porphyrins, haemoglobin and bilirubin
TRANSCRIPT
R. C. GuptaM.D. (Biochemistry)
Jaipur (Rajasthan), India
Porphyrins are formed by the union of fourpyrrole rings through methenyl bridges
They usually contain a metal ion linked tothe nitrogen atoms of the pyrrole rings
Biologically important porphyrins areusually present as conjugated proteins
Some important porphyrin-containing compounds are:
Haemoglobin
Myoglobin
Cytochromes
Catalase
Peroxidase
Tryptophan pyrrolase
Haemoglobin
Haemoglobin is a conjugated protein madeup of four subunits
Each subunit contains a haem group and apolypeptide chain
The haem group is made up of porphyrinand a ferrous ion
Haemoglobin can reversibly combine withoxygen, and transports oxygen in the body
Myoglobin
Structure is similar to that of haemoglobin
The difference is that it is a monomer
Myoglobin is present in muscles
It can reversibly combine with oxygen
Contain iron-porphyrin conjugated toproteins
Iron-porphyrin portion similar to that ofhaemoglobin
Components of respiratory chain inmitochondria; transport electrons
Some cytochromes perform other functionsas well e.g. microsomal hydroxylation
Cytochromes
An iron-porphyrin containing enzyme thatis present mainly in animals
Acts on, and detoxifies, hydrogen peroxide
Catalase
Another iron-porphyrin containing enzymethat acts on hydrogen peroxide
It occurs mainly in plants
Peroxidase
Iron-porphyrin containing enzyme
Acts on tryptophan
Tryptophan pyrrolase
Carbon atom numbers 1 to 8 have different substituents attached to them
The substituents may be acetate (A), propionate (P), methyl (M) and vinyl (V)
There are two types of porphyrins −porphyrin I and porphyrin III
Type III porphyrins are found more commonly than type I
Uro-porphyrins
Copro-porphyrins
Proto-porphyrins
The important porphyrins in human beings are:
Uroporphyrins are found in urine
Coproporphyrins are found in faeces
Protoporphyrins are found in blood andtissues
Synthesis of porphyrins begins with thecondensation of succinyl CoA with glycine
Succinyl CoA is an intermediate of citricacid cycle
This reaction is catalysed by d-amino-levulinic acid synthetase (ALA synthetase)
Synthesis
a-Amino-b-ketoadipic acid is decarbo-
xylated to d-aminolevulinic acid (ALA)
The reaction is catalysed by ALA synthetase
Pyridoxal phosphate (PLP) is required as acoenzyme
Two ALA molecules are condensed toform the first pyrrole compound, porpho-bilinogen
This reaction is catalysed by ALAdehydrase
Different porphyrins are formed fromporphobilinogen
The exact reactions leading to thesynthesis of porphyrins are not fullyunderstood
Four porphobilinogen molecules react toform hydroxymethylbilane
The reaction is catalysed by uropor-phyrinogen I synthetase
Hydroxymethylbilane can spontaneouslycyclize to form uroporphyrinogen I
It can be enzymatically cyclized to uro-porphyrinogen III
The enzymatic reaction is catalysed byuroporphyrinogen I synthetase and uro-porphyrinogen III cosynthetase
Uroporphyrinogens can be converted into coproporphyrinogens
Coproporphyrinogens can be converted into protoporphyrinogens
Protoporphyrin III is the most abundantporphyrin
Haem is synthesized from protopor-phyrin III
It is also the most important porphyrin
Haem synthesis is catalysed by haemsynthetase (ferro-chelatase)
Haem can combine with different poly-peptides to form various haemoproteins
Protoporphyrin III + Fe++ Haem synthetaseHaem
The major purpose of porphyrin synthesisis to form haem
The regulatory enzyme in the pathway isALA synthetase
The regulator is haem itself
Regulation occurs by repression andderepression
Regulation
When haem is not being utilized, itsconcentration increases
It combines with an aporepressor to formthe repressor
Repressor acts on ALA synthetase geneand represses synthesis of ALA synthetase
This decreases the synthesis of porphyrins
When haem begins to be utilized, itsconcentration decreases
The synthesis of ALA synthetase isderepressed
The enzyme concentration increasesand so does the porphyrin synthesis
Haemoglobin (Hb) is the most abundantporphyrin-containing compound
It is a tetramer made up of four subunits
