台灣慢性病人醫療利用之探討－－以慢性腎臟病、糖尿病及高血壓為例

Objective To compare the prevalence and correlation factors of chronic kidney disease (CKD) in urban and rural areas in Minhang district of Shanghai through the social economic and clinical data of the elderly population. Methods Jiangchuan Street and Pujiang town were randomly selected to represent the urban and rural population in Minhang district of Shanghai, respectively. Based on the over-60-year old people health examination program, 6151 objectives with complete clinical-epidemiological data and bio-chemical index were investigated. The prevalence of CKD in urban and rural areas was compared, and the correlation factors for the urban and rural CKD were evaluated by multiple logistic regression analysis. Results (1) The survey objectives with an average age of (69.57±7.04) years, including 4345 cases of the city residents and 1806 cases of rural residents, were enrolled. The age structures of urban and rural showed differences, population over 80 years old account for 13.1% of the rural total, significantly higher than 7.4% in the urban population (P<0.001). (2) The prevalence rates of diabetes, hyperuricemia, hyperlipidemia and hyperlipidemia in urban residents were higher than those in rural residents, which were 26.4% vs 13.7%, 9.9% vs 2.3%, 53.7% vs 37.4%, 51.4% vs 15.6% (all P<0.01). The awareness rates of kidney disease and hyperlipidemia showed significant differences in urban and rural areas, which were 32.9% vs 44.2%, 84.6% vs 62.8% (all P<0.01). Compared with those in rural areas, the treatment rates of hypertension and high blood lipids in urban residents were increased (all P<0.01). (3) The prevalence of CKD was 23.4%. Female CKD prevalence was higher than male, respectively 26.3% and 18.5% (P<0.01). In urban CKD prevalence was 22.2%, lower than 25.2% in rural. The prevalence rate of hematuria in urban areas was lower than in rural areas, but the prevalence rate of decline in renal function was higher (all P<0.05). With the increase of age, the prevalence rate of CKD was increased (P<0.01). (4) Age (OR=1.072), smoking history (OR=1.543), previous history of kidney disease (OR=1.351), diabetes (OR=1.373), hyperuricemia (OR=2.498), obesity (OR=1.364), history of interventional therapy (OR=1.896) had positive correlation with CKD in city elderly population, while the higher education (OR=0.676, OR=0.604) and drinking (OR=0.585) had negative correlation (all P<0.05). Age (OR=1.032), female (OR=1.860) had positive correlation with CKD in rural elderly population (all P<0.05). Conclusions CKD has been a common chronic progressive disease of the aged in Minhang district. The prevalence of CKD is higher in urban areas than in rural. Age is a common factor for CKD in urban and rural. Previous smoking, history of kidney disease, diabetes, hyperuricemia, obesity, history of interventional therapy, education and drinking have correlation with urban CKD patients. Female has correlation with rural CKD population. Key words: Renal insufficiency, chronic; Aged; Prevalence; Risk factors; Urban and rural

