肝脏储备功能定量评估的实验研究
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摘要
目的：肝脏是一个具有多种生理机能的器官，并且有巨大的再生潜能和代偿能力，它参与机体的消化、代谢、解毒、排泄和免疫等多种过程，如何准确评估肝脏储备功能是目前肝病领域的重要课题之一。
传统肝储备功能的定量评估方法很多。有肝功能Child分级法、Child—Pugh分级方法、佐藤分级法等。ICG负荷试验是目前常用的评估肝脏储备功能的方法之一。以99mTc标记去唾液酸糖蛋白(GSA)作为特异性配体，通过SPECT闪烁扫描测定肝脏去唾液酸糖蛋白(ASGP)受体的量，以此评估肝脏储备功能是近年来开展的定量评估肝脏储备功能的新方法。文献报道该方法能较直观地反映肝脏清除去唾液酸糖蛋白的能力。相映指标可以定量评估肝脏储备功能。用流式细胞仪对分离的肝细胞进行ASGP受体分析以评估肝脏储备功能是处于实验阶段的新方法。
去唾液酸胎球蛋白(ASF)是肝细胞ASGP受体的天然配体，能被ASGP受体特异结合并被肝细胞清除，被广泛用于肝脏ASGPR研究。
能否将吲哚氰绿负荷试验和肝脏ASGP受体核素扫描显像相关指标进行有机的结合，探索一种更加准确更加敏感的对肝脏储备功能进行定量评估的方法?
针对以上问题，本研究试图以99mTc—ASF作为配体探讨SPECT肝脏ASGP受体扫描的有关指标与常规肝功能指标间的相关性，并比较各项指标的灵敏性。选择其中比较敏感的指标作参数，建立一个综合定量评估肝脏储备功能的评分体系，为临床提供参考。
方法：以雄性Wistar大鼠为试验对象，建立四氯化碳肝硬化模型、肝脏不同比例部分切除模型，分别进行常规肝功能指标测定、吲哚氰绿储留率测定、肝脏ASGP受体核素扫描测定15min配体清除率(HH15)、受体指
数（LHL15）、受体修正指数（MRI）、肝细胞 ASGP受体体外流式细胞仪（FCM）
分析等，探讨各项指标的相关性及敏感性。对不同肝损害肝切除模型进行
常规肝功能指标、ICGR15以及mI、HH15、LHL15等指标的综合测定，通
过回归分析，寻求一种涵盖多项指标的综合评估肝脏储备功能的方法。
统计学方法：统计资料表达采用M土SD。统计学处理采用SPSS及
Microsoft Excel软件进行单因素方差分析、COX回归、线性相关分析、计
数资料用X’检验。确定P狈．05为有统计学意义。
结果：在四氯化碳肝硬化模型及肝切除模型中，反映肝脏功能状态方
面的指标之间多数有显著相关性；FCM分析正常大鼠肝细胞的ASGP受体
量明显高于肝硬化大鼠的该受体量。在肝脏容量丢失15％以内，ICGR15
不能反映出肝脏储备功能的变化，即该指标不够敏感。相关指标的敏感性
依次为：MRI、HH15汀CGR15儿HL15。通过回归分析建立的综合评估肝脏储
备功能的回归方程式：Y＝33．188 X MRI—44．844 XHH；s＋24．032XLHL；s一
34．915 X ICGR；s能比较敏感地反映肝脏储备功能。当评估系数 Y值小干 30
时，大鼠在72小时内100％死亡；当Y值在30～40之间时，72小时内死亡率
为37．46％；当Y值40以上时，大鼠在72 ’J’时内没有死亡。以Y＝＝35为界，
当Y低于该值时大鼠72小时内的死亡率为81．8％。
结论：1、在大鼠四氯化碳肝硬化模型及肝脏部分切除模型中，常用评
估肝脏储备功能指标之间的相关性多数有显著的统计学意义。2、用流式细
胞仪对肝细胞ASGP受体进行体外分析能够反映肝脏细胞ASGP受体量，可
以反映肝脏的功能状态。3、涵盖MRI、HH15、ICGR15、LHL15等四项
指标的定量评估肝脏储备功能的回归方程 Y ＝＝ 33．188 X Mi一 44．844 X
HH15＋24刀32 XLHL15—34．gl5XICGR15，能够对正常及四氯化碳肝硬化大
鼠模型的肝脏储备功能作出准确可靠的定量评估。
Objective: Liver is an organ that posses multiple physiological function, great regeneration potential and compensation. A great deal of processes such as digestion, metabolism, detoxication, excretion and immunity are undertaken in liver. At present, how to evaluate hepatic function reserve accurately is a challenge in treatment of liver disease.
