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Lee ZM, Chang LS, Kuo KC, Lin MC, Yu HR. Impact of Protein Binding Capacity and Daily Dosage of a Drug on Total Serum Bilirubin Levels in Susceptible Infants. CHILDREN (BASEL, SWITZERLAND) 2023; 10:926. [PMID: 37371159 DOI: 10.3390/children10060926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/17/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023]
Abstract
Hyperbilirubinemia is a common pathological condition in neonates. Free bilirubin can penetrate the blood-brain barrier (BBB), which can lead to bilirubin neurotoxicity. In the context of predicting the risk of bilirubin neurotoxicity, although the specificity and sensitivity of free bilirubin levels are higher than those of total serum bilirubin (TSB), free bilirubin is not widely monitored in clinical practice. The threshold TSB levels at which phototherapy must be administered have been established previously. However, TSB levels are not well correlated with neurodevelopmental outcomes. Currently, TSB levels are commonly used to guide phototherapy for neonatal hyperbilirubinemia. Some clinical drugs can displace bilirubin from its albumin-binding sites, and consequently upregulate plasma bilirubin. Daily dosages play a vital role in regulating bilirubin levels. A drug with both a high protein binding capacity and high daily dosage significantly increases bilirubin levels in infants. Premature or very low birth weight (VLBW) infants are vulnerable to the upregulation of bilirubin levels as they exhibit the lowest reserve albumin levels and consequently the highest bilirubin toxicity index. Because bilirubin is involved in maintaining the balance between pro-oxidant and antioxidant agents, the downregulation of bilirubin levels is not always desirable. This review provides insights into the impact of protein binding capacity and daily dosage of drugs on the bilirubin levels in susceptible infants.
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Affiliation(s)
- Zon-Min Lee
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
- Department of Pharmacy, Tajen University, Pingtung 907, Taiwan
| | - Ling-Sai Chang
- Kawasaki Disease Center and Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
| | - Kuang-Che Kuo
- Division of Pediatric Infection, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
| | - Meng-Chiao Lin
- Department of Pharmacy, St Joseph's hospital, Yunlin 632401, Taiwan
| | - Hong-Ren Yu
- Department of Pediatrics, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Graduate Institute of Clinical Medical Science, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
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Models of bilirubin neurological damage: lessons learned and new challenges. Pediatr Res 2022:10.1038/s41390-022-02351-x. [PMID: 36302856 DOI: 10.1038/s41390-022-02351-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 09/26/2022] [Accepted: 10/03/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Jaundice (icterus) is the visible manifestation of the accumulation of bilirubin in the tissue and is indicative of potential toxicity to the brain. Since its very first description more than 2000 years ago, many efforts have been undertaken to understand the molecular determinants of bilirubin toxicity to neuronal cells to reduce the risk of neurological sequelae through the use of available chemicals and in vitro, ex vivo, in vivo, and clinical models. Although several studies have been performed, important questions remain unanswered, such as the reasons for regional sensitivity and the interplay with brain development. The number of new molecular effects identified has increased further, which has added even more complexity to the understanding of the condition. As new research challenges emerged, so does the need to establish solid models of prematurity. METHODS This review critically summarizes the key mechanisms of severe neonatal hyperbilirubinemia and the use of the available models and technologies for translational research. IMPACT We critically review the conceptual dogmas and models used for studying bilirubin-induced neurotoxicity. We point out the pitfalls and translational gaps, and suggest new clinical research challenges. We hope to inform researchers on the pro and cons of the models used, and to help direct their experimental focus in a most translational research.
