Wavelength-dependence of the relative rate constants for the main geometric and structural photoisomerization of bilirubin IX alpha bound to human serum albumin. Demonstration of green light at 510 nm as the most effective wavelength in photochemical changes from (ZZ)-bilirubin IX alpha to (EZ)-cyclobilirubin IX alpha via (EZ)-bilirubin

Quantitative effects of bilirubin structural photoisomers on the measurement of direct bilirubin via the vanadate oxidation method

BACKGROUND

Exposing blood serum samples to ambient white light-emitting diode (WLED) light may accelerate bilirubin photoisomer production. We previously demonstrated the quantitative effect of bilirubin configurational isomers (BCI) on direct bilirubin (DB) value using the vanadate oxidation method. However, the effects of bilirubin structural photoisomers (BSI) remain unclear.

METHODS

In Study 1, the relationship between WLED irradiation time and BSI production was examined. Serum samples from five neonates were irradiated with WLED light for 0, 10, 30, 60 and 180 min. Bilirubin isomer concentration and BSI production rates were calculated. In Study 2, we performed quantitative investigation of BSI effect on DB values: Differences in DB, BCI and BSI values before and after irradiation were calculated as ⊿DB, ⊿BCI and ⊿BSI, respectively. Assuming the coefficient of BCI affecting DB values was 'a', relational expression was ⊿DB = a*⊿BSI + 0.19*⊿BCI. Serum samples from 15 neonates were irradiated with green LED light for 10 and 30 s. The respective bilirubin isomer levels were measured, and the coefficient was derived.

RESULTS

In Study 1, the median BSI production rate was 0.022 mg/dL per min in specimens with an unconjugated bilirubin concentration of 10.88 mg/dL. In Study 2, assuming that ⊿DB-0.19*⊿BCI was Y and ⊿BSI was X, the relational expression was Y = 0.34X-0.03 (R² = 0.87; p < .01) and a = 0.34.

CONCLUSIONS

Under ambient WLED light, serum sample generated 1.3 mg/dL BSIs in 1 h. Approximately 34% (0.44 mg/dL) of BSI concentrations was measured as DB when using the vanadate oxidation method according to the above equation.

Fetal and neonatal bilirubin metabolism

Human fetal and neonatal bilirubin metabolism is centered on 4Z,15Z-bilirubin IXα (BR) due to the extremely low BR conjugating capacity of the liver. BR is a unique, highly lipophilic substance with physiological and toxic effects in the cell membranes of organs and body tissues. The fetus excretes BR through the placenta to the maternal circulation. After birth, BR is thought to act as an antioxidant against the increase in reactive oxygen species caused by the rapid increase in oxygen concentration during the adaptation process from in amniotic fluid to in air. However, bilirubin encephalopathy is a toxic effect of bilirubin. Due to the lipophilic nature of BR, it must be bound to a carrier to be distributed to various parts of the body by hydrophilic blood. This carrier of BR is human serum albumin (HSA). In humans, BR can be excreted efficiently after undergoing photochemical reactions upon high affinity binding to HSA. HSA also plays an important role in the prevention of bilirubin encephalopathy. This review focuses on the developmental and physiological role of bilirubin metabolism during the fetal and neonatal periods.

Blue-Green (~480 nm) versus Blue (~460 nm) Light for Newborn Phototherapy-Safety Considerations

We have previously shown that the phototherapy of hyperbilirubinemic neonates using blue-green LED light with a peak wavelength of ~478 nm is 31% more efficient for removing unconjugated bilirubin from circulation than blue LED light with a peak wavelength of ~452 nm. Based on these results, we recommended that the phototherapy of hyperbilirubinemic newborns be practiced with light of ~480 nm. Aim: Identify and discuss the most prominent potential changes that have been observed in the health effects of phototherapy using either blue fluorescent- or blue LED light and speculate on the expected effects of changing to blue-green LED light phototherapy. Search the phototherapy literature using the terms neonate, hyperbilirubinemia, and phototherapy in the PubMed and Embase databases. Transitioning from blue fluorescent light to blue-green LED light will expose neonates to less light in the 400-450 nm spectral range, potentially leading to less photo-oxidation and geno-/cytotoxicity, reduced risk of cancer, and decreased mortality in extremely low-birthweight neonates. The riboflavin level may decline, and the increased production and retention of bronze pigments may occur in predisposed neonates due to enhanced lumirubin formation. The production of pre-inflammatory cytokines may rise. Hemodynamic responses and transepidermal water loss are less likely to occur. The risk of hyperthermia may decrease with the use of blue-green LED light and the risk of hypothermia may increase. Parent-neonate attachment and breastfeeding will be positively affected because of the shortened duration of phototherapy. The latter may also lead to a significant reduction in the cost of phototherapy procedures as well as the hospitalization process.

Action spectrum of phototherapy in hyperbilirubinemic neonates

BACKGROUND

Phototherapy with blue light matching plasma absorption spectrum of the bilirubin-albumin complex with peak at 460 nm is standard treatment of neonatal hyperbilirubinemia.

