PEMERIKSAAN ADENOSIN

DEAMINASE (ADA) UNTUK DIAGNOSA

TUBERKULOSIS EKSTRAPULMONER
MENGGUNAKAN ALAT KIMIA KLINIK

Ina S Timan
Dept Patologi Klinik FKUI-RSCM, Jakarta

HKKI Makasar 280815

 Tuberculosis TB)
Top infectious disease killer worldwide
In 2014, 9.6 juta TB, mortalitas 1.5juta
95% mortalitas TB negara penghasilan low- middle, top 5
penyebab kematian wanita 15-44 th.
2014, 1 juta anak TB, 140 000 meninggal
TB pembunuh utama pada HIV-positif, 1 dari 3 kematian HIV
akibat TB
Global 2014, 480 000 penderitanya MDR-TB
Millennium Development Goal target: stop epidemi TB
43 juta terselamatkan karena TB diagnosis & terapi (2000-
2004)
2030 target stop TB : Sustainable Development Goals.
Tuberculosis TB)
 Tuberculosis TB)

TB ekstrapulmoner-pleura : penyebab tersering efusi pleura didaerah

endemik TB
Insidens TB pleura variasi :
USA 3-5%, Burundi 25%, RSCM efusi pleura TB 46% , RSP TB pleura TB 42%
Penyebab kematian terbanyak ke-2 setelah infeksi HIV
WHO 2014 : Indonesia (254 juta jiwa)
324,539 TB
19,653 TB ekstra paru.
 Mycobacterium Tuberculosis (MTB)

Basil aerob, tidak membentuk spora,tidak motil dengan

pertumbuhan lambat (Generation time 12-18 jam
pertumbuhan 3-6 minggu)
ini ditransmisikan melalui udara dan akan didapat melalui
inhalasi dalam bentuk droplet nuclei
Dinding sel karakteristik pada pewarnaan
Peptidoglikan : hidrofobik
Asam mikolat : sifat tahan asam
Patogen intraselular mampu bertahan &
bereplikasi di dalam fagosit
 Manifestasi Klinis

Lokal
Batuk kronis > 2 minggu
Batuk darah
Nyeri dada / Pleuritic Pain
Sesak Napas /Dyspneu

Sistemik
Demam
Malaise
Penurunan berat badan
Anoreksia
Keringat malam
 Pemeriksaan Penunjang

Bakteriologi dahak, cairan pleura, cairan serebrospinal,

bilasan bronkus, bilasan lambung, urin, feses & biopsi
Biakan Kuman media konvensional, mesia lain : MGITT &
BACTEC
Uji Tuberkulin (Mt)
Pemeriksaan Radiologis foto toraks, CT-scan, dan MRI
Lainnya:
Analisa caira pleura
Histopatologi jaringan
Pemeriksaan darah
 Pleural Efusi TB :
Curiga klinis efusi pleura TB (+)
Analisa cairan pleura : Eksudat MN
>50%,
Aktivitas adenosine deaminase
(ADA) > 40 U/l
Biakan TB lama
Biopsi : invasif

Perlu diagnosis utk OAT

TERSERING
 Pemeriksaan Laboratorium TB pleura

Analisa cairan pleura : eksudat, MN > 50%

BTA : densitas basil 10.000/mL Sensitivitas rendah
BTA Sitosentrifugasi : sensitivitas lebih baik
Biakan : densitas 10-100, sensitivitas rendah
Biakan cair : sensitivitas lebih baik , lebih singkat
ADA : Penelitian Sn 91-100% , Sp 81-94%
Banyak cut off 40 U/L paling sering digunakan (Sn&Sp
92% & 89%)
Nusantara : cut off 43 U/L
Kirana : Cairan otak : Sensitivitas 64%, spesifisitas 85%
 Adenosine deaminase (ADA)

adenosine aminohydrolase
Enzyme in purine metabolism, breakdown of adenosin (food,
turnover nucleic acid in tissues)
Present all mammalian cells, in humans development &
maintenance of immune system
Polypeptide chain, 363 AA, high degree of conservation in
species.
Core : Zn to remove amine group
Zn : provoke removal of H+ forms hydroxyl group
attacks substrate /amine group.
Instability of Zn decrease activity ADA
 Purine Metabolism

ADA irreversibly deaminate adenosine, convert to inosine by substitution of

amino group by hydroxyl group
Inosine then removed from ribose by purine nucleoside phosphorylase (PNP),
converting to hypoxanthine
Hypoxanthine catalyzed by xanthine oxidase form Uric acid
 Methodology for ADA

Determination of increase of
products per unit time
2. Inosine
(2) Enzymatic method

546nm

Blue colour
606nm

High sensitive High precision accurate

 Clinical Significance ADA

Tuberculous
Hepatic disease
disease

Elevated serum ADA : acute

hepatitis, alcoholic hepatic Increased ADA :
fibrosis, chronic active tuberculous pleuritis
hepatitis, liver cirrhosis, viral
hepatitis & hepatoma

Low serum ADA : serious

Leukemia, iron-deficiency
immuno defficiency
anemia

Immune disease Other disease

 Methodology for ADA

Determination of increase of
products per unit time
2. Inosine
(2) Enzymatic method

546nm

Blue colour
606nm

High sensitive High precision accurate

 Mindray ADA performance introduction

1-200 U/L

Linear Regression
300.0 Sample Level Measured value
250.0 y = 52.158x - 1.7843 0 0.0
R = 0.9992
1 50.2
ADA U/L

200.0

150.0 2 101.4
100.0 3 154.1
50.0
4 202.9
5 263.0
0.0
0 1 2 3 4 5 6
-50.0
sample level
 Mindray ADA performance introduction

100
Mean 90.1
90
80 SD 0.2916186
70
Value

60
CV 0.32%
50
40
30
20
One level of control is tested and
10
0
repeated for 20 times, which exhibits
0 5 10 15 20 good reproducibility with a CV< 1%.
No.
Mindray ADA performance introduction

12.0

12.0 10.0
10.0

valuevalue
10.0 8.0
8.0
8.0 6.0
6.0
6.0 4.0
4.0
4.0 2.0
2.0
2.0
0.0
0.0 0 1 2 3 4 5
00 100
0.8 1.6200 2.4300 3.2 400 4 500
bilirubin(mg/dL)
Intralipid(mg/dL
Ascorbic acid(mg/dL)
)

Low Low Concentration

LowConcentration
Concentration High Concentration
High Concentration
High Concentration

Substance Level Tested Observed Effect

Ascorbic acid 4 mg/dL NSI*
Lipemia 500 mg/dL NSI
Bilirubin 5 mg/dL NSI
Hemoglobin 500 mg/dL NSI
* NSI: No Significant Interference (within 10%)
 Mindray ADA advantages

Advantages

High sensitivity: Measured Low limit of detection 1U/L

Wide linearity range: Measured 1~200 U/L
Excellent precision at lower end
Strong anti-interfering ability for lipemia, bilirubin, hemaglobin &
ascorbic acid
Good correlation to reference method
Calibrators standardized to International Reference Material ERM-
AD455/IFCC
Long shelf life: 18 months
 Summary - ADA

adenosine aminohydrolase, enzyme in purine metabolism,

Serum ADA mainly from liver, (cytoplasm enzyme)

Median ADA PE TB : 55.1 U/L , non TB 10.6 U/L (p=0,005)

Area under curve (AUC) ROC = 0,923.
Cut off ADA 35 U/L : sensitivity 90.6 %, spesivicity 82.0 %
differenciate TB/non TB PE & CSF
Scoring system for clinician ADA + mostly TB PE
Terima kasih