Lipid Biochemistry Flashcards

1
Q

3 things that impact TGL breakdown

A

insulin decreases it
epineprine and cortisol increase it

Hormone sensitive lipase turns TGL into glycerol (end destination: glucose in the liver) and fatty acids (to be beta oxidized inthe liver)

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2
Q

What happens to fatty acids in the liver?

A

Beta oxidation –> acetyl CoA

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3
Q

Impacts on gluconeogenesis in the liver

A

Glucagon and cortisol increase it via DHAP

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4
Q

alpha oxidation

A

is a process by which certainFAs are broken down by removal of a single carbon from the carboxyl end.

In humans, a oxidation is used inperoxisomes ** to break down dietary phytanic acid, which cannot undergob oxidation due to its β-methyl branch, intopristanic acid.

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5
Q

Enzymatic deficiency in a-oxidation

A

(most frequently inphytanoyl CoA dioxygenase)
leads toRefsum’s disease, in which the accumulation of phytanic acid and its
derivatives leads to neurological damage.
Other disorders ofperoxisome biogenesis also prevent a oxidation from occurring.

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6
Q

Acetyl CoA’s destination

A

Citric Acid cycle or linked together (2 of them) to form ketone bodies –> muscle and brain

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7
Q

omega oxidation

A

process ofFA metabolism in some species of animals.
It is an alternative pathway tob oxidation that, instead of involving the β carbon, involves the oxidation of the ω carbon (the carbon most distant from thecarboxyl group of the FA).
The process is normally a minor catabolic pathway for medium-chain fatty acids (10-12 carbon atoms), but becomes more important when β oxidation is defective.

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8
Q

b-oxidation

A

the process by which FA molecules are broken down in the mitochondria to generate acetyl-CoA, which enters the citric acid cycle, and NADH and FADH2, which are used by the electron transport chain to generate ATP.
There are at least 25 enzymes and specific transport proteins in the β oxidation pathway.
Of these, 18 have been associated with human disease asinborn errors of metabolism.

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9
Q

The trip from FA to ATP

A

FA–> beta oxidation –> acetyl CoA–> TCA cycle/ ox phos –> ATP

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10
Q

insulin resistance

A

FA-CoA –> DAG and Ceramide which can lead to insulin resistance

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11
Q

Short vs Long chain FAs

A

Short chain FAs (2-4 C) and Medium chain FAs (6-12 C) diffuse freely into mitochondria to be oxidized
Long chain FAs (14-20 C) activated first then transported into mitochondria by a Carnitine shuttle to be oxidized
Very long chain FAs ( >20C) enter peroxisomes via unknown mechanism for oxidation

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12
Q

Activation of FAs

A
  • long chain FAs (LCFA) must be activated by ATP and CoA by AcylCoA synthetase – Fatty acyl CoA
    - short chain FAs are activated in mitochondria
    - when FA is activated, ATP converted to AMP and PPi (pyrophosphate)
    - 2 high energy bonds required for FA activation
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13
Q

Transport of Fatty acyl CoA from cytosol into mitochondria

A

Cytosolic Fatty acyl CoA reacts with Carnitine forming Fatty acyl Carnitine by

     - CAT I (carnitine acyl transferase 1) or CPT I (carnitine palmitoyl transferase I)
     - Fatty acyl Carnitine passes to inner mitochondrial membrane, reacts with CAT II (CPT II)
     - Fatty acyl Carnitine reforms Fatty acyl CoA and enters mitochondrial matrix and b-oxidation
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14
Q

Fatty acid activation, Transport, and b-oxidation

A

Long chain FAs are activated on outer mitochondrial membrane
Fatty acyl synthetase binds FA + CoA FA-CoA
Carnitine acyltransferase 1 (CAT-1 or CPT I) replaces CoA with carnitine to form FA-carnitine
FA-carnitine translocates across inner mitochondrial membrane by the carnitine transporter
Carnitine releases FA and it is shuttled back across the membrane to transport more FA
Carnitine acyltransferase-2 (CAT-2 or CPT-II) transfers Fatty acyl group back to CoA
FA-Acyl CoA then undergoes b-oxidation and forms Acetyl CoA

