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

Globin

Hemoglobin

Heme
Biliverdin

Liver

Bilirubin albumin
complex

Unconjugated bilirubin

Conjugated bilirubin
Urobilinogen
Stercobilin

Red blood cells are

broken down in the
Reticuloendothelial Sys
tem

Red blood cells

break down to
hemoglobin which is
further broken down
to iron, globin, and
heme

Bilirubin Metabolism- 2
Reticuloendothelial System
Iron
Red blood cells

Heme is further
broken down to
biliverdin then to
unconjugated
bilirubin by the
enzyme
biliverdin reductase

Hemoglobin

Heme

Biliverdin

Liver

Bilirubin albumin
complex

Unconjugated bilirubin

Conjugated bilirubin
Urobilinogen
Stercobilin

Globin

Unconjugated bilirubin
is then carried to the
liver by albumin

Bilirubin Metabolism- 3
Reticuloendothelial System
Iron
Red blood cells

The liver then

converts
unconjugated
bilirubin to
conjugated
bilirubin where it
is excreted in the
intestines

Hemoglobin

Globin

Heme
Biliverdin

Liver

Bilirubin albumin
complex
Unconjugated bilirubin

Conjugated bilirubin
Urobilinogen
Stercobilin

The intestines
then convert the
conjugated
bilirubin into
urobilinogen and
then stercobilin

Bilirubin Metabolism- 4
Reticuloendothelial System
Iron
Red blood cells

Hemoglobin

Globin

Heme

Biliverdin

Liver

Bilirubin albumin
complex
Unconjugated bilirubin

Conjugated bilirubin
Urobilinogen
Stercobilin

Urobilinogen is
excreted in the
urine
Stercobilin is
excreted in the
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
2)
3)
4)
5)

partial oksigen yang rendah

umur sel darah merah pendek dan
peningkatan resirkulasi enterohepatal dari bilirubin
Kurangnya ambilan (uptake) hati dampak penurunan
konsentrasi protein pengikat bilirubin (seperti ligandin)
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

Heme

Biliverdin

Liver

Bilirubin albumin
complex
Unconjugated bilirubin

Conjugated bilirubin
Urobilinogen
Stercobilin

Globin

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

Heme
Biliverdin

Liver

Bilirubin albumin
complex
Unconjugated bilirubin

Conjugated bilirubin
Urobilinogen
Stercobilin

Globin

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

Heme
Biliverdin

Liver

Bilirubin albumin
complex
Unconjugated bilirubin

Conjugated bilirubin
Urobilinogen
Stercobilin

Globin

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 CriglerNajjar 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 - UDPglucuronsyltransferase 1A1

G6PD

Pentose Phosphate Pathway

The G6PD enzyme

is responsible for
reducing NADP+
(nicotinamide
adenine
dinucleotide
phosphate) to
NADPH (reduced
nicotinamide
adenine
dinucleotide
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
defisiensi

Aktivitas Enzim

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

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

Heme
Biliverdin

Liver

Bilirubin albumin
complex
Unconjugated bilirubin

Conjugated bilirubin
Urobilinogen
Stercobilin

Globin

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

Heme
Biliverdin

Liver

Bilirubin albumin
complex
Unconjugated bilirubin

Conjugated bilirubin
Urobilinogen
Stercobilin

Globin

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 kacangkacangan
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