Bilirubin Metabolism

Harliansyah, Ph.D
Dept of Biochemistry, FKUY
2013, May
What Is Bilirubin?
Bilirubin is the by product of the breakdown of
heme which is found in red blood cells.

Normal red blood cell destruction accounts for
80% of daily bilirubin produced in the newborn.

Infants produce twice as much bilirubin per day
than as an adult.

There are two types of bilirubin - unconjugated
(indirect) bilirubin and conjugated (direct)
bilirubin.



Bilirubin complexed to albumin
(Unconjugated Bilirubin) is transported to
liver, where it is processed into
Conjugated Bilirubin, by the liver cells.

In this form Bilirubin enters the bile fluids
for transport to the small intestine
(Conjugated Bilirubin is converted to
Urobilinogen).
Unconjugated Bilirubin
Unconjugated (indirect) bilirubin
Fat-soluble
Not yet metabolized by by the liver
Is not easily excreted
Is the biggest concern for newborn jaundice
If it is not converted it can be deposited into
the skin which causes the yellowing of the
skin or into the brain which can lead to
kernicterus.
Conjugated Bilirubin
Conjugated (direct) bilirubin
Water soluble
It is metabolized by the liver
It is mostly excreted in stool and some in the
urine
Bilirubin Metabolism- 1
Red blood cells are
broken down in the
Reticuloendothelial
System
Red blood cells
break down to
hemoglobin which is
further broken down
to iron, globin, and
heme
Iron
Globin
Heme
Biliverdin
Unconjugated bilirubin
Hemoglobin Red blood cells
Liver
Conjugated bilirubin
Urobilinogen
Stercobilin
Reticuloendothelial System
Bilirubin albumin
complex
Bilirubin Metabolism- 2
Iron
Globin
Heme
Biliverdin
Unconjugated bilirubin
Hemoglobin Red blood cells
Liver
Conjugated bilirubin
Urobilinogen
Stercobilin
Reticuloendothelial System
Unconjugated bilirubin
is then carried to the
liver by albumin
Heme is further
broken down to
biliverdin then to
unconjugated
bilirubin by the
enzyme biliverdin
reductase
Bilirubin albumin
complex
Bilirubin Metabolism- 3
Iron
Globin
Heme
Biliverdin
Unconjugated bilirubin
Hemoglobin Red blood cells
Liver
Conjugated bilirubin
Urobilinogen
Stercobilin
Reticuloendothelial System
The liver then
converts
unconjugated
bilirubin to
conjugated
bilirubin where it
is excreted in the
intestines
The intestines
then convert the
conjugated
bilirubin into
urobilinogen and
then stercobilin
Bilirubin albumin
complex
Bilirubin Metabolism- 4
Iron
Globin
Heme
Biliverdin
Unconjugated bilirubin
Hemoglobin Red blood cells
Liver
Conjugated bilirubin
Urobilinogen
Stercobilin
Reticuloendothelial System
Urobilinogen is
excreted in the
urine
Stercobilin is
excreted in the
stool
Bilirubin albumin
complex
Mechanism of Bilirubin Formation
Enzyme-catalysed degradation of haem. Haem degradation begins by haem oxygenase-catalysed
oxidation of the a-bridge carbon of haem, which is converted to CO, leading to opening of the
tetrapyrrole ring and release of the iron molecule. The resulting biliverdin molecule is subsequently
reduced to bilirubin by cytosolic biliverdin reductase.
Murray et al., 2009
Ryter et al., 2002
What Is Physiologic Jaundice
Physiologic jaundice is an exaggerated
normal process seen in 60% of term
infants, and 80% of premature infants
It normally occurs during the first week of
life
It is normally benign and self-limiting
Associated with a bilirubin level greater
than 5-7mg/dL
Factors That Contribute To Physiologic
Jaundice
Prematurity
Polycythemia
Penyebab Peningkatan Kadar Bilrubin
a. Proses Fisiologis
1) volume sel darah merah tinggi kompensasi tekanan
partial oksigen yang rendah
2) umur sel darah merah pendek dan
3) peningkatan resirkulasi enterohepatal dari bilirubin
4) Kurangnya ambilan (uptake) hati dampak
penurunan konsentrasi protein pengikat bilirubin
(seperti ligandin)
5) Kurangnya konjugasi masih rendahnya aktivitas
glukoronil transferase




