第三節 應用與建議
1. 建議衛生主管機關
建議衛生主管機關重視慢性腎臟病的重要性，加強宣導並教導國 民及早就醫及慢性腎臟病的正確治療觀念。
2. 建議醫療機構
對於慢性腎臟病患的衛教照顧相當重要，尤其是高危險病患，如 糖尿病或年長者，可加強追蹤及衛教，以期能提早發現問題並及時解 決。
3. 建議後續研究者
可以再加入生化檢驗數值，尤其是蛋白尿的檢測及分析對末期腎 臟病或死亡的影響相當巨大。另外諸如藥物的使用對腎臟功能的影響，
生活習慣中抽菸的數量以及是否戒菸等，都可以在將來的研究中討論。
還有血糖、血壓或血脂肪等的變化是否會影響死亡或末期腎臟病的發 生也值得繼續探討。
39
表 1. 第三、四、五期慢性腎臟病患的基本資料
全部 第三期 第四期 第五期
N=4702 N=2150 N=1380 N=1172 P-value 人數 (%) 人數(%) 人數(%) 人數 (%)
40
41
發現方式
自我察覺 1542 (32.8) 740 (34.4) 410 (29.7) 392 (33.5) 0.012 健康檢查時發現 624 (13.3) 360 (16.7) 149 (10.8) 115 (9.8) <0.0001 其他疾病檢查發現 2248 (47.8) 961 (44.7) 773 (56) 514 (43.9) <0.0001 missing 288 (6.1) 89 (4.1) 48 (3.5) 151 (12.9) 家族史 1619 (34.4) 768 (35.7) 444 (32.2) 407 (34.7) 0.093 初次eGFR(ml/min/1.73m2):
Mean (SD)
27.6 (14.1) 40.7 (7.05) 22.8 (4.33) 9.25 (3.20) <0.001
追蹤時間(月), Mean (SD) 28.2 (18.9) 31.4 (19.0) 30.0 (18.7) 20.2 (16.3) <0.001 有結案之人數 1762 (37.5) 494 (23.0) 508 (36.8) 760 (64.9)
原因 血液透析 574 (32.6) 34 (6.9) 120 (23.6) 420 (55.3) <0.0001 腹膜透析 137 (7.8) 7 (1.4) 22 (4.3) 108 (14.2) <0.0001 腎臟移植 24 (1.4) 1 (0.2) 4 (0.8) 19 (2.5) <0.0001 死亡 239 (13.6) 98 (19.8) 86 (16.9) 55 (7.2) 0.068 失聯 400 (22.7) 135 (27.3) 153 (30.1) 112 (14.7) <0.0001 其他 388 (22) 219 (44.3) 123 (24.2) 46 (6.1) <0.0001
42
表 2-1. 第三、四、五期慢性腎臟病進入 ESRD 的發生率
第三期 第四期 第五期 合計
N=2150 N=1380 N=1172 N=4702
性別 n1/n2 (R ) n1/n2 (R ) n1/n2 (R ) n1/n2 (R ) 男性 31/1608 (1.93) 94/827 (11.4) 262/573 (45.7) 387/3008 (12.9) 女性 11/542 (2.03) 52/553 (9.40) 285/599 (47.6) 348/1694 (20.5) 合計 42/2150 (1.95) 146/1380 (10.6) 547/1172 (46.7) 735/4702 (15.6) 年齡, 歲
<45 11/200 (5.5) 31/129 (24.0) 88/133 (66.2) 130/462 (28.1) 45-59 17/420 (4.05) 48/261 (18.4) 172/320 (53.8) 237/1001 (23.7) 60-69 7/398 (1.76) 25/286 (8.74) 129/254 (50.8) 161/938 (17.2)
≧70 7/1132 (0.62) 42/704 (5.97) 158/465 (34.0) 207/2301 (9.0) n1 = ESRD 人數，n2 = 樣本數；R = ESRD 發生率, %
43
44
45
抽菸 194 (26.4) 21 (50.0) 48 (32.9) 125 (22.9) <0.001 喝酒 142 (19.3) 16 (38.1) 31 (21.2) 95 (17.4) 0.004
檳榔 38 (5.2) 4 (9.5) 10 (6.9) 24 (4.4) 0.20
初次收案之eGFR (ml/min/1.73m2)
Mean (SD) 12.3 (8.7) 37.6 (7.07) 20.2 (4.19) 8.2 (3.13) <0.001 追蹤時間(月), Mean (SD) 18.2 (15.9) 29.0 (16.7) 25.5 (16.6) 15.4 (14.3)
原因
血液透析 574 (78.1) 34 (81.0) 120 (82.2) 420 (76.8) 0.71 腹膜透析 137 (18.6) 7 (16.7) 22 (15.1) 108 (19.7)
腎臟移植 24 (3.3) 1 (2.4) 4 (2.7) 19 (3.5)
46
表 3-1. 慢性腎臟病患者性別及年齡別致死率
