血液透析病人發生心血管疾病相關因素之探討

Abstract

背景：心血管疾病具有複雜的致病機制，尤其是生活在現代，除了個人遺傳及不良生活型態的影響外，暴露於空氣污染環境也增加了發病的風險。本研究以血液透析病人為高風險族群探討心血管疾病之發生率、危險因子及城鄉比較。研究目的在評估血液透析病人個體危險因子與群體臺灣環境空氣品質對心血管疾病關係之探討。 方法：本研究以「衛生福利部健康資料加值應用協作中心」之資料庫，包括個人屬性檔、全民健保處方及治療明細檔之門急診、全民健保處方及治療明細檔之住院、全民健保處方及治療醫令明細檔之門急診、全民健保處方及治療醫令明細檔之住院、死因統計檔串入環保署空氣品質指標資料做現場合併分析，以了解評估其城鄉差異、使用Statin類藥物與心血管疾病發生風險。研究設計採前瞻性世代追蹤研究法，以十年健保巨量資料合併臺灣環境保護署所記錄的全台城鄉各地空氣污染指標（懸浮微粒及PSI）記錄，依地區串聯民眾就醫記錄，以評估環境對當地民眾心血管健康危害程度。 結果：二百萬抽樣人口中有4,885位血液透析病人，男性2553人（52.3%），女性2332人（47.7%），55歲以上的血液透析人口佔總透析人口80%以上，此2000年抽樣的研究世代死亡率高，2001~2011十年死亡人口高達88.6%。十年透析病人急性心肌梗塞發生密度為0.57% ~1.43%，缺血性心臟病發生密度為5.98% ~7.41%。在空污方面，懸浮微粒濃度平均變異約30%，花東變異高達75%。PSI濃度方面，高屏為全臺灣之首。個人危險因子之多變項分析，「性別」、「年齡」、「糖尿病」、「高血壓」、「共病性」均為透析病人罹患心血管疾病之危險因素。罹患「糖尿病」的血液透析病人發生急性心肌梗塞的校正後風險是沒有糖尿病的3.26倍（OR：3.26 , 95% CI：1.58 ~6.69）；在缺血性心臟血管疾病方面，「性別」（OR：1.19 , 95% CI：1.04 ~1.36）、「年齡」55~64歲（OR：2.76 , 95% CI：2.18 ~3.48）; 大於等於65歲（OR：3.09, 95% CI：2.45 ~3.89）、「糖尿病」（OR：1.36 , 95% CI：1.15 ~1.59）、「高血壓」（OR：1.16 , 95% CI：1.61 ~1.33）及「共病性」（OR：1.51 , 95% CI：1.32 ~1.71）均是獨立預測因子；但加入空氣污染指標校正因素後，空氣汙染的影響力未達統計上的顯著意義，而性別、年齡、共病性則仍為顯著危險因子。在罹患急性心肌梗塞方面，加入環境因子校正後的多變項分析結果相似，環境危險因素對血液透析病人不顯著，個人因素也只剩「年齡」為統計上的獨立危險因子。 結論：老年血液透析病人罹患心肌梗塞或缺血性心臟血管疾病之風險高於中年病人，且年齡越大、罹患糖尿病、同時具共存之慢性疾病患者有較高的致病風險。環境因子對心血管事件的影響，在本研究結果未達統計上的顯著意義，建議未來研究針對這些族群發病前一年的居住所在地之空污累積量做進一步的分析，以確知環境因子之影響效果。

Background: Cardiovascular disease has a complex pathogenesis. For instance, individual genetic differences, bad lifestyle, moreover, the exposure to air pollution, are contributing to the risk of disease. In this study, we compare urban-rural discrepancy effect on hemodialysis patients to determine their risk factors and incidence rate of cardiovascular disease in this cohort. Perhaps, our main aim is to access the effect of Taiwan ambient air quality on cardiovascular disease risk in hemodialysis patients. Methods: In this study, we performed a prospective cohort analysis and studied whether individual characteristics, environmental factors act as effect modifiers. At the outset, we merge National Health Insurance data from ""Health and Welfare Statistics Application Center (HWSAC), Ministry of Health and Welfare"" and Taiwan EPA daily air pollution data (particles matters and PSI) to establish a database which string into subjects’ medical condition and EPA environment database. Following this, we try to identify urban and rural discrepancy, different dose of Statin drugs usage, and evaluation of population cardiovascular risk. Result: 4,885 hemodialysis patients from a 2000 year cohort are our main study group (0.24% respect to 200 million populations), male 2553 people (52.26%) and female 2332 people (47.74%). There is more than 80% dialysis patients’ age over 55 years old. However, our cohort subjects had very high mortality rate, which up to 88.6% from 2001 to 2011. Acute Myocardial Infraction incidence density was 0.57%~1.43%, Ischemia Heart Disease incidence density was 5.98% ~7.41 %. Air pollution had dramatically changes in Taiwan over the past 10 years. Especial, the central area, the Southwestern area and the southern area (Kaohsiung-Pingtung) has the largest variation. Approximately 30% variation in particles matters concentration for the past decade, particularly, the particular matter concentration variance of eastern area hit up to 75%. About PSI level, we find out Kaohsiung and Pingtung areas have the highest PSI concentration in ambient air of Taiwan. For the multivariate analysis of dialysis patients’ individual risk factors, ""Sex"", ""Age"", ""diabetes"", ""hypertension"", ""comorbidity"" are the risk factors of the cardiovascular diseases. After adjusting for the risk of acute myocardial infarction incidence, hemodialysis patient with diabetes, their risk is 3.26 times then without diabetes (OR: 3.26, 95% CI: 1.58 ~ 6.69). For ischemic heart disease, ""sex"" (OR : 1.19, 95% CI: 1.04 ~ 1.36), ""ages of 55 to 64 years"" (OR: 2.76, 95% CI: 2.18 ~ 3.48); ""Age elder than 65 years"" (OR: 3.09, 95% CI: 2.45 ~ 3.89) , ""diabetes"" (OR: 1.36, 95% CI: 1.15 ~ 1.59), ""high blood pressure"" (OR: 1.16, 95% CI: 1.61 ~ 1.33) and ""comorbidity"" (OR: 1.51, 95% CI: 1.32 ~ 1.71) were independent predictors. However, when adding air pollution factors, the influence of air pollution didn’t show the statistical significance. In contrast, individual variables, such as sex, age, comorbidity, are the significant risk factors. For acute myocardial infarction, the results of multivariate analysis is similar to previous one. Environmental risk factors in hemodialysis patients were not significant, only ""age"" variable is significant risk factor. Conclusions: According to our result, we found that the risk of elderly hemodialysis patients’ myocardial infarction or ischemic cardiovascular diseases incidence is higher than middle-aged patients. Older people, presence of diabetes contribute to increase risk of cardiovascular disease in the present cohort. Although air pollution have risk for cardiovascular disease, but this study found that personal factors play more weight than the impact of environmental factors. We suggest that future research can put more emphasis on the accumulation of air pollution. For example, consider subject residential location’s cumulative air pollution concentration one year before disease onset, which may explain the impact of environmental factors.