2型糖尿病患者心脏代谢指数与非酒精性脂肪性肝病的关系研究

省预防医学科研课题（Y2018109）；镇江市社会发展重点研发计划项目（SH2019041）；镇江市第五期“169工程”科研项目 背景　近年来2型糖尿病（T2DM）及非酒精性脂肪性肝病（NAFLD）的发生率逐年升高，已经成为严重的公共卫生问题，多项指南提出T2DM患者NAFLD的筛查应得到充分重视，但临床及基层操作困难。目的　探讨T2DM患者心脏代谢指数（CMI）与NAFLD的关系。方法　选取2018年5月-2020年3月于江苏大学附属医院就诊的T2DM患者501例，依据超声检查结果分为NAFLD组336例以及非NAFLD组（non-NAFLD组）165例。收集研究对象的临床资料，依据CMI三分位数法将患者分为T1组（CMI<0.765）、T2组（CMI 0.765~1.375）、T3组（CMI>1.375），每组167例。比较NAFLD组和non-NAFLD组患者临床资料，T1组、T2组、T3组患者NAFLD发生率；分析CMI与其余临床指标的相关性，探究T2DM患者发生NAFLD的影响因素及CMI对T2DM患者发生NAFLD的预测价值。结果　NAFLD组患者年龄低于non-NAFLD组，T2DM病程短于non-NAFLD组，有高血压病史者所占比例、舒张压（DBP）、体质指数（BMI）、内脏脂肪面积（VFA）、皮下脂肪面积（SFA）、内脏与皮下脂肪面积比值（VSR）、丙氨酸氨基转移酶（ALT）、天冬氨酸氨基转移酶（AST）、三酰甘油（TG）、总胆固醇（TC）、谷氨酰转肽酶（GGT）、尿酸（UA）、空腹C肽（FC-P）、空腹胰岛素（FINS）、稳态模型评估胰岛素抵抗指数（HOMA-IR）、CMI高于non-NAFLD组，高密度脂蛋白胆固醇（HDL-C）低于non-NAFLD组（P<0.05）。T2组、T3组患者NAFLD发生率高于T1组（P<0.05）；T3组患者NAFLD发生率高于T2组（P<0.05）。CMI与DBP、BMI、VFA、SFA、VSR、ALT、AST、TC、GGT、UA、空腹血糖（FPG）、FC-P、FINS、HOMA-IR呈正相关（P<0.05），与年龄、T2DM病程呈负相关（P<0.05）。二分类Logistic回归分析结果显示，T2DM病程〔OR=0.996，95%CI（0.994，0.999）〕、BMI〔OR=1.400，95%CI（1.264，1.551）〕、FC-P〔OR=1.959，95%CI（1.442，2.661）〕、CMI〔OR=2.053，95%CI（1.422，2.964）〕是T2DM患者发生NAFLD的影响因素（P<0.05）。CMI预测T2DM患者发生NAFLD的受试者工作特征（ROC）曲线下面积为0.738〔95%CI（0.691，0.784），P<0.01〕，最佳截断值为0.692，灵敏度、特异度分别为83.6%、51.5%。采用二分类Logistic回归分析对CMI联合BMI进行拟合，拟合方程Log（P）=-9.103+0.938×CMI+0.358×BMI，CMI联合BMI预测T2DM患者发生NAFLD的ROC曲线下面积为0.816〔95%CI（0.776，0.856），P<0.01〕，灵敏度、特异度分别为84.2%、64.8%。结论　CMI是T2DM患者发生NAFLD的影响因素，且CMI联合BMI对NAFLD具有良好的预测价值，CMI有望成为T2DM患者NAFLD发生风险的预测指标。

Relationship between Cardiometabolic Index and Risk of Nonalcoholic Fatty Liver Disease in Patients with Type 2 Diabetes Mellitus

Background　The increasing prevalence of type 2 diabetes mellitus （T2DM） and nonalcoholic fatty liver disease（NAFLD） has emerged as a critical public health problem.Recent guidelines recommend that more attention should be paid to the screening of NAFLD in T2DM patients，but it is difficult to perform the screening in clinical practice，especially in primary care.Objective　To investigate the relationship between cardiometabolic index （CMI） and risk of NAFLD in patients with T2DM.Methods　A total of 501 individuals with T2DM were recruited between May 2018 and March 2020 at the Affiliated Hospital of Jiangsu University and divided into NAFLD group（n=336） and non-NAFLD group（n=165） according to the result of ultrasound.The clinical data of the two groups were collected and analysed.NAFLD prevalence was compared across the tertile groups of CMI（CMI <0.765，0.765-1.375 and >1.375，167 cases in each tertile）.The correlation of CMI with other clinical indicators was analyzed to explore the influencing factors of NAFLD and the predictive value of CMI for NAFLD in patients with T2DM.Results　Compared with T2DM patients without NAFLD，those with NAFLD showed lower average age，shorter average T2DM duration，higher prevalence of hypertension，higher average levels of diastolic blood pressure，body mass index （BMI），visceral fat area（VFA），subcutaneous fat area（SFA），visceral-to-subcutaneous fat area ratio（VSR），alanine aminotransferase（ALT），aspartate transaminase（AST），triglyceride，total cholesterol（TC），gamma-glutamyl transpeptidase（GGT），uric acid，fasting C-peptide（FC-P），fasting insulin（FINS），homeostasis model assessment of insulin resistance（HOMA-IR） and CMI ，as well as lower average high-density lipoprotein cholesterol （P<0.05）.The low CMI tertile group had lower NAFLD prevalence than other two groups（P<0.05）.The medium CMI tertile group had lower NAFLD prevalence than top CMI tertile group（P<0.05）.CMI was positively correlated with diastolic blood pressure，BMI，VFA，SFA，VSR，ALT，AST，GGT，uric acid，TC，fasting plasma glucose，FINS，FC-P，and HOMA-IR （P<0.05），but negatively correlated with age and T2DM duration in correlation analysis（P<0.05）.The binary Logistic regression analysis showed that T2DM duration〔OR=0.996，95%CI（0.994，0.999）〕，BMI〔OR=1.400，95%CI（1.264，1.551）〕，FC-P〔OR=1.959，95%CI（1.442，2.661）〕and CMI〔OR=2.053，95%CI（1.422，2.964）〕were influencing factors for NAFLD in patients with T2DM （P<0.05）.The area under the ROC curve predicted by CMI for NAFLD was 0.738〔95%CI（0.691，0.784），P<0.01〕，and the optimal cut-off value was 0.692，with sensitivity and specificity of 83.6% and 51.5%，respectively.The binary Logistic regression analysis was used to fit the equation of CMI and BMI，where the fitting equation was Log（P）=-9.103+0.938×CMI+0.358×BMI，and the AUC of CMI with BMI was 0.816〔95%CI（0.776，0.856），P<0.01〕，with sensitivity and specificity of 84.2% and 64.8%，respectively.Conclusion　CMI was associated with NAFLD in patients with T2DM，and it with BMI may have good predictive value for NAFLD.CMI is expected to become a predictor for NAFLD in patients with T2DM.