Annals of Clinical Biochemistry: International Journal of Laboratory Medicine

Impact Factor: 2.587

5-Year Impact Factor: 2.775

 Contents 

 PDF / ePub  More

Abstract
Lipoprotein metabolism is dependent on apolipoproteins, multifunctional proteins
that serve as templates for the assembly of lipoprotein particles, maintain their
structure and direct their metabolism through binding to membrane receptors and
regulation of enzyme activity. The three principal functions of lipoproteins are
contribution to interorgan fuel (triglyceride) distribution (by means of the fuel
transport pathway), to the maintenance of the extracellular cholesterol pool (by
means of the over!ow pathway) and reverse cholesterol transport. The most
important clinical application of apolipoprotein measurements in the plasma is in
the assessment of cardiovascular risk. Concentrations of apolipoprotein B and
apolipoprotein AI (and their ratio) seem to be better markers of cardiovascular risk
than conventional markers such as total cholesterol and LDL-cholesterol.
Apolipoprotein measurements are also better standardized than the conventional
tests. We suggest that measurements of apolipoprotein AI and apolipoprotein B are
included as a part of the specialist lipid pro"le. We also suggest that lipoprotein (a)
should be measured as part of the initial assessment of dyslipidaemias because of
its consistent association with cardiovascular risk. Genotyping of apolipoprotein E
isoforms remains useful in the investigation of mixed dyslipidaemias. Lastly, the
role of postprandial metabolism is increasingly recognized in the context of
atherogenesis, obesity and diabetes. This requires better markers of chylomicrons,
very-low-density lipoproteins and remnant particles. Measurements of
:
 very-low-density lipoproteins and remnant particles. Measurements of
apolipoprotein B48 and remnant lipoprotein cholesterol are currently the key tests
in this emerging "eld.

Introduction
Abnormalities in lipoprotein metabolism are important in atherogenesis, obesity,
insulin resistance and diabetes; all being major areas of concern for public health,
individual wellbeing and research. Control of lipoprotein metabolism through
lifestyle measures and medication has become an essential part of cardiovascular
prevention.

This paper aims to provide a perspective on apolipoproteins and their

measurement in the context of lipid metabolism and associated clinical disorders.

First, lipid metabolism is brie!y reviewed, with an emphasis on the role of

apolipoproteins as markers of lipoprotein particles and as metabolic agents. The
apolipoproteins are then discussed under the three headings: structure and
function, clinical signi"cance and methodology.

Lipoprotein metabolism
Lipoproteins are lipidated protein particles that carry hydrophobic substances in the
hydrophilic environment of plasma. They are classi"ed on the basis of their
hydrated density – in an ascending order – into chylomicrons, very-low-density
lipoproteins (VLDL), intermediate-density lipoproteins (IDL), low-density lipoproteins
(LDL) and high-density lipoproteins (HDL). The term IDL is often used
interchangeably with ‘remnant particles’. However, because the VLDL remnants may
distribute both in the IDL fraction (1.006–1019 kg/L) and the VLDL fraction (<1.006
kg/L), the equivalence is not complete. For a general outline of lipid metabolism, the
reader is referred to a current textbook,1 and literature on earlier lipid research can
be found in a number of previous reviews.2–6
:
 be found in a number of previous reviews.2–6

The surface of a lipoprotein particle consists of either hydrophilic or amphipathic

substances such as phospholipids and cholesterol as well as apolipoproteins, which
serve as receptor-binding and regulatory proteins. The cores of these particles
contain hydrophobic molecules such as triglycerides (TG) and cholesteryl esters.

Lipoproteins di#er in size, lipid composition and apolipoprotein content. These

characteristics change as a result of action of enzymes such as lipoprotein lipase
(LPL),7 hepatic triglyceride lipase (HTGL),8 lecithin-cholesterol acyltransferase
(LCAT)9,10 and cholesteryl ester transfer protein (CETP).11 Apolipoproteins regulate
the activities of these enzymes, and can transfer between di#erent lipoprotein
classes. Lipoprotein assembly and metabolism are a#ected both by apolipoprotein
content and by their conformation. Apolipoproteins control cellular uptake of
lipoproteins through binding to membrane lipoprotein receptors. Apolipoprotein
B100 (apoB100) and apolipoprotein E (apoE) bind to the apoB/E (LDL) receptor.12
Apolipoprotein E (apoE) also binds to the LDL receptor-related protein (LRP).13
Apolipoproteins A bind to the scavenger receptor BI.14

Lipoproteins contribute to body fuel metabolism by enabling TG distribution

between tissues. They also serve as an extracellular reservoir, and a vehicle for
transport, of cholesterol. Plasma TG measurements re!ect the "rst, and
measurements of total cholesterol (TC) and LDL-cholesterol (LDL-C) the second and
third function. Clinical disorders may result from both defects in fuel transport and
in cholesterol homeostasis. Often a defect in one process will secondarily a#ect the
other.

Abnormalities in fuel metabolism are present in cardiovascular disease (CVD),

obesity and diabetes mellitus – conditions representing the three major
contemporary epidemics. Hypercholesterolaemia is related to the entry of
cholesterol-containing lipoprotein particles into vascular intima and thus
atherogenesis,15 while hypertriglyceridaemia, apart from its association with
cardiovascular disease, leads to steatosis and may precipitate pancreatitis.
Discussion of atherogenesis is beyond the scope of this article but it has been
:
 Discussion of atherogenesis is beyond the scope of this article but it has been
extensively reviewed elsewhere.16,17

Pathways of lipoprotein metabolism

To describe lipoprotein metabolism, this paper employs the conceptual framework
of the fuel transport pathway (metabolism of chylomicrons, VLDL and remnant
particles), the over!ow pathway (the metabolism of LDL) and reverse cholesterol
transport (the metabolism of HDL).18 We believe that this approach facilitates
understanding of the pathogenesis of lipid disorders and relevant therapeutic
interventions.

The fuel transport pathway

The fuel transport pathway delivers TG to peripheral tissues. The TG transport
function is shared by chylomicrons and VLDL. While chylomicrons are assembled
during the absorptive phase of the feed-fast cycle, VLDL can be present in plasma at
any time.

TG are incorporated into chylomicrons in the enterocytes, on the template of

apoB48 and are secreted into the lymph (Figure 1).19 Nascent chylomicrons contain
apoB48, apolipoprotein AIV (apoAIV) and apolipoprotein AV (apoAV). Later, they
acquire (probably from HDL) apoAI and apoAII and apolipoproteins C (apoCI, CII,
CIII) as well as apoE. ApoAIV is released into plasma.
:
 Figure 1 Apolipoproteins in the fuel transport pathway of lipoprotein metabolism: the

chylomicrons. Chylomicrons transport triglycerides from the intestine to the peripheral

tissues. Apolipoprotein B48 (present in the concentration of one molecule per particle)
tracks a particle from a nascent chylomicron to a chylomicron remnant and is the most

important marker of chylomicron metabolism. Note extensive apolipoprotein exchanges

between di#erent particles. The measurement of apolipoprotein B48 re!ects both nascent

chylomicrons and chylomicron remnants. On the other hand, the measurement of

remnant lipoprotein cholesterol (RLP-C) re!ects the sum of chylomicron remnants and
VLDL remnants (compare Figure 2) but excludes nascent or mature chylomicrons. AI,

apolipoprotein AI; AII, apolipoprotein AII; AIV, apolipoprotein AIV; AV, apolipoprotein AV;

B48, apolipoprotein B48; CI, apolipoprotein CI; CII, apolipoprotein CII; CIII, apolipoprotein

CIII; E, apolipoprotein E; CE, cholesteryl esters; LRP, LDL receptor-like protein; TG,

triglycerides

In the periphery, chylomicron TG are digested by LPL, an enzyme present in the

vascular endothelium. Fatty acids are released to cells. Chylomicrons decrease in
size and become chylomicron remnants. Now apoA, most apoC, and probably
:
 size and become chylomicron remnants. Now apoA, most apoC, and probably
apoAV, are returned to the HDL. The remnants are internalized in the liver after
binding to the LRP and to the LDL receptor, mediated by apoE.

In contrast to TG absorbed from the intestine, endogenous TG are secreted from

the liver in VLDL particles (Figure 2). Nascent VLDL contain apoB100 as a sole
apolipoprotein. They subsequently acquire (mostly from HDL) apoA (AI, AII, AIV),
apoC (CI, CII and CIII) and apoE. VLDL TG are, analogously to the chylomicrons,
partially digested by LPL. This transforms VLDL particles into VLDL remnants.20,21
VLDL remnants are internalized through the LDL receptor, to which they bind
through apoE but not apoB. Note that the TG-rich particles in the fuel transport
pathway lose some TG to HDL, in exchange for cholesteryl esters,22 in a process
mediated by the CETP.23,24
:
 Figure 2 Apolipoproteins in the fuel transport pathway of lipoprotein metabolism: the
VLDL. Apolipoprotein B100 tracks the metabolism of VLDL. It is present in the

concentration of one molecule per particle. Note the parallels with chylomicron
metabolism (compare Figure 1) in particular with regard to apolipoprotein exchanges with

HDL. The fuel transport pathway generates LDL through the action of HTGL. The
measurement of apoB100 includes all the particles in this pathway together with all LDL
particles in the over!ow pathway (compare Figure 3). AI, apolipoprotein AI; AII,

apolipoprotein AII; AIV, apolipoprotein AIV; AV, apolipoprotein AV; B100, apolipoprotein
B100; CI, apolipoprotein CI; CII, apolipoprotein CII; CIII, apolipoprotein CIII; E,

apolipoprotein E; CE, cholesteryl esters; HTGL, hepatic triglyceride lipase

The over!ow pathway

Internalization of the remnants returns these particles to the liver. This would neatly
complete the fuel transport pathway, if not for the fact that the internalization
occurs in parallel to further lipolysis, this time by the HTGL, which is bound to
endothelium in the hepatic microvasculature. During this process, the remnants
lose apoC, and apoE (which are transferred to HDL), decrease in size, and become
LDL.25 Thus the LDL particles are generated as a result of ‘over!ow’ from the fuel
transport pathway. This process is clinically important, because when remnant
supply from the fuel transport pathway is excessive – due to oversupply or
ine%cient removal – more LDL particles are generated.

The over!ow pathway involves further metabolism of LDL (Figure 3). ApoB100, the
main apolipoprotein of the LDL, controls their internalization by binding to the
apoB/E (LDL) receptor. It has lesser a%nity to the LDL receptor than apoE in the
remnants, and the LDL residence time in the circulation exceeds that of the
remnants.
:
  Cite article

Cite article

COPY CITATION

OR

Download to reference manager

If you have citation software installed, you

can download article citation data to the
citation manager of your choice

Select your citation manager software:

(select option)

Figure 3 Apolipoproteins in the over!ow Privacy  Direct

pathway of lipoprotein import
metabolism: the LDL. The

name over!ow pathway re!ects the fact that LDL are generated from the fuel transport
pathway. The oversupply of remnants would increase the number of generated LDL. The
predominant lipoprotein of LDL is B100, present in the concentration of one molecule per

particle. The measurement of apoprotein B100 re!ects the sum of LDL particles, the VLDL
and the VLDL remnants. Note that LDL is generated in a range of sizes. The main

determinant of their plasma concentration is the activity of the LDL receptor and the rate
of cellular uptake. B100, apoprotein B100; HTGL, hepatic triglyceride lipase. Note: the
empty circles in the upper part of the "gure represent lipoproteins in the fuel transport

pathway (refer to Figures 1 and  2)

:
  Share
The LDL serve as an extracellular cholesterol depot: their cellular options
uptake increases
when LDL receptor expression increases as a result of a decrease in the intracellular
cholesterol concentration.
Share this article
Reverse cholesterol transport and cholesterol recycling
Share with
Metabolism of HDL, known as reverse cholesterol transport email
(RCT), is a pathway of
removal of cholesterol from peripheral cells to the liver (Figure 4).26–28 This view is
EMAIL ARTICLE LINK
now being challenged, since HDL also remove cholesterol from the liver inserting it

back into the VLDL and remnant particles,26 through the exchange mechanism
Share on social media
mentioned above. Transport of cholesterol from macrophages to the liver
(macrophage RCT: the central concept in atherogenesis) involves only a small
  
fraction of circulating HDL. It seems therefore that HDL, similarly to LDL, contribute
Facebook Twitter Linkedin WeChat
to the maintenance of the extracellular cholesterol pool.

Share access to this article

Sharing links are not relevant where the

article is open access and not available if
you do not have a subscription.

For more information view the SAGE

Journals article sharing page.

