Elevated bilirubin can also occur in infants when the liver has not fully matured. Itll also help determine if you have sickle cell disease or other conditions that cause hemolytic anemia.
Gilbert syndrome - Diagnosis and treatment - Mayo Clinic Infant jaundice usually occurs because a baby's liver isn't mature enough to get rid of bilirubin in the bloodstream. But there are a few things you should avoid doing. The most frequent sign of Gilbert syndrome is an occasional yellowish tinge of the skin and the whites of the eyes as a result of slightly higher levels of bilirubin in the blood.
Adult Jaundice: Symptoms, Causes, Diagnosis, Treatment & Prevention A smaller portion of reabsorbed urobilinogen is filtered into the kidneys. A high amount of unconjugated bilirubin may indicate that many red blood cells are being damaged. [51] Mean serum total bilirubin levels in adults were found to be higher in men (0.72 0.004mg/dl) than women (0.52 0.003mg/dl). 2009;124:1193. [49] The causes of jaundice in the intensive care setting is both due to jaundice as the primary reason for ICU stay or as a morbidity to an underlying disease (i.e. Highly respected database from the National Institutes of Health Total bilirubin is the sum of direct bilirubin and indirect bilirubin. 7,752,060 and 8,719,052. Should my family members get genetic tests to check for Gilbert's syndrome? Jaundice is a buildup of bilirubin in the blood. Post-hepatic hyperbilirubinemia touches on problems arising after bilirubin conjugation, including intrinsic or extrinsic obstruction of the biliary tree that impedes excretion of conjugated bilirubin with bile. Trusted Source Less than this tend to indicate obstructive causes. The AST:ALT ratio can be a good indicator of whether the disorder is alcoholic liver damage (above 10), some other form of liver damage (above 1), or hepatitis (less than 1). Gilbert's syndrome and unconjugated hyperbilirubinemia due to bilirubin overproduction. Haptoglobin is formed when the hemoglobin mixes with another chemical. [22] Dubin-Johnson syndrome is associated with ABCC gene mutations, creating insufficient functional MRP2 transporters for bilirubin excretion. People with a mutated UGT1A1 gene only make about 30% of the enzymes they need. Jaundice in Newborns: Parent FAQs; 2017 June 19 [cited 2022 Jan 3]; [about 3 screens]. [60] There was not sufficient evidence to conclude that sunlight by itself is an effective treatment.
Jaundice - Wikipedia Formula-fed infants usually should have 1 to 2 ounces (about 30 to 60 milliliters) of formula every two to three hours for the first week. PubMed Central Causes of hyperbilirubinemia mainly arise from the liver. If the skin looks yellow where you pressed, it's likely your baby has mild jaundice. Marijke Vroomen Durning, RN, has been writing health information for the past 20 years. Gilbert's syndrome is a mild condition. Causes Diagnosis Home remedies Gilbert syndrome is an inherited genetic condition in which a person has slightly high levels of bilirubin pigment, because the liver does not process it. Trusted Source Jaundice is a condition in which the skin, sclera (whites of the eyes) and mucous membranes turn yellow. [6] A complete blood cell count illustrating decreased fraction of intact erythrocytes signifies haemolysis, hinting for haemolytic diseases. Bilirubin is a yellowish pigment produced when hemoglobin in your red blood cells breaks down. Dark-colored urine or clay-colored stool.
