慢病管理创新实践：糖肝全-专管理新模式

doi:10.12114/j.issn.1007-9572.2025.0067

中国全科医学 ›› 2025, Vol. 28 ›› Issue (23): 2841-2845.DOI: 10.12114/j.issn.1007-9572.2025.0067

• 论著·慢性病共病专题·糖肝共管 • 上一篇下一篇

慢病管理创新实践：糖肝全-专管理新模式

白雪¹, 陈倩倩², 李婕¹^,^*()

1．210008　江苏省南京市，南京大学医学院附属鼓楼医院感染性疾病科
2．210008　江苏省南京市，南京中医药大学鼓楼临床医学院感染性疾病科

收稿日期:2025-04-10 修回日期:2025-04-26 出版日期:2025-08-15 发布日期:2025-06-17
通讯作者: 李婕

【专家简介】　李婕，南京大学医学院附属鼓楼医院感染性疾病科主任，主任医师、教授、博士生导师，美国斯坦福大学、香港大学访问学者，国家医学高层次人才（优秀青年医师），江苏省医学会感染病分会候任主任委员，中国研究型医院学会肝病专业委员会常委，中华医学会肝病学分会青年委员。承担5项国家自然科学基金及其他国家、省部级课题共27项，获省部级科研奖励共10项。在Lancet Gastroenterology & Hepatology、Hepatology、American Journal of Gastroenterology、eClinicalMedicine、Clinical Gastroenterology Hepatology，Protein & Cell等杂志发表SCI论文80余篇，其中3篇入选ESI高被引，入选全球前2%顶尖科学家榜单。

作者贡献：

白雪负责撰写文章、文献检索及图片绘制；陈倩倩负责文章修改；李婕负责审校，对文章总体负责。

基金资助:
国家自然科学基金面上项目(82170609，81970545); 国家自然科学基金国际（地区）合作与交流项目(82411560273); 江苏省自然科学基金面上项目(BK20231118); 国家科技创新2030重大专项(2023ZD0508802)

Innovative Practices in Chronic Disease Management: a New Model for Generalist-Specialist Combination Management of Diabetes and Metabolic Dysfunction-associated Fatty Liver Disease

BAI Xue¹, CHEN Qianqian², LI Jie¹^,^*()

1. Department of Infectious Diseases, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
2. Department of Infectious Diseases, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Nanjing 210008, China

Received:2025-04-10 Revised:2025-04-26 Published:2025-08-15 Online:2025-06-17
Contact: LI Jie

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摘要/Abstract

摘要： 由非酒精性脂肪性肝病（NAFLD）到如今的代谢相关脂肪性肝病（MAFLD），诊断名词的不断规范，意在突出"代谢紊乱"在脂肪性肝病的发生、发展中的重要作用，而2型糖尿病作为全球常见的代谢性疾病之一，目前也被认为是MAFLD最常见的合并症，两者相互影响，加速疾病进展，导致肝内肝外不良结局。面对此状况，亟需充分发挥"整体医学观"，探索基于糖尿病的脂肪肝全周期、全方位管理新模式对于改善糖尿病和脂肪肝患者的预后具有重要意义。本文总结MAFLD和T2DM共病的流行病学和发病机制、分享基于"糖肝共管"理念提出的全-专管理新模式的创新实践，旨在为MAFLD和T2DM的共同管理提供更多帮助。

关键词: 代谢相关脂肪性肝病, 2型糖尿病, 全专结合, 慢病管理

Abstract:

The evolution of diagnostic term from non-alcoholic fatty liver disease (NAFLD) to the metabolic dysfunction-associated fatty liver disease (MAFLD) aims to highlight the critical role of "metabolic dysfunction" in the development and progression of fatty liver diseases. As one of the most common metabolic disorders globally, type 2 diabetes mellitus (T2DM) is now considered as the most common complication of MAFLD. The two diseases interact in ways that adversely affect various systems within the body. With regard to this situation, it is urgently to fully implement the "holistic medical approach" and explore a full-cycle and comprehensive management model for patients with both T2DM and MAFLD, which is of great significant for improving their prognosis. This article summarizes the epidemiology and pathogenesis of patients with MAFLD and T2DM, and shared the innovative practices of the new multidisciplinary management model, aiming to provide more support for the co-management of MAFLD and T2DM.

Key words: Metabolic dysfunction-associated fatty liver disease, Type 2 diabetes mellitus, Integration of general practice and speciality, Chronic disease management

白雪,陈倩倩,李婕. 慢病管理创新实践：糖肝全-专管理新模式[J]. 中国全科医学, 2025, 28(23): 2841-2845. DOI: 10.12114/j.issn.1007-9572.2025.0067.
BAI Xue,CHEN Qianqian,LI Jie. Innovative Practices in Chronic Disease Management: a New Model for Generalist-Specialist Combination Management of Diabetes and Metabolic Dysfunction-associated Fatty Liver Disease[J]. Chinese General Practice, 2025, 28(23): 2841-2845. DOI: 10.12114/j.issn.1007-9572.2025.0067.

图/表 1

参考文献 29

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慢病管理创新实践：糖肝全-专管理新模式

Innovative Practices in Chronic Disease Management: a New Model for Generalist-Specialist Combination Management of Diabetes and Metabolic Dysfunction-associated Fatty Liver Disease

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