在台灣慢性腎病患者中會增加風險活躍的結核分枝桿菌

Increased risk of Active mycobacterium tuberculosis development in patients with chronic kidney disease in Taiwan.

Sithembiso Tiyandza Dlamini(Sithembiso Tiyandza Dlamini)

指導教授 ： 杜鴻賓

高雄醫學大學/醫學院/醫學研究所碩士班/碩士(2019年)

摘要

背景 - 慢性腎病被定義為腎功能的進行性喪失。腎臟的主要功能是過濾血
液中的廢物和多餘的液體，然後從尿液中排出。當慢性腎病進入晚期階段
時，高水平的液體，電解質和廢物產物可能在體內積聚。在慢性腎病的早
期階段，症狀可能很少。免疫力的變化早在第3階段慢性腎病 就已經開
始，並且隨著腎功能惡化和廢物產生在後期惡化。世界衛生組織(WHO)
報告了活動性肺結核 與慢性腎病 之間的關係。這是一個新興的全球綜合
症。由於肺結核 病流行地區慢性腎病的 患病率高，慢性腎病和結核病流
行可能引起嚴重的公共衛生問題，因此衛生部門必須及早篩查，診斷和治
療這些高風險患者。
研究目的 - 主要目的是評估台灣慢性腎功能衰竭患者結核病風險的增加，
以及探討與慢性腎病患者發生結核病風險相關的風險因素。
研究方法 - 這是一項基於人群的隊列研究，使用來自台灣國民健康保險數
據庫的數據。在該隊列研究中，從1997年1月1日到2010年12月31日，對
20,985例腎病患者和20,985例無腎病患者進行隨訪。使用廣義線性模型
(PROC GENMOD) 計數型因變量的 發生率比率(IRR)回歸。通過使用比例
風險回歸模型調整住宅區和合併症後，計算調整風險比(HR) 和95％置信
區間(CI)及其P值。本研究中的所有統計學檢驗均為0.05的顯著性水平 所
有統計分析均使用SAS (9.4) 。
結果 - 在總共20985名腎病患者中，120名患者在隨訪3年後出現結核
病。 （IRR 3.96 95％CI：2.71-5.80）p ≤0.001。與非腎病患者相比，
腎病患者的結核病早期發病風險是其三倍。終末期腎病患者的風險更高
（IRR 3.67 95％CI 2.27-5.9），酒精濫用（IRR 1.30 95％CI 0.32-
5.38），慢性肺病（IRR 1.69 95％CI 1.13）發現任何惡性腫瘤（IRR
1.86 95％CI 1.16-2.97）會增加腎病患者發生結核病的風險。然而，脂質
9
紊亂（IRR 0.50 95％CI 0.34-0.73）和維生素D（IRR 0.66 95％CI 0.43-
1.01）使用者顯示對結核病具有保護作用。
結論 - 研究結果表明，患有腎病的患者更容易發生結核病的早期發展，並
且觀察到患有終末期腎病的患者風險更高，應該定期和仔細篩查以及早期
發現結核感染。與女性相比，男性患結核病的風險更高。結果還表明維生
素D在預防腎病患者結核病中的治療作用。維生素D補充劑可能對針對結
核感染的先天免疫應答具有有益作用，對於患有慢性腎病的患者的治療可
能是 非常重要的

關鍵字

腎 ； 透析 ； 尿毒症

並列摘要

Background
Chronic kidney disease is defined as the progressing loss of kidney
function. The main function of the kidneys is to filter waste and excess
fluids from the blood, which are then excreted in the urine. When chronic
kidney disease reaches an advanced stage, high levels of fluid,
electrolytes and wastes products may accumulate in the body. During the
early stages of chronic kidney disease, there may be few symptoms.
Change in immunity begins as early as stage 3 CKD and worsen in the
later stages as kidney function detoriates and waste products. World
Health Organization (WHO), reported the association between active
tuberculosis (TB) and chronic kidney disease (CKD). This has since been
an emerging global syndemic. Due to the high prevalence of CKD
in TB endemic areas, CKD and TB epidemics could have significant
public health concern, therefore it important for the health sector to for
early screening, diagnosis and treatment for this high risk patients,
Aims of the study
The main objective was to assess the increasing risk of tuberculosis
among patients with chronic renal failure in Taiwan, also to explore the
risk factors associated with risk of developing tuberculosis in patients with
Chronic kidney disease.
Materials and Methods
This is a population-based-cohort study that used data taken from the
Taiwan National Health insurance database. In this cohort study, 20,985
patients with renal disease, and 20,985 patients without renal disease
were followed from January 1, 1997 to December 31, 2010. Incidence rate
ratio (IRR) was calculated by using generalized linear model (PROC
GENMOD) to perform Poisson regression. Adjusted hazard ratio (HR)
7
with 95% confidence intervals (CI) and their p values were calculated after
adjustment for residential region and comorbidities by using a cox
proportional-hazards regression model. All statistical tests in this study
were significant at a level of 0.05.all the statistical analysis was performed
using SAS V. 9.4.
Results
In the total 20985 kidney patients 120 patients developed tuberculosis
after 3 years of follow up. (IRR 3.96 95% CI: 2.71-5.80) p=<0.001. Kidney
disease patients were three times at risk of early development of
tuberculosis compared with the non-kidney disease patients. The risk was
more increased in the patients with end stage renal disease, (IRR 3.67
95%CI 2.27-5.9), Also, alcohol abuse (IRR 1.30 95% CI 0.32-5.38),
chronic pulmonary disease (IRR 1.69 95%CI 1.13-2.55) and any
malignancy,( IRR 1.86 95% CI 1.16-2.97) were found to increase the risk
of developing tuberculosis in patients with kidney disease. However, lipid
disorders (IRR 0.50 95% CI 0.34-0.73) and Vitamin D (IRR 0.66 95% CI
0.43-1.01) users showed to have a protective effect against tuberculosis
Conclusion
The study findings suggest that patients with renal disease were more at
risk of early development of tuberculosis and also it was observed that
patients with end stage renal disease are more at risk and should be
screened routinely and carefully for early detection of TB infection. Males
were found to be at higher risk of developing tuberculosis when compared
with females. The results also suggest a therapeutic role for vitamin D in
prevention of tuberculosis in renal disease patients. Vitamin D
supplementation may have a beneficial effect on the innate immune
response against TB infection may be very crucial in management of
patient with chronic renal disease

並列關鍵字

kidney ； dialysis ； ESRD, ； uremic

參考文獻

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