HUBUNGAN HbA1C (GLYCATED HEMOGLOBIN), GULA DARAH …

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HUBUNGAN HbA1C (GLYCATED HEMOGLOBIN), GULA DARAH PUASA

DAN GULA DARAH 2 JAM POST PRANDIAL DENGAN PROFIL KAKI

PASIEN DIABETES MELITUS TIPE 2 DI RSUD DR MOEWARDI

SKRIPSI

Untuk Memenuhi Persyaratan

Memperoleh Gelar Sarjana Kedokteran

ERLYN MERIKA

G0015068

FAKULTAS KEDOKTERAN

UNIVERSITAS SEBELAS MARET

SURAKARTA

2018



PERNYATAAN

Dengan ini menyatakan bahwa dalam skripsi ini tidak terdapat karya yang pernah

diajukan untuk memperoleh gelar kesarjanaan di suatu perguruan tinggi dan

sepanjang pengetahuan penulis juga tidak terdapat karya atau pendapat yang

pernah ditulis atau diterbitkan oleh orang lain, kecuali yang secara tertulis diacu

dalam naskah dan disebutkan dalam daftar pustaka.

Surakarta, 8 Oktober 2018

Erlyn Merika Kusuma Putri

NIM. G0015068


ii

ABSTRAK

Erlyn Merika, G0015068, 2018. Hubungan Hba1c(Glycated Hemoglobin), Gula

Darah Puasa Dan Gula Darah 2 Jam Post Prandial Dengan Profil Kaki Pasien

Diabetes Melitus Tipe 2 Di RSUD Dr Moewardi

Latar Belakang: Kaki Diabetik merupakan salah satu komplikasi pada DM tipe 2

yang sudah menjadi masalah yang rumit dan tidak terkelola di seluruh dunia

terutama Indonesia. Hal ini disebakan karena sedikitnya tenaga kesehatan,

kurangnya pengetahuan masyarakat, dan biaya pengelolaan yang besar membuat

masalah kaki diabetik belum tertangani dengan baik. HbA1c merupakan kadar

gula darah rata-rata dalam jangka waktu 2-3 bulan. Kadar HbA1c 7% akan

mempunyai risiko lebih tinggi terkena kaki diabetik dibandingkan dengan

penderita Diabetes Melitus tipe 2 dengan kadar HbA1c <7%. Selain itu kadar

GDP dan G2PP ikut berperan dalam risiko terjadinya kaki diabetik. Penelitian ini

bertujuan untuk mengetahui hubungan antara HbA1c, GDP dan G2PP terhadap

profil kaki pasien DM tipe 2 di RSUD Dr.Moewardi.

Metode: Penelitian ini bersifat observasional analitik dengan pendekatan cross

sectional. Subyek penelitian adalah pasien DM tipe 2 di Poliklinik Penyakit

Dalam Sub Endokrinologi RSUD Dr Moewardi. Subyek penelitian dipilih dengan

menggunakan metode simple random sampling pada bulan Agustus 2018 -

September 2018. Data penelitian didapatkan melalui pemeriksaan laboratorium

gula darah, pemeriksaan monofilamen dan ABI sesuai Foot Diabetics Assesment

berdasarkan NICE Guideline. Data kemudian dianalisis menggunakan uji regresi

logistik ganda.

Hasil: Terdapat korelasi yang positif antara HbA1c, GDP dan G2PP terhadap

profil kaki pasien DM tipe 2, dimana masing-masing parameter dapat

meningkatkan risiko terjadinya kaki diabetik(OddsRatioHbA1C=3,677179;

OddsRatioGDP=1.04; OddsRatioG2PP=1.01)

Simpulan: Terdapat hubungan antara HbA1c, GDP dan G2PP terhadap profil

kaki pasien DM tipe 2 di RSUD Dr.Moewardi Surakarta.

