臺灣透析病人的存活研究

Survival Study of Dialysis Patients in Taiwan

高芷華(Tze-Wah Kao)

指導教授 ： 王榮德 ； 陳保中

共同指導教授 ： 吳寬墩(Kwan-Dun Wu)

國立臺灣大學/公共衛生學院/職業醫學與工業衛生研究所/博士(2012年)

https://doi.org/10.6342/NTU.2012.10778

摘要

前言
透析病人的存活時間一般比健康民眾短，而會影響透析病人存活長短的因子很多，包括年齡的大小、殘餘腎功能的多寡、營養狀態的好壞、發炎的情況、糖尿病的有無、憂鬱的程度、社會支持的多少以及健康相關生活品質的得分高低等。在末期腎病病人，血管鈣化的存在與範圍也是預測此等病人罹患心血管疾病及死亡率的重要指標，但這類研究大部份是針對血液透析的病人，而血管鈣化對腹膜透析病人存活的影響則鮮有研究。至於血液透析病人還是腹膜透析病人的存活較長至今仍然是一個備受爭議的題目；因為要接受何種透析方法經常受到各種因素的影響，故若要靠執行大規模的隨機臨床研究來回答上述的問題有其困難。若對透析病人罹病及死亡的原因有更多的認識，則應能找出各種改善透析病人存活的方法。
隨著人類壽命的延長和慢性疾病的增加，全世界包括臺灣透析病人的數目有逐漸增加的趨勢。特別在臺灣，因有全民健康保險的福利及優良的透析品質，末期腎病的盛行率更是高居不下。延長臺灣透析病人的存活固然重要，但如何改善其健康相關生活品質及減輕國家的疾病相關經濟負擔亦不可忽視，因此能為末期腎病病人提供生活品質良好並合乎成本效益的透析治療是當前極為重要的課題。

研究目的：
(1)估計臺灣透析病人的平均存活時間及找出影響此等病人存活的各種因素。
(2)比較臺灣血液透析及腹膜透析病人以存活做調整後的生活品質得分。
(3)比較臺灣血液透析及腹膜透析病人的每年和終身由全民健康保險負擔的醫療花費。

研究方法：
(1)以在國立臺灣大學醫學院附設醫院(簡稱臺大醫院)接受長期透析的病人為研究對象，用配對、Kaplan Meier和Monte Carlo等方法來比較血液透析及腹膜透析病人的存活率、預期壽命(life expectancy, LE)及預期年壽命損失(expected years of life loss, EYLL)，並用Cox proportional hazard model分析影響此等病人存活的相關因素。
(2)以臺灣長期透析的病人為研究對象，用配對、Kaplan Meier和Monte Carlo等方法來比較血液透析及腹膜透析病人的存活函數和預期壽命，並用Kernel-type smoothing方法來計算臺大醫院和北部十三家醫院透析病人的長期健康相關生活品質得分，再用iSQoL軟體估算出和比較血液透析及腹膜透析病人以預期壽命來調整的終身生活品質得分。
(3)以臺灣長期透析的病人為研究對象，用配對、Kaplan Meier和Monte Carlo等方法來比較血液透析及腹膜透析病人的存活函數和預期壽命，並用全民健康保險的資料，估算臺灣血液透析及腹膜透析病人的每年和終身由全民健康保險負擔的醫療花費。

研究結果：
(1)在臺大醫院接受長期血液透析及腹膜透析的病人，在以年齡、性別和有否糖尿病的情況配對後，得知血液透析及腹膜透析病人兩者的存活率、預期壽命及預期年壽命損失並無統計上的差異，只有高齡和患有糖尿病為影響透析病人存活的重要原因；而在糖尿病病人，接受血液透析治療者其存活比接受腹膜透析治療的病人長。
(2)血液透析病人的physical functioning及role emotional兩項終身生活品質得分比腹膜透析病人高；在透析的前三年，腹膜透析病人在social functioning和mental health兩項有較高的生活品質得分，而在透析三年後，血液透析病人有五項生活品質得分高於腹膜透析者。
(3)在臺灣，腹膜透析治療的每年和終身醫療花費比血液透析者低。

