The ZJU index: a useful indicator for recognizing insulin resistance in the Chinese general population

Assessment of the clinical value of five noninvasive predictors of metabolic dysfunction-associated steatotic liver disease in Han Chinese adults

BACKGROUND

Fatty Liver Index (FLI), Triglyceride-Glucose Index (TyG), Lipid Accumulation Product (LAP), Zhejiang University Index (ZJU), and Visceral Adiposity Index (VAI) are five classical predictive models for fatty liver disease. Our cross-sectional study aimed to identify the optimal predictors by comparing the predictive value of five models for metabolic dysfunction-associated steatotic liver disease (MASLD) risk.

METHODS

Data on 2687 participants were collected from West China Hospital of Sichuan University. Controlled attenuation parameters assessed by transient elastography were used to effectively diagnose MASLD. Logistic regression analysis was used to estimate the odd ratios and 95% confidence intervals between indices and MASLD risk. Receiver operating characteristic curves were plotted to evaluate the predictive value of indices.

RESULTS

This study included 1337 normal and 1350 MASLD samples. The average age of MASLD patients is 47 years old, and the prevalence was higher in males (39.3%) than in females (10.9%). Five indices were positively correlated with MASLD risk, with the strongest correlation for TyG. Overall, the area under the curve of the indicators was: ZJU 0.988, FLI 0.987, LAP 0.982, TyG 0.942, and VAI 0.941. In the gender stratification, ZJU (0.989) performed best in males. FLI (0.988) and ZJU (0.987) had similar predictive ability in females. In the age stratification, FLI performed better in predicting the middle-aged group aged 30-40 years (0.991).

CONCLUSION

For Chinese Han adults, ZJU is the best predictive index for initial screening of MASLD. FLI can serve as an alternative tool for ZJU to predict females.

Association between the ZJU index and risk of new-onset non-alcoholic fatty liver disease in non-obese participants: a Chinese longitudinal prospective cohort study

Background

Non-alcoholic fatty liver disease (NAFLD) is increasingly observed in non-obese individuals. The ZJU (Zhejiang University) index has been established as a new and efficient tool for detecting NAFLD, but the relationship between the ZJU index and NAFLD within non-obese individuals still remains unclear.

Methods

A post-hoc evaluation was undertaken using data from a health assessment database by the Wenzhou Medical Center. The participants were divided into four groups based on the quartile of the ZJU Index. Cox proportional hazards regression, Kaplan-Meier analysis and tests for linear trends were used to evaluate the relationship between the ZJU index and NAFLD incidence. Subgroup analysis was conducted to test the consistency of the correlation between ZJU and NAFLD in subsgroups. Receiver operative characteristic (ROC) curve analysis was performed to evaluate the predictive performance of the ZJU index, compared with the Atherogenic index of plasma (AIP) and Remnant lipoprotein cholesterol (RLP-C) index.

Results

A total of 12,127 were included in this study, and 2,147 participants (17.7%) developed NAFLD in 5 years follow-up. Participants in higher ZJU quartiles tended to be female and have higher liver enzymes (including ALP, GGT, ALT, AST), GLU, TC, TG, LDL and higher NAFLD risk. Hazard Ratios (HR) and 95% confidence intervals (CI) for new-onset NAFLD in Q2, Q3, and Q4 were 3.67(2.43 to 5.55), 9.82(6.67 to 14.45), and 21.67(14.82 to 31.69) respectively in the fully adjusted model 3. With increased ZJU index, the cumulative new-onset NAFLD gradually increased. Significant linear associations were observed between the ZJU index and new-onset NAFLD (p for trend all<0.001). In the subgroup analysis, we noted a significant interaction in sex, with HRs of 3.27 (2.81, 3.80) in female and 2.41 (2.21, 2.63) in male (P for interaction<0.01). The ZJU index outperformed other indices with an area under the curve (AUC) of 0.823, followed by AIP (AUC=0.747) and RLP-C (AUC=0.668).

Conclusion

The ZJU index emerges as a promising tool for predicting NAFLD risk in non-obese individuals, outperforming other existing parameters including AIP and RLP-C. This could potentially aid in early detection and intervention in this specific demographic.