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15
Q

Myopathic CAT/CPT deficiency

A
mucle aches, weakness
myoglobinuria
provoked by prolonged exercise, esp. if fasting
biopsy: elevated muscle triglyceride
most common form: AR, late onset
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16
Q

MCAD deficiency

A
fasting hypoglycemia
no keton bodies (hypoketosis)
C8-C10 acyl carnitines in blood
vomiting
coma, death
AR with variable expression
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17
Q

Carnitine deficiency:

A
  • leads to impaired carnitine shuttle activity
    - decreased LCFA metabolism
    - accumulation of LCFAs in tissues and wasting of acyl-carnitine in urine produces
    cardiomyopathy, skeletal muscle myopathy, encephalopathy and impaired liver function
    due to inherited CTP-I or CPT-II deficiency (rare disorders - autosomal recessive inheritance)
    impaired carnitine synthesis due to liver disease
    disorders of b-oxidation
    - CPT-I deficiency produces fasting hypoglycemia, inability to use LCFAs as fuel by liver
    - CPT-II deficiency – common, muscle weakness upon exercise, hyperammonemia, death
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18
Q

CPT-I and II treated by

A

avoiding fasting, dietary restrictions of LCFAs, carnitine supplement

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19
Q

What is the rate-limiting step of FA oxidation?

A

carnitine on the outer mitochondrial membrane

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20
Q

Pathogenesis of carnitine deficiency

A

Many diseases have been linked to deficiency of Carnitine, CPT-I and CPT-II

Symptoms range from mild muscle cramping to severe weakness and even death

Muscle, kidney and heart tissues are primarily affected

Muscle weakness during prolonged exercise – important characteristics
of CPT deficiency

Muscle relies on FAs as a long term source of energy

Medium chain (C8 - C10) FAs does not require carnitine to enter 
     mitochondria are oxidized normally in these patients
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21
Q

Causes of Carnitine deficiency:

A

Inadequate intake (e.g., due to fat diets, lack of access, or long term TPN-total parenteral nutrition)

Inability to metabolize carnitine due to enzyme deficiencies (e.g., CPT deficiency)

Decreased endogenous synthesis of carnitine due to severe liver disorder

Excess loss of carnitine due to diarrhoea, diuresis, or hemodialysis

A hereditary disorder in which carnitine leaks from renal tubules (Primary carnitine deficiency)

Increased requirements for carnitine when ketosis is present or demand for fat oxidation is high (e.g., during a critical illness such as sepsis or major burns;
after major surgery of the GI tract)

Decreased muscle carnitine levels due to mitochondrial impairment

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22
Q

Clinical manifestations of Carnitine deficiency

A

Carnitine deficiency may cause muscle necrosis, myoglobinuria, hypoglycemia,
fatty liver, muscle aches, fatigue, and cardiomyopathy.

Most common presentation is progressive cardiomyopathy with or without
skeletal muscle weakness beginning at 2-4 years of age. Energy deprived
muscle cells are damaged

Some patients may present with fasting hypoglycemia during the 1st year of
life before cardiomyopathy becomes symptomatic.

Blockage of the transport of LCFAs into mitochondria deprives the patient of
energy production, as the FA oxidation is impaired; glucose oxidation supplies
the minimum energy needs resulting in hypoglycemia

Compensatory ketosis in carnitine induced hypoglycemia is not observed as
Acetyl CoA is not available for ketone body production

The main source of Acetyl CoA is FA oxidation and that is impaired in carnitine
deficiency

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23
Q

General Carnitine deficiency leads to:

A

Symptoms and the age at which symptoms appear depend on the cause
Carnitine deficiency may cause:
muscle necrosis, myoglobinuria
lipid-storage myopathy, hypoglycemia, fatty liver, and hyperammonemia
muscle aches, fatigue,confusion, and cardiomyopathy.
hypoketotic hypoglycemic encephalopathy, accompanied by hepatomegaly, elevated liver transaminases
Cardiomyopathy is the other classic presentation (affecting older children); onset may occur with rapidly progressive heart failure
Cardiomyopathy can also be observed in older patients with a metabolic presentation, even if they are asymptomatic from a cardiac standpoint
Pericardial effusion has also been observed in association with primary carnitine deficiency

24
Q

CPT-I deficiency?