研究結論：
血液透析病人和腹膜透析病人的存活無統計上的差異，但因腹膜透析病人前三年的生活品質較好，且腹膜透析治療的每年和終身醫療花費比血液透析者低，故建議末期腎病患者首選腹膜透析治療。但因糖尿病病人若接受血液透析其存活較好，故建議在血糖控制不良及有嚴重併發症的糖尿病病人優先選擇血液透析治療。

關鍵字

血液透析 ； 腹膜透析 ； 存活 ； 預期壽命 ； 生活品質 ； 醫療花費

並列摘要

Introduction
The survival time of dialysis patients is generally shorter than that of a healthy population. Factors that affect the survival of dialysis patients include age, residual renal function, malnutrition, inflammation, diabetic status, depression, social support, and health-related quality of life (HRQOL). The existence and extent of vascular calcification are also strong predictors of cardiovascular morbidity and mortality in patients with end-stage renal disease (ESRD). However, the latter correlations are mainly shown in hemodialysis (HD) patients and have not been completely investigated in peritoneal dialysis (PD) patients. Whether HD or PD is better in terms of patient survival has long been under debate as all previous comparison results were not yielded from large randomized clinical trials. Knowing the causes of morbidity and mortality in dialysis patients will help in the successful implementation of methods to improve the survival of these patients.
With the extension of human life expectancy and the increase of chronic diseases, both the numbers of dialysis patients in the world and in Taiwan are rising. The prevalence of ESRD in Taiwan has been constantly high due to the full coverage of National Health Insurance and the high quality of dialysis treatment. To extend the survival of dialysis patients in Taiwan without jeopardizing their health-related quality of life or the corresponding national economic burden is consequential. Therefore, the issue of providing ESRD patients with cost-effective dialysis and good HRQOL is currently of utmost importance.

Goals of Study
(1) To estimate the survival time of dialysis patients in Taiwan and to determine the factors that affect their survival
(2) To measure the lifetime quality of life scores of dialysis patients in Taiwan
(3) To measure the yearly and lifetime cost of dialysis patients in Taiwan.

Results of Study
(1) After matching, HD and PD patients had similar life expectancy and expected years of life lost. Survival was better for diabetic patients if they received HD.
(2) The lifetime QOL scores of physical functioning and role emotional were higher in HD than in PD patients. When the dialysis vintage was 3 years or less, PD patients had significantly higher QOL scores than HD patients in social functioning and mental health. After 3 years of dialysis, however, HD patients were found to have significantly higher QOL scores than PD patients in 5 domains.
(3) In Taiwan, the total lifetime costs paid by the NHI for PD patients were significantly lower than those for HD patients.

Conclusions of Study
Survival between HD and PD patients in Taiwan was not different. As PD patients had higher QOL scores of social functioning and mental health in the first 3 years of dialysis, and the total lifetime costs paid by the NHI were lower for PD than for HD patients, we recommend that PD might be promoted as the first-line dialysis therapy followed by HD in later years. Among patients with poorly-controlled diabetes mellitus and multiple comorbidities, however, HD should be considered first.

並列關鍵字

hemodialysis ； peritoneal dialysis ； survival ； life expectancy ； health-related quality of life ； medical cost

參考文獻

22.Tseng, H.M., Lu, J.R., & Tsai, Y.J. (2003). Assessment of health-related quality of life in Taiwan (II): norming and validation of SF-36 Taiwan version. Taiwan Journal of Public Health, 22(6), 512–518.

24.Kao, T.W., Tsai, D.M., Wu, K.D., Shiah, C.J., Hsieh, B.S., & Chen, W.Y. (2003). Impact of religious activity on depression and quality of life of chronic peritoneal dialysis patients in Taiwan. Journal of the Formosan Medical Association, 102(2), 127–130.

References for Introduction:

1.Spinale J, Cohen SD, Khetpal P, Peterson RA, Clougherty B, Puchalski CM, Patel SS, Kimmel PL. Spirituality, social support, and survival in hemodialysis patients. Clin J Am Soc Nephrol 2008;3:1620-1627.

2.Marron B, Remon C, Perez-Fontan M, Quiros P, Ortiz A. Benefits of preserving residual renal function in peritoneal dialysis. Kidney Int Suppl 2008;108:S42-51.