影響慢性腎病3-5期患者預後之臨床相關因素研究

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题名:	影響慢性腎病3-5期患者預後之臨床相關因素研究 Clinical factors associated with prognostic outcome for patients in chronic kidney disease stage 3-5 intervention program
作者:	楊凱玲;Kai-Ling Yang
贡献者:	公共衛生學系碩士班
关键词:	慢性腎臟病;第3 期至第5期;臨床預後相關因素;Chronic kidney disease,;Stages 3 to 5,;Clinical prognostic factors
日期:	2013-07-31
上传时间:	2013-10-02 09:50:42 (UTC+8)
出版者:	中國醫藥大學
摘要:	台灣慢性腎病患者需長期接受透析患者的盛行率高居世界第一，近年來因積極推動慢性腎病防治以及民眾提昇對慢性腎病的認知，透析患者的發生率已逐年下降。歐美的文獻報告顯示，大部分的慢性腎病患者在進入透析前死亡，死亡原因以心血管疾病和感染症為主。但台灣的慢性腎病患者，大多數進入透析。然而目前的腎病防治計劃中接受介入患者的長期預後狀況仍少有文獻報告。本研究的目的為1.分析目前腎病防治計劃中3-5期的預後(進入透析或死亡)。2.分析慢性腎病患者收案時的症狀、共病症、生活習慣、用藥習慣、運動習慣與預後的相關性，鑑別疾病惡化至透析或死亡的危險因子，期望未來能由危險因子中，評估積極治療的目標，進一步改善患者預後。從2003年1月到2012年8月間，慢性腎病防治計劃共收案4832位慢性腎病3-5期患者，患者的平均年齡為69.1±13.6歲，男女比為1.35比1，慢性腎病分期3a患者有720位，3b 患者有818位，第4期患者996位，第5期患者2298位。按慢性腎病分期死亡率分別:3a為1.9%， 3b為5.5%，第4期為11.2%，第5期為8.1%。患者於追蹤期間，進入透析治療的發生率分別:3a為40.6%，3b為43.4%，第4期為49.4%，第5期為65.8%。以3a慢性腎病患者為例，進入透析的患者為死亡的20倍，第5期為8倍。因年齡、慢性腎病分期(3a、3b、4、5)及糖尿病為患者死亡的主要危險因子，因此，在分析患者死亡風險時，做為校正因子。校正後的腎病3a、3b、第4期患者的進入透析風險沒有顯著差異，第5期患者進入透析風險明顯高於3-4期患者。探討患者進入透析風險時，以年齡、腎病分期(3-4期或5期)、糖尿病、高血壓及慢性腎絲球腎炎做為校正因子。患者在收案時合併有頭暈、眼花之現象或貧血症狀，有較高的死亡風險。患者出現胃口不好、頭暈、眼花之現象或貧血症狀，超音波檢查異常時進入透析的風險較高。在共病症之中，合併鬱血性心臟病、腦血管病變、慢性肝病/肝硬化及惡性腫瘤的患者死亡風險明顯較高，而缺血性心臟病及腦血管病變則是患者進入透析的危險因子，合併高血脂症患者進入透析治療的風險反而較低。在用藥習慣中，使用偏方的患者有較高的死亡風險，而使用處方用藥，健康食品患者進入透析風險較低。有抽菸，嚼檳榔習慣的患者進入透析的風險較高。患者每週運動次數越多，死亡風險明顯下降，能從事越長的運動時間的患者，其進入透析的風險也下降。在各種運動方式中，散步能明顯降低死亡風險，而長期臥床患者死亡風險較高，而散步也能有效降低透析風險。在慢性腎病患者常用藥物之中，使用紅血球生成素，鈣離子阻斷劑，鐵劑能降低死亡風險，使用血管收縮素轉化脢抑制劑或血管收縮素II抑制劑，鐵劑能降低透析風險。較多的衛教次數也能降低死亡和透析風險。綜合以上危險因子分析中，鬱血性心衰竭(p = 0.001)，腦血管病變 (p = 0.015)，慢性肝疾病卅肝硬化 (p <0.001)，惡性腫瘤(p <0.001)，貧血(p <0.001)，使用偏方(p=0.007)，長期臥床(p = 0.012)為患者死亡的危險因子，而較多的每週運動次數(p =0.043)，使用紅血球生成素( p = 0.043)，服用鈣離子阻斷劑(p <0.001)，鐵劑(p <0.001)，越多的衛教次數(p <0.001)能降低死亡風險。能降低慢性腎病患者透析風險的因素為，使用處方用藥(p = 0.002)，健康食品(p = 0.05)，較長的運動時間(p = 0.05)，使用血管收縮素轉化脢抑制劑或血管收縮素II抑制劑(p <0.001)，鐵劑(p <0.001)，以及較多的衛教次數(p <0.001)。台灣大部分慢性腎臟患者進入透析治療而非在疾病進程中死亡，慢性腎病診斷時的臨床症狀，共病症，生活習慣和藥物治療都與患者預後有關。本研究的發現，可能運用在臨床治療上，在患者診斷慢性腎病時，區分出可能死亡或進入透析的高危險群，給予積極治療，以改善慢性腎病患者預後。 The prevalence of dialysis among patients with chronic kidney disease (CKD) has been the highest in Taiwan worldwide. The Taiwan CKD prevention program has been implemented since 2003 and the incidence of dialysis has declined since 2008. Most of CKD patients in the US die during the progression of CKD, while most of Taiwan CKD patients received dialysis prior to death. However, very limited studies are available on the long-term outcome of CKD patients who are in the Taiwan CKD program. The aims of the study are to 1. Evaluate the prognosis of CKD 5 stage for patients who were in Taiwan CKD program at China Medical University Hospital. 2. Identify possible prognostic factors associating with the outcome including comorbidity, medication habits, life styles. A total of 4831 CKD stage 3-5 patients were recruited in the CKD program at China Medical University Hospital. The average age of patients was 69.1±13.6 years old and male to female ratio was 1.35 to the study patients consisted of 720 in stage 3a, 818 in stage 3b, 996 in stage 4 and 2298 in stage 5. The mortality rate was 1.9% for CKD stage 3a patients, 5.5% for 3b, 