中国人内脏脂肪指数及内脏脂肪面积与糖尿病肾病的相关性及其预警价值

doi:10.3969/j.issn.1004-583X.2022.12.004

摘要/Abstract

摘要：

目的探讨中国人内脏脂肪指数(Chinese visceral adipose index, CVAI)及内脏脂肪面积(visceral fat area, VFA)与糖尿病肾病(diabetic nephropathy, DN)的关系及病情预警价值。方法选取2020年10月至2021年10月于甘肃省人民医院内分泌科住院治疗的2型糖尿病(type 2 diabetes mellitus,T2DM)患者240例,收集患者临床资料(一般资料、体格检查、生化指标等)。根据有无DN分为DN组(n=114)、非DN组(n=126)。将CVAI及VFA与尿白蛋白排泄率(urinary albumin excretion rate, UAER)、尿白蛋白/肌酐比值(urine albumin creatine ratio,UACR)、估算肾小球滤过率 (estimated glomerular filtration rate, eGFR)作Spearman相关性分析。采用多因素logistic逐步回归分析法筛选T2DM患者发生DN的独立危险因素,并建立多因素logistic回归模型,通过受试者工作特征(receiver operating characteristic, ROC)曲线对模型及各危险因素的预测价值进行评估。结果与非DN组比较,DN组糖尿病病程较长,体重、体质量指数、腰围、臀围、腰高比、腰臀比、颈围较大,空腹血糖(FPG)、UAER、UACR、糖化血红蛋白(HbA₁c)较高,eGFR较小,脂质蓄积指数、CVAI、VFA、皮下脂肪面积较高,差异均有统计学意义(P<0.05)。对两组进行Spearman相关性分析,结果显示,UAER、UACR与CVAI、VFA呈正相关(均P<0.05)。Logistic回归分析结果显示,CVAI、VFA、FPG及糖尿病病程是T2DM患者发生DN的独立危险因素(均P<0.05)。ROC曲线分析显示, CVAI的曲线下面积(area under the curve, AUC)为0.6730,敏感度为0.3947,特异度为0.8810;VFA的AUC为0.6453,敏感度为0.7456,特异度为0.4921;logistic回归模型曲线下面积(AUC)为0.7493,敏感度为0.7368,特异度为0.6825,此结果均优于各单因素参数。结论 CVAI、VFA、FPG和糖尿病病程是T2DM患者发生DN的独立危险因素,CVAI及VFA可作为T2DM患者发生DN的病情预警指标,为内脏型肥胖患者的管理提供重要的依据。

关键词: 糖尿病肾病, 内脏脂肪面积, 中国人内脏脂肪指数, 危险因素

Abstract:

Objective To explore the correlation between Chinese visceral adipose index (CVAI) and visceral fat area (VFA) with diabetes nephropathy (DN) in Chinese population, and their values of early warning. Methods Clinical data of 240 patients with type 2 diabetes (T2DM) hospitalized in the Department of Endocrinology of Gansu Provincial People's Hospital from October 2020 to October 2021 were retrospectively analyzed, including the baseline characteristics, physical examination findings, and biochemical indicators. They were divided into DN group (n=114) and non-DN group (n=126) according to the presence or absence of DN. The correlation between CVAI and VFA with urinary albumin excretion rate (UAER), urinary albumin-to-creatinine ratio (UACR), and estimated glomerular filtration rate (eGFR) was assessed by the Spearman’s correlation test. Independent risk factors of DN in T2DM patients were screened by multivariatestepwise logistic regression analysis, and a multivariate logistic regression model was created. The predictive value of the model and each risk factor was evaluated by plotting the receiver operating characteristic (ROC) curve. Results Compared with those of the non-DN group, patients in DN group presented significantly longer duration of diabetes, larger weight, body mass index, waist circumference, hip circumference, waist height ratio, waist hip ratio, and neck circumference, and higher fasting plasma glucose (FPG), urinary albumin excretion rate (UAER), urine albumin-creatinine ratio (UACR), glycosylated hemoglobin(HbA₁c), lipid accumulation production, CVAI, VFA and subcutaneous fat area, and lower estimated glomerular filtration rate (eGFR) (all P<0.05). Spearman’s correlation test showed that UAER and UACR were positively correlated with CVAI and VFA (all P<0.05). Logistic regression analysis showed that CVAI, VFA, FPG and the course of diabetes were independent risk factors for DN in T2DM patients (all P<0.05). ROC curve analysis showed that the area under the curve (AUC), sensitivity and specificity of CVAI were 0.6730, 0.3947, and 0.881, respectively, which of VFA were 0.6453, 0.7456, and 0.4921, respectively. Besides, AUC, sensitivity and specificity of the created logistic regression model were 0.7493, 0.7368, and 0.6825, respectively. The predictive potential of the logistic regression model was better than that of a single independent risk factor. Conclusion CVAI, VFA, FPG and the course of diabetes are independent risk factors for DN in T2DM patients. CVAI and VFA can be used as early warning indicators for DN in T2DM patients, providing an important basis for the management of visceral obesity patients.

