disease in kawasaki syndrome: incidence and natural history. am heart j. 1990;120:366–72. 9. moran am, newburger jw, sanders sp, et al. abnormal myocardial mechanics in kawasaki disease: rapid response to gamma-globulin. am heart j. 2000;139:217–23. 10. rowley ah, shulman st. kawasaki syndrome. pediatr clin n am. 1999;4:313–29. 11. cunha ba, pérez fm, alexiadis v, gagos m, strollo s. adult kawasaki's disease with myocarditis, splenomegaly, and highly elevated serum ferritin levels. heart & lung. 2010;39:164-72. 12. burns jc, shike h, gordon jb, malhotra a, schoenwetter m, kawasaki t. sequelae of kawasaki disease in adolescents and young adults. j am coll cardiol. 1996;28:253–7. 13. jcs joint working group. guidelines for diagnosis and management of cardiovascular sequelae in kawasaki disease (jcs 2008). circ j. 2010;74:1989–2020. 14. k i m d s . k a w a s a k i d i s e a s e . yo n s e i m e d j . 2006;47(6):759-72. 15. newburger jw, sleeper la, mccrindle bw, et al. randomized trial of pulsed corticosteroid therapy for primary treatment of kawasaki disease. n engl j med. 2007;356:663-75. 16. chang fy, hwang b, chen sj, lee pc, meng cc, lu jh. characteristics of kawasaki disease in infants younger than six months of age. pediatr infect dis j. 2006;25:241-4. 17. suzuki a, miyagawa-tomita s, komatsu k, et al. active remodeling of the coronary arterial lesions in the late phase of kawasaki disease: immunohistochemical study. circulation. 2000;101;2935-41. 18. gordon jb, kahn am, burns jc. when children with kawasaki disease grow up myocardial and vascular complications in adulthood. j am coll cardiol. 2009;54:1911–20. 19. sakata k, hamaoka k, ozawa s, niboshi a, yahata t, fujii m, et al. matrix metalloproteinase-9 in vascular lesions and endothelial regulation in kawasaki disease. circ j. 2010;74:1670–5. 20. senzaki h. long-term outcome of kawasaki disease. circulation. 2008;118:2763-72. 21. newburger jw, takahashi m, gerber ma, et al. diagnosis, treatment, and long-term management of kawasaki disease: a statement for health professionals from the committee on rheumatic fever, endocarditis, and kawasaki disease, council on cardiovascular disease in the young, am heart assoc circulation. 2004;110:2747-71. 22. kuramochi y, ohkubo t, takechi n, fukumi d, uchikoba y, ogawa s. hemodynamic factors of thrombus formation in coronary aneurysms associated with kawasaki disease. pediatr int. 2000;42:470–5. 23. suzuki a, miyagawa-tomita s, nakazawa m, yutani c. remodeling of coronary artery lesions due to kawasaki disease. jpn heart j. 2000;41:245-56. 24. chow lt, chow w, tse cc, wong eh, wong k., yip dc. kawasaki disease—sudden death as the first presenting symptom. cardiol young. 1992;2:73-7. 25. iemura m, ishii m, sugimura t, akagi t, kato h. long term consequences of regressed coronary aneurysms after kawasaki disease: vascular wall morphology and function. heart. 2000;83:307–31. 26. mitani y, ohashi h, sawada h, et al. in vivo plaque composition and morphology in coronary artery lesions in adolescents and young adults long after kawasaki disease: a virtual histology-intravascular ultrasound study. circulation. 2009;119:2829–36. 27. kaichi s, tsuda e, fujita h, et al. acute coronary artery dilation due to kawasaki disease and subsequent late calcification as detected by electron beam computed tomography. pediatr cardiol. 2008;29:568–73. 28. tsuda e, arakaki y, shimizu t, et al. changes in causes of sudden deaths in patients with coronary arterial lesions due to kawasaki disease. cardiol young. 2005;15:1–8. 29. tsuda e, abe t, tamaki w. acute coronary syndrome in adult patients with coronary artery lesions caused by kawasaki disease: review of case reports. cardiol young. 2011;21:74–82. 30. negoro n, nariyama j, nakagawa a, et al. successful catheter interventional therapy for acute coronary syndrome secondary to kawasaki disease in young adults. circ j. 2003;67:362–5. 31. fukazawa r, ogawa s. long-term prognosis of patients with kawasaki disease: at risk for future atherosclerosis? j nippon med sch. 2009;76(3):124-33. 32. muneuchi j, joo k, morihana e, mizushima a. detectable silent calcification in a regressed coronary artery aneurysm of a young adult with a history of kawasaki disease. pediatr cardiol. 2008;29:195–7. 33. noto n, okada t, yamasuge m, et al. noninvasive assessment of the early progression of atherosclerosis in adolescents with kawasaki disease and coronary artery lesions. pediatrics. 2001;107:1095–9. 75 3 original article acta med indones indones j intern med • vol 49 • number 1 • january 2017 the validity and reliability test of the indonesian version of gastroesophageal reflux disease quality of life (gerdqol) questionnaire laura a. siahaan1, ari f. syam1, marcellus simadibrata1, siti setiati2 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 clinical epidemiology and evidence-based medicine unit, cipto mangunkusumo hospital, jakarta, indonesia. coresponding author: ari fahrial syam, md., phd. division of gastroenterology, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: ari_syam@hotmail.com. abstrak tujuan: mendapatkan kuesioner gerd-qol yang andal dan sahih untuk digunakan di indonesia. metode: sebagai tahap awal, kuesioner gerd-qol terlebih dahulu diterjemahkan dengan metode back to back translation ke dalam bahasa indonesia, dan dievaluasi oleh tim peneliti sehingga dihasilkan kuesioner gerd-qol versi bahasa indonesia. sembilan puluh satu orang pasien yang telah didiagnosis gerd secara klinis sebelumnya berdasarkan kriteria montreal, diwawancarai dengan menggunakan kuesioner gerd-qol versi indonesia dan kuesioner sf 36. kesahihan dinilai menggunakan kesahihan konstruksi dan kesahihan eksternal dan keandalan dinilai melalui metode konsistensi internal dan tes ulang. hasil: gerd-qol berbahasa indonesia memiliki keandalan konsistensi internal kuesioner yang baik (cronbach alpha: 0.687–0.842) dengan keandalan tes ulang yang baik (intra class correlation coefficient: 0.756-0.936, p<0.05). gerd-qol juga terbukti memiliki kesahihan yang baik dengan korelasi setiap pertanyaan dengan sf-36 terbukti tinggi (p<0.05). kesimpulan: gerd-qol berbahasa indonesia terbukti sahih dan andal untuk menilai kulitas hidup penderita gerd. kata kunci: gerd, kualitas hidup, gerd-qol, kesahihan, keandalan. abstract aim: to obtain a valid and reliable gerd-qol questionnaire for indonesian application. methods: at the initial stage, the gerd-qol questionnaire was first translated into indonesian language and the translated questionnaire was subsequently translated back into the original language (back-to-back translation). the results were evaluated by the researcher team and therefore, an indonesian version of gerd-qol questionnaire was developed. ninety-one patients who had been clinically diagnosed with gerd based on the montreal criteria were interviewed using the indonesian version of gerd-qol questionnaire and the sf 36 questionnaire. the validity was evaluated using a method of construct validity and external validity, and reliability can be tested by the method of internal consistency and test retest. results: the indonesian version of gerd-qol questionnaire had a good internal consistency reliability with a cronbach alpha of 0.687–0.842 and a good test retest reliability with an intraclass correlation coefficient of 0.756-0.936; p<0.05). the questionnaire had also been demonstrated to have a good validity with a proven high correlation to each question of sf-36 (p<0.05). conclusion: the indonesian version of gerd-qol questionnaire has been proven valid and reliable to evaluate the quality of life of gerd patients. keywords: gerd, quality of life, gerd-qol, validity, reliability. laura a. siahaan acta med indones-indones j intern med 4 introduction gastroesophageal reflux disease (gerd) is a condition characterized by a reflux of gastric content into the throat causing symptoms such as epigastric pain and regurgitation and it may lead to complications. several recent studies show an increasing gerd prevalence in asia.1,2 however, no certain data has been available in indonesia regarding the increasing prevalence of gerd in asia. based on the study conducted by syam et al, it has been reported that the prevalence of gerd at cipto mangunkusumo hospital has been increased from 5.7% in 1997 to 25.18% in 2002.3-6 moreover, the most recent online survey conducted by syam et al.7 between august 2013 and june 2015 reported that of 2045 subjects who participated the survey in indonesia, there were 57.6% subjects with gerd. gerd is a chronic disease that often needs long-term treatment and it can affect quality of life by disturbing the quality of eating and drinking, physical activities and rest.6,8,9 anxiety and depression in gerd patients are significantly higher compared to healthy subjects group. it demonstrates that gerd can affect mental and emotional aspects of an individual that eventually lower the quality of life.9-14 the socio-economic burden caused by gerd is also quite severe, which may need a special attention. the effect of gerd on the quality of life of patients who have experience the disease does not correlate with the lesion on mucosa as seen on endoscopy; therefore, improved quality of life has become another target of gerd management.10,11 many questionnaires have been developed to evaluate gerd, either the general questionnaires to evaluate quality of life or questionnaires that have been specifically developed for gerd. the sf-36 is a generic instrument that has been applied in various countries and has become the gold standard to evaluate quality of life; however, it is not specific to evaluate a certain disease and therefore, it is better to use it with another questionnaire, which is more specific in evaluating certain disease.9,12 chan et al. have tried to developed an instrument to evaluate the quality of life of gerd patients in china before and after having pharmacological treatment. the gerd-qol questionnaire has also been tested for its validity and reliability, in which the results show that it is a relatively good instrument, but it has not widely applied.10,12,13 the gerd-qol questionnaire has been tested for its validity and reliability for asian populations and it is considered to be a relatively good and specific instrument to evaluate the quality of life of gerd patients.10 the questionnaire evaluates the quality of life of asian population before and after receiving proton pump inhibitor (ppi) treatment. it indicates that the questionnaire can also be used in indonesia. since indonesia has different cultures, a study is required to test its reliability and validity before applying the gerd-qol questionnaire for gerd patients in indonesia.10,12 methods the study was a cross-sectional study to test the reliability and validity of the indonesian version of gerd-qol questionnaire involving 91 patients who had been diagnosed with gerd according to the montreal criteria. the involved patients were recruited by consecutive sampling. the inclusion criteria in the study were patients with gerd aged over 18 years old who visited the outpatient clinic of gastroenterology between july and august 2016; while the exclusion criteria were patients who were unwilling to participate in the study, illiterate or had any difficulty in communication. the patients were informed about the aim of the study and their consent asked before the study was initiated. patients were asked to fill in the gerd-qol and sf-36 questionnaires. they dealt with the gerd-qol questionnaire two weeks later. characteristics data such as age, sex, last education level, body mass index, duration of gerd, treatment and other comorbidities were also obtained from each patient. the study had been approved by the ethical committee on health research, faculty of medicine, universitas indonesia cipto mangunkusumo hospital on june 13th, 2016 with a reference number of 482/un2.f1/etik/2016. vol 49 • number 1 • january 2017 the validity and reliability test of the indonesian version of gerd-qol 5 questionnaire the gerd-qol questionnaire is a specific questionnaire to evaluate the quality of life of gerd patients, which was filled in by the patients themselves (self-administered questionnaire). the questionnaire consisted of 16 questions, which were a combination of four domains, i.e. the daily activity (8 questions), treatment effect (3 questions), diet (3 questions) and psychological well-being (2 questions). patients were asked to select their answer according the symptoms felt by the patients within the last 7 days. next, all answers were scored and the higher the score showed a better quality of life.10 before conducting a reliability and validity test, the original version of gerd-qol questionnaire was translated into indonesia language using forward–backward translation method. initially, the original questionnaire was translated by two certified translators into indonesian language; then, the results were evaluated by the investigator team. when there was no significant difference on the works between the two translators, the results were back-translated into english version by two native translators. the final result of translation was subsequently compared to the original version of questionnaire. afterwards, a pretest stage was conducted in 20 patients and each patient was asked for their understanding of each question in the questionnaire. the stages of study can be seen in figure 1. the study used sf-36 questionnaire, which the indonesian version has been validated, as a comparator since the sf-36 is the gold standard questionnaire to evaluate quality of life.15-17 the questionnaire consisted of 8 domains, i.e. physical function, role limitations due to physical health problems, bodily pain, general health, vitality, social function, role limitations due to emotional problems and mental health.18 the original version of gerd-qol questionnaire translation into indonesian language (1a) translation into indonesian language (1b) translation synthesis of the indonesian version of gerd-qol questionnaire (2) back translation into english (3a) back translation into english (3b) the final result of the indonesian version of gerd-qol questionnaire (4) pre-test stage in 20 gerd patients at the outpatient gastroenterology clinic cipto mangunkusumo hospital the final result of the indonesian version of gerd-qol questionnaire validity and reliability test report of the study results eligible gerd patients who visited the outpatient gastroenterology clinic cipto mangunkusumo hospital fill in the questionnaire c o m p a re d s t a g e 1 s t a g e 2 s t a g e 3 c o m p a re d figure 1. study flow chart laura a. siahaan acta med indones-indones j intern med 6 statistical analysis a valid instrument means that the instrument can be used to measure what it is supposed to; while a reliable instrument is an instrument that will produce exact data when the same object is measured repeatedly. reliability can be tested by various methods and in the study, the method of internal consistency and test retest were used. internal consistency was evaluated using the cronbach alpha coefficient. a value of cronbach alpha of more than 0.7 was considered as an indicator of good internal consistency and good reliability. the test and retest method were performed by presenting a test on a group of subjects twice within 14 days of time interval and subsequently evaluated the intra-class (icc) coefficient. a coefficient of icc over 0.70 was considered as a reliable result.19 the validity in the study was evaluated using a method of construct validity and external validity. the construct validity was aimed to evaluate the correlation between each question in the questionnaire against the total score of its domain. a questionnaire is considered to have a good construct validity when it has a high correlation when it is compared with the domain of the question and likewise, it has a low correlation when it is compared with a different domain. the construct validity was measured using a multitrait multimethod by convergent and discriminant method. the external validity was measured by comparing the gerd-qol questionnaire with the gold standard questionnaire, i.e. the sf-36. a value of pearson correlation of r >0.6 means that it has a good correlation. all of statistical tests were conducted using a two-tailed test and was considered as statistically significant when the p <0.05. the calculation of statistical analysis was performed using the spss software version 23.0. results a total of 91 patients had fulfilled the inclusion criteria and they were involved in the study. the characteristics of all patients can be seen in table 1. reliability of 91 patients, 80 patients were selected, i.e. those who were stable and had received no change of treatment within 14 days. the eighty patients were asked to fill in the gerd-qol questionnaire on the first day and on the 14th day in order to evaluate the consistency of their answers between the first and the 14th day. results of cronbach alpha and icc can be seen on table 2. all domains in gerd-qol questionnaire had cronbach alpha and icc value of more than 0.7 except for the domain of diet. table 1. subject characteristics at the final stage variables value sex (male), n (%) 34 (37) age (years), mean (sd) 48.6 (12.84) body mass index, median (min-max) 23.31 (14.19 41.09) duration of having gerd (months), median (min-max) 12 (1 360) comorbidities, n (%) with comorbidities 51 (56) without comorbidities 40 (44) therapy, n (%) h2-antagonist 2 (2) ppi 75 (82) sucralfate 10 (11) prokinetics 15 (16) rebamipide 23 (25) on demand 9 (10) education level, n (%) elementary 5 (5) junior high 6 (7) senior high 42 (46) university (d1-s3) 36 (41) occupation, n (%) employed 45 (49) housewives 29 (32) students 1 (1) unemployed 16 (18) endoscopic results, n (%) never had endoscopy 17 (19) non-erosive 30 (33) la grade a 27 (30) la grade b 15 (16) la grade c la grade d 1 (1) vol 49 • number 1 • january 2017 the validity and reliability test of the indonesian version of gerd-qol 7 validity the gerd-qol questionnaire had a convergent and discriminant validity as each question was highly correlated when it was compared with its own domain and had a low correlation when it was compared with other domains. the pearson correlation between a total domain of gerd-qol questionnaire and each domain of the sf-36 questionnaire showed a fair correlation (r=0.19-0.40, p<0.001). results of construct validity can be seen on table 3. discussion gerd-qol questionnaire was firstly developed in china and it has been translated into english. the specific questionnaire is made to evaluate the quality of life before and after pharmacological treatment.10 until now, many studies have been done to evaluate the quality of life in gerd patients and many questionnaire instruments have been developed; however, not all of them can describe the quality of life in multidimensional sense and can be used specifically in gerd patients. different interpretations on gerd symptoms have also become a unique challenge to develop an appropriate questionnaire for certain population; moreover, the available questionnaire must be tested for its reliability and validity prior to the application.10,13 in the era of international and multicenter studies, the instrument used in the studies measuring the quality of life of gerd patients must be appropriate with the studied population, either regarding the culture, language and social customs. a good instrument must have criteria such as sensitive to diagnose a disease, easily scored, easily understandable, easily translated into local languages, able to assess the disease comprehensively, including the typical and the non-typical symptoms and can be selfadministered by the patients, economical as well as has been tested for its validity and reliability using psychometric tests.12 the study results showed that the indonesian version of gerd-qol questionnaire is a valid and reliable instrument to evaluate the quality of life of gerd patients in indonesia. table 2. cronbach alpha of gerd-qol questionnaire domain cronbach alpha icc (n=80) (14-day interval) daily activity 0.739 0.890 treatment effect 0.717 0.756 diet 0.687 0.833 psychological wellbeing 0.842 0.936 total 0.822 0.880 table 3. correlation between each question and the domains of gerd-qol questionnaire daily activity treatment effect diet psychological well-being gerd-qol total q2, q4, q5, q8, q10 – q13 (da) 0.49 – 0.68 0.04 – 0.31 0.16 – 3.23 0.10 – 0.38 0.29 – 0.45 (p<0.001) q3, q7, q14 (te) 0.09 – 0.037 0.74 – 0.78 0.16 – 0.27 0.30 – 0.38 0.44 – 0.57 (p<0.001) q1, q6, q9 (di) 0.21 – 0.37 0.11 – 0.29 0.74 – 0.81 0.23 – 0.43 0.50 – 0.59 (p<0.001) q15, q16 (pw) 0.31 – 0.37 0.36 – 0.43 0.37 – 0.41 0.92 – 0.93 0.74 – 0.79 (p<0.001) table 4. correlation between total score of gerd-qol domains and specific domain of sf-36 sf-36 domain physical functioning physical role bodily pain general health vitality social functioning emotional role mental health gerd-qol 0.309 0.352 0.276 0.402 0.319 0.192 0.326 0.286 p-value 0.000 0.000 0.000 0.000 0.000 0.010 0.000 0.000 laura a. siahaan acta med indones-indones j intern med 8 the characteristics of 91 patients were similar to those in the original questionnaire conducted in hong kong that found greater number of female respondents than male. the mean age of patients in the study was 48.6 years with a standard deviation (sd) of 12.84 mimicking the characteristic of respondent age in the original study.10 in the study, the test retest method was used to evaluate reliability and the interval used was 2 weeks by involving 80 patients with stable condition and who did not have any change in their treatment. the two-week interval was selected as there were not many changes of the patients’ clinical condition within the interval. the icc results found in each domain of the study were within a range of 0.756-0.936, which was similar to the original questionnaire conducted by yawen et al in hong kong that found icc between the first and second test ranged between 0.73–0.94, with p<0.001.10 internal consistency was evaluated by measuring the cronbach alpha. of the four domains in the gerd-qol questionnaire, the domain of daily activity, treatment effect and psychological well-being have a cronbach alpha of more than 0.7; however, the domain of diet had a cronbach alpha of 0.687 (table 2). there is no certain measurement on the number of questions suggested for each domain. some available studies suggest that the cronbach alpha would be found lower than the actual value when the questions of each domain are less than four. on the other hand, too many domains will also affect the cronbach alpha value to be lower. moreover, the cronbach alpha is also affected by other factors, such as the number of sample, homogenicity of the respondents, the poor association of each question in each domain.20 table 3 shows that each item of questions in the gerd-qol questioner is convergently valid. when the item of question in daily activity domain was compared to different domains, i.e. the domain of diet, treatment effect and psychological well-being, a value of r<0.4 was found. likewise, the questions in the domain of treatment effect had a low correlation when compared to the domains of daily activity, diet and psychological well-being. in diet domain, there were questions with r>0.4 when they were correlated with the domain of in physchological well-being; however, when the value of r was compared to the domain of diet itself, we found a lower r value. it indicates that each item of questions in the gerd-qol questionnaire is discriminantly valid. the external validity evaluated the correlation among similar domains between gerd-qol and sf-36 questionnaires. the correlation is considered good when the questionnaire is valid and the correlation value found is r>0.4. in the present study, we found a correlation ranged between 0.192 and 0.402. gerd-qol has a good correlation with sf-36 domains, i.e. physical functioning, physical role, general health and emotional role. the weakest correlation was found in the domain of social functioning, i.e. 0.192. (table 4). the findings of domains with r<0.3 did not always mean that the gerd-qol questionnaire has a weak correlation, but it may occur as the compared domains between both questionnaires were incomparable or the study did not evaluate the same domain.4 the limitation of the study is that it only involved the gerd patients in the outpatient clinic. it did not correlate the education level and did not evaluate the effect of treatment, the presence of comorbidities as well as the disease severity on the quality of life. conclusion gerd-qol questionnaire is a reliable and valid instrument to evaluate the quality of life of gerd patients in indonesia. acknowledgments this research was supported by pitta grants from drpm ui (directorate of research and community engagement, universitas indonesia). references 1. min bh, huh kc, jung hk, et al. prevalence of uninvestigated dyspepsia and gastroesophageal reflux disease in korea: a population-based study using the rome iii criteria. dig dis sci. 2014;59(11):2721-9. 2. goh kl, choi kd, choi mg, et al. factors influencing treatment outcome in patients with gastroesophageal vol 49 • number 1 • january 2017 the validity and reliability test of the indonesian version of gerd-qol 9 reflux disease: outcome of a prospective pragmatic trial in asian patients. bmc gastro. 2014;14(1):156-64. 3. marcellus s. gastroesophageal reflux disease in indonesia. indones j gastroenterol, hepatol, dig endosc. 2009;10(3):53-4. 4. syam af, aulia c, renaldi k, simadibrata m, abdullah m, tedjasaputra tr, editor. revisi konsensus nasional penatalaksanaan penyakit refluks gastroesofageal (gastroesophageal reflux disease/gerd) di indonesia. jakarta: perkumpulan gastroenterologi indonesia; 2013. 5. syam af, abdullah m, rani aa. prevalence of reflux esophagitis, barret’s esophagus and esophageal cancer in indonesian people evaluation by endoscopy. canc res treat. 2003;5:83. 6. va r a n n e s s b , d u c r o t t é p, va l l o t t, e t a l . gastroesophageal reflux disease: impact on work productivity and daily-life activities of daytime workers. a french cross-sectional study. dig liver dis. 2013;45(3):200-6. 7. syam af, sobur cs, abdullah m, makmun d. gerdq online survey: prevalence and risk factors of gerd in the indonesian population. am j gastroenterol. 2015;110:s709-10. 8. rensburg cjv, kulich kr, carlsson j, wiklund ik. what is the burden of illness in patients with reflux disease in south africa? south african gastroenterol rev. 2005:16-21. 9. masoumi sj, khademolhosseini f, mehrabani d, moradi f, mostaghni aa, zare n, saberi-firoozi m. correlation of quality of life with gastroesophageal reflux disease amongst qashqai nomads in iran. arch iran med. 2012;15(12):747–50. 10. chan y, ching jyl, cheung cmy, et al. development oand validation of a disease-specific quality of life questionnaire for gastro-oesophageal reflux disease: the gerd-qol questionnaire. aliment pharmacol ther. 2009;31:452–60. 11. tomita t, yasuda t, oka h, et al. atypical symptoms and health-related quality of life of patients with asymptomatic reflux esophagitis. j gastroenterol hepatol. 2015;30:19–24. 12. m o u l i v p, a h u j a v. q u e s t i o n n a i r e b a s e d gastroesophageal reflux disease (gerd) assessment scales. indian j gastroenterol. 2011;30(3):108-17. 13. guan, xiao-li, hui wang. quality of life scales for patients with gastroesophageal reflux disease: a literature review. int j nurs sci. 2015;2(1):110-4. 14. yang xj, jiang h m, hou xh, song j. anxiety and depression in patients with gastroesophageal reflux disease and their effect on quality of life. world j gastroenterol. 2015;21(14):4302–9. 15. rachmawati y, perwitasari da, adnan. validasi kuesioner sf36 versi indonesia terhadap pasien hipertensi di puskesmas yogyakarta. pharmacy. 2014; 11:14-26. 16. perwitasari da. development the validation of indonesian version of sf-36 questionnaire in cancer disease. indonesian j pharm. 2012;23(4):248-53. 17. novitasari l, perwitasari da, khoirunnisa sm. validity of short form 36 (sf-36) indonesian version on rheumatoid arthritis patients. jkki. 2016;7(3):80-6. 18. montazeri a, goshtasebi a, vahdaninia m, gandek b. the short form health survey (sf-36): translation and validation study of the iranian version. qual life res. 2005;14(3):875-82. 19. cao y, yan x, ma xq, wang r, johansson s, wallander ma, he j. validation of a survey methodology for gastroesophageal reflux disease in china. bmc gastroenterol. 2008;8:37-49. 20. spiliotopoulou g. reliability reconsidered: cronbach’s alpha and paediatric assesment in occupational therapy. aust occup ther j. 2009;56:150-5. 4 acta med indones indones j intern med • vol 55 • number 1 • january 2023 original article abstract background: continuous ambulatory peritoneal dialysis (capd) is an alternative therapy for renal replacement in patients with kidney failure in developing countries such as indonesia. the capd program in malang indonesia has been running since 2010. until now, there has been little research on the mortality of capd therapy in indonesia. we aimed to provide report on the characteristics and 5-year survival of capd therapy in patients with end-stage renal disease (esrd) in developing countries like indonesia. methods: we conducted a retrospective cohort study involving 674 patients with end-stage renal disease receiving capd therapy from the medical records of the capd center rsud dr. saiful anwar from august 2014 to july 2020. the 5-year survival rate was analyzed using kaplan-meier, and the hazard ratio was analyzed using cox regression. results: of 674 patients with end-stage renal disease who underwent capd, 63.2% survived up to 5 years, with general survival rates at 1, 3, and 5 years of 80%, 60%, and 52%, respectively. the 3-year survival rate for patients with end-stage renal disease and comorbid hypertension was 80%, while it was 10% for patients with comorbid hypertension and type ii diabetes mellitus. the hazard ratio for patients with end-stage renal disease who had comorbid hypertension and type ii diabetes mellitus was 8.4 (95% ci = 6.36-11.21). conclusion: patients with end-stage renal disease who receive capd therapy have a favorable 5 years survival rate. patients with end-stage renal disease on capd therapy who have comorbid hypertension and type ii diabetes mellitus have a lower survival rate than patients with comorbid hypertension alone. keywords: survival, end stage renal disease, continuous ambulatory peritoneal dialysis. five-year survival rate of patients with end-stage renal disease on continuous ambulatory peritoneal dialysis (capd) at malang capd center, indonesia atma gunawan1*, pandu tridana sakti2 1division of renal and hypertension, departement of internal medicine, faculty of medicine, brawijaya university dr. saiful anwar hospital, malang, indonesia. 2departement of internal medicine, faculty of medicine, brawijaya university, malang, indonesia. * corresponding author: atma gunawan, md., phd. division of renal and hypertension, departement of internal medicine, faculty of medicine, brawiijaya university. jl. ja. suprapto no. 2, malang, indonesia. email: atma_gunawan.fk@ub.ac.id. introduction continuous ambulatory peritoneal dialysis (capd) may be the primary option for efficient and cost-effective renal replacement therapy for end-stage renal disease in developing countries such as indonesia. despite the fact that capd is better tolerated in patients with end-stage renal disease, it is more cost-effective than hemodialysis (hd).1 the annual cost of hd per patient in indonesia is approximately 12,000 usd, while the cost of capd is approximately 6,000 usd. furthermore, capd has fewer requirements in terms of medical personnel and facilities than hd. therefore, the use of capd in developing countries can help to bridge the gap between the demand and supply of renal replacement therapy (rrt) for patients with end-stage renal disease. the number of active patients with end-stage renal disease in indonesia until 2018 was 132,142 vol 55 • number 1 • january 2023 five-year survival rate of patients with end-stage renal disease 5 patients (499 patients per million population), while new cases of end-stage renal disease in 2018 were 53,940, with hypertensive kidney disease (36%) and diabetic nephropathy (27.8%) being the most common etiologies. east java province has the highest number of active capd patients in indonesia, with 561 patients, 75% of whom came from the capd center of rsud dr. saiful anwar malang.2 in indonesia, hypertension (42%) and diabetes mellitus (16%) are the most common comorbidities in patients with end-stage renal disease.2 capd also has serious complications, such as peritonitis, which can progress to systemic infection.3 these comorbidities and complications can increase the mortality of capd patients and decrease their survival rate. there are currently no reports on the therapeutic success and survival analysis of patients with end-stage renal disease who undergo capd in developing countries like indonesia. patients with end-stage renal disease and hypertension alone or in combination with diabetes mellitus still have a low survival rate. we aimed to analyze the five-year survival of capd patients with endstage renal disease caused by hypertension alone or in combination with diabetes mellitus at one of indonesia’s capd centers. methods the study design was a retrospective cohort study. the research was conducted at the capd unit of rsud dr. saiful anwar malang, using medical record data of capd patients. the target population of this study was patients with end-stage renal disease who were undergoing capd therapy. data is collected using medical records and telephone interviews for additional data not found in the medical record. the inclusion criteria of the study were patients with end-stage renal disease who underwent capd installation surgery at dr. saiful anwar malang from august 2014 to july 2020. the exclusion criteria included capd drop-out patients for reasons other than death and capd patients traveling to other capd centers. this study was approved by the health research ethics commission dr. saiful anwar hospital, malang, indonesia (reference no. 400/083/k.3/102.7/2022). the patient’s comorbidities were the confounding variable in this study. the sample size required to determine the difference in survival rates of patients with end-stage renal disease who had comorbid hypertension alone versus hypertension and type 2 diabetes mellitus was 190 samples with a 0.05 significance level and 80% study power with a 0.15 effect size rate. the spss 25 program was used for the survival analysis. kaplan-meier analysis was used to distinguish the 5-year survival rate between patients with end-stage renal disease who had comorbid hypertension alone and those who also had hypertension and type 2 diabetes mellitus. cox regression analysis was used to determine the adjusted hazard ratio (hr) with a 95% confidence interval (ci). the p-value of <0.05 indicates a significant value. results during the period of august 2014 to july 2020, there were 840 capd operations at the capd center of dr. rsud. saiful anwar malang. from the total of 840 cases, 166 cases (19.5) dropped out of capd (due to mechanical problems, recurrent peritonitis, switching to other renal replacement therapies, or traveling to another capd center) were excluded from this study. as a result, this study involved 674 patients. within 5 years, there were 248 deaths (29.5%) with cardiovascular disease being the leading cause of death (79.8%). the sample in this study was male (58.8%), the highest age group when starting capd therapy was 46-59 years (42.6%), and hypertension was the most common comorbid condition (57.7%). table 1. characteristics of capd patients characteristic n=674n (%) gender men 389 (58.8) women 285 (41.2) age 12-25 years 61 (9.1) 26-45 years 195 (28.9) 46-59 years 287 (42.6) >60 years 120 (17.8) atma gunawan acta med indones-indones j intern med 6 marital status single 61 (9.1) married 613 (90.9) smoker yes 287 (42.6) no 287 (57.4) history of hypertension medication calcium channel blocker 195 (28.9) angiotensin-converting enzyme inhibitor 287 (42.6) angiotensin receptor blocker 192 (28.48) comorbidity hypertension 381 (57.7) hypertension and diabetes mellitus 278 (42.3) cause of mortality cardiovascular disease 198 (79.8) cerebrovascular disease 8 (3.2) sepsis (peritonitis) 40 (16.1) other 2 (0.8) in general, the survival rate of patients with end-stage renal disease who were receiving capd therapy within 12 months (1 year) was 80%, 36 months (3 years) was 60%, and 60 months (5 years) was 52%, with a mean survival rate of 42.4 months (95% ci = 40.3-44.5). survival rates between 1 and 3 years of patients with end-stage renal disease who had comorbid hypertension and type 2 diabetes mellitus who received capd therapy were 61% and 10%, respectively, with a median survival of 16 months (95% ci = 13.6-18.3) and comorbid hypertension alone were 90% and 80%, respectively, with a mean survival of 49.9 months (95% ci = 47.951.8). the hazard ratio of patients with end-stage renal disease who had comorbid hypertension and type ii diabetes mellitus was 8.4 (95% ci = 6.36-11.21), p-value <0.001. figure 1. kaplan-meier survival curve of patients with the end-stage renal disease treated with capd therapy. vol 55 • number 1 • january 2023 five-year survival rate of patients with end-stage renal disease 7 discussion the survival rate of end-stage renal disease patients undergoing capd therapy in this study was 80%after one year, 60% after three years, and 52% after five years, with a mean survival rate of 42.4 months (95%ci = 40.3-44.5), the same as in several other studies. research in hong kong from 2002 to 2006 found that the patients survived for one year (90.8%), three years (68.2%), and five years (48.4%).4–6 in thailand, the 2012 survival rates of capd patients were one year (79.2%), three years (66%), and five years (57%).7–9 in china, the 2006 survival rates for capd patients were one year (94%), three years (81%), and five years (64%).10 in continental europe, the 2012 survival rate of capd patients was two years (81.7%).11 in the united states, the 2013 survival rates for capd patients were one year (90%), two years (79%), and five years (50%).11 in canada, the 2013 survival rates for capd patients were one year (94%), three years (73%), and five years (55%).12 in latin america, the 2000 survival rates for capd patients were one year (91%), three years (77%), and five years (58%).12 these data show that both developing and developed countries have nearly the same 5-year survival rate of capd, which is above 50%. recent research on capd mortality showed that 248 patients (36.8%) died, while 426 patients (63.2%) survived for five years. capd peritonitis is the second leading cause of 40 (16.1%) mortality cases after cardiovascular disease. the most common bacteria causing capd peritonitis was coagulate-negative staphylococcus, with as many as 15 (37.5%) cases.13 the survival analysis of patients with endstage renal disease on capd therapy with comorbidities revealed that survival at 1 and 3 years was 61% and 10% for hypertensive patients with type 2 diabetes mellitus, respectively, and 90% and 80% for patients with only comorbid hypertension, respectively. according to a 2013 research conducted in australia in, the survival rate of capd patients with comorbid diabetes was 1 year (89%), 3 years (61%), and 5 years (39%).14 this is similar to the 2013 new zealand study, which found that capd patients survived for one year (89%), three years (59%), and five years (34%).14 these data show that patients with end-stage renal disease who have comorbid diabetes have a lower survival rate. hyperfiltration in diabetes is caused by efferent arteriolar vasoconstriction due to an activated renin-angiotensin-aldosterone system (raas). however, it has become increasingly figure 2. kaplan-meier survival curve comparison of capd patients with end-stage renal disease who had comorbid hypertension and those who had hypertension and type ii diabetes mellitus. atma gunawan acta med indones-indones j intern med 8 evident over the years that hyperglycemia is not the sole cause of nephropathy, despite inarguably playing a major role. several pathophysiologic pathways are involved in the development of nephropathy, and this review will attempt to elucidate those pathways and, hopefully, shed some light on therapeutic options that may one day play a role in halting the nephropathy epidemic and suppressing the progression to esrd.15 in clinical practice, physicians should pay special attention to capd patients with diabetes mellitus and hypertension comorbidity. there were several limitations to this study, including the fact that there were 15 patients who did not have comorbid hypertension and diabetes mellitus, so we did not analyze them and only made an analysis for the survival rate of patients who did. because the retrospective data for the last 5 years recorded in medical records is insufficient, including data on the etiology of esrd, data on whether or not hypertension and diabetes mellitus are controlled, and data on other characteristics and comorbidities, we cannot include them in the sample characteristics. the inability to determine the survival status of some patients in the study population had a negative impact on the internal and external validity of the study’s main result the cumulative survival probability -as well as the ability to correlate the study’s independent variables to patient survival. a template or format may be used to improve the quality of documentation in the future. at least two phone numbers should be requested from the patient to ensure adequate communication. it is also recommended that similar research be conducted on a regular basis for capd patients. this may be addressed by improving community awareness of the disease, introducing selfexamination concepts, and providing screening services. conclusion this study was conducted to improve understanding of the capd patients in malang. capd patients have a survival rate of 80% within 12 months (1 year), 60% within 36 months (3 years), and 52% within 60 months (5 years). diabetes was found to have a negative impact on the survival of capd patients. the survival rate of end-stage renal disease with diabetes and hypertension is lower than hypertension alone. conflict of interest the author declares no conflict of interest or funding in this research. references 1. li pk-t, chow km, van de luijtgaarden mwm, et al. changes in the worldwide epidemiology of peritoneal dialysis. nat rev nephrol. 2017;13(2):90–103. 2. indonesia pn. 11th report of indonesian renal registry 2018. jakarta perhimpun nefrol indones. 2018 3. witowski j, lópez-cabrera m. peritoneal dialysis and its local and systemic complications: from the bench to the clinic. front physiol. 2020;11:188. 4. canney m, er l, antonsen j, copland m, singh rs, levin a. maintaining the uptake of peritoneal dialysis during the covid-19 pandemic: a research letter. can j kidney heal dis. 2021;8:2054358120986265. 5. klomjit n, kattah ag, cheungpasitporn w. the cost-effectiveness of peritoneal dialysis is superior to hemodialysis: updated evidence from a more precise model. kidney med. 2021;3(1):15. 6. sukul n, mukhopadhyay p, schaubel de, et al. peritoneal dialysis and mortality, kidney transplant, and transition to hemodialysis: trends from 1996-2015 in the united states. kidney med. 2020;2(5):610–9. 7. thurlow js, joshi m, yan g, et al. global epidemiology of end-stage kidney disease and disparities in kidney replacement therapy. am j nephrol. 2021;52(2):98–107. 8. wo u k n . e n d s t a g e r e n a l d i s e a s e : medical management. am fam physician. 2021;104(5):493–9. 9. hansson jh, finkelstein fo. peritoneal dialysis in the united states: lessons for the future. kidney med. 2020;2(5):529. 10. wu c, chen x, ying wang a, et al. peritoneal dialysis in sichuan province of china–report from the chinese national renal data system. ren fail. 2018;40(1):577–82. 11. preka e, bonthuis m, harambat j, et al. association between timing of dialysis initiation and clinical outcomes in the paediatric population: an espn/era-edta registry study. nephrol dial transplant. 2019;34(11):1932–40. 12. prasad b, jafari m, shah s, mcnaught c, diebel l. barriers to peritoneal dialysis in saskatchewan canada: results from a province-wide survey. can vol 55 • number 1 • january 2023 five-year survival rate of patients with end-stage renal disease 9 j kidney heal dis. 2020;7:2054358120975545. 13. sianturi da, gunawan a. peritonitis as the cause of death of capd patients at rsud dr. saiful anwar malang 2014-2020. clin res j intern med. 2022;3(1):239–44. 14. mcdonald sp. australia and new zealand dialysis and transplant registry. kidney int suppl. 2015;5(1):39–44. 15. toth-manikowski s, atta mg. diabetic kidney disease: pathophysiology and therapeutic targets. j diabetes res. 2015;2015. case report 307acta medica indonesiana the indonesian journal of internal medicine an east-asian-type caga helicobacter pylori infected patient with clinical manifestation of gastric ulcer yudith a.a. rezkitha1, muhammad miftahussurur1,2,3, iswan a. nusi2, ummi maimunah2, pangestu adi1, yoshio yamaoka3 1 institute of tropical disease, universitas airlangga, surabaya, indonesia. 2 department of internal medicine, faculty of medicine universitas airlangga dr. soetomo teaching hospital, surabaya, indonesia. 3 department of environmental and preventive medicine, oita university faculty of medicine, yufu, japan. corresponding author: muhammad miftahussurur, md, phd. department of environmental and preventive medicine, oita university faculty of medicine, 1-1 idaigaoka, hasama-machi, yufu-city, oita 879 5593, japan. email: miphto@yahoo.co.id. abstrak kami melaporkan sebuah kasus seorang laki-laki, 72 tahun, etnis tionghoa dengan keluhan utama buang air besar berwarna hitam lembek. pemeriksaan fisik menunjukkan warna pucat pada konjungtiva palpebra yang dikonfirmasi dengan hasil hitung darah lengkap. pemeriksaan gastroduodenoskopi menemukan adanya ulkus berukuran 3 mm di antrum (forrest stage iii). infeksi h. pylori dinyatakan positif berdasarkan lima metode berbeda (urinary antibody tests, rapid urease test, kultur, histologi dan imunohistokimia). analisis dengan sequencing berbasis polymerase chain reaction didapatkan bahwa pasien terinfeksi oleh strain berjenis east-asian-type caga dan vaca s1m1. analisis lanjutan dengan menggunakan tujuh housekeeping gen mengkonfirmasikan bahwa strain tersebut tergolong dalam kelompok hspeasia. pasien diberikan infus intravena kontinyu pompa proton inhibitor dan standar triple therapy regimens untuk terapi eradikasi h. pylori. kata kunci: helicobacter pylori, ulkus peptikum, east-asian-type caga, vaca. abstract we reported a male, 72 yo, chinese ethnic with chief complaint black mushy defecation. physical examination revealed pale on conjunctival palpebra which confirmed as anemia on complete blood count. gastroduodenoscopy revealed a 3 mm ulcer at the antrum (forrest stage iii). h. pylori infection was positive based on five different test methods (urinary antibody tests, rapid urease test, culture, histology ad immunohistochemistry). used polymerase chain reaction-based sequencing, we found the patient infected by caga producing, east-asian-type caga and vaca s1m1-strain. further analysis using 7 housekeeping genes confirmed that the strain categorized in to hspeasia group. the patient was given continuous intravenous infusions of proton pump inhibitor and standard triple therapy regimens eradication of h. pylori. keywords: helicobacter pylori, gastric ulcer, east-asian-type caga, vaca. 308 yudith aa. rezkitha acta med indones-indones j intern med introduction gastric ulcer (gu), part of peptic ulcer disease (pud), is a deep lesion penetrating through the entire thickness of the gastro intestinal mucosa and muscularis mucosa with a diameter of at least 0.5 cm.1 helicobacter pylori infection plays an important role in the pathogenesis of gu, causes more than 90% of cases when non steroidal anti-inflammatory agents (nsaid) are excluded.2 several studies reported that caga and vaca, the best studied being virulence factors of h. pylori, are a risk factor of gu.3,4 nomura et al.3 reported that subjects with seropositivity for both h. pylori and caga had an odds ratio of 4.4 (95% ci: 1.8, 10.5) for gu. in addition, in vitro study reported that caga with an epiya-d segment (east-asiantype caga) has a higher binding affinity to src homology-2 domain-containing phosphatase 2 (shp2) than caga with an epiya-c (westerntype caga). further, individuals infected with east-asian-type caga strains reportedly have an increased risk of pud compared with those with western-type caga strains.5 on the other hand, the gene encoding vaca displays allelic diversity including the signal (s) regions s1 and s2 and middle (m) regions m1 and m2. based on in vitro experiments, s1m1 strains have the highest cytotoxicity because they consistently induce cell vacuolation, followed by s1m2 strains (in which cell vacuolation is not consistently induced) and s2m2 strains, which have no cytotoxic activity due to a failure to induce cell vacuolation.6 in agreement with in vitro data, many studies examining populations in western countries7-9 have shown that individuals infected with vaca s1 or m1 h. pylori strains have an increased risk of pud compared with those with s2 or m2 strains. in contrast with several southeast asian countries where have high prevalence of h. pylori infection; e.g., the h. pylori infection rate reported ranged from 54.1–76.1% in thailand, most researchers reported low prevalence of h. pylori infection in indonesia; 0–11.2% by the urea breath test and 5.7–12.8% by histology.10 interestingly the highest h. pylori prevalence on surabaya, indonesia was found in patients from the chinese indonesian population instead of patients from the javanese population,10 although the prevalence of h. pylori infection in indonesians of chinese descent was lower than that of chinese non-immigrants.11 moreover multilocus sequence typing (mlst) of seven housekeeping genes from different geographical, ethnic, and/or linguistic origins identified a high incidence of gastric cancer was found in regions prevailed by hp east-asia strains (including china, japan and korea) than other population.12 we reported a chinese indonesian patient was infected with an east-asian-type caga h. pylori with clinical manifestation gu. case illustration a 72 years old male, chinese indonesian ethnic (father, mother and grandparents are chinese ethnic), was admitted to the hospital for having black mushy defecation since 3 days ago. he also had abdominal discomfort since 5 months ago, aggravated by meals without radiating pain and temporary relief by antacids. p h y s i c a l e x a m i n a t i o n s r e v e a l e d t h e conjunctival palpebra were pale and no sign of jaundice. there was no lymph nodes enlargement. the thorax and abdominal examination was normal. the extremities were a few pale. complete blood count revealed hemoglobin 8 g/dl, hematocrit 23%, leukocytes 7300/ul, granulocytes 75%, platelets 378.000/ul. the biochemical analysis were sgot 11/ul, sgpt 8/ul, albumin 3.86 g/dl, total bilirubin 0.52 mg/ dl, direct bilirubin 0.16 mg/dl, bun 17 mg/dl, creatinine 0.98 mg/dl, random blood glucose 105 mg/dl, sodium 137 meq/l, potassium 3.7 meq/l, chloride 107 meq/l and hbsag negative. h. pylori urinary antibody test result was positive. chest x-ray showed the heart and lungs were normal. abdominal ultrasonography showed the liver size within normal limit and there was no splenomegaly. gastroduodenoscopy revealed a 3 mm ulcer at the antrum which categorized on forrest stage iii (figure 1). biopsy was taken three from antrum used for h. pylori culture, rapid urease test (clo-test), and histological examination of specimens and one from the corpus for histological examination. the result was positive for clo-test. histology examination confirmed by immunohistochemistry showed 309 vol 48 • number 4 • october 2016 an east-asian-type caga helicobacter pylori infected patient h. pylori positive with density 1 both in the antrum and corpus. based on the updated sydney system; the degree of neutrophil activity, inflammation, atrophy and intestinal metaplasia were 1, 2, 1, 0, respectively for antrum and 1, 1, 0, 0, respectively for body. according to the operative link on gastritis assessment (olga) system, the degree of gastritis scores was stage 1. the h. pylori bacteria culture were growth, we termed as the sbypud-1 strain. the polymerase chain reaction (pcr) amplification of caga conserved region was caga producer, whereas vaca genotype was s1m1. the lists of primers are shown in table 1. direct sequencing of a conserved region of caga identified epiya-a, -b and -d segments, therefore categorized in to east-asian-type caga (figure 2). the sequences of seven housekeeping genes confirmed this strain categorized in to hspeasia group (figure 3). the patient was given soft and low fiber diet, 80 mg intravenous bolus pantoprazole followed by infusion 8 mg/h. he was also given h. pylori gastric ulcert gastric ulcert figure 1. antral gastric ulcer (forrest iii) was confirmed by gastroduodenoscopy examination which maybe a cause of melena. table 1. the primers used for detecting virulence factors of h. pylori genes name of primer primer sequences (5’→3’) pcr product (bp) pcr conditions caga cagomf agcaaaaagcgaccttgaaa 521 95°c, 1 min; 56°c, 1 min; 72°c, 1 min (35 cycles)cagomr agtggctcaagctcgtgaat vaca 94°c, 1 min; 52°c, 1 min; 72°c, 1 min (35 cycles) s1/s2 vai-f atggaaatacaacaaacacac 259/268 vai-r ctgcttgaatgcgccaaac m1/m2 vag-f caatctgtccaatcaagcgag 567/642 vag-r gcgtcaaaataattccaagg atpa atpa-f ggactagcgttaaacgcacg 821 94°c, 1 min; 56°c, 1 min; 72°c, 1 min (35 cycles)atpa-r cttgaaaccgacaagcccac efp efp-f ggcaatttggatgagcgagctc 642 94°c, 1 min; 56°c, 1 min; 72°c, 1 min (35 cycles)efp-r cttcaccttttcaagatactc muty muty-f gtggttgtagytggaaactttacac 639 94°c, 1 min; 56°c, 1 min; 72°c, 1 min (35 cycles)muty-r cttaagcgtgtgtytttctagg ppa ppa-f ggagattgcaatgaatttaga 676 94°c, 1 min; 53°c, 1 min; 72°c, 1 min (35 cycles)ppa-r gtggggttaaratcgttaaattg trpc trpc-f tagaatgcaaaaaagcatcgccctc 950 94°c, 1 min; 58°c, 1 min; 72°c, 1 min (35 cycles)trpc-r taagcccgcacactttattttcgcc urei urei-f aggttattcgtaaggtgcg 875 94°c, 1 min; 53°c, 1 min; 72°c, 1 min (35 cycles)urei-r gtttaaatcccttagattgcc yphc yphc-f cacgcctatttttttgactaaaaac 950 94°c, 1 min; 55°c, 1 min; 72°c, 1 min (35 cycles)yphc-r cattyaccctcccaatgatgc 310 yudith aa. rezkitha acta med indones-indones j intern med eradication therapy consisted of pantoprazole 2x20 mg, clarithromycin 2x500 mg, amoxicillin and 2x1 g for 7 days. the black mushy defecation was stop on 3rd day of admission. discussion although h. pylori was discovered more than 30 years ago by warren and marshall.13, consensus e p i y a k v n k k k a g q a t s p e e p i y a q v a k k v s a k i d q l n e a a s sbypud-1 e p i y a q v n k k k a g q v a s p e e p i y a q v a k k v n a r i d r l n k i a s consensus a i n r k i d r i n k i a s a g k g v g g f s g a g r s a s p e p i y a t i d f d e a n q a g sbypud-1 t i n a k v d q l n k t a s a s k g v g g f s g a g r s a s p e p i y a t i d f d e a n q a g epiya-a epiya-b epiya-d figure 2. sequence analysis of caga structural polymorphisms of sbypud-1 strain. sequences of a, b and d segments almost similar with segments in east-asian-type caga consensus. hspamerind s b y p u d -1 0.01 hpeurope hspeastasia hspmaori hpeastasia hpsahul hpasia2 hpneafrica hpafrica2 hpafrica1 figure 3. phylogenetic tree of sbypud-1 based on the seven housekeeping genes of h. pylori. sequence data sets of the seven housekeeping genes of 1,126 strains with different genotypes were obtained from the pubmlst database (62 from hpasia2, 493 from hpeurope, 76 from hpneafrica, 50 from hpsahul, 28 from hpafrica2, 279 from hpeastasia, and 138 from hpafrica1) then compared to sbypud-1. neighbor-joining trees were constructed in mega v.5.05 using kimura-2 parameters. the scale bar indicates genetic distance. which method should be considered as a gold standard for detection of h. pylori infection remains unclear. culture from biopsy specimens has the potential of leading to a high sensitivity, given that only one bacterium can multiply and provide billions of bacteria. however, both strict transport conditions and careful handling in the laboratory are necessary. on the other hand rapid urease test, such as the clo test, can be useful as a rapid diagnostic method. however, these results can also be affected by the bacterial load.14 histological diagnosis depends on the density of h. pylori biopsy sites; thus, these tests can occasionally show false negative results and very much dependent on the expertise of the pathologists. immunohistochemistry staining could increase histology accuracy due to using a specific h. pylori antibody which has the highest sensitivity and specificity and better interobserver agreement compared to histochemical stains.15 therefore the combination of two or more tests should be applied to determine the accurate prevalence of infection. although h. pylori infection is a major factor to severe gastroduodenal disease, the infection remains latent in the majority of infected patients, and only a minority of individuals with h. pylori infection ever develop the disease.16 the difference of h. pylori infection rate is not enough to explain the difference of the incidence of gastric cancer around the world. in addition to host and environmental factors, as a part, the difference of the incidence of gastric cancer irrespective of h. pylori infection rate can be explained by the difference of virulence factors.17 in general, strains with caga positive 311 vol 48 • number 4 • october 2016 an east-asian-type caga helicobacter pylori infected patient (especially east-asian-type caga) and vaca s1m1 are considered to be more virulent and induced higher inflammation and/or atrophy than caga-negative, western-type caga, and/or other vaca types. in fact, the investigators from the early and mid-twentieth century in malaysia and java, indonesia reported that gastric cancer and pud typically associated with h. pylori, were rare in the indigenous populations but were common among the more recently arrived chinese and indian immigrants.18 it is suggested that the chinese indonesian might be become a high-risk population of h. pylori associated disease even in indonesia. mlst characterized isolates of bacterial and fungal species using nucleotide sequences of internal fragments of housekeeping genes. this method is finding a place in clinical microbiology and public health by providing data for epidemiological surveillance19 and also reported to give more detailed information about human population structure than the method using human microsatellite or mitochondrial dna.20 recently, the genomic diversity within h. pylori populations was examined by employing the mlst method using 7 housekeeping genes (atpa, efp, muty, ppa, trpc, urei, and yphc).2123 at present, h. pylori strains can be divided into seven population types on the basis of geographical associations and designated as follows: hpeurope, hpeastasia, hpafrica,1 hpafrica2, hpasia2, hpneafrica, and hpsahul.23 hpeurope includes almost all h. pylori strains isolated from ethnic europeans, including people from countries colonized by europeans. hpeastasia is common in h. pylori isolates from east asia also includes subpopulations, i.e. hspmaori (polynesians, melanesians, and native taiwanese), hspamerind (amerindians), and hspeasia (east asians). hpasia2 strains have been isolated in south, southeast, and central asia. hpafrica1 includes 2 subpopulations, hspwafrica and hspsafrica; hpafrica2 is very distinct and has only been isolated in south africa. hpneafrica is predominant in isolates from northeast africa. hpsahul strains are isolated from aborigines of australia and highlanders in new guinea.24 this case report patient was categorized as hspeasia, which suggested that his descents were likely from east asian region. it is also confirmed the previous study that the hspeasia group mostly contained east-asian-type caga and vaca s1m1.17 most patients with pud present with abdominal discomfort, pain or nausea. the pain is located in the epigastrium and usually does not radiate. however, these symptoms are neither sensitive nor specific. classically, gu pain is aggravated by meals, whereas the pain of duodenal ulcers is relieved by meals. hence, patients with gus tend to avoid food and present with weight loss, while those with duodenal ulcers do not lose weight.25 although it is still controversy about the ability of h. pylori infection as the initial or primary cause of the gu, there is no doubt of the value of h. pylori eradication leading to long-term healing of gu. eradication of this bacterium improves gu recovery and is a primary and secondary prophylaxis to reduce the risk of recurrent ulcer bleeding. a meta-analysis suggested a remission rate of 97% of gu after successfully eradicating infection compared to 61% in patients with persistent infection. in addition, treatment of h. pylori infection is superior to ulcer healing drugs and reduces recurrent bleeding by 17% compared with ranitidine or omeprazole. the use of iv ppi is perhaps best established in the treatment of complicated pud, and has largely replaced the use of h2ra. a meta-analysis of 24 randomized controlled trials with 4373 patients, comparing iv or oral ppi with placebo or h2ra in bleeding pud, reported that ppi treatment in pud bleeding reduces rebleeding and surgery compared with placebo or h2ra. several studies have looked at the efficacy of ppis, given in a combination of oral, iv bolus (defined as administration with an iv push at regular intervals) and high dose iv continuous infusion forms (usually preceded by an 80 mg bolus iv push, followed by an infusion at 8 mg/h), in achieving and maintaining this ph target goal of >6.26 according to current guidelines, standard triple therapy containing a ppi and two antibiotics, amoxicillin and clarithromycin or metronidazole, is still the first-line regimen for treatment of h. pylori infection.27-30 however, in recent years, 312 yudith aa. rezkitha acta med indones-indones j intern med the efficacy of legacy triple regimens has been seriously challenged and eradication rates lower than 70% are now reported in many countries.31 unfortunately indonesia only has old local antimicrobial resistance data, around 10 years ago and collected from 1 city which cannot be generalized across indonesia.32 first-line treatment should be recommended on the basis of an understanding of the local prevalence of h. pylori antimicrobial resistance.33,34 the local antibiotic resistance surveillance update, selection of appropriate first-line regimen and detail evaluation of patient prior antibiotic usage are essensial to combat h. pylori antibiotic resistance in indonesia. conclusion in addition to the positivity of h. pylori infection, the severity of gastroduodenal disease outcome could be explained by the difference of h. pylori virulence factors. references 1. tarnawski a, szabo il, husain ss, soreghan b. regeneration of gastric mucosa during ulcer healing is triggered by growth factors and signal transduction pathways. j physiol paris. 2001;95(1-6):337-44. 2. ballesteros-amozurrutia ma. peptic ulcer and helicobacter pylori. results and consequences of its eradication. rev gastroenterol mex. 2000;65(4suppl 2):41-9. 3. nomura am, perez-perez gi, lee j, stemmermann g, blaser mj. relation between helicobacter pylori caga status and risk of peptic ulcer disease. am j epidemiol. 2002;155(11):1054-9. 4. matsunari o, shiota s, suzuki r, watada m, kinjo n, murakami k, fujioka t, kinjo f, yamaoka y. association between helicobacter pylori virulence factors and gastroduodenal diseases in okinawa, japan. j clin microbiol. 2012;50(3):876-83. 5. vilaichone rk, mahachai v, tumwasorn s, wu jy, graham dy, yamaoka y. molecular epidemiology and outcome of helicobacter pylori infection in thailand: a cultural cross roads. helicobacter. 2004;9(5):453-9. 6. sahara s, sugimoto m, vilaichone rk, mahachai v, miyajima h, furuta t, yamaoka y. role of helicobacter pylori caga epiya motif and vaca genotypes for the development of gastrointestinal diseases in southeast asian countries: a meta-analysis. bmc infect dis. 2012;12:223. 7. atherton jc, cao p, peek rm, jr., tummuru mk, blaser mj, cover tl. mosaicism in vacuolating cytotoxin alleles of helicobacter pylori. association of specific vaca types with cytotoxin production and peptic ulceration. j biol chem. 1995;270(30):17771-7. 8. sugimoto m, yamaoka y. the association of vaca genotype and helicobacter pylori-related disease in latin american and african populations. clin microbiol infect. 2009;15(9):835-42. 9. sugimoto m, zali mr, yamaoka y. the association of vaca genotypes and helicobacter pylori-related gastroduodenal diseases in the middle east. eur j clin microbiol infect dis. 2009;28(10):1227-36. 10. miftahussurur m, shiota s, suzuki r, et al. identification of helicobacter pylori infection in symptomatic patients in surabaya, indonesia, using five diagnostic tests. epidemiol infect. 2015;143(5):986-96. 11. shi r, xu s, zhang h, ding y, sun g, huang x, chen x, li x, yan z, zhang g. prevalence and risk factors for helicobacter pylori infection in chinese populations. helicobacter. 2008;13(2):157-65. 12. yamaoka y. helicobacter pylori typing as a tool for tracking human migration. clin microbiol infect 2009;15(9):829-34. 13. marshall bj, warren jr. unidentified curved bacilli in the stomach of patients with gastritis and peptic ulceration. lancet. 1984;1(8390):1311-5. 14. mégraud f, lehours p. helicobacter pylori detection and antimicrobial susceptibility testing. clin microbiol rev. 2007;20(2):280-322. 15. nguyen lt, uchida t, kuroda a, et al. evaluation of the anti-east asian caga-specific antibody for caga phenotyping. clin vacc immunol. 2009;16(11):168792. 16. kusters jg, van vliet ah, kuipers ej. pathogenesis of helicobacter pylori infection. clin microbiol rev. 2006;19(3):449-90. 17. yamaoka y. mechanisms of disease: helicobacter pylori virulence factors. nat rev gastroenterol hepatol. 2010;7(11):629-41. 18. graham dy, yamaoka y, malaty hm. thoughts about populations with unexpected low prevalences of helicobacter pylori infection. transact royal soc trop med hygiene. 2007;101(9):849-51. 19. sullivan cb, diggle ma, clarke sc. multilocus sequence typing: data analysis in clinical microbiology and public health. mol biotechnol. 2005;29(3):245-54. 20. wirth t, wang x, linz b, novick rp, lum jk, blaser m, morelli g, falush d, achtman m. distinguishing human ethnic groups by means of sequences from helicobacter pylori: lessons from ladakh. proc natl acad sci usa. 2004;101(14):4746-51. 21. falush d, wirth t, linz b, et al. traces of human migrations in helicobacter pylori populations. science. 2003;299(5612):1582-5. 22. linz b, balloux f, moodley y, et al. an african origin for the intimate association between humans and helicobacter pylori. nature. 2007;445(7130):915-8. 23. moodley y, linz b, yamaoka y, et al. the peopling of the pacific from a bacterial perspective. science. 313 vol 48 • number 4 • october 2016 an east-asian-type caga helicobacter pylori infected patient 2009;323(5913):527-30. 24. s u z u k i r , s h i o t a s , ya m a o k a y. m o l e c u l a r epidemiology, population genetics, and pathogenic role of helicobacter pylori. infect genet evol. 2012;12(2):203-13. 25. amandeep k, robin s, ramica s, sunil k. peptic ulcer: a review on etiology and pathogenesis. int res j pharm. 2012;3(6):34-8. 26. pang sh, graham dy. a clinical guide to using intravenous proton-pump inhibitors in reflux and peptic ulcers. ther advanc gastroenterol. 2010;3(1):11-22. 27. fock km, katelaris p, sugano k, et al. second asiapacific consensus guidelines for helicobacter pylori infection. j gastroenterol hepatol. 2009;24(10):1587600. 28. kim sg, jung hk, lee hl, jang jy, lee h, kim cg, shin wg, shin es, lee yc. korean college of upper gastrointestinal r. [guidelines for the diagnosis and treatment of helicobacter pylori infection in korea, 2013 revised edition]. korean j gastroenterol. 2013;62(1):3-26. 29. asaka m. a new approach for elimination of gastric cancer deaths in japan. int j cancer. 2013;132(6):12726. 30. chinese society of gastroenterology csgohp, liu wz, xie y, cheng h, et al. fourth chinese national consensus report on the management of helicobacter pylori infection. j dig dis. 2013;14(5):211-21. 31. papastergiou v, georgopoulos sd, karatapanis s. treatment of helicobacter pylori infection: meeting the challenge of antimicrobial resistance. world j gastroenterol. 2014;20(29):9898-911. 32. kumala w, rani a. patterns of helicobacter pylori isolate resistance to fluoroquinolones, amoxicillin, clarithromycin and metronidazoles. southeast asian j trop med public health. 2006;37(5):970-4. 33. shiota s, murakawi k, suzuki r, fujioka t, yamaoka y. helicobacter pylori infection in japan. expert rev gastroenterol hepatol. 2013;7(1):35-40. 34. miftahussurur m, yamaoka y. appropriate first-line regimens to combat helicobacter pylori antibiotic resistance: an asian perspective. molecules. 2015;20(4):6068-92. 414 acta med indones indones j intern med • vol 54 • number 3 • july 2022 original article the role of high sensitivity c-reactive protein to predict delirium persistence in elderly patients with pneumonia: a prospective cohort study roza mulyana1*, yuliarni syafrita2, hirowati ali3, arina w. murni1 1department of internal medicine, faculty of medicine universitas andalas, padang, sumatera barat, indonesia. 2department of neurology, faculty of medicine universitas andalas, padang, sumatera barat, indonesia. 3department of biomedics, faculty of medicine universitas andalas, padang, sumatera barat, indonesia. *corresponding author : roza mulyana, md. department of internal medicine, faculty of medicine universitas andalas – m. djamil hospital. jl. perintis kemerdekaan padang 25171, sumatera barat, indonesia. email: mulyanaroza@yahoo.com. abstract background: delirium is a disorder of acute full attention, and cognitive function commonly occurs at elderly which can prolong hospitalization, dependence rate, morbidity, and mortality, with pneumonia infection as one of its risk factors. several markers have been studied for delirium, but relationship between delirium severity and persistence remains unclear. this study aimed to examine the role of hs-crp, pnf-h, s100b, and nlr to predict delirium persistence. methods: a prospective cohort study was conducted among 80 subjects who were admitted to the internal ward in dr. m. djamil hospital in padang. subjects were grouped based on severity of delirium using the memorial delirium assessment scale and followed up until discharged to determine delirium persistence event. results: mean age of subjects is 70.7±7.4 years, 39 (48.8%) male and 41 (51.2%) female,consisting of 29 mild, 26 moderate, and 25 severe delirium. levels of hs-crp in mild, moderate, and severe delirium are 13.36±0.79, 13.56±0.78, and 13.88±0.59 mg/l (p=0.038), respectively. median nlr values for mild, moderate, severe delirium were 6.80 (1.00-31.00), 9.50 (3.60-46.00), and 11.90 (2.80-46.50) (p=0.026). cut off value hs-crp 13.61 mg/l has significant difference for delirium persistence event (or 2,54; 95% ci 1,01-6,39). median levels of pnf-h and s100b are not significant in different delirium severity, regardless of non-persistent or persistent. conclusion: hs-crp levels exceeding 13.61 can predict risk of persistent delirium, but not with levels pnf-h, s100b, and nlr. keywords: delirium persistence, hs-crp, elderly, pneumonia. introduction delirium is an acute global impairment of attention and cognitive function common in old age.1 the incidence of delirium is associated with prolonged length of stay, high mortality, and risk for cognitive impairment later in life. delirium occurs due to the interaction between predisposing factors that determine the susceptibility of the patient and precipitating factors.1 infection is one of the triggers of delirium.2 pneumonia is the most common infection and is the leading cause of hospitalization and death in the elderly. the incidence of delirium during hospitalization in pneumonia patients is about 31%.3 research shows delirium is a predictor of mortality in elderly pneumonia patients.4 delirium conditions can be reversible but can also persist for a longer time, known as persistent delirium. several studies set different times as a standard for persistent delirium, one of which is at the time of discharge.5 cole et al. found a persistent delirium proportion of 44.7% upon vol 54 • number 3 • july 2022 the role of high sensitivity c-reactive protein 415 discharge.6 lee et al.5 found prolonged delirium in elderly patients after hip fracture surgery 20% at four weeks.5 this persistent condition of delirium sometimes causes confusion and misunderstanding for families. systemic inflammation will continue to be neuroinflammatory and cause increase in bloodbrain barriers’ permeability leading to damage to the synapse.7 the severity of inflammation in infection can be assessed by various markers, including high sensitivity c-reactive protein (hs-crp) and neutrophil-lymphocyte ratio (nlr). systemic inflammation will continue to be neuroinflammatory and cause activation of microglia and astrocytes, which will excrete s100 beta (s100b).8 mietani et al. observed elevated level of phosphorylated neurofilament heavy subunits (pnf-h), the main structures of the central axons of the nervous system levels, in 30 of the 41 patients who had non-cardiac postoperative delirium under general anesthesia.9 it is not yet clear whether hs-crp, pnf-h, s100b, and nlr are associated with the persistence of delirium. this study aims to determine the role of hs-crp, nlr, s100b, and pnf-h levels in predicting risk of persistence of delirium in elderly patients with pneumonia in the acute medical ward. methods this prospective cohort study was conducted in the acute medical ward of dr. m. djamil hospital from february 2021 to december 2021. subjects were recruited after obtaining approval from ethical review board. the study sample was delirium patients aged 60 years or older with pneumonia infection. patients who consumed antipsychotic drugs, suffered parkinson’s, acute stroke, rheumatoid arthritis, head trauma, or undergoing surgery were excluded. eligible patients were followed up until discharge. patients who were still delirium when discharged were classified as persistent delirium. ethical approval the research ethics committee of medical faculty andalas university number 227/ un.16.2/kep-fk/2021. delirium assessment delirium was assessed using the confusion assessment method-intensive care unit instrument. delirium was diagnosed if there is a change in mental status with acute onset or fluctuating course, inattention, disorganized thinking, or altered level of consciousness.10 a geriatrician carried out delirium assessments. the severity of delirium was assessed with the memorial delirium assessment scale (mdas), which has ten items with four scales and a maximum value of 30. an mdas score of 1316 indicates mild delirium, a score of 17-24 moderate, and severe delirium if the score >24. 11 specimen collection and methods of analyses a 3 ml blood sample was collected within 24 hours of hospitalization in an acute medical ward. serum was separated within 2 hours and stored at a temperature of -800c until later analysis. examination of hs-crp, s100b, and pnf-h is carried out at the biomedical laboratory of the faculty of medicine, universitas andalas. serum concentrations of hs-crp, pnf-h, and s100b were measured by the enzyme-link immunosorbent assay (elisa) by biorad. hscrp was measured using high sensitivity human elisa kits (dbc canada), abbexa for pnf-h, and lsbio reagent for s100b analyzed. each examination was carried out duplo. the nlr assessment was carried out by calculating the differential count of leukocytes at the central laboratory of dr. m. djamil hospital padang. statistical analysis differences in hs-crp levels at varying severity of delirium were analyzed with anova, while differences in nlr values, pnf-h levels, and s100b were analyzed with the kruskal wallis test because the data were not normally distributed. the role of these markers in predicting persistent delirium is done by first establishing a cut-off point using the receiver operating characteristic curves. the analysis continued with multivariate logistic regression. furthermore, the odds ratio of each marker is determined in predicting risk of persistent delirium. the odds ratio not crossing one is said to be significant. roza mulyana acta med indones-indones j intern med 416 results of the 170 patients initially screened for the study, 15 patients were excluded and 75 patients died before discharge. thus, 80 patients completed the study and were included in the analysis. thirty-two (40%) subjects were still in delirium at discharge and classified as persistent delirium (figure 1). the average age of the study subjects was 70.7±4 years. about half of the subjects were women (51.2%), comorbidities were chronic kidney disease (52.50%), diabetes mellitus (50%), and hypertension (50%). (table 1). table 2 shows differences in hs-crp, pnf-h, s100b, and nlr levels at varying severity of delirium. there were significant differences in hs-crp and nlr levels between mild, moderate, and severe delirium, with the highest value in severe delirium. subject recruitment (n=170) excluded (n=15) drop out (n=75) due to death before discharge subject analyzed (n=80) mild delirium (n= 29) moderate delirium (n= 26) severe delirium (n= 25) not persistent (n = 48) persistent (n = 32) figure 1. subject recruitment flow. table 1. subject characteristics (n=80). characteristics total persistent delirium(n=32) non-persistent delirium (n=48) age (mean ± sd) 70.7±7.4 71.5±7.3 70.2±7.6 gender male (n, %) female (n, %) 39 (48.8) 41 (51.2) 12 (37.5) 20 (62.5) 27 (56.3) 21 (43.8) comorbidities (n, %) diabetes hypertension cardiac disease chronic kidney disease (ckd) 40 (100.0) 40 (100.0) 26 (100.0) 42 (100.0) 18 (45.0) 18 (45.0) 14 (53.8) 19 (45.2) 22 (55.0) 22 (55.0) 12 (46.2) 23 (54.8) delirium severity mild 29 (100.0) 2 (6.9) 27 (93.1) moderate 26 (100.0) 9 (34.6) 17 (65.4) severe 25 (100.0) 21 (84.0) 4 (16.0) sd, standard deviation table 2. hs-crp, pnf-h, s100b, and nlr levels at the baseline. variables total mild delirium (n=29) moderate delirium (n=26) severe delirium (n=25) p value hs-crp (mg/l) pnf-h (pg/ml) s100b (pg/ml) nlr 13.59±0.75 598 (18.36-4759.94) 21.73 (17.49-531.16) 9.35 (1.00-46.50) 13.36±0.79 605.86 (18.36-3309.20) 22.74 (17.91-36.99) 6.80 (1.00-31.00) 13.56±0.78 542.12 (25.28-4759.94) 21.53 (18.13-99.23) 9.50 (3.60-46.00) 13.88±0.59 643.27 (82.09-4669.88) 20.89 (17.49-37.68) 11.90 (2.80-46.50) 0.038 0.813 0.074 0.026 vol 54 • number 3 • july 2022 the role of high sensitivity c-reactive protein 417 the analysis results showed that hs-crp was significantly associated with persistent delirium events. subjects with hs-crp levels exceeding 13.61 had a 2.5-fold increased risk of delirium persistence, whereas pnf-h, s100b, and nlr levels showed no significant association with delirium persistence. discussion the study found high levels of hs-crp (exceeding 13.61 mg/l) can predict the risk of persistent delirium (or 2.54, 95%ci 1.01-6.39), but this is not the case with pnf-h, s100b, and nlr. in systemic inflammatory conditions, neutrophils activate and cross endothelial cells in the vascular brain, and release reactive oxygen species (ros) and proteases, which will cause the destruction of endothelial cell arrangement. disruption of the blood-brain barrier will increase the transport of cytokines to the brain. these cytokines will activate microglia that produce inflammatory markers and reactive oxygen species (ros).12,13 the formation of ros by neutrophils and microglia causes oxidative stress that leads to neuronal damage and apoptosis.14 endothelial dysfunction will cause impaired blood flow and the release of various biochemical mediators resulting in delirium.15 systemic inflammation will continue to be neuroinflammatory and cause various activation of microglia and astrocytes which will excrete s100b, a calcium-bound protein that will increase neuronal inflammatory conditions and blood-brain barriers’ permeability. damage to the blood-brain barrier will increase the transport of cytokines to the brain leading to damage to the synapse.7 high sensitivity-crp is a relatively stable marker for a long time and has high sensitivity, in contrast to s100b, which has a short half-life so that within 24 hours, it returns to normal levels.16 evident in this study, s100b levels are generally normal (<100 pg/ml). ischemia and neuron apoptosis lead to neuronal damage characterized by high pnf-h levels in delirium subjects. the pnf-h levels found in neuron axon damage can last up to 21 days. almost all delirium patients in this study had positive pnf-h levels and did not differ in those who were persistent or not. hayakawa et al. concluded that s100b could be used as an early marker, while pnf-h is used as a delayed marker in neuronal injury.17 research on the relationship between crp and persistent delirium is still lacking. some existing studies only link crp levels to the occurrence of delirium. zhang, who examined crp levels in icu patients, found an increase in crp >8.1 mg/l in 24 hours associated with a 4-fold increased risk of delirium. patients with delirium had a longer treatment duration than patients without delirium. this study did not record the incidence of persistent delirium.18 research on patients undergoing vascular surgery also showed crp as a marker for an increased risk of post-surgical delirium events.19 (pol). vasunilashorn’s study (2017) found high crp levels associated with delirium duration.20 mcgrane (2011) found a link between hs-crp levels and the shorter duration of delirium free in critically ill patients.21 this study supports the role of hs-crp as an inflammatory marker in predicting the risk of persistent delirium. further research with larger sample size and different subjects is needed to support this finding. high levels of hs-crp also indicate the severity of the inflammatory process occurring in delirium patients. the limitation of this study is the definite onset of delirium was unclear because patients had had delirium when admitted to the ward. table 3. relationship of hs-crp, pnf-h, s100b, and nlr levels with delirium persistence. bivariate analysis multivariate analysis variable cut off auc (95% ci) or (95% ci) p value or (95% ci) p value hs-crp (mg/l) 13.61 0.627 (0.504-0.751) 2.54 (1.01-6.39) 0.045 2.54 0.047 pnf-h (pg/ml) 549.00 0.508 (0.370-0.640) 0.75 (0.30-1.83) 0.523 s100b (pg/ml) 21.58 0.459 (0.326-0.592) 0.53 (0.21-1.31) 0.167 0.74 0.583 nlr 9.35 0.538 (0.409-0.668) 1.52 (0.62-3.74) 0.361 auc area under the curve, or odd ratio roza mulyana acta med indones-indones j intern med 418 conclusion high sensitivity of c-reactive protein but not pnf-h, s100b, and nlr could be used to predict the risk of persistent delirium. conflict of interest all authors declare no conflict of interest related to this study. acknowledgments t h e a u t h o r s w o u l d l i k e t o t h a n k t o participants, nurses, research assistants, and laboratory staffs for participating in this study. references 1. inouye sk, growdon m, fong t. delirium. in: halter jb, ouslander jg, studenski s, et al, editors. hazzard’s geriatric medicine and gerontology. seventh edition. new york: mcgraw hill. 2017. p. 709-22. 2. george j, bleasdale s, singleton sj. causes and prognosis of delirium in elderly patients admitted to a district general hospital. age and aging. 1997; 26:423-7. 3. aliberti s, bellelli g, belotti m, et al. aging. clin exp res. 2015;27(4):523-31. 4. pieralli f, vannucchi v, mancini a, et al. delirium is a predictor of in-hospital mortality in elderly patients with community acquired pneumonia. intern emerg med. 2014;9(2):195-200. 5. lee kh, ha yc, koo kh. frequency risk factor and prognosis of prolonged delirium in elderly patients after hip fracture surgery. clin orthop relat res. 2011;469(9):2612-20. 6. cole mg, ciampi a, belzile e, zhong l. persistent delirium in older hospital patients: a systematic review of frequency and prognosis. age and ageing. 2008;38:19-26. 7. dillon st, vasunillashorn sm, ngo l, et al. higher c-reactive protein levels predict postoperative delirium in older patients undergoing major elective surgery: a longitudinal nested case-control study. biol psychiatry. 2017;15:81(2):145-53. 8. gao y, duan j, ji h, lu w. levels of s100 calcium binding protein b (s100b), neuron-specific enolase (nse), and cycliphillin a (cypa) in the serum of patients with severe craniocerebral injury and multiple injuries combined with delirium transferred from the icu and their prognostic value. ann palliat med. 2021;10(3):3371-8. 9. mietani k, sumitani m, ogata t, et al. dysfunction of the blood-brain barrier in postoperative delirium patients, referring to the axonal damage biomarker phophorylated neurofilament heavy subunit. plos one. 2019;14(10):e0222721. 10. ely ew, inouye aj, bernard gr, et al. delirium in mechanically ventilated patients, validity and reliability of the confusion assessment method for the intensive care unit (cam-icu). jama. 2001;286(21):2703-10. 11. kuswardhani t, sugi y. factors related to the severity of delirium in the elderly patients with infection. gerontol geriatric med. 2017;3(2):233372141773918. 12. cerejeira j, firmino h, vaz-serra a, mukaetovaladinska eb. the neuroinflammatory hypothesis of delirium. acta neuropathol. 2010;119(6):737-54. 13. tsuruta r, oda y. a clinical perspective of sepsisassociated delirium. j intens care. 2016;4(18):1-7. 14. egberts a, mattace-raso fu. increased neutrophillymphocyte ratio in delirium: a pilot study. clin intervent aging. 2017;12:1115-21. 15. mcneil jb, hughes cg, girard t, et al. plasma biomarkers of inflammation, coagulation, and brain injury as predictors of delirium duration in older hospitalized patients. plos one. 2019. https://doi. org/10.1371/journal.pone.0226412:1-10. 16. loy d, sroufe a, pelt j, et al. serum biomarkers for experimental acute spinal cord injury: rapid elevation of neuron-specific enolase and s-100beta. neurosurgery. 2005;56: 391–7. 17. hayakawa k, okazaki r, ishii k, et al. phosphorylated neurofilament subunit nf-h as a biomarker for evaluating the severity of spinal cord injury patients, a pilot study. spinal cord. 2012;50(7):493-6. 18. zhang z, pan l, deng h, ni h, xu x. prediction of delirium in critically ill patients with elevated c-reactive protein. j crit care. 2014;29:88-92. 19. pol ra, van leeuwen bl, izaks gj, et al. c-reactive protein predicts postoperative delirium following vascular surgery. am vasc surg. 2014;28:1923-30. 20. vasunilashorn sm, dillon st, inouye sk, ngo lh, fong tg, jones rn. high c-reactive protein predicts delirium incidence, duration, and feature severity after major non-cardiac surgery. j am geriatr soc. 2017;65(8):e109-e116. 21. mcgrane s, girard td, thompson jl, et al. procalcitonin and c-reactive protein levels at admission as predictors of duration of acute brain dysfunction in critically ill patients. critical care. 2011;15: (r78):1-8. 40 acta med indones indones j intern med • vol 55 • number 1 • january 2023 original article the role of new pulmonary artery wedge pressure formula to predict diastolic dysfunction in obstructive sleep apnea telly kamelia1*, lukman hakim makmun2 1 division of respirology and critical care, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo general hospital, jakarta, indonesia. 2 professor emeritus of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo general hospital, jakarta, indonesia. *corresponding author: telly kamelia, md, phd. division of respirology and critical care, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo general hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: tellykamelia99@gmail.com. abstract background: heart failure (hf) is a common condition with high morbidity and mortality in obstructive sleep apnea (osa), especially in obese patient. the causes of hf are often abnormal conduction pathways, pump filling and/or heart valves. right heart catheterization using swan-ganz catheter remains the gold standard to determine pulmonary hemodynamics, but it is costly and invasive. herein, we propose a new formula for noninvasive pulmonary artery wedge pressure (pawp) measurement using tissue doppler echocardiography. the purpose of this research is to explore the correlation between the new formula to calculate pawp to predict diastolic dysfunction in osa patients. methods: a cross-sectional study was conducted in jakarta, in march until october 2021. eighty-two subjects were enrolled in the study, consist of 34 females and 48 males. all subjects underwent polysomnography and tissue doppler echocardiography. noninvasive measurement of pawp were obtained from combined assessment of e/e’ and left atrial parameters. results: based on 82 subjects included, 66 subjects (80.5%) had obstructive sleep apnea, and 16 subjects (19.5%) did not have it. there was a significant difference in pawp between patients with and without osa (p value <0.01). ten subjects osa (12.1%) had diastolic dysfunction, while all non-osa subjects had normal diastolic function, with no statistical significance between two groups (p value = 0.20). diastolic dysfunction significantly associated with pawp measured using proposed formula (r = 0.240, p value = 0.030). conclusion: the new formula could be used to indirectly calculate pawp and predict diastolic dysfunction in osa. obstructive sleep apnea is associated with elevated pawp. the increased risk of diastolic dysfunction in osa, especially in obesity patient may indicate for the risk of cardiovascular morbidities. keywords: pulmonary artery wedge pressure, obstructive sleep apnea, diastolic dysfunction. introduction heart failure (hf) is a common condition with high morbidity and mortality, which places a significant financial burden on the community due to reduced productivity, repeated hospitalizations and treatment costs. moreover, 40% to 50% of patients who now present with heart failure with preserved ejection fraction (or hfpef) are reported to have sleep apnea.1 left ventricular diastolic dysfunction, defined by impaired relaxation of the myocardium, is a hallmark of heart failure in patients who present with heart failure reduced ejection fraction (hfref) or heart failure preserved ejection fraction (hfpef). this classification of hf causes is important, when one has to assess vol 55 • number 1 • january 2023 the role of new pulmonary artery wedge pressure formula 41 patients with hf for the possibility of sleep apnea and develop a treatment plan as some hf types may be more sensitive to obstructive sleep apnea (osa).2 diastolic dysfunction is a condition that reflects an impairment of the filling properties of the left ventricle (lv) that has been demonstrated to be a predictor of future development of heart failure. the association between osa and diastolic dysfunction is not well studied, although osa is frequent in heart failure patients. proposed mechanisms that affect left ventricular performance in patients with osa include several mechanical, neurohumoral, inflammatory, endothelial, and oxidative effects. more research is required to determine basic mechanisms by which osa exerts its adverse effects on the cardiovascular system. such investigations could include studies of the impacts of intermittent hypoxia on cardiovascular function at both cellular and molecular levels, and genetic susceptibilities to adverse cardiovascular risks of osa.3 left ventricular filling can be measured directly by placing a catheter in the left ventricle to obtain the end-diastolic pressure (lvedp), or indirectly by placing a catheter in the pulmonary artery to measure the pulmonary capillary wedge pressure (pcwp). both of these invasive techniques involve cardiac catheterization with its attendant risk and expense.1 echocardiography is essential to the evaluation of heart failure, and guidelines exist to identify diastolic dysfunction noninvasively. however, up to 50% of patients with hfpef have normal resting diastolic function parameters. on echocardiographic examination with doppler, the velocity of ve and va can be determined, where va is the rate of filling of the end-diastolic blood phase from la to lv due to la contraction as seen with p waves on the ecg. with this va velocity component, it can be used to determine the conversion formula from va to pulmonary artery wedge pressure (pawp), so that it is enough with a non-invasive examination to determine pawp pressure (pc = pulmonary capillary) indirectly, and there is no need to perform invasive catheterization again.2 extensive technical improvements in echocardiography have increased its sensitivity for quantifying pawp and it is now recognized as a safe and available alternative to right heart catheterization. pawp represents an alternative measure to left ventricular enddiastolic pressure (lvedp), which is the gold standard for determining left ventricular filling pressure.4 the mean pawp that integrates the atrial pressure tracing throughout systole and diastole provides an integrated measure of the hemodynamic burden imposed by the left atrial (la) operating compliance on the pulmonary circulation.5 pawp is a surrogate marker of left atrial pressure (lap). sleep apnea is often found in patients with heart failure. obstructive sleep apnea patients r e v e a l a c u t e a n d c h r o n i c h e m o d y n a m i c changes. nevertheless, the combination of sleep apnea and heart failure is different to the previously mentioned combinations (i.e. osa with hypertension and cad) as the majority of the sleep apnea cases are central or mixed in heart failure patients.3 nevertheless, osa can cause heart failure: systolic heart failure as after a myocardial infarction, or diastolic heart failure as is often the case in hypertensive patients. almost half of heart failure patients have a preserved systolic function, i.e. a left ventricular (lv) ejection fraction (lvef) >45%. lv hypertrophy (lvh) often seems t o b e a s s o c i a t e d w i t h t h i s lv d i a s t o l i c dysfunction.6 several predisposing factors for osa include obesity, neck circumference size, age, sex, hormones, and airway anatomic abnormalities. another study reported that neck circumference (>42.5 cm) was associated with an increase in apnea-hypopnea index (ahi).7 obesity can change the volume and anatomical shape; the tongue can be raised thereby reducing the volume of the upper airway. four large-scale prevalence studies suggest that one in five white adults with an average body mass index (bmi) of 25–28 kg/ m2 has an ahi 5 times per hour. it is reported that one in fifteen of osa patients has an ahi of 15 or more.8 telly kamelia acta med indones-indones j intern med 42 since the pawp is a substitute marker of left atrial pressure and chronic airflow obstruction is the most important cause of pulmonary artery remodeling that can lead to diastolic dysfunction, the main purpose of this study was to obtain the pulmonary artery wedge pressure (pawp) based on echocardiography, which was estimated using a new mathematical model formula based on measurements of left atrial pressure and the influencing factors with parameters related to the osa incidence. in addition, to build a new pawp formula using a mathematical model that functions as a non-invasive procedure to predict diastolic dysfunction and compare the new formula with the existing formula. methods this cross-sectional study was conducted in jakarta, between march until october 2021. the study was approved by universitas indonesia, faculty of medicine ethic committee (ket1205/un2.f1/etik/ppm.00.02/2020). this formula has been registered to the indonesian copyright service for predicting diastolic dysfunction in obstructive sleep apnea the new pulmonary artery wedge pressure (pawp) formula by lukman h. makmun (reg. no. ec00202297046 and reg. no. ec00202297063). we included obese subjects aged from 18 to 65 years. in asia-pacific countries, the agreed cutoff point for obesity was defined as bmi (kg/m2) between 25.0 and 29.9. written informed consent was obtained from all subjects. exclusion criteria included the following: unstable cardiorespiratory status, defined as the existence of respiratory failure, congestive heart failure, or if they were unable to participate. patient demographic data were obtained, including age, gender, body mass index, and blood pressure. each subject underwent polysomnography (somnomedics type 2) according to welle s t a b l i s h e d p r o c e d u r e . t h e m o n i t o r i n g included recording from surface leads for e l e c t r o e n c e p h a l o g r a p h y, b i t e m p o r a l electro-oculography, submental and leg electromyography, and electrocardiography. oxygen saturation and respiration was monitored by oronasal airflow and finger-pulse oximeter. polysomnography recordings were scored for sleep, breathing, and oxygenation. we took the average number episodes of apnea and hypopnea per hour of sleep (apnea/hypopnea index) and the time during sleep spent with an oxygen saturation below 90%. osa was diagnosed if the apneafigure 1. pathophysiology of diastolic dysfunction in obstructive sleep apnea and obesity6 vol 55 • number 1 • january 2023 the role of new pulmonary artery wedge pressure formula 43 hypopnea index (ahi) was more than 5 times in 1 hour of sleep. echocardiography was performed with an ultrasound system (general electronics ultrasound vivid e95) using 2.5and 3.5-mhz. images were stored digitally for off-line analysis using echopac software (general electronics). standard m-mode and 2-dimensional views were used. the following measurement were determined, such as peak early (e) and late (a) diastolic mitral annular velocity, the ratio of e and a velocities (e/a), and the deceleration time (dt). e’ ≤ 8 was used as an indicator of left ventricular diastolic dysfunction and e/e’ was calculated for the prediction of pcwp.9 diastolic dysfunction was classified according to recent guidelines: 1) normal diastolic function (e’ (lateral) >10 cm/s, e’ (medial) >8 cm/s and lavi <34 ml/m2 ; 2) mild diastolic dysfunction (e/a <0.8, e’ (lateral) <10 cm/s and e’ (medial) <8 cm/s and; 3) diastolic dysfunction with elevated filling pressures (e/e’ >13 cm/s or e/e’ >9 and lavi >34 ml/m2).9 during end diastolic phase, left atrium contracts to empty the remaining early and middiastolic blood volumes that remain in the left atrium (la-ved = la-volume end diastolic). there are amounts of blood transferred from the la into the lv. when the afterload has reached the maximum load, there is no further increase in the dimension length (maximum isometric), so it can be assumed that the magnitude of s and the laved is constant. 10 the systolic left atrial pressure determined as depicted previously relates to strain in the left atrium during the pulmonary s wave. essentially, diastolic left atrium pressure is the pressure during the pulmonary d wave.10 since pulmonary s and d waves have generally a similar duration, we estimated mean left atrial pressure as the average between systolic and diastolic left atrial pressure.10 at this end diastolic time, the la space is also filled with blood volume which will be partially flowed at a smaller speed, namely va which is normally smaller than ve. because after this phase, there is an isometric contraction phase, where there is no change in the size of the magnitude again, the volume of the heart chambers do not change. thus, the components for measuring la pressure can be collected, namely: geometric la volume, so that the blood volume in la can be calculated, so that the amount of blood mass that will press against the la stereometric wall is a force (f = force). la area dimensions can be calculated using stereometric mathematics. blood flow or displacement from la to lv, defined from la midpoint to lv midpoint or modified from la basal to mitral valve cross section, the distance or distance (d) can be determined.11 in the phase of ejection of blood into the aorta is also due to lv contraction which is an electrical stimulation of the lv, seen from the ecg picture with qrs complex. then begins the relaxation phase (diastole), in which lv pressure decreases and muscle tone decreases. meanwhile the la is filled with blood volume that has returned from oxygenation in the lungs, the pressure in the la increases while the pressure in the lv decreases, so that the mitral valve opens, massive lv filling occurs.11 while filling the lv, there is a replenishment of blood to the la. at the end of diastole, la contraction occurs which is indicated by a p wave on the ekg and a wave on the la pressure curve, and lv filling is seen which is described as an a wave which is a velocity so it is named va. the final pressure in the lv is lvedp (left ventricular end diastolic pressure). this lvedp pressure is equivalent to la pressure and is also equivalent to pawp (pulmonary artery wedge pressure).12 figure 2 normal cardiac pressure.5 figure 2. normal cardiac pressure.5 telly kamelia acta med indones-indones j intern med 44 based on that condition, pulmonary artery wedge pressure (pawp) can be estimated using new formula that we proposed using calculation of the conversion of the value of va to the pawp value (pc) equivalent to pla (pressure on the la area). this pressure stereometrically caused by the suppression of the blood volume contained in the la in the end diastolic phase. the final new simplified equation formula to calculate pawp: pla= 18,525 x va 2 mmhg (va on m/s) in determining the geometry calculation, because the shape of the heart resembles the shape a tube and also the length of the outer curved line is approximately equal to the height, it will have an error factor value for the final number of the constant 18.525. to determine the value of this error factor, it is actually necessary to compare it with the swan ganz catheter examination, which is the gold standard method for determining pawp. however, it is expensive, invasive, and there is also no medical indication for healthy people. amr abbas et al, using subjects with cardiovascular and pulmonary disease, compared the results of echo directly, namely trv (tricuspidal regurgitas velocity) with a right heart catheter and obtained pvr (pulmonal vascular resistant) values.13 the amr abbas formula would be (sensitivity 77% dan specivicity 81%): pvr = trv/tvirvot x10 + 0,16 nagueh s et al, performed simultaneous examination of hf patients with doppler echo and invasive.10 the researcher used the components: e’ and e velocity of the mitral valve. the nagueh formula is as follows: pcwp = 1,24* (e/ e’ ) + 1,9 e’ = (e’ lat + e ’ med) /2. the mean value of the early diastolic velocity of the mitral annulus is e’. e is the mitral inflow velocity in early diastolic. the echo mode used to determine e’ is tdi (tissue doppler imaging), by measuring the velocity of blood flow in the myocardial tissue at the angles of the mitral annulus septal and lateral during the early diastolic phase. by using the ratio e/e’, it is possible to determine the approximate size of the pcwp, the sensitivity and specificity are 66% and 50%. it is necessary to compare the pawp results according to the new formula with the nagueh formula as validation. statistical analyses were performed with spss version 25.0 for windows. the baseline subject characteristics were expressed as mean and minimum-maximum values or frequency and percentages for categorical data. normally distributed data were presented as mean and analyzed using student’s t test for comparisons of baseline characteristics and parameters between groups. non-parametric data were analyzed with mann-whitney u test. fisher’s exact test was used for univariate analysis to look for association between various factors. a value of p < 0.05 was considered significant. spearman’s correlation analysis was used to assess the possible correlation between osa and clinical data or echocardiographic variables. to i d e n t i f y s i g n i f i c a n t i n d e p e n d e n t determinants of resting and dynamic lv diastolic function in osa patients, their individual association with echocardiographic variables was assessed by multivariate analysis, using a bidirectional stepwise regression. results of 82 patients in this study, 48 (58%) were male and 34 (41%) female, with mean age was ± 49 (40-51) years. subjects in the osa group were 65% male and 34% female with mean age ± 49 (42-52) years than those in the non-osa group 31% male and 68% female with mean age ± 40 (30-49) years with p value < 0.01. the mean bmi measured in all study subjects was 32.60 ± 4.76 kg/m2. subject in the osa group had a bmi 32.87 ± 5.24, while those in the non-osa group 32.42 ± 3.81 but bmi did not significantly different between the 2 groups (p=0.75). vol 55 • number 1 • january 2023 the role of new pulmonary artery wedge pressure formula 45 the following variables were included into the analysis: age, gender, systolic and diastolic blood pressure, body mass index (bmi), neck circumference, mid upper arm circumference, waist circumference, fat percentage, muscle mass, visceral fat, mallampati score, and laboratory parameter such as hba1c and soluble st-2 and standard echocardiographic measurements. from all obese subjects included in this study, there were 66 subjects (80.5%) had obstructive sleep apnea, and 16 subjects (19.5%) did not have obstructive sleep apnea. the mean ahi was 9 to 47 events per hour in osa group and 5 to 34 events per hour in all subjects. baseline subject characteristics are presented in table 1. fat percentage was found to be higher in the non-osa group (37.95 (30.68-42.23)) than in the osa group (30.70 (28.55-38.90)) and were considered significant with p value 0.04. while for muscle mass and visceral fat was found to be higher in the osa group 28.30 (22.70-29.95) and 19.83 ± 6.33 respectively, although that two variable were not significant with p value 0.07 and 0.32. there were 10 (15.2%) subjects with osa have abnormal diastolic dysfunction, while all 16 subjects without osa have normal diastolic function, without significant correlation among subjects with osa and no osa. according to the standard classification, all 10 subjects with osa are considered to have diastolic dysfunction grade i. however, derived indices of diastolic dysfunction showed significant differences (p value = 0.01), with e/e’ as a central parameter, increased with presence of osa. left atrial volume as a marker of left atrial size correlated significantly with osa (p value = 0.01). table 1. subject characteristics. variable alln = 82 no osa (ahi < 5) n = 16 osa (ahi ≥ 5) n = 66 p value age (years) 49 (40-51) 40 (30-49) 49 (42-52) < 0.01 gender, male 48 (58%) 5 (31%) 43 (65%) gender, female 34 (41%) 11 (68%) 23 (34%) systolic blood pressure (mmhg) 140 (128-147) 132 (128-139) 141 (127-149) 0.05 diastolic blood pressure (mmhg) 90 ± 11 87 ± 9 91 ± 11 0.18 waist circumference (cm) 105.03 ± 10.03 102.88 ± 11.47 106.02 ± 10.24 0.28 mean upper arm circumference (cm) 35.72 ± 3.65 35.41 ± 3.33 36.01 ± 3.96 0.58 neck circumference (cm) 40.00 (36.58-43.00) 38.50 (36.25-41.63) 41.00 (36.80-43.00) 0.32 bmi 32.60 ± 4.76 32.42 ± 3.81 32.87 ± 5.24 0.75 fat percentage (%) 31.90 (28.65-40.25) 37.95 (30.68-42.23) 30.70 (28.55-38.90) 0.04 muscle mass 27.45 (22.03-29.78) 23.00 (21.30-28.78) 28.30 (22.70-29.95) 0.07 visceral fat 19.39 ± 6.20 18.06 ± 5.84 19.83 ± 6.33 0.32 mallampati score 2 (1-3) 2 (1-2) 2 (1-3) 0.09 hba1c (%) 5.80 (5.40-6.23) 5.55 (5.40-5.98) 5.80 (5.50-6.30) 0.13 sst2 (ng/ml) 13.12 (10.49-18.43) 12.28 (9.12-16.87) 13.13 (10.72-18.65) 0.39 table 2. polysomnographic variables. variable all n = 82 no osa (ahi < 5) n = 16 osa (ahi ≥ 5) n = 66 p value ahi (events/hour) 12 (5-34) 3 (2-3) 20 (9-47) < 0.01 lowest sao2 (%) 81 (75-87) 87 (84-90) 79 (72-85) < 0.01 odi (%) 21 (11-42) 8 (6-11) 27 (17-58) < 0.01 arousal index (events/hour) 42 (34-48) 43 (36-48) 41 (33-51) 0.75 sleep duration (minute) 300.73 ± 161.43 340.69 ± 116.92 286.77 ± 166.67 0.23 telly kamelia acta med indones-indones j intern med 46 of note, this study time measured in both groups also showed difference with p value 0.03. there was a significant difference in non-invasive measurement of pawp between osa group and non-osa group with p value <0.01 and measured higher in the subjects with osa (10.70 (8.07-13.07)) than in the non-osa group (8.07 (6.07-9.48)). echocardiographic measurements are outlined in table 3. the equation derived was then tested prospectively in obese population for the prediction of pawp. further analysis was performed to compare subjects with high pawp and group with normal pawp, in osa group study. of the 66 subjects with osa, there were 23 subjects who had higher pawp. in subjects with osa, there were significant differences in systolic blood pressure, hba1c, and ejection fraction between subject group with abnormal pawp and normal pawp. systolic blood pressure was found to be significantly higher in the osa group with high pawp values (146 (139-155)) compared to the osa group with normal pawp values (140 (122-145)). hba1c values were also found to be significantly higher in the osa group with high pawp values (6.00 (5.50-7.43)) than in the osa group with normal pawp values (5.70 (5.40-6.05). in addition, the osa group with high pawp values had a significantly higher ejection fraction value (74.22 ± 5.54) compared to the osa group with normal pawp values (69.42 ± 6.58). multiple stepwise logistic regression analysis was performed with variables, including age, fat percentage, ahi, odi, lowest sao2, and echocardiographic variables such as e/e’, e/a, la volume, deceleration time, and pulmonary artery wedge pressure calculated. this analysis showed that e/e’ and deceleration time was the predictor of diastolic dysfunction. table 3. echocardiographic characteristics. variable alln = 82 no osa (ahi < 5) n = 16 osa (ahi ≥ 5) n = 66 p value ejection fraction (%) 71.34 ± 6.29 71.44 ± 5.60 71.09 ± 6.61 0.85 diastolic dysfunction 10 (12.2%) 0 (0%) 10 (15.2%) 0.20 tapse 2.40 (2.18-2.60) 2.50 (2.33-2.98) 2.40 (2.10-2.60) 0.07 e/a ratio 1.04 (0.51-2.39) 1.28 (0.62-2.39) 0.98 (0.51-1.72) 0.04 e/e’ 7.78 (0.47-14.85) 6.41 (0.53-9.42) 8.11 (0.47-14.85) 0.01 s’ 13 (11-14) 13 (12-14) 12 (11-14) 0.96 deceleration time 193.17 (77-311) 176.50 (119-303) 197.21 (77-311) 0.03 la volume (ml/m2) 23.04 (11.94-34.92) 20.47 (13.45-28.46) 23.67 (11.94-34.92) 0.01 pulmonary artery wedge pressure (mmhg) 10.14 (8.01-13.07) 8.07 (6.07-9.48) 10.70 (8.07-13.07) < 0.01 *using new pawp formula table 4. multivariate analysis to identify predictors of diastolic dysfunction. variable or (95% ci) correlation matrix (r2) p value age 0.967 (0.662-1.236) -0.449 0.69 fat percentage (%) 1.000 (0.840-1.191) -0.352 0.99 ahi 1.003 (0.906-1.112) 0.061 0.94 odi 1.017 (0.909-1.137) -0.259 0.77 lowest sao2 1.015 (0.904-1.139) -0.554 0.80 e/e’ 1.874 (1.052-3.340) -0.169 0.03 e/a 0.001 (0.000-1.027) -0.380 0.05 la volume (ml/m2) 1.149 (0.879-1.502) 0.009 0.30 deceleration time 1.032 (1.005-1.059) -0.393 0.02 pulmonary artery wedge pressure 0.904 (0.662-1.236) -0.060 0.52 vol 55 • number 1 • january 2023 the role of new pulmonary artery wedge pressure formula 47 discussion the mean la pressure is the source pressure for lv filling, determining the lv filling pressure is a key element in the diagnosis and management of patients with suspected decompensated heart failure. measurement of the pulmonary capillary wedge pressure with the swan-ganz catheter has become the gold standard for determining lv filling pressure. this invasive procedure is more expensive and produce complications, especially in critically ill patients. two randomized clinical studies found no benefit from the use of the swan-ganz catheter to manage critically ill patients. thus, a reliable non-invasive method for determining lv filling pressure is needed.9 although right heart catheterization remains the gold standard for measurement of intracardiac pressures, enthusiasm for placement of swan– ganz catheters has dwindled over the past decade on account of complications that include infection, cardiac perforation, and tamponade. in addition, the use of swan-ganz cathters is commonly used in the sick population so that it requires measuring the use of a catheter.14 in healthy populations, measurements can be performed noninvasively using doppler echocardiography in an outpatient setting that is more cost-effective. doppler echocardiography is generally acknowledged to be a noninvasive alternative to swan–ganz catheterization. hitherto, a number of noninvasive doppler echo measurements of left ventricular (lv) filling pressure, right atrial pressure, and cardiac output and the changes following load interventions have correlated closely with measurements made by swan–ganz catheterization.13 pulmonary vascular resistance (pvr) is a hemodynamic variable that contributes to the management of patients with advanced cardiovascular and pulmonary conditions. based on the formula issued by abbas et.al , doppler echocardiography may provide a reliable, noninvasive method to determine pvr using mean pulmonary artery pressure and pulmonary artery wedge pressure (pawp) or cardiac output. the weakness of this formula is there must be a pulmonary artery systolic pressure (pasp), pulmonary artery diastolic pressure (padp) and mean pulmonary artery pressure (mpap) value. however, the formula is directly related to transpulmonary pressure gradient (δp) and inversely related to transpulmonary flow (qp).13 the term pawp is used interchangeably with pulmonary capillary wedge pressure and pulmonary artery occlusion pressure in the general literature.10 non-invasive measurement of pawp is useful for the evaluation intravascular fluid volume and pressure status to identify diastolc dysfunction. nagueh formula can be used for calculation of pawp from the doppler derived mitral e/e’ ratio. pawp is usually equal to the left atrial pressure and hence the left ventricular filling pressure. e’ (ea) has been considered as a preload independent index of left ventricular relaxation. nagueh formula uses mitral e velocity during early diastolic flow corrected for the influence of left ventricular relaxation (e/e’ ratio) to estimate the mean pawp. nagueh formula: pawp = 1.24 [e/e’] + 1.9. ea was taken from the lateral mitral annulus in the pioneering study of nagueh sf et al. patients had invasive measurement of pawp and simultaneous doppler echocardiography.9 in addition, the formula proposed by vladislav et.al also plays a role in determining pawp using echocardiography. in his research tricuspid regurgitation velocity (trv), average e/e′ ratio, lv ejection fraction (lvef), rv fractional area change (rvfac), ivc diameter, and left atrial volume index (lavi) were found to be independent predictors of pawp ratio without any evidence of multicollinearity between variables. the model accurately identified patients with precapillary, isolated postcapillary, and combined ph, with no cases of undetermination and outperforming current echocardiographic algorithms, by using variables routinely acquired in echocardiographic laboratories.15 this present study compared pawp with the value predicted using standard tissue doppler measurement method validated by nagueh et al.9 and it is found that pawp derived using these 2 methods has fair correlations, suggesting that this method will give similar results to the tissue doppler method in most examples. diastolic dysfunction significantly associated with pulmonary artery wedge pressure telly kamelia acta med indones-indones j intern med 48 measured using proposed formula (r = 0.240, p value = 0.030). these results emphasize the pathophysiologic process of passive pulmonary hypertension; namely, that increased left atrial pressure will necessitate a higher driving pressure across the pulmonary capillary bed.11 at present, echocardiography is the only noninvasive technique that allows estimation of pulmonary and lv filling pressures in hf). precisely defining the role of osa in the origin of some cardiovascular complications has been difficult for several reasons. one limitation figure 3. spearman correlation between pawp and diastolic dysfunction figure 4. pearson correlation between pawp and e/e’ vol 55 • number 1 • january 2023 the role of new pulmonary artery wedge pressure formula 49 figure 5. pearson correlation between pawp and e/a figure 6. pearson correlation between pawp and dt telly kamelia acta med indones-indones j intern med 50 has been the various methods by which the diagnosis of pulmonary hypertension is made in studies of subjects with osa, many by way of doppler echocardiography, with varying pulmonary artery pressure thresholds. t h i s s t u d y u s e d e c h o c a r d i o g r a p h i c procedures to assess the impact of osa on cardiovascular function and structural without symptoms of heart failure. subjects with osa jshowed a decreased in e/a ratio, higher la volume and deceleration time compared with subjects with no osa. all subjects with osa manifest diastolic dysfunction, while none of the subjects without osa have abnormal diastolic function. however, this difference was not statistically significant between the two groups. various mechanisms might explain the presence of diastolic dysfunction in osa patients. patients who experience chronic hypoxemia, which might result in abnormalities of myocardial relaxation because of myocyte hypoxia due to intracellular calcium transport disturbances.16 the results of this present study suggest that subjects with osa have changes in pulmonary hemodynamics. obstructive sleep apnea can be assimilated to a müller’s maneuver, which is an inspiratory effort against a closed glottis, and the pawp reflects the changes in intrathoracic pressure; the latter may decrease by as much as 30 mmhg during an osa, with a subsequent fall of pawp which decreases to negative values.17 these results are in accordance with the research conducted by solin et al. which analysed sleep-disordered breathing with hemodynamic parameters. from this study, the group with sleep disorders had higher pcwp and pulmonary artery pressure (pap) values compared to the control group or the group without sleep disorders.18 other studies have also shown that pawp experienced significant changes during the cycle in patients with osa. it has been shown that osa patients might have an increased in left ventricular mass, and alterations of the neurohumoral system might contribute to the elevation of pulmonary artery pressures and pcwp in patients with osa. diastolic dysfunction is a condition with increased resistance to filling of the left ventricle, leading to an inappropriate rise in the diastolic pressure-volume relationship and causing symptoms of pulmonary congestion during exercise. the potential mechanisms leading to changes in cardiac structure and function in patients with osa have been studied in animal models. fletcher et al demonstrated ventricular hypertrophy in rats exposed to short bursts of repetitive hypoxia over an extended period and that intermittent severe hypoxia can lead to a sustained rise in bp within 35 days.4 diastolic dysfunction leads to elevated left atrial filling pressures which are transmitted to the pulmonary venous system. long standing elevation in pulmonary venous pressures leads to secondary changes in pulmonary vascular resistance. conclusion the pulmonary artery wedge pressure (pawp) is a surrogate marker of left atrial pressure and chronic airflow obstruction is the most important cause of pulmonary artery remodelling, that table 5. comparison between the new pawp formula, nagueh formula, and abbas formula 16 the new pawp formula nagueh et al. formula abbas et al. formula formula pla= 18,525 x va 2 mmhg (va 2 on m/s) pcwp = 1,24* (e/ e’ ) + 1,9. e’ = (e’ lat + e ’ med) /2. pvr= trv/tvirvot x10 + 0,16 research population obese with obstructive sleep apnea patients heart failure patients cardiovascular and pulmonary disease patients strengths this formula has more complete parameters and does not require tricuspid regurgitation to be used this formula does not require tricuspid regurgitation to be used this formula had been validated by the swan-ganz catheter weaknesses this formula had not been validated by the swan-ganz catheter other echocardiographic and even invasive measurements should be used to supplement the e/e’ parameter in some cases. this formula requires a tricuspid regurgitation condition on patients vol 55 • number 1 • january 2023 the role of new pulmonary artery wedge pressure formula 51 can lead to diastolic dysfunction. this study has proved echocardiography can be replaced invasive cardiac catheterization to assess lv filling with high feasibility and good accuracy to estimate lv filling pressure that leads to diastolic dysfunction. the new mathematical formula based on echocardiographic variables had a good accuracy because it can estimated indirectly the la pressure and pawp which can described the stage of diastolic dysfunction and it could be readily applied in daily clinical practice. obstructive sleep apnea is one of the health problems that may lead to cardiovascular c o m p l i c a t i o n s . t h i s s t u d y s h o w e d t h a t patients with osa have a higher risk of cardiovascular remodeling than those without. obscure cardiac comorbidities may be present in patients with significant osa. it is highly recommended for patients with osa to have routine echocardiogram, as development of cardiovascular morbidities is common and proper treatment should not be delayed. references 1. naughton mt, kee k. sleep apnoea in heart failure: to treat or not to treat? respirology. 2017;22(2):217–29. 2. agrawal v, d’alto m, naeije r, et al. echocardiographic detection of occult diastolic dysfunction in pulmonary hypertension after fluid challenge. j am heart assoc. 2019;8(17):e012504. 3. floras js, bradley td. sleep apnea and heart failure. circulation. 2003;107(12):1671–8. 4. dewan na, nieto fj, somers vk. intermittent hypoxemia and osa: implications for comorbidities. chest. 2015;147(1):266–74. 5. reddy yn v, el-sabbagh a, nishimura ra. comparing pulmonary arterial wedge pressure and left ventricular end diastolic pressure for assessment of left-sided filling pressures. jama cardiol. 2018;3(6):453–4. 6. m a r r o n e o , b o n s i g n o r e m r . p u l m o n a r y haemodynamics in obstructive sleep apnoea. sleep med rev [internet]. 2002;6(3):175–93. available from: https://www.sciencedirect.com/science/article/ pii/s1087079201901856 7. ahbab s, ataoğlu he, tuna m, et al. n eck circumference, metabolic syndrome and obstructive sleep apnea syndrome; evaluation of possible linkage. medical science monitor: international medical journal of experimental and clinical research. 2013;19:111–7. available from: https://pubmed.ncbi. nlm.nih.gov/23403781 8. lee w, nagubadi s, kryger mh, mokhlesi b. epidemiology of obstructive sleep apnea: a populationbased perspective. expert rev respir med [internet]. 2008;2(3):349–64. available from: https://pubmed. ncbi.nlm.nih.gov/19690624 9. nagueh sf, appleton cp, gillebert tc, et al. recommendations for the evaluation of left ventricular diastolic function by echocardiography. eur j echocardiography. 2009;22(2):107–33. 10. nagueh sf, middleton kj, kopelen ha, zoghbi wa, quiñones ma. doppler tissue imaging: a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. j am coll cardiol. 1997;30(6):1527–33. 11. ryan jj, rich jd, thiruvoipati t, swamy r, kim gh, rich s. current practice for determining pulmonary capillary wedge pressure predisposes to serious errors in the classification of patients with pulmonary hypertension. am heart j. 2012;163(4):589–94. 12. solin p, bergin p, richardson m, kaye dm, walters eh, naughton mt. influence of pulmonary capillary wedge pressure on central apnea in heart failure. circulation [internet]. 1999;99(12):1574–9. available from: https://www.ahajournals.org/doi/abs/10.1161/01. cir.99.12.1574 13. abbas ae, fortuin fd, schiller nb, appleton cp, moreno ca, lester sj. a simple method for noninvasive estimation of pulmonary vascular resistance. j am coll cardiol. 2003;41(6):1021–7. 14. st john sutton m. a comprehensive noninvasive hemodynamic assessment of systolic heart failure. vol. 3, circulation: heart failure. am heart assoc; 2010. p. 337–9. 15. chubuchny v, pugliese nr, taddei c, et al. a novel echocardiographic method for estimation of pulmonary artery wedge pressure and pulmonary vascular resistance. esc heart fail. 2021;8(2):1216–29. 16. kraiczi h, caidahl k, samuelsson a, hedner j. impairment of vascular endothelial function and left ventricular filling: association with the severity of apnea-induced hypoxemia during sleep. chest. 2001;119(4):1085–91. 17. kum ro, ozcan m, yılmaz yf, gungor v, yurtsever kum n, unal a. the relation of the obstruction site on muller’s maneuver with bmi, neck circumference and psg findings in osas. indian j otolaryngol head neck surg [internet]. 2014;66(2):167–72. available from: https://pubmed.ncbi.nlm.nih.gov/24822156 18. galiè n, humbert m, vachiery jl, et al. 2015 esc/ ers guidelines for the diagnosis and treatment of pulmonary hypertension. eur heart j [internet]. 2016;37(1):67–119. available from: http://erj. ersjournals.com/content/46/4/903.abstract 406 acta med indones indones j intern med • vol 54 • number 3 • july 2022 original article effect of cholecalciferol supplementation on disease activity and quality of life of systemic lupus erythematosus patients: a randomized clinical trial study fiblia1, iris rengganis2*, dyah purnamasari3, alvina widhani2, teguh h. karjadi2, hamzah shatri4, rudi putranto4 1department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2division of allergy immunology, department of internal medicine, faculty of medicine universitas indonesia -cipto mangunkusumo hospital, jakarta, indonesia. 3division of endocrinology and metabolism, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 4division of psychosomatics and palliative care, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. *corresponding author: prof. iris rengganis, md., phd. division of allergy immunology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email:irisrengganis@yahoo.com. abstract background: increase in the prevalence and survival rates has led to the assessment of disease activity and quality of life of sle patients as targets in treatment. cholecalciferol was considered as having a role in reducing disease activity and improving quality of life. methods: a double blind, randomized, controlled trial was conducted on female outpatients aged 18-60 years with sle, consecutively recruited from september to december 2021 at cipto mangunkusumo hospital. sixty subjects who met the research criteria were randomized and equally assigned into the cholecalciferol and placebo groups. the study outcomes were measured at baseline and after 12 weeks of intervention. results: out of 60 subjects, 27 subjects in cholecalciferol group and 25 subjects in placebo group completed the intervention. there was a significant improvement on the level of vitamin d (ng/ml) after intervention in the cholecalciferol group, from an average of 15,69 ng/ml (8.1-28.2) to 49,90 ng/ml (26-72.1), and for the placebo group from 15,0 ng/ml (8.1-25,0) to 17.35 ng/ml (8.1-48.3) (p<0,000). results of the mex-sledai score showed significant differences in both groups after the intervention, with a significant decrease in the cholecalciferol group from 2,67 (0-11) to 1,37 (0-6), compared to the placebo group from 2,6 (0-6) to 2,48 (0-6) (p<0,001). there were no significant differences on the quality of life in both groups. conclusion: supplementation of cholecalciferol 5000 iu/day for 12 weeks was statistically significant in increasing vitamin d levels and improving disease activity, but did not significantly improve the quality of life of sle patients. keywords: cholecalciferol, disease activity, quality of life, systemic lupus erythematosus. vol 54 • number 3 • july 2022 effect of cholecalciferol supplementation on disease activity 407 introduction systemic lupus erythematosus (sle) is a chronic systemic autoimmune disease characterized by autoantibody deposits in tissues, organ damage and various clinical manifestations. sle is better known as a syndrome than a single disease and the course of sle is still unpredictable; it can persist, recure, or recover.1 the diagnosis and therapy of sle had improved and made a significant impact on increasing the survival rate of sle patients.2 by increasing the survival rate, the target of treatment is not only to control disease activity and prevent organ damage but also to pay attention to the patient’s quality of life.3 vitamin d deficiency has a role in the pathogenesis of sle, especially in the regulation of growth, proliferation, apoptosis, and immune system function. low vitamin d is associated with decreased regulatory t-cells (tregs), which function to increase tolerance to self-antigens. in addition, it also increases the auto reactive activation of b cells to produce autoantibodies, increases the activation and proliferation of th1 helper cells and produces interferon-alpha (ifn-α) through plasmatocytoid dendritic cells (pdc), producing an excess of pro inflammatory cytokines through macrophages. this process forms immune complexes, which leads to tissue damage and continuous release of self-antigens.4,5 in vitro studies have shown that 1,25 dihydroxy vitamin d can inhibit the differentiation of dendritic cells (dcs), t cell proliferation, cytokine production, activated b cell proliferation and plasma cell formation.5,6 the relationship between vitamin d and sle is complex since sle can cause low levels of vitamin d and vitamin d deficiency further plays a role in the etiology and worsening of sle symptoms.6,7 however, the relationship between vitamin d levels and sle disease activity has been reported to be inconsistent and is still debated.8 several studies have shown that vitamin d is associated with sle disease activity through several mechanisms; meanwhile, other studies have reported that there was no relationship between vitamin d levels and sle. effect of vitamin d supplementation on sle disease activity is still controversial, and its role on the quality of life of indonesian sle patients has never been studied. as a result, this study aims to examine the benefits of vitamin d supplementation on disease activity and quality of life of sle patients in indonesia. methods this study is a double blind randomized controlled trial. subjects were allocated in each treatment arm using permuted block randomization, with a block size of four and concealed code lists. investigators, doctors, and subjects were blinded to treatment allocation (double blind). study participants women with systemic lupus erythematosus aged 18-60 years old with hypovitaminosis d as inclusion criteria. exclusion criteria included declining consent to participate, late stage chronic kidney disease (staged 4-5), decompensated liver cirrhosis, consumption of glucocorticoids (equivalent to prednisone 20 mg/ day) in the past 30 days, pregnant or lactating, patients with acute infection, hypercalcemic patients, anticonvulsant consumption. dropout criteria included unwillingness to continue participation in the study, compliance rate <70% for both arms, side effects to vitamin d such as nausea, vomiting, diarrhea, cramps that could not be controlled with medication, hospitalized due to infection, changes in the regiment or dose of immunosuppressant or glucocorticoids (equivalent to prednisone 20 mg/day) during the trial. subjects were consecutively recruited from september 2021 to december 2021 at allergy and immunology outpatient clinic in cipto mangunkusumo hospital, jakarta. intervention protocol after providing written consent, eligible subjects were randomly assigned to either the cholecalciferol (prove d3 1x5000 iu) or placebo (saccharum lactis 1x5000 iu) arm. both the cholecalciferol and placebo tablets were indistinguishable by appearance. the allocated treatment was dispensed to the subjects every four weeks. the collected data consisted of subjects’ demographic data fiblia acta med indones-indones j intern med 408 (age, income, level, duration of illness, body mass index, organ involvement, treatment, comorbidities, initial methylprednisolone dose, initial mex-sledai score), clinical data (level of hemoglobin, white blood cell, platelets, erythrocyte sedimentation rate, creatine kinase (ck), estimated glomerular filtration rate (egfr), micro-albuminuria, anti-dsdna, vitamin d levels, blood calcium levels). quality of life was assessed using the lupus quality of life (lupus qol) questionnaire with a 5-point likert scale. measurement of study outcomes was conducted at baseline and after 12 weeks of intervention. levels of vitamin d were measured using the elisa kit, and disease activity was measured using the mex-sledai score, with a score ranging from 0 to 34. quality of life was assessed using the lupus quality of life (lupus qol) questionnaire with a 5-point likert scale ranging from 0 to 100. all variables were measured initially and 12 weeks after intervention. adverse events, side effects, and compliance rates were evaluated every four weeks. sample size the minimum sample size required to assess disease activity of sle was 10 subjects in each treatment arm. a minimal sample to assess the quality of life was not determined due to the novel nature of the study. total number of subjects in each treatment group was 30 subjects. ethics this study was approved by the ethical committee of faculty of medicine universitas indonesia / cipto mangunkusumo hospital (no. ket-745/un2f1/etik/ppm.00.02/2021). the study procedure was performed in accordance with the declaration of helsinki. this study has been registered in clinicaltrial.gov (registered no. nct05326841). statistical analysis data analysis was performed using statistical package for the social sciences (spss) version 20. dropout subjects were excluded from the analyses (per-protocol analysis). mean and standard deviation values were calculated for normally distributed numerical data. calculation of median and interquartile range values was performed for numeric data with non-normal distributions. unpaired independent t tests were performed to analyze the changes in the variables between the vitamin d (prove d3) group and placebo when the data distribution was normal. in cases of non-normal data distribution, mannwhitney tests were performed. results despite recruiting 70 sle subjects to participate in the study, as many as 10 subjects were excluded from this clinical trial, based on the research criteria, which resulted in 60 subjects who were randomized and equally assigned into cholecalciferol (prove d3) and placebo groups. a total of 27 subjects in the cholecalciferol group and 25 subjects in the placebo group had completed the intervention trial (figure 1). from 27 subjects who completed the intervention in the cholecalciferol group, the mean age was 32,9 (20-40) years old, and most (60%) had an education level of up to senior high school. eighteen subjects (40%) had a duration of disease greater than 5 years. most subjects (30%) weighed within normal ranges of bmi. in the placebo group, the mean age was 29.5 (19-49) years old, with a majority (56.7%) having middle school education level. a plurality (46.7%) of subjects in this group had a duration of disease greater than 5 years, and normal weight was observed in 13 subjects (43.3%). in the cholecalciferol group, mucocutaneous organ involvement was found in all subjects, followed by musculoskeletal involvement in 29 subjects (96.7%). hydroxychloroquine (hcq) was the most commonly prescribed treatment, given to 21 subjects (70%), followed by myfortic (63.3%) and imuran (23.3%). most patients had at least one comorbidity with 5 subjects (31.3%) having only one. in the placebo group, mucocutaneous involvement was present in 29 subjects (96.7) followed by musculoskeletal involvement in 25 subjects (83.3%). treatment by hcq was standard for 23 subjects (76.7%), followed by myfortic in 17 subjects (56.7%) and imuran in 3 subjects (10%). ten subjects (33.3%) had one comorbidity, with most having more than one. results of the demographic characteristics are summarised in table 1. vol 54 • number 3 • july 2022 effect of cholecalciferol supplementation on disease activity 409 figure 1. flow diagram of randomized control trial. enrollment: assessed for eligibility (n = 70) 10 patients excluded: llevel of vitamin d (25(oh)d) ≥ 30 ng/ml randomized (n=60) allocated to cholecalciferol (n=30) allocated to placebo (n=30) 3 patients drop out 1 death caused by sepsis pneumonia 2 resigned 5 patients drop out l1lossof follow up l2 admitted to hospital and changed immunosuppressant l1 admitted due to dengue hemorragic fever l1 resigned analyzed (n=27) analyzed (n=25) table 1. characteristic study subjects. variables intervention (n=30) placebo (n=30) age (year), median (iqr) 32.9 (20-46) 29.5 (19-49) level of education, n (%) low 3 (10.0) 3 (10.0) middle 18 (60.0) 17 (56.7) high 9 (30.0) 10 (33.3) income, n (%) <umr 16 (53.3) 19 (63.7) >umr 14 (46.7) 11 (37.3) disease of duration, n (%) <1 year 6 (20.0) 7 (23.3) 1-5 year 6 (20.0) 9 (30.0) >5 year 18 (40.0) 14 (46.7) imt, n (%) underweight 6 (20.0) 4 (13.3) normoweight 9 (30.0) 13 (43.3) overweight 8 (26.7) 8 (26.7) obesity 7 (23.3) 5 (16.7) organ involvement, n (%) mucocutaneous 30 (100) 29 (96.7) musculosceletal 29 (96.7) 25 (83.3) renal 18 (40.0) 10 (33.3) hematology 15 (50.0) 8 (26.7) neuropsychiatric systemic lupus erythematosus (npsle) 1 (3.3) 2 (6.7) serositis 2 (6.7) 0 treatment, n(%) hydroxyichloroquine (hcq) 21 (70.0) 23 (76.7) fiblia acta med indones-indones j intern med 410 quality of life in the two groups had similar median values across the 8 domains. in the physical health domain, the average cholecalciferol group score was 79.6 (50-100), which was slightly higher than the average placebo group, which was 79.0 (21-100). pain scores in the cholecalciferol group (median 73.3 [33-100]) were on average lower than the placebo group (median 78.5 [25-100]). on average, the planning score in the cholecalciferol group was 79.1 (25-100), which was lower than the placebo group score of 84.4 (25-100). the median intercourse score in the cholecalciferol group was 86.2 (12.5-100), which was higher than the placebo group (median 81.4 [0-100]). emotional health scores in the cholecalciferol group (median 65.4 [8-95]) were lower than the placebo group (median 75.4 [25-100]), and median self-image scores in both groups were 66.4 (15-100) and 77.1 (15-100) for the cholecalciferol and placebo arm respectively. fatigue score in the intervention group (median 57.7 [12.5-93]) was lower on average, compared to the placebo group (median 70.2 [18-100]). quality of life scores is summarised in table 2. myfortic 19 (63.3) 17 (56.7) imuran 7 (23.3) 3 (10.0) methotrexate (mtx) 0 1 (3.3) comorbidity, n (%) none 3 (18.8) 11 (36.7) one 5 (31.3) 10 (33.3) two 3 (18.8) 4 (13.3) three 2 (12.5) 4 (13.3) four 2 (12.5) 3 (3.3) five 1 (6.3) 0 (0.0) initial dose of methylprednisolone mg/day, median (iqr) 3.53 (0-16) 5.13 (0-16) initial mex-sledai score, median (iqr) 2.67 (0-11) 2.6(0-6) iqr: interquartile range ; n= total subjects the initial levels of vitamin d 25 (oh) in the two groups before intervention were similar. after an intervention, the cholecalciferol group had an increase of average vitamin d 25(oh) levels from 15.69 ng/ml (8.1-28.2) to 49.90 ng/ ml (26-72.1), resulting in an average increase of 33.8 ng/ml. in the placebo group, average vitamin d levels also increased slightly by 2.5ng/ml from 15.0 ng/ml (8.1-25,0) to 17.35 ng/ml (8.1-48.3). the difference in the increase in average vitamin d 25(oh) levels between the two groups was statistically significant (p<0.000). results of initial laboratory values and analysis of vitamin d changes are summarised in table 3 and table 4, respectively. the effect of giving cholecalciferol on sle disease activity, based on the mex-sledai results, showed a significant difference between the cholecalciferol group and the placebo group. an average decrease in the mex-sledai value of about 1.29 in the intervention group was observed, compared to the average decrease of 0.12 in the mex-sledai value of the placebo group. this indicates that the intervention with cholecalciferol provided an improvement, in the table 2. characteristic initial quality of life. variables intervention (n=30) placebo (n=30) lupus qol, median (iqr) physical health 79.6 (50-100) 79.0(21-100) pain 73.3 (33-100)) 78.5 (25-100) planning 79.1 (25-100) 84.4 (25-100) intimate relationship 86.2 (12.5-100)) 81.4 (0-100) burden to others 63.0 (7-100) 72.1 (10-100) emotional health 65.4 (8-95) 75.4 (25-100) body image 66.4 (15-100) 77.1 (15-100) fatique 57.7 (12.5-93) 70.2(18-100) vol 54 • number 3 • july 2022 effect of cholecalciferol supplementation on disease activity 411 table 3. initial laboratory characteristics. variables intervention (n=30) placebo (n=30) hemoglobin (g/dl), median (iqr) 11.9 (7.2-14.1) 12.0 (7.8-14.3) white blood cell (/ul), median (iqr) 6639 (4100-10670) 7048 (3190-13110) platelets (/ul), median (iqr) 298966 (202000-396000) 320066 (139000.0-549000) led (mm), median (iqr) 38.1 (0-140) 41.8 (0-144) ck (u/l), median (iqr) 66.0 (16.0-167.0) 54.7(16-178) egfr (ml/min/1.73m2), median (iqr) 111 (68-140) 105.7 (12-131) microalbuminuria (mg/g kreatinin), median (iqr) 169 (0-2085) 118.3 (0-792) anti dsdna (iu/ml), median (iqr) initial vitamin d (ng/ml), median (iqr) calsium level mg/dl, mean (sd) 266.7 (1.1-1235) 15.69 (8.1-28.2) 9.27 (0.49) 223.1 (1.9-967.0) 15.0 (8.1-25.0) 9.40(0.30) iqr= rentang interquartile; sd= standard deviation table 4. changes in pre and post intervention vitamin d levels. variables group [mean (sd)] pintervention (n=30) placebo (n=30) vitamin d (ng/ml) 33.8 (sd 12.04) 2.5 (sd 10.58) <0.000 unpaired t-test. table 5. effect of cholecalciferol supplementation on sle disease activity using mex-sledai. variable group [median (iqr)] p intervention (n=30) placebo (n=30) mexsledai -1.29 (-5.0; 4.0) -0.12 (-5.0; 6.0) 0.015 form of a decrease in sle disease activity (p = 0.015). the analysis of the sle disease activity post intervention is described in table 5. the effect of giving cholecalciferol compared to placebo on the lupus quality of life (lupus qol) scores showed that there was no significant difference in the quality of life between the two groups across all domains including physical health, pain, planning, intimate relationships, burden to others, emotional health, self-image and fatigue (table 6). table 6. changes in the total quality of life of sle patients pre and post intervention. lupus qol intervention (n=30) placebo (n=30) p total qol mean (sd) 21.32 (90.57) 14.4 (78.2) 0.773 discussion in this study, the results in the vitamin d group showed a significant increase in 25(oh) d levels when compared to the placebo group. these results are in accordance with the randomized trial by abou-raya et al. where sle patients receiving vitamin d 2000 iu/day and had a greater increase in post-intervention vitamin d 25(oh)d levels, compared to the placebo group. on average, the vitamin d 25(oh) level was greater by 17.9 ng/ml with a mean of 37.8±16.3 ng/ml in the intervention group, compared to 19.9±16.2 ng/ml in the placebo group (p<0.05).9 the effect of cholecalciferol supplementation on sle disease activity, showed that there was a greater decrease in average mex-sledai values of the intervention group compared to the placebo group. the results of this study are concordant with the research by kalim et al, where a double-blinded randomized clinical trial was conducted involving 20 sle patients who were given vitamin d supplementation of 1200 iu/day for 3 months, compared to 19 sle patients who received a placebo. the results of this study showed a significant decrease in the sledai scores from an average of 12.65 ± 4.85 to 6.20 ± 2.67 in the vitamin d group, compared to the slight decrease in sledai scores of the placebo group (10.74±2,75 to 9.68±2.26).10 vitamin d plays a role in regulating treg cells through the process of tolerogenic induction of dendritic cells, which will produce il10 through cd4+ t cells and treg-specific antigens. high levels of vitamin d can stimulate the transcription factor foxp3, which plays fiblia acta med indones-indones j intern med 412 a role in the formation and enhancement of treg function. high vitamin d levels are also associated with anti-inflammatory lymphoid polarization. tregs stimulated by vitamin d will function to control the immune response of t cells, both alloreactive or autoreactive, by producing inhibitory cytokines, namely il-10 and tgf-beta, through the release of granzyme and perforin or expression of ctla-4 to prevent antigen presentation or proinflammatory response. vitamin d can increase tregs both directly or indirectly. the results of the study showed that there was a relationship between high treg levels and immunosuppressive phenotypes. vitamin d supplementation can decrease sle activity. this is due to the role of vitamin d in inhibiting th1, th17 and increasing tregs and th2. vitamin d also decreases the differentiation and proliferation of b cells.12 after the intervention, there was an increase in the lupus qol score in the cholecalciferol and the placebo group, but the differences between the two results were not significant (p=0.773). this was due to the good baseline quality of life in both groups since both groups had a median score greater than 50 in each domain prior to intervention. in addition, several factors can affect the quality of life in this study such as age, duration of illness, level of education, disease activity. in this study, the difference in age between the two groups was not much different and on average subjects were relatively young. in addition, the duration of illness and level of education may also play a role in the quality of life since a patient with longer duration of disease may have better physical health, mental health and emotional regulation. higher education levels on average will lead to a better quality of life. quality of life in this study was good and not related to disease activity and organ involvement.14 although there were three serious adverse events (saes) reported in the vitamin d group (nausea, pneumonia, iron deficiency anemia), further investigation showed that they were not related to vitamin d administration. the advantage of this study was that it used a double-blinded randomized trial design, with a long observation time of 12 weeks. in addition, the use of cholecalciferol tablets in this study at a dose of 5000 iu was in accordance with the guidelines of the european food safety authority, which recommends the use of vitamin d at a daily average of 4000 iu/ day (100µg/day) for adults and the elderly with normal weights. the tablet preparations taken are also small, tasteless, and odorless, making it easier for patients to consume. this study was also successful in increasing vitamin d levels, achieving sufficient values, and succeeded in significantly improving disease activity. the study also succeeded in improving the quality of life of the subjects, albeit slightly. the weakness of this study is a large number of tablets that have to be consumed per day and the absence of specific inflammatory marker examinations that can explain the decrease in sle disease activity. with respect to the quality of life study, the sample size needs to be increased, and the research time needs to be longer than at least 6 months. conclusion in this study, the results showed that daily cholecalciferol (5000 iu) supplementation for 12 weeks improved disease activity, but did not significantly improve the quality of life of sle patients. from this study, it can be proven that cholecalciferol (5000 iu)/day supplementation for 12 weeks increases vitamin d levels and improves disease activity in sle patients. however, it is necessary to conduct an assessment in the form of inflammatory markers that are more specific for inflammatory conditions in the les so that they can explain the activity of the les. and related to the role of cholecalciferol supplementation on the quality of life of sle patients, it is still not significant in this study, so further research is needed with a larger sample size and a longer time of at least 6 months. acknowledgments acknowledgments and affiliations. individuals with direct involvement in the study but not included in authorship may be acknowledged. the source of financial support and industry affiliations of all those involved must be stated. vol 54 • number 3 • july 2022 effect of cholecalciferol supplementation on disease activity 413 references 1. bertsias g rc. sle pathogenesis and clinical feature. eular-fpp-indd. 2012;36(12):1503. 2. olesińska m, saletra a. quality of life in systemic lupus erythematosus and its measurement. 2018;45–54. 3. buleu f, gurban c, sarbu e, et al. the relationship between vitamin d, inflammation and the activity of systemic lupus erythematosus. fiziol physiol. 2015;25(november):87. 4. nguyen mh, bryant k, o’neill sg. vitamin d in sle: a role in pathogenesis and fatigue? a review of the literature. lupus. 2018;27(13):2003–11. 5. antico a, tampoia m, tozzoli r, bizzaro n. can supplementation with vitamin d reduce the risk or modify the course of autoimmune diseases? a systematic review of the literature. autoimmun rev [internet]. 2012;12(2):127–36. 6. christie m, bartels hsd. systemic lupus erythematosus (sle). medscape [internet]. 2020;2(2):2319–6718. 7. hassanalilou1 t, khalili l, ghavamzadeh s, et al. role of vitamin d defciency in systemic lupus erythematosus incidence and aggravation. autoimmun highlights. 2018;9(1):890–4. 8. hassanalilou t, khalili l, ghavamzadeh s, et al. role of vitamin d defciency in systemic lupus erythematosus incidence and aggravation. autoimmun highlights [internet]. 2018;9(1):1–10. 9. schoindre y, jallouli m, tanguy ml, et al. lower vitamin d levels are associated with higher systemic lupus erythematosus activity, but not predictive of disease flare-up. lupus sci med. 2014;1(1):1–8. 10. rifaâi, kusworini a, kusworini hksw. effect of vitamin d supplementation on disease activity ( s l e d a i ) a n d f a t i g u e i n s y s t e m i c l u p u s erythematosus patients with hipovitamin d: an open clinical trial. indones j rheumatol. 2008;8(2):501–7. 11. lomarat w, narongroeknawin p, chaiamnuay s, asavatanabodee p. randomized double-blind controlled trial to evaluate efficacy of vitamin d supplementation among patients. 2020;7980:24–32. 12. fisher sa, rahimzadeh m, brierley c, et al. the role of vitamin d in increasing circulating t regulatory cell numbers and modulating t regulatory cell phenotypes in patients with inflammatory disease or in healthy volunteers: a systematic review. plos one. 2019;14(9):1–18. 13. mcelhone k, abbott j, teh ls. a review of health related quality of life in systemic lupus erythematosus. lupus. 2006;15(10):633–43. 14. lima gl, paupitz j, aikawa ne, takayama l, bonfa e, pereira rmr. vitamin d supplementation in adolescents and young adults with juvenile systemic lupus erythematosus for improvement in disease activity and fatigue scores: a randomized, doubleblind, placebo-controlled trial. arthritis care res. 2016;68(1):91–8. 374 acta med indones indones j intern med • vol 53 • number 4 • october 2021 original article abstract background: one of the methods to record immunogenicity after vaccination is to measure antibody titer. this study aimed to get the value of antibody titer post sinovac vaccination and to analyze factors that associate with it. the trend of titer changes within 3 months period and the incidence of covid-19 were also observed. methods: a prospective cohort study was conducted in march until may 2021 involving 250 health care workers of siloam hospitals lippo-cikarang who have completed two doses of sinovac vaccination. we collected 3 titer data from each participant to observe the trend of changes. the incidence of covid-19 among post-vaccinated subjects was also calculated. results: from total of 250 participants, 88 (35.2%) were males and 162 (64.8%) were females. fourteen days after vaccination, 248 subjects (99.2%) had seroconversion. the median antibody titer amounted to 63.58 u/ml (0.4->250 u/ml). the titer was higher in age group 26-39 years (85.1 u/ml, p=0.003) and in women (78.7 u/ml, p=0.007). within 3 months period, 162 from 200 participants (81%) who completed 3 titer tests, had antibody titer reduction (p=0.231). in observation, 94 from 245 (38.3%) participants tested positive covid-19, with only 5 out of 94 (5.3%) participants being hospitalized. conclusion: the highest median titer was achieved 14 days after sinovac vaccination (63.58 u/ml). younger age group and women are associated with higher value. the reduction trend in titer within 3 months is insignificant. among post-vaccinated infection subjects, the hospitalization rate is low, which shows that sinovac vaccination still has a protective effect. keywords: sinovac, sars-cov-2, covid-19, antibody, vaccination, health care workers. factors associated with sars-cov-2 antibody titer after sinovac vaccination among health care workers theresia santi1*, baringin de samakto2, lina kamarga3, feronica k. hidayat4, ferry hidayat5 1 department of pediatric, siloam hospitals lippo cikarang, bekasi, indonesia. 2 department of internal medicine, siloam hospitals lippo cikarang, bekasi, indonesia. 3 department of neurology, siloam hospitals lippo cikarang, bekasi, indonesia. 4 department of clinical pathology, siloam hospitals lippo cikarang, bekasi, indonesia. 5 resident medical officer, siloam hospitals lippo cikarang, bekasi, indonesia. *corresponding author: theresia santi, md. department of pediatric, siloam hospitals. jl. mh. thamrin kav. 105, lippo cikarang, bekasi, indonesisa. email: therezdaton@gmail.com. introduction severe acute respiratory syndrome corona virus 2 (sars-cov-2) is a novel corona virus that spreads corona virus disease 2019 (covid-19) worldwide, and vaccination to control the pandemic of covid-19 has begun since december 2020.1,2 sinovac is an inactivated whole virus vaccine for covid-19 developed by sinovac life sciences which already completed its phase-3 clinical trials. since january 11th 2021, sinovac has already been approved by the indonesian food and drugs agency for emergency use of authorization in indonesia, and the first target population was the health care workers as the front liners in fighting covid-19.3-9 vol 53 • number 4 • october 2021 factors associated with sars-cov-2 antibody titer 375 one of the methods to record immunogenicity after covid-19 vaccination is the anti-sarscov-2 immunoassay which detects antibody titer of spike protein (s-protein) from sarscov-2.10-12 there are many factors that affect the antibody titer after vaccination as stated in many journals and researches.13 age and gender has been already known to influence immune response after vaccination. other factors such as body mass index, exercise, sleep duration had varied correlation with different types of vaccinations.13-18 correlation of those factors with covid-19 vaccination is still unknown. in its clinical trial, sinovac showed high immunogenicity among the subjects,3-7 but the data about immune response post sinovac vaccination among health care workers were still limited. it is important to have data on antibody titer, factors that influence the immunogenicity and incidence of infection after vaccination to monitor the impact of vaccination for health care workers and further get feedback for the next plan of their protection against covid-19. this study observed the data of quantitative antibody response 14 days after the second dose of sinovac vaccination followed by 1 month and 2 months later, among the health care workers of siloam hospitals lippo cikarang. the main purpose of this study is to get the value of antibody titer post sinovac vaccination and to analyze factors that might correlate with the titer (i.e age, gender, exercise, sleep and body mass index). the trend of titer changes and the incidence of covid-19 after vaccination were also observed as an additional objective. methods this study used a cohort design held at siloam hospitals lippo cikarang from march to may 2021. to improve quality of reporting, the strengthening the reporting of observational studies in epidemiology (strobe) guidelines were followed.19 the subjects of this study were health care workers who have already got two doses of sinovac vaccines, administered intramuscularly with 14 days interval, with the dose of 30 µg in a volume of 0.5 ml of aluminium hydroxide diluent solution per dose. in our hospital, there was a policy that all employees must undergo post vaccination evaluation of antibody titer using the elecsys anti-sars-cov-2 s-antibody assay at the hospital’s laboratory. the tests were taken 3 times, beginning at 14 days after getting the second dose of sinovac vaccine, followed by 2 consecutive months afterward. during and after the study period, participants were observed for covid-19 infection by the hospital surveillance team for approximately 5 months (march-july 2021). all of the antibody titer data were collected to observe trend of changes. for correlation analysis of antibody titer with age, sex, bmi, duration of sleep and exercise, we used the first antibody data taken 14 days after completed vaccination. we collected data from our laboratory as secondary data that has already been saved in its database. we distributed google form questionnaires via whatsapps application to collect demographic data and the health status of the participants. the questionnaires asked about age, sex, body weight, body height, sleep duration per day, and routine exercise. before filling the questionnaires, all participants were given written explanations and informed consent forms were attached to the questionnaires. antigen-specific humoral immune response was analyzed using quantitative elecsys anti-sars-cov-2 s-immunoassay (roche diagnostics, mannheim, germany).20 it is an electrochemiluminescence immunoassay used to detect antibodies (including igg) to the sarscov-2 spike protein receptor-binding domain (rbd) on the cobas e411 module (roche diagnostics, mannheim, germany). in this study, we used a commercial test that was usually used among the community, with the measurement ranges from 0.4 u/ml to 250 u/ml (values higher than 250 u/ml will be stated as >250 u/ml). a concentration of < 0.80 u/ml considered negative and > 0.80 u/ml considered positive. the who international standard for anti-sars-cov-2 immunoglobulin is bau/ml (binding arbitrary units per ml). the correlation between u/ml and bau/ml was: u = 0.972 bau. according to the manufacturer, the correlation test between roche elecsys antisars-cov-2 s units per ml and who international standards for antisars-cov-2 immunoglobulins was excellent theresia santi acta med indones-indones j intern med 376 (r2 = 0.9992, slope =0.972, intercept = 0.0072), thus allowing to consider specific roche elecsys anti-sars-cov-2 s u/ml units equivalent to who international standard bau/ml.21 we excluded the participants with a history of confirmed covid-19 on the reverse transcriptase polymerase chain reaction test (rt-pcr) before and during antibody titer examination. we also excluded participants with a history of reactive serology or rapid screening tests. the regular qualitative serological screening had been conducted by our hospital since july 2020 (7 months before the vaccination program), using the elecsys anti-sars-cov-2 assay (roche diagnostics) which detected antibodies to nucleocapsid (anti-n). all health care workers had this serology screening every 10 days. if the result turned reactive, they would have to continue for rt-pcr test. the history of confirmed covid-19 and reactive serological tests were obtained from laboratory data confirmed by the confession of the participants in the questionnaires. ethical approval this research was approved by the mochtar riady institute for nanotechnology ethics committee (protocol no: 2104011-03). the sample size calculation the sample size was determined using the formula for mean difference for two different groups. from a previous study from hospital workers in geneve, switzerland,22 the mean difference for two groups was 49 u/ml and the deviation standard was 156, so the minimum sample size calculated was 158 subjects. statistical analysis statistical analysis was performed using the ibm spss 26.0 (statistical package for the social sciences, ibm corp,. armonk, ny, usa). normality test was done using kolmogorovsmirnov, if the p-value were more than 0.05 then the data would be considered normally distributed. according to the data distribution, numerical data would be presented in mean and deviation standard or median and interquartile range. values lower than 0.4 u/ml were assumed as 0.4, and values higher than 250 u/ml were calculated as 251 u/ml. p values <0.05 were considered statistically significant. we used bivariate analysis to predict the association between variables. if the data were normally distributed, the association would use an independent t-test (for two groups), or oneway anova (for more than 2 groups). if the data were not normally distributed, the mannwhitney test (for two groups) or the kruskal wallis test (for more than two groups) would be applied. the statistical significance was set to p<0.05. results we invited 503 health care workers who eligible for vaccination from january to february 2021. twenty-seven of them were excluded because of being confirmed with covid-19 infection within 3 months prior. thus, as many as 476 participants who were vaccinated twice and had their antibody titer tests were eligible, but only 440 of them returned the questionnaires. sixty five out of 440 participants were excluded due to confirmed covid-19 (positive rt-pcr swab test) and 125 participants were excluded due to reactive serological or rapid antibody screening before vaccination. finally, we enrolled 250 eligible participants (in accordance with the minimum sample size requirement). a summary of the sampling process can be seen in figure 1. 2 5 0 h e a l t h c a r e w o r k e r s w e r e n o t homogeneously distributed, with age grouping based on the age quartile <25 years: 60 people (24%), age 26-39 years: 131 people (52.4%), and age >40 years: 59 people (23.6%). the youngest age of participants was 21 years old (4 subjects) and the oldest age of participants was 60 years old (2 subjects). 248 out of 250 participants (99.2%) who have received sinovac vaccination twice were being tested for their first-month antibody titer had antibody titer >0.8 u/ml (reactive), while 2 subjects had antibody titer: 0.4 and 0.7 u/ml. the median antibody titer of 250 participants amounted to 63.58 u/ ml (minimum 0.4 u/ml, maximum >250 u/ml). the description of hcw who participated in the study can be seen in table 1. vol 53 • number 4 • october 2021 factors associated with sars-cov-2 antibody titer 377 table 1. demographics of health care workers who participated in the study (n= 250). variables n (%) age < 25 years old 26-39 years old > 40 years old 60 (24.0) 131 (52.4) 59 (23.6) gender male female 88 (35.2) 162 (64.8) body mass index underweight (<18.5) normoweight (18.51–22.99) overweight (23–24.99) obesity i (25–29.99) obesity ii (>30) 28 (11.2) 90 (36) 48 (19.2) 65 (26) 19 (7.6) sleep duration <7 hours/day >7 hours/day 144 (57.6) 106 (42.4) physical exercise not routine routine 177 (70.8) 73 (29.2) 1st antibody titers, u/ml 63.58 (0.4 – >250) category variables: n(%) numeric variables: median (min-max) when the bivariate analysis was performed to analyze the association between the first month antibody titer with age, there was a significant difference among antibody levels of the age groups < 25 years, 26-39 years, and > 40 years (64.1 u/ml, 85.1 u/ml, and 38.2 u/ ml, respectively), kruskal wallis test, p=0.003, <0.05). antibody titer was also significantly different between men and women, which were higher in women (78.7 u/ml vs 49.6 u/ml respectively). antibody titer was not significantly associated with bmi, sleep duration and exercise. (table 2). in addition, data about vitamin consumption of the participants were also collected. there was no association between vitamin d, c, and e consumption and antibody titer of the participants (p-value were 0.700, 0.270 and 0.223, respectively). we also collected the data of the participant’s blood type and found no association between blood type and antibody figure 1. the overview of the research sampling process and participation rate theresia santi acta med indones-indones j intern med 378 titers of the participants (p=0.364). history of influenza vaccination also showed no significant association with the antibody titer (p=0.884). in this study, the trend of antibody titer was observed in 3 months. the number of participants who were examined for the first antibody titer was 250, the second was 234 and the third was 200. based on the results of 200 participants who completed the laboratory tests within 3 months, we identified that the antibody titer of 162 participants (81%) were gradually reduced. as many as 31 participants (15.5%) had increased antibodies, and 7 participants (3.5%) were stable. the median of the first antibody titer in 200 health care workers was 68.65 u/ml (1.02>250 u/ml), the second one was 57.65 u/ml (6.13->250 u/ml), and the third one was 55.59 u/ml (4.80->250 u/ml). the reduction of median antibody titer from the first month until the third-month post-vaccination were 16% and 3.5%, respectively. however, the reduction was not statistically significant (kruskal wallis test, p=0.231). the trend of antibody titer reduction can be seen in figure 2. we observed the incidence of covid-19 among participants within 4 months after completed vaccination, and after completing the monitoring of antibody titer trends (between table 2. association of first month antibody titer with factors of age, sex, bmi, sleep duration and exercise (n=250). antibody titer (median, range, u/ml) p value age <25 years old (n=60) 26-39 years old (n=131) >40 years old (n=59) 64.1 (0.7->250) 85.1 (1.02–>250) 38.2 (0.4–>250) 0.003 a gender male (n=88) female (n=162) 49.6 (0.4->250) 78.1.02–>250) 0.007 b body mass index underweight (<18.5) (n=28) normoweight (18.5– 22.99) (n=90) overweight (23– 24.99) (n=48) obesity i (25–29.9) (n=65) obesity ii (>30) (n=19) 44.1 (0.4–>250) 58.29 (0.7–>250) 70.65 (7.41->250) 90.9 (1.02–>250) 44.9 (7.73->250) 0.383 c sleep duration <7 hours/day (n=144) >7hours/day (n=106) 62.2 (0.4–>250) 64.5 (3.8–>250) 0.245 b physical exercise <3x/week (n=177) >3x/week (n=73) 64.7 (0.4–>250) 55.6 (0.7–>250) 0.450 b akruskall-wallis test, post-hoc mann whitney group <25 years vs group 26-39 years, p-value = 0.814, group 26-39 years vs. group >40 years, p-value = 0.001, group <25 years vs group >40 years , p value= 0.009 b mann whitney test ckruskall-wallis test figure 2. reduction trend of antibody titer (n = 200). vol 53 • number 4 • october 2021 factors associated with sars-cov-2 antibody titer 379 sinovac vaccination. previous studies have shown that antibodies to sars-cov-2 s-rbd would also increase after infection and could be detected until several months.24,25 although our study did not obtain antibody titer before the sinovac vaccination, we tried to make sure that the antibody was not influenced by the past covid-19 infection by excluding subjects who had been confirmed covid-19 based on the history of rt-pcr results and subjects who had reactive rapid or serological tests before vaccination. our hospital has already screened all health care workers routinely for early detection of covid-19 with rapid serological tests and periodic rt-pcr examinations, so it was possible to exclude prior infection status of our participants. age has been shown to have a major influence on a person’s response to vaccination. vaccines response showed suboptimal effects in the elderly, who also have more rapid waning of antibodies.13 causes of a decreased immune response to vaccination include changes in cellular immunity, changes in humoral immunity, and the structure of lymphoid tissue.26 previous studies have shown a decrease in cellular and humoral immunity with age, thus affecting the response to vaccination.13,26 sinovac vaccine administration protocols are also different in those over 60 years of age, using a vaccination schedule of 0-28 days.27 research by pellini et al14 showed that the antibody titer after bnt162b2 (pfizer-biontech) sars-cov-2 vaccination was related to age, i.e. young people had the highest antibody levels compared to other age groups. research on health care workers in israel after bnt162b2 (pfizer-biontech) vaccination also showed that antibody levels decreased with age.15 our study showed similar results, that antibody titer post-sinovac vaccination differed significantly according to age, which was higher in the age group 26-39 years. gender has been known to have different effects on immunity in general. women tend to have antibody responses, basal immunoglobulin levels and b cell counts higher than men.16 the causes of the different immune responses between women and men are related to the x chromosome which regulates more immune june-july 2021). five out of 250 participants were resigned from the hospital, leaving 245 remaining participants. the incidence of covid-19 infections among the participants was 94 cases (38.3%): 9 cases (9.6%) were asymptomatic, 80 cases (85.1%) had mild symptoms, and 5 cases (5.3%) were admitted to the hospital due to moderate symptoms. we did not find any severe-symptom cases nor death cases among the infected participants. thirty seven out of 94 infected participants (39.3%) had the first median antibody titer higher than baseline value (>63.58 u/ml), and 20 out of 37 participants still had high antibody titer 1 month before the infection. discussion the anti-sars-cov-2 s-immunoassay is one the methods of serology testing which detects antibodies, including igg antibody titers of spike proteinreceptor binding domain (s-rbd) sars-cov-2.20,23 assessment of immunogenicity in clinical trials of covid-19 vaccines were conducted using immunoassays that detect binding antibody titer, and also neutralizing antibody examination as the gold standard of functional antibody, which requires laboratory facilities with biosafety level 3.7,10 the assays of s-rbd which detect antibodies against the s-protein of the sars-cov-2 virus have a strong correlation with neutralizing antibodies.7,22,23 due to the strong correlation between s-rbd and neutralizing antibody, the examination of antibody s-rbd titer is a good choice in further research on the immune response to vaccination, and may help to monitor the antibody response in patients after vaccination. in sinovac phase 1 and 2 clinical trials, seroconversion rates were defined as a change from seronegative at baseline to seropositive on day 14 after vaccination or a 4-fold increase antibody titer in those who were already seropositive.8 the seroconversion rate of sinovac vaccination in phase 2 clinical trial in china was 97%,8 and in the interim report of phase 3 clinical trial in indonesia was 99.7%.6 in our study, we found that 99.2% of participants had detectable antibody on day 14 after the second theresia santi acta med indones-indones j intern med 380 functions, and the presence of hormonal factors that play a role in the regulation of the immune system. gender has been known to produce differences in antibody titer after covid-19 vaccination. research on health care workers in italy found that post-bnt162b2 vaccination, antibody levels in women were higher than in men.14 research by jabal et al15 on workers in israel also showed significant differences in antibody levels post bnt162b2 vaccination in women and men. our study results were in accordance with the two studies above that antibody titer in women was higher than men. systematic review from zimmerman13 stated that body mass index, sleep and exercise can be associated with immune response after immunization, but in our study, those factors were not associated with antibody titers after sinovac vaccination. body mass index has long been known to correlate with the immune response to vaccination due to some influences in the increased body fat and production of leptin.13 according to asia pacific criteria, body mass index is classified as underweight (<18.5), normoweight (18.5-22.9), overweight (23-24.9), and obese (>25).28 obesity is a product of biological and environmental influences that leads to an increase of excess adipose tissue, which correlates with an increase in debilitating conditions associated with increased morbidity and mortality.29 the pro-inflammatory hormone leptin, which has many immunologic functions, has been shown to correlate with body fat mass since it is produced and secreted from adipocytes. adipocytes also produce signaling molecules, such as tnfα, il-6, and resistin, together with leptin induce a chronic state of inflammation.29 the chronic inflammatory state has been shown to interfere with a proper vaccine-induced immune response through several mechanisms, including altered production of cytokines and t cells, diminished natural killer cell activity, and poor response to antigens, which leads to a dysregulated immune system.29 so that, obesity may interfere with an obese individual’s ability to mount an effective immune response to vaccination or infection due to increased body fat and increased leptin production.29 many kinds of researches show that there is a correlation between obesity and decreased vaccine-induced immune response for example hepatitis b vaccine, influenza, tetanus and rabies.30,31 in our research, there was no correlation between antibody serum level and body mass index. this finding is in accordance with the phase iii trial of the sars-cov-2 vaccine from bnt162b232 and mrna-127333, whereas no difference in immunogenicity between the normal bmi group and the obese group. studies have found that shorter sleep duration (measured naturally) was related to reduced influenza and hepatitis b vaccine response in healthy young and middle-aged adults.17 sleep on the night after experimental vaccinations against hepatitis a produced a strong and persistent increase in the number of antigen-specific t helper cells and antibody titer.34 the impact of sleep on immune response after covid-19 vaccination so far is still unknown. data from the phase 3 trial covid-19 vaccine from bnt162b2 did not show a clear role of sleep in modulating vaccine efficacy.35 in our study, we did not find an association between sleep duration and antibody titer after sinovac vaccination. so far we have not yet found any studies about association between sleep and sinovac vaccination. further study to investigate association between certain duration and sleep quality around the time of vaccination with antibody titer needs to be explored for further insight. exercise has been identified as a behavioral factor that can increase immune function, possibly acting as an adjuvant for the immune response after vaccination. a meta-analysis from chastin et al18 from 6 studies about the interventional effect of physical activity to the result of h1n1, h3n3, influenza b, pneumococcus, and varicella zoster vaccination, concluded that routine moderate to high-grade physical activity (3 times a week, 60 minutes duration, within 20 weeks before vaccination) related with increase vaccine potency. however, there was a different result between young adult and old age population. the young adult had a lesser effect of exercise on immune response after vaccination compared to the older age.36 our study did not find any significant correlation between regular exercise and antibody titer vol 53 • number 4 • october 2021 factors associated with sars-cov-2 antibody titer 381 after vaccination. it was probably affected by the greater percentage of young age subjects compared to the old ones and we also did not know about the intensity (mild/moderate/high) or duration of the exercise. in the future, we need a specific study with a certain type and duration of exercise on the homogenous population to better elucidate the association. concerns had been raised about the factors that affect the immunogenicity of vaccines against sars-cov-2. studies from different platforms of sars-cov-2 vaccines showed several common influencing factors on humoral response, that were assessed by antibody titer or neutralizing antibody. the publications which showed correlation between age, gender and body mass index with immunogenicity after sars-cov2 vaccination were summarized in table 3. the observation of antibody titer trend within 3 months duration in our study showed reduction tendency. this finding is in line with the interim report of clinical trial phase 3 of sinovac vaccine in bandung which showed a reduction trend of igg seropositive rate and neutralization antibody until 44.1% within 6 months after the second dose of sinovac vaccination.6 the interim report of phase 2 coronavac trial in jiangsu, china, also showed that neutralizing antibody titer induced by the first two doses declined after 6-8 months to below the seropositive cutoff.41 prior shreds of evidences that showed waning antibody titers indicate that sars-cov-2 vaccines induced humoral immunity might not be as durable as that of other virus vaccines. but some studies showed that antigen-specific cd4 and cd8 t cells responses had an association with reduced disease severity while neutralizing antibody titer did not.7,10-12 table 3. summary of the previous studies about association between age, gender and body mass index with immunogenicity after sars-cov-2 vaccination. study methods/samples results obesity may hamper sars-cov-2 vaccine immunogenicity pellini r et al, 2021.14 248 health care workers (hcw) antibody titres ,7 days after second dose of bnt162b2 (pfizer) higher antibody in female, young age and lean body weight. impact of age,ethnicity,sex,and prior infection status on immunogenicity following a single dose of the bnt162b2 mrna covid-19 vaccine: real-world evidence from health care workers, israel, december 2020 to january 2021 jabbal et al, 2021.15 514 hcw antibody titres, 21 days after first dose of bnt162b2 (pfizer) reduction of antibody titer with increasing age. no correlation of antibody titer with sex. assesment of factors affecting inactivated covid-19 (coronavac) vaccine response and antibody response in healthcare proffesionals ozdemir ho et al, 2021.37 264 hcw antibody titres, 28 days after second dose of coronavac lower immunogenicity in advanced age and male safety and immunogenicity of an inactivated sars-cov-2 vaccine, bbibpcorv: a randomized, double-blind, placebo-controlled, phase 1/ 2 trial.xia s, et al.38 320 participants antibody titers, day 0, day 28, and day 56 after first dose of bbibpcorv (sinopharm) a randomised, double-blind, placebocontrolled trial people age 60 and above produced significantly fewer antibody than those aged 18-59. antibody persistence through 6 months after the second dose of mrna-1273 vaccine for covid-19 doria-rose n, et al.39 33 participants neutralizing antibodies at 180 days after second dose of mrna-1273 (moderna) age group 18 to 55 had higher antibody titer compared to older age groups safety and immunogenicity of chadox1 ncov-19 vaccine administered in a primeboost regimen in young and old adults (cov002) ramasamy et al.40 560 participants neutralizing antibodies at 28 days after second dose of chadox1 (astra-zeneca) a single-blind, randomized, controlled trial the neutralizing antibody titer did not differ significantly between the vaccinated population aged 18 to 55 years and those over 55 years of age. theresia santi acta med indones-indones j intern med 382 in our study, we had 200 subjects who had 3 complete antibody titer data within 3 months period, 162 of them (81%) showed a reduction of antibody titer. the titer on the third examination showed a 19% reduction compared to the first one (55.59 u/ml vs 68.65 u/ml). although we found the downward trend, it was statistically insignificant, probably due to the short period of observation. thus, a study with a longer period of observation is needed policy makers about the timing of vaccine boosters in the community. the observation about covid-19 among our participants showed that vaccination protected 61.7% of participants from infections. this finding was similar to a prospective national cohort study in chile, which also used sinovac in a large number of participants, which had 65.9 % adjusted vaccine effectiveness.42 vaccination in our study also prevented 94.7% of infected participants from being hospitalized (only had mild or no symptoms at all), whereas the study in chile had 87.5 % for the prevention of hospitalization and 90.3 % prevention of icu admission. data on the hospitalized participants in our study revealed no severe-symptom cases or death (0%) and no icu admission. it shows that although there are many persons infected with covid-19 after completed vaccination, it still has protective effects on morbidity and mortality, which is in line with the findings of a study in chile.42 in order to reveal the variant of virus which infected participants, we did a whole-genome sequencing of 3 participants’ samples (2 with moderate symptoms and 1 with mild symptoms). the results showed that three of them were infected by sars-cov-2 delta variants. delta variants which were initially detected in india have been predominant in indonesia, as the covid-19 surged up since june 2021. indonesian ministry of health reported that until 7 august 2021, there were 1477 cases of new sars-cov2 variants, whereas delta variants were predominant with 1368 cases.43 from our study, we thought that sars-cov-2 delta variants might reduce sinovac vaccine efficacy which impacts on many infections among our participants. the strengths of our study are that we used the elecsys anti-sars-cov-2 assay which its unit of measurement is equivalent to who international standard bau (binding arbitrary unit per ml) and our participants were selectively screened to be free from covid-19. however, this study had some limitations. firstly, that we used the assay without dilution (for commercial purposes, budget restriction) which could only detect the highest titer up to 250 u/ ml. other limitations are: the observation period of antibody titer trend is not long enough and we only did whole-genome sequencing to 3 of our subjects who got covid-19 after completed vaccination due to access and time limitation. this study showed the immune response of health care workers who have been vaccinated with 2 doses of sinovac vaccine in the real world, outside clinical trials which have been done in indonesia. to the authors’ knowledge, there has not yet been any published indonesian study about sars-cov2 antibody titer and incidence of covid-19 after competed sinovac vaccination. we got the basic data of antibody titer after vaccination which can be used as a comparison for other research in the future. up till now, the optimal protective value of antibody against sars-cov-2 is still unknown, many studies with a bigger scale and longer duration are needed to reveal it. conclusion the highest median antibody titer occurs 14 days after the sinovac vaccination (63.58 u/ml). age group 26-39 years and women are associated with the higher antibody titer. the antibody titer within 3 months after vaccination is not significantly reduced in all participants. covid-19 incidence post-vaccination is quite high but the hospitalization rate is low with no mortality, which shows that sinovac vaccination still has a protective effect. conflict of interest the authors report no conflict of interest acknowledgments the authors wish to thank the following groups for their supports: siloam hospitals vol 53 • number 4 • october 2021 factors associated with sars-cov-2 antibody titer 383 lippo cikarang, mochtar riady institute of nanotechnology, and pelita harapan university. the authors also wish to thank: veli sungono m epid from pelita harapan university, professor irawan yusuf md, phd, and ivet suriapranata, phd, head and researcher of mochtar riady institute of nanotechnology, dr. albert limanto, mm, mars, hospital director of siloam hospitals lippo cikarang, dr. grace frelita indradjaja, mm, managing director of siloam hospitals group; and caroline riady, ceo and deputy president director of siloam hospitals group. references 1. zhu n, zhang d, wang w, et al. a novel coronavirus from patients with pneumonia in china, 2019. n engl j med. 2020;382(8):727-33. 2. world health organization. the covid-19 candidate vaccine landscape. 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[cited 2021 august 9] available at: https://www.who.int/publications/m/item/whobs-2020.2403. 22. huilier ag, meyer b, andrey do, et al. antibody persistence in the first 6 months following sarscov-2 infection among hospital workers: a prospective longitudinal study. clin microbiol infect. 2021: 27:784e1-8. 23. higgins v, fabros a, kulasingam v. quantitative measurement of anti-sars-cov-2 antibodies: analytical and clinical evaluation. j clin microbiol. 2021;59(4):e03149-20. 24. wajnberg a, amanat f, firpo a, et al. robust neutralizing antibodies to sars-cov-2 infection persist for months. science. 2020;370:1227–30. 25. ni l, ye f, cheng m, et al. detection of sars-cov-2specific humoral and cellular immunity in covid-19 convalescent individuals. immunity. 2020;52: 971–7. 26. crooke sn, ovsyannikova ig, polland ga, kennedy ng. immunosenescence and human vaccine immune responses. immun ageing. 2019;16:25. available from https://doi.org/10.1186/s12979-019-0164-9. 27. wu z, hu y, xu m, et al. safety, tolerability, and immunogenicity of an inactivated sars-cov-2 vaccine (coronavac) in healthy adults aged 60 years and older: a randomised, double-blind, placebocontrolled, phase 1/2 clinical trial. lancet infect dis. [internet] 2021 [cited 2021 august 9]; s1473-3099( 20)30987-7. available from https://doi.org/10.1016. 28. annurad e, shiwaku k, nogi a. the new bmi criteria for asians by the regional office for the western pacific region of who are suitable for screening of overweight to prevent metabolic syndrome in elder japanese workers. j occup health. 2003;45:335-43. 29. scott painter sd, ovsyannikova i, polland ga. the weight of obesity on the human immune response to vaccination. vaccine. 2015;33(36):4422–9. doi:10.1016/j.vaccine.2015.06.101. 30. liu f, guo z, dong c. influences of obesity on the immunogenicity of hepatitis b vaccine. hum vaccin immunother. 2017;3(5):1014–7. 31. sheridan pa, j handy, karlsson ea. obesity is associated with impaired immune response to influenza vaccination in humans. int j obes. 2012;36:10727. 32. pollack fp, thomas sj, kitchin n, et al. safety and efficacy of the bnt162b2 mrna covid-19 vaccine. n engl j med. 2020;383(27):2603-15. doi:10.1056/ nejmoa2034577. 33. baden lr, sahly hm, essink b, et al. efficacy and safety of the mrna-1273 sars-cov2 vaccine. n engl j med. 2021;384(5):403-16. 34. besedovsky l, lange t, bojn j. sleep and immune function. eur j physiol. 2012;463:121-37. 35. benedict c, cadernaes j. could a good night’s sleep improve covid-19 vaccine efficacy? lancet. 2021;9:447-8. 36. edward km, booy r. effects of exercise on vaccineinduced immune responses. hum vaccin immunother. 2013;9:907–10. 37. ozdemir ho, tosun s, coskuner sa, demir s. assessment of factors affecting inactivated covid-19 (coronavac) vaccine response and antibody response in healthcare professionals. [internet]. reseachgate [preprint]. 2021. [cited 2021 nov 25]: 14 p. available from: https://doi.org/10.21203/rs.3.rs-506854/v1. 38. x i a s , z h a n g y, wa n g y, e t a l . s a f e t y a n d immunogenicity of an inactivated sars-cov-2 vaccine, bbibp-corv: a randomized, double-blind, placebo-controlled, phase 1/ 2 trial. lancet infect dis. 2020;21:39-51. 39. doria-rose n, suthar ms, makowski m, et al. antibody persistence through 6 months after the second dose of mrna-1273 vaccine for covid-19. n engl j med. 2021;384:2259-61. 40. ramasamy mn, minassian am, ewer kj, et al. safety and immunogenicity of chadox1 ncov-19 vaccine administered in a prime-boost regimen in young and old adults (cov002): a single-blind, randomized, controlled, phase 2/ 3 trial. lancet. 2021;396:1979-93. 41. pan h, wu q, zeng g, et al. immunogenicity and safety of a third dose, and immune persistence of coronavac vaccine in healthy adults aged 18-59 years: interim results from a double-blind, randomized, placebocontrolled phase 2 clinical trial. [internet]. medrxiv. [cited 2021, august 9]. available from https://doi.or g/10.1101/2021.07.23.21261026. 42. jara a, undurraga ea, gonzales c, et al. inactivated sars-cov-2 vaccine effectively prevented covid 19, including severe disease and death, supporting implementation of mass vaccination campaigns. n engl j med. 2021;385:875-884. 43. kompas. sebaran variant alpha, beta dan delta di indonesia hingga 7 agustus 2021. [internet] 2021 august 8; [cited 2021 august 9]. available from: https:// nasional.kompas.com/read/2021/08/09/16390581/ sebaran-varian-alpha-beta-dan-delta-di-indonesiahingga-7-agustus-2021?page=all. 517acta med indones indones j intern med • vol 54 • number 4 • october 2022 original article abstract background: the blood level of rifampicin, one of the tuberculosis (tb) drugs, depends on the organic anion transporting polypeptide 1b1 (oatp1b1) in hepatocytes. this protein is encoded by the solute carrier organic anion 1b1 (slco1b1) gene. its genetic variation has been reported to have an impact on clinical outcomes and drug efficacy. however, the polymorphism in the slco1b1 gene has not been examined in indonesia yet. we aimed to identify the frequency of polymorphism in slco1b1 gene among pulmonary tb patients in bandung, indonesia. methods: cross-sectional study was conducted in west java. 145 pulmonary tb patients who were treated with first-line drugs treatment (including rifampicin 450 mg daily) were analyzed for polymorphism in slco1b1 gene. patients aged between 18–64 years old and mainly came from sundanese ethnic group (92.4%). genetic variants were detected using polymerase chain reaction (pcr) and sanger sequencing. results: polymorphism of c.463c>a(rs11045819) was not identified, while heterozygous and homozygous polymorphism of c.85-7793c>t(rs4149032) were identified in 74 (51.0%) and 56 (38.6%) patients, respectively. the minor allele frequency (maf) of t (mutant) allele of c.85-7793c>t(rs4149032) was 64.13% (186/209), higher than in the general population, which the maf of rs4149032 is 53.6% based on 1000 genome database. conclusion: this study highlights the presence of different allele frequencies of polymorphisms within the population, which might affect treatment outcomes. keywords: c.85-7793c>t (rs4149032), c.463c>a (rs11045819), drug transporter, gene polymorphism, west java, indonesia. polymorphisms of slco1b1 gene in sundanese ethnic population of tuberculosis patients in indonesia prayudi santoso1*, henny juliastuti2, heda melinda nataprawira3, arto yuwono soeroto1, bachti alisjahbana4, rovina ruslami5, josephine debora6, yunia sribudiani7, ani melani maskoen8 1 division of respirology and critical illness, department of internal medicine, faculty of medicine, universitas padjadjaran hasan sadikin general hospital, bandung, indonesia. 2 department of biochemistry, faculty of medicine, universitas jendral achmad yani, cimahi, indonesia 3 division of respirology, department of pediatrics, faculty of medicine, universitas padjadjaran, hasan sadikin general hospital, bandung, indonesia. 4 division of infectious and tropical diseases, department of internal medicine, faculty of medicine, universitas padjadjaran hasan sadikin general hospital, bandung, indonesia. 5 division of pharmacology, department of biomedical science, faculty of medicine, universitas padjadjaran hasan sadikin general hospital, bandung, indonesia. 6 department of internal medicine, faculty of medicine, universitas padjadjaran hasan sadikin general hospital, bandung, indonesia. 7 division of biochemistry and molecular biology, department of biomedical science, faculty of medicine, universitas padjadjaran, bandung, indonesia. 8 laboratory of molecular genetic, faculty of dentistry, universitas padjadjaran, bandung, indonesia. * corresponding author: prayudi santoso, m.d. division of respirology and critical illness, department of internal medicine, faculty of medicine universitas padjadjaran dr. hasan sadikin general hospital. jl. pasteur no. 38, bandung 40161, indonesia. email: prayudi@unpad.ac.id. prayudi santoso acta med indones-indones j intern med 518 introduction lungs are the most commonly m. tuberculosis (m.tb)-infected organ. there are five standard first-line drugs for the treatment of pulmonary tuberculosis (tb), namely: rifampicin, isoniazid, ethambutol, pyrazinamide, and streptomycin.1,2 the administration of tb drugs is divided into two categories. the first category is given to new patients, who did not have a previous history of tb treatment, while the second one is given for relapsed cases or patients that were lost to followup during treatments, with additional injection regimens and longer duration.2,3 among those five drugs, rifampicin, derived from amycolatopsis rifamycinica is the backbone for tb treatment, as it is one of the most effective bactericidal agents against m. tuberculosis (m.tb) by inhibiting mycobacterial rna polymerase through suppression of chain formation in rna synthesis.4,5 the activity of rifampicin against m.tb is determined by plasma concentrations of rifampicin.6,7 lower plasma concentrations of rifampicin can affect the results of the treatment, including a higher rate of relapse in the continuous phase.8 aside from the severity of the disease, low plasma concentration of rifampicin is also related to the course and absorption of drugs inside the patients’ body or pharmacokinetics. weiner et al. mentioned that the polymorphism of c.463c>a (rs11045819) solute carrier organic anion transporter family member 1b1 (slco1b1) gene significantly influenced the pharmacokinetics of rifampicin, resulting in lower plasma concentrations of rifampicin.9 it was reported that patients with polymorphisms c.463c>a (rs11045819) in the slco1b1 gene experienced lower peak concentrations of rifampicin by 42% compared to wild types.9 organic anion transporting polypeptide 1b1 (oatp1b1), encoded by the slco1b1 gene, plays a role in mediating drugs and their absorption in hepatocytes.10-13 a study conducted by kwara in 2014, reported that polymorphism c.463c>a (rs11045819) slco1b1 gene resulted in lower plasma concentrations of rifampicin, especially in men.14 other than c.463c>a (rs11045819) polymorphism, chigutsa et al., identified that c.85-7793c>t (rs4149032) polymorphism in slco1b1 decreased rifampicin concentration in pulmonary tb patients.8 moreover, the study detected an allele frequency for this polymorphism of around 70%.8 in asia, it is found that the allele frequency for polymorphisms of c.85-7793c>t (rs4149032) slco1b1 is around 56%. while the allele frequency for polymorphism of c.463c>a (rs11045819) slco1b1 is approximately 3%.8,9,15,16 minor allele frequencies of these polymorphisms in tb patients have not been reported yet. we aimed to determine the frequency of polymorphisms of the slco1b1 gene in tb patients. knowing the frequencies of the polymorphisms is important to determine the association between these variables and the effect of tb drugs on clinical outcomes. methods this is a cross-sectional descriptive study to evaluate the frequency of c.463c>a (rs11045819) and c.85-7793c>t (rs4149032) polymorphisms in the slco1b1 gene in pulmonary tb patients receiving anti-tb drug. this study was approved by the ethics committee of the faculty of medicine, universitas padjadjaran, (15/un6. c1.3.2/kepk/pn/2016, 22). written informed consent was obtained from all the subjects before the commencement of the study. population a total of 145 tb patients receiving firstline anti-tb drugs and residing in bandung were enrolled in this study. patients included were patients aged between 18 and 65 years old, undergoing an intensive phase at the time of the study, and with normal liver function. normal liver function was defined as an sgpt level below 2.5 x the upper normal limit. the ethnicity of study participants was determined by interview, which is the ethnicity of the subjects’ previous two generations (parents and grandparents). data collection two phases of data collection were done; initial screening was performed to collect and sort out pulmonary tb patients who met the inclusion and exclusion criteria. when the inclusion criteria are met, whole blood samples were taken. dna extraction followed by pcr of vol 54 • number 4 • october 2022 polymorphisms of slco1b1 gene in sundanese ethnic population of tb 519 the slco1b1 gene was performed. furthermore, the pcr products were sequenced to obtain the sequence of nucleotide bases which is further analyzed for c.463c>a (rs11045819) and c.857793c>t (rs4049302) polymorphisms. an indepth analysis of each with polymorphism in each patient was done. dna extraction genomic dna was extracted from patients’ whole blood using the salting out method. the cleaned and washed dna pellet was resuspended with te buffer to complete the process of dna extraction.17 pcr reaction t h e p r i m e r m i x t u r e s w e r e u s e d t o produce amplicons. forward primer was ggggaagataatggtgcaaa, and reverse primer was catccagttcagatggacaaaa. the amplification was done in the following condition: 10 min of initial denaturation pcr activation at 94ᴼc; 35 cycles of denaturation at 94ᴼc for 5 min; annealing at 58ᴼc for 30 seconds, elongation at 72ᴼc for 1 min; and final elongation at 72ᴼc for 7 min. the pcr products were then visualized by mixing 10 ul amplicons with sybersafe and loading it to 2% gel agarose then electrophoresis with 1% tae buffer was performed at 100 v for 40 min.17 sanger sequencing the pcr product was purified by adding 2 μl of exosap-it reagent (usb corporation, cleveland, oh, usa) to 5 μl of pcr product and incubated for 15 minutes at 37ᴼc and 15 minutes at 80ᴼc for denaturation.17 furthermore, dna concentration was measured using an nd-1000 spectrophotometer (nanodrop tech., rockland, de, usa) and dissolved up to 100 mg.17 after adding 0.1 μm of the sequencing primer sequence, the solution was reacted with the bigdye terminator cycle sequencing kit (applied biosystems, foster city, ca, usa) when the cycle sequencing is performed in a thermal cycler.17 the result was analyzed using bioedit software to detect snps. results patient characteristics data related to subsequent data analysis, including age, ethnicity, sex, drugs other than anti tb drugs, body weight, body mass index, hiv status, diabetes mellitus status, and the dose of rifampicin/kg body weight were collected. the basic characteristics of the patients involved are presented in table 1. table 1. patient characteristics. characteristics n=145 age, years median (range) 36 (18–64) age categories, years (%) 18–60 >60 134 (92.4) 11 (7.6) gender (%) male female 80 (55.2) 65 (44.8) ethnicity (%) ambonese/ south moluccans bataknese buginese javanese minangnese sundanese 1 (0.7) 1 (0.7) 1 (0.7) 7 (4.8) 1 (0.7) 134 (92.4) body weight, kilograms mean (sd) range 46 (5) 34–58 body mass index/bmi, kg/m2 mean (sd) range 17.4 (1.9) 13.8–23.1 bmi categories, kg/m2 (%) <18.5 18.5–23.0 107 (73.8) 38 (26.2) hiv (+) (%) 3 (2.1) diabetes mellitus (%) 3 (2.1) a total of 145 patients were enrolled in this study. most patients were under 60 years old. the proportion of gender in this study (male vs. female) was similar. since this study was conducted in bandung, nine out of ten subjects’ ethnicity were sundanese. the mean weight of the patients in this study was 46 kg and about three-quarters were underweight (bmi <18.5 kg/m2). there were three patients with hiv coinfection (2.1%) and three patients with diabetes mellitus comorbidity (2.1%). table 2. the number of polymorphism c.463c>a (rs11045819) and c.85-7793c>t (rs4149032) of slco1b1 gene characteristics n=145 c.463c>a (rs11045819) slco1b1 (%) cc ca aa 145 (100) 0 (0.0) 0 (0.0) c.85-7793c>t (rs4149032) slco1b1 (%) cc ct tt 15 (10.3) 74 (51.1) 56 (38.6) prayudi santoso acta med indones-indones j intern med 520 there were no polymorphism c.463c>a (rs11045819) identified as presented in table 2. however, 130 (89.6%) patients were identified carrying c.85-7793c>t (rs4149032) polymorphism of the slco1b1 gene from the analysis of sequencing results. half of the patients were heterozygous c.85-7793c>t (rs4149032), around 40% were homozygous (c.85-7793t>t (rs4149032) and the remaining 10% of the patients were wild type c.857793c>c (rs4149032). furthermore, the minor allele frequency of c.85-7793c>t (rs4149032) in this group of patients was 64.13% (186/290). the distribution of these polymorphisms based on gender, ethnicity, body weight, and rifampicin dose are presented in table 3. discussion tuberculosis (tb) is one of the top global problems in the world requiring special attention. it is also the second leading cause of death from a single infectious agent, after the human immunodeficiency virus (hiv).18 the success of pulmonary tb treatment is influenced by many factors, such as the dose of the drug, the method of administration of the drug, patient compliance, and tb germs. what is important and often overlooked is the achievement of therapeutic concentrations of rifampicin in plasma. from a previous study, it has been proved that genetic variation in the slco1b1 gene affects rifampicin oatp1b1 transporter and has a negative effect on plasma rifampicin concentration, which might contribute to tb treatment outcome.8,9,14 several studies in indonesia, especially in bandung, showed low concentrations of plasma rifampicin which varied between individuals. this variation can be caused by the polymorphism of the oatp1b1 transporter encoding gene in the pharmacokinetics process of rifampicin, the slco1b1 gene. most of the patients were under 60 years and 92.4% were sundanese.19,20 further study needs to be done, including other indonesian ethnicities to generalize the result of the indonesian population. rifampicin is a substrate with oatp1b1 as its transporter. this transporter is expressed on the sinusoidal membrane of hepatocytes.13 in the liver, it has a role in metabolic processes. the oatp1b1 transporter is encoded by the slco1b1 gene.16 solute carrier organic anion transporter family member 1b1 (slco1b1) is a gene that encodes the organic anion protein transporter for membrane binding (oatp1b1). this protein transporter facilitates the absorption of rifampicin in the hepatocellular level. the slco1b1 gene is known to have many possibilities for polymorphisms.10,12,14-16 snp or single nucleotide polymorphism is the change of a single nitrogenous base in a gene that has > 1% frequency of occurrence. this genetic variation can cause molecular changes both at the level of metabolic enzymes, drug targets or receptors, and table 3. the distribution of polymorphism c.85-7793c>t (rs4149032) of slco1b1 gene based on gender, ethnicity, body weight, and rifampicin dose. variables polymorphism c.85-7793c>t (rs4149032) slco1b1 p valuecc (reference) n=15 ct n=72 tt n=56 gender (%) male female 8 (53.3) 7 (46.7) 32 (44.4) 40 (55.6) 39 (69.6) 17 (30.4) 0.017* ethnicity (%) ambonese bataknese buginese javanese minangnese sundanese 0 (0.0) 0 (0.0) 1 (6.7) 0 (0.0) 0 (0.0) 14 (93.3) 1 (1.4) 1 (1.4) 0 (0.0) 5 (6.9) 0 (0.0) 65 (90.3) 0 (0.0) 0 (0.0) 0 (0.0) 2 (3.6) 1 (1.8) 53 (94.6) 0.188 body weight, kg mean ± sd 47.0 ± 5.3 45.5 ± 5.0 47.6 ± 5.5 0.073 dose per kg bw mean ± sd 9.7 ± 1.3 10.0 ± 1.1 9.6 ± 1.1 0.095 *: statistically significant vol 54 • number 4 • october 2022 polymorphisms of slco1b1 gene in sundanese ethnic population of tb 521 patients came from a relatively homogeneous ethnic group which is sundanese. the sundanese is part of the deutro-melayu ethnic group which gnomically is similar to the chinese. this might explain why this polymorphism was also not identified in this study. in a previous study, pasanen (2008) investigated the diversity of slco1b1 gene at a global level. this study involved 941 patients within 52 populations. the study was carried out by dividing populations into 8 regions, namely: sub-saharan africa, north africa, middle east, europe, south/ central asia, east asia, oceania, and america. the allele frequency of polymorphism c.463c>a was found to be 0.4% in the east asian region. this number was considered very small compared to europe (17%) and the united states (7.2%).27,28 the presence of slco1b1 polymorphisms correlated with geography.29 this is consistent with a study conducted by niemi et al (2011) which stated that polymorphism in c.463c>a associated with decreased rifampicin concentration in plasma, only be around 0–3% of the population in east asia.16 polymorphism heterozygous and homozygous mutant of c.85-7793c>t (rs4149032) of the slco1b1 gene was found in 74 and 56 patients, respectively (51.0% and 38.6%). hence the maf of this polymorphism in this group of tb patients is 64.13% (186/290). a previous study by chigutsa et al. in africa found at least 70% of allele frequency of polymorphism c.85-7793c>t (rs4149032) of slco1b1 gene.8 in other reports, allele frequency of polymorphism c.85-7793c>t (rs4149032) was 75% in nigerians, 29% in caucasians, and 56% in asian.8,26,27 this study found a higher minor allele frequency of polymorphism c.85-7793c>t (rs4149032) slco1b1 gene than that in caucasians, and other asian but lower than that in the african population. preliminary studies conducted by od sampurno in jakarta, included 30 healthy people, 60% of men aged between 25–58 years received the results of the slco1b1 gene with the snp in c.463c>a, with the proportion of genotype cc 46.7%, ca 46.7%, and aa 6.6% whereas in rs4149032 there was no polymorphism detected.30 this is protein transporters.21 pharmacokinetic changes, caused by genetic polymorphisms, might affect drug efficacy.22-24 the polymorphisms of slcob1 gene, c.463c>a (rs11045819) and c.85-7793c>t (rs4149032) have been reported to be associated with lower plasma rifampicin concentrations compared to wild type.8,9,14 genetic variations between individuals can cause differences in the concentration of rifampicin through the role of the transporter. for example, polymorphism c.85-7793c>t (rs414903232) slco1b1 gene is associated with c-max, auc, and confounding factors such as gender, ethnicity, weight, rifampicin dose per kgs of body weight.14,16 pharmacogenetic polymorphism is an important factor in the high variation of plasma rifampicin concentration. genetic polymorphisms in enzyme metabolism and drug transporters might explain the occurrence of 30% pharmacokinetics variations of the drug.25 in this study, two types of polymorphisms w e r e e x a m i n e d , w h i c h a r e c . 4 6 3 c > a (rs11045819) and c.85-7793c>t (rs4149032) of slco1b1 gene. at the end of the examination, not a single polymorphism of c.463c>a (rs11045819) slco1b1 gene was identified in the group of tb patients in bandung, indonesia. based on data from dbsnp150 database at ncbi (national center for biotechnology information), the minor allele frequency (maf) of rs11045819 (c.463c>a) was 0,0649/325, meaning that a minor (mutant) allele (a allele), was identified in 6,5% within the population (these data were generated from sequencing of 325 individuals/650 chromosome).8,26,27 if the sample size is 100 (200 chromosomes), it means that the probability of allele a will be found in 6 samples with heterozygous genotype or 3 samples with homozygous genotype (minor/ mutant) or a mix between heterozygous and homozygous type. the obtained information after tracing the data on dbsnp150, maf data of rs11045819 showed that this polymorphism only occured populations/ ethnicity of african americans, mexicans, and caucasians. on the contrary, asian ethnicities, including japanese and chinese (han chinese) do not have this polymorphism. in this study, the majority of prayudi santoso acta med indones-indones j intern med 522 polymorphism allele frequency in tb patients, which may affect treatment outcomes. acknowledgments the authors would like to express our gratitude to the research assistants and health care workers in all of the primary healthcare settings that participated in this research. conflict of interest the authors report no conflicts of interest in this work. funding this study was funded by research grants for doctoral programs from universitas padjajaran (riset disertasi doktor unpad/rddu no.2914/un6.c/hk/2014) and department of internal medicine dr. hasan sadikin general hospital. references 1. pai m, behr ma, dowdy d, et al. tuberculosis. nature reviews disease primers. 2016;2(1):16076. doi:10.1038/nrdp.2016.76 2. world health organization. international standards for tuberculosis care. 3rd edition. 2014. 3. ve r n o n a a . c u r r e n t s t a n d a r d tr e a t m e n t . antituberculosis chemotherapy. karger publishers; 2011. p. 61-72. 4. ahmad z, makaya nh, grosset j. history of drug discovery: early evaluation studies and lessons learnt from them. antituberculosis chemotherapy. karger publishers; 2011. p. 2-9. 5. g u m b o t. c h e m o t h e r a p y o f t u b e r c u l o s i s , mycobacterium avium complex disease, and leprosy. goodman & gilman’s the pharmacological basis of therapeutics. 2011;12:1549-70. 6. abulfathi aa, decloedt eh, svensson em, diacon ah, donald p, reuter h. clinical pharmacokinetics and pharmacodynamics of rifampicin in human tuberculosis. clinical pharmacokinetics. 2019;58(9):1103-29. 7. s t o t t k , p e r t i n e z h , s t u r k e n b o o m m , e t a l . pharmacokinetics of rifampicin in adult tb patients and healthy volunteers: a systematic review and metaanalysis. j antimicrobial chem. 2018;73(9):2305-13. 8. chigutsa e, visser me, swart ec, et al. the slco1b1 rs4149032 polymorphism is highly prevalent in south africans and is associated with reduced rifampin concentrations: dosing implications. antimicrobial agents and chemotherapy. 2011;55(9):4122-7. 9. weiner m, peloquin c, burman w, et al. effects likely due to differences in study location setting, patients, and ethnicity. the relative difference in the contribution of transporter polymorphisms that affect the pharmacokinetics depends on the patient’s ethnic background.31 presence of polymorphism found in this study highlights the possibility of suboptimal plasma rifampicin concentration in tb patients treated with first-line drugs in bandung. it is necessary to determine the optimal dose in different populations to ensure that each patient is given ideal treatment. since examination of slco1b1 polymorphisms before starting therapy is rather difficult to implement, increasing the dose of rifampicin may be considered. previous study showed that increasing the dose of rifampicin by 150 mg daily in subjects with homozygous polymorphism c.85-7793tt (rs4149032) and heterozygous polymorphism c.85-7793ct (rs4149032) will give the same plasma rifampicin concentration value as the wild type c.857793cc (rs4149032).8 higher dose of rifampicin will increase the peak concentration (cmax) in the polymorphism group.8 the possibility of suboptimal treatment also accentuates the need of drug monitoring during tb treatments. this study’s limitation is that it focused on the sundanese population, therefore it is essential to characterize the frequency of polymorphisms and their functional consequences in other ethnic groups, as different genetic variations may be observed in different ethnic groups. there is also a need for further study regarding rifampicin pharmacokinetics and slco1b1 polymorphisms. the relationship between the polymorphisms and treatment outcomes also still needs to be identified. it is recommended to discover all the polymorphisms that might occur in pulmonary tb patients by examining samples with whole-genome sequencing. conclusion this study reported the high presence of polymorphism c.85-7793c>t (rs4149032) of the slco1b1 gene in tb patients in bandung, especially in the sundanese population. there were no polymorphisms c.463c>a. (rs11045819) of the slco1b1 gene identified in this study. this study highlights the presence of vol 54 • number 4 • october 2022 polymorphisms of slco1b1 gene in sundanese ethnic population of tb 523 of tuberculosis, race, and human gene slco1b1 p o l y m o r p h i s m s o n r i f a m p i n c o n c e n t r a t i o n s . a n t i m i c r o b i a l a g e n t s a n d c h e m o t h e r a p y. 2010;54(10):4192-4200. 10. litjens ch, van den heuvel jjw, russel fg, aarnoutse re, te brake lh, koenderink jb. rifampicin transport by oatp1b1 variants. antimicrobial agents and chemotherapy. 2020;64(10):e00955-20. 11. prasad b, evers r, gupta a, et al. interindividual variability in hepatic organic anion-transporting polypeptides and p-glycoprotein (abcb1) protein expression: quantification by liquid chromatography tandem mass spectroscopy and influence of genotype, age, and sex. drug metabolism and disposition. 2014;42(1):78-88. 12. lee hh, ho rh. interindividual and interethnic variability in drug disposition: polymorphisms in organic anion transporting polypeptide 1b1 (oatp1b1; slco1b1). brit j clin pharmacol. 2017;83(6):1176-84. 13. rattanacheeworn p, chamnanphon m, thongthip s, et al. slco1b1 and abcg2 gene polymorphisms in a thai population. pharmacogenomics and personalized medicine. 2020;13:521. 14. kwara a, cao l, yang h, et al. factors associated with variability in rifampin plasma pharmacokinetics and the relationship between rifampin concentrations and induction of efavirenz clearance. pharmacotherapy: j human pharmacol drug ther. 2014;34(3):265-71. 15. dompreh a, tang x, zhou j, et al. effect of genetic variation of nat2 on isoniazid and slco1b1 and ces2 on rifampin pharmacokinetics in ghanaian children with tuberculosis. antimicrobial agents and chemotherapy. 2018;62(3):e02099-17. 16. niemi m, pasanen mk, neuvonen pj. organic anion transporting polypeptide 1b1: a genetically polymorphic transporter of major importance for hepatic drug uptake. pharmacological reviews. 2011;63(1):157-81. 17. roe ba, crabtree js, khan a. dna isolation and sequencing. vol 11. wiley-blackwell; 1996. 18. world health organization. global tuberculosis report 2017 (who/htm/tb/2017.23). world health organization, geneva, switzerland http://apps who int/ iris/bitstream/10665/191102/1/9789241565059_eng pdf. 2017; 19. ruslami r, nijland h, aarnoutse r, et al. evaluation of high-versus standard-dose rifampin in indonesian patients with pulmonary tuberculosis. antimicrobial agents and chemotherapy. 2006;50(2):822-3. 20. ruslami r, nijland hm, alisjahbana b, parwati i, van crevel r, aarnoutse re. pharmacokinetics and tolerability of a higher rifampin dose versus the standard dose in pulmonary tuberculosis patients. antimicrobial agents and chemotherapy. 2007;51(7):2546-51. 21. meyer zu schwabedissen he, grube m, kroemer h k . pharmacogenetics of drug transporters . pharmacogenetics and individualized therapy. 2012:101-48. 22. giacomini km sy. membrane transporters and drug response. goodman & gilman’s the pharmacological basis of therapeutics. 2018:65–84. 23. s h a rg e l l , a n d r e w b , wu p o n g s . a p p l i e d biopharmaceutics & pharmacokinetics. 6th ed. appleton & lange stamford; 2012. 24. thomas l, sekhar miraj s, surulivelrajan m, varma m, sanju cs, rao m. influence of single nucleotide polymorphisms on rifampin pharmacokinetics in tuberculosis patients. antibiotics. 2020;9(6):307. 25. mcilleron h, abdel-rahman s, dave ja, blockman m, owen a. special populations and pharmacogenetic issues in tuberculosis drug development and clinical research. j infect dis. 2015;211(suppl3):s115-s125. 26. ramesh k, hemanth kumar a, kannan t, et al. slco1b1 gene polymorphisms do not influence plasma rifampicin concentrations in a south indian population. int j tubercul lung dis. 2016;20(9):12315. 27. pasanen mk, neuvonen pj, niemi m. global analysis of genetic variation in slco1b1. 2008; 28. consortium hp-as. mapping human genetic diversity in asia. science. 2009;326(5959):1541-5. 29. sortica vda, ojopi eb, genro jp, et al. influence of genomic ancestry on the distribution of slco1b1, s l c o 1 b 3 a n d a b c b 1 g e n e p o l y m o r p h i s m s among brazilians. basic clin pharmacol toxicol. 2012;110(5):460-8. 30. sampurno od. tinjauan farmakogenomik rifampisin dalam pengobatan tuberkulosis paru. jurnal biotek medisiana indonesia. 2015;59:70. 31. giacomini k, balimane p, cho s, et al. international transporter consortium international transporter consortium commentary on clinically important transporter polymorphisms. clin pharmacol ther. 2013;94:23-6. 19acta med indones indones j intern med • vol 55 • number 1 • january 2023 original article efficacy and safety of clopidogrel in the prevention of primary failure of arteriovenous fistula in patients with end-stage renal disease: a systematic review wahyudi1,2, dono antono3*, pringgodigdo nugroho4, ikhwan rinaldi5,6, ika prasetya wijaya3, hamzah shatri6, em yunir7, lusiani rusdi3 1 department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 2 department of internal medicine, faculty of medicine, andalas university rsup m djamil, padang, indonesia. 3 division of cardiology, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 4 division of kidney and hypertension, department of internal medicine, faculty of medicine, universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 5 division of hematology and medical oncology, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 6 clinical epidemiology unit, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 7 division of endocrine and metabolic, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. *corresponding author: wahyudi, md. department of internal medicine, faculty of medicine, andalas university rsup m djamil. jl. perintis kemerdekaan, padang, indonesia. email: wahyudi@med.unand.ac.id. abstract background: arteriovenous fistula (fav) is the most widely used vascular access for end-stage renal disease (esrd) patients undergoing routine hemodialysis in indonesia. however, fav can become dysfunctional before it is used for the initiation of hemodialysis, a condition known as primary failure. clopidogrel is an anti-platelet aggregation that has been reported to reduce the incidence of primary failure in fav compared to other antiplatelet aggregation agents. through this systematic review, we aimed to assess the role of clopidogrel to the incidence of primary fav failure and the risk of bleeding in esrd patients. methods: a literature search was carried out to obtain randomized control trial studies conducted since 1987 from medline / pubmed, ebscohost, embase, proquest, scopus, and cochrane central without language restrictions. risk of bias assessment was performed with the cochrane risk of bias 2 application. results: all of the three studies involved indicated the benefit of clopidogrel for the prevention of avf primary failure. however, all of the studies have substantial differences. abacilar’s study included only participants with diabetes mellitus. this study also administered a combination of clopidogrel 75 mg and prostacyclin 200 mg/day, while dember’s study gave an initial dose of clopidogrel 300 mg followed by daily dose 75 mg and ghorbani’s study only gave clopidogrel 75 mg/day. ghorbani and abacilar started the intervention 7-10 days before avf creation, while dember started 1 day after vaf creation. dember gave treatment for 6 weeks with an assessment of primary failure at the end of week 6, ghorbani’s treatment lasted for 6 weeks with an assessment at week 8, while abacilar gave treatment for one year with an assessment at weeks 4 after avf creation. in addition, the prevalence of bleeding did not differ wahyudi acta med indones-indones j intern med 20 between the treatment and control groups. conclusion: clopidogrel can reduce the incidence of primary fav failure without significant increase of bleeding events. keywords: arteriovenous fistula, primary failure, clopidogrel, end-stage renal disease, systematic review. introduction arteriovenous fistula (fav) is the most widely used vascular access by 75% of end stage renal disease patients undergoing routine hemodialysis in indonesia.1 it is often used due to the lower risk of dysfunction and infection with long-term use compared to other vascular accesses.2 however, newly created fav cannot be used immediately and might become dysfunctional before the initiation of hemodialysis. this condition also known as primary failure is a major problem in esrd patients undergoing fav creation. the incidence of thrombosis is found in 65-85% of fav, hence, it is estimated that thrombosis plays a major role in the incidence of primary failure.3 the administration of heparin or aspirin reportedly does not reduce the prevalence of primary failure. meanwhile, clopidogrel is an anti-platelet antiaggregation that has a pleiotropic effect and reduces fav primary failure.4–6 to date, there is no recommendation for the use of clopidogrel in preventing fav primary failure. patients with esrd are also at high risk for bleeding due to disturbances in coagulation factors. therefore, we aimed to assess the role of clopidogrel to the incidence of fav primary failure and the risk of bleeding in esrd patients undergoing fav surgery. methods this is a systematic review conducted based on the preferred reporting items for systematic review and meta-analysis (prisma). we registered our protocol on the international prospective register of systematic reviews (prospero) with id crd42022323934. inclusion and exclusion criteria the inclusion criteria were randomized control trials on subjects aged > 18 years, studies using clopidogrel for the treatment arm, with primary fav failure as the primary outcome, and bleeding as the secondary outcome. the exclusion criteria were active bleeding, known coagulopathy, thrombocyte < 75.000/ mm3 and pregnancy. search strategy a comprehensive literature search was conducted by authors (wa and lu) from january until august 2022 using the databases medline/pubmed, ebscohost, embase, proquest, scopus, and cochrane library databases as well as manual searches on studies published since 1987 without language restrictions. the search used medical subject heading (mesh) and a combination of keyword synonyms (boolean mode) for fav, primary failure, and clopidogrel. the fav synonym used was arteriovenous fistula or arteriovenous shunt or hemodialysis access or dialysis access, with mesh namely “arteriovenous shunt, surgical”. meanwhile, the synonym used for clopidogrel was clopidogrel or p2y12 inhibitor or p2y12 antagonist or antiplatelet or antithrombotic or anti-aggregation or antiaggregant, where mesh is “clopidogrel”. the synonym for primary failure was patency or maturation or immature or stenosis or thrombosis or fail, while the mesh used was “vascular patency”. extraction data data extracted by authors (wa and lu) from the studies included the name of the first author, year of publication, the number of samples, average age, gender, type and dose of treatment given, time of assessment of primary failure, the proportion of primary failure, degree of bleeding and its proportion in each group, mortality, as well as the bleeding time before and after treatment, the data were then summarized in a tabular form. risk assessment bias the assessment of the risk of bias was carried out using the cochrane risk of bias 2 vol 55 • number 1 • january 2023 efficacy and safety of clopidogrel in the prevention of primary failure 21 application. differences between the authors (wa and lu) were discussed until an agreement was reached or consultation with the third author (ir). publication bias was analyzed by the rank correlation test and the egger regression test. results the search on 6 databases generated 496 literatures. 147 duplicate literatures were removed. there were 348 irrelevant articles table 1. keywords for searching the database. database keywords filter number of literature pubmed "arteriovenous shunt, surgical"[mesh] or “arteriovenous fistula*”[tiab] or “arteriovenous shunt”[tiab] or “hemodialysis access”[tiab] or “dialysis access”[tiab] and "clopidogrel"[mesh] or clopidogrel[tw] or “p2y12 inhibitor*”[tiab] or “p2y12 antagonist*”[tiab] or “antiplatelet”[tiab] or “antithrombotic”[tiab] or “antiaggregation”[tiab] or “antiaggregant”[tiab] and "vascular patency"[mesh] or “patency”[tiab] or maturation[tiab] or immature[tiab] or stenosis[tiab] or thrombosis[tiab] or “fail*”[tiab] human, age ≥ 19 years old 79 ebscohost (mm "arteriovenous shunt, surgical") or arteriovenous fistula(ab) or arteriovenous shunt(ab) or hemodialysis access(ab) or dialysis access(ab) and (mm "clopidogrel“) or clopidogrel[text] or p2y12 inhibitor (ab) or p2y12 antagonist(ab) or antiplatelet(ab) or antithrombotic(ab) or antiaggregation(ab) or antiaggregant(ab) and (mm "vascular patency“) or patency(ab) or maturation(ab) or immature(ab) or stenosis(ab) or thrombosis (ab)or failure(ab)” human, age ≥ 19 years old 116 proquest (mesh.exact("arteriovenous shunt, surgical") or ab("arteriovenous fistula") or ab("arteriovenous shunt") or ab("hemodialysis access") or ab("dialysis access")) and (mesh.exact("clopidogrel") or ft(clopidogrel) or ab(“p2y12 inhibitor”) or ab(“p2y12 antagonist”) or ab(antiplatelet) or ab(antithrombotic) or ab(antiaggregation) or ab(antiaggregant)) and (mesh.exact("vascular patency") or ab(patency) or ab(maturation) or ab(immature) or ab(stenosis) or ab(thrombosis) or ab(fail*)) human, article 151 embase 'arteriovenous shunt, surgical'/exp or 'arteriovenous fistula':ab or 'arteriovenous shunt':ab or 'hemodialysis access':ab or 'dialysis access':ab and 'clopidogrel'/exp or clopidogrel or 'p2y12 inhibitor':ab or 'p2y12 antagonist':ab or antiplatelet:ab or antithrombotic:ab or antiaggregation:ab or antiaggregant:ab and "vascular patency”/exp or patency or maturation or immature or stenosis or thrombosis or fail* (‘randomized controlled trial’/ exp or ‘clinical trial’/exp or ‘cohort’) and (humans)/lim 48 scopus "arteriovenous fistula" or "arteriovenous shunt" or "hemodialysis access" or "dialysis access“ and clopidogrel or "p2y12 inhibitor" or "p2y12 antagonist" or antiplatelet or antithrombotic or antiaggregation or antiaggregant and "vascular patency“ or patency or maturation or immature or stenosis or thrombosis or fail “randomized controlled trial” or “ clinical trial” or “cohort” 171 cochrane (mesh descriptor: [arteriovenous shunt, surgical] explode all trees or “arteriovenous fistula”, “arteriovenous shunt”, “hemodialysis access”, “dialysis access”) and (mesh descriptor: [clopidogrel] explode all trees or clopidogrel, “p2y12 inhibitor”, “antiplatelet drug”, “antiplatelet agent”, “antiaggregation agent”, “antiaggregation drug”) and (mesh descriptor: [vascular patency] explode all trees or patency or maturation or immature or stenosis or thrombosis or failure) trials 305 based on title and abstracts were removed. assessment for eligibility based on full text literatures, resulted in the exclusion of 9 articles, with 7 being non-rct study reports, and 2 other articles did not include clopidogrel in the studies. therefore, 3 articles remained and were reviewed further.. the literature search flow is shown according to the prisma flow chart. we did the last search on 13 july 2022. wahyudi acta med indones-indones j intern med 22 characteristics of study this systematic review involved 3 rct studies with substantial differences. all participants in the abacilar study were diabetes mellitus, in contrast to dember and ghorbani’s study which involved less than 50% of participants with diabetes mellitus. furthermore, abacilar administered a combination of clopidogrel 75 mg and prostacyclin 200 mg/day, while dember gave an initial dose of clopidogrel 300 mg followed by daily dose 75 mg and ghorbani only gave clopidogrel 75 mg/day. ghorbani and abacilar started the intervention 7-10 days before avf creation, while dember started 1 day after avf creation. there were also differences in the duration of intervention and the time for the assessment of avf primary failure. dember gave treatment for 6 weeks with figure 1. study flow chart according to prisma. an assessment of primary failure at the end of week 6, ghorbani’s treatment lasted for 6 weeks with an assessment at week 8, while abacilar gave treatment for one year with an assessment at weeks 4 after avf creation.4–6 based on the three studies involved, the incidence of bleeding in the intervention group was similar to placebo group. the number of major bleeding events between the two groups was the same but the incidence of minor bleeding was slightly higher in the intervention group than in the control group. in ghorbani’s study, there was no significant difference between bleeding time before and after intervention. a similar result was found regarding mortality in both groups based on p > 0.99 (dember) and p = 0.47 (ghorbani). vol 55 • number 1 • january 2023 efficacy and safety of clopidogrel in the prevention of primary failure 23 table 2. characteristics of the study included in systematic review. study number of participants average age (years) male gender diabetes mellitus type of treatment (duration) primary failure assessment primary failure treatment control treatment control treatment control treatment control treatment control p-value dember et al, 20084 441 436 52,7 (±14.7) 54,5 (±14.4) 63.1% 61.9% 49.2% 47% clopidogrel 300 mg the first day, then 75 mg/day (42 days) day 42 12.2% 19.5% 0.18 (rr 0.63) ghorbani et al, 20095 40 46 44,23 (±3.36) 45,8 (±2.84) 51.6% 51.6% 15.1% 11.8% clopidogrel 75 mg/day (42 days) day 56 5.2% 21.6% 0.03 (hr 0.72) abacilar et al, 20156 50 46 54,23 (±2.6) 55,8 (±2.84) 68% 69.5% 100% 100% clopidogrel 75 mg and prostacyclin 200 mg daily (365 days) day 28 8% 30.4% 0.001 (hr 0.82) table 3. comparison of bleeding events in the treatment and the control group. no. study major bleeding minor bleeding mortality bleeding time before treatment bleeding time after treatment treatment control treatment control treatment control treatment control treatment control 1. dember et al, 20084 7 (1.6%) 7 (1.6%) 6 (1.4%) 5 (1.2%) 4 (0.9%) 4 (0.9%) no data no data no data no data 2. ghorbani et al, 20095 0 0 7 (7.4%) 7 (7.5%) 2 (2.1%) 2 (2.1%) 8.1±0.3 minutes 8.4±0.6 minutes 8.5±0.4 minutes 8.6±0.3 minutes 3. abacilar et al, 20156 0 0 9 (18%) 6 (13%) 0 0 no data no data no data no data risk of bias based on cochrane’s risk of bias 2 application, ghorbani’s research had a moderate risk of bias (some concerns) because it did not explain sequence generation process and concealment in detail. ghorbani only provided a few variables on baseline characteristic that does not show comprehensive equality, and still shows p-value to express difference. meanwhile, other studies had a low risk of bias. publication bias assessment of publication bias of the three articles were done with rank correlation tests and egger regression tests. the results for each test were p = 1.00 and p = 0.446. a p-value < 0.05 in both tests indicates publication bias, and the results of the two tests were p > 0.05.9 table 4. assessment risk of bias based on cochrane’s risk of bias 2 study id experimental comparator outcome d1 d2 d3 d4 d5 overall dember clopidogrel placebo avf primary failure ghorbani clopidogrel placebo avf primary failure abacilar clopidogrel and prostacyclin placebo avf primary failure d1 : randomization process d2 : deviations from the intended interventions d3 : missing outcome data d4 : measurement of the outcome d5 : selection of the reported result low risk some concerns high risk + wahyudi acta med indones-indones j intern med 24 discussion this systematic study involved three randomized controlled trials with a total of 1048 subjects with mean age being below 65 years. based on the results, patients above 65 years and underwent fav surgery have a higher risk of vascular access failure than those aged less than 65 years. this is associated with reduced blood flow and a smaller cross-section of blood vessels, especially in patients with comorbidities such as coronary heart and peripheral vascular disease, as well as diabetes mellitus.10 lok et al (2005), reported that patients aged 65 years or above are 1.7 times at risk of experiencing primary failure.11 most of the subjects in this systematic study were male, this is associated with a tendency for a larger cross-section of blood vessels in males compared to females.12,13 the average number of patients with diabetes mellitus in the ghorbani, dember, and abacillar studies was 13.45%, 48.1%, and 100%, respectively.4-6 according to lin, diabetes alone does not predispose an individual to primary fav failure. however, older adults with diabetes might have an increased risk of primary failure.14 afsar showed that diabetic patients with hba1c less than 7 have a risk of primary failure with no significant difference from patients without diabetes, while diabetes mellitus patients with hba1c more than 7 have a 2.8 times higher risk for primary failure.15 administration of higher initial dose than the daily dose does not have a significant effect on primary fav failure. the initial dose is usually given to speed up the onset of action and the time to achieve the maximum anti-aggregation effect. a single dose of 75 mg clopidogrel has an onset of 24 hours and reaches its maximum anti-aggregation effect in 4-7 days. meanwhile, the administration of clopidogrel 300 mg has an onset of action of 2 hours and reaches its maximum anti-aggregation effect after 24 hours.16 in dember’s study, administration of clopidogrel 300 mg 1 day after surgery followed by 75 mg/day did not provide a significant reduction in the incidence of primary fav failure compared with the control group.4 this can be attributed to the inflammatory process that occurred due to the vascular trauma during the fav creation operation 1 day earlier. the administration of clopidogrel 75 mg/ day 7-10 days before fav operation such as in the ghorbani study culminated in a better reduction in the incidence of primary failure than in dember. this can be attributed to the action of clopidogrel which has reached its maximum anti-aggregation effect at the time of the fav preparation operation. therefore, the incidence of thrombosis due to the postoperative inflammatory process is suppressed. similar to ghorbani’s study, abacillar who performed the treatment 7-10 days before fav surgery also achieved significant results in decreasing primary fav failure in the treatment group compared to the control. however, abacilar added prostacyclin 200 mg/day, a derivative of arachidonic acid which is a vasodilator and also anti-platelet aggregation. as a vasodilator, prostacyclin can reduce the risk of primary failure by decreasing shear stress, which in turn reduces the risk of inward remodeling (stenosis).6,17 previous reports suggested pleiotropic effect of clopidogrel as a vasodilator. clopidogrel may also improve endothelial function as well as antiinflammation caused by the release of no and decreased levels of proinflammatory cytokines, including il-1α, il-2, il-6, il-13, tnf-α, and tnf-β thereby reducing vascular remodeling and the risk of vascular stenosis.18–21 there was no difference in the incidence of bleeding between the treatment and the control group presumably due to the mean age of the subjects in each study which was less than 65 years. age over 65 years is a risk factor for bleeding due to the administration of anti-platelet aggregation.22 the limitation of this study is that it involved only three rct studies and the differences in each study. however, the three studies above had a low risk of publication bias based on rank correlation and egger regression tests. conclusion the administration of clopidogrel can reduce the incidence of primary fav failure in patients with end-stage renal disease (esrd). the incidence of bleeding in patients with esrd who received clopidogrel was not different from vol 55 • number 1 • january 2023 efficacy and safety of clopidogrel in the prevention of primary failure 25 the control group. further research is needed for application in daily clinical practice, especially to assess various factors (like age, gender and diabetes melitus) that can affect the risk of primary fav failure and bleeding following clopidogrel administration. for example, clopidogrel daily dose 75 mg since 7-10 days before avf creation until hemodialysis initiation. conflict of interest the authors declare that this article has no conflict of interest funding the authors received no financial support for the research acknowledgements thanks to internal medicine department, medical faculty of universitas indonesia and cipto mangunkusumo hospital for their support in this study. references 1. pernefri. 11th report of indonesian renal registry 2018. 2018:1–46. 2. lok ce, huber ts, lee t, et al. kdoqi clinical practice guideline for vascular access: 2019 update. am j kidney dis. 2020;75(4):s1–164. 3. quencer kb, oklu r. hemodialysis access thrombosis. cardiovasc diagn ther. 2017;7(3):s299–308. 4. dember lm, beck gj, allon m, et al. effect of clopidogrel on early failure of arteriovenous fistulas for hemodialysis: a randomized controlled trial. j am med assoc. 2008;299(18):2164–71. 5. g h o r b a n i a , a a l a m s h a h m , s h a h b a z i a n h , ehsanpour a, aref a. randomized controlled trial of clopidogrel to prevent primary arteriovenous fistula failure in hemodialysis patients. indian j nephrol. 2009;19(2):57–61. 6. abacilar af, atalay h, dogan of. oral prostacycline analog and clopidogrel combination provides early maturation and long-term survival after arteriovenous fistula creation: a randomized controlled study. indian j nephrol. 2015;25(3):136–42. 7. higgins jpt, thompson sg. quantifying heterogeneity in a meta-analysis. stat med. 2002;21(11):1539–58. 8. tawfik a, elshimy w. clopidogrel versus acetyl salicylic acid in arteriovenous fistula salvage. egyptian j surg. 2015;34(4):222. 9. higgins jpt, thomas j, chandler j, cumpston m, li t, page mj, welch va (editors). cochrane handbook for systematic reviews of interventions version 6.3. cochrane; 2022. 10. misskey j, faulds j, sidhu r, baxter k, gagnon j, hsiang y. an age-based comparison of fistula location, patency, and maturation for elderly renal failure patients. j vasc surg. 2018;67(5):1491–500. 11. lok ce, oliver mj, su j, bhola c, hannigan n, jassal sv. arteriovenous fistula outcomes in the era of the elderly dialysis population. kidney intern. 2005;67. 12. miller cd, robbin ml, allon m. gender differences in outcomes of arteriovenous fistulas in hemodialysis patients. kidney int. 2003;63(1):346–52. 13. marcus rj, marcus da, sureshkumar kk, hussain sm, mcgill rl. gender differences in vascular access in hemodialysis patients in the united states: developing strategies for improving access outcome. gend med. 2007;4(3):193–204. 14. lin sl, huang ch, chen hs, hsu wa, yen cj, yen ts. effects of age and diabetes on blood flow rate and primary outcome of newly created hemodialysis arteriovenous fistulas. am j nephrol. 1998;18(2):96– 100. 15. afsar b, elsurer r. the primary arteriovenous fistula failure-a comparison between diabetic and nondiabetic patients: glycemic control matters. int urol nephrol. 2012;44(2):575–81. 16. gurbel pa, antonino mj, tantry us. recent developments in clopidogrel pharmacology and their relation to clinical outcomes. exp opin drug metab toxicol. 2009;5:989–1004. 17. stitham j, midgett c, martin ka, hwa j. prostacyclin: an inflammatory paradox. front pharmacol. 2011. 18. warnholtz a, ostad ma, velich n, et al. a single loading dose of clopidogrel causes dose-dependent improvement of endothelial dysfunction in patients with stable coronary artery disease: results of a double-blind, randomized study. atherosclerosis. 2008;196(2):689–95. 19. quinn mj, bhatt dl, zidar f, et al. effect of clopidogrel pretreatment on inflammatory marker expression in patients undergoing percutaneous coronary intervention. am j cardiol. 2004;93(6):679–84. 20. antonino mj, mahla e, bliden kp, tantry us, gurbel pa. effect of long-term clopidogrel treatment on platelet function and inflammation in patients undergoing coronary arterial stenting. am j cardiol. 2009;103(11):1546–50. 21. froldi g, bertin r, dorigo p, montopoli m, caparrotta l. endothelium-independent vasorelaxation by ticlopidine and clopidogrel in rat caudal artery. j pharm pharmacol. 2011;63(8):1056–62. 22. lin t, lai w, hsin h, li a, wang c, kuo c. effects of clopidogrel on mortality, cardiovascular and bleeding outcomes in patients with chronic kidney disease data from taiwan acute coronary syndrome full spectrum registry. 2013;8(8):1–9. 35acta med indones indones j intern med • vol 54 • number 1 • january 2022 original article one year survival of extrahepatic cholangiocarcinoma patients who did not undergo curative resection and paliative chemotherapy and its associated factors pieter saragih1, dadang makmun2, juferdy kurniawan3*, ikhwan rinaldi4 1 department of internal medicine, faculty of medicine universitas indonesia, jakarta, indonesia. 2 division of gastroenterology, pancreatobiliary and digestive endoscopy, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 3 division of hepatobiliary, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 4 division of hematology and medical oncology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. *corresponding author: juferdy kurniawan, md. division of division of hepatobiliary, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. e-mail: juferdy.k@gmail.com; psaragih1@gmail.com. abstract background: extrahepatic cholangiocarcinoma is rare but fatal. patients who come are usually already in the advanced stage that can not undergo curative resection and chemotherapy also seems to be very rarely done. the survival rate and its associated factors in indonesia are unknown. this study aimed to identify 1-year survival of patients with extrahepatic cholangiocarcinoma without curative resection and palliative chemotherapy and its associated factors. methods: this is a cross-sectional study using medical records of extrahepatic cholangiocarcinoma (perihilar and distal) inpatient and outpatient patients at cipto mangunkusumo hospital, jakarta from january 2015 to march 2020, reviewed retrospectively. the following factors were analyzed in terms of mortality: metastasis, sepsis, hypoalbuminemia, serum bilirubin level, serum ca 19-9 level, billiary drainage, neutrophyl lympocyte ratio (nlr) and comorbid factors. results: 115 out of 144 patients were enrolled in this study with male proportion of 50.4%, and proportion of patients aged 65 years or above was 71.3%. 1 year survival rate was 10 % and median survival was 3 months (ci 95% 2.388-3.612)multivariate analysis showed that only sepsis, unsuccessful or no prior biliary drainage and total bilirubin >19.8 mg/dl were independent predictors of mortality. conclusion: 1 year survival of extrahepatic cholangiocarcinoma without curative resection and paliative chemotherapy was 10 %.sepsis, unsuccessful or no prior bilirary drainage, and total biirubin >19.8 mg/dl are factors significantly associated with shortened survival in malignant obstructive jaundice patients. keywords: survival, extrahepatic cholangiocarcinoma, curative resection, paliative chemotherapy, mortalityrelated factors pieter saragih acta med indones-indones j intern med 36 introduction cholangiocarcinomas are malignancies that arise from the biliary tract epithelia. patients with cholangiocarcinoma usually present at late stages of the disease, and early symptoms might be nonspecific. therefore, these cancers remain difficult to diagnose and treat and their prognosis is generally poor. approximately half of untreated patients die within 3–4 months.1 until now there is no data on the prevalence of cholangiocarcinoma published in indonesia, but in daily practice extrahepatic cholangiocarcinoma cases are more common, and patients who come usually undergo biliary drainage therapy. patients who come are usually already in the advanced stage that could not undergo curative resection. chemotherapy also seems to be very rarely done, as patients usually come with poor performance status. several overseas studies have been conducted to try to identify factors related to the survival of people with cholangiocarcinoma, especially extrahepatic cholangiocarcinoma. metastasis2, sepsis3, comorbid4, failure of drainage therapy3, hypoalbuminemia5, hyperbilirubinemia5, high ca 19-96 and high neutrophyl lympocyte ratio (nlr).7 until now there has been no comprehensive research on the survival of extrahepatic cholangiocarcinoma patients in indonesia and the factors that affect it. there has also been no research on the survival of extrahepatic cholangiocarcinoma sufferers who do not undergo resection and palliative chemotherapy. so the purpose of this study is to find out the survival of one year of extrahepatic cholangiocarcinoma sufferers who do not undergo curative resection and palliative chemotherapy and factors that affect the mortality of 1 year. methods this is a cross-sectional study which was retrieved using total sampling technique by tracing medical records and electronic health record of the extrahepatic biliary cancer (perihilar and distal) patients aged 18 years or older who had been hospitalized in cipto mangunkusumo hospital in jakarta from january 2015 to march 2020. we include patients without curative resection and paliative chemotherapy. this study has been approved by the ethics committee of the faculty of medicine, university of indonesia, with registry number ket-31/un2.f1/etik/ ppm.00.02/2021. the subjects characteristics are divided into two, clinical characteristics and characteristics by treatment. clinical characteristics contain age, gender, symptoms, onset of symptoms to diagnosis, tumor location, risk factors for cholangiocarcinoma, bilirubin levels, ca levels 19-9, albumin levels, nlr values, presence of cholangitis, sepsis, comorbidity, and metastasis. characteristics based on therapy are: resectability, drainage type, drainage failure, drainage failure based on drainage method, failed drainage based on tumor location, ercp stent type, ercp complications, and ptbd complications eight potential prognostic factors were studied: metastasis, comorbidity, sepsis, unsuccessful or no history of biliary drainage, albumin levels, bilirubin levels, ca 19-9 levels and neutrophyl lympocyte ratio. all malignant tumors found in the extrahepatic biliary duct (perihilar and distal) were included in the study after confirmation through computed tomography (ct) scan and/or mri-mrcp (magnetic resonance imaging-magnetic resoncance cholangiopancreatography and/or endoscopic retrograde cholangiopancreatography (ercp) and/or endoscopic ultrasound (eus) with or without biopsy confirmation. the presence of comorbidities in the subjects was identified based on the total score of charlson comorbidity index as documented on their medical records. sepsis was identified according to sepsis-3 criteria with the quick sofa score ≥ 2. laboratory parameters include albumin, bilirubin and ca 19-9, and were measured on the first day of admission. albumin levels below 3.4 g/dl was defined as hypoalbuminemia. high bilirubin was defined if bilirubin ≥19.8 mg/dl. high ca 19-9 levels was defined as levels ≥300 u/ml. biliary drainage had been performed through ptbd (percutaneous transhepatic biliary drainage) and ercp. drainage procedure vol 54 • number 1 • january 2022 one year survival of axtrahepatic cholangiocarcinoma patients 37 was considered success if a minimal 2 mg/dl bilirubin serum decreased after 2 to 5 days post drainage. patients were divided into two groups: first group with history of successful biliary drainage procedure and the second group with unsuccessful or no history of biliary drainage. we evaluated outcomes of mortality and the time of death of the observed subjects (time to event), which were determined since the first visit to hospital. follow up for assessment of survival was done by phone calls. if the patient was unreachable via phone call, we did a home visit to the patients’ registered adress. data analysis was performed using spss version 23.0 for univariate, and multivariate analyses. the level of significance used in our study was α = 0.05. variables were considered significant when the p value < 0.05. cumulative one year survival was measured from the date of diagnosis of extrahepatic cholangiocarcinoma to the event and calculated by the methods of kaplan-meier, which was followed by cox proportional hazard regression. the variables were then included into a multivariate model when the p value < 0.25. results within the period of the study, we found 154 adult patients aged >18 years with extrahepatic cholangiocarcinoma. as many as 29 subjects were excluded due to data loss in their medical records; 10 were excluded for having curative resection (5 patients) and paliative chemotherpay (5 patients) therefore, we were left with 115 subjects with characteristics as shown in table 1. table 1. clinical characteristics of subjects clinical characteristic frequency, n (%) n=115 age ≥65 82(71.3) <65 33(28.7) sex male female 58(50.4) 57(49.6) risk factors, hepatitis b hepatitis c cirrhosis choledochal cyst 8(6.9) 1(0.8) 5(4.3) 1(0.8) symptoms icterus abdominal pain weight loss itching 112 (97.4) 57 (49.6) 46 (40.0) 12 (10.4) onset from symptom to diagnosis (median) 2 months (0-12) tumor location perihilar distal 92 (80.0) 23 (20.0) cholangitis yes no 59 (51.3) 56 (48.7) sepsis yes no 31 (27.0) 84 (73.0) comorbidity (cci index) ≥ 2 0-1 13 (11.3) 102 (88.7) metastasis yes no 64 (55.7) 51 (44.3) total bilirubin >10 mg/dl ≤10 mg/dl 104 (90.4) 11 (9.6) total bilirubin >19.8 mg/dl ≤19.8 mg/dl 71 (61.7) 44 (38.3) ca 19-9 >300 iu/ml ≤300 iu/ml 60 (52.2) 55 (47.8) albumin <3.4 g/dl ≥3.4 g/dl 100 (87.7) 15 (12.3) neutrophyl/lymphocyte ratio (nlr) >7.45 ≤7.45 54 (47.0) 61 (53.0) neutrophyl/lymphocyte ratio (nlr) >5.5 ≤5.5 68 (59.1) 47 (40.9) pathology results adenocarcinoma atipical malignancy suspicion atypical dysplasia malignant no malignant cell not examined 23 (20.0) 4 (3.4) 22 (19.1) 2 (1.7) 3 (2.6) 26 (22.6) 35 (30.6) table 2. clinical characteristic by treatment. treatment characteristic frequency, n(%)n = 115 resectability unresectable resectable (not resected) 75(65.2) 40(34.8) biliary drainage success not success/no drainage 81(70.4) 34(29.6) pieter saragih acta med indones-indones j intern med 38 drainage type ercp ptbd no drainage 92 (80.0) 16 (13.9) 7 (6.1) failed drainage by drainage type ercp(n=92) ptbd(n=16) 23/92 (25.0) 6/16 (37.5) failed drainage by tumor location perihilar (n=92) distal (n=23) 21/92 (22.8) 8/23 (34.7) ercp stent type (n=92) plastic metal nbd (nasobiliary drainage) 64/92(69.6) 26/92(28.3) 2/92(2.1) ercp complications, (n=92) pancreatitis post sphincterotomy bleeding perforation (non fatal) cholangitis (fatal) 12/92 (13.0) 2/92 (2.0) 1/92 (1.0) 1/92 (1.0) ptbd complication, (n=16) perforation (fatal) leakage 1/16(6.2) 1/16(6.2) the proportion of survival in patients with extrahepatic cholangiocarcinoma based on observation of month 3, 6, 9, and 12 was 35%, 23%, 10%, and 10%, respectively as can be seen in table 2; therefore, we found that the proportion of 1 year mortality in patients with extrahepatic cholangiocarcinoma who did not undergo curative resection and paliative chemotherapy was 90%. by the kaplan-meier curve in figure 1, showed that median survival time (which was the time when 50% of study subjects survived) was 3 months (ci 95% 2.388-3.612). bivariate analysis, which is presented in table 3, was performed to evaluate factors that affect the survival of subjects with extrahepatic cholangiocarcinoma. the analysis was done using cox regression analysis. the degree of association was presented in the form of hazard ratio (hr). seven variables, which were included as candidates in the multivariate analysis using cox proportional hazard model were variables with p value < 0.25 in the bivariate analysis. those factors were metastasis, unsuccessful biliary drainage or no drainage, comorbidity, sepsis, high bilirubin, low albumin and high nlr. tabel 4. univariate analysis on factors affecting 1-year survival in patients with extrahepatic cholangiocarcinoma who did not undergo curative resection and paliative chemotherapy. variables mortality person time incidence rate (10-3) hr (ik95%) pno yes failed biliary drainage, n (%) yes 1 (2.9) 33 (97.1) 86 38.37 no 20 (24.7) 61 (75.3) 411 14.84 2.377 (1.535-3.680) <0.001 sepsis, n (%) yes 2 (6.5) 29 (93.5) 69 42.03 no 19 (22.6) 65 (77.4) 428 15.18 2.497 (1.585-3.932) <0.001 comorbidity (cci index) , n (%) 0≥2 0 (0.0) 13 (100.0) 37 35.14 0-1 21 (20.6) 81 (79.4) 460 17.61 1.859 (1.027-3.365) 0.040 table 3. proportion of survival in patients with extrahepatic cholangiocarcinoma who did not undergo curative resection and paliative chemotherapy. survival at month cumulative survival 0 0.50 3 0.35 6 0.23 9 0.10 12 0.10 figure 1. the kaplan-meier curve on 1-year survival of patients with extrahepatic cholangiocarcinoma who did not undergo curative resection and paliative chemotherapy. vol 54 • number 1 • january 2022 one year survival of axtrahepatic cholangiocarcinoma patients 39 meaningful variables in multivariate analysis are sepsis, bilirubin levels > 19.8 mg/dl and failed or unattributed biliary drainage. shown in table 4 are the hazard ratio (hr) with a confidence interval (ik) of 95% of each meaningful prognosis factor. discussion in this study there were 58 patients (50.4%) that were male. the most common age group was ≥ 65 years old with as many as 82 people (71.3%), and the median age of the subjects being 58 years (29-86) years. it is similar with a study by ruiz et al in spain, where the population of extrahepatic cholangiocarcinoma consists of 34 (50%) males. however, the average age in their study was higher at 73.4±11.5 years.4in a study in korea by park et al, the proportion of male extrahepatic cholangiocarcinoma patients was 67%, with mean age of 62±10.1.2 in research in china by wang et al in patients with extrahepatic cholangiocarcinoma, proportion of men were 65%, with a higher mean age of 68.9±11.158.8 in this study, the proportion of perihilar cholangiocarcinoma (klatskin tumor) was greater, which is 92 (80%) compared to distal 23 (20%). this is approximately the same as the proportion of incidence of cholangiocarcinoma in general where perihilar cholangiocarcinoma is the most common type of tumor that is 60% cases, 30% cases of distal cholangiocarcinoma and 6-10% cases of intrahepatic cholangiocarcinoma.9 in this study, strong risk factors were hepatitis b 8 (6.9%), hepatitis c 1 (0.8%), cirrhosis 5 (4.3%), and choledochal cyst 2 (1.7%). some other risk factors were diabetes 12 (10.4%) and alcohol 1 (0.8%). this is more or less similar to the population of cholangiocarcinoma sufferers in study by yusoff inmalaysia.10 in this study, based on the criteria of resectability via imaging, it was found that as many as 40 (34.8%) were suitable for resection.11 this is similar to the study that approximately one-third of patients can be resected during diagnosis.9 but only 5 patients did undergo resection for curative purpose. the reason for this were many, such as refusing surgery, not coming for further evaluation, poor performance status, and preoperative restaging. in multivariate analysis bilirubin levels ≥ 19.8 mg / dl, failed / not performed biliary drainage and sepsis was found as an independent prognostic factor. in our study, the proportion of patients with high bilirubin levels (>10 mg /dl) was 104 out of 115 patients (90.4%). median value of bilirubin tabel 5. multivariate analysis on factors affecting 1-year survival in patients with extrahepatic cholangiocarcinoma who did not undergo curative resection and paliative chemotherapy. variables hr (ci 95%) p sepsis 1.879 (1.171-3.014) 0.009 total bilirubin >19.8 mg/dl 1.972 (1.248-3.117) 0.004 unsuccessful biliary drainage/no drainage 1.807 (1.150-2.842) 0.010 metastasis yes 7 (10.9) 57 (89.1) 231 24.67 no 14 (27.5) 37 (72.5) 266 13.91 1.653 (1.085-2.517) 0.019 total bilirubin,n (%) >19,8 mg/dl 13 (12.5) 91 (87.5) 99 27.73 ≤ 19,8 mg/dl 8 (72.7) 3(27.3) 398 10.81 2.369 (1.505-3.729) <0.001 ca 19-9 , n (%) >300 iu/ml 12 (20.0) 48 (80.0) 232 20.68 ≤300 iu/ml 9 (16.4) 46 (83.6) 265 17.35 1.113 (0.742-1.671) 0.605 albumin, n(%) <3,4 g/dl ≥3,4 g/dl 16(16.0) 5(35.7) 84(84.0) 9(64.3) 108 385 21.82 8.33 2.428(1.201-4.907) 0.014 neutrophyl/lymphocyte ratio (nlr) , n (%) >5,5 6 (8.8) 62 (91.2) 246 25.20 ≤5,5 15 (31.9) 32 (68.1) 251 12.75 1.844(1.19-2.848) 0.006 pieter saragih acta med indones-indones j intern med 40 was 22 mg / dl (ranging from 5,3 mg / dl to 53.40 mg / dl) which was higher than other studies.8, 12 high bilirubin levels caused by biliary obstruction will cause impaired liver function, disrupt endotoxin cleansing, cause coagulation s y s t e m d i s o r d e r s , i m m u n e s y s t e m a n d gastrointestinal intestinal barrier. endotoxins in normal liver conditions are produced in small amounts and then through the portal vein it enters the liver and are inactivated by the liver reticuloendotelial system. increased levels of endotoxins in biliary obstruction conditions plus impaired liver function will cause a condition named systemic inflammatory response syndrome (sirs) which will cause sepsis and then multiple organ failure. so if these high bilirubin levels were not treated with good drainage, it tends to cause infection, sepsis and death.13-15 under normal conditions the bile fluid is in a sterile state. however, tumor obstruction can lead to bacterial growth and colonization in approximately 25% of patients.16 li, et al17 in china found the proportion of patients with bile duct obstruction due to solid tumors experiencing biliary tract infection was 21 % while in study by gaspersz et al18 in netherland, there are 45% patients with perihilar cholangiocarcinoma experiencing biliary tract infection before the procedure of biliary drainage could be carried out. in our study, 59 patients (51.3%) had acute cholangitis at admission and 31 (27%) had sepsis. while sepsis was one of independent predictive factor in our study. the tendency to develop biliary tract infection in our population may be due to several reasons, namely delays in diagnosis (median from onset to diagnosis was 2 month), and higher bilirubin levels in our study indicating that there has been a long obstruction. from the results obtained above, the role of biliary drainage becomes very important to improve survival that can be caused by hyperbilirubinemia and sepsis. from our study unsuccessful biliary drainage became one of independent predictive factor for mortality. biliary drainage in cases of biliary obstruction due to malignancy is considered an important palliative therapy because it can reduce symptoms caused by hyperbilirubinemia, thus allowing patients to undergo surgery, chemotherapy, radiotherapy and local therapy against tumors so as to increase survival in patients with malignant etiology.19 research by kurniawan et al., with the same drainage success criteria, obtained biliary drainage that failed or not performed will increase the risk of death. other studies by brountzos et al20, zhang,et al19, with different drainage success criteria also found similar results. in this study, the 1-year survival rate of extrahepatic cholangiocarcinoma patients who did not undergo curative resection and palliative chemotherapy was 10%, with a median survival of 3 months it is more or less similar to research in malaysia by yusoff et al.10 in this study there were only 5 patients who performed resection with curative purposes and 5 patients who received palliative chemotherapy during this study, which were excluded in this study. in study by yusoff et al in malaysia, there were more patient to be resected and these might be due to the median duration from symptom to diagnosis being more early compared to our study which was 30 days, making curative resection more likely to be achieved.10 this study, is the first study in indonesia that examines the survival of extrahepatic cholangiocarcinoma patients (perihilar and distal) and is also the first research in to study the population of extrahepatic cholangiocarcinoma undergoing supportive therapy only, giving us data on extrahepatic cholangiocarcinoma prognosis if no procedures that can improve survival (curative resection and palliative chemotherapy) were done and the positive benefit of biliary drainage in this setting. limitations of this study include the possibility of information bias due to retrospective design. there were very little histopathological data, so the accuracy of diagnosis in extrahepatic cholangiocarcinoma in this study became less accurate, for in our study the positive result of malignancy from pathology were only 20%. however, this was due to the diagnostic procedure of cholangiocarcinoma extrahepatic examination that is commonly done such as bile duct brushing through ercp and cytology examination of bile fluid aspiration through vol 54 • number 1 • january 2022 one year survival of axtrahepatic cholangiocarcinoma patients 41 ptbd has a low sensitivity although the specificity is very high.9 conclusion one year survival of patients with extrahepatic cholangiocarcinoma in our study was 10 % and sepsis, unsuccessful or no biliary drainage and total bilirubin >19.8 mg/dl were the three independent prognostic factors for mortality. references 1. p a t e l t. c h o l a n g i o c a r c i n o m a : c o n t r o v e r s i e s and challenges. nat rev gastroenterol hepatol. 2011;8(4):189-200. 2. park j, kim mh, kim kp, et al. natural history and prognostic factors of advanced cholangiocarcinoma without surgery, chemotherapy, or radiotherapy: a large-scale observational study. gut liver. 2009;3(4):298-305. 3. kurniawan j hi, gani ra, simadibrata m. mortalityrelated factors in patients with malignant obstructive jaundice. acta med indones. 2016;48(4):282-7. 4. fernandez-ruiz m, guerra-vales jm, colinar u i z d e l g a d o f. c o m o r b i d i t y n e g a t i v e l y influences prognosis in patients with extrahepatic c h o l a n g i o c a r c i n o m a . wo r l d j g a s t r o e n t e r o l . 2009;15(42):5279-86. 5. aktas g kt, balkan a, metin t, gulsen mt, abali h. prognostic factors in patients with advanced e x t r a h e p a t i c c h o l a n g i o c a r c i n o m a . m e d i c i n e (baltimore). 2019;98:e14556. 6. harder j, kummer o, olschewski m, otto f, blum he, opitz o. prognostic relevance of carbohydrate antigen 19-9 levels in patients with advanced biliary tract cancer. cancer epidemiol biomarkers prev. 2007;16(10):2097-100. 7. wu ce, chou wc, hsieh ch, et al. prognostic and predictive factors for taiwanese patients with advanced biliary tract cancer undergoing frontline chemotherapy with gemcitabine and cisplatin: a realworld experience. bmc cancer. 2020;20(1):422. 8. wang y, pang q, jin h, et al. albumin-bilirubin grade as a novel predictor of survival in advanced extrahepatic cholangiocarcinoma. gastroenterol res pract. 2018:8902146. 9. khan sa db, goldin rd, heaton n, et al. guidelines for the diagnosis and treatment of cholangiocarcinoma: an update. gut. 2012;61:1657-69. 10. yusoff ar, razak mm, yoong bk, vijeyasingam r, siti zm. survival analysis of cholangiocarcinoma: a 10-year experience in malaysia. world j gastroenterol. 2012;18(5):458-65. 11. benavides maa, j gallego, go´mez ma, et al. biliary tract cancers: seom guidelines. clin trans oncol. 2015;17:982-7. 12. weber a ls, scnhneider j, stangl m, et al. long term outcome and prognostic factors of patients with hilar cholangiocarcinoma. world j gastroenterol. 2007;13(9):1422-6. 13. yang lc sh, huang jw, lee kt. biliary stenting for unresectable cholangiocarcinoma: a population based study of long term outcomes and hospital costs in taiwan. kaohsiung j med sci. 2015;31(7):370-6. 14. qiu yd bj, xu fg, ding yt. effect of perioperative biliary drainage on malignant obstructive jaundice : a metaanalysis. world j gastroenterol. 2011;17(3):3916. 15. pavlidis et pt. pathophysiological consequences of obstructive jaundice and perioperative management. hepatobiliary pancreat dis int. 2018;17(1):17-21. 16. rerknimitr r, fogel el, kalayci c, esber e, lehman ga, sherman s. microbiology of bile in patients with cholangitis or cholestasis with and without plastic biliary endoprosthesis. gastrointest endosc. 2002;56(6):885-9. 17. li l, zhu c, huang h. clinical epidemiology and outcomes of biliary tract infections caused by klebsiella pneumoniae. ann transl med. 2019;7(14):304. 18. gaspersz mp, buettner s, van vugt jla, et al. conditional survival in patients with unresectable perihilar cholangiocarcinoma. hpb (oxford). 2017;19(11):966-71. 19. zhang gy, li wt, peng wj, li gd, he xh, xu lc. clinical outcomes and prediction of survival following percutaneous biliary drainage for malignant obstructive jaundice. oncol lett. 2014;7(4):1185-90. 20. brountzos en, ptochis n, panagiotou i, malagari k, tzavara c, kelekis d. a survival analysis of patients with malignant biliary strictures treated by percutaneous metallic stenting. cardiovasc intervent radiol. 2007;30(1):66-73. editorial 259acta medica indonesiana the indonesian journal of internal medicine the predictive role of carotid intima-media thickness: what is the clinical relevance? dante s. harbuwono department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: dante saksono harbuwono, md., phd. division of endocrinology and metabolism, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: danteid@yahoo.com. carotid intima-media thickness (cimt) has long been known as a surrogate marker for cerebrovascular and cardiovascular events.1-3 although the data is still controversial in several meta-analysis, increased cimt has been proven to be correlated with future event of stroke or acute coronary syndrome.1,4 diabetes is an important risk factor for endothelial dysfunction and atherosclerosis.1 it has been estalished that diabetes is an independent risk factor for macroand microvascular complications.5 thus, diabetes, increased cimt and macrovascular complications are a continuum chain. in this issue, acta medica indonesiana – the indonesian journal of internal medicine is introducing a study conducted by indra wijaya et al.6 with a title of “scoring system development and additional value of albuminuria to estimate carotid intima-media thickness (cimt) in type2 diabetes mellitus patients”. in their study, wijaya et al.6 have exposed the role of cimt as a surrogate marker for endothelial dysfunction, which may occur in systemic circulation, both in small and large blood vessels. the early paragraphs of the study show the evidences of macrovascular endothelial dysfunction by citing results of several studies such as the cardiovascular health study (chs), atherosclerosis risk in communities study (aric), the insulin resistance atherosclerotic study (iras), and carotid atherosclerosis progression study (caps); while the microvascular endothelial dysfunction is shown by citing the prevention of renal and vascular end stage disease (prevend) study. their study also has proposed the additional value of albuminuria in estimating cimt. albuminuria itself is a surrogate marker for nephropathy, which is one of microvascular complications of diabetes. in other words, wijaya tell us both conditions are happen vice versa. albuminuria is an important risk factor and can be a good predictor for renal impairment and cardiovascular events.7 cimt also has a role as a strong predictor for cardioand cerebrovascular events. there have been only few studies on the correlation between albuminuria and cimt. in addition to the wijaya et al.6 study, a study conducted by jadhav um and kadam nn8 in western indian population also has showed a strong correlation between microalbuminuria and increased cimt as well as coronary artery disease in diabetic patients. however, the measurement of cimt by carotid ultrasound has several limitations as has been mentioned in wijaya’s manuscript; therefore, a modest and simple approach such as a scoring system to estimate thickening of cimt is essential. the results of the wijaya’s study have shown that there is only a 2.3% increase on diagnostic value of cimt compared to previous model using three variables (duration of diabetes, hypertension, dyslipidemia). moreover, albuminuria could also increase the cost of treatment, which has not been included in the final model. the scoring system, which is developed using those three variables, can be used as a screening tool for dante s. harbuwono acta med indones-indones j intern med 260 early diagnosis and to determine whether the patients should undergo carotid ultrasound test. the study provides new evidences on the correlation between microalbuminuria and carotid intima-media thickness or between microand macrovascular complication. carotid intima-media thickness is a useful tool for detecting the severity of subclinical vascular disease and atheroclerosis. it can predict future cardiovascular and cerebrovascular events. it is a safe and non-invasive procedure for promoting primary and secondary prevention of cardiovascular disease. the carotid ultrasound is a rising star for detecting cimt since there are some limitations of traditional risk factors in the framingham study risk stratification to predict cardiovascular events.9 cimt also provides precise information about the burden of atherosclerosis when electrocardiogram has not yet found any abnormality. some studies have also found that information obtained from cimt imaging using ultrasound is similar with pathological findings under the microscope.9 nowadays, not all diabetes and endocrinology associations recommend carotid ultrasound as a routine screening tool for subclinical atherosclerosis in diabetes patients, including the indonesian society for endocrinologists (perkumpulan endokrinologi indonesia – perkeni). nevertheless, several studies have concluded the benefit of screening for asymptomatic type 2 diabetes patients with severe coronary artery disease, which may have equivalent benefits to revascularization. clinicians have to consider that carotid ultrasound is an operator-dependent approach and we must carefully perform patient screening for those who are indicated to have carotid ultrasound test. a screening tool as proposed by wijaya et al.6 can be one of screening tests for clinical purpose. along with indra wijaya’s article, in this issue, we are also publishing several studies written by distinguished physicians and researchers, such as cosphiadi irawan who has jotted down several biomarker expressions of breast cancer bone metastasis (cxcr4, il11ra, tff1, and mlf1p) and fauzi yusuf who has presented his study about new markers and microbiota composition for colorectal cancer patients. a large study about survival of acute respiratory distress syndrome by zulkifli amin will give us new evidences and perspective on critical respiratory care service in a tertiary hospital in indonesia. in this issue, we are also focusing on many other studies, reviews, and case reports written by general internists and consultant internists in indonesia in addition to a study from bangkok, which was carried out by phuping akavipat. the bangkok researchers have studied on the parameters affecting the length of stay at the intensive care unit among neurosurgical patients in their center. finally, please enjoy reading our journal. let the evidences be the part of our reference to perform the best clinical care for our patients. references 1. lorenz mw, price jf, robertson c, et al. carotid intima-media thickness progression and risk of vascular events in people with diabetes: results from the progimt collaboration. diab care. 2015;38:1921-9. 2. nezu t, hosomi n, aoki s, matsumoto m. carotid intima-media thickness for atherosclerosis. j atheroscler thromb. 2016;23:18-31. 3. we b e r l a , c h e e z u m m k , r e e s e j m , e t a l . cardiovascular imaging for the primary prevention of atherosclerotic cardiovascular disease events. curr cardiovasc imaging rep. 2015;8(36):1-13. 4. qu b, qu t. causes of chages in carotid intima-media thickness: a literature review. cardiovasc ultrasound. 2015;13(46):1-10. 5. fowler mj. microvascular and macrovascular complications of diabetes. clin diab. 2011;29(3):11622. 6. wijaya i, yunir e, dharmeizar, wijaya ip, setiati s. scoring system development and added value of albuminuria to estimate carotid intima-media thickness (cimt) in type 2 diabetes mellitus patients. acta med indones – indones j intern med. 2016;48(4):269-74. 7. satchell sc, tooke je. what is the mechanism of microalbuminuria in diabetes: a role for the glomerular endothelium? diabetologia. 2008;51:714-25. 8. jadhav um, kadam nn. association of microalbuminuria with carotid intima-media thickness and coronary artery disease: a cross-sectional study in western india. j assoc physic india. 2002;50:1124-9. 9. lee cj, park s. the role of carotid ultrasound for cardiovascular risk stratification beyond traditional risk factors. yonsei med j. 2014;55(3):551-7. 531acta med indones indones j intern med • vol 54 • number 4 • october 2022 original article diagnosis of chronic lymphocytic leukemia using iwcll 2018 compared with nci-wg96 criteria in cipto mangunkusumo hospital: a practical consideration in resource limited setting lugyanti sukrisman*, ikhwan rinaldi division of hematology and medical oncology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. * corresponding author: lugyanti sukrisman, md., phd. division of hematology and medical oncology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: lugyanti@gmail.com. abstract background: the diagnosis of chronic lymphocytic leukemia (cll) is mainly based on blood count, morphology, and immunophenotyping. in indonesia, the diagnosis is more challenging as the availability of immunophenotyping tests is limited. the european society of medical oncology (esmo) stated flowcytometry as a prerequisite to establishing diagnosis of cll, meanwhile in the original international workshop on chronic lymphocytic leukemia (iwcll) 2018 criteria, which has been widely accepted by physicians caring for patients with cll, the diagnosis of cll can be made in patients with cytopenia using bone marrow biopsy where flowcytometry test is not available. the aim of the study was to compare the utility of iwcll 2018 compared with national cancer institute working group 96 (nci-wg96) criteria in the diagnosis of cll in indonesia, especially in limited resource settings. methods: the data of newly diagnosed cll patients, including baseline demographic, clinical, and laboratory characteristics was retrieved retrospectively from medical records in cipto mangunkusumo general hospital from 2015 until 2021. diagnosis of cll using iwcll 2018 diagnostic criteria were then compared with nci-wg96 criteria. results: thirty-eight patients were enrolled to this study. the median age was 59.5 years and dominated by males. most of them were classified in the late-stage disease (63.4% in binet c and about 70% in rai iii-iv). four cases were cd5-negative cll. based on nci-wg96 guideline, only 24 patients (63.2%) fulfilled all four criteria for cll. similarly, using the iwcll 2018 flowcytometric criteria without biopsy data, 26 patients (68%) were diagnosed as cll. however, if bone marrow biopsy in patient with cytopenia was taken into account, all patients (100%) can be confirmed as cll. conclusion: the iwcll 2018 criteria which included bone marrow biopsy in the presence of cytopenia was more applicable to establish the diagnosis of cll in indonesia where flowcytometry is not available. keywords: chronic lymphocytic leukemia, diagnosis, nci-wg96 criteria, iwcll 2018 criteria. introduction chronic lymphocytic leukemia (cll) is defined as a clonal expansion of small, mature, cd5-positive neoplastic b-cell lymphocytes having a characteristic immunophenotype in the peripheral blood, spleen, bone marrow, and other lymphoid tissues.1 this disease is the most prevalent leukemia among adults in western countries, accounting for 37% of newly diagnosed leukemia in the united states, followed by acute lugyanti sukrisman acta med indones-indones j intern med 532 myeloid leukemia (aml).2 however, cll in asia differs from western countries due to its lower prevalence.3,4 this might be explained by variation in genetic background between different regions.5 another reason for this lower incidence is due to the asymptomatic nature of most cll cases, many are left undiagnosed, particularly in resource limited countries. until now, there is no population-based study regarding epidemiology of cll in indonesia, especially regarding prevalence and diagnostic aspects of cll. this lack of data can hinder the efforts to evaluate the incidence and trends of the disease among different populations. over the last few decades, the criteria to diagnose cll has undergone substantial revisions. the first consensus criteria to standardize the diagnosis of cll was available in 1988. at that time, automated blood counter and immunophenotyping test were not routinely available, thus absolute lymphocyte counts (alc) above 5x109/l was used as the threshold for diagnosis.6,7 in the 2008 revisions to the cll diagnostic criteria, b-cell count rather than alc above 5x109/l was adopted as the basis for diagnosis.8 nowadays, the diagnosis of cll is mainly based on laboratory features, including blood count, morphology, and immunophenotyping, as described in the iwcll 2018.9 society guidelines for cll stressed on the importance of cll diagnosis from peripheral blood using b-cell count and flowcytometry alone. in the national comprehensive cancer network (nccn) guidelines, bone marrow biopsy is recommended if the initial workup is non-diagnostic.10 moreover, the european s o c i e t y o f m e d i c a l o n c o l o g y ( e s m o ) guidelines suggest doing bone marrow biopsy if flowcytometry result remain inconclusive.11 this is considered convenient for patients since these recommendations prevent the procedural risk and unnecessary pain from bone marrow biopsy. however, flowcytometry is not widely available in developing countries. after thorough review of the iwcll 2018 diagnostic criteria, it was stated that “the presence of a cytopenia caused by a typical marrow infiltrate establishes the diagnosis of cll regardless of the number of peripheral blood b lymphocytes or of the lymph node involvement.”7 therefore, in the absence of immunophenotyping facility, bone marrow biopsy can be used to establish cll diagnosis. the present study aimed to evaluate the diagnosis of cll using iwcll 2018, which allowed cll diagnosis from bone marrow biopsy where flowcytometry test is not available, compared with nci-wg96 and to determine demographic and immunophenotypic profiles of cll in indonesia , . this is the first study to compare the diagnosis of cll according to the nci-wg96 and the iwcll 2018 guidelines in such settings. methods based on the nci-wg96 guideline, the diagnosis criteria of cll include: (1) peripheral absolute lymphocyte count >5x109/l; (2) lymphocytes were positive for cd5 and cd19/ cd20/cd23; (3) atypical cells (prolymphocytes) <55%; (4) bone marrow lymphocytes > 30%.12 meanwhile, in iwcll 2018 criteria, cll diagnosis can be made if there are: (1) peripheral b-cell count ≥5x109/l; and (2) lymphocytes were positive for cd5 and cd19/cd20/cd23. alternatively, cll can also be diagnosed by “the presence of cytopenia caused by a typical bone marrow infiltrate, regardless of the number of peripheral b-cell count or lymph node involvement”.9 this was a cross-sectional study done at department of hematology and medical oncology, cipto mangunkusumo general hospital, jakarta from 2015 until 2021. patients with newly-diagnosed cll were recruited from the database of patients who visited the hematology and medical oncology outpatient clinic. sampling was done by total sampling obtained from the list of cll patients in the registry. inclusion criteria was patients diagnosed with cll. exclusion criteria was incomplete laboratory data. information regarding baseline demographic, clinical (including age, sex, rai and binet stage, lymphadenopathy, hepatosplenomegaly), and laboratory (including complete blood count, absolute lymphocyte count, erythrocyte sedimentation rate, ldh, serum protein electrophoresis, and immunophenotyping) vol 54 • number 4 • october 2022 diagnosis of chronic lymphocytic leukemia using iwcll 2018 533 characteristics were obtained retrospectively from medical records. the sample of bone marrow aspirate and biopsy were collected to confirm the diagnosis by flow cytometry immunophenotyping and morphologic analysis were performed to examine the percent of bone marrow lymphocytes. the study protocol was approved by the local ethics committee of faculty of medicine universitas indonesia (no. ket-452/un.2.f1/ etik/ppm.00.02/2021). the data was expressed in frequency (percentage, %) for categorical variables and median (range) for continuous variables. all analysis was performed using spss version 24 for mac. results there were thirty-eight cll cases in cipto mangunkusumo general hospital, jakarta between 2015 and 2021, which were recorded in the registry. all subjects fulfilled the inclusion criteria and were recruited into this study. the characteristics of the subjects are summarized in table 1. their age at diagnosis ranged from 4182 years (median 59.5 years) and was dominated by individuals aged ≤65 years (89.5%) and male (60.5%). two of those patients (5.3%) was diagnosed as prolymphocytic leukemia (pll), the aggressive form of cll. hypertension (28.9%), dyspepsia/gerd/gastritis (15.8%), and diabetes mellitus (13.2%) were the most common comorbidities in the patients. two of the patients had history of malignancy: thyroid cancer (2.6%) and breast cancer (2.6%). most of the patients with cll at time at diagnosis were found in the late stage of the disease, 63.4% of the patients were in binet stage c and around 70% of the patients were in rai stage iii-iv. additionally, palpable splenomegaly was presented in 63.2% of the patients. the median hemoglobin, leucocyte count and absolute lymphocyte count at diagnosis were 8.9 g/dl, 59.86 x 109/l, and 47.83 x 109/l, respectively. serum ldh levels were available in 24 of 38 patients, and only 9 of 38 patients (23.7%) had an elevated ldh levels. table 1. clinical and laboratory characteristics of the subjects cll/pll (n=38) age at diagnosis (years), median (range) 59.5 (41-82) age group (years), n (%) ≤65 34 (89.5) >65 4 (10.5) sex, n (%) male 23 (60.5) female 15 (39.5) diagnosis, n (%) cll 36 (94.7) pll 2 (5.3) comorbidities, n (%) hypertension 11 (28.9) dyspepsia/ gerd/ gastritis 6 (15.8) diabetes mellitus 5 (13.2) hyperuricemia 4 (10.5) chronic kidney disease 2 (5.3) congestive heart failure 2 (5.3) stroke 1 (2.6) aiha 1 (2.6) beta thalassemia trait 1 (2.6) thyroid cancer 1 (2.6) breast cancer 1 (2.6) hepatitis c 1 (2.6) asthma/ allergy 2 (5.2) lugyanti sukrisman acta med indones-indones j intern med 534 immunophenotyping results from thirtyeight subjects were shown in table 2. cells from all cases were positive with cd19, and the majority were cd5, cd20, cd23, and kappa positive. lambda were positive in a minority of cases. four cases were cd5-negative. table 2. membrane markers of cll/pll cases marker number of cases % positive tested positive cd5 31 27 87.1% cd19 33 33 100% cd20 36 34 94.4% cd23 21 17 81% kappa 15 11 73.3% lambda 9 3 3.3% for nci-wg 1996, 37 patients fulfilled criteria of absolute lymphocytosis > 5x109/l in the peripheral blood, 27 patients fulfilled immunophenotyping criteria (lymphocytes were positive for cd5 and > 1 b-cell marker), 36 patients fulfilled atypical cells (prolymphocytes) < 55%, and 35 patients fulfilled bone marrow lymphocytes > 30% (figure 1). using the immunophenotyping criteria, a total of eleven patients that did not fulfill the criteria. however, it should be noted that 7 out of 11 patients did not have complete immunophenotyping examinations. binet, n (%) a 11 (28.9) b 3 (7.9) c 24 (63.2) rai, n (%) 0 1 (2.6) i 2 (5.3) ii 7 (18.4) iii 20 (52.6) iv 8 (21.1) lymphadenopathy >1 cm, n (%) yes 16 (42.1) no 22 (57.9) palpable hepatomegaly, n (%) yes 9 (23.7) no 29 (76.3) palpable splenomegaly, n (%) yes 24 (63.2) no 14 (36.8) hemoglobin (g/dl), median (range) 8.9 (2.8-16.1) hematocrit (%), median (range) 28.25 (12.6-47.1) leukocyte count (x109/l), median (range) 59.86 (4.04-558.35) absolute lymphocyte count (x109/l), median (range) 47.83 (2.00-530.43) platelet count (x109/l), median (range) 163.5 (41-468) esr (mm/h), median (range) 57.5 (2-153) ldh, n (%) above the limit (>350 iu/l) 9 (23.7) normal levels 15 (39.5) n/a 14 (36.8) serum protein electrophoresis, n (%) monoclonal 5 (84.2) polyclonal 1 (2.6) n/a 32 (84.2) esr, erythrocyte sedimentation rate; ldh, lactate dehydrogenase; n/a, not available vol 54 • number 4 • october 2022 diagnosis of chronic lymphocytic leukemia using iwcll 2018 535 fi gu re 1 . n um be r o f p at ie nt s th at f ul fil le d n c i-w g 9 6 g ui de lin e an d iw c ll 2 01 8 d ia gn os tic c rit er ia . lugyanti sukrisman acta med indones-indones j intern med 536 based on nci-wg96 guideline, only twentyfour patients (63.2%) fulfilled all four criteria and thus were diagnosed as cll (figure 2). similarly, using the iwcll 2018 criteria without bone marrow biopsy, twenty-six patients (68%) were diagnosed as cll. using the iwcll 2018 bone marrow biopsy part of the criteria only, there were thirty-five cases (92%) of cll (figure 2). overall, using the bone marrow biopsy criteria of iwcll 2018 yielded more cll diagnosis than using all four nci-wg96 criteria for cll diagnosis or iwcll flowcytometric criteria. if bone marrow biopsy in patient with cytopenia was taken into account in the patients who did not fulfill the flowcytometric criteria of iwcll 2018, all patients (100%) can be confirmed as cll. discussion in the present study, the median age of study population at diagnosis was 59.5 years and cll cases were predominantly among males. this results is in accordance to prior studies.13,14 chronic illnesses, such as hypertension, gastrointestinal problem (dyspepsia or gastritis), and diabetes mellitus were the top three comorbid conditions in our patients. although cll incidence may be secondary to aging, chronic illnesses may be a contributing factors despite the mechanisms remaining unclear.15–17 according to cll international data, cll incidence rate (irs) is highest in western countries (e.g. north america, europe), and the lowest in asian countries.18–20 indeed, cll incidence was varied by race as noted in a multicenter study by dores et al that the irs of cll among whites, blacks, and asian/pacific islander were 4.18, 3.01, and 0.84 cases per 100,000 people, respectively.20 the variability of cll incidence cases between different regions might be influenced by the variations in genetic background.5 the sustained low irs of cll in asians who have migrated to the united states support that genetic influence is greater than environmental factors.21,22 this low irs in asians might explain why we had limited sample size. in addition, underdiagnosis and shortened life expectancy may contribute to the low incident cases. since patients with early stage cll are mostly asymptomatic, the diagnosis is often overlooked. moreover, in indonesia there is lack of infrastructure to diagnose cll properly. flowcytometry, which is essential to determine b-cell clonality, is only available in few large cities. figure 2. number of patients categorized as cll based on nci-wg 96 guideline, iwcll 2018 guideline flowcytometric criteria, bone marrow biopsy criteria, and flowcytometry or bone marrow biopsy. flow: flowcytometry; bmb: bone marrow biopsy. vol 54 • number 4 • october 2022 diagnosis of chronic lymphocytic leukemia using iwcll 2018 537 call et al demonstrated that the majority of cll incident cases diagnosed using the nci-wg96 criteria were observed in the early stages: 60.9%, 33.9%, and 5.2% for rai stage 0, i/ii, and iii/iv, respectively as it was mostly diagnosed in primary care settings.23 molica et al, villavicencio et al, and strati et al also provided similar results.16,24,25 this is truly contrast to our data where most of cll cases was diagnosed in the advanced-stage disease, either binet c or rai iii-iv, because patients in indonesia usually sought medical help when they developed symptoms (b-symptoms, lymphadenopathy, marrow failure); and only a minority of the patients were diagnosed through incidental finding of an alc above the defined threshold. apparently, most of the cases were diagnosed in tertiary care setting because of the limited availability of flow cytometry immunophenotyping. the typical immunophenotypic feature of b-cell clone in cll is the co-expression of cd5, cd19, cd20, and cd23. however, some cases of cll have cd5-negative b-cell clone. its incidence varies from 7% to 20%.26,27 in our study, the incidence of cd5-negative cll was 10.5% (four in 38 cases) and all of them had splenomegaly. similarly, several studies reported a higher incidence of splenomegaly in cd5negative cll compared to cd5-positive cll cases. furthermore, some studies pointed out that cd5-negative cll patients had a more advanced stage of disease and shorter survival.26,28,29 in the present study, all those four patients was in binet c and rai iii. one patient in the present study had the alc of 2x109/l and no organomegaly, but presented with b-symptoms, anemia, typical bone marrow infiltrate, and immunophenotyping of cll. in other cases, the diagnosis of cll in cd5negative cases was made according to clinical and morphological features. accordingly, these patients met the iwcll 2018 bone marrow criteria for cll which only requires the presence of cytopenia caused by typical bone marrow infiltrate, regardless of b-cell count or nodal involvement.9 the disadvantage of the immunophenotyping test is the cost and it is not widely available in indonesia. in addition, very few pathologists have completed the flowcytometry interpretation training. the expensive testing cost pose another problem since it is not covered by the national health insurance. hence, the use of immunophenotyping as stated in the flowcytometric criteria of iwcll 2018 is not applicable in indonesia. based on our data, more than 90% of the patients can be diagnosed as cll by bone marrow biopsy alone. meanwhile, only 63.2%% of the patients fulfilled all the nci-wg96 criteria and 68% of patients met the iwcll flowcytometry without bone marrow biopsy) criteria. these findings showed that in our cll patients, bone marrow biopsy alone is more sensitive to diagnose cll, even without flowcytometry data. this study depicted another insight into the iwcll 2018 cll diagnostic criteria. in the absence of flowcytometric immunophenotyping, bone marrow trephine biopsy showing marrow infiltrate can be utilized to diagnose cll. in contrast to flowcytometric immunophenotyping, trephine biopsy is reimbursable by the national health insurance. the procedure can be performed in remote areas with limited resources, with the pathologic review done in large centers using the preserved samples sent in 10% formalin preservatives. in our study, only three patients (8%) did not fulfill the iwcll 2018 bone marrow criteria for cll. however, all three patients were confirmed for cll by flowcytometry. it can be proposed that bone marrow biopsy is mandatory in diagnosis of cll, especially in limited settings where flowcytometry is not available. our study is subject to several limitations. this study was a single center study which only had small number of subjects. race or ethnicity was not gathered in our study as it might influence the incidence of cll. additionally, immunophenotypic analysis was not available for all patients. immunophenotyping test is still limited and only available in several urban areas across indonesia. moreover, as cll is usually diagnosed incidentally and patients present with minimal signs and symptoms, thus financial barriers to accessing primary health care providers or specialists or laboratory tests may hamper the detection rate of cll. further studies are needed to confirm the findings of this study, lugyanti sukrisman acta med indones-indones j intern med 538 especially with bigger sample size and emphasis on diagnostic agreement. another drawback of the bone marrow trephine biopsy is that this procedure is not routinely performed in diagnosis of cll in all centers in indonesia. this study showed that bone marrow biopsy in addition to bone marrow aspirate is the best available modality to diagnose cll in indonesia when flowcytometry is not available. conclusion the iwcll 2018 criteria involving bone marrow biopsy in the presence of cytopenia were more applicable to establishing cll diagnosis in indonesia. also, it may be applied to other countries with limited access to immunophenotyping tests. acknowledgments the authors are thankful to the cll patients who provided their health information for this study. we also thank renata tamara, m.d. for data collection and dimas priantono, m.d. for assisting in the manuscript preparation. conflict of interest the authors declare no conflict of interest. references 1. pérez-carretero c, gonzález-gascón-y-marín i, rodríguez-vicente ae, et al. the evolving landscape of chronic lymphocytic leukemia on diagnosis, prognosis and treatment. diagnostics (basel). 2021;11(5):853. 2. american cancer society. cancer facts & figures 2020 [internet]. 2020 [cited 2021 sep 20]. available from: https://www.cancer.org/content/dam/cancer-org/ research/cancer-facts-and-statistics/annual-cancerfacts-and-figures/2020/cancer-facts-and-figures-2020. pdf 3. wu sj, chiang cj, lin ct, tien hf, lai ms. a nationwide population-based cross-sectional comparison of hematological malignancies incidences between taiwan and the united states of america. ann hematol. 2016;95(1):165–7. 4. chihara d, ito h, matsuda t, et al. differences in incidence and trends of haematological malignancies in japan and the united states. br j haematol. 2014;164(4):536–45. 5. seftel md, demers aa, banerji v, et al. high incidence of chronic lymphocytic leukemia (cll) diagnosed by immunophenotyping: a population-based canadian cohort. leuk res. 2009;33(11):1463–8. 6. cheson bd, bennett jm, rai kr, et al. guidelines for clinical protocols for chronic lymphocytic leukemia: recommendations of the national cancer institute-sponsored working group. am j hematol. 1988;29(3):152–63. 7. chronic lymphocytic leukemia: recommendations for diagnosis, staging, and response criteria. ann intern med. 1989;110(3):236. 8. hallek m, cheson bd, catovsky d, et al. guidelines for the diagnosis and treatment of chronic lymphocytic leukemia: a report from the international workshop on chronic lymphocytic leukemia updating the national cancer institute–working group 1996 guidelines. blood. 2008;111(12):5446–56. 9. hallek m, cheson bd, catovsky d, et al. iwcll guidelines for diagnosis, indications for treatment, response assessment, and supportive management of cll. blood. 2018;131(25):2745–60. 10. wierda w, brown j, abramson j, et al. chronic lymphocytic leukemia/small lymphocytic lymphoma, version 2.2022, nccn clinical practice guidelines in oncology. journal of the national comprehensive cancer network; 2022. 11. eichhorst b, robak t, montserrat e, et al. chronic lymphocytic leukaemia: esmo clinical practice guidelines for diagnosis, treatment and follow-up. ann of oncol. 2021;32(1):23–33. 12. cheson bd, bennett jm, grever m, et al. national cancer institute-sponsored working group guidelines for chronic lymphocytic leukemia: revised guidelines for diagnosis and treatment. blood. 1996;87(12):4990– 7. 13. eichhorst b, robak t, montserrat e, et al. chronic lymphocytic leukaemia: esmo clinical practice guidelines for diagnosis, treatment and follow-up. ann of oncol. 2015;26:v78–84. 14. burger ja, o’brien s. evolution of cll treatment — from chemoimmunotherapy to targeted and individualized therapy. nat rev clin oncol. 2018;15(8):510–27. 15. thurmes p, call t, slager s, et al. comorbid conditions and survival in unselected, newly diagnosed patients with chronic lymphocytic leukemia. leuk lymphoma. 2008;49(1):49–56. 16. strati p, parikh sa, chaffee kg, et al. relationship between co-morbidities at diagnosis, survival and ultimate cause of death in patients with chronic lymphocytic leukaemia (cll): a prospective cohort study. br j haematol. 2017;178(3):394–402. 17. rotbain ec, niemann cu, rostgaard k, da cunhabang c, hjalgrim h, frederiksen h. mapping comorbidity in chronic lymphocytic leukemia: impact of individual comorbidities on treatment, mortality, and causes of death. leukemia. 2021;35(9):2570–80. 18. shvidel l, shtarlid m, klepfish a, sigler e, berrebi vol 54 • number 4 • october 2022 diagnosis of chronic lymphocytic leukemia using iwcll 2018 539 a. epidemiology and ethnic aspects of b cell chronic lymphocytic leukemia in israel. leukemia. 1998;12(10):1612–7. 19. finch sc, linet ms. chronic leukaemias. baillière’s clinical haematology. 1992;5(1):27–56. 20. dores gm, anderson wf, curtis re, et al. chronic lymphocytic leukaemia and small lymphocytic lymphoma: overview of the descriptive epidemiology. br j haematol. 2007;139(5):809–19. 21. nishiyama h, mokuno j, inoue t. relative frequency and mortality rate of various types of leukemia in japan. gan. 1969;60(1):71–81. 22. herrinton lj, goldoft m, schwartz sm, weiss ns. the incidence of non-hodgkin’s lymphoma and its histologic subtypes in asian migrants to the united states and their descendants. cancer causes control. 1996;7(2):224–30. 23. call tg, norman ad, hanson ca, et al. incidence of chronic lymphocytic leukemia and high-count monoclonal b-cell lymphocytosis using the 2008 guidelines. cancer. 2014;120(13):2000–5. 24. villavicencio a, solans m, zacarías-pons l, et al. comorbidities at diagnosis, survival, and cause of death in patients with chronic lymphocytic leukemia: a population-based study. int j environ res public health. 2021;18(2):701. 25. molica s, giannarelli d, mirabelli r, et al. changes in the incidence, pattern of presentation and clinical outcome of early chronic lymphocytic leukemia patients using the 2008 international workshop on cll guidelines. expert rev hematol. 2014;7(5):691–5. 26. cartron g, linassier c, bremond jl, et al. cd5 negative b-cell chronic lymphocytic leukemia: clinical and biological features of 42 cases. leuk lymphoma. 1998;31(1–2):209–16. 27. de rossi g, mauro fr, lo coco f, et al. cd5 negative lymphocytosis mimicking typical b-chronic lymphocytic leukaemia. description of 26 cases. nouv rev fr hematol. 1993;35(4):451–5. 28. geisler ch, larsen jk, hansen ne, et al. prognostic importance of flow cytometric immunophenotyping of 540 consecutive patients with b-cell chronic lymphocytic leukemia. blood. 1991;78(7):1795–802. 29. demir c, kara e, ekinci ö, ebinç s. clinical and laboratory features of cd5-negative chronic lymphocytic leukemia. med sci monit. 2017;23:2137– 42. supplementary data the 1996 national cancer institute-sponsored working group guidelines (nci-wg 96) guideline no criteria 1 absolute lymphocytosis > 5x109/l in the peripheral blood 2 lymphocytes were positive for cd5 and > 1 b-cell marker (cd19/cd20/cd23) 3 atypical cells (prolymphocytes) < 55% 4 bone marrow lymphocytes > 30%. the 2018 international workshop on chronic lymphocytic leukemia guidelines (iwcll 2018) guideline b lymphocytes > 5x109/l in the peripheral blood and cll cells were positive for cd5 and b-cell antigens (cd19/cd20/ cd23) or presence of cytopenia caused by a typical marrow infiltrate regardless of the number of peripheral blood b lymphocytes or of the lymph node involvement 72 acta med indones indones j intern med • vol 54 • number 1 • january 2022 original article the association of kidney function monitoring adherence and estimated glomerular filtration rate changes among patients at-risk for chronic kidney disease afiatin1*, andre indrajaya2, ria bandiara1 1 division of nephrology and hypertension, department of internal medicine, faculty of medicine universitas padjadjaran dr. hasan sadikin hospital, bandung, indonesia. 2 department of internal medicine faculty of medicine, universitas padjadjaran dr. hasan sadikin hospital, bandung, indonesia. *corresponding author: afiatin, md, ph.d. division of nephrology and hypertension, department of internal medicine, faculty of medicine universitas padjadjaran dr. hasan sadikin hospital, bandung, indonesia. email: afiatinmakmun@gmail.com. abstract background: kidney disease: improving global outcome in 2012 has provided recommendations to prevent ckd progression by monitoring kidney function periodically according to the ckd stage and the clinician’s adherence to these guidelines is important. this is the first study on the relationship between adherence to monitoring renal function and changes in estimated glomerular filtration rate (egfr) in patients at risk for ckd in indonesia. methods: this study was a comparative observational study with a cross-sectional approach. research subjects were electronic medical record data from the hasan sadikin general hospital information system (sirs) data collected with the sql server report builder and “hclab” applications on patients at risk for ckd at the hasan sadikin general hospital’s outpatient clinic from january 2018 to march 2020. the patients’ data were taken by the total sampling technique and then processed with the chi-square test. results: from 376 subjects, the results showed that poor adherence in renal function monitoring would increase the risk of decreasing egfr by 1.51 times compared to good monitoring adherence (pr 1.51 95% ci (1.172 1.935); p-value 0.007). the egfr changes were significant (p-value 0.002) with mean 10.84 ml/min/1.73m2 (95% ci: 4.17 – 17.50). conclusion: the study demonstrated that poor renal function monitoring adherence had an association with a decrease in egfr in a group of patients at risk for ckd. keywords: frequent monitoring, ckd progression, egfr. introduction chronic kidney disease (ckd) presents a global public health problem with an increasing prevalence and incidence, poor prognosis, and high cost. based on the global burden of disease report, ckd is the 27th leading cause of death globally and increased to the 12th in 2017. ckd treatment ranks as the fourth most expensive cost of the national health insurance after heart disease in indonesia.1-3 early detection of ckd and frequent monitoring of kidney function in a patient with diseases at risk of ckd complications are vital. early detection means assessing renal function based on laboratory tests when the underlying disease is diagnosed for the first time, usually asymptomatic. at the same time, frequent monitoring is scheduled to assess the progress vol 54 • number 1 • january 2022 the association of kidney function monitoring 73 of the complications which is ckd. those are essential because the first onset of ckd is difficult to assess. therefore, concurrent management of both underlying disease and complications (ckd) is an important step to reduce the risk of cardiovascular disease, progression of kidney disease, and death.4 in 2012, kidney disease: improving global outcome recommends frequent monitoring of renal function for patients at risk according to ckd stage.2 this is following the national institute for health and care excellence (nice) guideline that stated early detection of ckd should be implemented for patients with diabetes, hypertension, history of acute renal impairment, cardiovascular disease, renal structural abnormalities, multisystem diseases (such as systemic lupus erythematosus), and patients with nephrotoxic drugs (such as lithium, cyclosporin, and nsaids).4-6 on the contrary, some guidelines based on expert opinions such as the united states preventive service task force (uspstf) and the american college of physicians (acp) do not recommend assessing renal function in asymptomatic patients. to date, there are no randomized clinical trial (rct) study that examines the role of early detection of kidney injury with patient’s clinical outcome. both uspstf and acp stated that early detection of kidney damage has potential adverse effects, including discomfort during blood collection, psychological effects related to ckd stigma, drug side effects from treatment with an uncertain diagnosis, and financial impacts. 7, 8 there is no data on the clinician’s adherence to monitor the population at risk of ckd in indonesia. since there is a discrepancy in the recommendation to monitor the population of risk of ckd, this study aims to determine the association between monitoring adherence and changes in estimated glomerular filtration (egfr) in the population at risk. methods this study was a comparative observational study with a cross-sectional approach. we retrospectively analyzed outcomes of at-risk ckd patients who underwent early detection and monitoring between march 2018 and march 2020, at one tertiary-care outpatient clinic government hospital. ethics the institutional ethics committee of hasan sadikin hospital approved the ethical clearance for this study (lb.02.01/x.6.5/001/2021). patients’ data from medical records were deidentified and analyzed anonymously. inclusion and exclusion criteria we retrospectively extracted and examined patient data from the hasan sadikin general hospital information system (sirs). data were collected with the sql server report builder and “hclab” applications on patients at risk for ckd at the hasan sadikin general hospital’s outpatient clinic from january 2018 to march 2020. we chose patients at risk for ckd covering congestive heart failure patients in the cardiology clinic, hypertension patients in the nephrology clinic, spondyloarthropathy patients who routinely used non-steroidal anti-inflammatory drugs, systemic lupus erythematosus (sle) patients in the rheumatology clinic, diabetes patients in the endocrinology clinic, and cancer patients who underwent platinumbased chemotherapy in the oncology clinic. information on age, sex, ckd risk factors, baseline egfr, and proteinuria were recorded. demographic data were collected at the time of study enrollment. we then recorded egfr at the first encounter with a doctor in our clinic (early detection) and 1 year later (monitoring) to see the changes and counted the number of creatinine examination that was performed within one year to assess the adherence to kdigo 2012 monitoring recommendation. we used ckd classification based on gfr category and albuminuria category according to kdigo 2012 (table 1). the inclusion criteria required at-risk patient aged >18 years who had creatinine results at the first encounter with the doctor in our clinic and one year later. we excluded patients who had previously undergone hemodialysis and patients with the possibility of acute kidney injuries such as infection and acute heart failure. afiatin acta med indones-indones j intern med 74 the outcome of the study was ckd progression, shown by changes in estimated glomerular filtration rate (egfr). statistical analysis the doctor’s adherence to monitoring egfr was categorized into adherent and non-adherent groups. baseline characteristics were described across these groups. estimated gfr changes were categorized into normal and decreased. the comparison of egfr between patients in the adherent and the non-adherent group was performed using dependent t-test or wilcoxon signed rank test, alternatively. bivariate analysis between monitoring adherence and egfr changes was performed using the chisquare test and reported as prevalence risk (pr) with its 95% confidence interval. statistical significance was set at ≤0.05 with a two-tailed hypothesis. statistical analyses were performed with statistical product and service solution (spss) version 22.0 for windows. results there were 522 subjects with underlying diseases having a risk for ckd. a total of 376 subjects met the inclusion criteria. the remaining were excluded from the study due to incomplete data. (figure 1) baseline characteristics patients in the adherent group had a risk factor of sle (21.9%), hypertension (20.7%), and dm type 2 (20.1%). in the non-adherent group, most patients had a risk factor of congestive heart failure (34.9%) and nasopharyngeal carcinoma (23.3%). the subjects’ characteristics based on adherence monitoring are shown in table 2. overall, 64.1% of subjects were not tested table 1. recommended egfr monitoring frequency for at-risk patients based on kdigo 2012 albuminuria category a1 (<30 mg/g) a2 (30–300 mg/g) a3 (>300 mg/g) egfr category (ml/ min/1.73m2) g1 ³90 1 time/year 1 time/year 2 times/year g2 60-89 1 time/year 1 time/year 2 times/year g3a 45-59 1 time/year 2 times/year 3 times/year g3b 30-44 2 times/year 3 times/year 3 times/year g4 15-29 3 times/year 3 times/year ³4 times/year g5 <15 4 times/year ³4 times/year 4 times/year 522 ckd at-risk patients in hasan sadikin general hospital’s outpatient diabetes clinic 75 diabetes mellitus patients rheumatology clinic 6 spondiloartropathy patients 73 sle patients oncology clinic 74 paltinum based chemoterapy patients nephrology and hypertension clinic 74 hypertension patients cardiology clinic 74 congestive heart failure clinic 8 complaint 67 non complaint 0 complaint 79 non complaint 15 complaint 59 non complaint 5 complaint 69 non complaint 15 complaint 59 non complaint 2356 patients ÿ no data of creatinin serum at the strat of monitorimg ÿ no data of creatinin serum at the end monitoring figure 1. study sample selection vol 54 • number 1 • january 2022 the association of kidney function monitoring 75 for proteinuria at their first admission. at the start of monitoring, most of the patients had stage g2 (36.2%), followed by stage g1 (31.4%), g3a (18.4%), g3b (10.1%), g4 (3.1%), and g5 (0.8%). in the non-adherent group, most patients had stage g1 (55.8%) followed by g2 (25.6%), g3a (14.0%), g3b (2.3%), g4 (2.3%) and g5 (0%) while in the adherent group, most patients were at stage g2 (37.5%), g1 (28.2%), g3a (18.9%), g3b (11.1%), g4 (3.3%) and g5 (0.9%). the median (range) of follow-up in the adherent group was 5 (1-17) times per year, while in the non-adherent group was 1 (1-2) times per year. the adherent group had a mean ± sd egfr of 72.02±27.04 ml/min/1.73m2 at the start and 72.84±29.32 ml/min/1.73m2 at the end of monitoring. the egfr changes was not significant (p>0.05) with mean 0.08 ml/ min/1.73m2 (95% ci 1.54 to 1.70ml/min/1.73m2 (figure 2). the association between monitoring adherence with renal function and egfr changes is shown in table 3. non-adherent monitoring had a higher decreased egfr (65.1%) than the adherent group (43.2%). non-adherent monitoring significantly decreased the egfr than the adherent group (p<0.05). tabel 2. baseline characteristics baseline characteristics totaln=376 monitoring adherence p valueadherent n=333 non-adherent n=43 creatinine monitoring frequency per year g 5 (1 – 17) 5 (1 – 17) 1 (1 – 2) <0.001 a* proteinuria monitoring frequency per year g 1 (0 – 16) 1 (0 – 16) 0 (0 – 3) <0.001 a* age (years)g 61 (18 – 86) 62 (18 – 86) 58 (18 – 84) 0.184a sex, n (%) male 146 (38.8) 127 (38.1) 19 (44.2) 0.444b female 230 (61.2) 206 (61.9) 24 (55.8) risk factor, n (%) diabetes mellitus 75 (19.9) 67 (20.1) 8 (18.6) <0.001b* congestive heart failure 74 (19.7) 59 (17.7) 15 (34.9) cervical cancer 13 (3.5) 11 (3.3) 2 (4.7) bladder cancer 15 (4) 13 (3.9) 2 (4.7) lung cancer 13 (3.5) 12 (3.6) 1 (2.3) nasopharyngeal cancer 33 (8.8) 23 (6.9) 10 (23.3) hypertension 74 (19.7) 69 (20.7) 5 (11.6) spondyloarthropaties 6 (1.6) 6 (1.8) 0 (0) systemic lupus erythematous 73 (19.4) 73 (21.9) 0 (0) baseline proteinuria, n (%) negative 101 (26.9) 101 (30.3) 0 (0) <0.001b* 1+ 12 (3.2) 12 (3.6) 0 (0) 2+ 11 (2.9) 11 (3.3) 0 (0) 3+ 5 (1.3) 5 (1.5) 0 (0) 4+ 6 (1.6) 5 (1.5) 1 (2.3) not examined 241 (64.1) 199 (59.8) 42 (97.7) albuminuria stages, n (%) a1 101 (26.9) 101 (30.3) 0 (0) <0.001b* a2 12 (3.2) 12 (3.6) 0 (0) a3 263 (69.9) 220 (66.1) 43 (100) stadium g1 118 (31.4) 94 (28.2) 24 (55.8) g2 136 (36.2) 125 (37.5) 11 (25.6) g3a 69 (18.4) 63 (18.9) 6 (14.0) g3b 38 (10.1) 37 (11.1) 1 (2.3) g4 12 (3.1) 11 (3.3) 1 (2.3) g5 3 (0.8) 3 (0.9) 0 (0.0) gmedian (min-max), amann whitney, bchi square, *significant p<0,05 afiatin acta med indones-indones j intern med 76 discussion this study was a comparative observational study with a cross-sectional method that identifies the association between monitoring adherence with renal function and egfr changes. to the authors’ best knowledge, this is the first investigation conducted in indonesia. the international society of nephrology and the international federations of kidney foundations, on world kidney day 2020, has the theme “kidney health for everyone everywhere from prevention to detection and equitable access to care”. the theme emphasizes that ckd and progression to end-stage renal disease (esrd) can be prevented with proper access to early detection (primary prevention), frequent monitoring (secondary prevention), and simultaneous management (tertiary prevention). 9 kidney disease has an enormous economic burden. high-income countries allocate more than 2-3% of the annual health care budget to treat kidney failure. based on the united states renal data system report in 2019, all ckd patients require an increase in the need for care as the disease progresses, especially if the patient has reached end-stage renal disease requiring renal replacement therapy. 10, 11 our study showed that at the start of monitoring, most patients were at stage g2 (36.2%), followed by stage g1 (31.4%), g3a (18.4%), g3b (10.1%), g4 (3.1%), and g5 (0.8%). this is in accordance with usrds 2019 data and the meta-analysis conducted by hill et al. in 2016 that found ckd stages 1-3 are more common than stages 4-5. therefore, the management of ckd should focus on preventing progression, not on kidney replacement.11,12 many countries have implemented national policies and strategies for non-communicable diseases. however, specific policies directed at education and awareness of kidney disease with early detection, frequent monitoring, 88,21 72,92 77,37 72,84 50 55 60 65 70 75 80 85 90 95 100 kepatuhan pemantauan tidak baik kepatuhan pemantauan baik awal pemantauan akhir pemantauan p= 0.002 p = 0.927 eg fr non-adherent adherent start of monitoring end of monitoring figure 2. comparison of renal function in one year monitoring table 3. association of monitoring adherence and estimated glomerular filtration rate changes monitoring adherence n egfr changes p-value*) pr (ci 95%) decrease constant/increase non-adherent 43 28 (65.1) 15 (34.9) 0.007 1.51 (1.17 – 1.93) adherent 333 144 (43.2) 189 (56.8) *) chi-square; pr (prevalence ratio) (ci 95%) vol 54 • number 1 • january 2022 the association of kidney function monitoring 77 management, and treatment of ckd are still inadequate. until now, the management of patients with kidney disease is still not optimal. many patients were presented with kidney failure when first referred to a nephrologist.13 lack of knowledge about ckd prevention is reflected in the number of proteinuria assessments as the first screening test. our study showed that only 35.9% of patients had proteinuria examination at first admission at the outpatient clinic. the nkfkdoqi, nice 2008, kdigo 2012, and cari 2013 guidelines recommend proteinuria as one of the basics for early detection and monitoring of ckd progression. proteinuria serves as the most common etiologic marker of ckd (dm, hypertension, and glomerular disease) and in kidney transplant recipients.4, 14 in our study, the non-adherent monitoring increased the risk of decreased egfr compared to adherent monitoring with a prevalence ratio of 1.51 (95% ci 1.172 to 1.935, p=0.007). these results have very significant clinical implications. a study conducted by matsushita et al. in 2009 found that the group that had a higher decrease in egfr per year, had an increased incidence of acute coronary syndrome events and mortality. our study also strengthens the kdigo 2012 guideline recommendations stating that more frequent monitoring of renal function is needed as renal injury progress. the kdigo 2012 recommendations were based on one of the main studies, namely the prevention of renal and vascular end-stage disease (prevend). the prevend study found that the rate of decrease in egfr in the proteinuria and hypertension group was faster than in the other groups, indicating the importance of egfr and proteinuria assessment to determine the number of monitoring frequencies. in addition, our study shows an association between monitoring adherence with renal function and ckd progression. therefore, our results strengthen the confidence of kdigo 2012 recommendations serving the basis for determining the minimum amount of renal function monitoring in at-risk patients. o u r s t u d y p r o v i d e s e p i d e m i o l o g i c a l evidence to reduce the level of trust in other guidelines such as uspstf 2012 and acp 2013. these guidelines do not recommend frequent monitoring of the ckd population, especially in asymptomatic patients stages 1 – 3. these recommendations are made only based on expert opinion because no studies have assessed the accuracy, precision, specificity, or sensitivity of frequent monitoring to detect egfr changes. both uspstf and acp hesitate that the benefit of early detection and frequent monitoring is greater than the harm of adverse event. 7, 8 our study has shown that frequent monitoring is essential to reduce ckd progression. however, some limitations should be noted. most of the patients (64.1%) had no baseline proteinuria data. baseline proteinuria data in the adherent group reached 59.8%, while in the non-adherent groups, almost all patients were not assessed (97.7%). this follows a study conducted by plantinga et al. in 2010 revealing awareness of damage detection and frequent monitoring of kidney function both at the patient and doctor level is very low.15,16 to overcome this limitation, we determined the a3 grade if proteinuria was not checked with the worst assumption so that it could describe the milder a1 or a2 condition. this study did not include the variables of management changes made, whether appropriate or not since the data were retrospectively taken. there is the potential for selection bias. this bias mainly lies in temporal ambiguity. we cannot conclude that exposure is a risk factor for a particular disease. this may be because one patient may have more than one risk factor. therefore, we assessed risk factors based on data from the main polyclinic where their underlying disease was controlled. further research is needed with more accurate information regarding the timing and occurrence of the underlying disease and sensitivity analysis is required. conclusion renal function monitoring adherence is associated with changes in egfr in a group of patients at risk for ckd. patients with poor adherence monitoring were likely to develop decreased egfr by 1.51 times compared to the adherent monitoring group. afiatin acta med indones-indones j intern med 78 acknowledgments we thank evan susandi, s. si, m. stat for the useful suggestions on statistic matters. references 1. ministry of health of the republic of indonesia data and information center. situasi penyakit ginjal kronis. 2017. 2. kdigo. clinical practice guideline for the evaluation and management of chronic kidney dis ease. international society of nephrology. 2012. 3. cockwell p, fisher l-a. the global burden of chronic kidney disease. lancet. 2020;395(10225):662-4. 4. nice. early identification and management of chronic kidney disease in adults in primary and secondary care. 2014. 5. kidney early evaluation program (keep). national kidney foundation. 2008. 6. levey as, coresh j, bolton k, culleton b, kusek j, levin a. k/doqi clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. am j kid dis. 2002;39:s1-s266. 7. qaseem a, jr. rhh, sweet de, starkey m, shekelle p. screening, monitoring, and treatment of stage 1 to 3 chronic kidney disease: a clinical practice guideline from the american college of physicians. ann intern med. 2013;159:835-47. 8. moyer v. screening for chronic kidney disease: u.s. preventive services task force recommendation statement. ann intern med. 2012;157:567-70. 9. hradsky a. 2020 wkd theme belgium: international society of nephrology; 2020 [available from: https:// www.worldkidneyday.org/2020-campaign/2020-wkdtheme/. 10. luyckx va, b mt, stanifer jw. the global burden of kidney disease and the sustainable development goals. bulletin of the world health organization. 2018;96:414-22. 11. us renal data system 2019 annual data report: epidemiology of kidney disease in the united states. usrds. 2019. 12. hill nr, fatoba st, oke jl, hirst ja, o’callaghan ca, lasserson ds. global prevalence of chronic kidney disease – a systematic review and metaanalysis. plos one. 2016;11(7). 13. stevens la, cooper sep, singh rs, levin a. detection of chronic kidney disease in non-nephrology practices: an important focus for intervention. bcmj. 2005;47(6):305-11. 14. strasinger sk, lorenzo msd. in: fratantoro c, editor. urinalysis and body fluids. 5th edition. philadelphia: f. a. davis company; 2008. p. 60. 15. plantinga lc td, powe nr. awareness of chronic kidney disease among patients and providers. adv chronic kidney dis. 2010;17(3):225-36. 16. bravo-zúñiga j, gálvez-inga j, carrillo-onofre p, gómez rcv, castro-monteverde p. early detection of chronic renal disease: coordinated work between primary and specialized care in an ambulatory renal network of peru. braz j nephrol. 2019;41:176-84. 1acta med indones indones j intern med • vol 55 • number 1 • january 2023 editorial chronic kidney disease care in indonesia: challenges and opportunities ni made hustrini* division of nephrology and hypertension, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. * corresponding author: ni made hustrini, md. division of nephrology and hypertension, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: madekum99@gmail.com. the burden of chronic kidney disease (ckd) is a significant global health concern. previous study reported that the ckd incidence reached 200 cases per million per year in many countries with the prevalence 11.5% (4.8% in stages 1-2 and 6.7% in stages 3-5).1 other study further reported that the estimate prevalence of ckd was 15% higher in lowand middle-income countries compared to the high-income countries.2 however, there are limited statistics available on the epidemiology of ckd in indonesia. according to the basic health research (riset kesehatan dasar [riskesdas], 2018], the prevalence of ckd in indonesia increased from 0.2% in 2013 to 0.3% in 2018.3-4 these results may, however, understate the true prevalence of ckd in our population. despite the limited data on the ckd prevalence, the number of patients receiving kidney replacement treatment (krt), primarily in the form of hemodialysis, is rapidly rising (i.e., more than 132.000 in 2018).5 chronic hemodialysis therapy results in extremely high expenses, correspond to the indonesian health profile 2021 report, where kidney failure spending coming in fourth overall after heart disease, cancer, and stroke. however, the report also showed that the current health financing model places more emphasis on the curative or treatment area, while promotive and preventive measures merely occupy a very small portion (i.e., 0.3%).6 addressing nephrology care, especially in developing country such as indonesia, is not an easy task. in addition to the size of indonesian population, which is expected to reach 271 million in 2021, we also have a shortage of nephrology professionals (doctors, nurses, technicians) and medical facilities. meanwhile, the triple burden of disease continuously becoming our national health challenge. this is the result of inadequate control of infectious, re-emerging, and new emerging diseases; a demographic and nutritional transition which causing chronic diseases to be the top five list of catastrophic disorders; and the steady rise in the number of injuries and traumas.7 moreover, the prevalence of metabolic diseases associated with the progression of ckd increased over time, according to data from the national basic health survey (riskesdas, from 2007 to 2018) [e.g., diabetes mellitus 8.3% to 10.9%; hypertension 25.8% to 34.1%; stroke 7% to 10.9%; obesity 26.6% to 34.6%; and cancer 1.4% to 1.8%].3-4,8 also, our previous study demonstrated that hypertension prevalence among adults >18 years is as high as 41%, of which only 36.2% subjects treated with anti-hypertensive with less than a third (21.7%) of subjects consumed the medication regularly.9 a comprehensive nephrology referral system is also a challenge. we can argue this statement with evidence from the tertiary care, where it was reported that most kidney failure patients (83%) commenced dialysis with an urgent start, along with late referral to nephrologist (90%), started dialysis with temporary catheter ni made hustrini acta med indones-indones j intern med 2 (95.2%), and the median egfr to start dialysis was 5.3 (range: 0.6 – 14.6) ml/minute/1.73 m2.10 however, individual awareness, as well as an effective screening and prevention program for high-risk group are also a significant hurdles. meanwhile, screening program to identify kidney diseases among population will cause a massive economic burden, thus specific ckd riskfactors should be known for indonesian unique population. our study was able to identify ckd risk factors that are significantly different from those in western countries (i.e., hepatitis [or 3.406; ci 2.496-4.64]). this study underlined that indonesia might need a different approach to ckd prevention program, that is not only focusing on the traditional risk factors (i.e., diabetes, hypertension, etc.) but also to include the communicable diseases, such as hepatitis.9 since 2022, the ministry of health has initiated a health transformation program to improve the health system, to address health disparities, both within the country and between countries. there are six pillars of health transformations. first is transformation of primary services, which put more emphasis on promotive and preventive efforts. this aims to provide education related to disease prevention, and also to increase the capacity and capability of health workers in primary care. second is transformation of referral services, focuses on increasing access and equitable distribution of health services in all regions in indonesia. third, the health resilience system which includes efforts to increase resilience in medical response and strengthen resilience during health crises. fourth, transformation of health financing system to develop health financing regulations with the aim of building equity, easy accessibility for the community, and sustainability of financing allocations. fifth, transformation of health human resources, to improving the quality of human resources ensuring and ensuring an even distribution of health workers in all over indonesia. lastly, transformation of health technology to encourages technological development and digitization in the health sector.11 one of the health transformation programs which specify in nephrology care is the implementation of the uro-nephrology support program (program pengampuan uro-nefrologi), with the aim to strengthen services, provide equal distribution of services and increase the latest technology for the diagnosis and treatment of urology/nephrology diseases in indonesia. this program included secondary and tertiary care to improve the extent and quality of care to slowing the ckd progression, improving kidney replacement therapy (hemodialysis, peritoneal dialysis, and kidney transplant) access and treatment, as well as to provide dialysis training program for health care workers. providing high-quality nephrology care that all indonesians can access is challenging. yet, steps have already been taken in the direction of service enhancement. thus, there is hope for better kidney health in indonesia. governments, academic medical centres, nephrology societies, as well as the citizen will all need to work together and take consistent effort to make a sustainable and comprehensive kidney care. references 1. levey as, coresh j. chronic kidney disease. lancet. 2012;379:165-80. 2. mills kt, xu y, zhang w, et al. a systematic analysis of worldwide population-based data on the global burden of chronic kidney disease in 2010. kidney int. 2015;88(5):950-7. doi: 10.1038/ki.2015.230. 3. the national institute of health research and development, indonesian ministry of health. laporan riset kesehatan dasar (riskesdas) 2013. jakarta: indonesian ministry of health; 2013. 4. the national institute of health research and development, indonesian ministry of health. laporan riset kesehatan dasar (riskesdas) 2018. jakarta: indonesian ministry of health; 2018. 5. indonesian society of nephrology. 11th annual report of indonesian renal registry 2018. bandung: indonesian society of nephrology; 2018. 6. indonesian ministry of health. indonesian health profile 2021. jakarta: indonesian ministry of health; 2021. 7. siswati t, paramashanti ba, rialihanto mp, waris l. epidemiological transition in indonesia and its prevention: a narrative review. jocamr. 2022;18(1):50-60. doi: http://doi.org/10.9734/ jocamr/2022/v18i130345. 8. the national institute of health research and development, indonesian ministry of health. laporan riset kesehatan dasar (riskesdas) 2007. jakarta: indonesian ministry of health; 2007. 9. hustrini nm, susalit e, rotmans ji. prevalence and vol 55 • number 1 • january 2023 chronic kidney disease care in indonesia 3 risk factors for chronic kidney disease in indonesia: an analysis of the national basic health survey 2018. j glob health. 2022:12;04074. 10. lydia a, rachmaningrum g, shatri h, nugroho p. factors associated with late referral in end stage renal disease patents at dr. rsupn cipto mangunkusumo hospital. j penyakit dalam indones. 2020;7(2):110-6. 11. transformasi kesehatan indonesia. kementerian kesehatan indonesia. https://d3v.kemkes.go.id/id/ layanan/transformasi-kesehatan-indonesia. accessed march 1, 2023. 397acta med indones indones j intern med • vol 53 • number 4 • october 2021 original article positive deviance: frequent blood pressure monitoring among non-hypertensive middle-aged women in rural indonesia mayumi mizutani1*, heri sugiarto2, harumi bando3, riyanto2, izumi kondo4, jeremiah mock5 1 department of public health nursing, mie university graduate school of medicine, mie, japan. 2 indramayu college of health science, indramayu, indonesia. 3 faculty of nursing, school of medicine, nara medical university, nara, japan. 4 master’s program in design, graduate school of comprehensive human sciences, university of tsukuba, ibaraki, japan. 