AIM

To demonstrate clinically the action (efficacy) spectrum of phototherapy in hyperbilirubinemic neonates, through determination of the fraction of total serum bilirubin (TSB) decreased by phototherapy with peak emission wavelengths ≥478 nm (blue-green) compared with that of light of 459/452 nm (blue).

METHODS

TSB values were compiled from three earlier trials, in which hyperbilirubinemic neonates were randomized to receive 24 h of either blue-green light (478/490/497 nm) (intervention groups) or blue light (459/452/459 nm) (control groups) with equal irradiance and exposed body surface areas. Ratios (efficacy) between the decrease in TSB between intervention and control groups were calculated and graphed versus peak wavelengths, demonstrating the course of the action spectrum.

RESULTS

Calculated efficacy ratios were 1.31, 1.18, and 1.04 for light with peak wavelengths of 478, 490, and 497 nm, respectively. The action spectrum increases from 452/459 to maximum at 478 nm, from where it decreases to 1.18 and finally to 1.04.

CONCLUSION

For optimal phototherapeutic treatment, neonates need to be exposed to light with peak wavelength some 20 nm longer than is presently used.

IMPACT

The action (efficacy) spectrum of phototherapy for hyperbilirubinemic neonates has its peak wavelength at 478 nm. The peak wavelength of this action spectrum is 20 nm longer than the wavelength presently believed to be most efficient. The peak is also different from the peak found in vitro. For optimal phototherapeutic effect, neonates need to be treated with light of wavelengths some 20 nm longer than are presently used.

Characteristics of bilirubin photochemical changes under green light-emitting diodes in humans compared with animal species

Phototherapy using light-emitting diodes (LEDs) centered on the green spectrum, which has a high cyclobilirubin production rate, was as effective as that centered on the blue spectrum for neonatal hyperbilirubinemia. There are no reports of species differences in bilirubin photochemical changes in this spectrum, and the characteristics of bilirubin photochemical changes in humans must be elucidated to proceed with the development of new light sources that include these spectra. This report describes the characteristic photochemical kinetics of bilirubin under green-spectrum LEDs in human, rat, rabbit, dog, pig, sheep, bovine and chicken serum albumin and rhesus monkey serum. These albumin-bilirubin complex solutions were irradiated by green LEDs, and the time-course changes in bilirubin photoisomers were measured by high-performance liquid chromatography. The cyclobilirubin production rates in humans, pigs, and monkeys were significantly higher than those in other species. The rate constant of (EZ)-cyclobilirubin production from (EZ)-bilirubin 'k' was significantly higher in humans and monkeys than in other species. In conclusion, bilirubin photochemical kinetics under green spectrum LEDs in humans were characterized by a high cyclobilirubin production rate at a low substrate concentration. The bilirubin photochemical kinetics in monkeys were similar to those in humans.

Effects of bilirubin configurational photoisomers on the measurement of direct bilirubin by the vanadate oxidation method

BACKGROUND

Direct-reacting bilirubin concentrations measured using vanadate chemical oxidation method do not exactly match the conjugated bilirubin concentration. One of the causes is the effect of bilirubin photoisomers. However, the quantitative evaluation of the effects of these photoisomers has not been sufficiently conducted. In particular, the influence of bilirubin configurational isomers on direct bilirubin is the most critical factor.

METHODS

Sixteen residual serum samples were used. For quantitative analysis based on the change in direct bilirubin and bilirubin configurational isomer, samples were irradiated via blue light-emitting diodes to suppress the production of bilirubin structural isomers. Total bilirubin and direct bilirubin concentrations were measured using the vanadate chemical oxidation method. Concentrations of 4Z,15Z-bilirubin IXα and its photoisomers were measured using high-performance liquid chromatography. The sum of 4Z,15E-bilirubin IXα and 4E,15Z-bilirubin IXα was notated as bilirubin configurational isomer, and the differences between the measured values of the irradiated and non-irradiated samples were calculated and notated as ΔDB and ΔBCI.

RESULTS

In non-irradiated and irradiated samples, total bilirubin and direct bilirubin concentrations were 10.73 mg/dL with significant a decrease to 10.60 mg/dL and 0.69 mg/dL with a significant increase to 0.78 mg/dL, while bilirubin configurational isomer values were 1.00 mg/dL and 1.52 mg/dL, respectively. The linear regression equation revealed a significant positive correlation of Y = 0.187X-0.006 between ΔDB (Y) and ΔBCI (X).

CONCLUSION

Applying the vanadate chemical oxidation method affected approximately 19% of the bilirubin configurational isomer concentration for direct bilirubin. Extreme caution is necessary when interpreting the measured values of samples indicative of unconjugated hyperbilirubinaemia.

The effectiveness of phototherapy using blue-green light for neonatal hyperbilirubinemia - Danish clinical trials

The effectiveness of phototherapy for neonatal hyperbilirubinemia based on Danish clinical trials is presented. Randomized controlled trials on the quality of light showed that blue-green fluorescent light (peak emission at 490 nm) was more efficient than blue fluorescent light (peak emission at 452 nm); blue-green light-emitting diode (LED) light (peak emission at 478 nm) was more efficient than blue LED light (peak emission at 459 nm); and blue-green LED light (peak emission at 497 nm) was equivalent to blue LED light (peak emission at 459 nm). Bilirubin-reducing effects correlated with irradiance, dependent on hemoglobin concentration, and independent of rotating infants. Phototherapy from both above and below was more efficient than therapy applied only from above at high levels of irradiance. In conclusion, we estimate and recommend the use of blue-green LED light (peak emission at 480 nm) rather than blue light (peak emission at 460 nm) for treating of neonatal hyperbilirubinemia.