Gilbert's Syndrome: Symptoms, Causes, Tests & Treatment - Cleveland Clinic including chemotherapy. Gilbert Syndrome, a hereditary disease affecting 5% of the US population, leads to stress-induced mild hyperbilirubinemia. The former, referring to elevated unconjugated bilirubin, is often caused by haemolytic diseases resulting in increased bilirubin production and impaired bilirubin conjugation. Kernicterus is rare in adults but is prevalent in newborns with underdeveloped blood-brain barriers and lower albumin binding capacities, which otherwise buffers excess bilirubin in adults. AST levels greater than 15 times normal tend to indicate acute hepatocellular damage. health information, we will treat all of that information as protected health Very strenuous exercise, such as marathon running, can increase your bilirubin levels. If your provider thinks you might have a liver disease or a red blood cell disorder, you may need other tests. Go to source In people with Gilbert syndrome, bilirubin levels may increase due to: Make an appointment with your health care provider if you have jaundice, which has many possible causes. Most commonly, interferences in all three major steps of bilirubin metabolism uptake, conjugation, and excretion usually occur in hepatocellular jaundice. Newborns are especially vulnerable to hyperbilirubinemia-induced neurological damage, so must be carefully monitored for alterations in their serum bilirubin levels. High levels of bilirubin can cause Thats a disorder where red blood cells are destroyed faster than theyre made. Mayo Clinic on Incontinence - Mayo Clinic Press, Mayo Clinic on Hearing and Balance - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Book: Mayo Clinic Family Health Book, 5th Edition, Newsletter: Mayo Clinic Health Letter Digital Edition, Fasting or eating a very low-calorie diet, Both your parents carry the modified gene that causes the disorder, Irinotecan (Camptosar), a cancer chemotherapy drug. 23rd ed. Investigation of liver and biliary disease", "Obstructive jaundice and perioperative management", "Management of Malignant Biliary Obstruction", "Jaundice in primary care: a cohort study of adults aged >45 years using electronic medical records", "Serum bilirubin levels in the U.S. Population: Gender effect and inverse correlation with colorectal cancer", "Is breastfeeding really favoring early neonatal jaundice? Available from: Testing.com [Internet]. If a bilirubin blood test indicates elevated bilirubin, your doctor may order additional tests to determine what is causing the high bilirubin. It filters toxins from blood, digests fats and stores glucose (a blood sugar) as glycogen to use for energy. Bilirubin is a metabolic waste product present in the blood. 2005 - 2023 WebMD LLC, an Internet Brands company. [4] Other conditions can also cause yellowish skin, but are not jaundice, including carotenemia, which can develop from eating large amounts of foods containing carotene or medications such as rifampin. [59] A 2021 Cochrane systematic review found that sunlight can be used to supplement phototherapy, as long as care is taken to prevent overheating and skin damage. [33] A small portion of urobilinogen is reabsorbed back into the gastrointestinal cells. With newborns, blood is usually drawn by using a needle to break the skin of the heel. Get useful, helpful and relevant health + wellness information. PubMed Central Anemia is diagnosed when the number of red blood cells is lower than usual. PubMed Central Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. Bilirubin is a yellowish substance made during your body's normal process of breaking down old red blood cells.
[16][17], Eye conjunctiva has a particularly high affinity for bilirubin deposition due to high elastin content. Causes High bilirubin in newborns Symptoms Tests Treatment FAQs The body produces bilirubin when it breaks down red blood cells, and the liver helps excrete it. Bilirubin is created by the activity of biliverdin reductase biliverdin, a green tetrapyrrolic bile pigment that is also a product of heme catabolism. When you have an ineffective gene, your blood contains excess amounts of bilirubin because your body doesn't produce enough of the enzyme. What causes high bilirubin? Accessed April 2, 2018. Unconjugated (indirect) bilirubin. Normal results for conjugated (direct) bilirubin should be less than 0.3 mg/dl. When you have a migraine, you'd try anything to feel better.
Dubin-Johnson Syndrome: Symptoms & Causes - Cleveland Clinic Your health care provider may order more tests to investigate your condition. [6], Physical examination reviews clinical symptoms like degree of jaundice, vital signs and sensations of pain, further followed by urine tests, blood analysis and imaging. https://www.uptodate.com/contents/search. You should call your healthcare provider if you experience: You may want to ask your healthcare provider: Gilbert's syndrome is a mild disorder that doesnt require treatment. Excess bilirubin (hyperbilirubinemia) is the main cause of jaundice. Bilirubin is found in bile, a digestive liquid produced by the liver that helps the body absorb fat. [41], Treatment of jaundice varies depending on the underlying cause. It can also give levels of two different types of bilirubin: unconjugated and conjugated.
