不同亚型非酒精性脂肪性肝病患者代谢性心血管病风险因素的特征分析

高黎黎; 王勇; 严华芳; 王晓亮; 王云峰

doi:10.12449/JCH250110

不同亚型非酒精性脂肪性肝病患者代谢性心血管病风险因素的特征分析

DOI: 10.12449/JCH250110

高黎黎^1a,
王勇²,
严华芳^1b,
王晓亮^1c,
王云峰^3, , ,

1a.
上海市浦东医院，复旦大学附属浦东医院医学科研与创新中心，上海 201399
1b.
上海市浦东医院，复旦大学附属浦东医院健康管理部，上海 201399
1c.
上海市浦东医院，复旦大学附属浦东医院普通外科，上海 201299
2.
上海市浦东新区周浦医院肝胆外科，上海 201318
3.
上海市浦东新区人民医院普通外科，上海 201299

基金项目:

国家自然科学基金 (81670514);

浦东新区卫生健康委员会卫生计生科研项目 (PW2021A-39)

伦理学声明：本研究于2021年5月7日经由上海市浦东医院伦理委员会审批，批号：QWJW-03。

利益冲突声明：本文不存在任何利益冲突。

作者贡献声明：高黎黎负责课题设计，资料分析，论文撰写；王勇、严华芳、王晓亮参与现场沟通，数据收集，论文修改；王云峰负责拟定写作思路，指导撰写文章及最后定稿。

详细信息

通信作者:
王云峰， wangyunfeng197911@163.com （ORCID： 0000-0003-3428-3208）

计量
- 文章访问数: 636
- HTML全文浏览量: 217
- PDF下载量: 51
- 被引次数: 0
出版历程
- 收稿日期: 2024-05-17
- 录用日期: 2024-07-10
- 出版日期: 2025-01-25

Characteristics of cardiometabolic risk in patients with different subtypes of non-alcoholic fatty liver disease

1a.
Center for Medical Research and Innovation Shanghai Pudong Hospital，Pudong Hospital Affiliated to Fudan University Shanghai 201399，China
1b.
Department of Health Examination Shanghai Pudong Hospital，Pudong Hospital Affiliated to Fudan University Shanghai 201399，China
1c.
Department of General Surgery，Shanghai Pudong Hospital，Pudong Hospital Affiliated to Fudan University Shanghai 201399，China
2.
Department of Hepatobiliary Surgery，Shanghai Pudong New District Zhoupu Hospital，Shanghai 201318，China
3.
Department of General Surgery，Pudong New Area People’s Hospital，Shanghai 201299，China

Research funding:

National Natural Science Foundation of China (81670514);

Pudong Bureau of Health and Family Planning (PW2021A-39)

More Information

Corresponding author: WANG Yunfeng， wangyunfeng197911@163.com （ORCID： 0000-0003-3428-3208）