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Lahmann JM, Faase RA, Leu HY, Jacques SL, Scottoline B, Schilke KF, Baio JE, Higgins AZ. Microfluidic photoreactor to treat neonatal jaundice. BIOMICROFLUIDICS 2021; 15:064104. [PMID: 34853627 PMCID: PMC8616629 DOI: 10.1063/5.0066073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 11/09/2021] [Indexed: 06/13/2023]
Abstract
While in most cases, jaundice can be effectively treated using phototherapy, severe cases require exchange transfusion, a relatively risky procedure in which the neonate's bilirubin-rich blood is replaced with donor blood. Here, we examine extracorporeal blood treatment in a microfluidic photoreactor as an alternative to exchange transfusion. This new treatment approach relies on the same principle as phototherapy but leverages microfluidics to speed up bilirubin removal. Our results demonstrate that high-intensity light at 470 nm can be used to rapidly reduce bilirubin levels without causing appreciable damage to DNA in blood cells. Light at 470 nm was more effective than light at 505 nm. Studies in Gunn rats show that photoreactor treatment for 4 h significantly reduces bilirubin levels, similar to the bilirubin reduction observed for exchange transfusion and on a similar time scale. Predictions for human neonates demonstrate that this new treatment approach is expected to exceed the performance of exchange transfusion using a low blood flow rate and priming volume, which will facilitate vascular access and improve safety.
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Affiliation(s)
- John M. Lahmann
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
| | - Ryan A. Faase
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
| | - Hsuan Yu Leu
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
| | - Steven L. Jacques
- Department of Bioengineering, University of Washington, Seattle, Washington 98105, USA
| | - Brian Scottoline
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon 97239, USA
| | - Kate F. Schilke
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
| | - Joe E. Baio
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
| | - Adam Z. Higgins
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
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Diagnostic methods for neonatal hyperbilirubinemia: benefits, limitations, requirements, and novel developments. Pediatr Res 2021; 90:277-283. [PMID: 33948000 DOI: 10.1038/s41390-021-01546-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 02/20/2021] [Accepted: 04/10/2021] [Indexed: 11/09/2022]
Abstract
Invasive bilirubin measurements remain the gold standard for the diagnosis and treatment of infants with severe neonatal hyperbilirubinemia. The present paper describes different methods currently available to assess hyperbilirubinemia in newborn infants. Novel point-of-care bilirubin measurement methods, such as the BiliSpec and the Bilistick, would benefit many newborn infants, especially in low-income and middle-income countries where the access to costly multi-analyzer in vitro diagnostic instruments is limited. Total serum bilirubin test results should be accurate within permissible limits of measurement uncertainty to be fit for clinical purposes. This implies correct implementation of internationally endorsed reference measurement systems as well as participation in external quality assessment programs. Novel analytic methods may, apart from bilirubin, include the determination of bilirubin photoisomers and bilirubin oxidation products in blood and even in other biological matrices. IMPACT: Key message: Bilirubin measurements in blood remain the gold standard for diagnosis and treatment of severe neonatal hyperbilirubinemia (SNH). External quality assessment (EQA) plays an important role in revealing inaccuracies in diagnostic bilirubin measurements. What does this article add to the existing literature? We provide analytic performance data on total serum bilirubin (TSB) as measured during recent EQA surveys. We review novel diagnostic point-of-care (POC) bilirubin measurement methods and analytic methods for determining bilirubin levels in biological matrices other than blood. Impact: Manufacturers should make TSB test results traceable to the internationally endorsed total bilirubin reference measurement system and should ensure permissible limits of measurement uncertainty.
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5
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Experimental models assessing bilirubin neurotoxicity. Pediatr Res 2020; 87:17-25. [PMID: 31493769 DOI: 10.1038/s41390-019-0570-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 07/29/2019] [Accepted: 08/16/2019] [Indexed: 02/08/2023]
Abstract
The molecular and cellular events leading to bilirubin-induced neurotoxicity, the mechanisms regulating liver and intestine expression in neonates, and alternative pathways of bilirubin catabolism remain incompletely defined. To answer these questions, researchers have developed a number of model systems to closely recapitulate the main characteristics of the disease, ranging from tissue cultures to engineered mouse models. In the present review we describe in vitro, ex vivo, and in vivo models developed to study bilirubin metabolism and neurotoxicity, with a special focus on the use of engineered animal models. In addition, we discussed the most recent studies related to potential therapeutic approaches to treat neonatal hyperbilirubinemia, ranging from anti-inflammatory drugs, activation of nuclear receptor pathways, blockade of bilirubin catabolism, and stimulation of alternative bilirubin-disposal pathways.
