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7/21/2019 Komplikasi Kronik Diabetes Melitus 2010-Sorong
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KOMPLIKASI KRONIKKOMPLIKASI KRONIK
DIABETES MELITUSDIABETES MELITUS
HIMAWAN SANUSIHIMAWAN SANUSISUBBAGIAN ENDOKRIN DAN METABOLIKSUBBAGIAN ENDOKRIN DAN METABOLIKBAGIAN PENYAKIT DALAM FKUH RS DRBAGIAN PENYAKIT DALAM FKUH RS DRWAHIDIN SUDIROHUSODO MAKASSARWAHIDIN SUDIROHUSODO MAKASSAR
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Komplikasi KronikKomplikasi Kronik
KronikHiperglikemia
Mikrovaskuler Makrovaskuler
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Pancreas
Hyperinslinemia
Hiperglikemia
!lyca"e# pro"ein T$rom%osis
PAI&'
Li(er
HDL
))A
Dyslipi#emia
*LDL +T!,
O%esi"y
Skele"al m
scle
))A
Hyper-lycemia
A#ipocy"es
Li! P "ir#ula$io% &''&
(v
TN)&
Hyper"ension
)i%rino-en
Lipemia
.RP
A#(ance#
!lycosyla"ion
En#pro#c"
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MAKROAN!IOPATIMAKROAN!IOPATI
Pe%!aki$ )a%$u%( Koro%er *P)K+Pe%!aki$ )a%$u%( Koro%er *P)K+ An-ina pek"oris #an in/ark miokar#An-ina pek"oris #an in/ark miokar#
Ma"i men#a#akMa"i men#a#ak
Pe%!aki$ sererovaskulerPe%!aki$ sererovaskulerSeran-an iskemik "ransien"Seran-an iskemik "ransien"
S"rokS"rok
Pe%!aki$ vaskuler ,eri-erPe%!aki$ vaskuler ,eri-er Kla#ikasi in"ermi""enKla#ikasi in"ermi""en
!an-ren!an-ren
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Penyaki" 0an"n- Koroner pa#a
Dia%e"es
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Penyaki" 0an"n- Koroner pa#aPenyaki" 0an"n- Koroner pa#a
Dia%e"esDia%e"es
. An-ina pek"orisAn-ina pek"oris
. In/ark miokar# ak"In/ark miokar# ak"
. Ma"i men#a#ak +Ma"i men#a#ak +suddensudden
cardiac arrestcardiac arrest ,,
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Sekitar 50-75%
kematianpada DM disebabkanoleh
Pen akit antun
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Historical Model of AtherogenesisHistorical Model of AtherogenesisHistorical Model of Atherogenesis
healthy subclinical symptomatic
ThresholdThreshold
DecadesDecades YearsYears--MonthsMonths MonthsMonths--DaysDays
PlaquePlaque
IntimaIntima
MediaMediaLumen
Stable anginaStable angina
Stable plaques withStable plaques with narrowingnarrowing
Simple diagnostic (!"# angiography$Simple diagnostic (!"# angiography$
%are MI%are MI
asy to treatasy to treat
Adapted from Antischkow N.Adapted from Antischkow N. Beitr Path Anat Allg PathBeitr Path Anat Allg Path 1913;56:3791913;56:379404.404.