Validation of non-invasive indicators in the screening of metabolic dysfunction-associated fatty liver disease: a cross-sectional study among Uighurs in rural Xinjiang

BACKGROUND

Metabolic dysfunction-associated fatty liver disease (MAFLD) is the most common chronic liver disease in China. Our study aimed to evaluate the screening value of the fatty liver index (FLI), hepatic steatosis index (HSI), lipid accumulation product (LAP), visceral adiposity index (VAI), and Zhejiang University index (ZJU), as well as other single indicators for MAFLD. We aimed to find the optimal screening tool and its appropriate cut-off values for rural Uyghur adults.

METHODS

We completed a survey of 14,321 Uyghur adults in 51 groups in Kashgar, Xinjiang, in 2016 using a typical sampling method, with 12,794 patients ultimately included in statistical analyses. Fatty liver was diagnosed using ultrasonography.

RESULTS

The prevalence of fatty liver disease (FLD) and MAFLD was 16.73% and 16.55%, respectively, and the FLI, HSI, LAP, VAI, and ZJU were all independently associated with an increased risk of MAFLD. The areas under the receiver operating characteristic curves (AUCs) of the FLI for diagnosing MAFLD in men and women were 0.853 and 0.847, respectively. The AUCs of the body mass index (BMI) for diagnosing MAFLD in men and women were 0.850 and 0.852, respectively. Compared with other metabolic-related markers, FLI had the largest AUC. In men, the optimal cut-off values of FLI and BMI for diagnosing MAFLD were 45 (sensitivity 84.83%, specificity 69.57%) and 27.4 (sensitivity 78.47%, specificity 76.30%), respectively. In women, the optimal cut-off values of FLI and BMI for diagnosing MAFLD were 45 (sensitivity 80.11%, specificity 74.23%) and 28.0 (sensitivity 79.56%, specificity 75.41%), respectively. In men and women, an FLI score of < 30 ruled out MAFLD, while a score of ≥ 50 was a basis for diagnosis.

CONCLUSION

FLI and BMI had good screening ability for MAFLD and were superior to HSI, LAP, VAI, and ZJU in both sexes.

The ZJU index is associated with the risk of obstructive sleep apnea syndrome in Chinese middle-aged and older people: a cross-sectional study

BACKGROUND

The ZJU index, a novel calculation that combines body mass index, triglycerides, fasting blood glucose and the ratio of alanine aminotransferase to aspartate aminotransferase, is a closely related measure of obesity and insulin resistance. Studies of the ZJU index in relation to obstructive sleep apnea syndrome (OSAS) have not been reported. This study assessed the correlation between the ZJU values and OSAS risk.

METHODS

A total of 2,130 participants who underwent polysomnographic monitoring were included in the study. The participants' basic information and laboratory biochemical indicators were collected, and the ZJU index was computed. The ZJU index was divided into quartiles. The correlation between the different ZJU index levels and OSAS risk was assessed using logistic regression. Drew a receiver operating characteristic (ROC) relationship curve, with prediction efficacy judged by the area under the curve (AUC), and found the optimum cut-off point for ZJU index to predict OSAS. Relative risks were presented as odds ratios (OR). The range of OR values is expressed in the form of 95% confidence intervals (95% CI).

RESULTS

The number of patients diagnosed with OSAS increased progressively with increasing ZJU index (T1: 9.4%; T2: 20.6%; T3: 28.3%; T4: 41.7%; P < 0.001). The additional confounders were adjusted by the logistic regression models, the study revealed an independent correlation between ZJU index and OSAS. (P < 0.001). The OSAS risk was notably higher at the highest ZJU index levels. (OR = 2.046 [95% CI: 1.057 to 3.964]). The ROC curve for the ZJU index showed an AUC of 0.64 (P < 0.001) for males and 0.75 (P < 0.001) for females, with a specificity of 64% and 55% and a sensitivity of 60% and 92% for males and females, respectively, with the optimum cut-off values of 36.568 and 34.722, respectively.

CONCLUSION

A high ZJU index was significantly associated with an increasing risk of OSAS. The ZJU is expected to be a meaningful index for detecting OSAS in the general population.

Dose-response association of the ZJU index and fatty liver disease risk: A large cohort in China

AIM

The aim of this study is to investigate the sex-specific association between the ZJU index and risk of fatty liver disease in a large Chinese cohort.