摘要

摘要: 目的由于代谢紊乱诱发的心血管事件是非酒精性脂肪性肝病（NAFLD）的首位死因，本研究旨在从代谢角度对不同亚型NAFLD患者的心血管病发生风险的差异进行探索。方法利用整群抽样选取上海市浦东新区3家代表性医院进行多中心横断面研究，共收集2022年7月—2023年6月体检资料37 122份，并根据BMI对数据分层处理。计数资料的组间比较采用χ²检验，通过多因素Logistic回归分析不同亚型NAFLD与代谢性心血管病风险因素的相关性。结果 NAFLD共9 372例（检出率为25.25%），其中超97%的患者被诊断为代谢相关（非酒精性）脂肪性肝病（MAFLD）。亚组分析显示，瘦型、超重型和肥胖型NAFLD检出率分别为7.72%、33.99%和63.56%。肥胖型NAFLD患者合并血压、血糖、TG、HDL及尿酸异常的比例较瘦型及超重型患者高（P值均<0.001）。风险因素中，瘦型NAFLD与TC升高相关（P<0.05），超重型及肥胖型NAFLD与TC异常不相关（P>0.05）；肥胖型NAFLD与TG异常不相关，瘦型及超重型NAFLD与TG异常相关（P值均<0.05）；各型NAFLD与腰臀比、血压、血糖、LDL、HDL及尿酸异常均相关（P值均<0.05）。结论上海市浦东地区不同亚型NAFLD检出率与国内外报道接近，NAFLD的流行病学数据可类推于MAFLD。不同亚型NAFLD在代谢性心血管病风险因素的分布及相关性方面存在一定差异，需结合各型NAFLD的整体代谢特点制定针对性干预措施。
- 非酒精性脂肪性肝病 /
- 人体质量指数 /
- 心血管疾病 /
- 危险因素
Abstract: Objective To investigate the difference in the risk of cardiovascular diseases between patients with different subtypes of non-alcoholic fatty liver disease （NAFLD） from the perspective of metabolism， since cardiovascular events induced by metabolic disorders are the leading cause of death in NAFLD. Methods The cluster sampling method was used to conduct a multicenter cross-sectional study among three representative hospitals in Pudong New Area of Shanghai， China. A total of 37 122 sets of physical examination data from July 2022 to June 2023 were collected and stratified according to body mass index （BMI）. The chi-square test was used for comparison of continuous data between groups， and a multivariable Logistic regression analysis was used to investigate the association between NAFLD subtypes and cardiometabolic risk factors. Results A total of 9 372 cases of NAFLD were detected， with a detection rate of 25.25%， and more than 97% of these patients were diagnosed with metabolic associated fatty liver disease （MAFLD）. The subgroup analysis showed that the detection rates of lean， overweight， and obese NAFLD were 7.72%， 33.99%， and 63.56%， respectively. Compared with the patients with lean or overweight NAFLD， the patients with obese NAFLD showed a significantly higher proportion of patients with abnormalities in blood pressure， blood glucose， triglyceride （TG）， high-density lipoprotein （HDL） or uric acid （all P<0.001）. Among related risk factors， lean NAFLD was associated with the increase in total cholesterol （TC）（P<0.05）， while overweight NAFLD and obese NAFLD were not associated with TC abnormalities （P>0.05）； obese NAFLD was not associated with TG abnormalities， while lean NAFLD and overweight NAFLD were associated with TG abnormalities （both P<0.05）； all types of NAFLD were associated with the abnormalities of waist-hip ratio， blood pressure， blood glucose， low-density lipoprotein， HDL， and uric acid （all P<0.05）. Conclusion The detection rates of different subtypes of NAFLD in Shanghai Pudong are close to those reported in China and globally， and the epidemiologic data of NAFLD can be used analogously for MAFLD. There are certain differences in the distribution and association of cardiometabolic risk factors between different subtypes of NAFLD， and targeted interventions should be formulated based on the metabolic characteristics of each type of NAFLD.
- Non-alcoholic Fatty Liver Disease /
- Body Mass Index /
- Cardiovascular Diseases /
- Risk Factors

HTML全文

表 1 体检人群的一般特征

Table 1. General characteristics of the health check-up people

项目	例数（%）	项目	例数（%）
年龄		性别
18～60岁	28 342（76.35）	男	17 309（46.63）
≥60岁	8 780（23.65）	女	19 813（53.37）
WHR		血压
正常	22 873（61.62）	低	1 221（3.29）
升高	14 249（38.38）	正常	23 929（64.46）
BMI		高	11 972（32.25）
低	1 227（3.31）	TC
正常	16 552（44.59）	正常	26 602（71.66）
超重	14 527（39.13）	偏高	7 990（21.52）
肥胖	4 816（12.97）	升高	2 530（6.82）
血糖		TG
低	123（0.33）	正常	26 575（71.59）
正常	31 717（85.44）	偏高	6 093（16.41）
IFG	2 493（6.72）	升高	4 454（12.00）
DM	2 789（7.51）	LDL
尿酸		正常	26 699（71.92）
正常	30 936（83.34）	偏高	6 800（18.32）
HUA	6 186（16.66）	升高	3 623（9.76）
NAFLD		HDL
无	27 750（74.75）	降低	4 762（12.83）
有	9 372（25.25）	正常	32 360（87.17）
注：IFG，空腹血糖受损；DM，糖尿病。

下载: 导出CSV

表 2 不同亚型NAFLD患者一般特征及代谢指标的差异

Table 2. Characteristics and metabolic indicator of lean， overweight and obese individuals with NAFLD

