417
S-13-4
Serum
and
Liver
Concentrations Surgical
K in
Patients
H. Tanimura,
Department of 27 Shichibancho,
of Vitamin
and T. Tsuji
Gastroenterological Surgery, Wakayama 640(Japan)
Wakayama
Medical
College,
I.
INTRODUCTION Vitamin K1 (Phylloquinone) and K2 (Menaquinone-4) as two commercially available drugs in Japan are routinely utilized in patients before and after surgery. However, the metabolism of the vitamin Ks in the human body and the optimal dose for surgical patients are not clear. Recently small amount of Phylloquinone and Menaquinones can be determined by HPLC that enabled simultaneous determination of Phylloquinone and Menaquinones in the plasma and the liver tissue from surgical patients. In addition to the change of the vitamin K concentration in various cases including postoperative patients, we have been studying clotting functions.
II.
MATERIALS The
AND
analytic
method
column
temperature
and
was
methanol, 0.6
slope
and is
so
tissue
can
dependent
vitamin
be
measured
clotting
biliary in vitamin
cirrhotic
in
22
the
tumor,
clotting
up proteins
and
assessing and
11
13
conhuman K-
carboxylase
free
levels
in Vitamin
and
y
in
—Gla.
1
hepatocellular
3
hemangioma,
hepatocellular the
gradient The
to
minutes.
with
was rate
none-4, Our
flat.
K as
one flow
Menaqu
MK-4
hepatolithiasis,
cases,
followed
75 vitamin
patients 4
of
almost
urine
hepatectomized
non-cirrhotic were
by
an whose
used,
separated.
and
as
The
peak
within
into
liver
the
remains
activated
C-18 column,
were
sufficiently line
NOVA-PAK reduction
isopropanol.
Phylloquinone
are
excreted
a
solutions 75%
so
base from
a as
of and
simultaneously
in cases
K-dependent
the
metastatic
carcinoma
kinds
minutes,
proteins
functions 1
RC-10
ethanol
are
Ks
and
coagulative carcinoma,
20
that
of
hepatocytes
Two 25%
Phylloquinone
gentle
centration
using
IRICA
50•Ž. was
within
Menaquinone-5
performed,
platinum
at
other
ml/min
was
a
set
the
was
the
METHODS
analytical
The
2
carcinoma of
vitamin
K,
urinary ƒÁ-Gla.
III. RESULTS 1) By our method, at fasting early in the morning, the level of Phylloquinone was 0.95ng/ml in the plasma of Japanese healthy volunteers and highest among the vitamin Ks. Our volunteers showed only 0.71ng/ml of Menaquinone-7. Menaquinone-9 to 13 which have longer isoprenyl chains in the plasma were not detected. Total amount of vitamin Ks was 3.35ng/ml. 2) For 5 fasting patients without any pharmaceutical vitamin Ks for more than 24 hours after elective surgery, 10mg of MK-4 was administered by intravenous drip infusion for 60 minutes. The plasma level of Menaquinone-4 was 50ng/ml after 6 hours and maintained higher than 5 ng/ml after 16 hours, which we believe 10mg of Mk-4 administration is too much for daily requirement even with the concomitant antibiotics.
Symposium
418
13 Vitamin
K
3) However in the short bowel syndrome, oral administration of vitamin syrup cannot increase the plasma level. Only intravenous injection Menaquinone-4 or fat emulsion can maintain the high plasma level [1]. 4)
Fat
emulsion
contains of
made
from
10
fat
makes the
5)
As
of to
emulsion 60
to
120
to
is 90 ƒÊg
daily
required
only
patients
with
taking
the
Clinimeal
group
residue
weight
500ml
patient,
which
diets
in
and
is
of
3
that equivalent
diet
plasma
concentration became
was
added Ks
before
the
intenplasma
operation
and
from of
6
150
Phylloquinone
than
con2.9ng/g.
100ng/g in
containing
lower
Clinimeal contains
vitamin
days
general
Japan,
Besvion
diets,
change
given
obviously
body
Japan,
when
humans.
elemental the
The
regimen group
of
hospital
50mg
Phylloquinone,
one
hylloquinone/day.
the
in
instance,
administration,
low
studied
available For
to
for
of
We
commercially
Phylloquinone dose
Elental,
tionally.
oil, Phylloquinone.
available 18ng/g
Whereas
soybean
administered of
commercially
tains
10
180ng/ml
K2 of
that
of
the
for
7
patients
to
450 ƒÊg
in
Clinimeal
hospital
diet
[2].
