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Arteriosclerosis, Thrombosis, and Vascular Biology. 1995;15:1875-1881

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(Arteriosclerosis, Thrombosis, and Vascular Biology. 1995;15:1875-1881.)
© 1995 American Heart Association, Inc.


Articles

Lipid Composition of HDL Subfractions in Dog Plasma and Lymph

Laurence Wong; Bela Sivok; Eva Kurucz; Charles H. Sloop; Paul S. Roheim; Bela Asztalos

From the Division of Lipoprotein Metabolism and Pathophysiology, Department of Physiology, Louisiana State University Medical Center, New Orleans.

Correspondence to Laurence Wong, Division of Lipoprotein Metabolism and Pathophysiology, Department of Physiology, Louisiana State University Medical Center, New Orleans, LA 70112.


*    Abstract
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*Abstract
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Abstract We report the lipid composition of dog plasma and peripheral lymph lipoproteins as separated into pre-ß, {alpha}, and pre-{alpha} fractions by agarose gel electrophoresis. Plasma lipoproteins with {alpha} mobility have a composition different from that of plasma lipoproteins with pre-{alpha} mobility, having 9% versus 11% free cholesterol, 21% versus 17% cholesterol ester, 1% versus 16% triacylglycerol, and 69% versus 56% phospholipid. On the other hand, lymph {alpha} and pre-{alpha} lipoproteins have compositions that are quite similar (9% versus 7% free cholesterol, 17% versus 17% cholesterol ester, 2% versus 4% triacylglycerol, and 71% versus 71% phospholipid). The lipid compositions of plasma and lymph {alpha} lipoproteins are quite similar (9% versus 9% free cholesterol, 21% versus 17% cholesterol ester, 1% versus 2% triacylglycerol, and 70% versus 72% phospholipid). The lipid compositions of plasma and lymph pre-{alpha} lipoproteins are different (11% versus 7% free cholesterol, 17% versus 17% cholesterol ester, 16% versus 4% triacylglycerol, and 56% versus 71% phospholipid). Peripheral lymph lipoproteins with pre-ß mobility contained 15% cholesterol, 13% cholesterol ester, 10% triacylglycerol, and 61% phospholipid. Compared with plasma, peripheral lymph lipoproteins are free cholesterol–enriched in all fractions. Calculated stoichiometric ratios of lipid to apoA-I indicate that pre-ß lipoproteins contain one molecule of apoA-I per particle, {alpha} lipoproteins have two molecules of apoA-I per particle, and pre-{alpha} lipoproteins have four molecules of apoA-I per particle.


Key Words: high density lipoproteins • phospholipids • cholesterol • cholesterol ester • triacylglycerol


*    Introduction
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up arrowAbstract
*Introduction
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down arrowDiscussion
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It is well known that HDLs are heterogeneous. The heterogeneities could be based on flotation density, immunological composition, molecular size, or electrophoretic mobility. DeLalla and Gofman1 could detect three different HDLs on the basis of analytical ultracentrifugation. These different HDL subpopulations were termed HDL1, HDL2, and HDL3. Using antibodies, Alaupovic2 could isolate HDLs containing apoA-I only and HDLs containing apoA-I and apoA-II. These were called LpAI and LpAI:AII particles, respectively. There is recent evidence to suggest that LpA-I and LpA-I:A-II particles may have different metabolic properties.3 By using nondenaturing gradient polyacrylamide gel electrophoresis (NODEGRA-PAGE), Blanche et al4 have identified different HDLs on the basis of size. Castro and Fielding5 and Fielding and Fielding6 used a two-dimensional separation of lipoproteins combining agarose gel electrophoresis with NODEGRA-PAGE to detect at least six populations of apoA-I–containing lipoproteins in human plasma.

