Department of Biochemistry

PLM CM

DESCRIBE the general composition,

functions and physical characteristics of
blood

ENUMERATE the different plasma proteins

and DESCRIBE each as to :
Synthesis, properties, mode of action, location or
distribution, structure and degradation
Biochemical basis resulting from derangement in
their functions

DESCRIBE the formation, composition and

structure of RBC

Define the blood groups and describe all the blood

types in the ABO system
Give the effects of cations, anions and enzymes
on the RBC membrane
Discuss the metabolism of RBCs
Explain the biochemical basis of disorders arising
from defects in RBC metabolism

DISCUSS heme as to :
Structure
Biosynthesis, giving all the factors and enzymes
involved, their roles and mode of action
Discuss the clinical disorders which may result
from defects in the enzymes
Discuss the process, factors involved in the
degradation of heme

Is a CIRCULATING TISSUE
1/12of body weight (85ml/kg)
Composed of 2 parts :

Plasma
Formed elements - RBC , WBC and platelets
Whole blood - formed elements = plasma
Whole blood - (formed elements + clotting
factors) = Serum
Plasma - clotting factors = serum

TRANSPORT - of nutrients, gases, hormones,

waste products of metabolism

DEFENSE against microorganisms and

excessive hemorrhage

MAINTENANCE - of normal body

temperature, acid base, water
and electrolyte balance,
excretion of waste products

Red Blood Cells (RBC)

2.White Blood Cells (WBC)
I.Granulocytes (PMNL)
1.

A. Neutrophils - for phagocytosis during acute

inflammations
B. Basophils - increased during hypersensitivity
reactions, contains Heparin and Histamine
C. Eosinophils - increased in parasitism and allergies

II. Lymphocytes - B or T cells

III. Monocytes - precursor of Macrophages
3. Platelets

PHYSICAL
CHARACTERISTICS
Arterial vs. venous blood

High viscosity
PH is 7.4
If removed from circulation, RBCs settle
out if clotting is prevented : ERYTHROCYTE
SEDIMENTATION RATE (ESR)

Increased fibrinogen and globulins can

increase ESR
Also an increase in cholesterol:phospholipid
ratio
Increased during pregnancy, menstruation
Faster ESR in women as compared to men
and
infants

FUNCTION : to TRANSPORT oxygen to

tissues and disposal of CO2
Mature RBCs are anucleate with simple
cellular structure
RETICULOCYTES are young RBCs
Mature RBCs have no organelles. It's
implication?
Reliant on GLYCOLYSIS for ATP formation
ATP has 3 functions in RBCs what are these?

For energy

To maintain its biconcave shape

To regulate transport of ions and water in

and out of the cell

Formed in the bone marrow

Lifespan 120 days
Contains less H20 than other body cells
Biconcave shape is important for increasing
surface to volume ratio of RBC
beneficial for gas exchange
Formation of RBCs is stimulated by
ERYTHROPOIETIN and requires a
MATURATION FACTOR (Vit. B12)

Night time during

sleep

LOW

Awake states and

during daytime
Exercise
Living at high
altitudes
Increased atmospheric
temperatures
Emotional excitement
Any condition that
lowers oxygen content
of the blood

HIGH

Major regulator of erythropoiesis

Site of synthesis : Kidneys
Stimulus for Release : Hypoxia
In the Bone Marrow :

Reacts with red cell progenitor, BFU-E causing it

to proliferate and differentiate
Also reacts with CFU-E
Erythropoietin requires Interleukin-3 and
Insulinlike Growth Factor

Glucose is major substrate of RBCs used in :

Glycolysis producing Lactate
Rapoport Luebering cycle producing 2,3DPG
Pentose phosphate pathway

Transported via FACILITATED DIFFUSION via

GLUT1 which IS NOT Insulin dependent
No ATP formation via oxidative
phosphorylation

Metabolism

Iron of Hb must be in the FERROUS STATE

thru the action of NADH-dependent
methemoglobin reductase system (using cyt
b5 and cyt b5 reductase)
No synthesis of glycogen, nucleic acids,
fatty acids and proteins in mature RBCs