第三期 第四期 第五期 合計
N=2150 N=1380 N=1172 N=4702
性別 n1/n2 (R ) n1/n2 (R ) n1/n2 (R ) n1/n2 (R )
男性 84/1608 (5.22) 61/827 (7.40) 30/573 (5.02) 175/3008 (5.80) 女性 14/542 (2.58) 25/553 (4.50) 25/599 (4.20) 64/1694 (3.80) 合計 98/2150 (4.56) 86/1380 (6.20) 55/1172 (4.70) 239/4702 (5.10) 年齡, 歲
< 60 9/620 (1.45) 4/390 (1.03) 6/453 (1.32) 19/1463 (1.30) 60-69 8/398 (2.01) 9/286 (3.15) 11/254 (4.33) 28/938 (2.99)
≧70 81/1132 (7.16) 73/704 (10.37) 38/465 (8.17) 192/2301 (8.34) n1 = 死亡人數，n2 = 樣本數；R = rate 致死率, %
47
48
心血管疾病 21 (8.8) 11 (11.2) 6 (7) 4 (7.3) 0.59 慢性肝疾病 10 (4.2) 1 (1) 7 (8.1) 2 (3.6) 0.05 惡性腫瘤 27 (11.3) 11 (11.2) 13 (15.1) 3 (5.5) 0.22 高血脂 19 (7.9) 9 (9.2) 6 (7) 4 (7.3) 0.83 其他 42 (17.6) 16 (16.3) 14 (16.3) 12 (21.8) 0.64
轉介科別
內科 73 (30.5) 28 (28.6) 29 (33.7) 16 (29.1) 0.67 非內科科別 20 (8.4) 10 (10.2) 7 (8.1) 3 (5.5)
其他醫療院所 37 (15.5) 12 (12.2) 13 (15.1) 12 (21.8) 自己 45 (18.8) 21 (21.4) 15 (17.4) 9 (16.4) Missing 64 (26.8) 27 (27.6) 22 (25.6) 15 (27.3)
使用藥物病史 25 (10.5) 7 (7.1) 8 (9.3) 10 (18.2) 0.09 生活習慣
抽菸 79 (33.1) 41 (41.8) 23 (26.7) 15 (27.3) 0.06 喝酒 45 (18.8) 25 (25.5) 12 (14) 8 (14.6) 0.09 檳榔 5 (2.1) 1 (1) 3 (3.5) 1 (1.8) 0.55
初次eGFR (ml/min/1.73m2)
Mean (SD) 26.4 (12.6) 38.8 (7.2) 22.5 (4.6) 10.4 (2.8) 追蹤時間(月), Mean (SD) 24.2 (15.5) 26.7 (15.8) 24.9 (16.2) 18.8 (12.9)
49
表 4. 慢性腎臟病患第三期進入透析相關因子的單變相及多變相分析
Sample size, N 2150 Poisson Cox model analysis*
Number of ESRD, n 42 單變項 多變項
50
Yes 184 2 10.9 0.64 (0.15, 2.65) 0.80 (0.19, 3.39)
No 1966 40 20.3 1.00 1.00
抽菸
Yes 876 21 24.0 1.55 (0.84, 2.83) 1.76 (0.84, 3.71)
No 1274 21 16.5 1.00 1.00
喝酒
Yes 659 16 24.3 1.50 (0.80, 2.79) 1.41 (0.65, 3.05)
No 1491 26 17.4 1.00 1.00
嚼檳榔
Yes 131 4 30.5 2.10 (0.75, 5.88) 1.30 (0.43, 3.96)
No 2019 38 18.8 1.00 1.00
中草藥或不明成分藥物
Yes 424 7 16.5 0.86 (0.38, 1.95) 0.82 (0.36, 1.85)
No 1726 35 20.3 1.00 1.00
止痛藥
Yes 131 0 0.0 0.00 0.00
No 2019 42 20.8 1.00 1.00
*校正性別、年齡、糖尿病、高血壓、高血脂、心血管疾病及抽菸 CI, confidence interval (可信限)；RR, rate ratio (發生率比); aHR, adjusted hazard ratio (校正危害比)
51
表 5. 慢性腎臟病患第四期進入透析相關因子的單變相及多變相分析 Sample size, N 1380 Poisson Cox model analysis*
Number of ESRD, n 146 單變項分析 多變項分析
52
心血管疾病
Yes 131 8 61.1 0.67 (0.33, 1.38) 0.81 ( 0.40, 1.66)
No 1249 138 110.5 1.00 1.00
抽菸
Yes 483 48 99.4 0.91 (0.65, 1.29) 0.77 (0.52, 1.15)
No 897 98 109.3 1.00 1.00
喝酒
