臺灣博碩士論文加值系統

背景：台灣2011年透析病人數為62,963人，腎臟移植為末期腎臟病患最佳治療方式，於1997-2009年屍體腎臟移植案例數僅1,883人，過去文獻多為探討腎臟移植之存活率，缺乏針對未移植透析病患與移植失敗透析病患來探討其腎臟移植失敗是否會影響其存活時間與相對風險。
目的：本研究欲探討腎臟移植失敗透析病患與無腎臟移植透析病患之存活比較及相對風險。
方法：研究對象為台灣全民健康保險研究資料庫1997-2009年間新發生透析病患100,665位，為了避免選擇性誤差，估算其腎臟移植之機率，並利用傾向分數以1:5比例配對，取得腹膜透析者840人、血液透析者2,760人，研究對象共3,600人。分析透析患者至2009年是否存活，以Cox對比涉險模式分析有移植失敗與無移植病患其存活相對風險與影響因素，並繪製存活曲線。
結果：以血液透析而言，移植失敗後繼續透析病患之死亡風險為無移植病患的0.7倍(95% CI: 0.56-0.87)；而腹膜透析移植失敗繼續透析病患之死亡風險為無移植病患的0.4倍(95% CI: 0.18-0.51)。就血液透析病患而言，男性死亡風險較女性高，且年紀越大、投保金額相對較低及有其他共病症者(充血性心臟病衰竭、糖尿病、腫瘤、慢性肝炎及腦血管疾病)其死亡風險越高，不同於其他共病症有高血壓之透析病患存活情形較佳。在主要透析醫院中固定至區域醫院、地區醫院以及基層診所透析者之死亡風險較不固定就醫者低；以腹膜透析病患來說，男性死亡風險較女性高，年齡越長其死亡風險較高，且固定至區域醫院與基層診所就醫者較不固定就醫者存活情形較佳。
結論：腎臟移植失敗繼續透析並不會增加病人死亡之風險。因此，政府與醫療院所應加強推廣台灣捐腎之風氣，增加移植率。

Background: In Taiwan, 62,963 patients received dialysis treatment in 2011. Even though the renal transplant is the optima treatment for patients with end-stage renal disease (ESRD), only 1,833 cases had renal transplantation from 1997 to 2009. However, since previous study focused on the survival rate of renal transplantation, there were fewer studies examining the differences in survival and related factors between failure of renal transplantation and never renal transplantation among ESRD patients.
Objectives: This research used the matching method based on propensity of transplantation to compare the survival of ESRD patients between failure of renal transplantation and never renal transplantation among ESRD patients, and to find related factors that influenced patients’ survival.
Method: The study population was 100,665 dialysis patients from 1997 to 2009 in Taiwan. Matching based on propensity of transplantation was used and the matching ratio was 1 to 5. This study included 840 peritoneal dialysis patients (PD) and 2,760 patients with hemodialysis (HD) after matching. These 3,600 patients were observed until 2009 to examine their survival status. Cox proportional hazards model was applied to find the relative risks of death.
Results: HD patients returning to dialysis after transplant failure had lower death risk than HD patients without transplantation (HR= 0.70; 95% CI: 0.56-0.87). In addition, the death risk of PD patients returning to dialysis after transplant failure was 0.4 times (95% CI: 0.18.0.51) than PD patients without transplantation. For HD patients, male had higher death risk than that of female. People with older age, lower premium-based salary, or suffering from co-morbidity, such as congestive heart failure, diabetes, cancer, chronic hepatitis and cerebral vascular disease have higher death risk. However, the death risk of HD patients suffering from hypertension was lower than those without hypertension. Patients were dialyzed in regional hospitals, district hospitals or clinics had lower death rate than those were dialyzed in irregular hospitals. In terms of PD patients, male or older patients had higher death risk. In addition, people were dialyzed in regional hospitals or clinics also had lower death risk than who were dialyzed in irregular hospitals.
Conclusions: The risk of death of patients returning to dialysis after transplant failure was not increased. Therefore, government and hospitals should promote kidney donation for increasing the renal transplant rate.

目錄
摘要 I
Abstract III
致謝 V
目錄 VI
表目錄 VIII
圖目錄 IX
第一章 緒論 1
一、研究背景與動機 1
二、研究目的 2
第二章 文獻探討 3
一、慢性腎臟病定義、分期 3
二、末期腎衰竭病患之替代療法 5
三、國內外腎臟移植之流行病學與存活率 7
四、影響透析病患存活之相關因素 13
五、文獻小結 16
第三章 研究方法 17
一、研究架構 17
二、研究假設 17
三、研究對象 19
四、資料來源 22
五、研究變項與操作型定義 23
六、統計分析方法 26
第四章 結果 28
一、透析病患等待移植時間 28
二、配對後透析病患之特性 29
三、透析病患腎臟移植失敗與無腎臟移植存活之雙變項分析 30
四、影響透析病患存活之相對風險因素 31
第五章 討論 34
一、探討腎臟移植失敗對透析病患之存活情形 34
二、影響腎臟移植失敗與未移植透析病患之存活相關因素 36
第六章 結論與建議 38
一、結論 38
二、建議 39
三、研究限制 40
參考文獻 68
附錄一、透析病患共病症編碼 73
附錄二、都市化程度分級表7級 74

 
表目錄
表2-1-1 慢性腎臟病分期 4
表2-1-2 ESRD與PRE-ESRD之國內外定義比較 4
表2-3-1 美國與台灣腎臟移植人數與移植率 8
表3-4-1 本研究變項之操作型定義 24
表3-6-1 腎臟移植手術後死亡人數 27
表4-1-1 移植病患從第一次透析日至移植日期所經歷時間 28
表4-2-1 腎臟移植失敗與無腎臟移植之血液透析病患PSM前後雙變項分析 41
表4-2-2 腎臟移植失敗與無腎臟移植之腹膜透析病患PSM前後雙變項分析 44
表4-2-3 配對後病患第一次透析時間分布 47
表4-3-1 血液透析病患各變項與存活與否之雙變項分析 48
表4-3-2 腹膜透析病患各變項與存活與否之雙變項分析 51
表4-4-1 血液透析病患是否存活之相關因素(排除30天內死亡) 54
表4-4-2 腹膜透析病患是否存活之相關因素(排除30天內死亡) 57
表4-4-3 血液透析病患是否存活之相關因素(排除90天內死亡) 60
表4-4-4 腹膜透析病患是否存活之相關因素(排除90天內死亡) 63

 
圖目錄
圖2-3-1 1998-2007年台灣境內外腎臟移植人數 9
圖2-3-2 美國與台灣腎臟移植病人存活率 11
圖2-3-3 美國與台灣腎臟移植器官存活率 12
圖3-1-1 研究架構 18
圖3-3-1 對象擷取流程圖 21
圖4-4-1 血液透析病患腎臟移植失敗繼續透析與未移植之存活曲線 66
圖4-4-2 腹膜透析病患腎臟移植失敗繼續透析與未移植之存活曲線 67

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