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  • 學位論文

末期腎病透析患者得到癌症之風險評估-以健保資料庫分析

Risk of Cancers among ESRD Patients under Dialysis in Taiwan: A Nationwide Population-Based Cohort Study

指導教授 : 張浤榮

摘要


研究目的:本研究的目的在探討國內透析患者罹患癌症的發生與其危險因素。了解性別、年齡、糖尿病以及不同透析方式,對於透析患者罹癌的影響。研究結果提供衛生行政單位作為癌症防治計畫和癌症疾病管理的決策參考資料。 研究方法及資料:本研究利用健保資料庫LHID 2000 (Longitudinal Health Insurance Database 2000)版本,此資料庫以中央健康保險署所提供的2000年承保資料檔保險對象為抽樣母群體。以亂數產生函數隨機抽樣一百萬人。經過擷取該一百萬人在2004年到2013年所有就醫資料後,從該資料庫內以回溯性方法篩選出跟本研究所定義的研究對象。從資料庫內篩選出末期腎病透析病患,然後串連這些病患的就醫紀錄。接著配對1:1年紀、性別、發生年都一樣的對照組,比對統計探討本研究對象末期腎病透析病患與罹患癌症的關聯性。本研究採用SPSS 22.0版套裝軟體進行描述性及推論性統計分析。描述性分析以數值和百分比呈現類別變項分布。以平均值及標準差描述連續變項。析推論性分析以卡方檢定各項自變項與依變項之間的差異。以Cox Proportional Hazard Regression Model 分析癌症與各變項間的關係危害比與95% 信賴區間( confidence interval ,CI) ; 顯著統計水準訂為 p<0.05。 研究結果:共有2555位透析病患符合收案研究。其中血液透析病患2317位,腹膜透析病患238位。與對照組2555位比較,有較高比例透析病患患有高血壓、糖尿病及高血脂症,具有統計上的差異。對照組共有 287件癌症發生,透析組共有 462 件癌症發生。其中血液透析病患431件,腹膜透析病患31件。以incidence density (per 1000 PY)來比較,透析實驗組的癌症發生率是對照組的 1.72倍。透析病患中生殖泌尿道癌症的風險比最高,HR高達3.97 (95% CI:2.96-5.35)。血液透析病患尿道癌症風險比HR 3.97,95%信賴區間2.93-5.38。腹膜透析病患尿道癌症風險比HR 2.22,但是95%信賴區間0.56-8.70。整個消化道癌症的風險比HR 1.39,95%信賴區間1.08-1.78。血液透析整個消化道癌症的風險比HR 1.38,95%信賴區間 1.07-1.78。腹膜透析整個消化道癌症的風險比HR 1.43,但是95%信賴區間 0.37-5.49。消化道癌症當中,肝癌的風險比最高HR 1.68,95%信賴區間 1.14-2.48。血液透析肝癌的風險比 HR 1.63,95%信賴區間1.10-2.42。腹膜透析肝癌的風險比HR 3.47,但是95%信賴區間 0.29-41.67。 末期腎病透析病患女性和男性具有不同的癌症發生比率,並且有統計上的差異。在透析族群中,女性有較高的比率發生癌症。透析族群中,具有糖尿病的患者跟不具有糖尿病的患者比較癌症的發生率,有統計上的差異。不具有糖尿病的透析患者比具有糖尿病的透析患者有比較高的癌症發生。 結論與建議:由研究結果末期腎病透析病有較高的癌症發生比率。非糖尿病及女性透析病患有比較高機會得到癌症。本研究建議末期腎臟病之病患,應定期癌症篩檢,早期發現,以減少癌症之死亡。

並列摘要


Objective:Cancer is becoming much more important with the progressive aging of dialysis patients and their prolonged life spans. We used an incident dialysis population matched with the non-dialysis patients according to age, sex, and index date to explore the association of dialysis and the risks of cancers. The aim of this study was to investigate the risks of various cancers in an incident dialysis group in comparison with a non-dialysis group. Methods and Materials:We conducted a population-based cohort study through the Taiwan National Health Insurance Research Database (NHIRD), which contains claims information and health care data on more than 99% of the population of Taiwan. This study is approved by the ethical review board of Chung-Shan Medical University (CS2-15050) The subjects in LHID 2000 (Longitudinal Health Insurance Database 2000) were randomly sampled from the entire insured population from 2004 to 2013, from which one million people were randomly selected from all insurants. There are no differences in the age and sex distributions between the LHID2000 and the general population. A matching procedure was used to enhance the comparison between the dialysis and control groups. The index year was defined as the year of dialysis for the dialysis group, whereas the index year was the year of an outpatient visit for the control group. The distributions of age, sex and co-morbidities between controls and patients were analyzed by x2 tests. Cox proportional hazard regression was used to estimate the hazard ratio (HR) of developing malignant cancer. All statistical analyses were performed by using the SPSS 22.0 statistical software. Results:The 2555 ESRD patients consisted of 2317 HD patients, 238 PD patients as well as 2555 controls were recruited. Compared with the control group, the ESRD group has more percentage of hypertension, diabetes, and hyperlipidemia (p<0.0001).The mean duration of follow-up was 7.48 years in ESRD patients (7.55 years in HD patients, 6.77 years in PD patients) compared with 7.94 years in controls. There are 287 cancer events in control group and there are 462 cancer events in ESRD group. The incidence of malignancy among ESRD patients is higher by 1.72-fold than the control group. The adjusted hazard ratio of malignancy was 1.70 among ESRD patients and the subgroups were 1.71, 1.53, in HD and PD patients respectively. In ESRD dialysis group, genitourinary cancer hazard ratio is 3.97 (95% CI:2.96-5.35). In hemodialysis group, genitourinary cancer hazard ratio is HR 3.97 (95% CI:2.93-5.38). In peritoneal dialysis group, genitourinary cancer hazard ratio is 2.22, but 95% CI:0.56-8.70. In ESRD dialysis group, digestive tract cancer hazard ratio is 1.39, 95% CI:1.08-1.78. In hemodialysis group, digestive tract cancer hazard ratio is 1.38, 95% CI: 1.07-1.78. In peritoneal group, digestive tract cancer hazard ratio is 1.43, but 95% CI: 0.37-5.49. In ESRD dialysis group, hepatoma hazard ratio is 1.68, 95% CI:1.14-2.48. In hemodialysis group, hepatoma hazard ratio is 1.63, 95% CI:1.10-2.42. In hemodialysis group, hepatoma hazard ratio is HR 3.47 but 95% CI: 0.29-41.67. In dialysis group , there is significant difference of cancer incidence between female ESRD patients and male ESRD patients. In dialysis group , there is significant difference of cancer incidence between diabetic patients and non-diabetic patients. In non-diabetic dialysis group , there is no significant difference of cancer incidence between male and female patients .In diabetic dialysis group , there is significant difference of cancer incidence between male and female patients. Conclusion and Suggestion:The risks of all cancers and site-specific cancers are increased in the incident dialysis population. There is different cancer risk among ESRD population on different dialysis modiality. In dialysis group , non-diabetic patients and female patients increase susceptible to cancers. The underlying mechanisms require further investigation. These findings suggest that cancer screening in ESRD population should be a selective approach, based on individual condition and life expectancy.

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