進階搜尋


   電子論文尚未授權公開,紙本請查館藏目錄
(※如查詢不到或館藏狀況顯示「閉架不公開」,表示該本論文不在書庫,無法取用。)
系統識別號 U0026-3008201203233500
論文名稱(中文) 第二型糖尿病患之長效血糖檢查指標及他汀類降血脂藥物治療與慢性腎病變之相關性
論文名稱(英文) The impact of diabetic HbA1c test and statin treatment on the occurrence of chronic kidney disease in Type 2 diabetic Patients
校院名稱 成功大學
系所名稱(中) 環境醫學研究所
系所名稱(英) Institute of Environmental and Occupational Health
學年度 100
學期 2
出版年 101
研究生(中文) 張嫚紜
研究生(英文) Man-Yun Chang
學號 s76981115
學位類別 碩士
語文別 中文
論文頁數 51頁
口試委員 指導教授-張志欽
口試委員-郭浩然
口試委員-郭炤裕
中文關鍵字 糖尿病  健保資料庫  他汀類藥物 
英文關鍵字 Diabetes  Insurance database  Statin 
學科別分類
中文摘要 糖尿病在台灣是很常見的慢性疾病,其盛行率約為7-9%,其中第二型糖尿病是糖尿病中最常見的類型,約佔97% 。糖尿病患者的增加已成為國家重要的健康問題,而其引起的併發症也造成龐大醫療成本負擔;其中,糖尿病腎病變為糖尿病病患最常發生的併發症之一,40%的糖尿病患將會發展成慢性腎病變。而糖尿病治療包括藥物治療、飲食控制、規律運動、血糖監測及合併症預防等;過去曾有研究指出,67歲以上的糖尿病病患,若每年定期接受兩次以上糖化血色素(HbA1c)檢驗檢查,則可降低28.8%大血管病變、 28.7% 動脈粥樣硬化心臟病及23.1% 慢性及末期腎病變發生,然而直至目前為止,其他年齡群之糖尿病患者其檢驗監測符合照護標準與否與糖尿病併發症間的相關性仍無定論。除此之外,由於statin類藥物對於治療血脂異常及心血管併發症的預防有顯著成效,因此服用他汀類(statin)降血脂藥物的糖尿病病患也日漸增多;但過去研究發現,服用statin類藥物將影響糖尿病病患之血糖控制,然而此類藥物對於預防心血管疾病及治療血脂異常之臨床效益仍高於其對血糖控制造成的影響,但目前為止,服用statin類藥物與糖尿病併發症的相關性仍未明。因此,本研究主要探討第二型糖尿病患遵循臨床建議接受HbA1c檢驗與否以及statin類藥物治療與慢性腎臟病之相關性。本研究利用回溯式世代研究,資料來源採用國家衛生研究院全民健康保險資料庫2000年之百萬歸人檔,選取1998-2003年之糖尿病新發生個案,做為本研究之觀察對象。統計方法採用Cox Regression探討觀察期間內糖尿病患遵循臨床建議準則進行HbA1c檢驗及服用statin類藥物與否與慢性腎臟病之相關性。研究結果發現,相較於追蹤期間最後三年內未遵循照護指引進行HbA1C檢驗的糖尿病患,最後三年內遵循臨床建議進行HbA1C檢驗的糖尿病患,有較低的風險【HR=0.631,95% CI=0.629-0.637 ,P<0.0001】發生慢性腎臟病。而服用20 mg/day【HR=0.997,95% CI=0.996-0.998,P<0.0001】及40mg/day【HR=0.994,95% CI=0.992-0.996,P<0.0001】 statin類藥物皆有顯著降低慢性腎臟病的影響。
英文摘要 Diabetes mellitus is one of the most common diseases in Taiwan. The increasing incidence and prevalence of diabetes in adults constitute a global public health burden. And its complication significantly contributes to the morbidity and mortality. Adherence to proposing HbA1c test guideline can be effective in slowing disease progression and risk reduction of complication, but little is known about the relationship between timely intervention of the test that meet the guideline and chronic kidney disease (CKD). Statin treatment can significantly decrease dyslipidemia risk and reduce cardiovascular complication in diabetic patients , but it also deteriorates glycemic control. The purpose of this study is to assess the association between adherence to proposing HbA1c test guideline and statin treatment with CKD in type 2 diabetic patients. The incidence cases are the patient with type 2 diabetes mellitus identified from National Health Insurance Research Database (NHIRD) during 1998-2003 Cox regression is employed to evaluate the association between adherence to proposing HbA1c test guideline or statin treatment with of CKD. A total of 22474 patients are identified as newly diagnosed diabetes and 2113 of them develop CKD during the following period. Comparing to patients not with routine HbA1c test for three years before censor date, the hazard ratio of CKD for these with routine HbA1c test are 0.631【95% CI=0.629-0.637,P<0.0001】, comparing to patients not routine to accept HbA1c test had lower risk of CKD. Long-term 20mg/day statin may have impact on the decreased risk of CKD.