There are many classical methods evaluating hepatic function reserve quantitatively, including Child classifying method of hepatic function, Child-Pugh classifying method, Safuji classifying method, and so on. ICG stress test is the popular method evaluating hepatic function reserve. In recent years, the quantitation of ASGP receptor by 99mTc-labeling neogalactoalbumin SPECT scintiscan is the up-to-date method that is applied to quantitatively evaluate hepatic function reserve. Literature reported that the capability of eliminating ASGP of the liver can be reflected more directly by this method, and correlative index can be applied to quantitatively evaluate hepatic function reserve. Analysing the surface ASGP receptor on separated liver cell by flow cytometer, and is a new method evaluating hepatic function reserve, however, this kind of study is still at its experiment stage. Asialofetuin (ASF) is the ligand of ASGP receptor residing on liver cell surface, can bind its receptor specifically and be degradat
eded by liver cell. Now ASF is applied to investigate ASGP receptor of liver extensively.
Whether or not can the indocyanogen green retention rate test be combined effectively with the correlative index of liver ASGP receptor nuclin scanning, so that a more accurate and more sensitive method of evaluating
quantitatively hepatic function reserve can be selected.
Aiming at above problems, the objective of this experiment is to discuss correlation between indices of SPECT liver ASGP receptor scintiscan with the ligand of 99mTc - ASF and classical liver functional index, and sensitivity of those indices. Further, we hope to choose a more sensitive parameter from those indices, and provide a guiding standard for clinical staff to select a quantitatively evaluation method of hepatic function reserve.
Methods: Wistar rats (male) were used to establish a model of carbon tetrachloride inducing cirrhosis and differently proportional resection of rodent liver. Classical liver functional index, indocyanogen green retention rate test, 15min ligand clearance estimated by liver ASGP receptor nuclin scanning (HH15), liver uptaking rate (LHL15), modified receptor index (MRI), and in vitro analysis of ASGP receptor on liver cell surface detected by Flow cytometer were investigated respectively. The correlation and sensitivity of each index were discussed.
The indices of differently damaged liver model and differently proportional resection of rodent liver such as Classical liver functional index, ICGR15,MRI,HH15,and LHL15,were be evaluated combined. And then a synthetic method including many indices of evaluating hepatic function reserve could be found out by regression analysis.
Statistic methods: Statistic data were expressed as M SD. And those data were analysed by software of SPSS and Microsoft Excel. Single equation variance analysis, COX regression, linearity correlation analysis , and X2 test were undertaken. The test standard was p<0.05.