Information, rights and

:
 Information, rights and
 permissions

Published In
Figure 4 Apolipoproteins in reverse cholesterol transport: the HDL. HDL particles transport
AnnalsRCT)
cholesterol from peripheral cells and macrophages (macrophage of Clinical Biochemistry
to the liver but also
insert cholesteryl esters into the fuel transport pathway byVolume 48, Issue
exchanging 6 TG with
them for

TG-rich proteins. In this way, HDL contributes to the maintenance of the

Pages: 498 extracellular
- 515
cholesterol pool. The measurement of ApoAI is the most important marker of the activity
Article "rst published online: October 25,
of reverse cholesterol transport. AI, apolipoprotein AI; AII, apolipoprotein AII; AIV,
2011
apolipoprotein AIV; AV, apolipoprotein AV; CI, apolipoprotein CI; CII, apolipoprotein CII; CIII,
Issue published: November 2011
apolipoprotein CIII; E, apolipoprotein E; CE, cholesteryl esters; B48, apolipoprotein B48;

LCAT, lecithin cholesteryl-ester transferase; CE, cholesteryl-esters; ABCA1, ATP-binding

A%liations
cassette transporter A1; RCT, reverse cholesterol transport; TG, triglycerides

Marek H Dominiczak
NHS Greater Glasgow and Clyde Clinical
HDL are assembled on the matrix of the apoA. ApoA Biochemistry
is secreted Service and and
by the liver College of
Medical, Veterinary and Life Sciences,
University
intestine and is lipidated extracellularly, transforming of Glasgow,
into nascent Department
(pre-beta) HDL, of
Biochemistry, Gartnavel General Hospital,
phospholipid-rich, discoid particles. They acquire cholesterol
1053 Greatby bindingRoad,
Western to theGlasgow G12
0YN
membrane ATP-binding cassette transporter A1 (ABCA1) that controls e&ux of free

cholesterol from cells. Cholesterol is subsequently esteri"ed by LCAT. Accumulation
View all articles by this author
of cholesteryl esters changes the particle to spherical HDL3. HDL3 transfer
Muriel J Caslake
cholesteryl esters, apoA, apoC and apoE to TG-rich lipoproteins in exchange for TG
(see above). This process enlarges the HDL particles which became HDL2. HDL2
subsequently o&oad cholesteryl esters by docking into the scavenger receptor BI
(there is no particle internalization).

Conventional markers of lipoprotein metabolism

The conventional ‘routine’ markers of lipoprotein metabolism include TC, LDL-
cholesterol (LDL-C), HDL-cholesterol (HDL-C) and plasma TG. More detailed
:
 Metrics and citations
assessment of a lipid pro"le includes ultracentrifugation-based analysis. Since

lipoprotein components such as cholesterol or TG are present in more that one
lipoprotein class, neither of them can serve as an absolute marker of a particular
Journals
class. Moreover, LDL, similarly to VLDL, are heterogeneous in metrics
size.29,30 All this
means that measurement of LDL-C is not a good indicator of the number of LDL
This article was published in Annals of
particles.
Clinical Biochemistry: International Journal of
The most commonly measured substance, cholesterol, is measured either in the
Laboratory Medicine.
plasma (TC)31 or in lipoprotein fractions (LDL-C, HDL-C). TC predominantly re!ects
the concentration of LDL particles. HDL-C constitutes around 25% of TC.
VIEW ALL VLDLMETRICS
JOURNAL

normally constitute only approximately 15% of the total. Measuring HDL-C together
with TC enables computing the TC/HDL-C ratio, assumed to re!ect *the balance
Article usage
between transport of cholesterol to the periphery and its return to the liver.
Total
The measurement of TG, the third component of the views and
traditional downloads:
‘fasting 11020
lipid pro"le’,
*
re!ects the concentration of VLDL and remnant particles, and, postprandially,
Article usage tracking started in December
chylomicrons and their remnants. In routine practice,
2016measurements of TC, HDL-C
and TG allow calculation of LDL-C by the Friedewald formula:32
Altmetric

See the impact this article is making

through the number of times it’s been read
Thus LDL-C is estimated by taking into account the HDL-C and TG concentration.
and the Altmetric Score.
LDL-C calculated in this way in fact includes VLDL-C, IDL-cholesterol (IDL-C) and
Learn more about the Altmetric Scores
lipoprotein (a) (Lp(a))-cholesterol. Naturally, this calculation incorporates the errors
of TC, HDL-C and TG measurements. The formula is not applicable at TG
concentrations above 4.5 mmol/L. In spite of these limitations, the formula has
been commonly used for the assessment of cardiovascular risk and particularly for
the monitoring of lipid-lowering treatment.

More recent is the calculation of non-HDL cholesterol (NHDL-C). This is calculated

as:
:
  Figures and tables
NHDL-C has been recommended as superior to the LDL-C. NHDL-C is a simple
estimate of a sum of cholesterol contained in VLDL, remnant particles, LDL and
Lp(a). It seems to be a better predictor of coronary heart disease (CHD) than LDL-
C.33–36 Its use has been recommended by the American Diabetes Association and
the American College of Cardiology.

The ‘gold standard’ method of measuring lipids and lipoproteins (the so-called beta-
quanti"cation) employs ultracentrifugation to partially separate lipoproteins.37 After
removal of VLDL by ultracentrifugation, the other apoB-containing lipoproteins in
the infranatant are precipitated using heparin and manganese chloride, leaving HDL
in solution for cholesterol measurement. LDL-C is calculated as:

Note that here the calculated LDL-C value also includes IDL-C and Lp(a) cholesterol.
This method is available in the UK in specialized lipid laboratories.

As already mentioned, the LDL-C measurement re!ects just one component of LDL
particles and cannot provide precise estimation of the LDL particle number, an
important parameter relating to LDL atherogenecity.

In Friedewald's paper, the di#erences between calculated and measured LDL, after
exclusion of patients with TG above 4.5 mmol/L (400 mg/dL), were 4.8–9.8%
depending on the type of dyslipidaemia.32 When Friedewald-formula-derived LDL-C
and LDL-C obtained through beta-quanti"cation were compared across "ve
categories of LDL-C concentration, the misclassi"cation rates (instances where a
result obtained by each method would fall into a di#erent category) were 20–30%.
On the other hand, using standardized methodology of apolipoprotein
measurement and reference material SP-07, the between-laboratory coe%cient of
variation for apoA was 2.1–5.6% and for apoB 3.1–6.7%.38

Thus there are both technical inadequacies and scienti"c limitations inherent in
‘conventional’ methods of lipid and lipoproteins assessment. For a more detailed
account of the conventional tests, the reader is referred to other reviews.31,39
:
 account of the conventional tests, the reader is referred to other reviews.31,39
View Options

Structure and function of apolipoproteins

PDF/ePub
Please refer to Table 1 throughout this section.

View PDF/ePub

Table 1 Structure and function of apolipoproteins

Examples of
Apo Genes Synthesis Structure Function
isoforms

AI Chromosome Six Liver, 243 AA, Structural in HDL

11, polymorphic intestine 28,000 Da LCAT activator
AI/C3/A4/A5 isoforms.
gene cluster Mutations: Apo Access options
AI Tangier, AI
Milano AI If you have access to journal content via a
Marburg
personal subscription, university, library,
AII Chromosome1   Liver, 77AA, select from
employer or society, Structural
the in HDL
intestine 17,400 and fatty acid
options below:Da. metabolism. Link
Mainly with apoE in HDL
present
 SAGE as dimer pro"le
Journals
(mol.
mass
above is
that of
the
dimer)

AIV Chromosome ApoAIV 360 Liver,   Metabolism of TG

11, (common), intestine rich particles.
A1/C3/A4/A5 ApoAIV-1, Interacts with CII
gene cluster ApoAIV-2 LPL. LCAT activato

AV Chromosome Multiple Liver   Chylomicron- and

11, A1/C3 variants VLDL assembly. L
A4/A5 gene activator
cluster
:
 cluster

CIII Chromosome Variants with Liver, 79AA, LPL inhibitor. Ma

11, A1/C3 di#ering sialic intestine 8,800 Da or displaces apoE
A4/A5 gene acid content: from LRP
cluster CIII-0, CIII-1,
CIII-2

CII Chromosome   Liver, 79AA, LPL activator:

19 intestine 8900 Da de"ciency leads t
gross
hypertriglycerida
OR
CI Chromosome   Liver, 57AA LCAT activator, LP
19 intestine inhibitor, CETP
inhibitor. Inhibits
apoE binding to L

B100 Chromosome Over 100 Liver 4536 AA, Structural

2 polymorphisms 550,000 component of VL
Da IDL, LDL. Ligand f
LDL-receptor

B48 Chromosome   Intestine 2152 N- Structural

2 terminal component of
AA of chylomicrons and
B100, chylomicron
264,000 remnants
Da. 8–
10% CHO

E Chromosome Three main Liver, 299 AA, Multifunction pro

19, E/C1/C2/C4 isoforms: e2, intestine, 34,200 Da LDL-receptor liga
gene cluster e3, e4. Many brain, 
for LDL and
variants kidney, chylomicron
spleen, remnants. LRP lig
adrenals Role in RCT.
and other Modulates LPL, C
LCAT, HTGL.
:
 LCAT, HTGL.
Antioxidant mole
Regulator of
in!ammatory
response

(a) Chromosome Over 20 Liver Variable  

6. Linkage with isoforms, molecular
plasminogen dependent on mass:
gene. Kringle 4 number of 187,000 –
region most kringle 4 800,000
variable repeats Da Pre-
beta
mobility.
High sialic
acid
content

CHO, carbohydrates; AA, aminoacids; RCT, reverse cholesterol transport; LRP, LDL
receptor-like protein

Please see text for references

Apolipoprotein B100
ApoB100 consists of 4536 amino acids and has a molecular mass of 550,000 Da.
After cleavage of 27 amino acids from the N-terminal end, the molecular mass
decreases to 513,000 Da.40,41 It possesses a globular amino-terminal domain, which
reacts with microsomal TG transfer proteins.42 The gene for apoB is located on the
short arm of chromosome 2. One hundred and twenty-three genetic variants in the
apoB gene were identi"ed in the Copenhagen City Heart Study. ApoB
polymorphisms include T2488T and E4154K,43 which are signal peptide
insertion/deletion polymorphisms. Mutation of apoB100 at amino acid residue 3500
a#ects its receptor-binding and leads to a disorder known as familial defective ApoB
(FDB).44 ApoB100 is synthesized in the hepatocytes and its excess is degraded
within cells. It resides in the VLDL, LDL and LDL particles at a ratio of one molecule
per lipoprotein particle. Thus, it is a marker of the number of these particles.
:
 Apolipoprotein B48
ApoB48 has 2152 amino acids and a molecular mass of 264,000 Da. It is a truncated
form (amino-terminal 40%) of apoB100.45 ApoB100 and apoB48 are produced from
a single gene. During the editing process of the apoB mRNA, deamination of a
cytidine nucleotide 6666 to uridine converts that codon to a stop codon. This results
in synthesis of apoB48. ApoB48 is synthesized by enterocytes and secreted in
chylomicrons, and is retained in chylomicron remnants. Since one molecule of
apoB48 is present in each chylomicron particle, it serves as a marker of the number
of chylomicrons and their remnants. ApoB48 does not possess the LDL-receptor
binding domain: the remnants are internalized by the apoE-binding LRP and also to
a degree by the LDL receptor, to which they also bind through apoE.46

Particles smaller than 70–80 nm can penetrate the vascular wall. Therefore,
chylomicron remnants, but not nascent chylomicrons, are regarded as atherogenic.
Chylomicron remnants are enriched in cholesteryl esters through exchange with
HDL (see above).47

Apolipoprotein AI
ApoAI is a protein of 243 amino acids. The apoA gene is located on chromosome 11,
and is part of the APOA1/C3/A4/A5 gene cluster.48 It is synthesized in the liver and
intestine.49 The concentration of apoAI is controlled by its degradation rate: apoAI
that cannot acquire lipids is rapidly degraded. ApoAI constitutes 70% of HDL
apolipoproteins. It activates LCAT and is also an anti-in!ammatory molecule and an
antioxidant.50 Plasma levels of apoAI vary and depend on method of measurement
and population.

Apolipoprotein AII
ApoAII is a 77-amino acid homodimer with molecular mass of 17,400 Da. It is
predominantly expressed in the liver. ApoAII accounts for approximately 20% of
HDL protein. HDL particles contain just apoAI (these are designated as LpAI) or both
apoAI and apoAII (LpAI/AII).51 ApoAII concentration is determined by its production
:
 apoAI and apoAII (LpAI/AII).51 ApoAII concentration is determined by its production
rate. It inhibits LPL activity (and may also inhibit HTGL), and serves as a co-factor for
LCAT and CETP. It may replace apoCII (a LPL activator) in the VLDL, or directly inhibit
the LPL. LPL activation by the HDL particles was impaired in transgenic mice
expressing human apoAII.52 Experiments in transgenic mice also demonstrated that
apoAII is associated with obesity and insulin resistance. In contrast to the results of
mouse studies,53 it seems that it may be inversely associated with the risk of
coronary disease in humans.54 ApoAII has been reviewed by Tailleux et al.55

Apolipoprotein AIV
ApoAIV is a glycoprotein with molecular weight of 46,000 Da. It is synthesized in the
intestine and is incorporated into nascent chylomicrons. It is also present in HDL.
Because it is relatively hydrophilic, it may be displaced from lipoproteins by apoCII
and apoE and circulates predominantly as lipid-free protein. It participates in
intestinal lipid absorption, in the assembly of chylomicrons and a#ects various
aspects of lipoprotein response to diet. Its polymorphism Q360H leads to an
increased postprandial TG concentration, a reduced LDL response to dietary
cholesterol and an increased HDL response to dietary fat. The e#ects of T347S
polymorphism are opposite to Q360H. ApoAIV also modulates the activity of LPL
and activates LCAT.56

Apolipoprotein AV
ApoAV modulates hepatic VLDL synthesis and secretion. The gene coding for apoAV
(APOA5) has been strongly associated with TG concentration. ApoAV de"ciency
leads to type V dyslipidaemia and to reduced post-heparin LPL activity. On the other
hand, its overexpression leads to a decreased TG concentration. ApoAV is
synthesized in the liver.57 In the Australian Genetic Epidemiology of Metabolic
Syndrome (GEMS) family network study, the most common haplotype was
associated with low TG and high HDL-C.58 Two other haplotypes were associated
with an opposite pro"le.

The recent large-scale Mendelian randomization experiment has con"rmed the

:
 The recent large-scale Mendelian randomization experiment has con"rmed the
association of −1131T > C APOA5 gene promoter with lipid values and CHD risk.59
Each C allele was associated with a 16% increase in TG compared with common
homozygotes.

