LIPIDS

(LIPID PROFILE)

Introduction

The major lipids present in the plasma are:

fatty acids, Triglycerides, cholesterol and phospholipids.

Other lipid-soluble substances, present in much smaller amounts (e.g. steroid hormones ). Elevated plasma concentrations of lipids, particularly cholesterol, are related to the pathogenesis of atherosclerosis.

Lipids transport

Lipids are carried in the bloodstream by complexes known as lipoproteins. This is because these lipids are not soluble in the plasma water. Thus they travel in micelle-like complexes composed of phospholipids, cholesterol and protein on the outside with cholesteryl esters, and triglycerides on the inside. The four main types of lipoproteins are chylomicrons, VLDL, LDL, and HDL

Clinical Significance

Cholesterol and triglycerides, like many other essential components of the body, attract clinical attention when present in abnormal concentrations. Increased or decreased levels usually occur because of abnormalities in the synthesis, degradation, and transport of their associated lipoprotein particles. Increased or decreased plasma lipoproteins are named hyperlipoproteinemia & hypolipoproteinemia respectively.

Early and late atherosclerotic lesions

Fatty streak

Thrombotic athero lesion, myocardial infarct

Generic Lipoprotein

Metabolic Syndrome: Disease of the Modern Era Constellation of several risk factors that increase chance of coronary artery disease, peripheral vascular disease, stroke and type 2 diabetes. Combination of 3 or more of the following risks:

Abdominal obesity
Triglyceride levels above 150 mg/dL Low HDL cholesterol Elevated blood pressure (>130/85 mm Hg) Fasting blood glucose > 100 mg/dL Aging a major contributor: prevalence in 20-29 yr olds = 6.7%; 60-69 yr olds = 43.5%

Lipoprotein Nomenclature and Composition

CM
Major Protein Major Lipid apoB

VLDL

IDL

LDL

HDL

apoB

apoB

apoB

apoA-I

TG

TG

CE

CE

CE

CM= chylomicron VLDL= very low density lipoprotein IDL= intermediate density lipoprotein LDL= low density lipoprotein HDL= high density lipoprotein Apo = apolipoprotein

TG=triglyceride CE= cholesteryl ester

Site of Synthesis of Lipoproteins

Liver Intestine
apoCs
apoCs
apoA-I

VLDL
apoB-100

apoA-I

apoE

Nascent-HDL

CM
apoB-48

Nascent-HDL
apoE
apoB-100 LDL

IDL
apoB-100

Lipids as Biochemical Markers of Disease

Clinical chemistry laboratories offer many tests for lipid disorders. One of the most common tests is the lipid profile.

This panel of tests includes measurement of triglycerides and cholesterol in the form of lipoprotein-cholesterol molecules, low density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C).

The results of testing for these lipids provide measures of risk for coronary artery disease.

It is therefore clear that lipid measurements should be made in all patients known to have vascular disease, and in those at increased risk. Thus plasma lipids should be measured in the individuals with the following:
CHD (and cerebrovascular and peripheral vascular disease) a family history of premature coronary disease (occurring at age <60 years) other major risk factors for CHD (e.g. diabetes mellitus, hypertension) patients with clinical features of hyperlipidaemia patients whose plasma is seen to be lipaemic.

Positive and Negative Risk Factors in Atherosclerosis

Positive
Age: Males > 45 years Females > 55 years Family history of early CHD Elevated LDL cholesterol (>130 mg/dL) Elevated triglyceride (>150 mg/dL) Diabetes mellitus Hypertension Obesity Smoking
CHD, coronary heart disease

Negative
Elevated HDL cholesterol Low LDL cholesterol Good genes Female gender (estrogen) Exercise

Triglycerides

Glycerol backbone with FA attached by ester bonds

Sources of Triglycerides:

