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Article(id=1210676785990210493, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1210676785113600955, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.2021.05.10, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1609948800000, receivedDateStr=2021-01-07, revisedDate=1615824000000, revisedDateStr=2021-03-16, acceptedDate=null, acceptedDateStr=null, onlineDate=1766577439066, onlineDateStr=2025-12-24, pubDate=1622131200000, pubDateStr=2021-05-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1766577439066, onlineIssueDateStr=2025-12-24, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1766577439066, creator=13701087609, updateTime=1766577439066, updator=13701087609, issue=Issue{id=1210676785113600955, tenantId=1146029695717560320, journalId=1189873630562394117, year='2021', volume='46', issue='5', pageStart='425', pageEnd='530', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1766577438858, creator=13701087609, updateTime=1766718730270, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1211269404306838321, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1210676785113600955, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1211269404306838322, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1210676785113600955, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=486, endPage=491, ext={EN=ArticleExt(id=1210676786728408012, articleId=1210676785990210493, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=The value of changes in diagnostic criteria for fatty liver in stratified management of cardiovascular risk, columnId=1190310109000602400, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Clinical Research, runingTitle=null, highlight=null, articleAbstract=

Objective To investigate the clinical value of changing the diagnostic criteria for non-alcoholic fatty liver disease (NAFLD) to metabolism-associated fatty liver disease (MAFLD) in the risk-stratification and management of cardiovascular disease. Methods A total of 234 patients with fatty liver diagnosed by ultrasound examination were selected from February 2019 to September 2020 in the Gastroenterological Department of the Sixth Medical Center of Chinese PLA General Hospital. All the enrolled patients were collected of the anthropological parameters, history of chronic diseases [hypertension, type 2 diabetes mellitus (T2DM)], liver function, blood lipid, hemoglobin, platelet, blood uric acid, blood urea, bile acid, fasting blood glucose and nonalcoholic fatty liver disease fibrosis score (NFS). According to the different diagnostic criteria of fatty liver, 157 patients who met the diagnostic criteria of NAFLD were classified as NAFLD group and 213 patients who met the diagnostic criteria of MAFLD were classified as MAFLD group. The MAFLD group was regrouped and compared according to the presence or absence of T2DM and alcohol consumption. Results The proportion of male patients, hypertension, T2DM and the levels of alanine aminotransferase(ALT), aspartate aminotransferase (AST), glutamyl transpeptidase (GGT), total cholesterol (TC), triglyceride (TG), low density lipoprotein cholesterol (LDL-C) and the hemoglobin in the NAFLD group were lower than those in the MAFLD group; and the level of high density lipoprotein cholesterol (HDL-C) in the NAFLD group was higher than that in the MAFLD group, the difference was statistically significant (P<0.05). In the MAFLD group, 75 patients were combined with T2DM and 138 had no T2DM. The proportion of patients with hypertension and the levels of ALT, AST, GGT and alkaline phosphatase (ALP) in patients with T2DM were higher than those without T2DM, and the proportion of patients without liver fibrosis (NFS <–1.455) was lower than those without T2DM, the difference was statistically significant (P<0.05). There were no significant differences in age, gender and BMI between the two groups (P>0.05). In the MAFLD group, 70 patients were drinkers and 143 non-drinkers. The age of the drinking group was lower than that of the non-drinking group, and the proportion of male, hypertension, T2DM and the levels of BMI, ALT, AST, GGT, pre-albumin, TG, TC, LDL-C, hemoglobin, uric acid and fasting blood glucose in the drinking group were higher than those in the non-drinking group, with statistical significance (P<0.05). Conclusion The diagnostic criteria of MAFLD are easier to identify high-risk population of cardiovascular diseases than those of NAFLD, which is helpful for targeted management.

, correspAuthors=Li-Hong Cui, authorNote=null, correspAuthorsNote=
*E-mail:
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目的 探讨非酒精性脂肪性肝病(NAFLD)诊断标准变更为代谢相关脂肪性肝病(MAFLD)对心血管疾病风险分层管理的临床价值。方法 选取2019年2月—2020年9月解放军总医院第六医学中心消化内科收治的经超声检查诊断为脂肪肝的患者234例，收集其人体学指标、慢性疾病病史[高血压、2型糖尿病(T2DM)]、肝功能、血脂、血红蛋白、血小板、血尿酸、血尿素、胆汁酸、空腹血糖及非酒精性脂肪肝纤维化评分(NFS)等情况，根据脂肪肝诊断标准的不同进行分析，其中符合NAFLD诊断标准者作为NAFLD组(157例)，符合MAFLD诊断标准者作为MAFLD组(213例)，再将MAFLD组患者分为有无T2DM、有无饮酒组，比较各组临床资料。结果 NAFLD组的男性、高血压、合并T2DM患者比例，以及谷丙转氨酶(ALT)、谷草转氨酶(AST)、谷氨酰转肽酶(GGT)、总胆固醇(TC)、三酰甘油(TG)、低密度脂蛋白胆固醇(LDL-C)、血红蛋白水平等均低于MAFLD组，高密度脂蛋白胆固醇(HDL-C)水平高于MAFLD组，差异有统计学意义(P<0.05)。MAFLD组中合并T2DM 75例，不合并T2DM 138例。合并T2DM组中高血压患者比例及ALT、AST、GGT、碱性磷酸酶(ALP)水平等均高于不合并T2DM组，无肝纤维化(NFS<–1.455)比例低于不合并T2DM组，差异有统计学意义(P<0.05)，两组的年龄、性别及BMI水平差异无统计学意义(P>0.05)。MAFLD组中饮酒者70例，不饮酒者143例。饮酒组的年龄小于不饮酒组，男性、高血压、合并T2DM患者比例，以及BMI、ALT、AST、GGT、前白蛋白、TG、TC、LDL-C、血红蛋白、尿酸及空腹血糖水平等均高于不饮酒组，差异有统计学意义(P<0.05)。结论 与NAFLD诊断标准相比，MAFLD诊断标准更易于识别心血管疾病高危人群，有助于对其进行有针对性的管理。

