臺灣末期腎臟病患腹膜透析與血液透析之存活比較

Abstract

快速增加的末期腎臟病患為全世界健康照護體系共同面臨的困境，而台灣無論發生率或盛行率又為世界最高。因腎臟捐贈有限，透析治療乃延續病患生命的唯一途徑，透析模式以腹膜透析和血液透析為主。不同透析模式之探討為國際熱門研究，在存活比較上，由於缺乏隨機詴驗，研究結果隨方法和地區不同而分歧，目前尚無定論。本研究以整體台灣透析病患為分析對象，採用傾向分數-一個類隨機的研究設計，針對不同透析模式與病患存活的關係，期能提供更詳盡之概觀。 本研究屬回溯性次級資料分析，利用1997年至2007年之全民健保申報資料，選取1998年1月至2006年12月間台灣成年血液透析與腹膜透析新發病患，追蹤其存活情形至2007年12月。為了解病患於透析開始時之透析模式選擇與其存活之關係，本研究採用intention-to-treat (ITT)分析方式，以Kaplan-Meier(KM)法計算存活時間，並以Extended Cox Regression Model比較相對死亡風險。 研究結果顯示，不同透析模式與病患存活顯著相關，此關係又隨病患年齡、糖尿病有無和透析時間而有差異。49歲以下無論是否糖尿病，腹膜透析之相對死亡危險性為血液透析的0.7- 0.9倍；50-59歲非糖尿病患，相對危險性為0.9-1.0倍；50-59歲糖尿病患，相對危險性為1.2倍；60歲以上無論是否糖尿病，腹膜透析之存活較差，危險性約為血液透析1.1-1.7倍。透析時間與病患存活在各年齡和糖尿病分層中皆呈現相同趨勢，隨透析時間增加，腹膜透析之相對危險性逐漸提高，透析時間愈長對腹膜透析病患存活愈不利。 本研究結論認為，與血液透析相較，腹膜透析於較年輕和非糖尿病患中存活較好，但此優勢同時隨年齡、糖尿病和透析時間增加而遞減。如何建立透析模式轉換之最適模型，並以存活情形異於常模之特殊族群進行更深入之臨床分析，提供增進病患透析照護結果之治療建議，應為後續研究共同努力的方向。

The increasing numbers of end-stage renal disease (ESRD) patients is one of the important issues for healthcare systems around the world. Taiwan in particular for faces a difficult challenge since its prevalence and incidence rates in Taiwan are the highest of the world. Due to the scarceness of kidney donation, most of ESRD patients can only rely on dialysis therapies, including peritoneal dialysis (PD) and hemodialysis (HD). Research comparing PD and HD in different aspects is popular over the past decade. Studies comparing patient survival on HD and PD, however, have yielded conflicting results, depending on different populations and analysis methodologies. The present study is conducted by a Propensity Score analysis, which is a quasi-randomization design, estimating the survival and relative mortality hazard for PD and HD patients in the ESRD population in Taiwan. This study was a retrospective cohort of incident patients between January 1, 1998 and December 31, 2006. To compare the survival functions between PD and HD patients, the Kaplan-Meier life table was applied. Both proportional and non-proportional Cox regression models were employed to evaluate the relative hazard of death by dialysis modality using the intention-to-treat approach. Results showed that the hazard ratios (HR) of PD and HD patients varies by age and with/without diabetes (DM). Among patients under age 49 with or without DM, PD was associated with a lower risk of death. Adjusted mortality rates among patients aged between 50-59 with DM were higher on PD than on HD, but were lower without DM. Within patients aged over 60, whether DM or not, mortality rates were higher on PD than on HD. We also found that mortality rates for PD and HD were not proportional over time. The risk of death for PD patients was generally lower during the first year or first two years after the onset of dialysis. Thereafter, the risk of death increased on PD patients. In conclusion, there was an initial survival advantage of PD compared with HD among younger or non-DM patients. As the increase in age, with the presence of DM, as well as dialysis age, this relative survival advantage vanished, and even reversed. Further analyses are suggested in order to establish optimal care for ESRD dialysis patients, such as appropriate timing for modality switched and extra ordinary cases having better survivals than expected.