Each subunit contains a haem group and apolypeptide chain
Haemoglobin
The polypeptide chains are of five typesviz. a, b, g, d and e
The a chain is made up of 141 amino acids
The b , g, d and e chains are made upof 146 amino acids each
The genes for polypeptide chains ofhaemoglobin are called globin genes
The globin genes are present in twoclusters on two different chromosomes
The a cluster is present on chromosome16 and the b cluster on chromosome 11
The a cluster contains a and z genes
The a gene locus has two genes, a1 anda2
The a1 and a2 genes are nearly identical
The b cluster contains b, d, e and g genes
There are two g genes – Ag and Gg
The Ag and Gg are nearly identical
Haemoglobin synthesis occurs in red bloodcell precursors
It begins in pro-erythroblasts
About 65% synthesis is completed byerythroblast stage
The remaining 35% is completed byreticulocyte stage
Part of haem synthesis occurs inmitochondria
The synthesis stops when mitochondriadisappear from red blood cells
Globin is synthesized on ribosomes incytosol
Synthesis of haem and globin issynchronous
Expression of globin genes isdevelopmentally regulated
Haemoglobin synthesis begins at threeweeks of gestation
The a gene is expressed throughout life
The e and z genes are expressed untilabout eighth week of gestation
The predominant haemoglobin at thisstage is a2e2, with some a2z2
After eighth week, the expression of e andz genes declines
Expression of g gene begins andpredominates until birth
The major haemoglobin at this stage isa2g2
After birth, the expression of g genedeclines, and that of b gene increases
The major haemoglobin after birth andthroughout life is a2b2, with some a2d2
The a2b2 haemoglobin is the normal adulthaemoglobin (HbA)
It accounts for 95-98% of the totalhaemoglobin in adults
A small amount of a2d2 haemoglobin(HbA2) is also found in adults
The a2e2 (and a2z2) form of Hb is known as
embryonic haemoglobin
The a2g2 form is foetal haemoglobin (HbF)
which is the predominant form in foetal life
HbF may also be present in adults in very
small amount
The major secondary structure in theglobin chains is a-helix
In b, g, d and e chains, there are eight a-helical regions named A through H
There are seven helices in a chain (thehelix D is missing)
Structure of haemoglobin
Helices in globin chain
A ferrous ion is present at the centre ofeach haem group
It has six electrons in its outermost orbit
Four of these link iron to the four nitrogenatoms of haem
One electron of iron links it to a histidineresidue of the polypeptide chain
This is His87 in the a chain and His92 in band other non-a chains
These histidine residues are present in thehelix F
The bond between iron and His87/His92 isknown as the proximal iron-histidine bond
Helix F
Proximal histidine
Haem
One other histidine residue in helix E is onthe opposite co-ordination position
This is His58 in the a chain and His63 in thenon-a chains
His58/His63 is known as the distal histidineresidue
Distal histidine residue prevents oxidation ofFe+2 by any oxidizing agent in the vicinity
On exposure to high oxygen tension,oxygen enters the space between the distalhistidine residue and Fe+2
Oxygen binds loosely to Fe+2, which isknown as oxygenation of haemoglobin
Haemoglobin can exist in two thermo-dynamic conformations
The conformations are known as Tense (T) and Relaxed (R)
Binding of oxygen changes the thermo-dynamic state of haemoglobin from T to R
During T→R transition, one pair of a and bsubunits rotates by 15° relative to the otherpair
The gap between the two b polypeptidechains becomes narrower when oxygenattaches to iron
2,3-Biphosphoglycerate (2,3-BPG) is animportant regulator of oxygenation anddeoxygenation of haemoglobin
It is formed in erythrocytes from 1,3-bi-phosphoglycerate (1,3-BPG) which is anintermediate of the glycolytic pathway
Central cavity
There is a central cavity in the Hb molecule
surrounded by the four polypeptide chains
2,3-BPG enters the central cavity when its
concentration is high
2,3-BPG
2,3-BPG binds to the two b chains by
salt bonds
2,3-BPG
b1 - Chain
b2 - Chain
