末期腎臟病變有種族差異趨勢


  March 23, 2007 — 根據3月23日的發病率與死亡率週報透過主要診斷描述美國1994年至2004年末期腎臟病變的趨勢。
  
  明尼蘇達密蘇里美國腎臟資料系統(USRDS)聯合中心D. Gilbertson博士與其同事表示,在美國,造成末期腎臟病變(ESRD;例如腎臟衰竭需要透析或是移植)的主因是糖尿病,接著是高血壓與腎絲球腎炎,這三種情況代表了2004年ESRD新病例的80%;需要有更多持續性的介入,例如強調控制血糖與血壓,來降低這些造成腎臟衰竭風險因子的發生率,以及改善有這些情況族群的照護。
  
  由國家衛生研究院(NIH)國家糖尿病、消化系統及腎臟疾病機構的行政監督之下,USRDS收集、分析以及發佈來自醫療保險與補助服務中心(CMS)有關於接受ESRD治療病患的臨床與給付數據;研究者分析來自USRDS的數據,以檢驗在美國,主要診斷為ESRD病患的趨勢。
  
  自1994年至2004年,所有接受分析的種族因為腎絲球腎炎造成ESRD的發生率下降、且美印地安人裔/阿拉斯加原住民(AI/ANs)及亞洲/太平洋島國(A/PIs)因糖尿病與高血壓造成ESRD的發生率同樣是下降的,但白人或是黑人就不是這樣了。
  
  在同一時期,黑人以糖尿病作為主要診斷的年齡校正後ESRD發生率,比AI/ANs高,最後是A/PIs;在白人,其發生率自每百萬人77.6人增加至117.1人,然而黑人部分,發生率自1994年至1998年的每百萬人291.0人增加至399.1人,且在1999年至2004年達到穩定狀態;在AI/ANs,發生率從1994年的每百萬人358.6人增加到1999年的440.4人,接著於2004年下降至362.4人;在A/PIs,發生率從1994年至1999年的每百萬人130.1增加至175.1人,接著於2004年下降至158.8人。
  
  從1994年至2004年,以高血壓為主要診斷的ESRD病患,黑人的比例比其他三個種族高出三倍;白人的發生率則從每百萬人53.4人增加至65.6人,但黑人的增加幅度較小,從每百萬人302.2人增加至310.7人;而在A/PIs族群則是些微下降,從每百萬人86.0人下降至84.2人;AI/ANs在1999年之前並未偵測到明顯的趨勢,但是高血壓相關ESRD發生率在1999年至2004年之間,從每百萬人58.1人減少至45.8人。
  
  相較於其他種族族群,黑人ESRD病患以腎絲球腎炎為主要診斷的發生率最高;在1994年至2004年,所有種族年齡校正後的發生率皆下降,黑人的發生率從每百萬人63.5人下降至55.0人,A/PIs從56.7人下降至36.8人、AI/ANs從45.1人下降至26.7人、而白人自25.2人下降至22.8人。
  
  在隨後的主編評論中,這些發現至少有4項限制:這些ESRD病患的數據皆來自CMS的資料;主要診斷資料是採自CMS醫學證據報告;USRDS資料庫中的種族錯誤分類可能影響特定族群發生率;以及因為USRDS種族分類並未包括拉丁美裔,所以並未分析其ESRD發生率。

Racial Differences Seen in Tre

By Laurie Barclay, MD
Medscape Medical News

March 23, 2007 — The March 23 issue of the Morbidity and Mortality Weekly Report describes racial differences in trends of end-stage renal disease, by primary diagnosis, in the United States from 1994 to 2004.

"The leading cause of end-stage renal disease (ESRD) (i.e., kidney failure requiring dialysis or transplantation) in the United States is diabetes, followed by hypertension and glomerulonephritis," write D. Gilbertson, PhD, from the United States Renal Data System (USRDS) Coordinating Center in Minneapolis, Minnesota, and colleagues. "These three conditions accounted for approximately 80% of new cases of ESRD treated during 2004.... Continued interventions, such as those addressing blood-glucose and blood-pressure control, are needed to reduce the prevalence of these risk factors for kidney failure and to improve care among persons with these conditions."

With administrative oversight by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health (NIH), the USRDS collects, analyzes, and distributes information from clinical and claims data reports to the Centers for Medicare and Medicaid Services (CMS) regarding patients being treated for ESRD. The investigators analyzed data from the USRDS to examine trends in the primary diagnosis of ESRD in the United States.

From 1994 to 2004, ESRD incidence caused by glomerulonephritis decreased among all races analyzed, and ESRD incidence caused by diabetes or hypertension also decreased for American Indians/Alaska Natives (AI/ANs) and Asians/Pacific Islanders (A/PIs) but not for whites or blacks.

During the same period, incidence of age-adjusted ESRD with diabetes as the primary diagnosis was higher among blacks and AI/ANs than among whites and A/PIs. Among whites, incidence increased from 77.6 to 117.1 per million, whereas among blacks, incidence increased from 291.0 to 399.1 per million during 1994-1998 and then plateaued during 1999-2004. Among AI/ANs, incidence increased from 358.6 per million population in 1994 to 440.4 in 1999, then decreased to 362.4 per million by 2004. Among A/PIs, incidence increased from 130.1 to 175.1 per million during 1994 to 1999, then decreased to 158.8 in 2004.

From 1994 to 2004, incidence of ESRD with hypertension as the primary diagnosis was at least 3 times higher among blacks than among the other 3 racial groups. Among whites, incidence increased from 53.4 to 65.6 per million, but among blacks the increase was smaller, from 302.2 to 310.7, and among A/PIs it decreased slightly, from 86.0 to 84.2 per million. No clear trends among AI/ANs were detected before 1999, but incidence of hypertension-related ESRD decreased from 58.1 to 45.8 per million during 1999-2004.

Compared with other racial populations, blacks had the highest incidence of ESRD with glomerulonephritis as the primary diagnosis. During 1994-2004, age-adjusted incidence decreased for all races: from 63.5 to 55.0 per million population among blacks, from 56.7 to 36.8 among A/PIs, from 45.1 to 26.7 among AI/ANs, and from 25.2 to 22.8 among whites.

An accompanying editorial note lists at least 4 limitations of these findings: data were collected for persons whose ESRD treatment was reported to CMS; primary diagnosis was taken from the CMS Medical Evidence Report; racial misclassification in USRDS data might have affected the magnitude of the rates in specific populations; and ESRD incidence among Hispanics was not analyzed because USRDS racial categories do not include ethnicity.

"ESRD is a costly and disabling condition associated with a high mortality rate," the editorial notes. "The findings in this report indicate some encouraging trends in ESRD incidence rates.... Reasons for these trends cannot be determined from surveillance data but might include a reduction in the prevalence of risk factors for kidney failure as a result of early detection or better treatment with new pharmacologic agents, such as angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers.

"Continued awareness and interventions (e.g., blood-glucose and blood-pressure control to reduce the prevalence of these risk factors and improve care among persons with diabetes or hypertension are needed to sustain and improve trends in ESRD incidence," the editorial concludes. "Additional strategies are needed to decrease ESRD incidence attributable to diabetes or hypertension among blacks and whites because ESRD incidence in these populations did not decrease during 1999-2004 as it did among AI/ANs and A/PIs."

MMWR. 2007;56(11):253-256

    
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