원저 Lab Med Online Vol. 3, No. 4: 191-197, October 2013 진단혈액학 혈소판기능측정기 Multiplate 지표의한국인참고치에대한기초자료 Basic Data for Reference Intervals in Koreans for Parameters Produced by Multiplate Platelet Function Analyzer 백세연 1 홍지만 2 임영애 3 Sae Yun Baik, M.D. 1, Ji Man Hong, M.D. 2, Young Ae Lim, M.D. 3 녹십자의료재단 1, 아주대학교의과대학신경과학교실 2 진단검사의학교실 3 Green Cross Laboratories 1, Yongin; Departments of Neurology 2 and Laboratory Medicine 3, Ajou University School of Medicine, Suwon, Korea Background: The Multiplate analyzer (Dynabyte GmbH) has been recently introduced as a platelet function test for patients taking antiplatelet drugs. The study aimed at providing basic data for determining the reference interval of parameters produced by Multiplate in Koreans and to study the factors that influence those parameters. Methods: Blood was collected from 35 healthy volunteers (female 18, male 17) into tubes containing hirudin or 3.2% sodium citrate. Whole blood platelet aggregations triggered by adenosine-5 -diphosphate (ADP), ADP-high sensitive (ADP+PGE1 only in hirudin samples), arachidonic acid (AA), collagen or thrombin receptor activator peptide (TRAP) were investigated using Multiplate according to the manufacturer s instructions. Data from healthy volunteers for the area under the curve (AUC) were determined from the central 95th percentile of the results. Results: The values of AUC in hirudin samples for all agonists were significantly higher than those in sodium citrate samples. The AUC values in hirudin (sodium citrate) samples were as follows: ADP 38-107 (18-119) U; ADP+PGE1 16-91 U; AA 64-156 (32-117) U; collagen 53-112 (26-108) U; and TRAP 81-163 (49-149) U. The parameters from Multiplate were significantly correlated with leukocyte counts, but not with hematocrit levels. Conclusions: Although our data were derived from only 35 subjects, the results are expected to be helpful in determining the reference interval at a single institute and may serve as basic data for future cumulative data of reference intervals from multiple institutes in Korea. Key Words: Reference intervals, platelet function, Multiplate analyzer 서론 항혈소판제를복용하거나복용할예정인환자들에서약물에대 한반응여부를확인하기위해서는혈소판기능검사가필요하다. 이 Corresponding author: Young Ae Lim Department of Laboratory Medicine, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon 443-721, Korea Tel: +82-31-219-5786, Fax: +82-31-219-5778 E-mail: limyoung@ajou.ac.kr Received: September 10, 2012 Revision received: December 11, 2012 Accepted: December 14, 2012 This article is available from http://www.labmedonline.org 2013, Laboratory Medicine Online This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 러한목적으로현재사용되는혈소판기능검사로는 1960년대에개발된고전적인광투과식응집측정기 (light transmission ag- gregometry) 가있으나혈소판풍부혈장의제조로많은검체량이필요하고검사시간이길고복잡하다는단점때문에실제항혈소판약물의추적기능검사로사용하기에는어려웠다. 