Plasma Unconjugated Bilirubin Research Articles

Orlistat Treatment of Unconjugated Hyperbilirubinemia in Crigler-Najjar Disease: A Randomized Controlled Trial

Unconjugated hyperbilirubinemia in Crigler-Najjar (CN) disease is conventionally treated with phototherapy and phenobarbital. Orlistat treatment increases fecal fat excretion and decreases plasma unconjugated bilirubin (UCB) concentrations in Gunn rats, the animal model for CN disease. We determined in CN patients the effects of orlistat treatment on plasma UCB concentrations, and on fecal excretion of fat and UCB. A randomized, placebo-controlled, double-blind, cross-over trial was conducted in 16 patients, simultaneous with their regular treatment (phototherapy, n = 11, and/or phenobarbital, n = 6). Patients received orlistat or placebo, each for 4-6 wk. Compared with placebo, orlistat increased fecal fat excretion (+333%) and fecal UCB excretion (+43%). Orlistat treatment significantly decreased plasma UCB concentration (-9%). In 7 of 16 patients, the decrease in plasma UCB levels was clinically relevant (>10%, mean 21%). In patients with a clinically relevant response, plasma UCB concentrations during orlistat were strongly, negatively correlated with fecal fat excretion (r = -0.93). Clinically relevant response to orlistat treatment was not correlated with age, sex, CN type, BMI, or co-treatment with phototherapy or phenobarbital, but appeared correlated with a relatively lower dietary fat intake. In conclusion, orlistat treatment decreases plasma UCB concentrations, particularly in a subgroup of CN patients. Dietary fat intake may determine the responsiveness to orlistat treatment.

Effect of drug transporter genotypes on pravastatin disposition in European- and African-American participants

Our aims were to evaluate the effects of polymorphisms in the hepatic drug uptake transporter organic anion transporting polypeptide 1B1 (OATP1B1, SLCO1B1) and efflux transporters multidrug resistance-associated protein 2 (MRP2, ABCC2), bile salt export pump (BSEP, ABCB11), and breast cancer-related protein (BCRP, ABCG2) on single-dose pravastatin pharmacokinetics in healthy European- and African-American participants. The pharmacokinetics of a single oral 40 mg dose of pravastatin was determined in 107 participants (69 European-Americans and 38 African-Americans). Participants were genotyped for known OATP1B1, MRP2, BSEP, and BCRP polymorphisms. Baseline serum total and unconjugated plasma bilirubin concentrations were also determined. OATP1B1 genotypes were ethnicity-dependent with a 521C allele frequency of approximately 15% in European-Americans and approximately 1% in African-Americans. SLCO1B1 521TC genotype was associated with significantly higher pravastatin area under the curve [AUC(0-5)] (P=0.01) and Cmax values (P<0.05). When analyzed by diplotype, SLCO1B1*1a/*15 (N=8) participants exhibited 45 and 80% higher AUC values than SLCO1B1*1a/*1a (N=29) (P=0.013) and SLCO1B1*1b/*1b (N=34) (P=0.001) carriers, respectively. SLCO1B1*15/*15 (N=2) participants exhibited 92 and 149% higher AUC values than SLCO1B1*1a/*1a (P=0.017) and SLCO1B1*1b/*1b (P=0.011) carriers, respectively. European-Americans had significantly higher plasma pravastatin AUC(0-5) (P=0.01) and Cmax values (P=0.009) than African-Americans. Neither ABCC2, ABCB11, nor ABCG2 genotypes were associated with differences in pravastatin pharmacokinetics. We did not observe an effect of SLCO1B1 genotype on baseline total or unconjugated bilirubin levels. SLCO1B1 genotype, in particular the 521C allele, had a significant effect on the pharmacokinetics of pravastatin. Even when adjusted for the presence of the SLCO1B1 521C or 388G variant allele, European-Americans demonstrated significantly higher pravastatin AUC and Cmax values than African-Americans.

