Unconjugated Bilirubin Levels Research Articles

A Brief Review on Kernicterus

Kernicterus is a rare neurological condition which occurs when the unconjugated bilirubin levels rises above 25 mg/dL in the blood leading to decreased elimination and increased production of bilirubin. Most commonly, it affects newborns and infants of age three to four years, in that the premature infants are more prone to this condition. Accumulation of toxic levels of bilirubin in blood as well as in brain leads to life threatening complications. However, early diagnosis and management of this condition helps in preventing brain damage and also developmental abnormalities in an infant. In this article, we mainly reviewed about the epidemiology, etiology, pathophysiology, clinical manifestations, diagnosis and the treatment of kernicterus. It is necessary for the health care team and professionals to detect the early signs of kernicterus by close monitoring of infant at the time of birth to prevent it from getting worsen. However, there are various effective and advanced techniques available to treat the condition as soon as it is diagnosed and thus it is a preventable condition if managed with utmost care.

Gilbert's Syndrome and the Gut Microbiota - Insights From the Case-Control BILIHEALTH Study.

The heme catabolite bilirubin has anti-inflammatory, anti-oxidative and anti-mutagenic effects and its relation to colorectal cancer (CRC) risk is currently under evaluation. Although the main metabolic steps of bilirubin metabolism, including the formation of stercobilin and urobilin, take place in the human gastrointestinal tract, potential interactions with the human gut microbiota are unexplored. This study investigated, whether gut microbiota composition is altered in Gilbert’s Syndrome (GS), a mild form of chronically elevated serum unconjugated bilirubin (UCB) compared to matched controls. Potential differences in the incidence of CRC-associated bacterial species in GS were also assessed. To this end, a secondary investigation of the BILIHEALTH study was performed, assessing 45 adults with elevated UCB levels (GS) against 45 age- and sex-matched controls (C). Fecal microbiota analysis was performed using 16S rRNA gene sequencing. No association between mildly increased UCB and the composition of the gut microbiota in this healthy cohort was found. The alpha and beta diversity did not differ between C and GS and both groups showed a typical representation of the known dominant phyla. Furthermore, no difference in abundance of Firmicutes and Proteobacteria, which have been associated with the mucosa of CRC patients were observed between the groups. A sequence related to the Christensenella minuta strain YIT 12065 was identified with a weak association value of 0.521 as an indicator species in the GS group. This strain has been previously associated with a lower body mass index, which is typical for the GS phenotype. Overall, sex was the only driver for an identifiable difference in the study groups, as demonstrated by a greater bacterial diversity in women. After adjusting for confounding factors and multiple testing, we can conclude that the GS phenotype does not affect the composition of the human gut microbiota in this generally healthy study group.

Oxidative Stress and Related Biomarkers in Gilbert's Syndrome: A Secondary Analysis of Two Case-Control Studies.

Bilirubin is an important antioxidant and a modulator of biological functions. However, most of the protection against oxidative stress was shown in vitro or ex vivo. The aim of this case-control study was to investigate whether subjects with Gilbert’s syndrome (GS) experience different levels of lipid and protein oxidation (as well as differences in oxidative stress related markers) compared to healthy controls. GS subjects (n = 119) demonstrated higher serum levels of unconjugated bilirubin (p < 0.001), a lower BMI (p < 0.001), 37% higher antioxidant potential assessed as ferric reducing ability potential (p < 0.001), higher advanced oxidation protein products (p < 0.01) andlower apolipoprotein B (p < 0.05), hs-C-reactive protein (p < 0.05), interleukin 6 (p < 0.001) and interleukin 1 beta (p < 0.05) values compared to healthy controls (n = 119). Furthermore, the resting heart rate was significantly lower in the GS group (p < 0.05). Stronger protective effects for GS subjects were demonstrated in the older subgroup (n = 104, average age 50 years) compared to those of the younger group (n = 134, average age 27 years). Although not all markers related to oxidative stress were different between the groups (e.g., malondialdehyde, homocysteine, oxLDL, and myeloperoxidase; p > 0.05), the observed differences contribute to the explanation of why GS serves as an important protector in the pathogenesis of metabolic, oxidative stress related diseases.

Effects of Hydroxyurea Treatment on Haemolysis in Patients with Sickle Cell Disease at Muhimbili National Hospital, Tanzania.

Tanzania is one of the countries with a high burden of sickle cell disease (SCD). Haemolytic anaemia is a clinical feature of SCD, and has been linked to major complications leading to morbidity and mortality. Treatment with hydroxyurea (HU) has shown to induce foetal haemoglobin (HbF) which in turn decreases haemolysis in patients. This study aimed to investigate the effects of HU on haemolysis in SCD patients attending Muhimbili National Hospital, Tanzania by comparing their haemolytic parameters before and after therapy. Patients meeting the criteria were initiated on HU therapy for 3 months. Two haemolytic biomarkers: unconjugated plasma bilirubin levels and absolute reticulocyte counts were measured from patients' blood samples at baseline and after 3 months of HU therapy and compared. Both absolute reticulocyte counts and indirect plasma bilirubin levels significantly declined after HU therapy. Median (IQR) plasma unconjugated bilirubin levels dropped significantly from 20.3 (12.7-34.4) μmol/L to 14.5 (9.6-24.1) μmol/L (p < 0.001) and mean (SD) absolute reticulocyte counts dropped significantly from 0.29 (0.1) × 109/L to 0.17 (0.1) × 109/L (p < 0.001) after therapy, thus, a decline in both haemolytic biomarkers after treatment was observed. This study found a potential for use of HU therapy in managing SCD patients in our settings evidenced by improvements in their haemolytic parameters. Clinical trials with a lager sample size conducted for a longer time period would be beneficial in guiding towards the inclusion of HU in treatment protocols for the Tanzanian population.