Standardization of phototherapy for neonatal hyperbilirubinemia using multiple-wavelength irradiance integration

BACKGROUND

Phototherapy with radiation of 460-490 nm wavelengths provides the most potent therapeutic effect for neonatal jaundice. However, the efficacy of phototherapy has been estimated using single-wavelength detectors with sensitivity at approximately 460 nm. Cyclobilirubin formation capacity (CFC), which comprises the sum of the irradiance values from three wavelengths multiplied by their specific coefficients, has been proposed as an alternative marker to evaluate the efficacy of phototherapy. This study aimed to test whether two types of phototherapy devices with distinct spectral characteristics provide similar therapeutic effects on adjustment of device-to-patient distances to deliver similar CFCs.

METHODS

Using a three-wavelength spectroradiometer, CFCs and footprints of the light-emitting diode and fluorescent tube devices were assessed. Having determined the device-specific distances that ensured similar CFCs, 32 newborn infants, requiring phototherapy for hyperbilirubinemia, were randomized into the light-emitting diode and fluorescent tube groups. The total serum bilirubin levels before and after phototherapy were assessed.

RESULTS

The light-emitting diode and fluorescent tube devices had comparable CFCs at distances of 60 and 50 cm, respectively. Phototherapy reduced the total serum bilirubin levels from 18.1 to 14.6 mg/dL and from 19.1 to 15.1 mg/dL in the light-emitting diode and fluorescent tube groups, respectively. The two groups did not differ significantly with respect to the patients' clinical backgrounds, serum bilirubin levels, or changes before and after phototherapy.

CONCLUSION

At similar CFCs, the two phototherapy devices reduced the total serum bilirubin levels by comparable amounts. Hence, determining CFCs may help predict phototherapy efficacy. This may ensure better safety and greater efficacy of the treatment for newborn infants.

The effect of light wavelength on in vitro bilirubin photodegradation and photoisomer production

BACKGROUND

The action spectrum for bilirubin photodegradation has been intensively studied. However, questions still remain regarding which light wavelength most efficiently photodegrades bilirubin. In this study, we determined the in vitro effects of different irradiation wavelength ranges on bilirubin photodegradation.

METHODS

In our in vitro method, normalized absolute irradiance levels of 4.2 × 10¹⁵ photons/cm²/s from light-emitting diodes (ranging from 390-530 nm) and 10-nm band-pass filters were used to irradiate bilirubin solutions (25 mg/dL in 4% human serum albumin). Bilirubin and its major photoisomer concentrations were determined; the half-life time of bilirubin (t_1/2) was calculated for each wavelength range, and the spectral characteristics for bilirubin photodegradation products were obtained for key wavelengths.

RESULTS

The in vitro photodegradation of bilirubin at 37 °C decreased linearly as the wavelength was increased from 390 to 500 nm with t_1/2 decreasing from 63 to 17 min, respectively. At 460 ± 10 nm, a significantly lower rate of photodegradation and thus higher t_1/2 (31 min) than that at 500 nm (17 min) was demonstrated.

CONCLUSION

In our system, the optimum bilirubin photodegradation and lumirubin production rates occurred between 490 and 500 nm. Spectra shapes were remarkably similar, suggesting that lumirubin production was the major process of bilirubin photodegradation.

Green light-emitting diode phototherapy for neonatal hyperbilirubinemia: Randomized controlled trial

BACKGROUND

The main photochemical pathway in phototherapy for neonatal hyperbilirubinemia is the production and elimination (in bile or urine) of cyclobilirubin, which is a structural photoisomer of bilirubin, and which is most efficiently produced by green light. Green light-emitting diode (LED) phototherapy, however, has not been evaluated in the clinical setting because it is not recommended in American Academy of Pediatrics guidelines. We therefore compared the efficacy of green LED phototherapy and blue LED phototherapy in patients with neonatal hyperbilirubinemia.

METHODS

In this prospective randomized controlled trial, neonates with hyperbilirubinemia were randomly allocated to a green LED or blue LED phototherapy group. Both groups underwent 24 h of phototherapy, and blood was sampled before and after 24 h of phototherapy. Total serum bilirubin (TSB) was measured using enzymatic methods and bilirubin photoisomers were measured on high-performance liquid chromatography.

RESULTS

Thirty-four infants were randomized (green, n = 16; blue, n = 18). TSB decreased significantly from 15.3 ± 1.5 to 13.9 ± 1.5 mg/dL in the green LED group (P < 0.01) and from 16.2 ± 1.3 to 14.5 ± 1.7 mg/dL in the blue LED group (P < 0.01) after 24 h of phototherapy. No significant difference was found in TSB reduction after phototherapy between the groups.

CONCLUSIONS

Both light sources produced a significant reduction in TSB, indicating clinical effectiveness.