論文目次 目錄
中文摘要.....................................i
第一章 研究背景...............................1
第二章 文獻回顧與探討..........................4
第一節 糖尿病之通論......................... .4
第二節 糖尿病之流行病學........................5
第三節 糖尿病的控制與照護現況 ..................10
第四節 他汀類降血脂藥物與糖尿病及慢性腎臟病之相關性.15
第五節 糖尿病與慢性腎臟病之相關性................17
第三章 研究目的...............................19
第四章 研究方法...............................20
第一節 研究設計...............................20
第二節 研究變項及操作定義.......................26
第五章 研究結果...............................31
第一節 研究個案之基本變項特徵 ...................31
第二節 各因子慢性腎臟病危險比 ....................33
第六章 研究討論...............................35
第七章 結論與建議..............................37
參考文獻.....................................38
附錄、表......................................46


參考文獻 參考文獻
Lin T, Chou P, Tsai ST, Lee YC, Tai TY. 2004. Predicting factors associated with costs of diabetic patients in Taiwan. Diabetes Res Clin Pract 63(2): 119-125.
Briganti EM, Atkins RC, Chadban SJ. 2003. Albuminuria and renal insufficiency prevalence guides population screening. Kidney Int 64(2): 760-761; author reply 761-762.
Tseng KH. 2006. Standards of medical care in diabetes--2006: response to the American Diabetes Association. Diabetes Care 29(11): 2563-2564; author reply 2564-2565.
Nathan DM, Zinman B, Cleary PA, Backlund JY, Genuth S, Miller R, et al. 2009. Modern-day clinical course of type 1 diabetes mellitus after 30 years' duration: the diabetes control and complications trial/epidemiology of diabetes interventions and complications and Pittsburgh epidemiology of diabetes complications experience (1983-2005). Arch Intern Med 169(14): 1307-1316.
[Anonymous]. 2010. Incidence of end-stage renal disease attributed to diabetes among persons with diagnosed diabetes --- United States and Puerto Rico, 1996-2007. MMWR Morb Mortal Wkly Rep 59(42): 1361-1366.
Yang WC, Hwang SJ, Chiang SS, Chen HF, Tsai ST. 2001. The impact of diabetes on economic costs in dialysis patients: experiences in Taiwan. Diabetes Res Clin Pract 54 Suppl 1: S47-54.
Suying L, Jiannong L, Gilbertson D, McBean M, Dowd B, Collins A. 2008. An instrumental variable analysis of the impact of practice guidelines on improving quality of care and diabetes-related outcomes in the elderly Medicare population. Am J Med Qual 23(3): 222-230.
Oh SW, Lee HJ, Chin HJ, Hwang JI. 2011. Adherence to clinical practice guidelines and outcomes in diabetic patients. Int J Qual Health Care 23(4): 413-419.