, correspAuthors=崔立红, authorNote=null, correspAuthorsNote=
崔立红，E-mail：
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吴婉雯，硕士研究生，主要从事肠道微生态与消化系统疾病研究

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吴婉雯，硕士研究生，主要从事肠道微生态与消化系统疾病研究

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Med J Chin PLA, 2020, 38(6): 23-26., articleTitle=Changes of peripheral blood CD4+ T cell subsets in newly diagnosed type 2 diabetes mellitus patients with nonalcoholic fatty liver disease, refAbstract=null), Reference(id=1210676794219434312, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1210676785990210493, doi=null, pmid=null, pmcid=null, year=2020, volume=38, issue=6, pageStart=23, pageEnd=26, url=null, language=null, rfNumber=[26], rfOrder=34, authorNames=李颖, 匡霞, 吕晓楠, journalName=解放军医学杂志, refType=null, unstructuredReference=[李颖, 匡霞, 吕晓楠, 等. 初诊2型糖尿病合并非酒精性脂肪性肝病患者外周血 CD4+T细胞亚群的比例变化[J]. 解放军医学杂志, 2020, 38(6): 23-26.], articleTitle=初诊2型糖尿病合并非酒精性脂肪性肝病患者外周血 CD4+T细胞亚群的比例变化, refAbstract=null), Reference(id=1210676794341069137, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1210676785990210493, doi=null, pmid=null, pmcid=null, year=2021, volume=70, issue=5, pageStart=962, pageEnd=969, url=null, language=null, rfNumber=[27], rfOrder=35, authorNames=Mantovani A, Petracca G, Beatrice G, journalName=Gut, refType=null, unstructuredReference=Mantovani A, Petracca G, Beatrice G, et al. Non-alcoholic fatty liver disease and risk of incident diabetes mellitus: an updated meta-analysis of 501 022 adult individuals[J]. Gut, 2021, 70(5): 962-969., articleTitle=Non-alcoholic fatty liver disease and risk of incident diabetes mellitus: an updated meta-analysis of 501 022 adult individuals, refAbstract=null), Reference(id=1210676794433343827, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1210676785990210493, doi=null, pmid=null, pmcid=null, year=2020, volume=71, issue=3, pageStart=907, pageEnd=916, url=null, language=null, rfNumber=[28], rfOrder=36, authorNames=Yang JD, Ahmed F, Mara KC, journalName=Hepatology, refType=null, unstructuredReference=Yang JD, Ahmed F, Mara KC, et al. Diabetes is associated with increased risk of hepatocellular carcinoma in patients with cirrhosis from nonalcoholic fatty liver disease[J]. Hepatology, 2020, 71(3): 907-916., articleTitle=Diabetes is associated with increased risk of hepatocellular carcinoma in patients with cirrhosis from nonalcoholic fatty liver disease, refAbstract=null), Reference(id=1210676794513035608, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1210676785990210493, doi=null, pmid=null, pmcid=null, year=2005, volume=42, issue=1, pageStart=132, pageEnd=138, url=null, language=null, rfNumber=[29], rfOrder=37, authorNames=Adams LA, Sanderson S, Lindor KD, journalName=J Hepatol, refType=null, unstructuredReference=Adams LA, Sanderson S, Lindor KD, et al. The histological course of nonalcoholic fatty liver disease: a longitudinal study of 103 patients with sequential liver biopsies[J]. J Hepatol, 2005, 42(1): 132-138., articleTitle=The histological course of nonalcoholic fatty liver disease: a longitudinal study of 103 patients with sequential liver biopsies, refAbstract=null), Reference(id=1210676794601115996, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1210676785990210493, doi=null, pmid=null, pmcid=null, year=2016, volume=22, issue=43, pageStart=9488, pageEnd=9505, url=null, language=null, rfNumber=[30], rfOrder=38, authorNames=Mikolasevic I, Milic S, Turk Wensveen T, journalName=World J Gastroenterol, refType=null, unstructuredReference=Mikolasevic I, Milic S, Turk Wensveen T, et al. Nonalcoholic fatty liver disease - A multisystem disease?[J]. World J Gastroenterol, 2016, 22(43): 9488-9505., articleTitle=Nonalcoholic fatty liver disease - A multisystem disease?, refAbstract=null)], funds=[Fund(id=1210676790469726329, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1210676785990210493, awardId=CHJ12J027, language=EN, fundingSource=PLA Naval Logistics Research Project(CHJ12J027), fundOrder=null, country=null), Fund(id=1210676790587166846, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1210676785990210493, awardId=CHJ12J027, language=CN, fundingSource=海军后勤科研计划课题(CHJ12J027), fundOrder=null, country=null), Fund(id=1210676790675247236, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1210676785990210493, awardId=首发2020-2-5113, language=EN, fundingSource=Project of Capital Health Development(首发2020-2-5113), fundOrder=null, country=null), Fund(id=1210676790750744712, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1210676785990210493, awardId=首发2020-2-5113, language=CN, fundingSource=首都卫生发展科研专项(首发2020-2-5113), fundOrder=null, country=null)], companyList=[AuthorCompany(id=1210676787336582108, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1210676785990210493, xref=1, ext=[AuthorCompanyExt(id=1210676787340776413, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1210676785990210493, companyId=1210676787336582108, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510280, China), AuthorCompanyExt(id=1210676787349165022, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1210676785990210493, companyId=1210676787336582108, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1南方医科大学第二临床医学院，广州 510280)]), AuthorCompany(id=1210676787424662497, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1210676785990210493, xref=2, ext=[AuthorCompanyExt(id=1210676787433051106, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1210676785990210493, companyId=1210676787424662497, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2Department of Gastroenterology, the Sixth Medical Center of Chinese PLA General Hospital, Beijing 100048, China), AuthorCompanyExt(id=1210676787437245411, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1210676785990210493, companyId=1210676787424662497, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2解放军总医院第六医学中心消化内科，北京 100048)])], figs=[ArticleFig(id=1210676789781860433, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1210676785990210493, language=EN, label=Tab.1, caption=

