BCH 313 : LIPID METABOLISM

1.0 Biosynthesis of Fatty acids

The cytosol is the primary site for lipogenesis or de novo synthesis of fatty acids. Many tissues,

including the liver, mammary gland, kidney, brain, adipose tissues and lung, contain this system.

Among its cofactor requirements are ATP, biotin, Mn, NADPH and HCO3 (source of carbon

dioxide). The immediate substrate is acetyl CoA, and the final product is free palmitate.

Fatty acid biosynthesis occurs in the cytosol, so acetylCoA has to be transported from the

mitochondria to the cytoplasm. This is done via a shuttle system called the Citrate Shuttle. As

acetylCoA can not cross the membrane, it is transported out of mitochondria as citrate.

AcetylCoA reacts with oxaloacetate to give citrate. Citrate is formed by the condensation of

acetyl CoA with oxaloacetate by the enzyme citrate synthase .A tricarboxylate translocase

transports citrate from mitochondria to cytosol.

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 The first and foremost controlling step involved in the fatty acid biosynthesis is the
production of malonyl-CoA.
 In the initial reaction, acetyl-CoA is carboxylated to malonyl-CoA in the presence of
ATP and acetyl-CoA carboxylase, which calls for bicarbonate as a source of CO2. This
enzyme is crucial for controlling the synthesis of fatty acids.
 The fatty acid synthase (FAS) enzyme complex produces fatty acids following the
synthesis of malonyl-CoA. This multienzyme polypeptide complex, which includes the
acyl carrier protein (ACP), links the individual enzymes necessary for fatty acid
synthesis.
 The multienzyme complex includes 4′-phosphopantetheine, a form of the vitamin
pantothenic acid.
 Initially, a cysteine (-SH group) joins with an acetyl-CoA priming molecule, while
malonyl-CoA joins with the -SH group next to it on the 4′-phosphopantetheine of ACP of
the other monomer. Malonyl acetyl transacylase catalyses these reactions resulting in the
formation of the acetyl (acyl)-malonyl enzyme.

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  With the help of 3-ketoacyl synthase, the acetyl group attacks the methylene group of the
malonyl residue and releases CO2 to create the 3-ketoacyl enzyme, which then releases
the cysteine -SH group.
 Decarboxylation enables the reaction to proceed to completion, moving the entire chain
of reactions forward.
 To create the corresponding saturated acyl-enzyme, the 3-ketoacyl group is first reduced,
then dehydrated and reduced once more.
 The saturated acyl residue is transferred to the free cysteine -SH group when a new
malonyl-CoA molecule joins with the -SH of 4′-phosphopantetheine.
Up until the formation of a saturated 16-carbon acyl radical (palmitoyl), the series of reactions is
repeated six more times. Before the free palmitate can move along any other metabolic pathway,
it must first be activated to acyl-CoA.

Palmitic Acid Synthesis

Conversion of Acetyl CoA to Malonyl CoA

The acetyl - CoA is carboxylated in the cytoplasm in the presence of acetyl CoA
carboxylase, a vitamin Biotin containing enzyme, which helps in carbondioxide
fixation. Acetyl CoA carboxylase is the regulatory enzyme in the fatty acid
biosynthesis.

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Conversion of malonyl CoA to palmitic acid

The malonyl CoA is converted to palmitic acid by several steps and each of these
steps are catalysed by different enzymes of fatty acid synthetase complex.

Acetyl CoA and malonyl CoA condenses to form butyryl-ACP with the formation
of intermediates. This cycle repeats itself six times and in each cycle two carbon

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atoms (malonyl CoA) is added to butyryl ACP, ultimately resulting in the
formation of palmitoyl CoA, a 16 carbon molecule.
Palmitate contains a 16-carbon saturated fatty acid called palmitic acid which is the most
common fatty acid found in palm oil.

Acetyl-CoA and malonyl-CoA are combined to form palmitate, as per the following equation:

CH3CO-S-CoA (Acetyl CoA) + 7HOOCCHCO-S-CoA (7 Malonyl CoA) + 14NADPH +

14H+ → CH3(CH12)14COOH (Palmitate) + 7CO2 + 6H2O + 8CoA-SH + 14NADP+

Unsaturated Fatty Acids: Fatty acid desaturase, an enzyme in the endoplasmic reticulum,

introduces double bonds between carbons 9 and 10 in palmitate and in stearate,

producing palmitoleic acid (16:1:Δ9) and oleic acid (18:1:Δ9), respectively.

Fatty acid desaturase requires O2 and either NAD+or NADPH.