Revalidation and rationale for high pKa values of unconjugated bilirubin

BackgroundOur prior solvent partition analysis, published in 1992, yielded pKa values for unconjugated bilirubin of about 8.1 and 8.4, but these results have been challenged and studies by other methods have suggested pKa values below 5.0.MethodsWe repeated our published solvent partition studies, using 14C-unconjugated bilirubin highly purified by extraction of residual labeled impurities from CHCl3 into an aqueous buffer, pH 7.0. Partition ratios at six pH values from 5.0 to 9.0 were determined by radioassay and compared with our prior values obtained by diazo assay.ResultsAt pH values ranging from 4.8 to 9.2, stable aqueous/chloroform 14C-partition ratios did not differ significantly from our published partition ratios based on diazo assay.ConclusionThese results support the high pKa values of unconjugated bilirubin, above 8.0, derived from our earlier solvent partition study. In both studies, our measurements were based on the rapid analysis of clearly under-saturated solutions of highly-purified bilirubin over a wide pH range, using properly purified and preserved solvents. No previous direct estimate of the aqueous pKa values of unconjugated bilirubin meets all these preconditions. Three theoretical factors acting in combination, each related to the unique, extensive internal H-bonding of the -COOH groups, are proposed to support high pKa values of unconjugated bilirubin in water: a) donation of an H-bond from the -OH moiety of the -COOH group, which is broken on ionization; b) hindered solvation of the -COO- group after ionization; and c) restricted rotation of the -COO- and -COOH groups. Our findings and rationale rebut methodological and theoretical criticisms leveled against our prior work. High pKa values for unconjugated bilirubin dictate that: a) bilirubin diacid, which readily diffuses across membranes and can cause neurotoxicity, is the dominant unbound bilirubin species of unconjugated bilirubin in plasma at physiological pH; b) at the near-neutral pH range of gallbladder bile, the monoanion is the major unconjugated bilirubin anion present, concordant with the finding that the calcium bilirubinate precipitated in gallstones is the monoanion salt. Our conclusions are thus relevant to understanding bilirubin-induced neurological disease in severely jaundiced neonates and the precipitation of calcium bilirubinate salts in gallstones.

‘‘Iatrogenic Gilbert syndrome’’– A strategy for reducing vascular and cancer risk by increasing plasma unconjugated bilirubin

The catabolism of heme, generating biliverdin, carbon monoxide, and free iron, is mediated by heme oxygenase (HO). One form of this of this enzyme, heme oxygenase-1, is inducible by numerous agents which promote oxidative stress, and is now known to provide important antioxidant protection, as demonstrated in many rodent models of free radical-mediated pathogenesis, and suggested by epidemiology observing favorable health outcomes in individuals carrying high-expression alleles of the HO-1 gene. The antioxidant impact of HO-1 appears to be mediated by bilirubin, generated rapidly from biliverdin by ubiquitously expressed biliverdin reductase. Bilirubin efficiently scavenges a wide range of physiological oxidants by electron donation. In the process, it is often reconverted to biliverdin, but biliverdin reductase quickly regenerates bilirubin, thereby greatly boosting its antioxidant potential. There is also suggestive evidence that bilirubin inhibits the activity or activation of NADPH oxidase. Increased serum bilirubin is associated with reduced risk for atherogenic disease in epidemiological studies, and more limited data show an inverse correlation between serum bilirubin and cancer risk. Gilbert syndrome, a genetic variant characterized by moderate hyperbilirubinemia attributable to reduced hepatic expression of the UDP-glucuronosyltransferase which conjugates bilirubin, has been associated with a greatly reduced risk for ischemic heart disease and hypertension in a recent study. Feasible strategies for boosting serum bilirubin levels may include administration of HO-1 inducers, supplementation with bilirubin or biliverdin, and administration of drugs which decrease the efficiency of hepatic bilirubin conjugation. The well-tolerated uricosuric drug probenecid achieves non-competitive inhibition of hepatic glucuronidation reactions by inhibiting the transport of UDP-glucuronic acid into endoplasmic reticulum; probenecid therapy is included in the differential diagnosis of hyperbilirubinemia, and presumably could be used to induce an ''iatrogenic Gilbert syndrome''. Other drugs, such as rifampin, can raise serum bilirubin through competitive inhibition of hepatocyte bilirubin uptake--although unfortunately rifampin is not as safe as probenecid. Measures which can safely achieve moderate serum elevations of bilirubin may prove to have value in the prevention and/or treatment of a wide range of disorders in which oxidants play a prominent pathogenic role, including many vascular diseases, cancer, and inflammatory syndromes. Phycobilins, algal biliverdin metabolites that are good substrates for biliverdin reductase, may prove to have clinical antioxidant potential comparable to that of bilirubin.