Apolipoproteins C
ApoCIII is an 8800-Da glycopeptide synthesized mostly in the liver and also in the
intestine. There are three isoforms of apoCIII characterized by a di#erent degree of
sialylation: 0, 1 and 2. ApoCIII-1 and -2 comprise 90% of apoCIII in the plasma.
APOC3 gene is part of the APOA1/C3/A4/A5 gene cluster.60,61

Apolipoproteins C participate in the assembly of VLDL and chylomicrons.

ApoCI is present in TG-rich lipoproteins and displaces apoE in lipid emulsions.

ApoCII, on the other hand, activates LPL and therefore contributes to VLDL lipolysis.
ApoCIII cycles between lipoproteins: chylomicrons acquire apoC and apoE from
other lipoproteins. ApoCI and apoCIII inhibit LPL, and probably also HTGL. They may
also inhibit the uptake of remnant particles by inhibiting apoE binding to receptors.
ApoAV may counteract the e#ects of apoCIII.

Apolipoprotein E
ApoE is a single-chain glycoprotein of 299 amino acids with a molecular weight of
34,200 Da.62,63 It is widely distributed across lipoprotein classes: it is present in
chylomicron remnants, mature VLDL, VLDL remnants, LDL and HDL. It binds with a
high a%nity to the LDL-receptor as well as to the LRP (the binding is mediated by
apoCI). It facilitates clearance of chylomicron and VLDL remnants. Approximately
60% of plasma apoE is present in the HDL, which exchange it with other
lipoproteins. It is also synthesized by macrophages (including macrophages present
in atherosclerotic lesions)63 and by brain astrocytes.64,65 ApoE controls cholesterol
e&ux from cells together with apoAI.66 It also has antioxidant properties and plays a
role in the regulation of in!ammatory response.

ApoE exists in three isoforms, E2, E3 and E4, coded by alleles ϵ2, ϵ3 and ϵ4.67 The
:
 ApoE exists in three isoforms, E2, E3 and E4, coded by alleles ϵ2, ϵ3 and ϵ4. The
di#erences between the isoforms are due to amino acids at positions 112 and 158.
ApoE3 (frequency 60–70% in the general population) has cysteine at position 112
and arginine at position 158, apoE4 (frequency 15–20%) has arginine 112 and
arginine 158, and apoE2 (frequency 5–10%) has cysteine at both 112 and 158.
Individuals with ϵ4 allele have higher plasma cholesterol concentration than those
with ϵ2.68 Such individuals are also characterized by more e%cient cholesterol
absorption and increased apoB synthesis. Their apoB100 metabolism is slower.
ApoE activates LPL, HTGL and LCAT. ApoE3 and apoE4 have similar a%nity to the
LDL receptor, while apoE2 has lower a%nity. ApoE-de"cient mice show increased
plasma cholesterol concentration, and over-expression of apoE in transgenic rabbits
and mice decreases plasma cholesterol. The ϵ2/2 genotype is associated with
familial dysbetalipoproteinaemia (also known as type III hyperlipidaemia). However,
although one per cent of the population possess this genotype,
dysbetalipoproteinaemia is present in only one person in 10,000.69 On the other
hand, more than 90% of patients with dysbetalipoproteinaemia have ϵ2/2 genotype,
and genotyping is used as a con"rmation of diagnosis (see below).

Plasma apoE explains 20–40% of the variability of TG concentrations in humans.

Overexpression of apoE leads to hypertriglyceridaemia through stimulation of VLDL
production and decrease in its clearance (for a review see Huang).70

Apolipoprotein (a) and lipoprotein (a)

Lp(a) consists of apolipoprotein (a) (apo(a)) attached to apoB100 by a disulphide
linkage.71 An important characteristics of the apo(a) is its structural
polymorphism.72 Apo(a) contains multiple kringles (kinks in the polypeptide chain),
and the so-called kringle 4 is the most polymorphic one of these. Apo(a) is
synthesized in the liver and it may undergo post-translational modi"cations. Its
molecular mass ranges between 187,000 and 800,000 Da and its plasma
concentration ranges from 0.1 to 1000 mg/dL. Its synthesis is controlled by a series
of autosomal alleles. The rate of synthesis is the main determinant of its
concentration in plasma.
:
 concentration in plasma.

Lp(a) binds to the LDL receptor. It is removed by the liver in rodents but in humans
it is also partly cleared by the kidney. Thus, Lp(a) concentration is elevated in renal
failure. CVD risk associated with Lp(a) is also associated with high concentrations of
LDL-C. Lp(a), similarly to the LDL, can penetrate vascular walls and associate with
intimal proteoglycans.73 Lp(a) is structurally related to plasminogen and potentially
can interfere with its action.74,75 Although its protease activity appears to be
minimal, it might in!uence the activation of plasminogen and thus a#ect
"brinolysis. Lp(a) has been shown to inhibit tissue plasminogen activator.76 Its
concentration in plasma correlates with concentrations of "brinogen and D-dimer.

Clinical applications of apolipoprotein measurements

Apolipoproteins A and B and cardiovascular risk
The plasma concentration of apoB is positively associated, and that of apoAI
inversely associated, with cardiovascular risk.77 The apoB/apoAI ratio has been
interpreted, similarly to the TC/HDL-C ratio, as a re!ection of the balance between
the atherogenic potential of the VLDL, IDL and LDL, and the antiatherogenic e#ect
of HDL. Current debate focuses on whether the measurements of apoB and apoAI
should complement (or substitute) measurements of TC, LDL-C and HDL-C as
markers of cardiovascular risk. There is ample, although not completely uniform,
evidence that apoB concentration is a better marker of cardiovascular risk than TC
or LDL-C.78 A major piece of evidence was provided by the Apolipoprotein-Related
Mortality Risk Study (AMORIS),79,80 which included 175,553 individuals followed up
for approximately 65 months. The relative risk (RR) of fatal myocardial infarction
(MI) associated with 1 standard deviation (SD) increase in apoB concentration was
about 2.7. This increased to 3.6 in individuals younger than 70 years. The apoB/AI
ratio was associated with an even higher RR of almost 4. ApoB/AI ratio, but not TC
or TG, retained predictive power after the age of 70 years. Particularly interesting
was the observation of a high predictive power of the ratio in women older than 70
years, where RR reached values between 8.0 and 9.1.
:
 years, where RR reached values between 8.0 and 9.1.

Another major study, INTERHEART, was based on 12,461 cases and 14,637 controls
from 52 countries. It showed that apoB/A1 ratio was related to the incidence of MI81
with RR 1.59 (95% CI 1.53–1.64) per 1 SD increase. Results were consistent across
age, gender and ethnicity. In this study, TC lost its predictive power in patients aged
70 and older, whereas apoAI, apoB and apoB/A1 remained predictive. The RR was
also consistently higher for the apoB/AI than for TC/HDL-C ratio. The RR for MI
associated with 1 SD change in each of the parameters was 1.16 for TC, 0.85 for
HDL-C, 1.21 for non-HDL-C, 0.67 for apoAI, 1.32 for apoB, 1.17 for TC/HDL-C and
1.59 for apoB/apoAI. Importantly, a high apoB/AI was associated with the highest
risk, even if TC/HDL-C ratio was relatively low.

The results of the Copenhagen City Heart Study also suggest that apoB predicts
ischaemic cardiovascular disease better than LDL-C.82 The study involved 9231
asymptomatic women and men followed prospectively for eight years. For apoB,
the upper versus the lower tertile hazard ratios (HR) for CHD were 1.8 (1.2–2.5), for
MI 2.6 (1.4–4.7) and for any ischaemic cardiovascular event 1.8 (1.3–2.3). ApoB
showed higher predictive ability than LDL-C for CHD, MI or any ischaemic event as
well as any non-fatal ischaemic event.

In the earlier Quebec Cardiovascular Study,83 after "ve years follow-up, the RR of
CHD associated with a 1 SD increase in apoB concentration was 1.4. The RR
associated with apoAI was 0.85 but adjustment for selected lipids and lipoproteins
eliminated this association. In that study, the apolipoproteins were measured using
the now largely abandoned Rocket immunoelectrophoresis method.

In the Third National Health and Nutrition Examination Survey Mortality Study
(NHANES III) involving 7594 American men and women (mean age 45, followed up
on average by 124 person–months), the apoB measurements predicted death (HR
1.98, CI 1.09–3.61).84 ApoAI was negatively associated with risk (HR 0.48 [CI 0.27–
0.85]). TC was associated with mortality to a lesser extent (HR 1.17 [CI 1.02–1.34]).
HDL-C showed a HR of 0.68 (CI 0.45–1.05), which was borderline-signi"cant. ApoB/AI
ratio showed a HR of 2.14 (CI 1.11–4.10) and TC/HDL-C ratio demonstrated a HR
:
 ratio showed a HR of 2.14 (CI 1.11–4.10) and TC/HDL-C ratio demonstrated a HR
1.10 (CI 1.04–1.16). After adjustment for other risk factors, only apoB with HR 2.01
(CI 1.05–3.86) and apoB/AI ratio with HR 2.09 (CI 1.04–4.19) remained signi"cant
predictors of CHD death.

On the other hand, in the MONICA/KORA Augsburg study of men and women
followed up for 13 y, the predictive power of apoB/AI and TC/HDL-C was similar.85

In 2009, the Emerging Risk Factor Collaboration (ERFC), a group of investigators with
access to data from 122 previously conducted prospective studies, performed a
meta-analysis comparing the value of NHDL-C and HDL-C testing with
measurements of apoAI and apoB in the assessment of vascular risk.86 They
analysed population-based studies of persons with no history of cardiovascular
events. However, they excluded AMORIS because of the lack of baseline data on
several risk factors. This meta-analysis combined studies that measured
apolipoproteins using di#erent methodologies (Table 2). The mean age of
participants was 58 years, 40% were women and 60% men, and a median of 6.1
years elapsed to the "rst outcome. Associations with risk were similar for NHDL-C
and apoB, and for HDL-C and apoAI. The HR was 1.50 (1.38–1.62) for the NHDL-
C/HDL-C ratio (taken as a ‘statistical’ equivalent of TC/HDL-C) and 1.49 (1.39–1.60)
for 1 SD increase in apoB/AI. The median NHDL-C and HDL-C values in analysed
studies would correspond roughly to TC concentrations of 6–6.8 mmol/L (taking into
account the lowest and highest reported HDL-C concentrations). The ERFC authors
concluded that there is ‘epidemiological equivalence’ of cholesterol and
apolipoprotein ratios. As far as population-wide assessment of cardiovascular risk is
concerned, they concluded that ‘lipid assessment in vascular disease can be
simpli"ed by measurement of either cholesterol levels or apolipoproteins without
the need to fast and without regard to triglyceride’. They suggested that judgements
regarding apolipoprotein measurements in clinical practice should be made on the
basis of factors such as cost or methodological aspects.

Table 2 Methods of measurement of apolipoprotein A and B used in clinical studies

:
 Table 2 Methods of measurement of apolipoprotein A and B used in clinical studies
analysed by the Emerging Risk Factors Collaboration consortium62

Method Number of studies

Immunoturbidimetry of nephelometry 16

Immunoradiometric assays 4

Immunoelectrophoresis 1

Immunochemical methods 1

Total number of analysed studies 22

Apolipoprotein concentrations were also shown to predict cardiovascular risk in

patients treated with statins. In the Air Force/Texas Coronary Prevention Study
(AFCAPS/TEXCAPS; 6605 participants with average initial TC concentration but low
HDL-C), apolipoproteins, but not LDL-C, were predictive of the "rst acute event.87
Moreover, only apoB/AI and apoB predicted subsequent risk on treatment. The
American Diabetes Association and American College of Cardiology now
recommend apolipoproteins as a best choice to assess statin treatment.88

On the other hand, in the Veterans A#airs High-Density Lipoprotein Intervention

Trial (VAHIT) of "brate treatment, where the LDL-C was relatively low, neither LDL-C
nor apoB predicted CVD risk.89 Interestingly, however, in that study the number of
LDL particles was better associated with cardiovascular risk than the LDL-C.

Apolipoproteins A, B and the metabolic syndrome

The measurements of apoAI and apoB proved useful in assessing CVD risk in
patients with metabolic syndrome – an entity primarily associated with
abnormalities in the fuel transport pathway.90 In the Attica Study of 1514 men and
528 women,91 the apoB/A1 ratio was the best diagnostic marker of the metabolic
syndrome as de"ned by the National Cholesterol Education Program Adult
:
 Treatment Panel III (NCEP ATPIII) criteria. The RR for metabolic syndrome in
individuals with apoB/A1 greater than 0.74 was 3.21 (CI 2.56–4.21). Similar results
were obtained by Onat et al.,92 during prospective evaluation of 1125 men and 1123
women (age 28–74 years), followed up for 5.9 years. ApoB predicted dyslipidaemia,
metabolic syndrome and, in women, hypertension and diabetes. This was
independent of markers of central obesity and in!ammation. Individuals in the top
tertile of apoB concentrations had a RR of developing the metabolic syndrome
about two-fold that of those in the bottom tertile.

Apolipoproteins A and B in the diagnosis of speci"c disorders of

lipoprotein metabolism
Abnormalities in apolipoprotein concentrations de"ne speci"c disorders of lipid
metabolism. Hyperapobetalipo-proteinaemia is a condition characterized by an
increased concentration of apoB and normal TC and variable TG concentrations.93
De Graaf et al.94 have developed a diagnostic algorithm to use apoB measurements
in the diagnosis of dyslipidaemias. Sniderman and Faraj95 also reviewed data
concerning apoA and apoB and cardiovascular risk in relation to metabolic
syndrome, insulin resistance and abdominal obesity.