Causes of High / Low Bilirubin Levels + Health Benefits Both of these conditions can also have ALT and AST greater than 20 times normal. To check on an existing liver disease or disorder. [31], Unbound plasma bilirubin past a threshold exerts neurotoxic effects through triggering diversified metabolic cascades. Treatment is available while the liver becomes fully functioning, usually within a week. Bilirubin is a brownish-yellow substance that forms as red blood cells break down at the end of their normal life cycle. Elevated bilirubin or hyperbilirubinemia is when the levels of bilirubin in the blood are higher than usual. Right-upper quadrant ultrasound is adopted primarily for its high sensitivity and specificity in detecting gallstones and biliary damage. Gilbert's syndrome is an inherited (genetic) liver disorder that affects the bodys ability to process bilirubin. If you experience any of these symptoms along with jaundice, seek immediate medical care (call 911): Elevated bilirubin may occur This bilirubin is "unconjugated", "free", or "indirect" bilirubin. the excretion of bilirubin. information submitted for this request. A nurse or lab technician will draw blood through a small needle inserted into a vein in your arm. You may experience slight pain or bruising at the spot where the needle was put in, but most symptoms go away quickly. ", "Bilirubin Metabolism an overview | ScienceDirect Topics", "ABC of diseases of liver, pancreas, and biliary system. [51] Higher bilirubin levels in adults are found also in non-Hispanic white population (0.63 0.004mg/dl) and Mexican American population (0.61 0.005mg/dl) while lower in non-Hispanic black population (0.55 0.005mg/dl). These tests may include: To diagnose the cause of elevated bilirubin, your doctor may ask you several questions: Treatment for elevated bilirubin levels depends on the cause. Bilirubin New York, N.Y.: McGraw-Hill Education; 2016. https://www.accessmedicine.mhmedical.com. [Internet]. https://www.merckmanuals.com/professional/hepatic-and-biliary-disorders/approach-to-the-patient-with-liver-disease/jaundice, Back and Neck Surgery (Except Spinal Fusion), View All Symptoms and Conditions Articles, https://medlineplus.gov/lab-tests/bilirubin-in-urine/, https://medlineplus.gov/lab-tests/bilirubin-blood-test/, https://link.springer.com/article/10.1007/s10620-016-4282-3, https://www.merckmanuals.com/professional/pediatrics/metabolic,-electrolyte,-and-toxic-disorders-in-neonates/neonatal-hyperbilirubinemia, https://familydoctor.org/condition/gallstones/, https://www.ncbi.nlm.nih.gov/books/NBK544252/, https://www.ncbi.nlm.nih.gov/books/NBK470290/, https://familydoctor.org/condition/nonalcoholic-fatty-liver-disease/, https://www.ncbi.nlm.nih.gov/books/NBK549796/, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6337523/, https://www.ncbi.nlm.nih.gov/books/NBK562172/, https://www.cdc.gov/ncbddd/jaundice/facts.html, changing medications if they caused the elevated levels, surgery to remove gallstones or the gallbladder, surgery to clear obstructions in the ducts of the liver or pancreas. Feb. 5, 2020. ", "Bili Lights for Jaundice: Effectiveness for Neonatal and Adults | Heliotherapy Research Institute", "Home- versus hospital-based phototherapy for the treatment of non-haemolytic jaundice in infants at more than 37 weeks' gestation", "Sunlight for the prevention and treatment of hyperbilirubinemia in term and late preterm neonates", "Increased vigilance needed to prevent kernicterus in newborns", Icterus | Define Icterus at Dictionary.com, https://en.wikipedia.org/w/index.php?title=Jaundice&oldid=1159874557. However, in newborns with jaundice Jaundice in the Newborn Jaundice is a yellow color to the skin and/or eyes caused by an increase in bilirubin in the bloodstream . Conjugated bilirubin in urine (bilirubinuria) gives urine an abnormally dark brown color. Hepatitis, commonly virus- or alcohol-induced, causes internal liver inflammation and disrupts conjugated bilirubin transport. 2014;89:87. Healthgrades Can Help. Dysark, K. C. (2021). What are jaundice and kernicterus? In adults, jaundice usually doesn't need to be treated. It is processed by the liver and gallbladder and excreted in stool and urine. All rights reserved. bilirubin is hard to break down and is toxic. Prompt treatment may prevent significant lasting damage. Gallstones are more common in pregnant women due to elevated hormones and cholesterol levels, which block the bile duct and obstruct bilirubin excretion. 9500 Euclid Avenue, Cleveland, Ohio 44195 |, Important Updates + Notice of Vendor Data Event, (https://www.aafp.org/afp/2017/0201/p164-s1.html), (https://www.merckmanuals.com/home/liver-and-gallbladder-disorders/manifestations-of-liver-disease/jaundice-in-adults), (https://www.cdc.gov/ncbddd/jaundice/facts.html).
