Lipids and Lipoproteins

Lipid Transport in Plasma

• Free fatty acid (FFA) bound to albumin
• As lipoprotein complexes
Surface layer:
Polar lipids (free cholesterol,
phospholipids)
Proteins (Apolipoproteins)
Core:
Non-polar lipids
(triglycerides,
cholesterol esters)

Apolipoproteins:
• Lipid binding
• Cofactors for enzymes that metabolise lipoproteins
• Interact with cell receptors to mediate uptake into cells
LIPOPROTEIN STRUCTURE
TEM of isolated lipoproteins
 MAJOR LIPOPROTEINS

1. Chylomicrons (“extremely low” density lipoproteins)

2. Very Low Density Lipoproteins (VLDL)

3. Intermediate Density Lipoproteins (IDL)

4. Low Density Lipoproteins (LDL)

5. High Density Lipoproteins (HDL)

 Table 11.2 (Beckett et al); see Luxton Fig. 13.2

Note: 1. Density ↑ as particle size ↓

2. Different major lipid constituents of different lipoproteins
3. Each class heterogeneous
TEM of isolated lipoproteins
 Triglyceride Metabolism
Adipose
Tissue
Liver Lipoproteins
+ Fat
TG
FFA
↓ lipase
FFA + monoglycerides
TG
↓ Cholesterol,
apolipoproteins
TG + ApoB,C
VLDL

Loss of TG HDL is formed in the liver and

intestinal mucosa
Into circulation via thoracic
duct

Lipoprotein lipase Tissue Lipoprotein lipase

Beckett et al, Fig. 11.2;

see Luxton Fig. 13.2
 Cholesterol Metabolism

Dietary cholesterol
• 1-2 g cholesterol into intestine per day
• 400-700 mg dietary 30-60% absorbed
• 750-1250 mg as bile → into chylomicrons

Endogenous cholesterol
Liver de novo synthesis (900 mg/day) (HMG-CoA Reductase control step)
→ (1) VLDL
(2) bile acids
(3) free cholesterol in bile
Cholesterol Pathways

1. VLDL → LDL → cholesterol supply to cells

2. “Reverse cholesterol transport”
• Cholesterol in tissue cell membranes (free or unesterified) taken
up by HDL
→ esterified by HDL LCAT (lecithin-cholesterol acyltransferase)
→ cholesterol ester
LCAT
Cholesterol + FA Cholesterol ester

→ transferred (by CETP) to LDL, VLDL, chylomicrons, or directly

to liver for excretion
[CETP – cholesterol ester transfer protein]
Apolipoproteins

1. Apo A-1, A-11

• components of HDL
• Apo A-I activates LCAT

2. Apo B: 2 major forms

apoB100 – in LDL mainly
apoB48 – only in chylomicrons

• structural protein (for chylomicrons, VLDL, IDL, LDL)

• binds tissue receptors
3. Apo C-I, C-II, C-III
• in HDL between meals
→ transfer to TG-rich lipoproteins (after meals)
• Apo C-II activates lipoprotein lipase

4. Apo E-I to E-IV

• in nascent HDL
• transfers with CE from HDL to lipoprotein remnants
• important in recognition of remnants

5. Apo (a)
• component of Lp(a), along with apoB100
 Atheroma and ischaemic heart disease (IHD) /
coronary artery disease (CAD)
(atheroma = atherosclerotic plaque in an artery)

Relationship between plasma lipoproteins and

pathogenesis of atherosclerosis:
1. High plasma levels of LDL, IDL, but not VLDL alone are
associated with ↑ risk of premature atherosclerosis and CAD

2. Plasma HDL cholesterol is a negative risk factor

i.e. high HDL → protection against CAD
low HDL → ↑ risk of CAD
 CHD incidence vs cholesterol

Beckett et al
Other Risk Factors
• Hypertension
• Glucose intolerance
• Cigarette smoking
• Stress
• Physical inactivity

Note: Lipoprotein (a)

• similar to LDL; has similar lipid composition to LDL
→ may have a considerable role in atherogenesis
 Process of Atherosclerosis
Injured blood vessel (endothelial injury)

LDL attracted through chemotaxis

LDL oxidised (e.g. by oxygen free radicals)

Engulfed by macrophages (and smooth muscle cells)

Foam cells

Foam cells die to form core of atherosclerotic plaque

Non-contractile scar tissue

Cell rigidity, hypertension

Plaque rupture
Platelets (Marieb, Human Anatomy and
Physiology, 5th Ed, pp 722-3)
Clot (thrombus)
orkney-mcn.org
 LABORATORY ASSESSMENT

