基于社区老年人群比较代谢相关脂肪性肝病与非酒精性脂肪性肝病的人群差异
DOI: 10.3969/j.issn.1001-5256.2022.03.011
Population differences of metabolic associated fatty liver disease and nonalcoholic fatty liver disease based on a community elderly population
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摘要:
目的 本研究拟比较新命名“代谢相关脂肪性肝病”(MAFLD)与旧命名“非酒精性脂肪性肝病”(NAFLD)的人群差异。 方法 选择2020年11月—2021年1月在北京某社区体检的65岁以上老年人群共624例进行横断面调查,收集人口学、既往史、实验室指标以及肝脏超声和弹性等指标。按照超声诊断有无脂肪肝分为2组:脂肪肝组389例,非脂肪肝组235例。正态分布的计量资料两组间比较采用独立样本t检验,非正态分布的计量资料两组间比较采用Mann-Whitney U秩和检验,计数资料两组间比较采用χ2检验。 结果 389例脂肪肝患者中,387例(99.5%)符合MAFLD诊断;368例(94.6%)符合NAFLD诊断;合并大量饮酒史19例,表面抗原阳性2例。同时符合MAFLD和NAFLD诊断的患者366例,分别占MAFLD和NAFLD患者的94.6%和99.5%。与非脂肪肝组相比,MAFLD组的BMI(t=-11.228)、腰围(Z=-8.532)、臀围(Z=-6.449)、腰臀比(Z=-5.708)、ALT(Z=-5.027)、AST(Z=-2.880)、PLT(t=-3.623)、TG(Z=-8.489)、空腹血糖(Z=-3.516)、HbA1c(Z=-2.884)、稳态模型计算胰岛素抵抗指数(Z=-0.394)、超敏C反应蛋白(Z=-4.912)、控制衰减参数(t=13.744)、肝硬度值(Z=-7.69)均增加,差异均有统计学意义(P值均<0.05),而HDL- C(t=6.348,P<0.001)水平下降。同时,MAFLD患者合并更多的代谢相关疾病,如超重、肥胖、中心性肥胖、血脂异常、高血压(χ2值分别为9.978、65.472、36.571、9.797、5.128,P值均<0.05)。在MAFLD组中,30.7%的患者为非肥胖脂肪肝(BMI ≥25 kg/m2),11.1%为瘦人脂肪肝(BMI<23 kg/m2);与肥胖MAFLD患者相比,非肥胖MAFLD患者年龄(Z=-3.042)、BMI(Z=-15.705)、腰围(Z=-9.589)、臀围(Z=-10.275)、稳态模型计算胰岛素抵抗指数(Z=-2.081)、控制衰减参数(t=-3.468)、肝硬度值(Z=-3.630)、NFS(t=-4.433)更低(P值均<0.05)。根据肝硬度值进行判断,进展期肝纤维化占MAFLD人群的3.6%,不能排除进展期肝纤维化占10%。 结论 在老年人群中,MAFLD的诊断基本能够覆盖NAFLD人群,在类似人群中基本可以直接替代NAFLD的概念。但是在其他人群中的应用尚有待进一步研究。 Abstract:Objective To investigate the population differences of the newly named "metabolic associated fatty liver disease" (MAFLD) and the former name "nonalcoholic fatty liver disease" (NAFLD). Methods From November 2020 to January 2021, a cross-sectional survey was conducted among 624 elderly individuals aged above 65 years in a community in Beijing, China, and related data were collected, including demographic data, past history, laboratory markers, liver ultrasound, and liver elasticity. According to the presence or absence of fatty liver based on ultrasonic diagnosis, the individuals were divided into fatty liver group with 389 individuals and non-fatty liver group with 235 individuals. The independent samples t-test was used for comparison of normally distributed continuous data between the two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between the two groups; the chi-square test was used for comparison of categorical data between the two groups. Results Among the 389 patients with fatty liver, 387(99.5%) were diagnosed with MAFLD and 368(94.6%) were diagnosed with NAFLD, and there were 19 patients with a history of heavy alcohol consumption and 2 with positive surface antigen. A total of 366 