5 institute for health & aging and the department of social and behavioral sciences, university of california, san francisco, san francisco, california, usa. *corresponding author: mayumi mizutani, department of public health nursing, mie university graduate school of medicine, 2-174 edobashi, tsu, mie 514-8507, japan. email: m-mizutani@med.mie-u.ac.jp. abstract background: in indonesia, as in many low and middle-income countries, hypertension is a significant health issue. community health nurses need to identify those with early onset of hypertension by promoting frequent blood pressure (bp) checks, even among those with normal bp. positive deviance approaches focus on identifying people who undertake uncommon preventive actions. among middle-aged women in rural west java, indonesia, we aimed to identify covariates of the positive deviant practice of having one’s bp checked at least once every three months even when having normal bp. methods: we conducted a cross-sectional survey recruiting participants at health centers. our structured questionnaire measured socio-demographic characteristics, frequency of bp checks, bmi, beliefs and practices. we used binomial logistic regression to identify covariates. results: among 520 participants, 265 had normal bp, and of those 156 had obtained frequent bp checks, making them positive deviants. for women with normal bp, significant covariates of obtaining frequent bp checks were: 1) having bmi ≥25.0 (adjusted odds ratio (aor) =2.57, 95% confidence interval (ci)=1.39–4.78), 2) greater tendency to seek health information (aor=1.13, 95% ci=1.03–1.24), 3) receiving less support from family members (aor=0.87, 95% ci=0.77–0.97), and 4) receiving greater support from health volunteers (aor=1.12, 95% ci=1.01–1.23). conclusion: positive deviants were more likely to be proactive because of the convergence of their own individual-level tendencies to learn about their health, family-level conditions that allowed for greater autonomy, and community-level capacity of health volunteers to provide them with support. community health nurses should focus simultaneously on activating individual-level, family-level, and community-level capacity to prevent hypertension. keywords: blood pressure screening, middle-aged, women, rural, positive deviance. mayumi mizutani acta med indones-indones j intern med 398 introduction in lowand middle-income countries (lmics), large proportions of populations have undiagnosed hypertension.1 frequent blood pressure (bp) checks are an important modifiable health practice for preventing and controlling hypertension, and thus reducing subsequent complications. in high-income countries, the importance of home-based self-monitoring of bp to reduce and control bp is well established in the literature.2, 3 frequent home bp monitoring is associated with decreased cardiovascular events and mortality.4-6 in lmics, many people in rural communities have limited access to preventative screening through home bp monitoring devices.7, 8 in limited-resource settings in lmics, here is an urgent need to facilitate frequent bp checks, particularly in at-risk populations.9 worldwide, several factors have been found to be associated with frequency of bp checks. less frequent bp checks have been associated with socio-demographic characteristics such as lower education,10 lower income,11,12 not having hypertension,11,13 and living in a rural area.12 indonesia has an extensive network of pusat kesehatan masyarakat: puskesmas (community health centers) and pos pelayanan terpadu: posyandu (health posts) that provide monthly preventive healthcare services, including checking bp.14 however, in indonesia as in many lmics, little is known about factors that effectively promote frequent bp checks. in community health, researchers have recently taken more interest in studying positive deviance.15,16 positive deviants are individuals who deviate substantially from the norm in that they engage in uncommon favorable behaviors, practices or habits despite living in the same group as the majority or facing the same difficult conditions as the majority.17 the positive deviance approach to health promotion focuses on studying and highlighting people who successfully discover solutions based on assets in their communities.17 the approach of studying positive deviants can be applied even in limited resource settings because in some cases the solutions are within the community. the first step in this approach is to identify positive deviants, and then study what they are doing and why. in this study, in rural communities in west java, indonesia we sought locate and study middle-aged women who were positive deviants in that they had obtained frequent bp checks even though they had normal bp. hypertension prevention in middle-aged women is important because they may experience increased arterial stiffness due to estrogen decrease, which leads to increased blood pressure.18,19 the purpose of this study was to identify covariates of practicing frequent bp checks among these nonhypertensive women. methods study design, sample, and operational definition of positive deviants in a rural district of west java, indonesia, in december 2016, we conducted a cross-sectional survey. we recruited 530 middle-aged female participants from two community health centers. inclusion criteria were: 1) self-identifying as female, 2) ages 40-64, and 3) living in one of the communities in the district. exclusion criterion was: not agreeing with participation in the study. having a healthcare professional check one’s bp once or more every three months is recommended by the indonesian ministry of health. we developed and administered a structured paper-and-pencil questionnaire in bahasa indonesia language. we collected data by having research assistants ask a participant face-to-face each questionnaire item and then recording the participant’s answers on the questionnaires because some of the participants had somewhat low levels of formal education.20 research assistants who were nursing students or public health students in a bachelor’s degree program in the district collected all of the data. the researchers trained the research assistants on the study aims, methods, ethical considerations, and personal safety. the two research assistants worked as a pair to double-check that they were following the protocol correctly. during data collection, whenever the research assistants had questions they contacted the investigators for clarification. we measured the outcome variable based on the intersection of two variables. first, we vol 53 • number 4 • october 2021 positive deviance: frequent blood pressure monitoring 399 assessed current bp based on the medical record where normal bp was defined as systolic below 140 mmhg and diastolic bp below 90 mmhg based on the current indonesian guidelines for management of hypertension in cardiovascular disease.21 second, we measured frequency of bp checks using a five-point likert-type scale of 1 = never, 2 = have ever, 3 = once a year, 4 = once in three months, and 5 = once a month. we classified cases as positive deviants if they had normal bp and had checked their bp at least once in three months.22 questionnaire items measured participants’ age, level of educational attainment, occupation, monthly family income, and whether or not they had health insurance. we also asked participants to respond to 47 statements using either a fourpoint likert scale (1 = never to 4 = routinely) or a five-point likert scale (1 = strongly disagree to 5 = strongly agree). we grouped the 47 statements for form composite measures of 1) seeking health information, 2) receiving support from family members, 3) receiving support from health volunteers, 4) receiving support from health professionals, 5) caring about others, 6) practices based on prior experiences, 7) motivated to practice healthful behaviors, 8) sense of competence, 9) devout spiritual practice, and 10) belief in allah’s gifts (see specific items and grouping in supplementary table). for logistic regression modeling, a standard recommendation is to have at least 10 observations for each variable entered in a model.23-25 our instrument contains 17 explanatory variables, thus requiring a sample size of 170 for each group (hypertensive and non-hypertensive). ethics approvals and consent to participate informed consent was obtained from the all participants prior to the collection of the data. we explained all the eligible participants about the purpose and procedures of the study, voluntary participation, confidentiality, and right to withdrawal. we submitted our research protocol and a request for permission to conduct this study to badan kesatuan bangsa, politik dan perlindungan masyarakat (the agency for national unity, politics, and community protection) and the dinas kesehatan kabupaten (the district health office), and permissions were obtained in 2016 (no.37/070/rekomlit/ kesbangpol/2016, no.070/1727/um.peg, respectively). ethical approval for this study was received from the research ethics committee of shiga university of medical science, japan in 2016 (no.28-068). data analysis we excluded respondents from our analysis if data was missing for frequency of bp checks. we first calculated descriptive statistics for all variables. then, we conducted bivariate analyses using chi-square tests and unpaired t-tests by comparing participants of each group (normal bp, elevated bp, and total) based on their status (frequent bp checks vs. less-frequent bp checks) against the socio-demographic characteristics and other covariates. we then conducted univariate and multivariate analyses by specifying logistic regression models to identify covariates of frequent bp checks for each group (normal bp, elevated bp, and total) while controlling for potential confounding variables. we calculated the crude and adjusted odds ratios (or and aor) for each variable. statistical analyses were performed using ibm spss statistics 26.0 for windows. significance levels were set at p < 0.05 for all tests. for logistic regression models, significance levels were assessed by 95% confidence interval (ci). results participants’ characteristics of the 530 people we attempted to recruit, 100% agreed to participate in the study. we excluded 10 from analysis because of missing data of blood pressure check frequency. among the 520 participants, 265 had normal bp, and 255 had elevated bp. of those with normal bp, 156 were positive deviants (30% of the total sample). the mean age of the sample was 51.2 years (sd = 7.3 years). more than half of the participants had not completed primary school (58.1%) and had limited monthly family income (56.7%). the proportion of frequent bp checks was higher among participants with elevated bp status (69.8%) than among those with normal bp status (58.9%) (table 1). among those with normal bp, univariate analysis shows that mayumi mizutani acta med indones-indones j intern med 400 (aor=1.07, 95% ci=1.01–1.14), not receiving support from family members (aor=0.90, 95% ci=0.84–0.96), and receiving a lot of support from health volunteers (aor=1.10, 95% ci=1.03–1.18). discussion this study is the first to apply the concept of positive deviance to examine frequency of bp checks in an lmic. in among middle-aged women living a rural district in indonesia, we found that 30.0% of participants met our definition of being positive deviants i.e., those with normal bp who obtained bp checks at least once or more every three months. this proportion was similar to proportions identified in other public health studies on positive deviants.26-28 our study showed that those women with normal bp who had high bmi scores (≥25.0) were about two and a half times more likely to have their bp checked frequently. this suggests that many women in our study who had normal bp but were overweight realized that their excess weight was a substantial risk factor for developing hypertension. previous studies have shown that self-care for bp checks is associated with having relevant knowledge and health awareness.29,30 our study shows that middle-aged rural indonesian women with normal bp who obtained bp checks frequently had a stronger tendency to seek health information from family, friends, health volunteers, health centers, and health posts. it is important for health professionals not only to provide knowledge, but also to support people seeking and obtaining health information by themselves. further study is necessary to explore deeply what kind of information, which sources, and how people seek information. our study identified another covariate for being a positive deviant – receiving support from health volunteers in the forms of expressing concern and encouragement, giving suggestions, and accompanying women when they needed to visit healthcare facilities. in rural indonesia, a community health volunteer is a person chosen by community members who takes on the role of mobilizing their community to use basic health services like those provided at community health the mean of aggregated scores for those who checked their bp frequently was significantly greater than for those who checked their bp less frequently for measures of seeking health information (16.4 vs. 14.9), receiving support from health volunteers (19.2 vs. 17.8), receiving support from health professionals (16.3 vs. 15.4) and caring about others (9.5 vs. 8.9) (table 2). for those with elevated bp, the only significant difference was for measures of practices based on prior experiences (15.7 vs. 14.9). covariates of frequent bp checks a preliminary univariate logistic regression revealed that middle-aged women with elevated bp were more likely to obtain frequently bp checks (or=1.62, 95% ci =1.12–2.32) (table 3). to run multivariate logistic regression models, we created an outcome variable of frequency of bp checks (0 = less than once in 3 months, 1 = once or more in 3 months), and then we ran fully specified models to identify covariates. among women with normal bp, models revealed that after controlling for age, bmi (which was a significant covariate with bmi ≥ 25 having an aor=2.57, 95% ci=1.39–4.78), educational level, occupation, income, and health insurance status, participants with normal bp were significantly more likely to have had their bp checked every 3 months if they had higher aggregate scores on seeking health information (aor =1.13, 95% ci=1.03–1.24), receiving a lot of support from health volunteers (aor=1.12, 95% ci=1.01–1.23) and less likely if they had received a lot of support from family members (aor=0.87, 95% ci=0.77–0.97). we conducted analyses using data from women who had elevated bp (n = 255). fully specified logistic regression models revealed that for women with elevated bp, the only statistically significant covariate of women with elevated bp getting a bp check once or more every 3 months was having not received a lot of support from family members (aor=0.89, 95% ci=0.81–0.98). bmi was not a significant covariate. additional logistic regression analysis of the total sample (n = 520) revealed that bmi ≥25.0 and moderate household income were significant covariates of having frequent bp checks, along with seeking health information vol 53 • number 4 • october 2021 positive deviance: frequent blood pressure monitoring 401 ta bl e 1. p ar tic ip an t c ha ra ct er is tic s n or m al b p (n = 2 65 ) e le va te d b p (n = 2 55 ) to ta l ( n = 5 20 ) c he ck ed b p fr eq ue nt ly le ss fr eq ue nt c he ck ed b p fr eq ue nt ly le ss fr eq ue nt c he ck ed b p fr eq ue nt ly le ss fr eq ue nt (n = 1 56 , 5 8. 9% ) (n = 1 09 , 4 1. 1% ) (n = 1 78 , 6 9. 8% ) (n = 7 7, 3 0. 2% ) (n = 3 34 , 6 4. 2% ) (n = 1 86 , 3 5. 8% ) n % n % p n % n % p n % n % p b p s ta tu s 0. 00 9 n or m al b p – – – – – – – – 15 6 58 .9 10 9 41 .1 e le va te d b p – – – – – – – – 17 8 69 .8 77 30 .2 a ge g ro up 0. 98 6 0. 93 3 0. 93 9 4 0– 49 y ea rs 74 58 .7 52 41 .3 55 71 .4 22 28 .6 12 9 63 .5 74 36 .5 5 0– 59 y ea rs 60 59 .4 41 40 .6 69 69 .0 31 31 .0 12 9 64 .2 72 35 .8 6 0– 64 y ea rs 22 57 .9 16 42 .1 54 69 .2 24 30 .8 76 65 .5 40 34 .5 b m i 0. 00 3 0. 56 5 0. 00 4 < 18 .5 9 56 .3 7 43 .8 4 80 .0 1 20 .0 13 61 .9 8 38 .1 1 8. 5– 24 .9 52 47 .3 58 52 .7 62 66 .0 32 34 .0 11 4 55 .9 90 44 .1 ≥ 25 .0 93 68 .9 42 31 .1 11 1 71 .6 44 28 .4 20 4 70 .3 86 29 .7 e du ca tio n 0. 72 7 0. 03 1 0. 24 9 n ot c om pl et ed p rim ar y sc ho ol 77 56 .6 59 43 .4 10 8 65 .1 58 34 .9 18 5 61 .3 11 7 38 .7 c om pl et ed p rim ar y sc ho ol 50 61 .0 32 39 .0 40 71 .4 16 28 .6 90 65 .2 48 34 .8 c om pl et ed m id dl e sc ho ol 14 56 .0 11 44 .0 19 95 .0 1 5. 0 33 73 .3 12 26 .7 c om pl et ed h ig h sc ho ol o r ab ov e 15 68 .2 7 31 .8 10 83 .3 2 16 .7 25 73 .5 9 26 .5 o cc up at io n 0. 34 0 0. 07 5 0. 05 9 h ou se w ife 10 2 61 .1 65 38 .9 11 8 73 .8 42 26 .3 22 0 67 .3 10 7 32 .7 o th er w or k 54 55 .1 44 44 .9 60 63 .2 35 36 .8 11 4 59 .1 79 40 .9 in co m e (in do ne si an ru pi ah ) 0. 13 2 0. 06 1 0. 01 6 < 1 m ill io n 86 60 .6 56 39 .4 11 4 74 .5 39 25 .5 20 0 67 .8 95 32 .2 ≥ 1 m ill io n – <2 m ill io n 51 53 .1 45 46 .9 56 60 .9 36 39 .1 10 7 56 .9 81 43 .1 ≥ 2 m ill io n 18 75 .0 6 25 .0 8 80 .0 2 20 .0 26 76 .5 8 23 .5 h av in g he al th in su ra nc e 0. 19 8 0. 70 2 0. 17 2 n o 70 54 .7 58 45 .3 74 68 .5 34 31 .5 14 4 61 .0 92 39 .0 y es 85 62 .5 51 37 .5 10 4 70 .7 43 29 .3 18 9 66 .8 94 33 .2 c hi -s qu ar e te st mayumi mizutani acta med indones-indones j intern med 402 ta bl e 2. u ni va ri at e as so ci at io ns w ith fr eq ue nt b p c he ck -u ps n or m al b p (n = 2 65 ) e le va te d b p (n = 2 55 ) to ta l ( n = 5 20 ) c he ck ed b p fr eq ue nt ly le ss fr eq ue nt c he ck ed b p fr eq ue nt ly le ss fr eq ue nt c he ck ed b p fr eq ue nt ly le ss fr eq ue nt (n = 1 56 , 5 8. 9% ) (n = 1 09 , 4 1. 1% ) (n = 1 78 , 6 9. 8% ) (n = 7 7, 3 0. 2% ) (n = 3 34 , 6 4. 2% ) (n = 1 86 , 3 5. 8% ) m ea n s d m ea n s d p m ea n s d m ea n s d p m ea n s d m ea n s d p s ee ki ng h ea lth in fo rm at io n (r an ge 7 –2 8) 16 .4 3. 8 14 .9 4. 0 0. 00 1 15 .5 4. 0 15 .6 3. 8 0. 86 0 15 .9 3. 9 15 .2 3. 9 0. 03 2 s up po rt fro m fa m ily m em be rs (r an ge 7 –3 5) 28 .3 3. 0 28 .7 3. 2 0. 26 1 27 .0 4. 5 27 .7 5. 0 0. 23 6 27 .6 4. 0 28 .3 4. 1 0. 04 7 s up po rt fro m h ea lth v ol un te er s (r an ge 5– 25 ) 19 .2 3. 1 17 .8 4. 1 0. 00 2 18 .2 3. 4 17 .5 3. 8 0. 13 9 18 .7 3. 3 17 .7 4. 0 0. 00 3 s up po rt fro m h ea lth p ro fe ss io na ls (r an ge 4– 20 ) 16 .3 2. 1 15 .4 2. 9 0. 00 4 15 .6 2. 7 15 .7 2. 7 0. 73 8 15 .9 2. 5 15 .5 2. 8 0. 09 9 c ar in g ab ou t o th er s (r an ge 4 –1 6) 9. 5 2. 0 8. 9 2. 1 0. 01 5 8. 8 1. 9 9. 1 2. 4 0. 30 4 9. 1 2. 0 8. 9 2. 2 0. 45 7 p ra ct ic es b as ed o n pr io r e xp er ie nc es (r an ge 4 –2 0) 15 .2 3. 0 15 .0 2. 7 0. 52 7 15 .7 2. 1 14 .9 2. 6 0. 01 0 15 .5 2. 6 14 .9 2. 7 0. 01 7 m ot iv at ed to p ra ct ic e he al th fu l b eh av io rs (r an ge 5 –2 5) 21 .7 1. 9 21 .5 2. 0 0. 25 6 21 .4 2. 0 21 .1 2. 5 0. 33 7 21 .6 1. 9 21 .3 2. 2 0. 17 8 s en se o f c om pe te nc e (r an ge 3 –1 5) 12 .4 1. 2 12 .4 1. 3 0. 87 8 12 .2 1. 5 12 .0 1. 7 0. 38 4 12 .3 1. 3 12 .2 1. 5 0. 65 8 d ev ou t s pi rit ua l p ra ct ic e (r an ge 4 –1 6) 10 .7 2. 8 10 .1 2. 8 0. 09 3 10 .7 3. 1 10 .4 2. 9 0. 41 4 10 .7 3. 0 10 .2 2. 8 0. 06 6 b el ie f i n a lla h' s gi fts (r an ge 4 –2 0) 18 .1 1. 8 18 .1 1. 8 0. 96 3 18 .1 1. 9 18 .3 1. 7 0. 43 5 18 .1 1. 9 18 .2 1. 7 0. 60 6 u np ai re d tte st vol 53 • number 4 • october 2021 positive deviance: frequent blood pressure monitoring 403 ta bl e 3. l og is tic r eg re ss io n m od el id en tif yi ng p re di ct or s of fr eq ue nt b p c he ck -u ps o ut co m e va ri ab le : f re qu en cy o f b p c he ck -u ps (0 = le ss th an o nc e in 3 m on th s, 1 = o nc e or m or e in 3 m on th s) n or m al b p (n = 2 65 ), n ag el ke rk e r 2 = 0 .2 32 e le va te d b p (n = 2 55 ), n ag el ke rk e r 2 = 0 .1 99 to ta l ( n = 5 20 ), n ag el ke rk e r 2 = 0 .1 69 u na dj us te d a dj us te d u na dj us te d a dj us te d u na dj us te d a dj us te d o r 95 % c i p a o r 95 % c i p o r 95 % c i p a o r 95 % c i p o r 95 % c i p a o r 95 % c i p b p s ta tu s n or m al b p – – – – – – – – – – – – – – – – 1. 00 1. 00 e le va te d b p – – – – – – – – – – – – – – – – 1. 62 1. 12 – 2. 32 0. 01 0 1. 54 1. 01 – 2. 36 0. 04 7 a ge g ro up 4 0– 49 y ea rs 1. 00 1. 00 1. 00 1. 00 1. 00 1. 00 5 0– 59 y ea rs 1. 03 0. 50 – 2. 16 0. 92 7 0. 93 0. 36 – 2. 40 0. 87 7 1. 11 0. 56 – 2. 21 0. 76 5 0. 76 0. 28 – 2. 10 0. 59 7 1. 03 0. 68 – 1. 54 0. 89 5 1. 30 0. 76 – 2. 22 0. 33 5 6 0– 64 y ea rs 1. 06 0. 50 – 2. 27 0. 87 2 1. 27 0. 51 – 3. 16 0. 60 4 0. 99 0. 52 – 1. 88 0. 97 4 1. 01 0. 47 – 2. 17 0. 98 6 1. 09 0. 68 – 1. 76 0. 72 4 1. 31 0. 69 – 2. 50 0. 40 6 b m i < 1 8. 5 1. 43 0. 50 – 4. 12 0. 50 4 1. 99 0. 61 – 6. 49 0. 25 6 2. 06 0. 22 – 19 .2 5 0. 52 5 2. 83 0. 23 – 34 .4 3 0. 41 4 1. 28 0. 51 – 3. 23 0. 59 7 1. 82 0. 67 – 4. 95 0. 23 8 1 8. 5– 24 .9 1. 00 1. 00 1. 00 1. 00 1. 00 1. 00 ≥ 25 .0 2. 47 1. 46 – 4. 16 0. 00 1 2. 57 1. 39 – 4. 78 0. 00 3 1. 30 0. 75 – 2. 26 0. 34 8 1. 02 0. 54 – 1. 95 0. 94 5 1. 87 1. 29 – 2. 72 0. 00 1 1. 67 1. 10 – 2. 55 0. 01 7 e du ca tio n n ot c om pl et ed p s 1. 00 1. 00 1. 00 1. 00 1. 00 1. 00 c om pl et ed p s 0. 61 0. 23 – 1. 59 0. 31 1 0. 49 0. 14 – 1. 74 0. 27 1 0. 37 0. 08 – 1. 76 0. 21 2 0. 22 0. 04 – 1. 25 0. 08 8 1. 19 0. 78 – 1. 80 0. 42 6 1. 38 0. 80 – 2. 36 0. 24 7 c om pl et ed j h s 0. 73 0. 27 – 1. 98 0. 53 6 0. 53 0. 15 – 1. 84 0. 31 8 0. 50 0. 10 – 2. 54 0. 40 3 0. 48 0. 09 – 2. 71 0. 40 7 1. 74 0. 86 – 3. 50 0. 12 1 2. 24 0. 95 – 5. 30 0. 06 7 c om pl et ed h s o r a bo ve 0. 59 0. 18 – 1. 96 0. 39 3 0. 52 0. 12 – 2. 28 0. 38 4 3. 80 0. 31 – 47 .2 1 0. 29 9 3. 53 0. 24 – 50 .8 7 0. 35 4 1. 76 0. 79 – 3. 90 0. 16 5 2. 45 0. 95 – 6. 30 0. 06 3 o cc up at io n o th er w or ks 1. 00 1. 00 1. 00 1. 00 1. 00 1. 00 h ou se w ife 1. 28 0. 77 – 2. 12 0. 34 0 0. 99 0. 53 – 1. 83 0. 96 2 1. 64 0. 95 – 2. 83 0. 07 6 1. 29 0. 68 – 2. 46 0. 43 5 1. 42 0. 99 – 2. 06 0. 06 0 1. 12 0. 73 – 1. 71 0. 60 4 in co m e < 1 m ill io n 1. 00 1. 00 1. 00 1. 00 1. 00 1. 00 ≥ 1 m ill io n – <2 m ill io n 0. 51 0. 19 – 1. 37 0. 18 2 0. 77 0. 23 – 2. 53 0. 66 5 0. 73 0. 15 – 3. 59 0. 69 9 1. 78 0. 28 – 11 .2 1 0. 54 1 0. 63 0. 43 – 0. 92 0. 01 6 0. 57 0. 36 – 0. 89 0. 01 4 ≥ 2 m ill io n 0. 38 0. 14 – 1. 03 0. 05 8 0. 47 0. 14 – 1. 56 0. 21 9 0. 39 0. 08 – 1. 94 0. 24 9 0. 90 0. 14 – 5. 63 0. 90 8 1. 54 0. 67 – 3. 54 0. 30 5 1. 16 0. 45 – 2. 99 0. 76 0 h av in g he al th in su ra nc e n o 1. 00 1. 00 1. 00 1. 00 1. 00 1. 00 y es 1. 38 0. 84 – 2. 26 0. 19 8 1. 69 0. 93 – 3. 05 0. 08 5 1. 11 0. 65 – 1. 91 0. 70 2 1. 11 0. 59 – 2. 06 0. 74 9 1. 28 0. 90 – 1. 84 0. 17 3 1. 40 0. 93 – 2. 11 0. 11 0 s ee ki ng h ea lth in fo rm at io n (r an ge 7 –2 8) 1. 11 1. 04 – 1. 19 0. 00 2 1. 13 1. 03 – 1. 24 0. 01 3 0. 99 0. 93 – 1. 06 0. 86 0 1. 05 0. 96 – 1. 15 0. 32 3 1. 05 1. 00 – 1. 10 0. 03 2 1. 07 1. 01 – 1. 14 0. 02 4 s up po rt fro m fa m ily m em be rs (r an ge 7– 35 ) 0. 95 0. 88 – 1. 03 0. 26 1 0. 87 0. 77 – 0. 97 0. 01 2 0. 96 0. 90 – 1. 03 0. 23 8 0. 89 0. 81 – 0. 98 0. 01 5 0. 95 0. 91 – 1. 00 0. 05 0 0. 90 0. 84 – 0. 96 0. 00 1 s up po rt fro m h ea lth v ol un te er s (r an ge 5– 25 ) 1. 12 1. 04 – 1. 20 0. 00 2 1. 12 1. 01 – 1. 23 0. 03 1 1. 06 0. 98 – 1. 14 0. 14 0 1. 11 0. 99 – 1. 23 0. 07 5 1. 08 1. 03 – 1. 14 0. 00 2 1. 10 1. 03 – 1. 18 0. 00 7 s up po rt fro m h ea lth p ro fe ss io na ls (r an ge 4– 20 ) 1. 17 1. 05 – 1. 31 0. 00 4 1. 04 0. 90 – 1. 22 0. 57 6 0. 98 0. 89 – 1. 09 0. 73 7 1. 00 0. 86 – 1. 16 0. 99 9 1. 06 0. 99 – 1. 13 0. 09 0 1. 01 0. 92 – 1. 12 0. 76 8 c ar in g ab ou t o th er s (r an ge 4 –1 6) 1. 16 1. 03 – 1. 31 0. 01 7 1. 02 0. 86 – 1. 22 0. 80 5 0. 93 0. 81 – 1. 06 0. 26 2 0. 93 0. 78 – 1. 10 0. 39 3 1. 03 0. 95 – 1. 13 0. 44 0 1. 02 0. 91 – 1. 14 0. 72 8 p ra ct ic es b as ed o n pr io r e xp er ie nc es (r an ge 4 –2 0) 1. 03 0. 94 – 1. 12 0. 52 5 0. 99 0. 88 – 1. 11 0. 87 5 1. 18 1. 05 – 1. 32 0. 00 6 1. 18 1. 00 – 1. 40 0. 05 4 1. 09 1. 01 – 1. 16 0. 01 8 1. 05 0. 95 – 1. 15 0. 33 2 m ot iv at ed to p ra ct ic e he al th fu l b eh av io rs (r an ge 5 –2 5) 1. 08 0. 95 – 1. 23 0. 25 5 1. 12 0. 92 – 1. 37 0. 27 0 1. 07 0. 94 – 1. 21 0. 29 4 1. 03 0. 87 – 1. 21 0. 72 2 1. 06 0. 97 – 1. 16 0. 17 8 1. 07 0. 95 – 1. 20 0. 27 2 s en se o f c om pe te nc e (r an ge 3 –1 5) 1. 02 0. 83 – 1. 25 0. 87 7 0. 97 0. 73 – 1. 30 0. 86 0 1. 08 0. 91 – 1. 28 0. 38 4 1. 02 0. 81 – 1. 29 0. 86 4 1. 03 0. 90 – 1. 17 0. 65 7 1. 05 0. 88 – 1. 25 0. 58 4 b el ie f i n a lla h' s gi fts (r an ge 4 –2 0) 1. 00 0. 87 – 1. 14 0. 96 3 0. 96 0. 78 – 1. 19 0. 70 9 0. 94 0. 81 – 1. 10 0. 45 4 0. 88 0. 73 – 1. 07 0. 20 1 0. 97 0. 88 – 1. 08 0. 61 2 0. 91 0. 80 – 1. 03 0. 14 2 d ev ou t s pi rit ua l p ra ct ic e (r an ge 4 –1 6) 1. 08 0. 99 – 1. 18 0. 09 4 1. 06 0. 96 – 1. 18 0. 26 7 1. 04 0. 95 – 1. 13 0. 41 3 1. 06 0. 95 – 1. 18 0. 31 9 1. 06 1. 00 – 1. 13 0. 06 7 1. 07 1. 00 – 1. 15 0. 05 4 mayumi mizutani acta med indones-indones j intern med 404 posts.31 in indonesia, there is a wide network of community-level health centers and health posts that emphasize prevention, early detection, and control of ncds where community members can receive bp checks as well as counseling and health education.14 the benefits communities receive from the work of non-professional lay health workers have been shown in indonesia and other lmics.32 a randomized controlled trial in lmics showed an effect of lifestyle intervention by female community health volunteers on controlling bp.33 health professionals need to work more closely with health volunteers to support community members’ health practices. further study is also needed in indonesia to learn more about how health volunteers support community members. for women with normal bp, those who received higher levels of family support were less likely to have their bp checked frequently. in rural west java, middle-aged women’s lives are often embedded within a context of strong family bonds. providing care for older female family members is an important family value rooted in culture and religion.34 younger family members, particularly younger women, are highly involved in taking care of their older female family members by attending to their physical symptoms and spiritual needs.35,36 when middle-aged women live in such a highly supportive family environments, they may feel reluctant to have their bp checked frequently at health centers, health posts, or clinics because they may assume that their family members who take care of them know what is best and are doing what is necessary to care for their health. conversely, those middle-aged women who need to be more self-reliant in terms of looking out for their own health may be more likely to seek care outside of their family circles consistently, and therefore may have a greater tendency to have their bp checked more frequently. this is one possible explanation for the association between middle-aged women with normal bp obtaining frequent bp checks and receiving less support from family members. in our additional analysis of covariates of frequent bp checks among middle-aged women with elevated bp, we also found the association between receiving less family support and obtaining frequent bp checks, suggesting that this may be a universal factor. our analysis showed some indication that women with elevated bp who had practices based on their own prior experiences or those of others they knew were more likely to obtain frequent bp checks. if women with elevated bp heard about someone whose health status deteriorated for example because of a stroke due to uncontrolled hypertension, they might be able to imagine their health could deteriorate similarly and have fear about not knowing their bp levels. community people have a right over their healthcare decisions.37 in lmics that lack health check systems based on the law, community members have to make decisions by themselves about whether and when to go have health checks. our findings suggest that it is important to provide health information based on peers’ experiences. other studies have mentioned the importance of narratives or storytelling by peers to motivate community members.38 further study is needed to find out what types of information about peers’ experiences will motivate middle-aged indonesian women in rural areas to have their bp checked more frequently. there were some limitations to this study. because the data are cross-sectional, we cannot assert that there were causal relationships between the frequency of a woman getting her bp checked and the covariates identified in our analysis. longitudinal studies are necessary to determine whether the associations we identified are causal. in addition, it is important to explore how positive deviants get their bp checked frequently. future research using qualitative methods should be conducted to examine the processes middle-aged women in these communities engage in to have their bp checked frequently. another limitation is about selection bias because we conducted a study in one district. we need to conduct further study to examine the situation of bp checks and their covariates in rural indonesia. conclusion in rural west java of indonesia, as is likely to be the case in many rural places in lmics, vol 53 • number 4 • october 2021 positive deviance: frequent blood pressure monitoring 405 middle-aged women who have not developed hypertension appear to benefit in monitoring their bp frequently when they tend to seek health information in a context when they have somewhat greater health autonomy within their families, and when they can receive support from health volunteers. the convergence of these three factors shows the importance of understanding what needs to happen simultaneously at the individual level, the family level, and the community level so that preventive positive deviant practices become the norm. our findings can be used to inform health promotion on bp screening. activating factors simultaneously at the individual, family, and community levels is the first step for developing community health nursing approaches for primary hypertension prevention. acknowledgments we are grateful to the participants in indonesia. we are also grateful to the district health office and the community health centers in indonesia for their cooperation. funding this research was financially supported by the japan society for the promotion of science (jsps) grants-in-aid for scientific research (kakenhi) (grant number: 15h06291). conflict of interest the authors declare that there is no conflict of interest regarding the publication of this paper. references 1. hussain ma, mamun aa, reid c, et al. prevalence, awareness, treatment and control of hypertension in indonesian adults aged ≥40 years: findings from the indonesia family life survey (ifls). plos one. 2016;11(8):e0160922-e. 2. glynn lg, murphy aw, smith sm, et al. interventions used to improve control of blood pressure in patients with hypertension. cochrane database syst rev. 2010(3):cd005182. 3. crabtree mm, stuart-shor e, mcallister m. home blood pressure monitoring: an integrated review of the literature. j nurse pract. 2013;9(6):356-61. 4. fuchs sc, mello rgbd, fuchs fc. home blood pressure monitoring is better predictor of cardiovascular disease and target organ damage than office blood pressure: a systematic review and 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28, 2018. http://www.p2ptm. kemkes.go.id/dokumen-p2ptm/petunjuk-teknis-pospembinaan-terpadu-penyakit-tidak-menular-posbinduptm. 15. pascale r, sternin j, sternin m. the power of positive deviance: how unlikely innovators solve the world’s toughest problems. boston, ma: harvard business school publishing. 2010. 16. banerjee es, herring sj, hurley ke, et al. overcoming obesity: a mixed methods study of the impact of primary care physician counseling on low-income african american women who successfully lost weight. am j health promot. 2018;32(2):374-80. 17. positive deviance collaborative. what is positive mayumi mizutani acta med indones-indones j intern med 406 deviance? n.d. accessed may 4, 2019. https:// positivedeviance.org/. 18. staessen ja, van der heijden-spek jj, safar me, et al. menopause and the characteristics of the large arteries in a population study. j hum hypertens. 2001;15(8):511-8. 19. coylewright m, reckelhoff jf, ouyang p. menopause and hypertension: an age-old debate. hypertension. 2008;51(4):952-9. 20. mizutani m, tashiro j, maftuhah, et al. model development of healthy-lifestyle behaviors for rural muslim indonesians with hypertension: a qualitative study. nurs health sci. 2016;18(1):15-22. 21. perhimpunan dokter spesialis kardiovaskular indonesia [indonesian heart association]. pedoman tatalaksana hipertensi pada penyakit kardiovaskular [guidelines for management of hypertension in cardiovascular disease]. 2015. accessed september 2, 2021 https://inaheart.org/guideline/ 22. direktorat jenderal pengendalian penyakit dan penyehatan lingkungan kementerian kesehatan republik indonesia [directorate general of disease control and environmental health indonesian ministry of health]. profil pengendalian penyakit dan penyehatan lingkungan tahun 2011 [profile of disease control and environmental health 2011]. 2012. accessed may 2, 2014. http://pppl.depkes.go.id/ upt?id=85. 23. hair jf, black wc, babin bj, et al. multivariate data analysis: a global perspective. 7th ed. upper saddle river nj: pearson education; 2010. 24. peduzzi p, concato j, kemper e, et al. a simulation study of the number of events per variable in logistic regression analysis. j clin epidemiol. 1996;49(12):1373-9. 25. long js. regression models for categorical and limited dependent variables. thousand oaks, ca: sage publications 1997. 26. ma p, magnus jh. exploring the concept of positive deviance related to breastfeeding initiation in black and white wic enrolled first time mothers. matern child health j. 2012;16(8):1583-93. 27. wallace me, harville ew. predictors of healthy birth outcome in adolescents: a positive deviance approach. j pediatr adolesc gynecol. 2012;25(5):314-21. 28. marty l, dubois c, gaubard ms, et al. higher nutritional quality at no additional cost among lowincome households: insights from food purchases of “positive deviants”. am j clin nutr. 2015;102(1):190-8. 29. peters rm, templin tn. measuring blood pressure knowledge and self-care behaviors of african americans. res nurs health. 2008;31(6):543-52. 30. diederichs c, neuhauser h. the frequency and determinants of blood pressure measurement by a health professional in germany: a cross-sectional study. medicine (baltimore). 2019;98(16):e15093. 31. k e m e n t e r i a n k e s e h a t a n r e p u b l i k i n d o n e s i a [indonesian ministry of health]. peraturan menteri kesehatan republik indonesia nomor 8 tahun 2019 tentang pemberdayaan masyarakat bidang kesehatan [regulation of the minister of health of the republic of indonesia number 8 of 2019 concerning community empowerment in the field of health] 2019. accessed december 19, 2019. http://promkes.kemkes.go.id/ permenkes-no8-th-2019-tentang-pemberdayaanmasyarakat-bidang-kesehatan. 32. lewin s, munabi-babigumira s, glenton c, et al. lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. cochrane database syst rev. 2010(3):cd004015. 33. neupane d, mclachlan cs, mishra sr, et al. effectiveness of a lifestyle intervention led by female community health volunteers versus usual care in blood pressure reduction (cobin): an openlabel, cluster-randomised trial. lancet glob health. 2018;6(1):e66-e73. 34. kristanti ms, effendy c, utarini a, et al. the experience of family caregivers of patients with cancer in an asian country: a grounded theory approach. palliat med. 2019;33(6):676-84. 35. effendy c, vissers k, tejawinata s, et al. dealing with symptoms and issues of hospitalized patients with cancer in indonesia: the role of families, nurses, and physicians. pain pract. 2015;15(5):441-6. 36. lukman na, leibing a, merry l. self-care experiences of adults with chronic disease in indonesia: an integrative review. int j chronic dis. 2020;2020:1379547. 37. kruk me, gage ad, arsenault c, et al. high-quality health systems in the sustainable development goals era: time for a revolution. lancet glob health. 2018;6(11):e1196-e252. 38. perrier mj, martin ginis ka. changing healthpromoting behaviours through narrative interventions: a systematic review. j health psychol. 2018;23(11):1499517. case report 326 acta medica indonesiana the indonesian journal of internal medicine integrative approach in haemophillic arthropathy of the knee: a case report andri maruli t. lubis1, kurniadi husodo1, lugyanti sukrisman2, djajadiman gatot3 1 department of orthopaedic and traumatology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia 2 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta 3 department of pediatrics, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta. correspondence mail: department of orthopaedic and traumatology, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: andri_lubis@yahoo.com. abstrak haemophilic arthropathy adalah kelainan sendi yang paling sering dijumpai pada penderita hemofili. kelainan tersebut terdiri dari sinovitis kronik dan kerusakan progresif tulang rawan sendi. pada laporan kasus ini disajikan laporan mengenai sinovektomi secara artroskopi pada haemophilic arthropathy untuk mengurangi frekuensi perdarahan sendi. pasien adalah seorang anak laki-laki berusia 15 tahun dengan haemophilic arthropathy pada lutut kiri. kami melakukan arthroscopic synovectomy disertai dengan terapi penggantian faktor viii yang dimonitor intensif. intraoperatif ditemukan hipertrofi sinovial yang membentuk vili pada seluruh bagian sendi, defek tulang dan tulang rawan multipel, serta defisiensi anterior cruciate ligament (acl) dan posterior cruciate ligament (pcl). pada tindak lanjut 6 bulan pascaoperasi, keluhan subjektif dan frekuensi perdarahan jauh berkurang. visual analog scale (vas) membaik dari 5-6 menjadi 1-2 pascaoperasi dan skor international knee documentation committee meningkat dari 49 menjadi 66. frekuensi hemartrosis berkurang dari 4-8 kali per bulan menjadi kurang dari 1 kali per bulan. arthroscopic synovectomy yang dilakukan pada kasus ini mengurangi rasa nyeri, menurunkan frekuensi hemartrosis, dan meningkatkan luaran fungsional. kata kunci: arthroscopic synovectomy, haemophilic arthropathy, hemofilia, anterior cruciate ligament, posterior cruciate ligament. abstract haemophilic arthropathy is the most prevalent joint disorder in haemophilia. this disorder is characterized by chronic synovitis and progressive destruction of joint cartilage. we report a case of arthroscopic synovectomy to reduce bleeding frequency in haemophilic arthropathy of the knee. patient was a 15 years old male with haemophilic arthropathy of the left knee. we performed an arthroscopic synovectomy under tightly regulated factor viii replacement therapy. there were villous synovial hypertrophy at all part of the joint, multiple bone and cartilage defect, and also anterior cruciate ligament (acl) and posterior cruciate ligament (pcl) deficiency found intraoperatively. after 6 month follow up, subjective complain and bleeding frequency decreased significantly. the visual analog scale improved from 5-6 to 1-2, and the international knee documentation committee score increased from 49 to 66. bleeding frequency decreased from 4-8 times per month to less than 1 time per month. vol 47 • number 4 • october 2015 integrative approach in haemophillic arthropathy of the knee arthroscopic synovectomy performed in this case could reduce the pain, decrease the frequency of bleeding, and improve patient’s functional outcome. key words: arthroscopic synovectomy, haemophilic arthropathy, haemophilia, anterior cruciate ligament, posterior cruciate ligament. introduction haemophilia is an x-linked recessive blood coagulation disorder caused by deficiency of coagulation factor viii (haemophilia a) or ix (haemophilia b).1 worldwide prevalence of haemophilia a and b is estimated 1 in 10.000 males and 1 in 25.000 males respectively.2 clinical manifestation of haemophilia a and b is similar. bleeding in the joints (haemarthrosis) is the most frequent musculoskeletal manifestation in people with haemophilia. acute haemarthrosis is characterized by sudden swelling of the joints which may be preceded by prodromal symptoms such as stiffness and pain. with adequate treatment, acute haemarthrosis usually will subside. after repeated bleeding (chronic haemarthrosis) particularly in patients with severe haemophilia, joint abnormalities will progress to chronic synovitis, inflammatory arthritis, and progressive arthropathy.3 this article reports an arthroscopic synovectomy performed in haemophilic arthropathy of the knee with anterior and posterior cruciate ligament deficiency in a 15-year old teenager with haemophilia a. case ilustration a fifteen-year old teenager came to our outpatient clinic with complaint of swelling on his left knee since 2 years before. he was diagnosed as haemophilia a at the age of 5 months, when he had bruises at the skin spontaneously without history of trauma. since then, the patient came routinely to the haematology clinic in our hospital to get factor viii replacement therapy (koate®). factor viii was only given when there was bleeding (on demand), once to twice a month. since 2 years ago, there was slowly progressive swelling on his left knee. the knee was warm, tense, dan tender. the swelling subsided after factor viii replacement therapy was given. the frequency of swelling occurred once a month at the beginning, but became more frequent afterward. the patient was given factor viii replacement therapy only when there was swelling. since 6 months before, the frequency of swelling increased to 1-2 times a week and did not completely resolve after factor viii replacement therapy. the knee was more tense, tender, and stiff, the international knee documentation committee (ikdc) score was 49. patient had a history of intracranial haemorrhage and bleeding from both ears 3 years ago. there was no history of haemophilia in his family. on physical examination, the patient’s body mass index was 16 kg/m2. there was effusion at the left knee with muscle atrophy at the left thigh and lower leg. the knee was warm and tender, with range of motion 10-135o (figure 1). the haemoglobin level was 7 g/dl, activated partial thromboplastin time (aptt) was 84.4 seconds (control: 30.1 seconds). at plain x-ray there were osteoporotic bones with erosion on lateral femoral condyle and the articular surface of patella, subchondral cyst at femoral epiphysis, tibial epiphysis, and medial surface of patella (figure 2). figure 1. preoperative clinical picture of the knee; (a) maximum extension, (b) maximum flexion. our working diagnosis was haemarthrosis with haemophilic arthropathy of the left knee. we performed arthroscopic synovectomy under tightly regulated factor viii replacement therapy. factor viii (koate®) at the dose of 40 u/kgbw (1,440 unit) was given intravenously 12 hours before surgery, followed by 25 u/kgbw/24hours 327 andri maruli t. lubis acta med indones-indones j intern med (900 unit/day) until the bleeding stops. the patient received 450 cc packed cell transfusion before surgery and preoperative haemoglobin level was 10.0 g/dl. after anaesthesia, we performed an intraoperative physical examination, range of motion was 10-135o, varus and valgus stress test was negative, anterior and posterior drawer test was positive, lachman test was +3 (more than 10 mm). during surgery, standard anterolateral, anteromedial, and superolateral arthroscopic portal was created. there was haemarthrosis at the left knee, so an irrigation procedure was performed. we found villous synovial hypertrophy at all parts of the joint (figure 3), anterior cruciate ligament (acl) and posterior cruciate ligament (pcl) deficiency at the intercondylar notch (figure 4a), 4x5 cm bone defect on the lateral femoral condyle (figure 4b), 1x3 cm international cartilage repair society (icrs) grade iv defect at the medial femoral condyle (figure 4c), 4x4 cm icrs grade ii defect at tibial plateau (figure 4d). we shaved the synovium until there was no villous synovial hyperthophy left on the joint area (figure 4e). there was unremarkable during postoperative care. on the next day the patient started to move his left knee, although still felt pain (vas 6-7), range of motion was 45-55o, on sixth day, the pain was decreasing, range of motion was 30-60o, and the patient started to walk using bilateral crutches. on the next day, patient was discharged. patient routinely came to the haematology clinic every three days to get factor viii replacement therapy. three weeks after the surgery patient came to our clinic, pain at the left knee has decreased significantly (vas 2-3) and could walk with a unilateral crutch, range of motion was 2090o (figure 5). the patient got factor viii replacement therapy 15 u/kgbw twice a week. at the sixth week after the operation pain at the left knee was minimal (vas 1-2), he walked without crutch, range of motion was 10-125o (figure 6). postoperative plain x-ray of the left knee taken at 6th week showed similar result to preoperative plain x-ray, that there was efusion, epiphyseal enlargement, osteoporosis, erosion at the lateral figure 2. plain x-ray of the left and right knee; (a) sunrise view, (b) weight bearing anteroposterior view, (c) lateral view. figure 3. synovial hypertrophy at all part of the joint; villous synovial protrusion (asterisk sign), surface of the joint cartilage (plus sign). figure 4. (a) intercondylar notch with acl and pcl deficiency (arrow), (b) bone defect sized 4x5 cm at lateral femoral condyle, (c) icrs grade iv cartilage defect size 1x3 cm at medial femoral condyle, (d) icrs grade ii cartilage defect size 4x4 cm at tibial plateau, (e) after synovectomy, s y n o v i a l m e m b r a n e w i t h o u t v i l l o u s h y p e r t h r o p h y. 328 vol 47 • number 4 • october 2015 integrative approach in haemophillic arthropathy of the knee femoral condyle, and subchondral cysts (figure 7). the patient underwent physiotherapy twice a week in our hospital’s medical rehabilitation center. six months after the operation, pain was minimal (vas 1-2), patient walked without crutch, range of motion was 0-125o, ikdc score was 66. frequency of bleeding was less than once a month. patient got factor replacement therapy routinely twice a week. discussion haemophilia is classified as mild, moderate, or severe according to the activity of factor viii/ix in the circulation. in patients with severe haemophilia the levels of factor viii/ ix in circulation is less than 1%, moderate haemophilia 1% to 5%, and mild haemophilia 5% to 40%.1-2 patients with severe haemophilia will experience spontaneous bleeding, especially in the joint, muscles, soft tissues, and other lifethreatening location (eg. in the brain), other than minor bleeding from mucous membranes, nose, and eyes. patients with moderate haemophilia rarely experience spontaneous bleeding; bleeding usually occurs after mild trauma. patients with mild haemophilia usually bleed after surgery or major trauma.1 joint bleeding (haemarthrosis) is the most common musculoskeletal manifestation in haemophilia.3 after repeated bleeding, joint disorder will progress into haemophilic arthropathy, a disorder characterized by chronic synovitis and progressive articular cartilage destruction.3-4 in this case, the knee was warm, tense, tender without history of trauma 2 years ago, patient never complained pain at the knee before. this history of swelling in the left knee was thought to be the initial haemarthrosis. afterward swelling in the left knee occur more frequently, the affected knee was tender and stiff, and never completely subside after coagulation factor replacement therapy. it shows that joint disorders have progressed into haemophilic arthropathy, the pain never subsided completely because of chronic synovitis and progressive articular cartilage damage. the joint was also seen enlarged because of swelling, chronic synovitis, and epiphyseal enlargement.5-6 when he moved, there was pain and palpable crepitus indicating damage of the joint cartilage. this finding was confirmed by the presence of blood, and also bone and cartilage defects found at arthroscopy. the anterior drawer sign, posterior drawer sign, and lachman test also showed positive results. this finding was confirmed by figure 5. clinical picture of the knee 3 weeks after surgery; (a) maximum extension, (b) maximum flexion, range of motion was 20-90o. figure 6. clinical picture of the knee 6 weeks after surgery; (a) maximum extension, (b) maximum flexion, no sign of inflammation, range of motion of left knee was 10-125o. figure 7. plain x-ray 6 weeks after surgery; (a) anteroposterior standing view, (b) lateral view. 329 andri maruli t. lubis acta med indones-indones j intern med the absence of the acl and pcl in the left knee at the time of arthroscopic procedure. haemophilic synovitis is caused by chronic accumulation of blood in the joint. blood is not a normal element found in the synovial fluid. when intraarticular bleeding occurs, the degradation product of blood will be absorbed by synovial membrane. iron contained in the blood will cause severe inflammatory reaction of the synovial membrane. the normal synovial membrane has the capacity to absorb blood after an episode of haemarthrosis. therefore, initial haemarthrosis will only lead to nonspecific inflammatory reaction of the synovial membrane which will soon subside.5 after repeated bleeding occurred in the same joints, the amount of degradation products to be absorbed exceeds the absorbing capacity of synovial membrane, resulting in hypertrophy and chronic inflammation of the synovial membrane. increased vascularization is required to improve the ability of the synovial membrane to absorb the degradation product of blood into circulation more effectively. therefore, the synovial membrane becomes hypertrophic, villous, and the blood vessels dilate and form sinusoids. these hypertrophied, villous, and hypervascular synovial membrane are vulnerable to be entrapped between joint surfaces and cause recurrent bleeding.3,5,7 iron as a degradation product of haemoglobin will catalyze the formation of destructive oxygen metabolites that would cause apoptosis in chondrocytes. the iron was also thought to cause chronic synovitis and proliferation of synovial cell and vascular tissue at subsynovial membrane.8 this hypervascular, villous, and fragile synovial tissue will bleed easily, thus forming vicious cycle.8-9 therefore, synovectomy is a way to prevent recurrent bleeding by removing the hyperplastic, villous, and hypervascular synovial membrane.10 granulation tissue (pannus) formed will grow over the cartilage surface and prevent diffusion of nutrition to articular cartilage.11 cartilage destruction is also caused by enzymes and proinflamatory cytokines produced by cells infiltrating the synovial membrane, and by mechanical distension of the joint due to extravasation of blood which cause increased intraarticular pressure. this might lead to chondrocyte apoptosis and inhibition of proteoglycan synthesis that will cause permanent joint cartilage destruction.8-9 subchondral bleeding will cause erosion at the subchondral bone and result in collapse of the articular surface. these changes will cause irreversible damage to joint and lead to end stage arthropathy (severe arthritis and permanent deformity) in people with haemophilia.7,11 anteroposterior, lateral, and skyline projection of plain x-ray of the left knee showed effusion, osteoporosis, epiphyseal enlargement, erosion on the lateral femoral condyle and the articular surface of patella, and subchondral cyst at femoral epiphyses, tibial epiphyses, and medial side of patella. those characteristic was classified as arnold-hillgartner stage iv and petterson score 9.12-13 the arnold hillgartner system is a progressive scale, with the worst radiological findings determine the stage of a haemophilic arthropathy. pettersson score is an additive scale, any abnormality found was given a value of 0, 1, or 2. lowest score is 0 and the highest 13. arnold-hillgartner scale is simpler and easier to use, but pettesson score is more precise and may distinguish various stages of haemophilis arthropathy better. therefore, world federation of haemophilia in 1981 recommended the pettersson score to be widely used, but the arnold hillgartner scale is still commonly used.12 although early abnormalities in the joint, such as synovial hyperplasia, cartilage surface irregularity and mild narrowing of joint space is not visible on plain x-ray, when joint disorder has reached an advanced stage, the disease course can be monitored adequately by plain x-ray.12 the key in the treatment of haemophilic arthropathy is aggressive management at the time of initial haemarthrosis. these can be done with factor replacement therapy, joint aspiration, physiotherapy, and close clinical observation.5 if chronic synovitis have already set in, synovectomy may be done to slow the progression of haemophilic arthropathy and to prevent end stage arthropathy.5,7 before surgery, the patient was given ondemand coagulation factor therapy, i.e. only 330 vol 47 • number 4 • october 2015 integrative approach in haemophillic arthropathy of the knee when there was bleeding. based on research conducted by fischer et al,14 on-demand therapy use less coagulation factors compared to primary or secondary prophylaxis, which are 1260 iu/kg/ year (on-demand) and 1550 iu/kg/year (primary or secondary prophylaxis). these two values are not statistically significantly different, but the on-demand group experiences 3.2 times higher joint bleeding, 2.7 times higher clinical severity, and 1.9 times higher petterson score compare to group given prophylactic therapy.14 it explains the rapid progression of disease in this case. it is also mentioned that the progression of haemophilic arthropathy can be slowed or even prevented by administering the coagulant factor as primary prophylaxis.1 during arthroscopy procedure, we also found acl and pcl deficiency. this finding was consistent with the physical examination (anterior drawer sign, posterior drawer sign, and lachman test). until now, we have not found a report or literature describing cruciate ligament damage in haemophilic arthropathy. we hypothesized that it was caused by bone destruction at the origin or insertion of those ligaments, causing the ligaments to detach and being reabsorbed along with the haemarthrosis. a study in rabbits showed that a model haemarthrosis created by injecting autologous blood into rabbit knee joint daily for 7 days caused synovial proliferation and iron deposition in synoviocytes, but no abnormality found in the acl. total collagen content, collagenase activity, and biomechanical properties of acl in the knee that had haemarthrosis was no different from contralateral knee as the control.15 further study which aims to explain this acl and pcl deficiency may be conducted in the future. in the normal knee, the function of acl and pcl is restrain anterior and posterior translation of the tibia relative to the femur. in acl and/or pcl deficient knee, abnormal tibiofemoral translation may result in cartilage injury.16 in this patient, this effect might further exacerbate cartilage injury due to haemophilic arthropaty. as mentioned above, synovectomy reduce the frequency of bleeding by removing the hyperplastic and hypervascular synovial tissue. open synovectomy as the treatment of haemophilic arthropathy was first reported by storti et al. in 1969.7 although open synovectomy was effective in reducing the frequency of joint bleeding, its main complication is reduced postoperative range of motion of the joint. as stated by montane et al. that the haemophilic joint that has been performed open synovectomy “do not bleed (very often), do not hurt (very much), and do not move (very well)”.17 to overcome this problem, synovectomy with arthroscopic technique was developed. the advantages of arthroscopic synovectomy compared to open technique are less invasive, faster recovery time, less postoperative bleeding, shorter hospitalization, less complication, and better postoperative range of motion of the joint.7 in this case, synovectomy was performed by arthroscopy. postoperatively, there was a decrease in pain and bleeding frequency and increase in functional outcome. a study conducted by dunn et al. showed 97% reduction of bleeding frequency in patients with haemophilic arthropathy performed arthroscopic synovectomy.10 other study showed that despite a dramatic reduction in the frequency of bleeding, synovectomy do not stop the progression of joint destruction.7,18 in patients who underwent a second operation because of recurrent symptoms, intraoperative findings showed that those symptoms was more likely caused by cartilage destruction, there was no evidence indicating the presence of synovitis at the second operation.10,19 after the operation, the patient was hospitalized to receive coagulation factor replacement therapy and intensive physiotherapy. the purpose of physiotherapy is to maintain or restore range of motion, strengthen muscles, prevent or treat joint contracture, relieve pain, increase tolerance to activity, improve balance, coordination, and propioceptive. physiotherapy in patients with haemophilia often accompanied by coagulation factor replacement therapy to prevent bleeding.7 in follow-up care, the patient had a mild decrease in range of motion (preoperative 10o-135o, 6 weeks postoperative 10o-125o). this was consistent with those reported by wiedel that arthroscopic synovectomy in haemophilic arthropathy usually result in reduction of rom 331 andri maruli t. lubis acta med indones-indones j intern med 5-15o extension and 5-15o flexion.19 six months postoperatively the knee condition was stable, vas was 1-2, rom was 0-125o, and ikdc score was 66. postoperative x-ray of the left knee showed stage iv haemophilic arthropathy based on arnold-hillgartner scale and pettersson score 9, which was the same as the preoperative x-ray. this is consistent with the literature stated that arthroscopic synovectomy may slow but can not stop the progressivity of haemophilic arthropathy.11,18-19 when joint damage has reached an advanced stage, characterized by marked narrowing of cartilage space, significant decrease in rom, and severe pain, the patient will not have significant clinical improvement after synovectomy, arthroplasty should be done.7 until now, the absolute indication for arthroplasty in haemophilic arthropathy has not been determined. arthroplasty is usually performed at advanced stage of joint disorder characterized by marked cartilage damage, severe pain, deformity, and loss of joint motion that cause severe functional impairment.20 conclusion arthroscopic synovectomy performed in this case show good results, indicated by a marked decrease in pain and frequency of haemarthrosis and an increase in ikdc score. acl and pcl deficiency found in this case have not been reported in other literature. the underlying mechanism requires further study. arthroscopic synovectomy may slow but cannot avoid the progressivity of haemophilic arthropathy. references 1. rodriguez ni, hoots wk. advance in haemophilia: experimental aspect and therapy. pediatr clin n am. 2008;55:357-76. 2. rodriguez-merchan ec, goddard nj, lee ca. musculoskeletal aspect of haemophilia. oxford: blackwell science ltd.; 2000. 3. r o d r i g u e z m e r c h a n e c . a r t i c u l a r b l e e d i n g (haemarthrosis) in haemophilia (an orthopaedist’s point of view). treatment of haemophilia. 2000. 4. hoots wk. pathogenesis of haemophilic arthropathy. semin haematol. 2006;10:s18-s22. 5. silva m, luck jv, llinas a. chronic haemophilic synovitis. treatment of haemophilia. 2004. 6. kilcoyne r, nuss r. radiological evaluation of haemophilic arthropathy. semin thromb haemost. 2003;29:43-8. 7. raffini l, manno c. modern management of h a e m o p h i l i c a r t h r o p a t h y. b r i t j h a e m a t o l . 2007;136:777-87. 8. lafeber f, miossec p, valentino l. physiopathology o f h a e m o p h i l i c a r t h r o p a t h y. h a e m o p h i l i a . 2008;14(suppl.4):3-9. 9. valentino l. blood-induced joint disease: the pathophysiology of haemophilic arthropathy. j thromb haemost. 2009;8:1895-902. 10. dunn al, busch mt, wyly b, sullivan km, abshire tc. arthroscopic synovectomy for haemophilic joint disease in a pediatric population. j pediatr orthop. 2004;24:414-26. 11. yoon kh, bae dk, kim hs, song sj. arthroscopic synovectomy in haemophilic arthropathy of the knee. sicot. 2005;29:296-300. 12. jelbert a, vaidya s, fotiadis n. imaging and staging of haemophilic arthropathy. clin radiol. 2009;64:111928. 13. maclachlan j, gough-palmer a, hargunani r, farrant j, holloway b. haemophilia imaging: a review. skeletal radiol. 2009;38:949-57. 14. fischer k, van der bom jg, molho p, et al. prophylactic versus on-demand treatment strategies for severe haemophilia: a comparison of costs and long-term outcome. haemophilia. 2002;8(6):745-52. 15. ishizue kk, lyon rm, amiel d, woo sl-y. acute haemarthrosis: a histological, biochaemical, and biomechanical correlation of early effect on the anterior cruciate ligament in a rabbit model. j orthop res. 1990;8(4):548-54. 16. akhtar s, mofidi a, wilson c, williams r. time dependent chondral changes in the anterior cruciate deficient knee. j bone joint surg br. 2009:91-b:41920. 17. montane i, mccollough nc, lian ec-y. synovectomy of the knee for haemophilic arthropathy. j bone joint surg. 1986;68-a:210-6. 18. verma n, valentino l, chawla a. arthroscopic synovectomy in haemophilia: indication, technique and result. haemophilia. 2007;13(suppl.3):38-44. 19. wiedel jd. arthroscopic synovectomy of the knee in haemophilia. clin orthop relat res. 1996;328:46-53. 20. wiedel j, stabler s, geraghty s, funk s. joint replacement surgery in haemophilia. treatment haemophil. 2010;50:1-10. 332 307 original article acta med indones indones j intern med • vol 49 • number 4 • october 2017 effect of nigella sativa seed extract for hypertension in elderly: a double-blind, randomized controlled trial aulia rizka, siti setiati, aida lydia, esthika dewiasty department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: aulia rizka, md, phd. division of geriatric medicine, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: dr. auliarizka@yahoo.co.id. abstrak latar belakang: ekstrak biji nigella sativa (ns) pada penelitian in vivo menunjukkan potensi sebagai anti hipertensi karena memiliki efek diuretik, meningkatkan produksi oksida nitrit dan menghambat overaktivitas sistem saraf simpatis, sehingga potensial digunakan sebagai obat anti hipertensi pada pasien usia lanjut. penelitian ini bertujuan untuk mengetahui pengaruh pemberian ekstrak biji ns pada perubahan tekanan darah sistolik (tds) dan tekanan darah diastolik (tdd) pasien usia lanjut dengan hipertensi. metode: dilakukan uji klinis acak tersamar ganda mulai juni hingga september 2011 terhadap 76 pasien usia lanjut dengan hipertensi di tiga poliklinik di rs cipto mangunkusumo jakarta indonesia. dengan alokasi tersamar, subyek dibagi menjadi kelompok yang mendapat kapsul berisi ekstrak biji ns 300 mg sebanyak 2 kali sehari selama 28 hari dan kelompok yang mendapat plasebo. tekanan darah (td) diukur pada hari ke-1 dan ke-28. dilakukan analisis dengan uji-t tidak berpasangan untuk melihat perbedaan tekanan darah pada kedua kelompok setelah intervensi dengan prinsip analisis intention to treat. hasil: dari 85 subjek yang memenuhi kriteria awal, didapatkan 76 subjek yang sesuai kriteria penelitian dan dirandomisasi menjadi dua kelompok, masing-masing terdiri dari 38 subjek. pada akhir pengamatan, tds kelompok ns turun dari 160,4 (sd 15,7) menjadi 145,8 (sd 19,8) mmhg and pada plasebo turun dari 160,9 (sd 16,3) menjadi 147,53 (sd 22,0) mmhg (p=0,36). tdd pada kelompok ns turun dari 78,3 (sd 11,9) menjadi 74,4 (sd 8,2) dan pada kelompok plasebo turun dari 79,0 (sd 12,4) menjadi 78,2 (sd 8,9) mmhg. efek simpang yang dilaporkan adalah dispepsia pada 6 subjek (15,7%), mual pada 3 subjek (7,8%) dan konstipasi pada 2 subjek (5,2%). tidak didapatkan gangguan elektrolit, gangguan fungsi ginjal, hati, maupun hipotensi ortostatik. kesimpulan: meskipun menunjukkan kecenderungan penurunan tekanan darah, nigella sativa belum terbukti dapat menurunkan tekanan darah pasien usia lanjut dengan hipertensi. kata kunci: nigella sativa, hipertensi, usia lanjut. abstract background: nigella sativa (ns) seed extract shows diuretic activity, inhibits sympathetic nervous system overactivity and increases the production of nitric oxide in in vivo studies, thus it has a potential use as an adjuvant antihypertensive for elderly population. this study aimed to determine the effect of nigella sativa seed extract to systolic blood pressure (sbp) and diastolic blood pressure (dbp) of elderly patients with hypertension. methods: a double-blind, randomized controlled trial was conducted on elderly subjects with hypertension in three outpatient clinics in cipto mangunkusumo national hospital jakarta indonesia from june to september 2011. subjects were divided into intervention group given 300 mg nigella sativa seed extract twice daily for 28 days and into another group which was given placebo. blood pressure were measured on day 1 and 28. intention aulia rizka acta med indones-indones j intern med 308 to treat analysis using unpaired t-test to compare blood pressure after intervention between the two groups was performed. results: of a total of 85 patients, 76 subjects fulfilled the study criteria and were randomized into 2 groups, with 38 subjects in each group. both groups were comparable in all important prognostic factors. the mean systolic blood pressure of the ns group was decreased from 160.4 (sd 15.7) mmhg to 145.8 (sd 19.8) mmhg, and from 160.9 (16.3) mmhg to 147.53 (sd 22.0) mmhg in the placebo group (p=0.36). the mean diastolic blood pressure in the ns group was decreased from 78.3 (sd 11.9) to 74.4 (sd 8.2) mmhg, and from 79.0 (sd 12.4) to 78.2 (sd 8.9) in the placebo group (p=0.35). reported adverse events include dyspepsia in 6 subjects (15.7%), nausea in 3 subjects (7.8%), and constipation in 2 subjects (5.2%). no electrolyte abnormalities, liver and renal toxicities, or orthostatic hypotension were observed. conclusion: although a trend towards a slight decrease in blood pressure was observed, nigella sativa has not been proven to be effective in reducing blood pressure in elderly patients with hypertension. keywords: nigella sativa, hypertension, elderly. introduction to date, hypertension remains a major health problem in various countries. the financial burden, both direct and indirect, caused by hypertension is substantial. with cardiovascular complications that often follows, hypertension remains the number one cause of death in the elderly.1,2 results from riset kesehatan dasar (indonesian basic health research) reporting that the prevalence of hypertension in indonesia is 63.5% in populations aged 65-74 years old and 67.2% for those aged 75 years or more.3 despite this high prevalence, control of hypertension remains very poor in this population.4 with the increase of elderly population in indonesia which is predicted to reach 414% within 35 years, this problem becomes more important.5 the importance in decreasing blood pressure in elderly patients has been proven by a metaanalysis on seven large scale clinical trials involving a total of 1,670 patients. the analysis concluded that a decrease in blood pressure in patients aged over 60 years will reduce mortality and cardiovascular events significantly within the next 4.5 years.6 reducing 10 mmhg of systolic blood pressure or 5 mmhg of diastolic blood pressure at the age of 65 means reducing the risk of myocardial infarction by 25%, reducing the risk of stroke by 40%, and reducing the risk of congestive heart failure by 50%.7 nigella sativa, which is known in indonesian as jinten hitam (black cumin) or habatussauda, is a dicotyledon from the family ranunculaceae which has been used to resolve various diseases since hundreds of years ago.8 experimental studies on animal models have proven that the biological effects of nigella sativa including its effect in diuresis, decreasing sympathetic activities, and improving lipid profile, are potentially beneficial for the treatment of hypertension.9-11 in relation to the rigidity of arteries, which is a pathogenesis characteristic of hypertension in the elderly, nigella sativa also increases the production of nitrite oxide which may inhibit the rigidity of arteries.11 previous clinical trials by dehkordi 12 and qidwai13 involving adult patients with hypertension were unable to show conclusive results. to our knowledge, no clinical trial has been able to prove the efficacy of nigella sativa in elderly with hypertension, therefore we wished to perform a clinical trial to prove its efficacy in decreasing blood pressure in this specific population. methods this study was a double-blind, controlled, randomized clinical trial aimed to investigate the role of nigella sativa in decreasing the blood pressure of elderly patients with hypertension. this study was conducted in june – september 2011 at the geriatric outpatient clinic, renalhypertension outpatient clinic, and internal medicine outpatient clinic of the faculty of medicine of the university of indonesia/cipto mangunkusumo national hospital. the inclusion criteria were patients aged ≥60 years with hypertension (sbp>140 mmhg and or dbp>90 vol 49 • number 4 • october 2017 effect on nigella sativa seed extract for hypertension in elderly 309 mmhg). the exclusion criteria were patients with decreased renal function (glomerular filtration rate <30 ml/m3), decreased liver function (increased sgpt over 2 times the upper normal limit), severe dementia, depression, orthostatic hypertension, malignant hypertension, having consumed more than three antihypertensive agents at maximum dose and refusing to participate in the study. in order to calculate the minimum sample size required to acquire a difference in mean blood pressure after the intervention between the intervention and control groups, the sample size formula for independent numerical data was used, with standard deviation data taken from qidwai’s study.13 differences deemed significant were 10 mmhg for sbp (systolic blood pressure) and 5 mmhg for dbp (diastolic blood pressure), with a=0.05 and power 80%. the minimum sample size required was 64 subjects. subjects were randomized into two groups, in which one group received nigella sativa and another group received placebo at the time of visit. allocation concealment was also performed. each patient received 2 capsules per day for 28 days. patients in the treatment group received capsules containing a dose of 300 mg nigella sativa extracts, whereas patients in the placebo group received capsules of similar color, weight, and smell containing flour. both the investigator and study subjects had no knowledge of the randomized allocation (i.e. double-blind). p a t i e n t s w e r e a l l o w e d t o c o n s u m e antihypertensive medications previously taken. lifestyle, dietary habits (including salt, fat, and vegetable intake), smoking habits, exercising habits, and other supplementation usage were continued normally. in order to ensure that the drugs were taken by the patients, they were packaged in plastic which needed to be torn before consumption and was counted during examination on the 28th day. furthermore, a family member or caregiver would be asked to ensure that the drugs were consumed properly and to mark a tick on the drug consumption form. prior to drug administration, patients underwent interview, physical examination (including body mass index and blood pressure) and laboratory examination. blood pressure measurement was performed using validated bp monitor (omron, kyoto japan). on day 28, the patient would revisit the clinic for another round of interview, physical examination, and laboratory examination. patients were deemed to have completed the study if they were present at the examination on day 28 and have consumed all of the drugs with the assigned dose. characteristics (especially characteristics which may potentially affect the decrease in blood pressure such as age, drugs consumed and duration of hypertension) in each of the nigella sativa and placebo group were presented as means with standard deviation for numerical variables or as a proportion if the variables were categorical. a difference in blood pressure between the nigella sativa and placebo group after the intervention were analyzed with unpaired t-test or its alternatives. all analysis would apply a significance level of 5%, in conjunction with its 95% confidence interval. analysis at the end of the study were performed under the intention to treat analysis principles. this study was performed conforming to the helsinki declaration, guideline for good clinical practice from ich tripartite and consistent with the rules of clinical trials in indonesia. written consent had been obtained from each subject and the protocol of this study had approved by local independent ethical committee, numbered 283/ pt02.fk/etik/2011. results between july and september 2011, 76 hypertension patients fulfilled the study subject selection criteria. the patients then received drugs according to codes listed on a previously determined randomization table. at the start of the study, there were 38 subjects who were given nigella sativa and the remaining 38 subjects were given placebo. as many as 7 subjects (9.2%), which consisted of 5 subjects receiving nigella sativa and 2 subjects receiving placebo did not complete the study due to nausea (4 subjects; 5.2%), emergency surgery for abdominal trauma (1 subject; 1%), and forgetfulness (2 subjects; 2.6%). a total of 69 patients completed of the study, consisting of 33 subjects in the nigella sativa group and 36 subjects in the control group aulia rizka acta med indones-indones j intern med 310 as presented in figure 1. patients who completed the study declared that they have consumed all the drugs on the previously assigned dose. gastrointestinal disorders in the form of nausea and gastric discomfort were reported in six subjects receiving nigella sativa, one of whom experienced vomiting without signs of dehydration, and two others reported difficulty in defecation. a s p r e s e n t e d i n ta b l e 1 , s u b j e c t characteristics were comparable across all considered prognostic factors. at the end of the study, a repeat blood pressure measurement was performed and a tendency towards a reduced sbp was observed. this was clinically important but not statistically significant (p=0.36), as presented in table 2. no significant decrease in dbp (p=0.35) was observed in the group receiving nigella sativa, as presented in table 3. discussion subject characteristics in this study differs relatively from that of a study by kamso, et al.14 involving 565 elderly patients with hypertension, who were randomly selected from patients of a public health centers in special capital region of jakarta, indonesia. although most of the subjects were females, similar to that of kamso’s study, the mean age in this study was significantly higher (72 years old in the intervention group and 73.8 years old in the control group compared to 65.9 years old in kamso’s study). mean sbp in this study was also much higher which was 160.4 mmhg in the intervention group and 160.9 mmhg in the control group compared to 141 mmhg in the kamso study. to date, only two studies were known to have investigated the effects of nigella sativa on blood pressure, the studies of dehkordi and qidwai, both observed the young adult population.12,13 enrollment fulfilled inclusion criteria (n=85) fulfilled exclusion criteria (n=7) refused to participate in study (n=2) randomization (n=76) allocated to receive intervention (n=38) receive intervention as allocated (n=38) allocated to receive placebo (n=38) receive placebo as allocated (n=38) loss to follow up (n=0) stopped intervention (n=5) due to: -nausea (n=3) -trauma emergency surgery (n=1) -forgetfulness (n=1) loss to follow up (n=0) stopped intervention (n=2) due to: nausea (n=1) forgetfulness (n=1) included in analyses (n=38) included in analyses (n=38) allocation follow up analysis figure 1. study flowchart vol 49 • number 4 • october 2017 effect on nigella sativa seed extract for hypertension in elderly 311 table 1. baseline study subjects characteristics variables nigella sativa (n=38) placebo (n=38) male, % 13 (34) 8 (21) age (years), mean (sd) 72 (5.9) 73.8(6.8) education ≤ middle school, % 8 (21) 10 (26) duration of ht <5 years, % 21 (55) 22 (57.9) bmi (kg/m2), mean (sd) 24.5(3.5) 24.2(5.2) sbp (mmhg), mean (sd) 159.4 (15.7) 160 (16,3) dbp (mmhg), mean (sd) 78.7 (10.9) 79.2 (12.8) isolated systolic hypertension, % 23 (60) 25 (65) grade 1 ht, % 8 (21) 9 (24) >2 types antihypertensive agents, % 6 (15.7) 8 (21) routine consumption of antihypertensive agents 33 (86.8) 32 (84.2) type of antihypertensive agent ace inhibitor, % 10 (26) 8 (21) angiotensin receptor blocker, % 8 (21) 6 (15.7) calcium channel blocker, % 5 (13.1) 4 (10.5) diuretics, % 0 (0) 1 (2) combination of ace inhibitor and calcium channel blocker, % 7 (18.4) 9 (24) combination of angiotensin receptor blocker and calcium channel blocker, % 2 (5.2) 1 (2) combination of ace inhibitor, calcium channel blocker, and beta blocker, % 4 (10.5) 5 (13.1) combination of ace inhibitor, calcium channel blocker, and alpha blocker, % 2 (5.2) 3 (7.9) > 6 total drugs consumed, % 8 (21) 7 (18.4) routine nsaid use, % 2 (5.2) 3 (7.9) routine steroid use, % 0 (0) 0 (0) alcohol consumption >1 glass a day, % 0 (0) 0 (0) salt consumption >1 tsp./day, % 10 (26) 13 (34.2) smoking >10 cigarettes a day 1 (2) 1 (2) routine exercise <2x a week @ 30 minutes, % 25 (65) 23 (63) coffee consumption >2 cups a day, % 0 (0) 0 (0) diabetes mellitus, % 13 (34.2) 14 (36.8) dyslipidemia, % 2 (5) 1 (2.6) albumin (mg/dl), mean (sd) 4.2 (0.37) 4.1 (0.39) creatinine (mg/dl), mean (sd) 0.85 (0.17) 0.91 (0.17) sgpt (mg/dl), mean (sd) 19.5 (6.4) 21.22 (8.3) proteinuria more than +1, % 4 (10.5) 6 (15.7) table 2. effects of nigella sativa to systolic blood pressure before treatment mmhg (sb) after treatment mmhg (sb) delta (mmhg) nigella sativa (n=33) 160.4 (15.7) 145.8 (19.8) 14.6 placebo (n=36) 160.9 (16.3) 147.53 (22.0) 13.3 p=0.36* * unpaired t-test table 3. effects of nigella sativa to dyastolic blood pressure before treatment mmhg (sb) after treatment mmhg (sb) delta (mmhg) nigella sativa (n=33) 78.3 (11.9) 74.4 (8.2) 3.9 placebo (n=36) 79.0 (12.4) 78.2 (8.9) 0.8 p=0.35* * unpaired t-test aulia rizka acta med indones-indones j intern med 312 qidwai’s study observed blood pressure as a secondary outcome with the primary outcome being lipid profile.13 there were two important points found in this study. firstly, the administration of nigella sativa seed extract with a dose of 300 mg twice a day for 28 days in elderly patients with hypertension could not significantly reduce sbp and dbp. a study by dehkordi12 tested the effects of nigella sativa on mild hypertension in young adult subjects produced statistically significant decrease in blood pressure with 2 mmhg decrease in sbp after a 2x200 mg dose regimen for 4 weeks. the qidwai study used a 2x500 mg dose for 6 weeks and displayed higher sbp reduction (5.16 mmhg), although it has poor internal validity with a high dropout percentage, reaching 42%, due to low compliance.13 the findings of the current study differ from the other two studies performed in a young adult population. the lack of therapeutic effects from nigella sativa in this study compared to placebo appears to be unrelated to the dosage or duration, considering that the blood pressure was clinically reduced. one explanation for this is the rigidity of arteries, which is an important part of the pathogenesis of hypertension in the elderly, impedes the activity of nigella sativa in reducing blood pressure. although nigella sativa was found to improve hypertension through inhibition on alpha adrenoceptors after sympathetic stimuli, increasing the production of nitrite oxide, anti-inflammatory activities, and anti-sclerotic effects in in vivo studies performed on animals, it appears that those various mechanisms weren’t able to improve the rigidity of arteries in the elderly. another possible explanation is that sex characteristic of study subjects, which was dominated by females, plays a role in impeding the effect of nigella sativa in reducing blood pressure. blood pressure in elderly women has been known to be harder to control compared to elderly men.15 data from nhanes noted that the difficulty of controlling blood pressure in female patients stems from the higher prevalence of other cardiovascular risk factors in women, such as central obesity, increased total cholesterol level, and low ldl (low density lipoprotein) level.16 this study also found that nigella sativa had no influence on diastolic blood pressure. as previously noted, most subjects suffer from isolated systolic hypertension, a condition where the systolic blood pressure is high with normal or low diastolic blood pressure. the rigidity of arteries present in the elderly is a good explanation of that concept, while normal or even low dbp may be caused by the inability of the aorta or other arteries to enlarge during systole and contract during diastole, making it hard for dbp to increase. although gastrointestinal adverse events were not severe and most were resolved with the administration of proton pump inhibitors and increased intake of fiber consumption, they were quite bothersome for elderly patients considering their physiologically decreased meal intake compared to younger patients. these gastrointestinal disorders may potentially decrease fluid intake even further which will increase the risk of dehydration. gastrointestinal disorders were not reported in the dehkordi12 and qidwai13 studies on young adult patients. the difference in subject characteristics may explain the occurrence of said gastrointestinal adverse events. elderly patients also often consume other medications which may cause dyspepsia, such as nsaids, steroids, or anti-platelet related to their comorbidities. comorbidities such as diabetic gastroparesis, worsens the symptoms of patients with previous history of dyspepsia due to medication. although packaged in capsules, interactions between this medication and nigella sativa in the stomach with delayed emptying movements may have triggered dyspepsia. no side effects on the liver and kidney were found, similar to findings of the dehkordi and qidwai studies.12,13 the advantages of this study lies in its design (randomized, double-blind clinical trial), which is the best for experimental studies, and in it being the first clinical trial investigating the effects of nigella sativa in the elderly. this study is also the first one to confirm that nigella sativa has no therapeutic effects in elderly patients with hypertension. the limitations of this study lies in the fact vol 49 • number 4 • october 2017 effect on nigella sativa seed extract for hypertension in elderly 313 that the blood pressure measurements were only performed at the start and the end of intervention without any measurements taken between the two points in time. as a result, blood pressure fluctuations were not evaluated. another limitation is the relatively short duration of study. conclusion despite showing a clinically significant decrease in systolic blood pressure, nigella sativa has not been proven to improve hypertension in the elderly. nigella sativa also has not been proven to reduce diastolic blood pressure in elderly patients. references 1. bayley k, grossardt b, graves j. novel 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cyclosporine a-induced cardiotoxicity in rats. basic clin pharmacol toxicol. 2008;103(6):574-80. 12. dehkordi f, kamkhah a. antihypertensive effect of nigella sativa seed extract in patients with mild hypertension. fundamental and clin pharmacol. 2008;22:447-52. 13. qidwai w, hamza h, qureshi r, gilani a. effectiveness, safety, and tolerability of powdered nigella sativa (kalonji) seed in capsules on serum lipid levels, blood sugar, blood pressure, and body weight in adults: results of a randomized, double-blind controlled trial. j altern compl med. 2009;15:639-44. 14. kamso s, rumawas j, lukito w, purwantyastuti. determinants of blood pressure among indonesian elderly individuals who are of normal and overweight: a cross sectional study in an urban population. asia pac j clin nutr. 2007;16(3):546-53. 15. lloyd jones dm, evans jc, levy d. hypertension in adults across the age spectrum: current outcomes and control in the community. jama. 2005;294:466-72. 16. ong kl, tso aw, lam ks, et al. gender difference in blood pressure control and cardiovascular risk factors in americans with diagnosed hypertension. hypertension. 2008;51:1142-8. case report 333acta medica indonesiana the indonesian journal of internal medicine supraclavicular lymphnodes: unusual manifestation of metastase adenocarcinoma colon harijono achmad, rofika hanifa department of internal medicine, faculty of medicine brawijaya university saiful anwar hospital, malang, indonesia. correspondence mail: division of gastroenterohepatology, department of internal medicine, faculty of medicine, brawijaya university saiful anwar hospital. jl. veteran malang, lowokwaru, malang, jawa timur 65145, indonesia. email: gastro_mlg@ yahoo.com. abstrak kasus ini mengenai seorang pasien dengan getah bening supraklavikula simpul metastasis dari adenokarsinoma terlihat melintang di usus besar. terdapat keluhan batuk dan didiagnosis demam tifoid, bronkitis serta metastasis hati. perut sebah, penurunan berat badan, sembelit, tinja seperti pensil dengan adanya lendir dan darah, sakit tulang, dan urin berwarna seperti teh. pemeriksaan kolonoskopi pertama kali terungkap adanya ileitis limfositik dan temuan mikroskopis juga menunjukkan ileitis limfositik. usg dan ct scan mengungkapkan metastasis hati yang tidak diketahui asalnya. berdasarkan tanda dan gejala klinis, kami menduga bahwa karsinoma kolorektal adalah temuan utama. kemudian, kolonoskopi kedua dilakukan dan ditemukan aanya polip kecil, yang disertai dengan biopsi dan hasilnya mendukung usus adenokarsinoma berdiferensiasi baik. hasil serupa juga diungkapkan oleh evaluasi histopatologi. kami melaporkan kasus yang tidak biasa dari hati dan supraklavikula metastasis kelenjar getah bening yang timbul dari adenokarsinoma polip kecil dari usus besar. kata kunci: metastasis hati, karsinoma kolorektal, kelenjar limfe. abstract we report a patient with supraclavicular lymph node metastasis from an undetectable adenocarcinoma of the transverse colon, who presented with cough and was diagnosed with typhoid fever, bronchitis as well as liver metastasis. there were an abdominal fullness, weight loss, constipation, pencil-like stool with mucous and blood, low-grade fever, bone ache, and tea-color urine. the first colonoscopy revealed lymphocytic ileitis and microscopic findings also showed lymphocytic ileitis. abdominal usg and ct revealed liver metastasis of unknown origin. based on the clinical sign and symptoms, we suspected that colorectal carcinoma was the primary site. then, the second colonoscopy was performed and it revealed a small polyp, which was followed with a biopsy and the result supported a well-differentiated colon adenocarcinoma. similar result was also revealed by the histopathological evaluation. this is an unusual case of liver and supraclavicular lymph node metastasis arising from a small polyp adenocacinoma of the transverse colon. key words: liver metastase, colorectal carcinoma, lymph node. 334 harijono achmad acta med indones-indones j intern med introduction colorectal cancer (crc) remains a major public health problem in western countries. each year, worldwide, there are approximately 400,000 people die from colorectal cancer and 700,000 new cases are diagnosed. colorectal carcinoma is the second leading cause of death from cancer in the us. it is also the third most common malignancy in both men (after lung and prostate cancers) and women (after lung and breast cancers).1 approximately 60% of patients will develop metastatic disease, which is localized to the liver alone in half of them.1,2 by the time they are diagnosed, about 25% of colon cancers will have extended through the bowel wall; whereas cancers of the rectum will have spread through the bowel wall in 50%-70% of patients and metastasized to lymph nodes in 50%-60%.1 the most common site of extra lymphatic involvement is the liver and the lung is the most frequently affected extra-abdominal organ. metastatic liver tumors are largely silent until the disease is well advanced.2 patients with metastatic colorectal tumors frequently die of hepatic failure due to liver metastasis. the overall incidence of colorectal carcinoma (crc) is nearly identical in men and women. the risk of developing colorectal tumors begins to increase at 40 and rises with age. the incidence of crc is higher in industrialized regions of the world.1 specific causes of crc are unknown, but nutritional, genetic and familial factors, as well as pre-existing diseases, such as inflammatory bowel disease or certain cancers, have been found to be associated with this cancer. risk factors for the development of crc include highfat diet, daily alcohol use, smoking, decreased physical activity and obesity.1 case illustration a 53-year-old male patient presented with cough since 1 year ago without sputum production. he also had progressive epigastric pain for 5 months, accompanied with low-grade fever. he had been admitted to a hospital in surabaya a month before and the doctor said that he had chronic bronchitis and typhoid fever. he had difficulty in passing stool since 5 months before admission. he had pencil-like stool with mucous and blood and passed tea-color urine since 2 weeks before admission. his lost 11-kilograms in the last 5 months. he also said that he had bone ache since 37 years ago (1972), and he used to consume herbal medicine called puyer bintang toed joe since 1975 (34 years), once a month, and he started to consume jamu tawon api since 6 years ago as his pain developed progressively. he usually works using a lot of physical strengh. he has never suffered from frequent unperceived trauma or had fallen in his daily life. he used to drink alcohol from 1985 to 1990 and drank half a bottle per week. he used to smoke 10 cigarettes per day when he was young. then, since there were no improvements of his condition, he met an internist in malang, and he consulted his illness to the department of gastroenterohepatology. the cough was relieved after he had received steroid injection. on physical examination, the patient was in mildly ill condition. he was fully conscious with blood pressure of 110/80 mmhg, pulse rate at 80 beats per minute, respiratory rate was 18x/m. his axillary temperature was 36°c, with body weight of 70 kg, body height of 170 cm, and body mass index of 23.4. auscultation of the lungs and heart revealed normal result. the abdomen was tender, but we found hepatomegaly with smooth surface, sharp margin, and traube’s space dullness. the carotid and radial pulse were normal. cns examination revealed that the higher mental functions including the functions of cranial nerves and speech were normal. motor system ́and sensory examinations were also normal. examinations and review of other systems showed normal results. investigation of hemogram revealed leukocytosis (leukocytes of 28,700/mm3 with normal hemoglobin level (11 g/dl) and blood chemistry test revealed normal results. the albumin and random blood glucose levels were normal with salmonella typhi h titer of 1/640, paratyphi a-b titer of 1/640, and paratyphi titer of ch 1/160. however, the cytology of red blood smear revealed normocytic normochromic red cells. acid fast bacili and gram staining of sputum test revealed negative results; however, the result of 335 vol 47 • number 4 • october 2015 supraclavicular lymphnodes tb pcr was positive. the esr was 100-119 mm/hour, but bilirubin, alkaline phosphatase, alfa-fetoprotein and others blood and urine parameters were normal. with rough and heterogenic echo parenchyma and bull’s eye sign, which suggested a secondary hepatoma of unknown primary origin. considering the abovementioned clinical features and investigation, patient was diagnosed with liver cancer of unknown primary origin. due to his complaint of passing pencil-like stool and weight loss, he had a colonoscopy in surabaya on april, 4th, 2009. the doctor suspected colorectal carcinoma as the primary site, but colonoscopy results revealed internal hemorrhoids and normal colon (figure 4). figure 1. chest x-ray revealed increased bronchovascular pattern (increasing kv) plain radiographs were taken in march, 31th 2009. the chest radiographs showed increased bronchovascular pattern (figure 1). we suspected a possibility of hillar lymphadenophaty in this chest x-ray. an electrocardiogram revealed a normal sinus rhythm at rate of 90/min. abdominal usg and ct scan (figure 2 and 3) revealed hepatomegaly, multiple nodules, hyperechoic figure 2. abdominal usg revealed multiple nodules in right and left lobe of the liver. no calcification/ cystic lesion/ papils was found. figure 3. abdominal ct scan revealed metastatic process in the liver with unknown primary origin figure 4. the 1st colonoscopy revealed internal hemorrhoid and normal colon biopsy results revealed lymphocytic ileitis and subsequently we found lymph node enlargement in supraclavicular region. no enlargement was found in the inguinal region. malignant lymphoma was considered as the primary origin of liver metastasis since there was supraclavicular lymph node enlargement and lymphoid cell findings in the 1st ileum 336 harijono achmad acta med indones-indones j intern med biopsy. however, colorectal carcinoma was also considered as the primary origin because there were changes in bowel habits, hematochezia and weight loss. we continued our investigation by performing re-colonoscopy, tumor marker examination, and biopsy of liver and supraclavicular lymph nodes to find the primary cancer. investigations of tumor marker revealed normal results. the cea level was 50 ng /ml (normal range <5 ng/ml), which supported our diagnosis, i.e. colorectal carcinoma as the primary cancer. other tumor markers revealed normal results including ca 19-9 of 20.15 (<37 u/ml), afp of 1.63 ng/ml (<7.2 ng/ml), ca 125 of 15.78 u/ml<35 u/ ml). we continued our investigation further by performing another colonoscopy and biopsy of liver and supraclavicular lymph nodes. the last colonoscopy revealed small polyp of 20 centimeters in size extending from external anal orifice. the final diagnosis of our case was liver and lymph node metastasis originated from a small polyp in transversal colon. it was actually an infiltratrive spread of an adenocarcinoma. based on signs and symptoms of passing mucous pencil-like stool, hematoschezia, weight loss, hepatosplenomegaly, supraclavicular lymph node enlargement, multiple nodules of the liver, bull’s eye sign of ultrasonography findings and the results of colon biopsy, the diagnosis of colorectal carcinoma with metastasis to liver and supraclavicular lymph nodes was established. f l u i d a n d e l e c t r o l y t e s w e r e g i v e n intravenously. we treated the patient using 125 mg/24 hours intravenous medixon®, 40 mg/day omeprazole, 100 cc of 20% albumin transfusion, 20 mg of atorsan® in the morning and aminofusin® /0.9% normal saline with the rate of 21 drops/minute. on the 7th day of admission, we performed chemotherapy, using ca leucovorin and 5-fluorouracyl (de-gramont regimen). the patient showed a good response to chemotherapy. the nonproductive cough showed a good response to steroid. it is possible that there were granulomas such as koch pulmonum, sarcoidosis or aspergillosis in this patient as a result of impaired immune mechanisms. corticosteroid may acutely suppress the manifestations, improves the cough and reveals figure 5. the result of supraclavicular lymph node biopsy showed undifferentiated carcinoma metastasis figure 6. liver biopsy revealed metastasis of poorly differentiated adenocarcinoma figure 7. rectum biopsy revealed normal result; however, the biopsy of transversal colon showed a well-differentiated adenocarcinoma 337 vol 47 • number 4 • october 2015 supraclavicular lymphnodes better result of chest radiograph. however, further investigations are necessary to confirm the diagnosis of lung process. discussion colorectal carcinoma is the second leading cause of death from gastrointestinal tract (git) cancer in us. it is the 3rd common malignancy in both men and women, after lung, breast or prostate carcinoma.1 most of colorectal carcinoma developed metastatic disease (60%). the metastasic process to liver alone is account for 50%, which more frequently found in sessile polyps. according to petrek, the common location of colorectal carcinoma are rectum (22%), recto sigmoid (8%), sigmoid (20%), descendingt colon (12%), flexure lienalis (8%), transversum (6%), flexure hepatica (4%), ascending colon (6%), caecum (12%), and appendix (2%) of all colorectal carcinoma. signs and symptoms of colorectal carcinoma depend on the location and the size of the tumor itself. abdominal pain and polypoid fungating are signs and symptoms, which are commonly found in carcinoma of caecum and ascending colon; while recto sigmoid carcinoma usually presents the sign of obstruction/napkin rings or bleeding. in addition, colorectal carcinoma also may present with abdominal pain (60.5%), anemia (21.3%), weight loss (28.8%), changes in bowel habits (48%), diarrhea (12.7%), hematoschezia (48.5%), hemorrhoid (10.4%), abdominal mass (24.2%), rectal mass (7.9%), obstruction (17.0%), and asymptomatic (2.5%). sometimes, the tumor invades into the intestine wall and perforates. when this occurs, it will cause peritonitis and septicemia. if the tumor gets ulcerated and involves blood vessel, it may cause bleeding. according to odone, the first appearance of the tumor may need 3-12 months to be noticed; while according to petrek, colorectal carcinoma is uncommon in young age patients.1 the screening tests include stool examination, barium enema and detection of circulating antigen for all people over 40 years of age. cea, a tumor marker found by gold and freedman, is detected in 72-92% of patients with colorectal carcinoma. cea will be increased within 6-10 months before signs of metastasis develop or when the signs relapse. it is also will be markedly increased in poorly differentiated colorectal carcinoma as well as in colorectal carcinoma that has been spread to blood vessel and lymphatic nodes. supraclavicular lymph node is an unusual metastatic site for colorectal carcinoma. it is usually a metastatic site for gastric carcinoma. liver metastasis is a common complication of cancer occurring in up to 70% of patients with advanced breast or prostate cancer and approximately 15% to 30% of patients with carcinoma of the lung, colon, stomach, bladder, uterus, rectum, thyroid, or kidney.2 the patient was first diagnosed with carcinoma of unknown origin. later, he was diagnosed with carcinoma of unknown primary. carcinoma of unknown primary (cup) is a biopsy-proven diagnosis of malignancy (mainly epithelial) for which the anatomic site of origin remains unidentified after an intensive search. cup is one of the 10 most frequently diagnosed cancers worldwide. it contributes to approximately 3–5% of all cancer cases.4 most investigators rarely consider lymphomas, metastatic melanomas, and metastatic sarcomas that present without a known primary tumor to be cup since those cancers have specific stage and histological-based treatments. a standard workup for cup includes history taking, physical examination, and laboratory studies such as liver and renal function tests, hemogram, chest x-ray, ct scan of the abdomen and pelvis, mammography in women, and prostate-specific antigen (psa) test in men. with increasing availability of additional sophisticated imaging techniques and the emergence of targeted therapies that have been shown to be effective in several cancers, oncologists must decide on the extent of workup that is warranted. specifically, they must consider how additional diagnostic procedures may affect the choice of therapy and the patient’s survival and quality of life. the reason why tumors present as cup remains unclear. one hypothesis is that the primary tumor either regresses after seeding the metastasis or remains so small that it is not detected. it is possible that cup falls on 338 harijono achmad acta med indones-indones j intern med the continuum of cancer presentation where the primary has been contained or eliminated by the natural body defenses.3 alternatively, cup may represent a specific malignant event that results in an increase in metastatic spread or survival relative to the primary. whether the cup metastases truly define a clone that is genetically and phenotypically unique to this diagnosis remains to be determined.3,4 because all these reasons, liver metastasis is a serious and costly complication of cancer. the extent of angiogenesis in cup relative to that in metastases from known primaries has also been evaluated, but no consistent findings have emerged. physical examination, including a digital rectal examination in men and breast and pelvic examinations in women, should be performed. determining the status of patient’s performance, nutritional status, co-morbidities and cancerinduced complications are essential as it may affect the treatment strategies. most tumor markers, including cea, ca125, ca 19-9, and ca 15-3, when the levels are increased, are nonspecific and they are not helpful in determining the primary tumor site. men who present with the signs and symptoms of adenocarcinoma and osteoblastic metastasis should undergo psa test. patients with an elevated psa level should be treated as having prostate cancer.6 in patients with undifferentiated or poorly differentiated carcinoma (especially those with a midline tumor), elevated β-human chorionic gonadotropin (βhcg) and α fetoprotein (afp) levels suggest the possibility of an extragonadal germ cell (testicular) tumor. cytogenetic studies had a larger role in the past and the interpretation of these older studies can be challenging. they are indicated only occasionally. we reserve them for undifferentiated neoplasm with inconclusive immunohistochemical stains and for those for with a high suspicion of lymphoma. chest x-rays are always planned, but the results are often negative, especially with lowvolume disease. ct scans of the chest, abdomen, and pelvis can be used to help finding the primary tumor, evaluating the extent of disease, and selecting the most favorable biopsy site. older studies suggested that the primary tumor site is detected in 20–35% of patients who undergo a ct scan of the abdomen and pelvis; although by current definition these patients would not be considered as having cup. older studies also suggest a latent primary tumor prevalence of 20%; however, with more sophisticated imaging, this prevalence is <10% today. a conventional workup for a cervical cup (a neck lymphadenopathy with unknown primary tumor) includes a ct scan or mri and invasive studies such as indirect and direct laryngoscopy, bronchoscopy, and upper endoscopy. 18 f-fluorodeoxyglucose (fdg) positron emission tomography (pet) scans are useful in this patient population and it may help in guided biopsy, determining the extent of disease, facilitating the appropriate treatment including planning radiation fields and providing help with disease surveillance.6 invasive study including upper endoscopy, colonoscopy, and bronchoscopy, should be limited to symptomatic patients or those with laboratory or pathologic abnormalities. it suggests that these techniques will result in a high tumor yield. on light microscopy, 60% of cups are found to be adenocarcinoma and 5% are squamous cell carcinoma. the remaining 30% of lesions are diagnosed as poorly differentiated a d e n o c a r c i n o m a , p o o r l y d i ff e r e n t i a t e d carcinoma, or poorly differentiated neoplasm. a small percentages of lesions are diagnosed as neuroendocrine cancers (2%), mixed tumors (adenosquamous, or sarcomatoid carcinomas), or undifferentiated neoplasm. in the absence of a known primary cancer, developing therapeutic strategies for cup is challenging.5,7 the current diagnostic yield with imaging and immunochemistry is ~20–30% for cup patients. the use of gene expression studies holds the promise of substantially increasing this yield. gene expression profiles are most commonly generated using quantitative rt-pcr or dna micro array. it is often confused in early identification of primary site and management to prevent complication of the liver. by a thorough understanding of the etiologic factors and deforming forces, treatment can be planned for 339 vol 47 • number 4 • october 2015 supraclavicular lymphnodes each specific patient.8-10 virchow’s node (or signal node) is a lymph node in the left supraclavicular fossa (the area above the left clavicle). it takes its supply from lymph vessels in the abdomen cavity. the finding of an enlarged and hard node (also referred to as troisier’s sign) has long been regarded as strongly indicative for the presence of cancer in the abdomen, particularly the gastric cancer that has spread through the lymph vessels. conclusion the liver metastasis commonly remains unrecognized, particularly in the acute phase, until severe complications occur. we should perform biopsy although we could only find minimal lesion in colonoscopy / endoscopy examination early recognition and diagnosis as well as treatment strategies can be better formulated for the possible outcomes. references 1. jones rs, schlesinger mh. cancer of colon and rectum. in: schlesinger mh, fardtran if, eds. cancer colon and rectum . philadelphia: wb saunders; 1998. p. 1784-99. 2. anderson r. secondary tumour of liver. muir’s textbook of surgical pathology. london: the english language book society and edward arnold; 1996. p. 640. 3. abbruzzese jl. the biology of unknown primary tumors. semin oncol. 1993;20:238. 4. bugat r. summary of the standards, options and recommendations for the management of patients with carcinoma of unknown primary site. br j cancer. 2003;89 (suppl 1):s59. 5. culine s. cisplatin in combination with either gemcitabine or irinotecan in carcinomas of unknown primary site: results of a randomized phase ii study— trial for the french study group on carcinomas of unknown primary (gefcapi 01). j clin oncol. 2003;21:3479. 6. dennis jl, oienka. hunting the primary: novel strategies for defining the origin of tumours. j pathol. 2005;205:236. 7. greco fa, hainsworth jd. one-hour paclitaxel, carboplatin, and extended-schedule etoposide in the treatment of carcinoma of unknown primary site. semin oncol. 1997;24(6 suppl 19):s19. 8. kende ai. expression of cytokeratins 7 and 20 in carcinomas of the gastrointestinal tract. histopathol. 2003;42:137. 9. lobins r, floyd j. small cell carcinoma of unknown primary. semin oncol. 2007;34:39. 10. olson ja, jr. magnetic resonance imaging facilitates breast conservation for occult breast cancer. ann surg oncol. 2000;7:411. review article 340 acta medica indonesiana the indonesian journal of internal medicine the role of endothelial progenitor cell in cardiovascular disease risk factors rahmawati minhajat1,2, dina nilasari1, syakib bakri1 1 department of internal medicine. faculty of medicine hasanuddin university, makassar, indonesia. 2 department of histology, faculty of medicine hasanuddin university, makassar, indonesia. correspondence mail: department of internal medicine, faculty of medicine hasanuddin university. a building, 5th floor. tamalanrea km.11 makassar 90245, indonesia. email: rahmawati.minhajat@gmail.com. abstrak endothelial progenitor cells (epcs) adalah sel yang berasal dari sumsum tulang dan bersirkulasi di darah perifer. sel ini memiliki karakteristik mirip stem cell (sel punca), tetapi dengan kemampuan berproliferasi dan berdiferensiasi yang lebih terbatas. penemuan epc telah mengubah paradigma lama dalam bidang biologi vaskular dan membawa implikasi besar dalam dunia kedokteran karena epc dapat memediasi proses vaskulogenesis dan menjaga integritas pembuluh darah. peningkatan jumlah epc dalam sirkulasi menjadi penting karena berkorelasi positif dengan reendotelialisasi dan neovaskularisasi yang berhubungan erat dengan kesehatan kardiovaskular. dengan demikian, epc berpotensi digunakan untuk terapi penyakit akibat disfungsi endotel. kata kunci: endothelial progenitor cell, disfungsi endotel, vaskulogenesis, reendotelialisasi. abstract endothelial progenitor cells (epcs) are cell derived from bone marrow and the cells circulate in peripheral blood. these cells have characteristics similar to stem cells, but their ability to proliferate and differentiate is more limited. epc discovery has changed the old paradigm in the field of vascular biology and it brings huge implications in medicine as epcs can mediate the processes of vasculogenesis and maintain the vascular integrity. increasing amount of epc in the circulation is important since it has positive correlation with reendothelialization and neovascularization and they are closely linked to cardiovascular health. thus, epc could potentially be used for treatment of disease caused by endothelial dysfunction. key words: endothelial progenitor cell, endothelial dysfunction, vasculogenesis, reendothelialization. introduction endothelial progenitor cells (epcs) are cells derived from bone marrow and they circulate in peripheral blood. the cells have characteristics similar to stem cells, but their ability to proliferate and differentiate is more limited, i.e. they only can differentiate into endothelial cells.1,2 in 1997, asahara et al3 has successfully isolated epc from peripheral blood for the first time. the cells have positive surface antigen for mucosialin (cd34) and vascular endothelial growth factor receptor-2 (vegfr-2/flk-1). in vitro, the cells have a potency to develop into mature endothelial cells and in vivo, they have roles in neoangiogenesis. shi et al4 have demonstrated that mononuclear cells which contain bone-marrow-derived-cd34+ surface antigen can be mobilized to peripheral circulation vol 47 • number 4 • october 2015 the role of endothelial progenitor cell in cardiovascular disease risk factors 341 and can differentiate into mature endothelial cells. since the discovery, mononuclear cells of peripheral blood which have cd34+ surface antigen are believed to be derived from the bone marrow and the cells are originated from the same precursor of hematopoetic stem cells (hemangioblast) since both of them show the same surface antigen, i.e. which is positive to cd34, prominin-1 (cd133) and flk-1.3,5 the epc discovery has changed the old paradigm in the field of vascular biology, which believes that the process of vasculogenesis exclusively occurs only during embryogenesis. s o m e e v i d e n c e s i n d i c a t e t h a t p o s t n a t a l neovascularization is not only derived from proliferation, migration and remodeling of endothelial cells on vascular wall (angiogenesis), but it also involve epc recruitment from bone marrow, a process that has been known as vasculogenesis.6-8 the discovery has brought huge implications in medicine as epcs can mediate the processes of vasculogenesis and maintain the vascular integrity.3 risk factors for cardiovascular diseases are smoking, hypertension, diabetes mellitus and dyslipidemia, which show reduced number of epcs. thus, epc could potentially be used for treatment of ischemic disease by mechanisms of vasculogenesis through reendothelialization and neovascularization. both are the key process to improve the quality of blood vessels and to repair tissue ischemia.8,9 mobilization, differentiation and epc homing the main source of epcs is bone marrow, but the cells can also be isolated from peripheral and umbilical blood. in normal condition, the number of epcs from those various sources is very limited; while the mobilization from bone marrow and the number in the circulation are extremely affected by endogenous, exogenous factors as well as physiological and pathological conditions.6,10,11 the release of epcs from bone marrow is affected by various growth factors, enzymes, ligands and surface receptors. the natural response of body tissues when there is hypoxia is increasing the production and secretion of factors that stimulate neovascularization in order to reduce hypoxia. in hypoxia state, the hypoxia-inducible transcription factor1α (hif-1α) induces transcription of various proangiogenic proteins such as vegf, stromal cell-derived factor-1 (sdf-1) and monocytes chemotatic protein-1 (mcp-1), which will actively recruit epcs from bone marrow to the circulation and then guide them to hypoxic site. moreover, the local condition of bone marrow has important role in epc mobilization. the cytokines of granulocyte colony-stimulating factor (g-csf), matrix metalloproteinases-9 (mmp-9), vegf, sdf-1, endothelial nitric oxide synthases (enos) and nitric oxide (no) induce mobilization by interfering the interaction between epc and the stroma cells of bone marrow, which allow epcs to be released from bone marrow through endothelial sinusoid and entering the blood circulation. the process is the initial phase of epcs mobilization from the bone marrow.12,13 the process of epcs differentiation into mature endothelial cells is still poorly understood. various studies found that vegf induces epcs differentiation and the process of epcs differentiation into mature endothelial cells has occurred gradually since the migration of epcs from bone marrow to the systemic circulation.10,14 as a response to proinflammatory cytokines released by hypoxic tissue, endothelial cells will increase the expressions of adhesion molecules cells such as e-sellectin, intercellular adhesion molecule-1 (icam-1), vascular adhesion molecule-1 (vcam-1) and β1-integrin, which facilitate epcs attachment to local endothelial cells. next, the epcs secrete mmps and matrix metalloelastases (mmes), which locally impair extracellular matrix and it initiates neovascularization.12 morphologically, epcs cannot be identified, but there are some specific markers that can be used. in the early phase, the cells showed positive response to cd133, cd34 and vegfr-2. cells that shows positive response to those three markers are mainly still in the bone marrow; while the cells which are already present in peripheral circulation show diminishing expression of cd133; however, the expressions rahmawati minhajat acta med indones-indones j intern med 342 of cd34 and vegfr-2 are still present. the next development is the advance phase of epc (the mature endothelial cells), in which the expression of cd34 has diminished, but the vegfr-2 is still positive and the expressions of vascular endothelial cadherin (ve-cad), platelet endothelial cell adhesion molecule-1 (pecam-1/ cd31) and von willebrand factor (vwf) is initiated.13-15 markers of epcs mobilization include sdf-1, mmp-9, gcs-f and enos. marker which shows the quantity of epcs is the expression of total cd34; while the marker for epcs quality are viable cd34, vegfr-2 and epc culture cells.13 endothelial dysfunction and the role of epc endothelial cell is a layer of cell covering the inner side of vascular wall. the cell responds to each physical or chemical stimulation by releasing appropriate substances to maintain vasomotor balance and vascular hemostasis. a condition, in which the endothelial cell loses its ability to maintain the balance and when the endothelial cells have lost its physiological capacity to promote vasodilation, fibrinolysis and antiagregation effect, is called as endothelial dysfunction.14,15 t h e p a t h o p h y s i o l o g y o f e n d o t h e l i a l dysfunction is very complex and involves various mechanism through oxidative stress, i.e. a condition with increased reactive oxygen s p e c i e s ( r o s ) p r o d u c t i o n a n d r e d u c e d antioxidant level. increased ros causes deprivation in no availability, i.e. a substance produced by endothelial cells through enos activation.16 nitric oxide not only has a role in epcs mobilization, but it also has a role in epcs migration and proliferation.16 moreover, increased oxidative stress will initiate nf-κb that may lead to inflammatory process as a beginning of atherosclerosis process.17 there is a dynamic correlation between inflammation, oxidative stress and epcs mobilization. oxidative stress stimulates inflammatory process, in which proinflammatory cytokines will stimulate the production of growth factors such as vegf, that will further stimulate epcs mobilization to the circulation. inflammation may have good and bad impacts on epcs. the limited and temporary inflammatory response can stimulate epcs mobilization; while excessive and continuous response will cause reduced epcs in the circulation. an in vitro study has demonstrated that inflammation and oxidative stress may affect epc mobilization. the presence of continuous factors causes damages or continuous endothelial dysfunction which may ultimately cause reduction or exhaustion in epcs supply.13 the number of epcs in the circulation has negative correlation with the degree of endothelial dysfunction in patients with various cardiovascular risk factors. there is a correlation between the number of epcs and endothelial dysfunction, i.e. reduced number of epcs can predict the incidence of cardiovascular disease in the future.18,19 the role of epcs in vascular repair is through normalization of endothelial function and improvement of blood flow in injured vascular area. since endothelial cells are mature cells which has poor capacity to proliferate, i.e. only about 0.01%,20 therefore, epcs play an important role in maintaining endothelial layer through reendothelialization and neovascularization. it also indicates that epcs can be used as a potential therapy for treating endothelial dysfunction.21 condition and factors affecting the number and function of epcs the number of epcs in the circulation of healthy individual is very limited, i.e. less than 1% of total bone marrow cells and less than 0.01% of total mononuclear cells in peripheral blood; however various factors and conditions can affect its number and function.6 evidences of some studies show that patients with cardiovascular risk factors such as age, sex, smoking habits, hypertension, diabetes mellitus (dm) and dyslipidemia have reduced number and function of epcs. in contrast, some cytokines, hormones, medicines and physical activity can improve its number and function.11 a study has demonstrated that the number of epcs is increased significantly for a short of time after acute myocardium infarction (ami) attack and it reaches peak level on the seventh day after the vol 47 • number 4 • october 2015 the role of endothelial progenitor cell in cardiovascular disease risk factors 343 attack and subsequently, the level decreases.22 another study that evaluated the number of cd34+ cells in patients with heart failure shows that there is increasing biphasic response, i.e. increased cd34+ cells in patients with class i new york heart association (nyha), but it is reduced in patients with class iv nyha and the number is even lower when compared with control.23 there are physiological conditions affect the number and function of epcs, which include different age, sex and physical activity. estrogen has been known as a rapid stimulator for endothelial no production and enos activation. in addition, estrogen can also lower the level of endogenous asymmetric dimethylarginin (adma), which is the inhibitor of enos.24 fandini et al25 have reported that the number of epc is greater in fertile female than male subjects; however, the difference has not been found in postmenopausal women compared to men of the same age. the difference can represent the risk of cardiovascular risk in men and postmenopausal women, in which it is correlated to the low number of epcs. in aging process, there is also an imbalance between production of free radicals and the availability of antioxidant. there is a correlation between ros, inflammation and age, i.e. increased ros level will potentially stimulate chronic inflammation that ultimately will cause impaired epcs mobilization. thus, it has also been reported that there is reduced response of epc migration to vegf in elderly age as well as reduced clonogenic capacity of epc that has begun starting from the middle age.26 heiss et al27 have reported that the survival, migration and proliferation capacity of the epcs are lower in those with older age. the findings show that there is a negative effect of age on epc differentiation and proliferation, which is correlated to cardiovascular risk. physical exercise causes increased no production. in a study that evaluate the effect of physical exercise on epc in patients with stable coronary artery disease (cad), it found that the number of epc in the circulation increases significantly and the apoptosis is reduced after physical exercise for 28 days compared to the first day of exercise. increased epc number is correlated to higher no availability after physical exercise. the study demonstrates that physical exercise increases the number of epc in bone marrow and peripheral blood, in which the upregulation of epc in physical exercise depends on no and vegf.28 smoking is one of risk factors causing endothelial dysfunction. the high level of oxidative stress in smoker can potentially affect epc mobilization and survival in vivo, in which there is 50% reduction of epc number in smokers compared to the control.29 hypertension is also characterized by endothelial dysfunction and reduced no availability. endothelial dysfunction in patients with early stage of hypertension can induce the development of epcs mobilization factor as the mechanism of compensation in the body. in the advanced stage of hypertension, which has continuous process of oxidative stress and inflammation, it will give contrary effect, i.e. reduced quality and quantity of epcs.2,13 in patients with hypertension there is accelerated aging of epcs and reduced activity of telomerase that affect vascular remodeling.30 dysfunction of epcs in hypertension causes endothelial repair and neoangiogenesis cannot take place and it will worsen the microvascular abnormality and atherosclerosis, which is the beginning of target organ damage in hypertension.31 in a study of subjects with refractory hypertension, the number of epcs was reduced to 76.7% compared to the control.32 angiotensin ii accelerates the onset of epcs aging through increased oxidative stress.33 a clinical trial in cad patients has demonstrated that ramipril can increase the number of epcs 2-5 folds as well as its function.34 treatment using angiotensin ii receptor antagonist also increases the number of epcs significantly, in which olmesartan treatment can cause increased epcs from 231+24 to 465+71; while irbesartan treatment increases the number from 196+15 to 300+23 after 4-week treatment.35 in patients with type 1 and type 2 dm, there is reduced number and function of epc in circulation. tapper et al36 have demonstrated that isolated epcs from peripheral blood of patients rahmawati minhajat acta med indones-indones j intern med 344 with type 2 dm have reduced proliferation capacity in the culture up to 48% compared to normal individuals. loomans et al37 also have reported similar results in patients with type 1 dm, i.e. there is reduced epcs number of 44% compared to the non-diabetics control group. there is a significant increase of epcs number in dm patients who were treated with insulin or oral diabetic agents.38 insulin stimulates no production; while in insulin resistance, there is an imbalance between endothelial damage and the ability of repair. this condition is correlated to reduced availability of no, increased ros production and pi3k/akt down-regulation. it is potentially disrupt the process of vascular repair, which is the role of epcs, including impaired epc mobilization from the bone marrow.39 increased plasma cholesterol level has significant correlation with endothelial damage and dysfunction. it has been proven that the number of epcs is reduced significantly in patients with hypercholesterolemia and the number of epcs has negative correlation with the level of total cholesterol and low density lipoprotein (ldl) cholesterol.40 anti-inflammatory agents and antioxidants such as hmg-coa reductase inibitors(statin) have been proven to have positive effects on epc. statin increases mobilization and function of epc through upregulation of pi3k/ akt. the effect of statin in mobilizing epc to the circulation is correlated with increased reendothelialization and reduced neointima resulting in reduced restenosis.41,42 clinical application of epcs several studies have been conducted to sound out the application of epcs in clinical settings. although the basic biomolecular mechanism of epcs has not been fully understood, some studies have shown promising results. increasing epcs number in the circulation is essential as it correlates positively with reendothelialization and neovascularization, which has strong association with cardiovascular health.26 the use of epcs as target therapy is based on the results of some studies such as: local injection or infusion of fresh cd34+ cells isolated from human can accelerate the blood flow to the ischemic area in diabetic experimental animal model. in a clinical trial, epcs transplantation to those with myocardium infarct, ischemia, coronary arterial disease and heart failure has been proven to be appropriate and safe.43 epcs transplantation is one of promising strategies for restoring blood flow in ischemic diseases such as ischemic heart disease and peripheral artery disease (pad).44 in a study of transplantation of progenitor cells and regeneration enhancement in acute myocardial infarction (topcare-ami), epcs was given by intracoronary infusion to 20 patients with acute myocardium infarction. the study shows that there is significant increase of ejection fraction, smaller area of infarction and better perfusion of myocardium.45 as a target therapy, in addition to its benefit for additional vascularization in ischemic tissue, it can also be used to deliver antior pro-angiogenic agents.3 the very limited number of epcs will limit the use of epcs as a therapy. the number of epcs needed for therapy in human adults is relatively large, i.e. about 3x108 to 6x108 cells, which means that 8.5-120 liter of peripheral blood is necessary to generate adequate number of epcs.46 to overcome the limitation, we need an effort to expand the number of epcs. some strategies that have been considered as applied epcs for treatment are:44 1) in vivo expansion of epcs. some candidates can be used to induce epc in vivo such as vegf, gm-csf and statin; 2) ex vivo expansion of epc. the strategy is performed by taking mononuclear cells from peripheral blood of healthy individual and then the cells are cultured. after obtaining sufficient number of epcs, the epcs are then injected to ischemic area; 3) local injection of epc. local injection of sdf-1 can increase the accumulation of the transplanted epcs resulting in increased neovascularization. combination of sdf-1 local injection and epcs transplantation is a potential strategy for neovascularization therapy; 4) epcs modification through gen transfer. various studies have been conducted and still on going to enhance the effort of epc expansion including by genetic engineering, i.e by transferring human telomerase reverse transcriptase (htert) gene or coding genes for vol 47 • number 4 • october 2015 the role of endothelial progenitor cell in cardiovascular disease risk factors 345 proangiogenesis factor such as vegf into epcs. the prognostic value of epcs there is a correlation between the number of epcs and endothelial dysfunction, i.e. reduced number of epcs can predict the incidence of cardiovascular disease in the future. the number epcs isolated from the patients with cardiovascular risk factors has a significant negative correlation with the risk factor score based on the framingham score.47 epcs level is an independent predictor for mortality due to chronic heart failure, in which the level is not affected by the etiologies of heart failure, instead it is more correlated to clinical status of the patient evaluated by nyha classification. epcs level has been suggested to be an additional marker for clinical follow up of patients with chronic heart failure.48 the number of epcs in the circulation is extremely reduced in patients with type 2 dm, metabolic syndrome and individuals with insulin resistance. in those with metabolic syndrome, the epcs level has negative correlation with homa score. the level of epc in patients with type 1 and type 2 dm also has negative correlation with hba1c level.47,28,62 conclusion endothelial progenitor cell can be isolated from peripheral blood, in which the cells undergo differentiation into mature endothelial cells and are involved in reendothelialization as well as neovascularization in endothelial dysfunction. the cells is usually identified through positive expressions of cd133, cd34 and vegfr-2. epcs mobilization from bone marrow and its number in circulation is extremely affected by endogenous and exogenous factors as well as physiological and pathological conditions. the cells have important roles in prevention and therapy of cardiovascular diseases. the higher the number of endothelial progenitor cells in circulation, the more protective it is for blood vessels, particularly reendothelialization and neovascularization of ischemic tissue and epcs can be used as a predictor of cardiovascular disease in the future. references 1. kovacic jc, moore j, helbert a, et al. endothelial progenitor cells, angioblast, and angiogenesis: old term reconsidered from a current perspective. trends 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disease risk factors 347 49. fadini gp, de kreutzenberg sv, coracina a, et al. circulating cd34+ cells, metabolic syndrome, and cardiovascular risk. eur heart j. 2006;27:2247-55. 50. fadini gp, de kreutzenberg sv, coracina a, et al. circulating cd34+ cells, metabolic syndrome, and cardiovascular risk. eur heart j. 2006;27:2247-55. 175 original article acta medica indonesiana the indonesian journal of internal medicine clinical outcome and survival of osteosarcoma patients in cipto mangunkusumo hospital: limb salvage surgery versus amputation achmad f. kamal1, heru widyawarman2, kurniadi husodo2, errol u. hutagalung1, wulyo rajabto3 1 department of orthopaedic and traumatology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 resident, department of orthopaedic and traumatology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 3 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: achmad fauzi kamal, md, phd. department of orthopaedic and traumatology, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: fauzi.kamal@ ui.ac.id. abstrak tujuan: menganalisis luaran dan kesintasan pasien-pasien osteosarkoma yang menjalani limb salvage surgery (lss) dan amputasi di rumah sakit cipto mangunkusumo, serta faktor-faktor yang mempengaruhi luaran fungsional dan prognosis. metode: ini adalah studi kohort retrospektif pasien osteosarcoma pada rs cipto mangunkusumo yang menjalani operasi penyelamatan ekstremitas (lss), amputasi, lss + amputasi, dan menolak operasi dari tahun 1995-2014. pemilihan jenis tindakan dilakukan berdasarkan usia, stadium, lokasi, keterlibatan neurovaskular, tipe huvos, kebutuhan fungsional, pilihan pasien, dan keadaan umum pasien. luaran fungsional dinilai dengan skor musculoskeletal tumor society (msts) dengan nilai maksimal 30. hasil: subjek penelitian meliputi 80 laki-laki dan 52 perempuan berusia 4 hingga 61 tahun. tindakan yang dilakukan meliputi limb salvage surgery (lss) (n=37), amputasi (n=42), lss + amputasi (n=2), dan menolak pembedahan (n=51). angka kesintasan 5 tahun kumulatif adalah 14.6%. angka kesintasan 5 tahun masingmasing kelompok; lss, amputasi, kombinasi lss dan amputasi, dan menolak tindakan masing-masing adalah 34,8%; 15,9%, 0%, dan 0%. pasien ukuran tumor <8 cm cenderung menjalani lss dibandingkan amputasi (60,7% vs 39,3%, p=0,046). angka bebas rekurensi lokal 5 tahun untuk lss dan amputasi masing-masing adalah 96,2% dan 86,5% (p=0,586). lss menunjukkan skor fungsional msts yang lebih tinggi dibandingkan dengan amputasi (25,0% vs 18,5%, p=0,011). kesimpulan: kesintasan lss lebih baik daripada amputasi pada pasien osteosarkoma yang dirawat di rumah sakit cipto mangunkusumo. luaran fungsional skor msts pasien lss lebih baik daripada amputasi. kata kunci: osteosarkoma, limb salvage surgery, amputasi. abstract aim: to analyze the outcome and survival rate of osteosarcoma patients in our hospital as well as the factors affecting prognosis and functional outcome. methods: this is a retrospective cohort study of osteosarcoma patients in cipto mangunkusumo hospital underwent limb salvage surgery (lss), amputation, lss + amputation, and achmad f. kamal acta med indones-indones j intern med 176 refused surgery from year 1995 to 2014. the surgical decision was based on patient’s age, staging, location, neurovascular involvement, huvos type, functional demand, patient preference, and general condition. functional outcome was assessed using the musculoskeletal tumor society (msts) score with the maximum score of 30. results: subjects consisted of 80 male and 52 female aged 4 to 61 year-old. they underwent limb salvage surgery (lss) (n=37), amputation (n=42), lss + amputation (n=2), and refused surgery (n=51). overall 5-year cumulative survival rate was 14.6%. the 5-year survival rate for each group; lss, amputation, combined lss and amputation, and refused surgery was 34.8%; 15.9%; 0%; and 0%, respectively. patients with tumor size <8 cm tend to underwent lss compared to amputations (60.7% vs 39.3%, p=0.046). local recurrence-free survival for lss and amputation was 96.2% and 86.5% respectively (p=0.586). msts score was higher in lss than amputation group (25.0 vs 18.5, p=0.011). conclusion: lss had higher survival rate than amputation in osteosarcoma patients who were treated in cipto mangunkusumo hospital. msts functional score in the lss group was higher than amputation group. keywords: osteosarcoma, limb-salvage surgery, amputation. introduction osteosarcoma is a malignant bone tumor derived from primitive mesenchyme cells and consists of malignant cells that produce bone and osteoid matrix.1-3 it is the most common malignant bone tumor of non-hematopoietic origin, which is frequently found at the metaphyseal long bones such as the distal femur, proximal tibia, and proximal humerus during the second decade of life.1-3 incidence of osteosarcoma in all population is approximately 4-5 per 1,000,000 population.3 it is higher in adolescents to 8-11 per one million population per year at the age of 15-19 years.4-5 in the united states, osteosarcoma are the most common primary malignancy of bone, representing approximately 56% of malignant bone tumors in children.6-7 osteosarcoma is also the most common primary malignant bone tumor in cipto mangunkusumo hospital (cmh) jakarta, indonesia. kamal et al.8 reported 16.8 osteosarcoma new cases per year (total number 219 patients) who came to cmh from 1995 to 2008. because of the rapid and aggressive nature of this tumor, the standard management for osteosarcoma is limb amputation.9-10 however, over the past 3 decades, since the development of effective chemotherapy agents has reduced the incidence of metastasis, the prognosis for patients with osteosarcoma has changed dramatically.11-12 multiple studies have shown the results of limb-salvage operation compared to amputation.13-14 simon et al.15 and rougraff et al.16 have reported that the survival of patients with either limb salvage or amputation is no different, although there is a higher rate of local recurrence in patients with limb salvage. it is generally accepted that, if the surgery is carried out in an appropriate oncological manner, there is no detriment to the survival of patients treated with limb salvage in a variety of techniques.17-18 the aim of limb salvage surgery (lss) is to widely resect the local tumor and to preserve normal soft tissue as much as possible, thus provide a well-functioning, tumor-free, and painless limb. many options of lss have been developed, including resection arthrodesis, resection and reconstruction using bone graft (autograft, allograft, extracorporeally irradiated autograft or endoprosthetic composite), endoprosthesis reconstruction, ilizarov lengthening technique, rotation plasty, etc.13-14,18-19 in this study, we analyze the outcome and survival rate of osteosarcoma patients as well as the factors affecting prognosis in cipto mangunkusumo hospital, jakarta, indonesia. methods this is a retrospective cohort study using secondary data from musculoskeletal oncology registries, medical records, and follow up care in outpatient clinic or home visit treated in cipto mangunkusumo hospital, jakarta, indonesia, from 1995 to 2014. all lesions were clinically, radiologically, and histologically confirmed as vol 48 • number 3 • july 2016 clinical outcome and survival of osteosarcoma patient 177 osteosarcoma. for each patient, we recorded gender, age, presenting symptom and its duration, tumour size, location, haemoglobin, serum alkaline phosphatase (sap), type of biopsy performed, histologic type of osteosarcoma, huvos grade and treatment performed. we evaluated the presence of local recurrence, metastasis, musculoskeletal tumor society (msts) functional outcome score, and survival after treatment. age was classified in groups of decades. presenting symptoms were mass, pain, mass and pain, and bleeding. duration of symptoms were measured in months. tumor size was divided in 2 groups (<8 cm and >8 cm). type of biopsy were divided into fine-needle aspiration biopsy (fnab), core neddle biopsy, open biopsy, or combination between those. types of patient management were divided into operative (lss or amputation or both), chemotherapy only, and refused treatment. local recurrence was detected by physical, radiologic, and histopathology examinations. metastasis was detected by chest x-ray, computed tomography (ct) scan, and/or bone scintigraphy. osteosarcoma patients who did not complete the profile data and the follow up of their condition were excluded. statistical analysis was performed using statistical program for social sciences (spss) software version 20. chi-square analysis was performed to evaluate the tumor and patients’ demographics and its correlation to the presence of local recurrence, metastases, complications, and mortality rate. kaplan-meier curve was used to describe the survival in the univariate analysis, its correlation with types of surgery, time to event analysis where as time to local recurrence were analyzed by log rank test. a p-value of 0.05 was considered as statistically significant. this study had been approved by research ethics committee, faculty of medicine universitas indonesia, cipto mangunkusumo hospital number 247/h2.f1/etik/2014. results during january 1995 to june 2014 period, there were 132 consecutive osteosarcoma patients who were included in the study. seventy six (57.6%) patients were in relatively young age group (11 20 year-old) with median of 17.5 year-old (interquartile range 14.0 23.0 yearold). male and female patients were 80 (60.6%) and 52 (39.4%) respectively. the most common complaint was mass (79.5%) with median duration of 4.0 months (interquartile range 3.07.8 months), poor general condition (62.1%), relatively low hemoglobin level (median 11.6; interquartile range 9.7-13.3) and elevated level of alkaline phosphatase (56.2%). patients with tumor size smaller than 8 cm tend to undergo lss (60.7%) compared to amputation (60.7% vs 39.3%, p=0.046) (table 1). overall local recurrence-free survival for osteosarcoma patient was 93.4%. five year local recurrence-free survival for lss and amputation showed 96.2% versus 86.5% (p=0.586), respectively (table 2). msts score in lss group was significantly higher than amputation group (25.0 versus 18.5, p=0.011). however, no statistically significant difference was found between two surgical techniques to the msts score category (table 3). the mortality rate in amputation group was higher compared to the lss group (p = 0.038) (table 4). overall, the proportion of 5-year cumulative survival rate was 14.6%, where as the lss, amputation, combined lss and amputation, and refused treatment had 5 year survival rate of 34.8%; 15.9%; 0%; and 0%, respectively. lss group had the highest survival rate (figure 1). table 1. characteristics of osteosarcoma patients in cipto mangunkusumo hospital characteristics n=132 age, years, median (iqr) 17,5 (14,0–23,0) age groups, years, n (%) 0 -10 12 (9.1) 11-20 76 (57.6) 2130 22 (16.7) 3140 11 (8.3) >40 11 (8.3) gender male 80 (60.6) female 52 (39.4) achmad f. kamal acta med indones-indones j intern med 178 table 1. characteristics of osteosarcoma patients in cipto mangunkusumo hospital characteristics n=132 symptom, n (%) mass 105 (79.5) pain 18 (13.6) mass and pain 7 (5.3) bleeding 2 (1.5) symptom duration, months, median (iqr) 4 (3.0-78) general condition, n (%) poor 82 (62.1) moderate 24 (18.2) good 26 (19.7) hemoglobin, mg/dl, median (iqr) 11.6 (9.7-13.3) alkaline phosphatase, iu/l, median (iqr) 334 (185-666) normal 57 (43.8%) elevated (>270) 73 (56.2%) tumor size, cm, median (iqr) 12.0 (8.0-20.0) <8 cm, n (%) 41 (31.1) >8 cm, n (%) 91 (68.9) tumor location, n (%) femur distal 52 (42.4) femur proximal 4 (3.0) knee/patella 4 (3.0) tibia distal 5 (3.8) tibia proximal 42 (31.8) fibula distal 1 (0.8) fibula proximal 2 (1.5) humerus distal 3 (2.3) humerus proximal 7 (5.3) radius distal 1 (0.8) radius proximal 1 (0.8) forearm 1 (0.8) clavicle 2 (1.5) pelvis/ischium/ilium/sacrum 2 (1.5) rib 3 (2.3) foot/ankle 2 (1.5) table 1. characteristics of osteosarcoma patients in cipto mangunkusumo hospital characteristics n=132 stage (enneking), n (%) stage iib 101 (78.2) stage iii 31 (25.7) huvos type, n (%) huvos i 9 (33.3) huvos ii 7 (25.9) huvos iii 9 (33.3) huvos iv 2 (7.4) responsive 11 (40.7) unresponsive 16 (59.3) histological type, n (%) conventional 121 (91.7) giant cell rich 6 (4.5) small cell 4 (3.0) periosteal 1 (0.8) biopsy type, n (%) fnab 104 (78.8) open biopsy 16 (12.1) core biopsy 12 (9.1) type of surgery, n (%) limb salvage surgery (lss) 37 (28.0) amputation 42 (31.8) lss + amputation 2 (1.5) refused treatment 51 (38.6) table 2. local recurrence-free survival and average time-to-local recurrence 5-year local recurrence-free (95% ci) p value average time-to-local recurrence (95% ci) overall 93.4 (83.6–103.2) 0.586 168.3 (151.5–185.887) lss 96.2 (88.4–104.0) 164.3 (154.2–174.4) amputation 86.5 (66.9–106.1) 158.6 (123.5–193.7) discussion conventional osteosarcoma is more common in men than women by a ratio of 3 : 2. the tumor most commonly affect patients within the 2nd decade of life and more than 60% in patients less than 25 years old. the incidence of osteosarcoma is also increased at the 6th decade of life, so the disease has a bimodal distribution.3,20,21 vol 48 • number 3 • july 2016 clinical outcome and survival of osteosarcoma patient 179 table 3. functional outcome according to the type of surgery types of surgery p value lss amputation msts score, median (iqr) 25.0 (20.0-26.0) 18.5 (11.8–23.3) 0.011 msts score percentage, %, median (iqr) 83.3 (66.7–86.7) 61.7 (39.2–77.5) 0.011 msts score category, n (%) poor 0 (0.0) 1 (100.0) 0.212 fair 1 (33.3) 2 (66.7) good 5 (55.6) 4 (44.4) very good 11 (78.6) 3 (21.4) poor – fair 1 (25.0) 3 (75.0) 0.128 good – excellent 16 (69.6) 7 (30.4) table 4. mortality in relation to treatment, metastasis, and complication parameter no. (%) of patients p value dead alive treatment, n (%) lss 20 (54.1) 17 (45.9) 0.038 amputation 32 (76.2) 10 (23.8) metastasis, n (%) yes 55 (98.2) 1 (1.8) 0.001 no 47 (61.8) 29 (38.2) complication, n (%) yes 5 (55.6) 4 (44.4) 0.118 no 97 (78.9) 26 (21.1) osteosarcoma can occur in all bones, with the predilection site of metaphyseal region of the long bones (91%). distal femur and proximal tibia are the most common locations followed by proximal humerus, sometimes found in the diaphysis of long bones, but rarely found in the flat bones.1,3,4,20 in our study, male and female ratio is 1.54 : 1 with peak incidence in the second decade of life followed by the third decade. distal femur and proximal tibia are the most common locations of osteosarcoma. our result is similar with other study reported by picci et al.22 during 21 years of follow-up at one institution. the author also reported that osteosarcoma is more common in male patients, mostly in second and third decade of life with conventional osteosarcoma as the most common type and the most common location is in distal femur and proximal tibia. tan et al.23 also reported similar results. osteosarcoma patients usually come to the hospital because of pain that is initially mild and intermittent, but progressively becomes more intense and persistent. another common complaint is a lump in the extremities that swells rapidly and painful. tumor at the area near the joints often disturbs joint function. pathological fractures can occur in 5-10% of osteosarcoma patients.2,3 the other common symptoms are weight loss, fever, and malaise.1,3,4 laboratory tests are needed to assess patient’s general condition but cannot be the basis of diagnosis.4 increase in sap (serum alkaline phosphatase) usually occurs in osteosarcoma. sap level evaluation to show osteoblast activity are done regularly. the level of bone-specific achmad f. kamal acta med indones-indones j intern med 180 a figure 1. (a) overall survival curve for osteosarcoma patients. survival curve was based on kaplan-meier method. (b) comparison of survival curves according to the type of management of lss, amputation, combined lss and amputation, chemotherapy alone, and refused treatment. b alkaline phosphatase (bsap), although not specific for osteosarcoma should be used as a reference for a follow-up marker of metastasis and recurrence.3,21 in our study, sap values were divided into normal (43.2%) and increased (55.3%). in the management of osteosarcoma, biopsy plays a very important role for diagnosis. a biopsy can be done with fnab, core biopsy, or open biopsy. fnab is a technique which is simple, relatively safe and cheaper than the open biopsy with 70-90% diagnostic accuracy in determining the malignant primary bone lesions. fnab can also be done in the outpatient clinic, vol 48 • number 3 • july 2016 clinical outcome and survival of osteosarcoma patient 181 thus saving time and cost of hospitalization. neoadjuvant chemotherapy can also be given after fnab. another advantage is it only cause little interference or damage to soft tissue and bone with minimal risk of pathologic fractures.27-30 in our hospital, open biopsy in bone tumor is only performed if the result of fnab or core biopsy was inconclusive or inconsistent with the clinical and radiological findings. from 132 patients in this study, only 81 patients underwent surgery with 28.0%, 31.8%, and 1.5% patients underwent lss, amputation, and both procedures, respectively. the remainder of patients who refused surgery were further classified into receiving chemotherapy only (23.5%) and refused all treatment (15.2%). patients who only received chemotherapy came to the our hospital with enormous size of tumour that were indicated for amputation but refused it or due to advanced condition. they who refused any therapy possibly due to various factors such as socio-economic, health insurance, and beliefs. many still believe that chemotherapy may worsen patient’s condition and many are still afraid to undergo surgery. in general, these two groups (chemotherapy alone and refused any therapy) mostly came from patients that seek treatment before 2005. however after that era, our government provided national health insurance system for all indonesian resients and made them easier to gain health services in any level hospital. therefore, many patients came to the health care center early. in our study, tumor size and staging of cancer are the important factors which determine type of surgery. patients with tumor size smaller than 8 cm tended to undergo lss. osteosarcoma patients with stage iib who underwent the lss were less than those underwent amputation (52.6%). however, those with stage iii tended to undergo amputation (58.8%) compared to lss. several important factors to be considered for amputation are: large size tumor, neurovascular involvement, the presence of ulcer, hemorrhage from the tumor, and pathologic fracture. although in several cases of pathologic fracture, lss could be performed as long as the neoadjuvant chemotherapy gave good response. high sap values is one of the factors that determine prognosis. other prognostic factors include age ≤ 14 years, tumor volume > 200 ml, inadequate surgery, chemotherapy with a regimen of two drugs and poor histologic response to chemotherapy.21,24-26 in this study, lss group had higher survival rate than amputation group, with median survival time of 23.9 months. we believe that these results may be due to more complete chemotherapy in the group lss. other factors that influenced our patients’ survival are improvement of reconstruction technique of lss and biopsy type (fnab). they also affect the increase in survival of patients.31 we f o u n d a 5 y e a r s u r v i v a l r a t e o f osteosarcoma patients 14.6%. however, 5-year survival rate in patients who underwent lss was 34.8%. in other words, the lss group had higher survival rate than amputation group. lss group also had better result compared to chemotherapy alone or no treatment groups. it might be due to the patients who were performed lss received more complete chemotherapy compared to amputation group or more complete management (chemotherapy and surgery) than last two groups. this result is in contrast to tan et al.23 who reported a 5-year survival rate of 61.8% and foster et al.32 in canada who obtained 5-year survival rate of 62%. great difference in survival rate may be influenced by several factors such as the poor general condition of patients, large tumor size, chemotherapy completeness, unresponsive to chemotherapy (huvos grading), and complications. patients who underwent lss have a local recurrence rate of 3.8%, lower than patients who underwent amputation which is 13.5%. this result is in contrast to a study by dicaprio et al.33 who reported the incidence of local recurrence were higher in lss group compared to amputation. picci et al.34 reported that local recurrence in lss and amputation were 7% and 2.4%, respectively. some patients showed poor response to chemotherapy as showed with huvos histologic grading (55.6%), while the rest showed good response to chemotherapy (44.4%). these results differ from previous study that was reported by bacci et al.13 that showed histologic response to chemotherapy was good in 63% of patients. achmad f. kamal acta med indones-indones j intern med 182 histological response to chemotherapy is worse in our hospital may be due to resistance of chemotherapy regiments, different regiment type (in pediatric type), or larger tumor size. however, it is still needed for further evaluation. a number of patients died (80%) with 3.3% and 6.7% experienced local recurrence or complication, respectively. the percentage of patients in stage iii with metastases who had good and excellent functional status (66.7%) were lower than patients in stage iib (85.7%). unfortuntely, most of patients died and only 21.6% survived. on the contrary, only 35.1% patients experienced metastasis compared to those who did not (64.9%). the mortality rate in the amputation group was significantly higher than the lss group. high mortality rate was found in patients with metastases compared to those who did not. thus, it is concluded that metastases greatly affects survival. this result is consistent with other studies which mentioned rate of local recurrence and metastasis are important prognostic factors.35 metastasis to the lung is the most common. however, metastasis also occur to other bones (spine, acetabulum, cranium), lymph nodes, and heart. in our study, patients undergoing amputation were more likely to experience metastasis compared to lss. this could be due to more patients in the amputation group did not receive complete chemotherapy. only 16.6% of patients received complete chemotherapy. ward et al.18 reported tumor necrosis percentage of below 90% and inadequate chemotherapy were important risk factors associated with metastasis and death. the functional outcome based on msts system score in lss group was significantly higher compared to amputation group (83.3% versus 61.7%). patients who did not experience local recurrence were likely to have good and excellent functional outcome, whereas those with local recurrence had worse score. these results are supported by previous studies that mentioned functional outcomes in patients with lss procedure were better than amputation (without affecting the survival rate).16,36-38 aksnes et al.39 reported that amputation was one of the factors associated with low physical function. patients without metastasis and complications tend to have good and excellent functional scores. conclusion in our study, tumor size and staging of osteosarcoma were the important factors which determine type of surgery. combination of surgery and chemotherapy gave better survival than chemotherapy only. we confirmed that lss had higher survival rate than amputation in patients received complete chemotherapy in cipto mangunkusumo hospital. survival rate was influenced by the type of surgery, general condition, tumor size, chemotherapy completeness and responsiveness (huvos grading). msts functional score in the lss group was better than those in amputation group. patients who did not have metastasis and complication tended to have good and excellent functional scores. references 1. ando k, heymann mf, stresing v, mori k, redini f, heymann d. current therapeutic strategies and novel approaches in osteosarcoma. cancers (basel). 2013;5(2):591-616. 2. salter. neoplasm of musculoskeletal tissues. textbook of disorder and injuries of musculoskeletal system. philadelphia: lippincott-williams-wilkins; 1999. 3. raymond a, ayala a, knuutila s. conventional osteosarcoma. in: fletcher cdm, unni k, mertens f, eds. world health organization classification of tumors; 2002. 4. messerschmitt pj, garcia rm, abdul-karim fw, greenfield em, getty pj. osteosarcoma. j am acad orthop sur. 2009;17(8):515-27. 5. ritter j, bielack ss. osteosarcoma. ann oncol. 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wimonrat sriraj4 1 anesthesiology department, prasat neurological institute, bangkok, thailand. 2 department of obstetrics and gynecology, faculty of medicine, khon kaen university, khon kaen, thailand 3 department of biostatistics and demography, faculty of public health, khon kaen university, khon kaen, thailand. 4 department of anesthesiology, faculty of medicine, khon kaen university, khon kaen, thailand. corresponding author: phuping akavipat, m.d., frcat., m.sc. anesthesiology department, prasat neurological institute, 312 rajvithee road, bangkok 10400. thailand. email: ppakvp@hotmail.com. abstrak tujuan: untuk menentukan faktor-faktor prediktif penentu lama rawat inap pasien bedah saraf di icu. metode: semua pasien yang masuk icu bedah saraf rs saraf prasat, bangkok, antara 1 februari dan 31 juli 2011 ikut serta dalam penelitian. data demografi dan data klinis pasien untuk setiap variabel dikumpulkan dalam waktu 30 menit sejak masuk rumah sakit. lama rawat inap di icu dicatat dan dianalisis menggunakan model regresi linear dengan batas kemaknaan statistik p<0,05. hasil: sebanyak 276 pasien masuk rumah sakit dan 89,1% di antaranya merupakan kasus elektif. nilai rata-rata (ik 95%) dan median (minimum–maksimum) dari lama rawat inap di icu adalah 2,36 (2,09-2,63) dan 2 (1-25) hari. variabel yang berkaitan dengan lama rawat inap di icu dan persentase perubahannya (ik 95%) meliputi glasgow coma scale motor subscore (gcsm), 6,72% (-11,20 hingga -2,01) lebih rendah untuk setiap perubahan 1 skor poin; ph darah, 1,16% (0,11 hingga 2,21) lebih tinggi untuk setiap perubahan 0,01 satuan; dan jenis kegawatdaruratan saat masuk rawat, 58,30% (29,16 hingga 94,0) lebih tinggi bila dibandingkan dengan masuk rawat karena alasan elektif. kesimpulan: gcsm, ph dan kegawatdaruratan saat masuk rawat ternyata merupakan variabel prediktif utama untuk lama rawat pasien bedah saraf yang dirawat di icu. meskipun demikian, model ini perlu diteliti lebih lanjut pada ukuran sampel yang lebih besar dan menggunakan analisis subkelompok. kata kunci: glasgow coma scale score, ph, kegawatdaruratan saat masuk rawat, kinerja, prediksi. abstract aim: to determine the predictive factors on the length of stay of neurosurgical patients in the icu setting. methods: all patients admitted to the neurosurgical icu between february 1 and july 31, 2011 were recruited. patient demographics and clinical data for each variable were collected within 30 minutes of admission. the icu length of stay was recorded and analyzed by linear regression model with statistical significance at p-value <0.05. results: there were 276 patients admitted, of whom 89.1% were elective cases. the mean (95% ci) and median (min-max) of icu length of stay were 2.36 (2.09-2.63) and 2 (1-25) days. the variables associated with icu length of stay and their percent change (95% ci) were the glasgow coma scale motor subscore (gcsm), 6.72% (-11.20 to -2.01) lower for every 1 point score change; blood ph, 1.16% (0.11 to 2.21) higher for every 0.01 unit change; and emergency admission type, 58.30% (29.16 to 94.0) higher as compared to elective admission. conclusion: the gcsm, ph and emergency admission were found to be the main predictive variables phuping akavipat acta med indones-indones j intern med 276 introduction in assessing the performances of intensive care units (icus), three main considerations are relevant: effectiveness as measured by patient outcome1; efficiency of resource utilization as measured by the length of patient stay2; and qualitative factors such as complication rate, morbidity and the rate of infection.3 the icu length of stay is highly important to hospital providers, administrators, relatives and patients themselves for several reasons.4-5 the significant implications for economic costs, patient outcomes and hospital management have been previously articulated.6-8 a number of factors were found to be associated with length of stay in the icu. using a risk scoring algorithm, a set of variables that were predictive of length of stay in the icu were identified and validated to understand their causative relationship.9-10 however, the use of these factors in a predictive capacity in the subset of neurosurgical patients is less clear and often culminates in the ineffective allocation of resources. it has been suggested that this phenomenon may be attributed to variations in methodology11-13, diversity of study populations9,14, differing methods of outcome assessment10,15, inadequate power of risk-scoring algorithms16 or outdated research.11 this study was conducted in a large, single, tertiary neurosurgical icu to assess the predictive abilities of the factors associated with hospital mortality, in order to estimate the period of icu care required by neurosurgical patients. methods this observational study was registered to the thai clinical trials registry with the identification number of tctr 20151015002. approval for the study (no. 10/2555) was r e c e i v e d f r o m t h e p r a s a t n e u r o l o g i c a l institute ethics committee (chairman: suchat hanchaiphiboolkul) on feb 8, 2012. all new patients admitted into the neurosurgical icu at prasat neurological institute, bangkok, during february 1–july 31, 2011, were recruited for the study. written informed consent was obtained from all patients or from legal relatives in the case of unconsciousness. patient clinical data and personal information were assessed and collected within 30 minutes of admission by 2 certified neurosurgical registrar nurses. patient data for the following variables were collected: body temperature, mean arterial pressure, heart rate, respiratory rate, arterial oxygen tension (pao2), arterial carbon dioxide tension (paco2), arterial ph, serum sodium, serum potassium, bun, creatinine, hematocrit, white blood cell count, glasgow coma scale (gcs) score (scored for verbal subscale as 1 in the case of intubated patients), urine output per day, blood glucose, albumin, bilirubin and the length of hospital stay prior to icu admission. the length of icu stay was defined as the number of calendar days between icu admission date and icu discharge date. d e s c r i p t i v e s t a t i s t i c s w e r e u s e d f o r demographic data and were reported as mean, standard deviation (sd), median, minimummaximum, 95% confidence interval (95% ci), number and percentage. a logistic regression model was conducted using stata software version 13.1 (texas, usa, 2013) to determine the association of those variables and the mortality rate. the values were displayed in a kaplanmeier curve, showing the length of icu length of stay and associated mortality rate (figure 1). patients who died before icu discharge were censored. multivariable and univariate analysis of these variables on the length of icu stay was conducted using linear regression (table 1; table 2; and table 3). the multivariable linear regression model used the p<0.05 for significance. goodness of fit and likelihood ratio tests were also conducted to control for potential confounding of results and to demonstrate the of neurosurgical patient length of stay in the intensive care unit, however, the model should be further explored in a larger sample size and using subgroup analysis. keywords: glasgow coma scale score, ph, emergency admission, performance, prediction. vol 48 • number 4 • october 2016 parameters affecting length of stay among neurosurgical patients 277 performance of each predictive variable on the icu length of stay. the effect of each factor was displayed in mean difference or percent difference between groups of predictors using a 95% confidence interval (95% ci). results a total of 276 patients were admitted to the neurosurgical icu and were involved in this study. the mean of age (sd) were 47.84 (15.36) years with no comorbidity indicated chronic health problems, i.e., aids, hepatic failure, lymphoma, metastasis cancer, leukemia, immune-compromised, and cirrhosis. the demographics and patient characteristics are shown in table 1. the overall hospital mortality was of 9 (3.26%) however there were no deaths during icu stay. the mean (sd) and median (minimum-maximum) duration of patient stay in icu was 2.55 (2.51) days and 2 (1-25) days. the corresponding duration of icu stay for survivors was 2.45 (2.10) days and 2 (1-18) and 4.83 (6.74) days and 2 (1-25) days for non-survivors (table 1). the median and (minimum-maximum) length of hospital stay prior to icu admission was 3 (097) days for the study cohort; 3 (0-74) days for survivors; and 15.5 (0-97) days for non-survivors. according to a perfect agreement of the assessors (intraclass correlation coefficient: icc 0.97, 95% ci 0.95-0.99), the results of the table 1. patient characteristics and admission data variables n (%) age (years), mean (sd) 47.84 (5.36) sex (male) 120 (43.5) type of admission elective 246 (89.1) emergency 30 (10.9) diagnosis cerebral tumor 207 (75.0) cerebral vascular lesion 28 (10.1) spinal tumor 4 (1.5) spinal spondylosis 11 (4.0) other 26 (9.4) admission criteria impaired level of consciousness 39 (9.4) impaired ability of airway protection 24 (5.8) progressive respiratory impairment or required mechanical ventilation 37 (8.9) seizures 15 (3.6) clinical or evidence of raised intracerebral pressure 51 (12.3) threatening medical complications 20 (4.8) monitoring purpose 228 (55.1) 0 .0 0 0 .2 5 0 .5 0 0 .7 5 1 .0 0 p e rc e n t o f p a ti e n ts re m a in in g in in te n s iv e c a re u n it (x 1 0 0 ) 0 2 4 6 8 10 12 14 16 18 20 22 24 26 days in intensive care unit survivors at hospital discharge non-survivors at hospital discharge length of stay in intensive care unit figure 1. kaplan meier estimation for icu length of stay as demonstrated by mortality rate at discharge univariate linear regression model of the factors affecting icu length of stay are shown in table 2. in comparing the elective and emergency admission subgroups, patients with emergency admissions resulted in 81.08%, 95% ci (49.54 to 119.26); p-value <0.001 longer icu length phuping akavipat acta med indones-indones j intern med 278 table 2. univariate analysis of the predictors of icu length of stay variables mean (sd) median (min-max) percentage difference (95% ci) p age (per annum increase) 47.84 (15.39) 47 (9-87) 0.39 (-0.02 to 0.80) 0.06 heart rate (per 1 beat/min increase) 82.21 (16.66) 80 (50-144) 0.21 (-0.17 to 0.59) 0.28 map (per 1 mmhg increase) 108.72 (22.43) 104 (58-166) 0.27 (-0.03 to 0.57) 0.08 temperature (per 0.1ºc increase) 36.47 (0.77) 36.5 (34-39) 0.58 (-0.24 to 1.41) 0.16 rr (per 1 breath/min increase) 18.22 (3.88) 18 (10-28) -2.32 (-3.89 to 0.74) 0.004 hematocrit (per 1 % increase) 34.90 (4.70) 35.1 (22-49) -0.40 (-1.73 to 0.96) 0.56 wbc count (per 103/µl increase) 14.10 (5.65) 13.50 (4.4-38.4) 1.48 (0.36 to 2.61) 0.01 urine output/day (per 1 ml increase) 2646.0 (1072.0) 2450 (175-8350) 0 (0 to 0) 0.29 blood glucose (per 1 mg/dl increase) 163.79 (49.95) 153.5 (87-442) -0.07 (-0.20 to 0.05) 0.26 bun (per 1 mg/dl increase) 10.86 (7.27) 9.5 (3-96) 1.06 (0.18 to 1.93) 0.02 creatinine (per 1 mg/dl increase) 0.81 (0.33) 0.7 (0.4-3.2) 15.86 (-4.48 to 40.52) 0.13 sodium (per 1 meq/l increase) 137.98 (3.83) 138.2 (124.6-155.7) -1.10 (-2.72 to 0.55) 0.19 albumin (per 1 g/dl increase) 3.06 (0.53) 3.1 (1.4-5.4) -18.10 (-27.27 to -7.77) 0.001 bilirubin (per 1 mg/dl increase) 0.81 (0.40) 0.8 (0.1-3.4) 17.40 (0.06 to 37.74) 0.05 pao2 (per 1 mmhg increase) 200.74 (86.63) 199 (58-416) -0.08 (-0.15 to -0.04) 0.03 paco2 (per 1 mmhg increase) 37.69 (6.99) 38 (17-59) -1.44 (-2.32 to -0.56) 0.002 ph (per 0.01 unit increase) 7.39 (0.07) 7.38 (7.11-7.60) 2.17 (1.26 to 3.09) <0.001 gcs (per 1 score increase) 10.33 (3.63) 12 (3-15) -4.52 (-6.10 to -2.93) <0.001 gcse (per 1 score increase) 2.66 (0.96) 3 (1-4) -13.92 (-19.23 to -8.25) <0.001 gcsv (per 1 score increase) 2.69 (1.38) 3 (1-5) -8.68 (-12.67 to -4.51) <0.001 gcsm (per 1 score increase) 4.99 (1.77) 6 (1-6) -9.12 (-12.16 to -5.96) <0.001 potassium (per 1 meq/l increase) 3.78 (0.43) 3.78 (2.15-5.55) -12.35 (-24.25 to 1.42) 0.08 length of stay prior to icu admission (per 1 day increase) 5.82 (9.31) 3 (0-97) 0.41 (-0.27 to 1.10) 0.24 map: mean arterial pressure, rr: respiratory rate, gcs: glasgow coma scale score, gcse: eye subscale in glasgow coma scale score, gcsv: verbal subscale in glasgow coma scale score, gcsm: motor subscale in glasgow coma scale score, icu: intensive care unit. * statistical significance at p-value <0.05. table 3. multivariable analysis of the predictors of icu length of stay variables n (%) mean (sd) percentage difference (95% ci) p-value gcsm (in 1 point score increments) 4.99 (1.77) -6.72 (-11.20 to -2.01) 0.006* ph (in 0.01 unit increase) 7.39 (0.07) 1.16 (0.11 to 2.21) 0.03* type of admission: elective 246 (89.1) 58.30 (29.16 to 94.0) <0.001* emergency 30 (10.9) gcsm: glasgow coma scale motor subscale score. * statistical significance at p-value <0.05. of stay than patients with elective admissions. female patients had 8.3%, 95% ci (-19.29 to 4.19); p-value 0.18, shorter icu stays compared with male patients. patients admitted without cerebral tumors had 1.56%, 95% ci (-6.7 to 3.72; p-value 0.56 shorter stays than those patients with cerebral tumors. multivariable analysis of the predictors of the icu length of stay is demonstrated in table 3. vol 48 • number 4 • october 2016 parameters affecting length of stay among neurosurgical patients 279 discussion the relationship between prolonged icu stay and the rising cost of medical treatment has been previously documented.17-19 this study shows the predictive capacity of neurosurgical patients’ clinical variables on the length of stay in the icu. it is crucial to identify and understand these variables in order to develop strategies to manage icu costs as well as patient outcomes. the need for extended icu stays is often required, as shown in this study, and must be anticipated by both patients and relatives. previous studies have shown multiple independent predictors of higher icu length of stay in various settings. in the case of traumatic brain injury, the severity grading, mass lesion on admission head computed tomography, and delirium symptoms were found to be highly predictive of the length of icu stay.20-21 additionally, the boston acute stroke imaging scale has been shown to be highly predictive of in-hospital mortality, as having the occurrence of complications, length of stay and hospitalization cost of acute ischemic stroke patients.22 although the pre-admission assessment of neurological deterioration, as evaluated by the gcs, was determined as a good predictor of higher icu length of stay, the gcsm subscale has been shown to be a superior predictive tool.23 its simplicity to administer and high predictability of mortality in both neurological and neurosurgical patients make it superior to the gcs.24 moreover, acker et al. has shown that the gcsm alone does not differ in identifying children with serious traumatic brain injury from the gcs. eliminating the eye and verbal components of gcs does not adversely affect the accuracy of this predictive tool.25 our data analysis demonstrated that the glasgow coma scale score was also a strong indicator for icu length of stay. multiple linear regression analysis conducted separately from the motor subscale showed the percent difference of -2.95%, 95% ci (-4.55 to -1.24); p= 0.001 per 1 point score increase. the percent difference for the emergency admission subset was 54.70%, 95% ci (26.43 to 89.67); p-value <0.001, while the percent difference for ph was 1.11%, 95% ci (0.06 to 2.16); p= 0.04 per 0.01 unit increase. to account for the issue of multicollinearity, the adjusted r2 from multivariable analysis was taken into account. the test showed higher adjusted r2 (0.23) for the group of variables containing gcsm score, while the gcs composed was 0.22. therefore, the gcsm was selected as an acceptable predictor of the length of icu stay for neurosurgical patients. biochemical variables, especially ph balance, affect icu length of stay because of its potential impairment of cerebral blood flow and cerebrovascular vascular reactivity. this is likely due to ph being the dominant blood flow regulator under normal physiological brain conditions.26-28 these surrogated events may lead to ultimate clinical outcome as well as the icu length of stay. the multivariable analysis conducted in this study showed that the ph balance is predictive of higher duration of icu admission. surprisingly, previous studies have shown inconclusive evidence of this relationship.29-32 further study should be conducted to confirm a causal effect. for obvious reasons, many neurosurgical patients present to the icu unexpectedly because of a rapid deterioration of their condition. the review of a powerful predictor among emergency hospital admission type affected icu length of stay has been previously established.33-34 scenario simulation practice, development of standard treatment protocols together with a qualified neurocritical care service team have been suggested to improve quality of care and shorten the duration of icu stay.29,35 in this study of neurosurgical icu admissions, there were no patients with emergency admissions for continuous monitoring or after performing complex neurosurgery. the majority of patients were admitted for clinically increased intracranial pressure or impending brain damage, which may clarify the longer icu stay phenomenon. from previous studies, the intraoperative variables identified as affecting the length of icu stay, such as perioperative transfusion, perioperative complications, and location of brain lesions, were considered to be independent.21,36-38 one limitation of this study is that analysis of the post-operative group alone was not completed and may have been relevant. in future studies, further phuping akavipat acta med indones-indones j intern med 280 patient sub-group analysis of intraoperative factors such as blood transfusion, location of lesions in the brain and complications during the operation should be included. additionally, most of the study cohort was diagnosed with cerebral tumors or cerebral vascular lesions. there was only a small subset of spinal pathology patients and none with traumatic brain injuries. therefore, the patient diagnosis upon icu admission is relevant before generalizing these results to other circumstances and further subgroup analysis is needed in future research. conclusion the length of stay for neurosurgical patients in the icu differed from 1-25 days. the glasgow coma scale score motor subscale (gcsm), ph, and the type of hospital admission (emergency/ elective) were shown to be predictors of the duration of stay in the icu. in the future, the validity of this model should be further explored in a multicenter study with a larger and more varied cohort of 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pressure reactivity and cerebral oxygen regulation after severe head injury. neurocrit care. 2013;19(1):69-73. 28. kollmar r, georgiadis d, schwab s. alpha-stat versus ph-stat guided ventilation in patients with large ischemic stroke treated by hypothermia. neurocrit care. 2009;10(2):173-80. 29. kesinger mr, nagy lr, sequeira dj, et al. a standardized trauma care protocol decreased inhospital mortality of patients with severe traumatic brain injury at a teaching hospital in a middle-income country. injury. 2014;45(9):1350-4. 30. wang ch, huang ch, chang wt, et al. association between early arterial blood gas tensions and neurological outcome in adult patients following inhospital cardiac arrest. resuscitation. 2015;89:1-7. 31. bazzazi a, hasanloei ma, mahoori a, et al. correlation between arterial blood gas analysis and outcome in patients with severe head trauma. ulus travma acil cerrahi derg. 2014;20(4):236-40. 32. solaiman o, singh jm. hypocapnia in aneurysmal subarachnoid 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mekitarian filho e, brunow de carvalho w, cavalheiro s, et al. perioperative factors associated with prolonged intensive care unit and hospital length of stay after pediatric neurosurgery. pediatr neurosurg. 2011;47(6):423-9. 96 original article acta med indones indones j intern med • vol 50 • number 2 • april 2018 cardiovascular disease risk factors among blue and white-collar workers in indonesia nurhayati a. prihartono1, fitriyani1, woro riyadina2 1 department of epidemiology, faculty of public health, universitas indonesia, depok, indonesia. 2 the national institute of health research and development. indonesia ministry of health, jakarta, indonesia. corresponding author: nurhayati a. prihartono. department of epidemiology, faculty of public health, universitas indonesia. jl. prof. dr. sujudi, beji, depok 16424, indonesia. email: nurhayati-a@ui.ac.id. abstrak latar belakang: penyakit kardiovaskular (pkv) adalah penyebab kematian yang paling umum di indonesia. tujuan penelitian ini adalah mempelajari faktor risiko pkv pada pekerja umur 40 – 69 tahun yang dikaitkan dengan status pekerjanya. metode: studi potong lintang pada seluruh provinsi di indonesia. studi ini menganalisis faktor-faktor yang berhubungan dengan penyakit kardiovaskular. data berasal dari survei kesehatan nasional/ riskesdas (riset kesehatan dasar). analisis terbatas pada populasi pekerja usia 40-69 tahun. terdapat 137.378 subyek yang dianalisis. analisis cox’s regression yang dimodifikasi digunakan untuk menghitung rasio prevalensi hubungan antara penyakit kardiovaskular (pkv) dengan diabetes melitus (dm), hipertensi, stres, indeks massa tubuh (imt), merokok dan faktor demografi lainnya. hasil: pkv berhubungan dengan pekerjaan; pekerja white collar berisiko 1.6 kali terdiagnosis pkv dibandingkan dengan pekerja blue collar. namun, pekerja blue collar lebih cenderung melaporkan gejala pkv dibanding dengan pekerja white collar. prevalensi pkv lebih tinggi pada wanita dibandingkan dengan laki-laki. pkv meningkat berdasarkan usia dan pendidikan. hipertensi, dm, stres, dan peningkatan imt merupakan prediktor dari pkv: prevalence ratio (pr) 1,72 (95% ci 1,59-1,86), 3,89 (95% ci 3,43-4,44), 3.02 (95% ci 2,77-3,29) dan 1.42 (95% ci 1,28-1,57) pada imt ≥27 dibandingkan <25 kg/m2. studi ini tidak menjelaskan hubungan antara pkv dengan merokok. kesimpulan: studi ini membuktikan bahwa faktor risiko utama dapat dimodifikasi untuk menurunkan cvd. beberapa hubungan mungkin mencerminkan akses ke pelayanan kesehatan. kata kunci: penyakit kardiovaskular, pekerja, studi populasi, indonesia. abstract background: cardiovascular diseases (cvd) is the most common cause of death in indonesia. we aimed to examine risks of cvd in workers aged 40 to 69 year related to their occupational status. methods: a crosssectional study in all provinces of indonesia. data from a large-scale national health survey called riskesdas were used to analyze factors associated with cvd. analysis was restricted to the working population aged 40 to 69 year. there were 137,378 subjects included in the analysis. cox’s regression analysis was modified to calculate prevalence ratio for the association of cvd with diabetes mellitus (dm), hypertension, stress, body mass index (bmi), smoking, and particular demographic factors. results: cvd was associated with occupation; white collar workers were about 1.6 times as likely to be diagnosed with cvd as to blue collar workers. however, blue collar workers were more likely to report symptoms of cvd than white collar workers. prevalence of cvd was higher in women than men, increasing by age and education attainment. hypertension, dm, stress, and increased bmi added the prediction of cvd: prevalence ratio (pr) was 1.72 (95% ci 1.59-1.86), 3.89 (95% ci 3.43-4.44), 3.02 (95% ci 2.77-3.29) and 1.42 (95% ci 1.28-1.57) for bmi ≥27 relative to <25 kg/m2, respectively. vol 50 • number 2 • april 2018 cardiovascular disease risk factors among blue and white-collar workers 97 the study could not explain the association with smoking. conclusion: this study added evidence of major risk factors which could be modified to reduce cvd. some associations were likely to reflect access to health care. keywords: cardiovascular disease, worker, population-based study, indonesia. introduction epidemiologic transition indicated by a shift in the leading causes of mortality and morbidity from communicable disease to non-communicable disease has been occuring in indonesia since 1995. the proportion of mortality by non-communicable disease has increased from 43% in 1995 to 60% in 2007.1 cardiovascular disease (cvd), a class of noncommunicable diseases which includes heart disease and stroke, is the leading cause of death globally. indonesian household health survey shows that the number of death caused by cvd was increasing; it ranked 11 in 1972 and climbed to number 3 in 1986, and become the leading cause of death ever since.2 it is etimated that 17.3 million people died from cvd in 2008.3 cardiovascular disease is recognized as the degenerative condition that mostly affects older adults and the work force. numerous studies have been conducted to investigate the risk factors of cvd. biological and behavioral risk factors for cvd include older age, smoking, hypercholesterolemia, hypertension, diabetes, obesity, lack of exercise, psychosocial factors, and heredity.4 studies that examined determinants of cvd in workers show similar risk factors to those in the general population.5,6 furthermore, cvd studies among workers revealed an association between socio-economic status and cvd.7,8 this difference may be due to a disparity in educational background and health related lifestyle among socio-economic groups. efforts to reduce cvd risks and mortality have been successfully achieved in many developed countries.9 however, information on cvd risk factors among workers in indonesia is limited. the aim of this study was to examine factors associated with cvd in indonesia among workers aged 40 to 69 year, which is the age group with high-risk according to who. specifically, we aimed to determine whether there was a difference in prevalence of cvd between blue collar workers and white collar workers, and to explore factors contributing to the disparities of cardiovascular risks related to occupational status. methods we used data from the 2007 indonesian national health survey (riskesdas). the study design was a cross-sectional in all provinces of indonesia. details of the household health survey were described in a previous study.10 the study population were all households in indonesia. block census in each district/town was selected by probability proportional to size (pps) to the total households of the district/ town. sixteen households were then selected from block census by simple random sampling. all members of the selected households were included. trained interviewers used a structured and standardized questionnaire to obtain information. cardiovascular disease status was assessed from the subject’s report, based on diagnosis of a health provider or admission of symptoms of cvd (e.g. heart disease or stroke). employment status was assessed and categorized into whitecollar worker, blue-collar worker, and other. the white-collar workers include government/private official, army force, trader, and services. bluecollar workers were those who work as laborer, farmer or fishermen. others were those who were not specified as white collar or blue collar worker. other information was also assessed such as demograhic characteristics (e.g. age, sex, level of education), smoking status (ever versus never), bmi (according to 2010 bmi indonesia ministry of health category: <25, 25-26.9 and ≥27), hypertension and diabetes. hypertension was assessed from subject’s report, based on blood pressure measurement, a previous hypertension diagnosis, and current consumption nurhayati a. prihartono acta med indones-indones j intern med 98 of anti-hypertension drugs. we used jnc vii 2003 criteria to define hypertension as systolic blood pressure >140 mmhg or diastolic blood pressure >90 mmhg. in this analysis, 150,395 subjects aged 40 to 69 year old and currently employed were eligible. however, some subjects could not be analyzed because of missing information: 317 subjects had no information on education, 563 subjects missing smoking status, 1,883 subjects missing diabetes status, 4,345 subjects missing hypertention status, 749 subjects missing height and weight status, 2,617 subjects missing information on stress, and 2,543 subjects missing information on cvd. this led to 137,378 subjects to be included in the analysis. the prevalence of cardiovascular disease according to diagnosis and symptoms by putative risk factors and subgroup of workers were examined. we calculated adjusted prevalence ratio (and 95% confidence interval) derived from a modified cox regression to estimate the risk of cvd.11 results t h e s t u d y r e v e a l e d t h a t 2 , 7 5 4 ( 2 % ) respondents had been diagnosed with cvd and 14,595 (10.6%) respondents reported symptoms of cvd (table 1). the prevalence of cvd based on diagnosis were higher in those aged 60–69 year, female, college graduated, white collar and other employment, bmi ≥27, history of stress, and history of hypertension and diabetes. the prevalence of cvd based on reported symptoms showed a similar pattern, however there was a difference according to education and smoking in which the prevalence of cvd was higher in workers with primary school education or less (11.8%), smokers (11.1%), and blue collar worker (12%). multivariable adjusted estimates are shown in table 2. the data show an approximately 2-fold increased risk of cvd among those aged 60-69 year in comparison to those aged 40-49 year (pr 2.21, 95% ci 1.99-2.44). workers aged 50-59 were 1.5 times more likely to have cvd (pr 1.58, 95% ci 1.44-1.72). similarly, those who had a high level of education compared to those who completed primary education or less were 1.6 times more likely to develop cvd (pr 1.59, 95% ci 1.39-1.82). white collar workers had an approximately 40% increased risk in the prevalence of cvd compared to blue collar workers (pr 1.42, 95% ci 1.29-1.55). those who had bmi ≥ 27 were 1.4 times more likely to have cvd than the lowest bmi category (pr 1.42, 95% ci 1.28-1.57) while the risk of cvd was only slightly increased in those with bmi of 25.0 – 26.9 (pr 1.19, 95% ci 1.06-1.34). there was 3-fold increased risk of having cvd in workers who had stress compared to those who did not have stress (pr 3.04, 95% ci 2.77-3.29). additionally, there was an increased prevalence of cvd in those with hypertension compared to those who did not have hypertension (pr 1.72, 95% ci 1.59-1.86). the workers who had diabetes were 3.9 times more likely to have cvd compared to workers who did not have diabetes (pr 3.289, 95% ci 3.43-4.44). smoking was not associated with prevalence of cvd (pr 0.95, 95% ci 0.86 – 1.05). however, those who previously smoked had approximately 2-fold increase prevalence of cvd than those who never smoke (pr 1.94, 95% ci 1.71 – 2.21), and current smoker had 24% reduced prevalence of cvd compared to non-smoker (pr 076, 95% ci 0.68 – 0.84). the study did not find a difference in risk of cvd between male and female workers. when stratified by occupational status (while collar and blue collar), all risk estimates were elevated among white collar workers but were strongest in association with older age, college education, hypertension and diabetes. among the blue collar workers, bmi, stress, and diabetes showed the strongest associations (table 3). the cvd risk factors associated with level of education among blue collar workers could not be evaluated as there were a very small number of subjects (6 respondents) in the high level education category. discussion this study provides additional evidence on cvd risks among workers in indonesia. the prevalence of cvd among workers aged 40 to 69 year was 12.6% based on previous diagnosis and reported symptoms. factors contributing to an increased prevalence of cvd include older age, vol 50 • number 2 • april 2018 cardiovascular disease risk factors among blue and white-collar workers 99 education, education attainment, bmi levels, stress, hypertension or diabetes, similar to cvd risk factors in the general population. present study contrast previous studies reporting that high level of education increase the prevalence of cvd among white collar workers. another interesting finding from this study was that the prevalences of cvd were different between white collar and blue collar workers when information on cvd was derived from diagnosis by health provider or by reported symptoms. prevalence of cvd assessed in diagnosis was higher among white collar workers than blue collar workers. however, when the cvd was assessed by reported symptoms only, a higher prevalence of cvd was found among blue collar workers than white collar workers. this difference in prevalence of cvd based on diagnosis and symptoms reported between two subgroups of workers might be due to the difference in socio-econonmic status which play a role in access to health services. table 1. prevalence of cvd based on demographical characteristics variables subject diagnosis symptoms n = 137378 n = 2754 (%) n = 14595 (%) age (years) 40-49 69859 958 (1.4) 6320 (9.2) 50-59 45221 1046 (2.3) 5161 (11.7) 60-69 22298 750 (3.4) 3114 (14.5) sex male 88670 1679 (1.9) 8634 (9.9) female 48709 1075 (2.2) 5961 (12.5) education non to junior hs 107230 1908 (1.8) 12404 (11.8) high school 20370 532 (2.6) 1517 7.6) college 9778 314 (3.2) 674 (7.1) job blue-collar 82088 1268 (1.5) 9724 (12.0) white-collar 50385 1285 (2.6) 4330 (8.8) others 4932 201 (4.1) 541 (11.4) bmi (kg/m2) <25 107745 1906 (1.8) 11508 (10.9) 25.0 – 26.9 14486 353 (2.4) 1413 (10.0) ≥ 27 15147 495 (3.3) 1674 (11.4) smoking status ever 73743 1356 (1.8) 8051 (11.1) current 65557 917 (1.4) 6901 (10.7) past 8186 439 (5.4) 1150 (14.8) never 63635 1398 (2.2) 6544 (10.5) stress yes 13919 726 (5.2) 4250 (32.2) no 123459 2028 (1.6) 10345 (8.5) hypertension yes 62951 1761 (2.8) 7425 (12.1) no 74427 993 (1.3) 7170 (9.8) diabetes mellitus yes 2297 273 (11.9) 352 (17.4) no 135081 2481 (1.8) 14243 (10.8) nurhayati a. prihartono acta med indones-indones j intern med 100 table 2. prevalence ratios (pr) of diagnosed cvd according to risk factors variables cvd diagnosis crude pr (95% ci) adjusted pr (95% ci)yes (n=2754 (%)) no (n=134624 (%)) age (years) 40-49 958 (1.4) 69859 (98.6) 1 1 50-59 1046 (2.3) 45221 (97.7) 1.67 (1.53,1.82) 1.58 (1.44,1.72) 60-69 750 (3.4) 22298 (96.6) 2.41 (2.19,2.64 ) 2.21 (1.99,2.44) sex female 1075 (2.2) 48708 (97.8) 1 1 male 1679 (1.9) 88670 (98.1) 0.86 (0.80,0.93) 0.92 (0.85,0.99) education non to junior hs 1908 (1.8) 105322 (98.2) 1 1 high school 532 (2.6) 19838 (97.4) 1.47 (1.33,1.61) 1.37 (1.23,1.53) college 314 (3.2) 9464 (96.8) 1.80 (1.60,2.03) 1.60 (1.41,1.83) job blue-collar 1268 (1.5) 82008 (98.5) 1 1 white-collar 1285 (2.6) 50358 (97.4) 1.65 (1.53,1.78) 1.41 (1.29,1.55) other 201 (4.1) 4932 (95.9) 2.63 (2.27,3.06) 1.68 (1.44,1.97) bmi (kg/m2) < 25 1906 (1.8) 105839 (98.2) 1 1 25.0 – 26.9 353 (2.4) 14133 (97.6) 1.38 (1.23,1.54) 1.19 (1.06,1.34) ≥ 27 495 (3.3) 14652 (96.7) 1.85 (1.67,2.04) 1.42 (1.28,1.57) smoking status never 1398 (2.2) 62237 (97.8) 1 1 ever 1356 (1.8) 72387 (98.2) 0.84 (0.78,0.90) 0.95 (0.86,1.05) current 917 (1.4) 64640 (98.6) 0.64 (0.59,0.69) 0.76 (0.68,0,84) past 439 (5.4) 7747 (94.6) 2.44 (2.19,2.72) 1.94 (1.71,2,21) stress no 2028 (1.6) 123459 (98.4) 1 1 yes 726 (5.2) 12919 (94.8) 3.17 (2.92,3.46) 3.02 (2.77,3.29) hypertension no 993 (1.3) 74427 (98.7) 1 1 yes 1761 (2.8) 82951 (97.2) 2.09 (1.94,2.67) 1.72 (1.59,1.86) diabetes mellitus no 2481 (1.8) 135081 (98.2) 1 1 yes 273 (11.9) 2297 (88.1) 6.47 (5.71,7.33) 3.89 (3.43,4.44) previous studies in the us and japan showed that blue collar workers had higher prevalence and higher mortality caused by cvd than white collar workers.12-14 background characteristics as well as working environment exposures were among factors that contribute to the difference in prevalence. it is established that cvd is related to lifestyle and individual behavior. a previous study revealed that blue collar workers had a low education and low salaries were more likely to be exposed to unhealthy life styles and poor living conditions compared to white collar workers.15 a study done by nakamura et al found that obesity was more prevalent among blue collar workers than the white collar.12 the condition may escalate the risk of chronic diseases such diabetes and cvd, leading to a high risk of mortality.16,17 another study by greenlund et al supports these findings that low education and unhealthy life style were associated with cvd.18 the association between an increased risk of cvd and high education levels among vol 50 • number 2 • april 2018 cardiovascular disease risk factors among blue and white-collar workers 101 white collar workers in this study may be related to the accessibility of healthcare among those with high education, as observed in the study by dunlop et al.19 because very few subjects held college degrees among blue collar workers, the association of cvd with level of education could not be identified. in addition, chemical and physical hazards in the workplace are potential contributor to the risk of modifiable cvd such as hypertension, hypercholesterolemia or diabetes.20 this study found that higher bmi increased the prevalence of cvd both in white collar and blue collar workers. the findings were consistent with previous studies which observed increased risk of cvd in overweight groups.6,21 a study by kokkinos discovered that every increase in bmi increased cvd-related mortality, especially those with bmi >29 kg/m2 had the highest cvdrelated mortality.22 another study found other factors correlated with obesity including low income and low education.23 about 46% of the workers had hypertension. table 3. adjusted prevalence ratio of risk factors in diagnosed cvd based on employment variables white-collar workern=1285 (%) adjusted pr in white-collar worker blue-collar worker n=1268 (%) adjusted pr in bluecollar worker age (years) 40-49 513 (1.7) 1 423 (1.1) 1 50-59 514 (3.3) 1.67 (1.48-1.89) 470 (1.7) 1.39 (1.22-1.59) 60-69 258 (5.2) 2.57 (2.20-3.01) 375 (2.4) 1.81 (1.57-2.09) education non-junior hs 607 (2.3) 1 1207 (1.6) 1 high school 404 (2.7) 1.44 (1.26-1.64) 55 (1.4) 1.05 (0.80-1.38) college 274 (3.1) 1.69 (1.46-1.96) 6 (1.9) 1.21 (0.54-2.69) bmi (kg/m2) < 25 748 (2.2) 1 1026 (1.5) 1 25.0 – 26.9 206 (2.7) 1.12 (0.96-1.31) 117 (1.9) 1.26 (1.04-1.53) ≥ 27 331 (3.6) 1.37 (1.20-1.57) 125 (2.4) 1.49 (1.23-1.79) stress no 1001 (2.2) 1 875 (1.2) 1 yes 284 (6.8) 2.95 (2.58-3.38) 393 (4.3) 3.18 (2.82-3.58) hypertension no 439 (1.6) 1 495 (1.2) 1 yes 846 (3.6) 1.84 (1.64-2.08) 773 (2.1) 1.63 (1.45-1.83) diabetes mellitus no 1114 (2.3) 1 1204 (1.5) 1 yes 171 (11.7) 3.62 (3.08-4.27) 64 (10.3) 5.04 (3.91-6.49) t h i s s t u d y s h o w e d t h a t t h o s e w h o h a d hypertension were 1.6 to 1.8 times more likely to have cvd. the result was in agreement with the study conducted by conen et al that observed an increase of cvd by 56% among those who had hypertension compared to no hypertension over 4 years of follow-up.24 that study also found that those who had hypertension were more likely to have diabetes and hypercholesterolemia. diabetes appeared to be the strongest risk factor of cvd among workers; there was 3 to 5 times greater prevalence of cvd among workers who had diabetes compared to non-diabetes. it is postulated that insulin deficiency led to an increased blood glucose that influence glucose intolerance which is a predisposing factor of vascular disease.25 psychosocial hazards at work have been recognized as a risk factor of cvd. this study did not measure stress specifically related to work environment. however, about 10% of workers reported to experience stress; those who were reported with stress were 3 times nurhayati a. prihartono acta med indones-indones j intern med 102 more likely to have cvd. a study conducted by hirokawa et al on job-related stress in relation to cardiovascular stress reactivity found that job stressors contributed to the change of cardiovascular reactivity including blood pressure and heart rate.26 another study added to the evidence that job-related stress affected development of cvd through other cvd risk factor, namely smoking.27 smoking has been proved as a major risk of cvd. previous study found that smoking was the second largest risk of cvd.28 the present study observed about 54% of workers had history of smoking, but did not detect any association between history of smoking and prevalence of cvd. when smoking status was categorized into past and current smokers, however, those who smoked in the past had higher prevalence compared to current smokers. the results reflected the limitation of the cross-sectional study design in which those who develop cvd may change their risk factor. moreover, the findings are subjected to limitation as other risk factors, such as diet, cholesterol levels, and sedentary life style were not taken into account since they were not measured in present study. nevertheless, this analysis was done on a large sample representing workers in indonesia. conclusion this study indicates that increased prevalence of cvd was associated with diabetes, stress, hypertension, high level of bmi, and high education attainment among workers. however, it is not clear from this data whether high education attainment correlated with unhealthy lifestyles or healthcare accessibility. in addition, the higher prevalence of cvd among blue-collar workers assessed by self-reported symptoms need further study to clarify health care accessibility and lifestyles in the low income segment of workers. acknowledgments we thank professors yvette c. cozier and ratna djuwita for comments on the manuscript references 1. ministry of health, republic of indonesia. report of national basic health research (riskesdas 2007). jakarta: indonesia; 2008. 2. ministry of health, republic of indonesia. indonesian health profile 2003. jakarta: indonesia; 2003. 3. wo r l d h e a l t h o rg a n i z a t i o n . g l o b a l a t l a s o n cardiovascular disease prevention and control. world health organization. geneva; 2011. 4. hs buttar, t li, n ravi. prevention of cardiovascular diseases: role of exercise, dietary interventions, obesity and smoking cessation. exp clin cardiol. 2005;10(4):229-49. 5. pyakuel p, karki p, lamsal m, ghimire a, phokarel k. cardiovascular risk factors among industrial workers a cross-sectional study from eastern nepal. j occup med toxicol.2016;11(25):1-7. 6. kaur p, rao tv, sankarasubbaiyan s, et al. prevalence and distribution of cardiovascuar risk factors in an urban industrial population in south india. j assoc physicians india. 2007;55:771-6. 7. davey smith g, carroll d, rankin s. socio-economic differentials in mortality: evidence from glasgow graveyards. bmj. 1992;305:1554-7. 8. fukuda y, nakamura k, takano t. accumulation of health risk behaviours is associated with lower socio-economic status and women’s urban residence: a multilevel analysis in japan. bmc public health. 2005;5(53):1-10. 9. world health organization. global status report on non-communicable disease 2014. switzerland: who press, world health organization; 2014. 10. the national institute of health research and development, ministry of health. republic of indonesia. result of national basic health research (riskesdas 2007). jakarta, indonesia, 2008. 11. lee j, tan cs, chia ks. a practical guide for multivariate analysis of dichotomous outcomes. ann acad med singapore. 2009;38(8):714-9. 12. nakamura s, nakamura k, tanaka m. increased risk of coronary heart disease among in japanesse blue-collar workers. occup med. 2000;50(1):11-7. 13. buring je, evans da, fiore m, rosner b, hennekens ch. occupation and risk of death from coronary heart disease. jama. 1987;258:791-2. 14. lukhaupt se, calvert gm. prevalence of coronary heart disease or stroke among workers aged <55 years united states, 2008–2012”. centers for disease control and prevention: morbidity and mortality weekly report. 2014;60(30):645-9. 15. clougherty je, souza k, cullen mr. work and its role in shaping the social gradient in health. ann n y acad sci. 2010;1186:102-24. 16. d a v e y s m i t h g , h a r t c , b l a n e d . l i f e t i m e socioeconomic position and mortality: prospective observational study. bmj. 1997;314:547-52. 17. lynch jw, kaplan ga, shema sj. cumulative impact of sustained economic hardship on physical, cognitive, psychological, and social functioning. n eng j med. 1997;337:1889-95. 18. greenlund kj, zheng zj, keenan nl, giles wh, vol 50 • number 2 • april 2018 cardiovascular disease risk factors among blue and white-collar workers 103 casper ml, mensah ga, croft jb. trends in selfreported multiple cardiovascular disease risk factors among adults in the united states, 1991-1999. arch intern med. 2004;164:181-8. 19. dunlop s, coyteb pc, mcisaac w. socio-economic status and the utilisation of physicians’ services: results from the canadian national population health survey. soc sci med. 2000;51:123-33. 20. bhatnagar a. environmental cardiology: studying mechanistic links between pollution and heart disease. circulation res. 2006;99:692–705. 21. suka m, miwa y, ono y, yanagisawa h. impact of weight gain on cardiovascular risk factors in japanese male worker. j occup environ med. 2012;54:1288-92. 22. kokkinos p. pysical activity and cardiovascular disease prevention. united states: jones and bartlett publisher; 2010. 23. harrell js, gore sv. cardiovascular risk factors and socioeconomic status in african american and caucasian women. res nurs health. 1998;21:285-95. 24. conen david, ridker pm, buring je, glynn rj. risk of cardiovascular events among women with high normal blood pressure or blood pressure progression: prospective cohort study. bmj. 2007;335:452. 25. brownson, ross c, patrick l. remington, davis jr. chronic disease and control: diabetes. washington: american public health association; 1993. 26. hirokawa k, ohira t, nagayoshi m, et al. occupational status and job stress in relation to cardiovascular stress reactivity in japanese workers. preventive med rep. 2016;4:61-17. 27. green kl, johnson jv. the effect of social work organization on patterns of cigarette smoking among male chemical plant employees. am j public health. 1990;80:1368-71. 28. national center for cardiovascular diseases, china. report on cardiovascular diseases in china. encyclopedia of china publishing house; 2010. p. 62-2. 574 acta med indones indones j intern med • vol 54 • number 4 • october 2022 original article the effect of vitamin d supplementation on symptoms of depression in patients with type 2 diabetes mellitus: a systematic review and meta-analysis of randomized controlled trials rudi putranto1, kuntjoro harimurti1,2*, siti setiati1,2, eka dian safitri2, siti rizny f. saldi,2 imam subekti1, martina wiwie s. nasrun3, hamzah shatri1 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 clinical epidemiology and evidence-based medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 3 department of psychiatry, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. *corresponding author: kuntjoro harimurti, md, m.sc, phd. division of geriatrics, department of internal medicine. faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: kuntjoro.harimurti@gmail.com. abstract background: the effect of vitamin d supplementation on depressive symptoms in people with type 2 diabetes is still up for debate. the aim of this paper was to investigate the effect of vitamin d supplementation on symptoms of depression in type 2 diabetic patients. methods: the protocol for this review has been registered in prospero:crd42021231713. searching for literature was conducted using pubmed, ebscohost, and embase. randomised controlled trials (rcts) regarding vitamin d supplementation in type 2 diabetic patients with depression were retrieved through a systematic search. the outcome measured was a change in depressive symptoms evaluated with any validated rating scale. independent data extraction was conducted, and the study quality was assessed. a meta-analysis was carried out to calculate the improvement in depressive symptoms in the group receiving vitamin d and the control group. the available evidence in rcts was analysed using the prisma approach, and clinical significance was determined using the grade system. risk of bias was assessed using the cochrane risk of bias tool. results: four rcts were reviewed and three rcts were meta-analysed. in two studies, vitamin d was statistically effective in improving depressive symptoms in type 2 diabetic patients. three randomised controlled trials were included in the meta-analysis with 161 subjects using depression score as an outcome assessment. vitamin d is significantly more effective than placebo (95% ci: -0.70 to 0.08, p = 0.01). conclusion: vitamin d supplementation may improve the depressive symptoms in type 2 diabetic patients. future research with different geographical areas and larger samples should be done to further assess the benefits. keywords: depression, type 2 diabetes mellitus, vitamin d. introduction diabetes mellitus and depression are both significant chronic diseases that diminish life expectancy, reduce quality of life, and increase functional disability.1 diabetes and depression occur together approximately twice as frequently vol 54 • number 4 • october 2022 the effect of vitamin d supplementation on symptoms of depression 575 as they would be predicted by chance alone. comorbid diabetes and depression pose a significant clinical problem because the outcomes of both disorders are exacerbated by the presence of the other.2 despite the existence of biological, psychological, and environmental explanations, the underlying pathophysiology of depression is unknown, and several processes may be involved.3 a study by holt et al. showed that diabetic patients have an increased risk of developing depression. this phenomenon can be caused by several factors, either by patients’ perception of a disease or by biological changes that occur within the body. the diagnosis of diabetes mellitus often frightens patients. some of the reasons are that they are afraid that the disease cannot be cured and that it requires high discipline and compliance to take medications regularly to prevent further complications. moreover, diabetic patients should also change their lifestyle, which is not suitable and comfortable for some of them. on the other hand, diabetes can also cause decreased neurogenesis, which can further increase the risk of depression.2,3 the symptoms of depression in diabetic patients are correlated with a decreased quality of life, a higher risk of developing further complications, and increasing mortality. several solutions can be given to patients, and one of the solutions is giving anti-depressants. however, several anti-depressants have side effects of decreasing glycaemic control and causing weight gain, which are not suitable for diabetic patients. as a result, other solutions to this problem are being sought.4,5 in the past few years, other treatment options besides anti-depressants have been investigated to treat depressive symptoms. one of these treatment options is vitamin d. vitamin d receptors are found on neurons and glia in various parts of the brain, including the cingulate cortex and hippocampus, which have been linked to depression pathophysiology.6 furthermore, vitamin d is a supplement that is easily accessible and inexpensive. these reasons serve as a foundation for utilizing vitamin d supplementation to treat depressive symptoms in patients with type 2 diabetes. even though vitamin d is theoretically useful to treat depressive symptoms in type 2 diabetic patients, there are not many studies that are able to give conclusive conclusions regarding this matter.7-9 this review aimed to compile all the available evidence on the effectiveness of vitamin d in type 2 diabetes patients with depression when compared to placebo or other vitamin d doses in relieving depressive symptoms. methods this study followed the preferred reporting items for systematic reviews and metaanalysis guidelines (prisma).10 the protocol for this review is registered with prospero (crd42021231713).11 inclusion criteria we considered trials to be eligible if they included: (1) studies with the intervention of vitamin d supplementation and placebo as comparison – intervention can be single or combined with other drugs, such as antidepressants, psychotherapy treatment, or other adjuvant therapies (micronutrients, probiotics, etc.); (2) the patients in the studies were older than 18 years old; (3) type 2 diabetes mellitus patients diagnosed based on ada/who criteria with any depression questionnaire; (4) experimental studies; (5) studies in the form of randomized controlled trials (rcts); (6) studies written in english; and (7) full-text articles; original articles; and (9) studies that were published between january 1, 2009 and december 31, 2021. exclusion criteria the exclusion criteria in this study include (1) children and adolescents as subjects; (2) pregnant and breast-feeding mothers; (3) subjects with progressive illness (such as: chronic kidney disease, hepatic cirrhosis, known history of seizure and other neurological disorders, and previous history of depression); (4) correspondence, reviews, editorials, and conference abstracts. outcomes our primary outcome for all studies was a change in depressive symptoms evaluated with any validated rating scale. rudi putranto acta med indones-indones j intern med 576 search strategy the literature search was conducted in six databases: pubmed, ebscohost, and embase (up to 31 march 2022). the keywords used in the literature search were “depression” in conjunction with “diabetes mellitus” and “vitamin d”. synonyms used in the literature search keywords are obtained from the mesh terms (table 1). supplemental 2 provides the detailed search process. the search was limited to studies in english and was bound to articles that were published between january 1, 2009 and december 31, 2021. studies that have no available full-text reports were not looked into further. available full-text articles from the three databases were then screened based on their titles and abstracts. eligibility criteria were applied to the articles for further screening. suitable texts that fulfil all the criteria were taken into deeper analysis. in addition, all included publications’ reference lists were thoroughly checked to ensure that no relevant studies were missed. study selection following the removal of duplicates, all titles and abstracts were evaluated by three independent researchers (rp, kh, and ss). when studies were found eligible, the researchers collected full texts and conducted additional screening. consensus was used to settle disagreements. data extraction to address the differences, the three researchers (rp, kh, and ss) did data extraction and reviewed the results. some papers were eliminated from the data extraction process because they did not meet the study’s objectives, and the remaining articles were extracted by two different researchers independently (eds and srfs). study characteristics (first author’s name, year of publication, study location, publishing year, and study design), diagnosis, participant characteristics (mean age and gender of intervention and control group subjects, health condition of subjects, and the number of subjects in each group), types of intervention (type, dose, and duration of supplementation), mean and sd or percentage of clinical variables were collected from each study. quality assessment we assessed the risk of bias of rcts using the cochrane risk of bias tool.12 the following categories were examined: (1) method of randomisation, (2) allocation concealment, (3) blinding of subjects and personnel, (4) blinding of outcome assessment, (5) incomplete outcome data, (6) selective outcome reporting, and (8) other biases. each domain was labelled as low risk of bias (+), high risk of bias (-) or unclear risk of bias (?). two independent reviewers performed the quality assessment and resolved disagreements via discussion. review manager (revman) 5.4 software was used to assess the risk of bias.13we intended to assess publication bias using funnel plot techniques14, begg’s rank test15, and egger’s regression test15, as appropriate, given the known limitations of these methods. table 1. literature search strategy. database keywords results pubmed ((((depression[title/abstract] or depressive[title/abstract] or mood[title/abstract] or mental[title/abstract])))) and ((vitamin d[title/abstract] or vitamind2[title/abstract)) and ((diabetes mellitus[title/abstract] or diabetes[title/abstract])) 135 ebscohost (“depression” or “depressive” or “mood” or “mental”) and “vitamin d” and (“diabetes mellitus” or “diabetes”) 95 embase (depression or mood or mental or affective disorder*) and (vitamin d or cholecalciferol or vitamin d3 or ergocalciferol or vitamin d2 or alfacalcidol) and (type 2 diabetes mellitus or type ii diabetes mellitus or diabetes mellitus or diabetes) 69 vol 54 • number 4 • october 2022 the effect of vitamin d supplementation on symptoms of depression 577 statistical analysis on the basis of pre-to-post intervention changes, the effects of vitamin d supplementation were investigated. for all continuous outcomes, we utilized the standardized mean difference (smd) and 95 percent confidence intervals (cis). a fixed-effects model was applied to pool smds across studies by revman 5.4 software.13 the chi-squared test and i-squared values were used to measure statistical heterogeneity. moderate to substantial heterogeneity was indicated by i-squared >75 percent, mild heterogeneity by i-squared 50-75 percent, and low or no heterogeneity by i-squared < 50 percent. sensitivity analysis we utilized a “leave-one-out” evaluation procedure to assess the stability of the estimated measures in the sensitivity analysis. this evaluation is an iterative procedure in which one trial was excluded from each iteration, and a meta-analysis was conducted on the remaining sample of studies. this analysis demonstrates how each study influences the overall estimate of the other studies. we used the grading of recommendations assessment, development, and evaluation (grade) approach to evaluate the certainty of depression score as the outcomes, which values certainty at one of four levels, to objectively analyse the power of the included research (high, moderate, low, and very low).16 results after a thorough search and selection, our searches yielded 19,375 references. after duplicates were removed, 232 references remained for title and abstract screening. of these, 6 were identified and retrieved for full-text screening; all were in english. after a full text review, four rcts were included for the systematic review and three for the meta-analysis. the phases of the literature search are illustrated in figure 1. figure 1. preferred reporting items for systematic reviews and meta-analyses (prisma) diagram of study selection records identified through database searching (n = 256): pubmed (n = 92) ebscohost (n = 95) embasse (n = 69) records screened (n = 232 ) records excluded after title and abstract screening (n = 226 ) full-text articles assessed for eligibility (n = 6) full-text articles excluded (n=3), reasons: study design (cohort, review) id en tif ic at io n s cr ee ni ng in cl ud ed records after removal of duplicates (n = 232) e lig ib ili t rcts included in review (n = 4) additional rct included through manual searching (n=1) . rudi putranto acta med indones-indones j intern med 578 ta bl e 2. s tu dy c ha ra ct er is tic s of s el ec te d a rti cl es . s tu dy c ou nt ry ye ar s ub je ct s n ,g en de r d es ig n in te rv en tio n c om pa ri so n d ur at io n va lid at ed s ca le u se d o ut co m es r ay ga n et a l.1 7 ira n 20 18 ty pe 2 d ia be tic p eo pl e w ith c h d , 4 585 ye ar s ol d 60 (3 0 m al e, 30 f em al e) r c t 50 ,0 00 iu vi ta m in d + pr ob io tic p la ce bo 12 w ee ks b ec k d ep re ss io n in ve nt or y (b d i i i) sc al e im pr ov em en ts in b d i t ot al s co re (2. 8 vs -0 .9 , p =0 .0 1) o m id ia n et a l.1 8 ira n 20 19 p eo pl e w ith ty pe 2 d m an d m ild m od er at e de pr es si ve s ym pt om s, 30 -6 0 ye ar s ol d 68 (4 0 m al e, 28 f em al e) r c t 40 00 iu p la ce bo 3 m on th s b ec k d ep re ss io n in ve nt or y (b d i i i) sc al e b d i-i i s co re s de cr ea se d fro m 1 5. 2 to 9 .8 (p v al ue <0 .0 01 ) fa ze lia n et a l.1 9 ira n 20 19 w om en w ith ty pe 2 di ab et es a nd v ita m in d de fic ie nc y, 2 0 – 60 y ea rs o ld 51 w om en r c t 50 ,0 00 iu vi ta m in d 3 pl ac eb o 16 w ee ks d ep re ss io n, a nx ie ty , s tre ss s ca le s (d a s s -2 1) d ep re ss iv e ch an ge s w er e no t si gn ifi ca nt ly d iff er en t b et w ee n gr ou ps (p >0 .0 5) . w ith in g ro up an al ys is , i t s ho w ed s ig ni fic an t de cr em en t i n de pr es si on s co re in vi ta m in d g ro up (p =0 .0 3) m irz av an di et a l.2 0 ira n 20 20 p at ie nt s w ith ty pe 2 di ab et es m el lit us a nd vi ta m in d d efi ci en cy , 3 0 – 60 y ea rs o ld 50 (m al e 15 , fe m al e 35 ) r c t 20 0, 00 0 iu vi ta m in d in je ct io n at w ee k 0 an d w ee k 4 no ne 8 w ee ks b ec k d ep re ss io n in ve nt or y (b d i i i) sc al e n o si gn ifi ca nt d iff er en ce in de pr es si on s co re b et w ee n gr ou ps vol 54 • number 4 • october 2022 the effect of vitamin d supplementation on symptoms of depression 579 in table 2, we summarized the characteristics of the four rcts. the samples ranged from 50 to 68 subjects and the mean sample size was 57.25. a total of 229 patients within the studies were evaluated. among all subjects, 85 were men and 144 were women. the age of subjects included in these studies ranged from 30 to 85 years old, with a mean age of 52.7 in the experimental group and 54 in the placebo group. all of them were diagnosed with type 2 diabetes mellitus based on the american diabetes association or world health organization criteria. only subjects in the study by raygan et al. 15 had a comorbidity of coronary heart disease. the dose of vitamin d used ranged from 4000 iu to 200000 iu. the extracted scales used to measure depression in the selected studies included the bdi 17,16,20 and dass -21.19 for the post-intervention score, means and sd values were calculated from medians and ranges. two of the studies reported no adverse events, while the other two did not report anything regarding side effects. assessment of risk of bias the risk of bias of included rcts was assessed using the cochrane riskof-bias tool for randomized trial (rob 2).21 two reviewers independently assessed the risk of bias of the included rcts using the technique developed by higgins and green in the cochrane handbook for systematic reviews of interventions.12 selection bias (random sequence generation and concealment of allocation), performance bias (blinding of subjects and personnel), detection bias (blinding of researchers conducting outcome assessments), attrition bias (incomplete outcome data), reporting bias (selective reporting), and other sources of bias were all assessed. a judgement of ‘low risk’ of bias, ‘high risk’ of bias, or ‘unclear risk’ of bias was made for each domain. any disagreements were resolved by discussion or by involving a third reviewer until consensus was reached (figure 2 and 3). there were insufficient numbers of included studies to appropriately assess a funnel plot or more advanced regression-based assessments; hence, publication bias was not assessed.22 outcome evaluation and meta-analysis there was a statistically significant improvement in depressive symptoms in the vitamin d supplementation group as compared to the control group (95% confidence interval: -0.70 to 0.08, p = 0.01). only three studies were included because one study did not report the mean and sd, so it was not estimable.18 statistical heterogeneity was assessed using the chi-squared test and i-squared values. our metaanalysis showed 0% ≤ i-squared ≤50 % low or no heterogeneity. figure 2. risk of bias graph: review author’s judgements about each risk of bias item presented as percentages across all included studies rudi putranto acta med indones-indones j intern med 580 confidence in cumulative evidence for the effectiveness of treatment, the confidence in the cumulative evidence was considered moderate (table 3). the possibility that the actual effect may be significantly different from the estimated effect reduced our confidence in the efficacy of the treatment effect estimate. potential limitations, such as even rates and a small sample size, failure to assess compliance, and a nonrepresentative sample are likely to reduce confidence in the effect estimate. in addition, we found disparities in treatment effect estimates, unexplained heterogeneity in subgroup analyses, and minimal overlap of confidence ranges (ci). some of the findings were consistent with substantial benefit and substantial harm, implying that imprecision should be rated lower. discussion in this meta-analysis of 3 randomized controlled trials with a total of 161 subjects, vitamin d supplementation was significantly associated with improving depressive symptoms (p = 0.01). all four studies analysed have strong points and were conducted with a high level of evidence, adequate duration of therapy, multiple disguises, proper randomization using computergenerated randomization, similarities between groups during baseline, and similarities in the key: : low risk : unclear risk : high risk figure 3. risk of bias summary: review authors’ judgements about each risk of bias item for each included study figure 4. meta-analysis of randomised controlled trials of the effect of vitamin d supplementation in improving depressive symptoms in patients with type 2 diabetes mellitus. vol 54 • number 4 • october 2022 the effect of vitamin d supplementation on symptoms of depression 581 given therapy (high dose of vitamin d). all studies had similar sample size of around 50–68 patients. there were a number of patients who were not available for a follow-up, but none were attributable to the side effects or complications of the regimen given. the number of samples was low due to restrictive inclusion and exclusion criteria applied to these four studies. lower serum vitamin d levels have been linked to an increasing risk of depression. depressive symptoms in those with very low vitamin d levels could be alleviated with vitamin d supplementation.23-25 vitamin d supplementation increased the well-being in three pilot studies, and symptoms of depression were reduced when high doses of vitamin d3 (100 mcg per day) were given for 1 to 3 months.23 the studies by raygan et al.17 and omidian et al.18 showed that vitamin d supplementation led to significant improvement in depressive symptoms compared to placebo. in contrast, the study by fazelian et al.19 and mirzavandi et al.20 resulted in no statistically significant decrement of depression scores between groups. nevertheless, the study by mirzavandi et al. used non-experimental groups rather than the placebo group – control groups were not given intervention. this methodology makes the blinding process impossible to carry out, which may lead to an increasing risk of bias.20 moreover, the study by fazelian et al. stated that according to the within-group analysis, patients who had a low serum vitamin d level at baseline had a significant decrement in their depressive symptoms score.19 therefore, further research to assess the effect of vitamin d supplementation on the improvement of depressive symptoms in patients with low levels of serum vitamin d is still needed. the studies results by omidian et al.18 and mirzavandi et al.20 is highly applicable in type 2 diabetes mellitus patients with depression. raygan et al.17 did a study in diabetic patients with the comorbidity of coronary heart disease, while fazelian et al.19 did a study on depressed diabetic patients with low, moderate, or severe anxiety disorder. nevertheless, the generalizability of these studies to a larger population is still questionable since all of the studies were performed in iran. the studies by omidian et al.18 and mirzavandi et al.20 reported that vitamin d supplementation did not show any significant side effects, while raygan et al.17 and fazelian et al.19 did not report anything about adverse effects. these findings show that the benefits of vitamin d are much greater than the potential losses. consistent with the results of our study, o t h e r c l i n i c a l t r i a l s t h a t h a v e d i ff e r e n t population samples also showed that vitamin d supplementation was associated with improvement of depressive symptoms.26,27 a study by mozzafari et al. recruited depressed patients with vitamin d deficiency as their subjects and found that after 3 months of injected vitamin d, there was a significant improvement in depressive symptoms.26 penckofer et al. reported a significant effect of vitamin d supplementation on depressed diabetic women.7 a further study by penckofer et al. in the sunshine 2 study showed that there was a significant improvement in depressive symptoms in diabetic women over time, regardless of the vitamin d3 dose.28 furthermore, khoraminya et al. reported that table 3. the three studies included in the meta-analysis were graded using the grading of recommendations assessment, development, and evaluation (grade) evidence profile for the role of vitamin d supplementation for depression symptoms. certainty assessment effect certainty importancenumber of studies study design risk of bias inconsistency indirectness imprecision other considerations relative (95%ci) outcome: depressive symptoms score 3 rct not serious not serious not serious not serious none 0,70 0,08 moderate important rudi putranto acta med indones-indones j intern med 582 vitamin d supplementation as an adjunctive therapy to an antidepressant drug was effective.29 moreover, two cross-sectional studies have also proved that there is a correlation between low serum vitamin d and depressive symptoms.30,31 however, there are some observational studies that have found no association between these two variables.32,33 in this systematic review of rcts, the effect of vitamin d supplementation was significant for improvement in depressive symptoms in patients with type 2 diabetes mellitus. even though one of the rcts showed no significant effect of vitamin d supplementation, the study did show a possible trend of depressive symptom improvement by giving a vitamin d injection. the decrement of the bdi score was higher in the experimental group (-3.9 10.3) than in the non-experimental group (-1.0 2.5) 20 limitations to the best of our knowledge, this study is the first study to review the effect of vitamin d supplementation on the improvement of depressive symptoms in type 2 diabetic patients. moreover, this systematic review only included rcts with a high level of evidence, which ensured less study bias and was more reliable in assessing the effectiveness of medical treatment. in addition, the author also did some grey literature searching, which minimized the plausibility of missing evidence. the limitations of this study include the questionable generalizability of the findings because of concentrated patient samples, i.e., all studies were conducted in iran. furthermore, even though the included articles were focused on the effect of vitamin d supplementation on the improvement of depressive symptoms in type 2 diabetic patients, most of the studies lacked detailed information on the mechanisms of how vitamin d may affect depressive symptoms. due to the limitations of the study, the authors provide recommendations as follows: (1) larger patient samples and more varied patient demographics since all available studies were conducted in iran; (2) more studies that include within-group analysis, especially based on the level of serum vitamin d, are highly recommended to further explore the effect of vitamin d; (3) the addition of more different populations in the next research topic because the existing studies only examine specific populations, namely patients with type 2 diabetes mellitus who do not have complications from diabetes mellitus; and, (4) the dosing and form of vitamin d used should be more standardized for further studies. conclusion the results of the systematic review and meta-analysis demonstrated that vitamin d supplementation may improve the depressive symptoms in type 2 diabetic patients. sources of funding universitas indonesia, tadok no. nkb01/un2.r3.1/hkp.05.00/2019. conflict of interest the authors report no declarations of interest. acknowledgments the authors would like to thank retno prabandari, a librarian in universitas indonesia, for her help in literature searching. we would also thank stevanie, a medical doctor from universitas gadjah mada, for her contribution to the literature search and for the editing process. references 1. roy t, llyod ce. epidemiology of depression and diabetes: a systematic review. journal of affective disorders. 2012;s8–s21. doi: 10.1016/s0165 0327(12)70004-6 2. holt rig, groot m de, golden sh. diabetes and depression. curr diab rep. 2014;14(6):491. doi: 10.1007/s11892-014-0491-3. 3. anglin res, samaan z, walter sd, mcdonald sd. vitamin d deficiency and depression in adults: systematic review and meta-analysis. british journal of psychiatry. 2013:202(2):100-7. doi: 10.1192/bjp. bp.111.106666 4. nouwen a, winkley k, twisk j, et al. type 2 diabetes mellitus as a risk factor for the onset of depression: a systematic review and meta-analysis. diabetologia. 2010;53(12):2480–6. doi: 10.1007/s00125010-1874x. epub 2010 aug 14. 5. fisher l, glasgow re, strycker la. the relationship between diabetes distress and clinical depression with vol 54 • number 4 • october 2022 the effect of vitamin d supplementation on symptoms of depression 583 glycaemic control among patients with type 2 diabetes. diabetes care. 2010;33(5):1034–6. doi: 10.2337/ dc09-2175 6. groves nj, mcgrath jj, burne th. vitamin d as a neurosteroid affecting the developing and adult brain. annu rev nutr. 2014;34:117-41. doi: 10.1146/ annurev-nutr-071813-105557 7. penckofer s, byrn m, adams w, et al. vitamin d supplementation improves mood in women with type 2 diabetes. j diabetes res. 2017;2017:8232863. doi: 10.1155/2017/8232863. epub 2017 sep 7. 8. gowda u, mutowo mp, smith bj, wluka ae, renzaho amn. vitamin d supplementation to reduce depression in adults: meta-analysis of randomized controlled trials. nutrition. 2015;31:421-429s. 9. spedding s. vitamin d and depression: a systematic review and meta-analysis comparing studies with and without biological flaws. nutrients. 2014;6:1501-18. 10. page mj, mckenzie je, bossuyt pm, et al. the prisma 2020 statement: an updated guideline for reporting systematic reviews. bmj. 2021;372:n71. https://doi.org/ 10.1136/bmj.n71 11. national institute for health research. http://www. crd.york.ac.uk/prospero, registration number crd42021231713. 12. higgins jp, altman dg, gotzsche pc, et al. the cochrane collaboration’s tool for assessing risk of bias in randomized trials. bmj. 2011;343:d5928. 13. review manager (revman) [computer program]. version 5.4. the cochrane collaboration, 2020. 14. sterne jac, sutton aj, loannidis jpa, et al. recommendations for examining and interpreting funnel plot asymmetry in metaanalyses of randomised controlled trials. bmj. 2011;343:d4002. doi: https:// doi.org/10.1136/bmj.d4002 15. lin l, chu h. quantifying publication bias in metaanalysis. biometrics. 2018;74(3):785-94. doi:10.1111/ biom.12817 16. guyatt g, oxman ad, akl ea, et al. grade guidelines: introduction grade evidence profiles and summary of findings tables. j clin epidemiol. 2011;64:, 383-94. 17. raygan f, ostadmohammadi v, bahmani f, asemi z. the effects of vitamin d and probiotic cosupplementation on mental health parameters and metabolic status in type 2 diabetic patients with coronary heart disease: a randomized, double-blind, placebo-controlled trial. prog neuropsychopharmacol biol psychiatry. 2018;84(pt a):50–5. doi: 10.1016/j. pnpbp.2018.02.007 18. omidian m, mahmoudi m, abshirini m, et al. effects of vitamin d supplementation on depressive symptoms in type 2 diabetes mellitus patients: randomized placebo-controlled double-blind clinical trial. diabetes metab syndr: clin res rev. 2019;13:2375-80. doi: 10.1016/j.dsx.2019.06.011 19. fazelian s, amani r, paknahad z, khein s, khajehali l. effect of vitamin d supplement on mood status and inflammation in vitamin d deficient type 2 diabetic women with anxiety: a randomized clinical trial. int j prev med. 2019;10:17. doi:10.4103/ijpvm. ijpvm_174_18 20. mirzavandi f, babaie s, rahimpour s, et al. the effect of high dose of intramuscular vitamin d supplement injections on depression in patients with type 2 diabetes and vitamin d deficiency: a randomized controlled clinical trial. obes med. 2020;17:1-6. doi: 10.1016/j. obmed.2020.100192 21. sterne jac, savocić j, elbers rg, et al. rob 2: a revised tool for assessing risk of bias in randomized tools. bmj. 2019;366:l4898. 22. a b o u s e t t a ( h t t p s : / / s t a t s . s t a c k e x c h a n g e . c o m / users/24137/abousetta), metaanalysis: dealing with bias with a small number of studies, url (version: 201308-03): https://stats.stackexchange.com/q/66408 23. geng c, shaikh as, han w, chen d, guo y, jiang p. asia pacific journal of clinical nutrition. 2019;28 (4): 689 – 94. doi: 10.6133/apjcn.201912_28(4).0003. 24. li g, mbuagbaw l, samaan z, et al. efficacy of vitamin d supplementation in depression in adults: a systematic review. journal of clinical endocrinology and metabolism. 2014;99(3):757-67. doi:10.1210/ jc.2013-345 25. anglin re, samaan z, walter sd, mcdonald sd. vitamin d deficiency and depression in adults: systematic review and meta-analysis. br j psychiatry. 2013 feb;202:100-7. doi: 10.1192/bjp.bp.111.106666. pmid: 23377209. 26. mozaffari-khosravi h, nabizade l, yassini-ardakani sm, hadinedoushan h, barzegar k. the effect of 2 different single injections of high dose of vitamin d on improving the depression in depressed patients with vitamin d deficiency: a randomized clinical trial. j clin psychopharmacol. 2013;33(3): 378-85. 27. jorde r, sneve m, figenschau y, svartberg j, waterloo k. effects of vitamin d supplementation on symptoms of depression in overweight and obese subjects: randomized double-blind trial. j intern med. 2008;264(6):599-609. doi: 10.1111/j.13652796.2008.02008.x. epub 2008 sep 10. pmid: 18793245. 28. penckofer s, ridosh m, adams w, et al. vitamin d supplemetation for the treatment of depressive symptoms in women with type 2 diabetes: a randomized clinical trial. journal of diabetes research. 2022; id: 4090807: 1 – 10. https://doi.org/10.1155/2022/4090807 29. khoraminya n, therani-doost m, jayazeri s, hosseini a, djazayery a. therapeutic effects of vitamin d as adjunctive therapy to fluoxetine in patients with major depressive disorder. aust nzj psychiatr. 2013;47(3): 271-5. doi: 10.1177/0004867412465022 30. kjærgaard m, joakimsen r, jorde r. low serum 25-hydroxyvitamin d levels are associated with depression in an adult norwegian population. rudi putranto acta med indones-indones j intern med 584 pyschiatr res. 2011;190(2-3):221-5. doi: 10.1016/j. psychres.2011.06.024 31. hoogendijk wj, lips p, dik mg, deeg dj, beekman at, penninx bw. depression is associated with decreased 25-hydroxyvitamin d and increased parathyroid hormone levels in older adults. arch gen psychiatr. 2008;65(5):50812. doi: 10.1001/ archpsyc.65.5.508 32. zhao g, ford es, li c, balluz ls. no associations between serum concentrations of 25-hydroxyvitamin d and parathyroid hormone and depression among us adults. br j nutr. 2010;104(11):1696-702. doi: 10.1017/s0007114510002588 33. pan a, lu l, franco oh, yu z, li h, lin x. association between depressive symptoms and 25-hydroxyvitamin d in middle-aged and elderly chinese. j affect disord 2009;118(1-3):240-3. doi: 10.1016/j.jad.2009.02.002 136 acta med indones indones j intern med • vol 55 • number 2 • april 2023 original article abstract background: chronic kidney disease (ckd) patients, particularly those who require renal replacement therapy, have a higher risk of hospitalization and mortality compared than the general population. the patients can suffer hypoalbuminemia and anemia due to chronic inflammations, that might affect the risk of hospitalization risk. the aim of this study is to investigate the effect of albumin dan hemoglobin levels on the hospitalization incidence of patients with stage 5 chronic kidney disease who undergo chronic hemodialysis. methods: this retrospective cohort study enrolled patients aged 18 years and older with end stage kidney disease who underwent regular hemodialysis at the prof. dr. r. d kandou hospital, manado, indonesia. patients with malignancy were excluded. we measured the hemoglobin and albumin baseline level and observed the hospitalization incidence over the next 6 months. we used the chi square test with significance level of p-value 0.05, to analyze the association between both anemia and hypoalbuminemia with risk of hospitalization over 6 months of follow up period. results: we enrolled 202 patients as our participants, most of whom were men (61.8%), with a mean age of 60.21±9.32 years. there were 120 participants (59.4%) being hospitalized during 6-months-follow-up period. the mean level of albumin was 3.29±0.63 g/dl, while the mean hemoglobin level was 9.43±1.75 g/dl. this study found that most of the participants had hypoalbuminemia (62.9%) while 45% had anemia. we found significant associations between hypoalbuminemia and anemia with the risk of hospitalization within 6 months, with p values 0.001 and 0.007, respectively. the relative risk for being hospitalized over 6 months follow up period in patients having anemia was 2.32 (95% ci 1.29-4.17), and for hypoalbuminemia was 2.77 (95% ci 1.54-4.99). conclusion: hypoalbuminemia and anemia are associated with increased risk of all causes hospitalization within 6 months in stage 5 chronic kidney disease patients undergoing hemodialysis. keywords: anemia, hypoalbuminemia, chronic kidney disease, hemodialysis, hospitalization. the effect of anemia and hypoalbuminemia on six-months hospitalization risk in end stage chronic kidney disease patients undergoing hemodialysis: a retrospective cohort study octavianus umboh*, emma syarifih moies, stella palar division of nephrology and hypertension, department of internal medicine, faculty of medicine, sam ratulangi university prof. dr. r. d. kandou hospital, manado, indonesia. *corresponding author: octavianus umboh, md. department of internal medicine, faculty of medicine, sam ratulangi university, prof. dr. r. d. kandou hospital. jalan raya tanawangko, manado, indonesia. email: octavianus.umboh@gmail.com. introduction chronic kidney disease (ckd) is defined as an abnormality in the structure or function of the kidneys that occurs over a three-month period. chronic kidney disease is a progressive disease that affects more than 10% of the world’s population.2 according to the basic health research of the republic of indonesia in 2018, the prevalence of ckd among the indonesian population was 0.38%. this number was higher than the prevalence of ckd in 2013, which was 0.2% nationwide. chronic kidney disease mostly found in a population between the ages of 65 and 74 years old, and it is more common in vol 55 • number 2 • april 2023 the effect of anemia and hypoalbuminemia 137 men.3 obesity, hypertension, and type 2 diabetes mellitus, are akso risk factors of ckd.4 the failure of the excretion function of the kidneys leads to an accumulation of uremic particles, which act as oxidants and causes a chronic inflammatory condition.5 the classification of ckd can be assessed based on the glomerular filtration rates (gfr) which classify it into five stages. the patients with end stage ckd (stage 5) requires renal replacement therapy (hemodialysis).1 hemodialysis is one of the renal replacement therapies methods. it uses a special device to eliminate uremic toxins and regulate the body’s electrolyte fluids.6 according to the data published by the indonesian ministry of health in 2018, only 19.3% of patients with end stage ckd underwent hemodialysis therapy 3. in fact, if the treatment is not carried out properly, it can increase the risk of complications, for example, anemia. anemia is caused by a decreased in the level of erythropoietin produced by the kidneys, with is followed by decreased gfr.7 some laboratory parameters, including albumin and hemoglobin levels, can be used to evaluate the progression of of ckd, predicting its clinical outcomes, evaluating response to treatment, as well as predicting of the prognosis.8 to date, most of the published studies on this topic were conducted in japanese ,taiwanese, and singaporean populations, which may have different profile compared with indonesian patients in terms of ethnicity, lifestyle, socioeconomic level and health system9,10 the differences in socioeconomic status level between ckd patients in developed countries compared with those in emerging countries such as indonesia, may play significant role particularly in nutritional status and dietary intake. those factors may have effects on hemoglobin and albumin levels. the optimal management of anemia in ckd requires intravenous iron preparation and erythropoietin stimulating agent, which may not always available in all indonesian hospital, and may thus be unmeet need. based on those considerations, we want to investigate the effect of albumin dan hemoglobin levels on hospitalization, especially for patients with stage 5 chronic kidney disease undergoing hemodialysis in indonesia; therefore, we aimed to investigate the impact of anemia and hypoalbuminemia on risk of hospitalization over 6 months follow up period in patients with stage 5 chronic kidney disease undergoing hemodialysis. we believe the findings may serve as evidence for the importance of hypoalbuminemia and anemia management to reduce risk of hospitalization over the next 6 months in ckd patients. methods study design and participants this is a retrospective cohort study. the study enrolled ckd patients undergoing regular hemodialysis at the prof. dr. r. d kandou hospital, manado, indonesia. we screened eligible patients and collected data on their albumin and hemoglobin levels. we enrolled patients aged 18 years or older who underwent regular hemodialysis for at least 3 months with a duration of 8-10 hours per week (divided into two sessions). we excluded patients with malignancy. patients who met the inclusion criteria and agreed to sign the informed consent form would be asked several questions, including age, sex, education, occupation, and ethnicity. interviews were conducted by trained interviewers. if the patient did not show up for follow-up or the routine hd schedule, we contacted patient’s family member following to find out the reason for the patient’s absence, whether the patient had died, been admitted to the hospital, or been converted to capd therapy or a kidney transplant. if the patient is admitted to the hospital, the investigator searched the time of admission, as well as the primary and secondary diagnoses. for the next 6 months, we observed the hospitalization incidence as recorded in medical record. (january 1 to june 30, 2021). we did not include hospitalization caused by elective procedure (e.g. hospitalization for arteriovenous fistula operation). hypoalbuminemia was defined as albumin level lower than 3.5 g/dl. meanwhile, anemia was defined as hemoglobin level below 10g/dl. we used flowcytometry, method to measure hemoglobin level, and dye bromcresol green to measure the albumin serum level. both octavianus umboh acta med indones-indones j intern med 138 tests were carried out in the clinical pathology laboratory of prof r. d. kandou hospital.this study was approved by the ethics committee of prof. dr. r. d. kandou hospital manado (reference number 152/ec/kepk-kandou/ ix/2021). statistical analysis we analyzed the collected data using statistical package for social sciences (spss) program version 25.0. to determine the association between albumin and hemoglobin levels with hospitalization, we used chi-square test. if one of the cells had an expected count value less than 5, the fisher exact test was used. the p-value less than 0.05 was considered statistically significant. we also measured the effect size, presented as a relative risk and its corresponding 95% confidence interval. results we enrolled 202 patients with stage 5 ckd who underwent routine hemodialysis. the mean age in this study was 60.2±9.3 years, with 61.8% of total participants were men and 38.2% were women samples. in this study, the mean hemoglobin was 9.43±1.75 g/dl, while the mean albumin was 3.29±0.63 g/dl. most patients aged 60 years or younger who were hospitalized had hypoalbuminemia and did not have anemia. the table 1 presented the baseline characteristics of the study participants. table 1. the baseline characteristics of the study participants. characteristics men , n (%) 125 (61.8) age, mean±sd 60.21±9.32 age >60 years old, n (%) 96 (47.5) hospitalized patients, n (%) 120 (59.4) length of hospitalization stay, mean±sd (days) 6.97±18.15 anemia n(%) 91 (45) hypoalbuminemia, n (%) 127 (62.9) hemoglobin, mean±sd 9.43±1.75 albumin, mean±sd 3.29±0.63 there were 120 participants who had been hospitalized within 6 months follow up period. table 2 showed the associations as well as the effect sizes between anemia, hypoalbuminemia, and hospitalization in patients with ckd stage 5 on hemodialysis. we found statistically significant association between both anemia and hypoalbuminemia with hospitalization, with p-values 0.007 and 0.001, respectively. the relative risk for being hospitalized over 6 months follow up period in patients having screeenig patients n=220 included for this study n=210 included for final analyses n=202 reasons for exclusions: having malignancy n=10 missing follow up n=10 figure 1. flowchart of patients selection. vol 55 • number 2 • april 2023 the effect of anemia and hypoalbuminemia 139 anemia was 2.32 (95% ci 1.29-4.17), and for hypoalbuminemia was 2.77 (95% ci 1.54-4.99). table 2. the associations and effect size measurements between anemia and hypoalbuminemia with 6-months hospitalization in stage 5 ckd patients undergoing hemodialysis. variables hospitalization rr (95%ci)* yes no anemia yes 64 27 2.328 (1.299-4.174)no 56 55 hypoalbuminemia yes 87 40 2.768 (1.535-4.994) no 33 42 * pearson chi-square discussion the mean age of the subjects in this study was 60.2 years. data from the indonesian renal registry shows that ckd occurs most often between the age of 60-70 years old. in addition, ckd patients who undergo hemodialysis are usually aged 45-54 years. this shows that ckd patients undergoing hemodialysis have varied age ranges. this is related to the decline in nephron function, which is physiologically starting at this age (45-54 years). this study found that in ckd patients undergoing hemodialysis, the majority (61.8%) were men. this is congruent with the data from the indonesian renal registry in 2018, showing more male hd patients than female patients. based on irr data, out of 30,831 new patients undergoing hd in indonesia, 17,133 (56%) were men, and the remaining 13,698 (44%) were women. several factors are associated with increased ckd progression in men compared to women, such as a higher risk of causing diabetic nephropathy, hypertension, hyperglycemia, albuminuria, dyslipidemia, an increased body mass index, lifestyle factors, kidney structure, and sex hormones.11 this study’s hospitalization incidence was 59.4% in patients undergoing routine hd. arif et al. revealed that 48,621 patients started hemodialysis, of whom 22,338 (46%) performed routine hemodialysis as inpatients. the length of stay of patients starting hemodialysis was 10 (7-17 days). hemodialysis was initiated at a median of 3 (2-7 days) after hospital admission, and patients were discharged from the hospital 6 (3-10 days) after the first hemodialysis. based on a national retrospective cohort in the us, older inpatients can be found to have congestive heart failure and dementia. in addition, they experienced longer hospitalizations during hemodialysis.12 medical indications for hospitalization for hemodialysis include patients with congestive heart failure who experience fluid overload or older patients who experience severe consequences of uremia. li et al investigated the cause of ckd patients who were already on hemodialysis 1-2 years after their hemodialysis initiation. they found that infectious diseases such as pneumonia and urinary tract infection were s the most common indications for admission. comorbidities also played significant roles in increasing hospitalization risk with cardiovascular diseases being the most significant.13 tanmoy et al. analyzed the data of patients on maintenance hemodialysis who were hospitalized in india. they found that the mean length of stay was 10.31±6.07 days, which was longer than our finding. they also found that the most common cause of admission was left ventricular failure (59.18%) and respiratory tract infection (14.29%).14 we found in our study that anemia increased the risk of hospitalization by 2.3 times (p = 0.007). a systematic review by palaka et al. found that significant association between anemia and hospitalization in ckd stage 5 patients undergoing hemodialysis. they found that hospitalization risk among ckd 5 patients undergoing hd was inversely correlated with hemoglobin level. they found that the hazard ratio of hospitalization in patients on dialysis with hb 10–12 g/dl was 1.09 (1.07-1.11) and >12 g/dl was 0.91 (0.87–0.96).15 li et al. also found that in their study, the mean hemoglobin level on admission of hospitalized patients with maintenance hd was 7.72±1.82. this finding also showed anemia to be prevalent in ckd patients that were admitted.13 anemia is one of the important clinical conditions of dialysis patients. the guideline for treating anemia in indonesia is to use a limit of 10 g/dl to get supportive therapy. in general, patients with ckd on hemodialysis have hb levels <10 g/dl, with a percentage of 65.9-100%. this is in accordance with national data, where only 22% of hd patients achieve hb octavianus umboh acta med indones-indones j intern med 140 ≥ 10 g/dl. meanwhile, the other 78% have hb < 10 g/dl. anemia occurs because the kidneys are the main source of erythropoietin. it is one part of the progression of kidney failure. it is independently related to the occurrence of cardiovascular disease in chronic kidney failure. every decrease in the average hemoglobin of 1 g/ dl will increase the risk of heart failure by 25%. more strikingly, the risk of death increases by up to 14%. signs of anemia appear when gfr falls to 50 ml/minute. the average hemoglobin concentration is 2.3 g/dl. it might be lower in patients with a gfr of 50-25 ml/min compared to those with a gfr >50 ml/min.16 in patients with ckd, anemia is an independent predictor of death.17 in patients with ckd who are not on dialysis, the risk of cardiovascular events, including stroke, is greatly increased when anemia is present.18 a study in the united states investigated patients with ckd during the predialysis period. the study compared anemic ckd patients who did not use epo to those who regularly used epo. the results indicated that the regular use of epo led to an increase in hb levels.19 this is associated with a decrease in hospitalizations, including hospitalizations for cvd. mortality, morbidity, and cvd were also lower when these epo-treated patients were eventually on dialysis. in patients already on dialysis, the higher the hb level, up to 12 g/dl, the lower the patient’s mortality and hospitalization rate.17,20 correction of anemia with subcutaneous erythropoietin and intravenous iron often results in improved or at least stable renal function. in addition, the patient’s quality of life and exercise capacity also improve with anemia correction. in ckd patients, anemia can also play an important role in increasing the risk of death, coronary heart disease, stroke, and developing end-stage kidney disease. erythropoietin may have direct positive effects on the heart and brain, unrelated to the correction of anemia, by reducing cell apoptosis and increasing neovascularization. both of which may prevent tissue damage.21 we found a significant relationship between albumin and hospitalization in ckd 5 patients who underwent hd by 2.7 times (p = 0.001). antunes et al. conducted a study to investigate the impact of hypoalbuminemia on the clinical outcome of patients with chronic hd. they observed the patients for 13 months. they found that hypoalbuminemic patients had a significantly higher hospitalization rate and shorter hospitalization free period (p=0.008).22 hypoalbuminemia is a poor predictor of worse prognosis for dialysis patients. many recent studies have shown that serial measurement of serum albumin can even predict chronic inflammation and prognosis well. based on the results of several studies, it is clear that hypoalbuminemia is associated with mortality in cardio-cerebrovascular and ckd stage 5 patients undergoing hemodialysis. in several studies, the relationship between hypoalbuminemia and cardio-cerebrovascular diseases is a reflection of inflammation-induced malnutrition. the underlying mechanisms behind this are appetite suppression and increased catabolism by inflammatory cytokines. serum albumin is a potential barrier to free radicals. a decrease in serum albumin levels will lead to a decrease in antioxidant capacity and contribute to the harmful effects of oxidative stress on various tissues, including the arterial walls. these data suggested that hypoalbuminemia can more accurately be viewed as a composite marker reflecting malnutrition and increased acute phase inflammation, given that albumin is also a negative acute phase reactant.23, 24 based on our study, hypoalbuminemia and anemia may play a significant role in increasing the hospitalization risk. however, in this study we did not analyze other hospitalization risk factors as confounding variables, such as the patients’ comorbidities. future studies are also needed to assess the effectivity of hemoglobin and albumin correction in reducing hospitalization incidence among patients with chronic hemodialysis. conclusion in conclusion, we found a significant a s s o c i a t i o n b e t w e e n a n e m i a a n d hypoalbuminemiaemia with hospitalization within 6 months of follow up in patients with stage 5 chronic kidney disease who undergo chronic hemodialysis. optimizing anemia and hypoalbuminemia conditions are required to vol 55 • number 2 • april 2023 the effect of anemia and hypoalbuminemia 141 reduce the risk of hospitalization over the next 6 months. acknowledgments we would like to thank the department of internal medicine, sam ratulangi university, and prof. dr. r. d. kandou hospital for supporting this study. competing interest the authors declare no conflict of interest. funding this research received no external funding. references 1. kidney disease improving global outcomes (kdigo). clinical practice guideline for the evaluation and management of chronic kidney disease. journal of the international society of nephrology. 2013;3(1):5. 2. kalantar-zadeh k, li pkt. strategies to prevent kidney disease and its progression. nat rev nephrol. 2020;16(3):129-30. 3. kemenkes ri. hasil riset kesehatan dasar tahun 2018. kementrian kesehatan ri. 2018;53(9):1689-99. 4. nistala r, savin v. diabetes, hypertension, and chronic kidney disease progression: role of dpp4. am j physiol renal physiol. 2017;312(4):f661-70. 5. ruiz-ortega m, rayego-mateos s, lamas s, et al. targeting the progression of chronic kidney disease. nat rev nephrol. 2020;16(5):269-88. 6. alisa f, wulandari c. faktor-faktor yang berhubungan dengan kepatuhan pasien penyakit ginjal kronik (pgk) yang menjalani hemodialisa di rsup dr. m. djamil padang. jurnal kesehatan mercusuar. 2019;2(2). 7. watanabe r. hyperkalemia in chronic kidney disease. rev assoc med bras. 2020;66:s31-6. 8. tangri n, inker la, hiebert b, et al. a dynamic predictive model for progression of ckd. am j kid dis. 2017;69(4):514-20. 9. hounkpatin ho, fraser sds, honney r, et al. ethnic minority disparities in progression and mortality of predialysis chronic kidney disease: a systematic scoping review. bmc nephrol. 2020;21(1):1-14. 10. lim gj, liu yl, low s, et al. medical costs associated with severity of chronic kidney disease in type 2 diabetes mellitus in singapore. ann acad med singap. 2020;49(10):731-41. 11. major rw, cheng mri, grant ra, et al. cardiovascular disease risk factors in chronic kidney disease: a systematic review and meta-analysis. plos one. 2018;13(3). 12. arif fm, sumida k, molnar mz, et al. early mortality associated with inpatient versus outpatient hemodialysis initiation in a large cohort of us veterans with incident end-stage renal disease. nephron. 2017;137(1):15-22. 13. li hl, tai ph, hwang yt, lin sw, et al. causes of hospitalization among end-stage kidney disease cohort before and after hemodialysis. int j environ res public health. 2022;19(16):10253. 14. chattopadhyay t, banerjee a, mondal h. causes of hospitalization in patients on maintenance hemodialysis with arteriovenous fistula 1in a tertiary care hospital in west bengal, india. saudi j kidney dis transpl. 2021;32(5):1418-23. 15. palaka e, grandy s, van haalen h, et al. the impact of ckd anaemia on patients: incidence, risk factors, and clinical outcomes-a systematic literature review. int j nephrol. 2020;2020:7692376. 16. levin a. anemia and left ventricular hypertrophy in chronic kidney disease populations: a review of the current state of knowledge. kidney int suppl. 2002;61(suppl 80):s35–8. 17. levin a, djurdjev o, duncan j, et al. haemoglobin at time of referral prior to dialysis predicts survival: an association of haemoglobin with long-term outcomes. nephrol dial transplant. 2006;21(2):370-7. 18. jurkovitz ct, abramson jl, vaccarino lv, et al. association of high serum creatinine and anemia increases the risk of coronary events: results from the prospective community-based atherosclerosis risk in communities (aric) study. j am soc nephrol. 2003;14(11):2919-25. 19. abramson jl, jurkovitz ct, vaccarino v, et al. chronic kidney disease, anemia, and incident stroke in a middle-aged, community-based population: the aric study. kidney int. 2003;64(2):610-5. 20. vida c, oliva c, yuste c, et al. oxidative stress in patients with advanced ckd and renal replacement therapy: the key role of peripheral blood leukocytes. antioxidants (basel). 2021;10(7). 21. murphy st, parfrey ps. the impact of anemia correction on cardiovascular disease in end-stage renal disease. semin nephrol. 2000;20(4):350-5. 22. a n t u n e s a , e u g e n i a c , c a m p a s f, e t a l . hypoalbuminemiaemia seems to be associated with a higher rate of hospitalization in hemodialysis patients. j. bras. nefrol. 2016;38(1):70-5. 23. danielski m, ikizler ta, mcmonagle e, et al. linkage of hypoalbuminemiaemia, inflammation, and oxidative stress in patients receiving maintenance hemodialysis therapy. american journal of kidney diseases. 2003;42(2):286-94. 24. belinskaia da, voronina pa, shmurak vi, et al. serum albumin in health and disease: esterase, antioxidant, transporting and signaling properties. int j mol sci. 2021;22(19). medical illustration cerebral venous sinus thrombosis in systemic lupus erythematosus guntur darmawan1, laniyati hamijoyo1, amaylia oehadian1, ria bandiara1, lisda amalia2 1 department of internal medicine, faculty of medicine, padjadjaran university, bandung, indonesia. 2 department of neurology, faculty of medicine, padjadjaran university, bandung, indonesia. corresponding author: ria bandiara, md. phd. department of internal medicine, faculty of medicine, padjadjaran university hasan sadikin hospital. jl. pasir kaliki no. 190, pasteur, bandung, indonesia. email: riabandi81@yahoo.co.uk. figure 1. swelling and erythema at bilateral palpebral figure 2. axial brain mri showed empty delta sign (a), axial brain mri showed enhancement of straight sinus (b) and mr venography showed thrombosis in the cavernous sinus (c) 343acta med indones indones j intern med • vol 50 • number 4 • october 2018 guntur darmawan acta med indones-indones j intern med a 38-year-old woman presented with general weakness and vaginal bleeding. one month prior, she had been diagnosed with evans syndrome (haemolytic anemia with positive coombs test and thrombocytopenia) and was given oral steroid as maintenance therapy. her serology examination was negative for hepatitis b, hepatitis c, and human immunodeficiency virus (hiv). her obstetrical history was marked by miscarriage in second pregnancy and preeclampsia in third pregnancy. she used hormonal contraceptives until 5 months prior to admission. on physical examination, she had anemic conjunctiva and no organomegaly. blood tests were significant for anemia (3.4 g/dl) and thrombocytopenia (28,000/ µl). her vaginal bleeding had ceased, however her platelet continued decreasing to 12,000/µl during first several days of hospitalization despite receiving platelet transfusion. on the tenth hospital day, she suddenly complained of severe headache and blurred vision. she had bilateral edema and erythema of palpebral, chemosis, decreased in visual acuity, and reduced ocular motility. (figure 1) ear and nose examination were normal. peripheral blood smear showed no blast. prothrombine time (pt), inr, aptt tests were normal and d dimer was slightly increased (3.3 mg/l; nv ≤0.5 mg/l). urine examination revealed proteinuria with 24 hour urine protein was 1,863 mg (nv < 150 mg/day). we assessed her as cavernous sinus thrombosis and treated her empirically with intravenous broad-spectrum antibiotics, morphine drip. either digital subtraction angiography or anticoagulant was deferred due to low platelet. further examination revealed positive for ana, anti-ssa, and diagnosis of sle was established. anticardiolipin antibodies of igg and igm and anti-beta2 glycoprotein antibodies of igm and igg tests were non reactive. methylprednisolone pulse therapy (1g/day) was given for 3 consecutive days, and then tapered to oral methylprednisolone. she additionally received azathioprine 50 mg tab bid. meanwhile her clinical symptoms alleviated and platelet count was increased, brain mri and mr venography finally performed suggesting cerebral venous sinus thrombosis.(figure 2) she got additional oral anticoagulant rivaroxaban 15 mg tab bid and eventually discharged. cerebral venous sinus thrombosis may be the presenting symptoms or occur concomitantly within the onset of sle.1-3 our patient had sle, meeting 4 of the systemic lupus international collaborating clinic classification criteria (hemolytic anemia, thrombocytopenia, renal involvement, and positive for ana test). vasculitis due to endothelial cell injury mediated by immune-complex deposition is proposed to be the pathogenesis of cvst in sle. hypercoagulable state could be other etiology factor.1,4,5 antiphospholipid antibodies were absent in our case as reported in some cases, emphasizing vasculitis as the underlying mechanism.4,6 treatment of cvst in sle consisting of anticoagulant, steroid, and immunosuppressant. 4,7 this case elicits intriguing problem: cvst and thrombocytopenia. anticoagulant treatment is proposed as the cornerstone treatment for cvst, however it was deferred due to risk of bleeding in thrombocytopenia.1,8 steroid plays role in treatment of cvst in sle, owing to its antiinflammatory property. as shown in previous cases,4,7 the patient had remarkable response to high dose steroid treatment and eventually got anticoagulant after her platelet had increased. in summary, prompt diagnosis and treatment of cvst are important for a favorable prognosis. ethical statement informed consent was obtained from patient’s family prior to the publication of this case and accompanying image. references 1. saposnik g, barinagarrementeria f, brown rd, et al. diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the american heart association/american stroke association. stroke. 2011;42:1158–92. 2. ashjazadeh n, haghighi ab, poursadeghfard m, et al. cerebral venous-sinus thrombosis: a case series analysis. iran j med sci. 2011;36:178–82. 3. saadatnia m, fatehi f, basiri k, et al. cerebral venous sinus thrombosis risk factors. int j stroke. 2009;4: 111–23. 4. wang l, chen h, zhang y, et al. clinical characteristics of cerebral venous sinus thrombosis in patients 344 vol 50 • number 4 • october 2018 cerebral venous sinus thrombosis in sle with systemic lupus erythematosus: a single-centre experience in china. j immunol res. 2015:1-7. 5. faria r, gonçalves j, dias r. neuropsychiatric systemic lupus erythematosus involvement: towards a tailored approach to our patients? rambam maimonides med j. 2017;8:e0001. 6. nishida h, wakida k, sakurai t. cerebral venous thrombosis as a complication of neuropsychiatric systemic lupus erythematosus. intern med. 2015;54: 837–41. 7. lee mk, kim jh, kang hr, et al. systemic lupus erythematosus complicated with cerebral venous sinus thrombosis : a report of two cases. j korean med sci. 2001;16:351–4. 8. murthy k, chefitz d. cerebral venous sinus thrombosis: a case report with review of diagnosis and treatment strategies. j clin case reports. 2014;4:1-3. 345 133acta med indones indones j intern med • vol 55 • number 2 • april 2023 editorial we need epidemiological study from our own population laurentius aswin pramono* department of public health and nutrition, school of medicine and health sciences atma jaya catholic university of indonesia & department of internal medicine, st carolus hospital, jakarta, indonesia. *corresponding author: laurentius aswin pramono, md. department of public health and nutrition, school of medicine and health sciences atma jaya catholic university of indonesia, jl. pluit selatan raya no. 19, jakarta, indonesia. email: l.aswin.pramono@ gmail.com, aswin.pramono@atmajaya.ac.id. epidemiological data is a valuable source for decision-making in a clinical setting or from a public health perspective.1 it serves not only direct purposes by supporting evidence-based treatment but also indirectly contributes to guidelines and policies in healthcare services. currently, there remains a pressing need for further epidemiological or population-based studies to be conducted in indonesia. the availability of health data and information specifically from the indonesian population is still limited and highly sought after. it is common for us to depend on epidemiological data from foreign countries, but this practice can introduce bias into our decision-making process due to the disparities between their conditions and our own. indonesia possesses a distinct sociodemographic and health landscape, setting it apart from other countries. the diverse range of diseases, risk factors, healthcare access, health equity, and geographical characteristics all contribute to the uniqueness and variability of health problems within the nation.2 specific regions across the indonesian archipelago encounter health issues that are distinct to their locations. infectious diseases, particularly tropical diseases, and nutrient deficiencies continue to present significant challenges in numerous provinces throughout indonesia.2-4 variations are observed across different areas and timeframes of study. these dynamic and variable factors make population studies particularly intriguing. it is the responsibility of clinicians, researchers, and epidemiologists to delve into the intricacies of the population and study its health problems comprehensively. one of the prevailing epidemiological and clinical concerns related to micronutrient deficiency in indonesia is iodine deficiency, which requires immediate attention.5,6 despite its current lack of significant national focus, iodine deficiency disorders (idd) remain a crucial global issue, including within indonesia. idd stands as the most prevalent preventable cause of brain damage and hampers human growth and development.5 it contributes to thyroid complications such as hypothyroidism, hyperthyroidism, and an elevated risk of goiter, thyroid nodules, and thyroid cancer. furthermore, iodine-deficient areas experience an increased susceptibility to autoimmune thyroid diseases. over the years, the awareness regarding iodine deficiency problems has dwindled due to the successful implementation of global salt iodization and fortification programs. however, it is crucial to continually evaluate these nationwide initiatives and conduct further studies to generate attention, disseminate information, and provide ongoing support.7 surprisingly, 30% of the global population, including indonesia, still faces the risk of iodine deficiency disorders (idd).8 collaboration among epidemiologists, clinicians, public health stakeholders, and the government is essential to support all programs, including updated clinical and epidemiological studies, discussions, and policy updates regarding idd. in this issue, we present a population study conducted in magelang regency, which is laurentius aswin pramono acta med indones-indones j intern med 134 situated in the central java province. the study focuses on examining the iodine intake status and thyroid profiles of women of childbearing age. the article is authored by a team of endocrinologists from kariadi hospital in semarang, led by nugroho h. notably, this team has a rich research history spanning several decades, dating back to the 1970s, under the guidance of the esteemed late professor r djokomoeljanto, a prominent endocrinologist from universitas diponegoro in semarang. central java province, specifically magelang regency, is recognized as one of the areas in java island and indonesia with high endemicity of iodine deficiency disorders (idd). numerous studies focusing on public health and nutritional epidemiology of idd have been carried out in this region.9 as a matter of fact, magelang regency holds a prominent position as the hub for idd studies in indonesia. nugroho h et al.10 assessed iodine levels, dietary intake, goitrogenic food consumption, urinary iodine concentration, ft4, tsh, and total goiter rate in women of childbearing age. this study comprehensively examines iodine and thyroid status in a specific population. senggi village in magelang regency was chosen due to its geographical, climatic, topographical, and land material characteristics, which pose a moderate risk for iodine deficiency. the region’s soil is encompassed by the eruption-affected merapi mountain, heightening the vulnerability of residents to iodine deficiency disorders. in a prior study conducted in this area, a prevalence of 6% for congenital hypothyroidism was observed.10 the study found that women of childbearing age in senggi had adequate iodine and thyroid status but showed an increased total goiter rate and low urinary iodine concentration. the iodine content in the freshwater source, table salt, and daily dietary intake was also found to be low. the study did not find any associations between iodine status, daily goitrogen intake, and salt iodine concentration. adequate iodine status and a significant total goiter rate may indicate residual goiter from previous severe endemic iodine deficiency disorders or a higher rate of autoimmune thyroid disease or thyroiditis.10 this phenomenon can be further studied in the same or other populations. nugroho h et al.’s study,10 along with seven other original papers on anemia in end-stage renal disease, hypovitaminosis d and depression among patients with type 2 diabetes mellitus, mental health status in pulmonary tuberculosis patients, vitamin d levels and handgrip strength in pre-frail older adults, validity and reliability of the indonesian version of an arrhythmia-specific questionnaire, characteristics of recurrent malaria episodes, and quality of life of patients after kidney transplantation, are featured in our second edition for 2023. this issue presents highquality studies that provide data and information from our patients and the indonesian population. we hope this issue will expand our knowledge, strategies, and wisdom for diagnosing, treating, and providing education for our patients in a clinical setting. in short, idd represents just a single illustration of the numerous public health and clinical concerns that demand our attention. to effectively address these concerns, gathering data specific to our own population is imperative, enabling the identification of risk factors. this knowledge will empower us to devise and execute appropriate actions. collaboration among clinicians, researchers, and public health stakeholders is essential to facilitate research, disseminate vital information, establish local guidelines, and shape policies. the collective efforts undertaken in these areas will ultimately shape the future of our nation’s health status. references 1. marks js. epidemiology, public health, and public policy. prev chronic dis. 2009;6(4):1-4. 2. gbd 2019 indonesia subnational collaborators. the state of health in indonesia’s provinces, 1990-2019: a systematic analysis for the global burden of disease study 2019. lancet glob health. 2022;10(11):e163245. 3. fauziyah s, putri smd, salma z, wardhani hr, hakim fkn, sucipto th, aquaresta f, soegijanto s. how should indonesia consider its neglected tropical diseases in the covid-19 era? hopes and challenges (review). biomed rep. 2021;14(6):53. 4. ernawati f, syauqy a, arifin ay, soekatri mye, sandjaja s. micronutrient deficiencies and stunting were associated with socioeconomic status in vol 55 • number 2 • april 2023 we need epidemiological study from our own population 135 indonesian children aged 6-59 months. nutrients. 2021;13(6):1-9. 5. fitra s, susanto r, purwanti a, utari a. iodine deficiency profile of central java province indonesia during the year 2011. int j pediatr endocrinol. 2013;2013(suppl 1):p149. 6. kusrini i, farebrother j, mulyantoro dk. adequately iodized salt is an important strategy to prevent iodine insufficiency in pregnant women living in central java, indonesia. plos one. 2020;15(11):1-13. 7. zimmermann mb, boelaert k. iodine deficiency and thyroid disorders. lancet diabetes endocrinol. 2015;3(4):286-95. 8. hatch-mcchesney a, lieberman hr. iodine and iodine deficiency: a comprehensive review of a reemerging issue. nutrients. 2022;14(17):1-11. 9. mulyantoro dk, kusrini i, hidayat t, puspitasari c. assesment of thyroid function and its association with free thyroxin hormone among pregnant women in areas with previous history iodine deficiency in magelang, indonesia. j nutr sci vitaminol (tokyo). 2020;66:s474-8. 10. nugroho h, pemayun tdg, dharmono, rachmawati b. the iodine status of women of childbearing age in an iodine-repleted area: an epidemiological study in sengi village on merapi mountain area. acta med indones – indones j intern med. 2023;55(2):142-9. 216 original article acta medica indonesiana the indonesian journal of internal medicine performance of alpha fetoprotein in combination with alpha-1-acid glycoprotein for diagnosis of hepatocellular carcinoma among liver cirrhosis patients rino a. gani1, maulana suryamin2, irsan hasan1, c. rinaldi a. lesmana1, andri sanityoso1 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of internal medicine, persahabatan hospital, jakarta, indonesia. correspondence mail: division of hepatobiliary, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. a medical staff building, 8th floor. jl. diponegoro no. 71, jakarta 10430, indonesia. email: personaly@yahoo.com. abstrak tujuan: untuk menilai manfaat pemeriksaan alpha-1-acid glycoprotein (aag) untuk mendiagnosis karsinoma hepatoselular (khs), dan dalam kombinasi dengan alpha fetoprotein (afp) sebagai bagian dari pemeriksaan rutin pada pasien sirosis hati. metode: penelitian ini merupakan studi diagnostik dengan menggunakan desain potong lintang. sebanyak 106 pasien diikutsertakan dalam penelitian ini. data dasar seperti usia, jenis kelamin, kadar afp, kadar aag, pemeriksaan darah tepi, sgot dan sgpt diambil secara kolektif dari pasien sirosis hati dengan atau tanpa khs. pemeriksaan kadar aag serum dihitung dengan metode immunoturbodimetric assay dan pemeriksaan kadar afp dengan enzyme immune assay. analisis statistikal dilakukan dengan menggunakan spss 13.0. perbandingan data antar grup dilakukan dengan uji mann-whitney. nilai diagnostik masing-masing penanda dibandingkan secara paralel pada kasus khs. hasil: analisis receiver operating characteristic (roc) menunjukkan area di bawah kurva untuk kombinasi afp dan aag sebesar 88.1%, lebih tinggi dibandingkan afp saja (86.2%) atau aag saja (76.5%) dengan sensitivitas 83%, 73% dan 44% pada spesifisitas >80%. kesimpulan: penelitian ini memperlihatkan perbandingan peran pemeriksaan aag, afp, dan kombinasi keduanya dalam mendiagnosis khs pada pasien sirosis hati. kombinasi afp dan aag dapat digunakan untuk deteksi dini dan penapisan khs. kata kunci: alfa fetoprotein, alfa-1-acid glikoprotein, penanda biokimia, kanker hati. abstract aim: to evaluate the use of alpha-1-acid glycoprotein (aag) for diagnosing hepatocellular carcinoma (hcc), and to combine with alpha fetoprotein (afp) as part of routine examination in liver cirrhosis patients. methods: this is a diagnostic study using cross-sectional design. a hundred and six patients were included in this study. baseline data such as age, gender, afp, aag, peripheral blood count, ast and alt were consecutively collected from liver cirrhosis patients with or without hcc. serum aag were measured quantitatively using immunoturboditimetric assay and afp with enzyme immune assay (eia). statistical analysis were done using spss 13.0. data comparisons between group were done using mann-whitney test. diagnostic performance for each marker alone was compared to the surrogate use of both markers (combined parallel approach) in hcc cases. results: receiver operating characteristic (roc) analysis showed that area under the curve for afpvol 47 • number 3 • july 2015 performance of alpha fetoprotein in combination with aag 217 aag combination was 88.1% and higher than afp only (86.2%) or aag only (76.5%) with sensitivity of 83%, 73% and 44%, respectively, at specificity of >80%. conclusion: our study showed that combination of afp and aag is superior than either marker alone in diagnosing hcc in liver cirrhosis patients. combination of afp and aag may be used to prompt early diagnosis screening of hcc. key words: alpha fetoprotein, alpha-1-acid glycoprotein, biomarker, liver cancer. introduction hepatocellular carcinoma (hcc) is the second most common cause of death from cancer worldwide, estimated to be responsible for nearly 746,000 deaths in 2012 (9.1% of the total) (globoscan, 2012).1 most of the hcc incidence occurred in developing countries, particularly in asia and africa which are susceptible to hepatitis b and hepatitis c. however, recent trends indicate that incidence of hcc in developed countries is increasing.2 this could be explained by changes in the prevalence of hepatitis. screening for hcc can lead to early diagnosis and treatment. in most of the cases, hcc is diagnosed in its advanced stage that the treatment options are limited with lower survival rates. it means that diagnosing hcc in its early stage is of the utmost importance. based on a systematic review, several serum biomarkers can be used to detect hcc.3 alpha fetoprotein (afp) is the most widely studied screening test for detecting hcc. the normal range for serum afp levels is 10-20 ng/ml and a level > 400 ng/ ml is usually regarded as diagnostic for hcc. although asia-pacific association for study of the liver (apasl) consensus used lower level of afp (>200 ng/ml) for diagnosis of hcc, some reports have indicated that the high serum concentration of afp correlates with the poor prognosis of hcc patients. however, two thirds of hcc patients with the nodule less than 4 cm have serum afp levels less than 200 ng/ml and up to 20% hcc patients do not produce afp.4 it has been recognized that afp has a low sensitivity in detection of hcc. apasl guidelines 2010 do not recommend the use of afp only for diagnosing hcc. additional investigations are needed to establish the diagnosis.3 aag is an acute phase protein with normal levels of 50-120 mg/dl. this serum concentration increases in response to systemic tissue injury, inflammation or infection, and these changes in serum protein concentrations have been correlated with increases in hepatic synthesis.5 raised levels of aag were found in 80.6% of patients with hepatoma compared to 20% of patients with cirrhosis and only 5.7% of patients with hepatitis.6 our group found that aag was a potential biomarker in the diagnosis of hcc.7,8 in a study with 220 patients, of which 96 were control and 124 were hcc cases (61 were afp-low and 63 were afp-high), it was found that alpha-1-acid glycoprotein (aag) was more predictive of afp-low hcc than of afp-high hcc.7 the other study, combination between afp and aag could significantly improve the diagnostic accuracy. roc analysis of afp in combination with aag yielded auc (area under curve) value higher (0.943) than afp alone (0.750) or aag (0.907) alone.8 our previous study showed aag and afp combination was a good biomarker for diagnosis of hcc. however, aag determination in the previous study were measured with high performance liquid chromatography (hplc) that can be done only in a research center and not routinely available in clinical laboratories. furthermore, the subjects from previous studies did not specifically liver cirrhosis patients whom the risk of developing hcc are the greatest. in this study the quantitative measurement of serum aag was done with nephelometric (immunoturbidimetric) assay in routine clinical laboratorium. the subjects of this study were liver cirrhosis patients with hcc and compare it with liver cirrhosis patients without hcc. the objective of this study was to evaluate the use of aag in routine laboratory as biomarker for screening of hcc among liver cirrhosis patients in combination with afp. rino a. gani acta med indones-indones j intern med 218 methods this is a cross-sectional study. the subjects of this study were liver cirrhotic patients, aged 18 years and older. diagnosis of hepatocellular carcinoma in the subjects group were defined according to aasld guidelines on hepatocellular carcinoma9 or by presence of liver nodule, afp >200 ng/ml and supported with two imaging results with typical features of hepatocellular carcinoma. we included liver cirrhotic patients without liver nodule as control group in this study. a total of 106 patients who regularly followed up at hepatobiliary division, department of internal medicine, cipto mangunkusumo hospital, indonesia between january to august 2013 who meet the criteria were consecutively enrolled and serum samples were collected. for each patient, clinical data, including age, sex, afp value, aag, hemoglobin, leukocyte, thrombocyte, ast, and alt were obtained. diagnosis of hcc relied on the presence of malignant liver nodule, as established on imaging techniques according to apasl criteria or by pathological analysis of liver biopsy, if necessary. patients with other type of malignancies, without evident of liver cirrhosis, diagnosed with ongoing acute infections (pneumonia, colitis, acute hepatitis, sepsis or hiv), pregnant women, under treatment of corticosteroid, or recently recovered from surgery, trauma and myocardial infarction were excluded from the study. among 106 patients, 59 patients had cirrhosis with hcc and the other 47 patients had cirrhosis without hcc as negative control to hcc group. all patients gave informed consent to participate in the study and the protocol was approved by ethical committee of faculty of medicine, university of indonesia, jakarta. test methods a 10 ml blood sample were collected in serum separator tube and stored at ≤ -20oc until afp and aag measurement. alpha fetoprotein measurement alpha fetoprotein measurement remain the reference serum biomarker test in diagnosing hcc. the quantitative measurement of plasma afp was performed using advia centaur afp assay, a two-site sandwich immunoassay using direct chemiluminometric technology, which uses constant amounts of two antibodies. the first antibody is an affinity purified polyclonal rabbit anti-afp antibody labeled with acridinium ester. the second antibody, in the solid phase, is a monoclonal mouse anti-afp antibody covalently coupled to paramagnetic particles. after blood sample collection, blood samples were allowed to clot adequately before centrifugation, while keeping the keep tubes stoppered and upright all times. for condition when assay was not completed within 48 hours, the specimen was refrigerated at or below -20oc. when samples were ready for the assay, 10 μl of sample was dispensed into a cuvette. as much as 50 μl of lite reagent and 250 μl of solid phase were dispensed and incubated for 7.5 minutes at 37oc. the cuvettes were then separated, aspirated, and washed using reagent water. not less than 300 μl each of acid reagent and base reagent were dispensed to initiate the chemiluminescent reaction. a direct relationship exists between concentration of afp present in patient sample and the amount of relative light units (rlus) detected by the system. the results were reported in ng/ml with cutoff value of ≤15 ng/ml. alpha-1-acid glycoprotein measurements quantitative measurement of plasma aag concentration was performed using immunoturbidimetric assay by roche/hitachi cobas c system. after collection, blood samples were allowed to clot adequately for 30 minutes before centrifugation. samples were centrifuged at 1500 g for 10 minutes before performing the assay. the serum supernatant was extracted and dispensed into sample cup. anti-α1-acid glycoprotein antibodies react with antigen in the sample to form an antigen/antibody complex. following agglutination, this is measured turbidimetrically using cut-off value of 3.25 g/l. statistical analysis statistical analysis were done using spss 13.0. descriptive measures were determined for each variable in every group, presented in mean ± sd. data comparisons between group were done using mann-whitney test. spearman correlation coefficient (r) was applied to our result. a p-value <0.05 was considered statistically significant. vol 47 • number 3 • july 2015 performance of alpha fetoprotein in combination with aag 219 for choosing the best cut off value, receiver operator characteristic (roc) curve was generated and the youden’s index was calculated. the best cut off values had the highest youden indices. diagnostic performance for each marker alone (diagnostic specificity, sensitivity, positive and negative predictive values) was compared to the surrogate use of both markers (combined parallel approach) in hcc cases. results baseline data of the patients can be seen in table 1. there was not significant difference in the mean age between hcc dan cirrhosis. afp serum in patients with hcc and cirrhosis (mean: 34923.96ng/ml, sd: 80301.31 ng/ml) was significantly higher than patients with cirrhosis (mean: 31.53 ng/ml, sd: 169.98 ng/ml, |p = 0.0005, mann whitney test). as well as afp, aag serum in hcc patients (mean: 117.59 mg/ dl, sd: 60.95 mg/dl) was significantly higher than in cirrhosis patients (mean: 66.78 mg/dl, sd: 44.84 mg/dl, p=0.0005, mann whitney test).there was no correlation between afp and aag in all patients (r=0.172; p=0.079, correlation test) and between hcc and cirrhosis patients only (r=-0.038; p=0.773; spearman correlation test, figure 1). to evaluate the diagnostic value of serum afp and aag, auc value from roc curve were performed (figure 2). auc value in afp was 86.2% while auc in aag was 76.5%. combination afp and aag produce the highest auc value (88.1%) compared to afp only or aag only. at >80% specificity, the afp sensitivity was 73% in cut off 20.45 ng/ml and table 1. clinical characteristics of patients clinical features hcc + cirrhosis (n=59) cirrhosis (n=47) age-year (mean+sd) 55.53+12.01 55.60+11.59 gender (% male/female) 84.7/15.3 55.3/44.7 hemoglobin (mean+sd) 11.70+2.22 11.33+1.69 leucocyte (mean+sd) 9538.97+6612.86 6625.53+2600.99 thrombocyte (mean+sd) 232503.1+139378.0 123723.4+64576.5 ast (mean+sd) 171.93+216.30 63.74+46.46 alt (mean+sd) 86.31+117.92 49.68+31.19 hepatitis b (% y/n) 33.9/66.1 32/68 hepatitis c (% y/n) 66.1/33.9 59.6/40.4 300.00 250.00 200.00 150.00 100.00 50.00 0.00 0.00 100000.00 200000.00 300000.00 400000.00 afp a a g 300.00 250.00 200.00 150.00 100.00 50.00 0.00 a a g 100000.00 200000.00 300000.00 400000.00 afp 0.00 figure 1. scatter plot of afp and aag (no correlation) in all patients (left). scatter plot of afp and aag (no correlation) within hcc and cirrhosis patients (right). rino a. gani acta med indones-indones j intern med 220 aag sensitivity was 44% in cut off 129 mg/dl. combination afp and aag have the highest sensitivity (85%) compared to the other (table 2). discussion the prognosis and survival of patients with hcc is highly depend on the stage of disease at the time of diagnosis. hence, the role of screening assay would be beneficial in detecting early stage of hcc. a review of studies showed that afp, dcp, afp-l3 and gpc3 can be used as serum marker for hcc.3 afp is not a sufficient reliable marker to identify hcc patients due to its poor sensitivity. wang cs et. al10 found that dcp has a better diagnostic value than afp in differentiating hcc from nonmalignant chronic liver disease, with auc value of 85% and 73% respectively (among patients with non-cirrhotic chronic hepatitis, compensated cirrhosis, and hcc).10 on the other hand, nakamura s (2006) found that the auc value of dcp was significantly smaller than afp in tumor less than 3 cm in diameter (p<0.0001) and was significantly larger than afp in tumor greater than 5 cm in diameter (p<0.0001), with chronic hepatitis or cirrhosis as control.11 afp-l3 is a fucosylated variant of afp that reacts with lens culinaris agglutinin a and can differentiate an increase in afp due to hcc from that in patients with benign liver disease.3 the incidence of hcc was significantly higher in patients with elevated afp-l3% compared to those with elevated afp.12 subwongcharoen s et al. found that the auc value for diagnosis of hcc with afp (71%) is higher than afp-l3 (67%). in addition, the serum level of afp was significantly different between the small mass (occupying lesser than 50% of liver volume) and large mass (occupying more than 50% of liver volume) of hcc (p=0.040).13 figure 2. (a) afp roc curve, (b) aag roc curve, (c) combination afp and aag roc curve. 1.0 0.8 0.6 0.4 0.2 0.0 0.0 0.2 0.4 0.6 0.8 1.0 1-specificity s e n s it iv it y 1.0 0.8 0.6 0.4 0.2 0.0 s e n s it iv it y 0.0 0.2 0.4 0.6 0.8 1.0 1-specificity 1.0 0.8 0.6 0.4 0.2 0.0 s e n s it iv it y 0.0 0.2 0.4 0.6 0.8 1.0 1-specificity a b c vol 47 • number 3 • july 2015 performance of alpha fetoprotein in combination with aag 221 a meta-analysis of serum markers for diagnosis of hcc from 40 studies was established. afp was considered to be the reference biomarker. it was shown that the auc of combination afp+dcp (0.874), were superior to the reference afp biomarker (table 3).14 gpc3 is a heparan sulfate proteoglycan anchored to the plasma membrane. it has been reported that gpc3 messenger rna levels were increased in hcc.3 however, ozkan h et al. study found no correlation between gpc3 levels and prognostic parameters. gpc3 was not a useful diagnostic and prognostic marker for hcc. the sensitivity and specificity of afp (68.57, 94.55) were higher than gpc3 (61.33, 41.82).15 in this study, the auc values of afp (87.8%) was higher than aag (81.4%). the differences of control group may interfere the value of auc. in our study, the control group was patients with cirrhosis, in contrast with other studies using patients with cirrhosis and chronic hepatitis as the control.7,8 in the study by chio lf and oon cj6, it was showed that aag increased in 20% patients with cirrhosis and only 5.7% in patients with chronic hepatitis. combination afp and aag obtain the highest auc values (93%) compared to afp alone and aag alone. compared to the other serum biomarker that has been mentioned previously, the combination of afp and aag has the best auc value. the auc value of dcp and afp-l3% were lower than afp. as well as gpc3 which has lower sensitivity and specificity than afp. combination afp dan aag have sensitivity of 78% with npv and ppv were 73% and 91% respectively (at specificity 90%). in the study of our group by bachtiar et al. (2009), 220 patients were included, of which 124 had hcc and 61 (49%) of them were afp-low hcc (afp ≤20 ng/ml). the remaining 96 patients, consisted of 49 with chronic hepatitis b or c and 47 with table 2. cut-off and roc curve analysis of afp, aag, and combination of afp and aag test cut-off auc (95% ci) p se sp npv ppv afp 20.45 ng/ml 86.2% 0.0005 73% 92% 73% 92% aag 129 mg/dl 76.5% 0.0005 44% 92% 57% 87% afp + aag 20.45 ng/dl and/or 129 mg/dl 88.1% 0.0005 85% 83% 81% 86% table 3. auc for combination of afp + dcp14 biomarker number of studies auc afp 35 0.835 dcp 15 0.797 afp-l3 15 0.710 afp+dcp 8 0.874 afp+afpl3 3 0.748 cirrhosis, were included into control group. their result showed the combination of afp and aag have higher sensitivity than afp alone. compared to previous one, our study is the first to specifically differentiate the use of aag and afp for biomarker screening in cirrhosis patients therefore it is more applicable in clinical settings since only proven cirrhosis patients were included. although the research has reached its aims, there were some limitations acknowledged. due to the time and cost consideration, this research was conducted on small size of population using cross sectional design. the subject could be divided into groups based on severity of cirrhosis to study diagnostic value of aag, afp, and combination of both afp and aag on to different levels. ideally, the number of participant would have been more evenly distributed across gender but the actual data of hcc prevalence was mainly occurred in men. conclusion our study showed comparison between afp alone, aag alone, and combination of afp and aag in diagnosing hepatocellular carcinoma in liver cirrhosis patients. liver cirrhosis patients with afp higher than 24.5 ng/ml and aag higher than 130.3 mg/dl were highly associated with existence of hcc. prospective studies on larger patients are required to confirm this study. data rino a. gani acta med indones-indones j intern med 222 from this study may contribute to improve the prognosis of hcc patients by enabling early diagnosis and screening to provide early prompt, if possible, curative treatment. references 1. globocan 2012. estimated cancer incidence, mortality and prevalence worldwide in 2012. world health organization (http://globocan.iarc.fr/pages/fact_ sheets_cancer.aspx). 2. renumathy dhanasekaran, alpna limaye, roniel cabrera. hepatocellular carcinoma: current trends in worldwide epidemiology, risk factors, diagnosis, and therapeutics. hepat med. 2012;4:19–37. 3. omata m, lesmana la, tateishi r, et al. asian pacific association for the study of the liver consensus recommendations on hepatocellular carcinoma. hepatol int. 2010;4:439-74. 4. lin zhou, jia liu, fengluo. serum tumor markers for detection of hepatocellular carcinoma.world j gastroenterol. 2006;12(8):1175-81. 5. fournier t, medjoubi n, porquet d. alpha-1-acid glycoprotein. biochim biophys acta. 2000;1482:15771. 6. chio lf, oon cj. changes in serum alpha-1 antitrypsin, alpha-1 acid glycoprotein and beta-2 glycoprotein i in patient with malignan hepatocellular carcinoma. cancer. 1979;43:596-604. 7. bachtiar i, kheng v, wibowo ga, et al. alpha-1acid glycoprotein as potential biomarker for alphafetoprotein-low hepatocellular carcinoma. bmc res notes. 2010;3:319. 8. bachtiar i, santoso jm, atmanegara b, et al. combination of alpha-1-acid glycoprotein and alpha-fetoprotein as an improved diagnostic tool for hepatocellular carcinoma. clinical chimita acta. 2009;399:97-101. 9. bruix j, sherman m. aasld practice guideline: management of hepatocellular carcinoma. hepatol. 2005;42(5):1208-36. 10. wang cs, lin cl, lee hc, chen ky, chiang mf, chen hs, lin tj, liao ly. usefulness of serum des-gamma-carboxyprothrombin in detection of hepatocellular carcinoma. world j gastroenerol. 2005;11(39): 6115-9. 11. nakamura s, nouso k, sakaguchi k, ito ym, ohashi y, kobayashi y, toshikuni n, tanaka h, miyake y, matsumoto e, shiratori y. sensitivity and specificity of des-gamma-carboxyprothrombin for diagnosis of patients with hepatocellular carcinomas varies according to tumor size. am j gastroenterol. 2006;101(9):2038-43. 12. sterling rk, jeffers l, gordon f, et al. clinical utility of afp-l 3% measurement in north american patients with hcv-related cirrhosis. am j gastroenterol. 2007;102:2196–205. 13. subwongcharoen s, leelawat k, treepongkaruna sa, narong s. serum afp and afp-l3 in clinically distinguished hepatocellular carcinoma from patients with liver masses. j med assoc thai. 2011;94(suppl 2):s46-51. 14. bin hu, xiaohui tian, jie sun, xiangjun meng. evaluation of individual and combined applications of serum biomarkers for diagnosis of hepatocellular c a r c i n o m a : a m e t a a n a l y s i s . i n t j m o l s c i . 2013;14:23559-80. 15. ozkan h, erdal h, koçak e, tutkak h, karaeren z, yakut m, köklü s. diagnostic and prognostic role of serum glypican 3 in patients with hepatocellular carcinoma. j clin lab anal. 2011;25(5):350-3. case report 383acta med indones indones j intern med • vol 52 • number 4 • october 2020 autologous bone marrow transplant in multiple myeloma patient with bone marrow hematopoietic stem cell d. santosa1, c. suharti1, edi dharmana2 1 department of internal medicine, faculty of medicine, diponegoro university kariadi hospital, semarang, indonesia. 2 department of parasitology, faculty of medicine, diponegoro university, semarang, indonesia. corresponding author: d. santosa, md. division of hematology-medical oncology, department of internal medicine, faculty of medicine, diponegoro university kariadi hospital. jl. prof. soedarto, tembalang, semarang 50275, indonesia. abstrak multiple myeloma (mm) adalah keganasan dengan berbagai komplikasi seperti infeksi bakteri berulang, anemia, lesi osteolitik, kegagalan sumsum tulang, dan penurunan fungsi ginjal. di pusat transplantasi yang sudah berkembang, prosedur transplantasi sumsum tulang dilakukan oleh sumber sel induk darah tepi. mesin aferesis yang tidak selalu tersedia di semua pusat hematologi dan onkologi di indonesia diperlukan untuk pengambilan sel punca dari pbsc (peripheral blood stem cell). laporan transplantasi stem cell sumsum tulang belakang dari bm dengan waktu 24 jam masih sedikit. penyimpanan dalam beberapa kasus myeloma. kami melaporkan dua kasus dengan myeloma non-sekretorik stadium iii dan igg myeloma stadium ii (sistem pementasan internasional). kedua pasien dirawat dengan regimen induksi cybord sampai sembuh total. setelah remisi tercapai, prosedur transplantasi sumsum tulang autologus dilakukan. sumber sel punca hematopietik (hscs) dipanen dari sumsum tulang dan disimpan selama 24 jam pada suhu 4◦ c. komplikasi yang terjadi adalah neutropenia, anemia, trombositopenia, mukositis, diare, rambut rontok, kegelapan kulit. hsc tumbuh baik pada hari ke 12 dan ke 23. setelah perawatan di ruang isolasi, kondisi pasien membaik dan dipulangkan. kata kunci: mieloma, sel punca hematopoetik, sumsum tulang, transplantasi autologus. abstract multiple myeloma (mm) is a malignancy with multiple complications such as recurrent bacterial infections, anemia, osteolytic lesions, bone marrow failure and decreased kidney function. in developed transplant center, the bone marrow transplant procedure is performed by the source of peripheral blood stem cells. apheresis machine which is not always available in all haematology and oncology centre in indonesia, is required for harvesting stem cell from pbsc (peripheral blood stem cell). there are only a few reports on marrow-derived stem cells transplant from bm with a 24-hour storage in multiple myeloma cases. we report two cases with nonsecretory myeloma stage iii and igg myeloma stage ii (international staging system). both patients were treated with induction regimens cybord until a complete remission. once remission was achieved, an autologous bone marrow transplant procedures were performed. the source of haematopietic stem cells (hscs) were harvested from bone marrow and stored for 24 hours at a temperature of 4◦ c. the complications were neutropenia, anemia, thrombocytopenia, mucositis, diarrhea, hair loss, and skin darkness. the hscs grew well on day 12 and 23. after treatment in the isolation room, the patient’s condition improved and the patients were discharged. keywords: myeloma, haematopoetic stem cells, bone marrow, autologous transplants. d. santosa acta med indones-indones j intern med introduction multiple myeloma (mm) is a malignancy derived from lymphocytes-b, characterized by the accumulation of plasma cells clonal in bone marrow, increased production of immunoglobulin monoclonal (ig) or often called m protein in serum or urine.1 complications of mm are recurrent bacterial infections, anemia, osteolytic lesions, bone marrow failure and decreased kidney function.2-4 data globocan indicates a diagnosis of mm as many as 114 251 new cases every year, where 229 468 people are living with mm in the worldwide.5 over 26,000 newly diagnosed case is expected to occur in us, with more than 11,000 of them would be ended up in mortality.6 the incidence of mm increases 30% between the years 19752010.7 the median age for mm case is 65 year, with the 5-year survival of 44.9%.8 incidence of mm in asia is lower than western countries, but in taiwan has risen dramatically in recent years.9,10 mm management is necessary to distinguish whether a patient eligible to bone marrow transplant or not. standard therapy for patients who are not qualified for transplant is melphalan and prednisone (mp) or dexamethasone. vincristine adriamycin doxorubicin (vad) regimen is used as induction therapy in patients who eligible for the bone marrow transplant. 10cybord (cyclophosphamide, bortezomib, dexamethasone) is a new regimen and show good results with mild toxicity, especially with sub cutan bortezomib administration.11,12 the stem cell can be obtained from bone marrow (bm), peripheral blood stem cell (pbsc) or umbilical cord. harvesting of stem cell from bone marrow is a simple method, with multiple aspirations under general anesthesia.13,14 harvesting of stem cell from pbsc requires apheresis machine that may not be available at all hematology medical oncology center in indonesia. there are only a few reports on marrow-derived stem cells transplant from bm with a 24-hour storage in multiple myeloma cases.15 case illustration case 1 a 50-year-old male came with the complaint of low back pain, weakness of lower extremity. table 1. clinical data of the case. patients characteristics case 1 case 2 age 50 57 sex male male symptoms at admission low back pain, lower extremity weakness pain in the bones, stiffness in the fingers and toes of the both lower extremities type igg myeloma nonsecretory myeloma staging iss ii iii hsct source bone marrow bone marrow tnc 3.3 x 108/ kgbw 1.3 x 108/ kgbw medium for preservation rpmi, free preservative heparin as anticoagulant, procaine penicillin, gentamicin rpmi, free preservative heparin as anticoagulant, procaine penicillin, gentamicin storage 4◦ c, 24 ours 4◦ c, 24 ours conditioning melphalan 200mg/m2 melphalan 200mg/m2 platelet support multiple donor collection, filtered, irradiated single donor with apheresis, filtered, irradiated packed red cell support filtered, irradiated filtered, irradiated nutrition partial parenteral nutrition partial parenteral nutrition engraftment day 21 day 12 hospitalization 26 days 39 days maintenance thalidomide supportive care zolendronic acid 4mg/month (1 year) zolendronic acid 4mg/month (1 year) 384 vol 52 • number 4 • october 2020 autologous bone marrow transplant in multiple myeloma patient the bone survey showed multiple lytic lesion of calvaria, humerus, tibia, fibula, compression fracture of vertebra lumbalis, in accordance with the diagnosis of multiple myeloma. the serum protein electrophoresis showed monoclonal gammopathy. the immunofixation increased igg as igg myeloma. the bone marrow aspiration showed an increase in the plasma cell above 10%. the diagnosis of this patient was igg myeloma, stage ii (iss, the international staging system). case 2 a male, 57 years old, came with complaints of pain in the bones, stiffness in the fingers and toes of both lower extremities. the bone survey examination revealed multiple lytic lesions of calvaria and humerus, in accordance with the diagnosis of multiple myeloma. the results of a bone marrow biopsy was hypocellular according to age, suggesting indolent myeloma. serum protein electrophoresis did not show a monoclonal gammopathy. immunofixation examination obtained an increase in free light chain (flc) kappa. based on these data the patients diagnosed as non-secretory multiple myeloma stage iii (iss, the international staging system). both patients were given a chemotherapy with cybord protocol (cyclophosphamide iv, bortezomib sc, dexamethasone po). after 4 cycles of chemotherapy, a complete remission was achieved and patients prepare for a bone marrow transplant. bone marrow transplant program preparation of a bone marrow transplant program included; dental, mouth, nose, throat, lung function, and echocardiographic examination. screening of virology and communicable disease infection were conducted before the transplant program. culture from perineum, blood, urine, sore throat was performed for detection of possible bacterial infection. the haematopoietic stem cells harvested from bone marrow, obtained under general anesthesia with multiple aspiration. the bm product filtered with 200 microns and preserved with rpmi, free preservative heparin. procaine penicillin and gentamicin were added to protect bacterial contamination. the minimal target of total nucleated cells (tnc) was 2x108/ kgbb. the bm product was cultured before storage 4◦ c for 24 hours. patient transported to positive pressure room and prepared to conditioning chemotherapy. after conditioning with melphalan 200mg/m2, the stem cell were infused with 200 microns filter. in case 1, the blood culture was sterile. in case 2, culture result from throat secretion on day 20 showed klebsiella pneumoniae, sensitive to ciprofloxacin, while culture on day 21 samples taken from the central catheter and peripheral blood indicated staphylococcus aureus. clinically this infection resolved without severe complication. during treatment, hemoglobin level decrease but the patient did not require transfusion. thrombocytopenia improved with platelet supports. neutropenia improves with g-csf support. the engraftment occurred on day 21 and 12 cases respectively. however, case 2 have much longer hospitalization due to severe mucositis that impaired oral intake. the total lengths of stay of case 1 and case 2 during the bone marrow transplant program were 21 days and 39 days, respectively. patients were allowed to discharge home after mucositis resolved, neutropenia improved and platelets level above 20,000 without transfusions. both patients have received immunization according to protocol during 1st year follow up. serious complication experienced by case 1 was pneumonia that resolved with oral antibiotic. after 5 years post-transplantation, case 1 was still in remission with normal igg level and good quality of life (qol). after 3 years, case 2 was still in remission with normal flc and good qol. both patients are still being evaluated annually. discussion multiple myeloma (mm) is still an incurable disease, with 5-year survival rate of less than 40% 2, some patients can live within a few months to more than 10 years.16,17 median survival of patients with mm is approximately 33 months, similar to the rate suggested by a study conducted in china.18 with bone marrow transplant program, some studies suggested an increase in median survival up to 10 years. induction 385 d. santosa acta med indones-indones j intern med with cybord protocol i (cyclophosphamide, bortezomib, dexamethasone) provides 80% reduction in monoclonal protein in the second cycle and 88% partial remission. this new protocol provided fast response in case of new myeloma with controllable side effects.19 stem cell can be isolated from bone marrow, peripheral blood and cord blood, bone marrowderived stem cell can be harvested using general anaesthesia with multiple aspiration. peripheral blood stem cells (pbsc) were obtained by using apheresis machine, after mobilization with g-csf and chemotherapy. umbilical cord blood (ucb, umbilical cord blood) were obtained at birth by taking the blood and stored in the cord blood bank.20 stem cells can be stored in various ways as needed. products used fresh (fresh infusion) can be stored at a temperature of 4° c for 24 hours prior to use. if it will be used more than 24 hours, the product needs to be frozen to preserve cellular viability. for this purpose, the products are frozen in liquid nitrogen vapor phase or deep freeze -80°; the product can be stored for more than 10 years, while there is no storage time limit. long-term storage is generally carried out in liquid nitrogen phase.16 we have performed autologous bone marrow transplant in patients with myeloma using bm as source of hsct with 24 hours storage. pbsc harvest is simple and referred to the center that has apheresis machine. the results of this case report suggested that bmt using bm is a feasible option in the center with limited resource. the day engraftment of stem cell from bm is comparable with stem cells from peripheral blood. melphalan 200 is standard conditioning for the autologous bone marrow transplant in mm patient.21-24 complication due to conditioning regiment were nausea and vomiting, painful sore throat, mucositis, neutropenia, grade ii diarrhea, fever related to catheter insertion, skin darkness, and hair loss. blood cultures of peripheral and central venous access were performed to determine the type of bacteria and an appropriate antibiotic. patients treated with gcsf 300 mcg/day intravenously until anc (absolute neutrophil count) > 500. antibiotic imipenem-cilastatin 500/500 mg/ 8 hours and amikacin 500 mg/ 12 hours were given while awaiting culture results. antifungal fluconazole 200 mg/ 24 h or caspofungin 50 mg/ 24 hours for prophylaxis of systemic fungal infections. oral hygiene education, rinses with mouthwash free alcohol applied to the patient for management of mucositis. conclusion autologous bone marrow transplantation in myeloma by using stem cells from bone marrow with 4◦ c temperature storage in 24 hours is a simple, feasible, and satisfactory procedure. moreover, this particular procedure shows good results. day engraftment is comparable with stem cells from peripheral blood. during follow up, all patients are still in remission and show no significant complication. this procedure can be applied at center without apheresis machine in developing countries. acknowledgments the authors would like to thank ag soemantri, moedrik tamam, bambang s (department of pediatric, faculty of medicine, diponegoro university/dr. kariadi hospital, semarang), hendro wahjono (departement of microbiology , diponogoro university/dr. kariadi hospital, semarang), purwanto ap, herniah, nyoman suci, dian widyaningrum, muji rahayu (department of clinical pathology, diponogoro university/dr. kariadi hospital, semarang ), indrajanti (clinical pathology of smc laboratory, semarang) , maya ( smc laboratory, semarang), chusnul yuni (central laboratory of dr. kariadi hospital, semarang), the nurses who help in bmt process. references 1. drach j, kaufmann h. new developments and treatment in multiple myeloma: new insights on molecular biology. ann oncol. 2002;13:43-7. 2. anderson kc, kyle ra, dalton ws, et al. multiple myeloma: new insights and therapeutic approaches. hematology am soc hematol educ program. 2000;1:147-65. 3. bataille r, haousseau jl. monoclonal gammopathy of undetermined significance and the natural history of multiple myeloma. n engl j med. 1997;336:1657-64. 4. osborne tr, ramsenthaler c, de wolf-linder s, et 386 vol 52 • number 4 • october 2020 autologous bone marrow transplant in multiple myeloma patient al. understanding what matters most to people with multiple myeloma: a qualitative study of views on quality of life. bmc cancer. 2014;14:1-14. 5. world health organization. international agency for research on cancer. globocan 2012: estimated cancer incidence, mortality and prevalence worldwide in 2012. cited from: http://globocan.iarc.fr/default.aspx. 6. key statistics about multiple myeloma. american cancer society, 2018. cited from: https://www.cancer. org/cancer/multiple-myeloma/about/key-statistics. html. 7. myeloma seer stat fact sheets 2013. surveillance, epidemiology, and end results program. cited from: https://seer.cancer.gov/statfacts/html/mulmy.html. 8. multiple myeloma. american cancer society, 2018. cited from: https://www.cancer.org/cancer/multiplemyeloma.html. 9. huang sy, yao m, tang jl, et al. epidemiology of multiple myeloma in taiwan: increasing incidence for the past 25 years and higher prevalence of extramedullary myeloma in patients younger than 55 years. cancer. 2007;110:896-905. 10. bringhen s, larocca a, rossi d, et al. efficacy and safety of once-weekly bortezomib in multiple myeloma patients. blood. 2010;116:4745-53. 11. hainsworth jd, spigel dr, barton j, et al. weekly treatment with bortezomib for patients with recurrent or refractory multiple myeloma: a phase 2 trial of the minnie pearl cancer research network. cancer. 2008;113:765-71. 12. kiba, t. ito t, nakashima t, et al. bortezomib and dexamethasone for multiple myeloma: higher ast and ldh levels associated with a worse prognosis on overall survival. bmc cancer. 2014;14:462. doi: 10.1186/1471-2407-14-462. 13. thomas ed. bone marrow trnsplantation: a historical review. medicina. 2000;33:209-18. 14. watanabe h, watanabe t, suzuya h, et al.. peripheral blood stem cell mobilization by granulocyte colonystimulating factor alone and engraftment kinetics following autologous transplantation in children and adolescents with solid tumor. bone marrow transplant. 2006;37:661-8. 15. multiple myeloma research foundation. multiple myeloma high-dose chemotherapy and stem cell transplantation. p. 1-37. cited from: https://www. themmrf.org/multiple-myeloma-knowledge-center/ myeloma-treatments-guide/stem-cell-transplants/highdose-chemotherapy/. 16. decaux o, lodé l, minvielle s, avet-loiseau h. genetic abnormalities in multiple myeloma: role in oncogenesis and impact on survival. rev med interne. 2007; 28:677-81. 17. kumar sk, rajkumar sk, dispenzieri a, et al. improved survival in multiple myeloma and the impact of novel therapies. blood. 2008;111:2516-20. 18. tao zf, fu wj, yuan zg, wang dx, chen yb, hou j. prognostic factors and staging systems of multiple myeloma. chin med j. (engl). 2007;120:1655-8. 19. r e e d e r c b , r e e c e d e , k u k r e t i v, e t a l . cyclophosphamide, bortezomib and dexamethasone induction for newly diagnosed multiple myeloma: high response rates in a phase ii clinical trial. leukemia. 2009;23:1337-41. 20. kumar l. haematopoietic stem cell transplantation: current status. natl med j india. 2007;20:128-37. 21. bryant a, nivison-smith i, pillai es, et al. fludarabine melphalan reduced-intensity conditioning allotransplantation provides similar disease control in lymphoid and myeloid malignancies: analysis of 344 patients. bone marrow transplant. 2014;49:17-23. 22. lemoli rm, d’addio a. conditioning regimen using busulfan plus melphalan in hematopoietic stem cell transplantation : can this conditioning regimen be used in autologous or allogeneic transplantation for acute leukemia? rev bras hematol hemoter. 2011;33:172-8. 23. shimoni a, hardan i, shem-tov n, et al. comparison between two fludarabine-based reduced-intensity conditioning regimens before allogeneic hematopoietic stem-cell transplantation: fludarabine/ melphalan is associated with higher incidence of acute graftversus-host disease and non-relapse mortality and lower incidence of relapse than fludarabine/busulfan. leukemia. 2007;21:2109-116. 24. gyurkocza b, sandmaier bm. conditioning regimens for hematopoietic cell transplantation: one size does not fit all. blood. 2014;124: 344-53. 387 208 original article acta med indones indones j intern med • vol 50 • number 3 • july 2018 a clinical trial on biological half life of bioactive protein from lumbricus rubellus, dlbs1033 in healthy volunteers anggi gayatri1, nafrialdi1, rahajuningsih d. setiabudy2, raymond r. tjandrawinata3, liana w. susanto3, andika rachman4, melva louisa1 1 department of pharmacology and therapeutic, medical faculty universitas indonesia, jakarta, indonesia. 2 department of clinical pathology, medical faculty universitas indonesia, jakarta, indonesia. 3 dexa laboratories of biomolecular sciences, dexa medica group, indonesia. 4 department of internal medicine, medical faculty universitas indonesia, jakarta, indonesia. corresponding author: anggi gayatri, md. department of pharmacology and therapeutic, faculty of medicine universitas indonesia, jakarta, indonesia. email: anggig@gmail.com. abstrak latar belakang: dlbs1033 adalah fraksi protein bioaktif yang diekstraksi dari lumbricus rubellus, dan dari studi in vitro diketahui memiliki aktivitas fibrinogenolitik, fibrinolitik dan antiagregasi. waktu paruh obat dalam plasma merupakan parameter yang penting dalam menghitung dosis obat. studi ini dilakukan untuk mengevaluasi waktu paruh biologis dlbs1033 melalui pengukuran kadar plasmin-antiplasmin complex (pap complex). pap complex adalah senyawa hasil proses fibrinolisis yang stabil dan inaktif. metode: desain studi ini adalah uji klinik terbuka pada subyek dewasa sehat. subyek dibagi menjadi dua kelompok, kelompok yang mendapatkan dosis tunggal (diberi obat 3 x 490 mg) dan kelompok yang mendapatkan dosis berulang hingga mencapai steady state (diberi obat 3 x 490 mg/hari selama 3 hari). sampel darah untuk pemeriksaan konsentrasi pap complex diambil pada jam ke-0 (sebelum pemberian obat pada kelompok dosis tunggal), jam ke-0,5, 1, 1,5, 2, 3, 4, 6, 8, 10, 12, dan 24. parameter keamanan yang diperiksa pada penelitian ini adalah kreatinin, prothrombin time (pt), activated partial thromboplastin time (aptt), sgot, dan sgpt. hasil: waktu paruh biologis dlbs1033 dihitung berdasarkan rerata kadar pap complex pada tiap waktu pengambilan sampel darah di tiap kelompok. pada kelompok dosis tunggal, rerata tertinggi konsentrasi pap complex tercapai sebelum pemberian obat. hasil ini menunjukkan bahwa aktivitas dlbs1033 tidak bermakna ketika diberikan sebagai dosis tunggal. pada keadaan steady state, konsentrasi pap complex meningkat dalam 2 jam setelah pemberian obat terakhir. waktu paruh biologis dlbs1033 adalah 8,6 jam. pada penelitian ini tidak didapatkan hasil laboratorium yang bermakna dan kejadian tidak diinginkan yang serius. kesimpulan: pada penelitian ini disimpulkan bahwa efek fibrinolitik dlbs1033 dapat diukur pada keadaan steady state. waktu paruh biologis dlbs1033 pada kelompok steady state adalah 8,6 jam. tidak ditemukan kejadian tidak diinginkan yang serius pada kedua kelompok subyek. kata kunci: lumbricus rubellus, fibrinolitik, plasmin-antiplasmin complex, waktu paruh biologis, dlbs1033. abstract background: dlbs1033 is a bioactive protein fraction extracted from lumbricus rubellus, with fibrinogenolytic, fibrinolytic and anti-aggregation activities reported in an in vitro study. plasma half-life is an important parameter to calculate its dose. this study was conducted to evaluate the biological half-life of dlbs1033 by measuring serial plasmin-antiplasmin (pap) complex. pap complex is a stable and inactive compound as a result of fibrinolysis process. methods: this was an open-label clinical trial in healthy adult subjects. subjects were divided into two vol 50 • number 3 • july 2018 a clinical trial on biological half life of bioactive protein 209 groups to receive single dose drugs (received 3 x 490 mg) or repeated administration until steady state conditions (3 x 490 mg/day for 3 days). blood samples for pap complex measurement were collected at time 0 (before drug administration for single dose group), then at 0.5, 1, 1.5, 2, 3, 6, 8, 10, 12, and 24 hours after drug administration. safety parameters used in this study were creatinine, prothrombin time (pt), activated partial thromboplastin time (aptt), sgot, and sgpt. results: the biological half-life of dlbs1033 was calculated based on the mean of pap complex concentration on each time sampling. in single dose group, the highest mean of pap complex concentration was reached before drug administration. our result showed that the activity of dlbs1033 could not be determined after single dose administration. in steady state condition, the pap complex concentration increase in 2 hours after last drug administration. the biological half-life of dlbs1033 was 8.6 hours. there were no significant safety findings on all laboratory parameters and no serious adverse events. conclusion: it is concluded that the fibrinolytic effects of dlbs1033 can be measured in steady state condition. the biological half-life of dlbs1033 in steady state condition was 8.6 hours. there were no serious adverse events on two groups of subjects. keywords: lumbricus rubellus, fibrinolytic, plasmin-antiplasmin complex, biological half-life, dlbs1033. introduction enzyme from earthworm alimentary tract has been known for its ability to dissolve fibrin. in 1991, mihara et al1 extracted enzyme from alimentary tract of lumbricus rubellus, which consist of six isoenzyme serine protease that collectively named as lumbrokinase.1 from several studies, it has been known that lumbrokinase has fibrinolytic, fibrinogenolytic, antiinflammatory activities, and could reduce platelet aggregation.2-4 the efficacy of oral lumbrokinase has been investigated in some clinical trials. jin et al5 conducted a study on 51 cerebral infarct subjects who was given oral lumbrokinase for 28 days. they concluded that mechanism of lumbrokinase are inhibit intrinsic coagulation pathway and activate fibrinolytic pathway by increasing t-pa activity.5 fibrinolytic activity was also concluded by rey6, who conducted a study on 28 diabetic foot ulcer subjects, which were given three times 500 mg lumbrokinase/placebo per day (n=14) for seven days. in the treatment group, d-dimer was increased. from many clinical trials, it is concluded that effects of lumbrokinase can be seen after several days. it is different with intravenous fibrinolytic enzyme which effects can be seen immediately after used. therefore oral lumbrokinase could not replace the function of an intravenous fibrinolytic enzyme which is used on acute thrombosis. oral lumbrokinase might be used for secondary prevention after acute thrombosis, such as myocardial infarct and stroke. dlbs1033 is bioactive protein fraction which is extracted from lumbricus rubellus earthworm. this earthworm comes from pengalengan, west java, indonesia. dlbs1033 possesses eight major proteins with molecular weight below 100 kda, so it is named as lumbricus low molecular weight proteins (llp).2 this enzyme can be transported to the bloodstream via intestinal epithel.7 as a drug that consists of serine protease enzyme, it is suspected that the mechanism of action of lumbrokinase, especially as fibrinolytic and antithrombotic. in vitro study by trisina et al2 showed that dlbs1033 has fibrinogenolytic activities on fibrinogen α, β, and γ chain, decreasing platelet aggregation and prolong clotting time.2 plasma half-life is a very important parameter to calculate the dose and interval administration of dlbs1033. the active fraction of dlbs1033 in plasma could not be measured since the active isoenzyme is still unknown. therefore, the aim of this study was to evaluate the biological half-life of dlbs1033 by measuring serial plasmin-antiplasmin (pap) complex. pap complex is a stable and inactive compound as a result of fibrinolysis process which is started with activation of plasminogen to plasmin. this activation will produce free plasmin that binds to antiplasmin and becomes pap complex.8-10 anggi gayatri acta med indones-indones j intern med 210 methods this study was an open label clinical trial, which was done at pharmacology and therapeutic department and clinical pathologic department of faculty of medicine universitas indonesia, cipto mangunkusumo hospital in july december 2012. the study drug was enteric coated dlbs1033 tablet, which contained 490 mg bioactive protein fraction; and produced by pt dexa medica, tangerang, indonesia. subjects this trial was conducted on 14 healthy male subjects. subjects were considered healthy if vital signs, physical examination, and hematological parameters was within normal range. other inclusion criteria were male, 1855 years old, body mass index of 18-25 kg/m2, gave written informed consent and have pap complex level between 0-514 ng/ml. exclusion criteria were subjects with cardiovascular disease, diabetes mellitus, and dyslipidemia, creatinine serum (normal 0,5-1,5 mg/dl) of more than 1.5 x uln (upper limit normal), sgot (normal 10-35 unit) and sgpt (normal 10-40 unit) of more than 3 x uln, blood pressure ≥ 140/90 mmhg, fasting blood glucose >126 mg/dl, alcoholic patients, those who took any medications (including traditional medicines, supplements, and vitamins) one week before the study, had bleeding history with unclear etiology, hemoglobin level <10 g/dl, thrombocyte count <100.000/µl and a heavy smoker (brinkman index >600). brinkman index was calculated as the product of the number of tobacco smoke per year. brinkman index was calculated as tobacco smoke per day times number of year of active consumption. based on brinkman index, smokers was divided into two groups, heavy smoker (brinkman index ≥ 600) and light smoker (brinkman index <600).11 subjects was dropped out if there were hypersensitivity reactions because of study medicine, subject were not taking the studied medicine as instructed, or taking any other drugs when they were in this trial without permission from investigator. subjects were divided into two groups, one group for single dose administration and one group for steady state condition. ethical approval and informed consent the committee of medical research ethics of faculty of medicine, university of indonesia has reviewed the study protocol and issued the approval letter on 25th july 2011. consent and signed informed consent to enter the study was obtained from each participant after a full explanation and information leaflet has been given. this study was also registered at clinicaltrials.gov nct01905878. study procedure potential subjects were invited to receive explanation of the study. after informed consent form had been signed, investigator collected the subject’s medical history, data on alcohol consumption habit, data on medication that had been taken seven days before study (including traditional medicine and supplement), smoking habit, bleeding history with unknown etiology, and calculated the subject’s body mass index based on body weight and height measurement. subjects also undergone a clinical assessment including vital signs, and laboratory assessment of routine hematology, fasting blood glucose, liver function test (sgot and sgpt), renal function test (serum creatinine), thrombocyte aggregation and pap complex. procedure eligible subjects were randomized to receive single dose (3 x 490 mg) or repeated dose until steady state conditions (3 x 490 mg/day for 3 days). the eligible subjects of single dose group were instructed to come to study site on the scheduled day. blood samples were collected to assess pap complex concentration , serum creatinine, sgot, sgpt, pt (prothrombin time) and aptt (activated partial thromboplastin time). subjects were instructed to take three tablets of enteric coated dlbs1033 in front of investigator with 240 ml of water. blood samples were collected on 30 minute, 60 minute, 90 minute, 2 hour, 3 hour, 4 hour, 6 hour, 8 hour, 10 hour, 12 hour, and 24 hour to evaluate serial pap complex. the eligible subjects of steady state condition group instructed to come to study site on the scheduled day (day 1 and day 4). on day 1 vol 50 • number 3 • july 2018 a clinical trial on biological half life of bioactive protein 211 blood samples collected to assess pap complex concentration, serum creatinine, sgot, sgpt, pt, and aptt. subjects instructed to take one tablet enteric coated of dlbs1033 with 240 ml of water in front of the investigator. study drug package (consist of 8 tablets) dispensed to the subjects at day-1, and they were instructed to take the drug three times daily 30 minutes before meals. subjects also were instructed to record any adverse events and concomitant medication prescribed in diary card. subjects had to take the drug for three days (day 1, 2, and 3). on day 4, subjects were instructed to come to study site. blood samples were collected at time 0, 30 minute, 60 minute, 90 minute, 2 hour, 3 hour, 4 hour, 6 hour, 8 hour, 10 hour, 12 hour, and 24 hour to evaluate serial pap complex. all subjects were asked to stay for two nights in pt. equilab international laboratory staying room. subjects were only permitted to eat food from investigator and not permitted to smoke. subjects were requested to fast for 10 hours before drug administration for single dose group and prior plasma sampling for steady state group. all subjects were undergone a clinical assessment including vital signs and the presence of adverse events at the time of blood sampling. any adverse events were recorded on case report form (crf). statistical analysis demographic, clinical, and laboratory data were recorded in case report form for each subject. adverse events were evaluated by investigator and recorded in adverse event table 2. laboratory parameters of study subjects at baseline variables mean (sd) single dose group (n=7) steady state group (n=7) hemoglobin (g/dl) 15.5 (1.14) 14.9 (0.77) hematocrit (%) 45.3 (3.03) 44 (2.30) thrombocyte (/ml) 266 714.3 (50 135.53) 273 714.3 (56 870.36) sgot (u/l) 22.9 (7.60) 23.4 (3.91) sgpt (u/l) 17.3 (14.81) 21.4 (11.84) serum creatinine (mg/dl) 0.9 (0.07) 0.9 (0.11) fasting blood glucose (mg/dl) 74.9 (8.43) 74.3 (9.43) pap complex (ng/ml) 54.2 (9.94) 70.7 (20.78) thrombocyte aggregation (%) 78 (8.89) 71.9 (10.67) table 1. demographic characteristics of study subjects variables mean (sd) single dose group (n=7) steady state group (n=7) age (years) 23.8 (4.78) 32.4 (10.69) height (cm) 166 (6.11) 161 (5.07) weight (kg) 55.1 (6.01) 55.4 (4.72) body mass index (kg/m2) 20 (2.15) 21.5 (2.31) brinkman index 28.3 (25.15) 34.7 (47.68) form in case report form. serial pap complex concentrations were analyzed as descriptive data. results the result of demographic and laboratory screening were shown on table 1 and table 2. table 3. pap complex (ng/ml) after single dose dlbs1033 administration (n = 7) time of blood sampling (hours) 1 2 3 4 5 6 7 mean 0 60.59 63.24 58.24 51.47 69.56 44.71 56.32 57.73 0.5 42.21 52.35 58.38 39.26 56.62 45.88 59.12 50.55 2 35.44 42.5 58.97 43.24 53.24 31.76 53.09 45.46 3 41.47 56.18 31.91 27.79 44.85 25.44 42.06 38.53 4 26.62 32.79 31.91 30.44 32.94 34.12 88.09 39.56 5 30 47.06 47.21 31.76 24.12 12.5 36.18 32.69 6 16.62 28.68 37.94 30.15 26.03 10.88 13.97 23.47 8 9.85 33.09 18.24 16.91 21.32 28.68 20.44 21.22 10 15.59 16.76 13.68 16.91 13.82 17.94 21.03 16.53 12 8.53 8.24 12.21 17.21 24.12 9.26 9.12 12.67 14 25.29 11.47 22.94 15.29 27.35 9.56 4.71 16.66 24 2.65 15.74 15 7.94 11.91 10.88 15.88 11.43 anggi gayatri acta med indones-indones j intern med 212 biological half-life of dlbs1033 in single dose administration serial pap complex parameter after single dose administration of dlbs1033 were shown on table 3. the highest mean of serial pap complex (y) was 57.73 ng/ml, and was reached prior to drug administration. this result meant that the activity of dlbs1033 after single dose administration was too small to determine. biological half-life of dlbs1033 in steady state condition from data in vivo trial, the half life of dlbs1033 is 8 hours. it was predicted that 3 x 490 mg dlbs1033 per day for three days administration was enough to reach steady state condition. the result of serial pap complex concentration from steady state group is shown on table 4. the biological half-life of dlbs1033 was calculated based on mean of pap complex on each time sampling from seven subjects. figure 1 showed the mean pap complex on steady state condition of dlbs1033. in steady state condition, the pap complex concentration increased in 2 hours after last drug administration. from figure 1, the linier equation of mean serial pap complex was y = 2,9087x + 54,556. the highest mean of serial pap complex (y) was 59,18 ng/ml. that value become 29,59 ng/ml in: y = 2.9087x + 54.556 29.59 ng/ml = 2.9087x + 54.556 x = 8.6 hours in steady state condition, the biological half life of dlbs1033 was 8.6 hours. safety parameters there were five laboratory parameters that measured as safety parameters i.e. pt, aptt, sgot, sgpt, and creatinine serum. there were no significant findings on all laboratory parameters, only four adverse events from 14 subjects (table 5) and no serious adverse events in this study. table 4. pap complex (ng/ml) concentration on steady state condition of dlbs1033 (n = 7) time of blood sampling (hours) 8 9 10 11 12 13 14 mean 0 46.47 55.44 57.79 76.62 46.62 54.85 72.06 58.55 0,5 49.41 55.59 52.21 60.74 56.32 43.53 53.58 53.07 2 26.91 55 42.35 54.26 57.65 47.94 130.15 59.18 3 21.18 39.41 30 42.79 31.32 41.91 70.74 39.62 4 42.5 63.53 36.47 46.03 39.41 22.79 61.47 44.60 5 33.68 34.41 45.59 41.62 19.26 23.68 54.41 36.09 6 29.56 23.82 30.29 46.03 37.5 34.85 55.44 36.78 8 17.65 18.97 26.03 17.35 17.65 30.29 46.32 24.89 10 9.71 13.38 17.21 17.35 10.59 23.97 28.38 17.23 12 16.62 11.18 17.21 28.68 23.97 21.91 32.06 21.66 14 10.74 14.85 12.65 23.68 20.74 8.38 26.76 16.83 24 9.71 10.44 8.38 14.41 19.12 30.74 87.5 25.76 figure 1. mean of serial pap complex in each time sampling of 7 subjects from steady state condition of dlbs1033 group table 5. adverse events of single dose and steady state subject group (n = 14) no. adverse events no of subjects single dose group no of subjects steady state group 1 headache 1 2 dizziness 1 3 myalgia 1 1 total 3 1 vol 50 • number 3 • july 2018 a clinical trial on biological half life of bioactive protein 213 discussion dlbs1033 is a lumbrokinase extract obtained from lumbricus rubellus that possesses eight isoenzymes. similar to other lumbrokinase, we predict that the mechanism of action of dlbs1033, especially as plasminogen activator. this prediction is supported by the result in an in vitro study by trisina et al2, which showed that dlbs1033 has fibrinogenolytic activities, decreasing platelet aggregation and prolong clotting time. as a plasminogen activator, dlbs1033 will activate plasminogen to be plasmin. the free-plasmin will bind to antiplasmin and form plasmin-antiplasmin complex (pap complex). the pap complex concentration was used as a fibrinolytic parameter on this study.9,10 c o a g u l a t i o n a n d f i b r i n o l y s i s a r e a physiological process which is controlled by several factors. these two processess control our blood fluidity. fibrinolysis process starts when fibrins are deposited as a product of coagulation process. fibrin regulates its own degradation by bind to plasminogen and tpa. this binding activate tpa to convert plasminogen to plasmin. once formed, plasmin cleaves fibrin.9,13 plasmin binding-fibrin will degrade fibrin clot to be fibrin degradation product, and degrade cross-linked fibrin to be d-dimer.8,9 free plasmin will bind to antiplasmin and become plasmin-antiplasmin complex (pap complex) which is stable and inactive.10 normal concentrations of pap complex are different among individuals. it depends on some factors, such as inflammation; however, high level of pap complex concentration is not directly linked to inflammation.14 on single dose of dlbs1033 (table 3), the pap complex was not increased after drug administration. the highest pap complex c o n c e n t r a t i o n w a s r e a c h e d b e f o r e d r u g administration. this result indicated that the activity of dlbs1033 was too small to detect after single dose administration. dlbs1033 is an oral drug, and it needs to be absorbed and might pass the first metabolism process before exerting its effect.7 it might need few hours to reach steady-state condition to measure the dlbs1033 fibrinolytic activity. the biological half-life of dlbs1033 on steady state group was 8.6 hours. this result indicated that the effect as fibrinolytic could be measured after steady state condition was reached. the increase of pap complex concentration level in 2 hours also showed that the absorption was relatively fast and it was ensured that the absorbed dlbs1033 components were active form.12 the drug profile in steady state condition is important information for long term used drug. as an oral fibrinolytic drug, dlbs1033 can be used for long period in some clinical conditions, such as post cardiovascular events. one pilot study was conducted to evaluate the efficacy of oral lumbrokinase for stable angina pectoris. on that trial, ten subjects were given two tablets of 250 mg oral lumbrokinase, three times daily, for 30 consecutive days. it is concluded that the drug could improve the myocardial perfusion in patients.15 this result needs to be extrapolated to the bigger trial with more subjects. in current clinical practice, dlbs1033 usually use as an adjuvant drug for standard treatment. in our study, quantification of half-life used pharmacodynamics parameters, since the real elimination half-life of this drug is still unknown. the dlbs1033 half-life quantification could be more accurate if the concentration of dlbs1033 protein fraction in plasma can be quantified. conclusion on this study, we concluded that the fibrinolytic effects of dlbs1033 might be measured in steady state condition. the biological half-life of dlbs1033 in steady state condition was 8.6 hours. there were no serious adverse events on the two groups. result of this study can be used as a reference to quantify dose regimen for the next clinical trial using this drug. conflict of interest this trial was funded by dexa laboratories of biomolecular sciences, dexa medica, cikarang, indonesia. references 1. mihara h, sumi h, yoneta t, et al. a novel fibrinolytic enzyme extracted from the earthworm, lumbricus rubellus. japanese j physiol. 1991;41:461-72. anggi gayatri acta med indones-indones j intern med 214 2. trisina j, sunardi f, suhartono mt, tjandrawinata rr. dlbs1033, a protein extract from lumbricus rubellus, possesses antithrombotic and thrombolytic activities. j biomed biotechnol. 2011;1-19. 3. lee ck, shin js, kim bs, cho ih, kim ys, lee eb. antithrombotic effects by oral administration of novel proteinase fraction from earthworm eisenia andrei on venous thrombosis model in rats. arch pharm res. 2007; 30:475-80. 4. kholos ja. the anti-inflammatory and antiplatelet effects of boluoke (lumbrokinase) in cancer patients. townsend lett. 2009:62-6. 5. jin l, jin h, zhang g, xu g. changes in coagulation and tissue plasminogen activator after the treatment of cerebral infarction with lumbrokinase. clin hemorheol microcirc. 2000;23:213–8. 6. rey i. pengaruh pemberian lumbrokinase selama 7 hari terhadap status hiperkoagulasi pada penderita ulkus kaki diabetik. tugas akhir dalam rangka menyelesaikan pendidikan dokter spesialis ilmu penyakit dalam. fk-usu, medan. 2009. 7. yan xm , kim ch, lee ck, shin js, cho ih, sohn ud. intestinal absorption of fibrinolytic and proteolytic lumbrokinase extracted from earthworm, eisenia andrei. korean j physiol pharmacol. 2010;14:71-5. 8. oesman f, setiabudy rd. fisiologi hemostasis dan fibrinolisis. in: setiabudy rd, eds. hemostasis dan trombosis. 4th edition. jakarta: balai penerbit fkui; 2009. p. 1-14. 9. schmaier ah, thornburg cd, pipe sw. coagulation and fibrinolysis. in: mcpherson ra, pincus mr, eds. henry’s clinical diagnosis and management by laboratory methods. 21st ed. philadelphia: saunders elsevier; 2007. p. 729-37. 10. bauer ka, weitz ji. laboratory markers of coagulation and fibrinolysis. in: colman rw, hirsh j, marder vj, clowes aw, george jn, eds. hemostasis and thrombosis basic principles and clinical practice. 4th ed. philadelphia: lippincott williams & wilkins. 2001. p. 1113-7. 11. brinkman gl, coates eo jr: the effect of bronchitis, smoking and occupation on ventilation. ann respir dis. 1963;87:684-93. 12. tjandrawinata rr, trisna j, rahayu p, prasetya la, hanafiah a, rachmawati h. bioactive protein fraction dlbs1033 containing lumbrokinase isolated from lumbricus rubellus: ex vivo, in vivo, and pharmaceutic studies. drug design, development therapy. 2014;8: 1585-93. 13. cesarman-maus g, hajjar ka. molecular mechanisms of fibrinolysis. brit j haematol. 2005;129:307-21. 14. bouma b, maas c, hazenberg bpc, lokhorst hm, gebbink fbg. increased plasmin-α2-antiplasmin level indicate activation of the fibrinolytic system in systemic amyloidosis. j thromb haemost. 2007;5: 1139-42. 15. kasim m, kiat aa, rohman ms, hanifah y, kiat h. improved myocardial perfusion in stable angina pectoris by oral lumbrokinase: a pilot study. j alternat complement med. 2009;15:539-44. 