【專題演講 1-1】 Latest Evidence of Treatment in CKD Anemia with Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitors Masaomi Nangaku, MD/PhD Vice Dean, Professor and Head, Division of Nephrology and Endocrinology The University of Tokyo Graduate School of Medicine Hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs) were developed based on the discovery of the Noble Prize. HIF-PHIs are orally active small molecules and are launched as novel therapeutic agents for anemia in chronic kidney disease (CKD). In contrast to conventional exogenous erythropoietin (EPO) administration, HIF-PHIs stimulate endogenous EPO production within a physiological range and improve iron metabolism via stabilization of hypoxia-inducible factor (HIF). Clinical trials of various HIF-PHIs showed that HIF-PHIs increased and maintained hemoglobin levels in both nondialysis-dependent and dialysis-dependent CKD patients. HIF-PHIs also improved iron utilization and were comparably effective regardless of underlying inflammation and ESA hyporesponsiveness. HIF-PHIs will pave the new way in the field of treatment of anemia in CKD, and may also protect various organs including the kidney and the heart against hypoxic injury from a theoretical point of view. However, it is important to understand potential pleiotropic effects of HIF-PHIs, which might lead to either beneficial or undesirable off-target effects. References 1. Kurata Y, Tanaka T, Nangaku M. Hypoxia-inducible Factor Prolyl Hydroxylase Inhibitor in the

Treatment of Anemia in Chronic Kidney Disease. Curr Op Nephrol Hypertens 29, 414-422, 2020

2. Sakashita M, Tanaka T, Nangaku M. Hypoxia-Inducible Factor-Prolyl Hydroxylase Domain Inhibitors to Treat Anemia in Chronic Kidney Disease. Contrib Nephrol 198, 112-123, 2019

3. Hasegawa S, Tanaka T, Nangaku M. Hypoxia-inducible factor stabilizers for treating anemia of chronic kidney disease. Curr Op Nephrol Hypertens 27, 331-338, 2018

4. Sugahara M, Tanaka T, Nangaku M. Prolyl hydroxylase domain inhibitors as a novel therapeutic approach against anemia in chronic kidney disease. Kidney Int 92, 306-312, 2017

5. Shoji K, Tanaka T, Nangaku M. Role of hypoxia in progressive chronic kidney disease and implications for therapy. Curr Opin Nephrol Hypertens 23, 161-8, 2014

6. Tanaka T, Nangaku M. Angiogenesis and hypoxia. Nature Rev Nephrol 9, 211-22, 2013 7. Mimura I, Nangaku M. The suffocating kidney: Tubulointerstitial hypoxia in the pathogenesis

of end-stage kidney disease. Nat Rev Nephrol 6, 667-78, 2010 8. Nangaku M. Chronic hypoxia and tubulointerstitial injury. A final common pathway to end stage

renal failure. J Am Soc Nephrol 17, 17-25, 2006

【專題演講 1-2】 腎性貧血:透過真實世界研究如何改善未來治療 CKD Anemia: What Have We Learned from RWE in Taiwan & Where Should We Head for Better Patients Outcome? 唐德成 臺北榮民總醫院 腎臟科

Anemia is frequently encountered in patients with chronic kidney disease (CKD) and receiving hemo- or peritoneal dialysis. Erythropoietin deficiency, iron deficiency or diminished availability, chronic inflammation and malnutrition-cachexia syndrome are the main causes for renal anemia. Correction of anemia in CKD and dialysis patients with combinations of erythropoiesis-stimulating agents (ESA) and iron supplementation is the main strategy in current practice. Recent studies indicated that hemoglobin target and iron markers need to be more concerns in individualized treatment dependent upon the patient’s hemoglobin response, ESA and iron dosages and underlying co-morbidity. Based on the real world evidence (RWE) in Taiwan, we have better understandings on how we might improve CKD and dialysis patient’s outcomes.

【專題演講 2-1】

台灣 C 型肝炎之流行病學與防治政策 陳建仁 中央研究院基因體研究中心 1990 年台灣的 C 型肝炎病毒(HCV)感染盛行率，自願捐血者是 1%，血友病患者 90%，藥物成癮者 81%，B 型肝炎表面抗原(HBsAg)陽性的肝細胞癌(HCC)患者 17%，HBsAg 陰性的HCC 患者 63%。REVEAL-HCV 研究發現，C 型肝炎患者除了有顯著偏高的肝硬化及 HCC發生率而外，糖尿病、腎臟病、心臟血管疾病的發生率也會顯著增加。2003 年衛生署展開「慢性病毒肝炎治療試辦計畫」，直到 2016 年，台灣的 HCC 死亡率，已經顯著下降了40%。2015 年 C 型肝炎直接作用抗病毒藥在台灣許可上市後， 2017 年衛生福利部成立「國家 C 型肝炎旗艦計畫辦公室」，健康保險署啟動「C 型肝炎全口服新藥健保給付執行計畫」， 2018 年提出《國家消除 C 型肝炎政策綱領》，希望將世界衛生組織「2030 年消除 C 型肝炎」的目標，提前在 2025 年完成。

【專題演講 2-2】

HCV infection in CKD: Taiwan Perspectives 如何在慢性腎臟病人治療 C 型肝炎：台灣觀點 戴嘉言 高雄醫學大學附設醫院 肝膽胰內科科 The goal of treatment of hepatitis C virus (HCV)-infected persons is to reduce all-cause mortality and liver related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by a sustained virologic response (SVR). The clinical progress against HCV infection has to meet the goal to eradicate HCV infection. Elimination of HCV infection is the major task supported by WHO. In the management of the HCV infection, patients with chronic kidney disease (CKD) need special attention.

The prevalence of CKD is increased in patients with CHC. The patients with chronic hepatitis C (CHC) also have a higher prevalence of impaired renal function. The association between CHC and CKD has been elucidated and the treatment of the patients with CKD and CHC is a major unmet need until the appearance of the new all-oral direct antiviral agents (DAAs) which have achieved very high SVR rates with fewer adverse effects than the previous interferon (IFN)-based therapy. The clinical application of the new DAAs has continuously progressed in patients with CKD. Currently several DAAs have been developed and used in these patients without other special consideration; it is recommended to treat the patients according to the general recommendations, with no need for dose adjustments of DAAs. The excellent safety and efficacy in these patients have been elucidated which make the treatment easier.

WHO’s global hepatitis strategy, endorsed by all WHO Member States, aims to reduce new hepatitis infections by 90% and deaths by 65% between 2016 and 2030. Currently Taiwanese National Health Insurance has reimbursed all-oral DAA regimens for HCV since 2017. Overcoming the barriers to improve the awareness, the linkage-to-care and to treat patients is mandatory which needs the team work of all the professionals, government and non-government organizations. Taiwan MOHW have set a national HCV elimination strategy to achieve elimination in 2025. The strategies have been developed for curing HCV patients including those with CKD, such as universal screening, reflexing tests for definite diagnosis and outreaching clinics.

【專題演講 2-3】 如何在慢性腎臟病人治療 C型肝炎：西方觀點 Treatment of HCV in Chronic Kidney Disease: Western perspectives Raymond T Chung, MD 哈佛大學麻州總醫院 The HCV treatment revolution has been breathtaking in its ability to produce nearly 100% rates of cure among patients with chronic hepatitis C. The rising tide has lifted many boats, including populations of patients that previously had poor rates of response and tolerability to interferon-based regimens. These populations include those with chronic kidney disease and persons undergoing hemodialysis, peritoneal dialysis, and those who have undergone renal transplant. We will review the Western perspective on DAA combinations and their successful use in these populations.

【專題演講 2-4】 如何在末期腎臟病人或腎移植病人治療 C型肝炎：台灣觀點 Treatment of HCV in End Stage Renal Disease/Renal Transplant: Taiwan Perspectives 劉振驊 台大醫院 胃腸肝膽科 Despite the introduction of universal precautions and antiviral therapies, chronic hepatitis C virus (HCV) infection remains a common health problem in patients end-stage renal disease (ESRD) receiving maintenance dialysis. Because the potential nosocomial transmission in hemodialysis units, the prevalence rates of HCV infection in patients receiving hemodialysis are generally higher than patients receiving peritoneal dialysis. If left untreated, a higher proportion of HCV patients with ESRD may complicate with hepatic, cardiovascular and infectious-related mortality. Although HCV-infected patients with ESRD who undergo renal transplantation have a survival benefit than those who maintain maintenance dialysis, the graft and patient survival are significantly compromised after renal transplantation. Based on the perspective of HCV micro-elimination, treating HCV in patients who are on dialysis and who have undergone renal transplantation by effective and safe antiviral regimens is mandatory to improve patients’ health outcome and to reduce the risk of viral transmission. In contrast to interferon (IFN)-based therapies where the sustained virologic response (SVR) rates as well as the tolerability are far from satisfactory, the introduction of IFN-free direct acting antiviral agents (DAAs) have now become the standard of care for HCV, particularly for patients with ESRD and those with renal transplantation. Generally speaking, DAA can be classified as genotype-specific and pan-genotypic regimens, or be classified as sofosbuvir (SOF)-based or non-SOF-based regimens. Currently, no dose adjustment is needed for all types of DAAs in patients with EDRD or with renal transplantation. Combination with ribavirin (RBV) to DAAs is needed for patients of specific characteristics receiving certain DAA regimens. The sustained virologic response (SVR) rates are generally excellent (> 95%) for various DAA regimens in HCV-infected patients with ESRD or renal transplantation. The tolerance of DAAs for these patients are generally well, but variates among different regimens. Patients receiving protease-inhibitor (PI)-based DAAs have a higher risk of potential drug-drug interactions (DDIs), compared to those receiving SOF-based DAAs. The on-treatment monitoring should be on an individual basis, particularly for patients with HBV-coinfection, HIV-coinfection, polypharmacy, decompensated cirrhosis. For those who fail to first-line DAA regimens, there are still no formal clinical trials focusing on the rescue regimen for these patients, although the rescue agents are not prohibited in the package insert. Despite the excellent clinical performance of DAAs in patients with ESRD and those with renal transplantation, the long-term surveillance, such as HCC surveillance for those with advanced hepatic fibrosis or other co-morbidity, bed transfer for patients on maintenance hemodialysis, and reinfection surveillance, is needed to secure the long-term health outcomes in these patients.