6) The postoperative change of Phylloquinone in the plasma of the patients after abdominal surgery was studied. In cases 1, 3 and 4 who underwent biliary surgery, the plasma level of Phylloquinone dropped on Day 2, but recovered to the preoperative level on Days 5 and 7 by resuming food intake. In cases 2 and 5 who underwent gastrectomy and colectomy, although no food was ingested for 7 days after the operation, the plasma level was above the detection limit. The plasma levels in cases 3, 4 and 5 intravenously administered 4 mg of MK-4 for 4 consecutive days were higher than those of the not-dministered cases 1 and 2. After taking postoperative diet on Day 5, plasma levels of Menaquinone-7 and 8 became higher than the preoperative levels. However, they were lower than preoperative levels when the patients were given no food for 7 days . 7) The long-term total parenteral nutrition cases, who were daily administered 4mg of Menaquinone-4 as a vitamin mixture protected by a shield cover against sunlight. 4 days after the administration , the Menaquinone-4 level in the plasma soared 4.5 to 23.6ng/ml, higher than the non-detected level before treatment. Due to long-derm fasting , the Phylloquinone levels dropped below the detection limit after 7 days. Therefore, one to in the
we
2mg stable
of
concluded
4mg
Menaquinone-4 state during
of
are
Menaquinone-4
sufficient parenteral
total
is
as a nutrition.
excessive
daily
dose
dose
for
and
patients
8) It is difficult for us to judge accurately by coagulative functions in the postoperative state especially after hepatectomy, because of the postoperative administration of a large amount of Menaquinone-4 and fresh frozen plasma. Fasting period were 6 days and dosing period of antibiotics were 10 days. Daily dosis of Menaquinone-4 in non—cirrhotic and cirrhotic groups were 40mg and 48mg for 6 days and 12 days, respectively. The dosing period of Menaquinone-4 was significantly longer. 9)
Little
Phylloquinone
toperative volume
of
10)
The
In
cases,
the
non—cirrhotic
test.
On
cirrhotic
of
the
due of
on
the Days
same
thing
to
active
5
and
after
a
because
larger
MK-4
were
low
was
observed of
was surgery
with
with
than
cirthose
hepaplast
in
cases
of
preserved
than
that
a
liver
in
lower
non—cirrhotic
lower
in
levels was
pos-
maintained.
Menaquinone-4 activity
of
administered
considerablly
regeneration cases
7
plasma
to of
parameters
cirrhotic
the
are
higher
clotting
improved
levels
prothrombin The
the
urinary ƒÁ-—Gla cases,
plasma
postoperative
14,
in due
parameters
spite
cases. Day
significantly The
higher
In
detected cases,
clotting
cases.
rhotic
be
cirrhotic
Menaquinone-4, preoperative
cirrhotic
of
could
fasting.
significant
were liver
of
the
. nondif-
H. TANIMURA
fererice
in
11)
For
spite
recovery
of ƒÁ-Gla
in
lower
of
because
with
other
hepatectomized
MK-4
cases volume
and
compared
with
abdominal
surgery,
cirrhotic
[3]. which
exhibited
fuction
the
a of
postoperative
was
liver
course
postoperative
cases
rapid
the
of
recovery
slower
and
maintained
at
level.
We
investigated
total
the
vitamin
10,
probably
cases
419
administration
Therefore,
cirrhotic
al.
non-hepatectomized
shown,
intact.
the
12)
extensive the
were
remained
a
of
interest,
et
11,
12
showing
in
a
Ks,
that
the
liver
As
the
the
isoprenyl
chains
in
may
have
a
coefficient
Menaquinone-10
and liver,
greater
was
on
0.74 not
proteins 11
were
this
im-
in
higher
Menaquinones
effect
MK-4,
may
clotting
the
the
Menaquinone-4
K-dependent
cirrhotic
and plus
correlation Therefore,
of
than
urinary ƒÁ-Gla
Menaquinone-4
The
vitamin
levels
cases
the
administered
correlation.
activate
cirrhotic
between
the tissue.
significant
mediately liver.
correlation is,
the
in with
activating
non-
longer
system.
