program & abstract - NASWAAM 2018

Udayana University in collaboration with

S C I

Mesenchymal Stem Cells

StemLive

INCAAM

PROGRAM & ABSTRACT National Symposium and Workshop on Anti-Aging Medicine (NASWAAM)

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February 9 -11

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2018

Harris Sunset Hotel Sunset Road, Denpasar Bali

Hosted by: Center for Study of Anti-Aging Medicine Medical Faculty Udayana University, Denpasar, Bali - Indonesia e-mail : [email protected]

www.naswaambali.com

NASWAAM-2018

PROGRAM & ABSTRACT National Symposium and Workshopon Anti-Aging Medicine

(NASWAAM)

PROGRAM & ABSTRACT National Symposium & Workshop on Anti-Aging Medicine (NASWAAM)

Theme:

Anti-Aging Medicine & Improvement in The Quality of Life

February 9th-11th 2018 Harris Sunset Hotel Sunset Road, Denpasar Bali ISBN : 978-602-294-260-3

NASWAAM-2018

National Symposium & Workshop on Anti-Aging Medicine (NASWAAM)

Sambutan Ketua Panitia

NASWAAM-2018

Salam bahagia untuk kita semua,

National Symposium and Workshop on Anti-Aging Medicine (NASWAAM) 2018

Theme:

Anti-Aging Medicine & Improvement in The Quality of Life

Sang waktu berjalan begitu cepat. Tanpa terasa National Symposium & Workshop on Anti-Aging Medicine (NASWAAM) telah menjelang datang kembali. Bulan awal kami pilih sebagai bulan NASWAAM, yang menjadi lambang munculnya semangat yang selalu muda sesuai dengan konsep Anti-Aging Medicine. Setelah sepuluh tahun Program Pascasarjana dengan Kekhususan Anti-Aging Medicine diselenggarakan oleh Fakultas Kedokteran Universitas Udayana, telah banyak hasil studi yang menunjukkan manfaat konsep Anti-Aging Medicine bagi kehidupan kita. Perbaikan kehidupan itu ditunjukkan oleh peningkatan Kualitas Hidup. Kalau Kualitas Hidup meningkat dan menjadi lebih baik, maka kemampuan bekerja dan hasilnya pasti lebih baik juga. Pada akhirnya Indeks Pembangunan Manusia Indonesia juga ikut meningkat. Untuk tema besar acara NASWAAM 2018 ini kami pilih “Anti-Aging Medicine & Improvement in the Quality of Life”. Peningkatan Kualitas Hidup haruslah merupakan hasil akhir dan indikator berhasil tidaknya aplikasi konsep Anti-Aging Medicine. Inilah sebenarnya inti konsep Anti-Aging Medicine. Tema besar ini disampaikan dalam bentuk Plenary Lecture, Symposium & Workshop dengan topik masing-masing yang terkait. Dengan mengikuti acara ini, peserta akan mendapat informasi penting terkait Anti-Aging Medicine dalam pengertian yang benar dan kaitannya dengan Kualitas Hidup.

Usai acara, peserta dipersilakan menikmati keunikan Bali dalam berbagai aspeknya. Sampai berjumpa dan selamat menyerap informasi terkini dan sesungguhnya dalam Anti-Aging Medicine.

Prof. Dr. dr. Wimpie Pangkahila, SpAnd Ketua Pusat Studi Anti-Aging Medicine, Kekhususan Anti-Aging Medicine Program Studi Magister & Doktor Universitas Udayana Indonesian Center for Anti-Aging Medicine (INCAAM) iii

NASWAAM-2018

ORGANIZING STEERING COMMITTEE Prof. Dr. dr. Wimpie Pangkahila, SpAnd Prof. Dr. dr. Alex Pangkahila, M.Sc, SpAnd Prof. Dr. dr. AAG Budhiartha, SpPD-KEMD Dr. dr. Thomas Eko, SpS-K Dr. dr. AAGP Wiraguna, SpKK-K Dr. dr. Gde Indraguna Pinatih, MSc, SpGK ORGANIZING COMMITTEE: Chairman : Prof. Dr. dr. Wimpie Pangkahila, SpAnd Vice chairman: Prof. Dr. dr. AAG Budhiarta, SpPD-KEMD Secretary : dr. Oka Negara Treasure : dr. AAAN Susraini, SpPA(K) MEMBERS: Dr. dr. Desak Wihandani, M.Kes dr. N Iswayuni, MBiomed (AAM) dr. Rosalina Silvia Dewi, MBiomed (AAM) dr. Rusmiasih Anom, MBiomed(AAM) dr. Ristie Darmawan, MBiomed (AAM) dr. Dina Andaka, MBiomed (AAM) dr. IGA Dewi Ratnayanti, MBiomed (AAM) dr. IA Wiryantini, MBiomed (AAM) dr. Yukhi Kurniawan, SpAnd

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SCIENTIFIC SCHEDULE : NASWAAM BALI 2018 Harris Hotel Sunset Road, 09-11 Februari 2018

DAY-I | Friday 09 February 2018 : Symposium TIME

NASWAAM-2018

TOPIC | SPEAKERS & MODERATOR

07.30-08.30

Registration

08.15-08.55 08.15-08.30 08.30-08.35 08.35-08.40 08.40-08.45

Opening Ceremony : MC: dr. Dina Andaka,M.Biomed (AAM) Welcome Dance The National Anthem "Indonesia Raya" The Indonesian Medical Association Song Committee Reports | Chairman Prof. Dr. dr. Wimpie Pangkahila, Sp.And Speech Message from: President Elect of Indonesian Medical Association Prof. Dr. Ilham Oetama Marsis, Sp.OG Speech Message from: Rector of Udayana University Prof Dr dr A.A.Raka Sudewi, SpS (K)

08.45-08.50

08.50-08.55

08.55-09.05

Coffee Break

09.05-09.35

Plenary lecture I: Medicolegal Issue and Patient Safety Prof . Dr. Ilham Oetama Marsis, Sp.OG

09.35-10.05

Plenary lecture II: Anti-Aging Medicine and the Quality of Life Prof. Dr. dr. Wimpie Pangkahila, Sp.And

10.05-10.35

Plenary Lecture II: Update Report of Stem Cell Therapy: between research & application Prof. Dr. Thay-Yen Ling, PhD (National Taiwan University)

10.35-11.25 10.35-10.55 10.55-11.15 11.15-11.25

Symposium I: New insight of sexual dysfunction Moderator: TBA Sexual dysfunction as an indicator of aging process dr. Heru Harsojo Oentoeng, M.Repro.,SpAnd Update treatment of erectile dysfunction Prof. Dr. dr. Wimpie Pangkahila, Sp.And Q&A v

SCIENTIFIC SCHEDULE : NASWAAM BALI 2018 Harris Hotel Sunset Road, 09-11 Februari 2018

DAY-I | Friday 09 February 2018 : Symposium TIME 11.25-12.35

TOPIC | SPEAKERS & MODERATOR

12.25-12.35

Symposium II: Complex problems of obesity Moderator: TBA Nutrition for obesity dr. Ray Sugianto, MD, MNutr Hormonal aspect in obesity Prof. Dr. dr. AAG Budhiarta, SpPD-KEMD Exercise program for obese people Prof. Dr. dr. Alex Pangkahila, MSc, SpAnd Q&A

12.35-13.30

Friday Prayer & Lunch

13.30-14.40

Symposium III: Healthy food and supplement Moderator: TBA What is healthy food? Dr. dr. Gde Indraguna Pinatih, MSc, SpGK Supplements used in the context of Anti-Aging dr. Ray Sugianto, MD, Mnutr Intoxicated food products in Indonesia Dr. dr. Wayan Weta, MS, SpGK Q&A

11.25-11.45 11.45-12.05 12.05-12.25

13.30-13.50 13.50-14.10 14.10-14.30 14.30-14.40 14.40-16.40 16.40-17.00 18.30-21.30

NASWAAM-2018

Free papers (Indonesian Award for Anti-Aging Medicine) 2018 Coffee Break Faculty Dinner

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SCIENTIFIC SCHEDULE : NASWAAM BALI 2018 Harris Hotel Sunset Road, 09-11 Februari 2018

DAY-2 | Saturday 10 February 2018 : Symposium TIME

NASWAAM-2018

TOPIC | SPEAKERS & MODERATOR

08.30-09.00

Registration

09.00-09.30

Plenary lecture IV: Moderator: TBA Worldwide experimental and clinical data of Stem Cell Therapy Prof. Dr. Rita Huang, Ph.D (Taipei Medical University)

09.30-10.00

Plenary lecture V: Moderator: TBA Spreading of supplement and cosmetic products in the name of Anti-Aging: How to control ?3 Dra. Mayagustina Andarini, M.Sc.,Apt (BPOM Wilayah Bali)

10.00-10.20

Coffee Break

10.20-11.30

Symposium IV: Men's and Women's health : Implementing science for a better life Moderator: TBA

10.20-10.40

Role of Testosterone beyond sexuality dr. Nugroho Setiawan, MKes, SpAnd Causes and prevention of hyperandrogenism in women dr. Fransisca Mochtar, SpOG, MBiomed (AAM) Treatment of hyperandrogenism in women Prof. Dr. dr. Wimpie Pangkahila, SpAnd Q&A

10.40-11.00 11.00-11.20 11.20-11.30 11.30-12.20

Lunch Symposium: Holistic therapy for wrinkle and hyperpigmentation focus on oral collagen and antioxidant agent Moderator: dr. AAAN Susraini, SpPA-K

11.30-11.50

12.10-12.20

Holistic therapy for wrinkle and hyperpigmentation focus on oral collagen and antioxidant agent Dr. dr. AAGP Wiraguna, SpKK-K Oral Collagen and antioxidant therapy dr. Muliaman Mansur Q&A

12.20-13.20

Lunch

11.50-12.10

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SCIENTIFIC SCHEDULE : NASWAAM BALI 2018 Harris Hotel Sunset Road, 09-11 Februari 2018

DAY-2 | Saturday 10 February 2018 : Symposium NASWAAM-2018

TIME

TOPIC | SPEAKERS & MODERATOR

13.20-13.50

Plenary lecture VI : Why do we prefer allogenic Stem Cell? Moderator: TBA Why do we prefer allogenic Stem Cell? Dr. Tom Kuo, PhD (Taipei Medical University)

13.50-14.40

Symposium V: Stem cell therapy-between research and application Moderator: TBA

13.50-14.10

Death after Stem Cell Therapy: What is the problem? dr. Sandy Qlintang Application of Stem Cell Therapy Indra Bachtiar, Ph.D Q&A

14.10-14.30 14.30-14.40 14.40-15.30 14.40-15.00 15.00-15.20 15.20-15.30 15.30-15.50 18.30-21.30

Symposium VI: Exercise and aging process Moderator: TBA Exercise to delay aging process Dr dr Alex Pangkahila, SpAnd Exercise without steroid for muscle development dr Michael Triangto, SpKO Q&A Coffee Break Gala Dinner & Presenting Indonesian Award for Anti-Aging Medicine 2018

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SCIENTIFIC SCHEDULE : NASWAAM BALI 2018 Harris Hotel Sunset Road, 09-11 Februari 2018

DAY-3 | Sunday 11 February 2018 : Symposium & Workshop TIME

NASWAAM-2018

TOPIC | SPEAKERS & MODERATOR

08.30-09.00

Registration & Coffee Break

09.00-10.30

Symposium VII: Aesthetic aspect of Anti-Aging Medicine

Moderator: TBA 09.00-09.20 09.20-09.40 09.40-10.00 10.00-10.10

10.10-10.30 10.30-10.40

Prevention and treatment of aging skin dr. Teguh Tanuwidjaja, MBiomed (AAM) Threadlift: effect and side effect Dr. dr. AAGP. Wiraguna, SpKK-K Treatment of aging skin with ultrasound dr. Nenden Sobarna, SpKK Q&A

Prevention of side effects of filler and botox dr. Almond Wibowo, MBiomed (AAM) Q&A

10.40-12.40

Workshop I Procedures of Stem Cell Therapy Dr. Tom Kuo, Ph.D

12.40-13.30

Lunch

13.30-16.30

Workshop II: Up-date in Aesthetic intervention

13.30-15.00

Threadlift dr. Teguh Tanuwidjaja, MBiomed (AAM) Botox and filler dr. Almond Wibowo, MBiomed (AAM)

15.00-16.30 16.30-17.00

Closing Ceremony & Coffee Break

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NASWAAM-2018

National Symposium & Workshop on Anti-Aging Medicine (NASWAAM)

Contents Massage ……….............................................................................................

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Organizing Committee ...............................................................................

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Scientific Schedule ……….........................................................................

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Contents .......................................................................................................

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Plenary Lecture PL.1

Anti-Aging Medicine and the Quality of Life ........................ Prof. Dr. dr. Wimpie Pangkahila, Sp.And

PL-3

Cell Therapy and Regeneration Medicine: Current, Future, and Prospect ............................................................... Prof. Dr. Rita Huang, Ph.D - Taipei Medical University

6

Why do we prefer allogenic Stem Cell ? ..............................

7

PL-5

1

Dr. Tom Kuo, PhD (Taipei Medical University) Symposium I: New insight of sexual dysfunction S1.1 Sexual dysfunction as an indicator of aging process dr. Heru Harsojo Oentoeng, M.Repro.,SpAnd

8

S1.2

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Update treatment of erectile dysfunction ......................... Prof. Dr. dr. Wimpie Pangkahila, Sp.And

Symposium II: Complex problems of obesity S2.1

Nutrition for obesity ....................................................................

12

dr. Ray Sugianto, MD, Mnutr S2.2

Hormonal aspect in obesity ......................................................

14

Prof. Dr. dr. AAG Budhiarta, SpPD-KEMD S2.3

Exercise program for obese people .......................................

27

Prof. Dr. dr. Alex Pangkahila, MSc, SpAnd

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Symposium III: Healthy food and supplement S3.1

What is healthy food? ................................................................

28

Dr. dr. Gde Indraguna Pinatih, MSc, SpGK S3.2

Supplements used in the context of Anti-Aging .................

34

dr. Ray Sugianto, MD, Mnutr S3.3

Minimized Food Toxicity and Poisoning and Keep The Safety ............................................................................................. Dr. dr. Wayan Weta, MS, SpGK

Symposium IV: Men's and Women's health : Implementing science for a better life S4.1 Role of Testosterone beyond sexuality ............................... dr. Nugroho Setiawan, MKes, SpAnd

35

39

S4.2

Causes and prevention of hyperandrogenism in women dr. Fransisca Mochtar, SpOG, MBiomed (AAM)

41

S4.3

Treatment of hyperandrogenism in women ......................... Prof. Dr. dr. Wimpie Pangkahila, SpAnd

50

Symposium V: Stem cell therapy-between research and application S5.1 Terapi sel punca : harapan dan risiko ........................... dr. Sandy Qlintang S5.2

Application of Stem Cell Therapy .......................................... Indra Bachtiar, Ph.D

53 54

Symposium VI: Exercise and aging process S6.1

Exercise to delay aging process .............................................

61

Dr dr Alex Pangkahila, SpAnd S6.2

Exercise without steroid for muscle development ............. dr Michael Triangto, SpKO

xii

62

Symposium VII: Aesthetic aspect of Anti-Aging Medicine S7.2

Threadlift: effect and side effect ............................................ Dr. dr. AAGP. Wiraguna, SpKK-K

S7.1

Combating Aging Sign using Combination of Lifting Cone Thread – Volume Correction Polycaprolactone Collagen Stimulator .................................................................. dr. Teguh Tanuwidjaja, MBiomed (AAM)

S7-3

Hifu for Rejuvination Treatment .............................................. dr. Nenden Sobarna, SpKK

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65 66

Lunch Symposium Holistic therapy for wrinkle and hyperpigmentation focus on oral collagen and antioxidant agent S5.1

Holistic therapy for wrinkle and hyperpigmentation ...........

68

Dr. dr. AAGP Wiraguna, SpKK-K S5.2

Oral Collagen and antioxidant therapy .................................

70

dr. Muliaman Mansur

SS1

Prevention of side effects of filler and botox dr Almond Wibowo, MBiomed (AAM)

...................

73

Dapatkah terapi ozon mayor (MAH) mengembalikan lansia ke kondisi seperti pada usia yang lebih muda? Cynthia Sugiharto

75

Indonesian Award for AAM FP-1

FP-2

Skin booster as a facial skin anti-aging strategy ............... Findrilia Sanvira Santoso

FP-3

Fucoxanthin : a promising natural marine drug with neuroprotective effects .............................................................. Oki Nugraha Putra 1, Nani Wijayanti 2

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90

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FP-4 FP-5

FP-6

FP-8

FP-9

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Klotho, target terapi potensial untuk mencegah penuaan dr. Vitia Tandy Combination of triamcinolone acetonide and latanoprostfor eyebrows alopecia treatment ....................... Listya Paramita

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107

Molecular hydrogen as a preventive and therapeutic as an anti aging medicine .............................................................. Mulyadi Tedjapranata

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Prospek Media Sel Punca Jaringan Adiposa Terkondisi Sebagai Anti-Aging .................................................................. Bayu Tirta Dirja

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Ekstrak Etanol Daun Sirsak (Annona Muricata Linn.) Meningkatkan Sel Leydig pada Tikus (Rattus Norvegicus) Jantan Galur Wistar Diabetes ....................... Putu atu dewi yustisiani

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NASWAAM 2018

Planary Lecture

ANTI-AGING MEDICINE AND THE QUALITY OF LIFE Wimpie Pangkahila Post Graduate Program in Anti-Aging Medicine Department of Andrology and Sexology Medical Faculty Udayana University Indonesian Center for Anti-Aging Medicine (INCAAM)

Introduction Basically the concept of Anti-Aging Medicine (AAM) is aging process is considered as a disease that can be prevented, treated, and reversed. Aging is no longer accepted as a destiny with all disability, dysfunction, diseases, debility, or cognitive impairment. In the concept of AAM, chronological age is not identical with physiological age. With medical intervention, physiological age can be maintained and reversed to younger healthy condition. Many scientific data have reported that aging process can be slowed down, delayed, even reversed, and lifespan can be extended. Finally people can live longer in healthy condition with optimum Quality of Life (QoL). Therefore AAM is not a science about physical appearance or beauty only, but it is about whole body function as a healthy human being with good QoL. Difference of life expectancy The report of WHO in 2015 stated that there is clear difference in life expectancy between developed and developing or underdeveloped countries. As examples, life expectancy of Afghanistan was 60.5 year old for both sex, Mozambique 57.6, Iraq 68.9, Bangladesh 71.8, Libya 72.7 years old, Arab Saudi 74.5, and Malaysia 75.0 years old. 1

Anti-Aging Medicine & Improvement in The Quality of Life

Compared to people of developing countries, there was difference where their life expectancy was longer. People in Japan have life expectancy 83.7 years old. Switzerland 83.4, Singapore 83.1, Italy 82.7, Sweden 82.4, Netherland 81.9, South Korea 82.3, United Kingdom 81.2, Germany 81.0, Denmark 80.6, and USA 79.3 years old. However, there was a difference between life expectancy of men and women in all countries. Life expectancy of women in all countries was longer than men. For examples, in Japan life expectancy of women was 86.8 years old and for men was 80.5 years old. In Switzerland, life expectancy was 85.3 and 81.3 for women and men respectively. Same data also found in some other countries. In Singapore, life expectancy was 86.1.and 80.0 for women and men respectively. In Italy life expectancy was 84.8 and 80.5 for women and men respectively, and In USA life expectancy of women was 81.6 and men was 76,9 years old. How about Indonesian? Average life expectancy of Indonesian people in 2015 was 69.1 years old. Indonesian women also had longer life expectancy compared to men, 71.2 and 67.1 years old respectively. The difference of life expectancy between countries and between sexes, strongly demonstrated that there are certain factors influencing aging process. These factors are not the same in people with different countries and sexes. 2 These WHO report can be used as a proof that Indonesian cultural belief that “birth, growth, and death” is a destiny that can not be prevented and treated is not true. This cultural belief appeared when medical science and technology have not developed as today. The concept of AAM has brought a new paradigm and a new hope related to aging process.

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NASWAAM 2018

Quality of Life WHO defined the QoL as an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concern. It is a broad ranging concept affected in a complex way by the person's physical health, psychological state, personal beliefs, social relationships and their relationship to salient features of their environment. Domain

Aspects

I

Physical Health

1. Pain and uncomfort 2. Energy and fatigue 3. Sleep and rest 4. Dependence to medicines 5. Mobility 6. Daily activity 7. Work capacity

II

Psychosocial Health

8. Positive feeling 9. Negative feeling 10. Self esteem 11. Ability to concentrate 12. Image and physical appearance 13. Spirituality, religion, personal belief

III

Social relationship

14. Personal relationship 15. Sexual life 16. Social and friends support

IV

Environment

17. Safety in daily life 18. Physical environment (pollution/voice/traffic/weather) 19. Material source 20. Chance to get new information 21. Participation and chance to do recreation/relax 22. Condition of home 23. Health and social insurrance 24. Transportation

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Anti-Aging Medicine & Improvement in The Quality of Life

QoL includes 4 domains in life, those are Physical Health, Psychosocial Health, Social Relation, Environment. Each domain has some aspects that influence the QoL. Totally there are 24 aspects as follows. Most of all aspects are related to health condition and body functions, whether it is in healthy condition or not normal due to certain causes. Many psychogenic complaints actually related to or caused by physical problems. For example, in deficient or imbalanced hormone, there are many psychogenic complaints appear that decrease the QoL. 3 The intervention based on the concept of AAM will decrease all complaints and reverse the poor condition to a better healthy condition as in younger age. Finally this increase the QoL. The intervention of AAM should be based on practicing healthy life style. In detail, the interventions are as follows. 1. 2. 3. 4. 5. 6. 7. 8.

Regular exercise Enough sleep Balancing between activities and relaxation Healthy diet Avoid toxic substance Avoid or manage stress Healthy sexual life Do not consume any substance (mixture, medicine, supplement) without doctors’ recommendation or if doctors do not understand

9.

Do regular medical check up for early detection of aging process and age-related disorders or dysfunctions

10. Get treatment soon in the condition where aging process or risk factors start to appear. Replacement therapy is needed: supplement, hormone, and next stem cell therapy. All treatment must be evidence-based.

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NASWAAM 2018

Conclusion Based on the concept of AAM aging is no longer accepted as a destiny with all disability, dysfunction, diseases, debility, or cognitive impairment. However, aging process is considered as a disease that can be prevented, treated, and reversed. The intervention should be performed to prevent, delay, and reverse aging process to the optimum healthy condition like in younger age. Finally people can live longer in healthy condition with good QoL.

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Anti-Aging Medicine & Improvement in The Quality of Life

Planary Lecture

CELL THERAPY AND REGENERATION MEDICINE: CURRENT, FUTURE, AND PROSPECT Rita Yen-Hua Huang Distinguished Professor and Director Department of Biochemistry and Molecular Cell Biology, College of Medicine International PhD Program for Cell Therapy and Regeneration Medicine Center for Cell Therapy and Regeneration Medicine/GTP Laboratory Taipei Medical University

Abstract Cell therapy and regeneration medicine has been the new promising therapeutic strategies especially for the coming aging society. In aging population, more than 75% of aged 60 or over population will have one chronic disease; and around 50% of aged 60 or over population will have more than two chronic diseases. Cancer, inflammatory diseases, Parkinson's disease, Alzheimer's disease, and heart/ cardiovascular disease are the biggest killers of aging population. Thus, clinical use of cells and/or stem cells targeting on diseases of aging or unmet medical needs is urgently needs. In this talk, I will cover the most updated global development of cell therapy and regeneration medicine, the clinical safety and efficacy in cell/stem cell clinical trials will be highlighted.

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NASWAAM 2018

Planary Lecture

MANUFACTURING CELL THERAPIES FROM BENCH TO CLINIC Tom K. Kuo Hopkins Center for Precision Medicine, Director RESPERA Inc., CEO

Abstract Over the past decade, we have witnessed the beginning of a paradigm shift from conventional healthcare and treatment modalities to a focus on regenerative medicine. The evolution of cell biology research has demonstrated immense potential of treatment major debilitating diseases through cell therapy. Cell therapy is the administration of living cells as therapeutic products to treat or prevent a disease condition. As technologies are translated from lab scale to commercial scale, numerous attributes and technical hurdles need to be considered when developing living cell-based “drugs”, in order to achieve adequate product characterization, product efficacy, verifiable consistency, product efficacy, as well as balancing the cost of goods. Frequently, the root cause of commercial and clinical failures of candidate therapeutic products is the lack of sophistication in developing an appropriate bioprocess, leading to the impairment in critical product attributes and set the stage for clinical failure. In this workshop, using mesenchymal stem cells as an example, we will discuss the critical parameters for successful cell therapy, with emphasis on autologous versus allogeneic cell therapy, cell product characterization, choice of bioprocessing technologies, quality control and product standardization.

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Anti-Aging Medicine & Improvement in The Quality of Life Symposium I: New insight of sexual dysfunction

SEXUAL DYSFUNCTION AS AN INDICATOR OF AGING PROCESS Heru H. Oentoeng Siloam Hospitals Kebon Jeruk, Jakarta Abstract The sexual response cycle refers to the sequence of physical and emotional changes that occur as a person becomes sexually aroused and participates in sexually stimulating activities. Erotic stimuli initiate a series of physiologic changes that have collectively been termed the‘ sexual response cycle’ and are divided into four distinct phases: excitement, plateau, orgasm, and resolution; (EPOR) in male, and more complicated in female. From ‘sexual response cycle’ we could devided male sexual dysfunction into sexual desire disorders, erectile dysfunction, ejaculatory dysfunction and orgasmic dysfunction. And similar to male, female sexual dysfunction could devided into sexual desire disorders, sexual arousal disorders, orgasmic disorders and sexual pain disorders. Advances in health care are allowing individuals to live longer, healthier lives. However, longer lifespans create new health-related issues and problems that must be addressed. Older adults increasingly focus on quality of life concerns. Sexuality is a significant quality of-life consideration for all men and women, included older adults. Better sexual life by having a good interpersonal relationship, physical and mental factors also play a role in good sexual response. Stressed, poor relationship, depression will contribute sexual dysfunction in male and female. Healthy blood flow is the main factor which generate hard erection in male, and arousal response in female. When sexual problems occur, we should be alert to the disruption of endothelial function and hormonal disorders that are indicators of aging.

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NASWAAM 2018 Symposium I: New insight of sexual dysfunction

UPDATE TREATMENT OF ERECTILE DYSFUNCTION Wimpie Pangkahila Post Graduate Program in Anti-Aging Medicine Department of Andrology and Sexology Medical Faculty Udayana University Indonesian Center for Anti-Aging Medicine (INCAM) Introduction Erectile dysfunction (ED) is the persistent or recurrent inability to achieve or maintain penile erection sufficient for sexual intercourse. It means that ED is not about other components of sexual function. ED is one of the sexual dysfunctions that disturb many men and their partners in all over the world. The incidence of ED increases with age. The Massachusetts Male Ageing Study (MMAS) showed that 52 percent of respondents aged 4070 years reported some degree of ED. If the MMAS data is extrapolated, it is estimated 18-30 million American men have ED. Even though there is no exact data of ED in Indonesia, based on the patient records in the clinic it is no doubt that there are many ED people in this country. It is estimated not less than 10 percent of the Indonesian married men have ED. Update treatment Treatment of ED is divided into 3 lines. The first line therapy is oral PDE5 inhibitor. Second line therapy is intracavernous injection of alprostadil which is now rarely used. The third line therapy is surgery for penile implant, which is very rarely practiced any longer. The problem is many doctors do not make right diagnosis of ED. Many doctors diagnose ED only base on the complaint of patient that “My erection is weak”. In fact, “weak erection or lose of erection” does not always mean ED. 9

Anti-Aging Medicine & Improvement in The Quality of Life

Men who experience Hypoactive Sexual Desire Disorder also have weak or lose of erection. However, the treatment is difference with the treatment of ED. Therefore many doctors fail to treat ED patients with first line therapy. Another problem is doctors only focus on how to make better erection. In fact, ED is not a kind of disorder with no causes or risk factors. ED actually is “a symptom or sign” of many etiologies or risk factors. ED actually is an indicator of unhealthy condition including aging process. Even ED is a predictor of next future health problems. There are many causes or risk factors related to ED that are divided into two groups, those are physical factors and psychogenic factors. Included in physical factors there are hormonal, vasculogenic, neurogenic, and iatrogenic factors. Psychogenic factor include predisposing, precipitating, and maintaining factors. Therefore update treatment of ED should be as follows.

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1.

Make right diagnosis of ED, not other sexual dysfunction. Exactly differentiate with Sexual Desire Disorder

2.

Find the causes or risk factors related to ED, including psychogenic factors related to the couple.

3.

Treat the causes or risk factors Without treatment to the etiologies or risk factors, treatment with PDE-5 inhibitor will not be optimal, even fail. In the condition where Testosterone level decreases or deficient, response to PDE-5 inhibitor decrease or even fail. In ED patients caused by diabetes, when angiopathy and neuropathy occur extensively, PDE-5 inhibitor generally fail to result in full erection. In Metabolic Syndrome, where there are more factors involved, PDE-5 inhibitor does not work optimally even fail. Prostatectomy also may result in ED. Many of ED patients as the complication of prostatectomy do not respond to PDE-5 inhibitor.