【專題演講 3-1】 COVID-19 多重器官侵犯及急性腎損傷 Multi-Organ Involvement and Acute Kidney Injury in COVID-19 黃道民 醫師 台大醫院 腎臟科 2019 年發源自中國武漢的新型病毒性肺炎造成全球恐慌且有許多民眾因病喪生失能。疾病的嚴重度可以是無症狀感染但有傳染力，甚至部患者會發生多重器官衰竭，包含急性腎損傷需

要腎臟替代療法。這些對其他器官影響包括：心臟功能受損、肺部損傷、腎臟損傷、凝血功

能異常、以及類似免疫失調的反應 (免疫風爆)。其臨床表現歧異也導致相當嚴重的致病率或死亡率。本場次是一系列關於 COVID-19 與急性腎損傷議題的序幕，討論 COVID-19 在重症腎臟的角色及其可能的合併其他器官傷害其能使聽眾對此議題有清楚了解。 關鍵詞：新冠肺炎、武漢肺炎、多重器官傷害

【專題演講 3-2】 Acute kidney injury in COVID-19: Epidemiology viewpoints. 陳奕廷 基隆長庚紀念醫院 腎臟科 1. AKI COVID-19 Burden Total global COVID-19 global burden (2020/11/19) – 5560 ten thousand. Total global COVID-19 mortality (2020/11/19)- 134 ten thousands. Total global estimated AKI burden from COVID-19 (2020/11/19) - 5560 * 8.9 % = 495 ten thousands. 2. COVID-19 symptom presentation: about 4-5 days after exposure; Incubation period: 0-24 days,

median 3 days. 3. COVID-19 and Genders: Male present with higher number of deaths than females. 4. COVID-10 and Age: older patients demonstrated higher case fatality rate. 5. Clinical presentations of AKI in COVID-19: Elevated BUN, serum creatinine, proteinuria and

hematuria. 6. Associated lab abnormalities: elevated CRP, serum LDH, change in coagulation profile

(fibrinogen, d-dimer, FDP) 7. Risk factors of AKI in COVID-19:

Demographic risk factors – Old Age, Diabetes Mellitus, Hypertension, Chronic kidney Disease, Cardiovascular disease, Genetic risk factors (e.g. APOL1 genotype, ACE2 polymorphism), immunocompromised states Disease severity associated factors- severity of COVID-19, degree of viremia, respiratory status, rhabdomyolysis, nephrotoxic agents exposure (NSAIDs, antibiotic...) Hospitalization associated risk factors- Vasopressors, Mechanical ventilation, Hypovolemia.

8. AKI COVID-19 and dialysis treatment.

【專題演講 3-3】 新冠肺炎引發腎臟損傷之機轉 The Effects of COVID-19 on Kidney: Immunity, Endothelial Injury and Complement-induced Coagulopathy in COVID-19 黃俊德 臺中榮民總醫院 腎臟科 2019 年 12 月底開始的新冠肺炎全球大流行，迄今即將滿一年，然而在全球疫情仍未獲控制的情況下，了解新冠肺炎的致病機轉以及引發器官的相關併發症，將有助於臨床醫師在治療

第一線病人時，給予個別化的適當治療。新冠肺炎病毒引發的呼吸道感染，在重症病患約有

14-35％發生急性腎損傷。在少數的 COVID-19 死亡案例解剖中，有發現 SARS-COV-2 出現在腎臟的組織中的證據，究竟 SARS-COV-2 引發的急性腎損傷是透過病毒直接攻擊腎臟，還是因免疫系統的過度活化引發腎臟受損？ 抑或是其他原因造成？ 本次講題將整理最新的文獻，對此一主題做一個最完整的回顧。

【專題演講 3-4】 COVID-19 合併腎臟併發症之治療 Dialysis in COVID-19 Patients with Acute Kidney Injury 張智翔 醫師 林口長庚紀念醫院 腎臟科

Acute kidney injury is not rare in patients with COVID-19. Reported Renal replacement therapy

(RRT) rate is much higher in patients with severe sepsis and ARDS. RRT should be considerd for hyperkalemia, metabolic acidosis, uremia, or volume overload. A total of 1%-5% of the patients with COVID-19 require RRT; however, the requirement increased to 5%-23% when the patients were admitted to the intensive care unit (ICU). No RRT modality yielded a significantly better survival rate compared with others, and all modalities should be considered in the resource-constrained environment of the COVID-19 pandemic. Intermittent hemodialysis (iHD) and continuous renal replacement therapy (CRRT) are the 2 most common RRT modalities in AKI. The choice between iHD and CRRT depends on the hemodynamic status of the critically-ill patient; CRRT is the preferred modality in hemodynamically unstable patients. Although CRRT provides more accurate volume control, relative hemodynamic stability, and superior renal recovery, it requires a higher dose of anticoagulants and is associated with a higher possibility of hypophosphatemia and nutrition loss.

【專題演講 4-1】 未雨綢繆，腎損傷的風險評估及預防 Be ready for a rainy day- risk assessment and prevention of kidney injury 洪啟智 高雄醫學大學附設醫院 腎臟科 多項研究及統合分析顯示, 針對病患進行急性腎損傷之風險分級, 可以預測患者未來是否容易發生急性腎損傷。急性腎損傷早期不易察覺症狀, 診斷需靠肌酸酐及尿量的變化, 唯有詳細的風險評估, 針對高風險族群密監控與處置才能及早診斷與預防。 當病人發生了急性腎損傷, 對於惡化的風險, 對於影響腎功能恢復的風險, 也都需要注意。 本題目根據 2020 台灣急性腎損傷處置共識, 詳細討論 (1) 急性腎損傷的常見暴露及感受性因子。(2) 針對高風險族群密的監測方法。(3) 利用 furosemide stress test 做為急性腎損傷惡化或腎臟替代療法的預測工具。(4) 影響急性腎損傷恢復的嚴重度與感受性因子。

【專題演講 4-2】 水能載舟，亦能覆舟-急性腎損傷病患的體液控制 The water that bears the boat is the same that swallows it up- Fluid management in acute kidney injury. 王柏棠 台南市立安南醫院 腎臟科 自 Thomas Latta 在西元 1832 為霍亂病人進行輸液治療得到不錯的成效後，為低血容的病患進行輸液復甦在近 190 年來已變成醫療常規。據統計，約有 20%以上的重症患者接受過輸液復甦。而幾乎所有的住院病患也會使用靜脈輸液來維持體液平衡及用於藥物的稀釋。輸液

治療在醫院的日常可以說無所不在。依據近來的照護概念，我們應把輸液當作藥物看待。藥

物劑量不足與過量皆會導致不好的預後。因此，臨床上如何評估重症及急性腎損傷病患的體

液狀態、是否有輸液反應、輸液種類的選擇，對醫護人員來說是個重要課題。 2020 台灣急性腎損傷準則在輸液選擇部分，我們依序探討 1.如何預測重症病患的輸液反應、2.輸液種類與急性腎損傷的關聯、3.在特定族群(如敗血症)發生急性腎損傷的危險因子與目標指向的血行動力管理是否影響預後。藉由本次指引，希望可以ㄧ改過去對輸液治療的刻

板印象。在重症及有急性腎損傷風險的病患，我們應小心評估是否有輸液反應，根據不同的

臨床需求，為病患打造個別化的輸液治療，減少盲目且非必要的輸液治療，以免過多的體液

堆積導致不良的預後。

【專題演講 4-3】 成也蕭何，敗也蕭何，藥物引起之急性腎損傷 The wind that blows out candles kindles the fire- drug-induced AKI 邵時傑 基隆長庚紀念醫院 實證醫學中心

急性腎損傷的發生原因中，藥物相關因素可占 25%。許多常用於臨床照護的藥物均有腎毒性的發生風險，因此了解及評估腎毒性藥物對第一線臨床醫療人員為十分重要的議題。此次腎

毒性藥物章節由醫師與藥師團隊共同編撰，並針對非類固醇抗發炎藥與急性腎損傷議題進行

重新分析。本次演講同時將針對顯影劑、口服抗凝血劑和抗生素的腎毒性相關實證進行簡介，

並整理可能的預防措施及預後資料供與會人員參酌。

【專題演講 4-4】 腎臟替代治療的超前部署、擴大紓困與解封時機 Early deployment of kidney replacement therapy, expansion of bail-out, and timing of unsealing 蔡宜蓉 台大醫院 小兒部 Acute kidney injury (AKI) has been a major complication in critically ill patients, which is associated with mortality, the length of hospital stay, major adverse cardiac events (MACE), chronic kidney diseases (CKD) and the development of end-stage renal diseases (ESRD). And the management of AKI patients is supportive, and renal replacement therapy (RRT) is indicated in the care of patients with severe kidney injury with clinical comorbidity, including fluid overload, electrolyte imbalance, and the removal of toxins. Several RRT modalities are available, including intermittent hemodialysis (IHD), continuous renal replacement therapies (CRRTs) and hybrid therapies, known as prolonged intermittent renal replacement therapies (PIRRTs) that contain sustained low-efficiency dialysis (SLED) and extended-duration dialysis (EDD). Despite these several techniques, mortality in AKI patients remains high, that exceeds 40 to 50 percent in critically ill patients. Therefore, the choice of RRT modalities will be an issue in care of these critical patients. The timing of initiation of RRT in AKI patients preventing morbidities and mortality is another important issue which might affect the outcomes and prognosis in AKI patients. In addition, the dosing strategy and the application of anti-coagulation would be an important topic in the care of AKI patients underwent RRT. Of note, the transformation of RRT modalities and the timing of termination RRT has also been discussed in the care critically AKI patients. Some special population with AKI underwent RRT would be paid more attention, including patients under ECMO or pediatric patients. The techniques in these special population would be discussed in this section. It is possible that variations in the timing of initiation and termination, the choice of RRT modalities, and/or the dosing of RRT may affect clinical outcomes, particularly survival. After the systemic review, the application of evidence-based medicine, and several discussions and opinions in the expert meeting, we would like to share the Taiwan Acute Kidney Injury Consensus in the issue of RRT in the care of critically AKI patients.