HEREDITARY SPHEROCYTOSIS

Caused by a congenital defect in intracellular

glycolysis (defect in Enolase or Pyruvate Kinase)
Or a defect in spectrin
Failure to maintain biconcave shape
spherocytes are easily lysed

GLUCOSE-6-PO4 DEHYDROGENASE
DEFICIENCY

Defect in PENTOSE PHOSPHATE PATHWAY

lipid peroxidation of RBC membrane due to
accumulation of H02 hemolysis
Presence of HEINZ BODIES (sign of oxidative
stress)

OXIDATIVE STRESS - production of oxygen

species is greatly increased and level of
antioxidants are diminished
- imbalance of pro-oxidants vs antioxidants

PRO-OXIDANTS - chemicals that generate toxic

oxygen species

ANTIOXIDANTS - scavenges and disposes toxic

oxygen species

ROS - cause CELL INJURY AND CELL DEATH

THE OXIDANTS (REACTIVE SPECIES)

1. superoxide
2. hydrogen peroxide
3. hydroxyl radical most reactive
4. peroxyl radical

Formed (in RBCs) by the autooxidation of Hb

to metHb

Also formed through Cytochrome P450

reaction and Xanthine Oxidase reaction

- in Neutrophils, produced during

RESPIRATORY BURST upon contact with
bacteria as catalyzed by NADPH Oxidase

Can also release iron from ferritin via OH.

(iron overload in Hemochromatosis)

But superoxide is
counteracted by :
SUPEROXIDE DISMUTASE (SOD) which
hastens its spontaneous dismutation :

The H202 resulting from

SOD reaction has several
fates :

1. Has

3 possible fates that can neutralize it :

1.CATALASE - converts H202 to H20 and 02
2.MYELOPEROXIDASE - in WBCs, uses H202
and halides (Cl-) to produce HYPOHALOUS
ACIDS
3. GLUTATHIONE PEROXIDASE - acts on
reduced Glutathione and H202 oxidized
Glutathione + H20

-oxidation of the ferrous iron of Hb

into metHb (ferric) by Superoxide
- Cannot transport oxygen
- NADH-cytochrome b5
methemoglobin reductase (or
METHEMOGLOBIN REDUCTASE)
reduces the ferric iron into ferrous
state
- Methemoglobinemia may be
inherited or may be acquired

Hereditary type - due to deficiency of

methemoglobin reductase
Acquired type - may be due to ingestion of
drugs (sulfonamides) or chemicals
Cyanosis is the usual presenting sign if
>10% of the Hb is in the metHb form
Diagnosis : electrophoresis (detects
abnormal Hb), spectroscopic analysis
(characteristic absorption spectrum of
metHb)
Treatment : reducing agents : ascorbic
acid and methylene blue

Is a lipid bilayer interspersed with discrete

protein aggregates

Must be FLUID AND FLEXIBLE in order for

the RBC to be DEFORMABLE

Composed of 50% protein and 50% lipids

Most proteins are GLYCOPROTEINS with 50

60% carbohydrate

1.

ANION EXCHANGE PROTEIN (BAND 3) - C

terminal is external and N terminal is
internal
- a MULTIPASS membrane protein
- C02 from tissues enter the RBC as HC03 exchanged for Cl- in the lungs
- N terminal binds Hb, ankyrin, proteins
4.1 and 4.2 and glycolytic enzymes

1.