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Zheng J, Wei C, Zhao M, Zhao D. Phototherapy is associated with the decrease in serum globulin levels in neonatal hyperbilirubinemia. Biomed Rep 2018; 10:63-69. [PMID: 30588305 DOI: 10.3892/br.2018.1166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 10/31/2018] [Indexed: 12/13/2022] Open
Abstract
Previous studies have indicated that phototherapy may be associated with childhood immune disorders in later life. The present study aimed to assess the effects of phototherapy as a risk factor in the decrease in serum globulin (GLB) levels during neonatal hyperbilirubinemia. A total of 430 full-term infants aged between 1 and 28 days, diagnosed with neonatal hyperbilirubinemia, were enrolled in the present study. Neonates with intrauterine infection, genetic abnormalities and congenital diseases were excluded from the cohort. All neonates received single-side phototherapy (halogen lamps for 12 h per day, for 3 days) and/or intravenous albumin (IVALB; 1 g/kg/day, for 2 days) and/or intravenous immunoglobulin (1 g/kg/day, for 2 days). Total serum bilirubin (TSB), albumin (ALB) and GLB levels were examined twice, on the first and fourth days of hospitalization. Neonatal TSB concentrations decreased from 299.6±83.9 to 163.6±57.6 µmol/l following 3 days of intensive treatment (P<0.001). Pearson correlative analysis indicated that TSB was significantly correlated to the GLB level (r=0.249; P<0.01), but not with ALB level. There was a significant decrease in GLB levels following phototherapy+IVALB (P<0.001). The GLB levels decreased to 2-4 g/l (10-20% compared with their baseline levels) and were markedly decreased in infants >16 days old compared with those in patients aged <16 days (P<0.001). The decreases in GLB levels observed were 21.3±4.1 to 18.5±4.2 g/l in the phototherapy group, and 23.0±3.9 to 16.6±4.5 g/l in the phototherapy+IVALB (P<0.001). The decrease in GLB levels was associated with age (95% confidence interval; -0.152, -0.016). The results demonstrated that phototherapy decreased serum GLB levels, particularly in infants aged >16 days, while additional IVALB treatment promoted the decrease, along with increased age.
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Affiliation(s)
- Junwen Zheng
- Department of Pediatrics and Neonatology, Children's Digital Health and Data Center, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Cong Wei
- Department of Pediatrics and Neonatology, Children's Digital Health and Data Center, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Meng Zhao
- Department of Pediatrics and Neonatology, Children's Digital Health and Data Center, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Dongchi Zhao
- Department of Pediatrics and Neonatology, Children's Digital Health and Data Center, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
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Bortolussi G, Muro AF. Advances in understanding disease mechanisms and potential treatments for Crigler–Najjar syndrome. Expert Opin Orphan Drugs 2018. [DOI: 10.1080/21678707.2018.1495558] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Giulia Bortolussi
- Mouse Molecular Genetics Group, International Centre for Genetic Engineering and Biotechnology (ICGEB), Trieste, Italy
| | - Andrés Fernando Muro
- Mouse Molecular Genetics Group, International Centre for Genetic Engineering and Biotechnology (ICGEB), Trieste, Italy
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Okada H, Itoh S, Nii K, Sugino M, Fuke N, Koyano K, Yasuda S, Kusaka T. Bilirubin photoisomers in rhesus monkey serum. JOURNAL OF PHOTOCHEMISTRY AND PHOTOBIOLOGY B-BIOLOGY 2018; 185:50-54. [PMID: 29864726 DOI: 10.1016/j.jphotobiol.2018.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/10/2018] [Accepted: 05/14/2018] [Indexed: 10/16/2022]
Abstract
As rhesus monkeys exhibit physiological jaundice during the neonatal period, we used rhesus monkey serum to examine changes in bilirubin photoisomers. Bilirubin-rhesus monkey serum solution was irradiated with blue light-emitting diode, and changes in the absorbance and bilirubin fraction were compared with those in bilirubin- human serum albumin (HSA) and bilirubin-rat albumin solutions. The λmax decreased with light irradiation. The mean production rate of cyclobilirubin IXα was 1.98, 199 and 0.76 × 10-2/min in rhesus monkey serum, HSA and rat albumin, respectively. There was no significant difference between rhesus monkey serum and HSA. The (ZE)-bilirubin IXα/(ZZ)-bilirubin IXα ratio was 0.33, 0.45, and 0.10, respectively, differing significantly among the groups. The (EZ)-bilirubin IXα/(ZZ)-bilirubin IXα ratio was 0.020, 0.010, and 0.062, respectively, with no significant difference between rhesus monkey serum and HSA. The production rate of (EZ)-cyclobilirubin XIIIα(= (ZE)-cyclobilirubin XIIIα) was 0.73, 1.60, and 0.51 × 10-2/min, respectively, with differing significantly among the groups. The (EZ)-bilirubin IIIα/(ZZ)-bilirubin IIIα ratio was significantly different among the groups at 0.20, 0.38, and 0.15, respectively. This is the first report demonstrating the photoisomerization of bilirubin in rhesus monkey serum and the animal with the same cyclobilirubin production rate as HSA.Rhesus monkeys may be used as an animal model for neonatal hyperbilirubinemia in humans to evaluate the efficacy of phototherapy.