Comparison of clinical characteristics between NAFLD and MAFLD patients

, figureFileSmall=null, figureFileBig=null, tableContent=
指标NAFLD组(n=157)MAFLD组(n=213)t/Z/χ2P
年龄(岁，$\bar{x}±s$)56.0±9.554.5±9.71.4780.140
男性[例(%)]88(56.1)150(70.4)8.1350.004
BMI (kg/m2，$\bar{x}±s$)25.63±2.6226.76±2.69–4.061<0.001
高血压[例(%)]50(31.8)91(42.7)4.5330.033
T2DM[例(%)]38(24.2)75(35.2)5.1620.023
ALT (U/L，$\bar{x}±s$)24.82±9.8927.86±14.89–2.3560.019
AST (U/L，$\bar{x}±s$)21.33±5.2522.70±7.91–2.0000.046
GGT[U/L，M(Q1，Q3)]27.70(19.90，38.40)31.10(21.50，46.50)–1.9670.049
ALP (U/L，$\bar{x}±s$)81.69±24.6782.11±24.03–0.1640.869
白蛋白(mg/L，$\bar{x}±s$)41.10±3.1941.30±3.05–0.6040.546
前白蛋白(mg/L，$\bar{x}±s$)261.75±39.71266.53±42.48–1.1000.272
TG (mmol/L，$\bar{x}±s$)1.87±0.712.10±0.98–2.5900.010
TC (mmol/L，$\bar{x}±s$)4.89±0.985.14±0.94–2.4640.014
HDL-C (mmol/L，$\bar{x}±s$)1.24±0.261.18±0.242.0060.046
LDL-C (mmol/L，$\bar{x}±s$)2.89±0.763.11±0.72–2.9170.004
血红蛋白(g/L，$\bar{x}±s$)141.58±12.94144.81±16.64–2.0220.044
血小板(×109/L，$\bar{x}±s$)226.52±56.73228.66±55.00–0.3640.716
尿酸(μmol/L，$\bar{x}±s$)346.91±80.99363.20±78.55–1.9450.053
尿素(mmol/L，$\bar{x}±s$)5.29±1.235.32±1.21–0.2470.805
胆汁酸[μmol/L，M(Q1，Q3)]2.9(1.8，4.1)3.2(1.9，5.0)–1.4970.134
空腹血糖(mmol/L，$\bar{x}±s$)5.73±1.165.97±1.51–1.6720.095
无肝纤维化[例(%)]90(57.3)111(52.1)0.9900.320
), ArticleFig(id=1210676789874135128, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1210676785990210493, language=CN, label=表1, caption=

NAFLD组与MAFLD组一般资料比较

, figureFileSmall=null, figureFileBig=null, tableContent=
指标NAFLD组(n=157)MAFLD组(n=213)t/Z/χ2P
年龄(岁，$\bar{x}±s$)56.0±9.554.5±9.71.4780.140
男性[例(%)]88(56.1)150(70.4)8.1350.004
BMI (kg/m2，$\bar{x}±s$)25.63±2.6226.76±2.69–4.061<0.001
高血压[例(%)]50(31.8)91(42.7)4.5330.033
T2DM[例(%)]38(24.2)75(35.2)5.1620.023
ALT (U/L，$\bar{x}±s$)24.82±9.8927.86±14.89–2.3560.019
AST (U/L，$\bar{x}±s$)21.33±5.2522.70±7.91–2.0000.046
GGT[U/L，M(Q1，Q3)]27.70(19.90，38.40)31.10(21.50，46.50)–1.9670.049
ALP (U/L，$\bar{x}±s$)81.69±24.6782.11±24.03–0.1640.869
白蛋白(mg/L，$\bar{x}±s$)41.10±3.1941.30±3.05–0.6040.546
前白蛋白(mg/L，$\bar{x}±s$)261.75±39.71266.53±42.48–1.1000.272
TG (mmol/L，$\bar{x}±s$)1.87±0.712.10±0.98–2.5900.010
TC (mmol/L，$\bar{x}±s$)4.89±0.985.14±0.94–2.4640.014
HDL-C (mmol/L，$\bar{x}±s$)1.24±0.261.18±0.242.0060.046
LDL-C (mmol/L，$\bar{x}±s$)2.89±0.763.11±0.72–2.9170.004
血红蛋白(g/L，$\bar{x}±s$)141.58±12.94144.81±16.64–2.0220.044
血小板(×109/L，$\bar{x}±s$)226.52±56.73228.66±55.00–0.3640.716
尿酸(μmol/L，$\bar{x}±s$)346.91±80.99363.20±78.55–1.9450.053
尿素(mmol/L，$\bar{x}±s$)5.29±1.235.32±1.21–0.2470.805
胆汁酸[μmol/L，M(Q1，Q3)]2.9(1.8，4.1)3.2(1.9，5.0)–1.4970.134
空腹血糖(mmol/L，$\bar{x}±s$)5.73±1.165.97±1.51–1.6720.095
无肝纤维化[例(%)]90(57.3)111(52.1)0.9900.320
), ArticleFig(id=1210676789953826909, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1210676785990210493, language=EN, label=Tab.2, caption=

Comparison of clinical characteristics between MAFLD patients with or without T2DM