GLYCOPHORINS A, B AND C
- also a transmembrane protein
- a SINGLE PASS glycoprotein

Helps bind Spectrin to cell

membrane via protein 4.1

Is the basis of blood group MN

- A is major glycophorin which has binding
sites for Influenza and Plasmodium
falciparum

Are CYTOSKELETAL proteins that help

maintain RBC shape and flexibility
1. SPECTRIN
- major protein of cytoskeleton
- composed of 2 polypeptides, Spectrin 1()
and Spectrin 2 ()
- overall shape confers flexibility to the
membrane
- has 4 binding sites : for ankyrin, for selfassociation, protein 4.1 and for actin

2. ANKYRIN - pyramid shaped protein that

binds to Spectrin
- secures attachment of Spectrin to
membrane
3. ACTIN - binds spectrin and binds to
protein 4.1
4. PROTEIN 4.1 - forms Protein 4.1-spectrinactin ternary complex
- binds ternary complex to the membrane
by binding to Glycophorin A and C
- also connects lipid bilayer to
cytoskeleton

HEREDITARY SPHEROCYTOSIS
- hemolytic anemia + splenomegaly
- spherocytes have low surface to volume
ratio
- RBCs are susceptible to osmotic lysis
- Abnormal spectrin makes it unable to
react with membrane proteins
weakened cell membrane and spherocytic
shape
2. HEREDITARY ELLIPTOCYTOSIS - elliptical
RBCs
- defective spectrin or Glycophorin C
1.

ABO, Rh and MN systems

BLOOD GROUP - red blood cell antigens
controlled by a genetic locus having a
variable number of alleles (A, B and O)
BLOOD TYPE - is the antigenic phenotype
identified by the use of appropriate
antibodies

Type A - A antigen on the membrane and

anti-B in the plasma
Type B - B antigen on the membrane and
anti-A in the plasma
Type AB - both A and B antigens on the
membrane, no antibodies UNIVERSAL
RECIPIENT
Type O - no membrane antigen, has anti-A
and Anti-B in the plasma UNIVERSAL
DONOR

ABO substances are oligosaccharides

(glycosphingolipids)
Genes are in the long arm of chromosome 9
3 alleles, A and B are dominant while O is
recessive
H substances - is the blood group substance
in Type O

Precursor of both A and B substances

and is the blood group substance in Type O
H substance is formed by the action of
FUCOSYLTRANSFERASE
H locus codes for fucosyltransferase
h allele of the H locus codes for inactive
fucosyltransferase hh genotype cannot
generate H substance (precursor of A and B
substances ) Type O

H locus - codes for fucosyltransferase

A gene - codes for GalNac transferase
B gene - codes for Gal transferase

D (Rho) antigen is the Rh factor

15% of Caucasians are Rh negative
Transfusion of Rh positive blood will cause
formation of abs vs D antigen
Rho (D) immune globulin prevents
formation of abs against D antigen

CAUSES OUTSIDE OF THE MEMBRANE

Hypersplenism
Immunologic abnormalities
Toxins (from bacteria, snake venom)

CAUSES WITHIN THE MEMBRANE

Abnormalities in membrane proteins especially
spectrin (hereditary spherocytosis, etc)

CAUSES INSIDE THE RBC

Hemoglobinopathies (sickle cell anemia)
Enzymopathies (defects in HMP and EMP)

Active aerobic glycolysis

Active HMP shunt
Moderate oxidative phosphorylation
Are motile, phagocytic cells
High content of lysosomal enzymes
Involved in ACUTE INFLAMMATORY
RESPONSE once ACTIVATED

G-CSF - affects progenitor that induces

production of granulocytes
GM-CSF - affects progenitor that induces
granulocyte and macrophages

G-CSF - is sometimes given for the

management of neutropenia

1. Increase in vascular permeability - resulting

to edema
2. Entry of activated neutrophils into the tissues
- attracted by CHEMOTACTIC FACTORS
(complement fragment C5a, small peptides
from invading bacteria and some leukotrienes)
- neutrophils MARGINALIZE and ADHERE to
capillary endothelium
3. Activation of platelets
4. Spontaneous resolution - if invading organism
is successfully neutralized

Are adhesive proteins located on the

surfaces of neutrophils that enable them to
adhere to endothelial cells
Receptors to these proteins are present in
the capillary endothelial cells
Also involved in adhesion to other cells or to
the ECM
They link the outsides of cells (extracellular
domains) to their insides (intracellular
domains that bind to cytoskeleton)

