非酒精性脂肪肝纤维化程度与慢性肾病的关系

Relationship between fibrosis degree of nonalcoholic fatty liver disease and chronic kidney disease

目的探究4种无创血清学肝纤维化评分指标对超声诊断为非酒精性脂肪性肝病(nonalcoholic fatty liver disease,NAFLD)患者慢性肾病(chronic kidney disease,CKD)发生风险的预测价值,以及NAFLD患者肝纤维化评分与CKD的关系。方法共纳入昆明医科大学第二附属医院2013年6月-2018年6月入院的NAFLD患者249例,根据是否合并CKD分为NAFLD未合并CKD组(A组)及NAFLD合并CKD组(B组)。CKD定义为eGFR<60 ml/(min·1.73 m^2)。肝纤维化程度按FIB-4评分、非酒精性脂肪性肝病纤维化评分(nonalcoholic fatty liver disease fibrosis score,NFS)、天冬氨酸氨基转移酶/血小板比值指数(aspartate aminotransferase to platelet ratio index,APRI)、BARD(BMI,AST/ALT,DM)评分的传统最佳临界值分别分为高纤维化评分组和低纤维化评分组,比较两组CKD发生风险。同时绘制ROC曲线比较4种评分预测CKD发生风险的临床价值。以是否发生CKD作为因变量,以4种评分与单因素分析有统计差异的因素作为自变量分别构建4种回归变量模型,进行多因素logistic回归分析。结果249例NAFLD患者中,A组124例,B组125例,B组的年龄、尿素、肌酐、尿酸、表示肝纤维化程度的无创血清学肝纤维化评分系统FIB-4、NFS、APRI、BARD评分显著高于A组,血红蛋白、血小板计数、白蛋白、ALT、AST、总胆红素、eGFR则显著低于A组(P均<0.05)。多因素logistic回归结果显示:FIB-4、NFS、BARD均可预测CKD发生风险;其中,高FIB-4组患CKD的风险高于低FIB-4组(OR=2.337,95%CI:1.052~5.193),高NFS组患CKD的风险高于低NFS组(OR=3.058,95%CI:1.100~8.500),高BARD组患CKD的风险高于低BARD组(OR=3.300,95%CI:1.524~7.148)。4种评分诊断CKD的AUC和最佳临界值依次是FIB-4:0.711(1.553)、NFS:0.742(-0.510)、APRI:0.628(0.386)和BARD:0.636(1.500)。结论NAFLD高纤维化评分组CKD发生风险显著高于低纤维化评分组,FIB-4、NFS、BARD评分均可预测CKD发生,其中NFS是最佳预测因子。

Objective To examine the predictive value of four noninvasive fibrosis indices in identifying chronic kidney disease(CKD)among nonalcoholic fatty liver disease(NAFLD),and investigate the relationship between liver fibrosis scores and CKD in NAFLD patients.Methods A total of 249 NAFLD patients admitted to our hospital from June 2013 to June 2018 were selected and divided into group A(Non-CKD group)and group B(CKD group)according to the presence of CKD.CKD was defined by estimated glomerular filtration rate less than 60 ml/(min·1.73 m^2).The severity of hepatic fibrosis was determined by FIB-4 score,NFS(NAFLD fibrosis score),APRI score(AST to platelet ratio index),BARD score(BMI,AST/ALT,DM),respectively.Receiver operating characteristic curve was used to assess the predictive value of each marker.Using CKD as the dependent variable,four regression models were separately constructed using four noninvasive fibrosis scores and the factors which had statistical differences tested by univariate analysis.Results Among 249 patients with NAFLD,there were 124 patients in group A and 125 patients in group B.Age,urea,creatinine,uric acid,and the scores of four non-invasive serous fibrosis markers such as FIB-4,NFS,APRI,BARD in group B were all significantly higher than those of group A;However,hemoglobin,platelet count,albumin,ALT,AST,total bilirubin and eGFR were significantly lower than those in group A(all P<0.05).Multivariate logistic regression showed that FIB-4(OR,2.337;95%CI,1.052 to 5.193),NFS(OR,3.058;95%CI,1.100 to 8.500)and BARD(OR,3.300;95%CI,1.524 to 7.148)were independent predictors for CKD.The AUC and optimal cut-off value of the four scores were 0.711 and 1.553 for FIB-4,0.742 and-0.510 for NFS,0.628 and 0.386 for APRI,0.636 and 1.500 for BARD.Conclusion High noninvasive fibrosis score is associated with an increased risk of CKD.FIB-4,NFS,BARD are independent predictors of CKD among individuals with NAFLD,while NFS has optimal predictive ability.