Results: In the models of carbon tetrachloride inducing cirrhosis and differently proportional resection of rat liver, there was a significant correlation among commonly used indexes of hepatic functional reserve. The quantity of ASGP receptor of normal liver were significantly more than that of cihhorsis
by FCM. In the 15% losing of hepatic dimension, the change of hepatic functional reserve can not be reflected by ICGR15,that means this index is not sensitive enough. The sensitivity of those indices was that MRI , HH15>ICGR15>LHL15.The regression equation of evaluating hepatic functional reserve was that Y= 33.188 MRI-44.844 HH15+24.032 LHL15 - 34.915 ICGR15, and it was sensitive. When the evaluation coeffic
传统肝储备功能的定量评估方法很多。有肝功能Child分级法、Child—Pugh分级方法、佐藤分级法等。ICG负荷试验是目前常用的评估肝脏储备功能的方法之一。以99mTc标记去唾液酸糖蛋白(GSA)作为特异性配体，通过SPECT闪烁扫描测定肝脏去唾液酸糖蛋白(ASGP)受体的量，以此评估肝脏储备功能是近年来开展的定量评估肝脏储备功能的新方法。文献报道该方法能较直观地反映肝脏清除去唾液酸糖蛋白的能力。相映指标可以定量评估肝脏储备功能。用流式细胞仪对分离的肝细胞进行ASGP受体分析以评估肝脏储备功能是处于实验阶段的新方法。
去唾液酸胎球蛋白(ASF)是肝细胞ASGP受体的天然配体，能被ASGP受体特异结合并被肝细胞清除，被广泛用于肝脏ASGPR研究。
能否将吲哚氰绿负荷试验和肝脏ASGP受体核素扫描显像相关指标进行有机的结合，探索一种更加准确更加敏感的对肝脏储备功能进行定量评估的方法?
针对以上问题，本研究试图以99mTc—ASF作为配体探讨SPECT肝脏ASGP受体扫描的有关指标与常规肝功能指标间的相关性，并比较各项指标的灵敏性。选择其中比较敏感的指标作参数，建立一个综合定量评估肝脏储备功能的评分体系，为临床提供参考。
方法：以雄性Wistar大鼠为试验对象，建立四氯化碳肝硬化模型、肝脏不同比例部分切除模型，分别进行常规肝功能指标测定、吲哚氰绿储留率测定、肝脏ASGP受体核素扫描测定15min配体清除率(HH15)、受体指
数（LHL15）、受体修正指数（MRI）、肝细胞 ASGP受体体外流式细胞仪（FCM）
分析等，探讨各项指标的相关性及敏感性。对不同肝损害肝切除模型进行
常规肝功能指标、ICGR15以及mI、HH15、LHL15等指标的综合测定，通
过回归分析，寻求一种涵盖多项指标的综合评估肝脏储备功能的方法。
统计学方法：统计资料表达采用M土SD。统计学处理采用SPSS及
Microsoft Excel软件进行单因素方差分析、COX回归、线性相关分析、计
数资料用X’检验。确定P狈．05为有统计学意义。
结果：在四氯化碳肝硬化模型及肝切除模型中，反映肝脏功能状态方
面的指标之间多数有显著相关性；FCM分析正常大鼠肝细胞的ASGP受体
量明显高于肝硬化大鼠的该受体量。在肝脏容量丢失15％以内，ICGR15
不能反映出肝脏储备功能的变化，即该指标不够敏感。相关指标的敏感性
依次为：MRI、HH15汀CGR15儿HL15。通过回归分析建立的综合评估肝脏储
备功能的回归方程式：Y＝33．188 X MRI—44．844 XHH；s＋24．032XLHL；s一
34．915 X ICGR；s能比较敏感地反映肝脏储备功能。当评估系数 Y值小干 30
时，大鼠在72小时内100％死亡；当Y值在30～40之间时，72小时内死亡率
为37．46％；当Y值40以上时，大鼠在72 ’J’时内没有死亡。以Y＝＝35为界，
当Y低于该值时大鼠72小时内的死亡率为81．8％。
结论：1、在大鼠四氯化碳肝硬化模型及肝脏部分切除模型中，常用评
估肝脏储备功能指标之间的相关性多数有显著的统计学意义。2、用流式细
胞仪对肝细胞ASGP受体进行体外分析能够反映肝脏细胞ASGP受体量，可
以反映肝脏的功能状态。3、涵盖MRI、HH15、ICGR15、LHL15等四项
指标的定量评估肝脏储备功能的回归方程 Y ＝＝ 33．188 X Mi一 44．844 X
HH15＋24刀32 XLHL15—34．gl5XICGR15，能够对正常及四氯化碳肝硬化大
鼠模型的肝脏储备功能作出准确可靠的定量评估。
Objective: Liver is an organ that posses multiple physiological function, great regeneration potential and compensation. A great deal of processes such as digestion, metabolism, detoxication, excretion and immunity are undertaken in liver. At present, how to evaluate hepatic function reserve accurately is a challenge in treatment of liver disease.
