On thelipoprotein abnormality in type 3 hyperlipoproteinemia

Type III Hyperlipoproteinemia: Still Worth Considering?

Familial type III hyperlipoproteinemia (HLP) was first recognized as a distinct entity over 60 years ago. Since then, it has proven to be instructive in identifying the key role of apolipoprotein E (apoE) in removal of the remnants of very low density lipoproteins and chylomicrons produced by the action of lipoprotein lipase on these triglyceride-transporting lipoproteins. It has additionally shed light on the potent atherogenicity of the remnant lipoproteins. This review describes the history of development of our understanding of type III HLP, discusses the several genetic variants of apoE that play roles in the genesis of type III HLP, and describes the remarkable responsiveness of this fascinating disorder to lifestyle modification, especially carbohydrate restriction and calorie restriction, and, when required, the addition of pharmacotherapy.

Expert commentary: the safety of fibrates in lipid-lowering therapy

The use of fibrates in the management of lipoprotein disorders has a history dating back to the mid-1960s. This group of drugs has now been tested in several large long-term trials with cardiovascular end points. Overall, there is good evidence for the reduction of cardiovascular disease in primary prevention studies and in those of subjects with manifest disease. More recent trials have suffered from high interference due to 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor (statin) introduction, particularly in their placebo control groups. However, there is very good evidence for overall safety from a combined study of >20,000 patients in these controlled clinical trials lasting approximately 5 years. Abdominal pain has been observed more frequently in the statin vs placebo group. Myopathy, liver enzyme elevations, and cholecystitis have been potential adverse reactions of interest. However, these have occurred at a very low rate and are rarely found to be statistically more frequent in the active-treatment group compared with the subjects taking placebo. The recent Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study found a slightly higher incidence of pancreatitis, deep venous thrombosis, and pulmonary embolism. Small creatinine and homocysteine elevations are observed in many patients taking fibrates, and the effect of this on long-term outcomes is under study. The FIELD study also described a significant reduction in the rates of progression of proteinuria and vascular retinopathy with fibrate therapy. To date, there has been no study exclusive to patients with elevated triglycerides, raising the question of the potential benefit of these drugs in patients with the lipid abnormalities most effectively treated with fibrates.

High receptor binding affinity of lipoproteins in atypical dysbetalipoproteinemia (type III hyperlipoproteinemia)

Familial dysbetalipoproteinemia (or type III hyperlipoproteinemia) is characterized by the presence of abnormal, cholesteryl ester-rich beta-very low density lipoproteins (beta-VLDL) in the plasma. Subjects with typical dysbetalipoproteinemia are homozygous for an amino acid substitution in apolipoprotein (apo-) E at residue 158 and have defective apo-E-mediated binding of both pre-beta-VLDL and beta-VLDL to apo-B,E(LDL) (or LDL) receptors (1988. Chappell, D.A., J. Clin. Invest. 82:628-639). To understand the effect of substitutions in apo-E at sites other than residue 158, nine dysbetalipoproteinemic (dys-beta) subjects who were either homozygous or heterozygous for substitutions in apo-E at atypical sites were studied. These substitutions occurred at residue 142 (n = 6), 145 (n = 2), or 146 (n = 1) and are known to cause less defective binding than does the 158 substitution. The chemical composition and electrophoretic mobility of pre-beta-VLDL and beta-VLDL from atypical and typical dys-beta subjects were indistinguishable. However, lipoproteins from atypical and typical dys-beta subjects differed in their affinity for the apo-B,E(LDL) receptor on cultured human fibroblasts. The pre-beta-VLDL and beta-VLDL from atypical dys-beta subjects had 640- or 17-fold higher affinity, respectively, than did corresponding lipoproteins from typical dys-beta subjects. The higher binding affinity of lipoproteins from atypical dys-beta subjects was associated with a higher ratio of apo-E to total apo-C. Since higher binding affinity should cause more rapid receptor-mediated clearance of beta-VLDL in atypical than in typical dys-beta subjects in vivo, the mechanism of beta-VLDL accumulation may differ in these two groups.

Pre-beta-very low density lipoproteins as precursors of beta-very low density lipoproteins. A model for the pathogenesis of familial dysbetalipoproteinemia (type III hyperlipoproteinemia)