Humans lack the enzymes necessary to introduce double bonds beyond carbon 9. Thus linoleic

acid (18:2:Δ9,Δ12) and linolenic acid (18:2:Δ9,Δ12,Δ15) cannot be synthesized. These

are essential fatty acids. Linoleic acid can serve as a precursor for arachidonate, sparing it as an

essential fatty acid. Arachidonate is an important component of membrane lipids and, together

with linoleic and linolenic acid, serves as a precursor for the synthesis

of prostaglandins, thromboxanes, leukotrienes, and lipoxins.

Long-chain Fatty Acids : Propionyl-CoA is used as the primer rather than acetyl-CoA for the
synthesis of long-chain fatty acids. Especially for fatty acids with an odd number of carbon
atoms, which are found primarily in ruminant milk and fat.

2.0 Biosynthesis of Triacylglycerol and Phospholipids

Biosynthesis of Phosphatidate

One of the important intermediates in phospholipid biosynthesis is phosphatidate. This

biosynthetic pathway requires two precursors. One is an acyl-CoA containing the fatty acid to be

incorporated into the phosphatidate. The other precursor is glycerol-3-P derived from glycolysis

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(intermediary metabolism). A fatty acid in the form of the acyl-CoA can be esterified to the

glycerol-3-P by glycerol-3-P-phosphate acyltransferase. This reaction can take place both in the

endoplasmic reticulum and on the outer membrane of mitochondria. There are two

different enzymes, catalyzing the same chemical reaction, with the active site on the cytoplasmic

side of the membranes. In endoplasmic reticulum, the enzyme will use both saturated and

unsaturated acyl-CoA as substrate, whereas in mitochondrial outer membranes (mostly in the

liver), the enzyme preferentially utilizes saturated acyl-CoA. The product of this reaction is

lysophosphatidate.

The lysophosphatidate can also be synthesized from dihydroxyacetone phosphate which, as in

the case of glycerol-3-P, is derived from glycolysis. Dihydroxyacetone-P is also a precursor to

the synthesis of acyldihydroxyacetone-P. This compound has two fates. One is conversion to

lysophosphatidate and thus a precursor to the synthesis of phosphatidate. The other fate is

conversion to alkyldihydroxyacetone-P which is on the pathway to synthesis of the alkyl and

alkenyl lipids.

Lysophosphatidate is the substrate for 1-acylglycerol-3-P acyltransferase. The product formed is

phosphatidate. This reaction is more abundant in the endoplasmic reticulum than in

mitochondrial outer membranes.

Phosphatidate is at a pivotal point in the lipid biosynthetic pathways. It can be considered to have

at least three important roles. First, it serves as a precursor for the formation of diacylglycerol,

which can be used for the biosynthesis of phosphatidylcholine and phosphatidylethanolamine, or

can be a precursor for triglyceride biosynthesis. Second, phosphatidate is a substrate for the

reaction forming CDP-diacylglycerol, which is a precursor for the synthesis

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of phosphatidylinositol, phosphatidylglycerol, and diphosphatidylglycerol. Finally, phosphatidate

can be metabolized to fatty acids and glycerolphosphate by phospholipases.

2.1 Biosynhesis of Triacylglycerol

Three main pathways for triacylglycerol biosynthesis are known, the sn-glycerol-3-phosphate

and dihydroxyacetone phosphate pathways, which predominate in liver and adipose tissue, and a
monoacylglycerol pathway in the intestines. In maturing plant seeds and some animal tissues, a
fourth pathway has been recognized in which a diacylglycerol transferase is involved.

Kennedy pathway: The most important route to triacylglycerols is the sn-glycerol-3-phosphate

or Kennedy pathway, first described by Professor Eugene Kennedy and colleagues in the 1950s,
by means of which more than 90% of liver triacylglycerols are produced.

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In this pathway, the main source of the glycerol backbone was long believed to be sn-glycerol-3-
phosphate produced by the catabolism of glucose (glycolysis), but it is now known that a
significant proportion of the glycerol-3-phosphate is produced de novo by a process known as
glyceroneogenesis via pyruvate, possibly the main source in adipose tissue, or to a lesser extent
by the action of the enzyme glycerol kinase on free glycerol.

Subsequent reactions occur primarily in or at the endoplasmic reticulum. First, the precursor sn-
glycerol-3-phosphate is esterified by a fatty acid coenzyme A ester in a reaction catalysed by a
glycerol-3-phosphate acyltransferase (GPAT) at position sn-1 to form lysophosphatidic acid, and
this is in turn acylated by an acylglycerophosphate acyltransferase (AGPAT) in position sn-2 to
form a key intermediate in the biosynthesis of all glycerolipids - phosphatidic acid, reactions
described in greater detail in our web page on this lipid. Numerous isoforms of these enzymes
are known; they are expressed with specific tissue and membrane distributions, and they are
regulated in different ways.