13) Phylloquinone average concentration in the liver tissue was 19ng/g in non-cirrhotic group except one, which received fat emulsion and exhibit abnormal high concentration as much as 68ng/g, whereas Phylloquinone average concentration was 14ng/g in cirrhotic group. Because of administration before 16 hours preoperatively, the Menaquinone-4 average level in the liver tissue was stored 212ng/g in non-cirrhotic cases and 253ng/g in liver cirrhotic cases, respectively. Concerning the whole Menaquinone-10 to 13, Menaquinone-10 concentrations were 52 ng/g in non-cirrhotic cases, 18ng/g in cirrhotic cases. Likewise, Menaquinone-11 were 62 to 14, Menaquinone-12 19 to 4.94, Menaquinone-13 5.11 to 2.38, respectively. Therefore, the Menaquinone-10 and Menaquinone-11 levels of cirrhotic cases were surprisingly lower than those of non-cirrhotic cases. As for total vitamin Ks amount in the liver tissue, compared with 411ng/g in non-cirrhotic liver, the level in cirrhotic liver was 325ng/g, with no significant difference.
14) About the hepatolithiasis cases, all of the vitamin Ks in the lobe with stones expectedly decreased than in the lobe without stones of the same patient. But, in the lobe without stones Menaquinone-10 and Menaquinone-11 decreased than those in the normal liver. Vitamin Ks level in the stone-free lobe of hepatolithiasis were similar to that of the cirrhotic cases. This suggested that the levels of vitamin Ks in the liver may be attributed to the grade of atrophy or fibrosis in the liver.
IV.
CONCLUSIONS
1.
We
established
of
changing
way human
tissue
2.
500ml
To
the
of
is 4. 4
By
in daily
5. cases
bag than
in
to
K
the because
of
deficiency
50
in
Phylloquinone
below
the
fasting,
from
new
. of
fat
Ks
did
.
to
7-days
a Ks
minutes.
90ƒÊg
decreased
during
vitamin
administration
vitamin
administration level a
to
preoperative
vitamin 100ƒÊg
of
vitamin
Ks
shield
of
Menaquinone-4,
during cover
the during
the
plasma
postoperative
course
injection
,
we
might
Menaquinone.
Using
the
administer
amount. with
the
60
devised
the 75
patients,
levels
plasma,
and of
tissue.
higher
with
this
Compared
the
liver
a
infusion less
the 4mg
maintains
K2
gradient,
within from
preventing and
However, from
a
simultaneously
controlled for
fasting.
using concentrations
contains
K1
disappear stored
measured
efficient
HPLC The
emulsion
vitamins for
not
be
fat
of rate.
nutritional
is
Plasma
levels
method flow
could
long-term
emulsion 3.
a the
liver
the tissue,
vitamin
K
levels
Menaquinone-10
of
cirrhotic and
Menaquinone-11
and
non-cirrhotic levels
of
Symposium (13)
420
the former cases were lower than administration of Menaquinone-4 levels were over 200ng/g. 6.
In
spite
of
higher
toperative
clotting
especially
urinary ƒÁ-Gla)
Vitamin
those before
Menaquinone-4
of
K
the latter. operation,
levels
parameters
in
(Prothrombine were
lower
than
In their
cirrhotic
the cases with intrahepatic cases,
time,
Hepaplastin
those
of
the
postest,
non-cirrhotic
cases.
Thus, dependent
Menaquinone-4 may clotting proteins
Menaquinone-11 in the cirrhotic have a greater
levels liver, effect
not in
in
immediately the liver.
the non-cirrhotic the Menaquinones on this activating
work As
activate the vitamin the Menaquinone-10
liver were higher than with longer isoprenyl chains system, for posthepatectomized
Kand those may
patients.
Table.
1
Vitamin Ks concentrations
in the liver tissue
(Non-focus, ng/g)
Fig.l.
VKs levels in the liver Hepatolithiasis (3 cases)
tissue
REFERENCES [1] Tanimura, H., Tsuji, T. (1989): Vitamin K in surgical diseases. J. Clin. Exper. Med., 149, 296-298. [2] Usui, Y., Tanimura, II., Nishimura, N., et al. (1990): Vitamin K concentrations in the plasma and liver of surgical patients. Am. J. Clin. Nutr., 61:846-852. [3] Tsuji, T. (1991): Clinical study of vitamin K concentrations in the liver tissue and coagulative functions after hepatectomy. J. Wakayama Med. Soc., 42, 297-310.