Novel Kinetic Insights into Treatment of Unconjugated Hyperbilirubinemia: Phototherapy and Orlistat Treatment in Gunn Rats

Treatment with phototherapy or with the lipase inhibitor orlistat decreases plasma unconjugated bilirubin (UCB) concentrations in hyperbilirubinemic Gunn rats. We investigated the mechanism(s) underlying the effects of orlistat, phototherapy, and combined treatment, using steady-state 3H-UCB kinetics. After three weeks of treatment with orlistat (200 mg/kg chow), phototherapy (19 microW/cm2/nm) or combined treatment, tracer 3H-UCB was administered IV to treated and untreated (control) Gunn rats. Plasma samples and feces were collected every 12h for 60h, and bile for 30 min at 60h. The following results were obtained: 1) each treatment decreased plasma bilirubin levels compared with controls: orlistat- 19%, phototherapy-32%, combined treatment-53%; 2) plasma bilirubin concentrations were strongly, negatively correlated with fractional bilirubin turnover; 3) orlistat treatment induced net transmucosal excretion of UCB into the intestinal lumen, whereas phototherapy increased biliary UCB excretion rate; 4) all treatments profoundly increased the enterohepatic circulation of UCB derivatives, indicating enhanced metabolism by intestinal bacteria. In conclusion, orlistat and phototherapy lower plasma bilirubin concentrations in Gunn rats by increasing (net) intestinal influx of UCB, either by transmucosal excretion (orlistat), or increased biliary secretion (phototherapy). The mechanism of phototherapy and orlistat treatment involves increasing the availability of UCB in the intestinal lumen for fecal excretion and for metabolism by intestinal bacteria.

Bilirubin metabolism: Applied physiology

Summary Bilirubin is the breakdown product of the haem moiety of haemoglobin and other haemoproteins. Because of internal hydrogen bonding, bilirubin is water-insoluble and requires enzyme-mediated glucuronidation in the liver for biliary excretion. In normal circumstances, plasma bilirubin is mostly unconjugated and is tightly bound to circulating albumin. It is taken up by hepatocytes by facilitated diffusion, stored in hepatocytes bound to glutathione-S-transferases and conjugated to glucuronides by microsomal UGT1A1. Bilirubin glucuronides are actively transported into the bile canaliculi by the ATP-utilizing pump MRP2. Bilirubin is degraded in the intestine by bacteria into urobilinogens, which are partly excreted in the urine. Increased production, reduced uptake and low glucuronidation capacity can increase plasma unconjugated bilirubin levels. In cases of inherited or acquired deficiencies of bilirubin storage or excretion, both conjugated and unconjugated bilirubin accumulate in the plasma. Conjugated bilirubin is less tightly bound to albumin and is excreted in the urine. The capacities of the various steps of bilirubin throughput are finely balanced, and the expression of the gene products mediating these steps is coordinated by nuclear receptors.

