Plasma lipoprotein(a) levels and expression of the apolipoprotein(a) gene are dependent on the nucleotide polymorphisms in its 5'-flanking region

Lipoprotein(a) beyond the kringle IV repeat polymorphism: The complexity of genetic variation in the LPA gene

High lipoprotein(a) [Lp(a)] concentrations are one of the most important genetically determined risk factors for cardiovascular disease. Lp(a) concentrations are an enigmatic trait largely controlled by one single gene (LPA) that contains a complex interplay of several genetic elements with many surprising effects discussed in this review. A hypervariable coding copy number variation (the kringle IV type-2 repeat, KIV-2) generates >40 apolipoprotein(a) protein isoforms and determines the median Lp(a) concentrations. Carriers of small isoforms with up to 22 kringle IV domains have median Lp(a) concentrations up to 5 times higher than those with large isoforms (>22 kringle IV domains). The effect of the apo(a) isoforms are, however, modified by many functional single nucleotide polymorphisms (SNPs) distributed over the complete range of allele frequencies (<0.1% to >20%) with very pronounced effects on Lp(a) concentrations. A complex interaction is present between the apo (a) isoforms and LPA SNPs, with isoforms partially masking the effect of functional SNPs and, vice versa, SNPs lowering the Lp(a) concentrations of affected isoforms. This picture is further complicated by SNP-SNP interactions, a poorly understood role of other polymorphisms such as short tandem repeats and linkage structures that are poorly captured by common R² values. A further layer of complexity derives from recent findings that several functional SNPs are located in the KIV-2 repeat and are thus not accessible to conventional sequencing and genotyping technologies. A critical impact of the ancestry on correlation structures and baseline Lp(a) values becomes increasingly evident.

This review provides a comprehensive overview on the complex genetic architecture of the Lp(a) concentrations in plasma, a field that has made tremendous progress with the introduction of new technologies. Understanding the genetics of Lp(a) might be a key to many mysteries of Lp(a) and booster new ideas on the metabolism of Lp(a) and possible interventional targets.

Protein-coding repeat polymorphisms strongly shape diverse human phenotypes

Many human proteins contain domains that vary in size or copy number because of variable numbers of tandem repeats (VNTRs) in protein-coding exons. However, the relationships of VNTRs to most phenotypes are unknown because of difficulties in measuring such repetitive elements. We developed methods to estimate VNTR lengths from whole-exome sequencing data and impute VNTR alleles into single-nucleotide polymorphism haplotypes. Analyzing 118 protein-altering VNTRs in 415,280 UK Biobank participants for association with 786 phenotypes identified some of the strongest associations of common variants with human phenotypes, including height, hair morphology, and biomarkers of health. Accounting for large-effect VNTRs further enabled fine-mapping of associations to many more protein-coding mutations in the same genes. These results point to cryptic effects of highly polymorphic common structural variants that have eluded molecular analyses to date.

Structure, function, and genetics of lipoprotein (a)

Lipoprotein (a) [Lp(a)] has attracted the interest of researchers and physicians due to its intriguing properties, including an intragenic multiallelic copy number variation in the LPA gene and the strong association with coronary heart disease (CHD). This review summarizes present knowledge of the structure, function, and genetics of Lp(a) with emphasis on the molecular and population genetics of the Lp(a)/LPA trait, as well as aspects of genetic epidemiology. It highlights the role of genetics in establishing Lp(a) as a risk factor for CHD, but also discusses uncertainties, controversies, and lack of knowledge on several aspects of the genetic Lp(a) trait, not least its function.

Apolipoprotein(a) Kringle-IV Type 2 Copy Number Variation Is Associated with Venous Thromboembolism

In addition to the established association between high lipoprotein(a) [Lp(a)] concentrations and coronary artery disease, an association between Lp(a) and venous thromboembolism (VTE) has also been described. Lp(a) is controlled by genetic variants in LPA gene, coding for apolipoprotein(a), including the kringle-IV type 2 (KIV-2) size polymorphism. Aim of the study was to investigate the role of LPA gene KIV-2 size polymorphism and single nucleotide polymorphisms (SNPs) (rs1853021, rs1800769, rs3798220, rs10455872) in modulating VTE susceptibility. Five hundred and sixteen patients with VTE without hereditary and acquired thrombophilia and 1117 healthy control subjects, comparable for age and sex, were investigated. LPA KIV-2 polymorphism, rs3798220 and rs10455872 SNPs were genotyped by TaqMan technology. Concerning rs1853021 and rs1800769 SNPs, PCR-RFLP assay was used. LPA KIV-2 repeat number was significantly lower in patients than in controls [median (interquartile range) 11(6–17) vs 15(9–25), p<0.0001]. A significantly higher prevalence of KIV-2 repeat number ≤7 was observed in patients than in controls (33.5% vs 15.5%, p<0.0001). KIV-2 repeat number was independently associated with VTE (p = 4.36 x10^-9), as evidenced by the general linear model analysis adjusted for transient risk factors. No significant difference in allele frequency for all SNPs investigated was observed. Haplotype analysis showed that LPA haplotypes rather than individual SNPs influenced disease susceptibility. Receiver operating characteristic curves analysis showed that a combined risk prediction model, including KIV-2 size polymorphism and clinical variables, had a higher performance in identifying subjects at VTE risk than a clinical-only model, also separately in men and women.

A two-step genetic study on quantitative precursors of coronary artery disease in a homogeneous Indian population: case-control association discovery and validation by transmission-disequilibrium test

In spite of its strong familiality, gene identification for coronary artery disease (CAD) has not yielded a consistent picture. One major reason for this is that families or cases and controls were not recruited from a homogeneous population. We, therefore, attempted to map genes underlying 10 quantitative traits (QTs) that are known precursors of CAD in a homogeneous population (Marwari) of India. The QTs are apolipoprotein B (ApoB), C-reactive protein (CRP), fibrinogen (FBG), homocysteine (HCY), lipoprotein (a) (LPA), cholesterol - total (CHOL-T), cholesterol - HDL (CHOL-H), cholesterol - LDL (CHOL-L), cholesterol - VLDL (CHOL-V) and triglyceride (TG). We assayed 209 SNPs in 31 genes among members of Marwari families. After log-transformation and covariate-adjustment of the QTs, a two-step analysis was performed. In Step-1, data on unrelated individuals were analysed for association with the SNPs. In Step-2, for validation of Step-1 results, a quantitative transmission-disequilibrium test on parent- offspring data was performed for each SNP found to be significantly associated with a QT in Step-1 on an independent sample set drawn from the same population. Statistically significant results found for the various QTs and SNPs were: rs3774933, rs230528, rs230521, rs1005819 and rs1609798 (intronic, NFKB1) with APOB; rs5361 (Missense, R greatr than S, SELE) and rs4648004 (Intronic, NFKB1) with FBG; rs4220 (Missense, K greater than R, FGB) with HCY; and rs3025035 (Intronic, VEGFA) with CHOL-H. SNPs in SELE, VEGFA, FGB and NFKB1 genes impact significantly on levels of quantitative precursors of CAD in Marwaris.

Biochemistry and biomarkers of inflamed patients: why look, what to assess

Specific laboratory tests and physical findings are available to the practicing clinician that should raise the suspicion of inflammation. Inflammation is related to specific clinical outcomes. Once identified, changes in clinical practice may affect the level of inflammation in individual and or groups of dialysis patients with the hope that these changes may in turn affect outcome in a positive manner. Standard clinical tests and observations associated with inflammation are hypoalbuminemia, erythropoietin resistance, decreased iron saturation accompanied by high ferritin, frailty, low serum creatinine, reduced total and LDL-cholesterol, and increased C reactive protein (CRP). Inflammation is strongly associated with loss of physical function, dyslipidemia (low LDL- and HDL-cholesterol, increased triglycerides), and anemia that is unresponsive to erythropoietin. Inflammation is associated with cardiovascular events, increased hospitalization, and death. Correctible causes of inflammation are tunneled dialysis catheters, arteriovenous grafts, catheter infection, periodontal disease, poor water quality, and dialyzer incompatibility. Obesity also is a source of cytokines but may be less amenable to treatment. Inflammation is multifactorial in dialysis patients. Some sources are recognizable and correctable, such as vascular access type, clinical infection, and water quality, and some are not. Inflammation is strongly associated with outcome.