이러한단점을보완하여간편하게검사할수있는장비들이현재국내에소개되고있는데, VerifyNow (Accumetrics, San Diego, CA, USA) 와 Multiplate (Dynabyte GmbH, Munich, Germany) 장비이다 [1, 2]. 이중 Multiplate는새롭게국내에소개된장비로서광투과식응집측정기의변형형태인전기장애법 (electric impedance method) 을이용하며혈소판풍부혈장대신 300 μl의소량의전혈을이용하여 10분내에간편하게혈소판기능을평가할수있는장비이다. 더욱이검사당한개의 test cell을이용하지만각검사당 2개의감지기에서결과값이측정되어이들의평균값을제공하므로재현성이검증되는장점이있다 [3]. eissn 2093-6338 www.labmedonline.org 191
일반적으로혈소판기능의평가에사용되는검체는혈액응고검사에이용되는 sodium citrate를사용하고있으나, 이는칼슘이온을소진시키므로혈소판응집능검사에적합하지않다는보고가있다 [4]. 반면에 hirudin은보관검체에서더안정하며생리학적인칼슘수치를방해하지않는트롬빈억제제로 Multiplate장비에서는 sodium citrate 대신권장하고있는항응고제이다 [3]. Hirudin 검체를이용한 Multiplate 검사의참고치에대한일부외국보고들은있다 [5-7]. Multiplate를사용하여연구한국내보고는한기관에서만 sodium citrate로측정하여시행하였던보고이며 [1, 2], 한국인을대상으로한 Multiplate 참고치설정에대한초록보고가있었으나이역시 hirudin이아닌 sodium citrate에대한보고였으며 adenosine-5 -diphosphate (ADP) 와 arachidonic acid (AA) 에대한참고치만이있다 [8]. Multiplate 장비는분석을위하여제조사에서 3가지의지표를제시하는데, area under the curve (AUC), 분석중임피던스의증가 (increase of impedance during analysis, aggregation) 그리고응집의최대기울기 (maximal slope of aggregation, velocity) 이다. 이중진단시권장되는지표는 AUC로서 1 U는 10 AU min에해당되는데, 앞서언급한보고들은모두 AUC에대해서만참고치를산정하여보고하였다. 현재국내에 Multiplate 장비가보급되어사용되고있으나, 참고치산정을위하여정상인의자료를분석한보고는없는실정이다. 이는시약이비교적고가이고단일기관에서다수의정상인피험자를모집하기쉽지않기때문으로생각한다. 따라서이연구에서는한국인의 hirudin과 sodium citrate로채혈한검체에서응집촉진제로 ADP와 AA 이외에 ADP보다민감한지표인 ADP에 progstaglandin E1 (ADP+PGE1), thrombin receptor activating peptide (TRAP) 와 collagen을사용하였다. 또한 Multiplate 장비에서제공되는지표인 AUC 이외에도 aggregation과 velocity 지표에대하여정상인의자료를분석하고, hirudin과 sodium citrate 검체의연관성과 Multiplate 지표들에미치는요인들을조사하여 Multiplate 검사결과를판독하거나, 참고자료로이용하는데도움을주고, 추후국내참고치설정을위하여국내다기관자료축적을위한기본자료로서제공하고자하였다. 대상및방법 1. 채혈 연구계획서는아주대학교병원연구윤리심의위원회 (IRB) 에서승인을받았다. 대상자는혈색소를제외한건강검진상헌혈자선별검사상헌혈자로합당하였던 20세부터 50세까지 35명의건강인이었다. 연구서에동의한대상자중일주일이내에약물복용력이없는경우에채혈하였다. 21G 주사기를이용하여정맥에서 3개의시험관에채혈하였는데, 첫번째채취시유래될수도있는조직인자 (tissue factor) 가혈소판기능에미치는영향을최소화하기위하여첫번째시험관은 K2-EDTA (Becton Dickinson, Franklin Lakes, NJ, USA) 에채혈한후에 Multiplate 측정을위하여 3.2% sodium citrate (Becton Dickinson), 그리고 hirudin (Multiplate Service GmbH, Munich, Germany) 25 μg/ml 시험관순서로각각 3 ml씩채혈하였다 [6]. 채혈후에검체를잘혼합한후검사전까지실온에보관하였는데, 검사는채혈후 0.5-2시간이내모두시행하였다. 이중 K2-EDTA 혈액은혈액형과일반혈액검사를측정하는데사용하였고, 일반혈액검사는 LH750 (Beckman-Coulter, Brea, CA, USA) 을이용하여측정하였다. 2. Multiplate를이용한혈소판응집능검사혈소판응집능검사는시약과제품설명서에따라시행하였다. 