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National Institute for Biological Standards and Control

Conjugation reactions usually involve metabolite activation by a highenergy intermediate and have been classified into two general types: type I (e.g., glucuronidation and sulfonation), in which an activated conjugating agent combines with substrate to yield the conjugated product, and type II (e.g., amino acid conjugation), in which the substrate is activated and then combined with an amino acid to yield a conjugated product (Hodgson, 2004)

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Specifically, the increased loss of RBCs leads to the increased formation of bilirubin, which further triggers eryptosis by enhancing both Ca 2+ influx, SMase activation, and ceramide production, thus creating a vicious cycle