194 acta med indones indones j intern med • vol 53 • number 2 • april 2021 case report tocilizumab as a treatment for ‘cytokine storm syndrome’ in covid-19: a case report ari fahrial syam1, ceva w. pitoyo2, suhendro3, benny zulkarnain4, nuri d. indrasari5, dita aditianingsih6, cosphiadi irawan7, adityo susilo3, cleopas m. rumende2, ika p. wijaya8, fera ibrahim9, menaldi rasmin10, idrus alwi8, dadang makmun1 1 division of gastroenterology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 division of respirology and critical care, departement of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 3 division of tropical medicine and infectious disease, department of internal medicine, faculty of medicine unviersitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 4 department of radiology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 5 department of clinical pathology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 6 department of anesthesiology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 7 division of hematology and medical oncology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 8 division of cardiology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 9 department of microbiology clinic, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 10 department of pulmonology and respiratory medicine, faculty of medicine universitas indonesia persahabatan hospital, jakarta, indonesia. corresponding author: prof. ari fahrial syam, md., phd. division of gastroenterology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: ari_syam@hotmail.com. abstrak coronavirus disease 19 (covid-19) yang disebabkan oleh severe acute respiratory syndrome coronavirus-2 (sars-cov-2), saat ini tengah menjadi permasalahan di dunia, terutama karena tingginya kecepatan transmisi dan manifestasi klinis yang beragam. acute respiratory distress syndrome (ards) dan kegagalan multiorgan merupakan kejadian tersering yang ditemukan pada kasus berat covid-19. laporan kasus ini mendeskripsikan seorang pasien berusia 53 tahun yang didiagnosis dengan covid-19. evaluasi lebih lanjut dari pasien ini menunjukkan adanya peningkatan bermakna kadar il-6 dalam darah disertai dengan hiperferitinemia, yang sesuai dengan karakteristik sindrom badai sitokin. pasien diterapi dengan tocilizumah, sebuah antibodi monoklonal dan antagonis reseptor il-6. ikatan antara tocilizumab dan il-6 secara efektif menghambat dan menangani sindrom badai sitokin. meskipun laporan kasus ini melaporkan efektivitas tocilizumab dalam tata laksana sindrom badai sitokin, tocilizumab juga diketahui memiliki berbagai efek samping yang perlu dipantau secara ketat selama vol 53 • number 2 • april 2021 tocilizumab as a treatment for cytokine strom syndrome in covid 19 195 pengobatan. diperlukan uji klinis terkendali untuk mengevaluasi efektivitas dan keamanan pemberian tocilizumab pada subjek dengan karakteristik klinis yang bervariasi dan dengan jumlah subjek yang lebih banyak. kata kunci: covid-19, sars-cov-2, acute respiratory distress syndrome (ards), tocilizumab. abstract coronavirus disease 19 (covid-19) which is caused by severe acute respiratory syndrome coronavirus-2 (sars-cov-2), has been a problem worldwide, particularly due to the high rate of transmission and wide range of clinical manifestations. acute respiratory distress syndrome (ards) and multiorgan failure are the most common events observed in severe cases and can be fatal. cytokine storm syndrome emerges as one of the possibilities for the development of ards and multiorgan failure in severe cases of covid-19. this case report describes a case of a 53-year-old male patient who has been diagnosed with covid-19. further evaluation in this patient showed that there was a marked increase in il-6 level in blood accompanied with hyperferritinemia, which was in accordance with the characteristic of cytokine storm syndrome. patient was treated with tocilizumab, a monoclonal antibody and is an antagonist to il-6 receptor. the binding between tocilizumab and il-6 receptors effectively inhibit and manage cytokine storm syndrome. although this case report reported the efficacy of tocilizumab in managing cytokine storm syndrome, tocilizumab has several adverse effects requiring close monitoring. further clinical randomized control trial is required to evaluate the efficacy and safety of tocilizumab administration in participants with various clinical characteristics and greater number of subjects. keywords: covid-19, sars-cov-2, acute respiratory distress syndrome (ards), tocilizumab. introduction coronavirus disease 19 (covid-19) which is caused by severe acute respiratory syndrome coronavirus-2 (sars-cov-2), until now has been a problem worldwide. the high rate of transmission in covid-19 causes the disease difficult to control. covid-19 was first found in december 2019 and by 15th december 2020 this disease has caused 1,618,374 mortality worldwide.1 although most cases cause mild clinical manifestation, some cases may cause severe clinical manifestation and death. acute respiratory distress syndrome (ards) and multiorgan failure are the most common events found in severe cases and become the cause of death in most cases. until recently, cytokine storm syndrome emerges as one of the possibilities for the development of ards and multiorgan failure in patients with covid-19.2 cytokine storm syndrome is a systemic inflammatory response that can be instigated by many factors, including infection and medications. cytokine storm syndrome can be found in disease with disruption of immune system or immune related therapy, such as chimeric antigen receptor (car) t cell therapy, and viral infection.3 a study which was performed by huang et al found that in critically ill covid-19 patients, there was an increase in proinflammatory cytokine concentration, such as il-6, il-10, il-7, il-2 and ifn-γ.4 il-6 itself has an important role in inflammatory reaction and immune response. based on the previous study, it is known that il-6 is the most important cytokine in the occurrence of cytokine storm syndrome in covid-19. therefore, tocilizumab (tcz) which is a humanize antibody to il-6 receptor was considered as a treatment in severe cases of covid-19 to decrease mortality rate.5 in this article, we reported a covid-19 case who experienced cytokine storm syndrome, prompting tocilizumab as a therapeutic option. case illustration a male patient, 53-year-old, was admitted with the chief complaint of fever in the past 1 week prior to hospital admission. fever was felt intermittently. the patient also complained of muscle and joint pain. he also complained of pain in the lower right and left abdomen, accompanied with diarrhea 1 time/day. there was sore throat and mild dry cough which occurred ari f syam acta med indones-indones j intern med 196 after 3 days. complain of breathing difficulty was denied. on the third day of fever, patient underwent blood examination in the laboratory for dengue serology examination and obtained a negative result. due to the persistent fever although without diarrhea, the patient underwent another blood test and chest x-ray. the results of chest x-ray examination showed signs of pneumonia (figure 1). chest ct revealed ground glass appearance (ggo), multifocal subpleural and fibro-parenchymal opacity in both lungs. he was further hospitalized. upon admission to the hospital, the patient was diagnosed as patient under surveillance of covid-19. history of hypertension, diabetes, or cardiac disease was denied. history of allergy and other chronic disease was also denied. there was no other family member complaining similar symptoms. physical and vital signs examination revealed that the patient was stable and there was no abnormality in general examination. patient was then hospitalized in isolation room. during hospitalization, patient complained of intermittent fever. in the first three days of hospitalization, patient was afebrile. on day 4 of hospitalization, he felt intermittent fever for 4 days, with the highest recorded temperature was 38.9 0c. the patient also started to suffer from dry cough and occasional breathing difficulty particularly after physical activity, supported by the worsening of patient chest x-ray (figure 2). cough was usually felt after position changes, sometimes cough was accompanied with or without sputum. on hospitalization day-8, week-3 after the onset of fever, patient continuously had fever, body ache, and sleeping difficulty. during hospitalization, the patient did not have any gastrointestinal symptoms. until hospitalization day-12, the fever condition was still intermittent, accompanied by cough and shortness of breath, but oxygen saturation was adequate with oxygen supplementation through nasal cannula 4-5 liter. without oxygen supplementation, his oxygen saturation was 90-91%. however, based on observation every 6 hours, overall patient’s hemodynamic condition is quite stable. several laboratory tests were performed to the patient. complete blood count and differential count were still within normal range, although there was an increase in hematocrit to 38.8%, relative neutrophilia, and relative monocytosis. the relative increase in neutrophil and monocyte were in accordance with the increase of procalcitonin, quantitative crp, and ferritin in infection or inflammation condition. neutrophil-lymphocyte ratio (nlr) was initially increased from 6.35 and then it dropped to 4.94, before becoming back to normal normal 2.47. ferritin serum examination revealed an increase in ferritin concentration 2277.08 ng/ml. the results of troponin and kidney function test were within normal limits. liver function test showed an increase in ast to 41 u/l. crp examination revealed a concentration of 7.1 mg/l in day 1 and continue to increase with highest crp level was 95.5 mg/l. additionally, patient also underwent plasma il-6 level test and an increase in il-6 with a value of 84.0 pg/ml was found. serum ferritin examination showed an increase in ferritin level 2277.08 ng/ml. patient also figure 1. chest x-ray, one day before admission. result showing signs of pneumonia. figure 2. chest x-ray, day 4 admission. result showing worsening signs of pneumonia. vol 53 • number 2 • april 2021 tocilizumab as a treatment for cytokine strom syndrome in covid 19 197 underwent rt-pcr examination for sarscov-2 and sars-cov-2 antibody examination, which revealed positive sars-cov-2 results and non-reactive sars-cov-2 antibody. based on these clinical condition and laboratory findings, the patient was diagnosed with covid-19 with cytokine storm syndrome. upon admission, the patient received azithromycin 500 mg o.d, hydroxychloroquine 400 mg p.o. b.i.d. continued with 400 mg p.o. o.d. dose, and oseltamivir 75 mg p.o. o.d. oseltamivir was given for 3 days, but further continued with favipiravir as per protocol dose 800 mg b.i.d., continued with 400 mg b.i.d. dose for 2 weeks. intravenous paracetamol drip was administered if his temperature was above 38.5 degree celsius. patient was also given vitamin c 1000mg i.v. b.i.d., other multivitamin tablet p.o. o.d., vitamin d 1000 iu o.d, and zinc 30 mg o.d. before being hospitalized, patient experienced electrolyte disturbance, decreased potassium and sodium and received kcl drip. patient also experienced hypocalcemia and was given calcium gluconate injection. during administration of hydroxychloroquine therapy, patient underwent ekg examination to monitor cardiac abnormalities, and during cardiology evaluation, no cardiac abnormality was found. on hospitalization day-8, patient underwent blood coagulation system test. the patient had increased d-dimer and fibrinogen level with the result of 1080 mcg/ml and 700 mg/ dl, respectively. (figure 3). based on these results, the patient was given enoxaparin as anticoagulant. on day 10 of hospitalization, chest ctscan without contrast was performed and showed worsening condition with further consolidation. this was in accordance with the typical appearance of pneumonia with fibrotic appearance in lower lobe and thickening of the right pleura. on hospitalization day-10, patient was given anti-il6, tocilizumab or actemra, and after administration of the 600 mg single dose tocilizumab, patient’s condition ameliorated, fever subsides, cough and breathing difficulty gradually improves, until finally on day-18 the patient did not require supplemental oxygen. the patient was discharged on day-22 with good condition and normal laboratory parameters. although rt-pcr from nasopharynx and oropharynx still showed positive results, the ct (cycle threshold) value continue to increase, showing that the number of virus continue to decrease. until week-6 after first complaint, rt-pcr from nasopharyngeal swab was still positive, but patient’s clinical condition was good and improved, and the patient continued to do self-isolation. the chest x-ray taken before the patient was discharged also shown improvement (figure 4). the patient’s condition continued to 35 35,5 36 36,5 37 37,5 38 38,5 39 39,5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 te m pe ra tu re in c el ci u s day fever chart tocilizumab no fever figure 3. fever patterns before and after treatment with tocilizumab. ari f syam acta med indones-indones j intern med 198 ta bl e 1. r es ul ts o f o xy ge n sa tu ra tio n an d la bo ra to ry s er ie s to ci liz um ab ↓ d ay s of ad m is si on d ay 1 d ay 2 d ay 3 d ay 4 d ay 5 d ay 6 d ay 7 d ay 8 d ay 9 d ay 10 d ay 11 d ay 12 d ay 13 d ay 14 d ay 15 d ay 16 d ay 17 d ay 18 t( 0 c ) 37 .4 37 .3 37 .1 38 38 38 .5 38 .9 37 .9 37 .3 37 .8 36 .8 36 .6 36 .9 36 .5 36 .6 36 .7 36 .6 36 .7 r r (t im es / m in ) 17 17 16 24 17 28 30 18 24 40 30 24 28 21 24 22 20 20 p er ip he ra l ox yg en sa tu ra tio n (% ) 99 98 98 97 97 94 95 95 93 93 90 93 94 95 94 95 96 96 n eu tro ph il (x 10 9 /l ) 80 .8 74 .3 65 .7 ly m ph oc yt e (x 10 9 /l ) 12 .7 15 26 .5 a lt (u /l ) 41 69 54 a s t (u /l ) 28 93 94 ld h (u /l ) 31 9 n at riu m (m eq /l ) 13 3 12 8 13 4 13 3 13 0 13 2 13 6 13 6 13 5 to ta l c al ci um (m g/ dl ) 7. 7 7. 7 7. 5 7. 9 7. 8 p ro ca lc ito ni n (n g /m l) 0. 06 0. 12 0. 12 c r p (m g/ l) 7. 1 10 .3 75 .4 95 .5 4. 3 n lr 6. 35 4. 94 2. 47 p t (s ) 13 .4 in r 1. 02 fi br in og en 70 0 37 1 dd im er (u g/ m l) 10 80 11 37 68 0 26 4 fe rr iti n (n g/ m l) 68 8. 2 22 77 .0 8 86 5 il -6 84 .0 s a r s -c ov -2 r tp c r p os iti ve p os iti ve p os iti ve a nt ib od y s a r s -c ov -2 n on re ac tiv e r ea ct iv e ig m ig g vol 53 • number 2 • april 2021 tocilizumab as a treatment for cytokine strom syndrome in covid 19 199 improve and was able to carry on with normal activity 1 month after hospitalization with negative swab result. discussion c o v i d 1 9 i s a h i g h l y t r a n s m i t t e d infectious disease with various clinical manifestations, ranging from asymptomatic, mild pneumonia, severe pneumonia until critical clinical manifestation which causes death. several studies reported that covid-19 with severe manifestation showed an increase in proinflammatory cytokines causing cytokine storm syndrome.2 cytokine storm syndrome itself is marked by an increase in il-6 level accompanied with hyperferritinemia5. in this case report, we presented a moderate covid-19 case with cytokine storm syndrome which was marked by the increase in il-6 level in the blood, hyperferritinemia with coagulation disorder, hypocalcemia and electrolyte disturbance. the patient was treated with tocilizumab. in this case, the patient showed clinical and laboratory parameters improvement after administration of tocilizumab. the most relieving lessons of this experience was that not only the fever subsided, but also the saturation improvement prevented this patient from being intubated and the need of mechanical ventilation. this finding was in accordance with previous study involving 21 severe and critically ill covid-19 patients in china. in this retrospective study, it was found that administration of tocilizumab may improve clinical condition, which was supported with improvement of laboratory parameter such as decreased crp and il-6 level. additionally, chest ct-scan also showed significant improvement after tocilizumab administration in almost all patients.6 in this case, nlr may increase in early infection suggestive of systemic inflammatory response7. nlr examination has a sensitivity of 88% and specificity of 63.6% in determining the severity of covid-19 8. ferritin and crp are acute phase proteins, which levels increase in infection or inflammatory condition. other study in china involving covid-19 patients with more various clinical appearance, w h i c h w e r e c o v i d 1 9 w i t h m o d e r a t e pneumonia, severe pneumonia, and critically ill patients. this study was performed in 15 patients and showed that after administration of tocilizumab, 80% of patients showed clinical improvement, decreased crp and il-6 levels. administration of tocilizumab was considered to decrease or manage covid-19 with cytokine storm syndrome.9 in addition, another study was conducted in italy involving 85 covid-19 patients comparing 62 covid-19 patients who were given tocilizumab and 23 patients receiving standard therapy of hydroxychloroquine, lopinavir, and ritonavir. based on this study, it was found that the low dose tocilizumab administration might result in clinical improvement and decreased mortality in covid-19 patients compared to patient who did not receive tocilizumab.10 until now, the mechanism of cytokine storm syndrome in sars-cov-2 infection remains unknown. however, the incidence of cytokine storm syndrome is frequently associated with the increase in il-6 level. il-6 itself can be produced by almost all stromal and immune cells, such as b lymphocyte, t lymphocyte, macrophage, monocyte, dendritic cell, mast cell, and other non-lymphocyte cells, including fibroblast, endothelial cell, keratinocyte, glomerular mesangial cell, and tumor cell.11-12 in sarscov-2 infection, after the virus binds to the ace2 receptor in type ii pneumocyte in the lungs, it will invade the cell and replicate resulting figure 4. chest x-ray, day 22. result showing improving signs of pneumonia ari f syam acta med indones-indones j intern med 200 in cellular apoptosis and necrosis. it will also trigger the inflammatory response, including the production of inflammatory response in the form of proinflammatory cytokine, macrophage and th1 cell activation, followed by the production of ifn-γ, il-17a, il21, and il-22 by neutrophil, th17 cell, and cd8+ cell. in normal condition, the production of proinflammatory cytokine is followed by the production of anti-inflammatory cytokine, so cytokine storm did not occur. based on the study, the increase in il-6 level in covid-19 occurs because sars-cov-2 infects macrophage and cause the upregulation of il-6 production and the decrease of interferon expressions. the increase in il-6 will cause the rise in monocyte differentiation, b cell antigen-dependent differentiation modulation, igg production by b cell, and th2 response promotion by inhibiting th1 polarization. due to the sars-cov-2 invasion on pneumocytes and lung macrophages, local cytokine storm in covid-19 patients is potentially higher than the systemic storm. other studies reported that there was a strong correlation between il-6 serum and the incidence of respiratory failure. this correlation is potentially stronger than the correlation of plasma il-6 with the incidence of respiratory failure in ards (acute respiratory distress syndrome) due to other systemic sepsis, where plasma il-6 is much higher than plasma il-6 in covid-19, but the lung lesion appearance and the respiratory failure can be less severe.12 this explains that the respiratory failure in covid-19 is more prominent than the fever, and this also explain the reason covid-19 is more deadly. in this patient, the plasma il-6 was 84 pg/ml, which was highly significant because the normal plasma il-6 was 0 – 5 pg/ml or not more than 15 pg/ml. it can be imagined that the lung tissue il-6 level was potentially much higher than 84 pg/ml in the plasma, and the lung damage is potentially severe. based on a study, it was known that the increase of il-6 level more than 80 pg/ml was correlated with higher risk to develop respiratory failure. the administration of anti-il-6 may manage the cytokine storm syndrome which happen in covid-19, either systemic or in the lungs.13 tocilizumab is a monoclonal antibody and is an antagonist to il-6 receptor. il-6 will bind to the il-6r receptor and form a complex, which will further bind to glycoprotein 130 (gp130) signal transducer and stimulate the gene expression. il-6r itself can be found not only in the transmembrane (mil-6r) form, but also in the soluble (sil-6r) form. these two forms of il-6r will cause the signal transduction through different pathways, which are classic transduction and trans transduction pathway. in the classic transduction pathway, many cells did not respond to il-6 signal due to the low expression of mil6r. classic signal transduction is only limited to several cells, including macrophage, neutrophil, t lymphocyte, and other cells which express mil-6r. in the cytokine storm syndrome due to covid-19, there is an increase in il-6 exceeding normal limits. this causes the high expression of mil-6r and sil-6r. in trans transduction pathway, sil-6r itself can activate almost all cells in the body to regulate the pro-inflammatory reaction. inhibition to trans transduction pathway has previously been known to be effective in managing several autoimmune diseases.11,14-17 tocilizumab itself is an anti-il6 which can bind to both forms of il-6r. the binding between tocilizumab and mil-6r dan sil-6r may inhibit the classic and trans transduction pathway, which effectively may inhibit and manage cytokine storm syndrome.11,14,17 until now, tocilizumab has not received the approval to be used in the management of cytokine storm syndrome in covid-19 in china. the recommendation of management of covid-19 by who also stated that the use of tocilizumab in the management of covid-19 is still limited to clinical trials. nonetheless, “diagnosis and treatment plan of novel coronavirus pneumonia (seventh trial edition)” in china recommends the use of tocilizumab in patient with wide lung lesion, in severe covid-19 pneumonia, and in patients with high level of il-6. based on this recommendation, the recommended dose is 400 mg which is diluted in 100 ml nacl 0.9% and given intravenously in 1 hour.17 although the use of tocilizumab showed quite good efficacy in managing cytokine storm syndrome, there were several adverse effects which may happen due to the use of tocilizumab. vol 53 • number 2 • april 2021 tocilizumab as a treatment for cytokine strom syndrome in covid 19 201 based on united stated fda (food and drug administration) there were several adverse effects which may appear: (1) serious infection: the most common infection is pneumonia, urinary tract infection, cellulitis, herpes zoster, gastroenteritis, diverticulitis, sepsis, and bacterial arteritis; (2) gastrointestinal perforation which is reported as a complication of diverticulitis. most patients who experienced gastrointestinal perforation use tocilizumab in conjunction with nonsteroidal anti-inflammatory drugs (nsaids), corticosteroid, or methotrexate in the same time; (3) infusion reaction: the most common reported adverse effects during administration are hypertension, headache, and skin reaction; (4) anaphylaxis; this reaction is usually reported in the second to fourth administration of tocilizumab; and (5) laboratory parameter abnormality: such as thrombocytopenia, increased liver enzyme, and increased lipid profiles.17,18 conclusion tocilizumab could be used as a therapy for cytokine storm syndrome in covid-19 patients. however, the success of the treatment may be depending on the degree of covid-19 severity. further clinical randomized control trial is required to evaluate the efficacy and safety of tocilizumab administration in participants with various clinical characteristics and a greater number of subjects. references 1. world health organization. coronavirus disease 2019 (covid-19) situation report. 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[cited 2020 jun 16]. available from: https://apps.who.int/iris/ handle/10665/332196. 209 original article acta medica indonesiana the indonesian journal of internal medicine factors associated with in-stent restenosis in patients following percutaneous coronary intervention dedi wihanda, idrus alwi, muhammad yamin, hamzah shatri, e. mudjaddid department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. correspondence mail: department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: dediwihanda3@gmail.com. abstrak tujuan: mengetahui faktor-faktor yang berhubungan dengan in-stent restenosis (isr) pada pasien pasca percutaneous coronary intervention (pci). metode: desain penelitian ini ialah potong lintang retrospektif dengan menggunakan rekam medik pasien pasca pci yang menjalani follow-up angiografi antara bulan januari tahun 2009 hingga maret 2014 di pelayanan jantung terpadu/ rsupn dr. cipto mangunkusumo. in-stent restenosis dinyatakan apabila diameter stenosis pada saat follow-up angiografi sebesar ≥ 50 persen, baik di dalam stent maupun menjulur sejauh lima mm keluar dari ujung proksimal atau distal stent. hasil: didapat 289 subyek penelitan yang terdiri atas 133 subyek dengan isr dan 156 tanpa isr. kejadian isr pasca pci pada penggunaan bare-metal stent (bms) dan drug-eluting stent (des) yaitu berturut-turut sebesar 61,3% dan 40,7%. tipe stent (or=4,83; 95% ik 2,51-9,30), panjang stent (or=3,71; 95% ik 1,99-6,90), lesi di bifurkasi (or=2,43; 95% ik 1,16-5,10), merokok (or=2,30; 95% ik 1,33-3,99), diameter pembuluh darah (or=2,18; 95% ik 1,2-3,73), hipertensi (or=2,16; 95% ik 1,16-4,04) dan diabetes mellitus (or=2,14; 95% ik 1,23-3,70) merupakan faktor prediksi terjadinya isr. kesimpulan: tipe stent, panjang stent, lesi di bifurkasi, merokok, diameter pembuluh darah, hipertensi dan dm merupakan faktor-faktor yang berhubungan dengan isr pada pasien pasca pci. kata kunci: bare-metal stent; drug-eluting stent; in-stent restenosis. abstract aim: to determine factors associated with in-stent restenosis (isr) in patients following percutaneous coronary intervention (pci). methods: a retrospective cross-sectional study was conducted using secondary information from medical records of post-pci patients who underwent follow-up of angiography pci between january 2009 and march 2014 at the integrated cardiovascular service unit, cipto mangunkusumo hospital, jakarta. angiographic isr was defined when the diameter of stenosis ≥50% at follow-up angiography including the diameter inside the stent and diameter with five-mm protrusion out of the proximal and distal ends of the stent. results: there were 289 subjects including 133 subjects with and 156 subjects without isr. the incidence of isr in patients using of bare-metal stent (bms) and drug-eluting stent (des) were 61.3% and 40.7%, respectively. factors associated with isr are stent-type (or=4.83, 95% ci 2.51-9.30), stent length (or=3.71, 95% ci 1.996.90), bifurcation lesions (or=2.43, 95% ci 1.16-5.10), smoking (or=2.30, 95% ci 1.33-3.99), vascular diameter (or=2.18, 95% ci 1.2-3.73), hypertension (or=2.16, 95% ci 1.16-4.04) and diabetes mellitus (or=2.14, 95% ci 1.23-3.70). conclusion: stent type, stent length, bifurcation lesions, smoking, vascular diameter, hypertension and dm are factors associated with isr in patients following pci. key words: bare-metal stent; drug-eluting stent; in-stent restenosis. dedi wihanda acta med indones-indones j intern med 210 introduction advanced science and knowledge has allowed us to perform percutaneous coronary intervention (pci) for complex lesions of coronary arterial disease (such as multiple vessel and left main disease), which is characterized by the increasing number of pci procedures.1,2 a statistical report in 2014 about heart disease and stroke in the united states demonstrated that there is an increasing number of pci procedures in both men and women.3 moreover, data between 2002 and 2005 reported that there is also a greater number of coronary revascularization using pci procedures compared to coronary arterial bypass graft.4 the increasing number of pci procedures worldwide indicates that there is an increasing use of intracoronary stent covering as many as 75 to 80 percent.5 however, the procedure of stent deploy during pci will stimulate the growth of smooth muscle cells (smc).6 the smooth muscle cells will then migrate from the tunica media to intima. the cells subsequently will proliferate and develop the neo intimal hyperplasia (nih), which has important role in the development of stenotic lesion.7 the excessive nih growth will lead to in-stent restenosis (isr).6,8 the intention of using drug-eluting stent (des) in pci procedure is to reduce the incidence of isr caused by the use of baremetal stent (bms) and it is demonstrated by the increasing number of des utilization compared to the bms.3,9 however, the incidence of isr in patients following pci, either using des or bms remains high.10-12 therefore, our study was aimed to identify factors associated with isr. methods the design of our study was retrospective cross-sectional using secondary data from medical records of post pci patients who underwent follow-up angiography of pci in the period between january 2009 and march 2014 at the integrated cardiovascular service unit/ national central general hospital of dr. cipto mangunkusumo, jakarta. extraction of secondary data was performed between november and march 2014. the inclusion criteria were post pci patients who had undergone follow-up angiography within ≥6 months. the exclusion criteria were post-pci patients without medical record data or angiographic documentation. the dependent variable in our study was isr measured based on the quantitative coronary angiography (qca) evaluation. isr was defined when the diameter of stenosis ≥50% at followup angiography including the diameter inside the stent and diameter with five-mm protrusion out of the proximal and distal ends of the stent. the independent variables in our study were: (1) clinical variables such as age, sex, diabetes mellitus (dm), hypertension, chronic kidney disease (ckd) and smoking; (2) variables on lesions including the vascular diameter, the left anterior descending (lad) lesion, ostial lesion, chronic total occlusions (cto) lesion, bifurcation lesion, and (3) variables on the procedure, i.e. the type of stent, the length of stent and maximal balloon pressure. sample size was calculated based on formula of sample size for hypothetical study with different proportion and two independent populations. data analysis was performed using spss statistical analysis computer software. to analyze the correlation between independent and dependent variables, which both are categorical data, the chi-square statistical test was performed. the independent variables, which by bivariat analysis had p value <0.25 were included in multivariate analysis. to identify factors of independent variables associated with isr, a multivariate analysis was performed using double logistic regression test. to identify independent variables that had some effect on dependent variables, the effect was evaluated and expressed as odd ratio (or). our study had been approved by the ethical committee, faculty of medicine, university of indonesia. results there were 289 subjects including 133 subjects with (46%) and 156 subjects without (54%) isr (table 1). the incidence of isr in the use of bare-metal stent (bms) and drug-eluting stent (des) were respectively 61.3% and 40.7%. based on bivariate analysis, we found nine independent variables with p <0.25 including age, vol 47 • number 3 • july 2015 factors associated with in-stent restenosis in patients following pci 211 smoking, dm, hypertension, ckd, bifurcation lesion, type of stent, length of stent and vascular diameter. the independent variables with results of bivariate analysis of p <0.25 were included in the multivariate analysis (table 2). the results of multivariate analysis using double logistic regression test demonstrated that there were seven independent variables that had significant correlation with isr (table 3). discussion there was a greater number of male than female subjects. it is consistent with statistical report on heart disease and stroke in the united states in 2014, which demonstrated that there are more male subjects compared to female subjects.3 the time frame for follow-up angiography following the pci in our study, either using bms or des was 15 months, which was longer compared to other studies.13 however, sukhija et al14 also had long time frame for follow-up angiography in post-pci patients with dm, i.e. 16 months (±2 months).14 statistical report in 2014 found that there is higher utilization of des for pci procedures compared to the bms.3 our study also found that the use of des in pci procedure was more common than bms. statistical report in 2014 found that there is higher utilization of des for pci procedures compared to the bms.3 our study also found that the use of des in pci procedure was more common than bms. results of studies conducted by mohan and dall15 as well as bo et al16 showed that each study found lower incidence of isr following pci procedure when using des compared to using bms (7.7% vs. 33% and 23.2% vs. 48.8%, respectively). moreover, in post-pci patients who also had dm, sukhija et al14 found a high incidence of isr (62%). results of other studies also demonstrated the lower incidence of isr in post-pci patients when using des compared to bms.10-12 in our study, ther incidence of isr in post-pci patients using des was also found lower than those using bms (40.7% vs. 61.3%) (table 2). table 1. basic characteristics of the subjects (n=289) characteristics n (%) age (years), median (iqr) 61 (54; 67) age ≥60, n (%) 147 (50.9) sex male, n (%) 224 (77.5) clinical diagnosis during isr, n (%) aps 256 (88.6) uap 23 (8.0) nsteami 6 (2.1) steami 4 (1.4) time frame for follow-up angiography (months), median (iqr) 15 (11; 21) 6 to 12 114 (39.6) >12 to 24 120 (41.7) >24 54 (18.8) smoking, n (%) 166 (57.4) diabetes mellitus, n (%) 110 (38.1) hypertension, n (%) 215 (74.4) ckd, n (%) 93 (32.2) site of lesion, n (%) rca 83 (28.7) lcx 50 (17.3) lad 150 (51.9) lm 6 (2.1) ostial lesion, n (%) 25 (8.7) cto lesion, n (%) 18 (6.2) bifurcation lesion, n (%) 45 (15.6) stent type, n (%) bms 75 (26.0) des 214 (74.0) stent length (mm), median (iqr) 28 (18; 40.50) stent length, n (%) >40 72 (24.9) <40 217 (75.1) maximal balloon pressure (atm), median (iqr) 16 (12; 16) maximal balloon pressure, n (%) <14 80 (27.7) >14 209 (72.3) vascular diameter (mm), median (iqr) 2.99 (2.68; 3.49) vascular diameter, n (%) <3 147 (50.9) >3 142 (49.1) note: median (percentile 25; percentile 75) for data without normal distribution dedi wihanda acta med indones-indones j intern med 212 table 2. factors associated with in-stent restenosis variables with isr (n=133) without isr (n=156) p value or (95% ci) age ≥60, n (%) 59 (40.1) 88 (59.9) 0.054 0.62 (0.39 – 0.98) sex female, n (%) 27 (41.5) 38 (58.5) 0.495 0.79 (0.45 – 1.38) smoking, n (%) 88 (53.0) 78 (47) 0.008 1.96 (1.21 – 3.15) diabetes mellitus, n (%) 59 (53.6) 51 (46.4) 0.056 1.16 (1.01 – 2.65) hypertension, n (%) 106 (49.3) 109 (50.7) 0.076 1.69 (0.98 – 2.91) ckd, n (%) 36 (38.7) 57 (61.3) 0.112 0.65 (0.39 – 1.07) lad lesion, n (%) 65 (43.3) 85 (56.7) 0.404 0.80 (0.50 – 1.27) ostial lesion, n (%) 14 (56.0) 11 (44.0) 0.402 1.55 (0.68 – 3.54) cto lesion, n (%) 8 (44.4) 10 (55.6) 1.000 0.93 (0.36 – 2.44) bifurcation lesion, n (%) 28 (62.2) 17 (37.8) 0.027 2.18 (1.13 – 4.19) stent type, n (%) bms 46 (61.3) 29 (38.7) 0.003 2.32 (1.35 – 3.97) des 87 (40.7) 127 (59.3) stent length (mm), n (%) >40 46 (63.9) 26 (36.1) 0.001 2.64 (1.52 – 4.59) ≤40 87 (40.1) 130 (59.9) balloon pressure (atm), n (%) <14 40 (50.0) 40 (50.0) 0.479 1.25 (0.74 – 2.09) ≥14 93 (44.5) 116 (55.5) vascular diameter (mm), n (%) < 3 78 (53.1) 69 (46.9) 0.020 1.79 (1.12 – 2.86) ≥ 3 55 (38.7) 87 (61.3) table 3. multivariate analysis on factors associated with in-stent restenosis variables p or (95% ci) stent type 0.001 4.83 (2.51 – 9.30) stent length 0.001 3.71 (1.99 – 6.90) bifurcation lesion 0.019 2.43 (1.16 – 5.10) smoking 0.003 2.30 (1.33 – 3.99) vascular diameter 0.005 2.18 (1.27 – 3.73) hypertension 0.016 2.16 (1.16 – 4.04) dm 0.007 2.14 (1.23 – 3.70) one of possible reasons for the high isr incidence in our study is increased inflammatory response, which is consistent with the results of a study conducted by alwi17 who found high inflammatory response in patients with acute coronary syndrome/acs (dm with acs, dm with coronary heart disease/chd, nondm acs and non-dm chd) in indonesian population. the drug-eluting stent has grooves or ridges coated with polymers containing antiproliferation drugs against smc on vascular wall; therefore, the post-pci nih development can be reduced.18 mose et al19 and degertekin et al20 found low volume of nih in post-pci patients who used des compared to those using bms. in patients with steami who underwent pci, giglioli et al21 also found low isr incidence in des users compared to those who used bms. cassese et al22 and solinas et al23 also found low isr incidence in post-pci patients using des. furthermore, in dm patients who underwent pci, sukhija et al14 and boyden et al24 demonstrated low isr incidence when using des. likewise, our study also found that des utilization in postpci patients is a protective factor against the development of isr. in post-pci patients with des, hong et al25 found that stent length (>40 mm) as a predictor of isr development. cassese et al also found vol 47 • number 3 • july 2015 factors associated with in-stent restenosis in patients following pci 213 that each 10-mm increase of stent length is a predictor of isr development.22 furthermore, kang et al8 and kastrati et al13 found that stent length is a predictor of isr development in postpci patients with des. our study also found that stent length (>40 mm) is a predictor for developing isr. in post-pci patients with bms, park and park26 found bifurcation lesion as another predictor for developing isr; while in postpci patients with bms who had small vascular diameter, lijima et al27 also found that bifurcation lesion is a predictor of isr development. likewise, our study also found bifurcation lesion as a predictor for developing isr. in dm patients who underwent pci using des, hong et al28 found smoking as a predictor of isr development. moreover, in post-pci patients with bms, park and park26 also found smoking as a predictor for developing isr. our study also found that smoking is a predictor for isr development. the diameter of coronary blood vessel is associated with the incidence of isr.29 although there was no difference regarding maximal balloon pressures during pci procedure with bms between the group with small and large diameter, but akiyama et al30 found increased incidence of isr in the group with small diameter. similar results are also found by kastrati et al13 and casssese et al22 who found reduced vascular diameter of each 0.5 mm is a predictor for isr development. our study also found that the size of vascular diameter is a predictor for developing isr. back et al found that hypertension is an important factor for developing restenosis in patients following percutaneous transluminal coronary angioplasty.31 moreover, mohan and dhall15 found a significant correlation between hypertension and isr. our study also fond that hypertension is a predictive factor for developing isr. the results of serial ivus study by kornowski et al32 found that the number of narrowed minimal lumen diameter and nih growth in post-pci patients who also suffered from dm is higher than those without dm. a multi-analysis study about the correlation between dm and isr conducted by qing et al33 found that dm is a predictor for developing isr. the results of ivus study in post-pci patients using des conducted by rothera et al34 also found dm as a predictor of isr development. based on results of multivariate analysis in postpci patients with bms, park and park26 found that dm is a predictive factor for developing isr. by conducting a multi-analysis study, cassese et al22 found dm as a predictor of isr development, either using bms, first or second generation des. likewise, our study also found that dm is a predictor of isr development. our study has some limitations such as (1) it was an analytical retrospective and singlecentered study; 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2009;5:349-54. 52 acta med indones indones j intern med • vol 55 • number 1 • january 2023 original article the comparison of monocyte human leukocyte antigend-related (mhla-dr) expression levels between corona virus disease 2019 (covid-19) patients and healthy subjects musholli himmatun nabilah1,2, puspa wardhani3,4,5, aryati3,4, yetti hernaningsih3, bambang pujo semedi6 1laboratory medicine study interest, master program of basic medical science, faculty of medicine universitas airlangga, surabaya, indonesia. 2department of medical laboratory technology, health polytechnique, ministry of health republic indonesia, surabaya, indonesia. 3department of clinical pathology, faculty of medicine universitas airlangga dr. soetomo general academic teaching hospital, surabaya, indonesia. 4institute of tropical disease, universitas airlangga, surabaya, indonesia. 5postgraduate school of universitas airlangga, surabaya, indonesia. 6department of anesthesiology and reanimation, faculty of medicine universitas airlangga dr. soetomo general academic teaching hospital, surabaya, indonesia. *corresponding author: puspa wardhani, md. department of clinichal pathology, faculty of medicine universitas airlangga. jl. mayjen. prof. dr. moestopo no. 47, surabaya 60131, indonesia. email: puspa-w-2@fk.unair.ac.id. abstract background: sars-cov-2 can trigger a dysfunctional immune response in covid-19 patients and lead to immunosuppression. hla-dr molecule expressed on the surface of monocytes, known as mhla-dr, has been widely used as a reliable marker of immunosuppression. downregulation of mhla-dr reflects an immunosuppressed state. this study aimed to compare the expression level of mhla-dr between covid-19 patients and healthy subjects concerning immune system dysregulation that can be triggered by sars-cov-2 and lead to immunosuppression. methods: this was an analytic observational study with a cross-sectional design that measured the mhla-dr expression in edta blood samples from 34 covid-19 patients and 15 healthy subjects using the bd facslyrictm flow cytometry system. the mhla-dr examination results were expressed in ab/c (antibodies bound per cell) that were quantified using a standard curve constructed with quantibrite phycoerythrin beads (bd biosciences). results: expression of mhla-dr in covid-19 patients (n = 34) were 21,201 [2,646-92,384] ab/c, with 40,543.5 [9,797-92,384] ab/c mild cases (n = 22), 21,201 [9,831-31,930] ab/c moderate cases (n = 6), and 7,496 [2,646-13,674] ab/c severe to critical cases (n= 6). expression of mhla-dr in healthy subjects (n = 15) was 43,161 [25,147-89,846] ab/c. based on the mann-whitney u test, the mhla-dr expression in covid-19 patients significantly differed from the mhla-dr expression in healthy subjects (p = 0.010). conclusion: the level of mhla-dr expression in covid-19 patients was lower and significantly different from healthy subjects. moreover, immunosuppression could be indicated by the decrease of mhla-dr expression, which was below the reference range found in severe to critically ill covid-19 patients. keywords: covid-19, monocyte human leukocyte antigen-d-related (mhla-dr), immunosuppression. vol 55 • number 1 • january 2023 the comparison of monocyte human leukocyte antigen-d-related 53 introduction coronavirus disease (covid-19) is caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2). clinical manifestations in covid-19 patients range from asymptomatic, mild, moderate, and severe to critical symptoms.1 viral and host factors play a role in sars-cov-2 infection. the cytopathic effect of the virus and its ability to defeat immune response determine the severity of infection in covid-19 patients.2 several studies have shown that infection with sars-cov-2 could trigger immune dysregulation and immunosuppression that is associated with disease severity in covid-19 patients.3-5 some dysregulation of immune response in covid-19 patients can be triggered by excessive production of proinflammatory cytokines.3 excessive production of these proinflammatory cytokines lead to impaired antigen presentation by inhibiting hla-dr molecule expression.6 the hla-dr molecule is a transmembrane glycoprotein that plays a role in antigen presentation and t-cell activation.5 the stage of antigen presentation to lymphocytes is critical for activating an adaptive immune response and a sustained immune response to clear pathogens.7 zmijewski & pittet (2020) mentioned that hla-dr was a class ii human leukocyte antigen (hla) expressed on the surface of antigen-presenting cells (apcs), such as monocytes, differentiated macrophages, dendritic cells, and b lymphocyte cells.8 the mhla-dr is an hla-dr expressed on the surface of monocytes. monocytes derived from myeloid bone marrow precursors are considered as the key immune cell that takes part in the infection. furthermore, it is a firstline cellular response that initiates and promotes an adaptive immune response.9 the mhladr expressed on cd14+ monocytes plays an important role in synapsing innate immunity with adaptive immunity in infectious diseases.10 downregulation of mhla-dr expression on cd14+ monocytes represents a state of immunosuppression, also refers to an injuryassociated immunosuppression.9 as in the sepsis case, the expression of hla-dr in monocytes is expected to be a reliable marker for evaluating immune dysfunction in covid-19 patients.11,9 recent studies confirmed that immune dysregulation and immunosuppression in covid-19 patients with respiratory failure were associated significantly with downregulation of mhla-dr.3 m o n i t o r i n g i m m u n e d y s f u n c t i o n i n covid-19 patients is still not a complete concern because it is generally not monitored in clinical routines during patient care, especially in indonesia. understanding the role of immune cells (mhla-dr) in the various clinical symptoms of covid-19 is critical to develop the effective treatment strategies. accordingly, data regarding the measurement of mhla-dr expression in covid-19 in indonesia needs to be made available. studies on the measurement of mhladr expression in the covid-19 population in indonesia and healthy subjects as a comparison have never been carried out until now. from measurements in healthy subjects, normal values of mhla-dr expression can be obtained in the population of indonesia. this study uses the ab/c (antibodies bound per cell) unit of measurement as the result of mhla-dr expression using the flow cytometry method, in which ab/c describes the quantitative amount of the targeted molecule through its binding to specific fluorescently labeled antibodies.13 the unit is different from the mfi (mean fluorescent intensity) which is often used in the measurement results of flow cytometry method, which can only describe the fluorescence intensity of the targeted cell or molecule. this study aimed to analyze the level of mhla-dr expression in covid-19 patients concerning the incidence of immunosuppression by comparing the mhla-dr expression in covid-19 patients with healthy subjects. methods study design, participant, and data collection this cross-sectional study analyzed the differences of mhla-dr expression in covid-19 patients and healthy subjects. this study was conducted from june to september 2022 at dr. soetomo general hospital, surabaya, indonesia. inclusion criteria included covid-19 patients (aged >18 years), confirmed by nucleic acid amplification test (naat) from nasopharyngeal swab specimens using real-time pcr (rt-pcr) musholli himmatun nabilah acta med indones-indones j intern med 54 and was hospitalized, also healthy subjects (not having an acute illness or comorbidities) aged >18 years who have been confirmed negative through a rapid diagnostic test for sars-cov-2 antigen. we excluded covid-19 patients who receive immunosuppressive drugs, human immunodeficiency virus (hiv) patients or other diseases related to immune system disorders, patients with bacterial sepsis, or critical patients who were not accompanied by covid-19 pneumonia with ards despite showing positive pcr results. the hematology laboratory examination of the research subjects was evaluated on the blood specimens collected simultaneously for measurement of mhla-dr expression. ethics this study received approval from the health research ethics committee of dr. soetomo general academic teaching hospital, surabaya, indonesia (reference no. 0382/kepk/iii/2022, on march 8, 2022). sample size and sampling technique the method used in collecting samples in this study was consecutive sampling. the sample estimate was calculated using the “compare two means” formula, with α = 0.05, β = 0.2, and ratio groups 1 and 2 (r) = 1. the minimum number of samples required for each group was 13. the procedure of mhla-dr measurement with flow cytometry the instrument used for measuring mhladr was the bd facslyric™ flow cytometry. the reagents needed in this measurement were bd quantibritetm hla-dr pe/monocyte percp-cy5.5 (catalog numb: 340827), bd antihuman cd45 fitc (catalog numb: 347463), bd quantibritetm beads pe (catalog numb: 340495), bd facs lysing solution (catalog numb: 349202), and bd facsflowtm (catalog numb: 342003). the compensation was done before acquiring the samples using bd cs&t beads (lot id: 2031932). the instrument acquisition was set at 10.000 events at high speed. sample preparation we collected blood samples from covid-19 patients and healthy subjects with 3 ml volume in edta tubes. the blood was stored at 4-8 0c and immediately processed within 4 hours of withdrawal.12 before measuring with flow cytometry, whole blood edta (50 µl) was added into a falcon test tube, then stained with the addition of bd quantibrite hla-dr pe/monocyte percp-cy5.5 (20 µl) and antihuman cd45 fitc (20 µl). the mixtures were incubated in a dark chamber at room temperature for 25 minutes. the sample was lysed with the addition of bd facs lysing solution (450 µl), homogenized by vortex, and incubated at room temperature in a dark chamber for 10 minutes. next, centrifugation at 500 g (0.5 rcf) for 5 minutes after the incubation process was completed before discarding the supernatant. it was then rinsed with 1 ml bd facsflowtm, homogenized with a vortex and centrifugation again at 500 g (0.5 rcf). after centrifugation, the supernatant was discarded, and bd facsflowtm (400 µl) was added, which then was homogenized with a vortex. the sample was ready to run on bdfacslyric™ flow cytometry. beads pe measurement to calculate ab/c the number of antibodies bound per cell (ab/c) was quantified by calibration with a standard curve, determined with bd quantibritetm beads pe (phycoerythrin). one tube of bd quantibritetm beads pe was removed from the foil punch just before they were used. then it was reconstituted with 0.5 ml bd facsflowtm, homogenized with vortex, and run on bd facslyric™ flow cytometry. each bd quantibritetm beads pe tube contained lyophilized pelletized beads conjugated with four phycoerythrin (pe) grades. standard curves and linear regression equations were made from log10 of pe molecules per bead (low, medlow, medhigh, and high) from insert kit (x) against log10 of pe geo means of 4 populations of pe beads results from running with flow cytometry (y).13 mhla-dr expression measurement the same instrument was used to measure mhla-dr in the prepared sample. monocytes were first gated out from other leukocytes expressing cd45 (detected with bd anti-human cd45 fitc) based on their cd14 expression (detected with anti-cd14 conjugated with percp-cy5.5 in bd quantibritetm hla-dr vol 55 • number 1 • january 2023 the comparison of monocyte human leukocyte antigen-d-related 55 pe/monocyte percp-cy5.5, anti-cd14 percpcy5.5 could detect all monocytes [cd14 brightly positive and weakly positive]). the mhladr expression was then measured on their surface (detected by anti-hla-dr conjugated with pe (phycoerythrin) in bd quantibrite hla-dr pe/monocyte percp-cy5.5) as the median fluorescence intensity (mfi) which was associated with the entire population of monocytes.12,14,15 a linear regression line equation was used to quantify ab/c (figure 1). log10 of geo means of the sample measurement results were entered in the linear regression line equation as the “y” value. the equation was solved to find the “x” value as log ab/c, and then the antilog of “x” was determined to get the number of ab/c.13 the normal values of mhladr expression were >15,000 ab/c.12 statistical methods the data obtained in this study were presented in tables and graphs. data were analyzed by univariate and bivariate analysis using spss software (ibm statistical package for social sciences, version 26.0, chicago, illinois). in bivariate analysis, the data obtained were tested for normality with the shapirowilk test, and then tested for homogeneity with lavene’s test. we used independent t-test to find out whether there was a difference in the data on covid-19 patients with the healthy group, if the data were normally distributed. in contrast, the mannwhitney u was used if the data were not normally distributed. in categorical data, the chi-square test was used to see whether there were differences between groups. we considered difference between groups to be statistically significant if p value < 0.05. we presented normally distributed data in the form of mean ± sd, whereas skewed data were described with median and range as a median with the minimum-maximum value (median [min-max]). results characteristics and laboratory data of research subject this study involved 49 subjects consisting of 34 covid-19 patients and 15 healthy subjects. the characteristics and laboratory data of covid-19 patients and healthy subjects are presented in table 1. table 1. characteristics and laboratory data of research subjects. characteristics research subjects p-valuecovid-19 healthy n 34 15 gender n (%) male 20 (58.8) 8 (53.34) 0.633a female 16 (41.2) 7 (46.66) age (years) n (%) 18-30 2 (5.89) 6 (40) <0.001*b 31-40 2 (5.89) 3 (20) 41-50 4 (11.76) 4 (26.67) 51-60 8 (23.53) 2 (13.33) 61-70 7 (20.59) 71-80 5 (14.70) >80 6 (17.64) mean + sd 62.12 + 18.35 36.67 + 9.75 conditions n (%) with comorbidities 25 (73.53) <0.001*a diabetes 9 (26.47) hypertension 7 (20.58) kidney disease 9 (26.47) pulmonary disease 5 (14.7) malignancy 6 (17.64) without comorbidities 9 (26.47) 15 (100%) laboratory data (median [min-max]) total leukocyte counts (103/ul)# 9.02 [3.39-26.05] 7.89 [5.4-14.1] 0.288c monocytes (%)# 7.4 [1.3-15.3] 6.1 [4-12] 0.079c lymphocytes (%)# 12.95 [1.2-65] 28.3 [9-43] <0.001*c neutrophils (%)# 71.1 [4.8-89.4] 60 [48-82] 0.008*c notes: the results were expressed in mean ± sd, median [min-max], or n (%). data analysis using chi-square test (a), independent t-test (b), and mann-whitney u test (c). significant pvalue <0.05. data is significantly different*. reference values of total leukocytes: 3.37 – 10.0#; monocytes: 4.3 – 10.10#; lymphocytes: 23.1 – 49.9#; and neutrophils: 39.80 – 70.50#. musholli himmatun nabilah acta med indones-indones j intern med 56 the results of mhla-dr expression measurement with flow cytometry based on the normality test using the shapiro-wilk test, the data obtained from the mhla-dr expression in the two study groups were not normally distributed. hence, the data were presented as median [min-max] and p-value was obtained using mann whitney u. covid19 patients as the subject of this research consisted of 22 people with mild clinical manifestations (64.7%), six people with moderate clinical manifestations (17.65%), and six people with severeclinical manifestations (17.65%). in this study, the mhla-dr expression in covid-19 patients was 21,201 [2,646-92,384] ab/c, mild clinical manifestations were 40,543.5 [9,79792,384] ab/c, moderate clinical manifestations were 21,201 [9,831-3,930] ab/c, and severecritical clinical manifestations were 7,496 [2,646-13,674] ab/c. healthy subjects in this study consisted of 15 people with 43,161 [25,147-89,846] ab/c mhla-dr expression. expression of mhladr in covid-19 patients was lower and significantly different from the healthy subjects (p = 0.010) (figure 2). the gating strategy of facslyrictm flow cytometry in measuring the mhla dr expression of covid-19 patients with mild, moderate, and severe-critical clinical manifestations, also healthy subjects, can be seen in figure 3. table 2. the results of log pe molecule/beads on bd quantibritetm beads pe insert kit (catalog numb: 340495) and pe geometric means of four populations of pe beads runned by flow cytometry. no beads population log pe/beads (x) log pe geo means (y) 1 low 2.675778342 2.681241237 2 med-low 3.729083757 3.726156466 3 med-high 4.377360899 4.362199639 4 high 4.794738931 4.801328234 6 figure 1. standard curve and linear regression equation of log pe/beads against log pe geo means figure 2. differences in mhla-dr expression between the covid-19 group and thehealthy group vol 55 • number 1 • january 2023 the comparison of monocyte human leukocyte antigen-d-related 57 discussion in this study, the results of measuring the expressions of mhla-dr in covid-19 patients and the healthy groups showed a significant difference (p = 0.010), in which the expression of mhla-dr in covid-19 patients (21,201 [2,646-92,384] ab/c) were lower than in the healthy groups (43,161 [25,147-89,846] ab/c). this was in line with another study by bonnet et al. (2021) which stated that the hla-dr expressed in monocytes was significantly lower in the group of covid-19 patients, in which the mild case (21,566 ab/c) and severe case (5,926 ab/c) were lower than the healthy subjects (44,544 ab/c)12. the expression of mhladr in covid-19 patients in this study, whose most proportion was the mild case (64.7%), was still at the reference values (>15,000 ab/c). it indicated that the overall mean of immune response in covid-19 patients was normal and did not lead figure 3. gating strategy in facslyrictm flow cytometry on the analysis of mhla-dr expression of covid-19 patients with mild, moderate, severe-critical clinical manifestation, and healthy subjects. beads were gated based on their ssc and fsc characteristics, and pe fluorescence was plotted (a). scatter graph of ssc and fsc (b). patients’ leukocytes were gated based on their binding to cd45 fitc-a and the characteristics of ssc and fsc on the scatter graph of ssc to cd45 (c). the patient’s monocytes were gated based on their binding to cd14 percp-cy5.5-a and the characteristics of ssc and fsc on the scatter graph of ssc against cd14 (d). the mhla-dr expression was calculated based on the fluorescence of antihla-dr pe on monocytes (e). cd45 indicates a cluster of differentiation 45; cd14 indicates a cluster of differentiation 14; pe, phycoerythrin; covid-19, coronavirus disease 2019; fsc, forward scatter; ssc, side scatter; hla-dr, human leukocyte antigen-dr; mhladr, monocyte human leukocyte antigen-dr. musholli himmatun nabilah acta med indones-indones j intern med 58 to low mhla-dr expressions in association with immunosuppression. the low expression of mhla-dr in covid-19 patients compared to healthy groups could be due to the release of various proinflammatory cytokines, some of which could trigger the low expression of hladr molecules on monocytes through various signal transduction mechanisms.3,6 viral load could influence the immune response, including the number of proinflammatory cytokines released. on the other hand, although the difference could not be seen statistically due to the proportion of the number between groups that did not meet the statistical requirements, the expressions of mhla-dr in covid-19 patients with the severe-critical case were lower than in the moderate case. the expressions of mhladr in covid-19 patients with mild cases were lower than in the healthy groups. expressions of mhla-dr in patients with severe-critical clinical manifestation showed the results below the reference values (7,496 [2,646-13,674] ab/c). this was in line with other studies by spinetti et al. (2020), which stated that the mhladr (ab/c) expression of covid-19 patients treated in the icu (severe to the critically ill patients) was significantly lower and below the reference values (9,280 ab/c), compared to covid-19 patients that were not treated in the icu (30,900 ab/c).9 the expression of mhla dr which was below the reference values indicated a dysfunctional immune response and led to an immunosuppressed state.9 sars-cov-2 infection, in addition to activating the immune response against the virus, could also cause immune system disorders in severe cases, such as hyperinflammation characterized by excessive release of proinflammatory cytokines resulting in a cytokine storm.16 one factor that triggered hyperinflammation in covid-19 patients was the excessive release of the proinflammatory cytokine il-6.17 this excessive release of il-6 could further trigger the low expression of mhladr through signal transduction mechanisms in the stat3 (signal transducer and activator of transcription 3) signaling pathway.3,12 another study conducted by giamarellos-bourboulis et al. (2020) reported that high levels of il-6 were negatively correlated with the levels of mhladr expression in circulating cd14 monocytes.3 neutralizing il-6 via tocilizumab, which could restore hla-dr expression in monocytes, also supported this hypothesis.3 decreased expression of mhla-dr in cd14 monocytes indicated a decrease in antigen presentation capacity that caused impaired activation of cd4+ t cells.5 decreased expression of hla-dr led to increased surface expression of negative co-stimulator molecules such asprogrammed death 1 (pd-1), cytotoxic t-lymphocyte antigen 4 (ctla-4), and b-and tlymphocyte attenuator (btla), and their corresponding ligands, such as pd-1 ligand (pd-l1).8 increased surface expression of these negative co-stimulator molecules could disrupt innate and adaptive immune responses, such as impaired activation and induction of apoptosis in cd4 t cells that led to immune system dysregulation. moreover, the presence or absence of immune system dysregulation in patients with covid-19 also affected or related to the degree of disease severity.8 lymphopenia also occurred along with sars-cov-2 infection.18 decreased expression of mhla-dr and lymphopenia are some indications of immunosuppressed status.19 in this study, the results of lymphocyte measurements in covid-19 patients showed a lymphopenia state and a significant difference with healthy subjects (p = 0.002). lymphopenia in covid-19 could be caused by several mechanisms, including increased levels of proinflammatory cytokines, which could cause a reduction in the lymphocyte population as the disease progresses16. sars-cov-2 could directly infect t lymphocyte cells through the ace2 receptor, which was also expressed in t lymphocyte cells16. a damage to lymphatic organs by sars-cov-2 infection and an increase in lactic acid, especially in severe degrees, could also inhibit lymphocyte proliferation.16 conclusion the expression levels of mhla-dr in covid-19 patients were lower and showed a significant difference compared to the healthy groups. although a significant difference could not be seen due to the limitation of subjects in this vol 55 • number 1 • january 2023 the comparison of monocyte human leukocyte antigen-d-related 59 study, immunosuppression could be indicated by the decrease in mhla-dr expression below the reference value in severe to critical covid-19 patients. the limitation of this study was that the clinical degrees of the covid-19 patients involved were not proportionally (according to the number of statistics) collected due to limited samples collected. it was because the samples were collected when covid-19 cases were declining in indonesia. in future research, to see statistical differences in mhla-dr expression between clinical manifestation groups in covid-19 and the relationship between mhla-dr expression and disease severity in covid-19, it is suggested to group the covid-19 samples based on their clinical manifestations according to statistical requirements. acknowledgments we want to thank dr. soetomo general academic teaching hospital, surabaya, indonesia, for the opportunity and funding given to this research. we also thank mrs. atika, who helped analyze this study’s statistics. conflict of interest the authors ensure that there is no conflict of interest in this study. funding the authors received research funding from dr. soetomo general academic teaching hospital, surabaya, indonesia. references 1. who. 2022. covid-19: symptoms and severity. world health organization western pacific. the last update was on april 18, 2022. 2. qin c, zhou l, hu z, et al. dysregulation of immune response in patients with covid-19 in wuhan, china. clin infect dis. 2020;71(15):13-4. 3. giamarellos-bourboulis evangelos j, netea mg, rovina n, et al. complex immune dysregulation in covid-19 patients with severe respiratory failure. cell host microbe. 2020;27(6):992-1000. 4. c e r v a n t e s , l e t i c i a k u r i , p a m p e n a m , e t al. comprehensive mapping of immune perturbations a s s o c i a t e d w i t h s e v e r e c o v i d 1 9 . s c i e n c e immunology. 2020;15;5(49):4-5. 5. peruzzi, benedetta, bencini s, et al. quantitative and qualitative alterations of circulating myeloid cells and plasmacytoid dc in sars-cov-2 infection. british society for immunology. 2020;161(4):1-8. 6. ohno y, kitamura h, takahashi n, et al. il-6 downregulates hla class ii expression and il-12 production of human dendritic cells to impair activation of antigenspecific cd4(+) t cells. cancer immunol. 2016;65(2):193-204. 7. lukaszewicz, anne-claire, grienary, et al. monocytic hla-dr expression in intensive care patients: interest for prognosis and secondary infection prediction. crit care med. 2009;37 (10): 2746-2747. 8. zmijewski, jaroslaw w, pittet, jean-francois. human leukocyte antigen-dr deficiency and immunosuppression-related end-organ failure in severe acute respiratory syndrome coronavirus 2 infection. international anesthesia research. 2020; 131(4):989-92. 9. thibaud s, cedric h, michaela f, et al. reduced monocytic human leukocyte antigen-dr expression indicates immunosuppression in critically ill covid-19 patients. critical care and resuscitation. 2020;131(4):994-8. 10. steffen d, clemens g, katharina a, et al. case report: interferon-γ restores monocytic human leukocyte antigen receptor (mhla-dr) in severe covid-19 with acquired immunosuppression syndrome. frontiers in immunology. 2021;12:1-2. 11. pfortmueller, andrea c, christian m, michaela f, schefold, joerg c. assessment of immune organ dysfunction in critical illness: utility of innate immune response markers. intensive care med exp. 2017;5(49):1-16. 12. benjamin b, justine c, claire d, et al. severe covid-19 is characterized by the co-occurrence of moderate cytokine inflammation and severe monocyte dysregulation. ebiomedicine. 2021;73(103622):1-13. 13. bd biosciences. 2014. bd quantibrite™ beads pe fluorescence quantitation kit. san jose, ca 95131 usa. 14. bd biosciences. 2014. bd quantibrite™ anti–hladr/anti-monocyte kit. san jose, ca 95131 usa. 15. julie d, alexandre w, marie-christine j, et al. interlaboratory assessment of flow cytometric monocyte hla-dr expression in clinical samples. clinical cytometry. 2012;84(1):1-4. 16. yang l, liu s, liu j, et al. covid-19: immunopathogenesis and immunotherapeutics. 2020. 17. signal transduction and targeted therapy. 5:128. 18. sutadji, christianto j, widodo, wahyu ad, indiastuti, danti nur. mortality comparison of using anti interleukin-6 therapy and using standard treatment in severe covid-19. folia medica indonesiana. 2021; 57(2). 19. munawaroh f, agustina tb, hartono k, et al. characteristics of natural killer (nk) cell and t lymphocyte in covid-19 patients in surabaya, musholli himmatun nabilah acta med indones-indones j intern med 60 indonesia. research j.pharm and tech. 2022;15(5). 20. ihsane b, fabienne v, rémy c, morgane g, guillaume m. monocyte hla-dr measurement by flow cytometry in covid-19 patients: an interim review. journal of quantitative cell science. 2020;97a: 1217–21. medical illustration disseminated histoplasmosis in an indonesian hiv-positive patient: a case diagnosed by fine needle aspiration cytology nungki anggorowati1, rita c. sulistyaningsih1, ahmad ghozali1, yanri w. subronto2 1 department of anatomical pathology, universitas gadjah mada sardjito hospital, yogyakarta special province, indonesia 2 department of internal medicine, universitas gadjah mada sardjito hospital, yogyakarta special province, indonesia corresponding author: nungki anggorowati, md, ph.d. department of anatomical pathology, universitas gadjah mada. jalan farmako, sekip utara, yogyakarta 55281, indonesia. email: nungki@ugm.ac.id. figure 1. cervical node enlargement figure 2. normal chest radiography macrophage’s nucleus eccentric chromatin clear halo figure 3. histiocytes showing intra and extra cytoplasmic h. capsulatum’s yeasts (giemsa x1000) 360 acta med indones indones j intern med • vol 49 • number 4 • october 2017 vol 49 • number 4 • october 2017 disseminated histoplasmosis in an indonesian hiv positive patient a 30-year-old javanese-indonesian man was admitted with complaints of 3 months persistent fever, weight loss, and fatigue. he had never known his past history of unprotected hiv until the admission. his only risk factor is unsafe sex. the patient seemed well nourished. physical examination revealed blood pressure 100/60 mmhg, pulse 100 beats per minute, respiratory rate 20 times per minute, and temperature 3 8 . 8 ° c . m u l t i p l e c e r v i c a l a n d i n g u i n a l lymphadenopathies were also found (figure 1). electrocardiogram showed anterolateral ischemic finding, whereas chest x-ray were normal (figure 2). laboratory test results revealed pancytopenia with hemoglobin of 8.2 g/dl, leucocyte count 2000 cells/mm3, platelet 78000 cells/mm3, hematocrit 25.8%, ast 162 iu/l, alt 81 iu/l, decreased albumin of 2.72 g/dl. the clinical differential diagnosis were lymphoma or tuberculosis lymphadenopathy. fine needle aspirations of a left cervical lymph node were accomplished. microscopic morphology stained with giemsa exposed the presence of oval and round yeast-like organisms with eccentric chromatin and clear halo inside and outside histiocytes, consistent with the morphology of histoplasma capsulatum (figure 3). examination using acid fast bacilli staining (ziehl nielsen) presented negative result. the patient passed away just after all of these examinations were done. the terrestrial boundaries of the occurrence of infectious diseases are now distorted because of economic development and migration of the people across the nation. the extensive usage of chemotherapy and steroids, the implementation of organ transplants, and the pandemic of aids have released the unfamiliar infectious agents causing morbidity around the world.1 the cytopathologist usually is the first diagnostician to find the cause of an infectious agent. thus, it is important that the cytopathologist to be familiar with the morphology of the infectious agents and its cellular or tissue reaction. in some points the division between pathology and microbiology is very unclear due to the growth of the science. moreover, currently the number of pathologist who has trained with adequate knowledge of microbes is scarce.1 furthermore, in our opinion safe laboratory facilities for cytopathology is better to be established to cover the possible increase of infectious disease that need a diagnostic action. the finding of histoplasma capsulatum (hc) in the present case report of an aids patients by fine needle aspiration cytology (fnac) might indicate the increase infections caused by this pathogenic fungus. patients with immunocompromized condition, especially those with advanced hiv infection, have the greatest risk for severing fatal disseminated histoplasmosis (dh).2-5 histoplasmosis cases in hiv/aids patients are usually underestimated in the tropical countries such as indonesia due to any other tropical endemic infectious diseases such as malaria, tuberculosis or other disease such as lymphoma. furthermore, the health facilities deficiency and low financial situations pushes patients to treat themselves for example in case of fever. underestimation of dh and aids cases at the terminal stage will suspend the effectiveness of the system to fight against this emerging infectious disease.6 the patient in the current study was admitted to the hospital because of fever, weight loss, multiple lymphadenopathies (figure 1) and fatigue, resembling the symptoms of tuberculosis. the pancytopenia that occurred might explain whenever there is bone marrow involvement. the abnormality of liver enzyme might elucidate the involvement of the liver. the hc was found by fna from the cervical lymphadenopathy specimen. the normal chest x-ray (figure 2) might rule out the pulmonary participation. thus, this patient was suffering from disseminated histoplasmosis. histoplasma capsulatum (hc) performs as intracytoplasmic small round or oval bodies with the diameter 1-4 μm, surrounded by recognizable clear halo with a central or eccentric stained chromatin. fna, bronchial aspirates, bone marrow biopsy, or peripheral blood smear specimens stained with giemsa, may grunwald giemsa (mgg), wright, periodic acid of schiff (pas), or gomori methenamine silver are the simplest, rapid, inexpensive but relatively effective for the diagnosis although 361 nungki anggorowati acta med indones-indones j intern med the sensitivity is less than 50%.1,2 however, microbiological culture for fungal organisms is recommended to precisely detect the organism.7 in summary, dh should be considered as one of the diagnosis in patients with persistent fever, weight loss and immunodeficiency syndrome due to hiv or others. fine needle aspiration is an inexpensive method helpful to diagnose dh, despite its low sensitivity. to avoid delay of diagnosis, a more sensitive, specific, and effective method is needed. furthermore, a safe and well-equipped laboratory should be established to face this emerging infectious disease in indonesia. references 1. satyanarayana s, kalghatgi at. utility of fine needle aspiration cytology in the diagnosis of infective lesions. diagn histopathol. 2011;17:301-12. 2 doughan a. disseminated histoplasmosis: case report and brief review. travel med infect dis. 2006;4:332-5. 3. kauffman ca. histoplasmosis: a clinical and laboratory update. clin microbiol rev. 2007;20:11532. 4. subbalaxmi mv, umabala p, paul r, chandra n, raju ys, rudramurthy sm. a rare presentation of progressive disseminated histoplasmosis in an immunocompetent patient from a non-endemic region. med mycol case rep. 2013;2:103-7. 5. jeong hw, sohn jw, kim mj, et al. disseminated histoplasmosis and tuberculosis in a patient with hiv infection. yonsei med j. 2007;48:531-4. 6. ebenye cm. a case of disseminated histoplasmosis detected in peripheral blood smear staining revealing aids at terminal phase in a female patient from cameroon. case rep med. 2012;2012:215207. 7. aide ma. chapter 4--histoplasmosis. j bras pneumol. 2009;35:1145-51. 362 299 original article acta med indones indones j intern med • vol 49 • number 4 • october 2017 the differences in serum quantitative specific ige levels induced by dermatophagoides pteronyssinus, d e r m a t o p h a g o i d e s f a r i n a e a n d b l o m i a t r o p i c a l i s sensitization in intermittent and persistent allergic asthma agus j. susanto1, iris rengganis2, cleopas m. rumende2, kuntjoro harimurti2,3 1 department of internal medicine, faculty of medicine, university of sebelas maret dr. moewardi hospital, surakarta, indonesia. 2 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 3 clinical epidemiology and evidence-based medicine unit, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: iris rengganis, md., phd. division of allergy and clinical immunology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. salemba raya no. 4, jakarta 10430, indonesia. email: irisrengganis@yahoo.com. abstrak latar belakang: tungau debu rumah (tdr) merupakan alergen hirup yang penting pada asma alergik. namun, penelitian diagnostik molekuler menggunakan imunoglobulin e (ige) spesifik akibat sensitisasi alergen tdr dihubungkan dengan derajat keparahan asma alergik belum pernah dilakukan di indonesia. penelitian ini bertujuan mengetahui perbedaan kadar ige spesifik serum kuantitatif akibat sensitisasi alergen dermatophagoides (d.) pteronyssinus, d. farinae dan blomia (b.) tropicalis pada asma alergik intermiten dan persisten. metode: desain penelitian potong lintang pada pasien asma alergik dewasa yang diundang untuk pemeriksaan ige spesifik serum dan merupakan bagian dari penelitian payung di divisi alergi dan imunologi klinik, rs cipto mangunkusumo. derajat keparahan asma ditentukan berdasarkan kriteria global initiative on asthma (gina) 2015 dan dikelompokkan menjadi intermiten dan persisten. pemeriksaan ige spesifik serum kuantitatif menggunakan metode multiple allergosorbent test (polycheck allergy, biocheck gmbh, munster, germany). alergen tdr yang diperiksa adalah d. pteronyssinus, d. farinae, dan b. tropicalis. perbedaan antara dua kelompok dianalisis dengan uji mann-whitney. hasil: sebanyak 87 subyek dilibatkan dalam penelitian ini; 69 (79,3%) subyek adalah perempuan. rerata usia pasien adalah 40,2 tahun. enam puluh tiga (72,4%) pasien menderita asma dan rinitis alergik. sebanyak 58 (66,7%) pasien asma persisten. gambaran sensitisasi alergen tdr adalah 62,1% d. farinae; 51,7% d. pteronyssinus dan 48,3% b.tropicalis. median kadar ige spesifik secara bermakna lebih tinggi pada asma persisten dibandingkan asma intermiten untuk alergen d. farinae (1,30 vs. 0,0 ku/l; p=0,024) dan b. tropicalis (0,57 vs. 0,0 ku/l; p=0,015). kadar ige spesifik d. pteronyssinus lebih tinggi pada asma persisten dibandingkan intermiten (0,67 vs. 0,00 ku/l; p=0,066). kesimpulan: gambaran sensitisasi alergen secara berurutan didapatkan d. farinae 62,1%, d. pteronyssinus 51,7% dan b. tropicalis 48,3%. kadar ige spesifik akibat sensitisasi d. farinae dan b. tropicalis lebih tinggi secara bermakna pada pasien asma persisten dibandingkan asma intermiten. kadar ige spesifik akibat sensitisasi d. pteronyssinus lebih tinggi pada pasien asma persisten dibandingkan asma intermiten, tetapi secara statistik tidak bermakna. kata kunci: asma alergik, asma intermiten dan persisten, ige spesifik, sensitisasi alergen, tungau debu rumah. agus j. susanto acta med indones-indones j intern med 300 introduction worldwide prevalence of allergic asthma is projected to increase in the near future. by 2025, an estimated 400 million people will suffer from allergic asthma and nearly 500 million people will suffer from allergic rhinitis.1 allergic asthma is a type of asthma mediated by immunologic mechanisms. the immunoglobulin e (ige) is often associated with allergic asthma symptoms. based on the symptoms and severity of airway obstruction, asthma is classified into two major groups, intermittent and persistent asthma.2 there are hundreds of different allergens that can cause clinical symptoms of asthma and it is hard to identify which allergen has the most potential to cause clinical symptoms of asthma.3 for this reason, molecular diagnosis of allergic diseases is developed to help us understand the sensitization of a specific allergen by using ige levels measurement. using the allergen-specific ige, we have a stronger basis to establish allergic asthma diagnosis, which is the second largest phenotype of asthma. this procedure has been recommended in the guidelines on respiratory allergy disease management.4 there are three methods of the allergen-specific ige test: the qualitative method, which result is presented in a positive/negative form, the semiquantitative method which result is presented in a unit/class form (class 0–6), and the quantitative method which result is presented in a kku/l form which also serves as a standard reference recognized by who. quantitative detection of allergen-specific ige is important in allergy diagnosis.5 the study about serum quantitative specific ige levels and its correlation with allergic asthma is still lacking, there are only two known studies on the subject with different allergen profile. house dust mite (hdm) is the most common type of allergen causing asthma in china6, while cat and dog dander is the most common type of allergen causing asthma in sweden.7 in tropical countries, hdm exposure is the most important factor in the development abstract background: house dust mites (hdm) are an important inhalant allergen in allergic asthma. however, molecular diagnostic study of specific ige to hdm allergens has not been done in indonesia. in addition, the association of quantitative specific ige measurement with asthma severity has not been investigatedd. this study aimed to investigate the difference of serum quantitative specific ige levels induced by dermatophagoides (d.) pteronyssinus, d. farinae and blomia tropicalis sensitization in intermittent and persistent allergic asthma. methods: this was a cross-sectional study on adult allergic asthma patients who were invited for serum specific ige testing. this study was a part of a larger study within the division of allergy and immunology, cipto mangunkusumo hospital. asthma severity was defined based on global initiative on asthma (gina) 2015 criteria and were grouped as intermittent or persistent. quantitative specific ige testing was done on blood serum using a multiple allergosorbent test (polycheck allergy, biocheck gmbh, munster, germany). the hdm allergens tested were d. pteronyssinus, d. farinae, and blomia tropicalis. difference between two groups were analyze using mann-whitney test. results: a total of 87 subjects were enrolled in this study; 69 (79.3%) were women. mean patients’ age was 40, 2 years. sixty-three (72.4%) subjects had asthma and allergic rhinitis. fifty-eight (66.7%) subjects were classified as persistent asthma. the prevalence of sensitization was 62.1% for d. farinae, 51.7% for d. pteronyssinus, and 48.3% for blomia tropicalis. the median of specific ige levels were significantly higher in persistent asthma compares to intermittent asthma induced by d. farinae (median 1.30 vs. 0.0 ku/l; p=0.024) and b. tropicalis (median 0.57 vs. 0.0 ku/l; p=0.015) sensitization. level of specific ige d. pteronyssinus was also to be higher in persistent asthma than the level measured in intermittent asthma (0.67 vs. 0.00 ku/l; p=0.066). conclusion: sensitization of hdm allergens was shown to be highest for d. farinae 62.1%, followed by d. pteronyssinus 51.7% and blomia tropicalis 48.3%. specific ige level induced by d. farinae and blomia tropicalis sensitization were significantly higher in patients with persistent asthma compared to intermittent asthma, whereas specific ige level induced by d. pteronyssinus sensitization was higher in persistent asthma although not statistically significant. key words: allergic asthma intermittent and persistent, specific ige, allergen sensitization, house dust mites. vol 49 • number 4 • october 2017 the differences in serum quantitative specific ige levels 301 of allergy diseases, especially respiratory allergy. among all type of house dust mites, d. pteronyssinus, d. farinae and blomia tropicalis are the main sources of hdm allergens in tropical countries.8 in jakarta, hdm is the most important indoor allergen that can cause allergic reaction, including allergic asthma.9 the study on quantitative serum specific ige levels induced by d. pteronyssinus, d. farinae, and blomia tropicalis associated with allergic asthma in indonesia has never been published until this study is conducted. besides that, the hdm allergen profile in indonesia is still unknown, as well as its application in determining the severity of allergic asthma. considering the limitation of in vivo study using skin prick test and the difficulty of finding the allergen used in skin prick test, an in vitro study using quantitative measurement of specific ige levels is needed. this in vitro study is very sensitive in measuring the ige levels, compared to skin prick test.10 methods this was a cross-sectional study on adult allergic asthma patients who were invited for serum specific ige testing. this study was a part of a larger study within the division of allergy and immunology of cipto mangunkusumo hospital. this study was conducted on december 2016 until february 2017. the samples used in this study were allergic asthma patients, with age ranging from 19 – 59 years old. patients with non-allergic asthma; those who were not willing to be a participant of this study; patients with contraindications for spirometry testing, such as patients with increased intracranial pressure, patients with space occupying lesion of brain, retinal ablation, or acute exacerbation of asthma; patients who were receiving systemic steroid therapy, and patients with contraindications for skin prick test were excluded from this study. asthma severity classification every subject went through these steps: history taking, physical examination, spirometry test, skin prick test, quantitative serum specific ige test, and asthma severity classification based on global initiative on asthma (gina) 2015 criteria (i.e. intermittent and persistent). the data collected from each subject were then processed and analyzed. intermittent asthma was defined as a degree of asthma where the symptoms occur <2 days per week; nocturnal asthma occurs <2 days per month; the use of β-2 agonist to relieve the symptoms is <2 times per week; with no limitation of normal activities; the lung function predicted fev1 >80% and normal fev1/fvc. persistent asthma was defined as an asthma degree where the symptoms occur >2 days per week but not daily; nocturnal asthma occurs <3 – 4 times a month; the use of β-2 agonist to control symptoms is >2 times per week but it is not used daily, and it is not used more than twice a day; minor limitation in normal activities; lung function predicted fev1 >80% and normal fev1/fvc. skin prick test was considered positive if the diameter of the wheal is >3 mm. the specific ige test was considered significant if the specific ige levels is >0.35 ku/l (class 1). the cut-off value of specific ige testing is 0.35 101 ku/l. in this analytic statistic calculation, data valued <0.15 ku/l was considered as 0 ku/l, while data valued >100 ku/l was considered as 101 ku/l. the commercial cassette allergen kit from polycheck allergy, biocheck gmbh, munster, germany was used to test the specific ige levels. statistical analysis the data was then processed and analyzed using spss software version 16.0 for windows. the result of specific ige test was presented as numeric and categorical data. the numeric data shows mean levels of ige and confidence interval (ci) of 95%. specific ige levels was also presented in categorical (class) form, ranging from class 0 – 6 according to the calibration curve of who. the difference of specific ige levels in intermittent asthma group and persistent asthma group was then analyzed using the mann-whitney test. p-value of 0.05 or less was considered statistically significant. spoken and written explanations about the aim, use, and procedure of this study were given to every subject. this study had obtained the ethical clearance number 53/un2.f1/etik/2017 from fk ui ethical committee. results this study was conducted on december 2016 – february 2017 at the outpatient clinic of agus j. susanto acta med indones-indones j intern med 302 allergy and clinical immunology division of cipto mangunkusumo hospital in jakarta with the sample size of 88 subjects. one patient failed to undergo the specific ige test, thus the sample size was decreased to 87 subjects. the majority (79,3%) of the patients were women. the average age of the subjects was 40.2 years old and ranged from 19 to 59 years of age. most of these patients suffer from allergic asthma or allergic rhinitis and the majority of them were classified into the persistent-asthma group. the highest allergen sensitization was caused by d. farinae (table 1). of hdm-specific ige in some patients (table 2). thus, data is presented in median and iqr form. the data of specific ige serum levels also presented in categorical (class) form, ranged from class 0 – 6 according to calibration curve of who. it appeared that subjects’ specific ige levels varied widely. the majority of sensitized patients belong to class 2 compared to other classes. nevertheless, an equal proportion of class 6 was shown by each group, which was the class with the highest levels of ige beyond the machine’s detection range (figure 1). table 1. characteristics of subjects (n = 87) variables values sex (male), n (%) 18 (20.7) age (years), mean (sd) 40.2 (12.04) age group (y.o), n (%) <20 1 (1.1) 20-29 21 (24.1) 30-39 18 (20.7) 40-49 24 (27.6) 50-59 23 (26.4) diagnosis, n (%) allergic asthma 24 (27.6) allergic asthma + rhinitis 63 (72.4) fev1/fvc, mean (sd) 91.5 (9.0) fev1 (%), mean (sd) 69.3 (19.8) act score, n (%) fully controlled 16 (18.4) controlled 20 (23.0) poorly controlled 51 (58.6) asthma severity, n (%) intermittent 29 (33.3) persistent 58 (66.7) sensitization prevalence, n (%) d. pteronyssinus 45 (51.7) d. farinae 54 (62.1) blomia tropicalis 42 (48.3) table 2. quantitative specific ige serum level profile median (iqr) (ku/l) d. pteronyssinus 0.46 (12.0) d. farinae 0.80 (14.0) blomia tropicalis 0.32 (3.1) analysis of the difference of specific ige serum levels was done by comparing the median value and by using the mann-whitney test because the data distribution was abnormal. the analysis showed that persistent-asthma patients have higher levels of specific ige serum compared to intermittent-asthma patients, although the statistic significance was only achieved in d. farinae and b. tropicalis allergen (table 3). discussion the majority of the subjects were women (79.3%). on the contrary, another research stated that most of allergic asthma patients were men (with a ratio of 1:2), while women were more prone to non-allergic asthma.11 a study based in india which was conducted on 20 people with allergic asthma and/or allergic rhinitis showed that 16 out of 20 subjects (80%) were men.12 according to the literature, it was stated that most of asthmatic children were boys, but when they reach puberty the ratio switched; the prevalence of asthma becomes higher in girls.13 however, the exact effect of estrogen on asthma is still unknown. it is suspected that the effect of estrogen is mediated by its receptors, estrogen receptor alpha (er-α), which are expressed by mast cell. estrogen may trigger mast cell specific ige serum levels test resulted in quantitative data ranged from 0.15 – 100 ku/l. in this descriptive and analytic statistic calculation, data valued <0.15 ku/l was considered as 0 ku/l, while data valued >100 ku/l was considered as 101 ku/l. all of the mites-specific ige serum levels tested in this research showed abnormal data distributions. it was resulted from the absence vol 49 • number 4 • october 2017 the differences in serum quantitative specific ige levels 303 degranulation and increase ige-mediated immune reactions.14 the average age of the subjects in this study was around 40 years old. it is higher than the result of a study conducted in india with a sample size of 20 subjects, which stated that the average age of allergic asthma patients was 34.3 years old.12 patients aged >60 years old were excluded from this study, thus the maximal age of the subjects is 59 years old. allergic rhinitis was found in the majority of subjects. a study in india (stated above) showed that 65% bronchial asthma patients also suffer from allergic rhinitis.12 around 50% of respiratory allergy patients either suffer from allergic asthma or allergic rhinits.15 around 80% of all allergic asthma patients are suspected to suffer from allergic rhinitis as well. this finding soon became the basis of “one airway, one disease” concept found in respiratory allergy treatment.2 from the result of this study, the highest hdm exposure came from d. farinae (62.1%), followed by d. pteronyssinus and blomia tropicalis. a study using immunoassay method (immunocap) found that the number of d. farinae sensitization in allergic rhinitis patients in the united states is around 37.2%, this number is comparable to d. pteronyssinus (38.2%). up until now, immunocap still becomes the gold standard of in vitro specific ige levels testing, because the result from this method is consistent in a variety of allergen extract.17 immunocap testing kit is still unavailable in indonesia and this procedure costs more compared to other technique. nevertheless, the result of this study is different with the epidemiological profile of hdm allergen in indonesia which were tested using skin prick test. a study based in jakarta conducted on 107 subjects with respiratory allergy found the allergen with the highest sensitization prevalence was d. pteronyssinus (77.5%) and blomia tropicalis (72.0%), but d. farinae was not inspected in that study.18 another study in jakarta showed that d. pteronyssinus allergen prevalence is as high as 77.3%, followed by d. farinae (69.6%) and cockroaches (44.9%).19 compared to previous studies which used skin prick test, the hdm allergen prevalence checked figure 1. distribution of specific ige serum level class table 3. median value difference of specific ige serum level based on allergen type allergen intermittent asthma(ku/l) persistent asthma (ku/l) p value* d. pteronyssinus 0.00 0.67 0.066 d. farinae 0.00 1.30 0.024 blomia tropicalis 0.00 0.57 0.015 agus j. susanto acta med indones-indones j intern med 304 using in vitro technique appear to be lower. the median value of specific ige levels in subjects ranged from 0.3 – 0.8 ku/l. the highest median value in this study was caused by d. farinae allergen sensitization. this number is considered low, considering negative or class 0 patients were also taken into account in statistical analysis. on the other hand, the highest number that can be measured by the machine is limited to 100 ku/l. thus the median value of specific ige levels in this study did not represent the actual ige levels in the subjects. in this study, the subjects were classified into 2 groups based on the severity of asthma. to further compare the ige levels in mild, moderate, and severe intermittent asthma, a bigger sample size is needed. moreover, the measurement of specific ige levels could not be done with absolute number. patients with ige levels below the detection limit (<0.15 ku/l) were considered 0 ku/l, while the ige levels above the detection limit (>100 ku/l) were calculated by inputting the number 101 ku/l. a study conducted in spain found that bronchial asthma patients showed increased specific ige concentration caused by d. pteronyssinus when compared with nonasthmatic patients (median 40.2 vs 11.7 ku/l; p<0.001).20 that study used the immunoassay technique (immunocap-250 system, thermo fisher scientific) with the highest detection limit of 100 ku/l. similar to our study, to calculate the median value, researcher established 100 ku/l as the value for patients with specific ige levels above the detection limit.21 the result of this study showed that specific ige serum levels is significantly higher in persistent asthma patients sensitized to d. farinae and b. tropicalis allergen compared to intermittent asthma, but the increasing levels was not significant in d. pteronyssinus allergen sensitization. an epidemiological survey that took place in china and conducted on 6304 allergic asthma and rhinitis found that the percentage of d. pteronyssimus and d. farinae sensitization are higher in more severe asthma cases.6 although in that survey, the absolute levels was not analyzed. on the contrary, a study on 772 asthmatic patients in belgium found that specific ige levels caused by hdm sensitization in severe persistent asthma patients were comparable to ige levels found in mild-moderate persistent asthma patients (median value of 0.47 vs 0.65 ku/l, p>0.05). in that study, specific ige serum levels (unknown species) was tested using rast method (phadia, belgium) with positive detection limit >0.35 ku/l.21 this observed differences of ige reactivity in asian and european population may be caused by hdm sensitization difference. even though hdms are the most important indoor allergen in respiratory allergy worldwide22,23, there is a geographical difference in allergen distribution. for example, a study in sweden on asthmatic patients using immunoassay method (immunocap) found that dog (60.3%) and cat (56.1%) dander as the main allergen causing allergic asthma, while the prevalence of hdm allergen is far below, 27.0% for d. pteronyssinus and 24.8% for d. farinae.7 meanwhile, in china, the prevalence of sensitization to d. pteronyssinus allergen in mild-intermittent asthma patients is around 22.7% and it reached 79.1% in severe-persistent asthma patients; the prevalence of sensitization to d. farinae is around 21.0% in mild-intermittent asthma patients and 77.2% in severe-persistent asthma.6 another study on asthmatic patients in sweden and new zealand showed that increased specific ige levels in sweden mainly was caused by cat allergen, while in new zealand it was mainly caused by hdm allergen.24 in indonesia, the prevalence of hdm allergen checked by skin prick test is higher than 70%, showing the importance of hdm allergen as the trigger of respiratory allergy symptoms.18,19 however, the result of this study showed that there is no statistically significant difference in specific ige levels caused by d. pteronyssinus. it was probably due to the high number of d. pteronyssinus sensitization in society because of the high prevalence of d. pteronyssinus. among all the hdm allergens, d. pteronyssinus has the biggest number of species in the world. nevertheless, d. pteronyssinus sensitization not necessarily trigger allergic symptoms or asthma attack. the strength of this study are: first, to vol 49 • number 4 • october 2017 the differences in serum quantitative specific ige levels 305 researchers’ knowledge, this is the first study about the correlation of quantitative hdm specific ige serum levels testing and allergic asthma in indonesia. secondly, the measurement of specific ige serum levels in this study used a quantitative method, while other studies commonly used semi-quantitative method. thirdly, the amount of drop out patients in this study was <2%. the limitations of this study are: first, the subjects in this study are patients that have been diagnosed with allergic asthma and were voluntarily willing to contribute in this study. thus, the demographic profile of the subjects is not necessarily potray the actual demographic profile of allergic asthma patients in a bigger population. secondly, the measurement of specific ige serum levels in this study used a commercial kit available in indonesia and its diagnostic performance, especially its sensitivity and specificity in detecting specific ige in respiratory allergy patients, have never been investigated. thirdly, the specific ige serum levels tested in this study was only triggered by three type of hdm allergens, while the severity of allergic asthma may be caused by the sensitization of another type of allergen. the clinical application of our study is that quantitative serum of ige levels are recommended to be performed routinely in patients with persistent allergic asthma, especially those who are difficult to stop therapies and to control their medicine consumption. further studies can be developed to determine the prognosis of allergic asthma patients with the consecutive sampling methods and the larger samples number for each group of asthma. conclusion specific ige serum levels induced by dermatophagoides farinae and blomia tropicalis sensitization are significantly higher in persistent asthma patients compared to intermittent asthma patients. specific ige serum levels induced by dermatophagoides pteronyssinus sensitization is higher in persistent asthma patients compared to intermittent asthma patients, but the difference was not statistically significant. acknowledgments this work has been carried out with reagen support from polycheck allergy, biocheck gmbh, munster, germany. references 1. brozek jl, bousquet j, baena-cagnani ce, et al. allergic rhinitis and its impact on asthma (aria) guidelines. j allergy clin immunol. 2010;126:466–76. 2. national asthma education and prevention program. expert panel report 3: guidelines for the diagnosis and management of asthma. national heart, lung, and blood institute, national institutes of health. department of health and human services. baltimore; 2007. 3. yunginger jw, ahlstedt s, eggleston pa, et al. quantitative ige antibody assays in allergic diseases. j allergy clin immunol. 2000;105:1077-84. 4. wenzel se. asthma phenotypes: the evolution from clinical to molecular approaches. nat med. 2012;18:716-25. 5. cox l, williams b, sicherer s, et al. pearls and pitfalls of allergy diagnostic testing: report from the american college of allergy, asthma and immunology/ american academy of allergy, asthma and immunology specific ige test task force. ann allergy asthma immunol. 2008;101:580-92. 6. li j, huang y, lin x, et al. influence of degree of specific allergic sensitivity on severity of rhinitis and asthma in chinese allergic patients. respir res. 2011;12:95. 7. patelis a, janson c, borres mp, nordvall l, alving k, malinovschi a. aeroallergen and food ige sensitization and local and systemic inflammation in asthma. allergy. 2014;69:380-7. 8. baquerio s, russo m, silva v, et al. respiratory allergy to blomia tropicalis: immune response in four syngeneic mouse strains and assessment of a low allergen dose, short-term experimental model. respiratory res. 2010;11:1-11. 9. baratawidjaja ir, baratawidjaja pp, darwis a, soo hl, fook tc, bee wah l, batawidjaja kg. mites in jakarta homes. allergy. 1998;53:1226-7. 10. asha’ari za, suhaimi y, yusof ra, rushdan i, maraina chc. comparison of serum specific ige with skin prick test in the diagnosis of allergy in malaysia. med j malaysia. 2011;66:202–6. 11. romanet-manent s, charpin d, magnan a, lanteaume a, vervloet d, and the egea cooperative group. allergic vs. nonallergic asthma: what makes the difference? allergy. 2002;57:607-13. 12. kumar r, gupta n, kanuga j, kanuga m. a comparative study of skin prick test versus serum specific ige measurement in indian patients with bronchial asthma and allergic rinitis. indian j chest dis allied sci. 2015;57(2):81-5. agus j. susanto acta med indones-indones j intern med 306 13. horwood lj, fergusson dm, shannon ft. social and familial factors in the development of early childhood asthma. pediatrics. 1985;75:859-68. 14. narita s, goldblum rm, watson cs, et al. environmental estrogens induce mast cell degranulation and enhance ige-mediated release of allergic mediators. environ health perspect. 2007;115:48-52. 15. ozdoganoglu t, songu m. the burden of allergic rhinitis and asthma. ther adv respir dis. 2012;6:1123. 16. calabria cw, dietrich j, hagan l. comparison of serum-specific ige (imunocap) and skin prick test result for 53 inhalant allergens in patients with chronic rinitis. allergy and asthma proceeding. 2009;3:386-90. 17. ricci g, capelli m, miniero r, zannarini l, dillon p, masi m. a comparison of different allergometric tests, skin prick tests, pharmacia unicap and advia centaur, for diagnosis of allergic diseases in children. allergy. 2003;58:38-45. 18. baratawidjaja ir, baratawidjaja pp, darwis a, et al. prevalence of allergic sensitization to regional inhalant among allergic patient in jakarta, indonesia. asian pac j allergy immunol.1999;17:9-12. 19. sundaru h. house dust mite allergen levels and allergen sensitization as risk factor for asthma among student in central jakarta. med j indones. 2006;15:559. 20. vidal c, lojo s, juangorena m, gonzales-quintela a. association between asthma and sensitization to allergnes of dermatophagoides pteronyssinus. j investig allergol clin immunol. 2016;26:304-9. 21. manise m, bakayoko b, schleich f, corhay jl, louis r. ige mediated sensitisation to aeroallergens in an asthmatic cohort: relationship with inflammatory phenotypes and disease severity. int j clin pract. 2016;70:596-605. 22. gandhi vd, davidson c, asaduzzaman m, nahimey d, vliagoftis h. house dust mite interactions with airway epithelium: role in allergic airway inflammation. curr allergy asthma rep. 2013;13:262-70. 23. richardson g, eick s, jones r. how is the indoor environment related to asthma? literatur review. j adv nurs. 2005;52:328-39. 24. erwin ea, rönmark e, wickens k, et al. contribution of dust mite and cat specific ige to total ige: relevance to asthma prevalence. j allergy clin immunol. 2007;119:359-65. 556 acta med indones indones j intern med • vol 54 • number 4 • october 2022 original article usefulness of combining nt-probnp level and right atrial diameter for simple and early noninvasive detection of pulmonary hypertension among adult patients with atrial septal defect anggoro budi hartopo1*, dyah wulan anggrahini1, muhammad g. satwiko1, arditya damarkusuma1, armalya pritazahra1, muhammad reyhan hadwiono1, vera c. dewanto1, salvatore di somma2,3, noriaki emoto4,5, lucia kris dinarti1 1 department of cardiology and vascular medicine, faculty of medicine, public health and nursing, universitas gadjah mada dr. sardjito hospital, yogyakarta, indonesia. 2 department of medical-surgery sciences and translational medicine, university sapienza rome, sant’andrea hospital, rome, italy. 3 great network, and great health science, rome, italy. 4 laboratory of clinical pharmaceutical science, kobe pharmaceutical university, kobe, japan. 5 division of cardiovascular medicine, department of internal medicine, kobe university graduate school of medicine, kobe, japan. *corresponding author: anggoro budi hartopo, md, msc, phd. department of cardiology and vascular medicine, faculty of medicine, public health and nursing, universitas gadjah mada. radiopoetra building. 2nd floor west wing. jl. farmako sekip utara, yogyakarta 55281, indonesia. e-mail: a_bhartopo@ugm.ac.id. abstract background: atrial septal defect developed pulmonary hypertension (asd-ph) at first diagnosis due to late presentation are common in indonesia. transthoracic echocardiogram (tte) is a common tool to detect asd-ph, before proceeding to invasive procedure. the nt-probnp measurement to screen asd-ph is not yet considered the standard approach, especially in limited resource conditions. the objective of this study is to assess the value of nt-probnp, along with simple tte parameter, to screen ph among adults with asd. methods: this was a cross-sectional study. the subjects were adult asd-ph patients from the cohardph registry (n=357). right heart catheterization (rhc) was performed to diagnose ph. blood sample was withdrawn during rhc for nt-probnp measurement. the tte was performed as standard procedure and its regular parameters were assessed, along with nt-probnp, to detect ph. results: two parameters significantly predicted ph, namely nt-probnp and right atrial (ra) diameter. the cut-off of nt-probnp to detect ph was ≥140 pg/ml. the cut-off of ra diameter to detect ph was ≥46.0 mm. the combined values of nt-probnp level ≥140 pg/ml and ra diameter ≥46.0 mm yielded 46.6% sensitivity, 91.8% specificity, 54.3% accuracy, 96.5% positive predictive value and 26.2% negative predictive value to detect ph, which were better than single value. conclusion: nt-probnp level ≥140 pg/ml represented ph in adult asd patients. the nt-probnp level ≥140 pg/ml and ra diameter ≥46.0 mm had a pre-test probability measures to triage patients needing more invasive procedure and also to determine when and if to start the ph-specific treatment. keywords: atrial septal defect, n-terminal pro-bnp, pulmonary arterial hypertension, diagnostic test. vol 54 • number 4 • october 2022 usefulness of combining nt-probnp level and right atrial diameter 557 introduction in developed countries, registries of congenital heart disease (chd) in adults associated with pulmonary hypertension (ph) are dominated by heart congenital systemic-topulmonary shunt defects.1,2 in this context, its prevalence is much higher in developing countries due to ph complication as a late diagnosis and uncorrected systemic-to-pulmonary shunting.3-5 adult patients with undetected and delayed diagnosis of chd seek medical advice mostly due to complaints related to ph such as dyspnea, easily fatigued, dizziness, presyncope and chest discomfort.5,6 the most common chd with overlooked diagnosis is atrial septal defect (asd), which accounts for the most common uncorrected chd in adults.3,5,6 in asd patients, ph is a result of protracted hypercirculation and overloaded blood volume in the pulmonary circulation. its consequences are represented by: endothelial dysfunction, pulmonary vascular remodeling, increased pulmonary artery pressure and augmented pulmonary vascular resistance.7 the current guideline compels the utilization of right heart catheterization (rhc) to diagnose the hemodynamics of ph and guidance to confirm pulmonary artery hypertension (pah), by directly measuring mean pulmonary artery pressure (mpap), pulmonary vascular resistance (pvr) and pulmonary capillary wedge pressure (pcwp).8 the precise values of mpap ≥20 mmhg, pvr >3 wood units and pcwp ≤15 mmhg are determined for a confirmation of pah diagnosis.8,9 in asd, the values of rhc are not only used for pah diagnosis, but also for selecting patients suitable for defect closure as a definitive therapeutic choice which should have been done as early as possible in childhood.6 in indonesia, due to their late presentation at cardiologist visit, the majority of adult patients with asd have already developed ph at initial diagnosis.5 moreover, the number of hospitals which can provide rhc and heart defect correction are limited. the chest-x ray, electrocardiogram and transthoracic echocardiogram (tte) are the most common tools to detect suspicion of ph due to asd (asd-ph), before proceeding to rhc. the current guideline on diagnosis and management of pulmonary hypertension by indonesian heart association includes the tte as a first diagnostic tool to detect ph and the use of biomarker, ntprobnp, as a prognostic component of pah. although tte measurements are widespread, the use of nt-probnp as a diagnostic tool to help screen for asd-ph is not yet considered a standard approach. currently, in pah patients the use of nt-probnp is recommended only as prognostic value.8,9 therefore, the diagnostic role of nt-probnp for asd-pah needs to be further investigated, especially in the settings with limited resources and scarce facilities for more advanced procedures, such as rhc and surgical closure. consequently, we conducted a study to assess the sensitivity, specificity, accuracy and predictive value of circulating level of ntprobnp in early and non invasive detection of the ph presence among adult patients with asd. methods this was a cross-sectional design study. the variable tested for this study was the cutoff level of nt-probnp for diagnostic power of the presence of ph in adults with asd. we enrolled patients with diagnosis of ph already confirmed by rhc as a gold standard. the studied population was represented by adult patients in hospital with uncorrected asd, who were mostly symptomatics.5 the subjects of this study were patients registered into the congenital heart diseases in adult and pulmonary hypertension (cohardph) registry. the cohard-ph registry is a single-center, observational, and prospective registry which enrolls adult patients with chd and chd-associated ph in dr. sardjito hospital, jogjakarta, indonesia.5 the subjects selected for this study fulfilled the inclusion and exclusion criteria as follows. inclusion criteria were: (1) patients diagnosed with asd, (2) patients evaluated by rhc, and (3) patients in whom nt-probnp circulating levels was obtained. exclusion criteria were: (1) patients who underwent a previous asd closure procedure, (2) patients with other congenital defects or multiple septal defects, (3) patients with significant valve diseases other than tricuspid or pulmonal valves anggoro budi hartopo acta med indones-indones j intern med 558 regurgitation, (4) patients with component of post-capillary ph by rhc (i.e. mean left atrial pressure (mlap) or pcwp >15 mmhg) and (5) the incomplete haemodynamic result of rhc. the sample size estimation was determined from formula to calculate the accuracy index by receiver operating characteristics (roc) curve.10 the minimal sample size requirement was 114 for each case and control.10 all subjects signed an informed consent form as part of the inclusion in the cohard-ph registry and its subsequent studies. the study protocol conformed to the ethical guidelines of the 1975 declaration of helsinki and was approved by medical and health research ethical committee of faculty of medicine, public health and nursing universitas gadjah mada, indonesia (ref. no. ke/fk/0738/ec/2020 and ke/fk/1189/ec/2021). data collection the demographics, clinical characteristics, laboratory data and echocardiograms were retrieved from the cohard-ph registry database. the data were collected from the index of asd diagnosis, i.e. during tte and transoesophageal echocardiography (toe) examinations (g.e vivid 7 (g.e healthcare, u.s.a), g.e vivid s6 (g.e healthcare, u.s.a) or phillips hd 15 (philips n.v, the netherlands)). the measurement of defect diameter, right atrial (ra) diameter (minor dimension), right ventricle (rv) diameter (maximal minor dimension), tricuspid annular plane systolic excursion (tapse) and left ventricle ejection fraction (lvef) were performed based on standard procedures.11 the image acquisitions were conducted by experienced sonographers. the validation and confirmation of tte and toe results were performed by cardiologist consultants as described previously.5,12 the results of rhc data were retrieved from the cohard-ph registry database. during rhc, the hemodynamic measurements and calculations were determined by indirect fick methods, as previously described.5 the ph diagnosis in this study was determined as mpap ≥20 mmhg and pcwp or mlap ≤15 mmhg by rhc, at any calculated pvr index. the blood sample was collected from each patient during rhc by venipuncture from peripheral veins (for hemoglobin and hematocrit measurement by hemocytometer) and from inferior vena cava (for nt-probnp measurement by electrochemiluminescence immunoassay (elecsysprobnp ii) and a cobas e immunoassay analyzer (roche diagnostics, germany). these measurements were performed in our hospital’s central laboratory.5 statistical analysis the presentation of numerical data was in mean and standard deviation (sd) (for normal distribution of numerical data) or median and interquartile range (iqr) (for non-normal distribution of numerical data). the kolmogorov-smirnov test was applied as determination of normal and non-normal numerical data distribution. the presentation of categorical data was in percentage. the student t test or mann-whitney test was used to compare numerical data. the chi-squared test was used to compare categorical data. univariate and multivariable analyses were performed with logistic regression tests to analyze the independent predictors for ph. a correlation test was performed with either pearson (for normal distribution of numerical data) or spearman test (for non-normal distribution of numerical data). an roc curve was constructed to analyze the area under the curve (auc) and to determine the best cut-off point for accuracy of the diagnostic test for ph. the diagnostic tests were performed using the determined cut-off value. a p value <0.05 was considered statistically significant. results from july 2012 until december 2020, 910 consecutive adult patients with asd included in the cohard-ph registry were enrolled into the study. among them, 620 had undergone rhc procedure. as many as 436 patients had nt-probnp measurement during the rhc procedure. after being selected based on inclusion and exclusion criteria, 357 subjects were considered eligible to be included in this study. seventy-nine subjects were excluded due to incomplete rhc results. figure 1 showed the flow-chart of subjects’ enrollment and selection vol 54 • number 4 • october 2022 usefulness of combining nt-probnp level and right atrial diameter 559 from the cohard-ph registry. the majority of subjects were females (82.7%) with ages in their mid-thirties. the mean asd diameter was 2.4±0.8 cm. most subjects had already developed ph (82.9%), based on the criteria. subjects with asd-ph had significantly older ages, less bodyweight, less oxygen saturation, with higher hemoglobin and hematocrit levels. from tte result, they had larger septal defect diameter, greater ra and rv diameters, lower tapse and higher lvef. the nt-probnp level was significantly higher in subjects with asd-ph compared to asd patients with no ph. table 1 shows the demographic, clinical, laboratory, echocardiogram and hemodynamic characteristics of all subjects and their comparisons based on the presence of ph. among variables that were associated with ph in the univariate analysis, only nt-probnp level (adjusted or 1.004, 95% ci: 1.001-1.006, figure 1. the flow-chart of enrollment and selection of subjects from the cohardph registry. table 1. the demographic, clinical, laboratory, structural (tte) and hemodynamic (rhc) characteristics of all subjects and their comparison based on the presence of ph. characteristics total (n=357) asd, no ph (n=61) asd-ph (n=296) p value age (years) [mean±sd] 34.7±12.1 30.7±10.7 35.5±12.2 0.005 female sex, n (%) 292 (82.7) 53 (86.9) 239 (81.8) 0.344 body weight (kg) [mean±sd] 47.9±10.4 50.9±9.3 47.4±10.5 0.014 body mass index [mean±sd] 19.9±7.1 20.5±3.0 19.8±7.7 0.445 oxygen saturation (%)[mean±sd] 95.4±5.0 98.3±0.9 94.9±5.3 <0.001 hemoglobin (g/dl) [mean±sd] 14.1±2.1 13.2±1.9 14.3±2.1 <0.001 hematocrit (%) [mean±sd] 42.3±6.2 39.7±5.2 42.8±6.3 <0.001 nt-probnp (pg/ml) [median(iqr)] 383.8 (147.1-1309.0) 109.1(55.2-197.3) 606.1 (177.5-1706.3) <0.001 defect diameter (cm) [mean±sd] 2.4±0.8 2.1±0.9 2.5±0.8 <0.001 ra diameter (mm) [mean±sd] 45.8±6.7 42.0±5.6 46.6±6.6 <0.001 rv diameter (mm) [mean±sd] 43.2±6.8 38.7±5.5 44.1±6.8 <0.001 tapse (mm) [mean±sd] 25.1±5.3 27.3±4.5 24.6±5.4 <0.001 left ventricle ef (%)[mean±sd] 69.8±8.7 67.5±7.8 70.2±8.8 0.026 mpap (mmhg) [median(iqr)] 36.0 (22.0-56.0) 16.0(14.5-18.0) 43.0 (27.0-59.8) <0.001 pvri (wood unit.m2)[median(iqr)] 3.5(1.5-13.4) 1.3(1.0-2.0) 5.8 (2.2-17.3) <0.001 mrap(mmhg) [median(iqr)] 8.0(5.0-11.0) 5.0(3.0-8.0) 9.0(6.0-11.0) <0.001 mlap (mmhg) [median(iqr)] 9.0 (6.0-11.0) 6.0(5.0-9.0) 9.5 (7.0-12.0) <0.001 aorta saturation (%)[mean±sd] 91.8±7.6 96.2±4.2 90.9±7.9 <0.001 tte: transthoracal echocardiogram; rhc: right heart catheterization; asd: atrial septal defect, ph: pulmonary hypertension, sd: standard deviation, ra: right atrial, rv: right ventricle, tapse: tricuspid annular plane systolic excursion, ef: ejection fraction, mpap: mean pulmonary artery pressure, pvri: pulmonary vascular resistance index, mrap: mean right atrial pressure, mlap: mean left atrial pressure anggoro budi hartopo acta med indones-indones j intern med 560 p=0.008) and ra diameter (adjusted or 1.13, 95% ci: 1.01-1.28, p=0.028) were independently associated with ph diagnostic criteria. table 2 shows the results of the univariate analysis of covariables and multivariable logistic regression analysis which indicated that only nt-probnp level and ra diameter were significantly and independently associated with ph. the roc curve to determine the accuracy and cut-off point of nt-probnp level to detect ph among patients with asd is shown in figure 2. the auc of nt-probnp was 84.4% (95%ci: 80.1%-88.8%, p<0.001) to predict ph. the best cut-off of nt-probnp level to detect ph was ≥140 pg/ml. the nt-probnp level ≥140 pg/ml had a sensitivity of 85.1%, a specificity of 62.3% and accuracy of 81.2%. its positive predictive value was 91.6%, positive likelihood ratio was 2.26, negative predictive value of 46.3% and negative likelihood ratio was 0.24 to detect ph. table 3 indicates the results of the diagnostic tests with nt-probnp level ≥140 pg/ml to detect ph. the roc curve to determine the accuracy and cut-off point of ra diameter to detect ph among patients with asd was demonstrated in figure 3. the auc of ra diameter was 69.9% (95%ci: 63.2%-76.1%, p<0.001) to predict ph. the cut-off value of ra diameter to detect ph was determined at ≥46.0 mm. this value had a sensitivity of 51.0%, a specificity of 78.7% and accuracy of 55.7%. its positive predictive value was 92.1%, positive likelihood ratio was 2.40, negative predictive value of 52.2% and negative likelihood ratio was 0.62 to detect ph. table 4 indicates the results of the diagnostic tests with ra diameter of ≥46.0 mm to detect ph. table 2. the results of the univariate and multivariable analyses of covariables associated with asd-ph. covariables associated with asd-ph unadjusted or (95% ci) p value adjusted or (95% ci) p value age (years) 1.04 (1.01-1.07) 0.005 1.04 (0.99-1.08) 0.100 bodyweight (kg) 0.97 (0.94-0.99) 0.016 1.00 (0.96-1.05) 0.863 oxygen saturation (%) 0.54 (0.39-0.75) <0.001 0.72(0.49-1.04) 0.076 hemoglobin (g/dl) 1.33 (1.14-1.55) 0.003 1.66 (0.77-3.59) 0.200 hematocrit (%) 1.10 (1.04-1.16) 0.001 0.86(0.66-1.11) 0.271 nt-probnp (pg/ml) 1.005 (1.003-1.007) 0.019 1.004 (1.001-1.006) 0.008 defect diameter (cm) 1.92 (1.32-2.77) 0.001 1.81 (0.98-3.37) 0.060 ra diameter (mm) 1.13 (1.07-1.19) <0.001 1.13 (1.01-1.28) 0.038 rv diameter (mm) 1.15 (1.09-1.22) <0.001 1.08 (0.97-1.19) 0.160 tapse (mm) 0.91 (0.86-0.96) <0.001 0.95 (0.86-1.05) 0.344 left ventricle ef 1.04 (1.01-1.06) 0.028 1.03 (0.97-1.08) 0.321 asd: atrial septal defect, ph: pulmonary hypertension, ra: right atrial, rv: right ventricle, tapse: tricuspid annular plane systolic excursion, ef: ejection fraction figure 2. the roc curve and auc of nt-probnp (84.4%, 95%ci: 80.1%-88.8%, p<0.001) performance to detect the presence of ph among asd patients. vol 54 • number 4 • october 2022 usefulness of combining nt-probnp level and right atrial diameter 561 the combined values of nt-probnp level ≥140 pg/ml and ra diameter ≥46.0 mm yielded a sensitivity of 46.6%, a specificity of 91.8% and accuracy of 54.3%. its positive predictive value was 96.5%, positive likelihood ratio was 5.7, negative predictive value of 26.2% and negative likelihood ratio was 0.58 to detect ph. table 5 indicates the results of the diagnostic tests with the combined values of nt-probnp level ≥140 pg/ml and ra diameter ≥46.0 mm to detect ph. nt-probnp level showed a significant positive correlation with both mpap and pvri in all asd subjects (r value=0.639, p<0.001 and r value=0.587, p<0.001, respectively) and in asd-ph subjects (r value=0.517, p<0.001 and r value=0.515, p<0.001, respectively). the nt-probnp level had significant negative correlations with aorta saturation in asd subjects (r value=-0.543, p<0.001) and in asdph subjects (r value=-0.451, p<0.001). table 6 shows the correlation test results between ntprobnp levels and hemodynamic parameters by rhc. table 3. the results of the diagnostic tests with nt-probnp cut-off value of ≥140.0 pg/ml to detect asdph. asd-ph (n=296) asd-no ph (n=61) ntprobnp ≥ 140.0 pg/ml (n=275) 252 (85.1) 23 (37.7) ntprobnp < 140.0 pg/ml (n=82) 44 (14.9) 38 (62.3) sensitivity: 252/296=85.1% accuracy: 290/357 = 81.2% specificity: 38/61=62.3% prevalence: 296/357 = 82.9% positive predictive value: 252/275=91.6% negative predictive value: 38/82=46.3% positive likelihood ratio: 85.1/ (23/61) =2.26 negative likelihood ratio: 14.9/ (38/61) =0.24 figure 3. the roc curve and auc of ra diameter (69.6%, 95%ci: 63.2%-76.1%, p<0.001) performance to detect the presence of ph among asd patients anggoro budi hartopo acta med indones-indones j intern med 562 discussion our study results revealed that nt-probnp level ≥140 pg/ml demonstrated a diagnostic value to detect the presence of ph within adult patients with asd. the nt-probnp for this prediction effect showed a sensitivity of 85.1% and a specificity of 62.3%. these values represented the ability of nt-probnp ≥140 pg/ ml to screen for early detection of ph within adult patients with asd and ruling-out ph among those with nt-probnp level <140 pg/ml, and selecting those with nt-probnp level ≥140 pg/ml for ph and further pah confirmation with invasive procedure, i.e. rhc. the nt-probnp level ≥140 pg/ml showed 91.6% positive predictive value, which indicated its excellent ability to detect ph in adult patients with asd coming to hospital, in which the prevalence of ph is more than 80%. this ability was also supported by the 2.26 positive likelihood ratio of this cut-off value to detect ph among adult patients with asd. by combining the values of nt-probnp level ≥140 pg/ml and ra diameter ≥46.0 mm, obtained at tte evaluation, the specificity was increasing (91.8%), which denoted it had more power with the combined values to identify adult patients with asd as having ph. these combined values also had increasing positive predictive value and positive likelihood ratio, further supporting its role in detecting ph among adult patients with asd coming to hospital where there is a high prevalence of ph. the use of the ra diameter parameter measured by tte as a complement to the nt-probnp level has an added benefit since it is an already standardized measurement and easily non-invasively be table 5. the results of the diagnostic tests of nt-probnp ≥140 pg/ml and ra diameter ≥46.0 mm todetect asd-ph. asd-ph (n=296) asd-no ph (n=61) nt-probnp ≥ 140 pg/ml and ra diameter ≥ 46.0 mm (n=143) 138 (46.6) 5 (8.2) no both values (n=214) 158 (53.4) 56 (91.8) sensitivity: 138/296 = 46.6% accuracy: 194/357 = 54.3% specificity: 56/61 = 91.8% prevalence: 296/357 = 82.9% positive predictive value: 138/143 = 96.5% negative predictive value: 56/214 = 26.2% positive likelihood ratio: 46.6/8.2 = 5.7 negative likelihood ratio: 53.4/91.8 = 0.58 table 4. the results of the diagnostic tests with ra diameter cut-off value of ≥46.0 mm to detect asd-ph asd-ph (n=296) asd-no ph (n=61) ra diameter ≥ 46.0 mm (n=164) 151 (51.0) 13 (21.3) ra diameter < 46.0 mm (n=193) 65 (49.0) 48 (78.7) sensitivity: 151/296 = 51.0% accuracy: 199/357 = 55.7% specificity: 48/61 = 78.7% prevalence: 296/357 = 82.9% positive predictive value: 151/164 = 92.1% negative predictive value: 48/92 = 52.2 % positive likelihood ratio: 51.0/21.3 = 2.4 negative likelihood ratio: 49.0/78.7 = 0.62 table 6. the correlation between nt-probnp level with hemodynamic parameters measured by rhc in all subjects and in asd-ph subjects. variables* all subjects asd-ph r value pvalue r value pvalue mpap 0.636 <0.001 0.517 <0.001 pvri 0.587 <0.001 0.515 <0.001 mrap 0.082 0.128 -0.056 0.342 mlap 0.045 0.399 -0.095 0.105 aorta saturation -0.543 <0.001 -0.451 <0.001 * spearman correlation test rhc: right heart catheterization; mpap: mean pulmonary artery pressure, pvri: pulmonary vascular resistance index, mrap: mean right atrial pressure, mlap: mean left atrial pressure vol 54 • number 4 • october 2022 usefulness of combining nt-probnp level and right atrial diameter 563 obtained by any echocardiograph-dedicated machine. 11 furthermore, these measured parameters are already approved by indonesian guideline. as a screening tool, this measurement meets the requirements regarding expediency and availability. the tte findings can be used to examine the hemodynamic consequences of asd-related shunting, such as ra dilation, rv dilation, rv function, tricuspid annular dilation and tricuspid regurgitation, as an estimation of the presence of pah or severity of ph. in developing countries with limited resources or scarce facilities then we propose the triage of adult patients with asd combining the nt-probnp level and ra diameter non invasive evaluation to decide the urgent need to perform more advanced and invasive procedures, such as rhc (figure 4). adult asd with ntprobnp value <140 pg/ml can be ruled-out for the presence of pah. in these patients, there is less urgency to perform rhc, however the rhc would be eventually still required to correct the defect and measure hemodynamic parameters, especially in secundum asd suitable for non-surgery closure. patients with nt-probnp ≥140 pg/ml represent those with high probability of pah, and by adding the measurement of ra diameter, those with ra diameter ≥46.0 mm indicate the most urgent cohort of patients needing to undergo rhc to measure hemodynamic parameters and determine correctability criteria. the semi-urgent status for rhc is indicated in adult asd patients with both nt-probnp ≥140 pg/ml and ra diameter <46.0 mm. by producing this triage, the scheduling of rhc for adult patients with asd visiting the hospitals can be more efficiently performed. those with nt-probnp ≥140 pg/ml may also benefit from pah-specific medication before undergoing the rhc procedure, if any world health organization (who) functional class was indicated. large asd is associated with increased morbidity and mortality overtime if left uncorrected, from 0.6% and 0.7%/year in the first two decades of life until 4.5%/ year in the fourth decade of life.13 the most common morbidities and mortality are related with ph and right heart failure.13 adult patients with asd usually have a prolonged asymptomatic presentation or insidious obscured symptom courses which go undetected.5 the delayed symptoms most often arise in the third or fourth decades of life.14 at early phase of the disease, most symptoms occur during physical exertion which relate to the decrease in cardiac output because of the interatrial shunting.13 overtime, the severity of symptoms increases and patients seek medical help. our registry indicated that the prevalence of ph and pah among symptomatic adults with asd was 82.9% by rhc examination.5 the rhc is important to evaluate the pulmonary pressures and direction of the shunt flow in asd with ph and to guide the decision of appropriateness of defect closure, particularly in adult patients with asd. the combination of clinical signs, who functional capacity, tte/toe parameters, and rhc hemodynamic results determines the recommendation of defect closure.14 therefore, through ph screening among adult patients with asd with easy, comfortable and non-invasive tools, the selection of who will get the most urgent working up by more invasive procedures can be timelier and more efficiently executed. for patients with asd-ph, the urgency to undergo rhc for diagnostic, therapeutic and prognostic purposes are applicable in the current guidelines.8,16 for adult asd patients without ph, the rhc is needed for therapeutic purposes to close the defect. in this scenario, adult patients with asd figure 4. the triage scheme for urgency of invasive procedure by rhc among adult asd by using nt-probnp level and proceed by ra diameter anggoro budi hartopo acta med indones-indones j intern med 564 without ph can undergo rhc with less urgency. the utility of nt-probnp to triage, diagnose and risk stratify acute and chronic heart failure has been established.17 besides lv, nt-probnp is an established biological indicator of rv strain and overload.17,18 its circulating level correlates with cardiac and pulmonary hemodynamics in ph patients.19 in asd patients, nt-probnp was associated with rv dysfunction which improves after asd closure.20 the level of nt-probnp has been validated as a prognostic and therapeutic response biological marker in patients with pah.21, 22 the european society of cardiology/ european respiratory society guidelines use the nt-probnp threshold levels of 300 pg/ ml and 1400 pg/ml and categorize the risks as low (<5%), intermediate (5%–10%), or high (>10%) of 1-year mortality in pah, of which also being adopted by indonesian guideline.8 while the adaptation of these prognostic and therapeutic markers has been widely accepted in patients with pah, including asd, the broader utilization of nt-probnp as a diagnostic marker of pah in asd patients is not yet confirmed. this is because asd has the hemodynamic consequences of pulmonary chronic vascular overflow and right atrial/ventricle chronic volume overload before resulting in ph and pah. these long-term routes make it demanding to determine the timeliest point of ph diagnosis. the measurement of nt-probnp level in adult patients with asd can determine which patients experience ph and which had not. our study, which included subjects coming to hospitals due to the symptoms they felt, showed that the nt-probnp level identified and distinguished those who had already developed ph. prompt decisions for invasive procedures and initiation of therapy in adult asd patients with levels above the upper cut-off of nt-probnp may avoid further rv failure, and thereby reducing early morbidity and mortality.23 the result of this study needs to be externally validated in the cohorts of adult asd patients who are still frequently found in indonesia due to the lack of screening processes in childhood. these combination of nt-probnp level and ra diameter by tte was a simple parameter to discriminate patients who needed more invasive procedure which will need external validation especially from district hospitals, which become the first-line treating hospitals, and also referral hospitals, which had more advanced facility to treat asd patients with/without ph. in the future, the external validation process is important to test the usability and generability of this study finding. this study had several notable limitations. firstly, the sample size for control group did not meet the minimum requirement based on sample size calculation formula. secondly, it did not exclude subjects with eisenmenger syndrome since its current clinical and hemodynamic definitions are not clearly defined. third, patients with corrected asd who still developed pah were excluded. fourth, the time interval between index of asd diagnosis by tte and nt-probnp level measurement during rhc varied. and lastly, this study was conducted in a single ph center in indonesia, which needs further corroboration and externally validated by a large multicenter study. conclusion nt-probnp circulating level ≥140 pg/ml seems to represent ph in adult patients with asd. the nt-probnp level ≥140 pg/ml can be used together with ra diameter ≥46.0 mm at tte as pre-test probability measures to triage patients needing more invasive procedures and also to determine when and if to start the pah-specific treatment, especially in developing countries in which the adult asd delayed presentation is high and the facility for ph and pah diagnosis is limited and scarce. acknowledgments authors acknowledged the research assistants of the cohard-ph registry: arina prihesti md, theresia dwiamelia md, athanasius wrin hudoyo md, aristida cahyono md, reza pandu aji md, monika setiawan md, zaki horison islami md, dimas setiadji md, and aditya doni pradana md. authors acknowledged the echolab sonographers, cath-lab nurses, radiographers and residents who assisted the cohardph registry. authors recognized the english language editing center (klinik bahasa) in vol 54 • number 4 • october 2022 usefulness of combining nt-probnp level and right atrial diameter 565 faculty of medicine, public health and nursing universitas gadjah mada that provided the assistance of english languange consultation of the manuscript. funding the research received funding from (1) research grant penelitian dasar 2019 (no: 2798/ un1.ditlit/dit-lit/lt/2019) from direktorat riset dan pengabdian masyarakat, direktorat jenderal penguatan riset dan pengembangan, kementerian riset, teknologi dan pendidikan tinggi of indonesia via universitas gadjah mada, jogjakarta, indonesia and (2) penelitian hibah dana masyarakat tahun 2021 (no: 257/ un1/fkkmk/ppke/pt/2021 to principal investigator: a.b.h. conflict of interest all authors had no conflict of interests regarding the manuscript. references 1. rose ml, strange g, king i, et al. congenital heart disease-associated pulmonary arterial hypertension: preliminary results from a novel registry. intern med j. 2012;42(8):874-9. 2. schwartz ss, madsen n, laursen hb, hirsch r, olsen ms. incidence and mortality of adults with pulmonary hypertension and congenital heart disease. am j cardiol. 2018;121(12):1610-6. 3. vijarnsorn c, durongpisitkul k, chungsomprasong p, et al. contemporary survival of patients with pulmonary arterial hypertension and congenital systemic to pulmonary shunts. plos one. 2018;13:e0195092. 4. kaymaz c, mutlu b, küçükoğlu ms, et al. preliminary results from a nationwide adult cardiology perspective for pulmonary hypertension: registry on clinical outcome and survival in pulmonary hypertension groups (simurg). anatol j cardiol. 2017;18:242–50. 5. dinarti lk, hartopo ab, kusuma ad, et al. the congenital heart disease in adult and pulmonary hypertension (cohard-ph) registry: a descriptive study from single-center hospital registry of adult congenital heart disease and pulmonary hypertension in indonesia. bmc cardiovasc disord. 2020;20(1):163. 6. wilamarta kv, yuniadi y, rachmat j, fakhri d, hakim t, anwar m. adult congenital cardiac surgery in indonesia. cardiol young. 2011;21:639–45. 7. engelfriet pm, duffels mg, möller t, et al. pulmonary arterial hypertension in adults born with a heart septal defect: the euro heart survey on adult congenital heart disease. heart. 2007;93(6):682-7. 8. galiè n, humbert m, vachiery jl, et al. esc scientific document group. 2015 esc/ers guidelines for the diagnosis and treatment of pulmonary hypertension: the joint task force for the diagnosis and treatment of pulmonary hypertension of the european society of cardiology (esc) and the european respiratory society (ers): endorsed by: the association for european paediatric and congenital cardiology (aepc), and international society for heart and lung transplantation (ishlt). eur heart j. 2016;37(1):67119. 9. simonneau g, montani d, celermajer ds, et al. haemodynamic definitions and updated clinical classification of pulmonary hypertension. eur respir j. 2019;53(1):1801913. 10. hajian-tilaki k. sample size estimation in diagnostic test studies of biomedical informatics. j biomed inform. 2014;48:193-204. 11. rudski lg, lai ww, afilalo j, et al. guidelines for the echocardiographic assessment of the right heart in adults: a report from the american society of echocardiography endorsed by the european association of echocardiography, a registered branch of the european society of cardiology, and the canadian society of echocardiography. j am soc echocardiogr. 2010;23(7):685-713. 12. pratama rs, hartopo ab, anggrahini dw, dewanto vc, dinarti lk. serum soluble suppression of tumorigenicity-2 level associates with severity o f p u l m o n a r y h y p e r t e n s i o n a s s o c i a t e d w i t h u n c o r r e c t e d a t r i a l s e p t a l d e f e c t . p u l m c i r c . 2020;10(2):2045894020915832. 13. campbell m. natural history of atrial septal defect. br heart j. 1970;32:820–6. 14. alkashkari w, albugami s, hijazi zm. current practice in atrial septal defect occlusion in children and adults. expert rev cardiovasc ther. 2020;18(6):315-29. 15. jain s, dalvi b. atrial septal defect with pulmonary hypertension: when/how can we consider closure? j thorac dis. 2018;10:2890–8. 16. leuchte hh, ten freyhaus h, gall h, et al. risk stratification strategy and assessment of disease progression in patients with pulmonary arterial hypertension: updated recommendations from the cologne consensus conference 2018. int j cardiol. 2018;272s:20-9. 17. maisel a, mueller c, adams k jr, et al. state of the art: using natriuretic peptide levels in clinical practice. eur j heart fail. 2008;10(9):824-39. 18. lador f, soccal pm, sitbon o. biomarkers for the prognosis of pulmonary arterial hypertension: holy grail or flying circus? j heart lung transplant. 2014;33:341–3. 19. souza r, bogossian hb, humbert m, et al. n-terminalpro-brain natriuretic peptide as a haemodynamic marker in idiopathic pulmonary arterial hypertension. anggoro budi hartopo acta med indones-indones j intern med 566 eur respir j. 2005;25:509–13. 20. elsheikh rg, hegab m, szatmari a. nt-probnp correlated with strain and strain rate imaging of the right ventricle before and after transcatheter closure of atrial septal defects. j saudi heart assoc. 2013;25(1):3-8. 21. frantz rp, farber hw, badesch db, et al. baseline and serial brain natriuretic peptide level predicts 5-year overall survival in patients with pulmonary arterial hypertension: data from the reveal registry. chest. 2018;154:126–35. 22. chin km, rubin lj, channick r, et al. association of n-terminal pro brain natriuretic peptide and longterm outcome in patients with pulmonary arterial hypertension. circulation. 2019;139(21):2440-50. 23. blyth kg, groenning ba, mark pb, et al. ntprobnp can be used to detect right ventricular systolic dysfunction in pulmonary hypertension. eur respir j. 2007;29(4):737-44. clinical practice 88 acta med indones indones j intern med • vol 50 • number 1 • january 2018 measurement of health-related quality of life in patients with functional dyspepsia ibnu f. hantoro, ari f. syam departement of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: ari fahrial syam, md., phd. division of gastroenterology, departement of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71 jakarta 10430, indonesia. email: ari_syam@hotmail.com. abstrak hampir 80% pasien dispepsia yang berobat ke rumah sakit merupakan dispepsia fungsional. dispepsia fungsional walaupun tidak meningkatkan mortalitas, namun dapat menjadi beban bagi komunitas dan negara, karena menimbulkan gangguan terhadap fisik, mental dan sosial pasien, sehingga berpengaruh terhadap kualitas hidup pasien. kualitas hidup terkait kesehatan merupakan konstruksi multidimensi yang terdiri dari setidaknya tiga domain yaitu fungsi fisik, psikologis dan sosial yang ketiganya dipengaruhi oleh penyakit dan pengobatan yang diberikan. penilaian kualitas hidup terkait kesehatan merupakan hal yang penting pada pasien dispepsia fungsional untuk dapat mengidentifikasi dampak dari penyakit dan pengobatan yang diberikan kepada pasien. instrumen generik dan spesifik penyakit dapat digunakan untuk menilai kualitas hidup terkait kesehatan pada pasien dispepsia fungsional. masing-masing instrumen memiliki kelebihan dan keterbatasan. pemilihan instrumen untk menilai kualitas hidup terkait kesehatan ditentukan berdasarkan populasi penelitian, pertanyaan penelitian, entitas penyakit, dan preferensi dari peneliti. tujuan dari penulisan artikel ini adalah untuk menjelaskan mengenai konsep kualitas hidup terkait kesehatan dan penilaian kualitas hidup terkait kesehatan pada pasien dispepsia fungsional. kata kunci: kualitas hidup terkait kesehatan, dispepsia fungsional. abstract in up to 80% of dyspepsia patients who consult a physician in the hospital, dyspepsia is considered to be functional dyspepsia. although not associated with increased mortality, functional dyspepsia is a burden at both the community and national levels because it can cause physical, mental, and social distress that can affect a patient’s quality of life. health-related quality of life (hrqol) is a multidimensional construct comprising at least three broad domains—physical, psychological, and social functioning—which can all be affected by a disease and its treatment. it is important to assess hrqol in patients with functional dyspepsia to identify the effects of the disease and its treatment on patients. both disease-specific and generic instruments can be used to assess hrqol in patients with functional dyspepsia. each instrument has its own advantages and limitations. the selection of instrument to assess hrqol is determined by the study population, research questions, disease entities, and researcher preferences. the purpose of this article is to explain the concept of hrqol and the use of hrqol assessment in patients with functional dyspepsia. keywords: health-related quality of life, functional dyspepsia. vol 50 • number 1 • january 2018 measurement of health-related qol in patients with functional dyspepsia 89 introduction symptoms of dyspepsia are common in the community and clinical practice.1 in up to 80% of dyspepsia patients who consult a physician in the hospital, the condition is classified as functional dyspepsia.1,2 functional dyspepsia is defined as the presence of symptoms thought to originate in the gastroduodenal region in the absence of any organic, systemic, or metabolic disease that is likely to explain the symptoms. the rome criteria subdivide functional dyspepsia into postprandial distress syndrome and epigastric pain syndrome).3 the pathophysiology of functional dyspepsia is complex and is not fully understood, although it is known that abnormal gut motility, visceral hypersensitivity, genetic influence, infection, and psychosocial factors play a role.4 functional dyspepsia is a burden at both the community and national levels. it carries significant direct and indirect costs and decreases work productivity. 5,6 although functional dyspepsia is not associated with increased mortality,7 it can lead to physical, mental, and social distress, which can affect the quality of life.8–14 health-related quality of life (hrqol) is increasingly being assessed as a patient-reported outcome in clinical research.15,16 it is important to assess hrqol in patients with functional dyspepsia to identify the effects of the disease and its treatment in patients.17,18 both diseasespecific and generic instruments can be used to assess hrqol in patients with functional dyspepsia.19 however, as a new concept, hrqol is not well understood by many clinicians in indonesia, and its use in research and clinical practice is lacking. the purpose of this article is to explain the concept of hrqol and the use of hrqol assessment in patients with functional dyspepsia. d e f i n i t i o n o f h e a lt h r e l at e d quality of life the world health organization defines quality of life as an “individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns”.20 hrqol is a multidimensional construct comprising at least three broad domain physical, psychological, and social functioning which can all be affected by disease and treatment.21 the term hrqol is used to differentiate this measure from other more general aspects of life that are not considered to be health related such as income, freedom, and quality of the environment.22 w h y m e a s u r e h e a lt h r e l at e d quality of life? physicians often rely on objective findings when managing patients.17 however, patients may be less interested in the value of traditional biomarkers than physicians. 23 moreover, traditional biomarkers often fail to correlate with functional capacity and well-being.22 assessment of hrqol may counter this problem, and help physicians to understand that patients often value outcomes in a different way than their physician.23 hrqol assessment can guide physicians when making a clinical decision in situations in which there may be multiple effective strategies from which to choose. hrqol can offer an added value when choosing a treatment when there may be only a small difference in survival between treatments. physicians can also use hrqol to help them decide on a treatment strategy for patients with asymptomatic or mildly symptomatic disease.18 m e a s u r i n g h r q o l i s i m p o r t a n t f o r understanding the effects of chronic disease, especially for those diseases with major effects on morbidity but not mortality.22,23 determining disease burden by using traditional measures such as the prevalence of a disease, direct and indirect costs, and effects on productivity is insufficient for understanding the true burden of any disease.23 identifying the adverse effects of a disease on hrqol is important for society and health providers to appreciate fully the true burden. hrqol data can also help national health policy makers when developing a healthcare budget.23,24 ibnu f. hantoro acta med indones-indones j intern med 90 how to choose a health-related quality of life instrument the best and most relevant way to assess hrqol is to ask patients by using a validated questionnaire.17 hrqol instruments include a range of questions that correspond to the number of domains assessed. a domain is an area of behavior or experience and questions may relate to mobility, self-care, depression, anxiety, and well-being.22 the selection of the specific hrqol instrument to be used is determined by the study population, research questions, disease entities, and researcher preferences.18 each instrument has its own advantages and limitations. most current research uses a combination of generic and specific instruments. this combination can overcome the limitations of the use of only one type of instrument and help to obtain good sensitivity and generalizability.18,25 nevertheless, the combined use hrqol instruments may also increase the time required for the patient to complete the questionnaires, and modified questionnaires have been developed.18 generic instruments the generic questionnaire allows physicians and researchers to evaluate comprehensively the effects of different illnesses and symptoms on quality of life. generic instruments can be used to compare hrqol in patients with that in other groups with or without illness.17 however, a major limitation of generic instruments is that they may not include unique and important indicators for some special groups and may therefore be less sensitive to changes in specific symptoms.18,25 generic instruments are more reliable for identifying the general effects on wide range of daily activities, mental health and functioning.17,26 the short form 36 health survey (sf-36) is the most commonly used generic questionnaire in gastroenterology research.18,19 the sf-36 was originally developed to assess the health status of participants in the medical outcomes study this instrument is designed for use in clinical practice and research, health policy evaluation, and surveys in the general population.19,27 the sf-36 is commonly used to define and measure differences in hrqol between patients with gastrointestinal disease and control populations.27 the sf-36 includes one scale for each of eight measured health domains: physical functioning, role–physical, bodily pain, general health, vitality, social functioning, role–emotional, and mental health. the scores for these eight domains are aggregated into a physical component summary (pcs) and mental component summary (mcs). the pcs correlates with the scale of physical functioning, role–physical, and bodily pain, and the mcs correlates with mental health, role–emotional, and social functioning. three scales of vitality, general health, and social functioning correlate with both component summaries.28 all health domains are scored using norm-based scores ranging 0 to 100, with higher scores indicating better health. the sf-36 questionnaire can be self-administered by the patient, in a direct interview, or by telephone. the time required to complete the questionnaire is 5–10 minutes for most people and about 15 minutes in older people.28,29 the sf-36 instrument has been tested for reliability and validity. the median internal consistency alpha coefficient obtained from several studies is >0.8 for all scales except for social functioning, which has an alpha coefficient of 0.76. the test–retest correlation over 2 weeks is >0.8 for the physical functioning, vitality, and general health scales. the lowest coefficient of 0.6 is for the social functioning scale.29 the content validity of the sf-36 has been compared with other widely used generic health surveys. systematic comparisons show that the sf-36 includes eight of the most frequently assessed health concepts. some concepts not covered in the sf-36 including cognitive functioning, sleep, health distress, social support, family and marital functioning, sexual functioning, and physical and psychophysiologic symptoms. evaluation of 32 general concepts and 19 specific symptoms with eight scales and two summaries of the sf-36 show that the sf-36 scales correlate (r>0.4) with most general health concepts and with the frequency and severity of specific symptoms and problems.28 the results of the analysis of the seven dimensions of the sf-36 evaluating functioning and well-being were strongly associated with patient reports of overall vol 50 • number 1 • january 2018 measurement of health-related qol in patients with functional dyspepsia 91 general health. kruskal-wallis tests indicated clear linear trends for decreasing sf-36 scores (i.e., reporting more health related problems) on all seven dimensions with worsening self-rated general health.30 the sf-36 has been translated and validated for use in indonesia.31 disease-specific instruments a disease-specific instrument is designed to detect changes in hrqol that may not be detected using a generic instrument but may be important manifestations of disease. specific instruments tend to be more sensitive than generic instruments.26 however, an overly sensitive disease-specific instrument has the disadvantage of possibly detecting clinically unimportant changes in the placebo group.25 another limitation is that, because of its narrow focus, a specific instrument may be unable to detect unexpected major changes in the hrqol and cannot be used widely for different diseases.26 instruments may be specific to a disease (such as heart failure or asthma), a patient population (such as the frail elderly) to certain functions (such as sleep or sexual function), or specific problems (such as pain).22 the irritable bowel syndrome quality of life instrument and nepean dyspepsia index (ndi) are examples of specific questionnaires commonly used in functional gastrointestinal disorders in asia.19 the ndi was developed by a team of r e s e a r c h e r s i n s y d n e y, a u s t r a l i a . t h e questionnaire originally comprised 42 questions that assessed quality of life in 17 major aspects and a list of symptom frequency, intensity, and disturbance of 15 upper gastrointestinal symptoms within the past 2 weeks. the assessment of this questionnaire uses a five-level likert scale. the questionnaire has been translated from australian english into french, dutch, italian, german, spanish, and american english.32 the ndi was simplified from 42 questions to 25 questions for five subscales (domains): effects on general tension/sleep (nine items), interference with daily activities (six items), effects on eating/drinking (three items), knowledge/control of dyspepsia (four items), and the effects of dyspepsia on work/study (three items). validity testing noted good face validity and internal consistency results; cronbach’s a for all subscales was >0.85. good reliability of the questionnaire has also been reported, with an intraclass correlation of all subscales of >0.84.33 t h e n d i q u e s t i o n n a i r e w a s f u r t h e r simplified into 10 questions with each subscale comprising two questions. the ndi evaluates the symptoms and hrqol in patients with functional dyspepsia. the quality of life subscale associated with symptoms can be used to assess directly the severity of disease symptoms. the questionnaire is responsive and has sufficient internal consistency (>0.7) for all scales as well as a strong and meaningful correlation with the complete questionnaire.34 a short-form ndi has been translated and its validity tested for use in indonesia.35 conclusion it is important to assess hrqol in patients with functional dyspepsia to identify the effects of the disease and its treatment in patients. both disease-specific and generic instruments can be used to assess hrqol in patients with functional dyspepsia. understanding the advantages and limitations of both generic and disease-specific instruments is critical when choosing to assess hrqol in patients with functional dyspepsia. references 1. ghoshal uc, singh r, chang f, et al. epidemiology of uninvestigated and functional dyspepsia in asia: facts and fiction. j neurogastroenterol motil. 2011;17:235– 44. 2. syam a-f, abdullah m, rani a-a, et al. evaluation of the use of rapid urease test: pronto dry to detect h. pylori in patients with dyspepsia in several cities in indonesia. world j gastroenterol. 2006;12:6216–8. 3. tack j, talley nj, camilleri m, et al. functional g a s t r o d u o d e n a l d i s o r d e r s . g 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15. testa ma, simonson dc. assessment of quality of life outcomes. nejm. 2010;334:835–40. 16. borgaonkar irvine, e.j. mr. quality of life measurement in gastrointestinal and liver disorders. gut. 2000;47:444–54. 17. glise h, wiklund i. health-related quality of life and gastrointestinal disease. j gastroenterol hepatol. 2002;17:s72-84. 18. eisen gm, locke rg, provenzale d. health-related quality of life : a primer for gastroenterologists. am j gastroenterol. 1999;94:2017–21. 19. yacavone rf, locke gr 3rd, provenzale dt, eisen gm. quality of life measurement in gastroenterology: what is available? am j gastroenterol. 2001;96:285– 97. 20. who. whoqol: measuring quality of life. psychol med. 1998;28:551–8. 21. megari k. quality of life in chronic disease patients. heal psychol res. 2013;1:141–8. 22. guyatt gh, feeny dh, patrick dl. measuring healthrelated quality of life. ann intern med. 1993;118:622– 9. 23. s p i e g e l b m r . p a t i e n t r e p o r t e d o u t c o m e s i n gastroenterology: clinical and research applications. j neurogastroenterol motil. 2013;19(2):137–48. 24. cdc. population assessment of health-related quality of life. 2000. 25. lam cl. subjective quality of life measures – general principles and concepts. in: preedy vr, watson rr, editors. handbook of disease burdens and quality of life measures. 1st ed. spinger; 2009. p. 381–99. 26. choi m, jung h, words k. health related quality of life in functional gastrointestinal disorders in asia. j neurogastroenterol motil. 2011;17:245–51. 27. ware jej, sherbourne cd. the mos 36-item shortform health survey (sf-36): i. conceptual framework and item selection. med care. 1992;30:473–83. 28. maruish me, editor. user’s manual for the sf-36v2 health survey. 3rd ed. lincoln, ri: quality metric incorporated; 2011. 29. mcdowell i. measuring health: a guide to rating scales. vol. 8. statistics in medicine. 1989. p. 1308-9. 30. jenkinson c, wright l, coulter a. criterion validity and reliability of the sf-36 in a population sample. qual life res. 1994;3:7–12. 31. salim s, yamin m, alwi i, setiati s. validity and reliability of the indonesian version of sf-36 quality of life questionnaire on patients with permanent pacemakers. acta med indones. 2015;49:10–6. 32. talley nj, haque m, wyeth jw, et al. development of a new dyspepsia impact scale: the nepean dyspepsia index. aliment pharmacol ther. 1999;13:225–35. 33. talley nj, verlinden m, jones m. validity of a new quality of life scale for functional dyspepsia: a united states multicenter trial of the nepean dyspepsia index. am j gastroenterol. 1999;94:2390–7. 34. talley nj, verlinden m, jones m. quality of life in functional dyspepsia: responsiveness of the nepean dyspepsia index and development of a new 10-item short form. aliment pharmacol ther. 2001;15:207–16. 35. arinton ig, samudro p, soemohardjo s. the nepean dyspepsia index: translation and validation in indonesian language. indones j gastroenterol hepatol dig endosc. 2006;7:38–41. 513acta med indones indones j intern med • vol 54 • number 4 • october 2022 editorial raising awareness of acute kidney injury: unfolding the truth aida lydia division of nephrology and hypertension, department of internal medicine faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: aida lydia, md, phd. division of nephrology and hypertension, department of internal medicine faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: aidalydia@gmail.com. acute kidney injury (aki) is an extremely complex syndrome associated with severe morbidity and mortality.1 moreover, aki may cause loss of kidney function in the long term.2 both in developed and developing countries, aki is common among hospitalized patients, which can be up to 20% of overall patients.3,4 there is an urgent need to increase knowledge and awareness of aki, particularly in developing countries, including indonesia. aki is rarely being recognized as it may take place without any apparent symptoms. severe aki is commonly found in intensive care unit (icu) patients. a recent multinational study comprising of thousands of patients from 97 icus reported that 57% of patients had developed aki within 1 week of admission. about 39% of patients had severe aki (stage 2 or 3), in which 13.5% of them requiring kidney replacement therapy (krt). aki in the icu is an independent risk factor for death, as it may cause systemic effects on other vital organs including the lung, heart, liver, brain and immune system. some studies have reported that aki increases susceptibility to infection, doubles the rate of respiratory failure and impairs cardiac function. common causes of aki in the icu are sepsis, cardiac surgery, acute liver failure, intraabdominal hypertension, hepatorenal syndrome, malignancy, and cardiorenal syndrome.5 considering the substantial impacts of aki in icu patients, early implementation of preventive measures should be an essential program which consists of developing aki risk stratification in the icu and encouraging the use of novel aki biomarkers (timp-2, igfbp-7, cystatin c, il-18, kim-1 and ngal) as well as other risk stratification tools (clinical risk prediction scores, computer algorithms, furosemide stress test). furthermore, after icu patients have recovered, aki survivors are more likely to develop chronic kidney disease (ckd) and end-stage kidney disease (eskd), imposing significant morbidity in the future. nephrologist intervention is expected to help patients’ recovery, prevent further deterioration of renal function, and mitigate the risk of mortality as well as the development of ckd if patients survive. recent study has shown that nephrologist intervention was associated with lower risk of starting krt and progression of aki.2,6 the coronavirus disease 2019 (covid-19) pandemic has caused more than 800,000 deaths worldwide.7,8 kidney involvement in patients with covid-19 may present as proteinuria or hematuria and may lead to acute kidney injury (aki). some initial reports showed that the incidence of aki in covid cases was negligible.9-14 however, later reports suggested that aki is actually prevalent in patients with covid-19, particularly in icu patients. the rate of aki in covid-19 patients was more than 20% of hospitalized patients and more than 50% of patients in the icu.7,15-18 aki is now considered as a common complication of covid-19 and it is also associated with adverse aida lydia acta med indones-indones j intern med 514 outcomes, including development or worsening of comorbidities, yet little is known about the pathogenesis or optimal management of covid19-associated aki. definition and classification of aki (kdigo 2012) there was a lack of definition for aki for quite a long time. at first, the term “acute renal failure (arf)” was used to describe an acute deterioration in renal function, which usually calls for an emergency krt.2 afterwards, some experts and several specific working groups established the definition and staging of aki. in 2007, the term arf was officially replaced by aki and it was first defined using the rifle criteria (risk, injury, failure, loss, end-stage).2,19 the definition has subsequently evolved and currently corresponds to the criteria published in 2012 by kdigo (kidney disease: improving global outcome) working group. kdigo criteria defines staging of aki based on serum creatinine level and urine output as follows: (1) aki stage i with serum creatinine level of 1.5 to 2.0 baseline within 7 days or ≥ 26.4 µmol/l within 48 h and urine output of <0.5 ml/kg/h for 6-12 h; (2) aki stage ii with serum creatinine level of 2.0 to 2.9 times baseline and urine output of <0.5 ml/ kg/h for ≥ 12h; and (3) aki stage iii with serum creatinine level of ≥ 3.0 times baseline or an increase in serum creatinine to ≥ 353.6 µmol/l or the initiation of krt and urine output of < 0.3 ml/kg/h for ≥ 24 h or anuria for ≥ 12 h.2 etiology and pathophysiology of aki aki is a sudden loss in renal function that may be caused by a wide variety of clinical conditions. however, the causal relationship between aki and those clinical conditions, whether as the cause or adverse outcomes remains controversial in most studies.20-23 etiologies of aki are very heterogenous and may initiate multiple pathophysiological pathways. these etiologies can be classified into three main categories: pre-renal, intrinsic and post-renal. pre-renal aki is caused by renal hypoperfusion that leads to a decreased gfr without any damage to the renal parenchyma, such as hypovolemia (bleeding, volume depletion, etc), impaired cardiac function, or increased vascular resistance. intrinsic aki is due to a variety of injury that occurs in the kidney structures (tubules, glomeruli, interstitium or renal blood vessels). whereas, post-renal aki etiologies include any acute obstruction of the urinary flow that increases intra-tubular pressure and thus decreases the glomerular filtration rate (gfr). in the pathophysiological point of view, these etiologies usually cause imbalance of oxygen supply and demand that activates cascade of responses to hypoxemia and oxidative stress. subsequently, this may lead to persistent inflammation, hyperfiltration, progressive tubular damage, glomerulosclerosis and tubulointerstitial fibrosis, eventually leading to ckd, eskd, and other associated complications.24-26 currently, the pathophysiology of aki is not completely understood and is known to be mediated by a complex interplay of multiple pathophysiological process.2 this process will ultimately end up as irreversible renal damage. based on such pathophysiological perspective, the long-term impact of aki outcomes depends on the residual renal function and repair capacity after surviving renal stress.2 multiple impacts of aki, prevention and early diagnosis aki may have multiple clinical impacts, high risk of mortality, and risk of progressive deterioration of renal function, leading to ckd as well as eskd. consequently, aki decreases the quality of life and may contribute to the increasing medical costs and becomes national financial burden covered in the universal health coverage (bpjs kesehatan).27,28 some recent studies have also identified aki as risk factor for other adverse outcomes, including stroke, cardiovascular disease, sepsis, malignancy, bone fracture and upper gastrointestinal hemorrhage.29,30 in a general sense, aki-related adverse outcomes depend on the presence of preexisting comorbidities, namely cardiovascular disease, hypertension, diabetes mellitus, and most importantly, preexisting ckd.2 it can be said that presence of comorbidities is a key player in the longterm impact of aki. tight control of these comorbidities should prevent the progression of aki into ckd.31,32 it is important to preserve vol 54 • number 4 • october 2022 raising awareness of aki: unfolding the truth 515 renal function as much as possible to halt further renal deterioration. despite great advances in the understanding of risk factors, diagnosis and management of aki, mortality risk remains high.33,34 surprisingly, majority of patients had delayed consultation to nephrologists, which is known to be associated with higher mortality.35,36 further prevention measures may include improvement of tools used for early detection and diagnosis, identification of high-risk patients (the elderlies, patients with preexisting comorbidities and preexisting renal impairment), optimization of fluid management, proper antibiotic dosing, nutritional adjustments, withdrawal of nephrotoxic drugs, removal of hyperchloremic solutions and others.37 nephrologist intervention is an essential part of entire care in patients with aki and can influence progression of aki as well as aki-associated mortality. various efforts, specifically fluid adjustment, may prevent the need for krt and decrease the progression of aki. considering the multifactorial nature of aki, besides nephrologist intervention, aki demands for multidisciplinary approach as needed, in order to provide best quality of care for patients.6 conclusion aki is an important complex syndrome with multiple adverse outcomes in hospitalized patients, particularly in icu patients. the covid-19 pandemic has increased its complexity and thus proper treatment is vital to reduce morbidity, mortality and medical costs. some pivotal approaches in managing aki patients are (1) consideration of multiple risk factors and comorbidities, (2) use of early detection tools and diagnosis, and (3) implementation of preventive and therapeutic intervention as well as early nephrologist intervention as a part of multidisciplinary spectrum that lowers the risk of starting krt and aki progression. references 1. li pk, burdmann ea, mehta rl. acute kidney injury: global health alert. arab j nephrol transplant. 2013;6(2):75-81. 2. fortrie g, de geus hrh, betjes mgh. the aftermath of acute kidney injury: a narrative review of longterm mortality and renal function. critical care. 2019;23:24:1-11. 3. heung m, chwla ls. acute kidney injury: gateway to chronic kidney disease. nephron clin pract. 2014;127:30-4. 4. chawla ls, kimmel pl. acute kidney injury and chronic kidney disease: an integrated clinical syndrome. kidney int. 2012;82:516-24. 5. griffin br, liu kd, teixeira jp. critical care nephrology: core curriculum 2020. am j kidney dis. 2020;75(3):435-52. 6. iniguez jsc, aguilera pm, flores cp, et al. nephrologist interventions to avoid kidney replacement therapy in acute kidney injury. kidney blood pres res. 2021;46:629-38. 7. nadim mk, forni lg, mehta rl, et al. covid-19 associated acute kidney injury: consensus report of the 25th acute disease quality initiative (adqi) workgroup. nature reviews nephrology. 2020;16:74764. 8. zhu n, et al. a novel coronavirus from patients with pneumonia in china. n engl j med. 2019;382:727-33. 9. wang d, et al. clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus infected pneumonia in wuhan, china. jama. 2020;323:1061-9. 10. wang l, et al. coronavirus disease 19 infection does not result in acute kidney injury: an analysis of 116 hospitalized patients from wuhan china. am j nephrol. 2020;s1:343-8. 11. chen n, et al. epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study: lancet. 2020:395:507-13. 12. cheng y, et al. kidney disease is associated with inhospital death of patients with covid-19. kidney int 2020;97:829-38. 13. guan wj et al. clinical characteristics of coronavirus disease 2019 in china. n engl j med. 2020;382:170820. 14. wu j, et al. clinical characteristics of imported cases of covid 19 in jiangsu province: a multicenter descriptive study. clin infect dis. 2020;71:706-12. 15. pel g, et al. renal involvement and early prognosis in patients with covid-19 pneumonia. j am sac nephrol. 2020;31;1157-65. 16. zhou f et al. clinical course and risk factors for mortality of adult in patients with covid 19 in wuhan china: a retrospective cohort study. lancet. 2020;395:1054-62. 17. hirsch j s, et al. acute kidney injury in patients hospitalized with covid 19. kidney int. 2020;98:20918. 18. gupta s, et al. factors associated with death in critically ill patients with coronavirus disease 20190 in the us. jama intern med. 2020. available from: https://doi. org/10.1001/jamainternmed2020.3596[2020] aida lydia acta med indones-indones j intern med 516 19. mehta rl, kellum ja, shah sv, et al. acute kidney injury network report of an initiative to improve outcomes in acute kidney injury. crit care. 2007;11(2):r31. 20. rifkin de, coca sg, kalantar zadeh k. does aki truly lead to ckd? j am soc nephrol. 2012;23(6):97984. 21. hsu cy. yes. aki truly leads to ckd. j am soc nephrol. 2012;23(6):967-9. 22. james mt, wald r. aki: not just a short-term problem? clin j am soc nephrol. 2014;9(3):435-6. 23. fortrie g, stads s, aamoudse azj, zietse r, betjes mg. long-term sequelae of severe acute kidney injury in the critically ill patient without comorbidity: a retrospective cohort study. plos one. 2015;10(3) e0121482 24. venkatachalam ma, weinberg jm, kriz w, bidani ak. failed tubule recovery, aki-ckd transition and kidney disease progression. j am soc nephrol. 2015;26(8):1765-76. 25. basile dp, donohoe d, roethe k, osborn jl. r e n a l i s c h e m i c i n j u r y r e s u l t s i n p e r m a n e n t damage to peritubular capillaries and influences long-term function. am j physiol renal physiol. 2001;281(5):f887-99. 26. basile dp. rarefaction of peritubular capillaries following ischemic acute renal failure: a potential factor predisposing to progressive nephropathy. curr opin nephrol hypertens. 2004;13(1):1-7. 27. coca sg, yusuf b, shlipak mg, garg ax, prikh cr. long-term risk of mortality and other adverse outcomes after acute kidney injury: a systematic review and meta-analysis. am j kidney dis. 2009;53(6):96173. 28. ahlstrom a, tallgren m, peltonen s, rasanen p, pettila v. survival and quality of life of patients requiring acute renal replacement therapy. intensive care med. 2005;31(9):1222-8. 29. wu vc, wu pc, wu ch, et al. the impact of acute kidney injury on the long-term risk of stroke. j am heart assoc. 2014;3(4). https://doi.org/101161/ jaha114000933 30. wu pc, wu ci, lin ci, wu vc, national taiwan university study group on acute renal failure g. long-term risk of upper gastrointestinal hemorrhage after advanced aki. clin j am soc nephrol. 2015;10(3):353-62. 31. perico n, codreanu i, schieppati a, remuzzi g. prevention of progression and remission/regression strategies for chronic renal disease can we do better now than five years ago? kidney int suppl. 2005;98:521-4. 32. ruggenenti p, schieppati a, remuzzi g. progression, remission, regression of chronic renal diseases. lancet. 2001;357(9268):1601-8. 33. mehta ri, pascaul mt, soroko s, et al. spectrum of acute renal failure in the intensive care unit: the picard experience. kidney int. 2004;66:1613-21. 34. tohwani a. continuous renal replacement therapy for acute kidney injury. n engl j med. 2012;367(26)250514. 35. soares dm, pessanha jf, sharma a, brocca a, ronco c. delayed nephrology consultation and high mortality on acute kidney injury: a meta analysis. blood purif. 2017;43(1-3):57-67. 36. flores-gama c, merino m, baranda f, cruz dn, ronco c, vazquez rangel a. the impact of integrating nephrologists into the postoperative cardiac intensive care unit: a cohort study. cardiorenal med. 2013;3(1):79-88. 37. kellum ja, lameire n, aspelin p, et al. kidney disease: improving global outcomes (kdigo) acute kidney injury work group. kdigo clinical practice guideline for acute kidney injury. kidney int supplement. 2012;2(1):1-138. review article 159acta med indones indones j intern med • vol 50 • number 2 • april 2018 obesity as the sequel of childhood stunting: ghrelin and ghsr gene polymorphism explained harry f.l. muhammad department of nutrition and health, faculty of medicine, public health and nursing, universitas gadjah mada, yogyakarta, indonesia. corresponding author: harry freitag luglio muhammad, m.sc, rd. department of nutrition and health, faculty of medicine, public health and nursing, universitas gadjah mada. jl. farmako, sekip utara, yogyakarta 55281, indonesia. email: harryfreitag@yahoo.com. abstrak stunting pada anak merupakan masalah gizi yang cukup signifikan di negara-negara berkembang seperti indonesia. stunting dapat memengaruhi perkembangan otak dan fungsi kognitif. beberapa studi menyebutkan bahwa stunting juga meningkatkan risiko kejadian obesitas saat dewasa dan hal ini berkaitan dengan pengaruhnya pada efisiensi metabolik. anak-anak yang mengalami stunting memiliki resting energy expenditure yang lebih rendah dibandingkan dengan anak-anak yang tidak mengalami stunting. anak dengan stunting juga memiliki respiratory quotient yang lebih tinggi dimana hal ini menandakan tingginya penggunaan karbohidrat sebagai sumber energi dibandingkan dengan penggunaan lemak. mekanisme inilah yang diperkirakan memperantarai hubungan antara stunting dengan obesitas yaitu rendahnya oksidasi lemak serta kecenderungan yang lebih tinggi untuk menyimpan lemak. review ini membahas status penelitian terbaru di bidang nutrigenetik mengenai hubungan antara stunting pada anak dan kejadian obesitas di saat dewasa. diperkirakan bahwa anak dengan stunting lebih mudah mengalami obesitas karena memiliki metabolic rate yang rendah. beberapa gen telah diteliti dan gen yang berkaitan dengan mekanisme kerja ghrelin diketahui terlibat pada fenomena ini. kata kunci: stunting, obesitas, ghrelin, growth hormone secretague receptor (ghsr), gen polimorfisme. abstract stunting or short stature in children is a significant nutritional problem in developing and underdeveloped countries. stunting during childhood might affect brain development and impair development cognitive function. additionally, this condition associated with the increased risk for obesity during adulthood. several studies have shown that the increment risk of obesity and overweight in children with a short stature was due to their metabolic efficiency. children with stunting have lower resting energy expenditure compared to non stunting children. additionally, stunted children has higher respiratory quotient and carbohydrate oxidation but lower fat oxidation compared to non-stunting children. these results might explain why stunted children easily become obese, which is due to lower fat oxidation and leading to tendency to store fat. this review discussed the current status on studies in the nutrigenetic aspects of the relationship between stunting in the childhood and obesity in adulthood. i hypothesized that stunted children are more likely to become obese in their later life because they have lower metabolic rate and higher tendency of fat storage. there are several candidate genes and pathway involved in obesity and i suspected that ghrelin and its receptor growth hormone secretague receptor (ghsr) were responsible. keywords: stunting, obesity, ghrelin, growth hormone secretague receptor (ghsr), gene polymorphism. harry f. l. muhammad acta med indones-indones j intern med 160 introduction stunting or short stature is a significant nutritional problem especially in developing and underdeveloped countries. in 2010, the worldwide prevalence of stunting in under five years old children was 27%.1 although the global trend of stunting declined in the past two decades, several countries still have remaining high prevalence of stunting. it was reported that in india, the prevalence of stunting reached 48%2 while in indonesia the prevalence of stunting was 37.2%.3 it is important to discuss the impact of stunting as a risk factor for obesity because the world prevalence of obesity itself increases remarkably in the past few decades. the increasing rate of obesity is also seen in the developing countries such as indonesia. the ministry of health reported that the prevalence of overweight and obesity in indonesia is also increasing. in 2013, the prevalence of overweight and obesity in women were 32.9% while in men were 19.7%.3 it is also important to prevent the further increment of obesity because its disease manifestation such as diabetes mellitus and cardiovascular diseases4 as well as its significant economic burden. there are several consequences on the effect of stunting during childhood. first, stunting might affect brain development and impair development of cognitive function.5 second, stunting in childhood associated with the risk factor for obesity during adulthood. although it is still a controversy, several investigations were leading to the hypothesis that childhood stunting associated with increased risk of obesity. it was before shown that there was an increment in the risk of obesity and overweight in stunted children and adolescents.6–10 children (2-4 years old) with stunting had much higher body mass index (bmi), percent body fat and waist-to-hip ratio compared to the non-stunting children.11 a study in brazilian children and adolescents showed that there was a connection between malnutrition during childhood (weight and height for-age) and obesity in adolescence and adulthood.12 the correlation between lower stature and higher incidence of obesity was also seen in a crosssectional study in germany.13 several studies have reported that the increment of risk of obesity and overweight in children with a short stature is associated with their metabolic properties. the possible mechanism has been reviewed before.14 it was shown that stunted school girls had higher susceptibility to gain weight from a high fat diet compared to non-stunted girls.15 hoffman et al.16 investigated metabolic properties of pre-pubertal boys and girls with and without stunting and showed that children with stunting have lower resting energy expenditure compared to non stunting children. stunted children has higher respiratory quotient and carbohydrate oxidation but lower fat oxidation compared to non-stunting children. these results might explain how stunted children tend to become obese. this is because they have lower fat oxidation during fasting which lead to tendency to store fat instead of using them to produce energy. this review discusses current status of research on the nutrigenetic aspect of the relationship between stunting in the childhood and obesity in adulthood. in this paper we hypothesized that the connection between stunting and obesity was due to low metabolic rate and higher tendency of fat storage. there are several candidate genes and pathway that are involved in obesity and we suspected that ghrelin and its receptor namely growth hormone secretagogue receptor (ghsr) were responsible. ghrelin and lipid metabolism ghrelin is a stomach derived hormone composed with 28 amino acids. this peptide is not only has orexigenic effect but also involved in human lipid metabolism. because ghrelin was associated with promotion of feeding and adiposity, several studies showed this protein level was associated with body weight.17–19 in human, ghrelin level reduced in obesity and raised in anorexia nervosa.20,21 in animal model, ghrelin or ghrelin receptor knockout mice model were protected from diet-induced obesity.22,23 ghrelin works through activation of growth hormone secretagogue receptor 1a (ghsr1a). this receptor is highly expressed in hypothalamus region that regulate feeding and body weight homeostasis.24,25 it has been investigated that the effect of ghrelin was via the vol 50 • number 2 • april 2018 obesity as the sequel of childhood stunting: ghrelin and ghsr 161 orexigenic neuropeptide agouti related protein (agrp) and neuropeptie (npy) in the activityregulated cytoskeleton associated protein (arc). additionally, ghrelin also affect body fat though regulation of two important lipid metabolism pathways: de novo lipogenesis and fatty acid oxidation.25 the raised ghrelin level increased mrna expression of enzyme involved in de novo lipogenesis such as lipoprotein lipase (lpl), fatty acid synthase (fas) and stearoyl-coa desaturase (scd 1). ghrelin also induced reduction in carnitine palmitoyltransferase 1 (cpt 1) expression, an important protein that involved in regulation of fatty acid oxidation. the end process of this reaction is that the body tend to store fat and not using it for energy usage25 and because ghrelin level increased during fasting period, this metabolic process make sure that our metabolism is in higher energy efficiency. this is an human adaptation towards low food supply to decrease negative energy balance.26 ghrelin in stunting and obesity the role of ghrelin on growth in childhood and development of stunting are still controversial. in the early investigation of the physiology of ghrelin in human, it was stated that ghrelin level is varied depend on stage of development of the children. ghrelin level during pre-pubertal stage was higher than those in pubertal stage.27 interestingly, ghrelin level was negatively correlated with growth stimulating hormones such as insulin like growth factor-i (igf-i) leading to an assumption that reduction ghrelin level during late puberty is responsible for acceleration of growth within the period. however, in the study they did not found the correlation between ghrelin level and height in healthy children and adolescents.27 in order to further investigate the role of ghrelin on growth and stature, a study was done to compared ghrelin level in children with constitutional delay of growth (and puberty) (cdgp) (height standard deviation score/sds < -2), familial short stature (fss) (height sds <-2) and normal height (height sds >-2 and <2)(28). in the study they showed that children with cdgp and fss had a much higher ghrelin compared to normal height children.28 however, these findings were different with the finding from sen et al.29 in the study they showed that there were no significant differences in fasting ghrelin level or postprandial ghrelin level in children with cdgp compared to normal children, although there is a trend that children with cdgp had higher ghrelin level compared to normal children. the association between ghrelin and obesity is controversial and to date there is no exact evidence on whether ghrelin induces obesity or the state obesity induces disturbance in ghrelin production/action. one of the earliest reports on ghrelin level in human obesity was done by tschöp et al.20 they compared the plasma ghrelin concentration of obese and normal weight individuals and found that ghrelin concentration in obese caucasian was significantly lower compared to those in their normal weight counterpart. the result from this study was different with those found cruz-domínguez et al.30 who showed that ghrelin concentration in obese individuals (with bmi >30 and <40) was significantly higher compared to their normal counterpart. there were some explanations about the differences between studies. first, it seems that ethnicity has a role in the level of ghrelin since tschöp et al.20 suggested that caucasians have a significantly higher ghrelin level compared to the pima indians. second, the degree of insulin resistance or diabetes mellitus between obese individuals seems also have an influence on regulating ghrelin production. this was due to the fact that obese individuals with diabetes mellitus had a significantly lower ghrelin level compared to those without diabetes mellitus.30 additionally, it is very important to acknowledge that to work properly, ghrelin requires enzyme activation and sufficient receptor sensitivity. ghrelin should undergo an o-n-octanoylation process before activating ghsr. this process is mediated by an enzyme called ghrelin o-acyl transferase (goat) with the acyl originated from medium-chain fatty acids.31–33 in addition to goat, ghsr is also an important part that regulates the phenotypical harry f. l. muhammad acta med indones-indones j intern med 162 function of ghrelin. this is supported by the report showed that ghrelin antagonists and ghsr gene knockout model has ability to reduce ghrelin induced physiological function.23,33,34 ghsr gene polymorphism in stunting and obesity the role of single nucleotide polymorphism (snp) of ghsr on ghsr activity and obesity has been extensively studied in the past ten years. inoue et al35 screened for genetic mutations of ghsr gene in japanese patients with familial short stature and growth hormone deficiency. in the study they discovered 4 mutation points that were connected with ghsr activity including δq36 (106-108 del cag), p108l (323c>t), c173r (517t>c), and d246a (737a>c). most of the mutations have a significant impact on constitutive signaling activity of ghsr. this was done through various mechanism including intracellular retention; reduction in binding activity to ghrelin; and impaired agonistand inverse agonist – stimulated receptor signal. those data then supported by findings done by pugliese-pires et al36 who showed that transfection with a plasmid encoding ser84ile mutation induce reduction of ghsr expression at the surface of hek293 cells. there were some reports on clinical phenotypes of ghsr gene polymorphism especially on individual’s stature and obesity. the reports on genetic association between ghsr polymorphism, stature and obesity have been reviewed elsewhere.37 a large cohort study conducted by riedl et al(38) in australia followed 1362 children from birth to 10 years old. in the study they showed that there were 2 important snps including snps in rs482204 and rs562416. tt genotype in rs482204 vs tc/cc was associated with greater stature across the entire observation period while tt genotype in rs562416 vs tg/gg was correlated positively with tall stature at 3, 8, and 10 years old. these associations were not seen in french population.39 in our study, we showed that ghsr gene polymorphisms were slightly to be associated with stature in obese adolescent girls.40 (figure 1) despite the fact that only limited studies reporting the relationship between ghsr gene polymorphism and obesity, few of the results were tend to be controversial.37 it was showed that ghsr gene knock out model had a different properties in energy intake and adiposity.23 ghsr-null mice were failed to response to ghrelin signal thus eat less food and store less fat compared to the wild type mice. one of the in this study we analyzed two snps in ghsr include rs292216 and rs509035. in our previous study we showed the trend that aa genotype in ghsr gene rs292216 were more likely to have lower z score compared to those with at and tt. because all subjects were adoloescents, height was analyzed using a height-to-age z score. p-value was obtained from t-test by comparing mean height-for-age z score between aa genotype and at+tt genotype. figure 1. the association between height-for-age z score and ghsr gene polymorphism in obese female adolescents. vol 50 • number 2 • april 2018 obesity as the sequel of childhood stunting: ghrelin and ghsr 163 earlier investigations on snp in ghsr and obesity in human was done by baessler et al.41 who showed that snps and haplotypes within ghsr gene region were associated with obesity. interestingly, this result cannot be replicated by studies from european region.41 gueorguiev et al.42 showed that ghsr gene polymorphism rs572169 was significantly associated with obesity but the significance the diminished after corrected for multiple comparisons. in this review, author proposed an idea that ghrelin plays an important role in the connection between stunting in childhood and obesity in adulthood. this was based on trend that stunted children and obese adults possessed similar pattern on ghrelin concentration and ghsr sensitivity. author also proposed that ghsr gene polymorphism was previously reported to induce lack of ghrelin sensitivity. unfortunately, today there was no study that clearly demonstrated that ghsr gene polymorphism is induces stunting in children and obesity in adulthood by affecting individuals ghrelin concentration. in the future, it will be interesting to clarify the role of ghsr gene polymorphism and ghrelin sensitivity on stunting children followed until adults. since ghrelin appears to have role in development of short stature in children, developing a treatment targeting ghrelin and its receptor pathway could be potential to be done in the future. this is probably could be used as one of the treatment for stunted children to prevent future development of obesity. conclusion in summary, author supported the idea that stunted children were at higher risk of obesity in their adult life. this was due to the shifting in their metabolic properties which are likely to store fat and not using fat for the source energy. ghrelin was believed to have a role in this metabolic property because studies showed that there is disturbance in ghrelin concentration in stunted children. the disturbance of ghrelin sensitivity was associated with ghsr gene polymorphism and because ghsr gene polymorphism is associated ghrelin sensitivity, author suggested that this gene can explain the connection between stunting in childhood and obesity in adulthood. conflict of interest and funding disclosure there is no conflict of interest during writing this paper. there is no financial support from any institutions during the writing for this manuscript. references 1. de onis m, blössner m, borghi e. prevalence and trends of stunting among pre-school children, 1990– 2020. public health nutr. 2012;15(01):142–8. 2. international institute for population sciences & macro international. national family health survey (nfhs3), 2005–06: india: 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cordido f, et al. ghrelin and lipid metabolism: key partners in energy balance. j mol endocrinol. 2011;43–63. 26. nogueiras r, lópez m, diéguez c. regulation of lipid metabolism by energy availability: a role for the central nervous system. obes rev. 2010;11(13):185–201. 27. whatmore aj, hall cm, jones j, westwood m, clayton pe. ghrelin concentrations in healthy children and adolescents. clin endocrinol (oxf). 2003;59(5):649– 54. 28. camurdan mo, bideci a, demirel f, cinaz p. serum ghrelin, igf-i and igfbp-3 levels in children with normal variant short stature. endocr j. 2006;53(4):479– 84. 29. şen ta, şimflek dg, darcan ş, çoker m. ghrelin levels in children with constitutional delay of growth and puberty. jcrpe j clin res pediatr endocrinol. 2010;2(3):117–21. 30. cruz-domínguez mp, cortés dhm, zarate a, et al. relationship of ghrelin, acid uric and proinflammatory adipocytokines in different degrees of obesity or diabetes. int j clin exp med. 2014;7(5):1435–41. 31. gutierrez ja, 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delay of growth and puberty. eur j endocrinol. 2011;165(2):233–41. 37. gueorguiev m, korbonits m. genetics of the ghrelin system. ghrelin system. 2013;25–40. 38. riedl s, hughes i, harris m, et al. gh secretagogue receptor gene polymorphisms are associated with stature throughout childhood. eur j endocrinol. 2012;166(6):1079–85. 39. gueorguiev m, lecoeur c, benzinou m, et al. a genetic study of the ghrelin and growth hormone secretagogue receptor (ghsr) genes and stature. ann hum genet. 2009;73(1):1–9. 40. luglio hf, inggriyani cg, huriyati e, julia m sr. association of snps in ghsr rs292216 and rs509035 on dietary intake in indonesian obese female adolescents. int j mol epidemiol genet. 2014;5(4):195–9. 41. baessler a, hasinoff mj, fischer m, et al. genetic linkage and association of the growth hormone secretagogue receptor (ghrelin receptor) gene in human obesity. diabetes. 2005;54:259–67. 42. gueorguiev m, lecoeur c, meyre d, et al. association studies on ghrelin and ghrelin receptor gene polymorphisms with obesity. obesity (silver spring). 2009;17(4):745–54. 118 original article acta med indones indones j intern med • vol 49 • number 2 • april 2017 effect of metformin on handgrip strength, gait speed, myostatin serum level, and health-related quality of life: a double blind randomized controlled trial among non-diabetic pre-frail elderly patients purwita w. laksmi1, siti setiati1, tirza z. tamin2, pradana soewondo1, wasilah rochmah3, nafrialdi4, joedo prihartono5 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of physical medicine and rehabilitation, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 3 department of internal medicine, faculty of medicine universitas gajah mada sardjito hospital, yogyakarta, indonesia 4 department of pharmacology and therapeutic, faculty of medicine universitas indonesia, jakarta, indonesia. 5 department of community medicine, faculty of medicine universitas indonesia, jakarta, indonesia. corresponding author: prof. siti setiati, md., phd. division of geriatric, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: s_setiati@yahoo.com. abstrak latar belakang: sarkopenia berkontribusi terhadap terjadinya sindrom frailty. sindrom frailty berpotensi membaik dengan memodifikasi faktor inflamasi, resistensi insulin, dan miostatin. penelitian ini bertujuan mempelajari pengaruh metformin terhadap kekuatan genggam tangan, kecepatan berjalan, konsentrasi miostatin serum, dan kualitas hidup terkait kesehatan pada pasien lanjut usia (lansia) non-diabetes dengan pre-frail. metode: studi ini merupakan uji klinis acak tersamar ganda yang dilakukan pada pasien rawat jalan berusia ≥ 60 tahun dengan status pre-frail berdasarkan kriteria fenotip dan/atau indeks (cardiovascular health study dan/ atau frailty index 40 items) di rumah sakit cipto mangunkusumo yang direkrut dari bulan maret 2015 sampai juni 2016. subjek yang memenuhi kriteria penelitian dirandomisasi menjadi grup metformin (3 x 500 mg) atau grup plasebo (amilum 3 x 500 mg). luaran penelitian diukur pada awal studi dan 16 minggu setelah intervensi. hasil: dari 120 subjek, 43 subjek dari grup metformin dan 48 subjek dari grup plasebo yang menyelesaikan penelitian. terdapat peningkatan kecepatan berjalan pada kelompok metformin sebesar 0,39 (0,77) detik atau 0,13 (0,24) meter/detik yang tetap bermakna setelah disesuaikan dengan faktor prognostik penting (p=0,024). tidak didapatkan perbedaan bermakna kekuatan genggam tangan, konsentrasi miostatin serum, dan kualitas hidup terkait kesehatan antara kedua kelompok perlakuan. kesimpulan: pemberian metformin 3 x 500 mg selama 16 minggu secara bermakna meningkatkan kecepatan berjalan sebagai salah satu dimensi kualitas hidup terkait kesehatan, namun tidak meningkatkan secara bermakna skor indeks eq-5d, kekuatan genggam tangan, dan konsentrasi miostatin serum. kata kunci: kecepatan berjalan, kekuatan genggam tangan, kualitas hidup, metformin, miostatin, pre-frail, lanjut usia. vol 49 • number 2 • april 2017 effect of metformin on handgrip strength, gait speed, myostatin serum 119 abstract background: sarcopenia contributes to the development of frailty syndrome. frailty syndrome is potentially improved by modifying insulin resistance, inflammation, and myostatin level. this study is aimed to investigate the effect of metformin on handgrip strength, gait speed, myostatin serum level, and health-related quality of life (hr-qol) among non-diabetic pre-frail elderly patients. methods: a double blind randomized controlled trial was conducted on non-diabetic elderly outpatients aged ≥ 60 years with pre-frail status based on phenotype and/ or index criteria (cardiovascular health study and/ or frailty index 40 items) consecutively recruited from march 2015 to june 2016 at cipto mangunkusumo hospital. one-hundred-twenty subjects who met the research criteria were randomized and equally assigned into 3 x 500 mg metformin or placebo group. the study outcomes were measured at baseline and after 16 weeks of intervention. results: out of 120 subjects, 43 subjects in metformin group and 48 subjects in placebo group completed the intervention. there was a significant improvement on the mean gait speed of metformin group by 0.39 (0.77) second or 0.13 (0.24) meter/second that remained significant after adjusting for important prognostic factors (p = 0.024). there was no significant difference on handgrip strength, myostatin serum level, and hr-qol between both groups. conclusion: 3 x 500 mg metformin for 16 weeks was statistically significant and clinically important in improving usual gait speed as one of the hr-qol dimensions, but did not significantly improve the eq-5d index score, handgrip strength, nor myostatin serum level. keywords: elderly, gait speed, handgrip strength, health-related quality of life, metformin, myostatin serum, pre-frail. introduction sarcopenia, a progressive loss of muscle mass and function with advancing age, leads to decreased metabolic rate, muscle strength, and maximal vo2 resulting in clinical/ phenotypic manifestations of frailty syndrome (i.e. physical frailty) that is characterized by weight loss, exhaustion, weakness, slowness, and low physical activity level.1 sarcopenia is considered to be related to myostatin, a transforming growth factor-β (tgf-β) that trigger muscle protein degradation which leads to muscle growth inhibition.2,3 frailty syndrome is a continuum spectrum of normal/ robust, pre-frail, and frail states with dynamic transition from robustness to frailer state and vice versa.4 inflammation, insulin resistance, diabetes mellitus (dm), low vitamin d concentration and protein intake, poly-pharmacy (> 4 medications), and depression have significant association with the incidence of frailty syndrome.5–11 administration of metformin potentially improves frailty syndrome by modifying insulin resistance, hyperglycemia, inflammation, and myostatin level. not only does metformin activate cellular metabolic adenosine monophosphate-activated protein kinase (ampk), it also inhibits nuclear factor-ĸb (nf-ĸb) and mammalian target of rapamycin (mtor).12–14 metformin also improves na+k+atpase activity and increases circulating nitric oxide which optimize cellular energy production.15 on the other hand, previous studies indicated that ampk may trigger muscle protein degradation and down-regulate muscle protein synthesis by stimulating myostatin expression and mtor signal.16,17 bulcao et al18 study showed that 16-weeks administration of 2 x 850 mg metformin for pre-diabetic subjects significantly decreased body mass index (bmi), inflammation mediators (c-reactive protein/ crp and interleukin-6/ il6), and fasting blood glucose as well as improved insulin resistance (evaluated by homa ir). esteghamati et al19 reported that administration of 1000 mg metformin/day for 12 weeks in newly diagnosed type-2 diabetes mellitus (dm) patients significantly improved oxidative stress. furthermore, previous in vitro study showed that metformin increased the myostatin expression and myostatin protein level in c2c12 myotubes at low concentration (0.5 mm), but downregulated them at higher concentration (1.5 and 2.0 mm).17 purwita w. laksmi acta med indones-indones j intern med 120 a case-control study indicated the protective effect of metformin against frailty syndrome. this study showed significant difference of frailty status between metformin-treated and non-metformin-treated type-2 dm patients.20 however, there is no randomized, double blind, clinical trial on the effect of metformin on frailty syndrome, especially its effect on physical components of frailty syndrome and myostatin serum level. the aim of this study was to investigate the effects of metformin with the dose of 500 mg three times daily for 16 weeks on handgrip strength, gait speed, myostatin serum level, and health-related quality of life (hrqol) among non-diabetic pre-frail elderly. to the best of authors’ knowledge, this was the first study that investigated the effect of metformin administration in order to prevent physical frailty in non-diabetic pre-frail elderly. it was also the first study that investigated the effect of metformin on myostatin serum level in human. methods this was a double blind randomized controlled trial. subjects were allocated in each treatment group using permuted block randomization with block size of four and the code lists were concealed. investigators, doctors, and subjects were blinded to treatment allocation (double blind). study participants elderly outpatients aged 60 years and older with pre-frail status based on cardiovascular health study (chs)1 and/ or frailty index 40 items (fi 40 items) score,21 were consecutively recruited from march 2015 to june 2016 at geriatric and internal medicine clinic in cipto mangunkusumo hospital, jakarta, indonesia. exclusion criteria were unwillingness to participate in this study, malnutrition (body mass index/ bmi < 18.5 kg/m2 or mini nutritional assessment/ mna full form score < 17), diabetes mellitus, cognitive impairment (abbreviated mental test/amt score < 8), depression (geriatric depression scale/ gds score ≥ 10), acute phase of disease(s), and contraindication(s) to metformin. the minimum sample size for gait speed outcome was 29 subjects, whereas for handgrip strength, myostatin serum level, and hr-qol outcomes were 60 subjects for each treatment group. intervention protocol after giving written consent, eligible subjects were randomly assigned to metformin (3 x 500 mg) or placebo (amylum 3 x 500 mg) group for 16 weeks of intervention. both metformin and placebo capsules prepared by the hospital’s pharmacy unit were indistinguishable. the allocated treatment was dispensed to the subjects every four weeks. the collected data consist of subjects’ demographic data (age, sex, income, level of education), clinical data (illnesses and medications history), functional status (barthel index basic activity of daily living/ b-adl and lawton instrumental activity of daily living/ l-iadl), mental status (gds), cognitive status (amt), frailty status (chs and fi 40 items), level of activities (physical activity scale for the elderly/ pase), sarcopenia status (asian working group of sarcopenia/awgs criteria),22 anthropometry measurements, nutritional status (mna full form as well as food record of two weekdays and one holiday), and body composition (bioelectrical impedance analysis/ bia tahita sc 330). fasting venous blood samples were collected for myostatin serum level, oral glucose tolerance test (ogtt) as well as liver and renal function test. the measurement of study outcomes was conducted at baseline and after 16 weeks of intervention. handgrip strength of dominant hand was assessed using jamar hydraulic handheld dynamometer model j00105 and was conducted in accordance with american society of hand therapist (asht) recommended procedure.23 the 15-feet walk test was performed to measure usual gait speed. myostatin serum level was measured using elisa kit immundiagnostik ag, bensheim, germany cat #k1012. healthrelated quality of life was assessed using euro quality of life-5 dimensions (eq-5d) questionnaire with 3 likert scale. adverse events, drug’s side effects, compliance, level of activities, consumption of other medications, and co-morbidities were evaluated every four weeks. vol 49 • number 2 • april 2017 effect of metformin on handgrip strength, gait speed, myostatin serum 121 ethics this study was approved by the ethical committee of faculty of medicine universitas indonesia/ cipto mangunkusumo hospital (no. 69/un2.f1/etik/2015) and registered in clinical trial database www.clinicaltrials.gov with identifier number nct02325245. the study procedure was performed in accordance with the helsinki, guideline for good clinical practice from ich tripartite guideline (ich-gcp). statistical analysis data analysis were done using spss 20. drop-out subjects were excluded from the analyses (per protocol analysis). intention-totreat (itt) analysis was used to estimate the treatment’s efficacy in order to get the number needed-to-treat (ntt). ancova statistic test was used to analyze the study outcomes of the two assigned groups, since some important prognostic factors of the baseline subjects’ characteristics (including numerical and categorical data) were unequal. results despite recruiting 153 elderly patients to participate in the study, as many as 33 subjects were excluded from this clinical trial (of which 16 patients declined to participate and 17 did not meet the research criteria) which resulted in 120 subject who were randomized and equally assigned into metformin or placebo group (60 subjects in each group). there were 43 subjects in metformin group and 48 subjects in placebo group who completed the intervention (figure 1). from 91 subjects who completed the intervention, the mean age was 68.97 (5.34) years old and more than half (62.64%) were female. the top four co-morbidities in both groups were hypertension, dyslipidemia, knee osteoarthritis (oa), and stable coronary artery disease. there was no subject with sarcopenia based on awgs criteria. compared to subjects in placebo group, subjects in metformin group were less likely to have dyslipidemia, knee oa, and cirs score >5, but more likely to be enrollment: assessed for eligibility (n = 153) excluded (n = 33) � did not meet inclusion criteria (n = 17) � declined to participate (n = 16) � other reasons (n = 0) analyzed (n = 43) � lost to follow-up (reason: death) (n = 1) � discontinued intervention (n = 16), reasons: 2 poor compliances, 14 drug adverse effects allocated to metformin (n = 60) � lost to follow-up (n = 0) � discontinued intervention (n = 12), reasons: 7 poor compliances, 5 drug adverse effects allocated to placebo (n = 60) analyzed (n = 48) randomized (n = 120) figure 1. flow diagram of randomized clinical trial purwita w. laksmi acta med indones-indones j intern med 122 younger, consume acetylsalicylic acid (asa), as well as to have higher fat mass, bmi, upper arm muscle circumference, calf circumference, skeletal muscle index, and handgrip strength (table 1 and table 2). table 1. baseline demographic characteristic of the subjects characteristics metformin (n=43) placebo (n=48) age (years), median (min–max) 67.77 (5.14) 70.04 (5.34) sex, n (%) female 24 (55.8) 33 (68.8) male 19 (44.2) 15 (31.2) level of education, n (%) low 3 (7) 5 (10.4) moderate 10 (23.2) 13 (27.1) high 30 (69.8) 30 (62.5) co-morbidity, n (%) hypertension 38 (88.4) 39 (81.3) dyslipidemia 24 (55.8) 37 (77.1) knee osteoarthritis 23 (53.5) 30 (62.5) coronary artery disease 17 (39.5) 11 (22.9) cirs score, n (%) ≤ 5 22 (51.2) 17 (35.4) > 5 21 (48.8) 31 (64.6) poly-pharmacy, n (%) yes 31 (72.1) 38 (79.2) no 12 (27.9) 10 (20.8) medications used, n (%) statin 36 (83.7) 42 (87.5) proton pump inhibitor (ppi) 25 (58.1) 31 (64.6) angiotensin receptor blocker (arb) 28 (65.1) 24 (50) acetylsalicylic acid (asa) 24 (55.8) 13 (27.1) calcium-vitamin d supplement 9 (20.9) 16 (33.3) ace inhibitor 5 (11.6) 7 (14.6) table 3 shows that the baseline mean walking time in metformin group was 4.05 (0.93) seconds which represented the mean usual gait speed of 1.18 (0.26) meter/second, whereas the mean walking time in placebo group was 4.29 (1.38) seconds which represented the mean usual gait speed of 1.14 (0.26) meter/second. the table 2. baseline characteristic of subjects’ nutritional status parameter characteristics metformin (n=43) placebo (n=48) anthropometry measurements, mean (sd) mid-arm circumference (cm) 31.65 (3.3) 28.35 (2.93) male 30.08 (2.98) 28.00 (3.09) female 32.89 (3.06) 28.51 (2.88) upper-arm muscle circumference (cm) 24.37 (2.33) 22.41 (1.88) male 24.79 (2.54) 22.73 (1.40) female 24.09 (2.15) 22.27 (2.07) waist circumference (cm) 94.44 (9.56) 87.35 (9.71) male 93.23 (10.24) 88.02 (11.35) female 95.39 (9.09) 87.05 (9.04) thigh circumference (cm) 51.88 (4.35) 46.95 (4.69) male 50.44 (4.57) 46.46 (3.44) female 53.00 (3.89) 47.17 (5.19) calf circumference (cm) 37.22 (3,20) 34.74 (3.90) male 36.76 (2,78) 35.87 (3.67) female 37.59 (3,51) 34.22 (3.93) bmi (kg/m2) 27.40 (3.15) 23.90 (3.10) male 26.17 (3.28) 23.91 (2.85) female 28.37 (2.73) 23.90 (3.25) body composition muscle mass (kg), median (min–max) 39.8 (34.0–62.8) 37.4 (29.3–59.7) muscle mass index (kg/m2), median (minmax) 16.23 (14.69–20.35) 15.42 (12.77–20.66) male, mean (sd) 18.89 (1.38) 18.14 (1.19) female, mean (sd) 15.79 (0.51) 14.79 (0.97) fat mass (kg), mean (sd) 22.92 (8.25) 17.63 (6.81) male 16.52 (6.32) 13.16 (5.13) female 27.99 (5.7) 19.66 (6.55) dietary intake energy (kcal), mean (sd) 1,434.60 (320.87) 1,418.27 (265.32) protein (gram), mean (sd) 47.53 (11.80) 46.56 (12.09) vitamin d (mcg), median (min–max) 4.3 (0.1–20.8) 2.8 (0.1–17.10) calcium (mg), median (min–max) 304.5 (66.3-2,451.5) 372.25 (79.7–2,848.7) ogtt, mean (sd) fasting (mg/dl) 89.47 (9.26) 88.81 (8.85) post 75 gr glucose load (mg/dl) 127.67 (30.48) 136.31 (30.68) pre-diabetes, n (%) 18 (41.9) 21 (43.8) vol 49 • number 2 • april 2017 effect of metformin on handgrip strength, gait speed, myostatin serum 123 baseline median handgrip strength in metformin group was 24 (12–45) kg, whereas in placebo group was 20 (14–38) kg. the baseline median myostatin serum level of all subjects was 35.26 (17.77–133.95) ng/ml. the baseline median eq-5d index score in metformin group was 0.77 (0.57–1.0) with eq-5d vas score of 80 (40–90), whereas the median eq-5d index score in placebo group was 0.77 (0.59–1.0) with eq5d vas score of 75 (48–100). the compliance rate of both groups was good, which was 91.05 (5.67)% in metformin group and 91.74 (5.96)% in placebo group. ancova statistic test showed that at the end of intervention there was a significant difference in usual gait speed between metformin and placebo group, which remained statistically significant even after adjusting for age, sex, knee oa, acetylsalicylic acid consumption, as well as baseline handgrip strength, calf circumference, and bmi (table 4). the mean walking time in metformin group became 0.39 (0.77) seconds shorter than baseline. in other words, there was a significant improvement on usual gait speed by 0.13 (0.24) meter/second. although there was a significant difference in handgrip strength between metformin and placebo group in unadjusted model, the difference was statistically insignificant after adjusting for important prognostic factors. moreover, there were also no significant difference in myostatin serum level and hr-qol between the two groups (table 4). until the end of intervention, the dietary intake as well as physical activity level of the table 3. baseline characteristics of subjects’ level of activity, frailty status, and study outcomes characteristics metformin (n=43) placebo (n=48) b-adl score, n (%) independence 38 (88.4) 43 (89.6) mild dependency 5 (11.6) 5 (10.4) pase score (kcal per week), mean (sd) 1,200.69 (619.11) 1,206.82 (585.71) fi 40 items score, mean (sd) 0.147 (0.040) 0.151 (0.040) handgrip strength (kg), med (min– max) 24 (12–45) 20 (14–38) male, mean (sd) 32.53 (5.65) 27.27 (5.00) female, median (min–max) 20 (12–26) 18 (14–38) walking time (second), mean (sd) 4.05 (0.93) 4.29 (1.38) male 3.68 (0.78) 3.79 (0.69) female 4.35 (0.94) 4.52 (1.56) gait speed (meter/ second), mean (sd) 1.18 (0.26) 1.14 (0.26) male 1.29 (0.25) 1.24 (0.23) female 1.10 (0.25) 1.09 (0.27) myostatin serum level (ng/ml), median (min–max) 35.72 (17.77–56.85) 34.83 (18.33–133.95) health-related quality of life: eq-5d index score, median (min–max) 0.77 (0.57–1.0) 0,77 (0.59–1.0) health-related quality of life: eq-5d vas score, median (min–max) 80 (40–90) 75 (48–100) drug compliance (%), mean (sd) 91.05 (5.67) 91.74 (5.96) table 4. the effect of metformin on handgrip strength, walking time, myostatin serum level, and health-related quality of life study outcomes unadjusted p adjusted∞ pmetformin placebo metformin placebo mean (95%ci) mean (95%ci) mean (95%ci) mean (95%ci) handgrip strength (kg) 25.47 (23.51–27.42) 21.90 (20.04–23.75) 0.010 23.39 (22.28–24.49) 23.50 (22.57–24.44) 0.877 walking time (second) 3.66 (3.32–3.99) 4.25 (3.94–4.57) 0.012 3.72 (3.37–4.06) 4.23 (3.94–4.52) 0.024 myostatin serum level (ng/ ml) 35.77 (32.65–38.89) 36.58 (33.62–39.53) 0.711 34.82 (31.69–37.95) 37.43 (34.48–40.38) 0.244 eq-5d index score 0.83 (0.79–0.87) 0.82 (0.78–0.86) 0.761 0.85 (0.80–0.89) 0.83 (0.79–0.87) 0.660 ∞ ancova test purwita w. laksmi acta med indones-indones j intern med 124 metformin and placebo group were similar (data not shown). gastrointestinal symptoms, such as diarrhea, nausea, bloated, and epigastric pain were the side effects of metformin commonly reported in this study. there were five serious adverse events (saes) in metformin group: death after heart attack, recurrent stroke, malleolus ulcers, diarrhea, and melena. discussion according to the awgs criteria, the median handgrip strength in both intervention groups were within normal limit. similarly, the mean usual gait speed of both groups were also good, which were above 1 meter/second.22 at the end of intervention, the mean walking time in metformin group improved significantly by 0.39 (0.77) seconds which represented the mean gait speed improvement by 0.13 (0.24) meter/second. this finding is consistent with lee et al24 cohort study which reported that the decrease in gait speed among diabetic patients who received insulin sensitizer drugs (metformin or thiazolidinedione) was not only lesser than diabetic patients who received other types of oral anti-diabetic drugs but also lesser than nondiabetic patients. previous study indicated that the minimum improvement of gait speed by 0.05 meter/second is considered significant, whereas a 0.10 meter/ second change in gait speed is considered a substantial improvement.25 the age-adjusted relative risk ratio per 0.1 meter/second greater speed for b-adl dependence was 0.68 (95%ci 0.57–0.81) among male and 0.74 (95%ci 0.66–0.82) among female.26 every 0.1 meter/ second decrease in gait speed was also associated with a 7% increase in risk for falls.27 metaanalysis of 9 cohorts concluded that gait speed was associated with survival with pooled hr 0.88 (95%ci 0.87–0.90) per 0.1 meter/second improvement.28 hence, the 0.13 (0.24) meter/ second improvement of usual gait speed found in our study was not only statistically significant but also clinically important. insulin resistance state decreases muscle mass and muscle contractility due to cytokine, increased myostatin expressions, and ineffective insulin activity which result in reduction of blood flow and skeletal muscle glucose uptake, as well as muscle protein degradation.17,29 kuo et al30 study reported that among non-diabetic elderly patients, every 1 standar deviation increment of homa-ir value was parallel with a decrease in gait speed of 0.04 meter/second (p=0.003). the significant gait speed improvement in metformin group might be caused by the improvement in insulin resistance state, inflammation, oxidative stress, and nitric oxide. our study did not assess the laboratory parameter of inflammation nor insulin resistance. however, the significant decrease in bmi and waist circumference among subjects in metformin group (data not shown) might represent the improvement in their insulin resistance state. our study showed that handgrip strength was not a suitable parameter to investigate the effects of metformin. the purpose of handgrip strength measurement is to evaluate the isometric hand muscle contraction which is a sudden, fast, and high force activity. the muscle fibers that are particularly involved in this kind of activity are type-ii muscle fiber (fast twitch) whose source of energy comes from anaerobic metabolism of atp and creatine phosphate stored in the muscle.31,32 it seems that metformin has no important role in the utilization of stored atp and creatine phosphate to produce that kind of energy. furthermore, metformin was not found to increase muscle mass (data not shown), thus the stored atp and creatine phosphate in the muscle which are parallel with higher muscle mass was probably not elevated. in contrast to handgrip strength test, the 15feet (~4.57 meter) walking test is a dynamic, constant, and rhythmic muscle contraction without inflicted fatigue on oxygen transport system. the source of energy for this kind of activity may not only derive from anaerobic metabolism of creatinine phosphate, but also from glycogen and glucose aerobic metabolism. metformin administration increases the glucose and calcium uptake of the skeletal muscle by improving the insulin resistant state.13,29,32,33 therefore, gait speed improvement occurred in the metformin group. however, further investigation on the mechanism of how metformin improves gait speed is needed, especially regarding the vol 49 • number 2 • april 2017 effect of metformin on handgrip strength, gait speed, myostatin serum 125 muscle energy metabolism. intention-to-treat analysis on the absence or presence of increased gait speed of > 0.1 meter/second showed that there were 40 events out of 60 subjects (66.7%) in the metformin group and 45 events out of 60 subjects (75%) in the placebo group. absolute risk reduction (arr) was 8.3% (95%ci -7.9–24%; p = 0.422) which resulted in nnt of 12. it was suggested that the administration of metformin to 12 pre-frail elderly patients was needed to add one gait speed improvement of > 0.1 meter/second. the myostatin serum levels in this study was higher than what was reported in ryan et al34 study but almost similar to the mean plasma myostatin level in hittel et al35 study. the varying results in myostatin serum/ plasma level among studies are assumed to be related to distinct elisa assays of different antigen and antibody combinations with variances in the sensitivity and specificity, whether it measures both the mature active c-terminal dimer of myostatin and the n-terminal propeptide or it specifically measures the active c-terminal dimer. moreover, the mean and higher proportion body mass index of our subjects were classified as overweight–obese (based on asia-pacific criteria36) and 42.9% of the subjects were in prediabetic state. it has been reported that mrna myostatin expression in muscle and serum/ plasma myostatin level are increased in insulin resistant state and obesity.2,3,35,37 therefore, those factors also contributed to the higher myostatin serum level in our study. at the end of observation, our study did not find significant difference in myostatin serum level between metformin and placebo group. there was also no significant difference in myostatin serum level before and after intervention among subjects in metformin group. previous in vitro study showed inconclusive result whether metformin increases or decreases myostatin level.17 in contrast to our study, ryan et al34 and hittel et al35 reported that exercise, which is another ampk activator, significantly affected myostatin serum/ plasma level. however, those studies were not randomized controlled trials. myostatin level can be evaluated by measuring its concentration in serum or plasma and detecting mrna expression of myostatin in muscle. mrna expression of myostatin in the muscle represents biological activity of myostatin in the body. unfortunately, muscle biopsy to measure mrna expression of myostatin was not conducted in our clinical trial. furthermore, changes in mrna expression of myostatin in muscle are not always followed by changes in myostatin serum or plasma level. brandt et al38 reported that although mrna myostatin expressions in muscle were 1.4 times higher in type 2 dm subjects compared to normal subjects, there was no significant difference in plasma myostatin level between the two groups. therefore, whether metformin affected mrna expression of myostatin in skeletal muscle or not was still unknown. the median score of eq-5d index in our study was quite good since most subjects had good functional status with b-adl score ranged 19–20 and our study excluded subjects with depression and cognitive impairment. administration of metformin for 16 weeks did not show improvement in hr-qol among elderly outpatients. it seems that metformin did not directly enhance the overall hr-qol, but rather improved the mobility which is considered as one of the many dimensions of hr-qol. in the future, improvement in mobility is expected to increase patient’s capability in daily life activities. out of 17 subjects in the metformin group who drop-out, 14 subjects experienced the adverse effects of metformin, 1 subject died, and 2 subjects had poor compliance. in placebo group, there were 5 drop-out subjects due to drug adverse effects and 7 drop-out subjects due to poor compliance. the number needed to harm (nnh) was -12, which indicated that subjects in the placebo group had fewer risk of experiencing adverse effects compared to metformin group. however, this nnh value did not seem to represent the nnh of metformin in daily clinical practice which has been widely used as the first line treatment for type 2 dm. subject drop out due to gastrointestinal symptoms occurred mostly in the first week of the intervention. although re-education and counselling had been purwita w. laksmi acta med indones-indones j intern med 126 re-applied to them, those subjects still refused to continue the study. a review by scheen et al39 suggested that the elderly have relatively good tolerance to metformin and its safety is more related to the documented contraindications rather than age per se. although there were five serious adverse events (saes) reported in the metformin group (e.g. death after heart attack, recurrent stroke, malleolus ulcers, diarrhea, and melena), further investigation showed that all of those subjects had initially possessed the risk factors for those events. therefore, it can be concluded that saes were not related to metformin administration. there were several limitations of this study. the proportion of drop-out subjects was 24% due to drug side effects, poor compliance, and death. however, the important prognostic factors of the subjects who completed the study were similar to those drop-out subjects. the data analysis can only be applied to those who completed the study (per protocol analysis). however, due to logistic limitations, despite the prolonged subjects’ recruitment period for 15 months, this study did not meet the minimum sample size of 60 subjects who completed the study in each treatment group. nevertheless, the minimum sample size for the study outcome on gait speed was already met, which was a minimum of 29 subjects in each treatment group. therefore, the result analysis for gait speed was valid and has good statistical power (80%). objective measurement of insulin resistance and inflammation mediators, as well as measurement of lower extremities strength were not conducted in this study. therefore, this study cannot fully explain the mechanism of metformin in improving the study outcome. muscle biopsy to evaluate the mrna expression of myostatin was not conducted in this study. hence, it remains undetermined whether metformin affected mrna expression of myostatin in skeletal muscle or not. moreover, the measurement of body composition in this study used bia which is not as accurate as dualenergy x-ray absorptiometry (dxa). conclusion our results suggested that administration of metformin with the dose of 3 x 500 mg for non-diabetic pre-frail elderly subjects for 16 weeks was statistically significant and clinically 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myostatin in relation to type 2 diabetes. plos one. 2012;7(5):e37236. 39. scheen aj, paquot n. metformin revisited: a critical review of the benefit-risk balance in at-risk patients with type 2 diabetes. diabetes metab. 2013;39:179– 90. 18 original article acta med indones indones j intern med • vol 50 • number 1 • january 2018 meta-analysis of optimal management of lower pole stone of 10 20 mm: flexible ureteroscopy (furs) versus extracorporeal shock wave lithotripsy (eswl) versus percutaneus nephrolithotomy (pcnl) prahara yuri1, rinto hariwibowo2, indrawarman soeroharjo1, raden danarto1, ahmad z. hendri1, sakti r. brodjonegoro1, nur rasyid2, ponco birowo2, indah s. widyahening3 1 division of urology, department of surgery, faculty of medicine universitas gadjah mada sardjito hospital, yogyakarta, indonesia. 2 department of surgery, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 3 department of community medicine, faculty of medicine universitas indonesia, jakarta, indonesia. corresponding author: prahara yuri, md. division of urology, department of surgery, faculty of medicine universitas gadjah mada sardjito hospital. jl. kesehatan no. 1, sekip yogyakarta 55284, indonesia. email: prahara.yuri@gmail.com. abstrak latar belakang: pengelolaan optimal batu kaliks inferior masih kontroversial, karena tidak ada suatu metode tunggal yang sesuai untuk menghilangkan semua batu kaliks inferior. prosedur invasif (furs) minimal seperti extracorporeal shock wave lithotripsy (eswl), percutaneous nephrolithotomy (pcnl) dan flexible ureteroscopy adalah pilihan terapi untuk batu kaliks inferior. tujuan penelitian ini adalah untuk mengetahui manajemen optimal batu kaliks inferior ukuran 10 20 mm. metode: studi meta-analisis dari penelitian kohort sebelum juli 2016 dengan menggunakan database medline dan cochrane dilakukan. batu kaliks inferior ukuran 10-20 mm ditatalaksana dengan furs, eswl dan pcnl dengan follow up 1-3 bulan setelah tindakan merupakan kriteria inklusi, sedangkan batu saluran kemih di lokasi lain dan dengan ukuran yang berbeda di eksklusi. data dianalisis dengan fixed-effects model menggunakan metode mantzel-haenzel untuk menghitung pooled risk ratio (rr) dan 95% confidence interval (ci). heterogenitas dinilai dengan menghitung statistik i2. semua analisis dilakukan dengan review manager 5.3. hasil: kami menganalisis 8 penelitian kohort. angka bebas batu dari 958 pasien (271 pcnl, 174 furs dan 513 eswl), 3 bulan pasca operasi, adalah 90,8% (246/271) setelah pcnl, 75,3% (131/174) setelah furs dan 64,7 % (332/513) setelah eswl. berdasarkan angka bebas batu, pcnl lebih baik dari furs (overall rr 4,12 (95% ci 2,09 – 8,09); p<0,001 dan i2=0%) dan eswl (overall rr 0,23 (95% ci 0,16 – 0,35); p = <0,001 dan i2 = 32,8%). namun, bila dibandingkan antara furs dan eswl, furs lebih baik dari pada eswl dengan overall rr 0,66 (95% ci0,47 0,92; p = 0.015 dan i2 = 45,5%). kesimpulan: pcnl memberikan angka bebas batu yang lebih tinggi dibandingkan dengan furs dan eswl. studi meta-analisis ini diharapkan dapat membantu ahli urologi sebelum melakukan tindakan intervensi pada batu kaliks inferior ukuran 10-20 mm. kata kunci: batu kaliks inferior, flexible ureteroscopy, extracorporeal shock wave lithotripsy, percutaneus nephrolithotomy. vol 50 • number 1 • january 2018 meta-analysis of optimal management of 10-20 mm lower pole stone 19 abstract background: the optimal management of lower calyceal stones is still controversial, because no single method is suitable for the removal of all lower calyceal stones. minimally invasive procedures such as extracorporeal shock wave lithotripsy (eswl), percutaneous nephrolithotomy (pcnl) and flexible ureteroscopy (furs) are the therapeutic methods for lower calyceal stones. the aim of this study was to identify the optimal management of 10-20 mm lower pole stones. methods: a meta-analysis of cohort studies published before july 2016 was performed from medline and cochrane databases. management of 10-20 mm lower pole stone treated by furs, eswl and pcnl with follow-up of residual stones in 1-3 months after procedure were include and urinary stone in other location and size were excluded. a fixed-effects model with mantzel-haenzel method was used to calculate the pooled risk ratio (rrs) and 95% confidence interval (cis). we assessed the heterogeneity by calculating the i2 statistic. all analyses were performed with review manager 5.3. results: we analized 8 cohort studies. the stone free rate from 958 patients (271 pcnl, 174 furs and 513 eswl), 3 months after operation, was 90.8% (246/271) after pcnl; 75.3% (131/174) after furs; and 64.7% (332/513) after eswl. base on stone free rate in 10-20 mm lower pole stone following management, pcnl is better than furs (overall rr was 1.32 (95% ci 1.13 – 1.55); p<0.001 and i2=57%) and eswl (overall risk ratio 1.42 (95% ci 1.30 – 1.55); p=<0.001 and i2 = 85%). but, if we compare between furs and eswl, furs is better than eswl base on stone free rate in 10-20 mm lower pole stone management with overall rr 1.16 (95% ci 1.04 – 1.30; p=0.01 and i2=40%). conclusion: percutaneus nephrolithotomy provided a higher stone free rate than furs and eswl. this meta-analysis may help urologist in making decision of intervention in 10-20 mm lower pole stone management. keywords: lower pole stone, flexible ureteroscopy, extracorporeal shock wave lithotripsy, percutaneus nephrolithotomy. introduction the optimal management of lower calyceal stones is still in debate controversial and a dilemmatic for urologist.1–5 no single method is suitable for the removal of all lower calyceal stones. the goal of lower calyceal stone management is to achieve maximal stone clearance with minimal morbidity. newly developed minimally invasive procedures have displaced open stone surgery.1,6 extracorporeal shock wave lithotripsy (eswl), percutaneous nephrolithotomy (pcnl), and flexible ureteroscopy are the currently used therapeutic methods.5,7 to date, guidelines have confirmed eswl as the method of first choice for small and mid-sized urinary calculi. however, currently urologists and patients are more critical about eswl when considering the best treatment for a stone. the limited results of eswl, even after repeated treatment sessions for stones, in the lower pole, or for difficult stone compositions (e.g. calcium oxalate monohydrate, brushite or cystine), might explain stone development.8,9 advances in distal-tip deflection and scope durability have expanded the role of furs from a diagnostic to a therapeutic procedure. this improvement in technology has built on existing experience to expand the potential indications of flexible ureteroscopy including intrarenal stones, eswl failure, infundibular stenosis, morbid obesity, musculoskeletal deformities, and bleeding diathesis. endourological techniques and skills, especially for furs have been improved significantly, making furs both very efficient and safe.8 fernstrom and johansen in 1976 first described the technique of removing a kidney stone percutaneously. since then advances in technology, technical skill, and understanding of physiological principles have allowed percutaneous stone retrieval with increasing efficiency.10 it has a confirmed efficacy for managing lower-pole renal calculi, with a constantly high stone free rate (sfr) independent of stone size. the lower pole i study showed sfrs of 100%, 93% and 86% for stones of <10 mm, 10–20 mm and larger stones, respectively. other studies have confirmed these excellent results.8 patients prefer a noninvasive procedure and accept that long-term follow-up will be managed prahara yuri acta med indones-indones j intern med 20 by shockwave lithotripsy (eswl) if other factors allow. the impact of stone size on the results of eswl is more pronounced in lower pole (lp) stones than others. the recent advances in renal endoscopies and the development of percutaneous nephrolithotomy (pcnl) have provided the urologist with a safe and effective method for the treatment of 10 20 mm stones in the lower calyx.1 therefore, we did a systematic review to compare the outcome of eswl, furs and pcnl as different modalities of management of midsize (10–20 mm) lower calyceal stones. methods we searched the medline and cochrane databases for publications before july 2016. (lower pole) and urinary calculi) and flexible ureteroscopy) and extracorporeal shock wave lithotripsy) and percutaneus nephrolithotomy) or lower pole) or urinary calculi) or flexible ureteroscopy) or extracorporeal shock wave lithotripsy) or percutaneus nephrolithotomy were used as search strategy. finally, we checked references from relevant publications and review articles. eligibility criteria prospective study were included if treatment was done in adult patient (>18 years old), patient with lower pole stone (10-20 mm) who is treated by flexible ureteroscopy (furs) and/or extracorporeal shock wave lithotripsy (eswl) and/or percutaneus nephrolithotomy (pcnl) with follow-up of the stone free rate for 1-3 months after procedure. patients with urinary stone in other locations, non-english articles, case reports or case series were excluded. methodological quality quality of study was assessed by reviewing paper titles and abstracts. in the first screening, authors assessed all of the abstracts retrieved from the search and then obtained the full-text version of the articles that met the inclusion criteria. these authors evaluated the studies’ eligibility and quality, and they subsequently extracted the data. the process of identifying eligible studies is summarized in figure 1. 412 publications from database 41 publications were assessed in detail 8 publications are analyzed 371 publication are excluded base on title 33 publications are excluded : 5 publications treated by furs only 8 publications treated by eswl only 10 publications treated by pcnl only 19 publications the urinary stone in other location medline 235 publications cochrane 177 publications figure 1. literature search vol 50 • number 1 • january 2018 meta-analysis of optimal management of 10-20 mm lower pole stone 21 statistical analysis a fixed-effects model with mantzel-haenzel method was used to calculate the pooled risk ratio (rrs) and 95% confidence interval (cis) by comparing furs, eswl and pcnl in management of 10-20 mm lower pole stone. we assessed the heterogeneity by calculating the i2 statistic. the heterogeneity was classified as low (i2 25%-50%), moderate (i2 50%-75%) and high (i2>75%). all analyses were performed with review manager 5.3. results as presented in figure 1, 412 publications were identified from the database, out of which 371 publications were excluded based on the screening of the title and abstract. forty one potentially eligible publications were assessed in detail, and 8 publications met the eligibility criteria and analyzed (2 studies compare of all managements, 3 studies compare eswl and furs, 3 studies compare eswl and pcnl and a study compare furs and pcnl. (table 1) summarize the characteristics of the eligible studies. flexible ureteroscopy versus extracorporeal shock wave lithotripsy we obtained data from 705 patients from 5 literatures, comprises of 174 patients in furs and 531 patients in eswl group. we found 43 patient with residual stone from 174 patients treated with furs (follow-up 3 month, 75.3%) and 187 patients from 531 patients treated with eswl (follow-up 3 month, stone free rate 64.8%). figure 2 shows that furs is better than eswl based on the stone free rate in following <20 mm lower pole stone management with overall rr 1.16 (95% ci 1.04 – 1.30); p = 0.01 and i2 = 40%. flexible ureteroscopy versus percutaneous nephrolithotomy we obtained data from 463 patients from 5 literatures, comprises of 174 patients in furs and 289 patients in pcnl group. we found 43 patient with residual stone from 174 patients treated with furs (follow-up 3 month, 75.3%) and 25 patients from 289 patients treated with pcnl (follow-up 3 month, stone free rate 91.3%). (table 1) table 1. summary of findings table: stone free rate in management of lower pole stone outcome comparative risks (95% ci) risk ratio (95% ci) comparative risks (95% ci) risk ratio (95% ci) comparative risks (95% ci) risk ratio (95% ci) quality of evidence (grade)eswl furs eswl pcnl furs pcnl stone free rate 286/406, stone free rate 70.4%. 122/155, stone free rate 78.7% 1.16 (1.04–1.30) 229/352, stone free rate 65.1%. 228/251, stone free rate 90.8% 1.42 (1.30-1.55) 48/70, stone free rate 68.5% 171/183, stone free rate 93.4% 1.32 (1.13-1.55) moderate (5 studies with 561 participants) (4 studies with 603 participants) (3 studies with 253 participants) figure 2. forest plot comparison between furs and eswl stone free rate in lower pole stone ≤20 mm management. prahara yuri acta med indones-indones j intern med 22 figure 3 shows pcnl is better than furs based on the stone free rate in ≤ 20 mm lower pole stone management with overall rr 1.32 (95% ci 1.13 – 1.55); p<0.001 and i2=57%. percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy we obtained data from 820 patients from 4 literatures, comprised of 289 patients in pcnl and 531 patients in eswl group. we found 25 patient with residual stone from 289 patients treated with pcnl (follow-up 3 month, 91.3%) and 187 patients from 531 patients treated with eswl (follow-up 3 month, stone free rate 64.8%). figure 4 shows pcnl is better than eswl based on the stone free rate in ≤ 20 mm lower pole stone following management with overall rr 1.42 (95% ci 1.30 – 1.55); p = <0.001 and i2 = 85%. discussion lower pole (lp) renal stones provide a unique challenge when considering their management.11 the issues are mostly around the presence of one or more lower pole anatomical variations, an increased infundibular (if) length and a decreased if width and angle.12 lp stones that are symptomatic, locally obstructing, infection related, or increasing in size require intervention.13,14 methods for treatment of lpss 10 – 20 mm in length represent a major controversy in the urological literature.1,15,16 smaller, asymptomatic stones can be managed expectantly, though with periodic follow-up a significant number will exhibit increasing size or become symptomatic.17,18 for most stones smaller than 10 mm, swl is the treatment of choice, while for stones greater than 20 mm, percutaneous management is generally indicated.19,20 stones in the range of 10 20 mm represent an area of ongoing controversy regarding respective roles of swl, pcnl and ureteroscopy.1,13–15,17 in such cases, consideration should also be given to intrarenal anatomy and stone fragility in determining appropriate therapeutic intervention.17,21 based on this meta-analysis, it shows that pcnl is better than furs and eswl (p=<0.001). then, furs is better than eswl base on stone free rate in ≤20 mm lower pole stone management (p=0.01). with the minimal morbidity and widespread availability of eswl, pcnl had assumed a diminished role in stone management over the past two decades. several figure 3. forest plot comparison between furs and pcnl stone free rate in lower pole stone ≤ 20 mm management. figure 4. forest plot comparison between pcnl and eswl stone free rate in lower pole stone ≤ 20 mm management. vol 50 • number 1 • january 2018 meta-analysis of optimal management of 10-20 mm lower pole stone 23 indications remain well accepted, however, including stones failing swl, stones associated with distal obstruction, and the occasional patient in whom swl is contraindicated for factors such as body habitus or proximate calcified aneurysm. additionally virtually all studies to date comparing swl and pcnl demonstrate an inverse relationship between stone burden and stone free rates after swl, particularly in the lower pole calyx. in contrast, the success of pcnl is almost independent of stone size. stone burden, therefore, is a well recognized factor in the decision for swl or pcnl.17,21 a multicentre lower pole study group, conducted the first prospective randomized trial with the aim of determining the optimal treatment of lower pole calculi. the group compared stone-free rates in 52 patients undergoing swl and 55 randomized to pcnl. overall stone free rates for pcnl were far superior to that of swl (95% v. 37%), retreatments were more common in the swl group (16% v. 9%) and auxillary procedures were more frequent with swl patients (16% v. 2%). stratification by stone size was also consistent with prior studies, demonstrating swl stone-free rates of 68% for stones smaller than 10 mm in diameter, 55% for 10–20 mm stones and 29% for stones larger than 20 mm. the corresponding stone-free rates for pcnl were 100%, 93% and 86%, demonstrating that, for pcnl, stone-free rates are largely independent of stone size.4 the comparison of stone clearance rate between eswl and more invasive treatments such as pcnl or ureteroscopy was also done by many authors, however, overall complication rates in the lower pole study were not significantly different.4,20 in the treatment of lower calices stone of less than 20 mm, el-nahas et al.2 reported the matched groups which included 37 patients who underwent furs and 62 patients who underwent eswl. retreatment rate was significantly higher for eswl (60% vs 8%, p<0.001). preminger found that stone-free rates for calculi between 11 and 20 mm were 21% and 92% for swl and pnl, respectively.15 similarly, haroon et al3 reported the proportion of patients who were stone-free after 4 weeks was significantly higher in the pcnl group than in the swl group (83% vs. 51%, p<0.001). the cause of the higher retreatment and stone free rate in eswl may be the use of a second generation electromagnetic lithotripsy machine with a small focal area and lower shock energy in comparison with the original hm3. thus a stone larger than 10 mm is expected to require multiple sessions of eswl. on the other hand, the causes of retreatment in the furs group had unexpected incidents such as malfunction of the ureteroscope or laser machine and development of complications (e.g. perforation of the ureter).2,22 of the patients with nephrolithiasis in the united states who received commercial healthcare in 2000, the overall distribution of procedures was approximately 54% for eswl, 40% for urs, 5% for pcnl, and 1% for open surgery. although it is accepted that the selection criteria for pcnl (e.g. large and/or complex stone disease) will lead to lower usage rates, the factors affecting the disparity between the rates of eswl and urs are not as clear. understanding the trends in treatment choice requires accounting for numerous considerations through the perspective of hospitals, physicians, and patients.17,19,21 flexible ureteroscopy (furs) offers advantages in certain patient populations such as those with bleeding diathesis, those taking anticoagulants, those with renal anomalies such as a calyceal diverticulum, morbidly obese patients and those with orthopedic or other abnormalities with body habitus that may make eswl or pcnl challenging to perform.4 ozturk et al14 reported that success rates were 76, 94, and 73% respectively in eswl, pcnl, and furs. the highest stone-free rate was in the pnl group (p<0.05). for treatment of lower pole stones 10 – 20 mm in length, furs provide a significantly higher stone free rate and lower retreatment compared with eswl. the incidence of complications after furs was not significantly higher than after eswl and the severity of complications was comparable. these results support the increasing role of furs in the treatment of 10–20 mm lower pole stones.1,23,24 renal stones of less than 10 mm are usually treated successfully with eswl; larger stones, especially within the lower pole, are prahara yuri acta med indones-indones j intern med 24 more efficiently treated by pcnl. furs is recommended as a second-line treatment for smaller lower-pole stones and an as alternative for stones of moderate size if there are negative predictors for the success of eswl.16,25,26 in 10 – 20 mm renal stone, pcnl seem to be the most successful but most invasive method. despite this recommendation, furs is already used as the method of choice for such stones by many urologists, although individual factors and preferences must be considered.8,14 in this study, we are not considering individual factors and types of lithotriptors that may influence stone free rate. the rate of symptomatic episodes and stone growth can be low depending on disease factors and the patient population, and systematic re-treatment in the short term is not justified. further study is needed to improve our understanding of the risk of stone recurrence or progression after surgery using consistent definitions of small residual fragments and uniform treatment protocols. conclusion percutaneus nephrolithotomy (pcnl) provides a higher stone free rate than furs and eswl and may help urologist making decision of an intervention in 10-20 mm lower pole stone management. references 1. aboutaleb h, el-shazly m, badr eldin m. lower pole midsize (1-2 cm) calyceal stones: outcome analysis of 56 cases. urol int. 2012;89(3):348–54. 2. el-nahas ar, ibrahim hm, youssef rf, sheir kz. flexible ureterorenoscopy versus extracorporeal shock wave lithotripsy for treatment of lower pole stones of 10-20 mm. bju int. 2012;110(6):898–902. 3. haroon n, nazim sm, hammad ather m. optimal management of lower polar calyceal stone 15 to 20 mm. korean j urol. 2013;54(4):258–62. 4. a l b a r e e q r , d e n s t e d t j d . p e r c u t a n e o u s nephrolithotomy for the treatment of lower pole renal calculi. j can urol assoc. 2008;2(6):628–30. 5. sam z, nasehi a, basiri a, et al. pcnl in the management of lower pole caliceal calculi. urol j [internet]. 2004;1(3):174–6. available from: http:// www.ncbi.nlm.nih.gov/pubmed/17914683. 6. koo v, young m, thompson t, duggan b. costeffectiveness and efficiency of shockwave lithotripsy vs 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pole stone 25 referral stone center. j endourol. 2015;29(12):1371–8. 19. ozayar e, gulec h, bayraktaroglu m, et al. comparison of retrograde intrarenal surgery and percutaneous nephrolithotomy: from the view of an anesthesiologist. j endourol [internet]. 2016;30(2):184–8. available from: http://online.liebertpub.com/doi/10.1089/ end.2015.0517. 20. tok a, akbulut f, buldu i, et al. comparison of microperc and mini-percutaneous nephrolithotomy for medium-sized lower calyx stones. urolithiasis [internet]. springer berlin heidelberg; 2015;1–5. available from: http://link.springer.com/10.1007/ s00240-015-0804-2. 21. lin cc, hsu ys, chen kk. predictive factors of lower calyceal stone clearance after extracorporeal shockwave lithotripsy (eswl): the impact of radiological anatomy. j chinese med assoc. 2008;71(10):496–501. 22. soyupek s, oksay t, armaǧan a, özorak a, koşar a, perk h. success of extracorporeal shock wave lithotripsy in patients with lower caliceal stone and favorable anatomy. 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2011;67(3):217–20. available from: http://dx.doi.org/10.1016/s0377-1237(11)60044-0. 18 original article acta medica indonesiana the indonesian journal of internal medicine predictors of five days mortality in diabetic ketoacidosis patients: a prospective cohort study suhendro suwarto1, bambang sutrisna2, sarwono waspadji1, herdiman t. pohan1 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of epidemiology, faculty of public health universitas indonesia. correspondence to: division of tropical and infectious disease, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: suhendro@ui.ac.id. abstrak tujuan: untuk menentukan peran laktat serum dan derajat beratnya ketoasidosis diabetikum (kad) dalam memprediksi mortalitas lima hari pasien kad. metode: penelitian kohort prospektif dilakukan pada pasien kad yang masuk perawatan di ruang gawat darurat rs cipto mangunkusumo, jakarta, indonesia pada periode tahun 2007-2008. prediktor mortalitas 5 hari yang diteliti meliputi laktat serum dan derajat beratnya kad (glukosa plasma, ph arteri, bikarbonat serum, osmolalitas, anion gap, dan perubahan kesadaran) pada awal perawatan. cox’s proportional hazard regression model digunakan untuk menentukan prediktor independen terhadap mortalitas 5 hari pada pasien kad. hasil: dari enam puluh pasien yang diikutkan dalam penelitian, 24 (40%) pasien di antaranya meninggal dalam waktu 5 hari perawatan. pada analisis multivariat, konsentrasi laktat ≥4 mmol/l (hr, 3,09; 95% ik, 1.36-7.05), dan tingkat kesadaran stupor/koma (hr, 3,38; 95% ik, 1,457,87) diidentifikasi sebagai prediktor independen terhadap mortalitas 5-hari pasien kad dewasa. kesimpulan: konsentrasi laktat ≥4 mmol/l dan tingkat kesadaran stupor/koma dapat digunakan untuk memprediksi mortalitas 5-hari pada pasien kad. kata kunci: ketoasidosis diabetik, sepsis, konsentrasi laktat, tingkat kesadaran, mortalitas. abstract aim: to determine the role of serum lactate and diabetic ketoacidosis (dka) severity as predictors for fivedays mortality in dka patients. methods: a prospective cohort study was conducted in dka patients admitted to emergency department (ed) at cipto mangunkusumo hospital, jakarta, indonesia, during 2007-2008 periods. predictors for 5 days mortality in dka patients in this study including serum lactate and dka severity (plasma glucose, arterial blood ph, serum bicarbonate, osmolality, anion gap, and alteration in sensorium) at admission. cox’s proportional hazard regression analysis was used to determine independent predictors for 5-days mortality among study population. results: sixty patients with diabetic ketoacidosis were enrolled in the study; in which 24 (40%) patients were died within 5 days after admission. in the multivariate analysis, the lactate level ≥4 mmol/l (hr, 3.09; 95% ci, 1.36-7.05) and altered in sensorium stuporous/comatose (hr, 3.38; 95% ci, 1.45-7.87) were identified as independent predictors for 5-days mortality in dka adult patients. conclusion: lactate level ≥4 mmol/l and altered in sensorium stuporous/comatose can be used to predict 5-days mortality in adult patients with dka. key words: diabetic ketoacidosis, sepsis, lactate level, alteration in sensorium mortality. vol 46 • number 1 • january 2014 predictors of five days mortality in diabetic ketoacidosis patients 19 introduction diabetic ketoacidosis (dka) is the most serious and life-threatening acute complication of diabetes and is characterized by hyperglycemia, ketosis, and acidosis.1,2 the current diagnostic criteria and classifications of the severity of dka are based on plasma glucose, arterial ph, serum bicarbonate, serum osmolarity, anion gap, and mental state alterations.2,3 the majority of dka cases are precipitated by infections,2 which have a high incidence rate, especially in developing countries.4 despite significant improvements in monitoring and therapy, the mortality rate remains high, especially in dka patients with sepsis.5 in our tertiary hospitals, the mortality associated with dka is likely to be high because, characteristically, these patients often have low incomes, comorbidities, delays in seeking medical care, and a high rate of infections. the initial fluid therapy protocol for treating dka, which is based on evidence-based management, recommends that resuscitation should consist of isotonic saline (0.9% nacl) infused at a rate of 15-20 ml/kg/h during the first hour.3,6 in sepsis, where patients have hypoperfusion or septic shock, fluid resuscitation should follow the early goal-directed therapy (egdt) protocol.7 this approach seeks to achieve the following targets as a resuscitation end point: central venous pressure (cvp) of 8 to 12 mmhg, mean arterial pressure (map) ≥65 mmhg, and superior vena cava oxygenation (scvo2) saturation ≥70%; these tests should be completed within the first 6 hours.8 early recognition and management of sepsis is key to improving patient outcomes.8,9 the surviving sepsis campaign (ssc) recommends that in septic patients, lactate measurement within 3 hours should be used as a marker of tissue hypoperfusion to help identify patients at high risk for death and those who will benefit from the egdt approach. hypoperfusion and perfusion abnormalities may include an acute alteration in mental status.8 until now, there is no prospective study describing the prognostic value of serum lactate and dka severity on emergency department (ed) admission as predictors of mortality in dka patients, shortly after admission to the emergency department. therefore, we conducted this study to determine the roles of mortality predictors in adult dka patients using serum lactate and severity of dka on ed admission. methods this was a prospective cohort study conducted at the emergency department of cipto mangunkusumo hospital, a tertiary hospital in jakarta, indonesia. diabetic ketoacidosis (dka) patients, aged 16 years and older, who admitted from january 2007 through december 2008 and agreed to participate were included in the study, with exclusion criteria was pregnant women. diabetic ketoacidosis was diagnosed when the blood glucose at admission was >250 mg/dl with ketonaemia and blood acidemia (ph <7.3 or a serum bicarbonate concentration of <15 meq/l).2 the university ethics committee approved the study, and informed consent was obtained from all patients or their representatives. identification of predictors and outcome the classification severity of dka was based on the following: plasma glucose, arterial blood ph, serum bicarbonate, osmolality, anion gap and alterations in sensorium.2 alterations in sensorium were stratified into 2 groups: alert/ drowsy, and stupor/coma. serum osmolality was derived from the following formula: 2x [measured na+ (meq/l)] + glucose (mg/dl) / 18. the anion gap was calculated using the following formula: [(na+)–(cl+ hco3(meq/l)].2 arterial lactate samples were collected with heparinized syringes, and the subsequent measurements were performed using a hitachi 917 automated analyzer (roche diagnostics, mannheim, germany). the lactate results were stratified into 2 groups based on the cutoff values previously utilized by other authors10; these groups were as follows: <4.0 mmol/l and ≥4.0 mmol/l.8,10 the patient characteristics, comorbidities, triggers of dka, vital signs, clinical findings, blood collection results, and lactate measurements were recorded for each individual upon arrival at the emergency department for enrollment. the criteria for sepsis was defined according to the 2001 sccm/esicm/accp/ats/sis suhendro suwarto acta med indones-indones j intern med 20 international sepsis definitions conference.11 we defined the mortality outcome as any death occurring ≤5 days from the initial lactate measurement.10,12,13 all patients were treated according to a dka standardized cipto mangunkusumo hospital protocol. statistical analysis the sample size of the study was estimated based on an assumption 81.25% incidence of mortality for high lactate concentrations.14 assuming the relative risk is 1.75, with α = 0.05 and β = 0.20, minimal subjects required in the study was 58 patients. univariate analysis comparing serum lactate levels and the classification of dka severity on five-days mortality was performed to identify variables that potentially had a significant association with mortality. all variables with p-value <0.25 in univariate analysis were entered into a cox’s proportional hazard regression model using a backward selection algorithm to calculate the adjusted hazard ratios of mortality. kaplanmeier curve for each significant predictors were presented. all statistical analyses were performed using the stata statistical software version 9 (stata corp., college station, tx, usa). results patient characteristics a total of 60 patients with dka were enrolled in the study with mean age of 50.97 (sd 2.05) years 36 (60%) of them were women and 35 (58%) patients were diagnosed dka with sepsis. the main sites of infection in the septic group were the respiratory tract (51%), followed by soft tissue (34%), gastrointestinal tract (6%), abdomen (3%), and others (6%). the precipitating factors of dka in the non-septic patients were insulin omission (32%), stroke (20%), new-onset diabetes (8%), trauma (8%), tumor (8%), and gastrointestinal bleeding (4%). precipitating factors could not be identified in 20% of patients. out of the 60 patients, 24 (40%) died within 5 days. mortality in the septic patients (57%) was significantly higher than in the non-septic patients (16%). serum lactate in the septic patients (median: 2.89 mmol/l, range: 0.85 to 13.49 mmol/l) was significantly higher than in the non-septic patients (median: 1.67 mmol/l, range: 0.68 to 8.26 mmol/l). the patients’ characteristics are presented in table 1. table 1. diabetic ketoacidosis patients: comparison of survivors and non-survivors variables survivors (n=36) non-survivors (n=24) sex (n, male/female) 17/19 7/17 mean age (year)a 48.11 (sd 16.24) 54.92 (sd 15.97) blood pressure (sbp/dbp)a 118 (sd 19.93) / 67.22 (sd 23.37) 112.17 (sd29.30) / 63.75 (sd 28.41) temperature (°c)a 37.38 (sd 1.00) 37.04 (sd 1.79) heart rate (bpm)a 111.4 (sd 16.97) 111.4 (sd 14.35) respiration rate (bpm)a 29.00 (sd 8.36) 31.18 (sd 5.51) leukocyte count (/mm3)a 17,600 (sd 7715) 21,000 (sd 7500) serum lactate (mmol/l)b 1.70 (0.68-8.26) 4.2 (0.85-13.49)* glucose (mg/dl)a 442.33 (sd 140.47) 498.88 (sd 158.67) arterial pha 7.31 (sd 0.13) 7.24 (sd 0.17) serum bicarbonate (meq/l)a 12.11 (sd 5.12) 10.85 (sd 4.79) osmolality (mosm/kg)a 295.07 (sd 23.04) 297.42 (sd 19.45) anion gapa 21.57 (sd 7.76) 24.03 (sd 5.53) sepsis (n,%) 15 (43%) 20 (57%)** a data presented as the mean ± standard deviation b data presented as median, range * p<0.05 by mann-whitney u test, **p<0.05 by chi-square tests vol 46 • number 1 • january 2014 predictors of five days mortality in diabetic ketoacidosis patients 21 twelve of the 17 patients (71%) with high lactate levels (≥4 mmol/l) had normal blood pressure. the neurological symptoms alertness/ drowsiness and stupor/coma occurred in 40 (67%) and 20 (33%) patients, respectively. eight drowsy patients (62%) and 13 out of 20 (65%) stupor/coma patients had accompanying sepsis. the univariate analysis to predict mortality using serum lactate and the classification of dka severity are presented in table 2. the variables that had a significant effect based on univariate analysis were submitted to cox’s proportional hazard regression model. the following variables were found to be independent predictors of mortality: serum lactate ≥4 mmol/l and alterations in sensorium stuporous/comatose. organ dysfunctions.15 tissue hypoperfusion is an important factor in the development of multiple organ failure. therefore, the early recognition of sepsis-induced tissue hypoperfusion is crucial in implementing aggressive resuscitation to prevent organ damage.16 markers of tissue hypoperfusion include lactate levels.8 our prospective study identified prognostic factors to predict 5-day mortality. two variables were independently associated with mortality, specifically, serum lactate and alterations in sensorium. as reported by others, lactate levels were significantly higher in septic patients. azoulay et al.17 studied a retrospective analysis of 113 dka patients treated in a medical icu. they found that the lactate levels ranged from 1.9 to 3.3 mmol/l (median: 2.7) in patients with infection and from 1.3 to 1.8 mmol/l (median: 1.4) in patients without infection. other authors have reported that the lactate levels were 2.61 sd 0.56 mmol/l in dka septic patients and 1.32 sd 0.24 mmol/l in non-septic patients.5 in the present study, we observed that dka table 2. univariate analysis of the risk factors for mortality variables hazard ratio 95% confidence interval serum lactate ≥4 mmol/l 3.76 (1.69-8.38) glucose (mg/dl) 1.00 0.99-1.00 arterial ph 0.21 0.02-2.23 serum bicarbonate (meq/l) 0.97 0.90-1.06 osmolality (mosm/kg) 1.00 0.98-1.02 anion gap 1.03 0.97-1.08 alterations in sensorium stuporous/comatose 4.24 (1.86-9.64) table 3. final cox’s proportional hazard regression model to predict mortality variables hazard ratio 95% confidence interval serum lactate ≥4 mmol/l 3.09 1.36-7.05 alterations in sensorium stuporous/comatose 3.38 1.45-7.87 discussion as reported by others, sepsis is one of the most common precipitating factors of dka.3,5 mortality in sepsis may occur in the early phase (in the first 5 days) or the late phase (after 5 days).10,12,13 the mechanisms of mortality in the early phase are generally due to cardiovascular collapse, metabolic derangements, and multiple figure 1. kaplan-meier survival estimates suhendro suwarto acta med indones-indones j intern med 22 patients with high lactate levels (≥4.0 mmol/l) had significantly higher mortality than patients with low lactate levels (<2.0 mmol/l). to our knowledge, no other prospective studies have reported high lactate levels in dka and its association with high mortality. a potential reason that may explain our result was the patients’ delays in seeking medical care, which resulted in more severe disease and, therefore, higher mortality rates. rivers et al.9 demonstrated a significant mortality benefit for patients with severe sepsis and septic shock when early diagnosis and rapid intervention was provided within the first 6 hours. furthermore, our data demonstrated that blood pressure levels were not different between survivors and non-survivors. in addition, we found patients who had a lactate level ≥4.0 mmol/l in the presence of normal blood pressure. these results confirm that normotensive patients with high lactate levels or cryptic shock have a higher risk of death than patients with normal serum lactate.18 puskarich et al.19 reported that the risk of death in patients with high lactate levels was similar between those with cryptic and overt shock. these results are consistent with other studies that have reported that a lactate level ≥4.0 mmol/l increases the probability of acute mortality.10,12 altered mental status was another predictor of mortality in our study. the cause of altered sensorium in dka remains unclear; it may be due to various possibilities, including reduced cerebral blood flow, reduced glucose utilization, hyperosmolality and high blood glucose concentrations, acidosis, or a direct effect of ketone bodies or other factors.20 according to the recent international sepsis definitions conference, the diagnostic criteria for sepsis now includes altered mental status as a marker of global hypoperfusion.8 tissue hypoperfusion is an important factor in the development of multiple organ failure, which is a major cause of death in septic patients.15,16 in our study, 65% of the stupor/coma patients at admission also had an accompanying diagnosis of sepsis, and these characteristics were significantly related to mortality. these results are consistent with other studies that have reported that dka patients who present with disorientation, confusion, or stupor at admission are more likely to also have infections.17 in septic patients, encephalopathy was associated with mortality when graded by the glasgow coma score. a score of 15 had a 16% mortality rate, 13 to 14 had a 20% mortality rate, 9 to 12 had a 50% mortality rate, and 3 to 8 had a 63% mortality rate (p < 0.05) (21). chung et al.22 conducted a retrospective study of 164 patients with hyperglycemic crises to determine the clinical characteristics and predictors of mortality. they found that infection (74%) was the most common trigger of hyperglycemic crises. in a multivariate analysis, altered mental status on admission and age were associated with mortality.22 in the population that we studied, there were 35 patients (58%) with sepsis. mortality was significantly higher in these patients than in the non-septic patients. this indicates that a patient with serum lactate ≥4 mmol/l and alteration in sensorium stuporous/comatose is likely due to sepsis-induced tissue hypoperfusion, and in such cases, patients should be immediately resuscitated. this mortality prediction may help clinicians to identify the possibility of sepsis as a trigger of dka patients. based on dka guidelines, the initial fluid therapy in dka should consist of isotonic saline (0.9% nacl) at a rate of 15-20 ml/kg/h or 1-1.5 l within one hour. therefore, rehydration should be guided by the hemodynamic status, state of hydration, serum electrolyte levels, and urinary output.3,6 however, according to the surviving sepsis campaign, the goals of initial resuscitation of sepsis-induced hypoperfusion should include cvp 8 to 12 mmhg, map ≥65 mmhg, and scvo2 ≥70% (egdt), and these goals must be achieved within the first 6 hours.8 this strategy has demonstrated a significant reduction of in-hospital mortality compared with the standard therapy (30.5% vs. 46.5%).7 recent studies have shown that the outcome of sepsis may be improved with early recognition of hypoperfusion and optimal resuscitation.23 by using this mortality prediction may provide an initial risk-stratification tool to identify patients at high risk of death, and may help clinicians can consider to determine the appropriate resuscitation protocol to be vol 46 • number 1 • january 2014 predictors of five days mortality in diabetic ketoacidosis patients 23 used for a particular patient. this study has several limitations that need to be considered. first, we did not consider the effects of patient comorbidities, which may have influenced the outcomes. second, definite causes of the patients’ altered mental status were not identified. third, because our study was conducted at a single institution, a tertiary referral hospital in jakarta, indonesia, the results may not be representative of all dka patients. conclusion lactate level and altered in sensorium (stuporous/comatose) on admission to the emergency department can be used to predict acute mortality in dka adult patients. acknowledgments the authors thank prof. guntur hermawan, md, phd, prof. nuning mk masjkuri, md, mph, prof. siti setiati, md, msc, phd, prof. dinajani sh mahdi, md, phd and prof. amin subandrio, md, phd for helpful discussions. references 1. jervis a, champion s, figg g, langley j, adams gg. prevalence of diabetes ketoacidosis rises and still no strict treatment adherence. curr diab rev. 2013;9(1):54-61. 2. kitabchi ae, umpierrez ge, miles jm, fisher jn. hyperglycemic crises in adult patients with diabetes. diab care. 2009;32(7):1335-43. 3. nyenwe ea, kitabchi ae. evidence-based management of hyperglycemic emergencies in diabetes mellitus. diab res clin pract. 2011;94(3):340-51. 4. jayashree m, singhi s. diabetic ketoacidosis: predictors of outcome in a pediatric intensive care unit of a developing country. pediatr crit care med. 2004;5(5):427-33. 5. gogos ca, giali s, paliogianni f, et al. interleukin-6 and c-reactive protein as early markers of sepsis in patients with diabetic ketoacidosis or hyperosmosis. diabetol. 2001;44(8):1011-4. 6. westerberg dp. diabetic ketoacidosis: evaluation and treatment. am fam physician. 2013;87(5):337-46. 7. rivers e, nguyen b, havstad s, et al. early goaldirected therapy in the treatment of severe sepsis and septic shock. n engl j med. 2001;345(19):1368-77. 8. dellinger rp, levy mm, rhodes a, et al. surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. crit care med. 2013;41(2):580-637. 9. rivers ep, mcintyre l, morro dc, rivers kk. early and innovative interventions for severe sepsis and septic shock: taking advantage of a window of opportunity. cmaj. 2005;173(9):1054-65. 10. trzeciak s, dellinger rp, chansky me, et al. serum lactate as a predictor of mortality in patients with infection. int care med. 2007;33(6):970-7. 11. levy mm, fink mp, marshall jc, et al. 2001 s c c m / e s i c m / a c c p / at s / s i s i n t e r n a t i o n a l sepsis definitions conference. crit care med. 2003;31(4):1250-6. 12. shapiro ni, howell md, talmor d, et al. serum lactate as a predictor of mortality in emergency department patients with infection. ann emerg med. 2005;45(5):524-8. 13. otto gp, sossdorf m, claus ra, et al. the late phase of sepsis is characterized by an increased microbiological burden and death rate. crit care.15(4):r183. 14. singhal r, coghill je, guy a, bradbury aw, adam dj, scriven jm. serum lactate and base deficit as predictors of mortality after ruptured abdominal aortic aneurysm repair. eur j vasc endovasc surg. 2005;30(3):263-6. 15. hotchkiss rs, monneret g, payen d. immunosuppression in sepsis: a novel understanding of the disorder and a new therapeutic approach. lancet infect dis. 2013;13(3):260-8. 16. casserly b, read r, levy mm. hemodynamic monitoring in sepsis. crit care clin. 2009;25(4):803-23. 17. azoulay e, chevret s, didier j, barboteu m, bornstain c, darmon m, et al. infection as a trigger of diabetic ketoacidosis in intensive care-unit patients. clin infect dis. 2001;32(1):30-5. 18. howell md, donnino m, clardy p, talmor d, shapiro ni. occult hypoperfusion and mortality in patients with suspected infection. int care med. 2007;33(11):18929. 19. puskarich ma, trzeciak s, shapiro ni, heffner ac, kline ja, jones ae. outcomes of patients undergoing early sepsis resuscitation for cryptic shock compared with overt shock. resuscitation. 2011;82(10):1289-93. 20. nyenwe ea, razavi ln, kitabchi ae, khan an, wan jy. acidosis: the prime determinant of depressed sensorium in diabetic ketoacidosis. diab care. 2011;33(8):1837-9. 21. eidelman la, putterman d, putterman c, sprung cl. the spectrum of septic encephalopathy. definitions, etiologies, and mortalities. jama. 1996;275(6):470-3. 22. chung st, perue gg, johnson a, younger n, hoo cs, pascoe rw, et al. predictors of hyperglycaemic crises and their associated mortality in jamaica. diab res clin pract. 2006;73(2):184-90. 23. walker ca, griffith dm, gray aj, datta d, hay aw. early lactate clearance in septic patients with elevated lactate levels admitted from the emergency department to intensive care: time to aim higher? j crit care. 2013;28(5):832-7. 136 original article acta medica indonesiana the indonesian journal of internal medicine underutilization of anticoagulant for venous thromboembolism prophylaxis in three hospitals in jakarta t. djumhana atmakusuma1, karmel l. tambunan1, lugyanti sukrisman1, shufrie effendi1, andhika rachman1, arini setiawati2, ikhwan rinaldi1, nadia a. mulansari1, wulyo rajabto1, sally a. nasution1, muhadi1, tiara aninditha3, rudyanto sedono4, adhrie sugiarto4, ceva w. pitoyo1, diana paramitha5, nyoto w. astoro6, intan r. nasution6 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of pharmacology and therapeutics, faculty of medicine universitas indonesia, jakarta, indonesia. 3 department of neurology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 4 department of anesthesiology and intensive care medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 5 department of internal medicine, persahabatan hospital, jakarta, indonesia. 6 department of internal medicine, gatot subroto hospital, jakarta, indonesia. correspondence mail: division of hematology and medical oncology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: endjum@hotmail.com. abstrak tujuan: menilai penggunaan antikoagulan dan implementasi pedoman internasional mengenai profilaksis tromboemboli vena (tev) pada pasien rawat inap dengan penyakit medik akut di jakarta, indonesia. metode: studi multisenter, observasional, dengan mendata pasien terdiagnosis penyakit medik akut dan kondisi medis lainnya yang berisiko tev dan menjalani imobilisasi sedikitnya 3 hari. hasil: dari total 401 pasien, hanya 46.9% yang menerima antikoagulan, terdiri atas: unfractionated heparin (64.4%), fondaparinux (11.7%), enoxaparin (9.6%), warfarin (3.7%), dan kombinasi antikoagulan (10.6%). profilaksis tev dengan metoda fisik dan mekanik digunakan pada 81.3% pasien baik tunggal atau dikombinasi dengan antikoagulan. selama rawat inap, tev didapatkan pada 3.2% pasien. dari 13 pasien, 10 pasien (2.5%) mengalami tev di tungkai bawah dan 3 pasien (0.75%) diduga mengalami emboli paru. rujukan internasional utama yang digunakan adalah aha/ asa 2007 (47.4%), diikuti oleh accp 2008 (21.7%). kesimpulan: studi ini menunjukkan penggunaan profilaksis antikoagulan yang kurang. thromboprofilaksis mekanik baik tunggal atau kombinasi dengan antikoagulan merupakan yang tersering digunakan. unfractionated heparin paling sering dipilih sebagai profilaksis tev. rujukan tata laksana yang lebih sering digunakan adalah aha/asa 2007. profilaksis tev pada pasien dengan penyakit medik akut perlu ditingkatkan. kata kunci: thromboemboli vena (tev), profilaksis, pendataan, rawat inap bukan operasi. abstract aim: to assess the current use of anticoagulants and implementation of international guidelines in venous thromboembolism (vte) prophylaxis in hospitalized patients with acute medical illnesses in jakarta, indonesia. vol 47 • number 2 • april 2015 underutilization of anticoagulant for venous thromboembolism prophylaxis 137 methods: a multicenter, prospective, disease registry, recruiting patients diagnosed as acutely ill medical diseases and other medical conditions at risk of vte, with in-hospital immobilization for at least 3 days. results: of 401 patients, 46.9% received anticoagulants which included unfractionated heparin (64.4%), fondaparinux (11.7%), enoxaparin (9.6%), warfarin (3.7%), and combination of anticoagulants (10.6%). vte prophylaxis using physical and mechanical method was used in 81.3% of patients, either as a single modality or in combination with anticoagulants. during hospitalization, vte were found in 3.2% patients; 10 patients (2.5%) had lower limb events and 3 patients (0.75%) had a suspected pulmonary embolism. the main reference international guidelines used were aha/asa 2007 (47.4%), followed by accp 2008 (21.7%). conclusion: the study showed underutilization of prophylaxis anticoagulants in which mechanical thromboprophylaxis either alone or combination with anticoagulants was the most commonly used. unfractionated heparin was the preferable choice. the most commonly used guideline was aha/asa 2007. vte thromboprophylaxis in medically ill patients needs to be encouraged. key words: venous thromboembolism (vte), prophylaxis, registry, non-surgery hospitalization. introduction ve n o u s t h r o m b o e m b o l i s m ( v t e ) is commonly found at autopsy in patients who received medical treatment and died in the hospital. prophylaxis of vte has been less extensively studied in medical patients than in surgical patients, and the use of thromboprophylaxis is uncommon in medical patients. even though primary prophylaxis of vte was not standardized therapy in indonesia, this prophylaxis has been implemented in orthopedic surgery since year 2000 while some clinicians were doing secondary prophylaxis of vte. at least 3 large randomized clinical trials have demonstrated the efficacy and safety of vte prophylaxis in the medical setting. these studies used enoxaparin (medenox)1, dalteparin (prevent)2, and fondaparinux (artemis)3 compared to placebo in acutely ill medical patients hospitalized with heart failure, respiratory failure, infectious disease or inflammatory disease. all studies showed a significant reduction in the rate of vte, while the rate of major bleeding events was comparable to placebo. these results support the evidencebased recommendations for thromboprophylaxis in this clinical setting. the benefits of these 3 studies should be translated into general practice. to facilitate its implementation, the medical practitioners should be able to readily identify suitable patients who would gain most from prophylaxis with these anticoagulants and implement the best treatment protocols according to evidence-based and international guidelines. medenox, prevent, and artemis studies demonstrated the benefits of anticoagulants for acutely ill medical patients to prevent incidence of vte. international guidelines (aha/asa4, accp5, eso6, iua7) recommended the use of anticoagulants for thromboprophylaxis in acutely ill medical patients. in indonesia, there is lack of data on the use of anticoagulants in this group of patients. we presumed that even though all doctors had known about the guidelines of anticoagulant prophylaxis, not all doctors followed the guidelines properly. besides, we predicted as well that there was underutilization of anticoagulant prophylaxis or the guidelines were not applied optimally. this study would provide data on the appropriate use of anticoagulants, international guidelines implementation, demographic data and risk factors of patients in the prevention of vte within real clinical settings in jakarta, indonesia. the primary objectives were to assess current use of anticoagulants oral or intravenous for vte prophylaxis in hospitalized patients with acute medical illnesses and other medical conditions at risk of vte, to assess the underutilization and inappropriate use of anticoagulant prophylaxis, a n d t o a s s e s s i n t e r n a t i o n a l g u i d e l i n e s implementation in vte prophylaxis in jakarta, indonesia. the secondary objectives were to obtain demographic data of acutely ill medical patients who are at risk of vte events in jakarta, t. djumhana atmakusuma acta med indones-indones j intern med 138 and to assess vte prophylaxis method other than anticoagulants used in these patients. methods study design a multicenter, prospective, disease registry. the study protocol was approved by the ethics committee of the medical faculty, university of indonesia. patients inclusion criteria were 40 years of age and older, with a diagnosis of acutely ill medical disease or other medical condition at risk of vte, such as acute heart failure (nyha class iii / iv), acute respiratory infection, acute infective disease (cns, hematology), acute myocardial infarction, acute ischemic stroke, paraparesis/hemiparesis, malignancy. patients were hospitalized for at least 6 days and were immobilized for at least 3 days. patients who participated in other clinical study were excluded. written informed consents were obtained from the patients before participation in the study. treatment this was an observational study, therefore no specific treatment was recommended. data were collected based on physician’s daily practices without any intervention or scheduled visit. this study was performed without interfering with the patient’s routine management. there were no study tests or clinical interventions performed. if there was any adverse event (ae) or serious adverse event (sae) during visit, physician would report this ae or sae to the pharmaceutical company manufacturing the product through the spontaneous reporting procedure. statistical analysis numerical variables were summarized using mean and standard deviation, while frequencies and percentages are reported for nominal variables. these descriptive statistics were planned to describe the baseline characteristics of subjects, including risk factors, the choice of anticoagulants, the reference guidelines, other treatments given, and vte disease found. no comparison analysis was made. results characteristics of patients a total of 401 patients were recruited from 18 participating physicians in 7 centers from december 2009 until november 2011. characteristics of patients are shown in table 1. table 1. characteristics of patients (n=401) characteristics mean (sd*) age (years) 58.1 (10.96) weight (kg) 57.7 (12.40) bmi (kg/m²) 22.0 (4.47) systolic bp (mmhg) 130.0 (26.18) diastolic bp (mmhg) 78.0 (14.87) heart rate (bpm) 89.0 (15.4) respiratory rate (time/min) 22.0 (4.77) hospital stay (days) 18.4 (17.27) duration of anticoagulant use (days) 10.0 (17.73) male, n (%) 248 (61.8) female, n (%) 153 (38.2) patients at discharge, n (%) died 74 (18.0) alive 327 (82.0) risk factors majority of the patients had prolonged immobilization as risk factor, it was 77.6% (311 patients). most of the patients (80.6%) had at least 1 risk factor. only 19.2% had 2 risk factors or more as shown in table 2. table 2. risk factors in baseline characteristics of patients (n=401) risk factors n (%) prolonged immobilization (>72 hrs) 311 (77.6) history of malignancy 67 (16.7) obesity 45 (11.2) age >75 years 30 (7.5) trombophilia 11 (2.7) history of vte 7 (1.8) dehydration 2 (0.5) nephrotic syndrome 2 (0.5) varicose vein 1 (0.3) at least 1 risk factor 323 (80.6) ≥2 risk factors 77 (19.2) no data 1 (0.2) vol 47 • number 2 • april 2015 underutilization of anticoagulant for venous thromboembolism prophylaxis 139 methods of vte prophylaxis used methods of vte prophylaxis used in this study were mechanical thrombophylaxis (40.1%), pharmacological thrombophylaxis (5.7%), combination of mechanical and pharmacologic thrombophylaxis (41.1%), others (0.5%), and no documented prophylaxis (12.5%) as shown in figure 1. the majority of vte prophylaxis methods used in patients in this study was mechanical method or physiotherapy (326 of 401 patients (81.3%)), either used as a single method or in combination with pharmacological thrombophylaxis. current use of anticoagulants in hospitals in jakarta from the total of 401 patients, 188 patients (46.9%) received prophylaxis anticoagulants, and 213 patients (53.1%) did not. figure 2 shows the reasons for not using anticoagulants resulting in underutilization of anticoagulant prophylaxis, in which 37 of 213 patients (17.5%) were contraindicated, 22 patients (10.4%) were concerned for bleeding, 99 patients (46.2%) had no anticoagulant indication (based on the doctors’ opinion despite strong indication of anticoagulant prophylaxis in patients with >6 days bedridden), 45 patients (21.2%) for cost reasons, and 10 patients (4.7%) for other reasons. initial choice of anticoagulant table 3 shows the initial choice of anticoagulants as vte prophylaxis. initial choice of anticoagulants among the 188 patients were unfractionated heparin (ufh) in 121 patients (64.4%), low molecular weight heparin (enoxaparin) in 18 patients (9.6%), synthetic pentasaccharide (fondaparinux) in 22 patients (11.7%), oral anticoagulant (warfarin) in 7 patients (3.7%), and more than 1 anticoagulants in 20 patients (10.6%). figure 1. methods of vte prophylaxis used in this study figure 2. reasons for not using anticoagulants t. djumhana atmakusuma acta med indones-indones j intern med 140 signs or symptoms of vte signs or symptoms of vte were found during hospitalization in 13 patients among the total of 401 patients (3.2%), deep vein thrombosis (dvt) at lower limbs were found in 11 patients (edema in 2 patients, edema and pain in 2 patients, and edema, pain, red skin and changes in skin temperature in 7 patients), and suspected pulmonary embolism was found in 2 patients (apnea in 1 patient, dyspnea and quick breathing in 1 patient). in one patient, both local and general signs and symptoms of vte were found. in 13 patients with vte, the median of length of stay in hospital is 20 days with range 2-103, the detail of the patient’s length of stay and site can be found in table 4. among these 13 patients, 10 patients received ufh, 1 patient received fondaparinux, 1 patient received enoxaparin and warfarin, 1 patient did not receive anticoagulant and 10 patients were on mechanical vte prophylaxis. one patient who did not receive anticoagulant is patient with hepatic fibrosis, massive ascites, and hepatic encephalopathy, therefore the patient was considered to be contraindicated to anticoagulant. the patient then died due to suspected pulmonary embolism, since the patient showed sign or symptom of apnea, despite on mechanical vte prophylaxis. in the meantime, 12 patients who received vte prophylaxis anticoagulant, 5 patients died from their underlying diseases. six of those 12 patients with signs or symptoms of vte had underwent duplex ultrasound examination which showed venous thrombus in 2 patients, 1 patient with vein valve insufficiency, and no observed venous thrombus in 3 patients. the other 6 patients did not undergo duplex ultrasound examination due to various reasons (the signs of thrombosis were already clear in 1 patient, patients were treated directly in 2 patients, unconsciousness in 1 patient, the ultrasound has been performed previously in 1 patient, and no data in 1 patient). bleeding complications t h e r a t e o f m a j o r b l e e d i n g d u r i n g anticoagulant treatment in this group (188 patients) was 2.1% (4 patients), 3 patients received ufh and 1 patient received lmwh, while the rate of minor bleeding in gum, skin and gaster was 0.5% (1 patient) each, with 8.5% hematuria (16 patients), and 0.5% (1 patient) had decreased hemoglobin without any bleeding, and another 0.5% (1 patient) had prolonged aptt (> 3 x control). current international guidelines used figure 3 shows the reference international guidelines used in prescribing anticoagulant prophylaxis in this study. they were aha/ asa 2007 in 190 patients (47.4%), for which anticoagulants were used in 118 patients and not used in 72 patients, followed by accp 2008 in 87 patients (21.7%), where anticoagulants were used in 45 patients and not used in 42 patients. aha/asa 2007 and accp 2008 combination was used in 98 patients (24.4%), in which anticoagulants were used in 21 patients and not used in 77 patients. whereas eso 2008 was used in 24 patients (6.0%), and iua 2006 in only 1 patient (0.2%). discussion current use of anticoagulants in hospitals in jakarta in this study, the risk factors in baseline characteristics of patients referred to medenox study, which were immobilization and acute infection, while others factors were age, malignancy, previous history of vte, and obesity.1 there were some additional risk factors which were thrombophilia, varicose vein, pregnancy/postpartum8, nephrotic syndrome9, and dehydration.10 meanwhile, thrombocytosis, previously considered as a risk factor for vte, table 3. initial choice of anticoagulants as vte prophylaxis (n=188) anticoagulant n (%) ufh 121 (64.4) fondaparinux 22 (11.7) enoxaparin 18 (9.6) warfarin 7 (3.7) more than 1* 20 (10.6) *enoxaparin, ufh (9); enoxaparin, warfarin (1); enoxaparin, fondaparinux (3); enoxaparin, ufh, warfarin (1); ufh, warfarin (5); ufh, fondaparinux (1) vol 47 • number 2 • april 2015 underutilization of anticoagulant for venous thromboembolism prophylaxis 141 table 4. list of patients with vte site length of stay in hospital (days) sex age anticoagulant mechanical thrombophylaxis underlying diseases hematology 11 female 53 ufh 25000 u/24 hours yes deep vein thrombosis lower extremities, cellulitis, abscess, type 2 diabetes mellitus hematology 22 male 60 ufh 20000 u/24 hours yes irreversible shock, sepsis, hospital associated pneumonia, prostate adenocarcinoma, type 2 diabetes mellitus hematology 34 female 47 ufh 3x5000 u no lymphoma malignum hematology 18 male 42 ufh 20000 u/24 hours, warfarin 1x2 mg yes complete fracture simphisis ramus superior inferior hematology 23 female 45 ufh 20000 u/24 hours yes breast cancer stage iv hematology 103 male 45 ufh 10000 u/24 hours yes non st elevation myocardial infarction, chronic kidney disease on hemodialysis, hypertension, deep vein thrombosis neurology 58 male 68 fondaparinux 1x2.5 mg yes hypertension grade i, glaucoma ocular dextra and sinistra, hypokalemia, suspect peripheral arterial disease neurology 20 male 51 ufh 10000 u/24 hours yes deep vein thrombosis, congestive heart failure fc iii-iv, peripheral arterial disease, cardiogenic shock neurology 32 female 44 ufh 20000 u/24 hours yes suspect thrombosis, deep vein thrombosis left leg, coronary arterial disease cardiology 4 male 54 yes hepatic cirrhosis, pulmonary embolism cardiology 6 female 53 ufh 10000 u/24 hours, warfarin 1x2 mg no pulmonary embolism, pulmonary tuberculosis, type 2 diabetes mellitus others 11 male 60 enoxaparin 1x0.4 cc, warfarin 1x2 mg no type 2 diabetes mellitus, hypertension, deep vein thrombosis others 2 male 67 ufh 10000 u/24 hours, warfarin 1x1 tab yes deep vein thrombosis, diabetic neuropathy, bilateral cvc, type 2 diabetes was excluded from analysis due to no established supporting data. this finding is somewhat different to medenox study which found that most patients (>50%) had at least 2 risk factors. use of anticoagulants and vte in this study, 46.9% patients received prophylaxis anticoagulants, and 53.1% patients did not. among those who did not receive anticoagulants, the most frequent reason was no anticoagulant indication in about half of them (46.2%). this was contradictory to the eligibility criteria of patients entering this study with vte prophylaxis. the other reasons were cost, contraindications, concerned for bleeding and others as shown in figure 2. physicians identified that 46.2% of 213 t. djumhana atmakusuma acta med indones-indones j intern med 142 patients had no anticoagulant indication and did not use anticoagulants to the patients. this finding represents lack of compliance of physician to start with anticoagulant prophylaxis as mentioned in reference guidelines. vte incidence in this study was lower than those in other studies. patients in the other studies (medenox, artemis, prevent) had higher risk of vte on the whole (10.19% in medenox, 8.07% in artemis, 3.84% in prevent) because the proportion of vte risk factors such as age (73 years in medenox, 74.7 years in artemis, 68.5 years in prevent, 58.1 years in this study), history of vte (9.44% in medenox, 4.59% in artemis, 3.86% in prevent, 1.8% in this study), obesity (20.15% in medenox, 30.37% in prevent, 11.2% in this study), and varicose vein (25.32% in medenox, 27.63% in prevent, 0.3% in table 5. minor bleeding complications minor bleeding n (%) gum 1 (0.5) skin 1 (0.5) gaster 1 (0.5) hematuria 16 (8.5) decreased hemoglobin without bleeding 1 (0.5) prolonged aptt 1 (0.5) this study).1-3 table 6 shows the comparison of characteristics of previous studies with this study. the description of incidence vte (based on signs and symptoms) and types of prophylaxis is shown in table 7. we did not conduct analysis of vte prophylaxis and vte incidence in our study since the study was not designed to compare the incidence and also because of group population imbalance especially the types of prophylaxis given to the subjects. initial choice of anticoagulants as vte prophylaxis most of the physicians chose ufh as vte prophylaxis in this study because of safety concern. among 138 patients receiving ufh (either alone or in combination therapy), the main reason for choosing ufh was controllable administration in 107 patients (78%). the other reason was its low cost in 53 patients (39%). the main reason for choosing enoxaparin among 32 patients was its practical use in 27 patients (84%), followed by its safety in 9 patients (28%). the main reason for choosing fondaparinux was patient request in 22 of 26 patients (85%), while for warfarin, it was more practical (oral use) in 5 of 8 patients (63%). methods of vte prophylaxis used in this study were mechanical thrombophylaxis, p h a r m a c o l o g i c a l t h r o m b o p h y l a x i s , a n d figure 3. reference international guidelines used in this study vol 47 • number 2 • april 2015 underutilization of anticoagulant for venous thromboembolism prophylaxis 143 combination of mechanical and pharmacologic thrombophylaxis, and others. mechanical thromboprophylaxis as a sole prophylaxis measure was used only in cases of contraindications to the anticoagulants and in cases of high risk of bleeding. in the latter cases, mechanical thromboprophylaxis was used until the bleeding risk has decreased and at this time anticoagulants is substituted for or added to the mechanical t h r o m b o p r o p h y l a x i s . i n t h e a b s e n c e o f contraindications, a combination of mechanical and pharmacologic thromboprophylaxis is suggested.4-7 despite of lower risk condition, patients receiving anticoagulants in this study, had a similar incidence of vte as in medenox and artemis studies (4.8 % vs 5.5% and 5.6%). it should be noted that the use of mechanical thromboprophylaxis in this study was high (81.3%), while it is use in medenox and artemis studies was depended on the usual practice at each center but the extant was not specified. the low prescription of anticoagulants by the prescribing physicians, but the high use of mechanical thromboprophylaxis in this study revealed that there was a great need for vte prophylaxis, which was actually realized by the physicians, but they were reluctant to use anticoagulants, primarily because of concern for bleeding, and not because there was no indication.1,3 bleeding complication even there was a major and minor bleeding there was no patients reported died despite of the bleeding complications. it seems that the use of anticoagulant did not raise significant safety concern, since five (5) patients died due the underlying disease as we mention above. implementation of international guidelines on vte prophylaxis in jakarta as previously described, there are 4 (four) international guidelines used on vte prophylaxis: accp 2008, aha/asa 2007, eso 2008 and iua 2006. aha/asa 2007 was the most frequent of international guideline used (47.4%, figure 3) in this study. h o w e v e r, d e s p i t e a n t i c o a g u l a n t i s recommended in the guidelines, around half of the patients (49.06%) were given anticoagulant. this table 6. comparison of vte prophylaxis studies medenox prevent artemis trophy design rct, multicenter, in 9 countries rct, multicenter, in 26 countries rct, multicenter, in 8 countries multicenter, prospective, registry study subjects aim patients, >40 years, hospitalization of ≥6 days aim patients, aged ≥40 years, hospitalization of ≥4 days aim patients, ≥60 years, hospitalization of ≥4 days aim patients, ≥40 years, hospitalized ≥6 days prophylaxis 20 mg or 40 mg of enoxaparin 5000 iu of dalteparin 2.5 mg of fondaparinux various regimens outcomes lower vte incidence in group receiving 40 mg of enoxaparin (5.5%) than placebo (14.9%). lower vte incidence in group receiving prophylaxis (2.77%) than placebo (4.96%). lower vte incidence in group receiving prophylaxis (5.6%) than placebo (10.5%). thirteen patients (3.2%) of 401 patients had signs or symptoms of vte rct: randomized controlled trial; aim: acutely ill medical table 7. vte incidence and types of prophylaxis mechanical prophylaxis medical prophylaxis mechanical and medical prophylaxis no prophylaxis total vte 1 4 8 0 13 non vte 159 21 162 46 388 total 160 25 170 46 401 t. djumhana atmakusuma acta med indones-indones j intern med 144 reflects underutilization of the guidelines. even there is strong indication to use anticoagulant, only half use the guidelines. even if they use the recommendation only half fully follow the guidelines. others who partially use the guidelines, due to many reasons. according to eso and iua guidelines, use of anticoagulants in ischemic stroke is not recommended, due to the benefit of the anticoagulants are counterbalanced by the intracranial hemorrhage. in this setting, a s i n h e m o r r h a g i c s t r o k e , m e c h a n i c a l thromboprophylaxis is recommended.6,7 languasco et al.11 found that underuse and inappropriate vte prophylaxis in argentina. they found that 85.5% of the subjects received medical prophylaxis but only 60.6% of the subjects received appropriate prophylaxis. vte prophylaxis coverage (46.9%) in our study is lower than this study.11 the summary of a anticoagulant treatment according to several international guidelines for vte prophylaxis in medical ill patients is shown in table 9. unfortunately, there are no available regional guidelines either in asia or south east asia, as well as national guidelines. table 8. comparison of guideline implementation languasco et al (2011) trophy subject 310 prescriptions of medical general-ward admitted patients 401 acutely ill medical patients, aged ≥40 years, hospitalized for ≥6 days, immobilized for ≥3 days result 265 subjects (85.5%) received thromboprophylaxis, 188 subjects (60.6%) of these 265 subjects received appropriate prophylaxis according to the institutional guidelines, according to accp 2004 188 subjects (46.9%) received prophylaxis anticoagulants table 9. summary of anticoagulant treatment according to selected international guidelines for vte prophylaxis in medically ill patients aha/asa 2007* accp 2008 eso 2008* iua 2006+ indication for thrombophylaxis condition in which anticoagulant is recommended ischemic stroke, immobilized (seriously ill patients). chf; severe respiratory disease; confined to bed and have one or more risk factors (active cancer, previous vte, sepsis, acute neurologic disease, or inflammatory bowel disease) ischemic stroke patients with high risk of dvt or pulmonary embolism (e.g. due to immobilization, obesity, diabetes, previous stroke). age > 40 years old with acutely medical illness and/ or reduced mobility with one of morbidities : chf class iii/ iv, respiratory disease, active cancer requiring therapy, acute infective disease, rheumatic disease, ischemic stroke, or acute myocardial infarction; acute medical illness with reduced mobility and one of the risk factors : history of vte, malignant disease, or age over 75 years old. choices of anticoagulants lmwh grade ia for all subcutaneous anticoagulant in general grade ia grade ia grade a (enoxaparin 40 mg od / dalteparin 5.000 u od) lduh grade ia grade ia grade a (ufh 5.000 iu tid) fondaparinux grade ia (not specified) grade b (2.5 mg daily dose) chf, congestive heart failure; dvt, deep vein thrombosis; lmwh: low molecular weight heparin; lduh, low dose unfractionated heparin * for ischemic stroke + grade a: recommendations are based on level 1 evidence from randomized controlled trials with consistent results. grade b: recommendations are based on level 1 evidence from randomized controlled trials with less consistent results, limited power, or other methodological problems. grade c: recommendations are based on level 2 evidence from wellconducted observational studies with consistent results. vol 47 • number 2 • april 2015 underutilization of anticoagulant for venous thromboembolism prophylaxis 145 conclusion the present thromboprophylaxis registry in jakarta, indonesia, among acutely ill medical patients at risk of vte showed underutilization of prophylaxis anticoagulant. this registry also showed underutilization of lmwh compared to ufh. aha/asa guideline is the most commonly used guideline for vte prophylaxis, followed by accp guideline. the reasons of underutilization of anticoagulant prophylaxis were medical reasons (74.1%) which also included doctors’ opinion, cost (21.2%), and other reasons (4.7%). mechanical thromboprophylaxis either alone or in combination with pharmacological thromboprophylaxis is the most commonly used in this study population. vte thromboprophylaxis strategy in medically ill patients needs to be improved in clinical setting. conflict of interest financial support for this study and editorial support for this publication has been provided by sanofi. references 1. samama mm, cohen at, darmon jy, et al. a comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients (medenox study). new engl j med. 1999;341:793-800. 2. leizorovics a, cohen at, turpie ag, et al. randomized, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. circulation. 2004;110:874-9. 3. cohen at, davidson b, gallus as, et al. a multinational, randomized, double-blind comparison of once daily subcutaneous fondaparinux sodium with placebo for the prevention of venous thromboembolic events in acutely ill medical patients (artemis). blood. 2003;102:15a. 4. hirsh j, guyatt g, albers gw, et al. executive summary: american college of chest physicians (accp) evidence-based clinical practice guidelines. 8th ed. chest. 2008;133:71s-105s. 5. adams hp jr, del zoppo gl, alberts mj, et al. aha/ asa guidelines for the early management of adults with ischemic stroke. stroke. 2007;38:1655-711. 6. ringleb pa, bousser m-g, ford g, et al, for the european stroke organization (eso) executive committee and the eso writing committee. guidelines for management of ischemic stroke and transient ischemic attack. cerebrovasc dis. 2008;25:457-507. 7. nicolaides an, fareed j, kakkar ak, et al. for international union of angiology (iua). prevention and treatment of venous thromboembolism international consensus statement (guidelines according to scientific evidence). int angiol. 2006;25:101-61. 8. anderson fa, spencer fa. risk factors for venous thromboembolism. circulation. 2003;107: i-9-i-6. 9. ismail g, mircescu g, ditoju av, et al. risk factors for predicting venous thromboembolism in patients with nephrotic syndrome: focus on haemostasis – related parameters. int urol nephrol. 2014;46(4):787-92. pmid:24078010. 10. prandoni p. acquired risk factors for venous thromboembolism in medical patients. hematology (am soc hematol educ program). 2005;458-61. 11. languasco a, galante m, marin j, soler c, saubidet cl, milberg m. adherence to local guidelines for venous thromboprophylaxis: a cross-sectional study of medical inpatients in argentina. thromb j. 2011;9:18. clinical practice 279acta med indones indones j intern med • vol 49 • number 3 • july 2017 national consensus on management of dyspepsia and helicobacter pylori infection ari f. syam, marcellus simadibrata, dadang makmun, murdani abdullah, achmad fauzi, kaka renaldi, hasan maulahela, amanda p. utari the indonesian society of gastroenterology, jakarta, indonesia. indonesian helicobacter pylori study group, jakarta, indonesia. corresponding author: ari fahrial syam, md., phd. division of gastroenterology, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: ari_syam@hotmail.com. abstrak dispepsia merupakan salah satu dari berbagai keluhan umum yang dapat ditemui oleh dokter di berbagai bidang, tidak terbatas hanya pada ahli saluran cerna saja dalam praktik kesehariannya. pengertian mengenai patofisiologi dispepsia terus berkembang sejak dimulainya investigasi secara ilmiah pada 1980-an sampai dengan saat ini yang memandang infeksi helicobacter pylori sebagai salah satu faktor kunci dalam menangani dispepsia, baik terkait ulkus maupun non-ulkus. penatalaksanaan dispepsia tidak bisa dilepaskan dari penatalaksaan infeksi h.pylori, serta penambahan pengetahuan baru terkait definisi, patofisiologi, diagnosis dan penatalaksanaan dispepsia dan infeksi h.pylori. konsensus penatalaksanaan dispepsia dan infeksi h.pylori di indonesia ini dibuat berdasarkan evidence based medicine, sehingga dapat digunakan sebagai rujukan para dokter dalam menangani kasus-kasus dispepsia dan infeksi h.pylori di tempat praktik sehari-hari. dengan adanya konsensus terbaru ini diharapkan para dokter dapat lebih meningkatkan pelayanannya kepada pasien-pasien dispepsia dan infeksi h.pylori. kata kunci: dispepsia, h. pylori, saluran cerna. abstract dyspepsia is one of numerous general complaints, which is commonly encountered by doctors of various disciplines. in daily practice, the complaint is not only limited for gastroenterologists. knowledge on pathophysiology of dyspepsia have been developing continuously since a scientific investigation has been started in 1980’s, which considers helicobacter pylori as one of key factor in managing dyspepsia, either it is associated with ulcer or non-ulcer. the management of dyspepsia cannot be separated from the management of h. pylori and there is an additional new knowledge associated with definition, pathophysiology, diagnosis and treatment of both dyspepsia and h. pylori infection. this consensus document on the management of dyspepsia and h. pylori infection in indonesia has been developed using the evidence-based medicine principles; therefore, it can be used as a reference for doctors in dealing with dyspepsia and h. pylori infection cases in their daily practice. it is expected that with the new consensus, doctors can provide greater service to their patients who have dyspepsia and h. pylori infection. keywords: dyspepsia, h. pylori, gastrointestinal tract. ari f. syam acta med indones-indones j intern med 280 introduction dyspepsia is a common symptom found in daily practice and it has been known for a long period of time. there is a continuously developing definition starting from all symptoms originated from the upper gastrointestinal tract up to the exclusion of reflux symptoms; while the most recent definition refers to the rome iii criteria.1 h. pylori (hp) infection nowadays has been considered as one of important factors in dyspepsia management, both the organic or functional dyspepsia; therefore, any discussion on dyspepsia should be correlated with the management of hp infection. various metaanalysis studies have demonstrated that there is a correlation between hp infection and gastroduodenal diseases, which is characterized by symptoms/signs of dyspepsia. 2,3 the prevalence of hp infection in asia is relatively high and thus it should be noticed in the diagnosis approach and management of dyspepsia. hp eradication has been proven effective in eliminating symptoms of organic dyspepsia; however, for functional dyspepsia, further studies are still necessary.4 the consensus is developed to provide a guideline for general physicians, specialists, and consultants regarding the management of dyspepsia. the consensus has combined the management of dyspepsia and hp infection; therefore, it will achieve better results. epidemiology dyspepsia is an uncomfortable feeling (discomfort) originated from the upper part of abdomen. the discomfort can be one of or some of following symptoms, i.e. epigastric pain, epigastric burn, feeling of fullness after having meal, early satiated and bloating in the upper gastrointestinal tract area, nausea, vomiting and blurping.5 for functional dyspepsia, those abovementioned symptoms must occur for at least the last three months with symptom onset of six months before the diagnosis is defined. the prevalence of dyspepsia in health care units reaches 30% of services offerec by general physicians and 50% of services by gastroenterologists. most of asian patients with uninvestigated dyspepsia and without any alarm signs experience functional dyspepsia. the results of studies in asian countries (china, hong kong, indonesia, korea, malaysia, singapore, taiwan, thailand and vietnam) show that 43 to 79.5% patients with dyspepsia have dysfunctional dyspepsia.5 from the results of endoscopy, which had been performed in 550 patients with dyspepsia at some centers in indonesia between january 2003 and april 2004, there were 44.7% cases with minimal disorder of gastritis and duodenitis; 6.5^ cases with gastric ulcer and 8.2% of normal cases.6 in indonesia, the data on prevalence of hp infection in patients with peptic ulcers (without a history of using non-steroid anti-inflammatory drugs (nsaids)) varies between 90 and 100% and for patients with functional dyspepsia, the prevalence is 20-40% with various diagnostic methods (serology examination, culture and histopathology).7 the prevalence of hp infection in patients with dyspepsia who underwent endoscopic examination at various teaching hospital in indonesia between 2003 and 2004 was 10.2%. a relatively high prevalence was found in makassar, which was 55% (2011) and in solo as many as 51.8% (2008). the high prevalence was also found in yogyakarta of 30.6% and surabaya of 23.5% in 2013; while the lowest prevalence has been found in jakarta (8%).6,8-10 pathophysiology the pathophysiiology of peptic ulcer caused by hp and non-steroid anti-inflammatory drugs (nsaid) has been widely known.1 functional dyspepsia is caused by some major factors such as gastroduodenal motility disorder, hp infection, gastric acid, visceral hypersensitivity and psychological factors. other factors that may have role are genetics, life style, environment, diet and history of previous gastrointestinal infection.11,12 the role of gastroduodenal motility disorders the gastroduodenal motility disorder consists of reduced gastric capacity in accommodating meal (impaired gastric accommodation), antroduodenal incoordination and slow gastric vol 49 • number 3 • july 2017 national consensus on management of dyspepsia and h. pylori infection 281 emptying. it is also one of main mechanism in the pathophysiology of functional dyspepsia, which is associated with bloating after meal and it may be found in the form of abdominal distension, bloating and fullness.5,12 the role of visceral hypersensitivity visceral hypersensitivity has an important role in the pathophysiology of functional dyspepsia, particularly in increasing the sensitivity of peripheral and central sensory nerves against chemical and intraluminal receptor stimuli at the proximal part of the stomach. it can cause or aggravate dyspepsia symptoms.5 the role of psychosocial factors psychosocial disorder is one of inducers that may have roles in functional dyspepsia. the severity of psychosocial disorder is consistent with the severity of dyspepsia. various studies show that depression and anxiety have roles in the development of functional dyspepsia.5,12 the role of gastric acid gastric acid may have a role in developing symptoms of functional dyspepsia. it has also becomes an underlying reason for effective treatment using anti-secretory agents as shown by some studies in patients with functional dyspepsia. there is little data of studies on the gastric secretion and some reports in asia are still controversial.5 the role of hp infection the prevalence of hp infection in patients with functional dyspepsia varies from 39% to 87%. the correlation between hp infection and motility disorder is inconsistent; however, eradication of hp improves the symptoms of functional dyspepsia. biological markers such as ghrelin and leptin as well as altered expression of muscle-specific micrornas are correlated with pathophysiological process of functional dyspepsia, which still needs further studies.5,13 diagnosis diagnosis of dyspepsia dyspepsia that has been investigated consists of organic and functional dyspepsia. organic dyspepsia consists of gastric ulcer, duodenal ulcer, erosive gastritis, gastritis, duodenitis and a process of malignancy. functional dyspepsia refers to the rome iii criteria, which has not been validated in indonesia. the asia-pacific consensus (2012) has decided to follow the concept in the rome iii diagnosis criteria with some additional symptoms of bloating in the upper abdominal part, which is commonly found as the symptom of functional dyspepsia.5 dyspepsia according to the rome iii criteria is a disease with one or more symptoms associated with gastroduodenal abnormalities of: • epigastric pain • epigastric burn sensation • fullness or discomfort after meal • early satiety the symptoms must occur at least in the last three months with an onset of symptoms in six months before the diagnosis is established. the rome iii criteria categorize functional dyspepsia into 2 subgroups, i.e. the epigatric pain syndrome and postprandial distress syndrome. however, the most recent evidence demonstrates that there is an overlapping of diagnosis in two third of patients with dyspepsia.1 uninvestigated dyspepsia workups (consistent with indications) blood test endoscopy urea breath test abdominal usg functional dyspepsiaorganic dyspepsia peptic ulcer erosive gastritis moderate to severe gastritis gastric cancer distress sydrome after meal epigastric pain syndrome figure 1. algorithm for diagnosis of uninvestigated dyspepsia evaluation on the alarm signs must always be part of evaluation of the patients who come with a complaint of dyspepsia. the alarm signs for dyspepsia include weight loss (unintended weight loss), progressive dysphagia, recurrent or persistent vomiting, gastrointestinal bleeding, anemia, fever, a mass in the upper abdominal area, a family history of gastric cancer, dyspepsia with new onset in patients aged more than 45 years. patients with those complaints must be investigated first using endoscopy.5 ari f. syam acta med indones-indones j intern med 282 diagnosis of hp infection14 diagnostic test of hp infection can be performed both directly using endoscopy (rapid urease test, histological test, culture and pcr) and indirectly without endoscopy (urea breath test, stool test, urine test and serology). urea breat test has now become the gold standard for evaluating hp. one of the available urea breath tests is the 13co breath analyzer. there is a requirement for conducting hp evaluation, i.e. the patient must be free from antibiotic and ppi (proton-pump inhibitor) treatment for 2 weeks and there are some other factors that need to be taken into consideration such as clinical situation, prevalence of the infection, prevalence of the infection in a population, probability of pre-test infection, differences in test performance and factors that can affect the result of the test such as the use of anti-secretory and antibiotic treatment. management the management of dyspepsia is initiated by carrying out efforts on identification of pathophysiology and etiological factors as many as possible.11 treatment of dyspepsia can already be started based on the dominant clinical symptoms (although those symptoms have not been investigated) and the treatment is subsequently continued in consistent with the results of investigation. tabel 1. a comparison of various diagnostic tests for hp infection tests sn sp notes with endoscopy rapid urease test >98% 99% fast and inexpensive reduced sensitivity following treatment specimens are obtained from antrum histology >95% >95% increased detection using special staining warthinstarry/ hematoxylin-eosin/ giemsa) specimens are obtained from antrum and corpus culture very specific, poor sensitivity when transport medium is not available requires experience expensive, often unavailable specimens are obtained from antrum and corpus using media such as sparrow pcr sensitive and specific no standard specimens were obtained from antrum and corpus considered without endoscopy elisa serology 85-92% 79-83% less accurate and does not demonstrate active infection a reliable predictor of infection in developing countries with high prevalencei it is not recommended for a period after therapy inexpensive and available 13c urea breath test (ubt) such as: 13co2 breath analyzer 95% 96% it is recommended for establishing the diagnosis of hp infection before commencing therapy14 the test of choice for confirming eradication patient is not allowed having ppi and antibiotic treatment for 2 weeks prior to the examination.15,16 varied availability fecal antigen 95% 94% rarely used although it has high sensitivity and specificity, before and after therapy finger-stick serology very poor and can not match the elisa serology urinary antibody: urinebaed rapid urine test17-19 73.2-82% 78.6-90.7% right now, the urine test has not been available in indonesia sn: sensitivity, sp: specificity, elisa: enzyme-linked immunosorbent assay, pcr: polymerase chain reaction, ppi: proton-pump inhibitor vol 49 • number 3 • july 2017 national consensus on management of dyspepsia and h. pylori infection 283 uninvestigated dyspepsia the optimum management strategy for this phase is by providing empirical therapy for 1-4 weeks before receiving results of initial investigation, i.e. the examination evaluating the evidence of hp presence.11,13 for certain region and ethnicity and patients with high risk, the hp evaluation must be performed earlier. medications that can be used are antacids, gastric acid antisecretory agents (ppi such as omeprazole, rabeprazole and lansoprazole and/ or h2-receptor antagonist [h2ra]), prokinetics and cytoprotectors (such as rebamipide), in which the selection of the regimen is based on the dominant symptoms and previous medication. there is an ongoing development of a new drug which acts on the down-regulation proton pump that has been expected to have better mechanism of action than the ppi, i.e. the dlbs.24,11 associated with the high prevalence of hp infection, the test-and-treat strategy is applied for patients with dyspepsia symptoms without any alarm sign. the test-and-treat strategy is performed for:20 • dyspepsia patients without any complication, who do not response to life style changes, 2-4 weeks of treatment using single ppi and without any alarm sign. • patients with a history of gastric or duodenal ulcer, but have never been investigated. • patients who will receive nsaid, particularly those with a history of gastroduodenal ulcer. • patients with unexplained iron deficiency anemia, idiopathic thrombocytopenic purpura and vitaminb12 deficiency. test and treat is not performed in:20 • patients with gastroesophageal reflux disease (gerd). • children with functional dyspepsia. dyspepsia that has been investigated dyspepsia patients with alarm signs receive no empirical therapy; instead, they should be investigated first by endoscopy with or without histopathological assessment before they are treated as patients with functional dyspepsia. after the investigation, it does not exclude the possibility that in some of dyspepsia cases, gerd is found as the abnormality. organic dyspepsia w h e n a l e s i o n o f m u c o s a ( m u c o s a l damage) is found, which is consistent with the endoscopy findings, therapy is given based on the abnormalities that have been found. abnormalities that have been included into the organic dyspepsia group are gastritis, hemorrhagic gastritis, duodenitis, gastric ulcer, duodenal ulcer or malignancy process. in peptic ulcer (gastric and/or duodenal ulcer), the medication that can be given are a combination of ppi such as rabeprazole 2 x 20 mg or table 2. therapy regimen for hp eradication14,23 drug dose duration first line: ppi* 2x1 7-14 days amoxicillin 1000 mg (2x1) clarithromycin 500 mg (2x1) in an area where resistance to clarithromycin >20% ppi* 2x1 7-14 days bismuth subsalicylate 2x2 tablet metronidazole 500 mg (3x1) tetracyline 250 mg (4x1) when bismuth is not available: ppi* 2x1 7-14 days amoxicillin 1000 mg (2x1) clarithromycin 500 mg (2x1) second line: this class of drugs is used when there is a failure with clarithromycin-based regimen ppi* 2x1 7-14 days bismuth subsalicylate 2x2 tablets metronidazole 500 mg (3x1) ppi* 2x1 7-14 days amoxicillin 1000 mg (2x1) levofloxacin 500 mg (2x1) third line: when the second line regimen fails. whenever possible, the selection is based on resistance test and/or clinical changes ppi* 7-14 days amoxicillin 2x1 levofloxacin 1000 mg (2x1) rifabutin 500 mg (2x1) *ppi agents that have been used are rabeprazole 20 mg, lansoprazole 30 mg, omeprazole 20 mg, pantoprazole 40 mg and esomeprazole 40 mg. notes: sequential therapy (can be given as the first lilne when there is no data about resistance to clarithromycin): ppi + amoxicillin for 5 days followed by ppi + clarithromycin and nitroimidazole (tinidazole) for 5 days. ari f. syam acta med indones-indones j intern med 284 lanzoprazole 2 x 30 mg and mucoprotectors such as rebamipide 3 x 100 mg. functional dyspepsia when there is no mucosal damage found after the investigation, the treatment can be given in consistent with the presence of functional dyspepsia. the use of prokinetics such as metoclopramide, domperidone, cisapride, itopride and others can improve the symptoms of patients with functional dyspepsia. it may be associated with slow gastric emptying as one of pathophysiology in functional dyspepsia. caution must always be applied when using cisapride as it may have potency for cardiovascular complication.11 data about the use of antidepressants or antianxiolytic in patient siwht functional dyspepsia is still very limited. a recent study in japan has demonstrated a significant improved symptom in patients with functional dyspepsia who have receivied 5-ht1 agonists compared to placebo. on the other hand, the use of venlafaxin, a serotonine and norepinephrin inhibitor, does not show better results compared to placebo.5 psychological problems as well as sleep disturbance and defects on central serotonin sensitivity may become important factors in the response of antidepressant therapy in patients with functional dyspepsia.5 management of dyspepsia with hp infection hp eradication can provide long-term remission of dyspepsia symptoms.20 a crosssectional study conducted in 21 patients at cipto mangunkusumo hospital, jakarta (2010) found that the eradication therapy had improved the symptoms in a majority of dyspepsia patients with a percentage of symptom improvement as much as 76% and 81% had negative hp results when they were evaluated using ubt.21 figure 2. algorithm of managing dyspepsia at various levels of health care units5 vol 49 • number 3 • july 2017 national consensus on management of dyspepsia and h. pylori infection 285 *alarm signs: weight loss (unintended) progressive dysphagia, recurrent/persistent vomiting, gastrointestinal tract bleeding, anemia, fever, upper abdominal mass, family history of stomach cancer, new onset dyspepsia in patients aged >45 years. pe: physical examination; ugit: upper gastro intestinal tract, hcp-1: the first level health care provider, hcp-2-3: the second and third level of health care providers. figure 3. algorithm of managing functional dyspepsia5 a prospective study conducted by syam af et al in 2010 showed that hp eradication therapy using triple therapy (rabeprazole, amoxicillin and clarithromycin) for 7 days was better than the 5-day therapy.22 in an area where resistance to clarithromycin is high, we recommend to perform culture and resistance test (using endoscopic specimens) prior to therapy. a molecular test can also be performed to detect hp and resistance to clarithromycin and/or fluoroquinolone directly through gastric biopsy. a f t e r g i v i n g e r a d i c a t i o n t h e r a p y, a confirmation test must be done using ubt or h. pylori stool antigen monoclonal test. the test can be performed within at least 4 weeks after the end of treatment. for hpsa, there is a possibility of false positive result. ari f. syam acta med indones-indones j intern med 286 figure 4. algorithm of managing eradication of hp infection5 acknowledgments we express our gratitude to prof. dr. dr. daldiyono, prof. dr. h.a. aziz rani, dr. dr. chudahman manan and mrs. darwi in preparing the manuscript of this consensus. references 1. ford ac, moayyedi p. dyspepsia. curr opin gastroenterol. 2013;29:662-8. 2. saad am, choudhary a, bechtold ml. effect of helicobacter pylori treatment on gastroesophageal reflux disease (gerd): meta-analysis of randomized controlled trials. scand j gastroenterol. 2012;47:12935. 3. tang cl, ye f, liu w, pan xl, qian j, zhang gx. eradication of helicobacter pylori infection reduces the incidence of peptic ulcer disease in patients using nonsteroidal anti-inflammatory drugs: a meta-analysis. helicobacter. 2012;17:286-96. 4. lee yy, chua as. investigating functional dyspepsia in asia. j neurogastroenterol motil. 2012;18:239-45. 5. miwa h, ghoshal uc, gonlachanvit s, et al. asian consensus report on functional dyspepsia. j neurogastroenterol motil. 2012;18:150-68. 6. syam af, abdullah m, rani aa, et al. evaluation of the use of rapid urease test: pronto dry to detect h pylori in patients with dyspepsia in several cities in indonesia. world j gastroenterol 2006;12:6216-8. 7. rani aa, fauzi a. infeksi helicobacter pylori dan penyakit gastro-duodenal. in: sudoyo aw, setyohadi b, alwi i, simadibrata m, setiati s, eds. buku ajar ilmu penyakit dalam. jakarta: pusat penerbitan ilmu penyakit dalam fkui; 2006. p. 331-6. 8. hidayati ps, iswan abbas nusi ia, maimunah u. hubungan seropositivitas caga h. pylori dengan derajat keparahan gastritis pada pasien dispepsia. divisi gastroenterohepatologi departemen ilmu penyakit dalam fk unair – rsu dr soetomo surabaya; 2013. (unpublished manuscript). 9. jumlah data helicobacter pylori positif. rsud dr moewardi surakarta; 2008. (unpublished raw data). 10. parewangi aml. jumlah data helicobacter pylori positif di makassar. makassar: rsup dr. wahidin sudirohusodo; 2011. (unpublished raw data). 11. futagami s, shimpuku m, yin y, et al. pathophysiology of functional dyspepsia. j nippon med sch. vol 49 • number 3 • july 2017 national consensus on management of dyspepsia and h. pylori infection 287 2011;78:280-5. 12. choung rs, talley nj. novel mechanisms in functional dyspepsia. world j gastroenterol. 2006;12:673-7. 13. harmon rc, peura da. evaluation and management of dyspepsia. therap adv gastroenterol. 2010;3:87-98. 14. hunt rh, xiao sd, megraud f, et al. helicobacter pylori in developing countries. world gastroenterology organisation global guideline. j gastrointestin liver dis. 2011;20:299-304. 15. altschuler s, peura da. helicobacter pylori and peptic ulcer disease. in: mcnally pr, ed. gi/liver secrets plus. 4th ed. philadelphia, pa: elsevier mosby; 2010. p. 11. 16. chey wd, woods m, scheiman jm, nostrant tt, del valle j. lansoprazole and ranitidine affect the accuracy of the 14c-urea breath test by a ph dependent mechanism. am j gastroenterol. 1997;92:446-50. 17. nguyen lt, uchida t, tsukamoto y, et al. evaluation of rapid urine test for the detection of helicobacter pylori infection in the vietnamese population. dig dis sci. 2010;55:89-93. 18. leodolter a, vaira d, bazzoli f, et al. european multicentre validation trial of two new non-invasive tests for the detection of helicobacter pylori antibodies: urine-based elisa and rapid urine test. aliment pharmacol ther. 2003;18:927-31. 19. demiray gurbuz e, gonen c, bekmen n, et al. the diagnostic accuracy of urine igg antibody tests for the detection of helicobacter pylori infection in turkish dyspeptic patients. turk j gastroenterol. 2012;23:7538. 20. malfertheiner p, megraud f, o’morain ca, et al. management of helicobacter pylori infection--the maastricht iv/florence consensus report. gut. 2012;61:646-64. 21. utia k, syam af, simadibrata m, setiati s, manan c. clinical evaluation of dyspepsia in patients with functional dyspepsia, with the history of helicobacter pylori eradication therapy in cipto mangunkusumo hospital, jakarta. acta med indones. 2010;42:86-93. 22. syam af, abdullah m, rani aa, et al. a comparison of 5 or 7 days of rabeprazole triple therapy for eradication of helicobacter pylori. med j indones. 2010:113-7. 23. chey wd, wong bc, practice parameters committee of the american college of g. american college of gastroenterology guideline on the management of helicobacter pylori infection. am j gastroenterol. 2007;102:1808-25. review article 158 acta med indones indones j intern med • vol 49 • number 2 • april 2017 inflammation, immunity, and hypertension arisya agita1, mochammad thaha2 1 department of cardiology and vascular diseases, faculty of medicine universitas airlangga, surabaya, indonesia. 2 department of internal medicine, faculty of medicine universitas airlangga, surabaya, indonesia. corresponding author: prof. mochammad thaha, md., phd. department of internal medicine, faculty of medicine universitas airlangga. jl. mayjen prof. dr. moestopo 6-8, surabaya 60131, indonesia. email: mochthaha@yahoo.com. abstrak sistem imun, proses inflamasi serta hipertensi saling berkaitan. sistem imun alamiah dan adaptif memicu proses inflamasi, mengakibatkan peningkatan tekanan darah yang merangsang kerusakan organ. sel pada sistem imun alamiah memproduksi ros seperti superoksida dan hidrogen peroksida yang bertujuan membunuh patogen. proses inflamasi jangka-panjang meningkatkan produksi ros, menyebabkan stress oksidatif, mengakibatkan disfungsi endotel. endotel berfungsi mengatur tonus dan struktur pembuluh darah. saat inflamasi, bioavaibilitas no menurun, mengganggu fungsi utamanya, sehingga mencegah relaksasi dan vasodilatasi pembuluh darah. sel t efektor dan limfosit regulatori, bagian dari sistem imun adaptif, berperan pada konstriksi pembuluh darah pada hipertensi. sinyal dari sistem saraf pusat dan apc mengaktivasi diferensiasi limfosit t efektor, dan mempercepat melalui th-1 dan fenotip th-17. efektor th-1 dan th-17 berpartisipasi dalam inflamasi, mengakibatkan peningkatan tekanan darah. salah satu bagian cd4+ adalah regulatory t cells (tregs) yang menekan aktivasi respons imun dengan memproduksi sitokin imunosupresif seperti tgf-β dan il-10. transfer adoptif dari sel tregs menurunkan stres oksidatif pada pembuluh darah, disfungsi endotel, infiltrasi dari makrofag aorta dan sel t serta kadar sitokin proinflamasi dalam sirkulasi plasma. kata kunci: aktifasi sistem imun, proses inflamasi, disfungsi endotel, hipertensi. abstract the immune system, inflammation and hypertension are related to each other. innate and adaptive immunity system triggers an inflammatory process, in which blood pressure may increase, stimulating organ damage. cells in innate immune system produce ros, such as superoxide and hydrogen peroxide, which aimed at killing pathogens. long-term inflammation process increases ros production, causing oxidative stress which leads to endothelial dysfunction. endothelial function is to regulate blood vessel tone and structure. when inflammation lasts, no bioavailability decreases, disrupting its main function as vasodilator, so that blood vessels relaxation and vasodilatation are absent. effector t cells and regulatory lymphocytes, part of the adaptive immune system, plays role in blood vessels constriction in hypertension. signals from central nervous system and apc activates effector t lymphocyte differentiation and accelerate through th-1 and th-17 phenotypes. th-1 and th-17 effectors participate in inflammation which leads to increased blood pressure. one part of cd4+ is the regulatory t cells (tregs) that suppress immune response activation as they produce immunosuppressive cytokines, such as tgf-β and il-10. adoptive transfer of tregs cells can reduce oxidative stress in blood vessels, endothelial dysfunction, infiltration of aortic macrophages and t cells as well as proinflammatory cytokine levels in plasma circulation. keywords: immune system activation, inflamation process, endothelial dysfunction, hypertension. vol 49 • number 2 • april 2017 inflammation, immunity, and hypertension 159 introduction hypertension is a major risk factor for cardiovascular disease events that contribute broadly to morbidity and mortality worldwide. hypertension is a complex condition, with 90% of the cases are classified as essential hypertension with the exact cause is unknown. it is known that hypertension is associated with inflammatory processes. however, until then it has not been known for certain whether the inflammation is a cause or consequence of hypertension.1 the role of inflammation and immunity in the pathogenesis of hypertension has been widely known. infiltration of cells in innate and adaptive immune system to the kidneys, blood vessel wall and area around the blood vessels that occurs simultaneously with the stages of inflammatory process, such as an increase in cytokines release, reactive oxygen species (ros) production and the emergence of adhesion molecules, are hallmarks which are always found in hypertension.2 the study by yao et al shows an interesting fact about the relationship between interleukin-17 (il-17) and hypertension using cross-sectional data adjusted for other factors involved in heart disease and blood vessels. the data support harrison and his colleagues hypothesis’ stating that angiotensin ii stimulation can increase blood pressure associated with the activation of the immune response and inflammation.3 basic concept of immunity defense against microbes is mediated by the initial reaction of innate immune system followed by further response by adaptive immune system. initial mechanism of the immune system to fight pathogens are innate immune system.4 innate immunity is the front line for the body’s defense against microbes. important components of the innate immune system is physical and chemical defenses, such as chemical epithel and antimicrobials produced in epithelial surface. another component is the phagocytic cells (neutrophils and macrophages), dendritic cells, natural killer cells (nk cells) and lymphocytes. other components are blood proteins, including the members of the complement system as well as other inflammatory mediators.5 in contrast to innate immunity, there are other immune responses that will be stimulated by the presence of microorganisms and the exposure will increase, both its magnitude and the ability to survive, if there is exposure that gives a good response to some specific microbes. the immune response is called the adaptive immune response.6 the innate immune system plays an important role in the initiation of adaptive immune response. furthermore, activation of adaptive immune response takes 4-7 days, so that the innate immune system will be activated prior to that time frame.7 early concepts related to adaptive immunity is antigen presenting cell (apc) in peripheral tissues that processes foreign proteins, such as bacteria and viruses, to become a short peptide that is displayed on the major histocompatibility complex (mhc).4 the characteristics that must be found in adaptive immunity is extensive capabilities to identify molecules or fragments of molecules with different types, either extrinsic or with modified structure. in addition, adaptive immune system also has the ability to respond aggressively to repeated exposure to the same microbe, known as memory. adaptive immune response is divided into two: humoral and cellular responses. humoral response will produce antibodies reactive with a particular antigen. antibodies are a collection of proteins with similar structures, which, if collected collectively, will be the immunoglobulin (ig).7 in addition to cellular components, cytokines are important for the development of immune responses involving both innate and adaptive systems.6 all cells of the immune system may produce a minimal number of cytokines and express receptors that signal specifically for certain types of cytokines. structured group of cytokines that regulate the migration and movement of cells are known as chemokines.5 cytokines are a large group of proteins that dissolve and react in short term, which is produced by immune cells and blood vessels, as well as serve to activate specific receptors and modulate the function of various cells in tissues.8 both innate and adaptive immune response are components of the integrated system derived arisya agita acta med indones-indones j intern med 160 from the body’s host defenses where a large number of cells and molecules work and support each other’s function. the working mechanism of innate immunity is to provide an effective early defense against infection. however, unfortunately, many pathogens have the ability to resist innate immunity against a variety of microbes that elimination of those microbes will require stronger immune mechanism, ie adaptive immunity. there is some relationships between innate and adaptive systems. innate immune response against microbes will stimulate adaptive immune response and affect the origin of adaptive response. in contrast, the adaptive immune response works by enhancing the protective mechanisms of innate immunity, thus making the innate immune response be effective against pathogenic microbes.5 for the immune system can be activated, it takes the interaction between the phagocytic cells from innate immune system and t cells with high specificity capabilities from adaptive immune system. all of these are highly correlated with cardiovascular disease since pathogenic microbes mentioned above can lead to dramatic changes in communication between the cells involved to change the function of heart and blood vessels. ros and reactive nitrogen species (rns), which plays an important role in the cardiovascular system, are important parts of innate immunity.4 basic concept of inflammation inflammation is a protective response to damage or infection of a cell. inflammation is a complex process and involves inflammatory cells that will essentially identify the tissues involved, then recruit leukocytes to the tissues, eliminating the cause of inflammation and repair damaged parts of the cell.1 in infection area, macrophages that have been dealing with the microbes, will produce cytokines (such as tumor necrosis factor (tnf) and il-1) and activate endothelial cells to produce selectins, integrins and chemokines.5 to be able to enter into the inflamed tissue, the circulating leukocytes must stick to endothelial layer of the blood vessels walls. this process is called extravasation. leukocyte-specific cell-adhesion molecules (cams), which is expressed on cell surface, serves to regulate the travel path of the leukocytes from blood to the tissues around. production of proinflammatory cytokines and other inflammatory mediators in inflammatory regions will initiate the emergence of cams. vascular endothelium, which is known to have been inflamed, will experience an extravasation process, ie. the displacement of leukocytes to the endothelial tissue. in the event of the creation of leukocytes interaction with endothelium, neutrophils are the first cells that are activated by the inflammatory response, which causes the neutrophil to stick to the inflamed endothelium. then, they will penetrate the endothelium and eventually migrate toward extravascular tissue. the process of neutrophil extravasation can be divided into four stages, ie. attachment-rolling, activation, arrest-adhesion and extravasation.9 in immune system-mediated inflammation, the t-helper 1 (th-1) and t-helper 17 (th-17) cells secrete cytokines that recruit and activate leukocytes. il-17, produced by th-17 cells, activates neutrophils withdrawal. whereas, interferon-g, produced by th-1 cells, activates macrophages and tnf as well as chemokines, which are produced by t-lymphocytes and other cells, and is involved in withdrawal and activation of various types of leukocytes. although it has been emphasized that the th-1 and th-17 cells are the initial source of these cytokines, in cell injury there will be other cells that produce similar cytokines. tissue damage is the result of neutrophil and macrophage products that have been drawn and activated, such as lysosomal enzymes, ros, nitric oxide (no) and proinflammatory cytokines.5 there is some evidence related to the phenotype of proinflammatory cells through a vascular triangle illustrating paralleled vascular dysfunction by oxidative stress, both at the tissue and at cellular level (figure 1). the vascular dysfunction may occur through several mechanisms, including decreased no level, modified ldl, as well as an increase in circulating leukocytes adhesion. the inflammatory process is an integrated process involving oxidative processes and vascular dysfunction, which is primarily mediated by transcription factors vol 49 • number 2 • april 2017 inflammation, immunity, and hypertension 161 such as nfkb, with the target of reducing no bioavailability. this cycle occurs naturally, in which the stages of vascular dysfunction would create an environment that aggravate the ongoing inflammation and oxidative stress. in 2004, clapp and colleagues conducted a study to learn this cycle by inducing an inflammatory response in healthy subjects and observed a decrease in antioxidant status and endothelial function reduction. this study concluded that oxidative stress can decrease endothelial function by decreasing no bioavailability.10 it has been recognized that proinflammatory cytokines are produced by activated dendritic cells, such as il-1, il-6 and tnf. these p r o i n f l a m m a t o r y c y t o k i n e s w i l l c a u s e vasodilation that increases blood flow to the tissues. in addition, inflammatory chemokines will also cause some cells to migrate into the tissue. il-1 is used to stimulate lymphocytes and macrophage proliferation. whereas, il-6 stimulates the production of acute phase proteins derived from liver cells and tnf serves to activate neutrophils, endothelial cells, lymphocytes and acute phase proteins.7 basic concept of hypertension activation of the renin-angiotensinaldosterone system is one of important mechanisms that contribute to the occurrence of endothelial dysfunction, vascular remodeling and hypertension. renin, a protease produced by the juxtaglomerular cells of the kidney, will break angiotensinogen (substrate of renin produced in the liver) to angiotensin i, which is converted to angiotensin ii by the angiotensin converting enzyme (ace). interactions between angiotensin ii and receptor g protein-coupled angiotensin 1 activates a number of cellular processes that contribute to the onset of hypertension and accelerate the occurrence of end-organ damage associated with hypertension. there is strong evidence showing that either aldosterone, angiotensin ii or even renin, activate several signaling pathways that can reduce blood vessels function and cause hypertension. changes of structure and function, both from small and large arteries, have a major role in hypertensive pathogenesis and progress. endothelial layer in the blood vessels is an important component for the health of the blood vessels and lead to a solid defense to prevent hypertension.11 figure 1. vascular triangle10 arisya agita acta med indones-indones j intern med 162 the important role of the kidneys in the longterm control of blood pressure is through the regulation of body fluids and salt homeostasis. this is supported by the fact that the ability of the kidneys to excrete salt would still be decreasing without relying on the causes of hypertension, either through the blood, kidneys and sympathetic vessels. relationship between the activation of innate and adaptive immune system that causes inflammation of the kidneys and hypertension have been widely studied. some are by harrison et al4 and khodja et al2. one characteristic that is frequently found is an increase in infiltration of immune cells, including macrophages and t lymphocytes, in renal interstitial. in addition to the kidney, core regulation of blood pressure can be achieved through a balance between sympathetic and parasympathetic nervous innervation of the kidneys and blood vessels, in addition to the hypothalamic hormone that regulates thirst, renal sodium treatment and the functions of peripheral blood vessels and kidneys.12 o v e r t i m e , e n d o t h e l i a l d y s f u n c t i o n , neurohormonal activation and an increase in blood pressure would lead to remodeling of blood vessels. this condition will worsen the condition of hypertension. increasing thickness of the medial to lumen part of the blood vessel (medial to lumen ratio) is a sign of vascular remodeling caused by hypertension, either in small arteries or large arteries. vasoconstriction will initiate remodeling of small arteries. normal smooth muscle cells would reconstitute themselves around the diameter of the lumen of small arteries so that medial portion to the blood vessel lumen (medial to lumen ratio) will thicken. however, medial cross-sectional area will not change. by reducing the diameter of the lumen in peripheral circulation, systemic vascular resistance will increase so that it will lead to the occurrence of hypertension. instead, lumen remodeling of large arteries are characterized by the appearance of hypertrophic genes that will stimulate an increase in the thickness of medial to lumen ratio. the incidence of remodeling associated with this hypertrophy will cause an increase in the size of vascular smooth muscle cells and the accumulation of extracellular matrix proteins in smooth muscle, such as collagen, due to the activation of the transforming growth factor beta (tgf-b).11 figure 2. vascular remodelling in hypertension11 i m m u n i t y a n d i n f l a m m at i o n i n hypertensive physiology oxidative stress in hypertension oxidative stress contribution to disrupt renal hemodynamic and tubular function has been widely studied. oxidative stress in the kidney is commonly found in the study of hypertension. these studies affirm that ros is an important media for the occurrence of hypertension caused by exposure to angiotensin ii.13 t h e r e a r e m a n y f a c t o r s i n v o l v e d i n h y p e r t e n s i o n , i n c l u d i n g a n g i o t e n s i n ii, aldosterone, cytokines and changes in mechanical stress in blood vessels, such as stretching and tearing, which will stimulate the sources of enzymes, such as nicotinamide adenine dinucleotide phosphate (nadph) oxidase, uncoupled nitric oxide synthase and mitochondria, which will produce ros that contribute to hypertension.4 cells derived from innate immune system, such as neutrophils and macrophages, will produce ros such as superoxide (o2-) and hydrogen peroxide (h2o2), which aims to kill pathogens. nadph oxidase is a major source of ros production in the vasculature.1 vascular dysfunction is the damage of blood vessel function, which is caused by an imbalance of different factors in endothelial vasoactive substances. one endothelial cell within the blood vessels, which is for the protection of outer layer, is responsible for the release of several vasoactive substances, especially no. no is a vol 49 • number 2 • april 2017 inflammation, immunity, and hypertension 163 vasodilator which can cause direct relaxation of smooth muscle, blood flow and the delivery of the substrate to the tissues. no also has antiatherogenic components that can prevent the adhesion of leukocytes and platelets to blood vessel walls. the balance between vasodilation factors such as no, with vasoconstriction factors, such as endothelin-1 (et-1), will affect blood circulation. the decrease of no bioavailability and/or synthesis of oxide synthase (enos) will significantly reduces endothelium-dependent dilatation (edd), which will result in varied process over time, will reduce the function of blood vessels and initiate complications of the heart and blood vessels.10 an inflammatory process will continue until the inflammation-causing microorganisms can be destroyed or tissue repair process has been completed. however, chronic inflammatory process can trigger excessive ros produced. oxidative stress is defined as an unbalanced condition between ros production and breakdown, which may cause endothelial dysfunction.1in normal circumstances, kidneys will produce ros, including anions o2, h2o2, peroxynitrite (onoo¯) and hydroxyl radical (oh), which will be efficiently eliminated by catalase enzymatic superoxide dismutase (sod), glutathione peroxidase (gpx) and nonenzymatic systems (glutathione, vitamin c and e). ros overproduction is related to o2 and will culminate in a state of oxidative stress that will reduce the biological effects of no.14 ros activates transcription factors such as nuclear factor (erythroid-derived 2)-like 2 (nfe2l2), nuclear factor kappa-b (nfkb) and activator protein 1 (ap-i). these transcription factors will modulate gene expression, including adhesion molecules and chemokines, which causes the accumulation of inflammatory cells. in the event of an oxidative damage, the permeability of the endothelium will increase. this will cause an increase in the influx into subendothelial space, which will cause oxidation and inflammation. oxidized lipoproteins can interact with toll like receptors (tlr), in particular the tlr4, which can cause impaired blood vessel function. ros can affect the polarization of t cells and cytokine secretion. inflammatory cells such as macrophages and granulocytes may release ros that can aggravate oxidative ongoing.4 t-lymphocytes in hypertension as described previously, the interaction between vascular and inflammatory cells play an important role at the beginning and the development of hypertension. t cells effector that are part of the adaptive immune system, have a role in constricting blood vessels in hypertension. signals from central nervous system and apc activate t lymphocytes effector and accelerate the differentiation through proinflammatory t-helper (th-1) and th-17 phenotype. effector cells th-1 and th-17, produced by proinflammatory mediators, participate in inflammation that will lead to increased blood pressure and target organ damage. meanwhile, the regulatory t lymphocytes act otherwise in hypertension by holding innate and adaptive immune responses (figure 3).2 in addition, other than th-17 cells, another division of cd4 +, irrespective of th-1 and th-2, is the regulatory t cells (tregs). there is recent evidence related to the role of tregs in suppressing the activation of the immune response. it is known that natural tregs produce immunosuppressive cytokines like tgf-b and il-10.7 several recent studies indicate that tregs have a protective effect on hypertension. it has been recognized that these tregs can reduce oxidative stress in blood vessels, endothelial dysfunction, infiltration of aortic macrophages and t cells as well as the levels of proinflammatory cytokines circulating in plasma circulation. additionally, adoptive transfer of the t-regs may also decrease the incidence of cardiac hypertrophy and fibrosis, infiltration of immune cells and remodeling effects. therefore, it can be inferred that tregs have a high antihypertensive effect, with regard to its ability to produce antiinflammatory cytokines such as il-10.2 slight increase in blood pressure in response to hypertensive stimulus of such as angiotensin ii, aldosterone, et-1, salt diet and genetic influences, arising from signal increase in the central nervous system. this is likely to cause minor damage of the tissue and the formation of damps (damage associated molecular arisya agita acta med indones-indones j intern med 164 patterns) and neoantigen. this condition may trigger apc activation and gradually also activate and polarize naïve cd4, effector t-lymphocytes via proinflammatory t-helper (th-1) or th-17 phenotype that contribute to damage to blood vessels and kidneys through the production of ros, interferon-g and il17, and may trigger hypertension stability and progression of target organ damage. whereas, regulatory t-lymphocytes provide a resistance to hypertension and related damage by producing il-10 and suppresses innate and adaptive immune responses.1 proinflammatory cyokines release in hypertension in local inflammatory process, immune cells may enter into inflammation area through varied chemokines, including monocyte chemotactic protein-1 (mcp-1).12 once it is localized in the kidney, immune cells will release proinflammatory cytokines such as tnf-a, il-6, il-1b, il-17 and interferon-g, where the number of proinflammatory cytokines will increase in the kidneys and contribute to local tissue damage. the role of proinflammatory cytokines in the pathogenesis of hypertension is supported by studies designed to test the inhibitory effect of cytokines on blood pressure. for example, when etanercept is injected into the body to reduce biological activity of tnf-a in mice, it reduces the development of hypertension. it is associated with decreased expression of mcp-1 in renal cortex. the same event happens in the inhibition of il-6. the occurrence of hypertension can be prevented and associated with decreased expression of il-6, macrophage and t cell infiltration.15 apcs, like dendritic cells and monocytes or macrophages, will carry antigens that present in mhc-ii towards naïve t cells (th0) in the secondary lymphoid tissues, which will result in a differentiation in the form of t effector cells such as th-1, th-2, th-17 and regulatory t cells that depend on the combined stimulation originating from different cytokines. effector t cells lymphocytes and tregs then migrate to vasculature tissues, the tunica adventitia and perivascular fat. effector t lymphocyte cells (th1 and th17) will activate other immune cells and contribute to the onset of inflammation by producing proinflammatory cytokines such as interferon-g, il-6 and il-17. whereas, regulatory t cells will suppress innate and adaptive immune response through the production of anti-inflammatory cytokines such as il-10 and tgf-b.2 figure 3. role of t lymphocytes in hypertension2 vol 49 • number 2 • april 2017 inflammation, immunity, and hypertension 165 several studies have found that il-6, il-1 and tnf-a levels in hypertensive patients will be higher than those in patients with normal blood pressure.1 in addition, in their study in 2015, yao et al.3 have concluded that cytokines play an important role in the pathogenesis of hypertension. conclusion immunity, inflammation and hypertension have proven to be related to each other. the activation of those 3 factors triggers an inflammatory process, that will and increase the blood pressure and leads to organ damage. the innate immunity cells, such as neutrophil and macrophage, will produce ros such as anion superoxide (o2¯) and hydrogen peroxide (h2o2) that leads to reduced bioavailability of no resulting in increase blood pressure. in addition to this, t cell effector and regulatory lymphocyte will increase the differentiation throughout pro-inflammatory t helper (th-1) and th-17 and produce the pro-inflammatory cytokines while in the contrary, the tregs cells will suppress the activation of immune system and give protective effect against hypertension. a numerous research and study should be held to discover the relation between immunity, inflammation and hypertension in depth. so that the new methods in managing hypertension such as immunotherapy or even further might reduce the prevalence and incidence of hypertension. references 1. dinh qn, drummond gr, sobey cg, et al. roles of inflammation, oxidative stress, and vascular dysfunction in hypertension. hindawi publishing corporation; 2014. 