Advance Clinical Biochemistry

Course No. 5030521

Lipids, lipoproteins and their disorders

Dr. Moayad H. Khataibeh

Ph.D. in Biochemistry and Clinical Biochemistry
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Bachelor and Master in Biochemistry
Introduction to Lipids
“Lipids are organic compounds that contain hydrogen, carbon,
and sometimes may contain oxygen atoms, which forms the
framework for the structure and function of living cells.

Sources of lipids:-
 Exogenous: absorbed from diet.
 Endogenous: synthesized by the hepatic cells and
adipose tissue. must be transported b
They must be transported between the various tissues and organs,
through the blood, for utilization and storage.

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Introduction to Lipids
Types of Lipids:-
Hydrophobic lipids /non-polar such as triacylglycerol and
cholesterol esters, while some of the other type is amphipathic
in nature, such as phospholipids, fatty acids and cholesterol
and protein called apolipoproteins/ apoproteins.

 Since lipids are insoluble in water, the problem arises of

how to transport them in an aqueous solution such as the
blood.
 This problem is solved by associating them to make water-
miscible lipoproteins.
Introduction to Lipids
 So lipids travel as water-miscible complexes. composed of
phospholipids, cholesterol and proteins outside/ exterior
and cholesteryl esters and TAG inside/ interior.

 Cholesterol is an essential component of all animal cell

membranes along with a precursor for steroid / sex hormone
and bile acid biosynthesis
 Triglycerides (TGs): Central for the storage &
transportation of energy within body (functional lipids).

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Introduction to Lipids
Amphipathic compounds behaviors with extracellular
fluids and cytosol ( water).
Cholesterol and other lipids are carried on lipoprotein particles

Lipoproteins are multicomponent complexes of

proteins and lipids.

Each type of lipoprotein has a characteristic molecular

mass, size, composition, density (mentioned earlier )
and physiological role.
Structure of lipoproteins (Water-miscible complex).

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Structure Of Lipoprotein

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Function/Role Of Lipoproteins

• Lipoproteins function as transport vehicles, of

insoluble form of Lipids in blood plasma.

• Serves in transportation of
– Exogenous lipids (Dietary Source)
– Endogenous (Lipids biosynthesized)

• Lipoproteins deliver lipid forms (Cholesterol and TAG etc,,)

from one organ to other organs for their utilization, through
aqueous phase of Lymph and blood
Role of Lipoproteins Components

– Substrates for Energy Metabolism (TAG)

– Provide Essential components for cell structure (PL,
Cholesterol)
– Precursors for Hormones (Cholesterol)
– Precursors for Bile acids and Bile salts (Cholesterol)
– Carries Lipid soluble Vitamins (KEDA)
Lipoproteins

Four major types of lipoprotein

1. Chylomicron (CM): carry

TG from intestine to liver
2. Very low density lipoproteins
(VLDL): carry TG from liver
to other body cells
3. Low density lipoproteins
(LDL): carry cholesterol to all
body cells
4. High density lipoprotein
(HDL): carry cholesterol from
body cells to liver “ reverse
cholesterol transport”
Structure of Chylomicron and LDL
Four Major Classes of Human Plasma Lipoproteins

Different combinations of lipids and proteins produce particles of different densities

– can be separated by ultracentrifugation

Table 21-1 Major Classes of Human Plasma Lipoproteins: Some

Lipoprotein Density (g/mL) Protein Phospholipids Composition Composition Triacylglycerols
(wt %): Free (wt %):
cholesterol Cholesteryl
esters

Chylomicrons <1.006 2 9 1 3 85

VLDL 0.95–1.006 10 18 7 12 50

LDL 1.006–1.063 23 20 8 37 10

HDL 1.063–1.210 55 24 2 15 4
Four Major Classes of Lipoprotein Particles

• Named based on position of sedimentation

(density) in centrifuge
• Large enough to see in electron microscope
– Chylomicrons (largest and least
dense)
– Very low-density lipoproteins (VLDL)
– Low-density lipoproteins (LDL)
– High-density lipoproteins (HDL) –
smallest, most dense
Apolipoproteins in Lipoproteins