The physical, chemical, and receptor binding properties of very low density lipoprotein (VLDL) fractions from familial dysbetalipoproteinemic (dys-beta) subjects, homozygous for apolipoprotein (apo-) E2 (E2/2 phenotype), and subjects with the E3/3 phenotype were studied to gain insights into the pathogenesis of dysbetalipoproteinemia, a disorder characterized by the presence of beta-VLDL in the plasma. Pre-beta-VLDL from dys-beta subjects were larger (27 vs. 17 x 10(6) D) and more triglyceride rich (68 vs. 43% dry weight) than beta-VLDL. Pre-beta-VLDL predominated in the Sf greater than 100 flotation fraction, whereas beta-VLDL predominated in the Sf 20-60 fraction. Because lipolysis converts large VLDL (Sf greater than 100) in vivo to smaller, more cholesteryl ester-rich VLDL (Sf 20-60), it is likely that pre-beta-VLDL are precursors of beta-VLDL. Although beta-VLDL were not found in type V hyperlipidemic E3/3 subjects, they were induced by intravenous heparinization, suggesting that lipolysis of pre-beta-VLDL in vivo can result in beta-VLDL formation. Similarly, heparinization of a dys-beta subject produced more beta-VLDL, at the expense of pre-beta-VLDL. The pre-beta-VLDL from normolipidemic and type V hyperlipidemic E3/3 subjects, respectively, had 90 and 280 times the affinity for the apo-B,E(LDL) receptor than did the pre-beta-VLDL from dys-beta subjects. Heparin-induced beta-VLDL from type V hyperlipidemic subjects had a sixfold higher binding affinity than did heparin-induced beta-VLDL from dys-beta subjects. These data suggest that pre-beta-VLDL from E2/2 subjects interact poorly with lipoprotein receptors in vivo, decreasing their receptor-mediated clearance and increasing their conversion to beta-VLDL during lipolytic processing.

Treatment of type III hyperlipoproteinemia with gemfibrozil to retard progression of coronary artery disease

Eight type III hyperlipoproteinemic (type III HLP), homozygous E 2/2 patients were enrolled in two periods of long-term diet-gemfibrozil treatment. The combined therapy resulted in highly significant decreases in their low-density lipoprotein cholesterol, very-low density lipoprotein cholesterol, very-low density lipoprotein triglycerides, and increases in their high-density lipoprotein cholesterol during the first treatment period of 24 to 28 months. Type III HLP reasserted itself following an 8-week interruption of gemfibrozil therapy. Resumption of gemfibrozil therapy again lowered the high lipid-lipoprotein concentrations of these patients toward normal. Tuboeruptive xanthomata, palmar xanthoma, and xanthoma striata palmare subsided with treatment. Follow-up coronary arteriograms performed 2.5 to 3.0 years after initiation of diet-drug treatment showed stabilization of coronary arterial lesions, which was associated with improvement in exercise tolerance.

Remnants of lipoproteins of intestinal and hepatic origin in familial dysbetalipoproteinemia

We used the low molecular weight form of apolipoprotein B (B-48) as a marker for the identification of remnant particles formed from chylomicrons in the plasma of patients with familial dysbetalipoproteinemia. In the serum of patients fasted 14 hours, the d less than 1.006 g/cm3 lipoproteins of prebeta mobility, separated by starch block electrophoresis, contained only the primary hepatogenous species of apolipoprotein B (B-100), and their lipid composition resembled that of normal prebeta very low density lipoproteins. In contrast, the fraction with beta mobility contained both the B-48 and B-100 proteins; the B-48 protein was found primarily among the largest particles. All fractions of beta mobility were greatly enriched with cholesteryl esters. The beta fraction thus contains remnant particles which appear to originate both from chylomicrons and hepatogenous very low density lipoproteins. It appears that these remnant particles share a common removal mechanism which is impaired in familial dysbetalipoproteinemia.

Phenotype study of apolipoprotein E isoforms in hyperlipoproteinaemic patients

It has been suggested that apolipoprotein E (apoE) is inherited at a single genetic locus with three common alleles designated E2, E3, and E4. The products of these three alleles are apoE2, apoE3, and apoE4. The apoE phenotypes of 74 normal subjects and 226 hyperlipoproteinaemic subjects were ascertained by gel isoelectrofocusing. Patients with type I, type IIa, type IIb, and type IV hyperlipoproteinaemia had an apoE phenotypic distribution which was similar to that of normal subjects, with 40.0 to 60.0% being homozygous for E3. In contrast, 75% of type III patients had an E2 phenotype and 25% were E2/3 heterozygotes. Among type V patients 31.4% had an E4 phenotype, and 42.9% were E4 heterozygotes. No type III patient and only 5.7% of type V patients had E3 phenotype. The results suggest that apoE2 and apoE4 are associated with two distinctly different dyslipoproteinaemias and that apoE has at least two different physiological functions.

Familial dysbetalipoproteinemia. New aspects of pathogenesis and diagnosis

New aspects in the pathogenesis and diagnosis of familial dysbetalipoproteinemia are discussed, including the clarification of the chemical basis of the polymorphism of apoprotein E, the allelic nature of the primary isoforms of the protein, the relationship of the abnormality of apoprotein E to the accumulation of remnant lipoproteins in dysbetalipoproteinemia and in persons carrying the trait for abnormal apoprotein E, and the pathogenesis of hyperlipidemia in this disorder. The related clinical features of dysbetalipoproteinemia are included in the discussion.