Prematurity & Hyperbilirubinemia
Premature infants are more susceptible to
hyperbilirubinemia due to:
Immature hepatic system
Delayed enteral feedings
Decrease in serum albumin levels
Prematurity & Hyperbilirubinemia
Immature hepatic system - leads to decreased elimination of
bilirubin from the system; therefore, higher levels of indirect
bilirubin are in the blood which leads to hyperbilirubinemia

Iron
Globin
Heme
Biliverdin
Unconjugated bilirubin
Hemoglobin Red blood cells
Liver
Conjugated bilirubin
Urobilinogen
Stercobilin
Reticuloendothelial System
Bilirubin albumin
complex
Prematurity &
Hyperbilirubinemia
Delayed enteral feedings - if feedings are delayed it
decreases intestinal motility and removal of meconium, which
leads to reabsorption of direct bilirubin, which is converted back to
indirect bilirubin. Which means bilirubin increases in the blood
and leads to hyperbilirubinemia

Iron
Globin
Heme
Biliverdin
Unconjugated bilirubin
Hemoglobin Red blood cells
Liver
Conjugated bilirubin
Urobilinogen
Stercobilin
Reticuloendothelial System
Bilirubin albumin
complex
Prematurity & Hyperbilirubinemia
Decrease in serum albumin levels - if there is a
decrease in the amount of albumin receptors available,
bilirubin does not bind to the albumin; therefore, is
considered free bilirubin. Which means bilirubin
increases in the blood and leads to hyperbilirubinemia
Iron
Globin
Heme
Biliverdin
Unconjugated bilirubin
Hemoglobin Red blood cells
Liver
Conjugated bilirubin
Urobilinogen
Stercobilin
Reticuloendothelial System
Bilirubin albumin
complex
Polycythemia &
Hyperbilirubinemia
Polycythemia is an increased level of red blood
cells (RBCs) in the circulatory system

A infant has more RBCs than an adult, and the
lifespan of an RBC is shorter in neonates

Increased RBCs and a shorter lifespan leads to
increased destruction of RBCs, which leads to
more bilirubin in the blood, which leads to
hyperbilirubinemia
Factors That Contribute To
Pathologic Jaundice
Hemolytic anemia
Rh incompatibility
ABO incompatibility
G6PD (glucose-6-phosphate deficiency)
deficiency


b. Proses patologis
i. Peningkatan Produksi
Inkompatibilitas golongan
Defek biokimia (enzim) eritrosit: enzim G6PD, Pyruvat Kinase,
Hexokinase
Abnormalitas struktur (membran) eritrosit: Sferositosis
herediter, Elliptositosis herediter, Piknositosis infantil
Infeksi: Bakterial, Viral, dan Protozoal
ii. defek/kegagalan konjugasi
Def. kongenital enzim glukoronil transferase (sindroma Crigler-
Najjar dan sindroma Gilbert)
Inhibisi enzim glukoronil transferase (karena pengaruh obat dan
sindroma Lucey-Driscoll

iii. kelainan ambilan (uptake) oleh hati
iv. Sekuestrasi sel darah merah


Genetics &
Hyperbilirubinemia
The study was conducted in Taiwan
The reason for this is because the Asian
population has twice the incidence of
hyperbilirubinemia than the Caucasian
population.
They were looking to identify potential
genetic defects that contribute to the
higher incidence of hyperbilirubinemia

Genetics &
Hyperbilirubinemia
The three enzymes are:
G6PD - glucose-6-phosphate
dehydrogenase
OTAP 2 - organic anion
transporter 2
UGT1A1 - UDP-
glucuronsyltransferase 1A1

G6PD
The G6PD
enzyme is
responsible for
reducing NADP+
(nicotinamide
adenine
dinucleotide
phosphate) to
NADPH (reduced
nicotinamide
adenine
dinucleotide
phosphate)
Pentose Phosphate Pathway
Gen G6PD terletak pada Xq28
G6PD
Without adequate levels of NADPH, red
blood cells are more prone to stress and
oxidation, which leads to hemolysis of
red blood cells
If there is a G6PD deficiency there will
not be adequate levels of NADPH;
therefore, leading to increased hemolysis
of red blood cells
Increased hemolysis of red blood cells
leads to increased levels of bilirubin,
which then leads to hyperbilirubinemia
Kelas Tingkat
defisiensi
Aktivitas Enzim
G6PD
Keterangan
I Berat <10% normal Anemia hemolitik non sferositosis kronik; Varian
Harilou
II Berat <10% normal Anemia hemolitik akut; Varian Mediteranian
III Sedang 10-60% normal Hemolisis intermiten; Varian G6PD A
IV Normal 60-150% normal Jarang
V Normal >150% normal Jarang
Varian defisiensi enzim G6PD
Organic Anion Transporter 2 OATP 2
The function of the OATP 2 enzyme is
involved in the hepatic uptake of
unconjugated bilirubin