There are many classical methods evaluating hepatic function reserve quantitatively, including Child classifying method of hepatic function, Child-Pugh classifying method, Safuji classifying method, and so on. ICG stress test is the popular method evaluating hepatic function reserve. In recent years, the quantitation of ASGP receptor by 99mTc-labeling neogalactoalbumin SPECT scintiscan is the up-to-date method that is applied to quantitatively evaluate hepatic function reserve. Literature reported that the capability of eliminating ASGP of the liver can be reflected more directly by this method, and correlative index can be applied to quantitatively evaluate hepatic function reserve. Analysing the surface ASGP receptor on separated liver cell by flow cytometer, and is a new method evaluating hepatic function reserve, however, this kind of study is still at its experiment stage. Asialofetuin (ASF) is the ligand of ASGP receptor residing on liver cell surface, can bind its receptor specifically and be degradat
eded by liver cell. Now ASF is applied to investigate ASGP receptor of liver extensively.
Whether or not can the indocyanogen green retention rate test be combined effectively with the correlative index of liver ASGP receptor nuclin scanning, so that a more accurate and more sensitive method of evaluating
quantitatively hepatic function reserve can be selected.
Aiming at above problems, the objective of this experiment is to discuss correlation between indices of SPECT liver ASGP receptor scintiscan with the ligand of 99mTc - ASF and classical liver functional index, and sensitivity of those indices. Further, we hope to choose a more sensitive parameter from those indices, and provide a guiding standard for clinical staff to select a quantitatively evaluation method of hepatic function reserve.
Methods: Wistar rats (male) were used to establish a model of carbon tetrachloride inducing cirrhosis and differently proportional resection of rodent liver. Classical liver functional index, indocyanogen green retention rate test, 15min ligand clearance estimated by liver ASGP receptor nuclin scanning (HH15), liver uptaking rate (LHL15), modified receptor index (MRI), and in vitro analysis of ASGP receptor on liver cell surface detected by Flow cytometer were investigated respectively. The correlation and sensitivity of each index were discussed.
The indices of differently damaged liver model and differently proportional resection of rodent liver such as Classical liver functional index, ICGR15,MRI,HH15,and LHL15,were be evaluated combined. And then a synthetic method including many indices of evaluating hepatic function reserve could be found out by regression analysis.
Statistic methods: Statistic data were expressed as M SD. And those data were analysed by software of SPSS and Microsoft Excel. Single equation variance analysis, COX regression, linearity correlation analysis , and X2 test were undertaken. The test standard was p<0.05.
Results: In the models of carbon tetrachloride inducing cirrhosis and differently proportional resection of rat liver, there was a significant correlation among commonly used indexes of hepatic functional reserve. The quantity of ASGP receptor of normal liver were significantly more than that of cihhorsis
by FCM. In the 15% losing of hepatic dimension, the change of hepatic functional reserve can not be reflected by ICGR15,that means this index is not sensitive enough. The sensitivity of those indices was that MRI , HH15>ICGR15>LHL15.The regression equation of evaluating hepatic functional reserve was that Y= 33.188 MRI-44.844 HH15+24.032 LHL15 - 34.915 ICGR15, and it was sensitive. When the evaluation coeffic
