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完整後設資料紀錄
DC 欄位 | 值 | 語言 |
---|---|---|
dc.contributor.advisor | 簡國龍,杜裕康 | |
dc.contributor.author | Hon-Yen Wu | en |
dc.contributor.author | 吳泓彥 | zh_TW |
dc.date.accessioned | 2021-06-08T01:29:10Z | - |
dc.date.copyright | 2014-10-20 | |
dc.date.issued | 2014 | |
dc.date.submitted | 2014-07-29 | |
dc.identifier.citation | 1. Standards of medical care in diabetes--2014. Diabetes Care. 2014;37 Suppl 1:S14-80.
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dc.identifier.uri | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/18828 | - |
dc.description.abstract | Background: Due to the rising incidence of diabetes and the constrained health care resources in many countries, comparative effectiveness research are gaining importance for assisting decision making on controversial issues. Measurement of a random urine sample for albumin concentration (UAC) without simultaneously measuring urine creatinine is less expensive than measuring albumin to creatinine ratio (ACR), but whether their diagnostic performances for screening microalbuminuria are different has yet to be resolved. There is no consensus about the priority for treatments between angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), or the choice of antihypertensive drugs in combination with those renin-angiotensin system (RAS) blockers. The objective of this dissertation is to synthesize current evidence using advanced meta-analysis methods to resolve controversies regarding microalbuminuria screening and antihypertensive therapy in diabetic patients, and evaluate the effects of different antihypertensive treatments in a nationwide cohort study of diabetic patients
Methods: Three electronic databases (PubMed, MEDLINE, and Scopus) were systematically searched for studies assessing either UAC or ACR in detecting microalbuminuria among diabetic patients, and using urine albumin of 30-300 mg in 24-hour timed urine collection as the gold standard. Bivariate random-effects models were used for the pooling and comparisons of diagnostic performances. Four electronic databases (PubMed, MEDLINE, Scopus, and the Cochrane Library) were systematically searched for randomized clinical trials of antihypertensive treatments (ACEIs, ARBs, β-blockers, calcium channel blockers [CCBs], diuretics, and their combinations), which reported all-cause death, long-term dialysis, or doubling of serum creatinine. Bayesian network meta-analysis was applied to combine direct and indirect evidence and estimate the relative effects between treatments. Adult patients from the Longitudinal Cohort of Diabetes Patients of the National Health Insurance Research Database were assessed if they received at least 90 days of continuous antihypertensive treatment. Claims data including age, gender, comorbidities, income, occupation, geographic location, and outpatient prescriptions for antihypertensive drugs were obtained for each patient. Cox’s proportional hazard models were used to evaluate (1) ACEIs versus ARBs, and (2) CCBs versus thiazide diuretics as add-on treatment for RAS blockers, for the outcomes of long-term dialysis, acute kidney injury, hyperkalemia, and all-cause death. Results: Meta-analysis of screening tests for microalbuminuria showed pooled sensitivities of 0.85 and 0.87 for UAC and ACR, respectively, and pooled specificities of 0.88 and 0.88, respectively. No differences in sensitivity or specificity between UAC and ACR were found. Network meta-analysis of antihypertensive treatments showed that only ACEIs significantly reduced the doubling of serum creatinine levels (odds ratio 0.58, 95% credible interval 0.32 to 0.90) compared with placebo. The beneficial effects of ACEIs compared with ARBs did not reach statistical significance. The treatment ranking identified the combination of ACEI plus CCB to have the greatest probability (73.9%) for being the best treatment on reducing mortality, followed by ACEI plus diuretic (12.5%). The nationwide cohort study showed no difference between ACEIs and ARBs for long-term dialysis, acute kidney injury, and hyperkalemia. ACEI users showed a significantly higher mortality than ARB users (hazard ratio 1.20, 95% confidence interval 1.01 to 1.44), but this result is not consistently shown in subgroup analyses. The combination of RAS blocker plus CCB showed significantly higher risks of long-term dialysis (2.12, 1.62 to 2.78) and hyperkalemia (1.32, 1.07 to 1.64) compared with the combination of RAS blocker plus thiazide diuretic. Discussions and conclusions: UAC and ACR both yielded high sensitivity and specificity for the detection of microalbuminuria. Because the diagnostic performance of UAC is comparable to that of the ACR, we suggest UAC to be the screening tool of choice. As available evidence from experimental and observational studies is not able to clearly differentiate the protective effects of ACEIs and ARBs, we suggest the use of ACEIs as the first line antihypertensive agent in consideration of cost. The superior renoprotective effects of the combination of thiazide diuretic and RAS blocker required additional prospective studies to confirm. CCB therapy is the preferred add-on treatment if adequate blood pressure control cannot be achieved by ACEIs alone. | en |
