High-density lipoproteins estimated by an enzymatic cholesterol procedure, with a centrifugal analyzer.

We describe an assay for high-density lipoprotein cholesterol, adapted to a centrifugal analyzer, the GEMSAEC System 3, which includes use of an increased Mn2+concentration (91 mmol/liter) [J. Lipid Res. 19, 65 (1978)] and ethylenediaminetetraacetate [Clin. Chem. 22, 98 (1976)]. Modifications to the GEMSAEC system include reducing the mixing burst and preconditioning the sample tip. Accuracy of this procedure, as assessed by analysis of a control pool from the Center for Disease Control, was 99.2%. Day-to-day precision for two control pools was 320 +/- 13 and 506 +/- 17 mg/liter. Serum sample volume was decreased to 0.5 ml. In blanks with heparin/Mn2+ present, the pseudocholesterol concentrations resulting from a reaction of the enzymatic cholesterol reagent and the heparin/Mn2+ precipitating reagent depend on the source of the enzymatic reagent and appear to be enhanced slightly by the use of ethylenediaminetetraacetate. Pseudocholesterol concentrations reach a maximum at heparin/Mn2+ concentrations well below those needed to completely precipitate the low-density and very-low-density lipoprotein fractions. Population reference values were obtained from analyses done on 224 local physicians (mean: male, 500 mg/liter; female, 620 mg/liter) and 156 ambulatory patients (mean: male, 463 mg/liter; female, 553 mg/liter).     

Multi-laboratory comparison of three heparin-Mn2+ precipitation procedures for estimating cholesterol in high-density lipoprotein.

Plasma high-density lipoprotein is commonly estimated by measuring the cholesterol remaining in plasma supernatant solutions after other lipoproteins, which contain apolipoprotein B, are precipitated with heparin and Mn2+. The method (method I) now in use by the Lipid Research Clinics, in which Mn2+ is at 46 mmol/liter final concentration, is reasonably accurate, but precipitation and sedimentation of lipoproteins other than high-density lipoproteins is often incomplete. We evaluated two modifications of method I. In method II, the Mn2+ concentration was doubled; the second modification (method III) included the increased Mn2+ concentration in a combined heparin Mn2+ reagent, decreased sample volume (2 ml), and a shorter incubation time (10 min at room temperature). The percentages of samples with turbid supernates (i.e., incomplete sedimentation) by methods I, II, and III were 9, 3, and 2%, respectively. Among non-turbid supernates, the percentages of samples containing measurable apolipoprotein B (incomplete precipitation) were 79, 19, and 16%, respectively. We conclude that method III is the most convenient and accurate of the three procedures.     

An enzymic and centrifugal method for estimating high-density lipoprotein cholesterol.

Enzymic measurement of high-density lipoprotein cholesterol with a centrifugal analyzer is described. We used polyethylene glycol (Mr 6000), final concentration 100 g/L, to precipitate low-density and very-low-density lipoproteins, thereby eliminating the difficulties of the commonly used heparin/Mn2+ precipitation method and facilitating the use of ethylenediaminetetraacetate-stabilized plasma. As measured by rocket immunoelectrophoresis, this final concentration of polyethylene glycol completely precipitates beta-lipoproteins, leaving the alpha-lipoproteins in solution. Between-run reproducibility (CV) was 3.6%, within-run reproducibility (CV) 0.8%. Reagent costs currently are $US 0.13 per test and large numbers of samples can be handled conveniently. Normal ranges were compiled for 539 men and 444 women. The high-density lipoprotein cholesterol for men was 1.20 +/- 0.31 (SD) mmol/L and for women 1.52 +/- 0.38 (SD) mmol/L.     

Cholesterol in high-density lipoprotein: use of Mg2+/dextran sulfate in its enzymic measurement.