Objectives To investigate the effect of thyroid hormone on thyroid hormone level, malnutrition and left heart function in patients with chronic kidney disease(CKD). Methods 210 patients with chronic kidney disease in our hospital from February 2013 to February 2015 were selected, Group A: patients with CKD [eGFR <15mL·(min·1.73m2)-1](n=70), Group B: patients with CKD [15<eGFR <30mL·(min·1.73m2)-1](n = 70), Group C: patients with CKD[30 <eGFR <60mL·(min·1. 73m2)-1](n=70), Group D: healthy examinees during the same period in our hospital were selected as control group(n=70). The free triiodothyronine(FT3), free thyroxine (FT4), thyroid stimulating hormone (TSH) , hemoglobin(Hb), serum albumin(ALB), total cholesterol(TC), triglyceride(TG), serum creatinine(SCr), C-reactive protein(CRP) and left ventricular ejection fraction (LVEF) , left ventricular mass index(LVMI), subjective global assessment of nutritional act(SGA) and other indicators were detected in four groups. Patients in group A、B、C were divided into two sub-groups according to thyroid hormone levels: group 1(normal thyroid level ) and group 2 (abnormal). And the administration of small dose of thyroid hormone was given to patients in group 2, the effect of the administration was evaluated by the above indexes. Results The FT3 in group A 、B and C were significantly lower than that in group D(P<0.05). The incidence of low T3 syndrome rose with eGFR decline. There were significant differences of levels of ALB、CRP、SGA、LVEF、LVMI between group 1 and group 2, and the FT3 level in group 2 was significant correlated with eGFR, SGA, ALB, LVEF(r=0.912, P<0.001; r=0.721, P<0. 001; r=0.810, P<0.001; r=0.903, P<0.001) , negatively correlated with CRP, LVMI was(r=-0.981, P<0 001; r=-0.442, P<0.001). After treated with small dose of thyroid hormone, FT3 and LVEF were improved while FT4, TSH, ALB, SGA, CRP, LVMI were not improved in group 2.eGFR level was improved only in group C2(P<0.05). Conclusions Serum T3 levels were associated with severity of CKD. Small doses of thyroid hormone therapy had an impact on left ventricular systolic function in CKD patient with low T3 and subclinical hypothyroidism, eGFR improvement in patients with moderate renal impairment. Key words: Kidney Diseases; Chronic Disease; Thyroxine; Thyroid Hormones

Objective To investigate the relative factors of depression in elderly inpatients with multiple chronic diseases. Methods A total of 438 elderly inpatients with multiple chronic diseases were investigated and analyzed by the comprehensive geriatric assessment. Results Among 438 elderly inpatients with chronic diseases, 154 cases (35.15%) were accompanied by depression.The rates of female, non-marital status (single/widowed/divorced), lower income, frequent fall and insomnia were significantly higher in depression group than in non-depression group (P=0.02, 0.00, 0.00, 0.00, 0.00, respectively). The scores of cognitive function, nutritional status and activities of daily living were significantly lower in depression group than in non-depression group (P=0.03, 0.00, 0.00, respectively), and the pain score was significantly higher in depression group than in non-depression group (P=0.00). The prevalence of diabetes and chronic obstructive pulmonary disease was significantly higher in depression group (P=0.03, 0.04; respectively). Multiple Logistic regression analysis revealed that non-marital status, low income, insomnia, cognitive impairment, malnutrition and diabetes could significantly increase the risk of depression in elderly patients with chronic diseases (OR=2.291, 2.065, 2.384, 2.965, 2.561, 1.949, respectively, all P<0.05). Conclusions Female, non-marital status, falls, insomnia, cognitive dysfunction, malnutrition, decreased viability of daily life, diabetes, chronic pain and chronic obstructive pulmonary disease are positively associated with the late-life depression.Among them, non-marital status, low income, insomnia, cognitive dysfunction, malnutrition and diabetes could markedly increase the risk of depression in elderly patients with chronic diseases. Key words: Comprehensive geriatric assessment; Depression; Risk factors

Objective To study the health status of the elderly in Hubei province, in order to provide the evidence for health management in the elderly. Methods A stratified cluster random sampling method was applied.60 resident families who lived there for more than half a year were randomly extracted from each villages or community in 20 pre-confirmed counties(or cities, districts)from October to November 2013.Household questionnaire survey was conducted among these families.5 self-assessment indexes for health were selected.The health status of residents was evaluated by using comprehensive health assessment, and the score ranges were from 0 to 100, with a value of 0 indicating the worst health status and 100 indicating the best.The prevalence of chronic diseases in the elderly and its related factors were analyzed. Results The total number of study people aged 60 years and above were 8 358, with 3 738 urban residents(44.7%)and 4 620 rural residents(55.3%), 4 092 males(49.0%)and 4 266 females(51.0%), and the average age was(68.5± 7.1)years.The score of health self-assessment of the elderly was(72.7±14.7). The two-week morbidity rate in the elderly was 45.7%(3 816 cases), and the prevalence rate of chronic diseases was 73.8%(6 169). Hypertension and diabetes were the major diseases in the elderly based on the analysis of two-week morbidity and chronic diseases.Multiple logistic regression analysis showed that urban-rural difference, gender, age, education level, marital status and employment status were the related factors for the two-week morbidity rate(all P<0.05). And urban-rural difference, gender, age, education level, employment status and economic status were also the related factors for the prevalence rate of chronic disease(all P<0.05). Conclusions The self-evaluation of health and chronic diseases status are not optimistic in the elderly in Hubei province, which are associated with urban-rural, social, economic and environmental factors.Thus chronic disease management strategy for the elderly should be developed based on these characteristics. Key words: Health surveys; Prevalence; Chronic disease

