臺灣博碩士論文加值系統

背景:
腎臟疾病為國內十大死亡原因之一，罹患腎臟疾病的民眾容易罹患心血管疾病與中風等併發症，容易進入末期腎臟病進而需要透析治療。造成腎臟疾病的原因相當複雜，除了已知因素如老化、糖尿病、高血壓的影響外，其他環境因子特別是日常生活中接觸到的塑化劑及三聚氰胺等物質逐漸受到重視，台灣於2011年5月爆發塑化劑事件，許多孩童因而長期誤食含有高劑量塑化劑，最主要包括鄰苯二甲酸二(2-乙基己基)酯(di-(2-ethylhexyl) phthalate；簡稱DEHP)等的食品及保健食品等。三聚氰胺（melamine），如同塑化劑普遍存在於日常生活環境，我們研究團隊與國家衛生研究院共同合作，針對全台184位當時可能暴露於DEHP汙染食品的孩童(≤ 10歲)並有尿液檢體做初步分析發現，DEHP增加了兒童微量白蛋白尿的風險，同時接觸三聚氰胺可能會影響此風險。孕婦與孩童皆為易感性族群，接觸三聚氰胺或DEHP這兩種常見的有毒物質可能會對孕婦健康造成不利影響，包括腎臟損害。
先前的動物研究文獻曾提出DEHP會造成腎絲球與腎小管發炎等變化，亦提出塑化劑影響腎臟功能可能是經由氧化傷害造成的，三聚氰胺會在遠端腎小管中產生結晶而造成腎結石和急性腎損傷， DEHP 和三聚氰胺可能透過相似的途徑增加腎臟的氧化傷害，進而損傷腎小球或腎小管細胞。過去的流行病學研究觀察到共同暴露DEHP和三聚氰胺可能會存在交互的不利影響，進而增加腎臟傷害的風險。
我們利用兩個資料庫，一個資料庫對象為塑化劑汙染食品申訴者群體中的兒童與青少年(「塑化劑事件申訴者之環境毒物及健康風險評估研究」，前瞻性研究)，另一個資料庫對象為第三孕期孕婦(「台灣婦幼出生世代研究」，橫斷式研究)，塑化劑事件申訴者之環境毒物及健康風險評估研究持續追蹤這些暴露DEHP汙染食品的孩童與青少年，觀察其早期腎臟損傷指標的變化，是否會隨著時間的推移而逆轉，並且追蹤其尿液塑化劑代謝物濃度、尿液三聚氰胺濃度、尿液氧化傷害指標的變化及其交互相關性。台灣婦幼出生世代研究則是探討第三孕期孕婦的DEHP和三聚氰胺暴露與早期腎臟傷害指標的相關性。
方法:
200 名曾有攝取DEHP汙染食品的兒童及青少年（年齡< 18 歲）參加了第一輪調查（2012年8月至 2013年1月），170 名兒童與青少年參與第二輪追蹤（2014年7月至 2015年 2月），159 名兒童與青少年參與第三輪追蹤（2016年5月至 2016年10月）。在第一輪調查會使用問卷收集有關過去每日可能食用DEHP污染食品的資料來計算事件當時每日DEHP攝取量。以單次早晨第一次尿液樣本來測量塑化劑代謝物、三聚氰胺、及氧化傷害指標（malondialdehyde (MDA) and 8-oxo-2'-deoxyguanosine (8-OHdG））和早期腎臟傷害指標（微白蛋白尿, 微白蛋白與肌酸酐比值Albumin to Creatinine Ratio；簡稱ACR) and N-乙酰-b-氨基葡萄糖苷酶, N-acetyl-beta-D-glucosaminidase (NAG)）。
在2012年10月至 2015年5月期間召募受試孕婦於第三孕期接受問卷調查、身體檢查以及血液和尿液檢查。以單次早晨第一次尿液樣本測量三聚氰胺、11 種塑化劑代謝物和和早期腎臟傷害指標(ACR和NAG)。根據三種尿液 DEHP 代謝物來計算每日 DEHP 攝入量。異常微白蛋白尿被定義為尿液ACR 高於 3.5 mg/mmol。
結果:
使用廣義估計方程式 (Generalized estimating equation, GEE)分析結果發現，過去塑化劑汙染食品與尿液微蛋白尿濃度有正相關，時間與尿液微蛋白尿濃度也有正相關，因此分析塑化劑汙染食品與時間的交互作用與微蛋白尿濃度的相關性發現，大多數交互作用為負相關，在過去每日DEHP 攝取量最高的組（>50 μg/kg/天）中，其在第二波追蹤調查觀察顯著負相關性（交互作用P值 = 0.014）。研究結果發現汙染食品中含DEHP愈高會增加兒童微量白蛋白尿的數值，雖此影響在第二次追蹤調查中短暫減弱，但在第三次追蹤調查中仍發現汙染食品DEHP對兒童微量白蛋白尿的影響持續存在，此外亦發現尿液三聚氰胺濃度與尿液微白蛋白尿及尿液氧化傷害指標有顯著相關。
共分析了 1433 名第三孕期的孕婦，其尿液三聚氰胺的中位數值為0.63 mg/mmol Cr 和估計的每日DEHP 攝取量為 1.84 mg/kg/day。與DEHP 攝取量第1四分位數組(1st quartile)相比，估計的 DEHP 攝取量的第4 四分位數組(4th quartile)個案的異常微白蛋白尿比例顯著增加。尿液三聚氰胺和DEHP 攝取量對於尿 ACR 和 NAG存在顯著的交互作用。
結論:
塑化劑與三聚氰胺為生活上常見的環境汙染物，可能影響易感性族群(包括：懷孕婦女或幼童)的腎臟功能，攝取塑化劑汙染食品的孩童與青少年應持續持續監測其腎臟功能和其他長期健康後果，孕婦也應盡量避免塑化劑及三聚氰胺等化學物質以減少腎臟傷害的風險，我們的研究成果不僅可了解對塑化劑及三聚氰胺與腎臟影響的相關機制以增加學術新知，更可對社會人群暴露於新興環境化學物質提出風險評估之指引。

