研究背景：末期腎臟病（ESRD）接受透析治療導致的身體負擔是目前全球醫療的關注議題之一，依據美國腎臟登錄系統(USRDS)2010年的統計資料中，臺灣末期腎臟病的發生率與盛行率皆居世界之首。依據行政院衛生署在2012年統計資料顯示，臺灣目前接受透析治療的人數已達六萬六千多人，依據器官捐贈移植登錄中心2013年10月為止等待腎臟移植的人數已達六千三百多人，位居所有等待移植器官中的首位。透析治療的過程中，經常導致許多疾病的發生，其中骨質流失相關疾病，例如骨折與骨鬆症等，影響著病患的健康與生活品質，有鑑於此成為備受重視與探討之議題。
研究目的：本研究探討臺灣接受血液透析治療患者罹患骨鬆性骨折相關疾病的發生率以及醫療資源使用的情況，期望重視腎臟病惡化至接受透析治療的嚴重性，達到預防之成效。
研究方法：本研究屬回溯性研究(retrospective cohort study)，利用全民健康保險資料庫(National Health Insurance, NHI)來分析末期腎臟病的患者接受血液透析罹患骨鬆性骨折的發生率與醫療資源使用。本研究之研究期間為2001年至2007年，利用傾向配對方式，將樣本分為接受透析治療患者和未接受者兩大群組，探討罹患骨鬆性骨折之發生率，另外針對透析治療患者發生與未發生骨鬆性骨折兩個樣本進行醫療資源使用進行分析。
研究結果：末期腎臟病血液透析患者罹患骨鬆性骨折之發生率，上肢骨折為%，軀幹骨折為%，下肢骨折為%。血液透析患者與無血液透析患者發生骨鬆性骨折在性別、醫療機構特性有顯著相關性(P<0.0001)，血液透析患者有無發生骨鬆性骨折之醫療資源利用，門診、住院、急診就醫次數與醫療費用均有顯著相關。
結論：末期腎臟病接受血液透析患者罹患骨鬆性骨折之發生率高於沒有接受者，發生骨鬆性骨折之危險因子包括性別、年齡、共病性、有無透析治療。本研究使用健保資料庫進行分析，雖有大型的樣本數，仍有條件的限制，由於資料庫內沒有臨床生理生化值，未能說明血液透析與骨鬆性骨折之因果關係，診斷碼與病患的實際狀況可能也有差異，因此建議未來可以臨床測量搭配資料的分析以彌補不足之處。

Background: The burden of End Stage Renal Disease (ESRD) is a growing concern worldwide. According to the United States Renal Data System for 2010, the prevalence and incidence of hemodialysis in Taiwan is the highest in the world. Hemodialysis patients commonly have complications, including osteoporotic fracture-associated diseases, which affect the quality of life.
Objective: This study aimed to explore the incidences of various osteoporotic fractures and related risk factors.
Methods: A nationwide prospective study based on the Taiwan National Health Insurance database was conducted during 2001–2007. The study analyzed the incidence of osteoporotic fractures and medical resource utilization in ESRD patients. The International Classification of Diseases (ICD) 9-CM diagnosis codes and treatment codes were identified as the inclusion criteria for osteoporotic fractures. Data were statistically analyzed by means of descriptive analysis, independent t-test, Chi-square test, and logistic regression.
Results: A total of 4016 Taiwanese people with ESRD in hemodialysis were identified in 2001, and 729 injuries occurred during the 6-year follow-up period. The cumulative incidences of lower limb fractures, upper limb fractures, and vertebral fractures were 6.94%, 5.60%, and 4.75%, respectively. Hemodialysis patients with and without osteoporotic fractures were significantly different by sex and geographic region. A higher incidence of fractures was observed in females than in males.