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Affiliation(s)
- Hitoshi Okada
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan.
| | - Susumu Itoh
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Kohichiroh Nii
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Masashiro Sugino
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Noriko Fuke
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Kosuke Koyano
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Saneyuki Yasuda
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Takashi Kusaka
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan
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Seidel RA, Claudel T, Schleser FA, Ojha NK, Westerhausen M, Nietzsche S, Sponholz C, Cuperus F, Coldewey SM, Heinemann SH, Pohnert G, Trauner M, Bauer M. Impact of higher-order heme degradation products on hepatic function and hemodynamics. J Hepatol 2017; 67:272-281. [PMID: 28412296 DOI: 10.1016/j.jhep.2017.03.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 03/13/2017] [Accepted: 03/20/2017] [Indexed: 01/24/2023]
Abstract
BACKGROUND & AIMS Biliverdin and bilirubin were previously considered end products of heme catabolism; now, however, there is evidence for further degradation to diverse bioactive products. Z-BOX A and Z-BOX B arise upon oxidation with unknown implications for hepatocellular function and integrity. We studied the impact of Z-BOX A and B on hepatic functions and explored their alterations in health and cholestatic conditions. METHODS Functional implications and mechanisms were investigated in rats, hepatocytic HepG2 and HepaRG cells, human immortalized hepatocytes, and isolated perfused livers. Z-BOX A and B were determined by liquid chromatography-tandem mass spectrometry (LC-MS/MS) in acute and acute-on-chronic liver failure and hereditary unconjugated hyperbilirubinemia. RESULTS Z-BOX A and B are found in similar amounts in humans and rodents under physiological conditions. Serum concentrations increased ∼20-fold during cholestatic liver failure in humans (p<0.001) and in hereditary deficiency of bilirubin glucuronidation in rats (p<0.001). Pharmacokinetic studies revealed shorter serum half-life of Z-BOX A compared to its regio-isomer Z-BOX B (p=0.035). While both compounds were taken up by hepatocytes, Z-BOX A was enriched ∼100-fold and excreted in bile. Despite their reported vasoconstrictive properties in the brain vasculature, BOXes did not affect portal hemodynamics. Both Z-BOX A and B showed dose-dependent cytotoxicity, affected the glutathione redox state, and differentially modulated activity of Rev-erbα and Rev-erbβ. Moreover, BOXes-triggered remodeling of the hepatocellular cytoskeleton. CONCLUSIONS Our data provide evidence that higher-order heme degradation products, namely Z-BOX A and B, impair hepatocellular integrity and might mediate intra- and extrahepatic cytotoxic effects previously attributed to hyperbilirubinemia. LAY SUMMARY Degradation of the blood pigment heme yields the bile pigment bilirubin and the oxidation products Z-BOX A and Z-BOX B. Serum concentrations of these bioactive molecules increase in jaundice and can impair liver function and integrity. Amounts of Z-BOX A and Z-BOX B that are observed during liver failure in humans have profound effects on hepatic function when added to cultured liver cells or infused into healthy rats.