A

CPTI deficiency is thought to cause serious disorders of fatty acid metabolism
The nucleotide sequences of cDNA and genomic DNA encoding human CPTI have been characterized
A relationship between disease and mutation of the human CPTI gene has not been reported
It is very hard to find a case related to CPT-I deficiency relating to its sypmtoms!

25
Q

CPT-II deficiency

A

Muscle weakness is much more defined as CPT-II deficiency

26
Q

Clinical manifestations of Carnitine and/or

CPT I & CPT II deficiency

A
May cause:
muscle necrosis
Myoglobinuria
Rhabdomyolysis
Hypoglycemia
fatty liver
muscle aches
fatigue
cardiomyopathy (age 2-4 yrs, energy deprived muscle cells are damaged)

Diagnosis:
Patients have extremely reduced plasma and muscle carnitine
levels (1-2% of normal)
Fasting ketogenesis is normal if carnitine transport is normal.
Fasting ketogenesis is impaired when dietary carnitine intake is interrupted.
Hypoglycemia is a common finding.
Hypoglycemia is precipitated by fasting and strenuous exercise.
Muscle biopsy reveals significant lipid vacuoles.

27
Q

Treatment of carnitine/ CPTI/ CPT II deficiencies:

A

Pharmacological doses of oral carnitine is highly effective in correcting the cardiomyopathy, muscle weakness, and impairment in fasting ketogenesis

Patient must avoid fasting and strenuous exercise

Some patients require supplementation with medium-chain triglycerides and essential fatty acids (e.g., Linoleic acid, Linolenic acid)

Patients with a fatty acid oxidation disorder require a high-carbohydrate, low fat diet

28
Q

Systemic primary carnitine deficiency, summary

A

SPCD)also known ascarnitine uptake defect,carnitine transporter deficiency(CTD) orsystemic carnitine deficiencyis an inborn error of fatty acid transport.
Symptoms such as chronic muscle weakness,cardiomyopathy,hypoglycemia and liver dysfunction.
The first suspicion of SPCD in a patient with a non-specific presentation is an extremely low plasma carnitine level
Treatment for SPCD involves high dosecarnitine supplementation, which must be continued for life

29
Q

CAT-1 or CPT-I deficiency summary

A

is a raremetabolic disorder that prevents the body from converting certain fats called long-chainfatty acids into energy, particularly during periods without food.
Symptoms include low levels ofketones and low blood sugar (hypoglycemia).
People with this disorder typically also have an enlargedliver (hepatomegaly), muscle weakness, and elevated levels of carnitine in the blood.

30
Q

CAT-2 or CPT-IIdeficiency

A

is a metabolic disorder characterized by an enzymatic defect that prevents long-chain fatty acids from being transported into themitochondria for utilization as an energy source.
It is the most common inherited disorder of lipid metabolism affecting the skeletal muscle of adults
Treatment:High-carbohydrate (70%) and low-fat (less than 20%) diet to provide fuel for glycolysis; use of carnitine to convert potentially toxic long-chain acyl-CoAs to acylcarnitines

31
Q

Hyper-lipidemia orHyper-lipoproteinemia

A

is due abnormally elevated levels of any or alllipidsand/or lipoproteinsin theblood
The lipoprotein density and type ofapolipoproteinsit contains determines the fate of the particle and its influence onmetabolism.
Hyperlipidemias are divided into primary and secondary subtypes.
Primary hyperlipidemia is usually due to genetic causes (such as a mutation in a receptor protein), while
Secondary hyperlipidemia arises due to other underlying causes such asdiabetes.