, figureFileSmall=null, figureFileBig=null, tableContent=
指标合并T2DM组(n=75)不合并T2DM组(n=138)t/Z/χ2P
年龄(岁，$\bar{x}±s$)55.7±8.453.8±10.31.3440.180
男性[例(%)]58(77.3)92(66.7)2.6540.103
BMI (kg/m2，$\bar{x}±s$)26.75±2.6626.77±2.71–0.0360.971
高血压[例(%)]40(53.3)51(37.0)5.3260.021
ALT (U/L，$\bar{x}±s$)32.00±19.2425.61±11.352.6380.010
AST (U/L，$\bar{x}±s$)24.76±10.6621.58±5.642.4030.018
GGT[U/L，M(Q1，Q3)]33.90(25.70，54.80)28.62(20.40，42.80)–2.4080.016
ALP[U/L，M(Q1，Q3)]82.40(71.30，101.20)75.70(64.30，91.70)–1.9700.049
无肝纤维化[例(%)]15(20.0)96(69.6)47.836<0.001
), ArticleFig(id=1210676790025130083, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1210676785990210493, language=CN, label=表2, caption=

合并与不合并T2DM的MAFLD患者临床资料比较

, figureFileSmall=null, figureFileBig=null, tableContent=
指标合并T2DM组(n=75)不合并T2DM组(n=138)t/Z/χ2P
年龄(岁，$\bar{x}±s$)55.7±8.453.8±10.31.3440.180
男性[例(%)]58(77.3)92(66.7)2.6540.103
BMI (kg/m2，$\bar{x}±s$)26.75±2.6626.77±2.71–0.0360.971
高血压[例(%)]40(53.3)51(37.0)5.3260.021
ALT (U/L，$\bar{x}±s$)32.00±19.2425.61±11.352.6380.010
AST (U/L，$\bar{x}±s$)24.76±10.6621.58±5.642.4030.018
GGT[U/L，M(Q1，Q3)]33.90(25.70，54.80)28.62(20.40，42.80)–2.4080.016
ALP[U/L，M(Q1，Q3)]82.40(71.30，101.20)75.70(64.30，91.70)–1.9700.049
无肝纤维化[例(%)]15(20.0)96(69.6)47.836<0.001
), ArticleFig(id=1210676790146764905, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1210676785990210493, language=EN, label=Tab.3, caption=

Comparison of clinical characteristics between drinking and non-drinking patients in MAFLD group

, figureFileSmall=null, figureFileBig=null, tableContent=
指标饮酒组(n=70)不饮酒组(n=143)t/Z/χ2P
年龄(岁，$\bar{x}±s$)52.0±9.355.7±9.7–2.6840.008
男性[例(%)]69(98.6)81(56.6)39.664<0.001
BMI (kg/m2，$\bar{x}±s$)27.74±2.9026.29±2.44–3.834<0.001
高血压[例(%)]37(52.9)54(37.8)4.3760.036
T2DM[例(%)]32(45.7)43(30.1)5.0420.025
ALT (U/L，$\bar{x}±s$)33.11±21.0425.29±9.772.9570.004
AST (U/L，$\bar{x}±s$)24.95±11.2421.60±5.31–2.3660.020
GGT[U/L，M(Q1，Q3)]36.45(27.20，59.10)28.50(19.70，39.40)–3.899<0.001
ALP (U/L，$\bar{x}±s$)81.99±20.9782.17±25.460.0560.955
前白蛋白(mg/L，$\bar{x}±s$)276.91±48.24261.44±38.532.3430.021
白蛋白(mg/L，$\bar{x}±s$)41.51±2.9841.19±3.080.7280.468
TG (mmol/L，$\bar{x}±s$)2.42±1.271.94±0.74–2.8720.005
TC (mmol/L，$\bar{x}±s$)5.57±0.744.92±0.96–5.412<0.001
HDL-C (mmol/L，$\bar{x}±s$)1.20±0.251.14±0.231.5730.117
LDL-C (mmol/L，$\bar{x}±s$)3.46±0.522.95±0.75–5.795<0.001
血红蛋白(g/L，$\bar{x}±s$)150±21142±13–3.4480.001
血小板(×109/L，$\bar{x}±s$)226±53230±560.4900.625
尿酸(μmol/L，$\bar{x}±s$)386.77±71.44351.17±79.30–3.2670.001
尿素(mmol/L，$\bar{x}±s$)5.28±1.205.35±1.220.7560.721
胆汁酸[μmol/L，M(Q1，Q3)]3.6(2.0，6.4)3.0(1.9，4.4)–1.5060.132
空腹血糖(mmol/L，$\bar{x}±s$)6.42±1.975.76±1.17–2.5850.011
无肝纤维化[例(%)]35(50.0)76(53.1)0.1860.666
), ArticleFig(id=1210676790264205423, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1210676785990210493, language=CN, label=表3, caption=

