【作者】 徐娜；

【导师】 王建华；

【作者基本信息】 天津医科大学 ， 流行病与卫生统计学， 2014， 博士

【摘要】 目的：(1)比较老年2型糖尿病患者与非糖尿病患者空腹血清nesfatin-1水平是否有差异,探讨血清nesfatin-1水平及其它因素与2型糖尿病的关系。(2)利用小鼠胰岛探讨人重组nesfatin-1对胰岛素和胰高血糖素分泌的影响。(3)评价糖化血红蛋白(HbAlc)≥6.5%用于中国成人糖尿病诊断的价值。方法：(1)利用以社区为基础的病例-对照研究的方法。病例组为通过横断面调查,从社区人群中筛选年龄在60岁及以上的2型糖尿病现患患者；对照组为居住在病例组所居住社区且不患有糖尿病的老年居民。问卷调查研究对象的一般人口学资料、生活行为方式、糖尿病知识知晓情况、现患其他疾病现病史、糖尿病家族史、病例组糖尿病现病史等资料；同时进行体格检查和实验室检查。应用非条件Logistic回归分析血清nesfatin-1水平及其它因素与2型糖尿病的关系,计算OR及其95%CI,并结合专业知识对可能的混杂因素进行调整,建立2型糖尿病危险因素的主效应方程。(2)经胆总管不离体灌注胶原酶V消化分离小鼠胰岛。利用葡萄糖刺激实验,分析经不同浓度人重组nesfatin-1干预后胰岛胰岛素和胰高血糖素分泌量有无变化。采用酶联免疫吸附实验(ELISA)检测组织液中胰岛素和胰高血糖素水平。(3)利用诊断试验meta分析的方法评价诊断试验的准确性。检索PubMed, EMBASE, CNKI,万方数据库和维普数据库,检索2003年1月1日至2013年10月31日发表的利用OGTT为参考标准,评价HbAlc≥6.5%在中国成人糖尿病诊断价值的相关文献。利用诊断性试验准确性质量评价-2(QUADAS-2)工具对纳入研究进行质量综合评价。采用Meta-Disc1.4软件对纳入的研究进行综合定量评价,并绘制综合受试者工作曲线(SROC)曲线。结果：(1)本研究共纳入研究对象234人,其中病例组122人,对照组112人。病例组和对照组年龄、性别构成等一般人口学资料均衡可比。单因素Logistic回归分析显示与2型糖尿病有统计学关联的因素有：高BMI(OR=1.682,95%CI:1.162-2.436)、饮酒(OR=0.522,95%CI:0.290-0.943)、水果摄入量多(OR--0.215,95%CI：0.106-0.436)、蛋类摄入量高(OR=1.853,95%CI:1.051-3.268)、肉类摄入量高(OR=2.100,95%CI:1.097-4.021)、现患慢性病数量(除糖尿病外)(OR=1.933,95%CI:1.239-3.017)、现患冠心病(OR=1.679,95%CI:1.001-2.817)、高血压(OR=2.280,95%CI:1.334-3.866)、高血脂(OR=2.049,95%CI:1.093-3.841)、脑血管疾病(OR=2.528,95%CI:1.329-4.808)、糖尿病家庭史(OR=2.940,95%C：1.658-5.213)、尿素(OR=1.273,95%CI:1.008-1.607)、肌酐(OR=1.466,95%CI:1.151-1.866)、胰高血糖素水平(OR=1.521,95%CI:1.197-1.931)、nesfatin-1水平(OR=0.738,95%CI:0.583-0.935)、β细胞功能(OR=0.272,95%CI:0.195-0.379)、胰岛素敏感性(OR=0.708,95%CI:0.559-0.898)、胰岛素抵抗(OR=1.396,95%CI:1.103-1.768)。多因素Logistic回归分析结果提示,高BMI (OR=1.599,95%CI:1.052-2.429)、糖尿病家族史(OR=2.622,95%CI:1.411-4.875)、现患其他慢性病数(OR=1.831,95%CI:1.109-3.022)、肌酐水平高(OR=1.429,95%CI:1.093-1.868)、胰高血糖素水平高(OR=1.549,95%CI:1.185-2.025)是糖尿病发生的危险因素；而nesfatin-1水平高(OR=0.755,95%CI:0.576-0.988)则是糖尿病发生的保护因素。(2)成功分离小鼠胰岛,胰岛形态完整、功能良好。经不同浓度nesfatin-1干预后,低浓度葡萄糖(2.8mM)孵育1小时,未见小鼠胰岛胰岛素分泌量差异有统计学意义；低浓度葡萄糖(2.8mM)孵育1小时后胰高血糖素分泌量高于0分钟(F=5.869,P=-0.026),但不同浓度nesfatin-1干预组胰高血糖素分泌量差异统计学意义(F=2.283,P=0.131)。高浓度葡萄糖刺激后不同时点(F=14.206,P<0.001)、不同浓度nesfatin-1干预组(F=53.760,P<0.001)其胰岛素分泌量差异均有统计学意义。nesfatin-1浓度为1.00ng/ml组胰岛素分泌量高于0.01ng/ml组(P=0.006)和0.00ng/ml组(P<0.001),差异有统计学意义；nesfatin-1浓度为0.01ng/ml组胰岛素分泌量高于0.00ng/ml组,差异有统计学意义(P=0.004)。不同时点胰岛素分泌量比较,60分钟胰岛素分泌量高于30分钟(P=0.001)和0分钟(P<0.001),差异有统计学意义；30分钟胰岛素分泌量高于0分钟(P<0.001),差异有统计学意义。高浓度葡萄糖刺激后不同时点、不同浓度nesfatin-1干预组胰高血糖素分泌量变化均无统计学意义。(3)本研究共纳入9项研究,样本量为25932。合并灵敏度为0.518(95%Cl：0.499,0.537),合并特异度为0.956(95%Cl:0.953-0.959),合并阳性似然比为19.007(95%CI：9.509,37.993),合并阴性似然比为0.477(95%CI：0.379,0.599),合并诊断比值比为40.631(95%CI：18.225,90.583),AUCSROC为0.9294。结论：(1)此次研究结果表明老年2型糖尿病患者空腹血nesfatin-1水平低于非糖尿病老年人。高BMI、糖尿病家族史、现患其他慢性病病种多、肌酐水平高、胰高血糖素水平高是糖尿病发生的危险因素；而nefatin-1水平高是糖尿病发生的保护因素。(2)人重组nesfatin-1能够促进小鼠胰岛葡萄糖诱导的胰岛素分泌。(3)与OGTT相比,HbA1c≥6.5%为标准诊断中国成人糖尿病特异度较高而灵敏度较低,约有48.2%的新发糖尿病患者被漏诊。建议适当降低HbA1c标准来提高其在中国成人糖尿病诊断中的灵敏度。尚需要进行前瞻性研究来确定糖化血红蛋白值作为中国成人糖尿病的诊断标准。更多还原