2. khodja ni, oneeb r, pierre p, et al. dual opposing roles of adaptive immunity in hypertension. european heart j. 2014;35:1238-44. 3. yao w, sun y, wang x, niu k. elevated serum level of interleukin 17 in a population with prehypertension. j clinhypertens (greenwich). 2015. doi: 10.1111/ jch.12612. 4. harrison dg, guzik tj, lob he, et al. inflammation, immunity, and hypertension. am heart assoc hyperten. 2011;57:132-40. 5. abbas ak, lichtman ah, pillai s, et al. cellular and molecular immunology. elsevier. 2015;8:1-12. 6. todar k. immune defense against microbial pathogens. todar’s online textbook of bacteriology. 2005. http:// textbookofbacteriology.net/immune.html. 7. chapel h, haeney m, misbah s, et al. essentials of clinical immunology. wiley blackwell. 2014;6:3-24. 8. sparague ah, raouf ak. inflammatory cytokines in vascular dysfunction and vascular disease. us national library of medicine. 2009;78(6):539-52. 9. elgert kd. immunology; understanding the immune system. microbiology and immunology section department of biological sciences virginia tech. 2009;2:94-96 10. wadley aj, zanten jj, aldred s. the interactions of oxidative stress and inflammation with vascular dysfunction in ageing: the vascular health triad. am aging association. 2013;35:705-18. 11. lilly ls. braunwald’s heart disease: a textbook of cardiovascular medicine. elsevier. 2015;10:935–53. 12. ryan mj. an update on immune system activation in the pathogenesis of hypertension. am heart assoc. 2013;62:226–30. 13. cowley aw jr. renal medullary oxidative stress, pressure-natriuresis, and hypertension. hypertension. 2008;52:777–86. 14. thaha m, tanuseputra es, tomino y. reactive oxygen species, nitric oxide and the kidney. juntendo med j. 2010;56:37-44. 15. venegas-pont m, manigrasso mb, et al. tumor necrosis factor-alpha antagonist etanercept decreases blood pressure and protects the kidney in a mouse model of systemic lupus erythematosus. hypertension. 2010;56:643–9. 46 original article acta med indones indones j intern med • vol 50 • number 1 • january 2018 diabetic ketoacidosis in adolescents and children: a prospective study of blood versus urine ketones in monitoring therapeutic response aman b. pulungan, erlin juwita, antonius h. pudjiadi, siti rahmayanti, ireska tsaniya department of child health, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: aman bhakti pulungan, md, phd. division of endocrinology, department of child health, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: amanpulungan@mac.com. abstrak latar belakang: ketoasidosis diabetes (kad) adalah komplikasi diabetes melitus (dm) yang berpotensi mengakibatkan kematian. saat ini belum ada studi di indonesia yang membandingkan pengukuran kadar beta-hidroksibutirat (β-ohb) kapiler dengan asetoasetat pada urin untuk memonitor respon terapi dari dka pada remaja. metode: studi prospektif terhadap 37 remaja dan anak dengan diagnosis kad di rumah sakit dr. cipto mangunkusumo selama juni 2006-maret 2011 hingga kad dinyatakan resolusi. pemeriksaan gula darah sewaktu, β-ohb kapiler, dan keton urin dilakukan setiap jam, sedangkan analisis gas darah dan elektrolit dilakukan setiap empat jam. hasil: median waktu resolusi kad adalah 21 (9-52) jam. saat median resolusi kad, terdapat korelasi signifikan yang lebih baik antara kadar β-ohb kapiler dibandingkan dengan kadar keton urin terhadap ph (r= -0,52, p= 0,003 vs r= -0,49, p= 0,005) serta terhadap bikarbonat (r= -0,60, p= 0,000 vs r= -0,48, p= 0,007). kadar β-ohb kapiler seluruhnya menunjukkan hasil negatif saat median resolusi, sedangkan ketonuria masih ditemukan hingga 9 jam paska resolusi. kesimpulan: kadar keton darah menunjukkan korelasi yang lebih baik terhadap ph dan bikarbonat untuk menentukan respon terapi kad pada remaja dan anak bila dibandingkan dengan metode keton urin. kata kunci: betahidroksibutirat kapiler, ketoasidosis diabetes, keton urin, waktu resolusi. abstract background: diabetic ketoacidosis (dka) is a potentially lethal complication of diabetes mellitus (dm). there is no study in indonesia that compares the much-preferred capillary beta hydroxybutirate (β-ohb) measurement to urine acetoacetate in monitoring therapeutic response of dka in adolescents. methods: a prospective study of 37 adolescents and children with dka in cipto mangunkusumo hospital was done between june 2006 and march 2011. the patients were followed until the time of dka resolution. hourly measurements of random blood glucose, capillary β-ohb concentration, and urine ketones were done, while blood gas analysis and electrolyte were measured every four hours. results: median time to resolution was 21 (9-52) hours. compared to urine ketones, capillary β-ohb concentration showed stronger correlation with ph (r= -0.52, p= 0,003 vs r= -0.49, p= 0,005) and bicarbonate level (r=-0.60, p=0.000 vs r= -0.48, p=0.007) during the median time of dka resolution. all capillary β-ohb measurement yielded negative results at median time of dka resolution, while urine ketones were still detected up to 9 hours after resolution. conclusion: blood ketone concentration vol 50 • number 1 • january 2018 diabetic ketoacidosis in adolescents and children: a prospective study 47 showed a better correlation with ph and bicarbonate level, as a tool to monitor therapeutic response in dka in adolescent, compared to traditional urine ketones test in adolescents. keywords: capillary betahydroxybutirate, diabetic ketoacidosis, urine ketones, resolution time. introduction diabetic ketoacidosis (dka) is a potentially lethal complication of diabetes mellitus (dm).1 among young patients with type 1 diabetes mellitus (t1dm), dka is the most common cause of mortality and the risk of developing the condition ranges around 1-10% per patients per year.2,3 a report from the endocrinology taskforce of indonesian pediatric society from may 2009 to march 2011 demonstrated that 591 children and adolescents were living with t1dm across indonesia. in 2010, dr. cipto mangunkusumo hospital recorded 98 cases of dka over a fouryear period, which resulted in 14 deaths.4 t h e u r i n a r y k e t o n e ( a c e t o a c e t a t e ) measurement is traditionally used in monitoring dka patients. this examination does not measure the level of betahydroxybutirate (β-ohb) which is the predominant ketone body in dka.5 during the course of dka treatment, there are drastic changes in ratio of acetoacetate to β-ohb from the normal 3:1 ratio to 7:1, until 15:1.6 besides prone to subjectivity, the urine sample collection in young population is often difficult, impractical and time consuming.5,7 there are many factors that lead to high rates of false positive and false negative results in urine ketone examination.5,8,9 in respect of successful dka therapy, the conversions of β-ohb to acetoacetate take place, owing to chains of oxidative reaction in the liver. in turn, the level of acetoacetate and acetone will rise as the β-ohb concentration falls.10,11 motivated by the unreliability of urine ketone to assess dka severity and insulin response, the american diabetes association (ada) recommends the capillary β-ohb measurement in diagnosis and monitoring of dka.12 this study was the first in indonesia to compare the correlation between capillary β-ohb and ketone urine level to the blood gas analysis (bga) parameters, as the standard of monitoring dka therapeutic response. methods subjects aged 5-18 years admitted with diagnosis of dka to cipto mangunkusumo hospital, jakarta, were recruited consecutively from june 2006 to march 2011. in this study, dka was defined as clinical findings of random blood glucose (rbg) >200 mg/dl, ph <7.5 or bicarbonate level <15 meq/l, positive urine ketones (concentration >0.5 mmol/l), and positive capillary β-ohb (concentration >0.5 mmol/l). patients with hyperglycemia due to other causes, diagnosed with respiratory acidosis, and whose parents refused to consent were excluded from the study. those who failed to follow management protocol or died prior to 36 hours after admission were not included in the analysis. there were 40 episodes of dka recorded. two patients were excluded of unwillingness to participate and one patient who died in the first three hours of care was considered as a drop out. we followed 37 dka cases during the period of study. study protocol all patients arrived in the intensive or intermediate care were managed according to the standard procedure of dka management in our hospital. a prospective analytical study was done to all subjects until the time of dka resolution. basic data were obtained along with informed written consent from patients’ legal guardians. random blood glucose, capillary β-ohb concentration, and urine ketones were measured every hour. capillary β-ohb was measured using medisense optium® (abbott). required blood sample for the electrochemical strip was 5 μl, and the result was displayed after 30s. this system was accurate for β-ohb levels from 0 to 6 mmol/l and would show high (hi) value in above 6 mmol/l. the determination of urine ketones, multistix® (bayer) was utilized. blood gas analysis and electrolytes (sodium, potassium and chloride) were measured every aman b. pulungan acta med indones-indones j intern med 48 four hours. we followed the patients until dka resolutions were established (gcs=15, random blood glucose ≤200mg/dl and hco3 ≥15 meq/l) or during the first 36 hours since the start of observation. this study protocol was approved by the ethics committee of faculty of medicine, university of indonesia cipto mangunkusumo hospital, jakarta. statistical analyses data were statistically analyzed using spss 17.0 software. prior to the statistical analyses, data sets were tested for normality, to determine whether statistical correlations were appropriate. results clinical and metabolic characteristics of subjects t h e c l i n i c a l a n d m e t a b o l i c b a s e l i n e characteristics of the patients are summarized in table 1. among 37 dka cases (2 males, 35 females), the average age was 11.7 (sd 2.81). most subjects were adolescents aged ≥10 years, whose proportion compared to children <10 years old was 30 to 7 (4.28:1). all patients were previously diagnosed with t1dm. the median time to resolution was 21 (9-52) hours. the data distributions of dka resolution time were abnormal, comprised of <21 hours (24/37), 2236 hours (4/37), 37-48 hours (8/37), and >48 hours (1/37). marked prior laboratory findings in this study (table 1) included the presence of hyperglycemia (473.9 (sd 126.1 mg/dl)), hyperketonemia (4 (sd 1.1 mmol/l)), and urine ketones (median: 8 [4-6] mmol/l). metabolic acidosis observed with mean blood ph 7.1 (sd 0.1); base excess of -21 (sd 5.2) mmol/l, anion gap of 28.7 (sd 7.1) meq/dl, and median hco3 level of 6.9 (1.8-16.6) mmol/l. the subjects’ characteristics are summarized in table 1. capillary β-ohb and urinary ketone levels the median distribution of capillary β-ohb and urinary ketone levels decreased with respect to therapeutic response as shown in figures 1 and 2. following the median resolution time, there were 8 patients with persistent positive urine ketone until 9 hours after resolution, while β-ohb levels in all subjects were already within normal range. there was no correlation between both capillary β-ohb level and urine ketones level to bga parameters during early hours of treatment. at the median time of dka resolution (i.e. in the 21st hour of monitoring), moderate significant correlations between urine ketones level and blood ph (r=0.49, p=0.005), hco3 (r=-0.48, p=0.007), and anion gap (r=0.57, p=0.001) were found. on the other hand, moderate trends toward significant correlations were also found between capillary β-ohb level and blood ph (r= -0.52 and p=0.003) as well as hco3 (r= -0.60, p=0.000). however, capillary β-ohb level correlated weakly to anion gap during resolution (r=0.37, p=0.04). the comparison between correlations of urine ketones and β-ohb level to blood gas analysis parameters is presented in table 2. table 1. clinical and metabolic characteristics of subjects variables values (n=37) sex ratio (male: female) 1 : 17.5 age (years) 11.7 (2.81)# age group ratio (adolescents : children) 4.28 : 1 time to resolution (hours) 21 (9-52)* duration of insulin infusion (hours) 28 (9-60)* random blood glucose (mg/dl) 473.9 (126.1)# β-ohb (mmol/l) 4 (1.1)# urine ketones (mmol/l) 8 (4-16)* urea (mg/dl) 34 (10-72)* bun (mg/dl) 15.8 (4.64-33.4)* creatinine (mg/dl) 0.7 (0.4-1.64)* osmolality (mosm/kg) 306.9 (281.84-343.59)* blood ph 7.1 (0.1)# pco2 (mmhg) 18.5 (5.2) # pao2 (mmhg) 113.6 (33.1) # sao2 (%) 93.2 (7.2) # be (mmol/l) -21.9 (5.2)# hco3 (mmol/l) 6.9 (1.8-16.6)* sodium (meq/dl) 136.8 (5.4)# potassium (meq/dl) 4.8 (0.9)# chloride (meq/dl) 101.1 (5.6)# anion gap (meq/dl) 28.7 (7.1)# * median (range); # mean (sd) vol 50 • number 1 • january 2018 diabetic ketoacidosis in adolescents and children: a prospective study 49 figure 1. trend on median value of capillary b-ohb relative to time of measurement. figure 2. trend on median value of urine ketones relative to time of measurement. table 2. correlation between urine ketones level and capillary β-ohb level to blood gas analysis parameters variables correlation coefficient p value correlation formula ph at the first hour urine ketones r = -0.14 0.407 capillary β-ohb r = -0.18 0.292 ph at the 21st hour (median time of dka resolution) urine ketones r = -0.49 0.005 ph= 7.38+(-0.01) urine ketones capillary β-ohb r = -0.52 0.003 ph= 7.39+(0.04) β-ohb hco3 at the first hour urine ketones r = -0.04 0.832 capillary β-ohb r = -0.15 0.374 hco3 at the 21st hour (median time of dka resolution) urine ketones r = -0.48 0.007 hco3=16.16+(-0.57) urine ketones capillary β-ohb r = -0.60 0.000 hco3=17.31+(-2.37) β-ohb anion gap at the first hour urine ketones r = 0.15 0.363 capillary β-ohb r = 0.06 0.708 anion gap at the 21st hour (median time of dka resolution) urine ketones r = 0.57 0.001 ag=11.57+(1.29) urine ketones capillary β-ohb r = 0.37 0.04 ag= 12.82+(2.77) β-ohb there were moderate significant correlations between capillary β-ohb level and urine ketones at the beginning of monitoring time (r=0.51, p=0.001) and during the median time of dka resolution (r=0.58, p=0.000), as described in table 3. discussion in this study, we found that dka episodes were more frequent in female patients, with ratio of 1: 17.5 (male : female). rewers et al3 reported no difference in the ratio of dka incidence between sexes. the difference in this particular study might be attributed to higher number of female patients with recurrent dka episodes, table 3. correlation between capillary β-ohb level and urine ketones blood ketones correlation coefficient correlation formula for capillary β-ohb and urine ketones blood ketones at the first hour r = 0.51, p=0.001 β-ohb = 3.22 + (2.08) urine ketones blood ketones at the 21st hour r = 0.58, p=0.000 β-ohb = 1.34 + (1.86) urine ketones in accordance to a previous study stating that recurrent dka affects more female than male population.13 most patients were in the adolescent age category (≥10-year-old). similarly, a prior study mentioned that the risk of dka increased in age aman b. pulungan acta med indones-indones j intern med 50 later in the course of our study, around the median time of dka resolution, significant correlations were observed. the correlation of β-ohb to ph is stronger than correlation between urine ketones and ph (r=-0.52, p=0.003 vs. r=-0.49, p=0.04). the correlation between β-ohb and hco3 was also stronger compared to the correlation between urine ketones and hco3 (r=-0.60, p=0.000 vs. r=-0.48, p=0.007). conversely, better correlation between urine ketones and anion gap was demonstrated in comparison with β-ohb and anion gap (r=0.57, p=0.001 vs. r=0.37, p=0.04). strong correlations between β-ohb level and ph following therapeutic response were reported by turan et al21 (r=-0.41, p<0.05), ham et al19 (r=-0.61, p<0.0001), vanelli et al7 (r=-0.82, p<0.001), and rewers et al2 (r=-0.63, p<0.0001). significant correlation between β-ohb and hco3 were also reported by turan et al 21 (r= -0.35, p<0.05), vanelli et al7 (r= -0.63, p=0.001), and rewers et al13 (r= -0.74, p<0.0001). positive correlation between capillary β-ohb level and anion gap was reported by naunheim et al19 (r=0.66, p<0.001). the assessments of metabolic parameters that belong to independent variables in the change of acid-base balance such as lactate, serum albumin, and electrolytes such as calcium, magnesium, and phosphate were not done.22 the ph and bicarbonate were dependent variables in stewart’s acid-base balance approach, and highly influenced by the many independent variables.23 both β-ohb and ketone urine showed lack of correlations to ph, proving that ph was not specific to dka. shift in anion gap are correlated with immeasurable cations, protein, and phosphate. increase in organic acid is also inconsistent with the rise in anion gap. 71% patients with elevated lactate concentration had normal anion gap. this makes anion gap neither sensitive nor specific to acidosis.24 despite the low the sensitivities and specificities, the selection of ph, bicarbonate and anion gap as determinants in our study was based on standard criteria released by international society for pediatric and adolescent diabetes clinical practice (ispad).2 we observed a significant correlations 5 to 9 years and 10 to 14 years.3 higher insulin requirement in early pubertal age is explained by the increasing activities of sex steroids hormones and growth hormones, which both have antiinsulin effects.14 the median time of dka resolution in this study was 21 hours (9-52). dka resolved in abnormal distributions, with less than 21 hours (24/37), 22 36 hours (4 /37), 37-48 hours (8/37), and >48 hours (1/37). one subject, which dka was resolved in more than 48 hours had infection and cerebral edema. according to umpierrez et al15, the mean time to resolution was 16 (sd 2) hours. mrozik et al16 presented dka resolution with the median time to resolution based on bga parameters (defined as the median time to reach ph>7.3) at 14.2 (8.6-20.1) hours, hco3 >15 mmol/l at 12.9 (8.6-20) hours and anion gap <16.1 at 10.7 (8.2-15) hours. the study observed delayed improvement of acidosis in 50% of subjects related to hyperchloremic acidosis, related to loss of bicarbonate or due to iatrogenic effects of nacl infusion.16 another report of hyperchloremia incidence (indicated by the ratio of plasma chloride to natrium of more than 0.79) increased from 6% to 94%, from early to 20 hours after treatment initiation, respectively. the occurrence of hyperchloremic acidosis might influence the time of dka resolution. however, the correlation was not tested in this study. to minimize the incidence of hyperchloremic acidosis, a careful calculation in regards to the amount of resuscitation fluid was applied according to the ispad consensus. during the initial period of monitoring, there was no correlation between both capillary β-ohb level and urine ketone to bga parameters. this finding is consistent with prior studies held by vanelli et al7 and tantiwong et al.10 studies regarding correlation between β-ohb and bga parameters at the time of diagnosis yielded different outcomes. ham et al18 showed a significant correlation between β-ohb and ph (r= -0.62, p<0.0001). similarly, naunheim19 found a significant correlation between β-ohb level and anion gap (r= 0.66, p<0.001), while ali et al20 stated that β-ohb was significantly correlated with hco3 level (r= 0.68, p<0.001). vol 50 • number 1 • january 2018 diabetic ketoacidosis in adolescents and children: a prospective study 51 between β-ohb level and urine ketones in early monitoring period (r= 0.51, p= 0.001) and at the median time of dka resolution (r= 0.58, p=0,000). a positive correlation between β-ohb level and urine ketones later in monitoring was previously seen 7.8 (sd 2) hours post-therapy; r=0.8, p<0.05), but not in few first hours (3.3 (sd 1.4) hours post-therapy).21 prior studies found positive correlations between β-ohb level and urine ketones only at low level.5,25 significant correlation between β-ohb and urine ketone throughout this study showed that β-ohb is equal, if not better, in monitoring dka therapy response. periodic examination of capillary β-ohb level was superior compared to urine ketone. negative capillary β-ohb level (≤0.5 mmol/l) was found in all research subjects by the time of resolution, while 8 subjects remained urinary ketone-positive until 9 hours post dka resolution. this result is aligned with studies conducted by umpierrez et al15 and guerci et al11. positive urine ketone after resolution of dka caused by conversion of β-ohb to acetoacetate and the increased hepatocyte oxidative reaction resulted in rise of urinary ketones and acetone levels, along with diminution of capillary β-ohb concentration. the urine ketone test may depict a false picture of ketosis, leading to administration of unrequired high dose of insulin that might be harmful for the patients.7 conclusion capillary β-ohb elucidated better correlation to ph and bicarbonate when compared to urine ketones upon dka resolution. a significant correlation between capillary β-ohb and urine ketones suggests that the measurement of blood ketone level may be a replacement for urine ketones examination in monitoring therapeutic response of dka in children and adolescents. acknowledgments we would like to thank all personnel of emergency room and pediatric intensive care unit (picu) of dr. cipto mangunkusumo hospital, our pediatric residents, and the endocrinology division, departement of child health, faculty of medicine, university of indonesia for their contribution throughout the conduct of this study. this study was financed by pt 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aust crit care. 2009;22(4):172-7. 17. taylor d, durward a, tibby sm, et al. the influence of hyperchloraemia on acid base interpretation in diabetic ketoacidosis. intensive care med. 2006;32(2):295-301. 18. ham mr, okada p, white pc. bedside ketone d e t e r m i n a t i o n i n d i a b e t i c k e t o a c i d o s i s w i t h hyperglycemia and ketosis in the acute care settting. pediatr diabetes. 2004;5:39-43. 19. naunheim r, jang t, banet g, et al. point of care test identifies diabetic ketoacidosis at triage. acad emerg med. 2006;13(6):683-5. 20. ali m, karon b, basu a, kudva y, et al. can serum beta hydroxybutyrate be used to diagnose diabetic ketoacidosis? diabetes care. 2008;31:643-7. 21. turan s, omar a, bereket a. comparison of capillary blood ketone measurement by electrochemical method and urinary ketone in treatment of diabetic ketosis and ketoacidosis in children. acta diabetol. 2008;45(2): 83-5. 22. orlowski j, cramer c, fiallos m. diabetic ketoacidosis in the pediatric icu. pediatr clin n am. 2008;55:57787. 23. maciel at, park m. a physicochemical acid base approach for managing diabetic ketoacidosis. clinics. 2009;64:714-8. 24. salem m, mujais sk. gaps in the anion gap. arch intern med. 1992;152:1625-9. 25. sefedini e, prasek m, metelko z, novak b, pinter z. use of capillary beta hydroxybutyrate for the diagnosis of diabetic ketoacidosis at emergency room one year experience. diabetologia croatia. 2008;37:73-7. 110 original article acta med indones indones j intern med • vol 50 • number 2 • april 2018 diagnostic determinants of proliferative lupus nephritis based on clinical and laboratory parameters: a diagnostic study aida lydia1, mita h. saraswati1, dharmeizar1, meilania saraswati2, siti setiati1 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of pathology anatomy, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: aida lydia, md., phd. division of nephrology and hypertension, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: aidalydia@gmail.com. abstrak latar belakang: nefritis lupus (nl) proliferatif memiliki prevalensi yang lebih tinggi dan prognosis yang lebih buruk dibandingkan nl non-proliferatif. pemeriksaan histopatologi memegang peranan penting dalam diagnosis dan terapi nl proliferatif, namun terdapat beberapa kendala dalam pelaksanaannya. sistem skor nl proliferatif diperlukan untuk membantu diagnosis nl proliferatif terutama pada kondisi biopsi ginjal tidak dapat dilakukan. tujuan penelitian adalah menetapkan sistem skor diagnosis nl proliferatif berdasarkan determinan hipertensi, proteinuria, hematuria, egfr, kadar anti-dsdna, dan c3. metode: penelitian diagnostik dengan desain potonglintang terhadap 113 pasien nl yang terbukti dari pemeriksaan patologi anatomik di rscm sejak januari 2007 hingga juni 2017 dengan metode total sampling. data yang digunakan adalah data sekunder. analisis data dilakukan dengan program statistik spss statistics 20.0 untuk analisis univariat, bivariat, multivariat, receiving characteristics operator, serta analisis bootstrapping pada kalibrasi hosmer-lemeshow.hasil: sebanyak 191 subjek dianalisis untuk proporsi nl proliferatif, didapatkan proporsi nl proliferatif pada pasien nl yang terbukti dari biopsi ginjal di rscm sebesar 74,8%. sebanyak 113 subjek dianalisis untuk mendapatkan determinan nl proliferatif. pada analisis multivariat, hipertensi (or= 3,39; 95%ik 1,30-8,84), egfr <60ml/min/1,73m2 (or= 9,095; 95%ik 1,11-74,68), dan penurunan kadar c3 (or= 3,97; 95%ik 1,41-11,17) merupakan determinan nl proliferatif. hipertensi, egfr <60ml/min/1,73m2, penurunan kadar c3, dan hematuria, menjadi bagian sistem skor diagnosis nl proliferatif. pada kurva roc didapatkan auc sebesar 80,4% (95% ik 71,9-89), dengan titik potong skor 3. kesimpulan: proporsi nl proliferatif pada pasien nl yang terbukti dari biopsi ginjal di rscm adalah 74,8%. komponen sistem skor diagnosis nl proliferatif terdiri dari hipertensi, egfr <60ml/menit/1.73m2, penurunan kadar c3, dan hematuria. kata kunci: determinan, nefritis lupus proliferatif, sistem skor, les, klinikopatologi. abstract background: proliferative lupus nephritis (ln) has higher prevalence and worse prognosis than nonproliferative ln. renal biopsy plays an important role in diagnosis and therapy of ln, but there are some obstacles in its implementation. a diagnostic scoring system for proliferative ln is necessary, especially for cases in which renal biopsy cannot be performed. this study aimed to develop a diagnostic scoring system of proliferative ln based on its diagnostic determinants including hypertension, proteinuria, hematuria, egfr, anti-dsdna antibody, and vol 50 • number 2 • april 2018 diagnostic determinants of proliferative lupus nephritis 111 c3 levels. methods: a cross-sectional study with total sampling method was conducted. our subjects were adult ln patients who underwent renal biopsy in cipto mangunkusumo hospital between january 2007 and june 2017. results: from a total of 191 subjects with biopsy-proven ln in this study, we found a proportion of proliferative ln of 74.8%. there were 113 subjects included for analysis of proliferative ln determinants. the multivariate analysis demonstrated that determinants for proliferative ln were hypertension (or 3.39; 95% ci 1.30-8.84), egfr <60ml/min/1.73m2 (or 9.095; 95% ci 1.11-74.68), and low c3 levels (or 3.97; 95% ci 1.41-11.17). after further analysis, we found that hypertension, egfr <60ml/min/1.73m2, low c3 levels, and hematuria were essential components of the diagnostic scoring system on proliferative ln. the scoring system was tested with roc curve and an auc of 80.4% was obtained (95% ci 71.9-89). conclusion: the proportion of proliferative ln in biopsyproven ln patients of cipto mangunkusumo hospital is 74.8%. components of scoring system for proliferative ln consist of hypertension, egfr <60ml/min/1.73m2, low c3 levels, and hematuria. keywords: determinants, proliferative lupus nephritis, scoring system, sle, clinicopathology. introduction systemic lupus erythematosus (sle) is one of systemic autoimmune diseases commonly found in women at reproductive age. one of the clinical manifestations in sle is renal damage, which is known as lupus nephritis (ln). in the natural course of the disease, ln occurs in 40-60% patients.1,2 the cumulative incidence of ln is the highest among asian with higher prevalence of proliferative compared to nonproliferative ln.2-8 proliferative lupus nephritis (ln) has worse prognosis than non-proliferative ln, either regarding morbidity or mortality.5,9-11 however, with appropriate management, the prognosis may improve significantly in patients who have achieve remission.12 to achieve remission, earlier diagnosis of ln and appropriate treatment play an essential roles. however, it is not easy to establish early diagnosis of proliferative ln based on clinical and laboratory features since there are various clinical manifestations of ln. until now, the histopathological examination (renal biopsy) is still the gold standard for diagnosing ln as well as for principles of ln treatment.1,4,5,11 challenges in indonesia include uneven distribution of facilities for renal biopsy. moreover, there are also some conditions, which are the contraindications for performing renal biopsy. therefore, it is necessary to have a tool that can be used practically both in clinical and laboratory setting to diagnose proliferative ln. some parameters have been previously estimated to have some capacity in predicting histological class of ln and can differentiate proliferative from non-proliferative ln. those parameters are hypertension, degree of proteinuria, hematuria, egfr, anti-dsdna and low c3 levels. there have been extensive studies discussing clinicopathology of ln, however, no study has been specifically designed to develop a scoring system for proliferative ln based on clinical and laboratory parameters.1,5-8 in our study, we attempted to develop a scoring system to assist the diagnosis of proliferative ln based on clinical and laboratory parameters, particularly when the renal biopsy cannot be performed. methods the present study was a diagnostic study with a cross-sectional design in ln subjects who underwent renal biopsy in cipto mangunkusumo hospital between january 2007 and june 2017. the data used were secondary data obtained from patient medical records, data from the division of nephrology and hypertension and data of pathology anatomy department at cipto mangunkusumo national central general hospital. the inclusion criteria in our study were patients with biopsy-proven ln and aged over 18 years (adult patients); while the exclusion criteria of the present study were incomplete medical records. samples were obtained by total sampling. this study has been approved by the ethics committee of faculty of medicine universitas indonesia on may 29th, 2017, with a reference number 493/un2.f1/etik/2017. when the study criteria were fulfilled, aida lydia acta med indones-indones j intern med 112 anatomical pathology slides would be re-read by a pathology anatomy specialist and data were documented regarding hypertension, proteinuria, hematuria, creatinine level and egfr as well as anti-dsdna and c3 levels. hypertension was defined as a systolic blood pressure (sbp) of ≥140 mm hg and diastolic blood pressure (dbp) of (tdd) ≥90 mmhg according to jnc 7 classification or the patient had been diagnosed with hypertension previously. proteinuria was measured by calculating the level of protein in urine quantitatively within 24 hours (mg/24 hours). hematuria was defined by the presence of >5 red blood cells per high power field (hpf) in urine sediment and by excluding the presence of urinary stone, infection and other causes. estimated glomerular filtration rate (egfr) was calculated based on the ckd-epi formula. the level of anti-dsdna was measured by using elisa method. c3 was defined as low when it was <90 mg/dl. data analysis was performed using a spss statistic software program version 20.0 for univariate, bivariate and multivariate analysis, receiving characteristics operator, as well as bootstrapping analysis in hosmerlemeshow calibration. results there were 191 subjects aged >18 years with biopsy-proven ln who had undergone renal biopsy at cipto mangunkusumo national central general hospital within the period of january 2007 to june 2017. the proportion of proliferative ln in those 191 subjects who had been confirmed with ln on their renal biopsies was 74.8% (95%ci= 68.6-80.96%). there were 78 subjects that had been excluded from the study due to incomplete data. as many as 113 patients were included in data analysis. basic characteristics of all study subjects can be seen in table 1. table 1. basic characteristics of study subjects subject characteristics total sex, n (%) male 7 (6.2) female 106 (93.8) age, median (range, years) 27 (18-56) duration of sle, median (range, months) 9 (0-216) table 1. basic characteristics of study subjects subject characteristics total organ involvement, n (%) neurologic 10 (10.8) mucocutaneous 61 (66.3) hematological 48 (50) musculoskeletal 68 (73.9) serositis 25 (26.9) therapy, n (%) not available 7 (6.2) only steroids 24 (21.2) steroids and immunosuppresants 82 (72.6) hypertension, n (%) no hypertension 43 (38.05) hypertension 70 (61.95) pyuria (n=112), n (%) no pyuria 60 (53.6) pyuria 52 (46.4) hematuria, n (%) no hematuria 32 (28.3) hematuria 81 (71.7) cellular cylinders (n=111), n (%) no cellular cylinders 70 (61.9) cellular cylinders 41 (36.3) quantitative urine protein, median (range, mg/24 hours) 2812.5 (276.25-22140) creatinine level, median (mg/dl) 0.7 (0.3-7.3) egfr, n (%) >60 ml/minute/1.73 m2 85 (75.2) <60 ml/minute/1.73 m2 28 (24.8) median (range, ml/minute/1.73m2) 108.95 (7.2-172) albumin level, median (range, g/dl) 2.54 (0.8-4.69) anti-dsdna level, median (range, u/ml) 397.25 (1.5-5510.4) c3 level, n (%) normal 25 (22.1) low 88 (77.9) median (range, mg/dl) 55.6 (0.9-154) c4 level, n (%) normal 60 (53.1) low 51 (45.1) median (range, mg/dl) 11 (0-51) lupus nephritis classification (n=113) ln class i 3 (2.7) ln class ii 15 (13.3) ln class iii 21 (18.6) ln class iv 50 (44.2) ln class v 13 (11.5) ln class v+iii 1 (0.9) ln class v+iv 10 (8.8) vol 50 • number 2 • april 2018 diagnostic determinants of proliferative lupus nephritis 113 on bivariate analysis, we found that the determinants, which had significant correlation with proliferative ln were hypertension (p=0.002), hematuria (p=0.004), egfr <60 ml/ minute/1.73 m2 (p=0.001), anti-dsdna (p=0.027) and c3 level (p=0.002). those five variables together with the quantitative urine protein which had p<0.25 (p=0.181) were included in the multivariate analysis as shown in table 2. the development of scoring system for diagnosing proliferative a ln was carried out by calculating b coefficient and standard error, which resulted in a diagnostic scoring for proliferative ln based on clinical and laboratory parameters (table 3). the scoring system was tested on roc curve (figure 1) and an auc of 0.804 (95%ci 0.709-0.89) was found. from the curve, we obtained the intersection of sensitivity and specificity curve as well as the cut-off point for diagnosis (figure 2). based on tables and cut-off point curves of sensitivity, specificity with total score of diagnosis, we found that the best cut-off point to estimate the diagnosis of proliferative ln was table 2. multivariate analysis on determinants associated with proliferative ln variables p value odd ratio (or) 95% ci stage 1 c3 level 0.061 2.910 0.95-8.88 egfr 0.074 7.011 0.83-59.18 hypertension 0.016 3.308 1.25-8.88 hematuria 0.150 2.086 0.7-3.00 quantitative urine protein 0.699 1.000 0.86-3.59 anti-dsdna 0.420 1.000 0.99-1.00 stage 2 c3 level 0.058 2.942 0.96-8.98 egfr 0.074 6.990 0.83-58.85 hypertension 0.016 3.318 1.25-8.80 hematuria 0.139 2.125 0.78-5.77 anti-dsdna 0.430 1 0.99-1.00 stage 3 c3 level 0.021 3.481 1.20-10.031 egfr 0.068 7.221 0.87-60.2 hypertension 0.015 3.337 1.26-8.82 hematuria 0.137 2.117 0.79-5.69 stage 4 c3 level 0.009 3.972 1.41-11.17 egfr 0.040 9.095 1.108-74.68 hypertension 0.013 3.389 1.3-8.84 table 3. diagnostic scoring for proliferative ln no variables category score 1 hypertension yes 2 no 0 2 egfr < 60 ml/minute/1.73 m2 1 > 60 ml/minute/1.73 m2 0 3 c3 level low c3 level (<90) 2 normal c3 level (90-180) 0 4 hematuria yes 1 no 0 maximum total score 6 minumum total score 0 egfr, estimated glomerular filtration rate aida lydia acta med indones-indones j intern med 114 3 (three). the score of >3 had a sensitivity of 65.9%, specificity of 83.8%, positive predictive value of 91.5%, and negative predictive value of 48.14%. the scoring system had a good calibration based on statistical significance using hosmer-lemeshow test (p>0.05), in which the p value =0.157. following 1000 times bootstrappings, the calibration stays good based on the statistical significance using hosmerlemeshow test with p=0.157. discussion in our study, there were 106 female subjects out of 113 total subjects (93.8%). the result is similar to the results in himawan study13 in indonesia and wakasugi et al.5 in japan. in those studies, the proportion of female to male subjects was 93% and 93.7%, respectively. the median age of study subjects was 27 years (with a range of 18-56 years). moreover, the median figure 1. roc curve figure 2. the intersection of sensitivity and specificity curve and total score of diagnosis duration of time since the subjects had their first diagnosis of sle to the moment they underwent renal biopsy was 9 months (with a range of time of 0 – 216 months) and a mean duration of 21.16 months (sd 33.91 months). the medians and mean for duration of illness in our study are almost similar to those in wakasugi et al.5 and lumina14 studies. there were various organ involvement of sle patients with ln and in our study the most common one was musculoskeletal involvement, which is consistent to the findings in mavragani et al.6 and kalim et al.15 studies. the wide range of age and duration of illness as well as various organ involvement implicates that the outcomes of our study can be implemented in ln population with wide range of age and duration of sle as well as a varied manifestations of organ involvement in sle. the proportion of proliferative ln based on isn/rps 2003 in our study was 74.8% (95%ci of 68.6-80.96). the proportion of proliferative ln, which was higher than other classes, had also been found in other studies as presented in table 4. in our study, there were six determinant variables that had been studied, i.e. hypertension, quantitative urine protein, hematuria, egfr, anti-dsdna and c3 levels. among the six determinants, there are four variables that become the component of proliferative ln score, which are hypertension, hematuria, egfr and c3 level. hypertension occurred in 82.9% patients with proliferative ln. in the final model of multivariate analysis, we found that hypertension was correlated with proliferative ln. it is consistent with the results of mavragani et al. study.6 in ln, particularly vol 50 • number 2 • april 2018 diagnostic determinants of proliferative lupus nephritis 115 the proliferative ln, there were loss of nephrons and progressive glomerular damage. it can exacerbate hemodynamic changes of the kidney and increases renal vascular resistance as well as reduces renal blood supply, which leads to hypertension.16 in our study, there was no significant correlation between proteinuria and proliferative ln, which is consistent with hsieh et al.14 however, it is different from the results of wakasugi et al.5 and okpechi et al.8 studies. there is a significant difference regarding the median of proteinuria between our study and the wakasugi et al.5 study; while there is also a difference in method of measuring proteinuria between our study and the okpechi et al.8 study. proteinuria in sle patient is generally associated with deposition of immune complex in subepithelial (particularly in ln class v) and subendothelial tissues (particularly in ln class iv); therefore, nephrotic-range proteinuria is also commonly found in ln class v, which is included in the non-proliferative ln. in addition to the mechanism of immune complex deposition, neprhotic-range proteinuria may also occur due to podocyte injuries; therefore, it can also be found in ln class ii. the findings support the hypothesis that the degree of severity of ln histopathological findings does not always correlate with the degree of proteinuria.17 h e m a t u r i a i s o n e o f c o m p o n e n t s i n proliferative ln score. the addition of hematuria variable in the scoring system increases the discrimination capacity of the system, which was evaluated based on auc in roc curve. in addition to the better score discrimination capacity, the pathophysiological (biological plausibility) has also become our consideration when adding hematuria variable into the proliferative ln scoring system. hematuria in ln occurs due to extravasation of red blood cells into urine, which is caused by damage on glomerular basement membrane (gbm).18 several studies have demonstrated that hematuria is associated with proliferative ln including the martinez et al.19 and okpechi et al.8 studies. hematuria is associated with high ln activity index and most commonly found in ln class iii and iv.11,20,21 in ln, inflammation occurs in the kidney simultaneously with cytokines and chemokines production, which subsequently will stimulate leukocyte migration to glomerulus, amplify local inflammatory reaction that result in greater loss of nephrons and atrophy. it causes reduced glomerular filtration rate (gfr).22,23 in addition to inflammatory conditions, reduced gfr can also be affected by hypertension, which is consistent with the presence of renal vasoconstriction and the phenomenon of shift to the right of pressurenatriuresis correlation. gfr and renal plasma flow will be reduced.16 in our study egfr of <60 ml/minute/1.73 m2 is a determinant in diagnosing proliferative ln, which is consistent with the study by wakasugi et al.5 another study by vozmediano et al.24 has also found that egfr of <60 ml/minute/1.73m2 was more commonly found in patients with ln class iii and iv. in our study, there was no correlation between anti-dsdna level and proliferative ln, which is consistent with the alba et al.25 study, which showed that the anti-dsdna was table 4. frequency of lupus nephritis class (%) our study (n=191) mavragani6 (n=297) okpechi8 (n=251) guo4 (n=82) i 3.67 0.4 ii 12.04 15.83 13.5 9.76 iii 21.47 63.29 (class iii/iv) 20.7 12 iv 43.46 20.7 52.4 v 9.42 20.88 14.7 8.53 v+iii 0.52 11.2 7.31 v+iv 9.42 8.4 9.76 vi 8.4 aida lydia acta med indones-indones j intern med 116 not associated with histological class of nl. the wakasugi et al5 study showed that anti-dsdna was a determinant for diagnosing proliferative ln. there are differences in the method of evaluating anti-dsdna between our study and the wakasugi et al.5 study. in sle patients, the titer of their anti-dsdna did not follow the existing pattern, in which was higher when there was a flare and was lower without flare. the condition is known as serologically-active clinically quiescent (sacq) and clinicallyactive serologically quiescent (casq).26 other studies also could not demonstrate the correlation between anti-dsdna and the degree of ln severity. anti-dsdna in serum shows lower cross reaction compared to anti-dsdna found in the kidney of ln patients.27 another study suggests that in patients with active severe ln, the anti-dsdna serum levels can be low and is assumed to be due to the adsorption of antidsdna from blood circulation into the kidney; therefore, the anti-dsdna is deposited in the kidney. another explanation would be that in ln, there is proteinuria and in such condition antidsdna is found, which is excreted in the urine. several animal experimental studies have also found that there is a disassociation between antidsdna level and renal disorders.28-30 low c3 level is a determinant for diagnosing proliferative ln, which is supported by okpechi et al. and wakasugi et al. studies. low c3 level is caused by increased catabolic rate due to complement activation and reduced c3 synthesis, which is consistent with the role of complement in the pathophysiology of ln. products of complement activation in the circulation will stimulate inflammatory cascades that consequently will cause tissue damage.26 our study has developed a scoring system as a tool for diagnosing proliferative ln based on clinical and laboratory parameters. the advantage of developing the scoring system is to select ln patients that have high estimation value (which are characterized by higher score than the cut-off point limit) to experience proliferative ln, particularly when renal biopsy is not possible. to our knowledge, there have been many studies discussing the clinicopathology of ln; however only three studies had demonstrated determinant results to estimate ln with components of class iii/iv with different results among those studies. there are some differences between our study and previous studies, which are: (1) no study has been conducted which develop a scoring system for proliferative ln; (2) previous study was performed for different ethnical background, i.e. the study by wakasugi et al.5 in japan (asia), which also involved children population; (3) in the study by wakasugi et al.5 the estimation of proliferative ln was divided into silent and overt ln and there was no score model for overall estimation of proliferative ln; (4) mavragani et al.6 did not differentiate specifically the estimation for diagnosing proliferative ln and excluded the ln mixed class v; (5) in okpechi et al.8 study, ln mixed class v (v+ii) was included in proliferative ln and the proteinuria parameter was measured by dipstick test; while the gold standard of evaluating proteinuria should be performed by measuring 24-hour proteinuria. our scoring system is labeled as the diagnostic score for proliferative ln. the score system has good calibration and discrimination. when an analysis was performed on probability of total score in study subjects against the proliferative ln, we could see that the higher the total score, the greater the probability to have proliferative ln. in patients with total score of >3, e.g. those with total score of 4 had 80.77% probability; those with total score of 5 had 89.75% probability and those with score of 6 had 94.81% probability. following the analysis for probability, sensitivity and specificity tests was performed for score of >3 against proliferative ln. we found that the sensitivity for the score was 65.9%, the specificity was 83.9%, the positive predictive value (ppv) was 91.5% and negative predictive value (npv) was 48.2%. it indicates that score of >3 are specific to determine that the subject should be included in proliferative ln. it is also supported by the high ppv, although the score may not exclude the proliferative ln (65.9% sensitivity and 48.2% npv). our study has collected samples in a relatively long period, i.e. 10 years and it is the first study demonstrating the proportion vol 50 • number 2 • april 2018 diagnostic determinants of proliferative lupus nephritis 117 of proliferative ln in adult ln patients in indonesia with classification of nl class based on isn/rps 2003. the development of diagnostic scoring system for proliferative ln is the first attempt that has ever been done. the limitation of our study is that many patients had received corticosteroid treatment and/or immunosuppressant when the renal biopsy was performed. however, it was inevitable and had also been found in previous studies. our study also used secondary data; therefore, incomplete medical records made subjects became excluded. however, in the overall analysis, which is accompanied with missing data, there was no difference in basic subject characteristics. conclusion the proportion of proliferative ln in patients who have undergone renal biopsy is 74.8%. components of scoring system for proliferative ln consist of hypertension, egfr <60ml/ min/1.73m2, low c3 levels, and hematuria references 1. bihl gr, petri m, fine dm. kidney biopsy in lupus nephritis: look before you leap. nephrol dial transplant. 2006;21(7):1749–52. 2. imran tf, yick f, verma s, estiverne c. lupus nephritis: an update. clin exp nephrol. 2016;20(1):113. 3. o r t e g a l m , s c h u l t z d r , l e n z o , p a r d o v, contreras gn. lupus nephritis: pathologic features, epidemiology and a guide 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2012;21(9):1017–24. 9. yokoyama h, okuyama h. clinicopathological insights into lupus glomerulonephritis in japanese and asians. clin exp nephrol. 2011;15:321–30. 10. yokoyama h, wada t, hara a, yamahana j, nakaya i, kobayashi m. the outcome and a new isn/rps 2003 classification of lupus nephritis in japanese. kidney int. 2004;66:2382–8. 11. nived o, hallengren cs, alm p, jönsen a, sturfelt g, bengtsson aa. an observational study of outcome in sle patients with biopsy-verified glomerulonephritis between 1986 and 2004 in a defined area of southern sweden: the clinical utility of the acr renal response criteria and predictors for renal outcome. scand j rheumatol. 2013;42(5):383–9. 12. korbet sm, lewis ej, study c. complete remission in severe lupus nephritis: assessing the rate of loss in proteinuria. nephrol dial transpl. 2011;27:2813–9. 13. himawan s. pathological features of glomerulonephritis in jakarta. med j indones. 2002;11: 24–9. 14. bastian h, roseman j, mcgwin g, alarcón gs, friedman a, fessler bj, et al. systemic lupus erythematosus in three ethnic groups xii risk. lupus. 2002;11:152–60. 15. kalim h, gunawan a, rosandi r. kadar autoantibodi dan manifestasi klinis pada pasien nefritis lupus silent dan nefritis lupus overt. m med indones. 2012;46(3):157-62. 16. ryan mj. the pathophysiology of hypertension in systemic lupus erythematosus. am j physiol regul integr comp physio. 2009;296:r1258–67. 17. trivedi s, zeier m, reiser j. role of podocytes in lupus nephritis. nephrol dial transplant. 2009;24(12):3607– 12. 18. moreno ja, martín-cleary c, gutiérrez e, rubionavarro a, ortiz a, praga m, et al. haematuria: the forgotten ckd factor? nephrol dial transplant. 2012;27(1):28–34. 19. martinez-martinez mu, llamazares-azuara lmg, martinez-galla d, mandeville pb, valadez-castillo f, roman-acosta s, et al. urinary sediment suggests lupus nephritis histology. lupus. 2016;0:1-8. 20. shariati-sarabi z, ranjbar a, monzavi sm, esmaily h. analysis of clinicopathologic correlations in iranian patients with lupus nephritis. int j rheum dis. 2013;1–8. 21. s a t i r a p o j b , ta s a n a v i p a s p, s u p a s y n d h o . clinicopathological correlation in asian patients with biopsy-proven lupus nephritis. int j nephrol. 2015; 1-6. 22. allam r, anders hj. the role of innate immunity in autoimmune tissue injury. curr opin rheumatol. 2008;20(5):538–44. 23. kurts c, panzer u, anders h, rees aj. the immune system and kidney disease: basic concepts and clinical implications. nat publ gr. 2013;13(10):738–53. aida lydia acta med indones-indones j intern med 118 24. vozmediano c, rivera f, lópez-gómez jm, hernández d. risk factors for renal failure in patients with lupus nephritis: data from the spanish registry of glomerulonephritis. nephron extra. 2012;2:269–77. 25. alba p, bento l, cuadrado mj, karim y, tungekar mf, abbs i, et al. anti-dsdna, anti-sm antibodies, and the lupus anticoagulant: significant factors associated with lupus nephritis. ann rheum dis. 2003;62(6):556–60. 26. steiman aj. serologically active clinically quiescent s y s t e m i c l u p u s e r y t h e m a t o s u s : c l i n i c a l a n d immunological correlates by serologically active clinically quiescent systemic lupus erythematosus : clinical and immunological correlates [thesis]. canada: university of toronto; 2014. 27. goilav b, putterman c. the role of anti-dna antibodies in the development of lupus nephritis: an alternative, or complementary, viewpoint. semin nephrol. 2015;35(5):439–43. 28. isenberg da, manson jj, ehrenstein mr, rahman a. fifty years of anti-dsdna antibodies: are we approaching journey’s end?. rheumatology. 2007;46(7):1052–6. 29. sandhu g, bansal a, ranade a, aggarwal r, narayanswami g, jones j, et al. negative double stranded dna and anti-smith antibodies in lupus nephritis. nephrol rev. 2012;4(2):55–7. 30. waters st, mcduffie m, bagavant h, deshmukh us, gaskin f, jiang c, et al. breaking tolerance to double stranded dna, nucleosome, and other nuclear antigens is not required for the pathogenesis of lupus glomerulonephritis. j exp med. 2004;199(2):255–64. clinical practice 268 acta med indones indones j intern med • vol 50 • number 3 • july 2018 adult diphtheria vaccination iris rengganis department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: iris rengganis, md, phd. division of allergy and clinical immunology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: irisrengganis@yahoo.com. abstrak cakupan imunisasi dewasa yang rendah mungin berperan pada kejadian luar biasa (klb) difteria baru-baru ini di indonesia. meskipun dikenal sebagai vaksin anak, vaksinasi difteria harus diberikan sebagai ulangan pada remaja dan dewasa untuk pencegahan jangka panjang. vaksin dewasa berbeda dari vaksin anak tetapi memiliki proteksi yang sama. selain itu, dianjurkan pula vaksinasi untuk ibu hamil dan orang lanjut usia di atas 65 tahun. kata kunci: difteria, vaksin, kehamilan, pediatrika, usia lanjut. abstract low adult vaccination coverage in indonesia may contribute to a recent outbreak of diphtheria in indonesia. although well known as a pediatric vaccine, diphtheria vaccination should be administered as booster to adolescence and adults for longer prevention. adult vaccine differs from pediatric vaccine but have similar protection. additionally, there is special recommendation to vaccinate pregnant women and elderly people aged 65 years or more. keywords: diphtheria, vaccine, pregnant, pediatric, elderly. introduction diphtheria is regarded as a reemerging disease since an outbreak occurs in the soviet union in 1990s, more than 2 decades after universal childhood immunization was initiated and controlled the disease.1 recent outbreaks throughout the indonesian archipelago last year reemphasizes the importance of childhood vaccination and adult boosters. during 2017, there were 954 cases of diphtheria with death toll reaching 44 (4.6%) cases.2 consequently, an outbreak response immunization (ori) program has been launched in mid-december 2017 to control the spread of the disease further.3 unpublished data from the ministry of health, republic of indonesia showed that diphtheria cases did occur sporadically from1988 to 2016 at the national level. universal child immunization was launched in 1990 followed by vaccination for school-age children in 1999. since 1990, diphtheria cases showed a fluctuation until an outbreak occurred in 2012. the outbreak was resolved in 2014, but it remained a potential problem due to a sociocultural resistance to vaccination among a small group of people. diphtheria – the disease diphtheria is an acute bacterial disease caused by exotoxin-producing corynebacterium diphtheria. another toxin producing strain, i.e. c. ulcerans can cause a diphtheria-like illness.4 it usually affects the tonsils, throat, nose and/or vol 50 • number 3 • july 2018 adult diphtheria vaccination 269 skin. respiratory diphtheria is the most common manifestation. it is characterized by a grayishcolored pseudomembrane on the pharynx, palate, or nasal mucosa that can fatally obstruct the upper airway. the overall case-fatality for diphtheria is 5–10%.5 cutaneous manifestation of diphtheria can occur, resulting in indolent skin infection. transmission is by person-to-person contact through inhaling air droplets of infected person. symptoms of diphtheria may appear 2-4 days after infection with an incubation period of 1-10 days. most adult cases occur among unvaccinated or inadequately vaccinated people. immunity after contracting diphtheria may not lifelong, so patients recovered from diphtheria are still need to be immunized. diphtheria remains a public health problem in developing countries and potentially causes an outbreak. diphtheria antitoxin is predominated by immunoglobulin (igg) induced after vaccination with diphtheria toxoid. antitoxin concentrations of >0.1 iu/ml are generally considered protective, while concentration <0.01 iu/l are not protective.6 periodic vaccination is required to maintain immunity. immunity acquired from childhood vaccination wanes during adulthood if there are no decennial boosters. an american study showed that people with protective levels of diphtheria antibody decreased from 91% at 6-11 years of age to only 29.5% at 70 years.7 vaccine recommendation a tetanus-diphtheria-acellular pertussis (tdap) vaccination gives protection against tetanus, diphtheria and pertussis. a tetanusdiphtheria (td) vaccination gives protection against both tetanus and diphtheria. the current recommendations are:8 • tdap vaccine for adult >19 years: 1 dose if not vaccinated previously with tdap; • td vaccine (booster) 1 dose every 10 years. in addition, there is an off-label use of tdap, i.e. for pregnant women, 1 dose each pregnancy preferably given at 27 – 36 weeks of gestation. the advisory committee on immunization practices (acip) provides these recommendations in accordance to recommendations of the american academy of family physicians (aafp), the american college of obstetricians and gynecologists (acog), and the american college of physicians (acp). available vaccines in general, there are 4 vaccines that include protection against diphtheria, i.e. dtap, dt, tdap and td. the dtap and dt are pediatric vaccines for infants and young children. tdap is an inactive vaccine for adult primary vaccine, while td is a booster vaccine. compared with infant formulations dtap and dt, tdap and td contains reduced quantities (10–50%) of all toxoids and antigens. the reduced antigen content is designed to avoid the increasing reactogenicity historically seen with the fourth and fifth doses of infant vaccine. in the global market, there are 2 tdap vaccines available, i.e. adacel® (sanofi pasteur) for persons aged 11 – 64 years (16) and boostrix® (glaxosmithkline) for persons aged 10 – 18 years (17). both vaccines are licensed for single-dose administration. they do not contain thimerosal or other preservative. each 0.5-ml dose of adacel® contains 5 limit of flocculation (lf) tetanus toxoid, 2 lf diphtheria toxoid, and acellular pertussis antigens (2.5 µg detoxified pt, 5 µg fha, 3 µg pertactin, 5 µg fim). each 0.5-ml dose of boostrix® contains 5 lf of tetanus toxoid, 2.5 lf of diphtheria toxoid, 8 µg of inactivated pt, 8 µg of fha, and 2.5 µg of pertactin (69 kilodalton outer membrane protein). tetanus and diphtheria toxoids (td) are also available for adults and adolescents in indonesia, which is produced by bio farma company as single dose (bio td) and multiple dose vials (adsorbed td vaccine 10 doses). each dose of 0.5 ml vaccine contains 7.5 lf of tetanus toxoid and 2 lf of diphtheria toxoid. bio farma is the only vaccine manufacturer in indonesia recognized by world health organization and member of the developing countries vaccine manufacturers network (dcvmn).9 dose of tdap or td is 0.5 ml administered intramuscularly, preferably into the deltoid muscle.10 simultaneous injections with other vaccine can be safely done at a different anatomical site. iris rengganis acta med indones-indones j intern med 270 v a c c i n e i m m u n o g e n i c i t y a n d effectiveness no controlled clinical trial of the efficacy of the toxoid in preventing diphtheria has ever been conducted. there is, however, strong evidence from observational studies to support the effectiveness of vaccination, although effectiveness of diphtheria toxoid does not reach 100%: immunogenicity of the first dose tdap vaccine given to adults is very good. the postvaccination antibody levels >0.1 iu/ml were achieved by 96.1% of participants. for those who have received tdap vaccine 10 years before, 98.5% participants achieved the protective antibody.11 seroprotective diphtheria antibody levels were similar between tdap and td. the seroprotective concentration (> 0.1 iu/ml) can be achieved by 98% of adults receiving tdap and td vaccines.12 contraindications and precautions tdap vaccine is contraindicated in:8 • severe allergic reaction (e.g. anaphylaxis) after a previous dose or to a vaccine component. • encephalopathy (e.g. coma, decreased level of consciousness, or prolonged seizures) not attributable to another identifiable cause within 7 days of administration of previous dose of dtp, dtap, tdap. this is specifically a contraindication for the pertussis component of tdap. if present, the person should receive td instead of tdap. td (and dt) is contraindicated in severe allergic reaction (e.g. anaphylaxis) after a previous dose or to a vaccine components. when there is a history of anaphylactic reactions to the vaccine, the patient should be referred to an allergist to confirm the presence of specific allergy to tetanus toxoid and whether or not a desensitization therapy can be done. in addition, there are several precautions of giving tdap and td vaccines, i.e.:8 • progressive or unstable neurological disorder, uncontrolled seizures, or progressive encephalopathy until a treatment regimen has been established and the condition has stabilized; these precautions are for pertussis components (only for tdap); • guillain-barré syndrome <6 weeks after a previous dose of tetanus toxoid–containing vaccine; • history of arthus-type hypersensitivity reactions after a previous dose of tetanus or diphtheria toxoid–containing vaccines; defer vaccination until at least 10 years have elapsed since the last tetanus toxoid– containing vaccine; • moderate or severe acute illness with or without fever. adverse reactions of vaccination several adverse reactions have been reported after tdap or td vaccination. a study comparing tdap and td vaccines showed comparable post-vaccination symptoms. among persons receiving tdap and td vaccines respectively, the reported local reactions are pain (30.7% and 35.7%), swelling (4.2% and 2.5%), and erythema at the injection site (2.0% and 3.2%). the most frequent general symptoms were headache (20.4% and 15.7%), fatigue (17.0% and 14.5%), and myalgia (10.0% and 12.5%).12 o t h e r s t u d i e s h a v e c o m p a r e d p o s t vaccination adverse events between the naïve and repeat-dose groups. the reported adverse reactions were injection-site pain (84.4% and 87.8%), erythema (29.7% and 23.1%), swelling (23.3% and 20.5%), and myalgia (53.5% and 60.1%), headache (37.6% and 40.6%), malaise (29.0% and 29.4%), and fever (4.9% and 4.2%).11 vaccination during pregnancy the acip recommends pregnant women to receive tdap vaccine between 27 and 36 weeks of gestation.8,13 this time period was consistently protective against acute respiratory infection (ari) in the first 2 months of the infant’s life. a retrospective cohort study has included 99,434 infants and compared the infants born from mothers vaccinated with tdap during pregnancy and mothers who did not receive vaccination. the risk of ari at <2 months of age was 9% less likely (relative risk [rr] = 0.91; 95% confidence interval [ci] = 0.84-0.99) in infants from mothers vol 50 • number 3 • july 2018 adult diphtheria vaccination 271 who received tdap vaccination. furthermore, the risk was 17% lower if the mother was vaccinated between 27 and 36 weeks of pregnancy (rr = 0.83; 95% ci = 0.74-0.93).14 vaccination for elderly people initially, tdap vaccination or booster was recommended until the age of 64 years. elderly people > 65 years of age was not recommended due to a lack of safety and immunogenicity data. however, lack of standalone pertussis vaccine has force the use of tdap for people > 65 years due to prevent pertussis epidemic in this group of age.15 immunizing older adults with tdap not only reduce the risk of pertussis in the elderly but also prevent transmission to infants having close contact with them. study showed that in elderly people aged >65 years, tdap and td vaccine showed comparable safety. the most frequent adverse events were local injection-site reaction.16 there is no increased risk of reactogenicity after tdap vaccination to people with a history of receiving td vaccine within 5 years.17 tdap vaccine can also be co-administered with influenza vaccine to subjects >65 years of age without compromising of either the reactogenicity or immunogenicity profiles of both vaccines.18 conclusion diphtheria vaccination should be given to adults aged > 19 years with a decennial td booster dose. a single dose of tdap should be given to persons without a history of diphtheria vaccination. continued protection against diphtheria (and tetanus) is provided by booster doses of td every 10 years throughout life. pregnant women should have tdap vaccine in each pregnancy. tdap vaccination is also recommended for elderly people >65 years of age. tdap or td vaccine is administered as a single dose of 0.5 ml, intramuscularly into the deltoid muscle. references 1. vitek cr, wharton m. diphtheria in the former soviet union: reemergence of a pandemic disease. emerg infect dis. 1998;4(4):539–50. 2. bureau of communication and public service, ministry of health, republic of indonesia. pemerintah optimis klb difteri bisa teratasi. downloaded from: http://www.depkes.go.id/article/view/18011500004/ pemerintah-optimis-klb-difteri-bisa-teratasi.html. last access: april 30, 2018. 3. bureau of communication and public service, ministry of health, republic of indonesia. ingat, ori difteri ada 3 putaran. downloaded from: http:// www.depkes.go.id/article/view/18010800001/ingatori-difteri-ada-3-putaran.html. last access: april 30, 2018. 4. tiwari tsp, golaz a, yu dt, et al. investigations of 2 cases of diphtheria-like illness due to toxigenic c o r y n e b a c t e r i u m u l c e r a n s . c l i n i n f e c t d i s . 2008;46:395–401. 5. world health organization. diphtheria vaccine. wkly epidemiol rec. 2006:81:24–32. 6. ipsen j. circulating antitoxin at the onset of diphtheria in 425 patients. j immunol. 1946;54:325–47. 7. mcquillan gm, kruszon-moran d, deforest a, chu sy, wharton m. serologic immunity to diphtheria and tetanus in the united states. ann intern med. 2002;136:660–6. 8. liang jl, tiwari t, moro p, et al. prevention of pertussis, tetanus, and diphtheria with vaccines in the united states: recommendations of the advisory committee on immunization practices (acip). mmwr recomm rep. 2018;67(2):1–44. 9. jadhav s, gautam m, gairola s. role of vaccine manufacturers in developing countries towards global healthcare by providing quality vaccines at affordable prices. clin microbiol infect. 2014;20 (suppl.5): 37–44. 10. centers for disease control (cdc). general recommendation on immunization – recommendations of the advisory committee on immunization practice (acip). mmwr recomm rep. 2011;60(no. rr2):1–64. 11. halperin sa, scheifele d, de serres g, et al. immune responses in adults to revaccination with a tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine 10 years after a previous dose. vaccine. 2012;30(5):974–82. 12. thierry-carstensen b, jordan k, uhlving hh, et al. a randomised, double-blind, non-inferiority clinical trial on the safety and immunogenicity of a tetanus, diphtheria and monocomponent acellular pertussis (tdap) vaccine in comparison to a tetanus and diphtheria (td) vaccine when given as booster vaccinations to healthy adults. vaccine. 2012;30(37):5464–71. 13. murphy tv, slade ba, broder kr, et al. prevention of pertussis, tetanus, and diphtheria among pregnant and postpartum women and their infants recommendations of the advisory committee on immunization practices (acip). mmwr recomm rep. 2008;57(rr-4):1–51. 14. khodr zg, bukowinski at, gmbs gr, conlin ams. tetanus, diphtheria, and acellular pertussis vaccination iris rengganis acta med indones-indones j intern med 272 during pregnancy and reduced risk of infant acute respiratory infections. vaccine. 2017;35(42):5603–10. 15. mertens pl, stals fs, schellekens jf, houben aw, huisman j. an epidemic of pertussis among elderly people in a religious institution in the netherlands. eur j clin microbiol infect dis. 1999;18:242–7. 16. moro pl, yue x, lewis p, haber p, broder k. adverse events after tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (tdap) vaccine administered to adults 65 years of age and older reported to the vaccine adverse event reporting system (vars), 2005-2010. vaccine. 2011;29:9404–8. 17. tseng hf, sy ls, qian l, et al. vaccine safety datalink (vsd) team. safety of a tetanus-diphtheria-acellular pertussis vaccine when used off-label in an elderly population. clin infect dis. 2013;56:315–21. 18. weston wm, friedland lr, wu x, howe b. vaccination of adults 65 years of age and older with tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (boostrix(®)): results of two randomized trials. vaccine. 2012;30(9):1721–8. 42 original article acta med indones indones j intern med • vol 51 • number 1 • january 2019 profile of kawasaki disease in adolescents: is it different? najib advani, lucyana alim santoso, sudigdo sastroasmoro department of child health, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: najib advani, md., phd. department of child health, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: najib.advani@gmail.com. abstrak latar belakang: terdapat peningkatan populasi dewasa muda dengan penyakit arteri koroner yang memiliki penyakit kawasaki saat usia anak, dan dokter spesialis jantung/penyakit dalam harus siap untuk merawat mereka. penyakit kawasaki (pk) pada remaja dan dewasa masih jarang dan belum banyak dikenal, karena itu penting untuk mempelajari data pasien dengan mengetahui kriteria diagnostik dan pedoman pengobatan untuk kelompok usia ini. penelitian ini bertujuan membandingkan profil klinis penyakit kawasaki (pk) antara kelompok pasien berusia lebih dari 10 tahun (remaja) dan kurang dari 10 tahun (anak). metode: analisis dilakukan pada 1150 kasus pk selama periode januari 2003-desember 2016. profil klinis saat fase akut dibandingkan antara kelompok pasien berusia lebih dari 10 tahun dengan kurang dari 10 tahun. hasil: dari 1150 kasus pk ditemukan 17 kasus pk remaja (1,5%), dengan presentasi klinis yang lebih sering dijumpai adalah pk inkomplit (59%), lebih tinggi dibandingkan pada kelompok kurang dari 10 tahun (29%). beberapa tanda klinis lebih sering dijumpai pada anak dibandingkan remaja, seperti konjungtivitis (85% pada <10 tahun; 65% pada >10 tahun), perubahan mukosa (94% vs. 77%), ruam (86% vs. 59%), dan perubahan tangan dan kaki (68% vs 41%). sedangkan tanda klinis lain lebih sering dijumpai pada remaja seperti limfadenopati servikal (82% vs 39%) maupun dilatasi koroner (47% vs 29%). pada pemeriksaan laboratorium (hemoglobin, leukosit, laju endap darah, dan c reactive protein) tidak didapatkan perbedaan bermakna antara 2 kelompok. kesimpulan: penyakit kawasaki pada remaja memiliki profil klinis yang berbeda dengan anak-anak. mayoritas pasien remaja menunjukkan pk inkomplit. beberapa gejala klinis seperti konjungtivitis, kelainan mukosa, ruam, dan perubahan tangan/kaki lebih sering dijumpai pada pk kurang dari 10 tahun, sedangkan limfadenopati servikal dan dilatasi koroner lebih sering ditemukan pada pk remaja. rasio lelaki : perempuan jauh lebih tinggi pada pk remaja. kata kunci: penyakit kawasaki, remaja. abstract background: there is clearly growing population of young adults with potentially important coronary artery disease after kawasaki disease (kd) during childhood, and cardiologist must be prepared to take care for them. as kawasaki disease in adolescent and adult is rare and under-recognized, it is important to study data on patient presentations which may permit development of diagnostic criteria and treatment guidelines for this age group.this study aimed to compare the clinical profile of kd between adolescents (>10 years of age) and children ≤10 years. methods: this is a cross sectional study. a total of 1150 kd cases (age 1-192 months) during the period of january 2003-december 2016 were analyzed. the clinical profile of subjects aged >10 years (adolescents) and ≤10 years (children) at acute phase of kd were compared. results: we found 17 cases of kd in adolescents among 1150 total cases (1.5%). incomplete kd was more often seen in adolescents compared to children ≤ 10 years of age (59% vs. 29%). some clinical features were more frequently seen in children than in adolescents, e.g. conjunctivitis (85% in ≤ 10 years of age vs. 65% in > 10 years), mucosal changes vol 51• number 1 • january 2019 profile of kawasaki disease in adolescents: is it different? 43 (94% vs. 77%), rash (86% vs. 59%), and hand/foot changes (68% vs. 41%). while other clinical features were more often seen in adolescents, e.g., cervical lymphadenopathy (82% vs. 39%) and coronary dilatation (47% vs. 29%). laboratory results (hemoglobin, leukocytes, erythrocyte sedimentation rate and c-reactive protein) did not differ much between the two groups. conclusion: kawasaki disease in adolescents has some different clinical profile from that of younger age. majority of adolescent patients have incomplete presentation. some clinical features such as conjunctivitis, mucosal changes, rash, and hand/foot changes are more often seen in children ≤ 10 years compared to in adolescents, while cervical lymphadenopathy and coronary dilatation are more frequently seen in adolescents. the ratio of male to female is much higher in adolescents. keywords: kawasaki disease, adolescents. introduction kawasaki disease (kd) is an acute systemic vasculitis syndrome of unknown etiology that mainly affects infants and young children. kd was first reported by tomisaku kawasaki in 1967 in japan.1 kd typically affects young children, mostly below 5 years of age with the highest incidence between 1-2 years of age.2 in indonesia, it is estimated that over 2000 kd cases had been treated and presumably the majority of cases are still undiagnosed as the estimate incidence is approximately 5000 new cases per year.2 coronary artery aneurysm develops in 15 25% of untreated kd cases and may lead to myocardial infarction, sudden death, or ischemic heart disease.3 kd is extremely uncommon in patients 9 years of age and older.4,5 the recent epidemiologic survey in japan found that only 0.95% cases occurred in children 10 years of age and older.6 the clinical criteria that establish the diagnosis of kd are the same in all age groups.7 clinical findings at acute stage include fever persisting at least for 5 days, changes in the extremities (erythema of palms, soles, edema of hands, feet), polymorphous exanthema, bilateral conjunctival injection without exudate, changes in lips and oral cavity (erythema, strawberry tongue), unilateral cervical lymphadenopathy measuring >1.5 cm. diagnosis of kd relies on the clinical presentation; laboratory tests are not specific, although anemia, leukocytosis, increased erythrocyte sedimentation rate, and increased c-reactive protein are frequently found on laboratory examination at acute stage. the diagnosis of kd may be missed in older children with fever of unknown origin.8 there is clearly a growing population of young adults with potentially important coronary artery disease after kd during childhood, and cardiologist must be prepared to take care for them.9 antecedent kd should be considered in the evaluation of all cases of sudden, unexpected death in young adults.10 a history of kawasakilike illness in childhood should be sought for adult patients presenting with coronary artery aneurysms in the absence of generalized atherosclerosis disease.11 as kawasaki disease in adolescent and adult is rare and under-recognized, it is important to study data on patient presentations which may permit development of diagnostic criteria and treatment guidelines for this age group. we conducted this study to compare the clinical profile of kd between adolescents ( ≥10 years) and children (<10 years). methods this is a cross-sectional study using a database of subjects with kawasaki disease between january 2003 and december 2016 obtained from five hospitals in jakarta and its surroundings (cipto mangunkusumo hospital, jakarta; omni hospital alam sutera, tangsel; harapan kita hospital, jakarta; siloam hospital, tangerang; premier bintaro hospital, tangsel). the choice of these hospitals was simply based on the author’s (na) access. variables studied were age, gender, clinical presentations (fever, conjunctivitis, mucosal changes, cervical lymphadenopathy, rash, hand/ foot changes), laboratory (hemoglobin, leukocyte, esr, crp) and echocardiogram (coronary artery dilatation). diagnosis of kd was based on aha (american heart association) consensus najib advani acta med indones-indones j intern med 44 criteria either for complete or incomplete cases.7 the classic diagnosis of acute kd was based on fever persisting at least for 5 days, changes in the extremities (erythema of palms, soles, edema of hands, feet or peeling of fingers and toes at subacute stage), polymorphous exanthema, bilateral conjunctival injection without exudates, changes in lips and oral cavity (erythema, strawberry tongue), unilateral cervical lymphadenopathy measuring 1.5 cm or more. the presence of fever and ≥4 principal features allowed for the diagnosis of kd (complete kd). patient with fever ≥5 days and <4 principal features was diagnosed as incomplete kd when coronary artery abnormality was detected by echocardiogram. for assessment of coronary artery dilatation, we used a z score based on body surface area for right coronary artery (rca), left main coronary artery (lmca), and left anterior descending lad.7 all echocardiographic examinations were done by the author (na) at the time of diagnosis, at 2 weeks and then 6-8 weeks. initial coronary dilatations are usually transient ones, but could be regarded as sequelae of kd if they persist beyond 30 days.12 therefore, we determined the presence of coronary dilatation sequelae using the echocardiogram at >30 days. n e a r l y a l l ( 9 8 % ) p a t i e n t s r e c e i v e d intravenous immunoglobulin (2g/kg bw) with high-dose (80-100 mg/kg bw) aspirin on admission according to the aha consensus. eligibility criteria were all patients regardless of age who met the aha criteria for complete or incomplete kawasaki disease with complete data of laboratory tests (hemoglobin, leukocytes, esr and crp) and echocardiogram. laboratory tests were done on admission. anemia was considered as hemoglobin level below 10 g/dl. leukocytosis was considered leukocyte count of over 15.000/ml, esr increase as ≥40 mm /hour and increase of crp as ≥30 mg/l.7 this study has been approved by the ethics committee faculty of medicine universitas indonesia with a reference number 420a/pt02. fk/etik/2012. results we found 1150 subjects with kd (age 1-192 months) during the period of january 2003 to december 2016. among them there were 17 patients with age > 10 years (1.5%). while complete eligible data were obtained from 559 subjects, 542 from ≤ 10 years and 17 from > 10 years (adolescents). in the adolescent group there were only 3 females out of 17 subjects, with male to female ratio of nearly 4:1 while the ratio in the ≤ 10 years group was around 1.5:1. there was a difference between the two age groups in terms of the presence of mucosal changes (red lips and/or strawberry tongue) and rash which were less common in the adolescent group. on the other hand, cervical lymphadenopathy, incomplete kd and coronary artery dilatation were more commonly seen in the adolescent group. discussion kawasaki disease is the most common cause of acquired heart disease in children in the developed countries. the majority of kd patients are below 5 years of age;2 there are few case reports of kd in adolescents and adults. table 1. characteristics of kawasaki disease subjects characteristics of subjects age ≤ 10 years (n=542) > 10 years (n=17) age (mo), mean (sd) 27 (16) 135 (14) median (min-max) 24 (1-120) 134 (121-192) gender, n (%) male 330 (61) 14 (82) female 212 (39) 3 (18) clinical findings, n (%) fever 542 (100) 17 (100) conjunctivitis 462 (85) 11 (65) mucosal changes 509 (94) 13 (77) cervical lymphadenopathy 214 (39) 14 (82) rash 469 (86) 10 (59) hand/foot changes 367 (68) 7 (41) complete (%) 386 (71) 7 (41) laboratory results, n (%) anemia 103 (19) 4 (24) leukocytosis 299 (55) 7 (41) esr increase 406 (75) 15 (88) crp increase 412 (76) 14 (82) echocardiograpahy result, n (%) coronary artery dilatation 159 (29) 8 (47) vol 51• number 1 • january 2019 profile of kawasaki disease in adolescents: is it different? 45 the diagnostic criteria for kd were developed for children and have not been validated in adolescents or adults. fortunately, kd is uncommon in patients over 9 years of age.4,5 we reported 17 cases in adolescents (1016 years of age) out of 1150 total kd subjects (1.5%). this percentage is higher than that of survey in japan which was 0.95% for subjects over 10 years of age, 6 but is likely lower than the findings of momenah et al. which was 7.5% in children ≥9 years of age out of 133 total kd cases.8 we do not know the reason for the differences. in the adolescents, there were just 3 females out of 17 subjects with the ratio of male to female was nearly 4:1. while in the ≤ 10 years subjects the ratio was 1.5:1. it seems that the male to female ratio is higher in adolescents compared to the younger ones. this result is in accordance with the study of stockheim et al. which reported the ratio of male vs female kd ≥8 years was 2.5:1.13 momenah et al. reported the ratio of male vs female in ≥ 9 years of age 1:1.8 we could not explain the reason for this, whether it is by chance or any other reason. incomplete cases were more frequently seen in adolescents (59% vs. 29%). the presence of coronary artery defects on echocardiogram can aid the diagnosis in those lacking the typical clinical features. as many cases of kd in adolescents have incomplete presentation, they might not be diagnosed until relatively late in their illness. this may lead to development of coronary aneurysms and cause long-term morbidity that may impair the quality of life, and although rare, mortality. it would be beneficial if there are specific diagnostic criteria in adolescents to avoid under-diagnosis. however, as the number of kd in adolescent is quite small, making specific diagnostic criteria for this age group would not be easy. in this study 5 out of 17 adolescent cases (30%) were diagnosed after day 10 of illness (delayed diagnosis). while in the ≤ 10 years group 103 out of 542 subjects (19%) were diagnosed after day 10. it seems more difficult to diagnose kd in the adolescents as the majority of cases (60%) were incomplete type. so far there was no mortality until convalescence period in both groups. our study showed that there were some differences in the clinical profile between the adolescents and the younger group. some clinical features were more frequently seen in children ≤ 10 years than in adolescents such as conjunctivitis (85% in ≤ 10 years of age vs. 65% in > 10 years ), mucosal changes (94% vs. 77%), rash (86% vs. 59%), and hand/foot changes (68% vs. 41%). stockheim et al.13 reported that fever, conjunctivitis and exanthem were observed with an equal rate in adults and children. cervical lymphadenopathy was significantly more often seen in adolescent group (82% vs. 39%) as also reported by seve et al. in adults.14 likewise, coronary dilatation was more often seen in adolescents than in younger group. this is in line with the study of momenah et al.8 but different from other studies which found that coronary aneurysms were seen more frequently in children.13,14 laboratory results (hemoglobin, leukocytes, esr and crp level) did not differ much between the two groups. it is rather hard to compare our results of the adolescent kd with other studies as there are very few studies and with very limited subjects. the diagnosis of kd should be considered more often in adolescents and adults when patients present with fever, skin rash, and lymphadenopathy. as the main complication associated with kd is the development of coronary aneurysms which may cause long-term morbidity, awareness of the disease is essential to any physician either handling pediatric or adolescent patients. once kd is diagnosed, immunoglobulin should be administered immediately to prevent the risk of coronary artery aneurysms. conclusion kawasaki disease can occur in adolescents with some different clinical profile than that of the classical findings of the disease in younger children. the ratio of male to female is much higher in adolescents and nearly 60% of them have incomplete presentations. some clinical features are more often seen in children ≤10 years compared to adolescents such as conjunctivitis, mucosal changes, rash, and hand / foot changes. while cervical lymphadenopathy and coronary najib advani acta med indones-indones j intern med 46 artery dilatation were more frequently seen in adolescents. physicians must be alert of the occurrence of kd in older children and adolescents or even adults to prevent coronary complications. references 1. kawasaki t. acute febrile mucocutaneous lymph node syndrome with accompanying specific peeling of the fingers and the toes. jap j allergy. 1967;16:178-22. 2. advani n. kawasaki disease: risk factors for the development of coronary aneurysms, their clinical course, and number and quality of the endothelial progenitor cells. dissertation. jakarta: universitas indonesia. 2014. 3. kato h, sugimura t, akagi t, et al. long-term consequences of kawasaki disease: a 10-21 year follow up study of 594 patients. circulation. 1996;94:1379-85. 4. morens dm, anderson lj, hurwitz es. national surveillance of kawasaki disease. pediatrics. 1980;65:21-5. 5. yanagawa h, yashiro m, nakamura y, kawasaki t, kato h. epidemiologic pictures of kawasaki disease in japan: from the nationwide incidence survey in 1991 and 1992. pediatrics. 1995;95:475-9. 6. makino n, nakamura y, yashiro m, et al. descriptive epidemiology of kawasaki disease in japan, 20112012: from the results of the 22nd nationwide survey. j epidemiol. 2015;25:239-45. 7. newburger jw, takahashi m, gerber ma, et al. diagnosis, treatment and long-term management of kawasaki disease. circulation. 2004;110:2747-71. 8. momenah t, sanatani s, potts j, sandor gg, human dg, patterson mw. kawasaki disease in the older child. pediatrics. 1998;102:7. 9. gersony wm. the adult after kawasaki disease, the risk for late coronary events. j am coll cardiol. 2009;54:1921-3. 10. shimizu c, sood a, lau hd, et al. cardiovascular pathology in 2 young adults with sudden unexpected death due to coronary aneurysms from kawasaki disease in childhood. cardiovasc pathol. 2015:24:3106. 11. burns jc, shike h, gordon jb, malhotra a, schoenwetter m, kawasaki t. sequelae of kawasaki disease in adolescents and young adults. j am coll cardiol. 1996;28;253-7. 12. fukazawa r, ogawa s. long-term prognosis of patients with kawasaski disease: at risk for future atherosclerosis? j nippon med sch. 2009;76:124-33. 13. stockheim ja, innocentini n, shulman st. kawasaki disease in older children and adolescents. j pediatr. 2000;137:250-2. 14. seve p, stankovic k, small a, durand dv, merchand g, broussolle c. adult kawasaki disease: report of two cases and literature review. semin arthritis rheum. 2005:34:785-92. 26 original article acta med indones indones j intern med • vol 50 • number 1 • january 2018 indonesia cohort of io hat study to evaluate diabetes management, control, and complications in retrospective and prospective periods among insulin-treated patients with type 1 and type 2 diabetes achmad rudijanto1, made r. saraswati2, em yunir3, poppy kumala4, happy h. s. puteri4, veny v. v. mandang5 1 department of internal medicine, faculty of medicine, brawijaya university, malang, indonesia. 2 department of internal medicine, faculty of medicine, udayana university sanglah hospital, denpasar, bali, indonesia. 3 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 4 novo nordisk indonesia, jakarta, indonesia 5 department of internal medicine, faculty of medicine, sam ratulangi university, manado, indonesia. corresponding author: prof. achmad rudijanto, md., phd. division of endocrinology and metabolism, department of internal medicine, faculty of medicine, brawijaya university. jalan veteran, malang, indonesia. email: achmadrudijanto@yahoo.co.id. abstrak latar belakang: hipoglikemia merupakan efek samping utama dari terapi insulin pada pasien diabetes melitus. penelitian ini dilakukan untuk mengevaluasi kejadian hipoglikemia pada pasien diabetes melitus tipe 1 (t1dm) atau diabetes melitus tipe 2 (t2dm) yang diobati dengan insulin pada kohort indonesia. metode: penelitian kohort indonesia ini terdiri dari evaluasi retrospektif dan prospektif terhadap episode hipoglikemik, dengan menggunakan international operations hypoglycemia assessment tool (io hat) pada 374 pasien diabetes indonesia (t1dm; n=17 dan t2dm; n=357). pasien berusia ≥18 tahun dan diobati dengan insulin selama >12 bulan dipilih untuk penelitian ini (clinicaltrials.gov nomor: nct02306681). hasil: sebanyak 374 pasien disertakan untuk studi ini dan menyelesaikan self assessment questionnaire 1 (saq1). semua pasien t1dm (17 [100%]) dan 347 pasien t2dm (97,2%) menyelesaikan saq2. hampir semua pasien dalam 4 minggu periode prospektif melaporkan setidaknya satu kejadian hipoglikemi (t1dm 100%, t2dm 99,4%) dan tingkat kejadian hipoglikemia adalah 67,5 kejadian per pasien-tahun (ppy) dan 25,7 kejadian ppy masing-masing untuk pasien t1dm dan t2dm. diantara pasien dengan t1dm dan t2dm, 5,9% dan 36,4%, masing-masing, tidak mengetahui apa hipoglikemia pada awal penelitian. tercatat proporsi yang tinggi dari pasien memiliki kesadaran yang buruk akan kejadian hipoglikemi (82,4% dan 62,7%, masing-masing). kesimpulan: secara keseluruhan, proporsi yang tinggi dari pasien yang melaporkan kejadian hipoglikemi pada periode prospektif mengindikasikan kurang pelaporan selama periode retrospektif karena bias ingatan (recall bias). oleh karena itu dibutuhkan program pendidikan pasien untuk meningkatkan kesadaran akan hipoglikemia dari pasien diabetes di indonesia. kata kunci: alat penaksir hipoglikemia operasi internasional, hipoglikemia, pasien dengan diabetes yang diobati dengan insulin, observasional, indonesia. vol 50 • number 1 • january 2018 indonesia cohort of io hat study to evaluate diabetes management 27 abstract background: hypoglycemia is a major adverse event of insulin therapy for diabetes mellitus patients. the study was conducted to evaluate the incidence of hypoglycemia among insulin treated patients with type 1 diabetes mellitus (t1dm) or type 2 diabetes mellitus (t2dm) in the indonesian cohort. methods: this indonesian cohort study consisted of retrospective and prospective evaluation of hypoglycemic episodes, using international operations hypoglycemia assessment tool (io hat) in 374 patients with diabetes (t1dm; n=17 or t2dm; n=357). the patients of ≥18 years of age and treated with insulin for >12 months were selected for this study (clinicaltrials.gov number: nct02306681). results: a total of 374 patients were enrolled in this study and completed saq1. all patients with t1dm (17 [100%]), and 347 (97.2%) patients with t2dm completed saq2. almost all the patients in the 4-week prospective period reported at least one hypoglycemic event (t1dm 100%, t2dm 99.4%) and the incidence rate of any hypoglycemia was 67.5 events per patient-year (ppy) and 25.7 events ppy for t1dm and t2dm patients, respectively. among patients with t1dm and t2dm, 5.9% and 36.4%, respectively, did not know what hypoglycemia was at baseline, also high proportion of patients had impaired hypoglycemic awareness in the study (82.4% and 62.7%, respectively). conclusion: overall, high proportion of patients reported hypoglycemic events in the prospective period indicating under reporting during the retrospective period due to recall bias. therefore, there is a need for patient education program to improve the awareness of hypoglycemia in diabetes patient in indonesia. keywords: international operations hypoglycemia assessment tool, hypoglycemia, insulin-treated patients with diabetes, observational, indonesia. introduction i n d e v e l o p i n g c o u n t r i e s , i n c r e a s e d urbanization, along with sedentary lifestyle and modified diet are the major contributors to increased prevalence of diabetes.1,2 by the year 2040, the cases of diabetes in indonesia are expected to increase to 16.2 million, compared to 10 million cases in 2015.3 insulin therapy is the standard treatment option for type 1 diabetes mellitus (t1dm) a n d ty p e 2 d i a b e t e s m e l l i t u s ( t 2 d m ) patients due to progressive nature of disease.4,5 hypoglycemia is a major adverse event with insulin therapy. symptoms of hypoglycemia range from unpleasant experience to lifethreatening events; leading to patient fear and ultimately causing reduced compliance or even refusal of insulin treatment and also prevents health-care professionals from switching to insulin treatment or modifying the insulin dose whenever required.6-11 in a study conducted to assess the barrier of insulin treatment, 80% of the family physicians reported that insulin treatment is not commenced due to fear of hypoglycemia.10 apart from impacting diabetes management, hypoglycemia also increases economic burden by impacting work productivity, interfering with daily functioning of patients, increasing health care utilization, increasing mortality risk, and severe hypoglycemia increases risk of cardiovascular adverse events and death.7,12,13 diabcare asia study published in 2008 highlighted that despite the availability of clinical practice guidelines in the region, large number of t2dm patients (68%) still have poor glycemic control.14 treatment guidelines in indonesia have emphasized on the need for patient education, diabetes management during ramadan, and also stressed on regular blood glucose monitoring in patients who are at high risk of developing hypoglycemia.15,16 however, awareness-toadherence model study conducted in indonesia has shown that in spite of high awareness of guidelines among physicians, adherence to these guidelines is really low mainly due to inability to access guidelines, physicians’ attitude, and belief toward the guidelines.17 this further worsens the case as there is not much awareness regarding insulin-associated hypoglycemia among patients. this shows that data on hypoglycemic rates and its impact on economic and social life of patients is lacking in the region. there is an unmet need for such studies and increased patient education program in the region due to perceived risk of achmad rudijanto acta med indones-indones j intern med 28 hypoglycemia. the international operations hypoglycemia assessment tool (io hat) study was a noninterventional, real-world, observational 6-month retrospective and 4-week prospective study of self-reported hypoglycemic events in 7289 patients with insulin-treated t1dm and t2dm from nine countries.18 the aim of the present study was to evaluate the hypoglycemic rates in insulin-treated indonesian patients with t1dm and t2dm. in addition, impact of hypoglycemia on work/study and healthcare, patients’ response and patients’ knowledge of hypoglycemia were also studied. methods the io hat study was a retrospective and prospective observational study to evaluate hypoglycemic episodes using a two-part selfassessment questionnaire (saq1 and saq2) and patient diary (pd) (figure 1). the current study concentrates on the results from indonesian cohort of io hat study where insulin-treated t1dm and t2dm patients were recruited at 23 sites between 18 december 2014 and 04 april 2015 (for further details, please refer the study center details at the end of this manuscript). the study was conducted in accordance with the guidelines for good pharmacoepidemiology practices (2007), declaration of helsinki (2004), the international conference on harmonization guidelines for good clinical practice (1996), and the study protocol and the assessments were approved by country-specific regulatory and ethical agencies.19,20 the study material was translated to local language and the data obtained was back transferred to english for analysis purpose. study population male or female patients of ≥18 years of age with t1dm or t2dm, treated with insulin (e.g. pre-mixed, short-acting, and/or long-acting) for >12 months and who had given informed consent were eligible for this study. nonambulatory, illiterate patients with language barrier in understanding the questionnaire were excluded from this study. patients were recruited randomly into the study via consecutive sampling during routine clinical visit with their healthcare provider in indonesia. study objective primary objective was to determine the percentage of patients experiencing at least one hypoglycemic episode during the 4-week prospective observational period. the secondary objectives were to determine figure 1. io hat study design vol 50 • number 1 • january 2018 indonesia cohort of io hat study to evaluate diabetes management 29 the difference in incidence of various types of hypoglycemic episodes (e.g. any, nocturnal, and severe) between the 4-week retrospective period (or 6-month retrospective period for severe hypoglycemia) and 4-week prospective period, relationship between incidence of hypoglycemia and insulin regimen, patient knowledge of hypoglycemia, proportion of patients with hypoglycemic unawareness, fear of hypoglycemia, patients’ response to hypoglycemia, and impact of hypoglycemia on work/study. hypoglycemic assessments severe hypoglycemia is an episode requiring assistance of another person to actively administer carbohydrate, glucagon, or take other corrective actions (as per american diabetes association [ada] definition).21 non-severe hypoglycemia is an episode managed by the patient alone. any hypoglycemia is the sum of severe hypoglycemia and non-severe hypoglycemia. nocturnal hypoglycemia is hypoglycemia occurring between midnight and 06:00 hours. the incidence of hypoglycemia was captured in the saq1 and saq2 and in the pd. part 1 was used to record baseline demographic, treatment information, patient information, hypoglycemic unawareness, history of severe hypoglycemia over the last 6 months and any and nocturnal hypoglycemia over the last 4 weeks. part 2 was used to evaluate the occurrence of all types hypoglycemia over 4 weeks after baseline and the effect of hypoglycemia on productivity and healthcare utilization. to assist patients recall and as a reminder to complete saq2, patients were provided with a pd to capture hypoglycemic episodes. patient knowledge of hypoglycemia was evaluated by checking if the patient’s definition of hypoglycemia was consistent with ada hypoglycemia definition, and if there was awareness regarding hypoglycemia before reading the instructions provided in informed consent.22 hypoglycemic unawareness was assessed using saq, according to response to question: ‘do you have symptoms when you have a low blood sugar?’, if ‘yes’ denoted normal awareness, ‘usually’ denoted impaired awareness, and ‘occasionally’ and ‘never ’ denoted severely impaired awareness.22 fear of hypoglycemia was reported on a scale of 0 to 10 by the patients, where ‘0’ indicated ‘not afraid at all’ and ‘10’ indicated ‘absolutely terrified’. data analysis the primary endpoint was the percentage of patients who experienced at least one episode of hypoglycemia calculated together with the 95% confidence interval (ci). for secondary endpoints, the incidence rate (ir) of various type of hypoglycemia was calculated as the number of events per patient year (ppy) together with the 95% ci, computed as total number of events divided by total follow-up time in patient years. the incidence rate was reported by diabetes type (t1dm, t2dm) and insulin regimen used. all statistical tests were two-sided and regarded as exploratory, with statistical significance of p <0.05. there were no adjustments for multiple comparisons. continuous and categorical data was reported using descriptive statistics (as percentage of patients). results a total of 374 patients were enrolled in this study and completed saq1; of which 17 patients were with t1dm and 357 patients were with t2dm. all patients with t1dm (17 [100%]) and 347 (97.2%) patients with t2dm completed saq2 and pd. the demographic and baseline characteristics were comparable between t1dm and t2dm patients, with few exceptions (table 1). incidence of hypoglycemia any hypoglycemia. during the 4-week prospective period, 100% (95%ci: 80.5%, 100.0%) patients reported hypoglycemic events in tidm group and 99.4% (95%ci: 97.9%, 99.9%) patients reported hypoglycemic events in t2dm group. while during the retrospective period, 52.9% (95% ci: 27.8%, 77.0%) patients reported hypoglycemic events in t1dm group and 39.5% (95% ci: 34.4%, 44.8%) patients reported hypoglycemic events in t2dm group. in patients with t1dm, the ir of any hypoglycemia increased significantly from the retrospective period to prospective period (33.0 events ppy [95%ci: 23.9%, 44.4%] to 67.5 events ppy achmad rudijanto acta med indones-indones j intern med 30 [95%ci: 54.2%, 83.2%], respectively; p=0.015) (figure 2 [a]). similarly, a significant increase in incidence rate of any hypoglycemia was observed for t2dm patients from retrospective period to prospective period (11.2 events ppy [95%ci: 9.96%, 12.51%] to 25.7 events ppy [95%ci: 23.8%, 27.7%], respectively; p<0.001) (figure 2 [b]). nocturnal hypoglycemia. during the 4-week prospective period, 29.4% (95%ci: 10.3%, 56.0%) patients reported hypoglycemic events in tidm group and 15.3% (95%ci: 11.7%, 19.6%) patients reported hypoglycemic events in t2dm group. while during the retrospective period, 47.1% (95%ci: 23.0%, 72.2%) patients reported hypoglycemic events in t1dm group and 13.4% (95%ci: 10.1%, 17.4%) patients reported hypoglycemic events in t2dm group. the ir of hypoglycemia was higher in retrospective period compared to prospective period in t1dm patients, while the irs were comparable in both the periods in t2dm patients (figure 2 [a] and [b]). severe hypoglycemia. the proportion of t1dm patients with severe hypoglycemia was higher in the retrospective period (70.6%; [95%ci: 44.0%, 89.7%]) than in the prospective period (47.1%; [95%ci: 23.0%, 72.2%]); while the irs increased from the retrospective period (3.6 events ppy; [95%ci: 2.4%, 5.2%]) to the prospective period (7.7 events ppy; [95%ci: 3.7%, 14.1%]) (figure 2 [a]). in t2dm group, the proportion of patients with severe hypoglycemia was higher in prospective period (75.1%; [95%ci: 70.2%, 79.6%]) than in the retrospective period (59.0%; [95%ci: 53.7%, 64.1%]). the irs also increased significantly from retrospective period to prospective period (2.7 events ppy [95%ci: 2.4%, 2.9%] to 13.0 events ppy [95%ci: 11.7%, 14.5%], respectively; p-value<0.001) (figure 2 [b]). rates of hypoglycemia by insulin regimen in t1dm patient group, the estimated irs of any hypoglycemic events in the retrospective and prospective periods were highest in patients using short-acting insulin plus long-acting insulin regimen (figure 3 [a]). the irs of any hypoglycemic events in t2dm patients were almost comparable with no differences among table 1. baseline characteristics of patients in indonesian cohort variables t1dm (n=17) t2dm (n=357) age (years) 31.8 (13.9) 57.9 (10.1) male/female (%) 41.2/58.8 45.9/54.1 duration of diabetes (years) 11.5 (9.3) 11.2 (7.7) duration of insulin use (years) 8.7 (9.6) 4.0 (3.4) bmi (kg/m2) 22.4 (3.3) 26.2 (4.3) hba1c (mmol/mol) 73.8 (23.4) 71.5 (22.0) hba1c (%) 8.9 (2.1) 8.7 (2.0) fbg (mmol/l) 8.6 (4.2) 9.2 (3.9) ppg (mmol/l) 9.9 (4.4) 11.3 (4.3) oral anti-diabetic medications [n (%)]a alpha-glucosidase inhibitors 0 51 (14.3) metformin 2 (11.8) 96 (26.9) bile acid sequestrant 0 3 (0.8) dipeptydyl peptidase iv 0 46 (12.9) glucagaon-like peptide-1 0 1 (0.3) suphonylurea 1 (5.9) 32 (9.0) thiazoledinediones/ glitazones 0 2 (0.6) none 15 (88.2) 194 (54.3) missing 0 0 insulin regimen [n (%)]a short-acting insulin 0 21 (5.9) long-acting insulin 0 60 (16.8) pre-mix 4 (23.5) 107 (30.0) both short and long acting 13 (76.5) 164 (45.9) both short acting and pre-mix 0 1 (0.3) both long acting and pre-mix 0 4 (1.1) symptoms of diabetes-related complications, % tremor 100 86.3 sweating 82.4 69.2 weakness 88.2 68.1 hunger 82.4 66.7 yellow vision 82.4 62.5 data are mean (sd) unless otherwise stated. a percentages based on number of patients with evaluable data. bmi, body mass index; fbg, fasting blood glucose; hba1c, hemoglobin a1c; n, total number of subjects participating; ppg, postprandial glucose; sd, standard deviation; sglt2, sodium-glucose co-transporter-2; t1dm, type 1 diabetes mellitus; t2dm, type 2 diabetes mellitus. vol 50 • number 1 • january 2018 indonesia cohort of io hat study to evaluate diabetes management 31 different treatment regimens (figure 3 [b]). the ir of nocturnal hypoglycemia in patients with t1dm was highest in the retrospective period and prospective period in patients using short-acting insulin plus long-acting insulin regimen (14.1 events ppy and 9.0 events ppy, respectively) (figure 3[c]). similar to any hypoglycemia, the ir of nocturnal hypoglycemic events in t2dm patients was almost comparable with no differences among different treatment regimens. patient perspective on hypoglycemia at baseline, more patients with t1dm (94.1%) than with t2dm (63.6%) knew about hypoglycemia before providing the definition in saq1 (figure 4). among the patients who used blood glucose monitoring to determine hypoglycemia, majority of patients (94.1%t1dm and 77.6% of t2dm) provided consistent values of blood glucose measurements as per the standard definitions of hypoglycemia (≤3.9 mmol/l or ≤70 mg/dl). patient perspectives, including hypoglycemic awareness, fear of hypoglycemia, and response to hypoglycemia are described in table 2. most of the patients (82.4% and 67.2% patients with t1dm and t2dm, respectively) had impaired hypoglycemia awareness. both t1dm and t2dm patients experienced similar severity of fear; with a mean (sd) score of 5.1 (3.17) and 4.1 (2.99), respectively. overall, the proportion of patients who took actions was greater in t1dm than t2dm group in both retrospective and prospective periods (table 2). the proportion of t1dm and t2dm patients who increased calorie intake was greater in retrospective period (76.5% and 27.5%, respectively) than in prospective period (52.9% and 21.6%, respectively). similar results were observed for actions such as avoiding physical exercise and requiring any form of medical assistance. ‘any’ and ‘nocturnal’ based on 4-week period for both retrospective and prospective analyses. *retrospective data based on 6-month period and prospective data based on 4-week period. rr, rate ratio; t1dm, type 1 diabetes mellitus; t2dm, type 2 diabetes mellitus. figure 2. incidence of hypoglycemia rates in (a) t1dm and (b) t2dm patients. achmad rudijanto acta med indones-indones j intern med 32 data based on 4-week period for both retrospective and prospective analyses for any hypoglycemia. retrospective data based on 6-month period and prospective data based on 4-week period for nocturnal hypoglycemia. s+l, short-acting and long-acting insulin; t1dm, type 1 diabetes mellitus; t2dm, type 2 diabetes mellitus. figure 3. rates of hypoglycemia by insulin regimen: (a) any hypoglycemic events (t1dm), (b) any hypoglycemic events (t2dm), and (c) nocturnal hypoglycemic events (t1dm). figure 4. patient perspective on hypoglycemia. vol 50 • number 1 • january 2018 indonesia cohort of io hat study to evaluate diabetes management 33 table 2. patient perspectives on hypoglycemia variables t1dm (n=17) t2dm (n=357) knew what hypoglycemia was at baseline before saq1 [n/n total (%)]a 16/17 (94.1) 225/354 (63.6) hypoglycemia awareness (%) normal 17.6 13.7 impaired 82.4 67.2 severely impaired 0 13.7 fear of hypoglycemia (scale of 0 to 10; %)a 0 = no fear 5.9 14.6 1 11.8 9.0 2 5.9 9.8 3 5.9 14.8 4 11.8 9.0 5 23.5 14.0 6 5.9 5.9 7 5.9 7.6 8 5.9 5.6 9 0 2.2 10 = absolutely terrified 17.6 7.6 impact of hypoglycemic events on the medical system (%)a retrospective (n=17) prospective (n=17) retrospective (n=308) prospective (n=345) events requiring hospital admission 11.8 0 6.2 0.6 attended additional clinical appointments 0 5.9 1.9 1.7 made additional telephone contacts 0 11.8 2.9 2.9 patient response to hypoglycemia (%)a consulted their doctor/nurse 52.9 58.8 34.7 21.0 required any form of medical assistance 64.7 58.8 38.9 21.3 increased calorie intake 76.5 52.9 27.5 21.6 avoided physical exercise 35.3 41.2 14.6 9.5 reduced insulin dose 29.4 35.3 18.2 12.4 skipped insulin injections 17.6 11.8 6.4 7.5 increased blood glucose monitoring 29.4 52.9 17.9 14.1 n, total number of subjects participating; n, number of subjects who responded to the set of questions; a percentages based on number of patients with evaluable data. saq1, self-assessment questionnaire part 1; t1dm, type 1 diabetes mellitus; t2dm, type 2 diabetes mellitus impact of hypoglycemic events on work and study overall the proportion of patients with t1dm and t2dm, who had taken leave from work, arrived late to work, or left early from work due to hypoglycemic events was lesser in prospective period than in retrospective period. in retrospective period, 9 of 17 t1dm patients and 107 of 357 t2dm patients were either studying or were part-time or full-time employee. out of those, three (33.3%) t1dm patients had taken leave from work and left early from work or study in each category and two (22.2%) arrived late for work or study. in the prospective period, one (11.1%) t1dm patient arrived late and left early from work or study in each category. in t2dm patient group, ten (9.3%), nine (8.4%), and eight (7.5%) patients had taken leave, left early, and arrived late to work or study respectively, in the retrospective period, while five (4.9%) had taken leave and three (2.9%) each had left early and arrived late to work or study, in the prospective period. achmad rudijanto acta med indones-indones j intern med 34 impact of hypoglycemic events on the medical system in t1dm patient group, 11.8% of patients required hospital admission in the retrospective period, while in the prospective period. none of the t1dm patients required hospital admission due to hypoglycemic events, while 11.8% of patients made additional telephone contacts and 5.9% of patients took additional clinical appointments. in t2dm patient group, similar proportion of patients made additional telephone contacts (2.9% in both) and took additional clinical appointments (1.9% and 1.7%) in both retrospective period and prospective period respectively. the proportion of patients who required hospital admission was higher in retrospective period compared to prospective period (6.2% vs 0.6%, respectively). discussion this study describes results from indonesia cohort of the multicenter, international, 6 month retrospective and 4-week prospective study using a two-part saq to investigate the prevalence of hypoglycemia in insulin-treated adults with t1dm or t2dm. this is the first patient-reported observational study to assess hypoglycemia in indonesia. almost all the patients in the prospective period reported at least one hypoglycemic event (t1dm: 100%, t2dm: 99.4%). the lesser proportion of patients reporting hypoglycemia in the retrospective period could be attributed to patient recall bias as saqs were used to record data; in prospective period, pds were additionally used to improve recall. in contrast, the proportion of patients reporting nocturnal hypoglycemia was either comparable or more in the retrospective period than in the prospective period. this could have been possible as the patients had clear definition of nocturnal hypoglycemia in the prospective period and hence reported only those events which occurred during this period. moreover, the pds which were used to record events in prospective period can be difficult to fill at night probably resulting in under-reporting of nocturnal hypoglycemia. in addition, impact of nocturnal hypoglycemia may have resulted in increased reporting of nocturnal hypoglycemia in the retrospective period when patients were asked to recall. the incidence of any hypoglycemia was significantly higher in the prospective period compared to retrospective period in both t1dm and t2dm patients (t1dm: 33.0 vs. 67.5 events ppy, p=0.015; t2dm: 11.2 vs. 25.7 ppy, p<0.001). the higher incidence in the prospective period may be due to the fact that saqs and pds acted as a learning tool and reinforce patients’ knowledge resulting in increased hypoglycemic awareness. similarly, severe hypoglycemia was also reported with higher proportion in the prospective period compared to the retrospective period for t2dm patients. in this case, recall bias was more pronounced as retrospective data was based on 6 month period in contrast to 4 week period for any or nocturnal hypoglycemia. overall, the incidence of any hypoglycemia ( 11 . 2 t o 6 7 . 5 e v e n t s p p y ) a n d s e v e r e hypoglycemia (7.7 to 13.0 events ppy) in this sub-study was found to be higher than the previously reported studies.23,24 a systematic review and meta-analysis study by edridge et al23 had reported that ir of mild hypoglycemia was 19 events per patient year and ir of severe hypoglycemia was just 0.80 events per patient year in t2dm patients. an observational study in united states where hypoglycemic events were identified by claim showed that the overall incidence of hypoglycemia was just 3.46/100 patient years.24 the incidence of severe hypoglycemia in hypos-1 study in t1dm patients was found to be 0.49 events/patient years.25 there are no previous clinical trials or observational studies in this region to compare the results of this sub-analysis. nevertheless, higher irs of hypoglycemia in this region emphasize on the need for patient education and regular blood glucose monitoring in diabetic patients with insulin therapy. the guidelines on proper diabetes management should be made available to all healthcare professionals in the region and should focus on use of insulin regimens and newer treatment options which have low risk of hypoglycemia.26-28 in t1dm patients, the irs of any and nocturnal hypoglycemia were highest in patients receiving shortplus long-acting vol 50 • number 1 • january 2018 indonesia cohort of io hat study to evaluate diabetes management 35 insulin regimens during the retrospective and prospective periods, while in t2dm the irs of hypoglycemia were independent of the type of insulin regimen used and were in general higher in the prospective period than in the retrospective period. in general, 35% of patients did not know what hypoglycemia was at baseline. only 29.9% and 18.2% of the overall patients defined hypoglycemia by symptoms only and by both symptoms and blood glucose measurements, respectively. majority of the patients reported occasional symptoms of hypoglycemia during low blood glucose measurements indicating impaired hypoglycemia awareness. this indicates the need of patient education on the importance of blood glucose monitoring, risks associated with hypoglycemia and symptoms of hypoglycemia to create awareness in the region. hypoglycemia has an impact on quality of life (qol) such as work and study and also impacts healthcare utilization. the impact of hypoglycemia on the work life was lesser in the prospective period than in retrospective period. this suggests that study tools (saq and pds) may have played some role in hypoglycemia management in this period and therefore improving qol of patients’. a study by pranoto et al29 which were conducted to assess the safety of insulin when administered by primary health care providers in indonesia concluded that there were minimal hypoglycemic events noted with early initiation of insulin therapy and all of them were mild without requiring hospital admission. self-monitoring of blood glucose examination done in the study indicated that by creating awareness for use of insulin therapy among healthcare, providers will help in proper management of diabetic patients in the region. conclusion the high incidence of hypoglycemia in almost all patients reporting events during the prospective period may indicate under-reporting of hypoglycemia during the retrospective period due to recall bias. the influence of patient education during the study leading to increased hypoglycemia knowledge and therefore higher reporting during the prospective period was also one of the contributing factors. the successful management of diabetes is to achieve targeted glycemic control, while minimizing patient risk of hypoglycemia through appropriate monitoring and creating sufficient awareness about hypoglycemia. there is an unmet need for better education including the importance of self-monitoring of blood glucose, creating sufficient awareness by minimizing the fear of hypoglycemia, and need for newer treatment options with low risk of hypoglycemic profile. study centres details sahid sahirman memorial hospital, jakarta (1 investigator, 9 study subjects); fatmawati hospital, jakarta (1 investigator, 57 study subjects); mitra keluarga hospital, bekasi (1 investigator, 50 study subjects); jakarta medical center hospital, jakarta (1 investigator, 10 study subjects); gatot soebroto hospital, jakarta (1 investigator, 20 study subjects); siloam hospital, surabaya (1 investigator, 30 study subjects); ulin hospital, banjarmasin (2 investigators, 30 study subjects); ratu zalecha hospital, banjarmasin (1 investigator, 7 study subjects); sanglah hospital, denpasar (3 investigators, 16 study subjects); m. djamil hospital, padang (2 investigators, 22 study subjects); hasan sadikin hospital, bandung (3 investigators, 33 study subjects); saiful anwar hospital, malang (3 investigators, 45 study subjects); r.d. kandou hospital, manado (3 investigators, 45 study subjects). acknowledgments the authors acknowledge medical writing and submission support provided by maruthi prasanna from cognizant technology solution, funded by novo nordisk. statistical analysis was performed by paraxel international. competing interests all authors had provided their inputs into the data interpretation and preparation of the final manuscript for publication, met the icmje criteria for authorship, and had approved the final article for submission. the lead author affirms that this manuscript is an honest, accurate and transparent account of the study being reported; achmad rudijanto acta med indones-indones j intern med 36 that no important aspects of the study have been omitted; and that any discrepancies from the study as planned and registered have been explained. roy panusunan sibarani sahid sahirman memorial hospital, jakarta, ida ayu made kshanti fatmawati hospital, jakarta, olly renaldy mitra keluarga hospital, bekasi, susie setyowati gatot soebroto hospital, jakarta, soebagijo adi siloam hospital, surabaya, agus yuwono ulin hospital, banjarmasin, nanang miftah fajari ratu zalecha hospital, banjarmasin, rizqi rifani ulin hospital, banjarmasin, ketut suastika sanglah hospital, denpasar, i made pande dwipayana sanglah hospital, denpasar, asman manaf m. djamil hospital, padang, eva decroli m. djamil hospital, padang, hikmat permana hasan sadikin hospital, bandung, ervita ritonga dr. hasan sadikin hospital, bandung, octo indradjaja hasan sadikin hospital, bandung, laksmi sasiarini saiful anwar hospital, malang, rulli rosandi saiful anwar hospital, malang, yuanita langi r.d. kandou hospital, manado, and karel pandelaki r.d. kandou hospital, manado were the other principal investigators and investigators at their respective study sites. funding author, achmad rudijanto has received research funds from novo nordisk, sanofi aventis and diastika. participated in advisory board of novo nordisk, sanofi aventis and ely lilly. received lecture fees from local sanofi aventis, novo nordisk, tanabe, astrazeneca, and eli lilly. and received travel grand from astra zeneca, sanofi aventis, and novo nordisk. author, made ratna saraswati has received speaker fee from novo nordisk, aztra zeneca, msd, boehringer ingelheim, and sanofi. she has taken part in advisory boards for novo nordisk and sanofi, and received research grant from novo nordisk, astra zeneca, and boehringer ingelheim. author, em yunir has received speaker fees from novo nordisk, astra zeneca, msd, boehringer ingelheim, sanofi, and elli lily. and also has taken part in advisory boards for novo nordisk and sanofi, msd, astra zeneca, boeringer ingelheim, and elli lily. authors, poppy kumala and happy helene sulung puteri are employees of novo nordisk. there is no conflict of interest for author. novo nordisk provided the financial support for the conduct of the research. references 1. shaw je, sicree ra, zimmet pz. global estimates of the prevalence of diabetes for 2010 and 2030. diabetes res clin pract. 2010;87(1):4–14. 2. hu fb. globalization of diabetes: the role of diet, lifestyle, 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of non-severe hypoglycemic events on work productivity and diabetes management. value health. 2011;14(5):665–71. 9. workgroup on hypoglycemia american diabetes association. defining and reporting hypoglycemia in diabetes: a report from the american diabetes association workgroup on hypoglycemia. diabetes care. 2005;28(5):1245–9. 10. nakar s, yitzhaki g, rosenberg r, et al. transition to insulin in type 2 diabetes: family physicians’ misconception of patients’ fears contributes to existing barriers. j diabetes complications. 2007;21(4):220–6. 11. seaquist er, anderson j, childs b, et al. hypoglycemia and diabetes: a report of a workgroup of the american diabetes association and the endocrine society. j clin endocrinol metab. 2013;98(5):1845-59. 12. mcewan p, larsen thorsted b, wolden m, et al. healthcare resource implications of hypoglycemiarelated hospital admissions and inpatient hypoglycemia: retrospective record-linked cohort studies in england. bmj open diabetes res care. 2015;3(1): e000057. doi: 10.1136/bmjdrc-2014-000057 vol 50 • number 1 • january 2018 indonesia cohort of io hat study to evaluate diabetes management 37 13. moheet a, seaquist er. hypoglycemia as a driver of cardiovascular risk in diabetes. curr atheroscler rep. 2013;15(9):351. 14. soewondo p, soegondo s, suastika k, et al. the diabcare asia 2008 study – outcomes on control and complications of type 2 diabetic patients in indonesia. med j indones 2010;19(4):235–44. 15. goh s, hussein z, rudijanto a. review of insulinassociated hypoglycemia and its impact on the management of diabetes in south east asian countries. journal of diabetes investigation. doi: 10.1111/ jdi.12647/pdf. 16. soeatmadji dw, rosandi r, sasiarini l. indonesian guideline of type-2 dm management during ramadan, 2015. 17. widyahening is, yolanda van der graaf, soewondo p, et al. awareness, agreement, adoption and adherence to type 2 diabetes mellitus guidelines: a survey of indonesian primary care physicians. bmc fam pract. 2014;15:72. doi:10.1186/1471-2296-15-72 18. emral r, pathan f, cortes c, et al. self-reported hypoglycemia in insulin-treated patients with diabetes: results from an international survey of 7289 patients from nine countries. diabetes res clin pract. 2017; doi: http://dx.doi.org/10.1016/j.diabres.2017.07.031. 19. international society for pharmacoepidemiology (ispe); guidelines for good pharmacoepidemiology practices (gpp).initially issued: 1996. revision 2, april, 2007. 20. world medical association (wma) declaration of helsinki ethical principles for medical research involving human subjects. 64th wma general assembly, brazil, october 2013. 21. defining and reporting hypoglycemia in diabetes: a report from the american diabetes association workgroup on hypoglycemia. diabetes care. 2005;28(5):1245-9. 22. pedersen-bjergaard u, pramming s, thorsteinsson b. recall of severe hypoglycaemia and self-estimated state of awareness in type 1 diabetes. diabetes metab res rev. 2003;19:232-40. 23. edridge cl, dunkley aj, bodicoat dh, et al. prevalence and incidence of hypoglycaemia in 532,542 people with type 2 diabetes on oral therapies and insulin: a systematic review and meta-analysis of population based studies. plos one. 2015;10(6):e0126427. 24. curkendall sm, zhang b, oh ks, et al. incidence and cost of hypoglycemia among patients with type 2 diabetes in the united states: analysis of a health insurance database. jcom. 2011;18(10):455-62. 25. giorda cb, ozzello a, gentile s, et al. incidence and risk factors for severe and symptomatic hypoglycemia in type 1 diabetes. results of the hypos-1 study. acta diabetol. 2015;52(5):845-53. 26. kalra s, mukherjee jj, venkataraman s, et al. hypoglycemia: the neglected complication. indian j endocrinol metab. 2013;17:819-34. 27. martin gilmour of the diabetic hypoglycemia editorial team. diabetes treatment review: reducing the risk of hypoglycemia with basal insulin analogues. diabetic hypoglycemia. 2008;1(1):15-6. 28. eliaschewitz fg, barreto t. concepts and clinical use of ultra-long basal insulin. diabetol met syndr. 2016;8:2. doi: 10.1186/s13098-015-0117-1. 29. pranoto a, novida h, prajitno jh, et al. safety and efficacy in early insulin initiation as comprehensive therapy for patients with type 2 diabetes in primary health care centers. acta med indones. 2015;47(2):10410. 132 original article acta med indones indones j intern med • vol 50 • number 2 • april 2018 correlation between vitreous advanced glycation end products, and d-dimer with blood hba1c levels in proliferative diabetic retinopathy tonny loho1, venna1, rahajuningsih d. setiabudy1, ninik sukartini1, suzanna immanuel1, july kumalawati1, andi a. victor2, sarwono waspadji3 1 department of clinical pathology, faculty of medicine universitas indonesia, jakarta, indonesia. 2 department of ophthalmology, faculty of medicine universitas indonesia, jakarta, indonesia. 3 department of internal medicine, faculty of medicine universitas indonesia, jakarta, indonesia. corresponding author: tonny loho, dmm, md., phd. department of clinical pathology, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 69, jakarta 10430, indonesia. email: tonnyloho@yahoo.com. abstrak latar belakang: retinopati diabetik (rd) tipe proliferatif merupakan bentuk lanjut rd yang selanjutnya dapat menyebabkan kebutaan. kadar produk akhir glikasi/advanced glycation end products (ages) dan d-dimer cairan vitreus dapat menggambarkan perubahan patologi pada retina, tetapi hanya ada sedikit penelitian yang menilai korelasi antara kedua parameter tersebut dengan kadar hba1c dalam darah. tujuan penelitian ini menemukan hubungan antara kadar hba1c darah dengan kadar ages dan d-dimer cairan vitreus pada pasien dengan rd tipe proliferatif. metode: penelitian bersifat analitik potong lintang pada pasien dengan rd tipe proliferatif yang menjalani vitrektomi. pasien dibagi dalam 2 kelompok yaitu hiperglikemi tidak terkendali (hba1c > 7%) dan terkendali (hba1c < 7%). kadar ages dan d-dimer cairan vitreus diukur dan kadarnya dibandingkan antara pasien hiperglikemi tidak terkendali dan terkendali. uji korelasi statistik juga dilakukan antara kadar hba1c darah dengan kadar ages dan d-dimer cairan vitreus. hasil: pasien berjumlah 47, dengan 32 (68.1%) pasien adalah wanita. nilai median kadar ages cairan vitreus 11.0 (3.0 – 48.0) µg/ml, dan nilai median kadar d-dimer cairan vitreus 5,446.0 (44.0 – 37,394.0 ) ng/ml. nilai median kadar ages cairan vitreus lebih tinggi bermakna pada pasien dengan hiperglikemia tidak terkendali dibandingkan dengan hiperglikemia terkendali (14.0 vs. 4.0 mg/ml; p<0.001). terdapat korelasi positif bermakna dengan kekuatan sedang antara kadar hba1c darah dan kadar ages cairan vitreus (r = 0.524; r2 = 0.130; p=0.0001). kadar hba1c darah dapat digunakan untuk memperkirakan kadar ages cairan vitreus dengan menggunakan rumus: kadar ages cairan vitreus = -1.442+(1.740xhba1c darah). kadar d-dimer cairan vitreus pasien dengan hiperglikemia tidak terkendali tidak berbeda bermakna dengan pasien hiperglikemia terkendali (median 4607.5 vs. 5701.6 ng/ml; p = 0.458). terdapat korelasi positif bermakna tetapi dengan kekuatan lemah antara kadar hba1c darah dengan kadar d-dimer cairan vitreus (r = 0.342; p = 0.019). kadar ages cairan vitreus memiliki korelasi positif bermakna dengan kekuatan lemah dibandingkan dengan kadar d-dimer cairan vitreus (r = 0.292; p = 0.046). kesimpulan: nilai median kadar ages cairan vitreus lebih tinggi bermakna pada pasien rd proliferatif dengan hiperglikemia tidak terkendali dibandingkan hiperglikemia terkendali. kadar hba1c darah dapat digunakan untuk memperkirakan kadar ages cairan vitreus pada pasien rd proliferatif dengan menggunakan rumus: kadar ages cairan vitreus = -1.442+ (1.740x hba1c darah). kadar hba1c darah pada pasien rd proliferatif tidak dapat digunakan untuk memperkirakan kadar d-dimer cairan vitreus. kata kunci: produk akhir glikasi cairan vitreus, d-dimer cairan vitreus, retinopati diabetik proliferatif, hba1c darah. vol 50 • number 2 • april 2018 correlation between vitreous advanced glycation end products, and d-dimer 133 introduction diabetic retinopathy (dr) is one of the major microvascular complications of diabetes mellitus, which is caused by a retinal perfusion disorder due to chronic hyperglycemia. proliferative dr is an advanced form of dr, which is characterized by neovascularization originating from the retina and/or optic disk.1,2 a previous study in our hospital has shown that patients with proliferative dr have increased vitreous vascular endothelial growth factor (vegf), supporting its role in the pathogenesis of proliferative dr.3 various mechanisms are also involved in the pathogenesis of dr, such as activation of protein kinase c, stimulation of the polyol pathway and enhanced reactive oxygen species generation, activation of fructose-6-phosphate pathway, and increased production of advanced glycation end products (ages).4,5 in particular, high levels of ages may cause capillary membrane thickening and endothelial dysfunction that can stimulate coagulation system.6,7 ages accumulation may also stimulate glycation process in the platelet membrane protein and cause modification of the phospholipid structure of platelet’s membrane and increased platelet aggregation and adhesion leading to increased coagulation activation.8.9 a pro-coagulant state is indeed observed in diabetes. factors involved in coagulation system activation such as fibrinogen, factors vii, ix, etc. are usually elevated in diabetes.10 elevated ages levels are found not only in serum but also in the vitreous.11 the production of ages occurs to a much greater degree in patients with uncontrolled hyperglycemia. in diabetic patients, ages levels may increase to 20 folds in the vitreous humor.12 it is suggested that vitreous ages influence the transition from the non-proliferative to proliferative dr.13 ages abstract background: proliferative diabetic retinopathy (dr) is an advanced form of dr that eventually could lead to blindness. levels of vitreous advanced glycation end products (ages) and d-dimer may reflect the pathological changes in the retina, but only few studies have assessed their correlation with blood hemoglobin a1c (hba1c) levels. this study aimed to find the correlation between blood hba1c levels with vitreous ages and d-dimer levels in patients with proliferative dr. methods: an analytical cross-sectional study was performed in subjects with proliferative dr who underwent vitrectomy. subjects were divided into 2 subgroups, i.e. uncontrolled (hba1c >7%) and controlled (hba1c <7%) groups. vitreous ages and d-dimer levels were assessed; the levels were compared between uncontrolled and controlled hyperglycemic patients. statistic correlation tests were also performed for evaluating blood hba1c, vitreous ages, and d-dimer levels. results: a total of 47 patients were enrolled in this study and 32 (68.1%) of them were women. median vitreous ages level was 11.0 (3.0 – 48.0) µg/ml; whereas median vitreous d-dimers level was 5,446.0 (44.0 – 37,394.0 ) ng/ml. the median vitreous ages levels was significantly higher in patients with uncontrolled vs. controlled hyperglycemia (14.0 vs. 4.0 mg/ml; p<0.001). there was a significant positive correlation with moderate strength between blood hba1c level and vitreous ages level (r=0.524; r2=0.130; p=0.0001). blood hba1c level could be used to predict vitreous ages level by using the following calculation: vitreous ages = -1.442+ (1.740xblood hba1c). vitreous d-dimer levels were not significantly different between uncontrolled and controlled hyperglycemia (median 4607.5 vs. 5701.6 ng/ml; p = 0.458). there was a positive significant correlation between blood hba1c and vitreous d-dimer levels (r = 0.342; p = 0.019); however the correlation was weak. vitreous ages level had a positive significant correlation with vitreous d-dimer levels (r = 0.292; p = 0.046) and the correlation strength was also weak. conclusion: median vitreous ages levels were significantly higher in proliferative dr patients with uncontrolled than those with controlled hyperglycemia. blood hba1c level can be used to assess vitreous ages level in patients with proliferative dr by using the following calculation: vitreous ages = -1.442+(1.740 x hba1c). however, the blood hba1c level can not be used to predict vitreous d-dimer level in patients with proliferative dr. keywords: vitreous advanced glycation end products, vitreous d-dimer, proliferative diabetic retinopathy, blood hba1c. tonny loho acta med indones-indones j intern med 134 accumulation in the vitreous humor may cause chronic inflammation, neurodegeneration and retinal microvascularization dysfunction, which eventually impair vitreous permeability.14 d-dimer level has been used as a biomarker of hypercoagulability and fibrinolytic activity since it is a product of fibrin degradation.15 study assessing d-dimer from vitreous humor is scarce, but it is suggested that high level of vitreous d-dimer may indicate a substantial damage of the blood-retinal barrier because it has large molecular size (molecular weight of 180 kda) to penetrate into the vitreous body.16 therefore, it is an important biomarker to indicate a more advanced stage of dr. currently, there is no method to predict vitreous ages levels or fibrinolytic activity from blood biomarkers. this study aimed to find the correlations between blood hba1c levels, vitreous ages and vitreous d-dimers levels in patients with proliferative diabetic retinopathy. methods this was an analytical, cross-sectional study, which was conducted at the department of clinical pathology, cipto mangunkusumo hospital (cm hospital) jakarta, between january and june 2017. subjects were proliferative dr patients recruited from department of ophthalmology, cm hospital who were enrolled in the previous study3 and underwent vitrectomy. vitreous specimens were stored at -80oc in the laboratory of clinical pathology department, cm hospital. patients’ demography, clinical data and hba1c levels were retrieved from medical records. patients with hba1c levels of <7% was designated as controlled hyperglycemia, whereas hba1c of >7% was categorized in the uncontrolled hyperglycemia group. ethical approval was issued by the ethical committee, faculty of medicine, universitas indonesia by letter no. 487/un2.f1/etik/2017. measurement of intravitreal ages and d-dimer intravitreal ages levels were measured using enzyme-linked immunosorbent assay (elisa) method with a commercial kit (oxiselecttm advanced glycation end product competitive elisa kit, cell biolabs inc., usa). the result was expressed as µg/ml. intravitreal d-dimer levels were measured using enzyme-linked fluorescence assay (elfa) method with a commercial kit (vidas® d-dimer exclusion ii assay, bio mérieux, france) and the results were expressed as ng/ml. the reference value for plasma d-dimer was <300 ng/ml. statistical analyses patients’ demography and clinical data were presented descriptively. vitreous ages and d-dimer levels were expressed as median and range due to their skewed distribution. median differences between groups were analyzed using mann-whitney u test. a p value of less than 0.05 was considered significant. correlation tests were performed using spearman’s rho correlation coefficient for skewed data. statistical analyses were done using a statistical software spss version 17.0 (spss inc., chicago, illinois, usa). results a total of 47 patients were enrolled in this study and 32 (68.1%) of them were women. mean age of the patients was 53.0 (sd 8.03) years old. most patients had uncontrolled hyperglycemia (hba1c > 7%) and had been diagnosed for less than 15 years (table 1). table 1. subject characteristics (n=47) variables median (range) n (%) gender male 15 (31.9) female 32 (68.1) glycemic control (hba1c) 8.4 (5.4–13.5) controlled (hba1c <7%) 11 (23.4) uncontrolled (hba1c >7%) 36 (76.6) duration of diabetes 10 (1–35) <15 years 33 (70.2) >15 years 14 (29.8) vitreous ages and vitreous d-dimer levels median vitreous ages level was 11.0 (3.0 – 48.0) µg/ ml, whereas the median vitreous d-dimer level was 5,446.0 (44.0 – 37,394.0) ng/ ml. thirty-four (72.3%) patients had d-dimer level of >300 ng/ml. vol 50 • number 2 • april 2018 correlation between vitreous advanced glycation end products, and d-dimer 135 correlation between blood hba1c and vitreous ages and vitreous d-dimer levels vitreous ages levels were significantly higher in patients with uncontrolled (hba1c >7%) than controlled hyperglycemia (hba1c <7%). the median was 14.0 vs. 4.0 mg/ml (p<0.001) for uncontrolled and controlled hyperglycemia, respectively (figure 1). there was a significant positive correlation with moderate strength between blood hba1c level and vitreous ages level (r=0.524; r2=0.130; p=0.0001). blood hba1c level could be used to predict vitreous ages level by the following calculation: vitreous ages = -1.442 + (1.740 x hba1c) vitreous d-dimer levels were not significanly different between patients with uncontrolled and controlled hyperglycemia (median 4607.5 vs. 5701.6 ng/ml; p=0.458) (figure 2). there was a significant positive correlation with weak strength between hba1c and vitreous d-dimer levels (r=0.342; p=0.019). vitreous ages was weakly correlated with vitreous d-dimer levels (r=0.292; p=0.046). patients with vitreous d-dimer of more than 300 ng/ml tended to have higher vitreous ages level than those with d-dimer of ≤300 ng/ml (12 vs. 10 µg/ml; p=0.073). discussion this study is the first to evaluate the correlation among intravitreal ages, d-dimer levels and blood hba1c in indonesian patients with proliferative dr. to our knowledge, this study also provided first data on vitreous ages and d-dimer levels comparing controlled and uncontrolled hyperglycemic dr patients. female patients were predominant in this study, which is similar to another study about prevalence and risk factors for dr in malay ethnic, which was conducted in singapore (60-70%).21 the mean age of patients was also comparable with other asian populations with dr.22 our study has shown that high hba1c was moderately associated with higher vitreous ages levels. this supports the theory that uncontrolled hyperglycemia has an important role in the pathogenesis of proliferative dr.13 moreover, it can be said that we are able to predict vitreous ages levels based on hba1c levels obtained from a blood sample taken from the patients. this finding implies that hba1c levels can be used to monitor disease progression in an individual patient. high vitreous d-dimer levels in this study suggest that there was increased fibrinolytic activity in proliferative dr patients. a previous study has reported increased components of the fibrinolytic system, including d-dimer, in the vitreous body of vitreoretinal disorders. the mean vitreous d-dimer level was 1.64 µg/ml (1,640 ng/ml) in patients with proliferative vitreoretinal disorder.16 the high vitreous d-dimer levels might be surprising since in another study, blood d-dimer levels in diabetic patients with dr was figure 1. vitreous ages levels between patients with uncontrolled (hba1c >7%) and controlled (hba1c <7%) hyperglycemia figure 2. vitreous d-dimer levels between patients with uncontrolled (hba1c >7%) and controlled (hba1c <7%) hyperglycemia tonny loho acta med indones-indones j intern med 136 similar with diabetic patients without dr (0.2 vs. 0.2 µg/ml; p = 0.960). the breakdown of the blood-retinal barrier is thought to be responsible for increased vitreous d-dimer levels and also other components of the fibrinolytic system.16 the wide range and skewed distribution of vitreous d-dimer levels may affect the statistical correlation test. the regression test was performed based on an assumption that numerical data have linear distribution, but we observed that high vitreous d-dimer levels could be found in patients with normal hba1c levels. other factors are involved in the pathogenesis of coagulation and fibrinolytic activities and these may influence the d-dimer levels in the vitreous humor. this study has a limitation that it was not designed prospectively to provide evidences that uncontrolled hyperglycemia causes increased vitreous ages levels or fibrinolytic activity. prospective studies may not be suitable due to ethical problem to obtain vitreous specimens from asymptomatic dr subjects. however, this study may suggest that it is important to control hyperglycemia to prevent the increase of vitreous ages level. on the other hand, abnormalities of coagulation and fibrinolytic activity can still be present even in patients with good glycemic control. this is supported by a study showing that coagulation and fibrinolytic abnormalities has a strong association with the presence of diabetic vascular complications and the association was stronger than the degree of glycemia.24 conclusion median vitreous ages levels are significantly higher in patients with uncontrolled than those with controlled hyperglycemia. blood hba1c levels can be used to assess vitreous ages level by the following calculation: vitreous ages = -1.442+(1.740 x hba1c). blood hba1c level can not be used to predict vitreous d-dimer level. references 1. powers ac. diabetes mellitus. in: kasper dl. hauser sl, jameson jl, fauci as, longo dl, loscalzo j, editors. harrison’s principles of internal medicine. 16th ed. philadelphia: mcgraw hill; 2005. p. 2152-64. 2. powers ac. diabetes mellitus: complications. in: kasper dl. hauser sl, jameson jl, fauci as, longo dl, loscalzo j, editors. harrison’s principles of internal medicine. 19th ed. philadelphia: mcgraw hill; 2015. p. 2422-5. 3. victor aa, gondhowiardjo td, waspadji s, et al. effect of laser photocoagulation and bevacizumab intravitreal in proliferative diabetic retinopathy: review on biomarkers of oxidative stress. med j indones. 2014;23:79-86. 4. sacks db. diabetes mellitus. in: burtis ca, ashwood er, bruns de, editors. tietz textbook of clinical chemistry and molecular diagnostics. 5th ed. missouri: elsevier saunders; 2012. p. 1435-56. 5. frank rn. etiologic mechanism of diabetic retinopathy. in: ryan sj, retina, editors. 3rd ed. missouri: mosby inc; 2001. p. 1259-86. 6. yau jwy, rogers sl, kawasaki r, et al. global prevalence and major risk factors of diabetic retinopathy. diabetes care. 2012;35:556-64. 7. singh vp, bali a, singh n, jaggi as. advanced glycation end products and diabetic complications. korean j physiol pharmacol. 2014;18:1-14. 8. colwell ja, nesto rw. the platelet in diabetes: focus on prevention of ischemic events. diabetes care. 2003;26:2181-8. 9. natarajan a, zaman ag, marshall sm. platelet hyperactivity in type 2 diabetes: role of antiplatelet agents. diab vasc dis res. 2008;5:138-44. 10. carr me: diabetes mellitus: a hypercoagulable state. j diabetes complications. 2001;15:44–54. 11. stitt aw, moore je, sharkey ja, et al. advanced glycation end products in vitreous: structural and functional implications for diabetic vitreopathy. invest ophthalmol vis sci. 1998;39:2517–23. 12. sebag j, buckingham b, charles ma, reiser k. biochemical abnormalities in vitreous of humans with proliferative diabetic retinopathy. arch ophthalmol. 1992;110:1472–6. 13. choudhuri s, dutta d, sen a, et al. role of n-εcarboxy methyl lysine, advanced glycation end products and reactive oxygen species for the development of nonproliferative and proliferative retinopathy in type 2 diabetes mellitus. mol vis. 2013;19:100–13. 14. lee ot, good sd, lamy r, kudisch m, stewart jm. advanced glycation end product accumulation reduces vitreous permeability. invest ophthalmol vis sci. 2015;56:2892–7. 15. stang lj. d-dimer and fibrinogen/fibrin degradation products. methods mol biol. 2013;992:415-27. 16. ulrich jn, spannagl m, kampik a, gandorfer a. components of the fibrinolytic system in the vitreous body in patients with vitreoretinal disorders. clin exp ophthalmol. 2008;36:431-6. 17. consensus on management and prevention of type 2 diabetes mellitus in indonesia. jakarta: indonesian society of endocrinology; 2015. p. 45. 18. product manual. oxiselecttm advanced glycation vol 50 • number 2 • april 2018 correlation between vitreous advanced glycation end products, and d-dimer 137 end product (age) competitive elisa kit. cell biolabs, inc. 2017. 19. product manual. d-dimer elfa kit. vidas. bio mérieux. 2017. 20. marder vj, aird wc, bennet js, schulman s, white gc. secondary hemostasis and fibrinolytic. hemostasis and thrombosis, basic principles and clinical practice. 6th ed. philadelphia: william & wilkins. 2013. p. 316. 21. wong ty, cheung n, tay wt, wang jj, aung t. prevalence and risk factors for diabetic retinopathy: the singapore malay eye study. ophthalmology. 2008;115:1869-75. 22. chiang ppc, lamoureux el, cheung cy, et al. racial differences in the prevalence of diabetes but not diabetic retinopathy in a multi-ethnic asian population. invest opthalmol vis sci. 2011;52(10):7586-92. 23. nguyen tt, alibrahim e, islam fma, et al. inflammatory, hemostatic, and other novel biomarkers for diabetic retinopathy: the multi-ethnic study of atherosclerosis. diabetes care. 2009;32:1704-9. 24. yamada t, sato a, nishimori t, et al. importance of hypercoagulability over hyperglycemia for vascular complication in type 2 diabetes. diabetes res clin pract. 2000;49:23-31. medical illustration renal tuberculosis: the masquerader rudi supriyadi1, guntur darmawan2,3, emmy h. pranggono4 1 division of nephrology and hypertension, department of internal medicine, faculty of medicine, universitas padjadjaran hasan sadikin general hospital, bandung, indonesia. 2 department of internal medicine, faculty of medicine, universitas padjadjaran hasan sadikin general hospital, bandung, indonesia. 3 department of internal medicine, faculty of medicine, krida wacana christian university, jakarta, indonesia. 4 division of respiratory and critical illness, department of internal medicine, faculty of medicine, universitas padjadjaran hasan sadikin general hospital, bandung, indonesia. corresponding author: guntur darmawan, md. department of internal medicine, faculty of medicine universitas padjadjaran – hasan sadikin hospital. jl. professor eyckman no. 38, bandung 40161, indonesia. email: guntur.darmawan@ukrida.ac.id. figure 1. figure 2. tuberculosis (tb) remains a worldwide scourge and the most common cause of mortality from infectious disease. around 95% of cases occur in developing country. renal tb is a rare cases that complicates 3-4% of pulmonary tb patients and commonly overlooked in clinical practice due to its symptoms may mimic other diseases.1-3 a-39-year-old man was admitted to our institution due to flank pain. he had history of low grade fever and oligouria since 5 months prior. he had no complaint of cough, dyspnea, or night sweat. he was a non smoker and had no past medical history of tuberculosis. previous 4 months abdominal ultrasound showed left pelvocaliectasis and ureteral dilatation with suspicion of left ureteral stenosis. ureterolithiasis could not be excluded. no prostate enlargement or vesicolithiasis was seen. intravenous pyelography (ivp) examination demonstrated similar finding. (figure 1 and 2) initial laboratory blood examination showed anemia (10.7 g/dl), leukocytosis (14,080/ul), increased in serum creatinin (4.2 mg/dl), ureum (227 mg/dl), and calcium (6.78 mg/dl). serology 353acta med indones indones j intern med • vol 51 • number 4 • october 2019 rudi supriyadi acta med indones-indones j intern med examinations were negative for hiv, hbsag, anti hcv and blood culture had no growth. urinary examination revealed severe leucocyturia, hematuria, and negative for bacteria, nitrite and cast. urine culture was positive for candida glabrata. pulmonary x-ray suggested right pleural fibrotic. he was initially diagnosed as multiple myeloma with fungal infection. nevertheless, additional peripheral blood smear showed neither rouleaux formation nor blast. he underwent percutaneous nephrostomy and got micafungin intravenously. instead of improving, the patient deteriorated and transferred to intensive room. we then explored the possibility of tb infection. further examination revealed positive for mycobacterium tuberculosis in urinary polymerase chain reaction (pcr) test. tracheal sputum examination was positive for acid fast bacilli staining. there was low level of serum vitamin d2 (5.8 ng/ml). he got tb treatment with rifampicin, isoniazid, pyrazinamide, and ethambutol. unfortunately, the patient eventually succumbed. renal tb is the second most common form of extra-pulmonary tb after lymph node tb. the non specific clinical presentation of renal tb may result in delayed diagnosis and management of the disease, which might worsen morbidity and mortality. sterile pyuria is the most common clinical finding as seen in this case. there are no specific clinical symptoms or imaging finding, and low yield of culture techniques; therefore, a combination of clinical symptoms, imaging and laboratory examinations contribute to establish the diagnosis of renal tb. in addition, pcrbased test are promising and can significantly increase case detection. examination of urinary tb pcr gave the diagnostic clue in our case. urinary tb pcr test may demonstrate up to 100% in sensitivity.4-7 other interesting finding in our case was low level of serum vitamin d2 and hypercalcemia. many studies showed vitamin d deficiency is associated with the risk of tb infection, since vitamin d play important role in human immunity system.8-10 however, as in other granulomatous diseases, pth independent-hypercalcemia may occur in tb through ectopic production of 1α, 25(oh)2d3. pulmonary alveolar macrophages and lymphocytes upregulate expression of 25(oh)d3-1α-hydroxylase. moreover, pleural fluid contains substances such as γ-interferon that might potentiate the expression of 25(oh)d3-1αhydroxylase. the laboratory examination may show suppressed pth, elevated 1α, 25(oh)2d3, and normal or low 25(oh)d concentrations.11-13 whether vitamin d supplementation will be beneficial to tb treatment is still inconclusive. looking to the risk of hypercalcemia and a study by xia demonstrating no significant benefit of vitamin d supplementation in tb treatment, further rigorously controlled studies are suggested to fully answer the controversy in vitamin d supplementation.14 renal tb is a great masquerader in daily practice. the diagnosis of extra pulmonary tb is not easy and it needs high level of clinical suspicion, especially when encounters sterile pyuria. complementary finding of hypercalcemia and low serum vitamin d could help clinician in directing to tb. learning from this case, we should not overlook fibrotic finding in chest x-ray which could be a starting point of renal tb. references 1. de oliveira jl, da silva junior gb, daher edf. tuberculosis-associated chronic kidney disease. am j trop med hygiene. 2011;84(6):843-4. 2. kumar s, shankaregowda sa, choudhary gr, singla k. rare presentation of genitourinary tuberculosis masquerading as renal cell carcinoma: a histopathological surprise. j clin imag sci. 2014;4. 3. lima na, vasconcelos cc, filgueira pho, et al. review of genitourinary tuberculosis with focus on end-stage renal disease. revista do instituto de medicina tropical de são paulo. 2012;54(1):57-60. 4. abbara a, davidson rn. etiology and management of genitourinary tuberculosis. nature rev urol. 2011;8(12):678. 5. daher edf, da silva junior gb, barros ejg. renal tuberculosis in the modern era. am j trop med hygiene. 2013;88(1):54-64. 6. ramana k. pulmonary tuberculosis disseminating and presenting as bilateral hydronephrosis and renal abscess: a potential threat in the era of multi-drug resistant tuberculosis mdr-tb. am j infect dis microbiol. 2014;2:48-50. 7. rui x, li xd, cai s, chen g, cai b. ultrasonographic diagnosis and typing of renal tuberculosis. int j urol. 2008;15(2):135-9. 8. huang s-j, wang x-h, liu z-d, et al. vitamin d deficiency and the risk of tuberculosis: a meta-analysis. 354 vol 51 • number 4 • october 2019 renal tuberculosis: the masquerader drug design, development and therapy. 2017;11:91. 9. iftikhar r, kamran sm, qadir a, haider e, bin usman h. vitamin d deficiency in patients with tuberculosis. j coll physicians surg pak. 2013;23(10):780-3. 10. kearns md, tangpricha v. the role of vitamin d in tuberculosis. j clin transl endocrinol. 2014;1(4):167-9. 11. araujo ca, araujo na, daher ef, et al. resolution of hypercalcemia and acute kidney injury after treatment for pulmonary tuberculosis without the use of corticosteroids. am j trop med hygiene. 2013;88(3):592-5. 12. peces r, de la torre m, alcázar r, tejada f, gago e. genitourinary tuberculosis as the cause of unexplained hypercalcaemia in a patient with pre-end-stage renal failure. nephrology, dialysis, transplantation: official publication of the european dialysis and transplant association-european renal association. 1998;13(2):488-90. 13. tebben pj, singh rj, kumar r. vitamin d-mediated hypercalcemia: mechanisms, diagnosis, and treatment. endocrine rev. 2016;37(5):521-47. 14. xia j, shi l, zhao l, xu f. impact of vitamin d supplementation on the outcome of tuberculosis treatment: a systematic review and meta-analysis of randomized controlled trials. 2014. 355 editorial 183acta med indones indones j intern med • vol 50 • number 3 • july 2018 early detection of plasma leakage in dengue hemorrhagic fever erni j. nelwan department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: erni juwita nelwan, md., phd. division of tropical and infectious disease, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: e.nelwan@gmail.com. dengue viral infection remains a major public health problem. as many as 400 million people are infected yearly.1 even though the vaccine is available, the use of dengue vaccine is still limited due to some concerns. among patient infected with dengue viral infection, early recognition of the virus and prompt supportive treatment are important to avoid complication and mortality. the clinical spectrum of dengue viral infection is diverse ranging from undifferentiated fever to dengue shock syndrome characterized by plasma leak and hemoconcentration.2 no specific antiviral therapy is available. therefore, anticipation of complication should be performed adequately. the most dangerous complication of dengue infection is shock syndrome. hypothetically the occurrence of shock is a result of secondary viral infection. the manifestation of increased vascular permeability and low intravascular volume lead to the development of shock.3 in addition to that, another complex mechanism underlies the occurrence of shock such as endothelial dysfunction that could happened abruptly. no specific method exists to identify this condition as early as possible. during dengue infection, fever can be last between 2 and 7 days. the localized plasma leakage could happen and manifested as a pleural effusion fluid accumulation in abdominal cavity or hemoconcentration. this will only last for 48 hours and will be resolved later spontaneously.3,4 severity of leakage varies among patients and the unanticipated of leakage due to failure to recognize and treat this manifestation related to mortality.2-4 most of the fatal cases of dengue are related to late detection of the illness as shown by massive hemorrhage and severe intravascular volume depletion. the role of dendritic cells is as the initiator of immune response that facilitate virus uptake.4 on the other hand, the non-neutralize cross reactive antibodies will increase virus uptake and resulted in more viral replication. some studies showed higher ns1 protein were found in patients with more severe disease. in addition to that antibody to ns1 could bind to the endothelial cells and lead to apoptosis of these cells. both host and viral factors contribute to the severity of the illness. one of the important factors for dengue viral infection is the capacity of clinicians to identify the risk factors for shock. studies reported that female, infants, elderly, patients with concomitant diseases are prone to have more severe infection.5-7 virus serotype and genetic susceptibility may also contribute but the evidence is still limited. so, those are not sensitive enough be used in clinical setting. besides those, after the diagnosis of with dengue infection based on who criteria and confirmation by serology detection or viral material in the blood, no specific sign and symptoms are available to determine any potential severity. there were studies performed to monitor the plasma leakage using mean arterial erni j. nelwan acta med indones-indones j intern med 184 blood pressure (map) instead of hematocrit values. rapid intervention can be administered by monitoring map to avoid deleterious consequences.8,9 the classification of who 1997 or 2009 were not able to detect the plasma leakage earlier.10,11 nainggolan et al12 presented the resulted of their observation among early dengue infection which was the occurrence of gallbladder wall thickening as a manifestation of plasma leakage. ultrasonographic measurement is valuable and applicable to detect plasma leakage in earlier phase with positive likelihood ratio 2.14 (95% ci 1.12 – 4.12). similar report from indonesia also showed the role of ultrasonography in dengue.13 references 1. dengue. centre for disease control and prevention. https://www.cdc.gov/dengue/ 2. cogan je. dengue and severe dengue. who. http:// www.who.int/news-room/fact-sheets/detail/dengueand-severe-dengue. 3. world health organization. dengue. clinical diagnosis. who. http://www.who.int/csr/resources/ publications/dengue/012-23.pdf. 4. rajapakse s. dengue shock. j emerg trauma shock. 2011;4(1):120-7. 5. libraty dh, endy tp, houng hs, et al. differing influences of virus burden and immune activation on disease severity in secondary dengue-3 virus infections. j infect dis. 2002;185(9):1213–21. 6. vaughn dw, green s, kalayanarooj s, et al. dengue viremia titer, antibody response pattern, and virus serotype correlate with disease severity. j infect dis. 2000;181(1):2–9. 7. libraty dh, young pr, pickering d, et al. high circulating levels of the dengue virus nonstructural protein ns1 early in dengue illness correlate with the development of dengue hemorrhagic fever. j infect dis. 2002;186(8):1165–8. 8. daniel pt. dengue with severe plasma leakage: a new monitoring approach. acta méd. costarric [internet]. 2016;58(3):115-21. 9. bethell db, gamble j, loc pp, et al. non invasive measurement of microvascular leakage in patients with dengue hemorrhagic fever. clin infect dis. 2001; 32:243-253. 10. world health organization, geneva. dengue haemorrhagic fever. diagnosis, treatment, prevention and control. 2nd edition. 1997. geneva, office of publications who, geneva 1997. 11. world health organization, geneva. dengue. guidelines for diagnosis, treatment, prevention and control. new edition. geneva, who press 2009. 12. nainggolan l, wiguna c, hasan i, dewiasty e. gallbladder wall thickening as an early detection of plasma leakage in dengue infected adult patients. acta med indones. 2018;50(3):193-9. 13. michels m, sumardi u, de mast q, et al. the predictive diagnostic value of serial daily bedside ultrasonography for severe dengue in indonesian adults. plos negl trop dis. 7(6): e2277. 3 original article acta med indones indones j intern med • vol 51 • number 1 • january 2019 the role of fragmented qrs (fqrs) as a predictor of major adverse cardiac event within 30 days in acute coronary syndrome patients: a retrospective cohort study anastasia a. dinakrisma1, ika p. wijaya2, sally a. nasution2, esthika dewiasty3,4 1 department of internal medicine, faculty of medicine universitas indonesia, jakarta, indonesia. 2 cardiology division, department of internal medicine, faculty of medicine, universitas indonesia, jakarta, indonesia. 3 geriatric division, department of internal medicine, faculty of medicine universitas indonesia, jakarta, indonesia. 4 center for clinical epidemiology and evidence-based medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: ika prasetya wijaya, md., phd. cardiology division, department of internal medicine, faculty of medicine, universitas indonesia. jl. diponegoro no. 71, jakarta 10430, indonesia. email: ipwijaya@hotmail.com. abstrak latar belakang: beberapa penelitian menunjukkan komplek qrs terfragmentasi (fqrs) sebagai penanda bekas luka miokard, substrat aritmia ventrikel, remodeling ventrikel, dan aliran kolateral koroner yang lebih buruk, yang dapat meningkatkan insidensi kejadian kardiak yang merugikan (mace) setelah infark. penelitian ini bertujuan untuk mengidentifikasi peran fqrs sebagai salah satu faktor risiko untuk mace (kematian jantung dan reinfarction) pada pasien sindrom koroner akut dalam 30 hari pengamatan. metode: penelitian retrospektif kohort dilakukan dengan menggunakan data sekunder pasien sindrom koroner akut di unit perawatan jantung intensif rumah sakit cipto mangunkusumo dari juli 2015 hingga oktober 2017. analisis multivariat menggunakan regresi logistik dengan mengambil skor grace (risiko sedang dan tinggi), egfr rendah (<60 ml/ mnt), lvef rendah (<40%), diabetes mellitus, usia lebih dari 45 tahun dan hipertensi sebagai faktor perancu,. hasil: 353 subjek berhasil dikumpulkan pada penelitian ini. qrs terfragmentasi ditemukan pada 60,9% subjek; lebih sering terjadi pada sadapan inferior (48,8%) dengan awitan rata-rata 34 jam. kejadian kardiovaskular mayor (kkm) lebih tinggi pada kelompok fqrs vs non-fqrs (15,8% vs 5,8%). analisis bivariat menunjukkan probabilitas 30 hari kkm yang lebih tinggi dalam kelompok fqrs (rr 2,72; 95% ci 1,3 -5,71p = 0,08). analisis multivariat menunjukkan rr 2,79 (ci 95%: 1,29 4,43, p <0,05). egfr yang rendah adalah perancu potensial dalam penelitian ini. kesimpulan: fqrs persisten yang terjadi pada acs selama rawat inap adalah prediktor independen untuk kematian 30 hari pasca kejadian kardiovaskular mayor. kata kunci: sindrom koroner akut, qrs terfragmentasi (fqrs), kejadian kardiovaskular mayor (kkm). abstract background: some studies show fragmanted qrs (fqrs) as a marker of myocardial scar, ventricular arrhythmia, ventricular remodelling and worse coronary collaterals flow, which can increase the incidence of major adverse cardiac event (mace) after infarction. this study aimed to identify the role of fqrs as one of the risk factors for mace (cardiac death and reinfarction) in acute coronary syndrome patients within 30 days anastasia a. dinakrisma acta med indones-indones j intern med 4 introduction acute coronary syndrome (acs) is the highest cause of death in the world from 2000 to 2015, with total death count of 5-11% during treatment. the rate doubles in a year.1-5 das et al6 studied the presence of fragmented qrs (fqrs) waves on an electrocardiogram, which depicted ventricular conduction changes around the scarring myocardium in acs patients. some studies showed fqrs as a marker of myocardial scar, ventricular arrhythmia substrate, ventricular remodelling and worse coronary collaterals flow, so that it can increase the incidence of major adverse cardiac event (mace) after infarction.6-12 in contrast, a study by wang et al.13 failed to show that fqrs was superior than q wave as a predictor of myocardial scar (1.7% vs. 31.7% sensitivity). lorgis et al.14 in 2013 showed that fqrs was not a predictor for mace (reinfarction, heart failure and death) in 2 years observation. acute coronary syndrome patients in developing countries have different characteristics compared to those in developed countries. in developing countries, patients tend to have late presentation of infarct symptoms, delayed treatment and limited access to cardiac health center.15 this study is the first in indonesia, as a developing country, to predict the role of fqrs as one of the risk factors for mace (cardiac death and reinfarction) in acs patients within 30 days observation. observation. methods: a cohort retrospective study was conducted using secondary data of acute coronary syndrome patients at intensive cardiac care unit cipto mangunkusumo hospital from july 2015 to october 2017. multivariate analysis were done by using logistic regression with grace score (moderate and high risk), low egfr (< 60 ml/min), low lvef (< 40%), diabetes mellitus, age more than 45 years and hypertension as confounding factors. results: three hundred and fifty three (353) subjects were included. fragmented qrs was found in 60,9 % subjects. it was more frequent in inferior leads (48.8% ) with mean onset of 34 hours. major adverse cardiac events were higher in fqrs vs. non-fqrs group (15.8% vs. 5.8 %). bivariate analysis showed higher probability of 30 days mace in fqrs group (rr 2.72; 95%ci 1.3 -5.71p=0.08). multivariate analysis revealed adjusted rr of 2.79 (95% ci: 1.29 – 4.43, p<0.05). low egfr was a potential confounder in this study. conclusion: persistent fqrs developed in acs during hospitalization is an independent predictor of 30 days mace cardiac death and re-infarction. keywords: acute coronary syndrome, fragmanted qrs (fqrs), major adverse cardiac event (mace). methods this was a retrospective cohort study, which included all acs patients at the intensive cardiology care unit (iccu) ciptomangunkusumo hospital, within the period of july 2015 to october 2017. electrocardiograms were recorded using bionet/ cardiotouch 3000 machine, low-pass filter setting, ac 60 hz and a cut off of 150 hz was defined. das et al (2006) defined that fragmented qrs was present as an additional wave on r (r‘) or notch on r or s waves nadir, or the existence of more than one r’ on 2 successive leads, which related to the territory of the main coronary artery on a 12-lead ecg, with a duration of less than 120 ms.6 (figure 1). electrocardiograms were recorded in serial during hospitalization at emergency department and iccu. fragmented qrs criteria were fqrs pattern, with a qrs width of less than 120 msec and persistent during hospitalization. acute coronary syndrome and reinfaction criteria were set according to the third universal definition of myocardial infarction by the american heart association (aha) in 2012.16 cardiac deaths were all deaths caused by myocardial infarction, sudden cardiac death/ lethal arrythmia, and acute lung oedema, which was assessed by a cardiology consultant. inclusion criteria of this study were all iccu patients with new or recurrent acs (stemi, ntemi and unstable angina pectoris) of more than 30 days of last incident. acute coronary vol 51 • number 1 • january 2019 the role of fqrs as a predictor of mace within 30 days in acs patients 5 syndrome patients with wide qrs (qrs duration >120 ms), which was present as a prior history of arrhythmia, congenital heart disease , severe valvular heart disease and patients using pacemaker and those with incomplete data of medical record and ecg data (also known as complete missing data) were excluded from this study. all subjects were followed for 30 days for the incidence of cardiac death and or re-infarction that need hospitalization. confounding factors were age of more than 45 years, hypertension, diabetes mellitus, history of coronary heart disease, left ventricle ejection fraction less than 40%, egfr less than 60 ml/min and moderate to high risk for grace score. electrocardiogram interpretation was confirmed among two observers, the main researcher and one independent cardiologist by determining kappa value (a kappa value between 2 observers of 0.72 was considered good). if there were disagreement between 2 observers, a third independent cardiologist observer would confirm the result. this study has been approved by the ethics committee of faculty of medicine, universitas indonesia. sample size was calculated using the twoindependent proportions test formula for cohort study and we obtained a minimum sample size of 336 subjects. bivariate analysis was performed using the 2 x 2 table to determine relative risk (rr) probability on the occurrence of mace within 30 days between fragmented qrs vs. non-fragmented groups. qrs groups and chi square test were used to determine p value by using spss statistics version 23.0. multivariate analysis with logistic regression were done, including grace score (moderate and high risk), low egfr (<60 ml/min), low lvef (<40%), diabetes mellitus, age more than 45 years and hypertension as confounding factors. results out of 392 registered subjects with acs, 33 subjects were excluded because 11 subjects had complete bundle branch block, 14 subjects had rhythm abnormalities (11 with atrial fibrillation and 4 with total av block), 5 subjects had no ecg data and 3 subjects had unreadable ecg. total sampling was performed using consecutive technique, w hich had been done by taking all data of 359 subjects. of 359 subjects, 6 subjects were excluded because of loss to follow up. at the end of the study, 353 subjects were eligible for final analysis. there was no significant different proportion between fqrs and non-fqrs groups based on baseline characteristics (table 1). fragmented qrs were found in 60.9% (215 subjects) with major locations of fqrs area at inferior (48.8%) and anterior (20.0%) and the mean onset of 34 hours (sd 39.8 hours). the proportion of cardiac death and reinfarction were 11.9% with figure 1. six type of fragmented qrs (fqrs) pattern6 anastasia a. dinakrisma acta med indones-indones j intern med 6 table 1. baseline characteristics of patients by the presence of fqrs waves variables total (n,%)(n = 353) fqrs group (n,%) (n = 215 (60.9%)) non-fqrs group (n,%) (n = 138 (39.1%)) sex male 240 (68) 145 (67.4) 95 (68.8) female 113 (32) 70 (32.6) 43 (31.2) age (year), mean (sd) 56.96 (11.21) 56.5(10.57) age < 45 y.o 45 (12.7) 28 (13) 17 (12.3) 45-60 y.o 183 (51.8) 106 (49.3) 77 (55.8) >60 y.o 125(35.5) 81 (37.7) 44 (31.9) risk factors diabetes mellitus 148 (41.9) 90 (41.9) 58 (42) hypertension 232 (65.7) 147 (68.4) 85 (61.6) dyslipidemia 237 (67.1) 147 (68.4) 90 (65.2) smoking 150 (42.5) 90(41.9) 60 (43.5) history of prior coronary artery disease 139 (39.4) 79 (36.7) 60 (43.5) acs onset (hour), median (range) 8 (0.3 336) 8 (0.5 504 ) type of acs uap 88 (25) 56 (26) 32 (23.2) nstemi 129 (36.5) 72(33.5) 57 (41.3) stemi 136(38.5) 87 (40.5) 49 (35.5) infarct location anterior 134 (38) 87 (40.5) 47 (34.1) inferior 89 (25.2) 50 (23.3) 39 (28.3) lateral 64 (18.1) 37 (17.2) 27 (19.6) others 66 (18.7) 41 (19) 25 (18) infarct area large infarction 125 (35.4) 87(40.5) 47 (34.1) small infarction 228 (64.6) 128 (59.5) 91 (65.9) grace score category mild 230 (65.2) 136 (63.3) 94 (68.1) moderate 78 (22.1) 50 (23.3) 28 (20.3) high 45 (12.7) 29 (13.4) 16 (11.6) ef (%), median (range)b 49 (16 -81) 49 (15 76) lvef categoryb lvef < 40% 92 (27.1) 55 (26.8) 37 (27.6) lvef ≥ 40% 247 (72.9) 150 (73.2) 97 (72.4) egfr, median (range, ml/minute/m2) 80 (4.1 -131) 70.3 (2.9 124) egfr category egfr < 60 115 (32.6) 62 (28.8) 53 (38.4) egfr ≥ 60 238 (67.4) 153 (71.2) 85 (61.6) heart rate, median ( range) 75 (45-130) 75 (42. 120) pq time, median (range), msec 200 (120-280) 200 (120-240) qrs interval, median (range), msec 60 (40-100) 60 (40-100) qtc, median (range), msec 400 (260-520) 360 (280-550) a dyslipidemia: completely missing data 1.9% (n=7); b lvef: completely missing data 3.6 % (n=14) egfr: estimated glomerular filtration rate, grace: global registry of acute coronary events, lvef: left ventricle ejection fraction, msec: millisecond, nstemi: non st elevation myocardial infarction, sd: standard deviation, acs: acute coronary syndrome stemi: st elevation myocardial infarction, uap: unstable angina pectoris, qtc: qt corrected, y.o: year old. vol 51 • number 1 • january 2019 the role of fqrs as a predictor of mace within 30 days in acs patients 7 proportion of cardiac death of 7.9% (28 subjects) and reinfarction was 4.0% (14 subjects). the proportion of mace in fqrs group was 15.8%; while the proportion in the group without fqrs was 5.8%. in bivariate analysis, fqrs increased probability of mace during 30 days in acs patients with crude relative risk (rr) of 2.72 (95% ci: 1.3-5.71. p=0.008). (table 2) multivariate analysis were done by using logistic regression with grace score (moderate and high risk), low egfr (<60 ml/min), low lvef (<40%), diabetes mellitus, age more than 45 years and hypertension as confounding factors (p<0.25. table 3). our study revealed that the adjusted rr was 2.79 (95% ci: 1.29 – 4.43, p<0.05). low egfr was a potential confounder in this study. (table 4) discussion the present study showed that the proportion of mace in fqrs vs. no fqrs groups was 15.8% and 5.8%. bivariate analysis showed an increased probability of mace within 30 days table 2. bivariate analysis of fqrs and mace (cardiac death and reinfarction) variables mace total (n) rr (95% ci) p value fqrs yes no yes 34 (15.8%) 181 (84.2%) 215 (100%) 2.72 (1.3 -5.71) 0.008 no 8 (5.8%) 130 (94.2%) 138 (100%) total 42 311 353 mace: major adverse cardiac event; rr: relative risk; p: probability table 3. bivariate analysis between confounding factors and 30 day mace variable rr (95% ci) p value age (≥ 45 yo) 2.92 (0.73-11.67) 0.159 hypertension 1.66 (0.85-3.27) 0. 177 diabetes mellitus 1.67 (0.94-2.96) 0.103 dyslipidemia 0.92 (0.505-1.67) 0.924 history of coronary disease 1.15 (0.65-2.04) 0.746 lvef (< 40% ) 2.07 (1.15-3.72) 0.033 egfr (< 60) 2.38 (1.36-4.15) 0.003 type of infarction (stemi) 0.71 (0.38-1.32) 0.365 grace score category moderate-high 5.27 (2.74-10.11) 0.001 in fqrs group with crude relative risk (rr) of 2.72 (95% ci 1.3-5.71. p=0.008). of the 42 mace occurred within 30 days, there were 28 (7.9%) with cardiac death and 14 (4.0%) with reinfraction. the causes of death were sudden cardiac death (53.6%), cardiogenic shock (17.9%) and lethal arrhythmia (14.3%). yudhatama et al10 showed an increased risk of table 4. crude or and adjusted or and adjusted rr for fqrs and 30-day mace with 6 confounding factors fqrs variables or (95% ci) p value effect of confounding factors with adjusted or crude rr 2.72 (1.3-5.71) 0.008 crude or 2.8 (1.24-6.31) 0.013 adjusted or + grace score 2.727 (1.18-6.28) 0.019 2.8% + egfr 3.115 (1.32-7.32) 0.009 12.4% + lvef < 40% 3.25 (1.377.69) 0.007 4.1% + dm 3.25 (1.36-7.71) 0.008 0 + age > 45 y.o 3.252 (1.37-7.72) 0.008 6.1% + hypertension * 3.136 (1.31-7.46) 0.010 3.6% adjusted relative riska 2.79 (1.29-4.43) <0.05 * fully adjusted or a adjusted relative risk with zhang et al. 1998 conversion formula anastasia a. dinakrisma acta med indones-indones j intern med 8 ventricular arrhythmia (ventricular fibrillation. ventricular tachycardia and premature ventricle contraction) in fqrs group with adjusted hr of 2.8 (95% ci: 2.2 5.4, p<0.001). survival rate during treatment was worse in fqrs group compared to non-fqrs group (126 hours vs. 170 hours, logrank p<0.001). das. et al.6 and kadi et al.17 identified fqrs as a conduction disturbance marker, which was recorded in late potential on signal averaged electrocardiogram (saecg) from the fibrotic myocardial zone of infarction. late potential is generated from prolonged refractory period and repeated excitation from infarct area due to slow and inhomogenous conduction. this repeated excitation process is called re-entry mechanism, which increases the risk for having ventricular arrhythmias and sudden cardiac death in acs patient.18 a study by sheng et al.7 in stemi patients showed that there was an increased risk of arrhythmia maligna 4 times higher and left ventricle systolic dysfunction (lvsd) 7.5 times higher in fqrs group than non fqrs group. a retrospective cohort study by kadi et al.8 indicated fqrs as a predictor of poor formation of collateral coronary artery flow in patients with chronic total coronary without prior myocardial infarction (or 8.4 .95% ci 1.97-35.7. p=0.004). this may cause the infarction area prone to occlusion and having recurrent myocardial ischemia. multivariate analysis with logistic regression were done, including grace score (moderate and high risk), low egfr (<60 ml/min), low lvef (<40%), diabetes mellitus, age more than 45 years and hypertension as confounding factors. our study revealed an adjusted rr of 2.79 (95% ci: 1.29 – 4.43; p<0.05). low egfr was a potential confounder in this study. in subjects with egfr lower than 60 ml/min, we found that atherosclerosis and cardiac remodelling were accelerated, which might be due to the activation of the renin-angiotensinaldosteron system and sympathetic nerve system, increased inflammatory process and impaired balance between nitric oxide (no) and reactive oxygen species (ros).5 the clinical implication of fqrs as an important myocardial scar marker is correlated with re-entry substrate of arrhythmia, poor collateral coronary artery flow and myocardial remodeling, which can increase the risk of 30-day mace. administration of either antiremodelling or antiarrhytmic therapy for acs patient with persistent fqrs should be considered.19 yet. further studies on the efficacy of these agents are necessary. this study is the first in indonesia that evaluates the role of fqrs as a predictor of 30-day mace in acs patients. this study has limitation as it is a single-centered study at a tertiary referral hospital. conclusion fragmented qrs increases the probability of mace (cardiac death and reinfarction) in 30 days in acs patients with an adjusted relative risk of 2.79 (95%ci: 1.294 4.43). conflict of interest the authors declare that there is no conflict of interest regarding the publication of this paper. references 1. gaziano ta, prabhakaran d, gaziano m. global burden of cardiovascular disease. 10th ed. in: mann d. zipes d. libbby p. bonow r. braunwald e, eds. phildapelphia: elsevier saunders; 2015. p. 1-10. 2. chan my, du x, eccleston d, et al. acute coronary syndrome in the asia-pacific region. int j cardiol. 2016;202:861–9. 3. armen, prasetya i. validasi skor global registry of acute coronary event (grace) dalam memprediksi mortalitas selama perawatan pada pasien sindrom k o r o n e r a k u t d i i c c u r u m a h s a k i t c i p t o mangunkusumo. tesis. universitas indonesia. 2012. 4. badan penelitian dan pengembangan kesehatan kementerian kesehatan ri. riset kesehatan dasar. minist heal repub indones. 2013;(1):1–303. 5. dewiasty e. alwi i. estimasi laju filtrasi glomerulus sebagai prediktor mortalitas pada pasien sindrom koroner akut selama perawatan di iccu rscm. tesis. universitas indonesia: 2008. 6. das mk, suradi h, maskoun w, et al. fragmented wide qrs on a 12-lead ecg: a sign of myocardial scar and poor prognosis. circ arrhythm electrophysiol. 2008;1(4):258–68. 7. sheng q-h, hsu c, li j, hong t, huo y. correlation between fragmented qrs and the short-term prognosis of patients with acute myocardial infarction. j zhejiang univ sci b. 2014;15(1):67–74. vol 51 • number 1 • january 2019 the role of fqrs as a predictor of mace within 30 days in acs patients 9 8. kadı h, ceyhan k, koç f, celik a, onalan o. relation between fragmented qrs and collateral circulation in patients with chronic total occlusion without prior myocardial infarction. anadolu kardiyol derg. 2011;11(4):300–4. 9. güngör b, özcan ks, karataş mb, et al. prognostic value of qrs fragmentation in patients with acute myocardial infarction: a meta-analysis. ann noninvasive electrocardiol. 2016;21(6):604–12. 10. yudhatama d, makmun l, antono d. peranan fragmented qrs sebagai prediktor aritmia ventrikel pada pasien infark miokardium akut. universitas indonesia. tesis: 2011. 11. rhee j, sabatine m, llily l. acute coronary syndromes. in: lili l, editor. pathophysiology of heart disease: a collaborative project of medical student and faculty. 5th ed. philadelphia: lippincot williams & wilkins; 2011. p. 161–89. 12. seghieri c. mimmi s. lenzi j. fantini mp. 30-day inhospital mortality after acute myocardial infarction in tuscany (italy): an observational study using hospital discharge data. bmc med res methodol. 2012;12(1):170. 13. wang dd, buerkel dm, corbett jr. fragmented qrs complex has poor sensitivity in detecting myocardial scar. ann non-invasive. electrocardiol. 2010;15:308– 14. 14. lorgis l, jourda f, hachet o, et al. prognostic value of fragmented qrs on a 12-lead ecg in patients with acute myocardial infarction. heart lung. 2013;42(5):326–31. 15. medagama a, bandara r, silva c, de galgomuwa mp. management of acute coronary syndromes in a developing country ; time for a paradigm shift ? an observational study. bmc cardiovasc disord. 2015;1–8. 16. thygesen k, alpert js, jaffe as, et al. third universal definition of myocardial infarction. eur heart j. 2012;33(20):2551–67. 17. kadi h, kevser a, ozturk a, koc f, ceyhan k. fragmented qrs complexes are associated with increased left ventricular mass in patients with essential hypertension. ann noninvasive electrocardiol. 2013;18(6):547–54. 18. bhukkar m, makmun l, widodo d. late potential sebagai prediktor aritmia pasca infark miokard akut dengan menggunakan signal averaged ecg. tesis. universitas indonesia: 2005. 19. smith sc, benjamin ej, bonow ro, et al. aha/ accf secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the american heart association and american college of cardiology foundation. circulation. 2011;124(22):2458–73. 215 original article acta med indones indones j intern med • vol 49 • number 3 • july 2017 factors related with handgrip strength in elderly patients nur riviati1, siti setiati2, purwita w. laksmi2, murdani abdullah2 1 geriatric subspesialist fellow, faculty of medicine universitas indonesia, jakarta, indonesia. 2 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: prof. siti setiati, md., phd. division of geriatrics, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: s_setiati@yahoo.com. abstrak latar belakang: proses penuaan menyebabkan penurunan fungsi pada berbagai organ. otot rangka merupakan salah satu organ yang dipengaruhi oleh proses penuaan. hal ini dikenal sebagai sarkopenia. sarkopenia didefinisikan sebagai suatu sindroma yang ditandai oleh hilangnya massa dan kekuatan otot secara progresif. pemeriksaan kekuatan genggaman tangan seringkali diterapkan sebagai teknik penapisan sarkopenia. penelitian ini bertujuan untuk menentukan hubungan usia, status gizi dan penyakit kronik seperti stroke, hipertensi (ht), diabetes melitus (dm), penyakit jantung koroner (pjk) dan penyakit paru obstruktif kronik (ppok) dengan kekuatan genggaman. metode: ini adalah studi potong lintang untuk menentukan faktorfaktor yang berhubungan dengan kekuatan genggaman tangan pada pasien usia lanjut. penelitian dilaksanakan di poliklinik geriatri, rumah sakit cipto mangunkusumo dan rumah sakit mohammad hoesin sejak agustus hingga oktober 2015. terdapat 352 subjek yang memenuhi kriteria penelitian ini dan direkrut dengan teknik pengambilan sampel secara berurutan (consecutive sampling). variabel-variabel independen penelitian ini terdiri atas usia, jenis kelamin, status gizi, penyakit kronik (stroke, hipertensi (ht), diabetes melitus (dm), penyakit jantung koroner (pjk) dan penyakit paru obstruktif kronik (ppok) dan lingkar pinggang; sedangkan variabel dependen adalah kekuatan genggaman tangan. hasil: usia >75 tahun dan malnutrisi merupakan faktor risiko yang mempengaruhi lemahnya kekuatan genggaman tangan. usia >75 tahun akan meningkatkan risiko rendahnya kekuatan genggaman tangan sebanyak 2-3 kali lipat. malnutrisi meningkatkan risiko rendahnya kekuatan genggaman tangan sebanyak 1,9 kali. kesimpulan: usia >75 tahun dan malnutrisi akan meningkatkan faktor-faktor risiko menurunnya kekuatan genggaman tangan pada pasien usia lanjut. kata kunci: kekuatan gengaman tangan, usia lanjut, faktor. abstract background: the aging process causes decreasing in the function of various organs. skletal muscle is one of the organs affected by aging process. it is known as sarcopenia. sarcopenia is defined as a syndrome characterized by progressive loss of muscle mass and strength. the handgrip strength examination is often applied as a sarcopenia filtering technique. this study aimed to determine the relationship between age, nutritional status, and chronic diseases such as stroke, hypertension (ht), diabetes mellitus (dm), coronary heart disease (chd), and chronic obstructive pulmonary disease (copd) with handgrip strength. methods: a cross-sectional study to determine factors related to the handgrip strength in elderly patients was conducted in geriatric outpatient clinic of cipto mangunkusumo hospital and mohammad hoesin hospital from august to october 2015. there were 352 eligible subjects in this study recruited with consecutive sampling. the independent variables in the study consisted of age, sex, nutritional status, chronic disease (stroke, hypertension (ht), diabetes mellitus (dm), coronary heart disease (chd) and chronic obstructive pulmonary disease (copd)), waist circumference while nur riviati acta med indones-indones j intern med 216 introduction the elderly population in the world is predicted increase by three-fold within 50 years, from 600 million people in 2000 to over two billion in 2050. the number of elderly population in indonesia is ranked the top five in the world, reaching 18.1 million in 2010 and is estimated increase by two-fold to 36 million in 2025. life expectancy of the population indonesia (both male and female) reached 67.8 years in 20002005 and is predicted increase to 73.6 years in 2020-2025.1,2 the increasing elderly population is accompanied by increasing health problems as one of the effects of the aging process. the aging process is associated with decreasing function of various organs. skletal muscle is one of the organs affected by aging, which is well known as sarcopenia. sarcopenia is a syndrome characterized by progressive loss of muscle mass and strength.3-5 the prevalence of sarcopenia in the age of 60 to 70 years old was reported from 5% to 13% while in those aged >80 years is 11% to 50%. for the time being, the total number of sarcopenia cases is estimated to have reached at least 50 million cases, and in the period of 40 years the number can soar up to 200 million.6 a loss in muscle mass and strength would affect physical performance, functional status, mobility, the occurrence of impairment as well as increase the risk of death. decreasing muscle strength occurs more rapidly than that of the muscle mass. the loss of muscle strength can not be prevented by maintaining or increasing muscle mass.7,8 muscle strength can be measured on the upper and lower extremities with a dynamometer. there is a correlation between hand grip strength and muscle strength in other body parts. the handgrip strength examination is often applied as a sarcopenia filtering technique in clinical setting such measurement is considered inexpensive, simple, easy, and can be done with portable measuring tool. hand grip examinations conducted with jamar dynamometers warrant a higher accuracy rate and greater force than any other measuring tools, hence jamar dynamometers are more commonly used.9 putrawan10 found a positive relation between waist circumference and hand grip strength. meanwhile, keevil et al.11 demonstrated a negative relationship between waist circumference and handgrip strength as well as the relationship between body mass index (bmi) and waist circumference. however, controversies are still rife when it comes to the relation between bmi and hand grip strength as described by silva et al.,12 while westrop et al.13 found the relationship between bmi and grip strength was to be weak. on the other hand, a contrasting result reported by kamarul14 showed that the hand grip strength was not related with bmi. the bmi assessment is a crucial part of mini nutritional assessment (mna) examination. mna is an effective instrument to assess the nutritional status of elderly. moreover, a study by rantanen15 showed that there was a relation between hand grip strength and chronic diseases such as stroke, hypertension (ht), diabetes mellitus (dm), coronary heart disease (chd), and chronic obstructive pulmonary disease (copd). this study aimed to determine the relationship between age, nutritional status, and chronic diseases such as stroke, hypertension (ht), diabetes mellitus (dm), coronary heart disease (chd), and chronic obstructive pulmonary disease (copd) with handgrip strength. methods this was a cross-sectional study to determine factors related to handgrip strength in elderly patients, conducted in geriatric outpatient clinic of cipto mangunkusumo hospital and the dependent variable was handgrip strength. results: age of more than 75 years old and malnutriton were risk factors that affected hangrip strength. age of >75 years increase the risk for having low handgrip strength by 2,3-fold. malnutrition increased risk for low handgrip strength for 1,9-fold. conclusion: ages of >75 years old and malnutrition will increase the risk of low handgrip strength in elderly patients. keywords: handgrip strength, elderly, factor. vol 49 • number 3 • july 2017 factors related with handgrip strength in elderly patients 217 mohammad hoesin hospital from august to october 2015. the inclusion criteria were patients aged above 60 years old with comorbidity of chronic diseases. exclusion criteria were cognitive deficits (abbreviated mental test of <8), depression (geriatric depression scales of >10), and acute condition of diseases. there were 352 eligible subjects in this study recruited with consecutive sampling. the independent variables in the study consisted of age, sex, nutritional status, chronic disease (stroke, hypertension (ht), diabetes mellitus (dm), coronary heart disease (chd) and chronic obstructive pulmonary disease (copd)), waist circumference while the dependent variable was handgrip strength. the collected data was processed with spss 20 for windows. descriptive data was presented in the forms of text, tables, and images as appropriate. the bivariate analysis for categorical variables was done with chi-square analysis. the prevalence rate was displayed in the form of proportion (percentage) with its 95% of confidence intervals. variables with p<0.25 in the bivariate analysis would be incorporated into the multivariate analysis. the multivariate analysis was performed with cochran mantel haenzel analysis. numerical data was analyzed with t-test. this study had been approved by the ethical committee of faculty of medicine universitas indonesia/cipto mangunkusumo hospital on july 6th, 2015 (573/un2.f1/etik/2015). results there were 352 eligible subjects in this study and the percentage of every variables is presented on table 1. table 2 shows factors related to handgrip strength in elderly patients. age of >75 years old and malnutriton were the risk factors that were found to affect hangrip strength. age of >75 years increased risk for low handgrip strength by 2.3-fold, while malnutrition increased the risk for low handgrip strength by 1.9-fold. discussion this study has obtained the relationship between age and the decrease of handgrip strength (pr 1.7; 95% ci 1.4 to 2.2). the results of this study was consistent with that of forrest et al.16 and budziareck17 which showed that decreasing muscle strength began to occur at the age of 50 years old. decreasing handgrip strength in the elderly is associated with their fiber-type transformation, shifts in muscle fiber architecture and the process of excitation-contraction (ec) coupling, genetic factors, and oxidative stress (such as the increase in il-6 and proapoptotic cytokines tnf-α).18 however, the decreasing muscle fiber tye ii which plays an important role in anaerobic metabolism (i.e. glycolysis is high) is believed to be the main mechanism that initiates the declining muscle strength.19 the assessment of nutritional status with mna in the study had showed a significant association with handgrip strength (p<0.001). the result was in line with the study by karbarugi et al.20 which showed the correlation between mna score and handgrip strength( (r=0.47), p<0.001). despite many of the instruments utilized to assess the nutritional status such as bmi (body mass index), subjective global assessment, and the patient generated-subjective global assessment (pg-sga); mna remains to be a reliable instrument. decreasing muscle table 1. baseline characteristics (n=352) variables values sex, n (%) woman 212 (60.2) men 140 (39.8) age (years), mean (sd) 69.7 (6.3) age group, n (%) ≤ 75 267 (75.9) > 75 85 (24.1) waist circumfrence (cm), mean (sd) 90.6 (10.7) nutritional status, n (%) normal 304 (86.4) malnutrition 48 (14.6) comorbidity, n (%) hypertension 277 (78.7) diabetes mellitus 156 (44.3) coronary heart disease 84 (23.9) stroke 30 (8.5) copd 15 (4.3) handgrip strength (kg), mean (sd) woman 19.8 (5.1) men 29.1 (6.9) nur riviati acta med indones-indones j intern med 218 strength in malnourished condition is due to decreasing muscle protein supply which is a useful alternative energy source.21 the aging process is associated with changes in quantitative and qualitative motor cortex and bone marrow. the aging process is caused by reduced neurotrophic factors such as serotonergic, cholinergic, adrenergic, dopaminergic, γ-aminobutyric acidergic and glutamatergic system. the change will cause a state of hypoexcitability in the cortex, reduced ability to braid the motor coordination, and reduction in cortical plasticity. it will affect the motor performance, especially in skeletal muscle strength.22 denervation of type ii fibers and the formation of collateral reinnervation to the motor unit type i (slow type) occurs in elderly patients. some studies showed 57% decrease in muscle fiber tye ii and 25% decrease in muscle fiber type i 22. myofibrils tye ii plays a pivotal role in type 2 anaerobic metabolism (i.e. glycolysis is high) for high voltage and short duration. myofibrils tye i plays a role in aerobic metabolism (i.e. higher oxidation). conclusion age of >75 years old and malnutrition will increase the risk of handgrip strength in elderly patients. references 1. setiati s. geriatric medicine, sarkopenia, frailty, dan kualitas hidup pasien usia lanjut tantangan masa depan pendidikan, penelitian dan pelayanan kedokteran di indonesia. (pidato pengukuhan guru besar). jakarta: fakultas kedokteran universitas indonesia; 2013. 2. world population ageing 2013. department of economic and social affairs. united nations new york, 2013.[ diunduh 29 agustus 2014]. diunduh dari:http://esa.un.org/wpp/sources/country.aspx and htpp : // esa.un.org /unpp/ index.asp? panel=4. table 2. factors related handgrip strength variables handgrip strength, n (%) prevalence ratio (ci 95%) adjusted prevalence ratio (ci 95%) p low normal aged (years) > 75 48 (56.5) 37 (43.5) 1.7 (1.4-2.2)* 2.3 (1.7-2.9)# 0.001 ≤ 75 67 (25.1) 200 (74.9) waist circumfrence (cm), mean (sd) 90,8 (11.3) 90,5 (10.4) 0.8** nutritional status malnutrition 27 (56.2) 21 (43.8) 1.6 (1.2-2.3)* 1.9 (1.4-2.6)# <0.001 normal 88 (28.9) 216 (71.1) hypertension yes 90 (32.5) 187 (67.5) 0.9 (0.6-1.7)* 0.6 no 25 (33.3) 50 (66.7) diabetes mellitus yes 53 (34.0) 103 (66.0) 1.0 (0.9-1.2)* 0.6 no 62 (31.6) 134 (68.4) coronary heart disease yes 22 (26.2) 62 (73.8) 0.9 (0.8-1.0)* 0.1 no 93 (34.7) 175 (65.3) stroke yes 11 (36.7) 19 (63.3) 1.08 (0.7-1.7)* 0.748 no 104 (32.3) 218 (67.7) copd yes 5 (33.3) 10 (66.7) 1.0 (0.7-1.5)* 0.9 no 110 (32.6) 227 (67.4) *chi square test, # cochran mantel haenzel, **t test vol 49 • number 3 • july 2017 factors related with handgrip strength in elderly patients 219 3. ryall.jg, schertzer j.d, lynch gs. cellular and molecular mechanism underlying age-related skletal muscle wasting and weakness. biogerontol. 2008;9:213-28. 4. gale cr, martyn cn,cooper c,sayer aa. grip strength, body composition,and mortality. int j epidemiol. 2007;36:228-35. 5. nair ks.aging muscle. am j clin nutr. 2005;81: 95363. 6. cruz–jentoff aj, baeyens jp, bauer jm, et al. sarcopenia: european consensus on definition and diagnosis. report of the european working group on sarcopenia in older people. age ageing. 2010;39: 412-23. 7. clark cb, manini mt. what is dynapenia? nutrition. 2012;28:495-503. 8. delmonico mj, harris tb, visser m, et al. longitudinal study of muscle strength, quality, and adipose tissue infiltration. am j clin nutr. 2009;90:1579-85. 9. amaral jf, mancini m, junior jmn. comparison of three hand dynamometers in relation to the accuracy and precision of the measurement. rev bras fisioter. 2012;16(3):216-24. 10. putrawan p, kuswardhani t. faktor-faktor yang menentukan kekuatan genggaman tangan pada pasien lanjut usia di panti wreda tangtu dan poliklinik geriatri rsup sanglah-denpasar [tesis]. denpasar: universitas udayana; 2008. 11. keevil vl, luben r, dalzell n, et al. cross sectional associations between different measures of obesity and muscle strength in men and women in a british cohort study. j nutr health aging. 2015;19:3-11. 12. silva na, mezanes tn, melo rlp, pedraza df. handgrip strength and flexibility and their association with anthropometric variables in elderly. rev assoc med bras. 2013;59(2):128-35. 13. westropp nmm, gill tk, taylor aw, bohannon rw, hill cl. handgrip strength :age and gender stratified normative data in a population-based study. bmc res. 2011;4(127):2-5. 14. kamarul t, ahmad ts, loh wyc. handgrip strength in the adult malaysian population. j orthop surg. 2006;14(2):122-7. 15. rantanen t, masaki k, foley d, izmirlian g, white l, guralnik jm. grip strength changes over 27 yr in japaneseamerican men. cited from http://www. jap.org. 16. forest, mitchell kw, williams j, atherton p, larvin m, lund j, narici m. sarcopenia, dynapenia and the impact of advancing age on human skeletal muscle size and strength;a quantitative review. frontiers physiol. 2012;3:1-18. 17. budziarcek, manini tm, clark cb. dynapenia and ageing: an update. j gerontol a biol sci med sci. 2012;67a(1):28-40. 18. clark bc, manini tm. sarcopenia dyanapenia. j gerontol a biol sci med sci. 2008;63a(8):829-34. 19. schwarts sr, kohrt mw. exercise :physiological and functional effect. in: halter bj, ouslander gj, tinetti em, studenski s, high pk, asthana s, ed. hazard’s geriatric medicine & gerontology. 6th ed. new york: mc graw-hill; 2009. p. 1381-95. 20. karbarugi, garatachea n, lucia a. genes physical fitness and ageing. ageing res rev. 2013;12:90-102. 21. meng js, yu jiang l. oxidative stress, molecular inflammation and sarcopenia. int j mol sci. 2010;11:1509-26. 22. artigas sb, rolland y, zamboni m, leheudre a. how to assess functional status: a new muscle quality index. j nutr health aging. 2012;16(1):67-77. 314 original article acta med indones indones j intern med • vol 50 • number 4 • october 2018 association between a1166c polymorphism of the angiotensin ii type-1 receptor gene and type-2 diabetic nephropathy in an indonesian malay population zulkhair ali1, ida kusrini2, alwi shahab3, irsan saleh4 1 division of nephrology and hypertension, department of internal medicine, faculty of medicine universitas sriwijaya – mohammad hoesin hospital, palembang, south sumatera, indonesia 2 department of internal medicine, faculty of medicine universitas sriwijaya – mohammad hoesin hospital, palembang, south sumatera, indonesia 3 division of endocrinology and diabetes, department of internal medicine, faculty of medicine universitas sriwijaya – mohammad hoesin hospital, palembang, south sumatera, indonesia 4 department of pharmacology, faculty of medicine, universitas sriwijaya, palembang, south sumatera, indonesia corresponding author: zulkhair ali, md., phd. division of nephrology and hypertension, department of internal medicine, faculty of medicine universitas sriwijaya mohammad hoesin hospital. jalan jenderal sudirman km. 3.5, palembang 30121. email: riset.drzulkhair@gmail.com. abstrak latar belakang: nefropati diabetik (nd) adalah penyebab terpenting dialisis di dunia. penelitian terdahulu menunjukkan keterkaitan antara polimorfisme a1166c gen at1r dan keadaan hiperfiltrasi glomerulus pada patogenesis nd. diperlukan penelitian yang bertujuan untuk membuktikan hubungan antara polimorfisme a1166c at1r dan kerentanan individu yang menderita diabetes melitus tipe 2, khususnya pada populasi melayu, terhadap nd. metode: penelitian ini merupakan studi analitik observasional dengan desain kasus-kontrol, melibatkan 120 pasien diabetes melitus tipe 2 (dmt2), 40 pasien untuk tiap kelompok makroalbuminuria, mikroalbuminuria, dan normoalbuminuria sebagai kontrol, dengan metode consecutive sampling. adanya polimorfisme gen a1166c at1r diperiksa dengan metode pcr/rflp. hasil: alel c mutan ditemukan sebanyak 5% pada kelompok normoalbumnuria, 13.75% pada kelompok mikroalbuminuria, dan 12.5% pada kelompok makroalbuminuria. genotipe heterozigot ac ditemukan secara signifikan lebih tinggi pada kelompok mikroalbuminuria, dibandingkan dengan kelompok normoalbuminuria. genotipe ac (or 3.2 [1.01-10.08], p=0.03) dan alel c (or 2.8[0.95-8.67], p=0.038) ditemukan lebih tinggi pada kelompok nd, menandakan polimorfisme a1166c gen at1r sebagai faktor risiko nd pada pasien dmt2 ras melayu. kesimpulan: terdapat hubungan antara polimorfisme a1166c gen at1r dengan kejadian nd pada pasien dmt2 di populasi melayu indonesia. juga ditemukan bahwa polimorfisme a1166c gen at1r kemungkinan berperan dalam penurunan fungsi ginjal pada pasien dmt2 sejak tahap awal. kata kunci: angiotensin ii tipe-1 reseptor, polimorfisme, nefropati diabetik. abstract background: diabetic nephropathy (dn) is the leading cause of blood dialysis worldwide and a major etiology of end-stage renal disease cases in indonesia. previous studies showed a relevant link between a1166c polymorphism of angiotensin ii type-1 receptor (at1r) gene and glomerular hyper-filtration as a part of pathogenesis of dn. the aim of this study was to elaborate the association between a1166c at1r polymorphism and susceptibility of individual with type-2 diabetes to dn in malay indonesian population. vol 50 • number 4 • october 2018 association between a1166c polymorphism of the angiotensin ii type-1 315 methods: a case-control study of 120 consecutive patients with type-2 diabetes mellitus (40 patients in each groups for macro-albuminuria, micro-albuminuria, and normo-albuminuria) was conducted for a1166c at1r gene polymorphism. the a1166c polymorphism of the at1r gene was determined based on pcr/rflp. results: the mutant c allele was found in 5%, 13.75%, and 12.5% in normo-, micro-, and macro-albuminuria patients respectively. the heterozygote ac genotype was found significantly higher in micro-albuminuria, compared to normo-albuminuria group. heterozygote ac genotype (or 3.2 [1.01-10.08], p=0.03) and c allele (or 2.8[0.958.67], p=0.038) were significantly higher in dn, indicating a1166c at1r gene polymorphism as a risk factor for dn in malay indonesian population with type-2 diabetes. conclusion: there was positive association between a1166c at1r polymorphism and susceptibility of type-2 diabetics to dn in malay indonesian population. it also indicated that the a1166c at1r polymorphism could play a role in early pathogenesis of dn. keywords: angiotensin ii type-1 receptor, polymorphism, diabetic nephropathy. introduction diabetic nephropathy (dn) is the leading cause of end stage renal disease (esrd) and blood dialysis worldwide1. dn accounts for 22% of esrd in indonesia.2 playing a significant role for mortality in type-2 diabetes mellitus, dn affects almost 35% of patient with diabetes regardless of their glycemic control.3 despite the identification of risk factors, such as duration of diabetes, hypertension, hyperglycemia, chronic inflammation, and genetic components, no clear single etiologic entity of dn has been identified. the understanding of genetic susceptibility in dn, which has been affirmed by previous familial studies, can elucidate the pathogenesis, and lead to better treatment and prevention efforts of dn.4,5 the angiotensin ii type 1 receptor (at1r), found mostly in the kidney and vascular smooth muscle,6 may have a role in the natural history of dn. at1r is a g-protein coupled receptor,7 which angiotensin ii binds to produce proliferation, vasoconstriction, and cellular effects.8 some at1r gene polymorphism have been identified, and the a1166c polymorphisms is the most studied. the a1166c polymorphism of at1r gene due to a base replacement of cytosine for adenine at the position 1166 in the 3’untranslated region is related to the posttranslational modification of at1r mrna.9 previous studies has found that a mutant c allele was associated with an increased filtration fraction response to angiotensin ii infusion,10 thereby indicating the augmented angiotensin ii activity in the presence of c allele and thus enabling glomerular hyper-filtration, an early classical finding for micro-albuminuria stage of dn.11 several previous studies have investigated the role of at1r polymorphism in the involute etiology of dn although they showed conflicting results. those studies have signified12 or refuted13,14 the role of a1166c at1r gene variant in the natural history of type-2 dn. the inconsistent finding among studies is accredited to the genetic diversity and ethnicity background among various populations. we accordingly opted to explain for the first time the plausible association between the a1166c at1r polymorphic variants and dn in an malay indonesian diabetic population, as there is an absence of the comparable studies in an indonesian population. the aim of this study was to elaborate the association between a1166c at1r polymorphism and susceptibility of individual with type-2 diabetes to dn. in an attempt to gather better explanation about the role of the a1166c at1r polymorphism in natural history of dn, we eleborated dn into its two group stages, which were micro-albuminuria and macro-albuminuria. methods an observational analytic study with a casecontrol design was conducted at an outpatient clinic and inpatient wards in mohammad hoesin general hospital palembang, south sumatera. all consecutive patients were recruited. written informed consent were obtained from all patients. the study was approved by the local zulkhair ali acta med indones-indones j intern med 316 ethics committee from health research review committee of mohammad hoesin general hospital and faculty of medicine universitas sriwijaya on january 9th, 2012, with a reference number 004/kepkrsmhfkunsri/2011. the study population consisted of an malay indonesian population with diabetes who had resided in south sumatera for three generations. the minimum sample needed was 38 patients for each group. the inclusion criteria for case group were subjects with type-2 diabetes aged 40-65 years old, with dn, and normal renal function defined by estimated glomerular filtration rate (gfr) more than 60 ml/min/1.73m2. for the control group, the sex-and-age-matched individual with type-2 diabetes with normoalbuminuria (i.e. urinary albumin excretion below 30 µg/mg creatinine) were included. diagnosis of diabetes was made according to the american diabetes association standard medical of care which was adapted to indonesian national consensus on type-2 diabetes mellitus.15,16 the diagnosis of nephropathy was based on at least two consecutive occasions of microalbuminuria (urinary albumin excretion 30-300 µg/mg creatinine) or macro-albuminuria (urinary albumin excretion above 300 µg/mg creatinine) as a minimum criterion in non-oliguric patients with diabetic retinopathy without any other possible cause.16 in order to exclude the cause of proteinuria other than diabetes, those with evidence of previous renal disease that could be the secondary causes of albuminuria such as glomerulonephritis, nephro-ureterolithiasis, chronic infections, malignancy, and obstructive uropathy were not eligible to participate in the study. genetic analysis 2 ml of peripheral blood, were drawn by venipuncture in the upper limbs and placed into tubes containing 5% edta. genomic dna was then isolated from leukocytes and dna was extracted by standard techniques.17 a1166c polymorphism of the at1r gene were determined by polymerase chain reaction (pcr or restriction fragment length polymorphism (rflp) using modified method of previous studies.18 for the detection of a1166c polymorphism in 3’ untranslated region, the primer used were 5’gca cca tgt ttt gag gtt-3’ for sense primer and 5’cga cta ctg ctt agc ata3’ for antisense primer. the pcr product was 527 base pairs (bp) fragment. after digesting with ddei rflp enzyme for 3 hours, the pcr products was detected on 2% agarose gel electrophoresis stained with ethidium bromide (biorad, hercules, california usa). wild type allele, allele a, generated one fragment corresponding to size 527 bp. two fragments of 417 bp and 110 bp were observed as mutated allele c. the heterozygote genotype would generate three fragments of 417, 110, and 527 bp. statistical analysis values were presented as mean and standard deviations. the fisher exact test or chi square test was used for analysis of the categorical variables, and anova was used for continuous variables with normal distribution. the association between a1166c at1r gene polymorphism and dn susceptibility was assessed by calculating the odds ratios. p-values of less than 0.05 were considered to be significant. statistical analysis was performed using spss 16.0 for windows. results we generated the genotype of total 120 patients with type-2 diabetes mellitus there was 40 patients for each groups for macroalbuminuria, micro-albuminuria, and normoalbuminuria. demographic, clinical, and laboratorial characteristics of all patients are shown in table 1. there were no significant difference among groups’ demographic and clinical characteristics. the patients with dn, both micro and macro-albuminuria, had significantly lower hemoglobin level. they also tend to have significantly higher level of serum creatinine. the allele frequency and the genotype distribution of a1166c polymorphism in the groups of patient according to the clinical profile (macro-albuminuria, micro-albuminuria, and normo-albuminuria) are shown in table 2. the heterozygote genotype was found to be significantly higher in patients with microalbuminuria compared to normo-albuminuria. there was no cc genotype found. based on vol 50 • number 4 • october 2018 association between a1166c polymorphism of the angiotensin ii type-1 317 table 1. characteristics of the patients variables with dn without dn p micro-albuminuria macro-albuminuria normo-albuminuria sex, n (%) male 12 (30) 15 (37.5) 15 (37.5) 0.721 female 28 (70) 25 (62.5) 25 (62.5) diabetes duration (years), mean (sd) 5.98 (3.20) 7.98 (3.81) 6.57 (4.09) 0.052 age (years), mean (sd) 52.60 (9.19) 54.80 (5.81) 54.03 (4.89) 0.352 body mass index (kg/m2), mean (sd) 21.28 (1.43) 21.53 (2.33) 21.86 (1.65) 0.372 sbp (mmhg), mean (sd) 135.75 (11.07) 137.50 (15.48) 126.27 (24.01) 0.012* dbp (mmhg), mean (sd) 83.25 (7.64) 85.75 (9.0) 81.75 0.92 hemoglobin (g/dl), mean (sd) 12.35 (0.84) 12.54 (0.97) 12.95 (1.24) 0.032* hba1c (%), mean (sd) 8.91 (2.11) 8.76 (2.34) 7.86 (1.94) 0.062 blood urea (mg/dl), mean (sd) 31.58 (11.34) 33.20 (12.42) 28.75 (8.09) 0.182 creatinine (mg/dl), mean (sd) 0.73 (0.19) 0.92 (0.18) 0.64 (0.11) 0.002* note: sbp, systolic blood pressure; dbp, diastolic blood pressure; 1fisher exact test; 2one way anova; *p<0.05 their clinical diagnosis as shown in table 3, it was found that ac genotype (or 3.2 [1.0110.08], p=0.03) and c allele (or 2.8[0.95-8.67], p=0.038) were significantly higher in dn. discussion according to our knowledge, this study was the first to investigate at1r polymorphisms in the indonesian with type-2 diabetes, specifically in the malay ethnic group. the corroboration for the role of this gene in the pathophysiology of dn comes from studies in diabetics who had mutated c allele of a1166c at1r that asserted the infusion of angiotensin ii which leads to increased filtration fraction,10,19 an early pathogenesis hallmark of micro-albuminuria stage of dn. at1r is a g-coupled protein that is found mostly on kidney and systemic vasculature.6 it mediates the effects of angiotensin ii on vasoconstriction and cell transport of molecules. in the glomerulus of the kidney, the expression of at1r was localized mostly in the podocytes.20 an in vivo study on nephropathy-induced female brown norway mice observed an overexpression of at1r correlated to proteinuric state.21 the study also highlighted the inhibition of at1r which improved the proteinuria mainly caused by the reduction of functional protein on slit diaphragm. glomerular slit diaphragm is a membrane-like structure of glomerular basal membrane that functions as a barrier which averts table 2. allele frequency and genotype distribution of a1166c polymorphisms of at1r by clinical profile normo-albuminuria n=40 (n) micro-albuminuria n=40 (mi) macro-albuminuria n=40 (ma) p or (95% ci) genotype distribution aa 36 (90) 29 (72.5) 30 (75) 0.04* mi to n = 3.41 (1.03-11.86) ac 4 (10) 11 (27.5) 10 (25) 0.07 ma to n = 3.01 (0.85-10.54) cc 0 (0) 0 (0) 0 (0) 0.5 mi to ma = 1.13 (0.41-3.08) allelic frequency a 76 (95) 69 (86.25) 70 (87.5) 0.05 mi to n = 3.02 (0.92-9.95) c 4 (5) 11 (13.75) 10 (12.5) 0.08 ma to n = 2.7 (0.81-9.04) 0.5 mi to ma = 0.89 (0.35-2.24) note: chi square test, *p=<0.05; mi: micro-albuminuria; ma: macro-albuminuria; n: normo-albuminuria. 1odds ratio for heterozygote ac genotype/ mutant c allele between selected groups. zulkhair ali acta med indones-indones j intern med 318 plasma proteins leakage into urine.20 in patients with dn, the slit diaphragm damage is a focus of novel targeted therapy.22 previous studies found that a1166c allele frequencies varied widely, depending on ethnic heterogeneity. moradi et al13 reported the prevalence of the c allele in iranian (15.3%). our study did not find any mutant homozygote cc genotype. doria et al18 which conducted a research in usa and fradin et al12 which was conducted in caucasian french found 9% and 3% cc genotype respectively. our study found that the mutated c allele frequency was 13.1% in patients with type-2 dn, which was similar to the studies in iranian type-2 dn patients (13.2%)13 and lower than that observed in french caucasian (23.9%).12 our study showed that significant difference in genotype distribution was only found between micro-albuminuria and normo-albuminuria, and there was no significant difference in macroalbuminuria. altogether, these findings are interpreted to support the hypothesis that the a1166c polymorphisms might play a role in the early pathogenesis of dn.10,11 there was also no significant difference in allele frequency among three groups. similar findings were identified in study by chang et al14 which found no significant difference in allele frequency among normo-, micro-, and macro-albuminuria taiwan chinese type-2 dn patients. a different findings were identified, when comparing heterozygote ac genotype and c allele distribution in dn to non-dn group. heterozygote ac genotype and c allele was 3.2 times and 2.8 times in dn. these findings support the hypothesis that a1166c polymorphism was a risk factor for the susceptibility of type-2 diabetics to dn. a similar result was found in french caucasian.12 intriguingly, different results were found in two other studies in asian13,14 which identified null association between a1166c polymorphism and type-2 dn. there is a chance that the negative findings in mutant homozygote cc genotype is the caused of a selective loss in this study. further studies in larger sample size is needed. in spite of this limitation, our study was the first published attempt to elucidate the association between at1r polymorphism and dn in indonesian population which provides definitive support for the role of at1r polymorphism in type-2 dn. conclusion i n c o n c l u s i o n , a 11 6 6 c at 1 r g e n e polymorphism is a risk factor for dn among indonesian malay type-2 diabetics. our study also indicated that a1166c at1r polymorphism could play a role in early pathogenesis of dn. references 1. 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response to losartan and angiotensin ii. kidney int. 1999;56(6):2173-80. 11. paolo palatini; glomerular hyperfiltration: a marker of early renal damage in pre-diabetes and pre-hypertension. nephrol dial transplant. 2012;27(5):1708-14. 12. fradin s, goulet-salmon b, chantepie m, et al. relationship between polymorphisms in the reninangiotensin system and nephropathy in type 2 diabetic patients. j diabetes metab. 2002. 13. moradi m, rahimi z, amiri s, et al. at1r a1166c variants in patients with type 2 diabetes mellitus and diabetic nephropathy. j nephropathol. 2015;4(3):69. 14. chang hr, cheng ch, shu kh, et al. study of the polymorphism of angiotensinogen, anigiotensinconverting enzyme and angiotensin receptor in type ii diabetes with end-stage renal disease in taiwan. j chin med assoc. 2003;66(1):51-6. 15. american diabetes association. classification and diagnosis of diabetes: standards of medical care in diabetes-2018. diabetes care. 2018;41(supplement 1):s13-27. 16. soelistijo sa, novida h, rudijanto a, et al. konsensus pengelolaan dan pencegahan diabetes melitus tipe 2 di indonesia 2015. pb. perkeni. 2015. 17. miller sa, dykes dd, polesky hf. a simple salting out procedure for extracting dna from human nucleated cells. nucleic acids res. 1988;16:1215. 18. d o r i a a , o n u m a t, wa r r a m j h , k r o l e w s k i as. synergistic effect of angiotensin ii type 1 receptor genotype and poor glycaemic control on risk of nephropathy in iddm. diabetologia. 1997;40(11):1293-9. 19. duncan ja, scholey jw, miller ja. angiotensin ii type 1 receptor gene polymorphisms in humans: physiology and pathophysiology of the genotypes. curr opin nephrol hypertens. 2001;10(1):111-6. 20. siragy hm. angiotensin at1 and at2 receptors the battle for health and disease. nephrol dial transplant. 2007:22(11):3128–30. 21. suzuki k, han gd, miyauchi n, et al. angiotensin ii type 1 and type 2 receptors play opposite roles in regulating the barrier function of kidney glomerular capillary wall. am j pathol. 2007;170(6):1841-53. 22. khalilpourfarshbafi m, hajiaghaalipour f, selvarajan kk, adam a. mesenchymal stem cell-based therapies against podocyte damage in diabetic nephropathy. j tissue eng regen med. 2017;14(3):201-10. clinical practice 74 acta medica indonesiana the indonesian journal of internal medicine non-invasive ventilation in acute respiratory failure gurmeet singh, ceva w. pitoyo departement of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. correspondence mail: division of respirology and critical care, departement of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: pulmonologi89@yahoo.co.id. abstrak salah satu dasar perawatan kritis adalah memberikan dukungan pada sistem respirasi yang memburuk. terdapat 2 komponen utama dalam menangani gagal napas yaitu intervensi yang segera dan proses penyapihan. banyak penelitian bertujuan untuk menentukan metode optimal ventilasi dan proses penyapihan dengan ventilasi noninvasif sebagai alternatif ventilasi invasif, pada berbagai penyebab gagal napas akut. ventilasi noninvasif bertujuan untuk memberiikan dukungan ventilasi pada paru, tanpa intubasi trakea. ventilasi noninvasif telah menjadi alat yang penting pada penanganan gagal napas akut. ventilasi noninvasif positif telah mengalami evolusi yang luar biasa selama beberapa dekade terakhir dan diharapkan akan memegang peranan penting dalam menangani gagal napas baik akut dan juga kronis. terjadi perbaikan dalam pertukaran gas, mengembalikan otot pernapasan yang mengalami kelelahan, dan perbaikan klinis dengan mengurangi morbiditas dan mortalitas. namun demikian, kontraindikasi dan kegagalan perlu diidentifikasi secara jelas, sebab penundaan intubasi endotrakeal berkaitan dengan peningkatan morbiditas dan mortalitas. selanjutnya, meskipun pemasangan intubasi dan ventilasi mekanik merupakan hal yang umum dilakukan, komplikasi dapat disebabkan oleh proses intubasi (kerusakan jaringan lokal) dan selama ventilasi mekanik (pneumonia dan sinusitis yang berkaitan dengan ventilator) akan memperpanjang masa rawat di perawatan intensif, lama rawat di rumah sakit dan meningkatkan mortalitas pada pasien tertentu. kata kunci: ventilasi noninvasif, ventilasi mekanik, gagal napas akut. abstract one of the cornerstones of critical care medicine is support of the failing respiratory system. the 2 major components of managing respiratory failure are the acute intervention and the weaning process. many of the studies to determine the optimal methods of ventilation and weaning have focused on non-invasive positivepressure ventilation as an alternative to invasive ventilation, with various causes of acute respiratory failure. non-invasive ventilation refers to the provision of ventilatory support to the lungs, without the use of an endotracheal airway. it has emerged as an important tool in the treatment of acute respiratory failure. noninvasive positive ventilation has undergone a remarkable evolution over the past decades and is assuming an important role in the management of both acute and chronic respiratory failure. there is improvement in gas exchange, relief of respiratory muscle fatigue, and clinical outcome with reduced morbidity and mortality. nevertheless, contraindications and failures need to be identified early, as delaying endotracheal intubation is associated with increased morbidity and mortality. furthermore, although it is common practice to give intubation and mechanical ventilation, complications can result from the intubation process (damage to local tissue) and during the course of ventilation (pneumonia and sinusitis associated with ventilators), prolonging stay in intensive care, length of hospital stay and mortality in selected patients. key words: non invasive ventilation, mechanical ventilation, acute respiratory failure. vol 46 • number 1 • january 2014 non-invasive ventilation in acute respiratory failure 75 introduction one of the first descriptions of a “pulmonary plus pressure machine” in 1936 describes varying success in the treatment of cardiac asthma and bronchial asthma.1 emergency physicians are often confronted with patients with acute respiratory failure. on occasion it is necessary to select therapeutic interventions, including a method of non-invasive ventilation (niv), before a firm diagnosis is made.2 non-invasive ventilation refers to the provision of ventilatory support through the patient’s upper airway using a mask or similar device. this technique is distinguished from those which bypass the upper airway with a tracheal tube, laryngeal mask, or tracheostomy and are therefore considered invasive.3 it has the advantage that it can be applied intermittently, avoids the need for sedation, and allows the patient to eat, drink and talk. the incidence of nosocomial pneumonia during niv is lower than in intubated patients. non-invasive ventilation has the additional advantage that it can be used with success outside the intensive care unit (icu), thereby reducing the demand on icu beds.4 however, niv is not without its problems. the mask can be uncomfortable and claustrophobic for an acutely dyspnoeic patient. it can cause facial skin necrosis and, if poorly fitted, may be associated with large amounts of leakage which may compromise the efficiency of ventilation. gastric distension is also recognised. without the presence of an endotracheal/tracheostomy tube the lower airway cannot be easily accessed which makes bronchial toilet difficult. there has also been concern that niv may delay intubation leading to a worse outcome. the ability to predict those likely to fail with niv is important. patients in whom there is a high likelihood of failure would be spared the discomfort of a trial of niv and intubation would not be delayed. it would also be helpful in determining where niv should take place; a patient with a high likelihood of failing, and for whom intubation would be considered appropriate, is best managed in the icu, whereas the patient who is likely to be successfully treated with niv can be managed on the ward.4 if ward based niv is to be widely adopted into clinical practice, it would be useful to identify individuals who are likely to fail to respond to niv either before or shortly after a trial of therapy. this will allow such patients to be managed in a higher dependency area or an icu with ready access to invasive mechanical ventilation. the failure to do this may lead to a delay in intubation and an increase in mortality.5 despite overwhelming evidence to support its use, non-invasive positive pressure ventilation (nppv) is underused. residents and hospitalists need to identify nppv as a treatment option in acute respiratory failure.6 this clinical review will address the use of non-invasive ventilation in acute respiratory failure, the evidence for its use in an emergency setting, and make some recommendations concerning its optimal use. in this document niv refers to nppv, and other less commonly used techniques such as external negative pressure or rocking beds will not be discussed. respiratory failure respiratory failure is defined as a failure to maintain adequate gas exchange and is characterised by abnormalities of arterial blood gas tensions. type 1 failure is defined by a pao2 of <8 kpa (<60 mmhg) with a normal or low paco2. type 2 failure is defined by a pao2 of <8 kpa (<60 mmhg) and a paco2 of >6 kpa (>50 mmhg). respiratory failure can be acute, acuteon-chronic, or chronic. although not always clearcut, this distinction is important in deciding on the location of patient treatment and the most appropriate treatment strategy, particularly in type 2 respiratory failure:3 a). acute hypercapnic respiratory failure: the patient will have no, or minor, evidence of pre-existing respiratory disease and arterial blood gas tensions will show a high paco2, low ph, and normal bicarbonate. b). chronic hypercapnic respiratory failure: evidence of chronic respiratory disease, high paco2, normal ph, high bicarbonate. c). acuteon-chronic hypercapnic respiratory failure: an acute deterioration in an individual with significant pre-existing hypercapnic respiratory failure, high paco2, low ph, high bicarbonate. acute respiratory failure can result from a variety of etiologies. it can result from primary gurmeet singh acta med indones-indones j intern med 76 pulmonary pathologies or can be initiated by extra-pulmonary pathology with high mortality rate. causes are often multifactorial. acute respiratory failure can be caused by abnormalities in:6 a). central nervous system (drugs, metabolic encephalopathy, cns infections, increased cranial pressure, obstructive sleep apnea, central alveolar hypoventilation); b). spinal cord (trauma, transverse myelitis); c). neuromuscular system (polio, tetanus, myasthenia gravis, guillainbarre, critical care or steroid myopathy); d). chest wall (kyphoscoliosis, obesity); e). upper airways (obstruction from tissue enlargement, infection, mass; vocal cord paralysis, tracheomalacia); f). lower airways (bronchospasm, congestive heart failure, infection); g). lung parenchyma (infection, interstitial lung disease); h). cardiovascular system; i). mediastinal mass, which singh et al7 reported has high mortality rate (100%). knowledge of arterial blood gases is essential before making a decision as to whether niv is indicated. the patient should first be established on appropriate oxygen therapy and the arterial blood gases interpreted in light of the fio2. a proportion of patients who fulfil arterial blood gas criteria for niv at the time of admission to hospital may improve rapidly with initial medical treatment with an appropriate fio2. it will usually then be necessary to repeat measurement of arterial blood gas tensions to see if niv is still needed. measurement of arterial blood gas tensions should be considered in all individuals with breathlessness of sufficient severity to warrant the use of niv.3 non-invasive ventilation non-invasive ventilation via mouthpiece or mask (figure 1) has been used to treat acute respiratory failure of several etiologies. the main goals are to improve gas exchange and reduce the work of breathing. non-invasive ventilation may also prevent intubation and its potentially severe complications, such as pulmonary and upper-airway infection, which are associated with a higher mortality risk.8 non-invasive positive pressure ventilation should, however, be considered as an alternative to invasive mechanical ventilation rather than its replacement. nippv cannot take over the use of invasive mechanical ventilation. keys to the success of nppv and to improving clinical outcomes of patients with acute respiratory failure are careful patient selection and a well designed clinical protocol because failure of nppv only delays potentially more definitive therapy with invasive ventilation. non-invasive positive pressure ventilation can be delivered using various types of ventilatory equipment and interfaces. full-service icu ventilators, portable bi-level pressure generators, and devices specifically designed to be used for nppv are now available. the complete details of the application of nppv are beyond the scope of this review, but virtually any ventilator, mode, and interface techniques may be used successfully. in figure 2, caples et al proposed a protocol used for cpap and niv used in acute respiratory failure. non-invasive positive pressure ventilation is used with patients with respiratory failure of various etiologies, but it should not be used with patients who have a low level of consciousness or noncompetent airway. a few studies have suggested that nppv can be used for post-extubation ventilator weaning, and those studies found that nppv reduces the need for re-intubation and sedation and reduces the occurrence of ventilator-associated pneumonia. nppv remains controversial as a post-extubation technique, but nppv trials have used only face mask or nasal mask, and some of the extubation failures in those trials might be attributable to figure 1. photograph of a patient treated with non-invasive ventilation. vol 46 • number 1 • january 2014 non-invasive ventilation in acute respiratory failure 77 patient dissatisfaction with the masks.11 pathophysiological effects of noninvasive ventilation effects on the respiratory system12 extrinsically applied positive end expiratory pressure (epeep) increases alveolar size and recruitment. this expands the area available for gas exchange, reduces intrapulmonary shunt, improves lung compliance, and decreases the work of breathing. extrinsically applied peep (epeep) acts to negate the effects of intrinsic peep (ipeep), which is the cause of dynamic airway compression and gas trapping. ventilation is improved with beneficial effects on the alveolararterial gradient, hypercarbia and, to a respiratory ther apy driven protocol for cpap and niv use in acute respiratory failure i. pa tient eva luation � review histor y, diagnosis, inclusion, exclusion criteria and discuss with md � ascertain whether new niv use or an accustomed patient � assess for component of chronic respira tory fa ilure ii. indica tions and goals � choose as per patient dia gnosis, level of distress, and whether icu ba sed � decide opt ions in event of ea rly benefit or poor i nitia l response � rea ffirm code status a nd patient pr eferences r ega rdi ng alterna tive ther apy i ii. location � deter mine obser vation and m onitoring needs per pa tient condition a nd equi pm ent used (a step-down unit ma y be appropria te for sing le orga n failure or patients clear ly recover ing fr om multi-org an fa ilure). iv. equipm ent : conditions, initial settings, and targ ets � airflow g enera tor 1. cpap. presumed obstructive sleep apnea or ca rdiog enic arf for targ et of i mproved spo2 and paco2 2. portable bi -level device. acute on chr onic com ponent for targ et of improved pa co2 a nd reduced dyspnea using visual analog scale. use with por table battery atta chm ent for tra nsporting patients. 3. icu bi -level device. choose for patients in icu, more severe distress i n emergency departm ent, or poor synchr ony a nd need for wa veform m onitoring. 4. full servi ce icu ventilator . severely distressed patients with poor synchrony in considera tion of pressure or volum e contr ol m odes � setting s 1. cpap. set a t 10-12,5 cmh2o and titr ate a s needed for os a or dy spnea 2. portable bi -level device. initia l epap at minimum for neuromuscular disease patients. 5 cmh2o for others. ma y increa se epap for os a com ponent or for hypoxemia . attenti on to auto-peep, which may be countera cted by judicious use of epap. i nitial ipap at 8-10 cmh2o and target patient toler ance. i ncrease to 15-20 cmh20 as tol erance a llows for relief of dyspnea and respiratory ra te. 3. icu bi -level device. sa me epa p a nd ipap issues as for portable device but may need more a ggr essive titration as situa tion demands. a lter flow r ate, sensitivity a nd inspira tor y time to optimize synchrony. 4. full service icu venti lator. sam e issues as for i cu bi-lev el device but m ay consider use of volume control a nd other m odes. 5. oxy gen. guided by distress level a nd spo2. in those a t risk of worsening hypercapnia on cpa p, maintain between 88%-90% � masks 1. nasal. utilize for less disstr essed pati ents a nd those with chr onic component. a lso consider nasal pillows for more claustrophobic patients 2. full face mask. patients wi th severe distress or la rge or al air leaks v. monitoring � oxymetry. all patients � arterial blood ga ses. ba seline and discharge abg’s hig hly r ecommended. useful for i cu patients needing fr equent monitor ing of paco2. � ventila tor with wa veform monitoring for poor synchrony problem s vi. dismissal (education and comm unication) � anticipate early for patients wi th chronic component � review for diagnostic a nd reimbur sment requirem ents vii. nnv r egistry/oxym etry (recomm ended but not oblig atory) � documenta ti on. log progress and outcome for future patient use and prot ocol qua lity assessment. *reproduced from gay, pc, hubmayr, rd; “mechanical ventila tion par t ii: noninvasi ve.” in ir win and rippe’s: intensice care medicine 5th ed. 2003, p. 647-60 figure 2. respiratory therapy–driven protocol for continuous positive airway pressure (cpap) and noninvasive ventilation (niv) use in acute respiratory failure (arf). icu, intensive care unit; epap, expiratory positive airway pressure; peep, positive end-expiratory pressure; ipap, inspiratory positive airway pressure; abgs, arterial blood gases; osa, obstructive sleep apnea; nnv, noninvasive nasal ventilation.10 gurmeet singh acta med indones-indones j intern med 78 lesser extent, hypoxia. pressure support (alone or as part of bilevel positive airway pressure, bipap) further augments alveolar ventilation and allows some respiratory muscle rest during the inspiratory phase. effects on the cardiovascular system12 positive end-expiratory pressure reduces venous return to the right side of the heart. left ventricular preload, transmural pressure, and relative afterload are all decreased without altering myocardial contractility. thus, the ejection fraction improves without an increase in myocardial oxygen consumption. it appears that those with worst ventricular dysfunction show the most significant improvement in stroke volume index with continuous positive airway pressure (cpap). overall, cpap leads to a decrease in arterial pressure, heart rate, and rate-pressure product within 10 minutes, without exacerbation of hypotension. effects on other systems12 intracranial pressure (icp)—in patients with raised icp there may be an increase in icp by at least the same degree as the peep applied. renal—peep causes decreased sodium excretion and urine output, possibly due to raised vena caval pressure reducing cortical blood flow. patient selection as stated previously, the success of nppv is critically dependent on careful patient selection. there is strong evidence that patients with copd respond well to nppv, particularly under certain conditions. predictors of success include younger age, unimpaired consciousness, moderate rather than severe hypercarbia and acidemia, and prompt physiologic response (improvement in heart and respiratory rates and gas exchange within 2 hrs). confalonieri et al. recently published a logistic regression model to predict failure of nppv in patients with acute exacerbations of copd. based on 1,033 consecutive copd patients, of whom 236 (22.8%) failed nppv, the model showed the highest risk for failure occurred in those with a glasgow coma scale of <11, ph <7.25, and a respiratory rate of >30 breaths/min.10 based on the findings reported above, caples and gay10 proposed an algorithm for nppv and urge the use of established institutional protocols that are subjected to frequent reassessment (figure 3). studies often emphasize disease indications and the initiation process for nppv but are perhaps lacking in statements regarding response to failure and less appropriate use of nppv. for this reason, careful discussion of the goals and preferences of the patient and practitioners before initiating nppv treatment should be discussed. however, a “do not resuscitate or intubate (dnr/ dni)” order should not itself preclude a trial of nppv, which, as levy et al. recently showed, can be associated with a favorable outcome in the setting of an acute event such as congestive heart failure or copd exacerbation. in other settings of respiratory failure in dnr/dni patients, nppv may enhance patient comfort by reducing the work of breathing and may be appropriate for short-term use. however, fully informed consent should leave no ambiguity that nppv could prolong a terminal event.10 s h o u l d n o n i n va s i v e p o s i t i v e pressure ventilation be used in all forms of acute respiratory failure? although nppv has an established role as initial therapy in many forms of respiratory failure, it cannot be recommended for all patients in respiratory failure. in respiratory failure that develops soon after extubation, nppv causes harm. but, if nppv is used for patients who still at risk for respiratory failure after extubation, it can improve the outcomes of the patients. in the most severely ill patients with copd or hypoxemic respiratory failure, nppv is less likely to help. however, copd or hypoxemic respiratory failure patients who have no contraindications to nppv clearly shown improved outcome. in acute cardiogenic pulmonary edema, nppv offers no advantage over simpler, less expensive interventions. in patients who require instantaneous ventilatory support or airway protection due to impaired consciousness, and for those who would interface poorly with the face mask, use of nppv would be foolhardy. clinical judgment, wisdom, and experience must still guide patient selection, but there probably remain many unrecognized vol 46 • number 1 • january 2014 non-invasive ventilation in acute respiratory failure 79 or unrealized opportunities to improve patient care with nppv.13 problems with non-invasive ventilation non-invasive ventilation appears to be probably free of serious complications and side effects. the primary disadvantage of non-invasive ventilation is its reliance on a spontaneously breathing patient who is able to protect their airway against the risk of aspiration. if either of these conditions are not met, endotracheal intubation and traditional ventilation is indicated. the most commonly reported complications of non-invasive ventilation are nasal bridge skin abrasions and patient intolerance of the treatment. gastric distension and aspiration is a guarded support hypoxemia ±pneumonia failed extubatio n, medical severe acidosis (ph <7,2) glasgow coma scale <11 strong support copd exacerbation cardiogenic pulmonary edema immunocompromised host failed extubation, post -operative review of goals and indications* continue nppv until resolution intubation or reassess goals if pt is dni status, consider short trial for acute heart failure/copd; possible palliative therapy* assess for possible chronic hypoventilation or osa; dicharge planning if clinically stable, consider delay of intubation beyond 4 hours clinical improvement within 1-4 hours consider intubation initially or early if no improvement yes no discussion with patient must include frank explanation that nppv should be considered aggressive respiratory support that may not b e consistent with patient with prior directives. each patient situation requires addressing individual specific wishes and needs as nppv is also reasonable as a palliative treatment figure 3. noninvasive positive pressure ventilation (nppv) for acute respiratory failure. copd, chronic obstructive pulmonary disease; pt, patient; dni, do not intubate; osa, obstructive sleep apnea.10 frequently discussed side effect of non-invasive ventilation, but is relatively rarely described in clinical trial. non-invasive ventilatory systems are, generally, quite tolerant of leaks but mouth leaks with nasal masks can lead to therapeutic failure. case reports exist of other complications of noninvasive ventilation. a variety of arrhythmias (bradycardia, ventricular tachycardia, and ventricular standstill) have been reported during cpap but were all probably related to underlying myocardial infarction. pneumothorax is reported to have complicated treatment of pneumocystis carinii pneumonia, but these patients are at high risk of this when ventilated by traditional means. pneumocephalus has been described in one patient receiving cpap after weaning from gurmeet singh acta med indones-indones j intern med 80 traditional ventilation who had an unrecognised base of skull fracture as a result of a motor vehicle accident. one case of bilateral tympanic rupture and otorrhagia is reported in an agitated patient coughing against cpap. subconjunctival emphysema and corneal abrasions have also been reported.12 conclusion endotracheal intubation and mechanical ventilation remain the preferred treatment in most cases of severe acute respiratory failure, especially if other systems are deranged at the same time. continuous positive airway pressure provides relief of dyspnoea and an improvement in oxygenation in a proportion of patients, particularly those in whom hypoxaemia exists without hypercapnia. non invasive positive pressure ventilation is feasible in patients with acute on chronic respiratory failure characterised by both hypoxaemia and hypercapnia in whom intubation is considered inappropriate, difficulties with weaning are anticipated, or long term ventilatory support might be needed. admission to an intensive care unit can be avoided in some instances at least, and, if intubation does prove necessary, the technique may be useful as a means of helping the return of spontaneous breathing.14 acknowledgments the author would like to thank dr. tiona romauli and all staff of division of respirology and critical care department of internal medicine, cipto mangunkusumo general national hospital for their contribution and support in this study. references 1. cross am. review of the role of non-invasive ventilation in the emergency department. j accid emerg med. 2000;17:79–85. 2. cross a m, cameron p, kierce m, ragg m, kelly a m. non-invasive ventilation in acute respiratory failure: a randomised comparison of continuous positive airway pressure and bi-level positive airway pressure. emerg med j. 2003;20:531–4. 3. british thoracic society standards of care committee. non-invasive ventilation in acute respiratory failure. thorax. 2002;57:192–211. 4. lightowler jvj, elliott mw. predicting the outcome from niv for acute exacerbations of copd. thorax. 2000;55:815–6. 5. plant pk, owen jl, elliott mw. non-invasive ventilation in acute exacerbations of chronic obstructive pulmonary disease: long term survival and predictors of in-hospital outcome. thorax. 2001;56:708–12. 6. jallu ss, salzman ga. a case based approach to non-invasive positive pressure ventilation. hospital practice. 2011;39(3);168-75. 7. singh g, amin z, wuryantoro, wulani v, shatri h. profile and factors associated with mortality in mediastinal mass during hospitalization at cipto mangunkusumo hospital, jakarta. acta med indones. 2013;45:3-10. 8. bassani ma, de oliveira ab, oliveira neto af. non-invasive ventilation in a pregnant patient with respiratory failure from all-trans-retinoic-acid (atra) syndrome. respir care. 2009;54:969–72. 9. rochard lb, mangebo j, wysocki m, et al. noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. new engl j med. 1985;13:817-22. 10. caples sm, gay pc. non-invasive positive pressure ventilation in the intensive care unit: a concise review. crit care med. 2005;33:2651–8. 11. klein m, weksler n, bartal c, zilberstein g, gurman gm. helmet non-invasive ventilation for weaning from mechanical ventilation. respir care. 2004;49:1035–7. 12. cross am. review of the role of non-invasive ventilation in the emergency department. j accid emerg med. 2000;17:79–85. 13. hess dr, fessler he. should non-invasive positivepressure ventilation be used in all forms of acute respiratory failure? respir care. 2007;52:568–78. 14. elliott mw, steven mh, phillips gd, branthwaite ma. non-invasive mechanical ventilation for acute respiratory failure. br med j. 2000;300:358-60. editorial 173acta medica indonesiana the indonesian journal of internal medicine frailty syndrome: an emerging geriatric syndrome calling for its potential intervention purwita w. laksmi department of internal medicine, faculty of medicine, universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. correspondence mail: division of geriatrics, department of internal medicine, faculty of medicine, universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: pwlaksmi@yahoo.com. it is projected that the elderly population in indonesia will increase from approximately 19 million people in 2010 with life expectancy of 69.8 years during period of 2005-2010 to 29 million people in 2020 (11.11% of total population) with life expectancy of 73.6 years during period of 2020-2025. higher elderly female proportion compared to male (11.43% versus 10.78%) will also be found.1 aging process happens as people get older. its process is influenced by genetic and environmental factors that can lead to successful aging, usual (normal) aging or pathologic aging. people with pathologic aging would have an increased risk to become frail.2,3 nowadays, frailty syndrome is considered as one of the geriatric syndromes which increase the risk of worsening clinical outcome in mobility, functional status, hospitalization, institutionalization and mortality, as well as lower health-related quality of life.4,5 moreover, frailty syndrome reflects a biological age that predicts mortality risk better than chronological age [rr 1.57 (95% ci 1.41-1.74) versus rr 1.08 (95% ci 1.06-1.2)].6 no wonder, frailty syndrome has attracted clinician’s attention, especially the geriatricians, all over the world with increasing research in this field. frailty syndrome, a biological syndrome of decreased physiological reserved capacity and capability to endure upon stressors, can be perceived as a clinical syndrome (phenotype) or as deficits/co-morbidities/disabilities accumulation. based on these two concepts, a person can be classified as normal (fit/robust), pre-frail, and frail.6,7 a s a p h e n o t y p e , f r a i l t y s y n d r o m e is characterized by exhaustion due to poor endurance and lack of energy, as well as decrease in body weight (shrinking), muscle strength (weakness), gait speed (slowness), and physical activity. this concept of phenotype frailty differentiates frailty from disability.6 in contrast, clinical approach of frailty syndrome as deficits accumulation takes into account disabilities in addition to co-morbidities as characteristics of frail people. this concept based on consideration that the more the deficits accumulated in a person, the frailer the person will be.7,8 there are numerous score systems to diagnose frailty syndrome, mostly derived from phenotype concept described by fried et al.4 in cardiovascular health study or deficits accumulation concept described by rockwood et al.7 in canadian study of health and aging. the prevalences of frailty syndrome differ one another depend on the score system or the clinical setting used in the study.8 the concept of frailty syndrome is multidimensional to include physical, psychological and social domain, in which complex interactions among them contribute to the development and the severity of frailty syndrome.9 gill et al.10 shows the dynamic transition of frailty syndrome. it indicates that frailty syndrome is potentially reversible by managing modifiable contributing factors. fried et al.4 hypothesize the main element that contribute to physical frailty is sarcopenia (low of muscle purwita w. laksmi acta med indones-indones j intern med 174 mass and function). other conditions that may also contribute to development of frailty syndrome are inflammation, insulin resistance and diabetes mellitus (dm).11-13 diabetes mellitus patients tend to have an accelerated aging process that increases the risk to become frail at younger age.14 insulin resistance has long been known to contribute to the development of type 2 dm. longitudinal studies have shown that insulin resistance [hr 1.15 (95% ci 1.02-1.31] and hyperglycemia/a1c ≥8% [hr 3.33 (95% ci 1.24-8.93)] raise the incidence of frailty syndrome.12,13 insulin resistance contributes to the increased inflammatory and pro-thrombotic state, endothelial dysfunction, atherosclerosis and changes in lipid metabolism. insulin resistance has also been linked to sarcopenia with decreased gait speed and muscle strength.15 therefore, in this acta medica indonesiana-the indonesian journal of internal medicine edition, we bring this topic of frailty in relation to therapy in type 2 dm elderly patients. the oral anti-diabetic metformin is potentially able to modify factors contributing to frailty syndrome (insulin resistance, hyperglicemia, inflammation) through its activation on adenosine monophosphate-activated protein kinase (ampk), while inhibiting mediator inflammation nuclear factor-ĸb (nfĸb) and mammalian target of rapamycin (mtor).16,17 moreover, animal studies show potential ability of metformin to delay aging process and prolong the animal’s life span with various length of time depend on the species and strain.18 thus, the case-control study done by sumantri et al.19 to explore the relation between metformin use in elderly diabetics and the risk of frailty syndrome is important in providing insight about another beneficial effect of metformin. this study indicates that metformin has a protective effect against frailty syndrome in elderly patients with type 2 dm. surely this result will provide direction for future research in frailty syndrome intervention. references 1. badan perencanaan pembangunan nasional, badan pusat statistik, united nations population fund. proyeksi penduduk indonesia (indonesia population projection) 2000-2005. jakarta, 2005. 2. fedarko ns. the biology of aging and frailty. clin geriatr med.2011;27(1):27–37. 3. lowry ka, vallejo an, studenski sa. successful aging as a continuum of functional independence: lessons from physical disability models of aging. aging & disease. 2012;3(1):5-15. 4. fried lp, tangen cm, walston j, et al. frailty in older adults: evidence for a phenotype. j gerontol med sci. 2001;56(3):m146-56. 5. rizzoli r, reginster jy, amal jf, et al. quality of life in sarcopenia and frailty. calcif tissue int. 2013;93(2):101-20. 6. song x, mitnitski a, rockwood k. prevalence and 10-year outcomes of frailty in older adults in relation to deficit accumulation. j am geriatr soc. 2010;58:681-7. 7. r o c k w o o d k , h o g a n d b , m a c k n i g h t c . conceptualisation and measurement of frailty in elderly people. drugs aging. 2000;17:295-302. 8. strandberg te, pitkala kh, tilvis rs. frailty in older people. eur ger med. 2011;2:344-55. 9. de vries nm, staal jb, van ravensberg cd, et al. outcome instruments to measure frailty: a systematic review. ageing res rev. 2011;10:104-14. 10. gill tm, gahbauer ea, allore hg, han l. transitions between frailty states among community-living older persons. arch intern med. 2006;166:418-23. 11. puts mte, visser m, twisk jwr, deeg djh, lips p. endocrine and inflammatory markers as predictor of frailty. clin endocrinol. 2005;63:403-11. 12. barzilay ji, blaum c, moore t, et al. insulin resistance and inflammation as precursors of frailty: the cardiovascular health study. arch intern med. 2007;167:635-41. 13. kalyani rr, tian j, xue ql, et al. hyperglycemia and incidence of frailty and lower extremity mobility limitation in older women. j am geriatr soc. 2012;60:1701-7. 14. hubbard re, andrew mk, fallah n, rockwood k. comparison of the prognostic importance of diagnosed diabetes, co-morbidity and frailty in older people. diabet med. 2010;27:603-6. 15. chung hy, cesari m, anton s, et al. molecular inflammation: underpinnings of aging and age-related disease. aging res rev. 2009;8:18-30. 16. gong l, goswami s, giacomini km, altman rb, klein te. metformin pathways: pharmacokinetics and pharmacodynamics. pharmacogenet genomics. 2012;22(11):820-7. 17. salminen a, kaarniranta k. amp-activated protein kinase controls the aging process via an integrated signaling network. aging res rev. 2012;11: 230–41. 18. anisimov vn. metformin for aging and cancer prevention. aging. 2010;2(11):760-74. 19. sumantri s, setiati s, purnamasari d, dewiasty e. relationship of metformin and frailty syndrome on elderly people with type 2 diabetes. acta med indones indones j intern med. 2014;46(2):183-8. editorial 289acta med indones indones j intern med • vol 49 • number 4 • october 2017 are we ready for national diabetes prevention program? imam subekti department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: imam subekti, md., phd. division of endocrinology and metabolism, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: isubekti@yahoo.com. indonesia, as part of asian population, is one of the most growing diabetes population in the world.1,2 genetic, aging, urbanization, and sedentary lifetstyle are major determinants of diabetes in the developing world, include southeast asia countries.2 they are the causes of escalation of diabetes population in indonesia. increase from time to time, prevalence of diabetes mellitus in indonesia are reaching the number over 10% from total adult population.3 the number of prediabetes subjects are also increase from several studies.4 based on study from latest national basic health survey (2013) held by ministry of health republic of indonesia, re-analysed by idris h et al.,3 the prevalence of diabetes mellitus in indonesia is 13%. idris h et al. used population aged above 15th year-old and cut off 126 mg/ dl for fasting blood glucose or 200 mg/dl for 2 hours post-75 mg oral glucose tolerance test in their study. although used different lower limit of age (15th year-old versus 18th year-old) and criteria for diabetes from previous study held by pramono la et al.,5 who re-analysed 2007’s national basic health survey, the number are increased sharply from 5.6% to 13%. as comparison, international diabetes federation atlas (idf) also released data in 2012 which stated the prevalence of diabetes in indonesia reached 7.55% with prediabetes prevalence reached 12.55%.6 b a s e d o n c o m p r e h e n s i v e r e v i e w b y soewondo p et al.,1 prevalence of diabetes mellitus is varies between surveys, study locations, and time of studies. disparities of different studies are un-necessarily debated while several studies are using different methods and diagnosis criterias. one thing for sure, the prevalence is growing rapidly and will cause national problem since morbidity, mortality, and complications are increased and making economic burden for national health expenses.7 ministry of health, the indonesian society of endocrinology (called as perkeni), and indonesian diabetes association (called as persadia) have tried many strategies to reduce the burden of late-diagnose and chronic complications of diabetes mellitus by screening program at primary health care facilities, publication of national diabetes guidelines for general practitioners and internists, continuing medical education for general practitioners, internists, endocrinologists, diabetes nurses, podiatrists, and diabetes educators. despite the hardworks all these years, we need systematic and evidence-based prevention strategy which can be applied nationally. the diabetes prevention program (dpp) research group in united states, from 1996 to 1999, has done large clinical trial which titled the diabetes prevention program clinical trial, a multicenter clinical trial which include 3,234 subjects from 27 centers who were at high risk for diabetes.8 this national study formulated dpp lifetstyle intervention with 16-sessions core curriculum to increase the successful rate of diabetes prevention in prediabetes patients.9 the goals of intervention are to achieve and maintain at imam subekti acta med indones-indones j intern med 290 least a 7% weight loss and 700 calories/week of physical activity in all lifestyle participants. the main result of this clinical trial is decrease of type 2 diabetes incidence by 58% in lifestyle intervention group compared with 31% in the metformin-treated group.8,9 study from idris h et al.3 in this issue is a large observational study of diabetes prevalence from the latest national survey which is very important for our database. but, it is more important to make programs as a continuation from the study to formulate effective and applicative prevention programs. we have already known about all risk factors studied and correlated significantly in our diabetes patients; aging, gender, body mass index, blood pressure, lipid profiles, physical inactivity, unhealthy diet, and smoking habit.1,3,5 from these data, we can make further steps by discussing and formulating our own national diabetes prevention program clinical trial so we can give national recommendation based on the study. references from many epidemiology studies conducted across indonesia must be combined and systematically appraised to formulate national diabetes prevention program clinical trial. finland can be a role model which has successfully undertaken large-scale of diabetes prevention intervention in their country, while australia can be an example of country which focuses on scalling up the program in larger population.10 we can learn and implement how other countries did and success the program. take actions, sustained evaluation, monitoring, and scalling up are the key success for diabetes prevention program in a national scope.10 commitment from government, policy makers, clinical leaders, all physicians, and health care providers are very important and a key factor for the sustainability of diabetes prevention program in our society. right now, the question left is: are we ready for indonesian diabetes prevention program? references 1. soewondo p, ferrario a, tahapary dl. challenges in diabetes management in indonesia: a literature review. globalization and health. 2013;9(63):1-17. 2. nanditha a, ma rcw, ramachandran a, et al. diabetes in asia and the pacific: implications for the global epidemic. diabetes care. 2016;39:472-85. 3. idris h, hasyim h, utama f. analysis of diabetes mellitus determinants in indonesia: a study from the indonesian basic health research 2013. acta med indones. 2017;49(4):291-8. 4. soewondo p, pramono la. prevalence, characteristics, and predictors of prediabetes in indonesia. med j indones. 2011;20(4):283-94. 5. pramono la, setiati s, soewondo p, subekti i, adisasmita a, kodim n, sutrisna b. prevalence and predictors of undiagnosed diabetes mellitus in indonesia. acta med indones – indones j intern med. 2010;42(4):216-23. 6. idf diabetes atlas, 5th edition. international diabetes federation, update 2012. 7. idf diabetes atlas, 5th edition. international diabetes federation, 2011. 8. diabetes prevention program research group. reduction in the incidence of type 2 diabetes with lifestyle intervention of metformin. n engl j med. 2002;346(6):393-403. 9. the diabetes prevention program (dpp) research group. the diabetes prevention program (dpp). diabetes care. 2002;25:2165-71. 10. dunbar ja. diabetes prevention in australia: 10 years results and experience. diabetes metab j. 2017;41:1607. 26 original article acta med indones indones j intern med • vol 51 • number 1 • january 2019 validity and reliability studies of the indonesian version of the minnesota living with heart failure questionnaire (mlhfq): quality of life questionnaire for patients with chronic heart failure dinas yudha kusuma, hamzah shatri, idrus alwi, murdani abdullah department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: hamzah shatri, md., phd. division of psychosomatic, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: hshatri@ yahoo.com, dinas.yudha@ui.ac.id. abstrak latar belakang: minnesota living with heart failure questionnaire (mlhfq) adalah kuesioner yang paling umum digunakan dan memiliki skor empro (mengevaluasi pengukuran hasil pasien) yang baik. mlhfq telah diadaptasi dan digunakan oleh berbagai negara di seluruh dunia; namun, untuk digunakan di indonesia, diperlukan studi validitas dan reliabilitas. penelitian ini bertujuan untuk mendapatkan kuisioner gagal jantung jantung (mlhfq) versi indonesia yang valid dan andal sehingga dapat digunakan di indonesia. metode: penelitian ini adalah penelitian cross sectional dengan 85 subjek (usia rerata 58 (sb 11) tahun; 55% subjek adalah laki-laki) yang mengalami gagal jantung kronis dan dirawat di klinik rawat jalan kardiologi di rumah sakit dr. cipto mangunkusumo, jakarta. validitas mlhfq dinilai dengan mengevaluasi validitas konstruk menggunakan analisis multitrait-multimethod dan validitas eksternal dievaluasi dengan membandingkan mlhfq dengan kuesioner sf-36. keandalan dinilai menggunakan cronbach’s α dan koefisien korelasi intraclass (icc). hasil: versi bahasa indonesia dari mlhfq memiliki korelasi sedang hingga kuat antara domain dan item dalam kuesioner (r: 0,571-0,748; p<0,01) dan memiliki korelasi negatif sedang dengan kuesioner sf-36 (r -0,595; p<0,001). cronbach α dari mlhfq versi indonesia adalah 0,887; sedangkan iccs adalah 0,918. kesimpulan: mlhfq versi indonesia memiliki validitas dan reliabilitas yang baik untuk menilai kualitas hidup pasien dengan gagal jantung kronis di indonesia. kata kunci: gagal jantung kronis, minnesota living with heart failure questionnaire (mlhfq), kualitas hidup, reliabilitas, validitas. abstract background: minnesota living with heart failure questionnaire (mlhfq) is the most commonly used questionnaire and it has a good empro (evaluating the measurement of patient-reported outcomes) score. the mlhfq has been adapted and used by various countries worldwide. however, to be utilized in indonesia, it needs validity and reliability studies. this study aimed to obtain a valid and reliable indonesian version of the minnesota living with heart failure questionnaire (mlhfq) so that it can be used in indonesia. methods: the present study was a cross sectional study with 85 subjects (mean age 58 (sd 11) years; 55% subjects were male) who had chronic heart failure and was treated at the outpatient clinic of cardiology in dr. cipto mangunkusumo hospital, jakarta. validity of the mlhfq was assessed by evaluating the construct validity vol 51 • number 1 • january 2019 validity and reliability studies of the indonesian version of the minnesota 27 using multitrait-multimethod analysis and external validity was evaluated by compairing the mlhfq with the sf-36 questionnaire. reliability was assessed using cronbach’s α and intraclass correlation coefficients (icc). results: the indonesian version of the mlhfq had moderate-to-strong correlation between domains and items in questionnaire (r: 0.571-0.748; p<0.01) and it had moderate negative correlation with sf-36 questionnaire (r -0.595; p<0.001). the cronbach α of indonesian version of mlhfq was 0.887; while the iccs was 0.918. conclusion: the indonesian version of mlhfq has good validity and reliability to asses the quality of life of patients with chronic heart failure in indonesia. keywords: chronic heart failure, minnesota living with heart failure questionnaire (mlhfq), quality of life, reliability, validity. introduction heart failure has become a great health problem worldwide with an estimation of 26 millions of patients all over the world, including indonesia.1,2 in addition to cause physical problems, it also has psychological, social and economical impacts. as many as 20% of patients with heart failure, both ambulatory and hospitalized patients, experience severe depression. the high rate of depression and anxiety will affect treatment compliance, aggravate functional status, and increase hospitalization and mortality rates.3–5 the management of chronic heart failure includes physical, emotional, and social aspects. chronic heart failure treatment, both nonpharmacological and pharmacological treatment, aims to reduce symptoms/signs, to prolong survival, to increase functional capacity, to prevent exacerbation of disease, to prevent hospitalization, to improve quality of life and to reduce mortality rate.6–8 there are two types of instrument for measuring health-related quality of life, i.e. a generic instrument such as sf-36 and specific instrument that can be used to measure the quality of life of patients with heart failure.9,10 specific instruments, which are utilized to evaluate the quality of life of patients with chronic heart failure are quality of life in severe heart failure questionnaire (qlq-shf), chronic heart failure questionnaire (chq), kansas city cardiomyopathy questionnaire (kccq), left ventricular disfunction questionnaire (lvd36), chronic heart failure assessment tool (chat) and minnesota living with heart failure questionnaire (mlhfq). minnesota living with heart failure questionnaire (mlhfq) is the most commonly used questionnaire and it has a good empro (evaluating the measurement of patient-reported outcomes) score; therefore, its use has been recommended to evaluate quality of life of patients with chronic heart failure.10,11 the mlhfq has been adapted and used by various countries worldwide; however, to be utilized in indonesia, it needs validity and reliability studies. an instrument that has been demonstrated valid and reliable abroad may not be valid and reliable when it is used in indonesia due to differences in language and culture; therefore, an adaptation is necessary.12 the present study aimed to perform an adaptation and evaluation on reliability and validity of indonesian version of mlhfq. methods our study was a cross-sectional study consisted of two stages. the first stage was adapting questionnaire following a method according to the guidelines provided by beaton de, et al.13 the second stage was validity and reliability studies. validity of the mlhfq was assessed by evaluating inter-item correlation in the mlhfq domains with domains in the indonesian version of mlhfq and to evaluate the correlation of the indonesian version of mlhfq with the indonesian version of sf36 as the gold standard. reliability study was evaluated by calculating the intraclass correlation coefficient (icc) and internal consistency (cronbach’s α). the study had been approved by the ethic committee of health research, faculty of medicine, universitas indonesia number 189/ un2.f1/etik/2017 dated march 6th, 2017. dinas y. kusuma acta med indones-indones j intern med 28 subjects study subjects were patients with chronic heart failure who sought treatment at the outpatient cardiology clinic of the integrated heart services of cipto mangunkusumo hospital jakarta with a period of study between march 2017 and july 2017. the number of collected sample was 85 patients with inclusion criteria of adult patients with chronic heart failure who could read and write in indonesian language and were willing to participate in the study. patients who had communication barriers or cognitive disorder as well as those with exacerbated condition and those who were not available for re-test were excluded from the study. questionnaire the mlhfq questionnaire consisted of 21 questions with 6-point likert scale (0-5), developed to evaluate the effect of heart failure and treatment on patient’s quality of life. there were two domains in the questionnaire which were physical domains (8 questions) and emotional domains (5 questions) and the other 8 questions were not included in both domain categories; however, the questions were added to evaluate the overall scores. the higher the mlhfq score, the lower the quality of life of the patient.14,15 adapting questionnaire questionnaire adaptation was performed following the guidelines issued by the quality of life special interest group (qol-sig)translation and cultural adaptation group (tca group).16 the translation was performed by 2 translators of the indonesian version, 2 translators of english version and 1 linguistic expert in indonesian and english expert supervised by the researcher team. results of translation were tested on 30 subjects who gave evaluation on the translation results. the process developed an indonesian version of the mlhfq, which was used in the validity and reliability test. data analysis the collected data were managed using a spss statistic program version 20.0 for windows and the data were presented in tables and figures. data normality was calculated using kolmogorov-smirnov test (n >50). the correlation of data with normal distribution (p > 0.05) was evaluated using pearson test and when the distribution was abnormal (p< 0.05), the data was evaluated using spearman test. the validity of the questionnaire was calculated by evaluating the inter-item correlation of questions on domains in the questionnaire by using multitrait-multimethod analysis. the further analysis on validity was to evaluate correlation of each study in the mlhfq with the domain in the gold standard sf-36 questionnaire. reliability of the questionnaire was calculated using a re-test method by assessing the intraclass correlation coefficient of the mlhfq on day 1 and day 8. further reliability study included evaluating internal consistency of the questionnaire by calculating the cronbach’s α of the mlhfq. results there were 96 patients recruited at the beginning of the study; however, 11 subjects were excluded as they did not follow the re-test on day 8 and therefore, the other 85 patients with chronic heart failure participated as study subjects. there were 55 (61.2%) male subjects with mean age of 58.27 years. subjects with ef ≤ 40 % were 15 (17.6%) individuals and there was a domination of subjects with nyha fc i and ii of 43 (50.6%) and 33 (38.8%) subjects, respectively; moreover, there were 9 (10.6%) patients with nyha fc iii. as many as 62 (72.9%) subjects had concomitant coronary heart disease (table 1). table 1. subject characteristics variables n (%) sex, male, n (%) 55 (61.2) age, mean (sd) 58.27 (11.13) ≤ 40 7 (8.2) 41-50 15 (17.6) 51-60 20 (23.5) 61-70 33 (38.8) > 70 10 (11.8) education, n (%) primary 10 (11.8) junior high 14 (16.5) senior high 36 (42.4) university 25 (29.4) vol 51 • number 1 • january 2019 validity and reliability studies of the indonesian version of the minnesota 29 validity test correlation of items of question in physical domain with the physical domain was stronger compared to its correlation with emotional domain (r: 0.571 – 0.748 vs. r: 0.137 – 0.506). items of questions in emotional domain also had stronger correlation with emotional domain compared to its correlation with physical domain (r: 0.676 – 0.718 vs. r: 0.188 – 0.499). the correlation of physical and emotional domain with the total score of mlhfq had been demonstrated to be strong (r > 0.6) (table 2). the indonesian version of the mlhfq had negative correlation between the score of the mlhfq and sf-36 (r: -0.595). it indicates that the higher the score of the mlhfq (or the lower the quality of life), the lower the score of sf-36 (or the lower the quality of life) (table 3). table 1. subject characteristics (continued) variables n (%) marital status, n (%) single 4 (4.7) married 69 (81.2) widow/widower 12 (14.1) nyha, n (%) nyha fc i 43 (50.6) nyha fc ii 33 (38.8) nyha fc iii 9 (10.6) ejection fraction (%) ≤ 40 % 15 (17.6) > 40 % 70 (82.4) duration of diagnosis (years) < 1 25 (29.4) 1-5 37 (43.5) >5 23 (27.1) cad, n (%) present 62 (72.9) absent 23 (27.1) therapy, n (%) diuretics 28 (32.9) acei/arb 72 (84.7) β-blocker 68 (80) mra 30 (35.3) digitalis 3 (3.5) anti-coagulant 15 (17.6) nitrate 24 (28.2) double anti-platelet 28 (32.9) single anti-platelet 41 (48.2) reliability study results of the study showed that the questionnaire had a good icc score regarding the inter-item correlation (r: 0.592 – 0.984), interphysical domain (r: 0.896), emotional domain (r: 0.950) and total correlation (r: 0.918). internal consistency of the questionnaire was good as shown by the value of cronbach α for physical domain of 0.862, for emotional domain of 0.800 and for the total questionnaire score of 0.887. discussion the subject characteristic of the present study is similar to studies in east asia and south east asia.17–19 the validity study on the questionnaire has demonstrated a good result, which is represented by stronger item correlation of questions in physical domain with those in physical domain compared to correlation with the emotional domain (r: 0.571 – 0.748 vs. r: 0.137 – 0.506). items of questions in emotional domain also have stronger correlation with emotional domain compared to correlation with physical domain (r: 0.676 – 0.718 vs. r: 0.188 – 0.499). correlation of physical and emotional domains with total score of the mlhfq questionnaire has been demonstrated to be strong (r > 0.6). the present study has similar correlation of item-domain compared to the original study that has correlation of physical item-domain (r: 0.530.84) and emotional item-domain (r: 0.60-0.81).20 similar results on construct validity with other studies have also been observed, which describes greater item correlation of questions in physical domain with physical domain compared with emotional domain and likewise.17,21–23 the domain correlation of the mlhfq with sf-36 domain. the results of the study have demonstrated that overall we found a negative correlation between mlhfq score and sf-36 (r: -0.595). it indicates that the greater the score of mlhfq (the lower the quality of life), the lower the sf-36 score (the lower the quality of life). in details, the physical domain of the questionnaire has a strong negative correlation on pcs sf-36 (r: -0.652), a moderate negative correlation on mcs sf-36, physical functioning, role physical, role emotional and pain as well as a weak negative dinas y. kusuma acta med indones-indones j intern med 30 table 2. results of validity and reliability studies variables correlation icc cronbach α physical domain emotional domain total score physical domain 1.000 0.425** 0.871** 0.896 0.862 q2 0.571** 0.271* 0.483** 0.837** q3 0.712** 0.137 0.526** 0.912** q4 0.640** 0.271* 0.602** 0.889** q5 0.627** 0.367** 0.594** 0.774** q6 0.572** 0.369** 0.539** 0.832** q7 0.645** 0.346** 0.635** 0.902** q12 0.748** 0.357** 0.628** 0.808** q13 0.662** 0.506** 0.671** 0.883** emotional domain 0.425** 1.000 0.688** 0.950 0.800 q17 0.499** 0.718** 0.678** 0.935** q18 0.377** 0.692** 0.539** 0.984** q19 0.255* 0.676** 0.439** 0.858** q20 0.188 0.687** 0.396** 0.912** q21 0.293** 0.696** 0.488** 0.924** non domain q1 0.386** 0.020 0.321** 0.868** q8 0.230* 0.378** 0.430** 0.885** q9 0.487** 0.229* 0.541** 0.814** q10 0.160 0.195 0.330** 0.884** q11 0.261* 0.289** 0.454** 0.798** q14 0.170 0.161 0.321** 0.794** q15 0.160 0.320** 0.341** 0.592** q16 0.254* 0.347** 0.385** 0.752** total score 0.871** 0.688** 1.000 0.918** 0.887 table 3. correlation of the indonesian version of the minnesota living with heart failure questionnaire with sf-36 questionnaire sf-36 domain physical domain of the mlhf questionnaire emotional domain of the mlhf questionnaire total score of the mlhf questionnaire physical functioning -0.570** -0.134 -0.428** role-physical -0.466** -0.239* -0.463** role-emotional -0.484** -0.416** -0.492** energy/fatique -0.347** -0.269* -0.313** emotional well-being -0.229* -0.466** -0.306** social functioning -0.337** -0.340** -0.439** pain -0.491** -0.302** -0.416** general health -0.314** -0.336** -0.309** pcs -0.652** -0.239* -0.550** mcs -0.480** -0.524** -0.519** total sf-36 -0.651** -0.370** -0.595** vol 51 • number 1 • january 2019 validity and reliability studies of the indonesian version of the minnesota 31 correlation on sf-36 domains of energy/fatique, emotional well-being, social functioning and general health. meanwhile the emotional domain has a moderate negative correlation on mcs sf-36 (r: -0.524), which includes role emotional and emotional well-being; it also has a weak negative correlation on pcs sf-36 (r: -0.239) including role physical, energy/fatique, social functioning, pain and general health as well as a very weak correlation on physical functional domain (figure 1). the correlation of this study is almost the same with other studies.17,19,23 the present study was performed by calculating inter-item correlation of questions on day 1 and day 8, inter-domain correlation on day 1 and day 8 and total score of the mlhfq on day 1 and day 8. the results of the study have demonstrated that the questionnaire has a good icc value on inter-item correlation (r: 0.592– 0.984), correlation among physical domain (r: 0.896), emotional domain (r: 0.950) and total correlation (r: 0.918). the inter-item correlation of questions in the present study is also consistent with other studies such as a study in taiwan (r: 0.55 – 0.80)17, korea (r: 0.65 – 0.80)18, greece (r: 0.558 – 0.906).24 inter-domain correlation and total score of the mlhfq in the present study is relatively the same (physical domain with r: 0.896; emotional domain emosional with r: 0.950 and total with r: 0.918) when it is compared to the original study with correlation on physical domain, emotional domain and total of 0.89, 0.88 and 0.93, respectively.25 similar result has also been found in a study in thailand with the correlation of 0.84, 0.84, 0.88, respectively.19 it indicates that the reliability of re-test method for the indonesian version of mlhfq is good. the study has calculated the cronbach’s α for physical domain, emotional domain and total score of mlhfq. results of the study showed that the cronbach’s α for physical domain was 0.862; for the emotional domain was 0.800 and for total score of questionnaire was 0.887. the cronbach’s α of the indonesian version of mlhfq has lower value compared to the original study and several other studies, but the results is still considered good.17–20,24 it may be caused by the small sample size in the present study. the fewer number of study subject, the greater the bias on the cronbach’s α.26 in addition to sample size, some factors that may affect the value of cronbach’s α of the questionnaire, which are homogeneity of subjects and question items.27 strong correlation weak correlation moderate correlation very weak correlation note: physical domain of the mlhf questionnaire sf-36 questionnaire physical functioning role-physical role-emotional energy emotional well-being social functioning pain general health pcs mcs emotional domain of the mlhf questionnaire figure 1. correlation of the indonesian version of the minnesota living with heart failure questionnaire with the sf-36. dinas y. kusuma acta med indones-indones j intern med 32 benefits and limitation the study the present study has developed the indonesian version of the mlhf quality of life questionnaire with good validity and reliability. the questionnaire is an adaptation of the original questionnaire by considering the rule of cross-lingual adaptation following the standard guidelines compared to other previous translation endeavors.28,29 the questionnaire that has been developed in the study can be used in daily clinical practice as well as in further studies to evaluate the quality of life of patients with chronic heart in indonesia. the limitation of the study is the internal consistency of the study, which is lower than other studies that is caused by the fewer number of subjects in the present study compared to other studies. conclusion the indonesian version of the mlhf questionnaire has good validity and reliability to evaluate the quality of life of patients with chronic heart failure in indonesia. references 1. ambrosy ap, fonarow gc, butler j, et al. the global health and economic burden of hospitalizations for heart failure: lessons learned from hospitalized heart failure registries. j am coll cardiol. 2014;63(12):1123–33. 2. badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia. riset kesehatan dasar (riskesdas) 2013. jakarta: kemenkes ri; 2013. p. 306. 3. moser dk, arslanian-engoren c, biddle mj, et al. psychological aspects of heart failure. curr cardiol rep. 2016;18(12):119. 4. dekker rl, lennie t a, doering l v, chung ml, wu j-r, moser dk. coexisting anxiety and depressive symptoms in patients with heart failure. eur j cardiovasc nurs. 2014;13(2):168–76. 5. freedland ke, carney rm, rich mw, steinmeyer bc, skala ja, dávila-román vg. depression and multiple rehospitalizations in patients with heart failure. clin cardiol. 2016;39(5):257–62. 6. yancy cw, jessup m, bozkurt b, et al. accf/aha guideline for the management of heart failure: a report of the american college of cardiology foundation/ american heart association task force on practice guidelines. circulation. 2013;128(16). 7. ponikowski p, voors aa, anker sd, et al. esc guidelines for the diagnosis and treatment of acute and chronic heart failure. eur heart j. 2016;37(27):2129– 200. 8. mann dl. management of patients with heart failure with reduced ejection fraction. in: mann dl, zipes dp, libby p, bonow ro, braunwald e, editors. braunwald’s heart disease: a textbook of cardiovascular medicine. 10th ed. philadelphia: elsevier; 2015. p. 512–46. 9. guyatt gh, feeny dh, patrick dl. measuring health-related quality of life. ann intern med. 1993;118(8):622–9. 10. dunderdale k, thompson dr, miles jn v, beer sf, furze g. quality-of-life measurement in chronic heart failure: do we take account of the patient perspective? eur j heart fail. 2005;7(4):572–82. 11. garin o, herdman m, vilagut g, et al. assessing health-related quality of life in patients with heart failure: a 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process for patient-reported outcomes (pro) measures: report of the ispor task force for translation and cultural adaptation. 2005;8(2):94–104. 17. ho cc, clochesy jm, madigan e, liu c-c. psychometric evaluation of the chinese version of the minnesota living with heart failure questionnaire. nurs res. 2007;56(6):441–8. 18. moon jr, jung yy, jeon es, choi jo, hwang jm, lee sc. reliability and validity of the korean version of the minnesota living with heart failure questionnaire. hear lung j acute crit care. 2012;41(1):57–66. 19. tangsatitkiat w, sakthong p. thai version of the minnesota living with heart failure questionnaire : psychometric testing using a longitudinal design. 2010;4(6):877–84. 20. rector ts, cohn jn. assessment of patient outcome with the minnesota living with heart failure questionnaire: reliability and validity during a randomized, double-blind, placebo-controlled trial of vol 51 • number 1 • january 2019 validity and reliability studies of the indonesian version of the minnesota 33 pimobendan. am heart j. 1992;124(4):1017–25. 21. heo s, moser dk, riegel b, hall la, christman n. testing the psychometric properties of the minnesota living with heart failure questionnaire. nurs res. 2005;54(4):265–72. 22. franzén k, blomqvist k, saveman b-i. impact of chronic heart failure on elderly persons’ daily life: a validation study. eur j cardiovasc nurs. 2006;5(2):137–45. 23. naveiro-rilo jc, diez-juárez dm, romero blanco a, et al. validation of the minnesota living with heart failure questionnaire in primary care. rev esp cardiol. 2010;63(12):1419–27. 24. brokalaki h, patelarou e, giakoumidakis k, et al. translation and validation of the greek “minnesota living with heart failure” questionnaire. hell j cardiol. 2015;56(1):10–9. 25. rector ts, cohn jn. assessment of patient outcome with the minnesota living with heart failure questionnaire: reliability and validity during a randomized, double-blind, placebo-controlled trial of pimobendan. pimobendan multicenter research group. am heart j. 1992;124(4):1017–25. 26. yurdugül h. minimum sample size for cronbach’s coefficient alpha: a monte-carlo study. hu j educ. 2008;35(1999):397–405. 27. streiner dl. starting at the beginning: an introduction to coefficient alpha and internal consistency starting at the beginning: an introduction to coefficient alpha and internal consistency. 2016;389:37–41. 28. suharsono t. dampak home based exercise training terhadap kapasitas fungsional dan kualitas hidup pasien gagal jantung di rsud ngudi waluyo wlingi. universitas indonesia; 2011. 29. kaawoan aya. hubungan self care dan depresi dengan kualitas hidup pasien heart failure di rsup dr rd kandou manado. universitas indonesia; 2012. 124 original article acta medica indonesiana the indonesian journal of internal medicine in-hospital major cardiovascular events between stemi receiving thrombolysis therapy and primary pci irsad a. arso1,2, budi y. setianto1,2, nahar taufiq1,2, anggoro b. hartopo1,2 1 department of cardiology and vascular medicine, faculty of medicine, universitas gadjah mada sardjito hospital, yogyakarta, indonesia 2 department of internal medicine, faculty of medicine, universitas gadjah mada sardjito hospital, yogyakarta, indonesia correspondence mail: department of cardiology and vascular medicine, faculty of medicine, universitas gadjah mada – sardjito hospital. jl. farmako sekip utara, yogyakarta 55281, indonesia. email: irsadandi_kardiologi@yahoo.com. abstrak tujuan: untuk membandingkan kejadian kardiovaskular mayor pada penderita infark miokard akut dengan elevasi segmen st (ima-est) yang mendapatkan terapi trombolisis dengan intervensi koroner perkutan (ikp) primer selama perawatan di rumah sakit. metode: penelitian kohort retrospektif dengan melihat rekam medik penderita ima-est onset <12 jam yang dilakukan terapi trombolisis dan tindakan ikp primer di rs. dr. sardjito yogyakarta mulai 1 januari 2008 sampai dengan 31 maret 2010. luaran klinik utama adalah kejadian kardiovaskular mayor yaitu gabungan kematian sebab kardiovaskular, reinfark dan stroke selama perawatan di rumah sakit. luaran klinik sekunder adalah angina pektoris pasca infark, gagal jantung, syok kardiogenik dan efek samping perdarahan. hasil: dari 78 penderita yang mendapat terapi trombolitik dan 53 penderita yang dilakukan tindakan ikp primer ditemukan kejadian kardiovaskular mayor selama perawatan di rumah sakit tidak berbeda bermakna yaitu 10,3% vs. 9,4% (rr 1,09; 95% ci 0,33-3,55; p=0,87). kejadian angina pektoris pasca infark adalah 7% vs. 3,8% (rr 2,51; 95% ci 0,50-12,60; p=0,24). kejadian gagal jantung lebih tinggi dan berbeda bermakna pada terapi trombolitik (17,9% vs. 5,7%, rr 3,64; 95% ci 0,99-13,38, p=0,04) dengan penurunan risiko relatif 68,1% pada ikp primer. kejadian syok kardiogenik tidak berbeda bermakna. efek samping perdarahan mayor dan minor tidak berbeda bermakna. kesimpulan: tidak ditemukan perbedaan bermakna kejadian kardiovaskular mayor antara ima-est yang diterapi trombolisis dan ikp primer selama perawatan rumah sakit. kejadian gagal jantung akut lebih tinggi pada terapi trombolitik, dan ikp primer menurunkan risiko gagal jantung akut. kata kunci: kejadian kardiovaskular mayor, ima-est, ikp primer, trombolisis. abstract aim: to compare the in-hospital major cardiovascular events between thrombolysis therapy and primary percutaneous coronary intervention (pci) in patients with st-elevation acute myocardial infarction (stemi. methods: the study design is retrospective cohort. medical record of patients with stemi onset <12 hour receiving thrombolysis treatment or primary pci in dr. sardjito hospital yogyakarta between january 2008 and march 2010 are evaluated. the primary outcome is major cardiovascular events which comprise cardiovascular death, reinfarction and stroke during hospitalisation. the secondary outcomes are post infarction angina pectoris, heart failure, cardiogenic shock and bleeding. results: among 78 patients with thrombolysis and 53 patients with primary pci, in-hospital major cardiovascular events do not differ significantly (10.3% versus 9.4%; rr 1.09, 95%ci 0.33-3.55; p=0.87). post infarction angina pectoris is 7% versus 3.8% (rr 2.51, 95%ci 0.50-12.60; vol 46 • number 2 • april 2014 in-hospital major cardiovascular events between stemi 125 p=0.24). the incidence of heart failure is significantly higher in thrombolysis (17.9% versus 5.7%; rr 3.64, 95%ci 0.99-13.38; p=0.04), primary pci reduces 68.1% relative risk to develop acute heart failure in stemi. the incidence of cardiogenic shock is not different. major and minor bleeding do not differ significantly either. conclusion: the in-hospital major cardiovascular events between stemi receiving thrombolysis therapy and primary pci is not significantly different. heart failure is significantly higher in thrombolysis therapy and the primary pci reduces the risk. key words: major cardiovascular events, stemi, primary pci, thrombolysis. introduction c o r o n a r y h e a r t d i s e a s e s c u r r e n t l y rank number one as the cause of death in developed countries, with acute myocardial infarction (ami) as the most frequent clinical manifestation. in 2006, approximately 1.2 million new cases emerged.1 almost one third of ami is diagnosed as ami with st segment elevation (stemi). between 25% and 35% ami cases die before receiving medical treatment, with ventricular fibrillation as the main cause of death.2 the improvement of medical facilities and advancement of intensive managements have reduced the mortality rate.3 this especially occurs in stemi due to the enhancement of early management with reperfusion strategies such as thrombolysis therapy or primary percutaneous coronary intervention (pci).3 thrombolysis therapy has limitations due to its contraindication in about 25% of cases, its failure in 15% and the reocclusion within 3 months in 25% of cases. this limitations can be overcome by primary pci. however, primary pci requires advance facility, skilled human resources and longer time-frame (door to procedure time).4 extensive clinical research have been performed comparing the effectiveness of thrombolysis therapy and primary pci. most studies reveal the superiority of primary pci over thrombolysis therapy in the reduction of major adverse cardiovascular events such as mortality, stroke and reinfarction.5 however, the research mostly come from developed countries which pioneered the revascularisation procedures for stemi. in developing countries, such as indonesia, the primary pci for stemi is only recently introduced and routinely performed in hospitals with cath-lab facilities. our hospital is one of the cardiac centers in this country which is capable of performing the procedure. in our hospital, primary pci has been carried out routinely since 2008. however, no evaluation of the outcome has been performed yet. in the present study, we evaluated and compared the in-hospital major cardiovascular events, i.e. the composite of death, reinfarction and stroke, between thrombolysis therapy and primary pci in patients with stemi onset <12 hour in dr. sardjito hospital yogyakarta, indonesia. methods the study design was the retrospective cohort. the subjects were patients hospitalised in intensive cardiovascular care unit (iccu) dr. sardjito hospital with stemi and received thrombolysis therapy or primary pci. the medical record data of these patients were retrieved and evaluated from january 1, 2008 until march 31, 2010. inclusion criteria were stemi diagnosis, anginal pain onset before procedure <12 hour and receiving thrombolysis with full dose streptokinase (1.5 million units within 1 hour) or primary pci. stemi was diagnosed based on angina type chest pain more than 30 minutes, st segment elevation on ecg with st segment elevates >2 mmv in 2 consecutive precordial leads or >1 mmv in 2 consecutive limb leads or the new lbbb and dynamic elevation of creatin kinase mb (ck-mb) or troponin.6,7 exclusion criteria were shock cardiogenic which cannot be overcome by primary pci, end-stage renal disease and creatinin level >1.5 mg/dl. from the patients who satisfy the inclusion and exclusion criteria, we documented the age, gender, pain onset, time from pain onset irsad a. arso acta med indones-indones j intern med 126 to thrombolysis therapy or primary pci, history of hypertension and diabetes mellitus, smoking status, haemoglobin level, lipid profile, previous infarction, stroke, stenting or balloon angioplasty, cabg, history of medications, clinical parameters on admission, haemodynamic disturbance based on killip class and infarct location based on ecg. primary outcome of the study was major cardiovascular events, i.e. composite of cardiovascular death, reinfarction and stroke, during intensive hospitalisation in iccu. cardiovascular death was a death due to cardial process such as cardiogenic shock, cardiac arrest or death without any other causes. reinfarction was repeated anginal type chest pain and changes in ecg (i.e st-segmen elevation >2 mmv in 2 precordial leads or >1 mmv in limb leads or new q wave in 2 consecutive leads and repeated elevation of normalized ckmb. stroke was new permanent neurological deficit and/or the presence of cerebral hemorrhage or ischemic lesion. secondary clinical outcomes are postinfarction angina, heart failure, cardiogenic shock and side effects of major and minor bleedings. statistics analysis was performed with spss version 15. patient characteristics are compared with t test for numerical data and chi square test for categorical data. clinical outcomes were analysed with bivariate analysis by cross tabulation chi square test (95% confidence interval) and multiple logistic regression analysis for various significant confounding variables. this study was approved by ethic committee of faculty of medicine universitas gadjah mada yogyakarta. results from medical record data, we retrieved 136 patients with stemi <12 hour who received reperfusion procedures. thrombolysis therapy was performed in 80 patients, two of these patients are excluded because they did not receive full dose streptokinase. primary pci was performed in 56 patients, three of these patients are excluded because they suffered from cardiogenic shock. of 78 patients with thrombolysis therapy, five patients (6.4%) have failed thrombolysis as indicated by no signs of >50% depression of st segment within 1 hour after thrombolysis. of 53 patients with primary pci, forty-nine patients (92.4%) underwent stent placement, two patients (3.7%) had only balloon inflation and one patient (1.8%) had thrombus aspiration. patient characteristics on admission and during hospitalisation in iccu are shown in table 1. the proportion of smoker, the use of anticoagulants and inferior wall infarction is significantly higher in patients with thrombolysis therapy. posterior infarction is greater in patients receiving primary pci. the time from admission to procedure (door to procedure time) is significantly longer in patients with primary pci. t h e p r o p o r t i o n o f i n h o s p i t a l m a j o r cardiovascular events is not significantly different between patients receiving thrombolysis therapy and primary pci (10.3% versus 9.4%; rr 1.09, 95%ci 0.33-3.55; p=0.87). the proportion of cardiovascular death between patients receiving thrombolysis therapy and primary pci does not significantly differ. reinfarction only occurs in one patient with thrombolysis therapy, while stroke occurs in two patients. overall, no increased risk to develop in-hospital major cardiovascular events are detected in thrombolysis group. after adjusting using logistic regression analysis which included several risk factors which significantly differ between patients receiving thrombolysis therapy and primary pci, i.e. smoking, the use of anticoagulant, inferior infarct location, posterior infarct location, total cholesterol level, we found that the thrombolysis therapy did not increase the risk for in-hospital major adverse cardiac events. the incidence of post infarction angina pectoris is almost 4 times higher in thrombolysis therapy as compared with primary pci, however this difference is not statistically significant. the incidence of heart failure is significantly higher in thrombolysis therapy as compared to primary pci. furthermore, primary pci is associated with 68.1% risk reduction of heart failure as compared to thrombolysis (p=0.04). the incidence of cardiogenic shock is not significantly different in thrombolysis therapy as compared to primary pci (p=0.52). vol 46 • number 2 • april 2014 in-hospital major cardiovascular events between stemi 127 table 1. characteristics of patients with stemi receiving thrombolysis therapy and primary pci in dr. sardjito hospital from january 2008 to march 2010 characteristics thrombolysis therapy (n=78) primary pci (n=53) age (years), mean±sd 55.31±8.08 58.54±10.9 gender, n(%) male 67(85.9) 46(86.8) female 11(14.1) 7(13.2) hypertension, n(%) 31(39.7) 25(47.2) smoking, n(%) 50(64.1) 25(47.2) diabetes mellitus, n(%) 19(24.4) 12(22.6) previous myocardial infarction, n(%) 2(2.0) 5(9.4) previous pci, n(%) 0(0) 3(5.7) previous stroke, n(%) 3(3.8) 3(5.7) on-admission parameters, mean±sd systolic blood pressure (mmhg) 123.22±22.01 122.03±21.86 diastolic blood pressure (mmhg) 76.15±13.7 75.05±13.89 total cholesterol (mg/dl) 207.3±44.8 183.1±47.9 ldl cholesterol (mg/dl) 141.7±40.1 121.68±41.58 random glucose (mg/dl) 184.9±113.2 168.7±58.0 in-hospital medications, n(%) aspirin 77(98.7) 53(100) clopidogrel 76(97.4) 53(100) aspirin + clopidogrel 74(94.5) 53(100) anticoagulants 74(94.5) 35(66.1) beta blocker 20(25.6) 14(26.4) calsium channel blocker 2(2.6) 3(5.7) ace inhibitor/arb 58(74.4) 43(81.1) diuretics 19(24.4) 15(28.3) nitrate 55(70.5) 33(62.3) statin 70(89.3) 50(94.3) insulin 20(25.6) 11(20.8) peak ckmb, mean±sd 137.9±88.2 125.8±123.7 killip class, n(%) i 60(76.9) 43(81.1) ii 10(12.8) 6(11.3) iii 4(5.1) 2(3.8) iv 4(3.1) 2(1.5) infarct location, n(%) anterior 37(47.4) 27(50.9) anteroseptal 37(47.4) 27(50.9) inferior 40(51.3) 18(34.0) posterior 25(32.1) 6(11.3) lateral 16(20.5) 12(22.6) dextra 14(17.9) 5(9.11) pain onset (hour), mean±sd 4.4±2.4 4.8±3.9 door to procedur time (minute), mean±sd 71.4±42.1 96.2±70.4 irsad a. arso acta med indones-indones j intern med 128 based on age, the incidence of major cardiovascular events among patients >60 years old tends to be higher in those receiving thrombolysis therapy (23.3% versus 14.3%; rr 1.87, 95% ci 0.38-9.12; p=0.69). the side effect of bleeding tends to be higher in patients receiving thrombolysis therapy as compared to primary pci. the incidence of major bleeding is 1.3% in thrombolysis and 0% in primary pci (rr 1.68, 95% 1.46-1.94; p=1), minor bleeding is 12.8% in thrombolysis and 3.8% in primary pci (rr 3.75, 95% ci 1.46-1.94; p=0.12) and total bleeding is 14.1% in thrombolysis and 3.8% in primary pci (rr 4.18, 95% 0.88-19.72; p=0.07). discussion this study showed that in-hospital major cardiovascular events in stemi onset <12 hours did not differ significantly between patients receiving thrombolysis therapy and primary pci. adjusted with several confounding risk factors by logistic regression analysis also showed no significant difference. the incidence of cardiovascular death, reinfarction and stroke did not significantly differ either. previous studies, both clinical trials and cohort studies, which compared the effectiveness of thrombolysis therapy and primary pci in stemi showed different conclusions. studies which show no significant difference between thrombolysis therapy and primary pci are from every et al.,8 le may et al.,9 and ribichini et al.10 in contrasts, studies reported significantly increased major cardiovascular events in thrombolysis therapy compared to primary pci are studies performed by aversano et al.11 which reported 16.8% versus 9.8% (p=0.03) in stemi <12 hour, by garcia et al.12 which reported 17% versus 6.4% (p=0.01) in stemi <5 hour, by gusto iib trial13 which reported 13.6% versus 9.6% (p=0.03) incidence of 30-day major cardiovascular events in stemi <12 hours and by widimsky et al.14 which showed 23% versus 8% (p=0.02) incidence of 30-day mortality in table 2. the in-hospital major cardiovascular events in stemi patients receiving thrombolysis therapy and primary pci outcomes trombolysis (n=78) primary pci (n=53) rr 95% ci p value n % n % major cardiovascular events 8 10.3 5 9.4 1.09 0.33-3.55 0.87 cardiovascular death 5 6.4 4 7.5 0.83 0.21-3.28 0.80 reinfarction 1 1.3 0 0 0.98 0.96-1.01 0.40 stroke 2 2.6 3 5.7 0.43 0.07-2.71 0.36 table 3. logistic regression analysis with several risk factors for in-hospital major adverse cardiac events in patients with thrombolysis therapy as compared to patients receiving primary pci risk factors rr 95% ci p value thrombolysis therapy 0.95 0.14-4.81 0.95 smoker 1.43 0.36-5.55 0.60 total cholesterol levels 0.99 0.97-1.00 0.40 inferior infarct 0.13 0.06-1.63 0.16 posterior infarct 1.55 0.29-8.16 0.59 anticoagulant treatment 0.48 0.46-5.03 0.54 table 4. post infarction angina pectoris, heart failure and cardiogenic shock in stemi patients receiving thrombolysis therapy and primary pci outcomes trombolysis (n=78) primary pci (n=53) rr 95% ci p value n % n % post infarction angina 7 9.0 2 3.8 2.51 0.50-12.60 0.24 heart failure 14 17.9 3 5.7 3.64 0.99-13.38 0.04 cardiogenic shock 3 3.8 1 1.9 2.08 0.21-20.55 0.52 vol 46 • number 2 • april 2014 in-hospital major cardiovascular events between stemi 129 stemi <6 hours. keeley et al.5 performed a meta-analysis from 23 clinical trials in stemi <12 hours and reported cardiovascular events were higher in thrombolysis therapy as compared to primary pci (18% versus 8%, p<0.001). the incidence of post infarction angina pectoris in this study was not significantly different between patients receiving thrombolysis therapy and primary pci. reduction of the incidence of post-infarction angina pectoris by primary pci as compared to thrombolysis therapy have already been reported.9,10,12,14 however, our study could not replicate the previous findings although we showed the tendency of risk reduction of post infarction angina pectoris among primary pci. heart failure and cardiogenic shock after acute myocardial infarction are clinical manifestations of reduced left ventricular function, both systolic and diastolic functions.15 they are derived from reduced contractile function in the infarcted area, infarct expansion and increased pressure on ventricular wall due to increased intraventricular blood volume. many mediators and patomechanism occur in this vicious circle involving various organs such as heart, lung and kidney.16 the patency of coronary artery after reperfusion will improve the left ventricular function and heart contractility which halt the vicious circle.17 therefore, successful reperfusion will reduce the incidence of heart failure and cardiogenic shock. in our study, the incidence of heart failure in thrombolysis patients is significantly higher and primary pci reduces the risk of acute heart failure in about 68.1%. the risk of cardiogenic shock is also tended to decrease in primary pci. however,the gusto iib trial showed no significant difference of heart failure and cardiogenic shocks between the two arms.13 in this study, among elderly patients (age >60 years) the incidence of major cardiovascular events tend to be higher in thrombolysis therapy than in primary pci. primary pci associates with reduced risk of 38.6% among elderly. grines et al.18 investigated high-risk groups and found the incidence of 30-day cardiovascular events almost twice than low-risk groups. however, other study involving elderly >70 years showed no significant difference in major cardiovascular events.19 adverse effect of bleeding, both major and minor bleeding, tends to be greater in thrombolysis. the incidence of major bleeding in thrombolysis therapy is 1.3%, whereas no bleeding is observed in primary pci. minor bleeding in thromboysis therapy is almost fourtimes as compared to primary pci, but this is not significant. as a whole, total bleeding is slightly higher by the factor of four in thrombolysis therapy. the result is similar with other previous studies.10,11,13,14 several limitations are observed in this study. the first is the relatively small sample size that reduce the power to detect significant differences between groups. the second is the nature of the study design which involves many biases in the selection of patients and the allocation for revascularisation procedure. conclusion the study showed no significant difference on the incidence of in-hospital major cardiovascular events in stemi onset <12 hours between patients receiving thrombolysis therapy and primary pci the incidence of post-infarction angina pectoris, cardiogenic shock and events among elderly tend to be higher in thrombolysis therapy, primary pci reduced risk of these events. in-hospital heart failure was significantly higher in patients receiving thrombolysis therapy and primary pci reduced its relative risk. acknowledgments authors thank dr. dyah wulan anggrahini, ph.d for statistics analysis assistance during this study. references 1. thom t, haase n, rosamond w, et al. heart disease and stroke statistics—2006 update. a report from the american heart association statistics committee and stroke statistics subcommittee. circulation. 2006;113:e85-e151. 2. zheng zj, croft jb, gilews wh, et al. sudden cardiac death in the united states 1989-1998. circulation. 2001;104:2158-63. 3. rogers wj, canto jg, lambrew ct, et al. temporal trends the treatment of over 1,5 million patient with myocardial infarction in the us from 1990 through irsad a. arso acta med indones-indones j intern med 130 1999: the national registry of myocardial infarction 1,2 and 3. j am coll cardiol. 200;36:2056-63. 4. gusto angiografic investigators. the effects of tissue plasminogen activator, streptokinase, or both on coronary-artery patency, ventricular function, and survival after acute myocardial infarction. n eng med j. 1993;329:1615-22. 5. keeley ec, boura ja, grines cl. primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. lancet. 2003;361:13-20. 6. antman em, anbe dt, amstrong pw, et al. acc/ aha guidelines for management of patient with stelevation myocardial infarction-executive summary: a report of the american college of cardiology/ american heart association task force on practice guidelines. circulation. 2004;44:671-719. 7. vahanian a, camm j, de caterine r. acute myocardial infarction. compendium of abridged european society of cardiology guidelines. philadelphia: lippincot william & wilkins; 2008. p. 69-74. 8. every nr, parsons ls, hlatky m, et al. a comparison of thrombolytic therapy with primary coronary angioplasty for acute myocardial infarction. n eng med j. 1996;336:1253-60. 9. le may ml, labinaz m, davies rf, et al. stenting versus thrombolysis in acute myocardial infarction trial (stat). j am coll cardiol. 2001;37:985-91. 10. ribichini f, stefinino g, dellavalle a, et al. comparison of thrombolytic therapy and primary coronary angioplasty with liberal stenting for inferior myocardial infarction with precordial st-segment depression. j am coll cardiol. 1998;32:1687-94. 11. aversano t, aversano lt, passamani e, et al. thrombolytic therapy vs primary percutaneous coronary intervention for myocardial infarction in patients presenting to hospitals without on-site cardiac surgery. a randomized controlled trial. jama. 2002;287:1943-51. 12. garcia e, elizaga j, castellano np, et al. primary angioplasty versus systemic thrombolysis in anterior myocardial infarction. j am coll cardiol. 1999;33:60511. 13. gusto iib investigators. a clinical trial comparing primary coronary angioplasty with tissue plasminogen activator for acute myocardial infarction. n engl j med. 1997;336:1621-8. 14. widimsky p, groch l, zelizko m, et al. multicenter randomized trial comparing transpot to primary angioplasty vs immediate trombolysis vs combined strategy for patients with acute myocardial infarction presenting to a community hospital without a catherization laboratory. the prague study. eur heart j. 2000;21:823-31. 15. h o c h m a n j s . a c u t e m y o c a r d i a l i n f a r c t i o n : complication. in: topol er, et al, eds. textbook of cardiovascular medicine. 3th edition. new york: lippincott williams & wilkins; 2007. p. 303-26. 16. hartopo ab, setianto by, gharini ppr. predictive value of different estimated glomerular filtration rates on hospital adverse events following acute myocardial infarction. acta med indones-indones j intern med. 2013;45:114-22. 17. ralf gl, o’neill ww. interventional therapy of acute coronary syndromes. prog cardiovasc dis. 2002;44(6):455-68. 18. grines cl, westerhausen dr, grines ll, et al. a randomized trial of transfer for primary angioplasty versus on site thrombolysis in patients with hight risk myocardial infarction. j am coll cardiol. 2002;39:1713-9. 19. bueno h, betriu a, heras m, et al. primary angioplasty vs. fibrinolysis in very old patients with acute myocardial infarction: triana (tratamiento del infarto agudo de miocardio en ancianos) randomized trial and pooled analysis with previous studies. eur heart j. 2011;32:51-60. review article 320 acta medica indonesiana the indonesian journal of internal medicine intra-uterine growth retardation and development of hypertension haerani rasyid, syakib bakri department of internal medicine, faculty of medicine, hasanuddin university dr. wahidin sudirohusodo hospital, makassar, south sulawesi, indonesia. corresponding author: haerani rasyid, md., phd. division of nephrology-hypertension, department of internal medicine, faculty of medicine, hasanuddin university dr. wahidin sudirohusodo hospital. jl. perintis kemerdekaan no. 10, makassar 90245, south sulawesi, indonesia. email: haeraniabdurasyid@yahoo.com. abstrak bayi berat lahir rendah (bblr) didefinisikan sebagai bayi yang lahir dengan berat <2500 gram. penyebab bblr di negara maju umumnya adalah prematuritas, sedangkan di negara berkembang sebagian besar oleh karena gangguan pertumbuhan intra-uterin. konsep perkembangan penyakit pada usia dewasa khususnya hipertensi dan penyakit ginjal dihubungkan dengan lingkungan intrauterin, gangguan pertumbuhan intrauterin, kelahiran prematur dan nutrisi janin. hipotesis “the fetal origin” menyatakan bahwa penyakit metabolik secara langsung berhubungan dengan status nutrisi yang buruk pada fase awal kehidupan. terdapat hubungan terbalik antara bblr dengan risiko kejadian hipertensi di masa mendatang. patomekanisme hubungan antara bblr dan hipertensi bersifat multifaktorial yaitu hambatan nefrogenesis, faktor gen, hiperaktiifitas saraf simpatik, disfungsi endotel, defisiensi elastin, resistensi insulin dan aktivasi sistem renin angiotensin. kata kunci: gangguan pertumbuhan intra-uterin, hipertensi. abstract low birth weight (lbw) is defined as a birth weight of a liveborn infant of <2,500 gram. in developed countries, lbw is commonly caused by preterm birth; while in developing countries, it is mostly due to intrauterine growth retardation. the concept of developmental origins of adult diseases, particularly on lateonset diseases such as hypertension and kidney disease, implies that there is a correlation between intrauterine milieu, intrauterine growth retardation, premature birth and infant feeding. the ‘fetal origin hypothesis’ suggests that metabolic diseases are directly related to poor nutritional status in early life. there is an inverse association between lbw and later risk of hypertension. the pathomechanism that links lbw and hypertension is multifactorial including delayed nephrogenesis, genetic factors, sympathetic hyperactivity, endothel dysfunction, elastin deficiencies, insulin resistance and activation of renin-angiotension system. keywords: intra-uterine growth retardation, hypertension. vol 48 • number 4 • october 2016 intra-uterine growth retardation and development of hypertension 321 introduction low birth weight (lbw) is defined as a birth weight of a liveborn infant of <2,500 gram. in developed countries, lbw is commonly caused by preterm birth; while in developing countries, it is mostly due to intrauterine growth retardation. when it is associated with gestational age, lbw can be categorized into lbw that is appropriate for gestational age (aga) and lbw that is small for getational age (sga).1 it has been estimated that 8-26% of all child birth worldwide is lbw, in which higher prevalence is found in developing countries compared to the developed countries.2 fetal size is affected by maternal nutritional intake and available uterine space on fetal development. impaired fetal nutritional intake due to undernutrition during pregnancy, uterine vascular abnormalities (preeclampsia and cardiovascular risk factors including hypertension and smoking) as well as primiparity, hydroamnios, gemelli and low maternal body size may lead to lbw.3 the concept of developmental origins of adult diseases, particularly on late-onset diseases such as hypertension and kidney disease, implies that there is a correlation between intrauterine milieu, intrauterine growth retardation, premature birth and infant feeding.4 a study by barker et al.5 indicates that intrauterine factors have roles on adult-onset cardiovascular and metabolic diseases. various studies have also demonstrated the tendency of increased blood pressure in adult life in infants with small size at birth, small head circumference, small placenta size and disproportional birth weight to placenta size.6 fetal programming during intrauterine period, body tissues experience rapid cell divisions, which is called the critical periods. poor nutritional supply will reduce the capacity for cell division.7 low birth weight is an important indicator for nutritional status and fetal growth. the ‘fetal origin hypothesis’ suggests that metabolic diseases are directly related to poor nutritional status in early life. nutritional deprivation during pregnancy usually will cause low birth weight.8 baker et al.9 have demonstrated that impaired fetal growth is associated with increased mortality due to cardiovascular disease in later life. suboptimal intrauterine condition will cause fetal growth retardation and induce phenotype changes in consistent with the condition. such adaptive process is aimed to increase the capacity of intrauterine life and postnatal condition. for example, blood supply and nutritional delivery to the brain remain optimal by sacrificing the blood flow and nutritional supply to organs considered less vital. however, the adaptive response may result in later consequences such as hypertension, kidney disease, insulin resistance and type-2 diabetes mellitus, particularly in supporting postnatal conditions such as obesity, high salt intake and stress.3 pathomechanism link between lbw and hypertension blood pressure is affected by intravascular volume and peripheral resistance. an increase in one of those two factors will cause hypertension. t h e p a t h o m e c h a n i s m o f h y p e r t e n s i o n development in subjects with lbw has not been fully understood, but the available evidences have demonstrated that it may result from interactions of various factors: nephrogenesis inhibition experimental animal and human studies have demonstrated that kidney has a role on the correlation between maternal undernutrition and intrauterine programming of hypertension. brenner et al.10 suggest that a reduced nephron number is associated with hypertension. kidney structure, in this case, the nephron number, is the predictor of hypertension and chronic kidney disease incidences. in afro-american population, in which has high prevalence of hypertension and progressive kidney disease, autopsy studies have found smaller kidney size and less number of nephron.11 keller et al.12 has also demonstrated that patients with hypertension have smaller number of nephron than the control group that have normal blood pressure. reduced nephron number will cause glomerular hyperfunction. in this case, nephromegali, intraglomerular hypertension and glomerular hyperfiltration occur. in long term, the haerani rasyid acta med indones-indones j intern med 322 process will lead to glomerulosclerosis, damage of nephrons and increased blood pressure. rapid weight gain after birth can cause exacerbation of glomerular damage as the immense body mass will increase excretion load.12 other factors assumed as the cause of nephrogenesis impairment in intrauterine under-nutrition are: a). life history theory. it is assumed that impaired nephrogenesis is caused by a mechanism, which is known as the life history theory. the theory suggests that in under-nutrition condition, energy allocation will be prioritized for vital organ such as the brain by sacrificing the nutrition for less vital organ, in this case, including the kidney.12 b). the effect of maternal glucocorticoid on fetus. glucocorticoid has an important role on fetal growth due to its effect on the expressions of various proteins at cellular and molecular levels. during pregnancy, there is a lower glucocorticoid level in fetus than the maternal level. 11b-hydrosteroiddehydrogenase (11b-hsd2) is an enzyme that converts active cortisol into inactive form. the enzyme expression is increased in the placenta and it inhibits maternal glucocorticoid entering fetal blood circulation. it has been demonstrated that there is reduced level of 11b-hsd2 enzyme in experimental animals with low-protein diet that may explain the increased glucocorticoid level in fetus.13 fetal hypoxia can also reduce 11b-hsd2 level and the activity of cystotrophoblasts. there are evidences that glucocorticoid causes organogenesis inhibition in fetus. a study with lambs that had received only dexamethasone for 2 days (day 26 and day 28 of 150 days of pregnancy) shows that it can cause incrased blood pressure starting from the 4th month afterbirth until the later life of those experimental animals, in which the autopsy study has found reduced nephron number as many as 40% compared to control.14 c). the role of angiotensin ii. angiotensin ii (ang-ii) has been known to have an important role on organogenesis including the kidney. during the under-nutrition condition, the intrauterine renin-angiotensin (ra) system is suppressed. a study shows that there is reduced expression of rennin gene with protein restriction during pregnancy. cellular mechanism of organ development shows that growth depends on the balance between cell proliferation and apoptosis. in experimental animal, intrauterine growth restriction (iugr) is associated with increased apoptosis of kidney. the neonates of rats that were born from mothers with low protein intake during pregnancy have less glomerulus than those whose mothers had normal protein intake. morphological and molecular analysis has found that there is an increased metanephric apoptosis in iugr group. apoptosis has a role in normal nephrogenesis.15 genetic factors in the neonates of rats whose mothers have recieved low protein intake during pregnancy, there is an increased expressions of several genes including genes that code sodium transports such as bumetanide-sensitive na-k-2 cl cotransporter (bsc1) and thiazide-sensitive na-cl co-transporter (tsc). increased expressions of glucocorticoid receptors such as a1 and bi subunit na-k-atpase have been found in pregnant mothers with protein restriction. these genes will increase sodium and water reabsorption, which have roles in the pathogenesis of hypertension.11 hyperactivity of sympathetic nerves it has been known that increased sympathetic activity has a role in pathomechanism of hypertension. in lbw, increased heart rate and reduced heart rate variability during sleep has been found compared to infants with normal birth weight, which indicate impairment of autonomic nerve activity. in adult life, infants with lbw also show increased resting pulse rate. this condition has been demonstrated by an experimental animal study using rats model of placenta insuficiency. kidney denervation in rat neonates prevents the development of hypertension. increased sympathetic activity may affect the pressure natriuresis and vasoconstriction, which result in increased blood pressure.1 endothelial dysfunction endothelial dysfunction has an important role in the pathomechanism of cardiovascular diseases including hypertension. in lbw, endothelial dysfunction occurs, which in various studies is demonstrated by the presence of impaired flowmedicated dilatation. endothelial dysfunction causes disturbed vascular remodeling, increased vol 48 • number 4 • october 2016 intra-uterine growth retardation and development of hypertension 323 vascular reactivity and inflammatory activity, in which those processes have been known to have roles in the development of hypertension and atherosclerosis. endothelial dysfunction in lbw is caused by reduced expression and activity of endothelial nitric oxide synthase (enos), reduced substrate availability for no production and increased oxidative stress.11 the role of elastin one of factors, which are assumed to have role on the correlation between lbw and hypertension include the amount and proportion and elastin of blood vessels. elastin is a polymer protein with high molecular weight located in the aorta with a function to regulate the elasticity of blood vessels, both vasoconstriction and vasodilatation. elastin turnover has a half-life time of approximately 40 years. with increasing age, the amount of elastin is getting less and therefore, it causes vascular rigidity. a study has demonstrated that the amount of vascular elastin is lower in lbw than those who are non-lbw.14 insulin resistance barker and hales16 have made a hypothesis, which is called the thrifty phenotype. the hypothesis suggests that fetal under-nutrition causes metabolic and/or physiological adaptation, which is aimed to assure nutritional supply to vital organs, such as brain by sacrificing the less vital organs such as pancreas. adaptation that occurs during the critical periods may be permanent, such as reduced pancreatic b-cells and insulin skeletal receptors, which later can develop insulin resistance. it has been known that insulin resistance has a role in pathomechanism of hypertension through some effects such as stimulation of sympathetic nerves and sodium retention. studies on hypertension in lbw the incidence of hypertension due to lbw is associtated with birth weight of the born infants. a study of 8,760 males and females in finland shows that 1,404 of them have hypertension treatment during their adulthood. the incidence of hypertension is 20.2% in those who have birth weight of up to 3 kg; 16.7% in those who have birth weight up to 3.5 kg, 13.6% in those with birth weight up to 4 kg and 12.3% in those with birth weight over 4 kg. age affects the incidence of hypertension in lbw.5 american nurses study shows that in lbw, the incidence of hypertension is 3% in young age and it is increased to 8.5% in older age.1 a meta-analysis of 80 studies shows that there is lower systolic blood pressure of approximately 2 mmhg for each increase of 1 kg birth weight. another study has found that every increase of 1 kg birth body weight is associated with a decrease of 2-3 mmhg blood pressure in children and teenagers; and a decrease of 2-4 mmhg in adults.3 the enigma study by miles et al.18 involves 882 participants in england to evaluate the correlation between birth weight, blood pressure, arterial stiffness and pulse reflection. the study has found that in male with lbw, there are high brachial sbp (p=0.04) and central pulse rate (p=0.03). mu et al.19 conducted a meta-analysis study of 27 studies to evaluate the correlation between birth weight and the development of hypertension. they have found that lbw (<2500 gram) is associated with increased risk of hypertension compared to those with birth weight of >2500 gram (or 1.2; 95% ci, 1.13, 1.30). when lbw (<2500 gram) is compared to birth weight of >2500 gram, there is an increase of mean sbp as many as 2.28 mmhg (95% ci 1.24; 3.33). the result indicates that there is an inverse linear correlation between birth weight and the risk of hypertension and the correlation is particularly obvious on sbp increase. however, there is a study with different result, the study by chiolero et al.20, that performed an analysis on three cohort studies involving 1004 subjects aged 5.5–9.1 years, 1886 subjects aged 9.1– 12.5 years and 1575 children aged 12.5-15.5 years in syechelles, africa. the study concludes that changes in body weight regardless of the age since childbirth have an important role on blood pressure in childhood and teenagers, in which blood pressure gives greater response on the current changes of body weight compared to changes of body weight before birth. haerani rasyid acta med indones-indones j intern med 324 conclusion low birth weight is a risk factor for cardiovascular and metabolic disorder in adulthood. epidemiological studies indicate that there is a correlation between lbw and hypertension in adulthood. the pathomechanism that links lbw and hypertension is multifactorial including delayed nephrogenesis, genetic factors, sympathetic hyperactivity, endothel dysfunction, elastin deficiencies, insulin resistance and activation of renin-angiotension system. references 1. alexander bt. fetal programming of hypertension. am j physiol. 2006:290;1-10. 2. saenger p, czernichow p, hughes i. small for gestational age short stature and beyond. endocr rev. 2006:28(2);219-52. 3. herskovits d, burbea z, skorechi k, et al. fetal programming of adult kidney disease; cellular and molecular mechanism. clin j am soc nephrol. 2007:2; 334-42. 4. ingelfinger jr, nuyt am. impact of fetal programming, birth weight, and infant feeding on later hypertension. j clin hypertens (greenwich). 2012;14:365–71. 5. barker djp, bagby sp, hanson ma. mechanisms of disease: in utero programming in the pathogenesis of hypertension. nature clin pract nephrol. 2006:2:12;700-7. 6. adabag sa. birthweight and the future risk of cardiovascular disease: does intrauterine malnutrition have a role in fetal programming. j clin med. 2001:138;356-78. 7. tappia sp, gabriel ac. role of nutrition in development of the fetal cardiovascular system. expert rev cardiovasc ther. 2006:4(2);11-225. 8. zhang y, li h, liu s, et al. the associations of high birth weight with blood pressure and hypertension in later life: a systematic review and meta-analysis. hypertens res. 2013;36:725–35. 9. barker dj, osmond c, simmonds sj, wield ga. the relation of small head circumference and thinness at birth to death from cardiovascular disease in adult life. bmj. 1993;306:422–6. 10. brenner bm, garcia dl, anderson s. glomeruli and blood pressure. less of one, more the other? am j hypertens. 1988;335-47. 11. franco mcp, nigro d, fortes zb, et al. intrauterine u n d e r n u t r i t i o n r e n a l a n d v a s c u l a r o r i g i n o f hypertension. cardiovasc res. 2003:60;228-34. 12. keller g, zimmer g, mall g, et al. nephron number in patients with primary hypertension. n engl j med. 2003:348;101-8. 13. newnham jp, moss t, nitsos i. nutrition and the early origins of adult disease. asia pasific j clin nutr. 2002:11;537-42. 14. vehaskary vm, woods l. prenatal programming of hypertension: lesson from experimental models. j am soc nephrol. 2005:16;2545-56. 15. welham sj, wade a, woolf as. protein restriction in pregnancy is associated with increased apoptosis of mesechymal cells at the start of rat metanephrogenesis. kidney int. 2002:61;1231-42. 16. barker djp, shiell aw, barker me, et al. growth in utero and blood pressure levels in the next generation. j hypertens. 2000:18;843-6. 17. bagby ps. maternal nutrition, low nephron number, and hypertension in later life:pathways of nutrional programming. j nutr. 2007:137;1066-72. 18. miles kl, mcdonnell bj, maki-petaja km, et al. the impact of birth weight on blood pressure and arterial stiffness in later life: the enigma study. j hypertens. 2011;29:2324–31. 19. mu m, wang sf, sheng j, zhao y, li hz, hu cl, tao fb. birth weight and subsequent blood pressure: a meta-analysis. arch cardiovasc dis. 2012:105; 99-113. 