Clinical utility of apoB and apoAI measurements has been comprehensively

discussed in a Special Report from the Working Group of the Lipoproteins and
Vascular Diseases Division of the American Association for Clinical Chemistry.96 The
Group suggested the use of apoB measurement along with LDL-C to assess the LDL-
related risk. American Diabetic Association and American College of Cardiology
consensus also suggests that apolipoprotein measurements are important in the
metabolic syndrome.97 In a recently published roundtable discussion, there was
agreement that apoB assessments should be used by clinical lipidologists and be
incorporated into guidelines.98

Apolipoprotein B48 as a marker of postprandial metabolism and its

relation to cardiovascular risk
:
 Humans spend a substantial proportion of their time in the postprandial state.
Zilversmit99 in 1979 suggested involvement of postprandial metabolism in
atherogenesis. Later, Patsch100 demonstrated that individuals with CHD present
with more prolonged postprandial lipaemia. Postprandial lipaemia can predict
atherosclerosis.101 Non-fasting TG were also a signi"cant predictor of CVD.102,103
Plasma concentration of apoB48 correlated with postprandial lipaemia.104
Importantly, postprandial elevation of TG, chylomicrons and chylomicron remnants,
and also of apoB48, occurs in obesity, insulin resistance and diabetes mellitus. This
further emphasizes clinical relevance of the fuel transport pathway and its potential
markers.

Apolipoprotein CIII and cardiovascular risk

ApoCIII was found to predict cardiovascular risk. In the Turkish population, total
apoCIII, as well as non-HDL-apoCIII and HDL-apoCIII, predicted the metabolic
syndrome with a RR of 2.5. In that study, the total apoCIII and non-HDL-apoCIII were
also predictive of the incident CHD.105 Evidence linking apoCIII measurement with
cardiovascular risk has recently been reviewed by Chan et al.61

Apolipoprotein E and cardiovascular risk

Bennet et al.68 reviewed studies on apoE and CVD risk conducted between years
1970 and 2007, analysing data from 86,067 healthy participants and using the ϵ3/ϵ3
genotype as a reference point. Individuals with ϵ2/ϵ3 genotype compared with ϵ3/
ϵ4 had cholesterol lower by 6–9%. Individuals with ϵ2/ϵ2, compared with ϵ4/ϵ4, had
approximately 14% lower cholesterol concentration. The di#erences in HDL-C
between genotypes (both between ϵ2/ϵ3 and ϵ3/ϵ4, and between ϵ2/ϵ2 and ϵ4/ϵ4)
were approximately 5%. There was a non-linear association between the ϵ2
genotype and plasma TG, with the highest levels in ϵ2/ϵ2 and lowest in ϵ3/ϵ3. When
the ϵ3/ϵ3 genotype was used as a reference, ϵ2/ϵ2 showed odds ratio (OR) for
coronary risk of 0.83, ϵ2/ϵ3 0.82, ϵ2/ϵ4 0.93, ϵ3/ϵ4 1.05 and ϵ4/ϵ4 1.22.

Apolipoprotein E and obesity

:
 Apolipoprotein E and obesity
The Atherosclerosis Risk in Communities (ARIC) study demonstrated that the body
mass index progressively increased in persons with isoforms E4 to E3 to E2.106 Also,
in obese men, apoE4 isoform was associated with higher plasma insulin and glucose
concentrations.107,108 On the other hand, apoE-de"cient mice had reduced body
weight and impaired adipose tissue TG and lipid clearance.85,109,110 In other strains
of mice, apoE expression worsened glucose tolerance and decreased insulin
sensitivity and facilitated obesity.111 Inactivation of the LRP resulted in a reduction
in body weight parallel to the decreased postprandial lipid clearance.112 ApoE,
because of its role in the metabolism of chylomicron remnants, may be particularly
important in diet-induced weight gain. Little is known about the mechanisms linking
apoE expression and weight gain in humans. It may participate in the di#erentiation
of preadipocytes. Animal studies suggest that the most important candidate
mechanism is the facilitation of delivery of dietary lipids to the adipose tissue, a
process that may be impaired in either the absence of apoE expression or defects in
relevant receptors. Thus apoE, which is recognized to be atheroprotective, might be
a molecule that facilitates obesity (for a review see Kypreos et al.).62

Apolipoprotein E in the brain

ApoE concentration in the brain is secondary only to that in the liver. It is
synthesized by astrocytes and microglia, and to a lesser extent by neurones. Its
cellular uptake in the central nervous system (CNS) is mediated by the LDL receptor
and by LRP. It a#ects growth and repair of CNS cells, is involved in anti-
in!ammatory response and is an antioxidant. Individuals of ϵ4/ϵ4 genotype are at a
greater risk of developing a sporadic form of Alzheimer's disease (AD).113 The ϵ4
isoform is also a risk factor for mortality from intracerebral haemorrhage.114

Lipoprotein (a) and cardiovascular risk

Lp(a) concentration is almost entirely genetically determined. Lifestyle factors have
virtually no in!uence, with the exception of alcohol intake (heavy alcohol intake
lowers Lp(a) concentration). Catena et al.115 reviewed Lp(a) and cardiovascular risk
:
 lowers Lp(a) concentration). Catena et al. reviewed Lp(a) and cardiovascular risk
in the context of hypertension. Interestingly, Lp(a) was the best discriminator of the
presence of hypertensive organ damage.116 This was related to low molecular
weight apo(a) isoforms.115

Meta-analysis by Danesh et al.117 and by the ERFC118 also con"rmed the association
between Lp(a) and CVD risk. There was a continuous, independent, modest
association of Lp(a) with risk of CVD and stroke. On the other hand, studies where
such association was not observed include the Physicians' Health Study, the Helsinki
Heart Study and the Quebec Cardiovascular study. The discrepancies have been
ascribed to collection and sample storage problems as well as to the lack of assay
standardization.

The recent Reykjavik study included 8888 male and 9681 female participants with
no previous history of MI.119 The nested controls were matched by recruitment
year, sex and age. Lp(a) was measured using a monoclonal anti-Lp(a) antibody for
capture and polyclonal anti-apoB antibody for detection, and was not sensitive to
Lp(a) isoforms. An increase in Lp(a) was associated with the risk of CHD (OR 1.6–1.7;
comparison between the bottom and top tertiles of distribution): this was a lower
odds ratio than that observed for TC but higher than that for high-sensitivity C-
reactive protein or TG concentrations. Importantly, the RR increased with increasing
Lp(a) concentrations. The authors also performed a valuable meta-analysis of 31
previous studies, with 14 of them performed after completion of the earlier meta-
analysis by Danesh et al. The reported mean concentrations of Lp(a) varied from 1
to 30 mg/dL. There was a consistent association of Lp(a) with CHD risk (OR between
1.25 and 2.5 between bottom and top third of Lp(a) concentrations). In "ve studies it
was between 1 and 1.25, and in three studies there was no association.

Another systematic review of 40 studies involving 58,000 participants concluded

that people with smaller apo(a) isoforms have an approximately two-fold higher risk
of CHD or ischaemic stroke than those with larger ones.120 Further studies are
needed to determine whether the impact of smaller apo(a) isoforms is independent
from Lp(a) concentration and other risk factors.
:
 During the European Atherosclerosis Society (EAS) Congress in 2010, the EAS
Consensus Panel reported key points of the forthcoming scienti"c consensus
statement on Lp(a). They recommend that patients with moderate or high CVD risk
should be screened for Lp(a) and that there should be a treatment goal of Lp(a)
concentration below 50 mg/dL.121 This approach has been recently criticized.122

In view of the consistency of data linking Lp(a) with CVD risk, and the long-term
stability of Lp(a) concentrations, we recommend that Lp(a) measurement should be
part of the initial assessment of the CVD risk in clinical practice.

Table 3 summarizes changes in the concentrations of plasma apolipoproteins seen

in di#erent types of dyslipidaemia.

Table 3 Apolipoproteins in hypercholesterolaemia, hypertriglyceridaemia and in mixed

dyslipidaemia

Atherogenic
Mixed
Apo Hypercholesterolaemia lipoprotein Hypertriglyc
dyslipidaemia
phenotype

AI Variable Variable Low Often low

CIII        

CII       Rare apoCII d

causes severe
hypertriglyce

CI        

B100 High in FH, FDB, polygenic High in FCHL High – Usually norm
hypercholesterolaemia. marker of
Note: in small dense
hyperapobetalipoproteinaemia, LDL
apoB100 is high
in the presence of normal TC
:
 in the presence of normal TC

B48       High in LPL d

E Genotype/isoforms related to Genotyping    

plasma cholesterol useful in
concentration diagnosis of
familial
dyslipidaemia

Lp(a) Variable Variable Variable Variable

FH, familial hypercholesterolaemia; FDB, familial defective apoB; TC, total cholesterol;
FCHL, familial combined hyperlipidaemia; CVD, cardiovascular disease

Please see text for references

Methodology of apolipoprotein measurements

ApoAI and apoB measurements are carried out by immunological techniques using
antibodies raised against speci"c epitopes. In early years, techniques included radial
immunodi#usion, radioimmunoassay and electroimmunoassay. With the
emergence of automation and advances in the production of monospeci"c and
monoclonal antibodies, techniques used today include enzyme-linked
immunosorbent assays (ELISA), immunonephelometry and imunoturbidimetry.
About 20 years ago, the International Federation of Chemistry and Laboratory
Medicine (IFCC) initiated a programme to develop suitable reference material for
apoAI and B. This resulted in World Health Organization (WHO) International
Reference Materials for apoAI and apoB.123,124 Today all instruments and assay kits
should have calibrators that can be traced to the WHO-IFCC Reference Material. The
between-assay precision on human samples in the IFCC standardization project was
123
:
 4.0–6.7% for apoAI and 4.8–8.7% for apoB.123

Individual commercial reagent kits may show interference with lipaemia and
hyperbilirubinaemia: these interferences are noted in the technical data sheets. It is
general practice for upper limits to be quoted, e.g. it is common to see interference
at TG > 800 mg/dL (approx 9 mmol/L). Although the precision of currently available
apolipoprotein measurements is usually below 5%, values still vary between
laboratories, and external quality assurance systems show coe%cient of variation of
up to 10%. This is due to bias in di#erent methodologies such as nephelometry or
immunoturbidimetry, and the use of di#erent clinical chemistry analysers. With
advances in standardization, precision and automation, it is viable for all clinical
biochemistry laboratories to measure apoAI and apoB routinely. We, however,
recommend that each laboratory establishes individual reference ranges speci"c for
the instrument, assay kits and population served by the laboratory. This may be
di%cult to do in practice for individual laboratories, but is possible with the help of
specialist lipid laboratories. In the UK, there is a network of six laboratories in the
Supra-Regional Assay Service for Cardiovascular Biomarkers (http.//www.sas-
centre.org). They o#er advice on the analysis and clinical interpretation of a wide
range of specialist diagnostic tests for lipids and lipoproteins.

Similarly to apoAI and apoB, apoAII, apoCII, apoCIII and apoE (see below) were
historically measured by radial immunodi#usion, radioimmunoassay and
electroimmunoassay.125 Today, measurements of these apolipoproteins are mostly
used for research purposes. Many research laboratories use sodium dodecyl
sulphate-polyacrylamide gel electrophoresis (SDS-PAGE). However, for quantitation,
ELISA, immunonephelometry and imunoturbidimetry are the methods of choice.
Turbidimetric assay of apoCIII is a#ected by storage (freezing). There are currently
no reference methods or standards available; therefore, it is di%cult to compare
values between di#erent populations and studies. Again, it is important that every
laboratory establishes its own reference ranges, as those quoted in the technical
data sheet may refer to a di#erent population.
:
 Methods of assessment of postprandial metabolism
The di%culty in the assessment of postprandial metabolism has been a relatively
complex methodology. Measurement of chylomicrons has been notoriously di%cult
because of their short lifespan and necessity to di#erentiate them from the VLDL
particles. Di#erentiating between chylomicron remnants and VLDL remnants is also
di%cult. Two methodologies can be considered here: measurements of apoB48 and
of the remnant-like particles (RLP).

Conventional methods of chylomicron assessment involve ultracentrifugation: they

are separated as particles with density below 1.006 kg/L. This can be combined with
separation of apoB48 by PAGE. Chylomicrons can also be measured (without
ultracentrifugation) in whole plasma by SDS-PAGE, followed by measurement of
apoB48 using immunoblotting with anti-apoB48 antiserum and ELISA assays.126
There are, however, problems with sample stability and preparation, and the
method is technically di%cult and time-consuming.127 In the last few years, highly
sensitive ELISA assays became commercially available for accurate measures of
apoB48.128 However, these assays have not been standardized.

Methods of measurement of the remnant particles

Remnant lipoproteins include chylomicron and VLDL remnants.129 It is generally
accepted that remnant lipoproteins are an apoE-rich fraction within TG-rich
lipoproteins. Their short half-life has hampered the development of detection
methods.

Currently, two commercially available assays are available. Both isolate lipoprotein
fractions that are cholesteryl ester- and apoE-rich, and are sensitive to freeze-
thawing and long-term storage. The assay for RLP-cholesterol (RLP-C) has been in
use in the USA since 1993. In this assay, two monospeci"c monoclonal antibodies to
apoB100 and apoAI are coupled to Sepharose 4B. These antibodies do not
recognize apoE. After the non-remnant fraction is bound by the immunoa%nity gel,
the fractions are separated either by low speed ultracentrifugation or by shaking,
and RLP-C (or TG) can be measured in the unbound fraction.130–132 Cholesterol can
:
 and RLP-C (or TG) can be measured in the unbound fraction.130–132 Cholesterol can
be measured by conventional means in a clinical chemistry analyser. Using this
assay, RLP-C has been reported to be an independent risk factor in the Framingham
Study.133 RLP were also elevated in obesity,134 insulin resistance,135 and in patients
with diabetes and CVD.136

However, it has not been adopted widely into routine clinical biochemistry
laboratories due to the manipulations required for the a%nity gel pretreatment.

