Screening for kidney disease in adults with diabetes and prediabetes

PURPOSE OF REVIEW: Worldwide, we are facing an increasing prevalence of diabetes mellitus, the number one cause of end-stage renal disease. It is imperative that chronic kidney disease among adults with diabetes mellitus be detected early when interventions are most effective in preventing end-stage renal disease. RECENT FINDINGS: Screening tools work best when health care providers have a clear understanding of the natural history of the disease process. The use of urine albumin measurement as a screening tool for diabetic nephropathy is based on the well characterized evolution of nephropathy in type 1 diabetes mellitus. However, the evolution of chronic kidney disease among adults with type 2 diabetes mellitus appears to be more heterogeneous. In contrast to type 1 diabetes mellitus, a substantial percentage of adults with type 2 diabetes mellitus have decreased glomerular filtration rate in the absence of increased urine albumin excretion. Focusing solely on urine albumin excretion to screen for chronic kidney disease may miss a substantial number of cases in adults with diabetes mellitus. In addition, up to one-third of adults with newly diagnosed diabetes mellitus already have chronic kidney disease, which may have first developed during the prediabetic state. Screening for chronic kidney disease only after an adult develops diabetes mellitus may miss that 'early' window of opportunity in many patients. SUMMARY: To maximize the effectiveness of our screening programs, we must not only use tests with adequate sensitivity but also implement screening tests early in the disease process to prevent the progression of chronic kidney disease to end-stage renal disease.     

Association between prehypertension and chronic kidney disease in the Japanese general population

The increased prevalence of chronic kidney disease (CKD) is a consequence of the accumulation of risk factors, one of which is hypertension. Here we assessed the prevalence of CKD according to blood pressure among 232,025 patients in a Japanese nationwide database with a focus on the prevalence and risk factors of CKD in prehypertension. Patients were stratified by blood pressure and included 75,474 with optimal blood pressure (less than 120/80 mm Hg); 59,194 with prehypertension and a normal blood pressure (120-129/80-84 mm Hg) or 46,547 patients with high-normal blood pressure (130-139/85-89 mm Hg); and 50,810 with hypertension (over 140/90 mm Hg without anti-hypertensive drugs). CKD was defined as an estimated glomerular filtration rate of stage 3 or lower or having proteinuria greater than 1+ by a dipstick method. The prevalence of CKD among patients with optimal blood pressure, prehypertension having normal or high-normal blood pressure, and hypertension was 13.9, 15.6, 18.1, and 20.7% in men, and 10.9, 11.6, 12.9, and 15.0% in women, with a significant difference between genders at each strata of blood pressure. In men, but not in women, whose blood pressure was high-normal, the CKD risk was significantly greater (odds ratio 1.11) than those with optimal blood pressure. Obesity (body mass index over 25) was significantly associated with an increased risk of CKD in both men and women (odds ratio 1.43 and 1.26, respectively), and there was an additive effect of obesity and pre-hypertension on CKD risk in men compared with men with optimal blood pressure. Thus, the prevalence of CKD increased with the severity of blood pressure. Prehypertension with high-normal blood pressure, particularly in conjunction with obesity, was found to be an independent risk factor of CKD in men.     

Association between metabolic syndrome and chronic kidney disease in the Korean population

Aim:   We performed a retrospective study to examine the association between the metabolic syndrome (MS) and risk for the development of chronic kidney disease (CKD).
Methods:   This cohort study included 60 921 healthy adults recruited from two health promotion centres. Anthropometric measures, blood pressure, fasting glucose, lipid profile and serum creatinine were evaluated. The glomerular filtration rate was estimated (eGFR) using the abbreviated equation developed by the Modification of Diet in Renal Disease (MDRD) formula. CKD was defined as an eGFR of <60 mL/min per 1.73 m² or the presence of proteinuria.
Results:   The prevalence of MS and CKD was 19.0% and 7.2% respectively. Those with MS had a higher prevalence of CKD (11.0% vs 6.3%, P  < 0.001) than those without MS. As the number of MS components increased, the prevalence of CKD increased and the eGFR decreased. The multiple linear analyses showed that each of the components of the MS was negatively correlated with the eGFR. Unadjusted and multivariate adjusted associations were identified between MS and CKD. Individuals with MS had a multivariate adjusted odds ratio of 1.680 (95% confidence interval, 0.566–1.801) for CKD compared with those without MS.
Conclusion:   Our findings, which were obtained from a large Korean cohort, suggest that MS was associated with CKD.     