즉, Multiplate 장비에전극이부착된 test cell들을넣은뒤여기에 hirudin 혹은 sodium citrate 전혈과미리 37 로가온한희석액인생리식염수를 300 μl씩모두넣은후각각에혈소판응집촉진제를 20 μl씩넣고반응시킨후장비에서산출되는결과값을확인하였다. 혈소판응집촉진제는모두 Dynabyte GmBH사 (Munich, Germany) 제품을이용하였는데, 최종농도가 6.5 μm ADP (ADPtest), 6.5 μm ADP와 9.4 nm PGE1 (ADPtest HS), 0.5 mm AA (ASPItest), 3.2 μg/ml collagen (COLtest), 32 μm thrombin receptor activator peptide (TRAPtest) 가되도록하였다. Multiplate 지표는항응고제종류에따른각혈소판응집촉진제의 AUC (U=10 AU*min), aggregation (AU), 그리고 velocity (AU/min) 에대하여분석하였다. 3. 통계처리모든자료는평균 ± 표준오차로나타내었으며, 통계프로그램은 SPSS 12.0.1 for Windows (SPSS, Chicago, IL, USA) 와 Microsoft Office Excel 2007 (Microsoft, USA) 를사용하였다. 정상인의자료분석에는중앙 95 백분위수 (2.5-97.5 백분위수 ) 로정하였다 [5, 6]. 모든자료는 Kolmogorov-Smirmov 시험을실시하여, 모두정규분포를보임을확인하였다. 남녀및혈액형비교에는 Student s t-test, hirudin과 sodium citrate 항응고제비교에는 paired t-test를시행하였다. 상관성분석에는 Pearson 상관계수를구하였다. P <0.05인경우를통계학적으로유의한것으로간주하였다. 결과 1. 대상자특성 35 명의대상자들은여자 18 명, 남자 17 명으로평균연령 ( 범위 ) 은 192 www.labmedonline.org
31.9 ±1.2세 (22-48세) 였다. 이들의혈액형은모두 Rh 양성으로 ABO 혈액형은 A형 11명, B형 17명, O형 4명그리고 AB형 3명이었다. 평균혈소판수 239±6 10 9 /L (161-372 10 9 /L), 혈색소 13.8± 0.3 g/dl (11.3-16.8 g/dl), 백혈구수 6.3±0.2 10 6 /L (4-10.8 10 6 / L) 였다. 혈색소와혈소판수는남녀에따라차이를보였다. 2. 항응고제에따른 Multiplate 지표의비교 ADP 첨가시의 AUC와 aggregation을제외하고는, hirudin 검체의 AUC, aggregation 및 velocity 들은다른모든혈소판응집촉진제첨가시 sodium citrate 검체의결과보다유의하게높은값을나타내었다 (Table 1). 또한 TRAP을첨가한경우의 AUC 값을제외하고는, 다른혈소판응집촉진제첨가시 AUC, aggregation 및 velocity 자료들은 hirudin 검체와 sodium citrate 검체가유의한상관관계를나타내었다 (Table 1). 여성과남성의 AUC, aggregation, 그리고 velocity 값은대부분유의한차이가없었으나, hirudin 검체의 ADP velocity 값이여성 15.5±3.5 U로남성 12.5±2.9 U에비하여유의하게높았으며 (P = 0.01), sodium citrate 검체의 AA의 velocity 값이여성 18.8±5.6 U 로남성 15.6±2.8 U에비하여유의하게높았다 (P = 0.039). 3. Multiplate 지표에대한정상인의자료분석 Hirudin 검체의 AUC 분석자료는 ADP 38-107 U, ADP+PGE1 16-91 U, AA 64-156 U, collagen 53-112 U 그리고 TRAP 81-163 U였다. Sodium citrate 검체의 AUC 분석자료는 ADP 18-119 U, AA 32-117 U, collagen 26-108 U, 그리고 TRAP 49-149 U였다. 대부분의결과가 hirudin 검체에비하여 sodium citrate 검체의자료범위가넓은양상을보였다 (Table 2). 4. 기타요인과 Multiplate 지표와의상관성 Multiplate의분석지표인 AUC와 aggregation, AUC와 velocity, 그리고 aggregation과 velocity 지표는서로가항응고제나혈소판응집촉진제에상관없이모두 P <0.001의유의한상관성을보여지 Table 1. Comparison and Pearson s correlations (R value) for parameters from the Multiplate analyzer according to the anticoagulants and plateletaggregating agents Parameter Platelet aggregating agents (final concentration) ADP (6.5 μm) AA (0.5 mm) Collagen (3.2 μg/ml) TRAP (32 μm) AUC Hirudin 65.6±2.7 100.8±3.1 82.0±2.5 124.5±3.1 (U) Na-citrate 63.6±3.6 69.9±3.2 61.5±3.0 109.5±3.4 P value* 0.377 <0.001 <0.001 0.001 R 0.779 0.815 0.6696 