Cholesterol metabolism.

Bile acids and bile salts

Lali Shanshiashvili
• Cholesterol is an amphipathic lipid and is an
essential structural component of membranes,
where it is important for the maintenance of the
correct permeability and fluidity, and of the outer
layer of plasma lipoproteins.
• It is synthesized in many tissues from acetyl‐CoA and is
the precursor of all other steroids in the body, including
corticosteroids, sex hormones, bile acids, and vitamin D.
• As a typical product of animal metabolism,
cholesterol occurs in foods of animal origin
such as egg yolk, meat, liver, and brain.
• It is therefore of critical importance that the cells of the
body be assured an appropriate supply of cholesterol.
• To meet this need, a complex series of transport,
biosynthetic and regulatory mechanisms has evolved.
• The import carrier NPC1L1 brings mainly cholesterol
into the cell, but also some phytosterol.
• The export carriers ABCG5 and ABCG8 excrete the
undesirable phytosterols, together with part of the
absorbed cholesterol.
• Plasma low‐density lipoprotein (LDL) is the vehicle that
supplies cholesterol and cholesteryl ester to many tissues.
Free cholesterol is removed from tissues by plasma high‐
density lipoprotein (HDL) and transported to the liver,
where it is eliminated from the body either unchanged or
after conversion to bile acids in the process known as
reverse cholesterol transport.
• Cholesterol is a major constituent of gallstones.
However, its chief role in pathologic processes is as
a factor in the genesis of atherosclerosis of vital
arteries, causing cerebrovascular, coronary, and
peripheral vascular disease.
• In humans, the balance between cholesterol influx
and efflux is not precise, resulting in a gradual
deposition of cholesterol in the tissues,
particularly in the endothelial linings of blood
vessels.
 STRUCTURE OF CHOLESTEROL

• Cholesterol is a very hydrophobic compound. It consists of

four fused hydrocarbon rings (A‐D) called the “steroid
nucleus”, and it has an eight‐carbon, branched
hydrocarbon chain attached to carbon 17 of the D ring.
Ring A has a hydroxyl group at carbon 3, and ring B has a
double bond between carbon 5 and carbon 6 .
 Cholesteryl esters

• Most plasma cholesterol is in an esterified form (with

a fatty acid attached at carbon 3), which makes the
structure even more hydrophobic than free
(unesterified) cholesterol.
• Because of their hydrophobicity, cholesterol and its
esters are transported as a component of a lipoprotein
particle , or are solubilized by phospholipids and bile
salts in the bile.
 SYNTHESIS OF CHOLESTEROL

• Cholesterol is synthesized by all tissues in humans,

although liver, intestine, adrenal cortex, and reproductive
tissues, including ovaries, testes, and placenta, make the
largest contributions to the body’s cholesterol pool.
• All the carbon atoms in cholesterol are provided by
acetate , NADPH provides the reducing equivalents.
• The pathway is endergonic, being driven by hydrolysis of
the high‐energy thioester bond of acetyl coenzyme A
(CoA) and the terminal phosphate bond of adenosine
triphosphate (ATP).
• Synthesis requires enzymes in both the cytosol and the
membrane of the smooth endoplasmic reticulum (ER).
The pathway is responsive to changes in cholesterol
concentration, and regulatory mechanisms exist to
balance the rate of cholesterol synthesis within the body .
• Konrad Bloch and Feodor Lynen received the
Nobel Prize in Physiology and Medicine in 1964
“For their discoveries concerning the mechanism
and regulation of the cholesterol and fatty acid
metabolism”.
 Synthesis of 3‐hydroxy‐3‐methylglutaryl (HMG) CoA
• First, two acetyl CoA
molecules condense to form
acetoacetyl CoA.
• Next, a third molecule of
acetyl CoA is added,
producing HMG CoA, a six‐
carbon compound.

• Liver parenchymal cells

contain two isoenzymes of
HMG CoA synthase:
• the cytosolic enzyme
participates in cholesterol
synthesis
• the mitochondrial enzyme
functions in the pathway for
ketone body synthesis.
 Synthesis of mevalonate
• The reduction of HMG CoA
to mevalonate, is catalyzed
by HMG CoA reductase, and
is key regulated step in
cholesterol synthesis.

• It occurs in the cytosol

uses two molecules of
NADPH
as the reducing agent releases
CoA, making the reaction
irreversible.
Synthesis of cholesterol

[1] Mevalonate is converted to 5‐pyrophosphomevalonate in two

steps, each of which transfers a phosphate group from ATP.
• [2]—by the decarboxylation of 5 pyrophosphomevalonate
is formed a five-carbon isoprene unit— isopentenyl
pyrophosphate (IPP).
• The reaction requires ATP.
• [3] IPP is isomerized to
3,3-dimethylallyl
pyrophosphate (DPP).
• [4] IPP and DPP condense to form ten‐carbon
geranyl pyro phosphate (GPP).
• [5] A second molecule of IPP then condenses with GPP
to form 15‐carbon farnesyl pyrophosphate (FPP).
• Note: Covalent attachment of farnesyl to proteins, a
process known as “prenylation,” is one mechanism for
anchoring proteins to plasma membranes.
• [6] Two molecules of FPP combine,
releasing pyrophosphate, and are
reduced, forming the 30‐carbon
compound squalene.