Fish intake and LPA 93C>T polymorphism: gene-environment interaction in modulating lipoprotein (a) concentrations

High plasma lipoprotein (a) [Lp(a)] concentrations are an independent risk factor for atherosclerotic diseases. To date, no effective intervention strategies on reducing Lp(a) concentrations have been reported. The aim of the study was to evaluate the possible modulation of two polymorphisms of LPA gene (LPA 93C>T and LPA 121G>A) and nutritional habits on Lp(a) concentrations. We studied 647 healthy Italian subjects (260 M; 387 F) with a median age of 48 years (range: 19-78) enrolled in an epidemiological study conducted in Florence, Italy. A linear regression analysis showed a significant negative influence of fish intake (beta=-0.174+/-0.084; p=0.04) on Lp(a) concentrations, after adjustment for smoking habit, C-reactive protein serum concentrations, dietary habits and LDL-cholesterol concentrations. With regard to LPA polymorphisms, LPA 93C>T polymorphism resulted to significantly affect Lp(a) circulating concentrations in a dose-dependent manner, with lower concentrations shown by subjects carrying the T rare allele, whereas no significant influence of LPA 121G>A polymorphism on Lp(a) concentrations was observed. Moreover, by analyzing the possible interplay between LPA 93C>T and dietary fish intake, a significant interaction between these two determinants in lowering Lp(a) concentrations was reported. In addition, lower Lp(a) concentrations were observed in subjects carrying the T allele of the LPA 93C>T polymorphism and consuming a high intake of fish with respect to those being in the highest tertile of fish consumption but homozygotes for the common allele of the polymorphism. In conclusion, this study reported a significant interaction of daily fish intake and LPA 93C>T polymorphism in decreasing Lp(a) concentrations.

LPA +93C>T and +121G>A polymorphisms detection by electronic microchip technology

Lipoprotein(a) [Lp(a)] is a LDL-like particle containing a single copy of apolipoprotein B-100 (apoB-100), covalently attached to apolipoprotein(a) [apo(a)]. Apo(a) is encoded by LPA gene (6q26-27), and it has been hypothesized that LPA +93C>T and +121G>A polymorphisms in the 5' flanking region could influence the apolipoprotein(a) synthesis, so affecting Lp(a) levels. In order to permit a rapid detection of LPA polymorphisms, we performed an analysis protocol for the SNPs detection through Nanogen Technology with the Universal Reporting System, and we compared our results with those obtained with a more conventional method, such as PCR-RFLP assay. Our experiments evidenced that Nanogen Technology may be used as a high-throughput tool in LPA +93C>T and +121G>A polymorphisms analysis, minimizing the hands-on time and the costs for the SNPs detection. In particular, this Technology allows the analysis of polymorphisms at the LPA locus, able to modulate the levels of Lp(a), a relevant marker of atherosclerosis.

Three single-nucleotide polymorphisms in LPA account for most of the increase in lipoprotein(a) level elevation in African Americans compared with European Americans

BACKGROUND

The extent which universally common or population-specific alleles can explain between-population variations in phenotypes is unknown. The heritable coronary heart disease risk factor lipoprotein(a) (Lp(a)) level provides a useful case study of between-population variation, as the aetiology of twofold higher Lp(a) levels in African populations compared with non-African populations is unknown.

OBJECTIVE

To evaluate the association between LPA sequence variations and Lp(a) in European Americans and African Americans and to determine the extent to which LPA sequence variations can account for between-population variations in Lp(a).

METHODS

Serum Lp(a) and isoform measurements were examined in 534 European Americans and 249 African Americans from the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease Study. In addition, 12 LPA variants were genotyped, including 8 previously reported LPA variants with a frequency of >2% in European Americans or African Americans, and four new variants.

RESULTS

Isoform-adjusted Lp(a) level was 2.23-fold higher among African Americans. Three single-nucleotide polymorphisms (SNPs) were independently associated with Lp(a) level (p<0.02 in both populations). The Lp(a)-increasing SNP (G-21A, which increases promoter activity) was more common in African Americans, whereas the Lp(a)-lowering SNPs (T3888P and G+1/inKIV-8A, which inhibit Lp(a) assembly) were more common in European Americans, but all had a frequency of <20% in one or both populations. Together, they reduced the isoform-adjusted African American Lp(a) increase from 2.23 to 1.37-fold(a 60% reduction) and the between-population Lp(a) variance from 5.5% to 0.5%.

CONCLUSIONS

Multiple low-prevalence alleles in LPA can account for the large between-population difference in serum Lp(a) levels between European Americans and African Americans.

Inflammation: cause of vascular disease and malnutrition in dialysis patients

Inflammation occurs in response to tissue injury or the presence of foreign antigens and is important in the mobilization of specific immunologic and nonimmunologic defenses against injury. The vascular endothelium is altered to allow immune competent cells to access the interstitial space. Muscle and visceral proteins are catabolized and the amino acids are used either to supply energy or as substrates for the production of acute-phase proteins that play a role in defense. Restoration of muscle mass is impaired while inflammation is on going. Lipids are mobilized. Although serving a vital role in allowing host survival from acute injury or infection, if unimpeded, or if triggered inappropriately, the acute-phase response may instead lead to increased vascular injury and progressive loss of muscle and visceral protein pools causing malnutrition. Markers of inflammation (C reactive protein [CRP] or interleukin-6 [IL-6] levels) are associated with cardiovascular risk in the general population and in dialysis patients. Hypoalbuminemia also is associated with cardiovascular risk in dialysis patients. Although albumin is considered a marker of nutrition, changes in albumin levels are associated with increased levels of acute-phase proteins. Persistent changes in albumin levels are caused by reduced albumin synthesis associated with inflammation and not decreased normalized protein catabolic rate. The cause(s) of inflammation must be identified and treated to resolve malnutrition and reduce cardiovascular risk.

A common nonsense mutation in the repetitive Kringle IV-2 domain of human apolipoprotein(a) results in a truncated protein and low plasma Lp(a)

LPA, the gene coding for apolipoprotein(a) [apo(a)], is the major determinant of lipoprotein(a) [Lp(a)] plasma levels, which are associated with risk for coronary heart disease (CHD) and stroke. It is not completely understood how variation in LPA relates to Lp(a) concentrations. One type of variation related to Lp(a) levels is the number of Kringle (K) IV-2 (g.61C>T; GenBank L14005.1) repeats in LPA, but sequence variation may also contribute. Human apo(a) contains from two to >40 nearly identical K IV-2 repeats of genomic size 5.5 kb, which makes it difficult to detect mutations. To elucidate the genetic variation of the apo(a) K IV-2 domain, we isolated a single "nonexpressing" apo(a) allele with 26 K IV-2 repeats, followed by PCR, cloning and sequencing of 96 clones, resulting in an average coverage of each K IV-2 repeat of approximately four-fold. The previously described K IV types 2A and 2B (K IV-2A and K IV-2B) were detected in 74% of the clones. In addition, a new type designated 2C (K IV-2C) was present. A nonsense mutation in the first exon of K IV-2 (g.61C>T) predicted to result in a truncated protein (p.R21X) was found in nine clones on a K IV-2A background. The presence of this mutation was confirmed by analysis of genomic DNA and was shown to represent the rare allele (frequency 0.02) of a SNP. Immunoblot analysis of apo(a) from plasma confirmed the presence of a truncated apo(a) isoform in the index individual and family members. Our data show that SNPs affecting Lp(a) plasma concentrations also exist in the apo(a) K IV-2 domain.