Current concepts of the molecular structure and metabolism of human apolipoproteins and lipoproteins

During the last few years major advances have occurred in our knowledge of the structure, function, and metabolism of the plasma lipoproteins. Twelve human apolipoproteins have been isolated and characterized. The primary structure of apolipoproteins A-I, A-II, C-I, C-II, and C-III have been elucidated. The primary structure of these apolipoproteins contain no unique sequences, however the primary structure of several of the apolipoproteins contain segments which can be modeled into amphipathic helices. The helical segments may be important in protein-protein as well as protein-lipid interactions. The molecular properties of the apolipoproteins have been investigated and shown to undergo self-association with major increases in conformation. The molecular organization of the plasma lipoprotein particle has been studied, and an iceberg-sea model has been proposed. This model emphasizes the micellar organization of the phospholipids, and the possibility of secondary, tertiary as well as quaternary structure of the apolipoprotein associated with the lipoprotein particle. The metabolism of plasma lipoproteins has been extensively analyzed over the last several years. Two general types of apolipoprotein-lipoprotein particle interactions have been recognized. The first type involves a "quasi-irreversible" interaction between the apolipoprotein and lipoprotein particle, and is exemplified by apolipoprotein b. The second type of interaction is a "reversible" apolipoprotein-lipoprotein particle interaction. Apolipoproteins a-I, A-II, C-I, C-II, C-III, and E are examples of the reversible interaction. Within this framework two major apoB-lipoprotein particle cascades have been proposed. ApoB-triglyceride rich lipoproteins including chylomicrons and hepatic VLDL undergo sequential triglyceride hydrolysis. Following triglyceride hydrolysis chylomicrons are converted to remnants with hydrated densities principally of VLDL and IDL. Liver apoB-VLDL is converted initially to IDL and finally to LDL. Apolipoproteins which undergo reversible interactions are present in virtually all density fractions and the distribution of these apolipoproteins is determined by the laws of mass action. With these concepts rapid progress has been made in our understanding of apolipoprotein-lipoprotein biochemistry, physiology, and clinical disorders of lipoproteins and atherosclerosis. The next several years will undoubtedly provide further insights into the structure, function, and metabolism of plasma lipoproteins.

Lipoprotein lipase in cholesterol-fed and control guinea pigs

A study of the in vitro activity of lipoprotein lipase of guinea pigs has shown that (a) the lipolytic activity of activated post-heparin serum is depressed in hypercholesteremic guinea pigs compared to the serum of normocholesteremic guinea pigs; and (b) this depressed lipolytic activity in hypercholesteremic guinea pigs is not due to the presence of an inhibitor.

Kinetic model for production and metabolism of very low density lipoprotein triglycerides. Evidence for a slow production pathway and results for normolipidemic subjects

A model for the synthesis and degradation of very low density lipoprotein triglyceride (VLDL-TG) in man is proposed to explain plasma VLDL-TG radioactivity data from studies conducted over a 48-h interval after injection of glycerol labeled with 14C, 3H, or both. The curve describing the radioactivity of plasma VLDL triglycerides reaches a maximum at about 2 h, after which the decay is biphasic in all cases; the late curvature becoming evident only after 8--12 h. To fit the complex curve, it was necessary to postulate two pathways for the incorporation of plasma glycerol into VLDL-TG, one much slower than the other. A process of stepwise delipidation of VLDL in the plasma compartment, previously proposed for VLDL apoprotein models, was also necessary. Predicted VLDL-TG synthesis rates calculated with this model can differ significantly from those based on experiments of shorter duration in which the slow VLDL-TG component is not apparent. The results of these studies strongly support the interpretation that the late, slow component of the VLDL-TG activity curve is predominantly due to the slowly turning-over precursor compartment in the conversion pathway and is not due either to a slow compartment in the labeled precursor, plasma free glycerol, or to an exchange of plasma VLDL-TG with an extravascular compartment. It also cannot, in these studies, be attributed to a slowly turning-over VLDL-TG moiety in the plasma. The model was tested with data from 59 studies including normal subjects and patients with obesity and(or) various forms of hyperlipoproteinemia. Good fits were obtained in all cases, and the estimated parameter values and their uncertainties for 13 normolipemic nonobese subjects are presented. Sensitivty testing was carried out to determine how critical various parameter estimations are to the assumptions introduced in the modeling.

Separation of two serum very low density lipoprotein fractions using starch block electrophoresis

A quantitative electrophoretic method has been developed in order to differentiate very low density (VLDL) pre-beta lipoproteins from late pre-beta lipoproteins using starch as a supporting medium. It was possible to obtain a bimodal distribution of lipoprotein lipids from VLDL which on agarose gel electrophoresis had a pre-beta band and a late pre-beta band. Optimal conditions were: ammonium carbonate buffer, mu = 0.025, dialysis prior to electrophoresis. Agarose gel electrophoresis demonstrated that the fast and slow components obtained on starch block electrophoresis corresponded to the pre-beta and late pre-beta band respectively. With increasing migration towards the anode the ratio of cholesterol to triglycerides decreased continuously. It is suggested that the fast triglyceride rich component represent newly secreted VLDL species and the slower component mainly postlipolytic particles. The pre-beta band on agarose gel electrophoresis might represent more newly secreted VLDL than the late pre-beta band. However, it cannot be excluded that part of late pre-beta lipoproteins may be secreted de novo.