Then, the phosphate group is removed by a family of enzymes - phosphatidic acid

phosphohydrolases (PAPs or ‘phosphatidate phosphatases’ or ‘lipid phosphate phosphatases’ or
'lipins'), which produce sn-1,2-diacylglycerols as essential intermediates in the biosynthesis of
triacylglycerols and of the phospholipids phosphatidylcholine and phosphatidylethanolamine
(and of monogalactosyldiacylglycerols in plants). This is a key branch-point in lipid biosynthesis
as it may dictate the flow of lipids for storage or membrane biogenesis.

Dihydroxyacetone-phosphate pathway: In a second pathway for triacylglycerol biosynthesis,

dihydroxyacetone-phosphate in peroxisomes or the endoplasmic reticulum can be acylated with fatty acid CoA
esters by a specific acyltransferase to form 1-acyl dihydroxyacetone-phosphate, which is reduced by
dihydroxyacetone-phosphate oxido-reductase to lysophosphatidic acid and can then enter the pathway above to
triacylglycerols. The precursor dihydroxyacetone-phosphate has further importance as part of the biosynthetic
route to plasmalogens, and neutral plasmalogens can be significant components of cytoplasmic droplets in
many mammalian cells types but not in adipose tissue.

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In prokaryotes, the glycerol-3-phosphate pathway of triacylglycerol biosynthesis only occurs, but
in yeast both glycerol-3-phosphate and dihydroxyacetone-phosphate can be the primary
precursors, and synthesis takes place in both cytoplasmic lipid droplets and the endoplasmic
reticulum. In plants, the glycerol-3-phosphate pathway is most important

2.2 Biosynthesis of Phospholipids

Phospholipids are synthesized in the ER membrane from cytosolic precursors. Two fatty acids

linked to coenzyme A (CoA) carriers are first joined to glycerol-3-phosphate, yielding

phosphatidic acid, which is simultaneously inserted into the membrane. A phosphatase then

converts phosphatidic acid to diacylglycerol.

Phospholipids are the main constituent of biological membranes. The size, shape, charge, and

chemical composition of different phospholipid classes play a role in the formation and

maintenance of the plasma membrane bilayer of cells, as well as membranes surrounding

subcellular organelles and vesicles.

Phospholipids are esters of glycerol, fatty acids, phosphoric acid, and other alcohols. The most

common phospholipids are phosphatidylcholine, phosphatidylethanolamine, phosphatidylinositol

, and phosphatidylserine. These phospholipids share the common features of fatty acids esterified

to the 1 and 2 positions of the glycerol backbone with the phosphate group esterified to the 3

position.

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The assembly of phospholipids from simple precursors requires (1) synthesis of the backbone

molecule (glycerol or sphingosine); (2) attachment of fatty acid(s) to the backbone through an

ester or amide linkage; (3) addition of a hydrophilic head group to the backbone through a

phosphodiester linkage; and, in some cases, (4) alteration or exchange of the head group to yield

the final phospholipid product. In eukaryotic cells, phospholipid synthesis occurs primarily on

the surfaces of the smooth endoplasmic reticulum and the mitochondrial inner membrane. Some

newly formed phospholipids remain at the site of synthesis, but most are destined for other

cellular locations.

Cells Have Two Strategies for Attaching Phospholipid Head Groups The first steps of

glycerophospholipid synthesis are shared with the pathway to triacylglycerols : two fatty acyl

groups are esterified to C-1 and C-2 of L-glycerol 3-phosphate to form phosphatidic acid.

Commonly but not invariably, the fatty acid at C-1 is saturated and that at C-2 is unsaturated. A

second route to phosphatidic acid is the phosphorylation of a diacylglycerol by a specific kinase.

The polar head group of glycerophospholipids is attached through a phosphodiester bond, in

which each of two alcohol hydroxyls (one on the polar head group and one on C-3 of glycerol)

forms an ester with phosphoric acid . In the biosynthetic process, one of the hydroxyls is first

activated by attachment of a nucleotide, cytidine diphosphate (CDP). Cytidine monophosphate

(CMP) is then displaced in a nucleophilic attack by the other hydroxyl. The CDP is attached

either to the diacylglycerol, forming the activated phosphatidic acid CDP-diacylglycerol(strategy

1), or to the hydroxyl of the head group (strategy 2). Eukaryotic cells employ both strategies,

whereas prokaryotes use only the first. The central importance of cytidine nucleotides in lipid

biosynthesis was discovered by Eugene P. Kennedy in the early 1960s.