METHODS

A total of 28 729 adults without fatty liver disease at baseline and who completed at least one follow-up of annual examinations between 2009 and 2016 were included in this study. The Cox proportional hazards model was used to estimate hazard ratios (HRs) and 95% confidence intervals (CI) for fatty liver disease risk associated with the ZJU index.

RESULTS

During a median follow-up of 3.01 years, 7373 developed fatty liver disease. There were significant associations between the ZJU index and fatty liver disease for women and men with increasing HRs as the quartiles increase across Q2-Q4, corresponding HRs (95% CIs) in M3 were 2.28 (1.98-2.64), 3.52 (3.07-4.04), and 4.87 (4.24-5.59) for women and 2.44 (2.17-2.75), 4.18 (3.73-4.68), and 6.23 (5.56-6.98) for men. The association between the ZJU index and fatty liver disease risk remained significant in all the subgroups except that of T2DM and abdominal obesity subgroups for men. However, the association became nonsignificant when comparing Q3 and Q2 of the ZJU index with reference in the subgroups of T2DM for men, and nonsignificant when comparing Q3 of the ZJU index with reference in the subgroups of participants with T2DM and abdominal obesity for women.

CONCLUSION

The ZJU index was significantly associated with the risk of fatty liver disease in Chinese population. It will be better to keep body mass index, alanine aminotransferase, aspartate aminotransferase, triglyceride, and fasting plasma glucose at a normal level for preventing fatty liver disease.

Risk for the development of non-alcoholic fatty liver disease: A prospective study

BACKGROUND AND AIM

Non-invasive assessment was widely used to identify the risk of non-alcoholic fatty liver disease (NAFLD) among individuals with increased metabolic risks. This study aimed to investigate the prospective relationship between ZJU index and the development of NAFLD in a Chinese population.

METHODS

A cohort of 6310 initially NAFLD-free participants was enrolled in this prospective study. Abdominal ultrasound was used to diagnosis NAFLD. NAFLD incidence was calculated among participants with different baseline ZJU index quintiles. Cox proportional hazards regression analyses were conducted to calculate the risks for incident NAFLD.

RESULTS

During 37 705 person-year follow-ups, 1071 incident NAFLD cases were identified. The baseline ZJU index was linear and positively correlated with NAFLD incidence. The incidence was 5.53, 11.75, 23.77, 43.28, and 85.60 cases per 1000 person-year follow-up for participants with baseline ZJU index in quintiles 1-5, respectively. Compared with participants with baseline ZJU index in quintile 1, the hazard ratios (95% confidence interval) for incident NAFLD were 2.092 (1.458-3.002), 4.094 (2.942-5.698), 7.095 (5.167-9.742), and 13.191 (9.684-17.968) for participants with baseline ZJU index in quintiles 2-5, respectively. Further analysis found that the changes of ZJU index during follow-up was also independently associated with risk for incident NAFLD.

CONCLUSIONS

Baseline ZJU index and absolute ZJU index changes independently predicts the risk for incident NAFLD in Chinese population.

Validation of simple indexes for nonalcoholic fatty liver disease in western China: a retrospective cross-sectional study

Various noninvasive algorithms have been developed for predicting the presence of nonalcoholic fatty liver disease (NAFLD). The evaluation of the indexes' diagnostic performance has been reported in Europe and Asia over the past decade; however, external validation of them in China is rare. This study was aimed to evaluate various indexes for NAFLD in western China. It was a retrospective cross-sectional study, using data from a large-scale health check-up project at Sichuan provincial hospital. Receiver operating characteristic (ROC) curves of eight indexes, including the fatty liver index (FLI), the hepatic steatosis index, lipid accumulation product and etc., were developed to predict ultrasonographic NAFLD. There were 13,122 subjects in this study (2,692 NAFLD patients and 10,430 non-NAFLD participants). The area under ROC curve of FLI for predicting NAFLD was 0.880 (95% confidence interval, 0.874-0.886), which was significantly higher than other seven indexes. Accuracy, sensitivity and specificity of FLI for NAFLD were good (cut-off value = 30, 0.782, 0.832, 0.770 and cut-off value = 60, 0.838, 0.443, 0.940, respectively). Furthermore, FLI also presented advantages in expenditure and accessibility, compared with other indexes. It supports FLI as an easily accessible index for physicians and a reliable predictor for NAFLD screening in western China.