Phototherapy for neonatal hyperbilirubinemia

Approximately 60 years ago in England, phototherapy for neonatal hyperbilirubinemia was used in clinical practice. It was introduced in Japan approximately 50 years ago. At that time, the mechanism underlying the serum bilirubin concentration decrease by phototherapy was still unknown. The mechanism was identified by chemists, biochemists, and pediatricians. Clarification started with the report that unconjugated bilirubin was excreted into bile after photoirradiation in Gunn rats. After confirmation of the molecular structure of bilirubin on X-ray analysis, the mechanism for bile excretion of unconjugated bilirubin was verified based on geometric configurational photoisomers in the Gunn rat. Finally, the reaction and excretion of structural bilirubin photoisomers was proved to be the main mechanism for the decrease in serum bilirubin during phototherapy for neonatal hyperbilirubinemia, which differs from the mechanism in the Gunn rat. The most effective and safest light source and the optimal method to evaluate phototherapy, however, remain unknown. Moreover, as for bronze baby syndrome, which is a well-known adverse reaction to phototherapy, the etiology is unclear. Hence, we review phototherapy for hyperbilirubinemia including a fundamental understanding of the bilirubin photochemical reactions, and discuss the subclinical carcinogenic risk of phototherapy and the increased mortality rate of extremely low-birthweight infants due to aggressive phototherapy, which is becoming an increasing problem.

Reactivity of bilirubin photoisomers on the measurement of direct bilirubin using vanadic acid method

Objective

Investigation of the reactivity of fractions of bilirubin photoisomers with the vanadic acid oxidation method.

Methods

Bilirubin photoisomers were prepared by irradiating a bilirubin/human serum albumin solution with blue light emitting diode. Direct bilirubin and bilirubin fractions were measured using the vanadic acid oxidation method and high-performance liquid chromatography in the sample before and after irradiation.

Results

Direct bilirubin was increased in the solution containing bilirubin photoisomers. ( EE)-/( EZ) -cyclobilirubin-IXα and ( ZE)-/( EZ)-bilirubin-IXα completely disappeared after the addition of vanadic acid.

Conclusion

Bilirubin photoisomers reacted as direct bilirubin in the vanadic acid oxidation method.

Bilirubin isomer distribution in jaundiced neonates during phototherapy with LED light centered at 497 nm (turquoise) vs. 459 nm (blue)

BACKGROUND

Phototherapy using blue light is the treatment of choice worldwide for neonatal hyperbilirubinemia. However, treatment with turquoise light may be a desirable alternative. Therefore, the aim of this randomized, controlled study was to compare the bilirubin isomer distribution in serum of jaundiced neonates after 24 h of therapy with narrow-band (LED) light centered at 497 nm (turquoise) vs. 459 nm (blue), of essentially equal irradiance.

MATERIALS

Eighty-three neonates (≥33 wk gestational age) with uncomplicated hyperbilirubinemia were included in the study. Forty neonates were exposed to light centered at 497 nm and 43 infants with light centered at 459 nm. Irradiances were 5.2 × 10(15) and 5.1 × 10(15) photons/cm(2)/s, respectively.

RESULTS

After 24 h of treatment no significant differences in serum concentrations of total bilirubin isomers and Z,Z-bilirubin were observed between the 2 groups. Interestingly, concentrations of Z,E-bilirubin, and thus also total bilirubin isomers formed during therapy, were highest for infants receiving light centered at 459 nm, while the concentration of E,Z-bilirubin was highest for those receiving light centered at 497 nm. No significant difference was found between concentrations of E,Z-lumirubin.

CONCLUSION

Therapy with LED light centered at 497 nm vs. 459 nm, applied with equal irradiance on the infants, resulted in a different distribution of bilirubin isomers in serum.

Influence of bilirubin photoisomers on unbound bilirubin measurement in clinical settings

Background

Measured unbound bilirubin concentration is influenced by bilirubin photoisomers. Bilirubin photoisomers are produced even with only a slight light exposure, and clinical samples are inevitably exposed to light. The objective of the study was to evaluate the influence of bilirubin photoisomers on the measurement of unbound bilirubin using serum of jaundiced neonates during blue light phototherapy.

Methods

Five neonates treated with phototherapy for hyperbilirubinaemia were enrolled. The samples were taken 12 h after initiation of phototherapy. Samples were processed by irradiation with blue light, by indoor ceiling light, by both blue light and indoor ceiling light or shaded. Bilirubin subfractions, total bilirubin and unbound bilirubin were measured.

Results

Compared with the non-irradiated samples, the (EZ)-cyclobilirubin concentration and (ZE)-bilirubin/(ZZ)-bilirubin ratio significantly increased in the blue light-irradiated samples, the (ZE)-bilirubin/(ZZ)-bilirubin ratio significantly increased in the indoor ceiling light-irradiated samples, and the (EZ)-cyclobilirubin, (EZ)-bilirubin and (ZE)-bilirubin/(ZZ)-bilirubin ratio significantly increased in the samples irradiated with both lights. No change was noted in unbound bilirubin in any group.

Conclusions

We consider that changes in bilirubin photoisomers induced by light exposure during clinical practice do not influence the measured unbound bilirubin concentration.