patients met the diagnostic criteria for both MAFLD and NAFLD, accounting for 94.6% of the MAFLD patients and 99.5% of the NAFLD patients. Compared with the non-fatty liver group, the MAFLD group had significant increases in body mass index (BMI) (t=-11.228, P < 0.05), waist circumference (Z=-8.532, P < 0.05), hip circumference (Z=-6.449, P < 0.05), waist-hip ratio (Z=-5.708, P < 0.05), alanine aminotransferase (Z=-5.027, P < 0.05), aspartate aminotransferase (Z=-2.880, P < 0.05), platelet count (t=-3.623, P < 0.05), triglyceride (Z=-8.489, P < 0.05), fasting blood glucose (Z=-3.516, P < 0.05), HbA1c (Z=-2.884, P < 0.05), Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) (Z=-0.394, P < 0.05), high-sensitivity C-reactive protein (Z=-4.912, P < 0.05), controlled attenuation parameter (CAP) (t=13.744, P < 0.05), and liver stiffness measurement (LSM) (Z=-7.69, P < 0.05), as well as a significant reduction in high-density lipoprotein cholesterol (HDL-C) (t=6.348, P < 0.001). Meanwhile, MAFLD patients had more metabolic associated diseases, such as overweight, obesity, central obesity, dyslipidemia, and hypertension (χ2=9.978, 65.472, 36.571, 9.797, and 5.128, all P < 0.05). In the MAFLD group, 30.7% of the patients had non-obese fatty liver disease (BMI < 25 kg/m2), and 11.1% had lean fatty liver disease (BMI < 23 kg/m2); compared with the obese MAFLD patients, the non-obese MAFLD patients had significantly lower age (Z=-3.042, P < 0.05), BMI (Z=-15.705, P < 0.05), waist circumference (Z=-9.589, P < 0.05), hip circumference (Z=-10.275, P < 0.05), HOMA-IR (Z=-2.081, P < 0.05), CAP (t=-3.468, P < 0.05), LSM (Z=-3.630, P < 0.05), and NAFLD fibrosis score (t=-4.433, P < 0.05). According to LSM value, advanced liver fibrosis accounted for 3.6% of the MAFLD population, and 10% of the MAFLD population could not be excluded for advanced liver fibrosis. Conclusion The diagnosis of MAFLD can basically cover the NAFLD population in the elderly people, and it is supposed that MAFLD can almost directly replace the concept of NAFLD in similar populations. However, further studies are needed to investigate its application in other populations. -
表 1 MAFLD和非脂肪肝的临床特征比较
指标 MAFLD组(n=387) 非脂肪肝组(n=235) 统计值 P值 年龄(岁) 68.0(66.0~72.0) 69.0(67.0~74.0) Z=-2.474 0.030 男性[例(%)] 135(34.9) 102(43.4) χ2=4.501 0.034 BMI(kg/m2) 26.6±3.0 24.1±2.5 t=-11.228 <0.001 腰围(cm) 90.0(86.3~97.0) 86.0(81.0~90.0) Z=-8.532 <0.001 臀围(cm) 100.0(95.0~105.0) 96.0(92.0~100.0) Z=-6.449 <0.001 腰臀比 0.91(0.89~0.94) 0.89(0.87~0.92) Z=-5.708 <0.001 ALT(U/L) 21.0(16.0~28.0) 18.0(14.0~23.0) Z=-5.027 <0.001 AST(U/L) 19.0(16.0~23.8) 