Human plasma lipoprotein [a]. Structural properties

Recent advances in lipoprotein metabolism and the genetic dyslipoproteinemias

The elucidation of the structure and function of the plasma apolipoproteins has provided the unique opportunity to understand the physiological pathways for the transport and cellular metabolism of the plasma lipoproteins. The complexity of the individual density classes of plasma lipoproteins has been revealed by a detailed analysis of the apolipoprotein composition of the individual lipoprotein particles. In addition, the elucidation of the molecular defects in patients with dyslipoproteinemias has now permitted the understanding of the defects at the level of the apolipoprotein gene. The ability to define the genetic defect in individuals at risk for the development of premature cardiovascular disease provides the unique opportunity to now identify these individuals at an earlier age, and to initiate therapy to prevent the development of early heart disease.

The mysteries of lipoprotein(a)

Lipoprotein(a) [Lp(a)] is a macromolecular complex found in human plasma that combines structural elements from the lipoprotein and blood clotting systems and that is associated with premature coronary heart disease and stroke. It is assembled from low-density lipoprotein (LDL) and a large hydrophilic glycoprotein called apolipoprotein(a) [apo(a)], which is homologous to the protease zymogen plasminogen. Plasma Lp(a) concentrations vary 1000-fold between individuals and represent a continuous quantitative genetic trait with a skewed distribution in Caucasian populations. Variation in the hypervariable apo(a) gene on chromosome 6q2.6-q2.7 and interaction of apo(a) alleles with defective LDL-receptor genes explain a large fraction of the variability of plasma Lp(a) concentrations. Though of high theoretical and practical interest, many aspects of the metabolism, function, evolution, and regulation of plasma concentrations of Lp(a) are presently unknown, controversial, or mysterious.

HMG CoA reductase inhibitors lower LDL cholesterol without reducing Lp(a) levels

Lp(a) is a plasma lipoprotein particle consisting of a plasminogenlike protein [apo(a)] disulfide bonded to the apo B moiety of low-density lipoprotein (LDL). Increased plasma levels of Lp(a), either independently or interactively with LDL levels, have been shown to be a risk factor for atherosclerosis. Recently, a new class of lipid-lowering drugs, HMG CoA reductase inhibitors, have been introduced. These drugs act by decreasing liver cholesterol synthesis resulting in up-regulation of LDL receptors, increased clearance of LDL from plasma, and diminution of plasma LDL levels. In this study, we examined the effect of HMG CoA reductase inhibitors on Lp(a) levels in three groups of subjects, five volunteers and two groups of five and 14 patients. In all 24 subjects, mean decreases were observed in total cholesterol (43 +/- 5%), total triglyceride (35 +/- 8%), very low-density lipoprotein (45 +/- 9%), and LDL cholesterol (43 +/- 5%). The mean change in high-density lipoprotein cholesterol was an increase of 7 +/- 8%. Despite the very significant decrease in LDL cholesterol levels (p less than 0.001), Lp(a) levels increased by 33 +/- 12% (p less than 0.005). This was not associated with a measurable change in the chemical composition or size of the Lp(a) particle. This emphatically suggests that Lp(a) particles, despite consisting principally of LDL, are cleared from plasma differently than LDL. The surprising finding of an increase in Lp(a) levels suggests this class of drugs may have a direct effect on Lp(a) synthesis or clearance independent of its effect on LDL receptors.

Pronounced lowering of serum levels of lipoprotein Lp(a) in hyperlipidaemic subjects treated with nicotinic acid

Thirty-one consecutive unselected hyperlipidaemic patients were treated daily with 4 g of nicotinic acid for 6 weeks. The concentrations in serum of lipoprotein Lp(a), and the major lipoprotein classes, were determined before and after the treatment. Nicotinic acid significantly reduced the serum levels of Lp(a) in the whole patient group. Linear regression analysis showed a strong negative relationship between the percentage reduction of Lp(a) and the serum triglyceride level before treatment (r = -0.78), which implied that for patients with a serum triglyceride concentration above 7.5 mmol l-1 there was a rise of Lp(a). The average individual percentage decrease of the concentration of Lp(a) was calculated after the exclusion of four patients who had serum triglyceride levels above 10 mmol l-1. The decrease was 38% with a 95% confidence interval of 28-47%. The absolute decrease of Lp(a) was correlated with the pretreatment levels of Lp(a) (r = 0.91). Within the whole group of patients there was a linear relationship between the percentage decrease of Lp(a) and that of LDL cholesterol (r = 0.88). This latter strong relationship might be due to an inhibition of the synthesis of the protein common to the two lipoproteins, apolipoprotein B.

