第二型糖尿病患超過60%患有脂肪肝疾病


  【24drs.com】新研究顯示,一線醫療機構中,非侵犯性MRI顯示,幾乎有三分之二的第二型糖尿病患患有非酒精性脂肪肝疾病(nonalcoholic fatty-liver disease,NAFLD),核磁共振彈性成像發現,7%以上患有晚期纖維化。
  
  資深作者、加州大學聖地牙哥分校臨床醫學副教授Rohit Loomba醫師表示,大部份病患不知道他們患有脂肪肝,直到他們發生纖維化才知道,因此本病被稱為沉默殺手。
  
  但是,好消息是,肝臟是可以再生的,目前有許多新療法可以用在治療非酒精性脂肪肝疾病和非酒精性脂肪肝疾病相關的纖維化。
  
  所以,關鍵在於確認有哪些病患,我們將可以有能力制止疾病惡化;我們將可以用這些新療法逆轉肝硬化和肝纖維化,我們已經在某些病患達到這些目標。
  
  Loomba醫師等人也指出,有某些代謝症候群特徵,如腰圍比較大、血脂異常以及高血壓的病患,比較可能會發生非酒精性脂肪肝疾病。所以,直到建立比較好的篩檢方法之前,他們建議醫師使用這些臨床徵兆協助評估糖尿病患的脂肪肝疾病。
  
  這篇研究線上發表於9月15日的消化道藥理與治療學期刊,是一篇橫斷面分析,共包括100名第二型糖尿病成年病患,平均身體質量指數(BMI)是30.8 kg/m2,平均患糖尿病時間為8.5年。
  
  在納入研究後的30天,對病患進行MRI以評估肝臟的質子密度脂肪分率(MRI-PDFF),以及進行核磁共振彈性成像評估肝硬化程度。
  
  正如作者觀察,這兩種都是精準確切的測量方法,分別是非酒精性脂肪肝疾病以及晚期纖維化驗證過的非侵犯性影像基礎生物標記。
  
  65%研究對象的MRI-PDFF檢測≧5%,視為有非酒精性脂肪肝疾病,且無檢驗技術上的失誤。7.1%研究對象的核磁共振彈性成像發現硬度≧ 3.6 kPa,視為晚期纖維化。
  
  研究者指出,研究結果強調及早對糖尿病患進行非酒精性脂肪肝疾病和晚期纖維化之篩檢的重要性,或許在診斷有糖尿病時就進行,以預防後續的肝臟損傷。
  
  有趣的是,隨著年齡增加,非酒精性脂肪肝疾病的盛行率降低、晚期纖維化的盛行率上升。
  
  58歲以下的病患中,將近79%患有非酒精性脂肪肝疾病,58 -65歲者則是有68%罹患,65歲以上者中,約47%被發現有非酒精性脂肪肝疾病。反之,58歲以下的病患中,3%患有晚期纖維化;58 -65歲者有將近6%罹患,65歲以上者則是約有13%。
  
  Loomba醫師等人觀察發現,許多目前使用的測試方法,包括肝臟酵素,並不是非酒精性脂肪肝疾病的正確標記。
  
  腹部超音波對於輕度脂肪肝也缺乏敏感性,且不同觀察者之間的判讀差異也大。同樣地,電腦斷層對於輕症的敏感性也有限,且須曝露於放射線。
  
  他們強調,不過,某些風險因素顯著增加了糖尿病患患有非酒精性脂肪肝疾病的可能性,且已經可以在臨床上加以評估。
  
  舉例來說,這篇研究中,非酒精性脂肪肝疾病患者明顯比較年輕(P = .028)、平均身體質量指數(32.5 kg/m2)高於沒有此病症者(27.6 kg/m2) (P = .0008)。
  
  相較於沒有非酒精性脂肪肝疾病者,非酒精性脂肪肝疾病患者也有比較低的高密度脂蛋白膽固醇、比較高的三酸甘油脂,有脂肪肝疾病者的空腹葡萄糖與空腹胰島素值都顯著高於沒有該疾病者。
  
  這篇研究中,非酒精性脂肪肝疾病者的平均腰圍是106.6公分,無該疾病者為95.1公分,這也是非酒精性脂肪肝疾病的顯著預測因子(P < .0001)。另外,非酒精性脂肪肝疾病者有84.6%有代謝症候群,沒有非酒精性脂肪肝疾病者則是有40%(P < .0001)。
  
  Loomba醫師提醒,無論他們採用的篩選試驗是否在黃金時間進行,他們必須證明MRI-PDFF和核磁共振彈性成像都是具有成本效益。
  
  不過,非酒精性脂肪肝疾病惡化的預測因子還包括體重增加、高血壓、代謝症候群的其他特點,所以,醫師應依循這些進行判斷。
  
  Loomba醫師指出,如果醫師遇到有三個以上代謝症候群特點且有糖尿病的患者,我幾乎可以篤定的說他們有非酒精性脂肪肝疾病,如果他們50歲以上,或許還可能有一點纖維化。
  
  所以,如果醫師遇到這類病患,他們必須自問:「我有忽略掉肝臟疾病嗎?」,並將患者轉介給肝臟科醫師評估。
  
  資料來源:http://www.24drs.com/
  
  Native link:Fatty-Liver Disease in More Than 60% of Patients With Type 2 Diabetes

Fatty-Liver Disease in More Than 60% of Patients With Type 2 Diabetes

By Pam Harrison
Medscape Medical News

Almost two-thirds of patients with type 2 diabetes in the primary-care setting have evidence of nonalcoholic fatty-liver disease (NAFLD) on noninvasive MRI, while over 7% of them have advanced fibrosis on magnetic-resonance elastrography, new research shows.