Conclusions: In conclusion, the information regarding clinical symptoms was not available from our database because the National Health Insurance database has ICD 9-CM diagnosis codes only. This study also confirms the strong influence of dialysis treatment on all types of orthopedic injuries and osteoporotic fractures. We hope to present the risk factors as an important point through which to notify hemodialysis patients to prevent orthopedic injuries and osteoporotic fractures, so that these patients will regularly bone density measurements. Therefore, policy makers should take the prevention of osteoporotic fractures in ESRD patients into consideration.

論文審定書 I
誌謝 II
中文摘要 III
ABSTRACT IV
目錄 V
圖次 VII
表次 VIII
第一章 緒論 9
第一節 研究背景及動機 10
第二節 研究目的 11
第二章 文獻探討 12
第一節 國內外末期腎臟衰竭重大問題 12
第二節 末期腎臟衰竭之透析治療方式 16
第三節 骨質疏鬆症之介紹 18
一、 骨質疏鬆症的定義： 18
二、 骨質疏鬆症之危險族群與風險評估 18
第四節 末期腎臟病之醫療資源耗用情形 21
第五節 末期腎臟衰竭罹患共病症（COMORBIDITY）之影響 23
第六節 末期腎臟衰竭病患罹患骨鬆症之情形 24
第三章 研究方法 29
第一節 研究假設與架構 29
一、 研究設計 29
二、 研究流程 30
三、 研究架構 31
第二節 研究問題 32
第三節 研究對象、抽樣方法與資料收集程序 33
四、 研究資料 33
五、 研究變項與Charlson Comorbidty Index之定義 36
第四節 研究變項之操作型定義 42
第五節 研究資料之處理與分析 44
第四章 研究分析與結果 45
第一節 描述性統計分析 45
第二節 推論性統計分析 58
第五章 討論與建議 68
第一節 血液透析患者罹患骨鬆性骨折之發生率 68
第二節 血液透析患者罹患骨鬆性骨折之人口學變項 69
第三節 血液透析患者罹患骨鬆性骨折之共病性 70
第四節 血液透析患者罹患骨鬆性骨折之醫療資源利用情形 71
第六章 研究建議 72
第一節研究限制 72
第二節研究建議 73
第三節研究貢獻 74
文獻參考 76

文獻整理
英文文獻：
期刊文章
Alem, A. M., Sherrard, D. J., Gillen, D. L., Weiss, N. S., Beresford, S. A., Heckbert, S. R., Wong C.,& Stehman-Breen, C. (2000). Increased risk of hip fracture among patients with end-stage renal disease.Kidney international, 58(1), 396-399.
Apel, M., Maia, V. P., Zeidan, M., Schinkoethe, C., Wolf, G., Reinhart, K., & Sakr, Y. (2013).End-stage renal disease and outcome in a surgical intensive care unit. Critical Care, 17(6), R298.
Blume, S. W., & Curtis, J. R. (2011).Medical costs of osteoporosis in the elderly Medicare population. Osteoporosis International, 22(6), 1835-1844.
Chang, N. T., Lee, Y. H., Hsu, J. C., Chan, C. L., Huang, G. S., Renn, J. H., & Yang, N. P. (2013). Epidemiological study of orthopedic injuries in hemodialysis patients in Taiwan: a fixed cohort survey, 2004–2008. Clinical interventions in aging, 8, 301.
Chang, Y. K., Hsu, C. C., Hwang, S. J., Chen, P. C., Huang, C. C., Li, T. C., & Sung, F. C. (2012). A comparative assessment of survival between propensity score-matched patients with peritoneal dialysis and hemodialysis in taiwan.Medicine, 91(3), 144-151.
Chen, Y. R., Yang, Y., Wang, S. C., Chiu, P. F., Chou, W. Y., Lin, C. Y., Chang, J. M., Chen, T. W., Ferng SH.,& Lin, C. L. (2013). Effectiveness of multidisciplinary care for chronic kidney disease in Taiwan: a 3-year prospective cohort study. Nephrology Dialysis Transplantation, 28(3), 671-682.
Chen, Y. J., Kung, P. T., Wang, Y. H., Huang, C. C., Hsu, S. C., Tsai, W. C., & Hsu, H. C. (2014). Greater risk of hip fracture in hemodialysis than in peritoneal dialysis. Osteoporosis International, 1-6.