Background:
Chronic Kidney disease (CKD) has been one of tenth death causes in Taiwan, and these patients have higher risk of progression to dialysis and cardiovascular mortality. The pathophysiology of renal function downhill is complex and multifactorial, and some environmental chemicals have been considered as additional crucial hazards of renal injury. A major health threat of phthalate-tainted foodstuffs occurred in Taiwan during April-July, 2011. Melamine has been considered an environmental nephrotoxin since the Chinese toxic milk scandal in 2008. Although the 2008 toxic milk scandal and the 2011 Taiwan food scandal have subsided, both phthalate and melamine are still widely present in the environment in Taiwan and are probably ubiquitous worldwide. Few animal studies have suggested that phthalates, such as di-(2-ethylhexyl) phthalate (DEHP) and di-iso-nonyl phthalate (DINP), can induce glomerulonephritis and damage tubulointerstitial tissues. Besides, exposure to either melamine or phthalate, two common toxicants, during pregnancy may cause adverse health effects, including kidney damage.
How the exact mechanism of kidney damage by phthalates occurs is still unclear. In collaboration with the researchers from National Health Research Institutes, we found that a significant and positive association between the levels of DEHP-tainted foods and microalbuminuria in affected children. Exposure to melamine perhaps modifies that risk. Previous studies suggested that oxidative stress may play a pathologic role of renal injury after phthalate exposure. However, phthalates via what molecular mechanisms to induce oxidative stress remains unknown.
Therefore, we hypothesize that children exposed to DEHP may be susceptible to glomerular injury leading to dysfunction of kidney, and the mechanism may include oxidative stress. This proposal includes two studies. One prospective cohort study (The Risk Assessment of the Phthalate Incident, RAPIT) investigates whether renal injury resulting from exposure to DEHP-tainted foods from the 2011 Taiwan Food Scandal is reversed over time. The temporal and interactive effects of past daily DEHP intake, current daily DEHP intake, and urinary melamine levels on oxidative stress and renal injury were also examined. In addition, we investigated the independent and interactive effect of exposure to melamine and phthalates, particularly DEHP, on markers of early renal injury in women their third trimester of pregnancy in another nationwide birth cohort, the Taiwan Maternal and Infant Cohort Study (TMICS).
Methods:
In RAPIT cohort, two hundred possibly DEHP-affected children (aged < 18 years) were enrolled in the first survey wave (August 2012–January 2013), with 170 and 159 children in the second (July 2014–February 2015) and third waves (May 2016–October 2016), respectively. The first wave comprised questionnaires that were used to collect information about possible past daily DEHP intake from DEHP-tainted foods. One-spot first morning urine samples were collected to measure melamine levels, phthalate metabolites, and markers indicating oxidative stress (malondialdehyde and 8-oxo-2'-deoxyguanosine), and renal injury (albumin/creatinine ratio (ACR) and N-acetyl-beta-D-glucosaminidase) in all three waves.
In TMICS cohort, participants were administered questionnaires, physical examinations, and blood and urine tests during their third trimester between October, 2012 and May, 2015. One-spot overnight urine specimens were used to simultaneously measure melamine, 11 phthalate metabolites, and two markers of renal injury, microalbumin and NAG. Estimated daily DEHP intake was calculated based on measurement of three urinary DEHP metabolites. Microalbuminuria was defined as having a urinary ACR higher than 3.5 mg/mmol.
Results:
In RAPIT cohort, we found that the highest impact associated with exposure to DEHP-tainted foods in increasing urinary ACR of children (aged < 18 years) was observed during the first wave, and the effect may partially diminish over time. Urinary melamine levels were significantly correlated to both urinary ACR and oxidative stress markers. In TMICS cohort, pregnant women in the highest quartile of estimated DEHP intake to have significantly higher urinary ACR and the prevalence of microalbuminuria, compared to those in the lowest quartile. In addition, there was a significant interactive effect between urinary melamine and estimated DEHP intake on urinary ACR and NAG.
Conclusion:
These results suggest that continuous monitoring of renal health and other long-term health consequences is required in individuals who were affected by the scandal in 2011. In addition, these two ubiquitous chemicals together may be associated with markers of early kidney injury in pregnant women. These findings are highly significant not only in public health but also in clinical medicine, since nowadays people are commonly exposed to phthalates or melamine due to they are ubiquitously present in the environment in our daily life.

1. 中文摘要 ------------------------------------------------ 4
2. 英文摘要 ------------------------------------------------ 8
3. 研究前言與目的 --------------------------------------- 13
4. 材料與方法---------------------------------------------- 22
5. 研究結果 ----------------------------------------------- 34
6. 討論 ------------------------------------------------------ 42
7. 結論、進行中的計畫與未來展望-------------------- 52
8. 圖表 ----------------------------------------------------- 56
9. 參考文獻 ------------------------------------------------ 84
10. 已接受刊登的研究 -------------------------------------- 92

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