Heme Degradation & Hyperbilirubinemias

The Road Ahead

• Introduction
• History
• Structure
• Biochemistry
› Synthesis of Bilirubin
› Excretion of Bilirubin
• Function of Bilirubin
• Clinical Significance
› Hyperbilirubinemia & Types of Jaundice
› Inherited disorders of bilirubin metabolism
› Bilirubin Toxicity – Kernicterus
• Clinical estimation of Bilirubin
› Serum
• Urine Bilirubin
• Treatment Methods
• Phototherapy
• Exchange Transfusion
• Bilirubin – A true indicator of Liver function
 Linear Tetrapyrrole structure of Bilirubin

1
2
3 4

Methyl group
Vinyl group Propionic Acid
The four pyrrole rings are linked with Chemical Formula: C33H36N4O6
methylidine bridges.
 Formation of Bilirubin

• Primary site of synthesis:-

SPLEEN: The Graveyard

of Red Blood Cells

• Secondary site of synthesis:-
LIVER & BONE MARROW
 An average person TOTAL BILIRUBIN
produces about 4
mg/kg of bilirubin
per day. 85% 15%

HEMOGLOBIN RBC PRECURSORS

 The daily bilirubin FROM SENESCENT DESTROYED IN THE
production from all RBC’S DESTROYED IN BONE MARROW
sources in man RETICULOENDOTHELIAL
CELLS OF
averages from 250 LIVER, SPLEEN & CATABOLISM OF
to 300 mg. BONE MARROW HEME-CONTAINING
PROTEINS (MYOGLOBIN,
CYTOCHROMES &
PEROXIDASES)
 Liver.
metabolism of bilirubin
(1) uptake of bilirubin by liver parenchymal cells,

(2) conjugation of bilirubin with glucuronate in

the endoplasmic reticulum,

(3)secretion of conjugated bilirubin into the bile.

 1,uptake of bilirubin by liver
parenchymal cells
• In liver, the bilirubin is removed from albumin .
• taken up by a carrier-mediated saturable system.
• A facilitated transport system
• has a very large capacity, does not appear to be
rate-limiting in the metabolism of bilirubin.
• the net uptake of bilirubin will be dependent upon
the removal of bilirubin via subsequent metabolic
pathways.
• Ligandin (a family of glutathione S-transferases) and protein Y.
cytosolic proteins, keep it solubilized prior to
conjugation.. prevent efflux of bilirubin back .
 ,
2 Conjugation of Bilirubin.
NON- polar ---- polar, bio-medical importance
• adding glucuronic acid
•a specific glucuronosyltransferase endoplasmic reticulum.
•Through ester linkage, G A to Propionic acid = glucoronoids
3)secretion of conjugated bilirubin into the
bile.
• active transport mechanism
• probably rate limiting.
• protein involved is MRP-2 (multidrug resistance-like
protein 2), also called multi specific organic anion transporter (MOAT).
• located in the plasma membrane of the bile
canalicular membrane and handles a number
of organic anions. It is a member of the family
of ATP-binding cassette (ABC) transporters
• inducible by those same drugs
uptake, conjugation, and secretion
• Jaundice becomes clinically evident when the serum bilirubin
level exceeds 2.5mg/dL.

• Several types of Jaundice:

– Hemolytic
– Hepatocellular
– Obstructive

• Symptoms:
– Yellow discoloration of the skin, sclerae and mucous membranes
– Itching (pruritus) due to deposits of bile salts on the skin
– Stool becomes light in color
– Urine becomes deep orange and foamy
Different Causes of Jaundice

• Excessive Production of Bilirubin

• Reduced Hepatocyte Uptake
• Impaired Bilirubin conjugation
• Impaired Bile Flow
Prehepatic (hemolytic) jaundice
• Results from excess production of
bilirubin (beyond the livers ability to
conjugate it) following hemolysis

