01/10/2015

objectives
GANGGUAN
METABOLISME LIPID
BIOKIMIA KLINIKAL
NB2234
Dr Farah Fauzi

Overview
Lipids as biochemical markers of disease
Lipid Profile Test
TC, HDL, LDL

Dyslipidaemia

Blood Lipids
The major lipids present in the plasma are:

fatty acids
triglycerides
cholesterol
lipoproteins (HDL, LDL)

Blood Lipids
Diagnostic test for blood lipids: lipid profile test.
Recommended in the following individuals with:

history of CVD and CHD

history of premature CHD (occurring at age <60 years)
other major risk factors for CVD (e.g. T2DM, hypertension)
patients with clinical features of hyperlipidaemia
patients whose plasma is seen to be lipaemic

01/10/2015

Lipid Profile Test

Basic panel consisting of:

TG
total cholesterol
LDL
HDL

Functions:
estimate risk of developing CVD
monitor responses to treatment of lipid disorders

Lipid Profile Test

Non-diagnostic samples:

e.g. Reflotron
Fast results
Use test strips
Not comprehensive

Diagnostic samples:

e.g. Cobas
Use reagents
Comprehensive test
Reliable

Lipid Profile Test

Lipid Profile Test

12-hr overnight fasting blood sample is required.

Factors affecting the reliability of screening:

High-fat meal the night before test

Physical stress (e.g. exercise, infection, surgery)
Medication (e.g. steroids, oral contraceptives)
Underlying disease (T2DM, liver disease, thyroid disease)
Alcohol intake
Pregnancy

OPTIMAL BLOOD LIPID VALUES

LIPID

DESIRABLE
CONCENTRATION

Triglycerides

< 1.7 mmol.l-1

Total Cholesterol

< 5.2 mmol.l-1

LDL-C

< 2.6 mmol.l-1

HDL-C

> 1.5 mmol.l-1

Values are for fasting blood samples

Source: National Cholesterol Education Program (NCEP) of the National Institutes of Health (NIH)

01/10/2015

TRIGLYCERIDES

TRIGLYCERIDES

Body pool: 15 kg in non obese subjects

Plasma pool: 5 7 g.
Exogenous source: diet
Endogenous source: liver, adipose tissue
95 % of body fat is triglycerides!
Triglyceride catabolism is regulated by lipase,
epinephrine and cortisol.
Mostly transported in chylomicrons and VLDL.

TRIGLYCERIDES

TRIGLYCERIDES
Plasma triglycerides range:

(ester bonds)

TRIGLYCERIDES
Optimum

CONCENTRATION
< 1.7 mmol.l-1

Borderline high

1.7 2.3 mmol.l-1

High

2.3 - 5.6 mmol.l-1

Very high

> 5.6 mmol.l-1

Source: National Cholesterol Education Program (NCEP) of the National Institutes of Health (NIH)

01/10/2015

TRIGLYCERIDES
Elevated TG is an independent risk factor for CVD,
more so than cholesterol/LDL levels.
Elevated TG in plasma is associated with:
small, dense LDL (pattern B)
small HDL particles
low HDL levels

TRIGLYCERIDES
Predisposing factors for hypertrigliceridemia:

Obesity
Insulin resistance, T2DM
Liver, renal diseases
High CHO diet
Pregnancy
Excess alcohol intake
Defective lipoprotein lipase enzyme
Medications (corticosteroids, estrogen)

TOTAL CHOLESTEROL

TOTAL CHOLESTEROL

Found only in animals.

Important component of membranes, steroid hormones,
bile and Vitamin D.
Exogeneous source: diet
Endogenous source: liver
70% of cholesterol is found
in cellular components.
30% is in the plasma
( free form, esterified )

01/10/2015

TOTAL CHOLESTEROL

Plasma total cholesterol range:

TOTAL
CHOLESTEROL

VLDL

LDL

TOTAL CHOLESTEROL

HDL

TOTAL CHOLESTEROL
Optimum

< 5.2 mmol.l-1

Borderline high
High

CONCENTRATION
5.2 6.2 mmol.l-1
> 6.2 mmol.l-1

Source: National Cholesterol Education Program (NCEP) of the National Institutes of Health (NIH)

TOTAL CHOLESTEROL
Elevated TC levels are associated with:

Diet high in saturated fats

Men > 45 yrs, women > 55 yrs
Low levels of HDL (< 1.0 mml.l-1)
Obesity
Smoking
Hypertension
T2DM, CVD
Family history

LIPOPROTEINS

01/10/2015

Why are lipoproteins

important?

