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Sepsis-Induced Cholestasis REVIEW Sepsis-Induced Cholestasis Nisha Chand and Arun J. Sanyal aundice and hepatic dysfunction frequently accom- studies have reported widely varying numbers, from 0.6% pany a variety of bacterial infections. The relationship to 54%. This variability probably reflects both the report- between sepsis and jaundice, particularly in a pediat- ing bias and the populations of subjects studied (Table J 4,5 ric population, was reported as early as 1837.1 Jaundice 1). Sepsis is more likely to manifest with jaundice in may result either directly from bacterial products or as a infants and children than in adults. In this population, consequence of the host’s response to infection. Fre- males have a higher incidence of jaundice. However, in quently, both factors contribute to the development of adults, no gender predilection has been reported. jaundice. In addition, specific infections that target the Jaundice has been associated with infections caused by liver may cause jaundice because of the liver injury asso- several organisms including aerobic and anaerobic gram- ciated with hepatic infection. Although jaundice may be negative and gram-positive bacteria. Gram-negative bac- an isolated abnormality, it is often associated with features teria cause most of these cases. The primary site of of cholestasis. In critically ill patients, the development of infection is most often intraabdominal, but infection of jaundice and/or cholestasis complicates the clinical pic- various other sites such as urinary tract infection, pneu- ture and poses a clinical challenge both in diagnostic eval- monia, endocarditis, and meningitis have been associated uation and in management. In this article, we review the with this complication.4,6,7 Other specific infections current concepts about the pathogenesis of jaundice and known to cause jaundice are infections of the hepatobili- cholestasis with infection, their clinical presentation and ary tree, clostridial infection, typhoid fever, and legio- diagnostic assessment, and the optimal management of nella. these clinical problems. Although jaundice can occur in isolation in patients with septicemia, it is frequently associated with other el- Epidemiologic Considerations ements of cholestasis. Because the principal clinical man- ifestation of cholestasis is also jaundice, the published Jaundice is a well-known complication of sepsis or ex- literature has primarily focused on the syndrome of jaun- trabacterial infection. Sepsis and bacterial infection are dice, and the exact incidence of cholestasis with jaundice responsible for up to 20% of cases of jaundice in patients versus isolated jaundice remains unclear. of all ages in a community hospital setting.2 The inci- dence of jaundice in newborns and early infants varies Pathophysiology between 20% and 60%.3 There are no data from large- The pathogenesis of jaundice in systemic infections scale prospective studies on the incidence of hyperbiliru- is multifactorial. The development of jaundice may binemia in adults with sepsis. Several small retrospective occur from an aberration in the processing of bilirubin by hepatocytes or from other effects on the liver that Abbreviations: AHA, autoimmune hemolytic anemia; BSEP, bile salt export lead to the accumulation of bilirubin in the body. Such pump; BSP, tetrabromosulfophthalein; cMOAT, multispecific organic anion trans- processes include increased bilirubin load from hemo- porter; DIC, disseminated intravascular coagulation; IL, interleukin; KCs, Kupffer lysis, hepatocellular injury, and cholestasis from the cells; LPS, lipopolysaccharide; MRP2, multidrug-resistance-associated protein; NO, septic state and from various drugs used for the treat- nitric oxide; NTCP, sodium-dependent taurocholate cotransporter; OATP, organic anion transport protein; RBC, red blood cells; RES, reticuloendothelial system; ment of sepsis. The molecular and biochemical mech- SLCT, sulfolithocholyltaurine; TNF, tumor necrosis factor. anisms by which jaundice develops in subjects with From the Division of Gastroenterology, Hepatology and Nutrition, Department sepsis is best considered in the context of normal bili- of Internal Medicine, Virginia Commonwealth University Medical Center, Rich- mond, VA. rubin metabolism. Received May 28, 2006; accepted October 16, 2006. Address reprint requests to: Dr. Arun J. Sanyal, Professor of Medicine, Pharma- Normal Bilirubin Metabolism cology and Pathology, Virginia Commonwealth University Medical Center, MCV Bilirubin is the end product of the breakdown of the Box 980341, Richmond, VA 23298-0341. E-mail: [email protected]; fax: 804-828-4945. heme moiety of hemoproteins. In humans, 4 mg of bili- Copyright © 2006 by the American Association for the Study of Liver Diseases. rubin is formed daily from the degradation of hemopro- Published online in Wiley InterScience (www.interscience.wiley.com). teins, 80% of which is derived from