Serum and Bile Bilirubin Pigments in the Differential Diagnosis of Crigler-Najjar Disease

Objective. To differentiate between Crigler-Najjar (CN) disease types 1 and 2. Design. The patterns of serum bilirubins, bile pigment composition, and phenobarbital response were studied. Patients. Three infants, affected by high serum unconjugated bilirubin concentrations, previously classified as type 1 CN. Methods. Serum and bile bilirubin pigment composition, both before and after phenobarbital (PB) treatment, were determined by alkaline methanolysis and high-pressure liquid chromatography. PB was given for at least 3 weeks by oral administration (5 mg/kg bw per day). Results. No diconjugated bilirubin was found either before or after PB treatment in the serum of the three studied infants. In two patients traces of monoconjugated bilirubin were detected before PB therapy, and the ratio of conjugated/total bilirubin (percent) was increased by the PB response. In the third patient, traces of monoconjugated bilirubin appeared only after PB administration. However, the serum unconjugated bilirubin concentration decreased significantly only in the second patient, following the second cycle of PB treatment, leading to the diagnosis of type 2 CN. The analysis of the methyl ester derivatives of bile pigments was also performed on bile samples obtained in two patients by Entero-Test (R) both before and after PB treatment. An absolute increment in monoesterified bilirubin concentration was found after PB administration, although the percent concentration increased in one case and decreased in the other. No diesterified bilirubin was detected in the bile samples. Conclusions. The present results show that in types 1 and 2 CN disease it is possible to detect traces of monconjugated but not diconjugated bilirubin both in serum and in bile. Whereas PB treatment is effective in slightly increasing the serum monoconjugated bilirubin concentration even in type 1 CN disease, the diagnosis of type 1 or 2 is based on finding a substantial decrease of serum unconjugated bilirubin following PB administration.

Radioassay of UDP-glucuronyltransferase-catalysed formation of bilirubin monoglucuronides and bilirubin diglucuronide in liver microsomes

A radioassay for specific determination of the rates of UDP-glucuronic acid-dependent conversion of bilirubin into the two isomeric (C-8, C-12) bilirubin monoglucuronides and bilirubin diglucuronide is described and illustrated by its application to rat liver microsomes. The method is based on measurement of the relative amounts of radiolabel in unesterified bilirubin and its mono- and di-esterified reaction products after incubation with [14C]bilirubin as substrate. This analysis is performed by the alkaline-methanolysis procedure, combined with one of two t.l.c. systems developed in order to enhance the sensitivity, accuracy and precision of the radioassay. Results for rates of total bilirubin glucuronide formation obtained with the new assay and the standard enzyme assay based on the ethyl anthranilate diazo-method were identical. However, the sensitivity of the latter technique is approx. 10-fold lower than that of the radioassay.

Liquid-chromatographic assay and identification of mono- and diester conjugates of bilirubin in normal serum.

This liquid-chromatographic procedure for determining bilirubin mono- and diester conjugates in normal serum is based on pre-analysis conversion of bilirubin monosugar and disugar conjugates to the corresponding methyl esters by alkaline methanolysis. Here, extracted unconjugated bilirubin, bilirubin monomethyl esters, bilirubin dimethyl ester, and internal standard are separated on a reversed-phase column within 15 min, detected in the effluent at 436 nm, and quantified from their peak areas. Carotenoids do not interfere. Within-day and day-to-day CVs range from 5 to 13%. The smallest concentrations of monoconjugated and diconjugated pigments that are detectable and measurable are about 10 and 20 nmol/L, respectively. Such data are given for sera from 43 healthy adults. Total bilirubin concentrations in serum tended to be lower in women than in men, but the relative amounts of the various bilirubin fractions in sera from men and women were comparable. Analysis of ethyl anthranilate azoderivatives from serum permitted identification of the bilirubin ester conjugates in normal serum as bilirubin 1-O-acyl glucuronides.

Presence in normal human urine of a hypotensive and platelet-activating phospholipid

Urine from normotensive volunteers and patients with systemic lupus erythematosus glomerulonephropathy was sequentially concentrated by negative-pressure ultrafiltration, dialyzed against distilled water, and extracted into the chloroform phase of a mixture of organic solvents(chloroform:methanol:water, 1:1:0.9 vol/vol). The lipid fraction was further purified by thin-layer chromatography on silica gel plates using neutral, acidic, and basic mixtures of organic solvents and it was then tested for its ability to induce the release of [3H]serotonin from rabbit platelets. All of the samples contained a platelet-activating moiety similar to a synthetic platelet-activating factor (PAF-acether) on the basis of its chromatographic behavior, resistance to the pretreatment of platelets by 10(-6) M indomethacin, and loss of activity by alkaline methanolysis or treatment by phospholipases A2, C, and D. Cross-densensitization experiments between synthetic PAF-acether and the urine factor showed that both compounds act on platelets through the activation of the same putative receptor. Further, the urine factor induced hypotension when intra-arterially injected in normotensive rats, and this activity was also abrogated by alkaline methanolysis. In summary, these data provide evidence of the presence in normal human urine and, probably, of the release by the kidney of a lipid factor with platelet-activating and hypotensive activity whose general structure seems to be alkyl-acyl-glyceryl-phosphorylcholine and, therefore, is similar to the structure of the inflammatory mediator PAF-acether and the antihypertensive polar renomedullary lipid.

Biliprotein in adult icteric serum--demonstrated by extension of the alkaline methanolysis procedure.

We confirmed that the alkaline methanolysis procedure of Blanckaert (Biochem. J. 185: 115-128, 1980) converts the sugar conjugates of bilirubin (Bc) into their corresponding methyl and dimethyl esters, which can be extracted into chloroform along with underivatized unconjugated bilirubin (Bu). By this procedure, we accounted for Bu nearly quantitatively, but only 76-83% of total Bc. By pretreating samples containing Bu and (or) Bc with a caffeine/benzoate reagent, we improved the analytical recovery of Bc to 85-93% without affecting the Bu. When the method (+ caffeine/benzoate) was applied to adult icteric serum, a variable fraction (20-75%) of the original total bilirubin (based on diazo reactivity) remained with the protein pellet, which is routinely discarded in the original methanolysis procedure. In this pellet we demonstrated the occurrence of a strongly protein-bonded bilirubin fraction (biliprotein) similar to the recently described "delta" fraction (Clin. Chem. 28: 629-637, 1982). The analytical and clinical implications of our findings are discussed.

Liquid-chromatographic determination of bilirubin and its conjugates in rat serum and human amniotic fluid.

This newly developed and highly specific and sensitive procedure was applied to the determination of unconjugated bilirubin and its ester conjugates in rat serum and human amniotic fluid. Bilirubin conjugates in biological samples are converted to methyl esters by alkaline methanolysis, extracted into chloroform, and the unconjugated bilirubin and esterified pigment derivatives are fractionated by "high-performance" liquid chromatography. The separated pigments are measured spectrophotometrically. Bilirubin and its mono- and di-conjugates are readily quantitated, even in previously undetectable concentrations. Linearity was established from 0.07 to 121.2 mumol/L for unconjugated bilirubin, 0.07 to 34.6 mumol/L for the C-8 monoconjugate, 0.06 to 69.3 mumol/L for the C-12 monoconjugate, and 0.17 to 43.7 mumol/L for the di-conjugate fraction. The detection limit was 0.03 mumol/L for unconjugated bilirubin and for each monoconjugate, and 0.1 mumol/L for the di-conjugated pigment.