Yes 318 31 97.5 0.95 (0.64, 1.41) 0.90 (0.54, 1.49) No 1062 115 108.3 1.00 1.00 檳榔
Yes 89 10 112.4 1.31 (0.69, 2.48) 1.18 (0.59, 2.38)
No 1291 136 105.3 1.00 1.00
中草藥或不明成分藥物
Yes 303 37 122.1 1.26 (0.87, 1.82) 1.26 (0.86, 1.84)
No 1077 109 101.2 1.00 1.00
止痛藥
Yes 96 5 52.1 0.50 (0.20, 1.22) 0.59 (0.24, 1.46) No 1284 141 109.8 1.00 1.00 *校正性別、年齡、糖尿病、高血壓、高血脂、心血管疾病及抽菸 CI, confidence interval (可信限)；RR, rate ratio (發生率比); aHR, adjusted hazard ratio (校正危害比)
53
表 6. 慢性腎臟病患第五期進入透析相關因子的單變相及多變相分析 Sample size, N 1172 Poisson Cox model analysis*
Number of ESRD, n 547 單變項分析 多變項分析
54
No 1097 524 477.7 1.00 1.00
抽菸
Yes 315 125 396.8 0.93 (0.76, 1.14) 0.86 (0.68, 1.08)
No 857 422 492.4 1.00 1.00
喝酒
Yes 229 95 414.8 1.01 (0.81, 1.26) 1.03 (0.77, 1.37)
No 943 452 479.3 1.00 1.00
檳榔
Yes 66 24 363.6 0.92 (0.61, 1.38) 0.85 (0.55, 1.32)
No 1106 523 472.9 1.00 1.00
中草藥或不明成分藥物
Yes 256 102 398.4 0.81 (0.65, 0.99) 0.82 (0.66, 1.03)
No 916 445 485.8 1.00 1.00
止痛藥
Yes 60 17 283.3 0.55 (0.34, 0.89) 0.61 (0.37, 0.99)
No 1112 530 476.6 1.00 1.00
*校正性別、年齡、糖尿病、高血壓、高血脂、心血管疾病及抽菸 CI, confidence interval (可信限)；RR, rate ratio (發生率比); aHR, adjusted hazard ratio (校正危害比)
55
56
No 1966 87 44.3 1.00 1.00
抽菸
Yes 876 41 46.8 1.11 (0.74, 1.66) 0.91 (0.59, 1.40)
No 1274 57 44.7 1.00 1.00
喝酒
Yes 659 25 37.9 0.83 (0.53, 1.31) 0.73 (0.43, 1.22)
No 1491 73 49.0 1.00 1.00
檳榔
Yes 131 1 7.6 0.21 (0.03, 1.48) 0.34 (0.05, 2.52)
No 2019 97 48.0 1.00 1.00
中草藥或不明成分藥物
Yes 424 10 23.6 0.49 (0.26, 0.95) 0.62 (0.32, 1.19)
No 1726 88 51.0 1.00 1.00
止痛藥
Yes 131 4 30.5 0.68 (0.25, 1.85) 0.94 (0.34, 2.58)
No 2019 94 46.6 1.00 1.00
*校正性別、年齡、糖尿病、高血壓、高血脂、心血管疾病及抽菸 CI, confidence interval (可信限)；RR, rate ratio (發生率比); aHR, adjusted hazard ratio (校正危害比)
57
表 8. 第四期慢性腎臟病患死亡相關因子的單變相及多變相分析
Sample size(N) 1380 Poisson Cox model analysis*
Number of death(n) 86 單變項分析 多變項分析
58
No 1249 80 64.1 1.00 1.00
抽菸
Yes 483 23 47.6 0.68 (0.42, 1.10) 0.57 ( 0.34, 0.95)
No 897 63 70.2 1.00 1.00
喝酒
Yes 318 12 37.7 0.57 (0.31, 1.05) 0.63 (0.32, 1.25)
No 1062 74 69.7 1.00 1.00
檳榔
Yes 89 3 33.7 0.64 (0.20, 2.03) 1.15 (0.35, 3.78)
No 1291 83 64.3 1.00 1.00
中草藥或不明成分藥物
Yes 303 12 39.6 0.60 (0.33, 1.10) 0.74 (0.40, 1.37)
No 1077 74 68.7 1.00 1.00
止痛藥
Yes 96 6 62.5 1.06 (0.46, 2.42) 1.24 (0.53, 2.89)
No 1284 80 62.3 1.00 1.00
