A prospective study of the correlation between hepatic fibrosis and noninvasively measured fibrosis markers including serum M2BPGi and acoustic radiation force impulse elastography / 고신대학교의과대학학술지

Background@#Mac-2 binding protein glycosylation isomer (M2BPGi) was introduced as a noninvasively measurable serologic marker for liver fibrosis. Acoustic radiation force impulse imaging (ARFI) elastography is another noninvasive method of measuring hepatic fibrosis. There are limited data about the correlations between histologic fibrosis grade and noninvasively measured markers, including M2BPGi and ARFI. @*Methods@#This prospective study was conducted among patients admitted consecutively for liver resection, cholecystectomy, or liver biopsy. ARFI elastography, serum M2BPGi levels, and the AST to Platelet Ratio Index (APRI) score were evaluated before histologic evaluation. Histologic interpretation was performed by a single pathologist using the METAVIR scoring system. @*Results@#In patients with high METAVIR scores, M2BPGi levels and ARFI values showed statistically significant differences between patients with fibrosis and those without fibrosis. In 41 patients with hepatocellular carcinoma, as METAVIR scores increased, M2BPGi levels also tended to increase (p=0.161). ARFI values changed significantly as METAVIR scores increased (p=0.039). In 33 patients without hepatocellular carcinoma, as METAVIR scores increased, M2BPGi levels significantly increased (p=0.040). ARFI values also changed significantly as METAVIR scores increased (p=0.033). M2BPGi levels were significantly correlated with ARFI values (r=0.604, p<0.001), and APRI values (r=0.704, p<0.001), respectively. @*Conclusions@#Serum M2BPGi levels increased with liver fibrosis severity and could be a good marker for diagnosing advanced hepatic fibrosis regardless of the cause of liver disease.

Alcohol-related liver disease and liver transplantation / 고신대학교의과대학학술지

Alcohol-related liver disease (ALD) has become the major cause of liver transplantation (LT) in Korea, and is currently the most common cause of LT in Europe and the United States. Although, ALD is one of the most common indications for LT, it is traditionally not considered as an option for patients with ALD due to organ shortages and concerns about relapse. To select patients with terminal liver disease due to ALD for transplants, most LT centers in the United States and European countries require a 6-month sober period before transplantation. However, Korea has a different social and cultural background than Western countries, and most organ transplants are made from living donors, who account for approximately twice as many procedures as deceased donors. Most LT centers in Korea do not require a specific period of sobriety before transplantation in patients with ALD. As per the literature, 8%–20% of patients resume alcohol consumption 1 year after LT, and this proportion increases to 30%–40% at 5 years post-LT, among which 10%–15% of patients resume heavy drinking. According to previous studies, the risk factors for alcohol relapse after LT are as follows: young age, poor familial and social support, family history of alcohol use disorder, previous history of alcohol-related treatment, shorter abstinence before LT, smoking, psychiatric disorders, irregular follow-up, and unemployment. Recognition of the risk factors, early detection of alcohol consumption after LT, and regular follow-up by a multidisciplinary team are important for improving the short- and long-term outcomes of LT patients with ALD.

Effectiveness of Albumin-bilirubin Score as a Predictor of Post-hepatectomy Liver Failure in Patients with Hepatocellular Carcinoma / 대한소화기학회지

Background/Aims@#Post-hepatectomy liver failure (PHLF) is a major concern for patients with hepatocellular carcinoma (HCC) who have undergone liver resection. The albumin-bilirubin (ALBI) score is a novel model for assessing liver function. We aimed to investigate the effectiveness of the ALBI score as a predictor of PHLF in HCC patients who have undergone hepatectomy in South Korea. @*Methods@#Between January 2014 and November 2018, HCC patients who underwent hepatectomy and indocyanine retention rate at 15 min (ICG-R15) test were enrolled in this study. @*Results@#A total of 101 patients diagnosed with HCC underwent hepatectomy. Thirty-two patients (31.7%) experienced PHLF. The ALBI score (OR 2.83; 95% CI 1.22-6.55; p=0.015), ICG-R15 (OR 1.07; 95% CI 1.02-1.12; p=0.007) and ALBI grade (OR 2,86; 95% CI 1.08-7.58; p=0.035) were identified as independent predictors of PHLF by multivariable analysis. The area under the receiver operating characteristic curve of the ALBI score and ICG-R15 were 0.676 (95% CI 0.566-0.785) and 0.632 (95% CI 0.513-0.752), respectively. The optimal cutoff value of the ALBI score in predicting PHLF was -2.62, with a sensitivity of 75.0% and a specificity of 56.5%. @*Conclusions@#The ALBI score is an effective predictor of PHLF in patients with HCC, and its predictive ability is comparable to that of ICG-R15.