Quantitation and localization of apolipoproteins [a] and B in coronary artery bypass vein grafts resected at re-operation

Lp[a] is a lipoprotein whose plasma concentration is highly correlated with cardiovascular disease. Its protein moiety, apoLp[a], consists of two large polypeptides, apo[a] and apo B. The possible contribution of Lp[a] to atherosclerosis in saphenous vein aortocoronary bypass grafts was studied in a population of patients undergoing coronary re-bypass surgery. The vein graft tissue levels of apoLp[a] were compared with graft duration, gross and light microscopic pathology, as well as plasma levels of apoLp[a]. The localization pattern of apo[a] and apo B in vein graft tissue was determined. In addition, the plasma levels of cholesterol, triglycerides, apoproteins (apo) A-I, A-II, and E were measured. In a representative subpopulation of 17 patients with a mean age of 63 years from whom grafts with a mean duration of 112 months were resected, the mean total plasma cholesterol level was 221 mg/dl, the mean high density lipoprotein cholesterol level was 31 mg/dl, and the mean plasma triglyceride level was 228 mg/dl. In normal saphenous veins, the level of apoLp[a] was below measurable limits (less than 2 ng/mg), and the level of apo B was very low (3.3 ng/mg). In resected grafts, the mean tissue level of apoLp[a] was 32 ng/mg, and that of apo B was 70 ng/mg, demonstrating the net accumulation of these apoproteins in veins from the time of their grafting into the arterial bed. The apoLp[a]/apo B ratio was determined in 77 tissue segments from 59 grafts (28 patients) and was found to be 0.313. This tissue ratio was significantly higher (p = 0.02) than the plasma apoLp[a]/apo B ratio from these patients, which was 0.132. Immunostaining showed co-localization of apo[a] and apo B in the neointima of grafts. The most abundant pathologic features observed in resected grafts were proliferated intima (43/52), thrombus (28/52), and atherosclerotic core regions (21/52). The level of tissue apo B correlated well with the abundance of core regions (r = 0.501), whereas the level of tissue apoLp[a] did not correlate as well with this feature (r = 0.233). Although apo[a] and apo B are almost absent from normal saphenous vein, these apoproteins (and presumably the lipoproteins Lp[a] and low density lipoprotein) accumulate in bypass vein grafts. The data support the view that these lipoproteins play a significant role in vein graft atherosclerosis.

Lipoprotein(a) in nonhuman primates. Presence and characteristics of Lp(a) immunoreactive materials using anti-human Lp(a) serum

Lipoprotein(a) (Lp(a] immunoreactive materials were examined in serum samples from 77 nonhuman primates of 24 species by Ouchterlony's double diffusion procedure and an enzyme-linked immunosorbent assay (ELISA) using rabbit antisera to human Lp(a). The precipitates obtained with sera from orang-utan and chimpanzee formed reactions of complete identity with the Lp(a) precipitate with human serum. When sera from Old World monkeys and human subjects were tested in wells next to each other, spurs developed between the 2 precipitates, indicating that Lp(a)-like lipoproteins in Old World monkeys have partial identity with human Lp(a). Lp(a) immunoreactive materials were identified in association with lipids by means of fat staining of the precipitates. On the other hand, reactants which could be precipitated with anti-human Lp(a) sera were not detectable in prosimians and New World monkeys. These results suggest that serum Lp(a)-like lipoprotein is phylogenetically acquired in Old World monkeys. However, the possibility that the structures of serum Lp(a)-like lipoproteins in prosimians and New World monkeys are too different to react with anti-human Lp(a) sera cannot be ruled out.

The hyperlipoproteinemias

The association of disturbances of plasma lipid transport and atherogenesis has been recognized, and scientific data continue to accumulate to explain this association from a mechanistic viewpoint. A number of recent clinical trials have shown that cholesterol-lowering therapy can prevent the complications of atherosclerosis. Consequently, the attention of physicians to therapeutic intervention has increased and public awareness to plasma cholesterol levels has been heightened. This article summarizes current knowledge of how plasma lipid transport is regulated. The classical primary hyperlipoproteinemias are considered and hyperlipoproteinemias occurring secondary to other diseases are discussed. Standard methods to diagnose the defined genetic hyperlipidemias are outlined, and new approaches to assess risk of atherosclerosis are examined. Finally, the role of dietary measures and drugs in lowering blood lipids and reducing risk of coronary heart disease is delineated.

Lipoprotein(a) modulation of endothelial cell surface fibrinolysis and its potential role in atherosclerosis

Endothelial cells play a critical role in thromboregulation by virtue of a surface-connected fibrinolytic system. Cultured endothelial cells synthesize and secrete tissue-type plasminogen activator (t-PA) which can bind to at least two discrete sites on the cell surface. These binding sites preserve the catalytic activity of t-PA and protect it from its physiological inhibitor (PAI-1). N-terminal glutamic acid plasminogen (Glu-PLG), the main circulating fibrinolytic zymogen, also interacts specifically with the endothelial cell surface. Binding is associated with a 12-fold increase in catalytic efficiency of plasmin generation by t-PA which may reflect conversion of Glu-PLG to its plasmin-modified form, N-terminal lysine plasminogen (Lys-PLG). Lipoprotein(a) is an atherogenic lipoprotein particle which contains the plasminogen-like apolipoprotein(a) bound to low density lipoprotein. We report here that lipoprotein(a) interferes with endothelial cell fibrinolysis by inhibiting plasminogen binding and hence plasmin generation. In addition, we demonstrate lipoprotein(a) accumulation in atherosclerotic lesions. These findings may provide a link between impaired cell surface fibrinolysis and progressive atherosclerosis.