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Functions of Phospholipids
Phosphotidic acid is a key building block of phospholipid synthesis and a major lipid second
messenger conveying signaling information through it’s ability to recruit and/or activate specific
proteins in restricted compartments and within those only at defined submembrane areas

Phosphatidylglycerols are key intermediates in the biosynthesis of many lipids. They are

essential for the development of normal membranes of chloroplasts and mitochondria in higher

plants. In bacteria, phosphatidylglycerols are important for optimal functioning of the bacterial

machinery and play a role in protein folding and binding. Further, phosphatidylglycerols have a

role in the regulation of the innate immune response in the lungs.

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Phosphatidyl serine (PS) is a phospholipid nutrient found in fish, green leafy vegetables,
soybeans and rice, and is essential for the normal functioning of neuronal cell membranes and
activates Protein kinase C (PKC) which has been shown to be involved in memory function.

Phosphatidylethanolamine plays a role in the assembly of lactose permease and other membrane
proteins. It acts as a 'chaperone' to help the membrane proteins correctly fold their tertiary
structures so that they can function properly.

Phosphatidylcholine is a phospholipid that's present in foods like eggs and whole grains. It's used

to make an important neurotransmitter that plays a role in memory. PC benefits include its ability

to improve memory, reduce fat deposits, relieve ulcerative colitis symptoms and support

metabolic health

Phosphoinositols are signalling lipids that constitute a complex network regulating many cellular
processes. They are regulators of key sub-cellular processes such as membrane transport,
cytoskeletal function and plasma membrane signaling in eukaryotic cells

3.0 Cholesterol and its Relationship with other Lipids as Risk Factor in Coronary Heart
Disease
Cholesterol is a structural component of cell membranes and serves as a building block for
synthesizing various steroid hormones, vitamin D, and bile acids. Besides their structural role
providing stability and fluidity, cholesterol also plays a crucial role in regulating cell function.

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One of the modifiable risk factors associated with coronary heart disease (CHD) is
hypercholesterolemia. The major plasma lipids, including cholesterol and triglyceride, do not
circulate freely in blood, but rather in the form of lipoprotein complexes. The lipoproteins are
complexes of lipid and protein, which make the transport of plasma lipids in a stable, soluble
form possible. Essentially, each lipoprotein consists of a water-soluble surface coat that contains
the protein constituent and an inner core of insoluble lipid.

The atherogenicity of VLDL is an unresolved issue. Many patients with coronary heart disease
have elevated triglyceride levels and VLDLs. In some of these patients the high levels are due to
genetic hyperlipidemias, whereas in others it is caused by the presence of obesity or diabetes
mellitus. A high percentage of patients with coronary heart disease have hypertriglyceridemia,
but this appears to reflect other lipoprotein abnormalities that are the real atherogenic factors.
Fatty deposits can develop in the blood vessels. Eventually, these deposits grow, making it
difficult for enough blood to flow through the arteries. Sometimes, those deposits can break
suddenly and form a clot that causes a heart attack or stroke.

The retention of LDL leads to oxidative modification of LDL, allowing this oxidized LDL
(oxLDL) to be recognized by scavenger receptors on macrophages and other cells. Uptake of
oxLDL by macrophages leads to marked accumulation of cholesterol, converting them to foam
cells and initiating development of atherosclerotic lesions. In addition to serving as a substrate
for cholesterol accumulation, oxLDL exerts a wide range of bioactivities that are consistent with
it being critical for driving atherogenesis.

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4.0 Plasma lipoproteins and metabolism: classification of lipoproteins, types of
lipoproteins, functions of apolipoproteins.

4.1 Plasma Lipoproteins

Plasma lipoproteins are macromolecular assemblies of proteins and lipids found in the blood.
The lipid components of lipoproteins are amphipathic lipids such as phospholipids (PLs), and
unesterified cholesterols (UCs) and hydrophobic lipids such as cholesteryl esters (CEs) and
triglycerides (TGs).

Cholesterol and triglycerides, are insoluble in water so must be transported in association with
proteins (lipoproteins) in the circulation. Large quantities of fatty acids from meals must be

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transported as triglycerides to avoid toxicity. These lipoproteins play a key role in the absorption
and transport of dietary lipids by the small intestine, in the transport of lipids from the liver to
peripheral tissues, and the transport of lipids from peripheral tissues to the liver and intestine
(reverse cholesterol transport). A secondary function is to transport toxic foreign hydrophobic
and amphipathic compounds, such as bacterial endotoxin, from areas of invasion and infection.