Effective oral treatment of unconjugated hyperbilirubinemia in Gunn rats†

We sought to develop an oral treatment for unconjugated hyperbilirubinemia. In the Gunn rat model of unconjugated hyperbilirubinemia, dietary supplementation with the lipase inhibitor orlistat (Orl) or with calcium phosphate (CaP) decreases plasma unconjugated bilirubin (UCB) levels. We determined whether Orl, CaP, or their combination is superior to phototherapy, the conventional treatment, and whether the effects of Orl and CaP are influenced by dietary fat content. Gunn rats were treated with Orl (200 mg/kg chow), CaP (20 g/kg chow), Orl + CaP, or continuous phototherapy (19 muW/cm(2)/nm) during a low-fat (LF) diet (13 energy%) or high-fat (HF) diet (35 energy%). Plasma UCB and fecal fat excretion were measured before, during, and/or at the end of treatment. Orl treatment for 2 weeks (HF diet) reduced plasma UCB concentrations similar to phototherapy (-34% and -28%, respectively); the combination of both was more effective than either treatment alone (-48%; P < .001). After 3 weeks of a HF diet, plasma UCB was 46% lower compared with the LF diet (P < .001). Plasma UCB concentrations were negatively correlated with fecal fat excretion (r = -0.96; P < .001). Irrespective of dietary fat content, 3 weeks of combined treatment (Orl + CaP) decreased plasma UCB by approximately 50% (P < .01) and was more effective than phototherapy (P < .05) at the intensity provided. In conclusion, plasma UCB concentrations in Gunn rats are negatively related to fecal fat excretion and dietary fat content. Orlistat is equally effective as phototherapy for the treatment of unconjugated hyperbilirubinemia in Gunn rats, and combined oral treatment with Orl + CaP is more effective than phototherapy. The present results support the feasibility of an efficient oral treatment of unconjugated hyperbilirubinemia.

High-level mixed-type hyperbilirubinaemia due to rifampicin

Rifampicin, a highly colephilic antibiotic, is rarely toxic: its toxicity has predominantly minor hepatic and immunological effects. A 42-year-old man was admitted to our institution because of hepatotoxicity as a result of anti-tuberculosis therapy. He complained of jaundice, nausea, vomiting, and fever. At first presentation, he exhibited the following: plasma unconjugated bilirubin, 5.1 mg/dl; conjugated bilirubin, 1.9 mg/dl; SGOT, 180 IU/l; SGPT, 472 IU/l; alkaline phosphatase, 222 IU/l; LDH, 1,656 U/l. He had no peripheral blood eosinophilia. No evidence for haemolytic anaemia or viral hepatitis was observed. Four days later, transaminases and bilirubin levels had returned to normal. Anti-tuberculosis therapy was restarted, but the patient became jaundiced after an episode of chills, fever (39.5°C), nausea and abdominal pain. Transaminases and alkaline phosphatase levels gradually continued to decrease, however, LDH and unconjugated and conjugated bilirubin levels increased to a maximum of; 1,240 U/l, 15.1 mg/dl and 5.5 mg/dl, respectively. Gamma-glutamyl transpeptidase level was stable during the course of these febrile episodes. There was no cholelithiasis or hepatic lesion on abdominal computerised tomography. Rifampicin was excluded, and the patient was treated with isoniazid, streptomycin, ethambutol, and morphozinamide. He was cured after 9 months of anti-tuberculosis therapy. Because it impairs uptake and excretion of bilirubin by hepatocytes, rifampicin can cause high-level mixed-type hyperbilirubinaemia in sensitised patients.

Orlistat treatment increases fecal bilirubin excretion and decreases plasma bilirubin concentrations in hyperbilirubinemic Gunn rats

ObjectiveTo determine whether serum levels of unconjugated bilirubin (UCB) can be decreased by enhancing fecal fat excretion. Study designGunn rats were fed a high-fat diet (control) or the same diet mixed with the lipase inhibitor orlistat. At regular intervals, plasma UCB concentrations were determined and 72-hour fat balances were performed. ResultsOrlistat treatment decreased plasma UCB concentrations (at 3 weeks; 100 mg/kg, −33%±8%, P<.05; 200 mg/kg, −46%±10%, P<.01). Within days of treatment, orlistat treatment increased fecal excretion of UCB (at day 3; +220%, P<.05). During 24 weeks of orlistat treatment (200 mg/kg diet), the plasma bilirubin concentrations were continuously ≈35% lower than in control rats. Plasma UCB concentrations were inversely correlated with the amount of fecal fat excretion (n=12, r=−0.87, P<.001). ConclusionsIn Gunn rats, orlistat treatment increases the fecal excretion of fat and enhances the disposal of UCB. This approach could lead to novel strategies for prevention and treatment of unconjugated hyperbilirubinemia in patients.