【專題演講 5-1】 腎臟捐贈者長期的預後 The Prolonged Outcome of Kidney Donors 游棟閔 臺中榮民總醫院 腎臟科

由於國内尿毒患者接受透析數目持續增加，造成健保十分沉重的負擔。但是國内器官捐

贈來源極度匱乏，使腎臟移植數量無法有效成長，故增加親屬之間活體器官移植是解决此問

題主要的方法。國外已經行之有年，累積十分豐富的經驗，並且已經有相當不錯的成績，可

以增加腎臟移植的數目，佔移植總數的三分之一左右。 國內腎臟移植手術與術後照顧於早期發展，至今已經十分成熟，成績有目共睹，因此活

體腎移植十分值得國內積極推廣。但目前國内仍以大愛捐贈非活體 (deceased donor)器官移植案例為主，因此活體腎移植個案的數目仍然有限。

活體腎移植的啟端非常需要病人自身積極的意願與親屬家人之間的配合，兩造雙方缺一

不可。因此平時腎移植觀念的推廣與教育非常關鍵，而平時醫師與病人溝通的潛移默化十分

的重要。因此基層醫師在活體腎移植推廣的過程中，扮演的角色至為重要。 本次内容包括 當今歐美日活體腎移植的概況，並同時介紹活體腎臟捐贈者的術前手術評

估與日後的長期追蹤，主要包括腎臟衰竭的風險評估。 本次主題為如何借助國外經驗分享，期望能增加國内活體腎臟移植的成功數目。

【專題演講 5-2】 腎臟移植受贈者新生成及復發性腎絲球腎炎 De novo and recurrent glomerulonephritis in kidney transplant recipients 張浤榮 中山醫學大學附設醫院 腎臟科

The prevalence, pathogenesis, predictors, and natural course of patients with recurrent glomerulonephritis (GN) and de novo GN occurring after kidney transplantation remains incompletely understood. Hence, the treatment options and approaches to recurrent disease are mainly extrapolated from the general population, with responses to these treatments in those with recurrent or de novo GN post-transplantation poorly described.

This review focuses on the incidence, characteristics, clinical course, and risk of allograft failure of patients with recurrent or de novo GN after kidney transplantation, ascertaining potential differences between “high risk” diseases such as IgA nephropathy, idiopathic membranous glomerulonephritis, focal segmental glomerulosclerosis, and membranoproliferative glomerulonephritis.

The management of patients with high risk GN, including the pre-transplant assessment, post-transplant monitoring, and the available treatment options for disease recurrence will be discussed.

【專題演講 5-3】 腎臟移植細胞治療對免疫耐受性最新療法 Recent advances in cell therapy-based immune tolerance in kidney transplantation 吳欣旭 林口長庚紀念醫院 腎臟科

End-stage renal disease causes substantial medical and economic burdens all over the world.

Renal replacement therapy is essential for patients with ESRD. Among the choices of renal replacement therapy, renal transplant is the most effective treatment and patients have best quality of life and survival. However, most of the patients receiving renal transplant may need lifelong immuno-suppressants to overcome human leukocyte antigen barrier. Only small proportion of patients may wean from immune-suppressants, this is so called “immune tolerance”. Prolong using of immune-suppressants may cause unwanted adverse side effect, including increased risks of infection, new onset of diabetes and malignancy. Inducing immune tolerance in solid organ transplantation may reduce the need of these medications, which may also reduce the side effect in transplant patient care. Currently, immune tolerance in kidney transplant has been successfully achieved via mixed-chimerism establishment. Sustained mixed-chimerism of kidney transplant recipient can be done by donor CD34+ cells infusion. Other suppressive immune cells infusion for tolerance achievement are also under investigation now.

【專題演講 6-1】

推廣 ACP 預立醫療照護諮商的重要與挑戰 The Importance and Challenges for Facilitating Advance Care Planning 李隆軍 醫師 臺中榮民總醫院 家庭醫學部

《病人自主權利法》是為了尊重與保障病人自主權而生的法案，適用對象擴大為五款臨床條

件。透過預立醫療決定的簽署，讓自己擁有自行選擇接受或拒絕醫療的權利，對自己的醫療

照顧可以預先規劃，也為自己未來生命末期事先做出醫療決定，達到尊嚴善終的目標。根據

統計意願人的諮商動機以不希望家人承擔決定責任、預作生命安排、期待尊嚴善終佔大多數。

意願人的預立醫療決定以拒絕生命治療及人工營養與流體餵養佔絕大多數。但未來當意願人

符合臨床條件時，如何依照意願人當初的意願啟動預立醫療決定是一大挑戰。

【專題演講 6-2】 末期腎臟病患推廣 ACP 預立醫療照護諮商的臨床研究 The Empirical Studies on Facilitating Advance Care Planning for Patients with End-Stage Renal Disease 葉德豐 中臺科技大學 醫療暨健康產業管理系 根據 2017 年美國腎臟資料登錄系統(USRDS)年報中指出，台灣末期腎臟病(end -stage renal diseases, ESRD)發生率與盛行率位居世界第一。透析患者與其他疾病相比，隨時猝死的可能性較高、預期壽命較低。而如何突破東方傳統文化對死亡的忌諱，並參與預立醫療照護諮商

與簽署預立醫療決定，有權利為自己人生的最後一段旅程做抉擇與善終，以及讓家人減少必

要的心理負擔，成為當今最重要的議題。本研究目的旨在探討血液透析患者對預立醫療照護

諮商和病人自主權利法的知識、態度與意願之影響因素及關聯性。 本研究以中部某醫學中心血液透析患者為研究對象，採自擬結構式問卷進行調查，有效樣本

為 129 份，內容包括患者基本特性、預立醫療照護諮商與病人自主權利法知識、態度與意願及其他相關問題等。 研究結果顯示，大專以上、未婚、罹患糖尿病、對目前的透析決定沒有感到疑惑、醫護人員

曾提供有關預立醫療照護諮商(ACP)和預立醫療決定(AD)的資訊、曾經與家人討論過病情惡化至危及生命時的醫療抉擇，對預立醫療照護諮商與病人自主權利法有較高的知識；女性、

大專以上、未婚者、罹患高血壓、心血管疾病、心臟衰竭、一周透析為二次者、接受透析治

療 6～10 年、已簽署過不施行心肺復甦術(DNR)意願書或預立安寧緩和醫療暨維生醫療抉擇意願書、醫護人員曾與病人或家屬討論過病情惡化至危及生命時的醫療抉擇、曾經與家人討

論過病情惡化至危及生命時的醫療抉擇以及最想與醫護人員討論生命末期的意願，對預立醫

療照護諮商與病人自主權利法態度較為正向；女性、積蓄或退休金足以支應、罹患高血壓、

心血管疾病、癌症、曾經與家人討論過病情惡化至危及生命時的醫療抉擇，對參與預立醫療

照護諮商與簽署預立醫療決定意願較高。 病人自主權利法從立法到真正實施，相關教育訓練與推廣仍有所不足，大部分的血液透析患

者不瞭解病人自主權利法，知識不足導致對法案的認同度與意願不高，建議除積極宣導病人

自主權利法外，更應加強此類型患者對病人自主權利法的相關知識，以保障末期患者的選擇

權與善終權。

【專題演講 6-3】 未透析末期腎臟病患者推廣 ACP經驗分享 Experience in Promoting ACP for Patients with End-Stage Renal Disease without Dialysis 許碧珊 臺中榮民總醫院 家庭醫學部 2009 年 9 月起，中央健保局將八大類非癌末安寧療護納入服務範圍，其中「急性腎衰竭」及「慢性腎衰竭及腎衰竭」均納入給付目標。非癌末期與癌症末期個案臨床表現相當不

同，死亡的到來常常發生的非常突然，原團隊有時來不及徵詢個案的意願，而發生一些照顧

團隊與家屬照顧方向衝突或憂傷。「預立醫療決定」(Advance Decision, AD) 顧名思義，讓病人預先表達意願的權利受法律所保護，在符合特定臨床條件的情況下，接受或拒絕維持生命

治療、人工營養及流體餵養以正式書面文件的方式，傳達訊息與照護團隊跟家人。「預立醫療

照護諮商」(Advance Care Planning, ACP) 則指意願人為了將自主意願傳達清楚而與醫療機構的預立醫療照護諮商團隊、自己的親屬或其他關係人進行溝通討論的過程。這兩個要件在第

一次 ACP後，會簽署一份正式的 AD文件，方便後續團隊照顧此病人時的一個溝通基準與醫療決策的要件。AD在病人病況有可能即將發生 AD簽署內容狀況時、轉為安寧照顧時、預估生命期不到一星期時，應再次溝通確認審閱，並將其放入照顧計畫調整之中。 個案在慢性病照顧時所碰到的生活品質曲線因著慢性腎疾病臨床表現、合併其他疾病、醫療提供者、醫療照顧系統或家庭社區支持體系有不同的趨勢變化。根據 2017 台灣腎病年報，台灣 2006-2010 年末期腎臟病患者的五年存活率為 56.1%。在高齡者，隨著年齡的增長，透析所提供生存效益遞減，特別是對於行動不便和多發合併症的老年人。偏偏「預立醫療照

護諮商」在這樣的個案放入照顧計畫討論的比例並不高。有鑒於此，台中榮民總醫院安寧緩

和照顧團隊針對多種不同專業職類、不同的照顧體系進行多場推廣 ACP&AD 教育訓練，並嘗試實務練習。台中榮總自 108-109年度辦理相關教育訓練共 39場，實作課程共 7場。取得ACP 受訓證書醫事人員共 100人，其中有 33位醫師，分布於 16部科，護理師 54位、社工10位、心理師 2位、其他職類 1人。這兩年宣導 ACP達 6569人次，簽署 AD人數達 781人，其中 CKD簽署 AD個案僅 32人，尚需與各專科團隊做進一步合作與共振擴散。