As the global population ages, the incidence of chronic kidney disease (CKD) in the elderly has increased year by year. Due to changes in the physical, psychological, economic, and social status of the elderly, CKD in the elderly has its own particularity. Elderly patients with CKD are prone to diabetes, hypertension, cardiovascular and cerebrovascular diseases, and other basic diseases, and the possibility of drug treatment and surgical treatment is high, which increases the chance of kidney damage. Elderly patients with CKD are also prone to decline of physical and cognitive function, depression, malnutrition, osteoporosis, and weakness, which need comprehensive evaluation. Elderly patients with CKD have a high risk of complications and death. Thus it is necessary to evaluate the patients′ conditions individually to predict the risk of death or progression to ESRD, so as to decide whether to mainly provide supportive treatment for protecting the kidney, or to provide supportive treatment together with preparing the renal replacement therapy. High-quality clinical studies in elderly CKD patients should be conducted to provide more evidence-based data for the diagnosis and treatment. Key words: Chronic kidney disease; Elderly; Diagnosis; Complication

CKD of Unknown Origin in Central America: The Case for a Mesoamerican Nephropathy

Objective To analyze the risk factors of chronic kidney disease complicated with acute kidney injury and its treatment efficacy.Methods 180 chronic kidney disease patients complicated with acute kidney injury were divided into the elderly group and the young group.The underlying diseases,risk factors of acute kidney injury and clinical efficacy were compared between the two groups.Results The proportions of chronic glomerulonephritis,nephrotic syndrome and lupus nephritis in young and middle-aged group were 37.8％,15.6％ and 20.0％,which were significantly higher than those in the elderly group (17.8％,8.9％,2.2％) (P ＜ 0.05).The proportions of diabetic nephropathy and hypertensive renal injury in elderly patients were 31.1％ and 24.4％,which were significantly higher than those in the young and middle-aged group (6.7％,4.4％) (P ＜ 0.05).In the old age group,the proportions of infections and renal toxicity drugs were 28.9％ and 22.2％,which were significantly higher than those in the young group.In the young and middle-aged group,the proportions of malignant hypertension and deterioration of the primary disease were 22.2％ and 26.7％,which were significantly higher than those in the elderly group (P ＜0.05).The total effective rate of the young group was 88.9％,which was significantly higher than 71.1％ of the elderly group (x2 =6.846,P ＜ 0.05).Conclusion Elderly and young and middle-aged chronic kidney disease patients complicated with acute kidney injury have differences in risk factors and clinical efficacy. Key words: Nephrosis ; Kidney injury; Risk factors ; Age groups