hemoglobin.8 DOI 10.1002/hep.21480 Potential conflict of interest: Dr. Sanyal received grants from Sanofi-Aventis and Unconjugated bilirubin is a highly hydrophobic molecule Debiorision. and circulates tightly but reversibly bound to albumin in 230 HEPATOLOGY, Vol. 45, No. 1, 2007 CHAND AND SANYAL 231 Table 1. Reports of Jaundice and Sepsis Author (Year) N M/F Age TB/DB (mg %) Alk Phos ALT/AST Agents of Infection Bacteremia Site of Infection Deaths Notes Bernstein et al. 9 8/1 2-8 weeks 12-22/4-7 E. coli (5) 8 UTI (4) 9 (1962) Paracolon (2) P. Aeruginosa (1) Streptococcus (grp A) Hall et al. (1963) 11 10/1 15-65 years 2-17/.4-14 5-21 (KA Gr. ϩ Diplococci (5) Lungs (11) 2 U/100 mL) Hamilton et al. (196) 24 13/11 Ͻ 1 day-13 3-31/1-16 E. coli (18) 18 Urine (16) 11 weeks A. Aeruginosa (4) Umbilicus (2) Eye (1) Kibukamusoke et al. 21 21/0 17-65 years 3-27 8-19 (KA 8-150/13-150 Lungs (21) 1 (1964) U/100 mL) Eley et al. (1965) 5 2/3 35-54 years 3-23/8-15 11-26 (KA 16-34/24-88 Str. pyogenes (2) 3 Intraabdominal (4) 1 U/100 (U/ml) mL) E. coli (1) UTI (1) Proteus (1) Bacteroids (1) Vermillion et 7 4/3 18-72 years 5-24/4-16 3-26 1-3 (IU/ml) E. coli (3) 7 Lung (3) 6 al.(1969) (mU/ mL) Streptococcus (3) Intraabdominal (2) Pseudomonas (2) Pleural (1) S. aureus (2) Miller et al. (1969) 9 1.2-2.5 E. coli (8) Appendicitis (9) 0 Rooney et al. (1971) 22 19/3 1-3 weeks 7-50/1-37 E. coli (14) 19 UTI (9) 0 Proteus (3) CSF (1) Klebsiella (2) Umbilical (1) Miller et al. (1976) 30 15/15 15-27 years 2-20 (DB mean mean 128 mean 47.6 S. aureus (4) 11 Pneumonia (9) 13 6.78) P. aeruginosa (2) UTI (6) Paracolon Peritonitis (6) Klebsiella (6) Soft tissue (4) Ng et al. (1971) 6 6/0 2-8 weeks 4-33/3-21 20-41 (KA E. coli (5) 4 UTI (6) 0 U/100 mL) Paracolon (1) Borges et al. (1972) 13 8/5 2 months-3 3-31/2-14 28-300/50-920 E. coli (5) UTI (10) 0 years (U/mL) Proteus (5) Lung (4) Streptococcus (2) Staphlyococcus (2) Franson et al. (1985) 23 10/13 25-77 years 2-24/2-14 56-1694 23-3300 E. coli (8) 23 Lung (8) 14 Klebsiella (3) Abdominal cavity (5) Staphylococcus (6) UTI (4) Streptococcus (2) IV catheter/graft/ skin (3) plasma. Figure 1 shows normal bilirubin metabolism at gated to monoglucuronides and diglucuronides by the the hepatocyte. Bilirubin dissociates from albumin at the enzyme uridine diphosphate-glucuronosyltrans- sinusoidal, basolateral membranes of hepatocytes and is ferase.13 Conjugation of bilirubin converts it from a taken up inside in a carrier-mediated process that requires highly hydrophobic molecule to a relatively hydro- inorganic anions such as ClϪ.6,9,10 Organic anion trans- philic molecule that can be excreted into bile.6,9 Bili- port proteins (OATPs) are on the basolateral membranes rubin glucuronides are excreted into bile against a steep of hepatocytes.11 Their role in bilirubin transport has still concentration gradient by a canalicular membrane pro- not been directly established, but bilirubin is a presumed tein, the canalicular multispecific organic anion trans- substrate of OATPs.12 porter (cMOAT), also commonly referred to as the Following uptake into a hepatocyte, bilirubin is multidrug-resistance-associated protein (MRP2).6,9,14 bound by a group of cytosolic proteins (mainly gluta- This process is the major driving force of bilirubin thione S-transferases, GST) that prevent its efflux transport and is the rate-limiting step in bilirubin ex- from the cell. Within a hepatocyte, bilirubin is conju- cretion by the liver.15 232 CHAND AND SANYAL HEPATOLOGY, January 2007 Table 3. Mechanisms of Hemolysis in Sepsis 1. Normal RBCs a. Infections directly causing hemolysis (e.g. Clostridium perfringens) b. Immunologically mediated red cell injury 1. Cold agglutinin–associated hemolytic anemia a. Mycoplasma pneumoniae b. Legionella 2. Paroxysmal cold hemoglobinuria c. Drug-induced hemolysis d. Transfusion reactions e. Hypersplenism 2. Underlying red blood cell defects a. Inherited enzyme deficiency b. Sickle cell disease c. Hemoglobinopathies Fig. 1. Normal bilirubin metabolism. Bilirubin dissociates from al- bumin at the sinusoidal surface of the hepatocyte and is taken up by the patients with pneumonia and noted ferritin containing hepatocyte. Inside the hepatocyte, bilirubin is bound by a group of lysosomes in Kupffer cells.17 This was believed to be com- cytosolic proteins that prevent its efflux from the cell. Bilirubin is then conjugated to monoglucuronides and diglucuronides by the enzyme patible with hemolysis and secondary iron overload. Al- uridine diphosphate-glucuronosyltransferase. Bilirubin glucuronides are though hemolysis contributes to jaundice in sepsis, it is excreted into bile against a steep concentration gradient by a canalicular unlikely that it is the principal mechanism because the membrane protein termed canalicular multispecific organic anion trans- 18-20 porter (cMOAT), also commonly referred to as the multidrug-resistance- jaundice results from conjugated hyperbilirubinemia.
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