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Risk )ac"ors /or .ar#io(asclar Disease
Associa"ion 1i"$ "ype 2 Dia%e"es
Speci/ic Non Speci/icMicroal%minria
!lyca"e# LDL
!lyca"e# HDL
Hyper"ri-lyceri#emia
Small #ense LDL
.ar#iac a"onomic neropa"$y
En#o"$elial #ys/nc"ion
Al"ere# /i%rinolysis an#
"$rom%osis
Hyper"ension
Lipi#s
Decrease# HDL
O%esi"y
Renal /ailre
Feli( P/ Fros01a% LA2 E%3o#ri%olo(! a%3 Me$aolis1 &''456'6
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. A"asi /ak"or risikoA"asi /ak"or risiko
. Ken#alikan ka#ar -lkosa #ara$Ken#alikan ka#ar -lkosa #ara$. Pence-a$an #en-an aspirin3Pence-a$an #en-an aspirin3#an s"a"in#an s"a"in
. In/ark miokar# ak"In/ark miokar# ak" I..UI..U
Terapi P0K pa#a pasienTerapi P0K pa#a pasien
#ia%e"es#ia%e"es
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Penyaki" Ar"eri Peri/er
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Penyaki" Ar"eri Peri/erPenyaki" Ar"eri Peri/er
. Dasar 4 a"erosklerosisDasar 4 a"erosklerosis
. Ber$%n-an #en-an sia3 lamaBer$%n-an #en-an sia3 lama
#ia%e"es#ia%e"es. Pre(alensi sli" #i"en"kan ok -e5alaPre(alensi sli" #i"en"kan ok -e5ala
asimp"oma"ik #an neropa"i yan-asimp"oma"ik #an neropa"i yan-
6men-a%rkan76men-a%rkan7. Pasien #a"an- %ero%a" okPasien #a"an- %ero%a" ok
-an--ren 8 lcer iskemik-an--ren 8 lcer iskemik
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Dia-nosis PADDia-nosis PAD
!e5ala Klinis + )on"aine klasi/ikasi klinik,
Gra3e I 7 "ol3 se%sa$io%/ %u1%ess
Gra3e II 7 "lau3i#a$io% I%$er1i$$e%$
Gra3e III 7 %!eri saa$ is$ira0a$Gra3e I8 7 ulkus/ %ekrosis *s,o%$a%eus (a%(((re%+
Pemeriksaan )isis 4,ulsasi ar$eri 3orsalis ,e3is/
$iialis ,os$erior/ ,o,li$ea
Pemeriksaan "am%a$an7 USG Do,,ler/ A%kle
Bra#0ial I%3e9
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Terapi PAP pa#a DMTerapi PAP pa#a DM
. Far1akolo(is 7 vaso3ila$or/ a%$i a((re(asiFar1akolo(is 7 vaso3ila$or/ a%$i a((re(asi
,la$ele$ *as,iri%:#lo,i3ro(el+ ,e%$o9!-ili%e/,la$ele$ *as,iri%:#lo,i3ro(el+ ,e%$o9!-ili%e/
#ilos$a;ol2#ilos$a;ol2
. Revaskularisasi 7 s$e%$/ a%(io,las$!Revaskularisasi 7 s$e%$/ a%(io,las$!
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Komplikasi Mikroan-iopa"iKomplikasi Mikroan-iopa"iDia%e"ikDia%e"ik
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OXIDATIVESTRESSS
O2 NO
Hyperglicemia
Polyol pathwayGlco!e o"i#atio$
pathway
Protei$ glyco!ylatio$
pathway
AGE!
NO %e$chi$g
&D& o"i#atio$
A$tio"i#a$t
#e'e$ce
NADPH
E$#othelial #y!'$ctio$
NO(#epe$#e$t
)a!o#ilatatio$
*oaglatio$ acti)atio$
Hemorheologic alteratio$
Reti$opathy Va!clopathy Neropathy Nephropathy
Pa"o-enesis komplikasi mikroan-iopa"i #ia%e"ik
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NE)ROPATI DIABETIK
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Ne-ro,a$i 3iae$ikNe-ro,a$i 3iae$ik
!ides c"rrent "nti! #00$
%ia&etic nephropath'("rric"!"m )od"!e ***+7&
!ide # of 37
Risk factors
, -oor .!'caemic contro!
, /'per!ipidaemia
, /'pertension
, enetic predisposition
, !omer"!ar h'per+fi!tration d"rin.ear!' period
, 1thnicit'
, 2on. disease d"ration
, mokin.
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Ne-ro,a$i 3iae$ikNe-ro,a$i 3iae$ik
!ides c"rrent "nti! #00$
%ia&etic nephropath'("rric"!"m )od"!e ***+7&
!ide 3 of 37
Diabetic nephropathy
, A&o"t #0 to 30 of peop!ewith dia&etes
, *n t'pe # dia&etes4 a sma!!erfraction of these pro.ress to(5%
, -eop!e with t'pe # dia&etes o6er ha!f of those with dia&etesstartin. on dia!'sis
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Penan#a kersakan -in5alPenan#a kersakan -in5al
Serum &reum
Serum 'reatinin
'lirens 'reatinin
!ystatin-!
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DETEKSI DINIDETEKSI DINI
Pe%!aki$ Gi%
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Penyaki" !in5al Dia%e"es +ADAPenyaki" !in5al Dia%e"es +ADA299:,299:,
Parame"er Urine AER Urine AER Al%min
+;-8min, +m-82< $, rine8crea"
m-8-r
Normal =29 =>9 =>9
Mikroal%minria 29&'?? >9&2?? >9&2??