Bilirubin - Wikipedia Gallstones can be removed using acid or shock waves in litholytic therapy and lithotripsy, respectively. American Family Physician. Click here for an email preview. For discoloration of ABS plastic, see, Posthepatic causes (Obstructive jaundice), Abnormalities in heme metabolism and excretion, Glucose-6-phosphate dehydrogenase deficiency, Progressive familial intrahepatic cholestasis, "Jaundice associated pruritis: a review of pathophysiology and treatment", "Managing the jaundiced newborn: a persistent challenge", "A Systematic Approach to Patients with Jaundice", "Jaundice associated pruritis: A review of pathophysiology and treatment", "Unconjugated hyperbilirubinemia and early childhood caries in a diverse group of neonates", "What causes jaundice in hemolytic anemia?
Infant jaundice - Symptoms and causes - Mayo Clinic Accessed Jan. 13, 2020. In complete obstruction of the bile duct, conjugated bilirubin cannot access the intestinal tract, disrupting further bilirubin conversion to urobilinogen and, therefore, no stercobilin or urobilin is produced. Normal results can vary, but high bilirubin levels may mean your liver isn't working right. [citation needed], Prehepatic jaundice results from a pathological increase in bilirubin production: an increased rate of erythrocyte hemolysis causes increased bilirubin production, leading to increased deposition of bilirubin in mucosal tissues and the appearance of a yellow hue. [9] A bili light is often the tool used for early treatment, which often consists of exposing the baby to intensive phototherapy. [33], One way to understand jaundice pathophysiology is to organize it into disorders that cause increased bilirubin production (abnormal heme metabolism) or decreased bilirubin excretion (abnormal heme excretion). In cases when serum bilirubin levels are greater than 421mg/dl (68360mol/L), infant may be treated with phototherapy or exchanged transfusion depending on the infant's age and prematurity status. If bilirubin levels are high, substances formed when bile is broken down may accumulate, causing itching all over the body. The serum testing will include a complete blood count (CBC) and bilirubin levels. Bilirubin levels greater than 10 times normal could indicate neoplastic or intrahepatic cholestasis. You'll soon start receiving the latest Mayo Clinic health information you requested in your inbox. Definition, Symptoms, and Treatment, 7 Symptoms Never to Ignore If You Have Depression. As mentioned, cholelithiasis is the most common cause of hyperbilirubinemia. If ALT is higher than AST, however, this is indicative of hepatitis. Most hospitals have a policy of examining babies for jaundice before discharge. A simple blood test for bilirubin can measure bilirubin levels.
Palmar erythema (red coloration of the palms and fingertips). Elevated bilirubin or hyperbilirubinemia is when the levels of bilirubin in the blood are higher than usual. However, indirect or unconjugated Accessed June 1, 2022. It is intended for informational purposes only. It forms when red blood cells break down. Once it breaks down, it's sent through your liver, gallbladder, and bile ducts before being. [5][43][44][45], Hyperbilirubinemia, more precisely hyperbilirubinemia due to the unconjugated fraction, may cause bilirubin to accumulate in the grey matter of the central nervous system, potentially causing irreversible neurological damage, leading to a condition known as kernicterus. Diagnosis most commonly occurs when people are in their teens or early adulthood and getting blood tests for something else. [4] Gallbladder carcinoma displays enlarged liver with Courvoisier's sign, a mass in the liver's right-upper quadrant. Higher levels of indirect bilirubin may be a sign of other problems. It is not a substitute for professional medical advice, diagnosis or treatment. Spider angiomas (abnormal collection