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2010 年 7 10

1. 2. 見 3. 識理 4. 識 5. 6. 識理 7. 理

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) -1.154 x ( 年, years) - 0.203 x ( 女 0.742) 療

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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)

2004 年年數數數 3500 3000 數2500 2000 1500 1000 500 0 350 300 250 200 150 數0-19 20-44 45-64 65-74 75 100 50 0-19 20-44 45-64 65-74 75+ 年 HD PD 51.9 y 數數63.7 y 3500 3000 2500 2000 1500 1000 500 0 (ESRD) 0-19 20-44 45-64 65-74 75+ 年 HD+PD 62.7 y 0 0-19 20-44 45-64 65-74 75+ 0-19 20-44 45-64 65-74 75 As of 2007: mean age: 63.8 y 年 (2004 & 2007 data)

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

率率 (per 1000s) in 1998-2000 Country All-cause death ASCVD death Germany (5) 10.31 4.36 (42.3%) Belgium* (8) 10.28 3.54 (34.4%) Norway (32) 10.11 3.93 (38.9%) USA (2) 8.77 3.16 (36.0%) Canada (12) 7.21 2.39 (33.1%) Japan (4) 7.83 2.31 (29.5%) Korea (13) 5.15 1.12 (21.9%) Taiwan (1) 5.61 1.15 (20.5%) Australia (31) 6.83 2.49 (36.5%) Poland (28) 9.52 3.53 (37%) * Data in 1996 Numbers in parenthesis denote ranks of ESRD incidence in 2003

率率 (per 1000s) in 2000-2003 Country All-cause death ASCVD death Germany (5) 178 43.08 (24.2%) Belgium (8) 227 83.85 (36.9%) Norway (32) 269.1 100.89 (38.3%) USA (2) 242.5 109.29 (45%) Canada (12) 136.9 46.7 (34.1%) Japan (4) 87.5 42.2 (48.2%) Korea (13) 54.5 21.5 (39.5%) Taiwan (1) 145.5 N/A (~26-44%) Australia (31) 144.1 76 (52.7%) Poland (28) 182.6 N/A Numbers in parenthesis denote ranks of ESRD incidence in 2003

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

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% 1990 1992 1994 1996 1998 2000 2002 2004 2006 Calendar year Nephrol Dial Transplant 23:3977-3982, 2008

率, 罹? Wen et al, Lancet 2008;371:2173-2182 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

療 - Cr 不?! % Partly attributed to physicians? Am J Kidney Dis 48:727-738, 2006

糖尿,,, Stages 1-2 Stages 3 GFR 惡度 Stages 4 Stage 5 before dialysis 療

( ) GFR 降度 GFR decline (ml/min/year) 2.24 4.22 3.23 Chiu et al, Nephron Clin Prac 2008;109:c109 c118

( ) 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 c118 2003 ~ 2006

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

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

不率 CVD CVD Levin, Semin Dial 16:101-105, 2003

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;55:856-866

( ) 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

率率罹

& 行率 (1990 ~ 2007) 年 65 Prevalence Rate (pmp) 10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 NHI 1990 1992 1994 1996 1998 2000 2002 2004 2006 Age 75 Age 65-74 Age 45-64 All Patient Age 20-44 Age 0-19 Calendar year (2007 data)

度 & 行率 Taiwan USA Japan Nephrol Dial Transplant 2005;20:2587-2593

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

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療里立連量料錄療量

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

Taiwan Society of Nephrology Hospital Unit 100 80 60 40 20 0 5 Third grade Second grade First grade 12 19 44 79 79 2003 2004 2005 2006 2007 2008 89 2009 Calendar Year (2009 data)

數 10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 2252 26553034 3858 3519 6085 5699 4954 5315 7430 6859 8430 8795 9095 9197 9900 9619 9538 Calendar year (2007 data)

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CKD ESRD

? 念, CKD, 降率 CKD, drop-out, 糖尿, ESRD,

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;339:123-126

GFR 降度 1. The rates of annual egfr decline slowed significantly from -7.38 +/- 0.84 before referral to -1.02 +/- 0.45 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;13:730-736

? 念, CKD, 降率 CKD drop-out, 糖尿, ESRD,

25 2007 年 ESRD ESRD 率 395 376 345 362 374 339 404 386 371 北 216 444 446 488 483 464 481 368 518 411 524 446 474 (2007 data)

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