Polymorphism of apolipoprotein E. II. Genetics of hyperlipoproteinemia type III

Apolipoprotein E from human serum shows a genetic polymorphism determined by two autosomal codominant alleles, Apo En and Apo Ed. Homozygosity for the gene Apo Ed (phenotype Apo E-D) results in primary dysbetalipoproteinemia, but only some individuals with this phenotype develop gross hyperlipidemia (hyperlipoproteinemia type III). Vertical transmission of dysbetalipoproteinemia represents pseudodominance due to the high frequency of the gene Apo Ed. Dysbetalipoproteinemia is already expressed in childhood. To assess the influence of other genes on the expression of hyperlipidemia in phenotype Apo E-D, comparative studies were carried out in kindreds of hypercholesterolemic (group A) and normo- or hypocholesterolemic probands with dysbetalipoproteinemia (group B). This demonstrated the occurrence of familial (non-type III) forms of hyperlipidemia in group A but not in group B kindreds. Distribution of lipoprotein phenotypes in five of the group A kindreds was consistent with the occurrence of familial combined hyperlipidemia. Apo E phenotypes and hyperlipidemia segregated independently. It is concluded that primary dysbetalipoproteinemia is a frequent monogenic variant of lipoprotein metabolism, but not a disease. Coincidence in one individual of genes for this specific dyslipoproteinemia with any of the genes for monogenic or polygenic forms of familial hyperlipidemia results in hyperlipoproteinemia type III. Hence hyperlipoproteinemia type III is caused by at least two non-allelic genes and is a polygenic disorder.

Peripheral vascular disease in cigarette smokers and impaired hepatic metabolism of lipoprotein remnants

The metabolism of very-low-density lipoproteins and chylomicrons includes the extrahepatic hydrolysis of their triglycerides by lipoprotein lipase. This results in cholesterol-rich "remnants" which are further metabolised by the liver. There is experimental evidence that in both patients with type-III hyperlipoproteinaemia and cigarette smokers hepatic-remnant metabolism may be depressed. In type-III hyperlipoproteinaemia the defect is inherited while in smokers it occurs in response to raised blood concentrations of carboxyhaemoglobin. The striking clinical similarity between type-III hyperlipoproteinaemic patients and smokers--namely, a high incidence of peripheral vascular disease--may be due to a common cause, the accumulation of cholesterol-rich remnants in the plasma.

Evaluation of the classical methods for the diagnosis of type III hyperlipoproteinemia

Familial type III hyperlipoproteinemia is characterized by the presence of elevated plasma levels of very low density lopoproteins (VLDL) which contain an increased amount of cholesterol and by the presence of a significant amount of lipoproteins with an intermediate density between that of VLDL and low density lipoproteins (LDL); the intermediate density lopoproteins, designated IDL or Lp III, have a slower electrophoretic migration rate than VLDL, and are found in the ultracentrifugal top fraction as a contaminant. Classically, the diagnosis of type III is based on the demonstration of beta-migrating lipoproteins in the ultracentrifugal top fraction (density less than 1.006), thus "floating beta-lipoprotein". More recently, it has been proposed that an elevated VLDL-cholesterol to triglyceride ratio is diagnostic of the disorder. In the present report, we have compared the two methods for their diagnostic value and have concluded that the chemical index definition is the more reliable method for the diagnosis of type III hyperlipoproteinemia.

Concentration of lipoproteins containing apolipoprotein B in human peripheral lymph

The concentration of apolipoprotein B (apoB) in human serum and peripheral lymph was measured by quantitative immunoelectrophoresis with anti-serum to human low-density lipoprotein. In four normal and six hyperlipidaemic subjects, total lymph apob/ml was 5-10% of total serum apoB/ml in the same subject. These ratios were equivalent to lymph apob concentrations of 60-120 microgram/ml. When the assays were carried out under conditions in which unmasking of immunoreactive sites on lymph and serum apoB was assumed to be maximal (delipidation with Nonidet P40), the lymph/serum apoB concentration ratios in three normal subjects were similar to those obtained with untreated lymph and serum.

Lipoprotein composition in hypothyroidism

Sixteen patients with hypothyroidism have had their lipid status assessed before and during replacement therapy. More than 60% had hypercholesterolaemia and more than 60% had hypertriglyceridaemia. Significant reductions in plasma cholesterol, but not in plasma triglyceride, were seen during replacement therapy. A high cholesterol: triglyceride ratio was observed in VLDL and this relationship tended back to normal during treatment. This raises the possibility that in hypothyroidism, as in Type III hyperlipoproteinaemia, an abnormality in VLDL conversion to LDL is present.