引文
1． 日本消化器病学会 肝机能研究班 肝机能的检查法选择基准(6版)，日消志，2001；98：200—205．
2. Didolkar MS et al. SGO, 1989, 169(1): 17-22.
3． 李秋梅等，吲哚氰绿试验诊断肝病的价值，山东医药，1999，39(11)．
4． 芳贺克夫：侵袭评价法，手术．小川道雄编．知侵袭．东京，1999，p20～23．
5． 张海山等，非唾液酸糖蛋白受体显像在评估肝脏储备功能方面的应用价值，中国实验诊断学，5(5)：265-267．
6． 张荣军，万卫星，陶永辉等正常及肝损害模型ASGP受体实验研究，中华核医学杂志，2001，21(1)：55—58．
7. Yen C F, Kalunta C I, Chen F S, et al. Flow cytometric evaluation of LDL receptors using DiI-LDL uptake and T lymphocytic cell lines, J Immunol Methods,1994, 177(S1～2): 55～67.
8． 倪腥之等，门静脉高压症大鼠肺组织结构变化与低氧血症的关系，中华普通外科学，2001，16(7)400403．
9． 浙江大学博士学位论文(2002)，大鼠小体积肝移植模型的建立及不同体积肝移植的疗效，博士生梁廷波，导师郑树森、范上达．
10． 张荣军等，肝ASGP受体功能显像剂的制备及显像研究，核技术，2000，23(11)：780～785．
11． 温守明等，半乳糖受体的糖蛋白类配体的制备与分析，空军总医院学报 1994：10(4)：200～201．
12． 李文新等，肝细胞表面去唾液酸糖蛋白受体的流式细胞分析，生物化学与生物物理进展，2000，27(4)：394～397．
13. Rechnagel RO, Carbon tctrachloride hepatoxicity: Stalus quo and future prospects, Trends pharmacol Sci 1983; 4: 129.
14．李秋梅等，吲哚氰绿试验诊断肝病的价值，山东医药，1999，39(11)．
15．李昆等吲哚氰绿储留试验对肝储备功能评估的意义，第三军医大学学报，1998年10月：457～458．
16. Matsumata T. Kanematsu T, Yoshiad Y et al: The indocianine green test enables prediction of postoperative complications after hepatic resection. World J Surg11: 678-681,1987.
17. Hirota M, Sugi K,Inoue M: Asialofetuin metabolism in animals with obstructve jaundice, Intern Hepatol Commun3: 184-189,1995.
18. Ashwell G, Morell AG: The roll of surface carbohydrates in the hepatic recognition and transport of circulating glycoproteins. Adv Enzymol 41: 99-128,1974.
19. Stockert RJ, Morell AG. Hepatic binding protein: The galactose specific receptor of mammalian hepatocyte[J]. Hepatology, 1983, 3: 750.
20. Matsuura S, Nakada T et al: Distribution of an Asialoglycoprotein receptor on rat hepatocyte cell surface. J Biol Chen 95: 864-875,1982.
21. stockert RJ, Morell AG. Hepatic binding protein: Thegalactose specific receptor of mammalian hepatocyte[J]. Hepatology, 1983, 3: 750.
22. Stockert RJ, Morell, AG. Hepatic binding protein: The galactose specific receptor of mammalian hepatocyte[J]. Hepatology, 1983, 3: 750.
23. Ashwell G, Steer CJ. Hepatic recognition and catabolism of serumgly coproteins[J]. JAMA, 1981, 246: 2358. 22.
24. Marshall JS, Williams S, Jones P et al: Serun desialylated glycoproteins in patients with hepatobiliary dysfunction. J Lab Clin Med92: 30-37, 1978.
25. Sobue G, Kosaka A: Asialoglycoproteinemia in a case of primary hepatic cancer, Hepatogastroenterology27: 200-203,1979.
26. Sawamura T, Nakada H, Hazama H et al: Hyperasialoglycoproteinemia in patients with chronic liver disease and/or liver cell carcunoma.Gastroenterology 87: 1217-1221,1984.