4.

In case where psychogenic factors involved, counseling and education are needed

NASWAAM 2018

5.

Improve the erectile function with PDE-5 inhibitor, started with general low dose In case where patients do not respond to certain PDE5 inhibitor, double the dose or switch to PDE-5 inhibitor with longer half-life, that is tadalafil

Low dose of Tadalafil Exclusively for tadalafil, there are 2 kinds of administration, those are on demand administration of 10-20 mg and lower dose of 5 mg once daily administration. On demand administration is used before intercourse. Even though erection occurs optimally, but patients feel under control because they have to plan the intercourse and take the pill before. Once daily administration of low dose tadalafil brings an advantage where patients do not feel under control of the medicine. Patients feel like normal men with normal erectile function due to continuously sufficient concentration of tadalafil that result in high concentration of cGMP. Finally this offers ED patients a higher level of efficacy and flexibility in sexual intercourse. In this condition patients can have intercourse any time it is available and when they want. Conclusion Diagnose of ED should be established, differentiate with other sexual dysfunction that also result in erectile disturbance. The causes or risk factors should be found and treated. The use of daily tadalafil brings an advantage for ED patients in their sexual encounter.

*Presented in the National Symposium and Workshop on Anti-Aging Medicine (NASWAAM). Denpasar, February 9-11, 2018.

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Anti-Aging Medicine & Improvement in The Quality of Life Symposium II: Complex problems of obesity

NUTRITION FOR OBESITY Ray Sugianto Abstract

Obesity is a risk factor for a wide-range of medical conditions. Heart disease, cerebrovascular disease, and metabolic-related conditions are found to be associated with obesity. Not to mention musculo-skeletal and quality of life in general that also affected. As is the trend worldwide, we are already observing an increasing number of obesity patients in our daily practice, whether they are being seen for obesity-related conditions or not. The value of all physicians on addressing this problem cannot be underestimated, given that some obesity condition can be managed well without any referrals. Thus, this session aimed to equips clinicians on practical obesity management, which will cover: 1) The concept of energy balance: The basis of diet and physical activity prescription on weight management. 2) Monitoring progress in obesity case:The use of serial weight measurement, subcutaneous fat measurements, body impedance analysis, and other more recent techniques 3) Strategy 1: beverage review: How a simple inquiry on daily beverage habits might found the cause of obesity, followed by the significant energy contributors from drinks that is often overlooked by patients 4) Strategy 2: scheduling of meals: Discussing the current trends on scheduling, on intermittent fasting, on energy distribution throughout the day, and meal frequencies

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5) Strategy 3: Altering diet composition: How diet affect the appetite, on the satiety-satisfaction-mood link, and effect of high-protein diet 6)

Addressing misconceptions on diet-related strategies, the questions often raised by patients, and prevalent popular ideas related to metabolism and physiology.

1. Research Scholar, National University of Singapore

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Anti-Aging Medicine & Improvement in The Quality of Life Symposium II: Complex problems of obesity

HORMONAL ASPECT IN OBESITY A. A. Gd .Budhiarta Pusat Studi Anti-Aging Medicine Fakultas Kedokteran Universitas Udayana

Pendahuluan Obesitas merupakan penyakit kronis dan terjadi akibat ketidak seimbangan antara asupan dan pengeluaran energi. Kelebihan asupan energi akan disimpan sebagai lemak tubuh di dalam adiposit sehingga akan mengalami hipertrofi dan hiperplasi dan merupakan kelainan patologis yang karakteristik dari obesitas. Peningkatan masa lemak tubuh akan menimbulkan berbagai problema klinis yang berhubungan dengan obesitas. Obesitas menimbulkan berbagai kelainan pada sistim endokrin seperti kelainan kadar hormon yang diakibatkan oleh pola sekresi dan atau pola metabolismenya, perubahan dari transport hormon dan kerja hormon pada jaringan target7. Kelainan ini dapat sekunder disebabkan karena obesitas dan terbukti dapat ditimbulkan dengan nutrisi yang berlebih sebaliknya akan membaik setelah terjadi penurunan berat badan. Atau kelainan hormonal dapat sebagai penyebab dari perbagai kelainan yang dijumpai pada obesitas. Fenotipe dari obesitas yang berbeda akan menimbulkan gangguan kesehatan yang berbeda. Obesitas abdominal atau viseral dianggap lebih berbahaya dibandingkan dengan obesitas gluteofemoral atau obesitas ginekoid5

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Tabel 1. Kelainan endokrin pada obesitas Endocrine gland

Hormonal change

(1) Endocrine pancreas (2) Adipose tissue

Hyperinsulinemia Hyperleptinemia Adiponectin decrease Decrease in basal and stimulated GH Decreased response to prolactin stimuli Women: decreased SHBG. Increased free estradiol and testosterone Men: decreased SHBG. Decreased total and free testosterone Increased free urinary cortisol and normal plasma cortisol Ghrelin decrease

(3) Pituitary gland

(4) Gonads

(5) Adrenal glands (6) Gastrointestinal hormones (7) Thyroid gland

TSH and free T3 increase

Jaringan Adiposa Ditemukannya leptin pada tahun 1994 memperkuat dugaan sebelumnya bahwa jaringan adiposa merupakan organ endokrin. Jaringan adiposa mengeluarkan berbagai adipokine yang bekerja secara lokal (autokrin/parakrin) maupun secara sistemik (endokrin). Seperti adiponektin, tumor necrosis factor- (TNF-), interleukin-6 (IL6), plasminogen activator inhibitor-1(PAI-1), transforming growth factor1 (TGF-1), leptin, angiotensinogen, resistin, visfatin, adipsin, retinol binding protein-4 (RBP-4). Meningkat atau menurunnya berbagai adipokin ini akan menimbulkan berbagai kelainan. Timbunan lemak berlebih terutama pada daerah viseral berhubungan dengan resistensi insulin, hiperglikemia, dislipidemia, hipertensi, status protrombotik dan inflamasi dan dikenal sebagai sindroma metabolik1,3,5

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Leptin Hormon leptin terdiri dari 167- asam amino peptida dikoding oleh gene obesitas (ob) dan dihasilkan oleh jaringan adiposa. Kadar leptin dalam serum meningkat pada obesitas dan berhubungan langsung dengan masa lemak tubuh. Penemuan leptin meningkatkan pemahaman kita mengenai bagaimana jaringan adiposa melakukan komunikasi dengan sistim saraf pusat. Leptin merupakan satiety hormone memberikan umpan balik negatif ke hipotalamus untuk mengendalikan nafsu makan dan meningkatkan pengeluaran energi, sehingga leptin disebut sebagai hormon anti obesitas. Kadar leptin dalam serum meningkat pada obesitas dan sangat berhubungan dengan masa lemak. Kadar leptin yang meningkat akan menimbulkan penurunan asupan energi tetapi pada obesitas keadaan ini tidak dijumpai karena pada obesitas terjadi resistensi terhadap kerja leptin1,5 Adiponektin Adiponektin hanya dihasilkan oleh jaringan adiposa dan terjadi korelasi negatif yang kuat antara kadar adiponektin plasma dengan masa jaringan lemak. Kadar adiponektin menurun pada obesitas dan sebaliknya meningkat dengan penurunan berat badan. Adiponektin terbukti dapat meningkatkan kepekaan jaringan terhadap kerja insulin dan mempunyai peran protektif terhadap berbagai penyakit yang berhubungan dengan obsitas1,5 Adiponektin dihasilkan oleh jaringan adiposa melalui proses downregulation secara autokrin maupun parakrin melalui kontrol dari sitokin proinflamasi. Adiponektin memperbaiki resistensi insulin dan menghambat proses aterogenesis pembuluh darah10 Aksis Hipotalamus-Hipofisa- Gonadal Kebanyakan penelitian mengenai pengaruh dari obesitas terfokus pada aksis

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hipotalamus-hipofisa-gonadal dan perubahan endokrin yang menyertainya pada tingkatan gonadotropin terutama LH, penurunan kadar sex hormone binding globulin (SHBG), kadar testosterone, inhibin B dan peningkatan kadar oestradiol2 Tidak hanya obesitas dapat menimbulkan perubahan pada hormone seks tetapi sebaliknya terdapat bukti bahwa hormone seks juga dapat menimbulkan terjadinya fenotipe tertentu dari obesitas. Yang menarik adalah obesitas dapat menimbulkan hiperandrogenisme pada wanita dan sebaliknya menimbulkan hipoandrogenisme pada pria5. Faktor yang sangat berperan terjadinya perubahan status androgen pada wanita dan pria adalah SHBG dan gonadotrophin5. Pada wanita, obesitas dijumpai pada penyakit tertentu seperti prediabetes, diabetes, penyakit kardiovaskuler, dan PCOS. Pada fase menopause fungsi ovarium akan tertekan dan berhubungan dengan timbulnya obesitas karena menopause memacu terjadinya obesitas abdominal dan menimbulkan berbagai kelainan metabolik. Pada wanita, obesitas akan menimbulkan perubahan kadar steroid plasma. Kecepatan sekresi testosterone, dihidrotestosteron dan androstenedion lebih tinggi pada wanita dengan obesitas morbid1. Distribusi timbunan lemak tubuh juga merupakan faktor yang sangat sibnifikan ikut menentukan. Produsi hormon seks dan metabolismenya berbeda pada wanita dengan obesitas morbid dengan fenotipe lainnya.Wanita dengan obesitas abdominal disertai peningkatan sekresi androgen dengan peningkatan kadar testosteron bebas dan estradiol, sebaliknya wanita dengan obesitas gluteofemoral disertai dengan peningkatan kadar estrone oleh karena terjadi aromatisasi estrogen di perifer. Penelitian lain melaporkan bahwa pada wanita premenopause dengan obesitas, peningkatan masa lemak viseral secara bermakna berhubungan dengan penurunan SHBG dan penurunan rasio 17-beta estradiol/free testosterone dan peningkatan free testosterone. Pada wanita penurunan masa lemak viseral akan meningkatkan kadar SHBG dan rasio 17-beta estradiol/free testosterone. PCOS merupakan kelainan ovarium yang dijumpai pada

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wanita premenopause dengan obesitas. Sekitar 20-69 % wanita dengan PCOS disertai obesitas terutama obesitas abdominal. Setelah menopause penurunan kadar estrogen disertai dengan hiperandrogenisme sangat berperan meningkatkan berat badan dan perubahan dari distribusi lemak tubuh1 Tabel 2. Perubahan utama pada aksis hipotalamus-hipofisa-gonadal pada wanita dengan obesitas7 Condition

Alterations

Effect of obesity on sex hormones

Increased SHBG-bound and non SHBG-bound androgen production rate and Metabolic clearance rate Reduced SHBG synthesis and concentrations Increased percentage free testosterone fraction Normal gonadotropin secretion Increased estrogen production rate Altered active / inactive estrogen balance

Impact of central obesity

Worsened androgen imbalance Treatment with androgen increases visceral fat in postmenopausal women

Obesity, hyperandrogenism and PCOS

Half PCOS women are overweigh or obese Obesity may have a pathogenetic role in the development of hyperandrogen in PCOS Obese women with PCOS have a prevalence of visceral fat distribution Hyperinsulinemia represents a pathogenetic factor of hyperandrogenism The metabolic syndrome is part of the obesity PCOS association

Effects of weight loss

In simple obesity, improvement of androgen and SHBG imbalance In obese women with PCOS reduction of hyperinsulinemia and insulin resistance. Hyperandrogenism, and improvement of all clinical features, including fertility rate

PCOS, polycystic ovary syndrome; SHBG, sex hormone-binding globulin

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Laki-laki obesitas berhubungan dengan turunnya kadar testosterone total dan SHBG. Berbagai faktor sebagai penyebab adalah penurunan SHBG binding capacity, penurunan amplitude pulsatil dari sekresi LH dan hiperestrogenemia. Pada laki-laki terjadi hubungan terbalik antara kadar testosterone total, free testosterone dan SHBG dan lemak viseral1 Pada laki-laki terdapat hubungan terbalik yang kuat antara masa lemak tubuh dengan kadar testosterone. Pada laki-laki dengan obesitas abdominal berdasar berbagai studi ternyata berhubungan dengan rendahnya kadar testosteron. Timbunan lemak di daerah viseral selalu disertai dengan meningkatnya aktifitas aromatase yang merubah testosteron menjadi estradiol secara local pada laki-laki dengan obesitas. Peningkatan kadar estradiol secara langsung memberikan umpan balik negatif ke aksis hipotalamus- hipofisa- testikular melalui kisspeptin dan selanjutnya akan menurunkan kadar testosteron. Selanjutnya adipositokin seperti sitokin proinflamasi TNF-, IL-6 dan IL1 juga berperan dengan menghambat sekresi testosteron ditingkat hipotalamus- hipofisa dan testis. Leptin dapat memacu sekresi gonadotropin-releasing hormone (GnRH), tetapi pada obesitas meskipun terjadi peningkatan sekresi leptin oleh jaringan adiposa, aksis hipotalamus- hipofisa menjadi resisten terhadap kerja leptin. Sebagai tambahan leptin juga dapat menghambat rangsangan dari gonadotropin pada sel Leydig sehingga akan lebih menurunkan kadar testosteron. Penurunan testosteron di jaringan akan mempermudah penyimpanan trigliserida pada adiposit melalui peningkatan aktifitas lipoprotein lipase6,8 Testosteron juga memacu miosit dan menghambat perkembangan adiposit dari stem sel pluripotent sehingga akan meningkatkan masa otot, sedangkan pada keadaan defisiensi testosteron akan menimbulkan peningkatan masa lemak8

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Gambar 1. The hypogonadal-obesity-adipocytokine hypothesis. Keterangan: Kisspeptin adalah hormone neuropeptide pada hipotalamus yang bekerja pada G-protein reseptor untuk melepas gonadotropin releasing hormone (GnRH) dan merangsang sekresi LH, FSH dan testosteron 8

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Tabel 3. Perubahan utama pada aksis hipotalamus-hipofisa-gonadal pada laki-laki dengan obesitas7 Condition Effect of obesity on sex hormones

Alterations Reduced testosterone (free and total), and C19 Steroids Reduced SHBG concentrations Reduced luteinizing hormone secretion Increased estrogen production rate Altered aromatase activity (?)

Inpact of body fat distribution

Men with hypogonadism have typically enlarge visceral fat depots Relationship with waist-to-hip ratio (and other indices of fat distribution) controversial Association between androstane 3, 17ß-diol glucuromide and visceral fatness

Effects of weight loss

Improved sex hormone imbalance (increase of testosterone) SHBG can be restored to normal when nearnormal body mass index is achieved

Effect of testosterone therapy

Reduction of visceral fat Improvement of all parameters of metabolic syndrome

SHBG, sex hormone-binding globulin

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Gambar 2. Hubungan antara kelainan metabolik dengan jaringan lemak viseral dan defisiensi testosterone. Siklus visiosus terjadi antara lemak viseral yang berlebihan pada obesitas abdominal dan defisiensi testosterone dan menimbulkan kelainan vaskuler dan resistensi insulin 11 Aksis Growth Hormone/ IGF-1 Pada obesitas perubahan yang menonjol pada sistim hipotalamus-hipofisa adalah yang berhubungan dengan growth hormone (GH). Sekresi GH terutama tergantung dari interaksi antara growth hormone releasing hormone (GHRH) dan somatostatin. Ghrelin sebagai ligan endogen terhadap reseptor GH sekretagogus juga berperan terhadap sekresi GH. Sebagai tambahan berbagai neurotransmiter, hormon perifer dan berbagai signal metabolik berperan terhadap sekresi GH1. Kerja dari GH dimediasi oleh insulin-like growth factor-1 (IGF-1) terutama yang dihasilkan oleh hepar. Kadar IGF-1 serum merupakan gambaran dari aktifitas biologik GH. Kadar GH basal menurun pada obesitas dan penurunan ini sesuai dengan peningkatan masa lemak 22

NASWAAM 2018

tubuh. Menurunnya kadar GH pada obesitas dapat melalui berbagai mekanisme. Penyebab utama penurunan sekresi GH pada obesitas meliputi gangguan pada hipotalamus, gangguan fungsi hifisa atau gangguan dari signal perifer pada hipotalamus atau hipofisa1. Karena GH bersifat lipolitik dan anabolik diperkirakan bahwa penurunan kadar GH pada obesitas akan meningkatkan resistensi insulin dan memperburuk penyakit metabolik5 Penyebab utama dari gangguan sekresi GH pada obesitas mungkin pada hipotalamus, gangguan fungsi hipofisa atau gangguan dari signal perifer yang bekerja pada hipofisa maupun hipotalamus, hiperinsulinemia pada obesitas dapat menghambat sekresi GH5 Tabel 4. Main alteration of the growth hormone/insulin-like growth factor1 (GH-IGF-1) axis in obesity 7 Condition

Alterations

Effect of obesity on GH

Reduced GH levels in proportion to body fat Blunted response to any stimuli (including GHRH, GHRP-6 superanalogs, Reduced pituitary GH secretion Increased GH metabolic clearance rate

Relationship with boy fat distribution

Children and adults with GH deficiency typically have visceral obesity

Effect of obesity on the IGF-I system

IGF-I concentration normal or reduced (particularly in visceral obesity) Increased free IGF-I fraction

Effects of weight loss

Improvement of basal and stimulated GH levels (in proportion to body fat Possible effects of nutrition or GH secretion

Effect of GH replacement therapy

Reduction of visceral fat, in GH-deficient (Children and adults ) patient Obbes individuals

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Obesitas dan Kelenjar Adrenal Terdapat hubungan antara obesitas, distribusi lemak viseral dan tingginya kadar kortisol pada sindroma Cushing. Berdasar ini banyak penelitian telah dilakukan untuk membuktikan bahwa kortisol berperan untuk terjadinya obesitas. Kadar kortisol tidak meningkat pada obesitas dan ekskresi kortisol bebas 24 jam dalam urine biasanya dalam rentang normal tertinggi atau sedikit meningkat. Dengan kadar kortisol serum yang normal pada obesitas, diperkirakan terjadi peningkatan produksi kortisol secara lokal pada jaringan lemak sehingga meningkatkan kerja kortisol secara local dan menimbulkan kelainan metabolik yang sering dijumpai pada obesitas5 Jaringan adiposa sangat berperan terhadap metabolisme kortisol melalui kerja dari enzim 11-beta hydroxyl steroid dehydrogenase type 1 (11 -HSD1) yang dapat merubah kortisone (kortikoid inaktif) menjadi kortisol (kortikoid aktif) pada jaringan adiposa. Sehingga pada obesitas lebih banyak kortisol yang dihasilkan dari kortisone karena meningkatnya kerja dari enzim ini. Meningkatnya produksi kortisol pada obesitas lebih bersifat lokal pada jaringan adiposa sementara kadar kortisol serum tetap dalam batasan normal 5 Hormon Pankreas Perubahan yang paling spesifik pada obesitas adalah meningkatnya sekresi insulin dan menimbulkan hiperinsulinemia. Obesitas dan diabetes melitus tipe 2 sangat berhubungan dengan resistensi insulin. Berbagai faktor berperan terjadinya obesitas dan kerentanan terjadinya DM tipe2 termasuk komponen genetic dan epigenetic, pola hidup dan lingkungan. Jaringan adiposa mengatur metabolismenya dengan cara melepaskan asam lemak bebas dan gliserol, berbagai hormone seperti leptin, adiponektin, dan sitokin proinflamasi. Lepasnya asam lemak bebas merupakan faktor yang penting untuk terjadinya resistensi insulin. Peningkatan asal lemak bebas ini yang sering dijumpai pada DM tipe 2 dan obesitas menimbulkan resistensi insulin dan hiperinsulinemia1,9

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Hormon Gastrointestinal Ghrelin adalah hormone metabolik untuk merangsang konservasi energi dengan mengatur nafsu makan dan pengeluaran energi dan terdiri dari 28-asam amino peptide. Ghrelin terutama dihasilkan di lambung dan memiliki kemampuan merangsang sel somatotropik sehingga dapat memacu sekresi GH pada hipofisa. Berbagai penelitian membuktikan bahwa ghrelin memegang peran penting pada asupan makanan dan pengaturan berat badan. Kadar ghrelin meningkat dalam keadaan puasa dan menurun setelah asupan makanan. Berbagai studi membuktikan bahwa ghrelin dalam jangka panjang berperan mengatur berat badan dan keseimbangan energi. Pada manusia kadar ghrelin berbanding terbalik dengan derajat adipositas. Kadar yang rendah pada obesitas dan kadar meningkat dijumpai pada anoreksia nervosa, keganasan atau kaheksia. Kadar ghrelin meningkat setelah penurunan berat badan melalui diit saja atau melalui diit dan latihan jasmani dan kadarnya menurun setelah mendapat nutrisi yang berlebih. Diperkirakan resistensi insulin berperan menimbulkan penurunan kadar ghrelin pada obesitas1,10 Kelenjar Tiroid Hubungan yang komplek antara obesitas dan kelenjar tiroid bersifat dua arah. Disfungsi kelenjar tiroid (hipotiroid atau hipertiroid) mengakibatkan perubahan berat berat badan karena peran dari hormone tiroid yang mengatur thermogenesis dan nafsu makan. Hipotiroid sering disertai dengan peningkatan berat badan disertai menurunnya thermogenesis dan metabolisme, sebaliknya hipertiroid menimbulkan penurunan berat badan meskipun disertai dengan meningkatnya nafsu makan dan metabolisme. Berbagai studi membuktikan bahwa obesitas dapat juga mempengaruhi fungsi kelenjar tiroid dengan menimbulkan peningkatan kadar TSH tanpa disertai dengan perubahan kadar T3 dan T4. Berbagai studi memperlihatkan bahwa jaringan adipose yang mengalami disfungsi merupakan faktor utama yang menimbulkan gangguan homeostasis hormon tiroid. Penelitian longitudinal juga menemukan bahwa selalu terjadi hubungan 25

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antara kadar hormon tiroid dengan perubahan berat berat badan. Etiologi dari perubahan pada aksis hipotalamus-hipofisa-tiroid ini masih belum jelas. Berbagai mekanisme diperkirakan ikut berperan seperti akibat proses adaptasi terhadap peningkatan pengeluaran energi, peran dari leptin, perubahan dari aktifitas deiodinase, terjadinya resistensi hormone tiroid, low-grade inflammation dan terjadinya resistensi insulin4 Kepustakaan 1. Alvarez-Castro P., Sanglao-Alvarellos S., Brandon-Sanda I., Cordido F. 2011. Endocrine function in obesity. Endocrinol Nutr. 58: 422-32. 2. Bullen V., Judge S.2015. The impact of obesity on male fertility. British J Obes: 1(3): 99-104. 3. Delitala AP., Capobianco G., Delitala G.,Cherchi PG., Dessole S. 2017. Polycystic ovary syndrome, adipose tissue and metabolic syndrome. Arch Gynecol Obstet. Published online. 22 June 2017. 4. Fontanelle LC.,Feitosa MM.,Severo JS.,Freitas EC.,Morais JBS., TorresLeal FL., Henriques GS.,Marriero DN. 2016. Thyroid Function in Human Obesity: Underlying Mechanism. Horm Metab Res; 48:787-794. 5. Menucci MB and Burman KD. 2013. Endocrine Changes in Obesity. Endotext Editor De Groot Lj, Chrousos G et al. 6. Muraleedharan and Jones TH.2010, Testosterone syndrome. Ther Adv Endocrinol Metab. 1(5): 207-223

and

metabolic

7. Pasquali R and Vicennati V. 2001. Obesitas and Hormonal Abnormalities. In International Textbook of Obesity. Editor Per Bjorntorp. John Wiley & Son Ltd. p 225-239. 8. Rao PM., Kelly DM and Jones TH. 2013. Testosterone and insulin resistance in the metabolic syndrome and T2DM in men. Nat Rev Endocrinol. Advance online publication 25 June 2013: 1-15 9. Templeman NM., Skovso S., Page MM., Lim GE and Johnson JD. 2017. A causal role for hyperinsulinemia in Obesity. Journal of Endocrinology. 232: 173-183. 10. Zigman JM., Bouret SG and Andrews ZB. 2015. Review. Obesity Impairs the Action of the Neuroendocrine Ghrelin System. Trends in Endocrinology & Metabolism. XX: 1-10. 11. Zitzmann M. 2009. Testosterone deficiency, insulin resistance and the metabolic syndrome. Nat.Rev.endocrinol.5:673-681.

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NASWAAM 2018 Symposium II: Complex problems of obesity

EXERCISE PROGRAM FOR OBESE PEOPLE J. Alex Pangkahila Post Graduate Program in Anti-Aging Medicine, Department of Andrology and Sexology, Medical Faculty Udayana University Indonesian Center for Anti-Aging Medicine (INCAAM)

Abstract The cause of death was caused by most unhealthy lifesty, one of them is obesity. Obesity was not less experienced by people in various countries including in Indonesia. This population will grow longer and lead to various health problems. Obesity was caused by various factors including: Neuroendocrine Obesity, Drug-Induced Weight Gain, Cessation of Smoking, Sedentary Lifestyle, Diet, Psychological & Social, Socioeconomic, Etnick, Genetic and Congenital Disorders. the occurrence of obesity did not depend on age because this situation can occur at any age depending on various factors. One-third of the world's population are reported to be overweight before the age of 20 and two-thirds after the age of 20. Approximately 20% 25% of the population is overweight or obese before the age of 20 years and 50% after the age of 20 years, but there are also about 75% - 80% of adults are sometimes overweight. There are several facts reported that physical activity in obesity including sports programs and physical activity was not healthy recently and it was still done in everyday life. scientifically, integrated handling and prevention needs to be done so that physical training does not provide harmful side effects but can actually improve health, fitness and slow down the aging process. Integrated handling should not be the same for everyone but individually depending on individual circumstances. Prevention should be done as early as possible because the process of fattening can occur from birth depending on the handling by parents and environment. Integrated handling is a blend of lifestyle arrangements and adjustments to the environment. In addition to note some types of treatment / training that is contraindicated in groups who are overweight. Physical activity including sports should be based on FITT (Frequency, Intensity, Time Type).

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Anti-Aging Medicine & Improvement in The Quality of Life Symposium III: Healthy food and supplement

WHAT IS HEALTHY FOOD Indraguna Pinatih Centre for study on anti-aging medicine Dept. of community and preventive medicine Faculty of Medicine, Udayana University

Background Though not everybody aware, but Intentionally, everybody wants to be healthy, looks young or if possible can reach their maximum quality of life. They use as many as possible their possibility and resources to reach their purpose. Diet is one factor that can influence its purpose and food is part of diet which account to Diet. While healthy diet is easier to describe and applied, healthy food is hardly difficult to achieve. From three dictionaries observed, Healthy food shall compose of all nutrient needed by the body and safe in term of it will not creating any disease in the future, especially non infectious diseases in which it mostly incurable and/or speed the aging process. Healthy diet talks more on habit. It begins from healthy food, plus the amount of food consume including the frequency of meal, the balance of nutrient composition and the way of cooking. Therefore, to describe how healthy is the food, consideration shall be put on the density of nutrient, the glycemic and fat control, the way of processing and the way of cooking. Nutrient Density Versus Energy Density Density means the amount of substrate in a given space or weight. Food composes of nutrient and non-nutrient and nutrient composes either macro and/or micronutrient. Macronutrients determine the amount of calorie in the certain food. The more macronutrient composing the food, the higher it density content. Food composing

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highly macronutrient content particularly fat will be mentioned as high density food but food composing more micronutrient and non-nutrient will be mentioned as highly nutrient dense. For example, should we compare raisin and grape, raisin composing more sugar per 100 gram stuffs and grape composing less since it also composes of water. 100 gram raisins compose as much as80 gram carbohydrate and provide 320 kcal, while 100 gram grape compose of as much as 30 gram of carbohydrate and provide 120 kcal. Ideally food stuff shall content of many nutrients that useful to human body and function. Therefore, the more nutrients composing one food the healthier is that food. Glycemic Control High concentration of sugar in blood is hazardous to human body. Highly blood sugar increase insulin level. Long term high blood sugar triggers the insulin resistance lead to Diabetes Mellitus. Considering blood sugar content, calculation onglycemic load and glycemic index of food should be put into consideration. Glycemic index is a scale that ranks carbohydrate-rich foods by how much they raise blood glucose levels compared to a standard food. The standard food is glucose or white bread. It is a tool to measure how individual foods are expected to impact the blood glucose level. The Glycemic load is an equation that takes into account the planned portion size of a food as well as the glycemic index of that food. Glycemic Load = GI/100 multiplied by the net grams of planned carbohydrate (net carbohydrate is the total grams of carbohydrate minus the dietary fiber). It is important in glucose control since in theory, a large amount of a low GI food may increase your blood sugar as much as a small amount of a high GI food. To improve the quality of food base on the glycemic load, ones can mix high glycemic index with low glycemic index food.

