末期腎臟病預後存活及癌症發生相關因子之探討

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題名:	末期腎臟病預後存活及癌症發生相關因子之探討 Factors Associated with Survival and Cancer Risk in the Prognosis for Patients with End-Stage Renal Disease
作者:	張祐剛;Chang, Yu-Kang
貢獻者:	公共衛生學系博士班
關鍵詞:	癌症;慢性腎臟病;末期腎臟病;透析;死亡率;回溯性世代研究;存活分析;趨勢;Cancer;chronic kidney disease;end-stage renal disease;dialysis;mortality;retrospective cohort study;survival analysis;trend
日期:	2012-06-26
上傳時間:	2012-08-31 16:28:11 (UTC+8)
出版者:	中國醫藥大學
摘要:	世界各國的慢性腎臟病人口持續增加，使得需接受腹膜透析、血液透析及腎臟移植之末期腎臟病病患(end-stage renal disease，ESRD)的人數也與日俱增。根據美國腎臟登錄系統組織(United States Renal Data System，USRDS)的2011年報資料顯示，台灣之ESRD盛行率自2005年起至今維持世界第一高，而ESRD發生率則從2008年起次於墨西哥與美國，排名世界第三位。雖然末期腎臟病病患人口只佔台灣全體保險人口約0.3%，但每年卻耗用了超過8%之全民健康保險費用，對台灣社會已造成沉重的負擔。本篇博士論文利用全民健康保險資料庫，進行三項研究：1.評估血液透析在單位給付固定下之死亡趨勢。2.比較ESRD病患接受血液或腹膜透析的預後。3.探討透析病患的癌症發生率。首先，第一個研究主要利用8個不同年進入透析的病患世代，評估各追蹤四年間的死亡危害比(hazard ratio，HR)和醫療費用的趨勢。結果發現，血液透析病患實際單位給付金額從1997年的4,100元新台幣，到2005年降到3,473元新台幣，但是平均急診費用卻從每人每年12,930 (431美元)增加到22,110 (737美元)，而住院費用也從每人每年270,210 (9,007美元)增加到398,400 (13,280美元) 。然而，死亡危害比則逐年降低，和1998年進入透析的病患相比，死亡危害比從1999年進入透析病患世代的0.97 (95% CI = 0.91~1.02)降到2005年進入透析病患世代的0.86 (95% CI = 0.82~0.91)。研究顯示這樣的政策，雖然，沒使病患的死亡危害程度增加，反而造成急診及住院的負擔更加沉重。第二個研究，則是利用1997年到2006年全民健保資料庫，以傾向因子分數(propensity score)配對後各選取4,721名腹膜與血液透析病患，進行1997到2001及2002到2006進入透析的兩時段群病患，比較腹膜和血液透析在兩時段的死亡率及死亡危害比。結果發現，整體而言腹膜透析病患和血液透析病患的死亡率相似，分別為每100人年12.0及11.7。而腹膜透析相對於血液透析的死亡危害比為1.02 (95% CI = 0.96-1.08)。在第一個5年期間 (1997到2001)，腹膜透析死亡危害較高，相對於血液透析的死亡危害比為1.33 (95% CI =1.21~1.46)，但是在2002到2006年期間兩者則沒有顯著差異時。另外，研究也發現年輕的腹膜透析病患存活率比年輕的血液透析病患佳，尤其是小於40歲的病患。在這個亞洲的病患研究中，經過傾向因子分數配對的腹膜及血液透析病患在存活率方面並無顯著差異。所以，病患選擇透析的方式還是要回歸到病患本身的狀態及特性。未來應該在探討腹膜或血液透析的預後差異，應該進一步利用隨機分派的方法，才能提供更好的資訊給醫師及病患。最後一個研究，是利用回溯性的世代研究法，比較透析病患與年齡及性別配對的一般民眾罹癌危害性的差異。研究結果顯示，透析病患的癌症發生率顯著高於一般民眾，尤其是腎臟癌、膀胱癌及移行細胞癌的罹癌危害比分別是一般民眾的12~14倍。最後，研究也發現泌尿道感染、服用中草藥或乙醯胺酚(acetaminophen)都是透析病患罹癌的危險因子之一，但服用阿斯匹靈(aspirin)卻和降低罹癌的危害有關。而本篇論文的研究結果將可以作為末期腎臟病照護的改善及透析病患癌症預防等相關政策的參考依據。 The incidence and prevalence of chronic kidney disease (CKD) are on the rise worldwide. Patients with end-stage renal disease (ESRD) treated with hemodialysis (HD), peritoneal dialysis (PD) and kidney transplantation is also rising greatly. According to the US Renal Data System (USRDS) Annual Report in 2011, the prevalence of ESRD patients in Taiwan has become the highest in the world since 2002. The incidence in Taiwan was only lower than that in Mexico city and the U.S. ESRD patients accounted for only 0.3% of the total population in Taiwan in 2010; however, more than 8% of the annual national health expenditure was used to care these patients. Health care expenditures for ESRD patients have become a huge burden to the society. This dissertation studied this disease with three subprojects: 1. Evaluation on mortality for patients with hemodialysis treatment associated with fixed dialysis reimbursement. 2. Comparison study on the mortality between patients with peritoneal dialysis treatment and patients with hemodialysis treatment. 