of blood vessels near the surface of the skin). Bile is fluid secreted by the liver. A bilirubin test measures the amount of bilirubin in your blood. African-Americans tend to have lower bilirubin levels than people of other races. PubMed Central This remains the case in most liver disorders except for hepatitis (viral or hepatotoxic). This leads to elevated bilirubin levels in the blood. Certain medications may alter your results. Risk factors of hyperbilirubinemia vary depending on its pathophysiology. The three categories are: Prehepatic jaundice is most commonly caused by a pathological increased rate of red blood cell (erythrocyte) hemolysis. Pain on the right side of your belly is often related to one of the organs in that area. [19] While this may occur in children with hyperbilirubinemia, tooth discoloration due to hyperbilirubinemia is not observed in individuals with adult-onset liver disease. The first oxidation reaction is catalyzed by the microsomal enzyme heme oxygenase and results in biliverdin (green color pigment), iron, and carbon monoxide. To find out if there is a blockage in the bile ducts, the tubes that carry bile from your liver. Gilbert syndrome is an inherited genetic condition. information and will only use or disclose that information as set forth in our notice of American Liver Foundation. All rights reserved. Inflammation (swelling) of the gallbladder. Make your tax-deductible gift and be a part of the cutting-edge research and care that's changing medicine. THIS TOOL DOES NOT PROVIDE MEDICAL ADVICE. Medicines, including acetaminophen toxicity, penicillins. The increased breakdown of erythrocytes increased unconjugated serum bilirubin increased deposition of unconjugated bilirubin into mucosal tissue. Caffeine, penicillin, barbiturates, and nonsteroidal anti-inflammatory drugs (NSAIDs) called salicylates all lower your bilirubin levels. Causes of High / Low Bilirubin Levels + Health Benefits Medically reviewed by Biljana Novkovic, PhD | Written by Joe Cohen, BS | Last updated: December 15, 2022 Bilirubin is a product of the normal breakdown of hemoglobin from red blood cells. High levels of bilirubin can cause jaundice (yellowing of the skin and eyes, darker urine, and lighter-colored bowel movements). Jaundice is a condition in which the skin, whites of the eyes and mucous membranes turn yellow because of a high level of bilirubin, a yellow-orange bile pigment. Roughly 20% comes from other heme sources, however, including ineffective erythropoiesis, and the breakdown of other heme-containing proteins, such as muscle myoglobin and cytochromes. Jaundice (yellowish skin and eyes) occurs when too much bilirubin builds up in blood. Conjugated bilirubin, being water-soluble, is excreted through urine. When a tumour develops at the pancreas head or bile duct, the common bile duct is compressed, opposing bile flow, eventually leading to hyperbilirubinemia. High bilirubin levels are common in newborns. The medical term for it is icterus from the Greek word ikteros. However, infants are more susceptible than adults due to the shorter lifespan of red blood spells. To provide you with the most relevant and helpful information, and understand which Because chronic constipation can cause pain and bloating, it's understandable to seek quick constipation relief. of jaundice, including: If elevated bilirubin is due to an infection, symptoms may include: If elevated bilirubin is due to gallbladder conditions, such as gallstones, symptoms may include: If elevated bilirubin is due to liver disease or liver failure, symptoms may include: Occasionally, symptoms may indicate a life threatening or serious condition. However, jaundice and Gilbert's syndrome dont require treatment. Please reach out, we're human too. Before the test, tell your doctor about how active youve been and what food and medicines youve taken. All rights reserved.
