糖化血红蛋白对中老年人群糖代谢异常的诊断价值研究

发布时间：2018-09-10 14:49

【摘要】：目的评价糖化血红蛋白(HbA1c)对中老年人群糖代谢异常的诊断价值。方法采用整群抽样对兰州市8871例既往无糖尿病(DM)病史的年龄在40-80岁的中老年人群进行问卷调查,测量身高、体重、腰围、臀围、血压,计算腰臀比、体重指数(BMI)；并测定HbA1c、空腹血糖(FBG)、餐后2h血糖(2hPG)、高密度脂蛋白(HDL-C)、低密度脂蛋白(LDL-C)、总胆固醇(CHOL)、甘油三酯(TG)。采用受试者工作特征(ROC)曲线,研究以OGTT为“金标准”时,HbA1c对中老年人群糖代谢异常的诊断价值。结果1.最终纳入的8296例研究人群,按照1999年WHO诊断DM的标准,糖耐量正常者(NGT)、糖尿病患者及糖调节受损(IGR)者分别为4391(52.9%)、1206(14.5%)、2699(32.5%)；1206例OGTT诊断的DM中,i-FPG、i-2hPG、FPG且2hPG的DM患者分别为232(2.8%)、569(6.9%)、405(4.9%)；2699例OGTT诊断的IGR中,i-IFG、i-IGT、IFG且IGT分别为423(5.1%)、1633(19.7%)、643(7.8%)。2.以ADA2010推荐HbAlc≥6.5%作为DM诊断,共检出941例DM患者,其诊断OGTT-DM一致性一般(k=0.465)。其诊断OGTT-DM的特异性为94.8%,敏感度仅为47.4%,阴性预测值是93.6%,阳性预测值是60.8%。而单独应用以FPG≥7.0mmol/L作为OGTT-DM诊断标准,其敏感性仅为52.8%,漏诊率达47.2%,其与OGTT-DM诊断的一致性一般(1k-=0.604)。3.以ADA推荐的]HbAlc≥5.7%作为DM的诊断,共检出5069例IGR患者,其诊断OGTT-IGR的敏感性和特异度分别为79.7%、37.5%,阴性性预测值44.0%,阳性预测值80.0%。单以FPG≥6.1mmol/L筛查OGTT-IGR,其敏感性仅为39.5%,漏诊率达60.5%。4.以OGTT为诊断DM金标准,通过绘制ROC曲线,HbAlc≥_6.2%和FPG≥6.1mmol/L为预测DM的最佳切点,相对应灵敏性为67.4% vs 78.4%,特异度为80.5% vs 85.0%,阳性预测值为37.0%vs 47.0%,阴性预测值93.6% vs 95.9%,曲线下面积0.808 vs 0.902. HbAlc可用于OGTT-DM的筛查,但筛查能力较FBG差。5.通过绘制ROC曲线,HbA1c≥6.0%和FPG5.6mmol/L分别为预测OGTT-IGR的最佳阈值,灵敏性、特异度分别为52.7% vs 66.8%、72.2% vs 80.7%,阳性预测值、阴性预测值和曲线下面积(AUC)分别为53.8% vs 65.3%、71.3% vs79.3%、0.664 vs 0.807。FPG筛查OGTT-IGR的效果好于HbA1c, HbA1c用于筛查IGR状态的能力差。6.当联合HbA1c≥6.2%或FPG≥6.1mmol/L筛查OGTT-DM,其联合敏感性为93.0%,漏诊率仅为7.0%,较单用其一时敏感性提高了14.6%～25.6%；当同时联合HbA1c≥6.2%+FPG≥6.1mmol/L诊断DM时,其联合特异度高达97.1%,发生误诊概率仅为2.9%,较单用一种方法时特异度升高了12.1%-16.6%；而同时联合HbA1c≥6.5%+FPG≥6.1mmol/L,其联合特异度高达99.1%,误诊率不到1%。7.当联合HbA1c≥6.0%或FPG≥5.6mmol/L筛查OGTT-IGR,其联合敏感性高达93.3%,较只用其中一种方法时敏感性提高了26.5%-41.2%；当联合HbA1c6.0%+FPG≥5.6mmol/L时,联合特异度高达94.6%,较单独应用其一时特异度提高13.9%～22.4%。8.男性人群HbA1c筛查DM的最佳切点大于女性(6.2% vs 6.1%)；50岁以上人群稍高于40-49岁人群(6.2% vs 6.1%)；HbA1c在DM的诊断上具有BMI特异性,随着BMI的增大,HbA1c诊断DM的最佳切点具有升高的趋势,且敏感性和特异性并未呈现下降的趋势。结论HbA1c可用于甘肃地区DM的筛查和诊断,HbA1c可能不适用于筛查IGT人群。无论是DM还是IGR的筛查及诊断,效果均不及FPG,说明中老年人群更适合以血糖作为DM及IGR的筛查及诊断。无论用HbA1c还是FPG,单独用于DM或IGT的筛查及诊断均有一定的漏诊率和误诊率,错过最佳治疗时期。联合应用HbA1c与FPG筛查DM及IGR能获得较高的灵敏度及特异度,明显减少漏诊率及误诊率,有效提高早期诊断效率。
[Abstract]:Objective To evaluate the diagnostic value of glycosylated hemoglobin (HbA1c) in the elderly and middle-aged people with abnormal glucose metabolism. HbA1c, FBG, 2hPG, HDL-C, LDL-C, CHOL, TG were determined. The diagnostic value of HbA1c in middle-aged and elderly people with OGTT as the "gold standard" was studied by ROC curve. According to the WHO diagnostic criteria of DM in 1999, the patients with normal glucose tolerance (NGT), diabetes mellitus and impaired glucose regulation (IGR) were 4391 (52.9%), 1206 (14.5%) and 2699 (32.5%) respectively, and the patients with DMs diagnosed by OGTT, i-FPG, i-2hPG, FPG and 2hPG, were 232 (2.8%), 569 (6.9%) and 405 (4.9%) respectively. IGT was 423 (5.1%), 1633 (19.7%) and 643 (7.8%) respectively. A total of 941 patients with DM were diagnosed as HbAlc (> 6.5%) recommended by ADA2010. The diagnostic consistency of OGTT-DM was general (k = 0.465). The specificity, sensitivity, negative predictive value and positive predictive value of OGTT-DM were 94.8%, 47.4%, 93.6% and 60.8% respectively. For the diagnosis criteria of OGTT-DM, the sensitivity was only 52.8%, the missed diagnosis rate was 47.2%, and the consistency with the diagnosis of OGTT-DM was general (1k-=0.604). 