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摘要：
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摘要：目的 探讨稳态模型评估胰岛素抵抗指数（homeostasis model assessment of insulin
resistance，HOMA-IR）及γ-谷氨酰转移酶（γ-glutamyl transferase，GGT）对代谢相关
脂肪性肝病（metabolic associated fatty liver disease，MASLD）合并2型糖尿病患者进展
至肝硬化的预测价值。方法 选取2017年1月1日至2018年3月31日在新疆医科大学第一附
属医院就诊的161例MASLD合并2型糖尿病患者为研究对象。记录患者基线指标，包括
丙氨酸氨基转移酶（alanine aminotransferase，ALT）、天冬氨酸氨基转移酶（aspartate
aminotransferase，AST）、GGT、白蛋白、甘油三酯（triglyceride，TG）、总胆固醇
（total cholesterol，TC）、高密度脂蛋白胆固醇（high-density lipoprotein cholesterol，
HDL-C）、低密度脂蛋白胆固醇（low density lipoprotein cholesterol，LDL-C）、空腹
血糖、空腹胰岛素水平、C反应蛋白（C-reactive protein，CRP）等。计算HOMA-IR，
HOMA-IR = 空腹血糖水平 × 空腹胰岛素 / 22.5。采用瞬时弹性成像技术检测患者肝脏
硬度及受控衰减参数（controlled attenuation parameter，CAP）。根据患者随访5年发生
肝硬化情况分为非肝硬化组（126例）和肝硬化组（35例），采用Cox回归分析MASLD
合并2型糖尿病患者随访5年进展至肝硬化的影响因素并构建Cox风险得分模型，绘制
预测MASLD合并2型糖尿病患者进展至肝硬化的受试者工作特征（receiver operating
characteristic，ROC）曲线和决策曲线，分析独立预测因素的净收益率。结果 随访5年，
161例患者中共35例进展至肝硬化，发生率为21.7%（35/161）。多因素Cox回归分析表
明，有吸烟史（HR = 2.074，95%CI：1.238～3.647，P = 0.023）、GGT（HR = 2.675，
95%CI：1.249～3.789，P = 0.009）及HOMA-IR（HR = 2.179，95%CI：1.348～5.896，
P = 0.011）为MASLD合并2型糖尿病患者随访5年进展至肝硬化的独立危险因素。吸
烟史、GGT、HOMA-IR单独及联合预测MASLD合并2型糖尿病患者进展至肝硬化风
险的ROC曲线下面积分别为0.770（95%CI：0.659～0.881）、0.800（95%CI：0.698～
0. 902）、0.741（95%CI：0.623～0. 860）及0.924（95%CI：0.861～0.986）。决策曲
线分析显示，吸烟史、GGT以及HOMA-IR预测MASLD合并2型糖尿病进展至肝硬化均
具有良好的净收益率。Cox风险得分模型得分 = 0.723 × 吸烟（是= 1，否= 0）+ 0.996 ×
GGT（U/L）+ 0.837 × HOMA-IR － 18.775，其最佳诊断截点为1.46，MASLD合并2型糖
尿病患者Cox风险得分越高，其进展至肝硬化的时间越短，GGT及HOMA-IR自低危组向
高危组呈现由低表达向高表达的趋势。结论 HOMA-IR及GGT用于预测MASLD合并2型
糖尿病患者进展至肝硬化具有较高的净收益率。
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Abstract: Objective To investigate the predictive value of the homeostasis model assessment of
insulin resistance (HOMA-IR) and γ-glutamyl transferase (GGT) on the progression to liver cirrhosis
in metabolic associated fatty liver disease (MASLD) patients with type 2 diabetes mellitus (T2DM).
Methods Total of 161 patients with MASLD and type 2 diabetes mellitus who were admitted to
the First Affiliated Hospital of Xinjiang Medical University from January 1st, 2017 to March 31st,
2018 were selected. Baseline indicators were recorded, including alanine aminotransferase (ALT),
aspartate aminotransferase (AST), GGT, albumin, triglyceride (TG), total cholesterol (TC), highdensity
lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), fasting blood
glucose, fasting insulin levels and C-reactive protein (CRP). HOMA-IR was calculated as follows:
HOMA-IR = fasting blood glucose level × fasting insulin / 22.5. Liver stiffness and controlled
attenuation parameter (CAP) were measured using transient elastography. Patients were divided
into non-cirrhosis group (126 cases) and cirrhosis group (35 cases) according to the occurrence of
cirrhosis within the 5-year follow-up period. Cox regression analysis was used to identify factors
influencing the progression to cirrhosis within 5 years and to construct a Cox risk score model.
Receiver operating characteristic (ROC) curve and decision curve were plotted to assess the net
benefit rate of the independent predictive factors. Results Over the 5-year follow-up, 35 out of
161 patients progressed to liver cirrhosis, with an incidence rate of 21.7% (35/161). Multivariate
Cox regression analysis showed that smoking history (HR = 2.074, 95%CI: 1.238～3.647, P =
0.023), GGT level (HR = 2.675, 95%CI: 1.249～3.789, P = 0.009) and HOMA-IR (HR = 2.179,
95%CI: 1.348～5.896, P = 0.011) were independent risk factors for progression to liver cirrhosis
within 5 years in patients with MASLD and type 2 diabetes mellitus. The areas under the ROC
curve of smoking history, GGT, HOMA-IR alone and combined for predicting progression to liver
cirrhosis in patients with MASLD and type 2 diabetes mellitus were 0.770 (95%CI: 0.659～0.881),
0.800 (95%CI: 0.698～0. 902), 0.741 (95%CI: 0.623～0. 860) and 0.924 (95%CI: 0.861～0.986),
respectively. Decision curve analysis showed that smoking history, GGT and HOMA-IR all had
good net benefit rates in predicting the progression of MASLD complicated with type 2 diabetes
mellitus to liver cirrhosis. The Cox risk score model was defined as: score = 0.723 × smoking (yes =
1, no = 0) + 0.996 × GGT (U/L) + 0.837 × HOMA-IR － 18.775. The optimal diagnostic cutoff
value was 1.46. Higher Cox risk scores in patients with MASLD and type 2 diabetes mellitus
were associated with shorter cirrhosis-free survival time. GGT and HOMA-IR showed a trend of
increasing expression from the low-risk group to the high-risk group. Conclusion HOMA-IR and
GGT have a high net benefit rate for predicting the progression to cirrhosis in patients with MASLD
complicated with type 2 diabetes mellitus.
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