INTEGRINS
Are heterodimers with and subunits
LEUKOCYTE ADHESION DEFICIENCY (LAD) is
due to deficiency in 2 subunit
Results to decreased neutrophil response to
inflammed tissues - prone to recurrent
bacterial and opportunistic infections

Involves :

Activated by interacting upon contact with various

ligands ( bacteria via specific receptors, binding of
chemotactic factors or antigen-antibody
complexes)
G protein activation
ACTIVATION OF PHOSPHOLIPASE C
Inositol TriPO4 - release of Calcium from ER
DAG - activation of Protein Kinase C
ACTIVATION OF PHOSPHOLIPASE A2
Releases Arachidonic Acid converted to
active eicosanoids (thromboxanes,
prostaglandins, prostacyclins)

Increase in oxygen consumption by

phagocytic cells upon ingestion of bacteria
Production of reactive species : O2-, H202,
OH. And OCl- which are MICROBICIDAL
Production of these species is via Electron
Transport Chain system involving :

NADPH oxidase a flavoprotein - generates

superoxide (via reduction of oxygen by one
electron) and H202

RESPIRATORY BURST
System is in the plasma membrane of
phagocytic cells
Superoxide is then discharged to the
outside or within phagolysosomes to kill
bacteria
Within phagolylososomes : increased pH,
superoxide ion and other oxygen
derivatives, bactericidal peptides
(defensins) and cathepsin G assist in the
killing of bacteria

DEFECT IN NADPH
OXIDASE SYSTEM

Is CHRONIC GRANULOMATOUS DISEASE

Recurrent infections
Granulomas represent an attempt of the
body to wall off the infection

Present in neutrophil granules

Acts on H202 with Chloride to produce
HYPOHALOUS ACIDS (H0Cl) greenish
color of pus
HOCl - oxidizing agent , microbicidal,
stimulates Proteinases
In tissues reacts with primary/secondary
amines in neutrophils CHLORAMINES
Chloramines - also oxidizing agents and
microbicidal without causing tissue damage

Lysosomal enzymes in neutrophils

Capable of hydrolyzing elastin, collagen and

proteins of the ECM

ANTIPROTEINASES neutralize and prevent

excessive tissue damage
- Ex: 1antiproteinase inhibitor, 2
macroglobulin

Liquid medium of blood

Contains H20, electrolytes, metabolites,
nitrients, proteins and hormones
Total proteins of plasma is 7 7.5g/dL
3 major groups of plasma proteins :

Albumin
Fibrinogen
Globulins

Are synthesized mainly in the liver - but

gamma globulins are synthesized by plasma
cells

Plasma proteins are synthesized by membrane

bound ribosomes

Almost all are glycoproteins

Many exhibit polymorphism

Each has a characteristic half-life - which may

be affected by some disease processes

Increased during inflammatory states

Play a role in defense during acute and
chronic inflammation and cancers
Ex :

CRP - activates complement

Alpha 1 antitrypsin
Haptoglobin
Alpha 1 acid glycoprotein
fibrinogen

Is the major plasma protein

Synthesized as a preprotein
Levels are decreased in hepatic diseases,
malnutrition
Ellipsoidal in shape, low molecular weight
and present in high concentrations
Has 3 domains with different functions

1. Major determinant of plasma oncotic

pressure
2. Also binds to many ligands : steroid
hormones, drugs (aspirin, sulfa drugs,
penicillin)
3. Used as plasma expanders in burns and
circulatory shock

Glycoprotein that binds extracorpuscular

hemoglobin (Hb) in a tight complex (Hb-Hp)
Hb-Hp complex prevents loss of free Hb
into the kidneys conserves iron
Hb-Hp has short half-life (90 min) than Hp
alone (5 days)
Levels are decreased during hemolytic
anemias
Is an ACUTE PHASE PROTEIN
Has 3 polymorphic forms : Hp 1-1, Hp2-1,
Hp2-2 with no functional difference