32
Q

cholesterol transport

A

About half the cholesterol of the body arises by synthesis (~700 mg/dL), rest by diet.
All nucleated cells are capable of cholesterol synthesis, which occurs in ER and cytosol.
HDL is a transporter of cholesterol from peripheral tissues to liver for degradation
HDL-C acts as a scavenger to lower serum cholesterol (good cholesterol)
LDL-C is a transporter of cholesterol from liver to peripheral tissues
Excess LDL is responsible for artherosclerosis and is a risk factor for IHD (bad cholesterol)

33
Q

Hypercholesterolemia and the consequences

A

Prolonged elevated levels of VLDL, IDL, or LDL in plasma results in:
- Artherosclerosis – deposition of cholesterol and cholesterol ester from plasma
lipoproteins into artery wall
- damage to the endothelium (elevated LDL, free radicals from
cigarette smoking, diabetes (glycation of LDL), hypertension,
(increased advanced glycation end products (AGEs)., etc.
- Diabetes mellitus, lipid necrosis, hypothyroidism – often accompanied by severe
atherosclerosis, inflammation, free lipid accumulation and necrosis

34
Q

Primary hyperlipoproteinemia:

5 phenotypes – Fredrickson classification:

A

Type I hyperlipidemia (familial lipoprotein lipase deficiency)
Type II hyperlipidemia
Type III hyperlipidemia (familial dysbeta-lipoproteinemia)
Type IV hyperlipidemia (familial hypertriglyceridemia)
Type V

35
Q

Other types of hyperlipoprotinemia:

A

. Decreased synthesis of HDL

Hepatic lipase deficiency

36
Q

Type I hyperlipidemia (familial lipoprotein lipase deficiency)

A

Primary disorder
Deficiency of lipoprotein lipase in tissue leads to hyperlipidemia
Massive accumulation of chylomicrons in plasma
Severe elevation of plasma triglyceride levels
Plasma cholesterol levels are not elevated
Manifest in early childhood, with acute pancreatitis
Eruptive xanthomas - characteristic skin manifestation of this disorder

37
Q

Type II hyperlipidemia

A
Type II a
Accumulation of LDL
Familial LDL receptor deficiency and familial defective 
     apo-B100
Plasma cholesterol levels are elevated
Plasma triglyceride levels are normal
Manifest severe atherosclerosis 
May present with:
              - tendinous xanthomas, or
              - tuberous xanthomas, as well as,
              - xanthelasmas
Type II b
Accumulation of both LDL and VLDL
Defective apo-B100 protein
Variable elevations of both triglyceride and cholesterol levels
May present with:
              - tendinous xanthomas, or
              - tuberous xanthomas, as well as,
              - xanthelasmas
38
Q

Type III hyperlipidemia (familial dysbeta-lipoproteinemia)

A

Accumulation of IDL
Increase in both triglyceride and cholesterol levels
Various mutations of opo-protein E impairs its ability to bind to IDL receptor
Presents with
- premature atherosclerosis and
- xanthomas (plane xanthomas)

39
Q

Type IV hyperlipidemia (familial hypertriglyceridemia)

A

Over production of VLDL, resulting in extreme elevations of plasma
triglyceride levels.
Plasma cholesterol levels are normal
May present with
- eruptive xanthomas
- associated with coronary hear disease, type II diabetes mellitus,
obesity, and alcoholism.

40
Q

Type V hyperlipidemia (genetic defects of the apo-lipoprotein C–II gene)

A

Accumulation of chylomicrons and VLDL
Severe elevations of triglyceride levels in plasma
May present in early childhood (similar to type I) with
- acute pancreatitis
- eruptive xanthomas

41
Q

Decreased synthesis of HDL

A

decreased formation of apo-protein A-I and apo-protein C-III
decreased reversed cholesterol transport
Increased LDL levels
Presents with
- premature coronary artery disease
- plane xanthomas

42
Q

Hepatic lipase deficiency

A

Leads to accumulation of large triacylglycerol-rich HDL and VLDL
Presents with
- coronary heart disease
- xanthomas

43
Q

Secondary Hyper-lipidemia

A

Secondary hyper-cholesterolemia due to a variety of secondary causes:

       - pregnancy
       - hypothyroidism
       - cholestasis
       - acute intermittent porphyria

Secondary hyper-triglyceridemia can be associated with:

       - diabetes mellitus
       - pancreatitis
       - gout
       - type I glycogen storage disease
       - alcoholism
       - oral contraceptive use

Combined hyper-cholesterolemia and hyper-triglyceridemia found in:

       - nephrotic syndrome
       - chronic renal failure
       - steroid immunosuppressive therapy
44
Q

Xanthelasma palpebrarum

A
  • is the most common xanthomas
    - lesions are soft, velvety, yellow, flat,
    around the eyelids
    - associated with hyperlipidemia
    - secondary to cholestasis
45
Q