How dangerous Gilbert's syndrome is

Gilbert's syndrome is a benign (functional) hyperbilirubinemia, which is based on a hereditary disorder of bilirubin metabolism, as a result of which the concentration of unbound bilirubin can increase several times. Bilirubin, being a breakdown product of hemoglobin, circulates through the bloodstream, combining with albumin molecules. Such bilirubin is called indirect. In the endoplasmic reticulum, it is conjugated; the enzyme glucuronyltransferase is responsible for this process. In Gilbert's syndrome, as a result of insufficient production of this enzyme, the conjugation process is disrupted, and, as a result, the concentration of unconjugated bilirubin increases. According to statistics, this pathological condition is observed in about 5 % of Russians. This syndrome was first described in 1901 by the French physician Augustin Nicolas Gilbert, and was subsequently named after him. The literature also contains references to this syndrome, described as «constitutional hepatic dysfunction», «familial non-hemolytic hyperbilirubinemia», «idiopathic non-conjugated hyperbilirubinemia». Gilbert's syndrome is inherited in an autosomal recessive manner; men get ill 3–4 times more often than women. A number of scientists associate this with a possible inhibitory effect of testosterone on the enzyme UDP-GT1, which breaks down bilirubin. Clinically, Gilbert's syndrome is manifested by episodes of jaundice caused by an increase in the level of unconjugated bilirubin in the blood serum. Against the background of icterus of the sclera and skin, there is increased fatigue, the appearance of a feeling of bitterness in the mouth, loss of appetite, nausea, and sometimes vomiting. The association of Gilbert's syndrome with functional disorders of the biliary tract, in particular, with gallbladder dyskinesia, is often noted.

Longer Term Follow-up on the First Patients with Severe Hemoglobinopathies Treated with Lentiglobin Gene Therapy

Background: LentiGlobin Drug Product (DP) contains autologous CD34+ cells transduced with the betibeglogene darolentivec (BB305) lentiviral vector, encoding a human β-globin gene with a point mutation (AT87Q) that confers anti-sickling properties similar to those with γ-globin. Human proof of concept for LentiGlobin treatment in transfusion-dependent β-thalassemia (TDT) and severe sickle cell disease (SCD) has been established in HGB-205 (NCT02151526), the original clinical study of gene therapy for hemoglobinopathies. Here, we provide an update on 5 previously-reported patients (4 TDT, 1 SCD) as well as early data from 2 additional treated patients with SCD.Methods: HGB-205 enrolled patients (5−35 years old) with TDT (≥100 mL/kg of packed red blood cells [pRBCs] per year) or severe SCD (e.g., failed hydroxyurea treatment and ≥2 acute chest syndrome episodes [ACS] or ≥2 vaso-occlusive crises [VOC] in the preceding year/year prior to regular transfusions). Following mobilization/apheresis for TDT or bone marrow harvest for SCD, autologous CD34+ cells were transduced with the BB305 lentiviral vector. Patients underwent myeloablative conditioning with busulfan, were infused with transduced cells and monitored for hematologic engraftment, vector copy number (VCN), transgenic hemoglobin (HbAT87Q) levels, and adverse events (AEs). Transfusion requirements and biological markers for TDT, and VOCs for SCD were also assessed.Results: As of June 2, 2017, 4 patients with TDT and 3 patients with severe SCD have received LentiGlobin DP; median follow-up is 23.4 (range, 3.4 - 42.2) months. Patient and DP characteristics and key outcomes for these 7 patients are shown in Table 1. All patients engrafted successfully. The toxicity profile was consistent with myeloablative conditioning with single-agent busulfan, with no DP-related ≥ grade 3 AEs or serious AEs and no evidence of clonal dominance reported to date. For patients with TDT, VCN, total Hb and HbAT87Q levels in peripheral blood remain stable, with no evidence of decreasing efficacy (Table 1). All patients with TDT remain free of RBC transfusions. In all 3 β0/βE patients, Hb levels are stable near or within the normal range. Importantly, iron burden and biological hallmarks of dyserythropoiesis have largely returned to normal. Two patients with TDT have discontinued iron chelation therapy and transitioned to therapeutic phlebotomy while the third patient (1202) has been able to discontinue both.All 3 patients with SCD showed increase in HbAT87Q production through 6 months or last follow-up. The first treated patient with severe SCD (1204) had no clinical symptoms or complications of SCD until, at about 30 months post-treatment, the patient developed a VOC following an episode of acute gastroenteritis with fever and dehydration, and was subsequently hospitalized. His total Hb levels (12.4 g/dL), HbAT87Q (6.1 g/dL) and peripheral blood VCN levels (2.3) have remained stable at 30 months of follow-up. The 2 recently treated patients with SCD (1207 and 1208) have 6 and 3 months of follow-up, have not undergone transfusions since Day 21 and 15 post-infusion, and have total Hb of 8.8 g/dL and 9.8 g/dL and HbAT87Q of 1.8 and 1.5 g/dL, respectively as of last follow-up. At approximately 6 months post-treatment, patient 1207 experienced an episode of ACS and was hospitalized. Total % anti-sickling Hb ([HbAT87Q + HbF + HbA2]/Total Hb * 100) in the 3 patients with SCD was 52%, 39% and 36% as of last follow-up. Levels of unconjugated bilirubin, lactate dehydrogenase and reticulocyte count had improved compared to screening in the 2 patients with SCD (1204 and 1207) who had ≥ 6 months follow-up.Summary: Data from this pioneering phase 1/2 clinical study continue to suggest that treatment with LentiGlobin DP elicits sustained HbAT87Q levels which may be sufficient to alleviate the clinical and biochemical effects of severe SCD and TDT, with an acceptable safety profile. In patients with TDT, sustained levels of HbAT87Q with longer term follow-up, abatement of dyserythropoeisis and discontinuation of iron chelation therapy confirm the results seen to date. For patients with SCD, the marked clinical improvement in 1 patient with nearly 2.5 years of follow-up and increasing HbAT87Q levels in recently treated patients suggest gene therapy may be a promising option. Follow-up data on the 3 patients with SCD and 2-year primary follow-up for patients with TDT will be presented. [Display omitted] DisclosuresPayen:bluebird bio: Honoraria, Research Funding. Brousse:Add Medica: Membership on an entity's Board of Directors or advisory committees. Bartolucci:Novartis: Consultancy; AddMedica: Consultancy, Research Funding. Beuzard:bluebird bio: Consultancy, Equity Ownership. Asmal:bluebird bio: Employment, Equity Ownership. Miller:bluebird bio: Employment, Equity Ownership. De Montalembert:Addmedica: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Research Funding. Leboulch:bluebird bio: Consultancy, Equity Ownership, Membership on an entity's Board of Directors or advisory committees, Patents & Royalties. Ribeil:Addmedica: Membership on an entity's Board of Directors or advisory committees; Vitalaire: Other: Non-financial support; Novartis: Other: Non-financial support.