Torsion of Wandering Spleen in Adolescents Causing Small Bowel Obstruction: A Case Report / 대한소화기학회지

No abstract available.

Initial Experience with Single Incision Laparoscopic Appendectomy by Surgical Resident

PURPOSE: Laparoscopic appendectomy (LA) is a popular procedure for acute appendicitis. Its minimally invasive nature has made LA a commonly performed surgical technique for surgical residents. However, single incision laparoscopic surgery (SILS) poses a challenge to inexperienced surgical residents. We described our initial experience in teaching SILS for appendectomy in our medical center. METHODS: Twenty nine cases of SILA were performed by single surgical resident and 110 cases of LA were performed by four surgical residents and five board-certified surgeons. Data were reviewed retrospectively. RESULTS: The mean SILA and multi-port laparoscopic appendectomy (MLA) operative time was 44.5±14 min (range 25~85 min) and 74.8±26 min (range 20~125 min), respectively. The shorter time for SILA was significant (p<0.05). Postoperative hospital stay was 3.3±1.6 days (range 2~6 days) following SILA and 4.0±2.9 days (range 2~12 days) following MLA (p<0.05). Three cases of wound infection developed following SILA. Complications in the MLA patients included one cases each of operative bladder injury and postoperative ileus. CONCLUSION: SILA is a considerable training method for laparoscopic surgery for a surgical resident learning SILS.

Superior mesenteric vein thrombosis accompanied with severe appendicitis

Superior mesenteric vein (SMV) thrombosis caused by acute appendicitis is a very rare entity nowadays. We report a successfully treated case of a 21-year-old man with SMV thrombosis associated with severe acute appendicitis. Intravenous heparin was administered, and it was later substituted with warfarin. Systemic antibiotic therapy was continued for 1 week, and it was substituted with oral antibiotics, which were administered for 3 weeks. On the 45th postoperative day, follow-up computed tomography scan demonstrated dissolution of SMV thrombosis. Anticoagulation therapy was maintained for 3 months. He was discharged without any complications. SMV thrombosis can be treated successfully with emergency appendectomy, broad-spectrum antibiotics, and anticoagulation therapy.

Transumbilical single port laparoscopic appendectomy using basic equipment: a comparison with the three ports method / 대한외과학회지

PURPOSE: Single port laparoscopic surgery is a rapidly evolving laparoscopic surgical approach. We report a comparison of transumbilical single port laparoscopic appendectomy (TUSPLA) and conventional laparoscopic appendectomy (CLA) in a Korean military hospital. METHODS: This single-center retrospective study of 63 patients who received laparoscopic appendectomy was conducted between May 2011 and October 2011. Nineteen patients received TUSPLA and 44 patients received CLA. Clinical outcomes such as operation time, hospital stay, postoperative pain, diet, and postoperative complication were reviewed. RESULTS: There were no statistically significant differences between TUSPLA and CLA patients, respectively, in operation time (58.9 minutes vs. 52.3 minutes, P = 0.262), duration of hospitalization (10.2 days vs. 10.6 days, P = 0.782), mean visual analogue scale score (2.6 vs. 2.5, P = 0.894), and return to diet (1.6 days vs. 1.7 days, P = 0.776). There were two cases (10.5%) of short-term complications in the TUSPLA group and four cases (9.1%) of short-term complications in the CLA group. All patients were fully recovered at discharge. CONCLUSION: TUSPLA is a feasible alternative for CLA. When a glove port is used, no special instruments are needed. Thus, it can be performed in a hospital equipped with basic laparoscopic surgical instruments.