A proximal tissue-specific module and a distal negative regulatory module control apolipoprotein(a) gene transcription

The apo(a) [apolipoprotein(a)] gene is responsible for variations in plasma lipoprotein(a), high levels of which are a risk factor for atherosclerosis and myocardial infarction. The apo(a) promoter stimulates the expression of reporter genes in HepG2 cells, but not in HeLa cells. In the present study, we demonstrate that the 1.4 kb apo(a) promoter comprises two composite regulatory regions: a distal negative regulatory module (positions -1432 to -716) and a proximal tissue-specific module (-716 to -616). The distal negative regulatory module contains two strong negative regulatory regions [polymorphic PNR (pentanucleotide repeat region) and NREbeta (negative regulatory element beta)], which sandwich the postive regulatory region PREbeta (positive regulatory element beta). The PNR was shown to bind to transcription factors in a tissue-specific manner, whereas the ubiquitous transcription factors hepatocyte nuclear factor 3alpha and GATA binding protein 4 bound to NREbeta to repress gene transcription. The proximal tissue-specific module contains two regulatory elements: an activating region (PREalpha) that activates transcription in HepG2 cells, and NREalpha, which is responsible for repressing the apo(a) gene in HeLa cells. NREalpha binds to a HeLa-specific repressor. These multiple regulatory elements might work co-operatively to finely regulate apo(a) gene expression. Although the tissue-specific module is required for apo(a) gene activation and repression in a tissue-specific manner, the combinatorial interplay of the distal and proximal regulators might define the complex pathway(s) of apo(a) gene regulation.

Are common disease susceptibility alleles the same in outbred and founder populations?

Founder populations have been the subjects of complex disease studies because of their decreased genetic heterogeneity, increased linkage disequilibrium and more homogeneous environmental exposures. However, it is possible that disease alleles identified in founder populations may not contribute significantly to susceptibility in outbred populations. In this study we examine the Hutterites, a founder population of European descent, for 103 polymorphisms in 66 genes that are candidates for cardiovascular or inflammatory diseases. We compare the frequencies of alleles at these loci in the Hutterites to their frequencies in outbred European-American populations and test for associations with cardiovascular disease-associated phenotypes in the Hutterites. We show that alleles at these loci are found at similar frequencies in the Hutterites and in outbred populations. In addition, we report associations between 39 alleles or haplotypes and cardiovascular disease phenotypes (P<0.05), with five loci remaining significant after adjusting for multiple comparisons. These data indicate that this founder population is informative and offers considerable advantages for genetic studies of common complex diseases.

Characteristics and effects of inflammation in end-stage renal disease

Malnutrition and cardiovascular disease are associated with end-stage renal disease (ESRD) and both are closely associated with one another, both in cross-sectional analysis and when the courses of individual patients are followed over time. Inflammation, by suppressing synthesis of albumin, transferrin, and other negative acute-phase proteins and increasing their catabolic rates, either combines with modest malnutrition or mimics malnutrition, resulting in decreased levels of these proteins in dialysis patients. Inflammation also leads to reduced muscle mass by increasing muscle protein catabolism and blocking synthesis of muscle protein. More importantly, inflammation alters plasma protein composition and endothelial structure and function so as to promote vascular disease. Markers of inflammation, C-reactive protein (CRP), and interleukin (IL)-6 powerfully predict death from all causes and from cardiovascular disease in dialysis patients as well as progression of vascular injury. The causes of inflammation are likely multifactorial, including oxidative modification of plasma proteins, interaction of blood with nonbiocompatible membranes and lipopolysaccharides in dialysate, subclinical infection of vascular access materials, oxidative catabolism of endothelium-derived nitric oxide, and other infectious processes. Treatment should be focused on identifying potential causes of inflammation, if obvious, and reduction of other risk factor for cardiovascular disease.

Regulation of the expression of the apolipoprotein(a) gene: evidence for a regulatory role of the 5' distal apolipoprotein(a) transcription control region enhancer in yeast artificial chromosome transgenic mice

OBJECTIVE

The apolipoprotein(a) [apo(a)] gene locus is the major determinant of the circulating concentration of the atherothrombogenic lipoprotein Lp(a). In vitro analysis of the intergenic region between the apo(a) and plasminogen genes revealed the presence of a putative apo(a) transcription control region (ACR) approximately 20 kb upstream of the apo(a) gene that significantly increases the minimal promoter activity of the human apo(a) gene.

METHODS AND RESULTS

To examine the function of the ACR in its natural genomic context, we used the Cre-loxP recombination system to generate 2 nearly identical apo(a)-yeast artificial chromosome transgenic mouse lines that possess a single integration site for the human apo(a) transgene in the mouse genome but differ by the presence or absence of the ACR enhancer. Analysis of the 2 groups of animals revealed that the deletion of the ACR was associated with 30% reduction in plasma and mRNA apo(a) levels. Apo(a)-yeast artificial chromosome transgenic mice with and without the ACR sequence were similar in all other aspects of apo(a) regulation, including liver-specific apo(a) expression and alteration in expression levels in response to sexual maturation and a high-fat diet.

CONCLUSIONS

This study provides the first experimental in vivo evidence for a functional role of the ACR enhancer in determining levels of apo(a) expression.

Studies of apolipoprotein (a) promoter from subjects with different plasma lipoprotein (a) concentrations

OBJECTIVE

High plasma lipoprotein (a) [Lp(a)] level is closely related to coronary heart disease and cerebral thrombosis. The Lp(a) concentration is determined primarily by apolipoprotein (a) [apo(a)] gene and APO(a) mRNA abundance has been found to vary with apo(a) isoform. Our objective is to investigate whether APO(a) promoter activity is related to plasma Lp(a) level.

DESIGN AND METHODS

The 5' 1.4 kilobases (kb) promoter region of APO(a) was cloned into plasmid pGL-2 basic that carries luciferase reporter system. The promoter activity was assayed in HepG2 cells. DNA sequence of the promoter was also determined.

RESULTS

Few nucleotide changes besides the variations at the five polymorphic sites: -1270 (TTTTA repeat), -868 (T repeat), -772 (A/G variation), +93 (C/T variation) and +121 (A/G variation) were observed in these promoters. APO(a) promoter activity differed in subjects with different plasma Lp(a) levels.

CONCLUSION

The sequence variation of APO(a) promoter region may contribute to the variation of its transcription activity.

Factors that affect albumin concentration in dialysis patients and their relationship to vascular disease

INTRODUCTION

Hypoalbuminemia is a powerful risk factor for cardiovascular mortality in hemodialysis patients (HD). Inflammation causes a decrease in albumin synthesis and an increase in albumin fractional catabolic rate, providing two mechanisms for hypoalbuminemia. The inflammatory response alters the endothelium and plasma protein composition in ways that favor vascular injury. Plasma volume is expanded in HD patients, providing another mechanism for hypoalbuminemia. Fibrinogen levels are an independent risk factor for cardiovascular disease (CVD) in HD patients, and fibrinogen levels are increased in HD patients. Plasma volume expansion is also an independent risk factor for CVD.

METHODS

Albumin synthesis was measured in 74 HD patients as the disappearance of [125I] human albumin over six weeks. Fibrinogen was measured in plasma. Plasma fibrinogen mass was the product of fibrinogen concentration and plasma volume.

RESULTS

Albumin synthesis correlated positively with plasma volume (P < 0.001). Fibrinogen concentration and plasma fibrinogen mass both correlated positively with albumin synthesis (P < 0.001).