Effects of UGT1A1 Polymorphism, Glucose-6-Phosphate Dehydrogenase Deficiency and Deletional (-3.7кb) α-Thalassemia Among Young Nigerians with Sickle Cell Anemia

Several genetic factors modulate the clinical course of sickle cell anemia (SCA), such as the βs-haplotypes, 3.7кb α-globin gene deletions (-α3.7), glucose-6-phosphate dehydrogenase deficiency (G6PD), UGT1A1 polymorphism and influencers of fetal hemoglobin production. While many studies on these modifiers have been conducted among patients in the developed world, little is known about how they impact SCA among Nigerians.We hypothesized that these factors could modulate SCA in the Nigerian population. Hence, we set out to determine whether βs-haplotype, -α3.7deletion, G6PD, and UGT1A1 polymorphism influence the laboratory markers and clinical events in young Nigerians with SCA.The study was conducted among 101 hydroxyurea-naïve SCA patients aged 2-21years, (median 9 years) in steady state, on regular follow up at the pediatric hematology unit of the Ekiti State University Teaching Hospital (EKSUTH), Ado Ekiti, Southwest Nigeria.Molecular analysis were conducted to confirm the diagnosis of SCA by polymerase chain reaction (PCR) and direct sequencing; alpha thalassemia by GAP-PCR; to determine UGT1A1 genotypes by Fragment Analysis; and BS haplotypes and G6PD genotypes by TaqMan SNP genotyping assay at the Hemocentro - University of Campinas, Brazil. Automated analysers were used to carry out hematologic and biochemical analyses. Records of the patients were examined for clinical events and steady state laboratory parameters. Serial abdominal ultrasounds were done as clinically indicated to diagnose gallstones. Institutional review board approval was obtained and the study protocols followed the Declaration of Helsinki as revised in 2000.Four (TA)n alleles (5, 6, 7, and 8) were found with gene frequencies of 0.11, 0.44, 0.40, and 0.05, respectively, grouped into 11 genotypes: TA5/5, 5/6, 5/7, 5/8, 6/5, 6/6, 6/7, 6/8, 7/7, 7/8, 8/8. Low Activity UGT1A1 genotypes (TA7/7, 7/8, 8/8) were found in 25 (24.7%). The Benin/Benin βs-haplotype was found in 94 (93%), Benin/Cameroun 4 (4%), Benin/Bantu 2 (2%), and Benin/Arab 1(1%). Mutation for the African variant of G6PD deficiency (202G>A) was found in 21(20.8%). None had the Mediterranean (563C>T) mutation. The frequency of 3.7 κb α-globin gene deletion was 34 (33.6%) αα /-α3.7 as heterozygous, 7 (7%) -α3.7/-α3.7 homozygous. Additionally, we found one (1%) α-globin triplication (αααanti3.7/αα).There was significant difference in bilirubin levels of the patients when differentiated by the UGT1A1 genotypes according to expected enzyme activity (low > intermediate > high activity with median unconjugated bilirubin levels of 1.8, 0.8, and 0.6mg/dL, respectively, P <0.0001). The presence of either alpha thalassemia or G6PD deficiency or both did not alter this trimodal pattern of bilirubin levels. Asymptomatic gallstone was found in 6 (5.9%) patients aged 10 to 16 years. Five of them had the low UGT1A1 activity genotypes 4 (TA7/7) & 1(TA7/8). The low genotype was significantly associated with gallstone when compared to other genotype groups 5/25 vs 1/76, P=0.0033. Bilirubin levels of patients with gallstone was significantly higher than age & sex matched subjects without gallstone (4.7 vs 1.2mg/dl, p=0.002) suggesting that the pathway to developing hyperbilirubinemia and gallstone is primarily driven by the influence of UGT1A1 genotype of our study cohorts.When we evaluated the influence of -α3.7 deletion, we found that participants with alpha thalassemia had higher frequencies of pain crisis in the preceding one year of the study with median episodes of 3 (range 0-6) vs 0 (range 0-6), P <0.0001. The presence of alpha thalassemia was significantly associated with decreased mean corpuscular volume, mean corpuscular hemoglobin, reticulocyte count and with a higher hemoglobin concentration (P <0.05) However, none of the 6 participants with leg ulcers had alpha thalassemia 0/ 42 vs 6/59 (P=0.039). There were no significant associations of βs-haplotypes and G6PD deficiency with both laboratory parameters and clinical events.In conclusion, our findings confirmed that both alpha thalassemia and UGT1A1 polymorphism influence the laboratory markers and clinical events of young Nigerians with SCA. It appears the influence of UGT1A1 polymorphism outweighs the modest ameliorating effect of alpha thalassemia on hyperbilirubinemia and cholelithogenesis among the patients. DisclosuresFertrin:Alexion Pharmaceuticals: Consultancy.