27. Sawamura T, Nakada H, Hazama H et al: Hyperasialoglycoproteinemia in patients with chronic liver disease and/or liver cell carcunoma.Gastroenterology 87: 1217-1221,1984.
28．河 相吉，羽间 弘，小岛真通：糖糖受容体系应用新肝机能检查法开发—第2报糖定量性检讨．核医 23：907—916，1986．
29．久保田佳嗣，小岛真通，河 相吉糖糖受容体系应用新肝机能检查法开发—第1报99mTc标识糖肝检讨，核医 23：899—905，1986．
30．羽间 弘，河 相吉，小岛真通：第3报99mTc标识糖曲线解析肝机能检查法检讨．核医 23：917—926，1986．
31．工藤正俊，藤堂影男：肝细胞膜—结合性放射性药剂99mTc标识Galactosylneoglycoalbumin肝机能评价基础的临床应用．核医 24：1653-1662，1987．
32．工藤正俊，藤堂影男：肝细胞膜表面Asialoglycoproteinemia receptor结合性标识合成糖肝机能预备力诊断能评价．肝脏 28：1277—1286，1987．
33．幕内雅敏，高山忠利，长谷川博：肝硬变合并肝癌Strategy．外科
诊疗 29：1530-1536，1987．
34．田岛义证，富冈 勉，前田茂人：99mTc—GSA高度闭塞性黄疸症例肝预备能评估，日消外会志 32：528(618)，1999．
35. Klingensmith WC, Johnson CC et al: Complimentary role of Tc-99m-diethyl-IDA-and ultrasound in large and small duct biliary tract obstruction, Radiology 138: 177-184,1981.
36. Kudo M, Vera DR, Stadalnik RC, et al. In vivo estimation of hepatic binding protein concentration: correlation with classical indicators hepatic functional reserve[J]. Am J Gastroenterol, 1990, 85: 1142.
37．森敬一郎 他．综合临床，1990；39(7)：1826—1832．
2. Didolkar MS et al. SGO, 1989, 169(1): 17-22.
3． 李秋梅等，吲哚氰绿试验诊断肝病的价值，山东医药，1999，39(11)．
4． 芳贺克夫：侵袭评价法，手术．小川道雄编．知侵袭．东京，1999，p20～23．
5． 张海山等，非唾液酸糖蛋白受体显像在评估肝脏储备功能方面的应用价值，中国实验诊断学，5(5)：265-267．
6． 张荣军，万卫星，陶永辉等正常及肝损害模型ASGP受体实验研究，中华核医学杂志，2001，21(1)：55—58．
7. Yen C F, Kalunta C I, Chen F S, et al. Flow cytometric evaluation of LDL receptors using DiI-LDL uptake and T lymphocytic cell lines, J Immunol Methods,1994, 177(S1～2): 55～67.
8． 倪腥之等，门静脉高压症大鼠肺组织结构变化与低氧血症的关系，中华普通外科学，2001，16(7)400403．
9． 浙江大学博士学位论文(2002)，大鼠小体积肝移植模型的建立及不同体积肝移植的疗效，博士生梁廷波，导师郑树森、范上达．
10． 张荣军等，肝ASGP受体功能显像剂的制备及显像研究，核技术，2000，23(11)：780～785．
11． 温守明等，半乳糖受体的糖蛋白类配体的制备与分析，空军总医院学报 1994：10(4)：200～201．
12． 李文新等，肝细胞表面去唾液酸糖蛋白受体的流式细胞分析，生物化学与生物物理进展，2000，27(4)：394～397．
13. Rechnagel RO, Carbon tctrachloride hepatoxicity: Stalus quo and future prospects, Trends pharmacol Sci 1983; 4: 129.
14．李秋梅等，吲哚氰绿试验诊断肝病的价值，山东医药，1999，39(11)．
15．李昆等吲哚氰绿储留试验对肝储备功能评估的意义，第三军医大学学报，1998年10月：457～458．
16. Matsumata T. Kanematsu T, Yoshiad Y et al: The indocianine green test enables prediction of postoperative complications after hepatic resection. World J Surg11: 678-681,1987.