We describe a method for measuring high-density lipoprotein cholesterol. MgCl2 and dextran sulfate are used to precipitate all low-density and very-low-density lipoproteins. The supernate contains only high-density lipoproteins, the cholesterol concentration of which is estimated by an enzymic method, with a discrete analyzer (Abbott Bichromatic Analyzer). Concentration and instrument response are linearly related to 50 mg/liter. The precision of the method is excellent in the range of clinical interest (100 to 1000 mg of cholesterol per liter). The precision and efficiency of the precipitation are shown at various concentrations of high-density lipoprotein cholesterol. The method was compared to that of two laboratories in the Cooperative Lipoprotein Phenotyping Study group by testing a number of split samples, and agreement was good.     

Simultaneous determination of serum cholesterol in high- and low-density lipoproteins with use of heparin, Ca2+, and an anion-exchange resin.

Cholesterol concentrations in serum high-density and low-density lipoproteins are simultaneously determined simply, specifically, and rapidly by use of the precipitation method with heparin, Ca2+, and an anion-exchange resin. The isolation of lipoproteins is reproducible, selective, and complete, as judged by electrophoresis on polyacrylamide gel and by immunoelectrophoresis, with use of samples with very-low-density lipoprotein triglyceride concentrations of less than 3.5 g/liter. The precision of the present method is as good (CV, 2.8-3.1%) as that for the method used by the U.S. Lipid Research Clinics (CV 2.0-3.2%). The present method and the heparin-Mn2+ method of the Clinics gave results that agreed reasonably well (for low-density-lipoprotein cholesterol r = 0.935, P less than 0.001; for high-density-lipoprotein cholesterol r = 0.837, P less than 0.001). we also describe the relations between high- or low-density lipoprotein cholesterol and total cholesterol, and between cholesterol concentrations in these two lipoprotein classes.     

Enzymic determination of the free cholesterol fraction of high-density lipoprotein in plasma with use of 2,4,6-tribromo-3-hydroxybenzoic acid

A highly sensitive enzymic colorimetric reagent is described for determination of the free cholesterol fraction of high-density lipoprotein (HDL), which represents about 20% of the total cholesterol content of this lipoprotein. For greater sensitivity with respect to cholesterol, I used 2,4,6-tribromo-3-hydroxybenzoic acid instead of phenol in the cholesterol oxidase/peroxidase/4-aminoantipyrine reagent system. This allows determination of the free cholesterol fraction of HDL isolates prepared with polyethylene glycol 6000, a method for precipitating beta-lipoprotein that involves a twofold dilution of plasma. The reagent, adapted for use with a Cobas-Bio centrifugal analyzer, results in between-run and within-run CVs of less than 3% and a linearity to at least 400 mg of HDL free cholesterol per liter. Comparison with results by Trinder's cholesterol method, which measures cholest-4-en-3-one at 232 nm, showed good correlation (r = 0.9829, slope 1.0001, and y-intercept +2.4797 mg/L). With the manual procedure for HDL free cholesterol, between-batch and within-batch CVs were less than 5%, and results correlated well with those by the automated method (r = 0.9975, slope 0.9839, and y-intercept +2.4327 mg/L). The mean (and SD) HDL free cholesterol for 123 men was 96.8 (30.6) mg/L and for 122 women 136.4 (36.8) mg/L, indicating a distinct sex-related difference, similar to that found for HDL total cholesterol. HDL free cholesterol in plasma may therefore be a potential new predictor of coronary heart disease.     

Inhibition of cholesterol oxidase in a patient with Cushing's syndrome

Serum from a patient with Cushing's syndrome who was being treated with mitotane contained components that interfered with determination of cholesterol in the Du Pont aca. A measured concentration of cholesterol of 4.19 g/L in the undiluted serum increased to a calculated concentration of 9.50 g/L in diluted serum. Adding additional cholesterol oxidase (EC 1.1.3.6) overcame the reaction inhibition in the undiluted sample; adding additional cholesterol esterase (EC 3.1.1.13) had no effect. There is the potential for clinically significant underestimation of cholesterol with the aca in such patients, because the interference may remain undetected. On the other hand, the aca accurately quantified undiluted specimens containing as much as 10 g of cholesterol per liter when mitotane was not present.     