18.0(14.0~21.0) Z=-2.880 0.004 TBil(μmol/L) 15.0(11.4~18.6) 14.5(11.4~18.3) Z=-1.452 0.147 SCr(μmol/L) 64.0(54.0~75.0) 65.0(54.0~75.0) Z=-0.233 0.816 BUN(mmol/L) 5.3(4.4~6.7) 5.3(4.4~6.7) Z=-0.207 0.836 PLT(×109/L) 232.5±55.9 215.6±56.4 t=-3.623 <0.001 TG(mmol/L) 1.6(1.2~2.2) 1.2(0.9~1.6) Z=-8.489 <0.001 TC(mmol/L) 4.8(4.1~5.7) 4.7(4.0~5.6) Z=-0.920 0.358 HDL-C(mmol/L) 1.2±0.2 1.3±0.3 t=6.348 <0.001 LDL-C(mmol/L) 3.4(2.7~4.1) 4.2(2.5~3.9) Z=-1.418 0.156 FBG(mmol/L) 6.4(5.8~7.7) 6.1(5.5~7.2) Z=-3.516 <0.001 HbA1c(%) 6.2(5.8~6.9) 5.9(5.6~6.6) Z=-2.884 0.004 HOMA-IR 3.3(2.2~5.1) 2.0(1.4~3.5) Z=-0.394 <0.001 hs-CRP(mg/L) 1.6(0.9~3.1) 1.0(0.5~1.8) Z=-4.912 <0.001 CAP1)(dB/m) 294.9±44.5 238.1±45.1 t=13.744 <0.001 LSM1)(kPa) 5.4(4.3~6.7) 4.1(3.5~5.3) Z=-7.690 <0.001 注:1)因肝弹性检测有一定的失败率,在MAFLD组中,有CAP和LSM结果的为318例;在非脂肪肝组中,有CAP和LSM结果的为185例。 表 2 MAFLD患者合并代谢相关疾病情况
组别 MAFLD组(n=387) 非脂肪肝组(n=235) χ2值 P值 超重[例(%)] 76(19.6) 72(30.6) 9.978 0.002 肥胖[例(%)] 268(69.3) 84(35.7) 65.472 <0.001 中心性肥胖[例(%)] 324(83.7) 145(61.7) 36.571 <0.001 糖尿病[例(%)] 157(40.6) 89(37.9) 0.380 0.538 血脂异常[例(%)] 282(72.9) 142(60.4) 9.797 0.002 高血压[例(%)] 288(74.4) 154(65.5) 5.128 0.024 冠心病[例(%)] 113(29.2) 67(28.5) 0.021 0.886 脑卒中[例(%)] 50(12.9) 33(14.0) 0.180 0.672 肾功能不全[例(%)] 10(2.6) 4(1.7) 0.513 0.474 表 3 肥胖和非肥胖MAFLD比较
指标 非肥胖MAFLD组(n=119) 肥胖MAFLD组(n=268) 统计值 P值 年龄(岁) 67.0(66.0~71.0) 69.0(67.0~73.0) Z=-3.042 0.002 男性[例(%)] 44(37.0) 91(34.0) χ2=0.331 0.565 BMI(kg/m2) 23.9(22.6~24.5) 27.6(26.2~29.3) Z=-15.705 <0.001 腰围(cm) 87.0(82.0~90.0) 93.0(89.0~98.0) Z=-9.589 <0.001 臀围(cm) 95.0(90.0~98.0) 102.0(98.0~106.0) Z=-10.275 <0.001 腰臀比 0.91(0.88~0.93) 0.91(0.89~0.94) Z=-1.535 0.125 ALT(U/L) 21.0(16.0~28.0) 21.0(16.0~28.0) Z=-0.603 0.547 AST(U/L) 18.0(14.0~23.0) 19.0(16.0~24.0) Z=-1.835 0.067 TBil(μmol/l) 15.6(11.2~18.5) 14.8(11.5~18.7) Z=-0.082 0.934 SCr(μmol/L) 66.5±19.5 66.4±17.2 t=0.077 0.938 BUN(mmol/L) 5.1(4.3~6.8) 5.4(4.4~6.7) Z=-0.552 0.581 PLT(×109/L) 231.9±50.5 233.0±58.3 t=-0.174 0.862 TG(mmol/L) 1.6(1.2~2.3) 1.7(1.2~2.1) Z=-0.269 0.788 TC(mmol/L) 4.9(4.0~5.7) 4.8(4.2~5.5) Z=-0.126 0.900 HDL-C(mmol/L) 1.2±0.3 1.1±0.2 t=1.255 0.210 LDL-C(mmol/L) 3.4(2.7~4.0) 3.4(2.7~4.1) Z=-0.161 0.872 FBG(mmol/L) 6.3(5.6~7.8) 6.5(5.8~7.7) Z=-1.106 0.269 HbA1c(%) 6.1(5.7~6.5) 6.2(5.8~6.9) Z=-1.310 0.190 HOMA-IR 3.1(1.9~4.2) 3.5(2.2~6.3) Z=-2.081 0.037 Hs-CRP(mg/L) 1.5(0.6~2.5) 1.8(1.0~3.2) Z=-1.781 0.075 CAP1)(dB/m) 281.9±51.7 301.8±38.4 t=-3.468 0.001 LSM1)(kPa) 4.8(4.2~5.8) 5.7(4.7~7.1) Z=-3.630 <0.001 FIB-4 1.27(1.01~1.50) 1.33(1.04~1.68) Z=-1.710 0.087 NFS -1.35±0.85 -0.76±1.08 t=-4.433 <0.001 注:1)在非肥胖MAFLD组中,有CAP和LSM结果的为102例;在肥胖MAFLD组中,有CAP和LSM结果的为216例。 表 4 MAFLD肝纤维化分布