Rosen B, Porath A, Pawlson LG, Chassin MR, Benbassat J. 2011. Adherence to standards of care by health maintenance organizations in Israel and the USA. Int J Qual Health Care 23(1): 15-25.
Higuchi KS, Davies BL, Edwards N, Ploeg J, Virani T. 2011. Implementation of clinical guidelines for adults with asthma and diabetes: a three-year follow-up evaluation of nursing care. J Clin Nurs 20(9-10): 1329-1338.
Gugliucci A. 2000. Glycation as the glucose link to diabetic complications. The Journal of the American Osteopathic Association 100(10): 621-634.
Libby P, Plutzky J. 2002. Diabetic macrovascular disease: the glucose paradox? Circulation 106(22): 2760-2763.
Way KJ, Katai N, King GL. 2001. Protein kinase C and the development of diabetic vascular complications. Diabet Med 18(12): 945-959.
Jackevicius CA, Mamdani M, Tu JV. 2002. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA 288(4): 462-467.
Sica DA, Gehr TW. 2002. 3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors and rhabdomyolysis: considerations in the renal failure patient. Current opinion in nephrology and hypertension 11(2): 123-133.
Yokote K, Saito Y. 2009. Influence of statins on glucose tolerance in patients with type 2 diabetes mellitus: subanalysis of the collaborative study on hypercholesterolemia drug intervention and their benefits for atherosclerosis prevention (CHIBA study). Journal of atherosclerosis and thrombosis 16(3): 297-298.
Takano T, Yamakawa T, Takahashi M, Kimura M, Okamura A. 2006. Influences of statins on glucose tolerance in patients with type 2 diabetes mellitus. Journal of atherosclerosis and thrombosis 13(2): 95-100.
Parris ES, Lawrence DB, Mohn LA, Long LB. 2005. Adherence to statin therapy and LDL cholesterol goal attainment by patients with diabetes and dyslipidemia. Diabetes Care 28(3): 595-599.
Wild S, Roglic G, Green A, Sicree R, King H. 2004. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 27(5): 1047-1053.
Roglic G, Unwin N. 2010. Mortality attributable to diabetes: estimates for the year 2010. Diabetes Res Clin Pract 87(1): 15-19.
Chang CH, Shau WY, Jiang YD, Li HY, Chang TJ, Sheu WH, et al. 2010. Type 2 diabetes prevalence and incidence among adults in Taiwan during 1999-2004: a national health insurance data set study. Diabet Med 27(6): 636-643.
Tseng CH. 2004. Mortality and causes of death in a national sample of diabetic patients in Taiwan. Diabetes Care 27(7): 1605-1609.
Stratton IM, Adler AI, Neil HA, Matthews DR, Manley SE, Cull CA, et al. 2000. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 321(7258): 405-412.
Lloyd A, Sawyer W, Hopkinson P. 2001. Impact of long-term complications on quality of life in patients with type 2 diabetes not using insulin. Value Health 4(5): 392-400.
Saydah S, Tao M, Imperatore G, Gregg E. 2009. GHb level and subsequent mortality among adults in the U.S. Diabetes Care 32(8): 1440-1446.
O'Connor PJ, Crain AL, Rush WA, Sperl-Hillen JM, Gutenkauf JJ, Duncan JE. 2005. Impact of an electronic medical record on diabetes quality of care. Ann Fam Med 3(4): 300-306.
Pornet C, Bourdel-Marchasson I, Lecomte P, Eschwege E, Romon I, Fosse S, et al. 2011. Trends in the quality of care for elderly people with type 2 diabetes: the need for improvements in safety and quality (the 2001 and 2007 ENTRED Surveys). Diabetes Metab 37(2): 152-161.
Mangione CM, Gerzoff RB, Williamson DF, Steers WN, Kerr EA, Brown AF, et al. 2006. The association between quality of care and the intensity of diabetes disease management programs. Ann Intern Med 145(2): 107-116.
