CHOLESTEROL AND

KETONE BODIES
METABOLISM
Cholesterol, from the Greek chole- (bile)
and stereos (solid) followed by the chemical sufix -ol for
an alcohol, is an organic molecule. It is
a sterol (or modifide steroid), a lipid molecule.

Cholesterol is the principal sterol synthesized by

animals. All kinds of cells in animals can produce
cholesterol. In vertebrates the hepatic cells typically
produce greater amounts than other cells.
Francis Poulletier de la Salle first identified
cholesterol in solid form in gallstones in 1769.

In 1815 chemist Michel Eugene Chevreul named the

compound "cholesterine“.
 Functions of Cholesterol
• a precursor of steroid
hormones (progesterone,
testosterone, estradiol,
cortisol, etc.)
• a precursor of bile acids
• a precursor of vitamin D
• some research indicates
cholesterol may act as
an antioxidant

• cholesterol is required to build and

maintain membrane; it modulates membrane
fluidity over the range of physiological
temperatures.
 Sources of Cholesterol
• from the diet (realized via foods of
animal origin, chiefly as a component
of meat, liver, egg yolk, brains)
• can be synthesized (about 800 mg
of cholesterol per day)
- in the liver (major site)
- in the intestine
•800 mg of cholesterol is excreted
daily from the body in the form of
bile acids–products of cholesterol
biotransformation are eliminated
via feces and transformed into
coprostanol by the intestinal
bacteria enzymes.
For one day in the body formed
500 – 800 mg of cholesterol.
About 80 % of this amount are
synthesized in the liver,
the rest - in the cells of the
mucousa cells of intestine,
skin, adrenal glands,
nervous tissue. Enzymes
required for cholesterol synthesis,
are in all cells except red blood
cells.
 Synthesis of Cholesterol
Three stages of cholesterol biosynthesis
1. From acetyl CoA formed of isopentenyl
pyrophosphate, that is the key building block of
cholesterol.
2. Condensation of six molecules of isopentenyl
pyrophosphate to form squalene
3. Squalene cyclizes and the tetracyclic product is
converted into cholesterol

Acetyl CoA (C2) Isopentenyl pyrophosphate (C5)

Squalene (C30) Cholesterol (C27)
 A. Stage 1:
Acetyl CoA to Isopentenyl Pyrophosphate
• All carbons of cholesterol come from cytosolic
acetyl CoA (transported from mitochondria via
citrate transport system)
Two molecules
of acetyl CoA
condense to
form
acetoacetyl CoA.

Enzyme –
thiolase.
Acetoacetyl CoA reacts with acetyl CoA and
water to give 3-hydroxy-3-methylglutaryl
CoA (HMG-CoA) and CoA.
Enzyme: HMG-CoA synthase
In cytoplasm 3-Hydroxy-3-methylglutaryl CoA is reduced to
mevalonate.
Enzyme: HMG-CoA
reductase

In mitochondria 3-
Hydroxy-3-methylglutaryl
CoA is cleaved to acetyl
CoA and acetoacetate.
Enzyme: HMG-CoA lyase.
 HMG-CoA reductase
• HMG-CoA reductase is an integral membrane protein in the
endoplasmic reticulum
• Primary site for regulating cholesterol synthesis
• Cholesterol-lowering statin drugs (e.g. Lovastatin) inhibit HMG-CoA
reductase
• There are two intracellular pools of HMG-CoA in liver cells, those of
cytosol and of mitochondria. The mitochondrial pool of the
intermediate is mainly a precursor of ketone body, whereas the
cytoplasmic pool is a precursor for producing of cholesterol.

