空氣汙染及開放空間和慢性腎臟疾病之相關研究

Associations between Air Pollution, Open Space and Chronic Kidney Disease

楊雅茹(Ya-Ru Yang)

指導教授 ： 詹長權

國立臺灣大學/公共衛生學院/職業醫學與工業衛生研究所/碩士(2015年)

https://doi.org/10.6342/NTU.2015.01164

摘要

環境流行病學研究已證實空氣污染物，尤其是大氣微粒物質，與心血管疾病之罹病率與死亡率相關，開放空間也與肥胖、過重與壽命等健康效應相關，但針對空氣污染與開放空間對於腎功能的影響之研究仍有限，因此本研究旨在探討空氣汙染長期暴露及距離開放空間之遠近對於慢性腎臟疾病之關係。本研究研究對象居住於新北市人口密度大於兩萬人/平方公里的行政區，包含永和區、蘆洲區、板橋區、三重區、中和區與新莊區等六個行政區，利用研究對象之地址進行地理編碼，進一步套入2009年建立之土地利用回歸模式估計其長期空氣污染物暴露濃度，並利用ArcGIS 10.1計算研究對象距離住家最近開放空間之距離，本研究定義開放空間為學校以及休憩空間，研究對象參與新北市2007至2009年整合式健康篩檢資料，取得了研究對象之個人資料、血液與尿液等健康檢查資料，利用血液肌酸酐、年齡、性別與Modification of Diet in Renal Disease (MDRD) Study equation、Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation、MDRD-Japan、CKD-EPI-Japan、IDMS-MDRD-Taiwan及CKD-EPI-Taiwan等六個定義估計出研究對象的腎絲球過濾率，並以小於60 ml/min/1.73m2定義為罹患慢性腎臟病，此外亦以ICD-9 CM code (250.4*, 274.1*, 283.11, 403.*1, 404.*2, 404.*3, 440.1, 442.1, 447.3, 572.4, 580-588, 642.1*, 646.2*)疾病診斷碼定義慢性腎臟病，本研究之健康效應也將發炎指標數量、尿蛋白與早期慢性腎臟病等納入分析。統計模式採用一般線性模式與邏輯斯回歸模式，並校正年齡、性別、空腹血糖、抽菸狀態、高血壓及過重。研究共納入30-97歲21,656位成人，女性比男性約為2：1，模式結果發現在一年長期空氣污染暴露方面，PM10、PMCoarse及NOx與估計的腎絲球過濾率下降及罹患慢性腎臟病之危險勝算比顯著相關，以CKD-EPI-Taiwan公式為例，每上升10μg/m3之PM10，腎絲球過濾率約下降1.0 (95% CI：0.6-1.3) ml/min/1.73m2，罹患慢性腎臟病之危險勝算比(Odds Ratio)約增為1.1 (95% CI：1.0-1.3)倍，每上升5μg/m3之PMCoarse，腎絲球過濾率約下降0.7 (95% CI：0.5-0.9) ml/min/1.73m2，危險勝算比約增為1.1 (95% CI：1.0-1.2)倍，65歲以上每上升20μg/m3之NOx，腎絲球過濾率約下降0.7 (95% CI：0.2-1.2)ml/min/1.73m2；發炎指標數量與PM2.5、PM2.5Absorbance及NOx濃度呈正相關，每上升5 μg/m3的PM2.5，白血球約上升0.03 (95% CI：0.005-0.05) 103/μL，每上升1 10-5m-1的PM2.5Absorbance，白血球約上升0.07 (95% CI：0.02-0.1)103/μL，每上升20 μg/m3的NOx，白血球約上升0.29 (95% CI：0.003-0.05) 103/μL，血小板約上升0.1 (95% CI：0.2-2.2) 103/μL；罹患尿蛋白之風險與PM2.5及PM2.5Absorbance濃度相關，每上升5 μg/m3的PM2.5，尿蛋白危險勝算比增為1.2 (95% CI：1.1-1.4)倍，每上升1 10-5m-1的PM2.5Absorbance，尿蛋白危險勝算比增為1.8 (95% CI：1.3-2.5)倍；是否罹患早期慢性腎臟病之風險亦與PM2.5及PM2.5Absorbance濃度相關，每增加5 μg/m3之PM2.5，其危險勝算比約增為1.3 (95% CI：1.1-1.5)倍，每增加1 10-5m-1之PM2.5Absorbance，其危險勝算比約增為1.8 (95% CI：1.2-2.8)倍。在距離開放空間方面，在65歲以上的老年人中，距離開放空間之遠近與腎絲球過濾率的下降及罹患慢性腎臟病的風險相關，以CKD-EPI-Taiwan公式為例，距離開放空間每增加100公尺，其腎絲球過濾率顯著下降0.6 (95% CI：0.1-1.1) ml/min/1.73m2，慢性腎臟病危險勝算比增加1.1 (95% CI：1.0-1.2)倍；發炎指標數量、過重及肥胖的風險、是否罹患尿蛋白與是否罹患早期慢性腎臟病皆與距離開放空間之遠近無關。本研究得以下之結論：在35歲以上成人發現長期空氣汙染物(PM2.5、PM2.5Absorbance、PM10、PMCoarse與NOx)濃度上升與腎功能惡化有關，在65歲以上老年人亦發現住家距離開放空間愈遠與腎絲球過濾率下降和慢性腎臟病風險上升有關。