Continuous-flow enzymic determination of serum total and high density lipoprotein cholesterol using microlitre sample volumes

We determine serum total cholesterol and high-density lipoprotein cholesterol (HDL-C) using a modified Technicon Auto Analyzer II-BMC enzymic system. The method uses 25 microL of sample (serum or supernate) for cholesterol determinations. Pooled serum which was calibrated indirectly against CDC's Abell-Kendall method was used for standardization. Accuracy and precision for total cholesterol determinations are comparable to those obtained using a modified Technicon AAII method. Coefficients of variation for the determination of HDL-C prepared by heparin/Mn++ precipitation are 6.4% and 4.6% at concentration levels of 0.70 mmol/L and 0.94 mmol/L respectively. The interchangeable use of deionized-distilled water and 0.15 mol/L NaCl solution for dilution of samples analyzed by the micro method is shown to produce significantly different cholesterol estimates. The reduced reagent volumes significantly lower the cost of cholesterol determinations. The system is simple, inexpensive and yields reliable cholesterol and HDL-C results.     

The effect of freezing-thawing of human blood serum on the results of the determination of high density lipoprotein cholesterol

The effect of repeated freezing-defreezing of the serum on the values of high density lipoprotein cholesterol measured by Abel's method was studied. Mixtures for the precipitation of lipoproteins were as follows: heparin + Mn2+, dextran sulfate + Mg2+, phosphotungstic acid + Mg2+, and polyethylene glycol. Variations in the measured cholesterol values were insignificant. Statistically reliable results (p less than 0.05) were obtained only with polyethylene glycol, with the variations not surpassing 3%.     

Plasma high-density lipoprotein cholesterol concentrations determined after removal of other lipoproteins by heparin/manganese precipitation or by ultracentrifugation.

The widely used heparin/MnCl2 precipitation procedure for determination of plasma high-density lipoprotein cholesterol has been re-examined in light of recent reports that isolated preparations of the lipoprotein are only partly precipitated under the test conditions. In the present study, the procedure as applied to plasma tolerated rather wide variations in heparin and MnCl2 concentrations without significant effects on the assayed values in several plasma pools tested. The procedure was further tested on 129 individual samples by comparison with an ultracentrifugal method in which high-density lipoprotein-cholesterol is assumed to be represented by the cholesterol content of the plasma fraction of relative (to water) density greater than 1.063. Our results indicate that high-density lipoprotein is not precipitated under the test conditions when applied to unfractionated plasma.     

A micromethod for determining lipoprotein cholesterol in capillary blood

To measure the total cholesterol (CS) and high-density lipoprotein cholesterol (HDLP CS), the blood collected from the finger is mixed with an equal volume of physiologic saline with EDTA and the mixture is collected into a polyethylene tube to separate the diluted plasma from the formed elements by centrifugation. Low- and very low-density lipoprotein CS are sedimented after addition of heparin and Mn2+ ions to diluted plasma. Comparison of the values of the total CS and HDLP CS in the capillary blood plasma and in the blood sera of 20 patients has shown no significant difference between the two methods. The reproducibility and accuracy of the micro- and macromethods, compared in examinations of the same pool of sera, did not differ. This permits the use of the suggested micromethod for the aforesaid measurements during screenings of the population.     

Heparin--Mn2+ quantitation of high-density-lipoprotein cholesterol: an ultrafiltration procedure for lipemic samples.

We describe a modified heparin--Mn2+ procedure for high-density-lipoprotein cholesterol quantitation, especially in lipemic samples. High-density-lipoproteins may be estimated as cholesterol remaining in plasma supernates after precipitation of other lipoproteins by heparin and Mn2+ treatment. However, in lipemic samples or those from non-fasting individuals, the lower density of the precipitated chylomicrons, very-low-, and low-density-lipoproteins frequently prevents their sedimentation by the usual low-speed centrifugation, and high-density-lipoprotein cholesterol thus is overestimated in the resulting turbid supernates. Sedimentation is improved by a twofold increase in Mn2+ concentration to 92 mmol/liter. The procedure reported here produced clear supernates in more than 95% of samples tested. Any remaining turbid supernates can be cleared by a simple, convenient ultrafiltration technique. The filtration removed essentially all of the very-low- and low-density-lipoproteins without removing appreciable amounts of high-density-lipoproteins.     

