Lipids and Lipoproteins

Lipids
A group of water-insoluble substances that are extractable by nonpolar (fat) solvents, such as alcohol and ether. Include: fatty acids, neutral fats, waxes and steroids. Compound lipids: glycolipids, lipoproteins, and phospholipids. Main groups: cholesterol and esters, glycerol esters (TG), fatty acids, phospholipids.

Cholesterol
A sterol that is turned into bile acids and steroid hormones and is a key constituent of cell membranes. Largely endogenous and synthesized in liver. Diet influences blood levels by 10 to 20%. 30 to 60% of cholesterol in diet is absorbed mixed with conjugated bile acids, phospholipids, fatty acids, and monoacylglycerides.

Triglycerides
Most abundant dietary fat and compose 95% of all fat stored in adipose tissue. Prime function: furnish energy for the cell. In the intestines, in the presence of lipases and bile acids are hydrolyzed into fatty acids, glycerol and monoglycerides. After absorption, are reconstituted into chylomicrons. Unlike cholesterol, diet greatly affects levels.

Lipoproteins
Lipid-protein complexes in which lipids (which are hydrophobic) are transported in the blood. Lipoprotein particles consist of a spherical hydrophobic core of TG or cholesterol esters surrounded by an amphophilic monolayer of phospholipids, cholesterol, and apolipoproteins.

Lipoprotein Metabolism
Exogenous metabolism: from dietary fat to chylomicrons to glycerol, free fatty acids, and monoglycerides. Endogenous metabolism: from chylomicron remnant to the liver to synthesis of VLDL, IDL, LDL, HDL.

EXOGENOUS LIPOPROTEIN METABOLISM

Chylomicron
Lpl

Lpl

Glycerol, free fatty acids, monoglycerides

ENDOGENOUS LIPOPROTEIN METABOLISM

Triglycerides (stored) Energy (cells)

Liver
Remnant

Glycerol, free fatty acids, monoglycerides

VLDL
Lpl LCAT Nascent HDL Intestines Stored Cholesterol

HDL
IDL

Lpl LDL

Peripheral Tissues and Liver

Lpl=lipoprotein lipase

Chylomicrons
Large particles produced by the intestines that are very rich in triglycerides (90%) of dietary origin, poor in cholesterol and phospholipids, and low in protein (1%). Less dense than water due to high lipid to protein ratio and floats. Cause of milky plasma. Due to action of lipoprotein lipase, becomes triglyceride-poor: REMNANT.

VLDL
Very-low-density lipoproteins. Like chylomicrons, are triglyceride-rich (50%), can float and make plasma turbid. Unlike chylomicrons, are endogenous (liver). Contains cholesterol and phospholipids (40%), and protein (10%). Action of Lpl gives rise to IDL.

LDL
Low-density lipoproteins Make up 50% of total lipoproteins. Even when in high concentration, does not cause turbidity of plasma. Esterified cholesterol makes up 50% of mass. Subfraction: small particles with lower cholesterol/apoB ratio that are seen in dyslipoproteinemia associated with CAD.

HDL
High-density lipoproteins Contain 50% protein, mostly apoA-I and II. Subclasses: HDL2 and HDL3. Low levels of apoA-I related to Coronary Artery Disease.

Apolipoproteins
The hydrophilic components of lipoproteins (Lipids must be in water soluble micellar structures for transport in plasma.) Grouped by function: * ApoA: major protein of HDL; ApoA-I activates LCAT, which esterifies cholesterol in plasma. * ApoB: major protein (95%) of LDL. * ApoC: major protein of VLDL. ApoC-II activates lipoprotein lipase. * ApoD and ApoE

Patient Preparation
Cholesterol: * Nonfasting acceptable for screening * 12-14 hr fast for diagnosis HDL / LDL Cholesterol: 12 hr or more fasting Triglycerides: 12 hr or more fasting Apolipoproteins: 12 hr or more fasting

General Lab Precautions

Interference in laboratory testing will occur in specimens that are: * lipemic * turbid * hemolyzed * icteric Do not use lubricated test tube stoppers for Triglyceride test as free glycerol can increase value (correct with sample blank).

