THE DESCRIPTION OF LEVEL VITAMIN D, CALCIUM SERUM AND MANDIBULAR BONE DENSITY IN HIV/AIDS CHILDRENS 1 Primarti R.S, 1 Riyanti E, 2 Sufiawati I, 3 Azhari Departement of Pediatric Dentistry ,Oral Medicine and Oral Radiology, Faculty of Dentistry, Universitas Padjadjaran, Bandung Indonesia Background: Human immunodeficiency virus (HIV) is a virus attacks the immune system of the body, ussualy was caused by HIV type 1. The proportion of women in new HIV infections in Indonesia has grown from 34 percent in 2008 to 44 percent in 2011 will lead a rise infections among children. There is an association between low vitamin D and HIV disease progression. Vitamin D is not only involve in calcium homeostasis which is have a negative impact on bone health, but also in regulation of immune system. Bone alteration have been observed in the course of HIV which reduced bone mineral density is the common bone lesion found in HIV patients. Bone mineral density is a parameter that predict fracture risk which in turn correlates with a shorter life expectancy. This research will study the relationship between level vitamin D and calcium serum with mandibular bone density in HIV/AIDS childrens. Method : The research method is cross sectional study, serum 1,25-dihydroxyvitamin D and calcium levels were assessed from blood for randomly selected subject of HIV infected children enrolled treatment at Klinik Teratai FKUP Rumah Sakit Hasan Sadikin Bandung, West Java, Indonesia during March-June 2015. Panoramic radiograph were taken for measuring mandibular bone density. Result: All 40 subject HIV/AIDS children showed serum 1,25-dihydroxyvitamin D were classified as vitamin D deficient (≤ 20nm/ml). A few subject showed an insuficient serum calcium level and all patient have low mandibular bone density. Conclusion: Deficient vitamin D levels may lead lower mandibular bone density in HIV/AIDS children. Correspodency : Risti Saptarini Primarti Office: Department of Pedodontik Dentistry Faculty of Dentistry, Padjadjaran University Adress: Sekeloa Selatan I Bandung, West Java, Indonesia Post Code: 40132 Telephone/ Fax: +62-22-2532683 Email : [email protected]
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THE DESCRIPTION OF LEVEL VITAMIN D, CALCIUM SERUM AND MANDIBULAR BONE DENSITY IN HIV/AIDS CHILDRENS
1Primarti R.S, 1Riyanti E, 2Sufiawati I, 3Azhari Departement of Pediatric Dentistry ,Oral Medicine and Oral Radiology,
Faculty of Dentistry, Universitas Padjadjaran, Bandung Indonesia
Background: Human immunodeficiency virus (HIV) is a virus attacks the immune system of the body, ussualy was caused by HIV type 1. The proportion of women in new HIV infections in Indonesia has grown from 34 percent in 2008 to 44 percent in 2011 will lead a rise infections among children. There is an association between low vitamin D and HIV disease progression. Vitamin D is not only involve in calcium homeostasis which is have a negative impact on bone health, but also in regulation of immune system. Bone alteration have been observed in the course of HIV which reduced bone mineral density is the common bone lesion found in HIV patients. Bone mineral density is a parameter that predict fracture risk which in turn correlates with a shorter life expectancy. This research will study the relationship between level vitamin D and calcium serum with mandibular bone density in HIV/AIDS childrens. Method : The research method is cross sectional study, serum 1,25-dihydroxyvitamin D and calcium levels were assessed from blood for randomly selected subject of HIV infected children enrolled treatment at Klinik Teratai FKUP Rumah Sakit Hasan Sadikin Bandung, West Java, Indonesia during March-June 2015. Panoramic radiograph were taken for measuring mandibular bone density. Result: All 40 subject HIV/AIDS children showed serum 1,25-dihydroxyvitamin D were classified as vitamin D deficient (≤ 20nm/ml). A few subject showed an insuficient serum calcium level and all patient have low mandibular bone density. Conclusion: Deficient vitamin D levels may lead lower mandibular bone density in HIV/AIDS children.
Correspodency : Risti Saptarini Primarti Office: Department of Pedodontik Dentistry Faculty of Dentistry, Padjadjaran University Adress: Sekeloa Selatan I Bandung, West Java, Indonesia Post Code: 40132 Telephone/ Fax: +62-22-2532683 Email : [email protected]
Research Background
Human immunodeficiency virus (HIV) is a virus causing acquired immunodeficiency
syndrome (AIDS). Researches conducted in several countries showed a rapid increase in infected
women, which correspondingly increase the number of HIV infected children. HIV infection is
passed from infected mothers to their children through vertical transmission: through the
placenta during pregnancy (intrauterine), at birth (intrapartum), and afterbirth through
breastfeeding (Cowan et al., 1984). To date, it has been reported that as many as 3.3 million
children were infected with HIV (UNAIDS, 2013).The proportion of women in new HIV
infections in Indonesia has grown from 34 percent in 2008 to 44 percent in 2011 which lead to an
increase number of infections among children.
Ever since the introduction of highly active antiretroviral therapy (HAART) in mid 1990s,
the incidence and mortality rate related to opportunistic infections and malignancies that occured
due to the low immune system has been dramatically decreased. In the other hand, the use of
HAART caused various side effects, one of which is, according to several studies, the
relationship between antiretroviral therapy (ART) and vitamin D deficiency and low bone
density in infected patients. (Brown & Qaqish, 2006; Welz et al., 2010; Dao et al., 2011;
Adeyemi et al., 2011; Childs et al., 2012).
Numerous studies assessing bone mineralisation and metabolism in adult patients receiving
ART showed contradictory results (Paton et al., 1997; Nolan et al., 2001, Mondy et al., 2003).