Lipoproteins
B

sdad

B
Tg
Tg
Tg
Tg
Tg
Tg
Tg

Tg
Tg
Tg
Tg
Tg
Tg
Tg
CE

Tg
Tg
Tg
Tg
Tg
Tg
Tg
Tg
Tg

Tg
Tg
Tg
Tg
Tg
Tg
Tg
Tg
Tg

chylomicron

Lipoproteins

Tg
Tg
Tg
Tg
Tg
Tg
Tg
Tg

Tg Tg Tg
Tg Tg Tg
CE CE Tg
CE CE Tg
CE Tg

B
CE Tg
CE Tg
CE Tg

B
Tg Tg Tg
Tg Tg Tg
CE CE Tg
CE CE Tg
CE Tg

B
CE Tg
CE Tg
CE Tg

VLDL

LDL

A
CE
CE
Tg CE
A
CE
CE
Tg CE
A
CE
CE
Tg CE

HDL

Lipoproteins

Fraction

Diameter
(nm)

Major lipids

Major
apo

TG
(%)

Chol
(%)

Protein
(%)

Chylomicrons

1000

Dietary TG

B48

90

VLDL

30-80

Liver TG

B100

65

13

10

LDL

20-25

Cholesterol
Cholesteryl ester

B100

10

45

20

HDL

9-15

Cholesteryl ester
Phospholipid

A1

18

50

Separation of lipoproteins through ultracentrifugation.

More buoyant lipoproteins ( fat content) will float at the
top.

Source: Frayn K.N. 2003. Metabolic Regulation: a Human Perspective

01/10/2015

LDL
Low density lipoproteins (apoproteins)
Majority of the cholesterol in the blood is packaged
as LDL.
Transport cholesterol from liver to peripheral tissues.

LDL

LDL
Elevated levels of LDL have been strongly
associated with an increased risk of CVD.
Hence the name bad cholesterol
But not all LDL are bad!
Sizes and compositions determine the
atherogenicity of an LDL particle.

LDL-C
Plasma LDL cholesterol range:
LDL-C
Optimum

CONCENTRATION
< 2.6 mmol.l-1

Near optimum

2.6 3.3 mmol.l-1

Borderline high

3.4 4.1 mmol.l-1

High

> 4.2 mmol.l-1

Source: National Cholesterol Education Program (NCEP) of the National Institutes of Health (NIH)

01/10/2015

LDL subclasses

Small, dense LDL

LDL pattern B: risks for CVD/CHD.
More atherogenic than larger, buoyant LDL (A).
Atherogenicity is attributed to:

LDL particles are separated

into 4 major subclasses
based on density.
Density is related to TG
content.
LDL I, II: pattern A
LDL III, IV: pattern B

II

III

IV

lower binding affinity to LDL receptor on liver

penetrates arterial wall faster than larger LDL
increased susceptibility to oxidation
pattern A
pattern B
endothelial cells
oxidation

Rizzo et al. 2009. Atherogenic dyslipidemia and oxidative stress: a new look. Trans. Res. 153: 217- 223.

atherosclerosis

LDL patterns
3.3 mmol/l

pattern A

pattern B

diet high in SAT-fat

T2DM
obesity

01/10/2015

HDL
High density lipoproteins (apoproteins, TG)
Transport excess cholesterol from peripheral
tissues back to liver for excretion.
Process: reverse cholesterol transport.

HDL

HDL

HDL
Peripheral
Tissues

Blood

Liver

Strong association between high HDL-C and

protection against CVD.
Hence the name good cholesterol
However, sizes and compositions determine the
functionality of an HDL particle.

excess cholesterol
transported by HDL
bile

01/10/2015

HDL-C

HDL subclasses
HDL subclasses:

Plasma HDL cholesterol levels:

HDL-C

HDL2 (large buoyant, more protective)

HDL3 (small, less protective)

CONCENTRATION

Optimum

> 1.6 mmol.l-1

Acceptable

1.0 1.6 mmol.l-1

Low

< 1.0 mmol.l-1

Source: National Cholesterol Education Program (NCEP) of the National Institutes of Health (NIH)

Apolipoprotein composition:
Apo A-I (cardioprotective)
Apo A-II (controversial* ??)
Absence of apo A-I (non-functional HDL)
*Chan et al. Apolipoprotein A-II: Evaluating its significance in dyslipidaemia,
insulin resistance, and atherosclerosis. Ann. Med. 2011.