Kata kunci: HbA1c,GDP,G2PP, Profil Kaki


iii

ABSTRACT

Erlyn Merika, G0015068, 2018. The Relation of A1C, Fasting Plasma Glucose,

2 Hour-Plasma Glucose with the profile of Foot in Patient Type 2 Diabetes

Mellitus in RSUD Dr. Moewardi

Background: Diabetic foot is one of the complications in type 2 diabetes mellitus

which is a complicated global problem and poorly managed problem due to the

lack of health workers, lack of community knowledge, and large management

costs make diabetic foot problems not handled properly. HbA1c is the average of

glucose level for 2-3 months.HbA1c levels ≥ 7% will have a higher risk of diabetic

foot compared with type 2 diabetes mellitus patients with HbA1c levels <7%.

Besides that, the levels of GDP and G2PP play a role in the risk of diabetic foot.

This study aims to determine the relationship between HbA1c, GDP and G2PP on

the profile of foot in type 2 DM patients in Dr.Moewardi Hospital.

Methods: This study was an observational analytic study with cross-sectional

approach. The subjects are patient with type 2 Diabetes in in Dr. Moewardi

Hospital. The subjects were chosen with simple random sampling in August 2018-

September 2018 . The result is analyzed using Multiple Logistic Regression to

perform the significance and the contribution of independent variables.

Results: There is a positive correlation between the A1C, Fasting Plasma

Glucose, 2 Hour-Plasma Glucose with the profile of Foot in Patient Type 2

Diabetes Melitus, and each parameters increased the risk of foot

diabetics(OddsRatioHbA1c=3,677179;OddsRatioGDP=1.04;OddsRatioG2PP=1.

01)

Conclusions: There is a relation between the between the A1C, Fasting Plasma

Glucose, 2 Hour-Plasma Glucose with the profile of Foot in Patient Type 2

Diabetes Melitus

Keywords: A1C, Fasting Plasma Glucose, 2 Hour-Plasma Glucose, Foot Profile


iv

PRAKATA

Puji syukur kepada Tuhan Yang Maha Esa, penulis dapat menyelesaikan

skripsi dengan judul “Hubungan HbA1c, GDP, G2PP Terhadap Profil Kaki

Diabetik Pasien Diabetes Melitus Tipe 2 di RSUD Dr. Moewardi Surakarta.”

Skripsi ini disusun sebagai salah satu syarat kelulusan tingkat sarjana di

Fakultas Kedokteran Universitas Sebelas Maret Surakarta. Penulis menyadari

bahwa skripsi ini tidak lepas dari kerjasama dan bantuan dari berbagai pihak.

Untuk itu, penulis menghaturkan terima kasih yang sebesar-besarnya kepada:

1. Eva Niamuzisilawati, dr., Sp.PD,M.Kes,FINASIM dan R.P Andri Putranto,

dr., M.Kes, selaku pembimbing yang telah berkenan membagikan waktu dan

ilmunya untuk membimbing saya dengan sabar, baik, dan penuh motivasi

sehingga skripsi saya dapat berjalan dengan lancar.

2. Dr. Supriyanto Kartodarsono, dr., Sp.PD,KEMD, FINASIM selaku penguji

yang telah berkenan menguji dan mendampingi saya serta memberikan ide,

saran, dan nasehat yang sangat berguna bagi saya.

3. Bagian SMF Interna dan Poliklinik Interna Sub Endokrin RSUD Dr

Moewardi, dr.Wisnu, dr. Erry, dr. Dayat, Ibu Sulis, Pak Ari dan semua yang

telah membantu saya dengan sabar.

4. Staf Bagian Skripsi FK UNS Bapak Nardi dan Ibu Nita yang telah

memberikan arahan dalam penyusunan skripsi ini.

5. Untuk keluarga saya, ayah, ibu, kedua adik saya yang senantiasa mendukung

dan mendoakan saya.

6. Teman-teman PSFK UNS, KMK FK UNS, kelompok B6, Kak Dimas, Nadia,

sahabat saya Ervina, Tita, Hellen, Cindy, dan semua teman yang tidak bisa

saya sebutkan satu persatu.