A homogeneous assay for remnant lipoprotein cholesterol (RemL-C) has been

developed. The method uses a detergent (polyoxyethylene-polyoxybutylene block
co-polymer, POE- POB) which speci"cally modi"es VLDL remnants and IDL, and
phospholipase D which modi"es chylomicron remnants. This treatment makes
cholesterol contained in these lipoproteins (but not in other lipoprotein particles)
available to cholesterol esterase and cholesterol oxidase.

The assay allowed the measurements of cholesterol in chylomicron remnants, VLDL

remnants and IDL with no sample pretreatment.137 Within the last few years, an
automated RemL-C assay has become available, which may be used in routine
clinical chemical analysers.138

The two assays have been compared and show signi"cant correlations, although
RemL-C values tend to be higher than RLP-C. The RemL-C assay was found to be
more closely associated with VLDL2 and IDL than the immunoseparation RLP
assay.138,139 It has been suggested that the discrepancies arise because RLP values
poorly re!ect the smaller size remnants (IDL). Signi"cantly higher correlations have
been observed between plasma TG and RLP postprandially, when compared with
the fasting state.140 This has not been shown yet for RemL-C. Schae#er141 recently
commented on limitations of the RemL-C assay. He reported that RemL-C was not a
predictor of CHD risk in the Framingham O#spring Study cohort, either
prospectively or on a case-control basis. Furthermore, there was a strong
correlation with TG (r = 0.93, P < 0.001). The correlation between RLP-C and TG was
lower (r = 0.79, P < 0.001) and RLP-C was found to be an independent risk factor.133
On the other hand, the Rem-L assay may be useful in identifying patients with
:
 On the other hand, the Rem-L assay may be useful in identifying patients with
increased IDL concentrations. More studies need to be carried out to establish the
association of RemL-C with CHD risk.

The methods for assessment of postprandial metabolism were reviewed by Su et

al.46 They also include the measurements of retinyl esters, kinetic studies using
chylomicron-like emulsions and 13C breath tests. The authors suggested that
postprandial lipaemia might be best assessed using a combination of either serial
TG measurements in response to a standard fat load or day-long capillary TG
measurements, with apoB48 quantitation by the ELISA method.

Apolipoprotein E isoforms: phenotyping and genotyping

Phenotyping
Initially, detection of apoE polymorphisms was performed by measuring relevant
proteins.142 The three isoforms were separated by isoelectric focusing, followed by
transfer to nitrocellulose by Western blotting. The individual apoE bands were
visualized using monoclonal or polyclonal antibodies to apoE,143 or direct
immuno"xation.144

The separation patterns are attributable to the variations in charge. Usually

migration toward the anode is faster for the E2 isoform (Cys112/Cys158) than the E3
(Cys112/Arg158) and E4 isoforms (Arg112/Arg158) because arginine has a positive
charge and cysteine is uncharged. However, factors such as post-translational
modi"cations can a#ect the results of apoE phenotyping. A typical Western blot
showing common ApoE isoforms is shown in Figure 5.
:
 Figure 5 Typical Western blot showing common apoE isoforms. The order of migration
towards the anode is E2 > E3 > E4

Genotyping
Today, as most laboratories have access to molecular techniques and automated
equipment, apoE isoforms are detected by genotyping. DNA is subjected to
polymerase chain reaction using apoE primers. After digestion by nucleases (HhaI
endonuclease),145 fragments are separated on polyacrylamide gels. Genotyping can
be performed on whole blood. Capillary gel electrophoresis can also be used.146

There are ethical issues associated with detection of the ϵ4/ϵ4 genotype due to its
association with AD. Arguably, the result of genotyping by a lipid laboratory should
be reported as ‘consistent (or not consistent) with familial dyslipidaemia’.2,147

Phenotype–genotype non-concordance has been repeatedly reported. This could be

a result of post-translational modi"cation of the protein, such as glycation in
subjects with diabetes, or could be due to mutations in the apoE gene resulting in
protein variants, which a#ect the charge of amino acids, and thus migration on the
isofocusing gel. However, not all mutations would lead to functional di#erences in
apoE. It is important to remember that the reaction of apoE with the LDL receptor
family is dependent on a positive charge at apoE residues 130–150, and that
interaction with arterial wall proteoglycans depends on the alpha-helical character
of the carboxy-terminal of apoE, which contains the heparin-binding domain. We
suggest that apoE phenotyping still has a role to play in the identi"cation of
:
 suggest that apoE phenotyping still has a role to play in the identi"cation of
individuals at risk for dyslipidaemia when mutations in the apoE gene are
identi"ed.148

Measurement of apolipoprotein E in plasma

To date, research into apoE has concentrated on the investigation of isoforms
rather than plasma concentration of apoE. Variation in the plasma concentration of
apoE is to a large extent genetically determined.70 ApoE2 individuals have higher
plasma levels due to slower clearance of lipoprotein particles, and apoE
concentrations in E4 individuals are lower as a result of more e%cient clearance.
However, within each genotype there is individual variation in apoE concentration.
Plasma apoE concentrations are also a#ected by diet. Plasma apoE can be
measured by sandwich ELISA assay,149 and by more labour-intensive
electroimmunoassay.150

Schiele et al.150 developed extensive reference ranges for plasma apoE, studying the
French Stanislas Cohort. In this study, apoE was measured by electroimmunoassay.
Total plasma apoE concentration, as well as its concentrations in non-apoB and
apoB-containing fractions, were a#ected by age, gender, the common apoE
polymorphisms, puberty, serum lipid concentrations and alcohol consumption. It
was suggested that the concentration of apoE in apoB-containing lipoproteins
(remnants) is more informative than the total plasma apoE.

Interesting data on plasma concentration of apoE came from research on AD. Van
Vliet et al.151 assessed the risk of late-onset AD in a study of middle aged children of
persons with AD (mean age 49.8 and 51.6 years in the AD group and control group,
respectively). They found, not surprisingly, that individuals with parental history of
AD were more likely to be ε4 allele carriers. Interestingly, mean plasma apoE
concentration decreased from ϵ2 to ϵ3ϵ3 to ϵ4 carriers. Individuals with parental
history of AD had lower plasma apoE concentrations than individuals without such
history.

There is no clear evidence at present to suggest that apoE concentration should be

:
 There is no clear evidence at present to suggest that apoE concentration should be
measured routinely, although it may have a place in the elderly. Whereas the
association between the apoE genotype and CVD is well documented, the risk
associated with circulating apoE concentration is not known. In a study of 85-year-
old individuals, it was observed that those with high levels of apoE were at an
increased risk of cardiovascular death, independent of their apoE genotype.149

The reason for limited use of plasma measurements might be the distribution of
apoE across lipoprotein subfractions, including HDL. Consequently, it is relatively
di%cult to explain changes in its total plasma concentration, although the
decreased clearance of TG-rich lipoproteins remains a dominant cause of increased
concentration.

Measurement of lipoprotein (a)

The size variation of the number of apo(a) kringles challenges the measurement of
Lp(a) by immunochemical methods. Problems arise in the choice of apo(a) size as
the assay calibrator and the reactivity of antibodies directed to di#erent kringle
sizes. As a result, assays either underestimate or overestimate the quantity of
circulating Lp(a).

The IFCC led the development of an international reference material intended for
the transfer of an Lp(a) concentration to manufacturers' master calibrators (IFCC
Standard Reference Material, SRM2B). The assigned value is traceable to the
consensus reference method for Lp(a). The proposed reference material was tested
in the year 2000. When used as a calibrator, no uniformity of results was achieved
for isoform-sensitive methods.152 Currently, the only commercially available assay
that is not a#ected by kringle IV type-2 repeats is the one used to measure Lp(a) in
the Women's Health Study.74,153 The authors recommend that this be the assay of
choice.

Concentration of apolipoproteins in di#erent

lipoprotein subfractions
:
 lipoprotein subfractions
Apolipoprotein concentration in speci"c lipoprotein fractions might be a good
marker of CVD risk, although such measurements are not suitable for routine use.
Combining lipoprotein separation and apolipoprotein measurements yielded
particularly interesting results in the Cholesterol and Recurrent Events (CARE)
trial.154 CARE was a study of pravastatin treatment in 4159 patients with a history of
acute MI and a "ve-year follow-up. VLDL-apoB, VLDL-C and VLDL-TG were identi"ed
as predictors of recurrent coronary events. VLDL-apoB (but not VLDL-C) was a
strong predictor (with RR 3.2 between the lowest and highest quintile). The RR for
LDL-C was 1.7 and HDL-C and plasma TG were not signi"cant predictors. ApoCII in
VLDL-plus-LDL was a strong predictor with RR 2.25, as was the apoE in HDL, with
univariate RR 2.05. Risk associated with TG was explained by VLDL-apoB and the
sum of apoCIII concentrations in VLDL and LDL. In other studies, the sum of apoCIII
in VLDL and LDL was also increased in survivors of MI.155

ApoE in the plasma or its concentration in VLDL-plus-LDL was associated with

atherosclerosis – maybe only as a marker of apoCIII. HDL-apoE identi"ed patients
who underwent coronary artery bypass grafting.156

The measurements of apolipoproteins in lipid subfractions emphasize one

important point: the relative crudeness of routinely used tests such as TC and in
particular TG in relation to CVD risk. Measurement of apolipoproteins in lipid
subfractions appears to be a more speci"c marker of risk. However, there is a major
methodological barrier – the extra step of lipoprotein separation. It is therefore
unlikely that such methods will be used outside research laboratories.

The future
In the era of the ‘omics’, rapid advances are being made in the detection and
quantitation of biomarkers. Mass spectrometry has the potential to detect multiple
proteins in a small volume of sample at a high throughput rate. Such an application
for apolipoproteins has been reported using ultra-performance liquid
chromatography/tandem mass spectrometry.157 This showed results for apoAI that
:
 chromatography/tandem mass spectrometry.157 This showed results for apoAI that
were comparable with those obtained in a clinical analyser and were generated in a
fraction of the time. There are hurdles to overcome such as standardization, but
this technique has the potential to revolutionize the future analysis of
apolipoproteins. Superko158 and Mora159 have recently discussed, in an interesting
format, the potential applications of a wide range of biomarkers of lipid
metabolism.

Conclusions: apolipoprotein measurements in the

clinical biochemistry laboratories
The most important use of apolipoprotein measurements in clinical biochemistry is
as markers of cardiovascular risk. The inclusion of apoB and apoAI measurements
in the assessment of risk along with LDL-C has been recommended by a number of
professional bodies. We therefore suggest that specialist laboratories introduce
apoAI and apoB measurements, and lead the introduction of these assays to a
wider routine service. Delaying this may create a knowledge gap between day-to-
day clinical practice and international consensus.

Measurement of Lp(a) is also an important adjunct to risk assessment. Because of

the stability of its concentration over time, its measurement can be limited to the
initial assessment of risk.

Genotyping of apolipoprotein E is important in the diagnosis of familial

dyslipidaemia.

There is increasing recognition that postprandial metabolism is important in

atherogenesis, particularly in the context of obesity, insulin resistance and diabetes.

This is probably the most important emerging area in the "eld of lipoprotein
metabolism, and it increases the need for better markers of the fuel transport
pathway. Currently, the measurements of apoB48 and measurements of remnant
particle cholesterol have been the most promising markers.
:
 Finally, the assessment of cardiovascular risk is by de"nition multifactorial.
Assessments of both lipid and non-lipid CVD risk factors carry a degree of
uncertainty. This is due to methodological issues, to di%culties in precise de"nition
of a given risk factor's severity (e.g. family history) or to the application of binary
assessments to continuous variables (diabetes, blood pressure, smoking, de"nition
of metabolic syndrome). Therefore, the compilation of a multifactorial risk pro"le
remains essential.

DECLARATIONS
Competing interests: MHD delivered lectures supported by MSD, Solvay and
Abbott. MJC has received research support from Denka Seiken, Diadexus and
Japanese ImmunoResearch Laboratories. She also received research funding from
AstraZeneca, Sano"-Aventis, GlaxoSmithKline and consultancies with Sano"-Aventis
and Merck.

Funding: None.

Ethical approval: Not applicable.

Guarantor: MHD.

Contributorship: MHD wrote the majority of the review with signi"cant subsequent
editing and analytical input from MJC.

Acknowledgements: The authors are very grateful to Miss Jacky Gardiner for
excellent secretarial assistance.