【專題演講 6-4】 末期腎臟病患者推廣預立醫療照護諮商 Facilitating Advance Care Planning for Patients with End-Stage Renal Disease 黃政文 臺大醫院雲林分院 內科部腎臟科 依據病人自主權利法所以衍生的預立醫療照護雖已經通過立法並有施行辦法，可以在透析腎

友中推廣，但是面對台灣忌諱談死的文化中，在腎友中是否可以推廣，是透析醫護人員所未

知的狀況。這部份要從醫護人員對於這個議題的掌握度開始，在和腎友及家屬的預立醫療照

護諮商中的說明是否可以讓腎友接受，而且要讓腎友及家屬一起體認這個議題並仔細去考慮，

時機與內容都是影響諮商是否圓滿很重要的因素。預立醫療照護諮商介入的第一個時機，是

對透析療法做醫病共享決策時，這時間點病人面對透析，還沒有接受透析，家屬對於治療也

是陌生的，除了腎臟替代療法之外，同時接受預立醫囑的概念，他們就會同時考慮治療及未

來。因為透析有健保給付，經濟問題在台灣似乎不是腎臟安寧很主要的原因，所以在透析這

項治療的接受度很高，僅少數個案直接選擇不透析。這並不影響預立醫囑的推廣，所有的病

人都可以視為限時透析治療(Time limited trial of dialysis)，透析一段時間之後再決定。長期透析之後會有許多合併症出現，這些會改變腎友及家屬的思考方向。所以預立醫療照護諮商的

介入的第二個時機是透析腎友狀況改變時。何為狀況改變?可以用支持療法篩檢工具(palliative care screening tool)及驚訝問題(surprise question)兩種方式來評估，這也可以當作醫療人員對腎友及家屬說明的方向。臺大醫院腹膜透析病人中，約有 9%已經註記預立醫囑放棄急救，也有病人在最後生命末期撤除透析，這些經驗提供醫護團隊未來對於預立醫囑的推廣。 預立醫療照護諮商不一定需要是很正式會議性質，日常的聊天都可以提及這個議題。透析腎

友和醫護人員的接觸頻繁，關係較緊密且熟悉，在第二時機點時，是可以深入討論這個議題

的。

【專題演講 7-1】 2020 年台灣腎病年報概論 Annual Report on Kidney Disease in Taiwan: 2020 Update 許志成 國家衛生研究院

The incidence and prevalence of dialysis in Taiwan has long been listed as the world no. 1. In 2018, our dialysis incidence reached 523 per 1 million population; Taiwan became one of the only two countries that exceeded 500 (the other is Hungry with 508). We have significantly outnumbered our previous competitors, United States (395) and Japan (300). For dialysis prevalence, Taiwan (3587 per 1 million population) also largely surpassed Japan (2653) and USA (2354) and continued to win the world champion cup. It is believed no countries could defeat our record in a short period of time. This is a crisis for all medical societies in Taiwan! In this talk, some neglected risk factors of dialysis initiation and issues associated poor CKD/ESRD care will be discussed. This talk collaborated with other three organized in this symposium was designed to update the epidemiological pattern of CKD/ESRD in Taiwan, focusing on calling for actions to improve kidney health for our people.

【專題演講 7-2】 腎臟藥理相關議題：你、我、他 Nephropharmacology: As We Know and Does It Important 吳美儀 臺北醫學大學 衛福部雙和醫院 腎臟科 Chronic kidney disease (CKD) is emerging to be an important public health issue and global concern because of the high incidence and prevalence of end-stage kidney disease (ESKD). The previous epidemiologic study showed that the estimated CKD national prevalence is approximately 11.9% with the total burden of more than 2.5 million people in Taiwan. The National Health Research Institutes and Taiwan Society of Nephrology collaborated on the “2019 Annual Report on Kidney Disease in Taiwan” to describe the long-term epidemiological trends of kidney diseases. Several medications were analyzed before patients undergoing dialysis. The percentage of patients taking non-steroidal anti-inflammatory drugs (NSAIDs) before undergoing dialysis was decreased from 40.7% in 2000 to 26.6% in 2017. The analysis also showed a decline in the percentage of diabetes mellitus patients taking metformin before dialysis. Drug-associated nephrotoxicity is one of the risks that may cause acute kidney injury (AKI) or CKD. Besides NSAIDs and metformin, chemotherapy-induced kidney injury is also a noticeable problem faced by both oncologists and nephrologists. The growth of the kidney-cancer connection then generated the term “onco-nephrology” to provide the best nephrology care for cancer patients. A variety of chemotherapy drugs have been related to different pathologic findings and clinical renal syndrome. All conventional chemotherapy, target therapy, and immunotherapy should be aware of the complication of renal toxicity. A better understanding of the novel and growing area of “onco-nephrology” could help both the nephrologist and oncologist to prevent and resolve cancer patients with renal complications. To give comprehensive considerations to the nephropharmacology, and provide the optimal care, it is important to import the e-alert system to avoid renal toxicity induced by drugs. We hope to find ways to reduce the burden of drug-related kidney injury and to improve quality of care with evidence-based practice.

【專題演講 7-3】 台灣末期腎疾病前期照護計畫報告 The pre-end stage renal disease(ESRD) care program in Taiwan 吳珮瑜 高雄市立小港醫院 腎臟科

The incidence and prevalence of chronic kidney disease(CKD) patients under pre-ESRD care continuously increase, showing a higher participation rate in males than females and increased participation rate with age. The pre-ESRD care program started in 2006 with patients jointing at advance CKD stage 4-5, and after 2013, more were enrolled at CKD stage 3. The program's average stays also increased over time, demonstrating 6.04 years in 2018; however, a shorter stay was found in the younger participants.

In 2018, the pre-ESRD care program's mortality was 6.1%, rising to 10.5 % in age more than 75 years old. Even the raw incidence of dialysis, in the general, kept increasing, the incidence rate reduced year by year in participants within pre-ESRD care programs at 5.2% in 2018. In contrast to the general, the incidence of dialysis in pre-ESRD care programs was higher in the younger population. There was no change in the pre-ESRD care program's renal transplant rate, representing 0.1% in 2018.

The incidence and the prevalence of early-CKD care programs increased with age. The mortality in early-CKD care programs mildly increased year by year, and as expected, the elderly had a higher mortality rate. In 2018, 1.2% of patients in the early-CKD care program was shifted to the pre-ESRD care program. Conclusion

According to the annual report, the pre-ESRD care program's enrolment increased gradually, and the older adults contributed the most. Patients tended to join the pre-ESRD care program at an earlier stage in recent years.

【專題演講 7-4】 『初始透析』: 影響所及與其臨床軌跡 Incident Dialysis: Impact And Its Trajectory 廖家德 臺北醫學大學 衛福部雙和醫院 腎臟科 有別於長期透析的發生率、盛行率及死亡率分析，台灣腎病年報特別針對曾經透析過的患者

(指至少有過一次透析紀錄者)，以其接受首次透析的時間點為軸，回溯性描述透析前病患本身的流行病學特徵、共病症、醫療利用情形和用藥史，以及是否曾加入pre-ESRD program。另一方面，我們追蹤這些患者，在接受首次透析後的預後軌跡(outcome trajectory)，於五年內發生死亡或進入長期透析或長期存活無須透析的累積情形。我們更進一步比較首次透析中，『計

畫性透析(planned dialysis)』與『非計畫性透析(unplanned dialysis)』兩群病人，在臨床數據及預後之間的差異。這些重要的資訊，有助於指引台灣未來透析政策研擬之方向。

【專題演講 7-5】 末期腎臟病照護的醫療費用趨勢: 那些在透析以外的花費 Trends of medical utilization in ESRD care: what is beyond the expenditure on regular dialysis 楊禮嘉 高雄市立旗津醫院 腎臟科

Although the healthcare expenditure for patients with end-stage renal disease (ESRD) grew year by year from 2007 to 2017, it stagnated at about 9% of the annual expenditure of National Health Insurance. Out of the total healthcare spending for ESRD, the proportion of “Outpatient expense” decreases while the proportion of “Inpatient expense” increases in the past decade. Among the comorbidities of ESRD, infectious diseases and cardiovascular events were the predominant causes for hospitalization. The ESRD spending per person per month (PPPM) increased for non-dialysis related expenses but diminished for the dialysis-related expenses. The ESRD spending PPPM was higher in patients receiving dialysis than in those receiving kidney transplant. The ESRD spending PPPM was higher among the older patients.

As the increased expenditure of ESRD care may come from treating multiple comorbidities in this aging population, strategies to reduce disease burden or prevent disease complication might be cost-effective. The following evidence-based practices may be implemented. First, low dose aspirin should be advised if no contraindication because of its proven efficacy on secondary cardiovascular prevention in dialytic patients. Second, vaccination against influenza and pneumococcus should be encouraged because it was associated with a reduced mortality and infection-related hospitalizations in dialytic patients. Third, arteriovenous access creation before the initial dialysis should be promoted because it was associated with decreased risk of sepsis. Fourth, kidney transplantation should be advocated because it was associated with better long-term survival than undergoing dialysis.

In conclusion, a proper and comprehensive policy is warrant to guide medical professionals to attain optimal care for ESRD patients under limited medical and financial resources.