变量	瘦型（n=1 373）	超重型（n=4 938）	肥胖型（n=3 061）	χ²值	P值
年龄≥60岁［例（%）］	467（34.00）	1 605（32.50）	847（27.67）	26.74	<0.001
男性［例（%）］	525（38.24）	3 116（63.10）	2 027（66.22）	340.59	<0.001
WHR升高［例（%）］	507（36.93）	2 657（53.81）	2 515（82.16）	1 013.74	<0.001
高血压［例（%）］	514（37.43）	2 357（47.73）	1 880（61.42）	254.72	<0.001
血糖［例（%）］				53.64	<0.001
IFG	136（9.91）	656（13.28）	430（14.05）
DM	201（14.64）	750（15.19）	604（19.73）
HUA［例（%）］	231（16.82）	1 493（30.23）	1 222（39.92）	241.57	<0.001
TC［例（%）］				5.78	0.216
偏高	405（29.50）	1 462（29.61）	863（28.19）
升高	161（11.72）	522（10.57）	307（10.03）
TG［例（%）］				98.33	<0.001
偏高	257（18.72）	1 190（24.10）	765（24.99）
升高	303（22.07）	1 351（27.36）	968（31.62）
LDL［例（%）］				7.51	0.111
偏高	335（24.40）	1 261（25.54）	832（27.18）
升高	205（14.93）	813（16.46）	493（16.11）
HDL降低［例（%）］	215（15.66）	1 271（25.74）	981（32.05）	133.11	<0.001

下载: 导出CSV

表 3 不同亚型NAFLD代谢相关性的多因素Logistic回归分析

Table 3. Multivariable Logistic regression analysis of NAFLD among lean， overweight and obese people

变量	瘦型		超重型		肥胖型
变量	P值	OR（95%CI）	P值	OR（95%CI）	P值	OR（95%CI）
年龄≥60岁^1）					<0.001	0.76（0.66～0.88）
男性	0.080	1.14（0.99～1.31）
WHR升高^2）	<0.001	2.14（1.87～2.44）	<0.001	1.31（1.22～1.41）	<0.001	1.56（1.35～1.81）
高血压^3）	<0.001	1.59（1.39～1.82）	<0.001	1.25（1.15～1.35）	<0.001	1.38（1.21～1.58）
血糖^3）
IFG	<0.001	2.33（1.86～2.91）	<0.001	2.15（1.90～2.44）	<0.001	1.51（1.24～1.84）
DM	<0.001	3.71（3.02～4.54）	<0.001	2.40（2.12～2.71）	<0.001	1.94（1.61～2.33）
TC^2）
偏高	0.221	0.89（0.74～1.07）	0.402	1.05（0.94～1.18）
升高	0.001	0.61（0.45～0.83）	0.063	0.83（0.69～1.01）
TG^2）
偏高	<0.001	2.82（2.38～3.34）	<0.001	1.20（1.10～1.31）
升高	<0.001	6.23（5.14～7.55）	<0.001	2.72（2.43～3.05）
LDL^2）
偏高	<0.001	2.01（1.67～2.42）	<0.001	1.89（1.69～2.11）	<0.001	1.29（1.12～1.49）
升高	<0.001	2.85（2.17～3.74）	<0.001	2.30（1.95～2.71）	<0.001	1.88（1.55～2.28）
HDL^2）
降低	<0.001	0.64（0.52～0.78）	<0.001	0.58（0.52～0.64）	<0.001	0.72（0.63～0.83）
尿酸^2）
HUA	<0.001	1.73（1.43～2.09）	<0.001	1.58（1.45～1.73）	<0.001	1.33（1.16～1.51）
注：1）18～60岁组为参照；2）正常组为参照；3）低/正常组为参照。

下载: 导出CSV

参考文献(38)