3. A total of 5069 patients with IGR were diagnosed with HbAlc (>5.7%) recommended by ADA. The sensitivity and specificity of diagnosis of OGTT-IGR were 79.7%, 37.5%, negative predictive value 44.0%, positive predictive value 80.0%. The sensitivity of screening OGTT-IGR with FPG (> 6.1 mmol/L) was only 39.5% and the missed diagnosis rate was 60.5%. 4. Using OGTT as the gold standard for diagnosis of DM, the best cut-off points for predicting DM were HbAlc (> 6.2%) and FPG (> 6.1 mmol/L) by drawing ROC curves. The relative sensitivity was 67.4% vs 78.4%, specificity 80.5% vs 85.0%, positive predictive value 37.0% vs 47.0%, and negative predictive value 93.6%. HbAlc can be used for OGTT-DM screening, but the screening ability is worse than FBG. 5. By drawing ROC curve, HbA1c (> 6.0%) and FPG (> 5.6 mmol/L) are the best thresholds for predicting OGTT-IGR. The sensitivity and specificity are 52.7% vs 66.8%, 72.2% vs 80.7%, positive predictive value, negative predictive value and area under curve (AUC) respectively. The combined sensitivity was 93.0% and the missed diagnosis rate was only 7.0% when combined with HbA1c (> 6.2%) or FPG (> 6.1 mmol/L) for screening OGTT-DM. When combined with HbA1c (>6.2%) and FPG (>6.1 mmol/L), the combined specificity was 97.1% and the probability of misdiagnosis was only 2.9%, which was 12.1% - 16.6% higher than that of single method, while combined with HbA1c (>6.5%) and FPG (>6.1 mmol/L), the combined specificity was 99.1% and the misdiagnosis rate was less than 1%. The combined sensitivity of TT-IGR was 93.3%, 26.5% - 41.2% higher than that of only one method; the combined specificity was 94.6% when combined with HbA1c 6.0% + FPG (> 5.6 mmol/L), 13.9% - 22.4% higher than that of single application. 8. The best cut-off point of HbA1c screening for DM in men was higher than that in women (6.2% vs 6.1%); and the combined specificity was 94.6% when combined with HbA1c 6.0% + FPG (> 5.6 mmol/L). HbA1c had BMI specificity in the diagnosis of DM. With the increase of BMI, the best cut-off point of HbA1c in the diagnosis of DM had an upward trend, and the sensitivity and specificity did not show a downward trend. Conclusion HbA1c can be used in the screening and diagnosis of DM in Gansu Province, and HbA1c may not be suitable for the screening of IGT population. The screening and diagnosis of DM and IGR were less effective than that of FPG, indicating that blood glucose is more suitable for screening and diagnosis of DM and IGR in middle-aged and elderly people. High sensitivity and specificity can significantly reduce missed diagnosis rate and misdiagnosis rate, and improve early diagnosis efficiency.
【学位授予单位】：兰州大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R587.1

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