Carotenoids and non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is a growing health problem around the world, especially in developed countries. NAFLD includes all cases of fatty liver disease from simple steatosis to cirrhosis, without excessive alcohol intake, use of steatogenic medication or hereditary disorders. Pathogenesis is associated with dietary high fat intake, decreased free fatty acid (FFA) oxidation, increased hepatic lipogenesis and lipolysis from the adipose tissue. These metabolic alterations contribute to the hepatic fat accumulation. Consequently, stimulated oxidative stress and inflammation play a major role in hepatocellular damage. Therefore, antioxidant and anti-inflammatory agents may have a role in the prevention of this disease. Carotenoids are potent antioxidant and anti-inflammatory micronutrients, which have been investigated in the prevention and treatment of NAFLD. The main sources of the carotenoids are fruits and vegetables. In this article we review the potential role and possible molecular mechanism of carotenoids in NAFLD.     

初诊糖尿病患者高同型半胱氨酸血症与慢性肾脏病相关性研究

目的 探讨初诊糖尿病患者高同型半胱氨酸血症(HHcy)患病情况及其与慢性肾脏病(CKD)的相关性.方法 对来本院健康体检的成年人进行横断面研究,收集体检者临床资料包括年龄、性别、吸烟史等,进行人体测量(身高、体重、血压等),空腹8～10 h测定血糖、血脂、血肌酐、血尿酸、糖化血红蛋白等生化指标检测.初诊糖尿病定义为空腹血糖＞ 7.0 mmol/L和或糖化血红蛋白＞6.5％并排除既往诊断糖尿病及服用降糖药物者.HHcy定义为Hcy≥15μmol/L.CKD定义为肾功能下降[估测的肾小球滤过率(eGFR) ＜60 mL·(min·1.73m2)-1]或蛋白尿[尿常规蛋白≥1+].应用多因素logistic回归模型探讨HHcy与CKD的相关性.结果 共有1801例初诊成年糖尿病患者纳入该研究,年龄(61.3±10.1)岁,男性占83.9％,eG-FR(119.2±30.9)(范围36.4～155.9)mL· (min· 1.73m2)-1,HHcy的患病率高达28.0％.肾功能下降、蛋白尿及CKD的患病率分别为2.3％、8.1％及10.0％.其中Hcy最高四分位数组年龄、男性比例、高血压、肾功能下降及CKD患病明显大于其他三组(P＜O.001).多因素Logistic回归分析显示,HHcy与肾功能下降及CKD正相关,测定OR值分别为3.32(95％ CI:1.63～6.78)及1.45(95％ CI:1.01 ～2.08).在771例无高血压的亚组人群中分析,同样显示HHcy与CKD正相关,OR值为2.34(95％ CI:1.18 ～4.61).结论 初诊糖尿病患者HHcy患病率较高,且HHcy与CKD正相关,应在初诊糖尿病患者尤其是合并HHcy患者中加强CKD的筛查.     

绝经后女性非酒精性脂肪性肝病与骨密度的相关性研究

目的研究乌鲁木齐市绝经后女性非酒精性脂肪性肝病与骨密度的关系。方法根据非酒精性脂肪性肝病(NAFLD)诊断标准,将我院住院的66例绝经后中老年女性分为NAFLD组和正常对照组,NAFLD组34例,正常对照组32例。对所有研究对象的肝/脾CT比值、骨密度(BMD)、身高、体重和血液生化学指标进行数据收集及统计学处理。结果 (1)NAFLD组的体质指数(BMI)、谷酰转肽酶(GGT)、甘油三酯(TG)和空腹血糖(FBG)高于对照组,低密度脂蛋白(LDL)低于对照组(P0.05)。(2)NAFLD组的腰椎及髋部各部位BMD均低于对照组,但差异不具有统计学意义(P0.05)。(3)NAFLD组的肝/脾CT比值与大转子和全髋BMD呈正相关;谷丙转氨酶(ALT)、谷草转氨酶(AST)与股骨颈、Ward三角和全髋BMD呈正相关;FBG与股骨颈和Ward三角BMD呈正相关(P0.05)。对照组的LDL、脂蛋白a[LP(a)]与髋部BMD关系密切:LDL与股骨颈和Wards三角BMD呈正相关,LP(a)与髋部各部位BMD呈显著负相关(P0.05)。结论 (1)肝脂肪变可能会导致患NAFLD绝经后女性的髋部BMD减低,高血糖可能对患NAFLD的绝经后女性髋部BMD具有保护作用。(2)LP(a)可能是无NAFLD绝经后女性髋部发生BMD减低的危险因素。(3)NAFLD可能会使绝经后女性体内ALT、AST、LDL、LP(a)及血糖对髋部BMD的影响作用发生改变。     

