第六章、 結論與建議
第三節、 應用與建議
建議衛生主管機關加強宣導，應由國民教育著手，教導國民正確生 活行為，與慢性病治療正規觀念。
二、建議醫療機構
慢性腎臟病病人的衛教照護是有其必要性的，教育內容應著重於教 導國民正確生活行為，與正規慢性病治療觀念。並讓病患了解尊重專業 醫師的建議並遵從主治醫師的處方，不要重複就醫，浪費醫療資源又傷 身。在慢性腎臟病病人使用中藥或中西藥合併使用，仍應小心其腎毒性 與交互作用。
慢性腎臟病之憂鬱症二至五倍於常人，在衛教室與透析室中應對女 性老年與低收入者應提高警覺並多多利用憂鬱量表，儘早發掘潛在的憂 鬱症，及早施予治療。
三、建議後續研究者
本研究為病例對照及橫斷性研究，無法確定因果關係，不像追蹤研 究，可有縱貫性深入研究的因果關係結果。
本研究結果得知中西藥同時使用會增加透析風險，可能導因於藥物 交互作用、或多重用藥、或藥物過量，建議後續研究者針對中草藥、藥 物的部分加以研究探討，探討中草藥、藥物交互作用與末期腎臟病之間
關係，釐清藥物對腎臟功能產生之影響作用。針對 CKD、ESRD 與憂鬱 症長期追蹤研究，以了解憂鬱症對慢性腎臟病之長期後續影響。
表1. 世界各國末期腎臟病盛行率(每百萬人口)
2002 2003 2004 2005 2006 Taiwan 1,792 1,900 2,015 2,138 2,226
Japan 1,727 1,797 1,852 1,882 1,956
USA 1,452 1,498 1,543 1,589 1,641
Germany 920 948 998 1,057 1,114
Hong Kong 843 878 923 961 994
Korea 701 794 854 900 942
Jalisco(Mexico) 389 394 508 808 929
Australia 663 689 709 745 778
Finland 636 664 688 714 723
Israel 578 604 627 641 657
Malaysia 429 400 522 560 615
Iceland 435 480 479 482 484
China-Shanghai 286 327 364 404 447
Thailand 235 243 220 286
United States Renal Data System
末期腎臟病盛行率以台灣最高，日本次之，美國第三。
表2. 世界各國末期腎臟病發生率(每百萬人口)
2002 2003 2004 2005 2006
Taiwan 395 391 397 434 418
USA 338 342 346 353 363
Jalisco(Mexico) 232 280 346 302 346
China-Shanghai 156 232 263 275 282
Japan 256 263 267 271 275
Germany 174 186 194 203 213
Israel 166 199 201 197 203
Korea 129 152 171 173 185
Hong Kong 129 128 135 137 140
Thailand 97 78 123 110 139
Malaysia 97 102 110 103 119
Australia 94 100 97 112 115
Finland 73 95 97 96 84
Iceland 73 79 64 59
United States Renal Data System
表3. 透析病例與對照的基本資料
表4. 比較透析病例與對照的身體質量指數和疾病史
表5. 透析病例與對照的主就醫習慣和生活形態之比較
表6. 透析病例組與對照組的藥品及保健食品等使用
表7. 透析相關因子的多變項與逐步羅吉斯迴歸分析
多變項 逐步
OR (95% CI) OR (95% CI)
年齡，歲 18-49 Reference Reference
50-64 0.31 (0.12-0.80) 0.29 (0.12-0.73)
<20,000 0.43 (0.15-1.26) 0.48 (0.17-1.36) 20,000-50000 0.19 (0.07-0.51) 0.18 (0.07-0.46) >50,000 0.27 (0.09-0.85) 0.26 (0.09-0.75)
身體質量指數，kg/m2 <24 Reference Reference
24-26.9 0.49 (0.24-1.00) 0.53 (0.26-1.06)
≥27 0.25 (0.11-0.56) 0.21 (0.10-0.46)
糖尿病史 無 Reference Reference
有 0.24 (0.12-0.46) 0.25 (0.13-0.46)
高血脂史 無 Reference -
有 0.31 (0.09-1.02) -
心臟病史 無 Reference Reference
有 4.60 (1.83-11.5) 4.77 (1.97-11.5)
慢性腎臟病 無 Reference Reference
有 6.26 (2.27-17.3) 6.35 (2.40-16.8)
主要的就診情況 看中醫較多 0.94 (0.20-4.51) -
看西醫較多 0.74 (0.21-2.69) -
大約各佔一半 Reference -
運動習慣或勞力工作 無 Reference Reference
偶而/普通 0.40 (0.18-0.90) 0.46 (0.21-1.00) 很多 0.95 (0.41-2.18) 1.09 (0.49-2.43)
表8.透析相關因子的多變項與逐步羅吉斯迴歸(加上藥物服用因子)
0.18 (0.07-0.50) 0.18 (0.07-0.46)
>50,000 vs. 無 0.28 (0.09-0.93) 0.26 (0.09-0.75) BMI，kg/m2 24-26.9 vs. <24 0.47 (0.22-0.97) 0.53 (0.26-1.06)
≥27 vs. <24 0.23 (0.10-0.53) 0.21 (0.10-0.46)
表9. 中西醫就醫及服藥狀況與透析之相關性