A potential basis for the thrombotic risks associated with lipoprotein(a)

Lipoprotein(a) (Lp(a)) has been strongly linked with atherosclerosis and is an independent risk factor for myocardial infarction. Distinguishing Lp(a) from other low-density lipoprotein particles is its content of a unique apoprotein, apo(a). The recently described sequence of apo(a) indicates a remarkable homology with plasminogen, the zymogen of the primary thrombolytic enzyme, plasmin. Lp(a) may contain 37 or more disulphide-looped kringle structures, which are 75-85% identical to the fourth kringle of plasminogen. Plasminogen receptors are widely distributed on blood cells and are present at extremely high density on endothelial cells. These receptors promote thrombolysis by accelerating plasminogen activation and protecting plasmin from inhibition. If, by molecular mimicry, Lp(a) competes with plasminogen for receptors, then thrombolysis would be inhibited and thrombosis promoted. Here we provide support for such a mechanism being responsible for the thrombotic risks associated with elevated Lp(a) by demonstrating that Lp(a) inhibits plasminogen binding to cells.

Production of lipoprotein(a) by primary baboon hepatocytes

Primary baboon hepatocytes were cultured in a serum-free medium formulation that permitted the analysis of lipoprotein(a) (Lp(a] production by the cells. The hepatocytes were determined to synthesize Lp(a) on the basis of the following observations: (1) the culture medium reacted in an ELISA designed for detection of baboon Lp(a) in serum samples; (2) the Lp(a)-specific protein, apo(a), was detected in the culture medium by immunoblotting techniques; (3) the unique protein structure of Lp(a) was demonstrated (i.e., association of apo(a) with apoB via interchain disulfide bonds to form apoLp(a]; and (4) the Lp(a) proteins occurred in the medium at a density of about 1.05 g/ml when subjected to density gradient ultracentrifugation. De novo synthesis of Lp(a) by cultured hepatocytes was demonstrated by incorporation of [35S]cysteine. Lp(a) was produced by the hepatocytes throughout a 20 day culture period. Finally, apo(a) isoform patterns in the hepatocyte culture medium and the hepatocyte donors' serum were indistinguishable.

Genetics of the quantitative Lp(a) lipoprotein trait. III. Contribution of Lp(a) glycoprotein phenotypes to normal lipid variation

Apolipoprotein(a) [apo(a)] is a large serum glycoprotein with several genetically determined isoforms differing in their apparent molecular weight. We determined the effects of the apo(a) isoforms on total cholesterol, high-density lipoprotein (HDL)-cholesterol, lipoprotein(a), and triglyceride levels in a sample of 473 unrelated Tyrolean adults. Average lipoprotein(a) and total cholesterol levels were significantly different among apo(a) types. These significant differences were found among the 13 apo(a) isoform patterns observed in this sample and among several logical subsets of the isoform patterns (e.g. considering only the single band types). The data suggest that the effects of apo(a) alleles on Lp(a) levels are additive. The effects of apo(a) on total cholesterol levels cannot be entirely explained by the cholesterol fraction estimated to be contained in the lipoprotein(a) particle. We estimate that the apo(a) glycoprotein polymorphism accounts for 41.9% and 9.6% of the variability in lipoprotein(a) and total cholesterol levels, respectively. This is the strongest effect of a single polymorphic gene on plasma lipid and lipoprotein levels reported so far.

Lipoprotein a inhibits streptokinase-mediated activation of human plasminogen

Lipoprotein a [Lp(a)] inhibits human plasminogen (Pg) conversion to plasmin (Pm) by streptokinase- (SK-) mediated activation. Kinetic and binding studies indicate that Lp(a) inhibits Pg activation by competitive and uncompetitive inhibition. Lp(a) competes with Pg for SK and forms a stable complex. Lp(a) does not, however, inhibit Pg activation by the proteolytic SK-Pm complex. The SK-Pg and SK-Pg(act) intermediate complexes are possible targets of the Lp(a) uncompetitive inhibition. The competitive inhibition constant (Kic) is 45 nM or 14 mg/dL, and the uncompetitive inhibition constant (Kiu) is 140 nM or 42 mg/dL, corresponding to physiologic and pathophysiologic Lp(a) concentrations, respectively.