1. Hemopexin

- binds heme

- binds metheme (ferric heme)

methemalbumin transfers metheme to
Hemopexin

2. Albumin

* But these do not bind hemoglobin

Required in hemoglobin, myoglobin and

cytochromes
Absorption of Fe2+ in intestinal mucosa is
tightly regulated
Males lose 1mg/day, females of childbearing
age lose more
Elderly are also prone to iron deficiency

A 2-globulin synthesized in the liver

Important for iron metabolism : transports
iron to sites where it is required (bone
marrow, gut, etc)
Binding of iron to Tf reduces its toxicity
markedly
TOTAL IRON BINDING CAPACITY of plasma 300mg/dL of Tf can bind 300g/dL of iron
This may be reduced in iron-deficiency
anemia or excessively saturated in iron
excess (hemochromatosis)

Stores iron that may be used when the need

arises
Storage is mainly in the liver and in the
spleen
Increased body stores of iron greatly
increased amount of ferritin
HEMOSIDERIN - is a partly degraded form
of ferritin that still contains iron.
- increased when excessive storage of iron
occurs

Is an 2-globulin which binds 6 atoms of

copper so that it is not exchangeable
Carries 90% of copper in plasma IN A TIGHT
COMPLEX
Bluish in color
Decreased during liver diseases
Related to WILSONS DISEASE
(hepatolenticular degeneration)

A hereditary (autosomal recessive) disorder

wherein copper fails to be excreted in the bile
Lysosomes fail to excrete copper derived from
the breakdown of ceruloplasmin
COPPER TOXICOSIS results with hematologic,
neurologic and hepatic signs and symptoms
Plasma ceruloplasmin levels also decline
Kayser-Fleischer ring around the cornea is
pathognomonic
Treatment : low dietary copper and
administration of chelating agents ie,
penicillamine

An important cofactor of many enzymes :

superoxide dismutase, tyrosinase and
cytochrome oxidase
Bound to either albumin or ceruloplasmin
Partly excreted in the bile
Deficiency may also result to anemia
MENKES DISEASE (KINKY HAIR OR STEELY
HAIR DISEASE) - X-linked disorder of
copper metabolism
- usually fatal

Major component of the alpha-1 fraction of

plasma
Major serine protease inhibitor (Serpin or Pi)
of plasma
Inhibits trypsin, elastase and other
proteases by forming complexes
Highly polymorphic
Deficiency may cause EMPHYSEMA (ZZ
genotype) - cannot synthesize PiZ
phenotype

Met358 of antitrypsin is important for

binding to proteases
Smoking oxidizes this Met residue
inactivated enzyme results
Treatment : IV administration of 1-AT,
protein engineering or gene therapy
Mutant 1-AT may also cause hepatitis and
cirrhosis

B lymphocytes - derived from the bone

marrow or bursa of Fabricius
- responsible for HUMORAL IMMUNITY or the
production of immunoglobulins
- immunoglobulins are synthesized by
PLASMA CELLS
T lymphocytes - originate from thymus
gland
- CELL MEDIATED IMMUNITY for delayed
hypersensitivity, graft vs host reactions,
defense vs tumors and viruses

All have 2 identical light (L) chains and 2

identical heavy (H) chains joined by disulfide
bonds

L and H chains are synthesized separately

L chains have a CL (constant) region near the C

terminal and a VL (variable) region near the N
terminal

H chains is the VH region and is the CH

region (CH1, CH2 and CH3)

Portion that BINDS THE SPECIFIC ANTIGEN is the

VARIABLE REGION (N terminal) of both L and H

Fab - 2 antigen-binding fragments obtained

after digestion of the immunoglobulin (Ig)
by papain

Fc - crystallizable fragment

HINGE REGION - area in which papain

cleaves the Ig molecule

Light chains are either kappa () or lambda

()
Kappa chains are the more frequent in
humans
Determined by the differences in their C
L
regions
Always : an Ig contains 2 kappa or 2
lambda chains but NEVER A MIXTURE OF
BOTH