CONCLUSION

Albumin levels are reduced as part of the acute-phase response in HD. Plasma volume expansion also tends to decrease albumin concentration, but elicits an increase in its rate of synthesis, which, in turn, is associated with increased fibrinogen levels. Thus, both inflammation and plasma volume expansion factors that reduce albumin concentration and are independent cardiovascular risk factors, independently increase fibrinogen levels.

Association of polymorphisms of the apolipoprotein(a) gene with lipoprotein(a) levels and myocardial infarction

BACKGROUND

Serum lipoprotein(a) [Lp(a)] concentration is largely determined by variability at the apolipoprotein(a) gene locus. Most prominent effects relate to polymorphisms in the promoter (a pentanucleotide [PN] repeat) and coding regions (a kringle IV [K4] repeat), the latter of which also affects Lp(a) particle size. The impact of these polymorphisms on cardiovascular risk is poorly understood.

METHODS AND RESULTS

We studied both polymorphisms and Lp(a) levels in 834 registry-based myocardial infarction (MI) patients (38% women) and 1548 population-based controls. Lp(a) concentrations were inversely related with the numbers of K4 and PN repeats. However, the effect of the PN polymorphism was restricted to subjects producing small Lp(a) particles (<or=8 PN 66.1 mg/dL versus >8 PN 8.7 mg/dL; P<0.0001). The odds to present with MI were elevated in individuals producing small Lp(a) particles (<or=22 K4 repeats; OR 1.47 for men and 1.69 for women; P<0.002) and in women with <or=8 PN repeats (OR 1.46, P=0.009). Interestingly, in women, the frequent haplotype with <or=8 PN and <or=22 K4 repeats, which is related to high levels of small Lp(a) particles, resulted in an elevated OR for MI (1.79; P=0.01) independently of Lp(a) serum concentration.

CONCLUSIONS

The K4 and PN repeat polymorphisms largely explain the high variability of serum Lp(a) levels. A haplotype with <or=8 PN and <or=22 K4 repeats is characterized by high concentrations of small Lp(a) particles. Our observation that this haplotype was associated with MI independently of Lp(a) serum levels may suggest that Lp(a) particle size in addition to its concentration may modulate MI risk in women.

Effect of Aspirin Treatment on Serum Concentrations of Lipoprotein(a) in Patients with Atherosclerotic Diseases

Background: Increased serum lipoprotein(a) [Lp(a)] is an independent risk factor for atherosclerosis. We previously reported that aspirin reduced Lp(a) production by cultured hepatocytes via the reduction of apolipoprotein(a) [apo(a)] gene transcription.

Methods: We evaluated both the effect of aspirin treatment (81 mg/day) on serum Lp(a) concentrations and the correlation between the degree of reduction in serum Lp(a) and the type of apo(a) isoform in 70 patients with coronary artery disease or cerebral infarction.

Results: Aspirin lowered serum Lp(a) concentrations to ∼80% of the baseline values in patients with high Lp(a) concentrations (&gt;300 mg/L). The percentage of decrease in serum Lp(a) was larger in patients with high Lp(a) than in patients with low Lp(a) (&lt;300 mg/L), irrespective of apo(a) isoform size. The decreases in serum Lp(a) in high Lp(a) patients with both the high-molecular-weight and the low-molecular-weight isoforms were positively correlated with the baseline Lp(a) concentrations.

Conclusions: Because the secretory efficiencies of apo(a) in the same isoform are likely to be similar, the difference in serum Lp(a) concentrations in patients having the same apo(a) isoform depends on the transcriptional activity of the apo(a) gene. These findings suggest that aspirin decreases serum Lp(a) concentrations via a decrease in apo(a) gene transcription more effectively in patients with high transcriptional activity of this gene.

The apolipoprotein(a) size, pentanucleotide repeat, C/T(+93) polymorphisms of apolipoprotein(a) gene, serum lipoprotein(a) concentrations and their relationship in a Korean population

BACKGROUND

In addition to apolipoprotein(a) [apo(a)] kringle 4 variable number of tandem repeat (K4-VNTR), pentanucleotide repeat polymorphism (PNRP) and C/T(+93) polymorphism [C/T(+93)] of apo(a) gene have been suggested to be related to lipoprotein(a) [Lp(a)] concentration. We studied the distribution of these genetic polymorphisms and their relationship with Lp(a) concentrations in a Korean population.

METHODS

One hundred thirty-two Korean adults were examined. Lp(a) was measured with enzyme-linked immunosorbent assay (ELISA). Apo(a) K4-VNTR was measured by high-resolution SDS-agarose gel separation and ECL Western blotting method. PNRP was measured after DNA amplification. The C/T(+93) ratio was measured by a amplification refractory mutation system.

RESULTS

Lp(a) was inversely correlated with K4-VNTR (r=0.732, p<0.0001), but was associated neither with any PNRP haplotype nor with C/T(+93) by multiple regression analysis, although we found a significant decrease of Lp(a) in PNRP 9/9 individuals (p<0.01). There was a strong linkage disequilibrium between 9 haplotypes of PNRP and the T haplotype of C/T(+93).

CONCLUSIONS

Inverse relationship between serum Lp(a) and K4 number of apo(a) was confirmed in normal Korean adults. PNRP 9/9 genotype appeared to have a reducing effect on Lp(a), but neither 9 haplotype heterozygotes of PNRP nor the T haplotype C/T(+93) affected Lp(a) concentrations in Koreans.

A 31 bp VNTR in the cystathionine beta-synthase (CBS) gene is associated with reduced CBS activity and elevated post-load homocysteine levels

Molecular defects in genes encoding enzymes involved in homocysteine metabolism may account for mild hyperhomocysteinaemia, an independent and graded risk factor for cardiovascular disease (CVD). Although heterozygosity for cystathionine beta-synthase (CBS) deficiency has been excluded as a major genetic cause of mild hyperhomocysteinaemia in vascular disease, mutations in (non-)coding DNA sequences may lead to a mildly decreased CBS expression and, consequently, to elevated plasma homocysteine levels. We assessed the association between a 31 bp VNTR, that spans the exon 13-intron 13 boundary of the CBS gene, and fasting, post-methionine load and increase upon methionine load plasma homocysteine levels in 190 patients with arterial occlusive disease, and in 381 controls. The 31 bp VNTR consists of 16, 17, 18, 19 or 21 repeat units and shows a significant increase in plasma homocysteine concentrations with an increasing number of repeat elements, in particular after methionine loading. In 26 vascular disease patients the relationship between this 31 bp VNTR and CBS enzyme activity in cultured fibroblasts was studied. The CBS enzyme activity decreased with increasing number of repeat units of the 31 bp VNTR. RT-PCR experiments showed evidence of alternative splicing at the exon 13-intron 13 splice junction site. The 31 bp VNTR in the CBS gene is associated with post-methionine load hyperhomocysteinaemia that may predispose individuals to an increased risk of cardiovascular diseases.

The association of serum lipoprotein(a) levels, apolipoprotein(a) size and (TTTTA)(n) polymorphism with coronary heart disease

BACKGROUND

The association between lipoprotein(a) levels, apolipoprotein(a) size and the (TTTTA)(n) polymorphism which is located in the 5' non-coding region of the apo(a) gene was studied in 263 patients with severe coronary heart disease and 97 healthy subjects.

METHODS

Lp(a) levels were measured by ELISA, apo(a) isoform size was determined by SDS-agarose gel electrophoresis, and analysis of the (TTTTA)(n) was carried out by PCR. For statistical calculation, both groups were divided into low (at least one apo(a) isoform with < or = 22 Kringle IV) and high (both isoforms with >22 KIV) apo(a) isoform sizes, and into low number (<10 in both alleles) and high number of (> or =10 at least one allele) TTTTA repeats.

