| 摘要: | 本計畫的主題在建立不同年齡層完整之治療方式與照護模式。子計畫一的對象在末期腎臟病病人。由醫療經濟學的角度、治療成效和病患生活品質的角度，分別以橫斷式及縱貫式趨勢分析腹膜透析與血液透析之基本健保給付款、併發症發生率、活存時間及平均住院日數來評估整體成本效果，以提出國人何種年齡層、何種狀態適合作何種透析治療，以及設計預防性之復健計畫。慢性腎病(CKD) 的進展，乃由多項因素交互作用形成，研究資料顯示具有代謝症候群項目越多，其腎功能下降速度越快，因此子計畫二是評估慢性腎臟病之新興療法，可否減緩慢性腎臟病之進展，包括大豆蛋白質取代動物性蛋白質，抗氧化物 N-acetyl cysteine，Fibrate 類降三酸甘油脂藥物、Dextromethorphan (Dex) and silymarin、抗氧化之綠茶萃取物，並分析成本效果，以提出是否推廣運用之對象及建議國人。不論是長期透析或新增透析病患，原發病因係糖尿病之透析病患其比例有逐年遞增的趨勢由 31.5%增至 35.5%，且新增透析病患因罹患糖尿病而洗腎之比率逐年增高，由 48.5% 增至 52.7%。糖尿病易引發多種併發症，若糖尿病施以有效的跨領域跨專科治療可減緩腎功能的惡化及延後透析治療，因此子計畫三將以前瞻式的設計來比較跨專業團隊及跨科別治療之成本效果及治療照護差異，提出介入與建議結合模式以提昇照護品質。兒童腎臟病與成人腎臟病病因不同，進入慢性腎病的病因也和成人不同。兒童異於成人，多了生長和發育，包括生理及心理方面。加上對父母之心理壓力，進而造成兒童之心理及行為偏差，因此子計畫四之目的在建立一個理想可行的整體兒童及青少年慢性腎臟病及透析病童的治療照護模式，以延緩病程，並提升照護品質。慢性病照護是以維持功能、防止惡化及預防併發症發生為重點。子計畫五期由過去國民健康局於醫院及衛生局執行之腎臟病防治工作，擴大建立個人、醫院、社區、衛生部門等不同曾級之整合性預防及醫療照護模式與追蹤管理監控網路照護介入運作機制與監測網路及不同層級間分工合作機制。並且照護品質的評價指標，以提昇整體照護品質。
Taiwan has the highest incidence and the second highest prevalence of dialysis in the world. A nation-wide survey at the end of 2001 showed there were 1000,000 Taiwanese suffering from chronic kidney disease (CKD). These patients potentially will develop end stage renal disease (ESRD), and this will cause large burden of public health and National Insurance. Thus, prevention and retardation of the progression of CKD has become a major goal in medical research. The treatment of ESRD includes dialysis and renal transplantation. The dialysis modality includes peritoneal (PD) and hemodialysis (HD). PD is home-based therapy. Compared to HD, PD saves 20% cost. There are few studies comparing the efficacy and quality of life between HD and PD in Taiwan. The purpose of the study is to analyze these issues. The goal of sub-project 3-1 is divided into two parts. The first part is to compare the mortality, biochemical data, rehabilitation status, and cost effectiveness between PD and HD by collecting the national data from the Taiwan Society of Nephrology. A cross-sectional analysis will be performed in the first year and a longitudinal analysis will be done in the second and third year. The second part is to study the quality of life in incident PD or HD patients. Similarly, a cross-sectional analysis will be performed in the first year and a longitudinal analysis will be done in the second and third year. These results will offer the government further evidence to promote PD and provide the more appropriate choice of dialysis modality and rehabilitation plans for patients. The first goal of sub-project 3-2 are to retrospectively evaluate the renal protective effect of renal protective substans and regimens. Hyper-triglyceridemia (TG) was presented in diabetic nephropathy and CKD. Although the protective effects of statins to diabetic nephropathy and CKD were extensively explored, the evidences for the protective effects of fibrates were poor. Besides to its TG lowering effect, fibrates bear many non-lipid, pleotropic effects such as increasing renal blood supply in patients with type 2 DM, and protection to heart and liver。Peroxisome-proliferator-activated receptor- α (PPAR- α), activated by fibrates, was proved to prevent the progression of DM nephropathy in rat by anti-inflammation. The second goals of sub-project 3-2 are to explore the renal protective effect of fibrates and its molecular mechanism in present study. Cells normally have a number of mechanisms to resist against damage induced by free radicals. The major antioxidant defenses consist of antioxidant scavengers. The third goals of sub-project 3-2 are： 1. Use catechin or sialic acid in order to retard the decline of renal function in CKD patients. 2. Use catechin or sialic acid in order to reduce the degree of inflammation in CKD patients. 3. Use catechin or sialic acid in order to reduce the arteriosclerotic factors in CKD patients.。 4. Use catechin or sialic acid in order to improve the responsivesness of erythrocytes in CKD patients. 5. Use catechin or sialic acid in order to improve the defense mechanism in CKD patients. The increased production of reactive oxygen species (ROS) by granulocytes and a reduction in the antioxidant defense can cause oxidation of biological macromolecules, including proteins and lipids. The fourth goals of sub-project 3-2 will perform three types of antioxidants (1) catechins (2) soy multiple amino acids (3) Lentinula edodes on the progression of atherosclerosis and inflammation,in the patients with CKD. A successful treatment with the antioxidants can be directly used in the clinical study. The fifth goals of sub-project 3-2 are to confirm the correlation between oxidative stress and cardiovascular disease in CKD patients and to validate the feasibility and the benefits of anti-oxidant therapy 150 patients