5 classes of H chains in humans,

distinguished by their CH regions

Designated as ,, ,,
and have 4 C domains instead of 3
H

Type of H chain determine the Ig class: IgA,

IgD, IgG and IgM

Are very heterogenous in nature, no 2 variable

region of both L and H chains are alike

But there are shared patterns between the

regions among individuals

Thus, within the variable regions there are

some portions that are invariable there are
HYPERVARIABLE REGIONS scattered between
invariable positions

L chains have 3 hypervariable regions and H

chains have 4

Responsible for the class-specific EFFECTOR

FUNCTIONS of different Ig molecules
(placental transfer or complement fixation)

Determined by the Constant regions

especially CH2 and CH3 (and CH4 of IgM and
IgE) which constitutes the Fc fragment

There is one specific antibody for over 1

million antigens

Made possible by COMBINATIONS OF THE

VARIOUS STRUCTURAL GENES or GENE
REARRANGEMENT

IgA - predominant class in tears, saliva,

breastmilk, seminal fluid and mucous
secretions of the nose, lungs and GIT
- prevents attachment of bacteria to
mucous membranes
IgD - found on surfaces of B cells.
Function still unknown, although may be B
cell receptors (?)
IgE - found on surfaces of basophils and
mast cells, it plays a role in allergic
responses

IgG - only immunoglobulin that can cross

the placenta
-maternal antibodies protect the infant
during the first 6 months of life
- binds to and activates complement
- the most prevalent type of antibody
IgM - the first antibodies formed in the
primary response to antigens, provides
protection during the earliest stages of
infection
- effect is short-lived

Antibodies with identical specificity but of

different classes are generated in a specific
chronological order in response to the
immunogen
IgM abs respond first followed by IgG
A single type of Ig light chain can combine
with :

Antigen specific chain IgM molecule

Antigen specific chain with an identical VH
region IgG
Same light chain combines with heavy chain
containing identical VH region IgA molecule

IDIOTYPE - immunoglobulin molecules

against the same antigen have identical
variable domains of both their light (VL) and
heavy (VH) chains

Thus, the different classes of Igs are

determined by the CH regions that are
combined with the same antigen-specific VH
regions

MULTIPLE MYELOMA - excessive production

of specific classes of immunoglobulins or
specific immunoglobulin molecules
- clonal tumor of plasma cells

HYPOGAMMAGLOBULINEMIA
- Underproduction of a single class of Ig or
of all classes

20 labile plasma proteins designated from

C1 to C9
C9 involved in osmotic lysis
Activated via :

Classic pathway - interaction of C1 with antigenantibody complexes

Alternative pathway - direct interaction of
bacterial cell surfaces oor polysaccharides with a
component designated C3b

Porphyrins + Iron = Heme

Degradation of Heme = bilirubin
Knowledge of diseases related to porphyrins
and bilirubin
Porphyrias - rare genetic disorders caused
by abnormalities in the pathway of
biosynthesis of the various porphyrins
Jaundice - elevation of bilirubin in the
plasma

1.

2.

3.

4.

5.

HEMOGLOBINS - iron porphyrin attached

to protein globin
- reversibly combines with oxygen
MYOGLOBIN - respiratory proteins in
muscle cells
CYTOCHROMES - act as electron transfer
agents in oxidation-reduction reactions
CATALASES - iron porphyrins that
degrade H202
TRYPTOPHAN PYRROLASE - Catalyzes
oxidation of tryptophan to formyl
kynurenine

Precursors are succinyl CoA and glycine

PP important to activate glycine

ALA synthase (ALAS) is the rate-limiting

enzyme in porphyrin biosynthesis

ALAS is subject to both induction and

repression

NEGATIVE REGULATORS
Heme is the negative regulator of the
synthesis of ALAS

Glucose

Hematin - hydroxide of heme

POSITIVE REGULATORS
Some xenobiotics (barbiturates,
alcohol,etc) - because they require Cyt P450 a heme protein
* Iron in chelated form
* May precipitate attacks of porphyria