We have recently identified at least 12 populations of apoA-I–containing lipoproteins in the human plasma7 by using a two-dimensional system. Using this technique, we found that the apoA-I subpopulations in dog plasma were somewhat simpler; there were only six of them.8 In addition, there was only one population of pre-ß particles (pre-ß1), as opposed to the three populations that we and Castro and Fielding5 found (pre-ß1, pre-ß2, and pre-ß3) in human plasma. Our recent observation that the apoA-I distribution is changed in lymph (a model of interstitial fluid) suggests that complex lipoprotein interactions occur within the interstitial space as a result of reverse cholesterol transport.8 There was an increase in the pre-{alpha} and pre-ß populations with a corresponding decrease in the {alpha} population in the lymph.8 Because the difference between plasma and lymph lipoproteins probably represents a combination of (1) interaction of lipoproteins with the peripheral cells, (2) filtration through the interstitial matrix, and (3) interactions of the lipoproteins with the capillary endothelium, lipid analysis of these lipoproteins may shed some light on these processes. Recently, the existence of a pre-{alpha} particle was confirmed independently by another laboratory.9 Because of the observed differences in apoA-I subpopulations between plasma and lymph, as well as our description of a previously uncharacterized population of lipoproteins (pre-{alpha}), we have undertaken to characterize the subpopulations with respect to their chemical composition.

In this article, we report that there were differences in chemical composition between plasma and lymph pre-{alpha} particles and differences between plasma {alpha} and plasma pre-{alpha} particles. There was little difference between plasma and lymph {alpha} particles or between lymph {alpha} and pre-{alpha} particles. By quantifying the apoA-I in these subpopulations, we were able to estimate that pre-ß particles contained one molecule of apoA-I, {alpha} particles contained two molecules of apoA-I, and pre-{alpha} particles contained four molecules of apoA-I.


*    Methods
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up arrowAbstract
up arrowIntroduction
*Methods
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Materials
Purpose-bred male foxhounds were purchased from the Department of Veterinary Medicine, Louisiana State University, Baton Rouge. Unless otherwise stated, all solvents (eg, chloroform, methanol, hexane) were of HPLC grade and were purchased from Mallinckrodt (Baxter Scientific). Agarose was from FMC. Capillary gas chromatography columns (0.3 mm ID, 7.5 m) were from J&W Scientific. Lipid standards were from Serdary Research Laboratories. Silation reagent (BSTFA) with 1% (TMCS) was from Pierce Chemical. All other chemicals were from Sigma Chemical Co.

Procedures
Our methods for dog lymphatic cannulation and lymph collection have been described.10 The technique for two-dimensional gel electrophoresis of lipoproteins has also been described.7 Agarose electrophoresis was performed as previously described.8 We defined the apoA-I–containing lipoproteins by their electrophoretic mobility on agarose gels. Typically, 150 to 200 gels, in sets of four each, were run. A 0.5% agarose ME (medium electroendosmotic) was used for isolation of plasma and lymph lipoprotein fractions. After the electrophoresis, the gels were aligned and the ß, pre-ß, {alpha}, and pre-{alpha} segments excised. For evaluation of the completeness of separation of the fractions, one of every four gels cut was routinely subjected to re-electrophoresis on agarose gel and probed. This is shown in Fig 1Down for a typical lymph sample. It can be seen in the figure that contamination of the pre-{alpha} from {alpha} fractions is minimal. The same is true of contamination of the pre-ß from {alpha} fractions. The {alpha} fractions always contained some contamination with pre-{alpha} particles. It is estimated that {alpha} contained 5% to 10% pre-{alpha}–derived apoA-I. The excised gels were then placed into polycarbonate tubes and the lipoproteins were recovered by spinning of the gels in a Ti 50.2 rotor (Beckman) at 40 000 rpm for 1 hour. Recovery was typically from 90% to 95% as determined by the free cholesterol concentration (Table 1Down). After an aliquot was taken for apolipoprotein and phospholipid analyses, the remaining lipoprotein fractions were lyophilized by use of an Edwards lyophilizer (Edwards High Vacuum). Lipid was extracted from the lyophilized fractions by use of the method of Folch et al.11



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Figure 1. Immunoblot of routine reanalysis of electrophoretically separated lipoproteins. After agarose electrophoresis, the fractions were excised for lipid and apoprotein analyses. One of four of the excised agarose gels was also subjected to reanalysis by agarose gel electrophoresis to ensure that the proper fractions were analyzed.


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Table 1. Lipid Composition of ApoA-I–Containing Lipoproteins

After solid-phase extraction of the phospholipids,12 total lipid analysis was performed by gas-liquid chromatography by use of the method of Kuksis and colleagues.13 14 The analysis was performed on a Hewlett-Packard model 5890 gas chromatograph with automatic on-column sample injection (Hewlett-Packard). Injector temperature was 40°C. Temperature programming was 40°C for 0.5 minutes, 30°C/min to 150°C, 20°C/min to 230°C, and 6°C/min to 340°C and holding at 340°C for 3.5 minutes. Hydrogen carrier pressure was 6 psi constant flow at 40°C.