Effects of bezafibrate on HDL2/HDL3 ratio in postmenopausal hypertriglyceridemic women

The short-term effects of bezafibrate on high-density lipoprotein cholesterol quality and triglyceride-rich lipoprotein metabolism in 186 postmenopausal hypertriglyceridemic women were investigated. Patients were randomized to an untreated group and to bezafibrate (400 mg/d) for 6 months. Fasting lipid concentrations, high-density lipoprotein 2, and high-density lipoprotein 3 levels were measured at baseline and after 3 and 6 months. At 3 months, bezafibrate had significantly decreased mean serum triglycerides and remnant-like particle cholesterol levels (105.7 +/- 43.4 mg/dL and 5.33 +/- 2.1 mg/dL, P < .001, respectively) from baseline values (232.5 +/- 63.9 mg/dL and 9.69 +/- 3.8 mg/dL, respectively). It also maintained lower total cholesterol, low-density lipoprotein cholesterol, triglycerides, and remnant-like particle cholesterol concentrations to 6 months. After 3 months, it significantly increased mean serum high-density lipoprotein cholesterol (55.1 +/- 14.7 vs 64.8 +/- 12.1 mg/dL; P < .0001) and maintained higher high-density lipoprotein cholesterol at 6 months. The high-density lipoprotein 2-high-density lipoprotein 3 ratio was decreased after 3 months of therapy with bezafibrate (2.13 +/- 0.68) from the baseline (2.42 +/- 0.71) (P < .01).     

Efficacy and Tolerability of Low-dose Simvastatin and Niacin, Alone and in Combination, in Patients With Combined Hyperlipidemia: A Prospective Trial

BACKGROUND: Combination lipid-lowering therapy may be desirable in patients with elevated low-density lipoprotein cholesterol, high triglycerides, and low high-density lipoprotein cholesterol. This study was conducted to determine the lipid-lowering efficacy of the combination of low-dose simvastatin and niacin in patients with combined hyperlipidemia and low high-density lipoprotein cholesterol. METHODS AND RESULTS: In this multicenter, prospective, randomized trial, 180 patients with hypercholesterolemia and hypertriglyceridemia and/or low high-density lipoprotein cholesterol were randomized to combination simvastatin (10 mg/day) and niacin (0.75 g/day) or to either drug alone for 9 weeks. The dose of niacin was doubled (from 0.75 g/day to 1.5 g/day) in both the combination and niacin arms for the remaining 8 weeks. The combination of simvastatin, 10 mg/day, and niacin, 1.5 g/day, reduced total, low-density lipoprotein, and very low-density lipoprotein cholesterol and triglycerides by 24%, 29%, 45%, and 31%, respectively, while increasing high-density lipoprotein cholesterol by 31%. The addition of niacin to simvastatin did not enhance the low-density lipoprotein cholesterol by 31%. The addition of niacin to simvastatin did not enhance the low-density lipoprotein cholesterol-lowering effect of simvastatin; however, the combination was more effective than either monotherapy at raising high-density lipoprotein cholesterol and lowering very low-density lipoprotein cholesterol (P <.05). More patients discontinued treatment because of an adverse event in the niacin (P <.03) and combination groups (P =.06) than the simvastatin group. CONCLUSIONS: Treatment of patients with combined hyperlipidemia and/or low high-density lipoprotein with combination low-dose simvastatin and niacin resulted in large reductions in total, low-density lipoprotein, and very low-density lipoprotein cholesterol and increases in HDL cholesterol. Although the combination was well tolerated in the current trial, its safety needs to be evaluated in larger trials of longer duration.     