【專題演講 8-1】 高磷血症在慢性腎臟疾病中的”蝴蝶效應” “Butterfly Effect” of Hyperphosphatemia in Chronic Kidney Disease 鄭彩梅 雙和醫院 腎臟科 Hyperphosphatemia is a common problem in individuals with later stages of chronic kidney disease (CKD). Gradual decline in renal phosphorus clearance during the progression of CKD leads to increased serum phosphorus concentrations. This development may result in additional mineral and bone disorders, such as the inhibition of 1-alpha hydroxylation of 25-hydroxycalciferol via the hyperphosphatemia induced fibroblast growth factor-23 (FGF-23) pathway. Both hyperphosphatemia and calcitriol deficiency may result in hyperparathyroidism and chronic kidney disease related mineral and bone disorder (CKD-MBD). Hyperphosphatemia may also contribute to worsening vascular calcification and increased risk of cardiovascular morbidity. Hence, correction and prevention of hyperphosphatemia is a main component of the management of CKD. This goal is usually approached by both administering phosphorus binders and restricting dietary phosphorus intake. Dietary phosphorus restriction is recommended to help control hyperphosphatemia in hemodialysis patients, but many high phosphorus foods are important sources of protein. It is critical that restricting dietary phosphorus without avoiding malnutrition in hemodialysis patients. Although dietary phosphorus and protein are highly correlated, phosphorus intakes can range up to 600 mg/day for a given energy and protein intake level. Furthermore, the collinearity of phosphorus and protein may be biased because the phosphorus burden of food depends on: (1) the presence of phosphate additives, (2) food preparation method, and (3) bioavailability of phosphorus, which are often unaccounted for in nutrition assessments. Ultimately, we argue that clinically relevant reductions in phosphorus intake can be made without limiting protein intake by avoiding phosphate additives in processed foods, using wet cooking methods such as boiling, and if needed, substituting high-phosphorus foods for nutritionally equivalent foods that are lower in bioavailable phosphorus.

【專題演講 8-2】 續發性副甲狀腺功能亢進的內科療法 Medical Treatment for Secondary Hyperparathyroidism 盧國城 台北慈濟醫院 腎臟科

Secondary hyperparathyroidism is a complex pathophysiology that develops as chronic kidney disease progresses. The retention of phosphorus and the reductions in calcium and vitamin D levels stimulate the synthesis and secretion of parathyroid hormone as well as the proliferation rate of parathyroid cells. Parathyroid growth is initially diffuse but it becomes nodular as the disease progresses, making the gland less susceptible to be inhibited. Although the mechanisms underlying the pathophysiology of secondary hyperparathyroidism are well known, new evidence has shed light on unknown aspects of the deregulation of parathyroid function. Secondary hyperparathyroidism is an important feature of chronic kidney disease-mineral and bone disorder and plays an important role in the development of bone disease and vascular calcification. Thus, part of the management of chronic kidney disease relies on maintaining acceptable levels of mineral metabolism parameters in an attempt to slow down or prevent the development of secondary hyperparathyroidism. Here, we are going to talk about the latest evidence regarding several aspects of the clinical management of secondary hyperparathyroidism. The management of SHPT is essential to control CKD-MBD. Thus, the appropriate prevention and treatment of SHPT may derive in lower occurrence of metabolic bone disease, vascular calcifications, and mortality. The management of SHPT is based on avoiding hyperphosphatemia, maintaining adequate body vit-D store and decreasing PTH levels by administrating calcimimetics and, when needed, VDR activators. PTx is required in only a small proportion of patients.

【專題演講 8-3】 難治性副甲狀腺功能亢進症的外科治療 Surgical Treatment for Refractory Hyperparathyroidism 侯羿州 耕莘醫院安康院區 腎臟科 續發性副甲狀腺亢進為末期腎病病患常見的併發症。腎臟排磷能力的下降以及維生素 D 缺乏，會加重副甲狀腺亢進，臨床上常見表徵為血鈣下降，血磷上升。目前常用藥物治療為維生素

D 以及擬鈣劑的使用，但長期的副甲狀腺上升會促使副甲狀腺腺體增生轉為良性腫瘤，造成藥物治療失敗。副甲狀腺亢進的合併症包含腎骨病變(renal osteodystrophy)、鈣化防禦症(calciphylaxis)、貧血等，因此手術切除副甲狀腺為治療頑固性副甲狀腺亢進的重要選項。常見的手術方式為副甲狀腺全切除(total parathyroidectomy)合併腺體自體移植或者是部分副甲狀腺切除(subtotal parathyroidectomy)，皮下酒精注射為替代選項。低血鈣或者是惡骨症候群為常見的術後併發症。副甲狀腺切除除了可以改善病患高血鈣、高血磷等臨床指標，在長期存

活預後以及生活品質也可提供改善。在頑固性副甲狀腺亢進的治療，應將手術切除納入治療

選項。 關鍵字：續發性副甲狀腺亢進、副甲狀腺切除、末期腎病、惡骨症候群

【專題演講 9-1】 IgA 腎病變的治療 Treatment of IgA nephropathy 蔡尚峰 臺中榮民總醫院 腎臟科

IgA nephropathy is the most common cause of primary glomerulonephritis all over the world. It is considered as slow progression to end-stage renal disease occurs in up to 50 percent of affected patients after 20-year follow-up. How to identify the high risk patients is mandatory for better prognosis. We conducted a retrospective cohort study between January 2003 and December 2013. Clinical, pathological and laboratory data were all collected via available medical records. A Mann–Whitney U test was used for continuous variables and the Chi-square test was implemented for categorical variables. A Kaplan-Meier curve was put in place in order to determine patient survival and renal survival. The Youden index and Cox proportional hazard regression were used to investigate the possible factors for renal survival and predictive power. In addition to well-known risk factors for rapid progression, we found that a lower serum IgG (≤907 mg/dl) and serum C3 (≤79.7 mg/dl) were both risk factors for poor renal outcome. Additionally, this is the first study to reveal that serum C4 levels, an NLR >2.75, and a PLR>16.06 could suggest poor renal outcome.

The optimal treatment of IgA nephropathy is still uncertain. First of all, all patients should receive general interventions (not specific for IgA nephropathy) to slow progression, such as blood pressure control, and angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. Immunosuppressants with glucocorticoids with or without other immunosuppressive agents should be used in some selected patients. The patient selection is the key points for the treatment of IgA nephropathy. In June of 2020, the KDIGO had published a draft for public review, entitled ”clinical practice of guideline on glomerular diseases”. Herein, we will also reviewed the new update of treatment of IgA nephropathy and discuss more regarding the new published guideline.

【專題演講 9-2】 局部節段型腎絲球硬化症之治療 Treatment of focal segmental glomerulosclerosis 許永和 醫師 臺北醫學大學 新國民醫院 腎臟科 Focal segmental glomerulosclerosis (FSGS) is a histological pattern with clinical presentation of nephrotic proteinuria, hypoalbuminemia, edema and dyslipidemia. It is rather than a single disease but caused by diverse clinicopathological entities with different mechanisms of injury with the podocyte as the principal target of lesion, leading to the characteristic sclerotic lesions in parts (focal) of some (segmental) glomeruli. FSGS has shown an increasing prevalence over the past few decades and approximately 50% of patients progress to end-stage kidney disease within 5–10 years, particularly those not responding to the therapies. FSGS pathogenesis is largely unknown and podocyte is considered as the pathogenetic main target. Primary FSGS, usually presents with nephrotic syndrome, is thought to be caused by circulating permeability factors with a main role in podocyte foot process effacement. Secondary forms of FSGS include maladaptive FSGS due to glomerular hyperfiltration such as in obesity or in cases of loss in nephron mass, virus-associated FSGS, and drug-associated FSGS that can result in direct podocyte injury. As genetic FSGS is increasingly been recognized recently, it is crucial in distinguishing primary FSGS from secondary and genetic causes for disease prognostic significance and appropriate management. This presentation provides an overview on the treatment of idiopathic FSGS in adults with citing the latest published trials and the most reliable pathogenetic hypotheses of the disease. It focuses on emerging therapies, specifying for each new drug the assumed mechanism of action and the data available in experimental animals and humans. Some remaining issues including the identity of the plasma factor believed to be responsible for primary FSGS, the value of routine implementation of genetic testing, and the identification of more effective and less toxic therapeutic interventions for FSGS are also addressed.

【專題演講 9-3】 膜性腎病變的治療 Treatment of primary membranous nephropathy 姜文智 台大醫院 腎臟科

Primary membranous nephropathy MN is a disease of auto-antibody against podocyte antigen. The well-known antigens include phospholipase A2 receptor (PLA2R), thrombospondin type 1 domain containing 7A (THSD7A) and others. Anti-PLA2R and anti-THSA7A antibody related MN composed 60~75% and 3~5% primary MN respectively. The anti-antibody binds to subepithelial antigen, forms immune complex, then activates alternative or lectin complement pathway, therefore initiates the destruction of podocyte and subsequent inflammation. In addition to renal biopsy, ELISA (or immune fixation test) detection of anti-PLA2R antibody and PLA2R antigen staining in renal biopsy specimen are now available for the diagnosis of anti-PLA2R antibody related MN.

In Western countries, up to 30% of primary MN patients get spontaneous remission and steroid monotherapy was considered to be not better than observation only in non-complicated patients. Therefore, KDIGO guidelines suggest initiating immunosuppression when no improvement after 6 months of observation in non-complicated patients. Ponticelli et al. suggest alternative combined alkylating and steroid therapy for 6 months as the initial therapy. However, the spontaneous remission rate within 1 year is less than 10% and steroid monotherapy could achieve around 70% combined remission in Taiwan. Recently, anti-CD20 therapy (rituximab) was found to be not inferior to traditional immunosuppressive therapy. MENTOR trial found that the remission rate is higher in rituximab than cyclosporin treatment group. Another two trials comparing the effect of rituximab with tacrolimus or steroid/cyclosphosphamide were completed in 2019, but without detail information at present time. Other trails targeting CD38 or complement components (factor B) in anti-PLA2R Ab positive MN patients are undergoing.

Immunosuppression brings the risk of infection to patients, especially when combining with alkylating agents. The disease itself also has many complications, such as the risk of end stage renal disease, pulmonary embolism and others. The decision of management in MN patients depends on the risk and benefit evaluation in each individual patient. Targeting therapies (against antibody binding, generation and complement activation) may be other good choices in primary MN patients in the future.