Inheritance of type-III hyperlipoproteinemia. Lipoprotein patterns in first-degree relatives

The lipoprotein (LP) patterns were studied in the families of 19 index cases with type-III hyperlipoproteinemia (HLP). Seventy adult first-degree relatives (93% ascertainment) to the 19 probands were analyzed. The diagnosis of HLP type III among the first-degree relatives was based on three criteria, all of which had to be fulfilled to make the diagnosis: (1) presence of a slow-moving band in very-low-density LP (VLDL) on agarose gel electrophoresis migrating in beta or close to beta position; (2) A cholesterol/triglyceride ratio (mg/100 ml: mmoles/liter) in VLDL greater than 29.0; and (3) A "III-index" [cholesterol/triglycerides in VLDL x 10 divided by cholesterol/triglycerides in low-density LP (LDL)] greater than 1.30. When defined according to these criteria there was a marked over-representation of HLP type III among the relatives (27%). There was also an increased frequency of hypertriglyceridemia (28% against expected 15%), mainly because of a high prevalence of HLP type IV (24%). On agarose gel electrophoresis a "late pre-beta" band, probably indicative of an increased amount of intermediary LP particles, was frequently present (47%) among relatives not classified as HLP type III. Type-III patients with hypertriglyceridemia were characterized by a significantly higher body weight than those with normotriglyceridemic type III. However, there was no qualitative difference in the composition of the lipoproteins in normotriglyceridemic and hypertriglyceridemic type-III patients. A genetic analysis of the LP patterns within the families showed several examples of vertical transmission of HLP type III. There was no sex linkage. Six of thirteen analyzed parents showed LP patterns classified as HLP type III. Another two parents were most probably carriers of the gene. Of the siblings to the probands, 23% showed a type-III pattern and another four (7%) showed LP patterns very similar to type III, fulfilling two of three criteria for HLP type III. The data support the concept that HLP type III is inherited as an autosomal dominant gene. It was indicated that HLP type IV with a late pre-beta band in VLDL may represent another expression of the gene for HLP type III. It is suggested that HLP type III may be a pathogenetically heterogenous group of lipid disorders. A separation of type III into two subgroups with low or normal and high LDL cholesterol concentration, respectively, may facilitate the understanding of the inheritance of type III as well as of the pathogenesis behind this LP abnormality.

High-field 13C NMR Studies of certain normal and abnormal human plasma lipoproteins

High-field (63.4 kilogauss) Fourier transform nuclear magnetic resonance spectroscopy 13C in natural abundance has been used to study the structural organization and molecular dynamics of constituent lipids of normal human very low-density lipoproteins (VLDL) and low-density lipoproteins (LDL). The same method was used to study the abnormal beta-VLDL of two type III hyperlipoproteinemia patients having markedly differing ratios of VLDL cholesterol to triglyceride (0.3 and 0.6, respectively). Resolution obtained at 63.4 kilogauss has made possible the assignment of several additional resonances of cholesterol ring carbon atoms, not resolved in earlier studies at lower fields, in the VLDL spectra. The rotational reorientation of the ring portion of cholesteryl esters in VLDL (normal) and beta-VLDL (abnormal) is not highly anisotropic and is similar to that for cholesteryl esters disolved in excess triolein. The rotations of cholesteryl esters in LDL are more highly anisotropic and significantly more restricted. The results suggest that the structural organization of the lipid components in beta-VLDL resembles that found in normal VLDL but differs significantly from that for normal LDL.

Delayed clearance of chylomicron remnants following vitamin-A-containing oral fat loads in broad-beta disease (type III hyperlipoproteinemia)

Chylomicron "remnants" are formed by the selective removal of triglyceride catalyzed by lipoprotein lipase. To investigate a possible defect in the clearance of these remnants in the pathophysiology of broad-beta disease (type III hyperlipoproteinemia), subjects with this disorder and comparison subjects with endogenous hypertriglyceridemia (and type IV lipoprotein patterns) ingested an oral fat load (corn oil: cocoa butter, 1:1, 50 g/sq M) containing retinyl ester, 100 mg, with or without 15 muCi 15-(14) C-retinol (43.7 mCi/mg). The content of triglyceride and vitamin A was sequentially determined in chylomicrons (Sf more than 400) and very low density lipoproteins (VLDS, Sf20-400) over the ensuing 24-72 hr. Vitamin A was chosen as a marker for exogenous sterol assimilation since, like cholesterol, it is absorbed in the small intestine and cosecreted in esterified form with triglyceride in the chylomicron core; however, unlike cholesterol, once having been removed by the liver, it cannot be recycled inot VLDL, but subsequently circulates only as a complex with the high density retinol binding protein. Thus measurements of the vitamin A/triglyceride ratio in Sf greater than 20 lipoproteins reflected the relative efficiency of vitamin A versus triglyceride removal within these lipoproteins. These studies confirmed the intital concentration of exogenous vitamin A in chylomicrons but invariably disclosed an increasing proportion of the remaining Sf greater than 20 vitamin A in VLDL 24 hr after its ingestion. The vitamin A/triglyceride ratio also invariably increased between 6 and 24 hr in the Sf20-30 subfraction, reflecting the formation of vitamin A-rich "remnants" as intermediate species in the catabolism of chylomicrons and VLDL. Among those with mild to moderate endogenous hypertriglyceridemia the Sf greater than 400 vitamin A/triglyceride ratio declined between 6 and 24 hr, reflecting the efficient passage of the vitamin A through this fraction and/or continued secretion of Sf greater than 400 particles rich in triglyceride. Among those with severe endogenous hypertriglyceridemia, both the peak and decline in the Sf greater than 400 vitamin A/triglyceride ratio were delayed. However, among those with broad-beta disease, an increasing vitamin A/triglyceride ratio between 6 and 24 hr was frequent within all VLDL subfractions and invariable among lipoproteins of Sf greater than 400 regardless of the degree of antecedent hypertriglyceridemia. Although additional experiments disclosed a similar delay in both vitamin A and triglyceride assimilation when basal triglyceride levels were high in these subjects, marked reduction of triglyceride levels did not correct the rise in the Sf greater than 400 vitamin A/triglyceride ratio between 6 and 24 hr. Experiments employing preparative electrophoresis confirmed the identity of VLDL containing a high vitamin A/triglyceride ratio with the beta-VLDL which accumulate in broad-beta disease...