Exogenous source: Dietary Endogenous : Liver and tissue storage

H H H H C C C H OH OH OH H H H H C C C H O O O CO CO CO (CH2)n (CH2)n (CH2)n CH3 CH3 CH3

Glycerol

Triglyceride

13

Triglycerides

Serum triglycerides measurements are done for the following clinical reasons:
Hypertriglyceridemia increases the risk for pancreatitis. Hypertriglyceridemia is associated with the following clinical findings: eruptive xanthoma, lipemia retinalis, hepatomegaly, splenomegaly, depressed HDL-cholesterol. in characterizing risk of CVDs For the estimation of LDL-cholesterol, using the Friedewald equation

Enzymatic Method

Glycerol, released from triglycerides after hydrolysis with lipoprotein lipase, Tranformed by glycerolkinase into glycerol3-phosphate which is oxidized by glycerolphosphate oxidase into dihydroxyacetone phosphate and hydrogen peroxide. In the presence of peroxidase, the hydrogen peroxide oxidizes the chromogen 4aminophenazone/ESPT to form purple quinoneimine whose intensity is proportional to the concentration of triglycerides in the sample.

Enzymatic Method
Triglycerides
Lipoprotein lipase

Glycerol + 3 fatty acids

Glycerol-3 phosphate + ADP dihydroxyacetone + H2O2 phosphate Quinoneimine

Glycerol + ATP

glycerolkinase

Glycerol-3 phosphate

glycerolphosphate oxidase

peroxidase H2O2 + 4-aminophenazone/ESPT

Cholesterol
Cholesterol is a sterol compound that is found in all animal tissues Serves many important physiological functions including:

synthesis of bile acids, steroid hormones, and cell membranes.

Cholesterol also appears to be involved in atherosclerosis; thus cholesterol measurement is one of the most common laboratory tests used today.

Enzymatic Reaction

Determination of cholesterol after enzymatic hydrolysis and oxidation. The colorimetric indicator is quinoneimine which is generated from 4-aminoantipyrine and hydroxybenzoate by hydrogen peroxide under the catalytic action of peroxidase

Cholesterol Esterase Cholesterol oxidase

Cholesterol-3-one Peroxidase

HDL

HDL is a fraction of plasma lipoproteins It is composed of:

50% protein, 25% phospholipid, 20% cholesterol, and 5% triglycerides

Evidence suggests that high-density lipoprotein (HDL) cholesterol is a primary coronary heart disease (CHD) risk factor.

Analysis Methods

Ultracentrifugation Polyacrylamide Gel Electrophoresis Precipitation

based

on the ability of various agents to precipitate selectively the major lipoprotein fractions, except HDL against human lipoproteins are used to form antigen-antibody complexes with LDL, VLDL and chylomicrons in a way that only HDLcholesterol is selectively determined by an enzymatic cholesterol measurement

Immunological
Antibodies

Precipitation Method

In the plasma, cholesterol is transported by three lipoproteins: high density lipoprotein, low density lipoprotein, and very low density lipoprotein HDL lipoproteins are assayed, after precipitation of LDL and VLDL lipoproteins with polyethylene glycol (PEG) 6000. HDL is left in the supernatant solution for cholesterol quantitation.

Low Density Lipoprotein

[LDL-chol] = [Total chol] - [HDL-chol] - ([TG]/2.2)

Where all concentrations are given in mmol/L (note that if calculated using all concentrations in mg/dL then the equation is: [LDL-chol] = [Total chol] - [HDL-chol] - ([TG]/5) The quotient ([TG]/5) is used as an estimate of VLDL-cholesterol concentration. It assumes, first, that virtually all of the plasma TG is carried on VLDL, and second, that the TG:cholesterol ratio of VLDL is constant at about 5:1

Limitations of the Friedewald equation

The Friedewald equation should not be used under the following circumstances:
when chylomicrons are present when plasma triglyceride concentration exceeds 400 mg/dL in patients with dysbetalipoproteinemia (type III hyperlipoproteinemia