Yinzhihuang Oral Liquid Ameliorates Hyperbilirubinemia Induced by δ-Aminolevulinic Acid and Novobiocin in Neonatal Rats.

Yinzhihuang oral liquid (YZH) is a traditional Chinese medicine that has been widely used in Asia to prevent and treat neonatal hyperbilirubinemia, but the published preclinical studies on its anti-hyperbilirubinemia effect are conducted in adult animals, partly due to the lack of preclinical neonatal hyperbilirubinemia animal models. In the present study, we tested six reagents to induce hyperbilirubinemia in neonatal rats, and established two appropriate neonatal hyperbilirubinemia rat models by subcutaneous injection of δ-Aminolevulinic acid (ALA, 200 mg/kg) or novobiocin (NOVO, 200 mg/kg). Oral treatment of YZH (80, 160 and 320 mg/kg) significantly decreased serum conjugated bilirubin levels in ALA-treated neonatal rats and serum unconjugated bilirubin levels in NOVO-treated neonatal rats, respectively. Additionally, pre-treatment of YZH also prevented the increase of serum bilirubin levels in both ALA- and NOVO-treated rats. Mechanistically, YZH significantly up-regulated the mRNA expression of genes involved in hepatic bilirubin disposition (organic anion-transporting polypeptide 1b2, Oatp1b2; multidrug resistance-associated protein 2, Mrp2) and bilirubin conjugation (UDP-glucuronosyltransferase 1a1, Ugt1a1). Additionally, YZH up-regulated the mRNA expression of cytochrome P450 1A1 (Cyp1a1), the target gene of aryl hydrocarbon receptor (AhR), and increased the nuclear protein levels of AhR in livers of neonatal rats. YZH and its two active ingredients, namely baicalin (BCL) and 4'-hydroxyacetophenone (4-HT), up-regulated the mRNA expression of AhR target genes (CYP1A1 and UGT1A1) and increased nuclear protein levels of AhR in HepG2 cells. In conclusion, the present study provides two neonatal hyperbilirubinemia animal models and evaluates the anti-hyperbilirubinemia effect and mechanisms of YZH in neonatal animals.

Evaluation of Risk Factors for Exchange Range Hyperbilirubinemia in Neonates from Eastern Part of Nepal

&#x0D; &#x0D; &#x0D; &#x0D; Introduction: Neonatal hyperbilirubinemia continues to be the commonest cause of nursery and NICU admissions and readmissions in the neonatal period worldwide. Although most cases are physiological, toxic levels of un-conjugated bilirubin can lead to acute and chronic bilirubin encephalopathy. Hence, this study aimed to study the risk factors for exchange range hyperbilirubinemia in neonates.&#x0D; Methods: This was a hospital-based prospective observational study conducted in a teaching and referral NICU over a period of one year from July 2019 to August 2020. All neonates with diagnosis of hyperbilirubinemia requiring double volume exchange transfusion were included in the study. Risk factors for significant hyperbilirubinemia were analysed with descriptive statistics. P-value of &lt; 0.05 was considered significant wherever applicable.&#x0D; Results: The mean gestational age and birth weight were 38.06 ± 2.13wks and 2611.72 ± 389.39 gm respectively. Fifteen percent of the babies (162) developed hyperbilirubinemia and 28 (17.3%) required double volume exchange transfusion. Among neonates requiring exchange transfusion, 17 were females and 11 were males. Among 28 babies who required DVET, 20 (71.4%) were SGA. ABO incompatibility was present in 14 (50.0%) neonates and Rh incompatibility in 13 (46.4%) neonates. ABO along with Rh incompatibility was present in eight (28.6%) neonates. DCT was positive in six neonates with ABO incompatibility and nine neonates in Rh incompatibility. G6PD deficiency was present in four (14.3%) neonates.&#x0D; Conclusions: The most important risk factors identified were small for gestational age, ABO and Rh incompatibility followed by oxytocin use and sibling treated for jaundice.&#x0D; &#x0D; &#x0D; &#x0D;

Influence of UGT1A1 promoter polymorphism, α-thalassemia and βs haplotype in bilirubin levels and cholelithiasis in a large sickle cell anemia cohort.