"Most patients have no idea that they have fatty-liver disease until they develop cirrhosis, and that's why it's a silent killer," senior author Rohit Loomba, MD, associate professor of clinical medicine, University of California, San Diego, told Medscape Medical News.

"But the beautiful thing about the liver is that it can regenerate, and many new therapies are in the pipeline for the treatment of NAFLD and NAFLD-related fibrosis," he stressed.

"So identification of these patients is key: we will be able to be able to stop progression of disease; we will be able to reverse cirrhosis and fibrosis with these new therapies, and we already are doing so in some patients."

Dr Loomba and colleagues also showed that patients with certain components of the metabolic syndrome, including greater waist circumference, dyslipidemia, and hypertension, were more likely to have NAFLD than those without.

So until the screening methods they used are better established, they suggest that doctors use these clinical signs to guide them on assessing diabetes patients for fatty-liver disease.

Assess Diabetes Patients Early for NAFLD

The study, which was published online September 15 in Alimentary Pharmacology and Therapeutics, was a cross-sectional analysis and involved 100 consecutive adult patients with type 2 diabetes. The mean body mass index (BMI) was 30.8 kg/m2, and the mean duration of diabetes was 8.5 years.

Within 30 days of their initial research visit, patients underwent MRI to estimate the hepatic proton-density fat fraction (MRI-PDFF) and magnetic-resonance elastrography to estimate hepatic stiffness.

As the authors observe, these two measures are accurate, precise, and validated noninvasive image-based biomarkers of NAFLD and advanced fibrosis, respectively.

NAFLD as assessed by MRI-PDFF ?5% was present in 65% of the group, and there were no technical failures. Advanced fibrosis, as reflected by a threshold magnetic-resonance elastrography stiffness?3.6kPa, was evident in 7.1% of the group.

The findings emphasize the importance of initiating concomitant NAFLD and advanced fibrosis screening in diabetics early, perhaps at the time of diabetes diagnosis, to prevent further liver damage, the investigators stress.

Interestingly, the prevalence of NAFLD decreased with advancing age while the prevalence of advanced fibrosis increased.

In patients under the age of 58, NAFLD was present in almost 79% of this subset of patients compared with about 68% of patients between the ages of 58 and 65. For patients over the age of 65, NAFLD was detected in approximately 47% of the cohort.

Conversely, advanced fibrosis was detected in 3% of those under the age of 58; and in approximately 6% of those between 58 and 65 years of age, and about 13% of those over the age of 65.

Inaccurate Markers; Look for Clinical Signs Such as Waist Circumference, Obesity

Dr Loomba and colleagues observe that many currently performed tests are inaccurate markers of NAFLD, including liver enzymes.

Abdominal ultrasound also lacks sensitivity for mild steatosis and has high inter- and intra-observer variability. Similarly, computed tomography has limited sensitivity for mild disease and requires exposure to radiation.

However, certain risk factors significantly increase the likelihood that patients with diabetes have NAFLD and are readily accessible clinically, they stress.

For example, patients with NAFLD in the current study were significantly younger than those without (P=.028) and had a higher mean BMI, at 32.5 kg/m2 compared with 27.6 kg/m2 for those without (P=.0008).

NAFLD patients also had lower HDL-cholesterol levels and higher triglyceride levels than those without NAFLD, and both fasting glucose and fasting insulin levels were significantly higher in those with fatty-liver disease than those without.

Mean waist circumference, at 106.6 cm for patients with NAFLD in the study vs 95.1 cm for those without, was also a significant predictor of NAFLD (P < .0001), as was metabolic syndrome, which was present in 84.6% of patients with NAFLD vs 40% of those without (P < .0001).

Tests Not Ready for Prime Time

Dr Loomba cautioned, however, that neither of the screening tests they employed is ready for prime time yet, as they need to show that MRI-PDFF and magnetic-resonance elastrography are both cost-effective on a population level.

Nevertheless, predictors of NAFLD progression include weight gain, hypertension, and other features of metabolic syndrome, so doctors should be guided by these.

"If physicians have a patient with three or four features of the metabolic syndrome and they are diabetic, I can almost guarantee you that they have NAFLD, and they probably have some sort of fibrosis too, especially if they are 50 years of age or older," Dr Loomba noted.

"So if physicians have patients like this, they need to be asking themselves: 'Am I missing liver disease here?' and refer them to a hepatologist for evaluation."

The authors have no relevant financial relationships.

Aliment Pharmacol Ther. Published online September 15, 2015.

    
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