【專題演講 10-1】 晚期糖尿病合併腎臟病人的血糖治療 Role of DPP4 inhibitor of glycemic control in late stage CKD patient with diabetes 歐朔銘

臺北榮民總醫院 腎臟科

臺灣健保資料庫研究報告指出我國糖尿病之 DKD 的盛行率從 2000 年的 13.32%，逐年上升至 2009 年的 15.42%；接受透析的 ESRD 盛行率由 2000 年的 1.50% 上升至 2009 年的2.46%。糖尿病腎臟疾病(diabetic kidney disease, DKD) 為糖尿病病人經常罹患的小血管併發症。隨著糖尿病盛行率上升，DKD 的罹病人數也逐年增加。目前台灣所有透析患者約有 45% 是因為 DKD 導致腎臟衰竭。

理想的血糖控制可減少或延緩白蛋白尿的發生以及腎功能惡化。在 CKD 第 1 和 2 期時血糖控制目標可設定為 HbA1c

【專題演講 10-2】 如何提升慢性腎臟病人的血脂照護 Better Strategy for Dyslipidemia in CKD Patients - To do or not to do 郭克林 台北慈濟醫院 腎臟科 依 2019 ESC 歐洲心臟學會最新的治療指引建議，已發生過心肌梗塞、穩定或不穩定心絞痛、中風、以及冠狀動脈或其他動脈血管再通術等 ASCVD 動脈粥樣硬化性心血管疾病的患者，皆屬 very high risk 的病人，在次級預防的治療上，指引建議在低密度膽固醇的指標設定應可以 baseline 降低 50%而且低於 55 mg/dL 為目標。但在治療慢性腎臟病人的血脂照護上，卻不一定是越低越好的。 另外，依 2017 年發表的台灣高風險病人族群的血脂照護指引，建議是針對第 3a 期到第5 期的慢性腎臟病人，若 LDL-C 大於等於 100 mg/dL 之下，則建議開始使用 statin 治療。但也表示針對洗腎病人在使用 statin 或 statin+ezetimibe 下是沒有減少 CV Event 的好處的。 國內外多個研究已證實，還是有許多病人的血脂 LDL-C 指標是沒有辦法達標的。本場次演講將分享臨床上應該使用怎樣的治療策略，才能最佳化慢性腎臟病人的血脂照護。且說明

有哪些臨床試驗數據，告訴我們應如何針對不同類型的慢性腎臟病人調整處方。

【專題演講 11-1】 台灣慢性腎臟病的醫療資源運用：現況與未來展望 Healthcare Utilization of CKD in Taiwan: Reading the Past, Writing the Future 許志成 國家衛生研究院

In Taiwan, over 2.5 million people are living with chronic kidney disease (CKD) stage 1-5,

which corresponds to an estimated prevalence of 11.9%. Patients with CKD are threatened by 83% higher risk for all-cause death and 100% higher risk for cardiovascular diseases. In addition, CKD disease burden exerts huge impact on the healthcare system with high hospitalization rate.

Several pay-for performance (P4P) programs including early CKD program and pre-end-stage renal disease program have been initiated in Taiwan to improve clinical outcome and achieve cost-effective medical care. In this section, the past and current healthcare utilization of CKD in Taiwan will be introduced. Meanwhile, the future direction and perspective to further optimize the CKD healthcare utilization will also be discussed.

【專題演講 11-2】 探索 SGLT2 抑制劑在腎心症候群上的最新進展 Exploring the Latest Trend of SGLT2i in CardioRenal Syndrome Hiddo Heerspink Department of Clinical Pharmacy and Pharmacology of the University Medical Center Groningen, the Netherlands Cardiorenal syndrome is a recalcitrant problem that significantly reduces patients’ quality of life as well as life expectancy. The conditions of kidney and heart are highly correlated. Renal dysfunction may accelerate the progression of heart failure, and vice versa. Recent clinical trials showed that sodium-glucose cotransporter 2 inhibitor (SGLT2i) is associated with lower risks in cardiorenal-related outcomes. In this session, possible mechanisms and the latest evidences of SGLT2i in cardiorenal syndrome will be discussed based on current researches.

【專題演講 12-1】 IDPN 處方在慢性透病人的角色：醫師觀點 IDPN in Chronic Dialysis Patients: the Nephrologist Perspective 洪思群 台北慈濟醫院 腎臟科 Uremic malnutrition, also referred to as protein-energy wasting (PEW), represents a disorder with increasing incidence in CKD patients with or without dialysis. Patients with PEW experience higher rates of complications, which ultimately leads to reduced survival. Routine nutrition screening and assessment can identify patients at risk of PEW. Biomarkers such as nPCR, serum albumin as well as various nutrition-related laboratory tests are considered complementary tools but should not be interpreted in isolation to assess nutritional status. Bioimpedance and preferably multi-frequency bioelectrical impedance is recommended to assess body composition of hemodialysis patients when available. National guidelines suggest a trial of IDPN for HD patients to improve and maintain nutritional status if nutritional requirements cannot be met with existing oral and enteral intake. Although IDPN is a reasonable treatment option in selected HD patients with PEW, it should be initiated as early as possible because it may not provide sufficient calories and protein given for 4 hours during dialysis thrice weekly. Cano et al. have shown that increased prealbumin levels during the first 3 months of IDPN therapy reflect a lower risk of 2-year mortality. Therefore, ongoing monitoring and evaluation of nutritional status during IDPN therapy is necessary. Novel application of IDPN in special patient population, such as those with gut dysbiosis or high levels of carbamylated protein will be discussed in this talk. Future clinical trials comparing the independent effects of IDPN and oral nutritional supplement on nutritional status, morbidity, mortality, and quality of life are required.

【專題演講 12-2】 IDPN 處方在慢性透析病人的角色：藥師觀點 陳佳其 臺大醫院 藥劑部 依據現行治療指引，血液透析患者在營養缺乏時，可藉由透析中靜脈營養支持(intradialytic parenteral nutrition, IDPN)提供額外營養及熱量的補充。本課程中除了介紹一般情況下靜脈營養(parenteral nutrition, PN)的使用時機、成分及注意事項，另外也將以藥師的角度，探討臨床上給予血液透析患者 IDPN 時可能面臨的問題，以及如何依病人需求選擇適當的靜脈營養品項。

【專題演講 12-3】 透析中靜脈營養輸入對營養不良透析患者的影響:營養師觀點 Effect of Intradialytic Parenteral Nutritional in Malnourished Hemodialysis Patient 陳淑子 文林診所 長期透析患者常發生蛋白質熱量營養不良，研究顯示約有 25%的透析患者有嚴重營養不良。蛋白質熱量營養不良是長期透析患者致病率與死亡率重要的影響因子，血清白蛋白濃度

低的透析患者有較高的死亡率，營養狀態也影響透析治療效果與患者的生活品質。造成血液

透析患者易發生蛋白質熱量營養不良的原因包括：攝取不足、吸收降低與需要量增加。末期

腎臟病患者因尿毒症 (Uremia) 引起的酸血症與慢性發炎會增加蛋白質分解代謝(hypercatabolism)；產生的胰島素與 IGF1 抗性，會降低蛋白質合成。血液透析過程會流失胺基酸、胜肽、蛋白質和水溶性營養素，因此營養素的需要量增加。加上患者腸胃道功能也因

尿毒素導致蠕動降低甚至發生胃炎或潰瘍，影響正常的消化與吸收，且因尿毒症引起的噁心、

味覺改變及食慾不振，使得患者比較難攝取到足夠的營養素。因此，臨床治療上考慮以靜脈

輸入營養素來改善長期透析患者的營養不良。 患者血液透析治療時的血管通路可作為靜脈營養輸液的輸入路徑，因此透析中靜脈營養輸入(Intradialytic Parenteral Nutritional; IDPN)成為血液透析患者獲得蛋白質與熱量的容易方式。典型的 IDPN通常可以提供 800 至 1000卡的熱量與 30至 40克的蛋白質，其副作用為可能發生高血糖與反應性低血糖（postdialysis hypoglycemia），輸入脂質乳劑可能導致血液三酸甘油脂濃度上升。美國靜脈腸道營養學會（ASPEN）2010 年臨床指引（Clinical Guidelines）參考的研究證據顯示：營養不良的透析患者使用 IDPN 反而有較高的罹病率與死亡率，因此不建議 IDPN 作為營養不良透析患者的營養補充方式（IDPN should not be used as a nutrition supplement）。KDOQI 2020 建議：若使用 3 個月口服營養補充品後，無法改善營養狀態，可以試著使用 IDPN 以改善與維持營養狀態(a trial of IDPN for MHD patients to improve and maintain nutritional status)。 臨床觀察上，使用 IDPN對於改善患者的營養狀態並無顯著影響，通常不能增加血清白蛋白濃度，只能維持血清白蛋白濃度不下降。但是在使用 IDPN 同時，鼓勵患者盡量由口攝食足夠的蛋白質與熱量，其血清白蛋白濃度上升速度會比沒有使用靜脈營養輸液者快。營養不

良透析患者的主要問題是蛋白質攝取不足，這些患者血液胺基酸的組成可能是異常的，經由

靜脈輸入胺基酸後補足缺乏的氨基酸，可能因此增加體內蛋白質合成效率，繼而改善營養狀

態。此外，因為美味好吃的食物都是高糖高油富含熱量，只要不因為錯誤的觀念給予不適當

的限制，患者應該很容易攝取到足夠的熱量。IDPN輸入葡萄糖與脂質產生的副作用多，也許採用只輸入胺基酸並鼓勵患者攝取口服營養補充品合併富含蛋白質的食物(例如:蛋與豆乾等)，較能有效的改善營養狀態，提升血液白蛋白濃度。如此，患者通常在 2週到 1個月後食慾就能改善，不再需要 IDPN。

【專題演講 13-1】 從 2020 年國際腹膜透析學會之治療準則啟航居家透析之未來 The Future of Home Dialysis: Starting from ISPD 2020 Guideline 林志慶 台北榮總內科部腎臟科暨國立陽明大學醫學院

As the prevalence of end stage renal disease increases progressively in most developing and developed countries, high-quality studies are needed to address treatment issues and dialysis outcomes in these countries. Peritoneal dialysis (PD) has been suggested by many public health experts and policy makers as a critical component of universal health coverage for these uremic patients. The ISPD practice recommendations on prescribing high-quality goal-directed peritoneal dialysis is person-centered, individualized SDM approach for PD prescription and delivery, which covered (1) the core outcomes identified by patients, caregivers and healcare professionals in the standized outcomes in nephrology (SONG)-PD initiative, (2) non-standard PD delivery including incremental PD as well as frail/palliative patients, (3) special situations including pediatric PD and recommendations in low income countries, and (4) clinical factors from A to Z, including residual renal function, health-related quality of life, volume status as well as many other factors.