RESULTS

Lp(a) levels were higher (P=0.007), apo(a) isoforms size < or =22 KIV and TTTTA repeats > or = 10 were more frequent (P=0.007 and 0.01) in cases than in controls. Lp(a) levels were found to be increased with low apo(a) weight in both groups (both P<0.0001). In multivariate logistic regression analysis, only the Lp(a) levels (P=0.005) and (TTTTA)(n) polymorphism (P=0.002) were found to be significantly associated with CHD.

CONCLUSION

Nevertheless, these results indicate that in CHD patients the (TTTTA)(n) polymorphism has an effect on Lp(a) levels which is independent of the apo(a) size.

Functional analysis of the chimpanzee and human apo(a) promoter sequences: identification of sequence variations responsible for elevated transcriptional activity in chimpanzee

Lp(a) concentrations vary considerably among individuals and are primarily determined by the apo(a) gene locus. We have previously shown that mean plasma Lp(a) levels in the chimpanzee are significantly higher than those observed in humans (Doucet, C., Huby, T., Chapman, J., and Thillet, J. (1994) J. Lipid Res 35, 263-270). To evaluate the possibility that this difference may result from a high level of expression of chimpanzee apo(a), we cloned and sequenced 1.4 kilobase (kb) of the 5'-flanking region of the gene and compared promoter activity to that of its human counterpart. Sequence analysis revealed 98% homology between chimpanzee and human apo(a) 5' sequences; among the differences observed, two involved polymorphic sites associated with Lp(a) levels in humans. The TTTTA repeat located 1.3 kb 5' of the apo(a) gene, present in a variable number of copies (n = 5-12) in humans, is uniquely present as four copies in the chimpanzee sequence. The second position concerns the +93 C>T polymorphism that creates an additional ATG start codon in the human apo(a) gene, thereby impairing translation efficiency. In chimpanzee, this position did not appear polymorphic, and a base difference at position +94 precluded the presence of an additional ATG. In transient transfection assays, the chimpanzee apo(a) promoter exhibited a 5-fold elevation in transcriptional activity as compared with its human counterpart. This marked difference in activity was maintained with either 1.4 kb of 5' sequence or the minimal promoter region -98 to +141 of the human and chimpanzee apo(a) genes. Using point mutational analyses, nucleotides present at positions -3, -2, and +8 (relative to the start site of transcription) were found to be essential for the high transcription efficiency of the chimpanzee apo(a) promoter. High transcriptional activity of the chimpanzee apo(a) gene may therefore represent a key factor in the elevated plasma Lp(a) levels characteristic of this non-human primate.

Lipoprotein (a) and stroke

Strokes are one of the most common causes of mortality and long term severe disability. There is evidence that lipoprotein (a) (Lp(a)) is a predictor of many forms of vascular disease, including premature coronary artery disease. Several studies have also evaluated the association between Lp(a) and ischaemic (thrombotic) stroke. Several cross sectional (and a few prospective) studies provide contradictory findings regarding Lp(a) as a predictor of ischaemic stroke. Several factors might contribute to the existing confusion--for example, small sample sizes, different ethnic groups, the influence of oestrogens in women participating in the studies, plasma storage before Lp(a) determination, statistical errors, and selection bias. This review focuses on the Lp(a) related mechanisms that might contribute to the pathogenesis of ischaemic stroke. The association between Lp(a) and other cardiovascular risk factors is discussed. Therapeutic interventions that can lower the circulating concentrations of Lp(a) and thus possibly reduce the risk of stroke are also considered.

Lipoprotein Lp(a) and atherothrombotic disease

High plasma concentrations of lipoprotein (a) [Lp(a)] are now considered a major risk factor for atherosclerosis and cardiovascular disease. This effect of Lp(a) may be related to its composite structure, a plasminogen-like inactive serine-proteinase, apoprotein (a) [apo(a)], which is disulfide-linked to the apoprotein B100 of an atherogenic low-density lipoprotein (LDL) particle. Apo(a) contains, in addition to the protease region and a copy of kringle 5 of plasminogen, a variable number of copies of plasminogen-like kringle 4, giving rise to a series of isoforms. This structural homology endows Lp(a) with the capacity to bind to fibrin and to membrane proteins of endothelial cells and monocytes, and thereby inhibits binding of plasminogen and plasmin formation. This mechanism favors fibrin and cholesterol deposition at sites of vascular injury and impairs activation of transforming growth factor-beta (TGF-beta) that may result in migration and proliferation of smooth muscle cells into the vascular intima. It is currently accepted that this effect of Lp(a) is linked to its concentration in plasma, and an inverse relationship between apo(a) isoform size and Lp(a) concentrations that is under genetic control has been documented. Recently, it has been shown that inhibition of plasminogen binding to fibrin by apo(a) from homozygous subjects is also inversely associated with isoform size. These findings suggest that the structural polymorphism of apo(a) is not only inversely related to the plasma concentration of Lp(a), but also to a functional heterogeneity of apo(a) isoforms. Based on these pathophysiological findings, it can be proposed that the predictive value of Lp(a) as a risk factor for vascular occlusive disease in heterozygous subjects would depend on the relative concentration of the isoform with the highest affinity for fibrin.

Sequence conservation in kringle IV-type 2 repeats of the LPA gene

We have studied the homology of repeating kringle IV-type 2 (K IV-type 2) elements of the LPA gene. Two K IV-type 2 genomic polymerase chain reaction (PCR) fragment libraries were constructed, one from an individual with high and one from an individual with low Lp(a) lipoprotein level. Only minor K IV-type 2 repeat length heterogeneity was observed. Sequence analysis data from the cloned K IV-type 2 repeats revealed a high degree of LPA sequence conservation in exons as well as in introns both within and between the two libraries. This sequence conservation of the IV-type 2 kringles is in agreement with our previously reported results of simultaneous 'batch' DNA sequence analyses of all the K IV-type 2 repeats from single individuals. Sequence data from the clones, combined with genomic DNA sequencing, revealed that the K IV-type 2 reading frame of exons 1 and 2 are extended into the conserved flanking introns by 519 base pairs (bp) and 312 bp, respectively. The theoretical coding capacity of the exon 1 extended open reading frame (ORF I) is three times larger (173 amino acids, aa) than the translated exon 1, and that of the extended open reading frame of exon 2 (ORF II) is about twice (104 aa) the length of exon 2. A central portion of the intron separating exons 1 and 2 also exhibited a high degree of sequence conservation, with the exception of a polymorphic CA repeat. Within the 61 K IV repeat clones analysed, 19 different CA repeat patterns with 12-18 CA dinucleotide repeats were observed. A comparison between the 37 clones from the individual with high Lp(a) lipoprotein level and the 24 clones from the individual with low Lp(a) lipoprotein level, revealed that seven of the CA repeat variants were present in both clone libraries. The observed high level of sequence conservation in K IV-type 2 exons and introns matches relevant areas of the plasminogen gene, and our findings fit with recent K IV-type 2 duplications and evolutionary selection pressure theories, although gene conversion events could also explain the findings. DNA sequences within K IV-type 2 appeared to have no influence on Lp(a) lipoprotein level.