饮酒与不饮酒的MAFLD患者临床资料比较

, figureFileSmall=null, figureFileBig=null, tableContent=
指标饮酒组(n=70)不饮酒组(n=143)t/Z/χ2P
年龄(岁，$\bar{x}±s$)52.0±9.355.7±9.7–2.6840.008
男性[例(%)]69(98.6)81(56.6)39.664<0.001
BMI (kg/m2，$\bar{x}±s$)27.74±2.9026.29±2.44–3.834<0.001
高血压[例(%)]37(52.9)54(37.8)4.3760.036
T2DM[例(%)]32(45.7)43(30.1)5.0420.025
ALT (U/L，$\bar{x}±s$)33.11±21.0425.29±9.772.9570.004
AST (U/L，$\bar{x}±s$)24.95±11.2421.60±5.31–2.3660.020
GGT[U/L，M(Q1，Q3)]36.45(27.20，59.10)28.50(19.70，39.40)–3.899<0.001
ALP (U/L，$\bar{x}±s$)81.99±20.9782.17±25.460.0560.955
前白蛋白(mg/L，$\bar{x}±s$)276.91±48.24261.44±38.532.3430.021
白蛋白(mg/L，$\bar{x}±s$)41.51±2.9841.19±3.080.7280.468
TG (mmol/L，$\bar{x}±s$)2.42±1.271.94±0.74–2.8720.005
TC (mmol/L，$\bar{x}±s$)5.57±0.744.92±0.96–5.412<0.001
HDL-C (mmol/L，$\bar{x}±s$)1.20±0.251.14±0.231.5730.117
LDL-C (mmol/L，$\bar{x}±s$)3.46±0.522.95±0.75–5.795<0.001
血红蛋白(g/L，$\bar{x}±s$)150±21142±13–3.4480.001
血小板(×109/L，$\bar{x}±s$)226±53230±560.4900.625
尿酸(μmol/L，$\bar{x}±s$)386.77±71.44351.17±79.30–3.2670.001
尿素(mmol/L，$\bar{x}±s$)5.28±1.205.35±1.220.7560.721
胆汁酸[μmol/L，M(Q1，Q3)]3.6(2.0，6.4)3.0(1.9，4.4)–1.5060.132
空腹血糖(mmol/L，$\bar{x}±s$)6.42±1.975.76±1.17–2.5850.011
无肝纤维化[例(%)]35(50.0)76(53.1)0.1860.666
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脂肪肝诊断标准的变更对心血管疾病风险分层管理的价值分析
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吴婉雯 1, 2 , 李晓伟 2 , 崔立红 1, 2, *
解放军医学杂志 | 临床研究 2021,46(5): 486-491
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解放军医学杂志 | 临床研究 2021, 46(5): 486-491
脂肪肝诊断标准的变更对心血管疾病风险分层管理的价值分析
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吴婉雯1, 2, 李晓伟2, 崔立红1, 2, *
作者信息
  • 1南方医科大学第二临床医学院，广州 510280
  • 2解放军总医院第六医学中心消化内科，北京 100048

    • 吴婉雯，硕士研究生，主要从事肠道微生态与消化系统疾病研究

通讯作者:

崔立红，E-mail：
The value of changes in diagnostic criteria for fatty liver in stratified management of cardiovascular risk
Wan-Wen Wu1, 2, Xiao-Wei Li2, Li-Hong Cui1, 2, *
Affiliations
  • 1The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510280, China
  • 2Department of Gastroenterology, the Sixth Medical Center of Chinese PLA General Hospital, Beijing 100048, China
出版时间: 2021-05-28 doi: 10.11855/j.issn.0577-7402.2021.05.10
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目的 探讨非酒精性脂肪性肝病(NAFLD)诊断标准变更为代谢相关脂肪性肝病(MAFLD)对心血管疾病风险分层管理的临床价值。方法 选取2019年2月—2020年9月解放军总医院第六医学中心消化内科收治的经超声检查诊断为脂肪肝的患者234例，收集其人体学指标、慢性疾病病史[高血压、2型糖尿病(T2DM)]、肝功能、血脂、血红蛋白、血小板、血尿酸、血尿素、胆汁酸、空腹血糖及非酒精性脂肪肝纤维化评分(NFS)等情况，根据脂肪肝诊断标准的不同进行分析，其中符合NAFLD诊断标准者作为NAFLD组(157例)，符合MAFLD诊断标准者作为MAFLD组(213例)，再将MAFLD组患者分为有无T2DM、有无饮酒组，比较各组临床资料。结果 NAFLD组的男性、高血压、合并T2DM患者比例，以及谷丙转氨酶(ALT)、谷草转氨酶(AST)、谷氨酰转肽酶(GGT)、总胆固醇(TC)、三酰甘油(TG)、低密度脂蛋白胆固醇(LDL-C)、血红蛋白水平等均低于MAFLD组，高密度脂蛋白胆固醇(HDL-C)水平高于MAFLD组，差异有统计学意义(P<0.05)。MAFLD组中合并T2DM 75例，不合并T2DM 138例。合并T2DM组中高血压患者比例及ALT、AST、GGT、碱性磷酸酶(ALP)水平等均高于不合并T2DM组，无肝纤维化(NFS<–1.455)比例低于不合并T2DM组，差异有统计学意义(P<0.05)，两组的年龄、性别及BMI水平差异无统计学意义(P>0.05)。MAFLD组中饮酒者70例，不饮酒者143例。饮酒组的年龄小于不饮酒组，男性、高血压、合并T2DM患者比例，以及BMI、ALT、AST、GGT、前白蛋白、TG、TC、LDL-C、血红蛋白、尿酸及空腹血糖水平等均高于不饮酒组，差异有统计学意义(P<0.05)。结论 与NAFLD诊断标准相比，MAFLD诊断标准更易于识别心血管疾病高危人群，有助于对其进行有针对性的管理。