Plasma lipoproteins are divided into seven classes based on size, lipid composition, and
apolipoproteins

Classification of Lipoprotein
Plasma lipoproteins can be divided into seven classes based on size, lipid composition, and
apolipoproteins (chylomicrons, chylomicron remnants, VLDL, IDL, LDL, HDL, and Lp (a).
Chylomicron remnants, VLDL, IDL, LDL, and Lp (a) are all pro-atherogenic while HDL is anti-
atherogenic

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Lipoprotein Density Size Major Lipids Major Apoproteins
(g/ml) (nm)
Chylomicrons <0.930 75- Triglycerides Apo B-48, Apo C, Apo E, Apo
1200 A-I, A-II, A-IV
Chylomicron 0.930- 30-80 Triglycerides Apo B-48, Apo E
Remnants 1.006 Cholesterol
VLDL 0.930- 30-80 Triglycerides Apo B-100, Apo E, Apo C
1.006
IDL 1.006- 25-35 Triglycerides Apo B-100, Apo E, Apo C
1.019 Cholesterol
LDL 1.019- 18- 25 Cholesterol Apo B-100
1.063
HDL 1.063- 5- 12 Cholesterol Apo A-I, Apo A-II, Apo C, Apo
1.210 Phospholipids E
Lp (a) 1.055- ~30 Cholesterol Apo B-100, Apo (a)
1.085

Chylomicrons

These are large triglyceride rich particles made by the intestine, which are involved in the
transport of dietary triglycerides and cholesterol to peripheral tissues and liver. These particles
contain apolipoproteins A-I, A-II, A-IV, A-V, B-48, C-II, C-III, and E. Apo B-48 is the core
structural protein and each chylomicron particle contains one Apo B-48 molecule. The size of
chylomicrons varies depending on the amount of fat ingested. A high fat meal leads to the
formation of large chylomicron particles due to the increased amount of triglyceride being
transported whereas in the fasting state the chylomicron particles are small carrying decreased
quantities of triglyceride.

Chylomicron Remnants

The removal of triglyceride from chylomicrons by peripheral tissues results in smaller particles
called chylomicron remnants. Compared to chylomicrons these particles are enriched in
cholesterol and are pro-atherogenic.

Very Low-Density Lipoproteins (VLDL)

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These particles are produced by the liver and are triglyceride rich. They contain apolipoprotein
B-100, C-I, C-II, C-III, and E. Apo B-100 is the core structural protein and each VLDL particle
contains one Apo B-100 molecule. Similar to chylomicrons the size of the VLDL particles can
vary depending on the quantity of triglyceride carried in the particle. When triglyceride
production in the liver is increased, the secreted VLDL particles are large. However, VLDL
particles are smaller than chylomicrons.

Intermediate-Density Lipoproteins (IDL; VLDL Remnants)

The removal of triglycerides from VLDL by muscle and adipose tissue results in the formation
of IDL particles which are enriched in cholesterol. These particles contain apolipoprotein B-100
and E. These IDL particles are pro-atherogenic.

Low-Density Lipoproteins (LDL)

These particles are derived from VLDL and IDL particles and they are even further enriched in
cholesterol. LDL carries the majority of the cholesterol that is in the circulation. The
predominant apolipoprotein is B-100 and each LDL particle contains one Apo B-100 molecule.
LDL consists of a spectrum of particles varying in size and density. An abundance of small
dense LDL particles are seen in association with hypertriglyceridemia, low HDL levels, obesity,
type 2 diabetes (i.e. patients with the metabolic syndrome) and infectious and inflammatory
states. These small dense LDL particles are considered to be more pro-atherogenic than large
LDL particles for a number of reasons. Small dense LDL particles have a decreased affinity for
the LDL receptor resulting in a prolonged retention time in the circulation. Additionally, they
more easily enter the arterial wall and bind more avidly to intra-arterial proteoglycans, which
traps them in the arterial wall. Finally, small dense LDL particles are more susceptible to
oxidation, which could result in an enhanced uptake by macrophages.

High-Density Lipoproteins (HDL)

These particles play an important role in reverse cholesterol transport from peripheral tissues to
the liver, which is one potential mechanism by which HDL may be anti-atherogenic. In addition,
HDL particles have anti-oxidant, anti-inflammatory, anti-thrombotic, and anti-apoptotic
properties, which may also contribute to their ability to inhibit atherosclerosis. HDL particles are

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enriched in cholesterol and phospholipids. Apolipoproteins A-I, A-II, A-IV, C-I, C-II, C-III, and
E are associated with these particles. Apo A-I is the core structural protein and each HDL
particle may contain multiple Apo A-I molecules. HDL particles are very heterogeneous and can
be classified based on density, size, charge, or apolipoprotein composition.