關鍵字

腎絲球過濾率 ； 慢性腎臟病 ； 空氣汙染 ； 開放空間 ； 土地利用

並列摘要

Epidemiology studies have confirmed the association between air pollutions, especially particulate matters (PM), and morbidity and mortality of cardiovascular diseases. And several studies also found open space was associated with overweight, obesity and longevity. Yet, studies on the associations between air pollution, open space and chronic kidney disease (CKD) are still limited. The objective of the study was to investigate the associations between air pollution, open space, renal function, and CKD for adults in Taipei, Taiwan. Study subjects of this study were adults living in the metropolitan areas in New Taipei City in 2007-2009 and participated in the government-sponsored integrated health screening program. Health outcomes included estimated glomerular filtration rate (eGFR), CKD, inflammatory markers, proteinuria and early stage of CKD. eGFR was calculated by serum creatinine, age and gender through equations of Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, MDRD-Japan、CKD-EPI-Japan, IDMS-MDRD-Taiwan, CKD-EPI-Taiwan. CKD was defined by eGFR lower than 60 ml/min/1.73m2 or 250.4*, 274.1*, 283.11, 403.*1, 404.*2, 404.*3, 440.1, 442.1, 447.3, 572.4, 580-588, 642.1*, 646.2* in ICD-9 CM Code. Exposure variables were included air pollutions and open space. The individual exposures of air pollution were estimated by land use regression models for PM2.5, PM2.5Absorbance, PM10, PMCoarse, NO2 and NOx. Schools, recreation areas and parks were defined as open space. We applied generalized linear model (GLM) and logistic regression to estimate the associations between exposures and outcomes, adjusting for confounders of age, gender, fasting blood glucose, smoking, hypertension and overweight. The age of 21,656 subjects were 30-97, and the female to male ratio was approximately 2:1 in this study. We found increased long-term exposure of PM10, PMCoarse and NOx were associated with decreased eGFR and increased odds ratio of CKD. Using CKD-EPI-Taiwan as an example, a 10μg/m3 of PM10 increased was associated with 1.0 (95% CI：0.6-1.3) ml/min/1.73m2 decreased in eGFR and an odds ratio (OR) 1.1 (95% CI：1.0-1.3) of CKD. A 5μg/m3 of PMCoarse increased was associated with 0.7 (95% CI：0.5-0.9) ml/min/1.73m2 decreased in eGFR and an OR 1.1 (95% CI：1.0-1.2) of CKD. A 20μg/m3 of NOx increased was associated with 0.7 (95% CI：0.2-1.2) ml/min/1.73m2 decreased in eGFR for elderly who aged above 65. A 5μg/m3 of PM2.5 increased was associated with 0.03 (95% CI：0.005-0.05) 103/mL increased in WBC, an OR 1.2 (95% CI：1.1-1.4) of proteinuria and an OR 1.3 (95% CI：1.1-1.5) of early stage of CKD. A 10-5m-1 of PM2.5Absorbance increased was associated with 0.07 (95% CI：0.02-0.1) 103/mL increased in WBC, an OR 1.8 (95% CI：1.3-2.5) of proteinuria and an OR 1.8 (95% CI：1.2-2.8) of early stage of CKD. We also found increasing distance to open space among elderly who aged above 65 was associated with 0.6 (95% CI：0.1-1.1) ml/min/1.73m2 decreased in eGFR and an OR 1.1 (95% CI：1.0-1.2) of CKD. We concluded that PM (PM2.5, PM2.5Absorbance, PM10 and PMCoarse) and NOx were all associated with deterioration of renal function for adults above 30 years old. Increasing distance to open space among adults aged above 65 was associated with decreased eGFR and increased risk of chronic kidney disease.

並列關鍵字

Estimated glomerular filtration rate (eGFR) ； Chronic kidney disease (CKD) ； Air pollution ； Open Space ； Land use

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