探討合併慢性腎臟病與接受心導管介入術病人預後情形之影響

Explore the combined impact of chronic kidney disease and cardiac catheterization to accept the prognosis of patients

李小萍(Hsiao-Ping Li)

指導教授 ： 李顯章

臺北醫學大學/公共衛生暨營養學院/醫務管理學研究所/碩士(2014年)

摘要

研究目的：
心血管疾病於2013年佔台灣國人十大死因的第二位，而末期腎病變病人更是心臟血管疾病的高危險群，隨著心血管疾病伴隨末期腎病變更嚴重威脅國人健康，心血管疾病合併腎臟病變病人其死亡率相較於未合併腎病變之心血管疾病病人高達10-30倍。心血管疾病併有腎臟疾病之病人相較於未合併腎病變病人其血管差，接受心導管介入產生血管合併症的風險較高。然而目前國內針對腎臟疾病病人接受心導管介入術後產生血管合併症與預後之相關研究付之闕如。因此，本研究欲探討心血管疾病病人有無合併腎臟疾病在接受心導管介入術的預後影響之差異。
研究材料與方法：
本研究使用國家衛生研究院「全民健康保險學術研究資料庫」次級資料檔進行分析，擷取2009-2011年接受心導管介入病人之?漯鬤E處方及治療明細檔（CD）?說B?漲禨|醫療費用清單明細檔（DD）?說B醫療機構基本資料檔（HOSB）進行相關資料串連及分析。主要探討高危險群的心血管病人在接受心導管術後血管合併症的發生、急做冠狀動脈繞道手術（CABG）、死亡率以及醫療利用的情形。
研究結果：
心血管疾病合併腎臟疾病病人相較於沒有合併腎臟病的病人在接受心導管介入術後有較高的死亡率（p<.05）、較高的機率於住院期間發生血管合併症（p<.001)。再者，心血管疾病合併腎臟病變接受透析治療病人相較於尚未接受透析治療的病人在「住院期間發生血管合併症」、「出院後30天內發生血管合併症」（p<.05）與接受心導管術後住院期間「緊急接受冠狀動脈繞道手術」（p<.01）的機率高。
研究結論：
心血管疾病合併腎臟疾病病人是接受心導管介入術後產生不良預後的高危險群，並且在末期腎臟衰竭接受透析的病人更為顯著。接受心導管介入之病人及執行的醫師，在術前評估時應特別關注病人是否合併腎臟疾病或有無接受透析治療，以積極預防及降低其心導管術後各種併發症產生對病人產生的不良影響以及醫療耗用；醫療機構也應針對高危險族群病人進行疾病管理，追蹤治療後之後續發展，以評估病人治療之長期成效，以提升照護品質。

關鍵字

心血管疾病 ； 慢性腎臟疾病 ； 末期腎臟疾病 ； 心導管

並列摘要

Background and Objectives:
Cardiovascular disease(CVD) is the nation's second cause of death in Taiwan, 2013. Cardiovascular risk in patients with end-stage renal disease(ESRD). Patients with CVD and ESRD have higher death rates (about 10-30 times) than people who do not have ESRD. ESRD is common in patients with CVD, a health condition such as CVD with ESRD poses a threat to human health.
Patients with CVD and ESRD have more poorly conditions of blood vessel than people who do not have ESRD resulting in higher risk on vessel complications after cardiac catheterization. However, there is no study focus on patients with CVD and ESRD who receive cardiac catheterization and talk about their complication and influences. Therefore, this study is aim to explore the difference between patients with CVD with/without ESRD after cardiac catheterization.
Method:
In this study, 2695 cases were conducted from National Health Insurance Research Database(CD and DD and HOSB) of the National Health Research Institute in Taiwan during 2009 through 2011. This study is to investigate the complications such as vascular complications, underwent urgent acute coronary artery bypass surgery , mortality and health service utilization of CVD patinets with CKD after acute coronary artery bypass surgery.
Results:
CVD patients with CKD have higher mortality rate (p<.05) and more vascular complications in hospitalization (p<.001) than CVD patients without CKD after receiving cardiac catheterization. Moreover, CVD patients with ESRD who are on dialysis have higher risk on vascular complication in hospitalization (p<.05), higher risk on vascular complication in first 30 days after hospital discharge(p<.05), and underwent urgent acute coronary artery bypass surgery (p<.01) than CVD patients with ESRD who are not on dialysis after cardiac catheterization.
Conclusions:
Patients with CVD and CKD are at-risk populations with more complications after cardiac catheterization, especially for CVD patients with ESRD who are on dialysis. Physicians who perform cardiac catheterization may pay more attention on CVD patients whether combined with CKD/ ESRD on dialysis or not, and then prevent complications and decrease negative effect in the further. Otherwise, in order to promote quality of health care, medical institutions may conduct case management for high-risk populations, such as follow -up survey and assessment of long-term effects.

並列關鍵字

Cardiovascular disease ； Chronic kidney disease ； End-Stage Renal Disease ； Cardiac catheterization

參考文獻

中文部分

王震宇、王登鶴、留以堅、黃碧桃（2011）•慢性腎疾病病人的冠狀動脈疾病的藥物治療及冠狀動脈血管成形手術•內科學誌，22，145-152。

吳珮蓉（2012）•心導管檢查後接受傳統加壓與使用血管內閉合器止血者其穿刺部位合併症發生率與舒適程度之差異•臺灣大學•Available from Airiti AiritiLibrary database•（2012年）

李政翰、洪淑芬、陳儒逸、趙庭與、李貽恆、林立人、蔡良敏（2007）•The Efficacy and Safety of Anglo-Seal Percutaneous Femoral Artery Closure Device after Diagnostic and Therapeutic Cardiac Catheterizations-A Single Center's Experience.

在診斷和治療性心導管後使用Angio-Seal動脈黏合器之有效度及安全性. Acta Cardiologica Sinica, 23(4)，247-253。