Chou, C. Y., Liang, C. C., Kuo, H. L., Chang, C. T., Liu, J. H., Lin, H. H., Wang, I. K., Yang, Y. F., & Huang, C. C. (2014). Comparing Risk of New Onset Diabetes Mellitus in Chronic Kidney Disease Patients Receiving Peritoneal Dialysis and Hemodialysis Using Propensity Score Matching. PloS one, 9(2), e87891.
Chou, C. Y., Wang, I. K., Liu, J. H., Lin, H. H., Wang, S. M., & Huang, C. C. (2010). Comparing survival between peritoneal dialysis and hemodialysis treatment in ESRD patients with chronic hepatitis C infection. Peritoneal Dialysis International, 30(1), 86-90.
Deyo, R. A., Cherkin, D. C., & Ciol, M. A. (1992). Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. Journal of clinical epidemiology, 45(6), 613-619.
Fried, L., Bernardini, J., & Piraino, B. (2001).Charlson comorbidity index as a predictor of outcomes in incident peritoneal dialysis patients. American journal of kidney diseases, 37(2), 337-342.
Gal-Moscovici A,Sprague SM.(2007).Osteoporosis and chronic kidney disease. Semin
Dial,20:423-30.
Go, A. S., Chertow, G. M., Fan, D., McCulloch, C. E., & Hsu, C. Y. (2004). Chronic kidney disease and the risks of death, cardiovascular events, andhospitalization. New England Journal of Medicine, 351(13), 1296-1305.
Ha, S. K., Park, C. H., Seo, J. K., Park, S. H., Kang, S. W., Choi, K. H., & Han, D. S. (1996). Studies on bone markers and bone mineral density in patients with chronic renal failure. Yonsei medical journal, 37, 350-356.
Huang, G. S., Chu, T. S., Lou, M. F., Hwang, S. L., & Yang, R. S. (2009). Factors associated with low bone mass in the hemodialysis patients–a cross-sectional correlation study. BMC musculoskeletal disorders, 10(1), 60.
Keith, D. S., Nichols, G. A., Gullion, C. M., Brown, J. B., & Smith, D. H. (2004). Longitudinal follow-up and outcomes among a population with chronic kidney disease in a large managed care organization. Archives of internal medicine, 164(6), 659-663.
Khan, S. S., Kazmi, W. H., Abichandani, R., Tighiouart, H., Pereira, B. J., & Kausz, A. T. (2002). Health care utilization among patients with chronic kidney disease. Kidney international, 62(1), 229-236.
Levey, A. S., Coresh, J., Balk, E., Kausz, A. T., Levin, A., Steffes, M. W., Hogg, R. J., Perrone, R. D, Lau, J., Eknoyan, G.,& National Kidney Foundation. (2003). National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Annals of internal medicine, 139(2), 137-147.
Mares J, Ohlidalova K, Opatrna S, Ferda J. (2009).Determinants of prevalent vertebral fractures and progressive bone loss in long-term hemodialysis patients. J Bone Miner Metab.27(2):217–223.
Mittalhenkle, A., Gillen, D. L., & Stehman-Breen, C. O. (2004). Increased risk of mortality associated with hip fracture in the dialysis population. American journal of kidney diseases, 44(4), 672-679.
Myong, J. P., Kim, H. R., Koo, J. W., & Park, C. Y. (2013).Relationship between Bone Mineral Density and Moderate to Severe Chronic Kidney Disease among General Population in Korea. Journal of Korean medical science, 28(4), 569-574.
Odagiri, G., Sugawara, N., Kikuchi, A., Takahashi, I., Umeda, T., Saitoh, H., Yasui-Furukori N., & Kaneko, S. (2011). Cognitive function among hemodialysis patients in Japan.Annals of general psychiatry, 10(20), 1-5.
