This article is a summary of the presentations and discussions at the multidisciplinary International Bilirubin Workshop held in Trieste, Italy, in April 1992. Areas discussed included the following: (a) chemistry and physical chemistry; (b) conjugation and its genetic defects; ( c ) hepatocytic transport and its regulation; (d) the alternate pathways of bilirubin metabolism when conjugation is defective; and (e) the mechanisms of bilirubin toxicity and treatment of neonatal jaundice.Chemical Structure and Function. The fully protonated diacid form of unconjugated bilirubin (UCB) is held in a relatively rigid, ridge-tile conformation by a trio of internal hydrogen bonds between each of the two -COOH groups and the opposite dipyrromethenone half of the molecule. This internal bonding accounts for the very low water solubility and high pK'a values (both greater than 8.0) of UCB diacid. Ionization of the -COOH groups loosens these internal bonds so that the monoanion and dianion of UCB are progressively more water soluble than the diacid and interact more avidly with bile salts and albumin. At physiological pH values the major unbound species of UCB in plasma and bile is the diacid, and the major unbound anion is the monoanion (HB-). UCB diacid binds best to phospholipid membranes, whereas the monoanion appears to be the species preferentially transported across membranes, with cotransport of a proton. Bile is mildly supersaturated with UCB diacid and the dianion salt CaB but massively supersaturated with the monoanion salt Ca(HB),, which thus most readily precipitates in pigment gallstones. Peroxidation and polymerization of calcium bilirubinates, catalyzed by divalent metal cations (e.g., Cu2+), is the likely mechanism for formation of the black pigment network polymer in pigment gallstones.Biliary excretion of bile pigments requires the presence of an ionized -COO-group that is not internally bonded. Microsomal conjugation of bile pigments, by contrast, requires an internally bonded -COOH group. This explains why UCB-IXa diacid is not itself secreted into bile but is readily converted to monoglucuronide and diglucuronide conjugates (CB) that can be secreted. Hepatic uptake, or intracellular trafficking of bilirubins, is apparently regulated by differences in the affinity of binding to, and rates of dissociation from, plasma albumin and various cellular membranes and proteins, as well as rates of diffusion across the unstirred water layer. UCB, CB and heme exhibit potent physiological antioxidant properties.Coly'ugution and Its Genetic Defects. The supergene and messenger RNAs (mRNAs) for the UDP-glucuronosyltransferases (UGTs), family 1, which conjugate phenols and UCB, have been characterized in human and rat liver tissue. Each UGT shares a common C-terminal half, encoded by four constant exons at the 3' end of the gene. Mutations in these exons cause deficiencies of all UGTl isozymes. The variable upstream portion of the gene contains six unique exons, each with its own promoter; each exon encodes the N-termina...