Liver transplantation for acute-on-chronic liver failure from erythropoietic protoporphyria

Erythropoietic protoporphyria (EPP) is an inherited disorder of the heme metabolic pathway that is characterized by accumulation of protoporphyrin in the blood, erythrocytes, and tissues, and cutaneous manifestations of photosensitivity, all resulting from abnormalities in ferrochelatase (FECH) activity due to mutations in the FECH gene. Protoporphyrin is excreted by the liver, and excess protoporphyrin leads to cholelithiasis with obstructive episodes and chronic liver disease, finally progressing to liver cirrhosis. Patients with end-stage EPP-associated liver disease require liver transplantation. We describe here a 31-year-old male patient with EPP who experienced acute-on-chronic liver failure and underwent deceased-donor liver transplantation. Surgical and postoperative care included specific shielding from exposure to ultraviolet radiation to prevent photosensitivity-associated adverse effects. The patient recovered uneventfully and was doing well 24 months after transplantation. Future prevention and treatment of liver disease are discussed in detail.

A Case of Duodenal Wall Abscess Caused by a Foreign Body / 대한소화기내시경학회지

Duodenal abscess is a form of phlegmonous enterocolitis and is a rarely reported disease throughout the entire world. Duodenal abscess mostly develops from complications of duodenal ulcer perforation, and may result in a clinically fatal course because it is difficult to differentiate from some diseases such as gastric ulcer, gastric cancer, hepatobiliary disorders etc.. The therapeutic gold standard is surgical intervention including abscess removal and drainage. We experienced a case of duodenal abscess that expressed non-specific symptoms, weight loss and epigastric pain, and diagnosed by gastrointestinal endoscopy, abdominal computed tomography. We successfully treated it through surgical intervention with intravenous antibiotics.

Risk Factors for Intrahepatic Recurrence

PURPOSE: Although surgical resection offers patients with HCC the chance of a cure, the post-resection tumor recurrence rate is high, with reported cumulative 5-year tumor recurrence rates ranging from 40 to 70%. The objective of this study was to investigate risk factors for intrahepatic recurrence after resection of hepatocellular carcinoma, especially in patients with hepatitis B virus infection. METHODS: Between January 1999 and December 2003, 59 patients in our Hospital with hepatitis B virus infection underwent liver resection for hepatocellular carcinoma. Clinical, biological, and histopathological characteristics of these patients were collected and tested for their prognostic significance using a Chi-square test and a Student's t-test. Time to recurrence and survival rate were analyzed by the Kaplan-Meier method. RESULTS: Of the 59 patients who underwent liver resection, 24 (41%) experienced intrahepatic recurrence. The 1-, 3-, and 5-year overall survival rates of total enrolled patients were 83%, 63%, and 42%, respectively. The 1-, 3-, and 5-year overall survival rates after recurrence were 87%, 52%, and 20%, respectively. The risk factors for early recurrence were elevated serum aspartate aminotransferase (AST) level (p=0.044) and larger tumor size (p=0.049). For late recurrence, greater tumor size (p=0.039) was the only risk factor. CONCLUSION: Tumor size and serum aspartate aminotransferase are risk factors of intrahepatic recurrence after resection of HCC in patients with chronic hepatitis B virus infection. This finding indicates that patients who have these risk factors should be under more careful supervision and have more aggressive follow-up.

Does Calcineurin Inhibitor Plus Mycophenolate Mofetil Combination Therapy Decrease the Risk of Late Acute Rejection after Liver Transplantation? / 대한이식학회지

BACKGROUND: With advances in immunosuppression, graft and patient survival rates have increased significantly, but acute cellular rejection remains an important problem following liver transplantation (LT), and late acute rejection (LAR) occurs in a small percentage of recipients. Some risk factors for LAR have been identified, yet the cause of LAR has not been completely investigated. The efficacy of mycophenolate mofetil (MMF) administered in combination with calcineurin inhibitor (CNI) for reduction of LAR has been demonstrated. METHODS: Between January 2006 and August 2007, adult LT recipients (n=309) were enrolled in this study. Biopsy-proven acute rejection that occurred >6 months after LT was defined as LAR. The immunosuppression regimens, CNI or CNI plus MMF, were used continuously for at least 6 months after LT. The mean follow-up period was 34.8 months (range, 25~46 months). RESULTS: LAR occurred in 17 cases (5.5%). The incidence of LAR in the CNI (n=138) or CNI plus MMF groups (n=171) was 8.6% (n=12) and 2.9% (n=5), respectively (P=0.015). Multivariate Cox regression confirmed that CNI plus MMF versus CNI therapy is associated with a decreased risk of LAR (relative risk, 0.33; P=0.04). CONCLUSIONS: The incidence of LAR in the CNI plus MMF group was significantly lower than the CNI group. Thus, continuous use of CNI plus MMF may represent a better immunosuppression regimen to decrease the rate of LAR in LT recipients.