dc.description.provenance | Made available in DSpace on 2021-06-08T01:29:10Z (GMT). No. of bitstreams: 1 ntu-103-F99849017-1.pdf: 10328000 bytes, checksum: 9a30c7afd9ba9a9671ccf88d9da30745 (MD5) Previous issue date: 2014 | en |
dc.description.tableofcontents | 誌謝 I
摘要 II Abstract IV Table of Contents VII List of Figures X List of Tables XII List of Appendixes XIV Chapter One: Introduction 1 1.1 Diabetic nephropathy 1 1.1.1 Epidemiology and significance 2 1.1.2 Microalbuminuria in diabetic patients 3 1.1.3 Knowledge gap: choice of screening method for detecting microalbuminuria in diabetic patients 4 1.2 Hypertension in diabetic patients 5 1.2.1 Epidemiology and significance 5 1.2.2 Management of hypertension in diabetic patients 6 1.2.3 Knowledge gap: choice of antihypertensive therapy for diabetic patients 11 Chapter Two: Objectives 14 Chapter Three: Materials and Methods 16 3.1 Comparison between different screening tests for microalbuminuria in diabetic patients using meta-analysis strategy 16 3.1.1 Data sources and searches 16 3.1.2 Study selection 16 3.1.3 Data extraction and quality assessment 17 3.1.4 Data synthesis and analysis 18 3.2 Comparison between different antihypertensive treatments in diabetic patients using meta-analysis strategy 19 3.2.1 Data sources and searches 19 3.2.2 Study selection 20 3.2.3 Data extraction and quality assessment 20 3.2.4 Data synthesis and analysis 21 3.3 Evaluating the effects of different antihypertensive treatments in a nationwide cohort study of diabetic patients 23 3.3.1 Data sources 24 3.3.2 Study participants 25 3.3.3 Study design and exposure assessment 25 3.3.4 Primary and secondary outcomes 27 3.3.5 Statistical analysis 28 Chapter Four: Results 31 4.1 Comparison between different screening tests for microalbuminuria in diabetic patients using meta-analysis strategy 31 4.1.1 Search process 31 4.1.2 Study characteristics 31 4.1.3 Summary Diagnostic Performance Measures 32 4.2 Comparison between different antihypertensive treatments in diabetic patients using meta-analysis strategy 33 4.2.1 Search process 33 4.2.2 Study characteristics 34 4.2.3 Effects of antihypertensive treatments on all-cause mortality 35 4.2.4 Effects of antihypertensive treatments on long-term dialysis 37 4.2.5 Effects of antihypertensive treatments on doubling of serum creatinine 38 4.2.6 Comparisons between traditional pair-wise and Bayesian network meta-analyses 39 4.3 Evaluating the effects of different antihypertensive treatments in a nationwide cohort study of diabetic patients 39 4.3.1 Patient Characteristics 39 4.3.2 Analyses comparing ACEI therapy with ARB therapy 41 4.3.3 Analyses comparing the combination of ACEI/ARB plus CCB with the combination of ACEI/ARB plus thiazide diuretic 44 Chapter Five: Discussion 48 5.1 Comparison between different screening tests for microalbuminuria in diabetic patients using meta-analysis strategy 48 5.1.1 Main findings 48 5.1.2 Strengths of this study 48 5.1.3 Results in relation to other studies and reviews 49 5.1.4 Limitations of this study 50 5.2 Comparison between different antihypertensive treatments in diabetic patients using meta-analysis strategy 52 5.2.1 Main findings 52 5.2.2 Strengths of this study 53 5.2.3 Results in relation to other studies and reviews 54 5.2.4 Limitations of this study 58 5.3 Evaluating the effects of different antihypertensive treatments in a nationwide cohort study of diabetic patients 60 5.3.1 Main findings 60 5.3.2 Strengths of this study 61 5.3.3 Results in relation to other studies and reviews 61 5.3.4 Limitations of this study 67 5.4 Conclusions 69 References 71 Figures 85 Tables 103 Appendixes 139 | |
dc.language.iso | en | |
dc.title | 從白蛋白尿篩檢到高血壓治療:糖尿病照護的實證醫療 | zh_TW |
dc.title | From Albuminuria Screening to Antihypertensive Therapy: Evidence-Based Approaches in Diabetes Care | en |
dc.type | Thesis | |
dc.date.schoolyear | 102-2 | |
dc.description.degree | 博士 | |
dc.contributor.oralexamcommittee | 賴美淑,洪冠予,唐德成 | |
dc.subject.keyword | 白蛋白尿,血管收縮素轉化?抑製劑,血管收縮素受體阻斷劑,鈣離子阻斷劑,糖尿病,透析,利尿劑, | zh_TW |
dc.subject.keyword | albuminuria,angiotensin converting enzyme inhibitors,angiotensin receptor blockers,calcium channel blockers,diabetes,dialysis,diuretics, | en |
dc.relation.page | 157 | |
dc.rights.note | 未授權 | |
dc.date.accepted | 2014-07-29 | |
dc.contributor.author-college | 公共衛生學院 | zh_TW |
dc.contributor.author-dept | 流行病學與預防醫學研究所 | zh_TW |
顯示於系所單位: | 流行病學與預防醫學研究所 |
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