Physiologic Variation*
Component Total Cholesterol Triglycerides LDL-cholesterol HDL-cholesterol ApoA-1 ApoB Coefficient of Variation 5.0% 17.8% 7.8% 7.1% 7.1% 6.4%
* Kafonek, 1992

CV= SD/mean x 100

Assessment of Lipids
Cholesterol
2 fasting samples

Nonfasting or fasting < 200 mg/dl

Triglyceride Normal
2 fasting samples

>200 mg/dl

STOP

Males > 160 mg/dl Females > 135

LIPID PROFILE
Total Cholesterol, triglyceride, VLDL, HDL, total cholesterol:HDL ratio, coronary heart disease risk Screen for 2o disorders
Primary hyperlipidemia No 2o disorder 2o disorder present Monitor lipid profile

Hyperlipoproteinemia
TYPE I IIa IIb III LIPOPROTEIN PATTERN Extremely elevated TG due to chylomicrons Elevated LDL Elevated LDL and VLDL Elevated cholesterol; presence of b-VLDL; VLDL-C/plasma TG ratio >0.3 Elevated VLDL Elevated VLDL with chylomicrons

IV V

Fredrickson Classification*
Type I IIa IIb III IV V Refrigerator Test +, clear plasma -, clear plasma -, cloudy plasma +, cloudy plasma -, cloudy plasma +, cloudy plasma Electrophoresis Normal High b band High b & pre-b Broad b band High a-2 band High a-2 band

original method of classifying lipid-related diseases that enabled correlation of clinical disease syndromes to laboratory assessment.

Standing Plasma Test

PLASMA AT 4o C

Creamy layer

Creamy layer

Clear

Clear

Faintly Turbid

1to2+ Turbid

1to2+ Turbid

1to2+ Turbid

II-A

II-B

III

IV

1. 2 ml of plasma in a test tube is allowed to stand inside a refrigerator at 4o C undisturbed overnight. 2. Chylomicrons accumulate as a floating cream layer. 3. A turbid plasma contains excessive VLDL.

Lipid Disease Patterns

High cholesterol with High LDL-C High Triglycerides with Normal Cholesterol High Cholesterol and High Triglycerides with or without Low HDL-C Low Total Cholesterol with Low or Normal HDL Isolated Low HDL Isolated High HDL Lp (a) Lipoprotein Excess

Diagnosing Hypertriglyceridemia
Male > 160 mg/dl < 200 mg/dl
Diet and retest in one year

Female > 135 mg/dl >500 mg/dl

200-500 mg/dl
Evaluate for risk factors:
Alcoholism Diabetes Mellitus Glycogen Storage Disease Hypertension Hyperuricemia Hypothyroidism Medications Oral contraceptives Pancreatitis Pregnancy Renal disorder

Diet

Diet and drugs

No riskfactors

+ Risk factor or + Family history

Lipid Interpretation for Coronary Heart Disease

Lipids normal T Chol <200 mg/dl LDL <130 mg/dl HDL >45 mg/dl
Repeat after 5 yrs Lipids abnormal T Chol 200-239 mg/dl LDL 130-159 mg/dl HDL 35-45 mg/dl 0-1 risk factor No coronary HD Lipids abnormal T Chol >240 mg/dl LDL >160 mg/dl HDL <35 mg/dl

2 or more risk factors

Diet Retest in 1 yr

RISK FACTORS Cerebrovascular disease Cigarettes >10/day Diabetes mellitus FH of CHD/vascular disease Hypertension Male Occlusive peripheral vascular disease Overweight >30%

Diet and/or Drugs

Risk Factors for CHD

POSITIVE RISK FACTORS: - Age: Male >45 yr; Female >55 yr or premature menopause. Family history of premature CHD(<55 yr for father and <65 yr for mother) Current cigarette smoking Hypertension or on anti-HPN medication Low HDL-cholesterol Diabetes mellitus NEGATIVE RISK FACTOR: High LDL-cholesterol: >60 mg/dl
from NCEP Guidelines

Adults: Cholesterol and HDL*

Total Cholesterol: Desirable level Borderline High High
HDL-Cholesterol Low <200 mg/dl 200-239 mg/dl >240 mg/dl

<35 mg/dl

* National Cholesterol Education Program

Children of Hypercholesterolemics
Category Acceptable Borderline High T Chol (mg/dl) <170 170-199 >200 LDL-C (mg/dl) <110 110-129 >130

from NCEP Expert Panel on Children and Adolescents

GOOD DAY!