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We performed a systematic review to evaluate the association between serum bilirubin levels and lung function (FEV<jats:sub>1<\/jats:sub>), prevalence\/incidence of COPD, acute exacerbations of COPD, respiratory health status, and mortality.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Methods<\/jats:title>\n                <jats:p>MEDLINE\u00ae and Embase were searched using Ovid\u00ae (search updated October 1st, 2019). We included studies that measured serum bilirubin levels and outcomes of interest in adults with or without underlying lung disease. We excluded studies of those with liver disease or drug-induced elevations in bilirubin. We used the Newcastle\u2013Ottawa scale to assess individual study risk of bias (ROB) and the US Agency for Healthcare Research and Quality\u2014Evidence Based Practice tool to assess overall strength of evidence (SOE). Two authors independently determined eligibility, performed data abstraction, assessed ROB, and determined SOE.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p>Thirteen studies (5 low risk of bias, 3 moderate and 5 high risk) were included. We found low strength of evidence for the association between higher bilirubin levels and lower risk of acute exacerbations of COPD (2 studies), mortality (3 studies), COPD diagnosis (4 studies), and lung function (FEV<jats:sub>1<\/jats:sub>) (8 studies). We found insufficient evidence on the relationship between serum bilirubin and respiratory health status\/exercise capacity (1 study) and airflow obstruction (FEV<jats:sub>1<\/jats:sub>\/FVC ratio) (4 studies).<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusion<\/jats:title>\n                <jats:p>Higher bilirubin levels may be associated with lower mortality and improved COPD outcomes. Randomized trials are needed to evaluate the effect of medications that raise serum bilirubin on COPD outcomes.<\/jats:p>\n                <jats:p><jats:italic>PROSPERO registration<\/jats:italic>: CRD42019145747.<\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s12890-021-01395-9","type":"journal-article","created":{"date-parts":[[2021,1,20]],"date-time":"2021-01-20T08:02:51Z","timestamp":1611129771000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":16,"title":["Serum bilirubin and chronic obstructive pulmonary disease (COPD): a systematic review"],"prefix":"10.1186","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4489-1872","authenticated-orcid":false,"given":"David M.","family":"MacDonald","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ken M.","family":"Kunisaki","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Timothy J.","family":"Wilt","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Arianne K.","family":"Baldomero","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2021,1,20]]},"reference":[{"issue":"392","key":"1395_CR1","first-page":"1736","volume":"2018","author":"GBD Causes of Death Collaborators","year":"2018","unstructured":"GBD Causes of Death Collaborators. 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All other authors report that they have no affiliations with or involvement in any organization or entity with any financial or non-financial interest in the subject matter or materials discussed in this manuscript and have no conflicts of interest in this work.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"33"}}