Diagnosis of dyslipoprotein aemia by molecular sieve chromatography

Agarose gel molecular sieve chromatography has been used as a tool in the diagnosis of dyslipoproteinaemias. The elution profile from control plasma contained three peaks, corresponding to very-low-density lipoproteins (VLDL), low-density lipoproteins (LDL), and high-density lipoproteins (HDL). These accounted for 9.5%, 23.5% and 67% of the total lipoprotein absorption at 280 nm. Elution patterns from dyslipoproteinaemic serum showed alterations, not only in peak area, but also in peak migration rate through the agarose gel. These variations were reproducible and of such magnitude as to permit the use of molecular sieve chromatography as a tool in the diagnosis of dyslipoprotein-aemias of Type I, II (a + b), III, IV and V.

Changes in plasma lipoprotein constituents during constant infusions of heparin

Constant infusions of heparin of 4 to 6 hours' duration were used to estimate the transfer of very low density lipoprotein constituents to other plasma lipoproteins. Eleven subjects were studied, 3 with Type III and the remainder with either Type IV or V hyperlipoproteinemia. Whereas only about 5% of the triglyceride lost from VLDL was recovered in the other lipoproteins, 44% of the cholesterol was retained in the circulation, in equal amounts within low density (d 1.019-1.063) and intermediate density (d 1.006-1.019) lipoproteins. By contrast, there was no apparent loss of protein, more than half of that originally in VLDL being recovered in high density lipoprotein. In subjects with Type III hyperlipoproteinemia, lipid and protein was lost from the intermediate density lipoprotein as well as from VLDL. In subjects with marked hypertriglyceridemia, cholesterol became redistributed from larger to smaller VLDL. The esterification of plasma cholesterol as measured in vitro, was apparently suppressed during the early phase of the heparin infusions, but tended to recover later.

Characterization of remnants produced during the metabolism of triglyceride-rich lipoproteins of blood plasma and intestinal lymph in the rat

The metabolism of intravenously injected large and small chylomicrons from intestinal lymph and of very low density lipoproteins from blood plasma was studied in functionally eviscerated "supradiaphragmetic" rats. For studies with lymph lipoproteins, recipient animals were injected with 4-amino-pyrazolopyrimidine 18 h before injection of lipoprotein to prevent secretion of very low density lipoproteins into their blood plasma. In all cases, most of the triglycerides (labeled with 14C) were rapidly metabolized, whereas cholesteryl esters (labeled with 3H) persisted in the blood. Most of the cholesteryl esters remained in smaller "remnant" lipoproteins, less dense that 1.006, which retained an apparently spherical shape, as determined by electron microscopy of negatively stained preparations. Whereas the diameters and chemical compositions of large chylomicrons were substantially different from those of small chylomicrons and very low density lipoproteins, all remnants were similar in these respects. Average remnant diameters were 400-600 A and remnants were enriched in cholesteryl esters and in protein insoluble in tetramethylurea. In addition to triglycerides, remnants were depleted of phospholiarticle size, the composition of remnants, like that of their precursors, was consistent with the "pseudomicellar" model of lipoproteins, in which a core of nonpolar lipids is covered by a monolayer of polar lipids and protein. These results domonstrate the fundamental similarity of the initial step in the metabolism of triglyceride-rich lipoproteins from intestinal mucosa and liver and show that loss of triglycerides from the core of the particles is accompanied by removal of polar components from the surface.