S-13-4
Serum
and
Liver
Concentrations Surgical
K in
Patients
H. Tanimura,
Department of 27 Shichibancho,
of Vitamin
and T. Tsuji
Gastroenterological Surgery, Wakayama 640(Japan)
Wakayama
Medical
College,
I.
INTRODUCTION Vitamin K1 (Phylloquinone) and K2 (Menaquinone-4) as two commercially available drugs in Japan are routinely utilized in patients before and after surgery. However, the metabolism of the vitamin Ks in the human body and the optimal dose for surgical patients are not clear. Recently small amount of Phylloquinone and Menaquinones can be determined by HPLC that enabled simultaneous determination of Phylloquinone and Menaquinones in the plasma and the liver tissue from surgical patients. In addition to the change of the vitamin K concentration in various cases including postoperative patients, we have been studying clotting functions.
II.
MATERIALS The
AND
analytic
method
column
temperature
and
was
methanol, 0.6
slope
and is
so
tissue
can
dependent
vitamin
be
measured
clotting
biliary in vitamin
cirrhotic
in
22
the
tumor,
clotting
up proteins
and
assessing and
11
13
conhuman K-
carboxylase
free
levels
in Vitamin
and
y
in
—Gla.
1
hepatocellular
3
hemangioma,
hepatocellular the
gradient The
to
minutes.
with
was rate
none-4, Our
flat.
K as
one flow
Menaqu
MK-4
hepatolithiasis,
cases,
followed
75 vitamin
patients 4
of
almost
urine
hepatectomized
non-cirrhotic were
by
an whose
used,
separated.
and
as
The
peak
within
into
liver
the
remains
activated
C-18 column,
were
sufficiently line
NOVA-PAK reduction
isopropanol.
Phylloquinone
are
excreted
a
solutions 75%
so
base from
a as
of and
simultaneously
in cases
K-dependent
the
metastatic
carcinoma
kinds
minutes,
proteins
functions 1
RC-10
ethanol
are
Ks
and
coagulative carcinoma,
20
that
of
hepatocytes
Two 25%
Phylloquinone
gentle
centration
using
IRICA
50•Ž. was
within
Menaquinone-5
performed,
platinum
at
other
ml/min
was
a
set
the
was
the
METHODS
analytical
The
2
carcinoma of
vitamin
K,
urinary ƒÁ-Gla.
III. RESULTS 1) By our method, at fasting early in the morning, the level of Phylloquinone was 0.95ng/ml in the plasma of Japanese healthy volunteers and highest among the vitamin Ks. Our volunteers showed only 0.71ng/ml of Menaquinone-7. Menaquinone-9 to 13 which have longer isoprenyl chains in the plasma were not detected. Total amount of vitamin Ks was 3.35ng/ml. 2) For 5 fasting patients without any pharmaceutical vitamin Ks for more than 24 hours after elective surgery, 10mg of MK-4 was administered by intravenous drip infusion for 60 minutes. The plasma level of Menaquinone-4 was 50ng/ml after 6 hours and maintained higher than 5 ng/ml after 16 hours, which we believe 10mg of Mk-4 administration is too much for daily requirement even with the concomitant antibiotics.
Symposium
418
13 Vitamin
K
3) However in the short bowel syndrome, oral administration of vitamin syrup cannot increase the plasma level. Only intravenous injection Menaquinone-4 or fat emulsion can maintain the high plasma level [1]. 4)
Fat
emulsion
contains of
made
from
10
fat
makes the
5)
As
of to
emulsion 60
to
120
to
is 90 ƒÊg
daily
required
only
patients
with
taking
the
Clinimeal
group
residue
weight
500ml
patient,
which
diets
in
and
is
of
3
that equivalent
diet
plasma
concentration became
was
added Ks
before
the
intenplasma
operation
and
from of
6
150
Phylloquinone
than
con2.9ng/g.
100ng/g in
containing
lower
Clinimeal contains
vitamin
days
general
Japan,
Besvion
diets,
change
given
obviously
body
Japan,
when
humans.
elemental the
The
regimen group
of
hospital
50mg
Phylloquinone,
one
hylloquinone/day.
the
in
instance,
administration,
low
studied
available For
to
for
of
We
commercially
Phylloquinone dose
Elental,
tionally.
oil, Phylloquinone.
available 18ng/g
Whereas
soybean
administered of
commercially
tains
10
180ng/ml
K2 of
that
of
the
for
7
patients
to
450 ƒÊg
in
Clinimeal
hospital
diet
[2].
