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BILIRUBIN

BILIRUBIN

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Published by Jamshaid Iqbal

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Published by: Jamshaid Iqbal on Mar 07, 2011
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02/01/2013

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9
NNCOOOOOOHHHCNNHHHNNCOOOOOOHHHCNNHHH
CHAPTER
1
NNCOOOOOOHHHCNNHHHNNCOOOOOOHHHCNNHHH
CHAPTER
1
 
General introduction
 
Chapter 110
1. BILIRUBIN
The term
bilirubin
is derived from the Latin words for bile (
bilis
), and red (
ruber 
). Städeler
1
 first used it in 1864 to describe the orange-red colored bile pigment. When bilirubinaccumulates in the body it causes a yellow discoloration of the skin, sclerae and other tissues,referred to as
jaundice
(from the French
jaunisse
) or
icterus
(from the Greek
ikteros
), andhigh levels of bilirubin in the blood, hyperbilirubinemia. This thesis focuses on oral treatmentoptions for unconjugated hyperbilirubinemia. This general introduction successively describesbilirubin metabolism, unconjugated hyperbilirubinemia, Crigler-Najjar disease, kernicterus,current treatment options, the Gunn rat animal model, and two of our proposed treatmentoptions: orlistat, and bile salts. The outline of this thesis is presented in chapter 2.
2. BILIRUBIN METABOLISM2.1. Bilirubin production
Bilirubin is the end product of heme catabolism. The major source of heme (75-80%) ishemoglobin, from breakdown of erythrocytes. Other heme sources include cytochromes,peroxidase, catalase, myoglobin, and ineffective erythropoiesis.
2;3
The life span of erythrocytes is approximately 120 days in adults, 90 days in neonates and 50-60 days in rats.
4
 Senescent erythrocytes are removed from the circulation and destroyed in thereticuloendothelial system (RES), mainly localized in the spleen, liver and bone marrow. Inthe RES, heme is phagocytized by macrophages. Macrophages contain microsomal hemeoxygenase and cytosolic biliverdin reductase, two essential enzymes for degradation of hemeto bilirubin. Heme oxygenase catalyzes the first step in heme degradation: the opening of theporphyrin ring structure at the
α
-methene bridge (Figure 1).
Figure 1.
Bilirubin production from heme catabolism.
 
General introduction11
The intermediate blue-green pigment formed, biliverdin IX
α
, is water-soluble and nontoxic.The iron (Fe) is recycled and carbon monoxide (CO) is excreted by the lungs.
5
In mammals,biliverdin IX
α
is reduced by NADPH-dependent biliverdin reductase to produce bilirubinIX
α
, also known as unconjugated bilirubin
(UCB)
. Why the nontoxic, water-solublebiliverdin is converted to the non-water-soluble and potentially toxic UCB is unclear. Onehypothesis involves the need for products of fetal heme degradation to cross the placenta.
6;7
 Biliverdin cannot, whereas the more lipophilic UCB can cross the placenta. Another reasoncould be the antioxidant properties of UCB
8
(see paragraph 3.3).UCB production can be assessed by measurement of CO formation. Conversion by hemeoxygenase of one heme molecule to biliverdin produces one molecule of CO. Production rateof UCB is approximately 6-8 mg/kg per 24 hours in healthy full-term infants, and 3-4 mg/kgper 24 hours in healthy adults.
9;10
Infants produce more UCB per kg body weight because of their higher red blood cell (RBC) count, the relatively larger fraction of hepatic hemeproteins, and the shorter life span of fetal RBC’s. Fetal hemoglobin (HbF), which has a higheraffinity for oxygen than “adult” HbA, is broken down postnatal in the relatively oxygen-richenvironment. Apart from CO measurements, UCB production rate can be derived fromturnover of radioisotopically labeled bilirubin, under steady-state conditions.
2.2. Bilirubin chemistry
The systemic name of UCB (bilirubin IX
α
) is 1’8’-dioxo-1,3,6,7-tetramethyl-2,8-divinylbiladiene-
a
,
c
-dipropionic acid (4,5).
11;12
Its molecular weight is 584,7 gram. UCB is anearly symmetrical tetrapyrrole, consisting of two rigid, planar dipyrroles joined by amethylene (-CH
2
-) bridge at carbon atom 10 (Figure 2).
13
 
Figure 2.
Structure of unconjugated bilirubin. From McDonagh and Lightner.
14
 
UCB preferably has a “ridge-tile” conformation,
i.e.
is shaped like a partially open book.UCB structure was identified by analysis of X-ray diffraction.
15
Six internal hydrogen bondsmake the molecule insoluble in water because the hydrophilic polar COOH and NH groups

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