• [Note: Squalene is formed from six

isoprenoid units. Because three ATP
are hydrolyzed per mevalonate residue
converted to IPP, a total of 18 ATP are
required to make the polyisoprenoid
squalene.]
• [7] Squalene is converted to the sterol lanosterol
by a sequence of reactions catalyzed by ER‐
associated enzymes that use molecular oxygen and
NADPH.
• The hydroxylation of squalene triggers the
cyclization of the structure to lanosterol.
• [8] The conversion of lanosterol to cholesterol is a
multistep process, resulting in:
• the shortening of the carbon chain from 30 to 27
• removal of the two methyl groups at carbon 4
• migration of the double bond from carbon 8 to
carbon 5
• reduction of the double bond between carbon 24 and
carbon 25.
 Regulation of cholesterol synthesis

HMG CoA reductase is an

intrinsic membrane
protein of the ER, with the
enzyme’s catalytic domain
projecting into the
cytosol.
Regulation of HMG (3‐hydroxy‐3‐methylglutaryl) CoA
reductase

1. Sterol‐dependent regulation of gene expression

2. Sterol-accelerated enzyme degradation

3. Sterol‐independent phosphorylation/dephosphorylation

4. Hormonal regulation

5. Inhibition by drugs
 1. Sterol‐dependent regulation of gene expression:

Expression of the gene for HMG CoA reductase is controlled by the

transcription factor, SREBP‐2 (sterol regulatory element–binding
protein‐2) that binds DNA at the cis‐acting sterol regulatory element
(SRE) of the reductase gene. SREBP is an integral protein of the ER
membrane, and associates with a second ER membrane protein,
SCAP (SREBP cleavage–activating protein).
• When sterol levels in the cell are low, the SREBP‐SCAP complex is
sent out of the ER to the Golgi. In the Golgi, SREBP is sequentially
acted upon by two proteases, which generate a soluble fragment
that enters the nucleus, binds the SRE, and functions as a
transcription factor.
• This results in increased synthesis of HMG CoA reductase and,
therefore, increased cholesterol synthesis .
• If sterols are abundant, however, they bind SCAP at its sterol‐
sensing domain and induce the binding of SCAP to yet other ER
membrane proteins insigs.
• This results in the retention of the SCAP‐SREBP complex in the ER,
thus preventing the activation of SREBP, and leading to down‐
regulation of cholesterol synthesis.
2. Sterol-accelerated
enzyme degradation:

• The reductase itself is a sterol‐sensing integral protein of the ER

membrane. When sterol levels in the cell are high, the reductase
binds to insig proteins.
• Binding leads to ubiquitination and proteasomal degradation of the
reductase .
3. Sterol‐independent phosphorylation/dephosphorylation:

• HMG CoA reductase activity is controlled covalently through the

actions of adenosine monophosphate (AMP)–activated protein
kinase and a phosphoprotein phosphatase .
• The phosphorylated form of the enzyme is inactive
• the dephosphorylated form is active.
 4. Hormonal regulation:

• An increase in insulin and thyroxine favors upregulation of the

expression of the gene for HMG CoA reductase.

• Glucagon and the glucocorticoids have the opposite effect.

 5. Inhibition by drugs

• The statin drugs (atorvastatin, fluvastatin, lovastatin,

pravastatin, rosuvastatin, and simvastatin) are structural
analogs of HMG CoA, and are reversible, competitive
inhibitors of HMG CoA reductase .
• They are used to decrease plasma cholesterol levels in
patients with hypercholesterolemia.
• This ER‐associated pathway includes several different enzymatic
reactions. Smith‐Lemli‐Opitz syndrome (SLOS), a relatively common
autosomal recessive disorder of cholesterol biosynthesis, is caused
by a partial deficiency in 7‐dehydrocholesterol‐7‐reductase—an
enzyme involved in the migration of the double bond.
• SLOS is one of several multisystem, embryonic malformation
syndromes associated with impaired cholesterol synthesis.
• Niemann‐Pick type‐C (NPC) disease (Lysosomal storage disease) is an inherited
defect in lipid storage.
• In this disorder, cholesterol is not transported out of the lysosomes and instead
accumulates in lysosomes of liver, brain, and lung, bringing about early death.
• NPC is the result of a mutation in either of two genes, NPC1 and NPC2, essential to
moving cholesterol out of the lysosome and into the cytosol, where it can be
further metabolized.
• NPC1 encodes a transmembrane lysosomal protein, and NPC2 encodes a soluble
protein.
• These proteins act in tandem to transfer cholesterol out of the lysosome and into
the cytosol for further processing or metabolism.
 DEGRADATION OF CHOLESTEROL
• The intact sterol nucleus is eliminated from the body by
conversion to bile acids and bile salts, which are excreted
in the feces, and by secretion of cholesterol into the bile,
which transports it to the intestine for elimination.
• Some of the cholesterol in the intestine is modified by
bacteria before excretion. The primary compounds made
are the isomers coprostanol and cholestanol, which are
reduced derivatives of cholesterol.
 BILE ACIDS AND BILE SALTS