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Affiliation(s)
- Raphael A Seidel
- Department of Anesthesiology and Intensive Care Medicine/Center for Sepsis Control and Care, Jena University Hospital, Germany; Institute of Inorganic and Analytical Chemistry, Bioorganic Analytics, Friedrich Schiller University Jena, Germany
| | - Thierry Claudel
- HansPopper Laboratory of Molecular Hepatology, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Franziska A Schleser
- Department of Anesthesiology and Intensive Care Medicine/Center for Sepsis Control and Care, Jena University Hospital, Germany
| | - Navin K Ojha
- Center for Molecular Biomedicine, Department of Biophysics, Friedrich Schiller University Jena & Jena University Hospital, Germany
| | - Matthias Westerhausen
- Institute of Inorganic and Analytical Chemistry, Inorganic Chemistry I, Friedrich Schiller University Jena, Germany
| | | | - Christoph Sponholz
- Department of Anesthesiology and Intensive Care Medicine/Center for Sepsis Control and Care, Jena University Hospital, Germany
| | - Frans Cuperus
- HansPopper Laboratory of Molecular Hepatology, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria; Pediatric Gastroenterology and Hepatology, Center for Liver, Digestive, and Metabolic Diseases, University Medical Center Groningen, The Netherlands
| | - Sina M Coldewey
- Department of Anesthesiology and Intensive Care Medicine/Center for Sepsis Control and Care, Jena University Hospital, Germany
| | - Stefan H Heinemann
- Center for Molecular Biomedicine, Department of Biophysics, Friedrich Schiller University Jena & Jena University Hospital, Germany
| | - Georg Pohnert
- Institute of Inorganic and Analytical Chemistry, Bioorganic Analytics, Friedrich Schiller University Jena, Germany
| | - Michael Trauner
- HansPopper Laboratory of Molecular Hepatology, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Michael Bauer
- Department of Anesthesiology and Intensive Care Medicine/Center for Sepsis Control and Care, Jena University Hospital, Germany.
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Unconjugated free bilirubin in preterm infants. Early Hum Dev 2017; 106-107:25-32. [PMID: 28183002 DOI: 10.1016/j.earlhumdev.2017.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/23/2016] [Accepted: 01/08/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hyperbilirubinemia guidelines are based on total serum bilirubin (TSB), in combination with either gestational age (GA) or birth weight (BW), postnatal age and specific risk factors. However, TSB is a poor predictor of bilirubin-induced neurotoxicity (BIND). Free unconjugated bilirubin (UCBfree) and the UCBfree/TSB ratio are more directly related to BIND, but data on their postnatal courses are unknown. AIMS To characterize the postnatal courses of UCBfree and UCBfree/TSB ratio, and assess their relationships with clinical characteristics. SUBJECTS 72 preterm infants≤32weeks GA, admitted to the University Medical Center Groningen, The Netherlands. STUDY DESIGN During the first postnatal week, bilirubin plasma parameters were analyzed and their relationship with clinical parameters was analyzed. Postnatal changes were analyzed using Generalized Estimating Equations. Data are expressed as medians [ranges]. RESULTS Less than 10% of the cohort (GA: 29 [26-31] weeks; BW: 1165 [600-1975] g) showed hyperbilirubinemic risk factors. We observed a large variation in UCBfree (27 [1-197] nmol/L), that could partly be explained by postnatal age and gender, but not by other risk factors. Maximal UCBfree levels of 50 [13-197] nmol/L occurred at day 4 and were higher in males. In contrast to TSB, UCBfree/TSB ratios (0.19 [0.01-1.04]) were higher in infants with low GA/BW. CONCLUSION UCBfree levels vary considerably in preterm infants, despite a low incidence of hyperbilirubinemic risk factors and similar TSB-based phototherapy treatment. UCBfree could not be predicted by GA or BW, but UCBfree/TSB ratios are highest in the smallest preterms, while they have the lowest TSB levels.
