痛風或痛風石與慢性腎臟疾病發生率之相關性研究

目的：驗證痛風石患者及無痛風石的痛風患者，相較於非痛風患者之非暴露組，是否具較高的慢性腎臟疾病發生風險？並進一步探討痛風患者之不同就醫情形，其慢性腎臟疾病發生風險是否顯著不同？材料與方法：本研究為回溯性世代研究，資料來源為全民健保資料庫(NHIRD)，觀察期間為1998年至2011年。依據ICD-9診斷碼定義「痛風組」與「痛風石組」。「痛風組」共8,547人；「痛風石組」共3,031人。以統計軟體 SAS 9.4 版進行雙變項分析、Cox比例風險模式、分層分析、敏感度分析、軌跡分析，並計算慢性腎臟疾病發生率。結果：「非暴露組」發生率為3.08/每千人年，「痛風組」發生率為7.57/每千人年，「痛風石組」發生率為13.51/每千人年。Cox比例風險模式之分析結果，痛風者相較於沒有痛風者，發生慢性腎臟病的HR為3.12倍；痛風石者發生慢性腎臟病的HR為非暴露組的3.52倍。依軌跡分析區分不同就醫軌跡組別，其慢性腎臟疾病發生率之分析結果，「痛風石/疾病嚴重組」為31.8/每千人年；「痛風石/快速惡化組」22.8/每千人年；「痛風石/慢速惡化組」9.8/每千人年；「痛風石/自覺控制組」22.9/每千人年；「痛風石/疾病輕微組」5.3/每千人年。「痛風/疾病嚴重組」25.12/每千人年；「痛風/快速惡化組」14.46/每千人年；「痛風/慢速惡化組」8.27/每千人年；「痛風/自覺控制組」15.9/每千人年；「痛風/疾病輕微組」6.33/每千人年；「痛風/規律就醫組」12.98/每千人年。軌跡分析各組織發生率與非暴露組發生率之Cox比例風險模式結果顯示，其HR分別為「痛風石/疾病輕微組」HR=1.85；「痛風石/慢速惡化組」HR=3.38；「痛風石/自覺控制組」HR=4.56；「痛風石/快速惡化組」HR=6.53；「痛風石/疾病嚴重組」HR=7.01；「痛風/疾病輕微組」HR=1.76；「痛風/慢速惡化組」HR=3.23；「痛風/自覺控制組」HR=3.45；「痛風/快速惡化組」HR=4.46；「痛風/疾病嚴重組」HR=5.64；「痛風/規律就醫組」HR=4.24。結論：慢性痛風石關節炎的患者有最高的慢性腎臟病發生率，次之為痛風患者，再次之為非暴露組。。而不同就醫軌跡組別之分析，不論痛風石或痛風患者，「疾病嚴重組」有最高的慢性腎臟病發生風險；「快速惡化組」與「自覺控制組」次高；「疾病輕微組」有最低的慢性腎臟病發生風險；「慢速惡化組」與「規律就醫組」有次低的慢性腎臟病發生風險。

Objective:The objectives of this study are: (1) Assessing the incidencesof chronic kidney disease (CKD) in gout and tophi patients; (2) Observing the associations of medical treatment trajectories and chronic kidney disease incidences.Methods:This study using is the National Health Insurance Research Database (NHIRD), observation period was from 1998 to 2011. The definitions of "gout patients" and "tophi patients" based on the diagnostic code (ICD-9) given by the specialists. SAS 9.4 was used for statistical analysis, including bivariable analysis, Cox proportional hazard model, stratified analysis, sensitivity analysis, and trajectory analysis. CKD incidences were calculated.Results: The incidences (1000PYs: per thousand person-years) of CKD in the non-exposed group, gout group, and tophi group were 3.08/1000PYs, 7.57/1000PYs, and 13.51/1000PYs, respectively. Gout patients have 3.12 times CKD incidence, compare to non-exposed group; Tophi patients have 3.52 times CKD incidence, compare to non-exposed group. The incidences of different gout/tophi groups for medical treatment trajectory are shown: In tophi/serious disease trajectory group, the CKD incidence is 31.8/1000PYs, HR is 7.01 (compare to non-exposed group); the CKD incidence of tophi/rapid deterioration trajectory group is 22.8/1000PYsand HR is 6.53; the CKD incidence of tophi/slow deterioration trajectory group is 9.8/1000PYs and HR is 3.38; the CKD incidence of tophi/conscious control trajectory group is 22.9/1000PYsand HR is 5.63; the CKD incidence of tophi/mild disease trajectory group is 5.3/1000PYS and HR is 1.85. And in the gout/serious disease trajectory group, the CKD incidence is 25.12/1000PYs and HR is 5.64 (compare to non-exposed group); the CKD incidence of gout/rapid deterioration trajectory group is 14.46/1000PYs and HR is 4.46; the CKD incidence of gout/slow deterioration trajectory group is 8.27/1000PYs and HR is 3.23; the CKD incidence of gout/conscious control trajectory group is 15.9/1000PYs and HR is 3.45; the CKD incidence of gout/mild disease trajectory group is 6.33/1000PYs and HR is 1.76; the CKD incidence of gout/regular medical treatment group is 12.98/1000PYs and HR is 4.24.Conclusion: Tophi patients have the highest chronic kidney disease incidence, the next place is gout patients, and lowest in the non-exposed group. In the different medical treatment trajectory groups of gout or tophi patients, the highest CKD incidences are observed in serious disease trajectory groups, the next places are is the rapid deterioration trajectory groups and conscious control trajectory groups. The lowest CKD incidences are observed in the mild disease trajectory groups, and the next places are the slow deterioration trajectory groups and regular medical treatment groups.