Protein determination was by the method of Lowry et al.15 Apolipoprotein analyses were by slot blot (L.W. et al, unpublished data, 1995). Plasma and lymph fractions were diluted with PBS (0.01 mol/L sodium phosphate, pH 7.4, with 0.145 mol/L NaCl) containing 0.01% BSA. The samples were then applied in triplicate to a slot blot apparatus attached to a vacuum source. A standard curve was also constructed by use of a standard plasma of known apoA-I concentration. After 25 µL of each sample was applied to each slot, the membrane was removed, incubated for 10 minutes in PBS with 0.03% glutaraldehyde for 10 minutes, and washed twice and then incubated with PBS with 5% nonfat dry milk and 0.05% Tween-20 for another 10 minutes. Immunolocalization occurred when membrane was incubated in a solution containing PBS with 0.05% Tween (PBST) with 5% nonfat dry milk and the specific anti-dog apolipoprotein antisera. Incubation was at room temperature for 3 hours. The membrane was again washed three times for 5 minutes each time with PBST. The membrane was then incubated with iodinated anti-goat antibody, also for 3 hours, and washed as above. After the final wash, the membrane was completely dried and exposed on the PhosphorImager (Molecular Dynamics) cassette. Data were quantified on the phosphoimaging device. Phospholipid analyses were by the method of Zilversmit and Davis.16


*    Results
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up arrowMethods
*Results
down arrowDiscussion
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Almost all of the cholesterol content of dog plasma is transported in particles with HDL densities. Cholesterol levels of VLDL+IDL in the dog are only 5% of the total plasma content.17 If we assume that most of the apoB-containing lipoproteins are in VLDL+IDL, we see that only 5% of the total plasma apoB is found in peripheral lymph.17 Therefore, the amount of VLDL+IDL in the interstitial fluid would be less than 0.5% of that in plasma. In addition, we have determined that no apoA-I exists in the peripheral lymph VLDL+IDL fraction.17 To determine the presence of other lipoproteins in the fractions isolated, we subjected the fractions to SDS–polyacrylamide gel electrophoresis followed by immunoprobing with antibodies to dog apoB, apoE, apoA-I, and apoA-IV (data not shown). We reasoned that the presence of apoB and apoE may signify the presence of VLDL+IDL. The plasma pre-ß fraction showed immunoreactivity to apoB, apoE, apoA-I, and apoA-IV. Therefore, it would appear that the plasma pre-ß fraction is contaminated with other lipoproteins. In contrast, lymph pre-ß lipoproteins showed immunoreactivity only to apoA-I. Plasma and lymph {alpha} and pre-{alpha} fractions also showed immunoreactivity only to apoA-I. We interpret this to indicate that contamination with other lipoproteins is minimal and not likely to interfere with our determinations. A typical plasma and lymph profile of apoA-I is shown in Fig 2Down. The experimental molecular weights are shown in Table 2Down. The percent lipid distributions of the plasma and lymph lipoproteins are shown in Fig 3Down. From this figure it can be seen that there were both relative concentration and compositional differences between plasma and lymph pre-{alpha} lipoproteins. The plasma pre-{alpha} lipoproteins contained more triacylglycerol (16% versus 4%) and less phospholipid (56% versus 71%) than the lymph pre-{alpha} lipoproteins. Interestingly, there were no major differences between plasma and lymph {alpha}-migrating particles (9% free cholesterol, 20% cholesterol ester, 1% triacylglycerol, and 70% phospholipid). There were differences between plasma and lymph pre-ß particles. The plasma pre-ß particles contained more cholesterol ester (30% versus 13%) and less phospholipid (45% versus 61%) than lymph pre-ß particles. Triacylglycerol (9% versus 11%) and free cholesterol (16% versus 15%) amounts were similar between plasma and lymph pre-ß lipoproteins.



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Figure 2. Immunoblot of two-dimensional gel electrophoresis of apoA-I. Top, two-dimensional NONDEGRA-PAGE of plasma lipoproteins. The procedure has been described in a previous report.7 As opposed to results with human plasma, NONDEGRA-PAGE of dog plasma indicates the presence of only pre-ß1 and no high-molecular weight pre-ßs. Bottom, two dimensional NONDEGRA-PAGE of lymph lipoproteins. Note that approximately 50% of the lymph lipoproteins is in the pre-ß and pre-{alpha} fractions.


