血液透析病人周邊動脈阻塞疾病臨床因子探討及治療

Evaluation of Peripheral Artery Occlusive Disease in Hemodialysis：Clinical Factors and Therapy

陳思嘉(Szu-Chia Chen)

指導教授 ： 張哲銘

共同指導教授 ： 郭柏麟(Po-Lin Kuo)

高雄醫學大學/醫學院/臨床醫學研究所/博士(2017年)

摘要

台灣末期腎臟病患(End stage renal disease, ESRD)之發生率約每百萬人口384人，意即每壹百萬人口就有384位新發生必須接受腎臟替代治療的個案；盛行率約每百萬人口2288人，指的是每壹百萬人口中有2288人接受腎臟替代治療，無論是發生率或盛行率在美國腎臟資料登錄系統之排名皆高居全球第一位，高居世界排名第一位(USRDS,2010)。顯示腎臟病已是國人最嚴重的疾病之一。
周邊動脈阻塞性疾病(peripheral artery occlusive disease, PAOD)是主動脈弓以下的動脈產生粥狀硬化，隨著病程進展，動脈管徑越來越窄，影響血液灌流，造成其下肢的組織缺血症狀。研究發現一般族群罹患周邊動脈阻塞疾病的盛行率為4.3%，研究指出血液透析病人同時合併有周邊動脈阻塞性疾病者高達23%，由上述研究可見末期腎臟疾病病人周邊動脈阻塞性疾病盛行率較一般族群高出許多。研究也指出末期腎臟疾病病人併有周邊動脈阻塞性疾病的住院率及死亡率也比一般族群高。因此，對於末期腎臟病患來說，早期知道死亡的風險，對於醫療照護決策是否要對末期腎臟病患的周邊動脈阻塞性疾病進行更積極性的治療評估有著極大的幫助。
另外，自主神經功能失調(autonomic dysfunction)是尿毒性神經病變(uremic neuropathy)的其中之一，而且大部分在末期腎衰竭的患者身上發現。臨床上自主神經病變主要在於經由壓力接受器對血壓控制機能異常所致。許多慢性腎衰竭的患者有左心室肥大、缺血性心臟病、高血壓及貧血，都與自主神經功能有關。自主神經系統受到影響的情形會發生在慢性腎衰竭的病患身上。近二十年來有證據顯示在自主神經系統與心臟血管死亡率，包括心因性猝死，有很重要的關聯性。心率變異性被證實為一個強而有力且獨立的在心肌梗塞後死亡率的預測方法，並在1980年代末期漸漸受到重視。之前的研究指出心率變異性是一個能充分評估心臟自主神經調節功能的有效工具。心率變異性分析(Heart Rate Variability, HRV)對評估心臟自主神經調節功能已被證實為非侵入性且有效的工具。慢性腎衰竭患者的自主神經病變可由心率變異性降低來評估。
慢性腎臟病病人相較於一般族群有較高的心血管疾病罹病率及死亡率。慢性腎臟病病人所特有的廣泛性血管鈣化被認為是造成其心臟血管疾病的主要原因。血管鈣化可見於血管內膜和中膜，其機制尚未完全被了解。臨床上，評估是否出現血管鈣化及嚴重度，以做為預防、警示或治療參考的方法，目前大概有幾種包括腹部側面X光攝影，胸部X光主動脈弓鈣化、頸動脈壁厚度測量、心臟超音波檢測主動脈瓣之鈣化、動脈波傳導速度檢測、立體導航快速電腦斷層掃描評估血管鈣化指數，其指數的高低也用來預估心臟冠狀動脈發生病變的機率。
因此，博士論文研究是以血液透析病人為研究族群，想要探討(一)、血液透析病人周邊動脈阻塞疾病與自主神經功能失調的相關性，並看心率變異性對血液透析病人預後的相關性；(二)、血液透析病人由胸部X光測得主動脈弓鈣化程度，用主動脈弓鈣化程度與動脈鈣化作一連結，並看主動脈弓鈣化程度對血液透析病人預後的相關性；(三)、踝臂血壓比(ankle-brachial index, ABI)的下降或許可以當作不好的周邊動脈阻塞疾病結果的一個重要指標。此研究是看血液透析病人6年的每年ABI下降相關性及研究ABI下降的相關因子；(四)、最後探討在血液透析病人使用遠紅外線是否可改善周邊血管疾病。