Plasma Cholesterol and Triglycerides

Blood sampling from subjects:

• balanced diet ≥7 days
• fast 12-14 hr (esp. if measuring TGs)
• no severe stress (e.g. AMI, burns)
(→ ↑ plasma TG and variable cholesterol)
 Reference ranges

1. Triglyceride < 1.6 mmol/L

2. Cholesterol
Difficult to define
• Age: LDL ↑ from birth to age 60-70, then ↓
• Gender: HDL higher in women until menopause
• “Geography” - plasma cholesterol is:
– low in rural populations of developing countries
– high in “advanced” societies due to diet
Desirable levels of plasma cholesterol (wrt IHD)
Note: No clear cut-off
Previous guidelines
Either:
adults ≤ 5.5 mmol/L ( > 6.5 mmol/L high risk)
Or:
Desirable < 5.17 mmol/L
Borderline 5.17 - 6.18
High > 6.18 mmol/L
• Need to take account of other risk factors
• Children ≤ 4.5mmol/L
• Note: levels are higher in elderly
Primary classification of hyperlipidemias
Note: all fasting measurements
1. Hypercholesterolemia
2. Hypertriglyceridemia
3. Hypercholesterolemia and hypertriglyceridemia
(combined hyperlipidemia)

• adequate classification normally

• otherwise need further tests
• Note the need to differentiate cholesterol classes –
Total cholesterol vs LDL + HDL.
Methods of Analysis
1. Ultracentrifugation (Reference method)
• separation on basis of density

NOTE: expensive instrumentation; long analyses – not routine

2. Electrophoresis – +

• Fasting serum LDL VLDL HDL

• Cellulose acetate/Agarose
• Stain with lipophilic dye
(e.g. Oil red O)

Chylomicrons:
• absent from normal fasting plasma
• Remain at origin

IDL

• Does not provide a disease diagnosis

only a description of the phenotype
• The hyperlipidemia may be due to a
variety of diseases states (primary and
secondary)
 Appearance of serum on standing

Back-up data for electrophoresis

Turbidity related to size of lipoprotein (chylo>VLDL>LDL>HDL). Creamy
layer = chylomicrons; turbidity = ↑VLDL See Luxton Fig. 13.3
 Appearance of serum on standing

NOTE the following definitions:

Lipemic = presence of (fine emulsion) of lipid in blood

• due to ↑ TG
Lactescence = a milky appearance due to ↑ TG
3. HDL cholesterol

• add heparin/Mn2+ to plasma

→ selective pptn of chylomicrons, VLDL, LDL
→ HDL left in solution

• add polyethylene glycol (PEG-6000)

→ pptn of lipoproteins containing apo-B
→ HDL left in solution
4. Cholesterol
cholesterol esters → free cholesterol + FAs
[cholesterol esterase]

cholesterol → cholest-4-ene-3-one + H2O2

[cholesterol oxidase]

H2O2 + phenol + 4-aminophenazone

→ o-quinoneimine dye + 2H2O
[peroxidase]
 Cholesterol ester

O
II
R-C-O-
(Fatty acid → fatty acyl ester )
4. Cholesterol
cholesterol esters → free cholesterol + FAs
[cholesterol esterase]

cholesterol → cholest-4-ene-3-one + H2O2

[cholesterol oxidase]

H2O2 + phenol + 4-aminophenazone

→ o-quinoneimine dye + 2H2O
[peroxidase]
5. Triglycerides
5. Triglycerides

Triglycerides → glycerol + FFAs

[lipase]

Glycerol → glycerol 3-P + ADP

[glycerol kinase]

glycerol 3-P + O2 → DHAP + H2O2

[glycerophosphate oxidase]

H2O2 →
HYPERLIPIDEMIAS

Table 11.3 (Beckett et al)

 Primary Hyperlipidaemia
1. Hypercholesterolaemia
Primary hypercholesterolaemia
• ↑ LDL
• frequency of 1/500
• Most (~ 95%) patients have an unclassified disease that
has genetic/dietary influences
• A small proportion of patients have familial
hypercholesterolaemia
• Type IIa
• autosomal dominant
• deficient/abnormal LDL receptors (i.e. apoB100
receptors) on cells
• plasma cholesterol: heterozygotes 8-15 mmol/L
homozygotes 15-30 mmol/L
– +