Low availability of O2 in tissues increasesthe conversion of 1,3-BPG into 2,3-BPG
Binding of 2,3-BPG to haemoglobinchanges the R form into T form
This results in release of oxygen fromhaemoglobin
The reverse happens in lungs where theavailability of oxygen is high
Oxygen binding changes the T form intothe R form
This narrows the central cavity, leaving nospace for 2,3-BPG
Each subunit of Hb can bind one oxygenmolecule
There are four subunits in a molecule ofHb
So, one Hb molecule can bind four oxygenmolecules
Co-operative binding
Binding of one O2 molecule to haemo-globin facilitates the binding of other O2
molecules
This is known as co-operative binding andis responsible for the sigmoidal oxygendissociation/saturation curve
Co-operative binding is not shown bymyoglobin which is a monomer
Oxygenated myoglobin releases oxygenonly when oxygen tension is very low
Oxygen
saturation
(%)
pO2 (mmHg)
Haemoglobin
Myoglobin
Derivatives of haemoglobin
Haemoglobin can form the following derivatives:
Oxyhaemoglobin
Carboxyhaemoglobin
Methaemoglobin
Sulphaemoglobin
EMB-RCG
Oxyhaemoglobin
This is the oxygenated form of haemo-globin
It is bright red in colour
Oxygen is transported to tissues in theform of oxyhaemoglobin
Carboxyhaemoglobin
Haemoglobin combines with carbonmonoxide to form carboxyhaemoglobin
Affinity of haemoglobin for carbonmonoxide is 200 times that for oxygen
Carboxyhaemoglogin is cherry red incolour
Carboxyhaemoglobin is much more stableas compared to oxyhaemoglobin
Once it is formed, oxygen cannot displacecarbon monoxide from haemoglobin
Formation of carboxyHb decreases the O2
carrying capacity of the blood
Methaemoglobin
Some drugs and chemicals can oxidizethe ferrous ion of Hb to ferric ion
These include sulphonamides, antipyrine,nitrites, nitrobenzene etc
Hb is converted into methaemoglobin,which is brownish red in colour
Some methaemoglobin is formed normallyby endogenous oxidizing agents
However, RBCs possess methaemoglobinreductase and glutathione
These two continuously reduce met-haemoglobin to haemoglobin
Methaemoglobin cannot combine withoxygen
But methaemoglobin can combine withcyanide to form cyanmethaemoglobin
This property is used in the treatment ofcyanide poisoning
The patient is given sodium nitrite andsodium thiosulphate
Sodium nitrite converts haemoglobin intomethaemoglobin
Methaemoglobin combines with cyanideto form non-toxic cyanmethaemoglobin
Sodium thiosulphate reacts with cyanideto form non-toxic sodium thiocyanate
Sulphaemoglobin
Sulphonamides and H2S can converthaemoglobin into sulphaemoglobin
It is dirty brown in colour, and cannotcombine with oxygen
It persists in red blood cells throughouttheir remaining life span
Several abnormal haemoglobins result frommutations in the globin genes
Often, a single amino acid is substituted
Hundreds of mutant haemoglobins havebeen discovered
Abnormal haemoglobins
Most of mutant haemoglobins are capableof normal or near-normal functioning
Such mutants are known as haemoglobinvariants
In some mutants, amino acid substitutionoccurs in a critical region of the molecule
This impairs the functioning of haemoglobin
Such haemoglobins are known asabnormal haemoglobins
Diseases resulting from abnormal haemo-globins are called haemoglobinopathies
Some examples of abnormal haemoglobins and the diseases
resulting from them are:
Haemoglobin S
Haemoglobin M
Thalassaemia
HbS is formed when the glutamateresidue at position 6 in the b chain isreplaced by valine
This amino acid residue is present on thesurface of the haemoglobin molecule
Glutamate has a polar side chain whilevaline has a non-polar side chain
Haemoglobin S
Replacement of a polar residue by a non-polar residue alters the surface properties
Non-polar valine residue of one moleculeattracts the non-polar residue of another
This starts a chain reaction causingaggregation of several Hb molecules
Aggregated haemoglobin molecules
Aggregation results in the formation of afibrous structure
This distorts the erythrocyte into a sickle-shaped cell
Aggregated haemoglobin
molecules distort RBC
Normal
RBC
Sickled
RBC
Oxygenated haemoglobin exists in the Rstate