6) The postoperative change of Phylloquinone in the plasma of the patients after abdominal surgery was studied. In cases 1, 3 and 4 who underwent biliary surgery, the plasma level of Phylloquinone dropped on Day 2, but recovered to the preoperative level on Days 5 and 7 by resuming food intake. In cases 2 and 5 who underwent gastrectomy and colectomy, although no food was ingested for 7 days after the operation, the plasma level was above the detection limit. The plasma levels in cases 3, 4 and 5 intravenously administered 4 mg of MK-4 for 4 consecutive days were higher than those of the not-dministered cases 1 and 2. After taking postoperative diet on Day 5, plasma levels of Menaquinone-7 and 8 became higher than the preoperative levels. However, they were lower than preoperative levels when the patients were given no food for 7 days . 7) The long-term total parenteral nutrition cases, who were daily administered 4mg of Menaquinone-4 as a vitamin mixture protected by a shield cover against sunlight. 4 days after the administration , the Menaquinone-4 level in the plasma soared 4.5 to 23.6ng/ml, higher than the non-detected level before treatment. Due to long-derm fasting , the Phylloquinone levels dropped below the detection limit after 7 days. Therefore, one to in the
we
2mg stable
of
concluded
4mg
Menaquinone-4 state during
of
are
Menaquinone-4
sufficient parenteral
total
is
as a nutrition.
excessive
daily
dose
dose
for
and
patients
8) It is difficult for us to judge accurately by coagulative functions in the postoperative state especially after hepatectomy, because of the postoperative administration of a large amount of Menaquinone-4 and fresh frozen plasma. Fasting period were 6 days and dosing period of antibiotics were 10 days. Daily dosis of Menaquinone-4 in non—cirrhotic and cirrhotic groups were 40mg and 48mg for 6 days and 12 days, respectively. The dosing period of Menaquinone-4 was significantly longer. 9)
Little
Phylloquinone
toperative volume
of
10)
The
In
cases,
the
non—cirrhotic
test.
On
cirrhotic
of
the
due of
on
the Days
same
thing
to
active
5
and
after
a
because
larger
MK-4
were
low
was
observed of
was surgery
with
with
than
cirthose
hepaplast
in
cases
of
preserved
than
that
a
liver
in
lower
non—cirrhotic
lower
in
levels was
pos-
maintained.
Menaquinone-4 activity
of
administered
considerablly
regeneration cases
7
plasma
to of
parameters
cirrhotic
the
are
higher
clotting
improved
levels
prothrombin The
the
urinary ƒÁ-—Gla cases,
plasma
postoperative
14,
in due
parameters
spite
cases. Day
significantly The
higher
In
detected cases,
clotting
cases.
rhotic
be
cirrhotic
Menaquinone-4, preoperative
cirrhotic
of
could
fasting.
significant
were liver
of
the
. nondif-
H. TANIMURA
fererice
in
11)
For
spite
recovery
of ƒÁ-Gla
in
lower
of
because
with
other
hepatectomized
MK-4
cases volume
and
compared
with
abdominal
surgery,
cirrhotic
[3]. which
exhibited
fuction
the
a of
postoperative
was
liver
course
postoperative
cases
rapid
the
of
recovery
slower
and
maintained
at
level.
We
investigated
total
the
vitamin
10,
probably
cases
419
administration
Therefore,
cirrhotic
al.
non-hepatectomized
shown,
intact.
the
12)
extensive the
were
remained
a
of
interest,
et
11,
12
showing
in
a
Ks,
that
the
liver
As
the
the
isoprenyl
chains
in
may
have
a
coefficient
Menaquinone-10
and liver,
greater
was
on
0.74 not
proteins 11
were
this
im-
in
higher
Menaquinones
effect
MK-4,
may
clotting
the
the
Menaquinone-4
K-dependent
cirrhotic
and plus
correlation Therefore,
of
than
urinary ƒÁ-Gla
Menaquinone-4
The
vitamin
levels
cases
the
administered
correlation.
activate
cirrhotic
between
the tissue.
significant
mediately liver.
correlation is,
the
in with
activating
non-
longer
system.