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Fat Control Dyslipidemia is also important to be controlled. Elevated triglyceride and LDL-C cholesterol in blood are high risk to atherosclerosis cardiovascular and cerebral diseases. To treat and prevent it, besides enhancing physical activities, food containing high energy especially derived from long chain saturated fatty acid and/or trans fats should be eliminated. Medication is not a primary choice in preventing this situation. Non Toxic Toxin in food include the presence of pesticide, and the presence of any substance that in the long term use, it possible to influence health and causing diseases mostly cancer. Those foods include food additives either intentionally or unintentionally presence in food, and also the presence of precancerous food. The presence of pesticides residue and other pollutant in food give harmful health effect to human body. Some pesticide cause neuronal problems event kill the people who is poisoned and some of it can also destroy human inner organs such as stomach, liver and kidney. The other pollutant that can also possible to destroy human body and function are metal such as Lead and Mercury; and also wax and/or plasticizers. Hence, all pesticides and other pollutant shall be removed from the food prior to consumption. Food containing highly Pesticides mostly presence in cultivated fruits or vegetables include apples, peaches, bell peppers, celery, nectarines, strawberries, cherries, Kale, grapes, lettuce; while stuffs containing less pesticides mostly un cultivated such as onions, avocados, corn, pineapples, mangoes, asparagus, peas, Kiwi, Cabbage, eggplant and papaya. To remove pesticides and other toxins from food, fruit and vegetable should be wash properly in running water, the skin should be peeled from fruit; remove the outer part of leafy vegetables; remove the

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skin and fat from animal part since metal (mercury and lead) mostly accumulated in the skin and fat. Food additives include artificial flavour, artificial colour, texture stabilities, and nutrient additives. While intentional food additives have mostly controlled and accredited by an official body such as FDA, the unintentional additives are poorly and hardly difficult to be controlled. Plasticizers, food contact substances and dioxin from food packages are some examples of unintentional additives. Hormone and antibiotics given to the animal can also be addition to the food and it influence to the people health who consume it in the high amount. Way of Cooking Neither raw food is good nor cooked food is good. Raw food provides some more vitamins and enzyme rather than cooked food. However, some nutrients such as some protein and antioxidants are poorly absorbed when the food is raw. Cooked foods provide more plant resources antioxidant and available protein, butheating with high temperature destroy Vitamin C and vitamin E and also destroy the chain of poly unsaturated fatty acid (PUFA) in oil becoming saturated fat and trans fat. It also turns carbo stuffs to produce acrylamide through mailard reaction. Charbroiling produce polycyclic aromatic hydrocarbon (PAH) because of fat contact with fire and also heterocyclic Amin (HA) due to contact between fire with protein. These three stuffs are precancerous to human body if ingested highly for a long period. Food Irradiation The purpose of irradiating food stuffs is preserving the food from deterioration due to bacteria available in the environment, so that it will increase the life time of the food. Food is irradiated by gamma rays. There are controversies discussing this issue. Some people said it influences the nutrient content such as vitamin C and Vitamin E and therefore it reduces the quality of the food and in addition it also

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transforms the chemical composition and possible becoming precancerous while the other say that there is no evidence showing those hazardous side effects as long as it still follows the standard procedures. Unfortunately, there are very limited studies on these matter especially studies using longitudinal study method. Genetically Engineered Food Using technology on food is becoming more popular recently. Genetically modified has been applied since a bit long ago, even it might applied for quiet large kind of food especially food consumed by large number of people such as tomatoes, potatoes, corn etc.. The purpose to use this method mostly to increase economically value of the food. Some people us it to increase the number of the crop, others to increase the life time of the food. Likewise, the food irradiation, these methods are still under controversies between pro and contra. The pro people say that there will no health hazard as long as standard procedures are followed, while the disagree groups complain of the chemical component that might increase the side effects in the long term used. Unfortunately, there are very limited studies on these matter especially studies using longitudinal study method. Summaries Looking at problems appear for describing what means healthiness of food, I personally difficult to distinguish, since we cannot avoid environmental factors, people behavior on food include technology used started from production, processing up to way of cooking. It is easier to describe healthy diet and unhealthy food.

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References 1.

Hazekamp A., 2016, Evaluating the Effects of Gamma-Irradiation for Decontamination of Medicinal Cannabis, Front Pharmacol, 7: 108

2.

Malejka-Giganti D., Tretyakova N., 2006, Molecular Mechanisms of Carcinogenesis, in Baer-Dubowska W., Bartoszek A., Malejka-Giganti W (ed), Carcinogenic and Anti Carcinogenic Food Components, Taylor and Francis, pp 13-36

3.

Szyfter K., Gawecki J., 2006, Molecular Mechanisms of Carcinogenesis, in Baer-Dubowska W., Bartoszek A., Malejka-Giganti W (ed), Carcinogenic and Anti Carcinogenic Food Components, Taylor and Francis, pp 1-12

4.

Whitney E., Rolfes S.R., 2011, Food Biotechnology, Understanding Nutrition, Wadsworth Cengage Learning, Australia, pp 677-681

5.

Whitney E., Rolfes S.R., 2011, Consumer Concerns about Food and Water, Understanding Nutrition, Wadsworth Cengage Learning, Australia, pp 647-676

6.

Mukherjee P., 2017, Junk food vs healthy food, which one is healthier, Health and Wellness, available from http:\\www.stylecraze.com downloaded on 10 January 2018

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Anti-Aging Medicine & Improvement in The Quality of Life Symposium III: Healthy food and supplement

SUPPLEMENTS USED IN THE CONTEXT OF ANTI-AGING Ray Sugianto Abstract

Do supplements needed in the context of anti-aging? Of course, this question often asked by patients and clinicians alike, with the market currently being flooded with products that claims to delay aging, or even to reverse it. There view session will thus be focused on addressing how we, as clinicians, develop a framework to evaluate supplements, and what evidence-based research on several supplements found. First, we need to understand what is defined as aging and antiaging in the supplements’ beneficial claims presented. Both the objective/subjective measures, the short-/long-term outcomes are briefly reviewed, followed by evaluation of various study design. Second, we will review a range of supplements with their varying popularity and success rate. Also, how the underestimation and overestimation of claims often encountered in the media. The supplements reviewed include omega 3/oil substances, CoQ10, treated water, herbal compounds, isoflavones and specific antioxidant. Lastly, we will cover the apparent discrepancies between supplements-based studies and diet-based studies. How to appreciate the difference that would influence our decision making in the anti-aging context.

1. Research Scholar, National University of Singapore

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MINIMIZED FOOD TOXICITY AND POISONING AND KEEP THE SAFETY I Wayan Weta Department of Clinical Nutrition, Faculty of Medicine University of Udayana/Sanglah General Hospital

SUMMARY Introductory Every substances in foods are toxic, the dose separates it’s nontoxic to toxic. There are some terms using as parameter of toxic dose in foods. Lethal dose 50% (LD50) uses for the acute toxicity. Tumor dose 50% (TD50) is used for chronical toxicity that caused the malignancy tumor, and the non observable adverse effects level (NOAEL) if the toxin impact are other degeneratives disease outside cancers. The safe dose is known as accetable daily intake (ADI) (0.001 of NOAEL) and the dose generally recognized as safe (GRASS). Many toxins in foods are a naturally-occurring constituent or, formed as the result of handling or processing. Although all foods are potentially toxic, but the incidence of adverse reactions to food is relatively low. The possibility of foods toxicity usually due to contamination, overconsumption, allergy or an unpredictable idiosyncratic response. Many Toxins in foods Environmental contaminants; ₋ Selenium (Se) in grain, ₋

Methyl mercury (Hg) in seafood.

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Naturally formed substances such as:

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₋

Prussic acid in cherry, apple and peach pits;

₋

Hypericin in St. John’s wort; an herbal thought to alleviate symptoms of depression;

₋

Goitrogens (glucosinolates) in Brassica spp;

₋

Erucic acid in rape (Brassica napus L. or Brassica campestris L.) is produces oil-rich seeds for cooking oil.

₋

Furocoumarins represent a family of natural food constituents with phototoxic and photomutagenic properties. They are found mainly in plants the Rutaceae (e.g., citrus fruits) and Umbelliferae (e.g., parsnip, parsley, celery, carrots) families.

₋

(α) Amylase inhibitors, are found in aqueous extracts of wheat, rye and kidney beans.

₋

Thiaminase is found in fish, crab, clams and in some fruits and vegetables such as blueberries, black currants, red beets, Brussels sprouts and red cabbage.

₋

Pyrrolizidine, are hepatotoxic, mutagenic, teratogenic and/or carcinogenic. The comfrey tea products for internal use has been banned in the United States and Canada.

₋

Oxalic acid is an organic acid that can bind calcium and other minerals, making them insoluble and decreasing their bioavailability. Oxalic acid (oxalate) is found in rhubarb (0.2– 1.3%), tea (0.3–2.0%), spinach (0.3–1.3%), parsley (1.7%) and purslane (1.3%), may also be found in asparagus, broccoli, Brussels sprouts, collards, lettuce, celery, cabbage, cauliflower, turnips, beets, peas, coffee, cocoa, beans, potatoes, berries, and carrots.

₋

Cucurbitacins, the Cucurbitacea in family zucchini, cucumbers, pumpkins, squash, melons and gourds.

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Coumarins (tonka bean, woodruff, clover, inhibiting vitamin K, dicoumarol promotes bleeding.

₋

Phytates and phytic acid, is found in bran and germ of many plant seeds and in grains, legumes and nuts. Phytic acid is a dietary source of phosphorus and an effective chelator of divalent cations such as zinc, copper, iron, magnesium and calcium.

Substances formed as the result of product abuse: ⁻ Glycoalkaloids (solanine and chaconine) in potatoes. Substances formed as the result of processing: ⁻ Heterocyclic aromatic amines ⁻ Polycyclic aromatic hydrocarbons ⁻ Acrylamide ⁻ Chloropropanols ⁻ Furan ⁻ Trans fatty acids ⁻ Nitrosamines ⁻ Biogenic amines (histamine, tyramine cadaverine, putrescine, spermidine and spermine). Substances Passed from Animals to Humans: ⁻

Toxins in seafood ; Toxins involving algae, Paralytic shellfish poisoning, Neurotoxic shellfish poisoning, Amnesic shellfish poisoning (Domoic acid), Diarrhetic shellfish poisoning, Trimethylamine oxide,

⁻

Toxins from animal, non-seafood sources; Grayanotoxins in honey, Tremetol contamination of milk from white snakeroot.

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Protect and Prevent People from Toxic Food The food regulation are needed, as well as monitoring and evaluating from the goverment (ministry of agriculutural, marine and health, board of food and drug administration (BPOM)) of using chemical substances and safety method in food agriculturing, processing, and producing. Identify, avoid, and limited for safety consumption of toxic foods substances no more than ADI or GRASS. Consumption more antioxidant that contains phenolic compounds, as well as some vitaminhs and minerals, especially from functional food, such as green tea, colory fruits and vegetables. References 1. Dolan LC, Matulka RA and Burdock GA. Naturally Occurring Food Toxins. Toxins 2010, 2, 2289-2332; doi:10.3390/toxins2092289 2. Rameshrad M, Razavi BM, Hosseinzadeh H. Protective effects of green tea and its main constituents against natural and chemical toxins: A comprehensive review. Food and Chemical Toxicology Volume 100; 2017:115-137. 3. Lobo V, Patil A, Phatak A, Chandra N. Free radicals, antioxidants and functional foods: Impact on human health. Phcog Rev 2010;4:118-26

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NASWAAM 2018 Symposium IV.1: Men's & Women's health : Implementing science for a better life

TESTOSTERONE BEYOND SEXUALITY : THERAPY BENEFIT IN CARDIO-METABOLIC Nugroho Setiawan Abstract

Androgens have been shown to be important for survival in that a number of studies have linked androgen deficiency to increased mortality in men. Testosterone is the most important male androgen. Testosterone is most often associated with sex drive, and plays a vital role in sperm production. But it also affects bone and muscle mass, the way men store fat in the body, and even red blood cell production. A man’s testosterone levels can also affect his mood. Obesity is a major public health threat that has an enormous economic burden on society. Obesity increases risks for atherosclerosis, diabetes, metabolic syndrome, nonalcoholic fatty liver disease, heart disease among other comorbidities and reduces life expectancy.Obesity contributes to pathophysiological conditions such as hemodynamic, arrhythmic and anatomical modifications in the cardiovascular system. Obesity contributes to the decline of testosterone (T) and the prevalence of hypogonadism is greater than 70% in men with excessive obesity. A host of studies have suggested that reduced T levels are associated with increased total cholesterol (TC) and low- density lipoprotein cholesterol. Several long-term studies have demonstrated that testosterone deficiency syndrome is associated with increased cardiovascular and allcause mortality. Low total and bioavailable T levels were associated with increased risk of aortic atherosclerosis in elderly men.

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Men who received testosterone replacement therapy, a significant weight loss, a decrease in waist circumference and BMI, a modest reduction in serum total cholesterol (TC) were observed. Cardiometabolic parameters such as lipid profile, glycemic control, blood pressure and heart rate improved significantly and sustainably throughout the observation period.

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NASWAAM 2018 Symposium IV.2: Men's & Women's health: Implementing science for a better life

ADMINISTRATION OF AGED BLACK GARLIC EXTRACTS INCREASED FIBROBLAST VIABILITY AND HAMPERED THE PROGRESSION OF COLAGEN DEGRADATION IN UVB- EXPOSED HUMAN DERMAL FIBROBLAST Fransisca Romana Herin Anggreni Abstract UVB exposure is the major factor of premature skin aging (photoaging). ROS causes fibroblast DNA damage and activates AP-1 resulting in deterioration cell viability and progression of collagen degradation through the MMP-1 activation pathway. Black garlic contain phenolic, flavonoids, S-allylcystein, which have a strong radical-DPPH-scavengers activity. The black garlic extract cream (10%) has been proven to inhibit free radicals and prevent wrinkles due to UVB exposure in the mice’s back. This study aimed to prove the black garlic extract’s antiphotoaging effects at the cell level by increasing fibroblast viability and delay the in vitro collagen degradation. It was an in-vitro experimental study using human fibroblast culture which was differentiated into two UVB exposure groups (ie without exposure and UVB exposure of 250 mJ/cm2 ). Each exposure group was then divided into 4 groups to be administrated with different black garlic extract (BGE) dose (i.e., 0, 50, 100 and 150 μg/ml. The BGE is administrated 24 hours prior the UVB exposure. The viability of fibroblasts was measured using MTT-assay and collagen degradation measured using collagen soluble Sirius Red binding assay.

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The data were analyzed using one way anova followed by LSDtest, significance level p <0,05. The BGE doses of 50, 100, and 150 μg/ml was able to increase post-exposure UVB fibroblasts viability (p<0,05) and possesed the same effectiveness in increasing fibroblast viability (p>0.05). The BGE doses of 50, 100, and 150 μg/ml was able to inhibit collagen degradation progression after UVB exposed (p<0,05). Nevertheless, the most effective BGE dose to prevent collagent degradation progression was 50 μg/ml (p<0,05). BGE increased fibroblast viability and hampered the progression of collagent degradation, therefore BGE might be used as potential agent for skin antiphotoaging.

Keywords: black garlic-fibroblasts-UVB-fibroblast viability- collagen degradation

1. Pendahuluan UVB menyebabkan photoaging melalui pembentukan ROS secara langsung dengan merusak DNA dan tidak langsung dengan mengaktivasi kromosfor kulit (Svoboda dkk, 2006; Baran dkk, 2010). Pajanan UVB menurunkan viabilitas fibroblas (Cho dkk, 2007; Widodo, 2012) dan respon sel fibroblas terhadap stimulasi TGF-ß, serta meningkatkan aktivitas MMP-1 sehingga terjadi peningkatan degradasi kolagen dan penurunan sintesis kolagen (Cho dkk, 2007). Penurunan viabilitas fibroblas dan peningkatan degradasi kolagen telah diterima sebagai konsep dasar penuaan dini kulit akibat UVB (Widodo, 2012). Bawang hitam adalah hasil fermentasi bawang putih segar (Allium sativum) yang melalui proses pemanasan pada suhu 65-90°C pada kelembaban tertentu (60-80%) selama kurang lebih 30 hari. Bawang hitam mengandung antioksidan polifenol, flavonoid, SAC, dan aktivitas penangkal radikal-DPPH yang kuat (Kim dkk, 2012).

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2. Metodologi 2.1 Pembuatan Ekstrak Bawang Hitam (EBH) Bawang hitam tunggal produksi Balai Biotek, Badan Pengkajian dan Penerapan Teknologi (BPPT), Serpong, Tangerang. Daging bawang hitam diekstraksi dengan menggunakan metode maserasi, menggunakan pelarut ethanol 70%. Proses maserasi dilakukan selama 3 hari dan dilakukan remaserasi sebanyak 2 kali ditandai dengan hilangnya warna maserat dengan pengadukan. Filtrat yang diperoleh kemudian diuapkan menggunakan vacuum rotary evaporator pada suhu 60°C dan diperoleh ekstrak pekat. Selanjutnya ekstrak bawang hitam diuji fitokimia kandungan fenolik, flavonoid, dan kemampuan penangkalan radikal DPPH. 2.2 Kultur Sel Kultur sel fibroblas manusia subkultur ketiga yang diisolasi dari kulit normal (kulit sirkumsisi), dibiakkan dalam medium Dulbecco’s Modified Eagle’s Medium (DMEM)-Sigma TM lengkap yang mengandung 5% fetal bovine serum (FBS), 100 μg/ml penisilin streptomycin (Penstrep)-Gibco, 100 mg/ml ceftriaxon dan 2,5 μg/ml amphotericin B-Gibco TM. 2.3 Teknik Pemberian Ekstrak Bawang Hitam dan Pajanan UVB EBH dilarutkan dalam medium dimethyl sulfoxide (DMSO). Ekstrak ditimbang terlebih dahulu kemudian dilarutkan pada DMSO dengan konsentrasi larutan akhir medium <0,5% agar tidak bersifat toksik terhadap sel (Freshney, 2000). Sebanyak 2 x 104 suspensi fibroblast disebarkan pada kolom plate 96 well, dan diisi dengan PBS steril 200 μl. Sel diinkubasi selama 72 jam sesuai dengan waktu yang diperlukan sintesis kolagen dalam kondisi stabil, selanjutnya medium dibuang diganti dengan medium DMEM, EBH berbagai konsentrasi (0, 50, 100, dan 150 μg/ml), kemudian diinkubasi selama 24 jam. Setelah

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Anti-Aging Medicine & Improvement in The Quality of Life

itu, medium dibuang, dicuci 2 kali dengan PBS steril dan diisi dengan PBS steril 200 μl per sumuran. Plate kemudian dipajan UVB 250 mJ/cm2 dengan irradiance 0,8 mW/cm2 pada jarak 25 cm dari plate. 2.4. Pengukuran Vibilitas Fibroblast (MTT-Assay) Dua puluh empat jam setelah dipajan UVB, dilakukan pemeriksaan viabilitas fibroblast dengan metode MTT-assay menurut Freshney (2000). Semua medium yang tersisa di dalam sumuran microplate dikeluarkan, kemudian dimasukkan 200 μl medium baru pada setiap sumuran dan ditambahkan MTT 50 μl pada setiap sumuran. Microplate dibungkus menggunakan kertas aluminium foil, kemudian diinkubasi selama 4-8 jam (maksimal 8 jam) dalam inkubator. Setelah inkubasi, MTT dan medium dari setiap sumuran dikeluarkan dan ditambahkan 200 μl DMSO dan 25 μl glisin buffer pada setiap sumuran. Microplate kemudian dibaca dengan microplate reader panjang gelombang (λ) 550 nm. 2.5. Pengukuran Degradasi Kolagen (Sirius Red Binding- Assay) Pengukuran degradasi kolagen dilakukan dengan metode PicroSirius Red (PSR) menurut Taskiran dkk (1999), yaitu ambil 50 μl medium dari setiap sumuran kelompok pajanan dan tanpa pajanan, masing-masing masukkan ke dalam tabung eppendorf 1,5 ml dan tambahkan 50 μl PBS, tambahkan 1000 μl Sirius Red dan dikocok menggunakan vortex, sampel disentrifus pada 10.000 g selama 5 menit pada suhu 4 derajat Celcius untuk mengendapkan kolagen. Buang supernatan dengan hati-hati (tidak dibolak-balik). Tambahkan 1000 μl HCl 0,1 N ke dalam tiap tabung dan dikocok menggunakan vortex. Sampel disentrifus kembali pada 10.000 g selama 5 menit, pada suhu 4 derajat Celcius untuk mengendapkan kolagen. Buang supernatan dengan hati-hati hingga bersih. Tambahkan 1000 μl NaOH 0,5 N ke dalam setiap tabung dan dikocok menggunakan vortex. Masukkan masing-masing tabung ke dalam multiwell plate yang baru sesuai peta

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awal (1 sumuran=200 μl). Baca densitas optis dengan microplate reader panjang gelombang (λ) 550 nm. 3. Analisa Data Hasil disajikan dalam bentuk grafik rerata viabilitas fibroblast (%) dan densitas optis (DO) degradasi kolagen. Analisa statisitik untuk uji kemaknaan digunakan one way anova dilanjutkan dengan multiple comparisons LSD-test. 4. Hasil 4.1 Efek Ekstrak Bawang Hitam pada Viabilitas Fibroblas dan Degradasi Kolagen Penelitian ini membuktikan bahwa pemberian EBH dosis 50,100, dan 150 μg/ml dapat meningkatkan indeks viabilitas fibroblas pasca pajanan UVB sebesar 7,04 ±1,8%, 8,91 ± 1,4%, dan 6,1 ± 3,9% ( p < 0,05) (Gambar 1). Dosis EBH 50,100, dan 150 μg/ml memiliki efektivitas yang sama dalam meningkatkan viabilitas fibroblas pasca pajanan UVB (p>0,05). Pemberian EBH dosis 50,100, dan 150 μg/ml dapat menghambat peningkatan degradasi kolagen pasca pajanan UVB sebesar 0,0443 ± 0,0015 (DO), 0,0353 ± 0,0030 (DO), dan 0,0303 ± 0,0037 (DO) (p<0,05) (Gambar 2). Dosis EBH 50 μg/ml merupakan dosis terbaik dalam menghambat peningkatan degradasi kolagen (p<0,05), dibandingkan dosis 100 dan 150 μg/ml.

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Anti-Aging Medicine & Improvement in The Quality of Life

Gambar 1. Pemberian EBH meningkatkan proliferasi fibroblas pasca pajanan UVB (LSD-test); UVB=ultraviolet B 250 mJ/cm2, EBH=Ekstrak bawang hitam 0, 50,100, dan 150 μg/ml.

Gambar 2. Pemberian EBH menghambat peningkatan degradasi pasca pajanan UVB (LSD-test); UVB=ultraviolet B 250 mJ/cm2, EBH=Ekstrak bawang hitam 0,50,100, dan 150 μg/ml.

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5. Pembahasan EBH terbukti mampu meningkatkan viabilitas fibroblas dan menghambat peningkatan degradasi kolagen pasca pajanan UVB. Kemampuan EBH sebagai antiphotoaging kemungkinan disebabkan karena kandungan flavonoid dan SAC nya (Kim dkk, 2012; Kim dkk, 2013). Senyawa flavonoid tersebut memiliki 2 gugus hidroksil yang mendonorkan hydrogen untuk mereduksi radikal bebas akibat pajanan sinar UV (Yaar dan Gilchrest, 2007). SAC memiliki kemampuan menangkal ROS seperti superoksid, ion hidrogen peroksida, ion hidroksil dan menghambat peroksidasi asam lemak(Kim dkk, 2012; Gonzales dkk, 2012) serta menghambat jalur NF-κB dan AP-1 (Kim dkk, 2013). Kemampuan EBH dalam menangkal ROS, menghambat NF-kB dan AP-1 akan meningkatkan viabilitas fibroblas dan menghambat jalur aktivasi MMPs sehingga terjadi hambatan pada peningkatan degradasi kolagen, meningkatkan respon sel fibroblas terhadap stimulasi TGF-ß yang akhirnya akan meningkatkan deposisi kolagen dermis. Dosis EBH 50 μg/ml memiliki efek terbaik dalam menurunkan degradasi kolagen mungkin karena pada dosis tersebut antioksidan dalam EBH dalam jumlah dan kekuatan yang paling proporsional dalam menetralisir stres oksidatif pada sel fibroblas. Tubuh memiliki keseimbangan dalam mengatur kadar radikal bebas dan antioksidan. Antioksidan tubuh akan menetralisir radikal bebas tetapi juga tetap mempertahankannya dalam kadar tertentu karena dibutuhkan untuk sistem pertahanan dan merangsang perbaikan sel. Penggunaan suplemen antioksidan dengan dosis berlebihan akan menimbulkan “stres antioksidative”. Artinya, antioksidan tersebut malah akan menyebabkan penurunan fungsi pertahanan antioksidan internal sel dan menjadi prooksidan dengan meningkatkan stres oksidatif. Akibatnya, malah akan mempercepat proses penuaan dibanding tujuan awalnya yaitu memperlambat penuaan (Poljsak dkk., 2013). Dosis 100 dan 150 μg/ml memiliki efektivitas lebih rendah dari dosis 50 μg/ml diperkirakan karena antioksidan yang terkandung dalam dosis tersebut terlalu besar 47

Anti-Aging Medicine & Improvement in The Quality of Life

dari yang diperlukan sel sehingga malah menurunkan fungsinya dalam menghambat peningkatan degradasi kolagen. 6. Kesimpulan EBH yang diberikan sebelum pajanan UVB dapat meningkatkan viabilitas fibroblas dan menghambat peningkatan degradasi kolagen. Dengan demikian bawang hitam dapat menjadi kandidat obat herbal antiphotoaging. Penelitian lebih lanjut masih dibutuhkan untuk memperkuat pembuktian hasil tersebut. Tinjauan Pustaka

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1.

Baran, R. and Maibach, H.I. 2010. Textbook of Cosmetic Dermatology. Fourth edition. Informa Healthcare. New York,. London.

2.

Choi, M.S., Yoo, M.S., Son, D.J. 2007. Increase of collagen synthesis by obovatol through stimulation of the TGF-beta signaling and inhibition of matrix metalloproteinase in UVB-irradiated human fibroblast. J DermatolSci, 46: 127–137.

3.

Freshney, R.I. 2000. Cell Lines. In: Culture of Animal cell. A manual of basic technique. Pp 177-193, ed.4. Wiley-Liss, New York.

4.

Freshney, R.I. 2000. Cytotoxicity, In: Culture of Animal cell. A manual of basic technique. Pp 329-344, ed.4. Wiley-Liss, New York.

5.

Heng, E.C.K., Huang, Y., Black Jr, S.A., Trackman, P.C. 2006. CCN2, Connective tissue growth factor, stimulates collagen deposition by ginggival fibroblast via module 3 dan α6- and ß1 integrins. J Cell Biochem, 98-409-420.

6.

Kim, J., Nam, S., Rico, C., Kang, M. 2012. A comparative study on the antioxidantive and anti allergic activities of fresh & aged black garlic extracts. International Journal of Food Science & Technology, 47 (6):1176-1182.

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7.

Kim, S.R, Jung, Y. R. 2013. Anti-Wrinkle and Anti-inflammatory of Active Garlic Components and the Inhibitor of MMPs via NF-κB Signaling. Plos One 8(9). e7387.

8.

Kim, H.K., Jung, E.Y., Kang, D.H, Chang, U.J., Hong, Y.H., Suh, H.J. 2012. Physical stability, antioxidative properties, and photoprotective effects of functionalized formulation containing black garlic extract. Jornal of Photochemistry and Photobiology B: Biology, 117: 104-110.

9.

Svobodova, A., Walterova, D., Vostalova, J. 2006. Ultraviolet Light Induced Alteration to The Skin. Journal of Biomedic Palacky Olomouc University, 150(no.1): 25-38.

10. Taskiran, D., Taskiran, E., Yercan, H., Kutay, F.Z., 1999. Quantification of Total collagen in rabbit tendon by the Sirius Red Methode. Tr J Med Sciences, 29: 7-9. 11. Widodo, Y.W., Trisnowati, N., Budiyanto, A. 2012. Collagen deposition and cellular viability among UVB irradiated human dermal fibroblasts treated by platelets. Journal of Clinical Medicine and Research, 4(2): 29-33. 12. Yaar, A.R., and Gilchrest, B.A. 2007. Photoaging: mechanisme, prevention, and therapy. Br J Dermatol, 157: 874-884.

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Anti-Aging Medicine & Improvement in The Quality of Life Symposium IV.3: Men's & Women's health: Implementing science for a better life

TREATMENT OF HYPERANDROGENISM IN WOMEN J. Alex Pangkahila Post Graduate Program in Anti-Aging Medicine, Department of Andrology and Sexology, Medical Faculty Udayana University Indonesian Center for Anti-Aging Medicine (INCAAM)

Introduction In general androgen or testosterone is associated with men. Even many doctors do not realize that testosterone is also about women. Like men, all women need testosterone and other sex steroid hormones as well. However, abnormality of testosterone level, either decrease or increase will result in some signs, symptoms, and complaints. Increased level of testosterone to supraphysiological level is considered as hyperandrogenism. Therefore one of the conditions that must be controlled in Hormone Replacement Therapy is the hormone level should not be supraphysiological level. Hyperandrogenism Hyperandrogenism in men and women is a hidden problem. A study in 155 women showed that reference values were different between women with and without hyperandrogenism. The level of total testosterone was 0.48-3.42 vs. 0.54-2.72 nmol/L, calculated free testosterone was 3-65 vs. 3-39 pmol/L, and bioavailable testosterone was 0.06-1.35 vs. 0.06-0.81 nmol/L. In women, hyperandrogenism is a common hormone problem in reproductive-age. The prevalence is around 10-20%. Most patients (around 80-90%) with hyperandrogenism have polycystic ovary syndrome (PCO).