*校正性別、年齡、糖尿病、高血壓、高血脂、心血管疾病及抽菸 CI, confidence interval (可信限)；RR, rate ratio (發生率比); aHR, adjusted hazard ratio (校正危害比)
59
表 9. 第五期慢性腎臟病患死亡相關因子的單變相及多變相分析
Sample size, N 1172 Poisson Cox model analysis*
Number of death, n 55 單變項分析 多變項分析
60
No 1097 51 46.5 1.00 1.00
抽菸
Yes 315 15 47.6 1.18 (0.65, 2.14) 1.04 (0.52, 2.11)
No 857 40 46.7 1.00 1.00
喝酒
Yes 229 8 34.9 0.82 (0.39, 1.73) 0.66 (0.27, 1.67)
No 943 47 49.8 1.00 1.00
檳榔
Yes 66 1 15.2 0.37 (0.05, 2.67) 0.40 (0.05, 3.04)
No 1106 54 48.8 1.00 1.00
中草藥或不明成分藥物
Yes 256 9 35.2 0.69 (0.34, 1.40) 1.02 (0.49, 2.14)
No 916 46 50.2 1.00 1.00
止痛藥
Yes 60 5 83.3 1.72 (0.69, 4.32) 2.56 (0.96, 6.78)
No 1112 50 45.0 1.00 1.00
*校正性別、年齡、糖尿病、高血壓、高血脂、心血管疾病及抽菸 CI, confidence interval (可信限)；RR, rate ratio (發生率比); aHR, adjusted hazard ratio (校正危害比)
61
62
No 4312 702 16.3 5.7 (3.98, 8.07) 35.9 (25.9, 49.7)
抽菸
Yes 1674 194 11.6 3.9 (2.34, 6.54) 24.9 (15.5, 39.9) No 3028 541 17.9 7.3 (4.53, 11.7) 46 (29.6, 71.6)
喝酒
Yes 1206 142 11.8 3.8 (2.10, 7.05) 24.5 (14.3, 42.0) No 3496 593 17.0 6.7 (4.39, 10.3) 42.3 (28.4, 63.1)
檳榔
Yes 286 38 13.3 4.1 (1.25, 13.1) 18.8 (6.39, 55.2) No 4416 697 15.8 5.9 (4.09, 8.42) 38.2 (27.3, 53.3)
中草藥或不明成分藥物
Yes 983 146 14.9 7.9 (3.52, 17.8) 40.3 (18.5, 87.8) No 3719 589 15.8 5.2 (3.52, 7.56) 35.6 (25.2, 50.5)
止痛藥
Yes 287 22 7.7
No 4415 713 16.1 5.5 (3.90, 7.78) 35.1 (25.6, 48.3)
*校正性別、年齡、糖尿病、高血壓、高血脂、心血管疾病及抽菸 CI, confidence interval (可信限)；aHR, adjusted hazard ratio (校正危害比)
63
64 抽菸
Yes 1674 79 4.72 1.09 (0.65, 1.81) 2.31 (1.27, 4.21) No 3028 160 5.28 1.62 (1.12, 2.33) 1.94 (1.27, 2.97)
喝酒
Yes 1206 45 3.73 1.02 (0.51, 2.04) 1.96 (0.86, 4.43) No 3496 194 5.55 1.48 (1.07, 2.06) 2.02 (1.37, 2.97)
檳榔
Yes 286 5 1.75 5.27 (0.53, 52.62) 2.41 (0.15, 39.33) No 4416 234 5.30 1.39 (1.03, 1.87) 2.06 (1.45, 2.93)
中草藥或不明成分藥物
Yes 983 31 3.15 1.74 (0.74, 4.05) 2.79 (1.06, 7.30) No 3719 208 5.59 1.38 (1.01, 1.89) 1.94 (1.33, 2.82)
止痛藥
Yes 287 15 5.23 2.4 (0.64, 9.03) 4.19 (1.06, 16.64) No 4415 224 5.07 1.39 (1.03, 1.88) 1.92 (1.34, 2.76)
*校正性別、年齡、糖尿病、高血壓、高血脂、心血管疾病及抽菸 CI, confidence interval (可信限)；aHR, adjusted hazard ratio (校正危害比)
65
表12. 糖尿病、高血壓、高血脂在各分期透析危險因子的交互作用
Incidence rate Hazard Ratio (Cox model)
Stage 3 Stage 4 Stage 5 Stage 4 vs 3 Stage 5 vs 3 糖尿病 高血壓 高血脂 n ESRD Rate (%) n ESRD Rate (%) n ESRD Rate (%) aHR 95% C.I aHR 0.95 C.I.