[1]	YOUNOSSI ZM, GOLABI P, PAIK JM, et al. The global epidemiology of nonalcoholic fatty liver disease(NAFLD) and nonalcoholic steatohepatitis(NASH): A systematic review[J]. Hepatology, 2023, 77( 4): 1335- 1347. DOI: 10.1097/HEP.0000000000000004.
[2]	PAIK JM, HENRY L, de AVILA L, et al. Mortality related to nonalcoholic fatty liver disease is increasing in the United States[J]. Hepatol Commun, 2019, 3( 11): 1459- 1471. DOI: 10.1002/hep4.1419.
[3]	LU FB, HU ED, XU LM, et al. The relationship between obesity and the severity of non-alcoholic fatty liver disease: Systematic review and meta-analysis[J]. Expert Rev Gastroenterol Hepatol, 2018, 12( 5): 491- 502. DOI: 10.1080/17474124.2018.1460202.
[4]	LEE SW, LEE TY, YANG SS, et al. Risk factors and metabolic abnormality of patients with non-alcoholic fatty liver disease: Either non-obese or obese Chinese population[J]. Hepatobiliary Pancreat Dis Int, 2018, 17( 1): 45- 48. DOI: 10.1016/j.hbpd.2018.01.007.
[5]	CHEN F, ESMAILI S, ROGERS GB, et al. Lean NAFLD: A distinct entity shaped by differential metabolic adaptation[J]. Hepatology, 2020, 71( 4): 1213- 1227. DOI: 10.1002/hep.30908.
[6]	SANGWUNG P, PETERSEN KF, SHULMAN GI, et al. Mitochondrial dysfunction, insulin resistance, and potential genetic implications[J]. Endocrinology, 2020, 161( 4): bqaa017. DOI: 10.1210/endocr/bqaa017.
[7]	ESLAM M, FAN JG, MENDEZ-SANCHEZ N. Non-alcoholic fatty liver disease in non-obese individuals: The impact of metabolic health[J]. Lancet Gastroenterol Hepatol, 2020, 5( 8): 713- 715. DOI: 10.1016/S2468-1253(20)30090-X.
[8]	ZHU ZM. Cardiometabolic diseases: Concept, challenge and clinical practice[J]. Chin J Cardiol, 2021, 49( 7): 650- 655. DOI: 10.3760/cma.j.cn112148-20210506-00395. 祝之明. 代谢性心血管病: 理念、挑战与实践[J]. 中华心血管病杂志, 2021, 49( 7): 650- 655. DOI: 10.3760/cma.j.cn112148-20210506-00395.
[9]	YOUNOSSI Z, HENRY L. Contribution of alcoholic and nonalcoholic fatty liver disease tothe burden of liver-related morbidity and mortality[J]. Gastroenterology, 2016, 150( 8): 1778- 1785. DOI: 10.1053/j.gastro.2016.03.005.
[10]	ESLAM M, GEORGE J. Genetic contributions to NAFLD: Leveraging shared genetics to uncover systems biology[J]. Nat Rev Gastroenterol Hepatol, 2020, 17( 1): 40- 52. DOI: 10.1038/s41575-019-0212-0.
[11]	SOOKOIAN S, PIROLA CJ. Systematic review with meta-analysis: Risk factors for non-alcoholic fatty liver disease suggest a shared altered metabolic and cardiovascular profile between lean and obese patients[J]. Aliment Pharmacol Ther, 2017, 46( 2): 85- 95. DOI: 10.1111/apt.14112.
[12]	FAN R, WANG JF, DU JM. Association between body mass index and fatty liver risk: A dose-response analysis[J]. Sci Rep, 2018, 8( 1): 15273. DOI: 10.1038/s41598-018-33419-6.
[13]	YOUNOSSI Z, ANSTEE QM, MARIETTI M, et al. Global burden of NAFLD and NASH: Trends, predictions, risk factors and prevention[J]. Nat Rev Gastroenterol Hepatol, 2018, 15( 1): 11- 20. DOI: 10.1038/nrgastro.2017.109.
[14]	ESLAM M, ALKHOURI N, VAJRO P, et al. Defining paediatric metabolic(dysfunction)-associated fatty liver disease: An international expert consensus statement[J]. Lancet Gastroenterol Hepatol, 2021, 6( 10): 864- 873. DOI: 10.1016/S2468-1253(21)00183-7.