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[Management of jaundice in the newborn≥35 GW: From screening to follow-up after discharge. Guidelines for clinical practice]. Arch Pediatr 2017; 24:192-203. [PMID: 28094087 DOI: 10.1016/j.arcped.2016.11.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 11/22/2016] [Accepted: 11/27/2016] [Indexed: 11/23/2022]
Abstract
Jaundice due to unconjugated bilirubin is an everyday condition in the neonatal period because it results from the adaptation of bilirubin metabolism at this time of life. Hyperbilirubinemia has a potential neurotoxicity and although it most often resolves spontaneously, it can lead to acute and sometimes chronic encephalopathy. The latter condition is called kernicterus and induces severe and irreversible neurological sequelae. This rare complication is still reported in all countries throughout the world even if severe hyperbilirubinemia can be prevented and critical points points of failure in jaundice management are identified. Jaundice management are identified, jaundice is the most frequent symptom during the first days of life and after discharge from the maternity ward but also the major cause of readmission in the 15 first days of life. Therefore in the past 20 years, numerous countries have written national practical guidelines for the management of neonatal jaundice using various methodologies. Most of the time, the guidelines resulted from expert consensus more than from an evidence-based argument. The Société française de néonatologie created a working group to provide the first French clinical guidelines for the management of jaundice in the near-term newborn (35 weeks and more). They were written following a physiopathological argument and taking into account both clinical risk factors for severe hyperbilirubinemia and interindividual variability in vulnerability to bilirubin neurotoxicity. Practical tools were also developed to facilitate implementation of the guidelines and are also included.
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Abstract
Phototherapy is the main treatment for neonatal hyperbilirubinemia. In acute treatment of extreme hyperbilirubinemia, intensive phototherapy may have a role in 'detoxifying' the bilirubin molecule to more polar photoisomers, which should be less prone to crossing the blood-brain barrier, providing a 'brain-sparing' effect. This article reviews the biology of bilirubin isomers. Although there is evidence supporting the lower toxicity of bilirubin photoisomers, there are studies showing the opposite. There are methodologic weaknesses in most studies and better-designed experiments are needed. In an infant acutely threatened by bilirubin-induced brain damage, intensified phototherapy should be used expediently and aggressively.
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Affiliation(s)
- Thor Willy Ruud Hansen
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
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Albumin administration prevents neurological damage and death in a mouse model of severe neonatal hyperbilirubinemia. Sci Rep 2015; 5:16203. [PMID: 26541892 PMCID: PMC4635426 DOI: 10.1038/srep16203] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 10/12/2015] [Indexed: 11/12/2022] Open
Abstract
Therapies to prevent severe neonatal unconjugated hyperbilirubinemia and kernicterus are phototherapy and, in unresponsive cases, exchange transfusion, which has significant morbidity and mortality risks. Neurotoxicity is caused by the fraction of unconjugated bilirubin not bound to albumin (free bilirubin, Bf). Human serum albumin (HSA) administration was suggested to increase plasma bilirubin-binding capacity. However, its clinical use is infrequent due to difficulties to address its potential preventive and curative benefits, and to the absence of reliable markers to monitor bilirubin neurotoxicity risk. We used a genetic mouse model of unconjugated hyperbilirubinemia showing severe neurological impairment and neonatal lethality. We treated mutant pups with repeated HSA administration since birth, without phototherapy application. Daily intraperitoneal HSA administration completely rescued neurological damage and lethality, depending on dosage and administration frequency. Albumin infusion increased plasma bilirubin-binding capacity, mobilizing bilirubin from tissues to plasma. This resulted in reduced plasma Bf, forebrain and cerebellum bilirubin levels. We showed that, in our experimental model, Bf is the best marker to determine the risk of developing neurological damage. These results support the potential use of albumin administration in severe acute hyperbilirubinemia conditions to prevent or treat bilirubin neurotoxicity in situations in which exchange transfusion may be required.
