Determination of total 3 alpha-hydroxy bile acids in serum

Longitudinal profiles of 15 serum bile acids in patients with intrahepatic cholestasis of pregnancy

OBJECTIVES

Increased maternal serum bile acids are implicated in intrahepatic cholestasis of pregnancy. Individual bile acid profiles and their relationship with disease progression, however, remain unknown. The purpose of this prospective study was to determine the temporal changes in bile acids in normal pregnancy and in pregnancies complicated with intrahepatic cholestasis of pregnancy and pruritus gravidarum.

METHODS

A validated method for the evaluation of 15 bile acids (conjugated and unconjugated) in a single serum sample was developed using high-performance liquid chromatography/mass spectrometry (HPLC-MS) with an electrospray interface. Bile acid concentrations were assessed in samples (16 weeks of gestation to 4 weeks postpartum) from women with, or who later developed, intrahepatic cholestasis of pregnancy (n=63) and were compared with those from normal pregnant women (n=26) and from women with pruritus gravidarum (n=43).

RESULTS

Intrahepatic cholestasis of pregnancy was associated with a predominant increase in cholic acid conjugated with taurine and glycine, from 24 weeks of pregnancy. Ursodeoxycholic acid (UDCA) treatment (> or =21 days, n=15) significantly reduced serum taurocholic and taurodeoxycholic acid concentrations (P<0.01). Bile acid profiles were similar in normal pregnancy and pregnancy associated with pruritus gravidarum.

CONCLUSIONS

The bile acid profiles and effects of treatment by UDCA implicate a role for taurine-conjugated bile acids in the syndrome of intrahepatic cholestasis of pregnancy. [corrected] With regard to individual bile acid profiles, pruritus gravidarum is a disorder quite distinct from intrahepatic cholestasis of pregnancy.

Analysis of bile acid-induced regulation of FXR target genes in human liver slices

Information about the role of nuclear receptors has rapidly increased over the last decade. However, details about their role in human are lacking. Owing to species differences, a powerful human in vitro system is needed. This study uses for the first time precision-cut human liver slices in the nuclear receptor field. The farnesoid X receptor (FXR) was chosen as a model. We were able to demonstrate that human liver slices efficiently take up bile acids and show a stable expression of a wide variety of genes relevant for bile acid metabolism, including bile acid transporters, cytochrome P450 enzymes and transcription factors. Treatment with chenodeoxycholate induced small heterodimer partner, bile salt export pump and p-glycoprotein, ABCB4 and repressed cholesterol 7alpha hydroxylase, hepatocyte nuclear factor (HNF)1, HNF4 and organic anion transporting peptide (OATP)1B1. OATP1B3, FXR, HNF3beta and cytochrome P450 enzyme remained relatively constant. In contrast to what has been observed in mice and rat studies, SHP induction did not result in repression of sodium-dependent bile acid cotransporter expression. Further, regulation of genes seemed to be dependent on concentration and time. Taken together, the study shows that the use of liver slices is a powerful technique that enables to study nuclear receptors in the human liver.

Bile acids in health and disease

Over the last quarter of a century Danish research on bile acids has comprised studies of their physical and chemical properties, their physiology, pathophysiology, metabolism, and kinetics, and their clinical applicability. In the beginning of the period a major contribution was made to the understanding of the factors involved in the solubility of cholesterol in bile. The growing international understanding of the potential importance of the bile acids in health and disease gave raise to a substantial Danish contribution in the 1970s and 1980s in parallel with international achievements. Emphasis was on the possible clinical implications of bile acids. Studies on physiology and pathophysiology were in focus. Patients who have had an intestinal bypass operation for obesity served as a model for obtaining new knowledge on various aspects of the properties of the bile acids. Also the analytical methods were improved. Important physiological research on the mechanisms of hepatic bile flow was conducted. An intestinal perfusion model served as a tool providing information on absorption kinetics and on transmucosal water and electrolyte movements. The gallstone disease, liver diseases, inflammatory bowel disease, fat malabsorption, and other intestinal disorders were studied. The 'idiopathic ileopathy' as a cause for bile acid malabsorption causing diarrhoea was established as a new disorder. Thus, in the time period concerned, substantial Danish contributions emerged on major and minor topics of the bile acid field.

Serum bile acids in normal pregnancy

Serum bile acid levels were measured in a longitudinal study of 56 women throughout normal pregnancy. Postprandial levels of serum bile acids were measured at each visit. Mean serum bile acid levels increased significantly from 5.3 (2 SD 3.4) mumol/l at 16 weeks to 6.5 (2 SD 3.7) mumol/l at term (P less than 0.005).

Maternal serum bile acid levels and fetal distress in cholestasis of pregnancy

Cardiotocography (CTG) and serum total bile acid level were used in the perinatal surveillance of 117 pregnancies with intrahepatic cholestasis. Signs of fetal distress occurred more commonly in cholestasis pregnancies with high maternal bile acid levels. Despite careful monitoring one intrauterine fetal loss occurred without any warning signs in CTG. In this case the serum bile acid level was only moderately elevated. CTG seems to be suitable for detection of fetal distress in cholestasis pregnancies. Those with high maternal bile acid level should be subjected to a more intensive follow-up. Some fetal risk, however, seems to remain despite of the use of these methods.