Oh, K. H., Hwang, Y. H., Cho, J. H., Kim, M., Ju, K. D., Joo, K. W., Kim DK, Kim YS, Ahn C, & Oh, Y. K. (2012). Outcome of early initiation of peritoneal dialysis in patients with end-stage renal failure. Journal of Korean medical science, 27(2), 170-176.
Orsini, L. S., Rousculp, M. D., Long, S. R., & Wang, S. (2005). Health care utilization and expenditures in the United States: a study of osteoporosis-related fractures. Osteoporosis international, 16(4), 359-371.
Park, S. H., Jia, T., Qureshi, A. R., Bárány, P., Heimburger, O., Larsson, T. E., Axelsson J., Stenvinkel P., & Lindholm, B. (2013). Determinants and survival implications of low bone mineral density in end-stage renal disease patients. J Nephrol, 26(3), 485-494
Shao, C. J., Hsieh, Y. H., Tsai, C. H., & Lai, K. A. (2009). A nationwide seven-year trend of hip fractures in the elderly population of Taiwan. Bone, 44(1), 125-129.
Toussaint ND, Elder GJ, Kerr PG.A rational guide to reducing fracture risk in dialysis patients.Semin Dial. 2010;23(1):43–54.
USRDS.(2012).U.S. Renal Data System(2012).http://www.usrds.org/
Vanasse, A., Courteau, J., Cohen, A. A., Orzanco, M. G., & Drouin, C. (2010).Rural-urban disparities in the management and health issues of chronic diseases in Quebec (Canada) in the early 2000s. Rural & Remote Health, 10(4).
West, S. L., & Jamal, S. A. (2012).Determination of bone architecture and strength in men and women with stage 5 chronic kidney disease.InSeminars in dialysis (Vol. 25, No. 4, pp. 397-402). Blackwell Publishing Ltd.










中文文獻：
台灣腎臟病協會. (2009).HD及PD評量作業說明.
行政院衛生福利部全民健康保險署. (2014).2014年重大傷病證明統計表。取自
http://www.nhi.gov.tw/webdata/webdata.aspx?menu=18&menu_id=683
&webdata_id=3471&WD_ID=760
行政院衛生福利部. (2012).2012年死因統計結果分析
http://www.mohw.gov.tw/cht/DOS/Statistic.aspx?f_list_no=312
&fod_list_no=1717
行政院衛生福利部.(2011). 2011年台灣慢性腎臟病科技研究報告.
行政院衛生福利部.(2012). 2012年門診透析執行成果報告.
王怡寬， 王桂芸， 蔡文正， 吳志仁， 鄭光甫， 朱柏齡.(2008). 國人腹膜透析及血液透析治療效果及其成本效果分析比較
李瑋君, 韓岳津, 吳英黛, 曹昭懿. (2007). 骨質疏鬆相關骨折住院病患之健
保申報分析. 臺灣醫學, 11(1), 22-28.
林明彥, 黃尚志. (2007).台灣慢性腎臓病/末期腎臓病流行病學過去,現在與
未來. 腎臟與透析, 19(1), 1-5.
財團法人中華民國腎臟基金會. (2014). 漫談尿毒症的骨病變。取自http://www.kidney.org.tw/know/k7.html
國民健康署. (2000).2000年國民健康調查資料.
國民健康署. (2011).2011年骨質疏鬆症臨床治療指引
施得恩, 吳至行, 楊倫欣, 王明誠. (2009). 慢性腎臟病患的骨質疏鬆症治
療. 內科學誌, 20(6), 514-523.
黃貴薰,黃秀梨,朱宗信.(2004). 末期腎臟疾病患者骨質變化相關因素之探討
鄭振廷, 侯宏彬, 錢慶文. (2005). 影響洗腎病患定期血液透析醫療資源耗用之因
素. 醫務管理期刊, 6(3), 291-308.
魏鳳君.(2011). 臺灣末期腎臟衰竭接受透析治療者罹患憂鬱症之研究探討.
鄧瑞兆.(2007). 臺灣地區財政區域劃分之經濟分析.