KESINTASAN 28 HARI PASIEN SEPSIS BERDASARKAN KADAR VITAMIN D PADA AWAL PERAWATAN DI RSUP DR SARDJITO

MARIA NAINGGOLAN H, dr. Rizka Humardewayanti Asdie, Sp.PD-KPTI; dr. Deshinta Putri Mulya, M.Sc., Sp.PD-KAI

2020 | Tesis-Spesialis | ILMU PENYAKIT DALAM

Latar Belakang: Sepsis, suatu disfungsi organ yang mengancam jiwa dan disebabkan respon tubuh terhadap infeksi. Respon imun tubuh terhadap sepsis ditandai dengan respon proinflamasi dan antiinflamasi. Vitamin D memiliki peran penting sebagai regulator sistem imun alami dan sistem imun didapat. Beberapa penelitian terbaru menunjukkan adanya hubungan yang erat antara kadar vitamin D yang rendah dengan morbiditas dan mortalitas pada pasien sepsis. Tujuan Penelitian: mengetahui kesintasan klinis (survival rate) dalam 28 hari pada pasien sepsis berdasarkan kadar vitamin D di awal perawatan di RSUP Dr. Sardjito. Metode Penelitian: Penelitian kohort prospektif di High Care Unit dan bangsal penyakit dalam di RSUP Dr. Sardjito pada Desember 2018 hingga Oktober 2019. Pemeriksaan Vitamin D pada pasien sepsis akan dilakukan dalam 24 jam setelah admisi. Luaran klinis yang dinilai adalah kematian dengan semua penyebab dalam 28 hari sejak terdiagnosis sepsis. Hasil Penelitian: Dari 88 subjek penelitian dalam 11 bulan terdapat 28 (31,8%) pasien dengan kadar vitamin D <8,1ng/ml dan 60 (68,2%) pasien menunjukkan kadar vitamin D >=8,1 ng/ml). Mortalitas pada pasien dengan kadar vitamin D <8,1 ng/ml lebih tinggi dibanding kelompok vitamin D >=8,1 ng/ml (92% versus 65%). Analisa multivariat cox regresi menunjukkan hasil kadar vitamin D <8,1 ng/ml pada admisi (p=0,01) dan syok septik (p=0,02) berhubungan dengan kematian pada sepsis. Kelompok pasien dengan Vitamin D <8,1 ng/ml memiliki risiko kematian dalam 28 hari yang lebih tinggi dengan Hazard ratio 1,95, CI 95% 1,15-3,29, p=0,01. Kurva kesintasan Kaplan Meier menunjukkan pasien dengan kadar vitamin D <8,1 ng/ml memiliki kesintasan yang lebih rendah/pendek dibandingkan dengan pasien kadar vitamin D >=8,1 ng/ml (p=0,00). Rata-rata lama hidup (mean survival) adalah 9 hari pada kelompok vitamin D <8,1 ng/ml (median survival 6 hari) dan 14 hari pada kelompok vitamin D >=8,1 ng/ml (median survival 10 hari). Kesimpulan: Penelitian ini menunjukkan tingginya angka kejadian defisiensi vitamin D pada pasien sepsis. Pasien sepsis dengan kadar vitamin D <8,1 ng/ml memiliki risiko kematian dalam 28 hari yang lebih tinggi. Kesintasan 28 hari pasien dengan kadar vitamin D <8,1 ng/ml lebih rendah dibandingkan dengan pasien dengan kadar vitamin D >=8,1 ng/ml.

Background: Sepsis is a potentially life-threatening condition caused by the body's response to an infection. The host immune response in sepsis is characterized by both pro-inflammatory responses and anti-inflammatory immunosuppressive responses. Vitamin D has immune modulatory effects on both innate and adaptive immune responses. Recent studies have shown an association between low vitamin D status and high mortality in sepsis patients. Objective: To evaluate vitamin D status of septic patient at Dr. Sardjito Hospital and to describe sepsis 28 days survival with very low vitamin D (<8.1 ng/ml). Methods: We conducted cohort prospective study in High Care Unit and internal medicine ward at Dr. Sardjito Hospital including patients admitted with sepsis between December 2018 and October 2019. Vitamin D [25OH(D)] was prospectively measured within 24 hours from admission of septic patient. Data collected included serum 25-hydroxyvitaminD levels, the underlying disease, comorbidity, basic hematological and biochemical blood test results, and culture positivity. The primary end point was defined as all-cause mortality within 28 days from admission of septic patients. Results: We studied 88 patients over 11 months. Vitamin D <8.1ng/ml was observed in 28 (31.8%) of the patient and vitamin D >=8.1 ng/ml was observed in 60 (68.2%) of the patient. As primary outcome, sepsis related mortality rate was higher in patients with vitamin D levels <8.1 ng/ml (92% versus 65%). Multivariate cox regression analysis showed that vitamin D concentration <8.1 ng/ml on admission (p=0.01) and septic shock (p=0.02) were related of sepsis mortality. The hazard ratio of 28-day mortality was HR 1.95, CI 95% 1.15-3.29, p=0.01 for vitamin D <8.1 ng/ml. Kaplan Meier survival curve indicated that survival of patient with vitamin D <8.1 ng/ml was significantly shorter than those whose vitamin D concentration >=8.1 ng/ml (p=0.00). The average survival time was 9 days for vitamin D levels <8.1 ng/ml group (median survival time 6 days) compared with 14 days among those with vitamin D levels >=8.1 ng/ml group (median survival time 10 days). Conclusion: This study demonstrated that low vitamin D levels are common among septic patients. Lower serum vitamin D levels (<8.1 ng/ml) at admission were associated with 28 day mortality in septic patients. We observed shorter survival time among low vitamin D levels (<8.1 ng/ml) patients.

Kata Kunci : Sepsis, Vitamin D, kesintasan 28 hari