The outbreak of the coronavirus disease 2019 (COVID-19) since the end of 2019 has had a considerable impact on the global economy and also on the health care system. Compared to HD, peritoneal dialysis (PD) can be performed by patients themselves at home. Physicians can conduct telemedicine consultations and PD prescriptions. It may reduce the patient’s chances of getting into contact with other people or going to health care facilities, thereby minimizing the risk of COVID-19 infection. For patients with suspected or confirmed COVID-19, they can also be isolated at home without occupying the isolation ward for dialysis. Patients with severe COVID-19 may develop respiratory failure and require noninvasive or invasive ventilation. For such critically ill patients, current guidelines recommend conservative fluid management, because hypervolemia may worsen oxygenation. PD may be a better choice for them, since it is done more continuously than intermittent HD, resulting in less accumulation of body fluid.The efforts to clarify the effects of PD can help clinicians to improve the prognosis of ESRD patients needing home dialysis in the pandemic of COVID-19 as well as other possible future infectious diseases. .

【專題演講 13-2】 從 COVID-19 看雲端科技結合醫療的發展: 腹膜透析為例 The development and future of cloud medicine in COVID-19 era: peritoneal dialysis 鍾牧圻 臺中榮民總醫院 腎臟科 在 COVID-19 肆虐的年代，當病患需要常規至血液透析室洗腎，不論對於醫護團隊以及病患都是一件風險很高的事。大眾也因此更加發現到居家透析的重要性。 以 COVID-19 最嚴重的美國紐約和義大利為例，發現血液透析病患比起腹膜透析病患有顯著罹患 COVID-19 的風險。但當進一步的利用腹膜透析作為居家透析的方式，我們需要一種有效追蹤病患且有助雙向溝通的平台。 Sharesource APD (automated peritoneal dialysis)相較過去傳統的 APD，此升級版的硬體與軟體，可以自動的將透析完成的詳細記錄上傳到雲端，而醫護團隊可以透過雲端了解病患透析時是

否安全、是否有異常事件、或是醫囑的遵從性等等。台灣在經過這近兩年的使用經驗，醫護

團隊與病患使用經驗快速累積，針對多重共病的患者更是有其角色。Sharesource APD 也被強烈推薦，在 COVID-19 的年代中作為居家透析最好的守門員角色。 今天的演講會著重在 COVID-19 對透析病患的衝擊、Sharesource 是如何被利用、以及在台灣的使用經驗等。

【專題演講 13-3】 COVID-19 給予透析院所感控風險管理之啟示與未來 Implication and Future Prospective of COVID-19 Infection Control to The Risk Management of Dialysis Facilities 李佳蓉 高雄醫學大學附設醫院 腎臟科 COVID-19 大流行在全球造成重大危機及損失，透析病人必須常規且頻繁的接受專業人員的治療，此近距離、長時間、需要特殊機器設備、且多人群聚的環境，使得透析院所應變新興

傳染性疾病的整備至關重要。本題整理透析院所面臨 COVID-19 大流行的風險，闡述台灣腎臟醫學會應變小組迄今發展及發布相關指引的關鍵步驟，也探討目前 COVID-19 感控的現實及未來挑戰。面對新興疾病的衝擊，我們面對的不單只有醫療上的挑戰，危機處理、資源分

配、持續運營、風險管理及科學發展上，都是此一世紀疾病對我們示警的課題。

【專題演講 14-1】 淺談大數據與人工智慧 How Big Data and AI Work Together 黃宗祺 教授 Solution Architect Director, Healthcare, APAC, NVIDIA

大數據與人工智慧主要兩者可以用點, 線, 面來比喻，大數據是許多的點，人工智慧是串出來連接點的線，有用的連接就形成有功能有輪廓的面。整體訓練與執行流程大致上，大數據是

初始動能，透過神經網路方法去產生連結權重最後並執行，然而數據變得有用之前需進行資

料清理與結構化作為原始訓練的輸入，而人工智慧模型則是階段結國的輸出，即處理數據產

生的有效執行的功能，想是辨識，分類，預測，模擬…等，並大量將這些功能應用在數位影像及語音兩大類別上。 人工智慧與大數據兩者本質上有所不同，人工智慧體現是一種”運算形式”，它允許機器運算執行類似人的認知特徵與功能，對輸入的訊號起作用或作出反應，有別於傳統的運算應用程

式也會對數據做出反應，但反應和輸出都必須採用人類自己的人工編碼，過程上如果出現任

何的不一致，應用程式無法做出反應，而人工智慧系統可以透過不斷改變神經網路權重，以

適應不同的輸入進行結果變化的適應，這次演講將舉例監督學習，非監督學習與增強式學習

如何應用大數據再在許多現實情境中。

1

【專題演講 14-2】 EKG 於電解質不平衡之 AI 運用 Artificial Intelligence-assisted Electrocardiography to Detect Dyskalemia 林石化 三軍總醫院 腎臟科

The diagnosis of life-threatening dyskalemia almost always relies on the laboratory reports requiring the unexpected turnaround time. Since the cardiac tissue is very sensitive to dyskalemia, electrocardiography (ECG) as a non-invasive bedside tool universally used in emergent condition may detect the potentially fatal dyskalemia with limited accuracy before the laboratory report. Currently, artificial intelligence (AI) technique based on deep learning model (DLM) has been shown to achieve human-level performance and be effective to detect dyskalemia with large annotated ECG datasets. Using a large data-driven DLM, we have successfully developed the AI-ECG12NET to early detect severe dyskalemia. There are several clinical applications of ECG12Net. First, severe dyskalemia could be identified by ECG12Net within 3 minutes, much faster than laboratory testing, leading to more prompt management. Second, pseudodyskalemia, defined as an abnormal reported serum or plasma K+ concentration despite normal in vivo K+ concentration, can be excluded early by ECG12Net to avoid inappropriate treatment. Third, the ECG12Net model could be incorporated into ECG machines in ambulances or remote areas to facilitate telemedicine and applied to a wearable device for dyskalemia detection. Fourth, bloodless ECG12Net is germane and can be a guide therapy for patients with dyskalemia. Finally, ECG12Net may help the early diagnosis of diseases with dyskalemia such as thyrotoxic periodic paralysis and digoxin intoxication. Although AI-assisted ECG12Net may provide a real-time and bloodless diagnosis of dyskalemia, the limitation and factors affecting its accuracy must be also understood.

【專題演講 14-3】 人工智慧於透析中低血壓之應用 Application of artificial intelligent in intradialytic hypotension 吳志仁 台北馬偕醫院 腎臟內科 Blood pressure (BP) variation is frequently encountered and is associated with most complications during regular hemodialysis (HD). The intradialytic hypotension has strong implications for adverse outcomes, including increased cardiovascular events and overall morbidity and mortality With the advent of the era of big data and artificial intelligence, there are few reports applying the concept of big data in HD. The accumulated dialysis records in each HD session can be gathered to obtain big HD data with the potential to assist HD staff in increasing patient wellbeing. Due to the massive volume and complexity of the data, we utilized the Wistron Corporation Bestshape ® Dialysis Assistant System, comprising two parts, the VIP gateway device and a medical informatics analysis system program.The VIP gateway is a device that collects vital signs and corresponding dialysis machine settings. Then, the VIP uploads the records to a data lake located in the dialysis center. All data were double-checked on-site by a team of two nurses and were gathered electronically via the VIP gateway. Structured Query Language (SQL) was used to manage individual electronic medical records, which were then stored in the Oracle database. Other clinical information, including age, gender, and diabetes mellitus, was also collected in the Hospital Information System (HIS). With the ongoing advancements in artificial intelligence and machine-learning techniques, our data can be applied to different HD issues. This application enabled model selection, model prediction, parameter tuning, and the visualization of the results in a user-friendly interface based on this dataset. The construction of an BP prediction intelligent system through this HD dataset could aid in the clinical decision-making process and further help reduce the incidence of intradialytic hypotension.

【專題演講 14-4】 AI Application in Renal Care Jeffrey L. Hymes Len Usvyat “The world’s most valuable resource is data” according to various expert opinions. This session will focus on how Fresenius Medical Care North America (FMC) leverages artificial intelligence to guide the delivery of truly personalized care by insights gained using large structured and unstructured data sources. We will focus on several examples of machine-learning and deep-learning based predictive modeling algorithms designed for preemptive identification of patients at a greater risk of imminent all-cause and fluid related hospital admissions, prediction of COVID-19 infection, image-recognition models for aneurysm detection as well as several examples of using mathematical modeling to drive medication therapy. The session will also discuss some of the lessons learned and the essential ingredients for applying AI models in clinical practice.