Quantitative determination of human plasma apolipoprotein A-I by laser immunonephelometry

A technical procedure is described for quantitation of human apolipoprotein A-I (apo A-I) in normal plasma or serum by immunonephelometry. Dilution of the plasma samples with 6 mol/L guanidine chloride ensures maximum exposure of the antigenic sites of the apoprotein and enables optimum quantitation of the apo A-I without requiring extraction with organic solvents. Similar data are obtained by this assay and with radioimmunoassay for normal subjects (1.2--1.5 g/L), and the results obtained on 31 patients are correlated with a coefficient of 0.92. The apo A-I values are correlated with values for plasma high-density lipoprotein cholesterol (r = 0.64). The interassay CV for immunonephelometry is about 7% and the standard curve is linear between 0.1 and 1.0 microgram of apo A-I per sample, corresponding to a 150-fold dilution of serum or plasma. The assay is applicable to plasma samples containing as much as 4 g of triglycerides per liter. At higher concentrations plasma delipidation is required.     

Management of hypertriglyceridemia

Hypertriglyceridemia is associated with an increased risk of cardiovascular events and acute pancreatitis. Along with lowering low-density lipoprotein cholesterol levels and raising high-density lipoprotein cholesterol levels, lowering triglyceride levels in high-risk patients (e.g., those with cardiovascular disease or diabetes) has been associated with decreased cardiovascular morbidity and mortality. Although the management of mixed dyslipidemia is controversial, treatment should focus primarily on lowering low-density lipoprotein cholesterol levels. Secondary goals should include lowering non-high-density lipoprotein cholesterol levels (calculated by subtracting high-density lipoprotein cholesterol from total cholesterol). If serum triglyceride levels are high, lowering these levels can be effective at reaching non-high-density lipoprotein cholesterol goals. Initially, patients with hypertriglyceridemia should be counseled about therapeutic lifestyle changes (e.g., healthy diet, regular exercise, tobacco-use cessation). Patients also should be screened for metabolic syndrome and other acquired or secondary causes. Patients with borderline-high serum triglyceride levels (i.e., 150 to 199 mg per dL [1.70 to 2.25 mmol per L]) and high serum triglyceride levels (i.e., 200 to 499 mg per dL [2.26 to 5.64 mmol per L]) require an overall cardiac risk assessment. Treatment of very high triglyceride levels (i.e., 500 mg per dL [5.65 mmol per L] or higher) is aimed at reducing the risk of acute pancreatitis. Statins, fibrates, niacin, and fish oil (alone or in various combinations) are effective when pharmacotherapy is indicated.     

Enzyme-linked immunoabsorbant assay of apolipoprotein AII in plasma, with use of a monoclonal antibody

We produced a monoclonal antibody (C2-22) to human apolipoprotein (Apo) AII and describe its use in an enzyme-linked immunoabsorbant assay (ELISA) for Apo AII in human plasma and lipoprotein subfractions. No cross reactivity of the antibody with Apo CI, CII, CIII, E, or ablumin was detected. Apo AI and low- and very-low-density lipoprotein cross reacted by 0.25%, less than 0.2%, and less than 0.3%, respectively. Whole plasma high-density lipoprotein (HDL) and HDL subfractions (HDL2 and HDL3) produced parallel displacement curves. This quantitative ELISA is based on competition between solid-phase-bound Apo AII and free Apo AII. Bound C2-22 is detected by alkaline-phosphatase-labeled second antibody. The standard curve for the assay is linear for plasma diluted 500-fold originally containing 140 to 1140 mg of Apo AII per liter. Delipidation of plasma samples exposed no additional antigenic sites. Within- and between-run CVs were respectively 8.4% and 8.7% at 327 mg/L of Apo AII, and 6.8% and 7.4% at 587 mg/L. Results correlated well with those by a polyvalent-antisera-based RIA procedure: r = 0.916, p less than 0.01, RIA = 0.896 ELISA -19.1 mg/L.     