Makroal%minria @ 299 @>99 @>99
Diae$es #are &''=5&6 Su,,l7S>?S>&
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Ne/ropa"i Dia%e"ikNe/ropa"i Dia%e"ik
Mikroalu1i%uria 7Mikroalu1i%uria 7
? Ko1,likasi %e-ro,a$i 3iae$ik $a0a, 3i%iKo1,likasi %e-ro,a$i 3iae$ik $a0a, 3i%i
? Pe$a%3a ke
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Normal rinary
al%min
secre"ion
Pro"einria
En# S"a-e
Renal Disease
+ESRD,
Dea"$
Microal%minria
50%
(5-10 years)
20%
(20 year)
- 40%
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!am%aran klinis!am%aran klinis
ne/ropa"i #ia%e"ikne/ropa"i #ia%e"ik
.KD +!!K,.KD +!!K,
. Mual/ 1u%$a0Mual/ 1u%$a0
. A%oreksiaA%oreksia
. Fa$i(ueFa$i(ue
La%ora"orimLa%ora"orim
ne/ropa"i #ia%e"ikne/ropa"i #ia%e"ik
.KD +!!K,.KD +!!K,
. Kuli$ keri%(/ (a$alKuli$ keri%(/ (a$al
. E3e1aE3e1a
. Sesak *3is,%ea+Sesak *3is,%ea+
##ureum kreatininureum kreatinin
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TERAPI NE)ROPATI DIABETIKTERAPI NE)ROPATI DIABETIK
. Kon"rol -lkosa #ara$Kon"rol -lkosa #ara$
. Kon"rol $iper"ensiKon"rol $iper"ensi
. S"op rokokS"op rokok
. Die" ren#a$ pro"einDie" ren#a$ pro"ein
. )armakolo-i 4 Penyeka" A.E3 ARB)armakolo-i 4 Penyeka" A.E3 ARB
MIKROALBUMINURIANORMOALBUMINURIA
%ia&etic nephropath'
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!ides c"rrent "nti! #00$
%ia&etic nephropath'("rric"!"m )od"!e ***+7&
!ide 1# of 37
Interventions: glycaemic control
, %ia&etes (ontro! and (omp!icationsria! 8%((9
occ"rrence of microa!&"min"ria
&' 40 occ"rrence of macroa!&"min"ria
&' 50
, :nited in.dom -rospecti6e %ia&etest"d' 8:-%9
o6era!! micro6asc"!arcomp!ication rate &' #5
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$lood-gluose$lood-gluose targetstargets&or people&or people
'ith Diabetes'ith Diabetes
Para1e$erPara1e$er Nor1alNor1al
*1(:3l+*1(:3l+
GoalGoal
*1(:3l+*1(:3l+
Lakuka% Ti%3aka%Lakuka% Ti%3aka%
GDPGDP @ 4''@ 4'' 9&'29 @' or 4>' 1(:3l@' or 4>' 1(:3l
&)PP&)PP @ 4>'@ 4>' ='
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Kon"rol -lkosa #ara$ pa#a NDKon"rol -lkosa #ara$ pa#a ND
. Pe1eria% i%suli% ker
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Kon"rol Hiper"ensi pa#a NDKon"rol Hiper"ensi pa#a ND
. Turu%ka% TD i%$e%si-Turu%ka% TD i%$e%si-. Tar(e$ TD @ 4' : ' 11 H(/Tar(e$ TD @ 4' : ' 11 H(/
. "KD"KD TD @ 4& : 11H(TD @ 4& : 11H(. Die$ re%3a0 ,ro$ei% 3a% (ara1Die$ re%3a0 ,ro$ei% 3a% (ara1. Hi%3ari Alko0olHi%3ari Alko0ol
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O%a" An"i Hiper"ensiO%a" An"i Hiper"ensi
. Pili0a% ,er$a1a 7Pili0a% ,er$a1a 7 A.E in$i%i"orA.E in$i%i"or *#a,$o,ril/*#a,$o,ril/lisi%o,ril/ ra1i,ril+ a$aulisi%o,ril/ ra1i,ril+ a$au ARBARB * valsar$a%/* valsar$a%/
$el1isar$a%/ iresar$a%+$el1isar$a%/ iresar$a%+
Me%uru%ka% la
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An"i $iper"ensiAn"i $iper"ensi
Diu$u0ka% &? 1a#a1 oa$ a%$iDiu$u0ka% &? 1a#a1 oa$ a%$i
0i,er$e%si 70i,er$e%si 7
"a,$o,ril a$au %o,er$e%"a,$o,ril a$au %o,er$e%8alsar$a% a$au iresar$a%8alsar$a% a$au iresar$a%
"a a%$a(o%is *%orvask/ a1lo3i,i%+"a a%$a(o%is *%orvask/ a1lo3i,i%+re%i% a%$a(o%is * Rasile;+re%i% a%$a(o%is * Rasile;+
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N"risi pa#a ne/ropa"i #ia%e"ikN"risi pa#a ne/ropa"i #ia%e"ik
