Cl i ni cal Chemi stry Cl i ni cal Chemi stry

Lipids
! Descri pti on Descri pti on thi s refers to a cl ass of compounds that are thi s refers to a cl ass of compounds that are
sol ubl e i n organi c sol vents but nearl y i nsol ubl e i n water. sol ubl e i n organi c sol vents but nearl y i nsol ubl e i n water.
" Physical characteristics
! Organic they contain non-polar carbon to hydrogen
bonds and often yield fatty acids and/or complex
alcohols after hydrolysis.
! Hydrophobic they are not miscible with water or water
base solvents, are soluble with organic solvents and each
lipid falls into one of 6 groups:
# Cholesterol
# Fatty acids
# Acylglycerols
# Sphingolipids
# Prostaglandins
# Terpenes
! There is a special group of lipids called phospholipids. They
contain polar groups, which gives them an affinity in both
water and organic solutes.

! Descri pti Descri pti on on - -
" Purpose
! Protection- fat surrounds and protects organs and organ
systems.
! Insulation subcutaneous fat prevents heat loss. MYELIN
surround nerve cells and electrically insulates them from
one another.
! Regulation there are hormones that are fat based that
help to control and regulate reproduction. Prostaglandins
help to regulate tissue inflammation and repair.
! Vitamins fat-soluble provitamins combine with lipids to
become active. Vit A forms retinal, Vit D promotes calcium
uptake. Vit E promotes wound healing and Vit K is
necessary for clotting ** (know all the fat soluble vitamins A,
D, e AND k)
! Structure THEY PROVIDE STRUCTURE IN PRIMArily cell
membrane. In cell membranes Phospholipids provide
definition and cholesterol provide rigidity.
! Energy storage forms of fuel for body processes. 95% of
our stored fuel is fat and 10% is glycogen.


! Descri pti on Descri pti on
" Digestion and absorption of lipid
! Breakdown, absorption and transport Dietary fats are not
digested until the small intestine, in the duodenum and
they are absorbed into the proximal ileum. After they
reach the SI bile salts emulsify the large lipid droplets to
small lipid droplets. Bile salts are secrete in the liver and
stored in the gall bladder. They are released into the SI for
the emulsification. Lipase from the pancreas and intestine
will digest lipid molecules into free fatty acids, glygerol and
monoglycerides. After the breakdown is done absorption
of these components are reassembled in the intestinal
epithelial cells. Then they become packaged with
cholesterol to form chylomicrons. The chylomicrons are
transported into the lymphatic system and eventually will
reach circulation. The triglycerides are delivered to the
liver and peripheral cells after they have been hydrolyzed
to fatty acids by lipase.

! Di gesti on and Absorpti on Di gesti on and Absorpti on
o The i mage bel ow shows a di agram of what was descri bed The i mage bel ow shows a di agram of what was descri bed
above. Tri acel gl ycerol i s t he same as a t ri gl yceri de. above. Tri acel gl ycerol i s t he same as a t ri gl yceri de.

