血脂检测临床应用的有关问题

Related problems on clinical application of plasma lipids assay n Professor zhou xin n Department of Laboratory Medicine, n Zhongnan hospital of wuhan university. n Dr. Sheng-kai Yan , PhD n Department of Laboratory Medicine, n Peking Union Medical College Hospital All kinds of lipids in plasma were called blood lipids Total cholesterol， TC free cholesterol cholesterol ester Neutral fatty triglyceride， (TG) non esterified fatty acid （ free fatty acid ， FFA） phospholipid , glucolipid Lipids were insoluble in water ,they were transported in the form of lipoprotein Plasma lipids Plasma lipoprotein LDL Lp(a) VLDLIDLHDL structure of lipoprotein Clinical items for lipids detection n total cholesterol， TC n triglyceride， TG n high density lipoprotein cholesterol， HDL-C n low density lipoprotein cholesterol， LDL-C n apolipoprotein A1， ApoA1 apolipoprotein B， ApoB n lipoprotein(a) n The first four items were routine test ,and should be carried out in healthy examinations Cinical items for lipids analysis (2) n FFA n Cerebroside esterceramide n Sphingenine Sphingomyelin n Galactode-cerebroside Genotype n ApoE genotype ApoCIII genotype n ApoCII genotype Apo(a) genotype n LDLR genotype VLDLR genotype n HMGCoAR genotype SR genotype Cinical items for lipids analysis (3) Preanalytical Factors Affecting Lipid Test Results The following factors may cause preanalytical variations n Biological factors Individual biological variations, gender, age, and race, etc. n Life-style factors diet, obesity, smoking, stress, alcohol, and coffee intake, and exercise, etc. Behaviour factors (1) Diet n The food containing abundant unsaturated fatty acid can decrease the level of TC, LDL-C, apoB and TG. n The food containing abundant saturated fatty acid can elevate TC, LDL-C . n The food containing abundant fiber can reduce the leval of TC. n The levels of LDL-C and Lp(a) in vegetarians were lower (37 , 35 respectively) than non- vegetarians, while HDL-C were higher than that of 12 . Behaviour factors (2) Obesity TG， TC and LDL-C HDL-C Lost weight TG （ 40） TC（ 10 ） LDL-C （ 10 ） HDL-C （ 10 ） Smoking TG, LDL-C and Lp(a) apoA and HDL-C HDL-C Behaviour factors (3) Behaviour factors (4) Alcohol abuse n HDL-C, apoA ,apoA （ 1.2 oz/d or 34g/d） n Primry hypertriglyceridemia with mild drinking can lead to the level of TG increased further . n Alcohol has different effects on Lp(a) from other lipids . at the begin Lp(a) 33% six weeks later Lp(a) back to initial level n Proper drinking red wine can decrease the level of Lp(a) . Behaviour factors (5) nCoffee TC and LDL-C apoA , apoA , apoB and HDL-C seemed not be affected. nTension TC Hospitalization HDL-C and apoA ( 10 ) Behaviour factors (6) Exercise TG、 LDL-C and apoB HDL-C and apoA The degree was related to the kinds of sports and intensity. Intense exercises can increase the level of HDL-C obviously. Moderate regular exercises was a ideal way to decrease the level of blood lipid. Normal exercises have no influences on the level of Lp(a) ， while intense physical activity can increase the level of Lp(a) by 10 15 . Clinical factors therapeutic drugs (1) Antihypertensive agents n for example thiagine（ diuresis drug） can increase the level of TC, LDL-C, TG and apoB by 12%、 20%,7%, 20% respectively , decrease the leval of apoAI and HDL-C by 6% and 16% . n Beta-neg（ receptor blocker ） can increase the level of TG and decrease the leval of HDL-C. Estrogen n Oral taking contraceptive with progesterone can increase the leval of TC and LDL-C,and decrease the leval of HDL-C . n Estrin