【Abstract】 Objective:(1) To compare the levels of fast blood nesfatin-1between type2diabetes mellitus patients and non-type2DM patients in old people aged equal and over60years and to analyze the correlated factors to different levels of nesfatin-1. To explore nesfatin-1and other risk factors for type2diabetes mellitus.(2) To investigate whether human recombinant nesfatin-1has the effect on the secretion of insulin and glucagon of isolated mice islets.(3) A meta-analysis To evaluate the diagnostic value of glycosylated hemoglobin Alc (HbAlc)≥6.5%for diabetes in Chinese adults by a Meta-analysis.Methods:(1) A community-based case-control study was conducted. The case group with type2diabetes millituw and the control group without it are from the same community. The study subjects are generated based on a cross-sectional study. They are elders equal and over60year old. All the information was collected by questionnaire in face-to-face interview, including demographic data, lifestyle and behaviors, knowledge on diabetes, state of illness, diabetes family history, clinical data and laboratory data. Independent sample t-test method was used to compare the difference of nesfatin-1between case group and control group. Linear correlation and regression analysis were used to analyze the related factors of nesfatin-1. Unconditional Logistic regression model by was used to analyze the risk factors of diabetes.(2) Mice pancreas were digested by collagenase V through common bile-duct injection and islets were isolated manually. The islets were incubated with different concentrations of human recombinant nesfatin-1. The glucose-stimulated secretion test was used to investigate whether the amount of insulin and glucagon secreted by the islet were changed after incubation. Using the enzyme linked immunosorbent assay (ELISA) to measure the levels of insulin and glucagon.(3) Oral glucose tolerance test (OGTT) was selected as the reference standard. PubMed, EMBASE, CNKI, Wanfang Data, and VIP were searched to obtain all diagnostic tests with HbAlc≥6.5%for diabetes in Chinese adults published between January2003and October2013. Meta-DiSc software was used to conduct a comprehensive quantitative assessment, and summary receiver operating characteristic (sROC) curves were obtained.Results:(1)224subjects including122cases and112controls were investigated and analysed. The constitute of age and gender are comparable between case group and control group. In comparison with control group, case group has lower level of nesfatin-1. The Logistic regression analysis shows that the risk factors for type2diabetes are:higher BMI (OR=1.682,95%CI:1.162-2.436), drinking (OR=0.522,95%CI:0.290-0.943), eating more fruits (OR=0.215,95%CI:0.106-0.436)、eating more eggs(OR=1.853,95%CI:1.051-3.268), eating more meat(OR=2.100,95%CI:1.097-4.021) number of having chronic diseases (OR=1.933,95%CI:1.239-3.017), having coronary heart disease(OR=1.679,95%CI:1.001-2.817), having hypertension (OR=2.280,95%CI:1.334-3.866), having high blood lipids (OR=2.049,95%CI:1.093-3.841), having