N N N 249 2 0.80 135 7 5.19 167 90 53.9 7.99 (1.66, 38.6) 100.7 (24.67, 411.3) Y N N 101 6 5.94 102 15 14.7 91 59 64.8 3.75 (1.43, 9.83) 22.04 (9.21, 52.75) N Y N 671 8 1.19 394 38 9.64 378 169 44.7 7.95 (3.70, 17.06) 51.80 (25.34, 105.9) N N Y 71 2 2.82 40 7 17.5 17 6 35.3 6.35 (1.29, 31.13) 14.72 (2.89, 74.97) Y Y N 383 14 3.66 279 28 10.0 229 109 47.6 2.83 (1.49, 5.39) 25.96 (14.54, 46.35)
Y N Y 33 0 0.00 18 2 11.1 13 4 30.8 NA NA
N Y Y 391 6 1.53 199 20 10.1 153 59 38.6 7.21 ( 2.89, 17.99) 39.25 (16.67, 92.45) Y Y Y 251 4 1.59 213 29 13.6 124 51 41.1 7.54 (2.64, 21.54) 36.34 (13.05, 101.2) Adjusted for age and sex
aHR, adjusted hazard ratio (校正危害比)
66
表13. 糖尿病、高血壓、高血脂在各分期死亡危險因子的交互作用
Incidence rate Hazard Ratio (Cox model)
Stage 3 Stage 4 Stage 5 Stage 4 vs 3 Stage 5 vs 3 糖尿病 高血壓 高血脂 n Death Rate (%) n Death Rate (%) n Death Rate (%) aHR 95% C.I aHR 95% C.I
N N N 249 14 5.62 135 12 0.09 167 9 5.39 1.41 ( 0.64, 3.12) 1.71 (0.71, 4.12) Y N N 101 20 19.80 102 16 0.16 91 10 10.99 1.05 (0.54, 2.03) 1.62 (0.72, 3.63) N Y N 671 31 4.62 394 29 0.07 378 14 3.70 1.73 (1.04, 2.89) 1.73 (0.90, 3.36)
N N Y 71 0 0.00 40 2 0.05 17 0 0.00 NA NA
Y Y N 383 18 4.70 279 16 0.06 229 16 6.99 1.32 (0.67, 2.59) 5.06 (2.41, 10.63)
Y N Y 33 0 0.00 18 0 0.00 13 1 7.69 NA NA NA NA
N Y Y 391 9 2.30 199 1 0.01 153 1 0.65 0.28 (0.03, 2.22) 0.86 (0.10, 7.17) Y Y Y 251 6 2.39 213 10 0.05 124 4 3.23 2.21 (0.78, 6.24) 2.25 (0.61, 8.39) Adjusted for sex and age
aHR, adjusted hazard ratio (校正危害比)
67
68
圖2. Kaplan - Meier analysis measuring cumulative incidence of end-stage renal disease by stage of chronic kidney disease
Log-rank test for dialysis P-value Over all test <0.0001 3 vs 4 <0.0001 3 vs 5 <0.0001 4 vs 5 <0.0001
Stage 4
Stage 3
Stage 5
圖3
umulativee deaths foor patientss with
70
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*姓名： ______________ 病歷號碼： ______________ *身份證字號：
________________
*原發病大類：_____________________________（請參照腎臟醫學會透析軟體疾 病分類表）
*原發病細類：_____________________________
*其他：______________________________________________________
*發現至今歷史：時間：________ 周； _________ 月； __________ 年