The non-polar valine residues are notexposed on the surface in R state
Therefore, there is no aggregation ofhaemoglobin molecules
Deoxygenated haemoglobin exists in theT state
In T state, the non-polar valine residuesare exposed on the surface
Therefore, deoxygenated haemoglobin Sgets aggregated
Haemoglobin is present in deoxygenatedform when oxygen tension is low
There is aggregation of haemoglobin Smolecules and sickling of RBCs at lowoxygen tension
Sickled erythrocytes are susceptible topremature destruction
Rapid destruction of erythrocytes causeshaemolytic anaemia
Inheritance of sickle cell anaemia isautosomal recessive
If the defect is inherited from one parentonly, it results in sickle cell trait
Sickle cell trait doesn’t cause any clinicalabnormality
If the defect is inherited from both theparents, it results in sickle cell disease
Sickle cell disease causes severehaemolytic anaemia
Presence of haemoglobin S gives someprotection against malaria
The malarial parasite inhabiting RBCs getskilled when the RBCs are sickled
Prevalence of HbS has been found to behigher where malaria is endemic
Formed by replacement of His58 in the achain by tyrosine due to a point mutation
Phenol group of tyrosine is bonded withiron
This converts Fe+2 into Fe+3 (formingmethaemoglobin)
Methaemoglobin cannot combine withoxygen
Haemoglobin MBoston
Thalassaemia results from a decrease in,or lack of, synthesis of either a chains or bchains
Defective synthesis of a chains leads to a-thalassaemia and that of b chains leads tob-thalassaemia
Thalassaemia
A variety of genetic defects can cause thalassaemia such as:
Deletion of a part or whole of a gene
Defective processing of the primary transcript
Defective transport or translation of mRNA
Premature termination
Decreased synthesis or lack of synthesisof one type of chain leads to an over-production of the unaffected chain
This results in the formation of ahaemoglobin having only a chains or onlyb chains
When the defect is transmitted by only oneparent, it results in thalassaemia minorwhich is symptomless
When the defect is transmitted by both theparents, it results in thalassaemia majorwhich is associated with severe anaemia
Porphyria is a group of disorders
Large quantities of porphyrins and/or theirprecursors are excreted in urine
Excessive excretion occurs due to a defectin the synthetic pathway
Porphyria
An enzyme in the synthetic pathway isabsent or deficient in porphyria
This leads to accumulation of inter-mediates proximal to the block
The urine is normal in colour when fresh butbecomes pink on exposure to light
The change in colour occurs due to oxidationof porphyrinogens
Skin photosensitivity is common in porphyria
Early intermediates bind to nervous tissue,and produce neuropsychiatric abnormalities
Thus, a defect early in the pathway is moreharmful than a defect in the later steps
The defective gene is present in all the
tissues but the expression is usually
confined to a particular tissue
Depending upon the site of expression of
genetic defect, porphyrias may be divided
into:
Erythropoieticporphyrias
Hepatic
porphyrias
Hepatic porphyrias include:
Acute intermittent porphyria
Porphyria cutanea tarda
Hereditary coproporphyria
Variegate porphyria
Erythropoietic porphyriasinclude:
Congenital erythropoieticporphyria
Protoporphyria
Acute intermittent porphyria
Mode of inheritance
Affected enzyme
Site of expression
Autosomal dominant
Uropor-phyriogen I synthetase
Liver cells
Porphyria cutanea tarda
Mode of inheritance
Affected enzyme
Site of expression
Autosomal dominant
Uropor-phyriogendecarboxylase
Liver cells
Hereditary coproporphyria
Mode of inheritance
Affected enzyme
Site of expression
Autosomal dominant
Copropor-phyriogenoxidase
Liver cells
Variegate coproporphyria
Mode of inheritance
Affected enzyme
Site of expression
Autosomal dominant
Protopor-phyriogenoxidase
Liver cells
Congenital erythropoietic porphyria
Mode of inheritance
Affected enzyme
Site of expression
Autosomal recessive
Uropor-phyriogen III cosynthetase
Erythroidcells
Protoporphyria
Mode of inheritance
Affected enzyme
Site of expression
Autosomal dominant
Ferro-chelatase