Association between serum magnesium and anemia in patients with chronic kidney disease

International Urology and Nephrology - An inverse association was shown between serum magnesium levels and anemia in the general population. However, limited information is available about the...     

非酒精性脂肪肝与骨质疏松间的生物信息学关系

目的 通过生物信息学相关技术方法依托相关数据库探讨非酒精性脂肪肝与骨质疏松之间的相互影响机制。方法 分别以骨质疏松及非酒精性脂肪肝为关键词在相关疾病数据库( Disgenet、TTD、OMIM、Drugbank、Genecards)中筛选相关基因,去重整合后将两组预测靶基因进行映射得到关键靶点,通过STRING网站获得靶点PPI互相作用网络,根据degree值筛选出核心靶点并通过 DAVID 数据库进行GO富集分析以及 KEGG 通路分析。结果 通过相关疾病数据库搜索筛选出与骨质疏松症和非酒精性脂肪肝相关靶点分别为 875 个和952个,映射出关键靶点217个,以degree≥36筛选出核心靶点24个并导入 DAVID 数据库获得78项GO富集结果（P<0.05）及78条KEGG信号通路（P<0.05）。结论 IL-6、INS、VEGFA、AKT1等核心靶点作用于乙肝通路、类风湿关节炎通路、TNF通路、IBD通路调控炎症反应及糖脂代谢等生物过程,使骨质疏松及非酒精性脂肪肝互相影响,为临床治疗两种疾病提供了较为科学的理论基础。     

Skeletal muscle loss is associated with diabetes in middle-aged and older Chinese men without non-alcoholic fatty liver disease

BACKGROUNDSkeletal muscle, a key insulin target organ, has been reported to be associated with diabetes mellitus (DM). Compared to non-diabetic patients, diabetic patients have decreased muscle mass and a higher prevalence of sarcopenia, and patients with sarcopenia may be at increased risk of developing diabetes. In individuals with nonalcoholic fatty liver disease (NAFLD), sarcopenia is associated with the severity of fibrosis and steatosis. Previous studies have demonstrated that NAFLD is strongly associated with DM and sarcopenia.AIMTo determine the relationship between skeletal muscle mass and DM in Chinese middle-aged and elderly men, and whether the association is affected by NAFLD. METHODSSkeletal muscle mass was calculated as appendicular skeletal muscle mass (ASM) in kg/body weight × 100%. Liver fat content (LFC) was measured using a quantitative ultrasound method. RESULTSAs the ASM decreased, fasting blood glucose (FBG), 2-h postprandial blood glucose (2hBG), and LFC increased in both genders, as did the prevalence of DM and NAFLD. Spearman analysis showed that the ASM was negatively correlated with the FBG, 2hBG, and LFC. Stepwise logistic regression analysis showed that after adjustments, the ASM quartile was negatively associated with the presence of DM in males, but not in females. Subgroup analysis showed that the ASM quartiles remained negatively correlated with the presence of DM in the non-NAFLD population (including males and females), but no correlation was found between ASM quartiles and the presence of DM in the NAFLD population. When stratified by LFC quartiles, ASM was negatively correlated with the presence of DM in the first and second LFC quartiles in males.CONCLUSIONSkeletal muscle mass loss was shown to be associated with the presence of DM in males, but not in females; NAFLD weakens this association. The results suggested that the stratified management of diabetes mellitus should be considered according to skeletal muscle mass and NAFLD.     