Model 1 Model 2 Model 3 OR (95% CI) OR (95% CI) OR (95% CI) 現在/過去常吃止
痛藥
否/不知道 1.00 (reference) 1.00 (reference) 1.00 (reference) 是 1.63 (1.04-2.55) 1.55 (0.98-2.46) 1.52 (0.87-2.63) 現在或過去吃類固
醇
否/不知道 1.00 (reference) 1.00 (reference) 1.00 (reference) 是 1.54 (0.82-2.90) 1.24 (0.64-2.40) 1.35 (0.60-3.02)
曾經吃減重藥
否/不知道 1.00 (reference) 1.00 (reference) 1.00 (reference) 是 0.34 (0.11-1.08) 0.22 (0.07-0.75) 0.17 (0.04-0.83) 服用過民間偏方
否/不知道 1.00 (reference) 1.00 (reference) 1.00 (reference) 是 3.09 (1.44-6.62) 2.85 (1.32-6.19) 2.27 (0.88-5.83)
服西式保健食品
無 1.00 (reference) 1.00 (reference) 1.00 (reference) 有 0.72 (0.47-1.09) 0.69 (0.45-1.05) 0.71 (0.42-1.18)
服中式保健食品
無 1.00 (reference) 1.00 (reference) 1.00 (reference) 有 1.03 (0.69-1.58) 0.97 (0.63-1.50) 0.90 (0.53-1.52)
主要的就診情況
看西醫較多 1.00 (reference) 1.00 (reference) 1.00 (reference) 看中醫較多 2.65 (1.21-5.83) 2.74 (1.22-6.18) 1.86 (0.71-4.90) 各半 3.58 (1.37-9.33) 3.74 (1.41-9.96) 4.06 (1.38-12.0) Model 1：未校正
Model 2：校正年齡、性別
Model 3：校正年齡、性別、BMI、心臟病史、慢性腎病史
表10. 透析與相關因子之危險比及 95%可信限
Univariate Multivariate
OR 95% CI OR 95% CI Age, years
12-49 1.00 (reference) 1.00 (reference)
50-64 0.40 (0.23-0.72) 0.47 (0.23-0.96)
65-87 0.40 (0.23-0.71) 0.44 (0.21-0.90)
Sex
Female 1.00 (reference) 1.00 (reference)
Male 0.75 (0.49-1.13) 0.53 (0.27-1.05)
Smoking
No 1.00 (reference) 1.00 (reference)
Yes 1.04 (0.66-1.64) 3.07 (1.46-6.47)
Alcohol drinking
No 1.00 (reference) 1.00 (reference)
Yes 0.75 (0.55-1.02) 0.67 (0.43-1.06)
Obesity
No 1.00 (reference) 1.00 (reference)
Yes 0.48 (0.36-0.64) 0.50 (0.36-0.70) Chronic kidney disease
No 1.00 (reference) 1.00 (reference)
Yes 8.38 (3.98-17.6) 7.72 (3.09-19.3)
Visits of medical services
WM more 1.00 (reference) 1.00 (reference) TCM more 0.38 (0.17-0.83) 0.55 (0.21-1.42) Both WM and TCM 1.35 (0.41-4.47) 1.79 (0.45-7.11)
表11. 社經地位分數計分
分數 教育程度
國小以下 1
國中 2
高中 3
大學以上 4
職業
無/家管 1
農工 2
服務業/自由業 3
商/資訊業 4
軍公教 5
個人平均月收入
無 1
<20,000 2 20,000-50,000 3
>50,000 4
表12. 不同社經地位之研究對象的特徵
社經地位(分數)
低(3) 中(4-7) 高(8-13)
Mean ± SD Mean ± SD Mean ± SD p 值
人數 135 124 97
年齡，歲 62.0 ± 14.4 60.1 ± 12.6 56.7 ± 14.9 0.004 BMI，kg/m2 24.2 ± 4.7 24.2 ± 3.7 24.8 ± 3.5 0.31
男性，% 28.7 48.0 76.8 <0.0001
抽菸習慣，% 15.7 25.6 24.2 0.0002
喝酒習慣，% 9.1 14.4 17.4 0.013
肥胖，% 21.9 22.6 26.3 0.29
糖尿病，% 55.9 53.2 49.5 0.63
高血壓，% 61.9 54.4 57.1 0.46
高血脂史，% 6.6 8.0 11.1 0.46
心臟病，% 18.4 12.8 11.1 0.24
慢性腎臟病，% 17.7 12.8 21.2 0.24
中西醫就醫各半，% 6.3 10.1 3.3 0.10
透析病例，% 55.2 50.4 36.4 0.015
表13. 社經地位與透析的危險比及 95%可信限 社經地位
高 中 低
OR (95% CI) OR (95% CI) OR (95% CI) p for trend Model 1 1.00 (reference) 2.10 (1.17-3.79) 2.82 (1.51-5.25) 0.002 Model 2 1.00 (reference) 2.14 (1.13-4.07) 3.16 (1.54-6.49) 0.002 Model 3 1.00 (reference) 2.56 (1.27-5.19) 3.42 (1.56-7.48) 0.003 Model 1: adjusted for age and sex