The Complication Rate according to the Method of Pancreaticojejunostomy after Pancreaticoduodenectomy

PURPOSE: This study was designed to compare and analyze the complication rates of different anastomotic methods of pancreaticojejunostomy after performing pancreaticoduodenectomies by a single surgeon. METHODS: From January 2000 to August 2007, 92 patients underwent pancreaticoduodenectomy at a single institution. According to the texture of the pancreas and pancreatic duct size (below or above 3 mm), the type of pancreaticojejunal anastomosis was selected (either duct-to-mucosa pancreaticojejunostomy or end-to-side pancreaticojejunostomy with polyethylene tube). RESULTS: The pathologic diagnosis of the 92 patients included 81 patients with adenocarcinoma, five with chronic pancreatitis and three with GIST that developed in the duodenum. The adenocarcinomas include 33 distal CBD cancers, 18 pancreatic head cancers, 27 Ampulla of Vater cancers and 6 duodenal cancers. The pancreatic fistula rate was not significantly different between the duct-to-mucosa group and the end-to-side pancreaticojejunostomy group (nine of the 43 patients in the duct-to-mucosa group (20.9%) and six of the 46 patients in the tube insertion group (13.0%) (p=0.4). The rate of pancreatic fistula, as classified by three different consecutive periods (period I: 2000-2003; period II: 2004-2005; period III: 2006-2007), was markedly decreased and there were less complications with increasing experience (period I: 33.3%; II: 7.1%; III: 6.4%) (p=0.001). CONCLUSION: When performing pancreaticojejunostomy, both the duct-to-mucosa method and the tube insertion method were effective in decreasing the complication rate if the appropriate method was selected according to the texture of the pancreas and the size of pancreatic duct. The surgeon's experience and skill can affect the occurrence of pancreatic fistula after pancreaticojejunostomy. Enough experience is the most important factor to decrease the complication rate after pancreaticoduodenectomy.

Effectiveness of Plasmapheresis as a Liver Support for Graft Dysfunction Following Adult Living Donor Liver Transplantation / 대한이식학회지

BACKGROUND: Severe graft dysfunction has been occasionally encountered following adult living donor liver transplantation (LDLT). This study intended to assess the effectiveness of plasmapheresis (PP) as a liver supportive measure in LDLT recipients showing severe graft dysfunction. METHODS: During 1 year of 2007, 276 adult LDLTs were performed in our institution. Of them 27 underwent PP therapy as a liver support. RESULTS: Seventeen underwent PP during the first month following LDLT and another 10 underwent PP after that period. The underlying causes of such liver support were acute and chronic rejections, ischemic damage, viral hepatitis recurrence and unknown causes. A total of 329 sessions of PP were performed for these 27 patients, indicating 12.2+/-9.9 times per patient for 28.1+/-32.2 days. Concurrent hemodiafiltration was done in 66.7%. Serum total bilirubin level was significantly reduced following PP therapy: 23.2+/-6.5 mg/dL before PP and 14.4+/-5.6 mg/dL at 1 week after completion of PP (P<0.001). Other biochemical parameters did not significantly affected by PP. Overall 1-year patient survival rate was 63.0%. Six-month graft survival rate after completion of PP was 82.6% in 17 patients undergoing PP during the first posttransplant month and 30% in 10 patients undergoing PP after 1 month (P= 0.013). CONCLUSIONS: The results of this study implicate that PP has a beneficial effect on the recovery of liver graft function, especially during the early posttransplant period. We suggest to perform active application of PP therapy for liver recipients showing severe graft dysfunction of total bilirubin greater than 15~20 mg/dL.