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Clinical manifestations of hyperandrogenism include hirsutism, acne, androgenic alopecia, and virilization, as well as menstrual abnormalities and, often, obesity. Hirsutism means excessive growth of terminal hair in women in a male-like pattern. This is the most commonly used clinical diagnostic criterion of hyperandrogenism. The presence of hirsutism is usually determined by using a standardized scoring system of hair growth, called as Ferriman-Gallwey Scoring System. Hirsutism is present in up to 80% of patients with hyperandrogenism. Acne and androgenic alopecia are other common androgenic skin changes. These might be observed without hirsutism in some hyperandrogenic women. However, isolated presence of any of these manifestations is not used as a diagnostic criterion for hyperandrogenism. Virilization is a relatively uncommon feature of hyperandrogenism, and its presence often suggests an androgen-producing tumor. A thorough history and a focused clinical examination are extremely helpful in diagnostic evaluation of patients with suspected hyperandrogenism. Most women with hyperandrogenism usually come to the doctor for their acne, hirsutism or menstrual problem. However, there are other important implications regarding their health. Women with PCOS have varying degrees of insulin resistance, and an increased incidence of Type II diabetes mellitus, as well as unfavorable lipid patterns. The presence of these risk factors is suggested by upper segment obesity, darkening of the skin, and the other skin changes that make up acanthosis nigricans. Diagnosis involves measurement of circulating androgens together with prolactin and FSH when menstrual dysfunction is present. Many women with androgenic skin 2 changes have normal serum androgen levels, suggesting increased end organ sensitivity to androgens. Others have hyperandrogenism of ovarian or adrenal origin.

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Treatment Treatment is usually successful to cures acne, reduces hirsutism and stabilizes or partially reverses androgenic alopecia. Pharmacological approaches involve suppressing androgen levels, for example, the use of an appropriate oral contraceptive, or antagonizing androgen action with several medications that have this activity. There are four groups of medicine used in the hormonal treatment of acne: 1) androgen receptor blockers (spironolactone, flutamide, cyproterone acetate), which block the effect of androgens on the sebaceous gland; 2) oral contraceptives (OCs), which suppress ovarian androgen production; 3) glucocorticoids, which cause adrenal suppression of androgen production; and 4) enzyme inhibitors (5αreductase inhibitors). However, use of type I 5 alpha-reductase inhibitor did not result in clinical improvement of acne when used alone and did not enhance the clinical benefit of systemic minocycline. The combination of cyproterone acetate and ethinyl estradiol is found in an oral contraceptive pill named Diane-35®. Mechanism of cyproterone acetate as anti androgen as follows: 1. Bind androgen receptor, result in decreased free androgen, 2. Decrease sebum production in the skin. In healthy women who do not smoke, OCs can first be introduced. It can take up to three months to see improvement. At that time, spironolactone can be added if the response is not adequate. Dosing can range from 25 to 100 mg per day. Laboratory follow up is usually not necessary in healthy women. As the acne clears, other treatments, such as oral antibiotics, can be discontinued. OCs, usually in combination with topical retinoids, can be continued as part of a maintenance regimen. At least in the treatment of acne, hormonal aspect as the causative factor should be considered.

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NASWAAM 2018 Symposium V.1: Stem cell therapy-between research and application

TERAPI SEL PUNCA : HARAPAN DAN RISIKO (Unproven Stem Cell Treatments: The Hope and The Risks)

Sandy Qlintang Abstrak Pengobatan dengan menggunakan stem cell alias sel punca semakin menjadi pilihan dalam dunia kesehatan di Indonesia. Kendati belum sepenuhnya bisa dimanfaatkan, tren terapi sel punca tampaknya hanya tinggal menunggu waktu untuk menjadi solusi bagi banyak penyakit. Selain memiliki manfaat menyembuhkan penyakit, umumnya obat juga memiliki efek samping, terutama apabila penggunaaannya kurang memenuhi syarat. Begitu juga dengan metode pengobatan dengan stem cell atau sel punca. Ada beberapa risiko yang bisa ditimbulkan. Bagi yang berminat untuk melakukan terapi sel punca, faktor keamanan harus menjadi perhatian utama. Pasalnya, sel punca saat ini masih dalam tahap pengembangan. Oleh karena itu, demi faktor keselamatan, pilihan untuk melakukan terapi sel punca harus memperhatikan legalitas rumah sakit dan kompetensi dokter yang melakukan transplantasi sel punca serta, yang tidak kalah pentingnya, fasilitas pengelolaan / produksi sel punca. Apalagi tidak semua penyakit bisa disembuhkan dengan menerapkan terapi sel punca. Kesimpulan: Terapi Sel Punca, merupakan pengobatan yang berkembang pesat dan memiliki potensi yang sangat besar bagi dunia medis. Namun, pemahaman yang lebih dalam tentang terapi ini sangat diperlukan untuk memberikan manfaat maksimal dan khususnya keamanan bagi pasien.

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Anti-Aging Medicine & Improvement in The Quality of Life Symposium V.2: Stem cell therapy-between research and application

PROSPEK MEDIA SEL PUNCA JARINGAN ADIPOSA TERKONDISI SEBAGAI ANTI-AGING Indra Bachtiar Abstrak Keluhan kulit keriput dapat terjadi karena proses penuaan yang dapat disebabkan oleh faktor intrinsik dan ekstrinsik akibat paparan ultraviolet (UV). Penelitian kedokteran membuktikan media sel punca jaringan adiposa terkondisi (conditioned medium) mempunyai kandungan beberapa growth factor dan antioksidan, diduga dapat digunakan sebagai terapi anti-aging. Pendahuluan Setiap orang pasti akan mengalami penuaan yang merupakan suatu proses alamiah. Perubahan-perubahan di kulit wajah seperti keriput dan gangguan pigmentasi merupakan dampak yang sering dirisaukan. Faktor intrinsik dan ekstrinsik akibat paparan ultraviolet (UV) akan menimbulkan proses penuaan muncul lebih cepat dari waktunya. Perawatan konvensional dalam bentuk upaya rejuvenasi kosmetik seperti laser, antioksidan dan rejimen topikal diharapkan dapat menginduksi sintesis kolagen, sehingga kulit keriput dan testur kulit dapat diperbaiki. Namun, dengan perawatan konvensional membutuhkan waktu yang lama untuk mendapatkan hasil yang maksimal. Perkembangan ilmu pengetahuan dan teknologi saat ini diduga mampu menghambat proses penuaan, antara lain dengan teknologi sel punca (stem cell) dan sekretom (faktor tersekresi) yang dihasilkannya. Sel punca mesenkimal jaringan adiposa (Adipose-derived mesenchymal stem cells / ADMSCs) diduga dapat digunakan sebagai anti-aging. Dalam sebuah studi kasus, ADMSCs disuntikan secara 54

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intradermal pada kulit keriput (2 suntikan berturut-turut pada interval 2 minggu). Setelah 2 bulan, ditemukan tekstur dan ketebalan kulit meningkat.1 Hal ini terjadi karena ADMSCs mempunyai efek parakrin dari sekretom tersebut yang berperan penting dalam berbagai regulasi proses fisiologi termasuk pertumbuhan sel, replikasi, diferensiasi, signaling, apotosis, adesi, dan angiogenesis.2 Namun, pemberian terapi harus dilakukan secara autogenik untuk menghindari reaksi penolakan jaringan, pengambilan jaringan lemak tidak dapat dilakukan kepada orang usia lanjut, orang kurus, dan tidak dapat diproduksi secara masal. Berbagai penelitian tentang faktor sekresi yang berasal dari sel punca menunjukkan bahwa faktor yang disekresikan sendiri tanpa sel punca itu sendiri dapat menyebabkan perbaikan jaringan dalam berbagai kondisi. Sekretom dapat ditemukan di dalam media dimana ADMSCs dikultur. Media ini disebut sebagai conditioned medium (CM). Oleh karena itu, CM memiliki prospek yang menjanjikan untuk diproduksi sebagai obatobatan anti-aging untuk kulit menua dini. Mekanisme Penuaan Kulit Karena Paparan Ultraviolet (Photoaging) Paparan UV berulang akan menyebabkan terbentuknya ROS (reactive oxygen species) yang kemudian menyebabkan terjadinya inisiasi signaling, kerusakan oksidatif pada komponen seluler seperti dinding sel, membran lipid, mitokondria, dan DNA. ROS dapat meningkatkan transkripsi factor pada activator protein (AP)-1 yang merupakan faktor ranskripsi yang menghambat produksi kolagen dan meningkatkan kerusakan kolagen melalui regulasi enzim MMPs (matrix metaloproteinases). Selain itu, ROS juga menyebabkan penurunan ekspresi TGF-b yang merupakan sitokin untuk mensintesis kolagen, sehingga terjadi penurunan produksi kolagen.3

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Sel Punca Sel punca adalah sebuah sel yang belum memiliki fungsi khusus, dapat memperbaharui dan membelah diri menjadi sel yang serupa (selfrenew) atau mengubah diri (differentiate) menjadi jenis sel yang sama sekali berbeda tergantung lingkungannya. Saat ini dikenal 3 jenis sel punca, yaitu sel punca dewasa (adult stem cells), sel punca embrional (embryonic stem cell / ESC) dan sel punca pluripoten hasil induksi dari sel somatic / dewasa (induced pluripotent stem cell / IPSC).4,5,6 Salah satu sel punca dewasa adalah sel punca yang berasal dari sel mesenkimal (mesenchymal stem cell / MSC. MSC merupakan sel punca yang bersifat multipoten sehingga dapat berdiferensiasi menjadi sel myogenik, adipogenik, kondrogenik dan osteogenik. Namun, MSC juga memiliki sifat plastis, artinya selain berdiferensiasi menjadi sel yang sesuai dengan jaringan asalnya, MSC juga dapat mengalami transdiferensiasi menjadi sel jaringan lain.2,7 MSC terdapat di seluruh organ tubuh terutama di derah perivaskuler. Stroma jaringan adiposa, darah tali pusat dan sumsum tulang merupakan tiga sumber MSC terbanyak pada tubuh manusia. Jumlah MSC jaringan adiposa (ADMSCs) lebih banyak dibandingkan MSC dari kedua sumber lainya.8 Isolasi Jaringan lemak subkutan dapat diambil melaui proses lipoaspirate (sedot lemak), kemudian diisolasi secara mekanik atau enzimatik (enzim kolagenase) untuk memisahkan antara sel lemak dan nonlemak. Kumpulan sel-sel non lemak yang berhasil dipisahkan tadi dinamakan stromal vascular fraction (SVF). SVF mengandung beragam jenis sel antara lain sel-sel endotel, eritrosit, fibroblas, limfosit, monosit/ makrofag, pericytes, dan juga ADMSCs. Sebelum diberikan kepada pasien, ADMSCs harus diisolasi dari SVF, kemudian dikultur dan diperbanyak. Sehingga ekstrak dari CM dapat dipersiapkan tergantung dari metode yang digunakan.9,10 Homogenitas ADMSCs juga dapat dibuktikan berdasarkan kriteria minimum sebagai berikut, melekat pada

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plastik, mengekspresikan positif (>95%) penanda CD105, 73, 90, dan negatif (≤2%) penanda CD34, 45, 14, 19, HLA tipe II, dan memiliki kemampuan diferensiasi kondorogenik, osteogenik dan adipogenik pada kondisi in-vitro.11 Sekretom ADMSCs telah terbukti memiliki kemampuan mensekresikan berbagai sekretom seperti kemokin, sitokin, dan faktor pertumbuhan (growth factor). Serangkaian senyawa sekretom tersebut berfungsi sebagai mediator dalam komunikasi antar sel untuk memperbaiki dan meregenerasi jaringan yang rusak. Proses ini yang disebut sebagai sebuah efek parakrin. Efek parakrin dari sekretom tersebut memiliki peran penting dalam berbagai regulasi proses fisiologi termasuk pertumbuhan sel, replikasi, diferensiasi, signaling, apotosis, adesi, dan angiogenesis. Faktor pertumbuhan hasil sekresi dari ADMSCs sangat berperan dalam terapi anti-aging, seperti vascular endothelial growth factor (VEGF), basic fibroblasts growth factor (bFGF), transforming growth factor (TGF-b1), TGF-b2, hepatocyte growth factor (HGF), keratinocyte growth factor (KGF), platelet-derived growth factor (PDGFAA), type I collagen dan beberapa antioksidan seperti insulin-like growth factor-binding proteins (IGFBPs) dan superoxide dismutase (SOD).1,2,12 Efek anti-aging dari ADMSCs ADMSCs diketahui mampu memperbaiki jaringan yang rusak melalui diferensiasi dan efek parakrin. Pada beberapa hasil penelitian diduga ADMSCs dan sekretomnya mempunyai efek anti-aging. Penelitian yang dilakukan secara in-vitro, ADSCs terbukti meningkatkan kualitas epidermis dan dermis dalam mencegah penuaan.13 CM mempunyai efek parakrin terhadap human dermal fibroblast (HDFs). Terbukti CM menginduksi proliferasi HDFs usia tua dan produksi kolagen tipe 1, menurunkan produksi MMP-1 dan ekspresi p16.14 Pengendalian produksi melanin merupakan proses yang penting dalam mengobati pigmentasi kulit yang tidak normal. CM mempunyai sebuah 57

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efek pemutih pada percobaan in vitro model menggunakan sel melanoma B16 dengan cara menghambat sintesis melanin melalui aktivitas tirosinase. Mekanisme ini dimediasi melalui efek parakrin, terutama melalui TGF-b1.15 CM juga memiliki antioksidan yang kuat dan efek perlindungan pada HDFs yang mana merupakan kandidat yang baik dalam mengendalikan kerusakan kulit dari radikal bebas. Penelitian membuktikan bahwa CM mempunyai potensi anti-oksidan setara dengan 100 µM asam askorbat. Terjadi peningkatan enzim SOD dan glutation peroksidase (GPx) ketika kultur HDFs pada CM.12 Selain itu juga, CM menjanjikan harapan baru dalam pengobatan regenerasi kulit dengan menekan apoptosis akibat UV-B dan merangsang sintesis kolagen oleh HDFs.10,16 Dalam penelitian yang lebih luas, injeksi CM menggunakan microneedles pada 30 kulit wajah sukarelawan. Pengamatan dilakukan selama 3 bulan. CM injeksi menunjukan peningkatan yang significant pada melanin indeks, kecerahan kulit, kehalusan kulit, elastisitas kulit.17 Keuntungan dan kerugian dari CM Penggunaan terapi bebas sel punca dengan CM memiliki keuntungan sebagai berikut yaitu mudah diproduksi, dikeringkan beku, dikemas, dan mudah ditransportasikan. Selain itu, karena tidak memiliki sel, tidak perlu mencocokkan donor dan penerima untuk menghindari masalah penolakan.18 Kerugiannya adalah untuk memperoleh ADMSCs masih membutuhkan prosedur invasif (lipoaspirate). Kesimpulan CM memiliki prospek yang menjanjikan untuk diproduksi secara masal sebagai obat-obatan anti-aging untuk kulit menua dini. Hal ini terjadi karena efek parakrin dari sekretom tersebut berperan penting dalam menghambat proses penuaan. Selain itu juga penggunaan terapi bebas sel punca dengan CM dapat diberikan kepada orang lain tanpa adanya masalah penolakan / rejeksi.

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References 1.

Park BS, Jang KA, Sung JH, Park JS, Kwon YH, Kim KJ, et al. Adiposed-derived stem cells and their secretory factors as a promising therapy for skin aging. J Dermatol Surg. 2008;34:1323-6.

2.

Lee SH, Jin SY, Song JS, Seo KK, Cho KH. Paracrine effects of adipose-derived stem cells on keratinocytes and dermal fibroblasts. Ann Dermatol. 2012;24: 2.

3.

Helfrich YR, Sachs DL, Voorchees JJ. Overview of skin aging and photoaging. Dermatology Nursing. 2008; 20(3):177-83.

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Choumerianou DM, Dimitriou H, Kalmanti M. Stem cells: promises versus limitations. Tissue Eng Part B Rev. 2008;14(1):53-60.

5.

Evans MJ, Kaufman MH. Establishment in culture of pluripotential cells from mouse embryos. Nature 1981;292:154-6.

6.

Takahashi K, Yamanaka S. Induction of pluripotent stem cells from mouse embryonic and adult fibroblast cultures by defined factors. Cell 2006;126:663-76.

7.

Wang S, Qu X, Zhao RC. Clinical aplications of mesenchymal stem cells. Journal of hematology and oncology. 2012;5:9.

8.

Kern S, Eichler H, Stoeve J, Kluter H, Bieback K. Comparative analysis of mesenchymal stem cells from bone marrow, umbilical cord blood, or adipose tissue. Stem Cells. 2006;24:1294-301.

9.

BunnellBA ,Flaat M, Gagliardi C, Patel B, Ripoll C. Adipose-derived Stem Cells: Isolation, Expansion and Differentiation. Methods. 2008;45(2):115–120.

10. Wang T, Guo S, Liu X, Xv N, Zhang S. Protective effects of adiposederived stem cells secretome on human dermal fibroblasts from ageing damages. Int J Clin Exp Pathol. 2015;8(12):15739-15748. 11. Dominici M, Le BK, Mueller I, Slaper CI, Marini F, Krause D, et al. Minimal criteria for defining multipotent mesenchymal stromal cells. The International Society for Cellular Therapy position statement. Cytotherapy. 2006;8(4):315-7. 12. Kim WS, Park BS, Kim HK, Park JS, Kim KJ, Choi JS, et al. Evidence supporting antioxidant action of adipose-derived stem cells: protection of human dermal fibroblasts from oxidative stress. J Dermatol Sci. 2008;49(2):133-42. 59

Anti-Aging Medicine & Improvement in The Quality of Life 13. Metral E, Santos MD, Thépot A, Rachidi W, Mojallal A, Auxenfans C, et al. Adipose-derived Stem Cells Promote Skin Homeostasis and Prevent its Senescence in an In vitro Skin Model. J Stem Cell Res Ther. 2014;4:194. 14. Song SY, Jung JE, Jeon YR, Tark KC, Lew DH. Determination of adipose-derived stem cell application on photo-aged fibroblasts, based on paracrine function. Cytotherapy. 2011;13(3):378-84. 15. Kim WS, Park SH, Ahn SJ, Kim HK, Park JS, Lee GY, et al. Whitening effect of adipose-derived stem cells: a critical role of TGF-beta 1. Biol Pharm Bull. 2008;31(4):606-10. 16. Kim WS, Park BS, Park SH, Kim HK, Sung JH. Antiwrinkle effect of adipose-derived stem cell: activation of dermal fibroblast by secretory factors. J Dermatol Sci. 2009;53(2):96-102. 17. Wang X, Shu X, Huo W, Zou L, Li L. Efficacy of protein extracts from medium of adipose-derived stem cells via microneedles on asian skin. Journal of Cosmetic and Laser Therapy. 2017:1-8. 18. Pawitan JA. Prospect of Stem Cell Conditioned Medium in Regenerative Medicine. BioMed Research International. 2014;ID 965849.

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NASWAAM 2018 Symposium VI.1: Exercise and aging process

EXERCISE (PHYSICAL TRAINING) TO DELAY AGING PROCESS J. Alex Pangkahila Post Graduate Program in Anti-Aging Medicine, Department of Andrology and Sexology, Medical Faculty Udayana University

Abstract Indonesian Center for Anti-Aging Medicine (INCAAM)The aging process will be experienced by everyone without exception, but this process was experienced differently depending on several factors that affect each other. Differences of factors that affect this result in the age of people, there are longevity and some short-lived. Differences in the age of the population from each location / region or country are different, the pattern of life was very important and 64% cause of death is determined by a lifestyle. Several studies have been reported that one of the factors that can slow down the aging process is physical training that is scientifically specific to anti-aging. Common misconduct in society is that many people do sports that do not fit the scientific rules, especially sports achievements often accelerate the aging process. The facts on the field turned out only 9.1% of people who do intensive active exercise while others do not exercise intensively. Scientific rules based on frequency of exercise / week, intensity, duration of exercise and type of exercise (FITT) are rarely forgotten in everyday life including work activities. The consequences of such behavior must accelerate the aging process. Therefore, do physical training in accordance with scientific principles in order to inhibit the aging process.

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Anti-Aging Medicine & Improvement in The Quality of Life Symposium VI.2: Exercise and aging process

EXERCISE WITHOUT STEROID FOR MUSCLE DEVELOPMENT Michael Triangto Abstrak Dengan bertambahnya usia maka tubuh akan mengalami penurunan massa otot yang dikenal sebagai sarcopenia dan keadaan ini akan berpengaruh pada kemampuan kerja dari otot yang bersangkutan. Selain itu tuntutan zaman akan penampilan akan membuat banyak orang yang tertarik untuk menggunakan steroid dalam mengambil jalan pintas mendapatkan otot-otot yang besar dan kuat. Steroid sendiri di olahraga prestasi termasuk dalam kelompok obat terlarang / doping karena penggunaannya yang tidak tepat, dalam jumlah yang berlebihan dan jangka waktu panjang dipastikan akan menimbulkan dampak yang merugikan pada kesehatan. Olahraga untuk memperoleh otot yang besar / hypertrophy tidak sama dengan olahraga untuk meningkatkan strength/kekuatan. Selain program latihan yang tepat, ternyata menentukan lama darii stirahat juga perlumen dapat perhatian. Oleh sebab itu perlu dibuat program latihan dan edukasi bagi masyarakat yang berolahraga agar dapat mencegaht erjadinya sarcopenia dan memenuhi harapan dari mereka untuk membentuk otot dengan cara yang sehat. Abstract With increasing age, human body will undergo a reduction in muscle mass, which is well known as sarcopenia. This condition would definitely affect the working capacity of the muscles in question. Furthermore, current age demands on body appearance would gain interests in many individual to utilize steroids in order to gain both strong and big muscle mass. Steroids itself in competitive sport is classified as a drug/doping as unsupervised utilization in both dose and time would surely result in several adverse health impacts. Exercises performed to achieve bigger muscles/hypertrophy will not be the same like exercises which improves strength. Therefore, there is a need to design both exercise and educational programs for the exercising community in order to avoid sarcopenia, and fulfil their expectations for muscle building in healthy way. 62

NASWAAM 2018 Symposium VII.1: Aesthetic aspect of Anti-Aging Medicine

PREVENTION AND TREATMENT OF AGING SKIN A.A.G.P. Wiraguna Center for Study of Anti-Aging Medicine Dept. Dermatology-Venereology Medical Faculty Udayana University Indonesian Center for Anti-Aging Medicine

Abstract To prevent skin aging, formerly the causal or trigger factors of skin aging processes need to be known. Skin aging is a complex process that defined as changes throughout life time that could not be explained by single pathway or etiology. Skin aging developed as result of the changes of natural skin supporting structures, such as decreased sebum production that led to dry skin, decreased cell turnover that induced rough skin, also collagen tissue and elastin damage that caused saggy skin. Skin aging process is also accelerated by the influence of environmental factors, like sunlight (ultraviolet light), pollution, and extreme weather. As the other organs, the skin structures and functions physiologically continue decreasing with age. To maintain or repair the skin to stay look younger, great and continuous efforts are needed to achieve healthy, fresh, and clean skin regardless of age. Learn and understand the skin aging process can help to prevent and inhibit natural skin aging process as well as that affected by environmental factors. Realized or not, age and attractiveness often related to the skin appearance, as the aging signs thoroughly easier and faster to be observed on the skin. Skin is a primely organ to describe the intrinsic and extrinsic aging process. Skin aging signs that can be observed from outside include dry skin, dull skin, rough scaly skin, fine lines and deep

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wrinkle, border of jaw and eye lines diminished, uneven melanin development which known as the age spot. Declining of the skin function and health are attributed to 1) biological (intrinsic) aging, the aging that is affected by the genetic and hormonal factors that naturally developed, 2) aging that is influenced by environmental factors (extrinsic), mainly affected by free radical that produced by the accumulation of sun exposure, pollution, or cigarette smoke. To prevent the intrinsic and intrinsic skin aging, some steps can be undertaken, such as: 1) maintain the skin to stay healthy, fresh, and look younger by using good skin care based on the skin type, 2) applying emolient that contained antioxidant, 3) using physical or chemical sun screen if exposed by the sun light, 4) consuming antioxidant in order to against free radical that originated from the inside or outside the body. Whereas to overcome the clinical signs of skin aging, some invasive procedures can be done, include: 1) chemical peels; 2) microdermabrasion; 3) botulinum toxin A injection; 4) soft tissue augmentation (filler); and 5) laser. The aging skin management is not only consists of one procedure but it could be combination of some skin care methods with varies effectivity, risk, duration, and cost. This is important to be explained, so the society have an understanding about the advantages and limitations of the available skin care methods. Evaluation and education of skin aging management methods scientifically could help to achieve the prevention goals of skin aging as well as the therapy of skin aging.

Keywords: Skin Aging, Sun Protector, Antioxidant

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NASWAAM 2018 Symposium VII.2: Aesthetic aspect of Anti-Aging Medicine

COMBATING AGING SIGN USING COMBINATION OF LIFTING CONE THREAD – VOLUME CORRECTION POLYCAPROLACTONE COLLAGEN STIMULATOR Teguh Tanuwidjaja Abstract One of aging sign is losing volume of soft tissue under the skin (Sub-Cutaneous Soft Tissue) so it appears sagging face look and various wrinkles on the human face. Sagging skin tissue has been proven clinically to be overcome using Cone Thread with Poly L Lactic Acid material, while losing volume of soft tissue under the skin can be overcome by using Collagen Stimulator, made of Polycaprolacton, which actively triggers fibroblasts to increase the amount and increase the activity of generating collagen fibers especially collagen type 1 so it is able to actively maintain the soft tissue volume under the skin.

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Anti-Aging Medicine & Improvement in The Quality of Life Symposium VII.3: Aesthetic aspect of Anti-Aging Medicine

HIFU FOR REJUVINATION TREATMENT Nenden Sobarna Head Of Dermatology & Venereology Faculty Of Medicine Yarsi University Central Jakarta Abstract Non-invasive skin tightening procedures that are safe and effective are in demand as alternatives to aesthetic surgical procedures of the face, neck, and body.This modality is superior considering their ability to stimulate neocollagenesis and effect modest tissue tightening with minimal recover. Microfocused ultrasound was recently introduced as a novel energy modality for transcutaneous heat delivery that reaches the deeper subdermal connective tissue in tightly focused zones at consistent programmed depths. The goal is to produce a deeper wound healing response at multiple levels with robust collagen remodeling and a more durable clinical response. High-intensity focused ultrasound (HIFU) acoustic energyis known to propagate much deeper through tissue than laser or RF energy. It has been previously investigated for use in bulk heating for the treatments of subcutaneous lipolysis.The ultrasound waves penetrate into tissue, leading to vibration in molecules at the site of beam focus. The friction between tissue molecules produces heat and thermal injury at the focal site of the beam. Penetration depth is determined by frequency in which higher frequency waves produce a shallow focal injury zone and lower frequency waves have a greater depth of penetration to produce focal thermal injury zones (TIZs) at deeper layers. Initiation of the wound

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healing response with subsequent neocollagenesis and contraction leads to gradual lifting and tightening of the skin.

tissue

The ideal patient for nonsurgical tissue tightening displays mild to moderate skin and soft tissue laxity. Several absolute contraindications include active infection or open skin at the treatment site, cystic acne, and pregnancy. Relative contraindications include medical conditions and medications that alter or impair wound healing.