Model 2: adjusted for age, sex, smoking, and alcohol drinking
Model 3: adjusted for covariates in model 2 plus chronic kidney disease
表14. 有無抽菸習慣之研究對象的特徵
抽菸習慣
無 有
Mean ± SD Mean ± SD p 值
人數 252 106
年齡，歲 59.3 ± 14.5 61.4 ± 12.9 0.31
BMI，kg/m2 24.4 ± 4.2 24.3 ± 3.5 0.86
男性，% 29.8 93.4 <0.0001
喝酒習慣，% 8.0 49.0 <0.0001
肥胖，% 24.4 21.7 0.55
糖尿病，% 52.4 56.2 0.51
高血壓，% 58.2 56.6 0.78
高血脂史，% 7.9 9.4 0.64
心臟病，% 14.3 15.1 0.84
慢性腎臟病，% 17.9 14.2 0.39
中西醫就醫各半，% 5.9 9.0 0.27
透析病例，% 48.0 49.1 0.86
表15. 抽菸習慣與透析的危險比及 95% 可信限 抽菸習慣
無 有
OR (95% CI) OR (95% CI) Model 1 1.00 (reference) 1.52 (0.86-2.72) Model 2 1.00 (reference) 1.80 (0.97-3.35) Model 3 1.00 (reference) 2.39 (1.20-4.76) Model 4 1.00 (reference) 2.83 (1.35-5.90) Model 1: adjusted for age and sex
Model 2: adjusted for age, sex, and alcohol drinking
Model 3: adjusted for covariates in model 2 plus body mass index Model 4: adjusted for covariates in model 3 plus chronic kidney disease
表16. The characteristics of study participants in the depression study
一般族群 CKD 組 透析組
Mean ± SD Mean ± SD Mean ± SD p-value
人數 24020 1077 68
男性，% 50.9 52.9 42.7 0.1709
年齡，歲 41.8 ± 17.7 53.5 ± 16.3 54.5 ± 14.8 <0.0001 教育程度<12 年，% 41.8 62.0 67.7 <0.0001 月收入< 20,000
元，%
81.7 85.2 92.7 0.0008
身體質量指數，
kg/m2
23.1 ± 3.6 24.3 ± 3.8 22.2 ± 3.7 <0.0001
抽菸習慣，% 35.8 47.3 29.4 <0.0001
喝酒習慣，% 37.7 37.9 9.0 <0.0001
肥胖，% 13.8 21.9 12.1 <0.0001
憂鬱分數，分 5.0 ± 6.4 8.4 ± 8.9 11.4 ±11.4 <0.0001
憂鬱症，%† 4.4 12.7 22.1 <0.0001
†憂鬱量表分數≥19 分
表 17. The comparison of depression scores between men and women by age group
Female Male
Mean ± SD Mean ± SD p-value
Number 12331 12834
Age, years
<30 6.49 ± 7.21 4.87 ± 6.18 <0.0001 30-39 5.31 ± 6.3 4.24 ± 5.72 <0.0001 40-49 4.98 ± 6.43 4.14 ± 5.66 <0.0001 50-59 5.24 ± 6.88 3.93 ± 5.72 <0.0001 60-69 6.23 ± 7.42 4.23 ± 5.78 <0.0001
≥70 7.65 ± 8.29 5.62 ± 6.64 <0.0001
表18. Odds ratio and 95% confidence interval of depression in association with chronic kidney disease and ESRD
一般族群 有CKD ESRD
OR (95% CI ) OR (95% CI ) OR (95% CI ) p for trend
Model 1 1.00 (reference) 3.11 (2.56-3.78) 5.70 (3.19-10.2) <0.0001 Model 2 1.00 (reference) 3.09 (2.54-3.75) 5.54 (3.09-9.91) <0.0001 Model 3 1.00 (reference) 2.88 (2.35-3.53) 5.23 (2.82-9.71) <0.0001 Model 1: adjusted for age and sex
Model 2: adjusted for age, sex, education, and income
Model 3 adjusted for covariates in model 2 plus smoking, alcohol, and obesity
表19. Odds ratio and 95% confidence interval of depression in association with chronic kidney disease stratified by age
< 50 years ≥ 50 years Total OR (95% CI ) OR (95% CI ) OR (95% CI )
Number 17022 8143 25165