. Ba$asi ,e1eria% #aira% *Ba$asi ,e1eria% #aira% * ''''
##:0ari+##:0ari+. Ba$asi ,ro$ei% *3ie$ re%3a0Ba$asi ,ro$ei% *3ie$ re%3a0
,ro$ei%+,ro$ei%+ seki$ar '/=?'/ (r:k(seki$ar '/=?'/ (r:k(
BB:0ariBB:0ari
. AJasi kaliu1 3a% alu1i% 3ara0AJasi kaliu1 3a% alu1i% 3ara0
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Es"imasi !)REs"imasi !)R. GFR @ =' 1l:1i%GFR @ =' 1l:1i% ko%serva$i-ko%serva$i-
. GFR @ ' 1l:1i%GFR @ ' 1l:1i% ,re3ialisis,re3ialisis
. GFR @ 4 1l:1i%GFR @ 4 1l:1i% 3ialisis/3ialisis/
$ra%s,la%$asi$ra%s,la%$asi
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Neropa"i Dia%e"ikNeropa"i Dia%e"ik
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Neropa"i Dia%e"ikNeropa"i Dia%e"ik
. Diala1iDiala1i 'C ,e%3eri$a 3iae$es'C ,e%3eri$a 3iae$esse$ela0 4 $a0u%se$ela0 4 $a0u%
. Glove and stockingGlove and stocking %euro,a$i%euro,a$i
. Bila$eralBila$eral
. Ge
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Others ClassificationOthers Classification
Neuropati SensorikNeuropati Sensorik
Neuropati OtonomNeuropati Otonom
Neuropati MotorikNeuropati Motorik
Fenomena Reversibel CepatFenomena Reversibel Cepat
Manifestasi yang telah MenetapManifestasi yang telah Menetap
T0o1as PK2 I%$er%a$io%al Te9$ook o- Diae$es Melli$us/ &''>
Jenis Serabut Sara&
(espons terhadap )erapi
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Neropa"i Dia%e"ikNeropa"i Dia%e"ik
Fak$or risikoFak$or risiko
. Ko%$rol (like1i urukKo%$rol (like1i uruk
. La1a 1e%(i3a, Diae$esLa1a 1e%(i3a, Diae$es
. U1urU1ur
. Pe1i%u1 alko0olPe1i%u1 alko0ol
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Neropa"i Dia%e"ikNeropa"i Dia%e"ikSymp"oms4Symp"oms4
. ur%i%(ur%i%(
. ,i%s a%3 %ee3les,i%s a%3 %ee3les
. ,ai%,ai%
No s!1,$o1sNo s!1,$o1s
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Neropa"i Dia%e"ikNeropa"i Dia%e"ik
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.alls.alls
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Neropa"i o"onomNeropa"i o"onom
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A"onomic ner(eA"onomic ner(e
#ama-e#ama-e
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Dia%e"ic perip$eral neropa"$yDia%e"ic perip$eral neropa"$y
screenin- "es"sscreenin- "es"s
Tes" sensa"ionTes" sensa"ion
. Bio"$esiome"erBio"$esiome"er
. Tnin- /orkTnin- /ork
. '9 -r mono/ilamen"'9 -r mono/ilamen"
Ankle re/leesAnkle re/lees
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Assessmen" o/ $i-$ riskAssessmen" o/ $i-$ risk
c$arac"eris"icsc$arac"eris"ics
E)NS i# li / "$ " " " /
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E)NS -i#elines /or "$e "rea"men" o/E)NS -i#elines /or "$e "rea"men" o/
pain/l polyneropa"$ypain/l polyneropa"$y
Dru(s Ji$0 es$alis0e3 e--i#a#! i%#lu3e T"As/ SNRIs/Dru(s Ji$0 es$alis0e3 e--i#a#! i%#lu3e T"As/ SNRIs/
(aa,e%$i%/ ,re(aali%/ s$ro%( o,ioi3s a%3 $ra1a3ol(aa,e%$i%/ ,re(aali%/ s$ro%( o,ioi3s a%3 $ra1a3ol
EFNS7 Euro,ea% Fe3era$io% o- Neurolo(i#al So#ie$ies
Firs$ li%e $0era,!Firs$ li%e $0era,!Pre(aali% *L!ri#aPre(aali% *L!ri#a++: (aa,e%$i% *Neuro%$i%: (aa,e%$i% *Neuro%$i%++T"As:SNRIs or *evi3e%#e level A+T"As:SNRIs or *evi3e%#e level A+
Se#o%3 li%e $0era,!Se#o%3 li%e $0era,! O,ioi3s a%3 la1o$ri(i%e *evi3e%#e level B+O,ioi3s a%3 la1o$ri(i%e *evi3e%#e level B+
La#k o- orLa#k o- orJeak e--i#a#!Jeak e--i#a#!