7. Friska Erika, Nabila Boediono, Margaretha Hildaria sebagai rekan skripsi

yang selalu membuat saya termotivasi.

8. Pihak-pihak yang berperan dalam penulisan skripsi ini, yang tidak bisa saya

sebutkan satu persatu.

Surakarta, 27 November 2018

Erlyn Merika


v

DAFTAR ISI

PRAKATA ...................................................................................................... v

DAFTAR ISI .................................................................................................... vi

DAFTAR TABEL ............................................................................................ viii

DAFTAR GAMBAR ....................................................................................... ix

DAFTAR LAMPIRAN .................................................................................... x

BAB I ............................................................................................................... 1

A. Latar Belakang ..................................................................................... 1

B. Rumusan Masalah ................................................................................ 4

C. Tujuan Penelitian ................................................................................. 4

D. Manfaat Penelitian ............................................................................... 5

BAB II .............................................................................................................. 6

A. DIABETES MELITUS TIPE 2

1. Definisi ........................................................................................... 6

2. Epidemiologi .................................................................................. 6

3. Faktor Risiko .................................................................................. 7

4. Patofisiologi ................................................................................... 7

5. Kriteria ........................................................................................... 9

6. Komplikasi ..................................................................................... 11

B. KAKI DIABETIK

1. Definisi ........................................................................................... 12

2. Epidemiologi .................................................................................. 12

3. Faktor Risiko .................................................................................. 13

4. Patofisiologi ................................................................................... 13

5. Hubungan HbA1c,GDP, G2PP terhadap profil kaki diabetik ........ 14

6. Diagnosis ........................................................................................ 15

7. Interpretasi...................................................................................... 16

8. Algoritme ....................................................................................... 17

9. Tatalaksana ..................................................................................... 19

C. Kerangka Pemikiran ............................................................................. 21


vi

D. Hipotesis ............................................................................................... 22

BAB III ............................................................................................................ 23

A. Jenis penelitian ..................................................................................... 23

B. Lokasi penelitian .................................................................................. 23

C. Waktu penelitian .................................................................................. 23

D. Subyek penelitian ................................................................................. 23

E. Teknik sampling ................................................................................... 24

F. Besar sampel ....................................................................................... 24

G. Rancangan penelitian .......................................................................... 26

H. Variabel penelitian .............................................................................. 26

I. Definisi operasional penelitian ............................................................. 26

J. Instrumen penelitian ............................................................................. 29

K. Cara kerja penelitian ............................................................................ 30

L. Teknik analisis data .............................................................................. 34

M. Jadwal Penelitian .................................................................................. 36

BAB IV ............................................................................................................ 37

A. Deskripsi Sampel ................................................................................. 37

B. Karakteristik Sampel Penelitian ........................................................... 38

C. Analisis Data ........................................................................................ 40

BAB V .............................................................................................................. 45

A. Pembahasan .......................................................................................... 45

B. Hubungan HbA1c,GDP,G2PP terhadap profil kaki diabetik ............... 49

C. Keterbatasan Penelitian ........................................................................ 54

BAB VI ............................................................................................................ 55

A. Simpulan .............................................................................................. 55

B. Saran ..................................................................................................... 55

DAFTAR PUSTAKA ...................................................................................... 58


vii

DAFTAR TABEL

Tabel 2.1 Kriteria DM tipe 2 ....................................................................... 9

Tabel 2.2 Kategori DM tipe 2 terkontrol baik dan terkontrol buruk .......... 10

Tabel 3.1 Tabel Tingkat Hubungan Antar Variabel ................................... 35

Tabel 4.1 Karakteristik Demografi Sampel Penelitian ............................... 39

Tabel 4.2 Uji Kolmogorov-Smirnov Profil Kaki Diabetik ......................... 40

Tabel 4.3 Uji Regresi Logistik Ganda ........................................................ 41


viii

DAFTAR GAMBAR

Gambar 2.1Kerangka Pemikiran .................................................................... 21

Gambar 3.1Cara Penggunaan Monofilamen .................................................. 31