Tissue distribution of [3H]cholesteryl linoleyl ether-labeled human Lp(a) in different rat organs

The sites of tissue uptake of human lipoprotein(a) (Lp(a] were studied in rats using [3H]cholesteryl linoleyl ether [( 3H]CLE) as a marker. Since rat plasma has no cholesteryl ester transfer activity, the amount of label in various tissues should reflect the quantitative uptake of Lp(a). Isolated Lp(a) was labeled with [3H]CLE by incubation overnight of Lp(a), a source of cholesteryl ester transfer activity (1.23 g/ml infranate of human plasma), and [3H]CLE-labeled Intralipid. Following labeling, the homogeneity and integrity of Lp(a) was shown by agarose electrophoresis and immunoblotting. Intact Lp(a) was injected via the tail vein of rats (120-170 g, n = 4 at each time point), and tissues were collected at various times thereafter (4-48 h). The disappearance curve of [3H]CLE-labeled Lp(a) from rat plasma was bimodal and had an initial rapid t1/2 of 1.8 h followed by a slower component, t1/2 = 13.3 h. Tissue uptake at all sampling times was greatest in liver (28.5% at 48 h of total dpm injected), followed by the intestine (9-12%), with less than 3% uptake by spleen. The small intestine was divided into four segments, and while the 3H radioactivity was similar in the proximal segments, a time-related increase in [3H]CLE was seen in its most distal portion. These studies indicate that the tissue sites of degradation in the rat of human Lp(a) are similar to human low-density lipoproteins (LDL); the increase in label in the distal portion of the small intestine with time may represent [3H]CLE excreted through the bile and absorbed by the mucosal cells.

Reduction of Lp(a) by different methods of plasma exchange

Lipoprotein(a) has been shown to be an independent risk factor for atherosclerosis. The effect of different forms of plasmapheresis therapy on the removal of Lp(a) is examined. Plasmapheresis is successfully administered in a small number of hypercholesteremic patients who fail to respond to conventional therapy. Comparison of four different methods of plasma exchange (albumin substitution, anti-apoB antibody column, LDL precipitation, filtration) reveals significant differences in effectiveness in the ability to lower plasma Lp(a): plasma exchange with albumin und LDL precipitation seem to be the most effective, plasma filtration the least.

Genetic linkage between lipoprotein(a) phenotype and a DNA polymorphism in the plasminogen gene

Coronary heart disease risk correlates directly with plasma concentrations of lipoprotein(a) (Lp(a)), a low-density lipoprotein-like particle distinguished by the presence of the glycoprotein apolipoprotein(a) (apo(a)), which is bound to apolipoprotein B-100 (apoB-100) by disulfide bridges. Size isoforms of apo(a) are inherited as Mendelian codominant traits and are associated with variations in the plasma concentration of lipoprotein(a). Plasminogen and apo(a) show striking protein sequence homology, and their genes both map to chromosome 6q26-27. In a large family with early coronary heart disease and high plasma concentrations of Lp(a), we found tight linkage between apo(a) size isoforms and a DNA polymorphism in the plasminogen gene; plasma concentrations of Lp(a) also appeared to be related to genetic variation at the apo(a) locus. We found free recombination between the same phenotype and alleles of the apoB DNA polymorphism. This suggests that apo(a) size isoforms and plasma lipoprotein(a) concentrations are each determined by genetic variation at the apo(a) locus.

Enzyme-linked immunosorbent assay of lipoprotein(a) in serum and cord blood

We have developed a new sensitive method for quantifying lipoprotein(a) (Lp(a] in human serum, using a 'sandwich' type noncompetitive enzyme-linked immunosorbent assay (ELISA). The solid-phase used was a polystyrene plate. The anti-Lp(a) antibody-enzyme conjugate was labelled by linking Fab' fragments to peroxidase (EC 1.11.1.7) by the maleimide method. The minimum detectable concentration was 0.5 ng/well. Routinely, the assay was carried out with 1,000-fold diluted serum, and Lp(a) was quantified between 4.0 and 500 mg/l. Within-run coefficients of variation (CVs) ranged from 3.5% to 10.4% and between-run CVs from 5.0% to 11.1%. Results by the ELISA were in good agreement with those by radial immunodiffusion (r = 0.955). The distribution of Lp(a) in serum from 820 healthy donors was highly skewed: mean 141.1 mg/l, medium 97.9 mg/l. In cord blood, the mean and median were 15.6 and 9.8 mg/l, respectively. This ELISA for Lp(a) has the advantages of being highly sensitive and specific, simple to perform, and does not use radioisotopes.

Immunochemical characterization and quantitation of lipoprotein (a) in baboons. Development of an assay depending on two antigenically distinct proteins

We have raised specific antibodies against the protein component of baboon lipoprotein (a) (Lp(a]. Apolipoprotein (apo) Lp(a) is a very large protein which separates into two distinct proteins, apo B and apo (a), when 2-mercaptoethanol is included during sample treatment for sodium dodecyl sulfate-electrophoresis. The antibodies were specific for baboon apo (a) and apo B. The presence of the two distinct antigens in the lipoprotein permitted the development of an enzyme-linked immunosorbent assay that was specific for Lp(a) particles in serum. The assay could detect less than 1 ng of Lp(a) protein per well and was useful in the range of 1-9 ng. The assay was specific for Lp(a) and did not respond to other lipoproteins, such as low density lipoprotein. Lp(a) could be accurately quantitated in serum frozen at -80 degrees C in plastic tubing segments. Using the Lp(a) assay, the mean serum level of 80 unrelated baboons was 4.7 mg/dl, with the distribution skewed toward the lower levels. These data further support the value of the baboon as a model of the atherogenic lipoprotein Lp(a).

