THE
TREATMENT
OF
HYPERBILIRUBINEMIA
OF
THE
NEWBORN
WITH
SODIUM
GLUCURONATE
By Stuart Danoff, M.D., Audrey Boyer, A.M., and 1. Emmett Holt, Jr., M.D.
Department of Pediatrics, New tork University-Bellevue Medical Center
(Accepted Noveniber 14, 1958; submitted August 13.)
ADDRESS: (L.E.H.) 550 First Avenue, New York 16, New York.
PEDIATRICS, March 1959
570
T
IIEJSE is miov good evidence thatin-direct bihirubin is toxic to the brain. It
has been shown to inhibit the ‘
and oxidative phosphorylation2 of brain
slices and clinically it can be correlated
with the degenerative changes seen in
kernicterus . Direct-neactimig bilirubin on
the other hamid appears to be innocuous.
It vas established by Japanese wonkens
that direct-reacting bilirimbin was an ester
of the indirect-reacting variety, the ester
being subseqimently identified4 as bilinimbin
glucunonide. Thie conjugation with
glucu-nonic acid renders the pigment more water soluble, facilitating its excretion rather than
its passage into the nervous system. The
newborn infant lacks almost completely the
ability to conjimgate bilinimbin amid any
meas-mire that would facilitate it should be helpful
in avoiding brain damage.
Attempts to increase glucuromiiclation by
direct administration of glucuronic acid in
various toxic states have been
disappoint-ing. The liver of the newbormi has been
shown to lack several enzymes concerned
in the well-kmiown )athway of conjugation
that involves the formation of uricline
di-phosphate glucimronic acid
(
UDPGA) fromglucose and the transfer of ghmcuromiic acid
from UDPGA to the substance to be
con-jugated. A particularly discouraging
cx-peniment was that of Eisenberg et a!. who
failed entirely to demonstrate conjugation
in two adult males, omie of whom received
isotopically labelled sodium glucuronate
and the other glucimronolactone. In a similar
study carried on with an adult dog, Hsia
failed to demonstrate the conjimgation of
bihirubin after administration of tagged
sochiimni glucimnonate.
The experience of investigators with
di-nect glucuronidation has not, however, been
altogethier negative. Douglas and King,”
for example, working with rats, found that 2
to 6% of the labelled glucuronic acid
ad-ministered could be recovered from the
conjugate. Evidence that free sodium
gin-curonate would effect conjugation in
in-vitro systems has been obtained by Arias
et al.mm and by Brown et aim2
We reasomied that even if direct
conju-gation were inefficient, the reaction might
be made more effective by mass action,
namely, by the use of large closes of one of
the reacting componemits-glucunonic acid.
The quantities given in tIme two negative
experiments of Eisenbeng et ai.s were
rela-tively small. It is also possible that the
cx-peniments of Eisenbeng et (Ii. and of Hsia
failed to demonstrate cc)nj ugat :on because
the enzyme system responsible for
conjim-gation might he one which functioned
pni-manly in early life.
Our resimlts in treating
hyperhihirubi-nemia in newborn infants with relatvely
larger doses of glucimromiic acid and sodium
glucuronate have been encouraging.
Else-where” we have reported observations
made on 28 patients with
hypenbilirubi-nemia treated orally with glucuronic acid
0 A numiiber of examples are knowmi of enzyniatic
reactions which are carried out only in fetal life,
the niost fantihiar being the formation of fetal
h(mTIOglOl)iIi. The plasiiia fraction knowmi as fetuin
is also confirmed to this period of life.’ The ability of the miervous systeni to synthesize cholesterol”
and phiosphohipids’ is lost shortly after birth. Other
enzymiies which comitinime to function postnatally do
so at a far lower level of activity thami in fetal life.
This is true of the enzymiies comicerned with the
pentose phosphate pathway in erythrocytes,’ those
cOlicerne(l with glycogen formiiation, glycolysis amid
ARTICLES 571
and a smaller number treated intravenously
with sodium glucuronate. The present
re-port deals with a somewhat larger group
treated by the latter method which has
proved more satisfactory. The findings are
ilso presented in more detail.
MATERIALS
AND
METHODS
Twemity-five miewborn infamits with he
perbili-rubimiemiiia were treated with sodiumii
glucimro-nate. In three of these the material was givemi
by clysis; in the remaimiimig 22 it was given
imitra-vemiouslv. Sixteemi of these patients were
suffer-ing from hemriolytic disease (erthroblastosis
fetahis), three were premature imifants amid six
were imistamices of umiexplained
hvperbilirimbi-nemia in full-term imifants. The comicentratiomi of
l)ilirubimi (virtually all indirect-neactimig) imi the
serum exceeded 9.5 mg/100 ml in all in-stances.