REFERENCES
1. Baynes J, Dominiczak MH, eds. Medical Biochemistry. 3rd edn. London: Elsevier
Mosby, 2009:653
Google Scholar
:
 2. Durrington P. Dyslipidemia. Lancet 2003;362:717–31

Crossref

PubMed

ISI

Google Scholar

3. Rifai N, Warnick GR, Dominiczak MH, eds. Handbook of Lipoprotein Testing. 2nd
edn. Washington DC: AACC Press, 2000:817

Google Scholar

4. Dominiczak MH. Obesity, glucose intolerance and diabetes and their links to
cardiovascular disease. Implications for laboratory medicine. Clin Chem Lab Med
2003;41:1266–78
Crossref

PubMed

ISI

Google Scholar

5. Dominiczak MH. Lipids: the story so far. Br J Cardiol 1997;4:425–9

Google Scholar

6. Dominiczak MH. Risk factors for coronary disease: the time for a paradigm shift?
Clin Chem Lab Med 2001;39:907–19
Crossref
:
 PubMed

ISI

Google Scholar

7. Olivecrona T, Bengtsson-Olivecrona G. Lipoprotein lipase and hepatic lipase. Curr

Opin Lipidol 1990;1:222–30
Crossref

Google Scholar

8. Zambon A, Hokanson JE, Brown BG, Brunzell JD. Evidence for a new
pathophysiological mechanism for coronary artery disease regression: hepatic
lipase-mediated changes in LDL density. Circulation 1999;99:1959–64

Crossref

PubMed

ISI

Google Scholar

9. Rousset X, Vaisman B, Amar M, et al. Lecithin: cholesterol acyltransferase – from

biochemistry to role in cardiovascular disease. Curr Opin Endocrinol Diabetes Obes
2009;16:163–71

Crossref

PubMed

ISI
:
 Google Scholar

10. Applebaum-Bowden D. Lipases and lecithin:cholesterol acyltransferase in the

control of lipoprotein metabolism. Curr Opin Lipidol 1995;6:130–5

Crossref

PubMed

ISI

Google Scholar

11. Hesler CB, Swenson TL, Tall AR. Puri"cation and characterization of a human
plasma cholesterol ester transfer protein. J Biol Chem 1987;262:2275–82

Crossref

PubMed

ISI

Google Scholar

12. Brown MS, Goldstein JL. A receptor-mediated pathway for cholesterol

homeostasis. Science 1986;232:34–47

Crossref

PubMed

ISI

Google Scholar
:
 Google Scholar

13. Herz J. The LDL-receptor related protein: portrait of a multifunctional receptor.

Curr Opin Lipidol 1993;4:107–13

Crossref

Google Scholar

14. Rigotti A, Miettinen HE, Krieger M. The role of the high-density lipoprotein
receptor SR-BI in the lipid metabolism of endocrine and other tissues. Endocr Rev
2003;24:357–87

Crossref

PubMed

ISI

Google Scholar

15. Tabas I, Williams KJ, Boren J. Subendothelial lipoprotein retention as the

initiating process in atherosclerosis: update and therapeutic implications. Circulation
2007;116:1832–44

Crossref

PubMed

ISI

Google Scholar

16. Ross R. The pathogenesis of atherosclerosis: a perspective for the 1990s. Nature
1993;362:801–9
:
 1993;362:801–9

Crossref

PubMed

ISI

Google Scholar

17. Rader DJ, Daugherty A. Translating molecular discoveries into new therapies for
atherosclerosis. Nature 2008;451:904–13

Crossref

PubMed

ISI

Google Scholar

18. Dominiczak MH. Apoproteins and lipoproteins in human plasma. In: Rifai N,
Warnick GR, Dominiczak MH, eds. Handbook of Lipoprotein Testing. 1st edn.
Washington: AACC Press, 1997:1–24
Google Scholar

19. Powell LM, Wallis SC, Pease RJ, Edwards YH, Knott TJ, Scott J. A novel form of
tissue speci"c RNA processing produces apolipoprotein B48 in intestine. Cell
1987;50:831–40

Crossref

PubMed

ISI
:
 Google Scholar

20. Eisenberg S, Sehayek E. Remnant particles and their metabolism. Baillieres Clin
Endocrinol Metab 1995;9:739–53
Crossref

PubMed

ISI

Google Scholar

21. Cohn JS, Marcoux C, Davignon J. Detection, quanti"cation, and characterization

of potentially atherogenic triglyceride-rich remnant lipoproteins. Arterioscler Thromb
Vasc Biol 1999;19:2474–86

Crossref

PubMed

ISI

Google Scholar

22. Mann CJ, Yen FT, Grant AM, Bihain BE. Mechanism of plasma cholesteryl ester
transfer in hypertriglyceridaemia. J Clin Invest 1991;88:2059–66

Crossref

PubMed

ISI
:
 Google Scholar

23. Fruchart JC, Ailhaud G. Apolipoprotein A-containing particles: physiological role,

quanti"cation and clinical signi"cance. Clin Chem 1992;38:793–7

Crossref

PubMed

ISI

Google Scholar

24. Lee DM, Alaupovic P, Knight-Gibson C, Bagdade JD. Apolipoprotein-B subclasses

as acceptors of cholesteryl esters transferred by CETP. Eur J Clin Invest 2008;38:734–
42

Crossref

PubMed

ISI

Google Scholar

25. Havel RJ. The formation of LDL: mechanisms and regulation. J Lipid Res
1984;25:1570–6

Crossref

PubMed

ISI
:
 Google Scholar

26. Bruckert E, Hansel B. HDL-C is a powerful lipid predictor of cardiovascular

diseases. Int J Clin Pract 2007;61:1905–13

Crossref

PubMed

ISI

Google Scholar

27. von Eckardstein A, Huang Y, Assman G. Physiological role and clinical relevance
of high-density lipoprotein subclasses. Curr Opin Lipidol 1994;5:404–16

Crossref

PubMed

Google Scholar

28. Florentin M, Liberopoulos EN, Wierzbicki AS, Mikhailidis DP. Multiple actions of
high-density lipoprotein. Curr Opin Cardiol 2008;23:370–8

Crossref

PubMed

ISI

Google Scholar
:
 29. Austin MA, King MD, Vranizan KM, Krauss RM. Atherogenic lipoprotein
phenotype. A proposed genetic marker for coronary heart disease risk. Circulation
1990;82:495–506

Crossref

PubMed

ISI

Google Scholar

30. Austin MA, Edwards KL. Small, dense low density lipoproteins, the insulin
resistance syndrome and noninsulin-dependent diabetes. Curr Opin Lipidol
1996;7:167–71

Crossref

PubMed

ISI

Google Scholar

31. Dominiczak MH. Apoproteins and lipoproteins in human plasma. In: Rifai N,
Warnick GR, Dominiczak MH, eds. Handbook of Lipoprotein Testing. 2nd edn.
Washington DC: AACC Press, 2000:1–29

Google Scholar

32. Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concentration of low-
density lipoprotein cholesterol in plasma, without use of the preparative
ultracentrifuge. Clin Chem 1972;18:499–502
Crossref
:
 PubMed

ISI

Google Scholar

33. Liu J, Sempos CT, Donahue RP, et al. Non-high-density lipoprotein and very-low-
density lipoprotein cholesterol and their risk predictive values in coronary heart
disease. Am J Cardiol 2006;98:1363–8

Crossref

PubMed

ISI

Google Scholar

34. Shai I, Rimm EB, Harkinson SE, et al. Multivariate assessment of lipid parameters
as predictors of coronary heart disease among postmenopausal women: potential
implications for clinical guidelines. Circulation 2004;110:2824–30

Crossref

PubMed

ISI

Google Scholar

35. Jiang R, Schulze MB, Li T, et al. Non-HDL cholesterol and apolipoprotein B predict
cardiovascular disease events among men with type 2 diabetes. Diabetes Care
2004;27:1991–7
:
 2004;27:1991–7

Crossref

PubMed

ISI

Google Scholar

36. Blake GJ, Otvos JD, Rifai N, Ridker PM. Low-density lipoprotein particle
concentration and size are determined by nuclear magnetic resonance
spectroscopy as predictors of cardiovascular disease in women. Circulation
2002;106:1930–7

Crossref

PubMed

ISI

Google Scholar

37. Hainline AJ, Karon J, Kippel K. Manual of Laboratory Operations: Lipid Research
Clinics Program, Lipid and Lipoprotein Analysis. 2nd edn. Washington, DC: Department
of Health and Human Services, 1983
Google Scholar

38. Marcovina S, Packard CJ. Measurement and meaning of apolipoprotein B plasma

levels. J Intern Med 2006;259:437–46

Crossref

PubMed

ISI
:
 ISI

Google Scholar

39. Durrington PN. Hyperlipidaemia: Diagnosis and Treatment. 3rd edn. London:
Hodder Arnold, 2007:66–91

Crossref

Google Scholar

40. Olofsson SO, Borèn J. Apolipoprotein B: a clinically important apolipoprotein,

which assembles atherogenic lipoproteins and promotes the development of
atherosclerosis. J Intern Med 2005;258:395–410

Crossref

PubMed

ISI

Google Scholar

41. Knott TJ, Pease RJ, Powell LM, et al. Complete protein sequence and
identi"cation of structural domains of human apolipoprotein B. Nature
1986;323:734–8
Crossref

PubMed

ISI

Google Scholar
:
 42. Hussain MM, Shi J, Dreizen P. Microsomal triglyceride transfer protein and its
role in apoB-lipoprotein assembly. J Lipid Res 2003;44:22–32

Crossref

PubMed

ISI

Google Scholar

43. Blackhart BD, Ludwig EM, Pierotti VR, et al. Structure of the human
apolipoprotein B gene. J Biol Chem 1986;261:15364–7
Crossref

PubMed

ISI

Google Scholar

44. Innerarity TL, Mahley TL, Weisgraber KH, et al. Familial defective apolipoprotein
B-100: a mutation of apolipoprotein B that causes hypercholesterolemia. J Lipid Res
1990;31:1337–49

Crossref

PubMed

ISI

Google Scholar
:
 45. Hardman DA, Kane JP. Isolation and characterization of apolipoprotein B-48.
Methods Enzymol 1986;128:262–72
Crossref

PubMed

ISI

Google Scholar

46. Su JW, Nzekwu MMU, Cabezas MC, Redgrave T, Proctor SD. Methods to assess
impaired post-prandial metabolism and the impact for early detection of
cardiovascular disease risk. Eur J Clin Invest 2009;39:741–54

Crossref

PubMed

ISI

Google Scholar

47. Berry SEE. Postprandial lipaemia – the in!uence of diet and its link to coronary
heart disease. Nutr Bull 2005;30:314–22

Crossref

Google Scholar

48. Bruns GA, Karathanasis SK, Breslow JL. Human apolipoprotein A-I–C-III gene
complex is located on chromosome 11. Arteriosclerosis 1984;4:97–102
Crossref
:
 PubMed

Google Scholar

49. Feng H, Li X-A. Dysfunctional high-density lipoprotein. Curr Opin Endocrinol

Diabetes Obes 2009;16:156–62

Crossref

PubMed

ISI

Google Scholar

50. Kilimov AN, Gurevich VS, Nikiforova AA, et al. Antioxidative activity of high
density lipoproteins in vivo. Atherosclerosis 1993;100:13–8

Crossref

PubMed

ISI

Google Scholar

51. Cheung M, Albers JJ. Distribution of high density lipoprotein particles with
di#erent apoprotein composition: particles with AI and AII and particles with AI but
no AII. J Lipid Res 1982;23:747–53
Crossref

PubMed

ISI
:
 ISI

Google Scholar

52. Julve J, Escolà-Gil JC, Rotllan N, et al. A human apolipoprotein AII determines
plasma triglycerides by regulating lipoprotein lipase activity and high-density
lipoprotein proteome. Arterioscler Thromb Vasc Biol 2010;30:232–8
Crossref

PubMed

ISI

Google Scholar

53. Warden CH, Hedrick CC, Quiao J-H, Castellani LW, Lusis AJ. Atherosclerosis in
transgenic mice overexpressing apolipoprotein A-II. Science 1993;261:469–72
Crossref

PubMed

ISI

Google Scholar

54. Birjmohun RS, Dallinga-Thie GM, Kuivenhoven JA, et al. Apolipoprotein A-II is
inversely associated with risk of future coronary disease. Circulation 2007;116:2029–
35
Crossref

PubMed
:
 ISI

Google Scholar

55. Tailleux A, Duriez P, Fruchart JC, Clavey V. Apolipoprotein A-II, HDL metabolism
and atherosclerosis. Atherosclerosis 2002;164:1–13

Crossref

PubMed

ISI

Google Scholar

56. Weinberg RB. Apolipoprotein A-IV polymorphisms and diet–gene interactions.

Curr Opin Lipidol 2002;13:125–34

Crossref

PubMed

ISI

Google Scholar

57. Calandra S, Oliva CP, Tarugi P, Bertolini S. APOA5 and triglyceride metabolism,
lesson from human APOA5 de"ciency. Curr Opin Lipidol 2006;17:122–7

Crossref

PubMed

ISI
:
 ISI

Google Scholar

58. Laurila PP, Naukkarinen J, Kristiansson K, et al. Genetic association and

interaction analysis of USF1 and APOA5 on lipid levels and atherosclerosis.
Arterioscler Thromb Vasc Biol 2010;30:346–52

Crossref

PubMed

ISI

Google Scholar

59. Triglyceride Coronary Disease Genetics Consortium and Emerging Risk Factors
Collaboration. Triglyceride-mediated pathways and coronary disease: collaborative
analysis of 101 studies. Lancet 2010;375:1634–9

Crossref

PubMed

ISI

Google Scholar

60. Lai C-Q, Parnell LD, Ordovas JM. The APOAI/C3/A4/A5 gene cluster, lipid
metabolism and cardiovascular disease risk. Curr Opin Lipidol 2005;16:153–66

Crossref

PubMed
:
 ISI

Google Scholar

61. Chan DC, Chen MM, Ooi EMM, Watts GF. An ABC of apolipoprotein C-III: a
clinically useful new cardiovascular risk factor? Int J Clin Pract 2008;62:799–809

Crossref

PubMed

ISI

Google Scholar

62. Kypreos KE, Karagiannides I, Fotiadou EH, et al. Mechanisms of obesity and
related pathologies: role of apolipoprotein E in the development of obesity. FEBS J
2009;276:5720–8
Crossref