Lipoprotein (a) (Lp (a))

Lp (a) is an LDL particle that has apolipoprotein (a) attached to Apo B-100 via a disulfide bond.
This particle is pro-atherogenic.

ENZYMES AND TRANSFER PROTEINS INVOLVED IN LIPOPROTEIN METABOLISM

There are several enzymes and transfer proteins that play a key role in lipoprotein metabolism.

Lipoprotein Lipase (LPL)

LPL is synthesized in muscle, heart, and adipose tissue, then secreted and attached to the
endothelium of the adjacent blood capillaries. This enzyme hydrolyzes the triglycerides carried
in chylomicrons and VLDL to fatty acids, which can be taken up by cells. The catabolism of
triglycerides results in the conversion of chylomicrons into chylomicron remnants and VLDL
into IDL. This enzyme requires Apo C-II as a cofactor. Apo A-V also plays a key role in the
activation of this enzyme. In contrast Apo C-III and Apo A-II inhibit the activity of LPL. Insulin
stimulates LPL expression and LPL activity is reduced in patients with poorly controlled
diabetes, which can impair the metabolism of triglyceride rich lipoproteins leading to
hypertriglyceridemia.

Hepatic Lipase

Hepatic lipase is localized to the sinusoidal surface of liver cells. It mediates the hydrolysis of
triglycerides and phospholipids in IDL and LDL leading to smaller particles (IDL is converted to
LDL; LDL is converted from large LDL to small LDL). It also mediates the hydrolysis of
triglycerides and phospholipids in HDL resulting in smaller HDL particles.

Endothelial Lipase

This lipase plays a major role in hydrolyzing the phospholipids in HDL.

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Lecithin: Cholesterol Acyltransferase (LCAT)

LCAT is made in the liver. In the plasma, it catalyzes the synthesis of cholesterol esters in HDL
by facilitating the transfer of a fatty acid from position 2 of lecithin to cholesterol. This allows
for the transfer of the cholesterol from the surface of the HDL particle (free cholesterol) to the
core of the HDL particle (cholesterol ester), which facilitates the continued uptake of free
cholesterol by HDL particles by reducing the concentration of cholesterol on the surface of HDL.

Cholesteryl Ester Transfer Protein (CETP)

This protein is synthesized in the liver and in the plasma mediates the transfer of cholesterol
esters from HDL to VLDL, chylomicrons, and LDL and the transfer of triglycerides from VLDL
and chylomicrons to HDL. Inhibition of CETP activity leads to an increase in HDL cholesterol
and a decrease in LDL cholesterol.

Two major pathways are involved in Lipoprotein Metabolism

(1) Exogenous pathway

(2) Endogenous pathway

EXOGENOUS LIPOPROTEIN PATHWAY (CHYLOMICRONS)

Fat Absorption

The exogenous lipoprotein pathway starts in the intestine. Dietary triglycerides (from example
cheese burger) taken approximately 100 grams per day are hydrolyzed to free fatty acids and
monoacylglycerol by intestinal lipases and emulsified with bile acids, cholesterol, plant sterols,
and fat-soluble vitamins to form micelles.

The absorbed fatty acids and monoacylglycerols are utilized to synthesize triglycerides. The key
enzymes required for triglyceride synthesis are monoacylglycerol acyltransferase (MGAT) and
diacylglycerol transferase (DGAT). MGAT catalyzes the addition of a fatty acid to

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monoacylglycerol while DGAT catalyzes the addition of a fatty acid to diacylglycerol resulting
in triglyceride formation. The majority of the cholesterol absorbed by the intestine is esterified
to cholesterol esters by ACAT. The triglycerides and cholesterol esters are packaged into
chylomicrons in the endoplasmic reticulum. The size and composition of the chylomicrons
formed in the intestine are dependent on the amount of fat ingested and absorbed by the
intestine and the type of fat absorbed. Increased fat absorption results in larger chylomicrons.
The formation of chylomicrons in the endoplasmic reticulum requires the synthesis of Apo
B-48 by the intestinal cell. Microsomal triglyceride transfer protein (MTP) is required for
the movement of lipid from the endoplasmic reticulum to the Apo B-48.

The metabolism of the triglycerides carried in the chylomicrons results in a marked decrease
in the size of these particles leading to the formation of chylomicron remnants, which are
enriched in cholesterol esters and acquire Apo E. As these particles decrease in size
phospholipids and apolipoproteins (Apo A and C) on the surface of the chylomicrons are
transferred to other lipoproteins, mainly HDL. The transfer of Apo C-II from chylomicrons
to HDL decreases the ability of LPL to further breakdown triglycerides. These chylomicron
remnants are cleared from the circulation by the liver. The Apo E on the chylomicron
remnants binds to the LDL receptor and other hepatic receptors and the entire particle is
taken up by the hepatocytes.