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Anti-Aging Medicine & Improvement in The Quality of Life Lunch Symposium 1 Holistic therapy for wrinkle and hyperpigmentation focus on oral collagen and antioxidant agent

HOLISTIC THERAPY FOR WRINKLES AND HYPERPIGMENTATION Anak Agung Gde Putra Wiraguna Center for Study of Anti-Aging Medicine Dept. Dermatology-Venereology Medical Faculty Udayana University Indonesian Center for Anti-Aging Medicine Abstract Skin aging occurs due to natural changes of the skin supporting structures. One of the most recognizable signs of skin aging is wrinkles.The appearance of wrinkles can be caused by the intrinsic factors and accelerated by the extrinsic factors, such as ultraviolet (UV) lights, pollution, and extreme weather. The other sign of aging skin is the presence of uneven hyperpigmentation, that mostly observed on the skin that being exposed by the sunlights. The oxygen molecules (O2) beneath the epidermis is the main target of UV lights that penetrate the skin. The penetration of UV lights into the skin layers may act as donor of an electron to the oxygen molecules in epidermis. At the time when the oxygen molecules attract an electron from the adjacent normal molecules, those molecules would possess unpaired electrons, become unstable, and turn to be aggresive free radicals. UV lights exposure would activate the growth factors and cytokine receptors on the keratinocytes and fibrolasts surface. The active receptors induce the transduction signal pathway and excite the AP-1 transcription factors, that affect the transcription of MMP genes. Inside the fibroblasts, AP-1 also inhibit the expression of procollagen genes. Matrix metalloproteinases that secreted by the keratinocytes and 68

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fibroblasts would break down the collagens and other proteins that contained in dermal extracellular matrix. Ultraviolet lights exposure, beside reduce the mature collagens in the dermis, also sustainably damage the collagen synthesis, mostly through decreasing the regulation of expression of procollagen genes. Two mechanisms that responsible to diminished procollagen genes expression is the induction of AP-1 and declining of TGF- regulation. The imperfect repair of skin damage would disrupt the functional integrity and structures of extracellular matrix. Repeated UV lights exposure lead the accumulation of the damage collagens that finally creates wrinkles. Ultraviolet radiation directly and indirectly affects the melanisation, proliferation, and melanocytes survival. The effects of UV lights on keratinocytes are inducing synthesis and secretion of paracrine factors by the keratinocytes, that increase the melanogenesis and melanocyte proliferation. Increase of melanocyte activity and the interaction with the keratinocyte lead the darkening of skin color. To prevent or treat wrinkles and hyperpigmentation, antioxidants that relieve the production and bad effects of free radicals that is hasten the appearance of wrinkles and hyperpigmentation can be given. Furthermore, the oral collagen (Hydrolysed collagen) that consists of small peptides with low mollecular weight (0.3-8 kDA), which produced by natural collagens that found in the animal bone, skin, and connective tissue can also be administered. Due to the low mollecular weight, the hydrolysed collagen is easily digested, absorbed, and distributed to all over the body. Various clinical trials have been proved the efficacy and benefits of the collagen peptides for the skin, include increase hydration, improve elasticity, and reduce wrinkles. Several procedures have been used to reduce wrinkles, involving botox and filler injections, and better outcome would be achieved if those procedures are combined with the antioxidant.

Key words: wrinkles, antioxidant, hydrolised collagen 69

Anti-Aging Medicine & Improvement in The Quality of Life Lunch Symposium 2 Holistic therapy for wrinkle and hyperpigmentation focus on oral collagen and antioxidant agent

ORAL COLLAGEN AND ANTIOXIDANT THERAPY Muliaman M Nutrition, lifestyle, daily adequate physical exercise and other factors also determine how healthy the aging process can be. Nutrition is a key factor influencing skin health and consequently its appearance. How Does Nutrition Slow Down The Rate Of Aging? Special foods contains special nutrients for; -

Combat muscle fatigue Neutralize free radicals Reduce DNA damage Naturally detoxify Add youth, health, and strength

A wide range of dietary supplements is offered to improve skin health. Making our diet rich in fresh vegetables, fruits, and whole grain foods to provide the essential nutrients, vitamins, protein, fibre, collagen and antioxidants are natural and potent anti-aging therapy and thus for healthy function Oral Collagen Peptides: Collagen peptides are used as a bioactive ingredient in nutricosmetic products and have been shown in clinical studies to improve skin barrier function, to induce the synthesis of collagen and hyaluronic acid, and to promote fibroblast growth and migration. Collagen peptides present as a mix of specific peptides of different length with high abundance of the amino acids hydroxyproline, glycine, and proline, which are produced by enzymatic hydrolysis of native collagen extracted from animal connective tissues. 70

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The quality of the final collagen is dependent on type of collagen which type 1 is dominant in dermis, and also average molecular size, The molecular weight distribution of collagen peptides usually span in the range 0.3 - 8 kDa. Due to the low molecular weight, there are several advantages of using collagen peptides with respect to native collagen: - collagen peptides is highly digestible; - collagen peptides is easily absorbed and distributed in the human body. When administered orally, collagen peptides reaches the small intestine where it is absorbed into the blood stream into 2 hours, both in the form of small collagen peptides and free amino acids will be reach 95% into 12 hours. Through the network of blood vessels, these collagen peptides and free amino acids are then distributed in the human body, in particular to the dermis, where it has been proven they can remain up to 14 days. In the dermis, collagen peptides has a dual action mechanism: 1) free amino acids provide building blocks for the formation of collagen and elastin fibres; 2) collagen oligopeptides act as ligands, binding to receptors present on the fibroblasts’ membrane and stimulate the production of new collagen, elastin and hyaluronic acid. Oral Antioxidant Dietary antioxidants play a major role in maintaining the homeostasis of the oxidative balance. It is important to obtain many different kinds of fruits and vegetables since all antioxidants work in synergy. One of the many measures of the antioxidant activity in foods is the ORAC (Oxygen Radical Absorbance Capacity) value. Eating foods

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with high ORAC values (a.k.a. Anti-aging Points) may help to slow the aging process, anti-inflammatory and anticarcinogenic effect. Superfruits is the best dietary sources of bioactive compounds (BAC). They have delicious taste and flavor, have economic importance, and because of the antioxidant properties of BAC. The bioactive compounds in berries contain mainly phenolic compounds (phenolic acids, flavonoids, such asanthocyanins and flavonols, and tannins) and ascorbic acid. Berries, fruits full of BAC, are also very delicious, have low energy, and are often consumed in fresh form when the most BAC are still active and in the greatest amount g process and our health condition. Combination Oral Collagen Peptide + Antioxidants (superfruits) Supplementation with 1 gr/80 mL active Collagen/Collagen peptide type 1 with MW 3.6 KDa, 2 bottles on a daily basis for 90 days led to a noticeable and reduction in skin dryness, wrinkles, and nasolabial fold depth. In addition, a significant increase in collagen density, while the effect will be maximize when we combine with antioxidant that have high ORAC. Besides, a combination of variety of antioxidants has a synergetic effect and can be obtained naturally from fruit such as: Pomegranate 100 mg, Acai Berry : 25 mg, Acerola : 25 mg, Grape Seed: 25 mg , and also Selenium : 20 mcg (65% AKG), Lycopene : 25 mg, Vitamin A : 1000 IU (50% AKG), Vitamin E: 7.5 mg (50% AKG), and for healthy way Low Calorie– only 35 kcal/serving , No preservative and delicious taste are the advantages (DIVA Beauty Drink) Finally, given the trends to complement the cosmetic use with oral supplementation such as: collagen peptides and antioxidants/ vitamins are more effective compared to placebo or cosmetic use only in the improvement and maintenance of the elasticity, density and firmness of the facial skin.

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PREVENTION OF SIDE EFFECTS OF FILLER AND BOTOX Almond Wibowo With the current tendency of increasing minimally invasive cosmetic procedures, some rare but disastrous complications of facial filler and toxin injections come into sight, such as visual loss. The study aims to prevent the possible side effectscause by toxin and fillers. The writer have collected some data about side effects cause by toxin and filler, and the mechanism of action from those side effects. And come to some conclusion that most of the injector didn’t know about the mechanism of action from toxin and fillers that they use. For toxin, the understanding of muscle layers becoming the most importance of all, since toxin act as a muscle relaxant. For fillers, the understanding of the ingredients and in which depth our blood vessels lies in our face was the most importance things. Since filler give more permanent side effects compare than toxin.

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FREE PAPER

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Free Paper

DAPATKAH TERAPI OZON MAYOR (MAH) MENGEMBALIKAN LANSIA KE KONDISI SEPERTI PADA USIA YANG LEBIH MUDA? Cynthia Sugiharto Pengantar Sekarang ini, berumur panjang saja tidaklah cukup.Hampir semua orang termasuk para lansia juga ingin terlihat awet muda, nyaman dengan penampilannya dan menikmati hidup sepenuhnya. Angan-angan orang pada zaman sekarang tercermin melalui mahakarya pelukis Lucas Cranach yang diberi namaThe Fountain of Youth (1546). Lukisan yang dipamerkan di State Museum Berlin ini memperlihatkan sebuah kolam berisi air ajaib, Ketika orang-orang dalam kondisi tua, bahkan timpang, memasuki kolam ini, mandi dan berenang menyeberangi kolam, akan keluar dalam keadaan muda kembali dan siap untuk memulai suatu siklus kehidupan baru (Bocci, 2011). Angan-angan ini kini bisa diwujudkan menjadi kenyataan melalui Anti-Aging Medicine, yang membawa suatu konsep baru ke dalam ilmu kedokteran, bahwa proses penuaan ternyata dapat diperlambat, dihambat, diobati, dan dikembalikan ke kondisi seperti pada usia muda dalam keadaan sehat (Pangkahila, 2017). Dalam kehidupan manusia, penuaan merupakan suatu proses yang terjadi secara alami, yaitu ketika hormon-hormon seperti testosteron, estrogen, progesteron, DHEA (dehydroepiandrosterone), GH (growth hormone), dan IGF-1 (insulin-like growth factor-1) mengalami penurunan seiring dengan pertambahan usia (Pangkahila, 2007). Hormon-hormon testosteron, estrogen, progesteron, dan kortisol dihasilkan dari hormon DHEA yang merupakan induk dari semua

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hormon steroid ini. Kadar hormon DHEA berangsur turun sehingga pada usia 65 tahun jumlahnya hanya sekitar 10-20% dibandingkan ketika kita berusia 20 tahun.Penurunan kadarhormon DHEA berkaitan erat dengan munculnya sejumlah penyakit dan melemahnya daya tahan tubuh. Para ilmuwan memperkirakan, apabila para lansia dapat mengembalikan kadar DHEA seperti saat masih muda, kesehatan dan kekuatan tubuh mereka pun akan dapat kembali seperti saat mereka muda (Gordon, 2012). Dr. Joseph Meites dari Michigan State University memaparkan bahwa seiring dengan pertambahan usia, fungsi hipotalamus di alam otak mengalami penurunan akibat paparan radikal bebas dan toksin yang bersifat merusak, akhirnya menyebabkan “aus”-nya seluruh sistem endokrin beserta organ-organ dan jaringan-jaringan yang dikontrol oleh sistem tersebut. Di sisi lain, menurut Dr. Meites, antioksidan yang dapat membantu melawan menumpukan radikal bebas dan toksin, kemungkinan juga dapat menunda terjadinya penurunan fungsi endokrin (Klatz & Goldman, 2009). Peran Terapi Ozon Mayor/ Major Autohemotherapy (MAH) Dalam Meningkatkan Kapasitas Antioksidan Baik ozon maupun oksigen merupakan oksidan karena memiliki sifat menerima elektron, Dalam MAH, ozon (O3) dibuat oleh generator ozon dengan menggunakan oksigen (O2) dalam tabung, lalu listrik dipompakan, membuat molekul-molekul O2 terbelah menjadi 2. Pecahan O2 atau Onini bergabung dengan suatu molekul O2 yang lain dengan suatu ikatan yang lemah, maka O3 terbentuk. Kemudian setelah O3 melakukan fungsinya sebagai oksidan dan dekomposisi, akhirnya terbentuk suatu molekul oksigen aktif (Gambar 1).

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Gambar 1. Efek Oksidan Dalam Terapi Ozon. (naturalozone.co.nz) Putaran oksigen aktif ini menjadi sangat cepat, sehingga bila saling bertabrakan satu sama lain, akan memiliki cukup energi untuk menghancurkan obyek-obyek lain, misalnya bakteri dengan cara membuat lubang pada dindingnya (sel lysis). Di pihak lain ada miliaran radikal bebas terbentuk di dalam tubuh kita setiap detik, tidak ada reaksi kimia yang terjadi di dalam tubuh tanpa pembentukan radikal bebas. Radikal bebas merupakan muatan positif atau negatif yang tidak berpasangan.Asumsi bahwa radikal bebas selalu buruk tidaklah benar, sebab tubuh kita didesain untuk melawan radikal bebas, dengan enzimenzim radical scavenger seperti glutation peroksidase, superoksid dismutasedan katalase.Masalahnya terjadi ketika di dalam tubuh terjadi penumpukan toksin akibat pola makan, pola olahraga, serta proses detoksifikasi yang kurang baik. Keberadaan toksin ini akan menghalangi enzim-enzim tersebut untuk mengalami kontak fisik dengan radikal bebas, kemudian radikal bebas akan “bersembunyi” di tempat lain. Oksigen aktif tadi dapat menghancurkan toxin, sehingga antioksidan-antioksidan enzimatik tadi dapat melakukan kontak langsung dengan radikal bebas. Jadi pilihan selain daripada 75

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mengonsumsi antioksidan yang mahal, pembersihan toksin-toksin yang berbahaya bagi tubuh sebenarnya dapat dilakukan dengan mendapatkan ozon atau oksidan, sehingga enzim-enzim tersebut dapat kembali bekerja dengan baik. Sejumlah hasil pengujian telah menyatakan bahwa kapasitas sapu-sapu radikal bebas (free radical scavenger) alami dalam tubuh dapat meningkat melalui terapi ozon (naturalozone.co.nz) EfekPemberian Terapi Ozon Pada Lansia Apabila diberikan kepada kaum lansia, terdapat tiga efek penting yang bisa dicapai melalui terapi ozon medis ini, antara lain: aktivasi selsel yang immunocompetent, aktivasi metabolisme sel-sel darah merah (SDM) yang mengakibatkan peningkatan pelepasan oksigen, dan aktivasi antioksidan-antioksidan enzimatik yang mengakibatkan perbaikan kapasitas antioksidan ( Viebahn-Haensler, 2007). Sementara untuk kelainan-kelainan degeneratif pada retina mata, terapi ozon mayor (MAH)dapat meningkatkan ketajaman visual, terutama untuk age-related macular degeneration (AMD), myopia degeneratif, dan neuropati nervus optikus iskemik (Bocci, 2011). Teknik Pemberian Terapi Ozon Mayor Major utohemotherapy (MAH)

Gambar 3.Teknik Pemberian Terapi Ozon Mayor (MAH) (Pertozi, 2011)

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Darah vena dikeluarkan sebanyak 50-100mL dan ditampung dalam kantung darah berisi anti-koagulan.Lalu, campuran gas O2/O3dibuat dari oksigen murni menggunakan generator ozon dengan konsentrasi 10-30 µg/mL dan volume 50-100mL. Dosis ozon (yang merupakan hasil perkalian antara konsentrasi dengan volume) disesuaikan dengan gejala-gejala penyakit, yaitu antara 500-3000 µg. Dalam proses terapi, diusahakan supaya campuran gas O2/O3 diserap sebanyak mungkin oleh darah (perling). Setelah itu, darah diinfuskan kembali dengan tetesan 60-90 tetes/menit selama lebih kurang 15 menit (Pertozi, 2011).Frekuensi terapi MAH disesuaikan dengan kondisi pasien, pada awal terapi dapat dilakukan dengan frekuensi 2 (dua) kali seminggu selama 4 (empat) minggu, setelahnya dilanjutkan dengan 1 (satu) kali seminggu selama 6 (enam) minggu (Viebahn-Haensler, 2007). Praktik Pemberian Terapi Ozon Mayor (MAH) Terapi ozon mayor diberikan kepada pasien wanita berusia 77 tahun berdarah campuran Spanyol-Filipina.Saat pertama kali datang pasien mengeluhkan kondisi badan loyo, nyeri kepala hebat, lapangan pandang terbatas, dan di bagian belakang mata terasa ada inflamasi.Sehari-hari, pasien tidak dapat melakukan hobi berkebunnya karena tidak dapat melihat sampai ke bagian atas pohon.Hasil diagnosis dokter spesialis mata di Singapura menunjukkan adanya indikasi neuropati dan saluran yang agak kecil. Hasil pemeriksaan baik tekanan darah, nadi, saturasi oksigen perifer, maupun gula darah acak dalam batas normal. Terapi ozon mayor (MAH) pertama diberikan dengan konsentrasi 20 µg/mL sebanyak 100 mL dalam volume darah yang kurang lebih sama, dengan frekuensi 2 kali seminggu.Pada terapi MAH kedua nyeri kepala hebat yang sebelumnya dirasakan sudah hilang, lapangan pandang sudah kembali normal, dan saat berkebun pasien telah dapat melihat sampai ujung atas pohon.Pada terapikelima pasien mengaku 77

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tubuhnya sudah tidak loyo lagi dan sehat. Terapi MAH dilanjutkan dengan frekuensi 2 kali seminggu hingga 8 kali, kemudian dijarangkan menjadi 1 kali seminggu sebanyak 8 kali, selanjutnya sekali tiap 2 minggu dan akhirnya maintenance sebulan sekali. Kemajuan yang diperlihatkan pasien antara lain adalah berat badan yang kurang lebih sama namun ukuran celana lingkar pinggangjauh berkurang. Penampilan wajah semakin tirus, pipi terlihat lebih kencang dan tertarik ke atas, deposit lemak pada daerah leher (double chin) berkurang. Pasien terlihat semakin sehat, lincah dan enerjik meski pola makan dan aktivitas tidak mengalami perubahan berarti (Gambar 4).

Gambar 4. Kondisi Pasien Sebelum (Kiri) dan Sesudah (Kanan) Mendapat 20 kali Terapi MAH Kesimpulan Terapi ozon mayor (MAH) yang diberikan secara rutin, berkala, dan berulangdapat mengembalikan pasien lansia ke kondisi seperti pada usia yang lebih muda (efek anti-aging termasuk aspek estetika). Hal tersebut dapat tercapai karena terapi MAH dapat meningkatkan kapasitas enzim-enzim antiosidan seperti: glutation peroksidase, 78

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superoksid dismutase, dan katalase. Enzim-enzim ini berperan membantu melawan penumpukan radikal bebas dan toksin pada hipotalamus di otak, mencegah kerusakannya, sehingga pada akhirnya dapat berdampak pada seluruh sistem endokrin beserta organ-organ dan jaringan-jaringan yang dikendalikan oleh sistem tersebut Poros hipotalamus – hipofisa – adrenal (HPA axis), merupakan suatu rangkaian interaksi yang saling berpengaruh dan memberikan efek umpan balik antara hipotalamus dan hipofise (kelenjar pituitari) yang terdapat di otak dengan kelenjar adrenal/suprarenalis yang terletak di atas ginjal. Terbentuknya poros HPA dari organ-organ tersebut beserta interaksinya kemudian mempengaruhi sistem neuroendokrin utama yang mengontrol stres dan mengatur berbagai proses tubuh, termasuk pencernaan, sistem imun, suasana hati dan emosi, seksualitas, serta penyimpanan dan pengeluaran energi (Wikipedia). Dalam praktik pemberian terapi MAH pada pasien berusia 77 tahun, paparan ozon dalam kurun waktu dan frekuensi tertentu telah membantu meningkatkan kualitas hidup pasien. Di samping pasien terlihat lebih sehat, segar dan enerjik, penampilan wajah menjadi lebih muda dengan area pipi yang lebih kencang dan tertarik ke atas serta deposit lemak di bawah dagu berkurang. Sementara untuk keluhan yang berkaitan dengan mata, setelah menjalani terapi MAH lapangan pandang dan ketajaman visus mata pasien mengalami peningkatan dan nyeri kepala yang hebat sudah hilang. Referensi 1. The Oxidation Effect in Ozone Therapy, 2018.https://naturalozone.co.nz/blogs/ozone-therapy/oxidation. Accessed: January 23, 2018. 2. Hypothalamic-Pituitary-Adrenal Axis.https://en.wikipedia.org/wiki/Hypothalamic-pituitary-adrenal_axis. Accessed: January 24, 2018. 3. Bocci, V.,2011.Ozone A New Medical Drug.Springer, hlm.27, 221.

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Indonesian Award for AAM 4. Gordon, M.L., 2012. Board Certification Review: Physician’ Guide To AntiAging & Regenerative Medicine. American Academy of Anti-Aging Medicine.hlm. 116. 5. Klatz, R. & Goldman, R., 2009.The Official Anti-Aging Revolution: Stop the Clock: Time Is on Your Side for a Younger, Stronger, Happier You. Basic Health Publications, Inc., hlm. 53, 87 6. Pangkahila, W., 2007.Anti-Aging Medicine, Memperlambat Penuaan Meningkatkan Kualitas Hidup.Kompas,hlm. 68. 7. Pangkahila, W., 2017.Tetap Muda, Sehat, dan Berkualitas. Kompas,hlm.sampul depan, 8. Pertozi, 2011.Buku Pedoman Pelayanan Baku Terapi Ozon (SOP), hlm. 15, Lampiran 15. 9. Viebahn-Haensler, R.,2007.The Use Of Ozone In Medicine. Dr. J. Hänsler GmbH, hlm. 92, 94, 117.

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Free Paper

SKIN BOOSTER AS A FACIAL SKIN ANTI-AGING STRATEGY Findrilia Sanvira Santoso Abstract I suggest that the facial appearance is a distinctive feature in recognizing aging process. The development of cosmetic dermatology has been recorded for innovation purposes to decrease the aging process, especially on the skin. Researches and studies have shown that human skin reflects on general inner health status and aging. In recent days, skin booster has been very popular in the aesthetic world because of its’ benefit to the human skin. It is the intention of this article to review the ingredients, mechanism, and the effect of Skin Booster as one of facial skin anti-aging strategy Keyword : anti-aging, skin booster Introduction Aging is a gradual process of deterioration of bodily functions to repair itself or replace and maintain its normal function so that it cannot survive the infection and repair the damage surface (Ruta Ganceviciene, 2012). Aging process occur in every part of our cells and organs. The easiest way to recognize the process of aging is by looking at the changing of the very superficial part of our body, skin. Aging Skin Since ancient times, Aging skin has been an interesting research field for scientists; it is also a common field of interest for humans throughout the years. Aging skin is a complex biological process 81

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influenced by combination of endogenous or intrinsic features like cellular metabolism, genetics, hormone, and metabolic processes; and also exogenous or extrinsic features such as pollution, chronic light exposure, chemical, toxin, ionizing radiation factors. (Yamada, 2012) These join factors lead to cumulative structural and physiological alterations and progressive changes in each skin layer as well as changes in skin appearance. Aging skin appearance usually defined as finely wrinkled and dry intrinsically aged skin, premature photo-aged skin typically shows a thickened epidermis, mottled discoloration, deeply wrinkle, laxity, dullness and roughness. Gradual loss of skin elasticity leads to the phenomenon of sagging. (Gunn, 2009) Slowing of the epidermal turnover rate and cell cycle lengthening coincides with a slower wound healing and less effective desquamation in older adults. This fact is important when aesthetic procedures are scheduled. A marked loss of fibrillin-positive structures as well as a reduced content of collagen type VII, may contribute to wrinkles by weakening the bond between dermis and epidermis of extrinsically age skin. In older skin, collagen looks irregular and disorganized, the ratio of Col-3 , to Col-1 has been shown to increase significantly due to a loss of col-1. The overall collagen content per unit area of the skin surface is known to decline approximately by 1 percent per year. Glycosaminoglycans (GAG) are among the primary dermal skin matrix constituents assisting in binging water, in aging skin, this substances are unable to function effectively due to abnormal alastotic material. (Stefansson, 2005) The total Hyaluronic acid (HA) level in the dermis of skin that age intrinsically remains stable, however, epidermal HA reportedly diminishes. These four primary structural components of the dermis, collagen, elastin, GAGs, adn Hyaluronic acid have been the subjects of the majority of anti aging research and efforts for aesthetic-anti-aging

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strategies pertaining to the skin, from anti wrinkle creams to various filling agents. (Fontana, 2017) Skin Booster From Collins English Dictionary, booster means a device for increasing power of effectiveness, or to boost some function that already exist. Skin booster is a type of dermal filler used to improve the skin quality by boosting hydration levels deep within the skin and increasing its smoothness, elasticity and firmness. (www.euphoriacosmedicclinic.com, 2016) Most of skin booster is consist of non-cross-linked Hyaluronic acid, with low elasticity and low viscosity so it can spread evenly through the dermal layer.Hyaluronic acid exhibits no species or tissue specificity, is one of the most hydrophilic (water-loving) molecules in nature and can be described as nature moisturizer.(Necas, 2008; wee, 2016) As a physical background material, an extracellular matrix component, is a high molecular weight glycosaminoglycan composed of disaccharide repeats of N-acetylglucosamine and glucoronic acid. It has functions in space filling, lubrication, shock absorption, and protein exclusion. In addition, Hyaluronic acid has been implicated as a regulator of cell proliferation and locomotion, stimulates fibroblast to express col-1, MMP-1, tissue inhibitor of matrix metaloproteinase-1 (TIMP-1) as well as is participating in wound healing, modulation of inflammatory cells, interaction with proteoglycans of the extracellular matrix. But its main roles is to attract water so it will provide significant hydration and osmotic balance to the wrinkled and dry skin. In a year 2008, Prestwich and co workers found that HA hydrogel fils accelerate the healing of full-thickness wounds presumably by providing a highly hydrated and nonimmunogenic environment that is conducive to tissue repair. Moreover, as a result of its ability to form hydrated, expanded

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matrices, HA has also been successfully used in cosmetic applications such as soft tissue augmentation.(Necas, 2008) After skin booster application, fibers induce collagen production by cells, also the fibroblast proliferation is induced in the place where the Hyaluronic acid were injected that give lasting moisture and improvements on the skin surface. Some skin booster ingredients contain long-lasting synthetic semipermanent calcium hydroxyl apatite suspended in an aqueous carboxymethylcellulsoe gel carrrier. The CaHa particles act as a scaffold for new tissue formation and stimulates collagen formation around the microspheres leading to thickening of the dermis over time. Leach and Schimdt report that CaHa also corrects the narrowing of the lower orbit where these fillers is possible in the field of cosmetic dermatology. (Necas, 2008) Some other type of skin booster can consist of poly-L-Lactic acid (PLLA), a synthetic compound that encourages the formation of the new collagen. After the initial response lasting one week or less a delayed but progressive volumizing effect begins. The process of hydration, loss of cohesion and molecular weight, and solubilization and phagocytosis of PLLA by the host’s macrophages, degrades PLA into lactic acid microspheres and eliminates CO3by way of respiratory excretion. Crystals are left behind to stimulate collagen and a granulomatous reaction. This inflammatory reaction elicits reabsorption and the formation of fibrous connective tissue about the foreign body, causing dermal fibroplasias that leads to the desired cosmetic effect such as pH regulators, antimicrobial activity, skin lightening, and skin hydration as well.(wee, 2016) All of these features of skin booster have made it to be useful as an ideal structural compound and have raised injections of Hyaluronic acid products to the most acceptable and scientifically investigated-goldstandardprocedures for skin rejuvenation, soft tissue augmentation, and 84

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improving clinical features. were formulated to improve skin wrinkles and sagging of facial features. Conclusion While natural aging is genetically determined, extrinsic skin aging can be prevented, slowed down, and returned to its normal function. (Pangkahila, 2017)As mention above, skin booster which consist of several ingredients can be one of many strategies to prevent skin anti aging. I have personally tried this on several patients, and found out that skin booster give a significant improvements in term of skin hydration, reduce facial skin wrinkling, slightly augmentation of the facial soft tissue, minimizing facial pores, giving resurfacing effect on the scar. And 6 out of 10 patients who went through skin booster treatment got improvement on their melasma. The color of the black spots on their face were significantly lightened, but the mechanism of HA on the melanin has not come to a conclusive result and further analysis is required.

Figure 1. Skin lightening and Improvement of the skin texture after undergoing skin booster procedures.

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Figure 2. Minimizing pore size, reduced reddish color of the skin, and improvement of the skin texture. Result shown after the second injection of skin booster

Figure 3 . Blemishes of the skin are reduced after second injection of skin booster

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Last but not least; I believe that not only aesthetic dermatologists but every single one in the medical world should play a role in contributing a healthy aging process. Cosmetic industry tries to erase time vestiges in skin. However aesthetic dermatologist should play significant part in preventing, regenerating, and delaying aging skin by combining knowledge of possible local and systemic therapy, instrumental devices and invasive procedures, filling the lack of scientific investigations and becoming one of the important focuses of the aging research. Conflict of interest statement The authors declare no financial or other conflicts of interest in the writing if this paper. References 1. Flatt, T. (2012). A new definition of Aging. Frontiers in Genetics , 148. 2. Fontana, L. (2017). Ageing Research Reviews . Elsevier. 3. Gunn, D. A. (2009). Why Some Women Look Young for Their Age. Rockville Pike: U.S National Library of Medicine. 4. Hadley Claire King, M. (n.d.). Retrieved January 5, 2018, from www.realself.com: https://www.realself.com/question/long-term-effectshyaluronic-acid-fillers 5. Necas, J. (2008). Hyaluronic acid (hyaluronan : a review). Veterinari Medecina , 397-411. 6. Pangkahila, W. (2017). Tetap Muda, Sehat, dan Berkualitas. Jakarta: Kompas Media Nusantara. 7. Ruta Ganceviciene. Endocrinology , 45.

(2012).

Skin

Anti-Aging

Strategies.