Anaemia in acute, Plasmodium falciparum malaria in children from Orissa state, India.

The severity of anaemia associated with acute, Plasmodium falciparum malaria and the extent to which haemolysis, bone-marrow suppression, and pre-existent iron deficiency contribute to the anaemia were assessed in 102 Indian children aged 2-12 years. Blood haemoglobin (Hb), plasma unconjugated bilirubin and haptoglobin, serum iron and transferrin concentrations and transferrin saturation, red cell morphology and reticulocyte response were investigated in the patients and in 50 control children. Twenty-three patients with severe anaemia (< 70 g Hb/litre) were investigated further, by bone-marrow biopsy followed by iron staining of sections or touch smears of the biopsy material. There was evidence of haemolysis in the malaria cases: in the peripheral blood smears and the significantly higher plasma concentrations of unconjugated bilirubin, lower plasma concentrations of haptoglobin and lower blood concentrations of Hb than those seen in the controls. Haemoglobin concentration correlated directly with haptoglobin (r = 0.489; P < 0.001) and inversely with unconjugated bilirubin in malaria patients (r = -0.526; P < 0.001) but not in controls (r = -0.140 and -0.061, respectively). Parasitaemia (parasites/microliter) was not significantly correlated with Hb, haptoglobin or unconjugated bilirubin. Compared with the earlier samples, follow-up samples from the patients, collected 2 weeks after discharge from hospital and antimalarial therapy, showed significant increase in Hb, haematocrit, haptoglobin and decreases in both total and unconjugated bilirubin. There was evidence of hypercellularity and mild-moderate erythroid hyperplasia, mainly of normoblastic maturation with adequate reticulocyte response, in the bone-marrow samples from the cases of severe anaemia; dyserythropoiesis was only noticed in one case and no stainable iron was detectable in 17 of the 23 cases. These observations indicate that haemolysis is the prime cause of the anaemia seen in acute falciparum malaria, although destruction of parasitised erythrocytes is not the sole cause of the haemolytic process. Bone-marrow suppression appears to have an insignificant role but pre-existent iron deficiency aggravates the severity of the anaemia.

Evidence for erythrocyte lipid peroxidation in acute falciparum malaria

To assess the extent of oxidative stress in erythrocytes of patients with acute Plasmodium falciparum malaria, erythrocyte thiobarbituric acid-reactive substance (ETBAR), and intracellular, membrane and extracellular antioxidants were estimated in 102 cases of P. falciparum malaria and 50 control subjects. The mean concentration of ETBAR was significantly higher ( P < 0·001) and many of the antioxidants were significantly lower in patients than controls. Among the erythrocyte antioxidants, catalase, reduced glutathione (GSH) and tocopherol were significantly lower in the patients ( P < 0·05, 0·001, 0·001, respectively). Erythrocyte superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) were not reduced to a statistically significant level. Similarly, the plasma antioxidants ascorbate and albumin were significantly lower ( P < 0·001) but not urate. ETBAR correlated inversely with erythrocyte GSH and tocopherol ( P < 0·001), and plasma ascorbate and albumin ( P < 0·001) but not with the erythrocyte enzymic antioxidants. However, on multiple regression analysis only tocopherol correlated strongly with ETBAR, followed by GSH and plasma ascorbate. ETBAR also correlated well with haemolytic indices such as haemoglobin, plasma unconjugated bilirubin and haptoglobin concentrations ( P < 0·001, for all). On follow-up after 2 weeks, ETBAR and different antioxidants reached near control levels. These observations indicate an enhanced oxidative stress on erythrocytes in acute falciparum malaria that may contribute substantially to haemolysis and anaemia.

Decline in plasma retinol in unconjugated hyperbilirubinemia treated with bilirubin adsorption using an anion-exchange resin.