“Apo” for “without”…

– So “apolipoprotein” refers to the protein part of a lipoprotein particle.
Table 21-2 Apolipoproteins of the Human Plasma Lipoproteins
Apolipoprotein Polypeptide molecular weight Lipoprotein association Function (if known)

ApoA-I 28,100 HDL Activates LCAT; interacts with ABC

transporter

ApoA-II 17,400 HDL Inhibits LCAT

ApoA-IV 44,500 Chylomicrons, HDL Activates LCAT; cholesterol
transport/clearance

ApoB-48 242,000 Chylomicrons Cholesterol transport/clearance

ApoB-100 512,000 VLDL, LDL Binds to LDL receptor
ApoC-I 7,000 VLDL, HDL

ApoC-II 9,000 Chylomicrons, VLDL, HDL Activates lipoprotein lipase

ApoC-III 9,000 Chylomicrons, VLDL, HDL Inhibits lipoprotein lipase
ApoD 32,500 HDL

ApoE 34,200 Chylomicrons, VLDL, HDL Triggers clearance of VLDL and

chylomicron remnants

ApoH 50,000 Possibly VLDL, binds phospholipids such as Roles in coagulation, lipid metabol1is1m,
cardiolipin apoptosis, inflammation
Lipoproteins (LPs) : Chylomicrons (CMs) and Transport

• They transport dietary (exogenous) TAG and cholesterol from

intestine to other tissues in the body (such as hepatic &
peripheral cells).
• Can reach the circulation via lymph & are subjected to the
action of lipoprotein lipase (LPL) in the blood to give TGs
then hydrolyzed and taken up
• The remaining cholesterol-rich structure, no call
chylomicron-remnant is taken up by the liver cells
• In the liver, the remnants release their cholesterol and are
degraded in lysosomes.
• This pathway from dietary cholesterol to the liver is the
Exogenous pathway
Lipoproteins (LPs) : Chylomicrons (CMs) and Transport

• LPL-deficiency causes an elevated chylomicron

concentration (type I hyperlipidemia).
• No evidence s h o w s that CM are pro-atherogenic;
they are probably too large to penetrate
the vascular endothelium
Lipoproteins (LPs) : Chylomicrons (CMs) and Transport

Chylomicrons transport exogenous lipids

Lipoproteins (LPs) : Chylomicrons (CMs)

• Function: deliver TGs to body cells to be used as a fuel

• Rich in TGs (85 – 92%)
• diameters as large as 1200 nm
Lipoproteins (LPs) :VLDLs, Metabolism and Transport

 Very low density lipoproteins (VLDLs):

• They transport endogenous TAG and cholesterol (those
synthesized in the liver) to other tissue in the body.
• Produced by liver
• Excess fatty acids and cholesterol converted to triacylglycerols
or cholesteryl esters in the liver and packaged with specific
apolipoproteins into VLDL.
• Triacylglycerol loss converts some VLDL to VLDL remnants, also
called intermediate density lipoprotein (IDL).
• Further removal of triacylglycerol from IDL (remnants)
produces LDL
• Major carriers of endogenous triglycerides (TGs)
VLDLs transport endogenous lipids

• Transport endogenous triacylglycerol &

cholesterol from liver to adipose & muscle tissues
• VLDL METABOLISM:-
• Muscle uses the TAG for energy.
• Rich in TGs (70%)
• Function: deliver TGs to body cells
• Similar to chylomicrons, but made by different tissues
VLDLs transport endogenous lipids
Low density lipoproteins and Lipid Transport

Low density lipoproteins

• Form as a result of lipolysis of VLDL (lost majority of
their TGs)
• Derived from VLDL
• Made in the Liver
• Rich in cholesterol that is why called the bad cholesterol
• They transfer cholesterol from liver to other tissues (Harmful)
• Readily taken up by cells via LDL receptors in hepatic &
peripheral cells
• Significantly lesser than VLDL; can infiltrate to extracellular
space
Low density lipoproteins and Transport

• Function:
 deliver hepatic cholesterol to all body cells (LDL carries
cholesterol to extrahepatic tissues such as muscle, adrenal
glands, and adipose tissue.
 Muscle and adipose tissue have LDL receptors, that enable
myocytes and adipocytes to take up cholesterol via
receptor- mediated endocytosis