20. chiolero a, paradis g, madeleine g, hanley ja, paccaud f, bovet p. birth weight, weight change, and blood pressure during childhood and adolescence: a school-based multiple cohort study. j hypertens. 2011; 29:1871–9. clinical practice 369acta med indones indones j intern med • vol 49 • number 4 • october 2017 current and emerging therapy on lupus nephritis lucky a. bawazier department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta. corresponding author: lucky aziza bawazier, md., phd. division of nephrology, department of internal medicine, faculty of medicine universitas indonesiacipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: aziza.lucky17@gmail.com. abstrak nefritis lupus (nl) adalah keterlibatan organ ginjal pada pasien lupus eritematosus sistemik (les) dan merupakan salah satu keterlibatan organ yang paling sering ditemukan. ditemukannya nl pada pasien les akan berdampak besar baik secara prognosis dari pasien maupun dalam pengobatan itu sendiri. pengobatan nl dibagi menjadi dua tahap, induksi dan rumatan. target dari pengobatan tahap induksi adalah untuk secepatnya mencapai remisi, baik parsial ataupun komplit, karena akan memberikan prognosis yang lebih baik dan kejadian relapse yang lebih rendah. pada tahap rumatan, target yang ingin dicapai adalah untuk mempertahankan status remisi dan mencegah terjadinya relapse. evaluasi keberhasilan dari masing-masing tahap juga sangat penting karena akan berpengaruh pada kelanjutan pengobatan. kortikosteroid, siklofosfamid, mikofenolat mofetil, azatioprin, siklosporin dan takrolimus adalah obat-obat yang biasa dipakai dalam pengobatan nl. berbagai target pengobatan baru juga terus berkembang guna memberikan pilihan yang lebih luas dalam menangani kejadian nl. kata kunci: lupus eritematosus sistemik; nefritis lupus, ginjal. abstract lupus nephritis (ln) is involvement of the kidney in patient with systemic lupus erythematosus (sle) and one of the most common target organ in sle. the diagnosis of ln will significantly impact the clinical outcome and therapy of the patient. therapy regiment of ln is divided into two stages, induction and maintenance treatment. the main objective of the induction therapy is to achieve complete or partial remission as soon as possible since it is correlated with better prognosis and fewer relapse incidence. in the maintenance stage, the main aim of the therapy is to maintain the remission status and avoid future relapse. it is also important to evaluate the effectiveness of the therapy as it will affect the duration and the regiment therapy being used. corticosteroid, cyclophosphamide, mycophenolate mofetil, azathrioprine, cyclosporine and tacrolimus are example of drugs used in ln therapy. currently, studies are being conducted to evaluate and develop targeted drug therapy to further add treatment options for ln. keywords: systemic lupus erythematosus; lupus nephritis; kidney. lucky a. bawazier acta med indones-indones j intern med 370 introduction renal involvement in systemic lupus erythematosus (sle) plays a major factor that impact the clinical outcome on the patient. lupus nephritis (ln) was found in 40 – 60% of sle patients and can increase up to 70% over 10-year period after initial diagnosis.1 recent data shows 10-year survival of ln patient to range between 77 to 95%.2 despite advances in treatment, 26% of ln patients still develop end-stage renal disease (esrd) which cause a reduced in life expectancy by 15.1 – 23.7 years. infections, cardiovascular complication and malignancy contribute to the main cause of death associated with long-term ln treatment.3 the review aims to compare the regiments in terms of efficacy and safety for better clinical practice outcome. current induction therapy induction therapy is pivotal in treating patients with lupus nephritis (ln), the goal is to minimize renal damage, achieve rapid remission and/or complete remission.4 an effective induction therapy has been proven to give fewer episodes of relapse and better prognosis.4 induction therapy for ln patients is a continuously studied topic.4-6 in 1986, national institutes of health reported its 10-year follow up research and found that by combining high-dose steroids and cyclosphophamide (cyc) it gave a significantly better 10-year renal survival result than steroids alone.7 however, cyc also resulted various side effects such as suppression of bone marrow, malignancy, opportunistic infection, and so forth.7 despite, administration of steroids combined with intravenous (iv) cyc became the gold standard in treating ln patients until present.6 since then, researchers look for a safer immunosuppressants agents to replace cyc, for example mycophenolate mofetil (mmf), azathrioprine (aza), cyclosporine, and tacrolimus. mmf is the most promising alternative for cyc, although results from literatures displayed various results in inducing remission of ln between the two immunosuppressant’s agents.4,6,8 some studies concluded that mmf is more superior than cyc.9-11 on the other hand, others found that mmf is not-inferior or equal to cyc.12,13 nevertheless, most clinicians favor the use of mmf. unfortunately it is not covered in the health insurance program in indonesia.5 currently, researchers focus on multitarget induction therapy; combining multiple drugs to achieve better results and fewer side effects and shows promising results.14,15 a study in china compared a combination of tacrolimus, mmf, and steorids with the traditional iv cyc and steroids.13,14 the multitarget regiments showed a higher incidence of complete remission and less adverse events. a retrospective analysis in japan was conducted to examine the efficacy and safety of multitarget induction therapy using tacrolimus, mmf, and steroid with comparison of tac therapy (tacrolimus and steroid).15 it was found that all patients treated with multitarget therapy had complete remissions. a meta-analysis of randomized trials was done in 2017 to compare the efficacy and toxicity of newer immunosuppressants for ln.16 the study compared iv cyc, oral cyc, mmf, calcineurin inhibitor (cni), plasma exchange, rituximab, or azathioprine, alone or in combination. the study stated that mmf combined with cni was the most effective treatment to induce remission, followed by cni alone and mmf alone.16 although, it was also found that there was no difference on end-stage kidney disease or increasing of serum creatinine level between mmf or cci (alone or in combination) and iv cyc. according to kidney disease improving global outcomes (kdigo) 2012, the use of immunosuppressants are indicated for class iii/iv ln.17 class v ln are also given immunosuppressants in regards that endocapillary hypercellularity and/or subendothelial immune deposits is present and persistent nephrotic proteinuria.17 figure 1 shows the algorithm of induction therapy for ln. as for class i ln, kdigo 2012 does not recommend treatment due to no available data to suggest that it needs therapy.17 however, class ii ln with proteinuria under 1 g/d should be treated for extrarenal clinical manifestations and class ii ln with uncontrolled proteinuria (over 3 g/d) should be treated with corticosteroids or cnis.17 kdigo 2012 recommended 4 regiments to vol 49 • number 4 • october 2017 current and emerging therapy on lupus nephritis 371 be used in induction therapy, which are: regimen a (nih regimen), regimen b (euro-lupus regimen), regimen c (oral cyclosphophamide), and regimen d (mmf).17 all regimens used the same steroid dosing: initial dose of oral prednisone 1 mg/kg, tapering according to clinical response over 6-12 months. dosage and duration of the regimens can be seen in table 1. in addition, according to the spanish society of nephrology (sen) and society of internal medicine (semi) dosage of regimen b has minimum risk, almost to none, of ovarian failure because the total cyc given does not exceed 10 g.18 extrarenal manifestations must be treated with immunosuppression agents.17 american college of rheumatology (acr) also made a guideline for therapy of ln. mmf 2-3 g daily or iv cyc along with iv pulse steroids (500-1000 mg methylprednisolone daily for 3 doses) for class iii/iv ln are the recommended regimens, and both are considered equivalent based on recent studies.19 there are 2 recommended dosage for iv cyc, which are: low-dose cyc (500 mg iv fortnightly for a total of 6 doses) followed by maintenance therapy with daily oral aza and high-dose cyc (5001000 mg/m2 iv monthly for 6 doses) followed by maintenance therapy with mmf or aza.19 figure 2 shows the algorithm made by acr. class v ln have different recommendation than class iii/iv ln according to acr. they recommend the administration of prednisone (0.5 mg/kg/day) combined with mmf 2-3 g total figure 1. induction therapy algorithm according to kdigo 2012.17 (ln = lupus nephritis; iv cyc = intravenous cyclosphophamide; cyc = cyclosphophamide; mmf = mycophenolate mofetil) table 1. regimens for induction therapy in class iii/iv ln according to kdigo 201217 regimen dosage duration nih iv cyc 0.5-1 g/m2 monthly 6 months euro-lupus iv cyc 500 mg fortnightly 3 months oral cyclosphophamide oral cyc 1-1.5 mg/ kg/day 2-4 months mmf oral mmf 3 g/day 6 months if the patients have worsening ln or flare during the first 3 months, alternative induction therapy can be used as a replacement.17 table 2 shows the immunosuppressants used in ln. class vi ln is described as chronic injury, where over 90% of the glomeruli are sclerotic.17 kdigo 2012 does not recommend immunosuppressive therapy for this class, nevertheless, patients with table 2. immunosuppressants used in ln17 immunosuppressant agents dosage cyc iv 0.5-1 g/m2; oral 1-1.5 mg/ kg/day mmf 3 g/day aza cyclosporine 4-5 mg/kg/day tacrolimus 4 mg/day* cyc = cyclosphophamide; iv = intravenous; mmf = mycophenolate mofetil; aza = azathioprine; * = combined with mmf 1 g/day lucky a. bawazier acta med indones-indones j intern med 372 daily dose.19 if an adequate respond to induction therapy is not achieved, acr recommend that a switch of the immunosuppressants from either cyc to mmf or from mmf to cyc accompanied by iv pulse steroids for 3 days.19 according to acr, class i and class ii ln does not require immunosuppressive therapy.19 furthermore, hydroxychloroquine (hcq) must be given to all systemic lupus erythematosus (sle) patients with nephritis as it has been proven to lower renal damage and reduce the risk of clotting events.19 in addition, ln patients with proteinuria over 0.5 g/d should be given renin-angiotensin system (ras) blockers such as angiotensin-converting enzyme (ace) inhibitors and angiotensin receptor blockers (arbs).19 as for class vi ln, it requires renal replacement therapy rather than immunosuppressive therapy.19 current maintenance therapy the target of induction therapy in treating lupus nephritis (ln) is to rapidly attenuate inflammation process caused by accumulation of autoantibody immune complex and to give chance to parenchymal tissue for healing process.20 after this phase of treatment, only few patients achieve complete clinical remission, as renal response rates showed 50-80% at 1 year with the majority of the response was partial response.21 in order to consolidate remissions and prevent relapses of ln, one must receive maintenance therapy. guidelines of lupus nephritis treatment still recommends the use of either mmf or aza as the choice of maintenance therapy. there was still no definitive first line choice between the two options. based on kdigo (2012), in making the decision of treatment choice, clinical adjustments such as pregnancy plan or occurrence of side effects are considered.22 the use of aza as maintenance therapy is preferred if patient plan for pregnancy.23 treatment guidelines by acr (2012) recommends the use of either mycophenolate mofetil (mmf) 1-2 g/day or azathiprone (aza) 2 mg/kg/day in maintenance therapy of ln.19 figure 2. induction therapy for ln according to acr.19 (mmf = mycophenolate mofetil; cyc = cyclosphophamide; gc = glucocorticoids; iv = intravenous; aza = azathioprine; bsa = body surface area) vol 49 • number 4 • october 2017 current and emerging therapy on lupus nephritis 373 there were two big clinical trials aiming for optimal maintenance therapy for ln, which were the maintain study and aspreva lupus management study (alms). these two studies compared effectiveness between mmf and aza. in alms trial, 227 patients were randomized to receive either mmf (2 g/day) or aza (2 mg/ kg/day). the follow-up duration was 36 months. the primary end point was time to treatment failure (death, end-stage renal disease, doubling of serum creatinine level, renal flare, or rescue therapy). this trial showed that mmf was superior to aza in the aspect of time to treatment failure (hazard ratio 0.44; 95% confidence interval, 0.25—0.77; p=0.003) and time to rescure therapy (hazard ratio <1.00; p<0.05). serious adverse events occurred more in aza group than in mmf group (33.3% vs 23.5%, p=0.11).24 in maintain trial, with the same follow up duration (36 months), 105 patients were randomized to receive either mmf or aza with the same dosage.25 time to renal flare in mmf and aza group were statistically insignificant (19% and 25% respectively).25 the duration of therapy in maintenance phase is still questionable. according to kdigo 2012, the average duration of maintenance therapy was 3.5 years.22 a guideline by spanish society of nephrology (geas) recommended that duration of maintenance therapy was 2 years after complete remission.26 euro-lupus nephritis trial was a ten-year follow-up study which showed that 53% of the patients were still on maintenance therapy. advice from the dutch’s guideline on ln stated that clinicians should taper the dose of prednisone to 10 mg every other day at four years after the beginning of induction therapy and followed by decreasing 50% dose of aza or mmf 6 months later and continue until at least two more years.27 after 6.5 years, it is left to the treating clinician’s decision and the patient’s.28 table 3 summarize the comparison of guidelines on the maintenance therapy of lupus nephritis class iii/iv. evaluation currently, the gold standard of care for patients with lupus nephritis (ln) after induction therapy is to administer maintenance therapy for around 3 years. in a subset of patients with clinically silent disease, the decision to stop maintenance therapy should be done with caution. in order to decide whether these patients table 3. comparison of guidelines on maintenance therapy of lupus nephritis class iii/iv guidelines corticosteroid immunosuppresive agent choice duration and dosage tapering kidney disease improving global outcomes (kdigo)22; 2012 low-dose oral corticosteroids (≤10 mg/day prednisone equivalent) mmf 1-2 g/day or aza 1.5-2.5 mg/day continue at least 1 year after complete remission european league against rheumatism and european renal association-european dialysis and transplant association (eular/eraedta)23; 2012 low-dose oral corticosteroids mmf or aza. mmf was preferred if there was adequate response to mmf in induction phase. three years after complete remission. american college of rheumatology (acr)19; 2012 low-dose oral corticosteroids mmf 1-2 g/day or aza 2 mg/kg/day not specified. the task force panel did not vote on the rate of medication taper in maintenance phase. systemic autoimmune disease group of the spanish society of internal medicine and spanish society of nephrology (geas)26 low-dose oral corticosteroids mmf over aza two years after complete remission. dutch guidelines for diagnosis and therapy of proliferative lupus nephritis28; 2012 low-dose oral corticosteroids mmf over aza taper prednisone 10 mg every other day at 4 years after the beginning of induction phase, decrease 50% dose of aza or mmf after 6 months, and continue at least 2 more years (total: 6.5 years) lucky a. bawazier acta med indones-indones j intern med 374 do not need further therapy, repeated renal biopsy to confirm the histological evidence of non-active ln and laboratory work needs to be performed. repeat kidney biopsy in patients who have completed and responded well to the maintenance course treatment can also be planned to decide whether the therapy should be discontinued.29 the reason to be cautious before stopping therapy is that ln could still be active after several years of immunosuppressive therapy. renal flares after treatment withdrawal could lead to a more progressive chronic kidney injury. there are several criteria available to assess the renal response after therapy. however, those criteria are based on serum creatinine level, estimated glomerular filtration rate (egfr), proteinuria, urine protein creatinine ratio (upcr), hematuria, urinary sediment and cast. furthermore, flare criteria definition has been based on a guideline by kdigo which has criteria similar as to check renal response to therapy.30 table 4 presents the relapse renal flare criteria based on kdigd guidelines. novel and emerging treatment of lupus nephritis the pathogenesis of lupus nephritis (ln) is associated with activation of mainly b and t cells. activation of b cell further leads to formation of plasma cells and subsequently autoimmunity against the kidney, which will induce kidney damage through inflammation process. on the other hand, antigen presenting cells falsely presents autoantigen unto t cells which induces further inflammatory process through activation of pro-inflammatory cytokines. various proinflammatory cytokines have been described to be implicated in the pathogenesis of ln but it seems that interferon-α (ifn-α) is the master regulator of stimulating the differentiation of b cells and t cells.31,32 as stated before, b cells play an important role in ln and therefore it is an attractive target in ln treatment. one example of popular b cell depleting agent is rituximab, an anti-cd20 monoclonal antibody which has been studied extensively with mixed results. several early studies have reported potential benefit of rituximab. however, lupus nephritis assessment with rituximab study (lunar) failed to reproduce the same results from previous studies.33 currently, there is still ongoing interest in studying the effect of rituximab and other b cell depleting agents in the treatment of ln. scientists have questioned the trial design of lunar study as it was rather a short-term rather than a long-term study. rituximab as a b cell depleting agent has been argued not to resolve table 4. relapse/renal flare criteria based on kdigo guideline22 mild relapse moderate relapse severe relapse increased of hematuria from <5 to >15 erythrocyte/ hpf, with >2 acanthocyte/ hpf if baseline serum creatinine (scr) <2 mg/dl, moderate relapse is defined as increased of scr 0.2-1 mg/dl if baseline creatinine <2 mg/dl, severe relapse is defined as increased of scr >1 mg/dl. with/without if baseline serum creatinine (scr) >2 mg/dl, moderate relapse is defined as increased of scr 0.4-1.5 mg/dl if baseline creatinine >2 mg/dl, severe relapse is defined as increased of scr >1.5 mg/dl. recurrence of >1 erythrocyte, leucocyte (without infection), or both with/without with/without if baseline urine protein creatinine ratio (upcr) <500 mg/g, moderate relapse is defined as increased of upcr >1000 mg/g. increased of upcr >5000 mg/g if baseline upcr 500-1000 mg/g, moderate relapse is defined as increased of upcr between 2000-5000 mg/g. if baseline upcr >1000 mg/g, moderate relapse is defined as increased of upcr >2 times with absolute upcr <5000 mg/g. vol 49 • number 4 • october 2017 current and emerging therapy on lupus nephritis 375 acute inflammation of the kidney, but rather it might prevent future renal flares since it works by inhibiting autoimmunity response and not the acute inflammation process.37 to address this concern, a trial is underway to investigate the effect of similar b cell depleting agent like rituximab, which involves obinutuzumab, a type2 chimeric, anti-cd20 monoclonal antibody. early initial studies reported better results than rituximab. therefore, it is currently in clinical trial to evaluate the depletion of b cells in kidney tissues.38.39 another example of potential b cell depleting agents are belimumab and tabalumab, an anti-baff monoclonal antibody. b cells activating factors (baff) is needed to induce b cell proliferation and survival, thus the use of this agent in ln treatment is promising.40 current topic suggests that baff level increases after b cell depletion. it is stated that reactivation of b cells in baff-rich environment after b cells depletion will lead to more autoreactive b cells, which bypass the tolerance checkpoints. it is known that high baff level is associated with renal flares in sle. hence, it is suggested that targeting baff after initial b cell depletion is essential to prevent reactivation of b cells and hopefully make these b cells more tolerant, less autoreactive, and more sustained clinical response. the immune tolerance network calibrate study is currently testing this hypothesis in clinical trial.41 plasma cells are also an interesting target in sle. it is a product of b cell activation which produces autoimmunity against self-antigen. even though b cell depleting agents have been widely used, those agents do not directly eliminate all plasma cells which have been formed before the therapy is given.42 plasma cells, especially the long-lived one, can produce autoantibody and have been found in sle during flare. current standard treatment does not target the plasma cells in order to supress the long-lived plasma cells, but rather it emphasizes more on b cells depletion.43 proteasome inhibitor targets the plasma cells and induces apoptosis. several example of its agents are bortezomib, carfilzomib, delanzomib, and ixazomib. proteasome inhibitor is also known to have dual mechanism of action as anti-inflammatory by suppresing ifn-α and as anti-autoimmunity. currently, there are several clinical trials evaluating patients who are not responsive to initial standard of care treatment.44 ifn-α is a key biological target to attenuate inflammatory process in sle and ln patients. an example of an ifn-α which is currently in clinical trial is anifrolumab, a monoclonal antibody that targets ifn-α receptor 1. anifrolumab has shown its efficacy in non-renal sle when compared to placebo in patients who have high type ifn-α signature. the tulip ln 1 study is undergoing an investigation of anifrolumab combined with the gold standard treatment for proliferative ln. in this study, the researchers divides patients into table 5. response criteria definitions study complete remission partial remission national institute of health (nih)34 scr <130% from the lowest value, proteinuria <1 gr/24 hour, hematuria <10 red blood cells/hpf, without evidence of cellular cast scr <150% from the lowest value euro-lupus nephritis trial (elnt)35 this guideline does not divide remission criteria into complete or partial. remission criterias are as follow: hematuria <10 red blood cell/hpf, proteinuria <1 gr/24 hour, scr value does not increase 2 times above normal value. american college of rheumatology (acr)19 50% decrease of upcr + upcr <0.2 50% decrease of upcr + upcr 0.22.0 kdigo36 scr returns to baseline, plus decrease of upcr <500 mg/gr (<50 mg/mmol). stabilized (±25%) or improvement of scr but not return to normal, plus decrease of upcr >50%. if nephrotic proteinuria is found, upcr should decrease >50%. lucky a. bawazier acta med indones-indones j intern med 376 two groups. the first group consists of patients who have high ifn-α and the other group who have low ifn-α concentration. this is necessary to prevent treating patients who do not actually express the drug’s target which predictably will result in treatment failure.45 another appealing therapy strategy in ln is to target complement pathway. this alternative pathway seems to be important to cause kidney damage through inflammation process.46 current example of complement activation products include c3bi, c5a, and c5b-9. there is a hypothesis stating that inclusion of complement targeted therapy in combination with gold standard treatment might help to attenuate inflammation and reduce the use of corticosteroid.47 however, evidence of its efficacy in ln has not been extensively evaluated. therefore, further research regarding agents which target this pathway is important.48 references 1. patel m, clarke am, bruce in, symmons dp. the prevalence and incidence of biopsy-proven lupus nephritis in the uk: evidence of an ethnic gradient. arthritis rheumatol. 2006;54(9):2963-9. 2. borchers at, leibushor n, naguwa sm, cheema gs, shoenfeld y, gershwin me. lupus nephritis: a critical review. autoimmun rev. 2012;12(2):174–94. 3. yap d, tang c, ma m, lam m, chan t. survival analysis and causes of mortality in patients with lupus nephritis. nephrol dial transplant. 2012;27(8):324854. 4. bomback sa, appel gb. updates on the 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meara a, rovin bh. update on lupus nephritis. clin j am soc nephrol. 2016; doi:10.2215/ cjn.05780616. 21. rovin bh, furie r, latinis k, et al. efficacy and safety of rituximab in patients with active proliferative lupus nephritis. arthritis rheumatism. 2012;64(4):1215-26. 22. eknoyan g, lameire n, eckardt k, et al. kdigo clinical practice for glomerulonephritis. kidney intl suppl. 2012;2(2):221-32. 23. bertsias gk, tektonidou m, amoura z, et al. joint european league against rheumatism and and european renal association—european dialysis vol 49 • number 4 • october 2017 current and emerging therapy on lupus nephritis 377 and transplant association (eular/era-edta) recommendations for the management of adult and paediatric lupus nephritis. ann rheum dis. 2012;71:1771-82. 24. dooley ma, jayne d, ginzler em, et al. mycophenolate versus azathioprine as maintenance therapy for lupus nephritis. n engl j med. 2011;365:1886-95. 25. houssiau fa, cruz d, sangle s, et al. azathioprine versus mycophenolate mofetil for long-term immunosuppression in lupus nephritis: results from the maintain nephritis trial. ann rheum dis. 2010;69:2083-9. 26. ruiz ig, espinosa g, frutos ma. diagnosis and treatment of lupus nephritis. consensus document from the systemic auto-immune disease group (geas) of the spanish society of internal medicine (semi) and spanish society of nephrology (s.e.n.). nefrologia. 2012;32(1):1-35. 27. arends s, grootscholten c, derksen rh, berger sp, de sevaux rg. long-term follow-up of a randomised controlled trial of azathioprine/methylprednisolone versus cyclophosphamide in patients with proliferative lupus nephritis. ann rheum dis. 2012;71(6):966-73. 28. tellingen av, voskuyl ae, vervloet mg, et al. dutch guidelines for diagnosis and therapy of proliferative lupus nephritis. netherlands j med. 2012;70(4):199206. 29. corapi km, dooley ma, pendergraft wf. comparison and evaluation of lupus nephritis response criteria in lupus activity indices and clinical trials. arthritis res and ther. 2015;17:110. 30. haladyj e, cervera r. do we still renal biopsy in lupus nephritis? reumatologia. 2016;54(2):61-6. 31. ronbloom l, alm gv, eloranta ml. the type i interferon system in the development of lupus. semin immunol. 2011;23:113-21. 32. tucci m, quatraro c, lombardi l, pellegrino c, dammaco f, silvestris f. glomerular accumulation of plasmacytoid dendritic cells in active lupus nephritis: role of interleukin-18. arthritis rheum. 2008;58:251-62. 33. rovin bh, furie r, latinis k, et al. lunar investigator group: efficacy and safety of rituximab in patients with active proliferative lupus nephritis: the lupus nephritis assessment with rituximab study. arthritis rheum. 2012;64:1215-26. 34. mok cc, yap dy, navarra sv, et al. overview of lupus nephritis guidelines and perspective from asia. nephrol. 2014; doi:10.1111. 35. houssiau fa, vasconcelos c, d’cruz d, et al. immunosuppressive therapy in lupus nephritis: the euro-lupus nephritis trial, a randomized trial of lowdose versus high-dose intravenous cyclophosphamide. arthritis rheum 2002;46:2121-31. 36. sloan rp, schwartz mm, korbet sm, borok rz. lupus nephritis collaborative study group: long-term outcome in systemic lupus erythematosus membranous glomerulonephritis. j am soc nephrol. 1996;7:299305. 37. dooley ma, houssiau f, aranow c, et al. bliss-52 and -76 study group: effect of belimumab treatment on renal oucomes in patients with sle. lupus. 2013;22:63-72. 38. goede v, fischer k, busch r, et al. obinutuzumab plus chlorambucil in patients with cll and coexisting conditions. n eng j med. 2014;370:1101-10. 39. mossner e, brunker p, moser s, et al. increasing the efficacy of cd20 antibody therapy through the engineering of a new type ii anti-cd20 antibody with enhanced direct and immune effector cell-mediated b-cell cytotoxicity. blood. 2010;115:4393-02. 40. rovin bh, dooley ma, radhakrishnan j, et al. the impact of tabalumab on the kidney in systemic lupus erythematosus: results from phase 3 clinical trials. lupus. doi: 10.11177/0961203316650734. 41. pollard rp, abdulahad wh, vissink a, et al. serum levels of baff, but not april, are increased after rituximab treatment in patients with primary sjorgen’s syndrome: data from a placebo-controlled clinical trial. ann rheum dis. 2013;72:146-8. 42. c h e n g q , m u m t a z i m , k h o d a d a d i l , e t a l . autoantibodies from long-lived memory plasma cells of nzb/w mice drive immune complex nephritis. ann rheum dis. 2013;72:2011-7. 43. espeli m, boekrs s, giannco g, et al. local renal autoantibody production in lupus nephritis. j am soc nephrol. 2011;22:296-305. 44. hiepe f, domer t, hauser ae, et al. long-lived autoreactive plasma cells drive persistent autoimmune inflammation. nat rev rheumatol. 2011;7:170-8. 45. furie r, merrill jt, werth vt, et al. anifrolumab, an anti-interferon alpha receptor monoclonal antibody in moderate to severe systemic lupus erythematosus. am coll rheumatol. 2015. 46. barilla-labarca ml, toder k, furie r. targeting the complement system in systemic lupus erythematosus and other diseases. clin immunol. 2013;148:313-21. 47. glikeson gs. complement targeted therapies in lupus. current treat options rheum. 2015;1:10-18. 48. xiao h, dairaghi dj, powers jp, et al. c5a receptor (cd88) blockade protects against mpo-anca gn. j am soc nephrol. 2014;25:225-31. 97 original article acta medica indonesiana the indonesian journal of internal medicine profile of prmt-1 gene polymorphism in hemodialysis patients with increased adma levels mochammad thaha1,4, wenny p. nilamsari2, mochammad yusuf3,4, m. amin4 1 department of internal medicine, faculty of medicine, universitas airlangga dr. soetomo hospital, surabaya, indonesia. 2 department of clinical pharmacy, faculty of pharmacy, universitas airlangga, surabaya, indonesia. 3 department of cardiology and vascular medicine, faculty of medicine, universitas airlangga dr soetomo hospital, surabaya, indonesia. 4 institute of tropical disease, universitas airlangga, surabaya, indonesia. correspondence mail: department of internal medicine, faculty of medicine, universitas airlangga dr. soetomo hospital. jl. mayjen prof. dr. moestopo 4-6 surabaya, indonesia. email: mochthaha@yahoo.com. abstrak tujuan: untuk menentukan distribusi polimorfisme genetik prmt-1 dan kadar adma pada pasien hemodialisis berkelanjutan. metode: genotyping polimorfisme prmt-1 dilakukan pada 57 pasien hemodialisis di rumah sakit al-irsjad. semua partisipan menjalani pemeriksaan fisik, mengisi kuesioner dan pengambilan darah vena 5ml. darah kemudian diekstraksi dengan menggunakan kloroform. pemeriksaan single nucleotide polymorphism (snps) dilakukan dengan polimerase chain reaction-restriction fragment length polymorphism (pcr-rflp). kadar adma diukur menggunakan elisa dan pemeriksaan petanda kimia klinik serum. hasil: penelitian ini diikuti 57 pasien yang menjalani hemodialisis, 54 (95,4%) pasien tersebut mengalami kenaikan kadar adma. dilakukan sekuensing dna pada 13 pasien dan menunjukkan dugaan polimorfisme gen prmt-1 pada titik 5837, karena pada titik tersebut ada perbedaan genotip c dan g. kesimpulan: polimorfisme gen prmt-1 diduga menjadi salah satu penyebab peningkatan kadar adma. kata kunci: adma, prmt-1, polimorfisme, penyakit ginjal kronis. abstract aim: to determine the distribution of prmt-1 gene polymorphism and adma levels among continuing hemodialysis patients. methods: genotyping of prmt-1 polymorphism was performed in 57 hemodialysis patients at al irsjad hospital. all participants were recruited for physical examination, questionnaire, and collection of 5 ml fasting venous blood. the blood was treated with phenol-chloroform extraction of genomic dna. the candidate’s single nucleotide polymorphisms (snps) were genotyped by using polymerase chain reaction-restriction fragment length polymorphism (pcr-rflp). the adma plasma levels was determined by elisa and all biochemical indicators of serum were examined. results: fifty-seven hemodialysis patients participated in our study, 54 (95.4%) of them had increased adma plasma levels. dna sequencing analysis of 13 patients showed a suspected prmt-1 gene polymorphism at sequence 5837 as there were different genotypes between c and g. conclusion: the increased levels of adma might be caused by prmt-1 gene polymorphism. key words: adma, prmt-1 polymorphism, chronic kidney disease. m. thaha acta med indones-indones j intern med 98 introduction various research evidences suggest that renal dysfunction is associated with a high risk of cardiovascular disease (cvd) complications. chronic kidney disease (ckd) has been considered to be a risk factor for cvd. as endothelial dysfunction is an early stage of atherosclerosis in patients with hypertension, diabetes and ckd, the decline in the availability of nitric oxide (no) is considered as an independent risk factor for cvd among those patients.1 previous studies have shown that endothelial dysfunction may predict the current and future cvd.2 decreased availability of no is closely related to the asymmetric dimethyl arginine (adma), an inhibitor of nos.3 adma is an independent risk factor for atherosclerosis progression, death due to cvd and all causes of mortality.2 the increase of adma in animal studies increased blood pressure.4 moreover, in endothelial cell culture of patients with ckd who had increased adma levels, it is found that adma significantly inhibits no production.5 several recent studies have shown that concentrations of adma in ckd patients, even at stage 1, has increased.3,6,7 moreover, decreased levels of adma during hemodialysis is associated with improved endothelial function in patients with end-stage kidney disease.1 adma is produced about 300 mmol per day. dimethyl arginine was obtained from the degradation of protein methylation product and produced by the protein methyl transferase (prmt) enzymes. currently, there are 9 genes of prmt enzymes, which can be divided into 2 groups: prmt type i (1-4, 6 and 8) that produce adma and l-nmma, and prmt type ii (5, 7, 9) that produce symmetric dimethyl arginine (sdma) and l-nmma. meanwhile, 90% adma degradation is known to occur through the metabolism by dimethylarginine dimethylaminohydrolase (ddah) enzymes into citrulline and amines.1,3,8,9 the fact shows that an increase in adma levels is closely associated with the risk of cvd in patients with ckd. moreover, type i-prmt enzymes play a major role in the production of adma. however, the mechanism of type i-prmt on increased adma levels in patients with ckd remains unknown. our study was conducted to determine whether there was any gene polymorphism of type i-prmt enzyme that may lead to increased adma levels in ckd patients. we expected that the results of study may be used to elaborate the molecular mechanisms of increased adma levels. if there is genetic polymorphism of type-i prmt enzyme, which plays a major role in adma production; then the definitive management therapy can be determined to reduce adma levels. the study also tried to disclose molecular mechanisms underlying increase of adma in patients with end-stage kidney disease. since the adma synthesis is primarily carried out by type i-prmt enzymes, the authors hypothesized that there was a polymorphism of type i prmt gene that may lead to increased adma levels in patients with ckd. to test the hypothesis, in addition to performing pcr on blood samples of patients with ckd, we also examined adma levels in the same patients; therefore, we can identify the association between elevated adma levels and type i-prmt enzyme gene polymorphism. methods we conducted a cross-sectional study to determine the genetic polymorphism of prmt-i enzyme and adma levels in hemodialysis (hd) patients. the study took place at al-irsyad hospital and institute of tropical disease, airlangga university, surabaya. the study population was patients undergoing regular hd in al-irsyad hospital and institute of tropical disease, airlangga university surabaya. the samples were patients who met the inclusion criteria. sample size was all populations that met the inclusion criteria during the study or total population sampling. inclusion criteria were men/women aged 18-65 years, who were undergoing regular/sustainable hd for three months/more, stable, having hb >8g/dl and albumin >3 mg/dl, not taking drugs containing antioxidants in the last one month period, and have agreed and completed the informed consent form. exclusion criterion was a blood transfusion prior to sampling. to determine prmt-1 gene polymorphism, vol 46 • number 2 • april 2014 profile of prmt-1 gene polymorphism in hemodialysis patients 99 we performed blood sampling, dna extraction, dna amplification with pcr, and detection of pcr products by electrophoresis. two percent agarose gel that had been made previously containing ethidium bromide was placed in a gel electrophoresis apparatus, added with tbe buffer 1 x until the gel was completely submerged. a marker, as much as 10 ml, was mixed by pipetting gently with 10x loading buffer of 2 ml that had been dripped on parafilm. from the first round pcr products, as much as 7 ml was taken and mixed by gently pipetting with 10x loading buffer of 2 ml that had been dripped on parafilm. each of pcr product mixture was inserted into the gel slot. gel electrophoresis apparatus was closed and run with 100 volts for about 30 minutes. subsequently, it was observed under short-wave ultraviolet light. the observed results were documented with gel doc. dna isolation and purification with low melting agarose dna bands appeared white on electrophoresis with 2% agarose s gel. moreover, electrophoresis was repeated using low melting agarose gel (l). two percent agarose l gel containing ethidium bromide was prepared, then a mixture of 15 mldna and 10 x 2 ml loading buffer was made. this mixture was applied to the gel wells with intervals without the use of markers and subsequently, the electrophoresis instrument was run. electrophoresis results were observed with long-wave ultraviolet light. gel containing dna was isolated by cutting using a cutter that was washed each time of cutting. gel slices were put into a sterile eppendorf tube 1.5 ml. then, we carried out dna purification of pcr products from agarose l using qiaquick gel extraction kit (qiagen, inc.. cat. no. 28704). pcr for sequencing preparation labeling with pcr for sequencing was performed by using the ready reaction cycle sequencing kit (abi prism big dye terminator vii, applied biosystems). sequencing reaction with a total volume of 20 ml was made in a sterile microcentrifuge tube with composition of: dna from pcr results of 5 ml, sense or antisense primer of 4 pmol/ml for hbv; 1.5 ml (prmt primer), 2 ml ready reaction mixture big dye terminator, 7 ml buffer big dye, 4.5 ml dw, mixed by gently pipetting. subsequently, they were poured into pcr machine that had been set to a temperature of 96°c for 3 min. pcr was performed for 25 cycles. each cycle consisted of four stages: denaturation for 10 seconds in a temperature of 96°c, annealing for 5 seconds at 50°c, extension for 4 minutes at 60°c. once the cycle was complete, the temperature was cooled to 4°c. purification and precipitation of pcr products for dna sequencing preparation with sodium acetate-ethanol tu b e c o n t a i n i n g 2 0 ml s e q u e n c i n g reaction was removed from the pcr machine. subsequently, it was aspirated and transferred into a 1.5 ml sterile eppendorf tube. then, 2.5 ml sodium acetate and 50 ml absolute ethanol were added to 1.5 ml sterile eppendorf tubes, and mixed by flicking the tube. the mixture was incubated at room temperature for 5 minutes. then, it was centrifuged at 15,000 rpm for 15 min at 4°c. the existing supernatant was carefully aspirated and discarded into a container. as much as 100 ml of 70% ethanol was added into the 1.5 ml eppendorf tube. it was centrifuged once more at 15,000 rpm for 5 min at 4°c. again, the supernatant was carefully aspirated and discarded into containers. open tubes containing dna pellets were wrapped in a plastic wrap and dried using a vacuum pump for 15 minutes. thereafter, the dried dna pellet were stored at a temperature of 4°c and to avoid the direct rays it was closed tightly with aluminum foil. dna sequencing dna sequencing was performed using abi prism 310 genetic analyzer (applied biosystems). dna mixture had been prepared before sequencing. hidiformamide (applied biosystems) as much as 25 ml was added to tubes containing dried dna pellet. it was vortexed and incubated at a temperature of 95°c for 2 min. then, it was incubated in ice for about 3 minutes and subsequently spinned-down. the tube remained stored in ice until it was ready to be analyzed. moreover, it was aspirated and transferred into a sterile microtube specifically for sequencing. the tube was inserted into a m. thaha acta med indones-indones j intern med 100 sequencer machine and run on a abi prism 310 genetic analyzer. results in this study, samples were taken from hemodialysis unit, al-irsyad hospital, surabaya. the study was conducted between may and september 2013. there were 57 samples that met the inclusion criteria. table 1. subject characteristics variables n (%) sex male 39 (68.4%) female 18 (31.6%) ckd stage stage iv 14 (24.6%) stage v 43 (75.4%) mean of blood pressure systolic 160±2.5 mmhg diastolic 100±5.3 mmhg mean of age 55.4 normal adma increase adma figure 1. distribution of adma levels in ckd-hemodialysis patients stage 4 stage 5 a d m a le v e l ( m o l/ l) � figure 2. mean difference of adma level in each stage the first stage was the measurement of adma levels using elisa. of the 57 samples, there were 3 samples (5.6%) with normal range of adma levels (0.24 to 0.58 mmol/l) and 54 (95.4%) samples with increased adma levels. sequencing was performed in 13 samples with elevated adma levels. the sequencing results showed that there was a suspected occurrence of prmt-1 gene polymorphism, which was at sequence 5837 as we found figure 3. a-d. results on detection of pcr products by electrophoresis vol 46 • number 2 • april 2014 profile of prmt-1 gene polymorphism in hemodialysis patients 101 differences between genotype c and g at the sequence (figure 5). therefore, we performed dna sequencing in the other 44 samples in order to obtain clearer profile about the location of prmt-1 gene polymorphisms. discussion asymmetric dimethyl arginine (adma) is an endogenous molecule that can be detected in human blood and urine. adma blood samples are stable for 24 hours at 2°-8°c or for 24 months if it is frozen at -20°c. in addition to being stable, adma is easily measured. it also reflects the concentration of no and pathobiologically and directly contributes to the incidence of endothelial dysfunction. adma levels in vascular endothelium is ten times higher than those in plasma and the highest levels are found in kidney and spleen. normal adma levels in humans is 0.24 to 0.58 mmol/l or 80-150 ng/ml. measurement of serum adma is performed quantitatively using enzyme immunoassay adma®-elisa. it has been observed that adma has an important role in endothelial dysfunction and it may increase in the early stages of ckd.6 ckd figure 4. results of dna sequences figure 5. suspected location of polymorphism m. thaha acta med indones-indones j intern med 102 has become one of risk factors of cvd10 and adma has been considered as the link between ckd and cvd.1 the association between adma with cvd has been widely investigated in several studies. it has been recognized that adma infusion in healthy subjects decreases cardiac output and increases vascular resistance and blood pressure. miyazaki et al. reported a significant positive correlation between adma plasma levels with the thickness of carotid artery intima, which can serve as a marker of arteriosclerosis. adma can also lower heart rate and cardiac output. it can inhibit angiogenesis, and increase atherogenesis. an in vitro study demonstrates that it may also accelerate the aging process of endothelial dysfunction. high concentration of adma can inhibit the movement of endothelial progenitor cell (epc) from the bone marrow to damaged endothelial area. furthermore, adma inhibition can increase the expression of vascular endothelial growth factor (vegf) in endothelial cells and increase tube formation.3,7,8,11 intensive research on molecular and cellular mechanisms that lead to atherogenesis has produced an understanding that vascular endothelium plays an important role to functional changes in the early stages of the vascular wall, which in turn initiates and exacerbates atherogenic process.12 it has been found that the main cause of nos pathway disorder is the presence of endogenous nos inhibitors, the adma and n mono methyl arginine (nma). adma plasma levels is ten times greater than mma levels.8,9 adma levels on vascular endothelium is ten times greater than the levels in plasma. moreover, the highest levels are found in kidney and spleen.8 adma is synthesized in the cytoplasm of the cell and subsequently released into extracellular compartment and blood plasma. dimethyl arginine is formed during proteolysis of methylated proteins. protein methylation is a mechanism of post-translational modification of proteins contained in the body’s cells. this process causes a change in the tertiary structure and the function of proteins. proteolysis is catalyzed by the enzyme s-adenoylmethionine protein n-methyltransferases (protein arginine methyltransferases/pmrt). protein arginine methyltransferases i and ii remove one or more methyl groups from the methyl donor s-adenosilmethionine to l-arginine residues in the protein or polypeptide. adma is formed through the activity of pmrt i, depending on the number of removed methyl groups; while the symmetric dimethyl arginine (sdma) is formed through the activity of pmrt ii.3,8 there are several theories regarding the suspected cause of increased adma levels. some experimental animal studies suggest that there may be a decrease of ddah enzyme expression. moreover, it was found that prmt-i enzyme inhibition in animals had lowered the adma levels.1,8 however, the exact molecular mechanism on increased adma levels in ckd patients remains unknown. the results obtained from this study were in accordance with previous findings, i.e. we found increased adma levels in ckd patients. in ckd, asymmetric increase of dimethyl arginine (adma) may occur due to increased production of adma by protein arginine methyltransferases (prmt-1) or through the inhibition of adma elimination by either dimethylaminohidrolasedimethylarginine (ddah) or kidneys. in chronic kidney disease (ckd), adma levels is found to be increased by about 30-40% and there is no correlation with creatinine serum levels and the stage of ckd. other studies revealed that the higher the ckd stages, the higher the adma level. in ldl oxidation, the release of adma has also been increased significantly. oxidative stress, a condition that can occur in patients with ckd, is associated with adma synthesis via the stimulation of enzymes prmt1.3,8,9 conclusion of 57 hemodialysis patients with stage iv-v, there were as many as 54 patients (95.4%) who had increased adma levels; while three patients (5.6%) had adma levels between the normal range. prmt-1 gene polymorphism may occur at sequence 5837. further research should be carried out on the sequencing process with higher number of samples in order to obtain a better profile about the site of prmt-1 gene polymorphisms and vol 46 • number 2 • april 2014 profile of prmt-1 gene polymorphism in hemodialysis patients 103 to determine the association of prmt-1 gene polymorphism and adma level. references 1. ueda s, yamagishi si, kaida y, okuda s. asymmetric dimethylarginine may be a missing link between cardiovascular disease and chronic kidney disease. nephrology. 2007;12:582-90. 2. sibal l, agarwal sc, home pd, boger rh. the role of asymmetric dimethylarginine (adma) in endothelial dysfunction and cardiovascular disease. current cardiology rev. 2010;6:82-90 3. vallance p, leiper j. cardiovascular biology of the asymetric dimethylarginin: dimethylarginin dimethylaminohydrolase pathway. arterioscler thromb vasc biol. 2004;24:1023-30. 4. gardiner sm, kemp pa, bennet t, et al. regional and cardiac haemodynamic effect of ng, ng, dimethyll-arginine and their reversibility by vasodilators in conscious rats. br j pharmacol. 1993;110;1457-64. 5. xiao s, wagner l, schmidt rj, baylis c. circulating endothelial nitrix oxide synthase inhibitory factor in some patients with chronic renal disease. kidney int. 2001;59:1466-72 6. caglar k, yilmaz mi, sonmeza et. al. adma, proteinuria, and insulin resistance in non-diabetic stage i chronic kidney disease. kidney int. 2006:70;781-7. 7. kielstein tj. marked increase of asymmetric dimethylarginine in patients with incipient primary chronic renal disease. j am soc nephrol. 2001;13:1706. 8. baylis c. arginine, arginine analogs and nitric oxide production in chronic kidney disease. nature clin pract nephrol. 2006;2(4):209-20 9. cooke pj. asymetrical dimethylarginin: the uber marker? circulation. 2004:109(15):1813-8. 10. sarnak mj, levey as, schoolwerth ac, et al. kidney disease as a risk factor for development of cardiovascular disease: a statement from the american heart association councils on kidney in cardiovascular disease, high blood pressure research, clinical cardiology and epidemiology and prevention. circulation. 2003;108:2154-69. 11. miyazaki h, matsuoka h, cooke jp, et al. endogenous nitric oxide synthase inhibitor. a novel marker of atherosclerosis. circulation. 1999; 99:1141-6. 12. b o g e r r h . e l e v a t e d l e v e l s o f a s y m m e t r i c d i m e t h y l a r g i n i n e ( a d m a ) a s a m a r k e r o f cardiovacular disease and mortality. clin chem lab med. 2005;43(10):1124-9. special article 253acta medica indonesiana the indonesian journal of internal medicine extended dual antiplatelet for diabetic elderly patients after drug-eluting stent implantation: an evidence-based clinical review benedicta m. suwita1, purwita w. laksmi2, ika p. wijaya2 1 faculty of medicine universitas indonesia, jakarta, indonesia. 2 department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia correspondence mail: faculty of medicine universitas indonesia. jl. diponegoro no. 71, jakarta 10430, indonesia. email: benedicta.mutiara.s@gmail.com. abstrak terapi antiplatelet sangat penting untuk pasien dengan penyakit jantung koroner yang menjalani prosedur drug-eluting stent (des). panduan klinis saat ini merekomendasikan dual antiplatelet (dapt) dengan aspirin dan inhibitor p2y12 selama minimal 12 bulan. perpanjangan dapt lebih dari 12 bulan dapat dipertimbangkan untuk mencegah very late stent trombosis. beberapa faktor telah diketahui berkontribusi terhadap trombosis stent, termasuk diabetes dan usia lanjut, namun durasi optimal dapt untuk pasien tersebut masih kontroversial. kajian klinis ini membandingkan efektivitas terapi dual antiplatelet yang diperpanjang (>12 bulan) dibandingkan dengan durasi standar (12 bulan) dalam mengurangi kejadian infark miokard dan trombosis stent, terutama pada pasien diabetes berusia lanjut. pencarian literatur dilakukan dalam database pubmed dan cochrane dengan menggunakan kata kunci “dual antiplatelet”, “durasi”, “diabetes melitus onset dewasa”, “usia lanjut”, dan “drug-eluting stent”. jenis artikel berupa meta-analisis, uji klinis, atau uji klinis terandomisasi yang membandingkan dual antiplatelet diperpanjang dengan durasi standar. keluaran klinis adalah infark miokard dan trombosis stent. pencarian awal dilakukan secara spesifik untuk mencari penelitian pada populasi diabetes dan usia lanjut, namun lingkup pencarian diperluas menjadi pasien dewasa dengan/tanpa diabetes. didapatkan 5 uji klinis dan 1 meta-analisis, yang menunjukkan penurunan risiko dalam kejadian trombosis stent dan infark miokard. kajian klinis ini memiliki beberapa keterbatasan, antara lain potensi bias seleksi dan proporsi pasien diabetes serta usia lanjut yang terbatas dalam uji klinis. kajian klinis ini menunjukkan bahwa lebih baik memberikan perpanjangan dapt hanya untuk pasien dengan risiko iskemik tinggi dan risiko perdarahan rendah (tailored therapy). kata kunci: diabetes melitus, drug-eluting stent, dual antiplatelet diperpanjang, infark miokard, lanjut usia, trombosis stent. abstract antiplatelet is an important drug for patients with coronary heart disease undergoing drug-eluting stent implantation. current guidelines recommend dual antiplatelet with aspirin and a p2y12 inhibitor for at least 12 months. continuation of dapt beyond 12 months may be considered for preventing very late stent thrombosis. several patient-related factors that contribute to stent thrombosis have been recognized, including diabetes and advanced age, but the optimal dapt duration for these patients is still controversial. this article reviews the efficacy of extended (>12 months) compared to standard (12 months) dapt for reducing myocardial infarction and stent thrombosis rates, especially in diabetic elderly patients. benedicta m. suwita acta med indones-indones j intern med literature screening was conducted at pubmed and cochrane database using “dual antiplatelet”, “duration”, “adult-onset diabetes mellitus”, “elderly” and, “drug-eluting stent” as keywords. article types were limited to meta-analysis, systematic review, randomized clinical trial, or clinical trial that compared the efficacy of extended to standard duration of dapt. clinical outcomes used were myocardial infarction and stent thrombosis. the initial search was done to find relevant studies specifically assessing diabetic and elderly patients, then widened to diabetic and non-diabetic patients of any age above eighteen years. a total of 5 clinical trials and 1 meta-analysis were reviewed, showing an overall risk reduction of stent thrombosis and myocardial infarction. this review has several limitations, such as its potential selection bias and underrepresented proportion of diabetic and elderly patients. high-risk subgroups like diabetes mellitus has a tendency of increased ischemic risk, while advanced age could have both increased ischemic risk and bleeding risk. this review suggests that it is better to reserve extended dual antiplatelet therapy for patients with high ischemic risk and low bleeding risk (tailored therapy). key words: adult-onset diabetes mellitus, drug-eluting stent, extended dual antiplatelet, elderly, myocardial infarction, stent thrombosis. introduction c o r o n a r y h e a r t d i s e a s e i s c a u s e d by atherosclerosis of coronary arteries. revascularization of occluded coronary artery by percutaneous coronary intervention (pci) could be indicated both in the setting of acute coronary syndrome (acs) and non-acs, such as refractory angina despite optimal medical treatment. a coronary stent, as foreign body in blood vessel, will induce platelet adhesion and aggregation, resulting in thrombus.1,2 antiplatelet is an important therapy for inhibiting platelet aggregation and preventing stent thrombosis, especially in high-risk patients. the risk of stent thrombosis is increased dramatically in patients who prematurely discontinue antiplatelet therapy, and stent thrombosis is associated with a mortality rate of 20-45%.3 currently, the american heart association recommends dual antiplatelet therapy (dapt) with aspirin and p2y12 inhibitor for at least 12 months, continued with aspirin monotherapy indefinitely for patients receiving drug-eluting stent (des), both in acs and non-acs setting. lately, it has been shown that des has a higher incidence of very late stent thrombosis, which occurs more than 12 months after stent implantation. therefore, continuation of dapt beyond 12 months may be considered in patients undergoing des implantation. however, if the risk of morbidity from bleeding outweighs the anticipated benefit afforded by dapt, earlier discontinuation of p2y12 inhibitor therapy is reasonable.3 several patient-related factors that contribute to stent thrombosis have been recognized, including diabetes and advanced age. 3,4 diabetic patients are characterized by increased atherothrombotic risk, associated with their pro-inflammatory and prothrombotic status. platelet function is regulated by insulin, and the adhesion or aggregation of platelets is enhanced in insulin-resistant patients. the up-regulation of the p2y12 receptor signaling pathway has also been shown in type 2 diabetes. platelet in diabetic patients appear to be in activated state even in the absence of vascular injury, and respond more frequently even to subthreshold stimuli. insulin resistance also increases fibrinolysis suppression, and associated with the increased production of different coagulation factors promoting platelet adhesion to the vascular sub-endothelium.5 the complexity of platelet activation and subsequent higher risk of thrombosis in diabetic patients may become a reasonable consideration for prolonging dapt beyond the recommended duration. coronary stent implantion is one of the most frequent hospital procedure done in elderly population, and the proportion of patients undergoing pci who were 75 to 84 years of age has doubled, while those who were 85 years of age increased five fold.1,6 elderly undergo physiological changes, such as increased arterial stiffness and endothelial dysfunction. in addition, 254 vol 47 • number 3 • july 2015 extended dual antiplatelet for diabetic elderly patients after drug-eluting stent they usually present with multiple pathologies, such as hypertension, diabetes mellitus, and renal failure. such conditions may lead to increased atherothrombotic risk, and it may be reasonable to prolong dapt beyond the recommended duration. however, older patients are at higher risk of complications from antiplatelet therapies; it could make prolonging dapt contraindicated despite the potential clinical benefit.7,8 in addition, elderly patients often have multipharmacological treatment with many potential drug-drug interactions.9 therefore, any medication, including antiplatelet, should be scrutinized in order to determine whether it should be continued or not. several studies proved that dual antiplatelet therapy with aspirin and p2y12 can decrease cardiovascular mortality in patients after coronary des implantation. even so, the optimal duration is still controversial. therefore, clinicians need to know whether extended (>12 months) dapt after des implantation is: (1) indicated in all patients because the cardiovascular benefit outweighs the risk of bleeding; (2) considered in certain individual (tailored-therapy) with highrisk profile (such as diabetic or elderly patient) based on patient’s cardiovascular risk factor and bleeding risk; (3) contraindicated in all patients because of significantly increased morbidity or mortality associated with bleeding risk. clinical question in diabetic elderly patients, does extended dual antiplatelet (>12 months) after drug-eluting stent implantation reduce myocardial infarction and/or stent thrombosis rates better than standard (12 months) dual antiplatelet therapy? methods the search strategy and study selection criteria were based on problem-interventioncomparison-outcome (pico) model to answer the clinical question, as described in table 1. since the cilinical question type is intervention, searching would be focused to find metaanalysis, systematic review, or clinical trial to answer the clinical question. data sources and search strategy we screened pubmed and cochrane database on april 10–17, 2015 for data comparing extended duration and standard duration of dual antiplatelet therapy. dual antiplatelet therapy was defined as aspirin plus a p2y12 receptor inhibitor (clopidogrel, prasugrel, or ticagrelor). we used “dual antiplatelet”, “duration”, “adultonset diabetes mellitus”, “elderly” and, “drugeluting stent” as keywords. filters were used to limit article types, which is “meta-analysis”, “systematic review”, “randomized clinical trial”, or “clinical trial”. no filter for date of publication was used, and the articles found were publicated between 2006 and 2015. the keywords and number of articles found in each search were listed in table 2. selection criteria articles included in this review were systematic review, meta-analysis, randomized clinical trial, or clinical trial comparing twelve and over twelve months dual antiplatelet therapy after drug-eluting stent implantation. exclusion criteria for this review were: articles with observational design, dual antiplatelet duration of less than twelve months (clinical trial/meta-analysis/ systematic review) or duration timeframes not reported (meta-analysis or systematic review), animal studies, studies assessing endpoint other than stent thrombosis/ myocardial infarction, and studies assessing the effects of drug other than the combination of aspirin and a thienopyridine. articles written in languages other than english or indonesian were also excluded. the initial search was done to find relevant studies specifically assessing diabetic and elderly patients. however, due to the scarcity of table 1. pico components problem intervention comparison outcome diabetic elderly patients who underwent coronary drug-eluting stent implantation extended dual antiplatelet therapy (more than twelve months) and continued with aspirin monotherapy standard dual antiplatelet therapy (twelve months) and continued with aspirin monotherapy myocardial infarction and/ or stent thrombosis 255 benedicta m. suwita acta med indones-indones j intern med such studies, the scope of search was widened gradually from diabetic and elderly patients, to diabetic and non-diabetic patients of any age above eighteen years old. such steps were necessary to collect as many high-quality studies as possible. the literature screening, study selection, and reasons for exclusion were described in the prisma flowchart (figure 1). selection bias and publication bias all relevant studies were included in this review, even studies with negative results. however, selection bias could happen because not all relevant studies have full-text availability. several studies with no full-text availability were included in the meta-analysis we found, therefore they are indirectly included in this review. ultimately, only one relevant clinical trial were not included due to no full-text availability. eligible studies, which conformed to the inclusion and exclusion criteria, were assessed for their risk of bias. publication bias was graded using the components of evidence-based medicine recommended by the british medical journal (bmj), which consist of randomization, allocation concealment, blinding of participants, and other sources of bias. the characteristics of included studies, along with potential sources of bias were summarised in table 3 and table 4. results studies and patients from the 95 initial studies, 86 studies did not meet the prespecified inclusion criteria. table 2. searching strategy in several database engines search terms hits pubmed ((((((((dual antiplatelet) and duration) and drug eluting stent[mesh terms] and aspirin[mesh terms]) and thienopyridines[mesh terms])) and elderly)) and diabetes mellitus, adult onset[mesh terms] 0 pubmed (((((((dual antiplatelet) and duration) and drug eluting stent[mesh terms] and aspirin[mesh terms]) and thienopyridines[mesh terms])) and diabetes mellitus, adult onset[mesh terms] 0 pubmed (((((dual antiplatelet) and duration) and drug eluting stent[mesh terms] and aspirin[mesh terms]) and thienopyridines[mesh terms])) and elderly 29 pubmed (((dual antiplatelet) and duration) and drug eluting stent[mesh terms] and aspirin[mesh terms]) and thienopyridines[mesh terms] 49 cochrane ‘dual antiplatelet and “duration” and “drug eluting stent” and diabetes mellitus and elderly 0 cochrane ‘dual antiplatelet and “duration” and “drug eluting stent” and diabetes mellitus 0 cochrane ‘dual antiplatelet and “duration” and “drug eluting stent” and elderly 0 cochrane ‘dual antiplatelet and “duration” and “drug eluting stent” 46 a total of 5 clinical trials and 1 meta-analysis were finally included in the review (figure 1). clopidogrel and aspirin was the most frequent drug combination in dual antiplatelet therapy. follow-up period varied from 18 to 48 months after stent implantation. sample size varied between studies, from several hundreds to almost ten thousands. each study had varying proportion of diabetic and elderly subjects. all studies had less than 50% diabetic subjects, and all studies had subjects with mean age over 60 years old. only two studies analysed these high-risk subgroups separately (table 3 and table 4).10-15 stent thrombosis in three randomized clinical trials, extended dual antiplatelet therapy have similar clinical benefit to twelve-month therapy. extended dual antiplatelet therapy showed a reduction of roughly 50% in the rates of stent thrombosis for diabetic patients, and roughly 80% for elderly (>75 years old) patients. one clinical trial had no data for stent thrombosis, and another one reported a significantly different rates of stent thrombosis between the two groups, with a relatively small number needed to treat (table 3). a meta-analysis showed a reduction of roughly 70% in the odds of myocardial infarction and demonstrated statistically significant difference, but its number needed to treat (nnt) was relatively high (table 4). myocardial infarction in two clinical trials, myocardial infarction rates were similar in twelve-month and extended 256 vol 47 • number 3 • july 2015 extended dual antiplatelet for diabetic elderly patients after drug-eluting stent figure 1. prisma flowchart 257 benedicta m. suwita acta med indones-indones j intern med table 3. characteristics of included clinical trials comparing 12 months versus extended (>12 months) dual antiplatelet therapy criteria twelve or 30 months of dual antiplatelet therapy after drug-eluting stents (dapt trial)10 prolonged clopidogrel use after bare metal and drug-eluting stent placement: the veterans administration drug-eluting stent study11 duration of dual antiplatelet therapy after implantation of drug-eluting stents12 optimal duration of dual antiplatelet therapy after drugeluting stent implantation: a randomized. controlled trial (des-late trial)13 prolonged dual antiplatelet therapy improves clinical outcomes in high-risk patients implanted with sirolimus-eluting stents14 was the assignment of patients to treatments randomized? yes no (secondary data from hospital registry) yes yes no (consecutive sampling) -and was the randomization list concealed? yes no no were all the patients who entered the trial accounted for at its conclusion? and were they analysed in the groups to which they were randomized? yes (intention-totreat-analysis) yes (intention-totreat anaysis) yes (intention-totreat anaysis) yes (intention-totreat anaysis) yes (intention-totreat anaysis) were patients and clinicians kept “blind” to which treatment was being received? yes (doubleblind) no no (open-label) no (open-label) not mentioned aside from the experimental treatment. were the groups treated equally? yes (standard treatment according to international guidelines) yes (standard treatment according to international guidelines) yes (standard treatment according to international guidelines) yes (standard treatment according to international guidelines) not mentioned were the groups similar at the start of the trial? yes yes yes yes no (higher systolic dysfunction in dual therapy) control event rate (cer) stent thrombosis: 1.4% stent thrombosis: no data stent thrombosis: 0.4% stent thrombosis: 0.5% stent thrombosis: 5.6% myocardial infarction : 4.1% myocardial infarction: 7.4% myocardial infarction: 0.7% myocardial infarction: 1.2% myocardial infarction: 5.6% experimental event rate (eer) stent thrombosis: 0.4% stent thrombosis: no data stent thrombosis: 0.4% stent thrombosis: 0.3% stent thrombosis: 1.1% myocardial infarction: 2.1% myocardial infarction: 5.4% myocardial infarction: 0.7% myocardial infarction: 0.8% myocardial infarction: 1.1% relative risk reduction (rrr) stent thrombosis: 71.4% stent thrombosis: no data stent thrombosis: 0% stent thrombosis: 40% stent thrombosis: 80.4% myocardial infarction : 48.8% myocardial infarction: 27.0% myocardial infarction: -14.3% myocardial infarction: 33.3% myocardial infarction: 80.4% 258 vol 47 • number 3 • july 2015 extended dual antiplatelet for diabetic elderly patients after drug-eluting stent absolute risk reduction (arr) stent thrombosis: 1% (0.63 1.37%) stent thrombosis: no data stent thrombosis: 0% (-0.480.48%) stent thrombosis: 0.2% (-0.150.55%) stent thrombosis: 4.5% (0.628.38%) myocardial infarction : 2% (1.32-2.68%) myocardial infarction: 2% (1.22-2.78%) myocardial infarction: -0.1% (-0.75-0.55) myocardial infarction: 0.4% (-0.15-0.95%) myocardial infarction: 4.5% (0.62-8.38%) confidence interval (ci) 95% stent thrombosis: +/-0.37% stent thrombosis: no data stent thrombosis: +/-0.48% stent thrombosis: +/-0.35% stent thrombosis: +/3.88% myocardial infarction : +/0.68% myocardial infarction: +/ 0.78% myocardial infarction: +/ 0.65% myocardial infarction: +/ 0.55% myocardial infarction: +/ 3.88% number needed to treat (nnt) stent thrombosis: 100 (58 – 159) pts stent thrombosis: no data stent thrombosis: indefinite stent thrombosis: 500 pts stent thrombosis: 23 (11-162) pts myocardial infarction : 50 (38 – 76) pts myocardial infarction: 50 (3582) pts myocardial infarction: indefinite myocardial infarction: 250 pts myocardial infarction: 23 (11-162) pts additional information: dual antiplatelet duration 12 mo vs. 30 mo <12 mo vs >12mo 12 mo vs. 36 mo 12 mo vs. 36 mo 12 mo vs. 18 mo dual antiplatelet regimen aspirin 75 – 162 mg + clopidogrel 75 mg or prasugrel 10 mg daily aspirin 100 mg + clopidogrel 75 mg daily aspirin 100-200 mg + clopidogrel 75 mg daily aspirin 100-200 mg + clopidogrel 75 mg daily aspirin 100 mg + clopidogrel 75 mg daily time from stenting to group allocation 12 months none (secondary data) 12 – 24 months 12 – 18 months 12 months non-adherence rates at the end of study 4.6% (monotherapy) none 1.6% (monotherapy) 4.6% (monotherapy) none 4.7% (dual therapy) 17.1% (dual therapy) 5.4% (dual therapy) follow-up period (after stent) 30 months 48 months 36 months 36 months 18 months subjects (total) 9 961 14 925 2 701 5 045 336 diabetic (%) 30.1 (monotherapy) 42.8 (monotherapy) 27.1 (monotherapy) 28.2 (monotherapy) 46.9 (monotherapy) 31.1 (dual therapy) 44.3 (dual therapy) 25.1 (dual therapy) 28.0 (dual therapy) 40.3 (dual therapy) mean age (years old) 61.6 + 10.1 (monotherapy) 63.8+10.1 (monotherapy) 61.9 + 9.9 (monotherapy) 62.3 + 10.1 (monotherapy) 64.7 + 7.5 (monotherapy) 61.8 + 10.2 (dual therapy) 63.7+ 9.5 (dual therapy) 62.0 + 9.8 (dual therapy) 62.5 + 10.0 (dual therapy) 65.8 + 8.4 (dual therapy) subgroup analysis diabetic: stent thrombosis hr 0.53 (0.23 1.20) none none none none myocardial infarction hr 0.73 (0.51 – 1.05) none none hr 0.63 (0.35 – 1.12) none elderly : (defined as >75 years old) (defined as >65 years old) stent thrombosis hr 0.23 (0.03 2.06) none none none none myocardial infaction hr 0.76 (0.38 1.54) none none hr 0.81 (0.51 – 1.30) none evidence quality good poor fair fair poor 259 benedicta m. suwita acta med indones-indones j intern med dual antiplatelet therapy. in a randomized clinical trial, myocardial infarction rate differs significantly and the clinical benefit outweighs the bleeding risk, as shown by a number needed to treat of fifty patients or less. in dapt trial, extended dual antiplatelet therapy showed a reduction of roughly 30% in the rates of myocardial infarction for diabetic patients, and roughly 30% for elderly (>75 years old) patients. in des-late trial, extended dual antiplatelet therapy showed a reduction of roughly 40% in the rates of myocardial infarction for diabetic patients, and roughly 20% for elderly (>65 years old) patients. in another two trials, the clinical benefit is more pronounced, as shown by an even smaller number needed to treat; however, these trials have more potential bias than the other studies. a meta-analysis showed a reduction of roughly 50% in the odds of myocardial infarction with extended dual antiplatelet therapy and demonstrated statistically significant difference, but its number needed to treat was relatively high. table 4. characteristics of included meta-analysis comparing 12 months versus extended (>12 months) dual antiplatelet therapy criteria optimal duration of dual antiplatelet therapy after percutaneous coronary intervention with drug eluting stents: meta-analysis of randomised controlled trials15 is it a systematic review of high-quality studies which are relevant to your question? yes. all studies are randomized clinical trial comparing extended (>12 mo) vs 12 mo dual therapy. dual antiplatelet used are p2y12 inhibitor and aspirin does it include a methods section that describes: finding and including all the relevant trials? yes. literature search were done in all major database, congress proceedings and unpublished research. all relevant randomized clinical trials were included assessing their individual validity? yes were the results consistent from study to study? yes. no significant heterogeneity for both outcomes (stent thrombosis and myocardial infarction), as indicated by p value > 0.1 and i2 < 40% are they clinically significant? stent thrombosis (very late) cer = 0,98% eer = 0,32% rrr = 67,5% arr = 0,66% (0,41-0,91%) ci 95% = +/-0,25% nnt = 152 (109 – 244) pts odds ratio 0,33 (0,21 – 0,51) myocardial infarction cer = 2,89% eer = 1,55% rrr = 46,37% arr = 1,34% (0,88 – 1,80%) ci 95% = +/-0,46% nnt = 75 (55 – 114) pts odds ratio 0,53 (0,42 – 0,66) how precise are the results? the results can be interpreted with confidence. the confidence limits around the odds ratio demonstrated a statistical significance, favoring extended dual antiplatelet. evidence quality good *cer = control event rate, eer = experimental event rate, rrr = relative risk reduction, arr = absolute risk reduction, ci = confidence interval, nnt = number needed to treat 260 vol 47 • number 3 • july 2015 extended dual antiplatelet for diabetic elderly patients after drug-eluting stent discussion there were variable results across the clinical trials, with some trials reporting clinical benefits in preventing stent thrombosis or myocardial infarction despite increased bleeding risk, while others reported no benefit. three trials reported clinical benefit, one is an nonrandomized clinical trial with a relatively small sample size, and another one is also nonrandomized, with different dual antiplatelet duration within the trial. accordingly, the good results might happen due to pure coincidence. nonetheless, the clinical benefit might arise because a large proportion of patients in those trials had high ischemic risk, as indicated in the dapt trial. the extended group also showed a greater risk reduction in myocardial infarction than stent thrombosis, which might demonstrate a protective effect of dual antiplatelet on preventing thrombosis in coronary vessels, beyond the stented area.10,11 two rcts reported no clinical benefits from extended dual antiplatelet. however, these trials had inadequate statistical power and higher nonadherence rates in dual therapy group, especially in park, et al.12 in addition, the randomization occurred at a varying time-frame after stenting, mostly 18 months after stenting, so most subjects had stopped taking dual antiplatelet for six months.12,13 in those periods, the atherosclerotic process may had progressed; this could make dual antiplatelet, which primary function was for atherothrombotic prevention, less useful. coupled with the high non-adherence rate, this could make the adverse events in dual therapy group slightly higher than monotherapy in park, et al.12 therefore, the results from these trials must be interpreted carefully. one metaanalysis reported significant clinical benefit from extended dual antiplatelet. different types of p2y12 inhibitor and drug-eluting stents were used across and within trials. this situation reflected real-world clinical practice, where patients were treated with different antiplatelet and stent types, based on clinical settings and drug availability. another problem was different extended antiplatelet duration and follow up period between trials, which might affect the clinical outcomes.14 nonetheless, the meta-analysis showed little or no heterogeneity in the trials -suggesting that overall benefits of extended dual antiplatelet were robust and justified.15 overall, the diabetic population is underrepresented in all clinical trials, moreover the elderly population. elderly with multiple non-cardiovascular comorbidities, like many elderly patients in real-world clinical practice, were often excluded from trials, which further under-representing elderly population. the most representing clinical trial for these high-risk subgroups was jia et al.14 however, it had many potential bias and inadequate statistical power. therefore, none of the trials’ results could be extrapolated for diabetic or elderly subgroups. the varying results from clinical trials might indicate that the certainty of whether extended therapy is better than twelve-month therapy, could not be generalized to all patients. this might be caused by a spectrum of risk factors, which played important roles in ischemic events, and resulted in a tendency of increasing clinical benefit (lower number needed to treat), in accordance with increasing proportion of high-risk patients. with evidence showing the tendency of greater clinical benefit from extended dual antiplatelet, the question was not whether to extend the dual therapy, but for whom the clinicians need to reserve the extended dual antiplatelet. diabetes coronary artery revascularization of diabetics continues to be a challenge: these patients suffer from a worse outcomes after pci, compared with non-diabetics.16 this fact was also demonstrated in dapt trial’s subgroup analysis, with a smaller risk reduction for both stent thrombosis and myocardial infarction in diabetic patients than their non-diabetic counterparts.10 diabetic patients have been shown to have a poor response to clopidogrel in both the acute and chronic phases of therapy. moreover, insulin-requiring diabetics have the strongest platelet reactivity despite dual antiplatelet therapy.5 while it has been known that diabetes mellitus is associated with prothrombotic state, the question of what is the most effective way to use antiplatelet therapy for this matter, remains un-answered. currently, there is no 261 benedicta m. suwita acta med indones-indones j intern med evidence that increasing aspirin dose would be useful. increasing the loading or maintenance doses of clopidogrel may be an option. several studies showed that increasing loading dose or maintenance dose would improve drug responsiveness and antiplatelet effects.5 the current low-dose aspirin/clopidogrel regimen has a slightly increased bleeding risk if used for an extended duration, as demonstrated consistently across all studies in this review. the bleeding was mainly mild or moderate, and rarely fatal. however, if the dose was increased, the bleeding risk could increase greatly. further trials were needed to evaluate the safety profile of the highdose aspirin/clopidogrel regimen, as well as its clinical benefits, since most already existed trials measured laboratory outcomes, such as platelet activity, rather than clinical events. since most studies included in this review were performed under clopidogrel, further trials are needed to explore the effect of novel p2y12 inhibitor on diabetic patients. several studies indicated that prasugrel, as well as ticagrelor, was more superior than clopidogrel in preventing recurrent ischemic events for post-acs diabetic patients. since dual antiplatelet with clopidogrel was indicated to have deleterious effect on advanced diabetic nephropathy, using a novel p2y12 inhibitor or other antiplatelet, such as cilostazol, to replace clopidogrel might be an option for such patients.16,17 another option was adding a third antiplatelet, such as cilostazol; preliminary studies showed a more pronounced clinical benefit of triple antiplatelet compared to dual antiplatelet in diabetic patients.18 finally, the drug-eluting stent itself might also play a role in stent thrombosis, both in diabetic and general population, but no studies to date has evaluated the effects of extended dual antiplatelet therapy on different drug-eluting stent types.19-22 additionally, in real clinical practice, a diabetic patient often has several comorbidities or complications, which might increase the ischemic risk. therefore, further risk stratification are needed to evaluate each diabetic subgroups, such as diabetics receiving des for acs indications, insulin-requiring diabetics, diabetics without complications, with left ventricle systolic dysfunction, or with renal failure. elderly in the subgroup analysis, the incidence of major/moderate bleeding in elderly patients was surprisingly lower than non-elderly.9 this might be caused by pure coincidence, as a result of much smaller proportion of elderly patients compared to non-elderly. moreover, the elderly included in the trial, by design, most likely had a relatively low risk of bleeding, who experienced no major bleeding during twelve-month dual antiplatelet and tolerated the therapy well. meanwhile, in real-world clinical practice, elderly patients could present with comorbidities which can increase the bleeding risk, such as peptic ulcer or esophageal varices. results from dapt trial also showed increasing cancer-related bleeding in extended dual-therapy group, most likely caused by undiagnosed cancer before enrollment.9 several comorbidities could require drugs that increase bleeding risk, such as anticoagulants, glucocorticosteroid, or nsaid.23 certain drugs has also been shown to have impact on antiplatelet drugs, such as protonpump inhibitor (ppi), especially omeprazole and esomeprazole.4 therefore, it is necessary to do a comprehensive and holistic assessment for elderly patients, especially to screen for comorbidities which can increase ischemic or bleeding risk. it is also important to use rational prescribing to avoid potential drug interactions. several studies indicated an increasing clinical benefit of extended dual antiplatelet for patients with high ischemic risk. however, there is no good evidence that could show the optimal duration of dual antiplatelet for elderly patients, who often had risk factors for both ischemic and bleeding events. therefore, further trials are needed to evaluate the efficacy of extended dual antiplatelet therapy on elderly populations, especially in elderly with multiple pathologies. implications for clinical practice studies included in this review showed a tendency of greater clinical benefit from extended dual antiplatelet. however, as the incidence of very late stent thrombosis in general population is very small, the number needed to treat becomes very large, far over fifty patients. it indicates that 262 vol 47 • number 3 • july 2015 extended dual antiplatelet for diabetic elderly patients after drug-eluting stent the use of extended dual antiplatelet therapy for every post-des patients is ineffective, exposing patients to unnecessary bleeding risk, and clearly not cost-effective. this is especially important in asian population, which has a relatively low incidence of very late stent thrombosis.24 overall, this review suggests that the standard twelve-month dual antiplatelet therapy is not necessarily the optimal care. longer duration should be carefully considered, weighing the patient’s bleeding and ischemic risk profile. due to the uncertainty on increased bleeding risk, an extended dual antiplatelet regimen may better reserved to patients at high ischemic risk and low bleeding risk. further trials with adequate power are needed to test the clinical efficacy of such tailored dual antiplatelet. this review can-not be used as a guide for tailoring dual antiplatelet therapies for a specific patient. however, it can provide a little insight on which patient is more likely need an extended dual antiplatelet therapy. limitations this article has several limitations. first, its potential selection bias due to full-text unavailability. however, it is minimized by including meta-analysis, which analyzed the trials unavailable to the authors. second, the trials have an under-represented proportion of diabetic and elderly patients, therefore results can-not be extrapolated in these high-risk subgroups. third, this review only analyzed patient-related factors, not attending to other factors which may contribute to clinical outcomes, such as stentrelated factors and different dual antiplatelet regimens. lastly, this review did not compare the efficacy between different extended antiplatelet duration. conclusion it is not beneficial to extend dual antiplatelet therapy for every patients receiving drugeluting stents. overall, the extended dual antiplatelet therapy showed a risk reduction of stent thrombosis and myocardial infarction, at the price of increased bleeding risk. high-risk subgroups like diabetes mellitus has a tendency of increased ischemic risk, while advanced age could have both increased ischemic risk and bleeding risk. this review suggests that it is better to reserve extended dual antiplatelet therapy for patients with high ischemic risk and low bleeding risk (tailored therapy). references 1. antithrombotic trialists’ collaboration. collaborative meta-analysis of randomised trials of anti-platelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. bmj. 2002;324:71–86. 2. grove ecl, kristensen sd. stent thrombosis: definitions, mechanisms and prevention. eur soc cardiol j cardiol pract. 2007;5(32):1-5. 3. levine gn, bates er, blankenship jc, et al. accf/ aha/scai guideline for percutaneous coronary intervention. circulation. 2011;124:e574-e651. 4. windecker s, kolh p, alfonso f, et al. esc/eacts guidelines on myocardial revascularization. eur heart j. 2014;35(37):2541-619. 5. cola c, brugaletta s, yuste vm, campos b, angiolillo dj, sabaté m. diabetes mellitus: a prothrombotic state implications for outcomes after coronary revascularization. vasc health & risk man. 2009;5: 101-19. 6. resnick b. the geriatric patient: demography, epidemiology, and health service utilization. in: kane rl, ouslander jg, abrass ib, resnick b, eds. essentials of clinical geriatrics. 6th ed. new york: mcgraw-hill; 2008. p. 23-40. 7. c h e n g s , b e l l s m , z i e m a n s j . a g i n g a n d atherosclerosis. in: halter jb, ouslander jg, tinetti me, studenski s, high kp, asthana s, eds. hazzard’s geriatric medicine and gerontology. 6th ed. new york: mcgraw-hill; 2009. p. 897-908. 8. peterson ed, gharacholou sm. coronary heart disease. in: halter jb, ouslander jg, tinetti me, studenski s, high kp, asthana s, eds. hazzard’s geriatric medicine and gerontology. 6th ed. new york: mcgraw-hilll; 2009. p. 909-20. 9. kane rl. evaluating the geriatric patient. in: kane rl, ouslander jg, abrass ib, resnick b, eds. essentials of clinical geriatrics. 6th ed. new york: mcgraw-hill; 2008. p. 41-77. 10. mauri l, kerelakes dj, yeh rw, et al. twelve or 30 months of dual antiplatelet therapy after drug-eluting stents. n engl j med. 2014;371(23):2155-66. 11. faxon dp, lawler e, young m, gaziano m, kinlay s. prolonged clopidogrel use after bare metal and drugeluting stent placement: the veterans administration drug-eluting stent study. circ cardiovasc interv. 2012; 5:372-80. 12. park sj, park dw, kim yh, et al. duration of dual antiplatelet therapy after implantation of drug-eluting stents. n engl j med. 2010;362:1374-82. 13. lee cw, ahn jm, park dw, et al. optimal duration of dual antiplatelet therapy after drug-eluting 263 benedicta m. suwita acta med indones-indones j intern med stent implantation: a randomized, controlled trial. circulation. 2014;129:304-12. 14. jia d, zhou yj, zhao yx, et al. prolonged dual antiplatelet therapy improves clinical outcomes in high-risk patients implanted with sirolimus-eluting stents. clin cardiol. 2009;32(3):164-8. 15. navarese ep, andreotti f, schulze v, et al. optimal duration of dual antiplatelet therapy after percutaneous coronary intervention with drug eluting stents: metaanalysis of randomised controlled trials. bmj. 2015; 350:h1618-29. 16. rydén l, grant pj, anker sd, et al. esc guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the easd. eur heart j. 2013;34(39):3035-87. 17. ahn yk, jeong mh, jeong jw, et al. randomized comparison of cilostazol vs clopidogrel after drugeluting stenting in diabetic patients: cilostazol for diabetic patients in drug-eluting stent (cides) trial. circ j. 2008;72:35-9. 18. lee sw, park sw, kim yh, et al. drug-eluting stenting followed by cilostazol treatment reduces late restenosis in patients with diabetes mellitus: the declarediabetes trial. j am coll cardiol. 2008;51:1181-7. 19. jiménez-quevendo p, sabaté m, angiolillo dj, et al. long-term clinical benefit of sirolimus-eluting stent implantation in diabetic patients with de novo coronary stenosis: long-term results of the diabetes trial. eur heart j. 2007;28:1946-52. 20. kandzari de, barker cs, leon mb, et al. dual antiplatelet therapy duration and clinical outcomes following treatment with zotarolimus-eluting stents. j am coll cardiol intv. 2011;4:1119-28. 21. camenzind e, boersma e, wijns w, et al. modifying effect of dual antiplatelet therapy on incidence of stent thrombosis according to implanted drug-eluting stent type. eur heart j. 2014;35:1932-48. 22. feres f, costa ra, abizaid a, et al. three vs twelve months of dual antiplatelet therapy after zotarolimuseluting stents: the optimize randomized trial. jama. 2013;310(23):2510-22. 23. abrass ib. cardiovascular disorders. in: kane rl, ouslander jg, abrass ib, resnick b, eds. essentials of clinical geriatrics. 6th ed. new york: mcgraw-hill; 2008. p. 335-50. 24. nakamura s, ogawa h, bae jh, et al. low incidence of stent thrombosis in asian races: multicenter registry in asia 6 years follow-up result. circulation. 2011;124:a15630. 264 112 original article acta med indones indones j intern med • vol 49 • number 2 • april 2017 diagnostic performance of afternoon urine osmolality to assess optimal hydration status in an adult healthy population ni made hustrini1, parlindungan siregar1, ginova nainggolan1, kuntjoro harimurti1,2 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 clinical epidemiology and evidence-based medicine unit, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: prof. parlindungan siregar, md., phd. division of renal hypertension, department of internal medicine, faculty of medicine universitas indonesiacipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. e-mail: sparlindungan@yahoo.com, madekum99@gmail.com. abstrak latar belakang: hidrasi optimal merupakan hidrasi yang dianggap cukup untuk menggantikan kehilangan cairan, menjamin produksi urin adekuat untuk mengurangi risiko urolitiasis dan penurunan fungsi ginjal, serta mencegah keluarnya arginin vasopresin (avp). osmolalitas urin 24 jam diketahui dapat mengukur status hidrasi seseorang, namun dirasakan memberatkan karena kemungkinan urin tercecer dan membatasi aktivitas kerja. penelitian ini bertujuan mengetahui peranan pemeriksaan osmolalitas urin sewaktu sore hari untuk menilai status hidrasi optimal. metode: studi potong lintang dilakukan pada karyawan sehat berusia 18-59 tahun di lingkungan fkui/rsupn cipto mangunkusumo, memakai metode consecutive sampling. dilakukan analisis kurva roc untuk mendapatkan titik potong dan akurasi osmolalitas urin sore hari dalam menilai status hidrasi optimal. hasil: antara bulan agustus-september 2016 terkumpul 120 subjek (73,8% perempuan, median usia 32 tahun) yang memenuhi kriteria penelitian dengan median osmolalitas urin 24 jam 463,5 (95% ik, 136-1427) mosm/kg h2o dan median osmolalitas urin sore hari 513 (95% ik, 73-1267) mosm/kg h2o. pada analisis didapatkan korelasi sedang (r=0,59; p<0,001) antara osmolalitas urin sore hari dengan osmolalitas urin 24 jam. dengan kurva roc didapatkan nilai auc 0,792 (95% ik, 0,708-0,875) dengan titik potong 528 mosm/kg h2o. dalam menentukan hidrasi optimal, osmolalitas urin sore hari memiliki sensitivitas sebesar 0,7 (95% ik, 0,585-0,795) dan spesifisitas 0,76 (95% ik, 0,626-0,857) serta likelihood ratio (lr) (+) 2,917 (95% ik, 1,74-4,889) dan lr (-) 0,395 (95% ik, 0,267-0,583). kesimpulan: osmolalitas urin sore hari dapat menjadi indikator dalam menilai status hidrasi optimal pada populasi sehat dengan titik potong 528 mosm/kg h2o serta sensitivitas 0,7 dan spesifisitas 0,76. kata kunci: osmolalitas urin sore hari, hidrasi optimal. abstract background: optimal hydration represents adequate total daily fluid intake to compensate for daily water losses, ensure adequate urine output to reduce the risk of urolithiasis and renal function decline, and also avoid the production of arginine vasopressin (avp). twenty-four-hour urine osmolality has been used to assess hydration status, but it is challenging because of the possibility of spilling urine and limitation of daily activities. this study is aimed to determine the performance of the afternoon urine osmolality to assess the optimal hydration vol 49 • number 2 • april 2017 diagnostic performance of afternoon urine osmolality to assess optimal hydration 113 status compared with 24-hour urine osmolality. methods: a cross sectional study was conducted on healthy employees aged 18-59 years at universitas indonesia medical faculty/cipto mangunkusumo hospital, with consecutive sampling method. the roc curve was analyzed to obtain the optimal cut off point and the accuracy of the afternoon urine osmolality in assessing the optimal hydration status. results: between august-september 2016 there were 120 subjects (73.8% female, median age 32 years) who met the study criteria with a median 24-hour urine osmolality 463.5 (95% ci, 136-1427) mosm/kg h2o and median afternoon urine osmolality 513 (95% ci, 73-1267). we found moderate correlation (r=0.59; p<0.001) between afternoon urine osmolality and a 24-hour urine osmolality. using roc curve, the auc value was 0.792 (95% ci, 0.708-0.875) with the cut off 528 mosm/kg h2o. to assess the optimal hydration status, the afternoon urine osmolality had the sensitivity of 0.7 (95% ci, 0.585-0.795) and the specificity of 0.76 (95% ci, 0.626-0.857), likelihood ratio (lr) (+) 2.917 (95% ci, 1.74-4.889) and lr (-) 0.395 (95% ci, 0.267-0.583). conclusion: afternoon urine osmolality can be used as a diagnostic tool to assess the optimal hydration status in healthy population with cut off 528 mosm/ kg h2o, sensitivity of 0.7, and specificity of 0.76. keywords: afternoon urine osmolality, optimal hydration. introduction hydration is a dynamic balance between water intake and loss preserved in narrow range through behavioral and physiological response.1 our body needs 2-2.5 l of water per day which can be obtained from food and beverage.2 however, we still cannot declare a good hydration even when the amount of water was achieved. perrier’s3 study in 2015 shows that 24-hour urine osmolality <500 mosm/kg h2o could be an indicator of optimal hydration. in this term, optimal hydration means hydration that represents adequate total daily fluid intake to compensate for daily water losses, ensuring urinary output, and avoiding production of arginine vasopressin (avp).3 it has been proven that 24-hour urine osmolality has several weaknesses, including the possibility of spilling urine, limitation of daily activities, and error in sampling so there is a lack amount of urine in 30% of population.2 as an alternative method, we consider to substitute 24-hour urine osmolality with spot urine by the following evidence. kavouras’s4 study showed that morning urine has a correlation with hydration status. the result was contradictive with lee and chan’s5 study which observed desmopressin administration in children. they show that there is no difference of morning urine osmolality between two groups. moreover, a systematic review in 2012 which analyzed 9 studies found that night urine osmolality had stronger correlation with 24-hour urine osmolality than random spot urine [0.76 (0.60–0.86) and 0.35 (0.12–0.47), consecutively].6 another study from mann and gerber7 showed that afternoon urine sodium concentration has the strongest correlation with adjusted 24-hour urine sodium concentration (r=0.86, p<0.001). perrier’s8 study also shows that urine osmolality values obtained from late afternoon collection were the most likely to agree with 24hour value, with 87% of values falling within 50 mosm/kgh2o of corresponding 24-hour value. this study also showed that morning urine was still affected by avp from intrinsic mechanism, so it cannot represent 24-hour condition.8 based on these arguments, we can assume that the best time for spot urine collection is in the afternoon. the aim of this study was to prove that afternoon urine osmolality can be used as the indicator to assess optimal hydration status. by comparing it with 24-hour urine osmolality as the gold standard, we expect this study can measure the performance of afternoon urine osmolality to assess optimal hydration status easily. methods this was a diagnostic study with a crosssectional design was conducted from august to september 2016 at universitas indonesia m e d i c a l f a c u l t y / c i p t o m a n g u n k u s u m o hospital. we performed consecutive sampling ni made hustrini acta med indones-indones j intern med 114 on 18-59 years old subjects. subject with chronic illnesses such as diabetes mellitus, diabetes insipidus, hypertension, autoimmune, malignancy, urolithiasis, cerebro-cardiovascular diseases, chronic liver disease, impaired renal function (egfr<60 ml/min/1.73m 2), and abnormality in urinalysis were excluded. this study had obtained ethical approval from ethical committee on health research, faculty of medicine, universitas indonesia number 397/un2.f1/etik/2016 and written informed consent was obtained from each subject. we then proceeded to do history taking of identity and past medical history, vital signs examination (blood pressure, heart rate, breathing frequency, weight, and height), and also laboratory examination (plasma creatinine and urinalysis). then subjects were asked to collect their afternoon (5-7 pm) and 24-hour urine. hydration was considered optimal when the value of 24-hour urine osmolality is ≤500 mosm/kg h2o. the calculation and analysis of this study used spss software for windows version 24.0. correlation analysis of afternoon and 24-hour urine osmolality was done by spearman test. we also analyzed area under the curve (auc) value to determine performance of urine osmolality and optimal cut off point. sensitivity and specificity analysis were also calculated to determine accuracy of afternoon urine osmolality to assess optimal hydration status. results total of 120 subjects participated in this study with the recruitment algorithm as shown in figure 1 and the characteristics shown in table 1. the median of 24-hour urine osmolality was 463.5 mosm/kg h2o (95% ci, 136-1427) and afternoon urine osmolality was 513.5 mosm/ kg h2o (95% ci, 73-1267), with moderate correlation (r=0.594, p<0.001) (figure 2). there were 70 (58.3%) subjects who were optimally hydrated (with 24-hour urine osmolality ≤500 mosm/kg h2o). moreover, from roc analysis (figure 3) our study showed significant value (p<0.001) with auc 0.792 (95% ci, 0.708 – 0.875). the optimal cut-off of afternoon urine osmolality to predict optimal hydration status was 528 mosm/ kg h2o with sensitivity of 0.7 (95% ci, 0.5850.795) and specificity 0.76 (95% ci, 0.6260.857). this study also found positive predictive value (ppv) 0.803 (95% ci, 0.687-0.884) and negative predictive value (npv) 0.644 (95% figure 1. subject flowchart table 1. subjects’ characteristics characteristics value age (year), median (range) 32 (19-57) sex, female, n (%) 91 (75.83) systolic blood pressure (mmhg), mean (sd) 118.36 (13.475) diastolic blood pressure (mmhg), mean (sd) 76.95 (8.767) heart rate (beats/minute), mean (sd) 80.52 (10.854) weight (kg), median (range) 59.8 (38.6-93.3) height (cm), median (range) 158 (145-177) body mass index (kg/m2), mean (sd) 24.184 (4.196) estimated glomerular filtration rate (ml/min/1.73m2), median (range) 117.5 (65-146) urine volume (cc), median (range) 1600 (520-8440) vol 49 • number 2 • april 2017 diagnostic performance of afternoon urine osmolality to assess optimal hydration 115 ci, 0.517-0.754). furthermore, the lr (+) 2.917 (95% ci, 1.74-4.889) and lr (-) 0.395 (95% ci, 0.267-0.583). figure 2. the correlation between 24-hour urine osmolality and afternoon urine osmolality figure 3. the auc curve of afternoon urine osmolality table 2. afternoon urine osmolality performance analysis afternoon urine osmolality twenty four-hour urine osmolality total ≤500 mosm/ kg h2o >500 mosm/ kg h2o ≤528 mosm/kg h2o 49 12 61 >528 mosm/kg h2o 21 38 59 total 70 50 120 discussion yeh, et al.9 found that age, sex, race, body mass index (bmi), blood pressure, total of water consumption, plasma osmolality, alcohol, chronic illness, albuminuria, and diuretics drug affect the value of urine osmolality. since we only include healthy subjects to our study, the confounding factors would not influence both plasma nor urine osmolality values. our study found the median of 24-hour urine osmolality was 463.5 mosm/kg h2o. this result was different from a study in the usa which found that the mean 24-hour urine osmolality is 648 mosm/kg h2o. 9 another study from anyabolu, et al.10 in nigeria reported low 24-hour urine osmolality value (160 mosm/kg h2o). this differences happened because of intercultural variation which affect drinking habits (e.g. consumption of water, beer, wine) and food. moreover, water consumption increases with higher sodium and protein intake.11 our study found moderate correlation (r=0.594, p<0.001) between afternoon and 24hour urine osmolality. perrier’s12 study showed that urine parameters including osmolality, color, specific gravity, volume, and solute concentrations in 24-hour urine had strong correlation with total fluid intake. other study showed hydration parameters from urine had better accuracy than plasma to assess hydration status. the study also showed significant difference in urine parameters between high drinkers and low drinkers, while their plasma osmolality were similar.13 however, the challenges to collect 24-hour urine sample had become the weakness of the study. in addition, another study from perrier showed afternoon (during 4-8pm) urine osmolality most reflects 24-hour urine osmolality with 87% of total values 50 mosm/kg h2o from 24-hour urine osmolality.8 perrier’s study supports our result which obtained moderate correlation (59.4%) between the two variables. this result can be explained by review from truedel, et al.14 which observed circadian effect of avp excitation and found the highest level of avp in the night to prevent water loss during sleeping time. this process produces low volume and high concentration of first morning urine. ni made hustrini acta med indones-indones j intern med 116 claybough jr, et al.15 also support this study by finding the significant relation between urine osmolality and higher avp in night. from our study, the prevalence of subjects who were optimally hydrated was 58.3% using european food safety authority (efsa)’s cut off point (24-hour urine osmolality <500 mosm/kg h2o). previous studies found wide variation of prevalence for good hydration between countries. study in nigeria shows good hydration status in 10.3% of general population (cut off 300-750 mosm/kg h2o of 24-hour urine osmolality). 10 in contrast, the study in the us found that the prevalence of good hydration was 88.8% (cut off 450-840 mosm/kg h2o of 24-hour urine osmolality).9 this variation is due to multiple factors including total water intake, race, diuretic consumption, weather, sodium intake, etc. however, these differences may be caused by various 24-hour urine osmolality cut off that were used in their studies. our study discovered that auc value of afternoon urine osmolality was 0.792 (95% ci, 0.708-0.875). on the other hand, the auc value of previous study which compares 24-hour urine osmolality with adequate fluid intake according to efsa standard was 0.893.3 other study showed auc value of 24-hour urine osmolality was 0.80 in assessing hydration status.16 hooper l, et al.17 in his paper mentioned the auc value of 24hour urine osmolality to determine dehydration status in elderly was 0.56. in the same study, hooper17 found lower auc (0.58) when using specific gravity from dipstick urine; (0.51) when using urine color variable; and (0.54) when using urine volume. from the study, we can assume that urine osmolality still gives the best result comparing to other urine parameters in assessing dehydration status, especially in elderly. another of perrier’s3 study found that the optimal cut off for 24-hour urine osmolality in assessing optimal hydration status was 544 mosm/kg h2o. perrier applied efsa recommendation as minimum standard of total fluid intake. the study also obtained 525 mosm/ kg h2o as the optimal cut off to prevent formation of kidney stones in female with >1850 ml water intake each day.3 the reference of the amount of water intake that is used in perrier’s study was published before in 2004 by curhan, et al.18 meanwhile, the optimal cut off for 24-hour urine osmolality to prevent recurrent kidney stone formation was 488 mosm/kg h2o. 3 in general, the cut off values found in perrier’s study was not very different from efsa recommendation who suggests urine osmolality value to be less than 500 mosm/kg h2o. our study also found similar optimum cut off with efsa recommendation and perrier’s study. the afternoon osmolality cut off value to assess optimal hydration status found in our study was 528 mosm/kg h2o. the similarity can be explained by moderate correlation between the two variables, that have been mentioned earlier. sensitivity and specificity of afternoon urine osmolality to assess optimal hydration status in our study was 0.7 and 0.76, consecutively. previous study which compared 24-hour urine osmolality with total fluid intake based on efsa recommendation found that the sensitivity was 0.86 and specificity was 0.83. from our study, we obtained ppv 0.803 (95% ci, 0.687-0.884) and npv 0.644 (95% ci, 0.517-0.754) with lr (+) 2.917 (95% ci, 1.74-4.889) and lr (-) 0.395 (95% ci, 0.267-0.583). our study also found post-test probability (+) value 0.8 and post-test probability (-) value 0.35. by implementing this values, physicians can increase their confidence approximately 21.7% to determine optimal hydration status using afternoon urine osmolality. while, if someone have afternoon urine osmolality >528 mosm/kg h2o, it means they still have a chance of about 35% to be optimally hydrated. this study can be applied to patients with normal kidney function and in any conditions that do not influence urine osmolality value. for example, physicians can assess optimal hydration status using our cut off value in patients with vomitus, diarrhea, dengue fever, or other cases which affect hydration. there are conditions in which this study cannot be applied due to their effects on urine osmolality, such as (1) diabetes insipidus, where avp secretion is too low so urine osmolality will tend to decrease; (2) in elderly (>60 years old) where production of avp is increased due to hypertrophy of hypothalamus resulting in increased urine osmolality. vol 49 • number 2 • april 2017 diagnostic performance of afternoon urine osmolality to assess optimal hydration 117 this is the first study which reported afternoon urine osmolality as a diagnostic tool to determine optimal hydration status. this study also obtained a cut off value, so we can calculate the accuration of afternoon urine osmolality (sensitivity, specificity, and lr) to assess optimal hydration status. we can use afternoon urine osmolality value to replace 24hour urine osmolality considering its effectiveness. however, this study has limitation that it can only be applied in healthy people. moreover, because this was a diagnostic study, we categorized two hydration status, based on the cut off value (528 mosm/kg h2o), the optimal and the non-optimal ones. these categories impact the interpretation of hydration status which could be contradicting to what we found on physical examination. as an example, two patients with afternoon urine osmolality of 530 mosm/kg h2o and 900 mosm/ kg h2o which based on this study, both will be diagnosed as non-optimal hydration may have different hydration status (good hydration and hypo-hydration) clinically. conclusion afternoon urine osmolality has moderate correlation with 24-hour urine osmolality with correlation coefficient of 0.594. optimal hydration status can be predicted from afternoon urine osmolality with auc value 0.792 and optimum cut off ≤528 mosm/kgh2o (sensitivity 0.7 and specificity 0.76) in assessing optimal hydration status. references 1. kenefick rw, cheuvront sn, leon l, obrien kk. dehydration and rehydration. in aurbach ps, editor. wilderness medicine. 6thed. new york. raven press; 2015. p. 71-82. 2. jequier e. contstan f. water as an essential nutrient: the physiological basis of hydration. eur j clin nutr. 2010;64:115-23. 3. perrier et, jimenez ib, vecchio m, armstrong le, tack i, klein a. twenty-four-hour urine osmolality as a physiological index of adequate water intake. dis markers. 2015:1-8. 4. kavouras sa. assessing hydration status. curr opin clin nutr metab care. 2002;5(5):519-24. 5. lee kw, chan wky. is early urine osmolality a good predictor of response to oral desmopressin in children with primary monosymptomatic nocturnal enuresis? hk j paediatr. 2004;9:50-3. 6. chen j, sykes l, paul c, et al. systematic review of studies comparing 24 hour and spot urine collections for estimating population salt intake. rev panam salud publica. 2012;32(4):307-15. 7. mann sj, gerber lm. estimation of 24 hour sodium excretion from spot urine sample. j clin hypertens. 2010;12:174-81. 8. perrier e, demazieres a, girard n, et al. circadian variation and responsiveness of hydration biomarkers to changes in daily water intake. eur j appl physiol. 2013;113:2143-51. 9. yeh hc, lin ys, kuo cc, et al. urine osmolality in the us population: implications for environmental biomonitoring. environ res. 2015;136:482-90. 10. anyabolu e, chukwuonye i. urine osmolality in adults attending a general out-patient clinic: clinical implications. am j med sci. 2016;6(5):145-51. 11. armstrong le. assessing hydration status: the elusive gold standard. j am collnutr. 2007;26(5):575-84. 12. perrier e, rondeau p, poupin m, et al. relation between urinary hydration biomarkers and total fluid intake in healthy adults. eur j clin nutr. 2013;67:939-43. 13. perrier e, vergne s, klein a, et al. hydration biomarkers in free-living adults with different levels of habitual fluid consumption. br j nutr. 2013;109(9):1678-87. 14. trudel e, bourque cw. central clock excites vasopressin neurons by waking osmosensory afferent during sleep. nat neurosci. 2010;13:467-74. 15. claybaugh j, sato a, lk c, hassell l. effects of time of day, gender, and menstrual cycle phase on the human response to a water load. am j physiol regulintegr comp physiol. 2000;279:966-73. 16. munoz cx, mckenzie al, armstrong le. optimal hydration biomarkers: consideration of daily activities. obes facts. 2014;7(2):13-8. 17. hooper l, bunn dk, abdelhamid a, et al. water-loss (intracellular) dehydration assessed using urinary tests: how well do they work? diagnostic accuracy in older people. am j clin nutr. 2016;104(1):121-31. 18. curhan g, willet w, knight e, stampfer m. dietary factors and the risk of incident kidney stones in younger women. arch intern med. 2004;164:885-91. 10 original article acta med indones indones j intern med • vol 49 • number 1 • january 2017 validity and reliability of the indonesian version of sf-36 quality of life questionnaire on patients with permanent pacemakers simon salim1, muhammad yamin1, idrus alwi1, siti setiati2 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 clinical epidemiology and evidence-based medicine unit, cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: simon salim, md. division of cardiology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: simonsalim@gmail.com. abstrak tujuan: membentuk dan memvalidasi kuesioner sf-36 versi bahasa indonesia. metode: penelitian ini merupakan penelitian potong lintang yang terdiri atas 2 tahap: 1) adaptasi budaya dan bahasa; dan 2) uji validitas dan reliabilitas. kami mengevaluasi 32 orang pada tahap awal dan 20 orang pada tahap akhir dari bulan september 2014 hingga agustus 2015. subjek merupakan pasien dengan pacu jantung permanen. kami mengikuti petunjuk adaptasi lintas budaya untuk menghasilkan kuesioner sf-36 versi bahasa indonesia. kuesioner terjemahan akhir akan diperiksa validitasnya terhadap tes jalan 6 menit dan pemeriksaan nt pro-bnp. hasil: kuesioner sf-36 bahasa indonesia memiliki korelasi positif antara tes jalan 6 menit dengan domain pf (physical functional) (r=0,363; p=0,001), dan memiliki korelasi negatif antara nt pro-bnp dengan domain gh (general health) (r=-0,269; p=0,020) dan mh (mental health) (r=-0,271; p=0,019). konsistensi internal kuesioner sf36 bahasa indonesia, yang diukur dengan cronbach’s alpha dinilai baik dengan nilai >0,70. uji repeatability antara hari 1 dan hari 8 dinilai baik dengan korelasi positif kuat (r=0,626; p=0,003) dan tidak ada perbedaan bermakna pada level item, domain, dan keseluruhan kuesioner. kesimpulan: kuesioner sf-36 bahasa indonesia dapat digunakan sebagai kuesioner umum untuk menilai kualitas hidup pasien dengan pacu jantung permanen. kata kunci: kualitas hidup, kuesioner, sf-36, pacu jantung, indonesia. abstract aim: to construct and validate indonesian version of sf-36. methods: this is a cross-sectional study, which consist of 2 stages process: 1) language and cultural adaption; and 2) validity and reliability evaluation. we evaluated 32 pacemaker patients during language and cultural adaptation stage and 20 pacemaker patients during validity and reliability evaluation stages from september 2014 to august 2015. we followed cross-cultural adaptation guideline to produce indonesian version of the questionnaire. the final translated questionnaire was checked by assessing the correlation of sf-36 and 6-minutes walking test (6mwt) and nt pro-bnp result. results: indonesian version of sf-36 showed positive correlation between 6mwt result and physical functioning (pf) (r=0.363; p=0.001) and negative correlation between nt pro-bnp score with general health (gh) (r=-0.269; p=0.020) and mental health (mh) (r=-0.271; p=0.019). the internal consistency of indonesian version of sf-36 questionnaire, which measured by cronbach’s alpha, was good with value of >0.70. repeatability between day 1 and day 8 was good, with strong positive correlation (r=0.626; p=0.003). conclusion: the indonesian version of sf-36 could be used as a general questionnaire to assess quality of life in patients with permanent pacemaker. keywords: quality of life, questionnaire, sf-36, pacemaker, indonesia. vol 49 • number 1 • january 2017 validity and reliability of the indonesian version of sf-36 qol questionnaire 11 introduction as cardiovascular diseases (cvd) morbidity and mortality increased, the need of health intervention is increasing as well. permanent pacemaker, as one of innovation in cvd management, has been widely used for arrhythmia therapy. more than 500,000 procedures have been performed per year worldwide.1 many studies showed that the permanent pacemaker has improved survival in patients with cvd, especially in the case of complete av block.2 according to world health organization (who), health is a state of complete physical mental and social well-being and not merely the absence of disease or infirmity.3 hence, physicians need to consider quality of life in recommending a therapy. in the last 2 decades, health-related quality of life measurement has a strong impact in health care and medical intervention evaluation. quality of life measurement is also essential to predict effectiveness and successfulness of therapy.4,5 there are several studies that assessed the successfulness of pacemaker implantation, not only based on the survival of the patients but also the improvement of their quality of life. quality of life involves several dimensions: physical function, emotional state, social interaction, and somatic sensation. 5 the instrument to measure quality of life must not only be valid, appropriate, reliable, and responsive, but also capable of being interpreted.6 there are two types of instruments that can be used to measure quality of life, generic and disease specific instruments. using combination of both instruments may be more appropriate to evaluate quality of life, especially in patients with pacemaker. sf-36 has been well-known as a generic instrument which become a standard for measuring quality of life. it measures eight domains from physical and mental aspects: general health (gh), physical functioning (pf), role-physical (rp), bodily pain (bp), vitality (vt), social functioning (sf), roleemotional (re), and mental health (mh). sf-36 questionnaire has been translated into several languages.7 up to our knowledge, there is no satisfactory indonesian version of sf-36. a group of researchers had translated sf-36 into indonesian version for cancer study and suggested most questions to be reconstructed.8 the objective of this study was to translate and evaluate validity and reliability of the indonesian version of sf-36 for assessing quality of life, especially in indonesian language speaking pacemaker patients. methods this is a cross-sectional study, performed in an outpatient cardiology clinic of the cipto mangunkusumo hospital, within a 1-year period between september 2014 and august 2015. this study had been approved by the ethical committee on health research, faculty of medicine universitas indonesia cipto mangunkusumo hospital on september 14th, 2014 with a reference number of 629/un2.f1/ etik/2014. the study enrolled patients aged over 18 years with permanent pacemakers, which have been implanted for at least 3 months. we excluded patients with congestive heart failure nyha iii-iv, cognitive impairment, physical disability, not optimal echo window, and other comorbidities,such as pericardial effusion and pleural effusion. this study was divided into 2 steps, language and cultural adaptation and validity and reliability testing. the minimum of 30 patients were needed for the language and cultural adaptation process suggested by beaton et al.9. for validity and reliability testing, the minimum samples size were determined by calculating from confidence level 95% with power 80% and r=0.6. samples were collected consecutively. we finally involved 32 patients for language and cultural adaptation process and 20 patients for validity and reliability testing. step 1: language and cultural adaptation the procedures for translation into the indonesian language were modified from guillemin and beaton.9,10 this step consists of 6 stages: initial translation, translation synthesis, back translation, committee review, pretesting, and submission and appraisal of all written reports to the committee (table 1). two indonesian translators performed the initial translation process and they synthesized one simon salim acta med indones-indones j intern med 12 indonesian version. in the back translation stage, the synthesis questionnaire was then translated back to english by two english speaking mother tongue translators. the committee, which consists of methodological expert, clinical expert, and translators, reviewed the original at collaboration with the european questionnaire and each translation together with corresponding written reports. after being reviewed by the committee, the questionnaire was edited to be the pre-final version (figure 1). the pre-final translated version was then distributed to 32 pacemaker patients. the researcher documented any difficulties that the patients experienced during the time the patients completed the questionnaire. the documentations were reviewed and used to modify the questionnaire into the final version. step 2: validity and reliability testing the validity of the final version of indonesian language was assessed through the participation of 20 patients by comparing sf-36 questionnaire with functional class and 6-minutes walking test (6mwt). internal consistency was assessed by item-to-item correlation, item-to-domain, itemto-total correlation, and cronbach’s a coefficient. it was considered to be acceptable when item-totable 1. stages of the language and cultural adaptation9,10 stage participants product initial translation 2 translators (informed and uniformed translator) into target language translation 1 (t1) translation 2 (t2) translation synthesis 2 initial translators and observer 1 synthesis translation (t12) back translation 2 translators with english as the first language and unfamiliar to the questionnaire back translation 1 (bt1) back translation 2 (bt2) committee review research team (methodology expert, health expert, and translators) pre-final questionnaire pretesting 32 patients written report additional stage submission of documentation to the committee stage iii back translation back translation 1 (uninformed translator) back translation 2 (uninformed translator) stage iv committee review stage v pretesting final questionnaire stage i initial translation translation 1 (informed translator) translation 2 (uninformed translator) indonesian language stage ii synthesis 1 synthesized indonesian translation figure 1. language and cultural adaptation process item correlation was >0.2–0.4, item-to-domain correlation and item-to-total correlation were >0.2, and cronbach’s alpha was 0.7 or greater. repeatability was assessed by test-retest method by asking patient to fill the same questionnaire under the same condition in the next 7 days. if the correlation between two separate administration of the questionnaire is >0.8, the questionnaire is then considered has good test-retest reliability. results step 1: language and cultural adaptation a total of 32 patients participated in the language and cultural adaptation process with mean age of 65.8 (sd 15.096); in that, 53.1% were females and 28% were patients with bachelor degree or higher. most patients (62.5%) have pacemaker implantation for high degree or total av block and majority of them (81.3%) have dual chamber pacemaker. this step involved 2 native indonesia translators, which one of them has medical background, and 2 vol 49 • number 1 • january 2017 validity and reliability of the indonesian version of sf-36 qol questionnaire 13 native non-medical english translators. in the indonesian version of sf-36, most of the questions were translated without any significant changes (appendix 1: http://www. actamedindones.org/index.php/ijim/article/ view/275/pdf). some questions were clarified by adding some explanations. for example: the word “flight of stairs” in question number 6 and 7 was translated into ‘rangkaian tangga’ (lit. set of stairs), which normally consists of 10 to 12 stairs. but to facilitate patients understanding, the translators decided to add the word ‘lantai’ (lit. floor). “several flight of stairs” was explained by ‘satu lantai atau lebih’ (lit. one floor or more), while “one flight of stairs” was explained by ‘setengah lantai’ (lit. half floor). another example, the question number 9, “walking more than a mile”, was explained by adding 1.6 kilometers since indonesian people were not familiar with “mile”. the translators also added explanation for the word “blocks” by adding 100 meter (lit. one hundred meters) for one block and >100 meter (lit. more than one hundred meters) for several blocks. for number 21, the word “pain” has been translated into two different words by both indonesian translators. in indonesian language, the word “pain” can be translated into nyeri or sakit. even though indonesian people more familiarized with the word sakit but it also has another meaning, which is “sickness”. both translators finally decided to use the word nyeri to avoid misunderstanding. the translators also made some changes for options number 23–31. they used the words sepanjang waktu (lit. all of the time), sering (lit. often), cukup sering (lit. quite often), kadangkadang (lit. sometime), jarang (lit. seldom), and tidak pernah (lit. never) to express the words “all of the time”, “most of the time”, “a good bit of the time”, “ some of the time”, “a little of the time”, and “none of the time” in the original questionnaire. for number 36, the word “excellent” was translated into sangat baik (lit. very good). step 2: validity and reliability testing a total of 20 patients, with the mean age 62.35 (sd 16.69), were involved in validity and reliability testing.patients characteristics can be seen in table 2. data were retrieved between march 2015 and april 2015. sf-36 questionnaire consists of 36 items question, which grouped into 8 health domains. because each item has different scale, coding was used to equalize the weight of each item. item number 1, 2, 20, 22, 34, 36, which has 5 scale, were converted into 100, 75, 50, 25, 0; item number 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, which have 3 scale, were converted into 0, 50, 100; item number 13, 14, 15, 16, 17, 18, 19, which have 2 scale, were converted into 0 and 100; item number 21, 23, 26, 27, 30, which have 6 scale, were converted into 100, 80, 60, 40, 20, 0; item number 24, 25, 28, 29, 31 were converted into 0, 20, 40, 60, 80, 100; and item number 32, 33, 35 were converted into 0, 25, 50, 75, 100. validity of the questionnaire was measured by correlation of questionnaire and other supportive measures, 6mwt and nt pro bnp. correlation was considered very strong if r = 0.80–1.00; strong if r = 0.60–0.79, moderate if r = 0.40–0.59; weak if r = 0.20–0.39; and very weak if r = 0.00– 0.19. most of all domains in sf-36 indonesian version were not normally distributed, except gh and vt domain. meanwhile, the correlation between 6mwt and nt pro bnp was tested using kendall’s tau method. the result showed a very significant weak positive correlation between pf domain and table 2. patients’ characteristics in validity and reliability testing variables value (n=20) age (year), mean (sd) 62.35 (16.69) gender (male), % 55.00 educational background, % elementary school 25.00 junior high school 30.00 senior high school 10.00 diploma 5.00 bachelor degree 25.00 master degree 5.00 indication for pacemaker, % av block (high degree or total) 75.00 sick sinus syndrome 10.00 symptomatic bradycardia 15.00 type of permanent pacemaker, % single chamber 0.00 double chamber 100.0 simon salim acta med indones-indones j intern med 14 6mwt (r=0.363; p=0.001). on the other hand, there were 2 domains (gh and mh), which showed a significant weak negative correlation with nt pro bnp. indonesian version of sf-36, as a questionnaire, only showed weak negative correlation with nt pro bnp and did not have any significant correlation with 6mwt (table 3). meanwhile, reliability of the questionnaire was measured by internal consistency and repeatability test. internal consistency of the questionnaire was tested by cronbach α and inter-item and inter-domain correlation. if α coefficient is 0.70 or higher, it is considered acceptable. this result showed that cronbach α was higher than 0.7 for all domains (range: 0.751–0.922) except for social functioning (α=0.614) and vitality (α=0.434) domains (table 4). cronbach α for total sf-36 was 0.789. domain re and bp (0.614; p<0.01). some domains have positive moderate correlation (gh and sf 0.422; p<0.01; pf and rp 0.489; p<0.01; pf and sf 0.463; p<0.01; rp and re 0.574, p<0.01; rp and sf 0.414; p<0.01; sf and bp 0.416; p<0.01; sf and mh 0.445; p<0.01) and the others have weak positive correlation (gh and pf 0.282; p<0.05; gh and vt 0.311; p<0.01; gh and mh 0.308; p<0.05; pf and re 0.376, p<0.01; pf and bp 0.394, p<0.01; pf and vt 0.354, p<0.01; rp and bp 0.335, p<0.05; re and sf 0.29; p<0.05; sf and vt 0.269; p<0.05; bp and mh 0.302; p<0.05, vt and mh 0.360; p<0.01). however, all domains were very significantly correlated with total questionnaire (gh and total sf-36 0.410; p<0.01; pf and total sf 36 0.694; p<0.01; rp and total sf 36 0.582; p<0.01; re and total sf 36 0.549; p<0.01; sf and total sf 36 0.552; p<0.01; bp and total sf 36 0.446; p<0.01; vt and total sf 36 0.426; p<0.01, mh and total sf -36 0.422; p<0.01). repeatability repeatability test was conducted by asking the patients to fill in the questionnaire in 2 different times with the same condition. the patients were asked to visit the hospital 7 days after the first meeting. we analyzed the correlation, by using kendall’s test, and the difference, by using wilcoxon, of the items, domains, and total questionnaire. from the repeatability test, it was found that 20 items were correlated significantly between day 1 and day 8 (item 1 (0.517, p<0.05), item 2 (0.604, p<0.01), item 3 (0.821, p<0.01), item 4 (0.41, p<0.05), item 5 (0.514, p<0.05), item 10 (0.668, p<0.01), item 11 (0.498, p<0.05), item 12 (1.00, p<0.01), item 15 (0.685, p<0.01), item 18 (0.579, p<0.05), item 19 (0.577, p<0.05), item 21 (0.431, p<0.05), item 24 (0.454, p<0.05), item 25 (0.702, p<0.01), item 27 (0.535, p<0.01), item 28 (0.889, p<0.01), item 30 (0.649, p<0.01), item 32 (0.625, table 3. correlation between sf-36 domains and 6mwt and nt pro-bnp gh pf rp re sf bp vt mh total sf-36 6mwt 0.173 0.363** 0.028 -0.002 0.039 0.123 0.092 0.077 0.207 nt pro-bnp -0.269* -0.179 -0.131 -0.231 -0.16 -0.199 -0.14 -0.271* -0.261* *) p<0.05 (2-tailed); **) p<0.01 (2-tailed) table 4. internal consistency reliability domains cronbach α gh 0.751 pf 0.869 rp 0.878 re 0.842 sf 0.614 bp 0.922 vt 0.434 mh 0.824 total sf-36 0.789 inter item correlation were calculated in each domain. all items in domain rp, re, sf, and bp were significantly correlated. meanwhile in other domains, such as gh, pf, vt, and mh, some items were not significantly correlated to each other. s i n c e s f 3 6 c o n s i s t s o f 8 d o m a i n s , correlation between each domain was also calculated. domain score was obtained from total questionnaire in day 1 and day 8. the result showed strong positive correlation between vol 49 • number 1 • january 2017 validity and reliability of the indonesian version of sf-36 qol questionnaire 15 p<0.01), item 34 (0.570, p<0.01), and item 36 (0.476, p<0.05)). in domain level, all domains were correlated significantly between day 1 and day 8, except rp domain (gh 0.398 (p<0.05), pf 0.572 (p<0.01), re 0.478 (p<0.05), sf 0.479 (p<0.05), bp 0.434 (p<0.05), vt 0.376 (p<0.05), and mh 0.616 (p<0.05)). the total questionnaire was correlated significantly between day 1 and 8 with a strong positive correlation (r=0.626; p=0.003). meanwhile, there was no significant difference of the repeatability test in 20 patients in item level, domain level, and total questionnaire. discussion in the translation and back-translation process, there was no big discrepancy among the 2 indonesian versions and the 2 backtranslation versions performed in this study. in the cultural adaptation process, we did not make any significant changes since indonesian people are already familiar with some activities mentioned in the questionnaire. we only added several explanations, such as distances, because indonesian people might have a different perception in those regards. the validity evaluation of sf-36 indonesian version showed this questionnaire is valid to be used as a quality of life assessment tool in patients with permanent pacemaker. in validation process, this questionnaire has been through content validity, face validity, criterion validity, and construct validity. the content validity was assessed by receiving the input from patients as well as the expert about the content of the questionnaire. both of patients and the experts agreed that the content of the questionnaire are logic, comprehensive, and has been covered the characteristics to be measured. the face validity process was conducted by the observation of the researcher that the questions used in this questionnaire were relevant, reasonable, unambiguous, and clear. for the criterion validity, we evaluate the correlation with other criteria, which has been considered as gold standard, 6 minutes walking test and nt pro bnp. we found that sf-36 indonesian version has no significant correlation with 6mwt but has an inverse or negative correlation with nt pro bnp. this finding was different with other studies, which showed a moderate-strong correlation between 6mwt and physical function domain.11 in construct validity, we and the expert assessed that this questionnaire has good convergent validity and discriminant validity because some domains were correlated to assess the same thing and some other were different to assess the different concept. in the reliability evaluation, the internal consistency of this questionnaire was good. there were 2 domains, sf and vt, which showed the cronbach α score were less than 0.7. low reliability of sf and vt domains had been observed in other studies. a study of moroccan-arabic language groups in netherland reported reliabilities of 0.54 for vt and 0.63 for sf.12 the same result was also found in thailand, which reported reliabilities of 0.68 for vt and 0.55 for sf.13 translating the concept of social functioning is difficult since there are some cultural differences in indonesia. social functioning has also been rated as difficult in translations of sf-36 items in a cross-cultural comparison of 10 countries.14 meanwhile, items in vitality domain are intended to measure physical and mental energy and fatigue. the low reliability of vt might be caused by different perception of patient’s own condition. inter-item correlation in each domain showed weak to strong correlations. in rp, re, sf, and bp domains, the correlation between items were significant. on the other hand, some of the items in gh, pf, vt, and mh domains were not significantly correlated. based on study health care financing review, items in vitality and mental health domain have strong correlation with each other.15 this discrepancy might be caused by different perception of the patients in assessing their condition or embarrassment of answering the question. inter-domain correlation showed weak to strong correlation and it was in accordance to other study. the repeatability of sf-36 indonesian version was good because there was a good correlation between questionnaire obtained in day 1 and day 8. even though there were some differences in item 2, 3, 23 and 26, these differences were not meaningful if we compared to the domain and total sf-36. since simon salim acta med indones-indones j intern med 16 sf-36 questionnaire was designed to evaluate the health condition in 1 last month, the difference measurement in 1-week away would not give a meaningful difference. conclusion the indonesian version of sf-36 has good validity and reliability and could be used as a general questionnaire to assess quality of life in permanent pacemaker patients. from this study we assumed that indonesian version of sf-36 questionnaire could be applied to patients who have chronic disease or potentially having disability. the assessment of quality of life should be taken into consideration, especially in giving medical treatment to the patients. however, this study has several weaknesses. we did not evaluate the correlation between the receptiveness of the patients with their education level and ethnical background. we also excluded the patients with disability, especially those who could not conducted 6mwt. the validity and reliability of this questionnaire were good. however, we cannot conclude directly that this indonesian version of sf-36 can be used to monitor improvements, as it is not in the scope of our study. we also urge the need to validate our questionnaire in other patient groups, as our sample was very homogenous. acknowledgments we would like to thank the translators, patients, and expert committee for their participation in this study. references 1. moller m, arnsbo p, asklund m, et al. quality assessment of pacemaker implantations in denmark. europace. 2002;4(2):107-12. 2. vardas pe, auricchio a, blanc jj, et al. guidelines for cardiac pacing and cardiac resynchronization therapy: the task force for cardiac pacing and cardiac resynchronization therapy of the european society of cardiology. developed in collaboration with the european heart rhythm association. eur heart j. 2007;28(18):2256-95. 3. world health organization. constitution of the world health organization. basic documents, supplement 2006. 4. viens am. quality of life as a paradigm for health in a developed society. internet j law, healthcare ethics. 1999;1(1). 5. linde c. how to evaluate quality of life in pacemaker patients: problems and pitfalls. pace. 1996;19:391-7. 6. chen t-h, li l, kochen mm. a systematic review: how to choose appropriate health-related quality of life (hrqol) measures in routine general practice? j zhejiang univ sci. 2005;6b(9):936-40. 7. ware je, jr., gandek b. overview of the sf-36 health survey and the international quality of life assessment (iqola) project. j clin epidemiol. 1998;51(11):903-12. 8. perwitasari da. development the validation of indonesian version of sf-36 questionnaire in cancer disease. indonesian j pharm. 2012;23(4):248-53. 9. beaton de, bombardier c, guillemin f, ferraz mb. guidelines for the process of cross-cultural adaptation of self-report measures. spine. 2000;25(24):3186-91. 10. guillemin f, bombardier c, beaton d. cross-cultural adaptation of health-related quality of life measures: literature review and proposed guidelines. j clin epidemiol. 1993;46(12):1417-32. 11. alison ja, kenny p, king mt, et al. repeatability of the six-minute walk test and relation to physical function in survivors of a critical illness. phys ther. 2012;92(12):1556-63. 12. hoopman r, terwee cb, deville w, knol dl, aaronson nk. evaluation of the psychometric properties of the sf-36 health survey for use among turkish and moroccan ethnic minority populations in the netherlands. qual life res. 2009;18(6):753-64. 13. lim ll, seubsman sa, sleigh a. thai sf-36 health survey: tests of data quality, scaling assumptions, reliability and validity in healthy men and women. health qual life outcomes. 2008;6:52. 14. wagner ak, gandek b, aaronson nk, et al. cross-cultural comparisons of the content of sf36 translations across 10 countries: results from the iqola project. international quality of life assessment. j clin epid. 1998;51(11):925-32. 15. gandek b, sinclair sj, kosinski m, ware je, jr. psychometric evaluation of the sf-36 health survey in medicare managed care. health care fin rev. 2004;25(4):5-25. 540 acta med indones indones j intern med • vol 54 • number 4 • october 2022 original article abstracts background: most covid-19 patients have mild or moderate illnesses that can progress to severe illness, leading to hospitalization and/or mortality. the use of antivirals to prevent the progression of covid-19 in nonhospitalized patients shows conflicting result and efficacy remain unclear. this study evaluates the efficacy and safety of antivirals therapy in covid-19 outpatients. methods: search were conducted in pubmed, sciencedirect, cochrane library, springer, medrxiv, journal storage [jstor], and directory of open access journals [doaj] for articles investigating antivirals in covid-19 outpatients. in addition, clinical and virological outcomes, covid-19 hospitalization, all caused mortality, and adverse events were assessed. results: thirteen studies were included in this review. the consecutive data from these studies suggested that favipiravir is more optimally used in early disease, but improvement in symptoms shows inconsistent results. meanwhile, molnupiravir shows consistent results, which can reduce hospitalization and mortality risk. in addition, remdesivir and nirmatrelvirritonavir have the potential to prevent the progression of covid-19 in outpatients, but the data provided in this study are very limited. finally, there is no significant difference in serious and non-serious adverse events, highlighting that antivirals have a good safety profile. conclusion: this study provides an overview of the role of various antivirals therapy in covid-19 outpatients. molnupiravir, remdesivir, and nirmatrelvir-ritonavir have shown potential to prevent the progression of covid-19 in early disease. however, this review was based on very limited data. therefore, further clinical trials are needed to confirm this finding. keywords: covid-19, sars-cov-2, antiviral, outpatients, systematic review. antiviral treatment in covid-19 outpatients: a systematic review of randomized controlled trials david setyo budi1, puguh oktavian1, tri pudy asmarawati2, pudji lestari3*, fauziah ariviani1, raka ihsanulhaj1, tamara tsania1, danise febiola1, naomi lesmana putri1 1faculty of medicine universitas airlangga, surabaya, indonesia. 2department of internal medicine, faculty of medicine universitas airlangga universitas airlangga hospital, surabaya, indonesia. 3department of public health, faculty of medicine universitas airlangga, surabaya, indonesia. * corresponding author: pudji lestari, md. department of public health, faculty of medicine universitas airlangga. jl. mayjen prof. dr. moestopo 47, surabaya 60131, indonesia. email: pudjilestari70@fk.unair.ac.id. introduction coronavirus disease 2019 (covid-19) was declared a pandemic by the world health organization on march 11th, 2020.1 as of march 2nd, 2022, there were 437 million confirmed cases and 5.9 million deaths were caused by covid-19 worldwide.2 the clinical manifestation of covid-19 can range from asymptomatic status, acute respiratory disease, and pneumonia, to acute respiratory distress syndrome. one of the factors of disease progression of covid-19 are comorbidities such as chronic hypertension, organ damage, and coagulation dysfunction.3 currently, therapy is used based on the severity of covid-19. in hospitalized covid-19, corticosteroids and antivirals are recommended vol 54 • number 4 • october 2022 antiviral treatment in covid-19 outpatients 541 for severe covid-19. in addition, the majority of the patients were classified as mild or moderate illnesses with some of them progressing into severe illness and needing hospitalization.4 because of that, prevention of illness progression in an outpatient setting is important to decrease the risk of death and healthcare workload. the choice of treatment for outpatient covid-19 patients is still a matter of debate. neutralizing antibody exhibits a significant antiviral effect when administered early in covid-19 outpatients. however, the presence of the sars-cov-2 variant may escape the neutralizing antibody response.5 even so, antivirals are one of the treatment options in covid-19 outpatients since they are not affected by spike-protein variants. several antivirals have been used in clinical trials by covid-19 outpatients, including remdesivir, favipiravir, tenofovir disoproxil fumarate, and molnupiravir which are antivirals groups that inhibit rna synthesis.6,7 the active form of these drugs will act on the rdrp enzyme and can interfere with the transcription process. rdrp is an enzyme that works on the viral genome (+grna) and will form a complementary strand (-grna) through the transcription process, so it will be able to kill the virus via chain termination and mutagenesis.8 in addition, protease inhibitors such as nirmatrelvir, lopinavir, and ritonavir can inhibit the translation of polypeptides into protein components by inhibiting 3-chymotrypsinlike protease (3clpro). this enzyme plays a role in the viral life cycle by breaking down polyproteins (pp1a and pp1ab) into functional viral proteins.6,9,10 then there is umifenovir, a drug with a mechanism of action targeting spike protein, angiotensin-converting enzyme 2 (ace2), and inhibiting viral envelope membrane fusion11. moreover, there are sofosbuvir and daclatasvir which are ns5b polymerase inhibitors and ns5a inhibitors that can inhibit the viral replication process.12 studies on the use of antivirals in covid-19 outpatients are still scarce. according to its capability, antivirals can potentially prevent worsening of clinical manifestation especially when given earlier in the disease manifestation. several randomized controlled trials (rcts) on antiviral therapy in covid-19 outpatients have recently been published and produced conflicting results. therefore, in this systematic review, we aim to comprehensively evaluate the efficacy and safety of antivirals therapy in covid-19 outpatients. the parameters of efficacy were assessed based on clinical outcomes such as who average score, time to alleviation of symptoms, and covid-19 related symptoms. meanwhile, safety is assessed from non-serious adverse event and a serious adverse event. non-serious adverse events is defined as any unfavorable and/or unintended sign, symptom, or disease temporally associated with the use of an investigational product serious adverse events are defined as events that, at any dose, result in the following: death, life-threatening, in-patient hospitalization or prolongation of existing hospitalization, and persistent or significant disability. methods this systematic review and meta-analysis are written based on the 2020 guideline for preferred reporting items for systematic review and meta-analysis (prisma),13 and registered in the database for prospero (crd42022313970). eligibility criteria this study used randomized controlled trials (rcts) as the required type of study. two authors (dsb and po) scanned through the titles and abstracts for each journal based on the eligibility criteria as follows: (1) covid-19 outpatients; (2) studies involving antiviral therapy; (3) reported at least one of the outcomes of interest (4) english language literature. the primary outcomes included clinical recovery, the need for hospitalization, and adverse events with the secondary outcomes being laboratory outcomes. reviewed articles, non-human studies, irrelevant articles, and duplicates are excluded. search strategy and selection of studies two authors (po and fa) have been conducting keyword searches on september 10th, 2021 for related materials published in databases (pubmed, sciencedirect, cochrane library, springer, journal storage [jstor], and directory of open access journals david setyo budi acta med indones-indones j intern med 542 [doaj]). the following keywords were used: “((covid) or (sars-cov-2)) and ((antiviral) or (remdesivir) or (molnupiravir) or (favipiravir) or (nirmatrelvir)) and ((outpatient) or (non-hospitalized))”. we also performed manual searches, extended from september 11th, 2021 to march 10th, 2022. additional details about the search strategy can be found in supplementary materials. titles and abstracts were screened individually from every article gathered until this point to identify potentially eligible studies, to then having full text screening. any disagreements between these two authors were resolved by discussion with all authors until consensus was reached. data extraction relevant data were independently extracted using a structured and standardized format from each study selected by two authors (dsb and po). the following information was extracted: first author name and year of publication, study design, country of origin, sample size, patient age, disease severity, antivirals dose and duration, combination therapy and outcomes (clinical outcome, laboratory outcome, and adverse events). quality assessment the methodological quality of each study was assessed independently by two authors (dsb and po) using the cochrane risk of bias tool for randomized trials (rob ver.2).14 studies were classified as “low risk of bias”, “some concerns” or “high risk of bias”. statistical analysis considering the important differences in the comparison of each study and various outcome measures, we could not generate meta-analyses of the included studies; instead, we narratively synthesized the evidence. results study selection from the database and manual research, we acquired 5946 and 125 records, respectively. after a screening process of titles and abstracts, 36 potentially eligible articles were selected for review. after a full-text assessment, 13 studies were included for a systematic review. the study selection process is summarized in the prisma flow chart (figure 1). prisma 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources records identified from*: pubmed (n = 233) sciencedirect (n = 4689) cochrane library (n = 93) springer (n = 916) jstror (n = 12) doaj (n = 3) records removed before screening: duplicate records removed (n = 102) records marked as ineligible by automation tools (n = 0) records removed due to irrelevancy (n = 5751) records screened (n = 93) records excluded irrelevant (n = 52) systematic review (n = 2) reports sought for retrieval (n = 39) reports not retrieved (n = 5) reports assessed for eligibility (n = 34) reports excluded (n = 23), due to: letter to editor (n = 11) full text non-available (n = 8) irrelevant study design (n = 4) records identified from: medrxiv (n = 118) clinicaltrials.gov (n = 7) reports assessed for eligibility (n = 2) reports excluded (n = 0), due to: irrelevant (n = 0) systematic review (n = 0) studies included in systematic review (n = 13) identification of studies via databases and registers identification of studies via other methods id en tif ic at io n s cr ee ni ng in cl ud ed reports sought for retrieval (n = 16) reports not retrieved (n = 14) figure 1. prisma flow chart. vol 54 • number 4 • october 2022 antiviral treatment in covid-19 outpatients 543 quality assessment ten rcts15–24 were considered to be lowrisk of bias studies and three rcts25–27 have some concerns according to cochrane’s risk of bias 2 (rob2) assessment. in addition, details of the quality of assessment are summarized in supplementary materials. (table s2) study characteristics thirteen studies were found with a total of 3078 covid-19 outpatients belonging to the antivirals therapy group and 2839 patients belonging to the placebo or standard therapy as a control group. in this review, all studies are rcts conducted in the united states, france, iran, and multiple countries, including several centers in various countries. in this review, there are several antivirals used including favipiravir,15–17,25 molnupiravir,18,19,26 remdesivir,20 tenofovir disoproxil fumarate,27 nirmatrelvir-ritonavir,21 lopinavir-ritonavir,22 umifenovir,23 sofosbuvirdaclatasvir.24 meanwhile, standard therapy consisted of hydroxychloroquine, corticosteroid, antibiotics (such as azithromycin), and vitamin supplements.23–26 in clinical outcomes, several criteria are used, such as who average score, time to alleviation of symptoms, and covid-19 related symptoms. the eight-category ordinal scale defined by who consists of the following categories: no clinical or virological evidence of infection (score = 0), no limitation of activities (score = 1), limitation of activities (score = 2), hospitalized, no oxygen therapy (score = 3), oxygen by mask or nasal prongs (score = 4), noninvasive ventilation or high flow oxygen (score = 5), intubation and mechanical ventilation (score = 6), ventilation support, prc, ecmo (score = 7), and death (score = 8).23 the characteristics and outcomes summary for each study is presented in table 1 and table 2. patients characteristics the mean patient age was 45 ± 10 years. regarding disease severity, 61.6% of the outpatients were mild, and 38.4% were moderate.15–27 meanwhile, 6 studies consisted of a high-risk population that had comorbidities such as age >60 years old; active cancer; chronic kidney disease; chronic obstructive pulmonary disease; pulmonary hypertension; obesity; severe heart conditions; diabetes mellitus; history of transplantation; immunocompromised status due to disease or medication.16,18–22 while 7 studies consisted of low-risk populations in which comorbid factors were excluded.15,17,23–27 in addition, 6 studies are reporting on the vaccination status of which 4 studies used the unvaccinated population,16,18,19,21 while 1 study used the vaccinated population where at least 1 dose of vaccine was used,20 and 1 study used both vaccinated and unvaccinated populations.17 clinical outcomes seven studies report clinical outcomes with different parameters, such as time to alleviation of symptoms, who average score, and covid-19 related symptoms.15,16,20,23–25,27 the use of favipiravir reported no significant difference in median time to alleviation of symptoms between favipiravir versus placebo in the study conducted by bosaeed et al., 2022 (7 days [iqr: 4-11] vs 7 days [iqr: 5-10] ], p=0.51),15 and holubar et al., 2021 (15 days [iqr: 12-26] vs. 14 days [iqr: 11-18], p=0.43).16 meanwhile, ruzhentsova et al., 2021 reported significant results regarding the median time to alleviation of symptoms between favipiravir compared with standard therapy (6.0 days [iqr: 4.0-12] vs 14 days [iqr: 5.0-12], p=0.019 ).25 the remdesivir as an intervention of antivirals therapy reported an alleviation of symptoms on day 14 between the remdesivir group versus the placebo group of 23/66 patients (34.8%) vs 15/60 (25.0%), rate ratio of 1.41; 95% ci 0.73 to 2.69.20 meanwhile, the combined use of tenofovir disproxil fumarate plus emtricitabine did not show a greater improvement in covid-19 symptoms compared to standard therapy (6/30 (20%) vs 3/30 (10%), p=0.29).27 meanwhile, the use of sofosbuvir plus daclatasvir also did not show significant results in terms of reducing the symptoms of covid-19 on day 5 compared to standard therapy (12/27 patients (44%) vs. 12/28 (43%), p= 1.00).24 in addition, umifenovir showed a difference in the mean who score compared to placebo in the mild-asymptomatic group on day 5 (0.45 ± 0.11 vs. 0.88 ± 0.13, p= 0.019). these results contrast the moderate population where umifenovir compared with david setyo budi acta med indones-indones j intern med 544 ta bl e 1. c ha ra ct er is tic s of th e in cl ud ed s tu di es . r ef er en ce s s tu dy de si gn c ou nt ry s am pl e si ze a ge , y ea rs m ea n ± s d /m ed ia n (iq r ) d is ea se s ev er ity d os ag e an d ad m in is tr at io n in te rv en tio n (n ) c on tr ol (n ) in te rv en tio n c on tr ol in te rv en tio n c on tr ol b os ae ed e t a l., 20 22 15 r c t s au di a ra bi a 11 2 11 9 37 [3 1. 545 ] 36 [3 244 ] lo w ri sk , n on ho sp ita lis ed , m ild ill ne ss o ra l f av ip ira vi r 1 80 0m g tw ic e da ily o n da y 1 fo llo w ed b y 80 0m g tw ic e da ily fo r a to ta l du ra tio n of 5 to 7 d ay s th er ap y p la ce bo h ol ub ar e t a l., 20 21 16 r c t u ni te d s ta te s 75 74 42 .5 ± 1 2 42 .8 ± 1 2 u nv ac ci na te d, lo w ri sk n on ho sp ita lis ed , m ild ill ne ss o ra l f av ip ira vi r 1 80 0m g tw ic e da ily o n da y 1 fo llo w ed b y 80 0m g tw ic e da ily fo r a to ta l du ra tio n of 1 0 da ys th er ap y p la ce bo lo w e et a l., 20 22 17 r c t u ni te d k in gd om 18 0 (fa vi pi ra vi r+ lo pi na vi rrit on av ir= 6 1 fa vi pi ra vi r = 59 lo pi na vi rrit on av ir= 60 ) 60 fa vi pi ra vi r+ +l op in av irrit on av ir= 4 0. 3 ±1 3. 1 fa vi pi ra vi r= 40 .3 ± 12 .1 lo pi na vi rrit on av ir= 38 .6 ± 11 .5 40 .6 ± 12 .2 b ot h va cc in at ed a nd un va cc in at ed , l ow ris k, n on -h os pi ta lis ed , m ild il ln es s o ra l f av ip ira vi r 8 00 m g tw ic e da ily o n d ay 1 , fo llo w ed b y 40 0 m g fo ur tim es d ai ly fr om d ay 2 to da y 7 o ra l l op in av irrit on av ir 40 0m g/ 10 0 m g tw ic e da ily on d ay 1 , f ol lo w ed b y 20 0m g/ 50 m g fo ur ti m es da ily fr om d ay 2 to d ay 7 o ra l f av ip ira vi r ( 18 00 m g tw ic e da ily o n da y 1 fo llo w ed b y 40 0m g fo ur tim es d ai ly o n da ys 2 -7 ) p lu s lo pi na vi rrit on av ir (4 00 m g/ 10 0m g tw ic e da ily on d ay 1 , f ol lo w ed b y 20 0m g/ 50 m g fo ur ti m es da ily o n da ys 2 -7 ) p la ce bo b er na l e t a l., 20 21 18 r c t m ul tip le co un tri es 71 6 71 7 44 ± 1 5 45 ± 1 5 u nv ac ci na te d ad ul t, h ig h ris k no nho sp ita lis ed , m ild to m od er at e ill ne ss o ra l m ol nu pi ra vi r 8 00 m g fo r 5 d ay s tw ic e da ily p la ce bo vol 54 • number 4 • october 2022 antiviral treatment in covid-19 outpatients 545 fi sc he r e t a l., 20 22 19 r c t u ni te d s ta te s 14 0 : 23 =2 00 m g 62 =4 00 m g 55 =8 00 m g 62 20 0 m g: 34 .7 6 ± 11 .9 2 40 0 m g: 43 .7 3 ± 13 .5 5 80 0 m g: 42 .1 7 ± 10 .9 7 m ed ia n ag e (r an ge ): 39 (1 971 ) 39 .9 2 ± 11 ,1 8 u nv ac ci na te d ad ul t, hi gh ri sk n on ho sp ita lis ed , m ild to m od er at e ill ne ss o ra l m ol nu pi ra vi r 2 00 m g, 40 0 m g, a nd 8 00 m g fo r 5 da ys tw ic e da ily p la ce bo g ot tli eb e t a l, 20 22 20 r c t u ni te d s ta te s, s pa in , d en m ar k, u ni te d k in gd om 27 9 28 3 50 ± 1 5 51 ± 1 5 va cc in at ed , h ig hris k no nho sp ita liz ed , m ild to m od er at e ill ne ss iv re m de si vi r ( 20 0 m g on da y 1, 10 0 m g on d ay s 2 an d 3) p la ce bo h am m on d et al ., 20 22 21 r c t m ul tip le co un tri es 11 20 11 26 45 ± 1 0 46 ± 1 0 u nv ac ci na te d ad ul t, h ig h ris k, n on ho sp ita lis ed , m ild to m od er at e ill ne ss o ra l n irm at re lv ir (3 00 m g) + r ito na vi r ( 10 0 m g) fo r 5 da ys tw ic e da ily p la ce bo r ei s et a l., 20 21 22 r c t b ra zi l 24 4 22 7 54 [1 894 ] 53 [1 880 ] hi gh -r is k, n on ho sp ita liz ed , m ild to m od er at e ill ne ss o ra l l op in av irrit on av ir lo ad in g do se o f 8 00 m g an d 20 0 m g, re sp ec tiv el y, e ve ry 12 h ou rs in d ay 1 , f ol lo w ed by 4 00 m g an d 10 0 m g, re sp ec tiv el y, e ve ry 1 2 ho ur s fo r t he n ex t 9 d ay s p la ce bo r am ac ha nd ra n et a l., 2 02 22 3 r c t in di a 60 63 46 .0 8 ± 1. 93 47 .3 5 ± 1. 96 l ow ri sk , n on ho sp ita lis ed , m ild to m od er at e ill ne ss o ra l u m ife no vi r 8 00 m g fo r 1 4 da ys tw ic e da ily + s ta nd ar d of c ar e s ta nd ar d of ca re r oo zb eh e t a l., 20 20 24 r c t ira n 27 28 4 3. 3 ± 3. 7 46 .8 ± 3 .9 lo w ri sk n on ho sp ita liz ed , m ild to m od er at e ill ne ss o ra l s of os bu vi r ( 40 0 m g) + da cl at as vi r ( 60 m g) + hy dr ox yc hl or oq ui ne (2 00 m g) fo r 7 d ay s tw ic e da ily s ta nd ar d th er ap y r uz he nt so va et a l.2 02 12 5 r c t r us si a 83 44 41 ,7 ± 1 0, 6 42 ,0 ± 1 0, 4 lo w ri sk n on ho sp ita liz ed , m ild to m od er at e ill ne ss o ra l f av ip ira vi r l oa di ng d os e 18 00 m g b id o n da y 1, fo llo w ed b y 80 0 m g b id o n da ys 2 -1 0 s ta nd ar d of ca re david setyo budi acta med indones-indones j intern med 546 k ho o et a l., 20 21 26 r c t u ni te d k in gd om 12 m ol nu pi ra vi r ( 30 0 m g, n =4 ; 6 00 m g, n =4 ; 8 00 m g, n =4 ) 6 30 0 m g: 56 .0 [5 1. 080 ] 60 0 m g: 43 [2 260 ] 80 0 m g: 39 [2 563 ] m ed ia n ag e of s ta nd ar d of c ar e (r an ge ): 59 .0 (2 2. 063 .0 ) n on h os pi ta liz ed , as ym pt om at ic , m ild ill ne ss o ra l m ol nu pi ra vi r 3 00 m g, 60 0 m g, a nd 8 00 m g tw ic e da ily s ta nd ar d of ca re p ar ie nt i e t al .,2 02 12 7 r c t fr an ce 30 30 39 .9 ± 1 4. 8 42 .6 ± 1 6. 7 lo w ri sk n on ho sp ita liz ed , m ild to m od er at e ill ne ss o ra l s in gl e ta bl et of 2 45 m g te no fo vi r di so pr ox il fu m ar at e + 20 0 m g em tri ci ta bi ne (2 ta bl et s on d ay 1 , 1 ta bl et on d ay s 27) s ta nd ar d of ca re s d , s ta nd ar d de vi at io n; iv , i nt ra ve no us ; n a , n ot a va ila bl e vol 54 • number 4 • october 2022 antiviral treatment in covid-19 outpatients 547 ta bl e 2. d at a ex tra ct io n fo r e ac h in di vi du al s tu di es . r ef er en ce c lin ic al o ut co m es c ov id -1 9 re la te d ho sp ita liz at io n n (% ) m or ta lit y n (% ) la bo ra to ry p ar am et er s (m ea n ± s d / m ed ia n) a dv er se e ve nt s n (% ) in te rv en tio n c on tr ol in te rv en tio n c on tr ol in te rv en tio n c on tr ol in te rv en tio n c on tr ol in te rv en tio n c on tr ol b os ae ed e t a l., 20 22 15 ti m e to a lle vi at io n of s ym pt om s (m ed ia n) : 7 da ys (i q r : 4 -1 1) ti m e to a lle vi at io n of s ym pt om s (m ed ia n) : 7 da ys (i q r : 510 ) 6/ 11 2 (5 .3 % ) 2/ 11 9 (1 .6 % ) 0/ 11 2 (0 % ) 0/ 11 9 (0 % ) v ira l c le ar an ce w ith in 15 d ay s: 4 2/ 11 2 (3 7. 5% ) v ira l c le ar an ce w ith in 1 5 da ys : 49 /1 19 (4 1. 1% ) a ny a e : 8 /1 12 (7 .1 % ) a ny a e : 7 /1 19 (5 .8 % ) h ol ub ar e t a l., 20 21 16 ti m e to a lle vi at io n of s ym pt om s (m ed ia n) : 15 [1 226 ] ti m e to a lle vi at io n of s ym pt om s (m ed ia n) : 14 [1 118 ] 0/ 75 (0 % ) 4/ 74 (5 % ) 0/ 75 0/ 74 v ira l c le ar an ce a t d ay 7: 1 0/ 42 (2 4% ) v ira l c le ar an ce at d ay 7 : 1 0/ 47 (2 1% ) a ny a e : 1 9/ 75 (2 5. 3) s er io us a e : 0 /7 5 a ny a e : 1 0/ 74 (1 3. 5) s er io us a e : 1 /7 4 lo w e et a l., 20 22 17 n a n a n a n a 0 0 v ira l c le ar an ce a t da y 5 fa vi pi ra vi r: 25 (4 6. 3% )* lo pi na vi rrit on av ir: 1 7 (3 0. 4% ) fa vi pi ra vi r + lo pi na vi rrit on av ir: 2 0 (3 5. 7% ) v ira l c le ar an ce at d ay 5 : 14 (2 6. 9% ) a ny a e : fa vi pi ra vi r: 38 (6 4. 4) lo pi na vi rrit on av ir: 59 (9 8. 3) * fa vi pi ra vi r + lo pi na vi rrit on av ir: 55 (9 0. 1) a ny a e : 39 (6 5. 0) b er na l e t a l., 20 21 18 n a n a 28 /3 85 (7 .3 % ) 53 /3 77 (1 4. 1% ) 1 (0 .1 % )* 9 (1 .3 % ) c ha ng e of v ira l l oa d: at d ay s 3= -1 .0 8± 1. 28 7* at d ay s 5= -2 .0 9 ±1 .4 9* c ha ng e of v ira l lo ad : at d ay s 3= -0 .8 4± 1. 25 8 at d ay s 5= -1 .7 9± 1. 51 3 a ny a e = 21 6 (3 0. 4% ) s er io us a e =4 9 (6 .9 % ) a ny a e = 23 1 (3 3. 0% ) s er io us a e = 67 (9 .6 % ) david setyo budi acta med indones-indones j intern med 548 fi sc he r e t a l., 20 22 19 n a n a n a n a n a n a c ha ng e of v ira l l oa d: da y 5 20 0 m g: -1 .4 71 (0 .2 12 ) 40 0 m g: -1 .7 54 (0 .1 28 )* 80 0 m g: -1 .8 67 (0 .1 26 )* p os iti ve c ov id -1 9 at da y 5= 20 0m g: 1/ 22 (4 .5 ) 40 0m g: 0/ 42 * 80 0m g: 0/ 53 * c ha ng e of v ira l lo ad : d ay 5 : 1. 32 0 (0 .1 50 ) p os iti ve c ov id -1 9 at d ay 5= 6/ 54 (1 1. 1) a ny a e : p oo le d: a ny a e o f 2 00 m g = 11 (4 7. 8) a ny a e o f 4 00 m g = 20 (3 2. 3) a ny a e o f 8 00 m g = 11 (2 0. 0) a ny s er io us a e o f 20 0 m g = 0 a ny s er io us a e o f 40 0 m g = 2 (3 .2 ) a ny s er io us a e o f 80 0 m g = 1 (1 .8 ) a ny a e = 1 8 (2 9. 0) a ny s er io us a e = 1 (1 .6 ) g ot tli eb e t a l, 20 22 20 fl u -p r o p lu s qu es tio nn ai re : 61 /1 69 (3 6. 1% ) re po rte d im pr ov em en t i n sy m pt om s on da y 14 fl u -p r o p lu s qu es tio nn ai re : 33 /1 65 (2 0. 0% ) re po rte d im pr ov em en t i n sy m pt om s on da y 14 2/ 27 9 (0 .7 % )* 15 /2 83 (5 .3 % ) 0/ 27 9 (0 % ) 0/ 28 3 (0 % ) c ha ng e of v ira l l oa d at d ay 7 : 6 .3 1± 1. 75 to 4 .1 1± 1. 36 = − 1. 24 lo g1 0 co pi es p er m ill ili te r c ha ng e of v ira l lo ad a t d ay 7 : 6. 28 ±1 .7 9 to 4. 06 ±1 .1 9 = −1 .1 4 lo g1 0 co pi es p er m ill ili te r a ny a e : 1 18 (4 2. 3% ) s er io us a e : 5 (1 .8 ) a ny a e : 1 31 (4 6. 3% ) s er io us a e : 1 9 (6 .7 ) h am m on d et a l., 20 22 21 n a n a 8/ 10 39 (0 .7 7% )* 65 /1 04 6 (6 .3 1% ) 0/ 10 39 (0 % )* 12 /1 04 6 (1 .1 5% ) n a n a a ny a e = 2 51 (2 2. 6% ) s er io us a e = 1 8 (1 .6 % ) a ny a e = 26 6( 23 .9 % ) s er io us a e = 74 (6 .6 % ) r ei s et a l., 20 21 22 n a n a 14 /2 44 (5 .7 % ) 11 /2 27 (4 .8 % ) 2/ 24 4 (0 .8 % ) 1/ 22 7 (0 .4 % ) vi ra l c le ar an ce : 12 5/ 20 1 (6 2. 2% ) vi ra l c le ar an ce : 11 2/ 19 5 (5 7. 4% ) s er io us a e : 2 0/ 23 2 (8 .6 % ) s er io us a e : 12 /2 20 (5 .5 % ) r am ac ha nd ra n et a l., 2 02 22 3 a ve ra ge w h o sc or es fo r m ild as ym pt om at ic gr ou p at d ay 5 : 0. 45 ± 0 .1 1* fo r m od er at e gr ou p at d ay 5 : 1. 60 ± 0 .3 2 a ve ra ge w h o sc or es fo r m ild as ym pt om at ic gr ou p at d ay 5 : 0. 88 ± 0 .1 3 fo r m od er at e gr ou p at d ay 5 : 1. 95 ± 0 .3 2 n a n a 0 (0 ) 0 (0 ) v ira l c le ar an ce o f m ild as ym pt om at ic p at ie nt s at d ay 5 : 29 /4 0( 73 % )* v ira l c le ar an ce of m ild as ym pt om at ic pa tie nt s at d ay 5: 1 7/ 42 (4 0% ) a ny a e = 7 (1 1. 7% ) a ny a e = 7 (1 1. 1% ) vol 54 • number 4 • october 2022 antiviral treatment in covid-19 outpatients 549 r oo zb eh e t a l., 20 20 24 c o v id -1 9 re la te d sy m pt om s: da y 5 = 12 /2 7 (4 4% ) da y 7= 7 /2 7 (2 6% ) c o v id -1 9 re la te d sy m pt om s: da y 5 = 12 /2 8 (4 3% ) da y 7= 7 /2 8 (2 8% ) 1 (4 % ) 4 (1 4% ) n a n a n a n a n a n a r uz he nt so va e t al ., 20 21 25 ti m e to a lle vi at io n of s ym pt om s (m ed ia n) : 6. 0 [4 .0 -1 2] * ti m e to a lle vi at io n of s ym pt om s (m ea n ± s d / m ed ia n) : 14 [5 .0 -1 2] 3/ 11 2 (3 .6 % ) 2/ 56 (4 .5 % ) n a n a r at e of v ira l c le ar an ce : da y 3= 80 /1 12 (7 1. 4% )* da y5 =9 1/ 11 2 (8 1. 2% )* r at e of v ira l cl ea ra nc e: da y 3= 32 /5 6 (5 7. 1% ) da y5 =3 8/ 56 (6 7. 9% ) a ny a e : 8 0 (7 4. 1% ) s er io us a e =2 (1 .9 % ) a ny a e : 3 3 (6 0. 0% ) s er io us a e : 0 (0 % ) k ho o et a l., 20 21 26 n a n a n a n a n a n a n a n a a ny a e : 30 0 m g = 4 (1 00 .0 ) 60 0 m g = 4 (1 00 .0 ) 80 0 m g = 1 (2 5. 0) a ny a e : 5 (8 3. 3) p ar ie nt i e t al .,2 02 12 7 sy m pt om s re la te d to c o v id -1 9 at da y 7: 6 /3 0 (2 0% ) sy m pt om s re la te d to c o v id -1 9 at da y 7: 3 /3 0 (1 0% ) n a n a 0 (0 % ) 0 (0 % ) n a n a s er io us a e : 2 (6 % ) s er io us a e : 1 (3 % ) n r , n ot re po rte d; s d , s ta nd ar d de vi at io n; n a , n ot a va ila bl e; a e , a dv er se e ve nt s* p <0 .0 5 ** p <0 .0 01 david setyo budi acta med indones-indones j intern med 550 placebo did not show significant results (1.60 ± 0.32 vs. 1.95 ± 0.32, p = 0.281).23 covid-19 related hospitalization eight studies reported hospitalization that was correlated with covid-19.15,16,18,20–22,24,25 three rcts using favipiravir conducted by bosaeed et al., 2022, holubar et al., 2021 and ruzhentsova et al., 2021 have consistently shown that the favipiravir group did not reduce the risk of covid-19 related hospitalization when compared to the control group (6/ 112 (5.3%) vs 2/119 (1.6%), p= 0.16), (0/75 (0%) vs 4/74 (5%), p= 0.06), (3/112 (3.6%) vs 2/56 (4.5%), p=0.494), respectively.15,16,25 meanwhile, lopinavir-ritonavir also did not show any difference in terms of hospitalization compared to placebo (14/244 (5.7%) vs 11/227 (4.8%, p>0.05).22 sofusbufir plus daclatasvir therapy reported that 1/27 (4%) patients needed hospitalization, which was not significantly different from the standard therapy group 4/28 (14%) (p=0.352).24 remdesivir showed a lower risk of covid-19 related hospitalization by 87% in the remdesivir group compared to placebo group (hazard ratio, 0.13; 95% confidence interval [ci], 0.03 to 0.59; p = 0.008). 20 meanwhile, the combination of nirmatrelvir plus ritonavir showed lower hospitalizations rate compared to placebo (8/1039 (0.77%) vs. 65/1046 (6.31%), p<0.001).21 in addition, molnupiravir showed a lower mean hospitalized or death rate than placebo at day 29 (7.3% [28 of 385 participants vs 14.1% [53 of 377 participants, a treatment difference of 6.8 percentage points (95% confidence interval [ci], 11.3 to 2.4; p = 0.001).18 mortality three studies are reporting all-cause mortality outcomes.18,21,22 bernal et al., 2022 reported one death in the molnupiravir group and nine deaths in the placebo group on day 29. the risk of all caused mortality was lower by 89% (95% ci, 14 to 99) with molnupiravir than with placebo.18 meanwhile, nirmatrelvir plus ritonavir showed lower mortality in that there were 0 out of 1039 participant deaths in the intervention group compared to 12 out of 1046 participant deaths in placebo (p < 0.001).21 meanwhile, lopinavirritonavir did not show any significant difference when compared with placebo (2/244 (0.8%) vs. 1/227 (0.4%), p>0.05).22 laboratory parameters nine studies reported laboratory outcomes including rate and time of viral clearance, and change of viral load.15–20,22–25 giving favipiravir can increase the rate of viral clearance significantly compared to the standard therapy group on day three and day five (80/112 (71.4%) vs. 32/56 (57.1%), p=0.03) and (91/112 (81.2%) vs 38/56 (67.9%), p=0.022), respectively.25 meanwhile, on day 7, the rate of viral clearance did not show any difference between the favipiravir group compared to standard therapy (95 (84.8%) vs 46 (82.1%), p=0.296).25 in addition, bosaeed et al., 2022 reported that the rate of viral clearance at day 15 also showed no significant difference between recipient favipiravir versus placebo (42/112 (37.5%) vs. 49/119 (41.1%), p>0.05).15 meanwhile, giving favipiravir showed a significant viral clearance at day 5 compared to control group (25 (46.3%) vs. 14 (26.9%), p=0.03).17 next, holubar et al., 2021 reported no significant viral clearance between the favipiravir group versus control group on day 7 (10/42 (24%) vs 10/47 (21%), p=0.80).16 administration of molnupiravir was associated with greater reductions from baseline in mean viral load than the control group on day 3 (-1.08±1.287 vs -0.84±1.258) and day 5 (-2.09 ±1.490 vs -1.79±1.513).18 furthermore, fischer et al., 2022 reported that at 400 mg and 800 mg doses of molnupiravir, the least-squares mean viral load change from baseline was significantly greater at day 5 than in the placebo group, with differences of -0.434log10 copies/ml (p =0.030) and 0.547log10 copies/ml (p=0.006), respectively.19 in addition, administration of 400 mg and 800 mg of molnupiravir significantly increased viral clearance at day five compared to placebo (0/42 (0.0) vs 6/54 (11.1), p= 0.034) and (0/53 (0.0) ) vs. 6/54 (11.1), p=0.003).19 meanwhile, the administration of remdesivir showed no difference in the least-squares mean viral load change from baseline on day 7 compared to placebo administration, with differences (-1.24 log10 copies per milliliter vs -1.14 log10 copies per milliliter, p=0.07).20 vol 54 • number 4 • october 2022 antiviral treatment in covid-19 outpatients 551 administrations of lopinavir plus ritonavir (or, 1.04; 95% ci, 0.94-1.16) showed no difference in viral clearance compared to placebo.22 in mildasymptomatic patients receiving umifenovir showed greater viral clearance than standard therapy on day 5 (29/40(73%) vs 17/42 (40%), p=0.002).23 adverse events non-serious adverse events ten studies reported minor adverse events after receiving antiviral therapy.15–21,23,25,26 in four studies using favipiravir it was found that there was no significant difference between the favipiravir group compared to the control group (8/112 (7.1%) vs. 7/119 (5.8%), p>0.05);15 (19/75 (25.3) vs 10/74 (13.5), p=0.11);16 (38 (64.4) vs 39 (65.0), p>0.05);17(80 (74.1%) vs 33 (60.0%), p>0.05).25 the most common adverse events reported were dizziness and nausea.16 meanwhile, the three studies using molnupiravir also consistently reported no significant difference in the occurrence of minor adverse events (216 (30.4%) vs. 231 (33.0%), p>0.05).18 the most common minor adverse events related to molnupiravir therapy include nausea, diarrhea, and dizziness.18,19 gottlieb et al., 2022 reported several minor adverse events occurring in 118/279 participants (42.3%) in the remdesivir group and 131/283 participants (46.3%) in the placebo. the most common minor adverse events were nausea, headache, and cough but the difference were not statistically significant (p>0.05).20 the incidence of minor adverse events in the nirmatrelvir plus ritonavir group compared with placebo was not significant ( = 251 (22.6%) vs 266 (23.9%), p>0.05 ), in detail the minor adverse events that occurred included dysgeusia, diarrhea, fibrin d-dimer increase, mild transaminitis, and headache.21 in a study conducted by ramachandran et al., 2022, it was found that umifenovir showed few minor adverse events such as nasal discharge, headache, and stomach ache which were distributed almost similar to the placebo group (p>0.05).23 serious adverse events eight studies are reporting serious adverse events after receiving antiviral therapy.16,18–22,25,27 two favipiravir-related studies showed consistently insignificant results between the favipiravir group compared to controls in which the study conducted by holubar et al., 2021 reported serious adverse events in the placebo group. in contrast, serious adverse events did not occur in the favipiravir group (p> 0.05).16 in addition, a study conducted by ruzhentsova et al., 2021 reported that 2 participants (1.9%) experienced serious adverse events, while in the controls group there were no serious adverse events (p>0.05).25 serious adverse events include bone fracture and a decrease in saturation25. meanwhile, serious adverse events were also found in molnupiravir, bernal et al., 2022 reported that there were at least 49 (6.9%) participants experiencing serious adverse events when compared to the control group with 67 (9.6%) participants experiencing serious adverse events, this number is less numerically, but in an insignificant manner (p>0.05).18 in addition, fischer et al., 2022 reported four serious adverse events requiring hospitalization. two participants in the 400 mg molnupiravir experienced a cerebrovascular accident and the other experienced a decrease in oxygen saturation, while those in 800 mg molnupiravir experienced acute respiratory failure. therefore, despite the treatment with molnupiravir, the worsening condition of covid-19 was suspected to be the cause, considering that in the placebo group one participant experienced acute respiratory failure cause hypoxia that led to death 31 days after the onset of serious adverse events.19 administration of remdesivir in covid-19 outpatients reported some serious adverse events than placebo 5 of 279 participants (1.8%) vs. 19 of 283 participants (6.7%).20 more serious adverse events were reported in the lopinavirritonavir group compared with placebo (20/232 (8.6%) vs 12/220 (5.5%).) in the tenofovir disoproxil fumarate plus emtricitabine, two (6%) participants experienced serious adverse events, while one (3%) participant experienced serious adverse events in the standard therapy group.27 in detail, two serious adverse events in the tenofovir disoproxil fumarate plus emtricitabine experienced dyspnea (22 breaths/min), very high rt-pct viral load (14 ct), and inflammatory syndrome (crp = 21 mg/l) and one other participant need hospitalization for severe david setyo budi acta med indones-indones j intern med 552 covid-related pneumonia requiring high flow oxygen, which recovered without mechanical ventilation. one participant in the standard of care group experienced severe covid-related pneumonia requiring oxygen (6 l/min) and recovered.27 discussion prevention of covid-19 illness progression is an important topic to minimize mortality risk, and antivirals have the potential because apart from the therapeutic effect they are not affected by the sars-cov-2 spike protein mutation.28 in this study, several antivirals as monotherapy or combination have gone through clinical trials in early disease covid-19 outpatients, including favipiravir, molnupiravir, remdesivir, umifenovir, tenofovir disoproxil fumarate, nirmatrelvir plus ritonavir, lopinavir plus ritonavir, and sofosbuvir plus daclatasvir. the use of favipiravir showed conflicting results in time to alleviation of symptoms in which two studies had insignificant results,15,16 while one study was significant.25 this could be influenced by the different baseline characteristics among the three rcts, where insignificant results were found in patients with mild disease, while an acceleration of time to alleviate symptoms occurred in patients with moderate disease. in addition, different initiations of favipiravir may influence the outcome which in bosaeed et al., 2022 was initiated in the first 5 days of the onset.15 meanwhile, ruzhentsova et al., 2021 initiated favipiravir administration within 3-6 days.25 in addition, the consistent administration of favipiravir increased the rate of viral clearance significantly compared to the standard therapy group on the third and fifth days. however, above the 7th day, there was no difference. this maybe correlated with negative rt-pcr results where the number of negative rt-pcrs on day 5 is significant compared to controls,25 while on day 7 the results are insignificant.16 however, favipiravir consistently does not reduce the risk of hospitalization in covid-19 outpatients.15,16,25 meanwhile, an rct conducted by ruzhentsova et al., 2021 reported two serious adverse events on favipiravir administration, including bone fractures and decreased saturations, but these were not correlated with investigational drugs. the most common non-serious adverse events were dizziness and nausea.25 nevertheless, favipiravir has been used in various countries such as china, hungary, india, korea, poland, portugal, russia, serbia, thailand, and turkey.29 in the previous study, favipiravir did not reduce mortality and mechanical ventilation in moderate-severe patients.30 meanwhile, when used in mild to moderate, favipiravir could promote viral clearance, which is in line with the results of this study.31 in contrast to favipiravir, administration of molnupiravir in covid-19 outpatients has been shown to reduce the risk of being hospitalized or dead compared to placebo. the mortality risk was lower by 89% with molnupiravir therapy.18 in addition, molnupiravir was associated with greater reductions from baseline in mean viral load than placebo on days 3 and 5,18,19 which is accompanied by a decrease in covid-19 patients.19 the serious adverse event of molnupiravir was not significant compared to placebo.18,19 molnupiravir was well tolerated with no increase in treatment-related or serious adverse events. in addition, there is no evidence of hematological, renal, or hepatic toxicity related to molnupiravir.19 these results are in line with the previous systematic review which stated that molnupiravir could reduce disease progression and reduce the risk of hospitalization and/or death.8 at the same time, in the safety profile, we found that there were serious adverse events that occurred although they were not statistically significant. currently, there is no evidence that reports a mechanical relationship related to the duration of use and dosage of molnupiravir on serious adverse events such as acute respiratory failure. this opens the topic of the importance of a longer-term investigation of the safety profile of molnupiravir after receiving prophylaxis, which is currently still in the process of recruiting participants (clinicaltrials.gov identifier: nct04939428). like molnupiravir, remdesivir, and tenofovir disoproxil fumarate target the rna-dependent rna-polymerase (rdrp) enzyme used by the coronavirus for transcription and replication of its viral rna genome.32 administration of remdesivir vol 54 • number 4 • october 2022 antiviral treatment in covid-19 outpatients 553 in covid-19 outpatients showed a lower risk of hospitalization than in the placebo group. however, there was no difference in least-squares mean viral load change from baseline between remdesivir and placebo. in terms of safety profile, remdesivir caused nausea, headache, and cough the most but was insignificant when compared to placebo and the remdesivir group had few serious adverse events compared to placebo.20 administration of 3 days of remdesivir has qualitatively similar efficacy compared to single-dose neutralizing monoclonal antibodies.33–35 however, intravenous administration of remdesivir is the same as neutralizing antibodies, which is less efficient than other oral antivirals. in this study, tenofovir disoproxil fumarate plus emtricitabine did not significantly improve covid-19 symptoms compared to standard therapy.27 in a study conducted by parienti et al., 2021, gastrointestinal symptoms caused by covid-19 may resemble tenofovir disoproxil fumarate plus emtricitabine adverse events, so the assessment of clinical tolerance and clinical resolution of symptoms may be biased. several antiviral protease inhibitors were analyzed in this study, including nirmatrelvir, lopinavir, and ritonavir.21,22 the combined use of lopinavir-ritonavir did not reduce the risk of hospitalization compared to placebo in covid-19 outpatients.22 in contrast, the nirmatrelvir-ritonavir combination showed a lower hospitalization rate than the placebo in covid-19 outpatients.21 in addition, the risk of mortality was also decreased with nirmatrelvir-ritonavir compared with placebo, whereas with lopinavir-ritonavir there was no difference in mortality risk.21,22 next, for the virological outcomes was not associated with viral clearance. the safety profile of nirmatrelvirritonavir showed fewer serious adverse events than the placebo group.21 in this study, the combination of nirmatrelvir plus ritonavir had better efficacy and safety than lopinavir plus ritonavir. important, nirmatrelvir-ritonavir uses the unvaccinated and high-risk population, which is the most important population to receive interventions to prevent the progression of covid-19. unlike protease inhibitors and rna synthesis inhibitors, umifenovir-related rcts and the combination of sofosbuvir plus daclatasvir are still very limited. however, prior rcts using umifenovir in covid-19 outpatients have shown improvement in who clinical score analysis and greater viral clearance at day 5 if given earlier in mild disease.23 meanwhile, the combination of sofosbuvir plus daclatasvir did not show any reduction in covid-19 symptoms when compared to standard therapy.24 however, due to the lack of studies related to umifenovir and the combination of sofosbuvir plus daclatasvir, other rcts are needed to confirm these results. real-world populations tend to have confounders that are difficult to control. for instance, patients may receive different standard therapies which may influence the outcomes. additionally, population of these studies are covid-19 outpatient in which the severity criteria of the disease varies between each centers.36 this could lead to differences in clinical outcome. thus, the administration of standard therapy such us corticosteroids and hydroxychloroquine on top of the antiviral therapy could potentially obscure the effects of antivirals in covid-19 outpatients, especially in viral clearance and covid-19 related hospitalization endpoint. it is also important to note that the small sample size could affect the findings of this study. to the best of our knowledge, this is the first systematic review investigating the efficacy and safety of various antivirals in covid-19 outpatient. however, this systematic review has some limitations. first, this study mainly discusses favipiravir and molnupiravir because most published rcts are both favipiravir and molnupiravir associated studies, and existing studies on antivirals are scarce. second, several rcts have small samples which can undermine the result and cause failure in detecting slight differences. third, some studies did not have comparable rcts so results still need to be confirmed. therefore, further studies are required to address the limitation of our systematic review. conclusion various antivirals show different therapeutic effects in covid-19 outpatients. favipiravir david setyo budi acta med indones-indones j intern med 554 has shown inconsistent results concerning the time of improvement in covid-19 symptoms and is more optimal when used in early disease. meanwhile, molnupiravir has shown consistent results, which can reduce the risk of hospitalization and mortality, this is supported by a decreased change of viral load compared to baseline. remdesivir and the combination of antivirals nirmatrelvir-ritonavir may have potential because they can prevent the progression of covid-19 in early disease. however, the conclusion remains inconclusive due to limited data and the number of studies related to remdesivir and nirmatrelvir-ritonavir combinations. the safety profile of antivirals is relatively safe where there are no greater serious adverse events than controls. therefore, further studies are needed to confirm this finding. authors’ contributions statement dsb developed conceptualization, data curation, methodology, visualization, writing original draft, writing review & editing. po developed conceptualization, data curation, writing original draft, writing review & editing. tpa developed writing review & editing, manuscript validation, and supervision, pl developed conceptualization, writing review & editing, data analysis, manuscript validation, and supervision. fa and ri contributed to the writing review and editing, and visualization. tt, df and nl 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med indones indones j intern med • vol 50 • number 3 • july 2018 evaluation of iron overload between age groups using magnetic resonance imaging and its correlation with iron profile in transfusion-dependent thalassemia pustika a. wahidiyat1, stephen d. iskandar1, damayanti sekarsari2 1 department of child health, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 2 department of radiology, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia corresponding author: pustika amalia wahidiyat, md, phd. division of pediatric hematology oncology, department of child health, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: pa.wahidiyat@gmail.com. abstrak latar belakang: transfusi darah berulang pada pasien thalassemia menyebabkan penumpukan besi pada berbagai organ. penanda serum untuk kelebihan besi, yaitu feritin serum dan saturasi transferin, bersifat sensitif tetapi tidak spesifik. mri t2-star (t2*) sangat penting untuk mendeteksi kadar besi pada berbagai organ. penelitian ini bertujuan untuk mengetahui derajat hemosiderosis pada berbagai organ, perbedaan derajat penumpukkan besi antara anak dan dewasa, serta korelasinya dengan penanda serum untuk kelebihan besi. metode: penelitian ini merupakan penelitian potong lintang terhadap pasien thalassemia yang membutuhkan transfusi rutin. pasien-pasien tersebut menjalani pemeriksaan mri t2* di rs cipto mangunkusumo sejak 2014 2018. hasil: sebanyak 546 subyek terlibat dalam penelitian ini. jumlah subyek anak dan dewasa setara. pada umumnya, penumpukan besi di jantung masih dalam batas normal. perbedaan derajat hemosiderosis jantung antara anak dan dewasa signifikan (p=0.009). evaluasi organ hati menunjukkan umumnya pasien mengalami hemosiderosis sedang-berat, dengan perbedaan antara anak dan dewasa yang signifikan (p=0.017). evaluasi organ pankreas menunjukkan umumnya pasien mengalami hemosiderosis ringan dan penumpukan besi di pankreas terus meningkat dengan bertambahnya usia. kadar feritin serum mempunyai korelasi yang lemah dengan hasil mri t2* jantung, korelasi sedang dengan hasil mri t2* hati dan pankreas. korelasi saturasi transferin dengan hasil mri t2* pada berbagai organ sangatlah lemah. kesimpulan: terdapat perbedaan derajat hemosiderosis di jantung dan hati yang signifikan antara anak dan dewasa. hati merupakan organ dengan penumpukan besi terbanyak, diikuti oleh pankreas dan jantung. penumpukan besi di hati dan pankreas sudah terjadi sejak anak-anak. penumpukkan besi di pankreas terus meningkat dengan bertambahnya usia. kadar feritin serum dan saturasi transferin tidak boleh digunakan secara tunggal untuk menilai derajat hemosiderosis di berbagai organ. kami menyarankan agar pemeriksaan mri t2* minimal dilakukan 1 kali untuk mengetahui penumpukan besi di organ. kata kunci: talasemia mayor, penumpukan besi, t2 relaxation time, serum feritin, saturasi transferin. abstract background: routine blood transfusion in transfusion-dependent-thalassemia (tdt) causes iron accumulation in various organ. serum markers of iron overload, serum ferritin and transferrin saturation, are sensitive but not specific. mri t2-star (t2*) is valuable for detecting iron level in organs. this study aimed to vol 50 • number 3 • july 2018 evaluation of iron overload between age groups using mri and its correlation 231 explore the degree of iron overload in various organs, iron deposition difference between children and adults, also its correlation with serum marker of iron overload. methods: this was a cross-sectional study of tdt patients who had been evaluated by mri t2* examination in cipto mangunkusumo hospital from 2014 to 2018. results: a total of 546 subjects was included in this study. the number of subjects between children and adults was almost equal. most of subjects had normal cardiac iron deposition. the difference of cardiac iron overload between children and adults was significant (p=0.009). liver evaluation showed that most of subjects had moderate to severe iron overload. this difference between children and adults was significant (p=0.017). pancreas evaluation showed that either children or adults mostly had mild pancreatic iron overload. analysis of t2* showed that pancreatic iron deposition progressed with increasing age. serum ferritin had weak correlation with heart t2* mri, moderate correlation with pancreas and liver t2* mri. relationship between transferrin saturation and t2* mri was extremely weak. conclusion: cardiac and hepatic iron deposition between children and adults differ significantly. liver has the greatest iron overload, followed by pancreas and heart. iron deposition in liver and pancreas has been started from earlier age. pancreatic iron deposition rises with increasing age. serum ferritin and transferrin saturation should not be used solely to predict iron overload in various organs. we suggest that mri evaluation must be conducted at least once to assess iron deposition in organs. keywords: thalassemia major, iron overload, t2 relaxation time, serum ferritin, transferrin saturation. introduction thalassemia is a group of inherited blood disorder characterized by decrease or absence of one or more globin chains. it is the most common single gene disorder in the world. there are two main treatments for thalassemia: blood transfusion and iron chelation therapy.1 transfusion-dependent thalassemia (tdt) is the term given to individuals with thalassemia who require routine blood transfusions. there are three main purposes of transfusion in thalassemia: improve the anemia; suppress the ineffectiveness process of erythropoiesis; and prevent major skeletal and neurological complications. the excess iron from transfused erythrocytes will be accumulated in various organs. in non-transfusion dependent thalassemia (ntdt), gastro-intestinal absorption of iron increases several folds to accommodate the decrease of hemoglobin levels.2 iron overload is toxic to cells, causing severe and irreversible organ damage.1 serum markers of iron overload, serum ferritin and transferrin saturation, are inexpensive techniques to predict iron concentration in the body. those markers have been widely used to determine the needed for starting iron chelation therapy and monitoring therapeutic response. however, these techniques have many shortcomings and cannot be used solely to monitor iron levels in the body. they are sensitive but not specific. ferritin as an acute phase reactant will increase sharply in the presence of inflammation. patients who got frequent transfusion will have fully saturated transferrin.3-5 magnetic resonance imaging (mri) is valuable for detecting iron levels because it is non-invasive, reproducible, accurate, and can be used in various organ. the last characteristic is important because the ability of iron uptake varies in each organ.5 mri is an expensive method, it must be used cost-effectively. in this study, we wanted to explore the difference in iron deposition between children and adults. the result can be used to determine the degree of iron overload in various organs and the progress of iron deposition with increasing age. we also aimed to evaluate the correlation between mri t2* value in specific organs with iron markers (serum ferritin and transferrin saturation). methods this study was a cross-sectional study, conducted from 2014 to 2018. total sampling of all subjects (n=546) who had been evaluated by mri t2* examination in cipto mangunkusumo hospital were recruited in this study. this study has been approved by the ethics committee of faculty of medicine universitas indonesia on june 27th, 2016, with a reference number 547/un2.f1/etik/2016. pustika a. wahidiyat acta med indones-indones j intern med 232 subjects subjects were divided into two groups: children (≤ 18 years) and adults (> 18 years). we assessed three organs, including heart, liver, and pancreas. mri assessment was done using mri avanto 1.5 tesla (siemens avanto germany). quantification of t2* value was obtained using cmrtoolstm software (thalassemia-tools, london, united kingdom). liver t2* value was determined in the center of the liver using a single 10 mm slice at 12 different echo times (1.3-23 millisecond=ms). subjects were asked to hold their breath for 11-13 s. cut-off points of iron overload by t2* mri are as follows: heart: normal >20 ms, mild 14-20 ms, moderate 10-14 ms, severe <10ms; liver: normal >6.3 ms, mild 2.7-6.3 ms, moderate 1.4-2.7 ms, severe <1.4 ms; pancreas: normal >33 ms, mild 10-33 ms, moderate 2.5-10 ms, severe <2.5 ms.6,7 blood sample was collected to measure serum ferritin level (ng/ml) and transferrin saturation (%). data analysis data analysis between age groups and degree of iron overload was performed using chisquare analysis. correlations between mri t2* value with iron markers (ferritin and transferrin saturation) was assessed using pearson’s correlation analysis. results a total of 546 transfusion-dependent thalassemia subjects was included in this study. we found that the number of tdt subjects between male and female were almost equal. the number of child subjects (56.4%) was greater than adult subjects (43.6%), with only 3.5% of total subjects were younger than 9 years. most of the subjects were diagnosed as β-thalassemia and β-thalassemia and hbe/β-thalassemia. around 63.7% of them used deferiprone (dfp) monotherapy as iron chelator. (table 1) table 2 showed that most of the children (89.0%) and adults (82.7%) subject had normal iron deposition in the heart. however, cardiac iron overload had been observed more common in adults than children (p=0.009). the percentage of severe iron overload in adult subjects was four times greater than children. the result of liver t2* mri showed the opposite result, of which almost all subjects had iron overload in the liver. only few of children (9.4%) and adults (13.4%) still had normal liver iron levels. there was significant difference of severity degree of iron overload between children and adults (p=0.017). severe hepatic iron overload was observed more frequently in adults than children (table 2). iron deposition in the pancreas did not differ significantly between children and adults (p=0.387). only around a quarter of subjects still had normal pancreatic iron deposition. interestingly, most of them had mild pancreatic iron overload and only a few of them who had severe pancreatic iron overload (table 2). analysis of t2* values (ms) showed that iron deposition in pancreas increased with increasing age and the peak was reached at 4550 years. meanwhile, analysis of the heart and liver showed no specific progressive pattern with increasing age (figure 1). table 3 showed that serum ferritin and transferrin saturation were inversely correlated table 1. subject’s characteristics variables n (%) sex male 277 (50.7) female 269 (49.3) age ≤ 18 y.o 308(56.4) > 18 y.o 238 (43.6) type of thalassemia α-thalassemia 16 (2.9) β-thalassemia 257 (47.0) hbe/β-thalassemia 271 (49.6) hbe/α-β-thalassemia 2 (0.3) iron chelator monotherapy dfo 12 (2.2) dfp 348 (63.7) dfx 85 (15.6) combination therapy dfo+dfp 35 (6.4) dfo+dfx 10 (1.8) dfp+dfx 47 (8.6) without chelation 9 (1.7) vol 50 • number 3 • july 2018 evaluation of iron overload between age groups using mri and its correlation 233 with t2* mri. there was only weak relationship between serum ferritin and heart t2* mri. moderate relationship was observed between serum ferritin and liver t2* mri, also serum ferritin and pancreas t2* mri. the correlation of transferrin saturation with t2* mri was extremely weak. the scatter plots between those values was presented in figure 2. discussion the gold standard to quantify iron overload is direct measurement of iron concentration in table 2. comparison of cardiac, hepatic, and pancreatic iron deposition between children and adults variables n (%) p value normal mild moderate severe cardiac iron deposition ≤ 18 y.o 274 (89.0) 25 (8.1) 5 (1.6) 4 (1.3) 0.009 > 18 y.o 197 (82.7) 18 (7.6) 9 (3.8) 14 (5.9) hepatic iron deposition ≤ 18 y.o 29 (9.4) 87 (28.2) 107 (34.7) 85 (27.7) 0.017 > 18 y.o 32 (13.4) 49 (20.6) 69 (29.0) 88 (37.0) pancreatic iron deposition ≤ 18 y.o 79 (25.6) 169 (54.9) 57 (18.5) 3 (1.0) 0.387 > 18 y.o 69 (29.0) 121 (50.8) 45 (18.9) 3 (1.3) figure 1. mean t2* mri value in various organs table 3. correlation coefficients between serum markers of iron overload with t2* mri heart t2*mri liver t2*mri pancreas t2*mri serum ferritin 0.291 0.540 0.326 transferrin saturation 0.138 0.080 0.031 pustika a. wahidiyat acta med indones-indones j intern med 234 figure 2. scatter plots of serum markers of iron overload vs t2* mri. (normal iron overload: area on the right side of red line; mild iron overload: area between green and red line; moderate iron overload: area between blue and green line; severe iron overload: area on the left side of blue line) vol 50 • number 3 • july 2018 evaluation of iron overload between age groups using mri and its correlation 235 biopsy specimens using spectrophotometry. however, this technique is invasive and only available at specialized centers.8 t2* relaxometry mri demonstrated high accuracy and is very effective in quantifying iron concentration in various organs, especially liver.5 our study found that only few subjects had moderate-severe cardiac iron overload. leonardi et al9 found that low values of t2* myocardial was correlated significantly with decreased left ventricular ejection fraction (lvef). t2* value <9 ms has high sensitivity (100%) and specificity (89%) to diagnose ef <50%. however, its value was correlated poorly with diastolic function. interestingly, myocard was less affected by iron deposition compared to other organs. there are two reasons that may explain this phenomenon. firstly, extrahepatic tissues have lower kinetic ability of iron uptake because they selectively load circulating non-transferrinbound iron.10,11 the other reason was almost all subjects in our study consumed dfp, around 63.7% as single iron chelator and 15% as combined iron chelator. deferiprone had been proven to be effective in lowering cardiac iron stores.12 even, in some studies it had shown improvement in left and right ventricular ejection fraction.13 in our study, the trend of pancreatic iron deposition rose with increasing age, reaching its peak around 45-50 years. among other organs, liver was the most affected organ. theoretically, liver iron concentration describes total body iron contents. as the main site of iron storage, liver contain almost 70% of total body iron. therefore, it is very valuable to monitor the response of therapy.14 the data from our study should arise more awareness for further liver examination, such as liver elastography. factor that may contribute to increase the risk of hepatic iron overload is hepatitis infection. routine blood transfusion increased the risk of transfusion-transmitted infection. one of the study in our thalassemia center found that the prevalence of positive serological markers for hepatitis b, hepatitis c, and combination infection were 0.8%, 17.8%, and 0.8%, respectively. however, even in the absence of hepatitis infection and other cause of chronic liver disease, cirrhosis may develop from chronic hepatic iron overload.15 our study showed that only around 20% of subjects had moderate to severe pancreatic iron overload. meanwhile, noetzly lj, et al16 study showed less than 34% of subjects had normal to mild pancreatic iron overload. maybe it was because in their study mostly the subjects used deferasirox (dfx) as iron chelator (81%), whereas in our study mostly the subjects were on dfp (63.7%). deferiprone may improve the activity of glucoronyl transferase enzyme. pancreas t2* mri measurement showed that most of subjects had mild iron overload, started from earlier age. the same result was obtained in other noetzli lj, et al16 study, which showed that pancreatic iron overload occurr nearly a decade earlier than cardiac iron overload. this information can be very useful to monitor the response of iron chelation therapy. if a patient has normal cardiac but decreased pancreas t2* mri value, the physician should not wait cardiac iron overload appearance to modify or increase the chelation therapy.10 it is important because cardiac iron overload is the leading cause of death in tdt patients.17 in our study we found that serum ferritin value could not be used solely to predict the degree of iron overload in heart and pancreas because the small correlation between those values. serum ferritin may be used to predict the degree of hepatic iron overload because the correlation was moderate. however, we must notice that serum ferritin is an acute phase reactant, which is easily affected by any kind of inflammation.3 from our study, we also observed that transferrin saturation should not be used to predict the degree of iron overload in tdt patients. transferrin saturation is defined as the percentage of transferrin being occupied by iron, which indirectly describes iron overload states in the body. however, tdt patients get frequent transfusions which cause the iron accumulated in body, but it is not followed by the increased of iron-binding capacity. transferrin itself is reduced in the presence of any inflammation, which is almost unavoidable in thalassemia patients.18 therefore, almost all patients, either normal, mild, moderate, or severe iron overload pustika a. wahidiyat acta med indones-indones j intern med 236 had 100% transferrin saturation. other markers of non-transferrin bound iron (ntbi), like labile plasma iron (lpi) may be more useful to predict the degree of iron overload and evaluate the response of therapy. another interesting finding from our study was that 1.7% of tdt subjects had never used iron chelation. they had normal ferritin value, transferrin saturation, and t2*mri, although they got routine transfusion. certainly, protecting factors in this population, such as genetic factors, should be explored. it may become target treatment of iron overload in future. conclusion in conclusion, this study demonstrated significant difference of cardiac and hepatic iron deposition between children and adults. liver had the greatest iron overload, followed by pancreas and heart. hepatic and pancreatic iron overload in transfusion-dependent-thalassemia patients had started from earlier age. the trend of pancreatic iron deposition rises with increasing age. our findings suggest that serum marker of iron overload should not be used solely to predict the degree of iron overload. mri evaluation must be conducted at least once to monitor the deposition of iron in organs. references 1. marengo-rowe aj. the thalassemias and related disorders. proc (bayl univ med cent). 2007;20(1):27– 31. 2. langhi d, ubiali ema, marques jfc, et al. guidelines on beta-thalassemia major – regular blood transfusion therapy: associação brasileira de hematologia, hemoterapia e terapia celular: project guidelines: associação médica brasileira – 2016. rev bras hematol hemoter. 2016;38(4):341–5. 3. wang w, knovich ma, coffman lg, torti fm, torti sv. serum ferritin: past, present, and future. biochim biophys acta. 2010;1800(8):760–9. 4. puliyel m, sposto r, berdoukas va, et al. ferritin trends do not predict changes in total body iron in patients with transfusional iron overload. am j hematol. 2014;89(4):391-4. 5. echeverria jma, castiella a, emparanza ji. quantification of iron concentration in the liver by mri. insights imaging. 2012;3(2):173-80. 6. eghbali a, taherahmadi h, shahbazi m, bagheri b, ebrahimi l. association between serum ferritin level, cardiac and hepatic t2-star mri in patients with major β-thalassemia. iran j ped hematol oncol. 2014;4(1):17-21. 7. saggar k, sobti p. mri assessment of iron overload in thalassemia: an overview. endo-thal. 2013;11(1):2936. 8. hernando d, levin ys, sirlin cb, reeder sb. quantification of liver iron with mri: state of the art and remaining challenges. j magn reson imaging. 2014;40(5):1003-21. 9. leonardi b, margossian r, colan sd, powell aj. relationship of magnetic resonance imaging estimation of myocardial iron to left ventricular systolic and diastolic function in thalassemia. jacc cardiovasc imaging. 2008;1(5):572-8. 10. noetzli lj, papudesi j, coates td, wood jc. pancreatic iron loading predicts cardiac iron loading in thalassemia major. blood. 2009;114(19):4021-6. 11. noetzli lj, carson sm, nord as, coates td, wood jc. longitudinal analysis of heart and liver iron in thalassemia major. blood. 2008;112(7):2973-8. 12. belmont a, kwiatkowski jl. deferiprone for the treatment of transfusional iron overload in thalassemia. expert rev hematol. 2017;10(6):493-503. 13. berdoukas v, farmaki k, carson s, wood j, coates t. treating thalassemia major-related iron overload: the role of deferiprone. j blood med. 2012;3:119-29. 14. sirlin cb, reeder sb. magnetic resonance imaging quantification of liver iron. magn reson imaging clin n am. 2010;18(3):359-ix. 15. deugnier y, turlin b. pathology of hepatic iron overload. world j gastroenterol. 2007;13(35):4755-60. 16. noetzli lj, mittelman sd, watanabe rm, coates td, wood jc. pancreatic iron and glucose dysregulation in thalassemia major. am j hematol. 2012;87(2):155-60. 17. de montalembert m, ribeil ja, brousse v, et al. cardiac iron overload in chronically transfused patients with thalassemia, sickle cell anemia, or myelodysplastic syndrome. plos one. 2017;12(3):e0172147. 18. mclaren ce, li kt, gordeuk vr, hasselblad v, mclaren gd. relationship between transferrin saturation and iron stores in the african american and us caucasian populations: analysis of data from the third national health and nutrition examination survey. blood. 2001;98(8):2345-51. 176 acta med indones indones j intern med • vol 54 • number 2 • april 2022 original article evaluation of covid-19 patients according to the survival time adem atici1*, ramazan asoglu2, hasan ali barman3, mustafa adem tatlisu1, gonul aciksari1, yusuf yılmaz1, fatma betul ozcan1, mustafa caliskan1 1 cardiology department, istanbul medeniyet universityfaculty of medicine, goztepe training and research hospital, dr. erkin street, 34722, istanbul, turkey. 2 cardiology department, adiyaman training and research hospital, yunus emre mahallesi, 1164 sokak no:13, merkez/adıyaman, turkey. 3 cardiology department, faculty of medicine, istanbul university – cerrahpasa, institute of cardiology, istanbul,turkey. *corresponding author: adem atici, md. cardiology department, istanbul medeniyet university faculty of medicine dr. erkin street, 34722, istanbul, turkey. email: adematici10@gmail.com. abstract background: coronavirus disease 2019 (covid-19) was first detected as a form of atypical pneumonia. covid-19 is a highly contagious virus, and some patients may experience acute respiratory distress syndrome (ards) and acute respiratory failure leading to death. we aim to evaluate the clinical, imaging, and laboratory parameters according to survival time to predict mortality in fatal covid-19 patients. methods: fatal 350 and survived 150 covid-19 patients were included in the study. fatal patients were divided into three groups according to the median value of the survival days. demographic characteristics and in-hospital complications were obtained from medical databases. results: of the non-survived patients, 30% (104) died within three days, 32% (110) died within 4-10 days, and 39% (136) died within over ten days. pneumonia on computational tomography (ct), symptom duration before hospital admission (sdbha), intensive care unit (icu), hypertension (ht), c-reactive protein (crp), d-dimer, multi-organ dysfunction syndrome (mods), cardiac and acute kidney injury, left ventricular ejection fraction (lvef), right ventricular fractional area change (rv-fac), and tocilizumab/steroid therapy were independent predictors of mortality within three days compared to between 4-10 days and over ten days mortality. a combined diagnosis model was evaluated for the age, ct score, sdbha, hs-tni, and d-dimer. the combined model had a higher area under the roc curve (0.913). conclusion: this study showed that age, pneumonia on ct, sdbha, icu, ht, crp, d-dimer, cardiac injury, mods, acute kidney injury, lvef, and rv-fac were independently associated with short-term mortality in non-surviving covid-19 patients in the turkish population. moreover, tocilizumab/steroid therapy was a protective and independent predictor of mortality within three days. keywords: covid-19, mortality, acute respiratory distress syndrome, echocardiography. vol 54 • number 2 • april 2022 evaluation of covid-19 patients according to the survival time 177 introduction severe acute respiratory syndrome coronavirus 2 (sars-cov-2) or coronavirus disease 2019 (covid-19) was first detected as a form of atypical pneumonia in wuhan, china, in december 2019.1 covid-19 was an unprecedented epidemic, and the world health organization (who) declared it a pandemic.2 according to the who report, about 243 million people were diagnosed with covid-19 in 219 countries by 24 october 2021. covid-19 is a highly contagious virus and killed approximately 4.9 million people worldwide.3 mild acute respiratory infection symptoms such as fever, dry cough, and tiredness are common in the early stages of covid-19. some covid-19 patients may experience ards and acute respiratory failure leading to death. although pulmonary complications were the leading cause of death, multiple organ dysfunction syndrome (mods), myocardial, kidney, and liver injuries could lead to death in covid-19 patients.1,4-6 about two-thirds of severe covid-19 patients have a fatal outcome.7-9 therefore, many clinical features and laboratory parameters were evaluated to predict mortality in covid-19 patients. it was reported that age, gender, comorbidities, s m o k i n g h i s t o r y, a n d m a n y b i o m a r k e r s including d-dimer and troponin were a predictor of mortality.10-13 although there is no specific treatment for covid-19 so far, corticosteroids and some anti-inflammatory agents have been shown to be effective in treatment.14 in addition, supportive care and early detection are beneficial.15,16 therefore, the determination of simple and reliable predictors of survival in severe covid-19 patients is necessary. due to the limited number of intensive care unit beds and the financial burden of the covid-19 disease in some countries, adequate supportive therapy and correct triage are essential in the survival period. this study aimed to compare clinical, imaging, and laboratory parameters according to the day of death of patients who died from covid-19 and determine independent predictors according to the day of death. methods the study was planned with a retrospective, cross-sectional, multicenter and observational design. three hundred and fifty deceased and 150 surviving covid-19 patients were included in the research for 28 march 2020 and 15 january 2021. the presence of sars-cov-2 rna was detected by real-time reverse transcription-polymerase chain reaction (rt-pcr) in the ministry of health public health microbiology reference laboratory after obtaining oropharyngeal and nasal specimens by using the same swab and placing the swab on the same transport medium. the guidelines for covid-19, which the ministry of health prepared, were implemented, and the patients used the suggested medications. the anticoagulant, steroid, antibiotic therapy, antiviral therapy, invasive and non-invasive mechanical ventilation was performed according to these guidelines. covid-19 rt-pcr (+), surviving covid-19 patients, and deceased covid-19 patients were included in the study. patients with the following conditions were excluded from the study: age < 18 years, pregnancy, st-elevation myocardial infarction, advanced malignancy, severe valvular heart disease, and negative pcr tests. demographic characteristics and in-hospital complications were obtained from medical databases. patient age, gender, smoking status, hypertension (ht), diabetes mellitus (dm), coronary artery disease (cad), hyperlipidemia (hld), malignancy, chronic obstructive pulmonary disease (copd), and chronic kidney disease (ckd) history were recorded. also, laboratory parameters such as urea, creatinine, sodium, potassium, glucose, high-sensitivity troponin i (hs-tni), d-dimer, hemoglobin, white blood cell (wbc), procalcitonin, and c-reactive protein (crp) were obtained from hospital admission records. in all cases, a semiquantitative computational tomography (ct) severity scoring proposed by pan et al. was calculated for each of the five lobes considering the extent of anatomic involvement.17 deceased patients were divided into three groups according to the median value of the survival days. the study was conducted under the helsinki adem atici acta med indones-indones j intern med 178 declaration, and the study protocol was approved by the local ethics committee and the ministry of health (approval number: 2020/0623). definitions myocardial injury was defined as a troponin value exceeding the upper reference limit (url, 99%) according to the fourth universal definition of myocardial infarction (mi).18 acute kidney injury (aki) was defined based on the kidney disease: improving global outcomes (kdigo) definition.19 cad was diagnosed in patients with a history of previous percutaneous coronary intervention (pci) or coronary artery bypass surgery (cabg). mods is defined as the concurrent dysfunction of two or more organs or systems, including hematological, gastrointestinal, cardiovascular, neurological, respiratory, hepatic, and renal.9 t r a n s t h o r a c i c t w o d i m e n s i o n a l echocardiography two-dimensional echocardiography (2de) studies were performed by a cardiologist using an x5 transducer (philips epiq7; philips healthcare, inc., andover, ma, usa) to evaluate the parasternal and apical images (2d, m-mode, doppler echocardiography). the echocardiographic examination was performed within the first 24 hours after admission, and the data were recorded. in the echocardiographic examination, three cycles were recorded and analyzed during any phase of respiration. after the 2de images were recorded, the analysis was performed by two independent, experienced cardiologists blinded by the clinical data of the patients. echocardiographic images were obtained in all four standard views (long-axis parasternal, short-axis parasternal, two-chamber apical, and four-chamber apical) using the techniques recommended by the american society of echocardiography (ase) guidelines.20 electrocardiographic evaluation 12-lead admission electrocardiography (ecg) was obtained from each patient on admission before any treatment was started. all standard 12-lead electrocardiograms were recorded on digitized 12-lead ecg recordings using the on-screen digital caliper software (cardio calipers version 3.3, iconico, inc., new york, ny). all ecgs (filter range 0.5-150 hz, ac filter 60 hz, 25 mm/s, 10 mm/mv) were analyzed by two independent cardiologists blinded to the clinical data of the patients according to the modified minnesota criteria, and the findings were recorded on sheets.21 corrected qt interval (qtc); the qt interval measured in either lead ii or v5-6, qtc was calculated using bazett’s formula (qtc = qt / (√rr).22 qrs fragmentation (fqrs) was defined as a notch in the r wave or s wave in two consecutive leads associated with the myocardial region, or multiple r’ waves and qrs<120 ms.23 statistical analyses all statistical tests were conducted using the statistical package for the social sciences 21.0 for windows (spss inc., chicago, il, usa). the kolmogorov-smirnov test was used to analyze the normality of the data. normally distributed variables were expressed as mean ± standard deviation (sd), while non-normally distributed variables were expressed as median with interquartile range (iqr). the categorical variables are presented as percentages. a chisquare test was used to assess differences in categorical variables between groups. the primary analysis used anova to compare all reported data for parametric variables, whereas the kruskal–wallis test was used to compare nonparametric variables between the median value of the survival days. the univariate effects of type of age, gender, pneumonia on ct, symptom duration before hospital admission (sdbha), intensive care unit (icu), ht, cad, crp, d-dimer, cardiac injury, mods, acute kidney injury, lvef, rv-fac and tocilizumab/ steroid on death of patients was investigated using the log rank test. the possible factors identified with univariate analyses were further entered into the cox regression analysis, with backward selection, to determine independent predictors of death. the proportional hazards assumption and model fit was assessed by means of residual (schoenfeld and martingale) analysis. multinomial logistic regression analysis was used to identify independent predictors of mortality in three days. receiver operating characteristic (roc) curves were obtained, and the optimal values with the greatest total vol 54 • number 2 • april 2022 evaluation of covid-19 patients according to the survival time 179 sensitivity and specificity in the prediction of mortality in three days were selected. all the parameters in the roc curve analysis were included in the binary logistic regression analysis. combined model was created with the obtained probability value. a combined model, which was created with mortality predictors, was analyzed by roc curves. finally, 20 patients were assigned randomly to test the intra-observer and interobserver variability expressed as the intraclass correlation coefficient for the ct score, echocardiographic and electrocardiographic measurements, respectively. significance was assumed at a 2-sided p <0.05. results three hundred and fifty non-surviving patients were divided into three groups according to the day of the death. of the non-surviving patients, 30% (104) died within three days, 32% (110) died within 4–10 days, and 39% (136) died after ten days. the patients’ clinical and demographic characteristics are shown in table 1. the patients who died within three days were older than the others (p<0.001). while the body mass index (bmi), gender, and smoking were similar between study groups (p>0.05), heart rate (hr), respiratory rate (rr), pneumonia on ct, ct score, and sdbha were statistically different between the study groups (p <0.001). moreover, systolic arterial pressure (sap), diastolic arterial pressure (dap), icu admission and body temperature values were different in study groups (p<0.001). in patients’ past medical histories, dm, hld, and malignancy were similar in the study population. also, ht, cad, copd, and ckd were significantly higher in patients who died within three days (p<0.05). the hemoglobin, sodium, potassium, and glucose levels were similar among the three groups. wbc, creatinine, crp, hs-tni, d-dimer, procalcitonin, and oxygen saturation (so2) levels were significantly different in patients who died three days compared to other groups (p<0.05). the previous medication was similar between the study groups (p>0.05). while the used drugs were compared between the groups during the disease, steroid and tocilizumab were significantly higher in the survival group than the non-survival group. invasive mechanical ventilation (imv), non-invasive mechanical ventilation (nimv), high-flow oxygen (hfo), vasopressor, and renal replacement therapy (rtt) rates were higher in the non-surviving patients compared to surviving patients (p<0.05). mods, cardiac, and kidney injury rates were significantly higher in patients who died three days than in other groups (p<0.05). table 1. the demographic and clinical data of covid-19 patients. survivor (n=150) non-survivor≤3 days (n=104) non-survivor 4-10 days (n = 110) non-survivor >10 days (n = 136) p clinical characteristics age (years) 54.6±8.5# & @ 67.8±9.1# * a 64.0 ± 8.1& * 63.4 ± 7.7 @ a <0.001 male, n (%) 93(62) 69(66) 74(67) 77(56) 0.187 bmi (kg/m2) 23.9±3.3 23.4±2.3 24.2 ± 3.4 24.4 ±3.8 0.108 hr, beats/min 82.0±10.7# & 91.3±12.3# * a 86.4±14.9& * e 81.3±12.0 a e <0.001 rr, times/min 21.3±6.5# & 28.0±8.5# * a 24.0±4.8& * e 21.7±4.2 a e <0.001 sap, mmhg 107.6±14.8# 98.514.4# * a 104.2±13.7* 106.9±15.0 a <0.001 dap, mmhg 66.1±11.1# 60.5±11.3 # a 63.9±10.4 65.6±11.1 a <0.001 smoker, n (%) 65(43) 49(47) 54(49) 50(36) 0.125 pneumonia on ct, n (%) 98(65)# & 96(92)# * a 90(81) & * e 96(70) a e <0.001 ct score 2(0-4)# & 6(3-11)# * a 2(2-7)& * e 2(1-5) a e <0.001 sdbha (days) 4.1±2.0# & @ 7.23.1# * a 5.9±2.5& * e 4.9±2.1@ a e <0.001 hospital stay (days) 13(7-17)# & 2(2-2)# * a 5(4-8)& * e 15(12-18) a e <0.001 icu admission, n (%) 40(27)# & 75(72)# * a 48(43)& * 43(31) a <0.001 body temperature (°c) 36.9±1.2# 37.71.9# * a 37.0±0.8* 36.9±0.6 a <0.001 chronic medical illness ht, n (%) 68(45)# 71(68)# * a 57(51)* 65(47) a 0.012 dm, n (%) 36(24) 33(31) 25(22) 32(23) 0.301 adem atici acta med indones-indones j intern med 180 cad, n (%) 30(20)# 37(35)# * a 24(21)* 29(21) a 0.034 hld, n (%) 38(25) 28(26) 31(28) 38(27) 0.875 malignite, n (%) 9(6) 13(12) 9(8) 7(5) 0.203 copd, n (%) 18(12)# 26(25)# * a 14(12)* 18(12) a 0.037 ckd, n (%) 15(10)# 24(23)# * a 14(12)* 16(11) a 0.039 laboratory findings haemoglobin(g/dl) 11.02.3 11.2±2.4 11.7 ± 1.8 11.5 ± 2.0 0.167 wbc (103 /μl) 8.0(5.0-14.0)# 9.3(7.0-19.7)# * a 8.3(5.1-13.1)* 8.3(5.9-13.0) a 0.009 creatinine (mg/dl) 1.2(0.9-2.0)# 1.7(1.1-2.6)# * a 1.4(0.9-2.1)* 1.3(0.9-2.2) a 0.021 sodium (mmol/l) 140.0±6.4 141.7±9.2 139.9 ± 9.3 141.4 ± 9.7 0.346 potassium (mmol/l) 4.3±0.6 4.5±0.8 4.3 ± 0.8 4.3 ± 0.8 0.512 glucose (mg/dl) 135(99-199) 141(105-205) 136(102-205) 149(112-237) 0.462 crp (mg/dl) 110(80-165)# 131(111-185)# * a 114(89-171)* 113(70-172) a <0.001 hs-tni (nr<14pg/ml) 30(13-44)# & @ 60(32-152)# * a 47(20-93)& * e 34(14-58) @ a e <0.001 d-dimer (ng/ml) 1460(757-2920)#&@ 3490(1395-4080)#*a 2525(1120-4100)&*e 1465(925-3655) @a e <0.001 procalcitonin (ng/ml) 0.7(0.2-1.3)# & 1.8(0.4-11.7) # a 1.7(0.4-3.2) & e 0.9(0.3-2.7) a e 0.006 so2 95.8±5.0# & 90.5±5.3# * a 92.9±5.1& * e 94.4±3.9 a e <0.001 treatments acei̇/arb, n (%) 60(40) 50(48) 60(54) 58(42) 0.238 bb, n (%) 60(40) 51(49) 51(46) 52(38) 0.221 ccb, n (%) 38(25) 32(30) 35(31) 37(27) 0.665 asa, n (%) 45(30) 37(35) 39(35) 38(27) 0.341 statin, n (%) 38(25) 34(32) 32(29) 34(25) 0.421 oad, n (%) 48(32) 36(34) 38(34) 41(30) 0.688 steroid, n(%) 109(73)#&@ 40(39)#* a 60(55)&* 78(58)@ a <0.001 tocilizumab, n(%) 24(16)#&@ 1(1)# 6(6)& 7(5)@ 0.033 imv, n(%) 33(22)#& 72(70)#* a 39(36)&* 38(28) a 0.004 nimv, n(%) 21(14)#&@ 28(27)#* a 58(53)&* 66(49)@ a <0.001 hfo, n(%) 37(25)#& 3(3)# a 12(11)& e 31(23) a e 0.007 vasopressor, n(%) 24(16)#&@ 70(68)#* a 35(32)&* 40(30)@ a <0.001 rrt, n(%) 0(0)#&@ 27(26)# 20(19)& 28(21)@ 0.031 organ injury cardiac injury, n (%) 33(22)# & @ 62(59)# * a 42(38)& * 44(32) @ a <0.001 mods, n (%) 23(15)# 37(35)# * a 25(22)* 25(18) a 0.014 acute kidney injury, n (%) 26(17)# 38(36)# * a 25(22)* 33(24) a 0.042 # p<0.05 between surviver and ≤3 days groups, &p<0.05 between surviver and 4-10 days groups, @p<0.05 between surviver and >10 days groups, *p<0.05 between ≤3 days and 4-10 days groups, ªp<0.05 between 3 days and >10 days groups, ep<0.05 between 4-10 days and >10 days groups. abbreviations: bmi, body mass index; hr, heart rate; rr, respiratory rate; sap, systolic arterial pressure; dap, diastolic arterial pressure; ct, computed tomography; sdbha, symptom duration before hospital admission; icu, intensive care unit; ht, hypertension; dm, diabetes mellitus; cad, coronary artery disease; hld, hyperlipidemia; copd, chronic obstructive pulmonary disease; ckd, chronic kidney disease; wbc, white blood cell, crp, c-reactive protein; hs-tni, high sensitive-troponin i; nr, normal range; ck, creatinine kinase; so2, oxygen saturation ; ace, angiotensin-converting enzyme; arb, angiotensin receptor blocker; bb, beta blocker; ccb, calcium channel blocker; asa, acetylsalicylic acid; oad, oral antidiabetic; imv, invasive mechanical ventilation; nimv, non-invasive mechanical ventilation; hfo, high-flow oxygen; rrt, renal replacement therapy; mods, multiple organ dysfunction syndrome. the patients’ echocardiography and ecg parameters are shown in table 2. the lvef and tricuspid annular plane systolic excursion (tapse) values were statistically different among the study groups (p<0.001). left ventricular diastolic functions were lower in non-surviving patients than in patients who survived, and it was lowest in patients who died within the first three days. left atrium (la), right ventricular diameter, rv-fac, systolic pulmonary artery pressure (spap), and pericardial effusion values were significantly higher in patients who died three days compared to other patients (p<0.001). while the left ventricular end-diastolic diameter (lvedd) was similar between study groups, left ventricular end-systolic diameter (lvesd) was significantly higher in patients who died within three days. while there was no statistically significant difference between the groups in terms of the vol 54 • number 2 • april 2022 evaluation of covid-19 patients according to the survival time 181 table 2. comparison of conventional echocardiographic and electrocardiographic parameters of covid-19 patients. variables survive (n=150) non-survive 3 days (n=104) non-survive 4-10 days (n = 110) non-survive >10 days (n = 136) p left heart findings lvef (%) 59.9±7.1# & 53.1±9.9# * a 57.3 ± 7.4& * e 59.6 ± 5.7 a e <0.001 lvedd (mm) 44.9±3.5 45.7±4.1 44.6±3.4 44.7±3.4 0.091 lvesd (mm) 28.8±3.7# 30.7±4.0 # a 29.9 ± 3.9 28.9 ±3.3 a 0.013 la (mm) 36.7±4.1# 42.3±4.5# * a 36.5±3.3* 37.3±5.1 a <0.001 e/a ratio 1.2±0.4#& @ 0.7±0.2# * a 0.9±0.3& * 1.0±0.4@ a <0.001 rv diamater(mm) 33.1±4.8#& @ 39.5±4.7# * a 36.5±4.1& * 36.1±4.4@ a <0.001 rv-fac (%) 45.5±5.5# & 39.7±6.7# * a 42.9±5.3& * 43.9±4.8 a <0.001 tapse (mm) 21.4±3.4# & 18.2±3.2# * a 19.9±3.1& * e 21.5±3.0 a e <0.001 spap, mmhg 30.1±5.1# 34.8±7.8# * a 31.6±8.0* 30.6±7.9 a <0.001 acp, n(%) 0(0) 7(7) 3(3) 3(2) 0.129 pericardial effusion, n(%) 8(5)#& @ 31(30)# * a 16(17)& * 21(16)@ a 0.005 sinus rhythm, n (%) 139(93)# 82(78)# * a 97(88)* 125(91) a 0.008 hr, beats/min 78.9±12.7# & 91.3±12.3# * a 86.4±14.9& * e 81.3±12.0 a e <0.001 rbbb, n(%) 12(8) 16(15) 10(9) 10(7) 0.182 lbbb, n(%) 9(6) 11(10) 7(6) 6(4) 0.328 st depression,, n(%) 30(20)# 48(46)# * a 31(28)* 30(22) a <0.001 fqrs, n(%) 18(12) 15(14) 19(17) 19(14) 0.716 qtc 428.9±22.1 432.4±26.3 429.2±22.0 430.5±21.3 0.394 # p<0.05 between surviver and ≤3 days groups, &p<0.05 between surviver and 4-10 days groups, @p<0.05 between surviver and >10 days groups, *p<0.05 between 3 days and 4-10 days groups, ªp<0.05 between 3 days and >10 days groups, ep<0.05 between 4-10 days and >10 days groups. abbreviations: lvef, left ventricular ejection fraction; lvedd, left ventricular end diastolic diameter; lvesv, left ventricular end systolic diameter; la, left atrial; rv-fac, right ventricular fractional area change; tapse, tricuspid annular plane systolic excursion; spap, systolic pulmonary artery pressure; acp, acute cor pulmonale; hr, heart rate; rbbb, right bundle branch block; lbbb, left bundle branch block; fqrs, fragmante qrs; qtc, corrected qt. frequency of acute corrected qt values, it was highest in patients who died within the first three days. in the electrocardiographic analysis, right bundle branch block (rbbb), left bundle branch block (lbbb), fqrs, and qtc values were similar among the study groups. however, hr, st-depression, and non-sinus rhythm ratios were higher in patients who died within three days compared to other patients. parameters affecting mortality were evaluated by univariate and multivariate analyzes using cox regression analysis. age, pneumonia on ct, sdbha, icu, ht, crp, d-dimer, cardiac injury, mods, acute kidney injury, lvef, rv-fac, and tocilizumab/steroid parameters, which were statistically significant in the univariate analysis, were included in the multivariate analysis. these parameters were determined as independent predictors of mortality (table 3). table 4 shows the independent predictors of mortality within three days. first, a regression model was used to elicit mortality predictors in regression analyses. age, gender, pneumonia on ct, sdbha, icu, ht, cad, crp, d-dimer, mods, cardiac and acute kidney injury, lvef, rv-fac, and tocilizumab/steroid were included in the regression analyses. gender and cad were not independent predictors of mortality within three days. however, age, pneumonia on ct, sdbha, icu, ht, crp, d-dimer, mods, cardiac and acute kidney injury, lvef, rv-fac, and tocilizumab/steroid were independent predictors of mortality within three days compared to the 4–10 days and more than ten days mortality and the surviving patients. roc curve analysis was used to evaluate the values for age, ct score, sdbha, hstni, and d-dimer to predict mortality within three days (figure 1). areas under the curve (auc) for age, ct score, sdbha, hs-tni, and d-dimer were determined (0.755 / 0.734 / 0.766 / 0.639 / 0.620, respectively). table 5 shows the sensitivity, specificity, and cut-off values of age, ct score, sdbha, hs-tni, and d-dimer. the age, ct score, sdbha, hs-tni, and d-dimer were evaluated by binary logistic regression adem atici acta med indones-indones j intern med 182 analysis to determine the combined diagnosis model. then the combined diagnosis model was analyzed by the roc curve. in figure 2, the red line represents the combined diagnosis model, and the auc was 0.913. reproducibility ct score, and echocardiography and electrocardiography values of 20 patients were randomly selected to assess intra-observer and interobserver reliability. the intra-observer and interobserver variabilities for ct score were 0.93 and 0.90, respectively. the intra-observer and interobserver variabilities for echocardiography were 0.91 and 0.88, respectively, and the intra-observer and interobserver variabilities for electrocardiography were 0.94 and 0.91, respectively. discussion this study has investigated shortand longterm mortality predictors in surviving and nonsurviving covid-19 patients. first, we showed that age, pneumonia on ct, sdbha, icu admission, ht, crp, d-dimer, mods, cardiac and acute kidney injury, lvef, rv-fac and tocilizumab/steroid therapy were independent predictors of mortality within three days. second, the auc values of the age, ct score, sdbha, hs-tni, and d-dimer were statistically significant in showing mortality within three days. finally, the combined diagnosis model had a strong predictive value for mortality within three days in covid-19 patients who died. the rapid spread of covid-19 infection worldwide has put the health systems in a difficult situation that has never been experienced before. the exact cause of patient death has not been fully elucidated against the hyperinflammatory reaction and hypercoagulopathy that is the p r i m a r y p a t h o p h y s i o l o g i c a l m e c h a n i s m of covid-19.24,25 unlike classical ards, covid-19 ards is characterized by early pulmonary endothelial damage using ang 2 and icam-1 pathological pathways.26 it is known that icu patients have higher mortality rates than non-icu patients (30–70%).27 due to the high mortality rates in severe covid-19 patients, many previous studies tried to find the best model for predicting mortality. as in our research, the data presented in the literature indicate that age was an independent predictor of mortality.12,28,29 a recent study comparing patients according to age group showed that mortality increased with age.30 pulmonary infiltrates table 3. cox regression analysis on the risk factors associated with mortality in patientswith covid-19. variable univariate multivariate hr 95%ci p hr 95%ci p age 2.295 1.488-5.142 <0.001 1.110 1.033-1.254 0.001 gender 1.601 0.771-4.976 0.450 pneumonia on ct 5.245 2.101-10.431 <0.001 6.513 2.266-12.765 <0.001 sdbha 1.421 1.091-2.822 0.009 1.102 1.017-1.273 0.011 icu 3.003 1.641-8.499 <0.001 4.653 1.989-9.762 <0.001 ht 1.932 1.081-4.989 0.002 2.010 1.256-5.665 0.008 cad 1.210 0.991-1.909 0.231 crp 3.141 1.754-8.249 <0.001 1.975 1.168-4.052 0.005 d-dimer 1.215 1.084-1.413 <0.001 1.022 1.006-1.049 0.003 cardiac injury 3.165 1.622-8.555 <0.001 1.952 1.075-3.405 0.010 mods 3.972 1.255-7.973 <0.001 3.080 1.753-7.231 <0.001 acute kidney injury 1.563 1.107-3.882 <0.001 1.217 1.029-3.918 0.014 lvef 0.894 0.710-0.994 <0.001 0.924 0.886-0.981 <0.001 rv-fac 0.855 0.612-0.949 <0.001 0.875 0.811-0.951 <0.001 tocilizumab/steroid 0.377 0.218-0.689 <0.001 0.410 0.261-0.732 0.001 abbreviations: ct, computed tomography; sdbha, symptom duration before hospital admission; icu, intensive care unit; ht, hypertension; cad, coronary artery disease; crp, c-reactive protein; mods, multiple organ dysfunction syndrome; lvef, left ventricular ejection fraction; rv-fac, right ventricular fractional area change. vol 54 • number 2 • april 2022 evaluation of covid-19 patients according to the survival time 183 ta bl e 4. m ul tin om ia l l og is tic r eg re ss io n an al ys is o n th e ris k fa ct or s as so ci at ed w ith s ho rtte rm m or ta lit y in p at ie nt s w ith c o v id -1 9. s ur vi ve o r 95 % c i p va ri ab le (4 -1 0 da ys ) o r o r 95 % c i p va ri ab le (> 10 da ys ) o r 95 % c i p a ge 2. 11 3 1. 30 13. 44 3 0. 00 9 a ge 1. 65 4 1. 65 4 1. 06 42. 74 1 0. 01 7 a ge 1. 86 5 1. 09 43. 36 2 0. 01 1 g en de r 1. 42 1 0. 82 44. 43 2 0. 32 1 g en de r 1. 32 6 1. 32 6 0. 89 94. 14 1 0. 34 1 g en de r 1. 53 2 0. 87 24. 17 2 0. 51 2 p ne um on ia o n c t 7. 65 3 2. 53 412 .8 56 <0 .0 01 p ne um on ia o n c t 3. 03 1 3. 03 1 1. 75 46. 10 0. 00 1 p ne um on ia o n c t 6. 01 2 2. 21 013 .9 78 <0 .0 01 s d b h a 1. 43 2 1. 14 12. 46 5 0. 01 4 s d b h a 1. 23 1 1. 23 1 1. 09 22. 87 6 0. 02 2 s d b h a 1. 30 2 1. 09 91. 60 0 0. 01 8 ic u 3. 44 1 1. 58 08. 74 5 <0 .0 01 ic u 3. 35 2 3. 35 2 1. 24 38. 68 3 <0 .0 01 ic u 3. 21 2 1. 43 18. 43 5 <0 .0 01 h t 1. 87 6 1. 05 34. 12 6 0. 01 3 h t 1. 14 2 1. 14 2 1. 02 02. 63 7 0. 02 0 h t 1. 21 2 1. 07 84. 03 1 0. 01 6 c a d 1. 15 4 0. 85 32. 79 8 0. 37 2 c a d 1. 02 1 1. 02 1 0. 98 41. 07 2 0. 67 2 c a d 1. 14 2 0. 83 13. 57 9 0. 59 7 c r p 1. 95 7 1. 06 95. 13 2 0. 00 4 c r p 1. 47 4 1. 47 4 1. 09 12. 98 2 0. 00 9 c r p 1. 53 1 1. 10 32. 98 5 0. 00 7 d -d im er 1. 05 3 1. 01 11. 16 3 <0 .0 01 d -d im er 1. 01 2 1. 01 2 1. 00 31. 02 8 0. 00 3 d -d im er 1. 02 1 1. 00 61. 03 9 0. 00 1 c ar di ac in ju ry 4. 76 5 1. 94 911 .4 23 <0 .0 01 c ar di ac in ju ry 4. 23 1 4. 23 1 1. 46 310 .8 56 <0 .0 01 c ar di ac in ju ry 4. 97 2 1. 34 29. 18 7 <0 .0 01 m o d s 3. 96 5 1. 45 18. 76 3 <0 .0 01 m o d s 3. 44 2 3. 44 2 1. 47 47. 34 5 <0 .0 01 m o d s 3. 90 2 1. 79 28. 94 5 <0 .0 01 a cu te k id ne y in ju ry 1. 72 1 1. 06 84. 17 3 0. 01 2 a cu te k id ne y in ju ry 1. 45 1 1. 45 1 1. 14 33. 37 3 0. 02 6 a cu te k id ne y in ju ry 1. 60 5 1. 10 13. 86 9 0. 01 6 lv e f 0. 82 1 0. 71 30. 95 1 <0 .0 01 lv e f 0. 91 2 0. 91 2 0. 88 70. 97 2 0. 00 5 lv e f 0. 88 9 0. 79 80. 97 3 <0 .0 01 r vfa c 0. 81 7 0. 69 90. 94 8 <0 .0 01 r vfa c 0. 90 2 0. 90 2 0. 85 90. 94 9 0. 00 1 r vfa c 0. 87 3 0. 72 70. 95 6 <0 .0 01 to ci liz um ab / s te ro id 0. 31 0 0. 19 80. 63 2 <0 .0 01 to ci liz um ab / s te ro id 0. 40 9 0. 40 9 0. 23 80. 82 5 <0 .0 01 to ci liz um ab / s te ro id 0. 36 9 0. 22 00. 70 1 <0 .0 01 a bb re vi at io ns : c t, c om pu te d to m og ra ph y; s d b h a , s ym pt om d ur at io n be fo re h os pi ta l a dm is si on ; i c u , i nt en si ve c ar e un it; h t, h yp er te ns io n; c a d , c or on ar y ar te ry d is ea se ; c r p, c -r ea ct iv e pr ot ei n; m o d s , m ul tip le o rg an d ys fu nc tio n sy nd ro m e; l v e f, le ft ve nt ric ul ar e je ct io n fra ct io n; r vfa c , r ig ht v en tri cu la r f ra ct io na l a re a ch an ge . adem atici acta med indones-indones j intern med 184 table 5. parameter values predicting early mortality as a result of roc analysis in patients with death due to covid-19. variable auc p 95%ci sensitivity specificity cut-off value age 0.755 <0.001 0.701-0.810 65 66 ³ 64.5 ct score 0.734 <0.001 0.678-797 74 60 ³ 3.5 sdbha 0.766 <0.001 0.717-0.815 79 63 ³ 5.5 hs-tni 0.639 <0.001 0.576-0.701 59 57 40.5 d-dimer 0.620 <0.001 0.560-0.681 61 61 ³ 2705 cdm 0.913 <0.001 0.883-0.942 84 80 ³ 0.25 abbreviation: ct, computed tomography; sdbha, symptom duration before hospital admission hs-tni, high sensitivetroponin i; cdm, combined diagnosis model figure 1. in roc curve analyses, areas under the curve (auc) for age, computed tomography (ct) score, symptom duration before hospital admission (sdbha), high sensitive-troponin i (hs-tni), and d-dimer were determined (0.755 / 0.734 / 0.766 / 0.639 / 0.620 respectively). figure 2. the combined diagnosis model of the age, computed tomography (ct) score, symptom duration before hospital admission (sdbha), high sensitive-troponin i (hs-tni), and d-dimer was analyzed by the roc curve. the red line represents the combined diagnosis model, and the area under the curve (auc) was 0.913. vol 54 • number 2 • april 2022 evaluation of covid-19 patients according to the survival time 185 on ct are also an independent predictor of mortality over time. this study presented that covid-19 patients with pulmonary infiltration have a poor prognosis, consistent with other literature reports.30,31 unlike previous studies,11,32 we indicated sdbha was an independent predictor of mortality. possible mechanisms that affect sdbha as an independent predictor were advanced disease due to delayed diagnosis and thrombotic complications. given the importance of the early treatment of covid-19, it seems logical that delayed hospital admissions are related to short-term mortality. the current study presented that icu admission, ht, crp, and d-dimer were short-term mortality predictors, which has been proven many times in previous studies.33 covid-19 has adverse effects on the cardiovascular system, and the myocardial injury rate was 14%–19% in these patients.1,34 high platelet activation has been shown to correlate with disease severity, myocardial damage, and mortality.35 the current study showed that covid-19 associated myocardial injury was an independent predictor of shortterm mortality, consistent with the literature report.29,36,37 therefore, it seems logical that decreased lvef and rv-fac values were independent predictors of short-term mortality in covid-19 patients with cardiac injury. barman et al. demonstrated that decreased lvef and rv-fac were associated with disease severity in covid-19 patients.38 similar to our study results, a previous investigation showed that decreased left and right ventricular function were related to mortality in covid-19 patients.39 it is known that myocardial injury is associated with worse prognosis in covid-19 patients.12,40 it seems that cardiac functions are affected by many mechanisms and mortality significantly increased in these patients. the mechanisms that affect cardiac functions, such as: (i) cytokine storm and multi-organ failure due to acute systemic inflammatory response, (ii) an imbalance between myocardial oxygen supply and demand which secondary to severe hypoxia due to acute respiratory failure, (iii) medications related to cardiotoxicity, (iiii) increased coronary thrombosis and embolic complications due to systemic inflammation, (v) the heart inflammation caused by covid-19 can directly cause myocarditis. considering these mechanisms, decreased left and right ventricular functions affect early mortality in covid-19 patients. moreover, in the regression analyses, we determined mods was an independent predictor of short-term mortality. our study results showed the covid-19 adverse effect is not limited to lung injury but also renal insufficiency and cardiac injury.41,42 clinicians should be aware of and manage the potential systemic complications of covid-19, such as mods. covid-19 associated mortality predictors provide potential clinical benefit to improve characterization and comprehensive evaluation of these patients who have an inadequate response to conventional therapy. this study also determined that age, ct score, sdbha, hs-tni, and d-dimer were independently associated with short-term mortality in non-survived covid-19 patients. moreover, these parameters’ diagnostic value was compatible with previous studies.31,43-45 to determine the best-fitting model, we analyzed various variables in binary logistic regressions. then we used a combined model to find the best predictor of short-term mortality in covid-19 patients who died. the current study indicated the combined diagnosis model was a strong predictor of short-term mortality (auc value 0.91 (95% ci, 0.88–0.94)). because of the high mortality rate in critically ill covid-19 patients (49%), it is crucial to identify patients with a bad prognosis in the early stages.46 therefore, we assumed the combined diagnosis model might help physicians predict the prognosis of covid-19 patients earlier and guide their treatment methods. thus, severe covid-19 patients can be monitored closely for mortality and might be treated in the early stages of the disease. even though covid-19 patients may have a good or poor clinical prognosis, the course of the disease is not entirely predictable. the current study was designed to partially fill this critical gap. therefore, we have evaluated the effects of various clinical factors on mortality by days. the current study is unique and has specific strengths compared to previous studies. adem atici acta med indones-indones j intern med 186 covid-19 patients who died were categorized according to their survival time rather than other factors used in earlier reports. another advantage of our study is that the combined diagnosis model was created by clinical, laboratory, and imaging parameters. the combined model was a predictor of short-term mortality in non-surviving covid-19 patients, which is a strength of our study compared with literature data. another essential difference in our study is that we tried to find a more accurate definition of patients who died within the first 72 hours. if we can identify the acute phase, and then we can raise awareness to diagnose these patients earlier. on february 24, 2022, about 25 months since the first reported case of covid-19 and after a global estimated 426 million cases and 5.8 million deaths was reported.47 on 25 november 2021, the world health organization listed omicron as a new variant of concern. omicron has some deletions and more than 30 mutations.48 moreover, omicron has 15 mutations in the receptor-binding domain of spike. these mutations are increased transmissibility, higher viral binding affinity, and higher antibody escape.49,50 the omicron variant is more infectious than the previous variants.51 also, an increased risk of reinfection related to omicron.52 omicron variant is related to lower risk of covid-19 hospitalization.53 vaccinated people have a much lower risk of severe disease from omicron infection. cough, runny/stuffy nose, fatigue/lethargy, sore throat, headache, and fever were the most prevalent symptoms.54 the current covid-19 vaccines associated with lower immunity to the omicron variant. moreover, a new booster dose will increase the efficacy against omicron infection.55 by march 2021, thirteen vaccines have been authorized for use in many countries. these vaccines have been demonstrated to be effective in preventing the infection of covid-19 at varying efficacy. covid-19 vaccines have essentially focused on prevention of infection and hospitalizations.56,57 sars-cov-2 infection in vaccinated persons is expected to trigger memory antibody and cellular responses owing to prior vaccination; these immune responses could mitigate disease progression, possibly preventing life-threatening organ failure and death.58,59 tenforde et al. evaluated the association between vaccination and covid-19 hospitalization and disease severity. they presented that covid-19 hospitalization was strongly associated with lower likelihood of vaccination for previous variants. and vaccinated cases less commonly received invasive mechanical ventilation. moreover, covid-19 hospitalization was strongly related to a lower likelihood of vaccination. among patients hospitalized with covid-19, the outcome of death or invasive mechanical ventilation was associated with a lower likelihood of vaccination.60 we have designed our research in march 2020 and january 2021. and our patients had not got omicron variant at that time. we know that patients with omicron have lower hospitality and mortality. also, our patients were not vaccinated, so they have higher mortality rates than vaccinated patients. this study has limitations, including the retrospective study design, and the number of patients was relatively low. another limitation is that we did not include the complaints of the patients on admission. a subgroup analysis of mods was not performed due to the limited number of patients. also, the study’s design did not allow the accurate retrieval of data to include underlying diseases, potentially up or downscoring the net effect of each comorbidity. as criteria for hospitalization of covid–19 patients are different across different institutions, an inclusion bias cannot be excluded. finally, as this is an observational study, residual confounding may exist. conclusion in conclusion, this study discovered that age, pneumonia on ct, sdbha, icu, ht, crp, d-dimer, cardiac injury, mods, acute kidney injury, lvef, and rv-fac were all independently associated with short-term mortality in covid-19 patients in the turkish population. moreover, tocilizumab/steroid therapy was a protective and independent predictor of mortality within three days. the combined diagnosis model was a strong predictor of short-term mortality in nonvol 54 • number 2 • april 2022 evaluation of covid-19 patients according to the survival time 187 surviving covid-19 patients. because of the increased mortality risk in severe covid-19 patients, it is essential to identify poor prognosis markers at an early stage. more prospective randomized studies are needed to confirm our findings. competing interests all authors have no declarations of interest to report. funding this study received no grant from any funding agency in the public, commercial or not-for-profit sectors. authors’ contributions atici a, asoglu r, barman ha and aciksari g contributed to the conception and design of the study; baycan of, tatlisu ma and ozcan fb collected data; atici a, and yilmaz y analysed the data; atici a, and caliskan m wrote and revised the manuscript. acknowledgments i would like to express my gratitude to all those who helped me in writing this manuscript. references 1. chaolin huang, yeming wang, xingwang li, et al. clinical features of patients infected with 2019 novel coronavirus in wuhan, china. the lancet. 2020;395(10223):497–506. 2. world health organization. who director-general’s opening remarks at the media briefing on covid-19-11 march 2020. 2020; 3. coronavirus disease (covid-19) situation reports [internet]. 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[cited 2022 feb 24]. available from: https://www.gisaid.org/ hcov19-variants/ 49. greaney aj, starr tn, gilchuk p, et al. complete mapping of mutations to the sars-cov-2 spike receptor-binding domain that escape antibody recognition. cell host microbe. 2021;29(1):44–57. 50. harvey wt, carabelli am, jackson b, et al. sarscov-2 variants, spike mutations and immune escape. nat rev microbiol. 2021;19(7):409–24. 51. karim ssa, karim qa. omicron sars-cov-2 variant: a new chapter in the covid-19 pandemic. the lancet. 2021;398(10317):2126–8. 52. pulliam jr, van schalkwyk c, govender n, et al. increased risk of sars-cov-2 reinfection associated with emergence of the omicron variant in south africa. medrxiv. 2021. 53. sheikh a, kerr s, woolhouse m, et al. severity of omicron variant of concern and vaccine effectiveness against symptomatic disease: national cohort with nested test negative design study in scotland. 2021. 54. brandal lt, macdonald e, veneti l, et al. outbreak caused by the sars-cov-2 omicron variant in norway, november to december 2021. eurosurveillance. 2021;26(50):2101147. 55. khoury ds, steain m, triccas j, et al. analysis: a meta-analysis of early results to predict vaccine efficacy against omicron. medrxiv. 2021. 56. barda n, dagan n, balicer rd. bnt162b2 mrna covid-19 vaccine in a nationwide mass vaccination setting. reply. n engl j med. 2021;384(20):1970. 57. haas ej, angulo fj, mclaughlin jm, et al. impact and effectiveness of mrna bnt162b2 vaccine against sars-cov-2 infections and covid-19 cases, hospitalisations, and deaths following a nationwide vaccination campaign in israel: an observational study using national surveillance data. the lancet. 2021;397(10287):1819–29. 58. cromer d, juno ja, khoury d, et al. prospects for durable immune control of sars-cov-2 and prevention of reinfection. nat rev immunol. 2021;21(6):395–404. 59. s a d a r a n g a n i m , m a r c h a n t a , k o l l m a n n t r . immunological mechanisms of vaccine-induced protection against covid-19 in humans. nat rev immunol. 2021;21(8):475–84. 60. tenforde mw, self wh, adams k, et al. association b e t w e e n m r n a v a c c i n a t i o n a n d c o v i d 1 9 hospitalization and disease severity. jama. 2021;326(20):2043–54. case report 52 acta med indones indones j intern med • vol 49 • number 1 • january 2017 left circumflexus coronary artery total occlusion with clinical presentation as nstemi and acute pulmonary oedema budi y. setianto1,2 , nahar taufiq2, heri hernawan1 1 department of cardiology and vascular medicine, faculty of medicine, gadjah mada university – sardjito hospital, yogyakarta, indonesia. 2 department of internal medicine, faculty of medicine, gadjah mada university – sardjito hospital, yogyakarta, indonesia. corresponding author: budi yuli setianto, md., phd. department of internal medicine, faculty of medicine, gadjah mada university sardjito hospital. jl. kesehatan no.1 sekip, yogyakarta 55284, indonesia. email: budyuls@yahoo.com, budyuls@ gmail.com. abstrak pedoman manajemen pada pasien dengan sindroma koroner akut tergantung pada pembagian diagnosis menjadi infark miokard dengan elevasi segmen st (ima-est) atau infark miokard akut tanpa elevasi segmen st (ima-nest)/angina pektoris tidak stabil (apts). pasien dengan ima-est seawal mungkin dilakukan terapi reperfusi koroner untuk melisiskan trombus yang oklusif. elevasi segmen st merupakan kondisi ‘sine qua non’ untuk mendiagnosis oklusi total akut pada segmen arteri koroner yang menyebabkan infark miokard transmural. oklusi total pada arteri circumflexus kiri (lcx) sering dikategorikan sebagai ima-nest karena tidak adanya elevasi segmen st yang bermakna pada sadapan standar elektrokardiogram. elevasi segmen st ditemukan kurang dari 50% pada pasien dengan oklusi total lcx, sehingga terapi reperfusi terlambat diberikan. kami melaporkan seorang wanita berusia 77 tahun yang didiagnosis ima-nest dengan gambaran elektrokardiogram 12 sadapan berupa depresi segmen st di sadapan v2-v5. pada angiografi koroner ditemukan lesi culprit berupa oklusi total pada lcx. kata kunci: infark miokard dengan elevasi segmen st (ima-nest), lesi culprit, oklusi total, circumflexus kiri. abstract current guidelines for the management of patients with acute coronary syndromes (acss) focus on the electrocardiogram to divide patients into st-elevation acute myocardial infarction (stemi) or non-st-elevation acute myocardial infarction (nstemi)/unstable angina (ua). patients with stemi in the earliest time will receive reperfusion therapy to destruct occlusive thrombus. an st segment elevation is the ‘sine qua non’ for diagnosing acute total coronary occlusion causing transmural myocardial infarction. left circumflex coronary artery (lcx) occlusion is often categorized as nstemi because of the absence of significant st-elevation on the 12 lead standard electrocardiogram. an st segment elevation is presented in fewer than 50% of patients with lcx total occlusion, such that the reperfusion therapy is delayed. we reported a 77 years old woman whom being diagnosed with nstemi because a 12 lead electrocardiogram showed st segment depression in lead v2-v5. on coronary angiography, we found a total occlusion in the lcx artery as the culprit lession. keywords: st-elevation acute myocardial infarction (stemi), culprit lession, total occlusion, left circumflex. 53 vol 49 • number 1 • january 2017 left circumflexus coronary artery total occlusion with clinical presentation introduction a prompt restoration of blood flow in the infarct-related artery is essential to rescue the myocardium and reduce mortality following stelevation acute myocardial infarction (stemi). since the benefits of reperfusion therapy decline over time, a prompt and accurate diagnosis of stemi is very important in determining the initiation of reperfusion therapy.1 the 12 lead standard electrocardiography (ecg) has been an initial diagnostic tool in patients with suspected ami presenting in the emergency department (ed) and ideally should be performed and interpreted within 10 minute of arrival to the ed. based on the ecg recording, patients will be divided into stemi or non-st-elevation acute myocardial infarction (nstemi)/unstable angina (ua). however, this conventional ecg has a very low sensitivity for detecting stemi if the culprit lesion is in the left circumflex coronary artery (lcx).2 an st segment elevation is not seen on the 12 lead standard ecg in up to 60% patients in lcx-related ami. therefore, the patients will not be cathegorized as having stemi but nstemi instead and can possibly lead to an unwarranted delay of therapeutic decisions especially reperfusion therapy. because of the lack in ecg presentation, the patients with lcx total occlusion might be underdiagnosed by the physician in the ed. as consequences, the patients with a totally occluded lcx present with less st-elevation in ecg and the primary pci as an earliest reperfusion therapy they should be entitled is delayed or performed less as compared with other coronary segment occlusions.2,3 case illustration we report a 77-year old woman who came to the emergency department (ed) of dr. sardjito general hospital, yogyakarta complaining of shortness of breath since 6 hours before admission. in the previous day, the patient had a chest pain along with diaphoresis. the pain was non radiating. she complained no dyspnea, nausea nor vomitus. she went to ed in a private hospital. a 12-lead standard ecg was taken; however, we did not have the record. the laboratory test was done and showed normal cardiac enzyme, so she was discharged by the attending physician in the private hospital. on the day of admission, she came to ed complaining of shortness of breath during rest, but without chest pain. the 12 lead standard ecg showed st segment depression in lead v2-v5 (figure 1). the laboratory test showed figure 1. electrocardiogram on admission showed an st segment depression in leads v2-v5 54 budi y. setianto acta med indones-indones j intern med increased cardiac enzyme (creatine kinase : 3119 iu/l, creatine kinase mb isoenzymes: 587 iu/l and troponin i: 20,49 iu/l). the patient general condition was weak and slightly somnolence. the blood pressure was increased (190/110 mmhg), pulse rate was 130 times per minute, respiratory rate was 36 times per minute and basal rales was present in both of lung fields. p a t i e n t w a s d i a g n o s e d a s n s t e m i , hypertensive emergency and acute pulmonary edema. due to haemodynamic instability caused by myocardial infarction, patient was tranfered to catheterization laboratory. coronary angiography was performed and demonstrated a total occlusion in lcx. the totally occluded lcx was the culprit lesion responsible for the current myocardial infarction (figure 2). a drug eluting stent (des) was implanted into the culprit lesion and the coronary flow was restored completely (timi flow 3) (figure 3). after the procedure the patient was transferred to intensive cardiac care unit (iccu). discussion the cathegorization of patients with acs into an st-segment elevation or non st-segment elevation is an important step in order to rapidly triage patients candidate for primary reperfusion therapy. understanding the pathophysiology of stemi and nstemi/uap gives the basic knowledge of first treatment strategy in patient with acs.4 autopsy studies have shown that plaque rupture causes nearly 75% of fatal myocardial infarction, whereas superficial endothelial erosion was responsible for the remaining 25%.4 after either plaque rupture or endothelial erosion, the sub endothelial matrix is exposed to the circulating blood and leads to platelet activation and the subsequent formation of a thrombus. two types of thrombi can be formed, i.e. a platelet-rich clot, or a white clot, that is formed in areas of high shear stress and only partially occludes the artery and a fibrin-rich clot, or a red clot that is the result of an activated coagulation cascade. red clots are frequently superimposed on white clots and responsible for total occlusion.5 the differences in the pathophysiology of stemi and ua/nstemi consequently cause different therapeutic goals and approaches. in ua/nstemi, the goal of antithrombotic therapy is to prevent further thrombosis and to allow endogenous fibrinolysis dissolving the thrombus. revascularization in ua/nstemi is often required to increase blood flow and prevent reocclusion or recurrent ischemia. in contrast, in stemi, the infarct-related artery is usually totally occluded. immediate pharmacological or catheter-based reperfusion is the initial approach to restore normal coronary blood flow.4-6 total oclussion of coronary artery is associated with stemi; however, total occlusion can also be found in nstemi. apps et al.6 reported a total oclussion was found in 75% acs patients presenting with st elevation, 73% in patient with st depression or t invertion and 63% in acs patients without any st-t changes. in our case, coronary angiogram showed total occlusion ing the lcx. approximately, 48% of patients with total occlusion in lcx present with st-segment elevation on ecg recording and 30% have no significant st-t changes.7 a b figure 2. coronary angiogram showed an lcx total occlussion (arrow). a. rao 200 caudal 200 view and b. rao 100 cranial 300 view figure 3. coronary angiogram post des insertion showed a flow in the lcx (arrow) 55 vol 49 • number 1 • january 2017 left circumflexus coronary artery total occlusion with clinical presentation according to management guideline for acs, the latter will be treated inappropriately as nsteacs without having primary percutaneous coronary intervention or receiving fibrinolytic therapy at earliest time.3 data from several reports showed that lcx is the least frequent culprit artery.2,7 failure to detect lcx related ami may have great consequences because lcx supplies significant area in the left ventricle.8 an lcx supplies the inferobasal area of the myocardium. in the ecg, the posterior leads, reflecting the basal part of the left ventricle wall which lies on the diaphragm, can be easily detected by leads v7–v9 in the back. because the anterior ecg leads are relatively in the opposite direction of the inferobasal leads, an anterior st depression is often the mirror image of an inferobasal st elevation. none of the 12 standard ecg leads reflect the inferobasal wall, therefore an isolated inferobasal stemi often masquerades as a nstemi.9 in our case, the patient was diagnosed as nstemi based on ecg recording which showed st segment depression in leads v2-v5. it was possible that the ecg in the previous hospital showed normal ecg, such that the previous physician didn’t diagnose as acs and managed the patient based on acs guideline. the lack of ecg presentation in patients with lcx-related ami is multi-factorial. one possible reason of the absence of st segment changes is due to smaller infarct size. a previous study showed total mass of myocardium lost in lcxrelated ami is smaller than in other anatomic distributions, notably anterior mi. infarct size could be estimated by the amount of serum cardiac marker released and ejection fraction.2 however, our case had increased cardiac marker and acute pulmonary edema which reflected low ejection fraction. the lcx usually supplies the lateral and posterior walls of the left ventricle, which are not well detected by the 12 standard ecg leads. there were some studies suggested that patients without st segment changes were likely due to incomplete coronary occlusion from thrombus or vasospasm.2 again, our case confirmed the total lcx occlusion in coronary angiography. the coronary artery dominance may also obscure the ecg finding in lcx-related ami. right coronary dominance may act as a protective factor in acute occlussion of lcx by giving colateral or dual flow and minimize infarcted area which cause minimal changes in ecg recording.2 the additional chest lead ecg recording is not routine in acs. the esc guideline recommends to record additional ecg leads, i.e. v3r, v4r and v7–v9, when routine 12 lead ecg are inconclusive.10 it is recommended to record the v7-v9 leads to diagnose inferobasal or posterior stemi.10 however, in our case, no posteror ecg was recorded at time of admission. the management of patient with nstemi based on the risk stratification. invasive management is recommended when the patient has high risk profiles. in our case, invasive management was performed due to acute pulmonary edema and haemodinamic instability. in coronary arteriography, we found the total occlusion in lcx which was a culprit lesion and subsequently restored the coronary flow by implanting des in the culprit vessel. conclusion we reported a 77-year old woman with nstemi based on clinical presentation, the 12 lead standard ecg recording and cardiac enzyme, but in the coronary angiography we found a total occlussion of lcx as the culprit lesion. the 12 lead standard ecg does not adequate to diagnose lcx-related ami, therefore the physician must be aware of this condition and rule out the lcx when there is no ecg changes in patient suspected with acs. acknowledgments the authors would like to thank anggoro budi hartopo, md, phd for the assistance to conduct this case report. references 1. hiasa y, morimoto, wada t, et al. differentiation between left circumflex and right coronary artery occlusions: studies on st-segment deviation during percutaneous transluminal coronary angioplasty. clin cardiol. 1990;13:783-8. 2. kim ss, choi hs, jeong mh, et al. clinical outcomes of acute myocardial infarction with occluded left 56 budi y. setianto acta med indones-indones j intern med circumflex artery. j cardiol. 2011;57:290-6. 3. stribling wk, kontos mc, abbate a, et al. left circumflex occlusion in acute myocardial infarction (from the national cardiovascular data registry). am j cardiol. 2011;108:959-63. 4. tanaka a, shimada k, sano t, et al. multiple plaque rupture and c-reactive protein in acute myocardial infarction. j am coll cardiol. 2005;45:1594-9. 5. kumar a, canon cp. acute coronary syndromes: diagnosis and management, part i. mayo clin proc. 2009;84:917-38. 6. apps a, malhotra a, tarkin j, et al. high incidence of acute coronary occlusion in patients without protocol positive st segment elevation referred to an open access primary angioplasty programme. postgrad med j. 2013;89:376-81. 7. from am, best pjm, lennon rj, rihal cs, prasad a. acute myocardial infarction due to left circumflex artery occlusion and significance of st-segment elevation. am j cardiol. 2010;106:1081-5. 8. o’keefe jh jr, sayed-taha k, gibson w, christian tf, bateman tm, gibbons rj. do patients with left circumflex coronary artery-related acute myocardial infarction without st-segment elevation benefit from reperfusion therapy? am j cardiol. 1995;75:718-20. 9. wong ck, white hd. patients with circumflex occlusions miss out on reperfusion: how to recognize and manage them. curr opin cardio. 2012;27:327-30. 10. hamm cw, bassand jp, agewall s, et al. esc guidelines for the management of acute coronary syndromes in patients presenting without persistent stsegment elevation: the task force for the management of acute coronary syndromes (acs) in patients presenting without persistent st-segment elevation of the european society of cardiology (esc). eur heart j 2011;32:2999-3054. medical illustration paraneoplastic arthritis in a patient with non-hodgkin’s lymphoma guntur darmawan, indra wijaya, laniyati hamijoyo, trinugroho h. fadjari department of internal medicine, faculty of medicine, university of padjadjaran – hasan sadikin hospital, bandung, indonesia. corresponding author: guntur darmawan, md. department of internal medicine, faculty of medicine padjadjaran university – hasan sadikin hospital. jl. pasteur no. 38, bandung, indonesia. email: guntur_d@yahoo.com. figure 1. left neck mass before chemotherapy figure 2. bilateral joint swelling before chemotherapy figure 3. shrinkage of the mass after first cycle of chemotherapy figure 4. improvement of joint swelling after first cycle of chemotherapy 267acta med indones indones j intern med • vol 49 • number 3 • july 2017 guntur darmawan acta med indones-indones j intern med paraneoplastic syndromes are a group of disorders associated with benign or malignant tumors but not related to mass effect or invasion directly. paraneoplastic syndromes may affect any organic system of the human body, such as endocrine, neurologic, dermatologic, hematologic, rheumatologic. paraneoplastic rheumatic syndromes are not quite common, about 7-10% of paraneoplastic syndromes, and may mimic rheumatic diseases.1,2 we present an interesting case of paraneoplastic arthritis in a woman with non-hodgkin’s lymphoma. a-45-year-old non-smoker female presented to our institution with swollen joints and enlargement of lymph nodes on her neck. she had a history of recurrent tonsillitis in january 2016 and underwent bilateral tonsillectomy. histologic review of the right tonsil was consistent with chronic tonsillitis while the left tonsil demonstrated aggressive type of non-hodgkin’s lymphoma. she refused chemotherapy and remained well until june 2016, when she began to complain swelling, stiffness, and pain of her joints. she sought consult several times at medical clinics and treated with analgesics for arthritis. there was no improvement, and the patient even developed difficulty in performing daily activities due to progression of the pain and stiffness. meanwhile, she noticed slow-growing, non-tender left neck mass. she also reported weight loss, low grade fever, and decreased in appetite. physical examination revealed firm, non-tender left neck mass, 8 x 5 x 2 cm in size with intact overlying skin. there were symmetrical bilateral finger joints swelling with limited range of motion due to pain (figure 1 and figure 2). chest x-ray showed enlarged right paratracheal lymph nodes and x-ray of the hands showed neither erosion nor lytic lesion. abdominal ultrasound and cardiac echocardiography result were essentially normal. rheumatoid factor, hepatitis b antigen and antibodies for hepatitis c, hiv were negative. she then received chemotherapy with chop regimen (cyclophosphamide, vincristine, doxorubicin, and prednisone). there were improvement of joints complain and shrinkage of tumor after the first cycle of chemotherapy (figure 3 and figure 4). currently, she is still undergoing the chemotherapy on schedule. the relationship between malignancy and rheumatic diseases is complex. the pathogenesis of paraneoplastic rheumatic syndromes are not fully understood, involving a number of factors such as cytokines, hormones, peptides, and other mediators secreted by tumor.3-5 paraneoplastic rheumatic syndromes are not as frequent as paraneoplastic endocrine syndromes and often difficult to differentiate them from primary rheumatologic diseases.6,7 it may precede, occur simultaneously, or develop after the diagnosis of the neoplasm. medical history plays an important role in establishing the diagnosis since there is no consensus on when a patient with rheumatological complain should be screened for possible underlying malignancy. our patient was initially diagnosed as primary rheumatic disease for her joints despite having recent history of lymphoma. in 2 case series reported by morel and kisacik, around 10% of paraneoplastic arthritis was due to lymphoma.2,7 clinical presentation of our patient might mimic rheumatoid arthritis. it fulfilled the clinical factors of rheumatoid arthritis acr/eular diagnosis criteria with a total score of 6 (more than 10 joints and more than 6 weeks duration of signs and symptoms).8 the diagnosis may be a dilemma, since many rheumatic diseases especially those with autoimmune phenomena may increase the risk for malignancy. rheumatoid arthritis had been reported to increase the risk of developing lymphoma.9,10 however, the involvement of the distal interphalangeal joints, non-erosive joint on x-ray, negativity of rheumatoid factor made rheumatoid arthritis less favored and finally, a successful response to chemotherapy reinforced the diagnosis of paraneoplastic arthritis. references 1. pelosof lc, gerber de. paraneoplastic syndromes: an approach to diagnosis and treatment. mayo clin proc. 2010;85(9):838-54. 2. morel j, deschamps v, toussirot e, et al. characteristics and survival of 26 patients with paraneoplastic arthritis. ann rheum dis. 2008;67(2):244–7. 3. ciołkiewicz m, domysławska i, ciołkiewicz a, klimiuk pa, kuryliszyn-moskal a. coexistence of systemic sclerosis, scleroderma-like syndromes and neoplastic diseases. pol arch med wewn. 2008;118(3):119–26. 268 vol 49 • number 3 • july 2017 paraneoplastic arthritis in a patient with non-hodgkin’s lymphoma 4. andreasen ra, emamifar a, bang jc, møller mb, marie i, hansen j. severe joint pain as a manifestation of paraneoplastic rheumatic syndrome in a patient with a malignant lymphoma: a case report and review of the literature. itch pain. 2015;2:e759. 5. azar l, khasnis a. paraneoplastic rheumatologic syndromes. curr opin rheumatol. 2013;25(1):44–9. 6. şendur öf. paraneoplastic rheumatic disorders. turkish j rheumatol. 2012;27(1):18–23. 7. kisacik b, onat am, kasifoglu t, et al. diagnostic dilemma of paraneoplastic arthritis: case series. int j rheum dis. 2014;17(6):640–5. 8. aletaha d, neogi t, silman aj, et al. rheumatoid arthritis classification criteria: an american college o f r h e u m a t o l o g y / e u r o p e a n l e a g u e a g a i n s t rheumatism collaborative initiative. arthritis rheum. 2010;62(9):2569–81. 9. turesson c, matteson el. malignancy as a comorbidity in rheumatic diseases. rheumatol. 2013;52(1):5–14. 10. kiltz u, brandt j, zochling j, braun j. rheumatic manifestations of lymphoproliferative disorders. clin exp rheumatol. 2007;25(1):35–9. 269 review article 166 acta med indones indones j intern med • vol 49 • number 2 • april 2017 corneal sensitivity as a potential marker of diabetic neuropathy ratna sitompul department of ophthalmology, faculty of medicine universitas indonesia, jakarta, indonesia. corresponding author: ratna sitompul, md., phd. department of ophthalmology, faculty of medicine universitas indonesia. jl. salemba no. 6, jakarta 10430, indonesia. email: ratna_sitompul@yahoo.com. abstrak diabetes mellitus (dm) adalah kelainan metabolik kompleks dan kronis yang menyebabkan banyak komplikasi. salah satu komplikasi dm yang paling umum adalah neuropati diabetes. ada banyak penelitian yang mengeksplorasi sensitivitas kornea sebagai penanda potensial neuropati diabetes. artikel ini bertujuan untuk mengeksplorasi hubungan antara sensitivitas kornea dan neuropati diabetes. pada neuropati diabetes, sensitivitas kornea terganggu akibat rendahnya tingkat faktor trofik saraf kornea, serabut saraf sensorik terganggu, dan kehilangan komunikasi sel dendtritik. pada pasien diabetes, kondisi ini dapat dinilai dengan beberapa teknik, seperti estetika cochet bonnet, aesthesiometri kornea non-kontak, dan mikroskop konfokal. beberapa target terapeutik yang menjanjikan untuk sensitivitas kornea terganggu meliputi terapi faktor sel induk dan pertumbuhan yang dapat digunakan untuk mencegah komplikasi pada pasien dengan keratopati neurotropika diabetes. sensitivitas kornea yang terganggu berperan sebagai penanda potensial neuropati diabetes. dokter, dokter mata dan ahli penyakit dalam, harus mengantisipasi kemungkinan untuk mengamati perubahan berikut pada pasien diabetes dengan neuropati dengan menggunakan uji penilaian sensitivitas kornea. kata kunci: diabetes melitus, diabetik neuropati, sensitivitas kornea, uji penilaian. abstract diabetes mellitus (dm) is a complex and chronic metabolic disorder leading to many complications. one of the most common complications of dm is diabetic neuropathy. there are many studies exploring corneal sensitivity as a potential marker of diabetic neuropathy. this review aims to explore association between corneal sensitivity and diabetic neuropathy. in diabetic neuropathy, corneal sensitivity is impaired due to low level of corneal nerve trophic factors, impaired sensory nerve fibers, and lost communication of dendtritic cell. in diabetic patients, this condition can be assessed by several techniques, such as cochet bonnet aesthesiometry, non-contact corneal aesthesiometry, and confocal microscopy. few promising therapeutic targets for impaired corneal sensitivity include stem cell and growth factor therapy that can be used to prevent complication in patient with diabetic neurotrophic keratopathy. impaired corneal sensitivity serve as a potential marker of diabetic neuropathy. doctors, opthalmologists and internists, should anticipate the possibility of observing the following changes in diabetic patients with neuropathy by using corneal sensitivity assessment test. keywords: diabetes mellitus, diabetic neuropathy, corneal sensitivity, assessment test. 167 vol 49 • number 2 • april 2017 corneal sensitivity as a potential marker of diabetic neuropathy introduction diabetes mellitus (dm) is a complex and chronic metabolic disorder that can lead to death if not managed properly. it is estimated that 415 million (8.8%) adults in the world are living with diabetes in 2015 and this prevalence is predicted to grow to 642 million in the next 25 years.1 dm can lead to many debilitating acute and chronic complications, which include neuropathy, retinopathy, nephropathy, stroke, and myocardial infarction.2 diabetic neuropathy (dn) is the most common complication of dm, affecting 50% patients.1 early diagnosis of neuropathy in diabetic patient is important for risks evaluation and therapeutic management thus preventing complications. recently, there are many studies exploring corneal sensitivity as a potential marker of diabetic neuropathy.3,4 corneal innervation has higher density than skin or others and the assesment are not invasive nor difficult. this review aims to explore recent studies about association between corneal sensitivity and diabetic peripheral neuropathy. diabetes mellitus dm is a metabolic disorder which is caused by multiple etiologies. the main characteristic of dm is chronic hyperglycemia with disturbances of carbohydrate, fat, and protein metabolism due to inadequate insulin secretion, action, or both.4 microvascular and macrovascular complications are the pathologic hallmark of dm. it provokes changes in blood vessels by affecting the capillary basement membrane including arterioles in the glomeruli, retina, skin, muscle, myocardium.1 several complications that are included as acute complications are diabetic ketoacidosis, hyperosmolar hyperglycemic states, lactic acidosis, and hypoglycemia. if they are not treated immediately, death can occur.2 chronic complications of dm include diabetic nephropathy, atherosclerosis, diabetic retinopathy, and dn. as an organ with rich vascularization, the eyes are also one of the targets of these dm complications.1,2,5 dm and its associated ocular diseases encompass a complicated disorder with multiple etiologies, both genetic and environmental factors. diabetic retinopathy is the most common ocular diseases related to dm, affecting around 30% patient with dm worldwide. earliest change seen in diabetic retinopathy is the retinal blood barrier damage. this microvascular abnormality can lead to capillary occlusion and leakage. furthermore, retinal hypoxia, edema, and hemorrhage can occur.6 in this review, we will focus more in diabetic neurothropic keratopathy (dnk). diabetic peripheral neuropathy (dpn) one of the neurologic disorders for dm, dpn affects 50% of all diabetics patient.4 unfortunately, this complication is often recognized in later stage. there are several theories proposed to explain the pathogenesis of dpn including polyol pathway, accumulation of advanced glycosylation end-products (ages), low levels of growth factors, free radicaloxidative stress, and immunologic factors.4,7 well-known pathogenesis of dpn is increased polyol pathway flux. hyperglycemia induces activation of intracellular polyol pathway causing accumulation of sorbitol. this results in decreasing level of protein kinase c and na/katpase activity, thus cellular water, electrolyte imbalance and oxidative injury can occur.8 a n o t h e r w e l l k n o w n t h e o r y o f d m pathogenesis is ages; products of protein crosslinking causing damage in cellular structure and functions. these byproducts reduce the elasticity and increase permeability of blood vessels. furthermore, modified plasma proteins bind to receptors for ages on cells by inducing the production of reactive oxygen species (ros). it might activate several factors causing pathologic alteration in gene expression.9 singh et al10 reported that accumulation of ages can cause fiber loss in peripheral nerve of diabetic human. the formation and accumulation of ages in peripheral nerve take a major role in the development of diabetic neuropathy by affecting structural and functional proteins as well as indirectly activating receptors for ages.10 ages accumulation is responsible for the progression of diabetic keratopathy, but it’s not well understood. shi long et al11 found that ages induce apoptosis in retinal pericytes and corneal epithelium as suggested by corneal 168 ratna sitompul acta med indones-indones j intern med epithelium apoptosis in diabetic rats with ages accumulation. ros also plays important role in dn by mediating cellular responses to ages. excessive ros found in dm patients causes retinal pericyte apoptosis. shi long et al11 hypothesized that interaction between ages and receptor for ages (rage) might induce intracellular ros generation and activate c-jun n terminal kinase (jnk) and p38 mitogen-activated protein kinase (mapk), which play an important role for corneal epithelium apoptosis. there are several growth factors which undergo deficiency in diabetes. nerve growth factor, neurotrophins3-5, keratocyte growth factor, and transforming growth factor are found in corneal epithelium and stroma keratocytes. those factors are necessary for epithelial regeneration and repairing the damaged peripheral nerves. diabetes can inhibit neuron regeneration by detracting these neurotrophic factors.3 hyperglycemia also induce the expression of inflammatory cytokines of the innate immune system, such as il-1β and tnf-α which have an important role in lacrimal gland and cornea reepithelization impairment thus their expression may lead to corneal nerve alterations and cause neurotrophic lesion and dysfunction of feedback mechanism that controls tear secretion which results in diabetic dry eye.12 cornea the cornea is a transparent and avascular connective tissue which serves as a protective membrane which light pass on its way to the retina. cornea consists of five layers: epithelium, b o w m a n m e m b r a n e , s t r o m a , d e s c e m e n t membrane, and endothelium. cornea is in constant state of relative dehydration, called deturgesced state.13,14 the endothelium plays more important role than the epithelium in the mechanism of dehydration. age, trauma, and inflammation can decrease the number of endothelial cells. furthermore, endothelial cells have no mitotic activity. destruction of the endothelial cells causes transient edema of the cornea and loss of transparency which clears when the epithelial cells regenerate.13,14 corneal sensation is essential for optimal eye health. corneal epithelium is the most densely innervated and sensitive epithelium surface of the body. cornea is innervated by ophthalmic branch of trigeminal ganglion, while corneal stromal nerves comes from the sclera or ciliary body. superficial limbal and subconjunctival nerve networks also innervate the epithelium with denser central distribution. these sensory branches are the nasociliary branch of the ophthalmic nerve.15 corneal nerves produce a sensation of pain in humans from mechanical, thermal, and chemical stimulation. the corneal nerve functionality is assessed by corneal sensitivity test.3,16 corneal sensitivity assessment recent studies have explored corneal sensitivity as a potential marker of diabetic neuropathy.17 there are two clinical techniques that may be used to assess corneal sensitivity: cochet bonnet (cb) aesthesiometer and noncontact corneal aesthesiometry (ncca).18 cb aesthesiometer has been used as a standard clinical method for measuring corneal sensitivity. the instrument consists of a nylon monofilament of constant diameter which can give pressure based on its length. the length of filament which ellicit a sensation on subject represents the corneal touch threshold. this method is minimally invasive because it causes subclinical microtrauma to the contacted part of cornea.9 ncca is the non-invasive measurement of corneal sensitivity, which procedure uses controlled pulses of air with variable pressure to stimulate the cornea. the corneal nerve sensation threshold is measured to a composite stimulus outcome consisting of air pressure, tear film evaporation, disruption, and cooling.18,19 pritchard et al18 reported that composite scores used to evaluate neuropathy such as the neuropathy disability score (nds) have been associated with corneal sensitivity when measured using ncca and previously shown that a ncca reading of 0.66 millibars or more could be diagnostic of neuropathy in type 2 dm patients. bikbova et al3 reported that confocal microscopy is a non-invasive method for quantifying the damage of corneal sensory 169 vol 49 • number 2 • april 2017 corneal sensitivity as a potential marker of diabetic neuropathy nerves that can be a marker for diabetic neuropathy. in vivo corneal confocal microscopy is an established technique which has been used as a diagnostic tool with a variety of clinical applications in ocular and neurological diseases.17 pirchard et al20 reported that a 4-year incident neuropathy of type 1 diabetic patient that confocal microscope could predict the development of dpn with 63% sensitivity and 74% spesificity.21,22 measurement of neuropathy neuropathy can be measured by some methods, including diabetic neuropathy symptom score, modified neuropathy disability s c o r e ( n d s ) , n e u r o p a d , m o n o f i l a m e n t , electrophysiology, or quantitative sensory testing. the diabetic neuropathy symptom score is usually used in clinical setting, such as four questions regarding steadiness in walking and lower limb symptoms. a score between 0 and 4 are recorded; 0 means there is no neuropathy and 4 means polyneuropathy present. the modified nds is a clinical scoring system which uses a 128 hz turning fork, neurotip for pin prick sensation, warm and cold metal rods for temperature perception, and tendon hammer for the presence or absence of ankle reflex. the monofilament test using 10-gram nylon filament can be used by applying the tip of it to three pre-determined points on the sole of the hand and foot. toronto criteria is used to determine classification of neuropathic status and with either a modified nds >2 or diabetic neuropathy symptoms score >1 which indicates the presence of diabetic neuropathy.17,23 symptoms of neuropathy have also been shown to be associated with a loss of corneal sensitivity. more recently, the neuropathy symptom score was shown to be significantly associated with corneal sensitivity, such that the greater the symptom score the higher the non-contact corneal aesthesiometric sensation threshold.18 a direct relationship between corneal sensitivity and a comprehensive inventory of parameters of neuropathy has not been investigated. as the corneal sensation threshold measured using ncca is being explored as an additional non-invasive tool in diagnosing neuropathy, it is important to understand the relationship between corneal sensitivity and other measurement of neuropathy. altered corneal sensitivity as a form of dpn corneal sensitivity can be impaired by number of ocular and systemic diseases, such as dm. its impairment is found in nearly 20% of diabetic patients.23 pritchard et al18 reported that corneal sensation threshold was significantly higher for patients with neuropathy compared to those without neuropathy and controls (p=0.002). it was measured by several functional measures of neuropathy, such as ncca, nds, neuropad, monofilament, dnss, and others. patients with neuropathy showed poorer outcome of established neuropathy measures than diabetic patients without neuropathy and control. komolafe et al4 reported there was a strong, statistically significant negative correlation between corneal sensitivity and vibration pressure threshold (peripheral neuropathy). corneal sensitivity decreases significantly with the increase in vibration pressure threshold (p<0.001). many studies have shown that one of the functions of corneal nerve fibers is to maintain a healthy cornea.3 besides, nerve-derived trophic factors have functions in regulating the biochemistry of the corneal epithelium and controlling the normal as well as renewal processes in maintaining the corneal epithelial cells. hence, patients with impaired corneal innervation, such as in diabetic patients, have increased risk of corneal impairment caused by trophic factors deficiency. one of manifestation of diabetic polyneuropathy in cornea is diabetic neurotrophic keratopathy. zhou et al24 discovered that impaired corneal epithelial wound healing in diabetes can be caused by low level of corneal nerve trophic factors. in their study using quantitative pcr and elisa, the cilliary neurotrophic factor (cntf) mrna and protein levels were found to be significantly downregulated in diabetic mice. they found that low level of cntf causes delayed corneal epithelial wound healing. supplementation of the exogenous trophic 170 ratna sitompul acta med indones-indones j intern med factors can promote wound healing by activating corneal epithelial stem cells.24 gao et al25 considered that dm damaged the neural communications of dendritic cells and impaired sensory nerve regeneration resulting in diabetic neuropathy. diabetic-induced denervation of the cornea, damage the integrity of corneal epithelial cells and their ability to recover from injury. dm decreases the density of sensory nerve fibers and the number of cd iic-positive cells in the cornea. they found decreased number of dendritic cells is in tune with a decrease nerve fibers density. dm impairs communication between dendritic cells and nerve causing diabetic peripheral neuropathy, delayed cornea wound healing, impairs and reduces number of dendritic cells infiltration. this results in low level of cntf which has a vital role in corneal innervation.25 diabetic neuropathy may be involved in the progression of lacrimal gland dysfunction leading to dry eye syndrome. integrity of lacrimal function unit and normal function cornea is maintained by nerve fibers. the result of schirmer’s i test and corneal sensitivity were worse in diabetic patients with neuropathy compared to patients without neuropathy and control (p<0.001).26 delayed epithelial wound healing and lacrimal gland dysfunction may be the cause of recurrent erosions. reduced corneal sensitivity plays an important role on dry eye, thus predispose to corneal trauma and neurotrophic corneal ulcers. recurrent epithelial defects and abrasion were also found in intraocular surgeries of diabetic patients. accumulation of ages impairs epithelial basement membrane and causes delayed re-epithelialization. thus, it causes prolonged and recurrent epithelial defects and predispose the cornea to infection, such as fungal keratitis.27 normal post-cataract surgery patients with impaired corneal sensitivity is associated with impairment of normal blinking and tearing reflexes resulting in corneal epithelium impairment. in addition, inflammatory cytokines produced as a response to corneal incision healing may also decrease corneal sensitivity and cause tear film instability. sitompul et al28 reported that temporal site corneal incision may reduce corneal sensitivity in the surgical area because it may cut the base of corneal nerves. those effects are augmented in patients with diabetic keratopathy and decreased corneal sensitivity.29 jiang et al29 found that dry eye syndrome was higher in diabetic patients at seven days and one month after cataract surgery, which predispose them to infection post-surgery, such as endopthalmitis. pitchard et al18 studied corneal confocal microscopy and corneal sensitivity assessment as non-invasive techniques to detect early changes for diabetic neuropathy. many studies showed that the greater deficits in the neuropathy, the poorer the corneal sensitivity is.18,22,30 those findings show that corneal sensitivity does become a part of polyneuropathy in dm. bikbova et al3 reported there were a relationship between corneal neuropathy and systemic neuropathy from clinical and electrophysiology test of neuropathy. management diabetic neurotrophic keratopathy is a challenging condition because of its complex m a n a g e m e n t . p a t h o g e n e t i c o r i e n t a t e d pharmacological treatment for neurotrophic keratopathy is not yet available. there are only supportive treatment such as artificial tears, topical antibiotics, bandage contact lenses, amniotic membrane transplantation, or a conjunctival flap to treat neurotrophic corneal ulcers.17,25 corneal stem cells are likely associated with corneal wound healing. kramerov et al31 reported that there was a significant decrease of stem cell number in the corneo-limbal epithelium causing delayed wound healing in diabetic patient. limbal stem cells are regulated by environmental signals, cytokines, growth factors, and their interaction.32 there are numbers of studies exploring cytokines and growth factors that may contribute in activation and proliferation of corneal stem cell. duan et al33 studied the effect of pluripotin, an activator of embryonic stem cell self-renewal, in promoting rabbit limbal epithelial cells proliferation by improving the in vitro limbal 171 vol 49 • number 2 • april 2017 corneal sensitivity as a potential marker of diabetic neuropathy stem/progenitor cells. pluripotin may be a good alternative to improve the expansion of limbal stem/progenitor cells. ho et al34 studied the pigment epithelial-derived factor (pdef) as a promotor self-renewal of limbal stem cell. pdef and its fragment facilitate corneal wound healing by enhancing limbal stem cell proliferation in vitro. pedf also has mitogenic effect by induction of p38 mapk and signal transducer and activator of transcription 3 (stat3). ciliary neurotrophic factor (cntf) is another neuroprotective cytokine which is important in neurogenesis and regulation of neural stem cells. zhou et al24 studied cntf and found several functions in cornea epithelial cells. cntf can promote corneal epithelial wound healing; corneal healing in cntftreated mice is 48 – 72 hours faster than control. cntf stimulated the colony-forming efficiency, the mitogenic activity, and upregulated the expression levels of corneal epithelial stem/ progenitor cells-associated transcription factors. these give a promising future agent that can be used to prevent complication in patient with diabetic neurotrophic keratopathy.17,31 conclusion corneal sensitivity which is correlated with diabetic neuropathy and impaired corneal sensitivity may serve as a potential marker of diabetic neuropathy. doctors, especially ophthalmologists and internists, should anticipate the possibility of observing the following changes in diabetic patients with neuropathy by using corneal sensitivity assessment test. further study needs to be conducted to investigate progenitor/stem cells as a promising agent to cure diabetic keratopathy. references 1. chawla a, chawla r, jaggi s. microvasular and macrovascular complications in diabetes mellitus: distinct or continuum? indian j endocrinol metab. 2016;20(4):546. 2. cameron f. standards of medical care in diabetes 2016. aust fam physician. 2006;35(6):386–90. 3. bikbova g, oshitari t, baba t, yamamoto s. neuronal changes in the diabetic cornea: perspectives for neuroprotection. biomed res int. 2016;2016:1-8. 4. komolafe r, pedro-egbe c, awoyesuku e. correlation between corneal sensitivity and peripheral neuropathy in type 2 diabetics attending the endocrinology clinic of university of port harcourt teaching hospital (upth), nigeria. ophthalmol res an int j. 2016;6(3):1–9. 5. tapp, r. shaw, j. zimmet p. complications of diabetes. diabetes atlas. 2003;2015:72–111. 6. alghadyan aa. diabetic retinopathy an update. saudi j ophthalmol. 2011;25(2):99–111. 7. giacco f. oxidative stress and diabetic complications. circ res. 2011;107(9):1058–70. 8. hu x, li s, yang g, liu h, boden g, li l. efficacy and safety of aldose reductase inhibitor for the treatment of diabetic cardiovascular autonomic neuropathy: systematic review and meta-analysis. plos one. 2014;9(2). 9. perera hki, handuwalage cs. analysis of glycation induced protein cross-linking inhibitory effects of some antidiabetic plants and spices. bmc complement altern med. 2015;15:175–84. 10. singh vp, bali a, singh n, jaggi as. advanced glycation end products and diabetic complications. korean j physiol pharmacol. 2014;18(1):1–14. 11. shi l, yu x, yang h, wu x. advanced glycation end products induce human corneal epithelial cells apoptosis through generation of reactive oxygen species and activation of jnk and p38 mapk pathways. plos one. 2013;8(6):1–10. 12. alves mdc, carvalheira jb, módulo cm, rocha em. tear film and ocular surface changes in diabetes mellitus. arq bras oftalmol. 2008;71(6):96–103. 13. derek w. 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therapies in the treatment of diabetic retinopathy and keratopathy. 2015;1–10. 32. castro-muñozledo f. review: corneal epithelial stem cells, their niche and wound healing. mol vis. 2013;19:1600–13. 33. duan h, wang y, yang l, et al. pluripotin enhances the expansion of rabbit limbal epithelial stem/progenitor cells in vitro. exp eye res. 2012;100:52–8. 34. ho tc, chen sl, wu jy, et al. pedf promotes self-renewal of limbal stem cell and accelerates corneal epithelial wound healing. stem cells. 2013;31(9):1775–84. 318 original article acta med indones indones j intern med • vol 51 • number 4 • october 2019 validity and reliability of the indonesian version of kidney disease quality of life (kdqol-36) questionnaire in hemodialysis patients at hasan sadikin hospital, bandung, indonesia rudi supriyadi1, fauliza rakhima2, rubin s. gondodiputro1, guntur darmawan2,3 1 division of nephrology and hypertension, department of internal medicine, faculty of medicine universitas padjadjaran hasan sadikin hospital, bandung, indonesia. 2 department of internal medicine, faculty of medicine universitas padjadjaran hasan sadikin hospital, bandung, indonesia. 3 department of internal medicine, faculty of medicine, krida wacana christian university, jakarta, indonesia. corresponding author: rudi supriyadi, md. division of nephrology and hypertension, department of internal medicine, faculty of medicine universitas padjadjaran hasan sadikin hospital. jalan professor eyckman no. 38, bandung, jawa barat, 40161, indonesia. email: rudisdoc@gmail.com. abstrak latar belakang: prevalensi penyakit ginjal kronik (pgk) dan pasien dialisis meningkat setiap tahunnya di indonesia. pengaruh pgk dan dialisis terhadap kualitas hidup pasien merupakan bagian penting dalam tatalaksana pgk. kuesioner kidney disease quality of life (kdqol-36) merupakan instrumen khusus penilaian kualitas hidup pasien pgk dan dialisis yang telah diterjemahkan di berbagai negara, namun belum pernah dilakukan di indonesia. penelitian ini bertujuan untuk menentukan validitas dan reliabilitas kuesioner kdqol-36 versi bahasa indonesia pada pasien di indonesia. metode: penerjemahan kuesioner kdqol-36 ke bahasa indonesia dan penerjemahan kembali ke bahasa inggris dilakukan oleh penerjemah bersertifikat, dilanjutkan dengan penilaian kuesioner lebih lanjut oleh tim ahli. kuesioner versi akhir diuji pada pasien hemodialisis rutin di unit hemodialisis rsup. dr. hasan sadikin bandung. validitas dianalisis dengan uji korelasi pearson antara skor total skala target penyakit ginjal, kesehatan umum (sf-12) dan seluruh skala dalam kdqol-36. konsistensi internal diuji dengan koefisien cronbach alpha dan reliabilitas dianalisis dengan uji test-retest. hasil: subjek penelitian berjumlah 103 pasien, sebagian besar laki-laki (52,4%), dengan median usia 51 (22-75) tahun dan telah menjalani hemodialisis rata-rata 3,4 (sb 2,1) tahun. hasil uji validitas menunjukkan korelasi bermakna (p<0,001) antara skor total skala target penyakit ginjal, sf-12 dan setiap skor dalam skala tersebut. seluruh skala dalam kdql-36 menunjukkan reliabilitas tes-retest yang baik.nilai reliabilitas konsistensi internal dapat diterima dengan nilai cronbach alpha ≥ 0,7 untuk seluruh skala. kesimpulan: kuesioner kdqol-36 versi bahasa indonesia memiliki validitas dan reliabilitas yang baik untuk menilai kualitas hidup pasien hemodialisis rutin. kata kunci: kdqol-36, validitas, reliabilitas, hemodialisis. abstract background: the prevalence of chronic kidney disease (ckd) and dialysis patients is increasing every year in indonesia. the impact of ckd and dialysis on patient quality of life (qol) has been recognized as an important outcome measure in the management of ckd. the kidney disease quality of life (kdqol-36) has been validated and is widely used as a measure of qol for ckd and dialysis patients in many countries, but not in indonesia. the vol 51 • number 4 • october 2019 validity and reliability of the indonesian version of kdqol-36 questionnaire 319 aim of this study is to determine the reliabity and validity of the indonesian version of kdqol-36 on hemodialysis patients in indonesia. methods: the kdqol-36 was translated into indonesian language by a certified translator and then it was back-translated into english. the translated questionnaire was further reviewed by an expert panel. the final questionnaire was administered to hemodialysis patients in hemodialysis unit at hasan sadikin general hospital. validity was measured using pearson’s correlation between the kidney disease-targeted scores, generic dimensions (sf-12) scores and each scale score in kdqol-36. the internal consistensy was assessed using cronbach’s alpha and reliability was examined using test-retest. results: out of 103 patients, we found that most subjects were male (52.4%) with median age of 51 (22-75) years. the duration of hemodialysis was 3.4 (sd 2.1) years. the validity test showed a significant correlation (p<0.001) on kidney disease-targeted total score, sf12 and each score of the scale within it. all of the kdqol-36 scales showed good test-retest reliability. internal consistency reliability values were acceptable, with cronbach’s alpha >0,7 for all scales. conclusion: the indonesian version of the kdqol-36 questionnaire is valid and reliable for evaluating qol in reguler hemodialysis patients. keywords: kdqol-36, validity, reliability, hemodialysis. introduction chronic kidney disease (ckd) is a worldwide health problem, including indonesia.1,2 chronic kidney disease and dialysis affects the patient’s quality of life in terms of physical, psychological, social, and environmental aspects.3 quality of life assessment is an important part in ckd treatment.4,5 an evaluation instrument or questionnaire can provide accurate information on patient’s quality of life in order to select type of dialysis and to evaluate treatment result.6,7 kdqol-36 questionnaire is a special instrument to assess quality of life of ckd and dialysis patients. it has been used and translated into many languages with good validity and reliability.8-11 to date, no questionnaire has been available in indonesian language to assess patient’s condition and treatment. therefore, it is important to have the indonesian version of kdqol-36 questionnaire. moreover, considering cultural differences, we also need to make translation, cultural adaptation, validity, and reliability test.12 our study aimed to analyze validity and reliability of the indonesian version of kdqol-36 in hemodialysis patients at dr. hasan sadikin general hospital, bandung. methods the study was an analytic cross-sectional study, which was conducted at the hemodialysis unit of dr. hasan sadikin general hospital, bandung between may and july 2016. this study has been approved by the ethical committee of hasan sadikin hospital, reference number lb.04.01/a05/ec/128/iv/2016. subjects were patients who had regular or routine hemodialysis for more than 3 months. they were 18 years old or older, able to read and write in indonesian language, and willing to participate in the study. subjects with decreased consciousness and unable to have oral communication were excluded. minimum sample size in this study was calculated using the correlation coefficient formula. hence, minimum sample size in this study was 102 subjects. the study consisted of 2 steps, the first step was translation and adaptation of kdoql-36 questionnaire into indonesian language and the second step was validity and reliability test. the first step was performed according to rand corporate standard.13 we had acquired the copyright to translate kdqol-36 questionnaire from rand corporate. the questionnaire was translated into indonesian language by a certified translator and then it was translated back into english. an expert team consisted of 2 nephrologists and 1 certified translator then developed an adaptation of the translated questionnaire. we performed a normality test using kolmogorov-smirnov test. to analyze the construct validity, we used pearson’s correlation test on total score of kidney disease-targeted score, generic score and each of the subscales score. each scale in kdqol-36 was considered rudi supriyadi acta med indones-indones j intern med 320 valid when it showed statistically significant (p<0.05) results with low (r=0.200 – 0.399), moderate (r=0.400 – 0.599), high (r=0.600 – 0.799), or very high (r: 0.800 – 1.000) correlation. a reliability test was done using test-retest evaluation and internal consistency was estimated using cronbach’s alpha for each subscale of the kdqol-36. the testretest evaluation was performed in the form of 2 questionnaire interviews with 7 to 10 days interval. scale in kdqol-36 was considered reliable when there was no significant difference found between the first and second measurement (p > 0.05). internal consistency was considered reliable when the reliability coefficient cronbach alpha was ≥ 0.7. results the study was performed within 3 months, started from april 2016 until june 2016. initially, there were 107 subjects. we performed first interview then repeated interview within 7-10 days later. four subjects could not attend the second interview due to dyspnea (1 subject), decrease in consciousness (1 subject), and hospitalized (2 subjects). hence, a total of 103 subjects was included to data analyze (figure 1). baseline characteristics of these subjects were displayed in table 1. chronic hemodialyzed patients: 136 patients included to the study: 107 patients exclusion criteria : unable to be interviewed due to dyspnea, neurological problems, hearing loss, illiterate first interview of indonesian kdqol 36 data analysis second interview of indonesian kdqol 36: 103 patients figure 1. indonesian kdqol study algorithm table 1. baseline subject characteristics (n=103) characteristics value age (year), median (range) 51 (22 – 75) hemodialysis duration (year), mean (sd) 3.4 (2.1) sex male, n (%) 54 (52.4) education, n (%) elementary school 24 (23.3) junior high school 16 (15.5) senior high school/ vocational 32 (31.1) university 31 (30.1) occupation, n (%) employed 25 (24.3) unemployed 78 (75.7) race, n (%) sundanese 90 (87.4) javanese 9 (8.7) bataknese 2 (1.9) minangnese 1 (1.0) others 1 (1.0) religion (%) islam 100 (97.1) christian 1 (1.0) catholic 2 (1.9) a very strong correlation was found between symptoms/problems and total score of kidney disease-targeted scale (r = 0.815). a strong correlation was shown regarding the effect of kidney disease, burden of kidney disease scales and total scores of kidney disease-targeted scale, physical component summary, mental component summary and generic core (r= 0.6470.798; p < 0.001). such results demonstrated that the kdqol-36 questionnaire scales had a good validity. (table 2) a comparative test using paired t-test was used, which showed results presented in the form of mean score for each scale of kdqol-36 questionnaire. the results were not statistically significant in the first and second measurement. the correlation test on the mean score of each scale of kidney diseasetargeted scales and vol 51 • number 4 • october 2019 validity and reliability of the indonesian version of kdqol-36 questionnaire 321 mental function test between the first and second measurement demonstrated moderate to strong results (r = 0.635 – 0.746). the correlation test on the mean score of physical function between the first and second measurement showed moderately positive result (r = 0.518). such results indicated that all scales in the kdqol-36 were reliable. the internal consistency test of all the subscales in the kdqol-36 was very good with cronbach’s alpha values ranging from 0.706 to 0.886 (table 4). discussion our study was the first study that provides formal translation of kdqol-36 questionnaire into indonesian language and it is also the first study analyzing its validity and reliability. quality of life in patients with hemodialysis is worse throughout the time, which is affected by some factors. this questionnaire is important in measuring dialysis adequacy. the indonesian table 2. validity test result of kdqol-36 questionnaire scales number of questions n total score correlation coefficient (r)* p value* kidney disease target symptoms/problems 12 103 0.815 <0.001 effect of kidney disease 8 103 0.798 <0.001 burden of kidney disease 4 103 0.785 <0.001 generic core (sf-12) physical component summary (pcs) 6 103 0.647 <0.001 mental component summary (mcs) 6 103 0.701 <0.001 *pearson’s correlation test table 3. reliability test-retest result of kdqol-36 questionnaire scales i ii p value correlation coefficient (r)**mean (sd) mean (sd) kidney disease target symptoms/problems 72.09 (18.31) 74.88 (17.21) 0.061 0.648 effect of kidney disease 66.11 (19.55) 68.05 (21.16) 0.231 0.680 burden of kidney disease 47.69 (29.08) 49.88 (33.12) 0.327 0.746 generic core (sf-12) physical component summary (pcs) 35.07 (8.85) 34.75 (10.61) 0.735 0.518 mental component summary (mcs) 43.99 (10.53) 45.65 (10.44) 0.063 0.635 sd=standard deviation, *paired t-test, **pearson’s correlation test table 4. internal consistency test of the kdqol-36 scales number of questions cronbach’s alpha kidney disease target symptoms/problems 12 0.886 effect of kidney disease 8 0.736 burden of kidney disease 4 0.733 generic core (sf-12) physical component summary (pcs) 6 0.706 mental component summary (mcs) 6 0.721 version of kdqol-36 is very useful for all indonesian healthcare workers who are involved in hemodialysis care since some of the workers (nurses, nutritionist, or students) are not fluent in english. we did some adaptation within translation of the questionnaire. the item of “moderate activities such as moving a table, pushing a rudi supriyadi acta med indones-indones j intern med 322 vacuum cleaner, bowling, or playing golf” was adapted to “kegiatan sedang seperti memindahkan meja, menyapu atau mengepel, bersepeda, atau joging (moderate activities such as moving a table, sweeping or mopping, riding a bicycle, or jogging)”. pushing a vacuum cleaner, bowling, or playing golf were considered uncommon activities in indonesian community, therefore adaptation was made. we chose the substituting activities based on metabolic equivalent (met) for moderate activities (3-6 mets).14-15 we adapted the item of “climbing several flights of stairs” to “menaiki tangga beberapa lantai atau jalan menanjak (climbing several floors or uphill pathway)”. the team agreed to make a slight change in adaptation due to accuracy in indonesian language and various socio economic conditions in indonesian communities as some of them do not have stairs in their house. such adaptation in the questionnaire items has also been done by several countries such as korea, philippines, egypt, and china during their adaptation of the kdqol-36 and kdqolsf.8-10,16 tao, et. al. did a change from “bowling and playing golf” to “walking and tai chi” during the translation and validation of the kdqol-36 into chinese language.16 abd elhafeez et al.12 omitted “bowling and playing golf” during translation of the kdqol-36 into arabic language in egypt.8 “several flights of stairs” was translated to “ 1 or more floors” in egypt and to “3 or 4 floors” in korea.8,10 adaptation has been done due to different social and cultures in each country and intended to acquire equal understanding with the original version.12 another change in our translated kdqol-36 was “accomplished less than you would like” to “menyelesaikan pekerjaan kurang sesuai dengan yang diharapkan (accomplished less equal than you would like)” in order to ease understanding. answer choice for questions in subgroup “how do you feel and how things have been with you during the past 4 weeks” was changed from “enough time” to “sering (frequent)”, and answer choice for questions in subgroup “how true or false is each of the following statements for you” was changed from “mostly true” to “sangat benar (very true)” and “mostly false” to “sangat salah (very wrong)”. correlation test of the kdqol-36 for kidney disease-targeted and generic score showed strong correlation (r > 0.600) and the result was statistically significant (p < 0.001). hence, the indonesian version of kdoql-36 had good validity for all subscales. our result was in accordance with results of studies in other countries. thaweethamcharoen, et al.17 in thailand demonstrated a significant correlation between kidney disease target, physical component summary, and mental component summary (r = 0.226-0.542; p < 0.001).11 similar findings were also demonstrated by chen, et. al. with moderate correlation (r = 0.328-0.602; p < 0.05) within the scales.17 our indonesian questionnaire reliability test demonstrated a non-significant mean score of all scales between the first and second measurement (p > 0.05); meanwhile internal consistency showed the cronbach’s alpha of ≥ 0.7 (0.706 – 0.886) for all scales. the present study showed that the indonesian version of the kdqol-36 is reliable. similar studies in other countries have also demonstrated good reliability and internal consistency with cronbach’s alpha of ≥ 0.7. a study in thailand has shown a non-significant difference of test-retest result between the first and second measurement (p > 0.05) with cronbach’s alpha of ≥ 0.7 (0.706-0.827) for all scales.11 furthermore, studies in china and india have also demonstrated similar results.17,18 regarding the mean score for kidney disease target, our study demonstrated that the lowest score was found on the burden of kidney disease (47.69) and the highest score on the symptoms/problems (72.09). the result was similar to the study conducted in thailand and hong kong.11,16,19 such result might be due to similarity of the subject’s baseline characteristics including mean age, occupation, and duration of undergoing hemodialysis. mean age of subjects was 57.49 sd 15.9) in thailand and 47.6 (sd 14.2) in hong kong with most subjects were unemployed and had undergone hemodialysis for 3.8 (sd 3.4) years.11,16 however, a study of spanish version of the kdqol-36 by ricardo, et al.20, which studied vol 51 • number 4 • october 2019 validity and reliability of the indonesian version of kdqol-36 questionnaire 323 hispanic population in the united states of america showed that the highest mean score was in the effects of kidney disease. higher level of education (63.3% of subjects’ education level were university) and social cultural aspects might influence the result. higher score in effects of kidney disease scale than other scales also showed that chronic kidney disease did not affect hemodialysis patient’s quality of life in the united states of america. there were some limitations in our study. first, it was conducted only in a single unit of medical center and further studies in several centers are still required to reduce bias in social and cultural aspects. second, data collection was performed through one person interview since the subjects were not able to fill the questionnaire during hemodialysis treatment. further studies should be carried out to evaluate interviewer factor and difference in data collection methods, which may affect subject’s interpretation to the questions in the questionnaire. conclusion our study shows that the indonesian version of the kdqol-36 questionnaire has a good validity and reliability for evaluating qol in routine hemodialysis patients at dr. hasan sadikin general hospital, bandung. references 1. world health organization. the global burden of disease: 2004 update. geneva: who library cataloguing data. 2008. p. 3-30. 2. ministry of health republic of indonesia. basic health research. jakarta: ministry of health republic of indonesia; 2013. p. 5-20. 3. mujais sk, story k, brouillette j, et al. healthrelated quality of life in ckd patients: correlates and evolution over time. cjasn. 2009;4:1293-301. 4. morton rl, tong a, howard k, snelling p, webster ac. the views of patients and carers in treatment decision making for chronic kidney disease: systematic review and thematic synthesis of qualitative studies. bmj. 2010;17:340-8. 5. lee a, gudex c, povlsen jv, bonnevie b, nielsen cp. patients’ views regarding choice of dialysis modality. nephrol dial transplant. 2008;23:953-9. 6. fayers p, machin d. quality of life: the assessment, analysis and interpretation of patient-reported outcomes. 2nd ed. chicester: john wiley & sons; 2007. p. 28-42. 7. guyatt gh, feeny dh, patrick dl. measuring healthrelated quality of life. ann intern med. 1993;118:6229. 8. abd elhafeez s, sallam sa, gad zm, et al. cultural adaptation and validation of the “kidney disease and quality of life short form (kdqol-sf™) version 1.3” questionnaire in egypt. bmc nephrol. 2012;13:170-9. 9. bataclan rp, dial ma. cultural adaptation and validation of the filipino version of kidney disease quality of life--short form (kdqol-sf version 1.3). nephrology. 2009;14:663-8. 10. park hj, kim s, yong js, et al. reliability and validity of the korean version of kidney disease quality of life instrument (kdqol-sftm). tohoku j exp med. 2007;211:321-9. 11. thaweethamcharoen t, srimongkol w, noparatayaporn p, et al. validity and reliability of kdqol-36 in thai kidney disease patient. value health reg issues. 2013;11:98-102. 12. beaton de, bombardier c, guillemin f, ferraz mb. guidelines for the process of cross-cultural adaptation of self-report measures. spine. 2000;25:3186-91. 13. rand corporation. basic guidelines for translating surveys 2015. [cited 29 december 2015]. available at http://rand.org/health/surveystools/about translations. html. 14. allen k, amstrong le, balady gj, et al. acsm’s guidelines for exercise testing and prescription. 8th ed. georgia: lippincott; 2009. p. 4-5. 15. ainsworth be, haskell wl, whitt mc, et al. compendium of physical activities: an updated of activity codes and met intensities. med sci sports exerc. 2000;32:s498-504. 16. tao x, chow sky, wong fky. determining the validity and reliability of the chinese version of the kidney disease quality of life questionnaire (kdqol-36™). bmc nephrol. 2014;15(1):78-85. 17. chen jy, choi eph, wan eyf, et al. validation of the disease-specific components of the kidney disease quality of life-36 (kdqol-36) in chinese patients undergoing maintenance dialysis. plos one. 2016;11(5):91-113. 18. mateti uv, nagappa an, attur rp, nagaraju sp, mayya ss, balkrishnan r. cross-cultural adaptation, validation and reliability of the south indian (kannada) version of the kidney disease and quality of life (kdqol-36) instrument. saudi j kidney dis transpl. 2015;26(6):1246-52. 19. chow sky, tam bml. is the kidney disease quality of life-36 (kdqol-36) a valid instrument for chinese dialysis patients? bmc nephrol. 2014;15(1):21-30. 20. ricardo ac, hacker e, lora cm, et al. validation of the kidney disease quality of life short form 36 (kdqol-36) us spanish and english versions in a cohort of hispanics with chronic kidney disease. ethn dis. 2013;23(2):202-9. special article 363acta med indones indones j intern med • vol 49 • number 4 • october 2017 efficacy of curcumin as adjuvant therapy to induce or maintain remission in ulcerative colitis patients: an evidence-based clinical review marcellus simadibrata1, christopher c. halimkesuma2, benedicta m. suwita2 1 department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 2 faculty of medicine universitas indonesia, jakarta, indonesia. corresponding author: prof. marcellus simadibrata, md., phd. division of gastroenterology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: prof.marcellus.s@gmail.com. abstrak latar belakang: panduan tatalaksana untuk kolitis ulseratif (ku) belum tersedia. saat ini, mesalazine, kortikosteroid, dan imunomodulator merupakan pilihan terapi untuk ku. namun, obat-obatan tersebut memiliki efek samping yang tidak menyenangkan, misalnya mual, muntah, sakit kepala, hepatitis, dan infertilitas pria. curcumin terdapat dalam tanaman kunyit (curcuma longa l.) yang memiliki aktivitas anti-inflamasi dan antioksidan. artikel ini bertujuan menentukan apakah curcumin sebagai terapi adjuvan dapat menginduksi atau memelihara status remisi pada ku. metode: pencarian terstruktur pada tiga database (cochrane, pubmed, proquest) menggunakan “curcumin”, “remisi” dan “kolitis ulseratif” sebagai kata kunci. kriteria inklusi adalah uji klinis acak terkontrol, meta-analisis, atau review sistematis yang meneliti curcumin sebagai terapi adjuvan pada pasien ku dewasa. hasil: dari 49 artikel yang ditemukan, didapatkan 3 uji klinis acak terkontrol setelah eksklusi artikel – 2 meneliti efektivitas curcumin dalam menginduksi remisi, dan 1 untuk memelihara remisi pada kolitis ulseratif. curcumin lebih efektif secara signifikan dibandingkan plasebo pada semua uji klinis. efektivitas curcumin dapat dijelaskan oleh aktivitas anti-inflamasi yang dimilikinya, yaitu dengan inhibisi jalur nf-kb. regulasi keseimbangan oksidan/anti-oksidan dapat memodifikasi pelepasan sitokin. meski demikian, metode yang digunakan bervariasi antara uji klinis satu dengan yang lain. oleh karena itu, sulit untuk membandingkannya secara objektif. selain itu, jumlah sampel yang digunakan juga kecil (n= 50, 45, 89), sehingga tidak terdapat kekuatan statistik yang cukup untuk mewakili seluruh populasi pasien kolitis ulseratif dewasa. kesimpulan: studi yang ada menunjukkan bahwa curcumin memiliki potensi untuk menginduksi dan memelihara status remisi pada pasien ku tanpa menimbulkan efek samping yang serius. meski demikian, diperlukan studi lebih lanjut dengan jumlah sampel yang lebih besar sebelum curcumin dapat direkomendasikan sebagai terapi adjuvan untuk ku. kata kunci: curcumin, kolitis ulseratif, pemeliharaan, remisi. abstract background: treatment guidelines for ulcerative colitis (uc) not yet established. currently, mesalazine, corticosteroids, and immunomodulators are treatment options for uc. however, they are known to have unpleaseant side effects such as nausea, vomiting, headaches, hepatitis, and male infertility. curcumin is found in turmeric plants (curcuma longa l.), which possesses both anti-inflammatory and antioxidant properties. this study aimed to determine whether curcumin as adjuvant therapy can induce or maintain remission in uc marcellus simadibrata acta med indones-indones j intern med patients. methods: structured search in three database (cochrane, pubmed, proquest) using “curcumin”, “remission” and “ulcerative colitis” as keywords. inclusion criteria is randomized controlled trials (rcts), meta-analysis, or systematic review using curcumin as adjuvant therapy in adult uc patients. results: we found 49 articles. after exclusion, three rcts were reviewed; two examined curcumin efficacy to induce remission and one for remision maintenance in uc. curcumin was significantly more effective than placebo in all rcts. the efficacy of curcumin could be explained by its anti-inflammatory properties, which inhibit nf-kb pathway. regulation of oxidant/anti-oxidant balance can modify the release of cytokines. however, methods varied between rcts. therefore, they cannot be compared objectively. futhermore, the sample size were small (n= 50, 45, 89) therefore the statistical power was not enough to generate representative results in all uc patients. conclusion: available evidence showed that curcumin has the potential to induce and maintain remission in uc patients with no serious side effects. however, further studies with larger sample size are needed to recommend it as adjuvant therapy of ulcerative colitis. key words: curcumin, remission, maintenance, ulcerative colitis (uc). introduction ulcerative colitis (uc) is an immunemediated chronic intestinal condition that causes inflammation and ulcers on the large intestine’s inner lining. it is one of the two major types of inflammatory bowel disease (ibd). the incidence of uc varies between geographic areas, the highest incidence occurs in europe, united kingdom, and north america; its prevalence ranges from 21.4 – 246 cases per 100,000 person per year. however, the incidence of uc is rising in regions previously thought to have low incidence, for example in hong kong the incidence of uc has increased six-fold in the past two decades. uc’s peak age of onset is between 15 – 30 years old, and second peak occurs between 60 – 80 years old. mortality is the highest during the first years of disease, and in long-duration disease due to the risk of colon cancer. in a large population study, the standardized mortality ratios for uc was 1.1.1 in addition, uc also produces symptoms that impair quality of life and ability in carrying work or daily activities.2 therefore, an effective treatment regimen for uc is needed to relieve its symptoms and maintain disease remission. however, treatment guidelines for uc has not been established yet. currently, 5-aminosalicylates (5-asa), corticosteroids, s u l f a s a l a z i n e ( s z ) , m e s a l a z i n e , a n d immunomodulators are treatment options for patients with active uc. nonetheless, they are known to have unpleaseant side effects such as nausea, vomiting, headaches, hepatitis, and male infertility.3-6 moreover, 20 – 30% patients failed to respond to the drugs given for induction of remission.7 hence, new alternatives for uc treatment are being sought. inappropriate and persistent immune response against commensal intestinal bacterial flora plays a central role in the pathogenesis of uc. there is an enhanced t-cell response to the bowel luminal contents accompanied by excessive neutrophil influx in colonic tissue, leading to uncontrolled inflammation. the role of proinflammatory cytokines interleukin (il)1β, il-6, tumour necrosis factor (tnf)-α, il-12, and interferon (ifn)-γ in initiating and sustaining the mucosal inflammation has been established in animal models as well as in human studies. nuclear factor kappa b (nf-κb) is the main up-regulator of expression of these cytokines, and is strongly activated in uc, suggesting important role in its pathogenesis.1,8 curcumin is found in turmeric plants (curcuma longa l.), which possesses both anti-inflammatory and antioxidant properties. recently, its use for treatment of inflammatory diseases, including uc, has gained increasing interest for research. therefore, this review is focused on curcumin’s efficacy as adjuvant therapy to induce or maintain remission in adult uc patients. methods the search strategy and study selection criteria were based on problem-intervention364 vol 49 • number 4 • october 2017 efficacy of curcumin as adjuvant therapy to induce or maintain remission comparison-outcome (pico) model to answer the clinical question, as described in table 1. since the clinical question type is intervention, searching would be focused to find metaanalysis, systematic review, or clinical trial to answer the clinical question. data sources and search strategy we screened pubmed, proquest, and cochrane database on june 10th – 17th, 2016 for data comparing uc standard therapy with curcumin and uc standard therapy alone. we used “curcumin”, “remission”, and “ulcerative colitis” as keywords. filters were used to limit article types, which is “meta-analysis”, “systematic review”, “randomized clinical trial”, or “clinical trial”. no filter for date of publication was used, and the articles found were published between 2005 and 2015. the keywords and articles found in each search were listed in table 2. selection criteria articles included in this review were systematic review, meta-analysis, randomized clinical trial, or clinical trial comparing uc standard therapy with curcumin and uc standard therapy alone. exclusion criteria for this review were: articles with observational design, studies using patients <18 years old, studies using pregnant patients, animal studies, studies assessing endpoint other than maintenance or induction of disease remission, and studies assessing the effects of drug other than the combination of curcumin and standard uc therapy. articles written in languages other than english or indonesian were also excluded. the literature screening, study selection, and reasons for exclusion were described in the flowchart (figure 1). eligible studies, which conformed to the inclusion and exclusion criteria, were assessed for their risk of bias. publication bias was graded using the components of evidencebased medicine (ebm) toolkit recommended by the british medical journal (bmj), which consist of randomization, allocation concealment, blinding of participants, and other sources of bias. the characteristics of included studies, along with potential sources of bias were summarised in table 3. results from the 49 studies, 46 did not meet the inclusion criteria. three rcts were finally included in the review (figure 1); two examined curcumin efficacy to induce remission and one for maintenance in uc. curcumin as adjuvant therapy was signifiantly more effective than placebo in all rcts (table 3). curcumin as adjuvant to induce remission in ulcerative colitis lang et al used patients with active mild to moderate uc who did not respond to maximum dose of 5-asa oral and topical therapy; they were randomly assigned to groups given curcumin capsules (3 g/day) or placebo for table 1. pico components problem intervention comparison outcome adult patients (>18 years old) with ulcerative colitis, both in active and remission phase. standard uc therapy (e.g corticosteroids, mesalazine) plus curcumin, administrated via rectal or oral route standard uc therapy (e.g corticosteroids, mesalazine) plus placebo remission, as measured by ulcerative colitis disease activity index (ucdai) < 3 or colitis activity index (cai) <4 table 2. searching strategy in several database engines search terms hits pubmed (curcumin [mesh terms] and ulcerative colitis [mesh terms]) and remission 21 cochrane “curcumin” and “ulcerative colitis” and “remission” 15 proquest “curcumin” and “ulcerative colitis” and “remission” 13 365 marcellus simadibrata acta med indones-indones j intern med 1 month with continued 5-asa. this study reported 53.8% patients in curcumin group experienced remission compared to none in the placebo group (odds ratio (or) 42, 95% ci 2.3 – 760). clinical response (i.e. decrease in clinical score, but did not fulfill remission criteria) was also higher in the curcumin group (65.3% vs 12.6%, or 13.2, 95% ci 3.1 – 56.6).9 singla et al8 used patients with active mild to moderate uc in distal colon (<25 cm disease involvement from anal verge) who were already on oral mesalamine for at least 8 weeks. they were randomly assigned to groups given curcumin enema (ncb-02) plus oral 5-asa or placebo enema plus oral 5-asa once daily. this study reported 43.4% remission in curcumin group compared to 22.7% in placebo group. clinical response was also higher in the curcumin group (56.5% vs. 36.4%). number needed to treat in both studies were small, less than 50 patients. curcumin as adjuvant to maintain remission in ulcerative colitis hanai et al10 used patients with quiescent uc and randomly assigned to oral curcumin (2 g/ day) plus sulfasalzine or mesalamine (depending on which drug the patients already used before trial), or placebo capsules plus sulfasalazine or mesalamine (depending on which drug the patients already used before trial). patients experienced recurrence were fewer in curcumin group both at 6-month follow-up (10% vs. 14%) and 12-month follow-up (22.2% vs 31.8%).10 number needed to treat was small, less than 50 patients. discussion in all studies that we found, curcumin was significantly more effective as adjuvant therapy to induce or maintain uc remission, compared to placebo.8-10 a small number needed to treat showed that curcumin had significant benefit for patients and could potentially be used in figure 1. flow chart of search strategy table 3. critical appraisal of the randomized clinical trial articles (years) n um be rs o f s am pl e relevance validity importance p i c o r an do m lo ng fo llo w u p a ll pa tie nt s an al yz ed b lin d tr ea te d eq ua lly s im ili ar a t s ta rt c e r (% ) e e r (% ) r r r (% ) a r r (% ) n n t (c i 9 5% ) lang (2015)9 50 + oral, 3g/day + + + + + + + 0 53.8 53.8 2 (1–3) singla (2014)8 45 + enema, 1x/ day + + + + + + + 22.7 43.5 91.6 20.8 5 (3–17 ) hanai (2006)10 89 + oral, 2g/day + + + + + + + + 68.2 77.8 14.1 9.6 11 (4–12) p:patient, i: intervention, c: comparison, +: placebo. o: outcome, +: remission. in validity, +: yes, -: no. cer: control event rate, event=outcome. eer: experimental event rate, event=outcome. rrr: relative risk reduction, minus (-):rrr cannot be counted because the cer is 0 (zero) percent. arr: absolute risk reduction. nnt: number needed to treat. ci : confidence interval 366 vol 49 • number 4 • october 2017 efficacy of curcumin as adjuvant therapy to induce or maintain remission clinical settings. this effect might be explained by curcumin’s anti-inflammatory properties. inhibition of nf-κb was postulated as its main anti-inflammatory properties. the mechanism of action involves inhibition of ikk (iκb kinase) which leads to inhibition of both cytokine mediated phosphorylation and degradation of iκb, which is an inhibitor of nf-κb. as a result of nf-κb inhibition, il-2 synthesis, as well as il-2 and mitogen activation of human leukocytes are also inhibitied. curcumin is also indicated to have inhibiting effect on tumor necrosis factor α (tnf-α) and phorbol ester-induced binding of nf-κb transcription factors to sites located on the gstp-1 (glutathione s-transferase p1-1) gene promoter – therefore, it could induce apoptosis by inhibiting gstp-1 expression at the transcription level. in animal studies, curcumin also showed ability to suppresss cd4+ t-cell infiltration, thereby reducing the inflammatory response.8-11 adverse events were not significantly different in the placebo and curcumin groups in all trials.8-10 the most common side effects of curcumin was gastrointestinal complaint, such as nausea and sensation of abdominal distension; it was usually mild, transient and no subjects in the studies dropped out because of curcumin’s side effects.10 this side effects could be reduced by administering curcumin via rectal route (enema), especially for patients with distal uc. futhermore, topical preparation can bypass first pass metabolism in the liver, which is high for oral preparation of curcumin.8 the good safety profile of curcumin places it as a promising agent in uc treatment. moreover, not only curcumin could improve clinical symptoms, it could also improve endoscopic findings of the colon, as described by lang, et al.9 in animal models of colon cancer, curcumin was reported to inhibit dysplasia and neoplasia. this chemopreventive activities might be mediated by inhibition of cyclo-oxygenase-2 expression.8 curcumin also strongly inhibited proliferation of ht-29 and hct-15 human colon cancer cell lines. therefore long treatment with curcumin might also inhibit colorectal cancer development in uc patients, which needed to be studied further.11 however, all studies we found used a relatively small sample size (50,45, and 89), and one trial only conducted one month follow-up – the statistical power is not enough to generate representative results in all uc patients. moreover, the studies each used different curcumin dosage and routes of administration, and different follow-up period; it could not be objectively compared. futhermore, clinical scoring system used in each trial was slightly different from each other. as a result, the quantitative data from those trials could not be integrated to form a pooled analysis. we concluded that further studies with larger sample size are needed to recommend it as adjuvant therapy of ulcerative colitis. a d d i t i o n a l l y, s t u d i e s c o m p a r i n g t h e effectivity of various combination of curcumin and standard uc therapy were also needed, e.g curcumin-mesalamine, curcumin-steroids, etc. similar to curcumin, mesalamine also acts by inhibiting nf-κb pathway. the combination of curcumin and mesalamine had shown increased efficacy compared to mesalamine therapy alone. this might be due to synergistic action of curcumin with mesalamine, or inhibition of other inflammatory pathways by curcumin.8 comparison of synergistic effect between curcumin and various drugs used in uc therapy has not been established. furthermore, studies comparing various curcumin dosage (e.g 2 g/day, 3 g/day, etc). were needed to obtain curcumin dosage and avoid gastrointestinal side effects caused by unneccessarily high curcumin dosage. recently, various formulation of oral curcumin is also developed to increase its absorption rate, because curcumin is a poorly water-soluble drug. li et al12 used curcumin and piperine (pip) co-encapsulated into the nanoformulation called self-microemulsifying drug delivery system (smedds) to improve the stability and watersolubility of curcumin and enhance its anticolitis activity. lately, oral colon-specific drug delivery has been developed, using microparticles as drug carrier to achieve controlled drug-release in the colon. curcumin-loaded microparticles has been used in animal and in-vivo studies, and showed promising results.13 these methods might hold promis for more efficient clinical treatment of uc. therefore, studies comparing curcumin efficacy between different routes and formulation were also needed. 367 marcellus simadibrata acta med indones-indones j intern med conclusion available evidence showed that adjuvant therapy using curcumin has potential to induce and maintain remission in uc patients with no serious side effects. however, further studies with larger sample size are needed to recommend it as adjuvant therapy of ulcerative colitis. references 1. friedman s, blumberg rs. inflammatory bowel disease. in: longo dl, fauci as, kasper dl, hauser sl, jameson l, loscalzo j, editors. harrison’s principle of internal medicine. 18th ed. new york: mcgraw-hill. 2012. p. 1143-50. 2. head ka, jurenka js. inflammatory bowel disease part i: ulcerative colitis-pathophysiology and conventional and alternative treatment options. altern med rev. 2003;8:247–83. 3. xu c-t, meng s-y, pan b-r. drug therapy for ulcerative colitis. world j gastroenterol. 2004;10:2311–7. 4. allison mc, dhillon ap, lewis wg, et al. inflammatory bowel disease. london: mosby; 1998. p. 15–95. 5. hanauer sb. medical therapy of ulcerative colitis. gastroenterol. 2004;126:1582–92. 6. h a n a u e r s b . i n f l a m m a t o r y b o w e l d i s e a s e : epidemiology, pathogenesis, and therapeutic opportunities. inflamm bowel dis. 2006;12:s3–s9. 7. baumgart dc, sandborn wj. inflammatory bowel disease: clinical aspects and established and evolving therapies. lancet. 2007;369:1641–57. 8. singla v, mouli vp, garg sk, et al. induction with ncb-02 (curcumin) enema for mild-to-moderate distal ulcerative colitis – a randomized, placebo-controlled, pilot study. j crohn’s colitis. 2014;8:208-14. 9. lang a, salomon n, wu jcy, et al. curcumin in combination with 5-aminosalycilate induces remission in patients with mild to moderate ulcerative colitis in a randomized controlled trial. clin gastroenterol hepatol. 2015;13(8):1444-9. 10. hanai h, iida t, takeuchi k, et al. curcumin maintenance therapy for ulcerative colitis: randomized, multicenter, double-blind, placebo-controlled trial. clin gastroenterol hepatol. 2006;4:1502-6. 11. holt pr, katz s, kirshoff r. curcumin therapy in inflammatory bowel disease: a pilot study. digestive dis sci. 2005;50(11):2191-3. 12. li q, jiang q, huang r, et al. curcumin–piperine mixtures in self-microemulsifying drug delivery system for ulcerative colitis therapy. int j pharmaceut. 2015;490:22-31. 