【研究背景】
心臟血管疾病是長期透析病人主要的死因之一，約占全病因死亡的40%以上，其中以心衰竭、急性心肌梗塞、中風、心律不整與心跳停止相關的死亡為最為常見。血管張力素酶轉換抑制劑（ACEI）與血管張力素受體阻斷劑（ARB）在一般族群已被證實可顯著改降低日後發生心肌梗塞與中風機率，並降低心衰竭病人因病入院的風險，而現存的透析治療指引也建議在單純高血壓或併有心衰竭與中風後病人，應以ACEI/ARB 作為降壓藥品的首選。於是本研究旨在探討目前國內透析族群降壓藥品的處方型態，並分析影響醫師處方ACEI/ARB 潛在的因子，以提供醫師與醫療政策參考。
【研究方法】
以全民健康保險研究資料庫 2000年與2005年承保100萬人抽樣歸人檔，研究對象為2002年1月1日至2003年12月31日與2006年1月1日至2007年12月31日間，新進入透析並存活超過365天的病人。觀察進入透析後第90至270 天期間降壓藥品的處方型態，並以多變項邏輯思迴歸分析影響醫師處方ACEI/ARB 相關因子。最後執行敏感性分析審視相關因子影響的一致性。
【研究結果】
經過納入、排除與分組條件後，共1947位為本研究對象，平均年齡為60.7歲；90%的病人選擇以血液透析做為腎臟替代療法，而有77.3%的病人在進入透析時有高血壓的診斷。在降壓藥品選用中， dihydropyridine 類的鈣離子通道阻斷劑為使用病人比例最高的藥品，約占降壓藥品使用族群的70.3%。而在血液透析降壓藥品使用族群中，約有52-55%的曾經接受過ACEI/ARB 的治療，低於腹膜透析者的69-74%。
在預測醫師處方ACEI/ARB 的迴歸模型中，腹膜透析、透析前1年ACEI/ARB 使用經驗與在區域醫院等級以上就醫者，會顯著提高病人接受ACEI/ARB 治療的機會，但心血管疾病對醫師處方ACEI/ARB 的行為並無影響。最後執行敏感性分析的結果顯示，門診追蹤的醫療層級對醫師處方ACEI/ARB 的影響程度雖一度未達統計學顯著差異，然影響方向呈現一致。
【研究結論】
本研究顯示透析族群接受 ACEI/ARB 治療的比例有偏低的現象，而病人選擇的透析模式、先前ACEI/ARB 使用經驗與門診就醫的醫療層級，為進入透析後是否接受ACEI/ARB 治療重要的預測因子。

【Background】
Cardiovascular disease is the major causes of death in dialysis patients, accounting for over 40% of all-cause mortality. Among them, heart failure, acute myocardial infarction, stroke, arrhythmia and cardiac arrest-related deaths are the most common causes. In general population, angiotensin-converting enzyme inhibitor (ACEI) and angiotensin receptor blockers (ARB) have been shown to significantly reduce risks of myocardial infarction, stroke and hospitalization for heart failure in the future. And, existing treatement guideline for dialysis patient also recommends ACEI/ARB should be the first-line antihypertensives in uncomplicated hypertension or in patients complicated with heart failure and post stroke. Therefore, this study was aimed to investigate prescription pattern of antihypertensives in dialysis patients, and to identify factors assocaited with prescription of ACEI/ARB.
【Methods】
We used two cohort databases, which were sampled from the National Health Insurance Research Database (NHIRD) in year 2000 and 2005 respectively and each comprised 1,000,000 populations. This study population included incident
dialysis patients survived over 365 days who were identified from Jan. 2002 through Dec. 2003 and Jan. 2006 through Dec. 2007. We observed prescription pattern of antihypertensives between 90 and 270 days after entering dialysis and conduct multiple logistic regression to identify factors asssoicated with prescribing ACEI/ARB. Additionally, sensitivity analysis was used to examine robustness and consistent influence of associated factors identified from logistic regression.
【Results】
We identified a total of 1,947 incident dialysis patients with average age sixty years old after inclusion and exclusion criteria. There were about 90 percent of studied population receiving hemodialysis and 77.3 percent diagnosed hypertension. Dihydropyridine calcium channel blockers were the most common prescribed antihypertensives and accounted for 70 percent of receiving antihypertensives population. In hemodialysis population, about 52-55 % of patients had received ACEI / ARB treatment, which was less than that of in peritoneal dialysis population（69-74%）.
Factors identified from multiple logistic regression model significantly increased probability of ACEI/ARB prescription included peritoneal dialysis versus hemodialysis, ever use of ACEI/ARB one year within dialysis and OPD followed-up at the medical center and regional hospitial versus district hospital and primary clinics. However, cardiovascular comorbidity was not significantly associated with ACEI/ARB prescription. In sensitivity analysis, effect of accredited health care settings on ACEI/ARB prescription didn’t show any statistically significant difference, but remained in similar trend.
【Conclusions】
This study showed low proportion of ACEI/ARB prescribing in hemodialysis patients, while dialysis pattern, ever use of ACEI/ARB one year within dialysis initiation and accredited health care settings of OPD follow-up could significantly predict ACEI/ARB prescription.

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