Dermato

8. Stefansson, H. (2005). The Science of Ageing and Anti-Ageing. Rockville Pike, Bethesda, USA: U.S National Library of Medicine. 9. wee, Y. J. (2016). Biotechnological Production of Lactic Acid and Its recent Applications. Biothevnology, food Technology , 163-172. 10. www.euphoriacosmedicclinic.com. (2016). Retrieved january 8, 2018, from https://www.euphoriacosmedic.com.au/articles/what-is-a-skinbooster/Yamada, H. (2012). Anti-Aging for Appearance. Anti Aging Medicine , 114-118. 87

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Review Article

FUCOXANTHIN : A PROMISING NATURAL MARINE DRUG WITH NEUROPROTECTIVE EFFECTS Oki Nugraha Putra 1, Nani Wijayanti 2 1

Pharmaceutics Departement, Study Program of Pharmacy, Hang Tuah University, Surabaya; 2Biology Departement, Study Program of Pharmacy, Hang Tuah University, Surabaya Correspondence email : [email protected]

Abstract The marine carotenoid fucoxanthin can be found in marine brown algae or seaweeds and exhibit a great antioxidant activity. Antioxidant activity of fucoxanthin is suggested to be one of the factors for their disease preventingeffects. Presently, several lines of studies have provided insight into biological activities and neuroprotective effects of fucoxanthin including antioxidant, anti-neuroinflammatory, choline sterase inhibitory activity and the inhibition of neuronal death. It has been previously determined that inflammation and oxidation contribute to the courses of a neurodegenerative disease. Many categories of natural and synthetic neuroprotective agents have been reported. However, synthetic neuroprotective agents are believed to have certain side effects. A study demonstrates the ability of fucoxanthin to counteract the neuro-inflammation induced by lipopolysaccharide in BV-2 microglial cells. Fucoxanthin exerts both direct and indirect antioxidant effects against reactive oxygen species formation. Furthermore, fucoxanthin showed the ability to counteract the early neurotoxic event elicited by amyloid-beta oligomers, a specific neurotoxin for Alzheimer’s disease (AD). A recent study demonstrate that fucoxanthin protected against H2O2-induced neurotoxicity via concurrently activating the PI3-K/Akt cascade and inhibiting the ERK pathway, providing support for the use

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of fucoxanthin to treat neurodegenerative disorders induced by oxidative stress. Hence, fucoxanthin have great potential to be used for neuroprotection as part of pharmaceuticals, nutraceuticals and functional foods with several mechanisms. This contribution presents an overview of fucoxanthin neuroprotective effects and their potential application in neuroprotection. Keywords :

Fucoxanthin, Neuroprotective Effects, Reactive Oxygen Species, Alzheimer’s Disease

I. Introduction Ageing is a major risk factor of neurodegenerative diseases. Ageing not only makes patients more prone to neurodegenerative diseases, but also impairs their abilities of self-repair. Current therapeutic strategies for neurodegenerative diseases are focused on neurotransmitters, such as acetylcholine for Alzheimer disease and dopamine for Parkinson disease. Although these treatments can bring transient relief of symptoms, they cannot affect the diseases courses. When more neurons are lost during disease progression, the medications become less effective. Thus new therapeutic strategies such as neuroprotection or neurorestoration are needed to improve the prognosis of neurodegenerative diseases. Neurodegenerative diseases are estimated to surpass cancer as the second most common cause of death among elderly by the 2040s (1,2).Oxidative stress plays a critical role in neuronal loss of neurodegenerative disorders (3). Excessive reactive oxygen species (ROS), including hydrogen peroxide (H2O2), nitric oxide and highly reactive hydroxyl radicals, are released after the neuron injury during oxidative stress.ROS further promote neurotoxicity via interacting with macromolecules and regulating signaling pathways (4). Oxidative stress is the result of an imbalance between pro-oxidant and antioxidant

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Indonesian Award for AAM

homeostasis that leads to the generation of toxic reactive oxygen species (ROS) (5).Increased oxidative stress in the CNS will further lead to lipid peroxidation, DNA and protein damage (6). Oxidative stress in the CNS has been demonstrated to involve excitotoxicity and apoptosis, the two main causes of neuronal death. Furthermore, oxidative stress has also been implicated the progression of Alzheimer’s disease (AD), Parkinson’s disease (PD), multiple sclerosis (MS) and other neurodegenerative diseases (7,8). Pharmacological and nutritional strategis aimed at modulating microgial activation offer much potential for future brain aging and AD therapy as shown in figure 1. Fucoxanthin is one of the most abundant marine carotenoids found in edible brown seaweeds (9). Previous investigations have reported that fucoxanthin possesses different health benefits, including anti-oxidative activity in particular (10-12). Many categories of natural and synthetic neuroprotective agents have been reported. However, synthetic neuroprotective agents are believed to have certain side effects such as dry mouth, tiredness, drowsiness, sleepiness, anxiety or nervousness, difficulty to balance, etc (13). Hence, nowadays researchers have an interest in studying natural bioactive compounds that can act as neuroprotective agents. Marine algae represent one potential candidate neuroprotective agent. However, development of marine algae as neuroprotective agents still faces several challenges. The rationale for marine algal neuroprotective effects treatment in the CNS is based on established observations and experiments in vitro or in animal models only. This review focuses specifically on the neuroprotective effects of fucoxanthin and emphasizes its potential application as future pharmaceutical candidates to prevent neurodegenerative diseases.

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Figure 1. Summary of immunomdulatory bioactive and synthetic compounds (Adapted from Pena-Altamira et al, 2017) II. Neuroprotective Effects of Fucoxanthin Fucoxanthin has been shown to possess different health benefits, such as anti-obesity, anti-tumor, antiinflammatory as well as hepatoprotective activities.(14). Therefore, fucoxanthin might be used as a drug or a functional food to treat chronic diseases. We have recently reported that fucoxanthin can inhibit acetylcholinesterase and attenuate scopolamine-induced cognitive impairments in mice, indicating that this chemical can be used in the treatment of Alzheimer’s disease (15). However, it remains unclear whether fucoxanthin could produce neuroprotective effects. Recent studies have reported that fucoxanthin can prevent oxidative stress induced cytotoxicity in microglia cells, hepatic cells and fibroblast cells (16-19)

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Indonesian Award for AAM

A recent study by Yu et al, 2017 showed that fucoxanthin significantly protected against H2O2-induced neuronal apoptosis and intracellular reactive oxygen species. H2O2 treatment led to the reduced activity of phosphoinositide 3-kinase (PI3-K)/Akt cascade and the increased activity of extracellular signal-regulated kinase (ERK) pathway in SH-SY5Y cells. Moreover, fucoxanthin significantly restored the altered activities of PI3-K/Akt and ERK pathways induced by H2O2. Both specific inhibitors of glycogen synthase kinase 3β (GSK3β) and mitogenactivated protein kinase kinase (MEK) significantly protected against H2O2-induced neuronal death. Furthermore, the neuroprotective effects of fucoxanthin against H2O2-induced neuronal death were abolished by specific PI3-K inhibitors (20). Although the mechanisms underlying the pathogenesis ofAD are not clearly elucidated, recent studies suggested thatsolubleβamyloid (Aβ) oligomers are the main neurotoxicspecies that induce neuronal death and oxidative stress atthe early stage of this disease (21,22). Aβoligomers, aggregated from Aβmonomers, could induce neuronal apoptosis via increasing oxidative stress, possibly as a result of alteredregulation of signaling pathways (23-25). In neurons, Aβoligomers substantially increase the level of intracellularre active oxygen species (ROS) (25). Moreover, Aβoligomerswere reported to inhibit the prosurvival phosphoinositide3-kinase (PI3K)/Akt signaling pathway, overactivate thedownstream glycogen synthase kinase 3β(GSK3β), andinduce neuronal death in vitro (24). Furthermore, Aβ oligomers could act on the proapoptotic mitogen activated proteinkinase (MEK)/extracellular signal-regulated kinase (ERK)pathway, leading to neuronal apoptosis (25). A study by Lin et al, 2017 discovered that fucoxanthin, a marine carotenoid with antioxidative stressproperties, concentration dependently prevented Aβoligomer-induced increase of neuronal apoptosis and intracellular reactiveoxygen species in SH-SY5Y cells as ahown Aβoligomers inhibited the prosurvival phosphoinositide 3-kinase

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Indonesian Award for AAM

(PI3K)/Akt cascade andactivated the proapoptotic extracellular signalregulated kinase (ERK) pathway. Moreover, inhibitors of glycogen synthase kinase3β(GSK3β) and mitogen-activated protein kinase (MEK) synergistically prevented Aβoligomer-induced neuronal death,suggesting that the PI3K/Akt and ERK pathways might be involved in Aβoligomerinduced neurotoxicity (26).

Figure 2. Possible Mechanisms for neuroprotective activities of fucoxanthin (adapted from Xiang et al, 2017)

Conclusion In conclusion, fucoxanthin is a valuable source of neuroprotective agents and could be introduced for the preparation of novel functional ingredients in pharmaceuticals and functional foods as a good approach for the treatment and or prevention of neurodegenerative disease. Until now, most of the biological and neuroprotective activities of fucoxanthin has been observed in vitro or in mouse model systems. Therefore, further research studies are needed in order to investigate fucoxanthin neuroprotective activities in human subjects and further in large-scale controlled studies.

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References 1.

Bjarkam, C.R.; Sørensen, J.C.; Sunde, N.Å.; Geneser, F.A.; Østergaard, K. New strategies for the treatment of Parkinson’s disease hold considerable promise for the future management of neurodegenerative disorders. Biogerontology 2001, 2, 193–207.

2.

Ansari, J.; Siraj, A.; Inamdar, N. Pharmacotherapeutic approaches of Parkinson’s disease. Int. J. Pharmacol. 2010, 6, 584–590.

3.

Kim GH, Kim JE, Rhie SJ, et al. The role of oxidative stress in neurodegenerative diseases. Exp Neurobiol. 2015;24:325–340.

4.

Yoon SO, Yun CH, Chung AS. Dose effect of oxidative stress on signal transduction in aging. Mech Ageing Dev. 2002;123:1597–1604.

5.

Barnham, K.J.; Masters, C.L.; Bush, A.I. Neurodegenerative diseases and oxidative stress. Nat. Rev. Drug. Discov. 2004, 3, 205–214.

6.

Akyol, Ö.; Herken, H.; Uz, E.; FadIllIolu, E.; Ünal, S.; Söüt, S.; Özyurt, H.; Sava, H. The indices of endogenous oxidative and antioxidative processes in plasma from schizophrenic patients* 1: The possible role of oxidant/antioxidant imbalance. Progr. Neuro-Psychopharmacol. Biol. Psychiatr. 2002, 26, 995–1005.

7.

Migliore, L.; Coppedè, F. Environmental-induced oxidative stress in neurodegenerative disorders and aging. Mutat. Res-Gen. Tox. En. 2009, 674, 73–84.

8.

Behl, C.; Moosmann, B. Antioxidant neuroprotection in Alzheimer’s disease as preventive and therapeutic approach. Free Rad. Biol. Med. 2002, 33, 182–191.

9.

D’Orazio N, Gammone MA, Gemello E, et al. Marine bioactives: pharmacological properties and potential applications against inflammatory diseases. Mar Drugs. 2012;10:812–833.

10. Das SK, Hashimoto T, Kanazawa K. Growth inhibition of human hepatic carcinoma HepG2 cells by fucoxanthin is associated with downregulation of cyclin D.Biochim Biophys Acta. 2008;1780:743–749. 11. Woo MN, Jeon SM, Shin YC, et al. Anti-obese property of fucoxanthin is partly mediated by altering lipid-regulating enzymes and uncoupling

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Indonesian Award for AAM proteins of visceral adipose tissue in mice. Mol Nutr Food Res. 2009;53:1603–1611. 12. Maeda H, Hosokawa M, Sashima T, et al. Dietary combination of fucoxanthin and fish oil attenuates the weight gain of white adipose tissue and decreases blood glucose in obese/diabetic KK-Ay mice. J Agric Food Chem. 2007;55:7701–7706. 13. Narang, S.; Gibson, D.; Wasan, A.D.; Ross, E.L.; Michna, E.; Nedeljkovic, S.S.; Jamison, R.N. Efficacy of dronabinol as an adjuvant treatment for chronic pain patients on opioid therapy. J. Pain 2008, 9, 254–264. 14. Zhang H, Tang Y, Zhang Y, et al. Fucoxanthin: a promising medicinal and nutritional ingredient. Evid Based Complement Alternat Med. 2015;2015:723515 15. Lin J, Huang L, Yu J, et al. Fucoxanthin, a marine carotenoid, reverses scopolamine-induced cognitive impairments in mice and inhibits acetylcholinesterase in vitro. Mar Drugs. 2016;14:67. 16.

Pangestuti R, Vo TS, Ngo DH, et al. Fucoxanthin ameliorates inflammation and oxidative reponses in microglia. J Agric Food Chem. 2013;61:3876–3883.

17. Liu CL, Liang AL, Hu ML. Protective effects of fucoxanthin against ferric nitrilotriacetate-induced oxidative stress in murine hepatic BNL CL.2 cells. Toxicol In Vitro. 2011;25:1314–1319. 18. Zheng J, Piao MJ, Keum YS, et al. Fucoxanthin protects cultured human keratinocytes against oxidative stress by blocking free radicals and inhibiting apoptosis. Biomol Ther (Seoul). 2013;21:270–276. 19. Heo SJ, Jeon YJ. Protective effect of fucoxanthin isolated from Sargassum siliquastrum on UV-B induced celldamage. J Photochem Photobiol B. 2009;95:101–107 20. Jie Yu, Jia-Jia Lin, Rui Yu, Shan He, Qin-Wen Wang, Wei Cui, Jin-Rong Zhang. Fucoxanthin prevents H2O2-induced neuronal apoptosis via concurrently activating the PI3-K/Akt cascade and inhibiting the ERK pathway. Food & Nutrition Research, 2017. p.1-10

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Indonesian Award for AAM 21. W. L. Klein, “Synaptotoxic amyloid-beta oligomer: a molecular basis for the cause, diagnosis, and treatment of Alzheimer’s disease?,Journal of Alzheimer’s Disease, vol. 33, 2013, Supplement 1, pp. S49–S65 22. S. T. Ferreira and W. L. Klein, “The Aβ oligomer hypothesis for synapse failure and memory loss in Alzheimer’s disease,Neurobiology of Learning and Memory, 2011 vol. 96, pp. 529–543 23. S. Jimenez, M. Torres, M. Vizuete et al., “Age-dependent accumulation of soluble amyloid beta (Abeta) oligomer reverses the neuroprotective effect of soluble amyloid precursor proteinalpha (sAPP(alpha)) by modulating phosphatidylinositol 3-kinase (PI3K)/Akt-GSK-3beta pathway in Alzheimer mouse model,” The Journal of Biological Chemistry, 2011 vol. 286, pp. 18414–18425 24. Y. H. Chong, Y. J. Shin, E. O. Lee, R. Kayed, C. G. Glabe, and A. J. Tenner, “ERK1/2 activation mediates Aβ oligomerinduced neurotoxicity via caspase-3 activation and tau cleavage in rat organotypic hippocampal slice cultures,” The Journal of Biological Chemistry, 2006 vol. 281, pp. 20315–20325 25. B. Kim, J. Park, K. T. Chang, and D. S. Lee, “Peroxiredoxin 5 prevents amyloid-beta oligomer-induced neuronal cell death by inhibiting ERKDrp1-mediated mitochondrial fragmentation,” Free Radical Biology and Medicine, 2016 vol. 90, pp. 184–194 26. Jiajia Lin, Jie Yu, Jiaying Zhao, Ke Zhang, Jiachen Zheng, Jialing Wang, et al. Fuxoxanthin, a marine carotenoid, attenuates beta-amyloid oligomer-induced neurotoxicity possibly via regulating the PI3K/Akt and the ERK pathways in SH-SY5Y cells. Oxidative Medicine and Cellular Longevity Volume 2017. p 1-10. 27. Emiliano Pena-Altamira, Sabrina Petralla, Frencesca Massenzio, Marco Virgli et al. Nutrional and Pharmacological Strategis to Regulate Microgial Polarization in Cognitive Aging and Alzheimer’s Disease. 2017, Frontiers in Aging Neuroscience, Volume 9.

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Free Paper

KLOTHO, TARGET TERAPI POTENSIAL UNTUK MENCEGAH PENUAAN dr. Vitia Tandy Berdasarkan data yang diperoleh Badan Pusat Statistik pada tahun 2016, jumlah penduduk Indonesia diproyeksikan sebanyak 258 juta jiwa. Adapun penduduk yang berusia lanjut, yakni yang berusia 60 tahun ke atas, hanya berkisar sebanyak 8,72%(BPS, 2016). Persentase yang kecil tersebut tidak dapat dipungkiri diakibatkan oleh tingginya angka kesakitan dan kematian pada usia tua. Penyakit yang berkaitan dengan proses penuaan ini di antaranya adalah penyakit jantung koroner, stroke, hipertensi, diabetes mellitus, dan demensia. Hal ini menyebabkan fokus perhatian baik pemerintah maupun mayoritas tenaga medis dalam mengatasi masalah kesehatan di Indonesia adalah untuk mengobati penyakit yang timbul pada usia tua tersebut. Ilmu Kedokteran Anti-Penuaan atau yang lebih dikenal dengan Anti-Aging Medicinemengusung suatu konsep dan paradigma baru dalam menghadapi hal tersebut. Anti-Aging Medicine menitikberatkan fokus untuk mencegah, memperlambat, bahkan menghambat proses penuaan sehingga dapat mencegah timbulnya berbagai disfungsi, kelainan, dan penyakit yang berkaitan dengan penuaan. Dengan demikian tidak hanyasemata-mata usia harapan hidup yang menjadi lebih panjang tetapi kualitas hidup yang optimal pun dapat dicapai (Pangkahila, 2007). Pemahaman untuk dapat mencegah, memperlambat, dan menghambat proses penuaan tersebut tentu perlu didasari oleh pengetahuan mengenai proses penuaan itu sendiri. Penuaan pada manusia merupakan suatu proses kompleks yang melibatkan faktor genetik dan lingkungan. Kombinasi dari gen spesifik (genotipe) dapat menentukan rentang usia hidup dan perubahan pada sebuah gen 97

Indonesian Award for AAM

tunggal dapat mengakibatkan perubahan yang bermakna pada rentang usia seseorang (Rodero et al, 2011). Oleh sebab itu, walaupun modifikasi faktor lingkungan sebagai upaya untuk mencegah proses penuaan terkesan lebih mudah untuk dilakukan, faktor genetik memegang peranan yang substansial sehingga modifikasi faktor ini tidak kalah penting untuk dilakukan (Wang dan Sun, 2009). Salah satu gen yang diteliti memiliki peran dalam memperpanjang kehidupan dan memiliki kemampuan untuk mencegah penuaan adalah gen klotho. Dalam mitologi Yunani, terdapat tiga dewi yang menentukan rentang kehidupan dari setiap orang dengan mengatur benang kehidupan. Dewi-dewi tersebut adalah Klotho, Lachesis, dan Atropos yang masing-masing bertugas untuk memintal, mengukur, dan memotong benang kehidupan. Nama gen klotho diambil dari Dewi Klotho, sang pemintal benang kehidupan (Kuro-o, 2009). Gen klotho pertama kali ditemukan pada tahun 1997. Tikus-tikus yang secara tidak sengaja ekspresi gennya ditekan ternyata menunjukkan rentang hidup yang memendek dengan berbagai kelainan yang menyerupai sindrom penuaan dini pada manusia, di antaranya infertilitas, arteriosklerosis, atrofi kulit, osteoporosis, dan emfisema (Kuro-o et al, 1997). Lokasi gen klotho pada tikus terletak pada kromosom 13q12, mencakup 50 kb dan mengandung lima exon. Dua salinan yang berasal dari sebuah gen klotho tunggal melalui alternative RNA splicing telah diidentifikasi dan diprediksi berfungsi untuk mengkode protein membran dan protein yang disekresikan (Gambar 1). Protein membran mengandung 1.014 asam amino, dengan domain ekstraseluler yang terdiri dari ulangan internal ganda (disebut domain KL1 dan KL2), masing-masing memiliki panjang sekitar 450 asam aminodengan homologi terhadap β-glukosidase sebesar 20-40%. Protein yang disekresi berasal dari salinan alternatif dan hanya sepanjang 550 asam amino tanpa domain transmembran. Gen klotho pada manusia berlokasi di kromosom 13.1, yakni pada lengan panjang (q arm) kromosom 13 pada posisi 13.1 (NIH, 2018), mencakup 50 kb, dan terdiri dari 5 exon

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(Gambar 2). Sama seperti tikus, manusia juga memiliki dua salinan yang berasal dari sebuah gen klotho tunggal melalui alternative RNA splicing dan mengkode protein membran (1.012 asam amino) dan protein yang disekresikan (549 asam amino). Domain ekstraseluler dari protein membran klotho dapat dipecah dan dilepaskan oleh sekretase. Hal ini akan melepaskan domain ekstraseluler ke sirkulasi yang kemudian disebut soluble klotho yang mengandung domain KL1 dan KL2. Protein klotho pendek yang secara langsung dikode oleh salinan klotho yang disekresikan melalui alternative splicing disebut secreted klotho dan hanya mengandung domain KL1.Soluble klotho adalah bentuk yang memegang peranan utama dalam sirkulasi. Soluble klotho juga dapat ditemukan pada cairan serebrospinal dan urin mamalia. Sebagai substansi yang beredar di sirkulasi, soluble klotho berperan dalam memberikan efek biologis pada organ dan sistem yang terletak jauh (Bian et al, 2015).

Gambar 1 Diagram Skema Pembentukan Protein Klotho 99

Indonesian Award for AAM

Gambar 2 Lokasi Gen Klotho pada Kromosom 13

Klotho paling banyak diekspresikan pada ginjal dan epitel pada pleksus koroideus di otak. Ekspresi klotho dalam jumlah yang kecil juga dapat ditemukan pada kelenjar hipofisis, plasenta, otot rangka, kandung kemih, pankreas, testis, ovarium, kolon, dan telinga dalam (Kamemori et al, 2002; Kuro-o et al, 1997).Hal ini cukup menarik sebab walaupun gen klotho hanya diekspresikan pada beberapa jaringan tertentu, namun gangguan pada ekspresi gen klotho dapat mengakibatkan berbagai fenotipe yang menyerupai penuaan pada hampir semua sistem organ tikus (Kuro-o et al, 1997). Rentang hidup pada tikus dengan defisiensi klotho hanya berkisar 5-6% daripada wild-type-nya (Nabeshima, 2006). Sebaliknya ekspresi yang berlebih dari gen klotho dapat memperpanjang rentang hidup hingga 20%-30% (Kurosu et al, 2005). Tabel 1 akan menjabarkan perbandingan fenotipe pada tikus dengan defisiensi klotho dan tikus dengan ekspresi klotho yang berlebih.

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Tabel 1. Perbandingan Fenotipe Tikus dengan Defisiensi Klotho dan Tikus dengan Ekspresi Klotho yang Berlebih (Ikushima et al, 2006; Kurosu et al, 2005; Bektas et al, 2004; Mitani et al, 2002; Saito et al, 1998; Kuro-o et al, 1997) Parameter

Tikus dengan Defisiensi Klotho

Tikus dengan Ekspresi Klotho yang Berlebih

Berat tubuh

Terdapat hambatan pertumbuhan, menjadi inaktif, dan kekurangan tenaga pada usia 3-4 minggu

Normal

Rentang hidup ratarata

Sekitar 2 bulan (tikus wildtype: 2,5-3 tahun)

Sekitar 20-30% lebih panjang daripada tikus wild-type

Rentang hidup maksimal

Kurang dari 100 hari

Lebih dari 936 hari

Insulin

Penurunan sekresi insulin dan peningkatan sensitivitas insulin

Peningkatan resistensi terhadap insulin dan sinyal Insulin-Like Growth Factor-1 (IGF-1)

Homeostasis fosfat

Hiperfosfatemia

Normal

Homeostasis kalsium Penyakit

Kalsifikasi ektopik pada berbagai organ

Normal

Hipogonadisme, infertilitas, involusi timus prematur, kalsifikasi ektopik, penurunan kepadatan mineral tulang, atrofi kulit dan otot, ataksia, emfisema, gangguan kognitif, gangguan pendengaran, kalsifikasi pembuluh darah, penurunan sintesis nitric oxide (NO)pada sel endotel pembuluh darah

Proteksi dari kerusakan ginjal yang diinduksi angiotensin-II, penekanan apopotosis yang diinduksi H2O2 dan penuaan sel pembuluh darah, penurunan faktor resiko atherosklerosis, peningkatan kemampuan pendengaran

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Fungsi biologis dan fisiologis dariprotein yang dihasilkan oleh gen klotho yang berkaitan dengan proses penuaan adalah sebagai berikut: 1. Klotho menghambat jalur sinyal insulin dan IGF-1 Sebuah studi menunjukkan bahwa hambatan moderat terhadap jalur sinyal insulin/IGF-1 adalah salah satu mekanisme yang dapat menekan penuaan dan memperpanjang rentang hidup (Tatar et al, 2003). Adapun regulasi klotho terhadap insulin/IGF-1 ini juga dapat meningkatkan resistensi terhadap stres oksidatif di tingkat seluler dan organisme pada mamalia, di mana seperti yang telah diketahui bahwa stres oksidatif dapat memicu proses penuaan (Mitani et al, 2002). 2. Klotho berperan sebagai kofaktor/koreseptor dalam meregulasi sinyal Fibroblast Growth Factor (FGF) 23 FGF 23 adalah hormon yang berasal dari tulang yang berfungsi di ginjal untuk menghambat reabsorpsi fosfat dan biosintesis vitamin D, sehingga meningkatkan ekskresi fosfat di urin dan menekan kadar 1,25-dihidroksivitamin D3 (Liu et al, 2007). Penurunan produksi 1,25-dihidroksivitamin D3dapat menghindari munculnya fenotipe yang berkaitan dengan penuaan dan meningkatkan rentang hidup (Kusoru et al, 2005; Yamamoto et al, 2005; Tsujikawa et al, 2003). Sebaliknya peningkatan kadar 1,25-dihidroksivitamin D3 merangsang absorbsi fosfat dan kalsium di usus, sehingga menyebabkan hiperfosfatemia dan hiperkalsemia (Nabeshima, 2006) di mana peningkatan kadar kalsium dalam darah merupakan predisposisi terhadap kalsifikasi ektopik pada pembuluh darah dan jaringan lunak (Kuro-o, 1997). 3. Klotho berperan sebagai glukuronidase dan mengaktivasi kanal ion Transient Receptor Potential Vanilloid 5 (TRPV5) Klotho memiliki aktivitas β-glukuronidase yang memiliki peranan penting untuk aktivasi TRPV5 (Chang et al, 2005). Kanal ion

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TRPV5 adalah kanal kalsium yang berada di sel epitel tubulus kontortus distal. Fungsinya adalah sebagai pintu masuk untuk reabsorpsi kalsium dan berperan dalam homeostasis kalsium (Hoenderop et al, 2005; Nijenhuis et al, 2005). 4. Klotho mencegah terjadinya disfungsi endotel dan meregulasi produksi NO Gen klotho dan protein yang dihasilkannya memiliki efek antiapoptosis dan anti-penuaan pada sel endotel vaskular sehingga memberi proteksi terhadap disfungsi endotel pada sindrom dengan faktor resiko multipel. Mekanisme sintesis NO yang dimediasi oleh protein klotho belum diketahui. Akan tetapi, defisiensi klotho dapat menurunkan produksi eNOS dan NO. Protein klotho mungkin dapat berperan sebagai enzim yang mengkonversi prekursor inaktif menjadi bentuk biologis yang aktif namun studi lanjutan perlu dilakukan untuk menyelidiki bagaimana protein klotho meregulasi sintesis NO (Wand dan Sun, 2009). 5. Klotho mempengaruhi jalur sinyal p53/p21 Klotho menghambat penuaan dengan menekan sinyal p53/p21 di mana protein p53 terlibat dalam berhentinya siklus sel dan apoptosis yang menyebabkan penuaan sel dan prosesnya diaktivasi salah satunya oleh p21 (de Oliveira, 2016) 6. Klotho mempengaruhi jalur sinyal Wnt Wnt adalah salah satu faktor esensial yang berpengaruh pada proliferasi dan pemeliharaan sel punca. Stimulasi kronis pada sinyal Wnt dapat menyebabkan pengurangan pada jumlah dan fungsi sel punca sehingga berkontribusi pada proses penuaan (Kirsetter et al, 2006; Scheller et al, 2006). Domain ekstraseluler dari protein klotho dapat berikatan dengan beberapa ligan Wnt

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dan menghambat kemampuannya untuk mengaktivasi sinyal Wnt (Liu et al, 2007). Dengan berbagai peranan protein klotho dalam menghambat proses penuaan, maka terapi untuk meningkatkan protein klotho dapat menjadi target terapi yang potensial dalam mencegah penuaan dan menghambat berbagai penyakit yang berhubungan dengan penuaan. Beberapa metode yang dapat dilakukan untuk meningkatkan protein klotho dalam tubuh di antaranya adalah transfer gen klotho, pemberian protein klotho eksogen, dan aktivasi ekspresi klotho endogen. Transfer gen klotho menunjukan hasil yang efektif pada tikus yang memiliki defisiensi klotho untuk memperpanjang rentang hidup. Walaupun efektif pada penelitian hewan coba, keamanannya masih dipertanyakan dan aplikasi klinisnya masih sulit untuk diterapkan. Dibandingkan transfer gen, administrasi klotho eksogen lebih aman, lebih mudah, dan merupakan modalitas yang dapat langsung diaplikasikan untuk memulihkan defisiensi klotho. Protein klotho dapat mengembalikan atau menghambat kondisi berkurangnya sel punca dan menghambat proses patologis yang berhubungan dengan penuaan. Walaupun belum ada studi mengenai penggunaan protein klotho pada manusia, penelitian pada hewan coba menunjukkan data yang cukup meyakinkan bahwa administrasi protein klotho aman dan efektif untuk diberikan. Khusus pada kasus gagal ginjal akut, di mana tubulus ginjal sebagai tempat produksi klotho endogen tidak rusak seutuhnya namun kemampuannya untuk memproduksi protein klotho terhambat, strategi untuk meningkatkan produksi endogen merupakan pilihan terapi yang menguntungkan. Berbagai studi lanjutan terus dibutuhkan untuk mengembangkan potensi terapi dengan memanfaatkan protein klotho. Apabila aplikasi klinis pada manusia telah terbukti aman dan efektif, maka besar harapan modalitas ini dapat mendukung upaya untuk mencegah penuaan dan menghambat berbagai penyakit terkait penuaan di samping upaya dalam memodifikasi faktor lingkungan (Bian et al, 2015).

