Factors Associated with Survival and Cancer Risk in the Prognosis for Patients with End-Stage Renal Disease

• Main Authors: Yu-Kang Chang, 張祐剛
• Other Authors: Fung-Chang Sung
• Format: Others
• Language: zh-TW
• Published: 2012
• Online Access: http://ndltd.ncl.edu.tw/handle/84497331843715886477

博士 === 中國醫藥大學 === 公共衛生學系博士班 === 100 === The incidence and prevalence of chronic kidney disease (CKD) are on the rise worldwide. Patients with end-stage renal disease (ESRD) treated with hemodialysis (HD), peritoneal dialysis (PD) and kidney transplantation is also rising greatly. According to the US Renal Data System (USRDS) Annual Report in 2011, the prevalence of ESRD patients in Taiwan has become the highest in the world since 2002. The incidence in Taiwan was only lower than that in Mexico city and the U.S. ESRD patients accounted for only 0.3% of the total population in Taiwan in 2010; however, more than 8% of the annual national health expenditure was used to care these patients. Health care expenditures for ESRD patients have become a huge burden to the society. This dissertation studied this disease with three subprojects: 1. Evaluation on mortality for patients with hemodialysis treatment associated with fixed dialysis reimbursement. 2. Comparison study on the mortality between patients with peritoneal dialysis treatment and patients with hemodialysis treatment. 3. The risk of subsequent cancer for patients with dialysis. The first study used the population-based insurance claims data of Taiwan to evaluate the trends of cost and mortality risk for HD patients cared among 8 annual subcohorts with 4-year follow-up each. The results showed that the real payment for each HD service decreased from NTD $4,100 in 1997 to $3,473 in 2005. However, the corresponding mean cost per patient increased annually from NTD 12,930 (USD 431) to NTD 22,110 (USD 737) for emergency visit and from NTD 270,210 (USD 9,007) to NTD 398,400 (USD 13,280) for hospitalization. Compared with the 1998 subcohort, the hazard ratio (HR) of mortality in the 4-year follow-up decreased chronologically from 0.97 (95% confidence interval (CI) 0.91-1.02) for 1999 subcohort to 0.86 (95% CI 0.82-0.91) for 2005 subcohort. This study suggests that the risk of mortality for HD patients decreased annually. The increased uses of emergency services and increased hospitalization may reflect the increased attention to the care of disease. The second study also used the population-based insurance claims data of Taiwan from 1997 to 2006 to identify 4,721 patients treated with PD and randomly selected 4,721 patients treated with HD, frequency matched with the propensity scores. In the follow-up analyses, we measured mortalities and hazard ratios of death associated with comorbidities for 2 periods, 5 years in each period (1997-2001 and 2002-2006). In the 10-year period from 1997 to 2006, the overall mortality rates were similar for patients treated with PD and for patients treated with HD (12.0 vs. 11.7 per 100 person-years, respectively), with a PD-to-HD hazard ratio of 1.02 (95% CI, 0.96-1.08). In the first 5-year period (1997-2001), the mortality risk was higher for patient with PD (HR = 1.33, 95% CI 1.21-1.46). But the difference disappeared in the 2002-2006 cohort (HR = 0.99, 95% CI 0.87-1.14). Younger patients with PD treatment had better survival than those with HD treatment; this was especially true for patients younger than 40 years of age. In this Asian population, no significant survival difference was noted between propensity score-matched PD and HD patients. The selection of a dialysis modality must be tailored to the individual patient. Finally, the third study used the retrospective cohort study design and compared the cancer risk between dialysis patients and general population frequency matched with sex and age. The results showed that the incidence of cancer was significantly higher in dialysis patients than in the general population. Dialysis patients had extremely high risk of kidney cancer, bladder cancer and transitional cell carcinomas, approximately 12 to 14 folds greater than that for the general population. Furthermore, we found that patients with urinary tract infection, and taking herb and acetaminophen were at an elevated cancer risk. This study also found that aspirin was associated with the declined cancer risk. Our findings can be adapted to the care for patients with dialysis to reduce the risk of cancer.