Initial photochemistry of bilirubin probed by femtosecond spectroscopy

Bilirubin is a breakdown product from heme catabolism, and reduced excretion of bilirubin can lead to jaundice. Phototherapy is the most common treatment for neonatal jaundice, a condition frequently encountered in newborn infants. Knowledge of the photochemistry of bilirubin, which is dominated by (ultra)fast components, is necessary for the profound understanding of the processes in phototherapy. Here, we report results from femtosecond fluorescence upconversion measurements on bilirubin and half-bilirubin model compounds, as well as pump-probe absorption measurements on bilirubin. A fast component of ca. 120 fs in the multiexponential fluorescence decay, being only visible in the bilirubin molecule, is interpreted as exciton localization within the molecular halves. The slower components of several hundreds of femtoseconds and a few picoseconds, occurring in bilirubin and the half-bilirubin model, are interpreted as relaxation to a (twisted) intermediate, which decays further with ca. 15 ps to the ground state.

PLGA-microsphere mediated clearance of bilirubin in temporarily hyperbilirubinemic rats: An alternate strategy for the treatment of experimental jaundice

In the present study, we have demonstrated the suitability of microspheres in removal of plasma bilirubin from systemic circulation of hyperbilirubinemic rats. Poly (lactide co-glycolide) microspheres (PLGA microspheres) have been shown to bind with bilirubin in both a concentration and time dependent manner. The binding affinity of bilirubin to microspheres was enhanced when rat serum albumin (RSA) was loaded into the microspheres. On evaluating the potential of microspheres in elimination of bilirubin from the systemic circulation, RSA bearing microspheres were found to be competent in both removing bilirubin from the systemic circulation and controlling elevated plasma levels of liver function enzymes in temporarily hyperbilirubinemic rats. On the basis of results of the present study, we suggest that microsphere-based delivery system may help in development of safe, effective and alternate strategy for the treatment of hyperbilirubinemic conditions in model animals.

Formation of photoproducts and cytotoxicity of bilirubin irradiated with turquoise and blue phototherapy light

AIM

To compare a new turquoise ("green") fluorescent phototherapy lamp (490 nm) with a conventional blue phototherapy lamp (450 nm) with respect to cytotoxicity and photochemical effects of bilirubin.

METHODS

Mouse lymphoma cells (L5178Y-R) in the presence of bilirubin solutions were exposed to phototherapy light. Occurrence of necrosis and apoptosis, reduction of mitotic index and inhibited cell growth was assayed by appropriate methods. The presence of bilirubin and its photoisomers was measured by high-pressure liquid chromatography analysis and absorption spectroscopy.

RESULTS

At constant and equal light irradiances, the cytotoxic effects in the presence of bilirubin bound to human serum albumin showed that the green lamp caused significantly less necrosis (n = 4, p < 0.05) and less inhibition of cell multiplication (n = 3, p < 0.05) than the blue lamp. A slightly lower apoptotic fraction, although not statistically significant, was observed in cells exposed to the blue lamp. Photo-oxidation of bilirubin was more prominent with blue light irradiation. The photoequilibria between geometric isomers of bilirubin were different for the two lamps; more geometric photoisomers were formed by blue irradiation (n = 6, p < 0.05). The amounts of the most water-soluble isomers (presumably mainly lumirubin) were rather similar for the two lamps.

CONCLUSION

The two lamps were similar in the formation of therapeutically relevant photoproducts, but the blue lamp showed potential in forming more photo-oxidation products and in causing more severe cellular damage in the presence of bilirubin.

Change of bilirubin photoisomers in the urine and serum before and after phototherapy compared with light source

BACKGROUND

The clinical effect of phototherapy for neonatal hyperbilirubinemia is based on the production and elimination of cyclobilirubin. Generally, the clinical effect of light sources is estimated by the reduction in the total serum bilirubin level. One procedure with less invasiveness than blood collecting is urine collection. Whether the effectiveness of light sources used for phototherapy could be assessed using measurements of bilirubin photoisomers in urine was studied.

METHODS

This study was a retrospective analysis of 38 term infants with hyperbilirubinemia who underwent phototherapy. Bilirubin fractions in serum and urine before and 24 h after the phototherapy were measured by high-performance liquid chromatography. The light sources used for the phototherapy were blue-white light (n = 11), Biliblanket plus high output (n = 13) or green light (n = 14). The relationships between serum and urine bilirubin photoisomers after phototherapy and whether the levels of urine bilirubin photoisomer are affected by the light sources with different wavelength characteristic were analyzed.

RESULTS

There was no correlation between serum (ZE)-bilirubin and urine configurational isomers, but a weak positive correlation between serum (EZ)-cyclobilirubin and urine structural isomers after phototherapy. Although serum (ZE)-bilirubin levels depended on the wavelength characteristic of each light source during phototherapy, the urine configurational isomer levels did not depend on it. The increase in serum (EZ)-cyclobilirubin levels and the urine structural isomer levels were mostly in agreement.

CONCLUSIONS

The urine bilirubin structural isomers may be used to estimate the serum (EZ)-cyclobilirubin levels and to evaluate the clinical effects of light sources.

