Faktor Prognosis Nilai Rasio Total Bilirubin, Alanin Transaminase, dan Gamma Glutamil Transferase terhadap Kesintasan Pasien Atresia Biliaris pascaoperasi Kasai

HAFNI ZUCHRA NOOR, Dr. dr. Akhmad Makhmudi, Sp.B., Sp.BA(K); dr. Gunadi, Ph.D., Sp.BA

2019 | Tesis-Spesialis | BEDAH ANAK

Latar Belakang: Atresia biliaris (AB) merupakan penyakit hepar yang serius dengan prognosis yang tidak pasti. Karakteristik AB sebagai suatu obstruksi inflamatori sklerosis kolangiopati duktus biliaris intrahepatal dan ekstrahepatal. Tindakan operasi hepatikoporto-jejunostomi roux-enY (Kasai) secara signifikan dapat meningkatkan taraf hidup bayi, tetapi prognosis pasien AB masih tidak pasti bahkan sebagian besar pasien masih membutuhkan transplantasi hepar. Terdapat penelitian kesintesan native liver tanpa transplantasi hepar signifikan lebih baik bila rasio TB7/TB0 <0,8. Penelitian lain meneliti GGT dan indeks trombosit sebagai faktor prognosis atresia Biliaris pascaKasai. Belum ada penelitian serupa yang dilakukan untuk mengetahui faktor prognostik nilai cut-off Total bilirubin (TB), Alanin Transaminase (ALT) dan Gamma Glutamil Transferase (GGT) terhadap kesintesan pascaoperasi Kasai pada pasien atresia biliaris di RSUP Dr. Sardjito. Tujuan: Menentukan nilai cut-off (TB7/TB0), Alanin Transaminase (ALT7/ALT0) dan nilai cut-off Gamma Glutamil Transferase (GGT7/GGT0) terhadap kesintasan pascaoperasi Kasai di RSUP Dr. Sardjito. Metode: Penelitian retrospektif observasional cross-sectional menggunakan data rekam medis di RSUP Dr. Sardjito, mulai dari Agustus 2012 s/d Desember 2018 dengan metode consecutive sampling. Data tersebut dianalisis menggunakan ROC (Receiver Operator Curve) untuk menentukan nilai cut-off TB7/TB0, ALT7/ALT0 dan nilai cut-off GGT7/GGT0, serta analisis Kaplan-Meier, log-rank, dan odds ratio perkiraan kesintasan dengan program Stata Corp Stata dan SPSS 17. Hasil: Nilai cut off TB7/TB0 pada pasien atresia biliaris pascaoperasi Kasai adalah ≥0,93 (sensitivitas 69,23%, spesifisitas 60,61%, area under curve 0,627, 95% CI 0,44-0,812, P=0,18) secara klinis menyebabkan 2,2 kali terhadap mortalitas dari analisa Kaplan-Meier dan 3,46 dari analisa odds ratio (P=0,103) . Nilai cut off ALT7/ALT0 adalah ≥0,95 (sensitivitas 53,85%, spesifisitas 54,55%, area under curve 0,5851, 95% CI 0,402-0,767, P=0,22) secara klinis menyebabkan 1,98 kali terhadap mortalitas dari analisa Kaplan-Meier dan 1,40 dari analisa odds ratio (P=0,746). Nilai cut off GGT7/GGT0 adalah ≥0,87 (sensitivitas 53,85%, spesifisitas 45,45%, area under curve 0,5012, 95% CI 0,32-0,681, P=0,84) secara klinis menyebabkan 1,11 kali terhadap mortalitas dari analisa Kaplan-Meier dan 0,97 dari analisa odds ratio (P=1,00) di RSUP Dr. Sardjito. Kesimpulan: Faktor prognosis nilai cut off rasio TB7/TB0 (≥0,93) dan ALT7/ALT0 (≥0,95), GGT7/GGT0 (≥0,87) terhadap mortalitas tidak signifikan secara statistik, tetapi bermakna secara klinis dari rasio TB7/TB0 dan ALT7/ALT0 terhadap mortalitas pasien AB pascaoperasi Kasai.

Background: Many prognostic factors have been reported for the outcomes of biliary atresia (BA) patients after Kasai procedure, however, it still shows a conflicting result. Our study determined the impact of total bilirubin post-operative day 7 and pre-operative ratio (TB7/TB0), gamma-glutamyl transferase post-operative day 7 and pre-operative ratio (GGT7/GGT0), and alanine transaminase post-operative day 7 and pre-operative ratio (ALT7/ALT0) on the survival of BA patients following Kasai surgery. Methods: We analyze d retrospectively the medical records of BA patients who underwent Kasai procedure at Dr. Sardjito Hospital, Indonesia from August 2012 to December 2018. The cut off values of TB7/TB0, GGT7/GGT0, and ALT7/ALT0 for prediction of patients’ survival were determined by receiver operating characteristics (ROC) curves. Log-rank tests and odd ratio were utilized for association between cut off values and overall survival. Results: The cut off value of TB7/TB0 in patients with postoperative biliary atresia Kasai was ≥0,93 (sensitivity 69,23%, specificity 60,61%, area under curve 0,627, 95% CI 0,44-0,812, P = 0,18) clinically caused 2,2 times the mortality from the Kaplan-Meier analysis and 3,46 from the odds ratio analysis (P = 0,103). The cut off value of ALT7/ALT0 is ≥0,95 (sensitivity 53,85%, specificity 54,55%, area under curve 0,5851, 95% CI 0,402-0,767, P = 0,22) clinically causing 1,98 times the mortality from the Kaplan-Meier analysis and 1,40 from the odds ratio analysis (P = 0,746). The cut off value of GGT7/GGT0 is ≥0,87 (sensitivity 53,85%, specificity 45,45%, area under curve 0,5012, 95% CI 0,32-0,681, P = 0,84) clinically causing 1,11 times the mortality from the Kaplan-Meier analysis and 0,97 from the odds ratio analysis (P = 1,00). Conclusion: The cut off ratio of TB7/TB0, ALT7/ALT0 of postoperative patients with Kasai biliary atresia is a prognostic factor for the long duration of clinical stay, but not with GGT. Although all three are not statistically significant. Further multicenter studies with a larger sample size are important to clarify our findings.

Kata Kunci : biliary atresia, prognostic factors, Kasai surgery, total bilirubin ,, Alanin Transaminase, Gamma Glutamyl Transferase