Liver cells
The clinical abnormalities are mainlyneuro-visceral in hepatic porphyrias andcutaneous in erythropoietic porphyrias
However, some overlapping of signs andsymptoms is not uncommon
Acute attacks of abdominal pain, nauseaand vomiting occur in hepatic porphyrias
Over-active sympathetic nervous systemcauses tachycardia, tremors andhypertension
Hepatic porphyrias
Anxiety, insomnia, disorientation anddepression are also common
Motor neuropathy may cause progressivemuscular weakness
Seizures can also occur
Cutaneous photosensitivity is an additional feature in:
Hereditary copro-
porphyria
Variegate porphyria
Porphyria cutanea
tarda
Severe cutaneous photosensitivity ispresent from a very early age
Porphyrin precursors are present in skin,and damage skin on exposure to sunlight
Multiple vesicles erupt on the skin
The skin is pigmented and fragile
Erythropoietic porphyrias
Denuded areas on skin are prone toinfections
Bones and teeth may be pigmented due todeposition of porphyrin precursors
Haemolysis may occur due to binding ofporphyrin precursors to haemoglobin
In protoporphyria, liver damage also occursin some patients
Cutaneous manifestations are produced byexposure to sunlight
Neuro-visceral symptoms are precipitatedby steroids, alcohol and some drugs
The drugs include barbiturates, mepro-bamate, carbamazepine, mephenytoin,sulphonamides, griseofulvin etc
When life-span of RBCs is over, they arebroken down in reticulo-endothelial system
Haem and globin are separated
Globin is broken down into amino acids
Catabolism of haemoglobin
Methenyl bridge between ring I and ring IIof haem is broken by haem oxygenase
This releases iron and converts haem intobiliverdin
Biliverdin is a green pigment
Biliverdin is reduced to bilirubin bybiliverdin reductase
Bilirubin is yellow in colour
This is the major bile pigment in humanbeings
Bilirubin formed from haem is insoluble inwater
It is known as unconjugated bilirubin
It has to be made water-soluble for itsexcretion
Conjugation with glucuronic acid makesbilirubin water-soluble
Conjugation of bilirubin occurs in liver
Bilirubin, released from reticulo-endothelialcells, has to be transported to liver
Being water-insoluble, it is transported inassociation with albumin
Albumin has two bilirubin-binding sites ̶ ahigh-affinity site and a low-affinity site
Bilirubin is first bound to the high-affinitysite
If high-affinity sites on all the albuminmolecules are saturated, bilirubin is boundto low-affinity site
The normal plasma albumin concentration is3.5-5.5 gm/dl
This is sufficient for binding of 20-25 mg ofbilirubin on the high-affinity sites of albumin
If unconjugated bilirubin level exceeds 20-25 mg/dl, it begins to bind to low-affinity site
Bilirubin is taken up by liver cells from thecirculating albumin
The uptake occurs with the help of acarrier-mediated active transport system
In hepatocytes, bilirubin is conjugated withglucuronic acid to make it water-soluble
Glucuronic acid is conjugated with thepropionate group
Since there are two propionate groups,two glucuronate moieties can be added
The conjugation reaction occurs in twosteps
Bilirubin
Bilirubin monoglucuronide
Bilirubin diglucuronide
UDP-glucuronic acid
UDP
UDP
UDP-glucuronic acid
Bilirubin UDP-glucuronyl
transferase
Bilirubin UDP-glucuronyl
transferase
Bilirubin diglucuronide may also be formedby a trans-esterification reaction
The reaction occurs between two bilirubinmonoglucuronide molecules
It is catalysed by bilirubin-glucuronideglucuronosyl transferase (dismutase)
Bilirubin
mono-glucuronide
Bilirubin
Bilirubindiglucuronide
Bilirubin
glucuronide
glucuronosyltransferase
Bilirubin
mono-glucuronide
Bilirubin diglucuronide is also known asconjugated bilirubin
It is excreted by liver into the intestinethrough bile
Excretion takes place through an activetransport mechanism
Bilirubin is freed from glucuronic acid in thelarge intestine
It is reduced by the enzymes of intestinalbacteria to urobilinogen
Most of the urobilinogen is excreted in thefaeces
A small portion of urobilinogen is absorbedinto portal circulation and is taken to liver