cerebrovascular diseases (OR=2.528,95%CI:1.329-4.808), family history of diabetes (OR=2.940,95%C:1.658-5.213), higher urea (OR=1.273,95%CI:1.008-1.607), higher creatinine (OR=1.466,95%CI:1.151-1.866), higher level of glucagon (OR=1.521,95%CI:1.197-1.931), insulin resistance (OR=1.396,95%CI:1.103-1.768).And the protective factors are lower level of nesfatin-1(OR=0.738,95%CI:0.583-0.935), p cell function (OR=0.272,95%CI:0.195-0.379), insulin sensitivity (OR=0.708,95%CI:0.559-0.898). The results of multivariate Logistic regression analysis shows that the following factors are risk factors for type2diabetes:higher BMI (OR=1.599,95%CI:1.052-2.429)、 family history of diabetes (OR=2.622,95%CI:1.411-4.875), number of having chronic diseases (OR=1.831,95%CI:1.109-3.022), higher level of creatinine (OR=1.429,95%CI:1.093-1.868), higher level of glucagon (OR=1.549,95%CI:1.185-2.025); while the protective factor is higher level of nesfatin-1(OR=0.755,95%CI:0.576-0.988).(2) The pancreatic islets were successfully isolated. Islets were incubated with different concentrations of human recombinant nesfatin-1for60minutes. At2.8mM glucose, none of the tested concentrations of nesfatin-1caused any statistically significant change in insulin secretion during the1h incubation. At2.8mM glucose, the amount of glucagon secretion after1h incubation is statistically higher than baseline (F=5.869, P=0.026); however, there is no statistically difference between the different concentrations (F=2.283, P=0.131).At16.7mM glucose, nesfatin-1induced dose-dependent increase in insulin secretion in isolated mouse islets (F=53.760, P<0.001). At16.7mM glucose, none of the tested concentrations of nesfatin-1caused any statistically significant change in glucagon secretion during the1h incubation.(3) A total of nine studies with25932subjects were included. Pooled sensitivity was0.518. Pooled specificity was0.956. Pooled positive likelihood ratio was19.007. Pooled negative likelihood ratio was0.477. Pooled diagnostic odds ratio was40.631. AUCsROC was0.9294.Conclusion:(1) In comparison to non type2diabetes patients aged equal and over60years, type2diabetes mellitus patients aged equal and over60years have lower lever of nesfatin-1. This study suggests that higher BMI, family history of diabetes, number of chronic diseases, higher level of creatinine, higher level of glucagon may increase the risk for type2diabetes, while higher level of nesfatin-1may decrease the risk.(2) nesfatin-1stimulates glucose-induced insulin secretion of islets.(3) Compared with OGTT, employing HbAlc≥6.5%(48mmol/mol) to diagnose diabetes in Chinese adults exhibited high specificity and low sensitivity, which would have failed to diagnose48.7%of newly diagnosed diabetes. The diagnostic value could be reduced to improve sensitivity. Long-term prospective studies are required to establish an appropriate HbAlc value as a diagnostic criterion for diabetes in China.更多还原