Effect of Splenic Artery Interruption on Complete Blood Count Profiles in Living Donor Liver Transplant Recipients

PURPOSE: Splenectomy during living donor liver transplantation (LDLT) in a hepatitis C virus (HCV)-related cirrhotic recipient was performed by a Tokyo group to enhance the patient's tolerability to post-operative anti-viral treatment by improving complete blood count (CBC) profiles. At our institution, interruption of the splenic artery (SPA) by ligation or embolization in lieu of splenectomy, has been performed in LDLT to modulate portal blood flow in small-for-size graft LDLT or to prevent rupture of SPA aneurysms in recipients. We aimed to determine if interruption of the SPA can serve as an alternative management to splenectomy in LDLT recipients based on our data. METHODS: Patients were classified into the splenic artery ligation group (SAL; n=26) and splenic artery embolization group (SAE; n=19), respectively. Among the recipients without SPA interruption, age-, gender-, and severity of cirrhosis-matched 25 recipients were selected as a control group. Post-operative CBC profiles and spleen size were reviewed retrospectively and compared between the groups. RESULTS: After SAL, platelet and neutrophil counts were significantly increased at 3 and 6 months, and at 1 week and 1 month, respectively (p<0.05). After SAE, platelet and neutrophil counts were significantly increased at 3 and 6 months, and at 1 week and 3 months, respectively. There were no significant complications related to interruption of the SPA. CONCLUSION: Interruption of the SPA may have a role in improving neutrophil and platelet counts in LDLT recipients with severe pancytopenia or in whom antiviral treatment for HCV in anticipated.

Effect of Splenic Artery Interruption on Complete Blood Count Profiles in Living Donor Liver Transplant Recipients

PURPOSE: Splenectomy during living donor liver transplantation (LDLT) in a hepatitis C virus (HCV)-related cirrhotic recipient was performed by a Tokyo group to enhance the patient's tolerability to post-operative anti-viral treatment by improving complete blood count (CBC) profiles. At our institution, interruption of the splenic artery (SPA) by ligation or embolization in lieu of splenectomy, has been performed in LDLT to modulate portal blood flow in small-for-size graft LDLT or to prevent rupture of SPA aneurysms in recipients. We aimed to determine if interruption of the SPA can serve as an alternative management to splenectomy in LDLT recipients based on our data. METHODS: Patients were classified into the splenic artery ligation group (SAL; n=26) and splenic artery embolization group (SAE; n=19), respectively. Among the recipients without SPA interruption, age-, gender-, and severity of cirrhosis-matched 25 recipients were selected as a control group. Post-operative CBC profiles and spleen size were reviewed retrospectively and compared between the groups. RESULTS: After SAL, platelet and neutrophil counts were significantly increased at 3 and 6 months, and at 1 week and 1 month, respectively (p<0.05). After SAE, platelet and neutrophil counts were significantly increased at 3 and 6 months, and at 1 week and 3 months, respectively. There were no significant complications related to interruption of the SPA. CONCLUSION: Interruption of the SPA may have a role in improving neutrophil and platelet counts in LDLT recipients with severe pancytopenia or in whom antiviral treatment for HCV in anticipated.

The Current Status of Treatment for Patients with Severe Acute Pancreatitis

INTRODUCTION AND AIM: Acute pancreatitis is an inflammatory process of varying severity, ranging from a mild, self-limiting form to severe acute pancreatitis, which leads to complications such as necrosis, pseudocyst formation, and organ failure. This highly lethal condition should be differentiated from acute abdomen caused by other diseases as early as possible so appropriate management can be carried out. PATIENTS AND METHODS: A survey was carried out to determine the current status of management for this particular disease in Korea. A total of 269 patients were collected from 13 university hospitals during a four and a half year period (January 2000 to June 2004). RESULTS: Of the 269 patients, 103 (38.3%) were managed with surgery, and 166 (61.7%) were managed with conservative treatment. The most commonly performed surgical procedure was debridement of necrotic tissue with closed drainage. The most common etiology was alcohol, with 143 cases (53.4%), followed by gallstones, with 48 cases (17.9%). E. coli was the most commonly cultured bacterium. The mortality rate in surgically managed patients was 9.7%. The mortality rate in conservatively treated patients was 7.2% . CONCLUSION: Patients with infected pancreatic necrosis should be managed with surgical necrosectomy and drainage. However, patients with sterile necrosis should be managed conservatively unless organ complications or severe clinical deterioration develops despite intensive therapy. Patient survival is improved through early diagnosis, followed by adequate drainage in combination with intensive care.