Liver excretes most of it into the intestine(entero-hepatic circulation of urobilinogen)
A fraction enters the systemic circulation,and is excreted by the kidneys in urine
Haemoxygenase
Biliverdinreductase
Haem
Bilirubin UDP-gluc-uronyl transferaseBlood
vessel
Serum bilirubin ranges from 0.2-1.0 mg/dl in concentration
Jaundice
Unconjugated bilirubin
Conjugated bilirubin
This is total bilirubin which includes:
Concentration of unconjugated bilirubin inserum is 0.1-0.6 mg/dl
It is water-insoluble
It is also known as indirect reacting bilirubin
It reacts with Ehrlich’s diazo reagent onlyafter addition of methanol or ethanol
Concentration of conjugated bilirubin inserum is 0.1-0.4 mg/dl
It is water-soluble
It is also known as direct reacting bilirubin
It can react with Ehrlich’s diazo reagentwithout the addition of an organic solvent
A rise in serum bilirubin concentration isknown as hyperbilirubinaemia
When the level rises above 2 mg/dl,bilirubin gets deposited in tissues
The tissues are stained yellow
This is known as jaundice
The yellow staining can be seen in skinand mucous membranes
But is most clearly visible in the sclera
Jaundice can occur in a number of
diseases
Post-hepatic jaundice
Hepatic jaundice
Pre-hepatic jaundice
Depending upon the site of the defect,
jaundice can be divided into:
This is also known as haemolytic jaundice
It is due to an increased rate of haemolysis
Breakdown of haemoglobin is increased
Bilirubin is formed in large quantities
Pre-hepatic jaundice
Capacity of the liver cells to take up,conjugate and excrete bilirubin is exceeded
Concentration of unconjugated bilirubin inserum rises resulting in jaundice
Unconjugated bilirubin cannot be excretedby the kidneys
Therefore, urine doesn’t contain bilirubin
As the rate of formation of bilirubinincreases, so does the rate of formation ofurobilinogen
Therefore, urinary excretion of urobilinogenis increased
The laboratory findings in haemolytic jaundice are:
• Rise in unconjugated bilirubin in serum
• Absence of bilirubin from urine
• Increase in urobilinogen in urine
Haemolytic jaundice can occur in:
• Thalassaemia
• Sickle cell crisis
• Spherocytosis
• Glucose-6-phosphate dehydrogenase deficiency etc
A common cause of haemolytic jaundice is“physiological jaundice of neonates”
This occurs in some neonates between thethird and tenth days of life
Erythrocytes formed during foetal lifecontain HbF
These are rapidly destroyed after birth tobe replaced by erythrocytes containing HbA
Rate of formation of bilirubin is increased
The hepatic conjugating system is not fullydeveloped in the first two weeks of life
There is accumulation of unconjugatedbilirubin in blood causing jaundice
This is a transient and benign condition
A serious cause of haemolytic jaundice iserythroblastosis foetalis
It is also known as haemolytic disease ofthe newborns
This occurs when an Rh-negative motherconceives an Rh-positive baby
The Rh-antigen can be transferred acrossthe placenta from the foetus to the mother
Maternal immune system starts formingRh-antibodies
The antibodies are transferred across theplacenta to the foetus
The resulting Rh-incompatibility causessevere haemolysis in the foetus
Excessive haemolysis increases the levelof unconjugated bilirubin in serum
The baby is born with jaundice
The condition becomes serious if unconju-gated serum bilirubin exceeds 20-25 mg/dl
The excess bilirubin binds to low-affinitysite of albumin
This is off-loaded in the central nervoussystem which is rich in lipids
The lipids easily take up non-polar bilirubinfrom the low-affinity site of albumin
Bilirubin is attached to basal ganglia,hippocampus, cerebellum, medulla etc
Nervous tissue is stained yellow (knownas kernicterus)
Kernicterus is fatal or causes permanentneurological damage if the baby survives
Hepatic or hepatocellular jaundice is due torapid destruction of liver cells
This can be caused by hepatitis (viral oralcoholic), hepatotoxic drugs/chemicals,advanced cirrhosis and some inborn errors
Hepatic jaundice
Due to destruction of liver cells, capacity ofliver to take up and conjugate bilirubin isdecreased