 These tissues have plasma membrane LDL receptors that

mediates uptake of cholesterol and cholesteryl esters.
 LDL also delivers cholesterol to macrophages, sometimes
converting them into foam cells
 This pathway, from VLDL formation in the liver to LDL return
to the liver, is the Endogenous pathway of cholesterol
Low density lipoproteins and Transport

• A product of VLDL catabolism which later catalyzed by

lipoprotein lipase (LPL )
• Contain more than 60% cholesterol & account for more
than 60% of the total plasma cholesterol too.
• Have a high atherogenic potential?
 LDL activates monocytes (macrophages)
 Ox-LDL is a major source of cholesterol for macrophages in
atheromatous plaques
Effect of LDL on cellular cholesterol homeostasis

Endocytosed LDL release their cholesterol content into cells.

• Excess cellular cholesterol concentrations will:

1. Inhibit HMG CoA reductase and thus decreases
cholesterol de novo synthesis
2. Represses LDL receptor protein gene expression and thus
reduces LDL receptor protein synthesis. This limits LDL
cholesterol entry into cells
3. Activate acyl CoA: cholesterol acyltransferase (ACAT)
which increases cholesterol esterification
Lipoproteins/ LDLs

• Atheromatous plaque is also known as plaque

• An abnormal accumulation of different materials in
the inner layer of the wall of
an artery
It consistent of:
 Macrophages
 Debris, containing lipids
 Calcium
 Variable amount of fibrous connective tissue

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IPs / Intermediate Density Lipoproteins

 Intermediate density lipoprotein IDLs:

• Derived from both VLDL & HDL

• Expresses ApoB-100, Apo C & Apo E

IDL particles are either:

 Taken up by the liver, a process mediated by Apo E

 Reduced to LDL (by losing Apo E & TGs)

High density lipoproteins (HDLs):

High density lipoproteins (HDLs):

• They are the smallest ( in quantity) and the highest (in density)
among of plasma lipoproteins.
• Synthesized / originates in the liver and small intestine as
small, protein-rich particles that contain relatively little
cholesterol.
• Nascent HDL can also pick up cholesterol from
cholesterol-rich extrahepatic cells (including
macrophages and foam cells)
• Mature HDL then returns to the liver. (good)
• Can exist either as disk-shaped or spherical particles
• Capable of removing excess cholesterol from peripheral
cells and take it back to the liver. "reverse cholesterol
transporter“
LPs / High Density Lipoproteins

• Highly heterogeneous; can be separated into 13 or 14 sub-

fractions
• Potential to help reversing the heart diseases
• Produced by extrahepatic tissue & serves as a vehicle for
the transfer of cholesterol from the peripheral tissues
• HDLs take up the cholesterol liberated in the course of
normal cell membrane turnover
• Endogenous pathway = the pathway from VLDL formation
in the liver to LDL return to the liver

• Reverse cholesterol transport = the HDL circuit where HDL

picks up cholesterol from cholesterol-rich extrahepatic cells
and returns it to the liver for unloading
– much of this cholesterol is converted to bile salts and
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stored in the gallbladder
Function of HDL

• Functions:
1. HDL particles serve as a circulating reservoir of apo C-II and
apo
E.
2. HDL uptake of unesterified cholesterol from non-hepatic
(peripheral) tissues and return it to the liver as
cholesteryl esters
3. Esterification of cholesterol
4. Reverse cholesterol transport
lipoproteins

Remember that …
 Cholesterol rich lipoproteins: LDL & HDL

 Triglycerides rich lipoproteins: VLDL & CM

The summary for Lipoproteins

Fraction Source Major lipid

CM Intestine Dietary TAG

VLDL Liver Endogenous TAG
IDL VLDL Endogenous TAG
LDL VLDL Cholesterol to tissues
Liver &
HDL Cholesterol from tissues
Intestine

Forget these two facts….