will be recruited to participate in a prospective, randomized, double-blind, placebo-control study, which is to test the effects of the anti-oxidant therapy with N-acetylcysteine on kidney function, oxidative stress, chronic inflammation, and clinical parameters of cardiovascular disease in CKD patients. Silibinin ( an active component of silymarin) can reduce TGFβ -induced EMT in Cultured kidney cells and lipopolysaccharide (LPS)-induced cytokine expression in RAW cells. The seventh goals of sub-project 3-2 are clinical trial in non-diabetic stage 3-4 CKD patients with primary of entering dialysis and doubling the serum creatinine level. This project will be accomplished in 3 years with comparing the effects between Dextromethorphan (Dex) and silymarin. These studies can serve as pharmacological basis of the therapeutic strategy for retarding, or even reversing, the progression of renal fibrosis in CKD patients. Soy protein has been shown to slow progression of renal injury. The mechanism and components of soy responsible have not been fully established. The sixth goals of sub-project 3-2 are 1) To determine the efficacy of resistance training in improving protein utilization and muscle mass in patients with chronic renal insufficiency treated with a low-protein diet. 2). To investigate the effect of soy protein on renal function, blood pressure and lipid metabolism in CKD patients. Silibinin ( an active component of silymarin) can reduce TGFβ -induced EMT in Cultured kidney cells and lipopolysaccharide (LPS)-induced cytokine expression in RAW cells. The seventh goals of sub-project 3-2 are clinical trial in non-diabetic stage 3-4 CKD patients with primary of entering dialysis and doubling the serum creatinine level. This project will be accomplished in 3 years with comparing the effects between DM and silymarin. These studies can serve as pharmacological basis of the therapeutic strategy for retarding, or even reversing, the progression of renal fibrosis in CKD patients. Sub-project 3-3 is “Construture and Evalustion the Model of Chronic Kidney Diseases Treatment with Multiple-Professional and Multiple-Disciplinary”. The propose of this study is to explore the outcome of patients who are in the single division or the combined care. We try to manage the associated factors and effects in analysis of database. The results will provide some suggestions that an interred model should be ongoing for CKD patient’s treatment. Essentially, according to various populations’ needs, the health care provider can satisfy the complete of CKD approaches. Through multi-dementinal functional analysis. We can understand completely what the declineing rate of estimated- GFR is in CKD patients, and how the progression of comorbidity is. It will be benefit to slow the time on dialysis and to enhance the best possible of quality of care in CKD patients. In psychological assessment for the children with CKD and ESRD, the main goal of sub-project 3-4 is to explore the special needs and critical factors influencing those children’s social and psychological development. A sequential design study which takes advantage of the strength of both cross-sectional design and longitudinal design will be used. As such, three groups of children, i.e., pre-school-age group, elementary-school-age group, and junior-and-high-school-age group, with CKD and ESRD will be assessed for their psychosocial development, intelligence, learning skills, self-concepts, and interpersonal social skills in a three-year longitudinal study. This proposed study is anticipated to improve the quality of afflicted children’s mental health by providing proper psychological care, counseling and psychotherapy with respect to each individual’s needs. The purposes of sub-project 3-5 are: 1. Build the screen system for early detection of the chronic kidney disease (CKD) patients. 2. Construct CKD shared-care system (from local outpatients clinics, local patients care groups, hospital, community, and Bureau of Health of Taiwan) and build by caring model (from early detection, follow-up to monitor network). 3. Establish the management model of CKD cases 4. Set up the chronic patient's individualized support system. 5. Establish the evaluation index of the quality for caring CKD patients During first period, we will set up the management model of caring CKD cases and test the model During the second period, we will: 1. Enroll more than 20,000 to the shared-care system, and establish the quality control indexes. 2. Try to establish the individual support system and add it to the scoring system of quality control. We hope that the established caring model can be used nationally, and can be useful for reducing the ESRD incidence in Taiwan. |