Group of hereditary diseases due to

mutations in the genes directing the
synthesis of the enzymes involved in heme
biosynthesis accumulation of unwanted
metabolites or deficiency in a certain
product
Autosomal dominant mode of inheritance
except congenital erthropoietic porphyria
Detected by excess amounts of
COPROPORPHYRINS AND UROPORPHYRINS
in feces (or ALA AND PBG)
Disease of some royal houses in Europe
(British, Hanoverian and Prussian)

PATHOPHYSIOLOGY OF
PORPHYRIAS

IF LESION OCCURS EARLY IN THE PATHWAY

(BEFORE PORPHYRINOGEN FORMATION)
Accumulation of ALA and PBG in body fluids
These are toxic to CNS and abdominal nerves
ALA may inhibit ATPase in the CNS and affect
nerve conduction
SSX: abdominal pain, neuropsychiatric
manifestations

ENZYME BLOCKS LATER IN THE PATHWAY

Result in the accumulation of porphyrinogen

Oxidation results to porphyrins
Manifests as photosensitivity
Porphyrins react with oxygen - form reactive
radicals injure lysosomes skin damage
with scarring physical disfigurement
This is how the patients were mistaken for
werewolves or vampires

According to organ /cells affected

Or as acute or cutaneous
Because amount of metabolites vary in
different organs depending on the activity
of the heme-forming enzymes
Erythropoietic - affects the bone marrow
because it is the site of heme biosynthesis
Hepatic - because the liver is active in the
synthesis of cytochrome P-450, another
hemoprotein
Erythrohepatic

Due to the nature of the

disease, sufferers were
mistaken for :

King George III

(18th century)

Mary Queen of
Scots (16th century)

Treatment is symptomatic/palliative
Definitive treatment is gene therapy
Avoid alcohol, drugs, anesthetics
Carbohydrate loading is advised
Administration of hematin
Administration of B-carotene for those with
photosensitivity
sunscreens

10 -20m RBCs are destroyed per hour

Thus, a 70kg male produces 9 gms of
Hb/day
Hemoglobin is split into GLOBIN and HEME
portions
GLOBIN amino acids are reutilized
HEME - is opened and the Fe2+ enters iron
pool and is recycled
- Porphyrin ring is degraded by RES of liver,
spleen and bone marrow to become
BILIRUBIN

Heme is oxidized by the HEME OXYGENASE

of the microsomal fraction of the RES and
cleaved to release CO, and BILIVERDIN IX
Biliverdin reductase

BILIRUBIN IX (yellow)

1.

HEPATIC UPTAKE
Transported in the plasma by tight binding to
HIGH AFFINITY SITES of albumin
If in excess May also bind to LOW AFFINITY
SITES and are thus easily displaced (by some
drugs) into tissues
Taken up by the liver via FACILITATED DIFFUSION
by a high capacity transport system

2. CONJUGATION IN THE LIVER

Addition of polar groups to bilirubin TO MAKE IT

MORE WATER SOLUBLE
UDP GLUCORONYL TRANSFERASE*
UDP-Glucoronic Acid
Bilirubin
Mono-+ Bilirubin
glucoronide
+
UDP

UDP GLUCORONYL TRANSFERASE*

UDP-Glucoronic Acid
Bilirubin Diglu+ Bilirubin Monoglucocoronide + UDP
ronide
* inducible by drugs (Phenobarbital)

3. SECRETION OF BILIRUBIN INTO THE BILE

THROUGH BILE DUCTULES

Occurs by an active transport mechanism

RATE LIMITING for the entire process of bilirubin
metabolism
Same drugs affecting conjugation also affect
secretion
Conjugation and secretion are thus a
coordinated functional unit
Essentially ALL SECRETED BILIRUBIN IS
CONJUGATED
Can only find unconjugated bilirubin after
phototherapy