Liposome‐Bilirubin Interaction: A Novel Strategy to Eliminate Bilirubin from Systemic Circulation

In the present study, we established the role of liposomes in removal of bilirubin from systemic circulation of the hyperbilirubinemic rats. Bilirubin has been demonstrated to possess inherent tendency to interact with liposomes through ionic as well as hydrophobic interactions. The size as well as lamellarity of the liposomes does not seem to affect their binding with bilirubin. However, the charge on the surface of liposomes plays an important role in bilirubin-liposome interaction, e.g., bilirubin binds more extensively with positively charged liposomes as compared to the neutral or negatively charged liposomes. The present study further demonstrates that liposomes were effective in reducing the increased plasma bilirubin level in hyperbilirubinemic model animals as well. The results of the study suggest that positively charged liposome-mediated selective homing of excess plasma bilirubin to the hepatocytes seems to offer an important strategy in management of hyperbilirubinemic conditions.

Binding of bilirubin with albumin-coupled liposomes: implications in the treatment of jaundice

In the present study, we demonstrated the suitability of liposomes as a method of removing plasma bilirubin in hyperbilirubinemic rats. The liposomes have innate tendency to bind with bilirubin through hydrophobic interaction. Among different types of liposomes, the positively charged liposomes were found to have maximum affinity to free bilirubin. However, the entrapment or coupling of serum albumin on the surface of egg phosphatidylcholine liposomes can render a several-fold increase in their bilirubin binding capacity. The proteoliposomes were able to preferentially bind with bilirubin even in the presence of erythrocytes. Interestingly, these liposomes were found to displace bilirubin bound on the surface of erythrocytes as well. The results of the present study further demonstrate that albumin-bearing liposomes were equally effective in removing plasma bilirubin in experimental jaundiced animals. These observations indicate that liposome-mediated selective homing of excess plasma bilirubin to the liver cells (cf. hepatocytes) may help in the development of safer strategy for the treatment of hyperbilirubinemic conditions in the model animals.

Cyclobilirubin formation by in vitro photoirradiation with neonatal phototherapy light

BACKGROUND

The main mechanism of phototherapy for neonatal hyperbilirubinemia is the production and excretion of (EZ)- and (EE)-cyclobilirubin (4E,15Z- and 4E,15E-cyclobilirubin). Thus, the clinical efficacy of the light source for phototherapy must be evaluated by cyclobilirubin formation from (ZZ)-bilirubin in in vitro photoirradiation.

METHODS

In the present study, we investigated the in vitro production pattern of bilirubin photoisomers by phototherapy light from the bilirubin-human serum albumin complex.

RESULTS

No clear difference was found in the curves relative to (ZZ)-bilirubin and its photoisomers under aerobic and anaerobic conditions. The ratio of (EZ)-cyclobilirubin to (ZZ)-bilirubin increased proportionately to the dose of irradiating light and no photoequilibrium state was observed analogous to that found in configurational photoisomerization. The concentration of (EZ)- and (EE)-cyclobilirubin increased proportionately with the grade of the percentage decrease in A(460 nm) from 0 to 23%. With a percentage decrease in A(460 nm) of 23% or more, the cyclobilirubin concentrations reached a steady state. The reason for this appears to be that the concentration of (ZZ)-bilirubin, a substrate for photoisomers, dropped below 1 mg/100 mL. Biliverdin was produced only in trace amounts. However, the absorption at 520--700 nm increased after a percentage decrease in A(460 nm) of more than 23%.

CONCLUSIONS

The results of the present study show that little bilirubin photooxidation occurred with in vitro aerobic photoirradiation. Before the concentration of cyclobilirubin reaches a steady state, it is theoretically valid to use the percentage decrease in A(460 nm) for the evaluation of the clinical efficacy of the light source.

Accurate and sensitive high-performance liquid chromatographic method for geometrical and structural photoisomers of bilirubin IX alpha using the relative molar absorptivity values

It has been reported that considerable differences exist between the relative molar absorptivity values of the geometrical and structural photoisomers of bilirubin. We have devised an accurate HPLC method for photoisomer quantification based on the following principle: the sum of both the integrated peak areas corrected by each factor for each photoisomer, and the integrated peak area of unchanged (ZZ)-bilirubin [(ZZ)-B] after an anaerobic photoirradiation, should be constant and equal to the integrated peak area of initial (ZZ)-bilirubin [(ZZ)-Bi] before photoirradiation. On this basis, the following equation can be used to determine each factor. [equation: see text] alpha, beta, gamma and delta represent the factors used to correct the integrated peak areas of individual bilirubin photoisomers, and they are arranged in the order of the formula. It was demonstrated that the relative 455 nm molar absorptivity values for (ZZ)-bilirubin and all its geometrical and structural photoisomers, i.e., (ZZ)-bilirubin, (ZE)-bilirubin (EZ)-bilirubin, (EZ)-cyclobilirubin (= lumirubin) and (EE)-cyclobilirubin in the HPLC eluent, are, respectively, 1.0, 0.81 (= alpha), 0.54 (= beta), 0.47 (= gamma) and 0.39 (= delta).