Novel glucose-lowering drugs for non-alcoholic fatty liver disease

BACKGROUNDThe efficacy of novel glucose-lowering drugs in treating non-alcoholic fatty liver disease (NAFLD) is unknown.AIMTo evaluate the efficacy of glucose-lowering drugs dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RAs), and sodium-glucose cotransporter 2 (SGLT2) inhibitors in treating NAFLD and to perform a comparison between these treatments.METHODSElectronic databases were systematically searched. The inclusion criteria were: Randomized controlled trials comparing DPP-4 inhibitors, GLP-1 RAs, or SGLT2 inhibitors against placebo or other active glucose-lowering drugs in NAFLD patients, with outcomes of changes in liver enzyme [alanine aminotransferase (ALT) and/or aspartate aminotransferase (AST)] from baseline.RESULTSNineteen studies were finally included in this meta-analysis. Compared with placebo or other active glucose-lowering drug treatment, treatment with DPP-4 inhibitors, GLP-1 RAs, and SGLT2 inhibitors all led to a significant decrease in ALT change and AST change from baseline. The difference between the DPP-4 inhibitor and SGLT2 inhibitor groups in ALT change was significant in favor of DPP-4 inhibitor treatment (P < 0.05). The trends of reduction in magnetic resonance imaging proton density fat fraction and visceral fat area changes were also observed in all the novel glucose-lowering agent treatment groups.CONCLUSIONTreatment with DPP-4 inhibitors, GLP-1 RAs, and SGLT2 inhibitors resulted in improvements in serum ALT and AST levels and body fat composition, indicating a beneficial effect in improving liver injury and reducing liver fat in NAFLD patients.     

Association between cytomegalovirus disease and chronic rejection in kidney transplant recipients

BACKGROUND: It has long been suggested that cytomegalovirus (CMV) disease plays a role in the pathogenesis of chronic rejection (CR). However, its role has been difficult to prove, given the strong association between acute rejection and CMV, and the even stronger association between acute rejection and CR. To try to isolate the relative contribution of CMV infection in the pathogenesis of CR, we used multivariate techniques to examine risk factors for CR, including CMV disease. METHODS: Our study population consisted of adult recipients of a first kidney graft who underwent transplantation at a single center between 1/1/85 and 6/30/97 (n = 1339). RESULTS: Multivariate analysis using time to CR as the dependent variable demonstrated acute rejection to be the strongest risk factor (relative risk [RR] = 17.8, P = 0.0001), followed by older donor age (RR = 1.46, P = 0.01). The presence of CMV disease showed a trend toward increased risk for CR (RR = 1.30, P = 0.10), although the association was not as strong as with the other two variables. Comparing only those recipients with acute rejection and CMV disease versus those with acute rejection but no CMV disease, the relative risk of developing CR was 1.37 times higher in the former group. Recipients with acute rejection and CMV developed CR sooner and with a higher incidence versus those with acute rejection but no CMV (P = 0.002). It is interesting, however, that CMV disease was only a risk factor for CR in the presence of acute rejection. Recipients with no acute rejection and CMV disease did not have a higher incidence of CR versus those with no acute rejection and no CMV (P = NS). CONCLUSION: CMV disease seems to play some role in the pathogenesis of CR but only in the presence of acute rejection. Reasons may include (i) the inability to adequately treat acute rejection due to the presence of CMV disease or (ii) the increased virulence of latent CMV virus in recipients being treated for acute rejection. Our data may suggest a role for more aggressive prophylaxis against CMV disease, especially at the time of treatment for acute rejection.     

Albuminuria and insulin resistance in children with biopsy proven non-alcoholic fatty liver disease