The exogenous lipoprotein pathway results in the efficient transfer of dietary fatty acids to
muscle and adipose tissue for energy utilization and storage. The cholesterol is delivered to
the liver where it can be utilized for the formation of VLDL, bile acids, or secreted back to
the intestine via secretion into the bile. In normal individuals, this pathway can handle large
amounts of fat (100 grams or more per day) without resulting in marked increases in plasma
triglyceride levels. In fact, in a normal individual, a meal containing 75 grams of fat results
in only a very modest increase in postprandial triglyceride levels.

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ENDOGENOUS LIPOPROTEIN PATHWAY (VLDL AND LDL)

VLDL Metabolism

In the liver triglycerides and cholesterol esters are transferred in the endoplasmic reticulum
to newly synthesized Apo B-100. Similar to the intestine this transfer is mediated by MTP.
The availability of triglycerides is the primary determinant of the rate of VLDL synthesis. If
the supply of triglyceride is limited the newly synthesized Apo B is rapidly degraded.

VLDL particles are transported to peripheral tissues where the triglycerides are hydrolyzed
by LPL and fatty acids are released. This process is very similar to that described for
chylomicrons and there is competition between the metabolism of chylomicrons and VLDL.
High levels of chylomicrons can inhibit the clearance of VLDL. The removal of
triglycerides from VLDL results in the formation of VLDL remnants (Intermediate density
lipoproteins (IDL)). These IDL particles are relatively enriched in cholesterol esters and
acquire Apo E from HDL particles. In a pathway analogous to the removal of chylomicron
remnants these IDL particles can be removed from the circulation by the liver via binding of
Apo E to LDL receptors. However, while the vast majority of chylomicron remnants are
rapidly cleared from the circulation by the liver, only a fraction of IDL particles are cleared
(approximately 50% but varies). The remaining triglycerides in the IDL particles are
hydrolyzed by hepatic lipase leading to a further decrease in triglyceride content and the
exchangeable apolipoproteins are transferred from the IDL particles to other lipoproteins
leading to the formation of LDL. These LDL particles predominantly contain cholesterol
esters and Apo B-100. Thus, LDL is a product of VLDL metabolism.

LDL Metabolism

The levels of plasma LDL are determined by the rate of LDL production and the rate of LDL
clearance, both of which are regulated by the number of LDL receptors in the liver. The
production rate of LDL from VLDL is partially determined by hepatic LDL receptor activity
with a high LDL receptor activity resulting in a decrease in LDL production due to an increase in

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IDL uptake. Conversely, low LDL receptor activity results in an increase in LDL production
formation due to a decrease in IDL uptake. With regards to LDL clearance, approximately 70%
of circulating LDL is cleared via hepatocyte LDL receptor mediated endocytosis with the
remainder taken up by extrahepatic tissues. An increase in the number of hepatic LDL receptors
therefore increases LDL clearance leading to a decrease in plasma LDL levels. Conversely, a
decrease in hepatic LDL receptors slows LDL clearance leading to an increase in plasma LDL
levels. Thus, the level of hepatic LDL receptors plays a key role in regulating plasma LDL
levels.

HDL Synthesis

Several steps are required to generate mature HDL particles. The first step involves the
synthesis of the main structural protein contained in HDL, Apo A-I. Apo A-I is synthesized
predominantly by the liver and intestine. After Apo A-I is secreted, it acquires cholesterol
and phospholipids that are effluxed from hepatocytes and enterocytes. While initially
cholesterol and phospholipids are obtained from the liver and intestine, HDL also acquires
lipid from other tissues and from other lipoproteins. Newly formed HDL can obtain
cholesterol and phospholipids from chylomicrons and VLDL during their lipolysis by LPL.
This accounts for the observation that patients with high plasma triglyceride levels due to
decreased clearance frequently have low HDL cholesterol levels.

HDL Cholesterol Esterification

As noted earlier the cholesterol in the core of HDL is esterified (cholesterol esters). The
cholesterol that is effluxed from cells to HDL is free cholesterol and is localized on the
surface of HDL particles. In order to form mature large spherical HDL particles with a core
of cholesterol esters the free cholesterol transferred from cells to the surface of HDL
particles must be esterified. LCAT, an HDL associated enzyme catalyzes the transfer of a
fatty acid from phospholipids to free cholesterol resulting in the formation of cholesterol
esters. The cholesterol ester formed is then able to move from the surface of the HDL

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particle to the core. Apo A-I is an activator of LCAT and facilitates this esterification
process. LCAT activity is required for the formation of large HDL particles. LCAT
deficiency in humans results in decreased HDL cholesterol and Apo A-I levels and a higher
percentage of small HDL particles.