SSRIs/ #a,sai#i%/ 1e9ile$i%e/ o9#ara;e,i%e a%3SSRIs/ #a,sai#i%/ 1e9ile$i%e/ o9#ara;e,i%e a%3$o,ira1a$e *evi3e%#e level A+$o,ira1a$e *evi3e%#e level A+
LoJ s$re%($0 evi3e%#eLoJ s$re%($0 evi3e%#eor sa-e$! #o%#er%sor sa-e$! #o%#er%s
"ara1a;e,i%e a%3 val,roa$e"ara1a;e,i%e a%3 val,roa$e
Recommen#a"ions4
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Re"inopa"i Dia%e"ikRe"inopa"i Dia%e"ik
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Penyaki" Ma"a Dia%e"ikPenyaki" Ma"a Dia%e"ik
Re$i%o,a$i 3iae$ikRe$i%o,a$i 3iae$ik
Ka$arak 3iae$ikKa$arak 3iae$ik Iri$is rekure%Iri$is rekure%
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Skrinin- ma"a pa#a DMSkrinin- ma"a pa#a DM
. DM $i,e 4DM $i,e 4 ,eriksa o-$al1osko,i :,eriksa o-$al1osko,i :
-u%3usko,i-u%3usko,i se$ela0 $a0u%se$ela0 $a0u%
$er3ia(%osis/ sela%
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8isus8isus
Fu%3usko,i 3irekFu%3usko,i 3irek
Fu%3usko,i i%3irekFu%3usko,i i%3irek
Fo$o Re$i%aFo$o Re$i%a
Teka%a% i%$ra okuler Glauko1a Teka%a% i%$ra okuler Glauko1a
Skrinin- RDSkrinin- RD
) k" Ri ik)ak"or Risiko
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)ak"or Risiko)ak"or Risiko
Re"inopa"i Dia%e"ikRe"inopa"i Dia%e"ik
. Ko%$rol (lukosa 3ara0 urukKo%$rol (lukosa 3ara0 uruk
. Hi,er$e%siHi,er$e%si
. Disli,i3e1iaDisli,i3e1ia
. Ne-ro,a$i 3iae$ikNe-ro,a$i 3iae$ik
. La1a%!a 1e%(i3a, DMLa1a%!a 1e%(i3a, DM
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Klasi/ikasi RDKlasi/ikasi RD
No% ,roli-era$i- re$i%o,a$i 3iae$ikNo% ,roli-era$i- re$i%o,a$i 3iae$ik
1ikroa%euris1a1ikroa%euris1a
eksu3a$eksu3a$
,er3ara0a%,er3ara0a%
Proli-era$i- re$i%o,a$i 3iae$ikProli-era$i- re$i%o,a$i 3iae$ik
,e1e%$uka% ,e1ulu0 3ara0 aru,e1e%$uka% ,e1ulu0 3ara0 aru
,er3ara0a% ,re re$i%al,er3ara0a% ,re re$i%al
s#ar?$issues#ar?$issue
Ri%(a%/
Se3a%(/
Bera$
%ia&etic retinopath'
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!ides c"rrent "nti! #00$
%ia&etic retinopath'("rric"!"m )od"!e ***+7a %ia&etic retinopath'
!ide 11 of 39
Normal retina
)ac"!a
;ptic disc
%ia&etic retinopath'
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!ides c"rrent "nti! #00$
p '("rric"!"m )od"!e ***+7a %ia&etic retinopath'
!ide 1# of 39
Non-proliferative diabetic
retinopathy
/ard e
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%ia&etic retinopath'
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!ides c"rrent "nti! #00$
%ia&etic retinopath'("rric"!"m )od"!e ***+7a %ia&etic retinopath'
!ide 15 of 39
Proliferative retinopathy
New esse!s
-re+retina!