The sodium glucimronate was administered
imi a 2 to 3% solutiomi; the original 10% solutiomi
in which the product was simpphied#{176} beimig
diluted with 5% glucose solution. The total
quantity administered varied from 2 to 47
grams, the rate beimig kept between 100 amid
250 mg/ kg’hour.
Bihinubin detenmimiations were performed on
capillar blood by the method of Mallo’ and
Evelyn.20 Measunememits were made at least
twice before the admimiistnatiomi of glucuromiate
to establish the rise in bilirubin comicentration
and approximately every 3 to 8 hoimrs
there-after.
RESULTS
The details concerning the patients and
the observations are recorded in Table I
and in the accompanying figures.
The results of treatment varied and are
classified in three categories : a) a
well-dc-fined decrease in indirect bilirimbin in the
serum commencing within 2 or 3 hours of institution of therapy and often followed by
a rebound after cessation of therapy (20
pe-nods in 17 patients); no patient was in-eluded in this category unless the rate of
decline in bilirubin exceeded 5 mg in 24
hours; b) an arrest in the increase of, or a
slow decline in the concentration of indirect
bilirubin following therapy (5 patients); and
0 Supplied by the Vitarine Company, New York
City, through the courtesy of Mr. H. Newmark.
c) a negative result (4 patients).
Examples of the first type of response
are seen in Figures 1 to 4; Figure 5 shows
the second type of response; and Figimne 6
the last type. In a few instances a slight
increase in comicentration of direct bilirubin
accompanied the decrease in indirect form
of the pigment.
In this group of patients, in contrast to
our earlier experience with oral administra-tion of glimcuronic acid, no complications
were observed. All patients made an
un-eventful recovery and were discharged
from the hospital in good comiclition.
DISCUSSION
The observations mentioned appear to mis
to offer a promising amid simple therapy for
hypenbihirubinemia. However, our results
have been criticized, notably by Schmid
et ai.,21_24 on the following groimncls: 1) these
workers have been unable to duplicate our
results; 2) they arc inclined to belittle the
in-vitro evidence for direct conjimgation by
glucimnonic acid; amid 3) they suggest that
glucuronic acid, like sulfonamide drugs,
will shift bilirubin from the blood into the
tissues, thereby increasing the risk of brain
damage.
We have no good explanation as to why
these workers have not been able to
dupli-cate our results. It may be due to chance,
a matter which further experience will clear
up. It may be dime to a difference in clinical
material. The great majority of the patients
we studied have had hieniolytic disease
(erythroblastosis) and have had higher
bili-rubin levels. If our concept of the role of
mass action is correct, one would expect
less of a result from the same dose of
ghimcuronatc in the presemice of a lower
bili-rubin level. Fimrthcrmore, the dosage of
glucuronate given by Schmid et a!. was in
most instances smaller than that which we
employed.
In regard to the existence of pathways of
glucuronidation other thami the classical one
(
via UDPGA), we are inclined to give someweight to the evidence citedlm m for direct
conjugation by glucuronic acid.
glucuro-572 TREATMENT OF HYPERBILIRUBINEMIA
TABLE I
l).T FILOM 5 PATmENTS VITII IIYI’ERBIIAItUBINEMmA TREATED VITll
‘OI)I EM (;mt(II)N.%TF INTIIA ENOL SLY
; Rate of Bit- Told Serum Indirect Iiili.
.
irubirt I,, Dosage !)uralio,, rubin (nlg/’l(X) in!) .. Thug- .
_________
..
( ondthon\) #{188}% J% JI1. #{149} crease .\a (,Iu- of
________
Re-(omph-. . (stays) (pn) #{149} Before euronate Therapy Immed. immed. pon.,e ca1iou.
.