17. Hirota M, Sugi K,Inoue M: Asialofetuin metabolism in animals with obstructve jaundice, Intern Hepatol Commun3: 184-189,1995.
18. Ashwell G, Morell AG: The roll of surface carbohydrates in the hepatic recognition and transport of circulating glycoproteins. Adv Enzymol 41: 99-128,1974.
19. Stockert RJ, Morell AG. Hepatic binding protein: The galactose specific receptor of mammalian hepatocyte[J]. Hepatology, 1983, 3: 750.
20. Matsuura S, Nakada T et al: Distribution of an Asialoglycoprotein receptor on rat hepatocyte cell surface. J Biol Chen 95: 864-875,1982.
21. stockert RJ, Morell AG. Hepatic binding protein: Thegalactose specific receptor of mammalian hepatocyte[J]. Hepatology, 1983, 3: 750.
22. Stockert RJ, Morell, AG. Hepatic binding protein: The galactose specific receptor of mammalian hepatocyte[J]. Hepatology, 1983, 3: 750.
23. Ashwell G, Steer CJ. Hepatic recognition and catabolism of serumgly coproteins[J]. JAMA, 1981, 246: 2358. 22.
24. Marshall JS, Williams S, Jones P et al: Serun desialylated glycoproteins in patients with hepatobiliary dysfunction. J Lab Clin Med92: 30-37, 1978.
25. Sobue G, Kosaka A: Asialoglycoproteinemia in a case of primary hepatic cancer, Hepatogastroenterology27: 200-203,1979.
26. Sawamura T, Nakada H, Hazama H et al: Hyperasialoglycoproteinemia in patients with chronic liver disease and/or liver cell carcunoma.Gastroenterology 87: 1217-1221,1984.
27. Sawamura T, Nakada H, Hazama H et al: Hyperasialoglycoproteinemia in patients with chronic liver disease and/or liver cell carcunoma.Gastroenterology 87: 1217-1221,1984.
28．河 相吉，羽间 弘，小岛真通：糖糖受容体系应用新肝机能检查法开发—第2报糖定量性检讨．核医 23：907—916，1986．
29．久保田佳嗣，小岛真通，河 相吉糖糖受容体系应用新肝机能检查法开发—第1报99mTc标识糖肝检讨，核医 23：899—905，1986．
30．羽间 弘，河 相吉，小岛真通：第3报99mTc标识糖曲线解析肝机能检查法检讨．核医 23：917—926，1986．
31．工藤正俊，藤堂影男：肝细胞膜—结合性放射性药剂99mTc标识Galactosylneoglycoalbumin肝机能评价基础的临床应用．核医 24：1653-1662，1987．
32．工藤正俊，藤堂影男：肝细胞膜表面Asialoglycoproteinemia receptor结合性标识合成糖肝机能预备力诊断能评价．肝脏 28：1277—1286，1987．
33．幕内雅敏，高山忠利，长谷川博：肝硬变合并肝癌Strategy．外科
诊疗 29：1530-1536，1987．
34．田岛义证，富冈 勉，前田茂人：99mTc—GSA高度闭塞性黄疸症例肝预备能评估，日消外会志 32：528(618)，1999．
35. Klingensmith WC, Johnson CC et al: Complimentary role of Tc-99m-diethyl-IDA-and ultrasound in large and small duct biliary tract obstruction, Radiology 138: 177-184,1981.
36. Kudo M, Vera DR, Stadalnik RC, et al. In vivo estimation of hepatic binding protein concentration: correlation with classical indicators hepatic functional reserve[J]. Am J Gastroenterol, 1990, 85: 1142.
37．森敬一郎 他．综合临床，1990；39(7)：1826—1832．