Key words: diabetic nephropathies, visceral fat area, Chinese visceral adipose index, risk factors

中图分类号:

R587.24

贺枫, 牛璐, 雒杲, 杨睿斐, 李凡凡, 成晓琼, 安斌斌, 李京娟, 刘媛媛, 郭茜, 王金羊. 中国人内脏脂肪指数及内脏脂肪面积与糖尿病肾病的相关性及其预警价值[J]. 临床荟萃, 2022, 37(12): 1089-1093.

He Feng, Nin Lu, Luo Gao, Yang Ruifei, Li Fanfan, Cheng Xiaoqiong, An Binbin, Li Jingjuan, Liu Yuanyuan, Guo Qian, Wang Jinyang. Correlation of Chinese visceral adipose index and visceral fat area with diabetic nephropathy and their warning values[J]. Clinical Focus, 2022, 37(12): 1089-1093.

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链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2022.12.004

https://huicui.hebmu.edu.cn/CN/Y2022/V37/I12/1089

图/表 9

表1 两组一般资料比较

组别	例数	性别[例(%)]		年龄(岁)	糖尿病病程
组别	例数	男	女	年龄(岁)	糖尿病病程
非DN组	126	74(58.7)	52(41.3)	57.25±10.11	3.00(1.00, 10.00)
DN组	114	75(65.8)	39(34.2)	56.71±12.47	7.00(2.00, 12.50)
统计值		χ²=1.267		t=0.367	$Z$ =-2.149
P值		0.260		0.714	0.032

表1 两组一般资料比较

组别	例数	性别[例(%)]		年龄(岁)	糖尿病病程
组别	例数	男	女	年龄(岁)	糖尿病病程
非DN组	126	74(58.7)	52(41.3)	57.25±10.11	3.00(1.00, 10.00)
DN组	114	75(65.8)	39(34.2)	56.71±12.47	7.00(2.00, 12.50)
统计值		χ²=1.267		t=0.367	$Z$ =-2.149
P值		0.260		0.714	0.032

表2 两组体格检查比较

组别	例数	收缩压(mmHg)	舒张压(mmHg)	颈围(cm)		身高(cm)		体重(kg)
非DN组	126	130.00(117.75, 140.25)	81.24±9.58	36.55(34.00, 38.70)		167.50(160.00, 170.25)		67.50(59.75, 75.00)
DN组	114	133.00(119.50, 147.50)	82.22±13.30	38.00(35.10, 40.50)		168.00(160.00, 172.00)		70.50(63.88, 80.25)
统计值		$Z$ =-1.769	t=-2.006	$Z$ =-3.114		$Z$ =-1.227		$Z$ =-3.252
P值		0.077	0.050	0.002		0.220		0.001
组别	例数	BMI(kg/m²)	WC(cm)		臀围(cm)		腰高比		腰臀比
非DN组	126	24.06(22.19, 26.22)	90.00(83.00, 95.00)		95.00(90.00, 98.78)		0.54(0.50, 0.57)		0.94(0.90, 0.97)
DN组	114	25.34(23.52, 27.66)	97.00(90.00, 102.00)		98.00(93.00, 103.55)		0.57(0.53, 0.61)		0.97(0.933, 1.01)
统计值		$Z$ =-3.152	$Z$ =-5.563		$Z$ =-3.284		$Z$ =-5.163		$Z$ =-4.661
P值		0.002	0.000		0.001		0.000		0.000