1. Lipoproteins according to the density:
 HDL > LDL > IDL > VLDL > CM
2. Lipoproteins according to the size:
 HDL < LDL < IDL < VLDL < CM
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Functions of Lipoproteins

 Solubilize the hydrophobic lipids

 Act as cellular targeting

signals, providing recognition sites for cell
surface receptors

 Serving as activators (coenzymes) for

enzymes involved in lipoprotein metabolism
 Coenzyme is a non-amino acids part of compound enzyme

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Functions of Lipoproteins
Plaque Formation in Arterial Wall
• Macrophages can uptake LDL can be by two types of receptors:
1. Specific and regulated LDL receptors.
2. Nonspecific and unregulated scavenger receptor class A (SR-A)
• When intercellular cholesterol concentration is high, LDL receptor
synthesis is inhibited in both macrophages and liver. LDL will
accumulate in blood.
• LDL in blood is highly liable for oxidative damage by reactive
metabolic intermediates. Oxidized LDL cannot be uptaken by
specific LDL receptors
• Instead oxidized LDL will be up taken by SR-A in macrophages.
• SR-A is not down regulated by high intercellular cholesterol
concentrations. Therefore, it keeps up taking oxidized
LDL.
• This will accumulate cholesteryl esters in macrophages. This will
 Familial Hypercholesterolemia

• Due to genetic mutation in LDL receptor

• Impairs receptor-mediated uptake of cholesterol from
LDL
• Cholesterol accumulates in the blood and in foam cells.
• Regulation mechanisms based on cholesterol
sensing inside the cell don’t work.
• Homozygous individuals can experience severe CVD
as youths.

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Cardiovascular Disease (CVD) Is
Multifactorial

• Very high LDL-cholesterol levels tend to correlate

with atherosclerosis.
– although many heart attack victims have normal
cholesterol, and many people with high cholesterol do
not have heart attacks
• Low HDL-cholesterol levels are negatively associated
with heart disease.

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Lipoproteins and Disorders

• Dyslipidemia = dyslipoproteinemia: elevation of blood

cholesterol, TGs or both or a low HDL that
contributes to the development of atherosclerosis
 Includes disorders of lipid levels, abnormalities in
lipoprotein structure abnormal lipoprotein
&
composition or density
• Can be primary or
Fredrickson's classification of
secondary:
primary dyslipoproteinemia
 They can be classified into 5 types, each of which may
be familial or acquired
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Lipoprotein particles and vascular disease

• High blood levels of HDL ("good" cholesterol) correlate with

low incidence of atherosclerosis. Lifestyle changes affect HDL
levels— exercise can increase them, while obesity and smoking
lower them.

• Bacterial & viral infections, & some inflammatory disease

states decrease HDL & increase VLDL production by the liver.
• These & other changes associated with inflammation can lead to
increased risk of atherosclerosis if prolonged.

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Dyslipoproteinemia
Hyperlipoproteinemia
A. Primary hyperlipoproteinemia
(I, IIa, IIb, III, IV & V)
B. Secondary hyperlipoproteinemia
1. Diabetes mellitus (DM)
2. Hypothyroidism
3. Nephrotic syndrome (NS)
4. Obesity
5. Obstructive jaundice
Hypolipoproteinemia
A. A-a-lipoproteinemia =
Alphalipoprotein deficiency
(Tangier’s disease)
B. A-b-lipoproteinemia =
(Abetalipoproteinemia)
C. Hypobetalipoproteine
mia
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Fredrickson's classification (Self Study)

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Primary hyperproteinemia

Type Name Causes Lipoprotein TC TAG

Familial (-) LPL or

I hyperchylomicronemia (-) Apo-CII CM N or (+) (+)

Familial
IIa hypercholesterolemia (-) LDL receptors LDL (+) N

Familial combined (-) LDL receptors

IIb LDL & VLDL (+) (+)
hypercholesterolemia (+) Apo-B
Familial IDL & CM
III (-) Apo-E (+) (+)
dysbetalipoproteinemia remnants

IV Endogenous (+) VLDL VLDL N or (+) (+)

hyperlipemia
Familial (+) VLDL
V CM & VLDL (+) (+)
hypertriglyceridemia (-) LPL

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Type I / hyperlipoproteinemias