0.195 Aggregation Hirudin 120.4±4.4 178.5±5.2 175.5±4.5 212.1±5.3 (AU) Na-citrate 121.0±6.4 114.7±5.7 150.9±5.0 173.8±4.9 P value* 0.903 <0.001 <0.001 <0.001 R 0.749 0.589 0.590 0.583 Velocity Hirudin 14.0±0.6 22.9±0.7 20.2±0.6 26.6±0.7 (AU/min) Na-citrate 12.9±0.7 17.3±0.8 18.1±0.8 28.4±0.9 P value* 0.024 <0.001 0.011 0.045 R 0.708 0.803 0.353 0.412 *P values for data of hirudin versus Na-citrate by Student s t-test; P <0.001; P <0.05. Abbreviations: ADP, adenosine diphosphate; AA, arachidonic acid; TRAP, thrombin receptor activator peptide; AUC, area under the curve. Table 2. Reference range (central 95th percentile) for parameters from the Multiplate analyzer according to the anticoagulants and aggregating agents Parameter Anticoagulants Aggregating agents (final concentration) ADP (6.5 μm) ADP+PGE1 (6.5 μm) AA (0.5 mm) Collagen (3.2 μg/ml) TRAP (32 μm) AUC Hirudin 38-107 16-91 64-156 53-112 81-163 (U) Na-citrate 18-119 ND 32-117 26-108 49-149 Aggregation Hirudin 74.6-184.9 34.5-155.6 125.3-282.8 118.9-243.8 132.4-275.3 (AU) Na-citrate 34.1-210.4 ND 13.9-197.3 97.9-230.3 120-236.3 Velocity Hirudin 8.3-23.5 4.5-19.8 15.4-31 14.2-27.2 19.5-35.2 (AU/min) Na-citrate 4.9-22.5 ND 8-28.5 13-40.2 16.4-42.5 Abbreviations: ADP, adenosine diphosphate; PGE1, prostaglandin E1; AA, arachidonic acid; TRAP, thrombin receptor activator peptide; AUC, area under the curve; ND, not done. www.labmedonline.org 193
Table 3. Pearson s correlations between parameters from the Multiplate analyzer according to the anticoagulants and platelet-aggregating agents Parameter Table 4. Pearson s correlations between hematologic parameters, age and AUC (U) according to the anticoagulants and aggregating agents Factor Aggregating agents ADP ADP+PGE1 AA Collagen TRAP Platelet Hirudin 0.608* 0.506 0.363 0.457 0.222 Na-citrate 0.361 ND 0.409 0.311 0.094 Hb Hirudin -0.206-0.056 0.037 0.077 0.155 Na-citrate -0.065 ND -0.183 0.116 0.289 Hct Hirudin -0.201-0.049 0.035 0.082 0.144 Na-citrate -0.072 ND -0.174 0.109 0.28 WBC Hirudin 0.522 0.422 0.667* 0.586* 0.54 Na-citrate 0.418 ND 0.653* 0.564* 0.436 Age Hirudin 0.056 0.038 0.254 0.103 0.203 Na-citrate 0.13 ND 0.092 0.355-0.185 *P <0.001; P <0.01; P <0.05. For abbreviation and final concentration of aggregating agents, see Table 2. Platelet aggregating agents ADP ADP+PGE1 AA Collagen TRAP AUC-aggregation 0.969 0.948 0.969 0.914 0.811 AUC-velocity Hirudin 0.934 0.986 0.935 0.902 0.921 Aggregation-velocity 0.839 0.971 0.733 0.734 0.672 AUC-aggregation 0.976 NA 0.797 0.915 0.933 AUC-velocity Na-citrate 0.987 NA 0.964 0.746 0.834 Aggregation-velocity 0.962 NA 0.799 0.802 0.678 All correlation coefficiencts were significant (P <0.001). For abbreviations and final concentration of aggregating agents, see Table 2. 