11.2% for stage 4 and 8.1% for stage 5. The incidence rates of renal replacement therapy (RRT) were 40.6% for patients at stage 3a CKD (20-fold of the mortality rate in CKD stage 3a patients), 43.4% for those at stage 3b, 49.4% for those at stage 4 and 65.8% for those at stage 5 (8-fold of the mortality rate in CKD stage 5 patients). The major factors associated with mortality or RRT were age, diabetes and CKD stage. We found no differences in the RRT risk among CKD patients at stage 3a, 3b and 4 in this cohort. Thus the CKD stage was thus stratified as 3-4 or 5 in the analysis for identifying RRT risk. Hypertension, chronic glomerulonephritis were important prognostic factors for RRT and were considered as adjustment factors in the analysis of RRT risks. Among baseline that patients reported to the CKD program, dizziness was linked to a higher mortality risk. Poor appetite, dizziness or anemia and abnormal findings in renal echo were linked to an increased RRT risk. Congestive heart failure, stroke, liver disease/cirrhosis and cancer were linked to an increased mortality risk. Ischemic heart and stroke were linked to higher RRT risk. A history of using folk prescriptions in CKD patients was also associated with increased mortality risk. A history of using prescribed medications and healthy foods were linked to decreased RRT risks. Patients who smoked and used betelnut were more likely at higher risk for RRT. Patients who exercised more frequent had a decreased mortality risk. The RRT risk was lowered for those had long duration of exercise. Taking stroll was the style of exercise associating with decreased mortality and RRT risks. Among the most commonly prescribed medications for CKD patients, erythropoietin (EPO), calcium-channel blocker (CCB, anti-hypertensive) and iron replacement were linked to lower mortality risks. The use of angiotensin-converting-enzyme inhibitor (ACEI), Angiotensin II Receptor Blockers (ARB) or iron was linked to lower RRT risks. CKD patients who had more CKD education sessions are associated with decreased mortality and RRT risk. After controlling for patient confounding factors, We found that congestive heart failure, stroke, liver disease/cirrhosis, cancer, anemia, a history of using folk prescriptions and bed-ridden were associated with increased mortality risks. An increased exercise frequency, EPO, iron therapy or CCB and CKD education sessions were linked to decreased mortality risks. A history of using prescribed medications, taking healthy foods, performing longer exercise duration, using ACEI, ARB or iron replacement or receiving CKD education was independently linked to a decreased RRT risk. In conclusion, CKD patients in Taiwan are more likely to receive RRT in the course of disease progression than to progress to death. Some baseline symptoms, such as dizziness, anemia and appetite, etc. shown at the diagnosis of CKD are associated with the CKD outcomes. Comorbidity, life style and CKD medications are also associated with the outcomes of CKD. More studies are needed to evaluated specific treatments that can further improve the outcomes for CKD patients with certain symptoms.
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