Contribution of apolipoprotein(a) size, pentanucleotide TTTTA repeat and C/T(+93) polymorphisms of the apo(a) gene to regulation of lipoprotein(a) plasma levels in a population of young European Caucasians

Several studies indicate that the inter-individual variation in plasma concentrations of lipoprotein(a) (Lp(a)) is mainly under genetic control. To define the effect of three DNA polymorphisms on apolipoprotein(a) (apo(a)) expression, we have determined plasma Lp(a) concentrations, apo(a) isoform size, KpnI allele size, the TTTTA pentanucleotide repeat number in the 5' control region of the apo(a) gene and the +93 C/T polymorphism in a European Caucasian population. The simultaneous determination of the kringle 4 (K4) number by genotyping and by phenotyping revealed that the size distribution of non-expressed apo(a) alleles was markedly skewed towards alleles with greater than 25 K4 repeats. This is consistent with the inverse relationship frequently described between the kringle 4 number and the plasma Lp(a) level. Apportioning the Lp(a) concentration from the surface of the peaks on apo(a) phenotyping blots, we have observed that the Lp(a) plasma concentration associated with alleles having more than 25 K4 units does not exceed 400 mg/l, whereas the range of Lp(a) concentrations associated with smaller alleles was broad, from 0 to more than 1000 mg/l. It can thus be concluded that the number of K4 repeats is the main determinant of Lp(a) concentration when this number is more than 25, whereas other polymorphisms may be involved in the alleles with fewer than 26 K4. Analyses of the TTTTA repeat number and of the +93 C/T polymorphism were performed in subjects with KpnI alleles of the same length: low Lp(a) concentrations were shown to be preferentially associated with the presence of apo(a) alleles with more than eight pentanucleotide repeats while no association was revealed between Lp(a) plasma levels and the C/T polymorphism. These results demonstrate that the (TTTTA)(n) polymorphism affects the Lp(a) expression independently of apo(a) size polymorphism.

Sequence polymorphisms in the apolipoprotein(a) gene and their association with lipoprotein(a) levels and myocardial infarction. The ECTIM Study

Lp(a) concentrations are largely determined by apo(a) isoform size, but several studies have shown that apo(a) isoforms could not entirely explain the increase of Lp(a) levels observed in patients with coronary heart disease (CHD). Since up to 90% of the variance in Lp(a) levels has been suggested to be attributable to the apo(a) locus, the hypothesis that polymorphisms of the apo(a) gene other than size could contribute to the increase of Lp(a) levels in CHD patients must be considered. This hypothesis was tested in the ECTIM Study comparing 594 patients with myocardial infarction and 682 control subjects in Northern Ireland and France. In addition to apo(a) phenotyping, five previously described polymorphisms of the apo(a) gene were genotyped: a (TTTTA)n repeat at position -1400 from the ATG, a G/A at -914, a C/T at -49, a G/A at -21 and a Met/Thr affecting amino acid 4168. As reported earlier [Parra HJ, Evans AE, Cambou JP, Amouyel P, Bingham A, McMaster D, Schaffer P, Douste-Blazy P, Luc G, Richard JL, Ducimetiere P, Fruchart JC, Cambien F. A case-control study of lipoprotein particles in two populations at contrasting risk for coronary heart disease. The ECTIM study. Arterioscler Thromb 1992; 12:701-707], mean Lp(a) levels were higher in cases than in controls (20.7 vs 14.6 mg/dl in Belfast, 17.2 vs 8.9 mg/dl in France, P < 0.001 for case-control and population differences). In the present study, mean apo(a) isoform size differed significantly between cases and controls (25.7 vs 26.6 kr in Belfast, 25.9 vs 27.4 kr in France, P < 0.001 for case-control and P = 0.13 for population difference). After adjustment for apo(a) isoforms, Lp(a) levels remained significantly higher in cases than in controls (difference, 4.6 mg/dl; P < 0.001). Genotype and allele frequencies did not differ significantly between cases and controls for any of the five polymorphisms studied. The five polymorphisms were in strong linkage disequilibrium and had a combined heterozygosity of 0.83. In multivariate regression analysis adjusted for apo(a) isoforms, only the (TTTTA)n polymorphism was significantly associated with Lp(a) levels; it explained 4.5% of Lp(a) variability in cases and 3.1% in controls. The Lp(a) case/control difference was not reduced after taking into account the (TTTTA)n effect. We conclude that the increase of Lp(a) levels observed in MI cases, and which was not directly attributable to apo(a) size variation, was not related to the five polymorphisms of the apo(a) gene considered.

The seventh myth of lipoprotein(a): where and how is it assembled?

Our understanding of the genetics, metabolism and pathophysiology of the atherogenic plasma lipoprotein Lp(a) has considerably increased over past years. Nevertheless, the precise mechanisms regulating the biosynthesis and assembly of Lp(a) are poorly understood and controversially discussed. Lp(a) plasma concentrations are determined by synthesis and not by degradation. Transcriptional and post-translational mechanisms have been identified as regulating Lp(a) production in primary hepatocytes and transfected cell lines. Assembly of Lp(a) occurs extracellularly from newly synthesized apolipoprotein(a) and circulating LDL. This view has recently been challenged by in-vivo kinetic studies in humans which are compatible with an intracellular assembly event. Lp(a) assembly is a complex two-step process of multiple non-covalent interactions between apolipoprotein(a) and apolipoprotein B-100 of LDL followed by covalent disulfide linkage of two free cysteine residues on both proteins.

Genetic architecture and evolution of the lipoprotein(a) trait

Apolipoprotein(a) is coded by one of the most polymorphic genes known in humans. In white and Asian populations variation in this gene is the major determinant of the plasma concentrations of the atherogenic lipoprotein(a) which varies enormously between individuals and considerably across populations. Recent studies have shown that the genetic architecture of the quantitative Lp(a) trait differs among major human groups. In Africans there is evidence for a transacting factor. Three types of variation have been identified in the apo(a) gene: a size polymorphism in the coding region (K IV type 2 repeats), a pentanucleotide repeat polymorphism in the promoter (5'PNRP) and sequence variation in coding and non-coding regions of the gene including a C/T polymorphism at +93 which creates an additional ATG start codon but also affects transcription. The causal +93 C/T effect is masked by linkage disequilibrium in white populations. Analysis of apo(a) K IV 6-10 exons revealed the existence of population-specific spectra of polymorphism in this domain. However further sequence variation which may provide clues for the understanding of the regulation of apo(a) concentrations still needs to be identified. DNA sequencing and phylogenetic analysis have demonstrated that two types of apo(a) exist, in phylogenetically distant mammalian lineages a K IV derived primate form and a K III-derived hedgehog form which are products of convergent evolution.

Effects of apolipoprotein A gene polymorphisms on lipoprotein (a) concentrations in Japanese

1. Elevated plasma lipoprotein (a) (Lp(a)) concentrations have been correlated with an increased risk of premature cardiovascular disease. The plasma Lp(a) concentration is quantitatively heritable and the apolipoprotein (Apo) A gene is known as a major locus-determining Lp(a) concentration. 2. The aim of the present study was to evaluate the genetic effect of polymorphisms in the 5'-untranslated region (UTR) of the ApoA gene on plasma concentrations of Lp(a). 3. We analysed two sequence variations in the 5'-UTR, a pentanucleotide repeat (PNR) polymorphism and haplotypes composed of three single base substitutions, in 325 Japanese subjects. The ApoA size polymorphism was also analysed by western blotting. 4. The plasma Lp(a) concentration was inversely correlated with the size of the ApoA molecule. Both PNR and the haplotype polymorphisms had significant effects on serum Lp(a) concentrations (P = 0.001 and 0.004, respectively) when the effects were evaluated by ANCOVA using the ApoA size polymorphism as a covariate. 5. When a stratified subpopulation with a larger ApoA size was analysed, both variations influenced or tended to influence the serum Lp(a) concentration, confirming the results of the ANCOVA. 6. Pentanucleotide repeat showed a tight linkage disequilibrium with the haplotypes. This disequilibrium may account for the apparent effects of PNR on Lp(a) concentrations.

Biochemical risk factors and patient's outcome: the case of lipoprotein(a)

Lipoprotein(a) (Lp(a)) is a genetic variant of low density lipoproteins and consists of the covalent association of the unique and enigmatic apolipoprotein(a) to apoliprotein B100. Despite the high degree of homology with low density lipoproteins, Lp(a) displays distinctive physico-chemical properties, function and metabolism. The present article reviews the main biological and clinical evidences about the association between raised concentration of Lp(a) and atherothrombotic diseases and provides tentative guidelines to improve the clinical usefulness of Lp(a) measurements.