haemorrhae
%ia&etic retinopath'("rric"!"m )od"!e ***+7a %ia&etic retinopath'
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!ides c"rrent "nti! #00$
("rric"!"m )od"!e *** 7a %ia&etic retinopath'!ide 16 of 39
Advanced proliferativeretinopathy
car tiss"e
Pen-o%a"anPen-o%a"an
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Pen-o%a"anPen-o%a"an
Re"inopa"i Dia%e"ikRe"inopa"i Dia%e"ik
Terapi in"ensi/Terapi in"ensi/
Ko%$rol (lukosa 3ara0 aikKo%$rol (lukosa 3ara0 aik ,ro(resi-i$as RD &'?' C,ro(resi-i$as RD &'?' C
*UKPDS+*UKPDS+
Ko%$rol (lukosa 3ara0 o,$i1alKo%$rol (lukosa 3ara0 o,$i1al
> C> C
%ia&etic retinopath'("rric"!"m )od"!e ***+7a %ia&etic retinopath'
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!ides c"rrent "nti! #00$
!ide #3 of 39
reatment
, 2aser therap':
-an+retina! for pro!iferati6e
retinopath'=oca! or .rid for mac"!ar
oedema
Ko%$rol (ula 3ara0 aikKo%$rol (ula 3ara0 aik 1e%uru%ka%1e%uru%ka%
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Se"iap' H%A'. Penrnan
Risiko ke5a#ian
'
Kema"ian aki%a" #ia%e"es
Penyaki" 5an"n- koroner
Penyaki" -in5al #ia%e"es
Penyaki" pem%l$ #ara$
peri/er
UKPDS 35. BMJ 2000; 321: 05!12.
Ko%$rol (ula 3ara0 aikKo%$rol (ula 3ara0 aik 1e%uru%ka%1e%uru%ka%
risiko ko1,likasi 3iae$esrisiko ko1,likasi 3iae$es
&>F
&
,@'2'''4
&'
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KesimplanKesimplan
. Ko1,likasi kro%ikKo1,likasi kro%ik 1ikro 3a% 1akro21ikro 3a% 1akro2
. MikroMikro RD/ND/ Neuro,a$i 3iae$ikRD/ND/ Neuro,a$i 3iae$ik
. MakroMakro
P)K/ s$rok/ PAPP)K/ s$rok/ PAP. Skri%i%( ko1,likasi 3i,erluka% 3a% ilaSkri%i%( ko1,likasi 3i,erluka% 3a% ila3i$e1uka% 0rs 3i$era,i i%$e%si-3i$e1uka% 0rs 3i$era,i i%$e%si-
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Pence-a$anPence-a$anPri1erPri1er7 1e%#e(a0 a(ar $i3ak $i1ul DM7 1e%#e(a0 a(ar $i3ak $i1ul DM
Seku%3erSeku%3er 7 Me%#e(a0 a(ar ,asie% DM7 Me%#e(a0 a(ar ,asie% DM
$i3ak erko1,likasi$i3ak erko1,likasiTersierTersier7Me%#e(a0 a(ar $i3ak $er
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Pe%#e(a0a% ,ri1erPe%#e(a0a% ,ri1erNu$risiNu$risi
A$asi Ke(e1uka%A$asi Ke(e1uka%
Ke(ia$a% $0% / ,eriksa (lukosa $era$ur
TGT:GDPTTGT:GDPT I%$e%sive Li-e s$!le/ oa$&I%$e%sive Li-e s$!le/ oa$&
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Pe%#e(a0a% seku%3erPe%#e(a0a% seku%3er
A$asi 0i,er(like1iaA$asi 0i,er(like1ia
A$asi 0i,er$e%siA$asi 0i,er$e%si
PeraJa$a% kakiPeraJa$a% kaki
Pe%#e(a0a% P)KPe%#e(a0a% P)K
Pro$ei% 3ie$Pro$ei% 3ie$