3. The risk of subsequent cancer for patients with dialysis. The first study used the population-based insurance claims data of Taiwan to evaluate the trends of cost and mortality risk for HD patients cared among 8 annual subcohorts with 4-year follow-up each. The results showed that the real payment for each HD service decreased from NTD $4,100 in 1997 to $3,473 in 2005. However, the corresponding mean cost per patient increased annually from NTD 12,930 (USD 431) to NTD 22,110 (USD 737) for emergency visit and from NTD 270,210 (USD 9,007) to NTD 398,400 (USD 13,280) for hospitalization. Compared with the 1998 subcohort, the hazard ratio (HR) of mortality in the 4-year follow-up decreased chronologically from 0.97 (95% confidence interval (CI) 0.91-1.02) for 1999 subcohort to 0.86 (95% CI 0.82-0.91) for 2005 subcohort. This study suggests that the risk of mortality for HD patients decreased annually. The increased uses of emergency services and increased hospitalization may reflect the increased attention to the care of disease. The second study also used the population-based insurance claims data of Taiwan from 1997 to 2006 to identify 4,721 patients treated with PD and randomly selected 4,721 patients treated with HD, frequency matched with the propensity scores. In the follow-up analyses, we measured mortalities and hazard ratios of death associated with comorbidities for 2 periods, 5 years in each period (1997-2001 and 2002-2006). In the 10-year period from 1997 to 2006, the overall mortality rates were similar for patients treated with PD and for patients treated with HD (12.0 vs. 11.7 per 100 person-years, respectively), with a PD-to-HD hazard ratio of 1.02 (95% CI, 0.96-1.08). In the first 5-year period (1997-2001), the mortality risk was higher for patient with PD (HR = 1.33, 95% CI 1.21-1.46). But the difference disappeared in the 2002-2006 cohort (HR = 0.99, 95% CI 0.87-1.14). Younger patients with PD treatment had better survival than those with HD treatment; this was especially true for patients younger than 40 years of age. In this Asian population, no significant survival difference was noted between propensity score-matched PD and HD patients. The selection of a dialysis modality must be tailored to the individual patient. Finally, the third study used the retrospective cohort study design and compared the cancer risk between dialysis patients and general population frequency matched with sex and age. The results showed that the incidence of cancer was significantly higher in dialysis patients than in the general population. Dialysis patients had extremely high risk of kidney cancer, bladder cancer and transitional cell carcinomas, approximately 12 to 14 folds greater than that for the general population. Furthermore, we found that patients with urinary tract infection, and taking herb and acetaminophen were at an elevated cancer risk. This study also found that aspirin was associated with the declined cancer risk. Our findings can be adapted to the care for patients with dialysis to reduce the risk of cancer.
顯示於類別:	[公共衛生學系暨碩博班] 博碩士論文

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