Insulin resistance may favor increased urinary albumin excretion (UAE), leading progressively to chronic kidney disease (CKD). A recent study on non-alcoholic fatty liver disease (NAFLD), a condition of insulin resistance, associated this disease with the incidence of CKD in patients with type 2 diabetes. The aim of our study was to determine whether there is an association between insulin resistance and kidney function, based on estimates of UAE and creatinine clearance in children with biopsy-proven NAFLD. Kidney function was assessed in 80 patients with NAFLD and 59 individuals of normal weight matched for age and sex. Insulin resistance was measured by means of the homeostatic model assessment-insulin resistance (HOMA-IR) and limited to NAFLD patients by using the whole-body insulin sensitivity index. The HOMA-IR was found to differ significantly between the two groups (2.69 ± 1.7 vs. 1.05 ± 0.45; p = 0.002), while UAE (9.02 ± 5.8 vs. 8.0 ± 4.3 mg/24 h; p = 0.9) and creatinine clearance (78 ± 24 vs. 80 ± 29 mg/min; p = 0.8) did not. We found a significant but weak inverse correlation between insulin sensitivity and creatinine clearance in NAFLD patients (r _s = –0.25;p = 0.02). No difference was observed in kidney function between NAFLD children presenting with or without metabolic syndrome, low or normal HDL-cholesterol, and different degrees of histological liver damage (grade of steatosis ≥2, necro-inflammation, and fibrosis). Patients with hypertension had increased levels of UAE (p = 0.04). A longer exposure to insulin resistance may be required to cause the increase in urinary albumin excretion and to enable the detection of the effect of the accelerated atherogenic process most likely occurring in children with fatty liver disease. Longitudinal studies are needed to rule out any causative relationship between insulin resistance and urinary albumin excretion.     

SGLT-2 inhibitors in non-alcoholic fatty liver disease patients with type 2 diabetes mellitus: A systematic review

BACKGROUND Non-alcoholic fatty liver disease(NAFLD) is a common comorbidity with type 2 diabetes. The existing therapeutic options for NAFLD are not adequate.Hypocaloric diet and exercise is the cornerstone of therapy in NAFLD.Pioglitazone is the only drug recommended in diabetes patients with biopsy proven non-alcoholic steatohepatitis. The frequent coexistence of NAFLD and type 2 diabetes with their combined adverse health consequences and inadequate therapeutic options makes it necessary to search for newer alternatives.AIM To assess the effect of sodium glucose cotransporter-2(SGLT-2) inhibitors on liver enzymes in type 2 diabetes patients with NAFLD.METHODS We searched Pub Med/MEDLINE, Cochrane library, Google scholar, and Clinicaltrials.gov for the relevant articles to be included in this systematic review.Human studies done in type 2 diabetes patients with NAFLD treated with SGLT-2 inhibitors for at least 12 wk were included. Data from eight studies(four randomised controlled trials and four observational studies) were extracted and a narrative synthesis was done. A total of 214 patients were treated with SGLT-2 inhibitors in these studies(94 in randomised controlled trials and 120 in observational studies).RESULTS The primary outcome measure was change in serum alanine aminotransferase level. Out of eight studies, seven studies showed a significant decrease in serum alanine aminotransferase level. Most of the studies revealed reduction in serum level of other liver enzymes like aspartate aminotransferase and gamma glutamyl transferase. Five studies that reported a change in hepatic fat exhibited a significant reduction in hepatic fat content in those treated with SGLT-2 inhibitors. Likewise, among the three studies that evaluated a change in indices of hepatic fibrosis, two studies revealed a significant improvement in liver fibrosis. Moreover, there was an improvement in obesity, insulin resistance,glycaemia, and lipid parameters in those subjects taking SGLT-2 inhibitors. The studies disclosed that about 17%(30/176) of the subjects taking SGLT-2 inhibitors developed adverse events and more than 40%(10/23) of them had genitourinary tract infections.CONCLUSION Based on low to moderate quality of evidence, SGLT-2 inhibitors improve the serum level of liver enzymes, decrease liver fat, and fibrosis with additional beneficial effects on various metabolic parameters in type 2 diabetes patients with NAFLD.     

Association of genetic risk score and chronic kidney disease in a Japanese population

Chronic kidney disease (CKD) is a public health problem worldwide including Japan. Recent genome‐wide association studies have discovered CKD susceptibility variants. We developed a genetic risk score (GRS) based on CKD‐associated variants and assessed a possibility that the GRS can improve the discrimination capability for the prevalence of CKD in a Japanese population. The present study consists of 11 283 participants randomly selected from 12 Japan Multi‐Institutional Collaborative Cohort Study sites. Individual GRS was constructed combining 18 single‐nucleotide polymorphisms identified in a Japanese population. Participants with eGFR <60 mL/min per 1.73 m² was defined as case (stage 3 CKD or higher) in this study. Logistic regression analysis was used to examine the association between the GRS and CKD risk with adjustment for sex, age, hypertension and type 2 diabetes mellitus. The frequency of individuals with CKD was 8.3%, which was relatively low compared with those previously reported in a Japanese population. The odds ratio of having CKD was 1.120 (95% confidence interval: 1.042–1.203) per 10 GRS increment in the fully adjusted model (P = 0.002). The C‐statistic was significantly increased in the model with the GRS, comparing with the model without the GRS (0.720 vs 0.719, P_difference = 0.008). Increment of the GRS was associated with increased risk of CKD. Additionally, the GRS significantly improved the discriminatory ability of CKD prevalence in a Japanese population; however, the improvement of discriminatory ability brought about by the GRS seemed to be small compared with that of non‐genetic CKD risk factors.     