What Could Cause High Bilirubin? 13 Possible Triggers (List) Neonatal hyperbilirubinemia. Meanwhile, acute alcoholic hepatitis may develop with the same amount of alcohol intake within 2 hours, inducing acute hyperbilirubinemia.[6][10]. Find the latest information from the globally recognized leader in digestive diagnosis, treatments and surgical innovations. The pathology occurs after bilirubin conjugation in the liver, due to obstruction of the biliary tract and/or decreased bilirubin excretion. For the physiological event, see, "Yellowing" redirects here. Blood carries most bilirubin to the liver, where it combines with bile, a digestive fluid that the liver makes. [12] Finally, acute fatty liver of pregnancy caused by mitochondrial dysfunction leads to liver insufficiency. Sign up for free and stay up to date on research advancements, health tips, current health topics, and expertise on managing health. High bilirubin levels. Stercobilin is excreted via feces, giving stool its characteristic brown coloration. [36] End stage liver disease models also include hyperbilirubinemia as a critical parameter in prognosis of cirrhosis. Because this bilirubin is not soluble, it is transported through the blood bound to serum albumin. Submission of this form is subject to Healthgrades, Help Millions of people find the right doctor and care they need, Get immediate care and visit with providers from the comfort of your home, or anywhere, Urgent care centers can be faster and cheaper for situations that are not life threatening, Doctors and patients discuss the latest medical treatments and health tips, Search prescription drugs for why theyre used, side effects and more, Centers for Disease Control and Prevention (CDC). Metabolic enzyme disorders hinder conjugation to varying degrees. As a result, bilirubin doesnt move into bile the way it should. Conversely, conjugated bilirubin is hydrophilic and thus can be detected as present in the urine bilirubinuria in contrast to unconjugated bilirubin, which is absent in the urine. Your liver is part of the digestive system. Anything above that may be considered elevated. https://www.niddk.nih.gov/health-information/liver-disease/biliary-atresia/all-content. information is beneficial, we may combine your email and website usage information with When bilirubin levels remain high for prolonged periods, it usually means there is severe liver disease and possibly cirrhosis. Evaluation and treatment of neonatal hyperbilirubinemia. [5] If a bile duct blockage is present, surgery is typically required; otherwise, management is medical. [6] Vital signs, such as fever, tachycardia and hypotension, suggest hyperbilirubinemia induced by viral hepatitis. This causes your skin and the whites of your eyes to appear yellow. Drug-induced liver injury, as Hy's law states, patients with bilirubin of >3mg/dL have 10% mortality rate.
Causes of Elevated Bilirubin Levels | How To Adult Some general tips include: During the production of bilirubin, middle-aged women and men, in general, are more affected. People with Gilbert's syndrome dont produce enough liver enzymes to keep bilirubin at a normal level. A bilirubin blood test is used to check the health of your liver. Health Encyclopedia: Total Bilirubin (Blood); [cited 2017 Jan 31]; [about 3 screens]. Infant jaundice is a common condition, particularly in babies born before 38 weeks' gestation (preterm babies) and some breast-fed babies. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). Cleveland Clinic Community Care puts patients first by offering comprehensive, coordinated, personalized healthcare. [2] By definition, bilirubin concentration of greater than 3mg/ml is considered hyperbilirubinemia, following which jaundice progressively develops and becomes apparent when plasma levels reach 20mg/ml. One common, and harmless, cause of elevated bilirubin is Gilbert's syndrome, a deficiency in an enzyme that helps break down bilirubin. Occasionally, people who have jaundice or Gilbert's syndrome also experience: These things can raise bilirubin levels in people with Gilbert's syndrome, leading to jaundice: As a genetic condition, Gilbert's syndrome is present at birth. 13 Possible Triggers (List) Blood contains a yellowish pigment called bilirubin. [citation needed], While most cases of newborn jaundice are not harmful, when bilirubin levels are very high, brain damage kernicterus may occur[56][8] leading to significant disability.
High Bilirubin Levels: Meaning of Elevated Bilirubin - Healthgrades American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. What are the symptoms of high bilirubin?
Bilirubin test - Mayo Clinic Gilbert syndrome. The findings of urinalysis should be confirmed by serum testing. If the jaundice is caused by pancreatic or biliary tract cancers, the most common symptom is abdominal pain. Medications Certain medications can cause increased bilirubin levels in some people.
Available from: Healthy Children.org. Newborns are especially vulnerable to this damage, due to increased permeability of the bloodbrain barrier occurring with increased unconjugated bilirubin, simultaneous to the breakdown of fetal hemoglobin and the immaturity of gut flora. Mayo Clinic. Before the production of bilirubin, you may have what's called unconjugated jaundice due to increased levels of bilirubin caused by: During production of bilirubin, jaundice can be caused by: After bilirubin is produced, jaundice may be caused by obstruction (blockage) of the bile ducts from: Sometimes, the person may not have symptoms of jaundice, and the condition may be found accidentally. However, some symptoms appear to be universal. Accessed May 31, 2022. It is produced when red blood cells are destroyed. Another option is that theres a problem somewhere along the pathway that gets the bilirubin out of your liver and into your stool. People with a mutated UGT1A1 gene only make about 30% of the enzymes they need. Only in extreme cases does kernicterus, a type of brain injury, occur. Elsevier; 2021. https://www.clinicalkey.com. Hemolytic anemia is indicated by a low haptoglobin concentration in the circulation.
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