Conversion of type III hyperlipoproteinaemia to type IV hyperlipoproteinaemia by a fat-free, carbohydrate rich diet

Hyperlipoproteinaemia type III has been considered a clear cut clinical entity characterized by the presence of cholesterol rich "floating" beta very low density lipoproteins (VLDL) after ultracentrifugation. Carbohydrate inducibility is pronounced in type III. This study was undertaken to elucidate the effect of a high carbohydrate diet in type III as an effort to clarify a suggested association between type III and IV hyperlipoproteinaemia. On an isocaloric fat free carbohydrate rich diet the lipoprotein pattern changed as the VLDL triglycerides increased 31 per cent on average and LDL and HDL cholesterol decreased by 40 and 22 per cent. The high ratio cholesterol/triglycerides in VLDL was normalized. The lipoprotein levels in serum after carbohydrate induction showed all characteristics of a type IV with high VLDL triglycerides, normal cholesterol/triglyceride ratio in VLDL, subnormal cholesterol levels in LDL and HDL with changed relation between LDL1 and LDL2. On electrophoresis the floating beta band disappeared. It is probable that depending on the nutritional situation, the metabolic defect in type III may be expressed either as a type III or a type IV. An explanation of the effects of the carbohydrate rich diet on the lipoprotein pattern is suggested.

Broad-beta disease versus endogenous hypertriglyceridemia: levels and lipid composition of chylomicrons and very low density lipoproteins during fat-free feeding and alimentary lipemia

To assess the roles of endogenous and exogenous lipid in the production of the abnormal lipoprotein patterns characteristic of broad-beta desease (with a type IVIII lipoprotein pattern) and endogenous hypertriglyceridemia (with a type IV pattern), oral fat loads (50 g/M-2) were administered to six subjects with broad-beta disease and to eight with endogenous hypertriglyceridemia following at leat 72 hr of 0% fat, 85% carbohydrate isocaloric formula feeding. Total plasma and Sf greater than 400, 100-400, 60-100, 30-60, and 20-30 lipoprotein cholesterol, triglyceride, and phospholipid levels were measured at 0 hr, 6 hr (at or before the peak of alimentary lipemia), and 24 hr following the fat load. Following fat-free feeding the levels and composition of the endogenous Sf greater than 400 lipoproteins were similar in both disorders; whereas total Sf20-400, and most notably, Sf 30-60 and 20-30 levels were increased and enriched in cholesterol in the subjects with broad-beta disease.

Lipoprotein of the density 1.006-1.020 in the plasma of patients with type III hyperlipoproteinaemia in the postabsorptive state

Using a rate zonal ultracentrifugal technique in 10 patients with type III hyperlipoproteinaemia, very low density lipoproteins (VLDL) (d less than 1.006, S(f) greater than 20), an intermediate lipoprotein density class with a S(f) range of 15 - 20 (Lp III), and low density lipoproteins (LDL) (S(f) 6 - 8) could be isolated from the plasma. The Lp III was found as a symmetrical peak between VLDL and LDL; its plasma concentration was 248 mg/100 ml plasma (mean), 92 - 469 mg/100 ml plasma (range); the Lp III/LDL ratio was 0.65 (mean), 0.25 - 2.3 (range); the chemical composition w/w was 35.8 percent total cholesterol, 19.3 percent triglycerides, 24.3 percent phospholipids, and 20.4 percent protein (mean). In agarose gel electrophoresis, the Lp III migrated faster than LDL, but slower than VLDL. By means of a double immunodiffusion technique and immunoelectrophoresis, apo-Lp B and apo-Lp C were detectable. In an angle head rotor at 1.4 x 10-8 g. min. Lp III can be separated from VLDL at a solvent density of 1.006, and from LDL at a density of 1.025. In the postabsorptive state in one patient with type I hyperlipoproteinaemia, five with type II and 20 with type IV, and in 50 healthy persons of both sexes, this Lp III peak was not found. The finding of a high concentration of Lp III and a rather low concentration of LDL in the plasma of patients with type III hyperlipoproteinaemia can be regarded as further evidence for an impaired catabolism of VLDL to LDL at Lp III ("intermediate" lipoprotein).

A longitudinal assessment of lipid ratios in the diagnosis of type III hyperlipoproteinaemia

Type III hyperlipoproteinaemia (HLP) has been overdiagnosed in the past, but still may go undiagnosed because of technical difficulties. This longitudinal study of 19 ultracentrifugally proven cases of Type III HLP shows that 2 lipid ratios can be used to supplement the findings of a floating beta band. These patients have been followed for 3 months to 2.5 years whilst on dietary and/or drug treatment. A group composed of more than 100 Type IIB, Type IV and Type IIB-IV hyperlipoproteinaemic patients has been used for comparison purposes. From a total of 310 ultracentrifugal analyses, it was found that the following 2 ratios have more than a 90 percent predictability for Type III HLP: supernatant cholesterol/supernatant triglyceride greater than or equal to 0.35 (Ratio 2); supernatant cholesterol/whole plasma triglyceride greater than or equal to 0.25 (Ratio 3). These ratios are particularly valuable in Type III HLP when the plasma is grossly hyperlipaemic or when the lipid levels are low because of successful treatment.

Lipoproteins and lipid transport

Continued advances in the delineation of pathways of lipid transport in lipoproteins now provide substantial information on all phases of plasma triglyceride transport. Analysis of certain genetic human disorders, together with studies in experimental animals, has begun to show how lipoproteins transport cholesterol as esters of long chain fatty acids. Both triglycerides and cholesterol are esters of long chain fatty acids. Both triglycerides and cholesteryl esters are transported in the "core" of lipoproteins, but the polar lipids and the apoproteins at the aqueous interface critically determine the interactions with enzymes and cellular receptors that control this complex transport system. Differences in pathways as well as in rates of lipid transport appear to underlie the large interspecies variations in lipoprotein concentrations.