Objective To investigate the prevalence and possible influence factors in patients with inflammatory bowel disease (IBD) complicated with chronic kidney disease (CKD) . Methods Patients diagnosed as IBD at The Sixth Affiliated Hospital of Sun Yat-sen University, from March 2012 to March 2018 were retrospectively enrolled. These patients were divided into chronic kidney disease group and non-chronic kidney disease group according to the occurrence of CKD. Univariate and multivariate analysis were used to reveal the influence factors of chronic kidney disease. Results A total of 2499 patients with inflammatory bowel disease were enrolled in this study. The follow-up period was (39 ± 18) months. Chronic kidney disease was found in 151 of 2499 patients, the overall prevalence was 6.04%. The prevalence of CKD in Crohn′s disease was higher than that in ulcerative colitis (7.22% vs. 3.58%, P<0.05) . Nine of 122 patients of Crohn′s disease complicated with chronic kidney disease underwent renal puncture, of whom 8 cases were diagnosed as IgA nephropathy. Compared with the non-chronic kidney disease group, the chronic kidney disease group had more male (78.15% vs. 68.57%, P = 0.01) , lower BMI (17.72 kg/m2 vs. 18.75kg/m2, P<0.05) , longer course of disease (36 months vs. 24 months, P = 0.02) , higher operation rate (23.18% vs. 11.24%, P<0.05) . Multivariate analysis showed that male (OR: 1.72, 95% CI: 1.15-2.58) , IBD-associated surgical history (OR: 1.79, 95% CI: 1.17-2.73) and the use of immunosuppressive agents (OR: 2.76, 95% CI: 1.92-3.97) were the risk factors of inflammatory bowel disease complicated with chronic kidney disease, while normal BMI rather than low BMI (OR: 0.55, 95% CI: 0.38-0.80) was the protection factor of inflammatory bowel disease complicated with chronic kidney disease. Conclusions Chronic kidney disease is not rare in patients with inflammatory bowel disease. Male, IBD-associated surgical history and the use of immunosuppressive agents are the risk factors of chronic kidney disease in patients with IBD, while normal BMI is the protection factor. Key words: Inflammatory bowel disease; Chronic kidney disease; Prevalence; Clinical characteristics; Influence factors

Objective To investigate the prevalence of chronic kidney disease(CKD) and associated factors in BeiJie village of the central plains region. Methods 1819 residents older than 18 years old.in the village were selected. They were interviewed and received physical examination and measurements for the kidney damage indicators and the associated factors with CKD. Results Eligible data of 1380 subjects were enrolled in the study. After the adjustment of age and gender component, the prevalence of albuminuria,hematuria and reduced renal function was 6.2%, 7.3% and 1.6%, respectively. The prevalence of chronic kidney disease is 13.0%,and the awareness rate was 10.6% . The Logistic regression model showed that age, hypertension, diabetes mellitus and hyperuricaemia were independently correlated with CKD. Conclusions The prevalence of chronic kidney disease is 13.0% and the awareness rate is10.6% in the village of the central plains region. Independent risk factors associated with kidney damage are age, hypertension, diabetes mellitus and hyperuricaemia. Key words: Kidney disease,chronic; Prevalence; Epidemiology; Village

Objective To investigate the detection rate and possible factors of hyperhomocysteinemia(HHcy) in children with chronic kidney disease(CKD). Methods The clinical data of children with CKD between July 2012 and September 2016 in the Department of Pediatrics, Peking University First Hospital were retrospectively collected.The homocysteine(Hcy) level of patients were measured.The other data included the general information, diagnosis and laboratory test results. Results Seventy-six pediatric patients with CKD were enrolled including 49 boys and 27 girls.The average age of the patients was (9.9±3.4) years old.The main cause of the patients in the study was primary glomerulopathy(48.7%, 37/76 cases), and the rest were congenital and inherited glomerular diseases(36.8%, 28/76 cases), secondary glomerular diseases(9.2%, 7/76 cases)and renal tubular diseases(5.3%, 4/76 cases). Fifty patients (65.8%, 50/76 cases) had normal level of Hcy which was 10.40(7.30, 11.62) μmol/L.Twenty-six patients(34.2%, 26/76) were detected with HHcy whose Hcy level was 17.93(16.76, 24.11) μmol/L.The detection rate of HHcy in CKD stage 1, stage 2, stage 3, stage 4 and stage 5 was 13.9%(5/36 cases), 22.2%(2/9 cases), 50.0%(4/8 cases), 57.1%(4/7 cases) and 68.8%(11/16 cases) respectively, and the detection rate increased with CKD stages and the difference was statistically significant (χ2=17.574, P<0.001). The level of Hcy was 10.05(7.04, 12.47) μmol/L, 11.75(10.78, 16.44) μmol/L, 13.73(10.09, 18.23) μmol/L, 15.81(11.12, 20.71) μmol/L and 17.39(11.86, 24.76) μmol/L in CKD stage 1, stage 2, stage 3, stage 4 and stage 5, respectively.The Kruskal-Wallis test revealed that the distribution of homocysteine in CKD stages had statistically significant difference(P=0.001). Multiple linear regression model showed that creatinine clearance was an independent predicator of HHcy. Conclusions In this study of the CKD patients, the detection rate of HHcy was high and increased with the progression of CKD.HHcy is mainly influenced by creatinine clearance in CKD.The level of Hcy should be monitored regularly in children with CKD and HHcy should be treated with proper measures. Key words: Homocysteine; Chronic kidney disease; Creatinine clearance; Child