[15]	Fatty Liver and Alcoholic Liver Disease Group of the Hepatology Branch of the Chinese Medical Association, Steatotic Liver Disease Expert Committee of the Chinese Physicians Association. Guidelines of prevention and treatment for nonalcoholic fatty liver disease: A 2018 update[J]. J Clin Hepatol, 2018, 34( 5): 947- 957. DOI: 10.3969/j.issn.1001-5256.2018.05.007. 中华医学会肝病学分会脂肪肝和酒精性肝病学组, 中国医师协会脂肪性肝病专家委员会. 非酒精性脂肪性肝病防治指南(2018年更新版)[J]. 临床肝胆病杂志, 2018, 34( 5): 947- 957. DOI: 10.3969/j.issn.1001-5256.2018.05.007.
[16]	Chinese Society of Hepatology, Chinese Medical Association. Guidelines for the prevention and treatment of metabolic dysfunction-associated(non-alcoholic) fatty liver disease(Version 2024)[J]. J Prac Hepatol, 2024, 27( 4): 494- 510. 中华医学会肝病学分会. 代谢相关(非酒精性)脂肪性肝病防治指南(2024年版)[J]. 实用肝脏病杂志, 2024, 27( 4): 494- 510.
[17]	GE JB, XU YJ, WANG C, et al. Internal Medicine[M]. 9^th ed. Beijing: People’s Health Press, 2020: 733- 783. 葛均波, 徐永健, 王辰, 等. 内科学[M]. 9版. 北京: 人民卫生出版社, 2020: 733- 783.
[18]	YOUNES R, GOVAERE O, PETTA S, et al. Caucasian lean subjects with non-alcoholic fatty liver disease share long-term prognosis of non-lean: Time for reappraisal of BMI-driven approach?[J]. Gut, 2022, 71( 2): 382- 390. DOI: 10.1136/gutjnl-2020-322564.
[19]	WEINBERG EM, TRINH HN, FIRPI RJ, et al. Lean Americans with nonalcoholic fatty liver disease have lower rates of cirrhosis and comorbid diseases[J]. Clin Gastroenterol Hepatol, 2021, 19( 5): 996- 1008. DOI: 10.1016/j.cgh.2020.06.066.
[20]	MARGARITI A, DEUTSCH M, MANOLAKOPOULOS S, et al. The severity of histologic liver lesions is independent of body mass index in patients with nonalcoholic fatty liver disease[J]. J Clin Gastroenterol, 2013, 47( 3): 280- 286. DOI: 10.1097/MCG.0b013e31826be328.
[21]	DENKMAYR L, FELDMAN A, STECHEMESSER L, et al. Lean patients with non-alcoholic fatty liver disease have a severe histological phenotype similar to obese patients[J]. J Clin Med, 2018, 7( 12): 562. DOI: 10.3390/jcm7120562.
[22]	FELDMAN A, WERNLY B, STREBINGER G, et al. Liver-related mortality is increased in lean subjects with non-alcoholic fatty liver disease compared to overweight and obese subjects[J]. J Gastrointestin Liver Dis, 2021, 30( 3): 366- 373. DOI: 10.15403/jgld-3622.
[23]	ZOU B, YEO YH, NGUYEN VH, et al. Prevalence, characteristics and mortality outcomes of obese, nonobese and lean NAFLD in the United States, 1999-2016[J]. J Intern Med, 2020, 288( 1): 139- 151. DOI: 10.1111/joim.13069.
[24]	BEGAYE B, VINALES KL, HOLLSTEIN T, et al. Impaired metabolic flexibility to high fat overfeeding predicts future weight gain in healthy adults[J]. Diabetes, 2020, 69( 2): 181- 192. DOI: 10.2337/db19-0719.
[25]	NISHIOJI K, MOCHIZUKI N, KOBAYASHI M, et al. The impact of PNPLA3 rs738409 genetic polymorphism and weight gain≥10 kg after age 20 on non-alcoholic fatty liver disease in non-obese Japanese individuals[J]. PLoS One, 2015, 10( 10): e0140427. DOI: 10.1371/journal.pone.0140427.
[26]	ZAREAN E, LOOHA MA, AMINI P, et al. Sleep characteristics of middle-aged adults with non-alcoholic fatty liver disease: Findings from the Shahrekord PERSIAN cohort study[J]. BMC Public Health, 2023, 23( 1): 312. DOI: 10.1186/s12889-023-15251-4.