Beta-lipoprotein cholesterol quantitation with polycations.

We compared direct determination of beta-lipoprotein cholesterol after selective extraction of very-low-density and high-density lipoproteins from serum with poly(ethyleneimine) and a cation-exchange resin with the classical quantitation after lipoprotein fractionation with the ultracentrifuge. At beta-lipoprotein cholesterol concentrations between 1.50 and 5.00 g/liter the correlation is linear (r = 0.95). The precision for the extraction procedure is as good (CV 2.4-2.8%) as for the quantitation by ultracentrifugation (CV 3.2-6.0%). From solutions of isolated lipoproteins, very-low-density lipoproteins are 93% extracted and high-density lipoproteins 60%, but low-density-lipoproteins only 5%. The molecular mechanism of the extraction is supposed to be due to both hydrophobic interaction of long-chain fatty acid residues and ionic interaction of phospholipids located at the surface of very low-density and high-density lipoproteins and the lipophilic polycation.     

Electrophoretic separation of high-density lipoprotein choelsterol evaluated and compared with the modified lipid research clinic procedure.

We evaluated a new agarose-gel-electrophoretic procedure (Corning) (I) for separating and quantitating of high-density lipoprotein cholesterol (HDLC), comparing it with the modified Lipid Research Clinics (LRC) procedure (heparin 183 kilounits/L, MnCl2 92 mmol/L) (II). Method I was insensitive to an HDLC concentration of 50 mg/L, but gave a linear dose-response curve between 130 and 1200 mg/L. Method II is sensitive to 50 mg/L and linear from 50--1200 mg/L. The within-plate CV for the Corning method varied from 26.2% for an HDLC of 168 mg/L to 6.8% for 580 mg/L. Within-day between-plate CV for the Corning method ranged from 22.1% at 155 mg/L to 8.0% at 651 mg/L, compared to 3.0 and 0.8% for the modified LRC procedure. Between-day CV for method I was 20, 12.6, 4.3, and 3.5% for HDLC concentrations of 175, 435, 542, and 678 mg/L, respectively; for method II it was 14, 5, 3.5, and 2.6%, respectively. Analysis of HDLC in 100 patients by both procedures showed mean HDLC values to be significantly lower (mean + SD, 27.8 +/- 1.7 mg/L; p less than 0.001) by method I. In 46 patients with HDLC less than 450 mg/L, this difference was accentuated (mean + SD = 40.5 +/- 2.6 mg/L) and clinically significant. Electrophoretic methods offer a promising further alternative method for HDLC separation and quantitation, but the negative bias, present limited sensitivity, and lack of precision at less than 450 mg/L indicate that they are not yet optimal for routine clinical use for patients with values less than 450 mg/L.     

Interlaboratory proficiency survey of high-density lipoprotein cholesterol measurement

Proficiency surveys of Seattle-area laboratories suggest only slight improvement in overall performance in high-density lipoprotein (HDL) measurement between 1978 and 1982, although the reported workload for HDL has increased by 15%. The mean interlaboratory SD was 64 mg/L (ranging from 34 for a pool averaging 299 mg/L to 136 for a pool averaging 886 mg of HDL cholesterol per liter) in 1982, compared with 79 mg/L (range 48-155) in 1978-79. Of the individual laboratory results in the current survey, 39% deviated by more than 50 mg/L from target values as compared with 37% in 1978-79. The discrepant values were primarily ascribable to method inaccuracy: only 30% of laboratories in 1982 reported results that averaged within 30 mg/L of target values (vs 50% in 1978). For within-run precision, 80% of laboratories in 1982 had SDs of less than 30 mg/L, vs 70% in 1978. The 1982 survey included a lyophilized serum prepared by spray freezing and bulk lyophilization (Hyland Omega), identical to the pools used in the College of American Pathologists Comprehensive Chemistry Survey, and five pools of frozen plasma. Interlaboratory variation and biases for the Omega pool were similar to those for the frozen pools.