When an anion-exchange resin column (Plasorba BR-350) was used for the treatment of unconjugated hyperbilirubinemia, we found an unexpected decrease in plasma retinol (vitamin A) concentrations in a patient with type I Crigler-Najjar syndrome. The purpose of our study was to investigate the mechanism of this decrease in plasma retinol. When the patient's serum bilirubin exceeded the bilirubin binding capacity of 14.7 mumol bilirubin/g serum albumin (i.e., 720 mumol/L of bilirubin), abrupt deterioration of the patient's neurologic status (suppression in his gait and speech) occurred, so the need to apply plasmapheresis to reduce the unconjugated bilirubin was indicated. Blood was drawn from the radial artery at a flow rate of 160 mL/min and pumped into a membrane plasma separator at a rate of 40 mL/min. The plasma was passed through the bilirubin adsorbent column and returned to the venous blood line of the plasma separator. Plasma samples were taken at the inlet and outlet of the bilirubin adsorbent column before and after treatment. The concentration of unconjugated bilirubin in plasma was effectively reduced by the perfusion, but plasma retinol was coincidentally decreased by the perfusion to vitamin A deficiency levels. The patient's plasma retinol was 2,127 nmol/L at the beginning of therapy and decreased to 1,492 nmol/L after repeated adsorption treatments. As the amounts of decrease in retinol (912 +/- 123 nmol/L) after the perfusion were almost equal to those in retinol-binding protein (1,010 +/- 192 nmol/L), retinol may have been removed as a form of holo retinol-binding protein. Decreases in retinol and retinol-binding protein levels were also observed in low-density lipoprotein (LDL) apheresis with a dextran sulfate column (i.e., a cation-exchange resin column). In the patient with Crigler-Najjar syndrome, retinol taken dietarily was removed by plasmapheresis. However, the patient manifested no clinical symptoms associated with vitamin A deficiency, since his liver storage of retinol could supply the loss caused by plasmapheresis treatment. We should measure plasma retinol concentrations to evaluate the loss of retinol during plasmapheresis treatment coupled with an anion-exchange resin column.

Evaluation of the changes in serum iron levels in pre-eclampsia

Serum iron levels were studied in 50 patients with pre-eclampsia and the results were compared with 50 control cases. Their serum iron levels were found to be higher than the controls. Increase in serum iron was directly proportional to the increased levels of uric acid, urea and creatinine. Mean reticulocyte counts, plasma free haemoglobin and unconjugated bilirubin levels were also higher in these patients. It is suggested that haemolysis may be a major contributory factor for the increased levels of serum iron in pre-eclampsia.

The significance of bile pigment deconjugation by beta-glucuronidase in canine hyperbilirubinemia.

In dogs, the differentiation between haemolytic and cholestatic hepatobiliary diseases cannot be achieved by measuring of the unconjugated:conjugated bilirubin ratio, which is in contrast with generally held clinical concepts. The overlap of the bilirubin ratios between the two groups of icterus-generating diseases might in part be explained by deconjugation of conjugated bilirubin. Enzymatic cleavage by hepatic beta-glucuronidase might result in higher unconjugated bilirubin (UCB) fractions in cholestatic disease. The influence of deconjugation of bilirubins by beta-glucuronidase was investigated in 25 healthy dogs and 35 dogs with spontaneous hyperbilirubinemia due to either hepatobiliary or haemolytic disease. UCB and its mono- and diconjugates were measured by alkaline methanolysis and HPLC in plasma and liver tissue. The activity of beta-glucuronidase was also measured in both liver and plasma. In addition, semiquantitative histochemical quantitation of bilirubins in liver tissue was performed. The concentration and the fraction of UCB in plasma of dogs with hepatobiliary disease were not significantly different from those of dogs with autoimmune haemolytic anaemia. There was a correlation between the fraction of UCB in liver and plasma of jaundiced dogs (r = 0.42, P less than 0.01) and between the histochemically estimated and the biochemically measured total bilirubin concentration in liver tissue. There was no correlation between the beta-glucuronidase activity and either unconjugated or monoconjugated bilirubin in plasma or liver of diseased animals. The fraction and the concentration of UCB in the liver of dogs with hepatic and with haemolytic disease were identical. It is concluded that beta-glucuronidase activity is not the significant factor in explaining the similar levels and fractions of UCB in dogs with hyperbilirubinemia due to either hepatobiliary or haemolytic disease.