PubMed

ISI

Google Scholar

63. Mahley RW, Innerarity TL, Rall JSC, Weisgraber KH, Taylor JM. Apolipoprotein E:
genetic variants provide insights into its structure and function. Curr Opin Lipidol
1990;1:87–95

Crossref

Google Scholar
:
 64. Donahue JE, Johanson CE. Apolipoprotein E, amyloid-A, and blood–brain barrier
permeability in Alzheimer disease. J Neuropathol Exp Neurol 2008;67:261–70

Crossref

PubMed

ISI

Google Scholar

65. Boyles JK, Pitas RE, Wilson E, Mahley RW, Taylor JM. Apolipoprotein E associated
with astrocytic glia of the central nervous system and with nonmyelinating glia of
the peripheral nervous system. J Clin Invest 1985;76:1501–13

Crossref

PubMed

ISI

Google Scholar

66. Chroni A, Nieland TJ, Kypreos KE, Krieger M, Zannis VI. SR-BI mediates
cholesterol e&ux via its interactions with lipid-bound ApoE. Structural mutations in
SR-BI diminish cholesterol e&ux. Biochemistry 2005;44:13132–43

Crossref

PubMed

ISI

Google Scholar
:
 Google Scholar

67. Utermann G. Apolipoprotein E polymorphisms in health and disease. Am Heart J

1987;113:433–40

Crossref

PubMed

ISI

Google Scholar

68. Bennet AM, Di Angelantonio E, Ye Z, et al. Association of apolipoprotein E

genotypes with lipid levels and coronary risk. JAMA 2007;298:1300–11

Crossref

PubMed

ISI

Google Scholar

69. Brewer HB, Zech LA, Gregg RE, Schwartz D, Schae#er EJ. Type III
hyperlipoproteinemia: diagnosis, molecular defects, pathology and treatment. Ann
Int Med 1983;98:623–40
Crossref

PubMed

ISI

Google Scholar
:
 70. Huang Y. Mechanisms linking apolipoprotein E isoforms with cardiovascular and
neurological diseases. Curr Opin Lipidol 2010;21:337–45

Crossref

PubMed

ISI

Google Scholar

71. Loscalzo J. Lipoprotein(a): a unique risk factor for atherothrombotic disease.

Arteriosclerosis 1990;10:672–9
Crossref

PubMed

Google Scholar

72. Utermann G, Menzel HJ, Kraft HG, Duba HC, Kemmler HG, Seitz C. Lp(a)
glycoprotein phenotypes. J Clin Invest 1987;80:458–65
Crossref

PubMed

ISI

Google Scholar

73. Rath M, Niendorf A, Reblin T, Dietel M, Krebber H-J, Beisiegel U. Detection and
quanti"cation of lipoprotein (a) in the arterial wall of 107 coronary bypass patients.
:
 quanti"cation of lipoprotein (a) in the arterial wall of 107 coronary bypass patients.
Arteriosclerosis 1989;9:579–92

Crossref

PubMed

Google Scholar

74. McLean JW, Tomlinson JE, Kuang W-J, et al. cDNA sequence of human
apolipoprotein (a) is homologous to plasminogen. Nature 1987;330:132–7

Crossref

PubMed

ISI

Google Scholar

75. Karadi I, Kostner GM, Gries A, Nimpf J, Romics L, Malle E. Lipoprotein (a) and
plasminogen are immunochemically related. Biochim Biophys Acta 1988;960:91–7
Crossref

PubMed

ISI

Google Scholar

76. Loscalzo J, Weinfeld M, Fless G, Scanu AM. Lipoprotein (a), "brin binding and
plasminogen activation. Arteriosclerosis 1990;10:240–5
Crossref
:
 PubMed

Google Scholar

77. Andrikoula M, McDowell IFW. The contribution of apoB and apoA1

measurements to cardiovascular risk assessment. Diabetes Obes Metab
2008;10:271–8

Crossref

PubMed

ISI

Google Scholar

78. Thompson A, Danesh J. Association between apolipoprotein B, apolipoprotein

A1, the apolipoprotein B/A1 ratio and coronary heart disease: a literature-based
meta-analysis of prospective studies. J Intern Med 2006;259:481–92
Crossref

PubMed

ISI

Google Scholar

79. Walldius G, Jungner I. Apolipoprotein B and apolipoprotein A1: risk indicators of

coronary heart disease and targets for lipid-modifying therapy. J Intern Med
2004;255:188–205

Crossref

PubMed
:
 PubMed

ISI

Google Scholar

80. Walldius G, Jungner I, Holme I, et al. High apolipoprotein B, low apolipoprotein A-

1, and improvement in the prediction of fatal myocardial infarction (AMORIS study):
a prospective study. Lancet 2001;358:2026–33

Crossref

PubMed

ISI

Google Scholar

81. McQueen MJ, Hawken S, Wang X, et al. Lipids, lipoproteins, and apolipoproteins
as risk markers of myocardial infarction in 52 countries (the INTERHEART study): a
case-control study. Lancet 2008;372:224–33

Crossref

PubMed

ISI

Google Scholar

82. Benn M, Nordestgaard BG, Jensen GB, Tybjaerg-Hansen A. Improving prediction

of ischemic cardiovascular disease in the general population using apolipoprotein B:
the Copenhagen City Heart Study. Arterioscler Thromb Vasc Biol 2007;27:661–70

Crossref
:
 Crossref

PubMed

ISI

Google Scholar

83. Lamarche B, Moorjani S, Lupien PJ, et al. Apolipoprotein A-1 and B levels and the
risk of ischemic heart disease during a 5 year follow-up of men in the Quebec
Cardiovascular Study. Circulation 1996;94:273–8

Crossref

PubMed

ISI

Google Scholar

84. Sierra-Johnson J, Fisher RM, Romero-Corral A, et al. Concentration of

apolipoprotein B is comparable with the apolipoprotein B/apolipoprotein A-I ratio
and better than routine clinical lipid measurements in predicting coronary heart
disease mortality: "ndings from a multi-ethnic US population. Eur Heart J
2009;30:710–7
Crossref

PubMed

ISI

Google Scholar
:
 85. Meisinger C, Loewel H, Mraz W, Koenig W. Prognostic value of apolipoprotein B
and A-1 in the prediction of myocardial infarction in middle-aged men and women:
results from the MONICA/KORA Augsburg Cohort Study. Eur Heart J 2005;26:271–8
Crossref

PubMed

ISI

Google Scholar

86. The Emerging Risk Factor Collaboration. Major lipids, apolipoproteins, and risk
of vascular disease. JAMA 2009;302:1993–2000
Crossref

PubMed

ISI

Google Scholar

87. Gotto AM, Whitney E, Stein EA, et al. Relation between baseline and on-
treatment lipid parameters and "rst acute major coronary events in the Air
Force/Texas Coronary Atherosclerosis Prevention Study (AF-CAPS/TexCAPS).
Circulation 2000;101:477–84

Crossref

PubMed

ISI

Google Scholar
:
 88. Brunzell JD, Davidson M, Furberg CD, et al. Lipoprotein management in patients
in cardiometabolic risk: conference report from the American Diabetes Association
and the American College of Cardiology Foundation. JACC 2008;51:1512–24

Crossref

PubMed

ISI

Google Scholar

89. Otvos JD, Collins D, Freedman DS, et al. Low-density lipoprotein and high-density
lipoprotein particle subclasses predict coronary events and are favourably changed
by gem"brozil therapy in the Veterans A#airs High-Density Lipoprotein Intervention
Trial. Circulation 2006;113:1556–63
Crossref

PubMed

ISI

Google Scholar

90. Dominiczak MH. Metabolic syndrome. CPD Clin Biochem 2004;6:3–9

Google Scholar

91. Pitsavos C, Panagiotakos DB, Skoumas J, et al. Risk strati"cation of

apolipoprotein B, apolipoprotein AI and apolipoprotein B/AI ratio on the prevalence
of the metabolic syndrome: the ATTICA Study. Angiology 2008;59:335–41

Crossref
:
 Crossref

PubMed

ISI

Google Scholar

92. Onat A, Hergenc G, Yazc M, Karabulut A, Albayrak S. Serum apolipoprotein B

predicts dyslipidaemia, metabolic syndrome and, in women, hypertension and
diabetes, independent of markers of central obesity and in!ammation. Int J Obes
2007;37:1119–25

Crossref

ISI

Google Scholar

93. Teng B, Sniderman AD, Soutar AK, Thompson GR. Metabolic basis of
hyperapobetalipoproteinemia. Turnover of apolipoprotein B in low density
lipoprotein and its precursors and subfractions compared with normal and familial
hypercholesterolemia. J Clin Invest 1986;77:663–72
Crossref

PubMed

ISI

Google Scholar

94. De Graaf J, Couture P, Sniderman A. A diagnostic algorithm for the atherogenic

apolipoprotein B dyslipoproteinemias. Nat Clin Pract Endocrinol Metab 2008;4:608–
18
:
 18

Crossref

PubMed

Google Scholar

95. Sniderman AD, Faraj M. Apolipoprotein B, apolipoprotein A-I, insulin resistance

and the metabolic syndrome. Curr Opin Lipidol 2007;18:633–7

Crossref

PubMed

ISI

Google Scholar

96. Contois JH, McConnell JP, Sethi AA, et al. Apolipoprotein B and cardiovascular
disease risk: position statement from the AACC Lipoproteins and Vascular Diseases
Division Working Group on Best Practices. Clin Chem 2009;55:407–19
Crossref

PubMed

ISI

Google Scholar

97. Brunzell JD, Davidson M, Furberg CD, et al. Lipoprotein management in patients
in cardiometabolic risk: conference report from the American Diabetes Association
and the American College of Cardiology Foundation. JACC 2008;51:1512–24

Crossref
:
 Crossref

PubMed

ISI

Google Scholar

98. Brown WV, Myers GL, Sniderman A, Evan Stein E. Should we use apoB for risk
assessment and as a target for treatment? J Clin Lipidol 2010;4:144–51
Crossref

PubMed

ISI

Google Scholar

99. Zilversmit DB. Atherogenesis: a postprandial phenomenon. Circulation

1979;60:473–85
Crossref

PubMed

ISI

Google Scholar

100. Patsch JR, Miesenbock G, Hopferwieser T, et al. Relationship of triglyceride

metabolism and coronary artery disease. Arterioscler Thromb 1992;12:1336–45
Crossref

PubMed
:
 PubMed

Google Scholar

101. Karpe F. Postprandial lipoprotein metabolism and atherosclerosis. J Intern Med

1999;246:341–55

Crossref

PubMed

ISI

Google Scholar

102. Bansal S, Buring JE, Rifai N, et al. Fasting compared with nonfasting triglycerides
and risk of cardiovascular events in women. JAMA 2007;298:309–16

Crossref

PubMed

ISI

Google Scholar

103. Børge G, Nordestgaard BG, Benn M, et al. Nonfasting triglycerides and risk of
myocardial infarction, ischaemic heart disease, and death in men and women. JAMA
2007;298:299–308
Crossref

PubMed

ISI
:
 ISI

Google Scholar

104. Smith D, Watts GF, Dane-Stewart C, Mamo JC. Post-prandial CM response may
be predicted by a single measurement of plasma apolipoprotein B48 in the fasting
state. Eur J Clin Invest 1999;29:204–9
Crossref

PubMed

ISI

Google Scholar

105. Onat A, Hergenc G, Ayhan E, et al. Metabolism of serum apolipoprotein C-III in

high-density lipoprotein: a key diabetogenic risk factor in Turks. Diabet Med
2009;26:981–8

Crossref

PubMed

ISI

Google Scholar

106. Volcik KA, Barkley RA, Hutchinson RG, et al. Apolipoprotein E polymorphisms
predict low density lipoprotein cholesterol levels and carotid artery wall thickness
but not incident coronary heart disease in 12,491 ARIC study participants. Am J
Epidemiol 2006;164:342–8
Crossref
:
 PubMed

ISI

Google Scholar

107. Elosua R, Demissie S, Cupples LA, et al. Obesity modulates the association
among APOE genotype, insulin, and glucose in men. Obes Res 2003;11:1502–8

Crossref

PubMed

Google Scholar

108. Marques-Vidal P, Bongard V, Ruidavets JB, et al. Obesity and alcohol modulate
the e#ect of apolipoprotein E polymorphism on lipids and insulin. Obes Res
2003;11:1200–6

Crossref

PubMed

Google Scholar

109. Huang ZH, Reardon CA, Mazzone T. Endogenous ApoE expression modulates
adipocyte triglyceride content and turnover. Diabetes 2006;55:3394–402

Crossref

PubMed

ISI

Google Scholar
:
 Google Scholar

110. Hofmann SM, Perez-Tilve D, Greer TM, et al. Defective lipid delivery modulates
glucose tolerance and metabolic response to diet in apolipoprotein E-de"cient mice.
Diabetes 2008;57:5–12

Crossref

PubMed

ISI

Google Scholar

111. Gao J, Katagiri H, Ishigaki Y, et al. Involvement of apolipoprotein E in excess fat

accumulation and insulin resistance. Diabetes 2007;56:24–33

Crossref

PubMed

ISI

Google Scholar

112. Hofmann SM, Zhou L, Perez-Tilve D, et al. Adipocyte LDL receptor-related

protein-1 expression modulates postprandial lipid transport and glucose
homeostasis in mice. J Clin Invest 2007;117:3271–82

Crossref

PubMed

ISI
:
 Google Scholar

113. Saunders AM, Schmader K, Breitner JCS, et al. Apolipoprotein E allele

distributions in late-onset Alzheimer's disease and in other amyloid-forming
diseases. Lancet 1993;342:710–11

