湖北汉族人2型糖尿病与代谢综合症的遗传流行病学研究
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摘要
代谢综合症(Metabolic syndrome,MetS)是当今世界最重要的健康问题之一,包括腹部肥胖、高血压、高血糖和血脂异常等一系列心血管危险因素。不同种族代谢综合症的发病率差异很大。2型糖尿病(Type 2 diabetes,T2D)是一种慢性复杂多基因疾病,受遗传因素和环境因子及其互作的影响,其主要特征是胰岛素抵抗(Insulin resistance,IR)或β胰岛细胞分泌胰岛素不足导致高血糖。ENPP1/PC-1是IR、肥胖和T2D的候选基因之一。四个亚洲人群的全基因组关联研究(GWAS)报道KCNQ1基因多态性与T2D相关联。五个分别对欧洲白人和亚洲人的GWAS分析鉴定CDKAL1基因是T2D的易感基因。不同种族KCNQ1/CDKAL1多态性与T2D的关联研究结果不尽一致。本研究的目的:1)调查MetS.IR和T2D在中国湖北人群中的发病率及其相关性。2)采用病例-对照研究和Meta分析的方法,探讨湖北汉族人群ENPP1、KCNQ1和CDKAL1多态与T2D的遗传关联。
     材料和方法
     研究对象:流行病学调查在湖北宜昌的三个乡镇进行。共调查9877人,其中男4171人,女5706人,年龄23-90岁。MetS分别采用APWP-NAFLD、NCEP-ATPⅢ和IDF标准定义;采用稳态模型IR指数(HOMA-IR)及定量胰岛素敏感性指标(QUICKI)评价了8609人(男3598,女5011)的胰岛素抵性。T2D病例采用1999世界卫生组织亚洲诊断标准,高血压和肥胖按照2004世界卫生组织诊断标准定义。
     表型分析:检测的临床指标包括体重、身高、腰臀围、空腹血糖(FBG)、餐后血糖(PBG)、收缩压(SBP)、舒张压(DBP)、总胆固醇、甘油三酸酯、高密度脂蛋白(HDL-C)、低密度脂蛋白(LDL-C)、空腹胰岛素、体重指数(BMI)和腰臀围(WHR)。
     基因分型:采用PCR-RFLP方法,对646个研究对象(高血糖343人,非高血糖303人)ENPP1基因K121Q位点进行了基因分型;采用荧光定量PCR方法,对424个研究对象(T2D组223人,对照组201人)的KCNQ1基因SNP rs2237892位点进行了基因分型。
     统计分析:所有的统计分析利用SPSS11.5软件完成。采用t检验和ANOVA分析连续变量,组间不同变量的差异采用X2检验分析。Pearson's相关系数r用来衡量IR (HOMA-IR和QUICKI)与MetS之间的相关性。多元线性回归用来分析IR指数与MetS成分之间的相关性。T2D和对照组的基因型频率分别用Hardy-Weinberg平衡检验。基因型关联分析用logistic回归分析检验。以P<0.05为差异显著。
     Meta-分析:用stata 10.0软件分析各研究之间的异质性,如果有异质性,采用随机效应模型计算OR值;如果没有异质性,采用固定效应模型计算OR值,用egg's回归分析检测发表偏倚。
     结果
     1.整个人群中MetS的患病率是17.9%-15.8%,其中女性(20.1%-18.9%)显著高于男性(15.0%-11.5%)(p<0.001)。MetS最常见的成分是高血压(50.7%)、高空腹血糖(28.6%)、高甘油三脂(25.6%)和BMI>25(22.1%)。APWP-NAFLD和亚洲NCEP-ATPⅢ有很好的一致性(κ=0.891)。APWP-NAFLD、亚洲NCEP-ATPⅢ和IDF一致性也良好(k=0.642、0.739)。
     2.根据HOMA-IR(>2.7)的定义IR的患病率为15.8%,女性明显高于男性(16.7% vs.14.7%、p--0.014),而根据QUICKI(<0.33)的定义IR的患病率为12.9%,男性(12.1%)和女性(13.4%)没有差异,HOMA-IR和QUICKI之间有很好的相关性(k=0.879)。IR与代谢综合症的所有成分显著相关,多元线性回归分析显示IR与体重指数、腰围、高密度脂蛋白胆固醇、甘油三酯和高FBG相关。
     3.T2D和糖尿病前期患病率分别为2.9%(男性3.0%,女性2.8%)和6.9%(男性7.2%,女性6.8%),低于最近杨等(2010)在中国14个省市代表性样本的数据,T2D和糖尿病前期患病率随着年龄和BMI增加而增加。
     4.高血糖组ENPP1 K121Q等位基因频率比正常葡萄糖禁食组要高(10.5% vs.6.6%,p=0.013),K121Q多态与高血糖在调整年龄、性别和BMI前后均显著相关(p值分别为0.018和0.014),K121Q多态与T2D在调整年龄、性别和BMI前后也弱相关(p值分别为0.046和0.038)。不同性别的亚组分析表明XQ基因型和Q等位基因仅在女性组与T2D显著相关(XQ:OR=2.16,p=0.019;Q:OR=2.11,p=0.018),揭示湖北汉人ENPP1 K121Q多态与T2D的关联存在性别差异。
     5.在T2D病例中KCNQ1 rs2237892的C等位基因频率比对照组要高(p=0.001),等位基因C的OR值为1.65,无论是否调整年龄、性别和BMI, CC和CC+CT基因型都与T2D相关联。对15个东亚研究进行Meta分析,KCNQ1基因的多个单核苷酸多态性和T2D相关联,其中rs2237892 C, rs2237895 C, rs2237897 C和rs2074196 G的OR值分别为1.35(p<0.0001),1.27(p<0.0001),1.32(p<0.0001)和1.3(p<0.0001)。
     6.对30个符合要求的CDKAL1和T2D关联研究进行全面的Meta分析,证实CDKAL1基因与T2D相关联,rs7756992 G,rs7754840 C和rs10946398 C的OR值分别为1.15(p<0.0001),1.15 p<0.0001)和114(p<0.0001)。
     结论
     中国湖北汉人MetS发病率为17.90%-15.8%,并且女性高于男性。IR与MetS及其组分相关(15.8%-12.9%),特别是肥胖、低的高密度脂蛋白和高PBG。T2D和糖尿病前期的发病率较低,分别为2.9%和6.9%,并且随着年龄和BMI升高而升高,女性对MetS和IR更易感。
     湖北汉人特别是女性ENPP1 K121Q与高血糖易感性显著相关,有利于T2D的发展。在中国汉人和东亚人群中,KCNQ1多态与T2D相关。CDKAL多态也与T2D相关。
Metabolic syndrome (MetS) is one of the fastest growing health problems worldwide, characterized by a clustering of cardiovascular risk factors including abdominal obesity, high blood pressure, high glucose concentration, and dyslipidemia. Type 2 diabetes (T2D) is a chronic and complex, polygenic disease influenced by interaction between genetic and environmental factors. It is characterized by hyperglycemia due to insulin resistance (IR) and/or impaired insulin secretion in the pancreaticβcells. ENPP1 has been suggested as a candidate gene for IR, obesity and T2D. Recently four genome-wide association studies (GWAS) in East Asian populations reported the association of KCNQ1 variants with T2D. CDKAL1 was identified as a susceptibility gene for T2D through five subsequent GWAS in white Europeans and Asians. Several replication studies have been conducted for association between KCNQ1/CDKAL1 variants and T2D in multiple ethnic groups, but contradictory results have been reported. The aims of this study are:1) to investigate the prevalence of metabolic syndrome, insulin resistance, type 2 diabetes and to evaluate the association of insulin resistance with metabolic syndrome components in the Hubei Han Chinese population; 2) to investigate the association of polymorphisms in ENPP1, KCNQ1 and CDKAL1 with type 2 diabetes through Hubei Han Chinese case-control studies and meta-analysis.
     Material and methods
     Subjects:Epidemiological study was conducted in 3 towns in Yichang, Hubei Province. A total of 9877 subjects (4171 men and 5706 women) aged 23-90 years were recruited. MetS was defined according to the APWP-NAFLD, modified (Asian) NCEP-ATPⅢand IDF criteria. IR was assessed for 8609 subjects (3598 men and 5011 women) by both homeostasis model assessment for IR (HOMA-IR) and quantitative insulin check index (QUICKI). All T2D cases were defined according to the 1999 World Health Organization diagnostic criteria. Hypertension and obesity were defined according to the 2004 World Health Organization recommended criteria for Asians.
     Phenotyping:Clinical parameters measured and calculated for all subjects using standard methods included weight, height, waist and hip circumference, fasting blood glucose (FBG), postprandial blood glucose (PBG), systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol, triglyceride, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), fasting insulin, Body mass index (BMI) and waist to hip ratio (WHR).
     Genotyping:A total of 646 subjects (343 hyperglycaemic and 303 normoglycaemic subjects) were genotyped for ENPP1 K121Q using the PCR-RFLP method. Four hundred and twenty four subjects (223 T2D cases and 201 controls) were genotyped for KCNQ1 rs2237892 using the fluorescence quantitative real-time PCR SNP method.