Selective measurement of two lipase activities in postheparin plasma from normal subjects and patients with hyperlipoproteinemia

An assay has been developed for specific measurement of two different lipase activities in postheparin plasma. Lipoprotein lipase, derived from extrahepatic sources, is measured as protamine-inactivated lipase activity; hepatic lipase activity is protamine-resistant under the conditions of this assay. In 100 normal subjects, both enzyme activities were noted to be related to age and sex. Protamine-resistant lipase, which comprised 46-95% of the total activity, was highest in men over 18. Protamine-inactivated lipase activity was greatest in younger males and was age-correlated in women, doubling between the second and sixth decades. In 12 patients with hyperchylomicronemia, including five previously shown to have familial type I hyperlipoproteinemia, protamine-inactivated lipase activity was markedly reduced, whereas protamine-resistant lipase was below normal in only 1. The results were not due to lack of plasma activator, presence of plasma inhibitor, or diet, and the deficiency was not overcome by increasing the provoking dose of heparin from 10 U to 75 U/kg. Mean values for both lipase activities were not reduced in 32 other patients with hyperchylomicronemia, nine with "floating beta" lipoproteins (type III hyperlipoproteinemia), and 23 with hyperprebetalipoproteinemia (type IV). Mean protamine-resistant lipase activity was below normal in a group of four women with hypothyroidism, in whom protamine-inactivated lipase was not reduced. Both of the lipase activities were capable of hydrolyzing lipid in very low-density lipoproteins, but the relative rate of hydrolysis of chylomicrons by protamine-resistant lipase was markedly limited. These results indicate the importance of distinguishing between lipases of hepatic and extra-hepatic origin in the measurement of postheparin lipolytic activity.

Mechanism of the hypolipemic effect of clofibrate in postabsorptive man

Splanchnic metabolism of triglycerides and other major substrates was studied in the postabsorptive state in normotriglyceridemic and hypertriglyceridemic human subjects who received (1/2) g of clofibrate four times daily for 3 wk. Transport in blood plasma of triglycerides produced in the splanchnic region was quantified by three methods: (a) measurement of the transsplanchnic gradient of (14)C-labeled triglycerides during constant intravenous infusion of [1- (14)C] palmitate (b) chemical measurement of the transplanchnic gradient in concentration of triglycerides of very low density lipoproteins; and (c) determination of clearance of (14)C-labeled triglycerides in extrasplanchnic tissues. The first method measures only triglycerides derived from free fatty acids and the last two measure total splanchnic production. In hypertriglyceridemic subjects treated with clofibrate, average rates of total splanchnic production of triglycerides and production from free fatty acids were the same as those of comparable untreated subjects despite a consistent fall in plasma triglyceride levels. The hypotriglyceridemic effect of the drug was therefore accompanied by improved disposal of triglycerides in extrasplanchnic tissues. In treated normotriglyceridemic subjects, unlike their untreated counterparts, total splanchnic production was significantly higher than production from free fatty acids. Failure of clofibrate to reduce triglyceride levels in normotriglyceridemic subjects may have been related to increased total splanchnic production, coupled with improved extrasplanchnic disposal. Systemic transport and net splanchnic uptake of free fatty acids were similar in treated and control subjects but the fraction of [1-(14)C]palmitate converted to acetoacetate in splanchnic tissues was significantly higher in treated subjects. Net splanchnic extraction of plasma amino acids that enter the glucogenic pathway via pyruvate was increased in treated subjects and their arterial concentrations were reduced.

Primary dysbetalipoproteinemia: predominance of a specific apoprotein species in triglyceride-rich lipoproteins

Lipoproteins of very low density that are unusually rich in cholesteryl esters accumulate in blood plasma in a characteristic primary form of human hyperlipoproteinemia. These lipoproteins, which are thought to be products of the initial catabolic step in the metabolism of normal triglyceride-rich lipoproteins, have beta rather than pre-beta mobility on electrophoresis, presumably because they have lost certain protein components from their surface. In this study, we have used polyacrylamide gel electrophoresis of apoprotein components that are soluble in tetramethylurea to show that the very low-density lipoprotein fraction of blood serum from seven patients with hyperlipoproteinemia contains unusually large amounts of an arginine-rich protein. Pre-beta migrating, very low-density lipoproteins separated from serum of post-absorptive patients and chylomicrons obtained after a fat-rich meal contain normal amounts of this arginine-rich protein, but beta-migrating, very low-density lipoproteins and chylomicron-like particles separated from serum of post-absorptive patients contain more than twice as much. These apparently partially degraded lipoproteins also contain more tetramethylurea-insoluble protein and smaller amounts of the other soluble protein components than their normal counterparts.