Lovastatin
resembles
mevalonate
Mevalonate is converted into 3-isopentenyl
pyrophosphate in three consecutive reactions
requiring ATP and decarboxylation.
Isopentenyl pyrophosphate is a key building block for
cholesterol and many other important biomolecules.
 B.Stage 2:
Isopentenyl Pyrophosphate to Squalene
Isopentenyl pyrophosphate is isomerized to the
formation of C30 compound steroid nature - squalene.
C5 units isopentenyl pyrophosphate react with C5
units dimethylallyl pyrophosphate to yield C10
compound geranyl pyrophosphate
C10 compound geranyl pyrophosphate reacts with C5
units isopentenyl pyrophosphate and C15 compound is
formed - farnesyl pyrophosphate.
Reductive tail-to-tail condensation of two molecules of
farnesyl pyrophosphate results in the formation of
C30 compound squalene
 C. Stage 3:
Squalene to Cholesterol

Squalene activated by
conversion into squalene
epoxide.
Squalene epoxide is cyclized
to lanosterol (steroid C30)
that have one OH-group more
than squalene .
Lanosterol is converted into cholesterol with C27 in a
multistep process (reaction demethylation) -3CH3
groups.
 THE REGULATION OF
CHOLESTEROL BIOSYNTHESIS
Regulatory enzyme - 3-hydroxy-3-methylglutaryl
CoA reductase.

Tetrameric
enzyme.
NADPH -
coenzyme
1. Cholesterol as final product and
mevalonate (intermediate product) are
inhibits the activity of regulatory
enzyme 3-hydroxy-3-methylglutaryl CoA
reductase (feedback regulation).
2. Big amount of dietary cholesterol in the
body are inhibited synthesis of endogenous
cholesterol.
3. Glucagon inhibits activity of
3-hydroxy-3-methylglutaryl CoA
reductase, and insulin, in contrast,
stimulate activity of reductase. During
fasting, glucagon secretion is
increased and inhibited synthesis of
cholesterol, while consumption of large
amounts of carbohydrates and fats in
the action of insulin – stimulate
formation of cholesterol.
 Bridge to Pharmacology
Treatment of Hypercholesterolemia
Cholestyramine and other drugs that increase
elimination of bile salts force the liver to increase their
synthesis from cholesterol, thus lowering the internal
level of cholesterol in the hepatocytes. Decreased
cholesterol within the cell increases LDL receptor
expression, allowing the hepatocyte to remove more
LDL cholesterol from the blood.
HMG-CoA reductase inhibitors such as atorvastatin
and simvastatin inhibit de novo cholesterol synthesis
in the hepatocyte, which subsequently increases LDL
receptor expression.
Products of Cholesterol Metabolism
 What Is Atherosclerosis?

The desirable
level of
cholesterol in
blood plasma:
< 200 mg/dl
(< 5 mmol/l)
Cholesterol is often deposited on the inner walls of
blood vessels, together with other lipids, a condition
known as atherosclerosis, which often leads
to occlusion of blood vessels in the heart and the brain,
resulting in heart attacks and strokes, respectively.
 Atherosclerosis is a disease in which plaque builds up
inside your arteries. Arteries are blood vessels that carry
oxygen-rich blood to your heart and other parts of your
body.
 Plaque is made up of fat,
cholesterol, calcium, and other
substances found in the blood. Over
time, plaque hardens and narrows
your arteries.
Atherosclerosis can lead to serious
problems, including heat
attack, stroke, or even death.
For a
healthy
person, the
LDL/HDL
ratio is 3.5
KETONE BODY METABOLISM.
In the fasting state, the liver converts excess acetyl-
CoA from β-oxidation of fatty acids into ketone
bodies, acetoacetate and 3-hydroxybutyrate (β-
hydroxybutyrate), which are used by extrahepatic
tissues. Cardiac and skeletal muscles and renal
cortex metabolize acetoacetate and 3-
hydroxybutyrate to acetyl-CoA.
After a week of fasting, ketones reach a concentration
in blood high enough for the brain to begin
metabolizing them. If ketones increase sufficiently in
the blood, they can lead to ketoacidosis.
 KETONE BODIES
The entry of acetyl CoA into the citric acid cycle
depends on the availability of oxaloacetate.
The concentration of oxaloacetate is lowered if
carbohydrate is unavailable (starvation) or improperly
utilized (diabetes).
Oxaloacetate is normally
formed from pyruvate by
pyruvate carboxylase
(anaplerotic reaction).