Nonalcoholic fatty liver disease and diabetes

Nonalcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease in the world and represents a clinical-histopathologic entity where the steatosis component may vary in degree and may or may not have fibrotic progression. The key concept of NAFLD pathogenesis is excessive triglyceride hepatic accumulation because of an imbalance between free fatty acid influx and efflux. Strong epidemiological, biochemical, and therapeutic evidence supports the premise that the primary pathophysiological derangement in most patients with NAFLD is insulin resistance; thus the association between diabetes and NAFLD is widely recognized in the literature. Since NAFLD is the hepatic manifestation of a metabolic disease, it is also associated with a higher cardio-vascular risk. Conventional B-mode ultrasound is widely adopted as a first-line imaging modality for hepatic steatosis, although magnetic resonance imaging represents the gold standard noninvasive modality for quantifying the amount of fat in these patients. Treatment of NAFLD patients depends on the disease severity, ranging from a more benign condition of nonalcoholic fatty liver to nonalcoholic steatohepatitis. Abstinence from alcohol, a Mediterranean diet, and modification of risk factors are recommended for patients suffering from NAFLD to avoid major cardiovascular events, as per all diabetic patients. In addition, weight loss induced by bariatric surgery seems to also be effective in improving liver features, together with the benefits for diabetes control or resolution, dyslipidemia, and hypertension. Finally, liver transplantation represents the ultimate treatment for severe nonalcoholic fatty liver disease and is growing rapidly as a main indication in Western countries. This review offers a comprehensive multidisciplinary approach to NAFLD, highlighting its connection with diabetes.     

Innate immune signaling and gut-liver interactions in non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is the hepatic manifestation of the metabolic syndrome and covers a disease spectrum ranging from steatosis to inflammation, fibrosis, cirrhosis and hepatocellular carcinoma (HCC). The innate immune response in the liver plays an important role during NAFLD progression. In addition, changes in the intestinal microbial balance and bacterial translocation can further affect disease progression. Immune cells in the liver recognize cell damage or pathogen invasion with intracellular or surface-expressed pattern recognition receptors (PRRs), subsequently initiating signaling cascades that trigger the release of factors promoting the inflammatory response during NAFLD progression. Therefore, mechanisms by which cells of the immune system are activated and recruited into the liver and how these cells cause injury and stress are important for understanding the inflammatory response during NAFLD.     

Association between common iron store markers and hemoglobin in children with chronic kidney disease

Background

Serum ferritin and transferrin saturation (TSAT) are used to assess iron status in children with chronic kidney disease (CKD), but their sensitivity in identifying those at risk of lower hemoglobin (HGB) values is unclear.

Methods

We assessed the association of iron status markers (ferritin, TSAT, and serum iron) with age- and gender-related HGB percentile in mild-to-moderate CKD in 304 children in the Chronic Kidney Disease in Children (CKiD) Study. Standardized HGB percentile values were examined by KDOQI-recommended ferritin (≥100?ng/ml) and TSAT (≥20?%) thresholds. Regression tree methods were used to identify iron status markers and clinical characteristics most associated with lower HGB percentiles.

Results

The cohort was 62?% male, 23?% African American, and 12?% Hispanic, median age 12?years, and median HGB 12.9?g/dl. 34?% had low TSAT and 93?% low ferritin as defined by KDOQI. Distribution of HGB percentile values was lower in those with ferritin ≥100?ng/ml, while TSAT ≥20?% was associated with only modest increase in HGB percentile. In regression tree analysis, lower glomerular filtration rate (GFR), serum iron <50?μg/dl and ferritin ≥100?ng/ml were most strongly associated with lower HGB percentile.