Gambar 3.210 Titik Lokasi Pemeriksaan Monofilamen ................................ 31

Gambar 4.3.1Persamaan Regresi Logistik Ganda untuk HbA1c ................... 42

Gambar 4.3.2Persamaan Regresi Logistik Ganda untuk GDP ....................... 43

Gambar 4.3.3Persamaan Regresi Logistik Ganda untuk G2PP...................... 44


ix

DAFTAR LAMPIRAN

Lampiran 1. Surat Kelayakan Etik (Ethical Clearance)

Lampiran 2. Informed Consent

Lampiran 3. Foot Diabetic Screening and Assesment

Lampiran 4. Diabetes Foot Ulcer Assesment

Lampiran 5. Distribusi Sampel Penelitian

Lampiran 6. Hasil analisis statistik dengan SPSS (Uji Normalitas)

Lampiran 7. Hasil analisis statistik dengan SPSS (Regresi Logistik Ganda)

Lampiran 8. Data Responden

Lampiran 9. Surat Pengantar Penelitian di RSDM

Lampiran 10. Daftar Singkatan



xiii

LAMPIRAN

Lampiran 1. Surat Kelayakan Etik (Ethical Clearance)


xiv

Lampiran 5. Distribusi Sampel Penelitian


xv


xvi


xvii

Lampiran 6

Hasil Uji Normalitas Data


xviii

Lampiran 7

Hasil Uji Regresi Logistik

Notes

Output Created 14-DEC-2018 09:20:13

Comments

Input Data /Users/macbookpro/Documents/data akhir.sav

Active Dataset DataSet2

Filter <none>

Weight <none>

Split File <none>

N of Rows in

Working Data File 73

Missing Value

Handling

Definition of Missing User-defined missing values are treated as

missing

Syntax LOGISTIC REGRESSION VARIABLES

Hasil

/SELECT=g2pp1 LT 180

/METHOD=ENTER G2PP

/SAVE=PRED

/CLASSPLOT

/PRINT=CORR CI(95)

/CRITERIA=PIN(0.05) POUT(0.10)

ITERATE(20) CUT(0.5).

Resources Processor Time 00:00:00.03

Elapsed Time 00:00:00.00

Variables Created or

Modified

PRE_7

Predicted probability


xix

Case Processing Summary

Unweighted Casesa N Percent

Selected Cases

Included in Analysis 72 98.6

Missing Cases 0 .0

Total 72 98.6

Unselected Cases 1 1.4

Total 73 100.0

a. If weight is in effect, see classification table for the total number of cases.

Dependent Variable Encoding

Original Value Internal Value

risiko rendah 0

risiko tinggi 1

Block 0: Beginning Block

Classification Tablea,b

Observed

Predictedd

Selected Casesc Unselected Cases

e,f

Hasil Percentage

Correct

Hasil Percentage

Correct risiko

rendah

risiko

tinggi

risiko

rendah

risiko

tinggi

Step

0

Hasil

risiko

rendah 38 0 100.0 0 0 .

risiko

tinggi 34 0 .0 0 0 .

Overall

Percentage 52.8

a. Constant is included in the model.

b. The cut value is .500

c. Selected cases g2pp1 LT 180

d. There are no unselected cases. Therefore, no unselected cases are classified.


xx

e. Unselected cases g2pp1 GE 180

f. Some of the unselected cases are not classified due to either missing values in the

independent variables or categorical variables with values out of the range of the selected

cases.

Variables in the Equation

B S.E. Wald df Sig. Exp(B)

Step 0 Constant -.111 .236 .222 1 .638 .895

Variables not in the Equation

Score df Sig.

Step 0 Variables G2PP 8.059 1 .005

Overall Statistics 8.059 1 .005

Block 1: Method = Enter

Omnibus Tests of Model Coefficients

Chi-square df Sig.

Step 1 Step 10.493 1 .001

Block 10.493 1 .001

Model 10.493 1 .001

Model Summary

Step

-2 Log

likelihood

Cox & Snell R

Square

Nagelkerke R

Square

1 89.098a .136 .181

a. Estimation terminated at iteration number 5 because

parameter estimates changed by less than .001.