Hyperbilirubinemia in patients with sickle cell anemia (SCA) as a result of enhanced erythrocyte destruction, lead to cholelithiasis development in a subset of patients. Evidence suggests that hyperbilirubinemia may be related to genetic variations, such as the UGT1A1 gene promoter polymorphism, which causes Gilbert syndrome (GS). Here, we aimed to determine the frequencies of UGT1A1 promoter alleles, alpha thalassemia, and βS haplotypes and analyze their association with cholelithiasis and bilirubin levels. The UGT1A1 alleles, -3.7 kb alpha thalassemia deletion and βS haplotypes were determined using DNA sequencing and PCR-based assays in 913 patients with SCA. The mean of total and unconjugated bilirubin and the frequency of cholelithiasis in GS patients were higher when compared to those without this condition, regardless of age (P < 0.05). Cumulative analysis demonstrated an early age-at-onset for cholelithiasis in GS genotypes (P < 0.05). Low fetal hemoglobin (HbF) levels and normal alpha thalassemia genotype were related to cholelithiasis development (P > 0.05). However, not cholelithiasis but total and unconjugated bilirubin levels were associated with βS haplotype. These findings confirm in a large cohort that the UGT1A1 polymorphism influences cholelithiasis and hyperbilirubinemia in SCA. HbF and alpha thalassemia also appear as modulators for cholelithiasis risk.

Establishment of age- and sex-specific reference intervals for serum liver function tests in pediatric population aged 1-

BackgroundThe diagnosis, treatment, and prognosis of pediatric diseases rely on the accurate establishment of the reference interval (RI). This study aimed to establish pediatric RIs for liver function tests and evaluated the correlation of the analytes.MethodsPediatric population (aged 1–<18 years) was prospectively recruited in Jilin Province, China. Analytes detected by Ortho VITORS 5600 automatic biochemical analyzer. All strata were divided using the regression tree and Harris and Boyd's method. The dynamic changes of RI were evaluated by the lambda‐mu‐sigma method.ResultsReference individuals were comprised of 6,322 children and adolescents. Age and sex differences were present in all analytes except serum total protein. The serum albumin, total protein, γ‐glutamyl transferase, total bilirubin, and unconjugated bilirubin levels increased with age while serum aspartate aminotransferase was opposite. The serum alanine aminotransferase level reached a trough at the age of 5 and later steadily in males but slowly decreased in females. The serum alkaline phosphatase level dropped rapidly after reaching a peak at 9 years old in females and 12 years old in males. RIs were divided into 11 partitions at most and 5 partitions at least. The strongest correlation between analytes was total bilirubin and unconjugated bilirubin (r = 0.788), followed by total bilirubin and albumin (r = 0.511).ConclusionsAnalytes show unique dynamic changes in pediatric population. The correlations among liver function tests can inform future studies of particular variables. Age‐ and sex‐special pediatric RIs should be established to help an accurate diagnosis of disease.

Unconjugated bilirubin is associated with protection from early-life wheeze and childhood asthma

Wheeze and allergic sensitization are the strongest early-life predictors of childhood asthma development; the molecular origins of these early-life phenotypes are poorly understood. We sought to identify metabolites associated with early-life wheeze, allergic sensitization, and childhood asthma. We conducted a nested case-control study using Environmental influences on Child Health Outcomes Program cohorts for discovery and independent replication. Wheeze and allergic sensitization were defined by number of wheeze episodes and positive specific IgE at age 1 year, respectively. Asthma was defined as physician diagnosis of asthma at age 5 or 6 years. We used untargeted metabolomics, controlling for observed and latent confounding factors, to assess associations between the plasma metabolome and early-life wheeze, allergy, and childhood asthma. Eighteen plasma metabolites were associated with first-year wheeze in the discovery cohort (n= 338). Z,Z unconjugated bilirubin (UCB) and its related metabolites exhibited a dose-response relationship with wheeze frequency; UCB levels were 13% (β= 0.87; 95% CI, 0.74-1.02) and 22% (β= 0.78; 95% CI, 0.68-0.91) lower in children with 1 to 3 and 4+ wheeze episodes compared with those who never wheezed, respectively. UCB levels were also associated with childhood asthma (β= 0.82; 95% CI, 0.68-0.98). Similar trends were observed in 2 independent cohorts. UCB was significantly negatively correlated with eicosanoid- and oxidative stress-related metabolites. There were no significant associations between metabolites and allergic sensitization. We identified a novel inverse, dose-dependent association between UCB and recurrent wheeze and childhood asthma. Inflammatory lipid mediators and oxidative stress byproducts inversely correlated with UCB, suggesting that UCB modulates pathways critical to the development of early-life recurrent wheeze and childhood asthma.