表2 两组体格检查比较

组别	例数	收缩压(mmHg)	舒张压(mmHg)	颈围(cm)		身高(cm)		体重(kg)
非DN组	126	130.00(117.75, 140.25)	81.24±9.58	36.55(34.00, 38.70)		167.50(160.00, 170.25)		67.50(59.75, 75.00)
DN组	114	133.00(119.50, 147.50)	82.22±13.30	38.00(35.10, 40.50)		168.00(160.00, 172.00)		70.50(63.88, 80.25)
统计值		$Z$ =-1.769	t=-2.006	$Z$ =-3.114		$Z$ =-1.227		$Z$ =-3.252
P值		0.077	0.050	0.002		0.220		0.001
组别	例数	BMI(kg/m²)	WC(cm)		臀围(cm)		腰高比		腰臀比
非DN组	126	24.06(22.19, 26.22)	90.00(83.00, 95.00)		95.00(90.00, 98.78)		0.54(0.50, 0.57)		0.94(0.90, 0.97)
DN组	114	25.34(23.52, 27.66)	97.00(90.00, 102.00)		98.00(93.00, 103.55)		0.57(0.53, 0.61)		0.97(0.933, 1.01)
统计值		$Z$ =-3.152	$Z$ =-5.563		$Z$ =-3.284		$Z$ =-5.163		$Z$ =-4.661
P值		0.002	0.000		0.001		0.000		0.000

表3 两组实验室资料比较

组别	例数		总胆固醇(mmol/L)		TG(mmol/L)		LDL-C(mmol/L)		HDL-C(mmol/L)		FPG(mmol/L)
非DN组	126		4.47(3.70, 5.16)		1.63(1.18, 2.75)		2.57±0.83		1.01(0.87, 1.18)		8.24(6.43, 11.32)
DN组	114		4.42(3.80, 5.26)		1.85(1.29, 3.11)		2.68±0.76		0.97(0.84, 1.10)		9.29(7.16, 13.46)
统计值			$Z$ =-0.703		$Z$ =-1.633		t=-1.042		$Z$ =-1.342		$Z$ =-2.683
P值			0.482		0.102		0.299		0.180		0.007
组别		例数		UAER		UACR		eGFR[ml/ (min·1.73 m²)]		HbA₁c(%)
非DN组		126		11.46(8.05, 15.50)		14.47(9.42, 23.56)		98.13(89.25, 105.19)		8.30(6.90, 10.02)
DN组		114		45.42(27.17, 100.12)		53.802(34.56, 115.70)		92.98(79.64, 104.92)		8.70(7.450, 10.75)
统计值				$Z$ =-13.372		$Z$ =-12.360		$Z$ =-2.305		$Z$ =-1.780
P值				0.000		0.000		0.021		0.075

表3 两组实验室资料比较

组别	例数		总胆固醇(mmol/L)		TG(mmol/L)		LDL-C(mmol/L)		HDL-C(mmol/L)		FPG(mmol/L)
非DN组	126		4.47(3.70, 5.16)		1.63(1.18, 2.75)		2.57±0.83		1.01(0.87, 1.18)		8.24(6.43, 11.32)
DN组	114		4.42(3.80, 5.26)		1.85(1.29, 3.11)		2.68±0.76		0.97(0.84, 1.10)		9.29(7.16, 13.46)
统计值			$Z$ =-0.703		$Z$ =-1.633		t=-1.042		$Z$ =-1.342		$Z$ =-2.683
P值			0.482		0.102		0.299		0.180		0.007
组别		例数		UAER		UACR		eGFR[ml/ (min·1.73 m²)]		HbA₁c(%)
非DN组		126		11.46(8.05, 15.50)		14.47(9.42, 23.56)		98.13(89.25, 105.19)		8.30(6.90, 10.02)
DN组		114		45.42(27.17, 100.12)		53.802(34.56, 115.70)		92.98(79.64, 104.92)		8.70(7.450, 10.75)
统计值				$Z$ =-13.372		$Z$ =-12.360		$Z$ =-2.305		$Z$ =-1.780
P值				0.000		0.000		0.021		0.075