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Table 2. Particle Diameter and Molecular Weights of ApoA-I–Containing Particles



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Figure 3. Pie graphs show lipid composition of electrophoretically separated fractions. The results are data from 10 separate analyses (one animal per analysis). These results are expressed as percent of total lipid mass, excluding apolipoprotein content. Note the similarities between lymph (L) and plasma (P) {alpha}-migrating lipoproteins. Note also the difference between plasma and lymph pre-{alpha} particles. The graph of the lymph pre-ß lipid composition represents the first complete lipid analysis of pre-ß particles.

We have previously shown that lymph had a higher weight ratio of free to esterified cholesterol than did plasma,9 and we wondered where the increase in free cholesterol would reside in the lymph lipoprotein fractions. A plot of the free cholesterol–to–esterified cholesterol ratios of the lipoprotein fractions, illustrated in Fig 4Down (top), showed that all the lymph fractions are enriched in free cholesterol, with lymph pre-ß showing the greatest increase, followed by lymph {alpha} particles and lymph pre-{alpha} particles. The ratio of free cholesterol to phospholipid, illustrated in Fig 4Down (bottom), showed that both lymph and plasma pre-ß had the highest ratio of free cholesterol to phospholipid. The {alpha} and pre-{alpha} fractions had similar ratios, with lymph particles having slightly higher ratios than plasma.



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Figure 4. Bar graphs show lipid weight ratios of electrophoretically separated lipoproteins. Top, ratios of free to esterified cholesterol for plasma and lymph lipoproteins. Lymph lipoproteins are all enriched in free cholesterol, with lymph pre-ß particles being the most enriched. Bottom, ratios of free cholesterol to phospholipid for plasma and lymph lipoproteins. The plasma and lymph {alpha} and pre-{alpha} particles have essentially the same ratio of free cholesterol to phospholipid, whereas the plasma and lymph pre-ß particles have substantially higher ratios of free cholesterol to phospholipid. Note that our plasma pre-ß ratio of 0.22 was in excellent agreement with that reported by Castro and Fielding5 of 0.19.

For calculation of the stoichiometry of these particles, data from a set of three dogs were used. The plasma and lymph lipoprotein fractions were analyzed for lipid components and for apoA-I. The results are shown in Table 1Up. The majority of the lipid and apoA-I in plasma resided in the {alpha} fraction. Plasma pre-ß and pre-{alpha} accounted for 10% and 3% of the total plasma apoA-I, respectively. In contrast, lymph pre-ß and pre-{alpha} accounted for 14% and 37% of the total lymph apoA-I. By assuming a weighted average molecular weight for phospholipid (645 D), cholesterol ester (813 D), and triacylglycerol (886 D), we could calculate the stoichiometric relationship of the plasma and lymph particles. The results are presented in Table 3Down. Also presented in Table 3Down are the calculated molecular weights of the lipoprotein fractions. Because molecular weight standards were routinely run with NONDEGRA-PAGE, we could compare the calculated molecular weight with observed average molecular weights of particles in each mobility class (see Tables 2Up and 3Down). The calculated molecular weights of most particles were consistent with the actual determined molecular weights. Plasma and lymph pre-{alpha} particles probably contain four molecules of apoA-I, and plasma and lymph {alpha} particles probably contain two molecules of apoA-I. Lymph pre-ß particles probably contain one molecule of apoA-I. The calculated molecular weight of the plasma pre-ß particle did not correspond to that of the observed molecular weight. In view of our previous observation that plasma pre-ß particles contained apoE and other apolipoproteins, they were probably contaminated by other lipoproteins. Therefore, the lipid composition of plasma pre-ß particles was most likely a composite of different apoprotein-containing lipoproteins.


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Table 3. Calculated Lipid Composition of Dog Plasma HDL


*    Discussion
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up arrowResults
*Discussion
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Phillips et al18 and Wille et al19 have used agarose gel electrophoresis to identify a pre-{alpha} lipoprotein. The lipoproteins identified by these two groups showed a high lysophosphatidylcholine level, possibly because of the high albumin content of the fraction. The lipoproteins that we identified, however, migrate ahead of those they identified.