13. xiao b, si x, zhang m, merlin d. oral administration of ph-sensitive curcumin-loaded microparticles for ulcerative colitis therapy. colloids surf b biointerfaces. 2015;135:379-85. 368 120 original article acta medica indonesiana the indonesian journal of internal medicine serum tnf-α, il-8, vegf levels in helicobacter pylori infection and their association with degree of gastritis gontar a. siregar, sahat halim, ricky r. sitepu department of internal medicine, faculty of medicine universitas sumatera utara adam malik hospital, medan, indonesia. correspondence mail: gontar a. siregar. professor, division of gastroentero-hepatology, department of internal medicine, faculty of medicine universitas sumatera utara. komp. tasbi yy no 203 medan, indonesia. email: gontarsiregar@gmail.com. abstrak tujuan: untuk mengetahui kadar serum tnf-α, il-8, vegf pada infeksi helicobacter pylori dan hubungannya dengan derajat histopatologi gastritis. metode: studi potong lintang terhadap 80 pasien gastritis secara konsekutif yang datang ke unit endoskopi rumah sakit umum adam malik dan rumah sakit permata bunda, medan, indonesia dari juli-desember 2014. rapid urease test digunakan untuk diagnosis infeksi h. pylori. dinilai derajat keparahan inflamasi kronik, infiltrasi neutrofil, atrofi, dan metaplasia intestinal. dilakukan pemeriksaan kadar serum tnf-α, il-8, dan vegf. analisis univariat dan bivariat (chi square, fisher’s exact, dan mann-whitney test) dengan spss versi-22. hasil: sebanyak 41,25% dari 80 pasien terinfeksi h. pylori. kadar serum tnf-α dan vegf secara signifikan lebih tinggi pada kelompok yang terinfeksi h. pylori dibandingkan kelompok h. pylori negatif, tetapi tidak ada perbedaan signifikan antara kadar serum il-8 pada h. pylori positif dan negatif. terdapat hubungan yang signifikan antara kadar serum tnf-α dan il-8 dengan derajat inflamasi kronik, serta antara kadar serum il-8 dengan derajat infiltrasi neutrofil. terdapat hubungan yang signifikan antara kadar serum vegf dengan derajat atrofi dan derajat metaplasia intestinal. kesimpulan: kadar serum tnf-α yang tinggi berhubungan dengan derajat inflamasi kronik yang berat, kadar serum il-8 yang tinggi berhubungan dengan derajat inflamasi kronik dan infiltrasi neutrofil yang berat, serta kadar serum vegf yang tinggi berhubungan dengan derajat lesi gaster prakeganasan yang berat. kata kunci: sitokin, neoangiogenesis, helicobacter pylori, gastritis atrofi, metaplasia intestinal. abstract aim: to investigate the serum levels of tnf-α, il-8, vegf in helicobacter pylori infection, and their association with the degrees of gastritis histopathology. methods: a cross-sectional study was done on 80 consecutive gastritis patients admitted to endoscopy units at adam malik general hospital and permata bunda hospital, medan, indonesia from july-december 2014. the rapid urease test was used for the diagnosis of h. pylori infection. the severity of chronic inflammation, neutrophil infiltration, atrophy, and intestinal metaplasia were assessed. serum samples were obtained to determine circulating tnf-α, il-8, and vegf. univariate and bivariate analysis (chi square, fisher’s exact, and mann-whitney test) were done using spss version-22. results: there were 41.25% of 80 patients infected with helicobacter pylori. serum tnf-α and vegf levels in the infected group were significantly higher compared to h. pylori negative, but there were no significant differences between serum levels of il-8 in h. pylori positive and negative. there were significant associations between serum level of tnf-α and il-8 with degree of chronic inflammation, and also between serum level of il-8 and degree of neutrophil infiltration. there were significant associations between serum level of vegf and degree of atrophy, and also between serum level of vegf and degree of intestinal metaplasia. vol 47 • number 2 • april 2015 serum tnfa, il8, vegf levels in h. pylori infection 121 conclusion: high levels of tnf-α were associated with severe degree of chronic inflammation, high levels of il-8 associated with severe degree of chronic inflammation and neutrophil infiltration, and high levels of vegf associated with severe degree of premalignant gastric lesion. key words: cytokine, neoangiogenesis, helicobacter pylori, atrophic gastritis, intestinal metaplasia. introduction helicobacter pylori is the most common bacterial infection in humans that is specific for gastric epithelial cells. it is a gram negative, microaerophilic bacterium associated with chronic gastritis and peptic ulcer disease as well as gastric cancer and mucosa related tissue lymphoma (malt).1 the prevalence of h. pylori seems to be dependent on geographical location and the socioeconomical status of the population and it was found that approximately 50% of the world adult population was infected by h. pylori. the bacterium colonizes the human stomach and triggers gastric inflammation, promoting neutrophils and monocyte recruitment, and increases the release of cytokines which causes gastric mucosa damage.2 local production of inflammatory cytokines are thought to play a central role in the recruitment of inflammatory cells to the gastric mucosa in the presence of h. pylori.3 it remains unclear whether this inflammation is limited to gastric mucosa or causes systemic inflammation, since the stomach has a large surface area. it has been suggested that the chronic gastric mucosal inflammation induced by h. pylori potentially may have systemic effects based on the increase in serum proinflammatory cytokines.4 h. pylori plays a critical role in the pathogenesis of benign and malignant gastric diseases and is associated with activation of the host’s angiogenesis.5 among the pro-angiogenic factors known so far, vascular endothelial growth factor (vegf) represents one of the most potent stimuli of neoangiogenesis.6 vegf promotes vascular permeability. it is thus thought to contribute to growth of tumor and tumor metastasis.7 although cytokine-based gastric mucosal immune response and expression vegf to h. pylori infection have been documented very well, only few data on circulating levels of particular inflammatory cytokines and vegf are available. in the present study we aimed to investigate whether we can show increased circulating tnf-α, il-8, and vegf levels in h. pylori-infected patients with gastritis without systemic diseases and their association with with the degree of histopathology. methods patient selection the present study was a cross sectional study on eighty consecutive gastritis patients admitted to endoscopy units at the adam malik general hospital and permata bunda hospital, medan, indonesia from july-december 2014. inclusion criteria included all adult patients with gastritis. all patients gave informed consent and the study was approved by the local ethics committee. none of the patients had received antibiotics, bismuth compounds, h2 antagonists, proton pump inhibitors or immune modulating drugs within the last four weeks before endoscopy. patients with evidence of malignancy, immunosuppression, metabolic disorders, or gastrointestinal hemorrhage and patients who had a history of gastric surgery were excluded. histological assessment of gastritis the histopathological degree of gastritis was evaluated from biopsies of the mucosa of gastric antrum and body. biopsy specimens were fixed in 10% formalin and embedded in paraffin. the samples were stained using hematoxylineosin and were evaluated by the pathologist of anatomic pathology of the medical faculty of the university of sumatra utara referring to visual analogue scale of the updated sydney system. the higher degree was used if differences of degree were found between the body and antrum. the degree of chronic inflammation, neutrophil gontar a. siregar acta med indones-indones j intern med 122 infiltration, atrophy, and intestinal metaplasia were scored 0 to 3, i.e., normal (0), mild (1), moderate (2), and severe (3).8 helicobacter pylori detection the rapid urease test (clo test, kimberlyclark, utah, usa) was used to establish diagnosis of h. pylori infection. the results were read within 24 hours. yellow is considered a negative result. a positive result was reported if the color changed from yellow to red, magenta, pink or deep orange within 24 h of incubation at room temperature.9 serum levels of tnf-α, il-8, vegf venous blood was drawn using a serum separator tube and allowed to clot for 3045 minutes at room temperature before centrifugation for 15 minutes at approximately 1,000 g. serum was immediately stored frozen in aliquots at -20oc until assays for tnf-α, il8, vegf were performed. circulating tnf-α and il-8 levels were measured by means of a high sensitivity elisa that uses an additional amplification step (hs quantikine, r&d systems, inc., minneapolis).10,11 circulating vegf levels were examined in serum using the quantikine human vegf-elisa (quantikine, r&d system, inc., minneapolis). the levels above the mean were categorized as high level and the levels below the mean were categorized as low levels.12 statistical methods spss version 22 (spss inc., chicago) was used for the analysis. the data were analyzed using univariate and bivariate analysis with 95% confidence interval. bivariate analysis was carried out using fisher’s exact test, chi-square test, and mann whitney tests with a significance levels set at p<0.05. results demographics of respondents there were 80 subjects, consisted of 41 males (51.25%) and 39 females (48.75%). mean age was 49.3+13.4 (sd) years old. the highest number of age group was from the age group of 46-60. the majority of subject`s employment status was housewife (36.25%) and self-employed (32.5%). the majority of the subjects had a normal nutrition status (43 subjects, 53.75%). there were 33 patients (41.25%) infected with helicobacter pylori. table 1. characteristics of the subjects variables h. pylori positive h. pylori negative sex males 21 (26.25%) 20 (25%) females 12 (15%) 27 (33.75%) age (years) <30 5 (6.25%) 4 (5%) 30-45 10 (12.5%) 13 (16.25%) 46-60 10 (12.5%) 20 (25%) >60 8 (10%) 10 (12.5%) job self employed 11 (13.75%) 15 (18.75%) employee 5 (6.25%) 7 (8.75%) farmer 3 (3.75%) 3 (3.75%) housewife 9 (11.25%) 20 (25%) other 5 (6.25%) 2 (2.5%) nutritional status normal 16 (20%) 27 (33.75%) underweight and overweight 17 (21.25%) 20 (25%) total 33 (41.25%) 47 (58.75%) s e r u m t n f -α, i l 8 , v e g f l e v e l s i n helicobacter pylori infection tnf-α and vegf levels were significantly higher in infected group compared to h. pylori negative (p<0.05), but there were no significant differences between serum levels of il-8 in h. pylori positive and negative table 2. serum levels of tnfα, il-8, and vegf in hp (+) and hp (-) (mean+sd) serum level (pg/ml) h. pylori p positive negative tnf-α 4.34+3.72 2.76+1.51 0.029* il-8 38.96+25.92 36.01+24.69 0.635 vegf 683.18+428.37 485.26+306.75 0.048* association serum tnf-α, il-8, vegf levels and degree of histopathology of gastritis there was significant association between serum levels of tnf-α and degree of chronic vol 47 • number 2 • april 2015 serum tnfa, il8, vegf levels in h. pylori infection 123 inflammation [unadjusted or (95% ci): 2.750 (1.11-6.83), p=0.027]. there were significant associations between serum levels of il-8 and degree of chronic inflammation [unadjusted or (95% ci): 2.496 (1.01-6.16), p=0.045], and also between serum levels of il-8 and degree of neutrophil infiltration [unadjusted or (95% ci): 2.926 (1.04-8.20), p=0.037]. there were no associations between vegf levels and degree of chronic inflammation and also between vegf levels and degree of neutrophil infiltration. there were significant associations between serum levels of vegf and degree of atrophy [unadjusted or (95% ci): 4.333 (1.27-14.78), p= 0.027], and also between serum levels of vegf and degree of intestinal metaplasia [unadjusted or (95% ci): 4.678 (1.19-18.34), p= 0.037]. there were no associations between serum levels of tnf-α and degree of atrophy and also between serum levels of tnf-α and degree of intestinal metaplasia. there were no associations between serum levels of il-8 and degree of atrophy, and also between serum levels of il-8 and degree of intestinal metaplasia. discussion mean age of gastritis subjects in this study was 49.3+13.4 (sd) years, which is considered a productive age group. in addition, the age groups with most frequent gastritis were those in the age group of 46-60 and 30-45. this result is in accordance with the results from the previous studies such as that by garg b, et al.10, which reported the mean age of gastritis patients of 47 years and the study by mustapha sk, et al.14, which reported a mean age of 47.2 years.13,14 a l l s u b j e c t s e x p e r i e n c e d c h r o n i c inflammation, while neutrophil infiltration, atrophy, and intestinal metaplasia were found in 41.25%, 38.75%, and 27.5%, respectively. there were different results among studies. garg b, et al.10, for instance, reported chronic inflammation 100%, neutrophil infiltration in 33.33%, atrophy in 12.33%, and intestinal metaplasia in 7%,13 while zhang et al.15, reported chronic inflammation in 90.3%, neutrophil infiltration in 56.2%, atrophy in 36.8%, and intestinal metaplasia in 37%.15 another study by hashemi et al.16 found active chronic gastritis in table 3. association serum levels of tnf-α, il-8, vegf and degree of chronic inflammation and neutrophil infiltration cytokines vegf chronic inflammation neutrophil infiltration normal + mild moderate + severe or (95% ci) normal + mild moderate + severe or (95% ci) tnf-α high 14 (17.5%) 28 (35%) 2.75 (1.11-6.83) 29 (36.25%) 13 (16.25%) 1.255 (0.47-3.33) low 22 (27.5%) 16 (20%) 28 (35%) 10 (12.5%) il-8 high 14 (17.5%) 27 (33.75%) 2.496 (1.01-6.16) 25 (31.25%) 16 (20%) 2.926 (1.04-8.20) low 22 (27.5%) 17 (21.25%) 32 (40%) 7 (8.75%) vegf high 17 (21.25%) 23 (28.75%) 1.224 (0.51-2.96) 27 (33.75%) 13 (16.25%) 1.444 (0.55-3.83) low 19 (23.75%) 21 (26.25%) 30 (37.5%) 10 (12.5%) table 4. association serum levels of tnf-α, il-8, vegf and degree of atrophy and intestinal metaplasia cytokines vegf atrophy intestinal metaplasia normal + mild moderate + severe or (95% ci) normal + mild moderate + severe or (95% ci) tnf-α high 31 (38.75%) 11 (13.75%) 1.892 (0.62-5.75) 33 (41.25%) 9 (11.25%) 1.80 (0.55-5.95) low 32 (40%) 6 (7.5%) 33 (41.25%) 5 (6.25%) il-8 high 30 (37.5%) 11 (13.75%) 2.017 (0.66-6.12) 33 (41.25%) 8 (10%) 1.333 (0.42-4.27) low 33 (41.25%) 6 (7.5%) 33 (41.25%) 6 (7.5%) vegf high 27 (33.75%) 13 (16.25%) 4.333 (1.27-14.78) 29 (36.25%) 11 (13.75%) 4.678 (1.19-18.34) low 36 (45%) 4 (5%) 37 (46.25%) 3 (3.75%) gontar a. siregar acta med indones-indones j intern med 124 47.1%, atrophic changes in 25%, and intestinal metaplasia in 8.9%.16 the purpose of the present study was to assess the serum levels of tnf-α, il-8 as proinflammatory cytokines, and the vegf as a marker of angiogenesis in h. pylori infection, and their association with degree of histopathology of gastritis. at present there are few data on circulating levels of inflammatory cytokines in h. pylori and the results have been contradictory. in the present study, we studied the levels of circulatory cytokines, which may theoretically increase as a consequence of intense gastric mucosal cytokine activation. this study found that serum tnf-α levels in the infected group were significantly higher compared to h. pylori negative group (p<0.05). this result is in accordance with the results from the previous studies such as that by russo et al.17 and perri et al.18 which reported that h. pylori infection was associated with increased serum levels of tnf-α. our findings suggest that a strong immune response to h. pylori enhanced the systemic inflammation, which was reflected in an increased serum levels of tnf-α. several investigators have detected il-8 as an important mediator in h. pylori-associated gastritis as the most likely substance responsible for inducing further steps of the signal transducing pathway because it is up-regulated in epithelial cells infected with h. pylori.19,20 lindholm et al.21 found increased levels of mucosal il-8 in the h. pylori-infected subjects whereas cichoz-lach et al.22 found that mean levels of il-8 in patients with biliary gastritis was higher than the control group, and was found to be more increased in h. pylori infected patients than in uninfected ones.22 this study found that serum levels of il-8 were higher in h. pylori associated gastritis, but not significant compared to h.pylori negative. kim et al.23 showed that h. pylori strains that express caga were found to upregulate epithelial il-8 secretion and gene expression, a direct caga effect on il-8 induction by gastric epithelial cells.23,24 probably our limitations in this study was that we did not determine the caga status of our patients so we possibly had patients infected with less pathogenic strains of this bacterium such as with cag a-negative h. pylori. this might be a reason that there were no significant differences between serum levels of il-8 in h. pylori positive and negative. high serum levels of tnf-α were associated with severe degree of chronic inflammation, but not with the degree of neutrophil infiltration, atrophy, and intestinal metaplasia. high serum levels of il-8 were associated with severe degree of chronic inflammation and neutrophil infiltration, because of its potent chemotactic and stimulatory activity on neutrophils and lymphocytes. this study also found that serum vegf levels in the infected group were significantly higher compared to h. pylori negative (p<0.05). previous investigations suggested that h. pylori can activate host angiogenesis.3 mangia et al.25 and caputo et al.26 reported that h. pylori was able to upregulate vegf expression in gastric mucosa cells. tucillo et al.27 reported that h. pylori up-regulates the expression of vegf in human gastric epithelial cells in vitro and that this is apparently mediated through an egfr-, cox-2-related pathway. through the increased production of prostaglandins, this leads to further activation of egfr, and to the increased expression of angiogenetic vegf. all these events may ultimately be pivotal in the progression from chronic gastritis to adenocarcinoma in the multistep model of gastric carcinogenesis.27 atrophic gastritis and intestinal metaplasia are known to be premalignant gastric lesions, and patients with premalignant gastric lesions are at considerable risk of gastric cancer.28 feng et al.29 found that vegf expression was elevated in chronic atrophic gastritis as well as in metaplastic areas before the onset of gastric cancer and the detection of high levels of serum vegf in gastric premalignant lesions such as atrophic gastritis and intestinal metaplasia, suggesting that vegf may also contribute early in the process of gastric carcinogenesis. we did not find association between vegf levels and the degree of chronic inflammation or neutrophil infiltration. in this study, we found that high serum levels of vegf were associated with severe degree of atrophy and intestinal metaplasia. vol 47 • number 2 • april 2015 serum tnfa, il8, vegf levels in h. pylori infection 125 conclusion serum tnf-α and vegf levels were significantly increased in the infected h. pylori group, but there were no significant differences between serum levels of il-8 in h. pylori positive and negative group. high levels of tnf-α were associated with severe degree of chronic inflammation, high levels of il-8 were associated with severe degree of chronic inflammation and neutrophil infiltration, and high levels of vegf were associated with severe degree of premalignant gastric lesion. acknowledgments we would like to express our gratitude to prodia education and research institute for assistance in tnf-α, il-8, and vegf testing, to lidya imelda laksmi who has conducted the histopathological analysis in this study, as well as to khairani and sulasmi who have assisted the endoscopy procedure in all patients. the present study was a self-funded study. references 1. mccoll ke. clinical practice. helicobacter pylori infection. n engl j med. 2010;362:1597-604. 2. yeniova ao, kucukazman m, ata n, et al. investigation of the association between mean platelet volume and helicobacter pylori gastritis. afr j microbiol res. 2013;7:2179-83. 3. gatti ll, burbano rr, tunes mz, et al. interleukin-6 polymorphisms, helicobacter pylori infection in adult brazilian patients with chronic gastritis and gastric adenocarcinoma. arch med res. 2007;38:551-5. 4. bayraktaroglu t, aras as, aydemir s, et al. serum levels of tumor necrosis factor-a, interleukin-6 and interleukin-8 are not increased in dyspeptic patients with helicobacter pylori-associated gastritis. mediators inflamm. 2004;13:25-8. 5. strowski mz, cramer t, schafer g, et al. helicobacter pylori stimulates host vascular endothelial growth factor-a (vegf-a) gene expression via merk/erkdependent activation of sp1 and sp3. faseb j. 2004;18:218–20. 6. tahara t, arisawa t, shibata t, et al. effect of polymorphisms in the 3’-untranslated region (3’-utr) of vegf gene on gastric premalignant condition. anticancer res. 2009;29:458-90. 7. we i s s m , c h e r e s h d a . p a t h o p h y s i o l o g i c a l consequences of vegf-induced vascular permeability. nature. 2005;437:497-504. 8. rugge m, pennelli g, pilozzi e, et al. gastritis: the histology report. dig liver dis. 2011;43s:s373–84. 9. berry v, sagar v. rapid urease test to diagnose helicobacter pylori infection. jk science. 2006;8:868. 10. garg b, sandhu v, sood n, et al. histopathological analysis of chronic gastritis and correlation of pathological features with each other and with endoscopic findings. pol j pathol. 2012;3:172-8. 11. r&d system inc. quantikine hs human tnf-α immunoassay catalog number hsta00d. minneapolis: r&d system; 2010. p. 2-15. 12. r&d system inc. quantikine hs human il-8 immunoassay catalog number hs800. minneapolis: r&d system; 2012:. p. 1-9. 13. r&d system inc. quantikine elisa human vegf immunoassay catalog number dve00. minneapolis: r&d system; 2014. p. 1-9. 14. mustapha sk, bolori mt, ajayi n, et al. endoscopic findings and the frequency of helicobacter pylori among dyspeptic patients in north-eastern nigeria. internet j gastroenterol. 2006; 6(1). http://www.ispub. com (accessed 10 may 2014) 15. zhang c, yamada n, wu y, et al. helicobacter pylori infection, glandular atrophy and intestinal metaplasia in superficial gastritis, gastric erosion, erosive gastritis, gastric ulcer and early gastric cancer. world j gastroenterol. 2005;11:791-6. 16. hashemi mr, rahnavardi m, bikdeli b, et al. h. pylori infection among 1000 southern iranian dyspeptic patients. world j gastroenterol. 2006;12:5479-82. 17. russo f, jirillo e, clemente c, et al. circulating cytokines and gastrin levels in asymptomatic subjects infected by helicobacter pylori. immunopharmacol immunotoxicol. 2001;23:13-24. 18. perri f, clemente r, festa v, et al. serum tumour necrosis factor-alpha is increased in patients with helicobacter pylori infection and caga antibodies. ital j gastroenterol hepatol. 1999;31:290-4. 19. kusters jg, van vliet ah, kuipers ej. pathogenesis of helicobacter pylori infection. clin microbiol rev. 2006;19:449-90. 20. banerjee a, mukhopadhyay ak, paul s, et al. unveiling the intricacies of helicobacter pyloriinduced gastric inflammation: t helper cells and matrix metalloproteinases at a crossroad. in: mozsik g, editor. current topics in gastritis. croatia: intech publishers; 2013. p. 7. 21. lindholm c, quiding-jarbrink m, lonroth h, et al. local cytokine response in helicobacter pyloriinfected subjects. infect immun. 1998;66:5964-71. 22. cichoz-lach h, słomka m, celiński k, et al. level of serum cytokines in biliary gastritis and erosive gastritis with helicobacter pylori coinfection. ann univ mariae curie sklodowska med. 2001;56:271-4. 23. kim sy, lee yc, kim hk, et al. helicobacter pylori caga transfection of gastric epithelial cells induces interleukin-8. cell microbiol. 2006;8(1):97-106. gontar a. siregar acta med indones-indones j intern med 126 24. meine gc, rota c, dietz j, et al. relationship between caga-positive helicobacter pylori infection and risk of gastric cancer: a case control study in porto alegre, rs, brazil. arq gastroenterol. 2011;48:41-5. 25. mangia a, chiriatti a, ranieri g, et al. h. pylori status and angiogenesis factors in human gastric carcinoma. world j gastroenterol. 2006;12:5465-72. 26. caputo r, tuccillo c, manzo ba, et al. helicobacter pylori vaca toxin up-regulates vascular endothelial growth factor expression in mkn 28 gastric cells through an epidermal growth factor receptor-, cyclooxygenase-2-dependent mechanism. clin cancer res. 2003;9:2015-21. 27. tuccillo c, cuomo a, rocco a, et al. vascular endothelial growth factor and neo-angiogenesis in h. pylori gastritis in humans. j pathol. 2005;207:277–84. 28. de vries ac, van grieken nc, looman cw, et al. gastric cancer risk in patients with premalignant gastric lesions: a nationwide cohort study in the netherlands. gastroenterol. 2008;134:945-52. 29. feng cw, wang ld, jiao lh, et al. expression of p53, inducible nitric oxide synthase and vascular endothelial growth factor in gastric precancerous and cancerous lesions: correlation with clinical features. bmc cancer. 2002;2:8. 38 original article acta medica indonesiana the indonesian journal of internal medicine an observational study to evaluate the safety and efficacy of telbivudine in adults with chronic hepatitis b ali sulaiman1, laurentius a. lesmana1,2, nafrialdi3, helyanna4 1 department of internal medicine, faculty of medicine universitas indonesia, jakarta, indonesia. 2 digestive disease centre, medistra hospital, jakarta, indonesia. 3 clinical study unit, faculty of medicine, universitas indonesia, jakarta, indonesia. 4 pt. novartis indonesia, jakarta, indonesia. correspondence mail: prof. ali sulaiman, md, phd. division of hepatology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. salemba raya 4, jakarta 10430, indonesia. email: dr.ali.sulaiman@gmail.com. abstrak tujuan: untuk menilai keamanan dan efektifitas terapi telbivudine pada pasien dewasa dengan chb di indonesia. metode: desain penelitian adalah kohort prospektif. penelitian multisenter pada pasien chb dewasa yang memerlukan terapi antiviral oral dalam praktik klinis sehari-hari. seluruh pasien menerima 600 mg telbivudine setiap hari selama satu tahun. rekrutmen dan keputusan untuk memulai terapi telbivudine didasarkan pada indikasi klinis yang dinilai oleh dokter yang berpartisipasi. diutamakan adalah keselamatan pasien (adverse event atau efek samping yang serius), sedangkan titik akhir sekunder adalah serokonversi hbeag, perubahan serum tingkat dna hbv dan serum alt normalisasi. pasien dinilai pada minggu ke-24 dan ke-52 setelah terapi. hasil: sebanyak 176 kasus yang memenuhi kriteria untuk dianalisis, 104 (59,8%) hbeag-positif dan 70 (40,2%) pasien hbeag-negatif. efek samping yang dilaporkan pada 7 (4,0%) pasien, kebanyakan dari mereka adalah ringan. hilangnya hbeag dan tingkat serokonversi sebesar 28,8% dan 14,14%, masing-masing pada minggu ke-52. tidak terdeteksi hbv dna (pcr negatif) 51,8% pada minggu ke-24 dan 62,7% pada minggu ke-52. median tingkat hbv dna secara signifikan berkurang dari awal sampai minggu ke-24 dan minggu ke-52 setelah terapi (p<0,001, uji wilcoxon signed-rank). normalisasi aktivitas alt serum terjadi pada 85 (73,28%) pasien pada minggu ke-52. kesimpulan: terapi telbivudine umumnya aman dan dapat ditoleransi dengan baik pada pasien indonesia dewasa dengan hepatitis b kronis. pada pengobatan hilangnya hbeag serokonversi, perubahan tingkat hbv dna, dan normalisasi alt serum ditemukan hasil yang sama dengan studi sebelumnya. kata kunci: alanine aminotransferase, hepatitis b kronis, hbv dna, pengobatan antivirus oral, terapi telbivudine. abstract aim: to assess the safety and efficacy of telbivudine therapy in adult patients with chb in indonesia. methods: the study design was prospective cohort study. multicenter study of adult chb patients requiring oral antiviral therapy in daily practice setting. all patients received 600 mg of telbivudine daily for one year. recruitment and decision to start telbivudine therapy was based on clinical indication as assessed by the participating physicians. the primary end-point was patient safety (adverse event or serious adverse events); while the secondary endpoints were hbeag seroconversion, changes of serum hbv dna levels and serum alt normalization. patients were assessed at week-24 and week-52 of treatment. results: a total of 176 cases were eligible for analysis, comprising 104 (59.8%) hbeag-positive and 70 (40.2%) hbeag-negative patients. adverse events were reported vol 46 • number 1 • january 2014 an observational study to evaluate the study and efficacy of telbivudine 39 in 7 (4.0%) patients, most of them were mild. hbeag loss and seroconversion rate was 28.8% and 14.14% at week-52 respectively. undetectable hbv dna (pcr negativity) was 51.8% at week-24 and 62.7% at week-52. median hbv dna levels were significantly reduced from baseline to week-24 and week-52 treatment (both p<0.001; wilcoxon’s signed-rank test). normalization of serum alt activity occurred in 85 (73.28%) patients at week-52. conclusion: telbivudine therapy is generally safe and well tolerated among adult indonesian patients with chronic hepatitis b. treatment efficacy in terms of hbeag loss and seroconversion, changes of hbv dna levels and serum alt normalization were similar to previous reported studies. key words: alanine aminotransferase, chronic hepatitis b, hbv dna, oral antiviral treatment, telbivudine therapy. introduction chronic hepatitis b (chb) is still a major public health problem in indonesia. persistence of active hepatitis b virus (hbv) infection is associated with morbidity and mortality in chb due to the progression to cirrhosis or hepatocellular carcinoma.1,2 based on the asia pacific association for the study of the liver (apasl) guidelines,antiviral treatment is indicated for chb patients with serum alanine aminotransferase (alt) activity more than twice the upper limit of normal (>2x uln) and hbv dna levels ≥105in hbeag-positive or ≥104 copies/ml in hbeag-negative patients.3 the long-term goal of chb treatment is to prevent disease progression to cirrhosis, hcc and death caused by hbv replication and liver inflammation.4 unfortunately, complete eradication of hbv infection is impossible due to the persistence of covalently closed circular dna (cccdna) in the hepatocytes nuclei.5,6 therefore, the main aims of treatment are to achieve hbeag seroconversion or undetectable hbv dna levels or both; stop or reduce hepatic necroinflammation; and prevent hepatic decompensation. telbivudine demonstrated potent activity against hepatitis b with a significantly higher rate of response and superior viral suppression compared with lamivudine, the standard treatment.7,8 telbivudine has been introduced in indonesia since 2006 but has not been studied in indonesian population. this study design is aligned with the roadmap concept to optimize therapy in chb patients.9 central to this concept is the use of on-treatment monitoring strategies of early virologic responses which may be predictive of improved outcomes, including reduced risk of anti-viral resistance. this study is primarily designed to assess the safety and efficacy of telbivudine therapy in adult patients with compensated chb in indonesia. methods this was an observational, prospective cohort, multicenter study of chb patients treated with telbivudine.and was funded by novartis pharma. study was conducted on 184 patients from 191 physicians in 7 cities in indonesia from april 2009 to november 2011. inclusion criteria were male or female adult patients, aged more than 18 years, diagnosed with chb by positive hbsag for at least 6 months, had hbeag-positive or -negative, had a clinical history compatible with chb, and no prior history of chb treatment. patients were excluded if there was a known hypersensitivity to telbivudine or any of its ingredients, was pregnant or intended to become pregnant or planned to breastfeed during the study period, or had any clinically significant concurrent severe or unstable medical conditions. ethical approval was obtained from the ethical committee of medical research, faculty of medicine, university of indonesia. data collection data were collected and recorded in a written case report form (crf) specifically designed for this study. assessments and evaluations were performed according to the physician’s routine practice and standard care. data included patient demographics, background characteristics, details of the hepatitis b related medical history, ali sulaiman acta med indones-indones j intern med 40 concomitant diseases, vital signs, laboratory values, adverse events, compliance, and a final physicians assessment of the therapy with regard to effectiveness, safety, and tolerability. clinical and laboratory assessment patients were expected to complete a followup period of 52 weeks, including treatment response evaluation at week-24 and week-52. assessment included safety profile, including the number and type of adverse events (aes) or serious aes; virological response (hbeag loss and seroconversion; serum hbv dna level changes; pcr negativity (<300 copies/ ml or 60 iu/ml); and normalization of serum alt enzyme activity (<1x uln). statistical analysis data from the crf were entered into an electronic database in the clinical study unit, faculty of medicine, university of indonesia. patients’ demographic and baseline data were presented descriptively as percentage for categorical data or mean and standard deviation (sd) for numerical data. due to well-recognized clinical differences of hbeag-positive and hbeag-negative chb patients,10,11 analyses were done separately for both groups. adverse and serious adverse event data were presented and analyzed descriptively. hbeag loss, hbeag seroconversion, pcr negativity, and serum alt normalization were also presented and analyzed descriptively. median serum hbv dna changes were analyzed using the wilcoxon’s signed-rank test for skewed data. a p value less than 0.05 was considered significant. statistical analysis was done using spss version 17.0 for windows pc (spss inc., chicago, illinois). results characteristics of the study subjects two hundred and twenty three patients were recruited for this study; 39 patients did not return after baseline visit, resulting with 184 patients to be evaluated for safety analyses. eight patients had undetected hbv-dna levels at baseline and were excluded (figure 1). the final number of patients available for efficacy analyses was 176 patients, comprising 106 (60.2%) men and 70 (39.8%) women. patients mean age was 41.5 years, ranging from 18-70 years old; the basic characteristic of the 176 patients are shown in table 1. safety analysis the adverse events were reported in 7 (3.8%) patients, most of them were mild. adverse events were abdominal discomfort (2), neuropathy (1), common cold (1), nausea (1), myotoxicity (1), death (1), and pregnancy (1). the latter was reported by a patient who had a musculoskeletal problem, i.e. spondyloarthritis, and was not related to telbivudine therapy. telbivudine treatment was discontinued in one patient because of unexpected pregnancy. later she gave birth to a healthy baby boy. efficacy analysis evaluation of treatment response was done at week-24 and week-52 for all patients receiving treatment. among hbeag-positive patients, 9.18% patients achieved hbeag loss at week 24 and 23.23% at week 52; while seroconversion was detected in 5.10% at week-24 and 14.14% at week-52 (figure 2). seventy-two out of 139 patients (51.8%) had undetectable hbv dna levels (pcr 223 subjects enrolled: jakarta: 120 subjects surabaya: 28 subjects bandung: 22 subjects medan: 21 subjects banjarmasin: 18 subjects makassar: 10 subjects surakarta: 4 subjects 39 subjects did not return after baseline visit 184 subjects included in the safety analysis 8 subjects had undetected hbv-dna levels at baseline 176 subjects included in the efficacy analysis figure 1. flow of subjects throughout the study vol 46 • number 1 • january 2014 an observational study to evaluate the study and efficacy of telbivudine 41 negativity) after 24 weeks of treatment and increased to 62.5% after 52 weeks of treatment. pcr negativity was more profound in hbeag negative-patients (table 2). in both hbeag positive and negative patients, there was a significant reduction of median hbv dna level from baseline at week-24 and week-52 of treatment (table 2). there were 170 patients provided with serum alt level at week-52. normalization of serum alt activity occurred in 73.28% patients (table 2). discussion our study is the largest prospective, observational study of chb patients receiving telbivudine done in indonesia. more male patients participated in this study, which was also reported in many clinical trials,12-14 including globe trial.15 for the global prevalence of hbv infection between male and female is almost similar, 3.9% in men and 3.5% in women. however, the prevalence is higher in southeast asia (5% to over 6%).16 hbeag-negative patients were older than hbeag-positive patients which was consistent with the natural history ofchronic hbv infection.17 from our study, telbivudine therapy was generally safe and well tolerated, which was similar to globe studies. adverse events were reported in 7/184 (3.8%) patients, most of them were mild. types of adverse events were abdominal discomfort (2), neuropathy (1), common cold (1), nausea (1), myotoxicity (1), death (1), and pregnancy (1). since the aes were reported by patients during each visit, and occurred shortly before visit, they were estimated unlikely to be related to telbivudine. table 1. baseline characteristics of the study subjects (n=176) characteristic all patients* (n=176) hbeag (+) (n=104) hbeag (-) (n=70) gender, n (%) male 106 (60.2) 61 (58.7) 43 (61.4) female 70 (39.8) 43 (41.3) 27 (38.6) age, mean (sd) 41.5 (12.37) 37.9 (12.11) 46.8 (11.01) <40 years, n (%) 79 (44.9) 61 (58.7) 17 (24.3) >40 years, n (%) 93 (52.8) 41 (39.4) 51 (72.9) ast level (u/l), mean (sd) 99.8 (159.06) 90.0 (126.68) 115.6 (197.97) alt level (u/l), mean (sd)** 114.9 (169.58) 119.1 (192.71) 110.4 (133.66) <2x uln, n (%) 108 (61.4) 61 (58.7) 45 (64.3) 2-5x uln, n (%) 41 (23.3) 28 (26.9) 13 (18.6) >5x uln, n (%) 23 (13.1) 11 (10.6) 12 (7.1) albumin (g/dl), mean (sd) 4.2 (0.61) 4.2 (0.58) 4.1 (0.64) bilirubin (mg/dl), mean (sd) 1.4 (1.77) 1.2 (1.68) 1.7 (1.86) hbv dna (copies/ml) median 7.45 x 105 9.5 x 105 8.2 x 104 range 107 2.6 x 109 107 x 104-2.6 x109 462 6.9 x 108 * 2 patients have missing hbeag data, thus total patients is 176 while hbeag(+) plus hbeag (-) is 174. ** normal limit was 50 u/l for men and 34 u/l for women 9.18% 5.1% 23.23% 14.14% hbeag loss hbeag ser oconv er sion week-24 week-52 figure 2. hbeag loss and seroconversion after treatment ali sulaiman acta med indones-indones j intern med 42 for myotoxicity, the patient had specific musculoskeletal abnormality in the form of spondyloarthritis which probably caused this ae. this abnormality could lead to instability and fall. thus, the presence of myotoxicity in this case as well as its relationship with telbivudine is questionable. other studies have shown the incidence of myopathy, characterized by myalgia and increase in creatine kinase levels, was from 1.1 1.7% with telbivudine.18 creatine kinase levels were not part of the routine assessment in chb management in normal daily practice; therefore, assessment of this particular side effect was not done in our study population. regarding its efficacy, our study showed similar benefit with previous studies (globe and 2303 study). at week-52, hbeag loss was found in 23.23% of the patient population while seroconversion was found in 14.14% of the patient population. this result is similar to what was shown in the 52 week globe trial results (25.7% hbeag loss and 22.5% seroconversion), respectively.15 from these results, it can be concluded that telbivudine therapy is efficacious for chb treatment in the indonesian population.19 undetectable serum hbv dna levels by pcr at week-24 were similar with the results table 2. treatment response at week-24 and week-52 (n=176) treatment endpoint hbeag-positive (n=102) hbeag-negative (n=70) week 24 week 52 week 24 week 52 hbv dna levels (copies/ml) median 1.23 x 103 150 undetected undetected range undetected-1.1x108 undetected-1.1x108 undetected-3.8x104 undetected-1.1x108 p from baseline* <0.001 <0.001 <0.001 <0.001 hbv dna status by pcr positive 56 (71.8%) 50 (56.2%) 10 (16.9%) 6 (9.8%) undetected 22 (28.2%) 39 (43.8%) 49 (83.1%) 55 (90.2%) total 78 (100.0%) 89 (100%) 59 (100%) 61 (100%) p between visit 3 & 4 0.000 0.000 serum alt status above uln 34 (34.7%) 26 (26.3%) 14 (20.3%) 10 (14.5%) <1x uln 64 (65.3%) 73 (73.7%) 55 (79.7%) 59 (85.5%) total 98 (100%) 99 (100%) 69 (100%) 69 (100%) p between visit 3 & 4 0.000 0.000 *wilcoxon’s signed-rank test from the globe trial, i.e. 45% in hbeagpositive and 80% in hbeag-negative patients. however, at week-52, our results were lower than the globe trial which had pcr negativity of 60% in hbeag-positive and 88.3% in hbeagnegative patients.15 early hbv dna suppression during chb treatment is important to predict long-term outcomes. a recent study of telbivudine in 117 treatment-naïve chb patients (61.5% hbeagpositive) showed that serum hbv dna <200 iu/ ml at week 12 was predictive of favorable long-term outcomes, increase cumulative rates of hbeag seroconversion, alt normalization, and hbv dna undetectability.18 in our study, 73.28% of patients who came for the last follow-up visit at week-52 showed normalization of serum alt levels. in globe trial, the rates of normalization of serum alt at week-52 were reported more than 70% in patients treated with telbivudine.15 after two-years, alt normalization occurred in more than 80% of patients.19 higher serum alt levels at baseline could predict a higher rate of hbeag seroconversion with long-term telbivudine therapy. hbeag seroconversion was reported as high as 17.8% in patients with serum alt <2x uln, 32.3% in vol 46 • number 1 • january 2014 an observational study to evaluate the study and efficacy of telbivudine 43 patients with serum alt 2-5x uln, and 46.3% in patients with serum >5x uln respectively.20 conclusion telbivudine therapy is generally safe and well tolerated among adult indonesian patients with chronic hepatitis b. telbivudine is effective to produce hbeag loss, seroconversion, suppress hbv dna and normalization of serum alt levels. in terms of efficacy measures, results from this study are comparable with results from the globe trial. references 1. chu cm, liaw yf. hepatitis b virus-related cirrhosis: natural history and treatment. semin liver dis. 2006;26:142-52. 2. fattovich g, bortolotti f, donato f. natural history of chronic 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week 24. j hepatol. 2007;46(s1):s516. 9. keeffe eb, zeuzem s, koff rs, et al. report of an international workshop: roadmap for management of patientsreceiving oral therapy for chronic hepatitis b. clin gastroenterol hepatol. 2007;5:890-7. 10. lai cl, lim sg, brown na, et al. a dose-finding study of once-daily oral telbivudine in hbeag-positive patients with chronic hepatitis b virus infection. hepatol. 2004;40:719-26. 11. hadziyannis sj, papatheodoridis gv. hepatitis b e antigen-negative chronic hepatitis b: natural history and treatment. semin liver dis. 2006;26:130-41. 12. lai cl, chien rn, leung nwy, et al. a one-year trial of lamivudine for chronic hepatitis b. asia hepatitis b lamivudine study group. n engl j med. 1998;339:618. 13. chang tt, gish rg, de man r, et al. a comparison of entecavir and lamivudine for hbeag-positive chronic hepatitis b. n engl j med. 2006;354:1001-10. 14. marcellin p, heathcote j, buti m, gade e, de man ra, krastev z, et al. tenovofir disoproxil fumarate versus adefovir dipivoxil for chronic hepatitis b. n engl j med. 2008;359:2442-55. 15. lai cl, gane e, liaw yf, et al for the globe study group. telbivudine versus lamivudine in patients with chronic hepatitis b. n engl j med. 2007;357:2576-88. 16. ott jj, stevens ga, groeger j, wiersma st. global epidemiology of hepatitis b virus infection: new estimates of age-specific hbsag seroprevalence and endemicity. vaccine. 2012;30:2212-9. 17. lesmana la, leung nwy, mahachai v, et al. hepatitis b: overview of the burden of disease in the asia-pacific region. liver int. 2006;26:3-10. 18. seto wk, lai cl, fung j, et al. significance of hbv dna elvels at 12 weeks of telbivudine treatment and the 3 years treatment outcome. j hepatol. 2011;55:5228. 19. utama a, purwantono s, siburian md, et al. hepatitis b virus subgenotypes and basal core promoter mutations in indonesia. world j gastroenterol. 2009;15(32):4028-36. 20. zeuzem s, gane e, liaw yf, et al. baseline characteristics and early on-treatment response predict the outcomes of 2 years of telbivudine treatment of chronic hepatitis b. j hepatol. 2009;51:11-20. 226 original article acta medica indonesiana the indonesian journal of internal medicine the role of a novel digital microcapillary instrument in detecting blood and plasma hyperviscosity al rasyid1, jusuf misbach1, jan s. purba1, ina s. timan2, lugyanti sukrisman3, muchtaruddin mansyur4, efta yudiarsah5, suroto6 1 department of neurology, faculty of medicine, universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of clinical pathology, faculty of medicine, universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 3 department of internal medicine, faculty of medicine, universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 4 department of community medicine, faculty of medicine, universitas indonesia,jakarta, indonesia. 5 department of physics, faculty of medicine, universitas indonesia, jakarta, indonesia. 6 department of neurology, faculty of medicine, universitas sebelas maret, surakarta, indonesia. correspondence mail: department of neurology, faculty of medicine, universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: alrasyid50@yahoo.com, lydiakencana@yahoo.com. abstrak tujuan: menguji presisi dan akurasi mikrokapiler digital dalam mengukur viskositas darah dan plasma. metode: sebanyak 40 sampel darah untuk uji presisi diambil dari pasien medical check-up di rs cipto mangunkusumo (rscm) pada bulan desember 2011. uji akurasi menggunakan desain potong lintang, melibatkan 135 subjek stroke iskemik akut yang diambil baik dari pasien rawat inap maupun pasien poliklinik di departemen neurologi rscm, rs fatmawati jakarta, rs prikasih jakarta, dan rs bhakti yuda depok. baku emas yang digunakan adalah viskometer brookfield lv-dv iii. uji presisi dilakukan dengan menghitung coefficient of variantion (cv), interrater variability crohnbach alpha, dan coefficient reliability bland altman. uji akurasi dilakukan dengan uji diagnostik. baku emas yang digunakan untuk uji tersebut adalah viskometer brookfield lv-dv iii. hasil: hasil uji presisi adalah: cv = 0,04; interrater variability dari viskositas darah dan plasma = 0,94 dan 0,82; mean difference bland altman = –0,19. hasil uji akurasi adalah: sensitivitas untuk pemeriksaan viskositas darah dan plasma = 88,9% dan 100%; spesifisitas untuk pemeriksaan viskositas darah dan plasma = 88,9% dan 84%. kesimpulan: mikrokapiler digital memiliki presisi dan akurasi yang tinggi, karena itu, alat ini dapat dipertimbangkan untuk digunakan sebagai pemeriksaan skrining dalam mengukur viskositas darah dan plasma. kata kunci: viskositas darah, viskositas plasma, stroke. abstract aim: to test the precision and accuracy of a digital microcapillary instrument in measuring blood and plasma viscosity. methods: about 40 blood samples were drawn for precision test. the samples were obtained from patients admitted for medical check-up at ciptomangunkusumo hospital (rscm) in december 2011. accuracy test was evaluated using cross-sectional design and involving 135 patients with acute ischemic stroke. the patients underwent either inpatients or outpatients care at department of clinical pathology, department of neurology,and emergency unit of rscm, fatmawati hospital jakarta, prikasih hospital jakarta, and bhakti yuda hospital depok. the precision test was evaluated by calculating the coefficient of variation (cv), vol 46 • number 3 • july 2014 the role of a novel digital microcapillary instrument in detecting blood 227 interrater variability of cronbach alpha, and reliability coefficient of bland altman. the accuracy of the test was evaluated with a diagnostic test. the gold standard used for these tests was brookfield lv-dv iii viscometer. results: the results of precision test were: cv = 0.04; interrater variability of blood and plasma viscosity = 0.94 and 0.82, respectively; the bland altman mean difference = –0.19. the results of accuracy test were: sensitivity of blood and plasma viscosity measurement were 88.9% and 100%, respectively; specificity of blood and plasma viscosity measurement were 88.9% and 84%, respectively. conclusion: the digital microcapillary has high sensitivity and specificity; therefore the instrument can be considered to be used as screening test tool to measure blood and plasma viscosity. key words: digital microcapillary, blood viscosity, plasma viscosity, acute ischemic stroke. introduction blood viscosity is the resistance of blood to flow caused by friction due to blood movement through the lamina along the axis of blood vessels due to the differences in blood flow speed.1 blood viscosity is a laboratory variable in hemorheology, a field that studies blood flow and its properties, including the nature and cellular components of plasma and their relationship with the circulation. this hemorrheological approach can be used by clinicians (including neurologist, internist, and cardiologist) to understand clinical manifestations associated with vascular condition and blood circulation.2 many studies shows the correlation between blood flow—with blood viscosity as its component—and hemostasis and thrombosis. an increase in blood viscosity is associated with prothrombotic condition.3,4 blood viscosity value varies between individuals, and tends to be higher in populations with risk factors, such as old age, smoking, hypertension, diabetes melitus, ischemic heart disease, and dyslipidemia.3-6 therefore, blood viscosity value can describe other systemic conditions, and is associated with risk factors of many circulatory system diseases as well as metabolic syndromes. blood viscosity value may also play an important role in transient ischemic attack (tia) and ischemic stroke since it is increased in some of these patients (34% and 48%, respectively).7 the pathophysiology of cerebral ischemia is highly associated with blood flow, including the collaterals, the blood vessels, and the blood viscosity. blood hyperviscosity is found in most patients with acute ischemic stroke and it contributes to the severity of outcomes.8 several studies in many countries, including indonesia, have been conducted to assess the role of blood viscosity in acute ischemic stroke patients. meliala9 conducted a case control study of 75 subjects aged 35 years or older, diagnosed with ischemic stroke, and had their first attack. in this study, they found that blood hyperviscosity contributed as a risk factor of stroke. using the adjusted odds ratio (or) and multivariate analysis, the relationship between hyperviscosity and acute stroke was found to be statistically significant (p<0.02, or=2.32, 95%; confidence interval=1.07–5.11; p<0.001). rasyid10 in his study of 160 acute ischemic stroke subjects with up to 3 days onset reported that 65 subjects (40.6%) were found to have blood hyperviscosity. szaparyl11 studied 297 ischemic stroke subjects, and found that there were increase in hematocrit, fibrinogen, erythrocyte aggregation level, and blood viscosity. ott12 in his study stated that blood viscosity was increased in more than 40% subjects with acute ischemic stroke in 24 hours. blood viscosity represents vascular and circulatory conditions, and also plays a major role in ischemic stroke. therefore, assessment of this value is very important especially in patients with risk factors, and measurement in acute settings is crucial for stroke patients as it determines the treatment. to date, the assessment can only be done in large laboratory setting and the results cannot be obtained instantly. we have designed a simple and portable instrument to measure blood and plasma viscosity that produces immediate results. the instrument, digital microcapillary (dm), was analyzed to determine its precision and accuracy in its application for healthy patients, patients with risk factors, as well as acute ischemic stroke patients by comparing the values measured with dm to those of conventional instrument. al rasyid acta med indones-indones j intern med 228 methods the principle of viscosity measurements the principles of viscosity measurements in dm was adapted from microcapillary principles. when the blood or plasma is touched by the tip of microcapillary, it is forced by capillary suction force and flows through the tube. the blood or plasma along the tube will pass through two sensors. the first sensor will turn on the counter; while the second provides signal to the counter to stop counting. the blood or plasma passing time will be recorded and converted to blood or plasma viscosity (figure 1). leukocytes, and platelets laboratory tests (3 ml). to obtain plasma, the blood sample was centrifuged at 300 rpm speed for 20 minutes. the plasma was subsequently mixed with eosin (0.1 ml eosin for 0.5 ml plasma). subjects t h i s s t u d y w a s b a s e d o n l a b o r a t o r y examination to test the precision and accuracy of dm. the precision value was obtained by calculating the coefficient of variation (cv), interrater variability of cronbach alpha, reliability coefficient of bland altman. the number of samples was calculated using wang’s equation.13 the precision test used 40 blood samples withdrawn from patients aged 17 – 60 years old who were admitted in department of clinical pathology, cipto mangunkusumo hospital (rscm) for medical check-up in december 2011. for the precision test, we excluded patients with fever and abnormal laboratory tests (hemoglobin, leukocytes, platelets, erythrocytes, and total cholesterol). an additional test was performed to assess the effects of temperature on blood and plasma viscosity. the temperature in this study represented the tropical climate, i.e. 26 0c, 32 0c, and 37 0c. for this study, 20 samples were used. the accuracy was assessed using repeated cross-sectional study design. blood and plasma viscosity values measured by dm was compared with the values measured by the gold standard. we used brookfield lv-dviii as the gold standard for this test. with such design, the sensitivity, specificity, likelihood ratio, and predictive value of dm could be obtained. as many as 135 accuracy test samples were obtained from patients who underwent either inpatients or outpatients care, aged 35 – 74 years old, were diagnosed with acute ischemic stroke with up to 3 days onset, and were admitted in department of neurology in rscm, fatmawati hospital jakarta, prikasih hospital jakarta, and bhakti yuda hospital depok since march 2013 until the number of samples was considered adequate. the samples excluded in accuracy test were patients with transient ischemic attack history and patients with disorders affecting blood and plasma viscosity (anemia, policytemia, dengue descriptions a1 : diode laser 1 a2 : diode laser 2 b1 : photo diode sensor 1 b2 : photo diode sensor 2 c : active timer signal d : stop timer signal e : microcapillary tube e1 : sensor 1 detection zone e2 : sensor 2 detection zone f : power source figure 1. digital microcapillary. (source: rasyid a. modifikasi mikrokapiler digital untuk mengukur nilai viskositas darah dan viskositas plasma. kementrian hukum dan hak asasi manusia r.i. direktorat jenderal hak kekayaan intelektual direktorat paten p00201300222,mar.2013) procedure the instruments used in this study included 3 ml k3edta vacuum tubes, 2 ml tubes filled with anticoagulant, alcohol pad, plaster, blood tube shelves, and a digital microcapillary instrument.the venous blood sample was collected and put into a tube containing anticoagulant ethylene potassium ethylene diamina tetra acetic acid (k3edta) with the total volume of 5 ml (3 ml sample and 2 ml k3edta). the sample was then used for blood and plasma viscosity measurements (2 ml) and hemoglobin, hematocrit, erythrocytes, vol 46 • number 3 • july 2014 the role of a novel digital microcapillary instrument in detecting blood 229 hemorrhagic fever with diagnostic criteria of who 1997, trauma with massive bleeding/ first class bleeding classification, and diarrhea with diagnostic criteria of diarrhea without dehydration). at the beginning of the study, written informed consents were obtained. our study has been approved by ethics committee of faculty of medicine, universitas indonesia, jakarta. the data were analyzed using statistical product and service solution (spss) version 17 software. results precision test cv was calculated by measuring the microcapillary passage time of two different samples: red-stained samples and blood samples. (table 1) plasma viscosity value as the samples were redstained by eosin. (figure 2) modification of viscosity measured by digital microcapillary in accordance to temperature changes the effect of temperature on blood and plasma viscosity was assessed by modifying the temperature of an incubator that corresponded to the incubator where dm was used. the temperature tested represented the temperature in tropical climate, which were 26 oc, 32 oc, and 37 oc. the measurement categorized by gender was also done to evaluate the effect of sex differences on blood and plasma viscosity. the results are listed in table 3. from the analysis using general linear model (glm), we found that temperature had effects on blood viscosity (p=0.002) and plasma viscosity (p=0.014) and that sex differences had effect on blood viscosity (p=0.035), which were statistically significant. however, there was no significant effect of sex differences on plasma viscosity (p=0.517). the interaction between table 1. microcapillary passage time red-stained samples blood samples n 10 10 x (seconds) 2.88 5.82 sd 0.12 0.23 cv 0.04 0.04 each of the samples was tested ten times. the measured microcapillary passage time values were subsequently converted into viscosity values. table 1 shows that the test has a high precision, in accordance to the narrow cv (0.04). to convert the blood and plasma viscosity values measured by dm to the gold standard unit (poise), we used correlation test between dm and the gold standard. linear regression was used to work out the prediction (y) formula as listed in table 2. according to table 2, we concluded the formula as follows: for blood viscosity, y = 0.846x + 0.614; for plasma viscosity, y = 1.072x + (-0.160). these formulas were used to calculate the interrater variability of cronbach alpha, with the results of 0.94 and 0.82, respectively. the calculation of reliability coefficient of bland altman was used not only to measure the precision, but also to assess the stability of table 2. prediction formula of blood and plasma viscosity model standardized coefficient unstandardized coefficient p b std. error beta t plasma constant -0.160 0.063 -2.542 0.020 test 1.072 0.031 0.993 34.629 0.000 blood constant 0.614 0.429 1.431 0.170 test 0.846 0.099 0.896 8.554 0,000 figure 2. reliability coefficient of bland altman test result. the mean difference of bland altman was -0.19. al rasyid acta med indones-indones j intern med 230 temperature and sex differences did not have significant effect on blood and plasma viscosity, with p value 0.297 and 0.982, respectively. there was no significant difference of blood viscosity between 26 °c and 32 °c (p=0.061), and between 32 °c and 37 °c (p=0.539), but there was a significant difference between 26 °c and 37 °c (p=0.001). as for plasma viscosity, there was no significant difference between 26 °c and 32 °c (p=0.770), and between 26 °c and 37 °c (p=0.201), but there was a significant difference between 32 °c and 37 °c (p=0.012). accuracy test the optimal cut-off value, sensitivity, and specificity were determined by analyzing receiver operator characteristic (roc) curve. figure 3 shows the optimal cut-off value, which is described as follows. the optimal cutoff value of blood viscosity in female was 4.70 (sensitivity=97.3%, specificity=86.7%). the optimal cut-off value of blood viscosity in male was 5.09 (sensitivity=97.1, specificity=89.6%). the optimal cut-off value of plasma viscosity in female was 2.10 (sensitivity=91.4%, specificity=70.6%). the optimal cut-off value of plasma viscosity in male was 2.11 (sensitivity=92%, specificity=90%). the viscosity exceeded these cut-off value is categorized as hyperviscosity. the diagnostic test results for blood viscosity are described as follows: sensitivity was 88.9%, specificity was 88.9%, positive likelihood ratio was 8.01, negative likelihood ratio was 0.12, positive predictive value was 90.1%, negative predictive value was 87.5%, prevalence was 53% and accuracy was 91%. the diagnostic test results for plasma viscosity are: sensitivity was 100%, specificity was 84%, positive likelihood ratio was 6.25, negative likelihood ratio was 0.00, positive predictive value was 91.3%, negative predictive value was 100%, prevalence was 62%, and accuracy was 90%. table 3. blood and plasma viscosity measured by dm in various temperature viscosity male female p value 26°c 32°c 37°c 26°c 32°c 37°c blood, mean±sd (poise) 5.09±0.49 5.01±0.16 4.81±0.12 5.09±0.47 4.67±0.23 4.58±0.36 0.002* plasma, mean±sd (poise) 1.84±0.32 1.74±0.28 1.99±0.16 1.80±0.36 1.71±0.15 1.94±0.12 0.014** *p value of the effect of temperature on blood viscosity. **p value of the effect of temperature on plasma viscosity a b c d figure 3. a: roc curve of blood viscosity in female; b: roc curve of blood viscosity in male; c: roc curve of plasma viscosity in female; d: roc curve of plasma viscosity in male vol 46 • number 3 • july 2014 the role of a novel digital microcapillary instrument in detecting blood 231 discussion the precision of dm was assessed by calculating the cv, interrater variability of cronbach alpha, and reliability coefficient of bland altman. the obtained cv, which was 0.04 (less than 5%), indicated that the precision is good, as a good test is indicated by a narrow range of cv, while the less one is indicated by a wider range of cv.14 the correlation coefficients of blood and plasma viscosity were 0.81 and 0.99, respectively. it demonstrated that the blood and plasma passing time values in dm were almost the same with those in gold standard.15 dm also has high internal validity. gliem16 stated that high cronhbach alpha result shows that the test has a good internal consistency/ precision. the bland altman mean difference, which was -0.19 (close to 0), also indicates that the precision is good and eosin can be used to stain the samples for plasma viscosity measurement. according to the cv, interrater variability of cronbach alpha, and mean difference of bland altman, we conclude that the dm has a high precision in measuring the blood and plasma viscosity.17 additional test was done to show the effects of temperature and sex differences on blood and plasma viscosity, so that in the application of dm, both of these factors could be taken into account. this test shows that the effects of temperature on blood and plasma viscosity were significant, with p value 0.002 and 0.014, respectively. there was an increase of blood viscosity either in male or female subjects from 37 °c to 26 °c. the result of our study is somewhat similar to the study conducted by cinar.18 he observed the effect of temperature on blood viscosity value measured by capillary tube viscometer in 37 healthy subjects. he also found that the increase in viscosity occurred when the temperature was decreased from 37 °c to 25 °c; while reduced viscosity occurred when the temperature was elevated from 37 °c to 39 °c. the effect of sex differences on blood viscosity was statistically significant, which was showed by p value=0.035; however, the effect of sex differences on plasma viscosity was insignificant, with p value=0.517. the result had some impacts in determining the cut-off value of viscosity, which should be different between male and female. the study conducted by li19 in 31 subjects showed that there was a correlation between blood viscosity and sex differences. nemeth20 studied the correlation between erythrocytes aggregation and sex differences in rats, and found that it was statistically significant. in contrast, kesmarky21 in his study stated that plasma viscosity was not affected by sex differences. a study conducted by haliman22 also showed that sex differences had no effect on plasma viscosity. as the temperature significantly affected viscosity, setting one temperature as a standard temperature for dm would be necessary, which in this case, was 37 °c. the temperature was selected as it is the normal temperature of the human body; therefore, we expect that the viscosity measured by dm could represent the real viscosity in vivo. also, in the gold standard we found a temperature controller, which was set to 37 °c.23 subsequently, we put a temperature controller in dm to maintain the standard temperature of 37 °c during the viscosity measurement. the diagnostic test shows that dm had high sensitivity and specificity values for both blood and plasma viscosity measurements. it also indicates that dm has high precision in addition to its high accuracy. conclusion diabetes mellitus is a simple and a novel diagnostic instrument to measure blood and plasma viscosity which has high precision and accuracy. the test also indicates high sensitivity and specificity; therefore the instrument can be considered to be used as screening test tool to measure blood and plasma viscosity. references 1. burton jh, kee db. hemorheology of the cerebral circulation in stroke. stroke. 1985;16:765-72. 2. lowe g. blood viscosity and cardiovascular disease. thromb haemost. 1992:67(5):494-8. 3. uddin mj, mondol ba, ahmed s, ullah aa, jabbar ma, mohammad qd. smoking and ischemic stroke. bangladesh j of neurosci. 2008;24(1):50-4. 4. anonymous. smoking is a risk factor for stroke. available on: http://www.tcmwell.com/tcm diseases/ al rasyid acta med indones-indones j intern med 232 internal medicine/smoking is a risk factor for stroke. 2009. 5. mcdonald km. effect of hematocrit and colloid induced changed in blood viscosity arterial hemodynamics and renin release in the dog. circ res. 1974;34:112-2. 6. le dévéhat c, vimeux m, khodabandehlou t. blood rheology in patients with diabetes mellitus. clin hemorheol microcirc. 2004;30(3-4):297-300. 7. l e c h n e r h , o t t e , g e r t h a g . t h e r a p e u t i c a l aspects of cerebrovascular disease. eur-neurol. 1983;22(suppl.1):74-7. 8. a h m e d h s , h u c j , p a c z y n s k y r , h s u c y. patophysiology of ischemic injury. in: marc fisher, ed. stroke therapy. 2nd ed. london: butterworthheinemann; 2001. p. 25-32. 9. meliala c, nuradyo d, suryatmojo b. hiperviskositas sebagai faktor risiko stroke infark di rsup dr.sardjito fk ugm yogyakarta. tesis. yogyakarta: universitas gadjah mada; 1996. 10. rasyid a, nuradyo d, sutarni s. realibilitas dan validitas mikrokapiler hematokrit pada pemeriksaan viskositas darah penderita stroke iskemik akut dan stroke infark. berkala neuro sains. 2000;1(2):97-102. 11. szapary l, horvath b, marton z, et al. hemorheological disturbances in patiens with chronic cerebrovascular diseases. clin hemorheol microcirc. 2004;31(1):1-9. 12. ott e, fazekas f, tschinkel m, bertha g, lechner h. rheological aspect of cerebrovascular disease. eur neurol. 1983;22:35-37. 13. long bg, wang yg. method for comparing the capture efficiency of benthic sampling device. marine biol. 1994;121:397-9. 14. posponegoro hd, wirya iw, pudjiadi ah, bisanto j, zulkarnain sz. uji diagnostik. in: sastroasmoro s, ismael s, ed. dasar-dasar metodologi penelitian klinis. 2rd ed. jakarta: cv sagung seto; 2010. p.193-216. 15. riffenburgh rh. statistics in medicine. 2nd edition. new york: elsevier inc; 2006. p. 478-82. 16. gliem ja, gliem rr. calculating, interpreting, and reporting cronbach’s alpha reliability coefficient for likert-type scales. midwest research to preactice conference in adult, continuing, and community education. 2003. p. 82-8. 17. schoonjans f. med calc for windows: statistics for biomedical research. software manual. belgium; 2007. p. 109-12. 18. c i n a r y, k o s k u n . h y p o t h e s i s : t e m p e r a t u r e stress and blood viscosity affect the leukocyte flexibility, coagulation, intracranial hypertension, and hemodynamics. international conference on life science and technology. ipcbee. singapore: tacsit press; 2011. p. 120-6. 19. li sz, liang jb, fan jx, wu xy, wu wx. blood rheology analysis of 23436 samples and establishment of reference range by sitting and lying position. zhongguo ying yong sheng li xue za zhi. 2008;24(4):488-92. 20. nemeth n, kiss f, furka i, miko i. gender differences of blood rheological parameters in laboratory animals. clin hemorheol microcirc. 2010;45(2-4):263-72. 21. késmárky g, kenyeres p, rábai m, tóth k. plasma viscosity: a forgotten variable. clin hemorheol microcirc. 2008;39(1-4):243-6. 22. haliman mj, setiabudy rd, immanuel s. viskositas darah, plasma dan serum. nilai rujukan serta faktorfaktor yang mempengaruhi. tesis bagian patologi klinik fkui. jakarta: universitas indonesia; 1999. 23. brookfield dv iii ultra. programmable rheometer. manual no. m/98-211-b0104. usa: brookfield engineering laboratories inc. 24 original article acta medica indonesiana the indonesian journal of internal medicine effects of duration of breastfeeding during infancy on vascular dysfunction in adolescents sukman tulus putra1, muchtaruddin mansyur2, sudigdo satroasmoro1 department of pediatrics and child helath, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. correspondence mail: division of cardiology, department of pediatrics and child helath, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: sukmanputra@yahoo.com. abstrak tujuan: mencari hubungan antara lama pemberian asi pada masa bayi dengan karakteristik vaskular sebagai faktor risiko kardiovaskular pada anak remaja. metode: studi retrospektif kohort terhadap remaja berumur 15-18 tahun. lama pemberian asi diperoleh dengan kuesioner terhadap orangtua yang dikategorikan: 0-<2 , 2-<4, 4-<6, 6-,12 dan > 12 bulan. luaran yang dinilai adalah “flow mediated dilation” (fmd), ketebalan tunika intima media (cimt) dan ukuran antropometri. dilakukan analisis statistik menggunakan regresi linear dan manova general linier model dengan faktor risiko kardiovaskular sebagai variabel dependen dan durasi pemberian asi sebagai variabel independen dan dengan koreksi terhadap faktor perancu (confounders). hasil: terdapat 285 subjek penelitian berumur 15-18 tahun. durasi pemberian asi 4-<6 bulan ternyata mempunyai asosiasi dengan ketebalan tunika intima media (cimt) dan lebih menonjol bila disesuaikan dengan jenis kelamin dan terpajan dengan rokok pasca-natal (beda rerata 14,28 mikrometer, p=0,045). tidak ada hubungan bermakna antara durasi pemberian asi dengan flow mediated dilation (fmd). kesimpulan: lama pemberian asi 4-<6bulan berhubungan dengan ketebalan tunika intima media karotis (cimt) sehingga mempunyai efek proteksi terhadap terjadinya penyakit kardiovaskular. namun demikian hubungan durasi pemberian asi dengan fmd pada remaja belum jelas. kata kunci: durasi pemberian asi, fungsi dan struktiur vaskular, risiko kardiovaskular. abstract aim: to investigate the effect of breastfeeding duration on vascular characteristics in adolescence. methods: we conducted a retrospective cohort study on adolescents aged 15-18 years old. breastfeeding duration was inquired using a questionnaire filled by parents and categorized into 0-<2, 2-<4, 4-<6, 6-<12, and >12 months. outcomes assessed were flow mediated dilation (fmd), carotid intima media thickness (cimt), anthropometrics. analysis was done using linear regression and manova general linear model with cardiovascular risk factors as the dependent variables and breastfeeding duration as the independent variable with further adjustment for confounders. results: 285 subjects aged 15-18 years were enrolled. breastfeeding duration of 4-<6 months was associated with thinner cimt and the effect was more prominent after adjustment for gender and postnatal tobacco exposure (mean difference=24.28 micrometer, p=0.045). no statistically significant association was found with fmd. conclusion: breastfeeding duration of 4-<6 months is associated with thinner imt and thus has a protective effect on the development of cardiovascular disease. however the association with fmd in adolescence is less clear. key words: breastfeeding duration, vascular structure and function, cardiovascular risk. vol 47 • number 1 • january 2015 effects of duration of breastfeeding during infancy on vascular dysfunction 25 introduction cardiovascular disease (cvd) remains as the number one cause of death worldwide.1 it is estimated that 17.3 million deaths occur each year due to cvd and 48% of deaths related to non-communicable diseases are caused by cvd.2 the prevalence is even increasing in developing countries including in indonesia,3 where cerebrovascular and coronary heart diseases are the first and second most causes of death, respectively. it is widely recognized that the development of cvd has started in early life.4,5 increased cardiovascular risk factor levels have also been found in children and adolescents. a study in jakarta showed that 16.1% of young adults had hyperlipidemia, 32.6% were overweight or obese, and 48.8% had hypertension. 6 several studies also found a high prevalence of hypercholesterolemia (25-33%) among indonesian schoolchildren. autopsy studies have also shown that atherosclerosis is already found in young adults. moreover, fatty streaks, the initial lesions of atherosclerosis, have been found in children less than one year old and its occurrence increases with age, which is 20% in children aged 15-19 years and 40% in the age of 30-34 years.7 it has been suggested that changes in intima media thickness (imt) and endothelial dysfunction are early signs of atherosclerotic plaque formation.8,9 endothelial dysfunction can be assessed by the flow mediated dilation technique. the measurement uses ultrasound to detect changes in brachial vessel diameters after a shear stress is applied. intima media thickness reflects changes in vascular structure and has been considered as a strong predictor of cvd in adults. other biomarkers considered to be associated with early vascular injury are highsensitive c-reactive protein (hscrp) and the vascular cell adhesion molecule (vcam).10,11 various factors have been implicated to be involved in atherosclerosis formation. these include nutrition, physical activity, smoking exposure, obesity, hypertension, diabetes mellitus. in particular, nutrition in infancy has been suggested to play a role in the development of cvd.12 previous studies have indicated a protective effect of breastfeeding on cvd, in which adults who used to be breastfed have better arterial function than those who were formula fed.13 it is suggested that the long-chain polyunsaturated fatty acid (lc-pufa) contained in breastmilk increased vasodilator production and release, such as nitric oxide.14 lc-pufa may also have anti-atherosclerotic properties through suppressing pro-inflammatory cytokines. it has also been reported that breastfeeding of at least 3 months has, at least in adults, a positive effect on cardiovascular biomarkers, such as lower total/ ldl cholesterol and high sensitive c-reactive protein (hs-crp) levels.15 a l t h o u g h s e v e r a l s t u d i e s s h o w t h a t breastfeeding has a preventive effect on cvd, there are also studies revealing inconsistent results, in which longer duration of breastfeeding is associated with decreased arterial function and increased blood pressure in later life.16 moreover, the optimal breastfeeding duration in relation to cardiovascular risk is largely unknown. since early detection of atherosclerosis risk factors at a young age would enable early intervention to prevent cardiovascular disease in adulthood, we aimed to evaluate the effect of breastfeeding duration on vascular characteristics and other cardiovascular risk factors in adolescents. methods we conducted a retrospective cohort study on adolescents aged 15-18 years old from october 2012 until march 2013. subjects were recruited from a senior high school (sman 1 budi utomo) in jakarta, indonesia. the number of subjects were calculated using the formula of mean difference with the type i error of 5% and type ii error of 10% the minimal mean diffrence of cimt which is clinically significant was 0.45 and standard deviation of 0,40 mm. the minimal subjects of each category duration of breastfeeding was 19 subbjects. only adolescents whose mothers were able to recall the breastfeeding duration were enrolled. we excluded subjects who had an acute fever or illness during examination. parental informed consent was obtained for all subjects and the study has been approved by the ethics committee of faculty of medicine universitas indonesia. sukman t. putra acta med indones-indones j intern med 26 two weeks before enrolment, a health information session was arranged in school to explain the importance of preventing cvd at a young age and to invite students to participate in the study. of 300 students invited, 15 children rejected, mainly because of refusal to the blood sampling procedure. after consent had been obtained, a questionnaire was applied to parents to inquire for breastfeeding duration, which was further categorised into 0-<2, 2-<4, 4-<6, 6-<12, and >12 months. using the questionnaire, we also obtained information about age, gender, socioeconomic level, mothers’ age, and smoking exposure. we performed complete physical examination including subjects’ blood pressure, body weight and height, as well as waist and hip circumference. blood sampling was taken after a 12-hour fasting to measure total/hdl/ldl cholesterol, glucose, hs-crp, and vcam levels. after resting for 10 minutes, subjects underwent blood pressure, fmd, and imt examinations in supine position. to measure fmd, we first measured the brachial artery diameter using a vascular ultrasound (general electric logic e) with a 7-12 mhz transducer. afterwards, using a sphygmomanometer, we applied pressure of 200 mmhg or approximately 50 mmhg above systolic pressure to occlude the brachial artery for 1 (fmd1) and 4 minutes (fmd4). after pressure was released, diameter measurement was repeated to obtain the ratio of vascular diameter after occlusion to that of before occlusion. we also used the ultrasound device to measure cimt. all ultrasound examinations were done by an ultrasound technician blinded to data on breastfeeding duration. data were firstly described in a baseline table and presented as mean, median, or proportion as appropriate. to evaluate the association between breastfeeding duration and vascular characteristics as well as other cardiovascular risk factors, we initially performed univariable analysis using one-way anova with breastfeeding duration categories and potential confounders as the independent variables and cimt, fmd, as the dependent variables. potential confounders were taken into the multivariable model. multivariable analysis was done using m a n o va g e n e r a l l i n e a r m o d e l w i t h breastfeeding duration dichotomised into >4-6 months and other than >4-6 months as independent variable, while, cimt, fmd1, hs-crp taken simultaneously as the dependent variables due to possible interactions between these outcomes. the analysis was adjusted to gender and postnatal smoking exposure as both variables are likely to be associated with breastfeeding duration and cardiovascular risk factors. we particularly focus on breastfeeding duration of >4-6 months since it is the category that showed an association with vascular characteristics on univariable analysis and was in line with global recommendation of breastfeeding duration and also in the multivariate analysis the group of 4-6 months duration of breastfeeding tends to have a good results. results two hundred and eighty five senior high school students were enrolled. subjects’ characteristics based on breastfeeding duration categories are shown in table 1. there was a statistically significant difference in body weight across breastfeeding categories, in which prolonged breastfeeding was associated with smaller body weight (p=0.02). there was also a significant difference in mother educational level across bf duration categories. more mothers with low-to-middle education gave prolonged breastfeeding (more than 12 months) as compared to other categories (p=0.006). we found no significant differences in gender, birth weight, height, social economy status, and subjects’ exposure to parental smoking (before or after birth) based on breastfeeding categories. results of univariable analysis of the association between breastfeeding categories and vascular characteristics as well as other cardiovascular risk factors were shown in table 2. with increasing breastfeeding duration, blood pressure and cimt decreased although not statistically significant. children with breastfeeding duration of 4-<6 months had the thinnest imt compared to others. in vol 47 • number 1 • january 2015 effects of duration of breastfeeding during infancy on vascular dysfunction 27 further multivariable analysis we dichotomised breastfeeding duration to obtain more number of subjects within each group. table 3 shows the general linear model analysis with breastfeeding duration dichotomised as 4-<6 months and other than 4-<6 months as independent variable. there were statistically significant associations between breastfeeding duration of 4-<6 months and thinner cimt both in crude and adjusted analysis to gender and postnatal parental tobacco exposure (p=0.045). discussion this study provides further insight about factors associated with the development of atherosclerosis that starts early in life. we found that adolescents who had been breastfed for 4-<6 months have thinner cimt compared to others. they also tended to have larger fmd but the association was not statistically significant. flow mediated dilation (fmd) is one of the sensitive tools for detection of early dysfunction of the vascular endothelium. this study showed that there was no significant difference in 1 minute and 4 minute fmds across bf duration categories although fmd1 and fmd4 tended to be higher in the adolescents who had been breastfed for 4-<6 months compared to other categories. in terms of cimt, we found that children who used to receive breastfeeding for 4-<6 months had thinner cimt compared to other groups of bf duration. our findings were slightly different from a previous study in finland, which showed that fmd was highest table 1. baseline characteristics by breastfeeding duration variables breastfeeding duration (months) p value0 <2 (n=27) 2 <4 (n=42) 4 <6 (n=25) 6 <12 (n=54) >12 (n=137) total male sex, n (%) 8 (30) 18 (43) 11 (44) 22 (41) 39 (28) 98 (34) 0.22* birth weight,grams, n (%) < 2500 3 (11) 3 (7) 2 (8) 2 (4) 9 (7) 19 (7) 0.74# > 2500 24 (89) 39 (93) 23 (92) 52 (96) 128 (93) 266 (93) age, year, mean (sd) 15.5 (0.9) 15.6 (1.0) 15.6 (1.0) 15.4 (0.8) 15.7 (1.0) 15.6 (1.0) 0.61** body weight, kg, mean (sd) 59.9 (11.4) 60.9 (16.1) 58.3 (14.4) 57.5 (13.6) 54.2 (11.3) 56.7 (13.0) 0.02** height, cm, mean (sd) 159.3 (6.5) 162.2 (8.1) 161.3 (8.5) 161.1 (8.2) 159.2 (7.8) 160.2 (7.9) 0.17** current age mother (years) 30-40 8 (30) 8 (19) 4 (16) 9 (17) 35 (25) 64 (23) 0.77* > 40 19 (70) 34 (81) 21 (84) 45 (83) 102 (75) 221 (77) socioeconomic status, n (%) 0.20* low 8 (30) 10 (24) 7 (28) 13 (24) 49 (36) 87 (30) middle 14 (52) 28 (67) 16 (64) 35 (65) 80 (58) 173 (61) high 5 (18) 4 (9) 2 (8) 6 (11,1) 8 (6) 25 (9) mother education, n(%) 0.006* low 1 (4) 2 (5) 2 (8) 5 (9) 16 (12) 26(9) middle 10 (37) 17 (40) 9 (36) 21(39) 68 (50) 125 (44) high 16 (59) 23 (55) 14 (56) 28 (52) 53 (39) 134 (47) prenatal parental tobacco exposure, n (%) 12 (44) 14 (33) 9 (36) 22 (41) 64 (47) 164 (58) 0.25* postnatal parental tobacco exposure, n (%) 13 (48) 14 (33) 9 (36) 22 (41) 65 (47) 123 (43) 0.31* note: *chi-square test, **anova test, #fischer exact test sukman t. putra acta med indones-indones j intern med 28 in children who had exclusive breastfeeding compared to those formula-fed, which was 7.2 (sd 4.0) % versus 5.9 (3.4) %, but it showed no difference in cimt between the groups.17,18 however that study did not evaluate the effect of bf duration as our study did. an other study in england, also found that cimt of adults aged 32-88 years old who used to be breastfed was thinner than those who were formula-fed. however, that study did not provide evidence regarding the dose-response effect of breast milk on vascular structure and function.13 evelein et al. reported the effect of breastfeeding on cmit of 5 year old children. in this prospective cohort study, subjects who received breastfeeding for 3-6 months had cimt 21.1 micrometer (95% ci 5.0; 37,2; p=0.01) thicker compared to those who were formula-fed, which may be due to higher cholesterol content of breastmilk than formula milk.19 however, it was suggested that this was only a temporary condition, in which cimt of breastfed children will later decrease in the adolescence and adulthood. this phenomenon is called “nutritional programming effect” where the cholesterol metabolism changes over time due to high cholesterol exposure in breastmilk. in our study, blood pressure tended to be lower in adolescents with bf duration of 4-<6 months compared to other categories, but the difference was not statistically significant. there are some mechanisms by which breastmilk influences blood pressure, which are lower sodium intake and increased lc pufa intake. lc-pufa is an important component of vascular endothelial membrane, which protects against hyperinsulinism and insulin resistance. the association between breastfeeding and blood pressure in elderly were reported in metaanalysis by owen et al.20 and martin et al.21 that subjects who had exclusive breastfeeding will have a 1.1 (95%ci -1.79; -0.42) mmhg decrease in blood pressure compared to those who used to be formula-fed. table 2. cardiovascular risk factors based on breastfeeding duration categories (univariable analysis) variables breastfeeding duration (months) p value0 <2 (n=27) 2 <4 (n=42) 4 <6 (n=25) 6 <12 (n=54) >12 (n=137) vascular characteristics and biomarkers, mean (sd) fmd 1 minute (%) 9.2 (7.1) 9.2 (6.1) 10.9 (6.7) 9.2 (5.9) 9.5 (5.9) 0.80 fmd 4 minutes (%) 15.9 (7.1) 15.3 (8.4) 15.6 (8.1) 14.6 (7.5) 15.0 (6.9) 0.95 cimt (μm) 442.2 (67.8) 445.7 (63.0) 412.8 (56.1) 447.6 (77.6) 429.3 (67.6) 0.15 systolic bp (mmhg) 119.8 (15.5) 122.5 (16.2) 114.1 (15.8) 118.4 (18.5) 115.2 (13.8) 0.06 diastolic bp (mmhg) 70.9 (7.7) 72.7 (10.9) 68.5 (15.6) 70.8 (11.7) 68.9 (11.7) 0.37 table 3. association between breastfeeding duration of 4-<6 months and vascular characteristics/cardiovascular risk factors variables bf duration (months) p value 4 <6 (n = 25) other duration (n = 260) unadjusted adjusted* vascular characteristics and biomarker, mean (sd) fmd 1 min (%) 10.9 (6.7) 9.4 (6.0) 0.22 0.230 fmd 4 min (%) 15.6 (8.1) 15.1 (7.2) 0.72 0.700 cimt (μm) 412.8 (56.1) 437.1 (69.2) 0.09 0.045 systolic bp (mmhg) 114.1 (15.8) 117.5 (15.6) 0.30 0.130 diastolic bp (mmhg) 68.5 (15.6) 70.1 (11.2) 0.52 ** **: exclude from multivariate analysis multaivariat analysis adjusted to gender and postnatal parental tobacco exposure vol 47 • number 1 • january 2015 effects of duration of breastfeeding during infancy on vascular dysfunction 29 there were some limitations of this study. this was a retrospective cohort study involving recall of breastfeeding duration, which may cause misclassification in breastfeeding duration. breastfeeding duration recall has been reported to be accurate until 17-20 years.22 the other limitation of this study was that we did not perform diet analysis as diet may have influenced fat and sugar intake and thus cardiovascular homeostasis. however, blood sampling was done after subjects fasted for 12 hours. there are some confounding factors that may alter cardiovascular risk factor level such as gender, tobacco exposure, all of which has been adjusted in statistical analysis. to our knowledge, this was the first published study investigating the effects of breastfeeding duration on cardiovascular risk factors in adolescents. the results of this study provide additional knowledge on the benefits of breastfeeding, thus it may promote breastfeeding practice, which also has been recommended globally. since the subjects of this study have similar characteristics with most of the community in terms of socio-economic status, level of parents education, the results of this study could be applied to most adolescents in the country. conclusion adolescents who used to receive breast milk for 4-<6 months have thinner cimt compared to those with breastfeeding duration of less than 4 months or over 6 months. however the association with flow-mediated dilation (fmd) and other cardiovascular risk factors seems to be more subtle. acknowledgments the author would like to thank for the kind support, suggestions and a significant contribution in this study to, prof. dr. sarwono waspadji, prof. dr. rulina suradi, prof. dr. boerhan hidayat, prof. dr. rahayuningsih dharmasetiabudy, dr. dante saksono, and prof. dr. idrus alwi. my sincere thanks also to dr. nikmah salamia idris and, ms septiani madonna gultom for their assistance in preparing this manuscript. references 1. world health organization (who). global atlas on cardiovascular disease prevention and control. geneva: who;2011. 2. poulter n. global risk of cardiovascular disease. heart. 2003;89 (suppl 2):2-5. 3. basic health research 2010, ministry of health, republic of indonesia. 4. virmani r, robinowitz m, geer jc, breslin pp, beyer jc, mcallister ha. coronary artery atherosclerosis revisited in korean war combat casualties. arch pathol lab med. 1987;111:972-6. 5. berenson gs, wattigney wa, tracy re. atherosclerosis in the aorta and coronary arteries and cardiovascular disease risk factors in person aged 6-30 years and studied at necropsy (the bogalusa heart study). am j cardiol. 1992;70:851-8. 6. djer mm. prevalence of obesity in school-age children and associated factors [thesis]. jakarta: department of child health, faculty of medicine, university of indonesia; 1998. article in indonesian. 7. tanaka k, masuda j, umamura t. a nation-wide study of atherosclerosis in infants, children, and young adults in japan. atherosclerosis. 1988;72:143-56. 8. bonetti po, lerman lo, lerman a. endotelial dysfunction: a marker of atherosclerotic risk. arterioscler thromb vasc biol. 2003;23:168-75. 9. oren a, vos le, uiterwaal cspm, grobbee de, bots ml. cardiovascular risk factors and increased carotid intima media thickness in healthy young adults. arch intern med. 2003;163:1787-92. 10. zemecke a, weber c. inflammatory mediators in atherosclerotic vascular disease. basic res cardiol. 2005;100:93-101. 11. fragakis n, ioannidou e, bounda a, theodoridou s, klonizakis p, garipidou v. increased level of proinflammatory cytokines in children with family history of coronary heart disease. clin cardiol. 2010;8:501-5. 12. singhal a. early nutrition and long-term cardiovascular health.nutr rev. 2006;64:s44-8. 13. martin rm, ben-shlomo y, gunnel d, elwood p, yarnell jwg, smith gd. breastfeeding and cardiovascular disease risk factors, incidence and mortality: the caerphilly study. j epidemiol community health. 2005;59:121-9. 14. engler mm, engler mb, kroetz dl, boswell kd, neeley n, krassner sm. the effects of diet rich in docosahexainoic acid on organ and vascular fatty acid composition in spontaneously hypertensive rats. prostagland leukot essent fatty acids. 1999;61:28995. 15. ravelli ac, van der meulen jh, osmond c, barker dj, bleker op. infant feeding and adult glucose tolerance, lipid profile, blood pressure, and obesity. arch dis child. 2000;82:248-52. sukman t. putra acta med indones-indones j intern med 30 16. leeson cpm, kattenhorn m, deanfield je, lucas a. duration of breastfeeding and arterial distensibility in early adult life: population based study. bmj. 2001;322:643-4. 17. o’tierney, barker djp,osmond c, kajantie e, erickson jg. duration of breastfeeding and adiposity in adult life. j nutr. 2009;139:422s-5s. 18. jarvisalo mj, hutri-kahonen n, juonala m, et al. breastfeeding in infancy and arterial endothelial function later in life: the cardiovascular risk in young finns study. eur j clin nutr. 2009;63:640-5. 19. evelein avm, geerts cc, visseren flj, et al. the association between breastfeeding and the cardiovascular system in early childhood. am j clinnutr. 2011;110:1-7. 20. owen cg, whincup ph, odoki k, gilg ja, cook dg. infant feeding and blood cholesterol; a study in adolesecents and a systematic review. pediatrics. 2002;110:597-608. 21. martin rm, ben-shlomo y, gunnell d. breastfeeding and cardiovascular disease: risk factors, incidence and mortality: the caerphilly study. j epidemiol comm health. 2005;59:121-9. 22. natland st, anderson lf, nilsen til, torsmo s, jacobsen gw. maternal recall of breastfeeding twenty years after delivery. bmc med res method. 2012;12:179. clinical practice 163acta medica indonesiana the indonesian journal of internal medicine national consensus on management of non-variceal upper gastrointestinal tract bleeding in indonesia the indonesian society of gastroenterology department of internal medicine, faculty of medicine, universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. correspondence mail: department of internal medicine, faculty of medicine, universitas indonesia cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: pbpgi.jakarta@gmail.com, ari_syam@hotmail.com. abstrak pengurus besar perkumpulan gastroenterologi indonesia (pb pgi) menyusun suatu konsensus nasional mengenai tatalaksana perdarahan saluran cerna bagian atas non-variseal (non-variceal upper gastrointestinal bleeding/nvugib). hal ini merupakan upaya untuk meningkatkan kualitas pelayanan pasien nvugib terkait ulkus peptikum. adapun penyusunan konsensus ini merujuk pada tiga konsensus terbaru dalam tatalaksana nvugib dengan melakukan modifikasi dari proses delphi untuk menyusun panduan klinis. ketiga konsensus yang menjadi rujukan tersebut, antara lain: the international consensus recommendations on the management of patients with non-variceal upper gastrointestinal bleeding (icon-ugib), 2010; asia-pacific working group consensus on non-variceal upper gastrointestinal bleeding, 2011; dan management of patients with ulcer bleeding, acg guidelines,2012. konsensus ini disusun agar menjadi rujukan bagi para praktisi medis di seluruh indonesia dalam penatalaksanaan pasien dengan perdarahan saluran cerna bagian atas non-variseal terkait ulkus peptikum. namun, teknik pelaksanaanya sangat tergantung dengan fasilitas diagnostik dan terapeutik yang ada pada masing-masing pusat pelayanan kesehatan. kata kunci: endoskopi, perdarahan, perdarahan saluran cerna bagian atas non-variseal/nvugib, ulkus peptikum. abstract the indonesian society of gastroenterology has compiled a national consensus guideline for the management of non-variceal upper gastrointestinal bleeding (nvugib). it is an endeavor to raise the quality of service for nvugib patients associated with peptic ulcer. the references for developing this consensus include three recent consensus guidelilnes on the management of nvugib and a modification of delphi process was done to develop clinical guidelines. the three references are: the international consensus recommendations on the management of patients with non-variceal upper gastrointestinal bleeding (icon-ugib), 2010; asia-pacific working group consensus on non-variceal upper gastrointestinal bleeding, 2011; and management of patients with ulcer bleeding, acg guidelines, 2012. the consensus is compiled as a reference for indonesian medical practitioners all across the country on the management of patients with non-variceal upper gastrointestinal bleeding associated with peptic ulcer. however, the technical implementation extremely depends on diagnostic and therapeutical facilities available in each health care center. key words: endoscopy, bleeding, non-variceal upper gastrointestinal bleeding/nvugib, peptic ulcer. indonesian society of gastroenterology acta med indones-indones j intern med 164 introduction non-variceal upper gastrointestinal bleeding perdarahan saluran cerna bagian atas nonvariseal is a quite common clinical condition; however in general, the incidence tends to decline in peptic ulcer disease. there are 3 recent consensus guidelines on this topic, which are: the international consensus recommendations on the management of patients with non-variceal uppergastrointestinal bleeding (icon-ugib), 20101; asia-pacific working group consensus on non-variceal upper gastrointestinal bleeding, 20112; and management of patients with ulcer bleeding, acg guidelines, 2012.3 those consensus guidelines have used the most recent data about the management of nvugib by modifying the delphi process in order to compile a clinical guideline. although the guidelines do provide a comprehensive recommendation and utilize the most recent data from literatures, the international consensus recommendations of 2010 and the acg guidelines 2012, but there is no room for specific needs of limited-resources countries and ethnic differences. as an example, the use of proton pump inhibitors to reduce the degree of endoscopic lesion and the needs of interventional endoscopy are recommended by the icon-ugib. this gives a great financial burden to asia pacific countries, which have limited resources. moreover, there is no well-defined recommendation about the route of administration for ppi, either by intravenous or oral route. furthermore, it is realized that there are great differences on the degree of helicobacter pylori infection,1 drug metabolism and the use of anti-thrombotic drugs, which may affect the management of nvugib.1,2 most of the abovementioned issues have been addressed attemptively when compiling the asia pacific guideline and indonesia has also participated during the development of the guideline. however, it is also realized that indonesia has great differences from other countries regarding the limited availability of medical facilities and infrastructures for nvugib management. the major limation is the availability of endoscopy, which is the back bone issue in nvugib management. therefore, the task force in the organizing committee of indonesian society of gastroenterology has attempted to develop a national consensus on the management of ugib associated with peptic ulcer. it is an endeavor to bridge the varied availability of medical facilities and infrastructure in indonesia in order to raise the quality of service for patients who have ugib associated with peptic ulcer. moreover, the consensus may also serve as a professional recommendation for all medical practitioners in indonesia regarding the management of patients with non-variceal upper gastrointestinal bleeding that associated with peptic ulcer. however, the technical implementation extremely depends on diagnostic and therapeutical facilities available in each health care center. epidemiology an endoscopic study in patients with dyspepsia symptoms that has been conducted in several big cities in indonesia demonstrates that peptic ulcer, i.e. gastric and duodenal ulcers, is listed in he top five causes of dyspepsia.4 the incidence of ugib indicates that there are great geographical variations, starting from 48 to 160 cases per 100,000 populations with a higher incidence in male and elderly patients. it can be explained due to various causes including the different definition of ugib, population characteristics, different prevalence of druginduced ulcer and helicobacter pylori.5,6 despite the optimal management using therapeutical endocopy and treatment using gastric acid suppressants, the overall mortality of ugib remains stable in recent decades, which ranges between 6-14%. nevertheless, most deaths are not caused directly by massive blood loss, but much more by intolerance to blood loss, shock, aspiration and therapeutical procedures. the mortality due to ugib is associated with elderly age and severe comorbidity. the risk of mortality is also increased by recurrent bleeding, which is a major outcome parameter.5,7 there is a wide range of recurrent bleeding in patients with ugib from 5% to more than 20%, which depends on several factors, i.e.: 1) the etiology of bleeding – it is more common due to variceal bleeding and rarely due to small vol 46 • number 2 • april 2014 national consensus on management of nvugib in indonesia 165 mucosal lesion such as mallory-weiss tear.8 2) timing and adequate treatment of endocscopy – recurrent most likely occurs in early period of treatment and 24 hours are considered to be the most optimal time for endoscopic treatment.7,9 peptic ulcer bleeding (pub) is the most common cause of ugib. the incidence ranges between 31% and 67% of all cases, which is followed by erosive gastritis, variceal bleeding, esophagitis, malignancy and mallory-weiss tear. in a subgroup of patients with pub, the incidence of bleeding due to duodenal ulcer is slightly higher than that caused by gastric ulcer.5,9 in indonesia, there is a different distribution, the old data revealed that approximately 70% ugib is caused by ruptured esophageal varices. nevertheless, since there are increased care on chronic liver disease and raising population of elderly patients, it is estimated that the proportion of bleeding caused by peptic ulcer will also increase.8,10,11 data from one of hospitals in indonesia (sanglah hospital, bali) reveal that the most common cause of gastrointestinal bleeding is peptic ulcer, which is followed by erosive gastritis.12 based on a retrospective study, which was performed in 4,154 patients who underwent endoscopy in 2001-2005 at the endoscopic center of cipto mangunkusumo hospital, jakarta, there are about 807 (20.15%) patients who have experienced ugib. the study also demonstrates that the most common cause of ugib is ruptured esophageal varices (280 cases; 33.4%) followed by peptic ulcer bleeding (225 cases; 26,9%), and erosive gastritis (219 cases; 26.2%) (table 1).13 risk factors for peptic ulcer as seen in figure 1, h. pylori infection is a major factor in the development of ulcers, both duodenal and gastric ulcers. the data were taken from studies on western countries populations. although they may have a list with similar order, it is estimated that in developing countries, h.pylori plays a more significant role.14 the evaluation of clinical staging is an important early management step. elderly age, multiple comorbidity and hemodynamic instability call for aggressive treatment. regardless of the general clinical guideline, a systematical staging has been developed. table 1. the most common causes of ugib in patients who underwent endocopy at the endoscopic center of cipto mangunkusumo hospital in 2001-2005 causes cases percentage (%) ruptured esophageal varices 280 33.4 peptic ulcer bleeding 225 26.9 erosive gastritis 219 26.2 not found 38 4.5 others 45 9.0 total 807 100 unknown zes, others nsaid h.pylori infection duodenal ulcer gastric ulcer unknown zes, others nsaid h.pylori infection figure 1. proportion of risk factors for peptic ulcer.14 risk stratification for recurrent bleeding and mortality rockall scoring system is the most utilized scoring system, which provides an estimation risk for bleeding and mortality. the scoring system is developed based on three clinical factors and two endoscopic factors. these factors are presented in table 2. rockall scoring system may range between 0-11; while the score of 0-2 is associated with good prognosis. another scoring system, which is the blatchfor scoring system only utilizes laboratory and clinical factors and therefore, it is recommended for asian patients in the recent asia-pasific consensus guideline.2 unlike rockall scoring system, the major outcomes of this scoring system may predict the needs of clinical intervention such as endoscopy, surgery or blood transfusion. blatchford scoring system (table 3) ranges between 0-23; which the scores of 6 or higher are considered to require intervention. indonesian society of gastroenterology acta med indones-indones j intern med 166 some risk factors are also associated with bad prognosis after the bleeding incident associated with peptic ulcer (table 4). if this occurs, clinicians must be more aggressive in determining the management that will be carried out. diagnosis history taking the most common signs and symptoms of upper gastrointestinal tract bleeding are hematemesis (vomiting of blood), coffee ground emesis and melena (black tarry stool). about 30% of patients with ulcer bleeding present with hematemesis, 20% with melena and 50% with both. hematochezia (fresh blood in stool) usually indicates that the source of bleeding is in the lower gastrointestinal tract as the upper gastrointestinal bleeding will turn into black and tarry color during their passage through the gi tract resulting in melena. however, 5% of patients who experienced ulcer bleeding may present with hematochezia, which characterizes severe bleeding that usually is more than 1,000 ml. patients who present with hematochezia and other hemodynamic instability signs such as syncope, postural hypotension, tachycardia and shock must be considered as patients with upper gastrointestinal tract bleeding. table 2. rockall scoring system1 variables score 0 score 1 score 2 score 3 age (year) <60 60-79 >80 shock none pulse rate >100x/ minute, bp normal pulse rate >100x/minute, systolic bp <100 mmhg comorbidity none ischemic heart disease, congestive heart failure, and any major comorbidity renal failure, hepatic failure, metastasis endoscopy diagnosis mallory-weiss tear, no lesion observed, no stigmata of recent hemorrhage peptic ulcer, esophagitis, or erosive disease malignancy of upper gi tract stigmata of endoscopic or recent hemorrhage clean ulcer base, flat pigmented spot blood in upper gi tract, active bleeding, visile vessel without bleeding or adherent clot table 3. the blatchford scoring system to determine the needs of intervention5 variables points variables points systeolic blood pressure (mmhg) hemoglobin (male; g/dl) 100-109 1 12.0-12.9 1 90-99 2 10.0-11.9 3 <90 3 <10.0 6 ureum (mg/dl) hemoglobin (female; g/dl) 36.5-44.5 2 10.0-11.9 1 44.6-55.5 3 <10.0 2 55.6-139.9 4 >140 6 other variables pulse rate >100 1 presentation with melena 1 hepatic disease 2 heart failure 2 total table 4. risk factors that characterize bad prognosis in patients with peptic ulcer bleeding14 age >60 years bleeding onset at the hospital comorbid medical shock or orthostatic hypotension fresh blood in nasogastric tube coagulopathy requirement of repeated transfusion ulcer at the upper part of lesser curvature (near the left gastric artery) ulcer at the posterior duodenal bulb (near the gastroduodenal artery) endoscopic findings of arterial bleeding or visible blood vessel vol 46 • number 2 • april 2014 national consensus on management of nvugib in indonesia 167 non-specific signs and symptoms including nausea, vomiting, epigastric pain, vasovagal phenomenon and syncope as well as the most common comorbidities (such as diabetes mellitus, coronary heart disease, stroke, chronic kidney disease and arthritis) and the history of medication must also be identified.5,8,14 physical examination evaluation on hemodynamic status (pulse rate and blood pressure), respiratory rate, level of consciousness, pale conjunctiva, slow capillary refill time and no stigmata of chronic liver cirrhosis, which are the early symptoms, must be identified immediately. ta c h y c a r d i a o n r e s t a n d o r t h o s t a t i c hypotension indicate a considerably large amount of blood loss. low urine output, dry lips and collapse of jugular veins are relatively useful signs. it should be noted that tachycardia may not appear if the patient is on medication with beta blocker drugs, which are commonly used for patients with heart failure and liver cirrhosis.5,8,14 further assessment although it is not a routine procedure for peptic ulcer bleeding, inserting nasogastric tube (ngt) and evaluating the aspirate are usually useful for early clinical assessment. if bright red blood is detected, then the patient needs immediate endoscopic evaluation and should be managed at the intensive care unit. reduced hemoglobin level of 1g/dl is associated with 250 ml blood loss. if there is any coffee ground emesis, then the patient needs hospitalization and endoscopic evaluation within 24 hours. however, normal aspirate does not exclude gastrointestinal tract bleeding. about 15% of patients with normal aspirate remain to have active gastrointestinal tract bleeding or high risk for recurrent bleeding.5,8,14 endoscopy detects not only peptic ulcer, but also can be utilized to evaluate stigmata associated with increased risk of recurrent bleeding (figure 2). forrest classification is used to categorize findings during endoscopic evaluation with following description: ulcer with active spurting (forrest ia); ulcer with oozing bleeding (forrest ib); ulcer with non-bleeding visible vessel (forrest iia); ulcer with adherent clot (forrest iib); ulcer with flat pigmented spot (forrest iic); and clean-based ulcers (forrest iii). patients at high risk of rebleeding without treatment are those with active arterial bleeding (90%), the occurrence of a non-bleeding visible vessel (50%) an adherent clot (33%).5,8,14 complication complication that may occur due to peptic ulcer bleeding is hypovolemic shock, which may be followed with acute renal failure, multi organ failures and death. treatment early management an appropriate early evaluation and resuscitation are important measures that should be carried out for patients with ugib, especially for those who present with hematemesis, massive hematochezia, melena or progressive anemia. we suggest early management with multidisciplinary approach involving an internist/ gastroenterologist, an interventional radiologist and a surgeon/digestive surgeon.9,14,15 stratification of the patient into low or high risk category for recurrent bleeding and mortality may be carried out using blatchford and rockall scoring system (in keeping with the availability of endocopy facility). patients with high risk for recurrent bleeding and mortality should be hospitalized in intensive care unit.5,14 nasogastric tube (ngt) is inserted for the assumed ongoing bleeding, which is accompanied a b c d e f figure 2. endoscopic stigmata of recent hemorrhage of a peptic culter. a. active bleeding with spurting; b.oozing bleeding; c. visible vessel with an adjacent clot; d. adherent clot. e. based pigmented spot; f. a clean-based ulcer. indonesian society of gastroenterology acta med indones-indones j intern med 168 with hemodynamic instability. the purpose of ngt insertion is to prevent aspiration, provide gastric decompression and evaluate bleeding; therefore, it is not necessarily performed in all patients with bleeding.3 nasogastric or orogastric lavage can be performed in patients with upper gastrointestinal tract bleeding in certain circumstances. ice water is not recommended for gastric lavage.3 resuscitation measures include administration of intravenous fluid, oxygen supplementation, correction of severe coagulopathy and blood transfusion as needed. the threshold for blood transfusion depends on general medical condition and vital signs of the patients, but it is usually set at a hemoglobin level of ≤7.0 g/dl unless if there is ongoing or massive bleeding and there is comorbidity of coronary heart disease, hemodynamic instability (hypotension and tachycardia) and elderly age.9 the minimal hemoglobin level required for endoscopy is 8 mg/dl and if a therapeutical endoscopy will be provided, the minimal hemoglobin level is 10 mg/dl and the patient should have a stable hemodynamic status. preendoscopic ppi therapy can be recommended (1b recommendation) for patients with pub. the acidic environment may cause inhibition of platelet aggregation and plasma coagulation, which may also result in lysis of the already formed clots. administration of ppi therapy can rapidly neutralize intraluminal gastric acid, which results in stabilization of blood clot. in long term, antisecretory therapy also promotes mucosal healing. a recent study shows that preendoscopic ppi therapy has significantly reduced high-risk stigmata at early endoscopy (37% vs. 46%, or 0.67; 95% ci 0.54-0.84). however, it shows no effect on recurrent bleeding, mortality and surgery.16 when endoscopy will be delayed and can not be performed, an intravenous ppi therapy is recommended to reduce further bleeding.3 timing of endoscopy endoscopy has become a major tool of diagnosis and treatment of ugib. this procedure allows identification of the bleeding source and provides treatment in the same session. emergency endoscopy allows for early hemostatis, but it can potentially lead to blood aspiration and oxygen desaturation in unstable patients. in addition, excessive amounts of blood and clots may disturb targeted therapy for bleeding focus, which may cause the necessary repeated endoscopic procedures.3,9,14 the international consensus and asia pacific guidelines recommend early endoscopy within 24 hours after the patients have been hospitalized, as this treatment significantly reduces the length of hostpital stay and improve clinical outcome. the very early endoscopy (<12 hours) so far has not been shown to give additional advantages in terms of reduced risk for recurrent bleeding, surgery and mortality. however, emergency endoscopy should be considered in patients with severe bleeding. in patients with clinical manifestation of greater risks (such as tachycardia, hypotension, hematemesis or bright red blood in ngt), an endoscopy within 12 hours may increase clinical outcome.1-3 in patients with stable hemodynamic status and without any serious comorbidity, endoscopy should be performed first before discharging the patient from hospital.3 endoscopic therapy for pub the aim of therapeutic endocopy is to stop active bleeding and prevent recurrent bleeding. several techniques, including injection, ablative and mechanical treatment have been developed over recent decades. the selection of treatment can be adjusted according to the appearance of bleeding focus and related risk for persistent and recurrent bleeding (figure 3). in pub, patients with active bleeding or non-bleeding visible vessel in ulcer beds are at the highest risk for recurrent bleeding; therefore, they need immediate endoscopic hemostatic therapy. patients with low-risk stigmata (a clean-based ulcer or a pigmented spot in ulcer beds) do not need endoscopic therapy.3,7 patients with clean-based ulcers may have a soft diet and be discharged after endoscopy assuming they have a stable hemodynamic status, adequate hemoglobin level and they have no other medical problems.3 patients with active ulcer bleeding, hemostasis therapy shuld be given in combination (epinephrine in addition to other modalities such as hemoclip placement, vol 46 • number 2 • april 2014 national consensus on management of nvugib in indonesia 169 thermocoagulation and electrocoagulation). epinephrine injection is not recommended as single therapy. injection with clip placement is recommended as it may reduce the incidence of recurrent bleeding.3,14 patients who endoscopically have highrisk stigmata (active bleeding, visible vesells, clots (according to the forrest clasification)) are generally hospitalized for 3 days if there is no recurrent bleeding and no other indication for hospitalization. the patients can have clear liquid diet soon after the endoscopy and the diet should be customized gradually.3 patients with recurrent bleeding can usually be managed with endoscopic therapy. however, emergency surgery or angiographic embolization may be needed under certain circumstances, such as: spurting bleeding that can not be stopped by endoscopy, non-visible bleeding spot due to massive active bleeding, and recurrent bleeding that occurs after the second therapeutic endoscopy. post-endoscopic management antisecretory therapy pharmacotherapy plays a second major role in the treatment of ugib due to peptic ulcer. ppi therapy is more superior compared to the histamine-2 receptor antagonist. ppi can be administered orally or intravenously depending on the bleeding stigmata (forrest classification). available data have recommended the administration of high-dose continuous intravenous ppi therapy for pub patients with high-stigmata risks. patients with pub should also be discharged with a prescription for a single-daily-dose oral ppi to reduce the risk of recurrent bleeding. the duration and dose of ppi depend on the etiology and any other medication use. in patients with idiopathic (non-h.pylori, non-nsaid) ulcers can be recommended to have long-term antiulcer therapy (such as daily ppi). in patients with low-dose aspirin-associated bleeding ulcers, the urgent need for aspirin should be re-assessed.1,2,14 h. pylori eradication therapy h. pylori test is recommended in all patients with pub. the test is subsequently followed with eradication therapy for all patients who have positive results, continuous monitoring to assess the results of this therapy and renewed treatment for those with failed eradication. the triple therapy eradication has a successful rate of 80% or even 90% in peptic-ulcer patients without any significant side effects and has a minimal effect on antibiotic resistance. furthermore, regarding the evaluation of ulcer healing by endocopy, it is found that the success rate of one-week ppi therapy reaches 80—85%. after eradication of h. pylori has been confirmed, no maintance therapy of ppi is necessary unless in patients who are nsaids or antithrombotic users. diagnostic test for h. pylori has a low negative predictive value in acute ugib. it may be due to technical difficulties to perform a representative biopsy or inaccuracy of the test in an alkaline environment caused by the blood. negative results of biopsy obtained in the acute setting must be carefully interpreted and when necessary, repetition of the test should be performed during the follow up.1-3,9,17 active bleeding or non-bleeding visible vessel adheren clot flat pigmented spot or clean base endoscopic therapy can be considered as endoscopic therapy* without endoscopic therapy intravenous ppi therapy bolus + drip intravenous ppi therapy bolus + drip oral ppi therapy figure 3. the management options including endoscopic and intravenous ppi treatment for patients with ugib associated with peptic ulcer. ppi = proton pump inhibitor. *if the endoscopic therapy facility is optimal. indonesian society of gastroenterology acta med indones-indones j intern med 170 non-variceal upper gastrointestinal bleeding resuscitation (oxygen, fluid and blood supplementation*) pre-endoscopic ppi therapy endoscopy within 24 hours (in keeping with the available facilities) no lesion detected interventional radiology/ surgery lesion detected high-risk lesion adheren clot** flat spot, clean base endoscopy therapy is the patient stable ? � hospitalization for >24 -hour monitoring continue with administration of ppi � hospitalization in the ward � ppi reassessment recurrent bleeding � repeat endoscopy*** � consider surgery or interventional radiology � discharg e with a prescription of ppi treatment, if possible � schedule the follow -up � consider test for h. pylori and treatment test result for h. pylori (+) test result for h. pylori (-) eradication with three drugs / triple therapy repeat the te st when necessary successful eradication 1 month yes no no yes note: *hb <7 g/dl, massive, continuous bleeding, chd, hemodynamic instability, elderly age ** if the facility of endoscopic therapy is optimal *** repeat first-look endoscopy, if there is recurrent bleeding : repeat endoscopy. second look endoscopy, if there is still bleeding, consider surgery or interventional radiology. initial assessment (exclude the possibility of varices, cirrhosis) stop ppi therapy (unless for patients who are nsaids or antithrombotic users). figure 4. vol 46 • number 2 • april 2014 national consensus on management of nvugib in indonesia 171 references 1. barkun an, bardou m, kuipers ej, et al. international consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. ann intern med. 2010;152:101-13. 2. sung jj, chan fk, chen m, et al. asia-pacific working group consensus on nonvariceal upper gastrointestinal bleeding. gut. 2011;60:1170-7. 3. laine l, jensen dm. management of patients with ulcer bleeding. am j gastroenterol. 2012;107:34560;quiz 61. 4. syam af, abdullah m, rani aa, et al. evaluation of the use of rapid urease test: pronto dry to detect h. pylori in patients with dyspepsia in several cities in indonesia. world j gastroenterol. 2006;12:6216-8. 5. albeldawi m, qadeer ma, vargo jj. managing acute upper gi bleeding, preventing recurrences. cleve clin j med. 2010;77:131-42. 6. holster il, kuipers ej. management of acute nonvariceal upper gastrointestinal bleeding: current policies and future perspectives. world j gastroenterol. 2012;18:1202-7. 7. holster il, kuipers ej. update on the endoscopic m a n a g e m e n t o f p e p t i c u l c e r b l e e d i n g . c u r r gastroenterol rep. 2011;13:525-31. 8. djojoningrat d. perdarahan saluran cerna bagian atas (hematemesis melena). 1 ed. jakarta: interna publishing; 2011. 9. el-tawil am. trends on gastrointestinal bleeding and mortality: where are we standing? world j gastroenterol. 2012;18:1154-8. 10. waleleng bj, wibowo f. tukak duodenum. 1 ed. jakarta: interna publishing; 2011. 11. sanusi ia. tukak lambung. 1 ed. jakarta: interna publishing; 2011. 12. ariawan iwy, wibawa idn, purwadi n, suryadarma iga, mariadi ik. endoscopic features of non-variceal upper gastrointestinal bleeding at sanglah hospital denpasar. 2009. 13. syam af, abdullah m, makmun d, et al. the causes of upper gastrointestinal bleeding in the national referral hospital: evaluation on upper gastrointestinal tract endoscopic result in five years period. indones j gastroenterol hepatol & digest endosc. 2005;6:71-4 14. sleisenger mh, feldman m, friedman ls, brandt lj. sleisenger and fordtran’s gastrointestinal and liver disease : pathophysiology, diagnosis, management. 9th ed. philadelphia, pa: saunders/elsevier; 2010. 15. bestari mb, rachmat y, girawan d, et al. keberhasilan endoskopi terapeutik dalam pengelolaan perdarahan saluran makan. majalah kedokteran bandung. 2009;40:125-33. 16. sreedharan a, martin j, leontiadis gi, et al. proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. cochrane database syst rev. 2010:cd005415. 17. yusrie ku, syam af. clinical improvement of dyspepsia symptoms following eradication treatment for h. pylori. indones j gastroenterol hepatol & digest endosc. 2006;7:72-8. 31 original article acta med indones indones j intern med • vol 52 • number 1 • january 2020 six-month survival of patients with malignant distal biliary stricture following endoscopic biliary stent procedure and its associated factors luki kusumaningtyas1, dadang makmun2, ari f. syam2, siti setiati3 1 department of internal medicine, faculty of medicine universitas indonesia, jakarta, indonesia. 2 division of gastroenterology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 3 division of geriatrics, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: prof. dadang makmun, md., phd. division of gastroenterology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: hdmakmun@yahoo.com, lukikusumaningtyas@yahoo.com. abstrak latar belakang: pasien striktur bilier distal maligna unresectable memerlukan pemasangan stent bilier per endoskopik. tingkat kesintasan dan faktor-faktor yang memengaruhinya di indonesia belum diketahui. tujuan penelitian ini untuk mengetahui kesintasan 6 bulan pasien striktur bilier distal maligna pasca pemasangan stent bilier per endoskopik dan faktor-faktor yang berpengaruh. metode: penelitian dengan desain kohort retrospektif menggunakan rekam medik pasien striktur bilier distal maligna unresectable, yang meliputi kanker kaput pankreas, ampulla/ papilla vateri, atau kolangiokarsinoma distal pasca stent bilier per endoskopik, dilakukan di rsupn-cm pada juni 2015–agustus 2017. kesintasan kumulatif dinyatakan dengan kurva kaplan-meier. analisis bivariat dan multivariat dilakukan menggunakan regresi cox terhadap beberapa faktor yaitu kegagalan pemasangan stent, adanya perdarahan, sepsis, komorbid, malnutrisi, dan kadar albumin serum. hasil: dari total 120 subjek, 85 subjek meninggal 6 bulan pasca stent, dengan proporsi kesintasan 180 hari sebesar 24%, dan median kesintasan 81 hari (ik95% 56–106 hari). faktor komorbid, sepsis, malnutrisi, dan albumin ≤ 3,0 g/dl memiliki nilai p<0,25 pada analisis bivariat; sedangkan analisis multivariat berikutnya menunjukkan bahwa kadar albumin ≤ 3,0 g/dl memiliki hr 2,73 (ik95% 1,48–5,05; p=0,001). kesimpulan: kesintasan 6 bulan pasca stent bilier per endoskopik adalah 24% dengan median kesintasan 81 hari. kadar albumin ≤ 3,0 g/dl memiliki risiko 2,73 kali lebih besar untuk mortalitas 6 bulan. kata kunci: kesintasan, striktur bilier distal maligna, stent bilier per endoskopik, faktor terkait mortalitas, albumin. abstract background: unresectable malignant distal biliary stricture patients require endoscopic biliary stent placement procedure. the survival rate and its associated factors in indonesia are unknown. this study aimed to identify 6-month survival of patients with malignant distal biliary stricture following endoscopic biliary stent procedure and its associated factors. methods: a retrospective cohort study was conducted using medical records of patients with unresectable malignant distal biliary stricture, which involved caput of pancreas, ampulla of vater or distal cholangiocarcinoma following endoscopic biliary stent procedure between june 2015 and august 2017 at cipto mangunkusumo national central general hospital. the cumulative survival was defined by using the kaplanluki kusumaningtyas acta med indones-indones j intern med 32 meier curve. bivariate and multivariate analyses were performed using cox regression of some factors including failure of biliary stent insertion, bleeding, sepsis, comorbidities, malnutrition, and serum albumin levels. results: out of total 120 subjects, 85 subjects died within 6 months following the stent procedure with a proportion of 180day survival of 24% and a median survival of 81 days (ci 95%: 56–106 days). in bivariate analysis, factors of comorbidities, sepsis, malnutrition and albumin levels ≤ 3.0 g/dl had p values of < 0.25; while the subsequent multivariate analysis showed that albumin level of ≤ 3.0 g/dl had hr of 2.73 (ci 95%: 1.48 – 5.05; p = 0.001). conclusion: the 6-month survival following endoscopic biliary stent procedure is 24% with a median survival of 81 days. albumin level of ≤ 3.0 g/dl has a 2.73 times greater risk for 6-month mortality rate. keywords: survival, malignant distal biliary stricture, endoscopic biliary stenting, mortality-related factors, albumin. introduction distal biliary stricture with clinical manifestation of obstructive jaundice can be caused by pancreatobiliary malignancies and the cases are increasing from 48% 1 into 53% 2 at cipto mangunkusumo national central general hospital compared to previous data a decade ago. the pancreatobiliary malignancies may be primary, such as malignancies of the head of the pancreas (caput of pancreas), ampulla of vater, distal cholangiocarcinoma, or it may be secondary due to metastatic lesions, for instance.1,2 often, the patients are diagnosed with advanced stages, including both unresectable or unoperable patients; therefore, the mortality rate is high. in developing countries, the mortality rate due to pancreatobiliary malignancies ranks fifth following lung, colorectal, breast and prostate cancers.3 the 5-year survival rate of pancreatobiliary malignancy cases is only 5% or less, with a global median of 3to 6-month survival, and it is 4.1% in shanghai with a median survival time of 3.9 months.4 palliative care for biliary drainage may include performing endoscopic biliary stent procedure (ercp/ eus-bd).5,6 although the procedure is known as the first-line treatment in addition to percutaneous drainage or biliary bypass surgery, but it also has some risks for complications, which are associated with mortality.2,6 kurniawan et al found that the 3-month mortality rate for malignant obstructive jaundice cases is 55.2% with overall median survival time of 26 days.2 however, data on survival of patients with distal biliary stricture due to unresectable malignancy, particularly following palliative care of endoscopic biliary stent procedure has not been available in indonesia. the aim of our study was to identify 6-month survival rate of patients with malignant distal biliary stricture following endoscopic biliary stent procedure at pesc unit of cipto mangunkusumo national central general hospital in jakarta, as well as its associated factors. we assumed that some factors may affect the survival rate including comorbidities,2,7 malnutrition,7,8 low albumin level,9-11 bleeding,12,13 failure at biliary stent placement,2,13 and sepsis.2,7,8,14 methods our study was a retrospective cohort on adult patients (age >18 years), who had unresectable malignant distal biliary stricture case and underwent endoscopic biliary stent procedure at the gastrointestinal endoscopy center/ pusat endoskopi saluran cerna (pesc), department of internal medicine, cipto mangunkusumo hospital between june 2015 and august 2017. data was retrieved using total sampling technique by tracing medical records and electronic health record of the patients consecutively until the minimal limit of sample size was fulfilled, which was 120 subjects. the present study had been approved by medical ethic committee – faculty of medicine, university of indonesia with ethic number of 0298/un2.f1/etik/2018. t h e c o l l e c t e d d a t a i n c l u d e d s u b j e c t characteristics, which were age, sex, type of malignancies based on diagnostic workup (histopathology, radiology imaging and vol 52 • number 1 • january 2020 six-month survival of patients with malignant distal biliary stricture 33 ercp), history of other diseases for evaluation of comorbidities, sepsis, bleeding, status of successful biliary stent placement and the types, the current albumin level and nutritional status when the procedure was performed including malnutrition screening tools (mst) score and the current body mass index (bmi). the presence of comorbidities in the subjects was identified based on the total score of charlson comorbidity index of ≥ 4 as documented on their medical records. malnutrition was defined as unintentional weight loss or reduced dietary intake with mst score of ≥ 2, and/or the patient was categorized as underweight, i.e. bmi <18.5 kg/m2. the presence or absence of sepsis was categorized based on diagnosis made on the subjects’ medical records at their last hospitalization following biliary stent placement procedure, which was consistent with qsofa score criteria of ≥ 2 with an evidence of infection. hypoalbuminemia was defined as low serum albumin levels in subjects who had been examined on their last hospitalization for having endoscopic biliary stent procedure. the albumin level was categorized low when it was ≤ 3.0 g/dl. bleeding was defined when there is a clinical evidence of gastrointestinal bleeding or with difference of hb level of ≥ 2 gr/dl between before and after procedure. failure of biliary stent placement was defined by unsuccessful cannulation and/or biliary stent placement during ercp or eus-bd procedure by a competent operator. we evaluated outcomes of mortality and the time of death of the observed subjects (time to event), which were determined since the first placement of endoscopic biliary stent. when the subjects was untrackable (lost to follow up) on last observation after the procedure had been performed, the subject was considered as alive on the recorded date in last outpatient medical records and was censored in the survival analysis. data analysis was performed using statistic program of spss version 23.0 for univariate, bivariate and multivariate analyses. the level of significance used in our study was α = 0.05. variables were considered significant when the p value < 0.05. survival analysis using the kaplanmeier curve was performed, which was followed by cox proportional hazard regression. the variables were then included into a multivariate model when the p value < 0.25. results within the period of the study, we found 144 adult patients aged >18 years who fulfilled inclusion criteria. as many as 24 subjects were excluded due to incomplete data in their medical records; therefore, we found 120 subjects with characteristics as shown in table 1. table 1. subject’s characteristics characteristics n (%) age < 60 years 73 (60.8) ≥ 60 years 47 (39.2) sex male 56 (46.7) female 64 (53.3) histopathology carcinoma of caput pancreas 34 (28.3) papilla vater/ periampullar carcinoma 34 (28.3) distal cholangiocarcinoma 23 (19.2) inconclusive/ other lession 29 (24.2) stent successful 111 (92.5) plastic stent 80 (72.1) metal stent 31 (27.9) failed 9 (7.5) sepsis yes 28 (23.3) no 92 (76.7) bleeding yes 20 (16.7) no 100 (83.3) comorbidities present 59 (49.2) absent 61 (50.8) malnutrition yes 79 (65.8) no 41 (34.2) albumin > 3.0 g/dl 28 (23.3) ≤ 3.0 g/dl 92 (76.7) outcome 6 months 1 year alive 35 (29.2) 22 (18,3) dead 85 (70.8) 98 (81,7) luki kusumaningtyas acta med indones-indones j intern med 34 the proportion of survival in patients with malignant distal biliary stricture following endoscopic biliary stent procedure based on observation of day 30, 60, 90, 180 and 360 was 58%, 46%, 38%, 24% and 6%, respectively as can be seen in table 2; therefore, we found that the proportion of 3 month and 6 month mortality rate following the procedure was 62% and 76%, respectively. by the kaplan-meier curve in figure 1, showed that median survival time (which was the time when 50% of study subjects survived) was 81 days, with a range between 56-106 days after the biliary stent placement procedure had been done. affect the survival of subjects with malignant distal biliary stricture following endoscopic stent procedure. the analysis was done using cox regression analysis. the degree of association was presented in the form of hazard ratio (hr). four variables, which were included as candidates in the multivariate analysis using cox proportional hazard model (table 4), were variables with p value < 0.25 in the bivariate analysis, which were sepsis, the presence of table 2. proportion of survival in patients with malignant distal biliary stricture following endoscopic biliary stent procedure survival at day cumulative proportion of subjects alive (%) 30 58.0 60 46.0 90 38.0 180 24.0 360 6.0 figure 1. the kaplan-meier curve on 6-month survival of patients with malignant distal biliary stricture following endoscopic biliary stent procedure. table 3. bivariate analysis on factors affecting 6-month survival in patients with malignant distal biliary stricture following endoscopic biliary stent procedure. variables alive, n(%) dead, n(%) hr (95% ci ) p value stent failed 2 (22.2) 7 (77.8) 0.7 (0.3 – 1.6) 0.414 successful 33 (29.7) 78 (70.2) sepsis yes 4 (14.3) 24 (85.7) 1.6 (1.0 – 2.7) 0.035 no 31 (33.7) 61 (66.3) bleeding yes 6 (30.0) 14 (70.0) 1.2 (0.7 – 2.1) 0.592 no 29 (29.0) 71 (71.0) comorbidities present 14 (23.7) 45 (76.3) 1.4 (0.9 – 2.1) 0.119 absent 21 (34.4) 40 (65.6) malnutrition yes 18 (22.8) 61 (77.2) 1.8 (1.1 – 2.9) 0.017 no 17 (41.5) 24 (58.5) albumin ≤ 3.0 g/dl 19 (20.7) 73 (79.3) 2.7 (1.5 – 5.0) 0.001 > 3.0 g/dl 16 (57.1) 12 (42.8) bivariate analysis, which is presented in table 3, was performed to evaluate factors that vol 52 • number 1 • january 2020 six-month survival of patients with malignant distal biliary stricture 35 comorbidities, the presence of malnutrition and albumin level of ≤ 3.0 g/dl. at the end of multivariate analysis, we found a significant variable (p<0.05) that affected survival, which was serum albumin level of ≤3.0 g/dl. subjects with albumin level of 3.0 g/dl or less had a risk of death as great as 2.73 times (95% ci: 1.48 – 5.05) compared to subjects with albumin level > 3.0 g/dl. it was statistically significant with p value of 0.001. meanwhile, other variables, which were comorbidities, malnutrition and sepsis did not affect the subjects’ survival. discussion in the present study, out of 111 subjects who had successful placement of biliary stent procedure mostly were subjects with plastic stent, that were 80 (72.1%) subjects and the other 31 (27.9%) subjects had metal stent. median cumulative survival of subjects between both groups of biliary stent type was relatively very different, which was 66 days (95%ci: 38 – 93 days) for subjects with plastic stents and 160 days (95%ci: 53 – 267 days) for subjects with metal stent. the 3-month cumulative survival in a study conducted by kurniawan et al.2 on patients with malignant obstructive jaundice at cipto mangunkusumo hospital between 2010 and 2014 was 27.7% with median survival time of 26 days (95%ci: 20.8–31.2). such difference may occur since the sample population in kurniawan et al study also included all patients with pancreatobiliary malignancies that caused obstructive jaundice along with all kinds of treatment, both surgical and non-surgical treatment (endoscopic or percutaneous); while the population in our study was more homogenous, i.e. only unresectable pancreatobiliary malignancy cases located at the distal part of the biliary duct were included as the indication for performing endoscopic biliary stent procedure. another study conducted by saudale et al found that the one-year cumulative survival rate in patients with pancreatic cancer at cipto mangunkusumo hospital between 2012 and 2016 was 14% with median survival time of 6 months, which also means that the proportion of 6-month cumulative survival was 50% subjects.15 their results are different from our results that found the proportion of 6-month survival of 24% with median survival time of 81 days. the difference may occur since in the study15 is more specific and was only conducted in a population of pancreatic cancer patients with all kinds of care, either curative, palliative care or even without treatment. while in our study, we included all kinds of histopathological causes of malignant distal biliary stricture, not only the pancreatic cancer, but with homogenous treatment, i.e. only endoscopic biliary stent procedure as the biliary drainage. in the bivariate analysis of our study, we found that subjects who experienced sepsis had 1.6 times greater risk of death within 6 months following endoscopic biliary stent procedure table 4. multivariate analysis on factors affecting 6 month survival in patients with malignant distal biliary stricture following endoscopic biliary stent procedure steps variables hr (95%ci) p value 1st albumin ≤ 3.0 g/dl 2.22 (1.13 – 4.37 ) 0.021 malnutrition 1.31 (0.77 – 2.22) 0.314 comorbidities 1.28 (0.81 – 2.03) 0.292 sepsis 1.32 (0.79 – 2.19) 0.287 2nd albumin ≤ 3.0 g/dl 2.56 (1.38 – 4.75) 0.003 comorbidities 1.22 (0.78 – 1.92) 0.383 sepsis 1.36 (0.82 – 2.25) 0.232 3rd albumin ≤ 3.0 g/dl 2.58 (1.39 – 4.79) 0.003 sepsis 1.46 (0.91 – 2.36) 0.116 4th albumin ≤ 3.0 g/dl 2.73 (1.48 – 5.05) 0.001 luki kusumaningtyas acta med indones-indones j intern med 36 (95% ci: 1.0 – 2.7) and it was statistically significant on survival (p=0.035). however, when it was followed with multivariate analysis, sepsis became not significant (p=0.116). the results are different from those in chalya et al study in 2006 to 2010 that found sepsis as one of predictor factors for mortality in patients with obstructive jaundice (p<0.001).14 similar to that, a study by moghimi et al also support the results that sepsis is one of main predictors for mortality rate in hospitalized patients with odds ratio of 7.123 (95%ci: 4.78–13.54; p<0.001).8 another study by kurniawan et al found sepsis as an independent prognostic factor with hr of 2.46 (95%ci: 1.55–3.91; p<0.001) in addition to other evaluated factors, i.e. hypoalbuminemia, non-ampulla vater malignancies, initial bilirubin level of ≥15 mg/dl, unsuccessful/ no biliary drainage and charlson comorbidity index score of 4 or more.2 failure at endoscopic biliary placement had 0.7 times greater risk of death within 6 months following the procedure (95% ci: 0.3–1.6) based on bivariate analysis and it did not show statistically significant correlation to survival (p=0.414); therefore, it was not followed by multivariate analysis. biliary drainage in the malignancy cases was performed as an essential palliative therapy as it could alleviate clinical symptoms caused by hyperbilirubinemia; therefore, it enabled physical improvement and quality of life of the patient.6 with advances in endoscopic technique, ercp with biliary stent placement becomes main choice of treatment for malignant distal biliary stricture cases. when cbd cannulation is difficult to perform due to the obstructing tumor mass, the biliary stent can be placed using eus-bd.5,13 our study did not differentiate the proportion of how the procedure of endoscopic biliary stent placement was performed, whether by ercp or eus-bd. paik et al reported that there was no significant survival between ercp vs. eus-bd for biliary stent placement as primary palliative treatment in malignant obstructive jaundice, with overall median survival time in ercp group was 178 days compared to 144 days in the eus-bd group (p=0.92).16 the presence of comorbidities, which was evaluated with charlson comorbidity index score of ≥4, had 1.4 times greater risk of death within six months following endoscopic biliary stent procedure (95% ci 0.9–2.1) compared to subjects with score < 4 (p = 0.119). when it was continued with multivariate analysis, the comorbidities variable did not have a strong effect on 6-month survival and the power of this variable in our study was relatively low (31.4%). nakai y, et al.17 suggested that comorbidities have more roles as prognostic factors in patients with advanced stage of pancreatic cancer. though there are differences in capacity of predicting mortality using the index for cancer with a relatively long life expectancy (such as breast cancer or prostate cancer) compared to cancer with low life expectancy (lung cancer or pancreatic cancer), the charlson comorbidity index has been widely used in various studies that evaluate the correlation between comorbidities and mortality or with treatment success.18 based on bivariate analysis on the bleeding variable, we found that subjects with bleeding had mortality risk within 180 days following endoscopic biliary stent as many as 1.2 times (95%ci: 0.7–2.1). however, the presence or absence of bleeding did not have statistically significant correlation with subject’s survival (p > 0.592); therefore, it was not continued into multivariate analysis (p>0.25). bleeding with clinical evidence and signs of a decrease of hemoglobin level of more than 2 g/dl or there was a need for blood product transfusion were found as complications of ercp procedure performed at cipto mangunkusumo national central general hospital in 3 out of 54 patients (5.5%).12 although the rate of bleeding is relatively small, but with the presence of malignant lesion in biliary tract, particularly at distal area, the risk of difficult cannulation is also higher.13 hepatopancreatobiliar malignant lesion may cause hemostatic disorders, which are associated with impaired synthesis of clotting factors in the liver. the more difficult the cannulation procedure to be performed, the greater the risk of biliary trauma and bleeding.13 subjects with malnutrition had 1.8 times risk of death within 6 months following endoscopic vol 52 • number 1 • january 2020 six-month survival of patients with malignant distal biliary stricture 37 biliary stent procedure (95% ci=1.1–2.9) and had statistically significant correlation with subject survival (p=0.017). a study by prat et al7 suggested that the size of tumor and weight loss can also be predictors of survival. in patients with carcinoma of caput pancreas, 80-90% of them will experience a significant weight loss at the time the diagnosis is made.7 however, the factor is not consistent as prognostic factor. body weight does not exactly describe nutritional status of patients with cancer since there is extracellular fluid and edema. a more meticulous evaluation on nutritional status will increase the accuracy of the evaluation as in a study conducted by falconer et al that used albumin data.7 it is consistent with the results of multivariate analysis of our study, which found that malnutrition did not have a strong prognostic correlation on subject’s survival with the biggest p value (p=0.314) when it was compared to other variables. albumin is an acute phase protein and its level decreases during inflammation, trauma and injury. albumin level can not reflect an adequate nutritional intake of the patients. moreover, hypoalbuminemia is highly associated with outcomes of mortality and poor morbidities such as post-gastrointestinal surgery infection.19 based on multivariate analysis in our study, the factor that affected subject survival the most was low albumin level of ≤ 3.0 g/dl. subjects in such group had 2.73 times greater risk of mortality (95%ci: 1.48 – 5.05) compared to those in the group with albumin level of >3.0 g/dl, and it was statistically significant (p=0.001). it is similar to park et al study20, which demonstrated that patients with advanced stage of cholangiocarcinoma (unresectable) who had albumin level of >3.0 g/dl had better prognosis than patients with serum albumin level of ≤ 3.0 g/ dl. akirov et al21 reported that hypoalbuminemia at the time of hospital admission correlated with the further lower serum albumin level before hospital discharge or on patients’ mortality with risk of > 70%. normalization of albumin level before the patients are discharged from the hospital is associated with reduced risk of death as much as 51%. the benefits and limitations of study t h e p r e s e n t s t u d y i s t h e f i r s t s t u d y conducted to evaluate survival following palliative endoscopic biliary stent procedure for unresectable malignant distal biliary stricture cases at cipto mangunkusumo hospital in jakarta. using cohort design, we could identify the proportion, mortality time, median survival time and the associated factors. after we evaluate the power of survival analysis in this study to measure the effect of variables on the survival of the subject during 6 months of observation, we obtained one variable i.e hypoalbuminemia (serum albumin level ≤ 3.0 g/dl) that has excellent power (99.6%). the limitation of the present study is retrospective design as it was based on medical record data; therefore, the variables of sepsis, comorbidities and nutritional status could not be explored further. moreover, it is difficult to evaluate the non-clinical issues that could affect services for the patients such as the speed of referral system. our study was conducted only in a single hospital, which is the highest referral national hospital in indonesia; therefore, the results may be less representative for similar patients in other hospitals of various settings. conclusion as many as 24% patients with malignant distal biliary stricture at cipto mangunkusumo hospital survive within a period of 6 months following endoscopic biliary stent procedure with median survival time of 81 days. factors affecting 6-month survival in patients with malignant distal biliary stricture following endoscopic biliary stent procedure are albumin level of ≤ 3.0 mg/dl with 2.73 times greater risk for mortality incidence. the variable has an excellent power of study (99.6%). references 1. oto bt, fauzi a, syam af, et al. identification and stenting of malignant obstructive jaundice : determining the success rates of ercp. indones j gastroenterol hepatol dig endosc. 2012;13(1):19–22. 2. kurniawan j, hasan i, gani ra, simadibrata m. mortality-related factors in patients with malignant luki kusumaningtyas acta med indones-indones j intern med 38 obstructive jaundice. acta med indones-indones j intern med. 2016;48(4):282–8. 3. yunihastuti e, lesmana la, syam af, hasan i. nonsurgical biliary drainage on biliary obstruction due to malignancy. indones j gastroenterol, hepatol, dig endosc. 2001;2(2):8–20. 4. luo j, xiao l, wu c, zheng y, zhao n. the incidence and survival rate of population-based pancreatic cancer patients: shanghai cancer registry 2004–2009. plos one. 2013;8(10):1-7, e76052. 5. makmun d, fauzi a, abdullah m, syam af. the role of eus-bd in the management of malignant biliary obstruction: the indonesian perspective. diagn ther endosc. 2017;1–8. 6. pu lzct, singh r, loong ck, de moura egh. malignant biliary obstruction: evidence for best practice. gastroenterol res pract. 2016;1–7. 7. prat f, chapat o, ducot b, et al. predictive factors for survival of patients with inoperable malignant distal biliary strictures: a practical management guideline. 1998;76–80. 8. moghimi m, marashi sa, salehian mt, sheikhvatan m. obstructive jaundice in iran: factors affecting early outcome. 2008;7(5):515–9. 9. afshar m, khanom k, ma yt, punia p. biliary stenting in advanced malignancy: an analysis of predictive factors for survival. cancer manag res. 2014;6:475–9. 10. tipsunthonsak n, piriyasupong t, piriyaskanon a. efficacy of iliary stent drainage and factors associated with complications in endoscopic palliative treatment of patients with hilar cholangiocarcinoma. thai j surg. 2011;32:26–34. 11. waghray a, sobotka a, marrero cr, estfan b, aucejo f, menon kvn. serum albumin predicts survival in patients with hilar cholangiocarcinoma. 2017;5:62–6. 12. sitompul r, fauzi a, makmun d, abdulah m, fahrial a, marcellus s. post-endoscopic retrograde cholangio-pancreatography complications at dr . cipto mangunkusumo general national hospital. indones j gastroenterol hepatol dig endosc. 2009;10(2):41–5. 13. liao w, angsuwatcharakon p, isayama h, dhir v. international consensus recommendations for difficult biliary access. gastrointest endosc. 2017;85(2):295– 304. 14. chalya pl, kanumba es, mchembe m. etiological spectrum and treatment outcome of obstructive jaundice at a university teaching hospital in northwestern tanzania: a diagnostic and therapeutic challenges. bmc res notes. 2011;4(1):147. 15. saudale a, gani r, rumende c. kesintasan satu tahun kanker pankreas dan faktor-faktor yang memengaruhinya. universitas indonesia; 2018. 16. paik wh, lee th, park dh, et al. eus-guided biliary drainage versus ercp for the primary palliation of malignant biliary obstruction: a multicenter randomized clinical trial. am j gastroenterol. 2018;113(7):987–97. 17. nakai y, isayama h, sasaki t, et al. comorbidity, not age, is prognostic in patients with advanced pancreatic cancer receiving gemcitabine-based chemotherapy. crit rev oncol hematol. 2011;78(3):252–9. 18. chang c, yin w, wei c, wu c, su y. adjusted ageadjusted charlson comorbidity index score as a risk measure of perioperative mortality before cancer surgery. plos one. 2016;09:1–16. 19. afaneh c, gerszberg d, slattery e, seres ds, chabot ja, kluger md. pancreatic cancer surgery and nutrition management: a review of the current literature. hepato biliary surg nutr. 2015;4(1):59-71. 20. park j, kim m, kim k, et al. natural history and prognostic factors of advanced cholangiocarcinoma without surgery, chemotherapy, or radiotherapy : a large-scale observational study. gut liver. 2009;3(4):298–305. 21. akirov a, masri-iraqi h, atamna a, shimon i. low albumin levels are associated with mortality risk in hospitalized patients. am j med. 2017;130(12):1465. e11-1465.e19. 3 original article acta med indones indones j intern med • vol 50 • number 1 • january 2018 adaptation of the tool to estimate patient costs questionnaire into indonesian context for tuberculosis-affected households ahmad fuady1,2, tanja a.j. houweling1, muchtaruddin mansyur2, jan h. richardus1 1 department of public health, erasmus mc, university medical center rotterdam, the netherlands. 2 department of community medicine, faculty of medicine universitas indonesia, jakarta, indonesia. corresponding author: ahmad fuady, md, msc. department of public health, erasmus mc, university medical center rotterdam, the netherlands – wytemaweg 80, 3015 cn rotterdam, the netherlands. department of community medicine, faculty of medicine universitas indonesia. jl pegangsaan timur 16, jakarta 10320, indonesia. email: a.fuady@erasmusmc.nl, ahmadfuady01@ui.ac.id. abstrak latar belakang: indonesia adalah negara dengan prevalensi tuberkulosis (tb) tertinggi kedua di dunia. karena itu, sangat membutuhkan perbaikan dan inovasi atas strategi yang diterapkan di seluruh wilayah. satu langkah mendasar dalam memantau penerapan ini adalah menyiapkan alat yang divalidasi untuk mengukur total biaya pasien dan total biaya bencana. organisasi kesehatan dunia (who) merekomendasikan menggunakan versi kuesioner generik yang telah disesuaikan dengan konteks budaya lokal untuk menafsirkan temuan dengan benar. tujuan penelitian ini adalah mengadaptasi kuesioner “the tool to estimate patient costs” untuk menghitung biaya total dan biaya total katastrofik pada rumah tangga terdampak tuberkulosis (tb) di indonesia. metode: perangkat tersebut diadaptasi sesuai panduan terstruktur. berdasarkan ujicoba yang dilakukan pada studi sebelumnya (dinamakan sebagai ‘studi fase 1’). kami mengembangkan proses adaptasi dengan membandingkannya dengan kuesioner generik yang dikeluarkan oleh who serta mengevaluasinya dalam pertemuan komite pakar. kami melakukan uji coba pada 30 pasien tb, menerima umpan balik kemudian melengkapinya dengan lembar penjelasan sebelum finalisasi kuesioner. hasil: tujuh puluh dua perubahan mayor dilakukan selama proses adaptasi, termasuk mengubah pilihan jawaban agar sesuai dengan konteks indonesia, memperbaiki alur pertanyaan, menghapus pertanyaan, mengubah susunan kata dan mengembalikan pertanyaan asli yang diubah sebelumnya di studi fase 1. partisipan menyatakan bahwa pertanyaan jelas dan mudah dipahami. untuk mengatasi kesulitan partisipan mengingat data yang ditanyakan, kami melakukan beberapa perubahan untuk mendapatkan data yang mungkin tidak terisi, misalnya dengan merujuk data pada rekam medis, membuat proxy biaya, dan memandu pewawancara untuk menanyakan harga tertentu jika partisipan tidak yakin harga perkiraan pasar dari barang yang mereka jual. kesimpulan: ‘the tool to estimate patient costs’ yang diadaptasi dalam bahasa indonesia dinilai komprehensif, siap dipakai untuk studi lain tentang biaya katastrofik terkait tb dan untuk memonitor pencapaian target the end tb strategy. kata kunci: tuberkulosis, biaya pasien, biaya katastrofik, adaptasi, indonesia. abstract background: indonesia is the second-highest country for tuberculosis (tb) incidence worldwide. hence, it urgently requires improvements and innovations beyond the strategies that are currently being implemented throughout the country. one fundamental step in monitoring its progress is by preparing a validated tool to measure total patient costs and catastrophic total costs. the world health organization (who) recommends ahmad fuady acta med indones-indones j intern med 4 using a version of the generic questionnaire that has been adapted to the local cultural context in order to interpret findings correctly. this study is aimed to adapt the tool to estimate patient costs questionnaire into the indonesian context, which measures total costs and catastrophic total costs for tuberculosis-affected households. methods: the tool was adapted using best-practice guidelines. on the basis of a pre-test performed in a previous study (referred to as phase 1 study), we refined the adaptation process by comparing it with the generic tool introduced by the who. we also held an expert committee review and performed pre-testing by interviewing 30 tb patients. after pre-testing, the tool was provided with complete explanation sheets for finalization. results: seventy-two major changes were made during the adaptation process including changing the answer choices to match the indonesian context, refining the flow of questions, deleting questions, changing some words and restoring original questions that had been changed in phase 1 study. participants indicated that most questions were clear and easy to understand. to address recall difficulties by the participants, we made some adaptations to obtain data that might be missing, such as tracking data to medical records, developing a proxy of costs and guiding interviewers to ask for a specific value when participants were uncertain about the estimated market value of property they had sold. conclusion: the adapted tool to estimate patient costs in bahasa indonesia is comprehensive and ready for use in future studies on tb-related catastrophic costs and is suitable for monitoring progress to achieve the target of the end tb strategy. keywords: tuberculosis, patient costs, catastrophic costs, adaptation, indonesia. introduction indonesia is achieving slow progress in its struggle to eliminate tuberculosis (tb). with the world’s second-highest tb incidence worldwide,1 it urgently requires improvements and innovations beyond the strategies that are currently being implemented throughout the country. while training of healthcare workers is essential, it is also important to note that access to healthcare often brings financial hardship to tb patients. the most vulnerable are poor families, who must deal not only with medical costs, but also with non-medical costs, such as travel and supplementation costs, which can drain up to half of their annual income.2,3 all these costs are compounded by potential income loss.4 challenges in eliminating tb therefore go beyond clinical management and are often related to socioeconomic problems. these problems can increase delay in tb diagnosis and treatment and plunge patients into a more severe state of tb illness and a higher risk of treatment failure and mdr-tb development.2–4 this, in turn, will lead to more complicated cases with substantial implications for clinical management. clinicians should therefore consider the financial problems faced by tb patients and their affected families during consultations. many patients, because of embarrassment, prefer firstly to seek care from private providers rather than public health facilities, regardless of their financial capacity. assessing patients’ financial capability will help clinicians to decide whether they can prescribe additional diagnostic tests such as x-ray and branded drugs that may be unaffordable for patients. otherwise, they should refer patients to public health facilities linked to the national tuberculosis program (ntp) that provides free laboratory examinations and tb treatment. during tb treatment, clinicians should also assess whether patients can afford transportation costs before deciding the number of visits per month. assessing all of these issues is important to increase patients’ adherence to the tb diagnostic procedures and treatment, as well as tb treatment success. understanding the complexity of tb burden, the end tb strategy acknowledges the importance of these socioeconomic determinants in its target that by 2020, no tb-affected family should face catastrophic spending due to tb.5–7 in some countries including indonesia, it is very important that progress towards this target is monitored properly. one fundamental step in monitoring progress is preparing a validated tool for measuring total patient costs and catastrophic total costs. the world health organization (who) recommends using a version of the vol 50 • number 1 • january 2018 adaptation of the tool to estimate patient costs questionnaire 5 generic questionnaire “the tool to estimate patient costs”7,8 (henceforth referred to as the generic tool) that has been adapted to the local cultural context in order to interpret findings correctly.9,10 before indonesia implemented universal health coverage (uhc) in 2014, van den hof et al. had adapted the generic tool to be used in indonesia and it was pretested in 2013 study. for the sake of convenience, we refer to the study as the phase 1 study.11,12 however, the tool is no longer suitable with recent situation partly due to implementation of uhc and various answer categories in the phase 1 tool including categories on health insurance and healthcare facilities. also, since the pretesting in the phase 1 study involved only five multi-drug-resistant (mdr) tb patients, a larger sample size was needed to perfect the adaptation. to monitor progress towards the target of eliminating catastrophic spending on tb in indonesia, the present study aimed to pursue further adaptation of the questionnaire that had been developed in the phase 1 study. methods the adaptation of the tool to estimate patient costs questionnaire consisted of two phases. the first phase was performed separately by van den hof et al as a preliminary indonesian study (the phase 1 study) in 2013.12 our study, which was referred to henceforth as the phase 2 study, comprised the second phase of adapting the generic tool. our study had a cross-sectional design and was conducted in 2016. in line with existing guidelines,13,14 the whole process of adaptation consisted of seven steps. while the phase 1 study went through all the steps from i to vii, our phase 2 study re-ran steps v to vii, i.e. production of the definitive indonesian language version of the tool. (figure 1) study population we interviewed 30 tb patients who had undergone at least one month of tb treatment in two sub-district primary health centres (phcs, puskesmas), east jakarta, which were puskesmas cakung and puskesmas jatinegara. figure 1. study design: adaptation of the tool ahmad fuady acta med indones-indones j intern med 6 we tracked patients registered on the tb patient list and chose patients who met the inclusion criteria consecutively from the most recent date of treatment initiation. in phc cakung, we invited tb and mdr-tb patients to come to phc and interviewed patients who were coming to the phc consecutively. on three consecutive days, we interviewed 18 patients. in phc jatinegara, we made calls to the patients to make an appointment and visited them at home for an interview until 12 tb and mdr-tb patients had participated. if patient could not be interviewed because they were unable to communicate or not available at the time of interview, we asked their caregiver (termed “drug observer”) to participate in the study. the procedure brought the total number of interviewees to 30. phase 1 study the principal investigator of the phase 1 study was a researcher from the kncv tuberculosis foundation in the netherlands, where the generic tool was originally developed. the study was prepared in indonesia together with local researchers, one of whom was appointed to prepare for the forward translation into bahasa indonesia. various questions, such as insurance types, types of healthcare facility and reimbursement schemes, were adapted to the local context. to check for interpretation errors, the questionnaire was back-translated and then pretested on five mdr-tb patients at persahabatan hospital, in jakarta.11 its clarity for patients and interviewers was tested. after the pre-testing, further adaptations were made culminating in the final version of the phase 1 study tool. we obtained the final version and compared it with the english version of the generic tool. phase 2 study in our phase 2 study, we further refined the adapted version of the tool to current indonesian context. rather than going through all of the steps again, we used the phase 1 study tool as a starting point for adaptation and began the process at step v (i.e. expert committee review). before doing so, we contacted the researchers of the phase 1 study by telephone and email and asked their permission to use their version for further adaptation. expert committee review the objective of the expert committee review (step v) was to check the content of the tool once again. for the purpose, we held a meeting and invited key persons to discuss the phase 1 tool. besides local researchers, the meeting included the following external experts: a pulmonologist specialized in infectious disease, a staff member from the sub-directorate for tuberculosis at the ministry of health republic of indonesia and a psychometrics expert. before the meeting, the principal investigator, an indonesian citizen, made a brief report in which he commented on questions and choices in the generic tool that remained uncertain or could be misinterpreted. the committee then compared the generic tool and the phase 1 study tool, focusing on various sections in the who protocol that would need to be adapted to the local context. the adaptations included provider type, the tb care-delivery model, sociodemographic variables, net revenue from labourrelated activities, health insurance and social protection and household assets. in addition to revising these sections, the committee also checked the entire generic tool and suggested some changes to the phase 1 study tool. this stage resulted in a penultimate indonesian translation version of the tool. pre-testing in a one-day training session before the pre-testing, we trained six medical students to interview 30 tb and mdr-tb patients or their caregiver (if the patient were unable or unavailable for interview) in two sub-district phcs of east jakarta. after each respondent had been interviewed, interviewers reported any difficulties they had encountered with regard to completing the tool or to the respondents’ understanding of the questions. the researchers also discussed the findings, made changes and formulated the final version of the tool in indonesian language. final version after pretesting and refinement, we developed the final version of the tool. we also provided comprehensive explanation sheets to guide the interview. vol 50 • number 1 • january 2018 adaptation of the tool to estimate patient costs questionnaire 7 ethics pre-testing the tool was part of our main study, which assessed catastrophic total costs among tb-affected households. we had obtained ethical approval from the ethical committee of the faculty of medicine, universitas indonesia and cipto mangunkusumo hospital (no. 416/ un2.f1/etik/vi/2016) before commencing the study. before the interview, we provided oral and written explanation to respondents and required them to sign informed consent forms. we ensured the confidentiality of all information collected from the interview. results in total, 72 major changes were made during the adaptation process from the generic tool to the final version of phase 2 study (see annex). the adaptations consisted of the following: reformulating questions and choices to reflect the current indonesian context; re-structuring the ordering of several questions; deleting certain questions from the generic tool; and later restoring questions which had previously been deleted in the phase 1 study. phase 1 study involved 60 changes relative to the generic tool. as well as the addition of two question sets under new sub-topics (moving costs and adverse effect costs), these changes included changing question sets into table form, adding seven questions and one sub-question, altering five answer choices and two wordings, and deleting three question sets (sub-topics) and 33 questions. the most important change made in the phase 1 study was the overall flow of the tool. in the generic tool, the questions are grouped on the basis of the types of cost. this required respondents to recall the costs they had incurred back and forth between the pre-diagnostic, diagnostic, and treatment phases. to facilitate the flow of interview, the phase 1 study had rearranged the flow to match the time sequence. other prominent changes involved redesigning some questions into table form, which made it easier for the interviewers to ask them and thereby to complete the tool. during the expert review meeting in phase 2 study, we changed the answer choices relating to provider type from “health post (pos kesehatan)”, “phc (puskesmas), and “district hospital (rsud)” to “phc (puskesmas)”, “private clinic”, “public hospital”, “private hospital”, and “other”. with reference to the tb delivery model, we changed the term “dot” (directly observed treatment), which respondents may not know, to “visit to take tb drugs” to make it easier for participants to understand the questions. in the section with socio-demographic questions, we changed categories relating to income payments (paid regularly, uncertain, paid in kind, not paid, and others). we also changed a question from “currently formally employed” to “formally employed before being diagnosed”, and followed with the question “did you have to change or quit your employment after being diagnosed with tb?”. we restored a question “how many people regularly sleep in your household”, and modified it to “how many family members live in your household?”. as uhc had been implemented in indonesia since the phase 1 study, the insurance system had changed. using the abbreviation bpjs to indicate the national health insurance agency (badan penyelenggara jaminan sosial, bpjs), we adapted the types of insurance to governmentpaid bpjs, self-paid bpjs, and private insurance. no changes were made to questions in the revenue section. however, we made changes in the costs section, including the type of supplement taken (“drinks” to “milk”); the frequency of taking supplementation (from “per month” to “per week”); and the coping section (by changing the order of the questions on the amount of money gained from selling property). we also changed some wordings to make it easier for participants to understand questions, for example changing the term “smear” to “basil tahan asam (bta)” or the acid-fast bacili (afb) testing, and “pengembalian asuransi” to “reimbursement asuransi”. we retained 38 questions that were the result of adaptations made in the phase 1 study. we also restored 12 original questions from the generic tool that had been changed, and five original questions that had been deleted in the phase 1 tool. the restored questions included “date of ahmad fuady acta med indones-indones j intern med 8 first diagnostic examination”, “date of starting treatment”, “where did you seek treatment?”, “what symptoms did you experience?”, and “why didn’t you go to a public facility?”. we also deleted three questions and three answer choices that had been added in the phase 1 study. pre-testing seventy-four percent of the participants received the category i therapy regimen; only 7% took mdr therapy. the majority (63%) underwent tb treatment in the continuation phase. (table 1) added explanatory notes for interviewers in the interview guidance. instead of asking these data to participants, interviewers should track the data in the patients’ medical records. respondents had difficulty to estimate transportation costs if they used their own vehicle. to deal with that, we guided interviewers to ask transportationrelated costs such as parking or toll fees, but not fuel costs. many participants received bills from healthcare facilities that stated total amount of cost without any itemization. they had difficulty to distinguish between administration, laboratory, x-ray and drug costs. in such cases, we allowed interviewers to enter the total amount under administration costs. we deleted sub-questions under hospitalization costs and left only one question on total hospitalization costs since participants could not explain the detail of hospital item costs. if a tb patient had sold property and did not know the estimated market value, we added a question “did the price conform to the estimated market value?” and trained interviewers to ask the specific price when participants were uncertain about the market value of property they had sold. annex 2 (available on www.actamedindones. org) contains the final version of the questionnaire resulting from our phase 2 study, along with the explanatory notes. discussion the tool was successfully adapted to the current indonesian context. it is now ready for use in similar studies on tb cost measurement and for monitoring progress to achieve the end tb strategy target. under the terms of the strategy, the government should monitor the target until 2035. monitoring tb-related costs can help identify determinants of tb treatment outcomes and reduce the risk of treatment failure, severe adverse outcome, and further spread of tb, mdr-tb, or even xdr-tb because of socioeconomic problems.2,4,15–17 in our view, the adapted tool is suitable for the purpose as it is more comprehensive than previous versions and is fully consistent with the situation in indonesia since the implementation of uhc. the tool can measure not only total table 1. subject’s characteristics variables n (%) participant tb patients 27 (90.0) drug observers 3 (10.0) sex male 15 (50.0) female 15 (50.0) age category, years 18-30 5 (17.0) 31-40 6 (20.0) 41-50 5 (17.0) >50 14 (46.0) educational level low 10 (33.0) intermediate 20 (67.0) type of tb pulmonary, smear + 22 (73.0) pulmonary, smear 7 (23.0) pulmonary, smear unknown 1 (4.0) therapy regimen cat i 22 (73.0) cat ii 6 (20.0) mdr 2 (7.0) therapy phase intensive phase 11 (37.0) continuation phase 19 (63.0) the respondents indicated that the majority of questions were clear and easy to understand. however, they had problems answering some others. most respondents forgot the date of their first tb examination (63%) and the date they started treatment (57%). neither did they know their hiv status (53%). we therefore vol 50 • number 1 • january 2018 adaptation of the tool to estimate patient costs questionnaire 9 costs, but – as recommended by the who – also catastrophic total costs.7 besides the refinements made to the phase 1 version of the tool, the strengths of this study include the relatively large number of respondents recruited, their wide age-range, and the balance between the sexes. the limitation is the fact that we only interviewed participants who were undergoing tb and mdr-tb treatment in phcs. thereby we excluded those who underwent tb treatment in other types of health facility or who dropped out of tb treatment. however, this limitation has been acknowledged in the who protocol, which excludes tb patients treated in facilities that are not linked to the national tuberculosis program. it means that the adapted tool is now the most appropriate questionnaire for measuring catastrophic total costs. the translation version that has been followed from the phase 1 study is acceptable and easily understood and there was no need for re-translation from english into bahasa indonesia. however, difficulties were encountered when we were seeking appropriate translations for terms such “dot”, “dispensary”, and “mission hospital” that have no specific equivalent in indonesian language, which may cause misunderstanding. another potential source of misunderstanding was how participants define “primary income earner” or “pencari nafkah”, which may lead to confusion between “pencari nafkah” (primary income earner/breadwinner) and “kepala keluarga” (head of family). we therefore inserted an explanation of “primary income earner” as the highest earners who actually spent their earnings on financing the household. in rural or remote areas of indonesia where the indonesian language is not being used in daily life, future studies should further adapt the tool to the cultural context and local languages. it is imperative that all question items are explained clearly in the local languages. the adaptation of the tool also provides useful insights for clinical practice. instead of merely focusing on clinical complaints of tb patients, clinicians should also take socioeconomic problems into account, including the availability of health insurance, traveling costs to visit the health facility, and potential income or job loss faced by the patient and their families. assessing patients’ financial capacity will help clinicians to decide on appropriate prescription, including any additional supplements needed. clinicians may also refer patients to existing social protection programs, e.g., national health insurance or national employee insurance, if patients are uninsured, or refer them to primary health centers that provide tb diagnostic and treatment freely. conclusion our adapted version of the tool to estimate patient costs had been proven to be acceptable for use in indonesia. together with its explanations, it is easily understood by interviewers and interviewees. it is also ready for use in future studies on tuberculosis-related cost estimation and catastrophic spending measurement. acknowledgments special thanks are due to jahja umar, diah handayani, and budiyarti setiyaningsih for their discussion, valuable comments and inputs in the expert committee review. we also acknowledge edine tiemersma, firdaus hafidz, and bintari dwi hardiani who allowed and provided phase 1 tool for further adaptation. we also thank david alexander for language editing and all interviewers who helped collect the data. copyright license statement the authors declare that they have no competing interests and own the copyright of the phase 2 tool. references 1. world health organization. global tuberculosis report 2016. 21st ed. geneva: world health organization; 2016. 2. tanimura t, jaramillo e, weil d, raviglione m, lönnroth k. financial burden for tuberculosis patients in lowand middle-income countries: a systematic review. eur respir j. 2014;43(6):1763–75. 3. ortblad kf, salomon ja, bärnighausen t, atun r. stopping tuberculosis: a biosocial model for sustainable development. the lancet. 2015;386(10010):2354–62. 4. wingfield t, boccia d, tovar m, et al. defining catastrophic costs and comparing their importance for adverse tuberculosis outcome with multi-drug resistance: a prospective cohort study, peru. plos ahmad fuady acta med indones-indones j intern med 10 med. 2014;11(7):e1001675. 5. world health organization. who end tb strategy. geneva: world health organization; 2015. available from: http://www.who.int/tb/post2015_strategy/en/ 6. world health organization. global strategy and targets for tuberculosis prevention, care and control after 2015. geneva: world health organization; 2013. report no.: eb134/12. 7. world health organization. protocol for survey to determine direct and indirect costs due to tb and to estimate proportion of tb-affected households experiencing catastrophic total costs due to tb. geneva: world health organization; 2015. 8. mauch v, woods n, kirubi b, kipruto h, sitienei j, klinkenberg e. assessing access barriers to tuberculosis care with the tool to estimate patients’ costs: pilot results from two districts in kenya. bmc public health. 2011;11:43. 9. epstein j, santo rm, guillemin f. a review of guidelines for cross-cultural adaptation of questionnaires could not bring out a consensus. j clin epidemiol. 2015;68(4):435–41. 10. mokkink lb, terwee cb, patrick dl, et al. the cosmin checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: an international delphi study. qual life res int j qual life asp treat care rehabil. 2010 may;19(4):539–49. 11. tiemersma e, hafidz f. costs faced by (multidrug resistant) tuberculosis patients during diagnosis and treatment: report from a pilot study in indonesia. the hague, the netherlands: kncv tuberculosis foundation; 2014. 12. van den hof s, collins d, hafidz f, beyene d, tursynbayeva a, tiemersma e. the socioeconomic impact of multidrug resistant tuberculosis on patients: results from ethiopia, indonesia and kazakhstan. bmc infect dis. 2016;16:470. 13. bruyère o, demoulin m, beaudart c, et al. validity and reliability of the french version of the start back screening tool for patients with low back pain. spine. 2014;39(2):e123-128. 14. beaton de, bombardier c, guillemin f, ferraz mb. guidelines for the process of cross-cultural adaptation of self-report measures. spine. 2000;25(24):3186–91. 15. dheda k, barry ce, maartens g. tuberculosis. lancet. 2016;387(10024):1211–26. 16. lawn sd, badri m, wood r. tuberculosis among hiv-infected patients receiving haart: long term incidence and risk factors in a south african cohort. aids lond engl. 2005;19(18):2109–16. 17. baral sc, aryal y, bhattrai r, king r, newell jn. the importance of providing counselling and financial support to patients receiving treatment for multi-drug resistant tb: mixed method qualitative and pilot intervention studies. bmc public health. 2014;14:46. case report 51acta medica indonesiana the indonesian journal of internal medicine primary tuberculosis of the breast manifested as abscess: a rare case report samita gupta1, vikram j. singh2, gaurav bhatia2, kshitiz dhuria3 1 department of radiology, maharishi markendeshwar institute of medical sciences and research, mullana, distt-ambala, haryana, india. 2 department of surgery, maharishi markendeshwar institute of medical sciences and research, mullana, distt-ambala, haryana, india. 3 department of radiology, maharishi markendeshwar institute of medical sciences and research, mullana, distt-ambala, haryana, india. correspondence mail: dr. samita gupta, md. assistant prof, department of radiology, maharishi markendeshwar institute of medical sciences and research, mullana, distt-ambala, haryana, india. email: singalsurgery@yahoo.com. abstrak tuberkulosis primer di payudara merupakan suatu entitas penyakit yang jarang terjadi. kami melaporkan sebuah kasus tuberkulosis primer di payudara yang tampak sebagai abses payudara. secara histopatologi, kasus ini didiagnosis sebagai tuberkulosis payudara. aspirasi sitologi tidak dilakukan karena adanya abses di payudara. pasien diberikan obat anti-tuberkulosis. pada evaluasi lanjut, kondisi pasien ternyata membaik dalam 3 bulan. kata kunci: payudara, abses, tuberkulosis, pengobatan konservatif. abstract primary breast tuberculosis is a rare entity. we are reporting a case of primary breast tuberculosis, which presented as breast abscess. on histopathology, it was diagnosed as breast tuberculosis. aspiration cytology was not done due breast abscess. patient was put on anti-tubercular drugs. in follow up, after 3 months patient condition was improved. key words: breast, abscess, tuberculosis, conservative treatment. introduction breast tuberculosis (tb) is a rare form of extra pulmonary tb first described by sir astley cooper in 1829.1 although over one billion people suffer from tb worldwide, mammary tuberculosis is an extremely rare condition. the incidence of isolated tb of the breast ranges from 0.10% to 0.52%.2 is scarcely reported even in countries with a high incidence of tuberculosis infection. this is explained by a noticeable resistance of the mammary tissue to the mycobacterium tuberculosis.3 its primary form is even more infrequent. case illustration a 42 year old female reported with pain in the right breast since two months with on and off fever. she started feeling heaviness in her right breast since 20 days before. there were no other complaints. patient was taking treatment 52 samita gupta acta med indones-indones j intern med from private hospital but there was no relief. on examination of the right breast, temperature was raised and tender lump was felt in the upper outer quadrant. lump was firm in consistency. on needle aspiration, thick pus came out. total leukocyte counts and erythrocyte sedimentation rate was raised. rests of tests were within normal limits including chest x-ray. mantoux test was positive. ultrasonography of the breast revealed a large homogeneous capacity in right breast with area of asymmetrical density. (figure 1) thick pus of about 100 ml was drained out. pus was sent for acid fast bacilli stain and culture test which came negative. on histolopathology, to our surprisingly, diagnosis made as breast tuberculosis (figure 2). patient was put on anti tubercular drugs (rifampicin 600 mg, isoniazid 300 mg, pyrazinamide 1500 mg and ethambutol 1000 mg per day) was initiated for 2 months and continued with the addition of rifampicin and isoniazid therapy for an additional four months. in follow up of 3 months, patient recovered very well and advised to continue treatment. ranging from 0.10% to 0.52%.in the high tubercular endemic countries like india, the incidence represents 3 to 4.5% of the mammary pathologies.4 in the western countries, with a lower tubercular incidence, it represents less than 0.1% of the mammary lesions examined via histology.3,5 tuberculosis of the breast is usually affects women aged between 20 and 50 years. breast involvement can be either primary without any extra-mammary focus, or secondary to pulmonary tuberculosis. the primary form of the disease is rare.6 breast tissue, along with skeletal muscle and spleen, appears to be relatively resistant to tuberculous infection.7 the commonest location of the lump is the central or upper outer quadrant of the breast.8 the mass may be fluctuant and is usually covered with indurated tissue. it is usually fixed to the skin and fistulization is not uncommon. nipple and skin retraction can also occur but breast discharge and pain are not common.9 it may be classified into three types, namely: nodular, disseminated and sclerosing varieties. mckeown and wilkinson classified tuberculosis of the breast into five different types: the three stated above and acute miliary tuberculosis mastitis and tuberculosis mastitis obliterans.10 the nodular form is the most common variety and is characterized by a well defined, painless, figure 1. ultrasonography of breast showed hypoechoic lesion with multiple internal echoes discussion isolated tuberculosis of the breast is uncommon, even in developing countries where pulmonary and other forms of extrapulmonary manifestations of tb are endemic. the incidence of isolated tb of the breast remains low, figure 2. photomicrograph showing caseating granuloma in the breast (h & e ,x – 200) 53 vol 46 • number 1 • january 2014 primary tb of the breast manifested as abscess: a rare case report slow growing caseous lesion in the breast. involvement of overlying tissue is usually late and it is at this point that the mass becomes painful. as in our case patient presented with breast abscess and on histology diagnosis came as tuberculosis which is very rare. ultrasound is useful for characterising the ill-defined densities shown on mammography by excluding solid masses, but the findings of a hypoechoic lesion with heterogeneous internal echoes and irregular borders are not specific.2 microbiological and histological examinations remain the gold standard for the diagnosis of this uncommon disease. early diagnosis is difficult, as the characteristic sinuses occur late in the course of the disease. in young women tuberculosis of the breast is often diagnosed as pyogenic abscess and in the elderly as carcinoma. treatment of tuberculosis mastitis is best achieved by conservative surgery and anti-tuberculosis chemotherapy but in our case breast abscess was diagnosed which drained and on histology it diagnosed as tuberculosis. conclusion the diagnosis must be considered in young patients presenting with a palpable lump, especially if they are lactating. a histological examination is required for confirmation. we concluded that if presented with abscess then also we should go for aspiration cytology keeping in mind chances of tuberculosis. references 1. cooper. illustrations of the diseases of the breast. part i. london: longman, rees, orme, brown, and green; 1829. p. 73. 2. hale ja, peters gn, cheek jh. tuberculosis of the breast: rare but still extant. am j surg. 1985;150:620-4. 3. tewari m, shukla hs. breast tuberculosis: diagnosis, clinical features, and management. indian j med res. 2005;122:103-10. 4. gupta v, mohan h, jain p, singh s, singla n. tuberculous mastitis: a report of two cases in elderly females. jpn j infect dis. 2006;59:279-80. 5. kalac n, ozkan b, bayiz h, dursun ab, et al. breast tuberculosis. breast. 2002;11:346-9. 6. zandrino f, monetti f, gandolfo n. primary tuberculosis of the breast. a case report. acta radiol. 2000;41:61-3. 7. alagaratnam tt, ong gb. tuberculosis of the breast. br j surg. 1980;67:125-6. 8. morsad f, ghazli m, boumzgon k, et al. mammary tuberculosis: a series of 14 cases. j gynaecol obstet biol reprod. 2001;30:331-7. 9. green rm, ormerud lp. mammary tuberculosis: rare but still present in the united kingsom. int j juberc lung dis. 2000;4:788-90. 10. mckeown kc, wilkinson kw. tuberculosis disease of the breast. br j surg. 1952;39:420-9. special article 275acta med indones indones j intern med • vol 51 • number 3 • july 2019 tadalafil once a day for men with erectile dysfunction: is it superior than on-demand administration? dimas t. prasetyo, putu a.r. raharja, ben j. mantiri, david r.l. ringoringo, irham a. rahman, jody felizio, syifa f. fadhly, harrina e. rahardjo department of urology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: harrina e. rahardjo, md, phd. department of urology, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: harrinaerlianti@gmail.com. abstrak latar belakang: tadalafil adalah sebuah pde5i yang telah dilisensikan untuk menyembuhkan disfungsi ereksi sejak tahun 2003, efektif dari 30 menit setelah pemberian dan kemanjurannya dipertahankan hingga 36 jam. baru-baru ini juga diberikan oad dalam dosis yang lebih rendah untuk memungkinkan kegiatan seksual spontan. namun, apakah pemberian oad lebih efektif dibandingkan prn dalam meningkatkan ef masih belum ditetapkan. studi ini bertujuan untuk mengetahui apakah pemberian tadalafil sekali sehari lebih baik dalam meningkatkan fungsi ereksi pada pasien disfungsi ereksi (de) dibandingkan pemberian on-demand/pro re nata (prn). metode: penelusuran dilakukan dengan menggunakan medline, scopus, cochrane, dan cinahl. risiko bias pada tiap studi dinilai menggunakan cochrane risk of bias tool. hasil: kami menemukan 231 studi dari penelusuran literatur, namun hanya empat studi yang sesuai kriteria seleksi. berdasarkan penilaian kami, studi oleh kang et al. merupakan yang paling sesuai dengan situasi klinis kami. studi ini mendapatkan bahwa subyek yang mendapat tadalafil once a day (oad) mengalami peningkatan yang lebih tinggi dan signifikan untuk skor iief-ef (6.5 (sb 4.5) vs 4.9 (sb 4.2), p=0.032), proporsi “ya” terhadap sep-2 (81.8% vs 64.7%, p=0.025), dan proporsi “ya” terhadap sep-3 (77.3% vs 60.3%, p=0.034). kesimpulan: pemberian tadalafil oad akan memberikan peningkatan fungsi ereksi yang lebih baik dibandingkan dengan pemberian prn. kata kunci: tadalafil, sekali sehari, disfungsi ereksi, iief. abstract background: tadalafil is a pde5i which has been licensed for the treatment of erectile dysfunction (ed) since 2003, is effective from 30 minutes after administration and its efficacy is maintained for up to 36 hours. more recently, it is also given oad in a lower dose to allow spontaneous sexual activities. however, whether oad administration is more effective than prn administration in improving the ef is yet to be established. this study aimed to evaluate whether oad administration of tadalafil leads to a better improvement of erectile function (ef) in patients with erectile dysfunction (ed) compared to prn administration. methods: literature search of electronic database was performed through medline, scopus, cochrane library, and cinahl databases. cochrane risk of bias tool was then employed to assess the risk of bias in each study. results: initial literature search resulted in 231 hits, but only four studies were included in final selection. based on our judgements, the study by kang et al. was the most applicable in our clinical setting. this study showed that subjects who received tadalafil oad had statistically significant higher increases of mean iief-ef (6.5 (sd 4.5) vs 4.9 (sd 4.2), p=0.032), proportion of “yes” responses to sep-2 (81.8% vs 64.7%, p=0.025), and proportion of “yes” responses to sep-3 (77.3% vs dimas t. prasetyo acta med indones-indones j intern med 60.3%, p=0.034). conclusion: administration of tadalafil oad leads to a better improvement of ef compared to prn administration. keywords: tadalafil, once-a-day, erectile dysfunction, iief. introduction erectile dysfunction (ed) is defined as the persistent inability to attain and maintain an erection sufficient for satisfactory sexual performance.1 according to the massachusetts male aging study (mmas), one of the first epidemiology studies on ed involving a large number of subjects, the condition affects 52% of men between the ages of 40 and 70 years. furthermore, by the age of 70, approximately 68% of men reported to have ed, suggesting that ed is age-dependent.2 nicolosi et al. reported the prevalence of sexual dysfunction in several asian countries, including indonesia. based on their study, the prevalence of ed among adult indonesian men was 11% (95% ci = 7-15).3 several risk factors have been associated with ed. they include hypertension, diabetes, hyperlipidemia, and smoking.4 furthermore, trauma to the pelvic region and radical prostatectomy have also been reported to cause ed.5,6 treatment of ed starts from managing the modifiable risk factors and underlying conditions, which may involve lifestyle modifications. first-line therapy for ed is phosphodiesterase 5 inhibitors (pde5is), e.g. sildenafil, tadalafil, and vardenafil. the differences between each pde5i include the onset of action and duration of effect. to date, there is no guideline on which drug is more recommended for the treatment of ed. patient’s choice and physician’s judgement must be considered when prescribing pde5is.1 tadalafil, a pde5i which has been licensed for the treatment of ed since 2003, is effective from 30 minutes after administration and its efficacy is maintained for up to 36 hours. it is administered prn with doses of 10 mg and 20 mg.7 more recently, it is also given oad in a lower dose to allow spontaneous, rather than scheduled, sexual activities. however, whether oad administration is more effective than prn administration in improving the ef is yet to be established. case illustration a 61-year old sexually-active man came to a urologist, complaining of difficulty to achieve erection during sexual intercourse. on the occasions that he had an erection, he could not maintain penetration. patient has been taking medications for hypertension and hyperlipidemia since 3 years ago. patient did not have any history of surgery/trauma to the spine/pelvic region. when patient wanted to have sexual intercourse, he usually took tadalafil 20 mg, 30 minutes before the beginning of sexual intercourse. however, he felt it was rather inconvenient because he could not have spontaneous sexual intercourse with his sexual partner without taking tadalafil beforehand. the urologist read some publications stating that oad, low-dose administration of tadalafil helps patients to have spontaneous sexual intercourse. the urologist wondered whether oad administration of tadalafil is also more superior in improving ef compared to prn administration in terms of efficacy and safety. clinical question does oad administration of tadalafil lead to a better improvement of ef in patients with ed compared to prn administration? methods search strategy literature search of electronic databases was performed in november 2017. we searched the literatures through medline, scopus, cochrane library, and cinahl databases. the following key terms were used as mesh and free text terms: “tadalafil”, “erectile dysfunction”, “on demand”, “as needed”, “pro re nata”, “once a day”, and “daily” (table 1). multiple synonyms of each term were also searched. all titles and abstracts retrieved by electronic search were screened for relevance and duplicates by two 276 vol 51 • number 3 • july 2019 tadalafil once a day for men with erectile dysfunction reviewers (dtp and parr). following abstract screening, all full-text manuscripts of studies which did not undergo prior exclusion were reviewed for eligibility (figure 1). eligibility criteria studies which were included in this report fulfilled the following criteria: (1) study design was randomized control trial (rct), systematic review, or meta-analysis; (2) subjects were at least 18 years of age and diagnosed with ed; (3) study evaluated the efficacy or safety of tadalafil oad compared to prn administration for ed. studies were excluded if: (1) full text of english article was not available; (2) study did not measure ef using the international index of erectile function-erectile function (iief-ef) or the sexual encounter profile (sep)-2 (“were you able to insert your penis into your partner’s vagina?”) and sep-3 (“did your erection last long enough for you to have successful intercourse?”) scoring systems; (3) study was conducted in patients with prostate cancer; and (4) study was conducted in patients with history of surgery in the pelvic region. critical appraisal critical appraisals of the included studies were performed by dtp and parr, independently, using the rct critical appraisal sheet from the centre for evidence-based medicine. the cochrane risk of bias tool was then employed to assess the risk of bias in each study using seven domains: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other source of bias. authors’ judgments on the risks of bias for each study were divided into three categories: low risk, high risk, or unclear risk of bias (figure 2). table 1. keywords and search hits in pubmed, scopus, cochrane library, and cinahl databases search engine search terms number of articles pubmed (“tadalafil” and ("erectile dysfunction"[mesh terms] or erectile dysfunction [text word]) and (“on demand” or “as needed” or “pro re nata”) and (“once a day” or “daily”)) 69 scopus title-abs-key ("tadalafil" and "erectile dysfunction" and ("on demand" or "as needed" or "pro re nata") and ("once a day" or "daily")) 100 cochrane library "tadalafil" and "erectile dysfunction" and ("on demand" or "as needed" or "pro re nata") and ("once a day" or "daily") in title, abstract, keywords 54 cinahl “tadalafil” and “erectile dysfunction” and (“on demand” or “as needed” or “pro re nata”) and (“once a day” or “daily”) 8 * searches were performed on november 10th, 2017 figure 1. flow chart of search strategy for study selection. 277 dimas t. prasetyo acta med indones-indones j intern med results initial literature search using pre-determined terms in four search engines (pubmed, scopus, cochrane library, and cinahl) resulted in 231 hits. duplicates screening excluded 128 articles, while title and abstract screenings excluded another 103 articles. full-text articles for the 14 titles not-excluded were assessed for eligibility, resulting in further 10 articles being excluded for final review due to: three articles were not in english, three articles did not use rct design, one article used the same study subjects as one publication included in the critical appraisal, and three articles included subjects who did not meet the inclusion criteria of this study. the following four papers were included for final appraisal and assessment (table 2). buvat et al.8 studied the effect of tadalafil oad, tadalafil prn, and sildenafil prn towards several parameters including the iief-ef and sep. the rct involved 509 subjects with ed in a 24-week treatment period. tadalafil oad was given in a flexible dose adjustment between the 2.5 mg and 5 mg preparations, while tadalafil prn was given in a flexible dose adjustment between the 10 mg and 20 mg preparations. although the improvement of ef was not the main outcome, this study included the changes of iief-ef and sep from the baseline following treatment in the analysis. both the tadalafil oad and tadalafil prn groups showed increases in mean iief-ef (9.4 (sd 7.0) vs 9.6 (sd 6.1), p >0.05) and proportion of “yes” responses to sep3 (47.7% vs 49.9%, p >0.05). the differences, however, were not statistically significant. in a 12-week rct parallel study among 168 ed subjects aged 20 years and above with/ without underlying diseases, kang et al.9 studied the effect of tadalafil oad 5 mg in 84 subjects and tadalafil prn 20 mg in 84 subjects on ef as measured by iief-5 and sep scores. baseline characteristics of both groups were similar. sixtysix subjects who received tadalafil oad and 68 subjects who received tadalafil prn completed the 12-week treatment period. compared with subjects who received tadalafil prn, subjects who received tadalafil oad showed statistically significant higher increases of mean iief-ef (6.5 (sd 4.5) vs 4.9 (sd 4.2), p = 0.032), proportion of “yes” responses to sep-2 (81.8% vs 64.7%, p = 0.025), and proportion of “yes” responses to sep-3 (77.3% vs 60.3%, p = 0.034). mcmahon et al. 10 conducted an rct crossover study among 145 patients with ed over a 12-week treatment period comparing tadalafil oad (10 mg) with tadalafil prn (20 mg). compared with baseline, tadalafil oad and prn enhanced all efficacy outcomes (iiefef, sep). subjects receiving tadalafil oad experienced a higher increase of mean iie-ef score compared to subjects receiving tadalafil prn (11.9 vs 8.3, p = 0.001). likewise, sep-2 and sep-3 scores also experienced gains in the mean scores following treatment with tadalafil, with the oad regimen having higher increases compared with the prn regimen (sep-2 85% vs 73%, p <0.05; sep-3 80% vs 67%, p <0.05). the last study which was assessed in this report is the study by rubio-aurioles et al.11 the study involved men at least 18 years of age with history of ed and satisfactory response to current oral pde5i prn. three hundred and seventy-eight subjects were divided into six groups which received, alternatingly, tadalafil figure 2. authors’ judgements on each risk of bias item for appraised studies. 278 vol 51 • number 3 • july 2019 tadalafil once a day for men with erectile dysfunction ta bl e 2. s um m ar y of c ha ra ct er is tic s an d ou tc om es o f i nc lu de d st ud ie s s tu dy s tu dy de si gn p op ul at io ns n um be r of pa tie nt s a ge , ye ar s fo llo w -u p pe ri od o f tr ea tm en t in te rv en tio n an d do se re gi m en o f t ad al afi l, m g e ffi ca cy o ut co m e, % o a d p r n pva lu e b uv at e t a l. 20 13 8 r c t pa ra lle l e d p at ie nt s 50 9 53 .0 24 w ee ks o a d ; fl ex 5 (5 -2 .5 ) p r n ; fl ex 1 0 (1 020 ) iie fe f s e p -3 9. 4 (7 .0 ) 47 .7 9. 6 (6 .1 ) 49 .9 0. 73 > 0. 05 k an g et a l. 20 12 9 r c t pa ra lle l e d p at ie nt s 16 8 55 .6 12 w ee ks o a d ; fi xe d 5 p r n ; fi xe d 20 iie f5 s e p -2 s e p -3 6. 5 (4 .5 ) 81 .8 77 .3 4. 9 (4 .2 ) 64 .7 60 .3 0. 03 2 0. 02 5* 0. 03 4* m cm ah on e t a l. 20 05 10 r c t cr os so ve r e d p at ie nt s 14 5 57 .0 12 w ee ks o a d ; fi xe d 10 p r n ; fi xe d 20 iie fe f s e p -2 s e p -3 11 .9 85 80 8. 3 73 67 0. 00 1 <0 .0 5 <0 .0 5 r ub io -a ur io le s et al . 2 01 21 1 r c t cr os so ve r e d p at ie nt s 37 8 56 .2 8 w ee ks o a d ; fl ex 5 (5 -2 .5 ) p r n ; fl ex 2 0 (2 010 ) iie fe f 8. 7 (6 .7 ) 9. 5 (6 .8 ) 0. 09 2 r c t, r an do m iz ed c on tro lle d tri al ; o a d , o nc e a da y; p r n , o n de m an d; fl ex , fl ex ib le , d os e ad ju st m en t w as a llo w ed to a ch ie ve th e op tim al d os e; ii e fe f, iie fe f do m ai n sc or e ch an ge s fro m b as el in e; i ie f5, i ie f5 do m ai n sc or e ch an ge s fro m b as el in e; s e p -2 , pr op or tio n ch an ge s of “ ye s” r es po ns es t o s e p -2 f ro m b as el in e; s e p -3 , pr op or tio n ch an ge s of “ ye s” r es po ns es t o s e p -3 f ro m b as el in e; p -v al ue s w er e de te rm in ed b y un pa ire d t-t es t. *p -v al ue s w er e de te rm in ed b y ch i-s qu ar e te st s. oad 5 mg, tadalafil prn 20 mg, and sildenafil prn 100 mg for 8 weeks. ef was measured by iief-ef only. similar to other literatures included in this report, the study showed that subjects who received tadalafil oad had a higher mean iief-ef increase compared to those who received tadalafil prn, despite not being statistically significant (8.7 (sd 6.7) vs 9.5 (sd 6.8), p = 0.092). based on our judgements, the study by kang et al.9 is the most applicable in our clinical setting. the patients’ characteristics were similar to our patients and they used the same parameter to assess the ef by using the much simpler, iief5 questionnaire. however, as with most clinical trials evaluating the effect of pde5is towards ef, there were high risks of performance and detection biases due to the absences of participant 279 dimas t. prasetyo acta med indones-indones j intern med and outcome assessment blinding. some of the studies also compared the safety of tadalafil oad to prn. buvat et al.8 reported 10/257 (3.9%) and 7/252 (2.8%) patients from the oad and prn groups experienced adverse events, respectively (p = 0.623). however, no detail was listed regarding the adverse events. kang et al.9 reported 6/84 (7.1%) patients who received tadalafil oad and 7/84 (8.3%) patients who received tadalafil prn experienced adverse events with the difference being not statistically significant. facial flushing was the most common adverse events (oad group: n = 4; prn group: n = 4), followed by headache (oad group: n = 2; prn group: n = 2), and dizziness (prn group: n = 1). both articles did not report any serious adverse event caused by both tadalafil oad and prn during study period. discussion tadalafil is a selective pde5i with a half-life of 17.5 h, which is longer than other available pde5is. this proves to be an advantage to men taking tadalafil by providing a wide range of possibilities in which to engage in sexual intercourse. the launch of low-dose tadalafil oad, which can maintain a pharmacodynamic plasma concentration of 55 ng/ml throughout the 24-hour dosing interval12, enables men taking it to have spontaneous sexual intercourse in contrast to scheduled sexual intercourse when taking the prn dosage.13 the inconvenience caused by scheduled sexual intercourse when taking tadalafil prn may also have psychological implications for patients. these psychological factors could affect patients’ sexual intercourse performance, confidence, and quality of life. tadalafil’s half-life could be an important changing factor regarding this concern. in theory, a much longer effective plasma concentration could be maintained with an oad administration compared to prn regimen, thus allowing patients to feel ready for sexual intercourse at any time and enabling them to separate the stigma of drug intake from the act of sexual intercourse. we s t u d i e d w h e t h e r t a d a l a f i l o a d administration in patients with ed resulted in better improvement of ef compared to tadalafil prn. our extensive search retrieved four rcts which fulfilled our eligibility criteria for this report. all four studies reported increased iief-ef and iief-5 scores as well as higher proportion of “yes” responses to sep-2 and sep-3 following treatment with pde5is with most of them showing higher gains of iief-ef and iief-5 scores as well as higher proportion increase of “yes” responses to sep-2 and sep-3 in patients who received tadalafil oad compared to tadalafil prn. in general, there was no significant difference between tadalafil oad compared to tadalafil prn in term of incidence of adverse effects. regardless of which dosing regimen was used, the adverse effects were relatively rare and well tolerated. however, several studies found that tadalafil oad had a lower incidence of headache and flushing compared to the tadalafil prn dosing. one possible explanation is that headache and flushing are more likely to be associated with peak drug plasma concentration, which is much higher in tadalafil prn compared with tadalafil oad dosing.13 conclusion administration of tadalafil oad for the management of ed provides not only the possibility to have spontaneous sexual intercourse to the users, but also leads to better improvement of ef compared to prn administration. however, patient’s preference and physician’s judgment are still the most important considerations when deciding to give pde5i to patients with ed. acknowledgments we thank the department of urology, faculty of medicine universitas indonesia dr. cipto mangunkusumo hospital, jakarta for the assistance given during the writing of this article. 280 vol 51 • number 3 • july 2019 tadalafil once a day for men with erectile dysfunction competing interests the authors declare that they have no competing interests. funding all funding was made available by the authors personally. references 1. hatzimouratidis k, giuliano f, moncada i, muneer a, salonia a, verze p. eau guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. 2017. 2. feldman ha, goldstein i, hatzichristou dg, krane rj, mckinklay jb. impotence and its medical and physiological correlates: results of the massacheusetts male aging study. j urol. 1994;151:54–61. 3. nicolosi a, glasser db, kim sc, marumo k, laumann eo. sexual behaviour and dysfunction and help-seeking patterns in adults aged 40-80 years in the urban population of asian countries. bju int. 2005;95(4):609–14. 4. suzuki e, nishimatsu h, oba s, takahashi m, homma y. chronic kidney disease and erectile dysfunction. world j nephrol. 2014;3(4):220–9. 5. papadopoulou e, varouktsi a, lazaridis a, boutari c, doumas m. erectile dysfunction in chronic kidney disease: from pathophysiology to management. world j nephrol. 2015;4(3):379–87. available from: http:// www.pubmedcentral.nih.gov/articlerender.fcgi?artid= 4491929&tool=pmcentrez&rendertype=abstract. 6. hatzimouratidis k, eardley i, giuliano f, et al. guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. eur urol. 2010;57(5):804–14. available from: http://uroweb.org/ wp-content/uploads/14-male-sexual-dysfunction_ lr.pdf. 7. c u r r a n m p, k e a t i n g g m . ta d a l a f i l . d r u g s . 2003;63:2203–12. 8. buvat j, büttner h, hatzimouratidis k, et al. adherence to initial pde-5 inhibitor treatment: randomized openlabel study comparing tadalafil once a day, tadalafil on demand, and sildenafil on demand in patients with erectile dysfunction. j sex med. 2013;10(6):1592–602. 9. kang dh, lee jy, chung jh, et al. comparison of efficacy for erectile function and lower urinary tract symptoms of tadalafil 20 mg on-demand and 5 mg once daily in patients with erectile dysfunction. int j clin pract. 2012;66(8):813–20. 10. mcmahon c, kloner ra, hutter am, porst h. comparison of efficacy, safety, and tolerability of on-demand tadalafil and daily dosed tadalafil for the treatment of erectile dysfunction. j sex med. 2005;2(3):415–27. 11. rubio-aurioles e, porst h, kim ed, et al. a randomized open-label trial with a crossover comparison of sexual self-confidence and other treatment outcomes following tadalafil once a day vs. tadalafil or sildenafil on-demand in men with erectile dysfunction. j sex med. 2012;9(5):1418–29. 12. wrishko r, sorsaburu s, wong d, strawbridge a, mcgill j. safety, efficacy, and pharmacokinetic overview of low-dose daily administration of tadalafil. j sex med. 2009;6(7):2039–48. 13. peng z, yang l, dong q, wei q, liu l, yang b. efficacy and safety of tadalafil once-a-day versus tadalafil on-demand in patients with erectile dysfunction: a systematic review and meta-analyses. urol int. 2017;(37):343–52. 281 editorial 273acta medica indonesiana the indonesian journal of internal medicine adherence to highly active antiretroviral therapy (haart) in hiv/aids patient erni j. nelwan department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. correspondence mail: division of tropical and infectious diseases, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: ejnelwan@yahoo.com. hiv infection has been considered as a chronic illness since the availability of highly active anti retroviral treatments (haart). the introduction of haart to hiv/aids patient improve quality of life, life expectancy, decrease rate of resistance and further decrease mortality to aids related causes. many studies showed the evidence of haart efficacy to suppress viral replication among patient with continuum adherence to treatment. however, unlike other chronic medications which were only needed at least 70% adherence; success virological suppression rate in hiv/aids in patient required as high as 95% or near perfect adherence; and this remains to be an important issue for patient on haart.1 in term of treatment, a long-term follow up of patient’s adherence, i.e. daily medication intake monitoring for life, becomes a routine practice. however, no gold standard is established to measure patients’ adherence. thus in the beginning of treatment, assessment on how patient would be ready to take medication, existing any limitations such as mental illness or active drug use, understanding of disease and regimen, social support and patient schedule, should be asses. clinicians have to educate patient starting on hiv treatment for having very low missed doses, and this was based on evidence we have from a decades ago. by that time, treatment regimens were more complex. lowering the threshold of adherence would not be possible because allowing for missed dose will only favor to poor compliance within time. then, continuous support and intervention during treatment are needed to maintain high level of adherence to haart intake.2 there has been significant progress made r e g a r d i n g d e t e r m i n a n t s , m e a s u r e m e n t s , and interventions to improve adherence to antiretroviral therapies. systematic review on factors related to adherence of treatment classified several factors contributed to failure on adherence included: (1) patient related factor such as mental illness or physical symptoms, (2) beliefs about the medications, (3) life long treatment and (4) interpersonal relationships.3 all of these contributing factors should address equally in each patients. given the various assessment strategies and potential interventions available, the challenge for the treatment team is to select the techniques that provide the best fit for their treatment setting, resources, and patient population. the complexity of this topic and the importance of adherence encourage clinicians to continue to seek novel, patient-centered ways to prevent nonadherence and to tailor adherence interventions. early detection of non-adherence and prompt intervention can greatly reduce the development of viral resistance and the likelihood of virologic failure.4 on this edition, surilena et al.5 have shown the influence of emotive behavior therapy to haart adherence particularly in female patient. erni j. nelwan acta med indones-indones j intern med 274 references 1. kobin a, sheth n. level of adherence required for virological suppression among newer antiretroviral medication. ann pharmacol. 2011;45(3):372-9. 2. cote j, godin g, ramirez-garcia p, et al. virtual i n t e r v e n t i o n t o s u p p o r t s e l f m a n a g e m e n t o f antiretroviral therapy among people living with hiv. j med int res. 2015;17(1):e6. 3. hart je, jeon cy, ivers lc, et al. effect of directly observed therapy for highly active antiretroviral therapy on virologic, immunologic, and adherence outcome: a meta analysis and systematic review. j acquir immune defic syndr. 2010;54(2):167-79. 4. the dhhs panel on antiretroviral guidelines for adults and adolescents. guidelines for the use of antiretroviral agents in hiv-1-infected adults and adolescents. dept. of health & human serv. 2008;1-139. available online on http://www.aidsinfo.nih.gov/contentfiles/ adultandadolescentgl.pdf. 5. surilena, ismail ri, irwanto, et al. the effect of rational emotive behavior therapy (rebt) on antiretroviral therapeutic adherence and mental health in women infected with hiv/aids. acta med indones-indones j intern med. 2014;46(4):283-91. 44 original article acta medica indonesiana the indonesian journal of internal medicine lower serum level of anti-tetanus toxin antibodies in patients with type 2 diabetes mellitus m. nemati1, m. zarrin2, s.a. mir-abdollahi2, m.t. rezayati2, v. mirzaee3, a. bagheri2, m. ebrahimi5, a. jafarzadeh1,2,4 1 department of microbiology and immunology, medical school, kerman university of medical sciences, kerman, iran. 2 department of microbiology and immunology, medical school, rafsanjan university of medical sciences, rafsanjan, iran. 3 department of internal medicine, medical school, rafsanjan university of medical sciences, rafsanjan, iran. 4 molecular medicine research center, rafsanjan university of medical sciences, rafsanjan, iran. 5 pharmacology school, shiraz university of medical sciences, shiraz, iran. correspondence mail: abdollah jafarzadeh, professor of immunology, department of microbiology and immunology, medical school, rafsanjan university of medical sciences, enghlab sq, rafsanjan, iran. e-mail: jafarzadeh14@yahoo.com. abstrak tujuan: untuk menilai kadar antibodi toksin anti-tetanus (anti-tta) pada pasien dengan diabetes mellitus (dm) tipe 2 dan kelompok kontrol. metode: secara keseluruhan, 100 pasien dengan dm tipe 2 dan 100 orang sehat dengan usia dan jenis kelamin yang sesuai diikutsertakan dalam penelitian. diagnosis dm tipe 2 dipastikan menurut kriteria klinis dan para-klinis, misalnya kadar glukosa darah puasa di atas 126 mg/dl. sampel darah perifer diambil dari seluruh subjek penelitian. sampel serum peserta penelitian diperiksa untuk mengukur kadar anti-tta dengan metode elisa. kadar antitoksin di dalam serum ≥0,1 iu/ml ditentukan sebagai kadar antibodi protektif. hasil: tingkat seroprotektif di kelompok sehat lebih tinggi secara bermakna daripada kelompok diabetes (99% vs. 92%; p<0,02). titer rata-rata anti-tta pada kelompok orang sehat (5,32±0,26 iu/ml) secara bermakna lebih tinggi daripada pasien diabetes (3,46±0,26 iu/ml; p<0,001). pada pria penderita diabetes, nilai rata-rata titer anti-tta ternyata lebih tinggi secara bermakna dibandingkan dengan wanita penderita diabetes (3,94±0,34 iu/ml vs. 2,59±0,36 iu/ml; p<0,01). pada pasien diabetes, tingkat seroprotektif dan nilai rata-rata titer anti-tta pada subjek penelitian berusia >40 tahun juga lebih rendah daripada mereka yang berusia <40 tahun (89,23% vs. 97,14%; p<0,15 dan 4,57±0,38 iu/ml vs. 2,86±0,32 iu/ml; p<0,002). nilai rerata titer anti-tta lebih tinggi secara bermakna pada pasien yang menderita diabetes <5 tahun dibandingkan pasien yang menderita penyakit tersebut >5 tahun (3,91±0,35 iu/ml vs. 2,85±0,38 iu/ml; p<0,04). kesimpulan: hasil penelitian menunjukkan bahwa terdapat kadar anti-tta yang lebih rendah pada pasien dengan dm tipe 2, pada wanita penderita diabetes, pada pasien berusia >40 tahun, dan pada pasien yang telah menderita diabetes >5 tahun. kata kunci: imunitas, tetanus, antibody, diabetes tipe 2 abstract aim: to evaluate the serum levels of anti-tetanus toxin antibodies (anti-tta) in patients with type 2 diabetes mellitus (dm) and in a control group. methods: totally, 100 patients with type 2 dm and 100 age and sex-matched healthy individuals were enrolled to study. the presence of type 2 dm confirmed according to the clinical and para-clinical criteria such as fasting plasma glucose above 126 mg/dl. a peripheral blood sample was collected from all subjects. the serum samples of participants tested for the levels of anti-tta by vol 46 • number 1 • january 2014 lower serum level of anti-tetanus toxin antibodies in patients with type 2 dm 45 introduction tetanus is an infectious disease caused by neurotoxin secreted from the gram-positive anaerobic bacillus clostridium (c) tetani. despite being preventable with an effective vaccine, tetanus remains a significant cause of morbidity and mortality worldwide.1 contamination of wounds with spores of clostridium tetani usually causes tetanus, due to release of neurotoxin. tetanus is rare in people with history of complete vaccination course. however, inadequate tetanus toxoid vaccination and wound prophylaxis are associated with tetanus. risk for fatal disease is also reported to be higher in patients with 65 years of age and older.2 the current advisory committee on immunization practices and centers for disease control and prevention recommendation propose diphtheria, tetanus, and acellular pertussis (dtap) at ages 2, 4, 6, 15-18 months with a booster at 4-6 years.1 in iran, immunization against diphtheria, tetanus and pertussis has been applied since 1950 with using a local vaccine manufactured by razi institute (razi-dtwp).3 in most countries, booster immunization of diphtheria and tetanus is recommended to be performed every 10 years. booster td vaccine is recommended to start at the age of 11-12 years old.4 the prevalence of type 2 dm in iran has been reported to be 24% in individuals with age >40 years and 5.5% in those aged 15-65 years.5,6 similar results have been reported in other studies.7 it has been reported that the ulceration and some infectious diseases are common in diabetic patients.8 this susceptibility to infections has been associated to impaired immune system in diabetic patients.9 foot ulcers are also sizable in diabetic patients.8 the vulnerability of diabetic patients to slow-healing foot ulcers may provide a route for c. tetani spores and subsequent tetanus infection.8,10 contamination of a these ulcers with spores of c. tetani may result to tetanus. accordingly, it is expectable that the incidence of tetanus among diabetics patients is greater than non-diabetics subjects. the results of the some studies have demonstrated the diabetic patients were more susceptible to tetanus.11,12 moreover, it has been reported that the incidence of tetanus was higher in diabetic patients as compared to non-diabetics.13 the results of a study from united states have demonstrated the highest average annual incidence rate of tetanus among persons aged ≥60 years (0.35 cases/million population) and also among old adults (aged ≥60 years) with diabetes (0.70 cases/ million population).13 these studies indicate a higher risk of tetanus in diabetics and therefore the implication of the vaccination against tetanus has been recommended for diabetic patients, especially in those over 50 years of age.11,13,14 this study is conducted to evaluate the serum levels of anti-tta in patients with type 2 dm and in a healthy control group. methods from august 2012 to december 2012, a cross-sectional seroprevalence study was carried out in rafsanjan (a city that located in south-east elisa method. the serum antitoxin concentration ≥0.1 iu/ml was considered as a protective level of antibody. results: the seroprotective rate in healthy group was significantly higher than diabetic group (99% vs. 92%; p<0.02). the mean titer of anti-tta in healthy group (5.32±0.26 iu/ml) was also significantly higher than diabetic patients (3.46±0.26 iu/ml; p<0.001). in diabetic men the mean titer of anti-tta was significantly higher in comparison to diabetic women (3.94±0.34 iu/ml vs 2.59±0.36 iu/ml; p<0.01). in diabetic patients the seroprotective rate and the mean titer of anti-tta in subjects with age >40 years was also lower in comparison to those with age <40 years (89.23% vs 97.14%; p<0.15 and 4.57±0.38 iu/ml vs 2.86±0.32 iu/ml; p<0.002, respectively). the mean titer of anti-tta was significantly higher in patients with diabetes duration <5 years in comparison to patients with disease duration >5 years (3.91±0.35 iu/ml vs 2.85±0.38 iu/ml; p<0.04). conclusion: these results showed lower levels of anti-tta in patients with type 2 dm, in diabetic women, in patients aged >40 years and in diabetic patients with disease duration >5 years . key words: immunity, tetanus, antibody, type 2 diabetes. m. nemati acta med indones-indones j intern med 46 of iran in kerman province). 100 type 2 dm patients (mean age: 42.09±6.51 years; range: 24 to 54 years; 64 men and 36 women) and 100 healthy subjects (mean age: 41.12±7.65 years; range: 26 to 57 years; 61 men and 39 women) were included in the study. as mentioned, the universal vaccination of infants and children against diphtheria, tetanus and pertussis has been incorporated in the national immunization scheme in iran since 1950.15 accordingly all subjects born after this timepoint (including subjects enrolled to this study) received dtwp vaccine. primary vaccination has been done by using 3 doses of vaccine at 2, 4, and 6 months of age with 3 booster doses at age 18–24 months, 5–6 years and 18-24 years. there was no any other vaccination records regarding tetanus for participants. the type 2 dm patients selected from subjects referring to the pathobiological laboratory of rafsanjan university of medical sciences. the type 2 dm patients had disease, according to the fasting plasma glucose above 126 mg/dl (as a major criteria defined by the american diabetes association) and physician’s examination. the healthy control group was recruited among blood donors of rafsanjan blood transfusion center. the healthy controls were basically health, with normal fasting plasma glucose and no acute or chronic illnesses. subjects with disease such as history of recurrent infections, asthma, allergy and atopic diseases, any suspected immunological disorders, cigarette smoking and use of any drugs were all excluded from the study. other exclusion criteria were malignancy, surgery and major trauma within 6 months prior to blood collection. the participants did not even received any immunomodulating treatment during 6 month prior to sampling. all participants had normal cbc, normal liver and normal renal function tests. moreover, the blood lipids profile (including cholesterol and triglyceride) of all subjects were within normal range. this study was evaluated and approved by the ethical committee of rafsanjan university of medical sciences. all of participants gave written informed consent to take part in the study. peripheral blood (2-4 milliliter) were collected from the subjects of 2 groups and the serum separated and stored at –200c. determination of anti-tetanus toxin specific antibodies in serum serum levels of anti-tta was measured by an enzyme-linked immunosorbentassay (elisa) method by using commercial kits (ibl-hamburg gmbh, hamburg, germany). principally, the wells of elisa plate are coated with tetanus toxin as antigen. specific antibodies of the sample binding to the antigen coated wells are detected by a secondary enzyme conjugated antibody specific for human igg. after the addition of substrate the intensity of the color is proportional to the amount of igg-specific antibodies. results of samples can be determined directly using the standard curve. in the test procedure, after pipetting 100 μl of each standard and diluted serum (1/100) into the respective wells, plates were incubated for 60 min at 25 c. at the end of the incubation period, plate strips were washed four times with 300 μl washing buffer per well. then, 100 μl conjugate was added into each well. after the incubation period (for 30 min at 250c), plate strips were washed as previously described. thereafter, 100 μl of tetramethylbenzidine (tmb) substrate solution was added into each well and incubated for 20 min at 250c in dark. the substrate reaction was stopped by addition 50 μl of sulfuric acid into each well. optical density of each well measured with a photometer at 450 nm within 60 min after pipetting of the stop solution. anti-tta was measured by using standard samples with known concentrations of antitta expressed as iu/ml, provided by the manufacturer. according to manufacturer guideline, an antitoxin concentration ≥0.1 iu/ml was considered as protective level of antibody. tetanus antitoxin levels less than 0.1 iu/ml were considered to denote susceptibility. the sensitivity of elisa kit was 0.004 iu/ml. statistical analysis differences in variables were analyzed using t-test and chi-square test as appropriate and p-values of less than 0.05 were considered significant. all data were analyzed by spss software (version 15, chicago, il). vol 46 • number 1 • january 2014 lower serum level of anti-tetanus toxin antibodies in patients with type 2 dm 47 results the seroprotective rate of anti-tta in healthy control group (99%) was significantly higher than that observed in diabetic group (92%, p<0.02). the mean titer of anti-tta in healthy control group (5.32±0.26 iu/ml) was also significantly higher than that in diabetic patients (3.46±0.26 iu/ml; p<0.001). in diabetic men the mean titer of anti-tta was significantly higher in comparison to diabetic women (3.94±0.34 iu/ml vs 2.59±0.36 iu/ml; p<0.01). in healthy men the mean titer of anti-tta was higher than that observed in healthy women but the difference was not statistically significant (table 1). in both diabetes and control groups no significant difference was observed between men and women with respect to the seroprotection rate (table 1). in diabetic patients the mean titer of anti-tta in subjects with age >40 years was significantly lower in comparison to those with age <40 years (4.57±0.38 iu/ml vs 2.86±0.32 iu/ml; p<0.002). in healthy control group the mean titer of antitaa in subjects with age >40 years was also lower than that observed in those aged <40 years but the difference was not statistically significant (5.85±0.40 iu/ml vs 4.99±0.35 iu/ml; p=0.12). (table 2). in diabetes group the seroprotection rate was lower in patients with age >40 years as compared with patients with age <40 years but the difference was not statistically significant (89.23% vs 97.14%; p=0.15). moreover, in healthy control groups no significant difference was observed between subjects with age >40 years and subjects with age <40 years with respect to seroprotection rate (table 2). according to the duration of the diabetes the patients divided into two subgroups, 57 patients were diabetic for <5 years and 43 patients were diabetic for >5 years. the mean titer of anti-tta was significantly higher in patients with diabetes duration <5 years in comparison to patients with disease duration >5 years (3.91±0.35 iu/ ml vs 2.85±0.38 iu/ml; p<0.04). no significant difference was observed between patients with disease duration <5 years and patients with diabetes duration <5 years with respect to seroprotection rate, although this parameter table 1. serum concentrations of anti-tetanus toxin antibody in healthy and diabetic groups according to gender group gender number protection rate n (%) anti-tetanus toxin antibody (iu/ml) healthy group men 61 60 (98.36%) 5.51±0.33† women 39 39 (100%) 5.02±0.45 total 100 99 (99%) 5.32±0.26 diabetic patients men 64 59 (92.18) 3.94±0.34 women 36 33 (91.66) 2.59±0.36 total 100 92 (92%) 3.46±0.26 † the serum levels of anti-tetanus toxin antibody expressed as mean±sem table 2. serum concentrations of anti-tetanus toxin antibody in healthy and diabetic groups according to age group group age (year) number protection rate n (%) anti-tetanus toxin antibody (iu/ml) healthy group <40 38 37 (97.36%) 5.85±0.40† >40 62 62 (100%) 4.99±0.35 total 100 99 (99%) 5.32±0.26 diabetic patients <40 35 34 (97.14%) 4.57±0.38 >40 65 58 (89.23%) 2.86±0.32 total 100 92 (92%) 3.46±0.26 † the serum levels of anti-tetanus toxin antibody expressed as mean±sem m. nemati acta med indones-indones j intern med 48 was found to be higher in patients with disease duration <5 years (94.7% vs 88.4). the distribution of subjects according to their serum levels of anti-tta has been demonstrated in table 3. the rate of subjects with high serum levels of anti-tta (>4 iu/ml) in healthy control group was significantly higher in comparison to diabetic group (70% vs 35%; p<0.001). on the other hand the rate of subjects with low serum levels of anti-tta (<1 iu/ml) in diabetic group was significantly higher in comparison to healthy control group (19% vs 9%; p<0.05). discussion the results of the present study showed that both seroprotective rate and the mean titer of anti-tta were lower in diabetic patients as compared with healthy control subjects. these findings represent that diabetic patients have a greater susceptibility to tetanus infection. there is a few studies regarding the tetanus immunity among type 2 dm patients. two studies from turkey have observed that the mean titer of antitta was significantly lower in patients with dm as compared with healthy subjects.14,16 the lower levels of anti-tta in diabetic subjects can be attributed to some immune dysfunction in these patients. the lower antibody responses to other vaccines such as hepatitis b vaccine and influenza a vaccine have been also reported in patients with type 2 dm.17,18 moreover, it has been reported that diabetic patients are susceptible to infection and sepsis.19 furthermore, some immunologic disorders have been shown in patients with type 2 dm. dendritic cells (dc) play a key role in initiating innate and adapted immune responses. it has been demonstrated that absolute frequency of dc significantly were diminished in patients with type 2 dm.20 some defects in humoral immunity and complement system also demonstrated in diabetic patients.19 moreover, it has been demonstrated that the phagocytic activity of monocytes is attenuated in experimentally-induced type 2 diabetes in rat.21 furthermore, enhanced functions of regulatory t-cells demonstrated in experimentally-induced diabetes in mice.22 impaired functions of polymorphonuclear leukocyte have been also reported in patients with type-2 dm.23 it should be noted that the vaccination is one of the most significant tools for induction the prophylaxis against infection diseases. this prophylaxis mediated via inducing of immunologic memory.24 in addition to several immune dysfunctions in diabetic patients that mentioned above, the low levels of anti-tta in diabetic patients may be also attributed in part to impairment of immunological memory in this patients. the results of the present study also showed that mean titer of anti-tta was higher in men as compared to women. similar findings have been reported in other studies.25,26 this may be due to higher accident rates among men that increase the higher exposure to clostridium tetani which results in higher protective immunity. the results of a study from united state have demonstrated the differences in the tetanus incidence rates between men and women that varied by age group. for subjects aged <20 years, the incidence of tetanus among men reported as 2.7 times more than the incidence among women and for persons aged 20–59 years, the incidence of tetanus among men reported as 2.9 times more than the incidence among women.13 the results of a tenyear retrospective study from nigeria showed that the male: female ratio in tetanus patients was 3:1.27 it has been also reported that the men who had a history of dirty wounds or frequent soil exposure have more levels of anti-taa.26 moreover, a proportion of men may served in the army as young adults where they vaccinated against tetanus.25,28 further investigation is needed to clarify the reasons for greater tetanus immunity among men than woman. however, table 3. distribution of subjects according to anti-tetanus toxin antibody in healthy and diabetic group groups <0.1 iu/ml 0.1-1 iu/ml 1-2 iu/ml 2-3 iu/ml 3-4 iu/ml 4-5 iu/ml >5 iu/ml healthy group 1% 8% 7% 8% 6% 11% 59% diabetic patients 8% 11% 20% 19% 7% 5% 30% vol 46 • number 1 • january 2014 lower serum level of anti-tetanus toxin antibodies in patients with type 2 dm 49 there was no significant difference between men and women of healthy control group with respect to the seroprotection rate, probably due to the tetanus booster vaccination in women performed during pregnancy. the results of the present study also showed that the mean titer of anti-tta in subjects with age >40 years was lower in comparison to those with age <40 years. these finding represent that the anti-taa levels declined with age so that there is the greater the necessity for the older persons to receive a tetanus booster because of waning immunity in the older age group. in diabetes group, the seroprotection rate was observed in 89.23% of patients with age >40 years and 97.14% of patients with age <40 years. moreover, in healthy control groups the seroprotection rate was observed in 100% of subjects with age >40 years and 97.36% of subjects with age <40 years. it has been reported that the inadequate tetanus toxoid vaccination and wound prophylaxis are associated with tetanus. risk for fatal disease is also reported to be higher in patients 60 years of age and older.2,29 it should be noted that seroprotective rate against tetanus varies between countries. for example, seroprotective rate was noted in 33.9% of of people aged >50 years from turkey30, in 53% of people aged 20-50 years from india31, in 84.7% of people aged 20-64 years from brazil32, in 70% of people aged >80 years from germany33, in 53% of people aged >60 years from england and wales34, and in <75% of people aged >50 years from australia.35 this discrepancy may be attributed largely to differences in the age, job and race of participants, the primary vaccination schedule, and time intervals between vaccine administration and collection of blood samples. the results of the present study also showed that the mean titer of anti-tta were significantly higher in patients with diabetic duration <5 years as compared to patients with disease duration >5 years. these results represent a negative association between the duration of diabetes and the mean titer of anti-tta. the results of a investigation from korea demonstrated that that the type 2 dm patients with longer duration of diabetes had lower seroconversion rate after vaccination with a type of influenza a vaccine.17 according to serum levels of anti-tta we have arbitrary classified the subjects to several subgroups. in healthy control group 59% of subjects have the anti-tta >5 iu/ml whereas 30% of diabetic subjects have the anti-tta >5 iu/ml. on other hand the proportion of subjects with low anti-tta was higher in diabetes group in comparison to healthy control group. this classification can be use for designing of the revaccination program. according to manufacturer guideline, for individuals with antitoxin level <0.1 iu/ml (no protection), vaccine should be administered. individuals with antitoxin level 0.1-1.0 iu/ml should be control after 1-2 years. individuals with antitoxin level 1.1-5.0 iu/ml should be control after 2-4 years. individuals with antitoxin level >5.0 iu/ml should be control after 8 years. similar guideline has been presented for revaccination by centers for disease control and prevention.36 conclusion the results of the present study showed lower levels of anti-tta in patients with type 2 dm, in diabetic women and in patients aged >40 years. moreover, a reverse association was also observed between the duration of diabetes and the mean titer of anti-tta. references 1. ataro p, mushatt d, ahsan s. tetanus: a review. south med j. 2011;104(8):613-7. 2. reed db, westneat sc. exposure risks and tetanus immunization status in farmers ages 50 and over. south med j. 2009;102(3):251-5. 3. zarei s, jeddi-tehrani m, akhondi mm, et al. immunogenicity of a triple diphtheria-tetanus-whole cell pertussis vaccine in iranian preschool children. iran j immunol. 2007;4(2):101-9. 4. choi jh, choo ej, huh a, et al. immunogenicity and safety of diphtheria-tetanus vaccine in adults. j korean med sci. 2010;25(12):1727-32. 5. haghdoost aa, rezazadeh-kermani m, sadghirad b, baradaran hr. prevalence of type 2 diabetes in the islamic republic of iran: systematic review and metaanalysis. east mediterr health j. 2009;15(3):591-9. 6. azimi-nezhad m, ghayour-mobarhan m, parizadeh mr, et al. prevalence of type 2 diabetes mellitus in iran and its relationship with gender, urbanisation, education, marital status and occupation. singapore med j. 2008;49(7):571-6. m. nemati acta med indones-indones j intern med 50 7. pramono la, setiati s, soewondo p, et al. prevalence and predictors of undiagnosed diabetes mellitus in indonesia. acta med indones-indones j intern med. 2010;42(4):216-23. 8. suastika k. diabetic foot: a major medical, social and economic problem in patients with diabetes. acta med indones-indones j intern med. 2005;37(4):185-6. 9. tanaka y. [immunosuppressive mechanisms in diabetes mellitus]. nihon rinsho. 2008;66(12):2233-7. 10. panning ca, bayat m. generalized tetanus in a patient with a diabetic foot infection. pharmacother. 1999;19(7):885-90. 11. soulsby h, russell-jones d. does diabetes put you at risk of tetanus? pract diab int. 2010;27(9):381-2. 12. rogers lc, frykberg rg. tetanus prophylaxis for diabetic foot ulcers. clin pediatr med surg. 2006;23(4):769-75, vii-i. 13. pascual fb, mcginley el, zanardi lr, cortese mm, murphy tv. tetanus surveillance--united states, 1998-2000. mmwr surveill summ. 2003;52(3):1-8. 14. kilic d, kaygusuz s, saygun m, cakmak a, uzer h, doganci l. seroprevalence of tetanus immunity among noninsulin-dependent diabetes mellitus patients. j diab compl. 2003;17(5):258-63. 15. zarei s, jeddi-tehrani m, akhondi mm, et al. primary immunization with a triple diphtheria-tetanus-whole cell pertussis vaccine in iranian infants: an analysis of antibody response. iran j allergy asthma immunol. 2009;8(2):85-93. 16. tamer a, karabay o, ekerbicer h, tahtaci m, selam b, celebi h. impaired immunity against tetanus in type 2 diabetes. med sci monit. 2005;11(12):cr580-4. 17. nam js, kim ar, yoon jc, et al. the humoral immune response to the inactivated influenza a (h1n1) 2009 monovalent vaccine in patients with type 2 diabetes mellitus in korea. diab med. 2011;28(7):815-7. 18. alavian sm, tabatabaei sv. the effect of diabetes mellitus on immunological response to hepatitis b virus vaccine in individuals with chronic kidney disease: a meta-analysis of current literature. vaccine. 2010;28(22):3773-7. 19. koh gc, peacock sj, van der poll t, wiersinga wj. the impact of diabetes on the pathogenesis of sepsis. eur j clin microbiol infect dis. 2012;31(4):379-88. 20. seifarth cc, hinkmann c, hahn eg, lohmann t, harsch ia. reduced frequency of peripheral dendritic cells in type 2 diabetes. exp clin endocrinol diab. 2008;116(3):162-6. 21. takeda y, marumo m, wakabayashi i. attenuated phagocytic activity of monocytes in type 2 diabetic goto-kakizaki rats. immunobiol. 2011;216(10):1094102. 22. zhen y, sun l, liu h, et al. alterations of peripheral cd4+cd25+foxp3+ t regulatory cells in mice with stz-induced diabetes. cell mol immunol. 2012;9(1):75-85. 23. bhattacharya sk, shastri s, mahajan p, et al. polymorphonuclear leukocyte function in type-2 diabetes mellitus patients and its correlation with glycaemic control. nepal med coll j. 2007;9(2):111-6. 24. castellino f, galli g, del giudice g, rappuoli r. generating memory with vaccination. eur j immunol. 2009;39(8):2100-5. 25. wu cj, ko hc, lee hc, et al. decline of tetanus antitoxin level with age in taiwan. j formos med assoc. 2009;108(5):395-401. 26. alagappan k, rennie w, kwiatkowski t, et al. seroprevalence of tetanus antibodies among adults older than 65 years. ann emerg med. 1996;28(1):1821. 27. adekanle o, ayodeji o, olatunde l. tetanus in a rural setting of south-western nigeria: a ten-year retrospective study. libyan j med. 2009;4(2):78-80. 28. razzaghi r, khalifesoltani a, heravi mm, akbari h. tetanus immunity in individuals aged 50 years or older in kashan, iran. acta med iran. 2011;49(6):379-82. 29. koromath fs, sumarmi, hermawan ag. infectious disease pattern and serum albumin levels in elderly people hospitalized at dr. moewardi hospital surakarta during 2004. acta med indones-indones j intern med. 2008;40(3):114-6. 30. oncu s, onde m, ergin f, ozturk b. tetanus seroepidemiology and factors influencing immunity status among farmers of advanced age. health policy. 2011;100(2-3):305-9. 31. saxena s, jais m, dutta r, dutta ak. serological immunity to diphtheria and tetanus in healthy adults in delhi, india. trop doct. 2009;39(3):160-3. 32. dos santos am, ono e, lobato rt, do prado si, kopelman bi, cavalcanti cm, monomi mk, weckx ly, de moraes-pinto mi. diphtheria, tetanus, and varicella immunity in health care workers in neonatal units. am j infect control. 2008;36(2):142-7. 33. hof h, bartel j. [immunity against tetanus is often lacking in the elderly]. dtsch med wochenschr. 2011;136(4):148-50. 34. maple pa, jones cs, wall ec, et al. immunity to diphtheria and tetanus in england and wales. vaccine. 2000;19(2-3):167-73. 35. gidding hf, backhouse jl, burgess ma, gilbert gl. immunity to diphtheria and tetanus in australia: a national serosurvey. med j aust. 2005;183(6):301-4. 36. centers for disease, control, and prevention. neonatal tetanus, montana, 1998. mmwr morb mortal wkly rep. 1998;47(43):928-30. 283 original article acta med indones indones j intern med • vol 50 • number 4 • october 2018 kidney disease profiles among adolescents in indonesia partini p. trihono, lia rhodia, mulya r. karyanti department of child health, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: partini pudjiastuti trihono, md, phd. division of nephrology, department of child health, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: partinipt@yahoo.com. abstrak latar belakang: setiap gangguan ginjal berisiko menjadi penyakit ginjal kronik dan gagal ginjal terminal yang berkaitan dengan peningkatan mortalitas dan beban pembiayaan. di negara berkembang, khususnya di indonesia, data di komunitas mengenai penyakit ginjal kronik masih sangat terbatas. tujuan penelitian ini untuk mengetahui profil klinis dan karakteristik penyakit ginjal pada remaja berusia 15-18 tahun di indonesia. metode: penelitian ini merupakan studi potong lintang yang mengolah data riset kesehatan dasar 2013 pada anak remaja berusia 15-18 tahun. terdapat dua kelompok data berdasarkan pencatatan di lapangan. kelompok data i meliputi data subjek yang diperoleh dengan menggunakan kuesioner, meliputi riwayat batu ginjal, gagal ginjal kronik, riwayat hipertensi, riwayat minum obat antihipertensi, serta pemeriksaan fisis berupa pengukuran tekanan darah. kelompok data ii adalah subyek pada kelompok data i yang dilengkapi dengan data laboratorium, berupa kadar hemoglobin dan kreatinin serum. hasil: dari 52.454 didapatkan 20.537 (39%) remaja dengan penyakit ginjal pada kelompok data i, dengan karakteristik sebagian besar perempuan dengan status gizi baik. terdapat riwayat batu ginjal sebanyak 0,2%, gagal ginjal kronik 0,1%, riwayat hipertensi 0,6%, riwayat minum obat antihipertensi 0,1%. pada pemeriksaan tekanan darah ditemukan stadium pra-hipertensi dan hipertensi, masing-masing 51,4% dan 48,3%. kelompok data ii menunjukkan subjek dengan penurunan fungsi ginjal sebesar 1,4%. kesimpulan: angka hipertensi dan pra-hipertensi pada remaja usia 15-18 tahun di indonesia cukup tinggi. pemeriksaan tekanan darah secara teratur perlu dilakukan sebagai upaya deteksi dini, untuk mencegah progresivitas penyakit. kata kunci: remaja, penyakit ginjal, hipertensi, pra-hipertensi, riskesdas. abstract background: every kidney injury may develop into chronic kidney disease (ckd) and end stage renal disease (esrd) that are associated with high mortality and socio-economic burden. there is limited data about the clinical characteristics of children having ckd in developing countries, espesially in indonesia. this study aimed to describe clinical profiles and characteristics of kidney diseases in adolescents aged 15-18 years. methods: this study was a cross-sectional study using data from national basic health survey (riskesdas) 2013. there were two groups of data. the first data group consisted of questionnaires about history of kidney stone disease, hypertension, chronic renal failure, antihypertension administration, and blood pressure measurement. the second data group included subsamples of the first group which had laboratory test results, e.g. hemoglobin and serum creatinine levels. all of the data were classified based on nutritional status, estimated glomerulofiltration rate (egfr), blood pressure classification, and hemoglobin level. results: among 52,454 adolescents in the first data group, 20,537 (39%) had kidney diseases, were predominantly female and had good nutritional status. other findings were data on history of kidney stone disease (0.2%), chronic renal failure (0.1%), history of partini p. trihono acta med indones-indones j intern med 284 hypertension (0.6%), antihypertensive agents consumption (0.1%). prehypertension and hypertension were found in 51% and 48.3% of adolescents, respectively. adolescents with decreased egfr were accounted for 1.4%. conclusion: the proportion of prehypertension and hypertension in adolescents aged 15-18 years in indonesia was high. hence, routine blood pressure measurement is important for early detection and prevention of kidney disease progression. keywords: adolescent, kidney disease, hypertension, prehypertension, national basic health survey. introduction kidney damage is defined as any abnormality of kidney structure or function, which initially occuring without any change of glomerular filtration rate (gfr), leading to decreased kidney function, which may lead to the development of chronic kidney disease (ckd) and end stage renal disease (esrd).1 ckd has become a significant public health problem and a socioeconomic burden of almost 28 million dollars every year in the united states.2 in 2008, a study in turkey reported an increasing prevalence of children aged 5-18 years with ckd compared to the previous study in 2005.3 the incidence of children with ckd in vietnam reached 5.1 cases/million/year.4 a study in seven hospitals in indonesia found that 2% of 2,889 inpatient children presented with kidney diseases. the cases of children with ckd increased by 4.9% in 1991 to 13.3% in 1996-2000 at cipto mangunkusumo hospital, a tertiary referral hospital in jakarta.5 m o s t c h i l d r e n w i t h c k d m a n i f e s t asymptomatically and often are found at an advanced stage. they often complain of unspecific signs, such as: paleness, general weakness, and presenting with anemia, hypertension, or growth disorders. other ckd patients are found accidentally after serum creatinine and or urinalysis tests.6 the management of children with ckd especially among adolescents has its own challenges. children with ckd may have psychological problems and require assistance, while the parents of these children may need further guidance and understanding.7 since 2007, national institute of health research and development (nihrd), indonesia ministry of health has periodically conducted a nationwide community-based health research, known as indonesia basic health research (riset kesehatan dasar/riskesdas). this research was conducted every three years to evaluate the achievement of health programs that had been implemented in indonesia. data from indonesia basic health research can describe the situation at the national, provincial, and district levels due to their substantial sample numbers. they also provided laboratory examination data in the indonesia basic health research 2013.8,9 the data regarding the characteristics of kidney disease in indonesian adolescents are still limited. therefore, we aimed to describe the clinical profiles and characteristics of kidney disease among adolescents in indonesia based on basic health research 2013. methods the study design was a cross-sectional study using the large-scale data of national basic health research (riskesdas) year 2013 with selected subjects of adolescents aged 15-18 years. data were collected by trained enumerators or field officers using a structured and standardized questionnaires to obtain information, physical examination and laboratory tests.9 this study has been approved by the ethics committee of the faculty of medicine universitas indonesia with a reference number 532/un2.f1/etik/2017. for practical purposes, we grouped the data from national basic health research into two data groups. the first data group included data collected by a questionnaire about subjects’ age, gender, history of hypertension, current consumption of antihypertensive agents, history of kidney disease and kidney renal failure. this data group also included physical examination data of weight, height, and blood pressure measurement. the second data group consisted of subsamples of the first data group which had additional laboratory test data, such as vol 50 • number 4 • october 2018 kidney disease profiles among adolescents in indonesia 285 hemoglobin and serum creatinine levels. all data were then classified by nutritional status using nchs/cdc 2000 curve,10 by estimated glomerular filtration rate (egfr) using schwartz formula,11 by blood pressure classification according to the fourth report on the diagnostic: evaluation and treatment of high blood pressure in children and adolescent 2004,12 and by hemoglobin level according to anaemia classification of world health organization.13 classification of nutritional status using nchs/ cdc 2000 curve were as followed: underweight was defined as bmi (body mass index) of <5th percentiles; normal weight was bmi between the 5th and 85th percentiles; overweight was bmi between 85th and 95th percentiles; and obesity was bmi of >95th percentiles.10 estimated glomerular filtration rate (egfr) was calculated using schwartz formula; eg. egfr = [k x height (cm)/serum creatinine (mg/dl)] in ml/ minute/1.73 m2 bsa, with k is a constant which equals: 0.70 in boys 13-18 years of age and 0.57 in girls 13-18 years of age.11 normal kidney function was defined as egfr >90 ml/minute/1.73 m2, while decreased kidney function was defined as egfr <90 ml/minute/1.73 m2, which was divided to stage 1 (egfr 60-89 ml/minute/1.73 m2), stage 2 (egfr 30-59 ml/minute/1.73 m2), stage 3 (egfr 15-29 ml/minute/1.73 m2), and stage 4 (egfr <15 ml/minute/1.73 m2). hypertension was determined based on age, sex, and height and was classified as followed: (1) prehypertension: average of systolic blood pressure (sbp) and/or diastolic blood pressure (dbp) >90th and <95th percentile; (2) stage 1 hypertension: average of sbp and/or dbp >95th percentile; (3) stage 2 hypertension: average sbp and/or dbp >99th percentile+5 mmhg.12 hemoglobin level was classified according to anemia classification of the world health organization (who), and defined as anemia if hemoglobin (hb) levels <13.0 g/dl in boys and <12.0 g/dl in girls.13 in this analysis, there were 52,454 subjects in the first data group and 2,151 subjects in the second data group. (figure 1) the study results were managed electronically using spss (statistical product for social science) software version 17.0. data were presented in narrative and tabular forms and were analysed descriptively. results the basic health research year 2013 included 361,843 subjects aged 0-18 year, among them 56,409 (15.5%) adolescents aged 15-18 years, which were the subjects of this study. combination of data questionnaires and physical examination (data group 1) obtained from 52,454 subjects. this first data group showed that there were 20,537 (39%) out of 52,454 subjects had kidney diseases. they consisted of 9,100 males and 11,437 females. combination of data questionnaires, physical examination, and laboratory tests (data group 2) consisted of only 2,151 subjects. this second data group revealed that there were only 723 (33.6%) out of 2,151 subjects with kidney diseases, consisted of 334 males and 389 females. data of laboratory tests showed that 2,128 subjects had hemoglobin level test and 1,920 had serum creatinine level test. distribution of subjects are shown in figure 1, while their baseline characteristics of subjects with kidney diseases are shown in table 1. figure 2 showes the distribution of subjects with kidney diseases. table 2 shows that females who had a history of kidney disease and diagnosis of chronic renal failure were more prevalent than males, with proportion of 55.9% and 61.9%, respectively. most of the subjects who had history of kidney disease (73.5%) and diagnosis of chronic renal failure (57.1%) had normal weight. the prevalence of hypertension among subjects who had history of kidney disease was higher than those who had diagnosis of chronic renal failure, which were 38.2% and 33.3%, respectively. table 3 shows that females with hypertension a n d p r e h y p e r t e n s i o n d i s p l a y e d h i g h e r prevalences than males. most of the subjects with hypertension (79.9%) and prehypertension (86.1%) had normal weight. characteristics of subjects with decreased egfr are shown in table 4. there was no subjects with decreased egfr who had previous diagnosis of hypertension, antihypertensive agents used, chronic renal failure, and the history of kidney stone disease. most of the subjects who had decreased egfr had normal weight (96.2%). the prevalence of hypertension in subjects who had decreased egfr was 34.6%. there were 26 partini p. trihono acta med indones-indones j intern med 286 subjects who had decreased egfr, comprising of stage i (23 subjects), stage ii (one subject), end stage iii (2 subjects). no subject was with decreased egfr stage iv. discussion this study provides data about clinical profiles and characteristics of kidney disease among adolescents aged 15-18 years in indonesia. in our study, prehypertension and hypertension were found in 51% and 48.3% of adolescents, respectively. other studies conducted in america, egypt, and portuguese reported lower prevalence of hypertension 3%, 4%, and 12.1%, respectively.14-16 these differences in prevalence of hypertension might be due to the differences of subjects’ age. the american study included adolescents aged 12-19 years,14 while the egyptian study included adolescents aged 11-19 years,15 the study in portuguese was on adolescents aged 4-18 figure 1. data distribution of subjects vol 50 • number 4 • october 2018 kidney disease profiles among adolescents in indonesia 287 table 1. characteristics of subjects with kidney diseases gender, n (%) data 1(n=20,537) data 2 (n=723) male 9,100 (44.3) 334 (46.2) female 11,437 (55.7) 389 (53.8) data from the questionnaires, n (%) previous diagnosis of hypertension 116 (0.6) 10 (1.4) antihypertensive agents used 25 (0.1) 1 (0.1) chronic renal failure 21 (0.1) 0 (0) history of kidney stone disease 34 (0.2) 1 (0.1) physical examination nutritional status, n (%) underweight 1,550 (7.5) 85 (11.8) normal 17,064 (83.1) 576 (79.7) overweight 1,293 (6.3) 43 (5.9) obese 630 (3.1) 19 (2.6) blood pressure, n (%) normal blood pressure 75 (0.3) 2 (0.3) prehypertension 10,548 (51.4) 344 (47.6) hypertension 9,914 (48.3) 377 (52.1) stage i 9,079 (91.6) 352 (93.3) stage ii 835 (8.4) 25 (6.7) anemia, n (%) --125 (17.3) table 2. characteristics of subjects with kidney diseases gender, n (%) history of kidney stone disease (n=34) diagnosis of chronic renal failure (n=21) male 15 (44.1) 8 (38.1) female 19 (55.9) 13 (61.9) data from the questionnaires, n (%) previous diagnosis of hypertension 1 (2.9) 1 (0.9) antihypertensive agents used 0 (0) 0 (0) chronic renal failure 9 (26.5) -- history of kidney stone disease --9 (42.9) physical examination nutritional status, n (%) underweight 4 (11.8) 4 (19) normal 25 (73.5) 12 (57.1) overweight 3 (8.8) 2 (9.5) obese 2 (5.9) 3 (14.3) blood pressure, n (%) normal blood pressure 15 (44.1) 10 (47.6) prehypertension 6 (17.6) 4 (19) hypertension 13 (38.2) 7 (33.3) figure 2. distribution of kidney diseases among adolescents aged 15-18 years. years.16 several factors might influence the higher finding subjects with hypertension in our study. the subjects’ age in our study might presented a tendency of having a higher blood pressure due to essential hypertension which was more prevalent in adolesence.17 other factors are the difference in procedures and times in measuring the blood pressures. other possible causes of elevated blood pressure, such as family history of hypertension, history of prematurity or low birth weight, dietary and life style habits, which were not observed. among 52,454 children in the first data group, partini p. trihono acta med indones-indones j intern med 288 20,537 (39%) had kidney diseases with female predominance and normal weight. hypertension has been found to be correlated to obesity in adults. in our study, only 7.6% of subjects with hypertension were overweight, while 4.5% of subjects with hypertension were obese. a study done in turkey on children aged 5-18 years with hypertension found higher prevalence of overweight (11.4%) and obesity (7.6%).18 a metaanalysis of 63 studies consisted of 49,220 children, revealed that systolic blood pressure was higher by 4.54 mmhg in overweight children, and by 7.49 mmhg in obese children.19 a study in turkey showed that increased body mass index was associated with lower egfr.3 the relationship between obesity and hypertension had been known, and these two factors highly contributed in decreasing kidney function. hence, regular kidney function test is important to be performed in such high risk adolescents. in our study, the prevalence of adolescents who had the history of kidney stone disease was 0.2%. an american hospital-based study showed the prevalence of children with kidney stone disease of 0.057%,20 while a study in iraq reported a higher result in children with the kidney stone (15%).21 the prevalence of children with kidney stone disease varied in each country due to the geographical location. several countries located on areas called the kidney stone belt, the areas that have higher rates of developing of kidney stones, had a higher incidence and prevalence of kidney stone disease.22 kidney stone disease might lead to development of ckd. a study reported that 1.6% of children with kidney stones developed into early-stage ckd and the prevalence of children with both kidney stone disease and ckd was about 26.5%.23 another study on 14,245 children with kidney stone table 3. characteristics of subjects with hypertension and prehypertension characteristics hypertension (n=9,914) prehypertension (n=10,548) gender, n (%) male 4,663 (47) 4,412 (41.8) female 5,251 (53) 6,136 (58.2) data from questionnaires, n (%) previous diagnosis of hypertension 42 (0.4) 22 (0.2) antihypertensive agents used 15 (0.2) 8 (0.1) chronic renal failure 7 (0.07) 4 (0.04) history of kidney stone disease 13 (0.1) 6 (0.1) physical examination nutritional status, n (%) underweight 784 (7.9) 761 (7.2) normal 7922 (79.9) 9083 (86.1) overweight 758 (7.6) 528 (5) obese 450 (4.5) 176 (1.7) blood pressure, n (%) stage i 9079 (91.6) -- stage ii 835 (8.4) --table 4. characteristics of subjects with decreased egfr characteristics decreased egfr (n=26) gender, n (%) male 5 (19.2) female 21 (80.8) data from questionnaires, n (%) previous diagnosis of hypertension 0 (0) antihypertensive agents used 0 (0) chronic renal failure 0 (0) history of kidney stone disease 0 (0) physical examination nutritional status, n (%) underweight 0 (0) normal 25 (96.2) overweight 0 (0) obese 1 (3.8) blood pressure, n (%) normal blood pressure 4 (15.38) prehypertension 4 (15.4) hypertension 9 (34.6) stage i 7 (26.9) stage ii 2 (7.7) laboratory examination egfr <90ml/min/1.73m2, n (%) stage i 23 (88.5) stage ii 1 (3.8) stage iii 2 (7.7) stage iv 0 (0) anemia, n (%) 2 (7.7) vol 50 • number 4 • october 2018 kidney disease profiles among adolescents in indonesia 289 disease found that hypertension was one of the risk factors, especially in children under 10 years old.24 in our study, most of the subjects with kidney stone disease were well nourished, while overweight and obesity were in 8.8% and 5.9%, respectively. a study on 112 children reported that most children with kidney stone disease were also well nourished (49.1%).25 meanwhile, a study found that children with obesity and hypertension were more likely to have kidney stone disease (1.44 and 2.12 times, respectively).26 based on the first data group, we found 0.1% of subjects who had chronic renal failure. chronic renal failure in children has been known to be associated with poor growth and nutritional status. in our study, well nourished subject was more prevalent among subjects with chronic renal failure and decreased renal function. these findings were possibly due to the unknown onset of chronic renal failure. the earlier the onset of chronic kidney disease, the more the influence to nutritional status. complications of chronic kidney disease, such as anorexia, metabolic acidosis, and anemia, contribute to the poor nutritional status. in our second data group, there were 26 subjects (1.4%) with egfr <90 ml/min/1.73 m2. this finding was similar to the results of a community-based study done in turkey (2007) on 3,079 subjects aged 14-18 years (1.2%).3 however, a study in italy on 1,197 children aged 0-16 years found the prevalence of children with egfr <75 ml/min/1.73 m2 of 0.007%.27 the prevalence of adolescents with kidney disease who also had anemia in our study was 17.3%. there are many factors contributing to anemia in ckd, such as the underlying disease, nutritional status, degree of kidney function, hematinic (e.g. iron, folic acid, vitamin b12, and b1) deficiency. a three-year cohort study found that there was a relationship between anemia and hypoalbuminemia with decreased gfr in children with ckd.28 moreover, anemia in kidney disease has been associated with the chronicity of the ckd.29 our findings provide information about clinical profiles and characteristics of kidney disease among adolescents in the community. this information is valuable for estimating the socio-economic burden of kidney disease in indonesia. on the other hand, this study conceives all limitations of secondary data. the subjectivity and the vulnerability to recall bias on the questionnaires were possibly found in our study. another limitation of our study was that the blood pressures were measured only 2-3 times in a single time frame of examination and the size of the cuff being used for blood pressure measurement in our study also were not take into account. the findings in this study reveals the specific adolescent health problem in indonesia, meaning that this study results have limited generalisation, i.e. may generalised to countries with similar geographic-socio-demographic background. conclusion early detection of kidney disease in children is vigilant in initiating therapy and possibly reduce morbidity and mortality rates. data regarding the prevalence of kidney disorders in adolescents is still limited in developing countries, especially in indonesia. we found that the proportion of hypertension and prehypertension in adolescents aged 15-18 years in indonesia is high. therefore, routine blood pressure examination in children is essential in early detection of hypertension. acknowledgments we thank the national institute of health research and development (nihrd) indonesia ministry of health for allowing us to use their precious work of indonesia basic health research 2013. references 1. wong cs, furth s. chronic kidney disease. in: kher kk, schnaper hw, makker sp, editors. clinical pediatric nephrology. 2nd ed. chicago: informa; 2010. p. 339-49. 2. wong cs, furth s. chronic kidney disease. in: kher kk, schnaper hw, makker sp, editors. clinical pediatric nephrology. 2nd ed. chicago: informa; 2010. p. 63-9. 3. soylemezoglu o, duzova a, yalcinkaya f, et al. chronic renal disease in children aged 5-18 years: a population-based survey in turkey, the credit-c study. nephrol dial transplant. 2012;27:146-51. partini p. trihono acta med indones-indones j intern med 290 4. huong nt, long td, bouissou f, et al. chronic kidney disease in children: the national paediatric hospital experience in hanoi, vietnam. nephrology (carlton). 2009;14:722-7. 5. trihono pp. terapi konservatif untuk mencegah penurunan fungsi ginjal yang progresif pada gagal ginjal. in: adirawati, bahrun d, herman e, prambudi, editors. naskah lengkap sinas nefrologi anak viii ikatan dokter anak indonesia. palembang: badan penerbit ikatan dokter anak indonesia; 2001. p. 16372. 6. barrat tm, niaudet p. clinical evaluation. in: avner ed, harmon we, niaudet p, editors. pediatric nephrology. baltimore: lippincott williams and wilkins; 2004. p. 387-98. 7. tong a, wong g, mctaggart s, et al. quality of life of young adults and adolescents with chronic kidney disease. j pediatr. 2013;163:1179-85. 8. indonesia basic health research 2013 [internet]. national institute of health research and development (nihrd), ministry of health (indonesia). [cited 6 august 2015]. available from: http://www.litbang. depkes.go.id. 9. technical team of national institute of health research and development (nihrd), ministry of health indonesia. protocol of indonesia basic health research 2013. jakarta: biofarmaka ipb; 2012. p. 1-23. 10. national health examination surveys and the national health and nutrition examination surveys: 2000 cdc growth charts [internet]. hyattsville [cited 10 august 2015]. available from: https://www.cdc.gov/ growthcharts/cdc_charts.htm. 11. schwartz gj, haycock gb, edelmann cm, et al. a simple estimate of glomerular filtration rate in children derived from body length and plasma creatinine. pediatrics. 1976;58:259-63. 12. the fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. pediatrics. 2004;114:555-76. 13. nutritional anaemias. report of a who scientific group. world health organization technical report series. 1968;405:5-37. 14. may al, kuklina ev, yoon pw. prevalence of cardiovascular disease risk factors among us adolescents, 1999-2008. pediatrics. 2012;129:1035-41. 15. abolfotouh ma, sallam sa, mohammed ms, et al. prevalence of elevated blood pressure and association with obesity in egyptian school adolescents. int j hypertens. 2011;2011:1-8. 16. maldonado j, pereira t, fernandes r, et al. an approach of hypertension prevalence in a sample of 5381 portuguese children and adolescents. the aveleira registry. “hypertension in children”. blood press. 2011;20:153-7. 17. lande mb, flynn jt. treatment of hypertension in children and adolescents. pediatr nephrol. 2009;24:1939-49. 18. duzova a, yalcinkaya f, baskin e, et al. prevalence of hypertension and decreased glomerular filtration rate in obese children: results of a population-based field study. nephrol dial transplant. 2013;28:166-71. 19. friedemann c, heneghan c, mahtani k, et al. cardiovascular disease risk in healthy children and its association with body mass index: systematic review and meta-analysis. bmj. 2012;345:1-6. 20. routh jc, graham da, nelson cp. epidemiological trends in pediatric urolithiasis at united states freestanding pediatric hospitals. j urol. 2010;184:11004. 21. ladapo ta, esezobor ci, lesi fe. pediatric kidney diseases in an african country: prevalence, spectrum and outcome. saudi j kidney dis transpl. 2014;25:1110-6. 22. trihono pp, pardede so. batu saluran kemih pada anak. in: alatas h, tambunan t, trihono pp, pardede so, editors. buku ajar nefrologi anak. jakarta: balai penerbit fkui; 2002. p. 212-30. 23. vivante a, hildebrandt f. exploring the genetic basis of early-onset chronic kidney disease. nat rev nephrol. 2016;12:133-46. 24. schaeffer aj, feng z, trock bj, et al. medical comorbidities associated with pediatric kidney stone disease. urology. 2011;77:195-9. 25. kieran k, giel dw, morris bj, et al. pediatric urolithiasis--does body mass index influence stone presentation and treatment? j urol. 2010;184:1810-5. 26. kokorowski pj, routh jc, hubert kc, et al. association of urolithiasis with systemic conditions among pediatric patients at children’s hospitals. j urol. 2012;188:1618-22. 27. gonzalez celedon c, bitsori m, tullus k. progression of chronic renal failure in children with dysplastic kidneys. pediatr nephrol. 2007;22:1014-20. 28. furth sl, cole sr, fadrowski jj, et al. the association of anemia and hypoalbuminemia with accelerated decline in gfr among adolescents with chronic kidney disease. pediatr nephrol. 2007;22:265-71. 29. yusrizal m. analisis faktor risiko hipertensi pada remaja usia 15-17 tahun di indonesia tahun 2007 (analisis data riskesdas 2007) [internet]. [cited 15 august 2015]. available from: http://lib.ui.ac.id/ file?file=digital/20321142-s-ratna%20arista%20 dewi.pdf. medical illustration unilateral leg swelling umar zein1, hadiki habib2 1 dr. umar zein tropical and infectious diseases clinic, medan, indonesia. 2 departement of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia correspondence mail: dr. umar zein. jl.denai 269 medan, indonesia. email: uzein_2000@yahoo.com, salinahhabib@gmail.com. figure 1. lymphatic filariasis of right leg before treatment figure 2. microfilariae of w. bancrofti figure 3. after 2 weeks treatment of dec a 50-year old man was consulted due to right leg swelling concomitant with redness and pain since two months between admission. the patient experienced fever and dull pain in right inguinal region before the leg became swollen. antibiotic and antipyretic had been given but gave unsatisfaction response. no history of bedridden, hospitalization, or malignancy. he worked as a palm oil farmer in geragas village, langkat district, north sumatera, indonesia, an endemic region of bancroftian filariasis. physical examination revealed normal vital signs, there was non pitting oedema and redness in right gastrocnemius region (figure 1). laboratory results of routine blood count and haemostasis were within normal limit, except leucocytosis (12000/m3) and eosinophilia (15%). peripheral blood sample was drawn between 10 66 acta medica indonesiana the indonesian journal of internal medicine vol 46 • number 1 • january 2014 unilateral leg swelling pm and 2 am and showed positive microfilariae with gently curved body, a tail that is tapered to a point, and the nuclear column is loosely packed, appropriate for wuchereria bancrofti (figure 2). patient’s diagnosis was acute lymphangitis due to filariasis of w. bancrofti. treatment was based on protocol in cunha (2010).1 albendazole 1 x 400 mg po single dose plus diethylcarbamazine (dec): • day 1 : 50 mg po • day 2 : 50 mg po q8h • day 3 : 100 mg po q8h • day 4-14 : 2 mg/kg po q8h doxicycline 100 mg po q12h for 6 weeks is optional (doxyciclin was not given for this case) . paracetamol 3x 500 mg and cetirizine 10 mg daily for five days was given for symptomatic purposed. the diagnosis was reported to health department of north sumatera province for epidemiological input and preparation of mass drug administration. there were no serious side effect of dec treatment. after 2 weeks, the swelling was resolved (figure 3). the patient use compressive stocking to reduced puffiness of the right leg after long distance walking. this temporer swelling was mild sequel of the filariasis. lymphatic filariasis is one of neglected tropical diseases in indonesia. it is a mosquitotransmitted, helminth infection, transmitted predominantly by anopheles mosquitoes. there are 8 type of filarial worms but only 4 of them are that most causing human disease and complication, there are wuchereria bancrofti, brugia malayi, oncocherca volvulus, and loaloa.2 world health organization (who) in 2009 reported there were 120 milions people in 81 countries infected with filariasis, 40 milion people suffer from permanent damage because of these diseases, such as elephanthiasis, or urogenital swelling.3 almost all regions in indonesia are endemic with filariasis, espesciallly in the east indonesia region. from 2000 to 2009 chronic cases of filariasis there were 11.914 patients in 401 city/districts.4 wuchereria bancrofti is one of the most widely distributed not just in tropic region, but also in sub tropic. humans are the only definite hosts. the parasite has nocturnal periodicity, which mean that microfilariae density in human blood will increase and night, but the microfilaria will hardly be found.2 early clinical manifestation of filariasis are lymphangitis, lymphadenitis, epidydimitis or orchitis, due to adult worm activities in lymphatic drainage. people in endemic regions sometimes do not show symptoms of acute clinical manifestation. inappropiate or delayed treatment will cause chronic lymphatic obstruction (extremity elephantiasis, hydrocele, chyiluria).2,5 references 1. cunha ba, ed. antibiotic essentials. 9th edition. new york: physician’s press; 2010. p. 251. 2. pohan ht. filariasis. in: sudoyo aw, setiati s, alwi i, eds. buku ajar ilmu penyakit dalam. 3rd volume. 4th edition. jakarta: pusat penerbitan ilmu penyakit dalam fkui/rscm; 2006. p. 1789-92. 3. who. lymphatic filariasis. switzerland: world health organization; 2010. p. 1. 4. subdit filariasis & schistosomiasis. rencana nasional program akselerasi eliminasi filariasis di indonesia 2010-2014. jakarta: direktorat p2b2, ditjen pp & pl kementrian kesehatan republik indonesia; 2010. 5. mak j. pathology of lymphatic filariasis. iejsme. 2012;6:80-6. 67 special article 256 acta medica indonesiana the indonesian journal of internal medicine metal fume fever among galvanized welders wardhana1, e.a. datau2 1 department of internal medicine, siloam international hospitals. karawaci, indonesia. 2 department of internal medicine, prof. dr. rd kandou general hospital & sitti maryam islamic hospital, manado, north sulawesi, indonesia. correspondence mail: siloam hospitals group’s ceo office, siloam hospital lippo village. 5th floor. jl. siloam no.6, karawaci, indonesia. email: wadiswas@yahoo.com. abstrak demam uap logam/metal fume fever (mff) adalah sindroma demam inhalasi pada tukang las baja seng, yang menggabungkan dan memotong komponen-komponen logam dengan menggunakan lidah api atau percikan listrik dan sumber panas lainnya. inhalasi oksida logam tertentu yang baru saja terbentuk akibat proses pengelasan dapat menyebabkan mff sebagai suatu penyakit akut swasirna yang menyerupai flu (acute self-limiting flulike illness). penyebab mff yang paling umum adalah inhalasi seng oksida (zno). inhalasi partikel zno dapat mencetuskan sejumlah respons klinis yang disertai oleh perubahan komposisi cairan bilasan bronkoalveolar/ bronchoalveolar lavage (bal) fluid, yang meliputi peningkatan sitokin pro-inflamasi dini, penanda inflamasi dan rekrutmen sel-sel inflamasi di paru-paru. mff ditandai oleh demam, batuk, pengeluaran dahak, mengi, sesak di dada, lelah, menggigil, demam, mialgia, batuk, dispnea, leukositosis dengan pergeseran ke kiri, rasa haus, rasa metalik dan salivasi. diagnosis mff didasarkan pada temuan klinis dan riwayat pekerjaan. gejala menyembuh spontan. pengobatan mff sepenuhnya bersifat simptomatik, tidak ada pengobatan khusus yang diindikasikan untuk mff. tatalaksana utama mff adalah pencegahan paparan selanjutnya dari unsur logam yang membahayakan; termasuk membangun kesadaran masyarakat dan para dokter tentang mff agar dapat mengurangi tingkat kejadian penyakit ini. kata kunci: demam uap logam, seng oksida, inflamasi, pencegahan. abstract the metal fume fever (mff) is an inhalation fever syndrome in welders of galvanized steel, who join and cut metal parts using flame or electric arc and other sources of heat. inhalation of certain freshly formed metal oxides produced from welding process can cause mff as an acute self-limiting flulike illness. the most common cause of mff is the inhalation of zinc oxide (zno). the inhalation of zno particles can provoke a number of clinical responses of which accompanied by changes in composition of bronchoalveolar lavage (bal) fluid, including early increase in pro-inflammatory cytokines, inflammatory marker, and recruitment of inflammatory cells in the lungs. the mff is characterized by fever, cough, sputing, wheezing, chest tightness, fatique, chills, fever, myalgias, cough, dyspnea, leukocytosis with a left shift, thirst, metallic taste, and salivations. the diagnosis of mff diagnosis is based on clinical finding and occupational history. the symptoms resolved spontaneously. the treatment of mff is entirely symptomatic, no specific treatment is indicated for mff. the mainstay of management of mff is prevention of sub-sequent exposure to harmful metals. including public and physician awareness of mff may help to reduce the occurrence of the disease. key words: metal fume fever, zinc oxide, inflammation, prevention. vol 46 • number 3 • july 2014 metal fume fever among galvanized welders 257 introduction metal fume fever (mff) is an inhalation fever syndrome long recognized in metal workers. it was first described in the mid-1800 as brass founders’ ague in brass foundry workers, and in 1900s in welders of galvanized steel (the metallurgical combination of zinc and steel as the corrosion protection), particularly in the shipyard industry.1 the international standard classification of occupations (isco) defined welders are workers who join and cut metal parts using flame or electric arc and other sources of heat.2 inhalation of certain freshly formed metal oxides, produced from welding process, can cause mff, an acute self-limiting flulike illness. the most common cause of mff is the inhalation of zno, which is generated from molten bronze or welding galvanized steel.3 it is estimated that more than 700,000 workers in the united states are involved in welding operations, so the potential for inhalational exposure and mff is great. an estimated minimum of 1,500-2,000 cases of mff occur each year in the united states.4,5 a prevalence of 31% for mff and a prevalence of over 35% was reported, but an exact definition was not provided.5 when zinc is heated to its melting point, zinc oxide fumes are generated, the particle size of the generated fumes ranges from 0.1-1.0 μm in diameter, although aggregation with the formation of larger particles occurs readily. the underlying pathogenesis of mff is not completely understood, although there is evidence from controlled human exposure studies that zinc oxide fume inhalation induces leukocytes recruitment to the lungs with an associated release cytokines, which causes systemic symptoms.3 the diagnosis of mff is based on clinical finding and occupational history. the symptoms resolved spontaneously. the mff linked with inhalation of fumes of zno is characterized by fever, cough, sputing, wheezing, chest tightness, fatique, chills, fever, myalgias, cough, dyspnea, leukocytosis with a left shift, thirst, metallic taste, and salivations. the treatment of mff is entirely symptomatic, no specific treatment is indicated for mff.5-7 prevention relies on appropriate engineering controls and/or personal protective equipment to reduce exposure. there are no good data on the long term sequelae of repeated exposures.3 pathogenesis the zno is a common constituent of particulate air pollution and if inhaled in fine or ultra-fine fractions with a particle size smaller than 0.5μ-1μ and at a concentration exceeding 500 μg/m3 for 2 hours can induce acute systemic effects.6 a severe acute inflammation of peripheral bronchoalveolar structures following zinc fume is sign by a distinct increase of the total cell count and number of the polymorphonuclear (pmn) leukocytes. there are several hypothesis of the mff’s pathogenesis, such as the release of endogenous pyrogens from leukocytes, and the production of metal proteinases (composed of the inhaled particles and the damaged pulmonary tissue) that are recognized as antigens and lead to the formation of allergen-antibody complexes which cause the clinical symptoms, but the precise mechanism is still un-clear.6,7 inhalation of zno particles can provoke a number of clinical responses of which accompanied by changes in composition of bal fluid, including early increase in tumor necrosis (tnf)-α followed by interleukine (il)8 and il-6, matrix metalloproteinase (mmp)-9, myeloperoxydase (mo), α2-macroglobulin levels, and numbers of pmn. there is also an increase in c-reactive protein (crp) in blood.6,8 the cytokine networking mediated by the release of pro-inflammatory cytokines by pulmonary macrophages causes both local pulmonary inflammatory cellular (neutrophils recruitment) and systemic response, and also increased of reactive oxygen species (ros) production.9 the il-8 level peaked at 8 hours whereas il-6 value steadily increased with the time after exposure and reached a maximum concentration at 22 hours. the tnf-α level is elevated as soon as 3 hours after exposure, and it plays a large role in the initial response of mff, whereas il-6 and il-8 are likely involved in the later response. the tnf-α also has been shown to induce il-8 production.6,10 the mechanism by which zinc may induce cell signaling, nuclear translocation of nuclear factors in the cytokines wardhana acta med indones-indones j intern med 258 production, is not clear. it is postulated that zincinduced pulmonary inflammation may involve endothelial growth factor receptor-mediated activation of mitogen-activated protein kinase (mapk).11 the zno contained in the welding fume is likely to be deposited in the bronchiolar and alveolar regions of the lungs, and will generate more free radical activity leading to oxidative stress, of which one pathway is the formation of ros, and thus induce a greater inflammatory response.12 the high level of ros cause a change in the redox status of the cell, thereby triggering a cascade of events associated with inflammation and, at higher concentrations, apoptosis. typically ros are formed in cells through the reduction of oxygen by biological reducing agents such as reduced nicotinamide adenine dinucleotide (nadh) and reduced nicotinamide adenine dinucleotide phosphate (nadph).13 the oxidative stress is leading to activation of mapk-dependent nuclear factorkappa beta (nf-κβ), protein kinase c (pkc), and activator protein (ap)-1 (figure 1).10,14 t h e l u n g i s a n i m p o r t a n t s o u r c e o f inflammatory cytokines as well as the target organ for the effects of these mediators.14 the acute effects of the exposure to zn results in activation of the extra-cellular signal-regulated kinase (erk), c-jun nh2-terminal kinase (jnk) as a member of ap-1, and p38 mapk pathways.15 the mapks are an important group of serine or threonine signaling kinases that play a major role in converting mitogenic and stress stimuli into nuclear responses. three major groups of mapk have been identified. the erk1 and erk2 pathways transmit signals due to mitogenic and differentiation stimuli. the jnk and p38 pathways transmit stress signals resulting from oxidative stress or stimulation with inflammatory cytokines, such as tnf-α which may induce phosphorylation of p50 and p65 sub-units of nf-κβ. activation of these signal transduction pathways leads to either phosphorylation of transcription factors in the nucleus or translocation of nuclear factors, such as nf-κβ, to turn affect gene expression.16 np carbon black diesel exhaust particles welding fume coal fly-ash oxidative stress signaling pathways mapk transcription factors nf-kb, ap-1 pro-inflammatory mediators inflammation surface area organics, metals, surface area metals surface area figure 1. the different components of different combustion-derived nanoparticles can cause oxidative stress that acts through well-documented redox-sensitive pathways, such as mapk and nf-κb, to cause inflammation.14 vol 46 • number 3 • july 2014 metal fume fever among galvanized welders 259 the activation of the p38 mapk pathway is critical for many immune response-related functions, including t-cell differentiation and death, macrophage and neutrophils effector functions (e.g., respiratory burst, granular exocytosis, etc.), and the production of proinflammatory cytokines including tnf-α. there are 4 isoforms of p38 mapk: p38α, p38β, p38δ, and p38γ; and it seems that p38α and/or p38β is responsible for induction of tnf-α and il-6 mrna.17,18 the c-jun and the activating transcription factor (atf)-2 proteins are known targets of jnk kinase family members, and are phosphorylated on residues within the n-terminus trans-activation domain. the transactivation activation of atf-2, as a substrate for p38 mapk, is regulated post-translationally by phosphorylation, particularly by the jnk and p38 group of mapk, after exposure to cellular stress. the atf-2 has also been implicated in mediating a transcriptional response to c-jun promoter, and may interact with nf-κβ in a dna-independent manner, leading to increase transcriptional activity.19,20 the zno exposure may increase the binding of p65 of the nf-κβ to il-8 gene promoter and also increased the phosphorylation of p65 at ser276 and ser536.21,22 clinical presentation the mff has been defined as a “flulike” illness that develops after inhalation of metal fumes. the clinical symptoms of mff begin in 3-10 hours after exposure to zno in welding fume. the workers develop tachyphylaxis, that is symptoms appear only when the exposure, not when there are regular repeated exposures.3,5 moreover, as mff can be experienced on the first day by a new employee in the welding profession, without any latency, whereas airway obstruction and respiratory symptomatology require some latency periode, it is conceivable that mff, occurring shortly after exposure, could be a risk factor for the further development of respiratory symptoms and/or increased bronchial responsiveness.5 initially, there may be a sweet metallic taste in the mouth associated with throat irritation, accompanied by a worsening dry cough and shortness of breath. fever and shaking chills often develop and the worker feels ill.3,5 the principle elements of the systemic symptoms according to the clinical description of mff, included the following: history of a particular taste in the mouth (such as a sweet metallic taste), flue-like symptoms (such as fever, feeling of flue, general malaise, chills), myalgia, arthralgia, throat symptoms (such as dry, itchy, or constricted throat, dry cough, hoarness), digestive symptoms (such as loss of appetite, nausea, abdominal cramps), fatigue (such as weakness, yawning, difficulty concentrating), and history of respiratory symptoms (such as wheezing, chest tightness, shortness of breath, and cough).4 a case study of mff in 25 year old male welder with mff showed that he was suffering from aseptic meningitis with pericarditis, pleuritis, and pneumonia.6 diagnostic procedures the zno welding fumes were associated with a marked-dependent increase in the number of polymorphonuclear leukocytes recovered in bal fluid in 22 hours following exposure, although it was not associated with a clinically significant change in pulmonary function or airway reactivity.6 in non-smokers, welding fume exposure was associated with a mean increase in white blood cell (wbc) count by 0.8 x 103/ μl. likewise, neutrophil counts in non-smokers increased by 1.0 x 103/μl, indicating that the increase in wbc count following exposure may be mostly attributable to the increased neutrophil counts. the acute exposure to welding fume is associated with the increased levels of systemic inflammatory markers. additionally, smoking is found to modify the effect of welding fume on specific inflammatory markers. immediately following welding fume exposure, non-smokers experience a significant increase in circulating wbc counts, specifically absolute and relative neutrophil counts, and a significant decrease in fibrinogen level. sixteen hours after exposure, both non-smokers and smokers will experience significantly increased levels of crp.23 the chest roentgenogram of mff is usually normal but may show bilateral pulmonary infiltrates.24 a study in new zealand in 1996, found that an acute decrease in fev1 was more wardhana acta med indones-indones j intern med 260 prevalent among welders than the comparison group of non-welders, and more common among welders without local exhaust ventilation.23 another study in denmark between 1987 and 2004 among 68 steel welders and 32 non-welding production workers, found that long-term exposure to welding emissions may accelerate the age-related decline of lung function but at exposure level levels in range of 1.5 to 6.5 mg/ m3 the average annual excess loss of fev1 is un-likely to exceed 25 ml in smokers and 10 ml in non-smokers.23,25 the definitive diagnosis of mff is based on clinical findings and is confirmed by the occupational history combined with the rapid resolution of the symptoms which generally peak at 18 hours and resolve spontaneously with complete resolution of abnormalities within 1-2 days.3,24 the differential diagnosis includes common respiratory viral diseases, inhalation injury from polymer fumes or smoke, and true chemical pneumonitis following exposure to fumes from cadmium, manganese, mercury, or nikel. in the later cases, the condition is progressive and sometimes complicated by noncardiogenic pulmonary edema.24 treatment and prevention the treatment of mff is entirely symptomatic. the treatment including the control of elevated body temperature by anti-pyretics, analgetics, and oxygen therapy for hypoxemia may be required.3,24 the mainstay of management of mff is prevention of sub-sequent exposure to harmful metals. including public and physician awareness of mff may help to reduce the occurrence of the disease.24 the respiratory protective devices are used in only 20-30% of the work situations where they are needed, and this was attributed to environmental conditions, physical work demands, psychological and social factors, and the individual characteristic of the wearer.26 there is occupational exposure limits (oels), as the maximum permissible concentration of a hazardous substance that most healthy adults may be repeatedly exposed to without suffering adverse health effects. there maybe increased risk, for example, for a smoker, a person with pre-existing health problems or individuals who suffer from allergies. the oels are often assigned three values. one value is based on normal working conditions of 8 hours per day, over an average lifetime of exposure. if more than 8 hours are worked, this value must be adjusted. a second value provides a limit for 15 minutes, short term exposure. this is a value to which a worker may be exposed for 15 minutes, a maximum of 4 times per shift, with at least 1 hour between exposures. in this case, the 8 hour oel can not be exceeded. a third value is the ceiling limit. this limit must never be exceeded. if one or more than one type of contaminant is present, as in most welding situations, and the effects of exposure to each is similar, an exposure limit for the mixture is calculated. this value is lower than the limits set for exposure to individual contaminants. the amount of exposures are measure in parts-per-million (ppm) or milligrams per cubic meter (mg/m3), using sophisticated instruments and techniques.27 the ways to avoid hazard from welding, are by keeping the head out the fumes, do not breath the fumes, use enough ventilation, exhaust at the arch or both to keep fumes and gases from the breathing zone and the general area (figure 2 and 3), if adequacy of the ventilation or exhaust is un-certain or not used than approved respirators or air-supplied should be worn to remove the fumes from breathing zone, wear protective work clothing, and wash thoroughly immediately after exposure to zno.27,28 the steps to reduce the welding fumes and gases are by substituting less hazardous flux materials, introducing engineering control by using enclosures and improving ventilation, developing administrative controls, such as implementing work-rest, and wearing respiratory protection.28 there is need for proper education of this economically viable group on workplace hazards, the types and proper use of the different protective devices in order to safeguard the welders health. there is also need for a strong welder’s union that should make adequate and proper representation to the appropriate tier of government. the ministry of labour in conjunction with the ministry of health should collaborate to provide health care for this group vol 46 • number 3 • july 2014 metal fume fever among galvanized welders 261 of workers, as close as possible to where they live and work, in keeping with one of the principles of the primary health programme.2 conclusion metal fume fever (mff) is a disease caused by inhalation of certain freshly formed metal oxides, most common cause is the inhalation of zno. it is an acute self-limiting flulike illness, marked by changes in composition of bronchoalveolar lavage (bal) fluid, including early increase in pro-inflammatory cytokines, inflammatory marker, and recruitment of inflammatory cells in the lungs.it may be accompanied by leukocytosis and reduced in lung function, especially in those who have repeated exposure and smoking. the treatment of mff is entirely symptomatic and rest. the mainstay of management of mff is prevention of sub-sequent exposure to harmful metals. including public and physician awareness of mff may help to reduce the occurrence of the disease. references 1. kelleher p, pacheco k, newman ls. inorganic dust pneumonia: the metal-related parenchymal disorders. environmental health perspectives. 2000;108(s4):685-96. 2. isah ec, okojie oh. occupational health problems of welders in benin city, nigeria. j med biomed res. 2006;5(1):64-9. 3. balmes jr. occupational lung diseases. in: ladou j, eds. current occupational & environmental medicine. 4th ed. san francisco; 2007. p. 310-33. 4. el-zein m, malo jl, infante-rivard c, et al. prevalence and association of welding related systemic and respiratory symptoms in welders. occup environ med. 2003;60:655-61. 5. el-zein m, infante-rivard c, malo jl, et al. is metal fume fever a determinant of welding related respiratory symptoms and/or increased bronchial responsiveness? a longitudinal study. occup environ med. 2005;62:688-94. 6. cooper ross g. zinc toxicology following particulate inhalation. indian j occup environ med. 2008;12(1):103. 7. lewis r. metals. in: ladou j, eds. current occupational & environmental medicine. 4th ed. san francisco; 2007. p. 413-38. 8. vogelmeier c, konig g, bencze k, et al. pulmonary involvement in zinc fume fever. chest. 1987;92(5):9468. 9. palmer kt, mcneill-love r, poole jr, et al. inflammatory responses to the occupational inhalation of metal fume. eur respir j. 2006;27:366-73. 10. mcneilly jd, heal mr, beverland ij, et al. soluble transition metals cause the pro-inflammatory effects of welding fumes in vitro. toxicol appl pharmacol. 2004;16:95-107. 11. national institute for occupational safety and health. nomination of welding fumes for toxicity studies [cited 03 january 2011]. available from: url http://www. ntp.niehs.nih.gov/ntp/hedocs/chem-background/ exsumpdf/. 12. kodavanti up, schladweiler mcj, ledbetter ad, et al. pulmonary and systemic effects of zinc-containing emission particles in three rat strains:multiple exposure scenarios. toxicol sci. 2002;70:73-85. 13. ntziachristos l, froines jr, cho ak, et al. relationship figure 2. enough ventilation, exhaust at the arc, or both, to keep fumes and gases from your breathing zone and the general area.28 figure 3. the portable exhaust ventilation unit. these units moved 740 cubic ft. of air per minute and were positioned to pull the fume out of the welder’s breathing zone. the units are lightweight and are easily manipulated by employees. the combination of local exhaust and general ventilation reduced the amount of welding fume exposure by 51 percent.28 wardhana acta med indones-indones j intern med 262 between redox activity and chemical speciation of size-fractionated particulate matter. particle and fibre toxicol. 2007;4:5. 14. donaldson k, tran l, jimenez la, et al. combustionderived nanoparticles: a review of their toxicology following inhalation exposure. particle & fibre toxicol. 2005;2:10. 15. dong x, liu y, du m, et al. p38 mitogen-activated protein kinase inhibition attenuates pulmonary inflammatory response in a rat cardiopulmonary bypass model. eur j cardiothorac surg. 2006;30:77-84. 16. samet jm, graves lm, quay j, et al. activation of mapks in human bronchial epithelia cells exposed to metals. am j physiol. 1998;275:l551-l8. 17. mochida-nishimura k, surewics k, cross jv, et al. differential activation of map kinase signaling pathways and nuclear factor-κβ in bronchoalveolar cells of smokers and nonsmokers. mol med. 2001;7(3):17785. 18. olson cm, hendrick mn, izadi h, et al. p38 mitogenactivated protein kinase controls nfκβ transcriptional activation and tumor necrosis factor alpha production through rela phosphorylation mediated by mitogen and stressactivated protein kinase 1 in response to borrelia burgdorferi antigens. infect & immun. 2007;75(1):270-7. 19. kim hy, rikihisa y. roles of p38 mitogen-activated protein kinase, nfκβ, and protein kinase c in proinflammatory cytoki mrna expression by human peripheral blood leukocytes, monocytes, and neutrophils in response to anaplasma phagocytophila. infect & immun. 2002;70(8):4132-41. 20. xiao l, rao jn, zou t, et al. polyamines regulate the stability of activating transcription factor-2 mrna through rna-binding protein hur in intestinal epithelial cells. mol biol cell. 2007;18:4579-88. 21. zoumpourlis v, papassava p, linardopoulos s, et al. high levels of phosphorylated c-jun, fra-1, fra-2 and atf-2 proteins correlate with malignant phenotype in multistage mouse skin carcinogenesis model. oncogene. 2000;19:4011-21. 22. wu w, samet jm, peden db, et al. phosphorylation of p65 is required for zinc oxide nanoparticle-induced interleukine 8 expression in human bronchial epithelial cells. environment health perspect. 118(7):982-7. 23. kim jy, chen jc, christiani dc. exposure to welding fumes is associated with acute systemic inflammatory responses. occup environ med. 2005;62:157-63. 24. kurzbaum a, lieberman l, nasrallah n, et al. metal fume fever: an uncommon consequence of inhalation injury. israel j emerg med. 2007;7(3):39-41. 25. christensen sw, bonde jp, omland o. a prospective study of decline in lung function in relation to welding emissions. j occup med toxicol. 2008;3:6. 26. slater t, erkinjuntii-pekkanen r, fishwick d, et al. changes in work practice after a respiratory health survey among welders in new zealand. nz med j. 2000;113:305-8. 27. government of alberta, employment and immigration. welders guide to the hazards of welding gases and fumes. workplace health and safety bulletin 2009. 28. port kembla steelworks. metal fume fever. welding safety bulletin. 2002;23. 104 original article acta medica indonesiana the indonesian journal of internal medicine safety and efficacy in early insulin initiation as comprehensive therapy for patients with type 2 diabetes in primary health care centers agung pranoto, hermina novida, jongky h. prajitno, askandar tjokroprawiro department of internal medicine, faculty of medicine airlangga university-dr. soetomo teaching hospital, surabaya, indonesia. correspondence mail: endocrinology-metabolic division, department of internal medicine, surabaya diabetes and nutrition center, faculty of medicine airlangga university dr. soetomo hospital. jl. mayjen prof. moestopo 6-8, surabaya, indonesia. email: diabetes@rad.net.id. abstrak tujuan: menganalisis efikasi dan keamanan terapi insulin yang diberikan oleh dokter pada penderita diabetes melitus yang tidak terkontrol di pusat layanan kesehatan primer di surabaya, jawa timur, indonesia. metode: studi pre-post ini melibatkan 99 pasien dm tipe 2 dengan hba1c >8% yang belum pernah mendapatkan terapi insulin sebelumnya. studi dilakukan pada 10 puskesmas di surabaya antara oktober 2011 sampai dengan juni 2012. terapi insulin diberikan selama 12 minggu. pemeriksaan laboratorium yang dilakukan pada pasien meliputi glukosa darah puasa (gdp), glukosa darah 2 jam post prandial (gd2jpp) dan hba1c sebelum dan sesudah terapi. pemeriksaan gula darah mandiri juga dilakukan untuk menyesuaikan dosis insulin dan mencegah hipoglikemia. data dianalisis secara statistik dengan uji t-berpasangan. hasil: gdp awal adalah 209 mg/dl menjadi 152,07 mg/dl pada akhir studi (δ56,93 mg/dl; p=0,0001) dan gd2jpp juga turun dari 313,00 mg/dl menjadi 220,72 mg/dl (δ 92,28 mg/dl; p=0,0001). hba1c turun dari 11,60% pada awal studi menjadi 8,95% pada akhir studi (δ 2.65%; p=0,0001). selama penelitian, hipoglikemia didapatkan pada 6 patients (6,06%) dan keseluruhan ringan tanpa membutuhkan perawatan rumah sakit. kesimpulan: dokter umum pada layanan kesehatan primer dapat melakukan inisiasi terapi insulin dengan penurunan hba1c yang signifikan dan efek samping hipoglikemia yang rendah. kata kunci: insulin, dokter umum, pusat layanan kesehatan. abstract aim: to analyze the safety and efficacy of early insulin initiation therapy for patients with type 2 diabetes mellitus (t2dm) in primary health care provided by general practitioners (gps) in surabaya, east java, indonesia. methods: pre-post study of ninety nine diabetic patients without previous insulin treatment with hba1c levels >8% were involved in this study. the study was conducted in 10 primary health care centers in surabaya between october 2011 to june 2012. each patient received insulin therapy for 12 weeks. laboratory examination was performed for each patient including fasting plasma glucose (fpg), 2 hours post-prandial plasma glucose (2hppg) and hba1c examination before and after the study. self monitoring blood glucose (smbg) examination was conducted in order to adjust the insulin dose and prevent the incidence of hypoglycemia. data was statistically analyzed using paired-t test. results: fpg level was decreased from baseline data (209 mg/dl) to 152.07 mg/dl at the end of the study (δ56.93 mg/dl; p=0.0001). the average of 2hppg level was also decreased from 313.00 mg/dl to 220.72 mg/dl (δ 92.28 mg/dl; p=0.0001). hba1c was reduced from 11.60% at baseline to 8.95% at the end of study (δ 2.65%; p=0.0001). hypoglycemia was found in 6 patients (6.06%) in this study, but all events were mild and did vol 47 • number 2 • april 2015 safety and efficacy in early insulin initiation as comprehensive therapy 105 not need to be admitted to hospital. conclusion: the safety of insulin therapy iniatiation might be provided by gps at primary health centers with significant efficacy and minimal side effects. key words: insulin, general practioner, primary health center. introduction type 2 diabetes mellitus is a chronic metabolic disease with in current prevalence a rapid increased. the international diabetes federation (idf) estimated the number of people with diabetes from 387 million in 2014 will increase to 592 million in 2035. indonesia has 9.1 million people with diabetes in 2014.1 world health organization (who) estimated that the number of people with diabetes in indonesia will rise from 8.4 million in 2000 to 21.3 million in 2030. central statistics agency in 2003 showed the prevalence of dm was 14.7% or about 8.2 million in urban areas and 7.2% or about 5.5 million in rural areas. by assuming the population growth in 2030, it is estimated that dm in urban areas will reach 12 million people and in rural areas 8 million people. the report of basic health research in 2007 by the ministry of health showed that the prevalence of dm in indonesian urban areas for ages above 15 years was 5.7%.2,3 data at the dr. soetomo hospital in 2007 showed that the prevalence of dm who underwent hospitalization reached 16.4% with a range of complications and mortality reached 28.8%.4 as the prevalence of dm is increasing, it is very important to improve glycemic control to delay microangiopathy, neuropathy and other complications of diabetes. the united kingdom prospective diabetes study (ukpds) and other studies have shown that intensive glycemic control in type 2 diabetes significantly reduces the risk of microvascular complications and can improve cardiovascular outcomes.5,6 problems due to poor blood glucose control in indonesia were the reluctance of most of patients to start insulin although their blood glucose have not been well controlled by oral anti-diabetic drugs and reluctance of the physicians to provide insulin therapy due to lack of knowledge, experience and confidence.7-9 in addition, insulin was not well-distributed among primary health care services. patients with diabetes who have been poorly controlled with oral antidiabetic drugs for years and patients with special conditions requiring insulin therapy have to go to referral hospital for insulin therapy. this policy had lead to the difficulty of patients and health care providers in receiving insulin. constraints that arise from gps at primary health center is lack of knowledge about providing insulin include indication, dosage, insulin regimen selection, smbg and hypoglycemia side-effects treatment. the impact of increasing blood glucose is more complications arise. this will eventually make the cost higher for treatment of dm and its complications. another problem is that patients with diabetes in secondary and tertiary hospitals are stuck due to referrals made by primary health care physicians. this will eventually overwhelm doctors who work in secondary and tertiary health services because of the high ratio of patients per doctor. this could be a warning sign to start early intensive management of diabetes therapy at primary care level. health care strategy for patients with diabetes should be integrated into primary health care and hence, the role of gps is crucial. simple diabetic cases without complications can be managed completely by a gp, especially if blood glucose levels are well controlled. these reasons prompted us to conduct a research on the efficacy and safety of insulin initiation therapy provided by gps in patients with uncontrolled diabetes mellitus in primary health care centers in indonesia. results of this study will be used to recommend the insulin use at the level of primary health centers in indonesia. methods design the research was conducted at 10 primary health centers in surabaya between october 2011 and june 2012. this study was a pre-post agung pranoto acta med indones-indones j intern med 106 study, in which data were collected before and after insulin therapy. insulin therapy was performed by gp at related health center who had previously received training on insulin therapy, for three times face-to-face and regular meetings with research assistants every 2 weeks to monitor insulin therapy provided by those general practitioners. insulin therapy training materials included the using of insulin therapy, techniques of insulin injection, side effects of insulin therapy, such as hypoglycemia and its management, and self monitoring blood glucose (smbg) examination. the inclusion criteria were subjects with type 2 diabetes mellitus (t2dm) who had not received insulin treatment, subjects with hba1c levels >8%, and subjects who were willing to participate in the study by signing informed consent. the exclusion criteria included subjects who had insurance which requires the concerned to be referred to the hospital, subjects who were hypersensitive to insulin aspart, insulin detemir, biphasic insulin aspart 30 and ingredients of the products, and women in pregnancy, breastfeeding or planning a pregnancy in the next 6 months period. in this study, data collection included subject’s demographic, weight, duration of diabetes, complications and the medication based on interview and medical record. the subjects were also checked fasting plasma glucose (fpg), 2 hours post prandial glucose (2hppg) and hemoglobin a1c (hba1c) examination on baseline and the end of study. subjects also filled out questionnaires about quality of life before and after therapy. self monitoring blood glucose (smbg) examination was conducted in order to adjust the insulin dose and to prevent the incidence of hypoglycemia. smbg monitoring was done at waking up in the morning, after breakfast, before and after lunch and dinner. monitoring was done every three days. this research has been granted permission from the ethics committee of the faculty of medicine, airlangga university, no. 049/ec/kepk/ fkua/2011 dated 2 november 2011. data collection this study was a prospective study in which the data were documented in case record forms (crf) prepared for each patient. data were obtained through interviews and laboratory tests and other data contained in medical records. blood samples for hba1c examination were obtained through blood venous with edta 3 ml for all subjects recruited and analyzed using high performance liquid chromatography (hplc). for patients who have received insulin therapy, smbg was recorded by gps, and each week they met the researchers to report on smbg recording and insulin dose adjustments. monitoring was scheduled for every two weeks. study population the study was conducted at 10 primary health centers in surabaya, such as pakis, manukan kulon, asem rowo, tambak rejo, ketabang, mulyorejo, pacar keling, wonokusumo, takal and sawahan. the primary health centers were selected based on geographical distribution and high prevalence of dm. ninety-nine patients were recruited between december 2011 february 2012. statistical analysis data on subject demographic characteristics included age, body mass index, blood pressure, and duration of subjects suffering from diabetes mellitus, hba1c, fpg and 2hppg analyzed descriptively by calculating the mean and standard deviation, in addition to calculate the proportion of subjects, including sex, history of medication, side effects, and complications. to calculate the difference in body mass index (bmi), mean hba1c levels, fpg and 2hppg was done before and after insulin therapy. paired t-test was done preceded by normality test on data distribution of the two groups data using the kolmogorov-smirnoff test. results number of subjects participating in the study was 99 with characteristics shown in table 1. in this study, female subjects were more than male subjects (80 vs 20%). the mean age of the patients was 53.7+9.31 years old, ranging from 33 to 80 years old. the mean weight of the patients was 58+10.39 with bmi of 24.44±4.12kg/m2. mean duration of diabetes was 6.2±5.3 years. most of the older patients have been suffering from diabetes for 29 years and there were 7 patients vol 47 • number 2 • april 2015 safety and efficacy in early insulin initiation as comprehensive therapy 107 who have been suffering from diabetes for less than 3 months before the study (table 1). diabetes complications sixty four subjects had complications, with neuropathy as the most common single complication. in contrast, cardiovascular disease was rarely found as a single complication. sixteen subjects suffered from all of three complications and only 35 subjects had no complications. (table 1) the majority of the subjects (80%) had been previously treated with a combination of metformin and a sulfonylurea. six subjects received only sulfonylurea, and 7 subjects recieved only metformin. six subjects were previously not treated with either metformin or sulfonylurea, two subjects used herbal medicines and four subjects did not receive treatment at all. (table 1) glycemic control in this study, 99 subjects of the primary health centers received insulin, 79 subjects received basal insulin (insulin detemir) in combination with the previous oral anti-diabetic drugs, 2 subjects received premixed insulin (biphasic insulin aspart 30), 14 subjects received basal plus insulin (insulin detemir and 1-2x insulin aspart) and 4 subjects received basal bolus insulin (insulin detemir and 3x insulin aspart). fpg were significantly reduced 56.93 mg/dl (p=0.0001) from baseline (209 mg/dl) to 152.07 mg/dl at end of the study in 99 patients. two hours post prandial glucose also significantly reduced -92.28 mg/dl from 313.00 mg/dl to 220.72 mg/dl (p=0.0001). in this study, we also found a significant decrease of hba1c from 11.60% at baseline to 8.95% at the end of the study (p=0.0001). therefore, the mean reduction of hba1c obtained in patients receiving insulin was 2.65%. (table 2) hypoglycemic complications in this study, hypoglycemia was found in 6 subjects (6.06%), 4 subjects were receiving therapy with insulin detemir, 1 subject was receiving a premixed insulin and 1 subject was receiving basal bolus therapy. subjects receiving insulin detemir and 1-2 times insulin aspart were not having hypoglycemia. all hypoglycemia event were mild, subjects treated themselves at home, reported to their gp for insulin adjustment doses and did not need hospitalization. discussion many patients with t2dm are in poor glycemic control leading to an increase in the risk of more severe complications. in this study most of patients with t2dm treated in primary health centers were uncontrolled. the mean hba1c levels were 11.6%, which was still far from the standard recommended by perkeni in 2011 which is below 7%.3 type 2 diabetes is a disease with progressive natural course, because pancreatic beta cell function and insulin table 1. characteristics and patient demographics variables n (%) mean + sd total (n) 99 (100%) sex: male (%) 20 (21%) female (%) 79 (79%) age (year) 53.7 + 9.31 bodyweight (kg) 58 + 10.39 bmi (kg/m2) 24.44 ± 4.12 type 2 diabetes mellitus duration (years) 6.2 + 5.39 hba1c (%) 11.6 + 2.03 fasting blood glucose (mg/dl) 209 + 81.62 2 hour post prandial blood glucose (mg/dl) 313 + 112.32 complications : no complications 35(35,3%) cvd only 1(1%) eye only 5 (5%) neuropathy only 21(21,2%) cvd + eye 2 (2,1%) cvd + neuropathy 5 (5%) eye + neuropathy 14 (14,2%) all three complications 16 (16,2%) previous therapy history sulfonylurea only 6 (6%) metformin only 7 (7%) sulfonylurea + metformin 80 (81%) herbal therapy 2 (2%) no therapy 4 (4%) agung pranoto acta med indones-indones j intern med 108 physiological response will decrease over time despite good glycemic control management. thus, many patients still require insulin therapy whether with the increased dose or additional oral diabetic drugs. more than 60% patients with t2dm require insulin therapy within 6-10 years after the initial diagnosis.8,10 in this study, with an average duration of diabetes of 6.2 years, most of subjects had already required treatment with insulin (table 1). insulin is the most effective therapy to achieve glycemic targets. however, there is still a reluctance of both doctors and patients to initiate insulin therapy. factors related to the patient’s reluctance includes fears of insulin injection, insulin addiction, and sometimes skeptical of the success of insulin itself, while gp’s reluctance includes the fear of side effects of insulin, such as hypoglycemia and weight gain, limited time for education and training for the patients about the use of insulin. sometimes gps have lack of knowledge for using of insulin itself.11 another important cause is the availability of insulin in the primary health centers. insulin distribution did not cover primary health centers in indonesia. poor glycemic control and frequently delayed insulin therapy lead to various complications. the ukpds showed that the decrease in hba1c will lower the incidence of complications, both microvascular and neuropathic complications.5 similar with the ukpds, this study showed that 64.5% of patients were having complications with a high baseline of hba1c (11.6%). one of these complications, cardiovascular disease, retinopathy or neuropathy, was found in 27 t2dm subjects, while 21 subjects suffered from two complications (21.21%) and 16 subjects (16.16%) suffered from 3 complications. it means that 37.37% of patients with t2dm had more than one complications. similar results were found in a multicenter study in the united kingdom by holman et al who conducted study of 708 patients with suboptimal hba1c levels (between 7.0 to 10.0%). they found 17.2% of the patients had retinopathy, 19.1% with neuropathy, 19.5% with macroangiopathy and 9.6% with nephropathy.12 this showed that both in modern countries like united kingdom and developing countries like indonesia, the complications of diabetes are associated with glycemic control. (table 1) the study was conducted on t2dm patients with poor glycemic control, characterized by hba1c levels of >8%, both in subjects treated with and without oral anti-diabetic drugs. most of the subjects (81%) had been treated with the combination of oral diabetic drugs such as metformin and sulfonylureas available at primary health centers. those who received single oral drugs only were 13 (13%) subjects, and 6 (6%) subjects had used herbal medicine or never been treated at all. (table 1) the subjects had significant improvement in glycemic control after being treated with insulin, both in fpg and hba1c in all groups that received either basal insulin (insulin detemir) alone, premixed insulin, basal plus (combination of insulin detemir + insulin aspart 1-2 times) and basal bolus (insulin detemir combination + 3 times insulin aspart). overall reduction of hba1c was 2.65% from 11.60% at baseline to 8.95% at the end of study. the mean fpg decline was tabel 2. glycemic control in patients before and after insulin therapy fpg 2hppg hba1c n pre (mg/dl) post (mg/dl) δ p pre (mg/dl) post (mg/dl) δ p pre post δ p total 99 209.00 152.07 56.93 0.0001 313.00 220.72 92.28 0.0001 11.60 8.95 2.65 0.0001 detemir 79 206.96 147.46 59.50 0.0001 292.80 207.43 85.37 0.0001 11.56 8.75 2.81 0.0001 basal plus 14 202.21 148.64 53.57 0.397 345.84 228.06 117.80 0.004 11.52 9.65 9.65 0.011 basal plus 4 261.50 213.50 48.00 0.237 237.50 244.50 -7.0 0.469 12.83 11.43 1.47 0.359 premix 2 125.00 80.50 44.50 0.296 446.50 135.00 311.5 0.303 11.80 7.55 4.25 0.366 vol 47 • number 2 • april 2015 safety and efficacy in early insulin initiation as comprehensive therapy 109 56.93 mg/dl and the mean decline in 2hppg was 92.28 mg/dl. the highest reduction of hba1c and 2hppg was obtained in the premixed insulin group (4.25% and 311.5 mg/dl respectively). however, patients who received premixed insulin were only 2 people. the highest fpg reduction was obtained in the insulin detemir group, which was 59.59 mg/dl. (table 2) this study showed better results compared to previous studies conducted. hermansen et al studied 476 patients with hba1c ranged from 7.5 to 10.0% and he found that additional insulin detemir on oral anti-diabetic drugs therapy for 24 weeks decrease hba1c from baseline to 1.8%.13 a study by rosenstock showed that patients treated with insulin detemir showed decrease of hba1c from baseline to 1.4% after 52 weeks of insulin therapy and a decline of fpg from 10.8 mmol/l to 7.1 mmol/l.14 a study by holman et al revealed a 0.8% reduction of hba1c with basal insulin alone (insulin detemir), 1.3% with biphasic insulin (premix) and 1.4% with prandial insulin (insulin aspart) alone12, while the research by liebl et al.15 using basal-bolus insulin and biphasic insulin (premix) found a 1.56% and 1.23% decrease of hba1c.15 regarding these facts, this study showed decrease of hba1c, which was very likely because the baseline hba1c levels in this study was as high as 11.6% in health centers. the episode of hypoglycemia was found only in 6 (6.06%) patients, and all were mild episodes, which only required insulin dose adjustment and not requiring hospital treatment. no other side effects were found in this study, such as allergic or local reactions at the site of injection, quite similar with the study by hollander et al. who reported that hypoglycemia was as high as at 4.7%, and the adverse events (ae) were found in 86.4% of patients (185/214 patients).16 holman et al.12 showed that in patients with insulin detemir alone, three times mealtime insulin aspart and biphasic insulin resulted mean hypoglycemic events per patient per year of 2.3; 12.0 and 5.7. considering that the significant decrease of hba1c level and hypoglycemia episodes that were not much different from other previous studies, it is suggested that gps in health centers surabaya were competent to initiate insulin therapy for type 2 diabetes mellitus patients with poor glycemic control. conclusion despite getting oral anti-diabetic drugs therapy for several years, most patients with type 2 diabetes in primary health care centers had poor glycemic control which was shown by their high average of hba1c and blood glucose level. this study also showed that insulin therapy could significantly control blood glucose levels. it was indicated by decreased level of hba1c among patients with either basal, biphasic (premixed), or combination of basal and insulin-plus basal-bolus additional insulin therapy. all subjects turned out to have a significant reduction in hba1c levels. general practitioners at health centers can perform insulin therapy after obtaining training and the provision of sufficient material regarding insulin therapy. general practitioners at health center level are competent to perform insulin therapy indicated by a significant decrease in hba1c levels and the low rate of hypoglycemic incidence among patients with additional insulin therapy performed by gps involved in this study. acknowledgments rachmat t, dr.; henny yuniarti, dr.; amalia puspasari, dr.; listiawati pitna, dr.; anna ujihandayani, dr.; ratnaika, dr.; purdianti, dr.; lusiana arisanti, dr.; erna mindarti, dr.; tanti melania, dr.; yenni ludiandrini, dr.; larasati, dr.; ardiani vica, dr.; dian kusumawati, dr.; tienne,dr.; nur jamila, dr.,; i gede made otton, dr.; irene lp, dr.; aulia s, dr.; fadillah, dr. as general practioners in primary health centers. the head of health office, the city of surabaya, esti martiana, dr. dr. ari sutjahjo, dr, sppd k-emd as the head of endocrinology-metabolic division, department of internal medicine, faculty of medicine, airlangga university, dr. soetomo hospital, surabaya; sri murtiwi, dr. sppd k-emd, finasim; soebagijo adi, dr. sppd k-emd, finasim; sony wibisono, dr, sppd, k-emd, finasim as the senior staf of endocrinology-metabolic division, department of internal medicine and surabaya diabetes and agung pranoto acta med indones-indones j intern med 110 nutrition center (pdns), faculty of medicine, airlangga university, dr. soetomo hospital, surabaya. dr. anang endaryanto, dr., spa (k) as the head of uppm, faculty of medicine, airlangga university. references 1. international diabetes federation (idf). idf diabetes atlas 6th edition revision 2014, 2014. 2. ministry of health republic indonesia. report on result of national basic health research, 2007. 3. perkeni. konsensus pengelolaan dan pencegahan diabetes mellitus tipe 2 di indonesia, 2011. 4. dwi edi wahono. prediktor mortalitas pada penderita diabetes mellitus rawat inap. penelitian karya akhir bagian ilmu penyakit dalam fk unair-rsud dr. soetomo surabaya, 2007. 5. uk prospective diabetes study (ukpds) group. intensive blood glucose control with sulphonylurea or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes mellitus (ukpds 33). lancet, 1999; 354: 602-604 6. stratton im, adler ai, neil ha et al. association of glycemia with macrovascular and microvascular complications of type 2 diabetes mellitus (ukpds 35): prospective observational study. bmj, 2000; 321:405-412. 7. rodgers j. initiating insulin in primary care: factors to be considered. journal of diabetes nursing, 2004; 8: 291-293. 8. hirsch ib,bergenstal rm, parkin cg et al. a real world approach to insulin therapy in primary care practice. clin diabetes, 2005; 23: 78-86. 9. peyrot m, rubin rr, khunti k. addressing barriers to initiation insulin in patients with type 2 diabetes. primary care diabetes, 2010; 4(s1): s11-s18. 10. pearson j, powers ma. systematically initiating insulin: the staged diabetes management approach. diabetes educ, 2006; 32(s1): 19s-28s. 11. barag sh. insulin therapy for management of type 2 diabetes mellitus: strategies for initiation and longterm patient adherence. j am osteopath assoc, 2011; 111: s13-s16. 12. holman rr, thorne ki, farmer aj, davies mj, keenan jf, paul s et al. addition of biphasic, prandial, or basal insulin to oral therapy in type 2 diabetes. n engl j med, 2007; 357: 1716-1730. 13. hermansen k, davies m, derezinski t, ravn gm, clauson p, home p. a 26-week, randomized, parallel, treat-to-target trial comparing insulin detemir with nph insulin as add-on therapy to oral glucose lowering drugs in insulin-naive people with type 2 diabetes. diabetes care, 2006; 29: 1269-1274. 14. rosenstock j, davies m, home pd, larsen j, koenen c, schernthaner g. a randomised, 52-week, treat to target trial comparing insulin detemir with insulin glargine when administered as add-on to glucoselowering drugs in insulin-naive people with type 2 diabetes. diabetologia, 2008; 51: 408-416. 15. liebl a, prager r, binz k, kaiser m,bergenstal r, gallwitz b. comparison of insulin analogue regimens in people with type 2 diabetes mellitus in the prefer study: a randomized controlled trial. diabetes obesmetab, 2009; 11: 45-52. 16. hollander p, cooper j, bregnhoj j, pederson cb. a 52-week, multinational, open-label, parallel-group, noninferiority, treat to target trial comparing insulin detemir with insulin glargine in a basal-bolus regimen with mealtime insulin aspart in patients with type 2 diabetes. clinther2008; 30:1976-1988. 330 original article acta med indones indones j intern med • vol 49 • number 4 • october 2017 improving diagnostic of pulmonary tuberculosis in hiv patients by bronchoscopy: a cross sectional study prayudi santoso1, arto y. soeroto1, rianita juniati1, yovita hartantri1, rudi wisaksana1, bachti alisjabana1, heda m. nataprawira2, ida parwati3 1 department of internal medicine, faculty of medicine universitas padjadjaran hasan sadikin hospital, bandung, indonesia. 2 department of child health, faculty of medicine universitas padjadjaran hasan sadikin hospital, bandung, indonesia. 3 department of clinical pathology, faculty of medicine universitas padjadjaran hasan sadikin hospital, bandung, indonesia. corresponding author: prayudi santoso, md., fccp, finasim. division of respirology and critical care internal medicine, department of internal medicine, faculty of medicine universitas padjadjaran–hasan sadikin hospital. jl pasteur no. 38, bandung, 10430, indonesia. email: prayudimartha@yahoo.com. abstrak latar belakang: diagnosis tb paru pada pasien hiv merupakan suatu tantangan karena fitur klinis atau tampilan radiologis yang tidak spesifik. pasien hiv dengan sel cd4 <200 sel/ml yang terinfeksi m. tuberculosis memiliki kapasitas yang lebih rendah dalam menampung m. tuberculosis, membentuk granuloma, nekrosis, atau kavitas. kondisi ini disebabkan oleh melemahnya inflamasi yang kemudian mengurangi produksi sputum dan dapat menyebabkan hasil negatif palsu. penelitian ini bertujuan menilai perbedaan tingkat positivitas basil tahan asam (bta) dan kultur m. tuberculosis dari sputum non-bronkoskopi dibandingkan dengan sputum bronkoskopi (bronkoalveolar) pada pasien tersangka tuberkulosis (tb) paru hiv dengan cd4≤200 sel/μl. metode: penelitian potong lintang dilakukan pada pasien hiv dewasa yang dirawat di rumah sakit hasan sadikin dengan cd4 ≤200 sel/μl yang disangka memiliki tb paru dengan uji analitik komparatif berpasangan. semua pasien diminta memberikan dahak secara spontan atau dengan induksi sputum pada hari pertama. pada hari berikutnya dilakukan pemeriksaan bronkoskopi dengan bilasan bronkoalveolus. bahan yang diperoleh dari kedua cara diperiksa secara mikroskopis dengan pewarnaan ziehl neelsen (zn) dan kultur m. tuberculosis dengan media padat ogawa. positivitas, sensitivitas dan peningkatan sensitivitas bta dan kultur m. tuberculosis pada kelompok non-bronkoskopik dan bronkoskopik kemudian dibandingkan. hasil: terdapat perbedaan tingkat positivitas zn pada kelompok non-bronkoskopi dibandingkan bronkoskopi yaitu 7/40 (17,50%) vs 20/40 (50,00%) (p<0.001). perbedaan antara kultur kelompok non-bronkoskopi dengan kelompok bronkoskopi yaitu 16/40 (40,00%) vs 23/40 (57,50%) (p=0,039). bilasan bronkoalveolus menunjukkan tingkat positivitas pemeriksaan dahak bta lebih tinggi sebesar 32,5% (dari 17,5% menjadi 50%) dan juga kultur sebesar 17,5% (dari 40,0% menjadi 57,5%). kesimpulan: bilasan bronkoalveolar dapat meningkatkan tingkat positivitas pemeriksaan sputum bta dan kultur m. tuberculosis pada pasien tersangka tb paru dengan hiv positif dan cd4≤200 sel/μl. kata kunci: bronkoskopi, diagnostik mikrobiologi, hiv, sputum, tuberkulosis. abstract background: diagnostic of pulmonary tb in hiv patients is a problem due to non specific clinical features, or radiological appearance. hiv patients with cd4≤200 cells/ml infected with m. tuberculosis have less capacity in containing m. tuberculosis, developing granulomas, casseous necrosis, or cavities. this condition is caused vol 49 • number 4 • october 2017 improving diagnostic of pulmonary tb in hiv patients by bronchoscopy 331 by weakend inflammatory which later reduced sputum production and may cause false negative result. this study aimed to assess differences in the positivity level of acid fast bacilli (afb) and cultures of m. tuberculosis from nonbronchoscopic sputum (spontaneous and induced sputum) compared to bronchoscopic sputum (bronchoalveolar lavage) in hiv positive patients suspected pulmonary tuberculosis with cd4<200 cells/μl. methods: this cross sectional study was conducted in adult hiv patients treated in hasan sadikin hospital with cd4≤200 cells/μl suspected with pulmonary tuberculosis by using paired comparative analytic test. all patients expelled sputum spontaneously or with sputum induction on the first day. on the next day, bronchoalveolar lavage (bal) was performed. the two samples obtained from two methods were examined by afb examination with staining ziehl neelsen (zn) and cultured of m. tuberculosis on solid media ogawa on all patients. positivity, sensitivity and increased sensitivity of afb and culture of m. tuberculosis in the non bronchoscopic and bronchoscopic groups were compared. results: there were differences in the positivity level of afb with zn staining between nonbronchoscopic and bronchoscopic groups which were 7/40 (17.5%) vs 20/40 (50.0%) (p<0.001). the differences between the cultures of non-bronchoscopic and bronchoscopic groups were 16/40 (40.0%) vs 23/40 (57.5%) (p=0.039). bronchoscopic sputum increased the positivity level of the zn afb examination by 32.5% (from 17.5% to 50.0%) as well as on culture examination by 17.5% (from 40.0% to 57.5%). conclusion: bronchoalveolar lavage can improve the positivity level of smears and cultures in patients suspected of pulmonary tb in hiv patients with cd4<200 cells/μl. keywords: bronchoscopy, hiv, microbiological diagnostics, sputum, tuberculosis. introduction tuberculosis (tb) is still a major health problem in indonesia which has the second highest number of cases in the world after india.1 the problems of tb are increasingly complex due to complications from human immunodeficiency virus (hiv) infection which may increase the risk of acquiring pulmonary tuberculosis. the risk of developing tuberculosis in hiv patients is 20 to 37 times greater than non-hiv patients.2 diagnostic of pulmonary tb in hiv patients is problematic due to non specific clinical features, or radiological appearance. hiv patients with cd4 ≤200 cells/ml infected with m. tuberculosis have less capacity in containing m. tuberculosis, developing granulomas, casseous necrosis, or cavities.3,4 this condition is caused by weakend inflammatory which later reduced sputum production and may cause false negative result. this cause significant important problem in the diagnosis of tuberculosis.3,5 chest x-ray is unable to distinguish m. tuberculosis infection from pneumocystis jiroveci, fungal infection, or other microorganism.6 therefore, microbiologic test is necessary to confirm causative agent in suspected tb-hiv patients.7 previous studies and literatures reported that the best method to gain a good quality specimen is by bronchoalveolar lavage (bal).3,8-10 the aim the study is to assess differences in the positivity of acid fast bacilli (afb) and cultures of m. tuberculosis in the specimen acquired from non-bronchoscopic sputum (spontaeous and induced sputum) compared to bronchoscopic sputum (bronchoalveolar lavage) in hiv positive patients suspected of pulmonary tuberculosis with cd4<200 cells/μl. methods a c r o s s s e c t i o n a l s t u d y w i t h p a i r e d comparative diagnostic analysis was conducted in hasan sadikin hospital, a referral hospital in west java, bandung, indonesia. calculation of sample based on test formula of two proportions of mc nemar, with α = 0.05, hypothesis of two ways test, 95% confidence interval and power test 80%. we enrolled all patients older than 14 years old who were admitted to the hospital and clinic with a diagnosis of hiv and pulmonary infection. the study was conducted between november 2011 and october 2013. specimens were divided into two groups: the non-bronchoscopic specimens which was spontaneously expectorated and induced sputum sample (non-bronchoscopic group) and the bronchoscopic specimens which was sputum prayudi santoso acta med indones-indones j intern med 332 taken by bronchoscopy (bronchoscopic group). hiv infection was determined by elisa (allere/usa). the inclusion criteria for this study was the hiv patient with cd4 ≤200 cells/ μl and presumptive tb based on clinical findings and chest x-ray. patients with respiratory failure, chronic kidney disease, congestive heart failure, and diabetes mellitus, or on tb treatment were excluded. before expectorating out sputum, patients were educated on how to cough a good quality sputum. if the patient were unable to expectorate, sputum was induced with nebulizition using 5–10 mililiter of nacl 3% as recommended.11 bronchoscopy was done by principal investigator using olympus bronchoscopic based on standar operational in our department after informed consent was given. this study is part of the etiologic pulmonary infection in hiv patients study. in this study, 40 hiv-tb patients specimens were collected from expectorated and induced sputum sample. on the next day, bronchoalveolar lavage (bal) were perfomed on the same subject. all specimen were subjected to microscopic zn examination and cultured on solid media ogawa. the protocol of study had been approved by the ethics committee of hasan sadikin hospital in bandung, registration number: 264/fkup-hasan sadikin/kepk/kep./ec/2010. written informed consent was obtained from each subjects. primary endpoint the primary endpoint of our study was to assess the positivity rate of afb and mycobacterium tuberculosis sputum culture in non-bronchoscopic group compared to bronchoscopic group. statistical analysis the data was analyzed using spss 20.0 (chicago, usa). the data of positive and negative smear of non-bronchoscopic sputum and sputum from bronchoalveolar lavage was presented in a 2x2 table. the data collected at the beginning was statistically processed by calculating the sensitivity, specificity and accuracy using mc nemar test. significance of test results, was set at p≤0.05. results characteristics of subjects were presented according to age, gender and cd4 levels. normality of the data was tested using the shapiro-wilk test. based on the data normality test, the age and gender showed normal distribution (p>0.05), whereas cd4 levels were not normally distributed (p<0.05). the fourty subjects consisted of 23 men (57.0%) and 17 women (43.0%). the average age was 32.5 years old (20–44 years old). median cd4 levels was 22 with a range of 0–190 cell/mm3. comparison of afb with zn staining and m. tuberculosis culture results the non-bronchoscopic specimen (n=40) revealed positive result with zn staining in 7 samples (17.5%) and positive culture result in 16 samples (40.0%). the bronchoscopic specimen resulted in smear positive with zn staining in 20 samples (50.0%) and positive tb culture result in 23 samples (57.5%), p<0.001 (table 1). the difference between culture results of non-bronchoscopic patients and bronchoscopic patients was 16/40 (40.0%) compared to 23/40 (57.5%). the difference was significant, as shown by value of p=0.039. number of subjects (n=40) spontaneous sputum induced sputum (non-bronchoscopy) n=40 bronchoalveolar lavage (bronchoscopy) n=40 zn stained positive n=7 afb culture positive n=16 afb culture positive n=23 zn stained positive n=20 next day figure 1. charts results vol 49 • number 4 • october 2017 improving diagnostic of pulmonary tb in hiv patients by bronchoscopy 333 there was a 22.5% increase of positivity in the non-bronchoscopic culture group between zn and culture. the bronchoscopy group also underwent the same examination as in non-bronchoscopy group which included, zn examination and m. tuberculosis culture. there was an increase of 7.5% in the positivity of the group examined by m. tuberculosis culture in bronchoscopy group. (table 2) discussion as we know the highest cause of death of hiv patients in tb endemic countries is tb. therefore, early detection of tb in hiv patients is very important so that the patients are not late for treatment and reduce the disease transmission. the detection of afb in sputum will provide certainty of microbiologic diagnosis so that it will reduce the number of patients given therapy based on clinical symptoms, or ex juvantibus therapy by looking at therapeutic response. when the treatment is given only based on clinical diagnosis, there will be two possible consequences: overdiagnosis, or underdiagnosis.6 diagnostic confirmation of pulmonary tb in hiv patients becomes problematic when clinical symptoms is suspicious, but smear result was negative. this may occur in 24-61% of patients with active pulmonary tb.2 microbiologic examination is the most important test for detecting the etiologic microorganism. the problem is the need of good quality sample which is often very difficult to obtain in hiv-tb patients. that is why we conducted the study to confirm the value of table 1. results of afb with zn staining and culture of tb from non-bronchoscopic patients and the bronchoscopic patients non-bronchoscopic patients n (%) bronchoscopic patients n (%) p ziehl + 7 (17.5) 20 (50.0) <0.001 neelsen 33 (82.5) 20 (50.0) tb culture + 16 (40.0) 23 (57.5) 0.039 24 (60.0) 17 (42.5) * mc nemar test table 2. increase of positive results between nonbronchoscopy and bronchoscopy test positive with tb, % increase test positive with tb, % non-bronchoscopy zn 17.5 17.5 non-bronchoscopy culture 40.0 22.5 bronchoscopy zn 50.0 10.0 bronchoscopy culture 57.5 7.5 table 3. the contribution of non-bronchoscopic and bronchoscopic groups for the diagnosis of tuberculosis no bronchoscopy with zn bronchoscopy with zn test positive with tb 7 (17.50%) 20 (50.00%) additional test positive with tb 7 (17.50%) 13 (32.50%) sensitivity (95% ci) 43.75 (19.75 – 70.12) 73.91 (51.59 – 89.77) incremental sensitivity (95% ci) 43.75 (19.75 – 70.12) 30.16 (15.58 – 44.42) specificity (95% ci) 100 (85.75 – 100) 82.35 (56.57 – 96.20) ppv (95% ci) 100 (59.04 – 100.00) 85.0 (62.11 – 96.79) npv (95% ci) 72.73 (54.48 – 86.70) 70.0 (45.72 – 88.11) definition of abbreviations: zn=ziehl neelsen; npv=negative predictive value; ppv=positive predictive value additional test positive with tb was 32.5% and sensitivity was 73.9%. the increased sensitivity has 30% in bronchoscopic zn. proportion of truly positive test was 85% as shown by the ppv. (table 3) prayudi santoso acta med indones-indones j intern med 334 bal.8 in this study we found that in hiv-tb patients with cd4 cells less than 200 cells/ ul, the positivity of afb with zn staining and culture was higher in bronchoscopic group than non-bronchoscopic group. to our knowledge, this study is the first study using bronchoscopy for diagnosing pulmonary tuberculosis in hiv patients in indonesia. positivity on sputum culture in non-bronchoscopic group and also in bronchoscopic group were higher than zn smear examination. culture of m. tuberculosis is clearly more sensitive than examination of sputum smear zn because it requires fewer bacilli that is at least 100/ml compared to the acid fast bacilli that requires a minimum of 10.000 bacilli/ml to produce positive smear examination. positivity of smear examination of sputum zn correlated with concentrations of afb in sputum.6 positivity of zn smear examination by bronchoscopy was higher than sputum cultures for m. tuberculosis. this study shows that differences in both smear positivity with zn staining in bronchoscopic group was higher than non-bronchoscopic group (50% v.s. 17.5%). bronchoscopic increased the positivity of the zn afb examination from 17.5% to 50% as well as on culture examination from 40% to 57.5%. the improvement is quite high. it is reasonable to put in consideration to perfom bronchoscopy in hiv positive patients suspected of pulmonary tb when sputum smear zn was negative. the difference in positivity is influenced by the quality and quantity of the sample. bronchoalveolar lavage was obtained from bronchoscopy by way of flushing in alveolar resulting in an adequate amount and lavage derived directly from alveolar.12,13 the use of bronchoscopy increased the number of microbiologically confirmed cases from 18 to 26, a relative increase of 44% and this is in accordance increased sensitivity by 30% on the examination of afb zn with bronchoscopy.9 zn smear examination was more profitable than culture, based on time for detection. sputum culture with solid media requires time to grow of 3–8 weeks.14 liquid media detects approximately 10% more tb cases than solid media, and requires a shorter incubation period for mycobacterial growth.15 if nonbronchoscopic give negative result, but clinical symptom supported pulmonary tuberculosis, we suggest that bronchoscopy should be done immediately. this was because the positivity of bronchoscopy with afb zn was higher than the culture which took longer time. bronchoscopic examination might shorten the diagnostic time of pulmonary tb in hiv patients so that clinicians could immediately provide tb treatment. at the time of this study there were no xpert mtb/rif checks for sensitive tb diagnostics, since xpert mtb/rif examination was prioritized for patients with tb mdr (multi drug resistant) presumptive based on history of treatment, relaps, or treatment after loss to follow up. examination of bronchoscopy is an invasive procedure that can only be performed at a large health facility, or possibly at an advanced referral health facility, requiring trained and costeffective experts. in indonesia, bronchoscopy facilities are usually available at the advanced referral facilities that are usually present in the provincial capitals. however, a patient referral network has been established for primary and advanced health facilities in indonesia. the hiv patients suspected of tuberculosis, but not sputum, or phlegm negative and living in nonadvanced facilities can be referred to referral hospital for perfoming bronchoscopy. in this study the bronchoscopy relatively safe without any significant complications. the limitation of this study was that the patients with ordinary expectorants with sputum induction were not separated with spontaneous expectoran. liquid culture can be done to shorten the actual time and it can grow faster than solid media that is approximately 2 weeks.15 for further research it is necessary to examine the sample using naat (nucleic acid amplification test) which can detect targeted regions of the m. tuberculosis genome by amplifying specific regions of mycobacterial dna using xpert mtb/rif method which is more sensitive than the zn afb examination and can simultaneously detect rifampicin resistance. there is a difference in the positivity of smear results when different diagnostic and screening measures are performed. bronchoscopic method will increase positivity compared to nonvol 49 • number 4 • october 2017 improving diagnostic of pulmonary tb in hiv patients by bronchoscopy 335 bronchoscopy. culture of m. tuberculosis will also increase positivity compared to zn staining. the study recommends that if hiv patients as suspected of having pulmonary tb, but microscopic examination by spontaneous cough or sputum induction are negative, bal should be examined especially in facilities and by experts who can perform bronchoscopy. further studies are needed by using xpert mtb/rif examination and theoretically this examination will add positivity compared to zn afb examination. currently xpert mtb/ rif are available in almost all referral hospitals in indonesia, so incorporation of sampling with bal and diagnostics with xpert mtb/rif can be performed. conclusion t h e b o n c h o a l v e o l a r l a v a g e w i t h bronchoscopy can increase the positivity of smear and shorten the diagnostic time of patients suspected of pulmonary tb in hiv patients with cd4 cell counts below 200 cells/ul. acknowledgments the research was financially supported by grant national aids research commission (kpan, komisi penelitian aids nasional), and hcpi (hiv cooperation program for indonesia). the author would like to thank dr. melindah who prepared the patients and as bronchoscopy assistant. dr. dewi kt, sppk and dr. adhi k. sugianli, sppk who helped laboratory for our patients. the authors do not have any conflict of interest to disclosure. references 1. world health organization. global tuberculosis report 2016 (global tuberculosis control). switzerland: world health organization press; 2016. 