末期腎病 (End stage renal disease)病患的死亡率至少是一般民眾的十到二十倍。雖然相較於擁有正常腎功能的族群，慢性腎病和血液或腹膜透析病患有較高Framingham 危險因子盛行率，但越來越多的證據指出 “非傳統危險因子”，主要是指慢性發炎反應，也有可能使得慢性腎病病患的死亡率增加。此外，殘餘腎功能對於透析病患的死亡率亦是一種重要的預測因子；隨著殘餘腎功能下降，死亡率和發炎的嚴重程度會隨之上升，並且對於腹膜透析病患來說，腹膜成為排除毒素的主要途徑。目前已知對於慢性腎病病患來說，血管張力素轉換酶抑制劑(ACEI）與血管張力素受體阻斷劑（ARB）可以延緩殘餘腎功能的下降並且減輕發炎的嚴重程度，但是針對腹膜透析病患的研究並不多。因此本研究針對南台灣成大醫院腹膜透析病患，研究ACEI/ARB對於腹膜透析各項參數的影響，主要包括殘餘腎功能、腹膜功能和發炎反應的程度。本研究共納入102 位自民國92 年至97 年於台南市國立成功大學醫學院附設醫院腎臟科接受長期腹膜透析治療之病患。回溯性檢閱病歷並記錄相關資料，排除透析未滿六個月、使用ACEI/ARB 未滿六個月的病患和臨床資料不完整的病患，總共80 位病患納入分析。雖然記錄五年間之資料，但是平均追蹤時間是兩年半。本研究以SAS 9.1 統計套裝軟體進行各項分析。病患的基本資料以t-test和卡方檢定分析；針對每周腹膜和腎臟肌酸酐清除率、每週平均肌酸酐清除率、尿量、肌酸酐之D/P 值和CRP，運用linear mixed models repeated measure
with unstructured covariance matrix 來分析使用ACEI/ARB 的有無和時間之間的關係。相較於沒有使用ACEI/ARB 的病患，長期使用ACEI/ARB 的病患擁有顯著較緩慢的殘餘腎功能下降速率；雖然在尿量和每週平均肌酸酐清除率的分析中觀察到類似的現象，但是由於過大的標準誤差，使得此兩項分析失去統計學上的差異。
至於每週腹膜肌酸酐清除率方面，有長期使用ACEI/ARB 的病患可以維持甚至在追蹤兩年之後顯著的提升。相反地，沒有使用ACEI/ARB 的病患，在追蹤期間並沒有顯著的變化，甚至在追蹤兩年之後呈現下降的趨勢。目前還無法清楚看到ACEI/ARB 對於肌酸酐之D/P 值的影響，兩組腹膜透析的病患都在低平均到高平均的範圍中，代表皆有良好的預後。在對照組之中，肌酸酐之D/P 值並沒有顯著的變化，但是治療組的肌酸酐之D/P 值卻顯著地從低平均移動到高平均。在CRP 的分析方面，長期使用ACEI/ARB的病患，相較於對照組，擁有較低的CRP 值，而且此現象在非糖尿病患中更為顯著。
因此，本研究證實末期腎病病患新進入腹膜透析並且擁有殘餘腎功能者，長期使用ACEI/ARB 可以顯著地降低殘餘腎功能下降的速率、維持腹膜肌酸酐清除率、顯著地降低CRP 值，並且至少對於腹膜不會有不好的影響。因此針對此一族群，使用ACEI/ARB 是合理的選擇。

Background: Mortality among end stage renal disease patients (ESRD) is at least 10~20 times than general population. Although a greater prevalence of traditional Framingham risk factors has been observed in chronic kidney disease (CKD) patients and in patients on hemodialysis or peritoneal dialysis as compared with patients having normal kidney function, accumulating evidences indicated that “non-traditional risk factors”, mainly chronic inflammation, also predispose CKD patients an increased risk of mortality. Furthermore, residual renal function (RRF) is a strong predictor toward mortality in dialysis patients; as the decline of residual renal function, elevated mortality rate and inflammatory
state can be found and the function of peritoneal membrane becomes the life line of PD patient. It’s already known ACEI/ARB can slow the decline rate of RRF and have anti-inflammatory properties in CKD patients, but studies focus on PD patients are still lacking. Our study focused on the effects of ACEI/ARB on peritoneal parameters, including residual renal and peritoneal function at National Cheng Kung University Hospital in southern Taiwan.
Method: Clinical data and medical treatments were extracted from charts of 80 PD patients between 2003 and 2008. We excluded patients receiving PD less than 6 months, using ACEI/ARB less than 6 months and with incomplete data. Weekly renal and peritoneal creatinine clearance (CCr), total weekly CCr, urine volume, dialysate to plasma ratio for creatinine (D/P Cr) and inflammatory state were compared between patients treated with/without ACEI/ARB. Although we collected 5 years’ data, but the average follow-up duration is 2.5 years. Statistical analysis: We analyzed the data with adequate standard statistical method by statistical software SAS 9.1. Baseline characteristics were handled by t-test and Chi squared test; Weekly renal and peritoneal CCr, total weekly CCr, urine volume, D/P Cr and c-reactive protein (CRP) level were assessed by linear mixed models repeated measure with unstructured covariance matrix to analyze
the effect of treatment and time on patients.
Results: Compared with the control group, PD patients used ACEI/ARB could significantly reduce the decline rate of RRF, although slower decline rate was seen in urine volume and total weekly CCr of PD patients taking ACEI/ARB, it
lost statistical significance due to large standard error. As for weekly peritoneal CCr, patients taking ACEI/ARB could maintain and even significantly increase in PWCCr at second year after the start of follow-up. On the contrary, PWCCr in the control group did not have significant change and even presented a decreased pattern. It’s not clear of the role of ACEI/ARB in D/P Cr. Both groups of PD
patients were in the range from low average (LA) to high average (HA) transporters, which have better prognosis. There was no significant change of D/P Cr in the control group, but the intervention group was significantly moving
from LA to HA. Regarding to CRP value, using of ACEI/ARB could lower the CRP level, especially in non-DM patients. Conclusion: For ESRD patients new to PD with residual renal function, ACEI/ARB can preserve their residual renal function, maintain their peritoneal clearance, lower the inflammatory state, and at least do not have detrimental
effects on peritoneal membrane, so it’s rational to use ACEI/ARB in this patient group.

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