Objectives To explore the association of hyperhomocysteinemia(HHcy) with chronic kidney disease (CKD) in patients with newly diagnosed diabetes. Methods Adults who visited the health checkup clinic consecutively were included in the study. Questionnaires including the following questions, such as age, gender and smoking were fulfilled. Height, weight, blood pressure, blood sugar, serum lipid, serum creatinine, blood uric acid and glycosylated hemoglobin were measured. Newly diagnosed diabetes were defined as fasting plasma glucose levels of 7.0 mmol/L or higher and/or glycosylated hemoglobin of 6.5% or more. CKD was defined as decreased kidney function [(estimated glomerular filtration (eGFR) < 60 mL·(min·1.73m2)-1] or (proteinuria≥1+ ). Multivariable logistic regression analysis were used to study the association of hyperhomocysteinemia with CKD. Results In the study, 1801 adults with the average age(61.3±10.1) years were enrolled, of which 83.9% were males. The estimated glomerular filtration rate was (119.2±30.9)mL·(min·1.73m2)-1. The total prevalence of hyperhomocysteinemia reached up to 28.0%. The total prevalence of decreased kidney function, proteinuria and CKD was 2.3%, 8.1% and 10.0%, respectively. As a categorical outcome, age, male, and the prevalence of hypertension, decreased eGFR and CKD in the highest homocysteine quartile were higher than in the lower three quartiles (P<0.001). Multivariable logistic regression analysis indicated that hyperhomocysteinemia were independently associated with decreased kidney function (3.32, 95% CI: 1.63~6.78) and CKD (1.45, 95% CI: 1.01~2.08). The results were robust among 771 hypertension-free participants, the adjusted OR of hyperhomocyteinemia was 2.34(95% CI: 1.18~4.61)for CKD. Conclusions The prevalence of hyperhomocyteinemia is higher in adults with newly diagnosed diabetic patients. The issue of strengthening educational programmes of CKD is prominent and needs further attention in adults with diabetes, especially in diabetes adults with hyperhomocyteinemia. Key words: Key words Kidney Diseases; Diabetes Mellitus; Hyperhomocysteinemia

Blood Pressure Goals: How Low Is Safe in CKD?

