2014-05-012024-05-13https://scholars.lib.ntu.edu.tw/handle/123456789/644282摘要：隨著人均餘命的延長以及醫學的進步，高齡化社會已悄然成為世界各國的普遍現象；而人口的老化代表著潛在共病症(comorbidities)的增加，此為不可豁免的趨勢。慢性腎臟病是共病症中十分常見且重要的一環，而末期腎病更是醫療經濟學中無法忽視卻又無力承受之負擔；台灣每年花費在慢性透析的健保費用即高達三百多億。血液透析與腹膜透析是末期腎病患者接受慢性透析治療的主流方式，而文獻中報導，後者又較前者成本效益為高，且對殘餘腎功能保留的效果也更佳，然而，許多研究者卻也都提到，腹膜透析的最大致命傷，在於其感染的問題；特別是腹膜透析腹膜炎。根據美國及香港大規模病患的統計分析，腹膜炎為近四分之一腹膜透析患者的主要住院原因，且有三分之一的患者因此腹膜透析中止及移除導管。不同的腹膜炎感染源也各有不同特色，形成了照顧透析病患的醫師很大的難題，如何有效的避免腹膜炎發生，而發生之後仍可以早期診斷腹膜炎，並給予適當的對應治療；之前本院對此一複雜議題曾發表數篇論文進行探討，但迄今仍有不少課題亟待解決。另外對於腹膜炎的早期診斷，目前僅能依賴病人在操作腹膜透析時觀察透析液是否混濁，但因大多數是年老病人常併有白內障，而且有一大部分的糖尿病人常併有視網膜病變，對這些觀察病無法完全的正確。因此亟須一個客觀而及時且簡便的檢測方式，協助病人的居家照護。所以在本計畫中，第一年將進行腹膜透析腹膜炎的全國性調查：藉由健保資料庫取得腹膜炎相關資料進行分析，對於腹膜炎的發生率，危險因子，預後決定因素，及其他可能併發症的發生，先作明確的生態學分析；第二年我們將前瞻性研究病患發生腹膜透析腹膜炎時，其有關發炎機轉與病源體本身的探討，借助收集發生腹膜炎的病人之血液及透析液，來分析具有重要意義的發炎指數或其他指標變化，嘗試找到更可靠及有效率的預測因子。借助流式細胞儀及各種新式指標的分析協助，我們認為可以提早找出腹膜透析腹膜炎發生的原因並進行預防的工作；而研究發生腹膜炎時具特異性的指標變化，可以做為提早診斷的依據，協助有效地對症下藥安排治療，以改善這些病患的存活率以及相應的生活品質。<br> Abstract: With the progress of modern medicine, the pass of economic boom, and the decrease in fertility rate, countries around the globe are growing “older”. This means that each society, especially the developed one, faces the threat of population aging, and also the accompanying multi-comorbidity burden. Among the rising tide of comorbidities, chronic kidney disease (CKD) is an unavoidable and important one, as renal function decline is both physiologic (age-dependent) and pathologically linked with metabolic components (hypertension, diabetes mellitus, etc.). At its extreme, end-stage renal disease (ESRD) is the most important burden for the medical community and also governments implementing universal health insurance coverage, like Taiwan. Patients with ESRD are managed with chronic dialysis of either hemodialysis or peritoneal dialysis (PD) modality, and PD is often credited with economical advantage as well as beneficial impact on residual renal function preservations. Nonetheless, the Achilles heel of PD lies in infectious complications, among which PD peritonitis constitutes the main culprit. Several large registries reported that PD peritonitis accounts for one-fourth of hospitalization episodes for PD patients, and more than one-third of PD patients discontinue PD therapy with catheter removal due to refractory peritonitis. These features are intimidating to nephrologists during their recommendation of dialysis modalities to fresh ESRD patients. Treatment of PD peritonitis also needs tailoring to the offending pathogens, which could be diverse and difficult to be predicted without local epidemiologic data. There is an urgent need to devise strategy for earlier detection of PD patients prone to develop peritonitis, and also earlier diagnosis based on approaches other than traditional wait-for-culture one. Our PD unit has been one of the largest PD centers in Taiwan and also Asia, and is uniquely positioned for conducting such studies owing to the longitudinal nature and concise follow-up period. We have already published several articles focusing on PD peritonitis during recent years, but more work is still required to fully elucidate the complex issues in PD peritonitis, especially from an applicable perspective. Consequently, we will first utilize Taiwan National Health Insurance (TNHI) database to investigate the current status of PD peritonitis in Taiwanese PD patients, regarding incidence, risk factors, pathogen species, microbiologic features, prognostic factors, and other important endpoints. In the second year, we will collect effluent and blood samples from those with active PD peritonitis, and analyze the associations between specific pathogens and their respective fingerprints identifiable from the biologic specimens collected. Through the assistance of flow cytometry and analyzing additional peritonitis-specific parameters, we hope to accomplish the goal of earlier diagnosis of pathogen-oriented PD peritonitis, and possibly contribute to an optimal treatment planning, in order to improve patient outcome and prolong the technical survival of PD.