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COMBINATION OF TRIAMCINOLONE ACETONIDE AND LATANOPROST FOR EYEBROWS ALOPECIA TREATMENT Listya Paramita Department of Dermatology and Venereology Faculty of Medicine, Universitas Gadjah Mada / Dr. Sardjito General Hospital, Yogyakarta

Abstract Background: Hair loss on the eyebrow can occur partly or totally. Eyebrow loss may be seen as an eyebrow thinning, patches of alopecia on the eyebrows or total alopecia of the eyebrows.Management of alopecia in the eyebrows is quite challenging, because until now there has been no therapy that really effective and provide satisfactory results in patients. Case : A 20-year-old woman came with the main complaint of both her eyebrows fall out. The complaint was felt by the patient since 1 year ago. Initially patients complained of hair loss on the eyebrow, but only slightly so not too worried by the patient. Eyebrow hair loss is said to be not preceded by reddish or itchy patches, nor is it preceded by traumatic wounds. Eyebrow loss then continued to occur until finally 3 months ago, the patient went to see dermatologist. Patients get serum and cream therapy to be applied twice daily. After 3 months of using the serum and cream, patient felt no improvement, and even the eyebrows loss occurred more and more, and the patient felt both eyebrows bald. Some physical and laboratory examination conducted to find the etiology of the eyebrows alopecia, but all of the laboratory examination remain within normal limits. Patient treated with triamcinolone acetonide 40mg/ml intra muscular injection every 4 weeks, and latanoprost solutio to use twice a day in the eyebrows area. In week 8, we 105

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performed dermoscopy in the patient. Dermoscopy results show the increase in velocity density on the right and left eyebrows. The results are good, and the therapy is planned to be done for 6 months, Discussion : Management of eyebrow hair loss is based on the underlying etiology. The appropriate diagnosis is crucial for the selection of therapy to be administered to the patient. This patitent has not shown any suspicion leading to a particular etiology, the patient is then managed as a patient with idiopathic eyebrow alopecia.The therapy given to the patient is 40mg of intramuscular corticosteroid injection per month. This route of administration was chosen because in some studies it was mentioned that intramuscular injection administration route was more effective.Additional therapy given to patients is the topical latanoprost. Latanoprost is an analogue prostaglandin F2α, originally used as a therapy to reduce intraocular pressure in glaucoma patients. Latanoprost is known to have an effect as a hair growth stimulant. Keyword: eyebrows alopecia, triamcinolone acetonide, latanoprost

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MOLECULAR HYDROGEN AS A PREVENTIVE AND THERAPEUTIC AS AN ANTI AGING MEDICINE Mulyadi Tedjapranata Abstract Moleculer hydrogen ( H2,dihydrogen,or hydrogen gas ) has been accepted to behave as an inert gas at body temperature in mammalian cells. In fact,H2 seems to react with no biological compound,including oxygen gas in the absence of catalyst at body temperature. On the other hand,in some bacteria,H2 is enzymatically catabolized as an energy source for providing electrons,or is a product of some types of anaerobic metabolism. Molecular hydrogen (H2) has been accepted to be an inert and nonfunctional molecule in our body.We have turned this concept by demonstrating that H2 reacts with strong oxidants such as hydroxyl radical in cells,and proposed as potential for preventive and therapeutic applications.H2 has a number of advantages exhibiting extensive effects: H2 rapidly diffuses into tissues and cells,and it is mild enough neither to disturb metabolic redox reactions nor to affect signaling reactive oxygen species;therefore,there should be no effects of H2. Inhalation of H2 gas may be unsuitable or impractical for continuous H2 consumption in daily life for preventive use. Aging is the process of growing older and showing a progressive deterioration of bodily function over a period of time.It is the result of series of chemical activities in our bodies failing or malfunction. Aging is associated with a metabolic decline characterized by the development of changes in fat distribution,obesity,insulin resistance,etc .

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Dysfunctional humoral and cell-mediated immune responces occur with age,and these aberrations have been implicated in the increased incidence of infectious disease,hyporesponsiveness to vaccination,and the etiology of numerous chronic degenerative diseases. All these metabolic and immune alterations are associated with a very of age-related diseases. All these metabolic and immune can modulate many of the metabolic alterations characteristic of aging. Decreased of oxygen has been implicated in the pathogenesis of degenerative diseases that resemble those of old age. Premature aging occurs when your organs cease proper function before a reasonable lifespan has been achieved,skin get less elastic,it comes to wrinkles,lipopexia;what we normally refer to simply as “aging”.Mounting evidence has established strong links between chronic oxidative stress and a wide variety of pathologies,including malignant diseases,diabetes mellitus,atherosclerosis,and chronic inflammatory process as well as many neurodegenerative diseases and the aging process. Antioxidant is a substance that inhibits the above free radical damage.As free radical continue to scavenger for electrons from your body,antioxidants intercept by offering their own electrons to the free radicals in order to stop them scavenging yours.This converts the free radicals into simple harmless molecules.By doing this antioxidants protect your cells from the oxidative damage that leads to premature aging and disease. We have turned this concept by demonstrating that H2 reacts with strong oxidants such as hydroxyl radical in cells,and proposed as potential for preventive and therapeutic applications.H2 has a number of advantages exhibiting extensive effects: H2 rapidly diffuses into tissues and cells,and it is mild enough neither to disturb metabolic redox reactions nor to affect signaling reactive oxygen species;therefore,there should be no effects of H2. Inhalation of H2 gas may be unsuitable or impractical for continuous H2 consumption in daily life for preventive use.In contrast,solubilized H2( H2-dissolved water :namely,H2-water) 108

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may be beneficial since it is a portable,easily administered and safe way to ingest H2.H2 can be dissolved in water up to 0.8mM(1,6 mg/L) under atmosphereric pressure at room temperature without changing pH.Althought ad libitum drinking saturated H2-water was more effective than diluted one. The numerous publication on its biological and medical benefits revealed that H2 reduced oxidative stress not only by direct reactions with strong oxidants.but also indirectly by regulating various gene expressions.Moreover,by regulating the gene expressions,H2 function as an anti - inflammatory and anti – apoptotic,and stimulates energy metabolism,In addition to growing evidence obtained by model animal experiments,extensive clinical examinations were performed are under investigation.Since most drugs specifically act to their targets,H2 seems in differ from conventional pharmaceutical drugs,Because of its extremely tiny size,molecular hydrogen can get into cells to repair them,whereas other anitoxidants are too large to do this. Molecular hydrogen is soluble in both water and oil.This make it uniquely able to penetrate cell walls to get in,fight free radicals and even repair cells after they have been damaged.Molecular hydrogen,even after donating its extra electron to the most dangerous radical of all to becme harmless,neutral,water to be safety eliminated from the body.Molecular hydrogen removes the bad free radicals,and leaves the useful ones alone,is significant in helping the body maintain homeostasis.Molecular hydrogen signals the production of enzymes in the body which reduce the bad free radicals. Owing to its great efficacy and lack of adverse effect,H2 has promising potential for clinical use against many diseases and especially as an anti aging medicine.

Keywords:Molecular-hydrogen.antioxidant,anti-inflammation,anti-aging medicine.

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Free Paper

PROSPEK MEDIA SEL PUNCA JARINGAN ADIPOSA TERKONDISI SEBAGAI ANTI-AGING Bayu Tirta Dirja Abstrak Keluhan kulit keriput dapat terjadi karena proses penuaan yang dapat disebabkan oleh faktor intrinsik dan ekstrinsik akibat paparan ultraviolet (UV). Penelitian kedokteran membuktikan media sel punca jaringan adiposa terkondisi (conditioned medium) mempunyai kandungan beberapa growth factor dan antioksidan, diduga dapat digunakan sebagai terapi anti-aging. Pendahuluan Setiap orang pasti akan mengalami penuaan yang merupakan suatu proses alamiah. Perubahan-perubahan di kulit wajah seperti keriput dan gangguan pigmentasi merupakan dampak yang sering dirisaukan. Faktor intrinsik dan ekstrinsik akibat paparan ultraviolet (UV) akan menimbulkan proses penuaan muncul lebih cepat dari waktunya. Perawatan konvensional dalam bentuk upaya rejuvenasi kosmetik seperti laser, antioksidan dan rejimen topikal diharapkan dapat menginduksi sintesis kolagen, sehingga kulit keriput dan testur kulit dapat diperbaiki. Namun, dengan perawatan konvensional membutuhkan waktu yang lama untuk mendapatkan hasil yang maksimal. Perkembangan ilmu pengetahuan dan teknologi saat ini diduga mampu menghambat proses penuaan, antara lain dengan teknologi sel punca (stem cell) dan sekretom (faktor tersekresi) yang dihasilkannya. Sel punca mesenkimal jaringan adiposa (Adipose-derived mesenchymal stem cells / ADMSCs) diduga dapat digunakan sebagai anti-aging. Dalam sebuah studi kasus, ADMSCs disuntikan secara 110

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intradermal pada kulit keriput (2 suntikan berturut-turut pada interval 2 minggu). Setelah 2 bulan, ditemukan tekstur dan ketebalan kulit meningkat.1 Hal ini terjadi karena ADMSCs mempunyai efek parakrin dari sekretom tersebut yang berperan penting dalam berbagai regulasi proses fisiologi termasuk pertumbuhan sel, replikasi, diferensiasi, signaling, apotosis, adesi, dan angiogenesis.2 Namun, pemberian terapi harus dilakukan secara autogenik untuk menghindari reaksi penolakan jaringan, pengambilan jaringan lemak tidak dapat dilakukan kepada orang usia lanjut, orang kurus, dan tidak dapat diproduksi secara masal. Berbagai penelitian tentang faktor sekresi yang berasal dari sel punca menunjukkan bahwa faktor yang disekresikan sendiri tanpa sel punca itu sendiri dapat menyebabkan perbaikan jaringan dalam berbagai kondisi. Sekretom dapat ditemukan di dalam media dimana ADMSCs dikultur. Media ini disebut sebagai conditioned medium (CM). Oleh karena itu, CM memiliki prospek yang menjanjikan untuk diproduksi sebagai obatobatan anti-aging untuk kulit menua dini. Mekanisme Penuaan Kulit Karena Paparan Ultraviolet (Photoaging) Paparan UV berulang akan menyebabkan terbentuknya ROS (reactive oxygen species) yang kemudian menyebabkan terjadinya inisiasi signaling, kerusakan oksidatif pada komponen seluler seperti dinding sel, membran lipid, mitokondria, dan DNA. ROS dapat meningkatkan transkripsi factor pada activator protein (AP)-1 yang merupakan faktor ranskripsi yang menghambat produksi kolagen dan meningkatkan kerusakan kolagen melalui regulasi enzim MMPs (matrix metaloproteinases). Selain itu, ROS juga menyebabkan penurunan ekspresi TGF-b yang merupakan sitokin untuk mensintesis kolagen, sehingga terjadi penurunan produksi kolagen.3 Sel Punca Sel punca adalah sebuah sel yang belum memiliki fungsi khusus, dapat memperbaharui dan membelah diri menjadi sel yang serupa (self-

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renew) atau mengubah diri (differentiate) menjadi jenis sel yang sama sekali berbeda tergantung lingkungannya. Saat ini dikenal 3 jenis sel punca, yaitu sel punca dewasa (adult stem cells), sel punca embrional (embryonic stem cell / ESC) dan sel punca pluripoten hasil induksi dari sel somatic / dewasa (induced pluripotent stem cell / IPSC).4,5,6 Salah satu sel punca dewasa adalah sel punca yang berasal dari sel mesenkimal (mesenchymal stem cell / MSC. MSC merupakan sel punca yang bersifat multipoten sehingga dapat berdiferensiasi menjadi sel myogenik, adipogenik, kondrogenik dan osteogenik. Namun, MSC juga memiliki sifat plastis, artinya selain berdiferensiasi menjadi sel yang sesuai dengan jaringan asalnya, MSC juga dapat mengalami transdiferensiasi menjadi sel jaringan lain.2,7 MSC terdapat di seluruh organ tubuh terutama di derah perivaskuler. Stroma jaringan adiposa, darah tali pusat dan sumsum tulang merupakan tiga sumber MSC terbanyak pada tubuh manusia. Jumlah MSC jaringan adiposa (ADMSCs) lebih banyak dibandingkan MSC dari kedua sumber lainya.8 Isolasi Jaringan lemak subkutan dapat diambil melaui proses lipoaspirate (sedot lemak), kemudian diisolasi secara mekanik atau enzimatik (enzim kolagenase) untuk memisahkan antara sel lemak dan nonlemak. Kumpulan sel-sel non lemak yang berhasil dipisahkan tadi dinamakan stromal vascular fraction (SVF). SVF mengandung beragam jenis sel antara lain sel-sel endotel, eritrosit, fibroblas, limfosit, monosit / makrofag, pericytes, dan juga ADMSCs. Sebelum diberikan kepada pasien, ADMSCs harus diisolasi dari SVF, kemudian dikultur dan diperbanyak. Sehingga ekstrak dari CM dapat dipersiapkan tergantung dari metode yang digunakan.9,10 Homogenitas ADMSCs juga dapat dibuktikan berdasarkan kriteria minimum sebagai berikut, melekat pada plastik, mengekspresikan positif (>95%) penanda CD105, 73, 90, dan negatif (≤2%) penanda CD34, 45, 14, 19, HLA tipe II, dan memiliki kemampuan diferensiasi kondorogenik, osteogenik dan adipogenik pada kondisi in-vitro.11

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Sekretom ADMSCs telah terbukti memiliki kemampuan mensekresikan berbagai sekretom seperti kemokin, sitokin, dan faktor pertumbuhan (growth factor). Serangkaian senyawa sekretom tersebut berfungsi sebagai mediator dalam komunikasi antar sel untuk memperbaiki dan meregenerasi jaringan yang rusak. Proses ini yang disebut sebagai sebuah efek parakrin. Efek parakrin dari sekretom tersebut memiliki peran penting dalam berbagai regulasi proses fisiologi termasuk pertumbuhan sel, replikasi, diferensiasi, signaling, apotosis, adesi, dan angiogenesis. Faktor pertumbuhan hasil sekresi dari ADMSCs sangat berperan dalam terapi anti-aging, seperti vascular endothelial growth factor (VEGF), basic fibroblasts growth factor (bFGF), transforming growth factor (TGF-b1), TGF-b2, hepatocyte growth factor (HGF), keratinocyte growth factor (KGF), platelet-derived growth factor (PDGFAA), type I collagen dan beberapa antioksidan seperti insulin-like growth factor-binding proteins (IGFBPs) dan superoxide dismutase (SOD).1,2,12 Efek anti-aging dari ADMSCs ADMSCs diketahui mampu memperbaiki jaringan yang rusak melalui diferensiasi dan efek parakrin. Pada beberapa hasil penelitian diduga ADMSCs dan sekretomnya mempunyai efek anti-aging. Penelitian yang dilakukan secara in-vitro, ADSCs terbukti meningkatkan kualitas epidermis dan dermis dalam mencegah penuaan.13 CM mempunyai efek parakrin terhadap human dermal fibroblast (HDFs). Terbukti CM menginduksi proliferasi HDFs usia tua dan produksi kolagen tipe 1, menurunkan produksi MMP-1 dan ekspresi p16.14 Pengendalian produksi melanin merupakan proses yang penting dalam mengobati pigmentasi kulit yang tidak normal. CM mempunyai sebuah efek pemutih pada percobaan in vitro model menggunakan sel melanoma B16 dengan cara menghambat sintesis melanin melalui aktivitas tirosinase. Mekanisme ini dimediasi melalui efek parakrin,

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terutama melalui TGF-b1.15 CM juga memiliki antioksidan yang kuat dan efek perlindungan pada HDFs yang mana merupakan kandidat yang baik dalam mengendalikan kerusakan kulit dari radikal bebas. Penelitian membuktikan bahwa CM mempunyai potensi anti-oksidan setara dengan 100 µM asam askorbat. Terjadi peningkatan enzim SOD dan glutation peroksidase (GPx) ketika kultur HDFs pada CM.12 Selain itu juga, CM menjanjikan harapan baru dalam pengobatan regenerasi kulit dengan menekan apoptosis akibat UV-B dan merangsang sintesis kolagen oleh HDFs.10,16 Dalam penelitian yang lebih luas, injeksi CM menggunakan microneedles pada 30 kulit wajah sukarelawan. Pengamatan dilakukan selama 3 bulan. CM injeksi menunjukan peningkatan yang significant pada melanin indeks, kecerahan kulit, kehalusan kulit, elastisitas kulit.17 Keuntungan dan kerugian dari CM Penggunaan terapi bebas sel punca dengan CM memiliki keuntungan sebagai berikut yaitu mudah diproduksi, dikeringkan beku, dikemas, dan mudah ditransportasikan. Selain itu, karena tidak memiliki sel, tidak perlu mencocokkan donor dan penerima untuk menghindari masalah penolakan.18 Kerugiannya adalah untuk memperoleh ADMSCs masih membutuhkan prosedur invasif (lipoaspirate). Kesimpulan CM memiliki prospek yang menjanjikan untuk diproduksi secara masal sebagai obat-obatan anti-aging untuk kulit menua dini. Hal ini terjadi karena efek parakrin dari sekretom tersebut berperan penting dalam menghambat proses penuaan. Selain itu juga penggunaan terapi bebas sel punca dengan CM dapat diberikan kepada orang lain tanpa adanya masalah penolakan / rejeksi.

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Park BS, Jang KA, Sung JH, Park JS, Kwon YH, Kim KJ, et al. Adiposed-derived stem cells and their secretory factors as a promising therapy for skin aging. J Dermatol Surg. 2008;34:1323-6.

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Lee SH, Jin SY, Song JS, Seo KK, Cho KH. Paracrine effects of adipose-derived stem cells on keratinocytes and dermal fibroblasts. Ann Dermatol. 2012;24: 2.

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Helfrich YR, Sachs DL, Voorchees JJ. Overview of skin aging and photoaging. Dermatology Nursing. 2008; 20(3):177-83.

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Choumerianou DM, Dimitriou H, Kalmanti M. Stem cells: promises versus limitations. Tissue Eng Part B Rev. 2008;14(1):53-60.

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Evans MJ, Kaufman MH. Establishment in culture of pluripotential cells from mouse embryos. Nature 1981;292:154-6.

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Takahashi K, Yamanaka S. Induction of pluripotent stem cells from mouse embryonic and adult fibroblast cultures by defined factors. Cell 2006;126:663-76.

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Wang S, Qu X, Zhao RC. Clinical aplications of mesenchymal stem cells. Journal of hematology and oncology. 2012;5:9.

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Kern S, Eichler H, Stoeve J, Kluter H, Bieback K. Comparative analysis of mesenchymal stem cells from bone marrow, umbilical cord blood, or adipose tissue. Stem Cells. 2006;24:1294-301.

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BunnellBA ,Flaat M, Gagliardi C, Patel B, Ripoll C. Adipose-derived Stem Cells: Isolation, Expansion and Differentiation. Methods. 2008;45(2):115–120.

10. Wang T, Guo S, Liu X, Xv N, Zhang S. Protective effects of adiposederived stem cells secretome on human dermal fibroblasts from ageing damages. Int J Clin Exp Pathol. 2015;8(12):15739-15748. 11. Dominici M, Le BK, Mueller I, Slaper CI, Marini F, Krause D, et al. Minimal criteria for defining multipotent mesenchymal stromal cells. The International Society for Cellular Therapy position statement. Cytotherapy. 2006;8(4):315-7.

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12. Kim WS, Park BS, Kim HK, Park JS, Kim KJ, Choi JS, et al. Evidence supporting antioxidant action of adipose-derived stem cells: protection of human dermal fibroblasts from oxidative stress. J Dermatol Sci. 2008;49(2):133-42. 13. Metral E, Santos MD, Thépot A, Rachidi W, Mojallal A, Auxenfans C, et al. Adipose-derived Stem Cells Promote Skin Homeostasis and Prevent its Senescence in an In vitro Skin Model. J Stem Cell Res Ther. 2014;4:194. 14. Song SY, Jung JE, Jeon YR, Tark KC, Lew DH. Determination of adipose-derived stem cell application on photo-aged fibroblasts, based on paracrine function. Cytotherapy. 2011;13(3):378-84. 15. Kim WS, Park SH, Ahn SJ, Kim HK, Park JS, Lee GY, et al. Whitening effect of adipose-derived stem cells: a critical role of TGFbeta 1. Biol Pharm Bull. 2008;31(4):606-10. 16. Kim WS, Park BS, Park SH, Kim HK, Sung JH. Antiwrinkle effect of adipose-derived stem cell: activation of dermal fibroblast by secretory factors. J Dermatol Sci. 2009;53(2):96-102. 17. Wang X, Shu X, Huo W, Zou L, Li L. Efficacy of protein extracts from medium of adipose-derived stem cells via microneedles on asian skin. Journal of Cosmetic and Laser Therapy. 2017:1-8. 18. Pawitan JA. Prospect of Stem Cell Conditioned Medium in Regenerative Medicine. BioMed Research International. 2014;ID 965849.

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EKSTRAK ETANOL DAUN SIRSAK (Annona Muricata Linn.) MENINGKATKAN SEL LEYDIG PADA TIKUS (Rattus Norvegicus) JANTAN GALUR WISTAR DIABETES Putu atu dewi yustisiani Abstrak Tujuan penelitian ini adalah untuk membuktikan bahwa ekstrak etanol daun sirsak dapat meningkatkan sel Leydig pada tikus (rattus novergicus) jantan galur wistar Diabetes. Penelitian ini adalah penelitian eksperimental dengan menggunakan completely randomized posttest only control group design yang menggunakan 36 ekor tikus (Rattus Norvegicus) jantan galur wistar dewasa berumur 10-12 minggu, berat 200-250 gram yang terbagi menjadi 2 (dua) kelompok masing-masing berjumlah 18 ekor, satu kelompok sebagai kelompok kontrol yang diberi plasebo aquabidest (P0), dan satu kelompok perlakuan yang diberi ekstrak etanol daun sirsak 500mg/kg BB (P1). Hasil penelitian menunjukkan rerata jumlah sel Leydig pada kelompok kontrol adalah 29,57±7,46. Rata-rata jumlah sel Leydig pada kelompok perlakuan dengan ekstrak etanol daun sirsak adalah 38,13±7,97. Uji lanjutan menunjukan perbedaan ini kemudian dianalisis dengan menggunakan Independent T-test dan menunjukkan nilai P=0,002 (<0,05) yang berarti terdapat perbedaan rerata jumlah sel Leydig antar kelompok perlakuan. Simpulan: Etanol daun sirsak (Annona Muricata Linn.) dapat meningkatkan sel Leydig pada tikus (Rattus Norvegicus) jantan galur wistar diabetes. Kata kunci: Daun Sirsak, Sel Leydig, Diabetes Melitus.

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Pendahuluan Diabetes Melitus (DM) merupakan penyakit yang berbahaya dan dapat menyebabkan timbulnya masalah-masalah penyakit lain atau penyakit yang menyertai seperti: gangguan pada kulit, kesemutan atau parastesi, gangguan penglihatan, gangguan saluran kecing, rasa lemah, gangguan pencernaan, gangguan fungsi seksual dan reproduksi, gangguan kardiovaskular, ulkus atau ganggren. Penyakit-penyakit yang muncul akibat DM ini akan mempercepat proses penuaan. Salah satu masalah seksual yang paling umum terjadi pada penderita DM dan banyak membuat kaum pria mengalami depresi adalah disfungsi ereksi. Disfungsi ereksi ini adalah ketidakmampuan dalam mendapatkan dan atau menjaga ereksi untuk dapat melakukan hubungan seksual. Untuk mendapatkan ereksi yang baik, maka sistem pembuluh darah, sistem saraf, sistem hormonal pada pria harus dalam kondisi baik. Sel Leydig merupakan penghasil hormonTestosteron yang merupakan hormone androgen utama dalam sirkulasi darah yang berhubungan dengan pengaturan system seksual seperti ereksi penis spontan, rigiditas penis, intensitas ejakulasi, peningkatan periode refrakter dan sistem reproduksi atau disebut sistem androgenik, selain itu juga berfungsi dalam sistem anabolik seperti pembentukan massa otot, massa tulang, mengatur komposisi lemak tubuh, sistem imun, dan sistem hematopoesis. Tidak hanya pria yang memproduksi hormon testosteron ini, perempuan juga memproduksinya (Pangkahila, 2007). Jumlah testosteron juga berkaitan dengan jumlah sel Leydig yang juga berpengaruh dalam proses spermatogenesis. Testosteron yang diberikan berlebihan dari luar akan terjadi penekanan produksi Testosteron endogen dan bila terjadi terus menerus testis akan atropi dan jumlah sel Leydig akan menurun. Hormon yang dihasilkan testis berkurang termasuk produksi sperma. Semakin bertambahnya usia maka jumlah Sel Leydig semakin berkurang (Pangkahila, 2011).

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Berbagai cara ditempuh untuk menjaga keseimbangan hormon dan menjaga jumlah sel Leydig agar tidak menurun drastis. Banyak tanaman herbal yang mengandung zat-zat yang bermanfaat seperti antioksidan. Daun Sirsak (Annona Muricata) dipilih dalam penelitian ini karena tanaman sirsak termasuk tanaman yang banyak terdapat di banyak negara, termasuk Indonesia, sehingga mudah dicari, murah dan mempunyai banyak manfaat. Daun Sirsak pada penelitian sebelumnya baik secara in-vitro maupun in-vivo menghambat metastasis sel kanker, dan menyebabkan kerusakan sel kanker tanpa merusak sel yang sehat (George, 2012; Sun et al., 2016 dan Tundis et al., 2017). Penelitian pada tikus juga menghambat α-amilase dan αglukosidase dalam mengontrol diabetes melitus tipe 2 (Adewole, 2008; Purwatresna, 2012; Adelegha et al., 2015). Membantu mengontrol berat badan, menurunkan profil lipid, meningkatkan metabolism lemak pada diabetes (Adewole, 2008; Cercato et al., 2015). Selain itu ekstrak etanol daun sirsak pada percobaan pada tikus dapat meningkatkan energi dengan meningkatkan system siklus kreb dalam pembentukan ATP, mencegah kerusakan saraf dengan mencegah terbentuknya ROS (Nawwar et al., 2012; Son et al., 2016). Percobaan pada tikus yang diinduksi toksik oleh cafein setelah diberi EEDS berefek meningkatkan jumlah sperma, motilitasnya dan besar kepala sperma tikus, berat testis PH semen. Penelitian pada tikus untuk melihat adanya efek antidepresi EEDS bekerja pada reseptor serotonin 5HT1A (Ekaluo et al., 2013; Hasrat et al., 2017),) meningkatkan antioksidan endogen seperti SOD, katalase, Glutation Peroksidase pada percobaan selama 14 hari pada tikus (Awodele et al., 2014 dan Yahaya et al., 2014). Pada penelitian menggunakan babi sebagai hewan coba hipoksia yang diberi EEDS ditemukan peningkatan kontraktilitas yang bersifat inotropik positif dan penurunan jumlah foam cell sehingga atherosklerosis dapat dicegah (Bipat, 2016). Banyak manfaat dari Daun

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Indonesian Award for AAM

Sirsak karena mengandung zat-zat yang bermanfaat yang dapat membantu mengatasi masalah tersebut di atas. Ekstrak Daun sirsak kaya akan antioksidan, flavonoid, phenol, alkaloids. Antioksidan tersebut dapat menghambat terbentuknya Reactive Oxygen Species (ROS) akibat stress oksidasi karena Diabetes dan penyakit degeneratif yang lain. Selain itu ekstrak daun sirsak terutama mengandung Phenol dan flavonoid dapat menghambat aktivitas α-amilase dan α- glukosidase sehingga dapat mengurangi peningkatan gula darah setelah makan sehingga dapat mengatasi hiperglikemia. Berangkat dari hal-hal tersebut diatas, dimana diabetes dapat menyebabkan gangguan pada Sel Leydig, penulis ingin membuktikan bahwa pemberian ekstrak daun sirsak mempunyai pengaruh meningkatkan sel Leydig pada tikus diabetes. Metode Penelitian Penelitian ini adalah penelitian eksperimental, dengan menggunakan rancangan randomized post test only control group design. Subjek yang digunakan dalam penelitian ini adalah 36 ekor Tikus Wistar (Rattus norvegicus) jantan, berumur 10-12 minggu dengan berat badan kurang lebih 200-250 gram dan sehat. Seluruh tikus diinduksi dengan menggunakan STZ sehingga tikus dalam kondisi Diabetes Mellitus (DM). Tikus dinyatakan diabetes apabila kadar glukosa darah > 135 mg/dl. Tikus yang sudah dalam keadaan DM tersebut kemudian dilakukan alokasi random dan dibagi menjadi 2 kelompok perlakuan. Kelompok 1 (P0) adalah kelompok yang kontrol yang diberikan makan + placebo (air suling) sebanyak volume 1,5cc. Kelompok 2 (P1) merupakan kelompok perlakuan yang diberi makan+ Ekstrak Etanol Daun Sirsak (EEDS) dengan dosis 500mg/kg atau 100mg/200gr BB tikus yang dilarutkan dalam 1,5cc air suling.