hTherapy Ii.. (hr) Before .Ifler . rge
(mj ‘Izr)” (yrn) Therupy Therapy
m: F ( . I.(100 LlflkflOWfl 0.4:1 3. 5 I 4.6 10.0 ± fl(fl(
l: I.. ( 4 .UI(1 irknown 0.54 8.B I 3 .I 8.4 + none g od
:m F \\ 4 unknown 0.61 3 O .4 S). + none gi 0(1
4 M W .9l0 inknowii O. 4.5 I 10.55 I8.7 - fl(fl
5 F \V 4 :m.I#{149}‘() unknown 0.1 6 13 O .I .9 + none good
6 F Vs :m.io unknown 0.8 I .5 19 15 1 m ± none goo(1
7 M V ‘2 .I,37() unknown stationary .1 17 10.6 13.0 - none good
at 10(1
H F V 1 9 .600 unknown 0.51 3 5 15..5 10.3 - none good
at M V S S .670 unknown m.m 7 3s 8 .S 5.9 + non, go()(1
(large
cephalo-hematoma)
10 F C m
,
Rh incompat- 0.(13 5 1 3 4.7 + none goodihility
0.8 6 11 9..’; 1.4(1 +
1It F’ m
,
9.() Rh incompat---
---
----
--
---
-
------
none goo(libility 0.113 6.5 14 11 .06 +
I M v i 5,0(10 Rh ineompat- 0.7 0 48 14.3 7. ± none good
ibility
13 M W I 3.0’O liii ineompat- 0. .57 8 .8 50 10. 5 (. ± none goo(1
ibility
14 M I 370 Itli incompat- 0.9 4 13 10.2 0.6 + none good
ibility
I 0.7 4 18 17.0 15.7
-LIf M (‘ and ,443 AB() acorn- --- -- ---
---
-----
--- go()(l good3 patibility 0.15 Ii 0.04 14.0 +
16 l. W#{149} a 3,0() .B() ineom- 0. 11 16 2I .5. I 8.5 + none good
patil)ility
17 M W’ 3 3,111) .%BOineom- 0tI 4 17 15.5 10.1 + none goo,l
patihility
ms M V . :m
,
mao ABO incom- 0.1 10.8 1 7 6 1 4.I + none goodpatibility
19 M W#{149} 3.170 Alloincom- 0.41) 10.8 17 17.15 3.Z + none good
patibimity
0 M W 5.40 AIR) incom- 0.ma 39 65 .5 .0 6. + none goo(1
patibility
m M W s 3,360 ABO ineom- 0.5 8.7 10.6 + none goo(1
patibility
M Vi 3 3,410 Alto inoni- 0.31 7.7 17.(I I .6 + none good
patihimity
I 0.3 11 .7 m7. ±
8t M W s ,4(t AB() ineom-
---
---
---- -- --- --- none goodpatibility 0. 18 17 4.0 10.3 +
4 M \V 4 3,450 .13O ineom- stationary 47 .58 30. 10.6 + none good
patihility at 30
( o.ss 15 16 31.6 14.6 +
cv;t F U 3 #{149}t,wo AIR) ineom-
---
- ---- - none goodpatil)ility 0.21 I92 ± 3.0 s.m +
* Imniunologie data furnished by the laboratory of Dr. A. S. ‘Wiener.
.. ltiied on the tWo serum indirect bilirubin determinations obtaine(1 in(nie(liately prior to therapy.
tReceived two courses of therapy.
Given by elysis.
§the response was regarded as questionable if the ,1e’rease in biliruhin level was less than .5 mg in 4 moors.
#{182}1Fit biopsy before therapy: Itilirubin 4 pg/gm of fat Immediately after therapy: g/grn of fat
Itilirubin 50 pg/gm of fat 9 zg,gin of fat
nate therapy might drive bihirubin from the sulfonamide drugs caused such a
sulfona-NA
GLUCURONATE
6
GMS.
IV.
20
15
12400 -58
BABY B P05.
MOTHER B POS.
RECT
10
5
--
DIRECT
AGE
(hours)FI;. 1. Patiemit No. 5.
2:
SODIUM
GLUCURONATE
2590- 58
BABY 0 RH POS.
MOTHER 0 RH NEG.
GRAVA 3 PARA 3
COOMBS STRONGLY POSITIVE
PREVIOUS BABY EXCHANGED
4
GMS.
I.V.
0
10
20
30
40
AGE
(hours)50
60
70
80
Fic. 2. Patient No. 14.
E
0
0
E
z
:D
-I
:D
w
LI)
E
0
0
a)
E
z
:D
-I
w
17531-58
BABY B P05. MOTHER B POS.
E
0 0
a) E
z
:D
-J
:D
LU
LI)
E
0 0
a) E
z
-J
:,
LU
LI)
25
20
15
10
5
0
30
25
20
15
I0
5
0
AGE
(hours)Fic. :3. Patient No. 2:3.
NA GLUCURONATE
87
GMSI
l.V.
7000 -58
BABY A POS.
MOTHER 0 P05.
GRAVA 14 PARA 14
INDIRECT
---.----
:
DIRECT
30
FIG. 4. Patient No. 21.
NA
GLUCURONATE
IV.
IIGMS.
I6GMS.
I- I I
I
1
I I
I I
I I I
I ‘
I I
I I I I
I I
I I I I
I I
I I I
__4/
\,/\\ I II I
I
‘J-H
DIRECT
I I
I I
I I I
I
50
100
150
200
60
70
80
90
100
110
120
130
30
25
20
MOTHER TYPE AB NEG.
BABY TYPE B P08.
COOMBS STRONGLY POS.