2. getahun h, harrington m, o’brien r, nunn p. diagnosis of smear-negative pulmonary tuberculosis in people with hiv infection or aids in resourceconstrained settings: informing urgent policy changes. lancet. 2007;369:2042–9. 3. karakousis pc, chaisson re. mycobacterial infections and hiv infection. in: fishman a, elias j, fishman j, grippi m, senior r, pack a, eds. fishman’s pulmonary disesase and disorders. 4ed. new york: mc graw hill; 2008. p.2487-97. 4. nachega jb, maartens g. clinical aspects of tuberculosis in hiv infected adults. in: schaaf h, zumla a, ed. tuberculosis a comprehensive clinical reference. europe: saunders; 2009. p. 524-31. 5. gupta p, baloch z. pulmonary cytopathology. in: fishman a, elias j, fishman j grippi ma, senior rm, pack ai, ed. fishman’s pulmonary disesase and disorders. 4ed. new york: mc graw hill medical; 2008. p511-610. 6. tb care i. international standards for tuberculosis care, edition 3. tb care i, the hague, 2014. 7. fangman jjw, sax pe. human immunodeficiency virus and pulmonary infections. in: fishman ap, elias ja, fishman ja, grippi ma, senior rm, pack ai, eds. fishman’s pulmonary diseases and disorders. 4ed. new york: mc graw hill medical; 2008. p.2241–64. 8. aderaye g, g/egziabher h, aseffa a, worku a, lindquist l. comparison of acid-fast stain and culture for mycobacterium tuberculosis in preand postbronchoscopy sputum and bronchoalveolar lavage in hiv-infected patients with atypical chest x-ray in ethiopia. ann thorac med. 2007;2(4):154-7. 9. worodria w, davis j, cattamanchi a, andama a, boon s, yoo s. bronchosocopy is useful for diagnosing smear-negative tuberculosis in hiv-infected patients. eur respir j. 2010;446-56. 10. adewole oo, onakpoya uu, ogunrombi ab, et al. flexible fiberoptic bronchoscopy in respiratory care: diagnostic yield, complications, and challenges in a nigerian tertiary center. niger j clin pract. 2017;20(1):77-81. 11. garcia sb, perin c, silveira mmd, vergani g, mennabarreto ss, dalcin pdtr. bacteriological analysis of induced sputum for the diagnosis of pulmonary tuberculosis in the clinical practice of a general tertiary hospital. j bras pneumol. 2009;35(11):1092-9. 12. baughman rp, lower ee. diagnosis of pneumonia in immunocompromised patient. in: agusti c, torres a, eds. pulmonary infection in the immunocompromised patient: strategi for management. uk: john wiley and sons. ltd; 2009. p.65-70. 13. vachini a, seijo l, unger m, sterman d. bronchoscopy, transthoracic needle aspiration, and related procedures. in: fishman ap, elias ja, fishman ja, grippi ma, senior rm, pack ai, eds. fishman’s pulmonary diseases and disorders. 4th edition. new york: mc graw hill medical; 2008. p. 629-48. 14. a l z a m e l fa . d e t e c t i o n a n d d i a g n o s i s o f mycobacterium tuberculosis. expert rev anti infect ther. 2009;7(9):1099-108. 15. dinnes j, deeks j, kunst h, et al. a systematic review of rapid diagnostic tests for the detection of tuberculosis infection. health technol assess. 2007;11(3):1-155. 120 acta med indones indones j intern med • vol 54 • number 1 • january 2022 case report successful treatment bilateral panuveitis with multiple systemic infection in hiv/aids patient: a case report made susiyanti*, indra maharddhika pambudy department of ophthalmology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. *corresponding author: made susiyanti, md., phd. department of ophthalmology, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. kimia no. 8, jakarta 10440, indonesia. email: madesusiyanti@yahoo.com. abstract there is an increasing number of hiv/aids patients in indonesia, starting from <0.1% in 2010 to 0.4% in 2012, which warrants awareness of ocular manifestation in hiv. this might appear in 70-100% of patients with hiv. a 47 years old man came to the infection and immunology clinic with blurry vision on both eyes. he had been treated before but there was no clinical improvement. examination showed both eyes had vitreous haziness. visual acuity was 1/60 in both eyes with appearance of flare and cells within +3. uveitis workup showed positive results for hiv, hsv and syphilis. patient was given 100 mg of doxyciclin two times daily and fixed dose tablet which contains the combination of antiretroviral. three months later, final acuity was 6/10 on the right eye and 6/18 on the left eye. prompt diagnosis and treatment warrant good prognosis including multidisciplinary approach by ophthalmologist, clinical allergist and immunologist, and dermato-venerologist. keywords: hiv/aids, syphillis, ocular manifestation in hiv, bilateral panuveitis. introduction increasing number of hiv/aids patients in indonesia, from <0.1% in 2010 to 0.4% in 2012, warrants awareness of ocular manifestations of hiv. ocular manifestation of hiv might appear in 70-100% patients. in some cases ocular manifestations might be the initial presenting clinical finding in patients with hiv/aids.1 various causative agents might cause uveitis in these population, such as cmv, syphilis, toxoplasma, herpes, and tuberculosis.1-3 in this case report we present a successful management of panuveitis in hiv patients. the aim of this report is to demonstrate the management of uveitis in hiv patients and highlighting the importance of prompt and accurate diagnosis as well as proper treatment. case illustration a 47 years old man came with complaint of blurry vision for 2 months. one year before the patient complaint of having blurry vision and floaters on his left eye. two months before, the vision worsen accompanied with red eyes. the patient was initially treated with prednisolone acetate eye drop. there was history of promiscuity and tattoo. visual acuity was 1/60 in both eyes with cells +3 and flare. the vitreous was hazy, the optic nerve can not be examined in detail, exudate was found, other details was hard to be evaluated. the patient was initially assessed with panuveitis on both eyes caused by toxoplasma dd/ cytomegalovirus and aids without arv treatment. the patient was planned to have vol 54 • number 1 • january 2022 succesful treament bilateral panuveitis with multiple systemic inferction 121 fundus photograph taken, uveitis workup. and was treated with by the attending ophthalmologist with trimetripim + sulfametoxazole 2 x 960 mg. complete uveitis workup was done to the patient to rule in or out the possibility of infectious disease as the cause of uveitis, and the patient return three days later with the result. uveitis workup showed positive hiv; positive igg and igm for anti-hsv 2; reactive vdrl (1/512) and tpha test (>1:5120); positive igg for anti-cmv. cd4+ lymphocyte count was 9% and absolute count was 261 cells/mcl. other uveitis screening workup such as tuberculin test for tuberculosis, igm and igg for toxoplasma, showed negative result excluding the diagnosis. chest x-ray showed no signs infiltrate in both lungs. discussion most common ocular manifestation in hiv/aids patients includes hiv retinopathy, opportunistic infections, kaposi sarcoma, and adnexal disease, and might occur in 70-100% patients in this population.1 uveitis might be the first manifestations of aids stage of hiv infections. in patients with hiv/aids the course of the uveitis tend to be severe and produce more sequelae.1-3 uveitis in patient with hiv/aids might be caused by various etiology. study in taiwan in patients with uveitis as initial manifestations of aids, showed cmv, syphilis, and toxoplasmosis is the leading pathogen.2 in hiv patients with cd4+ lymphocyte count >200/mcl, one study showed infectious uveitis is mostly caused by syphilis and herpes virus.3 the diagnosis of syphilitic uveitis requires thorough history taking, clinical findings and established through serological test. the most common finding in the fundus are multifocal chorioretinitis associated with vitritis or severe vitritis alone but, necrotizing retinitis, retinal vasculitis, exudative retinal etachment, isolated papilitis and neuroretinitis can also be found. figure 1. the first fundus photograph showing he optic nerve head was hazy and other details were hard to be evaluated 1. figure 2. second fundus and photograph taken 2 weeks later. optic nerve head was round with clear margin, artery to venous ratio was 2/3, with cup to disc ratio 0.3-0.4, no hemorrhage or exudate can be found on both eyes. figure 3. final fundus photographed. optic nerve head was round with clear margin, artery to venous ratio was 2/3, with cup to disc ratio 0.3-0.4, no hemorrhage or exudate was found. the patient was treated as syphilitic panuveitis. because the patient was allergic to penicillin, he was treated with doxyciclin 2 x 100 mg. the hiv infection was treated with fixed dose tablet consisting zidovudine 300 mg and lamivudine 150 mg and efavirenz 600 mg once daily. because negative result test for toxoplasma, the treatment trimetropim and sulfametoxazole was stopped. two weeks later the patient’s acuity was 6/20 on the right eye and 6/18 on the left eye. anterior segment was quiet. posterior segment shows vitreous cells +1, with normal appearing optic nerve head and retina (figure 2). three months after treatment for syphilis, the patient’s visual acuity was 6/10 in the right eye and 6/18 in the left eye. anterior segment and posterior segment were within normal limit. his final titer for vdrl and tpha was 1:128. made susiyanti acta med indones-indones j intern med 122 panuveitis is not a rare manifestation of syphilitic uveitis, comprising of 40% cases in one study.4 two type of serological test are available for syphilis classified as non-treponemal, (e.g. vdrl test) , and treponemal test (e.g. tpha, fta-abs or mha-tp). current cdc recommendation is to test patient suspected of having syphilis with treponemal test, then if positive, should be tested for non-treponemal test.5,6 because of the wide possibility of the cause of uveitis in patients with hiv, our patients was tested with various tests to confirm the causative agent. the most common viral infection of uveitis in patient with hiv is cytomegalovirus, thus testing for this disease is very important. other important causative agents are varicella zoster virus and herpes simplex virus, which, unlike cmv that cause slowly progressive disease, causes rapidly developing and confluent retinitis. ocular toxoplasmic retinochoroiditis is also one of the most common ocular manifestation in patients with hiv, thus testing for toxoplasma infection is very important in these cases. infectious agents that can be commonly seen in hiv-negative uveitis patients such as syphilis and tuberculosis should also be tested since it these infection is commonly found in hiv positive patients.(2-,4) the treatment for ocular syphilis is the same with syphilis with neural involvement. cdc only recommended aqueous penicillin g 18-24 mu/d given iv as 3-4 mu every 4 hours for 10-14 days.5 european guidelines recommend the administration of oral doxycyclin 2 x 200 mg daily in cases of penicillin allergy, but the evidence is very weak (graded iv c).7 there is one case series that reports the improvement of clinical findings and visual acuity in one patients with ocular syphilis and penicillin allergy.8 our patient was a 47 years old hiv positive male with remarkable risk factors for sexually transmitted diseases. patients with hiv with history of promiscuity is at risk for other sexually transmitted infection. examination showed dense vitritis hampering proper examination of retina, and serological test showed positive test for both treponemal and non-treponemal test for syphilis, establishing the diagnosis of syphilitic uveitis. test for other diseases should be done, because the dense vitritis hampers the evaluation of the retina, making the diagnosis for disease that might cause retinal necrosis worth being considered. although test for hsv-2 igm and igg also showed positive result, clinical examination that support acute retinal necrosis or progressive outer retinal necrosis can not be found, thus excluding this diagnosis. but the serological test is still justifiable because on initial examination dense vitritis hamper the examination of the fundus. because our patient was diagnosed with syphilitic uveitis in both eyes as well as hsv-2 infection, we advise to cooperate with other fields of expert in order to properly manage this patient. our patient was allergic to penicillin, and given doxycycline 100 mg orally twice daily for two weeks. in spite of not adhering to cdc recommendation, and low evidence based on european guideline it is interesting to note that our patient had dramatic clinical improvement. the prognosis of patient with ocular syphilis is favorable if treated promptly. one research study showed that the final bcva for patients who had been treated with penicillin regimen ranging from 20/50 – 20-20 and no recurrences in 2 years. 9 another report stated that treatment more that 28 days since symptoms occur is a risk factor for poor prognosis.10 conclusion prompt diagnosis and treatment warrant good prognosis in these population. our patient came with poor visual acuity and severe inflammatory reaction, but with proper antibiotic and anti-retroviral treatment improve the visual acuity of our patient improve dramatically. the treatment involving multidisciplinary approach by ophthalmologist, clinical allergist and immunologist, and dermato-venerologist is required in these cases. acknowledgments address for reprints and sources of support that require acknowledgement is none. vol 54 • number 1 • january 2022 succesful treament bilateral panuveitis with multiple systemic inferction 123 references 1. moorthy rs, rao pk, read rw, et al. basic and clinical science course: intraocular infalmmation and uveitis. united states of america: american academy of ophthalmology; 2014. 2. tsen cl, chen sc, chen ys, sheu sj. uveitis as an initial manifestation of acquired immunodeficiency syndrome. int j std aids. 2017;15(5):73-80. 3. rose-nussbaumer j, goldstein da, thorne je, et al. uveitis in human immunodeficiency virus-infected persons with cd4+ t-lymphocyte count over 200 cells/ml. clin exp ophthalmol. 2014;42(2):118-25. 4. li jz, tucker jd, lobo am, et al. ocular syphilis among hiv-infected individuals. clin infect dis. 2010;51(4):468-71. 5. davis jl. ocular syphilis. curr opin ophthalmol. 2014;25(6):513-8. 6. lee sy, cheng v, rodger d, rao n. clinical and laboratory characteristics of ocular syphilis: a new face in the era of hiv co-infection. j ophthalmic inflamm infect. 2015;5(1):56. 7. french p, gomberg m, janier m, et al. iusti: 2008 european guidelines on the management of syphilis. int j std aids. 2009;20(5):300-9. 8. li jz, tucker jd, lobo am, et al. ocular syphilis among hiv-infected individuals. clin infect dis. 2010;51(4):468-71. 9. sahin o, ziaei a. clinical and laboratory characteristics of ocular syphilis, co-infection, and therapy response. clin ophthalmol. 2016;10:13-28. 10. tsuboi m, nishijima t, yashiro s, et al. prognosis of ocular syphilis in patients infected with hiv in the antiretroviral therapy era. sex transm infect. 2016;92(8):605-10. special article 270 acta med indones indones j intern med • vol 49 • number 3 • july 2017 current issues of gastroenterology in indonesia marcellus simadibrata1,2, randy adiwinata3 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of medical education, faculty of medicine universitas indonesia, jakarta, indonesia. 3 faculty of medicine, atmajaya catholic university, jakarta, indonesia. corresponding author: prof. marcellus simadibrata, md., phd. division of gastroenterology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta10430, indonesia. email: prof.marcellus.s@gmail.com. abstrak indonesia merupakan salah satu negara berkembang dengan penduduk terbanyak di dunia. sama seperti negara berkembang lainnya, indonesia mempunyai angka insidens penyakit gastroenterologi yang tinggi dan sebagian besar disebabkan oleh infeksi. beberapa tahun terakhir, indonesia juga mengalami peningkatan penyakit gastroenterologi non infeksi seperti inflammatory bowel disease, gastroesophageal reflux disease, dan kanker kolorektal. saat ini berkat kerjasama lintas sektor, telah terjadi perkembangan pesat dari modalitas diagnostic dan terapeutik. hal ini bertujuan untuk meningkatkan kesehatan pencernaan di indonesia. kata kunci: penyakit gastroenterologi, indonesia, negara berkembang, prevalensi, layanan kesehatan. abstract indonesia is one of the most populous developing countries in the world. similar with other developing countries, indonesia has been suffered from the high incidence of gastroenterology diseases that mainly due to infection. in the recent years, indonesia had also increased number of non-infectious gastroenterology diseases cases such as inflammatory bowel disease, gastroesophageal reflux disease, and colorectal cancer. nevertheless, the developments of diagnostic and therapeutic modality along with the cooperation between sectors have undergone rapid progress as an effort in improving digestive health in indonesia. keywords: gastroenterology disease, indonesia, developing country, prevalence, healthcare. introduction indonesia is one of the largest developing country in the world with total population of 255 million people and population density of 134 people/km2.1 as other developing countries, indonesia healthcare problems are related with poverty especially in rural area (62.76%) and low sanitation level due to lack of clean-drinking water access, hand and food hygiene awareness, also due to slum areas.2-4 in the past few years, indonesia has undergone significant improvement in the healthcare and economics field. national survey in 2015 showed the national percentage of households with clean drinking water access reached 70.97% and the number of hand hygiene awareness reached 65.83%.2 access to adequate and sustainable sanitation in 2015 reached the national coverage of 62.14%; however in rural areas the coverage was still less than 50%.5 these challenges contribute to the high incidence of gastrointestinal infections that lead to increased vol 49 • number 3 • july 2017 current issues of gastroenterology in indonesia morbidity and mortality. indonesia is also faced with increasing cases of gastrointestinal cancers that are often associated with changes in diet and lifestyle; therefore increasing early detection screening and cancer awareness are required for healthcare provider and community. g a s t r o e n t e r o l o g y d i s e a s e s i n indonesia gastroenterology diseases still remain major health problems in indonesia. national survey in 2010 showed that diarrhea, gastroenteritis, and colitis were ranked fifth in the list of top ten leading diseases in outpatient setting, while dyspepsia ranked sixth.6 (table 1) according to national hospitalization data, diarrhea was the most prevalent disease in inpatient setting with case fatality rate (cfr) of 1.79%, then followed by typhoid fever in third place, and dyspepsia in fifth place.6 (table 2) in 2007, the prevalence of diarrhea in indonesia were 9% and become the most common cause of death among babies (31.4%), also ranked fourth leading cause of death among all ages (13.2%). decreased diarrhea prevalence was reported in 2013 which declined to 7% among all ages.7 data in 2015 reported 18 outbreak cases of diarrhea were occurred in indonesia with cfr 2.47%. national morbidity rate of diarrhea reached 214/1,000 with estimation of 5,405,235 diarrhea cases were occurred in 2015, in which 74.3% of cases were managed in health care facility.2 the etiology of acute diarrhea in indonesia includes virus, bacteria, and parasites (table 3). the bacterial pathogens of acute diarrhea in indonesia are vibrio cholerae 01, vibrio cholerae 0139, vibrio parahaemolyticus, escherichia coli, campylobacter jejuni, salmonella sp., clostridium difficile, yersinia enterocoiltica and shigella sp.8 viral agents causing diarrhea are rotavirus, norovirus (calcivirus), adenovirus, astrovirus, cytomegalovirus, and coronavirus.8 while the parasites include protozoa (giardia lamblia, cryptosporodium) and helminthes (strongyloides sp.).8 report from one of referral hospital in jakarta, found that most cases of acute diarrhea were caused by e. coli pathogenic (38.29%), followed by v. cholera ogawa (18.29%), and aeromonas, sp. (14.29%).9 simanjuntak et al.10 reported the incidence of cholera cases caused by vibrio cholera ogawa from 1993 – 1999 ranged from 6 % to 72%; with the highest incidence in aceh, and the lowest incidence was in jakarta. surveillance study in indonesia conducted by oyofo et al.11 found that among 6760 acute diarrhea cases, 9% of the patient stools were positive for bacteria. the most prevalent pathogen isolated was shigella flexneri (39%), followed by salmonella sp. (26%), and vibrio sp. (26%). high prevalence number of acute diarrhea in indonesia is closely related with low level of environment sanitation, personal and food hygiene awareness, access to table 1. pattern of 10 most frequent diseases in the outpatient clinic in indonesian hospitalas year 20106 type of diseases new cases all cases acute upper respiratory tract infection 291 356 433 354 multiple body injury trauma 127 076 168 768 skin and subcutaneous diseases 122 076 192 414 refractive and accomodative abnormalities 111 513 143 404 diarrhea, gastroenteritis caused by specific infection (infective colitis) 105 279 141 556 dyspepsia 88 599 163 428 pulpa and periapical diseases 86 421 163 211 essential hypertension (primary) 80 615 277 846 conjunctivitis and other abnormalities 68 026 87 513 ear and mastoid processus diseases 61 438 99 663 table 2. pattern of 10 most frequent diseases in the inpatient ward in indonesian hospital year 20106 type of disease patient discharge patient death cfr (%) diarrhea, gastroenteritis by other specific infection (infective colitis) 71 889 1 289 1.79 dengue hemorrhagic fever 59 115 325 0.55 typhoid and paratyphoid 41 081 274 0.67 fever 40 636 276 0.68 pregnancy and other delivery complications 24 716 166 0.67 271 marcellus simadibrata acta med indones-indones j intern med clean drinking water, level of education, social status, and high number of malnutrition, poverty, population density, and flood events.12 regarding chronic diarrhea in indonesia, data from division of gastroenterology universitas indonesia showed prevalence rate of 15% among all colonoscopy procedures performed.13 simadibrata et al.13 reported that the most common etiology of chronic diarrhea in indonesia was due to infection (48.3%) which caused by candida albicans (48.6%), bacterial (pathogenic e.coli, etc.), parasites (entamoeba histolytica, helminthes, etc.) (table 4 and 5). while, the non-infectious causes of chronic diarrhea (33.3%) were carbohydrate maldigestion (62.6%), colorectal carcinoma (14%), chron’s disease (11.2%), radiation colitis, enteropathy, and others.14 (table 6) dyspepsia ranked sixth among the most common complaints in outpatients setting in indonesian hospital.6 study in indonesia found table 3. causative agents of acute diarrhea in indonesia8 bacteria viruses parasites vibrio cholerae o1 rotavirus protozoan v. parahaemolyticus norovirus (callcivirus) microsporidia escherichia coli adenovirus (serot.40/41) encephalitozoan bleneusi plesiomonas astovirus enterocytozoan intestinales aeromonas cytomegalovirus giardia intestinalis bacteroides fragilis coronavirus cryptosporidium hominis campylobacter jejuni entamoeba histolytica c. coli isospora belli cupsaliensis nontyphoidal cyclospora cayetanenesis salmonella dientamoeba fragillis clostridium difficile blastocystis hominis yersinia enterocolitica y. pseudotuberculosis helminths shigella species strongyloides stercoralis anglostrongylus costakensis schistosoma mansoni table 4. etiologies of chronic diarrhea14 pattern of chronic diarrhea n (%) chronic infective 100 (48.3) mixed chronic infective and non-infective 38 (18.4) chronic non-infective 69 (33.3) total 207 (100.0) table 5. etiologies in patients with chronic infective diarrhea14 microorganisms n (%) candida albicans 67 (48.6) pathogenic e.coli 48 (34.8) blastocystis hominis 9 (6.5) giardia lamblia 5 (3.6) entamoeba histolytica 5 (3.6) ascaris lumbicoides 5 (3.6) trichuris trichiura 5 (3.6) aerobacter aerogens 5 (3.6) mycobacterium tuberculosis 5 (3.6) klebsiella ocoma 5 (3.6) klebsiella oxytoca 5 (3.6) salmonella paratyphi 4 (2.9) klebsiella pneumonia 4 (2.9) alcaligens dizpar 4 (2.9) geotrichum 2 (1.5) pseudomonas spp. 1 (0.7) yersinia entercolytica 1 (0.7) clostridium perferingens 1 (0.7) shigella flexneri 1 (0.7) entamoeba coli 1 (0.7) shigella zoonotic 1 (0.7) that among 550 patients with dyspepsia who underwent endoscopic examination were found gastritis (44.7%), duodenitis (6.5%), peptic ulcer (3.6%), duodenal ulcer (8.2%) and gastric tumor 272 vol 49 • number 3 • july 2017 current issues of gastroenterology in indonesia (0.2%).15 several studies regarding h. pylori prevalence in indonesia had been conducted since 1998 to 2015, which showed prevalence between 0 to 68%, it depends on the location of study and diagnostic testing methods being used.16 in 2015, syam et al.16 conducted prevalence study of h. pylori infection in five islands in indonesia, which found prevalence of 22.1% (59/267), with the largest group was aged 50-59 years (29.8%).16 this finding suggested that the prevalence of h.pylori infection in indonesia is lower than other countries in asia and several countries in the world.17 the prevalence of h.pylori in indonesia shows variation between ethnic groups, with the highest was found among papuan (42.9%), batak (40.0%), buginese (36.7%), and chinese (13%).16 h. pylori antibiotic resistance data reported by miftahussurur et al.18 in 2016 stated that among 849 dyspeptic patients who underwent endoscopy in 11 cities in indonesia, there were total of 77 h. pylori strains with 28 strains (36.4%) were sensitive of all antibiotics, and they also found low resistance to clarithromycin (9.1%), amoxicillin (5.2%), tetracycline (2.6%). in contrast, high resistance rates to metronidazole (46.7%) and levofloxacin (31.2%) were identified. there were differences in h. pylori antibiotic susceptibility between cities in indonesia, such as clarithromycin resistance was found ranged between 0-21.4% and resistance to metronidazole ranged from 20 to 88.9%.18 previous study in 2006 showed that among 72 h. pylori specimens in jakarta were found resistant to metronidazole (100%), clarithromycin (27.8%), amoxicillin (19.4%), dan levofloxacin (1.4%).19 therefore it can be concluded that knowledge regarding local data of h. pylori antimicrobial susceptibility in indonesia are necessary to administer the most effective eradication regiments. the prevalence of gastroesophageal reflux disease (gerd) in indonesia is increasing recently; study from cipto mangunkusumo national referral hospital found increased prevalence from 5.7% in 1997 to 25.18% in 2002.20 another gerd prevalence study which involved 515 general practitioners in indonesia was found prevalence of 27.4%, with risk factors such as older than 50 years old, obesity, and smoking habit.21 beside the vast majority of gastrointestinal tropic-infection diseases problem, indonesia also has increased gastrointestinal tumor prevalence which warranted further action. according to globocan world health organization 2012, colorectal cancer ranked fifth as the most prevalent cancer in indonesia, followed by hepatoma in the seventh rank, gastric cancer in fourteenth place, and pancreatic cancer in the fifteenth (figure 1).22 among group of male, colorectal cancer is the second most prevalent cancer in indonesia (age standardized rate [asr] per 100,000: 15.9). the prevalence of colorectal cancer in indonesia for both sexes reached 9.3% with asr 12.8 per 100,000 and mortality rate of 9.5% (asr: 8.6).22 annual report from indonesian society of anatomic pathology in 1995 stated that more than 30% of colorectal cancer were found in patients aged below 40 years old and generally diagnosed at 45-50 years old.23 this finding was in contrast with report from american cancer society that up to 90% table 6. etiology in patients with chronic non-infective diarrhea14 causes n (%) carbohydrate maldigestion 67 (62.6) colorectal carcinoma 15 (14.0) chron’s disease 12 (11.2) colorectal polyp 11 (10.3) ulcerative colitis 10 (9.3) irritable bowel syndrome 9 (8.4) portal hypertensive enteropathy 7 (6.5) colorectal diverticulosis 6 (5.6) carbohydrate fat maldigestion 6 (5.6) radiation colitis 5 (4.7) lactose intolerance 5 (4.7) fat maldigestion 4 (3.7) jejunal villeus atrophy due to celiac disease 3 (2.8) lymphoma 3 (2.8) nsaid enteropathy 2 (1.9) prostigmin therapy 1 (0.9) food allergy 1 (0.9) amyloidosis 1 (0.9) eosinophilic duodeno-jejuno-ileo-colitis 1 (0.9) lymphocytic colitis 1 (0.9) jejunal carcinoma 1 (0.9) unknown 5 (4.7) 273 marcellus simadibrata acta med indones-indones j intern med of new cases and 93% death cases occurred in american citizens older than 50 years old.24 another report from one of digestive centers in indonesian private hospital showed that among 1695 patients whom undergone colonoscopy; 29.8% of them were found to have polyp or colon masses, and neoplastic lesion was found in 16.1% patients with adenoma (11.3%), in situ carcinoma (0.6%), and carcinoma (4.2%). polyp or masses were more commonly found in male (25% vs. 23.9%; p<0.001) and patients aged more than 50 years old (39.6% vs. 16.6%; p<0.001).25 increasing prevalence of colorectal cancer in indonesia may be seen as multifactor; which related with genetics, lifestyle changes, less fiber consumption, increased meat and alcohol consumption, obesity, smoking, inflammatory bowel disease (ibd), and low number of routine colonoscopy screening in population at risk.24-26 data regarding ibd prevalence in indonesia mostly derived from endoscopy unit which was hospital based. ibd prevalence in indonesia was reported 1.16-26.5%; with prevalence of ulcerative colitis (uc) between 5.4-26.5%, and chron’s disease (cd) ranged from 1 to 10.2%.27 indonesia has been listed in access (asia pacific chron’s and colitis epidemiology study) study group and was reported to have crude annual incidence (per 100,000) of 0.88 for ibd, 0.33 for cd, and 0.55 for uc. these findings were lower compared to crude annual incidence of ibd in asia (1.37), china (3.44), and australia (23.67). while, indonesia agestandarized incidence for ibd (0.83), cd (0.27), and uc (0.56) was reported.28 some risk factors related with increased ibd incidence are genetic predisposition, environmental factor such as smoking, increased sugar, fat, red meat intake, and low fiber diet.29 gastric tumors in indonesia is estimated to have asr 2.8 per 100,000 population for both sexes, whereas for men by 3.9 and 1.9 for women. the findings are much lower compared to other asian countries such as japan (asr 29.9), south korea (asr 41.8) or in the world (asr 12,1).22 several studies showed the prevalence of gastric tumor ranged between 0.25 to 9.1%.30,31 low number of gastric tumors in indonesia may be associated with low prevalence of h.pylori infection and the genotype which found to be less virulent.32 abdullah et al.33, showed that h. pylori positive japanese patients have higher gastritis incidence and grade, also higher number of atrophic gastritis and intestinal metaplasia compared with indonesian.33 figure 1. estimated age-standardised incidence and mortality rates in indonesia, both sexes.22 (asr rate per 100,000) 274 vol 49 • number 3 • july 2017 current issues of gastroenterology in indonesia development of health care and gastroenterology education in indonesia indonesian society of gastroenterology (isg) has cooperated with ministry of health republic of indonesia for improvement in gastrointestinal health programs. programs that have been implemented on include the improvement and dissemination of good hygiene and sanitation, also continuation of the ministry of health of indonesia programs in community health centers and hospitals as well as increased knowledge of digestive health in the community. isg also responsible for improvement of gastroenterology services at public hospitals and teaching hospitals or universities in indonesia through optimal screening, diagnosis, treatment, prevention and education for patients and in cooperation with private health insurance or the national health insurance (jaminan kesehatan nasional). research funding in the gastroenterology field has been provided by isg through higher education directorate in the ministry of education and culture republic of indonesia. the funding is in the form of competitive grants among indonesia universities and also internationally. isg also published research journal called indonesian journal of gastroenterology, hepatology, and digestive endoscopy that has been established since 1995 and publishing three times a year. every three years, national congress (konas) was being held in cooperation between isg, indonesian society of digestive endoscopy (isde), indonesian association for the study of the liver (ina-asl), and also every year there was working national conference (konker) held in 17 branches in indonesia. each year, isg hold indonesian digestive disease week (iddw) and the international gastrointestinal endoscopy workshop in jakarta, which is supported by the world gastroenterology organization (wgo), the asian pacific association of gastroenterology (apage), the american college of gastroenterology (acg). isde arranged jakarta international gastrointestinal endoscopy symposium & live demonstration every year since 2015. isg initiated the establishment of educational centers for subspecialty (consultants) in gastroentero-hepatology. currently there are 6 gastroenterology subspecialty education centers in indonesia which located in jakarta, medan, bandung, surabaya, yogyakarta and semarang.34 and also seven partial education centers located in palembang, bali, makassar, solo, padang, manado, and malang. gastrointestinal endoscopy training for internal medicine specialist, surgeon, and pediatrician has been developed in 10 educational centers. g a s t r o e n t e r o l o g y d i a g n o s t i c modality developments in indonesia gastroenterology diagnostic modalities in indonesia have made significant progress in detecting cancer, ibd or other functional disorders of entero-colon. diagnosis has been using some scoring system or criteria such as rome iv and gerd-q that had been validated in indonesian and combined with noninvasive or invasive examination.35 non-invasive examination such as gastrin and pepsinogen in serum to detect gastric cancer, detection for carcinoid using chromogranin a in serum and m2 pyruvate kinase (m2pk) stool test, pet ct-scan for gastrointestinal cancer staging, detection of inflammatory intestine intestinal inflammation by faecal calprotectin, elastase stool test to detect pancreatic insufficiency, h. pylori screening using h. pylori stool antigen test and urea breath test have been routinely done. other tests using flexible or semi-flexible endoscopes, capsule endoscopy, magnetic resonance cholangiopancreatography (mrcp) and endoscopy ultrasonography also been done to aid the diagnosis of gastrointestinal cancer. endoscopic equipment in indonesia is also supported with narrow band imaging (nbi) and virtual chromoendoscopy system. there are 313 hospitals that provide services for gastrointestinal endoscopy in indonesia based on data in 2013.34 gastroenterology therapeutic m o d a l i t i e s d e v e l o p m e n t s i n indonesia progress in gastroenterology therapy can be seen through the availability of medicines in 275 marcellus simadibrata acta med indones-indones j intern med accordance with the latest research developments and evidence-based that has been recommended by gastroenterology association around the world. biological agents such as infliximab and adalimumab have been given to ibdindicated patients. isg also routinely issues several guidelines for gastroenterology diseases management in indonesia. therapeutic endoscopy procedure has reached significant development in indonesia (table 7).34 techniques that are often used for rupture esophageal varices management in indonesia are endoscopic variceal ligation (evl) and endoscopic injection sclerosis (eis). endoscopic clipping is used for other cause of gastrointestinal bleeding. surgery for gastrointestinal polyps and cancers can also be performed with endoscopic submucosal dissection (esd), endoscopic mucosal resection (emr), and hot biopsy. other type of surgery that can also be performed is laparoscopic resection. as part of integrated gastrointestinal cancer management, there are some radiotherapy centers in indonesia which already well-established such as in dharmais national cancer hospital, cipto mangunkusumo hospital, hasan sadikin hospital, gading pluit hospital, and etc. conclusion indonesia as developing country is facing high burden of gastrointestinal tropical and infectious diseases, however, during the last few years there were also increased number of non-infectious gastrointestinal diseases such as gerd, ibd, gastric and colorectal cancer. references 1. statistics indonesia. statistical yearbook of indonesia [internet]. jakarta: bps-statistics indonesia; 2016 [cited 2017 feb 20]. available from: https:// www.bps.go.id/website/pdf_publikasi/statistikindonesia-2016--_rev.pdf. 2. ministry of health republic of indonesia. indonesia health profile 2015. [internet] jakarta: ministry of health republic of indonesia; 2016 [cited 2017 feb 18]. available from: http://www.depkes.go.id/ resources/download/pusdatin/profil-kesehatanindonesia/profil-kesehatan-indonesia-2015.pdf. 3. the united nations international children’s fund. air bersih, sanitasi, & kebersihan [internet]: unicef; 2012 [cited 2017 feb 18]. available from: https://www. unicef.org/indonesia/id/a8_-_b_ringkasan_kajian_ air_bersih.pdf. 4. statistics indonesia. number of villages/sub-districts by availability of settlement on river bank, below extra high voltage air channel, and slum settlement, 2014 [internet]. 2015 [cited 2017 feb 18]. available from: https://www.bps.go.id/linktabelstatis/view/ id/1762. 5. statistics indonesia. potret awal tujuan pembangunan berkelanjutan (sustainable development goals) di indonesia [internet]. 2016. available from: https:// www.bps.go.id/website/pdf_publikasi/potret-awaltujuan-pembangunan-berkelanjutan-di-indonesia--_ rev.pdf. 6. ministry of health republic of indonesia. indonesia health profile 2010 [internet]. jakarta: ministry of health republic of indonesia; 2011 [cited 2017 feb 18]. available from: http://www.depkes.go.id/folder/ view/01/structure-publikasi-pusdatin-profil-kesehatan. html. table 7. routinely done therapeutic endoscopy procedures in indonesia34 endoscopic procedure description upper gastrointestinal endoscopy sclerotherapy and esophageal varices ligation histoacryl injection in gastric varices polypectomy esophagus/pyloric dilatation percutaneous endoscopic gastrostomy foreign body extraction endoscopic hemostasis endoscopic (clip, adrenalin injection, coagulation) esophageal stenting lower gastrointestinal endoscopy polypectomy endoscopic hemostasis colonic stenting endoscopic retrograde cholangiopancreatography (ercp) biliary stone extraction foreign body extraction biliary dilatation enteroscopy enteroscopic hemostasis foreign body extraction endoscopic ultrasonography pancreatic cyst/ pseudocyst drainage biliary drainage 276 vol 49 • number 3 • july 2017 current issues of gastroenterology in indonesia 7. ministry of health republic of indonesia. indonesia health profile 2014 [internet]. jakarta: ministry of health republic of indonesia; 2014 [cited 2017 feb 18]. available from: http://www.depkes.go.id/ resources/download/pusdatin/profil-kesehatanindonesia/indonesia%20health%20profile%202014. pdf. 8. indonesia society of gastroenterology (isg). consensus of the management of acute diarrhea in adult in indonesia. jakarta: isg; 2009. 9. simadibrata m, daldiyono. acute diarrhea. in: setiati s, alwi i, sudoyo aw, kolopaking ms, setiyohadi b, syam af, eds. buku ajar ilmu penyakit dalam. volume 2. 6th ed. jakarta: interna publishing; 2014. p. 1899908. 10. simanjuntak ch, larasati w, arjoso s, et al. cholera in indonesia in 1993-1999. am j tropical med hygiene. 2001;65(6):788-97. 11. oyofo ba, lesmana m, subekti d, et al. surveillance of bacterial pathogens of diarrhea disease in indonesia. diag microbiol infect dis. 2002;44(3):227-34. 12. agustina r, sari tp, satroamidjojo s, boveeoudenhoven imj, feskens ejm, kok fj. association of food-hygiene practices and diarrhea prevalence among indonesian young children from low socioeconomic urban areas. bmc public health. 2013;13:977. 13. simadibrata m. diagnostic approach of chronic diarrhea. in: setiati s, alwi i, sudoyo aw, kolopaking ms, setiyohadi b, syam af, eds. buku ajar ilmu penyakit dalam. volume 2. 6th ed. jakarta: interna publishing; 2014. p. 1909-23. 14. simadibrata m. small bowel diseases causing chronic diarrhea [thesis]. university of amsterdam; 2002. 15. syam a, abdullah m, rani a, et al. evaluation of the use of rapid urease test: pronto dry to detect h pylori in patients with dyspepsia in several cities in indonesia. world j gastroenterol. 2006;12(38):6216-8. 16. syam af, miftahussurur m, makmun d, et al. risk factors and prevalence of helicobacter pylori in five largest islands of indonesia: a preliminary study. plos one. 2015;10(11):e0140186. 17. world gastroenterology organisation. world gastroenterology organisation global guideline: helicobacter pylori in developing countries. j clin gastroenterol. 2011;45(5):383-8. 18. miftahussurur m, syam af, nusi ia, et al. surveillance of helicobacter pylori antibiotic susceptibility in indonesia: different resistance types among regions and with novel genetic mutations. plos one. 2016;11(12):e0166199. 19. kumala w, rani a. patterns of helicobacter pylori isolate resistance to fluoroquinolones, amoxicillin, clarithromycin and metronidazoles. southeast asian j trop med public health. 2006;37(5):970-4. 20. indonesia society of gastroenterology (isg). national consensus on the management of gastroesophageal reflux disease in indonesia. acta med indones. 2014;46(3):263-71. 21. syam af, hapsari f, makmun d. the prevalence and risk factors of gerd among indonesian medical doctors. makara j health res. 2016;20(2):35-40. 22. international agency for research on cancer (iarc) who. globocan 2012 estimated cancer incidence, mortality and prevalence worldwide. france: iarc; 2012 [cited 2017 february 27]. available from: http:// globocan.iarc.fr/pages/fact_sheets_population.aspx. 23. ministry of health republic of indonesia. laporan tahunan kanker: direktorat jendral pelayanan medik dan perhimpunan patologi anatomik indonesia. jakarta: ministry of health republic of indonesia; 1995. 24. american cancer society. colorectal cancer facts & figures 2014-2016 [internet]. atlanta: american cancer society; 2014 [cited 2017 feb 26]. available from: http://old.cancer.org/acs/groups/content/ documents/document/acspc-042280.pdf. 25. sudoyo aw, lesmana cr, krisnuhoni e, pakasi ls, cahyadinata l, lesmana la. detection rate of colorectal adenoma or cancer in unselected colonoscopy patients: indonesian experience in a private hospital. asian pacific j cancer prevent. 2014;15(22):9801-4. 26. abdullah m, sudoyo aw, utomo ar, fauzi a, rani aa. molecular profile of colorectal cancer in indonesia: is there another pathway? gastroenterol hepatol fr bed to bench. 2012;5(2):71-8. 27. indonesia society of gastroenterology (isg). national consensus of the management of inflammatory bowel disease in indonesia. jakarta: isg; 2011. 28. ng sc, tang w, ching jy, et al. incidence and phenotype of inflammatory bowel disease based on results from the asia-pacific crohn’s and colitis epidemiology study. gastroenterol. 2013;145(1):15865.e2. 29. ng sc, tang w, leong rw, et al. environmental risk factors in inflammatory bowel disease: a populationbased case-control study in asia-pacific. gut. 2015;64(7):1063-71. 30. siregar ga. early gastric cancer. indones j gastroenterol, hepatol digest endosc. 2002;3(3):91-6. 31. saragih jb, akbar n, syam af, sirait s, himawan s, soetjahyo e. incidence of helicobacter pylori infection and gastric cancer: an 8-year hospital based study. acta med indones. 2007;39(2):79-81. 32. miftahussurur m, syam af, makmun d, et al. helicobacter pylori virulence genes in the five largest islands of indonesia. gut pathogens. 2015;7. 33. abdullah m, ohtsuka h, rani aa, sato t, syam af, fujino ma. helicobacter pylori infection and gastropathy: a comparison between indonesian and japanese patients. world j gastroenterol. 2009;15(39):4928-31. 277 marcellus simadibrata acta med indones-indones j intern med 34. makmun d. present status of endoscopy, therapeutic endoscopy and the endoscopy training system in indonesia. digest endosc. 2014;26 (suppl 2):2-9. 35. simadibrata m, rani a, adi p, djumhana a, abdullah m. the gastro-esophageal reflux disease questionnaire using indonesian language: a language validation survey. med j indones. 2011;20(2):125. 278 case report 151acta med indones indones j intern med • vol 49 • number 2 • april 2017 ventilator-associated pneumonia (vap) in a patient with guillain-barre syndrome anti dharmayanti1, dalima astrawinata2 1 department of clinical pathology, fatmawati central general hospital, jakarta, indonesia 2 department of clinical pathology, faculty of medicine,universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia corresponding author: anti dharmayanti, md, consultant of clinical pathology. division of infectious diseases, department of clinical pathology, fatmawati central general hospital. jl. rs fatmawati, cilandak, jakarta 12430, indonesia. email: antidharmayanti@yahoo.com. abstrak seorang pria usia 46 tahun, dari icu dengan diagnosis saat masuk guillain-barre syndrome (gbs) + sepsis ec suspek ventilator associated pneumoniae (vap), dimintakan bahan pemeriksaan laboratorium: darah lengkap, kultur, resistensi ujung selang suction, urinalisis dan kultur urin, kultur darah dan resistensi, procalcitonin dan laktat. didapatkan neutrofilia, peningkatan procalcitonin dan laktat sesuai diagnosis sepsis, dan pada hasil kultur selang suction didapatkan kuman pseudomonas luteola mdro yang kemungkinan berasal dari kolonisasi pada oropharynx pasien, akibat higiene oral pasien yang buruk dan tindakan perawatan higiene oral oleh perawat yang kurang efektif, sehingga kuman yang berkolonisasi tersebut terbawa saat pengambilan sampel. perawatan higiene oral yang tidak efektif potensial untuk terjadinya vap dan vap berulang. kata kunci: ventilator associated pneumonia (vap), guillain-barre syndrome (gbs), alur gyssen, higiene oral. abstract a 46-year-old man was admitted to icu with a diagnosis at the time of admission of guillain barre syndrome (gbs) and sepsis due to suspected ventilator-associated pneumoniae (vap). specimens for the following laboratory workup were inquired, i.e. complete blood count, culture and resistance workup using specimens obtained from the tip of suction pipe, urinalysis and urine culture, blood culture and resistance, procalcitonin and lactate levels. neutrophilia was found along with increased procalcitonin and lactate levels, which supported the sepsis diagnosis. moreover, the result of culture from suction pipe demonstrated colonies of pseudomonas luteola mdro, which might be originated from the oropharyngeal colonization of the patients due to poor oral hygiene and ineffective oral hygiene nursing; therefore, the colonies of the microorganism were swabbed away when obtaining the specimens. ineffective oral hygiene nursing may have a potency to cause vap and recurrent vap. keywords: ventilator associated pneumonia (vap), guillain-barre syndrome (gbs), gyssen algorithm, oral hygiene. anti dharmayanti acta med indones-indones j intern med introduction ventilator-associated pneumonia (vap) is a pneumonia that occurs 48 hours or longer after mechanical ventilation or following endotracheal intubation.1,2 it is the most common healthcare associated infections (hais) in the intensive care unit (icu).3,4 risk factors for vap include chronic obstructive pulmonary disease, abnormal cough reflex, neuromuscular diseases that may put the patients at risk of respiratory failure and may require mechanical ventilation using ventilator.1,2,5 healthcare personnel may have a role in vap due to ineffective hand washing, poor oral hygiene, letting patients in supine position that may facilitate the occurrence of aspiration and invasive procedures such as installation of nasogastric tube (ngt) and ventilator.5 the duration of installed intubation should be no more than 7 days and if the intubation is still necessary, it should be replaced with a new one.6-8 case illustration mr. m, a 46-year-old man came to the emergency department with a complaint of hands and feet paralysis and breathing difficulty. since the last 2 weeks, he felt weakness of both legs so that he could not walk and along with time, he also experienced weakness of his both arms, which caused him unable to raise his hand and subsequently, he felt difficulty in breathing. he was admitted for further care. he had an intravenous line and had received neurological medications, but had no improvement, the patient asked for a referral. on physical examination, the patient was fully alert with blood pressure of 135/80 mmhg, pulse rate of 80 beats per minute, respiratory rate of 30 times per minute and a temperature of 360c. poor oral hygiene, tetraparesis and motor strength grade 1 were found. there was no abnormality in sensory function. pathological reflex was not found. chest x-ray revealed that the heart and lung were within normal limit. a diagnosis of guillain-barre syndrome (gbs) with a threat of respiratory failure was established. the patient received treatment of intravenous fluid drip (ivfd) of ringer lactate (rl) at the dose of 10 drips/minute and gammaras (an intravenous immunoglobulin) at the dose of 0.5 ml/kgbw/day. at the emergency department, the patient had the following laboratory workup including complete blood count, urinalysis, blood chemistry test and blood gas analysis and then he was hospitalized in the icu. results of complete blood count revealed neutrophilia; while the urinalysis showed data of normal limit. the results of blood chemistry test demonstrated normal alt, ast, total protein, albumin, globulin and blood glucose levels. ureum and creatinine levels were within normal limits. the blood gas analysis showed an impression of acidosis with normal anion gap (table 1). table 1. results of laboratory workup variables value blood electrolytes sodium (meq/l) 135 potassium (meq/l) 3.8 chloride (meq/l) (normal anion gap) 106 blood gas analysis ph 7.350 pco2 (mmhg) 55 po2 (mmhg) 84.9 hco3 (mmol/l) 32 o2 saturated (%) 95.9 base excess (be) (mmol/l) -0.9 total co2 (mmol/l) 25.6 the results of complete blood count at the icu showed that there was a neutrophilia with a count of 16,000ul (normal range: 5000–10,000/ ul). peripheral blood smear showed normocytic normochromic result and neutrophilia with toxic granulation and vacuolization. the reticulocyte count was 1.1% (normal range: 0.5–1.5%). repeated chest x-ray showed a description of pneumonia on the left lung. the blood culture gave negative result. the resistance and culture test of the suction pipe tip showed results of pseudomonas putida microorganism (table 2). the patient was then treated with ceftazidime at the dose of 3 x 1 gram/day dan gammaras at the dose of 0.5 ml/kg bw/day. five days later, the chest x-ray was repeated and a description of improved pneumonia was found; treatment using ceftazidime antibiotic was then stopped. three days later, the patient seemed having short of 152 vol 49 • number 2 • april 2017 vap in a patient with guillain-barre syndrome breath, leukocytosis and increasing neutrophila at 26,3 x103/ul (5.0–10.0) 103/ul. results of blood gas analysis showed a combination of respiratory and metabolic acidosis along with increased anion gap (table 3). the microbiology culture test of the suction pipe tip was repeated and we found a result of pseudomonas luteola mdro; however, the possibility of contamination during obtaining the specimens due to colonization still could be excluded (table 4). discussion a patient with a complaint of breathing difficulty and tetraparesis since approximately 2 weeks before hospitalized. he was diagnosed with guillain barre syndrome with a threat of respiratory failure. guillain-barre syndrome is a rare autoimmune disease in the form of polyneuropathy due to demyelination of nerve fibers with characteristics of symmetrical and progressive ascending muscle weakness, paralysis and hyporeflexia, with or without sensory or autonomic symptoms. the muscle weakness causes respiratory failure and medical emergency that requires immediate care. the blood gas analysis results indicated a respiratory acidosis due to neuromuscular disease (gbs) causing abnormal chest wall motion and respiratory depression since there was abnormal co2 expiration, co2 accumulation and those resulting in respiratory acidosis and a threat of respiratory failure.9,10 the patient was then admitted to the icu and a ventilator was installed. two days following the ventilator installation in the icu, the patient had a fever (37.80c), severe leukocytosis and his chest x-ray revealed a description of pneumonia in his lower left lung and a diagnosis of sepsis due to vap (early onset vap) was established since it was developed during the first 4 days following an intubation or a ventilator installation. based on the onset of infection, vap is categorized into 2 groups, i.e. the early-onset vap, which the vap occurs within the first 4 days following an intubation and a ventilator installation; while the late-onset vap is vap that occurs more than 5 days after a ventilator installation. about 50% of vap cases occur in the first 4 days following a ventilator installation (early-onset vap), which table 2. results of culture and resistance test of the suction pipe tip gram staining: negative-gram rod, epithelial cells 5-6/ lpf, leukocytes 20-30/lpf isolates: pseudomonas putida amoxycillin clavulanic acid s amikacin s ampicillin sulbactam r gentamicin s cefuroxime r ciprofloxacin s ceftazidime s levofloxacin s cefotaxime r cotrimoxazole s ceftriaxone s chloramphenicol s cefepime s fosfomycin s meropenem s table 3. blood glass analysis and electrolyte variables value ph 7.350 pco2 (mmhg) 46.6 po2 (mmhg) 85.9 hco3(mmol/l) 20.2 o2 saturasi (%) 95.7 base excess (be) (mmol/l) -8.9 total co2 (mmol/l) 25.6 sodium (meq/l) 135 potassium (meq/l) 3.85 klorida (meq/l) 96 anion gap: 22.65 (increased); impression: respiratory + metabolic acidosis table 4. results of culture and resistance test of the suction pipe tip gram staining: negative-gram rod, epithelial cells 5-6/lpf, leukocytes 20-30/lpf isolates: pseudomonas luteola amoxycillin clavulanic acid r amikacin r ampicillin sulbactam r gentamicin r cefuroxime r ciprofloxacin r ceftazidime r levofloxacin r cefotaxime r cotrimoxazole s ceftriaxone r chloramphenicol r cefepime r fosfomycin r meropenem s procalcitonin level (semiquantitative test): ≥0.5 <2 ng/ ml; lactate level of 6.2 mmol/l 153 anti dharmayanti acta med indones-indones j intern med usually has a good prognosis and caused by bacteria that are still sensitive to many antibiotic treatment. on the contrary, late-onset vap is caused by multidrug-resistant organism (mdro) to antibiotics, which is usually due to excessive exposure to antibiotics or irrational antibiotic treatment and it has been associated with higher morbidity and mortality rate compared to the early-onset vap.1,5,6 furthermore, urinalysis, urine culture, blood culture and culture of the suction pipe tip were estimated. results of urinalysis showed no abnormality and urine culture demonstrated no growth and blood culture also gave negative results, but the results of suction pipe tip culture revealed pseudomonas putida, which was only resistant to ampicillin sulbactam, cefotaxime and cefuroxime. ventilator-associated pneumonia is usually caused by negative-gram bacteria, either single or polymicrobial infection or by positive-gram bacteria as well. in immunocompromised patients, although it is a rare occasion, vap may be caused by fungi such as candida sp or aspergillus sp. the negative-gram bacteria that commonly serve as the etiology are escherichia coli, klebsiella pneumoniae, pseudomonas sp (mostly p aeruginosa) and acinetobacter sp; while the positive-gram bacteria such as staphylococcus aureus or streptococcus sp may also be the cause of vap.1,2,6 el sohl1 as quoted from the american thoracic society, has found data that the causal bacteria of late-onset vap are s. aureus (29%), negativegram rod (15%), s. pneumoniae (9%) and pseudomonas sp (4%). mdro pathogens are mostly found in patients with late-onset vap or those with immunocompromised condition.1 other pseudomonas sp. such as p putida and p luteola are microorganisms that very much live in moist environment and places. they rarely infect humans, but may contaminate water and cause hais; however, they are not the causal microorganism of vap.2 considering the less common type of microorganism found in the cases, the possibility of contamination during obtaining specimens due to colonization still cannot be ruled out and good oral hygiene care is recommended for the patient to prevent microorganism colonization along with providing education for the icu nurses on how to obtain correct and appropriate specimens as well as repeated specimen collection. in the guillain-barre syndrome, abnormal cough reflex may occur4,5 and patients may have difficulties in expectorating sputum; moreover, the oral hygiene of the patient is also poorly maintained. pseudomonas putida, which was found in the culture is probably an environmental microorganism that had been colonized in the oral cavity and oropharynx of the patient and it was taken during collecting the sample from the suction pipe in the icu. collecting specimen from difficult sputum expectoration and considering that the specimen could be presented by a piece cut of suction pipe is actually not recommended as there is a huge possibility of contamination of colonization due to sample collection. however, when we look at the pathogenesis of vap, p. putida may still be considered as the cause of vap, which initially formed a colonization in the oropharynx and then it was inhaled during ventilator installation and it is assumed causing lung infection (vap) although it is a less common microorganism for causing vap and rarely cause infection in human. moreover, until now, there is no literature that suggests p. putida as the cause of vap. to confirm it, repeated sampling should be done at that time using the correct and appropriate technique of collecting specimens. without waiting for culture results, the patient was given empiric treatment, i.e. 5-day course of ceftazidime and he had improvement with normal description of chest x-ray. an evaluation using gyssen algorithm for ceftazidime treatment without waiting for the results of culture in the patient (empiric treatment) was found in his complete medical record, which also include appropriate indication, narrow-spectrum antibiotic, non-expensive, safe and most effective treatment as well as appropriate duration, dose, interval and route of administration; therefore, the evaluation using gyssen algorithm for empiric treatment of ceftazidime was seized at the number of zero, i.e. it was included as correct and appropriate category (figure 1). three days later, the patient had another 154 vol 49 • number 2 • april 2017 vap in a patient with guillain-barre syndrome fever (380c), neutrophilia and his chest x-ray revealed pneumonia on his upper right lung, he had purulent sputum, elevated procalcitonin and lactate levels and the blood glass analysis showed a description of respiratory and metabolic acidosis with increased anion gap. increased anion gap in this case occurred due to increased lactate levels. elevated hco3that may occur to compensate respiratory acidosis resulting from increased co2 levels in the blood (due to respiratory failure), had actually never been achieved. it may happen since there was metabolic acidosis due to increased lactate levels and therefore, the hco3concentration was reduced with decreased base excess. consequently, a condition of combined respiratory and metabolic acidosis took place. based on results of physical examination and laboratory data, a diagnosis of sepsis caused by vap was made, which was supported by the laboratory result of procalcitonin of >0.5-<2 ng/ml, which was in accordance with the sepsis category. moreover, there was also increased lactate levels (6.2 mmol/l), which was appropriate to the tissue hypo-perfusion that may be found in sepsis. based on those clinical and laboratory data, a diagnosis of guillain barre syndrome (gbs) + sepsis due to suspected ventilator associated pneumonia (vap) was established. an evaluation of culture and resistance test of the suction pipe tip was repeated including blood culture and resistance as well as urinalysis and urine culture and procalcitonin and lactate levels. it revealed a normal result of urinalysis, negative result of urine culture and negative result of blood culture. the culture of suction pipe tip showed a result of mdro pseudomonas luteola, which was still sensitive to cotrimoxazole and meropenem. the microorganism may probably derive from colonization of the patient’s oropharynx that was taken during sample collection from the suction pipe tip by nurse. however, it is also possible that p. luteola was the causal microorganism of vap that had been originally colonized in the patient’s oropharynx, which was then inhaled during ventilator installation and infected the lung. subsequently, vap may occur although until now p. luteola is rarely found cause direct infection in human and there is no data about p. luteola as the cause of vap. the intubation itself would suppress cough reflex that has a function as protection against incoming pathogens. it also suppressed reflex of the epiglottis and therefore disturbing secretion clearance surrounding endotracheal tube (ett). therefore, when the pathogens have successfully managed the entrance, they will easily form no yes stopcomplete data iappropriate indication duration too short correct dose correct interval correct rute iib iic iiib ivd ivc ivb vi v iva stop iiia more effective alternative narrower alternative less costly alternative iia less toxic alternative duration too long correct timing 0 = (correct) i start algorithm stops at zero (correct and appropriate) yes yes yes yes yes yes yes yes yes yes yes no no no no no no no no no no no figure 1. gyssen algorithm for evaluating ceftazidime (empiric treatment) 155 anti dharmayanti acta med indones-indones j intern med colonization in the area. aspiration of pathogens that have been colonized in oropharynx or the insertion of secretion containing microorganism from the surroundings of installed ett, is the main entrance for microorganism into the trachea.5 continuous aspiration of subglottis secretion will reduce the risk of microorganism invasion to the trachea.8 deriso as quoted by the american throacic society4 suggested that oropharyngeal colonization, particularly by negative-gram bacteria such as pseudomonas aeruginosa, which occurs before hospital admission or which is acquired during hospitalization in the icu are factors that have important roles in the development of vap. moreover, vap may also occur by colonization of pathogens in the ventilator circuit system such as humidifier and suction. colonization in the ett or in ventilator circuit may also have the potency as a reservoir which contribute to the development of vap.1,5 supine position facilitates the occurrence of aspiration compared to semi-recumbent or halfsitting position (30-450); therefore, the patient should be maintained at semi-recumbent position to prevent aspiration.1,2,11 a closed suctioning system may also reduce the risk of vap, but it is costly and has not been used widely.6,8 an immunocompromised condition or underlying disease related to respiratory disorder, colonization on the intubation pathway (oropharynx) prior to intubation, installation of invasive contaminated equipment and the presence of secretion retention in the contaminated subglottis area have a great role on the risk of developing vap. a procedure of continuous aspiration of subglottis secretion can reduce the risk for developing vap.1,2,5 in the icu, a close-system ventilator has been used and a 450-hob position has been performed; however, a contamination when obtaining sample due to colonization may still occur considering the poor oral hygiene of the patient. oral hygiene care was not effectively performed by the nurse. moreover, one of ventilator bundles, i.e. continuous suction of subglottis secretion was actually and technically difficult for the healthcare personnel and the maximum attempts were not performed; therefore, there is a possibility of microorganism colonization in the secretion concentrating in the subglottis area. the colonization of microorganisms has the potency for developing recurrent vap. yes no stop i iib iic iiib ivd ivc ivb vi v iva stop iiia iia 0 = (correct) i algorithm stops at v due to inappropriate indication yes yes yes yes yes yes yes yes yes yes yes no no no no no no no no no no no start complete data appropriate indication more effective alternative less toxic alternative less costly alternative narrower alternative duration too long duration too short correct dose correct interval correct rute correct timing figure 2. gyssen algorithm for evaluating meropenem (definitive) based on results of culture test 156 vol 49 • number 2 • april 2017 vap in a patient with guillain-barre syndrome the patient was then treated in accordance with the results of culture and resistance test, i.e. receiving meropenem and had an improvement. the evaluation using the gyssen algorithm can be considered from 2 points of view, which is when the treatment of meropenem as a definitive therapy based on the issued results of culture and resistance, then the definitive therapy of meropenem in this case is not appropriate to the indication, which was therapy against colonization; therefore, on the evaluation using gyssen algorithm, the meropenem therapy stops at the number v (figure 2). nevertheless, if p. luteola is actually considered as the cause of vap, then the evaluation of meropenem as the definitive treatment, we found a complete data of medical records, an appropriate indication, narrow-spectrum, less expensive, safe and most effective antibiotic with appropriate duration, dose, interval, route of administration and timing and the evaluation using gyssen algorithm for meropenem therapy stops at the number zero, i.e. it is included in the correct and appropriate category. to confirm this issue, repeated culture specimen collection before antibiotic treatment should be performed along with a correct and appropriate procedure, which in this case had not been done. conclusion ineffective oral hygiene care has the potency of developing vap and recurrent vap. obtaining samples must be performed using an appropriate procedure and if necessary, it must be repeated to have an accurate result. the interpretation of culture results must also be meticulously evaluated in order to provide useful information and effective for its management and treatment. references 1. american thoracic society. guidelines for the management of adults with hospital acquired, ventilator associated and healthcare associated pneumoniae. am j respir crit care med. 2005;171:388-409. 2. craven de, chroneou a. nosocomial pneumonia. in: mendell, douglas, bennets, ed. principles and practice of infectious disease. 7 th ed. philadelphia: churchill livingstone elsevier; 2010. p. 3717-21. 3. walkey aj, reardon cc, sulis ca, nace rn, brady mj. epidemiology of ventilator associated pneumonia in a long term acute care hospital. infect control hosp epidemiol. 2009;30(4):320-3. 4. neto ar, cherif n, youssef m, et al. diagnosis of ventilator associated pneumonia: a systematic review of the literature. crit care. 2008;12(2):1-14. 5. o’keefe s, carthy m, santiago c, lau g. ventilator associated pneumonia bundled strategies ; an evidencebased practice. worldviews on evidence based nursing. 2008;193-2003. 6. bouza e, brun b, chastre j, et al. ventilator associated pneumonia. eur resp j. 2001;17:1034-45. 7. rello j, lode h, cornaglia g, masterton r. a european care bundle for prevention of ventilator associated pneumonia. intensive care med. 2010;36:773-80. 8. wip c, napolitano l. bundles to prevent ventilator associated pneumonia: how valuable are they? current op inf dis. 2009;22:159-66. 9. arlene f, reyes td, ruppert sd, yun s, shiao pk. evidence based practice: use of the ventilator bundle to prevent ventilator associated pneumonia. am j crit care. 2007;16:20-7. 10. maurice v, allan r. adams and victor’s principles of neurology. 7th ed. baltimore: mcgraw-hill companies; 2001. p. 1380-7. 11. pluta rm, lynm c, golub rm. guillain-barre syndrome. j am med assoc. 2011;305(3):319-21. 157 case report 134 acta medica indonesiana the indonesian journal of internal medicine adrenal myelolipoma, cholelithiasis and calcified spleen: retrospective diagnosis of sickle cell anemia using a novel triad of abdominal imaging findings sandeep g. jakhere, raju s. kumbhar, harshal v. dhongade department of radiology, byl nair charitable hospital and tn medical college, mumbai central, mumbai, india. correspondence mail: department of radiology, byl nair charitable hospital and tn medical college, mumbai central, mumbai, india. email: drsandeepjakhere@gmail.com. abstrak anemia sel sabit merupakan kelainan pada rantai globin yang diwariskan dengan prevalensi tinggi di semenanjung india. proporsi yang bermakna dari pasien dengan anemia sel sabit muncul lambat dalam kehidupan dan berisiko menimbulkan sejumlah komplikasi misalnya sindroma dada akut dan episode nyeri hingga dicapai diagnosis pasti dan dimulainya pengobatan yang tepat. kami melaporkan trias pencitraan abdomen baru, yang belum dilaporkan dalam kepustakaan hingga kini dan yang dapat menunjukkan diagnosis anemia sel sabit dengan teknik retrospektif. dengan trias temuan abdomen ini, pasien perlu dicurigai menderita hemoglobinopati dan perlu dirujuk untuk pemeriksaan hematologic lebih lanjut. meskipun pada kasus kami, pasien ini didiagnosis menderita anemia sel sabit berdasarkan morfologi sel darah merah yang abnormal dan elektroforesis haemoglobin, perlu diingat bahwa trias temuan ini dapat juga ditemukan pada hemoglobinopati lainnya yang mencetuskan kondisi anemia kronik. kata kunci: anemia sel sabit, mielolipoma adrenal, batu empedu, limpa terkalsifikasi. abstract sickle cell anemia is an inherited abnormality of the globin chain with very high prevalence in the indian subcontinent. a significant proportion of these patients present late in life and are at a risk of complications like acute chest syndrome and painful episodes till a definitive diagnosis is reached and appropriate treatment is started . we report a novel triad of abdominal imaging findings which is not reported in literature until now and which may suggest a diagnosis of sickle cell anemia in retrospect. patients with this triad of abdominal findings should be suspected to have an underlying hemoglobinopathy and should be referred for further hematological workup. although in our case the patient was diagnosed to have sickle cell anemia depending on the abnormal morphology of red cells and hemoglobin electrophoresis, it should be remembered that this triad of findings may be seen in other hemoglobinopathies which induce a state of chronic anemia. key words: sickle cell anemia, adrenal myelolipoma, gall stones, calcified spleen. introduction adrenal myelolipoma is a rare non functional benign tumor which is incidentally diagnosed in asymptomatic patients in the 4th and 5th decades.1 it has a prevalence of approximately 0.08-0.4% on autopsy findings.2 the co existence of adrenal myelolipomas and cholelithiasis is indeed very unusual and has rarely been documented. in a vol 46 • number 2 • april 2014 adrenal myelolipoma, cholelithiasis and calcified spleen recent article published in 2011 dahiya et al.3 stated that this unusual association has been reported only twice prior to their publication4,5 we found another case report6 describing this unusual association taking the total count to four prior to our publication. however an extensive search for literature did not reveal any reports of association of a shrunken calcified spleen along with adrenal myelolipoma and gall stones and this is probably the first case report of this unusual triad of findings. we present a case of a 28 year old female who was retrospectively diagnosed to have sickle cell anemia based on this triad of findings on abdominal imaging. case illustration a 28 year old female presented with right hypochondriac pain for the past 6 months which was not associated with retrosternal burning pain or vomiting. on palpation there was mild tenderness in the right hypochondriac region and mild pallor was seen in the conjunctiva, otherwise, rest of the systemic examination was within normal limits. an abdominal ultrasound study revealed multiple gallstones ranging in size from 0.5 cm-1 cm. the gall bladder wall appeared normal and there was no evidence of any peri cholecystic fluid collection. a fairly large soft tissue mass was seen in the right supra renal region measuring approximately 6.9 cm x 5.5 cm in maximum dimensions. the mass was seen to be separate from the liver and the right kidney, however, the right adrenal gland could not be visualized separately. the mass appeared predominantly hyperechoic in echo texture with few hypoechoic areas within it. there was no calcification within the mass and doppler evaluation did not reveal any significant vascularity within the mass. a neoplastic mass arising from the right adrenal gland was suspected and the patient was referred for ct scan of the abdomen. ct scan showed a soft tissue mass in the right supra renal region measuring approximately 7 cm x 5.8 cm [figure 1, 4 (short arrow)]. the right adrenal gland could not be identified separately. the mass showed ill defined areas of soft tissue attenuation (25 hu) which showed mild enhancement on the post contrast scans. in addition few areas with fat attenuation (-5 hu) were also seen within the mass. based on these characteristic imaging findings, working diagnosis of right adrenal myelolipoma was made. in addition multiple hyper dense calculi were seen in the gallbladder without any radiological evidence of cholecystitis [figure 2]. the spleen could not be visualized in the splenic fossa. a densely calcified mass was seen in the splenic fossa which was presumed to be a chronic infarcted calcified spleen [figure 3, 4 (long arrow)]. figure 1. axial plain ct scan image showing a mass in the right supra renal region containing low attenuation areas consistent with myelolipoma. figure 2. axial plain ct scan image showing multiple hyper dense calculi in the gall bladder. figure 3. axial plain ct scan image showing a calcified mass in the splenic fossa. 135 sandeep jakhere acta med indones-indones j intern med blood examination revealed hemoglobin of 8.4 gm/dl and red blood cell count of 3.02 x 106/ microlitre. the mean corpuscular volume, mch and mchc were 81.7 fl, 27.8 pg and 34.0 gm/ dl respectively. few target cells and sickle cells were also seen. hemoglobin electrophoresis revealed an hb s of 86.4%, hb a2 of 3.3% and hb f of 6.5% thereby confirming a diagnosis of sickle cell anemia. at the time of submitting the case report for publication the patients is undergoing pre surgical workup for removal of the adrenal tumour. discussion sickle cell anemia is an inherited abnormality of the beta globin chain due to substitution of valine for glutamic acid resulting in abnormal shaped (sickled) red blood cells (rbc). these deformed rbc‘s have increased propensity for microvascular occlusion leading to ischemia and infarction in various body organs. as the rbc’s have abnormal shape, they are removed earlier from the blood circulation resulting in hemolytic anemia. the highest frequency of sickle cell disease is found in the tropical regions; particularly sub saharan africa, india and middle east.7 the prevalence of sickle cell disease in india has ranged from 9.4% to 22.2%8 in endemic areas with india alone accounting for 50% of cases all over the world.9 the association between adrenal myelolipoma and haemoglibinopathies including thalassemia,10,11 sickle cell anemia12 and hereditary spherocytosis13 has been proposed earlier by a few authors although there might definitely be more complex pathogenetic mechanisms underlying this entity. adrenal myelo lipomas are rare benign tumors composed of adipose tissue and myeloid elements. the association of myelolipoma with obesity, hypertension and malignancies has been described earlier14 however an association with gallstones has been described in only 4 cases prior to our publication.3-6 a chronically infarcted calcified spleen along with adrenal myelolipoma and gallstones on computed tomography has not been reported till now to the best of our knowledge. dahiya et al stated that the co occurrence of gall stones and adrenal myelo lipomas may be an incidental finding or there may be a pathogenetic mechanism which may be yet unknown. pleuripotent hematological stem cells are present in the embryonic mesonephros which subsequently differentiates to form the adrenal cortex. metaplasia of these embryonic nests of stem cells may give rise to the myeloid elements within the adrenal. occurrence of myelolipomas in association with hemoglobinopathies suggests that the myeloid elements in adrenal gland are under the influence of erythropoietin which is produced in abundance due to the chronic anemic state. thus extra medullary hematopoiesis within the adrenal may contribute to the development of myelolipomas.10 approximately 50% of adults and 20% children with sickle cell anemia patients have gallstones and 94% of patients undergo autosplenectomy by the age of 5 years.15 however the exact incidence of adrenal myelolipomas in patients with sickle cell anemia is not known with only a few case reports documented in literature. most probably the stimulation of adrenal myeloid cells is a chronic process which occurs over a long period of time as in our patient who was not diagnosed with sickle cell anemia upto the age of 28 years. the late presentation and chronic anemia also explain the calcified spleen that must have undergone repeated infarctions over a long period of time ultimately resulting in a calcified avascular mass. it is important to recognize this triad of findings on abdominal imaging and refer these patients for appropriate hematological workup. approximately 61% of patients with sickle cell figure 4. coronal mpr image showing the supra renal mass (short arrow) and the calcified mass in the splenic fossa (long arrow). note that the spleen is not visualized in the splenic fossa. 136 vol 46 • number 2 • april 2014 adrenal myelolipoma, cholelithiasis and calcified spleen anemia present by the end of the first year, 78% by the end of second year and 86% by the end of the third year. the remaining 14% present by the age of 10 although late presentation by the age of 20 years is also known.16 a sizeable number of patients present late in life and are at risk of complications until a definitive diagnosis is achieved and treatment is initiated. the mainstay of treatment of sickle cell anemia is hydroxyurea, an oral chemotherapeutic agent that acts by reducing the production of red cells containing a high concentration of sickle hemoglobin and favoring the production of red cells containing high fetal hemoglobin levels. a multicenter study of hydroxyurea in sickle cell anemia conclusively showed that, over 2.5 years, hydroxyurea diminished the morbidity of sca in adults with frequent painful episodes by reducing the incidence of painful episodes and acute chest syndrome by nearly half.17 conclusion young adults with sickle cell anemia are a vulnerable population with a high risk of mortality at the interface between pediatric and adult medical care. quinn et al18 even argued for creating special clinics for adolescent and young adults with sca, run jointly by pediatric and adult medical providers because young adults seem to be at high risk of death. it is of utmost importance that the diagnosis of sca be made at the earliest and this novel triad of abdominal findings should alert the radiologist to refer the patient for further detailed hematological workup. although in our case the patient was diagnosed to have sickle cell anemia depending on the abnormal morphology of red cells and hemoglobin electrophoresis, it should be remembered that this triad of findings may be seen in other hemoglobinopathies also which induce a state of chronic anemia. references 1. vick cw, zeman rk, mannes e, et al. adrenal myelolipoma; ct and ultrasound findings. urol radiol. 1994;6:7–13. 2. lam ky. lipomatous tumors of the adrenal gland. j urol pathol. 1995;3:95. 3. kalra r, dahiya n, singh g, modi s, godara r. adrenal myelolipoma associated with cholelithiasis – a case report. int j pharm sci res. 2011;2(4):1031-3. 4. kar dk, agarwal a, mishra ak, et al. adrenal myelolipoma associated with cholelithiasis. indian j urol. 2001;18:66-9. 5. solis daun jo, rodriguez garcia r, torres trejo a, alor guzman m. adrenal myelolipoma associated with lithiasic cholecystitis, hiatal hernia and esophagitis. rev gastroenterol mex. 1999;64:143-5. 6. kunieda y, miyazaki t, fujimoto n, higuchi a, suzuki t. a case of adrenal myelolipoma with colonic cancer and gallstones. gan no rinsho. 1990;36(8):949-54. 7. weatherall dj, clegg jb. inherited haemoglobin disorder: an increasing global health problem. bull. world health org. 2001;79(8):704–12. 8. awasthy n, aggarwal kc, goyal pc, et al. sickle cell disease: experience of a tertiary care center in a nonendemic area. ann trop med publ health. 2008;1(1):1–4. 9. kate sl, lingojwar dp. epidemiology of sickle-cell disorder in the state of maharashtra. int j human genetics. 2002;2(3):161-7. 10. au wy, tam pc, ma sk, lam ky. giant myelolipoma in a patient with thalassemia intermedia. am j hematol. 2000;65(3):265-6. 11. kelekis nl, alexopoulou e, brountzos en, et al. giant adrenal myelolipoma with minimal fat content in a patient with homozygous beta-thalassemia: appearance on mri. j magn reson imaging. 2003;18(5):608-11. 12. cina sj, gordon bm, curry ns. ectopic adrenal myelolipoma presenting as a splenic mass. arch pathol lab med. 1995;119(6):561–3. 13. sekido n, kawai k, takeshima h, et al. adrenal myelolipoma associated with hereditary spherocytosis. int j urol. 1996;3(1):61–3. 14. ersoy e, ozdoğan m, demirağ a, et al. giant adrenal myelolipoma associated with small bowel leiomyosarcoma: a case report. turk j gastroenterol. 2006;17(2):126-9. 15. lonergan gj, cline db, abbondanzo sl. sickle cell anemia. radiographics. 2001;21(4):971-94. 16. karnon j, zeuner d, ades ae, et al. the effects of neonatal screening for sickle cell disorders on lifetime treatment costs and early deaths avoided: a modelling approach. j public health med. 2000;22(4):500-11. 17. charache s, terrin ml, moore rd, et al. effect of hydroxyurea on the frequency of painful crises in sickle cell anemia. n engl j med. 1995;332:1317-22. 18. quinn ct, rogers zr, mccavit tl, buchanan gr. improved survival of children and adolescents with sickle cell disease. blood. 2010;115(17):3447-52. 137 138 original article acta med indones indones j intern med • vol 50 • number 2 • april 2018 the benefit of interferon-gamma release assay for diagnosis of extrapulmonary tuberculosis cleopas m. rumende, edward j. hadi, gloria tanjung, imelda n. saputri, raditya sasongko department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: c. martin rumende, md, phd. division of pulmonology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl diponegoro 71, jakarta 10430, indonesia. email: rumende_martin@yahoo.com. abstrak latar belakang: sudah banyak penelitian mengenai interferon-gamma release assay (igra) dalam tb luar paru, namun hanya sedikit yang berasal dari negara-negara berkembang. ini merupakan penelitian pertama tentang kegunaan igra dalam tb luar paru yang dilakukan di indonesia sebagai negara berkembang dengan kasus tb terbanyak kedua di dunia. studi ini bertujuan untuk mengetahui manfaat pemeriksaan igra dalam mendiagnosis tb ekstraparu. metode: sebanyak 84 pasien dengan dugaan tb ekstraparu dilakukan pemeriksaan igra dan pemeriksaan baku emas secara tersamar. pemeriksaan baku emas dilakukan pemeriksaan histopatologi dan pewarnaan bta jaringan. hasil: dari total 84 pasien didapatkan hasil baku emas positif pada 57 pasien, dimana 50 pasien diantaranya didapatkan hasil igra positif. dari 27 pasien dengan baku emas negatif didapatkan hasil igra positif pada 10 pasien. limfadenitis tb merupakan manifestasi tb ekstraparu yang paling banyak ditemukan. hasil uji diagnostik igra untuk tb ekstraparu yang didapat adalah sebagai berikut: sensitifitas 87,71%, spesifisitas 63%, nilai duga positif 83,33%, dan nilai duga negatif 70,83%. kesimpulan: pemeriksaan igra dapat digunakan sebagai salah satu sarana penunjang diagnosis tb ekstraparu, namun hasil yang negatif belum dapat menyingkirkan kemungkinan adanya infeksi tb tersebut. kata kunci: tb ekstraparu, igra, histopatologi, bta jaringan. abstract background: there are many researches about igra in extrapulmonary tuberculosis (tb), but there only few data from developing countries. this was the first research about the utility of igra in extrapulmonary tb performed in indonesia as developing country with the 2nd most frequent of tb cases in the world. this study aimed to identify the advantage of igra examination in diagnosing extrapulmonary tb. methods: eighty-four patients, presumed to have extrapulmonary tb were examined with igra and gold standard examination. the gold standard examination was performed by histopathologic examination, and tissue smear for acid-fast bacilli. results: among 84 patients included in the study, 57 patients were tested positive with gold standard, where 50 patients among them were also tested positive with igra. among 27 patients tested negative with gold standard, igra positive was found in 10 patients. lymphadenitis was the most common manifestation of the extrapulmonary tb. diagnostic test from igra for extrapulmonary tb found as follows: sensitivity 87,71%, specificity 63%, positive predictive value 83,33%, and negative predictive value 70,83%. conclusion: igra could be used as supporting tool in the diagnosis of extrapulmonary tb. the negative result, however, does not indicate absence of tb infection. keywords: extrapulmonary tb, igra, histopathology, tissue acid-fast bacilli. vol 50 • number 2 • april 2018 the benefit of interferon-gamma release assay for diagnosis of extrapulmonary tb 139 introduction tuberculosis (tb) is still a global health problem. in 2016, it was estimated that there were 1.3 million deaths due to tb in non-hiv patients and 374.000 deaths in hiv patients. it was also estimated that there were 10.4 million tb patients in 2016, and 56% came from 5 countries with the most-tb cases in the world, namely india, indonesia, china, philippines, and pakistan.1 although most of the patients suffered from pulmonary tb, about 15-25% suffered from extrapulmonary tb. of all extrapulmonary tb patients, most cases commonly found were lymph node tb (35-40%), followed by pleural tb (2030%), bone and joint tb (5-10%), genitourinary tb (3-6.5%), tuberculous meningitis (5-6%), peritoneal tb (3%), and others (11.8%).2-6 extrapulmonary tb is usually difficult to diagnose due to the unspecific symptoms, while the acid-fast bacilli smear and culture from tissue and body fluid often reveal negative result. hence, an invasive procedure is usually required for histopathologic diagnosis.7,8 the international standard for tb care 2014 also suggested genexpert mtb/rif tissue examination to diagnose extrapulmonary tb. however such examination is still not feasible.7 the measurement of adenosine deaminase (ada) level in body fluid is usually used as an alternative, although the utilization is still limited to pleural tb, pericardial tb and tuberculous meningitis.9 furthermore ada level within the body fluid will also increase due to purulent bacteria infection, sle or lymphoproliferative diseases.3 on the other hand, immunoassay staining to detect mycobacterium tuberculosis-specific immune host response is becoming popular as alternative tools for extrapulmonary tb diagnosis. mycobacterium tuberculosis (m.tb) will initiate cascade of immune respons which triggers cytokines secretion as well as th1 lymphocyte activation. the level of interferon-γ (ifnγ) as one of the cytokines produced by th1 cell, will increase due to m.tb infection. the interferon-gamma release assay (igra) aim to measure the level of ifn-γ released within the blood after being stimulated by purified protein derivate obtained from m.tb. interferon-gamma release assay in quantiferon gold-in tube assay (qft-git) used 3 m.tb-specific antigens, namely early secreted antigenic target 6 (esat6), culture filtrate protein 10 (cfp 10) and tb7.7 that only found in m.tb and not in either bcg strain or other nontuberculous mycobacteria.9 the goal of this study is to investigate the benefit of igra with elisa-based quantiferon-tb gold in-tube assay to diagnose extrapulmonary tb. there are many researches about igra in extrapulmonary tb, but most of them come from high-income countries and only a few from middle/low-income countries. this is the first research about the utility of igra in the diagnosis of extrapulmonary tb performed in indonesia as developing country with the 2nd most frequent of tb cases in the world. methods this cross-sectional study was done in cipto mangunkusumo hospital. samples were collected from october 2015-october 2017. this study had been approved by ethical clearance from the ethics committee faculty of medicine universitas indonesia on november 9th, 2015, with a reference number 976/un2.f1/etik/2015. patients selection samples were collected using consecutive methods, to include all patients suspected with extrapulmonary tb who came to the pulmonology clinic and was admitted to cipto mangunkusumo hospital. the inclusion criteria include over 18 year old patients, suspected with extrapulmonary tb but were not under any anti-tuberculosis medication, and consented to be subject of this study. the exclusion criteria include extrapulmonary tb patients with a homeostatic disturbance which prevents invasive intervention for tissue specimen collection. all patients who met the inclusion criteria underwent anamnesis, physical examination, routine laboratory, and radiologic examination according to the organ involvement. after that with blinding design igra examination from a blood specimen was performed to be compared with either histopathologic or tissue smear for acid-fast bacilli (afb) as the gold standard. to obtain tissue specimen, a biopsy was performed through invasive intervention from the organs cleopas m. rumende acta med indones-indones j intern med 140 involved. a positive result from biopsy indicates the presence of datia langhans cell, epithelioid cell, granuloma with central caseous necrosis or afb in the tissue. elisa-based quantiferon-tb gold in-tube assay three ml blood sample was drawn and stored into 3 different tubes, namely nil tube, tb antigen tube and mitogen tube. tuberculosis antigen tube contains 3 kinds of tb-specific antigen coated on its wall namely esat-6, cfp-10, and rb7.7. the tb antigen tube was used to assess the ifn-g production by the tlymphocyte in response to the tb-antigen. mitogen tube contains phytohemagglutinin that could trigger lymphocyte cell proliferation, indicating the presence of a viable cell. after 1 ml blood sample was obtained, all tubes were shaken slowly for 5 seconds until the blood sample covered the inner layer of the tube wall. this step was performed to optimize the interaction between blood sample with the tb-antigens on the tube wall. all blood samples were sent to the laboratory to be incubated at 370 c for 16-24 hours. after the incubation, all tubes were centrifuged in 2000-3000 g (rcf) for 15 minutes. two hundred µl blood plasma was pipetted from the tube and added to the quantiferon elisa plate. then, igra assay with elisa was performed using the automated elisa workstation. data from igra were analyzed using quaniferon analysis software.8 interpretation results obtained from igra were reported qualitatively in 3 categories: positive, negative and indeterminate. a positive result was indicated by the difference between ifn-γ level in the tb antigen tube and in the nil tube of ≥ 0.35 iu. to control for the presence of nonspecific ifn-γ, the response in the tb-antigen tube must be more than 25% of the level of ifn-γ in the nil tube. the indeterminate result was indicated by no increase in the level of ifn-γ in the mitogen tube or when there was a high level of non-specific-ifn-γ in the nil tube (>8 iu). therefore re-examination was performed in indeterminate result. by implementing positive internal control (mitogen tube), the igra assay could differentiate indeterminate result from the true negative result.8 data analysis the data analysis was done using spss 20. descriptive data were presented as the proportion of extrapulmonary tb and its clinical manifestation. the data were analyzed using 2x2 chi-square test to determine sensitivity, specificity, positive predictive value (ppv), negative predictive value (npv), positive likelihood ratio (plr) and negative likelihood ratio (nlr) with 95% confidence interval (ci). results o u t o f 8 4 p a t i e n t s s u s p e c t e d w i t h extrapulmonary tb with median age of 33.5 years (range 17-83 years), 57 patients were confirmed to have extrapulmonary tb based on gold standard examination. the characteristic of the subject and the type of extrapulmonary tb is shown in table 1. table 1. subject characteristic characteristic total (n=84) age (years), median (range) 33.5 (17-83) gender (male), n (%) 33 (39.3) positive gold standard, n (%) histopathology ( +) 56 (66.0) tissue smear for afb (+) 1 (1.19) negative gold standard, n (%) 27 (32.1) extrapulmonary tb type, n (%) lymph node tb 39 (46.2) cutaneus tb 9 (10.7) tuberculous spondylitis 3 (3.57) peritoneal tb 2 (2.38) tuberculous meningitis and lymph node tb 1 (1.19) tuberculous hepatitis 1 (1.19) genital tb 1 (1.19) renal tb 1 (1.19) most of the extrapulmonary tb patients were diagnosed based on histopathologic examination, with lymph node tb as the most frequent clinical manifestation. twenty seventh patients were tested negative for extrapulmonary tb with gold standard examination. most of them suffered from chronic non-specific lymphadenitis and metastatic lymph enlargement as shown in table 2. vol 50 • number 2 • april 2018 the benefit of interferon-gamma release assay for diagnosis of extrapulmonary tb 141 table 3 shows sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratio from igra compared to the gold standard. of 87.7% (95% ci 77.0-94%) and 63.0% (95% ci 44.0-78%), respectively. yun feng et al.10 found a better sensitivity and specificity values compared with our study namely 93.3% (95% ci 77.999.2%) and 88.9% (95% ci 80-94.8%). however, in that study extrapulmonary tb was not entirely diagnosed based on the gold standard. in some patients, the presence of extrapulmonary tb was diagnosed only based on clinical symptoms and radiological features, thus affecting the validity of the study. furthermore clinical manifestations of extrapulmonary tb in that study showed a different spectrum from our study; most of the patients (40%) exhibited central nervous system involvement, while lymph node involvement was only found in 10% of patients.10 in our study, lymph node tb was found in the majority of patients (46%), whereas tuberculous meningitis was only found in 1% of the patients. the study from oh-hyung cho et al.11 found a similar sensitivity value with our research, that is 84% (95% ci 78-89%), but with a lower specificity of 51% (95% ci 4358%). in that study, out of 153 patients (77.78%) were diagnosed with extrapulmonary tb based on gold standard, while the remaining 34 patients (22.22%) were diagnosed only based on clinical symptoms and response to anti-tuberculosis treatment. moreover, the indeterminate results of igra examination which was found in 8 patients (5.2%) were directly included to the group with negative igra outcomes.11 both of these would have affected research validity because in addition to the diagnosis problem that was not entirely accurate, the results of indeterminate igra was not necessarily negative. indeterminate igra result means that the result cannot be concluded as negative or positive, which may result from errors in examination technique or may be due to severe immune deficiency.12,13 in severe immune deficiency there will be a significant decrease in cd4 cell count so that the production of ifn-g will also be greatly decreased. to determine, it should be re-examined with better examination technique. in our study, from 84 patients examined by igra, no indeterminate outcome was found. lin fan et al.14 conducted a meta-analysis study with two different igra examination table 2. another extrapulmonary disease involved organ n=27 lymph, n (%) chronic non-specific lymphadenitis 10 (37.0) metastatic lymph enlargement 2 (7.40) kikuchi fujimoto lymphadenitis 1 (3.70) epidermoid cyst 1 (3.70) sialadenosis 1(3.70) skin, n (%) hyperplasia epitheliomatosis 1 (3.70) actinomycosis 1 (3.70) achantocys epidermis 1 (3.70) chronic ulcer 1 (3.70) epidermis cyst 1 (3.70) bone, n (%) chronic non-specific spondylitis 2 (7.40) chronic non-specific osteomyelitis 2 (7.40) others, n (%) chronic non-specific mastitis 2 (7.40) liver cirrhosis 1 (3.70) table 3. cross-tabulation of igra and gold standard igra gold standard total positive negative positive 50 10 60 negative 7 17 24 total 57 27 84 in this study, the sensitivity value of igra was 87.71% (95% ci 77.0-94,0%), while the specificity was 63.0% (95% ci 44.0-78%). positive predictive value of igra was 83.33% (95% ci 72.0-91.0%), while negative predictive value was 70.83% (95% ci 51.0-85.0%). positive likelihood ratio of igra was 2.37 (1.39-4.02), while the negative likelihood ratio was 0.2 (0.09-0.41). discussion a m o n g 8 4 p a t i e n t s s u s p e c t e d w i t h extrapulmonary tb, 57 were definitively diagnosed with extrapulmonary tb based on gold standard with sensitivity and specificity cleopas m. rumende acta med indones-indones j intern med 142 techniques, namely the elisa-based qft-git and elispot-based t-spot.tb. in elispotbased t-spot.tb the number of t cells that produce ifn-γ were calculated after exposure with all three antigens as in qft-git. the qftgit pooled sensitivity and specificity were 72% (95% ci 65-79%) and 82% (95% ci 78-87%), respectively. t-spot.tb showed a better pooled sensitivity value of 90% (95% ci 86-93%), but a lower pooled specificity of 68% (95% ci 64-73%). in this study, subgroup analysis was performed based on patient’s economic level. sensitivity and specificity values were still good enough in high-income countries namely 79-89% and 73-83%, respectively; but in low/ middle-income countries, lower values were obtained (29% with qft-git and 34% with t-spot.tb).14 there were some limitations in that meta-analysis, because 17 from 20 selected original studies were from high-income countries and only 3 studies from low/middleincome countries.14 also, although the clinical manifestations of extrapulmonary tb in that study included a variety of organ involvement, research on low/middle-income countries. involved only one organ system, each of which is pleura and meninges. this is different from our study that showed involvement of various organ systems with the most frequent manifestation being lymph node tb. the sensitivity of igra was influenced by antigen levels, host response to its antigen and the manifestations of organ involvement. with higher antigen level that marked by high levels of esat-6, cfp-10, and tb7.7 produced by genes in the region of difference-1 (rd1), the formed immune response will be stronger. in lymph node tb, high levels of antigen are obtained with a good immune response so that lymphocyte cells will produce ifn-γ efficiently. in contrast to tuberculous meningitis, low levels of antigen are found with low to moderate levels of host immune responses so that ifn-γ production by lymphocytes also becomes lower.11 this may explain why in this meta-analysis, when subgroup analysis is obtained, low sensitivity and specificity values were found in low/middle-income countries. in addition, blinding design which is a required in diagnostic research was only performed in 5 original research. shin ja et al.15 obtained a lower sensitivity value than our study of 70.2% (95% ci 63.774.8%) with a similar specificity of 66.7% (95% ci 32.9-90.6%). in subgroup analysis based on the organs involvement, sensitivity and specificity of igra in lymph node tb were better namely 81.8% (95% ci 61.4-90.4%) and 80% (95% ci 35.1-98.9%). contrastingly, pleural tb has lower values of 38.5% (95% ci 31.25-45.7%) and 50% (95% ci 2.797.3%).15 based on this study, igra in extrapulmonary tb is particularly useful in diagnosing lymph node tb compared with tuberculosis that affect other extrapulmonary organs.15 adilistya et al.16 conducted a study using igra on pleural fluid with t-spot.tb to diagnose pleural tb. sensitivity and specificity value from that study were 100% (95% ci 97100%) and 88.89% (95% ci 51.75-99.72%), with ppv and npv of 97.5% (95% ci 86.84-99.94%) and 100% (95% ci 63-100%), respectively. although igra’s diagnostic performance was much better than our study, there was a limitation that could affect study validity. this limitation was related to cut-off value for igra positivity in pleural fluid. in that study, igra test on pleural fluid was considered positive when there was ≥ 6 spot-forming units (sfu), which described the number of active t cells producing ifn-γ.16 until now there is no standard igra cut-off value for t-spot.tb in pleural fluid. xiao-xia zhou et al.17 in their meta-analysis also obtained a good pooled sensitivity and specificity of t-spot.tb for pleural liquid, 92% (95% ci 88-95%) and 85% (95% ci 78-91%), without using standard igra cut-off value. the current cut-off value for igra in pleural fluid is provided only for qft-git, which varies in value from 0.3 u/l to 10 u/l.8 other meta-analysis studies were also performed by qianqian liu et al.18 that were conducted in patients suspected with lymph node tb. from 10 selected original research, the pooled sensitivity and pooled specificity were 89% (95% ci 85-92%) and 81% (95% ci 77-83%), respectively. extrapulmonary tb diagnosis in this meta-analysis were also not entirely based on the gold standard. in some vol 50 • number 2 • april 2018 the benefit of interferon-gamma release assay for diagnosis of extrapulmonary tb 143 patients, the diagnostic criteria were based on the clinical response to anti-tuberculosis treatment.18 although that meta-analysis study shows similar sensitivity to our research and even with better specificity values, since it only involved one organ, it was less likely to describe extrapulmonary tb clinical spectrum in daily practice. there is a limitation in our study. from 84 patients enrolled, none of them showed any pleural involvement. this is because for diagnosing pleural tb there is currently available a safer and less invasive diagnosis modalities, with a good sensitivity and specificity namely ada examination. adenosine deaminase cut-off value for pleural tb is > 40 u/l with sensitivity and specificity of 89-99% and 8897%, respectively.8 the availability of ada examination results in a pleural biopsy performed by pleuroscopy becomes overly invasive, requiring more expensive costs, and a higher risk of intervention. conclusion the igra examination that is used to diagnose extrapulmonary tb shows good sensitivity and ppv of 87.7% and 83.3%, respectively, therefore igra examination can be used as a supporting tool for diagnosis. a low specificity value (63%) indicates that negative igra results cannot exclude possibilities of extrapulmonary tb. other modalities are still needed to confirm presenting of extrapulmonary tb with either non-invaive or invasive measure. references 1. tuberculosis disease burden. global tuberculosis report 2017. geneva: world health organization; 2017. 2. tatar d, senol g, alptekin s, gunes e, aydin m, gunes o. assessment of extrapulmonary tuberculosis in two provinces of tukey. iran j public health. 2016;45:30513. 3. lapausa m, saldana am, asensio an. extrapulmonary tuberculosis : an overview. rev esp sanid penit. 2015; 17:3-11. 4. kulchavenya e. extrapulmonary tuberculosis: are statistical report accurate? ther adv infect dis. 2014;2:61-70. 5. wani rls. clinical manifestations of pulmonary and extrapulmonary tuberculosis. south sudan med j. 2013;3:52-6. 6. gomes t, vinhas sa, santos br, et al. extrapulmonary tuberculosis: mycobacterium tuberculosis strain and host risk factor in a large urban setting in brazil. plos one. 2013;8:1-9. 7. tb care i. international standard for tuberculosis care. edition 3. tb care i, the hague, 2014. 8. lewinsohn dm, leonard mk, lobue pa, et al. official american thoracic society/infectious disease society of america/ centers for disease control and prevention clinical practice guidelines: diagnosis of tuberculosis in adults and children. clin infect dis. 2017;64:e8-e24. 9. lee jy. diagnosis and treatment of extrapulmanary tuberculosis. tuberc respir dis. 2015;78:47-55. 10. yun f, ni d, lingyun s, et al. interferon-gamma release assay performance in pulmonary and extrapulmonary tuberculosis. plos one. 2012;7:1-7. 11. cho oh, park kh, kim sm, et al. diagnostic performance of t-spot.tb for extrapulmonary tuberculosis according to site of infection. j infect. 2011;63:362-9. 12. kobashi y, sugiu t, mouri k, obase y, miyashita n, oka m. indeterminate result of quantiferon tb-2g test performed in routine clinical practice. eur respir j. 2009;33:812-5. 13. jeong sj, han sh, kim co, et al. predictive factors for indeterminate result on the quantiferon test in an indeterminate tuberculosis-burden country. j infect. 2011;62:347-54. 14. lin f, zhou c, xiao-hui h, zhong-yi hu, he-ping x. interferon-gamma release assays for the diagnosis of extrapulmonary tuberculosis: a systematic review and meta-analysis. fems immunol med microbiol. 2012; 1-11. 15. shin ja, chang ys, kim hj, ahn cm, byun mk. diagnostic utility of interferon-gamma release assay in extrapulmonary tuberculosis. diag microbiol infect dis. 2015;82:44-8. 16. adilistya t, astrawinata daw, nasir uz. use of pleural fluid interferon-gamma enzyme-linked immunospot assay in the diagnosis of pleural tuberculosis. acta med indones. 2016;48:41-7. 17. xiao xz, ya ll, kan z, huan zs, zhao ht. body fluid interferon-γ release assay for diagnosing of extrapulmonary tuberculosis in adults: a systematic review and meta-analysis. [cited october 27 2015]. available from: http://www.nature.com/ scientificreports. 18. qianqian l, wenzhang l, yunfeng c, et al. performance of interferon-γ release assay in the diagnosis of tuberculous lymphadenitis: a meta-analyisis. peer j. 2017;1-14. special article 172 acta medica indonesiana the indonesian journal of internal medicine tranexamic acid in the management of upper gastrointestinal bleeding: an evidence-based case report nur atikah1, gurmeet singh2, hasan maulahela2, rahmat cahyanur2 1 faculty of medicine universitas indonesia, jakarta, indonesia. 2 department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia correspondence mail: nur atikah. jl. percetakan negara viii no. 40 a, jakarta 10570, indonesia. email: nur.atikah28@gmail.com. abstrak tujuan: mengetahui efektivitas penggunaan asam traneksamat, yang dikatakan dapat menurunkan mortalitas lebih baik daripada plasebo. metode: melalui penelusuran literatur di cochrane library, pubmed, clinical key, ebsco, science direct dan proquest sesuai dengan pertanyaan klinis, didapatkan satu systematic review yang mengkaji tujuh randomized controlled trials. melalui telaah kritis, disimpulkan bahwa artikel tersebut memenuhi kriteria validitas dan relevansi. hasil: artikel tersebut menemukan bahwa tidak ada perbedaan yang jelas antara kelompok intervensi dengan kelompok placebo dalam hal mortalitas. kesimpulan: asam traneksamat tidak direkomendasikan untuk menurunkan mortalitas pada pasien perdarahan gastrointestinal bagian atas. kata kunci: asam traneksamat, mortalitas, perdarahan gastrointestinal bagian atas. abstract aim: to review the effectiveness of tranexamic acid therapy which has been proposed to reduce bleeding and in turn lower mortality rate. methods: following literature searching based on our clinical question on cochrane library, pubmed, clinical key, ebsco, science direct and proquest, one systematic review that includes seven randomized controlled trials is obtained. the article meets validity and relevance criteria. results: the systematic review found that there is no any clear evidence between intervention and control groups in term of mortality. conclusion: the use of tranexamic acid to reduce mortality in patients with upper gastrointestinal bleeding is not recommended. key words: tranexamic acid, mortality, upper gastrointestinal bleeding. introduction upper gastrointestinal bleeding includes hemorrhage from the esophagus to the ligament of treitz and has life-threatening potential.1,2 uk national audit in 2007 shows that peptic ulcers accounted for 36% of all causes of upper gastrointestinal bleeding.3 common clinical manifestations are hematemesis, coffee-ground emesis and melena.4,5 despite advances in therapy, mortality rate remains unchanged at 7 to 10% due to advances in patient age, more co-morbid diseases, and recurrent bleeding.3,6 biopsy samples from patients with gastric or duodenal ulcer showed a significant increase in fibrinolytic activity compared to patients without gastric or duodenal ulcer (p<0.05).7 tranexamic acid is an anti-fibrinolytic agent that slows down the conversion of plasminogen to plasmin. therefore, it prevents the breakdown of blood clots, resulting in hemostasis.5 several hospitals vol 47 • number 2 • april 2015 tranexamic acid in the management of upper gastrointestinal bleeding routinely use tranexamic acid for patients with upper gastrointestinal bleeding although guidelines have not generally recommended it.8 antifibrinolytic agents such as tranexamic acid are expected to reduce fibrinolytic activity, thus prevent recurrent bleeding and mortality. clinical question a 59-year-old woman came to the emergency unit complaining of dark-colored vomit since one hour before admission. she also felt nauseau and heartburn along with passing black stools once. the patient had a history of dyspepsia since five years prior. endoscopic examination found giant duodenal ulcer (forest ib) and erosive gastritis. her physician recommended administration of intravenous tranexamic acid 500 mg thrice daily as a part of her upper gastrointestinal bleeding treatment. thus, we formulate the following clinical question: in patients with upper gastrointestinal bleeding, does the use of tranexamic acid reduce mortality compare to without tranexamic acid? methods literature searching was done on november 17, 2013 in these databases: cochrane library, pubmed, clinical key, ebsco, science direct and proquest. keywords used were “tranexamic acid”, “upper gastrointestinal bleeding” and “mortality”. the results are presented in figure 1. “tranexamic acid ” and “upper gastrointestinal bleeding” and “mortality” cochrane library pubmed clinical key ebsco science direct proquest n=13 n=1959 n=8 n=365 n=138n=12 title and abstract screening (total n = 2.495) inclusion • randomized controlled trial • english or bahasa • mortality as outcome exclusion • animal or molecular study • pediatrics • short communication, editorial, commentary, letter n=16 merging duplicate articles full text availability n=8 n=4 critical appraisal ( table 1 ) “ figure 1. flow chart of literature searching 173 nur atikah acta med indones-indones j intern med results four eligible articles consisting of two original articles and two systematic reviews were obtained. among these articles, one systematic review study, gluud et al.6, already covered the remaining available articles (gluud et al8, biggs et al9, hawkey et al.10) with one systematic review (gluud et al8) as an earlier version of the other systematic review (gluud et al6). table 1 shows the process of critical appraisal based on guidelines by center for evidence-based medicine university of oxford. gluud et al6 reviewed seven double-blind randomized controlled trials published from 1973 to 2001. the sources of bleeding in these trials are peptic ulcers (mean proportion 59%, range 27% to 90%) and esophageal varices (mean proportion 8%, range 5% to 16%). three trials use oral tranexamic acid only, whilst the remaining trials use intravenous tranexamic acid for a maximum of two days or until endoscopy was performed, followed by oral medication. duration of treatment ranges from two to seven days with total daily dose ranges from 4 to 8 g. the total dose of tranexamic acid given for the entire treatment period ranges from 16 to 42 g. five of seven trials report to have lost-tofollow-up subjects, while the remaining do not have any drop-out subjects. the number of patients initially randomized is 1645. one among five subjects (21%) was excluded after initial randomization due to lack of verified bleeding, presence of malignant disease, terminal illness, late administration of treatment, or late admission to the hospital. worst case scenario and post hoc sequential analysis are performed to evaluate any potential influence of lost-tofollow-up subjects. as many as 41 of 829 patients (5%) in tranexamic acid group and 68 of 825 patients (8%) in placebo group passed away. random effect model meta-analysis found that tranexamic acid reduces mortality (rr 0.61; 95% ci 0.42 – 0.89; i2=0%). regression analysis found no clear evidence of bias (p=0.527). different result is obtained when the proportion of patients who were excluded after randomization is counted. worst case scenario analysis found no clear differences between intervention and control groups in terms of mortality (rr 0.78; 95% ci 0.58-1.05; i2=6%). in addition, post hoc analysis found that overall sequential results are not significant after repeated testing. discussion on tissue injury, activation of the coagulation cascade leads to the formation of thrombin, which cleaves fibrinogen to fibrin. these polymerize to form insoluble fibrin and produce a haemostatic seal on damaged blood vessel walls. the fibrinolytic system is activated by the deposition of fibrin and assists in keeping the vessel lumen open. fibrinolysis occurs when plasminogen binds to lysine residues on the surface of fibrin and is converted to plasmin in the presence of plasminogen activator. plasmin cleaves fibrin into fibrin degradation products that inhibit excessive fibrin formation.11 lysis of a excessive formed fibrin clot is an likely to be important in the clinical setting table 1. critical appraisal*6 validity relevance author c le ar c lin ic al qu es tio n p ro ba bl e m is se d st ud y e lig ib ili ty cr ite ri a a pp ra is in g st ud ie s va lid ity s tu dy to s tu dy co ns is te nc y d is cu ss io n d om ai n d et er m in an t o ut co m e le ve l o f ev id en ce gluud et al (2012) + + + + + + + + + 1a + stated clearly in the article; not being done; ? not stated clearly *appraisal guideline for systematic review was adopted from center for evidence based medicine university of oxford 174 vol 47 • number 2 • april 2015 tranexamic acid in the management of upper gastrointestinal bleeding of upper gastrointestinal bleeding.12 previous studies had found that fibrinolytic activity has been detected in gastric and duodenal tissues which contain high concentration of plasminogen activators. vreebur et al.7 found that mucosal fibrinolytic activity is enhanced in mucosal biopsies from patients with an ulcer with endoscopic sign of bleeding.7 tranexamic acid is a synthetic lysine amino acid derivative that has antifibrinolytic activity which acts by blocking the lysine binding sites of the plasminogen molecule that are essential for its binding to fibrin. with its high affinity lysine binding site of plasminogen, tranexamic acid is expected to reduce recurrent bleeding on upper gastrointestinal bleeding.11 however, gluud et al.6 found no clear evidence regarding the effect of tranexamic acid in reducing mortality in patients with upper gastrointestinal bleeding.6 study conducted by patchett et al.12 found that gastric juice is also contributes to gastrointestinal bleeding. pure gastric juice interferes with haemostatis both by delaying the rate of clot formation and by reducing the quality of the final clot formed. this study suggests that an acid dependent factor in gastric juice such as a gastric protease is responsible in impairing clot formation. thus, although tranexamic acid may be capable of inhibiting the plasmin mediated pathway, it has no activity against non-specific protease mediated clot lysis in patients with upper gastrointestinal bleeding. the systematic review conducted by gluud et al.6 does not have enough information about the side effect of tranexamic acid. although the study did not find significant correlation between tranexamic acid and the risk of thromboembolism events, the analysis does not have sufficient statistical power to make clear inferences. theoretically, tranexamic acid increases the risk of thrombosis due to unopposed fibrin generation. conclusion there is no clear evidence regarding the effect of tranexamic acid in reducing mortality in patients with upper gastrointestinal bleeding. because of the limited validity of both internal and external evidence, additional randomized controlled trial is needed to establish the effect of tranexamic acid in combination with current clinical practice. thus, the current use of tranexamic acid as routine therapy in upper gastrointestinal bleeding is still not recommended. references 1. wilkins t, khan n, nabh a, et al. diagnosis and management of upper gastrointestinal bleeding. am fam physician. 2012;85:469-76. 2. british society of gastroenterology endoscopy committee. non-variceal upper gastrointestinal haemorrhage: guidelines. gut. 2002;51:iv1–iv6. 3. lau yw, barkun a, fan d, et al. challenges in the management of acute peptic ulcer bleeding. lancet. 2013;381:2033–43. 4. albeldawi m, qadeer ma, vargo jj. managing acute upper gi bleeding, preventing recurrences. cleve clin j med. 2010;77:131-42. 5. gralnek im, barkun an, bardou m. management of acute bleeding from a peptic ulcer. n engl j med. 2008;359:928-37. 6. gluud ll, klingenberg sl, langholz e. tranexamic acid for upper gastrointestinal bleeding. cochrane database of systematic reviews. 2012;issue 1. 7. vreeburg em, levi m, rauws eaj, et al. enhanced mucosal fibrinolytic activity in gastroduodenal ulcer haemorrhage and the benefcial effect of acid suppression. aliment pharmacol ther. 2001;15:63946. 8. gluud ll, klingenberg sl, langholz e. systematic review: tranexamic acid for upper gastrointestinal. aliment pharmacol ther. 2008;27:752–8. 9. biggs jc, hugh tb, dodds aj. tranexamic acid and upper gastrointestinal haemorrhage a double-blind trial. gut. 1976;17:729–34. 10. hawkey gm, cole at, mcintyre as, et al. drug treatments in upper gastrointestinal bleeding: value of endoscopic findings as surrogate end points. gut. 2001;49:372–9. 11. mccormac pl. tranexamic acid: a review of its use in treatment of hyperfibrinolysis. drugs. 2012;72(5): 585-617. 12. patchett se, o’donogue dp. pharmacological manipulation of gastric juice: thrombelastographic assessment and implications for treatment of gastrointestinal haemorrhage. gut. 1995;36:358-62. 175 clinical practice 335acta medica indonesiana the indonesian journal of internal medicine targeted therapy for metastatic renal cell carcinoma andika afriansyah, agus rizal a.h. hamid, chaidir a. mochtar, rainy umbas department of urology, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: prof. rainy umbas, md., phd. department of urology, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: rainy.umbas@gmail.com. abstrak pada sepuluh tahun terakhir, perkembangan terapi target pada karsinoma sel renal bermetastasis menjadi harapan baru dan mampu meningkatkan prognosis penyakit tersebut. terdapat tiga terapi target yang telah dikembangkan termasuk multi-targeted tyrosine kinase inhibitors (tki), penghambat mammalian target of rapamycin (mtor) complex-1 kinase, dan antibodi monoklonal humanized antivascular endothelial growth factor (vegf). tujuan artikel ini secara kritis menelaah studi terkini terapi target untuk tatalaksana pasien tersebut. pada sebagian besar uji klinis yang mengevaluasi terapi target, pasien distratifikasi berdasakan model yang dikembangkan oleh memorial sloan kattering cancer center (mskcc) dan rekomendasi terapi berdasarkan tingkat resiko pasien. terapi target lini pertama (belum pernah mendapatkan terapi sistemik sebelumnya), sunitinib, pazopanib, atau bevacizumab ditambah ifn-α merupakan pilihan terapi dengan tingkat resiko menguntugkan dan sedang serta gambaran histologi sel jernih. pasien yang mengalami progresifitas pasca terapi sitokin, sorafenib atau axitinib adalah pilihan yang direkomendasikan. karsinoma sel ginjal bermetastasis tipe sel jernih dengan tingkat resiko menguntungkan dan sedang yang gagal pada terapi target lini pertama dapat ditatalaksana dengan sorafenib, everolimus, temsirolimus atau axitinib. akan tetapi, studi saat ini menunjukkan tidak ada pilihan terapi sekuensial terbaik pasca kegagalan terapi lini pertama. pasien dengan tingkat risiko buruk dan gambaran histologi bukan sel jernih, temsirolimus merupakan terapi target yang didukung oleh uji klinis fase iii. saat ini, beberapa obat baru masih dalam tahap uji klinis fase ii dan iii dan hasil uji klinis tersebut mungkin dapat mengubah terapi standar pasien karsinoma sel ginjal bermetastasis di masa yang akan datang. kata kunci: karsinoma sel ginjal metastasis, sel jernih, terapi target, terapi sekuensial. abstract in the past 10 years, recent development of targeted therapy in metastatic renal cell carcinoma (mrcc) has provided a new hope and significantly enhanced the prognosis of the disease. three class of targeted therapy were developed, including multi-targeted tyrosine kinase inhibitors (tki), the mammalian target of rapamycin (mtor) complex-1 kinase inhibitors, and the humanized antivascular endothelial growth factor (vegf) monoclonal antibody. hence, the objective of this article was to critically examine the current evidence of targeted therapy treatment for patients with mrcc. in the majority of trials evaluating targeted therapy, patients were stratified according to memorial sloan kattering cancer center (mskcc) risk model and the recommendation of targeted treatment based on risk features. in first-line setting (no previous treatment), sunitinib, pazopanib, or bevacizumab plus ifn-α were recommended as treatment options for patient with favorableor intermediaterisk features and clear cell histology. patients who progressed after previous cytokine therapy would have sorafenib or axitinib as treatment options. clear-cell mrcc with favorableor intermediaterisk features and failure with first-line tki therapy might be treated with sorafenib, everolimus, temsirolimus or axitinib. however, the current evidence did andika afriansyah acta med indones-indones j intern med 336 not show the best treatment sequencing after first-line tki failure. in patients with poor-risk clear-cell and nonclear cell mrcc, temsirolimus was the treatment option supported by phase iii clinical trial. in addition, several new drugs, nowadays, are still being investigated and waiting for the result of phase ii or iii clinical trial, and this might change the standard therapy for mrcc in the future. keywords: clear cell, metastatic, non-clear cell, renal cell carcinoma, sequential therapy targeted therapy. introduction kidney cancer is one of the most common malignancies worldwide with 2% of all adult malignancies, and approximately 271.000 new cases were diagnosed in 2008.1-3 approximately 90 % of all renal malignancy are comprised as renal cell carcinoma (rcc).4 the incidence of renal tumor differs between countries, with the highest incidence in australia, europe, and america, and the incidence is low in india, africa, and china.5 the mortality was highest in australia, new zealand, north america, and europe, whereas the lowest mortality rate was in africa and asia.2 over the last two decade until recently, the incidence of rcc increased approximately 2% in europe and worldwide, though the incidence decreased in denmark and sweden.6 the incidence of kidney cancer in indonesia is 2.4-3 cases/100.000 population which increased from the earlier estimation approximately 1.41.8 cases/100.000 population.7 data from cipto mangunkusumo hospital between 1995 to 2014, total of 120 patients was diagnosed with rcc. among them, 28% of patients were present with nodal metastasis and 24% of patients were present with distant metastasis (mochtar ca, et al, 2015, unpublished data). approximately one third of patients diagnosed with rcc present with metastatic diseases, and up to 40% of patients with clinically localized rcc will develop metastasis.8 patients with mrcc face a fatal prognosis, with 5-year survival rates less than 10%.9 in the past 20 years, cytokine therapy using interferon-α (ifn-α) was standard treatment of mrcc and became the main focus of the research for renal cancer. the response rate of mrcc patient treated with ifn-α was less than 10% and median overall survival (os) was 13 months. in several trials evaluated the cytokine, toxicity frequently occurred and required inpatient administration for intensive care. the limitations of cytokine therapy had intensified the research of a new class of drugs that much more specifics sites of cellular action than immunotherapy. recent development of more specific action, called targeted therapy, has provided a new hope for the treatment of mrcc and significantly improved the perspective of treatment from this disease.10 three classes of targeted therapy have been developed including multi-targeted tyrosine kinase inhibitors (tki): sorafenib, axitinib, pazopanib, and sunitinib; the mammalian target of rapamycin (mtor) complex 1 kinase inhibitors: temsirolimus and everolimus; the humanized antivascular endothelial growth factor (vegf) monoclonal antibody: bevacizumab with interferon (ifn)-α.8,11 abundance of targeted agents has been approved for treatment of mrcc, yet the most effective treatment of mrcc is still unknown. systemic targeted treatment may be life long and expensive, thus financial reason might be influence the patient compliance.12 in addition, current indonesia kidney cancer guideline does not clearly state the targeted treatment strategy for mrcc patient.13 in order to improve the benefits of the targeted therapy, mrcc patients should be treated based on the risk stratification, histopathology, and status of previous systemic treatment. hence, the aim of this article is to review the current evidence of targeted treatment and supplements the treatment strategy for mrcc patient in our current guideline. targeted therapy for metastatic clear-cell renal cell carcinoma several phase ii/iii trials evaluated tki, vegf monoclonal antibody, and mtor for treating mrcc patients. these trials predominantly recruited patients with clear-cell rcc histology. sunitinib, sorafenib, axitinib, pazopanib, bevacizumab+ ifnα were attempted vol 48 • number 4 • october 2016 targeted therapy for metastatic renal cell carcinoma 337 for clear cell mrcc patients with favorableor intermediate-risk feature. temsirolimus was ta bl e 1. t ar ge te d th er ap ie s of c le ar -c el l r c c a nd th ei r im pa ct s on o ve ra ll su rv iv al ( o s ) an d pr og re ss io n fr ee s ur vi va l ( p f s ) d ru g d os e s tu dy d es ig n e lig ib ili ty n (p at ie nt s) m ed ia n p fs (m on th s) m ed ia n o s (m on th s) r ef er en ce s c om pa re d w ith if n α s un iti ni b 50 m g/ d ay or al ly , 4 w ee ks on / 2 w ee ks -o ff r c t (s un iti ni b vs . if n -α ) c le ar c el l m r c c w ith ou t p re vi ou s sy st em ic th er ap y p re do m in an tly fa vo ra bl e o r in te rm ed ia te ris k 75 0 (3 75 v s. 37 5) 11 v s. 5 * 26 .4 v s. 2 1. 8 m ot ze r et a l 20 09 14 ,1 5 s or af en ib 40 0 m g tw ic e da ily r c t (s or af en ib v s. if n -α ) p re do m in an tly c le ar c el l m r c c w ith ou t p re vi ou s sy st em ic th er ap y f av or ab le or in te rm ed ia te -r is k 18 9 (9 7 vs . 92 ) 5. 7 vs . 5 .6 n. d e sc ud ie r et a l 20 09 16 b ev ac iz um ab 10 m g/ kg , ev er y 2 w ee ks in tr av en ou s r c t (i f n α+ b ev ac iz um ab v s. if n -α +p la ce bo ) p re do m in an tly c le ar c el l m r c c w ith ou t p re vi ou s sy st em ic th er ap y p re do m in an tly fa vo ra bl e o r in te rm ed ia te ris k 64 9 (3 27 v s. 32 2) 10 .2 v s. 5 .4 * 23 .3 v s. 2 1. 3 e sc ud ie r et a l 20 10 17 ,1 8 r c t (i f n α+ b ev ac iz um ab v s. if n -α ) p re do m in an tly c le ar c el l m r c c w ith ou t p re vi ou s sy st em ic th er ap y p re do m in an tly fa vo ra bl e o r in te rm ed ia te ris k 73 2 (3 69 v s. 36 3) 8. 5 vs . 5 .2 * 18 .3 v s. 1 7. 4 r in i e t a l 20 10 19 ,2 0 te m si ro lim us 25 o r 15 m g/ w ee ks in tr av en ou s r c t (t em si ro lim us vs . i f n -α ) p oo r ris k ad va nc ed r c c / m r c c w ith ou t p re vi ou s sy st em ic th er ap y 41 6 (2 09 v s. 20 7) 3. 8 vs . 1 .9 * 10 .9 v s 7. 3 h ud es e t a l 20 07 21 c om pa re d w ith p la ce bo p az op an ib 80 0 m g on ce da ily o ra lly r c t (p az op an ib v s. pl ac eb o) p re do m in an tly c le ar c el l a dv an ce d/ m et as ta tic r c c w ith o r w ith ou t p re vi ou s sy st em ic th er ap y p re do m in an tly fa vo ra bl e o r in te rm ed ia te -r is k 23 3 (1 53 v s. 78 ) 11 .1 v s. 2 .8 * 22 .9 v s. 2 0. 5 s te rn be rg e t a l 20 13 22 ,2 3 s or af en ib 40 0 m g tw ic e da ily o ra lly r c t (s or af en ib v s. pl ac eb o) c le ar c el l m r c c f av or ab le or in te rm ed ia te ris k p ro gr es se d af te r cy to ki ne th er ap y 90 3 (4 51 v s. 45 2) 5. 5 vs . 2 .8 * 17 .8 v s. 1 5. 2 e sc ud ie r 20 09 et a l24 ,2 5 c om pa re d w ith a no th er t k i p az op an ib 80 0 m g on ce da ily o ra lly r c t (p az op an ib v s. su ni tin ib ) c le ar c el l m r c c w ith ou t p re vi ou s sy st em ic th er ap y 11 10 ( 55 7 vs . 5 53 ) 8. 5 vs . 9 .5 28 .4 v s. 2 9. 3 m ot ze r et a l 20 13 22 ,2 3 a xi tin ib 5 m g tw ic e da ily r c t (a xi tin ib v s. so ra fe ni b) c le ar c el l m r c c p ro gr es se d af te r cy to ki ne th er ap y 25 1 (1 26 v s. 12 5) 12 .1 v s. 6 .5 * 29 .4 v s. 2 7. 8 r in i 2 01 1, m ot ze r 20 13 26 ,2 7 t k i= ty ro si ne k in as e in hi bi to rs ; n = n um be r of p at ie nt s; p f s = p ro gr es si on fr ee s ur vi va l; o s = o ve ra ll su rv iv al ; v s. = ve rs us ; r c t = ra nd om iz ed c on tr ol le d tr ia l; *= s ta tis tic al ly si gn ifi ca nt , n .d = n ot d et er m in ed evaluated in phase iii clinical trial for poor risk features (table 1). andika afriansyah acta med indones-indones j intern med 338 patient risk stratification the prognostic model to predict survival of mrcc patients was important for interpreting and designing a clinical trial. an ideal prognostic model must be easy to use and included the most relevant disease characteristics. there were several prognostic models, which predicted the patient survival and influenced the choice of targeted treatment. memorial sloan kattering cancer center (mskcc) and groupe francais d’immunotherapie were calculated the prognostic model based on the outcome of patient treated with immunotherapy, especially ifn-α and interleukin-2 (il-2).14-16 since the ifn-α was a considered as a suitable comparator of a new drug , the prognostic model that used for clinical trial should be derived from the population of mrcc patient treated with ifn-α therapy. mskcc model was the first prognostic model to predict survival of patients in interferon era, and was used in the majority of trials to evaluate the targeted treatment. mskcc risk system stratified patients with poor-, intermediate-, and favorable-risk categories based on the number of clinical features and laboratories (table 2).14,15 five agents as first line therapy i.e sunitinib, pazopanib, sorafenib, axitinib, and bevacizumab + ifnα (table 1). four of these trials were using ifn-α as comparator, and one trial was using placebo as comparator, and two trials were using another tki as comparator. the majority of trials included patients without prior systemic therapy. three trials included the patients with prior systemic immunotherapy using ifn-α or il-2. choosing between sunitinib and pazopanib as the first line therapy was still controversial, and two trials were performed to evaluate the efficacy between two agents. sunitinib. the first phase-iii trial in 750 showed that patients treated with sunitinib had longer pfs (11 month vs. 5 month) than ifn-α group.17 median os of this study was 26.4 months for sunitinib group and 21.8 months in ifn-α group (hr 0.82, 95% ci 0.67 – 1.00, p= 0.051). patients included in this study were predominantly favorable (n=264; 35.2%) or intermediate (n=421; 56.1%) according to mskcc risk features.17,18 analysis of large sunitinib global expanded-access study, a population based study that included a total of 4,543 patients from 50 countries treated with sunitinib, showed that median os was 18.4 months and 19.0 months in the patients with or without prior cytokine therapy, respectively. the median pfs was 9.3 and 9.7 months in the patients with or without prior cytokine therapy.19 other cohort study in different population setting showed different median os with 33.1 months and 17.3 months in the japan and canada population.20,21 data from renis (renal information system), a epidemiological database for patients treated with targeted therapy in czech republic, showed a small difference of pfs between patient in the population and clinical trials (10 months vs. 11 months).22 there are many factors that influence the effects of sunitinib (table 3). the reduction of os was significantly associated with six factors including eastern cooperative oncology group (ecog) performance status >1, time from diagnosis to treatment <1 year, hemoglobin <lower limit of normal (lln), calcium >upper limit of normal (uln), neutrophil count >uln, platelet count >uln. grassi et al showed that table 2. memorial sloan kattering cancer center (mskcc) criteria risk factors* cut-off point used karnofsky performance status <80 time from diagnosis to treatment <12 months hemoglobin <lln ldh >1.5 times uln corrected serum calcium >10.0 mg/dl (2.4 mmol/l) *favorable (low) risk: no risk factors; intermediate risk: one or two risk factors; poor (high) risk: three or more risk factors ldh = lactate dehydrogenase; lln = lower limit of normal; uln = upper limit of normal ta r g e t e d t h e r a p y f o r f a v o r a b l e t o intermediaterisk clear cell mrcc first line targeted therapy. most of the trials recruited patients with favorableor intermediaterisk group based on mskcc risk model. data from 7 randomized controlled trial (rct) were used to determine the efficacy of vol 48 • number 4 • october 2016 targeted therapy for metastatic renal cell carcinoma 339 liver metastasis treated with sunitinib had poor outcome. from a series of patients treated with sunitinib in japan, c-reactive protein (crp) ≥1 mg/dl, mskcc poor calcification, liver metastasis were associated with a decrease of os.19,21,23 izzedine et al showed that os might improve when mrcc patient with hypertensive disease treated with sunitinib and angiotensin inhibitors.24 another important thing in patient with palliative setting beside os was health-related quality of life (hrql). patient with improvement os should have improvement quality of life. analysis from phase iii trial compared sunitinib and ifn-α, the study found that hrql was significantly better in the sunitinib group than ifn-α group. hrql was measured by functional assessment of cancer therapykidney symptom index-15 item (fksi-15) and fksi disease-related symptoms (fksi-drs).17 sunitinib had higher quality adjusted life years (qalys) compared to ifn-α, 1.99 qalys vs. 1.33 qalys. however, the incremental cost for one qalys was still expensive, approximately $ 52,593 (idr 734,618,108).25 when sunitinib was compared to best supportive care (bsc), patient treated with sunitinib had higher qaly than bsc, 1.36 qalys vs. 0.39 qalys. for one extra qaly, there was incremental cost approximately €34,196 (idr 523,280,336) per qaly gained.26 pazopanib. strernberg et al performed phase iii clinical trial and randomized 435 patients with predominantly favorable(n=170, 39%) or intermediate(n=236; 54%) risk factor. this trial included the patients who had or had not been treated with cytokine therapy. the result of this trial showed that patients treated with table 3. factors associated with reduced os in mrcc patients treated with sunitinib study parameters hr 95% ci gore et al (2015)31 ecog ps >1 2.2 1.98-2.44 time from diagnosis to treatment < 1 year 1.32 1.21–1.44 hemoglobin < lln 1.84 1.68–2.01 calcium > uln 1.41 1.25–1.59 neutrophil count > uln 2.03 1.83–2.25 platelet count > uln 1.36 1.23–1.50 mizayaki et al (2015)33 poor mskcc clasification 1.73 n.p c-reactive protein ≥1.0mg/dl 2.80 n.p liver metastasis 2.37 n.p izzedine et al (2015)36 hypertension patients treated with angiotensin inhibitors 0.55 0.35-0.86 motzer et al (2013)39 white race 0.34 0.13-0.88 bone metastasis 2.34 1.28-4.29 baseline corrected ca > 10 mg/dl 4.36 1.66-11.44 patil et al (2010)40 ecog ps > 1 1.52 1.11-2.09 time from diagnosis to treatment < 1 year 1.70 1.25-2.33 ldh 2.01 1.54–2.62 corrected ca level 1.58 1.30–1.86 normal hemoglobin level 0.14 0.04-0.44 bone metastasis 1.46 1.08-1.99 hr = hazard ratio; ci = confident interval; ecog ps = eastern cooperative oncology group performance status; lln = lower limit of normal; uln = upper limit of normal; ca = calcium; mskcc = memorial sloan kattering cancer center; n.p = not presented andika afriansyah acta med indones-indones j intern med 340 pazopanib had longer pfs compared with placebo (median pfs 11.1 vs. 2.8 month). however, pazopanib treatment did not showed a statistically significant improvement in median os compared with placebo (22.9 months vs. 20.5 months, in pazopanib and placebo arm, respectively). diarrhea, hypertension, and nausea were the most common adverse effects observed in pazopanib arm.27,28 sorafenib. in phase ii trial, which evaluated sorafenib as first line therapy, patient treated with sorafenib had similar pfs as treated with ifn-α (approximately 5.7 months). because of this findings, there was not any phase iii trial which performed for evaluating sorafenib as the first-line therapy. however, greater numbers of patients showed regression of tumor size in sorafenib arm (68.2% vs. 39.0%).18 different result was found when sorafenib was used for patients with unsuccessful cytokine therapy. sorafenib showed effects on prolongs the median pfs compared to placebo, 5.5 months in sorafenib arm and 2.8 months in placebo arm. there was no statistically significant difference between sorafenib and placebo for prolonged the median os.29,30 propocio et al assessed sorafenib as first line and second line therapy in community setting, and found that the efficacy of sorafenib was generally as good as in clinical trial, especially when sorafenib was used as second line. patients treated with sorafenib as first line had median os 17.2 months and the second line had median os 16.3 months. this study suggested that sorafenib might be used as first line and second line setting, although the result from clinical trial, which assessed sorafenib as first line therapy, showed no difference compared with ifn-α.31 axitinib. phase iii trial evaluated the efficacy of axitinib compared with sorafenib in mrcc patients. in the subgroup analysis of patients who progressed with cytokine therapy, axitinib was statistically significant in prolonged median pfs, 12.1 months in axitinib arm vs. 6.5 months in sorafenib arm, but there was no statistically significant in prolong the os.32,33 bevacizumab plus ifn-α. there were two trials that evaluated the efficacy of combination bevacizumab +ifn-α compared to ifn-α alone. rini et al recruited 732 patients who treated with bevacizumab plus ifn-α or ifn-α alone, and found better results for pfs in bevacizumab plus ifn-α group than ifn-α mono-therapy (8.5 vs. 5.2 month). os between two groups was no statistically different (18.3 vs. 17.4 months).34 other trial from escudier et al showed statistically different of pfs outcome in bevacizumab plus ifn-α arm vs. placebo plus ifn-α (10.2 vs. 5.4 months).35 comparison between first-line therapy. several studies evaluated the efficacy of targeted therapy compared with ifn-α or placebo, whereas just pazopanib and sunitinib was compared in head-to head trial.17,28,36,37 two randomized clinical trial, comparz (comparing the efficacy, safety and tolerability of pazopanib versus sunitinib) and pisces (patient preference study of pazopanib versus sunitinib in advanced or metastatic kidney cancer) study, had been conducted to determine treatment options between sunitinib and pazopanib as first line targeted therapy. comparz trial showed the non-inferiority comparative effectiveness between pazopanib 800 mg once daily continuing dose and sunitinib once daily dose of 50 mg for 4 weeks followed by 2 weeks without treatment. disease-progression events developed in 60% of patients (336 of 557) in pazopanib arm and 58% patients (323 of 553) in sunitinib group. the noninferiority of pazopanib compared with sunitinib are also observed in pfs outcome (median pfs 10.2 months in sunitinib group vs. 10.5 months in pazopanib group).38 even tough the survival rate of sunitinib and pazopanib was similar, these agents might be different in the incidence of toxicities that influenced health-related qualityof-life (hrqol), and this circumstance should be considered in palliative setting. the pisces study was designed using crossover method to assess patient’s preference either pazopanib or sunitinib. this study reported that more patients were prefer using pazopanib (70% of patients) than sunitinib (22%), with hrqol and safety as independent influencing factors.39 milis et al40 conducted a meta-analysis of trial to evaluate the effectiveness of targeted therapy by using adjusted indirect comparison. they found the superiority of sunitinib compared vol 48 • number 4 • october 2016 targeted therapy for metastatic renal cell carcinoma 341 with bevacizumab plus ifn-α (hr 0.75, 95% ci 0.60-0.93, p = 0.001) and sorafenib (hr 0.58, 95% ci 0.38 to 0.36, p = 0.001) to improve the pfs. in addition, there was no difference between bevacizumab and sorafenib in prolong the os. hence, we recommended that sunitinib, pazopanib, and bevacizumab plus ifn-α were used for mrcc patient in first-line setting (no previous systemic treatment). in addition, sorafenib and axitinib were recommended for patient with previous immunotherapy (with ifn-α or il-2). sequential treatment after progressed with first-line therapy. most patients experienced disease progression with targeted therapy, and sequential therapy with different agents might be clinically benefits. however, choosing the sequence of tki remained clinical challenge. the rationale of using sequential therapy for treating progressing mrcc was evaluated in several trial including: record-1 (renal cell cancer treatment with oral rad001 given daily); introsect (investigating torisel as second-line therapy); switch (efficacy and safety of sorafenib followed by sunitinib versus sunitinib followed by sorafenib in the treatment of first-line advanced mrcc); record-3; axis (axitinib as second-line therapy for metastatic renal cell cancer). (table 4) record-1 trial. motzer et al conducted the first randomized trial of sequential targeted therapy in progressing mrcc patients who got targeted therapy with sunitinib or sorafenib. they randomized 416 patients to receive oral everolimus 10 mg per day or placebo. majority of patients in this study were favorableor intermediaterisk factors. the main outcome was pfs using recist criteria based on radiology evaluation. this study showed a statistically difference of pfs between everolimus arm and placebo arm with median pfs, which was 4.9 months versus 1.9 months respectively (hr 0.33; p<0.001). however, there was no statistically significant difference os in everolimus and placebo arm. this study concluded the efficacy and safety of everolimus in patients with mrcc after progression of sunitinib or sorafenib.41 introsect trial. this trial compared the efficacy of temsirolimus and sorafenib as second line therapy after progression on sunitinib. this study were randomly assigned 512 patients to receive 25 mg once weekly intravenous temsirolimus or oral sorafenib 400 mg twice per day. the trial found that there was no pfs advantage between temsirolimus and sorafenib, with median pfs in temsirolimus arm was 4.3 months compared with 3.9 months in sorafenib arm. however, in os outcome, there was a significant difference between median os of sorafenib arm compared to temsirolimus arm, 16.6 months vs. 12.3 months, respectively. the longer os suggested that the usage of sequence vegf inhibitor might have benefits in patients with mrcc.42 switch trial. this trial was the first prospective phase iii-rct that evaluated the sequential therapy with sorafenib-sunitinib (sosu) or sunitinib-sorafenib (su-so) in advanced/ mrcc. from the total of 365 patients included in this study, 182 patients were randomly assorted into so-su arm and 183 patients into su-so arm. median first-line pfs showed similarity between two groups, but median second-line pfs was longer in so-su than su-so. total pfs and os was no difference between to study group. the study concluded that both of treatment options were similarly effective in patients with advanced/mrcc.43 record-3 trial. this trial evaluated the sequential therapy with first-line everolimus and second-line sunitinib versus first-line sunitinib and second-line everolimus. the total of 471 patients with metastatic clear cell or non-clear cell rcc enrolled in this phase-ii clinical trial, 238 patients randomly assigned into everolimussunitinib and 233 patients into sunitinibeverolimus arm. the primary end point of this study was median os and pfs. the median combined pfs was not statistically different between two arms which the median pfs was 21.1 months for everolimus-sunitinib arm and 25.8 months for sunitinib-everolimus arm (hr 1.3; 95% ci 0.9 – 1.7). there was no statistically difference between two arms for prolonged os.44 axis trial. seven hundred twenty three patients were evaluated after progressed with first line treatment with sunitinib, temsirolimus, cytokines, or bevacizumab plus ifn-α. they andika afriansyah acta med indones-indones j intern med 342 table 4. sequential therapies and their impact on metastatic renal cell carcinoma clinical trial treatment groups study design study eligibility n (patients) median pfs (months) median os (months) record-145,46 sunitinib/sorafenibeverolimus vs. sunitinib/sorafenibplacebo randomized open label study clear-cell mrcc patients progressed on sunitinib or sorafenib 410 (272 vs. 138) 4.0 vs. 1.9* 14.8 vs. 14.4 introsect47 sunitinibtemsirolimus vs. sunitinib-sorafenib randomized open label study metastatic rcc patients (any histology) progressed after sunitinib as first line therapy 512 (259 vs. 253) 4.3 vs. 3.9 12.3 vs. 16.6* switch48 sorafenib-sunitinib vs. sunitinibsorafenib randomized open label study metastatic rcc (all histology) no prior systemic therapy 365 (182 vs. 183) 12.5 vs. 14.9† (5.9 vs. 8.5†† g 5.4 vs. 2.8†††) 31.5 vs. 30.2† record-349 everolimus-sunitinib vs. sunitinibeverolimus randomized open label study metastatic clear cell or non-clear cell rcc no previous systemic therapy 471 (238 vs. 233) 25.1 vs. 25.8† 22.4 vs. 23.8† axis26,27 sunitinib – axitinib vs. sunitinib sorafenib double blindrct metastatic clear-cell rcc progressed after sunitinib as first line therapy 389 (94 vs. 195) 4.8 vs. 3.4* 15.2 vs. 16.5 bevacizumab – axitinib vs. bevacizumab sorafenib double blindrct metastatic clear-cell rcc progressed after bevacizumab as first line therapy 59 (29 vs. 30) 4.2 vs. 4.7 14.7 vs. 19.8 temsirolimus axitinib vs. temsirolimus sorafenib double blindrct metastatic clear-cell rcc progressed after temsirolimus as first line therapy 24 (12 vs. 12) 10.1 vs. 5.3 18.0 vs. 8.5 tki = tyrosine kinase inhibitors; n = number of patients; pfs = progression free survival; os = overall survival; vs.= versus; rct = randomized controlled trial; *= statistically significant; †= combined median os/pfs after first-line and second line †† = median first-line pfs/os; †††= median second-line pfs/os. compared the axitinib 5 mg twice daily with sorafenib 400 mg twice daily. pfs is the primary end point using recist criteria. the secondary outcomes were os, objective respond rate, and disease progression. among 723 patients, 361 patients assigned to axitinib arm and 362 patients assigned to sorafenib arm. the median pfs was 6.7 months in axitinib arm compared with 4.7 months in sorafenib arm (hr 0.665; 95% ci 0.544-0.812; one sided p<0.001). axitinib was superior compared to sorafenib for the pfs in patients with previously treated with sunitinib. there was no difference in os data, which median os 20.1 months in axitinib arms and 19.2 months in sorafenib arm (hr: 0.969; 95% ci: 0.800-1.174, p = 0.374). in the subgroup analysis of patients previously treated with sunitinib, bevacizumab, and temsirolimus, the study did not record any statistically significant difference either in sunitinib or axitinib for prolong the os.32 t h e r e f o r e , a c c o r d i n g t o t h e s e t r i a l s reviewed, it concluded that any sequential therapy has similar effects on prolong pfs and os. sorafenib, everolimus, temsirolimus, and axitinib might be useful for patients who progressed after first line tki. in addition, axitinib was superior than sorafenib in term of prolonged pfs, but not prolonged os of patients who progressed after first line targeted treatment. vol 48 • number 4 • october 2016 targeted therapy for metastatic renal cell carcinoma 343 targeted therapy for poor-risk metastatic clear cell carcinoma the efficacy of targeted therapy, especially temsirolimus, in treating mrcc with poor-risk category was evaluated in phase-iii conducted by hudes et al. they randomly assigned 626 patients to receive 25 mg of intravenous temsirolimus, 3 million u of ifn-α subcutaneous three times weekly, or the combination therapies with 15 mg of temsirolimus weekly plus 6 million u of ifn-α three times weekly. the comparison between temsirolimus mono-therapy and ifn-α monotherapy illustrated that the os was statistically significant with median os 10.9 months in temsirolimus group versus 7.3 months in ifn-α group (hr 0.73, 95% ci: 0.58-0.92, p = 0.008). the combination of temsirolimus and ifn-α did not show a significant improvement of os and showed a greater risk of toxicity than monotherapy subgroup. in addition, this study showed the difference of median pfs in the ifn-α, temsirolimus, and combination-therapy: 1.9 month, 3.8 month, and 3.7 months, respectively.45 temsirolimus was better tolerated than ifn-α with the grade 3 and 4 adverse events lower in the temsirolimus group (67%) than in the ifn-α group (78%). although, grade 3 and 4 metabolic alteration (hypertriglyceridemia, hyperglycemia, and hypokalemia) and cutaneous rash were more common in temsirolimus group compared with ifn-α. asthenia, pyrexia, and neutropenia were more frequent in the ifn-α group. treatment discontinuations due to adverse event were lower in temsirolimus group than ifn-α, 7% and 4 % respectively.45 hudes et al45 is the only one phase-iii randomized clinical trial that evaluated the efficacy of targeted therapy in naïve poorrisk mrcc patients. if temsirolimus cannot be administrated to poor-risk patients, the alternatives of therapy might be answered from phase-iii trial that enrolled limited number of poor-risk patients. in the avoren trial assessing efficacy of bevacizumab, the study included 54 patients from 649 patients who classified as poor risk according to mskcc risk score. sub-group analysis of patients with poor risk found that there was no significant differences between patients treated with bevacizumab and bevacizumab plus ifn-α (hr: 0.87; 95% ci: 0.48-1.56).37 the same results was reported from other studies evaluating the sunitinib for patients with poor risk group. there was no significant difference between os comparing sunitinib and ifn-α (5.3 months in sunitinib vs. 4.0 months in ifn-α; hr 0.660; 95%ci: 0.360-1.207). in conclusion, bevacizumab plus ifn-α or sunitinib might be used for poor-risk mrcc patients when temsirolimus could not be used.17 targeted therapy for metastatic non-clear cell carcinoma because of diversity in the molecular and genetic basis of non-clear cell type, the trial was performed for clear cell mrcc, might not be extrapolated to other histology type of rcc. there was no current consensus about appropriate first line treatment due to lack of level 1 evidence. targeted treatment in non-clear cell rcc focused on temsirolimus, everolimus, sorafenib, and sunitinib. i n t h e a r c c ( a d v a n c e r e n a l c e l l carcinoma) trial, temsirolimus was evaluated in 73 patients with mrcc non clear-cell type (37 randomized to temsirolimus and 36 patients to ifn-α arm).45 this study found that the differences os between temsirolimus arm and ifn-α arm were 11.6 months and 4.3 months with hr 0.49; 95% ci 0.29-0.85. they also observed that pfs was longer in temsirolimus arm than ifn-α arm with median pfs in temsirolimus arm 7.0 months vs. 1.8 months in ifn-α arm (hr 0.38, 95% ci 0.23-0.62). this study concluded that temsirolimus had clinically benefits compared to ifn-α in non-clear cell histology.46 escudier et al47 performed phase ii trial to evaluate the efficacy of other mtor inhibitor, everolimus, for treating 92 patients with metastasis non-clear cell rcc. there were 59% of patients receiving everolimus that had nonprogressing disease within 6 months. median os was 21 months and median pfs was 7.6 months with grade ≥3 adverse events including asthenia (10.9%), fatigue (5.4%), and anemia (5.4%). the espn (everolimus versus sunitinib prospective evaluation in metastatic non-clear cell renal cell carcinoma) trial conducted andika afriansyah acta med indones-indones j intern med 344 by tannir et al48 was performed to evaluate the efficacy of everolimus or sunitinib to treat metastatic non-clear rcc. this study was multicenter randomized clinical trial with cross over design and used pfs as primary outcome. the study reported that os and pfs showed advantage of sunitinib group compared with everolimus (16.2 months vs. 14.9 months; p=0.01, and 6.1 months vs. 4.1 months; p=0.25, respectively). investigational agents with the advancement of knowledge of the molecular mechanism about rcc, several agents of new-targeted treatment were being developed for improving the survival of mrcc patients.49,50 recently, the majority of phase ii or phase iii clinical trial included vegf inhibition as mechanism of action to inhibit tumor progression. resistance to inhibition of vegf was being suggested as a reason for tumor progression after therapy of vegf inhibitor, and dual (or multiple) pathway inhibition was being developed for overcoming resistance to vegf.51 lenvatinib, an agent that inhibit both vegfr and fgfr, has been granted by food and drug administration (fda) as a potential treatment of advance rcc based on phase ii clinical trial conducted by motzer et al.52 lenvatinib monotherapy showed improvement of median pfs by 39% compared with everolimus (hr 0.61; 95% ci 0.38-0.98; p =0.048). os analysis showed better outcome in the combination of lenvatinib and everolimus compared with everolimus monotherapy.53 in the past decade, immunotherapy has been less studied due to the extensive development of vegfand mtordirected therapy. however, enthusiasm has been directed to immune surveillance due to dramatic response of anti pd-1 antibody in the patient of rcc.54 nivolumab was the most extensively studied pd-1 inhibitor in mrcc. clinical phase ii trial showed a promising efficacy of nivolumab in treating mrcc patients with previous antiangiogenic treatment. we are still waiting for the recent phase iii trial which comparing between nivolumab and everolimus in mrcc patient with previously treated by systemic therapy.55,56 cabozantinib, a tki with potent activity against met gene and vegfr 2 receptors, has showed clinical benefits in patients with advanced clear-cell rcc in a single arm trial. phase iii meteor (cabozantinib vs. everolimus in subjects with metastatic renal cell carcinoma) trial evaluated the efficacy of 60 mg cabozantinib compared with 10 mg temsirolimus, yet this trial is still on going.57 other, several clinical trials of phase ii or iii such as ags-003 (autologous dendritic cell immunotherapy) and mpdl3280a (an engineered anti-pdl1 antibody) are still in progress.58,59 conclusion the development of targeted therapy has significantly improved the perspective of mrcc treatment. sunitinib, pazopanib, and bevacizumab have demonstrated significant improvement of pfs as a first line targeted therapy in metastatic clear cell type rcc patients with favorableand intermediaterisk category. clear cell mrcc patients with favorableand intermediate-risk category who progressed after prior cytokine therapy, sorafenib, axitinib, and pazopanib showed improvement of pfs. there was no difference on prolonged pfs and os between sequential therapies. temsirolimus showed benefit in prolonged pfs and os in clear-cell poor risk category and non-clear cell mrcc. several new drugs are still being investigated and waiting for the results of phase ii or iii clinical trial. references 1. parkin dm, bray f, ferlay j, et al. global cancer statistics, 2002. ca cancer j clin. 2005;55(2):74-108. 2. ferlay j, shin hr, bray f, et al. estimates of worldwide burden of cancer in 2008: globocan 2008. int j cancer. 2010;127(12):2893-917. 3. ljungberg b, campbell sc, choi hy, et al. the epidemiology of renal cell carcinoma. eur urol. 2011;60(4):615-21. 4. gupta k, miller jd, li jz, et al. epidemiologic and socioeconomic burden of metastatic renal cell carcinoma (mrcc): a literature review. cancer treat rev. 2008;34(3):193-205. 5. ferlay j, parkin dm, steliarova-foucher e. estimates of cancer incidence and mortality in europe in 2008. eur j cancer. 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pazopanib versus sunitinib in patients with metastatic renal cell carcinoma: pisces study. j clin oncol. 2014;32(14):1412-8. 40. mills ej, rachlis b, o’regan c, et al. metastatic renal cell cancer treatments: an indirect comparison metaanalysis. bmc cancer. 2009;9:34. 41. motzer rj, escudier b, oudard s, et al. phase 3 trial of everolimus for metastatic renal cell carcinoma : final results and analysis of prognostic factors. cancer. 2010;116(18):4256-65. 42. hutson te, escudier b, esteban e, et al. randomized phase iii trial of temsirolimus versus sorafenib as second-line therapy after sunitinib in patients with metastatic renal cell carcinoma. j clin oncol. 2014;32(8):760-7. 43. eichelberg c, vervenne wl, de santis m, et al. switch: a randomised, sequential, open-label study to evaluate the efficacy and safety of sorafenibsunitinib versus sunitinib-sorafenib in the treatment of metastatic renal cell cancer. eur urol. 2015;doi: 10.1016/j.eururo.2015.04.017. 44. motzer rj, barrios ch, kim tm, et al. phase ii randomized trial comparing sequential first-line everolimus and second-line sunitinib versus firstline sunitinib and second-line everolimus in patients with metastatic renal cell carcinoma. j clin oncol. 2014;32(25):2765-72. 45. hudes g, carducci m, tomczak p, et al. temsirolimus, interferon alfa, or both for advanced renal-cell carcinoma. n engl j med. 2007;356(22):2271-81. 46. dutcher jp, de souza p, mcdermott d, et al. effect of temsirolimus versus interferon-alpha on outcome of patients with advanced renal cell carcinoma of different tumor histologies. med oncol. 2009;26(2):202-9. 47. escudier bj, bracarda s, maroto rey jp, et al. openlabel, phase ii raptor study of everolimus (eve) for papillary mrcc: efficacy in type 1 and type 2 histology. asco meeting abstracts. 2014;32(4_ suppl):410. 48. tannir nm, jonasch e, altinmakas e, et al. everolimus versus sunitinib prospective evaluation in metastatic non-clear cell renal cell carcinoma (the espn trial): a 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2014;23(3):305-15. 54. pal sk, haas nb. adjuvant therapy for renal cell carcinoma: past, present, and future. oncologist. 2014;19(8):851-9. 55. motzer rj, rini bi, mcdermott df, et al. nivolumab for metastatic renal cell carcinoma: results of a randomized phase ii trial. j clin oncol. 2015;33(13):1430-7. 56. xu ky, wu s. update on the treatment of metastatic clear cell and non-clear cell renal cell carcinoma. biomark res. 2015;3:5. 57. exiles. a study of cabozantinib (xl184) vs everolimus in subjects with metastatic renal cell carcinoma (meteor). in: clinicaltrials.gov [internet] bethesda (md): national library of medicine (us). 2015 [cited 2015 sept 2] available from: https://clinicaltrials. gov/ct2/show/nct01865747 nlm identifier: nct01865747. 58. hoffmann-la roche. a phase 2 study of mpdl3280a (an engineered anti-pdl1 antibody) as monotherapy or in combination with avastin (bevacizumab) compared to sunitinib in patients with untreated advanced renal cell carcinoma. in: clinicaltrials. gov [internet]. bethesda (md): national library of medicine (us). 2015 [cited 2015 sept 1] available vol 48 • number 4 • october 2016 targeted therapy for metastatic renal cell carcinoma 347 from: http://clinicaltrials.gov/show/nct01984242 nlm identifier: nct01984242. 59. argos therapeutics. phase 3 trial of autologous dendritic cell immunotherapy (ags-003) plus standard treatment of advanced renal cell carcinoma (rcc) (adapt). in: clinicaltrials.gov [internet]. bethesda (md): national library of medicine (us). 2015 [cited 2015 sept 2] available from: https:// clinicaltrials.gov/ct2/show/nct01582672 nlm identifier: nct01582672. case report 343acta med indones indones j intern med • vol 49 • number 4 • october 2017 a rare case series of ischemic stroke following russell’s viper snake bite in india venkata k. pothukuchi1, alok kumar2, chennamsetty teja1, archana verma3 1 department of internal medicine, siddhartha medical college and government general hospital, vijayawda, andhra pradesh, india. 2 department of forensic medicine and toxicology, uttar pradesh university of medical sciences, saifai, etawah, india. 3 department of neurology, uttar pradesh university of medical sciences, saifai, etawah, india. corresponding author: prof. alok kumar, md. department of forensic medicine and toxicology, uttar pradesh university of medical sciences, saifai, etawah. 206130 (u.p.), india. email: drsalok@rediffmail.com. abstrak gigitan ular adalah masalah medis yang utama di india. di antara berbagai manifestasinya, komplikasi serebral jarang ditemukan pada literatur. terlebih lagi, stroke iskemik akibat gigitan ular cukup langka. kami melaporkan serangkaian kasus dari dua kasus serupa yang mengembangkan manifestasi neurologis setelah gigitan ular viper russell. pada pemeriksaan ct scan menunjukkan infark serebral. kemungkinan mekanisme penyebab kejadian yang mencakup koagulasi intravaskular diseminata, toksin yang diinduksi vaskulitis, dan kerusakan endotel akan dibahas pada artikel ini. kata kunci: strok iskemik, infark serebral, ular viper russell, gigitan ular. abstract snakebite is an important medical problem in india. among their various manifestations, cerebral complications are uncommonly found in literature. moreover, ischemic stroke following snake bite is quite rare. here we report a case series of two such cases that developed neurological manifestations following russell’s viper bite. on computerized tomography (ct) scan of brain; cerebral infarcts were revealed. their likely mechanisms are discussed in present study which include disseminated intravascular coagulation, toxin induced vasculitis and endothelial damage. keywords: ischemic stroke, cerebral infarct, russell′s viper, snake bite. introduction over 20,00,000 cases of snake bites are reported annually in india, among them 35,000 to 50,000 people die.1,2 russell’s viper (vipera russelli siamensis), is widely distributed and responsible for most of the fatalities of snake bite in india.2,3 its envenoming causes multiple local and systemic manifestations including severe local bite site injury, cellulitis, neuroparalysis, coagulopathy, acute kidney injury (aki), renal failure, generalized rhabdomyolysis, shock, spontaneous systemic bleeding, and hemorrhagic manifestations including pituitary and intracranial hemorrhage.3 very often, the neurological manifestations confine only to cranial nerves commonly causing ptosis and external ophthalmoplegia. only very few cases of ischemic stroke due to snake bites have been reported, suggesting the mechanisms such as toxic vasculitis causing endothelial injury leading to thrombosis, 344 venkata k. pothukuchi acta med indones-indones j intern med hypotension and hypercoagulability state.4 here, we are presenting two cases of an unusual complication, cerebral infarction following russell’s viper bite. case illustration case 1 a 70-year-old, previously healthy male was admitted in emergency department with a history of snake bite on right foot one day back, when he was walking in his garden. the offending snake was killed by his neighbors and later on identified as russell’s viper. he presented with a history of bleeding gums, blackish colored urine, decreased urine output and swollen right foot. on examination, patient was conscious and coherent but bilateral ptosis was noted without any other focal neurological deficits and bleeding manifestations. his 20 minute whole blood clot test (20 wbct) and urine albumin test was positive with raised serum creatinine (2.5 mg/ dl). patient was treated with 20 vials of antisnake venom (asv) along with repeated doses of neostigmine 0.5 mg i/m half hourly and atropine 0.6 mg i/v till ptosis was recovered. antibiotic coverage along with tetanus toxoid was also given. patient was improving but on the 4th day, he had a seizure attack followed by involuntary movement of right upper limb along with decreased power of the right upper limb and lower limb for which he was treated with levetiracetam 500 mg tablet orally twice daily. his computerized tomogram (ct) scan of the brain was taken which revealed infarct in left capsuloganglionic area (figure 1). patient was treated with clopidogrel 75 mg per day orally. power was improved and patient was later discharged on 12th day. case 2 a previously healthy male of 55 years was admitted for a snake bite on his left foot, sustained during working in his fields. the snake was later killed and identified as russell’s viper. he presented with severe pain along with two deep fang marks, erythema and edema. there were no other hemorrhagic or neurological manifestations, but twenty minute whole blood clotting test (20 minute wbct) was positive. he was immediately treated with 30ml loading dose of equine polyvalent antisnake venom (asv-asia, bharat serum and vaccines ltd.), followed by continuous intravenous administration of 30ml of anti-snake venom in normal saline. while receiving treatment, he developed ptosis, immediately 10 vials of asv was given as infusion followed by again 10 vials of asv as infusion after 1 hour along with neostigmine 0.5 mg i/m half hourly and atropine 0.6 mg i/v till improvement. tetanus toxoid was given and a course of antibiotic injection of ceftriaxone was also started. on the next day also further 5 vials of asv was given as infusion along with tapering doses of atropine and neostigmine as 20 minute wbct was still positive, which normalized on the 3rd day. however, another dose of 10 vials of asv was given on that day. initial laboratory investigations revealed that blood sugar was 100mg/dl, blood urea was 60 mg/dl, serum bilirubin was 2.3 mg/dl, serum creatinine was 1.6 mg/dl, alanine transaminase was 38 iu, aspartate transaminase was 89 iu and alkaline phosphatase was 69iu/lt. on the seventh day, patient developed left side weakness and speech disturbances. left hemiplegia and expressive aphasia was also revealed on neurological examination. brain ct scan showed acute ischemic infarcts in bilateral frontal lobes. lipid profile, electrocardiogram, and echocardiogram were normal. patient was treated with asprin and clopidogrel orally. there was remarkable improvement in the motor power and speech on discharge at the tenth day. figure 1. ct brain showing acute infarcts in left capsuloganglionic area. 345 vol 49 • number 4 • october 2017 a rare case report of russel’s viper snake bite with ischemic stroke discussion this paper describes two cases of snake bite with an atypical clinical presentation. cerebral complications, particularly ischemic complications, after snake bite are rare. very few cases of cerebral infarction resulting from a viper bite have been reported.5-7 in a study including 309 snake bite patients, mosquera, et al.5 reported cerebrovascular complications in 8 patients (2.6%) only, 7 hemorrhagic strokes and 1 ischemic stroke. bashir and jinkins reported a case in whom russell’s viper envenomation resulted in hemiplegia and aphasia, consistent with bilateral frontal lobe infarction.6 similarly; murthy, et al.7 reported a case of cerebral infarction and diffuse encephalopathy following a viper bite. viper snake venom is a complex toxin with rich components dominantly affecting hemostatic mechanisms.8 in large doses, it can cause massive intravascular coagulation leading to small and even large vessel occlusions resulting in cerebral infarction.9 toxic vasculitis caused by certain viperine species may result in thrombosis.7 bashir and jinkins6 suggested direct action of the venom on vascular endothelial cells. hemorrhagins, the complement mediated, toxic components of viperidae snake venom may result in severe vascular spasm, endothelial damage and increased vascular permeability all of which may contribute to vascular occlusion.7 hypercoagulation due to procoagulants in the venom, such as arginine, esterase and hydrolase6,7 and hyperviscosity caused by hypovolemia and hypoperfusion secondary to hypotension may also contribute to vessel occlusion. our patient had both neurological (ptosis) and hematological manifestations (20mwbct positive). some of the russell’s viper bite from south india has produced neuroparalysis with incoagulable blood.10 in india whole blood clotting time of more than 20 min is virtually diagnostic of viper bite and rules out elapid bite.10,11 systemic spontaneous bleeding and 20 minutes whole blood clotting test (20wbct) are bedside tests to know systemic envenomation in viper bite. when there is no systemic envenomation the case should be observed for 24 hrs clinically and with repeated 20wbct before discharged.10,12 the patients developed cerebral infarction after 7 days, fairly similar to a report of an adolescent who developed bilateral posterior circulation stroke after 1 week of snake bite.13 they concluded that stroke was probably due to toxic vasculitis or toxin-induced vascular spasm and endothelial damage.13 ranawaka uk et al14 stated in their article that there was no agreed time cut-off for classifying neurological manifestations into ‘‘acute’’ and ‘‘delayed. serum sickness type reactions develop in 1 to 12 days after antivenom therapy (mean 7 days). clinical features include fever, nausea, arthralgia, myalgia, arthritis, mononeuritic multiplex, recurrent urticaria, lymphadenopathy, neuritis and even encephalopathy. they usually respond to oral antihistamine.10,11 but in our case, there were no such features and patient was improved with asprin and clopidogrel. it seems that the cerebral infarction in our patients was the result of toxic vasculitis or toxin induced vascular spasm and endothelial damage as no other risk factors were present. conclusion following snake bite, emphasis should be given to the prompt diagnosis and treatment because the most important factor in determining survival following a severe envenomation is the amount of time elapsed between the bite and specific treatment. early administration of asv is essential to neutralize the maximum circulating venom before it is fixed in tissue. therefore, it should be given to cases with evidence of systemic envenomation as early as possible. references 1. david aw. guidelines for the clinical management of snake-bites in the south-east asia region. new delhi: world health organization, regional office for south east asia; 2005. p. 1-67. 2. warrell da. snake venoms in science and clinical medicine. russell’s viper: biology, venom and treatment of bites. trans r soc trop med hyg. 1989;83:732-40. 3. narang sk, paleti s, azeez asad m a, samina t. acute ischemic infarct in the middle cerebral artery territory following a russell’s viper bite. neurol india. 2009;57:479-80. 346 venkata k. pothukuchi acta med indones-indones j intern med 4. mugundhan k, thruvarutchelvan k, sivakumar s. posterior circulation stroke in young male following snake bite. j assoc physicians india. 2008;56:713-4. 5. mosquera a, idrovo la, tafur a, del brutto oh. stroke following bothrops spp. snakebite. neurology. 2003;60:1577-80. 6. bashir r, jinkins j. cerebral infarction in a young female following snake bite. stroke. 1985;16:328-30. 7. murthy jm, kishore lt, naidu ks. cerebral infarction after envenomation by viper. j comput assist tomogr. 1997;21:35-7. 8. marsh na. snake venom affecting haemostatic mechanism a consideration of their mechanism, practical applications and biological significance. blood coagul fibrinolysis. 1994;5:399-410. 9. schwartzman rj, hill jb. neurologic complications of disseminated intravascular coagulation. neurology. 1982;32:791-7. 10. biranchni narayan mohapatra, cbk mohanty, cuttack. guidelines for anti snake venom therapy. medicine update. 2010;20:426-30. 11. deshpande, rushikesh prabhakar, et al. adverse drug reaction profile of anti-snake venom in a rural tertiary care teaching hospital. j young pharmacists. 2013:5(2):41-45. 12. simpson id. snakebite management in india, the first few hours: a guide for primary care physicians. j indian med assoc. 2007;105:324-35. 13. vale thiago cardoso, leite alysson ferreira, hora priscila ribeiro da, coury marayra inês frança, silva ricardo cipriano da, teixeira antônio lúcio. bilateral posterior circulation stroke secondary to a crotalid envenomation: case report. rev soc bras med trop. 2013;46(2):255-6. 14. ranawaka uk, lalloo dg, de silva hj. neurotoxicity in snakebite-the limits of our knowledge. plos neglected tropical diseases. 2013;7(10)e2302. special article 168 acta med indones indones j intern med • vol 50 • number 2 • april 2018 comparison of deferiprone to deferasirox and deferoxamine to cardiac and hepatic t2* mri in thalassemia patients: evidence-based case report pustika a. wahidiyat, mikhael yosia, teny t. sari department of child health, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: pustika amalia wahidiyat, md., phd. division of pediatric haematology oncology, department of child health, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. pangeran diponegoro no. 71, jakarta 10430, indonesia. email: pa.wahidiyat@gmail.com. abstrak latar belakang: saat ini terdapat tiga jenis kelasi besi yang tersedia untuk pasien di indonesia: deferiprone/ dfp (dengan merk dagang ferriprox), deferasirox/dfx (dengan merk dagang exjade) and deferoxamine/dfo (dengan merk dagang desferal). tujuan dari studi ini adalah untuk melihat kelasi besi mana yang paling efisien dalam menurunkan kelebihan besi pada miokard dan hepar yang dilihat dari hasil t2* mri. metode: pencarian jurnal dengan terminologi mesh dilakukan di pubmed dan scopus. studi pada pasien thalassemia mayor di semua umur yang menggunakan monoterapi kelasi besi dan melihat efeknya pada t2* mri liver atau miokard diikutkan ke dalam analisis. penilaian dari studi yang digunakan dilakukan dengan metoda penilaian studi dari oxford’s cebm dan joana brigs institute. hasil: total 11 studi dengan jumlah total 611 sampel diikutkan dalam analisa studi ini. nilai rerata t2* mri dan (jika tersedia) nilai rerata perubahan t2* mri setelah penggunaan satu jenis kelasi besi dianalisa dari semua studi yang diikutkan. studi komparasi maupun studi individu menemukan kontrol dan peningkatan miokardiak t2* mri pada sampel menggunakan dfp, sedangkan penggunaan dfo yang taat lebih baik dalam mengontrol dan meningkatkan liver t2* mri. kesimpulan: dfp lebih superior dalam mengontrol dan menurunkan beban besi miokard (dibuktikan oleh miokardial t2* mri) sedangkan dfo memiliki kemampuan lebih baik dalam mengontrol dan menurunkan beban besi pada hepar (dibuktikan oleh liver t2* mri). studi dengan waktu observasi lebih lama dan sampel yang lebih besar dibutuhkan untuk melihat efek signifikan dfx terhadap t2* mri. kata kunci: besi, talasemia, t2* mri. abstract background: there are currently three iron chelator readily available for patients indonesia; deferiprone/ dfp (branded as ferriprox), deferasirox/dfx (branded as exjade) and deferoxamine/dfo (branded as desferal). this study aims to determine which iron chelator is the most efficient in reducing cardiac and hepatic iron overload (measured by means of t2* mri). methods: journal search with determined mesh term was done in pubmed and scopus. studies that looked upon thalassemia major patient in all ages with usage of monotherapy iron chelation and its effect on myocardial t2* mri and/or liver t2* mri was included. appraisal of studies was done using oxford’s cebm appraisal tools and joanna brigs institute critical appraisal tools. results: total of 11 studies with grand total of 611 samples were included. mean t2* mri value or (when available) mean changes in t2* mri value after usage of specific iron chelator was gained from all the studies included. comparison study and individual studies shows better control and increase of myocardial t2* mri in those vol 50 • number 2 • april 2018 comparison of deferiprone to deferasirox and deferoxamine to cardiac with dfp, and of liver t2* in those with good adherence to dfo chelation. conclusion: dfp is superior in controlling or reducing myocardial iron load (as proven by mt2* mri) and dfo had better capabilities in controlling or reducing hepatic iron load (as proven by liver t2* mri). studies with longer observation and larger samples is needed to see a significant changes of t2* mri in dfx. keywords: iron chelation, thalassemia, t2* mri. introduction iron overload (hemochromatosis) is a condition of excess iron accumulation in the body from any cause, one of them being repeated blood transfusions.1 in patients who needs frequent and/or continuous blood transfusion (e.g. sickle cell anaemia, thalassemia, aplastic anaemia, leukaemia, etc), excess iron from donor blood accumulate and in time manifest itself into transfusional hemosiderosis in which iron accumulates in the liver, heart and endocrine organs causing clinical syndromes such as cardiomyopathy, diabetes and hepatic cirrhosis. in order to prevent manifestation of excess iron into diseases, iron chelator had long been used. there are currently three different types of iron chelator readily available for patients indonesia; deferiprone/dfp (branded as ferriprox), deferasirox/dfx (branded as exjade) and deferoxamine/dfo (branded as desferal). each of the three chelator offers different benefits and challenges to the patients; dfp comes in tablet (500 mg/tab) or syrup (100mg/ml) which makes it easier for children to consume, dfx are also available in 250 and 500 mg/tablet form, dfo is the first iron chelator available for use in rscm but it can only be administered via subcutaneous (sc) or intravenous (iv) injection thus explaining its unpopularity and low compliance.2 there are different means of assessing iron overload in patients; simple blood examination (total iron binding capacity/tibc, serum iron/ si, transferrin saturation/ts and serum ferritin/ sf) and radiology (t2* mri). as a more reliable mean to predict iron overload in organ (especially heart and liver), t2* mri had been meticulously used to assess hemosiderosis and whether dose adjustment or combination iron chelation therapy is needed.2 there are studies available that assess the benefits of all different iron chelator; luangasanatip et al1 and pepe et al2 both uses quality adjusted life years (qaly) assessment to see economic benefits of each drugs, xia et al3 look upon serum ferritin (sf), liver iron concentration (lic), myocardial iron content (mic), left ventricular ejection fraction (lvef) and adverse events (aes) as means of assessing effectiveness of each different iron chelator. yet the question still remains, which iron chelator is the most efficient in regards to reducing cardiac and hepatic iron overload through assessment via t2* mri. clinical question 11-year-old boy with beta-thalassemia major, had been receiving continuous blood transfusion. his recent t2* mri result shows a moderate hepatic and myocardial iron load. previous doctor prescribed dfo for the last 3 years, but compliance level had been very low due to the hassle of sc administration. current attending doctor decided to prescribed oral dfp with hopes that compliance level may increase and his body iron load can be controlled. the patient parents become concern with the change of iron chelator and t2* mri results, they asked whether the oral drug given is more effective compared to the sc ones their child had been using. from the case illustration, a clinical question arises: “which of the three iron chelator (dfp, dfx, dfo) is the most effective in reducing cardiac and hepatic iron load proven by means of t2* mri?” methods this review will consider all in vivo studies in human subjects of any age who suffers from thalassemia. intervention includes usage of dfp and/or dfx and/or dfo monotherapy in any dose. those on combination iron chelator aren’t 169 pustika a. wahidiyat acta med indones-indones j intern med going to be included. outcome measure wanted are t2* mri that assess both/either hepatic or cardiac iron load. all randomized control trial (rct), prospective study, retrospective study, cross-sectional study with full text available in english or indonesian since 20 years ago will be included. search strategy the initial search terms will be ‘iron chelator’, ‘mri t2*’, ‘thalassemia’, followed by proper mesh search (table 1). articles published in the following databases will be searched: pubmed and scopus. full copies of articles identified by the search, and considered to meet the inclusion criteria, based on their title, abstract and subject descriptors, will be critically appraised. results summary of the literature search process and result can be seen in figure 1. this study included 6 prospective studies, 1 randomized control trial, 1 prospective-comparative studies, 2 cross-sectional studies and 1 retrospective studies. in total, 11 studies are included with a total of 611 patients using different monotherapy of either dfp, dfo or dfx. all the studies used adhere to the criteria that is set by the table 1. search strategy and mesh term used database search terms hits selected article pubmed/scopus (“iron”[mesh terms] or “iron”[all fields]) and (“chelating agents” [pharmacological action] or “chelating agents” [mesh terms] or (“chelating” [all fields] and “agents” [all fields]) or “chelating agents” [all fields] or “chelator” [all fields]) and (“thalassemia” [all fields] or “thalassemia” [mesh terms] or “thalassemia” [all fields]) and (“magnetic resonance imaging” [mesh terms] or (“magnetic” [all fields] and “resonance” [all fields] and “imaging” [all fields]) or “magnetic resonance imaging” [all fields] or “mri” [all fields]) and t2 [all fields 140 10 figure 1. flowchart of search result 170 vol 50 • number 2 • april 2018 comparison of deferiprone to deferasirox and deferoxamine to cardiac joanna briggs institute (jbi) critical appraisal tools (for randomized control trial, cohort and cross-sectional studies – respectively appendix 1, appendix 2 and appendix 3), summary of appraisal result can be seen in table 3. breakdown for sample allocation and chelator dosage of each study present in table 2. oxford cebm appraisal of prognosis study was used to assess all of the studies, summary of the result can be seen in table 4. discussion the aim of this evidence based case report was to evaluate the effectiveness of dfo, dfp, and dfx alone in reducing hepatic and cardiac iron load (proven by means of mri t2* value) in transfusion-dependent patients with thalassemia major. table 2. summary of studies included with years of publication, age range of samples and type of chelator used in each study design years age range (years) chelator used samples (n) dose range (mg/kgbw/day) author prospective study 2013 6-29 dfx 30 25-35 ahmed et al4 prospective-comparative study 2016 5-18 dfx 17 30 gomber et al5 dfp 17 75 prospective study 2017 16-79 dfx 53 up to 40 ho et al6 prospective study 2011 6-29 dfx 30 20 increased to 35 merchant et al7 prospective study 2010 10-29 dfx 19 20 pathare et al8 prospective study 2010 13-28 dfx 101 92 pennell et al9 randomized control trial 2006 25-31 dfp 29 43 pennell et al10 dfo 32 33.6 ± 9.8 cross-sectional study 2006 19-39 dfp 18 75 pepe et al11 dfo 18 50 retrospective cohort 2011 19-41 dfp 42 72 ± 10 pepe et al12 dfo 89 30 ± 9 dfx 24 26 ± 6.3 prospective study 2013 3-19 dfp 73 79.1 ± 4.3 viprakasit et al13 cross-sectional study 2013 1-17 dfp 14 75–100 zachariah et al14 dfx 5 25–40 table 3. summary of study appraisal based on jbi appraisal checklist author design score based on appropriate jbi appraisal* overal appraisal1 2 3 4 5 6 7 8 9 10 11 12 13 ahmed et al4 prospective study y y y y y y y y y n y na na included gomber et al5 prospective study y y y n n y y y y n y na na included ho et al6 prospective study y y y n n y y y y y y na na included merchant et al7 prospective study y y y y y y y y y n y na na included pathare et al8 prospective study y y y y n y y y y n y na na included pennell et al9 rct u u y u u u y y y y y y y included pennell et al10 prospective study y y y y y y y y y y y na na included pepe et al11 cross-section y y y y n n y y na na na na na included pepe et al12 retrospective y y y n n y y y y y y na na included viprakasit et al13 prospective study y y y y y y y y y y y na na included zachariah et al14 cross-section y y y y y n n y na na na na na included *scored gained/maximum score, appropriate appraisal for either rct, cohort (prospective or retrospective) or cross-sectional study was used. rct 13 criteria, cohort 11 criteria, cross-section 8 criteria. y=yes; n=no; u=unclear; na=not applicable. 171 pustika a. wahidiyat acta med indones-indones j intern med ta bl e 4. b re ak do w n of s am pl e al lo ca tio n fo llo w ed b y va lid ity c rit er ia fu lfi lm en t a nd s tu dy im po rta nc e; b ei ng re pr es en te d by m ea n liv er a nd c ar di ac m r i t 2* re su lts p re a nd p os t c he la tio n. 9 5% c i a re in cl ud ed w he n th e da ta is a va ila bl e. c ha ng e de sc rib es th e nu m be r o f d ec re as e or in cr ea se o f m r i t 2* re su lt s tu dy a hm ed et a l4 g om be r et a l5 h o et a l6 m er ch an t et a l7 p at ha re et a l8 p en ne ll et a l9 p en ne ll et a l10 p ep e et a l11 p ep e et a l12 v ip ra ka si t et a l13 za ch ar ia h et a l14 subject to ta l ( n) 30 34 53 30 19 61 10 1 36 15 5 73 19 c on tro l/p la ce bo 0 0 0 0 0 0 0 0 0 0 0 d fp (n ) 0 17 0 0 0 29 0 18 42 73 14 d fo (n ) 0 0 0 0 0 32 0 18 89 0 0 d fx (n ) 30 17 53 30 19 0 10 1 0 24 0 5 validity c om m on p oi nt a ye s ye s ye s ye s ye s ye s ye s ye s ye s ye s ye s s uffi ci en t f ol lo w up b ye s ye s ye s ye s ye s ye s ye s ye s ye s ye s ye s b lin de d/ ob je ct iv ity c ye s ye s ye s ye s ye s ye s ye s ye s ye s ye s ye s importance ti m e fo llo w u p 18 m o 12 m o 12 m o 18 m o 18 m o 12 m o 24 m o cr os sse ct io n re tro sp ec tiv e 12 m o cr os sse ct io n c he la to r u se d d fx d fp d fx d fx d fx d fx d fp d fo d fx d fp d fo d fp d fo d fx d fp d fp d fx m ea n m r i t 2* c ar di ac (m s) p re 33 .3 0 32 .0 0 21 .9 2 23 .8 0 17 .2 0 13 .0 0 13 .3 0 11 .2 0 95 % c i 31 .8 634 .7 4 30 .0 034 .0 0 p os t 32 .3 0 31 .7 0 24 .1 0 24 .2 0 21 .5 0 16 .5 0 15 .0 0 14 .8 0 35 .0 0 27 .0 0 34 .0 0 27 .0 0 21 .0 0 37 .1 0 31 .7 0 95 % c i 30 .6 433 .9 6 29 .0 534 .3 5 c ha ng e (m s) -1 .0 0 -0 .3 0 2. 18 0. 40 4. 30 3. 50 2. 70 3. 60 pva lu e >0 .0 5 >0 .0 5 <0 .0 5 >0 .0 5 >0 .0 5 <0 .0 5 <0 .0 5 <0 .0 5 <0 .0 5 <0 .0 5 >0 .0 5 m ea n m r i t 2* li ve r ( m s) p re 1. 74 5. 40 5. 10 2. 58 95 % c i 1. 41 -2 .1 9 5. 20 -5 .6 0 4. 58 -5 .6 2 p os t 1. 76 5. 60 5. 40 3. 70 12 .0 0 6. 60 10 .9 0 5. 50 2. 93 95 % c i 1. 37 -2 .2 5 5. 34 -5 .8 6 4. 82 -5 .9 8 c ha ng e (m s) 0. 02 0. 20 0. 30 0. 35 pva lu e >0 .0 5 >0 .0 5 >0 .0 5 <0 .0 5 <0 .0 5 <0 .0 5 a pp lic ab le ye s ye s ye s ye s ye s ye s ye s ye s ye s ye s ye s le ve l o f e vi de nc e 2b 2b 2b 2b 2b 1b 2b 2b 2b 2b 2b a s am pl es a re re cr ui te d at th e sa m e po in t o f t he d is ea se p ro gr es si on ; b s am pl es ’ f ol lo w u p w er e su ffi ci en t a nd c om pl et e; c o ut co m e m ea su re s ar e bl in de d an d/ or o bj ec tiv e; m o= m on th s 172 vol 50 • number 2 • april 2018 comparison of deferiprone to deferasirox and deferoxamine to cardiac based upon study by saggar et al15, normal mri t2* range for iron deposition in several organs (namely pancreas, liver and myocardial) can be defined. in regards to myocardial t2* value; normal range is defined as >20 ms, mild to moderate as 10-20 ms while severe as <10 ms. value for hepatic iron load is defined as; normal t2* value would be >6.3 ms, mild is defined as 6.3-2.7 ms, moderate as 2.7-1.4 ms and severe <1.4 ms. these values would be used when talking about severity of siderosis for the sake of discussion in this study. myocardial t2* mri looking upon usage of dfo alone, mean mt2* value from two studies (both by pepe et al2) similarly shows 27.00 ms which can be defined as normal range of cardiac iron load. this result is very promising, considering that both study looked upon patients aged 19-41 years old where cardiac siderosis is usually already present (though not always as cardiac siderosis may be present at earlier age).16 other study that looked upon dfo is pennell’s randomized control trial, patient in this study had mild to moderate cardiac siderosis yet in the end of the study mean increase of 2.70 ms is observed in those treated with dfo. this result is in line with previous studies, namely by borna-pignatti et al17 that shows how iron-related heart disease had decreased after the introduction of dfo (with earlier therapy commencement being an important aspect). anderson et al18 shows that 3 months of continuous dfo (50-60mg/kgbw/ day) iv administration are able to normalize lvef. porter et al19, however, mentioned also that if mt2* <10 ms it would take a few years to normalize mt2* with continuous dfo infusion. dfp uses had somewhat been more preferable in many patients due to its ease of administration in oral form. five studies (gomber et al5, two of pepe et al2 studies, zachariah et al14 and pennell et al10) looked upon the effectiveness of dfp in improving mt2*. two of pepe’s studies and zachariah et al only had mean mt2* value; 35.00 ms (pepe’s cross-section), 34.00 ms (pepe’s retrospective), 37.10 ms (zachariah et al14). all of the results shows normal mt2* value, it should be noted that pepe’s studies had patient from 19 years of age – 41 years of age with pretty large sample size. zachariah had noted that his study had a limitation of low sample (with only 14 samples in dfp group). gomber et al5, curiously, saw a decrease in mt2* by -1.00 ms, though the study found that this changes is insignificant and blame this unusual result to small sample size combined with relatively short follow up time (12 months). pennell’s9 study had measurements of mt2* before and after iron chelation therapy; his sample includes patient with mild to moderate cardiac siderosis (13.00 ms) and after one year of dfp consumption significant (p-value <0.05) increase of 3.50 ms is observed. the benefits that dfp has on myocardium and cardiac function in general is in concordance with maggio et al’s20 study in which an improvement of left ventricular ejection fraction was observed in patients with dfp monotherapy. there are seven studies that looked upon the effect of dfx on mt2*, these are studies by gomber et al5, ho et al6, merchant et al7, pathare et al8, pennel et al9 (prospective study), pepe et al11 (retrospective study) and zachariah et al14. gomber et al5 looked upon those with good cardiac iron load and saw an insignificant decrease of 0.30 ms in mt2*, similar to what had been previously explained he blamed this odd results to sample size and follow up time. ho et al also looked upon patient with good cardiac iron load and saw a significant increase of 2.18 ms after 12 months of dfx. merchant et al saw an insignificant increase of 0.40 ms in patient with normal mt2*. pathare et al8 saw an insignificant increase of 4.30 ms in patient with mild-moderate mt2*, the study mentioned that more sample would probably resulted in a statistically significant value. pennel et al9,10 looked upon patient with mild-moderate mt2* and found a significant increase of 3.60 ms. pepe et al11 and zachariah et al14 only had mean mt2* value of those with dfx chelator (respectively, 21.00 ms and 31.70 ms), both studies found good mt2* mri value in all patients with dfx chelator. there are five studies present with direct comparison between two or more chelators and these are studies done by gomber et al5, pennell et al9,10, both studies by pepe et al11,12, and zachariah et al14. gomber et al5 compares dfp and dfx, results of his studies shows an 173 pustika a. wahidiyat acta med indones-indones j intern med insignificant decrease (increase in iron load) in mt2* mri for both dfp and dfx group (-1.00 ms and -0.30 ms respectively), though this study mentioned a somewhat lower decrease in dfx group, the result is insignificant due to very small sample size. pennell et al9,10 randomized control trial looked upon dfp and dfo use for 12 months and found a significant increase more favourable in those with dfp (increase of 3.50 ms compared to 2.70 ms), the study recommended a dose of around 90-100 mg/ kgbw/day in order to continually improve cardiac function (judged by increase in t2* mri). pepe et al9 cross sectional study found that mean t2* mri is more favourable in those with continuous dfp usage (35.00 ms) compared to those with dfo infusion (27.00 ms). this result is similar to mechanism of dfp that is mentioned by piga et al21, in this study dfp is deemed to be more effective in removing myocardial iron load due to its 10 fold higher capabilities in removing citrate bound iron (an important component of non-transferin-bound iron/ntbi, a major contributor of iron damage). previous effect is compounded by the fact that dfp has longer half-life and more frequent dosing (3 times/day, 7 day/week) resulting in more iron protection compared to dfo (8-12 hour/day, 5-7 times per week). pepe et al12 retrospective study looked upon mean mt2* mri result on patients with all three different chelators with dfp having significantly higher mean mt2* value (34.00 ms) followed by dfo (27.00 ms) and dfx (21.00 ms) resonating the results of previous studies. zachariah et al14 further support the trend that dfp patients seems to have higher mt2* (37.10 ms compared to 31.70 ms in dfx patient) which correlates with increase in patient’s cardiac function. in comparison to both dfx and dfo, dfp seems to be superior in removing iron from the myocardium due to several possible reasons; its higher capability to mobilize ntbi, longer time available in the blood stream. as studied and mentioned by anderson et al18, dfp also had a smaller molecular weight, though this means that the iron-chelator complex is somewhat less stable, it allows dfp to penetrates easier into cells thus allowing removal of more iron from the myocardium. liver t2* mri two studies both by pepe et al looked upon the effect of dfo on liver t2* mri value, with both study showing good mean mri t2* value (12.00 ms and 10.90 ms). these observations are resonated by several studies, such as those by brittenham et al and cappelini et al24, in which usage of dfo infusion at a dose of around 37 mg/ kgbb/day is enough to stabilize or even reduced lic (liver iron content). three studies, two by pepe et al12 and one by viprakasit et al13, looked upon the mean liver t2* in patient with dfp chelator. both study done by pepe et al12 only presented mean liver t2* at one point in time with both showing mild siderosis in group with dfp chelation (3.70 ms in the cross-sectional study and 6.00 ms in the retrospective study). viprakasit et al13 study showed more favourable result with an increase 0.35 ms after one year of dfp consumption in patient with moderate hepatic siderosis. an older study by fischer et al25 shows also that negative iron balance by means of lic can only be achieved in 1/3 of the patient using 75 mg/ kgbw/day of dfp. three studies by ahmed et al4, gomber et al5 and pepe et al11 looked upon dfx effect on liver t2* value. ahmed et al4 looked upon patient with moderate to severe liver t2* mri and found an insignificant increase of 0.02 ms after 18 months of dfx administration. gomber et al5 looked upon patient with mild liver t2* mri and also found and insignificant increase of 0.30 after 12 months of dfx administration. pepe et al11 on the other hand looked upon mean liver t2* mri in patient that had been consuming dfx and found a value of 5.50 (mild liver t2* mri). this results resonates previous studies by cappellini et al24 who mentioned that only moderate reduction of lic present in children under 6 years with average dose of 21.9 mg/kgbw/day. studies done by gomber et al5, and two studies by pepe et al11 compares mean liver t2* value between different chelators. gomber et al5 compares liver t2* value after 12 months of dfp or dfx, the study found insignificant change of 0.20 ms and 0.30 ms respectively in patient with mild liver siderosis. in pepe et al’s crosssectional present only mean liver t2* value, 174 vol 50 • number 2 • april 2018 comparison of deferiprone to deferasirox and deferoxamine to cardiac 3.70 ms (mild siderosis) in group with dfp and 12.00 ms (normal) in those with dfo. pepe et al’s retrospective study resonates similar result (in regards to effectiveness and normal liver t2* in those with dfp); patient with dfo had mean liver t2* value of 10.90 ms (normal liver t2*), those with dfp had 6.60 ms (borderline normal t2*), and patient with dfx with 5.50 ms (mild siderosis). through these comparisons alone, it can be seen that patient with treatment of dfo had better mean liver t2* mri and good improvement after continuous administration of either intravenous or subcutaneous dfo. looking back upon the aforementioned studies by cappellini et al24 and britenham et al23, it can be seen that dfo do have superior capability of controlling and even reducing liver iron. though it should always be taken into consideration that adherence to dfo therapy can sometimes be challenging to patient; as had been mentioned by viprakasit et al13, pennell et al10 whilst olivieri et al26 found that compliance of oral chelation (dfp) can reach 95% while those with intravenous chelation (dfo) can only reach 72% compliance rate. conclusion through analysis done in this study it can be seen that dfp is superior in controlling or reducing myocardial iron load (as proven by mt2* mri) and dfo had better capabilities in controlling hepatic iron load (as proven by liver t2* mri). usage of dfp or dfx, as oral chelator) is more preferable due to its ease of use, with several studies presenting higher compliance rate in patient with oral chelator compared to injection (sc or iv) chelator. studies with longer observation and larger samples is needed to see a significant changes of t2* mri in dfx. acknowledgments authors of these study would like to thank fellow doctors and faculty of medicine – cipto mangunkusumo hospital for their support. references 1. luangasanatip n, chaiyakunapruk n, upakdee n, wong p. iron-chelating therapies in a transfusiondependent thalassaemia population in thailand: a cost-effectiveness study. clin drug investig. 2011;31(7):493-505. 2. pepe a, rossi g, bentley a, et al. cost-utility analysis of three iron chelators used in monotherapy for the treatment of chronic iron overload in beta-thalassaemia major patients: an italian perspective. clin drug investig; 2017. 3. xia s, zhang w, huang l, jiang h. comparative efficacy and safety of deferoxamine, deferiprone and deferasirox on severe thalassemia: a meta-analysis of 16 randomized controlled trials. plos one. 2013;8(12):e82662. 4. ahmed j, ahmad n, jankharia b, krishnan p, merchant rh. effect of deferasirox chelation on liver iron and total body iron concentration. indian j pediatrics. 2013;80(8):655-8. 5. gomber s, jain p, sharma s, narang m. comparative efficacy and safety of oral iron chelators and their novel combination in children with thalassemia. indian j pediatrics. 2016;53(3):207-10. 6. ho pj, tay l, teo j, et al. cardiac iron load and function in transfused patients treated with deferasirox (the mile study). eur j haematol. 2017;98(2):97-105. 7. merchant r, ahmed j, krishnan p, jankharia b. efficacy and safety of deferasirox for reducing total body and cardiac iron in thalassemia. indian j pediatrics. 2012;49(4):281-5. 8. pathare a, taher a, daar s. deferasirox (exjade) significantly improves cardiac t2* in heavily ironoverloaded patients with beta-thalassemia major. ann hematol. 2010;89(4):405-9. 9. pennell dj, porter jb, cappellini md, et al. continued improvement in myocardial t2* over two years of deferasirox therapy in beta-thalassemia major patients with cardiac iron overload. haematologica. 2011;96(1):48-54. 10. pennell dj, berdoukas v, karagiorga m, ladis v, piga a, aessopos a, gotsis ed, tanner ma, smith gc, westwood ma, wonke b. randomized controlled trial of deferiprone or deferoxamine in beta-thalassemia major patients with asymptomatic myocardial siderosis. blood. 2006;107(9):3738-44. 11. pepe a, lombardi m, positano v, et al. evaluation of the efficacy of oral deferiprone in beta-thalassemia major by multislice multiecho t2*. eur j haematol. 2006;76(3):183-92. 12. pepe a, meloni a, capra m, et al. deferasirox, deferiprone and desferrioxamine treatment in thalassemia major patients: cardiac iron and function comparison determined by quantitative magnetic resonance imaging. haematologica. 2011;96(1):41-7. 175 pustika a. wahidiyat acta med indones-indones j intern med 13. viprakasit v, nuchprayoon i, chuansumrit a, et al. deferiprone (gpo-l-one((r)) ) monotherapy reduces iron overload in transfusion-dependent thalassemias: 1-year results from a multicenter prospective, single arm, open label, dose escalating phase iii pediatric study (gpo-l-one; a001) from thailand. am j hematol. 2013;88(4):251-60. 14. zachariah m, tony s, bashir w, al rawas a, wali y, pathare a. comparative assessment of deferiprone and deferasirox in thalassemia major patients in the first two decades-single centre experience. pediatric hematol oncol. 2013;30(2):104-12. 15. saggar k, sobti p. mri assessment of iron overload in thalassemia: an overview. rivista italiana di medicina dell’adolescenza-volume. 2013;11(1). 16. ambati sr, randolph r, mennitt k, kleinert da, giardina p. monitoring cardiac siderosis in patients with beta-thalassemia major on various chelation regimens. blood. 2011;118(21):3177. 17. borgna-pignatti ca, rugolotto si, de stefano p, zhao hu, cappellini md, del vecchio gc, romeo ma, forni gl, gamberini mr, ghilardi ro, piga an. survival and complications in patients with thalassemia major treated with transfusion and deferoxamine. haematologica. 2004;89(10):1187-93. 18. anderson lj, westwood ma, holden s, davis b, prescott e, wonke b, porter jb, malcolm walker j, pennell dj. myocardial iron clearance during reversal of siderotic cardiomyopathy with intravenous desferrioxamine: a prospective study using t2* cardiovascular magnetic resonance. british j haematol. 2004;127(3):348-55. 19. porter jb, tanner ma, pennell dj, eleftheriou p. improved myocardial t2* in transfusion dependent anemias receiving icl670 (deferasirox). blood. 2005;106(11):3600. 20. maggio a, vitrano a, lucania g, capra m, cuccia l, gagliardotto f, pitrolo l, prossomariti l, filosa a, caruso v, gerardi c. long‐term use of deferiprone significantly enhances left‐ventricular ejection function in thalassemia major patients. am j hematol. 2012;87(7):732-3. 21. piga a, gaglioti c, fogliacco e, tricta f. comparative effects of deferiprone and deferoxamine on survival and cardiac disease in patients with thalassemia major: a retrospective analysis. haematologica. 2003;88(5):489-96. 22. anderson lj, wonke b, prescott e, holden s, walker jm, pennell dj. comparison of effects of oral deferiprone and subcutaneous desferrioxamine on myocardial iron concentrations and ventricular function in beta-thalassaemia. lancet. 2002;360(9332):516-20. 23. brittenham gm, cohen ar, mclaren ce, martin mb, griffith pm, nienhuis aw, young ns, allen cj, farrell de, harris jw. hepatic iron stores and plasma ferritin concentration in patients with sickle cell anemia and thalassemia major. am j hematol. 1993;42(1):81-5. 24. cappellini md, bejaoui m, agaoglu l, porter j, coates t, jeng m, lai me, mangiagli a, strauss g, girot r, watman n. prospective evaluation of patientreported outcomes during treatment with deferasirox or deferoxamine for iron overload in patients with β-thalassemia. clinical therapeutics. 2007;29(5):90917. 25. fisher r. large-scale study in thalassemia using biomagnetic liver susceptometry. inproc. 11th int. conf/biomagnetism 1998. 26. olivieri nf, brittenham gm. final results of the randomized trial of deferiprone (l1) and deferoxamine (dfo). inblood 1997;90(10):1161. 176 case report 338 acta med indones indones j intern med • vol 51 • number 4 • october 2019 “fleshy” skin cellulitis: a triggering factor for anca associated vasculitis sim chun yang1, ruslinda mustafar2, lydia kamaruzaman2, kong wei yen2, rozita mohd2, rizna cader2 1 department of medicine, universiti kebangsaan malaysia medical centre (ukmmc), malaysia. 2 nephrology unit, department of medicine, universiti kebangsaan malaysia medical centre (ukmmc), malaysia. corresponding author: ruslinda mustafar. consultant nephrologist and physician. nephrology unit, department of medicine, universiti kebangsaan malaysia medical centre (ukmmc). jalan yaacob latiff, 56000 cheras, kuala lumpur, malaysia. email: ruslinda.m@gmail.com. abstrak seorang wanita usia 59 tahun dengan hipotiroidisme dermatitis kontak akut berkembang menjadi selulitis dengan infeksi bakteri superimposed dan cedera ginjal akut. dia merespons penatalaksanaan awal dengan antibiotik, namun seminggu kemudian mengalami vaskulitis kulit dan sistemik. biopsi kulit konsisten dengan vaskulitis leuko-sitoklastik yang dimediasi imun dan hasil tes darah positif antibodi sitoplasma-anti-neutrofil sitoplasma (c-anca). diagnosis vaskulitis terkait anca ditegakkan. wanita tersebut dirawat dengan imunosupresan plasmaferesis dan dukungan hemodialisis untuk gagal ginjalnya. laporan kasus ini menunjukkan bahwa infeksi jaringan lunak dapat memicu perkembangan vaskulitis terkait anca, latar belakang hipotiroidisme berfungsi sebagai faktor predisposisi karena kedua kondisi tersebut dilaporkan secara terpisah dalam beberapa studi kasus sebelumnya. kata kunci: selulitis, anti-neutrophil cytoplasmic antibodi, vaskulitis. abstract a 59-year-old lady with underlying hypothyroidism presented with acute contact dermatitis progressed to cellulitis with superimposed bacterial infection and acute kidney injury. she responded to initial management with antibiotics, but a week later, she had cutaneous and systemic vasculitis. her skin biopsy consistent with immune-mediated leuko-cytoclastic vasculitis and her blood test was positive for cytoplasmic-anti-neutrophil cytoplasmic antibody (c-anca). a diagnosis of anca-associated vasculitis was made and she was treated with immunosuppressant with plasmapheresis and hemodialysis support for her kidney failure. despite aggressive measures, the patient succumbed to her illness. this case report demonstrates that soft tissue infection could trigger the development of anca-associated vasculitis whilst a background of hypothyroidism serves as a predisposing factor as both condition were reported separately in a couple of case studies before. keywords: cellulitis, anti-neutrophil cytoplasmic antibody, vasculitis. 339 vol 51 • number 4 • october 2019 fleshy skin cellulitis: a triggering factor for anca associated vasculitis introduction anca associated vasculitis (aav) is a small vessel vasculitis (svv) which is necrotizing in nature with few or no immune deposits. it is associated with myeloperoxidase (mpo)anca or proteinase 3 (pr3)-anca antibody. in literature, aav is divided into 3 main categories namely microscopic polyangiitis (mpa), granulomatosis with polyangiitis (gpa), and eosinophilic granulomatosis with polyangiitis (egpa).1 despite a better understanding of the disease, the classification of aav remains tricky because of the unknown etiology and considerable overlap in the clinical expression of these vasculitis syndromes. it is well known that all the three types of aav have common clinical presentations, including some of the non-specific inflammatory symptoms and signs such as malaise, fever, anemia, weight loss, rashes and synovitis. therefore the exact diagnosis is often elusive and complex.2 as for now, to establish the definitive diagnosis of aav warrant a collective assessment of clinical manifestations, a biopsy of the involved organ and the positivity of anca in the plasma. in view of malignant nature of untreated aav, high clinical suspicion, early recognition and management are vital to retard the progression and to prevent life-threatening complications of the disease. here, we describe a case of multi-systemic aav precipitated by soft tissue infection in a patient with underlying thyroid disease that potentially increases the likelihood of such association. case illustration a 5 9 y e a ro l d l a d y w i t h u n d e r l y i n g hypothyroidism on thyroxine replacement for 2 years, presented with bilateral feet pain for one month duration. she consulted primary healthcare and was treated with oral analgesic (meloxicam mobic®) and vitamin supplements. a week later, as her feet got worse and became erythematous, she soaked her feet in cleansing solution (dettol®) for disinfection purposes. unfortunately, her feet started to develop multiple blisters which caused her to come to our hospital. she denied any history of fever and did not receive any antibiotic prior to her admission. physical examination revealed few oral ulcers as well as blisters and erythema of both feet. she was afebrile and her vital signs were normal with blood pressure (bp) of 129/69 mmhg and pulse rate (pr) of 117 beats per minute (bpm). investigations showed a total white count of 19.9x109/l and raised c-reactive protein (crp) of 21.89 mg/dl. she had normochromic normocytic anemia with hemoglobin (hb) of 8.7 g/dl whilst her renal profile was deranged with urea of 13.0 mmol/l and creatinine of 222µmol/l. her baseline creatinine 6 months earlier was normal at 63.5µmol/l. other systemic examination and investigations were unremarkable. her lungs were clear with normal chest x-ray. she was diagnosed to have acute contact dermatitis of both feet and cellulitis with superimposed bacterial infection with nonsteroidal anti-inflammatory drugs (nsaids) (cyclo-oxygenase-2 inhibitor) induced acute kidney injury (aki). she was started on intravenous (iv) ampicillin-sulbactam, potassium permanganate soak of her feet twice a day and oral prednisolone of 20 mg daily with tapering every 3 days. her serum creatinine peaked at 242.9 µmol/l. she completed a week of antibiotic, her feet and kidney function improved whilst her serum creatinine upon discharge was 198µmol/l. she was planned for clinic review and given betamethasone cream with her usual thyroxine replacement of 75 µg daily. unfortunately, a week later, she was readmitted with fever and pus discharge from the wounds of her feet. physical examination showed swollen macerated feet with cracked skin and pus discharge. there were purpuric rashes found bilaterally up till her thighs. she was febrile with bp of 120/75 mmhg and pr of 110 bpm. blood investigations revealed worsening anemia with hb of 6.6 g/dl, white cell count (wcc) of 11x109/l, crp of 25 mg/ dl, severe hyponatraemia with serum sodium of 118 mmol/l, worsening aki with urea of 25.7 mmol/l and creatinine of 959 µmol/l. she has no evidence of gastro-intestinal bleed and did not take any nsaids since discharge. 340 sim chun yang acta med indones-indones j intern med she was treated for infected bullous ulcer with sepsis causing worsening aki and cutaneous vasculitis. she was started on iv piperacillintazobactam, intravenous saline hydration, packed cell transfusions and oral prednisolone of 40 mg daily. ultrasound scan of the kidneys revealed normal kidneys size with no obstruction, urinalysis showed blood 3+ and protein 2+ with urine protein creatinine index (upci) of 0.28 g/ mmol creatinine. urine phase contrast showed isomorphic red blood cells. she had a negative antinuclear antibody (ana), normal c3 level of 71.5 mg/dl and normal c4 level of 12.9 mg/dl. panel immunoglobulin level was not raised with immunoglobulin (ig) m of 20.3 mg/dl, igg 767 mg/dl, and iga 209 mg/dl while cryoglobulins were also negative. her infective screening for hepatitis b and c, human immunodeficiency virus (hiv), anti-streptolysin o titre (asot), venereal disease research laboratory (vdrl) test were all negative with negative blood and urine culture and sensitivity (c+s). meanwhile, a swab c+s of her wounds showed a mixed growth – a combination of gram-positive and gram-negative organisms. a biopsy of the vasculitis lesions from her left shin (figure 1) revealed moderate perivascular neutrophilic inflammatory infiltrates with nuclear debris over the superficial dermis, these were stained positive for c3, igg and igm on immunofluorescence study. the findings were consistent with leuko-cytoclastic vasculitis and suggestive of immune-mediated lesion. her kidney function rapidly deteriorated and she required hemodialysis (hd). a renal biopsy was planned however it was postponed due to ongoing sepsis and thrombocytopenia with platelets of 65x109/l. her immunosuppressive medication was changed to iv methylprednisolone 50 mg daily. she progressed rapidly with multi-organ involvement; acute coronary syndrome due to carditis and hepatitis. she was dialysis dependent and still suffering from on-going sepsis. due to severe organ involvement due to systemic vasculitis, she was given pulsed corticosteroid with iv methylprednisolone 150 mg daily for 3 days followed by 50 mg daily and was also given first dose of iv cyclophosphamide to treat her active disease. meanwhile, her antibiotic was escalated to iv meropenem. she received only one session of plasmapheresis as she developed severe pancytopenia post procedure with hb of 7.3 g/dl, wcc of 1.0x109/l and platelets of 36x109/l. a computed tomography (ct) scan of thorax, abdomen and pelvis was performed to look for internal malignancy which was reported as negative. a qualitative test for cytoplasmic anca (c-anca) from a private laboratory was positive whilst perinuclear anca (p-anca) was negative. from the extensive investigations, she was treated aggressively for systemic vasculitis and multi-organ failure with superimposed sepsis due to cutaneous skin infections and the final diagnosis was attributed due to aav. her clinical condition gradually improved with our aggressive measures and was given a 2nd dose of iv cyclophosphamide. unfortunately, she also suffered from severe depression from her illness needing selective serotonin re-uptake inhibitor (ssri). she and her family were given extensive counselling on the disease and eventually they opted for conservative/palliative management. she finally succumbed to her illness. discussion primary systemic vasculitis associated with anti-neutrophil cytoplasmic antibodies (anca) is one of the common causes of rapidly progressive glomerulonephritis. ancas are directed against several myeloid enzymes figure 1. skin biopsy (40 x magnifications) showing perivascular neutrophilic infiltration (arrow). 341 vol 51 • number 4 • october 2019 fleshy skin cellulitis: a triggering factor for anca associated vasculitis namely c-anca and p-anca.3 testing for anca is by enzyme-linked immunosorbent assay (elisa) where c-anca reacts with proteinase 3 (anca-pr3) whilst p-anca reacts with myeloperoxidase (anca-mpo). anca-pr3-positivity is predominantly found in patients with granulomatous polyangiitis (gpa) and microscopic polyangiitis (mpa) meanwhile anca-mpo-positivity is found in patients with mpa and eosinophilic granulomatous polyangiitis (egpa) as well as in patients with other vasculitides and auto-immune conditions.4 our patient had biopsy-proven cutaneous vasculitis lesions with rapidly declining renal function that is attributed to rapidly progressive glomerulonephritis (rpgn) as well as sepsis which required hemodialysis support. her skin biopsy was suggestive of immune-mediated vasculitis however, we were unable to proceed with a kidney biopsy as her platelets were low and her condition was unstable. her plasma c-anca was positive and when we tied up together with her clinical conditions, these have led to the diagnosis of multi-systemic aav. despite the small percentage possibility coexistent of anca and anti-gbm positivity, we did not proceed with further test even testing the anca with elisa for mpo or pr3 specificity as it was very costly and would not change much of our current management. anca-associated glomerulonephritis is classically pauci-immune in nature from the renal histopathology immunofluorescence (if) study and unfortunately, in this case, we were unable to perform the renal biopsy due to her ill condition. however, from the skin biopsy, it was stained positive for c3, igg and igm on if. in literature, there were reported cases whereby immune complex deposits were found on skin and renal biopsies in aav.5 a study by haas and eustace on 126 renal biopsies with ancaassociated or arteritis-associated necrotizing crescentic gn found that 15% had positive immunofluorescence microscopy findings for igg, 49% for igm, 57% for c3 and 8% for c1q.6 as mentioned earlier, the exact pathogenesis and the significance of immune deposits in the affecting organs remain unclear. this case perhaps also illustrates the small percentage of cases that has positive anca in the plasma and her skin biopsy showed positivity for immune complexes. this case was initially treated for acute contact dermatitis with superimposed bacterial infection causing cellulitis. although she had mixed growth in swab culture, staphylococcus aureus remains the most common organism leading to soft tissue infections in the community.7,8 the hypothesis of an infectious agent such as staphylococcus aureus triggering the immune system has been suggested before. this theory emerged based on the observation that up to 70% of patients with chronic nasal gpa are carriers of this microorganism.9,10 william et al.11 suggested role of infections as triggers for aav and he also described anti-complement antibodies in patients with pr3-anca vasculitis. these antibodies were found to react to the peptide sequences from the complementary pr3-sequence, which has similarity with a number of infectious pathogens such as staphylococcus aureus. hence, infections as triggering factors for aav is a valid argument and in our case, we hypothesis that her initial infected dermatitis as the inciting event to a fullblown multi-systemic aav. previous studies and case reports have shown the association between two autoimmune diseases occurring together either simultaneously or sequentially.12 small vessels vasculitis has been reported to be associated with other autoimmune diseases.13,14 a population-based study reported that thyroid disease was prevalent at the time of diagnosis of aav in as many as 40% of cases.14 tanaka et al.15 found 4 cases out of 10 with mpoanca positive nephropathy had hypothyroidism and two of them were subclinical. concur to the report; lai et al.16 also reported a case of aav with hashimoto’s thyroiditis in malaysia. similarly as we illustrated in this case, our patient was diagnosed to have hypothyroidism for 2 years and was put on thyroxine replacement. even though there were no investigations to determine the etiology of her hypothyroidism, it was possible the cause of her hypothyroidism is due to hashimoto’s thyroiditis or due to iodine deficiency.17 we believe this case report supports the association between aav and autoimmune thyroid diseases as suggested by previous studies. 342 sim chun yang acta med indones-indones j intern med a av i s a n i m m u n e m e d i a t e d disease; therefore its treatment involves immunosuppression to induce remission followed by maintenance therapy to prevent relapses. a multitude of treatment options can be incorporated with agents such as corticosteroid, azathioprine, methotrexate, mycophenolate mofetil, cyclophosphamide and anti cd-20 monoclonal antibody such as rituximab.18,19 therapies such as plasma exchange (pe) also can be used in combination or sequential with the immunosuppressive medications especially in cases of severe, refractory or relapsing aav.20 however, despite significant evidence-based advances in our treatment strategies, aav remains a disease with substantial mortality and morbidity with worse prognosis in the elderly and for those with severe renal involvement.21,22 conclusion this case report suggests that cellulitis could be the trigger for the development of multi-systemic aav. her background history of hypothyroidism, potentially become a risk for such development and concur with very limited case reports before. under these circumstances we need to have a high index of suspicion to detect aav earlier and administer definitive treatment as soon as possible for a better prognosis to this devastating condition. acknowledgments no author of this paper has conflict of interest. we receive no financial support for this case report. references 1. jennette jc. overview of the 2012 revised international chapel hill consensus conference nomenclature of vasculitides. clin exp nephrol. 2013;17(5):603-6. 2. mckinney ef, willcocks lc, broecker v, smith kg. the immunopathology of anca-associated vasculitis. seminars immunopathol. 2014;36(4):461-78. 3. savige j, gillis d, benson e, et al. international consensus statement on testing and reporting of antineutrophil cytoplasmic antibodies (anca). american j clin pathol. 1999;111(4):507-13. 4. schonermarck u, lamprecht p, csernok e, gross wl. prevalence and spectrum of rheumatic diseases associated with proteinase 3-antineutrophil cytoplasmic antibodies (anca) and myeloperoxidase-anca. rheumatol. 2001;40(2):178-84. 5. el-ters m, muthyala u, philipneri md, hussein fa, lentine kl. immune-complex deposits in “pauci-immune” glomerulonephritis: a case report and 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association with autoimmune thyroid disease. med j malaysia. 2014;69(2):98-100. 17. vanderpump mp. the epidemiology of thyroid disease. british med bulletin. 2011;99:39-51. 18. belaconi in, toma cl, bogdan ma. [uptodate in the management and treatment of anca-associated vasculitis]. pneumologia. 2014;63(2):78-80, 3-6. 19. hamour s, salama ad, pusey cd. management of anca-associated vasculitis: current trends and future prospects. ther clin risk manag. 2010;6:253-64. 343 vol 51 • number 4 • october 2019 fleshy skin cellulitis: a triggering factor for anca associated vasculitis 20. walters g. role of therapeutic plasmapheresis in anca-associated vasculitis. pediatric nephrol. 2016;31(2):217-25. 21. tan ja, dehghan n, chen w, xie h, esdaile jm, avina-zubieta ja. mortality in anca-associated vasculitis: ameta-analysis of observational studies. annals rheumatic dis. 2017;76(9):1566-74. 22. weiner m, goh sm, mohammad aj, et al. outcome and treatment of elderly patients with ancaassociated vasculitis. clin j am soc nephrol: cjasn. 2015;10(7):1128-35. 193 original article acta med indones indones j intern med • vol 50 • number 3 • july 2018 gallbladder wall thickening for early detection of plasma leakage in dengue infected adult patients leonard nainggolan, candra wiguna, irsan hasan, esthika dewiasty departement of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: leonard nainggolan, md, phd. division of tropical and infectious disease, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta, 10430, indonesia. email: leonard.nainggolan@ui.ac.id, leonard.golan@yahoo.com. abstrak latar belakang: kebocoran plasma didefinisikan sebagai peningkatan hematokrit ≥20% dari baseline atau penurunan pemulihan atau bukti kebocoran plasma seperti efusi pleura, asites atau hypoproteinaemia/ hypoalbuminaemia. tanda-tanda kebocoran plasma ini, pada fase awal, biasanya sulit untuk dipastikan dengan pemeriksaan fisik dan tes laboratorium di mana pasien hanya mencerminkan tingkat ringan kebocoran plasma. penelitian ini bertujuan menentukan peran penebalan dinding kandung empedu dalam mendeteksi kebocoran plasma pada fase awal infeksi dengue. metode: penelitian ini adalah suatu studi diagnostik yang dilakukan pada pasien dengue yang mengalami demam kurang dari tiga hari dengan hasil uji non-structural protein 1 antigen dengue dan rt-pcr positif. pemeriksaan laboratorium dan usg toraks dan abdomen dilakukan setiap hari mulai hari ke-3 hingga hari ke-7 demam untuk melihat adanya penebalan dinding kandung empedu dan kebocoran plasma berdasarkan kriteria who 1997 selama perawatan. hasil: dari 69 subyek penelitian yang didapat, 52,2% adalah laki-laki, rerata usia 24,2 tahun, dan 46 pasien (66,7%) mengalami infeksi dengue sekunder. pada hari ketiga demam, terdapat 37 pasien dengan penebalan dinding kandung empedu dan 30 di antaranya terbukti mengalami kebocoran plasma selama perawatan. dari 46 pasien yang mengalami kebocoran plasma, 12 di antaranya sudah menunjukkan kebocoran plasma sejak hari ketiga demam. penebalan dinding kandung empedu pada demam hari ketiga memiliki nilai sensitivitas dan spesifisitas sebesar 65% (ik 95%: 0,51-0,79) dan 70% (ik 95%: 0,51-0,88); nilai duga positif dan nilai duga negatif sebesar 81% (ik 95%: 0,68-0,94) dan 50% (ik 95%: 0,33-0,67); rasio kemungkinan positif dan negatif sebesar 2,14 (ik 95%: 1,12-4,12) dan 0,5 (ik 95%: 0,31-0,81). kesimpulan: penebalan dinding kandung empedu dapat dipergunakan untuk mendeteksi adanya kebocoran plasma pada fase awal infeksi dengue. kata kunci: kebocoran plasma, penebalan dinding kandung empedu, ultrasonografi, kriteria who 1997, dengue. abstract background: plasma leakage is defined as ≥20% elevation of hematocrit from baseline or decrease in convalescence or evidence of plasma leakage such as pleural effusion, ascites or hypoproteinaemia/ hypoalbuminaemia. these signs of plasma leakage, in the early phase, are usually difficult to ascertain by physical examination and laboratory tests where the patient is only reflecting a mild degree of plasma leakage. this study aimed to investigate whether gallbladder wall thickening (gbwt) in the early phase of the disease can be used to detect the occurrence of plasma leakage in dengue patients. methods: a diagnostic study was conducted among dengue patients. patients with fever less than 3 days, positive results of non-structural leonard nainggolan acta med indones-indones j intern med 194 protein 1 antigen dengue and rt-pcr examination were included consecutively. laboratory tests and chest and abdominal ultrasonography examination were also performed daily from day-3 to day-7 of fever to confirm the occurrence of plasma leakage using who 1997 criteria during treatment. results: there were 69 patients included in this study. male patients were found more frequently (52.2%), average age was 24.2 years, and 46 patients (66.7%) presented with secondary dengue infection. on the third day of fever, 37 patients presented with gbwt, 30 of which showed plasma leakage during treatment. out of 46 patients found to have plasma leakage during treatment, 12 patients had presented with plasma leakage on the third day of fever. sensitivity and specificity of gbwt on the third day of fever were 65% (95% ci: 0,51-0,79) and 70% (95% ci: 0.51-0.88); ppv and npv were 81% (95% ci: 0.68-0.94) and 50% (95% ci: 0.33-0.67); lr (+) and lr (-) were 2.14 (95% ci: 1.12-4.12) and 0.5 (95% ci: 0.31-0.81), respectively. conclusion: gallbladder wall thickening in the early phase of the disease can be used to detect the occurrence of plasma leakage in adult dengue infected patients. key words: plasma leakage, gallbladder wall thickening, ultrasound, who 1997 criteria, dengue. introduction dengue infection is an arbovirus disease (arthropod-borne virus) that has become a major public health concern across the world. most of these infections are asymptomatic, but infections can also show clinical manifestations ranging from flu-like illness, mild fever, myalgia, arthralgia accompanied by signs of leucopenia, rash, lymphadenopathy, thrombocytopenia and diathesis, to fatal manifestations that are characterized by hypovolemic, shock, and death.1 several studies have suggested that plasma leakage is the main hallmark in dengue pathogenesis. a complex interaction between virus, host immune response and endothelial cells likely impacts the barrier integrity and functions of endothelial cells leading to plasma leakage.2 it is important to be able to demonstrate signs of plasma leakage because this condition can lead to the loss of intravascular volume and circulatory insufficiency, shock, and death.3 early detection of plasma leakage is essential in order to improve management and decrease mortality rate in dengue infection. according to world health organization (who) 1997 criteria, plasma leakage is defined as elevation of hematocrit by ≥20% from baseline or decrease in convalescence or evidence of plasma leakage such as pleural effusion, ascites or hypoproteinaemia/hypoalbuminaemia.1 these signs of plasma leakage, in the early phase, are usually difficult to ascertain by physical examination and laboratory tests where the patient is only reflecting a mild degree of plasma leakage. several studies have demonstrated that ultrasonography is useful to detect plasma leakage signs such as gallbladder wall thickening (gbwt), ascites, and pleural effusion but unfortunately, as of now, gbwt has not been included in the who criteria. a few other studies suggest that the underlying mechanism of gallbladder wall thickening is gallbladder subserosal edema and have been said to be the most common initial ultrasound finding compared to ascites and pleural effusion.4-5 therefore the purpose of this study is to investigate whether gallbladder wall thickening in the early phase of the disease can be used to detect the occurrence of plasma leakage in adult dengue infected patients. methods this was a diagnostic study comparing the accuracy of an index test of plasma leakage in the form of gallbladder wall thickening with a reference test in the form of who 1997 criteria. this research was performed in the internal medicine ward of cipto mangunkusumo hospital from july 2011 until october 2012. this study had been approved by the ethical committee on health research, faculty of medicine universitas indonesia – cipto mangunkusumo hospital with reference number 063/pt2.fk/etik/2010. selection of research subjects the sample selection was done by consecutive sampling; inclusion and exclusion criteria were set prior to selection of trials. the inclusion vol 50 • number 3 • july 2018 gallbladder wall thickening for early detection of plasma leakage 195 criteria in this study were dengue patients with a history of fever of less than 3 days, positive result of non-structural protein 1 antigen dengue (ns1) examination, which was later confirmed by reverse transcriptase polymerase chain reaction (rt-pcr), and willing to be included in the study. exclusion criteria in this study were patients who experienced other conditions that can cause gallbladder thickening, such as patients who suffers from gallstones, gallbladder malignancy, cirrhosis, right-sided heart failure, renal failure, and pancreatitis. sample analysis variables obtained and examined during this study including laboratory tests and ultrasonography examination were performed daily from day-3 to day-7 of fever to confirm the occurrence of gbwt and plasma leakage using who 1997 criteria during treatment. signs of plasma leakage according to who 1997 criteria include ≥20% elevation of hematocrit from baseline or decrease in convalescence o r e v i d e n c e o f p l a s m a l e a k a g e s u c h a s pleural effusion, ascites or hypoproteinaemia/ hypoalbuminaemia.1 assessment of hemoglobin, hematocrit, leucocyte, and platelet levels were performed using the sysmex kx-21 hemocytometer (medical electronics, japan). ns1 dengue and dengue serological test were conducted using the sd bioline dengue duo (dengue ns1 antigen and antibody combo). rt-pcr was performed using light cycler 2.0 and its reagents. abdominal and thoracic ultrasound examination was performed using usg aloka ssd 3500 series using convex probe with the frequency of 2.5-5 mhz. this examination was performed to detect plasma leakage in the form of gallbladder thickening, ascites and pleural effusion. gallbladder wall thickness was measured by calipers between two layers of the anterior wall and detected when the thickness of the posterior wall was perpendicular to the axis and the short axis was more than 3 mm and was seen as an anechoic zone visible as a double-layered wall. the examination was done after the patient underwent fasting for 6 hours. we examined the hepatorenal pouch and retrovesicular area in a supine position for ascites. fluid present in the hepatorenal pouch was recorded as present or absent. to detect pleural effusion, longitudinal scans of the right hemithorax at the midclavicular and the midaxillary line and a transverse scan of the right upper abdominal quadrant were performed in the supine position. a longitudinal scan at the right midaxillary line in an upright position was performed after subjects were in an upright position for at least 3 minutes. the vertical dimensions of the fluid collection were determined by measuring the distance between the top of the dome of the diaphragm and the base of the lung.6 the ultrasound examination was performed by an experienced sonographer who did not know the clinical and laboratory data of the subjects examined. inspection results will be printed, recorded, and reinterpreted by another experienced sonographer. interoperator suitability was assessed with kappa >0.9. statistical analysis statistical analysis was carried out with spss statistics software version 17. univariate analysis are shown in the form of subject characteristic table. categorical variables are presented in numbers and percentages, while numerical variables are shown in the mean and standard distribution. 2x2 crosstab is then created to get a positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio. results from july 2011 to october 2012, there were 69 patients out of 72 patients with dengue infection treated at the internal medicine ward of cipto mangunkusumo hospital, who were included in the study. three patients were excluded due to a negative rt-pcr result. a total of 36 patients were men. the mean age of the subjects was 24.2 years. the majority of patients were admitted on the second day of fever. a total of 46 patients or 66.7% had secondary infections. demographic and clinical characteristics of the subjects can be seen in table 1. leonard nainggolan acta med indones-indones j intern med 196 thickening of the gallbladder wall and plasma leakage on the third day of fever, there were 37 patients presented with gbwt with a mean thickness of 3.30 mm. among these 37 patients, 30 were proved to have plasma leakage during treatment. there were 16 patients who did not experience gbwt but were proved to have plasma leakage during treatment. by using the who 1997 criteria on the third day of fever, plasma leakage was only detected in 12 patients out of the 46 patients with plasma leakage during treatment. in the following days of treatment, there were 7 additional patients with gbwt which made it 44 patients out of 69 total. 0.68-0.94), while the negative predictive value was 16/32 or of 50% (95% ci: 0.33-0.67). its positive likelihood ratio was (30/46): (7/23) or equal to 2.14 (95% ci: 1.12-4.12) while its negative likelihood ratio was (16/46): (16/23) or equal to 0.5 (95% ci: 0.31-0.81). discussion dengue fever (df) is typically a selflimiting illness with a mortality rate of <1%. contrastingly, dengue hemorrhagic fever (dhf) has a mortality rate of 2-5% with treatment but without treatment mortality rate is as high as 50%.7 the course of dengue infection is divided into three phases: febrile, critical, and recovery phases. febrile phase is characterized by rapid onset of high-grade fever associated with muscle pain, vomiting, epigastric discomfort, and headache which lasts for up to about three days. in the critical phase, usually on day 3–7 of illness, there is a significant increase of capillary permeability which leads to plasma leakage and laboratory changes. the convalescent phase which occurs after critical phase is characterized by the stop of plasma leak and concomitant reabsorption of extravasated plasma and fluids occurs. even in those with complications, if managed successfully, full recovery often occur without sequelae and develop a life-long immunity against the particular virus serotype.1,7 increased capillary permeability is the main hallmark in dengue pathogenesis that leads to plasma leakage, hemoconcentration, table 1. characteristics of study subjects variables 3rd day of fever during treatment male gender, n (%) 36 (52.2) age (years), mean (sd) 24.2 (10) 2nd day of fever on admission, n (%) 50 (72.5) secondary infection, n (%) 46 (66.7) platelet count (/µl), mean (sd) 145.130 (48.430) gallbladder wall thickness (mm), mean (sd) 3.30 (1.10) gallbladder wall thickness, n (%) 37 (53.6) 44 (63.7) hemoconcentration, n (%) 0 (0) 15 (21.7) hypoalbuminemia, n (%) 0 (0) 25 (36.2) ascites, n (%) 10 (14.5) 19 (27.5) pleural effusion, n (%) 2 (2.9) 10 (14.5) plasma leakage according to the who 1997 criteria, n (%) 12 (17.4) 46 (66.7) table 2. crosstab table of gallbladder wall thickening on the third day of fever and plasma leakage based on who 1997 criteria during treatment plasma leakage during treatment total yes no gbwt on the third day of fever yes 30 7 37 no 16 16 32 total 46 23 69 from table 2, it can be calculated that the sensitivity of thickening of gallbladder wall on the third day of fever was 30/46 or equal to 65% (95% ci: 0.51-0.79), whereas its specificity was 16/23 or 70% (95% ci: 0.51-0.88) the positive predictive value was 30/37 or 81% (95% ci: vol 50 • number 3 • july 2018 gallbladder wall thickening for early detection of plasma leakage 197 hypovolemic, shock and death, which generally occurs in critical phase.1,2,8 serial hematocrit measurements to detect hemoconcentration, as well as serum albumin levels, evidence of pleural effusions and ascites by physical examination are frequently used to identify plasma leakage but often hard to be detected. a number of factors may affect hematocrit findings, such as individual variations (e.g. age, gender, and race), absence of baseline hematocrit levels, intravenous fluid administration, and bleeding.1 the albumin level cut-off used in this study was <3.5 g/dl, while the increase of vascular permeability up to a certain point would not change the level of serum albumin and studies showed that in severe cases, level of albumin was no longer decreased.9 determining ascites and pleural effusion by clinical and physical examination are generally difficult when only small amount of fluid is present. ultrasonography (usg) is a cheap, safe, rapid and widely available non-invasive imaging modality. furthermore, ultrasonography is also a portable imaging method that can be done at patient’s bedside.11 the main advantage of ultrasonography is its high sensitivity to detect even smaller amounts (minimal) of pleural effusion, ascites, and the possibility to visualize the gallbladder wall thickening.4 the rapid resolution of gallbladder wall thickening and ascites suggests that the underlying mechanism was a transient increase in permeability rather than inflammation. gallbladder wall thickening was also seen to significantly occur during 3rd to 5th day of fever, which proves that gbwt has started to occur from the febrile phase up until the critical phase of illness.6,11 gbwt resolves fast, there are higher chance of obtaining positive findings of gbwt when ultrasound examination is performed within 5 days from the onset of fever. gallbladder wall thickening is correlated with the degree of hemoconcentration, plasma albumin, and ast levels.6 so far, gbwt has not been included in who plasma leakage criteria, therefore gbwt ultrasonography examination in the febrile phase (early phase) may be needed to detect the presence of plasma leakage, and thus, the severity of the disease before they become clinically apparent could be detected. the aim of this study was to investigate whether gallbladder wall thickening can be used to detect the occurrence of plasma leakage in the early phase of the disease. the subjects included in this study were patients admitted to the internal medicine ward of cipto mangunkusumo hospital with onset of fever less than 3 days. evidence of dengue infection was based on a positive ns1 examination which later confirmed by rt-pcr. onset of fever less than 3 days was one of the inclusion criteria and was intended to enable ultrasound examination on the third day of fever in order to have early detection of plasma leakage. in this study, male gender was slightly higher (52.2%). this gender ratio was similar with studies conducted by vedaraju et al7 with 54 males out of a total 102 patients (52.9%), while hegde et al12 reported 68 male patients versus 32 female patients (68%). in general, it is found that in dengue infection the male: female ratio is 1:1. most studies on dengue infection was investigated in children while our study was conducted in adults with the mean age of 24.2 years. this is similar with studies conducted by vedaraju et al.,7 with the most common age group reported was 20-39 years7 and nagolu et al.13 who performed a study in dengue infection with an average age of 48.9 years. in endemic areas such as jakarta, secondary infections are usually more prevalent. in this study, 46 patients (66.7%) were admitted with secondary dengue infection. this figure was greater than zulkarnain’s study of 47%, but similar to the data from jakarta (67%).13,15 by using the who 1997 criteria, on the third day of fever plasma leakage was obtained in 12 patients (17.4%), ascites in 10 patients and pleural effusion in 2 patients. among these 12 patients, 9 patients had gallbladder wall thickening on the third day of fever, and 2 patients on the fifth day of fever. only 1 patient until the end of treatment did not have gallbladder wall thickening. there was no hemoconcentration and hypoalbuminemia on the third day of fever. those findings could be explained by the fact that signs of plasma leakage by usg such as pleural and pericardial effusion, ascites, and gallbladder wall thickening leonard nainggolan acta med indones-indones j intern med 198 were detectable before changes in hematocrit level and furthermore hypoalbuminemia and hemoconcentration generally occur on day 4 to day 7 of fever.9 during treatment, plasma leakage was found in 46 patients (66.7%) using the who 1997 criteria. hemoconcentration was seen in 15 patients (21.7%) while it was seen in 21 patients (31.8%) in a study conducted by michels et al.7 the difference of these findings was due to the fact that the patients in this study had been given fluid therapy shortly after the patients were admitted to the hospital. hypoproteinemia was seen in 25 patients (36.2%) and this hypoproteinemia was similar with previous findings which occur on the fourth and fifth day of fever.9 ascites was seen in 19 patients (27.5%). in other studies, ascites was found in 78.4% of patients by oliveira et al.5 and 55% of patients by hegde et al.12 we found pleural effusion to be the least common usg finding in this study, which was found in 10 patients (14.5%). oliveira et al5 and hedge et al12 reported that pleural effusion was present in 70.3% and 47% out of all their subjects, respectively. the lower number of patients found with ascites and pleural effusion in this study might be related to the fact that the subjects in this study were adult. some researchers suspected that vascular permeability in children is more common than in adults.16 the subjects of the other studies mentioned above were children. in our study, gallbladder wall thickening on the third day of fever was found in 37 patients (53.6%) and was the most common usg finding. to the best of our knowledge, there has been no study that shows the prevalence of gallbladder thickening on the third day of fever, however, the findings of our study are in accordance with previous studies by oliveira et al12 (89.2%) and vedaraju et al7 (83.3%), which also showed gbwt as the most common usg finding. lower number of patients found with gbwt in our study was due to the fact that the ultrasound examination in this study were done at an early phase of fever that was within 3 days of the onset of the fever (febrile phase) while the ultrasound examination on the studies mentioned above were mainly done after 3 days of the onset of the fever (critical phase) where plasma leakage has occurred. the difference in antigenic strains and patient susceptibility might also have contributed for the difference in the number of incidence of gbwt findings. furthermore, the presence of gallbladder wall thickening was associated with severity of the disease. the mean thickness of the gallbladder wall in this study was 3.30 mm (1.68 to 7.35 mm). kim et al17 reported mean gallbladder wall thickness of 6.1 mm (4.0 15 mm), but the study was conducted in dengue patients with impaired renal function. other studies that examined gallbladder wall thickening in patients with dengue infection did not mention the average thickness of the gallbladder wall. this study showed that on the third day of fever, the who 1997 criteria was only able to detect 12 patients with plasma leakage. who criteria is indeed often unable to detect plasma leakage that occurs in the early phase of dengue infection. in this study, it has been demonstrated that the sensitivity and specificity of thickening of gallbladder wall on the third day of fever were 65% and 70% respectively. whereas the positive predictive value and negative predictive value were 81% and 50% respectively. its positive likelihood ratio was 2.14, while its negative likelihood ratio was 0.5. based on these findings gbwt that appears at the beginning of dengue infection was actually a good indicator of plasma leakage. the presence of gallbladder wall thickening on the third day of fever was evidence that plasma leakage occurs on the third day of fever when physical and laboratory examination had not been able to detect plasma leakage. gallbladder wall thickening in dengue often precedes other plasma leakage parameters and these findings revealed that ultrasound examination of the gallbladder wall on the third day of fever has an important role in detecting plasma leakage in the early phase of dengue infection. gallbladder wall thickening in the early phase of the disease can be used to detect the occurrence of plasma leakage in adult dengue-infected patients. the early detection of plasma leakage is expected to be able to reduce mortality rate. vol 50 • number 3 • july 2018 gallbladder wall thickening for early detection of plasma leakage 199 conclusion we have conducted a study in adult patients with dengue infection and obtained a good positive predictive value for the early detection of plasma leakage by finding gbwt using ultrasonographic examination. ultrasonographic measurement of gallbladder wall thickening is a cheap, safe, rapid and non-invasive imaging method that can be useful to detect the occurrence of plasma leakage in the early phase of dengue infection. we believe that gbwt can be relied upon as an additional criterion to support the clinical diagnosis of dengue with plasma leakage (dhf). references 1. world health organization. dengue haemorrhagic fever. revised and expanded edition. diagnosis, treatment, prevention, and control. 2nd ed. geneva; 1997. 2. basu a, chaturvedi uc. vascular endothelium: the battlefield of dengue viruses. fems immunol med microbiol. 2008;53:287-299. 3. halstead sb. dengue. lancet. 2007;370:1644-52. 4. michels m, sumardi u, de mast q, et al. the predictive diagnostic value of serial daily bedside ultrasonography for severe dengue in indonesian adults. plos negl trop dis. 2013;7(6): e2277. 5. oliveira ga, machado rc, horyat jv, et al. transient reticular gallbladder wall thickening in severe dengue fever: a reliable sign of plasma leakage. pediatr radiol. 2010;40:720-4. 6. srikiatkhachorn a, krautrachue a, ratanaprakarn w, et al. natural history of plasma leakage in dengue hemorrhagic fever: a serial ultrasonographic study. pediatr infect dis j. 2007;26:283-90. 7. vedaraju ks, kumar krv, vijayaraghavachari tv, et al. role of ultrasound in the assessment of dengue fever. int j sci stud. 2016;3(10):59-62. 8. world health organization and the special programme for research and training in tropical diseases (tdr). dengue guidelines for diagnosis, treatment, prevention, and control. new edition. 2009. 9. tatura s, kalensang p, mandei jm, et al. albumin level as a predictor of shock and recurrent shock in children with dengue hemorrhagic fever. crit care shock. 2017;20:24-9. 10. k h u r r a m m , q a y y u m w, u m a r m , e t a l . ultrasonographic pattern of plasma leak in dengue haemorrhagic fever. j pak med assoc. 2016;66:260-3. 11. venkata s, dev b, krishnan r. role of ultrasound in dengue fever. br j radiol. 2005;78:416-8. 12. hegde s, sutay nr, tinmaswala ma, et al. ultrasound evaluation of dengue dever. jmscr. 2016;03(09):753845. 13. nagolu h, papireddygari vk, reddy prv, et al. role of ultrasonography in diagnosis and evaluation of dengue fever. int j anatomy, radiol surg. 2017;6(4):ro52-6. 14. zulkarnain i. gallbladder edema in dengue hemorrhagic fever and its association with hematocrite levels and type of infections. acta med indones-indones j intern med. 2004;36(2);84-6. 15. nainggolan l. primary study of dengue infection profile in community. jakarta: faculty of medicine universitas indonesia; 2009. unpublished. 16. maihuru ata, wagenaar j, brandjs dpm, et al. dengue: an arthropod-borne disease of global importance. eur j clin microbiol infect dis. 2004;23:425-33. 17. kim yo, chun ka, choi jy, et al. sonographic evaluation of gallbladder-wall thickening in hemorrhagic fever with renal syndrome: prediction of disease severity. j clin ultrasound. 2001;29:286-9. case report 146 acta medica indonesiana the indonesian journal of internal medicine a patient with plaque type morphea mimicking systemic lupus erythematosus wardhana1, ea datau2 1 department of internal medicine, siloam international hospitals. karawaci, indonesia. 2 department of internal medicine, prof. dr. rd kandou general hospital & sitti maryam islamic hospital, manado, north sulawesi, indonesia. correspondence mail: siloam hospitals group’s ceo office, siloam hospital lippo village. 5th floor. jl. siloam no.6, karawaci, indonesia. email: wadiswas@yahoo.com abstrak morfea merupakan penyakit jaringan penyambung yang jarang dengan gambaran utama berupa penebalan dermis tanpa disertai keterlibatan organ dalam. penyakit ini juga dikenal sebagai bagian dari skleroderma terlokalisir. berdasarkan gambaran klinis dan kedalaman jaringan yang terlibat, morfea dikelompokkan ke dalam beberapa bentuk dan sekitar dua pertiga orang dewasa dengan morfea mempunyai tipe plak. produksi kolagen yang berlebihan oleh fibroblast merupakan penyebab kelainan pada morfea dan mekanisme terjadinya aktivitas fibroblast yang berlebihan ini masih belum diketahui, meskipun beberapa mekanisme pernah diajukan. morfe tipe plak biasanya bersifat ringan dan dapat sembuh dengan sendirinya. morfea tipe plak yang penampilan klinisnya menyerupai lupus eritematosus sistemik, misalnya meliputi alopesia dan ulkus mukosa di mulut, jarang dijumpai. sebuah kasus morfea tipe plak pada wanita berusia 20 tahun dibahas. pasien ini diobati dengan imunosupresan dan antioksidan local maupun sistemik. kondisi paisen membaik tanpa disertai efek samping yang berarti. kata kunci: morfea, tipe plak. abstract morphea is an uncommon connective tissue disease with the most prominent feature being thickening or fibrosis of the dermal without internal organ involvement. it is also known as a part of localized scleroderma. based on clinical presentation and depth of tissue involvement, morphea is classified into several forms, and about two thirds of adults with morphea have plaque type. overproduction of collagen production by fibroblast is the cause of abnormality in morphea, and the hyperactivity mechanism of fibroblast is still unknown, although there are several mechanisms already proposed. plaque type morphea is actually a benign and self limited. plaque type morphea that mimicking systemic lupus erythematosus in clinical appearance, such as alopecia and oral mucosal ulcers, is uncommon. a case of plaque type morphea mimicking systemic lupus erythematosus in a 20 year old woman was discussed. the patient was treated with local and systemic immunosuppressant and antioxydant. the patient’s condition is improved without any significant side effects. key words: morphea, plaque type. 147 vol 47 • number 2 • april 2015 a patient with plaque type morphea mimicking sle introduction morphea is an uncommon persistent condition in which there are areas of thickened skin and cutaneus tissue from excessive collagen deposition and one of its type is plaque type. it is also known as localized scleroderma, and it may affect adults and children. morphea includes specific condition raging from very small plaques only involving the skin to widespread disease, and it is discriminated from systemic sclerosis by its supposed no internal organ involvement.1,2 plaque type morphea is mainly involved women. adequate studies on the incidence and prevalence have not been performed. plaque type morphea also may be under-reported as a physician may be unaware of this disorder and small morphea plaques may be less often referred to a dermatologist or rheumatologist.2,3 overproduction of collagen by fibroblast in affected tissues is common in plaque type morphea, although the mechanism by which these fibroblasts are activated is unknown. possible causes of morphea are radiation, infection and vaccination, trauma, genetic factor, endothelial cell injury, immunologic (autoimmunity) and inflammatory activation, and dysregulation of collagen production. in histologic finding, there is a thickening process and homogenous collagen bundles of the skin, and since the autoimmunity is the most possible cause of plaque type morphea, there are many autoantibodies may be found in individual affected.1,2 plaque type morphea is usually a benign and self-limiting disease.1 reported below is a case of a 20-year old woman with plaque type morphea, presenting with difficulty in swallowing, ulcers on oral mucosal and tongue, face redness, loss of hair, localized upper and lower arms skin tightness and redness, and also pain on chest, and abdomen. case illustration a 20-year old woman from ternate, north mollucas, came to our clinic with chief complaint of difficulty of swallowing since 1 month ago, accompanied by painless oral mucosal ulcers. she had a routine evaluation by an internist at ternate and regularly took celecoxib, esomeprazol, and chloroquin since the doctor said that she had lupus. before she felt this complaint, she already lost her hair slowly since 2 months ago, face redness about 1 month ago, and fever because of the influenza about 2 weeks ago followed by the appearance of redness and localized, painful, and hard circular plaques on the skin, each on her right upper and lower arms. since 9 years ago, the patient had 3 episodes of pain on her joints especially on both of her figure 1. the patient’s alopecia figure 2. multiple small ulcers at the patient’s oral to laryngeal mucosa and tongue a. upper arm b. lower arm figure 3. the patient’s right arm (the black arrows show lessions). 148 wardhana acta med indones-indones j intern med feet. the pain came after she got fever, usually because of the influenza. the pain and the fever disappeared although she did not take any medication at all. in the clinic, the patient was fully conscious, blood pressure 120/80 mmhg, pulse rate 87 x/ minute regularly, respiratory rate 20 x/minute, regular and symmetrically, the body temperature 36.6°c, and the body weight 40 kg. there were redness on the patient’s face, scarring alopecia and the hair easily felt down, pale conjunctiva, loss of eyebrows and eyelashes, multiple painless small ulcers at the oral to laryngeal mucosa, and coated tongue. there was no abnormality on the chest examination. the physical examination of the abdomen revealed pain on the right upper quadrant and there was a flat, soft, and painful hepatomegaly, approximately 3 cm below arcus costae. we found the extremities were warm on palpation and no edema. there were localized, hairless, painfull, and hard circular plaques with ivory color and violaceous border, about 3 cm in diameter, each on the upper and lower right arms. the early laboratory examination already done a month before in ternate and 5 days before in manado, demonstrated her hemoglobin 9.9 g/dl, haematocrite 29.7%, wbc 9,900/µl, platelet count 238,000/µl, mcv 52 fl, mch 17.3 pg, mchc 33.3%, esr 50 mm/hr, fasting blood sugar 70 mg%, ast 103 u/l, alt 140 u/l, alkaline phosphatase 79 u/l, γgt 76 u/l, blood ureum 20 mg%, serum creatinine 0.7 mg%, widal test positive (titer anti o 1/80 and anti h 1/160), urinalysis was with in normal limits, anti-nuclear antibody (ana) negative, le test negative, and no le cell was found. electrocardiogram (ecg) dan chest x-ray were normal. based on all clinical data above, the patient was suspected to have systemic lupus erythematosus, with the differential diagnosis of dermatomyositis and plaque type morphea, and she had also anemia because of chronic disease, and reactive hepatitis because of typhoid fever and drug induced possibly because of chloroquin side effect. the patient was treated with cefixime 100 mg twice daily for the typhoid fever, topical tacrolimus for the scalp and mometasone furoate for the other parts of body, methylprednisolone tablet 4 mg one tablet three times daily for 5 days continued with twice daily for 10 days, astaxanthine capsules 4 mg twice daily, and hepatoprotector. the c-reactive protein (crp), anti hbs, total hbc, total anti hcv, total ige, asma (sma), c3 and c4 complements, anti-dsdna examinations, abdominal ultrasonography examination and consultation to dermatology department were planned. on the 15th day of the treatment, the patient returned to the clinic. she was in better condition, the difficulty of swallowing was reduced, redness on the face was starting to resolve, the ulcers at oral to laryngeal mucosa were reduced in number and size, the hair was no longer easily felt down. there were changes on circular skin plaques on her upper and lower arms, the pain was reduced, the color was turning into normal, the skin was more firm than before, and there was a skin biopsy lesion. the blood examination results were asma (sma) negative, c3 complement 108 mg/dl (n : 90-180 mg/dl), c4 complement 26 mg/dl (n : 10-40 mg/dl), anti-ds-dna 52.1 iu/ml (n: ≤ 200 iu/ml), crp 0.39 mg/dl, anti hbs < 2 iu/l (non-reactive <10), total anti hbc 2.58 (non-reactive), total anti hcv negative, and total ige 43.93 iu/ml (n: 0-100 iu/ml). abdominal ultrasonography showed nonspecific hepatomegaly. the consultation with dermatology department came with skin biopsy result at the circular plaque: atropic epidermal, lots of dermal collagen bundles, trapped eccrin glands between collagen bundles, and bundels found also at the fat tissue. the histologic findings were likely a morphea at late stage, figure 4. the patient’s chest x-ray 149 vol 47 • number 2 • april 2015 a patient with plaque type morphea mimicking sle that support the plaque type morphea in the late sclerotic stage as the diagnosis. the treatment of this patient was continued with mycophenolate mofetil 180 mg twice daily, astaxanthine capsules twice daily, and hepatoprotector. discussion m o r p h e a , a l s o k n o w n a s l o c a l i z e d scleroderma, is a disorder characterized by excessive collagen deposition leading to thickening of the dermis, subcutaneus tissues, or both. morphea typically presents between age 20 and 40 and affect women 3 times more than men.2 according to clinical presentation, morphea is devided into 3 types: plaque morphea, linear scleroderma, and generalized morphea.4 the most frequent type of morphea is the plaque type (78.8%). the estimated incidence rate of morphea is 27 new cases per million population per year.2 in this case, the patient is a 20 year old woman and from clinical presentation she had plaque morphea type. many mechanisms are proposed to explain the induction of morphea. autoimmune mechanisms are considered to play an important role, and infection is considered to be the trigger factor figure 5. ultrasonography of the patient’s abdomen figure 6. the histologic findings of the skin biopsy at the lession 150 wardhana acta med indones-indones j intern med of morphea.1 the immune system responses to autoantigens are induced by cryptic self-epitops that are generated by modification of the selfantigens during apoptosis.5 the clinical presentation of patients with plaque type morphea varies depending on the level of tissue involvement and extend of the lesion. in general, we may find scalp alopecia, loss of eyebrows and eyelashes, nail dystrophy, restricted respiration if there is extensive truncal morphea, restricted mobility, contractures, and deformity, muscle weakness if there is peripheral nerves involvement, ptosis, extraocular muscle dysfunction, anterior uveitis, episcleritis, glaucoma, xerophthalmia, keratitis, altered dentition, malocclusion, and asymmetry of the tongue.1 the plaque type of morphea is the most common and the lessions are relatively superficial, primarily involving the dermis.1 plaque-type morphea lesions are characterized as circular, indurated palques that range from 1 cm to more than 20 cm in diameter. they often begins as erythematous to violaceous patches or slightly edematous plaques. with the disease progression, sclerosis develops centrally as the lesions undergo peripheral expansion. the surface become smooth and shiny over time, with loss of hair follicles and sweat glands. the margins are often surrounded by a zone of violaceous color or telengiectasias. over a period of months to years, the skin softens and the dermis becomes atrophic.1,2,6 in this patient, we found the patient had scalp alopecia, loss of eyebrows and eyelashes, and 2 plaque type morphea lesions, about 3 cm in diameter, each on the upper and lower right arms. on the additional examination in the patients with plaque type morphea, there are several blood parameters and also the histology examination of skin biopsy and other additional examinations. to make sure that there is no internal organs involvement, beside the routine blood parameters, the liver and kiney function should be measured and the ecg and chest x-ray should be done.1,2 several studies have shown increased levels of anti nuclear antibody, rheumatoid factor, anti-single-stranded dna antibodies, anticentromer antibody, antibodies to th/to ribonucleoprotein, antihistone antibody, anti-topoisomerase ii antibody, circulating intercellular adhesion mollecule-1 (icam-1), soluble vascular cell adhesion mollecule-1 (svcam-1), e-selectin, soluble cd4, cd8, cd23, and fibrogenic t-helper 2 cytokines such as interleukin (il)-4, il-6, and transforming growth factor-beta (tgf-β) in the patients with plaque type morphea, and anti-cu/zn-superoxide dismutase antibodies.7-13 these cytokines recruit eosinophils and other inflammatory cells, induce fibroblast to synthesize excessive collagen and connective-tissue growth factor which enchances and perpetuates the fibrotic effect of tgf-β.14 among those serum autoantibodies, antitopoisomerase 2-alpha is one of the major autoantibodies in localized scleroderma.4 histologic findings of the skin biopsy from the patients with plaque type morphea in the early inflammatory stage, the epidermis is flattened and athrophic with loss of the rete ridges. there is dermal edema and the collagen fibrils become eosinophylic. there is a perivascular infiltrate of lymphocytes, plasma cells or macrophages.1 in the late sclerotic stage, the inflammatory infiltrate typically disappears. collagen bundles in the reticular dermis and subcutis become thick, closely packed, and deeply eosinophylic. atrophic eccrine glands appear to be trapped within the middle of the thickened dermis as subcutaneus fat is replaced by collagen. a paucity of blood vessels is seen and the dermal appendages are lost.1,2,6 the patient in this case gave a clinical p r e s e n t a t i o n m i m i c k i n g s y s t e m i c l u p u s erythematosus but did not give any positive results in autoantibody measurements. the histologic findings supported the diagnosis as late sclerotic stage of plaque type morphea. the possibility of the autoantibody measurements did not give any positive results was the morphea was in the late sclerotic stage. we did not measure all the autoantibodies mentioned above because not all of them were available. anemia was possibly caused from chronic disease, and the increase of liver function was possibly from reactive hepatitis because of typhoid fever and the side effects of chloroquine. chloroquine can form higly reactive radicals, the hydroperoxides, which can cause hepatotoxicity.15 reactive hepatitis 151 vol 47 • number 2 • april 2015 a patient with plaque type morphea mimicking sle because of typhoid fever may happen in people with malnutrition and weakness of the immune system.16 the treament of morphea is difficult and only a few controlled clinical trials have been published. there are 2 kinds of therapy, the topical and systemic therapies. 16 the topical therapies are the ultra-potent topical steroids cream in superficial active lessions to reduce inflammation, tacrolimus to inhibit t cells activation, vitamin d derivatives inhibit proliferation of fibroblast lead to softening and repigmentation of morphea lession, phototherapy using puva and uva-1 will induce matrix metallo proteinase that reduces the procollagen in the skin.17-19 the systemic therapies are immunosuppression using the combination of methotrexate and corticosteroids, penicillin and penicillamine, oral vitamin d derivatives, mycophenolate mofetil which inhibits inosine mohophosphate dehydrogenase, an enzyme for controlling the novo purine synthesis used by proliferating lymphocytes, and vitamin a derivatives which inhibits tgf-β.20-22 this patient got cefixime 100 mg twice daily for the typhoid fever, mometasone furoate, methylprednisolone tablet 4 mg one tablet three times daily for 5 days continued with twice daily for 10 days then changed with mycofenolate mofetil 180 mg twice daily for the next 15 days, astaxanthine capsules 4 mg twice daily as antioxydant, and hepatoprotector. the prognosis of the plaque type morphea improved spontaneously within 3-5 years although it may last as long as 25 years, but atropy, induration and pigment changes may persist.6,23 the patient in this case had a good prognosis because of the significant clinical improvements to the therapies given. conclusion a case of plaque type morphea in a 20 year old woman has been discussed. the patient was diagnosed with plaque type morphea, anemia because of chronic disease, and reactive hepatitis hepatitis because of typhoid fever and drug induced possibly because of chloroquin side effect. the management of this patient were cefixime 100 mg twice daily for her typhoid fever, topical tacrolimus for the scalp and mometasone furoate for other parts of the body, methylprednisolone tablet 4 mg one tablet three times daily for 5 days continued with twice daily for 10 days then changed with mycophenolate mofetil 180 mg twice daily, astaxanthine capsules mg twice daily as antioxydant, and hepatoprotector. significant improvements were observed. the prognosis of this patient is good. references 1. rocken m, ghoreschi k. morphea and lichen sclerosus. in: bolognia jl, jorizzo jl, rapini rp, eds. dermatology. 1st ed. philadelphia: mosby; 2003. p. 1503-17. 2. james dw, berger tg, elston dm. connective tissue diseases. philadelphia: saunders elsevier; 2006. p. 171-6. 3. toledano c, rabhi s, kettaneh a, et al. localized scleroderma: a series of 52 patients. eur j intern med. 2000;20(3):331-6. 4. takehara k, sato s. localized scleroderma is an autoimmune disorder. rheumatol. 2005;44:274-9. 5. hayakawa i, hasegawa m, takehara k, sato s. antidna topoisomerase iiα autoantibodies in localized scleroderma. arthritis rheum. 2004;50(1):227-32. 6. docrat me. morphea (localized scleroderma). curr allergy clin immunol. 2006;19(4):192-4. 7. ruffatti a, peserica a, glorioso s, et al. anticentromere antibody in localized scleroderma. j am acad dermatol. 1986;15(4 pt 1):637-42. 8. yamane k, ihn h, kubo m, et al. antibodies to th/to ribonucleoprotein in patients with localized scleroderma. rheumatol (oxford). 2001;40(6):683-6. 9. yamane k, ihn h, kubo m, er al. increased serum levels of soluble vascular cell adhesion molecule 1 and e-selectin in patients with localized scleroderma. j am acad dermatol. 2000;42(1 pt 1):64-9. 10. ihn h, fujimoto m, sato s, et al. increased levels of circulating intercellular adhesion molecule-1 in patients with localized scleroderma. j am acad dermatol. 1994;31(4):591-5. 11. sato s, fujimoto m, kikuchi k, et al. soluble cd4 and cs8 in serum from patients with localized scleroderma. arch dermatol res. 1996;288(7):358-62. 12. sato s, fujimoto m, kikuchi k, et al. elevated soluble cd23 levels in the sera from patients with localized scleroderma. arch dermatol res. 1996;288(2):74-8. 13. leask a, denton cp, abraham dj. insights into moleculer mechanism of chronic fibrosis:the role of connective tissue groeth factor in scleroderma. j invest dermatol. 2004;122:1-6. 14. nagai m, hasegawa m, takehara k, sato s. novel autoantibody to cu/zn superoxide dismutase in patients with localized scleroderma. j invest dermatol. 152 wardhana acta med indones-indones j intern med 2004;122:594-601. 15. pari l, amali dr. protective role of tetrahydrocurcumin (thc) an active principle of turmeric on chloroquin induced hepatotoxicity in rats. j pharm pharmaceut sci. 2005;8(1):115-23. 16. widodo d. demam tifoid. in: sudoyo aw, setiyohadi b, alwi i, kolopaking ms, setiati s, eds. buku ajar ilmu penyakit dalam. jakarta: pusat penerbitan departemen ilmu penyakit dalam fkui; 2006. p. 1174-9. 17. kieffer ma. topical vitamin d analogs. dermatol nurs. 2004;16(1):89-90. 18. kreuter a, gambichler t, avermaete a, et al. combined treatment with calcipotriol ointment and low-dose ultraviolet a1 phototherapy in childhood morphea. pediatr dermatol. 2001;18(3):241-5. 19. kreuter a, hyun j, stuker m, et al. a randomized controlled study of low-dose uva1, medium-dose uva1, and narrowed band uvb phototherapy in the treatment of localized scleroderma. j am acad dermatol. 2006;54(3):440-7. 20. hulshof mm, bouwes bavinck jn, bergman w, et al. double-blind, placebo-controlled study of oral calcitriol for the treatment of localized and systemic scleroderma. j am acad dermatol. 2000;43(6):101723. 21. falanga v, medsger ta jr. d-penicillamine in the treatment of localized scleroderma. arch dermatol. 1990;126(5):609-12. 22. fitch pg, rettig p, burnham jm, et al. treatment of pediatric localized scleroderma with methotrexate. j rheumatol. 2006;33(3):609-14. 23. mayes md. classification and epidemiology of scleroderma. semin cutan med surg. 1998;17(1):22-6. 10 original article acta medica indonesiana the indonesian journal of internal medicine hemostatic status of pre and post intracoronary injection of peripheral blood stem cells in patients with recent myocardial infarction cosphiadi irawan1,teguh santoso1,3, djumhana atmakusumah1, idrus alwi1, agus kosasih2, auda aziz2, abdulmuthalib1, lyana-s2, sri inggriani3, ardian saputra3, merry wintery3, linda lison3, ary h. reksodiputro1, aru w. sudoyo1 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 dharmais cancer hospital, jakarta, indonesia. 3 medistra hospital, jakarta, indonesia correspondence mail: division of hematology and medical oncology, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: cosphiadi@yahoo.com abstrak tujuan: untuk melaporkan perubahan-perubahan parameter hemostasis, misalnya agregasi trombosit, viskositas darah dan plasma, waktu protrombin, aptt, crp, dan fibrinogen sebelum dan sesudah pemberian terapi sel punca. metode: terdapat 24 pasien yang ikut serta dalam penelitian ini. pbscs dipanen dan disuntikkan ke arteri yang berhubungan dengan infark (infarct-related artery) setelah pemberian g-csf selama 5 hari berturut-turut. rekombinan eritropoietin manusia/recombinant human erythropoietin diberikan pada saat penyuntikan pbscs intrakoroner dilakukan. hasil: kami dapat melakukan evaluasi pada 11 dari 24 pasien tentang status hemostasis pradan pasca-suntikan sel punca. tidak ada perbedaan yang bermakna antara data dasar dan 3 bulan kemudian dalam hal aggregasi spontan (p=0,350), pt (p=0,793), aptt (p=0,255) dan tt (p=0,254). juga tidak ada perbedaan bermakna antara data dasar dan 3 bulan kemudian dalam hal viskositas plasma (p=0,442) dan viskositas darah (p=0,843). meskipun demikian, pasien yang memiliki viskositas darah dan plasma di atas atau di bawah kisaran normal nilai laboratorium belum kembali ke titik normal setelah perlakuan. baik pt maupun aptt, keduanya menunjukkan nilai normal. kadar fibrinogen dan crp menunjukkan penurunan yang bermakna antara data dasar dan 3 bulan setelah pengobatan, masing-masing dengan nilai p=0,009 dan p=0,04. kesimpulan: kombinasi g-csf dan epo based-intracoronary infusion dari pbscs dapat membuka perspektif baru dalam pengobatan keadaan hiperkoagulabilitas pasca infark miokardium akut/ami. kata kunci: koagulasi, agregasi trombosit, infark miokardium, hiperkoagulasi. abstract aim: to investigate hemostatic parameter changes, such as platelet aggregation, blood and plasma viscosity, prothrombin time, aptt, crp and fibrinogen, before and after administration of stem cell therapy. methods: a total of 24 patients were enrolled. peripheral blood stem cells (pbscs) were harvested and injected into the infarct-related artery after 5 consecutive days of g-csf administration. recombinant human erythropoietin was administered at the time of intracoronary pbscs injection. results: we were able to evaluate vol 46 • number 1 • january 2014 hemostatic status of pre and post intracoronary injection 11 introduction cardiovascular disease has increased in the last half century, becoming one of the major causes of morbidity in all hospital admissions. hypertension and coronary heart disease (chd) constitute a major bulk of these cvd cases, where myocardial infarction (mi) constitutes half of all chd cases.1 in 2008, 1 of 6 deaths in united states was caused by coronary heart disease.2 current guidelines emphasize acute myocardial infarction (ami) therapy on early coronary reperfusion that alleviates mortality rates such as primary percutaneous coronary intervention (pci) or thrombolytic therapy. however, these conventional therapy sometimes cannot reverse the damage to infarcted myocardium.1,3 virchow in 1856 postulated a triad of predisposition to thrombus formation. these triads are abnormalities of blood flow, blood constituents, and vessel wall. abnormal elevation, even one of these factors, predispose to a “prothrombotic” or “hypercoagulable” state.4,5 population of patients with ami showed these state very clearly. even those undergoing optimal treatment procedure are still at risk for further ischemic events not only because procedurerelated platelet activation occurs, but also due to the persistent platelet hyperreactivity and enhanced thrombin generation associated with acs.6,7 hyperreactivity of platelets was shown in timi 12 trial up to 28 days and prepare trial in up to 6 months.8-10 it is not known how the acute coronary thrombosis alter the kinetics of the systemic coagulation system. there are some theory proposed like increased activity of fix and decreased fii and fv, elevated fvii antigen and coagulant activity.11 latest researches has highlighted stem cell therapy for patient population at risk for heart failure. recent meta-analysis showed adult stem cell have shown significant, safety and favourable impact in treating heart failure and myocardial infarction.3,12-15 g-csf-based stem cell therapy has been proposed as a practical and non-invasive alternative to stem cell therapy using bone marrow stem cells.16 g-csf might be considered mostly as a mobilizer to enrich peripheral blood stem cells (pbscs). despite the potential adverse effects of increasing vascular events, short term use of g-csf in patients with ami seems to be safe. in 2008, we published an article showing 18 patients with anterior st-segment elevation ami, which showed improvement in most of the cardiac functions after injection of peripheral blood stem cells (pbscs) into the infarct-related artery.3 with the same protocol we are able to evaluate 6 more patients further regarding preand posttreatment (3 months) hemostatic profile such as platelet aggregation, blood and plasma viscosity, prothrombin time, aptt, crp and fibrinogen. the purpose of this study is to investigate hemostasic parameter changes before and after administration of stem cell therapy. methods we enrolled 24 patients diagnosed with st-segment elevation anterior wall infarction who had successful pci with drug-eluting stent implantation and were referred late (more than 2 hours) to our hospital but still within 15 days after onset of symptom. none of the patients received fibrinolytic therapy. pci was performed regardless of the patients’ hemodynamic condition. other 11 from 24 of patients regarding hemostatic status pre–post stem cell injection. there were no significant difference between baseline vs 3 months in spontaneous aggregation (p=0.350), pt (p=0.793), aptt (p=0.255) and tt (p=0.254). there were also no significant difference between baseline vs 3 months in plasma viscosity (p=0.442) and blood viscosity (p=0.843). nevertheless the patient who had their blood and plasma viscosity above or below normal laboratory range return to normal level after the treatment. both pt and aptt also show normalization value. both fibrinogen and crp level show significant decrease between baseline and 3 months after treatment (p=0.009) and (p=0.04) respectively. conclusion: combined g-csf and epo basedintracoronary infusion of pbscs may open new perspective in the treatment of hypercoagulable state post ami. key words: coagulation, platelet aggregation, myocardial infarction, hypercoagulation. cosphiadi irawan acta med indones-indones j intern med 12 inclusion criteria were as follows: age 20 years or over and subject’s willingness to comply with specific follow-up evaluations. all patients had complete revascularization even in non-infarct related territory. exclusion criteria were: 1). hemodynamic instability during the procedure or any condition that may put the patient at undue risk such as pulmonary edema and cardiogenic shock, 2). previous or current severe co-existing diseases, such as cancer, hematological disorders (hb <10 g/dl, wbc <4 or >11x109/l, or platelets <100x109/l), renal failure (creatinine level >2.5 mg/dl, or creatinine clearance <30 cc/min), hepatic dysfunction, serious infection or any comorbidities that may impact patients’ survival), 3). valvular heart disease and prosthetic valves, 4). hypertrophic or restrictive cardiomyopathy, 5). women of child bearing potential, and 6). lack of informed consent. the study was conducted in accordance with the declaration of helsinki and was approved by the university of indonesia medical school ethical committee. all patients gave written informed consent. study protocol one-to-three days after pci, a daily dose of 10 μg/kg/day of g-csf (lenograstim [ g r a n o c y t e t m ] , av e n t i s s a n o f i ) ) w a s administered subcutaneously for 5 consecutive days. cd34+ and cd 45+ cells were quantified at days 1 (baseline), 3, and 5 after injection and subsequently the peripheral blood stem cells (pbscs) were harvested. a total of 150 ml of pbscs was processed from the brachial vein using cobe spectra and placed into a peripheral blood (pb) unfiltered collection bag (baxter health care corp, il), which was discarded after pb infusion. cd34+ and cd 45+ cells enumeration was performed using facscalibur (becton dickinson). to ensure sterility of the harvesting procedure, the white cell concentrate was cultured for bacteria and fungi. three milliliters of the cell concentrate was injected into bact alert pf pediatric tube (biomerieux inc, durham, nc, cat no. 259794) and the incubated in the bact alert 120 system (organon teknika, durham, nc) for 7 days or until the culture become positive. the cell concentrate was also cultured on sabouraud agar medium (oxoid, cat no. cm 0041) for fungi. patients were heparinized during stem cell injection. cells were injected with the use of a stop flow technique through an over the wire balloon catheter positioned within the segment containing of the stent. the balloon was inflated with low pressure to completely block the blood flow for 3 min, during which time 5-6 ml pbsc suspension was injected. this was interrupted by 3 min of reflow by deflating the balloon to minimize the likelihood of extensive ischemia. after completion of intracoronary cell transplantation, coronary angiography was repeated to ascertain vessel patency and absence of capillary plugging by measuring the myocardial blush grade. approximately 15-25 x 106 pbscs were injected during each procedure. all (except one) patients received subcutaneous 4000 iu of recombinant human erythropoietin (eprextm) and glycoprotein iib/iiia inhibitors (intergrellintm) intravenous bolus and infusion at the time of intracoronary pbscs injection. patients were discharged the day after. unless there was contraindication, all patients also received optimal standard therapy including aspirin, clopidogrel, nitrates, b-blockers, aceinhibitor/angiotensin-receptor blockers and statins. the additional parameter compared in this study were pt, aptt, tt, platelet aggregation, blood and plasma viscosity, fibrinogen and crp. all parameters were checked before and 3 months after treatment. results almost all patients were male in gender and most of them were at the age of 50-59. the common acs risk factors existed in the patient were dyslipidemia (52%), smoking (42%), and family history (25%). table 2 shows platelet aggregation from all patients before and after treatment of celltherapy. no significant difference between baseline and 3 months after in spontaneous aggregation (3.11%+0.02% vs 5.39%+0.07%; p=0.350). vol 46 • number 1 • january 2014 hemostatic status of pre and post intracoronary injection 13 no significant difference between baseline and after 3 months treatment in plasma viscosity (1.64+0.14% vs 1.63+0.07%; p=0.442) and blood viscosity (8.06 +1.70 vs 7.56+0.83%; p=0.843). on the other hand fibrinogen and crp level showed significant decrease between baseline and 3 months after treatment (575+165 table 1. patient’s characteristics criteria n (%) age group 40-49 2 (8.0) 50-59 16 (67.0) 60-69 6 (25.0) sex male 23 (96.0) female 1 (4.0) history hypertension 4 (17.0) diabetes 3 (13.0) dyslipidemia 13 (54.0) smoking 10 (42.0) obesity 5 (21.0) family 6 (25.0) blood test ureum >40 mg/dl (n=19) 5 (26.0) creatinin >1.5 mg/dl (n=19) 0 (0) total cholesterol >200 mg/dl (n=18) 7 (39.0) hdl <50 mg/dl (n=18) 16 (89.0) ldl >150 mg/dl (n=18) 4 (22.0) uric acid >7 mg/dl (n=15) 5 (33.0) table 2. platelet aggregattion at baseline and after 3 months treatment no. baseline 3 months after psct spont aggr aggre 5 aggre 10 spont aggr aggre 5 aggre 10 1 3.20% 2.30% 2.70% 6.40% 12.30% 9.10% 2 1.80% 10.00% 12.70% 3.20% 25.50% 35.90% 3 7.30% 10.00% 10.90% 4.10% 1.40% 4.50% 4 4.50% 4.50% 11.40% 4.10% 14.50% 13.20% 5 3.20% 10.90% 17.70% 3.60% 9.10% 20.50% 6 4.10% 57.30% 62.70% 0.90% 36.80% 47.30% 7 3.20% 21.40% 26.40% 1.40% 34.60% 45.00% 8 1.40% 50.90% 55.90% 3.60% 20.00% 32.30% 9 3.20% 8.60% 13.60% 5.60% 3.20% 12.90% 10 2.70% 19.80% 27.30% 1.10% 9.70% 15.00% 11 2.20% 5.80% 65.80% 3.10% 6.00% 8.00% mean+sd 3.35+0.02 18.32+0.10 27.92+0.23 3.37+0.02 15.74+0.12 22.15+0.15 p value 0.969 0.570 0.408 vs 354+93; p=0.009) and (p=0.04) respectively. eventhough table 2 shows no significant changes in blood and plasma viscosity, figure 1 show trends of normalization. the patients who had their blood and plasma viscosity above normal range returned to normal point after the treatment. the same thing observed in patient who have their viscosity below normal range, it elevated to normal range. no significant difference in: pt (12.31+0.80 vs 12.44+1.36; p=0.793), aptt (36.59+17.89 vs 30.25+2.52; p=0.255) and tt (15.9+0.33 vs 19.7 +7.52; p=0.254) at baseline and at 3 months after therapy. both pt and aptt also show normalization value, as seen in table 4. discussion stem cell therapy is an intervention strategy that introduces adult stem cells into damaged tissue in order to treat disease or injury. whereas stem cells are biological cells found in all multicellular organisms that can divide and differentiate into diverse specialized cell types and can self-renew to produce more stem cells. there are minimally 4 accessible source of adult stem cells in humans, bone marrow, adipose tissue, blood, and wharton jelly (umbilical cord).17-20 in this study we do an ad hoc analysis comparing hemostatic profile before and after injection of pbsc cell therapy. we emphasize the cosphiadi irawan acta med indones-indones j intern med 14 figure 1. normalization of blood and plasma viscosity at baseline and after 3 months of treatment table 4. pt-aptt-tt at baseline dan 3 months after treatment pt aptt tt baseline after 3 months baseline after 3 months no of patients baseline after 3 months 12.4 11.5 25.4 29.5 1 15.4 16.1 13.4 11.9 89.9 32.1 2 15.9 16.6 10.9 11.3 29.7 28.2 3 16.1 19.3 13.3 12.2 32.1 29.6 4 15.8 16.6 11.9 12.5 29.8 31.6 5 15.9 15.0 13.0 12.1 31.7 28.9 6 16.4 34.8 11.3 12.0 32.2 26.7 mean+sd 15.9+0.33 19.7+7.52 12.3 11.9 32.8 31.3 12.3 12.9 36.9 31.2 12.3 16.1 30.6 35.8 31.4 27.8 table 3. blood and plasma viscosity at baseline and after 3 months of therapy no blood viscosity plasma viscosity fibrinogen (mg/dl) crp baseline after 3 months baseline after 3 months baseline after 3 months baseline after 3 months 1 6.85 6.74 1.47 1.55 377 314 20,1 4 2 7.66 6.10 1.53 1.72 937 352 6,9 17,1 3 8.24 7.26 1.70 1.69 458 454 103,1 0,01 4 9.77 7.49 1.76 1.71 680 282 40,4 20,1 5 11.02 7.52 1.76 1.59 552 321 85,3 0,8 6 5.60 8.24 1.66 1.61 446 352 1,5 0,01 7 7.77 7.32 1.87 1.64 570 504 20 1,86 8 9.54 7.31 1.55 1.59 478 468 53,68 6,05 9 7.50 7.50 1.68 1.69 726 218 8,47 13,92 10 5.64 9.07 1.43 1.53 530 276 191,94 1,63 11 9.05 8.63 1.58 1.59 575.4 354.1 53.139 6.548 mean+sd 8.06+1.70 7.56+0.83 1.64+0.14 1.63+0.07 vol 46 • number 1 • january 2014 hemostatic status of pre and post intracoronary injection 15 use of g-csf as a mobilizer to enrich pbscs. from 24 patients, most of them are males. the 3 most common risk factors associated with acs are dyslipidemia, smoking, and family history which exist in 54%, 42%, and 25% of the patients. all patients in this study receive heparin until 3 days after intervention, and afterwards the treatments are continued with standard optimal therapy as indicated. from 24 patients, we are able to follow 11 patients regarding the hemostatic profile. as shown in table 2-4 there are no significant difference between platelet aggregation, blood and plasma viscosity, pt, aptt, and tt preand posttreatment. however, surprising result can be seen in figure 1. there are 8 patients who have increased blood viscosity and 3 patients with increased plasma viscosity before treatment who return to normal laboratory range after treatment. on the other side, there are 2 patients with decreased blood viscosity and 4 patients who have decreased plasma viscosity before treatment. and after treatment they have their laboratory result elevated to normal range. this event have never been reported before, and we refer this event to “normalization”. moreover, platelet aggregation, pt, aptt, and tt all also showed this normalization. these result does not attributable to anticoagulant therapy, because all patient receive heparin only until the third day post-pci. according to some studies, restenosis post pci in ami patients occurs in 10-60% cases.21 there are several proposed mechanism as to why these event could happen. first, mechanical disruption of coronary plagues by denudation of the arterial endothelium and subsequent exposure to thrombogenic matrix protein, in addition to underlying atherothrombotic disease, results in platelet activation during or after pci.6 second, it was found that acs was associated with persistent platelet hyperreactivity and enhanced thrombin generation. in the thrombolysis in myocardial infarction (timi) 12 trials, activation of platelets continues even until 28 days after clinical stabilization post-acs.6,10 another study, the platelet reactivity in patients and recurrent events (prepare) post-stenting study also demonstrated higher posttreatment adpinduced aggregation in patients who suffered ischemic events over a 6-month period compared with patients without ischemic events (p=0.02).6 there is also reported that the severity of thrombosis was related with more severe or higher level of prothrombotic state as well as reactivity of the platelets. other interesting parameter are fibrinogen and crp, both are acute phase markers, showed significant decrease before and after treatment. a research showed that an increase in 1 g/l of plasma fibrinogen was associated with a 45% increased risk of mi.22 crp is an indicator of the severity of stemi and the occurence of complications during hospitalization.23 it is also independently stratify patients for inhospital mortality risk.24 in 2005, feinbloom suggested new emerging risk factors for arterial thrombosis, and among them are elevated crp and fibrinogen.25 the 2008 jupiter trial demonstrates that there was another potential mechanism that increases arterial trombotic event among healthy individuals with elevated hscrp. recently, there is also an ongoing trial called cardiovascular inflammation reduction trial (cirt), which main purpose is to confirm the inflammatory hypotesis of atherothrombosis, which include decreasing crp level.26 all these parameter changes are in contrast with other research which show that there are no changes in hemostatic profile after optimal treatments.6,11 the mechanism of normalization and significant decrease of fibrinogen and crp is still unknown. but it may be related to how the stem cells works, such as paracrine effect and wound healing. the paracrine effect of stem cells has been reported to influence cardiac repair by protecting cardiac myocites from apoptotic stimuli or activate cardiac-resident stem cell to enhance endogenous repair capacity.17 another potential mechanism is that transplanted stem cell may secrete a variety of growth factor and cytokines, which in turn alter the systemic hemostatic profile.27 there were 3 limitations that need to be addresed regarding the present study. the first limitation concerns the size of the sample. the second limitation has to do with patient’s baseline hemostasis profile. and lastly, the cosphiadi irawan acta med indones-indones j intern med 16 third limitation there were no control group. therefore further study is needed to ensure the underlying mechanism of this event. if future researches are able to conclude the mechanism underlying normalization of hemostatic profile after cell-therapy injection post-ami, it will help in developing new strategies in the treatment of cardiovascular diseases. we also propose the use of teg platelet mapping in patients after pci treatment, to evaluate the complex interaction between fibrin, thrombin, platelets, and coagulation factors during a state of hypercoagulability, which will allow individualized therapy.28 conclusion our study showed that 3 months after injection of intracoronary peripheral blood stem cell, all the parameters of the hemostatic become normal. moreover, 2 parameters, fibrinogen and crp both showed significant improvement. future prospective studies are needed to investigate the underlying mechanism of this event. references 1. shim w, mehta a, lim sy, et al. g-csf for stem cell therapy in acute myocardial infarction: friend or foe?: cardiovascular research advance access; 2010 [cited 2012 20 november ]; available from: http:// cardiovascres.oxfordjournals.org/content/89/1/20. full?sid=b00cefbe-1f32-465b-9f40-23dedb94d80e. 2. roger v, go as, lloyd-jones dm, et al. executive summary: heart disease and stroke statistics--2012 update: a report from the american heart association. circulation. 2012;125:188-97. 3. santoso t, irawan c, alwi i, et al. safety and feasibility of combined granulocyte colony stimulating factor and erythropoetin based-stem cell therapy using intracoronary infusion of peripheral blood stem cells in patients with recent anterior myocardial infarction: one-year follow-up of a phase 1 study. acta med indones-indones j intern med. 2011;43(2):112-21. 4. lip g, blann ad. thrombogenesis and fibrinolysis in acute coronary syndromes. j am coll cardiol. 2000;36(7):2044-6. 5. chan m, andreotti f, becker rc. hypercoagulable states in cardiovascular disease. circ. 2008;118:228697. 6. braunwald e, angiolillo d, bates e, et al. the problem of persistent platelet activation in acute coronary syndromes and following percutaneous coronary intervention. clin cardiol. 2008;31:17-20. 7. shih j, shih jj. evaluation of hypercoagulability during acute coronary syndrome using serial teg platelet mapping. clin mol med. 2010;2(1):1-3. 8. ageno w, becattini c, brighton t, selby r, kamphusien pw. cardiovascular risk factor and venous thromboembolism: a meta-analysis. circulation. 2008;117:93-102. 9. holst a, jensen g, prescott e. risk factors for venous thromboembolism: results from the copenhagen city heart study. circulation. 2010;121:1896-903. 10. ault k, cannon cp, mitchell j, et al. platelet activation in patients after an acute coronary syndrome: results from the timi-12 trial. j am coll cardiol. 1999;33:634-9. 11. undas a, szułdrzyn´ski k, brummel-ziedins k, et al. systemic blood coagulation activation in acute coronary syndromes. blood. 2009;113:2070-8. 12. jeevanantham v, butler m, saad a, et al. adult bone marrow cell therapy improves survival and induces long-term improvement in cardiac parameters a systematic review and meta-analysis. circulation. 2012;126:551-68. 13. lipinski m, biondi-zoccai ggl, abbate a, et al. impact of intracoronary cell therapy on left ventricular function in the setting of acute myocardial infarction. j am coll cardiol. 2007;50:1761-7. 14. strauer b, yousef m, schanwell cm. the acute and longterm effects of intracoronary stem cell transplantation in 191 patients with chronic heart failure: the starheart study. eur heart j. 2010;12:721-9. 15. martin-rendon e, brunskill s, dorée c, et al. stem cell treatment for acute myocardial infarction. cochrane database of systematic review 2008. 16. kang h, lee hy, na sh, et al. differential effect of intracoronary infusion of mobilized peripheral blood stem cells by granulocyte colony–stimulating factor on left ventricular function and remodeling in patients with acute myocardial infarction versus old myocardial infarction the magic cell-3-des randomized controlled trial. circulation. 2006;114:145-51. 17. dimmeler s, burchfield j, zeiher am. cell-based therapy of myocardial infarction. arterioscler thromb vasc biol. 2008;28:208-16. 18. gimble j, gullak f, bunnell ba. clinical and preclinical translation of cell-based therapies using adipose tissue-derived cells. stem cell res ther. 2010;1(19):1-8. 19. lodi d, lannitti t, palmieri b. stem cells in clinical practice: applications and warnings. j exp clin can res. 2011;30(9):1-20. 20. teo a, vallier l. emerging use of stem cells in regenerative medicine. biochem j. 2010;428:11-23. 21. hoffman r, mintz gs. coronary in-stent restenosis predictors, treatment and prevention. eur heart j. 2000;21:1739-49. vol 46 • number 1 • january 2014 hemostatic status of pre and post intracoronary injection 17 22. van der bom j, de maat mpm, bots ml, et al. elevated plasma fibrinogen cause or consequence of cardiovascular disease? arterioscler thromb vasc biol. 1998;18:621-5. 23. dedobbeleer c, melot c, renard m. c-reactive protein increase in acute myocardial infarction. acta cardiol. 2004;59(3):291-6. 24. gheno g, libardoni m, zeppellini r, cucchini f. c-reactive protein on admission as a predictor of inhospital death in the elderly with acute myocardial infarction. cardiologia. 1999;44(12):1023-8. 25. feinbloom d, bauer ka. assessment of hemostatic risk factors in predicting arterial thrombotic events. arterioscler thromb vasc biol. 2005;25:2043-53. 26. ridker p. testing the inflammatory hypothesis of atherothrombosis: scientific rationale for the cardiovascular inflammation reduction trial (cirt). j throm haemost. 2009;7(suppl. 1):332-9. 27. abdel-latif a, bolli r, tleyjeh im, et al. adult bone marrow-derived cells for cardiac repair. arch intern med. 2007;167:989-97. 28. m i n g s h i h j , m i n g s h i h j j . e v a l u a t i o n o f hypercoagulability during acute coronary syndrome using serial teg platelet mapping. clin mol med. 2010;2(1):1-3. case report 237acta med indones indones j intern med • vol 50 • number 3 • july 2018 intravenous rituximab in severe refractory primary focal segmental glomerulosclerosis gan wee leng1, ruslinda mustafar2, lydia kamaruzaman2, rozita mohd2, rizna a. cader2, kong wei yen2, pau kiew bing3 1 department of medicine,universiti kebangsaan malaysia medical centre, malaysia. 2 nephrology unit, department of medicine, universiti kebangsaan malaysia medical centre, malaysia. 3 department of pharmacy, universiti kebangsaan malaysia medical centre, malaysia. corresponding author: ruslinda mustafar, md. consultant nephrologist and physician, nephrology unit, department of medicine, universiti kebangsaan malaysia medical centre. jalan yaacob latiff, 56000 cheras, kuala lumpur, malaysia. email: ruslinda.m@gmail.com. abstrak mengelola glomerulonefritis primer atau bahkan sekunder tetap menjadi tantangan bagi banyak nefrologis. pada glomerulosklerosis fokal segmental primer (fsgs) dengan proteinuria berat, blokade sistem renin aldosterone dan prednisolon oral dosis tinggi merupakan andalan pengobatan. obat imunosupresif lainnya seperti cyclophosphamide, cyclosporine a dan mycophenolate mofetil (mmf) dibenarkan jika remisi lengkap tidak tercapai. penulis mengilustrasikan kasus pria berusia 21 tahun dengan fsgs primer yang sulit mencapai remisi meskipun menggunakan steroid dosis tinggi dan cyclophosphamide oral. pasien juga tidak responsif terhadap kombinasi mmf dan cyclosporine a (csa) dan bahkan selama terapi ia mengembangkan steroid dan toksisitas csa yang signifikan. pasien dirujuk dengan sindrom nefrotik berat dan cedera ginjal akut yang membutuhkan hemodialisis akut. meskipun diberikan kembali prednisolon dosis tinggi, total 2,4g cyclophosphamide intravena, dan mmf, namun gagal mencapai remisi. kemudian diberikan rituximab intravena 500mg/minggu untuk 4 dosis dan mampu mencapai remisi selama 1 tahun. pasien mengalami kekambuhan dan pemberian kedua rituximab 500mg/mingguan 6 dosis untuk mencapai remisi. kasus ini menunjukkan kesulitan dalam mengelola fsgs steroid refrakter dan kami menemukan bahwa rituximab terbukti bermanfaat dalam hal ini untuk menginduksi remisi. kata kunci: refraktori glomerulo-sklerosis, intravena rituximab. abstract managing primary or even secondary glomerulonephritis remains a challenge to many nephrologists. in primary focal segmental glomerulosclerosis (fsgs) with heavy proteinuria, renin aldosterone system blockade and high dose of oral prednisolone is the mainstay of treatment. other immunosuppressive medications like cyclophosphamide, cyclosporine a and mycophenolate mofetil (mmf) are warranted if a complete remission is not achieved. we illustrate a case of 21 year old gentleman with primary fsgs that was difficult to achieve remission despite on high dose steroid and oral cyclophosphamide. he was also not responsive to a combination of mmf and cyclosporine a (csa) and even throughout the therapy he developed significant steroid and csa toxicity. he presented to our center with severe nephrotic syndrome and acute kidney injury requiring acute haemodialysis. despite re-challenged him again on high dose prednisolone, total of 2.4g of intravenous cyclophosphamide, and mmf, he failed to achieve remission. he was subsequently given intravenous rituximab 238 gan wee leng acta med indones-indones j intern med 500mg/weekly for 4 doses and able to attained remission for 1 year. he relapsed again and a second course of rituximab 500mg/weekly for 6 doses were given to attain remission. this case demonstrates the difficulty in managing refractory steroid dependent fsgs and we found that rituximab is proven beneficial in this case to induce remission. key words: refractory focal segmental glomerulosclerosis, intravenous rituximab. introduction focal segmental glomerulosclerosis (fsgs) is a kidney disease causing proteinuria due to glomerular sclerosis which may leads to renal dysfunction or end stage renal failure (esrf). fsgs can be classified as primary where no underlying cause has been found for the development of focal podocytes injury. whereas, secondary fsgs is considered if the podocytes injury can be explained due to other causes such as obesity, human immune virus infection, iga nephropathy, vasculitis, lupus nephritis, drugs including heroin and interferon treatment, reflux nephropathy or sickle cell anemia.1 it is important to distinguish between primary and secondary fsgs as treatment approach is different.2 the kidney disease improving global outcomes (kdigo) guideline stated that oral high dose prednisolone is the immunosuppressant of choice for primary fsgs presented with nephrotic range proteinuria. 3 the major prognostic indicator of renal survival is the initial response of the proteinuria to steroid therapy. thus, remission of proteinuria is the ultimate goal in primary fsgs. a complete remission that is defined as reduction of proteinuria to less than 200 to 300 mg/day, meanwhile partial remission can be defined as 50% or greater reduction in proteinuria to a level that is <3.5 g/day. any patients relapse while steroid is being tapered, or within two months of stopping steroid therapy, they are considered steroid dependent. patients with little or no reduction in urine protein excretion after 12 to 16 weeks of treatment are considered steroid resistant.3 most patients with steroid dependent fsgs required long-term low-dose corticosteroid therapy along with either cyclophosphamide (cyc), cyclosporine a (csa), mycophenolate mofetil (mmf) or rituximab to maintain clinical remission.4-6 angiotensin-converting enzyme inhibitor (acei) or angiotensin-ii receptor blockers (arb) is indicated in patients with fsgs but the results on proteinuria is variable.7,8 nevertheless, both acei and arb has been proven to retard the progression of chronic kidney disease to end stage kidney disease by reducing proteinuria and maintaining blood pressure.9,10 however, care must be taken to avoid symptomatic hypotension and increment of creatinine. fluid overload should be treated with diuretics especially loop diuretics. combination of loop diuretic with thiazide can be considered in refractory fluid overload. salt intake to 6 gram/day (2g of sodium) is essential to prevent fluid retention. it is always important to balance the side effects and the benefits of medications given to the patient. here we illustrate a case of a refractory primary fsgs and the management approach in our centre. case illustration a 21 year old gentleman presented 3 years ago at a state hospital with nephrotic syndrome. his creatinine was 105 µmol/l (egfr of 82 ml/min/1.73m2), serum albumin of 15g/l, urine protein creatinine index (pci) 0.93g/mmol creatinine. a diagnosis of fsgs; non-otherwise specified (nos) type was confirmed on renal biopsy and screening tests for secondary causes were all negative. he was initiated on high dose oral prednisolone (1mg/kg/day; 60mg/kg/day). he achieved complete remission after 1 month of high dose oral prednisolone with urine pci reduced to 0.01g /mmol creatinine, resolution of body edema and preservation of renal function. unfortunately, he relapsed while on tapering dose of oral prednisolone to 5mg daily at 6 months of therapy. a second course of oral prednisolone at (1mg/kg/day; 60mg/day) was then restarted. he developed multiple relapses while attempting to taper down the prednisolone. despite added on 239 vol 50 • number 3 • july 2018 intravenous rituximab in severe refractory primary focal segmental oral cyclophosphamide 125 mg daily (2.5 mg/kg/ day) for 2 months his disease remains difficult to control. he was then switched to oral cyclosporine a (csa) 100 mg twice a day for 9 months. oral mmf was started following cyclosporine toxicity with worsening of renal profile and gum hypertrophy which later resolved after withdrawal of the drug. he was kept on mmf 1g twice daily with maintaining high dose prednisolone at 60mg daily as every attempt to taper down his oral prednisolone, his urine protein will rose further. his urine pci was remained at 0.40 g/mmol creatinine after his second relapsed. he presented to our center with overt nephrotic syndrome and oliguric acute renal failure while he was on prednisolone 60mg/day and mmf 1gm twice daily. his serum albumin was 19 g/l, urine pci was 2.90 g/mmol creatinine, serum creatinine of 980 mmol/l and urea of 20 mmol/l. an ultrasound of the renal system was normal. magnetic resonance angiography and magnetic resonance venography showed no evidence of renal artery stenosis or renal vein thrombosis. renal biopsy was consistent with acute tubular necrosis with underlying focal segmental glomerulosclerosis – non-otherwise specified (nos) type (figure 1). he was treated with intravenous methylprednisolone 250 mg daily for 3 days followed by 50 mg daily then oral prednisolone 60mg daily. he required temporary haemodialysis. he was then given intravenous cyclophosphamide (iv cyc) 2 weekly for 5 doses with total cumulative dose of 2.4 gram; subsequently he was then continued with mmf 1 gm twice daily. his urine protein reduced to 1.2 g/day after 5 months and his kidney function was completely recovered. despite of compliance to his immunosuppressive treatment consist of prednisolone 35mg daily and mmf 1gm twice daily, he never achieved complete remission with urine pci remains between 0.12 to 0.14 g/ mmol creatinine (figure 2). calcineurin inhibitor was not started at that time as he was just recovered from acute kidney injury with past history of failure to csa. unfortunately, his high dose steroid therapy caused him to develop steroid induced diabetes mellitus requiring oral antidiabetic medication. due to refractory fsgs, we decided for 4 doses of intravenous (iv) rituximab 500mg/weekly. he responded well to the iv rituximab and in clinical remission (urine pci less than 0.03 g/ mmol creatinine, serum albumin of 37 g/l) for 1 year (figure 2) and subsequently was maintained with mmf 1 g twice daily, oral prednisolone 10mg daily and perindopril 4mg daily then gradually optimized to 8 mg daily. his blood pressure ranging between 110-120 mmhg/7080 mmhg. a year later, he relapsed again with urine pci increased to 1.70 g/mmol creatinine. serum albumin dropped from 38 to 19 g/l. his corticosteroid dose was increased again to 60mg/ day. mmf dose was maintained at 1gm twice a day and restarted on csa 50mg twice a day at 1mg/kg/day. he was compliant to his treatment and already had signs of steroid toxicity such as exogenous cushing’s; abdominal striae, and proximal myopathy. decision was made to give him another prolong course of iv rituximab comprised of 6 doses of 500 mg/weekly while his oral prednisolone was tapered to prevent further side effects. he responded very well and reduction of his urine protein after the second dose of iv rituximab (figure 2). we strongly believe that the effect on proteinuria reduction was driven by rituximab rather than the addition of low dose of csa itself. figure 1. renal biopsy showed capsular adhesion (upper left) and mesangial expansion and proliferation (upper right). tubules were dilated and exhibiting cytoplasmic vacuolations and blebbing of apical membrane (bottom left) with eeosinophilic proteinaceous casts within lumen (bottom right). 240 gan wee leng acta med indones-indones j intern med in view of previous history of csa toxicity (acute kidney injury, gum hypertrophy) at 2 mg/ kg/day, his csa is optimized at a slower pace. now, he is maintained with oral prednisolone 10mg daily, mmf 1g bd and csa 100mg twice daily (triple therapy). he is also double anti-proteinuric medications; perindopril 8mg daily, telmisartan 80mg daily and atorvastatin 20 mg at night. his signs of steroid toxicity such as proximal myopathy and abdominal striae have resolved upon tapering down his oral prednisolone and his diabetic control is well manage with dietary control only. discussion primary fsgs is a glomerular disease with variable clinical course. according to kdigo guideline, treatment with corticosteroid and other immunosuppressant are only indicated in primary fsgs associated with nephrotic syndrome.3 relapse after clinical remission is very common in primary fsgs. it is a challenge for nephrologist in managing refractory fsgs complicated with steroid toxicity as we experienced in this particular case. steroid is the mainstay of treatment for primary fsgs. pulse with high dose of iv methylprednisolone is associated with favorable clinical outcome in active refractory primary fsgs. however, prolonged steroid treatment can cause significant side effects such as diabetes mellitus and exogenous cushing. thus, for our patient, the ultimate aim was to optimize the steroid sparing immunosuppressant’s to render his primary fsgs to remissions and at the same time to taper down his steroid to prevent worsening of his steroid toxicity. cyclophosphamide (cyc) is an alkylating agent which is recommended as a steroid sparing immunosuppressant for steroid responsive primary fsgs.11 cyc is administered for 8 to 12 weeks. the combination of cyc with steroid is associated with a longer remission period in steroid dependent primary fsgs. treatment more than 12 weeks shows no beneficial clinical outcome.11 furthermore, bone marrow suppression, hemorrhagic cystitis and gonadal toxicity are well known complications of prolong cyc therapy. csa is a calcineurin inhibitor (cni) which may be beneficial in primary refractory fsgs unresponsive to cyc.12 it can also serve as first line therapy in primary fsgs where steroid treatment is contraindicated or intolerance to high dose. csa is associated with 50% reduction in relapse rate and as good as cyc.13 remission may take 3–6 months following treatment. relapses do occur after withdrawal of csa.12 however, prolong csa treatment, perhaps up to one year or longer after remission is achieved associated with low risk of relapse.14 side effects of csa include tremor, hypertrichosis, gum hypertrophy, hypertension, and nephrotoxicity. figure 2. relationship between serum creatinine and urine pci 241 vol 50 • number 3 • july 2018 intravenous rituximab in severe refractory primary focal segmental risk of nephropathy increases if high-dose csa (more than 5.5 mg/kg/d) is given, patient has pre-existing chronic renal failure with egfr less than 60 ml/min per 1.73 m2 and present of tubule-interstitial fibrosis in renal biopsy.14 thus, cni should be avoided if egfr is less than 30 ml/min/1.73 m2. tacrolimus (tac) may serve as alternative cni in cases of csa-resistant or csa-dependent fsgs.15 the cosmetic side effects such as hypertrichosis and gum hypertrophy are not seen with tac. thus, it is preferred in patient who cosmetic side effect is a major concern. however, the incidences of other risk factors such as nephropathy, tremor, and diabetes mellitus are the same for both tac and csa.14,15 mmf acts via inhibition of t cell and b cell. it is an alternative agent in primary fsgs when cni is contraindicated or refractory and developed complications following cni therapy.16 mmf is indicated in patients with partial response to steroid or serves as steroid sparing immunosuppressant in cases of steroid toxicity. in our patients; mmf was started following csa induced nephropathy. mmf is not inferior to cni in preventing relapses but only if given at high doses.16 mmf has relative fewer side effects compare to cni. some of the common mmf side effects include gastrointestinal symptoms such as diarrhea, abdominal pain and hyperlipidemia. as illustrated in our case, he received the conventional therapy as per recommendation in kdigo guideline. unfortunately, not only refractory to therapy namely high dose steroid, cyc (oral or iv), combination of prednisolone with csa as well as mmf, he also developed severe side effects such as nephrotoxicity and gum hypertrophy with csa and also cushing’s syndrome and diabetes due to the high dose of steroid. therefore rituximab was utilized in this case as adjunctive treatment to render him into remission. rituximab therapy here is reserved after attempts with steroid, cni, or mmf have failed to induce remission. rituximab is a chimeric monoclonal antibody that inhibits cd20-mediated b lymphocytes. rituximab has protective effect on podocytes. several reports have demonstrated successful treatment of rituximab in refractory steroid dependent primary fsgs.17-19 therapy for fsgs with iv rituximab has been reported in some case reports in recurrent nephrotic syndrome after renal transplantation in paediatric population.17,20 nevertheless, the potential usefulness of rituximab in adult fsgs has been varies in term of doses, regime and responses.21 utilization of rituximab as a treatment in adult refractory fsgs remains debatable on what will be the optimal dose and how frequent it should be. soluble urokinase-type plasminogen activator receptor (supar) levels were increased in fsgs as evidence by two large cohorts; the fsgs clinical trial (fsgs ct) and the podonet european fsgs consortium.22 supar is the cleaved molecule derived from urokinase type plasminogen activator receptor (upar) and upar is a membrane-bound protein linked to glycosylphosphatidylinositol (gpi) present on podocytes. supar may trigger the podocytopathy in the majority of patients with primary fsgs via activation of podocyte αvβ3 integrin. supar act as permeability factor that stimulates the podocyte αvβ 3 integrin signaling pathway causing proteinuria. rituximab inhibit supar-podocyte αvβ3 integrin signaling via modulation of sphingomyelin phosphodiesterase acid-like 3b.23 unfortunately, in this case we were unable to measure the supar as it is not available in our center. removal of this circulating factor by plasmapheresis is an option as it can reduce proteinuria and induced clinical remission. however, the efficacy of plasmapheresis in recurrent fsgs is quite variable. the average respond rate ranging 50% to 60%.24 the respond rate is dependent on the absolute level of the circulating permeability factor. relapse can occur during rapid tapering of plasmapheresis sessions and usually requires prolonged reinstitution of the plasmapheresis sessions. hence, individualization of treatment schedule depending on clinical response has been proposed. in this case, we opted to treat him with iv rituximab and in view of his good response, plasmapheresis was not done. plasmapheresis perhaps should be considered 242 gan wee leng acta med indones-indones j intern med if he does relapse again in the future. in those treated with plasmapheresis and responding, treatment should be continued until proteinuria has been reliably suppressed to below 0.5 g/day. t h e d e v e l o p m e n t o f a n t i r i t u x i m a b autoantibodies may be of concern in this case following repeated rituximab infusion.25,26 h e n c e , t h e p r e s e n c e o f a n t i r i t u x i m a b autoantibodies is suspicion for cases of severe infusion reaction and if b cell depletion is not observed following rituximab therapy. a close relation between b-cell depletion and clinical remission of refractory fsgs has been reported.25 the typical rituximab regimen is usually given at 2–6 doses (375 mg/m2/dose), administer once every 1 to 2 weeks. rituximab was well tolerated by our patient and allowed us to taper dose of prednisolone to prevent worsening of his steroid toxicity. he achieved full remission after 1st 4 cycles of rituximab with 500mg/week dose. though he relapsed a year later, a second course of rituximab 500mg/week for 6 weeks also resulted in gradual clinical remission without the need for high dose prednisolone. currently, his treatment is directed to optimization of his triple immunosuppressive therapy and anti-proteinuric medications while ensuring minimal side effects to induced complete remission as our ultimate target. conclusion the management of refractory primary fsgs as illustrated in this case remains a challenge for nephrologists. steroid in combination with immunosuppressant such as cni, cyc or mmf may induce partial if not total remission of proteinuria. rituximab should be considered as an alternative treatment in severe refractory primary fsgs associated with treatment toxicities. this case report supports a generalized effectiveness of rituximab treatment in fsgs. more studies are necessary to characterize further the type of patients who have fsgs that could benefit from rituximab administration. the optimal dosage and frequency of rituximab in this disease remains a challenge. although mechanistic effects of rituximab on the podocytes were clear and potential permeability factor has been identified, current evidence on the nature of this factor and on the pathogenesis of recurrent fsgs remains inconclusive. conflict of interest no author of this paper has conflict of interest. we receive no financial support for this case report. references 1. kim js, han bg, choi so, cha sk. secondary focal segmental glomerulosclerosis: from podocyte injury to glomerulosclerosis. bio med res int. 2016;2016:1630365. 2. valerio f, sottini l, turina s, et al. choosing the right treatment approach in focal and segmental glomerular sclerosis with chronic renal failure. giornale italiano di nefrologia: organo ufficiale della societa italiana di nefrologia. 2008;25 suppl 44:s88-s98. 3. radhakrishnan j, cattran dc. the kdigo practice guideline on glomerulonephritis: reading between the (guide)lines--application to the individual patient. kidney international. 2012;82(8):840-56. 4. ochi a, takei t, nakayama k, et al. rituximab treatment for adult patients with focal segmental glomerulosclerosis. internal medicine. 2012;51(7):75962. 5. cattran dc. cyclosporine in the treatment of idiopathic focal segmental glomerulosclerosis. seminars in nephrology. 2003;23(2):234-41. 6. cattran dc, wang mm, appel g, matalon a, briggs w. mycophenolate mofetil in the treatment of focal segmental glomerulosclerosis. clin nephrol. 2004;62(6):405-11. 7. crenshaw g, bigler s, salem m, crook ed. focal segmental glomerulosclerosis in african americans: effects of steroids and angiotensin converting enzyme inhibitors. american j med sci. 2000;319(5):320-5. 8. stiles kp, abbott kc, welch pg, yuan cm. effects of angiotensin-converting enzyme inhibitor and steroid therapy on proteinuria in fsgs: a retrospective study in a single clinic. clin nephrol. 2001;56(2):89-95. 9. korbet sm. angiotensin antagonists and steroids in the treatment of focal segmental glomerulosclerosis. seminars in nephrology. 2003;23(2):219-28. 10. maschio g, alberti d, janin g, et al. effect of the angiotensin-converting-enzyme inhibitor benazepril on the progression of chronic renal insufficiency. the angiotensin-converting-enzyme inhibition in progressive renal insufficiency study group. new engl j med. 1996;334(15):939-45. 11. cyclophosphamide treatment of steroid dependent nephrotic syndrome: comparison of eight week with 12 week course. report of arbeitsgemeinschaft fur padiatrische nephrologie. arch dis childhood. 243 vol 50 • number 3 • july 2018 intravenous rituximab in severe refractory primary focal segmental 1987;62(11):1102-6. 12. cattran dc, appel gb, hebert la, et al. a randomized trial of cyclosporine in patients with steroidresistant focal segmental glomerulosclerosis. north america nephrotic syndrome study group. kidney international. 1999;56(6):2220-6. 13. ponticelli c, edefonti a, ghio l, et al. cyclosporin versus cyclophosphamide for patients with steroiddependent and frequently relapsing idiopathic nephrotic syndrome: a multicentre randomized controlled trial. nephrol dial transplant. 1993;8(12):1326-32. 14. meyrier a, noel lh, auriche p, callard p. long-term renal tolerance of cyclosporin a treatment in adult idiopathic nephrotic syndrome. collaborative group of the societe de nephrologie. kidney international. 1994;45(5):1446-56. 15. segarra a, vila j, pou l, et al. combined therapy of tacrolimus and corticosteroids in cyclosporin-resistant or -dependent idiopathic focal glomerulosclerosis: a preliminary uncontrolled study with prospective follow-up. nephrol dial transplant. 2002;17(4):65562. 16. choi mj, eustace ja, gimenez lf, et al. mycophenolate mofetil treatment for primary glomerular diseases. kidney international. 2002;61(3):1098-114. 17. pescovitz md, book bk, sidner ra. resolution of recurrent focal segmental glomerulosclerosis proteinuria after rituximab treatment. new engl j med. 2006;354(18):1961-3. 18. ren h, lin l, shen p, et al. rituximab treatment in adults with refractory minimal change disease or focal segmental glomerulosclerosis. oncotarget. 2017;8(55):93438-43. 19. marasa m, cravedi p, ruggiero b, ruggenenti p. refractory focal segmental glomerulosclerosis in the adult: complete and sustained remissions of two episodes of nephrotic syndrome after a single dose of rituximab. bmj case rep. 2014;2014. 20. el-firjani a, hoar s, karpinski j, bell r, deschenes mj, knoll ga. post-transplant focal segmental glomerulosclerosis refractory to plasmapheresis and rituximab therapy. nephrol dial transplant. 2008;23(1):425. 21. fernandez-fresnedo g, segarra a, gonzalez e, et al. rituximab treatment of adult patients with steroidresistant focal segmental glomerulosclerosis. clin j am soc nephrol: cjasn. 2009;4(8):1317-23. 22. wei c, trachtman h, li j, dong c, et al. circulating supar in two cohorts of primary fsgs. j am soc nephrol. 2012;23(12):2051-9. 23. yoo th, pedigo ce, guzman j, et al. sphingomyelinaselike phosphodiesterase 3b expression levels determine podocyte injury phenotypes in glomerular disease. j am soc nephrol. 2015;26(1):133-47. 24. ponticelli c. recurrence of focal segmental glomerular sclerosis (fsgs) after renal transplantation. nephrol dial transplant. 2010;25(1):25-31. 25. nakayama m, kamei k, nozu k, et al. rituximab for refractory focal segmental glomerulosclerosis. pediatric nephrology. 2008;23(3):481-5. 26. ahn yh, kang hg, lee jm, choi hj, ha is, cheong hi. development of antirituximab antibodies in children with nephrotic syndrome. pediatric nephrol. 2014;29(8):1461-4. 