【摘要】：目的評(píng)價(jià)糖化血紅蛋白(HbA1c)對(duì)中老年人群糖代謝異常的診斷價(jià)值。方法采用整群抽樣對(duì)蘭州市8871例既往無糖尿病(DM)病史的年齡在40-80歲的中老年人群進(jìn)行問卷調(diào)查,測(cè)量身高、體重、腰圍、臀圍、血壓,計(jì)算腰臀比、體重指數(shù)(BMI)；并測(cè)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)、總膽固醇(CHOL)、甘油三酯(TG)。采用受試者工作特征(ROC)曲線,研究以O(shè)GTT為“金標(biāo)準(zhǔn)”時(shí),HbA1c對(duì)中老年人群糖代謝異常的診斷價(jià)值。結(jié)果1.最終納入的8296例研究人群,按照1999年WHO診斷DM的標(biāo)準(zhǔn),糖耐量正常者(NGT)、糖尿病患者及糖調(diào)節(jié)受損(IGR)者分別為4391(52.9%)、1206(14.5%)、2699(32.5%)；1206例OGTT診斷的DM中,i-FPG、i-2hPG、FPG且2hPG的DM患者分別為232(2.8%)、569(6.9%)、405(4.9%)；2699例OGTT診斷的IGR中,i-IFG、i-IGT、IFG且IGT分別為423(5.1%)、1633(19.7%)、643(7.8%)。2.以ADA2010推薦HbAlc≥6.5%作為DM診斷,共檢出941例DM患者,其診斷OGTT-DM一致性一般(k=0.465)。其診斷OGTT-DM的特異性為94.8%,敏感度僅為47.4%,陰性預(yù)測(cè)值是93.6%,陽性預(yù)測(cè)值是60.8%。而單獨(dú)應(yīng)用以FPG≥7.0mmol/L作為OGTT-DM診斷標(biāo)準(zhǔn),其敏感性僅為52.8%,漏診率達(dá)47.2%,其與OGTT-DM診斷的一致性一般(1k-=0.604)。3.以ADA推薦的]HbAlc≥5.7%作為DM的診斷,共檢出5069例IGR患者,其診斷OGTT-IGR的敏感性和特異度分別為79.7%、37.5%,陰性性預(yù)測(cè)值44.0%,陽性預(yù)測(cè)值80.0%。單以FPG≥6.1mmol/L篩查OGTT-IGR,其敏感性僅為39.5%,漏診率達(dá)60.5%。4.以O(shè)GTT為診斷DM金標(biāo)準(zhǔn),通過繪制ROC曲線,HbAlc≥_6.2%和FPG≥6.1mmol/L為預(yù)測(cè)DM的最佳切點(diǎn),相對(duì)應(yīng)靈敏性為67.4% vs 78.4%,特異度為80.5% vs 85.0%,陽性預(yù)測(cè)值為37.0%vs 47.0%,陰性預(yù)測(cè)值93.6% vs 95.9%,曲線下面積0.808 vs 0.902. HbAlc可用于OGTT-DM的篩查,但篩查能力較FBG差。5.通過繪制ROC曲線,HbA1c≥6.0%和FPG5.6mmol/L分別為預(yù)測(cè)OGTT-IGR的最佳閾值,靈敏性、特異度分別為52.7% vs 66.8%、72.2% vs 80.7%,陽性預(yù)測(cè)值、陰性預(yù)測(cè)值和曲線下面積(AUC)分別為53.8% vs 65.3%、71.3% vs79.3%、0.664 vs 0.807。FPG篩查OGTT-IGR的效果好于HbA1c, HbA1c用于篩查IGR狀態(tài)的能力差。6.當(dāng)聯(lián)合HbA1c≥6.2%或FPG≥6.1mmol/L篩查OGTT-DM,其聯(lián)合敏感性為93.0%,漏診率僅為7.0%,較單用其一時(shí)敏感性提高了14.6%～25.6%；當(dāng)同時(shí)聯(lián)合HbA1c≥6.2%+FPG≥6.1mmol/L診斷DM時(shí),其聯(lián)合特異度高達(dá)97.1%,發(fā)生誤診概率僅為2.9%,較單用一種方法時(shí)特異度升高了12.1%-16.6%；而同時(shí)聯(lián)合HbA1c≥6.5%+FPG≥6.1mmol/L,其聯(lián)合特異度高達(dá)99.1%,誤診率不到1%。7.當(dāng)聯(lián)合HbA1c≥6.0%或FPG≥5.6mmol/L篩查OGTT-IGR,其聯(lián)合敏感性高達(dá)93.3%,較只用其中一種方法時(shí)敏感性提高了26.5%-41.2%；當(dāng)聯(lián)合HbA1c6.0%+FPG≥5.6mmol/L時(shí),聯(lián)合特異度高達(dá)94.6%,較單獨(dú)應(yīng)用其一時(shí)特異度提高13.9%～22.4%。8.男性人群HbA1c篩查DM的最佳切點(diǎn)大于女性(6.2% vs 6.1%)；50歲以上人群稍高于40-49歲人群(6.2% vs 6.1%)；HbA1c在DM的診斷上具有BMI特異性,隨著BMI的增大,HbA1c診斷DM的最佳切點(diǎn)具有升高的趨勢(shì),且敏感性和特異性并未呈現(xiàn)下降的趨勢(shì)。結(jié)論HbA1c可用于甘肅地區(qū)DM的篩查和診斷,HbA1c可能不適用于篩查IGT人群。無論是DM還是IGR的篩查及診斷,效果均不及FPG,說明中老年人群更適合以血糖作為DM及IGR的篩查及診斷。無論用HbA1c還是FPG,單獨(dú)用于DM或IGT的篩查及診斷均有一定的漏診率和誤診率,錯(cuò)過最佳治療時(shí)期。聯(lián)合應(yīng)用HbA1c與FPG篩查DM及IGR能獲得較高的靈敏度及特異度,明顯減少漏診率及誤診率,有效提高早期診斷效率。
[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.
【學(xué)位授予單位】：蘭州大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類號(hào)】：R587.1

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