2型糖尿病患者合并非酒精性脂肪肝及脂肪肝纤维化的危险因素分析

Risk factors for nonalcoholic fatty liver disease and fatty liver fibrosis in type 2 diabetic inpatients

目的：探讨2型糖尿病（T2DM）患者合并非酒精性脂肪肝（NAFLD）及脂肪肝纤维化的危险因素。方法采集2008年5月至2009年12月期间，上海交通大学附属第六人民医院内分泌科住院的1109例T2DM患者的病史资料、生化指标、肝脏超声检查结果，根据B超检查结果将患者分为T2DM组和T2DM合并NAFLD组，采用非酒精性脂肪肝纤维化评分（NAFLDFS）的高诊断阈值（＞0.676）、低诊断阈值（＜-1.455）将T2DM合并NAFLD组分为纤维化亚组、不确定亚组、无纤维化亚组进行分析。结果（1）T2DM合并NAFLD患者体质量指数（BMI）、腰围（WC）、臀围（HC）、腰臀比（WHR）、舒张压（DBP）、丙氨酸转氨酶（ALT）、天冬氨酸转氨酶（AST）、谷氨酰转肽酶（GGT）、总胆红素（TBIL）、总胆固醇（TC）、甘油三酯（TG）、低密度脂蛋白胆固醇（LDL-C）、尿酸（UA）、空腹血糖（FPG）、餐后2h血糖（2hPBG）、空腹C肽（FCP）、FCP代替胰岛素改良稳态模型指数（HOMA-C肽）均更高（P＜0.01或P＜0.05），而年龄、糖尿病病程、高密度脂蛋白胆固醇（HDL-C）则显著低于T2DM患者（P＜0.01，表1）。（2）逐步logistic回归提示BMI[比值比（OR）＝1.325，95%CI 1.249～1.406]、ALT（OR＝1.025，95%CI 1.013～1.038）、TG（OR＝1.283，95%CI 1.105～1.490）是T2DM合并NAFLD的危险因素，HDL（OR＝0.532，95%CI 0.286～0.989）则是保护因素。（3） T2DM合并NAFLD患者中，纤维化亚组占13.4%。与无纤维化及不确定两亚组比较，年龄、病程、BMI、WC、HC、收缩压（SBP）、AST/ALT、GGT、糖化血红蛋白（HbA1c）显著增加（P＜0.01），然而ALT、白蛋白（ALB）、TG、血小板（Plt）显著减少（P＜0.01或P＜0.05），差异具有统计学意义。（4）有序多因素logistic回归提示，年龄、BMI、ALB、AST/ALT、Plt是T2DM合并NAFLD肝纤维化的危险因素。结论住院T2DM合并NAFLD患者比例较大，与BMI、TG、ALT及HDL-C密切相关，而T2DM合并NAFLD患者中存在一定比例肝纤维化风险，与年龄、BMI、AST/ALT、ALB、Plt密切相关。

Objective To investigate the risk factors for nonalcoholic fatty liver disease （NAFLD） and fatty liver fibrosis in type 2 diabetes mellitus （T2DM） inpatients. Methods A total of 1 109 T2DM patients hospitalized in our department from May 2008 to December 2011 were subjected in the study. Their clinical data, such as medical history, results of laboratory examinations, and hepatic ultrasonograms were collected and analyzed. They were divided into T2DM group and T2DM＆amp;NAFLD group according to the ultrasonic tomography results. Then the latter group was further assigned into non-fibrosis subgroup, uncertain subgroup and fibrosis subgroup according to NAFLD fibrosis score （〈-1.455, from -1.455 to 0.676, or 〉0.676）. Results （1） Body mass index （BMI）, waist circumference （WC）, hip circumference （HC）, waist-hip ratio （WHR）, diastolic blood pressure （DBP）, alanine aminotransferase （ALT）, aspartate aminotransferase （AST）, gamma-glutamyltransferase （GGT）, total bilirubin （TBIL）, total cholesterol （TC）, triglycerides （TG）, low density lipoprotein cholesterol （LDL-C）, serum uric acid （UA）, fasting blood glucose （FBG）, 2-hour postprandial blood glucose （2hPBG）, fasting C peptide （FCP）, and HOMA-C peptide were significantly higher （P〈0.05 or P〈0.01）, while age, T2DM course, and high density lipoprotein cholestererol （HDL-C） were significantly lower in T2DM＆amp;NAFLD＆amp;nbsp;group than in T2DM group （P〈0.01）. （2） Logistic analysis showed that BMI [odds ratio （OR）=1.325, 95% CI=1.249？1.406], ALT （OR=1.025, 95% CI=1.013？1.038）, and TG （OR=1.283, 95% CI=1.105？1.490） were the major risk factors for NAFLD in T2DM patients, while HDL-C （OR=0.532, 95% CI=0.286？0.989） was the protective factor. （3） Among the patients with NAFLD, the prevalence of fatty liver fibrosis was 13.4%. The age, diabetic course, BMI, WC, HC, systolic blood pressure （SBP）, AST/ALT, GGT and hemoglobin Alc （HbA1c） were significantly higher （P〈0.01）, but the ALT, albumin （ALB）, TG and platelet （Plt） were significantly lower in the fibrosis subgroup than in the non-fibrosis and uncertain subgroups （P〈0.01 or P〈0.05）. （4） Ordinal logistic regression indicated that the age, BMI, ALB, AST/ALT and Plt were the risk factors for fatty liver fibrosis. Conclusion Higher prevalence of coexisting NAFLD is found in the T2DM patients, which is closely associated with BMI, TG, ALT and HDL-C. What’s more, the T2DM patients with coexisting NAFLD are prone to developing liver fibrosis, which is closely associated with the age, BMI, AST/ALT, ALB and Plt.