Serum zinc changes in term neonates with hyperbilirubinemia after phototherapy

Background: Neonatal jaundice occurs due to the elevated levels of unconjugated bilirubin and may induce neurological sequelae, such as encephalopathy. Phototherapy remains the main primary management in neonatal jaundice; one of its effects is elevated in zinc level. Objectives: Assess serum zinc level in full term neonates who had hyperbilirubinemia and treated by phototherapy before and after phototherapy and study it`s relation to selected neonatal, maternal and labour factors. Methods: A prospective study has been carried out in Basrah Maternity and Children Hospital, 2nd neonatal care unit to assess serum zinc on 60 term neonates appropriate for gestational age with unconjugated hyperbilirubinemia treated by phototherapy. Neonatal, maternal data were collected, serum zinc was assessed before and after phototherapy, (normal range: 50-150 μg/dL), elevated in serum zinc was studied in relation to selected variables. Results: It was found that total serum bilirubin was lower after phototherapy and serum zinc was elevated. The result is statistically significant. Elevated serum zinc was found in 33.3% of cases. It was more in in extensive phototherapy than double or single. P value < 0.05. Also, more with prolonged period of phototherapy but the result was statistically not significant. It was not related to other neonatal or maternal characters. Conclusion: Serum zinc is elevated after phototherapy in neonates with hyperbilirubinemia, increase level is more with use of extensive phototherapy and increase level of total serum bilirubin.

Liver histologic changes in children with type 1 of Crigler-Najjar syndrome

To describe liver histology changes in patients who have undergone liver transplantation. This retrospective cross-sectional study was performed to evaluate the liver pathologies of patients with type 1 of Crigler-Najjar syndrome (CNS1). We analyzed medical records and liver histologic specimens of 53 children who were transplanted in Namazi Hospital Organ Transplant Center affiliated with Shiraz University of Medical Sciences between 2009 and 2019. We studied the tissue of the explanted liver, which was replaced by transplants. Most of the patients were less than 2 years old, with an average age of 1.7 years. The collected data were analyzed using SPSS 22 software. The prevalent pathology found in the liver of these patients was periportal fibrosis (96.2%). Cholestasis was the second common finding (94.3%) followed by pericentral fibrosis (86.7%) and ductal reaction (22.6%). A significant correlation was only present between phototherapy time and ductal reaction grade. Our results indicated a high prevalence of fibrosis of different grades among CNS 1 patients which bolds the necessity of histologic examination before considering treatments such as gene therapy or hepatocyte transplantation.

Platelet Counts and Mean Platelet Volume As Markers of Clinical Severity in Sickle Cell Disease

Introduction:Platelet counts in peripheral blood could possibly be used as prognostic markers in sickle cell disease (SCD), since these blood elements play an important role in the phenomena of vessel occlusion. In this context, the mean platelet volume (MPV) may also reflect the level of platelet activation, a parameter that is already used in the stratification of thrombotic processes in situations such as acute coronary syndromes. Thus, the aim of this study was to evaluate platelet counts and MPV in SCD as possible prognostic markers for the occurrence of clinical complications and their relation with laboratory markers of inflammation and hemolysis. Methods:A retrospective chart review was performed on two hundred and sixty-six adult SCD patients (median age 40 years, ranging from 14 to 66), followed from 2002 to 2019, distributed as follows: 156 HbSS, 16 HbSβ0, 15 HbSβ+ and 79 HbSC. Medical records were reviewed for laboratory data at baseline (first visit); clinical data and hospital admissions were recorded for sickle related complications throughout follow-up: acute chest syndrome, retinopathy, avascular bone necrosis, stroke, priapism, leg ulcers and venous thromboembolism. Results:The median platelet count was significantly different between the different genotypes (Kruskal-Wallis rank sum test, p &amp;lt; 0.001), with SS: 420 (95-1043) x 103/uL, Sβ0: 406.5 (206 -713), Sβ+: 362 (87-925) and SC: 295 (84 -927). This difference may be related to the degrees of inflammation and hyposplenia in each genotype. Regardless of the genotypes, platelet counts in peripheral blood tend to decrease with age (Rô = -0.201, p &amp;lt; 0.001). Interestingly, higher platelet counts are associated with the presence of leg ulcers (Wilcoxon rank sum test with continuity correction, p = 0.03), acute chest syndrome (p= 0.047), higher levels of microalbuminuria (p &amp;lt;0.001) and transfusion load accumulated throughout life (p = 0.03), pointing to a marker of disease severity in this specific cohort. In addition, patients with higher platelet counts tend to have lower hemoglobin (Rô = -0.252, p &amp;lt;0.001) and hematocrit levels (Rô = -0.229, p &amp;lt;0.001), as well as higher RDW (Rô = 0.131, p = 0.032), which could be related to the higher reticulocyte count (Rô = 0.333, p &amp;lt;0.001) suggesting higher levels of hemolysis, corroborated by the higher levels of unconjugated bilirubin (Rô = 0.227, p &amp;lt;0.001). There was also a positive relationship between platelet counts and number of total leukocytes (Rô = 0.343, p &amp;lt;0.001), neutrophils (Rô = 0.272, p &amp;lt;0.001), monocytes (Rô = 0.28, p &amp;lt;0.001) and lymphocytes (Rô = 0.257, p &amp;lt;0.001), probably reflecting an association with exacerbated inflammation and hematopoietic response. MPV index was above normal values in only 10 patients (3.75%) and there were no significant variations between the different genotypes. However, MPV seems to predict the occurrence of retinopathy in SC individuals (Wilcoxon rank sum test with continuity correction, p = 0.05). Moreover, there is an inverse relationship between MPV value and hemoglobin levels (Rô = -0.125, p = 0.041) and hematocrit (Rô = -0.156, p = 0.011), though no correlation with any other laboratory marker or clinical complication. Discussion: In this cohort of Brazilian patients, we observed that, despite the difference in platelet counts between the genotypes, the increase in platelet counts was related to a greater chance of leg ulcers, Acute Chest Syndrome, microalbuminuria and high transfusion load. Furthermore, platelet number was inversely correlated with hemoglobin and hematocrit levels, and was associated with changes in hemolysis and inflammation markers. MPV was related to the presence of retinopathy in HbSC individuals and MPV elevation was also associated with low levels of hemoglobin and hematocrit. Thus, it is important to evaluate the baseline platelet counts of SCD patients as possible predictor of clinical complications and more severe phenotypes. This simple measure has the potential to raise awareness in the care of these specific patients and to direct greater efforts in the prevention of chronic complications, especially in situations of fewer resources, as this is a cheap and easily available marker. Disclosures Costa: Novartis:Consultancy.