评分标准 排除F3 不能排除F3 ≥F3 F4 LSM1)[例(%)] 274(86.1) 32(10.0) 11(3.6) 1(0.3) FIB-42)[例(%)] 283(89.0) 30(9.4) 5(1.6) NFS3)[例(%)] 261(82.2) 38(11.9) 19(5.9) 注:1)LSM<8.0排除F3;8.0≤LSM<11不能排除F3,需行肝穿刺活检评估肝纤维化状态;11≤LSM<15诊断F3;LSM≥15诊断F4;2)FIB-4<2.0排除F3;2.0≤FIB-4≤3.25不能排除F3;FIB-4>3.25诊断F3;3)NFS<0.12排除F3;0.12≤NFS≤0.675不能排除F3;NFS>0.675诊断F3。 -
[1] ESLAM M, SANYAL AJ, GEORGE J. MAFLD: A consensus-driven proposed nomenclature for metabolic associated fatty liver disease[J]. Gastroenterology, 2020, 158(7): 1999-2014. e1. DOI: 10.1053/j.gastro.2019.11.312. [2] LIN S, HUANG J, WANG M, et al. Comparison of MAFLD and NAFLD diagnostic criteria in real world[J]. Liver Int, 2020, 40(9): 2082-2089. DOI: 10.1111/liv.14548. [3] ESLAM M, NEWSOME PN, SARIN SK, et al. A new definition for metabolic dysfunction-associated fatty liver disease: An international expert consensus statement[J]. J Hepatol, 2020, 73(1): 202-209. DOI: 10.1016/j.jhep.2020.03.039. [4] Chinese Society of Hepatology, Chinese Medical Association; Chinese Society of Gastroenterology, Chinese Medical Association; Chinese Society of Infectious Diseases, Chinese Medical Association. Consensus on the diagnosis and therapy of hepatic fibrosis(2019)[J]. J Clin Hepatol, 2019, 35(10): 2163-2172. DOI: 10.3969/j.issn.1001-5256.2019.10.007.中华医学会肝病学分会, 中华医学会消化病学分会, 中华医学会感染病学分会. 肝纤维化诊断及治疗共识(2019年)[J]. 临床肝胆病杂志, 2019, 35(10): 2163-2172. DOI: 10.3969/j.issn.1001-5256.2019.10.007. [5] NEWSOME PN, CRAMB R, DAVISON SM, et al. Guidelines on the management of abnormal liver blood tests[J]. Gut, 2018, 67(1): 6-19. DOI: 10.1136/gutjnl-2017-314924. [6] NAN Y, AN J, BAO J, et al. The Chinese Society of Hepatology position statement on the redefinition of fatty liver disease[J]. J Hepatol, 2021, 75(2): 454-461. DOI: 10.1016/j.jhep.2021.05.003. [7] WONG VW, WONG GL, WOO J, et al. Impact of the new definition of metabolic associated fatty liver disease on the epidemiology of the disease[J]. Clin Gastroenterol Hepatol, 2021, 19(10): 2161-2171. e5. DOI: 10.1016/j.cgh.2020.10.046. [8] YAMAMURA S, ESLAM M, KAWAGUCHI T, et al. MAFLD identifies patients with significant hepatic fibrosis better than NAFLD[J]. Liver Int, 2020, 40(12): 3018-3030. DOI: 10.1111/liv.14675. [9] YE Q, ZOU B, 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. [10] LI YY, XIE ZY. Advances in the etiology and treatment of non-obese nonalcoholic fatty liver disease[J]. J Clin Hepatol, 2021, 37(2): 452-457. DOI: 10.3969/j.issn.1001-5256.2021.02.043.李洋洋, 谢正元. 非肥胖型非酒精性脂肪性肝病的病因及治疗进展[J]. 临床肝胆病杂志, 2021, 37(2): 452-457. DOI: 10.3969/j.issn.1001-5256.2021.02.043.