Serum Lp(a) level as a predictor of vein graft stenosis after coronary artery bypass surgery in patients

Although the serum lipoprotein fraction Lp(a) has been associated with coronary artery atherosclerosis, its relationship to narrowing of saphenous vein grafts has not previously been elucidated. We therefore measured serum Lp(a) levels in 167 symptomatic patients undergoing cardiac catheterization who had had coronary artery bypass surgery 0.7 to 14.3 years earlier. Lp(a), total cholesterol, and total triglyceride levels were compared with the degree of saphenous vein graft stenosis to test for any association. Serum Lp(a) levels were significantly associated with the degree of stenosis of saphenous vein grafts (r = .24, p = .002). Mean Lp(a) levels (mg/dl) in the 135 patients with stenosis were almost double (32.0 +/- 32.7, mean +/- SD) those in the 32 patients with no graft stenosis (16.7 +/- 22.6; p = .002). Graft stenosis was not associated with previous myocardial infarction, hypertension, obesity, diabetes, or smoking. Serum cholesterol levels (mg/dl) were slightly higher in the stenosis group (251.3 +/- 69) than in the no-stenosis group (231.8 +/- 48.8), but the difference was of borderline significance (p = .06). A stepwise increase in mean Lp(a) was found in groups of patients with increasing vein graft stenosis. At a serum Lp(a) level of 31.6 mg/dl or above, 92% of the patients demonstrated vein graft stenosis. Thus, patients with elevated Lp(a) levels have an increased risk of developing saphenous vein graft stenosis after coronary bypass surgery.

Lp(a) phenotyping by immunoblotting with polyclonal and monoclonal antibodies

A new method that allows rapid phenotyping of genetic Lp(a) glycoprotein types in large numbers of samples is described. The method is based on sodium dodecyl sulfate gel electrophoresis of reduced serum or plasma in horizontal slab gels followed by immunoblotting with polyclonal anti-Lp(a) lipoprotein or monoclonal anti-Lp(a) glycoprotein antibodies. Phenotyping of 194 unrelated, healthy subjects resulted in Lp(a) allele frequencies of Lp(a)B = 0.013, Lp(a)S1 = 0.032, Lp(a)S2 = 0.106, Lp(a)S3 = 0.096, Lp(a)S4 = 0.156, and Lp(a)O = 0.600, and confirmed the recently recognized association of Lp(a) glycoprotein phenotype with Lp(a) lipoprotein concentration. The new procedure is suitable for large-scale population, genetic, and epidemiologic studies and may be important for atherosclerotic risk assessment.

Characterization of very-low-density lipoproteins isolated from baboons, and fractionated using heparin-Sepharose chromatography

Plasma very-low-density lipoproteins (VLDL) (d less than 1.006 g/ml) were purified from baboons by repeated ultracentrifugation. The weight composition of VLDL purified from these animals was 59% triacylglycerol, 17% phospholipid, 13% cholesterol plus cholesteryl esters, and 11% protein. When purified VLDL was fractionated using heparin-Sepharose chromatography, an average of 33% of the total recovered proteins were unbound in a saline solution, and 67% (range, 31 to 92%) were bound by the column, but could be eluted with 3 M NaCl. Recoveries of starting protein and the major classes of lipids in the two fractions were 70-80%. The two fractions differed in both apolipoprotein and lipid compositions. Analysis of sodium dodecyl sulfate-treated apolipoproteins using 3-21.5% acrylamide gradient gel electrophoresis indicated that both VLDL fractions contained apolipoprotein B, but only the bound fraction possessed significant amounts of apolipoprotein E. On a weight percent basis, the apolipoprotein-E-rich (bound) VLDL fraction contained significantly more cholesterol and cholesteryl esters (P less than 0.001) and less phospholipids (P less than 0.005) compared to the apolipoprotein E-poor (unbound) VLDL. Apolipoprotein-E-poor VLDL had shorter retention times than E-rich VLDL upon gel filtration chromatography, suggesting a larger size. There was no significant correlation between plasma levels of apolipoprotein-E-poor VLDL and levels of apolipoprotein B. These results demonstrate that baboons possess VLDL which can be separated into apolipoprotein-E-poor and E-rich fractions and these fractions differ in protein and lipid composition and in size.

In vivo studies on the binding sites for lipoprotein (a) on parenchymal and non-parenchymal rat liver cells

The direct correlation between lipoprotein (a) (Lp(a)) concentrations and atherosclerosis stimulated us to investigate the in vivo interaction of Lp(a) with the liver and the various liver cell types. In untreated rats the serum decay of Lp(a) is comparable to that of LDL. By estrogen treatment the interaction of LDL with parenchymal liver cells is increased 17-fold whereas only a 2-fold effect on Lp(a) is found. The decay of Lp(a) in estrogen-treated rats is slower than for LDL. The data indicate that Lp(a) in vivo shows a less efficient interaction than LDL with the estrogen-induced apo-B,E receptor on parenchymal liver cells. It is suggested that the inability of Lp(a) to interact efficiently with the LDL removal system of the liver might be related to its atherogenic action.