【專題演講 15-1】 知不足后能自反--專業自主首部曲 Demonstration of professional accountability: Clinical Auditing 廖熏香

財團法人醫院評鑑暨醫療品質策進會

專業自主是醫療專業的照護品質的核心,而能發展並確保實證支持處置的實施是種專業自主的展現。本會自 105 年引進英國 Healthcare Quality Quest (HQQ)臨床稽核(Clinical Audit)，以確認醫療照護人員遵從臨床照護指引之程度，並找出最需要進行品質改善的地方，以改善

病人照護結果。主要分為議題界定、依標準發展稽核指標、進行資料收集、指標結果與標準

之差異比較、確立間題進行改善及維持等五大階段。可以提供醫療專業團隊做自我檢視及改

善的模式。

本年度由醫策會與腎臟醫學會合作辧理的臨床稽核實踐班即是以以實證醫學為基礎自訂臨床

稽核指標，藉由臨床稽核了解臨床照護與臨床照護指引之間的差異，進一步分析，進行品質

改善，以提升院內醫療品質與病人安全。另外，可藉由臨床稽核課程提升醫院專業自主的內

部監測，使醫療人員具備診斷及解決問題之能力，亦能協助醫院運用品質指標於認證、訪查

及評鑑呈現腎臟病照護品質。來自 18 家醫院的腎內照護團隊,經過 5 個月三次課程,分別完成了不同主題範圍的臨床稽核,過程中的學習及結果讓團隊體會到稽核後知不足后能自反及改進。

【專題演講 15-2】 臨床稽核在腎臟科的實踐經驗分享(一)—耕莘醫院安坑分院 以「透析病人副甲狀腺機能亢進的有效控制」為例 侯羿州 耕莘醫院安康院區 腎臟科

臨床稽核的目的在於運用實證醫學與臨床稽核，找出照護過程中需要提升改善的項目，並進一步分析運用臨床稽核結果，擬定行動方案及執行改善，以降低照護過程中潛在風險危

害確保病人安全與醫療服務品質。 運用臨床稽核於品質提升的成功要素，首要訂定一個具體目標，而「目標」需轉換為「指標」(關鍵結果)，完善指標表現後，方能達到團隊追求的目標。此外，針對稽核發現問題，利用特性要因圖仔細找出潛在原因及確認要因，並與行動方案緊密連結，有效的執行力可增加

品質良率。 本次專案，團隊依據單位現況，選定以「透析病人副甲狀腺機能亢進的有效控制」稽核主題，將目標依據實證醫學及照護標準轉換為 6 項稽核指標，以臨床稽核資料收集表，實際稽核 74 個案。透過分析稽核發現找出 4 項問題，以特性要因圖找出要因後，團隊擬定建立補抽及覆核機制、建立趨近治療選項臨界值治療作業指引、以 SDM 輔助續發性副甲狀腺亢進的治療選擇及強化營養諮詢功能 4 項優先改善行動方案，並據以執行。 初次學習與應用臨床稽核手法於品質監測，過程及結果尚有許多技巧及策略需進一步修正。但對於強化臨床透析照護品質及促進跨單位合作，確有其助益，值得深入學習與應用，

為原有的醫療作業創造新價值。

【專題演講 15-3】 臨床稽核在腎臟科的實踐經驗分享(二)—臺中榮民總醫院 劉時安 臺中榮民總醫院 品質管理中心

因應未來醫策會評鑑認證趨勢，建置醫院內部的臨床稽核機制，希望藉由系統性稽核「臨床

作為」與「實證醫學」的落差，分析及改善，促進醫療專業成長，並提升團隊合作。本次課

程簡介臺中榮總臨床稽核發展歷程及推動成效，同時以腎臟科為案例說明臨床稽核落實之方

法。

【專題演講 15-4】 臨床稽核在腎臟科的實踐經驗分享(三)—高雄醫學大學附設醫院 郭美娟 高雄醫學大學附設醫院 腎臟科

臨床稽核可以協助醫療機構專業人員確保醫療服務的品質與病人的安全，找出照護過程中需

要提升改善的項目。透過臨床稽核，本院團隊嘗試於過去已十分熟悉的慢性腎臟病整體照護

著手。希望透過系統性檢視，找出照護過程中需進一步分析及改善的主題項目。藉由團隊內

部稽核、持續監測，希望能精進醫療照護品質，促進醫療專業成長並提升團隊合作。此次南

區臨床稽核課程，本照護團隊依據上述概念，決定稽核四項在慢性腎臟病第五期需要監測的

指標-末期腎臟病治療模式衛教完成率、慢性腎臟病病人平順進入透析比例、血磷監測率及達標率。藉由臨床稽核核心概念及實作步驟的學習，實際從臨床發現問題，發展慢性腎臟病第

五期臨床稽核指標，進行正確資料收集，內部分析稽核並發現問題，進而試行小規模改善作

為以改善醫療照護品質。

【專題演講 16-1-1】 真實世界的多重用藥與潛在不適當用藥的評估指標 Real World Polypharmacy and Potentially Inappropriate Medication (PIM) Evaluation Indicators 吳承誌 高雄長庚紀念醫院 藥劑部臨床藥學科 Abstract 1. From Age-Friendly Health System to “M”edication 2. Framework of polypharmacy

a. Definition Clinical Research

b. Prescribing cascade 3. Impact of polypharmacy 4. From polypharmacy to PIM criteria 5. Management strategies – rational deprescribing 6. Real-world case & role of pharmacist’s intervention

【專題演講 16-1-2】 多重慢性病患之周全性評估，以高齡醫學為例 Comprehensive assessment and care in older patients with multimorbidity 翁碩駿 臺中榮民總醫院 腎臟科 台灣高齡照護現況問題，在於老化與慢性疾病對大眾警示性太低，慢性病因人口老化帶來的

衝擊，將造成老年生活品質下降、家庭與國家財政負擔加劇。影響老年存活，或許我們看到

的只是表象，因為影響老年的存活非單一因素(除了重大疾病)可以決定。探討老年衰弱(frailty)的實證，發現認知功能變差，衰弱程度會變嚴重。身體衰弱中，影響最大為活動型衰弱

(mobility-type frailty)，依次低活動衰弱(low activity)，最後為非活動型衰弱(non-mobility-type frailty)，而非活動型衰弱和相對健康組(Robust)預後差不多。

高齡化與慢性疾病帶來的衝擊中，我們提出健康折舊與衰弱症的假說，高齡化健康折舊

比例偏高，進而健康花費與成本偏高；老年人普遍健康素養(health literacy)偏差、自我健康管理能力(self-management)不足；在台灣，家庭/社會支持系統比健康素養對老年疾病管理來的重要，此外，老年人罹患慢性疾病後，對家屬(家庭)依賴度變高。在討論 CKD 照護的反思與慢性腎臟病加上肌少症之不良預後之後，周全性老年評估在老年慢性腎臟病照護應用的重要

性，在於老年人潛在不適當用藥比例偏高、老年人罹患慢性病後，身體功能衰弱程度大大影

響“存活”與生活品質，也延長了住院天數與反覆在入院的情形。此外，口牙清潔的介入性研究發現可以減低出院後罹患肺炎。最後在高齡低健康素養者之照護原則與技巧，包含互動溝

通過程避免爭論或評論、善加利用非語言溝通、互動態度與神情；教學素材與工具：利用簡

單易懂、實體教具模組、口語化用詞、圖片、照片取代文字；溝通與指導方式：說話速度放

慢、避免過多訊息、生活化用詞與實例、分解動作與回覆示教。 周全性老年評估的重要性與最後結語：老化、器官衰退、認知功能下降、健康素養差，

帶來多重共病與多重用藥；周全性老年評估在老年慢性腎臟病是重要，除了避免老人慢性腎

臟病惡化、校正營養不良、校正貧血以外，可能可以盡早避免認知功能退化、身體功能衰退

與老年症候群的復發。

【專題演講 16-2-1】 醫院以病人為中心門診整合照護計畫 蔡淑鈴 衛生福利部中央健康保險署

隨著人口的老化、科技的進步與醫藥的發達，國人平均壽命持續延長，疾病的型態也從

細菌病毒感染之急性病，逐漸轉變成生活型態導致之慢性病。而慢性病治療與急性病不同，

大部分只能控制病情穩定而無法治癒，故慢性病患者人數不斷增加，其後續醫療照護問題，

對健保是一項挑戰。

中央健康保險署推動「醫院以病人為中心門診整合照護計畫」，目的為引導醫院各專科間

之適當整合，不再只從單一科別思考治療策略，鼓勵醫院對於門診就醫病患提供整合式門診

照護服務，使多重慢性病患可以獲得整合性照護服務，提升多重慢性病之照護品質，讓民眾

看病更安心，品質有保障。

病人經整合照護後病情穩定，期能落實分級醫療及轉診，使大醫院得以集中量能，照護

急重難症病人，提升醫療資源使用效率。

【專題演講 16-2-2】 多重慢性病整合照護之全人整合醫療理念 吳明儒 臺中榮民總醫院 內科部

近年來台灣多重慢性病引發之失能人口大幅增加，慢性病相關之就醫及長照需求也隨之

遽增。藉由分級醫療跨專科醫療團隊提供多重慢性病整合照護有機會防治更多的失能，國民

健康署推動試辦計畫希望整合多重慢性病跨專科團隊跨領域專家意見，提供以病人為中心之

多重慢性病整合照護建議，以慢性病照護模式為基礎，規劃有病人和家屬參與，後疫情期間

可行之智能化跨專科多重慢性病整合照護運作機制和可能精進的做法。藉由收集國內外優秀

整合照護團隊發表之文獻和經驗分享，召開跨專科跨領域專家的共識會議，凝聚可以推廣實

作之共識，完成『智能化增強病人和家屬參與的多重慢性病整合照護模式』的建議。 然而多重慢性病整合照護的成功要素包括：政府和各級院所積極宣導多重慢性病整合照

護，病人和家屬要有強烈意願參與整合照護，醫師要以病人為中心的整合照護認同且配合，

醫院必須完成院內各專科部門充分的協調，醫學中心和基層院診間建立良好的轉診照護機制，

政府相關機構長期提供足夠的獎勵方案作為鼓勵團隊和病患家屬的誘因等。有了以上條件並

且長期持續經營，才能創造多贏的多重慢性病整合照護，減少多重慢性病患者的失能，讓國

人活得更健康。

【專題演講 16-3-1】 多重慢性疾病照護在 CKD之整合共照 The integrated and coordinating care of Multi-morbidity in CKD 邱怡文 高雄醫學大學附設醫院 腎臟科 共病之盛行在 CKD 患者為一大挑戰。約六成超過六十歲患者合併兩種以上之共病。共病造成高死亡率，醫療花費與不良健康後果，尚不清楚有多少 CKD病患有多重共病未被診斷。台灣之專科醫師制使全人照護輕不易執行。面對 CKD之共病，主要之照護障礙包括沒有人主責CKD患者的多重共病照護，和對共病症的治療與追蹤無計畫。因為共病而需同時遵守多項臨床指引之困擾，有限之證據支持共照之療效，多重用藥造成順從度降低與藥物間之交互作用

等，皆使患者有更高風險無法接受適當之照護。解決之道仍是回歸以病人為中心，因不同共

病各自的病程，在適當時機活用整合與共照之互用。從醫院擴至社區，讓整合共照能普及，

有賴政策，學會與醫療院所就運作模式重新思考，提供 C