Conclusions

The level of GFR was significantly associated with HGB. Higher serum ferritin was associated with lower HGB in this cohort. Low serum iron in the context of normal/increased ferritin and low HGB may be a useful indicator of iron-restricted erythropoiesis.     

罗格列酮治疗非酒精性脂肪性肝病的研究

目的 探讨罗格列酮对非酒精性脂肪性肝病（non-alcoholic fattyliver disease,NAFLD）患者的治疗作用。方法 选取NAFLD患者62例（其中21例为对照组、41例为治疗组）,正常健康体检者20例（正常组）,分别测定空腹血糖、胰岛素、甘油三脂、总胆固醇、血清丙氨酸氨基转移酶（alanine aminotransferase,ALT）和天冬氨酸氨基转移酶（aspartate aminotransferase,AST）、血清Ⅲ型前胶原、四型胶原。行CT检查,分别记录其肝脏平均的CT值。治疗组予文迪雅4mg／d口服,连续6个月,低脂饮食;对照组予低脂饮食。期间密切监测两组肝功能、血脂水平及血糖水平及可能药物副作用。6个月后再次测定空腹血糖、胰岛素、甘油三脂、总胆固醇、血清ALT、AST、血清Ⅲ型前胶原和四型胶原。并再次行CT检查,记录其肝脏平均的CT值。结果 NAFLD患者胰岛素抵抗指数小于正常组（P〈0．05）,治疗组经罗格列酮治疗半年后胰岛素抵抗指数较治疗前明显增高（P〈0．05）,而对照组改变不明显（P〉0．05）;NAFLD患者肝纤维谱水平明显高于正常组（P〈0．05）,治疗组经治疗后,其血糖、血脂、肝纤维谱较治疗前明显下降（P〈0．05）,其肝脏CT值明显上升（P〈0．05）。而对照组改变不明显（P〉0．05）。结论 罗格列酮具有改善NAFLD患者的胰岛素抵抗、调节血脂及改善肝脏纤维化的作用,并且无明显肝功能损害.     

非酒精性脂肪性肝病的手术治疗进展

非酒精性脂肪性肝病（NAFLD）是目前最常见的慢性肝病,可进展为肝硬化及肝癌,是世界范围内的一个严重健康问题。NAFLD与代谢因素联系紧密,是代谢综合征的一个主要肝脏表现,常合并有肥胖、糖尿病、心血管疾病和其他代谢紊乱等疾病。为了更准确地反映其发病机制,2020年国际肝脏专家小组将NAFLD更名为代谢相关脂肪性肝病（MAFLD）。迄今为止,其病理生理学机制尚无明确理论可以阐明,其典型特征是肝细胞的过度脂质蓄积。随着肝细胞的损伤和纤维化的产生,NAFLD将逐渐发展为终末期肝病。早期NAFLD的治疗主要提倡饮食和生活方式的改变。NAFLD药物治疗主要以发病关键环节及相关代谢紊乱为靶点,但仍然缺乏特效药。肥胖相关的NAFLD以及NAFLD相关的终末期肝病患病率逐年递增。这些患者对饮食变化和运动无反应,或无法通过改变生活方式减重,从而导致疾病的恶化,因此手术治疗成为此类患者的新选择。减重手术可以改善肝脏组织学、降低转氨酶水平及心血管疾病的发病率等。常见的手术方式包括胃袖状切除术（SG）、可调节胃束带术（ABG）以及Roux-en-Y胃旁路术（RYGB）,其中SG是NAFLD相关肝硬化患者最常用的术式。但减重手术也存在一定的局限性,包括患者耐受程度、术者的技术水平以及围术期并发症的发生等,需要慎重考虑,其临床疗效和安全性还需要进一步研究,以使其适用于NAFLD患者。肝脏移植术是NAFLD相关终末期肝病患者唯一可能的治愈手段。近年来,随着移植技术和免疫抑制剂的成熟发展,肝移植术在终末期肝病的治疗中取得较为可观的成绩,但在NAFLD患者的治疗中仍存在诸多问题。边缘供肝的使用、等肝期的延长、移植术前评估与管理以及移植术后复发均影响着移植物存活率及患者生存率。本文主要综述了NAFLD的概况、一般治疗及手术治疗进展,以期为临床工作提供参考。