• Excess RBC lysis is commonly the

result of autoimmune disease;
hemolytic disease of the newborn
(Rh- or ABO- incompatibility);
structurally abnormal RBCs (Sickle
cell disease); or breakdown of
extravasated blood

• High plasma concentrations of

unconjugated bilirubin (normal
concentration ~0.5 mg/dL)
Intrahepatic jaundice

• Impaired uptake, conjugation, or

secretion of bilirubin

• Reflects a generalized liver

(hepatocyte) dysfunction

• In this case, hyperbilirubinemia is

usually accompanied by other
abnormalities in biochemical
markers of liver function
 Inhibition of Glucuronyl
Transferase activity
Breast milk jaundice
– Isomers of pregnanediol
– Inherited defect in steroid metabolism
Physiological jaundice
 Absenece of Glucuronyl
Transferase activity
• Crigler najjar syndrome (rare)
– Type 1, A R, fatal, uncon- hyper-Bilirubin
– Risk of Kernicterus
– Phototherapy
– Type 2, milder defect, uncon- hyper-Bilirubin
Posthepatic jaundice
• Caused by an obstruction of the
biliary tree.

• Plasma bilirubin is conjugated,

and other biliary metabolites,
such as bile acids accumulate in
the plasma.

• Characterized by pale colored

stools (absence of fecal bilirubin
or urobilin), and dark urine
(increased conjugated bilirubin).

• In a complete obstruction,
urobilin is absent from the urine.
Inherited Disorders of Bilirubin
Metabolism

• Gilbert’s Syndrome
• Crigler-Najjar (Type I)
• Crigler-Najjar (Type II)
• Lucey-Driscoll
• Dubin-Johnson
• Rotor’s Syndrome
 Algorithm for differentiating the familial causes of
Hyperbilirubinemia

Isolated increased serum bilirubin

Ruling out of hemolysis, subsequent fractionation of the bilirubin

Conjugated Unconjugated

Possibility of following syndromes

Possibility of the
based on the bilirubin concentration:
following syndromes:
• Gilbert’s - <3 mg/dl
• Dublin-Johnson
• Crigler-Najjar (Type I) - >25 mg/dl
• Rotor
• Crigler-Najjar (Type II) - 5 to 20 mg/dl

• Lucey-Driscoll - Transiently ~ 5 mg/dl

 Defect in hepatic Bilirubin clearance
• GILBERT’S SYNDROME , Hetrogenous as a result of
mutation in the bilirubin-UDP-glucuronyl transferase gene
• an autosomal recessive trait, familial non-hemolytic non-
obstructive jaundice.
• Males more frequently. Onset of symptoms is seen in
teens, early 20’s or 30’s. does not require any treatment
as it does not interfere with the normal lifestyle of a
person
• Unconjugated, benign condition, 3% – 5% of the
population. often misdiagnosed as chronic Hepatitis.
Defect in uptake or
• Reduced G T activity .
 Dubin-Johnson Syndrome
• It is a benign, autosomal recessive
condition characterized by jaundice with
predominantly elevated conjugated
bilirubin and a minor elevation of
unconjugated bilirubin.

• Excretion of various conjugated anions

and bilirubin into bile is impaired,
reflecting the underlying defect in
canalicular excretion.

• The Liver has a characteristic greenish

black appearance and liver biopsy
reveals a dark brown melanin-like
pigment in hepatocytes and kupffer
cells.
 Rotor’s Syndrome

• It is another form of conjugated hyperbilirubinemia.

• It is similar to dubin-johnson syndrome but without

pigmentation in liver.
Phototherapy
Exchange Transfusion
 Conjugated Bilirubin Is Reduced to
Urobilinogen by Intestinal Bacteria
• bacterial enzymes ( β-glucuronidases)
• Ceacum and colon.
• To colorless tetrapyrole compound
“urobilinogen”
ENTEROHEPATIC UROBILINOGIN CYCLE
normally most urobilinogen in colon are
oxidized to urobilin (colored) are excreated
in feces.