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1 2010 年 7 10

2 1. 2. 見 3. 識 理 4. 識 識 理 7. 理

3 糖尿, GFR (ml/min/1.73m 2 ),, or mild in kidney function ( 60 ml/min/1.73m 2 ) Moderate in kidney function (30-59 ml/min/1.73m 2 ) Severe in kidney function (15-29 ml/min/1.73m 2 ) (<15 ml/min/1.73m 2 ),, Stages 1-2 Stages 3 Stages 4 Stage 5 before dialysis 易 MDRD 186 x (, mg/dl) x ( 年, years) x ( 女 0.742) 療

4 來

5 療 數 52,537 48,072 4,465 行率 2,288 per million population 率 416 per million population PD 8.5 % HD 91.5 % (2007 data)

6 2004 年 年 數 數 數 數 數 年 HD PD 51.9 y 數 數63.7 y (ESRD) 年 HD+PD 62.7 y As of 2007: mean age: 63.8 y 年 (2004 & 2007 data)

7 行? 1. ( ) 異? 2. ( ) 率? 3. ( 糖尿, )? 4. 率? 5. 罹? 6. 療不 惡 度? 7.,?

8 率 率 (per 1000s) in Country All-cause death ASCVD death Germany (5) (42.3%) Belgium* (8) (34.4%) Norway (32) (38.9%) USA (2) (36.0%) Canada (12) (33.1%) Japan (4) (29.5%) Korea (13) (21.9%) Taiwan (1) (20.5%) Australia (31) (36.5%) Poland (28) (37%) * Data in 1996 Numbers in parenthesis denote ranks of ESRD incidence in 2003

9 率 率 (per 1000s) in Country All-cause death ASCVD death Germany (5) (24.2%) Belgium (8) (36.9%) Norway (32) (38.3%) USA (2) (45%) Canada (12) (34.1%) Japan (4) (48.2%) Korea (13) (39.5%) Taiwan (1) N/A (~26-44%) Australia (31) (52.7%) Poland (28) N/A Numbers in parenthesis denote ranks of ESRD incidence in 2003

10 率 率 - ( ) 異 ALL ALL Asian Asian USRDS 2002, Annual Data Report

11 新發生末期腎病的原發病因演變 (1990 ~ 2006) Chronic GN 50% CIN HTN DM nephropathy 全民健保 Incidence Rate (%) 40% 43.2% 38.6% 30% 20% 25.1% 24.7% 10% 0% Calendar year Nephrol Dial Transplant 23: , 2008

12 率, 罹? Wen et al, Lancet 2008;371: Total: 11.9% Stage 1: 1.0% Two millions Stage 2: 3.8% CKD population Stage 3: 6.8% but awareness Stage 4: 0.2% Stage 5: 0.1% rate is only 3.5% Wen CP et al. Lancet 2008 不 罹 療

13 療 - Cr 不?! % Partly attributed to physicians? Am J Kidney Dis 48: , 2006

14 糖尿,,, Stages 1-2 Stages 3 GFR 惡 度 Stages 4 Stage 5 before dialysis 療

15 ( ) GFR 降 度 GFR decline (ml/min/year) Chiu et al, Nephron Clin Prac 2008;109:c109 c118

16 ( ) 年 - CKD (n=433) Stage 3 Stage 4 Stage 5 (n=184) (n=142) (n=107) 3-year patients outcomes Chiu et al, Nephron Clin Prac 2008;109:c109 c ~ 2006

17 年 - CKD (n=121) Stage 1 Stage 2 Stage 3A Stage 3B Stage 4 Stage 5 (n=1) (n=6) (n=9) (n=25) (n=28) (n=52) Death RRT Death RRT 3-year patients outcomes 2005 ~ 2008

18

19 ( ) ( 年 ) Chiu et al, Nephron Clin Prac 2008;109:c109 c118

20 不 率 CVD CVD Levin, Semin Dial 16: , 2003

21 易罹 1. CKD : microalbuminuria or low egfr 2. A comprehensive screening program for CKD is equally important in both relatives (15.8% vs 7.5%) and spouses (41.1% vs 15.8%) of HD patients, especially for participants with the such risk factors as older age, hypertension, and DM. 3. Spousal concordance of CKD suggests that the shared environmental factors and health behaviors might have important roles in the development of CKD. Tsai et al, Am J Kidney Dis 2010;55:

22 ( ) CVD ( ): Sudden death Coronary heart disease (old MI, (+) cardiac thallium or coronary angiography) Congestive heart failure CVA (ischemia or hemorrhage) PAOD Chiu et al, Nephron Clin Prac 2008;109:c109 c118

23 率 率 罹

24 & 行率 (1990 ~ 2007) 年 65 Prevalence Rate (pmp) NHI Age 75 Age Age All Patient Age Age 0-19 Calendar year (2007 data)

25 度 & 行率 Taiwan USA Japan Nephrol Dial Transplant 2005;20:

26 廓 率 (Ccr) < 5 ml/min (Cr) 10.0 mg/dl 糖尿 度 Ccr 15 ml/min Cr 6.0 mg/dl 列 糖尿 度 Ccr 10 ml/min Cr > 8.0 mg/dl

27 來

28 療 里 立 連 量 料 錄 療 量

29 Parts of hospital and clinic global budget sectors Inpatient Dialysis Outpatient Dialysis Outpatient Dialysis Combined as a separate budget for outpatient dialysis service HD case payment PD fee for service 留

30 Taiwan Society of Nephrology Hospital Unit Third grade Second grade First grade Calendar Year (2009 data)

31 數 Calendar year (2007 data)

32 來

33 CKD ESRD

34 ? 念, CKD, 降 率 CKD, drop-out, 糖尿, ESRD,

35 率 ( ) - Live and let dialysis 1. Early referral (ER) and late referral (LR) were defined as referral to nephrologists greater or less than 6 months, respectively, before the initiation of HD. 2. ER patients were less likely to have hypoalbuminemia, more likely to have received erythropoietin or phosphate binder therapy, more likely to have a vascular access created at the first HD, and had a slower rate of renal function decline before HD. 3. LR (hazard ratio: 2.827; P = 0.049) and DM were both independently associated with increased mortality risk. 4. The survival benefits of ER seem to be originated from the period before initiation of renal replacement therapy, i.e., exclusion of lead-time bias. Chen et al, Am J Med Sci 2010;339:

36 GFR 降 度 1. The rates of annual egfr decline slowed significantly from / before referral to / ml/min per 1.73 m(2)/year after referral (mean +/- standard error of the mean, P < 0.001). 2. The nephrology referral was the most significant factor associated with the slowing of renal function progression, as was younger age and female sex. 3. Slowing renal functional decline in CKD patients after referral addresses the importance of nephrology referral for CKD care, which should be strongly promoted in CKD prevention projects in Taiwan. Chen et al, Nephrology 2008;13:

37 ? 念, CKD, 降 率 CKD drop-out, 糖尿, ESRD,

38 年 ESRD ESRD 率 北 (2007 data)

39 略 CKD CKD PreESRD care (, /, ) 離 PD 勵 ESRD 率 BNHI BHP ) BHP ) DOH ) (NSC, NHRI, DOH)