Accuracy Of Spiral Laminar Flow, Spectral Broadening And Murmur / Thrill As Av- Shunt Maturuty Predictors In Dr. Mohammad Hoesin Hospital Palembang

Background : Hemodialysis is a therapy for end-stage cornic kidney disease (ESRD) which is most often used as renal replacement therapy. Vascular access for hemodialysis is essential in the management of patients with chronic kidney disease. One type of vascular access is av fistula. A well-matured AVF is needed in order to function optimally during the hemodialysis process. The study of Srivastava et al. In India examined a predictor parameter of the maturation of AVF using Doppler ultrasound. The parameters studied were Spiral Laminar Flow (SLF), Spectral Broadening and Murmur / thrill. The results of this study state that SLF is the most important and early predictor of AVF maturation. Research on the accuracy of spiral laminar flow, spectral broadening and murmur / thrill as predictors of av-shunt maturity has never been carried out in Indonesia. This encourages this research to be carried out. Method : This type of research is the prognostic test. The study was conducted in the vascular and endovascular subdivisions from July September 2020 or until the number of research samples is met. Result : There were 30 samples in this study, Murmur / thrill had high sensitivity and specificity values on day 21 while SLF and spectral broadening had very high sensitivity and specificity


Introduction
Chronic kidney disease is an emerging public health problem worldwide. In the United States, the prevalence of end-stage kidney disease (ESRD) continues to increase. The growth of ESRD is associated with lower early detection of chronic kidney disease. Developed countries such as North America, Europe and Japan have the highest incidence of ESRD. More than 1 million patients are on dialysis worldwide with an incidence of about one quarter of a million per year. In the United States, the overall prevalence of chronic kidney disease increased from 12 to 14 percent between 1988 and 1994 and from 1999 to 2004 but has been relatively stable since 2004. 1 Hemodialysis is an ESRD therapy that is most often used as renal replacement therapy in addition to peritoneal dialysis or kidney transplantation. Vascular access for hemodialysis is important in the management of patients with chronic kidney disease because through this access, the patient's blood can be transferred to the dialysis filter and returned to the patient in a continuous process, which usually takes three to four hours, two to three times a week. However, access problems are a major determinant of morbidity among hemodialysis patients.
Pre-operative evaluation of the veins and arteries of the upper extremities using Doppler ultrasound is a recommended adjunct, especially in obese patients, who have a history of previous vascular access surgery, or patients with suspected venous or arterial disorders. 4,5 Doppler ultrasound examinations tend to take longer than physical examinations, and require a reliable examiner and specialized tools. However, Doppler ultrasonography has been shown to be effective in the assessment of vascular anatomical features and flow measurement and has high ultrasound diagnostic value on AVF. 6 The sensitivity, specificity, and accuracy of Doppler USG were 96.55%, 61.53%, and 74.48%. 7 This examination also provides information on the superficial and deep veins in the arm and provides complete data on arterial circulation. In addition, Doppler ultrasound is completely non-invasive, safe and repeatable. Doppler ultrasound is a diagnostic imaging technique that simultaneously displays the anatomy of an area and its blood supply. This Doppler ultrasound is the only examination that can be performed directly by a doctor that will establish vascular access, and is an undeniable advantage. 8 A well-matured AVF is needed in order to function optimally during the hemodialysis process. The study of Asif et al. Showed that the percentage of AVF that failed to develop adequately for dialysis ranged from 28% to 53%. 4,8 Generally, the term maturation refers to the development of physical characteristics that make AVF suitable for venipuncture with large needles. Failure to mature is a fistula that is difficult to cannulate or fails to produce the blood flow required (600 ml / min) for successful two-needle dialysis. In many cases, failing mature AVF is the reason why it cannot be used for dialysis. So it is often delayed by half a year or more to allow additional time for the fistula to develop. 4,8 The

Methods
This type of research is the prognostic test. The research was conducted at the Vascular Surgery Outpatient at Dr. Mohammad Hoesin Palembang from July -September 2020.
The population in this study were all patients who underwent surgery for the formation of arteriovenous fistulas at Dr. Mohammad Hoesin Hospital Palembang for the period July -September 2020.
All members of the population who meet the inclusion and exclusion criteria.
Determination of the sample size in this study using the rule of thumb formula, which is 5-10 times the number of independent variables studied. The sample size in this study is 10 x 3 = 30 samples.
The inclusion criteria in this study included patients who underwent surgery for the formation of arteriovenous fistulas, the patient had stated their consent to be the study sample.
Meanwhile, the exclusion criteria in this study were patients who experienced primary failure in the formation of arteriovenous fistulas.
The data collected is primary data from the results of the doppler ultrasound examination Data were presented in 2 excel form and analyzed using SPSS version 21 program.

Result General Characteristics
Based on gender, there were 23 (76%) male and 7 (24%) female. The mean age in months was 13 months, the youngest was 34 years old and the oldest was 77 years old.

Discussion
AV maturation can be calculated through the rule of six, namely after 6 weeks of surgery, the diameter of the fistula on the body is about 6 mm with a depth of not more than 6 mm and the mean blood flow must be 600 ml / min or more and also the length of the fistula must be 6 cm. 46 In most cases, the etiology of AVF failure remains largely undetermined. After AVF was made, initially the prediction of maturation was based on the presence of a thrill or murmur, although prediction of AVF maturation using a murmur / thrill was still a debate, but The spiral flow pattern is easily identified using Doppler by interrogating the vessel in the true transverse plane at a low velocity setting. This approach results in a characteristic "red / blue" split onto a transverse Doppler image. If SLF is disturbed for physiological and anatomical reasons, turbulent flow will occur. There will appear to be a loss of blue-redshift in the turbulence area.
Consistent with this study, Srivastava et al. 2019 also found that spectral broadening was significantly associated with AVF maturation in HD patients, but only on days 0 and 7 postoperatively. 5  found that SLF and broadening spectra have high accuracy in predicting AV maturation. 5,38,43 In contrast to this study, Srivastava et al concluded that SLF and spectral broadening were associated with AVF maturation with high accuracy values with the earliest clinical parameters. 5 However, Nasr et al 2015 is in line with this study where the murmur / thrill still has high accuracy.
In predicting AV maturation, Nasr et al 2015 41