HUBUNGAN ANTARA DERAJAT KAKI DIABETIK DENGAN NEUROPATI PERIFER DAN ISKEMI PERIFER PADA PENDERITA DIABETES MELITUS TIPE 2

Abstract

Background : Diabetic Foot (DF) is one of the serious complications of Diabetes Mellitus (DM), due to the presence of vascular diseases (both macro-vascular and micro-vascular) and peripheral neuropathy, then followed by infection progress to diabetic ulcer. Three factors are predispose to tissue damage in DF, consist of peripheral neuropathy, peripheral ischemia, and infection. Today, the incidence of DF disease are increase and they ussually come in a late stage. Early finding and treatment of the risk factors of DF may be decreasing the incidence of diabetic foot. Objective : To find-out the association between peripheral neuropathy and peripheral ischemia according to the level of DF in DM type 2 patients. Subject and method : Cross — sectional study was conducted in out-patient and in-patient of Dr Kariadi General Hospital between February to August 2001. The grade of peripheral neuropathy was examined by Electromyography (EMG). The grade of peripheral ischemia using Ankle Pressure Index (API) was measured by Doppler and grade of DF was measure using Wagner criteria. Contingency coefficient method with level of significant p < 0.05 was used to analyse the association between peripheral neuropathy, peripheral ischemia and DF. Result : This study found 70 patients (pts) of DM type 2 with DF, consists of 35 pts (50%) were grade 0, 13 pts (18.6%) were grade 1, 10 pts (14.3%) were grade 2 and 12 pts (17.1%) were grade 3. EMG results from DF grade 0 were 1 pts (2.9%) with normal, 15 pts (42.8%) with mild neuropathy and 15 pts (40%) with moderate neuropathy. DF grade I were 10 pts (76.9%) with severe neuropathy, whereas all pts of DF grade 2 and grade 3 with severe neuropathy. For all DF pts, only one pts (1.4%) had normal result and 15 pts (21.4%) had mild neuropathy, those pts were found in DF grade 0 only. API result of right extremity DF from DF grade 0 were 24 pts (68.6%) with mild ischemia. In DF grade 2 were 7 pts (70%) and grade 3 were 8 pts (66.7%) with moderate ischemia. Severe ischemia was only occupied in 2 pts (16.7%) with DF grade 3. API result of the left extremity DF from DF grade 0 were 21 pts (60%) with mild ischemia. In DF grade 2 were 6 pts (60%) and grade 3 were 7 pts (58.3%) with moderate ischemia. The result of study found that more severe peripheral neuropathy association with higher the grade of DF and more severe peripheral ischemia association with higher the grade of DF. Statistical analysis results showed the positive association between peripheral neuropaty and DF was significant (C = 0.63, p= 0.0001). The positive association between peripheral ischemia and DF was significant (C = 0.56, p= 0.0002). There was no association between peripheral neuropathy and peripheral ischemia. (C = 0.36, p= 0.30004) Conclusion : Mostly pts of DF grade 2 and 3 had severe peripheral neuropathy and moderat to severe peripheral ischemia, only pts of normal result and mild peripheral neuropathy had DF grade 0. There were positive association between peripheral neuropathy and peripheral ischemia with DF. Latar belakang :Kaki Diabetik (KD) merupakan salah satu komplikasi serius Diabetes Melitus (DM) yang ditandai dengan adanya gangguan vaskuler (mikrovaskuler dan makrovaskuler) dan neuropati perifer, kemudian disertai infeksi sehingga terjadi ulkus diabetik. Tiga faktor resiko terjadinya nekrosis jaringan pada kaki diabetik yang terdiri neuropati perifer, iskemik perifer dan infeksi. Saat ini kejadian KD meningkat dan kadang penderita datang dalam keadaan stadium lanjut. Penemuan dan pengobatan faktor neuropati perifer dan iskemi perifer lebih awal diharapkan akan menurunkan angka kejadian KD. Tujuan : Mengetahui hubungan antara neuropati perifer dan iskemi perifer dengan derajat kaki diabetik pada penderita DM tipe 2. Material dan metoda : Penelitian secara cross sectional dilakukan dari bulan Pebruari sampai Agustus 2001 di unit rawat jalan dan bangsal penyakit dalam RSUP dr. Kariadi. Derajat neuropati di periksa dengan Elektromiografi (EMG), derajat iskemi berdasarkan nilai Ankle Pressure Index (API) diperiksa dengan Doppler dan derajad KD sesuai !criteria Wagner Metode koefisien kontingensi untuk menilai hubungan antara derajat KD dengan neuropati perifer dan iskemi perifer berdasarkan nilai kemaknaanp < 0.05. Hasil : Dui 70 penderita KD didapat 35 penderita derajat 0 (50%), 13 penderita derajat 1 (18.6%), 10 penderita derajat 2 (14.3%) dan 12 penderita derajat 3 (17.1%). Pada pemeriksaan EMG, KD derajat 0 didapat 1 penderita (2.9%) dengan neuropati normal, 15 penderita (42.8%) dengan neuropati ringan dan 15 penderita (40.0%) dengan neuropati sedang. KD derajat 1 didapat 10 penderita (76.9%) dengan neuropati berat. Sedangkan KD derajat 2 dan derajat 3 semua didapat dengan neuropati berat. Dan semua penderita KD, normal 1 penderita (1.4%) dan neuropati ringan 15 penderita (21.4%) hanya didapat pada KD derajat 0. Hasil pemeriksaan API ektremitas kanan, pada KD derajat 0 didapat 24 penderita (68.6%) dengan iskemi ringan. KD derajat 2 didapat 7 penderita (70%) dan derajat 3 didapat 8 penderita (66.7%) dengan iskemi sedan& Hasil pemeriksaan iskemi berat 2 penderita (16.7%) hanya didapat pada KD derajat 3. Pemeriksaan API ektremitas kifi, pada KD derajat 0 didapat 21 penderita (60%) dengan iskemi ringan, KD derajat 2 didapat 6 penderita (60%) dan derajat 3 didapat 7 penderita (58.3%) dengan iskemi sedang. Penelitian ini didapat hubungan, semakin berat neuropati perifer makin berat derajat KD dan makin berat iskemi perifer makin berat derajat KD. Hasil perhitungan statistik didapat hubungan bermakna yang searah antara neuropati perifer dengan derajat KD (C = 0.63,p = 0.0001). hubungan bermakna yang searah antara iskemi perifer dengan derajat KD (C = 0.56, p = 0.0002). Iskemi perifer dengan neuropati perifer tidak ada hubungan bermakna. (C = 0.36, p = 0.3004). Kesimpulan : Hasil penelitian pada KD derajat 2 dan 3 semua didapat kelainan neuropati perifer berat dan iskemi perifer sedang sampai berat, sedangkan hasil normal dan neuropati perifer ringan hanya didapat pada KD derajat 0. Neuropati perifer dan iskemi perifer didapat hubungan bermakna yang searah dengan KD.