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Lampiran 1. Lembar Inform Consent
Persetujuan Setelah Penjelasan
(INFORMED CONSENT)
Berikut ini naskah yang akan dibacakan pada Responden / Ibu Responden Penelitian :
Bapak/Ibu Yth :
Saya Dhanny Candra Adiatma, mahasiswa Fakultas Kedokteran Universitas Diponegoro Semarang, Program Studi Kedokteran Umum. Saya bermaksud melakukan penelitian mengenai “Prevalensi dan Jenis Anemia Pada Pasien Penyakit Ginjal Kronik Yang Menjalani Hemodialisis Reguler”. Penelitian ini dilakukan sebagai tahap akhir dalam penyelesaian studi di Fakultas Kedokteran Universitas Diponogoro, Program Studi Kedokteran Umum. Pada penelitian ini akan dilakukan pengumpulan data berupa data karateristik demografi sampel berupa nama, umur, jenis kelamin, alamat, serta penyakit yang mendasari. Kemudian akan dilakukan pengambilan sampel darah vena sebanyak 5 cc untuk dilakukan pemeriksaan laboratorium yaitu kadar Hb, complete blood count, hitung retikulosit, serum besi, TIBC dan billirubin total. Terdapat ketidaknyamanan saat proses pengambilan darah vena. Analisis laboratorik akan dilakukan di laboratorium RSUP Dr. Kariadi Semarang. Seluruh biaya pada proses penelitian ditanggung oleh peneliti. Peneliti akan menjaga kerahasiaan identitas dan informasi yang diberikan dan hanya digunakan untuk kepentingan penelitian.
Terima kasih atas kerjasama Bapak/Ibu/Sdr.
Peneliti : Dhanny Candra Adiatma.
Nomor kontak peneliti : 085641221493
Setelah mendengar dan memahami penjelasan Penelitian, dengan ini saya menyatakan
SETUJU / TIDAK SETUJU
Untuk ikut sebagai responden / sampel penelitian.
Semarang,
Saksi : Nama Terang :
Nama Terang : Alamat :
Lampiran 2. Data Subjek
No Umur Sex Penyakit Hb MCV MCH MCHC Tromb Rtc Leu TIBC SI Bill total 1 55 W Diabetes Mellitus 8.95 91.4 30.9 33.8 245 2.76 5.98 245 37 0.18 2 76 P Hipertensi 9.85 90.5 30.7 33.9 160 1.41 5.37 287 44 0.39 3 64 P Diabetes Mellitus 10.5 86.6 29.3 33.8 252 3.72 5.57 234 37 0.23 4 48 P Diabetes Mellitus 8.5 75.9 27 33.2 248 3.72 7.62 249 38 0.23 5 54 P Diabetes Mellitus 10.1 84.4 27.9 33 143 3.79 8.99 346 56 0.78 6 44 W Hipertensi 10.3 90.4 29.6 32.8 251 1.56 4.85 222 114 0.31 7 50 P Diabetes Mellitus 9.7 81.9 27.5 33.6 144 1.35 6.47 269 34 0.51 8 43 P Obstruksi Ginjal 8.49 84.7 29.6 34.9 428 2.73 6.46 341 162 0.25 9 52 W Hipertensi 10.2 77.6 26.7 33.1 271.2 2 6.6 273 134 0.39 10 62 W Diabetes Mellitus 11.4 84.9 28 33 309.3 3.1 9.8 326 57 1.1 11 69 W Obstruksi Ginjal 8.7 85.8 29.1 34 406 0.4 3.9 175 8 0.33 12 52 P Obstruksi Ginjal 8.1 73.3 24.4 29 302 4.3 8.1 370 50 0.33 13 71 P Diabetes Mellitus 9.1 88 29 33.7 161.8 1.1 4.4 285 97 0.24 14 57 P Diabetes Mellitus 10.2 67.1 22.5 29.5 222.5 1.2 5.3 361 52 0.28 15 52 P Diabetes Mellitus 8.2 74.4 24.6 30 225.7 0.5 5.9 346 16 1.39 16 61 P Hipertensi 8.8 83 27.6 33.3 134 0.9 4.5 263 152 0.28 17 74 P Hipertensi 9.9 83.7 28.6 34.1 170 1.4 5.7 244 51 0.43 18 49 W Diabetes Mellitus 9.2 82.4 26.9 32 181.1 2.6 4.6 285 67 0.44 19 65 P Diabetes Mellitus 8.7 82.5 28.3 34.2 76 0.4 2.2 338 89 1.18 20 66 P Diabetes Mellitus 10.3 92.6 29.3 31.6 174.4 - 8.6 215 42 0.76 21 25 P Hipertensi 8.9 84.2 29.1 34.6 198 2.71 7.4 236 182 0.37 22 53 P Hipertensi 8.2 89 28 31.3 427 1.7 7.4 210 55 0.87 23 25 W Hipertensi 9.6 78 26 33 218 0.4 5.9 223 53 0.35 24 54 W Hipertensi 10.6 85 28 33.9 216.7 0.9 7 288 68 0.78 25 77 W Hipertensi 8.7 89.2 30.1 33.7 254.4 1.3 9.7 172 44 0.51 26 36 P Obstruksi Ginjal 8.2 83.2 28.8 34.5 209.5 1.33 6.1 235 50 -27 52 W Diabetes Mellitus 8.1 87 29.3 33.7 197.8 1.73 7.9 219 52 0.43 28 57 P Diabetes Mellitus 8.1 82 26.5 32.3 155 3 5.3 209 49 0.23 29 76 P Diabetes Mellitus 9.6 89.5 30.4 34 211.4 0.9 5.5 305 68 0.26 30 51 P Hipertensi 8.8 82 27.7 33.7 139 1.24 5.5 245 49 0.33 31 55 P Hipertensi 13.4 86.6 29.3 33.7 155.9 1.23 7.5 325 74 0.74 32 32 W Hipertensi 12.1 82.6 27.6 33.4 230 1.5 7.8 355 24 0.33 33 52 P Hipertensi 13.1 85 29 34 251 - 6.6 - - -34 55 W Diabetes Mellitus 12.5 82.6 27.7 33.6 208 - 6.7 298 61 -35 54 P Hipertensi 13 87 29 33.4 299.3 - 4.7 - -