Tuberous xanthomas

A

firm, painless, red-yellow nodules
usually develops in pressure areas,
extensor surfaces of knees, elbows
- associated with hypercholesterolemia
and increased levels of LDL
- secondary to nephrotic syndrome,
hypothyroidism

46
Q

Tendinous xanthomas

A
  • associated with severe hypercholesterolemia
    and elevated LDL levels.
    • lesions often related to trauma
    • nodules related to tendons or ligaments
    • secondary to cholestasis
47
Q

. Eruptive xanthomas

A
  • associated with hyper-triglyceridemia
    • erupt as crops of small, red-yellow
      papules, may spontaneously resolve
      over weeks
  • secondary to diabetes
48
Q

Plane xanthomas

A

associated with dysbetalipoproteinamia

  • can occur in any site
  • covers large areas of face, neck, thorax
  • secondary to cholestasis
49
Q

Laboratory Investigations of hyper-lipoproteinemia

A

Measurement of plasma lipid and lipoprotein levels after an overnight fast of 12-16 hrs.

Abnormal lipoprotein patterns need to be identified.

Performing electrophoresis and ultracentrifugation of whole plasma for diagnosis

Appropriate blood, urine, and radiographic workups are required to rule out secondary causes of hyperlipidemia

Lipoprotein profiles are used to assess cardiac risk and for diagnosis of lipid metabolism disorders

50
Q

Treatment of xanthomas

A

Dietary
Lipid-lowering agents, eg. Statins, fibrates, bile acid-binding resins, probucol, or nicotinic acid.
Xanthomas are not always associated with hyperlipidemia, but when they are, diagnosing and treatment underlying lipid disorders to decrease the size of xanthomas and to prevent risks of atherosclerosis
Eruptive xanthomas usually resolve within weeks of initiating systemic treatment
Tuberous xanthomas usually resolve after months of treatment
Tendinous xanthomas take years to resolve or may persist indefinitely

Supportive care

Weight reduction and a diet low in saturated fat and cholesterol are advocated
Patients should avoid alcohol and estrogen

Prognosis – is good if the underlying cause is treated

51
Q

Development of atherosclerosis

A

ROS produced by endothelial cells, SMCs, and macrophages oxidize LDL in the subendothelial space, at the sites of endothelial damage, initiating events that culminate in the formation of a fibrous plaque. Rupture of fibrous plaque leads to thrombus formation and occlusion of the vessel.

52
Q

HMG-CoA reductase inhibitors

A
HMG-CoA reductase is
the rate limiting enzyme.
HMG-CoA reductase inhibitors
inhibits de novo cholesterol
synthesis and increases LDL
receptor expression
53
Q

Mechanism of action of Statins

A

Inhibition of HMG CoA reductase

–> reduction of cholesterol synthesis in liver compensatory in synthesis of LDL receptors on hepatic and extra hepatic tissues increase in hepatic uptake of circulating LDL which decreases plasma LDL receptors.

Decrease TGs to some extent and HDL
Cardio protective: vasodilators and decrease atheroscelorosis (stabilize plaque)

54
Q

Treatment of Hypercholesterolemia

A

Reductions in circulating cholesterol levels can have profound positive impacts on cardiovascular disease, particularly on atherosclerosis, as well as other metabolic disruptions of the vasculature.
Control of dietary intake is one of the easiest and least cost intensive means to achieve reductions in cholesterol.
Drug treatment to lowerplasma lipoproteins and/or cholesterol is primarily aimed at reducing the risk of atherosclerosis and subsequent coronary artery disease that exists in patients with elevated circulating lipids

55
Q

Hypolipidemic Drugs Action

A

inhibition of cholesterol absorption in the intestine

reduced cholesterol transport to liver (chylomicrons)

up-regulation of LDL receptors in the liver

increased clearance of atherogenic lipoproteins in peripheral tissue

statin monotherapy- inhibits endogenous cholesterol synthesis

ezatimib mmonotherapy- inhibits dietary cholesterol absorption, and re-absorption of biliary cholesterol

statin + ezetimibe- together leads to greater LDL-C reduction