표끼리매우연관이있음을알수있었다 (Table 3). AUC 지표와연관성이있는요인들을살펴본결과 hirudin 검체를사용할경우, 혈소판수치는 TRAP를제외한혈소판응집촉진제와양의상관관계를, 그리고백혈구수치는모든혈소판응집촉진제에서 AUC와양의상관관계를보였다. Sodium citrate 검체를사용할경우에는혈소판수는 ADP와 AA, 백혈구수는모든혈소판응집촉진제, 그리고연령은 collagen AUC와양의상관관계를보였다 (P = 0.036). 혈색소와헤마토크리트치는모든혈소판응집촉진제에서두가지항응고제와 AUC 사이에는연관성이없었다 (Table 4). 자료는제시하지않았으나 O형과 O형이아닌군에서의모든지표들은차이가없었으며, velocity 는항응고제상관없이 ADP와 AA 첨가시혈소판수와양의상관관계를보이며, velocity 와 aggregation 지표는 AUC처럼백혈구수와는모든항응고제와혈소판응집촉진제에서양의상관관계를보였다. 고찰 이연구에서대부분의혈소판응집촉진제첨가시 AUC 뿐만아니라 aggregation 및 velocity 자료들도두가지항응고제검체들 사이에유의한상관관계가있음을확인하였다. 그러나 sodium citrate 검체를사용할경우에는 hirudin 검체에비하여, ADP 첨가시 AUC와 aggregation을제외하고는, 모두유의하게낮은값을나타내었다. 이연구는채혈 30분에서 2시간이내에시행되었는데, 혈소판응집능검사시혈소판의반응의주요변화는채혈 30분에서 2시간이내에발생하며, citrate 검체는시간이경과할수록응집능이손상되므로혈소판기능검사에 citrate 검체는권장되지않는다고하였다 [9]. 또한이연구에서 ADP 첨가시혈소판응집능이감소되지않았던이유는 citrate 검체는이온화칼슘의환원을유도하여 ADP에의한혈소판반응을강화시킨다는사실과관련이있는것으로생각된다 [10]. 반면트롬빈억제제는트롬빈형성이나트롬빈-유도혈소판활성을억제하지않으므로 [11], hirudin 검체는혈소판응집시좀더안정적인환경을제공하며 citrate 검체에비하여일간변이도적었다고하였다 [5]. 따라서 Multiplate 장비이용시채혈후즉시검사가시행되지않는다면가능한 hirudin 검체를사용하는것이안정적인결과를줄것으로생각되었다. 이연구에서일부응집촉진제를이용할때 velocity 를제외한다른 Multiplate 지표들이여성과남성의자료에차이가없었으므로외국의자료처럼 [5, 6] 합쳐서자료를분석하였다. Ruback 등 [5] 은 194 www.labmedonline.org
Table 5. Comparison of reference intervals of AUC (U) according to data from references (final conc.) Platelet aggregating agents ADP (6.5 μm) ADP+PGE1 (6.5 μm) AA (0.5 mm) Collagen (3.2 μg/ml) TRAP (32 μm) Reference (N) Hirudin 38-107 16-91 64-156 53-112 81-163 Ours (35) 48.3-117.3 ND 68.5-132.3 56-107 ND 5 (116-119) * 53-122 ND 74-136 46-116 94-156 7 (57-206) * Na-citrate 18-119 ND 32-117 26-108 49-149 Ours 38-119 ND 20-116 40-121 ND 6 (120) 21-81 ND 31-79 ND ND 8 (125) For abbreviations, see Table 2. *The number of individuals for the reference intervals of AUC differs according to agonist. 여성이더높은 AUC 값을보이기는하나그차이가미미하므로남녀를합쳐참고치를산정하였다고하였다. 이연구의결과와같이혈소판응집능은성별에차이가없다는보고들과 [6, 12] 여성이남성보다더높은혈소판응집능을보인다는보고들이있다 [5, 13-15]. 후자의이유로는 citrate 검체사용시낮은헤마토크리트를보이는노인이나여성은남성에비하여혈장내 citrate 농도가낮아서혈소판응집능이더높은것이라고설명하고있다 [13]. 그러나이는 hirudin 검체를사용한경우에는설명이되지않으며 Multiplate 장비를이용한이연구와 Ruback 등 [5] 보고에서는헤마토크리트와관련이없었으므로헤마토크리트와성별에따른차이를설명하기에는부족한것으로생각된다. 이이외도호르몬에의한영향으로도설명하기도하나 [14, 16] 명확한기전은잘알려져있지않다. 따라서혈소판응집능의성별에따른영향여부및그원인그리고 Multiplate 지표의성별에따른영향여부에대한추후연구가더필요할것으로생각된다. 이연구의정상인의분석결과에서동일한혈소판응집촉진제의경우 hirudin 검체가 sodium citrate 검체에비하여더높은경향과더좁은범위를보여주었는데 (Table 5), 국내외보고도이와유사하였다 [5-8]. 