In fasting or diabetes
the gluconeogenesis is
activated and
oxaloacetate is consumed
in this pathway.
Fatty acids are oxidized producing excess of acetyl CoA
which is converted to ketone bodies:

b-Hydroxybutyrate
Acetoacetate
Acetone
Ketone bodies are
synthesized in liver
mitochondria and exported
to different organs.
Ketone bodies are fuel
molecules (can fuel brain and
other cells during long
starvation)
Ketone bodies are
synthesized in liver
mitochondria and exported
to different organs. In
liver lacks enzyme
decomposition of ketones, it
cannot metabolize the ketone
bodies.

Ketone bodies are fuel

molecules (can fuel brain
and other cells during long
starvation)
 A. Synthesis of ketone bodies

Two molecules
of acetyl CoA
condense to
form
acetoacetyl CoA.

Enzyme –
thiolase.
Acetoacetyl
CoA reacts
with acetyl
CoA and water
to give 3-
hydroxy-3-
methylglutaryl
CoA (HMG-
CoA) and CoA.

Enzyme:
HMG-CoA
synthase
3-Hydroxy-3-
methylglutaryl
CoA is then
cleaved to
acetyl CoA and
acetoacetate.

Enzyme:
HMG-CoA lyase.
 3-Hydroxybutyrate is
formed by the reduction of
acetoacetate by
3-hydroxybutyrate
dehydrogenase.
Acetoacetate also
undergoes a slow,
spontaneous
decarboxylation to
acetone.
Acetone is exhaled via
lungs and sweat in
condition of ketone bodies
abnormal accumulation this
brings to a characteristic
acetone smell of the body.
3-Hydroxybutyrate is oxidized to produce
acetoacetate as well as NADH for use in
oxidative phosphorylation.

3-hydroxybutyrate
dehydrogenase
First way activation:
Acetoacetate is activated
by the transfer of CoA
from succinyl CoA in a
reaction catalyzed by a
specific CoA transferase.
The second way
acetoacetyl - CoA is
formed by reaction with
CoA with the participation
of ATP and the enzyme
acetoacetyl -CoA
synthetase.
Acetoacetyl CoA is
cleaved by thiolase
to yield two
molecules of acetyl
CoA (enter the
citric acid cycle).
CoA transferase is
present in all
tissues except
liver.
 B. Ketone bodies are a major fuel
in some tissues
Ketone bodies diffuse from the liver
mitochondria into the blood and are transported
to peripheral tissues.
Ketone bodies are important molecules in energy
metabolism.
Heart muscle and the renal cortex use
acetoacetate in preference to glucose in
physiological conditions.
The brain adapts to the utilization of
acetoacetate during starvation and diabetes.
The overall accumulation of
ketone bodies in blood and urine
is known - ketosis. The acids also
upset buffers in the blood to cause
acidosis (diabets, starvation,
alcoholism, smoking, fatty food,
long exercise).
Ketogenolysis Acetoacetate picked up from the blood is activated in
the mitochondria by succinyl-CoA acetoacetyl-CoA transferase
(common name thiophorase), an enzyme present only in extrahepatic
tissues; 3-hydroxybutyrate is first oxidized to acetoacetate.

Note the important times at which the brain switches from: • Glucose
derived from liver glycogenolysis to glucose derived from
gluconeogenesis (~12 hours) • Glucose derived from
gluconeogenesis to ketones derived from fatty acids (~1 week) In the
brain, when ketones are metabolized to acetyl-CoA, pyruvate
dehydrogenase is inhibited. Glycolysis and subsequently glucose
uptake in brain decreases. This important switch spares body protein
(which otherwise would be catabolized to form glucose by
gluconeogenesis in the liver) by allowing the brain to indirectly
metabolize fatty acids as ketone bodies.
Ketoacidosis • In patients with type 1 insulin-dependent
diabetes mellitus not adequately treated with insulin, fatty
acid release from adipose tissue and ketone synthesis in
the liver exceed the ability of other tissues to metabolize
them, and a profound, life-threatening ketoacidosis may
occur. An infection or trauma (causing an increase in
cortisol and epinephrine) may precipitate an episode of
ketoacidosis by activating HSL.
Alcoholics can also develop ketoacidosis. Chronic
hypoglycemia, which is often present in chronic
alcoholism, favors fat release from adipose. Ketone
production increases in the liver, but utilization in
muscle may be slower than normal because alcohol is
converted to acetate in the liver, diffuses into the blood,
and oxidized by muscle as an alternative source of
acetyl-CoA.
Associated with ketoacidosis: • Polyuria, dehydration,
and thirst (exacerbated by hyperglycemia and osmotic
diuresis) • CNS depression and coma • Potential
depletion of K+ (although loss may be masked by a
mild hyperkalemia) • Decreased plasma bicarbonate •
Breath with a sweet or fruity odor, acetone
Ketogenesis occurs in mitochondria of hepatocytes when excess
acetyl-CoA accumulates in the fasting state. HMG-CoA synthase
forms HMG-CoA, and HMG-CoA lyase breaks HMG-CoA into
acetoacetate, which can subsequently be reduced to 3-
hydroxybutyrate. Acetone is a minor side product formed
nonenzymatically but is not used as a fuel in tissues. It does,
however, impart a strong odor (sweet or fruity) to the breath,
which is almost diagnostic for ketoacidosis