非酒精性脂肪性肝病  /  代谢相关脂肪性肝病  /  心血管疾病  /  诊断标准

Objective To investigate the clinical value of changing the diagnostic criteria for non-alcoholic fatty liver disease (NAFLD) to metabolism-associated fatty liver disease (MAFLD) in the risk-stratification and management of cardiovascular disease. Methods A total of 234 patients with fatty liver diagnosed by ultrasound examination were selected from February 2019 to September 2020 in the Gastroenterological Department of the Sixth Medical Center of Chinese PLA General Hospital. All the enrolled patients were collected of the anthropological parameters, history of chronic diseases [hypertension, type 2 diabetes mellitus (T2DM)], liver function, blood lipid, hemoglobin, platelet, blood uric acid, blood urea, bile acid, fasting blood glucose and nonalcoholic fatty liver disease fibrosis score (NFS). According to the different diagnostic criteria of fatty liver, 157 patients who met the diagnostic criteria of NAFLD were classified as NAFLD group and 213 patients who met the diagnostic criteria of MAFLD were classified as MAFLD group. The MAFLD group was regrouped and compared according to the presence or absence of T2DM and alcohol consumption. Results The proportion of male patients, hypertension, T2DM and the levels of alanine aminotransferase(ALT), aspartate aminotransferase (AST), glutamyl transpeptidase (GGT), total cholesterol (TC), triglyceride (TG), low density lipoprotein cholesterol (LDL-C) and the hemoglobin in the NAFLD group were lower than those in the MAFLD group; and the level of high density lipoprotein cholesterol (HDL-C) in the NAFLD group was higher than that in the MAFLD group, the difference was statistically significant (P<0.05). In the MAFLD group, 75 patients were combined with T2DM and 138 had no T2DM. The proportion of patients with hypertension and the levels of ALT, AST, GGT and alkaline phosphatase (ALP) in patients with T2DM were higher than those without T2DM, and the proportion of patients without liver fibrosis (NFS <–1.455) was lower than those without T2DM, the difference was statistically significant (P<0.05). There were no significant differences in age, gender and BMI between the two groups (P>0.05). In the MAFLD group, 70 patients were drinkers and 143 non-drinkers. The age of the drinking group was lower than that of the non-drinking group, and the proportion of male, hypertension, T2DM and the levels of BMI, ALT, AST, GGT, pre-albumin, TG, TC, LDL-C, hemoglobin, uric acid and fasting blood glucose in the drinking group were higher than those in the non-drinking group, with statistical significance (P<0.05). Conclusion The diagnostic criteria of MAFLD are easier to identify high-risk population of cardiovascular diseases than those of NAFLD, which is helpful for targeted management.