Influence of photoisomers in bilirubin determinations on Kodak Ektachem and Hitachi analysers in neonatal specimens study of the contribution of structural and configurational isomers

We compared data obtained with the Kodak Ektachem and Hitachi 717 Analysers and HPLC from 83 neonates under phototherapy. Total bilirubin values determined with the Kodak and Hitachi are in good agreement, but we observed a large discrepancy in the results for conjugated (Kodak) and direct (Hitachi) bilirubin. HPLC revealed that all the samples contained configurational isomers, while only 7.7% and 30.8% contained conjugated bilirubin and structural isomers, respectively. We developed a device for the specific and quantitative production of configurational or structural isomers, by irradiation with blue or green light. In vitro, total bilirubin values are coherent for the routine analysers in the presence of configurational or structural isomers. With configurational isomers, unconjugated bilirubin (Kodak) is lower than total bilirubin (Kodak), and conjugated bilirubin (Kodak) is always equal to zero, so the apparatus gives a false positive response for delta bilirubin. In contrast, the direct bilirubin (Hitachi) is constant. Furthermore, in the presence of structural isomers, unconjugated bilirubin (Kodak) is unexpectedly higher than total bilirubin (Kodak), conjugated bilirubin (Kodak) is proportional to the quantity of these isomers, and direct bilirubin (Hitachi) is constant. The contribution of photoisomers in bilirubin measurements is discussed.

Cells, bilirubin and light: formation of bilirubin photoproducts and cellular damage at defined wavelengths

Cultured cells from one human and one murine cell line were treated with bilirubin and irradiated with visible light of different wavelengths, either from phototherapy lamps or from a Xenon/Mercury lamp equipped with a monochromator. Bilirubin bound to human serum albumin was also irradiated with light. After irradiation, the bilirubin and its photoisomers were extracted and analysed with High Pressure Liquid Chromatography. The formation of single strand breaks in the DNA of treated cells was studied using a fluorescence marker. Cytotoxicity in the mouse skin cell line was measured by loss of the ability to form visible colonies in vitro. Green light exposure favours the production of lumirubin, while blue light causes more DNA damage and cytotoxicity. Green light may be more efficient and safer than shorter wavelength exposure when treating jaundiced newborns with phototherapy.

Bilirubin bound to cells does not form photoisomers

Cultured cells from one human and one murine cell line were incubated with bilirubin by different methods that allowed bilirubin to be bound to cells. The cells were irradiated with visible light of different wavelengths. Bilirubin bound to human serum albumin was also irradiated with light. After irradiation, bilirubin and its photoisomers were extracted and analyzed by HPLC. No photoisomers were found in samples of irradiated cells, while the types and amounts of photoisomers that were expected from the literature were found in samples of irradiated bilirubin/albumin mixtures. We conclude that the formation of therapeutically active photoisomers during phototherapy most probably does not take place in skin cells, but most likely in bilirubin bound to albumin in the vessels or in the interstitial space.

Wavelength-dependent quantum yield for Z----E isomerization of bilirubin complexed with human serum albumin

The quantum yield, phi ZE, for configurational photoisomerization (4Z,15Z----4Z,15E) of bilirubin bound non-covalently to human serum albumin was determined (at 23 +/- 2 degrees C) by laser excitation and chromatographic analysis of products. Values obtained for photoexcitation at 465 nm were about one-half those previously reported. The quantum yield was dependent on excitation wavelength, decreasing from a value of 0.109 +/- 0.010 for excitation at 457.9 nm to a value of 0.054 +/- 0.005 for excitation at 514.5 nm. The wavelength dependence is consistent with rapid transfer of excitation energy between the two non-identical pyrromethenone chromophores of bilirubin in the singlet excited state. Since the quantum yields for photoisomerization and luminescence of bilirubin bound to serum albumin at room temperature are both low, internal conversion processes, rather than Z----E configurational isomerizations, are probably the major pathways for deactivation of photo-excited bilirubin.

Quantum yields for laser photocyclization of bilirubin in the presence of human serum albumin. Dependence of quantum yield on excitation wavelength

The quantum yield for laser photocyclization of bilirubin to lumirubin in the presence of human serum albumin (phi LR) was measured at five monochromatic excitation wavelengths in the range 450-530 nm. Solutions used were optically thin throughout the wavelength range and precautions were taken to exclude contributions from photocyclization of bilirubin XIII alpha impurities. The values obtained (7.2-18 x 10(-4] were lower than those previously reported and showed the following wavelength dependence: 457.9 less than 488.0 less than 501.7 less than 514.5 approximately equal to 528.7. However, the rate of lumirubin formation, normalized to constant fluence, decreased with wavelength over the same wavelength range and no evidence was found that photoisomerization of bilirubin to lumirubin is faster with green (514.5 or 528.7 nm) than with blue (457.9 or 488.0 nm) light. The stereoselectivity of the configurational isomerization of bilirubin to 4Z,15E and 4E,15Z isomers also was studied. This reaction became less regioselective for the 4Z,15E isomer with increasing wavelength. The observed wavelength dependence of phi LR and of the [4E,15Z]: [4Z,15E] ratio at photoequilibrium are consistent with an exciton coupling model in which intramolecular energy transfer can occur between the two pyrromethenone chromophores of the bilirubin molecule in the excited state. Relative rates of lumirubin formation in vivo at different excitation wavelengths and constant fluence were estimated for different optical thicknesses and for different skin thicknesses. These estimates suggest that the recently reported clinical equivalence of blue and green phototherapy lights probably reflects the marked variation of skin transmittance with wavelength more than wavelength-dependent photochemistry. The calculations also indicated that the optimal wavelength for phototherapy is probably on the long wavelength side of the bilirubin absorption maximum.