Colorimetric enzymatic measurement of serum total 3 alpha-hydroxy bile acid concentrations without extraction

A new method for the simpler colorimetric assay of serum total 3 alpha-hydroxy bile acid concentrations without prior extraction has been investigated. The lowest concentration that could be reliably measured was 3 mumol/l and the results obtained were in agreement with those obtained using extraction and the spectrofluorimetric enzymatic assay (y = 1.007x - 1.86, r = 0.99, n = 36). Results for 20 normal sera collected after an overnight fast were 6.2 +/- 5.1 mumol/l (mean +/- SD) and in 20 normal plasma randomly collected were 4.9 +/- 4.2 mumol/l. This new assay is comparable in specificity and sensitivity to the older spectrofluorimetric enzymatic assays and convenient for routine use.

Morphologic and biochemical changes in dogs after portacaval shunt plus bile fistula or ileal bypass: failure of bile fistula or ileal bypass to prevent hepatocyte atrophy

External biliary fistula (BF) or ileal bypass (IB) was performed in dogs at the time of or 2 weeks after portacaval shunt (PCS). The pathologic changes in the dog livers 2 to 4 weeks later were compared to those caused by PCS alone. Histopathologic differences between PCS alone vs. PCS plus BF or IB could not be found. Thus, the experiments did not confirm recent observations by others in rats that BF prevents or reverses the hepatic injury of PCS. As estimated by plasma mevalonic acid determinations, the increase in hepatic cholesterol synthesis that is characteristic after BF or IB was suppressed in animals with PCS. BF and IB reduced but did not eliminate the postprandial elevation in serum bile acid that occurs after PCS. The findings have possible relevance in planning the treatment of patients with familial hypercholesterolemia with the combined use of PCS and IB.

Treatment of familial hypercholesterolemia by portacaval anastomosis: effect on cholesterol metabolism and pool sizes

Measurements of the key parameters of cholesterol homeostasis and the mass of the body pools of cholesterol were carried out in two patients with familial hypercholesterolemia (FH), one homozygote and one heterozygote, before and 28 and 18 months, respectively, after portacaval anastomosis (PCA). In both patients the procedure significantly reduced the plasma concentrations of total and low density lipoprotein cholesterol and the daily rate of whole body cholesterol and bile acid synthesis. In addition, PCA caused a net efflux of accumulated tissue cholesterol as demonstrated by reductions in the rapidly exchangeable and total exchangeable masses of body cholesterol. Shunt patency was verified by demonstration of increased bile acids in serum from fasting patients and from patients 2 hr after a meal and by increased plasma glucagon before and after arginine infusion. Other than a persistently increased level of serum alkaline phosphatase, liver function tests have fallen within the normal range in both patients; there has been no evidence of hepatic encephalopathy. In the homozygous patient there has also been a striking resolution in xanthoma size and distribution. These multiple effects on cholesterol homeostasis and pool sizes strongly suggest that PCA can reverse the progressive accumulation of cholesterol in body tissues of FH patients.

Determination of total bile acids in serum. A comparison of a radioimmunoassay with an enzymatic-fluorimetric method

A solid phase radioimmunoassay kit method for total conjugated bile acids has been compared to an enzymatic fluorimetric method for total serum bile acids. The methods were compared with respect to: precision, cross-reactivity (molar equivalence) of different bile salts, recovery of different bile salts from serum, the reference range for a healthy population, linearity, coefficient of correlation, diagnostic effectiveness, cost and ease of assay. Both assays seemed equally capable of predicting the presence or absence of liver disease. Radioimmunoassay had little advantage over the enzymatic-fluorimetric method. Its relative ease was far outweighed by its greater cost and poorer analytical performance.

Serum levels and clearance of bile acids are unaffected by jejunoileal bypass with 3:1 or 1:3 jejunoileal ratio

Jejunoileal bypass may impair liver function. The hypothesis of the present study was that this may depend on the jejunoileal ratio of the segment left in continuity in a manner that affects the transport of bile acids from blood to bile. We investigated five extremely obese patients before and 29 patients 3, 9 and 15 months after bypass surgery with a 3:1 or 1:3 jejunoileal ratio of the functioning segment. Routine liver function tests, plasma disappearance rate of intravenously administered 3H-cholic acid and 14C-24-chenodeoxycholic acid, and fasting and postprandial serum concentrations of total 3-alpha-hydroxy bile acids showed no appreciable significant relationship with bypass surgery as such, time after surgery, or the jejunoileal ratio of the functioning segment.

Colorimetric determination of glycine conjugates of bile acids

A simple assay was developed for the determination of glycine-conjugated bile acids. Samples containing the glycine-conjugated bile acids in the range from 15 to 250 nmol were acidified with HCl, and extracted with ethyl acetate containing ethanol (50 ml/l). An aliquot of the organic phase was evaporated to dryness, and the dried residue was treated to develop the color by the addition of acetic anhydride, pyridine and a trace amount of phosphoric acid. the absorbance was measured at 429 or 456 nm after the reaction at 50 degrees C for 2 h. Color development did not occur with unconjugated and taurine-conjugated bile acid. Beer's law was obeyed from 12.5 to 200 nmol in a cuvette. The recovery of the conjugates from the rabbit gall bladder bile and liver homogenate was satisfactory. This method requires no hydrolysis step and is applicable to the determination of glycine-conjugated bile acids in bile, duodenal aspirate and liver homogenate.