In ileum and large intestines, the

conjugated bilirubin are reduced by
BACTERIAL GLUCORONIDASES Colorless
tetrapyrroles UROBILINOGENS
ENTEROHEPATIC CIRCULATION - small
amounts of urobilinogens are reabsorbed
and resecreted by the liver
Urobilinogens are OXIDIZED BY COLONIC
BACTERIA to UROBILINS (colored
compounds) brownish color of feces

Occurs when bilirubin >1mg/dL

JAUNDICE/ICTERUS - occurs when it
reaches 2 2.5mg/dL when it diffuses into
the tissues
3 possible causes :

1. HEMOLYTIC - excessive RBC destruction

causes increased formation of free bilirubin
2 OBSTRUCTIVE - partial or complete blockage of
bile ducts inside or outside of the liver.
Conjugated bilirubin cannot be excreted into the
intestines and appears in the plasma
- may be intrahepatic or extrahepatic

3. HEPATOCELLULAR - damage to hepatocytes

by toxins, infections impairs the livers capacity to
conjugate and excrete bilirubin
- both conjugated and unconjugated bilirubin
may be increased but more of the latter

*KERNICTERUS
- Excessively high free bilirubin in newborn or
preterm infants causes brain damage and
neurologic disorder or death due to immature liver
which lacks UDP-glucoronyl transferase

Only free/unconjugated bilirubin can cross

the BBB
Only conjugated bilirubin can appear in the
urine
Van den Bergh Direct Acting Bilirubin is
conjugated. Bilirubin can be observed
directly without the addition of methanol
Indirect Acting bilirubin is unconjugated or
free. Needs addition of methanol to
demonstrate its presence

May increase in the following conditions :

1.NEONATAL PHYSIOLOGIC JAUNDICE
- Most common cause of unconjugated
hyperbilirubinemia
- Cause : accelerated physiologic
hemolysis and immature liver that lacks
UDP-glucoronyl transferase or UDPglucoronate
- prone to kernicterus
- Tx : phototherapy which converts the
bilirubin into maleimide fragments that can
be excreted into the bile

2. CRIGLER NAJJAR SYNDROME TYPE I/

CONGENITAL NONHEMOLYTIC
JAUNDICE
- autosomal recessive disorder, fatal
- congenital absence of UDP- glucoronyl
transferase
3. CRIGLER NAJJAR SYNDROME TYPE II
- milder defect in bilirubin conjugating
system and is more benign
- may be due to a defect involving the
hepatic UDP glucoronyltransferase system
that adds the 2nd glucoronyl group

4. GILBERTS DISEASE
- defect in the uptake of bilirubin by the
liver or reduced activity of UDP-glucoronyl
transferase
5. TOXIC HYPERBILIRUBINEMIA
- chemicals may cause hepatic
dysfunction : chloroform, amphetamines,
acetaminophen, carbon tetrachloride,
amanita poisoning
- hepatic swelling may also cause a
concommitant increase in conjugated
bilirubin

Detectable in the urine because it is water

soluble (choluric jaundice)
If excessively high, may bind to albumin
(delta bilirubin) longer plasma half-life
than conventional conjugated bilirubin
1. CHRONIC IDIOPATHIC JAUNDICE
(DUBIN-JOHNSON SYNDROME)
- Defect in hepatic secretion of conjugated
bilirubin into the bile
- cannot also conjugate estrogens and
other compounds

2. BILIARY TREE OBSTRUCTION

- blockage of common and hepatic bile
ducts
- conjugated bilirubin is therefore
absorbed into the hepatic veins and
lymphatics
- CHOLESTATIC JAUNDICE - includes all
form of extrahepatic obstructive jaundice

3. ROTOR SYNDROME
-

benign condition
chronic conjugated hyperbilirubinemia
normal liver histology
unknown cause

Normally is present in minute amounts in

the urine
Biliary duct obstruction - absent in the
urine
Presence of bilirubin in the urine without
urnobilinogen suggestive of obstructive
jaundice
Increased urobilinogen and absent bilirubin
in the urine suggestive of hemolytic
jaundice

HAPPY SECOND SHIFTING!