     Statistical analysis:All statistical analyses were conducted using SPSS software (version 11.5) for Windows. The continuous variables were analysed by Student's t-test and ANOVA tests. The differences between groups for categorical variables were detected by theχ2 test. Pearson's correlation coefficient (r) was applied to investigate the correlation between IR indexes (HOMA-IR and QUICKI) and MetS components. Multivariate linear regression was applied to investigate the association between IR indexes and MetS components. The genotype frequencies in the T2D cases and controls were separately tested for Hardy-Weinberg equilibrium using theχ2 test before association analysis. The genotype-disease association analyses were performed by logistic regression analysis. Two-tailed p-values was considered to be statistically significant when p<0.05.
     Meta-analysis:Stata 10.0 software was used to evaluate the heterogeneity between studies. Pooled ORs were calculated using a random or fixed effects model according to the presence or absence the heterogeneity between studies, respectively. The conservative Egger's regression analysis was used to evaluate publication bias.
     Results
     1. The overall prevalence of MetS was 17.9%-15.8%, with a significantly higher rate among women (20.1%-18.9%) than men (15.0%-11.5%) (p<0.001). The most frequent components of MetS were high blood pressure (50.7%), high FBG (28.6%), high triglyceride (25.6%) and BMI>25 (22.1%). Very good agreement (κ=0.891) was observed between APWP-NAFLD and modified (Asia) NCEP-ATPⅢdefinitions. The agreement among APWP-NAFLD or modified (Asia) NCEP-ATPⅢand IDF definitions was substantial (κ=0.642,0.739, respectively).
     2. The overall prevalence of IR according to HOMA-IR (>2.7) definition was 15.8% with a significantly higher prevalence among women than men (16.7% vs. 14.7%,p=0.014). However, the prevalence of IR according to QUICKI definition (<0.33) was 12.9% with no difference between men (12.1%) and women (13.4%). Very good agreement (κ=0.879) between HOMA-IR and QUICKI definitions was observed. A significant correlation was found between IR and all MetS components. Multivariate linear regression analysis revealed that the BMI, waist circumference, low HDL-C, triglyceride and high FBG were significantly associated with IR.
     3. The overall prevalence of T2D and pre-diabetes were 2.9%(men 3.0% and women 2.8%) and 6.9%(men 7.2% and women 6.8%) respectively, being lower compared with Yang's report (2010) in a nationally representative sample from 14 Chinese provinces and municipalities. The prevalence rates of T2D and pre-diabetes were consistently increased with age and BMI.
     4. The K121Q polymorphism was associated with hyperglycaemia/T2D without and with adjustment for age, sex and BMI (for hyperglycaemia,p=0.018, and 0.014; for T2D,p=0.046 and 0.038, respectively). The stratified analysis results showed that the XQ genotype and Q allele were significantly associated with the T2D risk only in women subgroup (XQ:OR=2.16,p=0.019; Q:OR=2.11, p=0.018), suggesting sex-specific association of ENPP1 K121Q polymorphism with T2D in our study population.
     5. The frequency of C allele of KCNQ1 rs2237892 polymorphism in T2D cases was higher than those of controls group (p=0.001). The odds ratio for the risk allele C was 1.65. The CC and CC+CT genotypes were associated with T2D without and with adjustment for age, sex and BMI. A meta-analysis of fifteen East Asian studies of association between SNPs in KCNQ1 and T2D revealed that combined odds ratios of the rs2237892 C, rs2237895 C, rs2237897 C, rs2074196 G allele were 1.35 (p<0.0001),1.27 (p<0.0001),1.32 (p<0.0001),1.3 (p<0.0001) respectively.
     6. A global meta-analysis of thirty eligible association studies of CDKAL1 polymorphisms with T2D revealed that combined odds ratios for rs7756992 G, rs7754840 C and rs 10946398 C allele in CDKAL1 were 1.15 (p<0.0001),1.15 (p<0.0001), and 1.14 (p<0.0001) respectively.
     Conclusions
     The prevalence of MetS in Hubei Han Chinese was 17.9%-15.8%, being higher in women than in men. The prevalence of IR (15.8%-12.9%) was associated with MetS and its components, especially with obesity, low HDL-C and high PBG. The prevalence of T2D and pre-diabetes were lower (2.9%,6.9%), increasing with age and BMI. Hubei Han Chinese women were more susceptible to MetS and IR.
     The ENPP1 K121Q was significantly associated with the susceptibility for hyperglycaemia and may contribute to the development of T2D in Hubei Han Chinese, especially in women subjects. The KCNQ1 polymorphisms were associated with T2D in Han Chinese and East Asian populations. CDKAL polymorphisms were associated with T2D in global and stratified meta-analysis.
引文
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