Iron
Globin
Heme
Biliverdin
Unconjugated bilirubin
Hemoglobin Red blood cells
Liver
Conjugated bilirubin
Urobilinogen
Stercobilin
Reticuloendothelial System
Bilirubin albumin
complex
Organic Anion Transporter 2
OATP 2
In the study done, the identified polymorphisms
in the OATP 2 enzyme, which led to increased
risk for hyperbilirubinemia in the Asian
population
If the enzyme activity is delayed there will be
increased levels of unconjugated bilirubin in the
blood, therefore leading to hyperbilirubinemia


UDP - Glucuronsyltransferase 1A1 (UGT1A1)


The function of UGT1A1 is to convert
unconjugated or indirect bilirubin to
conjugated or direct bilirubin

Iron
Globin
Heme
Biliverdin
Unconjugated bilirubin
Hemoglobin Red blood cells
Liver
Conjugated bilirubin
Urobilinogen
Stercobilin
Reticuloendothelial System
Bilirubin albumin
complex
UDP - Glucuronsyltransferase 1A1
UGT1A1
In the study done, the authors identified
polymorphisms in the UGT1A1 enzyme
which, led to increased risk for
hyperbilirubinemia in the Asian population
If the enzyme activity is delayed there will
be increased bilirubin in the blood,
therefore leading to hyperbilirubinemia

Physiologic
Occurs 24 hours after
birth

Prematurity

Polycythemia

Pathologic
Occurs less than 24
hours after birth

Hemolytic anemia

G6PD deficiency
Physiologic Jaundice
versus
Pathologic Jaundice
Kernicterus
Kernicterus is used to describe the yellow staining of the brain nuclei
as seen on autopsy (kern means nuclear region of the brain; icterus
means jaundice).
Kernicterus is a rare, irreversible complication of
hyperbilirubinemia

If bilirubin levels become markedly elevated, the unconjugated
bilirubin may cross into the blood brain barrier and stain the brain
tissues

If staining of the brain tissues occurs there is permanent injury
sustained to areas of the brain which leads to neurological
damage

Picture Of A Brain With Kernicterus
Yellow staining in
the brain due to
increased
unconjugated
bilirubin passing
through the blood
brain barrier
Retrieved April 30, 2006, from
http://www.urmc.rochester.edu/neuroslides/sli
de156.html
Used with permission (9)

Diagnostic
In term infants a normal bilirubin level is
between 1.0 - 10.0 mg/dL
If an infant has a hematocrit greater than 65%
this places that infant at risk for
hyperbilirubinemia
If the reticulocyte count is greater than 5% in the
first week of life, this identifies the infant as
trying to replace destroyed red blood cells
A normal albumin level in a term infant is
between 2.6 - 3.6 g/dL
Manifestasi Klinis Defisiensi G6PD
1. hiperbilirubinemia pada neonatus
serum bilirubin > 5 mg/dL, tidak melebihi
10 mg/dL pada bayi kurang bulan dan
kurang dari 12 mg/dL pada bayi cukup
bulan.
Anemia dan ikterus
Hiperbilirubinemia seringkali
memerlukan transfusi tukar
sering terjadi pada varian G6PD
Mediteranean (kelas II)
dapat menjadi kern icterus dengan
gangguan neurologi berat bahkan dapat
menyebabkan kematian

2. hemolisis akut
paparan obat, infeksi, konsumsi kacang-
kacangan
Setelah 1-3 hari terpapar obat, gejala klinis yang
muncul:
Demam, Letargi, kadang disertai gejala GIT,
Hemoglobinuria* (urine berwarna merah gelap
hingga coklat), ikterus dan anemia, Takikardia, syok
hipovolemi hemolisis intravascular



Thank You