non-alcoholic fatty liver disease  /  metabolism-associated fatty liver disease  /  cardiovascular diseases  /  diagnostic criteria
吴婉雯, 李晓伟, 崔立红. 脂肪肝诊断标准的变更对心血管疾病风险分层管理的价值分析. 解放军医学杂志, 2021 , 46 (5) : 486 -491 . DOI: 10.11855/j.issn.0577-7402.2021.05.10
Wan-Wen Wu, Xiao-Wei Li, Li-Hong Cui. The value of changes in diagnostic criteria for fatty liver in stratified management of cardiovascular risk[J]. Medical Journal of Chinese People’s Liberation Army, 2021 , 46 (5) : 486 -491 . DOI: 10.11855/j.issn.0577-7402.2021.05.10
正文
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非酒精性脂肪性肝病(non-alcoholic fatty liver disease，NAFLD)是临床常见的慢性肝脏疾病[1]，其诊断须排除过度乙醇摄入、病毒感染、药物等可导致脂肪肝病变的因素及其他慢性肝病[2]。2020年初，国际专家小组将NAFLD更名为代谢相关脂肪性肝病(metabolic associated fatty liver disease，MAFLD)，定义为系统性代谢紊乱累及肝脏的表现，并将诊断标准由既往的“排除性”诊断更改为“肯定性”诊断，以影像学、血液生物标志物或病理活检诊断的肝脂肪变为基础，合并存在超重、2型糖尿病(T2DM)或代谢功能障碍即可诊断MAFLD[3]。目前尚缺乏论证该诊断标准变更在心血管风险分层管理方面价值的临床研究。本研究分别采用NAFLD与MAFLD标准对脂肪肝患者进行诊断，旨在探讨MAFLD诊断标准变更后患病人群的差异及该诊断标准变更的临床意义。
1 资料与方法
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1.1 一般资料
选取2019年2月—2020年9月解放军总医院第六医学中心消化内科收治的脂肪肝患者234例，均经超声检查确诊。符合NAFLD诊断标准的患者157例作为NAFLD组，符合MAFLD诊断标准的患者213例作为MAFLD组。本研究经本院伦理委员会审查通过。
1.2 诊断标准
1.2.1 脂肪肝诊断标准
以《非酒精性脂肪性肝病诊疗指南(2018年版)》[2]为依据行腹部超声诊断，符合以下两点即可诊断为脂肪肝：(1)肝脏近场回声增强；(2)肝内管道结构不清；(3)肝脏远场回声减弱。所有超声检查均由我院工作经验5年以上的同一位超声医师完成。
1.2.2 NAFLD诊断标准
行肝脏影像学或肝脏活检，诊断结果符合肝脂肪变，并除外酒精性肝病、病毒性肝病及药物性肝病等可导致肝脂肪变的疾病[4]。
1.2.3 MAFLD诊断标准
以影像学、肝脏活检或血清标志物诊断脂肪肝为基础，并符合以下三项中的任意一项：超重/肥胖[体重指数(BMI)>23 kg/m2]、T2DM、代谢功能障碍，即可诊断为MAFLD[3]。代谢功能障碍需符合至少两项下列代谢异常风险因素：(1)腰围男性≥90 cm，女性≥80 cm；(2)血压≥130/85 mmHg或正接受特异性药物治疗；(3)血浆三酰甘油≥1.70 mmol/L或正接受特异性药物治疗；(4)血浆高密度脂蛋白胆固醇男性<1.0 mmol/L，女性<1.3 mmol/L或正接受特异性药物治疗；(5)糖尿病前期：空腹血糖5.6~6.9 mmol/L，或餐后2 h血糖7.8~11.0 mmol/L或糖化血红蛋白5.7%~6.4%；(6)稳态模型评估胰岛素抵抗指数≥2.5；(7)血浆超敏C反应蛋白>2 mg/L。
1.3 观察指标
(1)人体学指标：性别、年龄、BMI；(2)慢性疾病病史：T2DM、高血压病史；(3)肝功能相关指标：谷丙转氨酶(alanine aminotransferase，ALT)、谷草转氨酶(aspartate aminotransferase，AST)、谷氨酰转肽酶(glutamyl transpeptidase，GGT)、碱性磷酸酶(alkaline phosphatase，ALP)、白蛋白、前白蛋白；(4)血脂相关指标：总胆固醇(total cholesterol，TC)、三酰甘油(triglycerides，TG)、高密度脂蛋白胆固醇(high density lipoprotein cholesterol，HDL-C)、低密度脂蛋白胆固醇(low density lipoprotein cholesterol，LDL-C)；(5)其他血清学指标：血红蛋白、血小板、血尿酸、血尿素、胆汁酸、空腹血糖；(6)非酒精性脂肪肝纤维化评分(nonalcoholic fatty liver disease fibrosis score，NFS)：当NFS<–1.455时，对排除肝纤维化有较高的阴性预测值，可认为无肝纤维化。
1.4 统计学处理
采用SPSS 20.0软件进行统计分析。计量资料以$\bar{x}±s$或M(Q1，Q3)表示，组间比较采用t检验或秩和检验。计数资料以例(%)表示，组间比较采用χ2检验或Fisher确切概率法。P<0.05为差异有统计学意义。
2 结果
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2.1 NAFLD组与MAFLD组一般资料比较
两组年龄差异无统计学意义(P>0.05)。NAFLD组男性、高血压、T2DM患者比例及BMI低于MAFLD组，差异有统计学意义(P<0.05，表1)。
2.2 NAFLD组与MAFLD组实验室指标比较
NAFLD组的ALT、AST、GGT、TG、TC、LDL-C及血红蛋白水平低于MAFLD组，HDL-C水平高于MAFLD组，差异有统计学意义(P<0.05)；两组的ALP、前白蛋白、白蛋白、血小板、尿素、尿酸、胆汁酸、空腹血糖水平及无肝纤维化比例差异无统计学意义(P>0.05)(表1)。
2.3 符合与不符合MAFLD诊断标准的NAFLD患者临床资料比较
NAFLD组157例中，有136例(86.6%)同时满足MAFLD的诊断标准。符合MAFLD组中合并高血压、T2DM的比例高于不符合MAFLD组[高血压：50(36.8%) vs. 0(0%)，χ2=11.328，P<0.001；T2DM：37(27.2%) vs. 1(4.8%)，χ2=4.995，P=0.027]，差异均有统计学意义。
2.4 合并与不合并T2DM的MAFLD组患者临床资料比较
MAFLD组213例患者中，合并T2DM 75例，不合并T2DM 138例。合并T2DM组中高血压患者比例及ALT、AST、GGT、ALP水平均高于不合并T2DM组，无肝纤维化比例低于不合并T2DM组，差异有统计学意义(P<0.05)。两组年龄、性别及BMI水平差异无统计学意义(P>0.05)(表2)。
2.5 合并与不合并饮酒的MAFLD患者临床资料比较
MAFLD组213例患者中，饮酒70例，不饮酒143例。饮酒组的年龄小于不饮酒组，男性、高血压、T2DM比例及BMI、ALT、AST、GGT、前白蛋白、TG、TC、LDL-C、血红蛋白、尿酸、空腹血糖水平高于不饮酒组，差异有统计学意义(P<0.05)；两组ALP、白蛋白、HDL-C、血小板、尿素、胆汁酸及无肝纤维化比例差异无统计学意义(P>0.05)(表3)。
3 讨论