Evaluation Of Some Markers Of Haemolysis – Endothelial Dysfunction And Haematological Parameters In People With Sickle Cell Disease Leg Ulcers

Abstract Introduction/Objective Sickle cell leg ulcer (SCLU) is one of the commonest cutaneous manifestation of the sickle cell anaemia (SCA). This study was designed to evaluate the haematological parameters and contribution of haemolysis to leg ulcers in persons with sickle cell anaemia Methods A comparative cross-sectional study of 73 participants (24 sickle cell leg ulcer-SCLU, 24 sickle cell without leg ulcer-SCWLU and 25 healthy controls). Physical examination was conducted to grade the SCLU. ELISA kits were used to analyse Nitric oxide, while FBC, Reticulocyte count, liver function test (AST and ALT), total Bilirubin (unconjugated and conjugated) were determined using standard methods. ANOVA was used to compare the association between sickle cell leg ulcers and markers of haemolysis-endothelial dysfunction among the three groups. Probability score of less than 5% (p-values&amp;lt;0.05) was considered statistically significant Results There was no statistically significant difference in the age distribution of the participants in this study. Those with SCLU were diagnosed at an older age and majority (52.2%) had clinical stage 2 leg ulcer. Among the markers for haemolysis-endothelial dysfunction (HED); Reticulocyte production index (PRI) was lower in SCLU (1.87 + 0.72) compared to SCWLU, (2.04 + 0.78) p= 0.01. Total and unconjugated bilirubin (µmol/L) level was higher for SCLU (53.0 + 17) in comparison to SCWLU (42.2 + 8.2) with statistical significance of p=0.00. Aspartate and alanine transaminases (AST and ALT) (U/L) were higher in SCLU in comparison with SCWLU, (60.1 + 21.5, 43.8 + 15.8 and 30.1 + 13, 29.8 + 11.7) respectively, and was statistically significant p= 0.00. However Nitric oxide was not statistically different between SCLU and SCWLU mean ± SD (49.57 + 12 and 46.19 + 9) respectively. p = 0.35 Conclusion Markers of haemolysis were higher in participants with sickle cell leg ulcer (SCLU) when compared to those without leg ulcer (SCWLU). However, no statistically significant difference was obtained for Nitric oxide (NO) between the two groups. Therefore, markers of haemolysis cannot be used as an effective predictor for risk of developing SCLU but early diagnosis of SCA can prevent SCLU.

S2468 Crigler-Najjar Syndrome Type 2 in an Adult Amish Male: A Rare Case Report of Unexplained Jaundice

INTRODUCTION: Crigler-Najjar type 2 syndrome is a rare genetic disorder caused by reduced enzyme activity of glucuronyl transferase, resulting in abnormally elevated levels of unconjugated bilirubin in blood. There are an estimated 100 known cases worldwide. We present a case of Crigler-Najjar type 2 (Arias syndrome) in an adult Amish male with new unexplained jaundice. CASE DESCRIPTION/METHODS: A 28 year old male with no medical history presented with 5 days of intermittent, right upper quadrant discomfort and jaundice. He denied any associated nausea, emesis or diarrhea. The night prior to symptom onset, he consumed several alcoholic beverages along with an unknown amount of acetaminophen. Initial laboratory work-up showed AST 10 unit/L, ALT 25 unit/L, total bilirubin 5.4 mg/dL and lipase 79 unit/L. Acetaminophen level was undetectable. Abdominal ultrasound demonstrated a heterogeneous liver measuring 15.26 cm, cholelithiasis and common bile duct of 3 mm in diameter. Endoscopic ultrasound revealed similar findings. Repeat liver testing showed uptrending total bilirubin of 8.4 mg/dL with indirect predominance (8.0 mg/dL).Viral hepatitis panel was negative. His abdominal pain resolved with simultaneous improvement of bilirubin levels without intervention. Genetic testing for UGT1A1*28 was sent and he was discharged in stable condition. Outpatient follow up revealed a single copy of the UGT1A1*28 allele, confirming Crigler-Najjar type 2. DISCUSSION: Different mutations to the coding sequence of the enzyme uridine diphosphate-glucoronyl transferase (UGT1A1) result in a spectrum of diseases known as Crigler-Najjar type 1 (CN1) and Crigler-Najjar type 2 (CN2). CN1 is diagnosed in infancy and results from absent or low levels of UGT1A1 due to abnormal protein production. CN2 typically presents later in life from point mutations that result in a single amino-acid substitution, rendering decreased enzymatic activity. Under physiologic stress, patients can develop unconjugated hyperbilirubinemia. Treatment of CN2 usually involves CYP450 induction with phenobarbital, which can also help differentiate between these 2 syndromes. While only about 100 cases of CN2 are known, studies have reported nearly 20% of these within the Pennsylvania Amish population. After thorough review of our patient’s family history, patrilineal descent of this population was discovered. Therefore, while a diagnostic challenge, specific family history can improve pretest probability for genetic testing of UGT1A1*28.