• The familial type is due to deficiency of

lipoprotein lipase (LPL)

• Lab findings:
 (+) CM
 (+) VLDL
 (-) LDL & HDL
 (+) TGs
 (+) cholesterol
 The plasma appearance is latescent (milky)

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Type II / hyperbetalipoproteinemia

• Also called, familial hypercholesterolemia (FH)

• Can be:
1. Familial (IIa), due to defective LDL receptors
2. The acquired type (IIb), occurs in hypothyroidism

• Lab findings:
 (+) LDL (2-3 folds)
 (+) cholesterol
 Plasma appearance is clear
• Clinical features: tendon & tuberous xanthoma

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Type III / dysbetalipoproteinemia

• The familial type is caused by defective Apo-E

necessary for uptake & metabolism of VLDL & CM-
remnants by liver

• Lab findings:
 (+) VLDL
 (+) IDL
 (+) chylomicron remnants
• The plasma appearance is turbid
• Hypercholesterolemia & hypertriacylglycerodemia are
being observed

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Type IV / hyperprebetalipoproteinemia

 Familial type, due to increased formation of

TAGs from carbohydrates
 Acquired, occurs in severe type-2 DM (T2DM), obesity &
alcoholism

• Lab findings:
 (+) VLDL
 (+) TGs
 (+/N) cholesterol
 The plasma appearance is turbid

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Type V / hyperchylomicronemia

• Also known as familial hypertriglyceridemia

• The direct cause, is not completely clear, but may be due to
increase formation of Apo-B (non-HDL)

• Lab findings:
 (+) chylomicrons
 (+) VLDL
 (+) TGs
• The plasma appearance is turbid
• Is usually associated with obesity & T2DM

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Hypolipoproteinemias

1. Alphalipoprotein deficiency:
• Familial disease: caused by failure of the
liver to synthesize Apo-A 
complete absence of Apo-A1

• Cholesterol esters accumulate in

the tissues (Tangier's disease)
 HDL is absent in Tangier disease
Tangier’s disease
• Plasma TAGs are increased due to
deficiency of Apo-CII the activator of
LPL

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Hypolipoproteinemias
2. A beta lipoproteinemia: a disorder that interferes with the
normal absorption of fat & fat-soluble vitamins

• A familial disease:
• Due to hepatic & intestinal failure to synthesize Apo-B
 absence of CM, VLDL & LDL in the blood
• Marked decrease in plasma lipids
• The intestine fails to absorb TAGs  fatty
diarrhea (steatorrhea)
• The liver fails to mobilize fats to the blood  fatty liver

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Hypolipoproteinemias

3. Hypo beta lipoproteinemia:

• Familial disease

• Caused by decreased formation of the Apo-B100

by the liver  decreased formation of VLDL & LDL

• Decreased plasma lipids

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Atherosclerosis

• Arteriosclerosis: group of conditions that cause

stiffening or hardening of the artery walls
 If caused by lipids (esterified cholesterol)
being deposited in artery walls  fatty streaks
• Atherosclerosis: narrowing of the artery because
of plaque build-up

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Atherosclerosis / pathogenesis

• Injury of arterial endothelial cells (ECs) by

hypercholesterolemia or other risk factors (HTN,
smoking & DM)  damage
• Monocytes attachment & endothelial cell dysfunction
with altered prostacyclin
 Endothelial prostacyclin inhibits platelet aggregation
 Platelets aggregation & thromboxane A2 (TXA2)
release
• Attached monocytes  free radicals that oxidize LDL &
destroy the receptors needed for normal receptor- mediated
clearance of LDL

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Dyslipoproteinemia / lab assessment

• Lipids profile: a group of blood tests requested together to

assess the risk of CHD & atherosclerosis
 Test requirements:
• An overnight fasting 10-12 hr. only water is allowed
• Withhold all medication for at least 24 hr. before testing (if
possible)
• Patient should abstain from alcohol for 48 hr.
before testing
• It is not recommended to use heparinized plasma
(TAG estimation)?
• It is not recommended to use citrate, oxalate or fluoride
plasma (cholesterol estimation)?
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Just go for it ….

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Questions??

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