320 original article acta med indones indones j intern med • vol 50 • number 4 • october 2018 association of periodontitis and arterial stiffness in type 2 diabetic patients anandhara i. khumaedi1, dyah purnamasari1, ika p. wijaya1, yuniarti soeroso2, siti marhamah2 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of periodontia, dentistry unit, cipto mangunkusumo hospital, jakarta, indonesia. corresponding authors: dyah purnamasari, md, phd. division of endocrinology and metabolism, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. salemba raya no. 6, jakarta, indonesia. email: dyah_p_irawan@yahoo.com. abstrak latar belakang: periodontitis merupakan penyebab utama infeksi kronis pada pasien diabetes. pasien diabetes memiliki risiko mengalami penyakit kardiovaskular empat kali lipat. inflamasi kronis yang disebabkan oleh periodontitis merupakan faktor risiko kardiovaskular baru (non-tradisional) dan telah dikenal luas memiliki peran penting dalam aterogenesis. pada subyek tanpa diabetes, didapatkan hubungan antara periodontitis dan kekakuan arteri; namun, hasil ini masih belum konsisten pada pasien diabetes. tidak ada penelitian sebelumnya yang meneliti proporsi periodontitis maupun hubungannya dengan kekakuan arteri pada populasi pasien dengan diabetes tipe 2 di indonesia. metode: penelitian ini merupakan penelitian potong lintang yang melibatkan 97 pasien dengan diabetes tipe 2 yang datang ke klinik endokrinologi antara bulan april hingga bulan agustus 2017. periodontitis diukur berdasarkan kedalaman kantong (pocket depth), kehilangan perlekatan klinis (clinical attachment loss) dan perdarahan dengan melakukan pelacakan (probing) oleh ahli periodonti. kecepatan gelombang nadi arteri karotis dan femoris (carotid-femoral pwv) diukur dengan menggunakan alat sphygmocor xcel melalui teknik tonometri bantalan (cuff-based tonometry). hasil: periodontitis ditemukan pada 99% pasien diabetes tipe 2 dan 78% di antaranya mengalami periodontitis berat. tidak ada korelasi yang bermakna antara kedalaman kantong dan clinical attachment loss dengan cfpwv (r=0,024, p=0,407 and r=0,011, p=0,456). sementara itu, terdapat korelasi positif antara kedalaman kantong dan pwv (r=0,294, p=0,041) pada pasien diabetes tipe 2 yang terkontrol dengan baik. kesimpulan: sebagian besar pasien diabetes tipe 2 mengalami periodontitis berat, tetapi korelasi antara periodontitis dan kekakuan arteri tidak dapat disimpulkan dari penelitian ini. kata kunci: periodontitis, kedalaman kantong, kehilangan perlekatan klinis, kecepatan gelombang nadi (pwv). abstract background: periodontitis is a major cause of chronic infection in diabetic patients. diabetic patients have four-fold risk of having cardiovascular disease. chronic inflammation caused by periodontitis, a nontraditional cardiovascular risk factor is widely known to play a major role in atherogenesis. among nondiabetics, an association has been found between periodontitis and arterial stiffness, but in diabetic patients the result is inconsistent. no study has investigated either the proportion of periodontitis or its correlation with arterial stiffness in type 2 diabetes population in indonesia. methods: this study was a cross-sectional study involving 97 patients with type 2 diabetics, who were recruited on endocrinology clinic from april to august vol 50 • number 4 • october 2018 association of periodontitis and arterial stiffness in type 2 diabetic patients 321 2017. periodontitis was measured for pocket depth, clinical attachment loss and bleeding on probing by a periodontist. carotid-femoral pwv (pulse wave velocity) was measured using sphygmocor xcel with cuffbased tonometry technique. results: periodontitis was found in 99% type 2 diabetic subjects and 78% of them had severe periodontitis. there was no significant correlation found between pocket depth, clinical attachment loss and cfpwv (r=0.024, p=0.407 and r=0.011, p=0.456); whereas there was a weak positive correlation between pocket depth and pwv (r=0.294, p=0.041) in well-controlled type 2 diabetics. conclusion: most of type-2 diabetics had severe periodontitis; however, the correlation between periodontitis and arterial stiffness could not be concluded in this study. keywords: periodontitis, pocket depth, clinical attachment loss, pulse wave velocity (pwv). introduction periodontitis is the most common cause of chronic infection in diabetes worldwide and in indonesia.1-4 the relationship between diabetes and periodontitis is working both ways. diabetes is known as a predisposing factor for developing periodontitis; while periodontitis may contribute to metabolic control derangement in diabetes. mechanisms underlying this relationship involve biofilm formation and defective immune system. oral plaque may form biofilm of gram-negative bacteria that induce activation of specific and non-specific immune system.5 meanwhile in diabetes, immune system defects occur in all phase of inflammation. in diabetes, there is a down regulation of icam-1 and age-mediated crosslink disruption, which lead to pmn adhesion and chemotaxis disturbance. age also may disrupt interaction between leucocytes and endothelial cells.6 hyper-reactivity of monocytes after lps exposure and agemediated activation of nf-kb results in increment of pro-inflammatory cytokine production in diabetes.7 this abundant cytokine production may lead to premature apoptosis of pmns and forbidding their bacterial killing ability. loss of bacterial killing activity combined with abundant pro-inflammatory cytokine production cause extensive destruction of periodontal tissue and alveolar bone. o r a l e n d o t o x i n , b a c t e r i a a n d p r o inflammatory cytokine may leak into systemic c i r c u l a t i o n w h e n s e v e r e d e s t r u c t i o n o f periodontal tissue occurs or during oral hygiene procedure such as tooth brushing, scaling and even with gentle mastication. this leak can cause low-grade systemic inflammation that may play a role in inducing atherogenesis. continuous inflammation will lead to lack of elastin production and increased production of collagen due to activation of fibroblasts. in addition, the matrix metalloproteinase (mmp) enzyme produced by activation of neutrophils and macrophages will degrade the vascular extracellular matrix which results in weakened collagen crosslinking and impairing elastin. both of the above mechanisms are accompanied by endothelial impairment due to ros contributing to the role in decreasing vascular distensibility, which is the initial stage of atherosclerosis. in compliant blood vessel, which has high shear stress, the endothelium will produce nitrite oxide (no) a vasodilator agent.8 whereas low shear stress condition, which occurs in rigid arteries, will lead to endothelial dysfunction that may play a role in atherosclerosis initiation.9 this increased inflammatory burden may exacerbate cardiovascular risk of type 2 diabetes patients with chronic infection such as periodontitis. periodontitis has been shown to be associated with clinically proven atherosclerosis and has a role in increasing cardiovascular risk.10–12 this data is supported by a study, which shows that non-surgical periodontal management plays a role in improving the progression of atherosclerosis.13 several studies have attempted to link periodontitis with subclinical atherosclerosis, which is assessed by some surrogate marker modalities; however, the results are different in each study. subclinical atherosclerosis can be measured by structural parameter such as carotid intima media thickness or by functional parameter. in general population, there is a linear relationship between the anandhara i. khumaedi acta med indones-indones j intern med 322 severity of periodontitis and the increase in the thickness of tunica intima media.14–16 these data are supported by reports of improvement of carotid thickness after periodontal treatment. on the other hand, studies using subclinical atherosclerotic functional parameters showed contradictory results.14,16-18 our study aimed to investigate the relationship between periodontitis and arterial stiffness measured by carotid femoral pwv (pulse wave velocity) in type-2 diabetes population. methods our study was a cross-sectional study involving 97 subjects. all of the subjects were recruited at an endocrinology outpatient clinic between april and august 2017. the study protocol had been approved by an appropriate ethics commission under the number of 130/un2.f1/etik/2017. the inclusion criteria were type-2 diabetic patients who were above 18 years old. patients with history of cerebro-cardio-vascular diseases, autoimmune diseases, gestational diabetes, recent antimicrobial consumption and who had ongoing infection were excluded from the study to prevent bias from other sources of inflammation. all participants agreed to participate in our study and had signed the informed consent form before all examinations were performed. all subjects were interviewed to obtain basic medical history such as duration of diabetes, diabetes complications, comorbidities and medications. the height, weight and office blood pressure were measured. the laboratory tests, pulse wave velocity (pwv) measurement and periodontal examination were conducted in the same day. laboratory measurement l a b o r a t o r y e x a m i n a t i o n i n c l u d e d measurement of quantitative c-reactive protein (crp), which was considered as a sign of systemic inflammation and hba1c. hba1c measurement was performed using ngsp-certified highperformance liquid chromatography method and crp measurement was done using elisa technique. arterial stiffness measurement cuff-based tonometry technique using a device, sphygmocor xcel was used to measure arterial stiffness in this study. the measurement was conducted in a temperature-controlled room (20oc) and all of the subjects had adequate rest for minimum 10 minutes before they proceeded to the measurement. during the measurement, all of the subjects were advised to remain still and refrain themselves from talking. patients laid in supine position and femoral cuff was placed on their left leg with its lower border 5 cm above the upper border of the patella. pwv was calculated from the measurement of the pulse transit time generated using a cuff-based device placed between femoral and carotid artery (carotid-femoral pwv). periodontal measurement periodontal examination was conducted by a certified periodontist. all participants underwent full-mouth examination. periodontal probe used in this study was aesculap® db874r periodontal probe. periodontal parameters used in this study included pocket depth (pd), clinical loss attachment (cal), bleeding on probing (bop) and plaque index (pi). pocket depth was defined as the distance between gingival margin and the base of pocket measured by periodontal probe. clinical loss attachment was measured using one fixed reference point (cemento-enamel junction). both cal and pd were recorded in millimeter (mm). the cal and pd scores were based on maximum cal and pd after fullmouth examination. bleeding on probing were measured according to saxer and muhlemann19 classification. the final bop score was the total score divided by the number of site examined. oral hygiene was measured using plaque index according to sillness and loe.19 the final score was the total score divided by the number of sites examined. all subjects were classified based on their cal according to american academy of periodontology 1999 criteria: (1) cal of 1-2 mm: mild periodontitis, (2) 3-4 mm: moderate periodontitis and (3) cal >5 mm: severe periodontitis. statistical analysis the obtained data were processed with statistical analysis using spss software program version 21.0. descriptive statistic was conducted to obtain the baseline characteristics of the study vol 50 • number 4 • october 2018 association of periodontitis and arterial stiffness in type 2 diabetic patients 323 subjects including age, sex, duration of diabetes, hba1c values, and quantitative crp level. goodness-to-fit test (kolmogorov-smirnov) was performed to acquire data distribution. all variables were not normally distributed and logarithmic transformation failed to normalize the data. further statistical analysis in this study was done using non-parametric test. baseline characteristics were presented based on periodontitis severity, which were expressed in median (interquartile range/iqr) for numeric data and percentage (%) for nominal data. correlation between pd and pwv as well as correlation between cal and pwv were analyzed using spearman correlation test. the interaction among other variables that were thought to interfere with the association including hba1c level, hypertension and age could not be assessed using multivariate analysis because all variables were not normally distributed and transformation failed to normalize the data. therefore, stratification analysis or by subgroup analysis based on hba1c level, hypertension and age were performed to analyze correlation between pd and cal; with pwv based on metabolic control, hypertension and age. in subgroup analysis, hba1c level was categorized as well-controlled and poor controlled level using a cut-off point of 7% hba1c target. hypertension was classified by the presence of hypertension in medical history, which was defined as objective proof of hypertension during blood pressure measurement or the patient was currently taking anti-hypertension drugs. as with age, the subjects were divided into two groups, i.e. those under 50 years and those above 50 years. the age of fifty years was used as a cutoff point since the significant change of arterial stiffness starts at the age of 50 years old in normal population.20 results a total of 97 subjects were included in the study. baseline characteristic of this study are summarized in table 1. female participants were comprised more than two-third of total participants. the median age of the subjects in this study was 51 years with an age range of 24 to 59 years. most of the participants had severe periodontitis (75.3%) and generalized disease (71.2%). metabolic and oral hygiene profile based on periodontitis severity are summarized in table 2. one participant did not suffer from periodontitis; thus, she was not included in the descriptive analysis. the median age of the subject increased with the degree of periodontitis. the median bop value in our study was 0.819, which belong to the mild gingivitis group. the mean plaque index in these patients was 1.619, indicating moderate category in oral hygiene. subjects in the severe periodontitis group had poorer dental hygiene compared with subjects in mild and moderate periodontitis. bop value also increased with the severity of periodontitis; however, subjects of the all three groups still had relatively mild gingivitis. the median duration of diabetes gained from interview in this study was 6 years. median hba1c was 8.2% with a range of 5.6 to 14.3%. patients with moderate and severe table 1. baseline characteristic of the study variables values gender, n (%) male 29 (29.9) female 68 (70.1) age (years), median (iqr) 51 (44.5 – 55.0) bmi (kg/m2), mean (sd) 26.6 (4.17) duration of diabetes (years), median (iqr) 6 (4 – 12) periodontitis, n (%) none 1 (1.0) mild periodontitis 7 (7.2) moderate periodontitis 16 (16.5) severe periodontitis 73 (75.3) extent, n (%) localized 28 (28.9) generalized 71 (71.1) pd (mm), median (iqr) 5 (1 – 6) cal (mm), median (iqr) 5 (4.5 – 7.0) bop, median (iqr) 0.8 (0.4 – 1.4) pi, mean (sd) 1.6 (0.72) pwv (m/s), mean (sd) 7.17(1.18) hba1c (%), median (iqr) 8.2 (6.7 – 9.5) crp (mg/l), median (iqr) 2.8 (1 – 4.8) bmi = body mass index, bop= bleeding on probing, cal = clinical loss of attachment, crp = c-reactive protein, pi = plaque index, pwv = pulse wave velocity anandhara i. khumaedi acta med indones-indones j intern med 324 table 2. metabolic and oral hygiene profile according to periodontitis severity variables mild periodontitis (n=7) moderate periodontitis (n=16) severe periodontitis (n=73) age (year), median (iqr) 45 (35 – 47) 50 (37 58) 52 (24 59) bmi (kg/m2), mean (sd) 26.0 (2.9) 29.1 (3.7) 25.8 (4.14) duration of diabetes (years), median (iqr) 5 (0.5 – 10.0) 5 (2.2 – 9.0) 7 (4.5 – 13.0) pd (mm), median (iqr) 5 (4 – 7) 3 (1 – 5) 5 (2 – 6) cal (mm), median (iqr) 5 (2 – 7) 4.5 (3 – 5) 6 (5 – 7) bop, median (iqr) 0.6 (0.2 – 0.9) 0.9 (0.5 – 1.4) 0.8 (0.4 – 1.5) pi, mean (sd) 1.2 (0.78) 1.1 (0.54) 1.7 (0.6) pwv (m/s), median (iqr) 5.8 (5.6 – 7.9) 7.1 (6.0 – 7.9) 7.0 (6.3 – 8.1) hba1c (%), median (iqr) 7.5 (6.8 – 8.7) 7.9 (6.4 – 9.4) 7.9 (6.7 – 9.9) crp (mg/l) median (iqr) 1.3 (0.7 – 3.9) 2.7 (1.7 – 6.8) 2.8 (1.0 – 4.8) bmi = body mass index, bop= bleeding on probing, cal = clinical loss of attachment, crp = c-reactive protein, pi = plaque index, pwv = pulse wave velocity figure 1. correlation of pd and cal with pwv periodontitis showed longer duration of illness, poorer metabolic control as represented by higher hba1c levels, older age and higher level of quantitative serum of crp. in this study, bivariate analysis was conducted to identify the correlation between pd, cal and arterial stiffness. correlation coefficient and p value between pd, cal and pwv is displayed in figure 1. since the multivariate analysis to assess interaction between hba1c, hypertension and age could not be performed, stratification by subgroup analysis was carried out by considering the risk factors found in the literatures that may affect the results of pwv. hba1c was divided into two groups based on the target of metabolic control in diabetes. the value of 7% was considered as the controlled level of hba1c. in groups with controlled hba1c, there was a weak correlation between pocket depth and pwv. while in uncontrolled hba1c group, there was no significant correlation between pd and cal against pwv. there was no significant correlation found in subgroup analysis for both hypertension and age. correlation in subgroup analysis is summarized in figure 2. discussion there is a notion that a positive correlation between pd and cal with pwv has not been proven in this study (pd: r = 0.024, p = 0.407 and cal: r = 0.011, p = 0.406). to our knowledge, no study on the association of pd and cal with cfpwv in dm populations has ever been conducted. heterogeneous subject characteristics, with different dm duration, vol 50 • number 4 • october 2018 association of periodontitis and arterial stiffness in type 2 diabetic patients 325 different metabolic controls, long life span, comorbidity and drug use may contribute to such result. however, there are some reports showing links between periodontitis and cardiovascular risk. several studies have shown that patients with periodontal disease have a fourfold risk of coronary heart disease.21,22 periodontitis also has been shown to be associated with clinically proven atherosclerosis and has a role in increasing cardiovascular risk.10–12 this data is supported by a study suggesting that non-surgical periodontal management plays a role in improving the progression of atherosclerosis.13 several studies have attempted to link periodontitis with subclinical atherosclerosis assessed by some surrogate marker modalities; however, the results are different in each study. subclinical atherosclerosis could be measured by structural parameter such as carotid intima media thickness (cimt), or by functional parameter such as pwv. in general population, there is a linear relationship between the severity of periodontitis and increase in the thickness of the tunica intima media.14–16 these data has been supported by reports showing improvement of carotid thickness after periodontal treatment. on the other hand, studies using subclinical atherosclerotic functional parameters have indicated contradictory results as described above.14,16–18 studies regarding arterial stiffness and periodontitis have shown contradictory results. several studies have demonstrated significant connection between arterial stiffness and periodontitis.16,23 both studies were conducted in general population and excluding subjects with traditional risk factors of cardiovascular or adjusting cardiovascular risk factors such as hypertension and age. the positive correlation was found to be weak in one study16 and the mean difference was small in another study; thus, its clinical significance was questionable.23 different results found in the two abovementioned studies with our study is likely to be influenced by the different characteristics of study subjects and the significant difference in the number of subjects involved. however, those results support the temporal relationship between risk of atherosclerosis and periodontitis in absence of other traditional risk factors. subgroup analysis of our study had suggested a weak positive relationship between periodontitis and arterial stiffness in well-controlled diabetes group as shown by hba1c level of <7%. other two studies, which had suggested similar result with results of our study, come from franek et al14 and miyaki et al17. franek et al14 showed that there was no difference between mean pwv in patients with periodontitis, gingivitis and healthy subjects; whereas significant difference was found in cimt. their study was conducted in type-2 diabetes population. miyaki et al17 also showed that there was no association between periodontitis and atherosclerosis measured by brachial ankle pwv (bapwv) after adjustment to traditional cardiovascular risk factors; however, the number of subjects involved was way less than the previous study.16 the contradictory result should be interpreted carefully. there are several factors that affect the value of pwv, including age, hypertension, duration of dm and hba1c level.1 chronic figure 2. correlation of pd and cal with pwv in hba1c > 7% group anandhara i. khumaedi acta med indones-indones j intern med 326 hyperglycemia exposure and enzymatic glycation that cause cross-reaction with collagen in the intimal layer of blood vessels will change the composition of blood vessel walls that reduce the elasticity of blood vessels. increasing activity of local renin-angiotensin-aldosterone in hypertension also causes vascular smooth muscle hypertrophy that will increase arterial stiffness.24 as in the effect of medications, studies in the general population show that angiotensin converting enzyme inhibitors (acei), aldosterone receptor blocker (arb), statins and calcium channel blockers have been shown to decrease the value of pwv in both acute and chronic administration. termination of the activation path of renin-angiotensinaldosterone (raa) will prevent vascular remodelling and improve aortic distensibility; while calcium channel blockers decrease arterial stiffness by vasodilation of blood vessels.8 the effect of statins on cfpwv is still under debate. on the one hand, statins will decrease the cfpwv of the population at risk, but in the general population study, it has been known that statin administration for 6 months does not provide a significant decrease in aortic pwv.25,26 no studies have examined the association of metformin with cfpwv in people with dm, but the underlying mechanism of cfpwv declining in diabetes patient possibly occurs through improvement of hba1c level. hence, our study might show the temporal association between periodontitis and risk of atherosclerosis in patients without traditional cardiovascular risk factor as the subgroup analysis showed positive correlation between pocket depth and pulse wave velocity. this is also supported by two previous studies that have demonstrated the relationship between periodontitis and arterial stiffness if traditional risk factors are ruled out by design or by statistical analysis.16,23 it may indicate that there is an association between periodontitis and risk of atherosclerosis; however, the association is weak and may be blunted by the influence of other uncontrolled and more prominent cardiovascular risk factors. as far as our concern, there is no study that has evaluated the association between periodontitis and arterial stiffness in well-controlled diabetic patients. the main limitations of our study were heterogeneous subject characteristics such as age, different diabetes duration, metabolic control and diabetic complications. the effects of medication could not be disregarded as they are given in accordance with the indications, so that the cessation of such drugs would violate ethics. our study was a hospital-based study, in which all subjects were recruited from an outpatient clinic setting; therefore, it may not represent the general diabetes population. also, the cross-sectional design in this study could not show causal relationship between periodontitis and the risk of atherosclerosis. further studies regarding association between periodontitis and arterial stiffness in well-controlled diabetes is needed. conclusion in general, this study failed to show the relationship between periodontitis and arterial stiffness in type-2 diabetes patients. such result may be blunted by more prominent traditional cardiovascular risk factors as the subgroup analysis showed the possible temporal association between periodontitis and arterial stiffness in patients with well-controlled diabetes. further studies are required, particularly on the association between periodontitis and arterial stiffness in well-controlled diabetic patients. acknowledgments we would like to thank dr. sm and dr. ci for their technical support and scientific advice. funding this research was fully supported by study grant from ministry of research, technology and higher education of the republic of indonesia. references 1. nelson r, shlossman m, budding l, et al. periodontal disease and niddm in pima indians. diabetes care. 1990;13(8):836–40. 2. borgnakke ws, ylöstalo p v, taylor gw, genco rj. effect of periodontal disease on diabetes : systematic review of epidemiologic observational evidence. j periodontol. 2013;84(4):135–52. vol 50 • number 4 • october 2018 association of periodontitis and arterial stiffness in type 2 diabetic patients 327 3. emor sf, pandelaki k, supit asr. hubungan status periodontal dan derajat regulasi gula darah pasien diabetes melitus. j e-gigi. 2015;3(1):210–5. 4. susanto h, nesse w, dijkstra pu, agustina d, vissink a, abbas f. periodontitis prevalence and severity in indonesians with type 2 diabetes. j periodontol. 2011;82(4):550–7. 5. klokkevold p, mealey b. influence of systemic conditions on the periodontium. in: newman m, takei h, klokkevold p, carranza f, eds. carranza’s clinical periodontology. 11th ed. philadelphia: elsevier saunders; 2015. p. 304–9. 6. preshaw p, alba a, herrera d, et al. periodontitis and diabetes: a two-way relationship. diabetologia. 2012;55(1):21–31. 7. mealey b, klokkevold p. impact of periodontal infection on systemic health. in: takei h, klokkevold p, carranza f, newman m, eds. carranza’s clinical periodontology. 12th ed. elsevier inc.; 2015. p. 328–30. 8. shirwany na, zou m. arterial stiffness: a brief review. acta pharmacol sin. 2010;31(10):1267–76. 9. brown a, teng z, evans p, et al. role of biomechanical forces in atherosclerosis. nat publ gr. nature publishing group. 2016;1:11. 10. demmer r, desvraieux m. periodontal infection and cardiovascular disease. j am dent assoc. 2006;137:14–20. 11. friedewald ve, kornman ks, beck jd, et al. the american journal of cardiology and journal of periodontology editors’ consensus: periodontitis and atherosclerotic cardiovascular disease. am j cardiol. 2009;104(1):59–68. 12. greenberg ems. meta-analysis of periodontal disease and risk of coronary heart disease and stroke. oral surg oral med oral pathol oral radiol endod. 2003;95(5):559–69. 13. kapellas k, maple-brown lj, jamieson lm, et al. effect of periodontal therapy on arterial structure and function among aboriginal australians: a randomized, controlled trial. hypertension. 2014;64(4):702–8. 14. franek e, januszkiewicz-caulier j, blach a, et al. intima-media thickness and other markers of atherosclerosis in patients with type 2 diabetes and periodontal disease. kardiol pol. 2012;70(1):7–13. 15. kapellas k, jamieson lm, do lg, et al. associations between periodontal disease and cardiovascular surrogate measures among indigenous australians. int j cardiol. elsevier ireland ltd; 2014;173(2):190–6. 16. hayashida h, saito t, kawasaki k, et al. association of periodontitis with carotid artery intima-media thickness and arterial stiffness in communitydwelling people injapan: the nagasaki islands study. atherosclerosis. elsevier ltd; 2013;229(1):186–91. 17. miyaki k, masaki k, naito m, et al. periodontal disease and atherosclerosis from the viewpoint of the relationship between community periodontal index of treatment needs and brachial-ankle pulse wave velocity. bmc public health. 2006;6(131):1–6. 18. vieira clz, cury pr, miname mh, et al. severe periodontitis is associated with diastolic blood pressure elevation in individuals with heterozygous familial hypercholesterolemia: a pilot study. j periodontol. 2011;82(5):683–8. 19. augusta m, rebelo b, queiroz ac de. gingival indices: state of art. 2009. 20. mceniery cm, yasmin, hall ir, et al. normal vascular aging: differential effects on wave reflection and aortic pulse wave velocity the anglo-cardiff collaborative trial (acct). j am coll cardiol. 2005;46(9):1753–60. 21. arbes s, slade g, beck j. association between extent of periodontal attachment loss and self-reported history of heart attack: an analysis of nhanes iii data. j dent res. 1999;78(12):1777–82. 22. beck j, elter j, heiss g, et al. relationship of periodontal disease to carotid artery intima-media wall thickness: the atherosclerosis risk in communities (aric) study. arter thromb vasc biol. 2001;21(11):1816–22. 23. houcken w, teeuw wj, bizzarro s, et al. arterial stiffness in periodontitis patients and controls a case – control and pilot intervention study. nat publ gr. nature publishing group; 2015;30(1):24–9. 24. catalano m, scandale g, dimitrov g. arterial stiffness: a review in type 2 diabetes. 2013. 25. orr js, dengo al, rivero jm, davy kp. arterial destiffening with atorvastatin in overweight and obese middle-aged and older adults. hypertension. 2009;54:763–8. 26. pirro m, schillaci g, mannarino mr, et al. effects of rosuvastatin on 3-nitrotyrosine and aortic stiffness in hypercholesterolemia. nutr metab cardiovasc dis. 2007;17:436–41. clinical practice 177acta med indones indones j intern med • vol 50 • number 2 • april 2018 current diagnosis and management of graves’ disease imam subekti1, laurentius a. pramono2 1 department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of internal medicine, st. carolus hospital, jakarta, indonesia. corresponding author: imam subekti, md., phd. division of endocrinology and metabolism, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo. jl. diponegoro 71, jakarta 10430, indonesia. email: isubekti@yahoo.com. abstrak penyakit graves atau graves’ disease merupakan penyakit autoimun yang mengenai kelenjar tiroid. penyakit graves merupakan penyebab tersering hipertiroidisme dan tirotoksikosis. pemahaman mengenai patofisiologi penyakit, strategi diagnosis dan terapi, serta pencegahan relaps penting diketahui oleh semua klinisi khususnya spesialis penyakit dalam untuk memberikan manajemen yang optimal dan komprehensif bagi pasien penyakit graves. artikel ini memberikan poin-poin klinis untuk manajemen pasien dengan penyakit graves berdasarkan review dan guidelines terbaru dari american thyroid association (ata), european thyroid association (eta), dan japan thyroid association/ japan endocrine society. kata kunci: penyakit graves, tiroid, american thyroid association (ata), european thyroid association (eta), japan thyroid association/ japan endocrine society. abstract graves’ disease (gd) is an autoimmune disorder which affect thyroid gland. graves’ disease is the most common cause of hyperthyroidism and thyrotoxicosis. understanding of disease pathophysiology, diagnostic and treatment strategies, and prevention of disease relapse are important for all clinicians especially internal medicine specialist to give optimal and comprehensive management for gd patients. this article highlights clinical points to treat gd patients from reviews and latest guidelines from american thyroid association (ata), european thyroid association (eta), and japan thyroid association/ japan endocrine society. keywords: graves’ disease, thyroid, american thyroid association (ata), european thyroid association (eta), japan thyroid association/ japan endocrine society. introduction graves’ disease (gd) was originally described by the irish physician, robert james graves in 1835. graves’ disease includes signs and symptoms consisting of goiter, palpitation (tachycardia), and exophtalmus.1 graves’ disease represents a part of more extensive autoimmune thyroid disease (aitd), leading to dysfunction of multiple organs, marked by the presence of thyroid stimulating hormone receptor antibody (trab).2 moreover, gd is different from any other autoimmune diseases, because it does not correlate with hypo-function, but on the contrary causes hyper-function of the organ (thyroid). hyperfunction of the thyroid can lead to thyrotoxicosis and enlarged of the thyroid gland.3 imam subekti acta med indones-indones j intern med 178 prevalence of gd is relatively high compared to other hyperthyroidism causes. according to weetman, from all hyperthyroidism cases, there are 60-80% cases which diagnosed with graves’ disease. these findings are affected by regional factors especially iodine intake.3 study at cipto mangunkusumo general hospital in 2004 showed that the prevalence of hyperthyroidism cases from all thyroid problems were 21%.4 knowing the fact that gd is an autoimmune disease, relapsing cases are common which can lead to prolonged time to treat the disease. like any other autoimmune diseases, remission time of this disease cannot be determined. from this statement, we need to understand the concept of treatment concerning the pathophysiology of graves’ disease. the aim of this review is to refresh clinical management points of gd from reviews and the latest guidelines (american thyroid association, european thyroid association, and japan thyroid association/ japan endocrine society). diagnosis diagnosis of graves’ disease (gd) made based on signs, symptoms, and the result of the ancillary laboratory tests. manifestation of this disease is the merseburger triad that consists of thyrotoxicosis, diffuse goiter, and ophthalmopathy (orbitopathy). other than those, dermopathy is also one of the manifestation of graves’ although it has low prevalence.5 manifestation of graves’ are various, from mild to full blown. the common signs and symptoms of graves are shown in table 1. clinically, gd can be diagnosed based on the signs and symptoms of thyrotoxicosis. although the diagnosis can be determined, treatment should be based on the result of the laboratory test (tshs and free t4) to confirm the diagnosis and as a basis for treatment evaluation. the same course of action (checking laboratory values) is applied if the signs and symptoms of thyrotoxicosis does not appear or unclear. based on low concentration of tshs and high ft4 concentration (depending on the reagents), the diagnosis of gd can be determined. t3 examination is needed if physical examination leads to gd, but the laboratory result shows low tshs concentration with normal ft4 value. when there is a doubt on the signs and symptoms of thyrotoxicosis, absence of visible enlargement of thyroid gland, scintigraphy (thyroid nuclear scan) can be done. even after doing all of those tests, it is not uncommon for the diagnosis of gd to still be undetermined. when that happen, trab test is recommended. the concentration of trab can be used for diagnostic purpose and evaluation of treatment and remission.6 treatment the goal treatment of gd is to control and correct the condition based on the pathophysiology of graves’ disease (antigen-antibody reactions in the thyroid glands). glucocorticoid can reduce the conversion of t4 to t3 and lower the thyroid hormone with unknown mechanism. considering the long duration of gd treatment, prolonged use of glucocorticoid may lead to more harm than benefits, therefore it is not usually used as first line treatment.7 modalities for gd treatment consists of antithyroid drugs, surgery, and radioactive iodine treatment (rai) with iodium-131 (131i). the choice of treatment is based on several factors; severity of the thyrotoxicosis, age, size of the goiter, availability of the modalities, response of the treatments, and other comorbidities.7 anti-thyroid drugs there are 2 types of anti-thyroid drugs which are propylthiouracil (ptu) and methimazole. ptu works by inhibiting the organification of iodides and coupling process, while methimazole inhibits the oxidation of iodine in the thyroid table 1. the common signs and symptoms of graves’ signs symptoms hyperactivity palpitation tachycardia agitation atrial fibrilation fatigue systolic hypertension heat intolerant warm and moist skin tremor hyper-reflexia increase apetite muscle weakness weight loss menstrual disorder vol 50 • number 2 • april 2018 current diagnosis and management of graves’ disease 179 gland. if one of these drugs used as a primary therapy, it should be given for at least 12-18 months, and will be stopped as the concentrations of tsh and trab reach normal value. azizi, et al8 reported that prolonged use of anti-thyroid drugs is effective and safe, especially for adults. therefore, anti-thyroid drugs is the first choice of treatment in graves’ disease. indication of oral anti-thyroid drugs: a). high possibility of remission (woman, mild clinical manifestation, mild goiter, negative or low trab); b). pregnant woman with gd; c). elderly, or comorbidity with other diseases that increases risk of surgery or short life expectancy; d). patients in nursing home or other health care facilities, unable to follow the regulation of radioactive iodine therapy; e). history of surgery or neck radiation; f). limited thyroid surgeon in the area; g). moderate or severe graves’ ophthalmopathy; h). immediate needs to lower thyroid (ft4) level.7 surgery near total and total thyroidectomy are the main types of surgery in hyperthyroidism cases. indication of surgery: a). woman planning on pregnancy in less than 6 months; b). enlarged goiter and compression of other organs surrounding thyroid gland; c). low uptake on the thyroid scanning; d). malignant or suspicious/indeterminate on the cytology examination; e). thyroid nodules larger than 4cm, or nonfuctioning or hypofunctioning on the thyroid scanning; f). hyperparathyroidism; g). high trab level (difficult of treat with antithyroid drugs); h). moderate or severe active graves’ ophthalmopathy.7,9 risks of thyroidectomy surgery are bleeding, paralysis of the vocal cord, and hypocalcemia. these risks can be minimalized by trained and experienced thyroid of head-neck surgeon.9 radioactive iodine therapy (rai) rai can be applied in patients with risks of anti-thyroid drugs side effect and with comorbidities. indication of rai therapy: a). woman planning on pregnancy more than 6 months after rai therapy; b). comorbidities that may increase surgery risks; c). history of surgery or external neck radiation; d). limited thyroid surgeon in the area; e). contraindicated for anti-thyroid drugs or failure to reach euthyroidism with drugs; f). patients with periodic thyrotoxicosis hypokalemic paralysis, right heart failure caused by pulmonary hypertension or congestive heart failure.7 other than those modalities, inhibition of beta adrenergic is recommended for all thyrotoxicosis patients with clear manifestations, especially in elderly, those with pulse of > 90x/ minute, or any other cardiovascular diseases. benefits of beta blocker are: a. decrease the hyper adrenergic-thyrotoxicosis signs and symptoms (palpitation, tremor, anxiety, and heat intolerant) rapidly before thyroid hormone reaches normal level. b. prevent the episodes of hypokalemic periodic paralysis. c. inhibit the conversion of t4 to t3 in the peripheral with high dose propranolol. d. preparation for surgery. relapse as an autoimmune disease, graves’ disease (gd) is a ‘relapse and remission’ disease. graves’ disease patients have a chance to experience relapse after stopping anti-thyroid drugs. these days, many explanation and evidences about relapse of gd published in many scientific forum and review. systematic review and meta-analysis from struja, et al.10 showed that occurrence of ophthalmopathy, smoking, thyroid volume and goiter size, ft4, ft3, trab, and tbii value were associated with disease relapse, while male sex, age, and initial t4 were not associated with relapse. study from eliana f, et al.11 in indonesian population revealed that besides family history, age at diagnosis, second degree of ophthalmopathy, enlarged thyroid gland which exceeded the lateral edge of the sternocleidomastoid muscles and duration of remission period; genetic polymorphisms of ctla-4 gene, tshr gene, and number of regulatory t cells and trab levels play a role as risk factors for relapse in patients with graves’ disease. titration of anti-thyroid drugs regimen for 12-18 months is an optimal strategy for preventing relapse in gd patients. it is not imam subekti acta med indones-indones j intern med 180 recommended to administer levothyroxine after successful anti-thyroid drugs treatment. studies give evidences to add immunosuppressive agents to decrease the recurrence rate after anti-thyroid drugs. consumption of vitamin d, selenium, and stop smoking may also beneficial to prevent relapse in gd patients.12 thyroid storm the most severe and acute condition of gd is thyroid storm or thyroid crisis which is an endocrine emergency. the diagnosis of thyroid storm is made by clinical observation and systemic decompensation of thyrotoxicosis with a known precipitating factors or triggering illnesses. since the mortality rate is very high, early suspicion, prompt diagnosis, and intensive management are needed by clinician in primary care and hospital.13 for decades, clinician used burch and wartofsky clinical scoring consists of temperature, central nervous system problems, heart rate and rhythm, congestive heart failure, gastrointestinal problems, and presence of precipitant history.7 these scoring system is very sensitive so that all cases with suspicious condition like thyrotoxicosis and other comorbidity (infection, heart condition, or post-operative patients) can be classified as thyroid storm. in 2016, japan thyroid association and japan endocrine society published new guideline for diagnosis and treatment of thyroid storm. this guideline is very comprehensive and clear to guide clinician for making diagnosis of thyroid storm. in japanese guideline, for making diagnosis of thyroid storm there must be presence of thyrotoxicosis with elevated level of ft3 or ft4 as prerequisite condition. definite thyroid storm is a condition when thyrotoxicosis and at least one central nervous system manifestation and fever, tachycardia, congestive heart failure, of gi/hepatic manifestations, or thyrotoxicosis and at least three combinations of fever, tachycardia, congestive heart failure, or gi/hepatic manifestations. suspected thyroid storm is a condition when thyrotoxicosis and combination of two of the following: fever, tachycardia, congestive heart failure, of gi/ hepatic manifestations, or patients who met diagnosis of definite thyroid storm condition except that serum ft3 or ft4 level are not available.13 these diagnostic criteria are more simple and clear than previous clinical score. t h e p r e s e n t g u i d e l i n e a l s o i n c l u d e s 15 recommendations for the treatment of thyrotoxicosis and systemic organ dysfunction affected by thyroid storm, such as central nervous system, cardiovascular system, gi/hepatic tract, admission criteria for intensive care unit. they also explain preventive approaches to thyroid storm, roles of definitive and supportive therapy of thyroid storm. treatment of thyroid storm includes anti-thyroid drugs (propylthiouracil or methimazole), drugs which blocked thyroid hormones secretion such as sodium iodide, potassium iodide and lugol solution, beta blockers (esmolol, propranolol, metoprolol), intravenous fluid resuscitation, glucocorticoid (hydrocortisone, methylprednisolone, or dexamethasone), and treat the precipitant condition (infection, metabolic or post-operative stress, etc).13 graves’ orbitopathy one special condition which always discussed and updated in many studies and guidelines of gd, hyperthyroidism, or thyrotoxicosis is graves’ orbitopathy (go) or graves’ ophthalmopathy or thyroid eye disease (ted) or thyroid associated ophthalmopathy (tao). this condition needs special attention and close collaboration with ophthalmologist (especially consultant in oculoplastic surgery or thyroid eye disease specialist). the latest guideline focusing on graves’ orbitopathy is the 2016 european thyroid association/eugogo (european group on graves’ orbitopathy) guidelines for management of graves’ orbitopathy.14 in this guideline, clearly stated all diagnostic modalities to diagnose and comprehensive treatment of go. the guideline also stressed about quality of life in patients with go and complete assessment of go. figure 1 is summary treatment algorithm for go patients. vol 50 • number 2 • april 2018 current diagnosis and management of graves’ disease 181 conclusion graves’ disease (gd) is an organ-specific autoimmune disorder that is marked by findings of trab, with manifestation of diffuse goiter, thyrotoxicosis, and ophthalmopathy. the diagnosis is determined by signs and symptoms of thyrotoxicosis, and confirmed by low tshs level and high thyroxin (ft4) level. if needed, trab examination can be done and diagnosis is confirmed by positive result. there are three modalities used to treat gd; anti-thyroid drugs, surgery, and rai therapy. choice of modality depends on the severity of the thyrotoxicosis, size of goiter, age, availability of the anti-thyroid drugs, response to the treatment, and comorbidities. if drugs were used as the primary therapy, it should be given for at least 12-18 months. if surgery is chosen for primary therapy, near total or total thyroidectomy is the choice of surgery. rai therapy can be done if there are side effects of the anti-thyroid drugs, history of neck surgery or external neck radiation. beta blocker can be used to reduce signs and symptoms of thyrotoxicosis and to inhibit the conversion of t4 to t3 in the peripheral organs. relapse is common in the treatment course. risk factors for relapse are presence of ophthalmopathy, smoking, high level of thyroid hormones and antibodies, large thyroid volume, and genetic polymorphisms variations. titration of anti-thyroid drugs for more than 12 months, immunosuppresive agents, vitamin d, selenium, and stop smoking are beneficial to prevent relapse in gd patients. thyroid storm and graves’ orbitopathy are two conditions in gd patients which need collaborative and special treatment. two latest guidelines from japan thyroid association and european thyroid association/eugogo explained comprehensive management of thyroid storm and graves’ orbitopathy respectively. references 1. weetman ap. graves’ disease. n eng j med. 2000;343(17):1236-48. 2. barnett ps, mcgregor am. immunological factors. disease of the thyroid: pathophysiology and management. in: wheeler mh, lazarus jh, eds. cambridge uk: chapman & hall medical; 1994. p. 85-103. figure 1. treatment algorithm of graves’ orbitopathy (go) form mild, moderate to severe, and sight threatening14 imam subekti acta med indones-indones j intern med 182 3. schott m, scherbaum wa, morgenthaler ng. thyrotropin receptor autoantibodies in graves’ disease. trend in endocrinol metab. 2005;16(5):243-8. 4. subekti i. diagnosis dan pengelolaan oftalmopati graves. jakarta endocrinology meeting. jakarta: divisi metabolik endokrinologi, departemen ilmu penyakit dalam fkui/rscm; 2008. p. 30-5. 5. drexhage ha. are there more than antibodies to the thyroid stimulating hormone receptor that meet the eye in graves’ disease. endocrinol. 2006;147(1):9-12. 6. b r e n t g a . g r a v e s ’ d i s e a s e . n e n g l j m e d . 2008;358:2594-605. 7. ross ds, burch hb, cooper ds, et al. american thyroid association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. thyroid. 2016;10:1343-421. 8. azizi f, malboosbaf r. long-term antithyroid drug treatment: a systematic review and meta-analysis. thyroid. 2017;27(10):1223-31. 9. rubio ga, sengul tk, vaghaiwalla tm, parikh pp, farra jc, lew ji. postoperative outcomes in graves’ disease patients: results from the nationwide inpatient sample database. presented at the 86th annual meeting of the american thyroid association, denver, co, september 21-25, 2016. 10. struja t, tehlberg h, kutz a, et al. can we predict relapse in graves’ disease? results from a systematic review and meta-analysis. eur j endocrinol. 2017; 176:87-97. 11. eliana f, soewondo p, asmarinah, et al. the role of cytotoxic t-lymphocyte-associated protein 4 (ctla4) gene, thyroid stimulating hormone receptor (tshr) gene and regulatory t-cells as risk factors for relapse in patients with graves’ disease. acta med indones – indones j intern med. 2017;49(3):195-204. 12. liu j, fu j, xu y, wang g. anti-thyroid drug therapy for graves’ disease and implications for recurrence. int j endocrinol. 2017;1-8. 13. satoh t, isozaki o, suzuki a, et al. guidelines for the management of thyroid storm from the japan thyroid association and japan endocrine society (first edition). endocrine j. 2016;63(12):1025-64. 14. bartalena l, baldeschi l, boboridis k, et al. the 2016 european thyroid association/european group on graves’ orbitopathy guidelines for the management of graves’ orbitopathy. eur thyroid j. 2016;5:9-26. special article 346 acta med indones indones j intern med • vol 50 • number 4 • october 2018 radiofrequency ablation versus resection in large single nodule of hepatocellular carcinoma: an evidence-based case report felix f. widjaja, kemal f. kalista, juferdy kurniawan department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: juferdy kurniawan, md. division of hepatology, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: felixfw@gmail.com. abstrak latar belakang: radiofrequency ablation (rfa) saat ini semakin luas dipergunakan sebagai terapi alternatif reseksi pada pasien dengan karsinoma sel hati (khs). bahkan pada ukuran nodul kurang dari 2 cm, rfa dapat menjadi lini utama pada kasus tersebut. reseksi merupakan terapi utama dan salah satu terapi kuratif pada nodul dengan kriteria milan, tetapi harus dipertimbangkan toleransi operasi pada pasien yang akan menjalani reseksi. pada laporan kasus berdasar bukti ini kami bertujuan memperlihatkan efektivitas rfa dibandingkan reseksi dalam hal kesintasan, tetapi pada khs nodul tunggal berukuran lebih dari 5 cm. metode: pencarian artikel dilakukan dengan menggunakan mesin pencari pubmed, scopus, web of science, dan cinahl dari ebsco dengan kata kunci “hepatocellular carcinoma”, “single nodule”, “radiofrequency ablation”, “resection”, dan “survival”. artikel dibatasi pada artikel berbahasa inggris dengan pertanyaan klinis “pada pasien dengan khs nodul tunggal berukuran lebih dari 5 cm, apakah rfa lebih baik dibandingkan dengan reseksi untuk memperpanjang kesintasan?” hasil: didapatkan tiga artikel penelitian retrospektif dengan satu artikel menggabungkan terapi rfa dan injeksi etanol dalam analisis dan satu penelitian menggabungkan rfa dengan transarterial chemoembolization (tace) dalam analisisnya. dari ketiga penelitian tersebut memperlihatkan penurunan risiko absolut 33% sampai peningkatan risiko absolut 60,6%. kesimpulan: seluruh penelitian menjadikan rfa sebagai alternatif reseksi bila reseksi tidak dapat dilakukan yang berarti tingkat keparahan lebih tinggi pada rfa, sehingga sulit mengambil kesimpulan bahwa rfa memberikan kesintasan lebih buruk. kata kunci: karsinoma sel hati, radiofrequency ablation, reseksi. abstract background: nowadays, radiofrequency ablation (rfa) is applied widely as an alternative therapy of resection in patient with hepatocellular carcinoma (hcc). moreover, in single nodule with size of less than 2 cm, rfa may be the primary treatment. although resection is the main treatment and one of the curative treatments in nodule meeting milan criteria, it needs consideration of risk stratification for surgical resection. this report was aimed to search evidence of rfa compared with rfa in term of survival in patient with hcc single nodule size of more than 5 cm. methods: the searching was done using pubmed, scopus, web of science, dan cinahl from ebsco with keyword of “hepatocellular carcinoma”, “single nodule”, “radiofrequency ablation”, “resection”, and “survival”. the limitation of the article was english with clinical question of “in patient with hcc single nodule size of more than 5 cm, was rfa more superior in resection in term of survival?”. results: there were three articles with retrospective studies. one of the article combined rfa and percutaneous ethanol injection in the analysis, meanwhile another article combined rfa and transarterial chemoembolization. these articles showed conflicting vol 50 • number 4 • october 2018 radiofrequency ablation versus resection in large single nodule of hcc data that showed absolute risk reduction of 33% till absolute risk increment of 60.6%. conclusion: all studies used rfa as the alternative of resection when the the tumor was unresectable which means the severity was higher in rfa group. hence, we can not solely conclude that rfa resulted in worse survival. keywords: hepatocellular carcinoma, radiofrequency ablation, resection. introduction hepatocellular carcinoma is responsible for 90% of liver cancer and is the second highest cause of cancer mortality in the world. most of hcc are caused by hepatitis b and/or hepatitis c, mainly in patients with liver cirrhosis.1 therapy for hcc includes resection, liver transplant, local ablation (includes radiofrequency ablation), transarterial chemoembolization (tace), radiation, and systemic therapy. the decision of treatment depends on nodule size, nodule number, vascular invasion, metastasis, liver function (child-pugh score), and also performance status. national, regional, or international guideline has their own algorithms that have some differences. meanwhile, in some condition, the treatment is needed to be decided by the multidisciplinary team. according to asia pacific association for the study of the liver (apasl)1 and indonesian liver cancer study group (ilcsg),2 resection is the first-line curative treatment for hcc in patient of child-pugh a, but ilcsg along with european association for the study of the liver (easl)3 has less strict criteria that include normal bilirubin, platelet ≥100,000/ml and without portal hypertension (≤10 mmhg). it is recommended that the resection is done using milan criteria, of which diameter less than 5 cm or maximal three nodules with size of less than 3 cm without any vascular invasion or metastasis.1,2 ilcsg stated resection may be done in single nodule with size of more than 5 cm and located in peripheral liver.2 it is clear that nodule size of more than 5 cm which was resected had worse outcome.4 ablation, particularly radiofrequency ablation (rfa) is recommended in hcc patient with child-pugh a or b and multiple nodule ≤3 of size ≤3 cm. moreover, it is the main treatment in nodule with size of ≤2 cm.1,2 ilcsg2 and easl3 recommend rfa as alternative in patient with single nodule size of ≤5 cm. there is still no recommendation about the applicability of rfa in single nodule >5 cm. there are also no clear recommendation about the treatment choice in patient with hcc single nodule size of >5 cm. hence, this evidence-based case report was aimed to search the evidence whether rfa was better than resection in single nodule size of >5 cm. clinical question a-62 year old man was diagnosed with hcc when he was screened for surveilance with ultrasound because of hepatitis b infection. the patient had a comorbid of coronary artery disease and underwent coronary bypass 5 years ago and still consumes clopidogrel and aspilet. the patient also had hypertension and it was controlled with amlodipin 10mg once daily. there was no complaint of sleep disturbance or other complaints of hepatic encephalopathy. no abnormality was found in physical examination. ascites was not found at physical or radiological examination. afp showed 4.7 iu/ml, hbsag was positif, albumin 4.0 mg/dl, bilirubin total 0.47 mg/dl, and inr 1.02. the liver status was child-pugh a. triple-phase abdominal computed tomography showed single nodule with size of 5.4x4.2x3.9 cm3 in segment 4a of liver. there was no metastasis. the patient asked whether there was another option (like rfa) than resection considering the comorbidity of the patient. based on the information from the presented case, the formulation of clinical question and pico framework are as follows: • p : hepatocellular carcinoma single nodule size of >5 cm. • i : radiofrequency ablation • c : resection • o : survival in hcc patients with single nodule size of >5 cm, how was the survival between rfa and resection? 347 felix f. widjaja acta med indones-indones j intern med methods the articles were searched in pubmed, cinahl (ebsco), web of science, and scopus on 11th desember 2017, with keywords of hepatocellular carcinoma, single nodule, radiofrequency ablation, resection, and survival, but in pubmed we omited the survival because of the lack of results (table 1). search strategy and the description including the inclusion and exclusion criteria was described in figure 1. table 2. search strategy according clinical question conducted in december 11th 2017 search engine description no. of articles web of science topic: (single nodule) and topic: (hepatocellular carcinoma) and topic: (radiofrequency ablation) and topic: (resection) and topic: (survival) 66 refined by: document types: ( article ) timespan: all years. indexes: sci-expanded, ssci, a&hci, cpci-s, cpcissh, bkci-s, bkci-ssh, esci. pubmed ((((("single person"[mesh terms] or ("single"[all fields] and "person"[all fields]) or "single person"[all fields] or "single"[all fields]) and nodule[all fields]) and ("carcinoma, hepatocellular"[mesh terms] or ("carcinoma"[all fields] and "hepatocellular"[all fields]) or "hepatocellular carcinoma"[all fields] or ("hepatocellular"[all fields] and "carcinoma"[all fields]))) and (radiofrequency[all fields] and ablation[all fields])) and resection[all fields]) and english[lang] 19 cinahl (ebsco) (single nodule) and (hepatocellular carcinoma) and (radiofrequency ablation) and (resection) and (survival) 27 scopus all ( "single nodule" ) and all ( "hepatocellular carcinoma" ) and all ( "radiofrequency ablation" ) and resection and all ( "survival" ) and ( limit-to ( doctype , "ar" ) ) and ( limit-to ( language , "english" ) ) 104 single nodule and hepatocellular carcinoma and resection and and radiofrequency ablation survival limit: article, english exclusion criteria: review web of science pubmed ebsco scopus 66 15 7 104 screening title and abstract 1 2 1 2 article gathered : 6 duplication : 3 article used : 3 figure 1. flow chart of search strategy *without keyword of survival 348 vol 50 • number 4 • october 2018 radiofrequency ablation versus resection in large single nodule of hcc selection after searching the articles, we found six articles from four search engines. three articles were duplicated, so there are three articles that were available and being appraised. all three articles are retrospective study. results ogihara et al5 did the study retrospectively in two health centres in honolulu, japan. total subjects were 87 hcc patients with single nodule recruited from period of 1995 until 2003. of total 40 patients undergone rfa, 36 patients had unresectable lesions or low healthy liver volume and 4 patients refused to undergo surgery. they divided to two groups, lesion with ≤5 cm or >5 cm and resection or rfa so there are four groups. in this report, we only discuss the part of the study that the size of nodule >5cm, so there were 29 patients in resection group and 14 patients in rfa group. this study also showed disease-free survival as an outcome. patients who had recurency were treated depends on the lesion. overall 1-year, 3-year, 5-year survival for therapy rfa vs resection were 65% vs 82%, 65% vs 67%, 65% vs 37%, respectively. the median were >63 months in rfa vs 47 months in resection. moreover, disease-free 1-year, 3-year, 5-year survival were 53% vs 64%, 44% vs 40%, 0% vs 30% with median 20 months vs 28 months in rfa vs resection, respectively. in rfa group, mean of age was older than resection group (72±10 years vs 60±13 years), but the tumor size was bigger in resection group than rfa group (10.2±4.7 cm vs 7.1±3.7 cm). liver condition was worse in rfa group showed by more child-pugh b in rfa group than resection (43% vs 10%). the stage of hcc according to tnm classification was also more advance in rfa than resection (64% vs 7%). ruzzenente, et al6 also did a cohort study retrospectively from period of 1995—2009 in a hospital in verona, italy. the advantage of the study is they did a propensity case-matched study, so the baseline characteristics were similar. they included percutaneous local ablative therapies (lat) and combined rfa and ethanol injection (pei). in that period, there were total 181 patients undergone rfa and 297 patients undergone lat (214 rfa and 83 pei). the indication of lat in this study were indicated when the location of the tumor was difficult or the patients refused to undergo liver resection, but all patients did not have absolute contraindication for resection. if the tumor relapsed, patients would be evaluated and undergone new treatment according to the indication. unfortunately, in this study the tumor size was only maximum of 6 cm. after matching was done, there were 88 patients had resection and 88 had lat. in lat group, 88.6% of subjects were undergone rfa and 11.4% pei. for single nodule with tumor size of ≥5 cm, there were only 13 cases undergone resection and 15 cases undergone lat. the overall 1-year, 3-year, 5-year survival in lat group versus resection group were 78.3% vs 76.9%, 31.3% vs 68.4%, and 7.8% vs 68.4%. meanwhile for disease-free 1-year, 3-year, 5-year survival in group lat versus resection were 20% vs 83.3%, 6.7% vs 52.9%, 6.7% vs 31.7%. moreover, in case of single nodule with size of ≥5 cm, lat gave hazard ratio of 3.8 (ci 95%: 1.3—11.2) for overall survival and 5.6 (ci 95%: 2—16) for disease-free survival. jung, et al7 also did a study retrospectively by taking the data in three hospitals in south korea in 2004—2009 with total patients of hcc of 2131 patients. the treatment choice for resection was evaluated based on the location of the tumor, child pugh a or b, and indocyanine green retention rate at 15 minutes <25% which means there was no portal hypertension. patients whose tumor was unresectable and who refused surgery would have rfa and transarterial chemoembolization (tace). there were 124 patients with single nodule with size of >5 cm and 41 patients (33.1%) undergone resection, 15 patients (12.1%) undergone rfa ± tace, and 68 patients (54.8%) undergone tace alone. child-pugh b was in 5% resection cases, 13% in rfa ± tace, and 18% in tace alone. median of overall survival was 84.2 months for resection, 74.1 months for rfa ± tace, and 28.9 months for tace alone. we measured the overall survival from the kaplan meier graphical analysis, because the authors did not write the data explicitely. the overall 1-year, 3-year, and 5-year survival for rfa ± tace vs resection were 91% vs 97.5%, 65% vs 85%, 65% vs 75%. 349 felix f. widjaja acta med indones-indones j intern med critical appraisal the appraisal forms obtained from toolkit in http://www.cebm.net/blog/2014/06/10/criticalappraisal/ and presented in table 2. all critical appraisals used therapy category in all articles although the studies were only retrospective. discussion from three articles that was found, none of the studies used randomized clinical trial, only retrospective studies, so the level of evidence is 2b. it is quite hard to compare resection and rfa because resection is still recognized as a ta bl e 2. c rit ic al a pp ra is al o f a ll th re e st ud ie s a rt ic le s (y ea r) r el ev an ce va lid ity im po rt an ce (5 -y ea r su rv iv al ) p at ie nt in te rv en tio n c om pa ri so n o ut co m e r an do m lo ng fo llo w -u p a ll pa tie nt s an al yz ed bl in d tr ea te d eq ua lly s im ila r at s ta rt r r r a r r n n t o gi ha ra , et a l5 (2 00 5) ± r fa re se ct io n o s , di se as e fre e su rv iv al + + + 89 % 33 % (6 5% v s 37 % ) 3 r uz ze ne nt e, et a l6 (2 01 2) + r fa o r p e i re se ct io n o s , di se as efre e su rv iv al + + + + -8 8% -6 0. 6% (7 .8 % v s 68 .4 % ) -1 .6 ju ng , e t a l7 (2 01 6) ± r fa ±t a c e re se ct io n o s + + + ? -1 5% -1 0% (6 5% v s 75 % ) -1 0 o s : o ve ra ll su rv iv al ; r fa : r ad io fre qu en cy a bl at io n; p e i: pe rc ut an eo us e th an ol in je ct io n; r r r : r el at iv e ris k re du ct io n (s ur vi va l r at e in in te rv en tio n m in us in co m pa ris on a nd th en d iv id ed to s ur vi va l r at e in in te rv en tio n) ; a r r : a bs ol ut e ris k re du ct io n (s ur vi va l r at e in in te rv en tio n m in us in c om pa ris on ); n n t: n um be r ne ed ed to tr ea t. n eg at iv e nu m be rs m ea n fa vo r t o re se ct io n r r r b ec om e r r i ( re la tiv e ris k in cr ea se ) , a r r b ec om e a r i ( ab so lu te ri sk in cr ea se ) a nd n n t be co m e n n h (n um be r n ee de d to h ar m ). 350 vol 50 • number 4 • october 2018 radiofrequency ablation versus resection in large single nodule of hcc curative treatment of hcc, although the usage of rfa is more widely used. rfa may have good prognostic as showed in ho, et al’s study8 in san fransisco, united states that showed in patients with hcc bclc b, rfa had lower hazard ratio in 1-year survival than other locoregional therapy (tace, transarterial embolization {tae}, and pei) (0.17 vs 0.38), but higher hazard ratio in 5-year survival (0.63 vs 0.31). in all studies found in this report, resection was the main treatment given to the patient if the tumor was resectable and the patients agreed, so the comparison between main treatment and alternative treatment was hard to be similar at the baseline. only in the second study by ruzzenente, et al6, the comparison may be thought similar because they were doing propensity matched study. it was difficult to make head to head comparison as hcc patients might had a relapse and there would be other treatment applied to the patient. hence it is difficult to make sure that the outcome was the result from the first treatment or the subsequent treatment. the interesting result of this report is the wide range results of three studies. ruzzenente, et al’s6 and jung, et al’s7 studies showed resection was more superior, otherwise ogihara, et al’s5 study showed rfa was more superior. rfa was also superior in the meta analysis of changyong, et al9 which included 4812 patients with hcc size of ≤7 cm (2419 patients in rfa group and 2393 patients in resection group), but there is no specific analysis among group with nodule >5 cm. they showed overall 3-year and 5-year survival was significantly better in rfa group, but we need to put note that from 25 studies included in the meta analysis, only two studies had tumor size of ≤7 cm and one study of ≤6 cm. ogihara, et al.5 showed there was decreasing of overall survival of resection in patient with single nodule >5 cm among 1-year, 3-year, 5-year survival from 82% to 67% to 37%, meanwhile in rfa groups, the overall survival was stagnan of 65% among till 5 years. the most common cause of death of resection and rfa were secondary to liver failure in 35% of deaths and 100% of deaths among each group. unfortunately the authors did not differentiate the cause of death between nodule >5 cm and ≤5 cm. in two studies which showed resection was more superior, there were also some notes. ruzzenente, et al6 combined two lat, e.g.: rfa and pei in the analysis, meanwhile jung, et al7 combined rfa with/without tace, so the efficacy of the treatment is not rfa alone. from jung, et al’s study,7 it is clear that by adding rfa would increase survival than tace alone. combination rfa and tace in hcc intermediate class (beyond milan criteria, include single nodule >5 cm) was proved to increase survival in another study with difference in median reached 31.7 months than supportive therapy alone.10 moreover, in a study by pan, et al11 showed combination of rfa and tace for tumor size ≤7 cm beyond milan criteria was significantly increased median overall survival when compared with resection (52 months vs 45 months). meanwhile, in the earlier stage of hcc that is still included in milan criteria, rfa showed more superior than tace alone both in overall survival and also progression-free survival, particularly after one year.12 among hcc bclc b with single nodule with size of >5 cm, tace alone was not better than resection in terms of overall 1-year, 3-year, and 5-year survival.13 the advantage of the study by ruzzenente, et al6 is they did matching in the analysis, comparison to similar in baseline characteristics, but the largest tumor size in this studies only 6 cm. other study by parisi, et al14 in perugia, italy compared rfa and resection in single nodule with size of >3 and ≤6 cm, but no specific analysis in size of >5cm. it showed that among child-pugh a, resection and rfa was not different in median survival (40 months vs 40 months), but resection was significantly better than rfa among patients with child-pugh b (44 months vs 30 months). from those studies, we may infer that resection was still superior in tumor up to 6 cm than rfa, although it is not proven in child-pugh a group. on the other hand, ogihara, et al5 showed that the baseline charateristics were worse in rfa group in terms of age, child-pugh and tnm stage, but not in tumor size. with these baseline, they found rfa was better than resection in 351 felix f. widjaja acta med indones-indones j intern med single nodule size of >5cm. moreover, only in this study, the rfa is not combined with other modalities. we also need to consider the technique of rfa and the type of the machine and puncture, because it will also affect the result. only ogihara, et al5 mentioned the technique of rfa that was done clearly. in the point of view of quality of life, chie, et al15 showed ablation was worse than surgery and embolization. the components of quality of life that were lower were dyspnea, loss of appetite, body image, and role of life. meanwhile, in surgery, the component of quality of life that was impaired was only pain. they also performed the adjustment for patients’ characteristics and severity of cases and still found ablation had worse outcome quality of life, but there was no explanation the cause of this result. conclusion we may conclude from this report that rfa can still be used in the single nodule with a size of >5 cm, although resection is still the first-line treatment when the patient has the proper criteria and reachable location. resection may be still superior till size of 6 cm. rfa combined with tace when the size is bigger may have more benefit than rfa alone. references 1. omata m, cheng a-l, kokudo n, et al. asia–pacific clinical practice guidelines on the management of hepatocellular carcinoma: a 2017 update. hepatol int. 2017;11(4):317-70. 2. indonesian liver cancer study group. konsensus nasional penatalaksanaan karsinoma sel hati. in: hasan i, loho im, eds. jakarta: perhimpunan peneliti hati indonesia; 2017. 3. dufour jf, greten tf, raymond e, et al. clinical practice guidelines easl – eortc clinical practice guidelines: management of hepatocellular carcinoma european organisation for research and treatment of cancer. j hepatol. 2012;56(4):908-43. 4. wong ll, hernandez by, shvetsov yb, kawano y, tang zy, ji jf. liver resection for early hepatocellular cancer: comparison of centers in 3 different countries. world j hepatol. 2016;8(31):1327-35. 5. ogihara m, wong ll, machi j. radiofrequency ablation versus surgical resection for single nodule hepatocellular carcinoma: long-term outcomes. hpb. 2005;7(3):214-21. 6. ruzzenente a, guglielmi a, sandri m, et al. surgical resection versus local ablation for hcc on cirrhosis: results from a propensity case-matched study. j gastrointest surg. 2012;16(2):301-11. 7. jung yk, jung ch, seo ys, et al. bclc stage b is a better designation for single large hepatocellular carcinoma than bclc stage a. j gastroenterol hepatol. 2016;31(2):467-74. 8. ho ey, cozen ml, shen h, et al. expanded use of aggressive therapies improves survival in early and intermediate hepatocellular carcinoma. hpb. 2014;16(8):758-67. 9. changyong e, wang d, yu y, liu h, ren h, jiang t. efficacy comparison of radiofrequency ablation and hepatic resection for hepatocellular carcinoma: a meta-analysis. j cancer res ther. 2017;13(4):625. 10. tanaka m, ando e, simose s, et al. radiofrequency ablation combined with transarterial chemoembolization for intermediate hepatocellular carcinoma. hepatol res. 2014;44(2):194-200. 11. pan t, mu l-w, wu c, et al. comparison of combined transcatheter arterial chemoembolization and ctguided radiofrequency ablation with surgical resection in patients with hepatocellular carcinoma within the up-to-seven criteria: a multicenter case-matched study. j cancer. 2017;8(17):3506-13. 12. hocquelet a, seror o, blanc j-f, et al. transarterial chemoembolization for early stage hepatocellular carcinoma decrease local tumor control and overall survival compared to radiofrequency ablation. oncotarget. 2017;8(19):32190-200. 13. zhong j-h, xiang b-d, gong w-f, et al. comparison of long-term survival of patients with bclc stage b hepatocellular carcinoma after liver resection or transarterial chemoembolization. plos one. 2013;8(7):e68193. 14. parisi a, desiderio j, trastulli s, et al. liver resection versus radiofrequency ablation in the treatment of cirrhotic patients with hepatocellular carcinoma. hepatobiliary pancreat dis int. 2013;12(3):270-7. 15. chie w-c, yu f, li m, et al. quality of life changes in patients undergoing treatment for hepatocellular carcinoma. qual life res. 2015;24(10):2499-506. 352 222 original article acta med indones indones j intern med • vol 50 • number 3 • july 2018 comparison of quality of life between patients undergoing chronic hemodialysis with reusable dialyzer and singleuse dialyzer: a retrospective cohort study lucky a. bawazier, suhardjono department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: lucky aziza bawazier, m.d., phd., facp, finasim. division of nephrology and hypertension, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro 71, jakarta, 10430, indonesia. email: tyasretno77@yahoo.co.id; aziza.lucky17@gmail.com. abstrak pendahuluan: di indonesia, pemakaian membran hemodialisis dengan metode reuse banyak digunakan karena hemat biaya. diperlukan data apakah tindakan hemodialisis dengan metode reuse cukup optimal untuk kualitas hidup pasien karena metode reuse dapat menimbulkan perubahan tertentu pada tingkat molekuler tubuh yang diduga dapat meningkatkan gejala dan keluhan. metode: studi ini menggunakan desain kohort retrospektif pada 39 subjek penelitian yang menjalani hemodialisis di unit hemodialisis rumah sakit cipto mangunkusumo pada maret – september 2017. subjek pernah menjalani hemodialisis dengan dua tipe membran, yaitu membran dialisator reuse (sebelum tahun 2015) dan membran dialisator single-use (sejak tahun 2015). sebanyak 19 dari 39 pasien tidak mengetahui penggantian membran dialisator. subjek diwawancara dengan kuesioner kidney disease quality of life-short form 36. hasil: rerata dimensi kualitas hidup komponen penyakit ginjal pada kelompok single-use adalah 74,87 (sd 13,54) dan reuse 68,74 (sd 13,54) (uji wilcoxon, p = 0,01). rerata dimensi komponen fisik pada kelompok single-use adalah 69,38 (sd 23,07) dan reuse 63,65 (sd 27,07) (uji wilcoxon, p = 0,217). rerata dimensi komponen mental pada kelompok single-use adalah 75,27 (sd 22,30) dan reuse 71,78 (sd 21,54) (uji wilcoxon, p = 0,315). pada uji analisa bivariat dan lanjutannya dalam model regresi linear ditemukan asosiasi yang signifikan antara pendapatan dibawah 5 juta rupiah dengan kualitas hidup (p=0,048). kesimpulan: dialisator reuse menurunkan kualitas hidup pasien yang menjalani hemodialisis dipengaruhi oleh faktor lain salah satunya pendapatan yang rendah. kata kunci: kualitas hidup, hemodialisis, dialisator reuse, dialisator single-use. abstract background: in indonesia, majority of hemodialysis centers use reusable dialyzer for cost efficiency reason. currently, there is no available data regarding the quality of life of the end stage-renal disease patient’who use reusable dialyzer measured by a standardized questionnaire, as it was stated that at molecular level, reusable dialyzer could worsen leukocyte activity and could affect patients’ complaints and symptoms. methods: this was a retrospective cohort study which involved 39 subjects. all subjects underwent hemodialysis at cipto mangunkusumo hospital. the study was conducted in march – september 2017. all subjects had experienced two kinds of dialyzers, the reusable dialyzers (before 2015) and the single-use dialyzers (after 2015). of all patients, 19 patients did not know the change of dialyzers. subjects were interviewed with kidney disease quality of life-short form 36 questionnaire. results: in kidney disease component dimension, there was a significant mean difference between reusable group (68.74; sd 13.22) and single-use group (74.87; sd 13.54) (wilcoxon test, p=0.01). the vol 50 • number 3 • july 2018 comparison of quality of life between patients undergoing chronic hemodialysis 223 physical component summary dimension, in reusable group was 63.65; sd 27.07 and in single-use group was 69.38; sd 23.07 (wilcoxon test, p=0.217). the mental component summary dimension, in reusable group was 71.78; sd 21.54 and in single-use group was75.27; sd 22.30 (wilcoxon test, p=0.127). bivariate analysis and further analysis showed significant association between income less than 5 million rupiah and low quality of life (p=0.048). conclusion: the reusable dialyzer membrane lowers the esrd patients’ quality of life influenced by another factor such as low income. keywords: kidney disease quality of life, hemodialysis, reusable dialyzer, single-use dialyzer. introduction chronic kidney disease (ckd) is still a health burden worldwide and in indonesia as well. the prevalence of ckd in indonesia based on national health research 2013 was 0.2%.1 according to 7th report of indonesian renal registry, there had been continuous rise in the number of new cases of patients undergoing hemodialysis (hd), from 15,128 patients in 2013 to 17,193 patients in 2014.2 the use of reusable dialyzer outnumbers the use of single-use dialyzer in indonesia. recent data from 2014 stated that a reusable membrane dialyzer could be used for more than 16 times in 40,636 patients.2 the utilization of reusable dialyzer remains controversial. efficiency and cost-effectiveness are two main reasons in using reusable dialyzer. several studies revealed no significant difference in outcome, such as insignificant mortality difference between patients who used reuse versus single-use membrane. however, there were arguments which suggested that single-use dialyzer was safer than reusable dialyzer due to the following advantages: lower possibility of pyrogen exposure, blood denaturation, and germicide residue in single-use membrane.3,4 patient with chronic disease such as chronic renal failure who requires hemodialysis is bound to possibly have abnormality in mental or even social health. a study revealed that patients with renal disease had worse quality of life (i.e. lower questionnaire score), higher mortality risk and hospitalization compared to general population.5,6 currently, there is no data available regarding end stage-renal disease patient’s quality of life using reusable dialyzer which is measured by a standardized questionnaire as it was stated that in molecular level, reusable dialyzer could worsen leukocyte activity and could affect patients’ complaints and symptoms. to our knowledge, the efficacy and safety of reuse membrane is still unknown in indonesia due to insufficient data, but the use of reusable dialyzer keeps rising.2 methods this study was an observational analytic study with retrospective cohort design. inclusion criteria in this study was adults aged ≥18 years old who had been undergoing hemodialysis treatment for at least 1 year and with frequency of hemodialysis twice a week. by using a sample formula with mean difference in paired groups according to sastroasmoro7, α value was determined as 0.05 and research power of 0.8. the mean standard deviation (sd) based on a study by rivara8 was set as 10.9. difference of value to be considered significant (d) was 4.8. by using simple random sampling method, a total of 39 subjects in cipto mangunkusumo hospital who experienced both of the two different dialyzers for hemodialysis at least more than once a week were included in this study. a total of two questionnaires from each subjects were taken, each was questioned once after periods of using different dialyzer types for hemodialysis. reusable dialyzer criteria was the dialyzers which were used for more than once and limited to 7 times of usage, according to the rules from indonesian committee of national health coverage. all patients were routinely undergoing hemodialysis since 2015, therefore wash out periods were not considered in this study. subjects were informed whether they were switched from reusable to single-use dialyzer and only half understand the difference, all research consents were provided to the patients to be included in this study. the study protocol has been approved by health research ethics committee, faculty of medicine universitas indonesia – cipto mangunkusumo hospital on march 13, 2017 with lucky a. bawazier acta med indones-indones j intern med 224 a reference number 229/un.2f1/etik/2017. research instruments research assistants conducted the interview using kidney disease quality of life-short form 36 (kdqol-sf 36) questionnaire to compare patient’s current quality of life with single-use dialyzer to previous patient’s quality of life when they underwent hemodialysis with reusable dialyzer. this questionnaire consists of eleven dimensions of kidney disease component (symptoms, effects of kidney disease, burden of kidney disease, work status, cognitive function, quality of social interaction, sexual function, sleep, social support, dialysis staff encouragement, and patient satisfaction), four dimensions of physical component (physical functioning, role-physical, pain, and general health perceptions), and four dimensions of mental component (emotional well-being, role-emotional, social function, and energy/ fatigue). a recall method was used to answer the questionnaire regarding patient’s quality of life when using reusable dialyzer membrane. covariates patients’ characteristics in this study were age, sex, educational level, monthly income, ethnicity, religion, marital status, history of hospitalization, etiology of ckd, vascular access type, duration of hemodialysis, hemoglobin, albumin, and glomerular filtration rate (gfr). age groups comprised of <35 years, 35-60 years, and >60 years. educational level was categorized into elementary school, junior high school, senior high school, and college. monthly income bracket (in indonesian rupiah or idr) comprised of <5 million, 5-10 million, and >10 million. ethnicity was categorized into javanese, betawi, and others. religion was divided into islam, christian, and buddhist. history of hospitalization in the past six months comprised of history and no history. etiology of ckd was categorized into hypertension, diabetes mellitus, glomerulonephritis, and others. vascular access type comprised of arteriovenous fistule, femoral, tunnel catheter, and double lumen catheter. duration of hemodialysis was presented in numerical data. laboratory results (hemoglobin, albumin, and gfr) were presented in numerical data. outcomes outcomes measured in this study was the each groups’ mean score of quality of life dimensions. statistical analysis the categorical data are presented in frequency and proportion. the numerical data of laboratory results (hemoglobin, albumin, and gfr) and quality of life dimensions in the kdqol-sf36 questionnaire are presented in mean and sd. data included in this study were subjects’ characteristics (age, sex, education, employment, income, ethnicity, religion, marital status, history of hospitalization, etiology of ckd, vascular access type, duration of hemodialysis, hemoglobin, albumin, and glomerular filtration rate), and mean of quality of life in reuse group and single-use group. bivariate analysis using spearman correlation tests (due to abnormal data distribution) were performed to correlate patients’ laboratory/supporting examinations and each main components of quality of life (kidney disease component, physical component, and mental component). analysis of background and characteristics of patients with each main components of quality of life were done using independent t-test. from the bivariate analyses, an arbitrary p-value of <0.2 was used to include some characteristics into the multiple linear regression analysis for adjusting confounding factors in the relationship between subjects’ characteristics and components of quality of life. mean difference of quality of life in reuse group and single-use group was analyzed using paired t-test if the data was normally distributed and alternative wilcoxon were used if the data was not normally distributed. the p-value of <0.05 indicates statistical significance. the statistical analysis was performed using spss statistics software version 20.0 (ibm corp., armonk, ny). results table 1 provides summary of the patients’ characteristics in this study. table 2 provides the bivariate analysis of demographic characteristics and main components of quality of life (kidney disease component, physical component, and mental component). vol 50 • number 3 • july 2018 comparison of quality of life between patients undergoing chronic hemodialysis 225 table 1. demographic characteristics of the patients variables n (%) age <35 years 3 (7.7) 35—60 years 29 (74.4) >60 years 7 (17.9) sex men 18 (46.2) women 21 (53.8) highest educational level achieved elementary school 5 (12.8) junior high school 2 (5.1) senior high school 13 (33.3) college 19 (48.7) employment unemployed 23 (59.0) employed 16 (41.0) monthly income bracket (idr) <5 millions 23 (59.0) 5—10 millions 11 (28.2) >10 millions 5 (12.8) ethnicity javanese 18 (46.2) betawi 8 (20.5) others 13 (33.3) religion islam 37 (94.9) christian 1 (2.6) buddhism 1 (2.6) marital status single/widowed/divorced 11 (28.2) married 28 (71.8) hospitalization history (past six months) yes 15 (38.5) no 24 (61.5) etiology hypertension 17 (43.6) diabetes mellitus 6 (15.4) glomerulonephritis 5 (12.8) others 11 (28.2) vascular access arteriovenous fistule 24 (61.5) femoral 7 (17.9) tunnel catheter 7 (17.9) double lumen catheter 1 (2.6) laboratory results, mean (sd) hemoglobin (g/dl) 9.75 (sd 2.17) albumin (g/l) 4.10 (sd 0.37) glomerular filtration rate/gfr (ml/min/1.73 m2) 5.56 (sd 3.92) table 2. bivariate analysis of demographic characteristics and main components of quality of life in the single-use group variables kdcp value pc p value mc p value age (age above 60 vs other)^ 0.550 0.141** 0.763 sex (male vs female)^ 0.759 0.271 0.905 education (elementary school vs others)^ 0.166** 0.636 0.983 unemployed vs others^ 0.079** 0.343 0.377 income <5 million vs others^ 0.189** 0.510 0.048* tribe (javanese vs others)^ 0.934 0.153** 0.289 never married vs others^ 0.581 0.748 0.701 history of hospitalization vs no history^ 0.832 0.551 0.932 hypertension as etiology vs other etiology^ 0.835 0.245** 0.813 av fistule vs no fistules ^ 0.745 0.610 0.966 hemodialysis duration# 0.276 0.192** 0.452 hemoglobin# 0.987 0.624 0.798 albumin# 0.348 0.290 0.834 egfr# 0.617 0.638 0.882 kdc: kidney disease component; pc: physical component; mc: mental component. (^) means mean comparison between dichotomous variable using independent t-test. (#) means correlation analyses. (*) p<0.05; (**) p<0.25 and be involved in multivariate analysis. table 3 provides mean difference of quality of life between reusable and single-use group. table 4 provides linear regression model in single-use group, associating between patients’ characteristics and quality of life dimensions. all variables with p – value of <0.25 adjusted with sample size were included in the linear regression analysis. discussion it is important to obtain data on how reusable dialyzers could affect esrd patients’ quality of life as the goal of hemodialysis is to maximizing the quality of life of esrd patients.9 reusable dialyzer practice began in the united states lucky a. bawazier acta med indones-indones j intern med 226 since 1980 with the following advantages: costefficient and reducing the biomedical waste in the surrounding environment.4 however, the report of blood contamination of germicides in reusable dialyzer was well documented.4 the subjects in this study had higher overall score of quality of life than a study by altable 3. mean difference of quality of life between reuse dan single-usegroup quality of life dimensions reusable group (n = 39) single-use group (n = 39) p-value kidney disease component (kdc) 68.74 (sd 13.22) 74.87 (sd 13.54) 0.01* symptoms 67.18 (sd 20.53) 79.60 (sd 16.50) 0.003* effects of kidney disease 72.83 (sd 23.25) 75.74 (sd 16.40) 0.43 burden of kidney disease 55.92 (sd 29.20) 70.59 (sd 28.74) 0.012* work status 56.41 (sd 38.35) 34.61 (sd 38.30) 0.006* cognitive function 77.77 (sd 21.26) 86.32 (sd 18.28) 0.038* quality of social interaction 79.14 (sd 18.30) 89.57 (sd 16.87) 0.004* sexual function 60.89 (sd 46.43) 58.58 (sd 42.64) 0.819 sleep 62.62 (sd 19.50) 76.76 (sd 19.39) 0.001* social support 74.78 (sd 15.70) 84.61 (sd 16.39) 0.035* dialysis staff encouragement 90.06 (sd 11.17) 92.94 (sd 13.69) 0.373 patient satisfaction 58.53 (sd 17.05) 64.09 (sd 14.07) 0.056 physical component (pc) 63.65 (sd 27.07) 69.38 (sd 23.07) 0.217 physical functioning 74.87 (sd 31.84) 69.87 (sd 28.38) 0.422 role – physical 57.69 (sd 45.93) 64.74 (sd 37.55) 0.421 pain 64.35 (sd 27.48) 74.48 (sd 22.47) 0.120 general health perceptions 57.69 (sd 24.16) 68.42 (sd 19.24) 0.022* mental component (mc) 71.78 (sd 21.54) 75.27 (sd 22.30) 0.315 emotional well-being 74.79 (sd 18.01) 80.60 (sd 17.67) 0.127 role – emotional 70.08 (sd 44.45) 66.67 (sd 40.46) 0.690 social function 77.88 (sd 26.51) 77.56 (sd 26.46) 0.982 energy/fatigue 64.35 (sd 19.77) 78.07 (sd 19.29) 0.001* overall health rating 68.33 (sd 14.92) 73.24 (sd 15.12) 0.059 (*) p<0.05 jumaih.10 this study also had higher score in physical functioning and social dimension than a study by sathvik.11 in physical and mental component, this study had higher score than a study by watanabe.12 majority of the patients were aged 35-60 years (74.4%). more than half of the patients table 4. linear regression model between patients’ characteristics and kidney disease component in the single-use group parameter estimate standard error ci 95% for parameter p value kidney disease component elementary school -6.2 6.7 -19.7 to 7.4 0.363 unemployed -6.3 4.5 -15.4 to 2.7 0.167 income <5 million -2.8 4.6 -12.3 to 6.5 0.542 physical component men -6.8 7.6 -22.3 to 8.5 0.372 javanese 11.0 7.5 -4.3 to 26.4 0.154 hypertension 6.2 7.6 -9.2 to 21.7 0.419 mental component income <5 million -14.3 6.9 -28.4 to -0.1 0.048 vol 50 • number 3 • july 2018 comparison of quality of life between patients undergoing chronic hemodialysis 227 were women (53.8%). almost half of the patients’ were college educated (49.8%). majority of the patients were unemployed (59%) and had income of <5 million idr (59%). majority of the patients were javanese (46.2%). majority of patients had islam as their religion (94.9%). more than half of the patients were married (71.8%). the majority of the patients had never been hospitalized in the past six months (61.5%). hypertension dominated as the majority of patients’ esrd etiology (43.6%). arteriovenous fistules were the most used vascular access by the patients (61.5%). the mean of patients’ hemoglobin was 9.75 g/dl (sd 2.17). the mean of patients’ albumin was 4.1 g/l (sd 0.37). the mean of patients’ gfr was 5.56 ml/min/1.73 m2 (sd 3.92). the mean of patients’ duration of hemodialysis therapy was 6.31 years (sd 4.14). there was significant association between income below 5 million indonesian rupiah (idr) and score of mental component of the quality of life (p=0.048). further analysis using linear regression model showed that when income was less than 5 million idr, as the income went lower the quality of life parameter would also be lower. this result was supported by lemos et al which stated that low family income was significantly associated with poor mental component and social aspect of quality of life in hemodialysis patients. socioeconomic stress could cause more burden for hemodialysis patients.13 the mean score of kidney disease component in single-use group (74.87; sd 13.54) was higher than reusable group (68.74; sd 13.22). the single-use group had significantly better score in dimension of symptoms, burden of kidney disease, cognitive function, quality of social interaction, sleep, and social support. in physical component, the single-use group had significantly better general health perceptions dimension than the reusable group. in mental component, the single-use group had significantly better energy/ fatigue dimension than reusable group. there was no significant difference in the summary of kidney disease component and physical component of the quality of life with other variables that were observed in this study. this study also noticed that several variables such as older age, unemployment, and education showed trend of decreasing quality of life, regardless of non-significant association. further analysis with the linear regression model showed that potential confounding factors had insignificant association with the main components of quality of life. this was contrary to previous studies which showed that some of patients’ characteristics were significant predictor of quality of life, including employment status, marital status, and sex.14-16 the insignificant association between patients’ characteristics as confounding factor and quality of life showed that the dialyzer membrane type alone could affect the difference of scores between both groups. one study by rao et al17 in the molecular level concluded that there was a significant association between practice of reuse membrane process and patients’ polymorphonuclear leukocyte function which may affect patients’ clinical outcome. single-use dialyzers also have advantage of avoiding “reuse syndromes” which can be caused by residual germicides used in the reuse practice, with the following symptoms of headache, nausea, or dyspnea due to formaldehyde inhalation which could affect patients’ quality of life.4,18 the strength of this study was that half of patients did not know the change of dialyzer membrane in 2015 and this condition could avoid recall bias. to our knowledge, there had not been any study which focused on the impact of dialyzer membrane on patients’ quality of life. majority of the studies focused on the mortality and morbidity of patients regarding to the dialyzer membrane type.19,20 a study with larger sample size with prospective design is needed in order to measure the hazardous effect of reusable dialyzer membrane. acceptance phase of patients was not measured in this study, which could be a bias factor, as stated by poppe21 that acceptance phase was a significant predictor of esrd patients’ quality of life. time also could not be controlled by this observational study, as it was stated in cruz22 that it was significantly associated with quality of life. nowadays, the reusable dialyzer membranes are not utilized anymore in most of developed countries. however, the reusable dialyzer lucky a. bawazier acta med indones-indones j intern med 228 membranes could be a cost-effective option in indonesia’s universal health coverage era. in fact, indonesia’s tertiary level hospitals like cipto mangunkusumo hospital uses single-use dialyzer membrane. at secondary level hospitals, mainly in almost all provinces in indonesia, the reusable dialyzer membranes are utilized in routine hemodialysis. our results are expected to help clinicians adjusting the use of dialyzer membrane based on goals in optimizing patients’ quality of life. conclusion the reusable dialyzer membrane lowers the esrd patients’ quality of life associated with factor like low income. it is suggested for health care providers using reusable dialyzer membrane to maintain the safety of reuse processes in order to achieve the main goal of hemodialysis, which is to maximize esrd patients’ quality of life. conflicts of interest the authors declare that there is no conflict of interest. funding statement this study received no specific financial support from any funding agency. acknowledgments we appreciate the assistance of staffs at hemodialysis unit of cipto mangunkusumo hospital. references 1. kementerian kesehatan republik indonesia. riset kesehatan dasar. jakarta: kemenkes ri; 2013. p. 132. 2. perkumpulan nefrologi indonesia. 7th report of indonesian renal registry. jakarta: pernefri; 2014. 3. galvao tf, silva mt, araujo me, bulbol ws, cardoso al. dialyzer reuse and mortality risk in patients with end-stage renal disease: a systematic review. am j nephrol. 2012;35:249-8. 4. upadhyay a, sosa ma, jaber bl. single-use versus reusable dialyzers: the known unknowns. clin j am soc nephrol. 2007;2:1079-86. 5. jaar bg, chang a, plantinga l. can we improve quality of life of patients on dialysis? clin j am soc nephrol. 2013;8:1-4. 6. theofilou p. quality of life in patients undergoing hemodialysis or peritoneal dialysis treatment. j clin med res. 2011;3(3):132-8. 7. maldiyono b, moeslichan s, sastroasmoro s, budiman i, purwanto sh. perkiraan besar sampel. in: sastroasmoro s, ismael s, eds. dasar-dasar metodologi penelitian klinis. 4th edition. jakarta: cv sagung seto; 2011. p. 360. 8. rivara mb, cohen cr, kestenbaum b, et al. changes in symptom burden and physical performance with initiation of dialysis in patients with chronic kidney disease. hemodial int. 2015;19(1):147-50. 9. finkelstein fo. performance measures in dialysis facilities: what is the goal? cjasn. 2015;10(1):156-8. 10. al-jumaih a, al-onazi k, binsalih s, hejaili f, al-sayyari a. a study of quality of life and its determinants among hemodialysis patients using the kdqol-sf instrument in one center in saudi arabia. arab j nephrol transplant. 2011;4(3):125-30. 11. sathvik bs, parhthasarathi g, narahari mg, gurudev kc. an assessment of the quality of life in hemodialysis patients using the whoqol-bref questionnaire. indian j nephrol. 2008;18(4):141-9. 12. watanabe y, ohno y, inoue t, takane h, okada h, suzuki h. home hemodialysis and conventional incenter hemodialysis in japan: a comparison of healthrelated quality of life. hemodial int. 2014;18:532-8. 13. lemos cf, rodrigues mp, veiga jrp. family income is associated with quality of life in patients with chronic kidney disease in the pre-dialysis phase: a cross sectional study. health qual life outcomes. 2015;13:202. 14. manavalan m, majumdar a, kumar kth, priyamvada ps. assessment of health-related quality of life and its determinants in patients with chronic kidney disease. indian j nephrol. 2017;27(1):37-43. 15. fukushima rld, menezes alc, inouye k, pavarini sci, orlandi fds. quality of life and associated factors in patients with chronic kidney disease on hemodialysis. acta paul enferm. 2016;29(5):518-24. 16. manen jgv, korevaar jc, dekker fw, reuselaars mc, boeschoten ew, krediet rt, et al. changes in employment status in end-stage renal disease patients during tjeir first year of dialysis. peritoneal dialysis international. 2001;21:595-601. 17. rao m, guo d, jaber bl, et al. dialyzer membrane type and reuse practice influence polymorphonuclear leukocyte function in hemodialysis patients. kidney international. 2004;65:682-91. 18. national kidney foundation. a clinical update on dialyzer membranes: state-of-the-art considerations for optimal care in hemodialysis. nkf: new york; 2017. 19. pereira bjg, natov sn, sundaram s, et al. impact of single use versus reuse of cellulose dialyzers on clinical parameters and indices of biocompatibility. j am soc nephrol. 1996;7:861-70. 20. feldman hi, bilker wb, hackett mh, et al. association of dialyzer reuse with hospitalization and survival rates vol 50 • number 3 • july 2018 comparison of quality of life between patients undergoing chronic hemodialysis 229 among u.s. hemodialysis patients: do comorbidities matter? j clin epidemiol. 1999;209-17. 21. poppe c, crombez g, hanoulle i, vogelaers d, petrovic m. improving quality of life in patients with chronic kidney disease: influence of acceptance and personality. nephrol dial transplant. 2013;28(1):11621. 22. cruz mc, andrade c, urrutia m, draibe s, martins lan, sesso rdcc. quality of life in patients with chronic kidney disease. clinics. 2011;66(6):991-5. 11 original article acta med indones indones j intern med • vol 50 • number 1 • january 2018 influence of diabetes mellitus on the development of multi drug resistant-tuberculosis in yogyakarta antonia m. i. saktiawati1,2*, yanri w. subronto1,2* 1 department of internal medicine, faculty of medicine universitas gadjah mada, yogyakarta, indonesia. 2 center for tropical medicine, faculty of medicine, universitas gadjah mada, yogyakarta, indonesia. * shared first authorship corresponding author: antonia morita iswari saktiawati, md. department of internal medicine, faculty of medicine universitas gadjah mada. jl. kesehatan no. 1, sekip, yogyakarta 55281, indonesia. email: a.morita@ugm.ac.id. abstrak latar belakang: hubungan antara diabetes melitus (dm) dan multi drug resistant tuberculosis (mdr-tb) belum pernah diteliti di antara pasien tuberkulosis (tb) di indonesia, sedangkan dm diketahui dapat mengganggu respons kekebalan tubuh dan memengaruhi farmakokinetik obat tb sehingga dapat menyebabkan kegagalan pengobatan tb dan terjadinya mdr-tb. penelitian ini bertujuan untuk menganalisis pengaruh dm pada perkembangan mdr-tb. metode: studi kohort retrospektif dilakukan dengan melibatkan 356 pasien tb di balai pengobatan paru-paru (bp4) dan rumah sakit sardjito, yogyakarta, indonesia pada tahun 2010-2014. diagnosis mdr-tb ditentukan dengan genexpert atau drug sensitivity testing, sementara dm ditentukan berdasarkan kriteria pedoman nasional. beberapa variabel demografik, epidemiologi, dan hasil pengobatan dikumpulkan. rasio odds (or) dan selang kepercayaan 95% (95% ci) dianalisis dengan simple logistic regression. hasil: di antara 356 pasien tb, 23 orang adalah pasien dengan dm, sedangkan 333 pasien tidak menderita dm. pasien dengan tuberkulosis dan diabetes melitus memiliki risiko 6,8 lebih besar (95% ci:2,0-23,7, p=0,003) untuk berkembang menjadi mdr-tb. individu dengan tuberkulosis dan diabetes melitus memiliki kemungkinan 4,4 lebih besar (95% ci:1,5-12,9, p=0,008) untuk memiliki hasil sputum positif pada bulan kedua pengobatan yang mengindikasikan keterlambatan dalam proses penyembuhan dari tuberkulosis. kesimpulan: terdapat hubungan yang bermakna antara diabetes melitus dengan perkembangan mdr-tb. oleh karenanya, direkomendasikan bagi klinisi di semua lapis pelayanan kesehatan untuk melakukan tes skrining mdr-tb di antara pasien kelompok ini. penelitian kohort prospektif perlu dilakukan untuk mengkonfirmasi hasil dari penelitian pendahuluan ini. kata kunci: diabetes melitus, tuberkulosis, faktor risiko, indonesia. abstract aim: the correlation between diabetes mellitus (dm) and multi-drug-resistant tuberculosis (mdr-tb) has never been studied among patients with tuberculosis (tb) in indonesia, while dm has been identified to alter immune response and pharmacokinetics of tb medications that may lead to a failure of tb treatment and develop mdr-tb. our study aimed to analyze the influence of diabetes mellitus on the development of mdr-tb. methods: a retrospective cohort study was carried out on 356 tb patients at the provincial lung clinics and sardjito hospital, yogyakarta, indonesia between 2010 and 2014. diagnosis of mdr-tb was established based on genexpert or drug sensitivity testing, while dm was determined based on the criteria in the national guidelines. demographic, epidemiological and outcome variables were collected. odds ratios and 95% confidence intervals (95% ci) were analyzed using simple logistic regression. results: among 356 tb patients, 23 patients were with binomial tb-dm, while 333 patients did not suffered from dm. patients antonia m.i. saktiawati acta med indones-indones j intern med 12 with tb-dm presented a 6.8-fold (95% ci:2.0-23.7, p=0.003) higher risk of developing mdr-tb. individuals with tb-dm had a 4.4-fold (95% ci:1.5-12.9, p=0.008) greater chance to have positive sputum smear by the second month of treatment indicating a delay in the resolution of the tuberculosis infection. conclusion: there was a significant correlation between diabetes mellitus and mdr-tb development. therefore, it is suggested that clinicians at all levels of health care service should conduct any kind of screening test for mdr-tb in such group of patients. further prospective cohort study is needed to confirm the findings of this preliminary study. keywords: diabetes mellitus, tuberculosis, risk factors, indonesia. introduction diabetes mellitus (dm) influences the natural development of tuberculosis (tb) through depressed cellular immunity, alveolar macrophages dysfunction, low interferon gamma level, pulmonary microangiopathy and micronutrient deficiency.1,2 globally, 70% of diabetics live in tb endemic countries. type-2 dm was found in around 2 9% of the population in 22 countries with the highest burden of tb.3 indonesia, with the second highest burden of tb in the world,4 has the seventh largest number of diabetics.5 the prevalence of type-2 dm among tb patients in indonesia was relatively low (13.2%). however, it was significantly associated with tb.6 indonesia is also one of the ten countries that currently have been estimated to have the highest number of multi drug resistant-tuberculosis (mdr-tb).4 mdr-tb is tb that does not respond to at least isoniazid and rifampicin treatment, the main anti-tb medications.4 the prevalence of type-2 dm among mdr-tb patients in indonesia has not yet been known. however, some studies have revealed that type-2 dm has been found among 18.8-23.3% of mdr-tb patients in some public hospitals in indonesia.7,8 the association between type2 dm and mdr-tb is not entirely clear and different studies have revealed conflicting results. some studies demonstrated that there was no association between type-2 dm and mdr-tb,9,10 while other reported that the risk of mdr tb increased among diabetic patients.11,12 however, type-2 dm has been shown to increase the risk of delayed sputum conversion and treatment failure.6,11,13 the correlation between type-2 dm and mrd -tb has never been studied among patients with tb in indonesia. therefore, our study aimed to analyze the influence of type-2 dm on the development of mdr-tb in indonesia. methods as a preliminary study, our retrospective cohort study was carried out involving all tb patients who were admitted to the provincial lung clinics and dr. sardjito referral hospital, yogyakarta, indonesia between 2010 and 2014. the criteria for establishing the diagnosis of type2 dm was in line with the national guidelines and was carried out by a physician. individuals who had fasted for at least 8 hours and showed a plasma glucose concentration of ≥126 mg/dl were considered diabetic.14 the diagnosis of dm was also made if patients had a history of known dm or had received antidiabetic agents. diagnosis of tb was established based on clinical examination, positive sputum smear examination for acidfast bacilli (afb) and or positive chest x-ray, which were consistent with the national and international guidelines.15 all tb patients were treated according to the national and international guidelines.15 mdr-tb diagnosis was determined by an examination using genexpert mtb/rif (cepheid, us) or drug sensitivity testing at the laboratory of tb, department of microbiology, faculty of medicine, universitas gadjah mada, yogyakarta. at the beginning of treatment, a routine blood examination was conducted, and human immunodeficiency virus (hiv) testing was performed for all patients. patient selection all pulmonary tb patients who were treated at the provincial lung clinics and dr. sardjito hospital were included in our study. mdr-tb patients were selected based on the vol 50 • number 1 • january 2018 influence of diabetes mellitus on the development of multi drug resistant-tb 13 results of drug sensitivity or genexpert testing, which were registered in their medical records. exclusion criteria were those who were less than 18 years old and had incomplete medical record. the study was conducted in accordance to the helsinki declaration of 2008 and had been approved by the medical and health research ethics committee at faculty of medicine, universitas gadjah mada, yogyakarta, indonesia on november 3rd, 2012 with reference number ke/fk/855/ec. based on the calculation of sample size formula for a cohort study (zα=1.96, p0=2.8%, p1=23.3%, zβ=0.80, and m=6.58; based on previous data on dm prevalence of tb and mdr-tb patients in indonesia), the minimum sample needed in the exposed group was 24 patients. since it was a preliminary study, 23 patients were considered as acceptable sample size. data collection epidemiological and clinical variables were obtained from medical records. the collected data variables were age, sex, body mass index (bmi), smoking status, an ethnic group, history of tb contact, history of tb treatment, result of sputum smear taken at the time of diagnosis and after two months of treatment, presence of a cavitary lesion on chest x-ray, and results of drug resistance test. study participants were followedup retrospectively through medical record until the end of treatment. data analysis bivariate analysis was carried out using chi square test or fisher’s exact test. a logistic regression was carried out to determine whether the type-2 dm was associated with multi drug resistance tuberculosis. univariate test were done to type-2 dm and other factors. factors with p<0.20 then were included in the multivariate model, p<0.05 was considered significant. odds ratios (or) and 95% confidence intervals (95% ci) were also calculated. spss software program version 24.0 (ibm, usa) was used for the calculations. results we excluded 35 patients due to incomplete data. table 1 shows general characteristics of 356 individuals included in the study. among the 356 tb patients, 23 patients were with binomial tuberculosis – diabetes mellitus and 333 tb patients did not suffered from diabetes mellitus. demographic characteristics were similar between tb patients with and without dm. patient with dm had more cavitary lesion (p=0.005) and positive sputum smear examination after two months treatment (p=0.2) than those without dm. table 1. characteristics of tb patients with and without diabetes mellitus (dm)a characteristics (n=356) tb-dm n (%) tb-nondm n (%) total n (%) age (years), mean (sd) 42.48 (14.23) 36.79 (14.89) 37.01 (0.79) age >37 years 12 (52.17) 131 (39.30) 143 (40.20) male sex 17 (73.91) 205 (61.56) 222 (62.36) bmi <18.5 or >25 kg/m2 17 (73.91) 262 (78.68) 279 (78.37) ethnic group: javanese 21 (91.30) 304 (91.29) 325 (91.29) others (sundanese, batak, others) 2 (8.70) 29 (8.71) 31 (8.71) history of smoking 7 (30.4) 113 (33.9) 120 (33.7) history of tb contact 5 (21.7) 93 (27.9) 98 (27.53) previous tb treatment 3 (13.0) 17 (5.1) 20 (5.6) cavitary disease 12 (52.2) 84 (25.2) 96 (26.97) positive ssm result at diagnosis 22 (95.65) 316 (94.89) 338 (94.94) positive ssm result at 2 mo of treatment 5 (21.7) 20 (6.01) 25 (7.0) mdr-tb 4 (17.4) 10 (3.0) 14 (3.93) sd: standard deviation; ssm: sputum smear examination; a data are n (%) unless otherwise stated table 2 shows factors significantly associated with mdr-tb development, which include age older than 37 years old (p=0.04), female (p=0.04), had previous tb treatment (p<0.001) and was with dm (p=0.009). among the tb-dm patients, 4 patients (17.4%) developed mdr-tb. the univariate analysis showed that patients antonia m.i. saktiawati acta med indones-indones j intern med 14 with binomial tuberculosis diabetes mellitus presented a 6.8-fold (95% ci:2.0-23.7, p=0.003) higher risk of developing mdr-tb compared to those without dm (table 3). meanwhile, the effect of dm increased (or=17.9, 95%ci: 3.396.8) when analyzed together with other factors. factor of previous tb treatment was not included in the multivariate analysis because of its wide confidence interval. individuals with binomial tuberculosisdiabetes mellitus had a 4.4-fold (95% ci:1.5-12.9, p=0.008) greater chance to have positive tuberculosis result of sputum smear after the second month of treatment indicating a delay in the resolution of the tuberculosis infection (table 4). table 2. factors associated with mdr-tba characteristics mdtr-tb total (n=356) p valueb yes no age >37 years 11 (78.6) 132 (38.6) 143 (40.2) 0.004 female sex 9 (64.3) 125 (36.5) 134 (37.6) 0.04 bmi <18.5 or >25 kg/m2 14 (100) 265 (77.5) 279 (78.37) 0.05 ethnic group: javanese 14 (100) 311 (90.9) 325 (91.29) 0.62 others (sundanese, batak, others) 0 (0.0) 31 (9.1) 31 (8.71) history of smoking 2 (14.3) 118 (34.5) 120 (33.7) 0.15 history of tb contact 2 (14.3) 96 (28.1) 98 (27.53) 0.37 previous tb treatment 13 (92.9) 7 (2.0) 20 (5.6) <0.001 cavitary lung lesion on radiology 1 (7.1) 95 (27.8) 96 (26.97) 0.12 positive ssm result at diagnosis 12 (85.7) 326 (95.3) 338 (94.94) 0.15 positive ssm result after 2 mo of treatment 2 (14.3) 23 (6.7) 25 (7.0) 0.26 presence of dm 4 (28.6) 19 (5.6) 23 (6.5) 0.009 a data are n (%) unless otherwise stated. b chi square test or fisher’s exact test were used when appropriate table 3. analysis between the significant factors associated with mdr-tb and the development of mdr-tb variables total n (%) mdrtb n (%) bivariate multivariate or (95% ci) p-valuea or (95% ci) p-valueb age>37 years 160 (44.94) 10 (71.43) 5.8 (1.6-21.3) 0.01 6.7 (1.7-26.3) 0.01 female sex 134 (37.6) 9 (64.3) 3.12 (1.0-9.5) 0.045 6.1 (1.4-26.8) 0.02 history of smoking 120 (33.7) 2 (14.3) 0.3 (0.1-1.4) 0.14 0.3 (0.1-1.7) 0.20 previous tb treatment 20 (5.6) 13 (92.9) 622.1 (71.2-5434.2) <0.001 cavitary lung lesion on radiology 96 (27.0) 1 (7.1) 0.2 (0.03-1.6) 0.12 0.1 (0.01-1.1) 0.06 positive ssm result at diagnosis 338 (94.9) 12 (85.7) 0.3 (0.1-1.4) 0.13 0.4 (0.1-2.2) 0.30 dm 23 (6.5) 4 (28.6) 6.8 (2.0 – 23.7) 0.003 17.9 (3.3-96.8) 0.001 a calculated with simple logistic regression; b calculated with multiple logistic regression. table 4. association between dm and positive ssm result after 2 months of treatment variables total n (%) tb-dm n (%) tb-non dm n (%) or (95% ci) p value positive ssm result at 2 mo of treatment 25 (7) 5 (21.7) 20 (6) 4.4 (1.5-12.9) 0.008 a calculated with simple logistic regression vol 50 • number 1 • january 2018 influence of diabetes mellitus on the development of multi drug resistant-tb 15 discussion our study showed that type 2 dm was significantly associated with the development of mdr-tb in yogyakarta, indonesia. the mechanism could be explained by lower plasma concentrations of anti tb drugs, particularly rifampicin,16 due to altered drug absorption, distribution, metabolism and excretion in tb patients with dm. the intestinal motility in diabetics is also lower, thus reduces gastric emptying, changes the ph levels and results in delayed absorption of some drugs. moreover, a study showed that tb diabetic patients had rifampicin serum levels that were 53% lower in tb non-diabetic patients.16 the low plasma level of anti-tb drugs was proposed to cause poor treatment outcome, in which risk on treatment failure was almost nine folds higher in patients with low drug exposure compared to patients with higher drug exposure. furthermore, it also has an association with acquired drug resistance.17,18 another hypothesis includes the mutations of katg gene. the gene has a function to protect the mycobacterium tuberculosis against oxidative stress and to encode catalase-peroxidase that induces isoniazid into its active form. in diabetic patients, there might be improved production of reactive oxygen species, thus the strains with such mutations are more likely to survive.19,20 our study also revealed that diabetic tb patients had delayed resolution of tuberculosis infection as shown by positive tuberculosis result of sputum smears in the second month of treatment. the findings are consistent with results of previous study that has identified a longer sputum conversion time in diabetic tb patients compared to non-diabetics.21 it might be related to altered immune response against tuberculosis found in diabetic patients, thus leading to higher baseline mycobacterial burdens in comparison to non-diabetic patients and resulting in longer sputum conversion time.21,22 moreover, another study in indonesia revealed that despite the similarity of culture conversion proportions for diabetic tb patients and nondiabetic tb patients after 2 months of treatment, the rate of treatment failure among diabetic tb patients was higher (22.2%) compared to the rate among non-diabetic tb patients (9.6%).23 meanwhile, patients with previous treatment failure will obtain longer treatment duration, which will increase the likelihood of developing drug-resistant mutation. we also found that patients with dm in our study had more cavitary lesions. our finding is in accordance with results of some previous studies,22,24 and the reason proposed was due to uncontrolled glycemic level (hba1c≥7) or insulin dependency.9 however, we could not collect data of neither hba1c levels nor insulin dependency. therefore, we could not confirm the hypothesis. in addition to the presence of diabetes mellitus, our data also revealed that being older than 37 years old, female and had previous tb treatment gave higher risk of developing mdrtb. previous studies indicated conflicting results for older age as a predisposing factor for mdrtb.25,26 however, in our study, it might be caused by the delayed diagnosis of mdr-tb since the free-cost and prompt diagnosis device for mdr-tb (genexpert) in yogyakarta was just available recently in 2012. female gender as a risk factor for the development of mdr-tb may be explained by low health-care seeking behavior among women when the disease was still not progressive, which corresponds with results of an earlier study.27 however, the role of this factor needs further investigation. meanwhile, a history of previous tb treatment has already been stated as one of the strongest predisposing factors of mdr-tb by who and some previous studies. it may be caused by multi-factorial causes, such as non-adherence, low level of drugs, poor health system, and human error.4,10,28 in 2015, who reported that 12% of tb patients in indonesia who were treated for tb in the past were estimated to develop mdr-tb.4 to prevent the development of mdr-tb among tb diabetic patients, clinicians need to pay attention on the co-management of tb and dm. a glycemic control could be hindered by tb infection, especially in the early stage of tb treatment. in this stage, increased inflammation would occur due to early bacterial killing, which may escalate insulin resistance.29 furthermore, there is a drug-drug interaction between tb and dm drugs. rifampicin decreases the plasma levels of some oral anti-diabetic drugs, especially antonia m.i. saktiawati acta med indones-indones j intern med 16 sulphonylureas and biguanides; while in patients using isoniazid, worse glycemic control may occur due to sulphonylureas.30 moreover, rifampicin serum levels in tb diabetic patients are lower than tb non-diabetic patients.16 in addition, the side effects of co-administrating tb and diabetes medications might influence patient adherence, which is another predisposing factor for developing mdr-tb. therefore, a strict glycemic control together with monitoring the blood levels of anti-diabetes and anti-tb drugs during tb treatment may give benefits to improve treatment outcome. despite having high numbers of estimated cases of dm and mdr-tb,4,5 the integrated systems for communicable and noncommunicable diseases have not yet been well developed in indonesia. there are some limitations in our study. the results of sputum examination is limited to the results of sputum smear on microscopic examination since culture examination is expensive and rarely conducted although culture would provide more information. our study also has a relatively small sample size, thus our findings need to be confirmed in larger sample and in this way, we may assess other risk factors for drug resistance. conclusion our study shows that diabetes mellitus increases the risk of developing mdr-tb. therefore, it is suggested that clinicians at all levels of health care service should make an appropriately targeted early clinical suspicion and conduct any kind of screening test of mdr-tb for such group of patients. further prospective cohort study should be conducted to confirm these preliminary findings. acknowledgments the work was supported by the directory of general higher education (dghe) of indonesia. authors retain the copyright to their work. the authors declare no competing financial interests. references 1. webb ea, hesseling ac, schaaf hs, et al. high prevalence of mycobacterium tuberculosis infection and disease in children and adolescents with type 1 diabetes mellitus. int j tuberc lung dis. 2009;13(7):868-74. 2. ottmani se, murray mb, jeon cy, et al. consultation meeting on tuberculosis and diabetes mellitus: meeting summary and recommendations. int j tuberc lung dis. 2010;14(12):1513-7. 3. lonnroth k, castro kg, chakaya jm, et al. tuberculosis control and elimination 2010-50: cure, care, and social development. lancet. 2010;375(9728):1814-29. 4. world health organization. global tuberculosis report. world health organization; 2016. 5. international diabetes federation. annual report. 2015. 6. alisjahbana b, van crevel r, sahiratmadja e, et al. diabetes mellitus is strongly associated with tuberculosis in indonesia. int j tuberc lung dis. 2006;10(6):696-700. 7. reviono juliana, indah harsini aphridasari, jatu sutanto, yusup s. comparison of clinical, radiological finding and culture conversion of diabetic and non diabetic multidrug resistant tuberculosis patients in dr. moewardi hospital. j respir indo. 2013;33(2):103. 8. risky akaputra, erlina burhan, arifin nawas. characteristics and evaluations of illness of multidrug resistant tuberculosis with and without diabetes mellitus. j respir indo. 2013;33:92-102. 9. park sw, shin jw, kim jy, et al. the effect of diabetic control status on the clinical features of pulmonary tuberculosis. eur j clin microbiol infect dis. 2012;31(7):1305-10. 10. tanrikulu ac, hosoglu s, ozekinci t, abakay a, gurkan f. risk factors for drug resistant tuberculosis in southeast turkey. trop doct. 2008;38(2):91-3. 11. chang jt, dou hy, yen cl, et al. effect of type 2 diabetes mellitus on the clinical severity and treatment outcome in patients with pulmonary tuberculosis: a potential role in the emergence of multidrug-resistance. j formos med assoc. 2011;110(6):372-81. 12. zhang q, xiao h, sugawara i. tuberculosis complicated by diabetes mellitus at shanghai pulmonary hospital, china. jpn j infect dis. 2009;62(5):390-1. 13. jimenez-corona me, cruz-hervert lp, garcia-garcia l, et al. association of diabetes and tuberculosis: impact on treatment and post-treatment outcomes. thorax. 2013;68(3):214-20. 14. perkumpulan endokrinologi indonesia. konsensus pengendalian dan pencegahan diabetes mellitus tipe 2 di indonesia. pb perkeni, jakarta; 2015. 15. world health organization. treatment of tuberculosis: guidelines– 4th ed. who, geneva, switzerland; 2010. 16. nijland hm, ruslami r, stalenhoef je, et al. exposure to rifampicin is strongly reduced in patients with tuberculosis and type 2 diabetes. clin infect dis. 2006;43(7):848-54. 17. pasipanodya jg, srivastava s, gumbo t. meta-analysis of clinical studies supports the pharmacokinetic variability hypothesis for acquired drug resistance and failure of antituberculosis therapy. clin infect dis. 2012;55(2):169-77. vol 50 • number 1 • january 2018 influence of diabetes mellitus on the development of multi drug resistant-tb 17 18. pasipanodya jg, mcilleron h, burger a, wash pa, smith p, gumbo t. serum drug concentrations predictive of pulmonary tuberculosis outcomes. j infect dis. 2013;208(9):1464-73. 19. gagneux s, burgos mv, deriemer k, et al. impact of bacterial genetics on the transmission of isoniazidresistant mycobacterium tuberculosis. plos pathog. 2006;2(6):e61. 20. schaible ue, kaufmann sh. malnutrition and infection: complex mechanisms and global impacts. plos med. 2007;4(5):e115. 21. guler m, unsal e, dursun b, aydln o, capan n. factors influencing sputum smear and culture conversion time among patients with new case pulmonary tuberculosis. int j clin pract. 2007;61(2):231-5. 22. ponce-de-leon a, garcia-garcia md mde l, garciasancho mc, et al. tuberculosis and diabetes in southern mexico. diabetes care. 2004;27(7):1584-90. 23. alisjahbana b, sahiratmadja e, nelwan ej, et al. the effect of type 2 diabetes mellitus on the presentation and treatment response of pulmonary tuberculosis. clin infect dis. 2007;45(4):428-35. 24. wang jy, lee ln, hsueh pr. factors changing the manifestation of pulmonary tuberculosis. int j tuberc lung dis. 2005;9(7):777-83. 25. drobniewski f, balabanova y, nikolayevsky v, et al. drug-resistant tuberculosis, clinical virulence, and the dominance of the beijing strain family in russia. jama. 2005;293(22):2726-31. 26. farazi a, sofian m, zarrinfar n, katebi f, hoseini sd, keshavarz r. drug resistance pattern and associated risk factors of tuberculosis patients in the central province of iran. caspian j intern med. 2013;4(4):7859. 27. lomtadze n, aspindzelashvili r, janjgava m, et al. prevalence and risk factors for multidrug-resistant tuberculosis in republic of georgia: a population based study. int j tuberc lung dis. 2009;13(1):68-73. 28. van der werf mj, langendam mw, huitric e, manissero d. multidrug resistance after inappropriate tuberculosis treatment: a meta-analysis. eur respir j. 2012;39(6):1511-9. 29. shoelson se, lee j, goldfine ab. inflammation and insulin resistance. j clin invest. 2006;116(7):1793801. 30. niazi ak, kalra s. diabetes and tuberculosis: a review of the role of optimal glycemic control. j diabetes metab disord. 2012;11(1):28-65. 283acta med indones indones j intern med • vol 54 • number 2 • april 2022 case report secondary choledocholithiasis in obstructive jaundice patient due to choledochoduodenal-fistula stricture m. begawan bestari*, eka surya nugraha, siti aminah abdurachman division of gastroenterohepatology, department of internal medicine, faculty of medicine universitas padjadjaran hasan sadikin hospital, bandung, indonesia. * corresponding author: m. begawan bestari, md, phd, fasge. division of gastroenterohepatology, department of internal medicine, faculty of medicine universitas padjadjaran hasan sadikin hospital, bandung, indonesia. email: begawan@ gmail.com. abstract choledochoduodenal fistula (cdf) is a rare condition marked by an abnormal connection between the biliary duct and duodenum. the common etiology of secondary cdf are cholecystolithiasis, tumor, and duodenal ulcer. cdf may also caused by prior inflammatory condition or as a complication of radiation therapy. management for this case is based on the patient condition. herein we aimed to present a case of secondary choledocholithiasis due to stricture in the cdf which presented with cholangitis treated by self-expanding metal stent (sems) for biliary drainage. patient admitted with jaundice, fever, right upper quadrant pain, and history of cholecystectomy. diagnosis of cdf was determined by endoscopic retrograde cholangiopancreatography (ercp) and followed by putting biliary stent for urgent biliary drainage. the follow up result after stent removal was excellent. keywords: choledochoduodenal fistula, cdf, cholangitis, choledocolithiasis. introduction choledochoduodenal fistula (cdf) is a rare condition in which an abnormal connection forms between the biliary duct and duodenum.1–3 they account for 5–25% of all internal biliary fistulas.1 biliary-enteric fistula was first described by bartholin in 1654.4 first case report of cdf was described in 1840, however there are only a few cases reported in the world.1–4 virtually 90% of cdf, the particular type of biliary-enteric fistulas, are caused by cholecystolithiasis.4,5 other causes are pancreatobiliary tumor, and less commonly by duodenal ulcer.5,6 cdf may ensue following inflammatory causes or as a consequence of radiation therapy. in few cases, it may serve as an alternative pathway of biliary drainage while the main biliary duct is obstructed.3 this is a case report of secondary choledocholithiasis due to stricture in the cdf which presented with cholangitis. case illustration a 43 years old female presented with jaundice in the last 10 days. she had fever for 7 days, with right upper quadrant abdominal pain. patient undergone cholecystectomy 3 years ago. on clinical examination, she was hemodynamically stable with tachycardia and fever (38.1℃). her sclerae was icteric and abdominal pain at the right upper quadrant. the rest of the physical examination was normal. laboratory investigations showed raised wbc count (16,550/mm3), ureum (52 mg/dl), creatinine (2,1 mg/dl), total bilirubin (9.27 mg/ dl), direct bilirubin (7.54 mg/dl), mildly raised liver enzymes (ast 70 u/l, alt 135 u/l), m. begawan bestari acta med indones-indones j intern med 284 increased alkaline phosphatase (247 u/l), gamma-gt (337 u/l), while amylase and lipase were within normal limits. ultrasonography revealed biliary stone with dilatation of intra and extra hepatic biliary ducts. patient was diagnosed with severe cholangitis based on tokyo guidelines for cholangitis, consequently required urgent biliary drainage. endoscopic retrograde cholangiopancreatography (ercp) was performed, however cannulation at ampulla of vater was unsuccessful. we discovered a fistula adjacent to the ampulla of vater, proceeded with fistula cannulation. medium contrast was injected showing a fistula between bile duct and duodenum with stricture at distal part toward the duodenum, multiple biliary stones in the bile duct, and total obstruction at ampulla of vater (figure 1). the stricture at distal fistula made secondary-choledocholithiasis which lead to severe cholangitis. a pigtail plastic stent 10f was inserted for urgent temporary bile-drainage (figure 2). subsequently patient’s condition improved clinically. second ercp was done and the plastic stent was replaced by fully-covered self-expanding metal stent (sems) 3 days afterwards (figure 3). six weeks later, third ercp was done and sems was removed. follow up cholangiography showed no stones in the bile duct, this result indicated the biliary stones passed spontaneously through the fistula while sems was still in placed (figure 4). discussion cdf was one of the rare conditions reported. a study presents 81 biliary fistula cases from 1948-1998 and choledochoduodenal fistula was only found in 7 cases (8.6%).7 the most common cause of cdf was cholecystolithiasis.1,6 some reported cdf was caused by duodenal ulcer, tumors, and tuberculosis.6,8 in a study reviewed in the period between 1976 and 1989, 14 (0.7%) patients who underwent ercp because of biliary disease were found to be having cdf.9 another figure 1. cbd cannulated via cdf with multiple biliary stones. figure 2. cbd plastic stent vol 54 • number 2 • april 2022 secondary choledocholithiasis in obstructive jaundice patient 285 study in china found 50 cases of cdf from 1200 patient with biliary disease who underwent ercp.10 the incidence of cdf in an endemic area of cholelithiasis documented as high as 2.53%.11 the exact pathophysiology of cdf formation is not well known. one hypothesis sugests that it is caused by recurrent gallstone or cholangitis resulting in increased proximal ductal pressure leading to the formation of the fistula. the clinical presentation of cdf is usually unclear. most of the patients with cdf presented with symptoms of cholangitis with right upper quadrant pain, jaundice, and fever.4 infection occurred due to the ascending bacteria from duodenum to the biliary tract.1,10,11 in our case, she was admitted with severe cholangitis, noticed by symptoms, ultrasound findings, and sign of organ failure which was acute kidney injury. although cdf is difficult to diagnose, recent advances in imaging and endoscopic techniques are developed to increase detection of cdf. fistulography and cholangiography are commonly used to acquire an accurate diagnosis for all fistula in all cases. the study demonstrated that imaging did not show the fistula in any various imaging modalities.12 however, some studies reported patients with cdf presenting with pneumobilia on their imaging workups (x-ray and/or ct).1,13–15 in 1975, ikeda classified cdf into two types of fistulas based on the location. type i was located on the longitudinal fold of the papilla, while type ii was on the posterior wall of the duodenal bulb.4,16 this patient was considered type ii ikeda classification, owing to the fact that the location of the fistula was posterior from papilla fold or minor papilla. the ampulla of vater orifice was completely obstructed since unsuccessful attempt of the cannulation. even so, cannulation resulted in biliary drainage success figure 3. sems. figure 4. post sems removal. m. begawan bestari acta med indones-indones j intern med 286 in duodenal bulb where the fistula presented. the option of cdf treatment was based on the etiology, type of the fistula, and severity of the disease. the management of cdf was surgery in general, however, in conditions where surgery remains a relative contraindication, endoscopic biliary drainage is the alternative option.1,3 the biliary drainage is aimed to reduce the intraluminal pressure to allow bile to flow. the stent will usually be left in place for four to six weeks and removed after excellent follow up result.17 previous study describes larger fistula orifices > 1 cm recommended to have surgical therapy since they have higher recurrence rate of cholangitis. however, for fistula orifices less than 1 cm, a biliary drainage can be considered as treatment.10 chintanaboina et al. demonstrated biliary stenting in alternative to surgery for cdf patient with several comorbidities.3 study from france shows successful treatment in cdf patient with biliary obstruction by placing endoprostheses for biliary drainage and have good clinical result in follow up.18 other studies demonstrated that using sems on endoscopic procedure are found to be effective and reliable for patient with bilioduodenal obstruction and the clinical outcome was excellent.19,20 we decided to insert 10f pigtail plastic stent, which was subsequently replaced with self-expandable metal stent (sems) to optimize drainage since it had a larger diameter. compared to plastic stents, the use of sems in malignant biliary obstruction results in higher rate of patient survival and lower risk of future complication.21 the follow up result was excellent, patient’s condition improved and laboratory parameters returned to normal. the benefit of using large diameter stent also allowed biliary stones to migrate spontaneously, which has never been reported yet. conclusion this case demonstrated a secondary choledocholithiasis with severe cholangitis due to the choledochoduodenal fistula stricture. inserting self-expandable stent in the fistula allows both bile and even biliary stone to pass spontaneously. fully covered sems insertion may serve as an alternative practice to avoid surgery procedures on biliary drainage and removing biliary stones, in choledochoduodenal fistula cases. references 1. b s b , k a r a , d u t t a m , e t a l . a c a s e o f choledochoduodenal fistula an unusual case report. clin case reports. wiley-blackwell. 2017;5(9):1462–4. 2. aguilar-espinosa f, maza-sánchez r, vargas-solís f, et al. cholecystoduodenal fistula, an infrequent complication of cholelithiasis: our experience in its surgical management. rev gastroenterol méxico. 2017;82(4):287–95. 3. chintanaboina j, mathew a, moyer mt. taking an alternate route home: stenting of choledochoduodenal fistula. acg case reports j. 2015;2(2):104–6. 4. wu m b , z h a n g wf, z h a n g yl , e t a l . choledochoduodenal fistula in mainland china: a review of epidemiology, etiology, diagnosis and management. ann surg treat res. 2015;89(5):240. 5. mallikarjunappa b, s. r. a. choledochoduodenal fistula: a rare case report with review of literature. jimsa. 2013;26(4):226. 6. chansaenroj p, wood s, rogers sj. selective management for gastrointestinal hemorrhage caused by choledochoduodenal fistula. siriraj med j. 2017;67:97–101. 7. stagnitti f, mongardini m, schillaci f, et al. spontaneous biliodigestive fistulae. the clinical considerations, surgical treatment and complications. g chir. 2000;21(3):110–7. 8. ya m a m o t o t, ya m a m o t o t, a b e k , e t a l . choledochoduodenal fistula associated with recurrent peptic ulcer. j med cases. 2012;3(4):243–6. 9. jorge a, diaz m, lorenzo j, et al. choledochoduodenal fistulas. endoscopy. 1991;23(02):76–8. 10. li z-h, ding j, ye y, et al. new strategy to prevent ascending cholangitis in larger choledochoduodenal fistula. anz j surg. 2006;76(9):796–800. 11. sheu bs, shin js, lin xz, et al. clinical analysis of choledochoduodenal fistula with cholelithiasis in taiwan: assessment by endoscopic retrograde cholangiopancreatography. am j gastroenterol. 1996;91(1):122–6. 12. oikarinen h, päivänsalo m, tikkakoski t, et al. acta radiologica findings in biliary fistula and gallstone ileus. acta radiol. 1996;37(6):917–22. 13. a n t o n y a . p n e u m o b i l i a r e s u l t i n g f r o m choledochoduodenal fistula secondary to metastatic colon adenocarcinoma. acg case reports j. 2016;3(2):112–4. 14. tonolini m. spontaneous pneumobilia revealing choledocho-duodenal fistula: a rare complication of peptic ulcer disease. j emerg trauma shock. wolters kluwer -medknow publications. 2013;6(2):146–7. 15. dadzan e, akhondi h. choledochoduodenal fistula vol 54 • number 2 • april 2022 secondary choledocholithiasis in obstructive jaundice patient 287 presenting with pneumobilia in a patient with gallbladder cancer: a case report. j med case rep. 2012;6(1):61. 16. ikeda s, okada y. classification of choledochoduodenal fistula diagnosed by duodenal fiberscopy and its etiological significance. gastroenterology. 1975;69(1):130–7. 17. crespi m, montecamozzo g, foschi d. diagnosis and treatment of biliary fistulas in the laparoscopic era. gastroenterol res pract. 2016;2016:6293538. 18. ponchon t, gallez j-f, valette p-j, et al. endoscopic treatment of biliary tract fistulas. gastrointest endosc. 1989;35(6):490–8. 19. hori y, naitoh i, hayashi k, et al. covered duodenal self-expandable metal stents prolong biliary stent patency in double stenting: the largest series of bilioduodenal obstruction. j gastroenterol hepatol. 2018;33(3):696–703. 20. lu l, tang x, jin h, et al. endoscopic ultrasoundguided biliary drainage using self-expandable metal stent for malignant biliary obstruction. gastroenterol res pract. 2017;2017:6284094. 21. dumonceau j-m, tringali a, papanikolaou i, et al. endoscopic biliary stenting: indications, choice of stents, and results: european society of gastrointestinal endoscopy (esge) clinical guideline – updated october 2017. endoscopy. 2018;50(09):910–30. 175 original article acta medica indonesiana the indonesian journal of internal medicine prevalence of urinary incontinence, risk factors and its impact: multivariate analysis from indonesian nationwide survey rochani sumardi1,6, chaidir a. mochtar1,6, junizaf2,6, budi i. santoso2,6, siti setiati3,6, siti a. nuhonni4,6, partini p. trihono5,6, harrina e. rahardjo1,6, firtantyo a. syahputra1,6 1 department of urology, faculty of medicine, universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 department of obstetrics and gynecology, faculty of medicine, universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 3 department of internal medicine, faculty of medicine, universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 4 department of physical medicine and rehabilitation, cipto mangunkusumo hospital / faculty of medicine, universitas indonesia, jakarta, indonesia. 5 department of pediatrics, faculty of medicine, universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 6 indonesian prevalence on incontinence study group – continence society of indonesia. correspondence mail: indonesian prevalence on incontinence study group – continence society of indonesia. pkmi building, 3rd floor. jl. kramat sentiong no. 49a, jakarta 10450, indonesia. email: dokter.tio@gmail.com. abstrak tujuan: untuk menggambarkan profil iu, menganalisis faktor resiko serta dampaknya. metode: subyek didapatkan secara konsekutif dari poliklinik anak, urologi, kebidanan & kandungan, dan geriatri pada enam rumah sakit pendidikan di berbagai daerah indonesia. pasien dengan infeksi saluran kemih dan diabetes mellitus dieksklusi dari penelitian. kuesioner iu diadaptasi dari the 3 incontinence questions (3iq). informed consent tertulis dimintakan sebelum wawancara dilakukan. hasil: sebanyak 2765 kuesioner lengkap didapat pada penelitian ini. prevalensi iu secara keseluruhan adalah sebesar 13,0% yang terdiri dari iu tipe tekanan (4,0%), iu desakan / oab basah (4,1%), oab kering 1,8%, iu campuran (1,6%), iu luapan (0,4%), enuresis (0,4%), iu lainnya (0,7%). prevalensi iu secara signifikan (p <0,001) didapatkan lebih tinggi pada populasi usia lanjut (22,2%), dibandingkan dengan orang dewasa (12,0%), dan anak (6,8%). tidak ada perbedaan prevalensi (p>0,05) antara laki-laki dan perempuan. enuresis dan iu desakan/oab basah adalah iu yang paling umum pada anak dengan prevalensi masing-masing sebesar 2,3% dan 2,1%. iu desakan dan iu tekanan adalah dua tipe yang paling umum pada populasi orang dewasa serta usia lanjut. analisis multivariat menunjukkan prevalensi iu meningkat dengan adanya luts (rp 4,22, 95% ik 2,98-5,97), batuk kronis (rp 2.08, 95% ik 1,32-3,28), dan inkontinensia alvi (rp 1,85, 95% ik 1,03-3,32 ). iu didapatkan memberikan dampak terhadap kehidupan berkeluarga (25,3%), hubungan seksual (13,6%), dan pekerjaan / prestasi sekolah (23,7%). sering pergi ke toilet dan mengurangi asupan cairan adalah dua perubahan perilaku yang paling umum ditemukan pada penderita. kesimpulan: prevalensi iu di indonesia menyerupai hasil penelitian pada negara-negara asia lainnya. prevalensi meningkat seiring pertambahan usia usia, dan tidak dipengaruhi jenis kelamin. luts, batuk kronis, dan inkontinensia alvi memiliki efek paling besar meningkatkan prevalensi. iu memberikan dampak pada kehidupan dan perilaku sehari-hari penderitanya. kata kunci: inkontinensia urin, kehidupan, luts, prevalensi, usia. rochani sumardi acta med indones-indones j intern med 176 introduction urinary incontinence (ui) is a common health problem, particularly in females and the elderly population.1 not only causing physical problems, ui also causes psychological, social, economic problems as well as impairs quality of life of the patients.2 therefore, patients with ui should have a holistic management of treatment and multidisciplinary approach. in 2008, there were about 348 million people (8.2%) worldwide with ui. it is estimated that the prevalence will be increasing to 8.5% by 2018.3 although the prevalence of ui is relatively high, but less than half of the patients seek treatment.4 some studies show that the female to male ratio of ui prevalence is 2:1.3,5 european studies demonstrate varied prevalence of ui in female subjects, which is 23% in spain, 41% in germany, 42% in uk and 44% in france.4 meanwhile, the prevalence in male subjects is 7% in france, 16% in netherlands and 14% in uk.6 different definitions of ui between one and other studies have caused highly varied data of ui prevalence. the international continence society provides a simpler definition of iu, which is ‘the complaint of any involuntary leakage of urine’.4 with such definition, questionnaire-based epidemiological studies on ui have been carried out in a more practical way. the prevalence of ui increases with age. the elderly population is the largest group of ui patients, both in male and female subjects.1 a study in malaysia demonstrates a higher prevalence ui in elderly male subjects compared to the female.7 an ui survey of elderly population in jakarta found that the prevalence of stress ui is 32.2%.8 various factors may increase the risk of ui development including multiparity, obesity, pelvic trauma, constipation, chronic disease (diabetes) and history of gynecological/ pelvic surgery.9 the magnitude of the ui problem in indonesia, either in pediatric, adult or elderly population, has not been known. the available data is the results of a survey conducted by division of geriatrics, department of internal medicine, national central general hospital cipto mangunkusumo hospital (rscm) in 208 subjects of elderly population in jakarta, which found that the prevalence of stress ui was 32.2%.8 it is estimated that the national prevalence of ui in indonesia is relatively high. the aim of this study was to obtain the profile of ui on pediatric, adult and elderly population abstract aim: to describe the profile of urinary infection (ui) and to analyze its risk factors and impacts. methods: subjects were enrolled consecutively from pediatric, urology, obstetrics & gynecology, and geriatric outpatient clinics at six teaching hospitals in various regions of indonesia. those with urinary tract infection and diabetes mellitus were excluded. the ui questionnaire was adapted from the 3 incontinence questions (3iq). written informed consent was obtained prior to the interview. results: about 2765 completed questionnaires were obtained. the overall ui prevalence was 13.0%, which consisted of prevalence of stress ui (4.0%), urgency ui/wet oab (4.1%), dry oab (1.6%), mixed ui (1.6%), overflow ui (0.4%), enuresis (0.4%), other ui (0.7%). the prevalence of ui was significantly higher (p<0.001) in geriatric population (22.2%) compared to the adult (12.0%), and pediatric population (6.8%). there was no prevalence difference (p>0.05) between male and female subjects. enuresis and urgency ui/wet oab were the most common ui in pediatric population. the prevalence was 2.3% and 2.1% respectively. urgency ui and stress ui were the two most common type in adult and geriatric population. both have an equal prevalence of 4.6%. the multivariate analysis showed that the prevalence of ui increased with luts (pr 4.22, 95%ci 2.98-5.97), chronic cough (pr 2.08, 95% ci 1.32-3.28), and fecal incontinence (pr 1.85, 95% ci 1.03-3.32). we found that ui impaired family life (25.3%), sexual relationship (13.6%), and job/school performance (23.7%). frequent toilet use and reducing fluid intake were the two most common behavior changes. conclusion: the prevalence of ui in indonesia is nearly similar to other asian countries. it increases with age and is not affected by gender. luts, chronic cough, and fecal incontinence may have significant effects on the prevalence. ui seems to impact daily life and behavior. key words: urinary incontinence, daily life, luts, prevalence, age. vol 46 • number 3 • july 2014 prevalence of urinary incontinence, risk factors and its impact 177 in indonesia and to identify risk factors and impacts of ui. methods a cross-sectional study was conducted at six hospitals in indonesia between 2008 and 2011, i.e. at cipto mangunkusumo hospital (jakarta), dr. kariadi hospital (semarang), wahidin sudirohusodo hospital (makassar), adam malik hospital (medan), dr. soetomo hospital (surabaya) and hasan sadikin hospital (bandung). the population of study was all patients including children, adult and elderly patients who had treatment at the pediatric, urology, obstetrics and gynecology, and geriatric outpatient clinics of those six hospitals. the inclusion criteria were patients aged 10 years or more and willing to fill in the given questionnaires. those who had urinary tract infection and diabetes mellitus were excluded. consecutive sampling was carried out. the consent to participate in the study was obtained by signing the written informed consent. eligible subjects were interviewed by a doctor according to guidelines for filling up questionnaire. the questionnaire consisted of five sections. the first section is about subject characteristics. the second section includes questions to identify the prevalence of ui, which is an adaptation from the 3 incontinence questions (3iq) by brown js, et al.10 the third part evaluates the risk factors of ui in adults and elderly. the fourth section identifies the risk factors of ui in children. the fifth section evaluates the impacts of ui on the patients. urinary incontinence was defined when the patients complained about involuntary leakage of urine during the last 3 months.11 ui was classified into: 1) stress type (stress ui) when the occurrence was associated with physical activities such as sneezing, coughing or physical exercise; 2) urge type (urgency ui/wet overactive bladder oab) when it was preceded by the urge of micturition and accompanied by urgency, frequency and nocturia. in this study, subjects with symptoms of urgency, frequency and nocturia without having ui were classified as subjects with dry oab; 3) mixed type (mixed ui) when there were components of stress and urgency; 4) overflow table 1. profile of study subjects profile number (%) gender female 1720 (62.2) male 1045 (37.8) age children (<18 years) 512 (18.5) adult (18-59 years) 1730 (62.6) elderly (≥60 years) 523 (18.9) type (overflow ui) when it was associated with a great amount of residual urine due to infravesical obstruction (enlarged prostate) or weak detrusor muscle of the bladder; 5) other types. the subjects in this study were divided into three age categories, i.e. 1) pediatric (10-17 years); 2) adult (18-59 years) and 3) elderly (≥60 years). data was analyzed using statistical program. the data analysis included univariate, bivariate and multivariate analysis. univariate analysis was performed on subject characteristics and each variable of the study to observe the distribution and percentage of variables. bivariate analysis was carried out to observe the correlation between two variables using chi square test. multivariate analysis was performed to identify risk factors that might have the greatest effect on the development of ui. statistical test used in the study was logistic regression test. the level of significance used in the bivariate analysis was p<0.05. variables with p < 0.25 were further analyzed using multivariate analysis. results from six hospitals, 2765 questionnaires were collected. the majority of patients were categorized in adult age group (table 1) with the mean age of 37.7±20.7 years. most subjects were female (62.2%), had last education level of senior high school (25.2%) and had been married (50.1%). of 1720 female subjects, 47.7% had history of normal delivery and 2.9% had undergone caesarean section. the overall ui prevalence was 13.0%, which consisted of prevalence of urgency ui/wet oab (4.1%), stress ui (4.0%), dry oab (1.6%), mixed ui (1.6%), overflow ui (0.4%), enuresis rochani sumardi acta med indones-indones j intern med 178 (0.4%), other ui (0.7%) as shown in table 2. the prevalence of ui in male subjects was 11.5%; while in female subjects was 13.5%. there was no significant difference of ui prevalence in male and female subjects. the prevalence of ui in elderly was 22.2%, which was significantly higher (p<0.001) compared to the non-elderly group (age <60 years), i.e. 10.8%. the most common type of ui in children was enuresis and urge ui/wet oab with the prevalence of 2.3% and 2.1%, respectively. while the most common type of ui in adult age group were stress ui (4.5%) and urge iu/wet oab (3.1%). in elderly, the two most common types were urge ui/wet oab (9.4%) and stress iu (4.8%). based on multivariate analysis (table 3), the prevalence of iu increased with lower urinary tract symptoms (luts) (pr 4.22, 95% ci 2.98-5.97), chronic cough (pr 2.08, 95% ci 1.32-3.28), and fecal incontinence (pr 1.85, 95% ci 1.03-3.32). for stress ui, the prevalence increased with luts (pr 4.10, 95% ci 2.307.29), chronic cough (pr 3.82, 95% ci 2.047.15) and female gender (pr 2.40, 95% ci 1.11 5.18). while for urge ui/wet oab, luts was the only factor that increased the prevalence (pr 6.99. 95% ci 3.88-12.62). ui impaired family life (25.3%), sexual relationship (13.6%), and job/school performance (23.7%). the most common behavior changes table 3. risk factors for ui risk factors mixed ui pr (95% ci) stress ui pr (95% ci) urge ui /wet oab pr (95% ci) luts 4.22 (2.98-5.97) 4.10 (2.30-7.29) 6.99 (3.88-12.62) chronic cough 2.08 (1.32-3.28) 3.82 (2.04-7.15) 0.99 (0.42-2.36) fecal incontinence 1.85 (1.03-3.32) 1.61 (0.62-4.23) 1.64 (0.59-4.51) neurological disorder 2.62 (0.68-10.10) 1.79 (0.18-17.36) history of abdominal surgery 1.40 (0.96-2.05) 1.19 (0.63-2.22) 0.85 (0.42-1.71) constipation 1.31 (0.88-1.94) 1.72 (0.94-3.13) 1.13 (0.59-2.18) gender 1.15 (0.79-1.69) 2.40 (1.11-5.18) 0.81 (0.46-1.42) stroke 0.85 (0.25-2.91) 0.82 (0.09-7.22) 0.80 (0.10-6.67) table 2. prevalence of ui based on age and gender children, n (%) adult, n (%) elderly, n (%) overall, n (%) m f t m f t m f t m f t normal 265 (93.0) 212 (93.4) 477 (93.2) 460 (90.2) 1062 (87.0) 1522 (88.0) 200 (80.0) 207 (75.8) 407 (77.8) 925 (88.5) 1481 (86.1) 2406 (87.0) ui 20 (7.0) 15 (6.6) 35 (6.8) 50 (9.8) 158 (13.0) 208 (12.0) 50 (20.0) 66 (24.2) 116 (22.2)* 120 (11.5) 239 (13.9) 359 (13.0) urge ui/ wet oab 6 (2.1) 5 (2.2) 11 (2.1) 12 (2.4) 42 (3.4) 54 (3.1) 28 (11.2) 21 (7.7) 49 (9.4) 46 (1.6) 68 (2.4) 114 (4.1) stress ui 4 (1.4) 4 (1.8) 8 (1.6) 16 (3.1) 62 (5.1) 78 (4.5) 3 (1.2) 22 (8.1) 25 (4.8) 23 (0.8) 88 (3.2) 111 (4.0) overflow ui 1 (0.2) 8 (0.7) 9 (0.5) 2 (0.8) 0 (0.0) 2 (0.4) 3 (0.1) 8 (0.3) 11 (0.4) mixed ui 1 (0.4) 1 (0.2) 5 (1.0) 16 (1.3) 21 (1.2) 7 (2.8) 14 (5.1) 21 (4.0) 13 (0.4) 30 (1.1) 43 (1.5) dry oab 2 (0.7) ¬ 2 (0.4) 13 (2.5) 26 (2.1) 39 (2.3) 4 (1.6) 5 (1.8) 9 (1.7) 19 (0.7) 31 (1.1) 50 (1.8) enuresis 6 (2.1) 6 (2.6) 12 (2.3) 6 (0.2) 6 (0.2) 12 (0.4) other ui 1 (0.4) 1 (0.2) 3 (0.6) 4 (0.3) 7 (0.4) 6 (2.4) 4 (1.5) 10 (1.9) 10 (0.3) 8 (0.3) 18 (0.6) *p<0.001 compared to the non-elderly, m = male, f = female, t = total vol 46 • number 3 • july 2014 prevalence of urinary incontinence, risk factors and its impact 179 due to ui were frequent toilet use and reducing fluid intake. discussion overall, the prevalence of ui in this study was 13.0%, which is similar to the prevalence in asia with a range of 19.7–24.4%.3 the prevalence of ui in female population (13.5%) was not as high as the findings in european studies that range between 25-45%.4 singh et al12 found that ui prevalence of female population in india is 21.8%. the lower prevalence in this study could be caused by culture in indonesia and most asian countries, in which ui is often regarded as a shameful condition; therefore, the patients did not complain about ui that they had experienced. however, it is estimated that there will be a higher surge of ui patients in asia (22%) compared to patients in america (18%) and europe (5%).3 it indicates that the magnitude of ui problems in asian regions is similar to the iceberg phenomenon. in the female population of this study, the most prevalent ui was the stress type ui. similar results are also found by singh et al,12 and kinchen ks et al.13 in women, there are many possible risk factors for stress ui, such as pelvic floor muscle, nerve and connective tissue damages that occur during pregnancy to labor, history of gynecological surgery and reduced level of estrogen hormone in menopause phase. those various factors may cause defects on intrinsic structure of urethral sphincter, urethral hypermobility and damages on urethral supporting tissue (anterior vaginal wall, levator ani, extrinsic structure of the urethra), which manifest as symptoms of stress ui.14 unlike the overseas data, this study did not find significant difference of ui prevalence between male and female subject. it might be due to different population of the subjects, which the majority of population in the overseas studies is a community;1 while this study had subjects of patients who visited the hospitals. the same result has also been found by zurcher s, et al in their study on elderly population who had been hospitalized.15 in male subjects, the prevalence of ui was 11.5% with the three most often types of urge ui/ wet oab, stress ui and dry oab, respectively. similar result is also found in the worldwide data, which indicates that the most frequent type of ui is urge type/wet oab followed by the mixed type.1 it could be explained as in men there are risk factors of luts that may be caused by abnormalities of bladder, bladder outlet (internal urethral sphincter, prostate and external urethral sphincter) or combination of both components. moreover, the most often etiology is prostate enlargement and its therapeutic intervention such as transurethral resection of the prostate (turp), open prostatectomy, or radical prostatectomy, which may also be the risk factors of ui.16,17 the elderly group was the most group which had the greatest prevalence of ui, i.e. 22.2%. the number is higher compared to a study in selangor, malaysia, which is 9.9%.7 while another study in hong kong had a result similar to the indonesian study that found the prevalence of ui in elderly of 24.5%.18 in elderly, there are numerous risk factors that can be found, which are depression,7 delirium,19 functional dependency,7 comorbidity such as diabetes mellitus,7 infection,19 history of vaginal delivery,20 high body mass index,20 medications,19 and the absence of hormone replacement therapy.20 there is a hypotheses that the domination of elderly patients in most of all ui types is associated with geriatric syndrome, which is a multifactorial condition causing disorders of various organs. elderly age is not an etiology of ui; instead, it is only one of predisposition factors. senility may result in anatomical and physiological changes of lower urogenital system such as degeneration of muscles and axons, reduced bladder capacity, increased detrusor activity, reduced detrusor contractility and increased residual urine.19 in the pediatric age group, the prevalence of ui was 6.8% with enuresis as the majority of types (2.3%). some studies in asia showed that enuresis is common in children with a prevalence ranging between 9.3-16.4%.21 another study in iran found that the prevalence of enuresis in children aged 5-18 years is 6.8%.22 prevalence of ui in pediatric age group in indonesia is lower compared to other countries. in general, ui in children may be caused by congenital anatomical defect (ectopic ureter, bladder extrophia and rochani sumardi acta med indones-indones j intern med 180 mielomeningocele), or functional defects.23 the pathophysiology of nocturnal enuresis in children includes delay in maturation in the form of disharmony between functional capacity of the bladder and increased excretion of urine as well as the inability to be aware of the sensations of a full bladder during sleep. the evidence of this issue is provided by reduced prevalence of enuresis in teenager age (9-19%) compared to age 3-5 years (1-2%).23 nocturnal enuresis in children is also strongly associated with the history of enuresis in parents and constipation.22,24-26 other factors associated with the development of enuresis are the level of education of the parents, the number of family member, the method of parenthood, home conflict, stress due to enuresis and bad school performance.22,27 a retrospective study in japanese female patients found that multiparity and urodynamic parameter are the main risk factors of the development of ui in luts. maximum free flow rate, maximal urethral closure pressure and functional profile length, which are the parameters of luts in urodynamic are associated with increased incidence of ui in female patients.28 another study in chinese female population found that elderly age, poor sanitation, spontaneous delivery, metabolic syndrome and urinary tract infection are the risk factors of urinary incontinence.29 a study in male population also found similar risk factors of ui, i.e. elderly age, metabolic disease, neurological disease, urinary tract infection, prostate enlargement and diabetes.30 in the present study, we found that ui impaired various aspects of life: family life (25.3%), sexual relationship (13.6%), and job/ school performance (23.7%). it is consistent with the study conducted by elbiss et al that found impaired social life aspects, physical activity, sexual relationship and religious duties due to ui.31 another study also concluded that ui may result in impaired quality of life of the patients.32 factors that affect the quality of life of ui patients are age, the severity of ui, the type of ui, the number of episode of ui, body weight, psychological factors and the pattern of seeking medical treatment.32 ui also causes impaired sexual life in the patients and their spouses.33 various studies mostly studied about the impact of ui in women; while little studies have been done on the impacts of ui in men. in elderly female patients group, factor that affects the quality of life is the severity of ui.34 the type of ui has also been proven to affect the impact of ui. patients with mixed type of ui tend to have more severe incontinence and it causes greater impairment on quality of life compared to urge ui and stress ui.35 although ui may cause various problems and impairment, only half of the patients seek for medical help.31 the limitation of study is that the data was only based on questionnaire and there was no confirmed diagnosis on urodynamic examination. this study shows that ui is generally found in indonesian population. the results are expected to be the most recent epidemiological data in association with the prevalence of ui in indonesia. conclusion the prevalence of ui in indonesia is nearly similar to other asian countries. it increases with age and is not affected by gender. luts, chronic cough, and fecal incontinence may become the main risk factors on the development of ui. the magnitude of ui problems may bring impacts on daily life and habit of the patients. references 1. buckley bs, lapitan mc. prevalence of urinary incontinence in men, women, and children--current evidence: findings of the fourth international consultation on incontinence. urology. 2010;76:26570. 2. hunskaar s, burgio k, diokno a, 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p, vahabi b, drake mj. bladder outlet physiology in the context of lower urinary tract dysfunction. neurourol urodyn. 2011;30:708-13. 18. leung e. the prevalence of urinary incontinence among the elderly in institutions. hong kong j gerontol. 1992;3:35-8. 19. wagg a, chen lk, kirschner-hermanns r, et al. incontinence in the frail elderly. in: abrams p, cardozo l, khoury s, wein a, eds. incontinence. 5th ed. paris: international consultation on incontinence; 2013. p. 1001-76. 20. senturk s, kara m. risk factors and prevalence of urinary incontinence in postmenopausal women living in turkey. clin exp obstet gynecol. 2012;39:69-71. 21. tekgul s, nijman r, hoebeke p, canning d, bower w, gontard a. diagnosis and management of urinary incontinence in childhood. in: abrams p, cardozo l, khoury s, wein a, eds. incontinence. 4th ed. paris: health publication; 2009. p. 701-92. 22. safarinejad mr. prevalence of nocturnal enuresis, risk factors, associated familial factors and urinary pathology among school children in iran. j pediatr urol. 2007;3:443-52. 23. nijman r, tekgul s, chase j, bael a, austin p, gontard a. diagnosis and management of urinary incontinence in childhood. in: abrams p, cardozo l, khoury s, wein a, eds. incontinence. 5th ed. paris: international consultation on incontinence; 2013. p. 729-826. 24. dolgun g, savaser s, balci s, yazici s. prevalence of nocturnal enuresis and related factors in children aged 5-13 in istanbul. iran j pediatr. 2012;22:205-12. 25. fockema mw, candy gp, kruger d, haffejee m. enuresis in south african children: prevalence, associated factors and parental perception of treatment. bju int. 2012;110:e1114-20. 26. yazici cm, nalbantoglu b, topcu b, dogan c. prevalence of nocturnal enuresis and associated factors in schoolchildren in western turkey. can j urol. 2012;19:6383-8. 27. srivastava s, srivastava kl, shingla s. prevalence of monosymptomatic nocturnal enuresis and its correlates in school going children of lucknow. indian j pediatr. 2013;80:488-91. 28. tseng lh, liang cc, lo hp, lo ts, lee sj, wang ac. the prevalence of urinary incontinence and associated risk factors in taiwanese women with lower urinary tract symptoms. chang gung med j. 2006;29:596-602. 29. liu b, wang l, huang s-s, wu q, wu d-l. prevalence and risk factors of urinary incontinence among chinese women in shanghai. int j clin exp med. 2014;7:68696. 30. shamliyan ta, wyman jf, ping r, wilt tj, kane rl. male urinary incontinence: prevalence, risk factors, and preventive interventions. rev urol. 2009;11:145-65. 31. elbiss hm, osman n, hammad ft. social impact and healthcare-seeking behavior among women with urinary incontinence in the united arab emirates. int j gynaecol obstet. 2013;122:136-9. 32. kwon be, kim gy, son yj, roh ys, you ma. quality of life of women with urinary incontinence: a systematic literature review. int neurourol j. 2010;14:133-8. rochani sumardi acta med indones-indones j intern med 182 33. hayder d. the effects of urinary incontinence on sexuality: seeking an intimate partnership. j wound ostomy continence nurs. 2012;39:539-44. 34. barentsen ja, visser e, hofstetter h, maris am, dekker jh, de bock gh. severity, not type, is the main predictor of decreased quality of life in elderly women with urinary incontinence: a population-based study as part of a randomized controlled trial in primary care. health qual life outcomes. 2012;10:153. 35. minassian va, devore e, hagan k, grodstein f. severity of urinary incontinence and effect on quality of life in women by incontinence type. obstet gynecol. 2013;121:1083-90. 38 original article acta med indones indones j intern med • vol 50 • number 1 • january 2018 analyzing determinant factors for pathophysiology of functional dyspepsia based on plasma cortisol levels, il-6 and il-8 expressions and h. pylori activity arina w. murni1, eryati darwin2, nasrul zubir1, adnil e. nurdin3 1 departement of internal medicine, faculty of medicine, andalas university m. djamil hospital, padang, indonesia. 2 department of histology, faculty of medicine, andalas university m. djamil hospital, padang, indonesia. 3 department of psychiatry, faculty of medicine, andalas university m. djamil hospital, padang, indonesia. corresponding author: arina w. murni, md., phd. division of psychosomatic medicine, departement of internal medicine, faculty of medicine, andalas university m. djamil hospital. jl. perintis kemerdekaan, padang, indonesia. email: arina_widya_murni@yahoo.com. abstrak latar belakang: berbagai faktor penentu diduga berperan dalam patofisiologi dispepsia fungsional, salah satunya adalah stres psikologis yang dapat meningkatkan kortisol, mengubah proses inflamasi dan memengaruhi aktivitas h. pylori. sampai saat ini belum ada penelitian yang menentukan faktor penentu mana yang dominan diantaranya. tujuan penelitian ini untuk menemukan faktor mana yang dominan di antara kadar kortisol plasma, ekspresi il-6, il-8 dan aktivitas h. pylori sebagai faktor yang mempengaruhi patofisiologi dispepsia fungsional. metode: penelitian potong lintang ini dilakukan pada penderita sindrom dispepsia di rumah sakit umum m. djamil, padang, sumatera barat, indonesia. pasien dibagi menjadi dua kelompok yakni kelompok stres dan kelompok non-stres berdasarkan kriteria pada kuesioner dass 42. penilaian ekspresi inflamasi (il-6 dan il-8) dan aktifitas h. pylori dilakukan dengan pemeriksaan imunohistokimia pada jaringan biopsi mukosa lambung dan kadar kortisol plasma diukur dari sampel darah perifer. data kemudian dianalisis dengan menggunakan regresi logistik multivariat biner. hasil: terdapat 80 orang penderita dispepsia fungsional, dengan rerata umur 38,9 tahun. kadar kortisol plasma pagi hari meningkat bermakna pada kelompok yang mengalami stres. ekspresi il-6 dan il-8 lebih tinggi pada kelompok non stress dibandingkan dengan kelompok stress, namun tidak bermakna secara statistic (il-6: 73,28 (sb 16,60) vs. 72,95 (sb 19,49); dan il-8: 18,45 (sb 17,32) vs. 14,80 (sb 12,71) (stres). helicobacter pylori pada kelompok stres lebih aktif karena reaksi ag-ab menginvasi submukosa. faktor yang dominan berperan pada dispepsia fungsional adalah kadar kortisol plasma sore hari. kesimpulan: banyak faktor dapat menjadi faktor determinan dari kerusakan mukosa lambung. kadar kortisol plasma sore hari merupakan faktor yang dominan. kata kunci: dispepsia fungsional, stress, kortisol plasma, il-6, il-8, h. pylori. abstract background: there are many determinant factors that may play roles in pathophysiology of functional dyspepsia. one of them is psychological stress that can increase plasma cortisol levels, alter inflammation process and affect helicobacter pylori activity. no study has been conducted to find out the dominant factor among them. this study aimed to find the dominant factor among plasma cortisol levels, il-6 and il-8 expressions and h.pylori activity, as the determinant factors in the pathophysiology of functional dyspepsia. methods: a cross-sectional study was conducted in 80 patients with dyspepsia syndrome at m. djamil general hospital, vol 50 • number 1 • january 2018 analyzing determinant factors for pathophysiology of functional dyspepsia 39 padang, west sumatera, indonesia. the patients were categorized into two groups, i.e. the stress and non-stress group, which were identified using dass 42 questionairre criteria. the inflammatory expressions (il-6 and il-8 expressions) as well as h. pylori activity were determined using immunohistochemistry of gastric biopsy specimens; while plasma cortisol levels was measured from peripheral blood samples. data were analyzed using binary multivariate logistic regression. results: there were 80 patients with functional dyspepsia with mean age of 38.9 years old. the morning cortisol levels was found significantly higher in the stress group. higher il-6 and il-8 expressions were found in patients of non-stress group compared to those in the other group (il-6: 73.28 (sd 16.60) vs. 72.95 (sd 19.49; and il–8: 18.45 (sd 17.32) vs. 14.80 (sd 12.71)); although stastically not significant. there was greater helicobacter pylori activity in the group with psychological stress compared to those in the non-stress group since there was antigen-antibody reaction invading the submucosa. the dominant determinant factor was the afternoon plasma cortisol levels. conclusion: many factors can become the determinant factors for gastric mucosal damage; however, our study has demonstrated that the dominant factor is afternoon plasma cortisol levels. keywords: functional dyspepsia, stress, plasma cortisol, il-6, il-8, h. pylori activity. introduction the pathophysiology of functional dyspepsia has yet to be established and there are many determinant factors that may induce symptoms of functional dyspepsia (fd). psychological stress is one of those factors.1 however, its role is still controversial and difficult to prove.2 the prevalence of functional dyspepsia in indonesia is increasing each year, which was 1.9% in 1988, 3.3% in 2003 and 5% in 2010 of all patient who visited the primary health care units. so many factors could determine and affect the pathophysiology of functional dyspepsia. darwin et al3 found that functional dyspepsia could be affected by psychological stress, which at first seemed to have no correlation with il-6 expression. yet, there are some evidences that it may correlate by increasing helicobacter pylori activity. psychological stress may induce various changes in our body including the enhanced role of cortisol hormone through the hpa axis and induction of the release of inflammatory mediators as well as affecting helicobacter pylori activity.4-6 murni7 conducted a study to evaluate histopathologic profile of gastric mucosa in patients with functional dyspepsia (fd), by comparing patients in the depressive group and non-depressive group. the study found that microscopical damage was more severe in patients of depressive group than non-depressive group as indicated by larger acute inflammatory area, more severe epithelial damage, worse inflammatory infiltration, more severe degree of metaplasia and more severe atrophy of gastric mucosa. it is assumed that h. pylori can induce upregulation of inflammatory mediators such as il-6 and il-8 that exacerbates fd symptoms.6 psychological stress may affect il-6 expression through hpa axis pathway.7 moreover, il-8 is a chemokine in gastric mucosa and its activation is induced by h. pylori virulence.8 we conducted a study to evaluate the association of psychological stress with plasma cortisol levels, il-6 and il-8 expressions as well as h. pylori activity in patients with functional dyspepsia and to find out the dominant determinant factor among them. methods this was an observational study using a cross-sectional design, conducted between may 2015 and may 2017 at primary health care unit and outpatient clinic of m djamil general hospital, padang, west sumatera, indonesia. the study protocol had been approved by the ethical committee on healthcare research, faculty of medicine, andalas university on may 25th 2015 (ethical study number: 081/ kep/fk/2015). eighty patients aged 18-65 years with symptom of dyspepsia were included in our study. subject with alarm symptom such as arina w. murni acta med indones-indones j intern med 40 patients with bleeding or patients with weight loss were excluded. patients with chronic diseases (e.g. diabetes, hypertension, liver cirrhosis, inflammatory bowel syndrome, renal failure, etc), pregnancy or who were using contraceptive pills, nsaid and steroids were also excluded. patients were selected using consecutive sampling. psychological stress was identified by using depression anxiety and stress scale (dass 42) criteria. gastric biopsy was performed to evaluate the inflammatory marker (il-6 and il-8) and h. pylori activity. plasma cortisol levels samples obtained from patients’ serum were examined using elecysys cortisol reagent kit and electrochemiluminescence immunoassay system (eclia) on roche elecsys 1010/2010 device with modular analitycs e 170. the normal morning serum was determined as 4.30 to 22.40 μg/ dl (i.e. the normal limit for adult at the age of 18 years ) and the normal limit for evening serum cortisol levels were determined as 3. 09 to 16.66 μg/dl (i.e. for adult subjects aged 18 year). histopathological assesment using immunohistochemistry (ihc), we evaluated the gastric tissue specimens obtained from antrum and fundus. fixation was performed using paraffin block and the specimens were stained using ihc technique to examine il-6 and il-8 expressions as well as the h. pylori activity. immunohistochemistry procedure antigen detection in tissues and cells was performed as an initial step including binding primary antibody to its specific epitope. the primary antibody was bound to a secondary antibody and then the step was followed by using an enzyme-labeled polymer or the polymer may be applied directly to have direct binding with the primary antibody. the bound primary antibody was detected by an enzyme-mediated colorimetric reaction. statistical analysis distribution of each variable was evaluated using univariate analysis and presented in charts and graphs. the association between each variable of psychological stress and non-stress group was performed by chi-square test; t-test was used for numerical data. the determinant factors were evaluated using multivariate analysis with binary dichotomy. results our study was conducted for approximately two years on 80 out of 105 participating patients. subjects were categorized into two groups (i.e. stress and non-stress groups) with 40 subjects in each group. the mean age of subjects in the stress group was 35.60 years which was lower than those in non-stress group (42.15 years); however, the difference was not statistically significant. in table 1, there is no difference in subject characteristics for both groups except for the dyspepsia score. the subjects in the stress group had higher score than those in the non-stress group indicating that they had more severe dyspepsia although endoscopy findings were similar for both groups. table 2 shows that the morning and afternoon serum cortisol levels were significantly higher in patients of the stress group than those in the non-stress group. table 1. subject characteristics variables stress (n=40) non-stress (n=40) age (years), mean (sd) 35.60 (10.58) 42.15 (12.79) gender male 14 18 female 26 22 occupational status working 20 23 not working 20 17 educational level lower 30 28 higher 10 12 income level low 9 12 moderate 22 19 high 9 9 dyspepsia score mild 10 7 moderate 23 31 severe 7 2 endoscopic finding hyperemia 27 25 normal 13 15 vol 50 • number 1 • january 2018 analyzing determinant factors for pathophysiology of functional dyspepsia 41 figure 1 shows that the expressions il-6 and il8 are similar. however, il-8 tends to be non-reactive or to have minimal expression. in table 3, we can see h. pylori activity in gastrointestinal mucosa in both groups, however higher activity was found in subjects of the stress group than those in the non-stress group. table 4 demonstrates that there was a higher percentage of h. pylori activity in in gastric mucosa in subjects of the stress group compared to the non-stress group, although it was not statistically significant (p=0.27). figure 2 shows a sign of h. pylori activity in the interstitial tissue, which was deeper than epithelial layer and was not usually found in normal condition. table 2. comparison of patients with functional dyspepsia based on plasma cortisol levels, il-6 and il-8 expression and h. pylori activity between both of groups with and without psychological stress group non-stress (mean) sd stress (mean) sd p morning cortisol 15.79 7.65 24.03 12.18 0.001 afternoon cortisol 6.43 4.53 12.42 9.25 0.000 il-6 73.28 16.70 72.95 19.49 0.94 il-8 18.45 17.32 14.80 12.71 0.29 a b figure 1. immunohistochemistry of il-6 (a) and il-8 (b) expression found in subjects of the stress group. table 3. distribution of patients with functional dyspepsia based on h. pylori activity in gastrointestinal mucosa group positiven (%) negative n (%) total non-stress 26 (65.0) 14 (35.0) 100.0 stress 31 (77.4) 9 (22.5) 100.0 table 4. distribution of functional dyspepsia patients based on activity of h. pylori in gastric mucosa group nonen (%) epithelial n (%) sub-mucosa n (%) p non-stress 14 (60.9) 7 (51.5) 9 (37.5) 0.27 stress 9 (39.1) 16 (48.5) 15 (62.5) discussion the association of psychosocial stress and psychological factors with clinical manifestations of functional dyspepsia can be explained scientifically. genetic factors, stressful situation in early life, environmental factors such as losing figure 2. helicobacter pylori activity in gastric mucosa of patients with functional dyspepsia arina w. murni acta med indones-indones j intern med 42 a family member, abuse and other negative factors may affect psychological development. they also may affect the ability in adapting to psychosocial problems later in life. in gastrointestinal tract, some changes may occur through the brain-gut-axis mechanism including changes in gastric and intestinal motility, mucosa immunity and visceral hypersensitivity. stress and psychological problems may affect the balance of autonomic nervous system, central and peripheral nervous system, immunity system and body hormonal function (i.e. psycho-neuro-immuno-endocrine functions). those changes may induce the development of signs and symptoms of functional dyspepsia. the mechanism will bring further effect on gastrointestinal tract, secretion, motility, vascularization and reduce pain onset, which may lead to deteriorating health and living activities.9-11 our study demonstrated that there was an increase in morning plasma cortisol levels in the subjects of stress group (24.03 (sd 12.18) µg/dl), which was significantly different from those in the non-stress group (15.79 (sd 7.65) µg/dl, p<0.005). contrasting results were found for the afternoon plasma cortisol levels, in which the levels were found within normal limits for both groups. nevertheless, the afternoon plasma cortisol levels in subjects of the stress group were higher than those in the non-stress group (12.42 (sd 9.25) vs. 6.43 (sd 4.53) µg/dl, p<0.005). a study conducted by murni12 has also demonstrated that afternoon plasma cortisol levels in patients with psychosomatic disorder was higher than normal, although statistically insignificant (163.09 (sd 130.29) nmol/l vs. 112.69 (sd 86.46) nmol/l). depressive patients in the study also had higher morning plasma cortisol levels than the normal healthy subjects (328.92 (sd 172.98) nmol/l vs. 188.84 (sd 103.14) nmol /l, p<0.05).11 actually, high morning plasma cortisol levels is a normal phenomenon found in about 77% at the population, which is known as the cortisol awakening response (car). it occurs due to increased reactivity of the hpa axis in the morning and the reaction is separated from the cortisol circadian rhythm. the cortisol awakening response is superimposed with the peak of cortisol secretion in early morning. the association of psychological stress with il-6 and il-8 expressions our study showed that there was lower il-6 expression in subjects of the stress group compared to the non-stress group. similarly, subjects in the non-stress group had higher il-8 expression. however no significant difference was found in both groups. il-6 (interleukin-6) is the first-line cytokine that plays a role in the central process of systemic inflammation. it is both proand anti-inflammatory agent that will activate inflammation through activating and proliferating lymphocytes, differentiating b cells, increasing the number of leukocytes and inducing the response of acute-phase protein in the liver. il-6 (22-27kd) is produced by various cells in immune system including monocytes, mesothelial cells, fibroblast, adipocytes and lymphocytes that account for response to physiological stimulus, such as tnf α, il-1 β, bacterial endotoxins, physical exercise, oxidative stress as well as psychological stress.12,13 plasma soluble il-6 is a form of free il6. after binding with il-6r, the receptor of il-6, in the circulation it can stimulate the hypothalamus-pituitary-adrenal (hpa). stress will affect il-6 expression through the hpa-axis pathway. numerous studies have demonstrated that individuals with low stress levels have improved immune system.7,12 p s y c h o l o g i c a l s t r e s s c a n s t i m u l a t e g a s t r o i n t e s t i n a l i m m u n e r e s p o n s e a n d aggravate inflammatory symptoms. although the mechanism of how stress can stimulating such response cannot be explained clearly, it has been suspected that the aggressive response of commensal bacteria may play a role, in which may lead to abnormality in gastric and intestinal function when an individual endures psychological stress. numerous studies have provided evidences of increased permeability of the mucosa. therefore, the microorganisms that causing such abnormality can be determined. hence, stress can trigger increased permeability of gastrointestinal mucosa, which may facilitate microorganisms and their antigens trespass the vol 50 • number 1 • january 2018 analyzing determinant factors for pathophysiology of functional dyspepsia 43 epithelial barrier and results in activation of mucosal immune response.14 our study has demonstrated some differences between both groups. for example, il-6 and il-8 expressions were more readily observable in the non-stress group than the stress group, although, the difference was not significant. other factors have been predicted to play a role in developing mucosal balance including the neuronal factor that can suppress il-6 and il-8 expressions. another presumption suggests that h. pylori infection may induce inflammatory response that can affect il-6 and il-8 expressions in the non-stress group. in the gastrointestinal mucosa, homeostasis of the immune system and autoimmune mechanism play important roles in maintaining mucosa stability by regulating t-cells activity through several mechanisms including: 1) controlling infection by activating il 17, il17f, il-21 and il-22 produced by th17; 2) protecting against parasites by activating il-4, il-5 and il-13 produced by th2; 3) protecting against intracell microbiota by regulating ifn; 4) regulating immune system by activation of il10, il-35, tgfβ, which are produced by treg.15 c h r o n i c s t r e s s c a n a l t e r m i c r o b i o t a composition and increase il-6 expression, which indicates immune system activation. cortisol does not only affect the hormonal pathway, but also neuronal pathway. vagal nerve can activate noradrenaline secretion that may cause altered microbiota composition and maintain the balance of immune system in the mucosa. some neurotransmitters may affect the composition of microbiota including serotonin, gaba, etc. the altered microbiota can influence the nerves and stimulate the brain to reduce inflammatory process. emotion can also be affected by the feedback mechanism of some neurotransmitters, tryptophan metabolism and spinal cord. such homeostasis process allows distinct expression of il-6 and il-8. in our study, chronic stress in patients with functional dyspepsia does not increase il-6 and il-8 expressions since there is another mechanism that covers the inflammatory response. the association of psychological stress with helicobacter pylori activity in our study, we attempted to evaluate the correlation between stress and h. pylori activity. we found positive h. pylori infection in subjects of both groups. the positive presentation is more visible in the stress group than non-stress group (77.5% vs. 65%). overall, about 71.25% our patients with functional dyspepsia had been infected by h. pylori. the rate is much higher than the world’s prevalence, which is about 30%. the result depends on what kind of the procedure used in the study for identifying h. pylori infection. the best technique or the gold standard is gastric mucosa biopsy, which had been performed in our study. our study also observed some differences between both groups regarding h. pylori infection. in individuals with psychological stress, higher h. pylori activity was found compared to those in the non-stress group. based on table 4 which presents the activity of h. pylori, higher activity involving submucosa was found in the stress group compared to the non-stress group (62.7% vs. 37.5%). it indicates that stress can stimulate h. pylori activity to be more aggressive to penetrate the epithelial and involve the submucosa that subsequently will cause more severe mucosal damages. murni7 has investigated the role of depressive mood on h. pylori infection by using gastric mucosa biopsy. the study suggested that patients with depressive mood had greater h. pylori infection and more severe histopathological feature. the role of h. pylori in the pathophysiology of functional dyspepsia is still controversial. activation of the immune system will enhance inflammation and stimulate the release of inflammatory mediators and chemotaxis factor such as il-6, il-8, il-1β, tnfα, il-10 and etc. it will accelerate the inflammatory response of gastric mucosa. it also can cause macroscopic and microscopic damage of gastric mucosa. toll-like receptor-2 (tlr-2) is a main receptor that can identify h. pylori infection and its inflammatory process. activating the receptor will cause further activation of arina w. murni acta med indones-indones j intern med 44 nf-κb, caspase and interferon pathway that produces pro-inflammatory cytokines such as il-1β, tnf-α, il-6, mcp-1 dan ifn-β. these cytokines will have further interaction with inflammatory mediators such as neutrophils or lymphocytes and then will activate immune response. gastritis, which is caused by h. pylori infection, is characterized by increased amounts of acute and chronic inflammatory cells that secrete cytokines and will contribute to greater local inflammation.16,17 determining the dominant factors of functional dyspepsia in patients with psychological stress in our study, we attempted to find out the dominant determinant factors in functional dyspepsia and we obtained results that the determinant factors included afternoon plasma cortisol levels, morning plasma cortisol levels, il-6 expression, h. pylori activity and il-8 expression. then, we found that in individuals with functional dyspepsia and psychological stress, the dominant factor was plasma cortisol levels, especially afternoon plasma cortisol levels. a study in thailand showed that h. pylori infection, anxiety and depression were frequently found in patients with functional dyspepsia. the highest prevalence of those symptoms was found in individuals with post-prandial distress syndrome (pds). h. pylori infection, anxiety and depressive are important factors that may lead to functional dyspepsia especially in patients with pds. however, the study does not suggest which factor is more dominant. appropriate management of h. pylori eradication and also treating anxiety and depression is the best treatment regimen. in addition, it can play a role in preventing gastric cancer. increased morning plasma cortisol levels in patients with psychological stress, particularly those with depression, had been observed in previous studies. it may also occur in individuals with chronic stress, as it may lead to negative feedback failure which happens repeatedly, thus maintain higher levels of cortisol and affect certain organs. the afternoon plasma cortisol levels also affects the development of dyspepsia syndrome. our study has demonstrated increased afternoon plasma cortisol levels, which was within the normal limit. the increased cortisol levels may be caused by inflammatory response characterized by increasing il-6 expression and when we observed the correlation between il-8 expression and cortisol levels, we found a significant difference. therefore, morning cortisol and afternoon cortisol levels are expected to be the objective parameters to confirm whether an individual has psychological stress problem or not. appropriate stress management could reactivate the negative feedback mechanism, therefore the progression to gastric mucosa damage can be prevented. the inflammatory response in gastric mucosa occurs due to various factors and one of them is psychological stress. in our study, we found that il-6 expression is more dominant than il-8. the evidence indicates that stress can lead to increased il-6 and il-8 expression, although, no significant difference was found. il-8 is more frequently associated with h. pylori activity. our study demonstrated that there were colonies of h. pylori in both stress and non-stress group. our result indicated that there was no significant difference in h. pylori activity; nevertheless, we found greater activity of h. pylori in the stress group than the non-stress group. when causing tissue or mucosal damage, h. pylori will interact with il-8. psychological stress will activate the hpa axis and alter the immune system or inflammatory system, which is characterized by activation of il-1, il-6 and il-8. moreover, it will also modulate stress response through some neurotransmitters such as serotonine and cortisol. the feedback mechanism of microbiota and h. pylori can also affect inflammation and activate hpa axis to increase cortisol levels in the circulation. when feedback mechanism of cortisol is still good, accordingly the circuit will be stopped and the inflammatory response can be repressed. therefore, it may have affected our study result in which il-6 and il-8 levels were found to be lower in the stress group compared to non-stress group. vol 50 • number 1 • january 2018 analyzing determinant factors for pathophysiology of functional dyspepsia 45 limitations of study our study did not consider the role of neuronal and neurotransmitter that can affect the inflammatory process in gastric mucosa. our study only observed the role hormonal pathway, which was measured through the increased cortisol levels, which were firstly assumed to have a correlation with increased il-6 and il-8 expressions. however, our study showed different result as we found that il-6 and il-8 expressions were higher in the non-stress group than the stress group. our study did not assess il-6 and il-8 expression in individuals with negative h. pylori findings. immune response may occur due to h. pylori activity, but it does prove that the psychological stress can affect the h. pylori activity. conclusion psychological stress is associated with increased cortisol serum levels, lower il-6 and il-8 expression and increased h. pylori and the dominant factor is afternoon plasma cortisol levels. references 1. talley nj, vakil nb, moayyedi p. american gastroenterological association technical review on evaluation of dyspepsia. gasteroenterol. 2005;129: 1756-80. 2. yarandi ss, christie j. functional dyspepsia in review: pathophysiology and challenges in the diagnosis and management due to coexisting gastroesophageal reflux disease and irritable bowel syndrome. hindawi publishing corporation – gastroenterology research and practice; 2013. p. 1-8. 3. darwin e, murni aw, nurdin ae. the effect of psychological stres on mucosal il-6 and helicobacter pylori activity in functional dyspepsia. acta med indones-indones j intern med. 2017;49 (2):100-4. 4. muhammad ep, murni aw, sulastri d. hubungan derajat keasaman cairan lambung dengan derajat dispepsia pada pasien dispepsia fungsional. j kes andalas. 2014;5(2):371-5. 5. mahadeva s, goh kl. epidemiology of functional dyspepsia, a global perspective. world j gastroenterol. 2006;17:2661-6. 6. konturek pc, brzozowski t, konturek sj. stress and gut: pathophysiology, clinical consequences, diagnostic approach and treatment options. j physiol pharmacol. 2011;62(6):591-9. 7. murni aw. hubungan depresi dengan infeksi helicobacter pylori serta perbedaan gambaran histopatologi mukosa lambung pada penderita dyspepsia fungsional. tesis sp2 divisi psikosomatik jakarta fakultas kedokteran universitas indonesia. 2010. 8. elhage r, clamens s, besnard s. involvement of interleukin-6 in atheroslerosis but not in the prevention of fatty streak fomation by 17 beta-estradiol in apoliprotein e-deficient mice. atherosclerosis. 2001; 156:315-20. 9. monack dm, mueller a, falkow s. persistent bacterial infections the interface of the pathogen and the host immune system. nat rev microbiol. 2004;2(9):74765. 10. douglass da. the functional gastrointestinal disorder and the rome iii. gasteroenterol. 2006;30;1377-90. 11. zubir n. diagnosis dan penatalaksanaan dispepsia fungsional. in: manaf a, amir e, fauzar, editors. naskah lengkap pib ipd iii. padang: bagian penyakit dalam fk universitas andalas; 2002. p. 115-22. 12. murni aw. kadar kortisol plasma pada penderita dispepsia fungsional dengan depresi. tesis sp1 penyakit dalam, padang. fakultas kedokteran universitas andalas. 2006. 13. harris tb, ferruci l, tracy rp. association of elevated interleukin-6 and c-reactive protein levels with mortality in the elderly. am j med. 1999;106:506-12. 14. huber sa, sakkinen p, conze d. interleukin-6 exacerbates early atherosclrerosis in mice. arterioscler thromb vasc biol. 1999;19:2364-7. 15. dinan tg, cryan jf. regulation of the stress response by the gut microbiota: impilications for psychoneurology. psychoneuroendocrinol. 2012;37: 1369-78. 16. campbell aw. autoimmunity and the gut. autoimmune disease. hindawi publishing corporation; 2014. p. 1-12. 17. odenbreit s, linder s, gebert-vogel b, rieder g, moran ap, haas r. interleukin-6 induction by helicobacter pylori in human macrophages is dependent on phagocytosis. helicobacter. 2006; 11(3):196–207. 18. guiney dg, hasegawa p, cole sp. helicobacter pylori preferentially induces interleukin 12 (il-12) rather than il-6 or il-10 in human dendritic cells. infect immun. 2003;71(7):4163–6. review article 169acta med indones indones j intern med • vol 51 • number 2 • april 2019 subclinical atherosclerosis in young adult population with first degree relatives of type 2 diabetes mellitus muhammad s. abdaly, mohamad s. azizi, ika p. wijaya, pringgodigdo nugroho, dyah purnamasari department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: dyah purnamasari, md., phd. division of endocrinology and metabolism, department of internal medicine, faculty of medicine universitas indonesia cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta 10430, indonesia. email: dyah_p_irawan@yahoo.com. abstrak penyakit kardiovaskular (cvd) menjadi penyebab utama kematian secara global. infark miokard akut pada orang dewasa muda jarang terjadi. aterosklerosis adalah penyebab utama cvd, termasuk infark miokard, stroke, gagal jantung, dan penyakit arteri perifer. kondisi ini dimulai sejak dini dan bersifat progresif. faktor risiko cvd termasuk hipertensi, dislipidemia, dan obesitas berperan dalam proses aterosklerosis dan merupakan komponen dalam sindrom resistensi insulin. salah satu faktor risiko untuk terjadinya resistensi insulin pada orang sehat adalah first degree relative (fdr) dari pasien diabetes melitus tipe 2 (t2dm). kelompok ini menunjukkan risiko resistensi insulin dan gangguan sel beta pankreas yang lebih tinggi bahkan pada masa remaja, walaupun asimtomatik. manifestasi klinis dari gangguan metabolik dan aterosklerosis akan muncul lebih awal pada kelompok fdr t2dm yang memiliki pola hidup sedentari dan obesitas, jika dibandingkan dengan kelompok non-fdr. beberapa penelitian sudah berusaha untuk mendeteksi gangguan metabolik dan aterosklerosis subklinis yang mungkin terjadi; oleh karena itu pencegahan dini dapat dilakukan pada kelompok berisiko tinggi ini. sayangnya, faktor-faktor yang memengaruhi onset dan tingkat keparahan manifestasi klinis yang akan terjadi selanjutnya dari studi-studi sebelumnya masih belum jelas. kata kunci: penyakit kardiovaskular, aterosklerosis, first-degree relative, diabetes melitus tipe 2. abstract cardiovascular disease (cvd) remain a leading cause of death globally. the concept of acute myocardial infarction in young adults was uncommon. atherosclerosis is the leading cause of cvd, including myocardial infarction, stroke, heart failure and peripheral artery disease. this condition is initiated early in childhood and progressive in nature. cvd risk factors includes hypertension, dyslipidemia and obesity play a role in the development of atherosclerosis and components in insulin resistance syndrome. one of many risk factors for insulin resistance in healthy individuals is a first-degree relative (fdr) of type 2 diabetes mellitus (t2dm) patients. this group shows a higher risk of insulin resistance and pancreatic beta cells disruption even in adolescence, although they often remains asymptomatic. clinical manifestations of metabolic disorders and atherosclerosis will appear earlier in the fdr t2dm group who have sedentary lifestyles and obesity, when compared to the non-fdr group. several studies have attempted to detect metabolic disorders and subclinical atherosclerosis that might occur; therefore an early prevention can be carried out in these high-risk groups. unfortunately, factors that affect the onset and the severity of the prospective clinical manifestations from the previous studies remained inconclusive. keywords: cardiovascular disease, atherosclerosis, first-degree relative, type 2 diabetes mellitus. muhammad s. abdaly acta med indones-indones j intern med 170 introduction cardiovascular disease (cvd) remain a leading cause of death globally. in 2013, approximately 17.3 million out of 54 million of total death per year was caused by cvd.1 based on a who report in 2014, cvd ranked as the leading cause of death in indonesia, at an approximate of 37% of all causes of death.2 the concept of acute myocardial infarction in young adults was uncommon. a study by mahle, et al.3 reported that only 5% of total number of acute coronary syndromes constituted of individuals younger than 40 years. a study by rithza, et al.4 described that the number of patients younger than 45 years old who suffered from acute coronary syndrome were 101 cases. atherosclerosis is the leading cause of cvd, including myocardial infarction, stroke, heart failure and peripheral artery disease. this condition is initiated early in childhood and progressive in nature. atherosclerosis remains asymptomatic for the first few decades before becoming clinically manifested. this condition is known as subclinical atherosclerosis.5 cvd risk factors includes hypertension, dyslipidemia and obesity play a role in the development of atherosclerosis and components in insulin resistance syndrome.6 one of many risk factors for insulin resistance in healthy individuals is a first-degree relative (fdr) of type 2 diabetes mellitus (t2dm) patients. this group shows a higher risk of insulin resistance and pancreatic beta cells disruption even in adolescence, although they often remains asymptomatic.7 clinical manifestations of metabolic disorders and atherosclerosis will appear earlier in the fdr t2dm group who have sedentary lifestyles and obesity, when compared to the non-fdr group. several studies have attempted to detect metabolic disorders and subclinical atherosclerosis that might occur; therefore an early prevention can be carried out in these high-risk groups. unfortunately, factors that affect the onset and the severity of the prospective clinical manifestations from the previous studies remained inconclusive. at h e r o s c l e r o s i s a n d i n s u l i n resistance atherosclerosis is a chronic systemic inflammatory process that is related to the elasticity of a blood vessel. it remains as the main cause of cardiovascular diseases such as coronary heart disease and stroke. blood vessels that are often affected include large blood vessels (aortic, carotid, iliac arteries) and moderate blood vessels (coronary arteries and popliteal arteries).8 the cause of atherosclerosis is not fully established yet. several previous studies have shown that atherosclerosis arises due to endothelial dysfunction that causes structural changes in the arterial wall which result in thickening and stiffening of blood vessels.9 endothelial dysfunction occurs due to several factors, such as hypertension, increased low density lipoprotein (ldl) concentration, toxic effects of cigarette, high density lipoprotein (hdl) transportation dysfunction, and insulin resistance. this process will reduce the production of nitric oxide (no) ultimately resulting in endothelial dysfunction.10 in t2dm, the process of atherosclerosis has occurred in the phase of insulin resistance, which precedes the onset of hyperglycemia, thus resulting in advanced cardiovascular c o m p l i c a t i o n s . i n s u l i n r e s i s t a n c e i s a condition of the inability of insulin to produce biological effects, including effects on glucose metabolism, protein, and lipids and to regulate blood vessel function. hyperinsulinemia is the body’s compensation mechanism to prevent hyperglycemia. hyperinsulinemia increases the individuals’ risk to develop glucose intolerance, increase triglyceride levels, decrease hdl cholesterol levels, and hypertension.11 hyperinsulinemia accompanied by hyperglycemia and dyslipidemia will increase the progression risk of atherosclerosis, which in turn will increase the risk of cvd.12 the pathophysiology of insulin resistance and atherosclerosis can be seen in figure 1. vol 51 • number 2 • april 2019 subclinical atherosclerosis in young adult population with first degree relatives 171 oxidative stress protein kinase c activation activation of advanced glycation end-product receptor endotelium nitric oxide nitric oxide nitric oxide endothelin-1 activation nf-κβ tissue factor angiotensin ii angiotensin ii pai -1 protein-1 activator prostacyclin hyperglycemia increased production of free fatty acid insulin resistance diabetes mellitus vasoconstriction hypertension growth of vascular smooth muscle cells thrombosis hypercoagulation platelet activation fibrinolysis inflammation release of chemokine and cytokine cam expression atherogenesis figure 1. the pathophysiology of atherosclerosis in diabetes mellitus12 insulin resistance in population with first-degree relatives of type 2 diabetes mellitus studies in twins indicate that insulin resistance is influenced by genetic and environmental factors but insulin secretion is mainly influenced by genetic factor.13 the role of genetics has been studied extensively but much less when compared to studies regarding the role of environmental factors in t2dm. genetic studies are challenging, considering that interethnic and interracial marriages are not uncommon, therefore it is difficult to conduct a study in a certain group of race. studies in siblings of t2dm in one european ethnic group showed that phase 1 and 2 insulin secretion was decreased with normal insulin sensitivity, whereas in africanamerican ethnic groups it showed that insulin resistance was the first clinical manifestation that was observed, without the presence of pancreatic beta cell secretion dysfunction.14 a study by rosenbaum, et al.14 in 2004 also reported a significant association between the family history of t2dm with impaired pancreatic beta cell function (not affected by body fat composition) without the presence of insulin resistance. in the study it was also reported that insulin resistance was mainly affected by increased in body fat composition. the offspring of individuals with t2dm is a high-risk population for insulin resistance and has more severe cardiovascular risk factors, such as thicker intra-abdominal fat, higher systolic blood pressure, higher blood triglyceride and total cholesterol levels, lower hdl cholesterol levels and higher endothelium dependent vasodilatation (edv), when compared with populations without family history of t2dm.15 relatives (siblings and biological children) of t2dm subjects who are still normoglycemic also have higher insulin concentrations, lower peripheral glucose uptake and more accumulation muhammad s. abdaly acta med indones-indones j intern med 172 of fat tissue in the muscle compared to subjects without a history of t2dm.15,16 studies regarding the prevalence of insulin resistance in t2dm-fdr population are still limited in indonesia. purnamasari, et al.17 have conducted a study in jakarta and showed that the prevalence of insulin resistance in siblings of patients with t2dm by 26,67%. kumar, et al.18 in india also conducted a study regarding the prevalence of insulin resistance in the fdr population and the results were 37.8%. however, prevalence of insulin resistance syndrome based on national cholesterol education criteria adult treatment panel iii (ncep atp iii) criteria in the adult general population in the united states is slightly lower at an approximate of 24%.19 s u b c l i n i c a l at h e r o s c l e r o s i s diagnosis subclinical atherosclerosis is a manifestation of endothelial dysfunction and the onset of cvd. in these conditions, there has been an alteration in the blood vessel walls without any significant symptoms; therefore, at this stage an early intervention is expected to prevent cardiovascular events in the future.20 several approaches are used to detect atherosclerosis as early as possible, both noninvasive and invasive techniques. invasive techniques have the advantage of a higher levels of precision and the ability to directly see abnormalities that occur in blood vessels. the disadvantages of this technique include discomfort for patients, higher costs, and higher risks of complication. while the non-invasive technique has relatively affordable cost and more convenient for patients.21 there are several non-invasive modalities that can be used to detect subclinical atherosclerosis including b-mode ultrasound examinations that can determine the thickness of the arterial intima-media arteries; high resolution magnetic resonance imaging (mri) that is capable of evaluating the volume, plaque composition, and integrity of fibrous cap; and electron-beam computed tomography (ebct) which can measure coronary artery calcification but cannot ascertain the tendency of plaque to rupture. whereas invasive techniques include coronary angiography which is able to directly assess the coronary stenosis and intravascular ultrasound examination which is able to identify plaque size and composition that cannot be done through coronary angiography.21 the assessment of tunica intima media t h i c k n e s s o f c a r o t i d a r t e r y b y c a r o t i d ultrasound has been approved by the american heart association as a diagnostic tool for atherosclerosis.21 in addition, the measurement of the thickness of the carotid artery is an examination that can be performed quickly, without radiation exposure, non-invasive and at affordable costs.22 carotid ultrasound examination had a sensitivity of 93.4% and a specificity of 94% to assess vascular calcification, blood vessel diameter, thickness of tunica intima media, assessing the presence of plaque and its expansion.23 the carotid intima media thickness a s c a r d i o v a s c u l a r d i s e a s e predictor t h e c a r o t i d i n t i m a m e d i a t h i c k n e s s (cimt) assessment is an examination of the thickness of the carotid artery wall, where atherosclerotic lesions in the common carotid artery depicted systemic atherosclerosis. this non-invasive procedure is relatively easy to perform and the results are comparable to other imaging techniques.23 compared with coronary angiography, cimt examination has a sensitivity and specificity in predicting coronary artery disease of 89.7% and 86.7%, respectively.24 the measurement carotid artery thickness has the prognosis to predict the incidence of stroke and coronary heart disease in the future. hazard ratio of the risk of coronary artery disease between the mean thickness of cimt ≥1 mm and <1 mm was 5.07 (in women) and 1.85 (in men). while the hazard ratio of stroke in the ratio of cimt thickness ≥1 mm and ¸0.6 mm was 8.5 (in women) and 3.6 (in men).25 a meta-analysis study involving 8 studies with a total of 37,197 subjects showed that a 0.1 mm increase in the cimt thickness of the carotid artery would increase the risk of myocardial infarction from 10 to 15% and the risk of stroke from 13 to 18%.26 thus a thicker cimt increases the risk vol 51 • number 2 • april 2019 subclinical atherosclerosis in young adult population with first degree relatives 173 for cardiovascular events, such as myocardial infarction and stroke. the genetic role of atherosclerosis in first degree relative of type 2 diabetes mellitus patients in atherosclerosis, a prospective study in caucasian ethnicity, which involved biological offsprings of patients with t2dm, who were normoglycemic and normotensive showed a more severe endothelial vasodilation and carotid artery thickening when compared to subjects without a family history of t2dm. this endothelial dysfunction is mediated by conditions of insulin resistance.27 i n s u l i n r e s i s t a n c e a ff e c t s t h e r e n i n angiotensin aldosterone system (raas). therefore, the development of atherosclerosis is also be affected by the raas. although there were several studies that has reported this relationship between raas and atherosclerosis in high-risk populations (hypertension, diabetes, cerebrovascular disease and arterial artery disease) and normal populations, the effect of raa systems on atherosclerosis in the fdr of t2dm patients remain unclear.28,29 a study by goldfine, et al. compared endothelial dysfunction and insulin resistance between 38 non-dm subjects with a history of t2dm in both parents and 38 control subjects. the study showed that the groups with family history of t2dm had a decreased endothelial dependent vasodilatation (edv) response and further multiple regressions analysis showed that family history of dm was a significant determinant of edv.30 several studies have shown that mitochondria play an important role in the development of atherosclerosis. mutations in mitochondrial dna (mtdna) at the nucleotide position 3243 a to g (a3243g) are the main genetic causes of diabetes.31 mitochondrial dna has a somatic mutation rate of 5 to 20 times greater than nuclear dna (ndna), as mtdna is located close to the respiratory chain that has the potential to produce reactive oxygen species (ros). ros is the main source of oxidative stress at cellular levels.32 damage to mtdna by ros will result in the dysfunction of protein synthesis for the respiratory chain, in turn resulting in atp production dysfunction and increased ros leakage, which causing a vicious cycle because further mtdna mutations will occur. insertion and deletion polymorphism of the angiotensin converting enzyme (ace) is one of the polymorphisms associated with atherosclerosis.33 a study also found that p22phox, the nad (p) h-oxidase subunit that produces ros, also has polymorphisms that is associated with polymorphism in atherosclerosis.34 the population of fdr t2dm has earlier endothelial dysfunction and subclinical atherosclerosis when compared to non-fdr t2dm, despite remaining normotensive and normoglycemic. the role of genetics in atherosclerosis has been studied extensively through genetic polymorphisms studies, for example mtdna polymorphism that has a protective role against atherosclerosis. carotid intima-media thickness in first degree relative of type 2 diabetes mellitus in 2003, pannacciulli, et al35 conducted the first study regarding the presence of atherosclerotic lesions in the population with fdr of t2dm. the study was conducted in italy involving a total of 401 subjects aged 18-45 years with normal blood glucose concentrations. the results in the fdr group had a greater thickness of media intima than the non-fdr group. the study also showed a positive correlation between the thickness of the carotid media intima with age, bmi, abdominal circumference, triglyceride levels, systolic blood pressure, fasting blood glucose, 1-hour and 2-hour post prandial blood glucose and homa-ir, while the hdl showed a negative correlation. ahmad, et al.36 in 2006 studied a total of 76 subjects who had normal blood glucose levels and were not obese in north india (38 subjects who had a family history of t2dm, 38 other subjects without a family history of t2dm). the results also indicate the same thing as the research conducted by pannacciulli, et al. in 2003. besides the thickness of the intima media, which was significantly different between the two groups, the crp levels and bmi in the fdr muhammad s. abdaly acta med indones-indones j intern med 174 of t2dm group were higher than the non-fdr group. the thickness of tunica intima media in this study had a positive correlation with systolic blood pressure, ldl cholesterol, post-prandial insulin levels and homa-ir. in 2017, kumar, et al.37 conducted similar study as ahmed et al. in india. the difference was that they differentiated subjects with a history of parents (father or mother or both) who suffer from type 2 diabetes in relation to inflammation, insulin resistance, body mass index and thickness of the intima media. the result showed that individuals who have a history of both parents suffering from type 2 dm had worse glycemic status, higher cimt compared to individuals who only have one parent suffering from type 2 dm. an unpublished study in indonesia by abdaly, et al.38 showed that the average cimt of the fdr group was 0.44 mm with a standard deviation of 0.06 mm. while the mean cimt of non-fdr group was lower than fdr subject, which was 0.38 mm with a standard deviation of 0.05 mm (p=0.005). the results of this study are in line with previous studies that examined the thickness of the cimt in the subject of fdr t2dm. this study shows that cimt in fdr and non-fdr group in indonesia have the lowest average when compared to subjects in brazil, italy, and india. this might be due to the higher body mass index of the caucasians and indians when compared to malays.39,40 the body mass index (bmi) has been shown to be a positively correlated factor with carotid artery intima-media thickness. bmi and waist circumference have a relationship with the occurrence of insulin resistance. in obese subjects with insulin sensitivity, insulin plays a role in inhibiting the up-regulation of inflammatory markers circulating in the blood. conversely, high levels of inflammatory markers due to impaired insulin inhibitory effects were found in obese subjects with insulin resistance.41 the increase in acute phase protein as a result of insulin resistance will later lead to endothelial dysfunction and atherogenesis.42 conclusion family history of the first degree of t2dm play an important role in the occurrence of subclinical atherosclerosis, especially at a young age in addition to other conventional factors for the occurrence of cardiovascular diseases such as hypertension, diabetes mellitus, dyslipidemia, smoking and obesity. thickness of the carotid artery intima media as the surrogate marker of atherosclerosis has been shown to be thicker in the fdr group when compared to non-fdr group. conflicts of interest none of the authors have any conflict of interest to declare. acknowledgments this review article was supported by hibah pitta 2018 funded by research and society services directorate, 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up, mohan v, weber mb, narayan kmv. type 2 diabetes in south asians: similarities and differences with white caucasian and other population. j diabetes. ann n y acad sci. 2013;4(1):51-63. 41. haffner sm. insulin resistance, inflammation, and the prediabetic state. am j cardiol. 2003;92(4a):18–26. 42. schmidt mi, duncan bb, sharrett ar, et al. markers of inflammation and prediction of diabetes mellitus in adults (atherosclerosis risk in communities study): a cohort study. lancet. 1999;353(9165):1649–52. 54 original article acta med indones indones j intern med • vol 51 • number 1 • january 2019 blood pressure profile of young adults at the faculty of medicine universitas indonesia lucky a. bawazier1, stanley buntaran2, wicensius sianipar2, aria kekalih3 1 department of internal medicine, nephrology and hypertension division, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. 2 faculty of medicine universitas indonesia, jakarta, indonesia. 3 department of public health, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: lucky aziza bawazier, m.d., facp, finasim. division of nephrology and hypertension, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro no. 71, jakarta, 10430, indonesia. email: tyasretno77@yahoo.co.id. abstrak latar belakang: hipertensi tetap menjadi beban global. komplikasi hipertensi yang tidak diakui dapat meningkatkan mortalitas seperti yang ditunjukkan oleh laporan who 2013 bahwa hipertensi menyebabkan 9,4 juta kematian di seluruh dunia. tidak ada data sebelumnya di indonesia tentang status tekanan darah pada orang dewasa muda dengan tingkat pendidikan yang sama. mahasiswa kedokteran berisiko tinggi terkena hipertensi dini karena kebiasaan gaya hidup modern. tujuan penelitian ini untuk menentukan profil tekanan darah mahasiswa kedokteran sebagai perwakilan dari populasi dewasa muda. metode: kami mengukur prevalensi hipertensi pada mahasiswa kedokteran. semua mahasiswa kedokteran yang setuju untuk berpartisipasi mengisi kuesioner. setelah itu, kami melakukan pemeriksaan fisik dan memperoleh sampel darah dan urin untuk menyaring tekanan darah, perkiraan laju filtrasi glomerulus, dan profil lipid. hasil: prevalensi mahasiswa dengan prehipertensi atau hipertensi adalah 29,6%. rata-rata lfg adalah 105,45 ml/menit/m2. total kolesterol rata-rata dalam batas normal. kesimpulan: prevalensi hipertensi pada mahasiswa kedokteran tinggi. studi ini menunjukkan bahwa deteksi dini hipertensi adalah kunci untuk mengobatinya sejak dini dan karenanya mengurangi morbiditas dan mortalitas. kata kunci: profil, mahasiswa kedokteran, hipertensi, penyakit ginjal kronis, dislipidemia. abstract background: hypertension remains a global burden. complications of unrecognized hypertension might increase mortality as shown by a who 2013 report that hypertension caused 9.4 million deaths worldwide. there is no prior data in indonesia on blood pressure status in young adults with similar education levels. medical students are at high risk of developing early hypertension due to modern lifestyle habits. this study aimed to determine the blood pressure profile of medical students as representative of the young adult population. methods: we measured the prevalence of hypertension in medical students. all medical students who agreed to participate completed a questionnaire. afterwards, we conducted a physical examination and obtained blood and urine samples to screen for blood pressure, estimated glomerular filtration rate, and the lipid profile. results: the prevalence of students with prehypertension or hypertension was 29.6%. the mean egfr was 105.45 ml/min/m2. the mean total cholesterol was within normal limits. conclusion: the prevalence of hypertension in medical students was high. this study shows that early detection of hypertension is key to treating it early and therefore to reducing morbidity and mortality. keywords: profile, medical students, hypertension, chronic kidney disease, dyslipidemia. vol 51 • number 1 • january 2019 blood pressure profile of young adults introduction based on a world health organization (who) brief report in 2013, hypertension (htn) caused 9.4 million deaths globally, due to hypertension complications. htn was responsible for 45% of deaths due to ischemic heart disease and 51% of deaths due to cerebrovascular disease.1 a report by zhang et al.2 revealed that by using the nhanes database, between 2013 and 2014 the prevalence of hypertension in individuals aged between 18–39 years old was 7.3%. medical students are among those young adults accounted for in the prevalence of hypertension based on the nhanes database. a report by nyombi kv et al.3 in uganda stated that the prevalence of elevated systolic blood pressure among preclinical year medical students was 14% and was associated with age, overweight, and a family history of cardiovascular disease. in india, a study by patnaik et al.4 reported an even higher percentage (67%) of medical students with both prehypertension and hypertension. the number of hypertensive young adults, in particular medical students, might increase even further due to a recently lowered blood pressure threshold released by the american heart association (aha) 2017 as compared to the joint national committee (jnc) vii guideline.5,6 studies on factors associated with the occurrence of htn, especially among young adults in indonesia, are scarce. a study in china by liu et al.7 revealed that htn was associated with the male sex, overweight/ obesity, and low cardiorespiratory fitness (crf).5 similar results were also observed in a young afro-carribbean population in which htn was associated with obesity, hyperglycemia, and hypertriglyceridemia.8 a report in china specifically on the working population stated that high body mass index (bmi), tobacco use, and alcohol consumption were factors associated with htn.9 our study aimed to outline the blood pressure profile of young adults at the faculty of medicine, universitas indonesia. methods this was a cross-sectional study conducted at the faculty of medicine universitas indonesia, from april 23rd to may 11th, 2018. the inclusion criteria were: all pre-clinical year medical students and agreement to participate in this study. medical students who did not continue their studies for any reason were excluded. the sampling method used for this study was consecutive sampling and all pre-clinical year medical students were given brief information about the study and were invited to participate. all students interested in participating were asked to visit the test center anytime between 8 am and 5 pm, where we obtained their history, conducted a physical examination, and obtained blood and urine samples. information about the procedure and a consent document were provided. the study protocol has been approved by the health research ethics committee, faculty of medicine universitas indonesia–cipto mangunkusumo hospital no. 299/un2.f1/etik/2017. medical history, physical examination, and laboratory examination a questionnaire was employed to collect information on their identity, previous and latest blood pressure measurements, firstand seconddegree relatives, smoking history, family history of chronic diseases (hypertension, diabetes, coronary heart disease, dyslipidemia, and stroke). the physical examination consisted of weight and height measurements and a determination of body mass index (bmi). height was measured using a plastic measuring tape embedded on the wall and a calibrated digital weight scale was used for weight measurement. blood pressure (bp) was measured twice using a mercury sphygmomanometer and digital device. a venous blood sample was taken via antecubital vein access. a total of 5 ml of venous blood was drawn and was placed directly inside a low-temperature blood container and sent to the laboratory for analysis. data on complete blood count (hemoglobin, hematocrit, leucocyte, platelets), kidney function (ureum, creatinine, cystatin-c, egfr with both ckd-epi creatinine based and cystatin-c based formula), lipid profile (total cholesterol, ldl, hdl, triglyceride), and random blood glucose were collected. a urine sample was also obtained from all participants for urinalysis (specific gravity, ph, white blood 55 lucky a. bawazier acta med indones-indones j intern med cells, red blood cells, nitrite, ketone, bilirubin, urobilinogen, protein, and glucose). outcome the primary outcome of this study was to determine the proportion of medical students with hypertension. statistical analysis participant characteristics are described as frequency and proportion (student grade, selfreported highest blood pressure, smoking history, history of chronic disease, bmi, current blood pressure) and were analyzed with the chi-squared test. data on age, lipid profile (total cholesterol, ldl-cholesterol, hdl-cholesterol, triglyceride), kidney function (ureum, creatinine, egfr), blood glucose, uric acid, routine blood count (hemoglobin, hematocrit, leukocytes, platelets), differential blood count (basophils, eusinophils, neutrophils, lymphocytes, monocytes), and urinalysis results were presented as mean and standard deviation (mean sd). all statistical analyses were conducted using spss statistics 23.0 (ibm corp., armonk, ny). results table 1 presents the blood pressure and risk factor profiles of medical students in this study. there were 250 medical students who came to the test center and agreed to participate. their mean age was 19.19 years, with most study participants from grade 1 (39.6%). the selfreported highest blood pressure data revealed that 61.2% of students were pre-hypertensive. most of the students were non-smokers (98%) and most had family history of hypertension (64.4%) and diabetes mellitus (56.4%). the bmi of most students corresponded with overweight or obese (56.8%). the on-site measured blood pressure revealed that 70.4% were normotensive. on the other hand, measurements with a digital device showed that the percentage of students with normal bp and pre-hypertensive bp were relatively similar (45.6% and 45.2%). the mean of the lipid profile data were within normal limits except for ldl cholestrol, which was slightly elevated. the mean of blood glucose, uric acid level, routine blood count, and differential blood count data were mostly within normal limits. table 1. blood pressure and cardiometabolic risk factors profile of medical students variables values age, mean (sd) 19.19 (1.06) self-reported highest bp (jnc 7), n (%) normotensive 44 (17.6) prehypertension 153 (61.2) hypertension 30 (12) family history of chronic disease, n (%) hypertension 161 (64.4) dyslipidemia 159 (63.6) heart disease 68 (27.2) diabetes mellitus 141 (56.4) stroke 108 (43.2) body mass index, n (%) underweight (<18.5 kg/m2) 15 (6) normoweight (18.5–22.9 kg/m2) 93 (37.2) overweight/obese (≥23 kg/m2) 142 (56.8) current students blood pressure (mercury) jnc7, n (%) normotensive 176 (70.4) prehypertension 65 (26) hypertension 9 (3.6) current students blood pressure (mercury) -aha 2017, n (%) normotensive 176 (70.4) elevated 34 (13.6) hypertension 40 (16) lipid profile, mean (sd) total cholesterol 180.56 (32.97) hdl-cholesterol 56.74 (11.75) ldl-cholesterol 101.51 (25.68) triglyceride 105.48 (62.21) kidney function test, mean (sd) ureum 23.24 (5.66) creatinine 0.94 (0.41) egfr (ckd-epi method) 105.45 (16.14) random blood glucose 96.12 (55.68) uric acid level 5.82 (3.12) discussion studies on university students, in particular on medical students, as representative of the young adult population in indonesia are rare. to the best of our knowledge, this is the first study on medical students regarding their current blood pressure status and other cardiovascular risk factors. we found that the prevalence of 56 vol 51 • number 1 • january 2019 blood pressure profile of young adults prehypertension and hypertension based on jnc vii criteria combined was 29.6%, with a prevalence of hypertension itself at 3.6%. we also found that the prevalence of hypertension based on the new aha 2017 criteria increased 12.4% to become 16%. this result is not surprising, given the hypertension criteria are stricter in current aha 2017 guideline.5 a similar increase in the prevalence in the population aged 45–75 years with hypertension was reported in the us (13.3%) and china (17%).10 in terms of medical students, this finding is similar to that of previous studies in uganda, saudi arabia, and ethiopia.3,11,12 however, a study in pakistan involving students from various faculties reported a lower prevalence of hypertension.8 this finding might be due to the higher stress level experienced by medical students, as has been previously reported.14 our study showed that total cholestrol level, ldl-cholesterol, hdl-cholesterol and triglyceride were all within normal limits. similar results were obtained in a study of university students in brazil.15 we also evaluated the kidney function by measuring ureum, creatinine, and estimated glomerular filtration rate using the ckd-epi method. to the best of our knowledge, this is the first study to measure kidney function in young adults. the mean egfr of all participants was 105.45 ml/ min/m2, which represents normal renal function. several studies have reported that the average egfr of people aged 20–30 years was around 110–120 ml/min/m2.16-18 the slightly lower egfr than average is of concern, because some of the students in our study had egfr <90 ml/min/m2. studies have reported increased cardiometabolic risk in patients with a low egfr.19 among all cardiometabolic diseases, a lower egfr is associated with an elevated framingham risk score for coronary heart disease.20,21 this fact is concerning given coronary heart disease develop earlier than in students who are not at risk, and could impact the productivity of students after they graduate from university. the mean random blood glucose levels in this study were within normal limits, which is line with a previous study.3 our study found that serum uric acid levels were within normal limits. this result is comparable with a previous study on mexican young adults.22 in terms of the urinalysis, white blood cell and red blood cell counts were only performed on women. the finding of white blood cells might be due to the method of urine collection in which mid-stream urine method was not used. furthermore, the finding of red blood cells in the women’s samples was due to the fact that some students had their period during urine collection. a pooled analysis of east and south asians found that a higher bmi is a risk factor for death from cardiovascular diseases, especially coronary heart disease and stroke.19 this fact is concerning because the prevalence of students in our study with overweight or obesity was 56.8%, and these did not know they were at risk and were not treated early. conclusion our study found that 3.6% of participating medical students had hypertension based on the jnc vii criteria and the number increased 4 times according to aha 2017. a limitation of this study was the sample size. the size would have been larger if all invited medical students participated, which would better represent the general young adult population. we are following all currently active medical students for the next 3–5 years. given the prevalence of hypertension in this study, we suggest a similar study on a larger sample of university students with the aim of early detection and treatment. conflicts of interest the authors declare no conflicts of interest. acknowledgments we would like to extend our gratitude to all involved staff at the faculty of medicine universitas indonesia. references 1. a global brief on hypertension: silent killer, global public health crisis. world health organization. 2013. 2. zhang y, moran ae. trend in the prevalence, awareness, treatment, and control of hypertension among young adults in the united states, 1999 to 2014. hypertension. 2017;70:736-42. 3. nyombi kv, kizito s, mukunya d, et al. high prevalence of hypertension and cardiovascular disease 57 lucky a. bawazier acta med indones-indones j intern med risk factors among medical students at makerere university college of health sciences, kampala, uganda. bmc res notes. 2016;9:110. 4. patnaik a, choudhury ka. assessment of risk factors associated with hypertension among undergraduate medical students in a medical college in odisha. adv biomed res. 2015;4:38. 5. khera r, lu y, lu j, saxena a, nasir k, jiang l, krumholz lm. impact of 2017 acc/aha guidelines on prevalence of hypertension and eligibility of antihypertensive treatment in united states and china: nationally representative cross-sectional study. bmj. 2018;362:2357. 6. chobanian av, bakris gl, black hr, et al. the seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: the jnc 7 report. jama. 2003;289:2560-71. 7. liu x, xiang z, shi x, schenck h, et al. the risk factors of high blood pressure among young adults in the tujia-nationality settlement in china. biomed res int. 2017;8315603. 8. ferguson ts, younger-coleman nom, tulloch-reid mk, et al. factors associated with elevated blood pressure or hypertension of afro-carribbean youth: a cross-sectional study. peer j. 2018;6:e4385. 9. shen y, chang c, zhang j, et al. prevalence and risk factors associated with hypertension and prehypertension in a working population at high altitude in china: a cross-sectional study. environ health and prevent med. 2017;22:19. 10. chen y, copeland wk, vedanthan r, et al. association between body mass index and cardiovascular mortality in east asians and south asians: pooled analysis from prospective data from the asia cohort consortium. bmj. 2013;347:f5446. 11. abdulghani hm, alkhanal aa, mahmoud es, ponnamperuma gg, alfaris ea. stress and its effect on medical students: a cross-sectional study at a college in saudi arabia. j health popul nutr. 2011;29:516-22. 12. tadesse t, alemu h. hypertension and associated factors among university student in gondar, ethiopia: a cross-sectional study. bmc public health. 2014;14:937. 13. nepal g, tuladhar et, acharya k, et al. dyslipidemia and associated cardiovascular risk factors among young nepalese university students. cureus. 2018;10:e2089. 14. baig m, gazzaz zj, gari ma, et al. prevalence of obesity and hypertension among university students and their knowledge and attitude towards risk factors of cardiovascular disease (cvd) in jeddah, saudi arabia. pak j med sci. 2015;31:816-20. 15. de freitas rwf, de araujo mfm, pereira dcr, alencar ampg, damasceno mmc. study of lipid profile in a population of university students. scielo. 2013;21:1151-8. 16. de freitas rwjf, de araujo mfm, lima acs, pereira dcr, alencar ampg, damasceno mmc. study of lipid profile in a population of university students. rev latino am enfermagem. 2013;21:1151-8. 17. slack tk, wilson dm. normal renal function: cin and cpah in healthy donor before and after nephrectomy. mayo clinic proc. 1976;51:296-300. 18. berg ub. differences in decline in egfr with age between males and females: reference data on clearance of inulin and pah in potential kidney donors. nephrol dial transplant. 2006;21:2577-82. 19. rule ad, gussak hm, pond gr, et al. measured and estimated gfr in potential kidney donors. am j kidney dis. 2004;43:112-9. 20. mathisen ud, melsom t, eriksen bo, et al. estimated gfr associates with cardiovascular risk factors independently of measured gfr. j am soc nephrol. 2011;22:927-37. 21. matsushita k, selvin e, coresh j. change in estimated gfr associates with coronary heart disease and mortality. j am soc nephrol. 2009;20:2617-24. 22. alegria-diaz a, valdez-ortiz r, murguia-romero m, et al. clinical significance of serum uric acid levels in mexican young adults. uric acid in chronic kid dis. 2018;192:125-34. 58 case report 50 acta medica indonesiana the indonesian journal of internal medicine mrsa infection in patients hospitalized at sanglah hospital: a case series a.a. ayu yuli gayatri, susila utama, agus somia, tuti p. merati department of internal medicine, udayana university sanglah hospital, denpasar, bali, indonesia. correspondence mail: division of tropical and infectious disease, department of internal medicine, udayana university sanglah hospital. jl. pb sudirman, bali 80232, indonesia. email: corrs_maliris@yahoo.com. abstrak laporan ini merupakan laporan pertama mengenai infeksi mrsa di rs sanglah. kami menelusuri 8 kasus mrsa dari catatan laboratorium antara januari hingga mei 2011, kemudian dilanjutkan dengan mengumpulkan data dari catatan medis pasien-pasien tersebut. lima kasus dengan sepsis, 1 kasus osteomyelitis, dan dua lainnya masing-masing dengan mediastinitis dan pneumonia. pasien-pasien ini segera dipindahkan ke ruang isolasi yang dilengkapi dengan teknik perlindungan khusus yang ketat. selanjutnya dilakukan kultur bahan dari hapusan rongga hidung, tenggorok dan aksila pasien serta para petugas kesehatan yang kontak langsung dengan pasien, namun tidak didapatkan kolonisasi mrsa. lima pasien menunjukkan respons yang baik dengan pemberian vankomisin atau linesolid. tiga di antaranya meninggal akibat syok septik sebelum hasil kultur dan tes kepekaan antibiotika selesai. semua strain kuman ini didapatkan dalam waktu setelah 48 jam perawatan dan juga menunjukkan beberapa faktor risiko infeksi mrsa yang didapat di rumah sakit. tes kepekaan antibiotika menunjukkan kekebalan terhadap ß-laktam, namun semua strain masih peka terhadap beberapa antibiotika non ß-laktam yang lain sebagaimana dilaporkan pada infeksi mrsa yang didapat di komunitas. pada masa mendatang diperlukan penelitian lebih lajut menggunakan pemeriksaan biomolekuler untuk mengetahui pengaruh dan perubahannya secara lengkap mengenai infeksi mrsa. kata kunci: mrsa, kepekaan antibiotika, pengobatan. abstract this is the first report of mrsa infection in sanglah hospital. we reviewed eight patients with mrsa infection from microbiologi laboratory records between january and may 2011, than followed by tracing medical records to obtained data of the patients. five of cases with sepsis, 1 case with osteomyelitis, and the two others with mediastinitis and pneumonia. the patients were kept in private isolated room and barrier-nursing technique was strictly followed. further action was culturing specimen taken from the patients nose, throat, axilla, and samples taken from the health care workers, with no mrsa colonization were found. five patients demonstrated good respond to intravenous administration of either vancomycin or linezolide. three were died due to septic shock before the laboratory culture and antimicrobial susceptibility availabled. all of the strains isolated more than 48 hours after admission and also demonstrated clinical risk factors for hospitalized acquired mrsa (hamrsa). these strains had resistance to ß-lactams but remain susceptible to many non ß-lactam antibiotics, as reported in some community acquired mrsa (ca-mrsa) isolates. future study using molecular typing required to fully understand the magnitude and ongoing evolution of mrsa infections. key words: mrsa, antimicrobial susceptibility, treatment. 51 vol 47 • number 1 • january 2015 mrsa infection in patients hospitalized at sanglah hospital: a case series introduction infections caused by methicilin–resistant staphylococcus aureus (mrsa) have become a global health concern during the past 2-3 decades. since then the epidemiology of mrsa infections has changed dramatically. the prevalence of mrsa has steady increased since the first clinical isolate was described in 1961. this was soon after the introduction of methicillin for clinical used. certain strains of mrsa were found to have the propensity to spread very quickly in hospitals. in 2005 the us estimated there were 94.360 invasif mrsa infection with approximately 18.650 associated hospital death.1,2 in some countries in asia, mrsa accounts for more than 70% of nosokomial s. aureus isolates. mrsa infection are associated with greater length of stay, higher mortality and increased cost.3,4 studies of the global epidemiology frequently have not included mrsa obtained from persons living in developing nations. there is only limited prevalence data on mrsa epidemiology in indonesia. mrsa infection is related to its potential for nosocomial transmission and limited number of antibiotics available for its treatment. this is the first report of mrsa infection in sanglah hospital, bali indonesia. case illustration eigth patients with severe infection were found to be mrsa positive from january to may 2011. staphylococcus aureus were identified by colony morphology, coagulation of citrated rabbit plasma with edta. multidrug susceptibility was determined by cefoxitin disk. the medical record of patient were reviewed and the risk factors for mrsa infection were recorded. health care workers and all of the patients were screened for mrsa carriage by the nasal swabs technique and found no mrsa. the demografic and clinical data of patients are shown in table 1 and 2. table 1. demographical and clinical data of patients with mrsa infection variables patients (isolate) 1 2 3 4 5 6 7 8 date of mrsa isolation january 2011 march 2011 march 2011 april 2011 april 2011 april 2011 april 2011 may 2011 specimen pus blood blood pus sputum blood blood blood sex/age (years) f/65 m/45 m/73 m/2 m/73 f/6 m/43 m/29 race balinese balinese balinese balinese balinese balinese balinese bima rehospitalization/ transfered yes no no yes no yes yes yes appropriate antibiotic usage yes yes yes yes yes yes yes yes comorbid condition fr. os femur hemorrhagic stroke fr.os patella, dm vsd hemorrhagic stroke combustio spleen rupture adeno ca prostat surgery orthopaedic neurosurgery orthopaedic sternostomy nil debride ment laparotomy pancysto stomy infection type osteomyelitis sepsis sepsis mediastinitis pneumonia sepsis sepsis sepsis therapy (iv) linezolide vancomycin vancomycin vancomycin vancomycin vancomycin vancomycin linesolide outcome cured cured died died cured cured cured died length of stay 30 days 38 days 41 days 20 days 13 days 21 days 98 days 43 days 52 a.a. ayu yuli gayatri acta med indones-indones j intern med case 1 a 65-year old male patient had been rehospitalized with osteomyelitis in one week after having an-operation of right collum femur fracture. mrsa infection was not identified at the time of treatment. the surgery site developed into a phleghmon with painfull swelling. he initially treated with ceftriaxon and then continued with quinolone, but no improvement. mrsa infection was proven by a positive mrsa pus culture in 1 month admission. case 2 a 45-year old male patient was transfered from a private clinic due to loss of contiousness. he had suffered for several years from cronic hypertension and then had haemorragic stroke. post trepanation intensive care was required, endotracheal tube and indwelling urine catheter were instituted. one month later, tracheal granuloma was diagnosed, which developed into sepsis syndrome. despite treatment with antibiotics including cefotaxime and meropenem, the symptoms worsened to gastrointestinal haemorrhage. bacterological blood test revealed an mrsa infection one month after operation. case 3 a 73-year old male patient who had a 15 year history of diabetes mellitus, hypertension and cronic kidney disease has been admitted to the hospital due to left patellar bone fracture that required surgery. during periode of post operation care, he suffered from pneumonia which then developed into sepsis syndrome. a bacteriological blood culture showed the presence of mrsa in three week observation periode. case 4 a 2-year old male patient had been readmitted to the hospital due to mediastinitis. three weeks after returning home from hospital after a-closure operation on congenital ventricular septal defect (vsd), he suffered from high fever and sign of surgical site infection. treatment in hospital included debridement and combined antibiotics therapy, to which the condition did not respond satisfactorily. one week later, mrsa was identified from surgical wound specimen. case 5 a 73-year old male patient suffered haemorrhagic stroke. he had medical treatment with intravenous line and indwelling urine catheter. one week after the treatment, he showed symptom of pneumonia accompanied by productive cough and an irritable, persistent shorthness of breath. mrsa was found in sputum bacteriologic test. case 6 a 6-year old female patient who was transferred from singaraja (north bali) general hospital with second degree wide combustion. the patient had 3 times surgical procedure during treatment in burn unit. problem that apper in this phase was skin damage due to burn-induced table 2. antimicrobial susceptibility pattern of mrsa isolates patients *antibiotics cefox ery cc sxt cip cef gen van lin 1 r s s r r r s s 2 r i s i r r r s s 3 r s s r r r r s s 4 r s s i r r r s s 5 r r r r r r s s s 6 r i s s r r r s s 7 r s s s r r r s s 8 r s s i r r r s s *cefox=cefoxitin, ery= erythromycin, cc= clindamycin, sxt= trimethoprim-sulfamethoxazole, cip=ciprofloxacin, cef= cefotaxime, gen= gentamycin, van= vancomycin, lin= linesolide 53 vol 47 • number 1 • january 2015 mrsa infection in patients hospitalized at sanglah hospital: a case series inflammation or infection process and problem of wound closure. mrsa was found in the specimen taken from the combustio wound. case 7 a 43-year old male patient who had severe abdominal injury with spleen rupture due to traffic accident that required laparotomy. one week later he experienced swelling and pain throughout the abdominal area. due to a suspected surgical site infection, debridement was performed. during the periode of observation, the infection was treated with repeated dose of antibiotics . two months later, sepsis syndrome developed. mrsa was identified in blood bacteriological test. case 8 a 67-year old male patient was transferred from mataram general hospital, with urine bladder mass. in 2008 he had a-prostatectomy operation due to prostate adenocarcinoma. treatment in hospital included pancystostomy and supportive therapy but 1 month later during a medical examination he showed symptom of pneumonia. following several day of antibiotic treatment, sepsis syndrome was developed. a bacteriological blood culture showed the presence of mrsa. discussion mrsa is a term applied to a special strain of staphylococcus called methicillin resistant staphylococcus aureus which is resistant to ß-lactam antibiotics. mrsa infection can be classified into community–acquired mrsa (ca-mrsa) and hospital–acquired mrsa (ha-mrsa). ca-mrsa is acquired by persons who have not been recently (within the past year) hospitalized or had a medical procedure (such as dialysis, surgery, catheters). these infection manifest usually as skin infections and occur in otherwise heathly people. when looking at mrsa types, ca-mrsa was less likely to cause bacteremia than was hamrsa (65% vs 77%), but it was more likely to be associated with cellulitis (23% vs 8%) and endocarditis (13% vs 5%) than was hamrsa. almost 18% of the patients died while hospitalized for mrsa. ca-mrsa contribute to invasive illness in hospitalized patients, but most the invasive mrsa disease is still associated with healthcare-related strains.5,6 although prevention, control, and management of ha-mrsa infections remain problematic, community-associated mrsa infections have emerged as increasingly prevalent and serious problem. ca-mrsa isolates have a tendency to be susceptible to other antibiotic classes and often are resistant only to ß-lactams antibiotics, while ha–mrsa is tipycally a multidrug resistant organism. the lack of resistance to multiple antibiotics suggest a community origin, because antibiotic selective pressure is much lower within the community than in hospitals, and the survival advantage of multiple drug resistance is lower. in this report, five of these cases developed sepsis syndrome, and the three others with mediastinitis, osteomyelitis and pneumonia. all cases were more likely to be resistant to ß-lactams but remain sensitive to many non ß-lactam antibiotics (including erythromycin, clindamycin and trimethroprim sulfamethoxazole), as reported in some camrsa isolates. initially, mrsa was almost exclusively a nosocomial pathogen, and even today healthcareassociated mrsa (ha-mrsa) infections remain a significant challenge. ha-mrsa infection is acquired by person admitted to hospital for more than 48 hours or those have medical history of mrsa infections or colonization during previous admission. the proportion of nosocomial s aureus infections demonstrating methicllin resistance nearly doubled, increasing from 36% to 64% between 1992 and 2003.4,5 mrsa has become a commonly encounterd pathogen in clinical setting. the elderly, the clinical ill patients and those who have endured a prolonged hospital stay are the most concern patients group. other important predisposing factors for the infection are: some kind of the lesion on the skin/ mucosal barrier (e.g. surgical wound, decubitus, and invasive dwelling divices: intravenous catheter, urinary catheter, mechanical ventilation, etc.), recent exposure to broad spectrum antibiotic therapy, and staying in intensive care unit. common sites of hamrsa are surgical wound infection, urinary tract infection and pneumonia. the mortality rates for 54 a.a. ayu yuli gayatri acta med indones-indones j intern med nosokomial mrsa infection are approximately 50% for bacteraemia and 33% for pneumonia.7 we note that all of the patient with co-morbid condition, seven of cases related to surgery care exposure. in another one case was recognize as pneumonia with medical treatment due to acute haemorrhagic stroke. all of strains have been isolated after 48 hours of hospitalization. i n t r a v e n o u s a n t i m i c r o b i a l a g e n t s are appropriate for patients with severe staphylococcal infection, particularly patient requiring hospitalization. vancomycin remains a first-line therapy for severe infections caused by mrsa. other intravenous agents such as linezolide, tigecyclin, daptomycin, clindamycin and quinopristin-dalfopristin may appropriate to be considered in some circumstances. as with methisillin-resistance, prevalence of resistance to non betalactam agents varies geographically and is likely to change over time. local susceptibility patterns of community s. aureus isolates should be monitored and the information used to guide empiric management decision.5,6 five of the eigth cases demonstrated good respond to intravenous administration of either vancomycin or linezolide (based on result of cultures and antimicrobial susceptibility testing) for 7-14 days. unfortunately 3 patients died due to septic shock. transmission of mrsa occurs mainly by contact transmission and droplet infection. patients who already have an mrsa infection or who carry the bacteria on their bodies but do not have symptoms (are colonized) are the most common sources of transmission. the carrier state is clinically significant because any surgical intervention or exudative skin colonization predisposes the mrsa carrier to mrsa infection. carriage of mrsa also plays an important role in the dissemination of this microorganism with in health care facilities, as well as into the community. the most common way of transmission is through human hands, especially health care workers’ hands. hands may become contaminated with mrsa by contact with infected or colonized patients. surgical wound infection and contamination occurs mainly trough contact with hands of health care worker or environmental surfaces contaminated with body fluid containing mrsa. droplet infection is another type of transmission which causes pneumonia and in such a case, the patient is infectious trough droplet infection to the surrounding patients and health care workers. several studies have demonstrated that carrier of mrsa are at greater risk for developing serious infection. and while 25% to 30% of population is colonized with staphylococcus aureus, approximately 1% is colonized with mrsa.8,9 so health care workers (including physicians, nurse and paramedicals) who carry mrsa colonies in their nostrils and skin are responsible for increase risk of getting surgical wound infections to patients when they deal with. nasal colonization with mrsa does not appear to have played a role in these mrsa cases. we identified throat, axilla and nasal swabs among the patients and health care workers but found no mrsa. we prepared a protocol which describes the tasks to be performed when an mrsa positive case occurs in the hospital. the protocol is based on the current international consensus guidelines includes performing hand hygiene, placing the patients in private isolated room with cleaning and decontamination facilities, and intravenous injection of either vancomycin or linezolide.1,9,10 the hospital patients safety team organized education on hand hygiene (handwashing or using alcohol hand gel) and isolation rules (through placing infected patients in private rooms or cohorting patients with similar infecton status) at our hospital. however clinical studies are required to clarify further therapeutic usses on timing, dosing & choise of optimum treatment and useful. conclusion this case series demonstrates the potential severity and rapid clinical progression of mrsa infections that can occur in the indoor hospital patients. making a diagnosis of mrsa infections is challenging; although microbial confirmation of the diagnosis is clearly required, a combination of epidemiologic, hystorical, physical examination, laboratory and radiographic findings may suggest this diagnosis, particularly in critical ill patient with rapidly progressive disease. in addition to appropriate supportive care, prompt initiation of 55 vol 47 • number 1 • january 2015 mrsa infection in patients hospitalized at sanglah hospital: a case series antibiotic therapy with activity against mrsa is warrated. this report aims at creating an awarness among physician about the posibility of mrsa infection in high risk patients, especially those on surgical wound infections, pneumonia, osteomyelitis, burn patient, bacteremia and sepsis syndrome. our hope is that this report will provide a starting point for future research into methicilline-resistant staphylococcus aureus infection to validate these findings and provide impetus for initiatives to improves antimicrobial drug use. references 1. coia je, duckworth gj, edwards di, et al. guidelines for the control and prevention of methicillin-resistant staphylococcus aureus (mrsa) in health care facilities. j hospital infect. 2006;63s:s1-s44. 2. chua k, laurent f, coombs g, grayson l, howden b. not community associated methicillin resistant staphylococcus aureus (ca-mrsa)! a clinician’s fuide to communuty mrsaits evolving antimicrobial resistance and implications for therapy. antimicrob resist cid. 2011;52:99-114. 3. ko ks, lee jy, suh jy, et al. distribution of major genotypes among methicillin-resistant staphylococcus aureus clones in asia countries. j clin microbiol. 2005;43(1):421-6. 4. campaline f, bongiorno d, borbone s, stefani s. methicillin fascets of an old pathogen. eur infect dis. 2010;4(1):70-6. 5. christopher s, verghis rm, antonisamy b, et al. transmission dynamics of methicillin-resistant staphylococcus aureus in a medical intensive care unit in india. plos one. 2011;6(7):e20604. available: http//www.plosone.org. 6. seybold u. are community associated methicillin resistant staphylococcus aureus (mrsa) strain replacing traditional nosocomial mrsa strain? clin infect dis. 2006;46:274-84. 7. bassim h, el maghraby m. methicillin-resistant staphylococcus aureus (mrsa) a challenge for infection control. asjog. 2005;2. available from: url: http//www.asjog.org 8. delorme t, rose s, senita j, callahan c, nasr p. epidemiology and susceptibilities of methicillin resistant staphylococcus aureus in northeastern ohio. am j clin pathol. 2009;132:668-77. 9. centers for disease control and prevention. community-associated mrsa information for clinicians. available at: http://www.ede.gov/ncidod/ dhqp/ar_mrsa_ca_clinicians.html. 10. tak chiu wu. clinical aspects and treatment of camrsa infections. hong kong med diary. 2007;12 (12):14-6. case report 244 acta med indones indones j intern med • vol 50 • number 3 • july 2018 catheter-related blood stream infection in a patient with hemodialysis anti dharmayanti1, dalima astrawinata2 1 department of clinical pathology, fatmawati central general hospital, jakarta, indonesia. 2 department of clinical pathology, faculty of medicine universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: anti dharmayanti, md. department of clinical pathology, fatmawati central general hospital. jl. rs fatmawati, cilandak, jakarta 12430, indonesia. email: antidharmayanti@yahoo.com. abstrak seorang pasien pria usia 31 tahun, datang berobat jalan ke rumah sakit untuk hemodialisis (hd) rutin 2 kali dalam seminggu. saat dilakukan tindakan hd mendadak pasien demam dan menggigil, saat itu ditegakkan diagnosis catheter-related blood stream infection (cr-bsi), dilakukan pencabutan catheter double lumen (cdl) dan pasien kemudian dirawat. hasil kultur tip cdl dan kultur darah perifer didapatkan kuman yang sama yaitu enterobacter cloacae. diagnosis cr-bsi pada kasus ini ditegakkan berdasarkan kriteria infectious disease society of america (idsa) tahun 2009. secara keseluruhan harus diperhatikan langkah pencegahan cr-bsi berupa edukasi pasien dan petugas yang memasang cdl, penerapan prosedur tindakan aseptik kulit yang benar serta perawatan exit site cdl, untuk mencegah terjadinya cr-bsi. kata kunci: catheter-related blood stream infection (cr-bsi), infectious disease society of america (idsa), catheter double lumen (cdl). abstract a 31-year-old patient came to visit the outpatient clinic at the hospital for his routine twice-weekly hemodialyis (hd) session. during hd, the patient suddenly developed a fever with shivering. at that time, a diagnosis of catheter-related blood stream infection (cr-bsi) was developed, hd catheter or the catheter double lumen (cdl) was uninstalled and the patient was hospitalized. results of culture withdrawn through the tip of catheter lumen and peripheral blood revealed identical microorganism, i.e. the enterobacter cloacae. diagnosis of crbsi in the present case was made based on the 2009 infectious disease society of america (idsa) criteria. in general, prevention measures for cr-bsi should be taken into account including education for patient, awareness of the health care providers who install the cdl, implementation of procedure for appropriate skin aseptic technique and best practice for hd catheter care, particularly on the exit site of the cdl to prevent the development of cr-bsi. keywords: catheter-related blood stream infection (cr-bsi), infectious disease society of america (idsa) criteria, catheter double lumen (cdl). vol 50 • number 3 • july 2018 catheter-related blood stream infection in a patient with hemodialysis introduction bacteremia or the presence of bacteria in the bloodstream may occur in patients who are undergoing hemodialysis (hd) treatment and generally the source of infection includes cannula or catheter double lumen (cdl).1 catheter-related blood stream infection (crbsi) is defined when the results of cultures show that microorganism isolated from catheter tips and peripheral blood cultures are identical without another source of infection other than the catheter/cdl itself in hd patients with symptoms of systemic infection.1-3 the term cr-bsi is determined based on accurate data of laboratory results, which identify cdl as the source of infection in the bloodstream. the term is usually used to establish diagnosis, provide treatment and study the epidemiology of bloodstream infection in patients who undergo cdl insertion.4,5 in order to establish the diagnosis of cr-bsi, laboratory data are necessary, which include data of paired culture obtained from cvc/cdl tips and peripheral blood.2-4 catheter related blood stream infection (cr-bsi) is a part of the primary bloodstream infection (pbi) or laboratory confirmed bloodstream infection, in which there is an infection in the bloodstream that occurs without any suspected organ or other tissue as the source of infection. the risk factors are susceptibility to infection and intravenous (iv) catheter insertion, which is associated with type of cannula, insertion method and duration of cannula insertion.6 catheter insertion for hd can be done permanently or temporarily, i.e. several months prior to the permanent insertion.5,7 whenever the permanent insertion has not been possible, the use of temporary insertion can be extended.7 permanent catheter insertion is usually carried out by performing surgical procedure of creating arteriovenous fistula (a-v fistula). the a-v fistula requires 2 to 8 weeks for recovery and maturation before it is ready and to serve a useful function for hd procedure; therefore, temporary cdl insertion can be useful as an alternative, particularly in emergency setting.5 temporary insertion of cdl is a catheter placement using vascular access through peripheral veins or large intrathoracic veins such as subclavian, internal jugular or femoral veins, which ends at the superior cava vein or right atrium. it serves a useful function in measuring central venous pressure or inserting hyperosmolar intravenous fluid during hemodialysis procedure.4,5 there are 4 types of cdl insertion based on technique and duration of catheter insertion, which are non-tunneled cdl, tunneled cdl, peripherally inserted central catheters (piccs) and implanted ports.4 case ilustration mr. a, a 31-year-old, came to outpatient clinic of hd in fatmawati hospital for his routine twice-weekly hemodialyis (hd) session. the patient had undergone hd within the last 2 months at fatmawati hospital and he had cdl insertion since the routine hd session was performed. he was on waiting list for having the cimino arteriovenous shunt cimino insertion in an operating room. during the hd procedure (± 4 hours after the hd had been initiated), the patient developed a fever with shivering and his doctor instructed to stop hemodyalisis and recommended the patient to be hospitalized. there was no history of fever during the previous routine hd sessions. history of having hypertension, urolithiasis or diabetes was denied. the patient worked as a casual laborer with an education level of junior high school. his physical examination revealed that his qualitative awareness level was compos mentis (fully alert) with blood pressure of 140/90 mmhg, pulse rate of 110 beats per minute, respiratory rate of 22 beats per minute, body temperature of 380c and normal body mass index (bmi = 21.48). on his neck, a cdl was inserted on the right internal jugular vein and there was redness around the exit site of the catheter with no purulent discharge. there were no abnormal findings of his chest, abdomen and extremities. the chest radiography showed that the heart and lungs were within normal limits. a diagnosis of chronic kidney disease (ckd) on hd + suspected catheter-related bloodstream infection (cr-bsi) was made. the cdl was then removed and the patient received following treatment, i.e. intravenous fluid drip of ringer 245 anti dharmayanti acta med indones-indones j intern med lactate (rl) at 10 drips/minute; ceftriaxone at the dose of 2 x 1 gram by intravenous route and 3 x 500 mg paracetamol by oral route. isolation of microorganisms, cultures and antimicrobial resistance testing were performed. cultures were carried out with samples obtained from cdl tip and blood withdrawn from the left cubital veins. the result of blood test revealed anemia with hb levels of 9.9 g/dl (normal limit: 13.2-17.3 g/dl), neutrophilia with neutrophil counts of 12,000/ul (normal limit: 5000-10000/ul); while the alt, ast, total protein and blood glucose levels were within the normal limits. there was high ureum level of 126 mg/dl (normal limit: 20-40 mg/dl) and the creatinine level was also high with 7.4 mg/dl (normal limit: 0.6-1.5 mg/ dl). the estimated creatinine clearance based on the chronic kidney disease epidemiology collaboration (ckd-epi) equation was 9. results of cultures through cdl tips and blood cultures as well as the antimicrobial resistance testing can be seen in table 1. results of culture withdrawn through the tip of catheter lumen and peripheral blood revealed identical microorganism, i.e. the enterobacter cloacae, which is one of multiple drug resistant organisms (mdro) and the results of antimicrobial resistance testing were also identical for both cultures. empirical treatment using ceftriaxone was administered for 3 days and after the results of culture were received, a definitive treatment using meropenem for 3 days was provided, which was adjusted to the culture results. the patient was discharged from hospital with improvement. discussion our patient is a 31-year-old male who came to outpatient clinic of hd in fatmawati hospital with a diagnosis of ckd + suspected cr-bsi. the whole blood count revealed normocytic normochromic anemia, neutrophilia as well as increased ureum and creatinine level, which supported a diagnosis of ckd. in this case, we found that the estimated creatinine clearance based on the chronic kidney disease epidemiology collaboration (ckdepi) equation was 9, which is appropriate to the diagnosis of kidney failure or stage 5 ckd according to the 2012 kdigo criteria and hd procedure is required. the neutrophilia indicated that there was an inflammatory process or an infection in the patient. samples for culture and antimicrobial resistance testing from the cdl tip and blood were sent and at the same time, cdl was removed and sent for further evaluation. results of culture withdrawn through the tip of catheter lumen and peripheral blood revealed table 1. results of culture and antimicrobial resistance testing with samples obtaind from cdl tip isolates: enterobacter cloacae amoxycillin clavulanic acid r amikacin s cefuroxime r gentamicin s ceftazidime r ciprofloxacin r cefotaxime r levofloxacin i ceftriaxone r cotrimoxazole r cefepime r chloramphenicol r meropenem s fosfomycin r results of blood culture amoxycillin clavulanic acid r amikacin s cefuroxime r gentamicin s ceftazidime r ciprofloxacin r cefotaxime r levofloxacin i ceftriaxone r cotrimoxazole r cefepime r chloramphenicol r meropenem s fosfomycin r 246 vol 50 • number 3 • july 2018 catheter-related blood stream infection in a patient with hemodialysis identical microorganism, i.e. the enterobacter cloacaeand the results of antimicrobial resistance testing were also identical for both cultures that the patient was still sensitive to the following antibiotics, i.e. meropenem, amikasin and gentamicin. there are some methods for laboratory culture evaluation with samples obtained from the catheter tip, which are qualitative and semi-quantitative methods.4,5,8 for culture using qualitative method, the tip of catheter is aseptically removed and immersed in liquid medium and then the procedure of growing in blood agar is carried out and the culture is incubated for 24 hours at 370c. the semiquantitative method includes rolling the tip of catheter (with ±5 cm length) on the surface of blood agar plate, the culture was incubated for 24 hours at 370c and the number of growing colonies was counted.3-5 according to one of criteria issued in the cdc’s national healthcare safety network (cdc’s nhsn) for cr-bsi as quoted from the association for professionals in infection control (apic),4 cr-bsi is defined when the result of culture through catheter tip is semiquantitatively positive (>15 cfu/tip), which is known as positive cr-bsi. semi-quantitative method for culture of catheter tip has been more recommended by the cdc’s nhsn than the qualitative method; however, the qualitative method has also been used widely until now.4,8 a study by marconi9 comparing qualitative and semi-quantitative method for cultures has found 100% sensitivity and 60% specificity for qualitative method; while 90% sensitivity and 71% specificity for semi-quantitative method. a study conducted by safdar as quoted by marconi has demonstrated 90% sensitivity and 72% specificity for qualitative method; while for semiquantitative method, the study has shown 85% sensitivity and 82% specificity. cultures using semi-quantitative method have demonstrated higher specificity than qualitative method with cut-off point of >15 cfu/tip, which can reduce the possibility of false positive result.9 in the present case, the patient came for routine dialysis session and during the hd procedure, he had suffered clinical symptoms of fever and shivering (pulse rate 110 beats per minute and body temperature of 38.5 0c) within several hours after having hd and he also had inflammatory signs at the site of cdl insertion. the chest radiography revealed that his heart and lungs were within normal limits. the hd procedure was stopped, double lumen catheter / cdl was removed, a diagnosis of ckd on hd + suspected cr-bsi was made and the patient was immediately hospitalized. cdl had been inserted since the patient had routine hd, i.e. within the last 2 months prior to hospitalization. the double lumen catheter (cdl) was inserted on the internal jugular vein (central vein) according to the non-tunneled cvcs technique for < 3 months insertion (short term). there was no history of fever and shivering during the previous routine hd session. in this patient, we found identical results between culture withdrawn through the tip of catheter lumen and peripheral blood as well as identical results of antimicrobial resistance testing, which is in consistent with the idsa criteria guideline for cr-bsi diagnosis. according to the guideline, diagnosis of cr-bsi is made when there are no bacteria in blood, there is clinical and laboratory indication of infection, no clear source of infection other than the cdl and positive culture reveal identical microorganism between blood culture and culture through cdl. definitive diagnosis of cr-bsi is established when during the cvc/ cdl insertion there is signs of infection on the insertion site, there is clinical symptoms of bacteremia or sepsis, the clinical signs resolved and diminished following the removal of cvc/ cdl, results on type of microorganism between culture withdrawn through the tip of catheter lumen and peripheral blood are identical, no other source of infection has been found to cause bacteriemia other than the cvc/cdl (primary bacteremia).3, i0 among those criteria, the most important gold standard for establishing the diagnosis of cr-bsi is when results between culture withdrawn through the tip of catheter lumen and peripheral blood at the same time are identical.2-4,8 in the present case, we found several evidences which pointed out to the possibility 247 anti dharmayanti acta med indones-indones j intern med that cr-bsi has occurred, i.e. on history taking, the patient had fever and shivering during hd procedure, which diminished immediately after the catheter was removed. on physical examination, there were signs of phlebitis on the exit site of the cdl, no other source of infection was found other than catheter and the results between culture withdrawn through the tip of catheter lumen and peripheral blood were identical, which is the diagnostic gold standard for cr-bsi. therefore, the data of our patient has fulfilled the diagnosis criteria for cr-bsi. accurate diagnosis of cr-bsi is extremely important and needed for effective and prompt management such as removing catheter as it may serve the source of infection and therefore, more serious complications can be avoided for the patient’s sake.2,10 cdl insertion must consider some issues, i.e. catheter must be inserted using aseptic technique and must be removed immediately when it is no longer necessary or if it is suspected leading to sepsis. catheter that has been inserted through jugular and subclavian veins must not be removed on a routine base and when it must be continued for longer use, gauze dressing for catheter must be checked and replaced every 48-72 hours.6 when performing cvc/cdl insertion, in addition to aseptic procedure, a good and appropriate hand hygiene must be carried out as well as using gloves and mask to prevent and reduce the incidence of infection. the use of skin antiseptic such as povidone iodine or 2% chlorhexidine gluconate prior to cvc/cdl insertion may reduce the incidence of cr-bsi. overall, the strategy of preventing cr-bsi includes measures of providing education for patients and health care providers who perform cvc/cdl insertion, the use of antibiotic lock or heparin lock on cvc/cdl insertion, applying the procedure of appropriate aseptic technique, the use 2% chlorhexidine gluconate for skin antiseptic when performing cvc insertion as well as checking and replacing dressing for cvc/ cdl once in every three days before and after hd procedure has been carried out.3,9,11 the incidence of cr-bsi, as quoted by fletcher,3 varies between 3 and 16 % depending on risk factors and types of the inserted catheter. the rate of cr-bsi incidence depends on different site and duration of catheter placement, types of catheter material that has been used, potency of contamination at the exit site or hub, cvc/cdl insertion technique and risk factors for infection in the patients themselves.7 the lowest incidence of infection has been found when cvc/cdl is inserted through subclavian vein followed by internal jugular vein as the insertion site and the highest incidence of cr-bsi is found when the femoral vein is used as the insertion site. regarding the catheter material, polyurethane or silicone catheters are good enough; however, further studies need to be done on selecting the best catheter material to prevent the development of cr-bsi.3 according to the 2012 kidney disease improving global outcomes (kdigo) criteria,12 ckd patients with creatinine clearance of <15 are categorized into patients with renal failure or end state renal disease who require hd procedure. in ckd patients who are on hd with insertion of cvc/cdl, there is a risk of developing cr-bsi.12 in addition to cvc/ cdl insertion, catheter caring and duration of cvc/cdl insertion may also have a risk for developing infection. some other risk factors that may have roles on the development of cr-bsi in patients with hemodialysis are elderly age, comorbidities of ckd such as diabetes mellitus, malignancy, hypoalbuminemia and anemia. in patients with diabetes mellitus and ckd, there can be some abnormalities of immune system, which can be aggravated by uremia that may facilitate the development of infection. hypoalbuminemia may also exacerbate immune defect in ckd patients.1,13 actually, the most common cause and microorganism that allows colonization or phlebitis on the site is staphylococcus sp. such as s. epidermidis or s.aureus. the most common bacteria causing cr-bsi in hd patients are gram-positive cocci (52 to 70%) such as s.aureus and s.epidermidis. gram-negative bacteria are found as etiologies in about 24 to 26.7% cases.13 (table 2) microorganism causing cr-bsi can enter bloodstream thorugh several mechanisms and the first is through direct migration from skin 248 vol 50 • number 3 • july 2018 catheter-related blood stream infection in a patient with hemodialysis surface, i.e. from the outer surface of catheter to catheter tip at the location of catheter insertion (extraluminal), which is usually associated with bacteria colonization on the skin surface. the second mechanism is through catheter hub, which is contaminated during hd procedure is performed; while the third mechanism is through contamination of dialysis fluid (intraluminal). bacteria on skin surface near the location of catheter insertion can migrate through catheter reaching the catheter tip and finally entering bloodstream and spread through catheter lumen.3,13 when the catheter is inserted, the exit site of the catheter will be immediately covered by serum protein such as fibrinogen, fibronectin, laminin and collagen that cover the outer surface of intravenous catheter. the protein layers along with glycocalix (slime) produced by the bacteria will develop a biofilm, which become the site of bacterial attachment, replication and colonization.3 in the present case, we found a different type of microorganism, i.e. the e. cloacae, which is a gram-negative rod bacteria and it is included in the enterobacteriaceae family. the free-living bacteria are found in gastrointestinal tract, septic tank, river water and plants. they have optimum growth at 370c and they are facultative anaerobs, oxidase negative and katalase positive. the bacteria can cause nosocomial infection in the hospital and resulting in bacteremia, skin and soft tissue infection and urinary tract infection. moreover, the bacteria can also produce beta laktamase and they easily become resistant to the third and fourth generation of cephalosporin or become multiple drug resistant organism (mdro). transmission of infection or outbreaks may occur through contaminated hands of the health-care workers, contaminated medical equipment or water. e. cloacae found in the present case was probably caught by the patient when he had a bath/cleaned himself in the public toilet at the hd department in the hospital and used water contained in water basin (tile tub) next to the toilet that might have been contaminated, which subsequently caused phlebitis at the exit site of cdl and then the bacteria entered the bloodstream when the hd procedure was performed. in the present case, although the wound dressing at the exit site has been checked and replaced each time the patient had a controlled visit for hd session twice a week, but waterproof occlusive dressing had not been used and therefore, it had a high potency for contamination. there are some ways for microorganism entering bloodstream, which are through contaminated dialysis fluid or through contaminated hub or through colonization at the exit site and the microorganism enters bloodstream during the hd procedure. unfortunately, no culture had been done based on samples from dialysis fluid in the present case; however, the most recent data on culture of dialysis fluid, which is performed every 3 months, shows that the dialysis fluid is still useable and there was no other case of crbsi found in other patients who also had used the dialysis fluid. based on findings of phlebitis signs and the development of fever within 4 hours following the hd procedure, there is a great possibility that the microorganism was caught through the exit site of cdl, which might have formed colonization at the exit site and entered the bloodstream during the hd procedure. education for patient is also necessary, particularly on cdl care when the catheter has been removed and replaced by a new cdl so that the catheter is always in a clean and dry condition without any contamination to avoid colonization or infection at the exit site of cdl. providing antibiotics such as i cefazolin, gentamicin (antibiotic lock), heparin (heparin table 3. profile of bacteria causing cr-bsi13 gram positive cocci 52-70% s. aureus 21.9-60% s. epidermidis 8.8-12.6% mrsa** 6.0-8.0% enterococcus faecalis 2.4-8.0% gram negative bacilli 24-26.7% pseudomonas aeruginosa 2.3-15.2% escherichia coli 10.4% acinetobacter spp. 12.8% serratia marcesens 1.2-2.3% klebsiella pneumoniae 6.4% enterobacter doacae 8.8% polymicrobial 16.2-20% 249 anti dharmayanti acta med indones-indones j intern med lock) into catheter lumen and skin antiseptics (chlorhexidine) will reduce the migration of microorganism from the intracutaneous to intravascular segment of the catheter.10,12,13 heparin lock was administered at the dose of 1.5 ml/ 7500 u heparin into the catheter lumen following the hd procedure, which has a role to prevent blood clot that may develop into septic thrombophlebitis. the heparin lock can be administered simultaneously with antibiotic lock. the antibiotic lock is usually given for long-term cdl for 7-14 days and it should not be given on a routine basis as may induce antimicrobial resistance. if bacteremia or sepsis has developed, clinical symptoms such as shivering, fever or even hypotension and shock may occur.14 antibiotics that are quite effective for the bacteria are aminoglycosides, cefotaxime and cefoperazone.15 antibiotic treatment should be based on results of culture and antimicrobial resistance test. 3,11 empiric treatment for gram-negative bacteria depends on pattern of microorganism and the severity of disease. usually, the fourth generation of cephalosporin, carbapenem, combined treatment of beta lactam and aminoglycosides are administered. vancomycin can be given as empiric treatment whenever the presence of methicillin resistant staphylococcus aureus (mrsa) is suspected. definitive antibiotic treatment for cr-bsi is usually given for 7 to 10 days; while for cr-bsi cases with complications, the antibiotic can be given up to 2 weeks.11,14,16 start complete data more appropriate more effective less toxic alternatives cheaper alternatives narrower spectrum alternatives duration is too long duration is too short no no yes yes yes yes no yes yes no no no no yes iiia iiib ivd ivc ivb iva v vi appropriate dose appropriate interval appropriate route appropriate timing no no no no no yes yes yes yes i iic iib iia the algorithm stops at iii b (duration too short) yes stop stop 0 = (appropriate) figure 1. gyssens algorithm for evaluating the use of meropenem 250 vol 50 • number 3 • july 2018 catheter-related blood stream infection in a patient with hemodialysis empiric treatment using ceftriaxone for 3 days in the present case obviously did not bring any significant clinical improvement as the patient was still having fever and the leukocyte count was increasing. after receiving the result of blood culture and culture of the cdl tip, we knew that the microorganism was indeed resistant to ceftriaxone. based on the results of antimicrobial resistance testing, blood culture and culture of the cdl tip, the antibiotic treatment was then replaced by meropenem. the meropenem treatment was provided after the result of blood culture and cdl tip had been known and it was obvious that there was identical microorganism between both cultures, which is consistent with the diagnosis criteria of cr-bsi. afterwards, there was clinical improvement and the patient was discharged from the hospital without any oral antibiotics. when evaluating the use of meropenem with gyssen algorithm (figure 1), we found that the data of medical records was complete, the indication for definitive treatment was appropriate, the antibiotic given had a narrow spectrum, inexpensive, safe and the most effective against e. cloacae; however, the duration of treatment was too short (less than 5 days); in contrast, the recommended duration of antibiotic treatment for cr-bsi should be at least 7 days; therefore, the evaluation for the used meropenem using gyssen algorithm stopped at the iii b, i.e. in the category of duration of treatment was too short. conclusion whenever there is a sudden fever during hemodialysis procedure, the possibility of developing catheter related blood stream infections (cr-bsi) should be considered. we found that results of culture withdrawn through the tip of catheter lumen and peripheral blood revealed identical microorganism, i.e. enterobacter cloacae, which supports the diagnosis of cr-bsi. overall, prevention measures for cr-bsi should be taken into account including education for patient, awareness of the health care providers who install the cdl, implementation of procedure for appropriate skin aseptic technique and best practice for hd catheter care, particularly on the exit site of the cdl to prevent the development of cr-bsi. references 1. fysaraki m, samonis g, valachis a, et al. incidence, clinical, microbiological features and outcome of blood stream infection in patients undergoing hemodyalisis. int j med sci. 2013;10(12):1632-8. 2. tomlinson d, mermel la, ethier mc, matlow a, gillmeister b, sung l. defining blood stream infections related to central venous catheters in patients with cancer: a systematic review. clin infect dis. 2011: 53(10);697-704. 3. fletcher s. catheter related blood stream infection. crit. care pain. 2005;5(2):49-50. 4. association for professionals in infection control. guide to the elimination of catheter related bloodstream infections. washington: apic; 2009. p. 8-13. 5. qureshi al, abid k. frequency of catheter related infections in haemodialysed uraemic patients. j pak med assoc. 2010;60(8):671-5. 6. departemen kesehatan republik indonesia. pedoman pengendalian infeksi nosokomial di rumah sakit. jakarta: depkes ri; 2001. p. 53-61. 7. barbosa d, taminato m, fram d, grothe c, belasco a. prevention of catheter-related bloodstream infections in patients on hemodialysis. infect control. 2012;25: 81-92. 8. marconi c, lourdes m, lyra jc, et al. comparison between qualitative and semiquantitative catheter tip cultures: laboratory diagnosis of catheter related infections in new borns. brazilian j microbiol. 2008; 39:262-7. 9. beekman se, diekema dj, huskins c, et al. diagnosing and reporting of central line associated blood stream infection. inf control hosp epidemiol. 2012;33(9):875-82. 10. mermel la, allon m, bouza e, et al. clinical practice guidelines for the diagnosis and management of intravascular catheter related infection: 2009 update by the infectious diseases society of america. clin infect dis. 2009;49:1-45. 11. chin g. treatment of dyalisis catheter infection. sydney: kidney health australia; 2012. p. 1-9. 12. kidney disease improvement global outcome. clinical prctice guideline for the evaluation and management of chronic kidney disease. 2012. kyowa: kdigo 2012. 13. saxena ak, panbotra br. haemodyalisis catheter related blood stream infections: current treatment options and strategies for prevention. swiss med wkly. 2005;135:127-38. 14. wilcox ta. catheter related blood stream infection. semin intervent rad. 2009;26(2):139-43. 15. deal en, micek st, ritchie dj, reichley rm, dunne 251 anti dharmayanti acta med indones-indones j intern med wm, kollef mh. predictors of in–hospital mortality for bloodstream infections caused by enterobacter species or citrobacter freundii. j clin microbiol. 2007; 27(2):191-9. 16. maki dg, kluger dm, crnich cj. the risk of blood stream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. mayo clin proc. 2006;81(9):115971. 252 5 original article acta med indones indones j intern med • vol 53 • number 1 • january 2021 the association of b2-microglobulin and fibroblast growth factor 23 with major adverse cardiac event in acute coronary syndrome patients with chronic kidney disease eka ginanjar,1 idrus alwi,1 aida lydia,2 suzanna immanuel,3 m. yamin,1 taufik indrajaya,4 kuntjoro harimurti5,6 1 division of cardiology, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 2 division of nephrology and hypertension, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 3 department of clinical pathology, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 4 division of cardiology, department of internal medicine, faculty of medicine sriwijaya university, palembang, indonesia. 5 division of geriatric, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital, jakarta, indonesia. 6 clinical epidemiology and evidence-based medicine, cipto mangunkusumo hospital, jakarta, indonesia. corresponding author: eka ginanjar, md., phd. division of cardiology, department of internal medicine, faculty of medicine universitas indonesia – cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: ekginanjar@gmail.com. abstrak latar belakang: penyakit ginjal kronik (pgk) diketahui meningkatkan keparahan dan mortalitas pada pasien sindrom koroner akut (ska). beta2-mikroglobulin (β2-m) sebagai penanda inflamasi dan fibrolast growth-factor 23 (fgf23) sebagai penanda ckd-bone mineral disorder (ckd-mbd) mungkin memiliki peran bermakna dalam proses patofisiologi pada pasien ska dengan pgk. penelitian ini bertujuan untuk mengetahui pengaruh β2-m dan fgf23 terhadap major adverse cardiac event (mace) pada pasien ska dengan pgk. metode: penelitian ini menggunakan desain potong-lintang dan kohort prospektif untuk kejadian mace. sampel penelitian merupakan pasien ska dengan pgk yang dirawat di rsupn dr. cipto mangunkusumo pada periode januari–oktober 2018. data dianalisis menggunakan regresi logistik dan cox’s proportional hazard regression. hasil: sebanyak 117 subyek yang memenuhi kriteria pemilihan diikutkan dalam penelitian. kadar β2-m, fgf23, dan derajat pgk secara bermakna berpengaruh terhadap mace (p = 0.014, p = 0.026, p = 0.014). pada analisis multivariat, ditemukan β2-m secara bermakna berpengaruh terhadap kejadian mace (hr 2.16; ik 95% 1.15-4.05, p = 0.017). kesimpulan: dalam penelitian ini ditemukan bahwa β2-m memiliki pengaruh bermakna terhadap mace, sedangkan fgf23 tidak demikian. temuan ini mendukung teori adanya peran inflamasi/peradangan dalam luaran kardiovaskular pada pasien ska dengan pgk melalui efek akut pada kondisi kronik (acute on chronic effect). kata kunci: beta2-microglobulin, fibroblast growth factor 23, sindrom koroner akut, major adverse cardiac event. abstract background: chronic kidney disease (ckd) increases the severity and risk of mortality in acute coronary syndrome (acs) patients. the role of β2-m as a filtration and inflammation marker and fgf23 as a ckd-mbd eka ginanjar acta med indones-indones j intern med 6 process marker might be significant in the pathophysiology in acs with ckd patients. this study aims to determine the association of β2-m and fgf23 with major adverse cardiac event (mace) in acs patients with ckd. methods: we used cross sectional and retrospective cohort analysis for mace. we collected acs patients with ckd consecutively from january until october 2018 at dr. cipto mangunkusumo general hospital. data were analyzed using logistic regression and cox’s proportional hazard regression. results: a total of 117 patients were selected according to the study criteria. in bivariate analysis, β2-m, fgf23, and stage of ckd had significant association with mace (p = 0.014, p = 0.026, p = 0.014, respectively). in multivariate analysis, β2-m but not fgf 23was significantly associated with mace (adjusted hr 2.16; ci95% 1.15–4.05; p = 0.017). conclusion: β2-m was significantly associated with mace, while fgf23 was not so. this finding supports the role of inflammation in cardiovascular outcomes in acs with ckd patient through acute on chronic effect. keywords: beta2-microglobulin, fibroblast growth factor 23, acute coronary syndrome, major adverse cardiac event. introduction cardiovascular disease is one of the main causes of death globally, and coronary artery disease (cad) contributes to more than half of cardiovascular disease.1 cad manifests widely from asymptomatic to acute coronary syndrome (acs). based on previous studies, chronic kidney disease (ckd) increases the risk of severity and mortality in acs patients. bae eh et al.2 reported 18% mortality in acute myocardium infarct patients with glomerulus filtration rate (gfr) <15 ml/min/1.73 m2 compared to 1,2% in patients with gfr >90 ml/min/1.73 m2. ckd patients also have a high prevalence of congestive heart failure (chf) which might be related to the progression of the remodeling process, left ventricle hypertrophy (lvh), and systolic and diastolic dysfunction.3 several studies reported that chronic inflammatory process, through the increased c h e m o t a x i s a n d i n f l a m m a t o r y m e d i a t o r activities, resulted in endothelial injury and accelerated the atherosclerosis process.4 beta2microglobulin (β2-m) is a component of major histocompatibility complex (mhc) class i, a polypeptide which potentially acts as a local and systemic inflammatory marker.5 the increased level of β2-m resulted in chronic inflammatory process and endothelial injury.6 elevated levels of β2-m as high as 1.58 mg/l increase the risk of cardiovascular disease by 1.5 times and mortality by 1.8 times.7 liabeuf, et al.8 reported β2-m increases as the stage of ckd progresses, especially at stage 4. a b n o r m a l m e t a b o l i s m o f m i n e r a l s , hyperparathyroidism, and vitamin d deficiency in ckd patients, also known as chronic kidney disease – mineral bone disorders (ckd-mbd), was reported to be related to worse outcome in acs patients with ckd. in ckd patients, fgf23 is thought to affect the metabolism of minerals (vitamin d, parathyroid hormone, calcium, and phosphate), especially in patients with ckd-mbd. fgf23 level increases as ckd progresses.6 elevated levels of fgf23 might increase the risk of coronary severity through left ventricular hypertrophy (lvh), blood vessel calcification, and klotho status deficiency.7 elevated fgf23 levels were also associated with major adverse cardiac event (mace).9 common outcomes of acs, widely known as mace, consists of cardiovascular complications such as myocardial reinfarction, cerebrovascular disease and stroke, pericarditis, cardiogenic shock, heart failure, arrhythmia, sudden cardiac death, urgent coronary artery bypass graft (cabg), and repeated percutaneous coronary intervention (pci) in one inpatient admission.10 the role of β2-m as a filtration and inflammation marker and fgf23 as a ckdmbd process marker might be significant in the pathophysiology in acs with ckd patients, especially in relation to coronary severity and mace. patients with ckd have chronic inflammation and may develop ckd-mbd. these two processes, along with other causes, may cause atherosclerosis. atherosclerosis eventually leads to coronary heart disease and causes remodeling and left ventricular hypertrophy. this sequence then leads to heart failure that can vol 53 • number 1 • january 2021 the association between b2-microglobulin and fibroblast growth factor 23 7 result in major adverse cardiac events. in ckd patients, structures identical to bone tissue are occasionally found in atherosclerotic lesions. the active process of transformation of smooth muscle cells into osteoblast-like cells then results in vascular calcification.11 through the ckd-mbd pathway, remodeling and lvh can occur directly without going through the classic process of atherosclerosis. as a result, heart failure is more common, especially in advanced ckd.7 the aim of this study is to determine the association of beta2-microglobulin (β2-m) and fibroblast growth factor 23 (fgf23) to major adverse cardiac event (mace) in acute coronary syndrome (acs) patients with chronic kidney disease (ckd). methods study subjects and sample size study subjects are acs patients with ckd who were admitted to dr. cipto mangunkusumo general hospital jakarta and underwent angiography between january and october 2018. we excluded patients with incomplete medical records and patients with severe comorbidities, such as acute stroke, hepatic cirrhosis, chronic inflammation disease, sepsis, autoimmune disease, and cancer. we also excluded patients lost to follow up. study design and procedure this was an observational study with cross sectional and retrospective cohort design for mace. data for this study were collected using consecutive sampling methods from january to october 2018. data were acquired from the intensive cardiac care unit (iccu) and internal medicine ward at dr. cipto mangunkusumo general hospital, jakarta. the protocol of this study had been approved by the ethics committee faculty of medicine university of indonesia with ethical approval no. 0128/un2.f1/etik/2018 was issued on 12th february 2018. case definitions were based on clinical diagnosis. acute coronary syndrome, which includes st-elevation myocardial infarction (stemi), non st-elevation myocardial infarction (nstemi), and unstable angina pectoris (uap), were diagnosed based on clinical symptoms, electrocardiogram, echocardiography, and elevated cardiac enzymes. chronic kidney disease was diagnosed based on clinical symptoms, elevated urea and creatinine serum, estimated gfr (egfr) calculation, and evidence of kidney damage (presence of albuminuria and structural abnormalities in ultrasonography). β2-m and fgf23 were obtained from blood samples and measured using the enzyme-linked immunosorbent assay (elisa) method. cut-off points for β2-m and fgf23 were determined using receiver operating characteristic (roc) analysis. mace was followed up to 30 days after admission by reviewing medical records and communicating directly with patients. data analysis data normality testing was done using the kolmogorov-smirnov test. we initially did bivariate analysis using χ2 test. p value < 0.05 was considered significant. significant variables were included in multivariate analysis using cox’s proportional hazard regression for mace, adjusted for diabetes mellitus. results from all patients diagnosed as acs with ckd who underwent angiography in dr. cipto mangunkusumo general hospital from january to october 2018, a total of 117 patients, consisting of 91 males (77.8%) and 26 females (22.2%), were included in this study based on the criteria. the mean age in this study is 57.79 (sd 10.018) years old. mace was observed in 39.3% of patients, with the most frequent events being congestive heart failure, mortality, and reinfarction. total mortality in this study was 14.5%, however, based on ckd stages, mortality among patients with ckd stage 1–2, 3a–3b, and 4–5 was 7.35%, 17.85% and 33.3%, respectively. the most common risk factors from patient history were hypertension (65%), smoking history (62.4%), and diabetes mellitus (39.3%). based on clinical diagnosis of acs, 62.3% are stemi, 18% are nstemi, and 19.7% are uap. based on egfr, 81.2% patients had renal dysfunction and were predominantly in ckd stage 2. the mean of egfr was 62.52 ml/ minute/1.73 m2. (table 1) eka ginanjar acta med indones-indones j intern med 8 determined at 210.125 mg/l (auc 0.564, sensitivity 70.21% and specificity 52.86%), also using roc to mace. β2-m level was elevated in 56.4% patients with median 2.78 mg/l. fgf23 level was elevated in 51.3% patients with median 214.95 pg/ml. bivariate analysis results (table 2) showed that β2-m, fgf23, and stage of ckd were significant for mace. in multivariate analysis for mace using cox’s proportional hazard regression (table 3), β2-m was found to be associated with mace (hr 2.082 (1.113 – 3.895), p = 0.022). meanwhile, fgf23 was not associated with mace (hr 1.749 (0.964 – 3.173), p = 0.066). further subgroup post hoc analysis showed significantly different β2-m levels based on ckd stages. figure 1 shows the β2-m elevation curve and median differences based on ckd table 1. characteristic of study population. variables n=117 gender, male n (%) 91 (77.8) age (years), mean (sd) 57.8 (10) risk factors, n (%) diabetes mellitus 46 (39.3) dyslipidemia 35 (29.9) hypertension 76 (65) obesity 15 (12.8) chronic kidney disease (anamnesis) 8 (6.8) smoking 73 (62.4) acs diagnosis, n (%) stemi 73 (62.3) nstemi 21 (18) uap 23 (19.7) ckd stage, n (%) 1 22 (18.8) 2 46 (39.4) 3a 16 (13.7) 3b 12 (10.2) 4 12 (10.2) 5 9 (7.7) kidney function egfr, ml/min/1,73 m2, mean (sd) 62.5 (30.5) urea, mg/dl median (interquartile range) 34 (25.2–51.6) creatinine, mg/dl, median (interquartile range) 1.19 (0.98–1.76) mace, n (%) 46 (39.3) mortality 17 (14.5) stroke 6 (5.1) cardiogenic shock 6 (5.1) heart failure 33 (28.3) arrhythmia 9 (7.7) myocardial reinfarction 17 (14.5) mace was followed up to 30 days after hospital admission and was recorded in 39.3% of patients. the most frequent events are congestive heart failure, mortality, and reinfarction. seventeen patients died during the follow up period and the main causes of death were stroke, myocardial reinfarction, cardiogenic shock, and arrhythmia. cut-off point for β2-m was determined at 2.66 mg/l (area under the curve/ auc 0.665, sensitivity 63.83%, specificity 57.14%) using receiving operating curve (roc) to mace analysis. cut-off point for fgf23 was table 2. bivariate analysis for mace. variables mace or (ci 95%) p value main independent variables β2-m 2.643 (1.209–5.775) 0.014 fgf23 2.353 (1.1–5.033) 0.026 clinical variables grace score 0.057 acs type 1.920 (0.895–4.120) 0.092 ckd stage 0.014 echocardiocraphy variables lv systolic function 0.504 (0.234–1.086) 0.078 lvh 0.673 (0.313–1.444) 0.308 lvh type 0.509 lv dilatation 2.211 (0.887–5.514) 0.085 lv diastolic function 0.095 la dilatation 3.045 (1.077–8.607) 0.096 rv systolic function 0.519 (0.229–1.176) 0.095 table 3. multivariate analysis, cox’s proportional hazard regression of β2-m and fgf23 to mace. variables hr (ci 95%) p value hr changes β2-m crude hr 2.08 (1.11 – 3.89) 0.022 adjusted hr + diabetes mellitus 2.16 (1.15 – 4.05) 0.017 3.56% fgf23 crude hr 1.75 (0.96 – 3.17) 0.066 vol 53 • number 1 • january 2021 the association between b2-microglobulin and fibroblast growth factor 23 9 stages. it should be noted that there was a spike in elevation after ckd stage 4. there was no significant difference in fgf23 levels in all ckd stages. independent t test was used to further evaluate the difference between β2-m and fgf23 levels based on mace. there was a significant difference in β2-m level based on mace occurrence (mean difference 1.597 mg/l, p = 0.006), whereas there was no significant difference in fgf23 level. hazard function analysis for mace in 30 days using a kaplan-meier curve (figure 2) showed a hazard difference between normal and elevated β2-m groups (logrank p = 0.019). however, in normal and elevated fgf23 groups, there were intersecting events during the first 5 days between the two groups, and after 5 days there were no events in the normal fgf23 group (log rank p = 0.069). discussion to the best of our knowledge, this is the first study investigating the role of β2-m and fgf23 in acs patients with ckd. the patients figure 1. median difference of beta-2 microglobulin level based on ckd stages. figure 2. hazard function showing hazard ratio difference between high and normal level β2-m (a) and fgf23 (b) in acs patients with ckd. eka ginanjar acta med indones-indones j intern med 10 in this study were in mild to severe conditions. this might be due to the status of dr. cipto mangunkusumo general hospital as a national tertiary hospital which generally accepts referral patients in more severe condition from secondary hospitals. total mortality in this study was 14.5%, with increasing percentage in higher ckd stage. this finding is in accordance with another study that reported the mortality in acs patients with gfr <15 ml/min/1.73m2 (18.3%) were higher than patients with normal gfr (1.2%).6 a s p r e v i o u s l y m e n t i o n e d , β 2 m , a cell membrane stabilizer, was a potential inflammatory mediator in local and systemic condition.5 β2-m, cystatin c and glucose level contribute to the process of atherosclerosis formation.6 glucose level affects the formation of advance glycation end products (ages).12 ages could modify β2-m and affect the mechanism of endothelial injury. the modified β2-m causes an increase in chemotaxis activity, tumor necrosis factor-α (tnf-α), interleukin-1β (il-1β) and interleukin-6 (il-6), which leads to chronic inflammation process and endothelial injury. further mechanisms include macrophage and lymphocyte recruitment, which accelerate the atherosclerosis plaque formation and blood vessel rigidity. the findings in this study might be caused by the characteristics of the patients, who predominantly experienced stemi. stemi is often related to the mechanism of thrombus disruption and thromboembolism, rather than endothelial rigidity. the thrombus disruption and thromboembolism mechanism results in predominantly single vessel disease. stemi is usually caused by obstruction in main vessels and the risk of plaque disruption depends on the composition, the activity of the connective tissue in the plaque, and plaque size. over half of infarct conditions are related to thrombus, which causes stenosis, vasoconstriction, inflammation, thrombosis, and embolization. the extent of myocardial necrosis is also related to the location and duration of obstruction, myocardial area and the presence of collateral vessels.13 meanwhile, fgf23 was mainly related to remodeling processes which affect the development of left ventricle hypertrophy and lead to congestive heart failure. several studies reported that fgf23 could induce cardiomyocyte hypertrophy through the plc (phospholipase c)γ-calcineurin-nfat (nuclear factor of activated t cell) signaling pathway. fgf23 is thought to activate klotho-independent fgf receptor-4 (fgfr-4), a specific receptor in cardiomyocyte, and subsequently induce a remodeling process, resulting in lvh.3,9,14 according to deo r.et al., lvh might cause dysfunction in diastolic function and atrial fibrillation.15 cut-off points for β2-m were described in several studies. in this study, the best cut-off point available was determined to be 2.66 mg/l with sensitivity 70.21% and specificity 52.86%. to get a more reliable cut-off point, a larger sample size would be required. several studies have attempted to determine the cut-off point for fgf23, but proper and reliable cut-off point is yet to be determined. this might be caused by the wide range of possible fgf23 levels. for this study, the cut-off point for fgf23 was determined to be 210.125 mg/l with sensitivity 63.83% and specificity 57.14%. our study found that β2-m was associated with mace. hazard function with kaplanmeier curve showed significant difference of mace occurrence in normal and elevated β2-m groups and posthoc subgroup analysis also found a significant difference in β2-m level based on ckd stages. a study by jin et al. found that monocytes incubated with β2-m exhibit a decrease in antigen presenting capacity and decreased t cell type i response. however, the growth and activity of those monocytes were stimulated by the increase in il-6 and il-10. thus, β2-m might affect the humoral immune system and promote inflammatory response.16 a study by liabeuf et al.8 also found a significant difference in β2-m level based on ckd stages in ckd-only patients. however, when compared, the results in this study form a steeper curve, with a notable spike of β2-m after ckd stage 4. these findings support the role of β2-m to promote greater inflammatory response in an acute state in acs patients, especially if it occurs in an existing chronic inflammation state such as in ckd patients. meanwhile, fgf23 was not found to be associated with mace. hazard function curve vol 53 • number 1 • january 2021 the association between b2-microglobulin and fibroblast growth factor 23 11 and subgroup analysis yield similar results. this might be due to the study design that observed patients in acute state when acs occurred, meaning any fgf23 elevation before acs occurred was not observed. furthermore, observation and follow up duration in other studies were longer. fgf23 might only reflect chronic conditions, which would increase over time as ckd progresses,3 while patients observed in this study were in an acute state. this difference could affect the measurements and yield different results from previous studies. previous studies found a significant effect of fgf23 on cardiovascular risks in patients without acute condition over a longer observation duration.3,12,17 gutierrez et al.23 and another cohort study with 2 year observation also reported that increased fgf23 level is associated with mortality. this study met the minimum sample requirement according to initial calculation. however, some variables showed abnormal distribution, especially fgf23. the wide range of fgf23 level and lack of further dilution might affect the results of this study. based on the results of our study, we formulated a theory of mechanism of acute inflammation in acs patients with ckd. figure 3 illustrates how ckd patients undergo chronic inflammation and ckd-mbd, indicated by the increased of β2-m and fgf23 level. these processes, along with other classical mechanisms such as diabetes, lead to atherosclerosis, which results in coronary heart disease. subsequently, coronary heart disease might trigger cardiac remodeling and left ventricle hypertrophy, which in the end will increases the risk of mace. figure 3. mechanism of inflammation in acute coronary syndrome patient with chronic kidney disease on mace. (1) in the event of acs, acute rupture of atheromal plaque causes acs, (2) which raisesβ2-m level in systemic circulation, which increases in accordance to the severity of ckd. (3) high level of β2-m triggers systemic acute inflammatory process (4) through rising of tnf-a, il-1b, il-6 and chemotaxis. acute condition of acs may trigger acute heart failure which can cause mace. (5) this acute inflammation causes raised mace prevalence in acs patient with ckd. abbreviations: acs, acute coronary syndrome; ckd, chronic kidney disease; il, interleukin; mace, major adverse cardiac event; tnf, tumor necrosis factor. eka ginanjar acta med indones-indones j intern med 12 conclusion in this study we found that β2-m was significantly associated with mace 30 days after hospital admission, while fgf23 was not. these findings support the role of inflammation in cardiovascular outcomes in acs with ckd patients through acute on chronic effect. β2-m and fgf23 might be associated with myocardial remodeling processes, which subsequently cause left ventricle hypertrophy and congestive heart failure. acknowledgments this study was sponsored by universitas indonesia through the pitta ui (hibah publikasi internasional terindeks untuk tugas akhir mahasiswa univeristas indonesia) 2018 and tadok ui (hibah tugas akhir mahasiswa doktor universitas indonesia) 2018 programs. references 1. muhadi, antono d, alwi i. karakteristik sindrom koroner akut dengan edema paru kardiogenik di iccu rs cipto mangunkusumo dan faktor-faktor yang berhubungan. tesis. jakarta: universitas indonesia; 2009. 2. bae eh, lim sy, cho kh, et al. gfr and cardiovascular outcomes after acute myocardial infarction: results from the korea acute myocardial infarction registry. am j kidney dis. 2012;59(6):795–802. 3. jimbo r, shimosawa t. cardiovascular risk factors and chronic kidney disease—fgf23: a key molecule in the cardiovascular disease. int j hypertens. 2014;2014;1-9. 4. amighi j, hoke m, mlekusch w, et al. beta2 microglobulin and the risk for cardiovascular events in patients with asymptomatic carotid atherosclerosis. stroke. 2011;42(7):1826–33. 5. joosten mm, pai jk, bertoia ml, et al. β2‐ microglobulin, cystatin c, and creatinine and risk of symptomatic peripheral artery disease. j am heart assoc. 2014;3(4):e000803. 6. rashid g, korzets z, bernheim j. advanced glycation end products stimulate tumor necrosis factor-alpha and interleukin-1 beta secretion by peritoneal macrophages in patients on continuous ambulatory peritoneal dialysis. isr med assoc j. 2006;8(1):36-9. 7. kawai k, kawashima s, miyazaki t, et al. serum beta2-microglobulin concentration as a novel marker to distinguish levels of risk in acute heart failure patients. j cardiol. 2010;55(1):99–107. 8. liabeuf s, lenglet a, desjardins l, et al. plasma beta-2 microglobulin is associated with cardiovascular disease in uremic patients. kidney int. 2012;82(12):1297–303. 9. lima f, el-husseini a, monier-faugere m-c, et al. fgf-23 serum levels and bone histomorphometric results in adult patients with chronic kidney disease on dialysis. clin nephrol. 2014;82(5):287-95. 10. arnlov j, carlsson ac, sundström j, et al. serum fgf23 and risk of cardiovascular events in relation to mineral metabolism and cardiovascular pathology. clin j am soc nephrol. 2013;8(5):781–6. 11. head sj, farooq v, serruys pw, kappetein ap. the syntax score and its clinical implications. heart. 2014;100(2):169–77. 12. gensini gg. a more meaningful scoring system for determining the severity of coronary heart disease. am j cardiol [internet]. 1983 feb;51(3):606. available from: https://doi.org/10.1016/s0002-9149(83)80105-2 13. stenvinkel p, carrero jj, axelsson j, et al. emerging biomarkers for evaluating cardiovascular risk in the chronic kidney disease patient: how do new pieces fit into the uremic puzzle? clin j am soc nephrol. 2008;3(2):505–21. 14. mosbah o, hruska ka, williams mj, sugatani t. chronic kidney disease–mineral and bone disorders. chronic ren dis. 2020;2(2):551–69. 15. chen zw, chen yh, qian jy, ma jy, ge jb. validation of a novel clinical prediction score for severe coronary artery diseases before elective coronary angiography. plos one. 2014;9(4):e94493. 16. mandelzweig l, battler a, boyko v, et al. the second euro heart survey on acute coronary syndromes: characteristics, treatment, and outcome of patients with acs in europe and the mediterranean basin in 2004. eur heart j. 2006;27(19):2285–93. 17. zoccali c, yilmaz mi, mallamaci f. fgf23: amature renal and cardiovascular risk factor? blood purif. 2013;36(1):52–7. 18. alwi i. infark miokard akut dengan elevasi. in: buku ajar ilmu penyakit dalam edisi 6. jakarta: interna publishing; 2014:1457-9. 19. nitta k. fibroblast growth factor 23 and cardiovascular disease in patients with chronic kidney disease. ren replace ther. 2018;4(1):1–8. 20. rosenberg, ma, manning wj. diastolic dysfunction and risk of atrial fibrillation. circulation [internet]. 2012 nov 6;126(19):2353–62. available from: https:// doi.org/10.1161/circulationaha.112.113233 21. xie j, wang y, freeman iii me, barlogie b, yi q. β2microglobulin as a negative regulator of the immune system: high concentrations of the protein inhibit in vitro generation of functional dendritic cells. blood, j am soc hematol. 2003;101(10):4005–12. 22. qin z, liu x, song m, et al. fibroblast growth factor 23 as a predictor of cardiovascular and all-cause mortality in prospective studies. atherosclerosis. 2017;261:1–11. 23. gutierrez om, mannstadt m, isakova t, et al. fibroblast growth factor 23 and mortality among patients undergoing hemodialysis. n engl j med. 2008;359(6):584–92. clinical practice 263acta medica indonesiana the indonesian journal of internal medicine national consensus on the management of gastroesophageal reflux disease in indonesia the indonesian society of gastroenterology department of internal medicine, faculty of medicine, universitas indonesia cipto mangunkusumo hospital, jakarta, indonesia. correspondence mail: department of internal medicine, faculty of medicine, universitas indonesia cipto mangunkusumo hospital. jl. diponegoro 71, jakarta 10430, indonesia. email: pbpgi.jakarta@gmail.com. abstrak penyakit refluks gastroesofageal atau gastroesophageal reflux disease (gerd) merupakan suatu gangguan dimana isi lambung mengalami refluks secara berulang ke dalam esofagus, yang menyebabkan terjadinya gejala dan/atau komplikasi yang mengganggu. berbagai penelitian epidemiologi menunjukkan adanya perbedaan secara regional dari segi prevalensi dan manifestasi klinik. data regional juga menunjukkan peningkatan angka kejadian komplikasi seperti barret’s esophagus dan adenokarsinoma. menanggapi situasi tersebut, pada tahun 2004, para ahli gerd di asia pasifik termasuk indonesia telah mengeluarkan suatu konsensus bersama untuk tatalaksana kelainan ini, kemudian direvisi pada tahun 2008. kemajuan teknologi kedokteran, khususnya teknik endoskopi gastrointestinal dan perangkat diagnostik lainnya seperti ph-metri 24 jam dan manometri, telah meningkatkan kemampuan penatalaksanaan gerd. di sisi lain, pengetahuan dan kemampuan para dokter, baik dokter umum maupun spesialis penyakit dalam di negara kita dalam penatalaksanaan gerd yang adekuat, dirasakan belum merata. begitu pula penyediaan sarana penunjang diagnostik dan terapeutik yang tidak sama antara satu daerah dengan yang lainnya. pengurus besar perkumpulan gastroenterologi indonesia (pb pgi) memandang perlu untuk merevisi konsensus nasional penatalaksanaan gerd di indonesia tahun 2004, yang diharapkan akan menjadi suatu pedoman penatalaksanaan gerd. kata kunci: barret’s esophagus, diagnosis, endoskopi, gerd, manometri, ph-metri. abstract gastroesophageal reflux disease (gerd) is a disorder, which gastric content repeatedly reflux into the esophagus causing disturbing symptoms and/or complications. various epidemiological studies show that there is regional difference on the aspect of prevalence and clinical manifestation. regional data also demonstrates increased incidence of complications such as the barret’s esophagus and adenocarcinoma. in response to the situation, the asia-pacific gerd experts, including indonesia, had published a consensus on the management of gerd in 2004, which was subsequently revised in 2008. advances in medical technology, especially on gastrointestinal endoscopy technique and other diagnostic instruments such as 24-hour ph-metry and manometry, have improved the capacity of management of gerd. on the other hand, we feel that adequate knowledge and skills of doctors, both for general physicians and specialists of internal medicine in our country are not well-distributed. moreover, the availability of instruments for diagnostic and therapeutical supports differs from one region to the others. the organizing committee of indonesian society of gastroenterology or pengurus besar perkumpulan gastroenterologi indonesia (pb pgi) considers that it is important to revise the national consensus on the management of gerd in indonesia 2004, which is expected to be the guideline of gerd management. key words: barret’s esophagus, diagnosis, endoscopy, gerd, manometry, ph-metry. the indonesian society of gastroenterology acta med indones-indones j intern med 264 introduction in recent years, attention of the experts on gastroesophageal reflux disease (gerd) is increasing, either on the aspect of endeavors evaluating the pathogenesis, establishing diagnosis or on the aspect of management. various epidemiological studies show that there is regional difference on the aspect of prevalence and clinical manifestation. in addition, regional data also demonstrates increased incidence of complications such as the barret’s esophagus and adenocarcinoma. in response to the abovementioned situation, the asia-pacific gerd experts, including indonesia, had published a consensus on the management of gerd in 2004, which was subsequently revised in 2008. gastroesophageal reflux disease (gerd) is defined as a disorder, which gastric content repeatedly reflux into the esophagus causing disturbing symptoms and/or complications. the statement was proposed by the asia-pacific consensus on the management of gerd in 2008 that stressing the word of “disturbing”, as it characterized the disturbance on quality of life and as an extraction of general opinion, which says that if esophageal reflux should be stated as a disease, it must affect the patients’ quality of life.1 gerd may also be regarded as a disorder that causes the reflux of gastric fluid and its various contents into the esophagus, causing typical symptoms such as heartburn (a burning sensation in chest, which is sometime accompanied with painful and stinging sensation) and other symptoms such as regurgitation (sour and bitter taste in mouth), epigastric pain, dysphagia and odynophagia.2 there are two groups of gerd patients, i.e. patients with erosive esophagitis, who are characterized by damages on esophageal mucosa as shown by endoscopic examination (the erosive esophagitis/erd) and another group is patients with disturbing reflux symptom, but the endoscopic examination shows no damage on esophageal mucosa (non-erosive reflux disease/nerd).1 advances in medical technology, especially on gastrointestinal endoscopy technique and other diagnostic instruments such as 24-hour ph-metry and manometry, have improved the capacity of management of gerd. on the other hand, we feel that adequate knowledge and skills of doctors, both for general physicians and specialists of internal medicine in our country are not well-distributed. moreover, the availability of instruments for diagnostic and therapeutical supports differs from one region to the others. the organizing committee of indonesian society of gastroenterology or pengurus besar perkumpulan gastroenterologi indonesia (pb pgi) considers that it is important to revise the national consensus on the management of gerd in indonesia 2004, which is expected to be the guideline of gerd management. during the process of compiling the consensus, the committee refers to various similar consensus issued by various centers worldwide, which are generally based on the evidence-based medicine. epidemiology gerd prevalence and complications in asian countries, including indonesia, is generally lower than the western countries; however, recent data shows that the prevalence is increasing. it is caused by changes of lifestyle that may increase the risk of gerd, such as smoking and obesity.1 epidemiological data in usa demonstrates that one of five aduls has esophageal reflux symptom (heartburn) and/or acid regurgitation once in a week and more than 40% of them have the symptoms at least once in a month.3 the prevalence of esophagitis in western countries shows a mean value ranges between 10-20%; while in asia, the prevalence ranges between 3-5% with an exception in japan and taiwan with a range between 13-15% and 15%. a recent study on the prevalence in japan reveals a mean value of 11.5% and gerd is defined as the sensation of burning in the chest of at least twice a week.4,5 until now, indonesia has no complete epidemiological data on this condition. the available data is a report from a study conducted by lelosutan sar et al in faculty of medicine, university of indonesia, cipto mangunkusumo hospital, jakarta (fkui/rscm-jakarta), which demonstrates that of 127 study subjects who underwent upper gastrointestinal endoscopy, 22.8% (30 subjects of them) had esophagitis.6 another study conducted by syam af et al.7, vol 46 • number 3 • july 2014 national consensus on management of gerd in indonesia 265 which is also from rscm/fkui-jakarta, shows that of 1718 patients who underwent upper gastrointestinal endoscopy on indication of dyspepsia for 5 years (1997-2002), there is an increased prevalence of esophagitis, from 5.7% in 1997 to 25.18% in 2002 (mean value of 13.13% per year).7 some risk factors for gerd have been evaluated in asia-pacific population, including elderly age, male, race, family history, high level of economic status, incrased body mass index and smoking. the strongest evidence is provided for association of certain risk factors wih the development of gerd in asia-pacific population, i.e. the increased body mass index and more than 25 clinical studies have supported the correlation.8 diagnosis careful history taking is the main method to establish gerd diagnosis. specific symptom of gerd is heartburn and/or regurgitation that occur after meal. however, it should be emphasized that most of diagnostic studies of heartburn and regurgitation symptoms are performed in caucasian population. in asia, the symptoms of heartburn and regurgitation are not the typical features for gerd. however, the experts have agreed that both symptoms are characteristics for gerd.1 in a tertiary referral hospital, before performing endoscopic examination to establish the diagnosis of gerd, other further investigation (laboratory, ecg, usg, chest x-ray and other investigation in accordance with the indication) should be also carried out to exclude diseases with symptoms similar to the gerd. the asia-pacific experts have stated by acclamation that the regional strategy of diagnostic gerd must consider the possibility of gerd exists with other comorbidities such as gastric cancer and peptic ulcer. however, regarding the h. pylori test to exclude infection in patients with gerd symptoms in regions with high prevalence of gastric cancer and peptic ulcer, there is a controversial opinion of the experts. nevertheless, the test is still recommended by considering risk factors including comorbidities, age, histological profile of the stomach, family history and patient’s preference.1 gerd-q gerd questionnaire (gerd-q) (table 1) an instrument of questionnaire developed to assist establishing the diagnosis of gerd and measuring response to therapy. the questionnaire is developed based on clinical data and information obtained from high-quality clinical table 1. gerd-q try to recall what you have experienced in the last 7 days.√ put a check mark (√) only at one single space for each question and count your total gerd-q score by doing summation of the point(s) for each question. no. question frequency of score (point) for symptoms 0 day 1 day 2-3 days 4-7 days 1. how often do you experience the sensation of burning behind your breastbone / sternum (heartburn)? 0 1 2 3 2. how often do you experience the gastric content backing up into your throat / mouth (regurgitation)? 0 1 2 3 3. how often do you feel epigastric pain? 3 2 1 0 4. how often do you feel nauseated? 3 2 1 0 5. how often do you have difficulty to have night sleep due to the burning sensation in the chest (heartburn) and/or the backing up of abdominal content? 0 1 2 3 6. how often do you take additional medication for treating the burning sensation in the chest (heartburn) and/or the backing up of abdominal content (regurgitation), other than prescribed by your doctor? (such as the over the counter drugs for treatment of stomach complaints) 0 1 2 3 result if your gerdq points <7, you probably do not have gerd. if your gerdq points is 8-18, you probably have gerd the indonesian society of gastroenterology acta med indones-indones j intern med 266 studies as well as from qualitative interviews with patients in order to evaluate the simplicity of filling up the questionnaire. gerd questionnaire is a combination of validated questionnaires used in the diamond study. improved accuracy of diagnosis by combining several validated questionnaire will increase the sensitivity and specificity of diagnosis.9,10 an analysis on more than 300 patients at a primary health care service demonstrates that gerd-q may provide sensitivity and specificity of 65% and 71%, which is similar to results obtained by gastroenterologists. moreover, gerd-q also shows the capacity to evaluate relative impacts of gerd on patients’ life and to provide assistance in selecting therapy.9 table 1 is the gerd-q that can be filled up by the patients themselves. for each question, respondent should fill up according to the frequency of symptoms that they have experienced in a week. score 8 or more is the recommended cut-off point to detect individuals with high tendency to have gerd.10 gerd-q has been validated in indonesia. upper gastrointestinal (ugi) endoscopy upper gastrointestinal endocopy (ugie) is considered the gold standard for establishing the diagnosis gerd with erosive esophagitis. using the ugie, we can find the mucosal break of esophagus. endoscopy in gerd patients is mainly used for individuals with alarm symptoms (progressive dysphagia, odynophagia, weight loss with unexplained etiology, new onset of anemia, hematemesis and/or melena, family history of gastric and/or esophageal malilgnancy, chronic use of nsaid medication, individuals with age over 40 years in a region with high prevalence of gastric cancer) and for those who do not response to empirical treatment using ppi twice daily.1,11,12 while until now, there is no gold standard for diagnosis of nerd. the following criteria is used as the guideline for establishing the diagnosis of nerd:1 • no mucosal break found in the upper gastrointestinal endoscopy, • positive results on esophageal ph test, • twice-daily empirical therapy with ppi gives positive response. endoscopy for g erd is not alw ays performed on the first visit since the diagnosis of gerd can be made based on symptoms and/or empirical therapy. the roles of upper gastrointestinal endoscopy in establishing the diagnosis of gerd are: • confirming the presence and absence of esophageal damages including erosion, ulceration, stricture, barret’s esophagus or malignancy, in addition to excluding other upper gastrointestinal abnormalilties. • evaluating the severity of mucosal break using modified los angeles classification or savarry-miller classification. • biopsy specimens are taken when there is a suspicion of barret’s esophagus or malignancy. histopathological examination histopathological examination as the diagnostic tool of gerd is essential to determine the presence of metaplasia, dysplasia or malignancy. no supporting evidence has been provided about whether biopsy specimen is needed in nerd cases. in the future, further studies on the role of high-resolution (magnifying scope) endocopy in nerd cases are necessary. 24-hour ph-metry test the roles of conventional 24-hour ph-metry test or 48-hour capsule (if available) in the diagnosis of nerd are:13,14 • evaluating gerd patients who do not respose to ppi therapy. • evaluating whether the patients are those with extra-esophageal symptoms before the ppi therapy or after failed ppi therapy. • confirming the diagnosis of gerd prior to anti-reflux surgery or evaluating symptoms of nerd repeatedly following the surgery. ppi test ppi test can be performed to establish the diagnosis in patients with typical symptoms and without alarm signs or risk for barret’s esophagus. the test is carried out by administering doubledose ppi for 1-2 weeks without the preceding endoscopy examination. if the symptoms subside with ppi administration and recur when the ppi treatment is stopped, then the diagnosis of gerd can be made. the test is considered as positive vol 46 • number 3 • july 2014 national consensus on management of gerd in indonesia 267 result, if there is clinical improvement of more than 50% in 1 week.1,11,15 a meta-analysis study demonstrates that ppi test has a sensitivity of 80% and specificity of 74% for establishing diagnosis of gerd patients with non-cardiac chest pain. it indicates that ppi test can be considered as a useful strategy and probably has economic value in management of patients with non-cardiac chest pain without alarm signs of suspected esophageal abnormalities.16 other diagnostic tests alternative tests that can be performed other than endoscopy and ph-metry are: • barium esophagography. although this test is not sensitive for gerd diagnosis, but in certain condition the test provides more advantages than endoscopy, i.e. in the case of esophageal stenosis and hiatal hernia. • esophageal manometry. the test has advantages, particulary for evaluating treatment of nerd patients and for the purpose of research. • impedance test. this new method can detect the presence of gastroesophageal reflux through altered resistance against electrical current between two electrodes when fluid and/or gas move between them. the test is mainly useful for evaluating nerd patient who does not response to ppi therapy; in which the documentation of non-acid reflux will change the management approach.14 • bilitec test. the test can detect the presence of gastroesophageal reflux by using the characteristics of optical bilirubin. the test is essential, particularly for evaluating patients with persistent symptoms of reflux despite the normal result of ph-metry when they have acid exposure on distal esophagus.14 • bernstein test. the test measures the sensitivity of esophageal mucosa by installing trans-nasal catheter and perfusion on distal esophagus with hcl 0.1 n in less than an hour. the test is a complementary to 24hour esophageal monitoring ph in patients who had atypical symptoms and for research purpose. surveilans barett’s esophagus the role of endoscopy surveillance in patients with barrett’s esophagus is still controversial even in the countries with high prevalence. in asia, the prevalence of barret’s esophagus is still low, which is reported about 0.08%. meanwhile in the united states, it is reported that the incidence of esophageal cancer in patients with barret’s esophagus is about 0.4%; while other studies reported that it ranges between 1-2%.1,17 up until now, the screening test for barret’s esophagus is still controversial due to less impact of the screening test on mortality of esophageal adenocarcinoma. surveillance endoscopy is suggested for individuals with high risks and it should be performed according to the grade of dysplasia found. for futher discussion, please refer to the associated references.17 management management means the action performed by doctors who treat gerd cases, including non-pharmacological therapy, pharmacological treatment, endoscopy and surgery. basically, there are 5 targets that should be achieved and must always be a concern when we plan, change and stop the therapy for gerd patients. the five targets are eradicating symptoms/complaints, recovering esophageal lesion, preventing recurrent illness, improving quality of life and preventing the development of complications. this guideline of management is expected to be applied in the primary, secondary and tertiary health care services.18-20 the clinical approach on the management of gerd includes treatment of gerd (nerd and erd), refractory gerd and non-acid gerd. in the first line, the diagnosis of gerd is made more based on clinical symptoms and symptombased gerd questionnaire. the management is provided based on clinical diagnosis (figure 1). non-pharmacological treatment the main concern is targeted on modifying overweight and elevating head around 15-20 cm during sleep as well as other additional factors such as smoking cessation, stop drinking, reducing food intake and medications that the indonesian society of gastroenterology acta med indones-indones j intern med 268 stimulate gastric acid and causing reflux, less satiating feeding and last evening meal at least 3 hours before bedtime.21 pharmacological treatment there are drugs that have been known to have capacity to overcome gerd symptoms, which include antacids, prokinetics, h2-receptor antagonists, proton pump inhibitor (ppi) and baclofen.22 the effectiveness of each drug class is shown in table 2. of all the abovementioned drugs, ppi is the most effective drug in eradicating symptoms and recovering esophagitis lesion in gerd.9 ppi has been proven providing more rapid recovery on esophagitis lesion as well as eradicating gerd symptoms compared to the h2 receptor antagonists and prokinetics. if ppi is not available, h2ra can be administered.24-26 in individuals with heartburn symptom or episodic regurgitation, the use of h2ra (h2receptor antagonist) and/or antacids can be helpful to provide rapid symptom eradication. moreover, in asia, the use of prokinetics (dopamine antagonists and serotonin receptor antagonist) may be beneficial as adjunctive therapy (figure 2).1 gerd treatment can be started with ppi after the diagnosis of gerd has been established (see diagnosis section). the initial dose of ppi is single dose each morning before meal for 2 – 4 weeks. if there gerd symptom is still found (ppi failure), ppi should be administered continuously in double dose until the symptoms has been eradicated. in general, double-dose therapy can be given up to 4-8 weeks (table 3). if there is no clinical improvement, endoscopy must be done to confirm the presence of any abnormality in upper gastrointestinal mucosa. further treatment can be given according to the severity of mucosal damage.29 for mild esophagitis, the treatment may be followed with ‘therapy on demand’ strategy. while for severe esophagitis, it can be followed with continuous maintenance therapy, which may be given up to 6 months.1,11,12 grade a and b are included in clinical category of mild esophagitis. grade c and d are the clinical category for severe esophagitis. suspect gerd gerd-q (-) not gerd (+) gerd alarm symptom negative positive ppi test refer negative positive gerd 8-week gerd therapy gerd negative gerd positive figure 1. algorithm of treatment based on diagnostic process in primary health care services table 2. effectiveness of drug treatment for gerd23 drug class improving symptoms recovering esophageal lesion preventing complication preventing recurrent illness antacids +1 0 0 0 prokinetics +2 +1 0 +1 h2-receptor antagonists +2 +2 +1 +1 h2-receptor antagonists and prokinetics +3 +3 +1 +1 high-dose h2-receptor antagonists +3 +3 +2 +2 ppi +4 +4 +3 +4 surgery +4 +4 +3 +4 vol 46 • number 3 • july 2014 national consensus on management of gerd in indonesia 269 for nerd, initial treatment can be provided by giving single dose ppi for 4-8 weeks. after the clinical symptoms diminish, therapy can be followed with ppi on demand. the ‘on demand’ treatment is suggested in order to maximize gastric acid suppression, which is administered in 30-60 minutes before breakfast.1,11 gerd, which is refractory to ppi therapy (no response to ppi therapy of twice daily for 8 weeks) must be confirmed by reevaluating the gerd diagnosis using endoscopy to confirm the presence of any esophagitis. if no esophagitis is found, the investigation is followed with phmetry test. based on the results of ph-metry, we can determine the dominant factor for reflux of gastric content, either by hyperacidity or pathological anatomy factors such as (seb disorder, hiatal hernia, etc). if the ph-metry demonstrates the domination of pathological anatomy factors and the clinical symptoms are still there, the diagnostic test using esophageal impedance and ph can be considered (figure 3) to confirm the next therapeutical measure (tertiary treatment measure).1,11 now, the treatment for non-acid reflux (nar) is still developing. studies on baclofen (a gaba-b agonist) has provided promising results; however, further data is needed to recommend the drug routinely. 30,31 the recommended treatment includes avoiding large and late meal, maintain head up position until 3 hours after the meal, reduced body weight and head-up tilt sleeping. however, no study has confirmed that such treatments are clinically significant. uninvestigated typical reflux symptom alarm symptoms present history gerq ppi test no alarm symptoms empirical therapy with ppi for 4 weeks and evaluation in 2-4 weeks h2ra if no ppi is available endoscopy radiology ph-metry persistent symptoms improved symptoms impedance esophageal manometry gastric scintigraphy try to stop ppi relapse frequent relapse or alarm symptoms therapy on demand start readministering ppi figure 2. algorithm of treatment based on diagnostic process in secondary and tertiary health care services.1 table 3. ppi dose for gerd treatment27,28 ppi types single dose double dose omeprazole 20 mg 20 mg twice daily pantoprazole 40 mg 40 mg twice daily lansoprazole 30 mg 30 mg twice daily esomeprazole 40 mg 40 mg twice daily rabeprazole 20 mg 20 mg twice daily table 4. gerd classification based on endoscopic results29 nerd erd grade a grade b grade c grade d mucosal break (-) no mucosal damage diameter <5 mm, single diameter <5 mm, several lesions, colonized diameter >5 mm, single, several lesions lesion encircling the lumen the indonesian society of gastroenterology acta med indones-indones j intern med 270 other lifestyle interventions such as smoking cessation and stop drinking alcohol as well as changing the pattern of food intake can significantly reduce the symptoms of gerd.21 modified life style is used as the first line therapy, such as reducing body weight, reducing smoking, stomach emptying of more than 3 hours before bedtime.1 a recent systematic study shows that of all lifestyle intervention, only weight reduction and head-up tilt sleeping that affect the gerd symptoms significantly. now, the consensus on the management of gerd, both the asia-pacific and american consensus, do not suggest excessive lifestyle changes in the management of such condition.1,19 it is suggested since altered lifestyle does not significantly reduce gerd symptoms and causes excessive stress to the patients. however, based on a meta-analysis conducted on those lifestyle factors, the asia-pacific consensus suggest to do modifications on overweight and head-up tilt sleeping.1 endoscopic treatment gerd complications such as barret’s esophagus, esophageal stricture, stenosis or bleeding can be treated with endoscopy using argon plasma coagulation, ligasi, endoscopic mucosal resection, bougination, hemostasis or dilatation. endoscopic treatment for gerd is still developing and until now it is still in the context of research. endoscopic treatments that have been developed are: • radiofrequency energy delivery • endoscopic suturing however, there is still no report available on endoscopic treatment for gerd until now in indonesia. surgical treatment surgical treatment includes antireflux surgery (nissen fundoplication, corrective surgery for hiatal hernia, etc) and surgery to fix complications. antireflux surgery (nissen fundoplication) can be suggested for patients who are intolerant to maintenance therapy or those who with persistent disturbing symptoms (refractory gerd). available studies show that if it is performed well, the effectiveness of the antireflux surgery is equal with medical treatment; however, it brings side effects such as dysphagia, bloating, difficulty in burping and intestinal 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