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
Reticuloendothelial System

Iron

Red blood cells Hemoglobin Globin

Heme

Biliverdin

Bilirubin albumin
complex
Liver Unconjugated bilirubin

Conjugated bilirubin

Urobilinogen

Stercobilin
Red blood cells are Red blood cells
broken down in the break down to
Reticuloendothelial hemoglobin which is
System further broken down
to iron, globin, and
heme
 Bilirubin Metabolism- 2
Reticuloendothelial System

Iron

Red blood cells Hemoglobin Globin

Heme is further
broken down to
biliverdin then to Heme
unconjugated Unconjugated bilirubin
bilirubin by the Biliverdin
is then carried to the
enzyme biliverdin liver by albumin
reductase
Bilirubin albumin
complex
Liver Unconjugated bilirubin

Conjugated bilirubin

Urobilinogen

Stercobilin
 Bilirubin Metabolism- 3
Reticuloendothelial System

Iron

Red blood cells Hemoglobin Globin

The liver then

converts
unconjugated Heme
bilirubin to
conjugated
bilirubin where it Biliverdin
is excreted in the
intestines
Bilirubin albumin
The intestines
Liver
complex
Unconjugated bilirubin
then convert the
conjugated
Conjugated bilirubin bilirubin into
Urobilinogen urobilinogen and
Stercobilin
then stercobilin
 Bilirubin Metabolism- 4
Reticuloendothelial System

Iron

Red blood cells Hemoglobin Globin

Heme

Biliverdin

Urobilinogen is
Bilirubin albumin
complex excreted in the
Liver Unconjugated bilirubin
urine
Conjugated bilirubin
Stercobilin is
Urobilinogen excreted in the
Stercobilin
stool
 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
Reticuloendothelial System

Iron

Red blood cells Hemoglobin Globin

Heme

Biliverdin

Bilirubin albumin
complex
Liver Unconjugated bilirubin

Conjugated bilirubin

Urobilinogen

Stercobilin
 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
Reticuloendothelial System
Iron

Red blood cells Hemoglobin Globin

Heme

Biliverdin

Bilirubin albumin
complex
Liver Unconjugated bilirubin

Conjugated bilirubin

Urobilinogen
Stercobilin
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
Reticuloendothelial System
Iron

Red blood cells Hemoglobin Globin

Heme

Biliverdin

Bilirubin albumin
complex
Liver Unconjugated bilirubin

Conjugated bilirubin

Urobilinogen

Stercobilin
 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
Pentose Phosphate Pathway phosphate)
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
 Varian defisiensi enzim G6PD

Kelas Tingkat
Aktivitas Enzim
defisiensi Keterangan
G6PD

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

 Organic Anion Transporter 2 OATP 2

The function of the OATP 2 enzyme is

involved in the hepatic uptake of
unconjugated bilirubin
Reticuloendothelial System
Iron

Red blood cells Hemoglobin Globin

Heme

Biliverdin

Bilirubin albumin
complex
Liver Unconjugated bilirubin

Conjugated bilirubin

Urobilinogen
Stercobilin
 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
Reticuloendothelial System
Iron

Red blood cells Hemoglobin Globin

Heme

Biliverdin

Bilirubin albumin
complex
Liver Unconjugated bilirubin

Conjugated bilirubin

Urobilinogen
Stercobilin
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 Jaundice
versus
Pathologic Jaundice

Physiologic Pathologic
Occurs 24 hours after Occurs less than 24
birth hours after birth

Prematurity Hemolytic anemia

Polycythemia G6PD deficiency

 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