Sidorenkov G, Haaijer-Ruskamp FM, de Zeeuw D, Denig P. 2011. A longitudinal study examining adherence to guidelines in diabetes care according to different definitions of adequacy and timeliness. PloS one 6(9): e24278.
Sloan FA, Bethel MA, Lee PP, Brown DS, Feinglos MN. 2004. Adherence to guidelines and its effects on hospitalizations with complications of type 2 diabetes. Rev Diabet Stud 1(1): 29-38.
De Berardis G, Pellegrini F, Franciosi M, Belfiglio M, Di Nardo B, Greenfield S, et al. 2008. Quality of diabetes care predicts the development of cardiovascular events: results of the QuED study. Nutrition, metabolism, and cardiovascular diseases : NMCD 18(1): 57-65.
Schouten LM, Hulscher ME, van Everdingen JJ, Huijsman R, Niessen LW, Grol RP. 2010. Short- and long-term effects of a quality improvement collaborative on diabetes management. Implement Sci 5: 94.
Giorgino F, Laviola L, Leonardini A. 2005. Pathophysiology of type 2 diabetes: rationale for different oral antidiabetic treatment strategies. Diabetes Res Clin Pract 68 Suppl1: S22-29.
Luna B, Feinglos MN. 2001. Oral agents in the management of type 2 diabetes mellitus. American family physician 63(9): 1747-1756.
Ginsberg BH, Tan MH, Mazze R, Bergelson A. 1998. Staged diabetes management: computerizing a disease state management program. Journal of medical systems 22(2): 77-87.
Chuang LM, Tsai ST, Huang BY, Tai TY. 2001. The current state of diabetes management in Taiwan. Diabetes Res Clin Pract 54 Suppl 1: S55-65.
Yu NC, Su HY, Tsai ST, Lin BJ, Shiu RS, Hsieh YC, et al. 2009. ABC control of diabetes: survey data from National Diabetes Health Promotion Centers in Taiwan. Diabetes Res Clin Pract 84(2): 194-200.
Biccard BM, Sear JW, Foex P. 2005. Statin therapy: a potentially useful peri-operative intervention in patients with cardiovascular disease. Anaesthesia 60(11): 1106-1114.
Colhoun HM, Betteridge DJ, Durrington PN, Hitman GA, Neil HA, Livingstone SJ, et al. 2004. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet 364(9435): 685-696.
Gazi IF, Mikhailidis DP. 2006. Efficacy and safety of atorvastatin in the prevention of cardiovascular end points in subjects with type 2 diabetes: the Atorvastatin Study for Prevention of Coronary Heart Disease Endpoints in Non-Insulin-Dependent Diabetes Mellitus (ASPEN): response to Knopp. Diabetes Care 29(11): 2561; author reply 2561-2562.
Knopp RH, d'Emden M, Smilde JG, Pocock SJ. 2006. Efficacy and safety of atorvastatin in the prevention of cardiovascular end points in subjects with type 2 diabetes: the Atorvastatin Study for Prevention of Coronary Heart Disease Endpoints in non-insulin-dependent diabetes mellitus (ASPEN). Diabetes Care 29(7): 1478-1485.
Shepherd J, Hunninghake DB, Barter P, McKenney JM, Hutchinson HG. 2004. Guidelines for lowering lipids to reduce coronary artery disease risk: a comparison of rosuvastatin with atorvastatin, pravastatin, and simvastatin for achieving lipid-lowering goals. 2003. Atherosclerosis Supplements 5(3): 115-123.
Haffner SM. 1998. Management of dyslipidemia in adults with diabetes. Diabetes Care 21(1): 160-178.
Omi H, Okayama N, Shimizu M, Fukutomi T, Imaeda K, Okouchi M, et al. 2003. Statins inhibit high glucose-mediated neutrophil-endothelial cell adhesion through decreasing surface expression of endothelial adhesion molecules by stimulating production of endothelial nitric oxide. Microvascular research 65(2): 118-124.