[27]	SAPONARO C, SABATINI S, GAGGINI M, et al. Adipose tissue dysfunction and visceral fat are associated with hepatic insulin resistance and severity of NASH even in lean individuals[J]. Liver Int, 2022, 42( 11): 2418- 2427. DOI: 10.1111/liv.15377.
[28]	GIBIINO G, SARTINI A, GITTO S, et al. The other side of malnutrition in inflammatory bowel disease(IBD): Non-alcoholic fatty liver disease[J]. Nutrients, 2021, 13( 8): 2772. DOI: 10.3390/nu13082772.
[29]	ZHAO YX, WANG YL, SU JH, et al. A study of factors influencing the comorbidity of type 2 diabetes mellitus in≥45-year-old patients with nonalcoholic fatty liver disease[J]. Pract Prev Med, 2024, 31( 5): 604- 607. DOI: 10.3969/j.issn.1006-3110. 赵永晓, 王艳丽, 苏江华, 等. ≥45岁非酒精性脂肪肝病患者合并2型糖尿病的影响因素研究[J]. 实用预防医学, 2024, 31( 5): 604- 607. DOI: 10.3969/j.issn.1006-3110.
[30]	MA XS. Investigation and analysis on the orientation and life pressure of“quasi-white-collar workers” in Qingdao and Shanghai[J]. Rural Econ Sci Technol, 2016, 27( 7): 125- 127. DOI: 10.3969/j.issn.1007-7103.2016.07.050. 马兴社. 关于青岛、上海等地“准白领”阶层定位和生活压力调查与分析[J]. 农村经济与科技, 2016, 27( 7): 125- 127. DOI: 10.3969/j.issn.1007-7103.2016.07.050.
[31]	YUE MC, HUANG C, LI K, et al. Equity analysis of national healthcare resources-based on GIS technology and gini coefficient[J]. J Traditi Chin Med Managt, 2024, 32( 9): 16- 20. DOI: 10.16690/j.cnki.1007-9203.2024.09.007. 岳铭冲, 黄超, 李凯, 等. 全国医疗卫生资源公平性分析——基于GIS技术和基尼系数[J]. 中医药管理杂志, 2024, 32( 9): 16- 20. DOI: 10.16690/j.cnki.1007-9203.2024.09.007.
[32]	ZHANG Q, ZHANG JM. The evolution of the matching on elderly population and healthcare resource space: An empirical analysis based on Shanghai statistical data[J]. Chin J Health Policy, 2019, 12( 7): 18- 23. DOI: 10.3969/j.issn.1674-2982.2019.07.003. 张强, 张健明. 老年人口与卫生资源空间匹配的演进趋势——基于上海统计数据的实证分析[J]. 中国卫生政策研究, 2019, 12( 7): 18- 23. DOI: 10.3969/j.issn.1674-2982.2019.07.003.
[33]	LIN YS, FENG XC, CAO X, et al. Age patterns of nonalcoholic fatty liver disease incidence: Heterogeneous associations with metabolic changes[J]. Diabetol Metab Syndr, 2022, 14( 1): 181. DOI: 10.1186/s13098-022-00930-w.
[34]	ZHOU F, ZHOU JH, WANG WX, et al. Unexpected rapid increase in the burden of NAFLD in China from 2008 to 2018: A systematic review and meta-analysis[J]. Hepatology, 2019, 70( 4): 1119- 1133. DOI: 10.1002/hep.30702.
[35]	SHI YW, WANG QY, SUN YM, et al. The prevalence of lean/nonobese nonalcoholic fatty liver disease[J]. J Clin Gastroenterol, 2019, 54( 4): 378- 387. DOI: 10.1097/mcg.0000000000001270.
[36]	ZOU ZY, WONG VWS, FAN JG. Epidemiology of nonalcoholic fatty liver disease in non-obese populations: Meta-analytic assessment of its prevalence, genetic, metabolic, and histological profiles[J]. J Dig Dis, 2020, 21( 7): 372- 384. DOI: 10.1111/1751-2980.12871.
[37]	YE Q, ZOU BY, YEO YH, et al. Global prevalence, incidence, and outcomes of non-obese or lean non-alcoholic fatty liver disease: A systematic review and meta-analysis[J]. Lancet Gastroenterol Hepatol, 2020, 5( 8): 739- 752. DOI: 10.1016/S2468-1253(20)30077-7.
[38]	WU TF, LIAO XH, ZHONG BH. Epidemiology of nonalcoholic fatty liver disease in some regions of China[J]. J Clin Hepatol, 2020, 36( 6): 1370- 1373. DOI: 10.3969/j.issn.1001-5256.2020.06.039. 吴挺丰, 廖献花, 钟碧慧. 中国部分地区非酒精性脂肪肝病的流行情况[J]. 临床肝胆病杂志, 2020, 36( 6): 1370- 1373. DOI: 10.3969/j.issn.1001-5256.2020.06.039.