Intestinal Perforation in Colorectal Cancers Treated with Bevacizumab (Avastin(R)) / Journal of the Korean Cancer Association, 대한암학회지

Bevacizumab is a monoclonal antibody that targets vascular endothelial growth factor (VEGF), and it has shown promise as a clinical agent against metastatic colorectal cancer, and particularly in combination with chemotherapy. Bowel perforation is a known risk that's associated with bevacizumab use, but the etiology is unknown. Here we report on two cases of metastatic colorectal cancer in which the patients suffered from intestinal perforation after chemotherapy with bevacizumab. For the first case, a 47 year-old man had rectal cancer with concurrent liver and lung metastasis. He underwent chmotherapy with 5-fluorouracil, irinotecan and bevacizumab. Fever and abdominal pain developed seven days later, and rectal perforation was identified upon exploration 13 days later. For the second case, a 48 year-old woman had sigmoid colon cancer with peritoneal and ovary metastases. After seven days of chemotherapy with 5-fluorouracil, oxaliplatin and bevacizumab, exploratory surgery revealed a perforation at the ileum.

Obstetrical Outcomes of Idiopathic Thrombocytopenic Purpura in Pregnancy / 대한주산의학회잡지

OBJECTIVE: Idiopathic thrombocytopenic purpura (ITP) frequently occurs in young women. Consequently, clinicians often give medical treatment to pregnant women who are diagnosed with ITP. This study might help to make a clinical guidelines for obstetrical ITP patients and their infants. METHODS: We retrospectively investigated the medical charts of 19 cases of deliveries and 22 neonates which from mothers with the diagnosis of ITP during pregnancy from March 1998 to March 2007. RESULT: Corticosteroid treatment was administrated in 13 cases, high-dose immunoglobulin therapy in 3 cases, and concentrated platelet transfusion in 17 cases during their antenatal care. Ten (45%) vaginal deliveries and twelve (55%) cesarean sections were performed. There were no obstetrical complications associated with their ITP and only four infants with platelet counts below the 150,000/micronLiter were reported after birth. However there were not any signs and symptoms of neonatal complications resulting from their maternal ITP. CONCLUSION : Our results demonstrate that mothers with ITP can successfully deliver healthy infants in most case. Although maternal and fetal bleeding may occur, such a fatal complication is uncommon.

Acute Hyperphosphatemia and Hypocalcemia Following the Administration of Phosphate-containing Laxatives in Patients with End Stage Renal Disease / 대한신장학회잡지

Oral or rectal sodium phosphate(NaP) preparation is commonly used for the colonic cleansing. Since the sole route of excretion of absorbed phosphate is renal, diminished renal function will limit the ability to excrete a sudden phosphate load. To date, about 20 adult cases of hyerphosphatemia associated with oral or rectal sodium phosphate solution have been reported, but not a single case in Korea to our knowledge. We report two cases of hyperphosphatemia and hypocalcemia after the administration of NaP(Colclean(R)) to reemphasizes the potential hazard of sodium phosphate bowel preparation in patients with compromised renal function.

The Expression of Peforin, Fas-ligand, and Granzyme B in Peripheral Blood Lymphocytes of Renal Allograft Recipients / 대한신장학회잡지

BACKGROUND: Previous findings demonstrated that the expression of cytotoxic effector molecules is increased in acute rejection of renal allografts. In the present study, we serially examined the gene expression of perforin, granzyme B and Fas ligand(FasL) in peripheral blood lymphocytes(PBLs) of renal allograft recipients to assess the potential of their expression as a marker of acute rejection. METHODS: PBLs were isolated from blood samples taken on days 2, 4, 6, 8, 10 and 12 after transplantation. Competitive PCR was performed to evaluate the abundance of mRNA of perforin, granzyme B and FasL. The mean value of each molecule plus 2 SD for the control group was set as a discriminatory level. RESULTS: When all measured samples were compared, perforin expression was significantly higher in patients with acute rejection than in the control group(1.84+/-3.01 versus 0.71+/-0.48, p=0.01). The percentage of perforin expression exceeding the discriminatory level was also significantly higher in patients with acute rejection(p=0.0003). Five patients in the rejection group(5/7, 71.4%) showed perforin expression exceeding the discriminatory level, while only 1 patient in the control group did so(1/8, 12.5%)(p= 0.02). Perforin expression of days 0 and 1 of rejection crisis was the highest over the study period. No consistent pattern of granzyme B and FasL expression was identified in relation to rejection crisis. CONCLUSION: Gene expression of perforin by PBLs was upregulated in accordance with acute rejection, thus offering the possibility that it may be utilized as a marker of acute rejection.