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1980年，一种病理特征类似酒精性肝病，但临床表现及实验室检查结果存在差异的疾病被正式命名为NAFLD。这一疾病无论从命名还是诊断标准都强调了须排除酒精所致肝脂肪变的情况。随着医学的发展，NAFLD逐渐被认为是一种高度异质性的疾病，其疾病进程受遗传、性别、酒精、代谢状态、肠道菌群等多种因素影响[5]。目前关于NAFLD的发病机制有多种学说，如“二次打击”“多重损伤模型”等[6]，但胰岛素抵抗在其发病机制中起核心作用，与代谢综合征相同[7]。而且，越来越多的研究认为NAFLD是代谢综合征在肝脏的表现[7]。这为NAFLD的诊断变更为MAFLD提供了理论依据。
《非酒精性脂肪性肝病诊疗指南(2018年版)》[2]将NAFLD定义为一种与胰岛素抵抗、遗传因素相关的代谢应激性肝损伤，其诊断标准仅须除外其他一切可致肝脂肪变的病因，这相当于排除了多个病因共同作用致肝脂肪变的现象。但在临床上，多个病因共存致肝脂肪变的现象是常见的。多项流行病学研究发现，肥胖合并过量饮酒人群肝脂肪变的患病率高于过量饮酒人群脂肪肝的患病率[8-9]；在慢性乙型肝炎患者中，NAFLD患病率达29.6%[10]。因此，再沿用“排除性”诊断标准很容易忽略“NAFLD”这一危险因素在其他肝病中所起到的作用，不利于临床医师对患者进行管理。
更新的“肯定性”MAFLD诊断标准能较好地避免上述“漏诊”情况发生。本研究选取超声诊断为脂肪肝的患者234例，其中诊断为NAFLD者占67.1%(157/234)，诊断为MAFLD者占91.0%(213/234)，这是因为更新诊断标准后，MAFLD组内有一部分患者合并存在酒精性肝病及病毒性肝病等肝脏疾病。MAFLD组的转氨酶及转肽酶水平高于NAFLD组，是因为MAFLD组患者存在至少一项的肝损病因，如合并酒精性脂肪性肝病时，酒精可作为“二次打击”通过加重肝细胞脂质蓄积、激活细胞死亡途径等来促进NAFLD的肝细胞损伤[11-12]；在MAFLD合并慢性乙型肝炎时，有研究者提出“双重打击理论”，即乙肝病毒为损伤肝细胞的“第一击”，NAFLD为加重肝细胞损伤，导致进行性肝炎、肝纤维化的“第二击”[13]。有研究发现非酒精性脂肪肝是心血管疾病发展的独立危险因素[14]。血红蛋白是铁代谢的指标之一[15]，也是预测心血管疾病发生、发展的指标之一[16]。铁代谢可直接或间接地影响脂质代谢[15]；增多的血红蛋白可通过改变血流动力学来减少肌肉对葡萄糖的摄取，加重胰岛素抵抗[17]，并对血管结构造成影响[16]。本研究发现MAFLD组血红蛋白水平与NAFLD组比较升高，结合上述文献提示变更后的诊断标准更能突出代谢障碍的脂肪肝人群具有较高的心血管疾病风险。
对于肥胖这一诊断标准，已有流行病学研究表明，NAFLD患病率的增高与普通人群中BMI和肥胖率的增高呈平行发展[18]，而且不同肥胖程度NAFLD患者的肝组织病理改变的严重程度也不同[19-20]。但并非所有的NAFLD患者都合并代谢综合征，本研究发现在NAFLD组的157例患者中，有21例(13.3%)不符合MAFLD的诊断标准，但因为样本量较少，所以未比较符合MAFLD组与不符合MAFLD组患者的血清学指标。此前，有学者通过病例对照研究发现合并代谢综合征的NAFLD患者罹患心血管疾病的风险较高，而未合并代谢综合征的NAFLD患者并发症的发生风险与健康对照组相似[21]。此类患者的BMI处于正常范围，称为瘦型脂肪肝。瘦型脂肪肝的发病机制与遗传易感性有关，如Patatin样磷脂酶域蛋白3(Patatin like phospholipase domain-containing protein 3，PNPLA3)基因多态性改变可引起独特的胆汁酸、肠道菌群及代谢特征[22]。Weinberg等[23]发现此类患者出现肝硬化、心血管疾病及代谢异常等合并症的比例较肥胖型脂肪肝患者低，且其发生非酒精性脂肪肝炎的概率也较低[24]。因此对此类患者采取的管理方法应与合并代谢综合征的NAFLD患者有所不同。
胰岛素抵抗是NAFLD与T2DM共有的关键病理机制，提示NAFLD与T2DM之间可能存在密切联系[25-26]。在流行病学方面，NAFLD患者罹患T2DM的风险是一般人群的2.2倍[27]，T2DM患者合并NAFLD的风险也增加。有研究指出，T2DM是NAFLD进展至晚期肝病的独立危险因素[28]。Adams等[29]通过肝脏活检证实，T2DM会加快NAFLD患者肝纤维化的进展。本研究发现，MAFLD合并T2DM组的转氨酶、转肽酶及碱性磷酸酶水平高于不合并T2DM组，无肝纤维化的比例低于不合并T2DM组。这是因为NAFLD合并T2DM时胰岛素抵抗加重，导致机体出现胰岛素促进脂肪生成而胰岛素抑制糖异生能力下降的情况；另外，胰岛素抵抗可使循环中游离脂肪酸增加，刺激肝脏摄取，从而促进肝脏脂肪的累积，加重NAFLD[30]。因此，脂肪肝的独立危险因素T2DM成为MAFLD的诊断标准之一。本研究发现，MAFLD组中合并T2DM的比例高于NAFLD组，差异有统计学意义，但两组的空腹血糖水平差异无统计学意义，可能是T2DM患者长期服用降糖药物所致。
NAFLD的诊断标准一直沿用排除性诊断，对乙醇的摄入量有明确的规定，但在临床中难以对患者乙醇摄入情况进行量化评估，因此出现“应酬性饮酒”或“少量饮酒”等定义含糊的表达。此外，NAFLD的排除性诊断否认了乙醇为脂肪肝疾病进展的危险因素。酒精性肝病患者常合并代谢综合征，胰岛素抵抗会加重疾病进展；而对于少量或适量饮酒的NAFLD患者来说，酒精也可作为“第二次打击”对肝脏造成影响，酒精因素和非酒精因素可共同作用于脂肪肝[12]。变更后的MAFLD诊断标准删除了对乙醇摄入量的规定。本研究发现在MAFLD患者中，饮酒组的ALT、AST、GGT、前白蛋白、TG、TC、LDL-C、血红蛋白、尿酸、空腹血糖水平均高于不饮酒组。因此对MAFLD患者进行管理时应控制饮酒等危险因素。
综上所述，相较于NAFLD的诊断标准，MAFLD的诊断标准更易于识别心血管疾病的高危人群，有助于对其进行有针对性的管理。
基金
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  • 海军后勤科研计划课题(CHJ12J027)
  • 首都卫生发展科研专项(首发2020-2-5113)
文献
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2021年第46卷第5期
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doi: 10.11855/j.issn.0577-7402.2021.05.10
  • 接收时间：2021-01-07
  • 首发时间：2025-12-24
  • 出版时间：2021-05-28
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  • 收稿日期：2021-01-07
  • 修回日期：2021-03-16
基金
PLA Naval Logistics Research Project(CHJ12J027)
海军后勤科研计划课题(CHJ12J027)
Project of Capital Health Development(首发2020-2-5113)
首都卫生发展科研专项(首发2020-2-5113)
作者信息
    1南方医科大学第二临床医学院，广州 510280
    2解放军总医院第六医学中心消化内科，北京 100048

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2种不同金属材料的力学参数
科
Family		 属数
Number of
genus		 种数
Number of
species		 占总种数比例
Percentage of
total species (%)		 属
Genus		 种数
Number of
species		 占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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