이러한현상은앞서지적한바와마찬가지로 hirudin 검체가 citrate 검체에비하여안정적인환경을제공하기때문으로생각된다. 인종에따라 Multiplate 지표들이어떠한영향에대한보고는없으므로이연구는한국인에서결과를해석에도움을줄것으로생각되었다. 이연구에서백혈구수는항응고제에상관없이 AUC와양의상관관계를보여주었다. 이러한양의상관관계는 Ruback 등 [5] 연구와는일치하는소견이었으나 Seyfert 등 [6] 은 AUC와백혈구수간에유의한상관관계는없었다고보고하였다. 백혈구로부터유래하는 cathepsin, elastase 등이혈소판을활성화시킬수있다 [17]. 그러나백혈구는혈소판응집시탈인산화과정을통하여 ATP를 ADP 로전환시켜응집을촉진하거나혹은 ADP를 AMP로전환시켜 ADP 유도응집을억제할수있으므로백혈구수가증가된경우에는이러한균형에영향을미칠수있다는보고도있다 [18]. 따라서 백혈구수와혈소판응집능과의관련성을단정적으로정의하기는어려운것으로여겨졌다. 또한 hirudin 검체를이용한본연구와 Ruback 등 [5] 은혈소판수와 ADP, AA와 collagen의 AUC와양의상관관계를보여주었으며, Seyfert 등 [6] 은 AA를제외한두가지혈소판응집촉진제에서양의상관관계를보여주어 AUC와혈소판수와의양의상관관계에대해서는다른연구들과도일치하는소견이었다. 이연구와같이 AUC와혈소판수혹은백혈구수와의양의상관관계는정상인뿐만이아니라아스피린복용중인관상동맥질환환자들에서도 collagen 10 μg/ml, AA 1 mm를사용할경우나타났는데, 특히, 혈소판수와혈소판응집능과의양의관계는 VerifyNow 보다 Multiplate 에서더현저하다고하였다 [19]. 이러한현상은전기장애법을이용한 Multiplate 와혼탁도광측정법 (turbidimetric optical detection) 을이용한 VerifyNow 각장비의원리의차이에의한가능성이있으므로, Multiple 지표들의해석시는이점에유의할필요가있을것으로여겨졌다. Hirudin 검체는연령과연관성이없었는데, 이러한소견은 17세부터 66세까지의건강인을대상으로할경우 Multiplate 지표들이연령에따른연관성이없었다는보고와일치하였으므로 [5], 성인에서연령에따른지표들의자료분석은큰의미가없는것으로생각되었다. O형은 von Willebrand factor의항원과 ristocetin cofactor 가 O형이외의혈액형에비하여낮으며, Thrombostat 4000과 PFA- 100 장비의 closure time이차이는크지않으나유의하게지연되었다는보고가있다 [20]. 비록이연구에서 O형이 4명밖에되지않았으나 O형과 A형은혈소판응집에차이가없었다는 Aylett와 Wilkinson의연구의결과와같이 [21] O형과 O형이외의혈액형사이의 Multiple 지표들은유의한차이가없었다. 이연구의제한점으로는정상인자료분석에참여한대상군이총 35명으로대상군이 100명을넘는다른보고들에 [5, 6, 8] 비하여적다는점이다. 본연구의분석결과범위가다른연구의결과의범위에비하여넓게설정되었는데, 이것이다른보고에비하여대상군이적기때문인지혹은다른이유때문인지는좀더보강되어져야할부분으로여겨졌다. 또한이연구의자료를바탕으로추후 www.labmedonline.org 195
국내다기관의자료가축적되어더많은한국인정상인을대상으로한참고치를설정하는데기본자료로유용하게사용될수있을것이다. 두번째제한점으로는이연구에서분석한것은약물을복용하지않은정상인을대상으로한결과이므로이범위가항혈소판약물을사용하는환자에게약물반응효과를판정하는지표로사용될수있는지여부에대해서는추가연구가필요할것이다. 외국보고에서도참고치와항혈소판치료제사용시의목표치, 그리고혈소판수혈의적응증을달리산정한보고가있기때문이다. 즉 AA와 ADP의참고치는각각 74-136 U, 53-122 U로산정하였으나항혈소판치료제사용시의목표치는각각 <30 U, <50 U, 그리고혈소판수혈의적응증은각각 <20 U, <30 U으로산정하였다 [7]. 세번째제한점으로는 AUC 이외에도정상인에서자료를분석한 aggregation 이나 velocity 에대한임상적의의에관한연구가없었기에이를더분석할수는없었다. 이들에대한임상적활용에대해서도추후더연구되어야할부분으로생각하였다. 결론적으로본연구에서는국내에서는처음으로 3.2% sodium citrate와 hirudin 검체에서 ADP, ADP+PGE1, AA, collagen 과 TRAP 첨가시 Multiplate 에서산출되는지표들의참고치산정을위한기본자료를제공하여항응고제종류에따른다양한혈소판응집촉진제의 AUC 결과해석에도움을줄수있을뿐만이아니라, aggregation이나 velocity 를이용한연구에도참고자료로도움을줄것으로생각한다. 요약 배경 : Multiplate (Dynabyte GmbH, Munich, Germany) 장비는항혈소판복용약물환자의혈소판기능검사로최근국내에소개되었다. 이연구는 Multiplate 관련지표들에대한한국인에서의참고치설정을위한기본자료를제공하고, 지표들에미치는영향을살펴보고자하였다. 방법 : 35명의건장한지원자로부터 ( 여성 18명, 남성 17명 ) hirudin 과 3.2% sodium citrate 시험관에채혈하였다. 