MANFAAT PENAMBAHAN ASAM AMINO RANTAI CABANG DALAM PENGOBAAN ENSEFALOPATI HEPATIKUM

Abstract

The benefit of an addition of Branched Chain Amino Acid (BCAA) in the standard treatment of hepatic encephalopathy (HE) has so far been considered controversial. More randomized controlled trial (RCT) to compare the efficacy of BCAA in the treatment of HE is still needed to solve this problem. Material & Method The study design was randomized control trial (RCT), using permutted block randomisation to compare the result of standard treatment plus BCAA with standard treatment only in the management of HE in Hepatic Cirrhosis patients. Population of study were HE patient who fulfilled the inclusion and exclusion criteria were hospitalized at Dr. Kariadi and St. Elisabeth hospitals in Semarang during the period 1 July 2000 up to 31 July 2001. The treatment group patients were received standard therapy plus BCAA infusion 1000 cc for 5 days, then followed by 3 sachet peroral of BCAA/150 gram per day for 21 days. The control group patients were received standard therapy only for the same trial and period. The outcome of study were evaluated every day for the 5 days (day 1,2,3,4,5) and then continued with 7 days for 21 days (day 12, 19, 26). The evaluation were consist of survival, level of conscious improvement, flapping tremor symptom, clinical performance, Number Correction Test (NCT) and.chance in serum albumin consentration. Fischer exact Test, student t-test and survival analysis were used for statistical analysis and level of significant p<0.05 was considered. Result Sixteen patients consist of 8 patients for each study group, were the study criteria and followed the study protocol. Baseline data comparison between two groups were statistically compared regarding all clinical characteristics and Child Pugh score. In comparison of study results, the addition of BCAA infusion to standard therapy showed a significantly better results interms of the improvement of consciousness recovery (p=0.0094), recovery improvement of the flapping tremor symptom (p=0.0030), improvement of the performance status (p=0.0030); while the survival period (p0.1435) and completion improvement of NCT (p=0.0882) were not statistically significant In the followed up until 21 days, the addition of oral BCAA compared to standard diet showed a significantly better results interms of lengthen the survival period (p=0.0023), the improvement of consciousness recovery (p=0.0025), improvement of the flapping tremor symptom (p=0.0031), improvement of the performance status (p=0- .0031) and completion improvement of NCT (p=0.0186); while change in serum albumin consentration was not significant (p-0.054). Conclusion The additon of BCAA in the standard therapy of HE were statistically significant produced faster and better improvement of consciousness, performance status and flapping tremor recovery, compared to standard therapy alone. An addition of oral BCAA on follow up dietetic therapy to prevent refractory HE, also showed a better result than the standard oral therapy alone. Key words : Hepatic Encephalopathy — Branched Chain Amino Acid infusion — Branched Chain Amino Acid oral. Manfaat penatnbahan Asam Amino Rantai Cabang (AARC) dalam pengobatan standar Ensefalopati Hepatikum (EH) sampai saat ini masih kontroversial. Penelitian dengan uji acak terkontrol yang membandingkan efektivitaq AARC dalam pengobatan EH masih diperlukan untuk memecahkan persoalan ini. Bahan dan cara penelitian Penelitian klinik komparatif acak terkontrol dengan randomisasi blok ini membandingkan hasil penambahan AARC dalam pengobatan standar Ell dengan hanya terapi standar pada pasien sirosis hati. Populasi studi adalah pasien EH yang memerlukan rawat inap yang memenuhi kriteria inklusi dan ekslusi di RSUP Dr Kariadi dan RS St Elisabeth Semarang, periode 1 Juli 2000 s/d 31 Juli 2001. Pada kelompok terapi diberikan terapi standar Ell dengan penambahan infus AARC 1000 cc selama 5 hari dilanjutkan dengan AARC peroral 3 sachet I 150 gam per hari selama 21 hari. Pada kelompok kontrol hanya diberikan terapi standar sesuai program terapi Eli selama ini. Hasil penelitian dinilai setiap hari selama 5 hari (hari ke-1,2,3,4,5) dan dilanjutkan tiap 7 hari selama 21 hari (hari ke-12, 19, 26). Evaluasi meliputi kematian/kelangsungan hidup, perbaikan tingkat kesadaran, perbaikan gejala flapping tremor, perbaikan penampilan klinis, perbaikan test hubungan angka (NCT) dan perubahan kadar albumin darah. Analisis statistik dengan menggunakan student t test, uji mutlak Fischer dan analisis kesintasan dengan tingkat kemalmaanp<0,05. Hasil Didapatkan 16 pasien dengan 8 pasien untuk masing-masing kelompok penelitian yang memenuhi kriteria penelitian. Perbandingan data dasar antara dua kelompok dalam hal karakteristik klinik dan skor Child Pugh secara statistik tidak dijumpai perbedaan yang bermakna. Penambahan infus AARC pada terapi standar dibandingkan dengan hanya terapi standar secara bennakna memberikan hasil yang lebih balk dalam hal perbaikan pemulihan kesadaran (p=0,0094), perbaikan gejala flapping tremor (p=0,0030), perbaikan penampilan klinis (p=0,0030) sedangkan hasil yang tidak bermakna dalam hal kelangsungan hidup pasien (p=0,1435) dan perbaikan penyelesaian tes hubungan anglca/NCT(p,0882). Penambahan AARC peroral sebagai terapi lanjutan dibandingkan dengan terapi standar secant bermakna memberikan hasil yang lebih baik dalam hal memperpanjang kelangsungan hidup (p=0,0023), pemulihan kesadaran (p=0,0025), perbaikan gejala flapping tremor (p,0031), perbaikan penampilan klinis (p=0,0031) dan perbaikan tes hubungan angka/ NCT ( p :1,0186) sedangkan perubahan kadar albumin darah memberikan hasil yang tidak bennalma (p=0,054). Kesimpulan Penambahan AARC dalam pengobatan standar Eli secara statistik memberikan hasil yang lebih baik dan lebih cepat dalam hal pemulihan kesadaran, gejala flapping tremor dan penampilan klinis dibandingkan dengan hanya menggunakan terapi standar Baja Penambahan AARC oral dalam terapi diet lanjutan mampu mencegah terulangnya kejadian EH, yang hasilnya juga lebih baik dibandingkan dengan hanya menggunakan terapi standar.