Identification of a glucocorticoid response element in the rat beta2-adrenergic receptor gene

Regulation of beta2-adrenergic receptor (beta2AR) levels by glucocorticoids is a physiologically important mechanism for altering beta2AR responsiveness. Glucocorticoids increase beta2AR density by increasing the rate of beta2AR gene transcription, but the cis-elements involved have not been well characterized. We now show that one of six potential glucocorticoid response elements (GREs) in the 5'-flanking region of the rat beta2AR gene is necessary for glucocorticoid-dependent stimulation of receptor gene expression. Using a nested set of deletion fragments of the rat beta2AR gene 5'-flanking region fused to a luciferase reporter gene, glucocorticoid-dependent induction of reporter gene expression in HepG2 cells was localized to a region between positions -643 and -152, relative to the transcription initiation site. In electrophoretic mobility shift assays, a double-stranded oligonucleotide incorporating a near-consensus GRE from this region (positions -379 to -365) formed complexes with the human recombinant glucocorticoid receptor, as well as with nuclear protein from dexamethasone-treated HepG2 cells. Mutation of a single base within this GRE sequence greatly diminished interaction of the mutated oligonucleotide with the human recombinant glucocorticoid receptor. The functional activity of the GRE was characterized using a luciferase reporter construct driven by a minimal thymidine kinase promoter. In HepG2 cells transfected with constructs containing the GRE, dexamethasone increased reporter gene expression approximately 3-fold, whereas a dexamethasone effect was not observed with constructs lacking the GRE. Taken together, these findings show that a GRE located at positions -379 to -365 in the 5'-flanking region of the rat beta2AR gene mediates glucocorticoid stimulation of beta2AR gene transcription.

Differential expression of double-band apolipoprotein(a) phenotypes in healthy Spanish subjects detected by SDS-agarose immunoblotting

A sodium dodecyl sulphate-agarose apolipoprotein(a) [apo(a)] phenotyping method was set up to attain accurate scanning densitometry of proteins. Serum samples from 99 healthy Spanish men were analysed and twenty-five different apo(a) isoforms (12 to 37 kringle 4 repeats) were detected. Double-band phenotypes accounted for 39.4% (n = 39) and three different patterns of protein expression were identified: pattern A (20.5% of double-band phenotyped samples) predominantly expressed the highest molecular weight isoform; pattern B (53.9%) mainly the lowest molecular weight isoform, and pattern AB (25.6%), expressed both isoforms equally. A significant linear association between expression pattern and lipoprotein(a) [Lp(a)] concentration > or = 0.30 g/l was observed. Single-band phenotyped samples (n = 60) were stratified according to apo(a) kringle 4 repeat categories and showed that 90% of isoforms < 20 K4 repeats had high Lp(a) concentrations (> or = 0.30 g/l), whereas isoforms with 20 to 24 or more than 24 kringle 4 repeats had Lp(a) concentrations > or = 0.30 g/l in 47% and 14%, respectively. A logistic regression model was fitted to test the association between apo(a) size, expression pattern and Lp(a) concentration. In this model, apo(a) isoform < 25 kringle 4 repeats was significantly associated with serum Lp(a) concentration > or = 0.30 g/l in both single and double-band phenotyped samples (odds ratio = 8.9, p < 0.001). In the latter, a differential expression pattern with respect to smaller size isoforms (pattern AB vs A) was significantly associated with Lp(a) concentration > or = 0.30 g/l (odds ratio = 17.97, P = 0.045). Heterogeneity in protein apo(a) size expressed according to kringle 4 repeat number could be categorized in heterozygous phenotypes as three patterns. When small-sized isoform was expressed (pattern B) or both isoforms were equally expressed (pattern AB), the probability of having Lp(a) > or = 0.30 g/l is higher.

Multi-modal expression of apolipoprotein (a) gene in vivo

The apolipoprotein (a) [apo(a)] gene encodes a protein component of lipoprotein (a) [Lp(a)] whose plasma levels vary among individuals. To study the implications of Lp(a), we examined plasma Lp(a) levels and molecular weights of apo(a) in patients with cerebrovascular disease (CVD) or diabetes mellitus (DN). Mean Lp(a) concentrations were higher in the CVD cases with atherothrombotic brain infarction than in those with brain hemorrhage and lacunar infarction. Lp(a) levels were lower in the DM cases on diet therapy alone than in those treated with insulin or oral hypoglycemic agents. These results suggest that Lp(a) is thrombogenic and atherogenic, and that insulin may modulate Lp(a) levels. We subclassified the apo(a) gene into four types (A-D) by polymorphisms in the 5'-flanking region. We also measured plasma Lp(a) concentrations and examined expression of the gene by an in vitro assay. Homozygotes of type C had higher Lp(a) levels than those of type D, and the relative expression of type C was higher than that of type D in vitro. Lp(a) levels, however, varied even within the same 5'-allele having similar apo(a) isoforms. Thus, Lp(a) concentrations are genetically determined and may be modified by some hormones and cytokines. When we examined transcript levels for apo(a) by RT-PCR in various normal tissues, apo(a) was strongly expressed in liver while not in thyroid or leukocytes. Small amounts of apo(a) transcript were observed in all other organs and tissues. Apo(a) in these tissues may also play a role in inframmation, tissue remodeling, cell migration, and other physiological functions.

Plasma lipoprotein(a) levels are high in patients with central retinal artery occlusion

High plasma lipoprotein(a) (Lp[a]) concentration is an independent risk factor for atherosclerosis and thrombosis. To study the implications of Lp(a) in central retinal artery occlusion (CRAO), we examined Lp(a) levels and molecular weights (MWs) of apolipoprotein(a) (apo(a)). Mean Lp(a) concentration was significantly higher in the cases with CRAO than in the controls. Lp(a) levels higher than 30 mg/dl were also more frequent in the CRAO cases than in the controls. Lp(a) concentrations correlated significantly with low-MW isoforms of apo(a). Impaired fibrinolysis and atherogenesis induced by Lp(a) may play a role in the pathophysiology of CRAO. Since high Lp(a) levels were reported in CRVO by other investigators, patients with central retinal vein occlusion (CRVO) were also examined for Lp(a). Although Lp(a) levels were higher in the CRVO cases than in the controls, the difference was not significant. Therefore, high Lp(a) levels may not be associated with venous thrombosis and/or embolism.

Insulin and 2-hour glucose levels are inversely related to Lp(a) concentrations controlled for LPA genotype

In this study we assessed the relationship of lipoprotein(a) [Lp(a)] with diabetes status and with measures of glucose and insulin in a population of Mexican Americans having a high prevalence of non-insulin-dependent diabetes mellitus (NIDDM). Because of enormous allelic diversity at LPA [the locus encoding the apo(a) protein] that directly influences Lp(a) concentrations, it was first necessary to adjust for the large effects of variation at LPA. We calculated residual Lp(a) concentration as the difference between observed and expected; expected Lp(a) concentration was based on information from all family members sharing each identical-by-descent (IBD) allele. We found significant effects of sex and age on residual Lp(a) concentrations that increased with age (P=0.0004) and in females (P=0.0034). Although diabetes status per se was not related to residual Lp(a) concentrations (P=0.097), we found that residual Lp(a) concentrations were inversely correlated with fasting insulin (P=0.0017) and with insulin (P=0.0028) and glucose (P=0.0429) concentrations measured 2 hours after a glucose challenge. Furthermore, significant inverse correlations with the 2 insulin measures were observed for a subgroup of nondiabetic individuals. Inclusion of 2 lipid measures (plasma concentrations of cholesterol and triglycerides) in the models showed that the correlations with insulin and glucose were independent of the relationship between Lp(a) concentrations and the lipid measures. Also, we determined the residual size for each apo(a) isoform by adjusting for the IBD isoform group average. Although not related to diabetes status, residual apo(a) isoform size was positively correlated with fasting insulin (P=0.0013) and with 2-hour glucose (P=0.0246) and 2-hour insulin (P=0.0182) concentrations. In addition, significant correlations for all 4 measures were found for the subgroup of nondiabetic individuals. Thus, the results demonstrate that glucose-intolerant individuals have significantly lower residual Lp(a) concentrations and a significant increase of residual apo(a) size.