채혈한전혈에 adenosine-5 -diphosphate (ADP), ADP-high sensitiv (ADP+PGE1, hirudin 검체만시행 ), arachidonic acid (AA), collagen 및 thrombin receptor activator peptide (TRAP) 를넣고제조사의지시에따라 Multiplate 장비로혈소판응집능검사를시행하였다. 건강한지원자로부터얻어진 area under the curve (AUC) 지표에대한자료는중앙 95 percentile로산정하였다. 결과 : 모든응집촉진제에서 AUC는 hirudin 검체에서 sodium citrate 검체의결과값보다모두유의하게높았다. Hirudin (sodium citrate) 검체의 AUC 결과는 ADP 38-107 (18-119) U, ADP+PGE1 16-91U, (AA) 64-156 (32-117) U, collagen 53-112 (26-108) U, TRAP 81-163 (49-149) U였다. Multiplate의지표들은헤마토크리트와는연관이없었으나백혈구수와는양의상관관계를보였다. 결론 : 비록대상군이 35명밖에되지않지만이자료들은단일기관의참고치를결정하는데도움을주며향후국내의다기관으로부터유래될참고치의누적자료에대한기본자료를제공하는데도움을줄것으로생각한다. REFERENCES 1. Woo KS, Kim BR, Kim JE, Goh RY, Yu LH, Kim MH, et al. Determination of the prevalence of aspirin and clopidogrel resistances in patients with coronary artery disease by using various platelet-function tests. Korean J Lab Med 2010;30:460-8. 2. Yoo NT, Bae HJ, Kim JE, Goh RY, Han JY, Kim MH, et al. Aspirin resistance may not be associated with clinical outcome after acute ischemic stroke: comparison with three different platelet function assays. Korean J Stroke 2012;14:35-42. 3. Tóth O, Calatzis A, Penz S, Losonczy H, Siess W. Multiple electrode aggregometry: a new device to measure platelet aggregation in whole blood. Thromb Haemost 2006;96:781-8. 4. Packham MA, Bryant NL, Guccione MA, Kinlough-Rathbone RL, Mustard JF. Effect of the concentration of Ca2+ in the suspending medium on the responses of human and rabbit platelets to aggregating agents. Thromb Haemost 1989;62:968-76. 5. Rubak P, Villadsen K, Hvas AM. Reference intervals for platelet aggregation assessed by multiple electrode platelet aggregometry. Thromb Res 2012;130:420-3. 6. Seyfert UT, Haubelt H, Vogt A, Hellstern P. Variables influencing MultiplateTM whole blood impedance platelet aggregometry and turbidimetric platelet aggregation in healthy individuals. Platelets 2007; 18:199-206. 7. Görlinger K, Jambor C, Hanke AA, Dirkmann D, Adamzik M, Hartmann M, et al. Perioperative coagulation management and control of platelet transfusion by point-of-care platelet function analysis. Transfus Med Hemother 2007;34:396-411. 8. Park SJ, Chi HS, Min SK, Choi MO, Jang S, Park CJ. Predicting response to antiplatelet drugs with the Multiplate analyzer. Korean J Lab Med 2008;28(S2):S476. 9. Kalb ML, Potura L, Scharbert G, Kozek-Langenecker SA. The effect of ex vivo anticoagulants on whole blood platelet aggregation. Platelets 2009;20:7-11. 10. Heptinstall S and Taylor PM. The effects of citrate and extracellular cal- 196 www.labmedonline.org
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