! Descri pti on Descri pti on
" Terms to understand and know
! Amphipathic** - this is a molecule that has a hydrophobic
and hydrophilic portion.
! Saturated fatty acids are categorized according to their
degreed of saturations. This means that all carbons are
singly bonded to hydrogens and that no double bonded
carbons exist.** This give the chanisn of carbons flexibility in,
which the carbon atoms can rotate freely around their
longitudinal axis.
! Unsaturated fatty acids: this has four different kinds:
# Cis/trans
# Mono/poly mono unsaturated fatty acids contains
one double bond. This can be either trans or cis. Poly
unsaturated means it contains multiple double bonds.
" All unsaturated fatty acids have fixed 30degree
bends in their chains at each double bond.
depending on the plane that the bend occurs the
cis or trans isomer is produced. In mammals all
naturally occurring unsaturated fatty acids are cis.
! Types of Li pi ds Types of Li pi ds that exi st that exi st
" Fatty acids RCOOH is the general chemical formula for a fatty
acid. The fatty acids of importance in human nutritions and
metabolism are included in the long chain class and contain an
even number of carbon atoms. Fatty acids can be saturated or
unsaturated and are usually found in free forming circulating
blood. Primarily they will be found bound to albumin or in
esterified forms such as triglycerides. Unsaturated fatty acids are
prone to oxidation by the non enzymatic reaction of oxygen
with their double bonds. Most fatty acids are synthesized by the
body except for a few (eg. linoleic acid this is essential and is
made only by plants). Fatty acids are very sensitive to
physiological energy demands and they are always available as
an alternate form of metabolic fuel. Fatty acids are catabolized
in the mitochondria and they produce energy for cells by a
series of reactions known as beta oxidation.
" Triglycerides these are made of 3 fatty acids bound to a
glycerol molecule. Another name for trigyceride is tracylglycerol).
They are a relatively efficient storage form of metabolic energy
because they are efficient in terms of space. They do not require
water for hydration unlike carbohydrates. Trigylericeds with
unsaturated fatty acids tend to be oils at room temp and are
usually come from plants corn or sunflower. Trigylericeds with
unsaturated fatty acids tend to be solid at room temp and are
usually from animals sources. Trigylericeds not used for fuel are
stored in adipose tissue. They constitute 95% of our tissue storage
fat.
" Cholesterol
" Steroids
" Phospholipids

! Types of Types of Li pi ds Li pi ds
" Fatty acids
" Triglycerides (triacylglycerol)
" Acylglycerol broken down glycerol and acyl group. Glycerol is
a 3 carbon alcohol that contains a hydroxyl group on each of its
carbon atoms. A class of acyglycerol is determined by the
number of acyl groups (fatty acid groups) that is present. If 3
fatty acids make a triglyceride, the two is a di-glyceride and 1 a
mono-glyceride.


! Types of Li pi ds Types of Li pi ds
" Cholesterol this is made of an unsaturated 4-ring hydrocarbon
with a hydroxyl group. On the 4
th
ring is where the hydroxyl group
is. It is found almost exclusively in animals and is a key membrane
component in all cells. It is relatively hydrophobic but it does
contain one polar hydroxyl group making it amphipathic. One
30-60% of ingested choresterol is absorbed. It is broken down in
the SI by Cholesterolases . a few of its role is as a Base chemical
for hormones
Cholesterol esters provide storage and transport. They are
manufactured by all cells but primarily in the liver and
intestine. Aside fromspecialize endocrine cells that use
Cholesterol for the syntheisi of hormones, most peripheral cells
have limited ability to further break down Cholesterol. It must
be returned to the liver to be broken down. 400 mg a day is
converted in the liver to bile acids. About 90% of these are
absorbed in the lower 3
rd
of the ileum and returned to the
liver. The bile acids that enter the LI will be broken down by
bacterial enzymes. An excess of Cholesterol can lead to
Cholesterol crystals. When the amount of Cholesterol in the
bile exceeds the capacity of break down agents, such as
those enzymes, it is possible for Cholesterol to precipitate and
form gallstones.
" Steroids these are synthesized from Cholesterol by specialize
endocrine cells in the adrenal glands and the gonads.
Cholesterol is acquired from the circulation in the form of LDL.
" Phospholipids they are amphipathic. They have a hydrophilic
exterior and a hydrophobic interior. Phospholipids are made of a
glycerol backbone, two fatty acids and a phosphate group.
They are the major component of all cell membranes because
they can form lipid bilayers. They are found in both the
membranes of the cells and/or in the organelles inside the cells.
" Prostaglandins these are derivative of fatty acids that have
hormone like actions. They have hormone like actions, but they
are different because they are synthesized where they are
needed. They are made in almost all tissues. They have very
short-lived effects and are catabolized within seconds.
! Eg Prostacyclin this has a powerful vaso-dilatory action
especially in the coronary arteries and also works to inhibit
platelet aggregation.