Мета роботи — провести аналіз основних показників обміну заліза у хворих на хронічне обструктивне захворювання легень (ХОЗЛ). Матеріал і методи. У дослідження включено 202 хворих на ХОЗЛ віком > 40 років. Хворих було розподілено на чотири досліджувані групи залежно від показників гемограми: 1‑шу групу склали 144 пацієнти без анемії, 2‑гу групу — 33 із анемією хронічного захворювання (АХЗ), 3‑тю групу — 12 із еритроцитозом та 4‑ту групу — 13 із залізодефіцитною анемією (ЗДА). Всім обстеженим пацієнтам проводили загальноклінічні, лабораторні, інструментальні дослідження. До комплексу лабораторних обстежень включали дослідження вмісту сироваткового заліза (СЗ), загальної залізозв’язувальної здатності сироватки крові (ЗЗЗЗ), ненасиченої залізозв’язувальної здатності сироватки крові (НЗЗЗ), трансферину, феритину, еритроцитарних індексів та кольорового показника (КП). Результати. Середній oб’єм еритрoцитів виявився нижчим у групі хворих на ХОЗЛ із ЗДА та в межах референтних значень серед хворих на ХОЗЛ із АХЗ. Середній вміст гемoглoбіну в еритрoциті, середня кoнцентрація гемoглoбіну в oб’ємі еритрoцитів та КП були в межах референтних значень у хворих на ХОЗЛ без анемії, з АХЗ та еритроцитозом та знижені у хворих на ХОЗЛ із ЗДА. АХЗ у хворих на ХОЗЛ є нормоцитарною та нормохромною, ЗДА — мікроцитарною та гіпохромною. Нами було встановлено, що хворі на ХОЗЛ із ЗДА мали низький вміст СЗ та феритину, та високий вміст ЗЗЗЗ, НЗЗЗ та трансферину. У групі хворих на ХОЗЛ із АХЗ виявлено вміст СЗ у межах референтних значень та низький вміст ЗЗЗЗ, НЗЗЗ та трансферину одночасно із високим вмістом феритину. Висновки. Анемія хронічного захворювання спостерігається у 16,3% хворих на хронічне обструктивне захворювання легень та є нормоцитарною та нормохромною. Залізодефіцитна анемія у хворих на хронічне обструктивне захворювання легень виявляється у 6,4% хворих. Низький вміст сироваткового заліза, загальної залізозв’язувальної здатності сироватки крові, ненасиченої залізозв’язувальної здатності сироватки крові та трансферину одночасно з підвищеним вмістом феритину у хворих на хронічне обструктивне захворювання легень є характерним для анемії хронічного захворювання; низький вміст сироваткового заліза та феритину та підвищений вміст загальної залізозв’язувальної здатності сироватки крові, ненасиченої залізозв’язувальної здатності сироватки крові та трансферину є характерним для залізодефіцитної анемії. Хворі на хронічне обструктивне захворювання легень без анемії та з еритроцитозом мають еритроцитарні індекси, кольоровий показник та показники обміну заліза в межах референтних значень.

Metabolic syndrome is associated with the kidney damage, and microalbuminuria is listed as one of the key diagnostic criteria of metabolic syndrome. In metabolic syndrome the risk of chronic kidney diseases is significantly increased. Moreover, kidney damage is also more severe in metabolic syndrome than in patients without metabolic disorders, and the severity of kidney damage is directly related to the number of the components of metabolic syndrome. Chronic kidney disease is shown to be associated with all the components of metabolic syndrome, including obesity, insulin resistance, hypertension. This article discusses the issues of drug nephroprotection in patients with metabolic syndrome (MS), including patients with uncontrolled arterial hypertension, in particular, the effectiveness of a fixed combination of perindopril arginine + indapamide. The available evidence clearly shows the advantages of this combination: favorable effect on adipokines, the level of noninfectious inflammation, vascular stiffness, which makes it unique and useful at all stages of the renal continuum in patients with MS and chronic kidney disease. This is confirmed by the reduction of the risk of cardiovascular and kidney complications.

With the increasing prevalence of chronic obstructive pulmonary disease (COPD) and the extremely high mortality, disability, symptom burden and dysfunction, as well as the need for continuous drug management and care and increased rehospitalization rate, it brings patients, families and even society huge economic burden. The transitional care model provides non-drug treatment method to help patients get through the transition period safely and steadily, it also improves patients' self-care ability, quality of life and reduce hospital readmission. This review will start from the concept of disease management in transitional period, elaborate on the problems and core elements of transitional caring, then discuss the application of advanced practice nurse-dominated transitional caring mode in COPD, so as to provide theoretical and practical basis for improving the quality of chronic diseases management in China. Key words: Pulmonary disease, chronic obstructive; Transitional care; Advanced practice nurse; Rate of hospitalization