Genetics of the quantitative Lp(a) lipoprotein trait. II. Inheritance of Lp(a) glycoprotein phenotypes

Lp(a) glycoprotein exhibits an apparent size polymorphism that is associated with genetically controlled Lp(a) lipoprotein concentrations in plasma (Utermann et al. 1988). We have tested the hypothesis that this polymorphism is genetically controlled by studying 15 matings with a total of 44 offspring. This confirmed our conclusion that Lp(a) types are controlled by a series of codominant alleles LpF, LpB, LpS1, LpS2, LpS3 and LpS4 and by a null allele LpO. Together with the data from the accompanying paper this indicates that the structural gene for the Lp(a) protein is the major gene locus determining Lp(a) lipoprotein concentrations in plasma.

Apolipoprotein polymorphism and multifactorial hyperlipidaemia

Apolipoproteins AIV, B, E, and the Lp(a) glycoprotein are genetically polymorphic in humans. Three common alleles epsilon 2, epsilon 3 and epsilon 4 control the polymorphism of apolipoprotein E. These code for proteins which differ in functional properties, e.g. receptor binding activity and in vivo catabolism. This explains the significant effect of the apoE gene locus on the variability of plasma lipoprotein concentrations and moreover the implication of apoE alleles in the aetiology of multifactorial forms of hyperlipidaemia e.g. familial type III hyperlipidaemia (apoE2; arg158----cys) and polygenic hypercholesterolaemia (apoE4; cys112----arg). A further gene locus controls the concentrations in plasma of the Lp(a) lipoprotein that is composed of an LDL-like particle containing apoB-100 and the disulphide-bonded Lp(a) glycoprotein. The latter exhibits a genetic size polymorphism (MW approximately 400 kD-700 kD) that is controlled by at least seven autosomal alleles. These alleles at the same time are involved in determining the plasma concentrations of the lipoprotein that range from less than 1 mg/dl to greater than 200 mg/dl. Thus there is evidence that genetic variability in apolipoproteins relates to the variability of lipoprotein concentrations in the population and is implicated in the aetiology of multifactorial hyperlipidaemias.

Genetics of the quantitative Lp(a) lipoprotein trait. I. Relation of LP(a) glycoprotein phenotypes to Lp(a) lipoprotein concentrations in plasma

The Lp(a) lipoprotein is a complex particle composed of a low density lipoprotein (LDL)-like lipoprotein and the disulfide bonded Lp(a) glycoprotein. The complex represents a quantitative genetic trait. SDS gel electrophoresis under reducing conditions of sera followed by immunoblotting with affinity-purified polyclonal anti-Lp(a) demonstrated inter- and intra-individual size heterogeneity of the glycoprotein with apparent Mr in the range 400-700kDa. According to their relative mobilities compared to apo B-100 the Lp(a) patterns were categorized into phenotypes F, B, S1, S2, S3 und S4 and into the respective double-band phenotypes. This size heterogeneity seems to be controlled by multiple alleles designated LpF, LpB, LpS1, LpS2, LpS3, LpS4 and a null allele (LpO) at a single locus. Phenotype frequencies observed in 441 unrelated subjects were in good agreement with those expected from the genetic hypothesis. Comparison of Lp(a) lipoprotein concentrations in the different phenotypes revealed a highly significant association of phenotypes B, S1 and S2 with high, and phenotypes S3 und S4 with intermediate Lp(a) concentrations. A third mode is represented by the null phenotype were no Lp(a) band is detected upon immunoblotting and Lp(a) lipoprotein is low or absent. We conclude that the same gene locus is involved in determining Lp(a) glycoprotein phenotype and Lp(a) lipoprotein concentrations in plasma. This major gene seems to be the Lp(a) glycoprotein structural gene locus.

Structural relationship of an apolipoprotein (a) phenotype (570 kDa) to plasminogen: homologous kringle domains are linked by carbohydrate-rich regions

At least six allelic forms of apolipoprotein(a), differing in molecular mass, could be detected by immunoblot analysis. One of these phenotypes with a molecular mass of 570 kDa has been investigated. After reduction and carboxymethylation it was digested with trypsin and the resulting peptides were separated by gel filtration and reverse phase HPLC. The tryptic fragments sequenced comprised a total of 356 amino acids. The N-terminus of apo(a) was highly homologous to the start of the kringle 4 domain from human plasminogen and the majority of the tryptic peptides isolated was also homologous to sequences from this kringle. At least five homologous "kringle 4" domains are present in apolipoprotein(a) whereby one domain occurs more frequently than the others. A carbohydrate-rich peptide was also obtained in high yield. This glycopeptide connects two "kringle 4" domains and contains one N-glycoside within the kringle and six potential O-glycosides in the linking region. From the recovery it can be estimated that this peptide occurs several times within the whole apolipoprotein (a) sequence. The high carbohydrate content is in sharp contrast to that of human plasminogen. Other peptides sequenced indicate that apo (a) also contains domains homologous to the kringle 5 and protease regions of plasminogen. No unique peptides were found. These studies suggest that apolipoprotein (a) could have arisen through duplication of specific regions from the human plasminogen gene. The size heterogeneity of apo (a) might then be explained by differences in the numbers of gene duplications.