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Pada hari ke-30, tikus diterminasi dengan melakukan injeksi ketamin dosis berlebih secara intraperitoneal, dan kemudian diambil testis melalui insisi transversal dibagian bawah abdomen. Testis tersebut kemudian difiksasi dengan larutan formalin 10% dan dilakukan perhitungan jumlah sel Leydig dengan metode pewarnaan HematoxylinEosin (HE) akan tampak berwarna merah keunguan, Sel Leydig akan tampak berwarna ungu tua kecoklatan Jumlah sel Leydig dihitung melalui mikroskop olympus CX 41 pada pembesaran 400x pada lima lapang pandang. Kemudian dihitung rerata jumlah sel Leydig pada masing-masing preparat. Hasil dan Pembahasan Sediaan jaringan testis tikus diproses dengan pewarnaan Hematoxylin-Eosin (HE) dan diperiksa dengan mikroskop olympus CX 41 pada pembesaran 400x pada 5 lapang pandang. Sediaan histologis dibawah mikroskop pada perbesaran 100x, 200x dan 400x disajikan pada Gambar 1A dan Gambar 1B. Hasil penelitian menunjukkan bahwa rata-rata jumlah sel Leydig pada kelompok control adalah 29,57±7,46 dan pada kelompok perlakuan adalah 38,13±7,97. Hasil ini mengindikasikan bahwa kelompok yang mendapat perlakuan ekstrak etanol daun sirsak memiliki jumlah sel Leydig yang lebih tinggi dibandingkan dengan kelompok kontrol. Perbedaan ini kemudian dianalisis kemaknaan dengan menggunakan Independent T-test dan menunjukkan nilai p=0,002 (<0,05) yang berarti terdapat perbedaan rerata jumlah sel Leydig antar kelompok perlakuan (Gambar 2). Jadi dapat disimpulkan bahwa pemberian ekstrak etanol daun sirsak (EEDS) peroral dapat menghambat penurunan jumlah sel Leydig tikus jantan galur wistar dengan diabetes melitus (DM).

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Ekstrak etanol Daun Sirsak (Annona Muricata Linn) ini digunakan dalam penelitian ini karena mengandung flavonoid 476,54 mg/100gr QE (Quarcetin Equivalent), Fenol 1500,95 mg/100gr GAE (Galic Acid Equivalent), dan uji aktifitas antioksidan cukup tinggi yaitu 10.981,13 mg/ 100 gr GAEC (Galic Acid Equivalent Antioxidant capacity). Flavonoid pada daun sirsak berfungsi sebagai antioksidan alami yang dapat melindungi sel Leydig dari kerusakan akibat radikal bebas, selain itu Flavonoid juga membantu meregenerasi sel Leydig. Antioksidan yang terkandung dalam EEDS (Ekstrak Ethanol Daun Sirsak) seperti flavonoid, quercetin, phenol berfungsi meningkatkan antioksidan endogen : seperti Katalase, Superokside dismutase (SOD), glutathion Peroksidase yang berperan dalam scavenging radikal bebas, ekspresi gen, faktor transkripsi enzim antioksidan, mengurangi terbentuknya ROS yang diinduksi oleh H2O2 (Nawwar et al., 2012; Son et al., 2016). Ekstrak Etanol Daun Sirsak juga menghambat mekanisme 4 jalur terbentuknya ROS akibat DM yaitu jalur Protein Kinase C (PKC), jalur Poliol, jalur heksosamine, dan jalur AGEs yang dapat menurunkan produksi ROS dan menurunkan risiko apoptosis sel β Pankreas, sel Leydig, sel endotel pembuluh darah, dan kerusakan saraf, sehingga gangguan pada Steroidogenesis dapat diatasi dan jumlah sel Leydig dapat dipertahankan. Kandungan Flavonoid dan Phenol pada EEDS dapat menghambat aktivitas α-amilase dan α-glukosidase sehingga tingginya kadar gula darah dapat diatasi, menghambat penyerapan glukosa, meningkatkan sekresi insulin, sehingga dapat menghambat kerusakaan sel Leydig akibat Diabetes yang tidak terkontrol. Profil lipid dan peroksidasi lipid juga akan dikurangi dengan ekstrak daun sirsak sehingga mencegah kerusakan membrane sel, mengatasi perubahan aktivitas enzym yang terikat pada membran sel dan reseptor, sehingga dapat mengurangi retensi insulin (Awodele, 2008). Penelitian pada tikus yang diinduksi cafein dapat melihat peranan EEDS dalam meningkatkan berat testis dan epididimis, meningkatkan motilitas sperma,

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meningkatkan jumlah sperma, dan mengurangi abnormal kepala sperma pada tikus (Ekaluo et al., 2013). EEDS bekerja pada agonis Dopamin dan berpengaruh pada testis dan sel Leydig, Sehingga penurunan jumlah sel Leydig dapat diatasi Banyak penderita DM yang tidak terkontrol mengalami hiperglikemia yang berkepanjangan yang dapat mengakibatkan gangguan fungsi seksual, baik libido yang menurun maupun disfungsi ereksi. Hal ini terjadi karena proses apoptosis atau kematian sel dari sel β pankreas dan sel Leydig. Perbaikan sel Leydig yang terjadi setelah diberikan ekstrak etanol daun sirsak dengan dosis 500 mg/kg BB disebabkan karena ekstrak etanol daun sirsak mengandung senyawa acetogenins, alkaloids, flavonoids, phenol yang dapat mencegah penurunan jumlah sel Leydig akibat diabetes melitus. Selain itu Ekstrak daun sirsak dapat mengatasi masalah diabetes melitus (Moghadamtousi et al., 2015). Diabetes merupakan salah satu penyakit yang dapat menyebabkan gangguan fungsi organ tubuh yang lain, selain gangguan fungsi seksual, sehingga penuaan lebih cepat terjadi. Dengan adanya perbaikan sel Leydig pada penderita diabetes, produksi hormone testosteron dan proses spermatogenesis akan menjadi lebih baik. Penurunan produksi hormon tidak terjadi maka penuaan dapat dihambat, kualitas hidup dan derajat kesehatan akan semakin baik, sehingga usia harapan hidup menjadi lebih panjang. Pemberian ekstrak etanol daun sirsak terbukti dapat memperbaiki jumlah sel Leydig sehingga masalah gangguan fungsi seksual pada pasien diabetes melitus dapat teratasi. Hasil penelitian ini dapat dijadikan referensi untuk penelitian selanjutnya dengan menggunakan dosis bervariasi, melihat efek samping ekstrak daun sirsak dan melalui uji klinis sehingga dapat diketahui efektivitas ekstrak etanol daun sirsak terhadap sel Leydig manusia, peningkatan hormon androgen, proses spermatogenesis,

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sehingga dapat dimanfaatkan untuk mengatasi gangguan fungsi seksual karena berkurangnya jumlah sel Leydig pada orang dengan gangguan diabetes. Simpulan Simpulan yang diperoleh dari hasil penelitian ini adalah bahwa ekstrak etanol daun sirsak (Annona Muricata) dapat meningkatkan sel Leydig pada tikus (Rattus Norvegicus) jantan galur Wistar Diabetes. Daftar Pustaka 1.

Adewole, S.O., Ojewole, J.A. 2008. Protective Effect of Annona Muricata Linn. (Annonaceae) Leaf Aqueous Extract on serum Lipid Profiles and Oxidative Stress in Hepatocytes of Streptozotocin Treated Diabetic Rats. Available from: http://www.ncbi.nlm.nih.gov/pubmed.

2.

Awodele, O., Ishala, I.O., Ikumayuoyi, V.O., Akindele A.J., Akintonug A, 2014 Toxicological evaluation of the lyopilized fruit juice extract of annona muricata linn. (Annonaceae) in rodent. available from http://www.ncbi.nlm.nih.gov/pubmed.

3.

Adefegha, S.A., 2015. Distribution of Phenolic content, Antioksidan, Petential Antihypertansive Properties, and Antioxsidative Effect of Soursop (Annona Muricata L) Fruit Parts in Vitro. Available from : http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4519917.

4.

Bipat, R., Toelsie, J.R., Magali, I., Soekhoe, R., Stender, K., Wangsawirana, A., Odaira

5.

Djsingh, K., Pawirodihardjo, J., Mans, D.R. 2016. Beneficial effect of medical plants on the contractility of post hipoxic isolated guinea pig atria-Potential implications for the treatment of ischemic-reperfusion injury. Available from: http://www.ncbi.nlm.nih.gov/pubmed.

6.

Cercato, L.M., white, P.A., Namp, F.K., Santos, M.R., Camargo, E.A. 2015. A Systematic review of Medicinal Plants Used Loss in Brazil: Is There Potential for Obesity Treatment. Available from:http://www.ncbi.nlm.nih.gov/pubmed.

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7.

Ekaluo, U., Ikpeme E.V., Ibiang Y.B., Ormodia, F.O., 2013. Effect of Soursop (Annona Muricata L.) Fruit Extract on sperm Toxicity Induced by Caffeine in Albino rats. Available from: http//scialert.net/abstract/?doi=jms.2013.67.71.

8.

George, V.C. 2012. Quantitative Assessment of the Relative Antineoplastic potential of the N-Butanolic laf Extract of Annona Muricata linn, in Normal and Immortalized human cell lines. Available from : http://www.ncbi.nlm.nih.gov/pubmed.

9.

Hasrat, J.A., De Bruyne, T., De Backer, J.P., Vanquelin, G., Vientinla, A.J. 2017. Isoquinoline derivates isolated from the fruit of annona muricata as 5-Htergic 5-HT1A reseptor agonist in rats: unexploited antidepressive (lead) products. Available from:http://www.ncbi.nlm.nih.gov/pubmed.

10. Ishola I.O., Awodele O., Okusayero A.M., Ochieng C.O., 2014. Mechanisms of analgesic an Anti-inflammatory Properties of Annona Muricata Linn. (Annonaceae) Fruit Extract in Rodents Available from : http://www.ncbi.nlm.nih.gov/pubmed. 11. Kim, G.T., Tran, N.K., Choi, E.H., Song, Y.J., Song, J.H., Shim, S.M., Park, T.S. 2016. Immunomodulatory Efficacy of Standarized Annona Muricata ( Graviola) Leaf Extract via Activation of MitogenActivated Protein Kinase pathway in raw 264,7Macrophages. Available from :http//www.ncbi.nlm.nih.gov/pubmed. 12. Moghadamtousi, S.Z., Fadaeinasab, M., Niekad, S., Mohan, G., Moh. Ali H., Abdur kadir, H. 2015. Annona Muricata (annonaceae) : A Review of Its Traditional Uses Isolated Acetogenins and Biological Activities. available from http:// ncbi.nlm.nih.gov/pmc/articles/PMC4519917/figure/ijms-16- 15625f002. 13. Nawwar, M., Ayoub, N., Hussein, S., Hashim, A., El- Sharawy, R., Wende, K., Harms, M., Lindequist. 2012. A Flavonol Triglycoside and investigation of the Antioxidant and cell stimulating activities of Annona Muricata Linn. Available from : http://www.ncbi.nlm.nih.gov/pubmed.

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14. Oliveira, A.P. 2017. Exploratory Studies on The In Vitro AntiInflammatory Potential of Two Herbal Teas (Annona Muricata L and Jasmine Grandiflorum L.), and Relation with Their Phenolic Composition. Available from http://www.ncbi.nlm.nih.gov/pubmed. 15. Pangkahila, W. 2007. Anti Aging Medicine. Memperlambat Penuaan Meningkatkan Kualitas Hidup. Kompas, Jakarta. 16. Pangkahila, W. 2011. Anti Aging . Tetap Muda dan Sehat. Kiat menghindari Penuaan Dini. Penerbit :Kompas, Jakarta. 17. Purwatresna, E. 2012. Aktifitas Antidiabetes Ekstrak air dan Etanol Daun Sirsak Secara Invitro melalui inhibisi enzim a glukosidase. Available from :http// respository.ipb.ac.id/handle/123456789/58641. 18. Somzak, V. 2016. In Vivo Antimalaria activity of Annona Muricata leaf Extract in mice Infected with Plasmodium berghei. available from : http;//www.ncbi.nlm.nih.gov/pmc/pubmed. 19. Son, Y.R., Choi, E.H., Kim, G.T., Park, T.S., Shim, S.M. 2016. Bioefficacy of Graviola leaf extracts in scavenging free radical and upregulating antioxidants genes. Available from: http://www.ncbi.nlm.nih.gov/pubmed. 20. Suharyadi, A., Sukohar, A., Muhartono. 2014. Pengaruh Pemberian Ekstrak Etanol Daun Sirsak Terhadap gambaran Histopatologi Ginjal Tikus yang Diinduksi DMBA. Available from:http://juke.kedokteran. unila.ac.id/index.php/majority/ article/view/240. 21. Sun, S., Liu, J., Zhou, N., Zhu, W., Dou, Q.P., Zhou, K. 2016. Isolation of Three New Annonaceous Acetogenins From Graviola Fruit (Annona Muricata) And Their Anti Proliferation on Human Prostate Cancer cell PC-3. Available from:http://www.ncbi.nlm.nih.gov/pubmed. 22. Tundis,R.A., Xiau, J., Loizzo, M.R.2017. Annona Muricata (Annonaceae): A Rich Source Of Potential Antitumor Agents. available from: http://www.ncbi.nlm.nih.gov/pupmed. 23. Yahaya, G., Faten, A.E., Fred, W., Hany, A.S. 2014. Phytochemical screening, anti-oxidant activity and in vitro anticancer potential of ethanolic and water leaves extracts of annona mricata (Graviola). Available from : http://www.ncbi.nlm.nih.gov/pubmed

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Indonesian Award for AAM Case Report. Novelty PBSC Treatment in Diabetes Mellitus @NASWAAM Bali 2018

PERIPHERAL BLOOD STEM CELL (PBSC) UNTUK TERAPI DIABETES MELLITUS TYPE 2 Syaifudin1. Niswatin2. Rahmawati3. Roihah3 1

Stem Cell Research and Therapy. MMC Hospital Lamongan. Jawa Timur. Indonesia; Stem Cell Laboratorium. MMC Hospital Lamongan. Jawa Timur. Indonesia; 3Nurse Departement. MMC Hospital Lamongan. Jawa Timur. Indonesia Correspondence to: Syaifudin M. Stem Cell Research and Therapy. MMC Hospital Lamongan. Jawa Timur. Indonesia. Email: [email protected]

2

Abstrak DMT2 saat ini menjadi ancaman kesehatan global, terapinya tidak cukup dengan mengontrol dan pengendalian saja. Membutuhkan terapi alternative masa depan yang bisa menurunkan insiden dan meningkatkan kualitas hidup penderita dan masyarakat. Penelitian ini bertujuan untuk mengamati kemampuan regenerasi sel beta pancreas pada penderita DMT2 melalui pengukuran kadar gula darah puasa dan HbA1c. Penelitian ini menggunakan rancangan one group pre-posttest design dan case study terhadap 20 pasien diabetes mellitus type 2 (DMT2) terdiri dari 7 pasien DMT2 tanpa komplikasi dan 13 pasien DMT2 dengan komplikasi yang diberikan terapi autologous maupun allogenic peripheral blood stem cell (PBSC) melalui infus di pembuluh darah vena kubiti media. Diperoleh hasil kadar GDP pre terapi rata-rata 279 91.18 mg/dL, kadar GDP post terapi 187.6

98.97 dengan nilai p=0. Hasil kadar

HbA1c pre terapi rata-rata 11.68 2.6, kadar HbA1c post terapi 9.63 2.33% dengan nilai p=0.

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Terapi sel punca CD34+ (PBSC) dapat diberikan untuk penyembuhan DMT2 baik yang non komplikasi maupun dengan komplikasi. Tidak ditemukan adanya efek samping yang dominan. Keyword: Autologous/ Allogenic PBSC, DMT2, Gula Darah Puasa, HbA1c

Pendahuluan Insiden dan prevalen penyakit diabetes mellitus saat ini menjadi ancaman global dan nasional (Menkes RI. 2017). .Menurut Perkumpulan Endokrinologi Indonesia (Perkeni) dan American Diabetic Association (ADA) 2015, penyakit diabetes mellitus saat ini termasuk penyakit degeneratif progresif yang tidak dapat disembuhkan dan diderita seumur hidup. Terapi konvensional medikamentosa pada DMT2 hanya untuk pengelolaan, pengendalian, mencegah kerusakan dan kegagalan organ (Perkeni, 2015) Saat ini pengendalian diabetes mellitus dengan cara edukasi, latihan jasmani, diet nutrisi dan farmakoterapi. Parameter pengendalian yang digunakan adalah gula darah, HbA1c, profil lipid, Index massa tubuh (IMT) dan tekanan darah. Penyebab patogenesis DMT2 adalah resistensi insulin pada 8 organ yaitu 1) kegagalan sel beta pancreas: penurunan sekresi insulin. 2) liver: peningkatan produksi glukosa. 3) otot: penurunan absorbsi glukosa. 4) sel lemak: peningkatan lipolisis 5) usus: penurunan efek inkretin. 6) sel alfa pankreas: peningkatan sekresi glukagon. 7) ginjal: peningkatan reabsorbsi glukosa dan 8) otak: disfungsi neurotransmiter (Perkeni. 2015). Akibatnya pasien DMT2 mengalami inflamasi kronis, gangguan imun dan mikro-makro vaskuler melalui gangguan sitokin sehingga menimbulkan manifestasi klinis DMT2 dan komplikasinya (Wehbe. 2016)

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Riset terapi regeneratif diabetes mellitus terus dikembangkan dengan tujuan pengobatan penyakit untuk mencapai status kesehatan yang optimal (Pangkahila. 2017). Yang paling sering digunakan adalah dengan menggunakan sel punca bone marrow mesenchymal stem cell (BM-MSC), bone marrow hematopoietic stem cell ((BM-HSC), umbilical cord mesenchymal stem cell (UC-MSC), adipose derived stem cell (ADSC) dan peripheral blood stem cell (PBSC) (Badawy. 2015). Saat ini riset terapi sel punca pada diabetes ditujukan untuk meregenerasikan sel beta pankreas yang rusak. Jika berhasil maka terapi sel punca ini akan menyempurnakan kelemahan dari terapi cangkok pankreas (Lilly, 2016). Penelitian ini menggunakan PBSC dengan alasan etik, ekonomis dan efektif. Terapi PBSC merupakan kandidat untuk pengobatan DMT2 dengan hasil yang signifikan dan tidak ada efek samping yang dominan (Badawy. 2015). Pasien dan Metode Penelitian ini menggunakan rancangan one group pre-posttest design dan case study beberapa kasus. Melibatkan 20 pasien DMT2 yang tidak terkontrol dengan variabel bebas: 1) peripheral blood stem cell (PBSC) ; variabel terikat: 1) Kadar gula darah. 2) Kadar HbA1c. Pasien mempunyai kadar gula darah puasa > 126 mg/dLselama 3 bulan dan

HbA1c lebih dari 7% selama 1 tahun. Pasien mendapatkan

diagnosis DMT2 tanpa komplikasi dan DMT2 dengan komplikasi tetapi kondisi organ vital jantung. liver, paru-paru dan ginjal relatif selama 3 bulan masa penelitian dan tidak ada infeksi aktif.

stabil

Dilakukan nasehat: diet, olah raga, ehindari stress, meditasi dan evaluasi medis kepada masing masing pasien untuk memperoleh kondisi optimal selama penelitian. Pemberian obat oral anti diabetes (OAD) dari internis tetap diberikan namun dilakukan tapering off bila kondisi klinis membaik.

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Metode pengambilan PBSC dengan isolasi dari darah tepi pasien (autologous) maupun orang lain dari anak atau saudara (allogenic), lolos skrining pemeriksaan fisik dan laboratorium bebas virus hepatitis B dan virus HIV. Pemurnian PBSC dengan metode densitas sentrifugasi kemudian dilakukan sorting dan penghitungan sel. Pengambilan sel secara autologous hanya boleh dilakukan 1 kali selama periode 3 bulan Hasil separasi sel dilakukan tes subyektif mikroskopis mikrobiologi dan morfologi sel. Dosisi PBSC sebesar 4x106 sel/kg BB.Terapi prakondisi diberikan infus nutrisi asam amino, vitamin dan anti oksidan. PBSC dilarutkan dalam 50 mL larutan salin dan diinfuskan melalui vena kubiti media lengan kanan atau kiri selama 20 menit. Pasien diperbolehkan pulang 2 jam setelah protokol selesai. Setiap pasien disarankan melakukan protokol terapi PBSC setiap bulan. Untuk DMT2 non komplikasi 3-5 kali terapil, sedangkan DMT2 dengan komplikasi diberikan 8-12 kali terapi (Badawy, 2015). Setiap kunjungan dilakukan pemeriksaan fisik, kadar gula darah puasa dan HbA1c. Hasil 20 pasien DMT2 diambil dari periode Agustus 2014 hingga Oktober 2017. Terbagi menjadi 7 pasien DMT2 tanpa komplikasi dan 13 pasien DMT2 dengan komplikasi dengan variasi umur 47-72 tahun. Semua pasien, hasil pemeriksaan pretes gula darah puasa > 126 mg/dL dan HbA1c > 7% (Tabel 1)

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Tabel 1: Pre dan post terapi PBSC 20 Pasien No

Kela

Umur

GDP

GDP

HbA1c

HbA1c

min

tahun

pre

post

pre

post

terapi

terapi

terapi

terapi

L/P

Komplikasi pre terapi

mg/dL

mg/dL

%

%

P

52

389

545

15

13.2

None

L

60

156

123

9.6

6.3

None

3

L

54

239

124

10.8

8.2

None

4

L

52

210

153

8.8

8.3

None

L

49

205

128

8.8

8

None

6

L

57

258

210

11.2

10.2

None

7

P

47

232

145

12.7

8.9

None

8

P

60

342

252

15

14.2

PJK

9

L

64

210

254

9.4

12.1

Parkinson’s. HT

10

P

50

236

156

15

13.2

Gastropathy

11

L

58

212

160

7.8

7.2

PJK

12

P

54

254

162

14

10.3

Kaki Gangrene

13

P

43

320

134

13.8

9

L

48

254

154

13

6.7

15

L

67

324

97

15

8.4

16

P

72

372

221

11.7

11.3

Polineuropathy

L

54

215

110

8

6.3

CRF

18

P

48

359

168

12.5

10.2

Retinopathy

19

L

49

554

278

14

11.2

Retinopathy.Poli

20

L

60

241

120

7.4

6.9

1 2

5

14

1

2

3

TB Paru DE. Polineuropathy HT. Polineuropathy

17

4

neuropathy CRF

Dari data 20 pasien di atas diperoleh hasil kadar GDP pre terapi PBSC rata-rata 279 91.18 mg/dL, kadar GDP post terapi 187.6 98.97 dengan nilai p=0 signifikan. Hasil kadar HbA1c pre terapi rata-rata 11.68 2.6, kadar HbA1c post terapi 9.63 2.33% dengan nilai p=0 signifikan

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Tabel 2: Pair T Test Kadar GDP dan HbA1c pre dan post terapi PBSC Mean 187.65

N 20

Std. Deviation 98.9366

GDP_pre

279.1

20

91.17762

HbA1c_post

9.635

20

2.33267

HbA1c_pre

11.675

20

2.68365

Kadar GDP dan HbA1c Pair 1 GDP_post

Pair 2

p 0,000

0,000

Dari 20 pasien DMT2, 16 pasien DMT2 menjalani terapi 2 kali oleh karena faktor keterbatasan biaya, sedangkan 4 pasien melanjutkan terapi 3-8 kali dengan durasi waktu 1 bulan tiap kali terapi. Pada 4 pasien yang meneruskan terapi 3-8 bulan, pasien-1 adalah DMT2 non komplikasi setelah 3 kali terapi PBSC, kadar GDP=123mg/dL dan HbA1c=6,3%, bebas DMT2. Pasien-3, -4 adalah DMT2 dengan komplikasi, setelah 8 dan 6 kali terapi PBSC, kadar GDP berturut-turut 124mg/dL dan 106mg/dL, kadar HbA1c=6,7% dan 6,3%,

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bebas DMT2, Adapun pasien-2 kadar GDP= 125mg/dL, HbA1c=8% dikarenakan kurang disiplin melaksanakan pola hidup sehat. Diskusi DMT2 merupakan penyakit degeneratif yang progresif dan merupakan

ancaman

kesehatan

global.

Diperlukan

terobosan

pendekatan holistik anti aging medicine dengan terapi sel punca yang tidak hanya mengontrol penyakit tetapi dapat menyembuhkan DMT2 (Liew, 2008). Dalam 6 studi penelitian yang melibatkan 149 pasien DMT2, untuk memperoleh PBSC digunakan mobisitator sel punca CD34+ yaitu granulocyte-colony stimulating factor (G-CSF), dosis PBSC infus intra venus adala 6,993,28x106 sel/kg/BB. Setelah 6 bulan terapi terdapat penurunan kadar gula darah dan HbA1c signifikan dari 10,142,16

menjadi

5,940,31%,

p<0,0001).

Faktor

onset

DMT2

berpengaruh dalam penyembuhan , makin pendek waktu menderita DMT2 makin cepat regenerasi sel beta pankreasnya. Selama penelitian ini tidak didapatkan efek samping dominan. (Badawy, 2015) Mekanisme regenerasi sel beta pankreas oleh PBSC melalui homing dengan bantuan modulasi lingkungan mikro, growth factor dan sitokine yang diekspresikan sel punca PBSC. PBSC eksogen yang diberikan melalui infus ditangkap secara kemotaksis oleh sel beta pangkreas yang rusak dengan bantuan sinyal molekul stromal cell derived factor-1 (SDF-1), CXC chemokine ligand (CXCR-4), toll like receptor (TIR/ TLR-4) dan MAC1. PBSC mengalami proliferasi dan diferensiasi dengan ditandai adanya ekspresi Pdx-1 (transdiferensiasi) dan Pax-4, c-Peptide (diferensiasi dan maturasi) menjadi sel beta pankreas yang sehat dan normal, (Gambar 3) (Rantam, 2015) Gambar 3. Mekanisme homing sel punca CD34+ PBSC meregenerasi sel beta pankreas

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Kesimpulan Terapi sel punca CD34+ PBSC dapat diberikan untuk penyembuhan DMT2 baik non komplikasi maupun dengan komplikasi. Pemberiannya tetap diperlukan modalitas terapi pola hidup sehat dan terapi tapering medikamentosa. Penelitian ini perlu dikembangkan dengan penambahan variabel lain untuk mendapatkan data yang lebih baik dan akurat.

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Kepustakaan 

Badawy A. Badri N. 2015. Clinical efficacy of stem cell therapy for diabetes mellitus: a meta-analysis. Plos one. 1-16



Liew CG, Andrews PW. 2008. Stem cell therapy to treat diabetes mellitus. Rev Diabet Stud. (5):203-9



Lilly MA, Davis MS, Fabie JE, Terhune EB, Gallicano GI. 2016. Current stem cell based therapies in diabetes. Am J Stem Cell; 5(3):87-98



Menkes RI. 2017. Tahun 2030 prevalensi diabetes mellitus di Indonesia mencapai 21,7 juta orang. Depkes RI.



Pangkahila W. 2017. Stem cell therapy for anti aging purpose. Slide presentation of national symposium and work shop stem cell for the future medicine. Surabaya. 1-45



Perkeni. 2015. Konsensus pengelolaan dan pencegahan diabetes mellitus tipe 2 di Indonesia. 1-93



Rantam FA, Purwati, Setiawan B, Wibisono F, Ferdiansyah, Wahyuadi J, Mouli E, Utomo DN, Suroto H, Bumi C. 2015. Induced derived HSCs (CD34+) with LPS accelerated homing rate bone marrow mesenccymal stem cell (BM-MSCs, CD105) in injured pancreas. J Biomedical Science and Engineering, 8: 333-344



Wehbe T. Chahine NA. Sisi S. Joaude IA. Chalhoub L. 2016. Bone marrow stem cell therapy for type 2 diabetes mellitus. Stem cell investig; (3) 87:1-6

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