The isolation of lipoproteins from the plasma and lymph of dogs by electrophoretic mobility would result in lipoproteins having limited purity. Two sources of impurities are considered: contamination by plasma proteins and contamination by other lipoproteins. In plasma, apoA-I–containing pre-ß lipoproteins comigrated with VLDL+IDL to the same electrophoretic mobility. In addition, in human plasma, Castro and Fielding5 defined three populations of apoA-I–containing pre-ß–migrating lipoproteins (pre-ß1, pre-ß2, and pre-ß3). Dog plasma and lymph lipoprotein patterns are simpler. Dogs have only one population of pre-ß–migrating apoA-I–containing lipoproteins (pre-ß1)8 and two molecular weight populations of {alpha} and pre-{alpha} lipoproteins. However, contamination by other lipoproteins cannot be ruled out. We tested for these contaminations immunologically. Our tests showed that plasma pre-ß fractions were indeed contaminated by other lipoproteins (VLDL+IDL and apoA-IV–containing lipoproteins). However, lymph pre-ß lipoproteins did not show such contamination by VLDL+IDL. Contamination by plasma proteins was ignored in all fractions because the plasma proteins do not bind significant amounts of lipid. We should also emphasize that the calculated stoichiometric compositions of plasma and lymph lipoproteins are averages of the two molecular weight populations of {alpha} and pre-{alpha} lipoproteins.

This is the first report of the lipid composition of plasma and lymph pre-{alpha} and lymph pre-ß particles. The lipid composition of plasma {alpha} and pre-{alpha} particles suggests that these two lipoprotein populations are clearly distinct from each other. Plasma and lymph {alpha} particles have similar compositions (Fig 3Up). This makes it likely that lymph lipoproteins with {alpha} mobility are derived directly from plasma lipoproteins with {alpha} mobility. The similarity of composition between plasma and lymph {alpha} lipoproteins suggests that either the {alpha} lipoproteins did not pick up any lipids after they crossed the interstitial space or that after interaction with cells the {alpha} lipoproteins acquire a different mobility. The lipid composition of plasma pre-{alpha} particles is significantly different from lymph pre-{alpha} particles. Plasma pre-{alpha} lipoproteins contained more triacylglycerol than lymph pre-{alpha} lipoproteins. The increased triacylglycerol content of plasma pre-{alpha} lipoproteins is probably caused by the action of cholesterol ester transfer protein (CETP). The dog has low but detectable CETP activity20 ; therefore, the triacylglycerol could come from the exchange of cholesterol ester for triacylglycerol. The fate of the plasma pre-{alpha} lipoprotein triacylglycerol after it crossed the capillary wall is enigmatic. Because the lymph pre-{alpha} lipoprotein did not have high triacylglycerol, it seems likely that the lipid is either hydrolyzed by lipases in the interstitial space or removed as the particles cross the capillary wall. Indeed, we have found lipoprotein lipase but not hepatic lipase in the peripheral lymph.21 One consideration is whether lymph pre-{alpha} particles could be derived from plasma pre-{alpha} particles. The concentration of apoA-I in peripheral lymph is only 10% of that of plasma. Because the lymph pre-{alpha} particles have molecular weights similar to those of plasma {alpha} and pre-{alpha} particles, we would expect the same amount of pre-{alpha} particles to be filtered through the interstitial space as that of plasma {alpha} lipoproteins (10%). By analyzing the absolute concentration of apoA-I from plasma and lymph pre-{alpha} fractions (plasma has 6 mg/dL apoA-I and lymph has 8 mg/dL apoA-I), we conclude that only 0.6 mg/dL of lymph pre-{alpha} particles could come from plasma. The vast majority (7.4 mg/dL) of the lymph pre-{alpha} particles must be derived from other particles. This conclusion leaves open the possibility that lymph pre-{alpha} particles may be generated in part within the interstitium. The most likely source of lymph pre-{alpha} particles is the lymph {alpha} particles. Evidence in support of this latter suggestion is our observation that the lymph pre-{alpha} and {alpha} particles have very similar lipid compositions (Fig 3Up). As to the fate of the majority of plasma pre-{alpha} particles (5.4 mg/dL), they could simply be taken up by the liver. Bamberger et al22 have provided evidence that hepatic lipase stimulates the uptake of HDL cholesterol in liver cells. It is conceivable that the plasma pre-{alpha} lipoproteins, with their high triacylglycerol content, are good substrates for hepatic lipase.