Apolipoprotein B: structure, biosynthesis and role in the lipoprotein assembly process

The complete amino acid sequence of the liver-synthesized apolipoprotein B (apoB) species, apoB 100, has been derived from cloned cDNA. The protein consists of 4536 amino acids (+ a 27 amino acid signal sequence). Cysteine is clustered in the N-terminal 1/10 of the protein, suggesting the presence of a stabilized tertiary structure in this part of the molecule. Three types of structure are suggested to be of importance for the binding of the protein to lipids; (i) hydrophobic sequences with a high probability for beta-sheet structure, (ii) strict amphipathic beta-sheets, and (iii) amphipathic alfa-helices. An apoB 100 molecule is completed within 10-14 min and secreted after approximately 30 min, 1/3 of which is due to the transfer through the endoplasmic reticulum (ER), while 2/3 is spent in the Golgi apparatus. ApoB 100 is co-translationally N-glycosylated and 25% of the oligosaccharide chains is processed in the Golgi compartment. Other posttranslational modifications that have been discussed include covalent acylation and phosphorylation. It has also been suggested that the lipid moiety of the apoB 100 lipoproteins are modified during the passage through the Golgi apparatus. The site of lipoprotein assembly is suggested to be separated from the site of apoB 100 synthesis, and apoB 100 appears to be co-translationally bound to the ER membrane and from this transferred to the ER lumen. Based on these observations a model for the assembly of apoB 100 lipoproteins is discussed in this paper. The intestinal derived apoB species, apoB 48, has a molecular mass of 210 kDa and appears to correspond to the N-terminal 48% of apoB 100. The mechanism by which apoB 48 is formed is still not known. Available data indicate that the protein is formed within the intestinal cells, these data also argue against the possibility that apoB 48 is formed by posttranslational proteolysis of apoB 100. The formation of a separate apoB 48 mRNA by alternative splicing has been suggested, based on the observation of a 7 kb mRNA which corresponds to the 5' portion of the apoB 100 mRNA. However, the most abundant apoB mRNA species found in the intestine have a size that corresponds to that of the apoB 100 mRNA, furthermore the observation that apoB 48 appears to terminate in a 7.5 kb exon that appears to lack alternative splice sites, does not favour the possibility of alternative splicing.

Apolipoprotein genetic variation in the assessment of atherosclerosis susceptibility

Apolipoproteins are the protein constituents of lipoproteins, the particles that transport cholesterol and triglycerides in the plasma. Numerous epidemiologic studies have associated variations in plasma levels of lipoproteins and apolipoproteins with the development of atherosclerosis. Furthermore, genetic variations in lipoproteins and apolipoproteins have been associated with disorders of lipid metabolism. Recent advances in biochemical and molecular genetic methods have resulted in an increased understanding of interindividual variations in lipoprotein metabolism and of their relationship to atherosclerosis and the dyslipoproteinemias. In particular, certain DNA restriction fragment length polymorphisms of the apolipoprotein genes have, in the last few years, been associated with atherosclerotic diseases and dyslipoproteinemias. We believe that genetic markers, when used in conjunction with traditional clinical and biochemical determinations, may one day be useful in predicting atherosclerosis susceptibility in the general population.

A study of the structural heterogeneity of low-density lipoproteins in two patients homozygous for familial hypercholesterolaemia, one of phenotype E2/2

The structural heterogeneity of the low-density lipoproteins (d 1.019-1.063 g ml-1) in two female patients homozygous for familial hypercholesterolaemia, one of phenotype E2/2, has been evaluated using a new ultracentrifugal density gradient procedure. The mass distribution, chemical composition, particle size and heterogeneity, hydrated density and apolipoprotein content of 16 LDL subfractions were determined. By gradient gel electrophoresis, the lighter LDL subfractions (d 1.016-1.037 g ml-1) displayed a single particle species which progressively diminished in size from 24.8 to 22.0 nm with increase in density. By contrast, subfractions of higher density (d greater than 1.037 g ml-1) exhibited two LDL particle species of distinct size; one component decreased in size from 21.8 to 20.4 nm with increase in density, while the second maintained an essentially constant diameter (between 22.5 and 23.5 nm) across these LDL subfractions. Immunoblotting with anti-apo-B100 of LDL subspecies separated by gradient gel electrophoresis showed all particles to contain apo-B100. However, dot-blots and immunoblotting with a monoclonal antibody to lipoprotein (a) (Lp(a)) revealed that the LDL particle subspecies of greatest diameter (22.5-23.5 nm) present in the denser subfractions (d greater than 1.037 g ml-1) also contained the Lp(a) antigen. These findings, taken together with the high plasma Lp(a) levels (greater than 60 mg dl-1) in our patients, raise the possibility that Lp(a) may contribute in a significant manner to the atherogenic process in homozygous familial hypercholesterolaemia.