treatment can decrease the leval of Lp(a) by 50% . nImmunosuppressive agents Codelcortone can increase the level of TC, LDL-C, HDL-C, TG, apoA and apoB. Ciclosporin can increase the level of TC, LDL-C, apoB， and decrease the level of Lp(a) . Tacrolimus FK506 can decrease the level of TC. Clinical factors therapeutic drugs (2) The division of abnormal lipids level The lipid level was diverse in different nation and area. It has been suggested that the level which can increase the risk of CHD obviously should serve as the division standard for abnormal level of lipid, meanwhile we claim to formulate the therapeutics destination and intervene the procedure according to the level . suggestions n Adopt the standards of suggestions on prevention and cure lipid abnormality in china. Risk rate TC and CHD Plasma TC Medical decision level for lipid assay mmol/L(mg/dl) n index china （ 1997） NCEP-ATP n Serum TC n Suitble leval 5.20(200) 5.20(200) n margine increase 5.23-5.69(201-219) 5.20-6.21(200-239) n Increse 5.72(220) 6.24(240) n Serum LDL-C n Suitble leval 3.12(120) 3.38(130) n margine increase 3.15-3.61(121-139) 3.38-4.13(130-159) n Increse 3.64(140) 4.16(160) n serum HDL-C n Suitble leval 1.04(40) 1.56(60) Is a n negative risk factor of CHD n Decrese 0.91(35) 0.91(35) Is a n risk factor of CHD n Serum TG n Suitble leval 1.70(150) 2.26(200) n margine increase 2.26-4.52(200-400) n Increse 1.70(150) 4.52(400) The classification of lipid level in ATP-III of the American National choleterol education project, mmol/L(mg/dl) n LDL-C TC HDL-C TG leval judgement 6.24(240) 1.56(60) 2.265.64(200499) high n 4.92(190) 5.65(500) very high n 300mg/L was abnormal (recommend) Lp(a) is an independent risk factor of atherosclerosis n Lp(a) increased Acute phase reaction : AMI, operation, acute wound 、 acute inflammation, last stage of nephrosis， nephrotic syndrome， maglinant tumor except for liver cancer， pregnancy and so on. Cinical significance of lipid assay (6) n The risk of AS was higher in low HDL-C anemia. n The lower the level of HDL-C , the higher the risk of AS . n When the HDL-C decreased by 1%, the risk of CHD might increase by 2%. Cinical significance of lipid assay (7) Progression Regression ? ? ? ? ? ? HDL LDL VLDL IDL Lp(a) RLP Im goodIf treatable, were not that bad! The Good The Bad The Ugly? Plasma HDL-C level was affected by following diseases secondary ： acute disease: AMI、 operation, adustum、 acute inflamation diet with low fat and high sugar smoking, obesity hypomotility hormone decrease drug: receptor blocking phamacon secondary ： alcohol abuse primary biliary cirhosis CETP activity increase HTGL activity decrease drug-induced： ACH、 insulin、 estrogen、 Micotinamide and its inductor 、 HMG-CoA reductase blocker、 chlorinated hydrocarbons primary ： Tanger desease LCAT deficiency apoA sbnormality familial hypercholesterolemia famililial compated hyperlipidemia primary ： CETP deficiency HTGL hypoactivity（ macula opacity） apoA1 synthesis accenton HDL receptor abnormality HDL-C decreasedHDL-C inceased hereditary Lipid metabolic disorder lipoprotein gene deficiency lipoprotein receptor gene deficiency lipid metabolic enzyme gene deficiency cytolysosome lipid metabolism enzyme gene deficiency Cinical significance of lipid assay (8) for instance : Lysosomal hydrolase hereditary defect , phospholipid metabolism disorder were very common. Gene analysis of lysosomal storage disease The Structure and Function of Lysosome Lysosome was such a kind of organelle like a film in the cell, with a cystiform structure,and it contained many kinds of hydrolase,it worked so that it can break down many kinds of endogenous and exogenous substance, so it was also considered as a peptic in the cell. Phospholipid could be divided into glycerophospholipide and sphingolipid; the latter could be divided into sphingomyelin and glycosylsphingolipid. The lysosome contained about 50 kinds of hydrolase, such as protease, nuclease, glycosidase, lipase, phosphatase, phosphonolipidase and sulfatidase etc. 