PREVIOUS BABY EXChANGED
GLUCURONIC
‘
ACID
46
GMS.
I0
I
5
0
10
20
30
40
50
60
70
80
90
100
ARTICLES ow
E
0 0
a)
E
z
-I
LU
LI)
AGE
(hours)FIG. 5.
mide drugs permitted bilirubin from
hyper-bihirimbinemic senum to pass through a
cello-phiane membrane, apparently by displacing
the i)ilirubimi from its combination with
serum Iroteins. However, the assuml)tiOn
that glimcimnonate might act like sulfonamide
clntmgs was not borne otmt by Oclell’s
expeni-ments, for under like comiclitions glucuronic
acid produced no such effect.
The experiments of Johnson et 27 in
genetically jaundiced rats of the Gunn
strain bean omi thie question as to whether
sodium glimcuronate caimses a shift in
bihi-rubin distribution similar to that caused by
sulfonamides. Their report dealt with five
rats of the Gimnn strain in which bilirubin
levels were depressed following the
ad-ministration of sodium ghmcuronate; these
rats later died of kernicterus. From a
per-sonal communication2 it was learned that
this series has since been extended. Of 18
rats treated with glucimronate, 13 have shown the phenomenon described. This is
clistimictly higher than the percentage of
rats (50) who develop kernicterus in any
case. It is of interest that control studies
were carried out in which sahimie solution
rather thiami sodium ghimcimronate was given
to Gunn rats with identical results.
There-fore, if these investigators arc regarded as
having demonstrated that glimcuromiate
drives bihinmbin from the circimlation into the brain, they must also I)e credited with having demonstrated that salimie sohimtion
also does this.
We should like to point to certain
differ-ences in the behavior of the Gimmin rats and
of the infants to whom we gave sodium
glu-curonate. The tissimes of the rats appeared
to become more deeply pigmented as the
bihirubin level of the senimm decreased,
whereas in the infants the reverse was the
case, as judged by oimr clinical impressions
and by two instances in which biopsies
were made of the subcutaneous fat before
dif-E
0 0
a)
E
z
-J
:D
LU
LI)
30
25
20
25
10
5.
0
10107-58
NA
GLUCURONATE
MOThEROPOS.2.1
GMS.
I.V.
- _hsuP4+m.h4i_ .. - - - -.. .- .- ‘- .
-30
‘50
‘-7b
‘9’o
‘IIb
AGE
(hours)Fm:. 6. Patient No. 7.
576 TREATMENT OF HYPERBILIRU BINEMIA
feremice was that the rats developed
ker-miicterns (1hhitt negimlarly, whereas the babies
(mite
regularly liladle an uneventfumlre-covery.
\Ve still lack imlipressive evidence as to
where the bihirubimi is going when its level
decreases iii the blood senimm of the infamits.
In three instances we macic measurements
of the urine amid foummid the bilirimbin
excre-tiomi increased after therapy. The major
pathway of excretiomi-the bile-we have
miot vet foumid it feasible to mneasimre
quami-titatively.
Imi regard to whether or not glucuronate
therapy fur hivperbihirubimiemnia is to be
necom’nm’nenclecI at the Presemit time, our
sition is that it is a promisimig therapy which
mieeds to h)e further explored by critical
imi-vestigatons 1)efore a final evaluation can be
givemi. It miiay lie that fimrthier observatiomis
will reveal untoward svm’nptomns caused 1w
ghmcuromiate. This has beemi the history of
every kmi )Vsfl thieral)eutic agent. If presemit
therapy l)Y miieamis of exchange transfumsions
were devoid of risks there WOimldi perhaps
be no mieecl to search for anything better.
However it lP1)ear5 that presemit therapy is
by no mi#{238}eansdevoid of risk as is
enipha-sized 1)\’ tWo recent pimblicatiomis froni
Eng-land. 29. ((( No dloUl)t the mortality froni this
1)rocedltmre is reduced imi direct I)rPrti1i
to experiemice, 1)tmt evemi iii the most
expe-niemiced medical centers it that
die-sI)ite the best techiniqume with exchiamige
tnansfimsions the niortality from kermiicterus
is still around 3. There is at Presemit ho
reason for 1)ehieVimig that the miiortahity
fol-lowing glucuromiate therapy is higher. In
imistamices in which glucimronate fails to)
con-trol the 1)ihniml)inemia arm exchiamige
tramisfu-sion can still be givemi.
CONCLUSION
Twemity-five cases of livpenbihirumbimiem’nia
have beemi treatedi with paremiteral sodiimm
ARTICLES 577
vith hemolytic disease (erythroblastosis).
The authors believe the resumhts have been
encouraging amidi warrant a further
experi-mental trial o)f this form of therapy by
cniti-cal investigators.
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