Association of levels of lipoprotein Lp(a), plasma lipids, and other lipoproteins with coronary artery disease documented by angiography

In a study of 307 white patients who underwent coronary angiography, the relationship of coronary artery disease (CAD) to plasma levels of lipoprotein Lp(a) and other lipid-lipoprotein variables was examined. Lp(a) resembles low-density lipoprotein (LDL) in several ways, but can be distinguished and quantified by electroimmunoassay. CAD was rated as present or absent and was also represented by a quantitative lesion score derived from estimates of stenosis in four major coronary vessels. Coronary lesion scores significantly correlated with Lp(a), total cholesterol, triglycerides, LDL cholesterol, and high-density lipoprotein (HDL) cholesterol levels by univariate statistical analysis. By multivariate analysis levels of Lp(a) were associated significantly and independently with the presence of CAD (p less than .02), and tended to correlate with lesion scores (p = .06). Among subgroups Lp(a) level was associated with CAD in women of all ages and in men 55 years old or younger. An apparent threshold for coronary risk occurred at Lp(a) lipoprotein mass concentrations of 30 to 40 mg/dl, corresponding to Lp(a) cholesterol concentrations of approximately 10 to 13 mg/dl. Plasma Lp(a) in white patients appears to be a major coronary risk factor with an importance approaching that of the level of LDL or HDL cholesterol.

Characterization of an unusual lipoprotein similar to human lipoprotein a isolated from the baboon, Papio sp

An unusual lipoprotein was detected and purified from the blood of some members of a large colony of baboons, Papio sp. This lipoprotein was found to be similar to human lipoprotein a in all respects and is therefore termed lipoprotein a. Baboon lipoprotein a had a density of 1.052 g/ml and was located between low- and high-density lipoproteins in a density gradient ultracentrifugation. However, despite its greater density, baboon lipoprotein a was larger than low-density lipoprotein, based on gradient gel electrophoresis and gel filtration. The lipoprotein contained a very large apolipoprotein (apolipoprotein-lipoprotein a) which was found to consist of an apolipoprotein B linked to another protein called apolipoprotein a by a disulfide bridge(s). In all these characteristics, baboon lipoprotein a was similar to human lipoprotein a.

A dominant role of lipoprotein(a) in the investigation and evaluation of parameters indicating the development of cervical atherosclerosis

The correlation of serum levels of lipoprotein (a) [Lp(a)] with the progression of cervical atherosclerosis was investigated and compared with the common risk factors. The carotid arteries of 100 subjects were examined by direct bi-directional Doppler ultrasonic imaging. A highly significant elevation of the mean values of Lp(a) in group 1 (P1, with smooth surface plaques) and in group 2 (P2, with exulcerations) vs the control (P0, with no detectable plaques) was established. Low density lipoprotein cholesterol (LDL-C) was highly significantly elevated in P1, but only significantly higher in P2. Total cholesterol (TC) was significantly higher in P1 and highly significantly elevated in P2. Diabetes was also found to be significantly associated with atherosclerotic plaque formation, in contrast to triglycerides (TG), high density lipoprotein cholesterol (HDL-C) and its ratio to TC, hypertension and cigarette smoking. In a smaller collective of 30 patients--40-60 years old--being equally divided into 3 groups (p0, p1, p2), Lp(a) showed again to be the most significant parameter. LDL-C, TC and its ratio to HDL-C were highly significantly altered in subgroup p1 and significantly altered in subgroup p2. In this selection there were 12 patients with and 18 without cerebral infarction (CI). The difference of the medians of Lp(a) serum levels between these 2 groups was also found to be highly significant.

Levels of lipoprotein Lp(a) decline with neomycin and niacin treatment

Total and low density lipoprotein cholesterol concentration reduction in patients with markedly increased levels of these substances, leads to a decline in the incidence of myocardial infarction and death. A unique cholesterol-rich lipoprotein, lipoprotein Lp(a), has been identified which not only can be confused with low density lipoproteins, but has also been associated with premature cardiovascular disease. Using the cholesterol-lowering drugs neomycin and niacin in 14 type II hyperlipoproteinemic subjects, we determined the effect of lipid-lowering therapy on lipoprotein Lp(a) concentrations. Neomycin (2g/day) reduced low density lipoprotein cholesterol and lipoprotein Lp(a) concentrations by 23% and 24%, respectively. Combination therapy with neomycin (2 g/day) and niacin (3 g/day) induced a 48% decline in low density lipoprotein cholesterol levels and a 45% reduction in the concentration of lipoprotein Lp(a). These changes in lipoprotein Lp(a) levels were associated with a striking decline in the intensity of the slow pre-beta-lipoprotein fraction determined Lp(a) by lipoprotein electrophoresis. This slow pre-beta-lipoprotein fraction contained Lp(a) determined by immunofixation. These observations indicate that lipoprotein Lp(a) concentrations can be altered pharmacologically and that the progression of cardiovascular disease may be altered through changes in lipoprotein (a) levels.