The Association between Serum Bilirubin Levels and Colorectal Cancer Risk: Results from the Prospective Cooperative Health Research in the Region of Augsburg (KORA) Study in Germany.

Emerging studies have suggested that bilirubin, particularly unconjugated bilirubin (UCB), has substantial anti-inflammatory and antioxidant properties that protect against oxidative stress-associated diseases such as cancer. Few observational studies have investigated the etiological role of bilirubin in colorectal cancer (CRC) development. In this case-control study, nested in the population-based prospective cohort of the Cooperative Health Research in the Region of Augsburg (KORA) study in south Germany, pre-diagnostic circulating UCB concentrations were measured by high-performance liquid chromatography in 77 CRC cases and their individually matched controls. Multivariable unconditional logistic regression was used to estimate the odds ratios (OR) and 95% confidence intervals (CI) for associations between log-transformed UCB levels (log-UCB), standardized per one-standard-deviation (one-SD) increment, and CRC risk. The models were a priori stratified by sex based on previous evidence. In the fully adjusted models, each one-SD increment in log-UCB was indicative of a positive association with CRC risk (OR, 1.20; 95% CI, 0.52–2.79) among men, and of an inverse association (OR, 0.76; 95% CI, 0.34–1.84) among women (Pheterogeneity = 0.4 for differences between men and women). We found little evidence for sex-specific associations of circulating bilirubin with CRC risk, and further studies are needed to confirm or refute the potential associations.

Outcome of neonatal jaundice in term neonates with ABO incompatibility at tertiary level center

Background: Neonatal jaundice is extremely common as almost every new-born develops an unconjugated serum bilirubin level of more than 1.8 mg/dl during the first seven days of life. ABO incompatibility is associated in about 20% of all pregnancies but manifestations of ABO haemolytic disease of new-born occurs in &lt;10% of these cases. True incidence of ABO incompatibility, particularly in developing countries like Nepal, is not understood sufficiently. Furthermore, the confirmation of severe ABO incompatibility cannot be made accurately using only a single test. Hence, this study was done to know the outcome of jaundice in ABO incompatibility patients.Methods: This was a descriptive cross-sectional study done at Department of Paediatrics, between August 2018 to July 2019. All term neonates born to ‘O’ positive mother, with blood group A or B positive, and fulfilling the selection criteria were included in the study. Sample size was calculated to be 114 with confidence level at 95% and prevalence of ABO haemolytic disease as 11.4% with margin of error 5%.Results: Severe ABO incompatibility as evident by presence of jaundice within 24 hours of life, a positive result on direct coomb’s test and haemolytic picture on peripheral blood smear was observed in 12% of the total enrolled 200 neonates. Modalities of treatment showed significant relation with severe ABO incompatibility indicating increased need for double volume exchange transfusion in neonates with severe ABO incompatibility.Conclusions: Phototherapy was found to be effective in the management of most of the cases of neonatal jaundice in term ABO incompatible neonates but some cases, requiring exchange transfusion can occur, mostly in presence of positive result on direct Coomb’s test.

Low Serum Levels of Fibroblast Growth Factor 2 in Gunn Rats: A Hyperbilirubinemia Animal Model of Schizophrenic Symptoms.

Fibroblast Growth Factor (FGF) 2 (also referred to as basic FGF) is a multifunctional growth factor that plays a pivotal role in the pro-survival, pro-migration and prodifferentiation of neurons. Because alterations in FGF2 levels are suggested to contribute to the pathogenesis of schizophrenia, we investigated serum levels of FGF2 in the Gunn rat, a hyperbilirubinemia animal model of schizophrenic symptoms. The enzyme-linked immunosorbent assay showed that the serum levels of FGF2 in Gunn rats were 5.09 ± 0.236 pg/mL, while those in the normal strain Wistar rats, serum levels were 11.90 ± 2.142 pg/mL. The serum FGF2 levels in Gunn rats were significantly lower than those in Wistar rats. We also measured serum levels of Unconjugated Bilirubin (UCB) and found a significant negative correlation between UCB and FGF2 in terms of serum levels in all the rats studied. Since it is known that FGF2 regulates dopaminergic neurons and have antineuroinflammatory effects, our finding suggests that low FGF2 levels may contribute to the pathogenesis of schizophrenia, in which imbalanced dopamin-ergic signaling and neuroinflammation are supposed to play certain roles.