Age- and sex-specific pediatric reference intervals for biochemistry analytes as measured with the Ektachem-700 analyzer.

Using the Ektachem-700 multilayer film analyzer, we defined age- and sex-specific reference intervals for 20 analytes in sera from a healthy population of neonates and children ages one to 19 years. Upper and lower normal reference intervals for each analyte were determined by nonparametric methods as the 0.975 and 0.025 fractiles, respectively. Newborns have lower concentrations of total protein and albumin, and higher concentrations of phosphate, bilirubin, and enzymes in serum than older children do. Concentrations of urea, glucose, calcium, phosphate, and bilirubin change rapidly postnatally. Outside the neonatal period, no significant age- or sex-related difference was found for plasma glucose, serum amylase, conjugated or unconjugated bilirubin, or lipase. There was no sex-related difference in reference intervals for albumin, total protein, calcium, phosphate, or urea. However, concentrations of uric acid and creatine kinase are much higher in postpubertal boys than in girls. Alkaline phosphatase values peak later in boys. Except for lactate dehydrogenase and gamma-glutamyltransferase, the reference intervals defined here do not differ strikingly from data derived with use of other analyzers. The age- and sex-related trends are independent of method. However, each laboratory should determine the degree to which these reference ranges can be directly applied to analyses performed with another analyzer.

Bilirubin metabolism in canine hepatobiliary and haemolytic disease.

The kinetics of unconjugated 3H-bilirubin are described in 25 healthy dogs and 35 dogs with spontaneous hepatobiliary or haemolytic disease, using a two-compartment model. The bilirubin production rates from erythrocyte degradation (PE), ineffective erythropoiesis (PI) and catabolism of hepatic haemoproteins (PL), were derived from the incorporation of 14C-glycine into haemoglobin and stercobilin. These combined measurements permitted an integral survey of bilirubin metabolism in health and disease. The concentration of unconjugated bilirubin in plasma and its fraction of total bilirubin levels were similar in hepatic and haemolytic disorders. This was explained by the highly increased bilirubin production rates in both types of disease. In addition, the hepatic bilirubin clearance was severely impaired in fulminant hepatitis and in cirrhosis, and moderately decreased in the other hepatobiliary diseases and in primary haemolysis. The erythrocyte lifespan was reduced in all animals but one. In addition to haemolysis, the contribution of PI and PL was variable, and in two dogs PL was the principle source of highly increased bilirubin production rates. These data indicate that the concentration of unconjugated bilirubin in plasma or its fraction of total pigments is unreliable in the discrimination of canine hepatobiliary disease from haemolytic disorders.

The implication of bilitranslocase function in the impaired rifamycin SV metabolism in Gilbert's syndrome

1. The plasma disappearance rate and the increment in plasma unconjugated bilirubin after intravenous administration of 5.9 mumol of rifamycin SV (RSV)/kg body wt. were investigated in 51 subjects with Gilbert's syndrome and 35 control subjects of both sexes. 2. Both the plasma disappearance rate and the unconjugated hyperbilirubinaemia after RSV administration were higher (P < 0.001) in Gilbert's syndrome. Females, both normal and with the syndrome, showed a significantly shorter t1/2 and a lower hyperbilirubinaemic response as compared with males. A linear correlation (P < 0.001) was present between RSV plasma half-life and the hyperbilirubinaemic response. 3. In vitro, RSV was shown to inhibit sulphobromophthalein (BSP) uptake in rat liver plasma-membrane vesicles with a Ki of 20 mumol/l. Evidence that this effect was due to competition for bilitranslocase was sought on preparations of the purified protein. Under these experimental conditions, RSV inhibited BSP binding with a Ki of 17 mumol/l. 4. Since RSV competes with BSP for binding to bilitranslocase in vitro, the data are interpreted as suggesting that reduced bilitranslocase function might underlie the delayed RSV plasma clearance and the exacerbated unconjugated hyperbilirubinaemia present in Gilbert's syndrome.

The effects of nutrition on unconjugated plasma bilirubin concentrations in squirrel monkeys.