13) Phylloquinone average concentration in the liver tissue was 19ng/g in non-cirrhotic group except one, which received fat emulsion and exhibit abnormal high concentration as much as 68ng/g, whereas Phylloquinone average concentration was 14ng/g in cirrhotic group. Because of administration before 16 hours preoperatively, the Menaquinone-4 average level in the liver tissue was stored 212ng/g in non-cirrhotic cases and 253ng/g in liver cirrhotic cases, respectively. Concerning the whole Menaquinone-10 to 13, Menaquinone-10 concentrations were 52 ng/g in non-cirrhotic cases, 18ng/g in cirrhotic cases. Likewise, Menaquinone-11 were 62 to 14, Menaquinone-12 19 to 4.94, Menaquinone-13 5.11 to 2.38, respectively. Therefore, the Menaquinone-10 and Menaquinone-11 levels of cirrhotic cases were surprisingly lower than those of non-cirrhotic cases. As for total vitamin Ks amount in the liver tissue, compared with 411ng/g in non-cirrhotic liver, the level in cirrhotic liver was 325ng/g, with no significant difference.
14) About the hepatolithiasis cases, all of the vitamin Ks in the lobe with stones expectedly decreased than in the lobe without stones of the same patient. But, in the lobe without stones Menaquinone-10 and Menaquinone-11 decreased than those in the normal liver. Vitamin Ks level in the stone-free lobe of hepatolithiasis were similar to that of the cirrhotic cases. This suggested that the levels of vitamin Ks in the liver may be attributed to the grade of atrophy or fibrosis in the liver.
IV.
CONCLUSIONS
1.
We
established
of
changing
way human
tissue
2.
500ml
To
the
of
is 4. 4
By
in daily
5. cases
bag than
in
to
K
the because
of
deficiency
50
in
Phylloquinone
below
the
fasting,
from
new
. of
fat
Ks
did
.
to
7-days
a Ks
minutes.
90ƒÊg
decreased
during
vitamin
administration
vitamin
administration level a
to
preoperative
vitamin 100ƒÊg
of
vitamin
Ks
shield
of
Menaquinone-4,
during cover
the during
the
plasma
postoperative
course
injection
,
we
might
Menaquinone.
Using
the
administer
amount. with
the
60
devised
the 75
patients,
levels
plasma,
and of
tissue.
higher
with
this
Compared
the
liver
a
infusion less
the 4mg
maintains
K2
gradient,
within from
preventing and
However, from
a
simultaneously
controlled for
fasting.
using concentrations
contains
K1
disappear stored
measured
efficient
HPLC The
emulsion
vitamins for
not
be
fat
of rate.
nutritional
is
Plasma
levels
method flow
could
long-term
emulsion 3.
a the
liver
the tissue,
vitamin
K
levels
Menaquinone-10
of
cirrhotic and
Menaquinone-11
and
non-cirrhotic levels
of
Symposium (13)
420
the former cases were lower than administration of Menaquinone-4 levels were over 200ng/g. 6.
In
spite
of
higher
toperative
clotting
especially
urinary ƒÁ-Gla)
Vitamin
those before
Menaquinone-4
of
K
the latter. operation,
levels
parameters
in
(Prothrombine were
lower
than
In their
cirrhotic
the cases with intrahepatic cases,
time,
Hepaplastin
those
of
the
postest,
non-cirrhotic
cases.
Thus, dependent
Menaquinone-4 may clotting proteins
Menaquinone-11 in the cirrhotic have a greater
levels liver, effect
not in
in
immediately the liver.
the non-cirrhotic the Menaquinones on this activating
work As
activate the vitamin the Menaquinone-10
liver were higher than with longer isoprenyl chains system, for posthepatectomized
Kand those may
patients.
Table.
1
Vitamin Ks concentrations
in the liver tissue
(Non-focus, ng/g)
Fig.l.
VKs levels in the liver Hepatolithiasis (3 cases)
tissue
REFERENCES [1] Tanimura, H., Tsuji, T. (1989): Vitamin K in surgical diseases. J. Clin. Exper. Med., 149, 296-298. [2] Usui, Y., Tanimura, II., Nishimura, N., et al. (1990): Vitamin K concentrations in the plasma and liver of surgical patients. Am. J. Clin. Nutr., 61:846-852. [3] Tsuji, T. (1991): Clinical study of vitamin K concentrations in the liver tissue and coagulative functions after hepatectomy. J. Wakayama Med. Soc., 42, 297-310.