Concentration of unconjugated bilirubin inserum increases even though the rate offormation of bilirubin is normal
In viral hepatitis, the surviving liver cells areinflammed and swollen, and compress thebiliary canaliculi
This results in intra-heptatic biliaryobstruction
Due to obstruction, conjugated bilirubinregurgitates into systemic circulation
Hence, serum level of conjugated bilirubinis also raised in viral hepatitis
As conjugated bilirubin is water-soluble, itis excreted in urine
Therefore, urine contains bile pigments
The laboratory findings in viral hepatitis are:
• Unconjugated bilirubin is raised in serum
• Conjugated bilirubin is raised in serum
• Bilirubin is present in urine
• Urinary urobilinogen is usually normal
This is also known as obstructive jaundiceas it is due to an obstruction to the flow ofbile
The obstruction may be intra-hepatic orextra-hepatic
The commonest cause of biliary obstructionis presence of gall stones in the bile duct
Post-hepatic jaundice
The other causes of obstruction are:
• Cancer of pancreas
• Cancer of gall bladder/bile duct
• Stricture of bile duct
• Congenital atresia of bile duct
• Cholangitis
Conjugated bilirubin is regurgitated into circulation
As it is water-soluble, it is excreted in urine
Due to biliary obstruction, bilirubin conju-gated in liver
As bilirubin doesn’t reach the intestine,urobilinogen cannot be formed
Therefore, urobilinogen is absent fromurine
The laboratory findings in obstructive jaundice are:
• Rise in conjugated bilirubin in serum
• Presence of bilirubin in urine
• Absence of urobilinogen from urine
Jaundice also occurs in the following inherited disorders of
bilirubin metabolism:
• Gilbert’s syndrome
• Crigler-Najjar syndrome
• Lucey-Driscoll syndrome
• Rotor’s syndrome
• Dubin-Johnson syndrome
The active transport system for hepaticuptake of bilirubin is defective
Bilirubin UDP-glucuronyl transferaseactivity in liver cells is also sub-normal
The concentration of unconjugated biliburinis raised in serum
Gilbert’s syndrome
Inheritance of Gilbert’s syndrome isautosomal dominant
A mutation occurs in the promoterregion of the gene for bilirubin UDP-glucuronyl transferase
Expression of the gene is decreasedthough the enzyme is normal in function
Concentration of unconjugated bilirubin inserum is mildly raised
There is no clinical abnormality other thanthe permanent yellow discoloration
No treatment is required
Crigler-Najjar syndrome
This is an autosomal recessive disorder
Two types have been recognized:
Crigler-Najjarsyndrome, type I
Crigler-Najjarsyndrome, type II
In type I, a variety of mutations occur inthe gene for bilirubin UDP-glucuronyltransferase
The mutations may be deletions,insertions, mis-sense mutations andpremature stop codons
The result is a totally non-functionalenzyme
Concentration of unconjugated bilirubinis greatly elevated in serum
Kernicterus is common
Phototherapy and repeated plasma-pheresis can prevent kernicterus up topuberty but not later
In type II, there is a point mutation inone allele of the gene
Bilirubin UDP-glucuronyl transferaseactivity is sub-normal but not absent
Concentration of unconjugated bilirubinin serum is moderately increased
Prognosis is much better
This rare disorder is believed to be dueto an inhibitor of bilirubin UDP-glucuronyl transferase
The inhibitor is present in maternalblood for a short period only
Lucey-Driscoll syndrome
Severe unconjugated hyperbilirubinaemiadevelops in the newborn
The condition is transient
Phototherapy and, sometimes, exchangetransfusion may be required in the firstfour days of life
The active transport system for excretion ofconjugated bilirubin is defective
This leads to a moderate rise in conjugatedbilirubin in serum
The inheritance is autosomal recessive
Rotor’s syndrome
The inheritance is autosomal recessive
The nature of the defect is similar to that inRotor’s syndrome
In addition, porphyrins are deposited inliver giving it a black appearance
Dubin-Johnson syndrome
Concentration of conjugated bilirubin inplasma is raised
Apart from visible jaundice, there is nosign and symptom
No treatment is required