Standardization and clinical management of lipoprotein(a) measurements

The present article proposes personal suggestions to improve determinations and clinical interpretation of results of lipoprotein(a) assays. Methods and procedures for sampling and quantification of the various isoforms of lipoprotein(a) in serum, plasma and urine are reviewed with the aim of improving the reliability and reproducibility of results and reinforcing the clinical utility of lipoprotein(a) measurements.

Biogenesis of lipoprotein(a) in human and animal hepatocytes

The atherogenic plasma lipoprotein complex Lp(a) consists of low density lipoprotein (LDL) and the highly polymorphic glycoprotein apolipoprotein(a) covalently linked by a disulfide bridge. A size polymorphism of apolipoprotein(a) results from a variable number of tandemly arranged kringle IV repeats. The largely varying plasma concentration of Lp(a) is nonnormally distributed in the population and correlates inversely with the molecular mass of apolipoprotein(a). In vivo turnover studies have revealed that differences in Lp(a) plasma concentrations reflect different synthesis rather than degradation. Plasma Lp(a) originates exclusively in the liver. Detailed studies of the intracellular metabolism of apolipoprotein(a) in transfected human hepatoma cells as well as in primary baboon hepatocytes have revealed an unusual secretory pathway of this protein. Due to complex folding and processing, an immature precursor form of apolipoprotein(a) is retained in the endoplasmic reticulum for a prolonged time. This retention leads to a massive accumulation in the endoplasmic reticulum which stands in contrast to most secretory proteins. Since the retention time correlates positively with the apolipoprotein(a) isoform size, this intracellular mechanism could explain the inverse correlation between the isoform size and plasma concentrations observed in the general population. These findings therefore demonstrate a novel cellular regulatory mechanism lor a secretory human plasma protein with genetically controlled concentrations. The majority of the above-mentioned studies revealed another unusual feature of the biogenesis of Lp(a). The mature Lp(a) complex is formed, at least in the investigated cell models, only following separate secretion of apolipoprotein(a) and LDL-like particles. Work that is related to both aspects of Lp(a) formation, both from our laboratory and from other authors, is reviewed.

Characterization of multiple enhancer regions upstream of the apolipoprotein(a) gene

Plasma concentrations of the atherogenic lipoprotein(a) (Lp(a)) are predominantly determined by inherited sequences within or closely linked to the apolipoprotein(a) gene locus. Much of the interindividual variability in Lp(a) levels is likely to originate at the level of apo(a) gene transcription. However, the liver-specific apo(a) basal promoter is extremely weak and does not exhibit common functional variations that affect plasma Lp(a) concentrations. In a search for additional apo(a) gene control elements, we have identified two fragments with enhancer activity within the 40-kilobase pair apo(a)-plasminogen intergenic region that coincide with DNase I-hypersensitive sites (DHII and DHIII) observed in liver chromatin of mice expressing a human apo(a) transgene. Neither enhancer exhibits tissue specificity. DHIII activity was mapped to a 600-base pair fragment containing nine DNase I-protected elements (footprints) that stimulates luciferase expression from the apo(a) promoter 10-15-fold in HepG2 cells. Binding of the ubiquitous transcription factor Sp1 plays a major role in the function of this enhancer, but no single site was indispensable for activity. DHIII comprises part of the regulatory region of an inactive long interspersed nucleotide element 1 retrotransposon, raising the possibility that retrotransposon insertion can influence the regulation of adjacent genes. DHII enhancer activity was localized to a 180-base pair fragment that stimulates transcription from the apo(a) promoter 4-8-fold in HepG2 cells. Mutations within an Sp1 site or either of two elements composed of direct repeats of the nuclear hormone receptor half-site AGGTCA in this sequence completely abolished enhancer function. Both nuclear hormone receptor elements were shown to bind peroxisome proliferator-activated receptors and other members of the nuclear receptor family, suggesting that this enhancer may mediate drug and hormone responsiveness.

Biogenesis of Lp(a) in transgenic mouse hepatocytes

Lipoprotein(a) [Lp(a)] biogenesis was examined in primary cultures of hepatocytes isolated from mice transgenic for both human apolipoprotein(a) [apo(a)] and human apoB. Steady-state and pulse-chase labeling experiments demonstrated that newly synthesized human apo(a) had a prolonged residence time (approximately 60 min) in the endoplasmic reticulum (ER) before maturation and secretion. Apo(a) was inefficiently secreted by the hepatocytes and a large portion of the protein was retained and degraded intracellularly. Apo(a) exhibited a prolonged and complex folding pathway in the ER, which included incorporation of apo(a) into high molecular weight, disulfide-linked aggregates. These folding characteristics could account for long ER residence time and inefficient secretion of apo(a). Mature apo(a) bound via its kringle domains to the hepatocyte cell surface before appearing in the culture medium. Apo(a) could be released from the cell surface by apoB-containing lipoproteins. These studies are consistent with a model in which the efficiency of post-translational processing of apo(a) strongly influences human plasma Lp(a) levels, and suggest that cell surface assembly may be one pathway of human Lp(a) production in vivo. Transgenic mouse hepatocytes thus provide a valuable model system with which to study factors regulating human Lp(a) biogenesis.

Reporter gene analysis of four DNaseI hypersensitive sites in the plasminogen/apolipoprotein(a) intergenic region

We have previously described four DNaseI hypersensitive sites (DH 1 to DH4) in the 40-kb intergenic region between the plasminogen gene and the apo(a) gene. Here, we wanted to analyse whether any of these sites, located 4, 21, 28 and 34 kb upstream of the apo(a) transcriptional start site, would act as an enhancer on a minimal apo(a) promoter. Starting from a cloned, highly expressed apo(a) allele, we obtained four fragments comprising the DHI to DH4 sites, respectively. These fragments were cloned in both orientations into a luciferase reporter gene plasmid comprising a minimal apo(a) promoter (-100 to +141 with respect to the transcriptional start site). Our results from transfection studies with the resulting series of reporter gene plasmids into liver (HepG2) and non-liver (HeLa) cells suggest that the four DH sites from the selected apo(a) allele do not provide a strong, liver-specific enhancer activity.

Lipoprotein(a) concentration and molecular weight of apolipoprotein(a) in patients with cerebrovascular disease and diabetes mellitus

Plasma lipoprotein(a) [Lp(a)] concentrations are genetically determined, and hyper-Lp(a)-emia is an independent risk factor for atherosclerosis and thrombosis. To study the implications of Lp(a) in cerebrovascular disease (CVD) and diabetes mellitus (DM), we examined plasma Lp(a) levels and molecular weights of apolipoprotein(a) [apo(a)] in 118 patients with CVD, and 125 cases with DM. Although mean Lp(a) concentrations were higher in those cases with atherothrombotic brain infarction than in those with brain hemorrhage and lacunar infarction, the difference was not statistically significant. Lp(a) levels were significantly higher in the DM cases treated with insulin and in those treated with oral hypoglycemic agents than in those on diet therapy alone, suggesting that insulin and oral agents modulate apo(a) expression. Lp(a) concentrations correlated significantly with the low-molecular-weight isoforms of apo(a) in all CVD and DM groups.