Model 1 3.19 (2.39-4.25) 3.28 (2.58-4.19) 3.26 (2.70-3.92)† Model 2 3.25 (2.44-4.35) 3.21 (2.52-4.09) 3.23 (2.68-3.89)† Model 3 2.89 (2.15-3.89) 3.02 (2.33-3.91) 3.01 (2.48-3.66)†
*Chronic kidney disease included end-stage renal disease Model 1: adjusted for sex
Model 2: adjusted for sex, education, and income
Model 3: adjusted for covariates plus smoking, alcohol, and obesity
†Plus age in each model
表20. Odds ratio and 95% confidence interval of depression in association with chronic kidney disease stratified by gender*
Female Male Total
OR (95% CI ) OR (95% CI ) OR (95% CI )
Number 12331 12834 25165
Model 1 3.41 (2.69-4.33) 3.04 (2.25-4.10) 3.26 (2.70-3.92)† Model 2 3.40 (2.68-4.31) 2.97 (2.20-4.01) 3.23 (2.68-3.89)† Model 3 2.98 (2.31-3.85) 2.93 (2.16-3.98) 3.01 (2.48-3.66)†
*Chronic kidney disease included end-stage renal disease Model 1: adjusted for age
Model 2: adjusted for age, education, and income
Model 3: adjusted for covariates plus smoking, alcohol, and obesity
†Plus sex in each model
表21. Factors associated with risk of depression in patients with chronic kidney disease and hemodialysis compared with general population.
Chronic Kidney Disease Hemodialysis OR (95% CI) OR (95% CI)
Sex
Male 1.00 (reference) 1.00 (reference)
Female 2.66 (2.26-3.13) 2.71 (2.31-3.19)
Age, years
<50 1.00 (reference) 1.00 (reference)
50-69 0.92 (0.77-1.10) 0.98 (0.81-1.17)
≥70 1.49 (1.24-1.79) 1.62 (1.35-1.94)
Education, years
≥13 1.00 (reference) 1.00 (reference)
<13 0.93 (0.80-1.08) 0.94 (0.81-1.09) Income
≥20000 1.00 (reference) 1.00 (reference)
<20000 1.60 (1.31-1.95) 1.60 (1.31-1.95) Smoking
No 1.00 (reference) 1.00 (reference)
Yes 1.96 (1.66-2.32) 2.06 (1.74-2.43)
Alcohol drinking
No 1.00 (reference) 1.00 (reference)
Yes 1.04 (0.91-1.20) 1.05 (0.92-1.21)
Obesity
No 1.00 (reference) 1.00 (reference)
Yes 0.91 (0.76-1.08) 0.95 (0.80-1.13)
There were only 68 cases with hemodialysis that could not perform logistic regression
CKD：Chronic Kidney Disease
圖1. 生活型態、藥物服用-個案對照研究
圖2. 憂鬱症研究統計分析過程圖
羅吉斯迴歸 成功受訪者人數26755 人
選取成功填寫台灣憂鬱量表者25,165 名 1590 人去除 (未填憂鬱量表)
ESRD 透析病患68 名 CKD
(無透析者) 1077 名 一般民眾
(無CKD 者) 24020 名
是否憂鬱症
社會人口學因素 身體健康因素 生活型態因素 年齡 BMI 抽菸習慣 性別 CKD 喝酒習慣 教育程度 透析
收入 肥胖
Model 1 Model 2 Model 3
圖3. 憂鬱症量表得分在研究對象的分布
0 10 20 30 40 50
0 1-5 6-10 11-15 16-20 21-25 26-30 31-35 35-40 41-45 46-50 51-54 Depression scores
Percent
General CKD Dialysis
圖4. 一般人口、慢性腎臟病患者和透析患者憂鬱症量表得分累積曲線的性別比較
0 10 20 30 40 50 60 70 80 90 100
0 1-5 6-10 11-15 16-20 21-25 26-30 31-35 35-40 41-45 46-50 51-54
Depression scores
Cumulative percent
Female, general Female, CKD Female, dialysis Male, general
Male, CKD Male, dialysis
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