Other studies involving HIV-positive children and teenagers receiving ART showed astonishing
bone metabolism rate, which was asessed by bone turnover biochemical (O’Brien et al., 2001;
Mora et al., 2001; Tan et al., 2001). A longitudinal study lso confirmed low bone mineral density
as well as bone metabolism abnormality in HIV- infected children treated with etabolismral
(Mora et al., 2014). Results of stidues above showed that HAART was suspected to contribute
to the decrease of bone mass and bone metabolism alteration in HIV- infected children.
Klinik Rawat Jalan Teratai FKUP - RS. Dr. Hasan Sadikin Bandung merupakan pusat
pelayanan dan penelitian untuk penderita HIV yang ada di Provinsi Jawa Barat, Indonesi. Total
populasi pasien anak HIV yang tercatat di klinik Teratai sebanyak 170 anak. Penelitian ini
bertujuan untuk mengetahui kadar kalsium serum, vitamin D dan densitas tulang mandibula pada
anak HIV yang mendapat terapi HAART lebih dari tiga tahun
Research Method
Penelitian yang dilakukan adalah penelitian cross sectional dan populasi penelitian anak
yang terinfeksi HIV-AIDS di Klinik Rawat Jalan Teratai FKUP - RS. Dr. Hasan Sadikin
Bandung berusia di bawah 15 tahun. Jumlah sampel ditentukan dengan menggunakan
consecutive sample atau sampel seadanya, artinya seluruh sampel yang memenuhi persyaratan
inklusi diikutsertakan pada penelitian. Kriteria inklusi adalah 1) penderita HIV-AIDS yang
sedang melakukan rawat jalan di Klinik Teratai FKUP-RS Dr. Hasan Sadikin Bandung; 2) Laki-
laki atau perempuan berusia kurang dari 5-15 tahun. Kriteria eksklusi adalah 1) pasien HIV –
AIDS yang mendapatkan pengobatan HAART kurang dari tiga tahun; 2) pasien dengan kelainan
genetic; 3) pasien dengan kelainan tumbuh kembang lainnya.
Penelitian dilaksanakan setelah mendapatkan ijin dari Komite Etik Penelitian Kesehatan
dan mendapatkan ijin orang tua setelah menandatangani informed consent, anak yang memenuhi
kriteria inklusi dilakukan pengambilan darah untuk pemeriksaan kadar kalsium serum dan
vitamin D. Kadar Kalsium dengan menggunakan metode O-Cresol Phtalein, darah yang
digunakan sebangak 200 µl sedangkan untuk kadar Vitamin D dengan menggunakan metode O-
Cresol Phtalein diperlukan darah sebanyak 300 µl.
Densitas tulang mandibula diukur dengan menggunakan radiograf panoramik,
pengukuran dilakukan dengan menggunakan 1 set komputer dan software untuk mengukur
Penelitian lain menunjukkan pasien terinfeksi HIV dengan kadar 1,25(OH)2D3 yang
sangat rendah dapat menyebabkan berhentinya produksi PTH walaupun kadar kalsitonin dalam
darahnya normal. PTH dapat meningkatkan absorpsi kalsium yang memicu ekspresi RANKL
pada osteoblas sehingga dapat menstimulasi maturasi osteoklas. Teichman melakukan penelitian
terjadinya osteopenia pada pasien wanita HIV yang mendapat terapi HAART terutama obat yg
sifatnya protease inhibitor. Penelitian ini menunjukkan adanya kaitan antara rendahnya penanda
kecepatan pembentukan tulang dan reabsorpi tulang yang ditandai oleh peningkatan ekskresi
kalsium. Lebih lanjut penurunan kadar 1,25(OH)2D3 berkontribusi terhadap ketidak seimbangan
kadar kalsium dan penghambatan pembentukan tulang (Ross dkk, 2012).
Infeksi HIV juga dapat menurunkan jumlah monosit dan makrofag dan reseptor TNF,
sehingga akibatnya menuruhkan reseptor PTH dan respon cAMP yang berperan untuk stimulasi
produksi PTH (Teichman dkk, 2003). Mekanisme vitamin D menyebabkan osteopenia dan
osteoporosis belum diketahui dengan pasti, tetapi pada pasien HIV sejalan dengan lamanya
infeksi, viral load yang tinggi dan kadar laktat dan alkalin fosfatase yang tinggi. Oleh karena itu
kadar vitamin D yang adekuat dan kadar PTH herus selalu dievaluasi sedini mungkin pada
pasein yang terinfeksi HIV.
Beberapa penelitian yang telah dipaparkan diatas menunjukkan adanya keterkaitan
langsung antara infeksi HIV dengan defisiensi vitamin D. Efek 1,25(OH)2D3 diperantarai oleh
interaksinya dengan reseptor vitamin D (VDR) sehingga memudahkan untuk berikatan dengan
nukleus yang berikatan dengan elemen reseptor vitamin D (VDRE) yang ikut membatu regulasi
transkripsi gen (Beard dkk, 2011; Ross dkk, 2012). Ekspresi gen VDR tidak hanya pada jaringan
sistem skeletal tetapi juga pada monosit, makrofag, sel dendritik, sel natural killer, sel T dan B
yang membantu efek imunomodulasi (immunomodulatory) vitamin D (Ross dkk, 2012). Efek
imunomudulasi vitamin D berkaitan juga dengan polimorfisme gen VDR dan berbagai tingkat
keparahan penyakit HIV/AIDS.
Conclusion
Deficient vitamin D levels may lead lower mandibular bone density in HIV/AIDS children.
References
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