Crossref

PubMed

ISI

Google Scholar

114. McCarron MO, Ho#mann KL, DeLong DM, Gray L, Saunders AM, Alberts MJ.
Intracerebral hemorrhage outcome: apolipoprotein E genotype, hematoma, and
edema volumes. Neurology 1999;53:2176–9
Crossref

PubMed

ISI

Google Scholar

115. Catena C, Novello M, Lapenna R, et al. New risk factors for atherosclerosis in
hypertension: focus on the prothrombotic state and lipoprotein (a). J Hypertens
2005;23:1617–31

Crossref

PubMed
:
 ISI

Google Scholar

116. Sechi LA, Kronenberg F, De Carli S, Falleti E, Zingaro L. Association of serum

lipoprotein (a) levels and apolipoprotein (a) size polymorphism with target-organ
damage in arterial hypertension. JAMA 1997;277:1689–95

Crossref

PubMed

ISI

Google Scholar

117. Danesh J, Collins R, Peto R. Lipoprotein (a) and coronary heart disease: meta-
analysis of prospective studies. Circulation 2000;102:1082–5

Crossref

PubMed

ISI

Google Scholar

118. The Emerging Risk Factors Collaboration. Lipoprotein (a) concentration and the
risk of coronary heart disease, stroke, and nonvascular mortality. JAMA
2009;302:412–23

Crossref

PubMed
:
 ISI

Google Scholar

119. Bennet A, Di Angelantonio E, Erqou S, et al. Lipoprotein(a) levels and risk of

future coronary heart disease. Large-scale prospective data. Arch Intern Med
2008;168:598–60

Crossref

PubMed

Google Scholar

120. Erqou E, Thompson A, Di Angelantonio E, et al. Apolipoprotein(a) isoforms and

the risk of vascular disease. J Am Coll Cardiol 2010;55:2160–7

Crossref

PubMed

ISI

Google Scholar

121. European Atherosclerosis Society (EAS). Consensus Panel Presentation at the

Meeting of the European Atherosclerosis Society, Hamburg, 2010

Google Scholar

122. Goldhaber SZ. European Atherosclerosis Society screening recommendations

for lipoprotein (a) and high-sensitivity C-reactive protein: double standard or failure
of evidence-based medicine? Clin Chem 2010;56:1544–6
:
 Crossref

PubMed

ISI

Google Scholar

123. Marcovina SM, Albers JJ, Dati F, Ledue TB, Ritchie RF. International Federation of
Clinical Chemistry standardisation project for measurements of apolipoprotein A-I
and B. Clin Chem 1991;37:1676–82
Crossref

PubMed

ISI

Google Scholar

124. Marcovina SM, Albers JJ, Kennedy H, Mei JV, Henderson LO, Hannon WH.
International Federation of Clinical Chemistry standardisation project for
measurements of apolipoprotein A-I and B. IV. Comparability of apolipoprotein B
values by use of international reference material. Clin Chem 1994;40:586–92

Crossref

PubMed

ISI

Google Scholar

125. Labeur C, Rosseneu M. Immunological assays of apolipoproteins A-II, A-IV, C-I,

:
 125. Labeur C, Rosseneu M. Immunological assays of apolipoproteins A-II, A-IV, C-I,
C-II, and C-III in plasma: methods and applications. In: Rifai N, Warnick GR,
Dominiczak MH, eds. Handbook of Lipoprotein Testing. 2nd edn. Washington DC:
AACC Press, 2000:387–400

Google Scholar

126. Smith D, Proctor SD, Mamo CLM. A highly sensitive assay for quantitation of
apolipoprotein B48 using an antibody to human apolipoprotein B and enhanced
chemiluminescence. Ann Clin Biochem 1997;34:185–9

Crossref

PubMed

ISI

Google Scholar

127. Karpe F, Hamsten A. Determination of apolipoproteins B-48 and B-100 in

triglyceride-rich lipoproteins by analytical SDS-PAGE. J Lipid Res 1994;35:1311–7
Crossref

PubMed

ISI

Google Scholar

128. Valdivielso P, Puerta S, Rioja J, et al. Postprandial apolipoprotein B48 is

associated with asymptomatic peripheral arterial disease: a study in patients with
type 2 diabetes and controls. Clin Chim Acta 2010;411:433–7

Crossref

PubMed
:
 PubMed

ISI

Google Scholar

129. Havel RJ. Remnant lipoproteins as therapeutic targets. Curr Opin Lipidol
2000;11:15–20
Crossref

ISI

Google Scholar

130. Nakajima K, Saito T, Tamura A, et al. Cholesterol in remnant-like lipoproteins in

human serum using monoclonal anti apoB-100 and anti apoA-I immunoa%nity
mixed gels. Clin Chim Acta 1993;223:53–71
Crossref

PubMed

ISI

Google Scholar

131. Mc Namara J, Shah PK, Nakajima K, et al. Remnant lipoprotein cholesterol and
triglyceride reference ranges from the Framingham Study. Clin Chem 1998;44:1224–
32

Crossref

PubMed
:
 ISI

Google Scholar

132. Van Hees AMJ, Saris WHM, Dallinga-Thie GMD, Hul GB, Martinez JA. Fasting and
postprandial remnant-like particle cholesterol concentration in obese participants is
associated with plasma triglycerides, insulin resistance and body fat distribution. J
Nutr 2008;138:2399–405

Crossref

PubMed

ISI

Google Scholar

133. McNamara JR, Shah PK, Nakajima JM, et al. Remnant-like particle (RLP)
cholesterol is an independent cardiovascular risk factor in women: results from the
Framingham Heart Study. Atherosclerosis 2001;154:229–36

Crossref

PubMed

ISI

Google Scholar

134. Chan DC, Watts GF, Barrett PH, et al. Markers of triglyceride-rich lipoprotein
remnant metabolism in visceral obesity. Clin Chem 2002;48:278–83

Crossref
:
 PubMed

ISI

Google Scholar

135. Abbasi F, McLaughlin T, Lamendola C, et al. Fasting remnant lipoprotein

cholesterol and triglyceride concentrations are elevated in nondiabetic, insulin-
resistant, female volunteers. J Clin Endocrinol Metab 1999;84:3903–6

PubMed

ISI

Google Scholar

136. Higashi K, Ito T, Nakajima K, et al. Remnant-like particles cholesterol is higher in

diabetic patients with coronary artery disease. Metabolism 2001;50:1462–5

Crossref

PubMed

ISI

Google Scholar

137. Miyauchi K, Kayahara N, Ishigami M, et al. Development of homogeneous assay

to measure remnant lipoprotein cholesterol. Clin Chem 2007;53:2128–35
Crossref

PubMed

ISI
:
 ISI

Google Scholar

138. Nagashima M, Mori Y, Morita R, et al. Remnant lipoprotein cholesterol

homogeneous assay (RemL-C) is closely associated with very-low-density lipoprotein
remnants:comparison with the immunoseparation assay. Rinsho Byori 2008;56:973–
9

PubMed

Google Scholar

139. Yoshida H, Kurosawa H, Hirowatari Y, et al. Characteristic comparison of

triglyceride-rich remnant lipoprotein measurement between a new homogenous
assay (RemL-C) and a conventional immunoseparation method (RLP-C). Lipids Health
Dis 2008;7:18–22

Crossref

PubMed

ISI

Google Scholar

140. Nakajima K, Nakano T, Moon HD, et al. The correlation between TG vs. remnant
lipoproteins in the fasting and postprandial plasma of 23 volunteers. Clin Chim Acta
2009;404:124–7
Crossref

PubMed

ISI
:
 ISI

Google Scholar

141. Schae#er EJ. Limitations of automated remnant lipoprotein cholesterol assay

for diagnostic use. Clin Chem 2009;55:2061–2

Crossref

PubMed

ISI

Google Scholar

142. Siest G, Pillot T, Régis-Bailly A, et al. Apolipoprotein E: an important gene and

protein to follow in laboratory medicine. Clin Chem 1995;41:1068–86

Crossref

PubMed

ISI

Google Scholar

143. Havekes LM, de Knij# P, Beisiegel U, Havinga J, Smit M, Klasen E. A rapid

micromethod for apolipoprotein E phenotyping directly in serum. J Lipid Res
1987;28:455–63

Crossref

PubMed

ISI
:
 Google Scholar

144. Hackler R, Schaefer JR, Motznu S, et al. Rapid determination of apolipoprotein E

phenotypes from whole plasma by automated electric focusing using PhastSystem
and immuno"xation. J Lipid Res 1994;35:153–8
Crossref

PubMed

ISI

Google Scholar

145. Hixson JE, Vernier DT. Restriction isotyping of human apolipoprotein E by gene
ampli"cation and cleavage with HhaI. J Lipid Res 1990;31:545–8
Crossref

PubMed

ISI

Google Scholar

146. Siest G, Schlenck A, Starck M, et al. Apolipoprotein E: laboratory determinations

and clinical interest. In: Rifai N, Warnick GR, Dominiczak MH, eds. Handbook of
Lipoprotein Testing. 2nd edn. Washington DC: AACC Press, 2000:401–40
Google Scholar

147. National Institute on Aging/Alzheimer's Association Working Group. Consensus

statement. Apolipoprotein E genotyping in Alzheimer's disease. Lancet
:
 statement. Apolipoprotein E genotyping in Alzheimer's disease. Lancet
1996;347:1091–5

Crossref

PubMed

ISI

Google Scholar

148. Stephens JW, Sozen MM, Whittall RA, et al. Three novel mutations in the
apolipoprotein E gene in a sample of individuals with type 2 diabetes mellitus. Clin
Chem 2005;51:119–24

Crossref

PubMed

ISI

Google Scholar

149. Mooijaart SP, Berbea JFP, van Heemst D, et al. ApoE plasma levels and risk of
cardiovascular mortality in old age. PLoS Med 2006;3:874–88
Crossref

ISI

Google Scholar

150. Schiele F, Vincent-Viry M, Starck M, et al. Apolipoprotein E in apolipoprotein B

(apo B)- and non-apo B-containing lipoproteins in 3523 participants in the Stanislas
Cohort: biological variation and genotype-speci"c reference limits. Clin Chem
2002;48:291–300
:
 2002;48:291–300

Crossref

PubMed

ISI

Google Scholar

151. Van Vliet P, Westendorp RGJ, Eikelenboom P, et al. Parental history of

Alzheimer disease associated with lower plasma apolipoprotein E levels. Neurology
2009;73:681–7

Crossref

PubMed

ISI

Google Scholar

152. Marcovina SM, Albers JJ, Scanu A, et al. Use of reference material proposed by
the International Federation of Clinical Chemistry and Laboratory Medicine to
evaluate analytical methods for the determination of plasma lipoprotein (a). Clin
Chem 2000;46:1956–67

Crossref

PubMed

ISI

Google Scholar
:
 153. Danik JS, Rifai N, Buring JE, Ridker PM. Lipoprotein (a), measured with an assay
independent of apolipoprotein (a) isoform size, and risk of future cardiovascular
events among initially healthy women. JAMA 2006;296:1363–70

Crossref

PubMed

ISI

Google Scholar

154. Sacks FM, Alaupovic P, Moye LA, et al. VLDL, apolipoproteins B, CIII and E, and
risk of recurrent coronary events in the Cholesterol and Recurrent Events (CARE)
trial. Circulation 2000;102:1886–92

Crossref

PubMed

ISI

Google Scholar

155. Luc G, Fievet C, Artweiler D, et al. Apolipoproteins CIII and E in ApoB and non-
apoB-containing lipoproteins in two populations at contrasting risk for myocardial
infarction: the ECTIM study. J Lipid Res 1996;37:508–17

Crossref

PubMed

ISI

Google Scholar
:
 Google Scholar

156. Chivot L, Mainard F, Bigot E, et al. Logistic discriminant analysis of lipids and
apolipoproteins in a population of coronary bypass patients and the signi"cance of
apolipoproteins CIII and E. Atherosclerosis 1990;82:205–11

Crossref

PubMed

ISI

Google Scholar

157. Kay RG, Gregory B, Grace PB, Pleasance S. The application of ultra-performance
liquid chromatography/tandem mass spectrometry to the detection and
quantitation of apolipoproteins in human serum. Rapid Commun Mass Spectrom
2007;21:2585–93

Crossref

PubMed

ISI

Google Scholar

158. Superko HR. Advanced lipoprotein testing and subfractionation are clinically
useful. Circulation 2009;119:2383–95
Crossref

PubMed

ISI
:
 Google Scholar

159. Mora S. Advanced lipoprotein testing and subfractionation are not (yet) ready
for routine clinical use. Circulation 2009;119:2396–404

Crossref

PubMed

ISI

Google Scholar

Related content

Similar articles:

Free access

Plasma lipoprotein β-amyloid in subjects with Alzheimer's disease or mild cognitive

impairment

Show details 

Free access

A place for assaying serum apolipoprotein AI and B?

Show details 

Open Access

Apolipoprotein pro"ling as a personalized approach to the diagnosis and treatment of

dyslipidaemia
:
 dyslipidaemia

Show details 

View more

SAGE recommends:

SAGE Knowledge
Book chapter

Lipid, Lipoprotein, and In!ammatory Markers of Atherosclerosis

Show details 

SAGE Knowledge
Entry

Physical Activity and Blood Lipids

Show details 

SAGE Research Methods

Entry

Cholesterol

Show details 

View more

Also from SAGE Publishing

:
 CQ Library

American political resources

Data Planet

A universe of data

SAGE Business Cases

Real-world cases at your "ngertips

SAGE Campus

Online skills and methods courses

SAGE Knowledge

The ultimate social science library

SAGE Research Methods

The ultimate methods library

SAGE Video

Streaming video collections

:
 Streaming video collections

Technology from SAGE

Make learning and research easier

: