Evaluation of the Appropriateness of Red Cells, Platelets and Fresh Frozen Plasma Utilization / 대한진단검사의학회지

BACKGROUND: We reviewed the guidelines for the transfusion of red cells, platelets, and fresh frozen plasma (FFP) of the Korean Society of Blood Transfusion and modified the previous guidelines for transfusions at our hospital. We evaluated the appropriateness of the current hospital transfusions with these algorithms based on these guidelines. METHODS: The medical records of 266 transfusion episodes of patients receiving transfusions of red cells (144), platelets (61), and FFP (61), were reviewed retrospectively at Ewha Womans University Mokdong Hospital during 2002. RESULTS: Inappropriateness rates for transfusion episodes were 2.8% for red cells, 4.9% for platelets, and 44.3% for FFP. 144 red cell transfusions comprised 73 episodes (50.7%) in acute blood loss and 71 (49.3%) in chronic anemia. Among them, 2 episodes in each condition were assessed as inappropriate, respectively. 61 platelet transfusions comprised 32 episodes (52.5%) for a prophylaxis in marrow failure and 13 (21.3%) for active bleeding and 6 (9.8%) for acute disseminated intravascular coagulation (DIC) and 10 (16.4%) for others. Among them, 3 episodes for clinical bleeding were assessed as inappropriate. Out of 61 FFP transfusions, 34 episodes (56%) (16 liver disease with complications, 11 acute DIC, and 7 others) were assessed as appropriate and 27 episodes (44%) (8 liver diseases without complications, 10 surgical procedures and 9 others) were assessed as inappropriate. CONCLUSIONS: We modified our previous guidelines for transfusions according to the transfusion guidelines proposed by the Korean Society of Blood Transfusions. These guidelines could be easily applied to evaluate the appropriateness of transfusions performed at our hospital and to specify the cases of inappropriate transfusions.

The Relationship of Histologic Activity to Serum ALT, HCV genotype and HCV RNA titers in Chronic Hepatitis C

It is unclear whether serum ALT levels or virological characteristics of hepatitis C virus(HCV) including HCV genotypes and HCV RNA titers, can reflect the degree of histological injury in chronic hepatitis C. The aim of this study was to investigate the relationships between the levels of histological damage and serum ALT levels, HCV genotypes or circulating HCV RNA titers in chronic hepatitis C. A total of 56 patients underwent liver biopsy and the histological activity index (HAI) was evaluated by Knodell's scoring system. HCV genotype by RT-nested PCR and HCV RNA quantitation by competitive RT-PCR were performed. Thirty-four patients were infected with HCV genotype 1b, 20 patients with genotype 2a, and 2 patients with undetermined type. Serum ALT levels were not positively correlated with total HAI score or HCV RNA titers, but showed a linear correlation with scores of piecemeal necrosis (r=0.32, p<0.05) and portal inflammation (r=0.27, p<0.05). HCV genotype had no significant correlation with RNA titers, HAI score or with serum ALT levels. Also, no statistical relationship was seen between HCV RNA titer and HAI score. These results suggest that liver histology is essential to evaluate the severity of chronic hepatitis C precisely.

Surgical Treatment of Small Hepatocellular Carcinoma

PURPOSE: The hepatectomy has been regarded as the only curative treatment for small hepatocellular carcinomas. However, in recent years, non-surgical methods, such as ethanol injection therapy, arterial embolization, and high frequency coagulation, have come to be widely used in the treatment of small hepatocellular carcinomas. There have also been reports that survival rates comparable to those obtained by surgical resection can be achieved with non-surgical methods. In a retrospective analysis, the authors evaluated the surgical role in treating small hepatocellular carcinomas, regarding the survival rate and the pathological report. METHODS: Eighty-seven patients with a small hepatocellular carcinoma, defined as less than 5 cm in diameter, underwent a hepatectomy at our department during the 9 years between January 1990 and December 1998. We analyzed the pathologic findings, the operation method, and the survival rate as functions of the tumor size. RESULTS: Multiple nodules were presented in 18 (20.7%) of the 87 patients, and the incidence of multiple nodules was significantly higher for large-sized tumors. The incidences of capsule invasion, extranodular growth, and portal and intrahepatic metastasis were closely related to tumor size. For tumors less than 2 cm, no multiple nodules, portal invasion, or intrahepatic invasion was observed; however, very small incidences of capsule invasion and extranodular growth (27.3% and 11.1% respectively) and a high incidence (45.5%) of well differentiated tumors were noted. The operative mortality was 3.45% (3/87 hepatectomies): two died of hepatic failure, and one died of gastrointestinal bleeding. The 1-, 3- and 5- year survival rates were 86.9%, 72.0%, and 61.1%, respectively, and the tumor size and number were significantly related to survival rate the amount of resections however, was not significantly related to the survival rate. CONCLUSION: Tumors less than 2 cm in size have a good prognosis and are quite different pathologic ally compared to tumors, over 2 cm in size.

Protective Effect of Tacrolimus and Prostaglandin E1 in Ischemia-Reperfusion Injury of Rat Livers

BACKGROUND: Liver ischemia and reperfusion injury is associated with activation of several inflammatory pathways including cytokines, tumor necrosis factor (TNF) and cell-mediated tissue damage. tacrolimus causes a regulatory effect on some inflammatory pathways, such as cytokines, TNF, adhesion molecule and inflammatory cells. Prostaglandin E1 (PGE1) has shown vasodilatation by relaxing vascular smooth muscles and inhibits the effect of proinflammatory cytokines which could reduce leukocyte- sinusoidal and platelet-sinusoidal interactions. METHODS: Liver ischemia was induced in rats by occluding the vessels, the supplying median segment, and the left lateral segment with an aneurysmal clip for 60 minutes. The rats received tacrolimus (0.5 mg/kg, tacrolimus group) or PGE1 (100 ug/kg, PGE1 group) or normal saline (Control group) 30 and 5 minutes before ischemia and reperfusion of the liver, respectively. The serum ALT, nitric oxide, and TNF were determined at 1, 24, and 48 hours after reperfusion, and hepatic necrosis was determined at the same times by using HE staining and a microscopic grading system. RESULTS: 1) In the control group, the serum ALT and TNF levels had peak values at 1 hour and were gradually decreased, but the serum nitric-oxide level was gradually increased after the time of reperfusion (p<0.05). No necrosis existed at in one hour, but the tissue necrosis at 24 hours was higher than that at 48 hours (p<0.05). 2) At one hour, the tacrolimus group had significantly lower serum ALT and TNF levels and a higher serum nitric-oxide level in the liver compared with the control group, but the serum nitric-oxide level did not change significantly after reperfusion (p<0.05). The extent of hepatic necrosis was significantly inhibited in the tacrolimus group when compared with that in the control group and the PGE1 group (p<0.05). 3) The PGE1 group exhibited improved hepatic necrosis compared with the control group (p<0.05). The improved hepatic necrosis was reflected in reductions of the serum ALT and TNF and an increase in the serum nitric-oxide level. CONCLUSIONS: These result suggest that tacrolimus and PGE1 protect the liver against ischemia- reperfusion injury by reducing the serum TNF level and increasing the serum nitric-oxide level. The protective effect of tacrolimus is more beneficial than that of PGE1.