Clinical Correlate In untreated type 1 diabetes

mellitus, there is no insulin. Although glucose may be
high, no insulin is released, HSL is active, β-oxidation
is not inhibited, and ketone bodies are generated.
 KETOSIS
The absence of insulin in diabetes mellitus
 liver cannot absorb glucose  activation of fatty
 inhibition of glycolysis acid mobilization by
 activation of adipose tissue
gluconeogenesis
 deficit of oxaloacetate

 large amounts of acetyl CoA which can

not be utilized in Krebs cycle

 large amounts of ketone bodies (moderately strong acids)

 severe acidosis (ketosis)

Impairment of the tissue function, most importantly
in the central nervous system
The effect of nervous system on lipid metabolism

Sympathetic nervous system activates

the splitting of triacylglycerol (lipolysis)
аnd oxidation of fatty acids.

Parasympathetic nervous system activates

the synthesis of lipids and cholesterol in
organism.
 Endocrine regulation of lipid metabolism

The effect of somatotropic hormone on lipid

metabolism:
• stimulates lipolysis;
• stimulates the oxidation of fatty acids.

Prolactin.
- stimulates synthesis of lipids in mammary
glands.
 Lipotropic hormone

-stimulates the mobilization of lipids from depot.

Thyroxine and triiodthyronine

- activate the lipid oxidation and mobilization.

Insulin
- enhances the synthesis of lipids;
- promotes the lipid storage activating the carbohyd-
rate decomposition;
- inhibits the gluconeogenesis
 Glucagon

-activates the lipolisis;

Lipocain

- activates the formation of phospholipids in liver and

stimulates the action of lipotropic alimentary factors;
- activates the oxidation of fatty acids in liver.

Epinephrine
- activates the tissue lipase, mobilization of lipids and
oxidation of fatty acids.
 Glucocorticoids
- promote the absorption of lipids in
intestine;
- activate lipolysis;
- activate the conversion of fatty acids in
carbohydrates.