LDL VLDL HDL

IDL
LDL uptake and catabolism
LDL uptake and catabolism
2. Hypertriglyceridaemia
Familial hypertriglyceridaemia (Type IV)
• ↑ VLDL
• 1/1000, autosomal dominant
• ↑ production or ↓ catabolism of VLDL
(i.e. A group of diseases)
Some patients with this disease also develop
chylomicronaemia: this appears to occur secondary to
another, underlying disease such as diabetes or alcoholism.
i.e. these patients have ↑ VLDL and ↑ chylomicrons
= (Type V)
→ may see eruptive xanthomas
– +

LDL VLDL HDL

IDL
Lipoprotein lipase deficiency (Type 1)
• ↑ chylomicrons
• rare disease; presents in infants
• deficiency of lipoprotein lipase or its activator apo-C II
→ eruptive xanthomas
– +

LDL VLDL HDL

IDL
3. Combined hypercholesterolaemia and
hypertriglyceridaemia
• Familial combined hyperlipidaemia
• heterogeneous group
• ↑ LDL and/or VLDL (↑ LDL, ↑ VLDL → Type IIb)
• ↑ risk of IHD
• Remnant hyperlipoproteinaemia
• ↑ IDL rich in cholesterol and TG
• see broad β-band on electrophoresis (Type III)
• apoE defect plus additional unknown defects
→ defective hepatic uptake of chylomicron
remnants and partially degraded VLDL
→ accelerated atherosclerosis
• rare
• cutaneous xanthomas
– +

LDL VLDL HDL

IDL
3. Combined hypercholesterolaemia and
hypertriglyceridaemia
• Familial combined hyperlipidaemia
• heterogeneous group
• ↑ LDL and/or VLDL (↑ LDL, ↑ VLDL → Type IIb)
• ↑ risk of IHD
• Remnant hyperlipoproteinaemia
• ↑ IDL rich in cholesterol and TG
• see broad β-band on electrophoresis (Type III)
• apoE defect plus additional unknown defects
→ defective hepatic uptake of chylomicron
remnants and partially degraded VLDL
→ accelerated atherosclerosis
• rare
• cutaneous xanthomas
– +

LDL VLDL HDL

IDL
 Secondary hyperlipidaemia

Less than 20% of hyperlipidaemias are secondary to other

disease
Examples:

Hypothyroidism → hypercholesterolaemia through

increased LDL due to ↓ LDL catabolism

Diabetes mellitus → hypertriglyceridaemia due to

mobilisation of adipose tissue TG
→ increased VLDL due to ↑ VLDL synthesis
Ketone body formation and ketoacidosis
 Indications for plasma lipid assessment
1. Clinical
• Xanthomas (RE macrophages of connective tissue
filled with lipid
Eruptive
•↑ TG (eruptive Xanthomas)
•↑ cholesterol (tendon Xanthomas)

Tendon
 Indications for plasma lipid assessment

Xanthelasma (lipid-filled cells in dermis → yellow raised

plaques around eyelids) (due to ↑ cholesterol)
 Indications for plasma lipid assessment

Premature arcus - opaque ring at edge of cornea

(due to ↑ cholesterol)
 Indications for plasma lipid assessment
Clinical
• premature vascular disease
Laboratory
• lipaemic plasma
Screen groups with:
• vascular disease of early onset (esp. premature IHD)
• Diabetes mellitus, hypertension
• family history of hyperlipidaemia or premature
atherosclerosis
• clinical manifestations suggestive of hyperlipidaemia
 Medical Management
Look for 2° hyperlipidaemia and if found treat 1° disorder.
Otherwise:

1. Diet
• particularly wrt ↑ LDL-C
• diet for ≥ 6 months
• reduce saturated fats, cholesterol
(saturated fats and cholesterol suppress hepatic
LDL receptor → ↓ plasma clearance of LDL)
• replace saturated fats with mono- or poly-unsaturated fats
Note: obesity/caloric excess → ↓ HDL, ↑ LDL
aerobic exercise → ↑ HDL, ↓ LDL
2. Drugs to reduce cholesterol

• bile acid sequesterants (Cholestyramine, colestipol)

→ interrupt enterohepatic circulation of bile acids (bind bile
salts in intestine → excretion of cholesterol)

• Niacin (Nicotinic acid)

→ reduces VLDL synthesis
• inhibitors of HMG-CoA reductase
(enzyme that catalyses HMG-CoA → Mevalonate)
eg. “statins”:
Lovastatin, Simvastatin, Atorvastatin (Lipitor)