關鍵字

血液透析 ； 周邊動脈阻塞疾病 ； 心率變異性 ； 主動脈弓鈣化 ； 遠紅外線

並列摘要

In Taiwan, the end-stage renal disease (ESRD) incidence is about 384 people per million population, which means that every million people there are 384 new cases of renal replacement therapy occur. The ESRD prevalence is about every hundred million population of 2288 people, which means that each one million population of 2288 people receiving renal replacement therapy. Regardless of incidence or prevalence in the United States kidney data entry system ranking, whcih are highest in the world, ranking first in the world (USRDS, 2010). Kidney disease is one of the most serious diseases in Taiwan.
Peripheral arterial occlusive disease (PAOD) is atherosclerosis of the arteries below the aortic arch. As the course of the disease progresses, arterial diameter becomes narrower, affecting blood perfusion, resulting in ischemic symptoms of lower extremities. The studies found that the prevalence of PAOD is 4.3% in general population, and up to 23% in ESRD population. Therefore, the prevalence of PAOD is higher in ESRD than in general population. The studies also noted that higher morbidity and mortality rates in ESRD population combined with PAOD. Thus, the early decision in determining whether medical decision-making is more aggressive in assessing PAOD in patients with ESRD.
In addition, autonomic dysfunction is one of uremic neuropathy, and most in patients with ESRD. Clinical autonomic neuropathy is mainly due to pressure receptors with abnormal blood pressure control function. Many ESRD patients have left ventricular hypertrophy, ischemic heart disease, hypertension and anemia, which are related to autonomic nervous function. The autonomic nervous system is affected by the situation in patients withESRD. Nearly two decades have evidence that there is a very important association between the autonomic nervous system and cardiovascular mortality. Heart rate variability (HRV) has been shown to be a powerful and independent predictor of post-myocardial mortality in the late 1980s. Previous studies have shown that HRV is an effective tool for adequately assessing cardiac autonomic regulation. HRV has been shown to be a noninvasive and effective tool for assessing cardiac autonomic nervous function. Autonomic neuropathy in patients with chronic renal failure can be assessed by a reduction in HRV.
Patients with ESRD have a higher incidence of cardiovascular disease morbidity and mortality than the general population. Extensive vascular calcification, which is unique to patients with ESRD, is thought to be the leading cause of cardiovascular disease. Vascular calcification can be seen in the vascular intima and media, the mechanism has not yet been fully understood. Currently, there are several methods, including abdominal X-ray radiography, thoracic X-ray aortic arch calcification, carotid wall thickness measurement, and cardiac ultrasonography, sonic wave detection of calcification of the aortic valve, arterial wave velocity measurement, rapid three-dimensional navigation CT scan to assess vascular calcification index. The level of the index is also used to predict the probability of coronary artery disease.
Therefore, based on the study group of hemodialysis patients, we want to explore (a), the association between PAOD and HRV, related to autonomic dysfunction, and HRV on clinical outcomes in hemodialysis patients; (B) the association between aortic arch calcification, from thoracic X-ray measurement, with arterial stiffness, and to see the prognosis of aortic arch calcification on clinical outcomes in hemodialysis patients; (c), The decline in ankle-brachial index (ABI) may be an important indicator of PAOD outcome. This study is to look at 6 years of hemodialysis patients ABI decline in the relevance and study of ABI decline related factors; (d), and finally explore the effect of far infrared ray therapy on PAOD in hemodialysis patients.

並列關鍵字

hemodialysis ； heart rate variability ； aortic arch calcification ； far infrared ray therapy

參考文獻

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