Formation of cholesteryl ester.

5.0 Clinical disorders associated with lipoprotein metabolism, fatty liver

Lipoprotein disorders associated with lipoprotein metabolism can be classified based on the
primary biochemical disturbance, such as high or low plasma levels of low-density lipoprotein,
cholesterol, high density lipoprotein, cholesterol, triglycerides or combination of these.
Hyperlipoproteinemia is an elevation of serum total cholesterol and /or triglycerides or reduced
high density lipoprotein cholesterol that predisposes one to the development of atherosclerosis. It
results from an inability to break down lipids or fats in the body, specifically cholesterol and
triglycerides. Familial combined hyperlipidemia (FCH): This is a fairly common disorder that

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causes low HDL but very high LDL and triglycerides. It occurs due to changes in multiple genes
and environmental factors, such as diet and lifestyle.

Apo E is crucial for this process and mutations in Apo E (for example the Apo E2 isoform)
can result in decreased chylomicron clearance and elevations in plasma cholesterol and
triglyceride levels (Familial dysbetalipoproteinemia).

If there is excessive cholesterol in the blood circulation, some of the excesses can become
trapped in arterial walls, over time, this builds up and forms plaques. These plaques can
narrow blood vessels and make them less flexible; this process is called atherosclerosis.

 Atherosclerosis of the coronary circulation results in coronary arterial disease (CAD)

 Atherosclerosis of the carotid and vertebral arteries results in stroke manifestations.

5.1 Fatty Liver Disease

Fatty liver disease is a condition in which the liver preserves an excessive amount of fat. The
vast majority of people show no indications or symptoms, and it causes them no significant
problems. It can, however, cause liver damage in some circumstances. Fatty liver disease may
be avoided or even reversed by making changes. There are two major classifications: (1)
Nonalcoholic Fatty Liver Disease (NAFLD) is a condition in which fat accumulates in the liver
of persons who do not consume alcohol. (2) Alcoholic Fatty Liver Disease (AFLD) often known
as Alcoholic steatohepatitis. Alcoholic liver disease (ALD) is brought on by consumption of
alcohol, nonalcoholic fatty liver disease (NAFLD) is not caused by alcohol. Both ALD and
NAFLD are major health issues globally.

5.1.1 Causes of Alcoholic Fatty Liver Disease

Within the liver, there are 2 main pathways of alcohol metabolism, alcohol dehydrogenase and

cytochrome P-450 2E1 (CYP2E1). Alcohol dehydrogenase (ADH) is a hepatocyte cytosolic

enzyme that converts alcohol to acetaldehyde. Acetaldehyde subsequently is metabolized to

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acetate via the mitochondrial enzyme acetaldehyde dehydrogenase (ALDH). Both steps are

coupled to the reduction of NAD to NADH. An increased NADH/NAD ratio has profound

effects on the metabolism of carbohydrates and lipids. Gluconeogenesis is impaired and substrate

flow through the citric acid cycle is diminished with acetyl-coA diverted towards ketogenesis

and fatty acid synthesis. Together with the inhibition of mitochondrial fatty acid β-oxidation, this

latter effect of the altered redox state contributes to the pathogenesis of fatty liver (steatosis).

5.1.2 Non Alcoholic Fatty Liver

The pathophysiology of NAFLD involves increased de novo synthesis of fatty acids in

hepatocytes, the retention of lipids due to impaired hepatocyte apolipoprotein secretion or beta-

oxidation. The well-known primary causes of NAFLD are obesity, type II diabetes, dyslipidemia,

and insulin resistance. Increased presence of dead and dying hepatocytes, increased ROS, and

altered adipokine/cytokine production are thought to promote a profibrotic milieu in the liver.

5.2 Treatment of Fatty Liver

There are currently no medications to treat NAFLD. Depending on the stage of the disease,
however, it may be reversed.

Gradually reducing body weight by at least 7–10%.

However, losing weight too quickly can make NAFLD worse. A healthful way to lose weight
gradually is with a balanced diet and regular exercise.

People who have alcoholic fatty liver disease may be able to reverse liver damage and
inflammation or prevent it from getting worse by not consuming alcohol. However, this will not
reverse cirrhosis.

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Some people might find giving up alcohol extremely difficult, but a doctor can advise on how to
do so in a safe and supported way.

Complications from NASH and alcoholic fatty liver disease can include cirrhosis and liver
failure. Medication and surgery are both treatment options at this stage.

Liver failure may require a liver transplant.

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