表4 两组血脂相关指标比较[M(P25,P75)]

组别	例数	LAP	CVAI	VFA(cm²)	SFA(cm²)
非DN组	126	43.79(27.14, 81.02)	120.51(97.10, 140.95)	97.50(70.75, 120.00)	176.00(147.75, 224.00)
DN组	114	59.67(41.29, 108.71)	139.05(112.76,163.92)	114.00(96.00,137.00)	209.00(170.00, 252.50)
$Z$ 值		-3.475	-4.627	-3.886	-2.955
P值		0.001	0.000	0.000	0.003

表4 两组血脂相关指标比较[M(P25,P75)]

组别	例数	LAP	CVAI	VFA(cm²)	SFA(cm²)
非DN组	126	43.79(27.14, 81.02)	120.51(97.10, 140.95)	97.50(70.75, 120.00)	176.00(147.75, 224.00)
DN组	114	59.67(41.29, 108.71)	139.05(112.76,163.92)	114.00(96.00,137.00)	209.00(170.00, 252.50)
$Z$ 值		-3.475	-4.627	-3.886	-2.955
P值		0.001	0.000	0.000	0.003

表5 CVAI、VFA与肾功能的spearman相关性分析

因变量	CVAI		VFA
因变量	$r s$ 值	P值	$r s$ 值	P值
UAER	0.258	0.000	0.209	0.001
UACR	0.196	0.002	0.128	0.048
eGFR	-0.116	0.073	0.013	0.843

表5 CVAI、VFA与肾功能的spearman相关性分析

因变量	CVAI		VFA
因变量	$r s$ 值	P值	$r s$ 值	P值
UAER	0.258	0.000	0.209	0.001
UACR	0.196	0.002	0.128	0.048
eGFR	-0.116	0.073	0.013	0.843

图1 多因素logistic回归模型森林图

表6 多因素logistic逐步回归分析

因素	回归系数	标准误	Wald χ²值	P值	$O R$ 值	95%CI
因素	回归系数	标准误	Wald χ²值	P值	$O R$ 值	下限	上限
CVAI	0.015	0.005	8.167	0.004	1.015	1.005	1.025
FPG	0.123	0.037	11.023	0.001	1.131	1.052	1.216
VFA	0.010	0.005	4.101	0.043	1.010	1.000	1.020
糖尿病病程	0.057	0.021	7.073	0.008	1.058	1.015	1.104
常量	-4.737	0.809	34.260	0.000	0.009

表6 多因素logistic逐步回归分析

因素	回归系数	标准误	Wald χ²值	P值	$O R$ 值	95%CI
因素	回归系数	标准误	Wald χ²值	P值	$O R$ 值	下限	上限
CVAI	0.015	0.005	8.167	0.004	1.015	1.005	1.025
FPG	0.123	0.037	11.023	0.001	1.131	1.052	1.216
VFA	0.010	0.005	4.101	0.043	1.010	1.000	1.020
糖尿病病程	0.057	0.021	7.073	0.008	1.058	1.015	1.104
常量	-4.737	0.809	34.260	0.000	0.009

图2 多因素logistic回归模型及各危险因素的ROC曲线

表7 多因素logistic回归模型与各独立危险因素对T2DM患者发生DN的预测价值

预测项目	AUC	标准误	P值	95%CI		敏感度	特异度	约登指数	界值
预测项目	AUC	标准误	P值	下限	上限	敏感度	特异度	约登指数	界值
CVAI	0.6730	0.03465	0.0001	0.605	0.741	0.3947	0.8810	0.2757	154.45
VFA	0.6453	0.03555	0.0073	0.576	0.715	0.7456	0.4921	0.2377	96.50
FPG	0.6003	0.03647	0.0320	0.529	0.672	0.7544	0.4127	0.1671	7.25
糖尿病病程	0.5802	0.03686	0.0001	0.508	0.652	0.6667	0.5159	0.4193	3.50
多因素logistic回归模型	0.7493	0.03157	0.0001	0.687	0.811	0.7368	0.6825	0.4193	0.44

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