Classification Tablea

Observed

Predictedc

Selected Casesb Unselected Cases

d,e

Hasil Percentage Hasil Percentage


xxi

risiko

rendah

risiko

tinggi

Correct risiko

rendah

risiko

tinggi

Correct

Step

1

Hasil risiko

rendah 29 9 76.3 0 0 .

risiko

tinggi 18 16 47.1 0 0 .

Overall

Percentage 62.5 .

a. The cut value is .500

b. Selected cases g2pp1 LT 180

c. There are no unselected cases. Therefore, no unselected cases are classified.

d. Unselected cases g2pp1 GE 180

e. Some of the unselected cases are not classified due to either missing values in the


cases.



95% C.I.for EXP(B)

Lower Upper

Step 1a G2PP .013 .005 7.720 1 .005 1.013 1.004 1.022

Constant -2.688 .947 8.050 1 .005 .068

a. Variable(s) entered on step 1: G2PP.

Correlation Matrix

Constant G2PP

Step 1 Constant 1.000 -.963

G2PP -.963 1.000


xxii

Logistic Regression

Notes


Comments

Input Data /Users/macbookpro/Documents/data akhir.sav


Filter <none>

Weight <none>

Split File <none>

N of Rows in


Missing Value

Handling

Definition of Missing User-defined missing values are treated as missing


xxiii

Syntax LOGISTIC REGRESSION VARIABLES Hasil

/SELECT=gdp1 LT 130

/METHOD=ENTER GDP

/SAVE=PRED

/CLASSPLOT

/PRINT=CORR CI(95)

/CRITERIA=PIN(0.05) POUT(0.10)

ITERATE(20) CUT(0.5).




Modified

PRE_8 Predicted probability



Selected Cases Included in Analysis 72 98.6

Missing Cases 0 .0

Total 72 98.6


Total 73 100.0

a. If weight is in effect, see classification table for the total

number of cases.



risiko rendah 0

risiko tinggi 1



xxiv


Observed

Predictedd


e,f

Hasil

Percentage

Correct

Hasil

Percentage Correct

risiko

rendah

risiko

tinggi

risiko

rendah

risiko

tinggi

Step 0 Hasil

risiko rendah 38 0 100.0 0 0 .

risiko tinggi 34 0 .0 0 0 .

Overall Percentage 52.8 .



c. Selected cases gdp1 LT 130


e. Unselected cases gdp1 GE 130

f. Some of the unselected cases are not classified due to either missing values in the independent

variables or categorical variables with values out of the range of the selected cases.



Step 0 Constant -.111 .236 .222 1 .638 .895


Score df Sig.

Step 0 Variables GDP 22.336 1 .000




Chi-square df Sig.

Step 1 Step 26.427 1 .000

Block 26.427 1 .000

Model 26.427 1 .000


xxv

Model Summary

Step

-2 Log

likelihood

Cox & Snell R

Square

Nagelkerke R

Square

1 73.163a .307 .410




Observed Predictedc


d,e

Hasil

Percentage

Correct

Hasil

Percentage

Correct

risiko

rendah

risiko

tinggi

risiko

rendah

risiko

tinggi

Step 1 Hasil risiko

rendah 32 6 84.2 0 0 .

risiko

tinggi 10 24 70.6 0 0 .

Overall

Percentage 77.8 .


b. Selected cases gdp1 LT 130


d. Unselected cases gdp1 GE 130



cases.


xxvi



95% C.I.for EXP(B)

Lower Upper

Step 1a GDP .040 .010 16.507 1 .000 1.041 1.021 1.061

Constant -5.717 1.378 17.226 1 .000 .003

a. Variable(s) entered on step 1: GDP.

