ILE ACIDS serve at least two physiological roles, both of which are dependent on their enterohepatic circulation. Bile acid flux is the major driving force of bile production and they are essential for the normal absorption of fats from the gastrointestinal tract. Bile is a mixture of waste products, notably bilirubin and other conjugates, along with bile acids, lipids and inorganic ions, most of which are reabsorbed. Both functions now seem equally important. Whilst bile acids are an essential component of bile they are themselves toxic. The main function of other constituents, notably phospholipids and cholesterol, is to protect against the harmful effects of bile acids, through the formation of mixed micelles. The complete cycle of enterohepatic circulation of bile acids involves transport across two epithelia, as well as passage through the gut and portal blood. Only about 2% of the bile acids excreted daily into the GI tract are lost in the stool. A single transporter appears be responsible for this conservation through uptake in the distal ileum. The apical sodium-dependent bile salt transporter (ASBT) (1,2) is a transmembrane protein similar to the sodiumdependent bile acid transporter found in hepatocytes (NTCP) (3), which is discussed below. The gene is located on chromosome 13q33 and has the symbol SLClOA2 (4). The protein, when expressed in vitro has Ki values in the range of 3.3 PM (chenodeoxycholate) to 41.5 PM (cholate) for bile acids but very high Ki values for a number of other organic anions (5). This contrasts with NTCP, which appears to have a much broader specificity. Recessive, loss of function, mutations in the ASBT gene have been found in patients with primary bile acid malabsorption (4). Bile acids are removed from the portal circulation by hepatocytes. The major bile acid transporter in the basolateral membrane of hepatocytes is the sodium taurocholate co-transporting polypeptide (NTCP) (3). The organic anion transporting polypeptides are capable of transporting bile acids, along with many amphipathic compounds. Whether OATP plays a physiologically significant role in bile acid transport in not clear. Bile acid export from hepatocyes operates against a steep concentration gradient. The biliary bile acid concentration is at least lOOO-fold higher than that in hepatocytes. It is not surprising therefore that the transport of bile acids across this membrane has been shown to be an energy-dependent process. The major transporter is called the bile salt export pump and is encoded by ABCBll (previously called BSEP or SPGP). When the rat cDNA was expressed in vitro, the protein proved to be an effective ATP-dependent bile acid transporter with a Km for taurocholate of -5 ,uM (6). The protein has therefore been named the bile salt export pump. Mutations in the human gene have been found in patients with progressive familial intrahepatic cholestasis with normal levels of serum yGT (7). In those where it has been measured, they also have low levels of biliary bile acids; this correlates well with the low yGT. A similar phenotype has been found in patients with mutations in a P-type ATPase, also located in the hepatocyte canalicular membrane (8). The protein may well be acting as an aminophospholipid flipase. However, it is not clear how mutations in this gene lead to an interruption in the efflux of bile acids from hepatocytes. Most of the major bile acid transporter genes have now been cloned. The intracellular transport of bile acids is less well understood. Recessive mutations have so far been found in three transporter genes, though
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