Sukhija R, Prayaga S, Marashdeh M, Bursac Z, Kakar P, Bansal D, et al. 2009. Effect of statins on fasting plasma glucose in diabetic and nondiabetic patients. Journal of investigative medicine : the official publication of the American Federation for Clinical Research 57(3): 495-499.
Endo K, Miyashita Y, Saiki A, Oyama T, Koide N, Ozaki H, et al. 2004. Atorvastatin and pravastatin elevated pre-heparin lipoprotein lipase mass of type 2 diabetes with hypercholesterolemia. Journal of atherosclerosis and thrombosis 11(6): 341-347.
Elisaf M, Mikhailidis DP. 2002. Statins and renal function. Angiology 53(5): 493-502.
Tsiara S, Elisaf M, Mikhailidis DP. 2003. Early vascular benefits of statin therapy. Current medical research and opinion 19(6): 540-556.
Collins R, Armitage J, Parish S, Sleigh P, Peto R. 2003. MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial. Lancet 361(9374): 2005-2016.
Levey AS, Andreoli SP, DuBose T, Provenzano R, Collins AJ. 2007. Chronic kidney disease: common, harmful, and treatable--World Kidney Day 2007. Clinical journal of the American Society of Nephrology : CJASN 2(2): 401-405.
Kuo HW, Tsai SS, Tiao MM, Yang CY. 2007. Epidemiological features of CKD in Taiwan. Am J Kidney Dis 49(1): 46-55.
Parving HH, Lehnert H, Brochner-Mortensen J, Gomis R, Andersen S, Arner P. 2001. The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. N Engl J Med 345(12): 870-878.
Hwang SJ, Tsai JC, Chen HC. 2010. Epidemiology, impact and preventive care of chronic kidney disease in Taiwan. Nephrology (Carlton) 15 Suppl 2: 3-9.
Brownlee M, Cerami A, Vlassara H. 1988. Advanced glycosylation end products in tissue and the biochemical basis of diabetic complications. N Engl J Med 318(20): 1315-1321.
Koya D, King GL. 1998. Protein kinase C activation and the development of diabetic complications. Diabetes 47(6): 859-866.
Ha H, Kim KH. 1999. Pathogenesis of diabetic nephropathy: the role of oxidative stress and protein kinase C. Diabetes Res Clin Pract 45(2-3): 147-151.
Onuigbo MA. 2012. Association between glycemic control and adverse outcomes in diabetic patients with CKD. Arch Intern Med 172(7): 596; discussion 596-597.
Shlipak M. 2010. Diabetic nephropathy: preventing progression. Clin Evid (Online) 2010.
de Boer IH, Rue TC, Hall YN, Heagerty PJ, Weiss NS, Himmelfarb J. 2011. Temporal trends in the prevalence of diabetic kidney disease in the United States. JAMA 305(24): 2532-2539.
Hamano Y:Evaluation of efficacy and safety of long-term use of atorvastatin, a new HMG-CoA reductase inhibitor, in diabetic patients with hypercholesterolemia(in Japanese,with title translated by the authors).Prog Med, 2002;22:2730-2739.
Sasamoto K:Evaluation of efficacy and and safety of long-term use of atorvastatin in hypercholesterolemia patients with diabetes mellitus (in Japanese,with title translated by the authors).Prog Med,2003;23:2381-2388.
Suzuki D: Evaluation of long-term efficacy of a HMG-CoA reductase inhibitor, atorvastatin in type2 diabetes mellitus patients with hypercholesterolemia (in Japanese,with title translated by the authors).Prog Med, 2005;25:2170-2175.

論文全文使用權限
  • 同意授權校內瀏覽/列印電子全文服務,於2022-12-31起公開。
  • 同意授權校外瀏覽/列印電子全文服務,於2022-12-31起公開。


  • 如您有疑問,請聯絡圖書館
    聯絡電話:(06)2757575#65773
    聯絡E-mail:etds@email.ncku.edu.tw