Bolivian squirrel monkeys (Saimiri sciureus) have fasting unconjugated hyperbilirubinemia (males: 2.0 +/- 0.14; females: 3.0 +/- 0.26 mg per dl) which resembles that of humans with Gilbert's syndrome. Closely related Brazilian squirrel monkeys have fasting levels (males: 0.29 +/- 0.045; females: 0.36 +/- 0.073 mg per dl) similar to normal people. The purpose of this study was to identify the underlying mechanisms and the nutritional factors involved. Both Bolivian and Brazilian squirrel monkeys had higher plasma bilirubin concentrations after an 18 hr fast than 4 hr after feeding. The development of fasting hyperbilirubinemia was progressive for at least 24 hr. Both populations that received a semipurified diet containing 5% fat had lower fasting and postprandial plasma bilirubin concentrations than did animals receiving 0.3% fat but much lower than those receiving 20% fat. The emulsified complete meal, or glucose, sucrose, casein, or lactalbumin alone when given by intragastric tube lowered the plasma bilirubin levels of Bolivian monkeys to less than one-half of fasting values within 1 to 4 hr. Water or butter did not have a significant effect. Glucose or fructose, when given intravenously, lowered the plasma bilirubin levels to less than half of fasting values; the fat emulsion, Intralipid, did not have a statistically significant effect. Subcutaneous epinephrine increased plasma glucose concentrations and reduced plasma bilirubin concentrations. When glucose or glucose plus butter were given by stomach tube to Bolivian squirrel monkeys for 48 hr, a very low plasma bilirubin concentration resulted whereas butter given alone resulted in high values.(ABSTRACT TRUNCATED AT 250 WORDS)

A nonhuman primate model of Gilbert's syndrome.

A Bolivian population of squirrel monkeys, Saimiri sciureus, exhibits several features of Gilbert's syndrome in man, and is proposed as a nonhuman primate model of the condition. The Bolivian population was found to have higher fasting (40.6 +/- 2.7 microM; mean +/- S.E.) and postcibal (9.9 +/- 0.9 microM) plasma unconjugated bilirubin concentrations (p less than 0.001) than a closely related Brazilian population (fasting 5.5 +/- 0.7 microM); postcibal (2.4 +/- 0.7 microM). After intravenous administration of [3H]bilirubin as a tracer dose or at 3.4 mumoles per kg body weight, there was delayed plasma clearance in the Bolivian monkeys. Hepatic UDP-glucuronyl transferase activity for bilirubin (164 +/- 25 nmoles per 30 min per gm liver) and biliary bilirubin diglucuronide to monoglucuronide ratios (2.9 +/- 0.2) were lower in Bolivian monkeys than in Brazilians (421 +/- 36 nmoles per 30 min per gm liver--p less than 0.01 and 4.1 +/- 0.1--p less than 0.02, respectively). Hepatic cytosol glutathione-S-transferase B activity (ligandin) levels were similar for the two populations. After phenobarbital therapy, fasting (11.1 +/- 0.9 microM) and postcibal (5.3 +/- 1 microM) plasma bilirubin concentrations in Bolivian monkeys were significantly reduced (p less than 0.001). Sulfobromophthalein clearance was slightly slower in the Bolivian than in the Brazilian monkeys. SGOT, lactate dehydrogenase, gamma-glutamyl transpeptidase and alkaline phosphatase activities were not increased in Bolivians. Fasting serum conjugated bile salt concentrations in Bolivian monkeys were lower than that in Brazilian monkeys (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Drug-Induced Displacement of Bilirubin from Albumin in the Newborn

Kernicterus is probably caused by precipitation of insoluble bilirubin acid in brain cells. The pigment is transferred from blood plasma to cells. The tendency for precipitation depends upon the ratio of unconjugated plasma bilirubin concentration to the concentration of reserve albumin for binding of bilirubin and is increased when part of the albumin is occupied by competitive binding of a drug. Laboratory methods are available whereby it is possible, on certain well-defined presumptions, to measure this drug effect in quantitative terms. Measurements can be made in systems with pure albumin as well as in plasma samples from treated patients. It would thus appear feasible at the present stage to establish a basis for official testing of the bilirubin-displacing effects of drugs.