Lymph lipoproteins have a higher ratio of free to esterified cholesterol mass9 than plasma lipoproteins. An analysis of the electrophoretically separated fractions showed that pre-ß, {alpha}, and pre-{alpha} all had higher ratios of free to esterified cholesterol mass (Fig 4Up), but lymph pre-ß particles had the highest ratio of all. When data were expressed as molecules per unit apoA-I, lymph pre-ß particles had 10 molecules of free cholesterol to 7 molecules of cholesterol ester.

Several investigators have proposed that the ratio of free cholesterol mass to phospholipid mass on a lipoprotein particle is more important than the apolipoprotein species in determining the ability of the particles to accept or donate cholesterol from or to the cell.23 24 If the ratio is high, then the net flux is from particle to cell membrane; otherwise, it is the reverse. This hypothesis would predict that both plasma and lymph pre-ß particles function as net donors of cholesterol to cells, whereas the other particles are cellular cholesterol acceptors. Our data for dog plasma pre-ß lipoproteins' ratio of free cholesterol to phospholipid is in excellent agreement with that reported by Castro and Fielding5 for human pre-ß1 particles (0.19 versus 0.22). The observation that such a particle is in fact a good cellular cholesterol acceptor suggests that either lymph pre-ß particles result from the combination of cell-derived cholesterol and another apoprotein A-I–containing particle or that factors other than the ratio of free cholesterol to phospholipid play a role in cellular cholesterol efflux. Indeed, Fielding and Fielding6 have found a unique epitope on pre-ß1 particles that may also be responsible for cholesterol efflux. It should be pointed out that the hypothesis concerning ratios of free cholesterol to phospholipid was studied with recombinant HDLs, whereas our experiments, and those of Castro and Fielding5 were carried out with native lipoproteins. Even though lymph {alpha} and pre-{alpha} lipoproteins have a higher ratio of free to esterified cholesterol, their ratio of free cholesterol to phospholipid may not be high enough to make them net cholesterol donors. Although it is unlikely, we cannot rule out the possibility that plasma and lymph pre-ß particles may be generated in their respective compartments and that the two are independently formed.

Once the lipid and apolipoprotein contents of these lipoproteins are known (Table 1Up), it is not difficult to calculate the stoichiometric relationship of apoA-I to other lipids. Our data suggest that pre-ß particles contain one molecule of apoA-I. This is similar to the observation of Castro and Fielding,5 who reported partial lipid data for pre-ß1 particles. That {alpha} particles contained two molecules of apoA-I is consistent with previous reports.25 26 Using chemical crosslinking, Swaney26 and others have found that HDL2 contained four molecules of A-I per particle. The pre-{alpha} particles, which contained four molecules of apoA-I per particle, may very well be part of HDL2. Determined on the basis of the calculated molecular weight, the data are within experimental error of the results found by use of our NONDEGRA-PAGE technique. However, as determined by the amount of apolipoprotein, this particle is relatively lipid poor and may not be stable. We postulate that this particle is formed by the combination of four pre-ß particles or by the relative delipidation of {alpha} particles. Whether this particle is converted to other forms is also not known. Clearly, more studies are needed to clarify these questions.

Because lymph pre-{alpha} and {alpha} particles have similar lipid compositions, the difference in charge between the two particles is most likely caused by a difference in phospholipid amount (56% versus 71%) and species (for example, an increase in phosphatidylethanolamine and phosphatidylinositol). The amount of material we recovered is insufficient for us to conduct a detailed phospholipid analysis of the different particles.

In conclusion, we have provided lipid composition data on dog plasma and lymph lipoprotein particles separated by electric charge. Their differences and similarities with respect to cholesterol metabolism have also been discussed.


*    Acknowledgments
 
This research was supported by NIH program project grant HL-25596. We wish to thank our colleagues Dr J.J. Thompson and Dr Lucille Lee for their many suggestions and discussions. We also wish to thank Dr A. Kuksis of the University of Toronto and Dr P. Dolphin of Dalhousie University for their help in setting up the gas-liquid chromatograph for lipid analyses. The expert technical assistance of Kati Horvath, Asya Shoichet, Chandra Tate, and Colleen Tierney is gratefully acknowledged.

Received April 24, 1995; accepted August 14, 1995.


*    References
up arrowTop
up arrowAbstract
up arrowIntroduction
up arrowMethods
up arrowResults
up arrowDiscussion
*References
 

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