Sex hormones
- enhance the oxidation of lipids;
- inhibit the synthesis of cholesterol.
Pathologies of lipids metabolism:
 Obesity
Obesity means having too much body fat.
Obesity occurs over time when you eat more
calories than you use. The balance between
calories-in and calories-out differs for each
person. Factors that might affect your weight
include your genetic factors, stress, age,
overeating, eating high-fat foods, and not being
physically active.
Being obese increases your risk of diabetes,
heart disease, stroke, arthritis, and some
cancers.
 Fatty liver degeneration
Disbalance in synthesis and breakdown of fats and
the transport of their from the cells leads to fatty
liver degeneration. In normal state liver contain
only 1% of fats.
Increase mobilization of fat from
fatty depots and, consequently,
the delay of fat in the liver can
occur an diabetes, fasting,
deficiensy of choline and proteins,
protein starvation, infection
diseases, malignant tumors also
causes fatty liver degenaration.
 Substances that prevent fatty liver
degeneration, called lipotropic factors.
Lipotropic factors - choline, methionine ,
serine.
Lack of choline and methionine (donor of
methyl groups), besides reducing the synthesis
of phospholipids, also cause decrease level of
carnitine - a carrier of fatty acids from the
cytoplasm to the mitochondria. Thus, through
the decrease level of carnitine be suppressed
permanently the rate of oxidation of fatty acids,
which also contributes to the accumulation of
fats.
SPHINGOLIPIDS Sphingolipids are important
constituents of cell membranes. They are similar in
structure to the glycerophospholipids. The various
classes of sphingolipids differ primarily in the nature of
the hydrophilic region.
Classes of sphingolipids and their hydrophilic groups
include:
• Sphingomyelin: phosphorylcholine
• Cerebrosides: galactose or glucose
• Gangliosides: branched oligosaccharide chains
terminating in the 9-carbon sugar, sialic acid (N-
acetylneuraminic acid, NANA)
 Genetic Deficiencies of Enzymes in Sphingolipid
Catabolism
Sphingolipids released when membrane is
degraded are digested in endosomes after fusion with
lysosomes. Lysosomes contain many enzymes, each of
which removes specific groups from individual
sphingolipids.
 Genetic Deficiencies of Sphingolipid Catabolism
Disease Lysosomal Enzyme Substrate Symptoms
Missing Accumulating in
Inclusion Body
Toy-Sachs Hexosaminidase A Ganglioside GM2 • Cherry red spots in
macula • Blindness •
Psychomotor retardation
• Death usually <2 years
• Startle reflex
Gaucher Glucocerebrosidase Glucocerebroside • Type 1 (99%): adult
hepatosplenomegaly •
Erosion of bones,
fractures • Pancytopenia
or thrombocytopenia •
Characteristic
macrophages •
(crumpled paper
inclusions)

Niemann-Pick Sphingomyelinase Sphingomyelinase • May see cherry red

spot in macula •
Hepatosplenomegaly •
Microcephaly, severe
mental retardation •
Foamy macrophages
with zebra bodies • Early
death
 Symptoms of Gaucher disease
Gaucher disease is a hereditary disease, which is based on a lack of an
enzyme called glucocerebrosidase, which cleaves the products of
human cell metabolism. Because of this, virtually all internal organs
accumulate specific cells (Gaucher cells), especially the liver and
spleen.
Main signs of Gaucher disease:
- Increased size of the liver and spleen;
- The appearance of subcutaneous hematoma, prolonged bleeding of
wounds after even minor injuries.
- Decrease in hemoglobin, increased liver enzymes (detected in blood
tests).
- Pain in the bones, their fragility, frequent fractures.
- Violation of joint mobility due to the destruction of bone tissue.
The emergence of neurological symptoms: uncontrolled contractions
of certain muscle groups, seizures, respiratory failure.
Fabry Disease. Fabry disease is the only one that is X-
linked recessive. Fabry is caused by a mutation in the gene that
encodes the lysosomal enzyme alpha-galactosidase. Ceramide
trihexoside accumulates in the lysosomes. Fabry disease presents
during childhood or adolescence:
• Burning sensations in the hands which gets worse with exercise
and hot weather
• Small, raised reddish-purple blemishes on the skin
(angiokeratomas)
• Eye manifestations, especially cloudiness of the cornea
• Impaired arterial circulation and increased risk of heart attack
or stroke
• Enlargement of the heart and kidneys
• Often there is survival into adulthood but with increased risk of
cardiovascular disease, stroke.
• Renal failure is often the cause of death. Enzyme replacement
therapy is available and, although expensive, slows the progression
of the disease.
Niemann-Pick disease is an inherited condition involving
lipid metabolism, which is the breakdown, transport, and use
of fats and cholesterol in the body. In people with this
condition, abnormal lipid metabolism causes harmful
amounts of lipids to accumulate in the spleen, liver,
lungs, bone marrow, and brain. Niemann-Pick disease
type A appears during infancy and is characterized by an
enlarged liver and spleen (hepatosplenomegaly), failure to
gain weight and grow at the expected rate (failure to thrive),
and progressive deterioration of the nervous system. Due to
the involvement of the nervous system, Niemann-Pick
disease type A is also known as the neurological type.