Critical period of bilirubin-induced cerebellar hypoplasia in a new Sprague-Dawley strain of jaundiced Gunn rats

Homozygous (j/j) and heterozygous (j/+) newborn Gunn rats of the Sprague-Dawley strain were photoirradiated for 24 h at scheduled postnatal days and the effects of irradiation on the cerebellar development were examined at 30 days of life. Improvement of the survival rate was the most notable effect of photoirradiation. A single 24-h dose of photoirradiation during a period of postnatal days 4-11 effectively prevented hypoplasia in the j/j rat cerebellum. No prevention by light was observed at days 3 and 12. It was found that the most effective day of irradiation on the cerebellar development of j/j rats was centered on postnatal day 7. When plasma bilirubin was assessed during the period of postnatal days 7-10, a distinct diminution of the concentration was observed, restricted to only the period of the light treatment. Although there were some differences in the effective day as well as in the degree of efficacy of phototherapy among cerebellar lobules or sublobules, day 7 was the most critical for cerebellar hypoplasia due to bilirubin.

Efficacy of fluorescent daylight, blue, and green lamps in the management of nonhemolytic hyperbilirubinemia

The efficacy of fluorescent daylight, green, and blue lamps in reducing bilirubin levels was compared in two groups of infants with nonhemolytic hyperbilirubinemia: healthy infants in a term nursery and infants in an intensive care unit. The decline of serum bilirubin concentration was most rapid with the blue lamps, with the duration of exposure required being significantly shorter than that with the other two types of light in both groups. The rate of decline over the first 24 hours, as well as the overall rate of decline for the whole duration of phototherapy, was also significantly greater with the blue lamps, the rate being about twice that for the green lamps in the infants in the intensive care unit; the daylight lamps were intermediate in efficacy. The daylight lamps permitted easy clinical monitoring with minimal side effects, whereas the green and blue lamps were equally disturbing to the attending personnel. The green lamps caused severe erythema and tanning in the initial 200 hours of phototherapy. It appears preferable to use either daylight lamps, which permit enhanced clinical monitoring with adequate efficacy, or special blue lamps, which provide maximal therapeutic effect, rather than green lamps, which offer neither.

Bilirubin photoconversion induced by monochromatic laser radiation. Comparison between aerobic and anaerobic experiments in vitro

Structural and geometric photoisomerization of bilirubin bound to human serum albumin was investigated. Solutions were irradiated with monochromatic light emitted by an Ar ion laser, the 457.9, 488.0 and 514.5 nm wavelengths being selected. Photoproducts were separated and analysed by h.p.l.c. Visible-absorption spectra of pure ZZ-bilirubin, ZE-bilirubin and lumirubin in the eluent were registered in the 350-550 nm region by collecting single fractions by h.p.l.c. Wavelength-dependence of bilirubin photoconversion was studied within photoequilibrium and up to a large decrement of the total concentration. Experiments were performed in aerobic and anaerobic conditions in order to assess the contribution of the photo-oxidation to the overall process. The presence of O2 was found to increase the rate of bilirubin degradation and unexpectedly to favour lumirubin production. The ability of 514.5 nm irradiation to induce bilirubin cyclization was definitively confirmed.

The effect of bilirubin photoisomers on unbound-bilirubin concentrations estimated by the peroxidase method

Unbound bilirubin is oxidized to nearly colourless substances in the presence of H2O2 or ethyl hydroperoxide and horseradish peroxidase. To predict the risk of kernicterus (degenerated yellow pigmentation of nerve cells), this principle has been widely utilized for estimating the concentration of unbound bilirubin in hyperbilirubinaemic serum. However, the serum contains polar geometric photoisomers of bilirubin. Therefore, to clarify the effect of bilirubin photoisomer concentrations on unbound-bilirubin concentration, the concentration of bilirubin and its photoisomer and of unbound bilirubin in samples obtained from experiments in vivo and in vitro were simultaneously and individually estimated by h.p.l.c. and the peroxidase method. During photoirradiation, both in vivo and in vitro, the serum polar (ZE)-bilirubin IX alpha concentration increased remarkably, but unbound-bilirubin values were not affected at all. However, during experiments in vitro, unbound bilirubin concentrations increased only when concentrations of the rather polar (EZ)- and (EE)-cyclobilirubin IX alpha increased considerably in a human serum albumin-bilirubin solution irradiated with blue light. Thus it is concluded that unbound-bilirubin concentrations, and consequently the initial rate of the peroxidase reaction, is not accelerated by the increase in either (ZE)-bilirubin or (EZ)-cyclobilirubin concentration within the clinically observed range.