! Types of Li pi ds Types of Li pi ds
" Lipoproteins
! General description they are spherically shaped
transport macromolecules that are synthesized in the liver
and intestine. They contain non-polar neutral lipids such as
triglycerides and cholesterol esters in their core with more
polar amphipathic lipids such as phospholipids and free
cholesterol at their surface. In addition on their surface
they contain one of more specific proteins called
apolipoproteins. Their density is based on the protein
content of their shell. Pg 412 table 23-4 and 5 checks.
Types of lipoproteins are (by density):
# Chylomicrons these are produced by the SI and are
the largest particle, which means they can transport
more lipids. They are the least dense in terms of their
shell protein. Their role is to transport triglycerides and
cholesterol esters to the liver and peripheral cells. They
can be seen in postprandial specimens as turbidity also
known as lipemia. Sometimes if you store a serum long
enough they will form a creamy layer at the top of the
serum.
# Very low density lipoproteins these are produced by
the liver. In the density charts on chylomicrons are less
dense. They contain more shell proteins than
chylomicrons and are rich in hepatic derived
triglycerides. VLDL may cause a fasting specimen to be
cloudy. However they will not form a creamy layer after
storage.
# Low density lipoproteins this is also known as the bad
cholesterol. It is produced from lipolysis of VLDL. The
cargo, whats in the core, has more cholesterol and
shell protein than VLDL. This category can be taken up
by cells with LDL receptors. It is smaller than VLDL so it
can infiltrate tissues. Macrophages that contain LDL
become a foam cell that makes up early
atherosclerosis.
# High density lipoproteins, HDL these are considered
the good cholesterol. They are the smallest and most
dense lipoprotein that can be spherical or discoid. This
will have lipoproteins and apolipoproteins.
# Lipoprotein a this is an apolipoprotein that and this is
a special linkage between it and other apolipoproteins.
It performed 3 major functions
" Modulates the activity of enzymes that act on
lipoproteins.
" Maintains the structural integrity of the lipoprotein
complex.
" Facilitates the uptake of lipoproteins by acting as
ligands for specific cell surface receptors.

! Types of Li pi ds: Li poprotei ns Types of Li pi ds: Li poprotei ns

" Chylomicron
! Carries 80-95% Triglycerides and 2-7% Cholesterol

" VLDL
! Carries 55-80% Triglyceride and 5-15% Cholesterol
! Types of Li pi ds: Li poprotei ns Types of Li pi ds: Li poprotei ns
" LDL
! Carries 5-15% Triglyceride and 40-50% Cholesterol

" HDL
! Carries 5-10% Triglycerides and 15-25% Cholesterol
Li poprotei n (a) Li poprotei n (a)
! Ei cosanoi ds Ei cosanoi ds - - These are Oxidized 20C !3, and !6 fatty acids. They are
signaling molecules that exert complex control over many bodily
systems mainly inflammation or immunity. They also act as messengers
in the CNS. The networks of control that depends on these compounds
are amongst the most complex in the human body. The amount and
balance of these in a persons diet affect the bodies Ei cosanoi ds Ei cosanoi ds
control functi ons. Uncontrol l ed they can have effects on control functi ons. Uncontrol l ed they can have effects on
cardi ovascul ar di seases, the amounts of tri gl yceri des, b cardi ovascul ar di seases, the amounts of tri gl yceri des, bl ood l ood
pressure and arthri ti s. Anti pressure and arthri ti s. Anti - - i nfl ammatory drugs such as aspi ri n i nfl ammatory drugs such as aspi ri n
acts by down regul ati ng Ei cosanoi ds synthesi s. There are acts by down regul ati ng Ei cosanoi ds synthesi s. There are
form mai n types: form mai n types:
" Prostaglandins pg 410 table 23-2. These mediate local
symptoms of inflammation such as vasoconstriction, vasodilation,
coagulation, pain and fever.
" Thromboxanes there are more than 1. Thromboxane A2 is
found in platelets. They all work as vasoconstrictors and play a
role in platelet aggregation.
" Leukotrienes these are though to play a role in Ei cosanoi ds Ei cosanoi ds
che chemotaxi s and i n i nfl ammati on. Bl ocki ng motaxi s and i n i nfl ammati on. Bl ocki ng Leukotrienes
receptors can pl ay a rol e i n the management of receptors can pl ay a rol e i n the management of
i nfl ammatory di seases such as asthma. i nfl ammatory di seases such as asthma.
" Li poxi ns Li poxi ns

! Metabol i c Pathways of Li poprotei ns Metabol i c Pathways of Li poprotei ns i n general there are 4 i n general there are 4
maj or pathways. The fi rst 3 depend on l i poprotei n maj or pathways. The fi rst 3 depend on l i poprotei ns that s that
contai n B apoprotei ns. contai n B apoprotei ns.
" Absorption this involves dietary lipids. 90% of dietary
triglycerides are absorbed but on about half (30-60%) of dietary
cholesterol is absorbed. The first method of metabolic pathways
of lipoproteins is:
Exogenous main goal is to transport dietary lipids from the
intestine to the liver and peripheral cells. The transport is
mediated by chylomicrons in which they interact with
lipoprotein lipase in the capillaries. LPL hydrolyzes triglycerides
into glycerol and free fatty acids. Glycerol and fatty acids will
be taken up by cells and used for fuels. If they are not used
they become re-esterized into triglycerides and stored in
adipose tissue. There is strong hormonal control of triglycerides,
in which cortisol and epinephrine will promote the hydrolysis,
whereas insulin prevents it.
Endogenous the main function is to transfer hepatically
derived lipids especially triglycerides to peripheral cells for
energy and metabolism.
Reverse cholesterol pathway the function is to remove
excess cellular cholesterol from peripheral cells and return it
to the liver for excretion.

! Di seases i nvol vi ng l i pi ds Di seases i nvol vi ng l i pi ds
" Atherosclerosis this is a build up of plaque in blood vessels. If the
build up is taking place in the arms or legs it is known as
peripheral vascular disease (PVD). If the build up takes place in
the heart it is known as coronary heart disease (CAD). If the build
up takes place in the brain it is cerebrovascular disease. It is
caused by an increase in blood lipid levels:
hyperlipoproteinemia, hypercholesterolemia and
hypertriglyceridemia. It affects men earlier than women but after
menopause the risk fro AMI (acute myocardial infarction) is
equal . it affects men earlier than women because the
hormones in womens bodies uses more cholesterol which leads
to less build up. The begging of Atherosclerosis begins with fatty
streaks and are deposits of esterified cholesterol. After this will be
cell injury. LDL will bring lipids so that new membranes can form.
Some of the LDLD will become oxidized and become absorbed
by macrophages. These macrophages are now foam cells that
can now enter the vessel wall. This will causes the passage-way
(or lumen) to narrow. The blockages are created by clots or
more lipid deposits. This can be treated by avoiding fatty foods
and exercise. However companies have invented drugs such as
Lipitor, nevocore and zocore that are in a category called
statins. They work to lower LDL and total cholesterol. They do
have side effects such as hepatotoxicity (bad for the liver). They
can also be placed in a sequestrant category, they drugs
prevent cholesterol from being absorbed in the intestine.
Supplement are: niacin (raises HDL levels), but excessive intake
can cause diarrhea. Another drug called probucol prevents lipid
oxidation and macrophage uptake.
! Definition/description
! Causes
! Gender link
! Progression
! Treatment
# Lifestyle
# Drugs/supplements

! Di seases i nvol vi ng l i pi ds Di seases i nvol vi ng l i pi ds a l i st of 4 geneti c di sorders of a l i st of 4 geneti c di sorders of
l i poprotei n metabol i sm: l i poprotei n metabol i sm:
" Defi ci ency of l i poprotei n l i pase acti vi ty Defi ci ency of l i poprotei n l i pase acti vi ty
" Fami l i al combi ned hyperl i pi demi a Fami l i al combi ned hyperl i pi demi a
" Fami l i al hyper tri gl yceri demi a Fami l i al hyper tri gl yceri demi a
" Type V hyper l i poprotei nemi a Type V hyper l i poprotei nemi a
# Xanthomas these are benign tumors with lipid deposits.
# Steroid hormone abnormalities an example is tangier disease. It is
characterized by hypo-alpha-lipoproteinemia. It is a rare genetic
disease and there is a notable reduction in HDL. It has 3 seemingly
strange symptoms: hyperplastic orange tonsils, splenomegaly and
peripheral nephropathy. Other hormone abnormalities affect lipid
levels because an increase steroid hormones will lead to a
decrease in available cholesterol.
# Liver-related lipid abnormalities this may be hepatitis. These
patients will have lipid abnormalities in their blood work.
# Lipid storage diseases - There are 3 lipid storage diseases that are
phospholipid disease: neiman pick, gauchers disease and Tay
Sachs disease.

! Li pi d Measurement Li pi d Measurement - - nowadays chol esterol enzymati c nowadays chol esterol enzymati c
methods are the methods of choi ce. The i deal speci men i s methods are the methods of choi ce. The i deal speci men i s
s s erum that has been fasti ng for 12 hrs. erum that has been fasti ng for 12 hrs. i n i n ci rcul ati on ci rcul ati on
chol esterol i s transported by l i poprotei ns. I f you want to chol esterol i s transported by l i poprotei ns. I f you want to
assay i t you must l i berate i t from i ts transport protei n. I t i s a assay i t you must l i berate i t from i ts transport protei n. I t i s a
mul ti step col ori metri c and enzymati c assay i n whi ch: mul ti step col ori metri c and enzymati c assay i n whi ch:
" Method
! Cholesterol ester Cholesterol + FA
! Cholesterol +O2 Cholestenone + H2O2
! H2O2 + dye
peroxidase
color + H2O
" Reference Range
! 140 200 mg/dl
! Li pi d Measurement Li pi d Measurement the i deal speci men i n serum fasti ng for the i deal speci men i n serum fasti ng for
12 hrs. Tri gl yceri des i n ci rcul ati on are transported by 12 hrs. Tri gl yceri des i n ci rcul ati on are transported by
chyl omi crons, VLDL and chyl omi crons, VLDL and LDL and must be l i berated to assay. LDL and must be l i berated to assay.
Thi s i s another col ori metri c and enzymati c rxn. Thi s i s another col ori metri c and enzymati c rxn.
" Method:
! Trig + Lipase glycerol + fatty acids
! Glycerol
Glycerol kinase
Glycerol-3-phosphate + ADP
! G-3-P
glycerophosphate oxidase
Dihydroxyacetone PO4 + H2O2
! H2O2 + dye
peroxidase
color + 2H2O
" Reference Ranges: 60 150 mg/dl


! Li pi d Measurement Li pi d Measurement (HDL/LDL) (HDL/LDL)
" Specimen: same specimen
" Methods:
! Electrophoresis can be measured by this but not
generally done. The orderin which they migrate:
# Chylomicrons wont migrate
# LDL will migrate to the beta area
# VLDL will migrate to the pre beta area
# HDL will migrate to the alpha area.
! Immunochemistry - this is mostly used. These are direct
assays that measure only HDL. The other non-HDL fractions
will not interfere with the enzymes for HDL measurement.
This direct assay can use polymers, antibodies, or
complexing agents to detect HDL.
! Direct HDL
! Freidwald calculation: LDL used to be an indirect method
and used freidwald calculation. But it had a set back
because it cannot be used with triglycerides higher than
400 mg/dl. You also couldnt use it if the sample wasnt
non- fasting.
# LDL= TC HDL (TRIG/5)
# Unable to be used if Trig > 400
" Reference Ranges:
! LDL 50 130 mg/dl; HDL 40 75 mg/dl

! Li pi d Measurement Li pi d Measurement mi scel l aneous mi scel l aneous l i pi ds l i pi ds
" Lecithin/Sphingomyelin Ratio most common one. It is
performed using thin layer chromatography. The test sample is
amniotic fluid that is used to test fetal lung maturity.
" Fecal fat needs 72 hour specimen
" High sensitivity C-reactive Protein this is an Acute-phase
reactant
! Increased serum CRP concentrations are associated with
risk of future CHD events. The hypothesis is the
inflammation; atherothrombosis, diabetes and
hypertension are interrelated and share common
pathogenic mechanisms. HSCRP is a strong predictor or
AMI, stroke, peripheral vascular disease and sudden
cardiac death, even in people with no history of cardiac
disease. Less than 1 mg/l is a low risk. 1-3 mg/l is moderate
and greater than 3 g/l is at a higher cardiovascular risk
group.