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Hulzebos CV, Dijk PH. Bilirubin-albumin binding, bilirubin/albumin ratios, and free bilirubin levels: where do we stand? Semin Perinatol 2014; 38:412-21. [PMID: 25304058 DOI: 10.1053/j.semperi.2014.08.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Treatment for unconjugated hyperbilirubinemia is predominantly based on one parameter, i.e., total serum bilirubin (TSB) levels. Yet, overt kernicterus has been reported in preterm infants at relatively low TSB levels, and it has been repeatedly shown that free unconjugated bilirubin (freeUCB) levels, or bilirubin/albumin (B/A) ratios for that matter, are more closely associated with bilirubin neurotoxicity. In this article, we review bilirubin-albumin binding, UCBfree levels, and B/A ratios in addition to TSB levels to individualize and optimize treatment especially in preterm infants. Methods to measure bilirubin-albumin binding or UCBfree are neither routinely performed in Western clinical laboratories nor incorporated in current management guidelines on unconjugated hyperbilirubinemia. For bilirubin-albumin binding, this seems justified because several of these methods have been challenged, and sufficiently powered prospective trials on the clinical benefits are lacking. Technological advances in the measurement of UCBfree may provide a convenient means for integrating UCBfree measurements into routine clinical management of jaundiced infants. A point-of-care method, as well as determination of UCBfree levels in various newborn populations, is desirable to learn more about variations in time and how various clinical pathophysiological conditions affect UCBfree levels. This will improve the estimation of approximate UCBfree levels associated with neurotoxicity. To delineate the role of UCBfree in the management of jaundiced (preterm) infants, trials are needed using UCBfree as treatment parameter. The additional use of the B/A ratio in jaundiced preterms has been evaluated in the Bilirubin Albumin Ratio Trial (BARTrial; Clinical Trials: ISRCTN74465643) but failed to demonstrate better neurodevelopmental outcome in preterm infants <32 weeks assigned to the study group. Awaiting a study in which infants are assigned to be managed solely on the basis of their B/A ratio (with TSB excluded ) versus TSB levels alone-and determining which group does better-the additional use of the B/A ratio in the management of hyperbilirubinemia in preterms is not advised. In conjunction with TSB levels, other parameters possibly allow for more accurate prediction of bilirubin toxicity. Yet, different methodologies for estimating these parameters exist, and sufficiently powered, prospective clinical trials supporting their clinical benefit, i.e., reduced bilirubin neurotoxicity when using these parameters, are lacking. Their use in addition to TSB needs to be prospectively evaluated, especially in preterm neonates, and preferentially in randomized clinical trials, which include specific risk factors and assessment of clinical relevant outcome measures for detecting those infants at risk of bilirubin toxicity.
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Affiliation(s)
- Christian V Hulzebos
- Department of Pediatrics, Beatrix Children׳s Hospital, University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen 9713 GZ, The Netherlands.
| | - Peter H Dijk
- Department of Pediatrics, Beatrix Children׳s Hospital, University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen 9713 GZ, The Netherlands
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Bilirubin alone as a biomarker for short-term mortality in acute-on-chronic liver failure: an important prognostic indicator. Ann Hepatol 2014. [DOI: 10.1016/s1665-2681(19)30910-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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16
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Schreuder AB, Rice AC, Vanikova J, Vitek L, Shapiro SM, Verkade HJ. Albumin administration protects against bilirubin-induced auditory brainstem dysfunction in Gunn rat pups. Liver Int 2013; 33:1557-65. [PMID: 23742048 DOI: 10.1111/liv.12219] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 05/11/2013] [Indexed: 02/13/2023]
Abstract
BACKGROUND Free bilirubin (Bf), the unbound fraction of unconjugated bilirubin (UCB), can induce neurotoxicity, including impairment of the auditory system, which can be assessed by brainstem auditory evoked potentials (BAEPs). We hypothesized that albumin might reduce the risk of neurotoxicity by decreasing Bf and its translocation into the brain. AIM To determine the effects of albumin on BAEPs and brain bilirubin content in two Gunn rat pup models of acute hyperbilirubinemia. METHODS We used Gunn rat pups, which have a deficiency of the bilirubin-conjugating enzyme UGT1A1. We induced haemolysis by injection of phenylhydrazine (phz) into 14-days old pups. Subsequently, pups were treated with either i.p. human serum albumin (HSA; 2.5 g/kg; n = 8) or saline (control, n = 8). We induced acute neurotoxicity by injecting 16-days old pups with sulphadimethoxine (sulpha) and treated them with either HSA (n = 9) or saline (control, n = 10). To assess bilirubin neurotoxicity, we used the validated BAEP method and compared relevant parameters; i.e. peak latency values and interwave interval (IWI) between peak I and peak II, a marker of acute neurotoxicity. RESULTS Phz and sulpha significantly increased IWI I-II by 26% and 29% (P < 0.05) in the haemolysis and the displacement model, respectively. Albumin completely prevented the increase of IWI I-II in either model. The beneficial effect of albumin in the displacement-model by means of normal BAEPs was in line with less bilirubin in the brain (NS). Interestingly, in the haemolysis model the accumulation of total bilirubin in the brain was unaltered, and BAEPs still appeared normal. This might advocate for a role of brain Bf which was calculated and showed that albumin treatment non-significantly reduces Bf concentrations in brain, compared with saline treatment. CONCLUSIONS Albumin treatment is neuroprotective in acute hyperbilirubinemia in Gunn rat pups. Our present results underline the importance of functional diagnostic test of neurotoxicity above biochemical concentrations.
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Affiliation(s)
- Andrea B Schreuder
- Pediatric Gastroenterology and Hepatology, Department of Pediatrics, Center for Liver, Digestive, and Metabolic Diseases, University of Groningen, Beatrix Children's Hospital - University Medical Center Groningen, Groningen, the Netherlands
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17
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Schreuder AB, Vanikova J, Vitek L, Havinga R, Ahlfors CE, Hulzebos CV, Verkade HJ. Optimizing exchange transfusion for severe unconjugated hyperbilirubinemia: studies in the Gunn rat. PLoS One 2013; 8:e77179. [PMID: 24143211 PMCID: PMC3797100 DOI: 10.1371/journal.pone.0077179] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 09/06/2013] [Indexed: 01/21/2023] Open
Abstract
Background Severe unconjugated hyperbilirubinemia carries the risk of neurotoxicity. Phototherapy (PT) and exchange transfusion (ET) are cornerstones in the treatment of unconjugated hyperbilirubinemia. Studies to improve ET efficacy have been hampered by the low application of ET in humans and by the lack of an in vivo model. The absence of an appropriate animal model has also prevented to determine the efficacy of adjunct or alternative treatment options such as albumin (Alb) administration. Aim To establish an in vivo model for ET and to determine the most effective treatment (combination) of ET, PT and Alb administration. Methods Gunn rats received either PT, PT+Alb, ET, ET+PT, ET+PT+Alb or sham operation (each n = 7). ET was performed via the right jugular vein in ∼20 min. PT (18 µW/cm2/nm) was started after ET or at T0. Albumin i.p. injections (2.5 g/kg) were given after ET or before starting PT. Plasma unconjugated bilirubin (UCB), plasma free bilirubin (Bf), and brain bilirubin concentrations were determined. Results We performed ET in 21 Gunn rats with 100% survival. At T1, ET was profoundly more effective in decreasing both UCB −44%, p<0.01) and Bf −81%, p<0.05) than either PT or PT+Alb. After 48 h, the combination of ET+PT+Alb showed the strongest hypobilirubinemic effect (−54% compared to ET). Conclusions We optimized ET for severe unconjugated hyperbilirubinemia in the Gunn rat model. Our data indicate that ET is the most effective treatment option, in the acute as well as the follow-up situation.
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Affiliation(s)
- Andrea B. Schreuder
- Pediatric Gastroenterology and Hepatology, Department of Pediatrics, Center for Liver, Digestive, and Metabolic Diseases, Beatrix Children’s Hospital - University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jana Vanikova
- Institute of Medical Biochemistry and Laboratory Diagnostics, 1st Faculty of Medicine, Charles University, Prague 2, Czech Republic
| | - Libor Vitek
- Institute of Medical Biochemistry and Laboratory Diagnostics, 1st Faculty of Medicine, Charles University, Prague 2, Czech Republic
- 4th Department of Internal Medicine, 1st Faculty of Medicine, Charles University, Prague 2, Czech Republic
| | - Rick Havinga
- Pediatric Gastroenterology and Hepatology, Department of Pediatrics, Center for Liver, Digestive, and Metabolic Diseases, Beatrix Children’s Hospital - University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Charles E. Ahlfors
- Stanford University, School of Medicine, Stanford, California, United States of America
| | - Christian V. Hulzebos
- Neonatology, Department of Pediatrics, Beatrix Children’s Hospital - University Medical Center Groningen, Groningen, The Netherlands
| | - Henkjan J. Verkade
- Pediatric Gastroenterology and Hepatology, Department of Pediatrics, Center for Liver, Digestive, and Metabolic Diseases, Beatrix Children’s Hospital - University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- * E-mail:
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