Phosphatidylcholine and bile salts are quantitatively the

most important organic components of bile.
• Bile can either pass directly from the liver where it is
synthesized into the duodenum through the common bile
duct, or be stored in the gallbladder when not
immediately needed for digestion.
 Structure of the bile acids

• The bile acids contain 24 carbons, with two or three

hydroxyl groups and a side chain that terminates in a
carboxyl group. The carboxyl group has a pK of about six
and, therefore, is not fully ionized at physiologic pH—
hence, the term “bile acid.”
 Synthesis of bile acids

• Bile acids are synthesized in the liver by a multistep pathway in

which hydroxyl groups are inserted at specific positions on the
steroid structure, the double bond of the cholesterol B ring is
reduced, and the hydrocarbon chain is shortened by three carbons,
introducing a carboxyl group at the end of the chain. The most
common resulting compounds, cholic acid (a triol) and cheno
deoxycholic acid, are called “primary” bile acids.
The rate‐limiting step in bile acid synthesis is the
introduction of a hydroxyl group at carbon 7 of the
steroid nucleus by cholesterol‐7‐α‐hydroxylase, an
ER‐associated cytochrome P450 (CYP) enzyme
found only in liver. The enzyme is down‐regulated
by cholic acid.
 Synthesis of bile salts

• Bile acids are conjugated to a

molecule of either glycine or
taurine (an endproduct of
cysteine metabolism).
• These new structures include
glycocholic and glyco cheno
deoxycholic acids, and
taurocholic and tauro cheno
deoxy cholic.
• The ratio of glycine to taurine
forms in the bile is
approximately 3:1.
 Action of intestinal flora on bile salts

• Bacteria in the intestine can remove glycine and taurine from bile
salts, regenerating bile acids.
• They can also convert some of the primary bile acids into
“secondary” bile acids by removing a hydroxyl group, producing
deoxycholic acid from cholic acid and lithocholic acid from
chenodeoxycholic acid.
Enterohepatic circulation

• Bile salts secreted into the intestine are efficiently

reabsorbed (greater than 95%) and reused. The liver
converts both primary and secondary bile acids into bile
salts by conjugation with glycine or taurine, and secretes
them into the bile.
• The mixture of bile acids and bile salts is absorbed primarily
in the ileum via a Na ‐bile salt cotransporter.
• They are actively transported out of the ileal mucosal cells
into the portal blood, and are efficiently taken up by the
hepatocytes via an isoform of the cotransporter.
• Bile acids are hydrophobic and require a carrier in the portal blood.
• Albumin carries them in a noncovalent complex, just as it transports fatty
acids in blood.
Bile salt deficiency:
cholelithiasis

• The movement of cholesterol from the liver into the

bile must be accompanied by the simultaneous
secretion of phospholipid and bile salts. If this dual
process is disrupted and more cholesterol enters the
bile than can be solubilized by the bile salts and
phosphatidyl choline present, the cholesterol may
precipitate in the gallbladder, leading to cholesterol
gallstone disease—cholelithiasis .
• This disorder is caused by a decrease of bile acids in the bile,
which may result from:
• 1) gross malabsorption of bile acids from the intestine, as
seen in patients with severe ileal disease;
• 2) obstruction of the biliary tract, interrupting the
enterohepatic circulation;
• 3) severe hepatic dysfunction, leading to decreased
synthesis of bile salts, or other abnormalities in bile
production;
• 4) excessive feedback suppression of bile acid synthesis as a
result of an accelerated rate of recycling of bile acids.
Types of Gallstones: Gallstones can be of mainly three types:
• Cholesterol stones: They are single or multiple, mainly formed of cholesterol,
mulberry-shaped and are not radiopaque.
• Pigment stones: Consist of bile pigments and calcium with other organic
substances. Small multiple stones, dark green or black, not radiopaque.
Mixed stones: Consist of mixture of cholesterol + pigments + calcium and organic material.
Most common form, may be radiopaque. Stones: Faceted and dark brown.

Laparoscopic cholecystectomy is
currently the treatment of choice
pp. 634‐655
Thanks for attantion!