HDL-C
High HDL levels are associated with:
females
exercise habit
diet high in MUFA and PUFA

DYSLIPIDEMIA
Abnormal levels of
lipids in the blood
primary
vs.
secondary

10

01/10/2015

1 DYSLIPIDAEMIA

DYSLIPIDAEMIA
Manifested as one or more of the following:

elevated total cholesterol (TC)

elevated low-density lipoproteins (LDL)
elevated triglycerides (TG)
decreased high-density lipoproteins (HDL)

Also known as familial dyslipidemia.

Single or multiple gene mutations that affect:

2 categories:
Primary dyslipidaemia
(genetic disposition)

Secondary dyslipidaemia

LDL receptor
lipoprotein lipase enzyme
ABCA-1 transporter
CETP

Result in overproduction or
defective clearance of lipids.

(lifestyle, disease)

Fredrickson Classification

1 DYSLIPIDAEMIA
Associated with very high levels of cholesterol and TG
in the blood.
Classified according to the Fredrickson
classification, based on the pattern of lipoprotein
that is dominant.

Type

Elevated particles

Associated clinical disorders

Serum TC

Serum TG

Chylomicrons

Lipoprotein lipase deficiency,

apolipoprotein C-II deficiency

IIa

LDL

Familial hypercholesterolemia,
polygenic hypercholesterolemia,
nephrosis, hypothyroidism,
familial combined
hyperlipidemia

IIb

LDL, VLDL

Familial combined
hyperlipidemia

11

01/10/2015

Fredrickson Classification

Familial Hypercholesterolaemia

Type

Elevated particles

Associated clinical disorders

Serum TC

Serum TG

III

IDL

Dysbetalipoproteinemia

IV

VLDL

Familial hypertriglyceridemia,
familial combined
hyperlipidemia,
hypertriglyceridemia, diabetes

Chylomicrons,
VLDL

Diabetes

Type IIa, autosomal dominant:

Heterozygous: LDL 2x
Homozygous: LDL 5 7x

Onset of coronary artery disease:

Heterozygous: 30 40 yrs
Homozygous: 0 20 yrs

Familial Hypercholesterolaemia

Expression of LDL receptors decreased accumulation

of LDL in circulation.
Signs: xanthomas in tendons and cutaneous.

2 DYSLIPIDAEMIA
Dyslipidemia that results from existing diseases or
conditions.
Result in overproduction or defective clearance of TG
and LDL, or underproduction of HDL.

12

01/10/2015

2 DYSLIPIDAEMIA
Hypercholesterolemia

Hypertriglyceridemia

Low HDL

Hypothyroidism; liver disease; nephrotic

syndrome; coronary artery disease

Obesity, Type-2 DM, pregnancy, alcohol,

stress, acute hepatitis, drugs

INSULIN

Disturbances in
insulin functions
can result in
dyslipidemia.

Obesity, Type-2 DM, malnutrition, cigarette

smoking

Insulin

Insulin Resistance

Insulin promotes glucose uptake into cells.

Insulin also promotes lipogenesis and inhibits lipolysis in
adipose tissue.
In insulin-resistant state, cells do not respond to insulin.

Increased lipolysis increased fatty acids (TG) in

circulation fatty acid deposition in liver increased
production of VLDL accumulation of TG in circulation

13

01/10/2015

Atherogenic Dyslipidaemia

Atherogenic Dyslipidaemia

Typical patterns of dyslipidaemia in T2DM and obese

individuals:
elevated
TG
ATHEROGENIC
LIPOPROTEIN
PHENOTYPE

low
HDL
small,
dense LDL

Summary
2 dyslipidemia is becoming more common due to
unhealthy lifestyle.
TG is a prominent risk for CVD/CHD .
Insulin resistance and obesity are associated with
atherogenic lipoprotein phenotype.
Measurement of HDL and LDL subclasses provide a
better picture for lipid diagnostics.

GANGGUAN
METABOLISME LIPID
BIOKIMIA KLINIKAL
NB2234
Dr Farah Fauzi

14