Correlation Matrix

Constant GDP

Step 1 Constant 1.000 -.978

GDP -.978 1.000


xxvii

Logistic Regression

Notes


Comments

Input

Data /Users/macbookpro/Documents/data akhir.sav


Filter <none>

Weight <none>

Split File <none>


xxviii

N of Rows in


Missing Value

Handling

Definition of Missing User-defined missing values are treated as missing

Syntax LOGISTIC REGRESSION VARIABLES Hasil

/SELECT=HBA1C1 LT 7

/METHOD=ENTER HbA1c

/SAVE=PRED

/CLASSPLOT

/PRINT=CORR CI(95)

/CRITERIA=PIN(0.05) POUT(0.10) ITERATE(20)

CUT(0.5).




Modified

PRE_9 Predicted probability



Selected Cases

Included in

Analysis 72 98.6

Missing Cases 0 .0

Total 72 98.6


Total 73 100.0

a. If weight is in effect, see classification table for the total number of cases.


xxix



risiko rendah 0

risiko tinggi 1



Observed

Predictedd


e,f

Hasil

Percentage

Correct

Hasil

Percentage

Correct

risiko

rendah

risiko

tinggi

risiko

rendah

risiko

tinggi

Step

0

Hasil risiko

rendah 38 0 100.0 0 0 .

risiko

tinggi 34 0 .0 0 0 .

Overall

Percentage 52.8 .



c. Selected cases HBA1C1 LT 7


e. Unselected cases HBA1C1 GE 7

f. Some of the unselected cases are not classified due to either missing values in the


cases.


xxx



Step 0 Constant -.111 .236 .222 1 .638 .895


Score df Sig.

Step 0 Variables HbA1c 32.503 1 .000




Chi-square df Sig.

Step 1 Step 89.346 1 .000

Block 89.346 1 .000

Model 89.346 1 .000

Model Summary

Step

-2 Log

likelihood

Cox & Snell R

Square

Nagelkerke R

Square

1 10.244a .711 .949


xxxi




Observed

Predictedc


d,e

Hasil

Percentage

Correct

Hasil

Percentage

Correct

risiko

rendah

risiko

tinggi

risiko

rendah

risiko

tinggi

Step

1

Hasil risiko

rendah 37 1 97.4 0 0 .

risiko

tinggi 1 33 97.1 0 0 .

Overall

Percentage 97.2 .


b. Selected cases HBA1C1 LT 7


d. Unselected cases HBA1C1 GE 7



cases.


xxxii



95% C.I.for EXP(B)

Lower Upper

Step 1a HbA1c 15.118 6.190 5.965 1 .015 3677179.703 19.793 683136373606.913

Constant -108.650 44.181 6.048 1 .014 .000

a. Variable(s) entered on step 1: HbA1c.

Correlation Matrix

Constant HbA1c

Step 1 Constant 1.000 -1.000

HbA1c -1.000 1.000


xxxiii


xxxiv

Lampiran 8. Dokumentasi Penelitian


xxxv

Skripsi dengan judul: Hubungan HbA1c, GDP, G2PP Terhadap Profil Kaki

Diabetik Pasien Diabetes Melitus Tipe 2 di RSUD Dr. Moewardi Surakarta

Erlyn Merika, NIM: G0015068, Tahun: 2018

Telah diuji dan sudah disahkan di hadapan Dewan Penguji Skripsi

Fakultas Kedokteran Universitas Sebelas Maret

Pada Hari Selasa, Tanggal 27 November 2018

Pembimbing Utama

Nama : Eva Niamuzisilawati, dr., Sp.PD,M.Kes

NIP : 197907112014122001 (…………………………..)

Pembimbing Pendamping

Nama : R.P Andri Putranto, dr.,M.Si

NIP : 196305251996031001 (…………………………..)

Penguji

Nama : Supriyanto Kartodarsono, dr., Sp.PD(K)EMD

NIP : 195501281981011002 (…………………………..)

Surakarta, 2018

Ketua Tim Skripsi Kepala Program Studi

Kusmadewi Eka Damayanti, dr., M.Gizi Sinu Andhi Jusup, dr., M.Kes.

NIP 19830509 200801 2 005 NIP 19700607 200112 1 002