鞘脂代谢 Sphingolipid metabolism Lysosomal lipids storage disorders disease Enzymen defect Stored lipid Clinical symptom (Fucosidosis) (Fucosidase) gene locus : 1p34 Cer-Glc-Gal-GalNAc-Gal -Fuc H-allo antigen (H-lsoantigen) cerebrum degenerate ， Convulsive tic， (Generalized gangliosidosis) (GM1-galactosidase) gene locus : 3pter-p21 Cer-Glc-Gal(NeuAc)- GalNA-Gal (GM1Ganglioside) mental aphrenia ， skeleton deform hepatauxe， (Tay-Sachs disease) (Hexosaminidase A) gene locus : 15q13.1 Cer-Glc-Gal(NeuAc)- GalNAc (GM2Ganglioside) mental aphrenia， acroisa amyasthenia Metachromatic leukodystrophy, MLD) (Arysulfatase A) gene locus : 10q21.1 Cer-Gal-OSO3 (3- suffogalactosyl- ceramide) mental aphrenia ， mental retardate in adult， demyelination (Krabbes disease) (-Galactosidase) gene locus : 14q31 Cer-Gal (Galactosylceram ide) mental aphrenia :nearly no myelin (Gaucher disease, GD) (-Glucosidase, -glu) gene locus : 1q21.1 Cer-Glc (Glucosylcerami d splenohepatomegali a， Bone causticize ， mental retardate in youge child (Niemann-Pick disease) (Sphingomyelinase,AS M) gene locus : 11p15.1-p15.4 Cer-_P- (Sphingomyelin) splenohepatomegal mental retardate Die in youge child (Farber disease,) (Ceramidase) Acyl-(Ceramide) Acyl- (Ceramide) NeuAc,(N-acetylneuraminic acid)； Cer， (ceramide)； Glc， (glucose)； Gal, (galactose)； Fuc， (fucose)； -enzyme action site 1. complete physical examination 2. cytological examination of marrow and peripheral blood cells mainly finding the large foam cells. 3. determination of routine biochemical indicator especially the lipid level and functional examination of liver and kidney. Laboratory diagnosis of hereditary lysosomal lipids storage disease Gaucher cell Niemann-Pick cell？ 4. lysosomal enzyme activity assay vChitotriosidase, CT To identify diagnosis of Lipids Storage Disease Gaucher disease increased lightly Niemann-Pick disease more than 100 times vSphingomyelinase To confirm the diagnosis of Niemann-Pick disease. vGlucocerebrosidase To Confirm the diagnosis of Gaucher disease. 5. High performance liquid chromatogram , HPLC To analyze the composition of lipids To detect the enzymes activity 6. Physical examination To check up the pathological changes of liver, spleen, skeleton and brain. 7. Gene analysis If the basic mutations resulted in the substitution of amio acids or the nucleotide depletions and/or insertions were identified, you can get a final diagnosis. The lipid detection while the level of TC was normal Serum : TC=VLDL-C+LDL-C+HDL-C for instance： A and B were two person taken healthy examination n TC=VLDL-C+LDL-C+HDL-C A. TC = 0.5 + 2.9 + 1.7 = 5.1 B. TC= 0.6 + 3.7 + 0.8 = 5.1 A. TC is normal HDL-C 0.9mmol/L LDL-C3.12 n So B have a higher risk of AS than A. Lipoproteins which resulted in AS n CM and VLDL remnants n Modified LDL n Small dense LDL n Lp(a) Liver Artery Transportation of TC Physiological functions of HDL and LDL Transportation of TC Non-HDL-C n In ATP , non-HDL-C was recommend to regard as a second treatment target for high TG patient. n When the chief treatment target arrived, while the level of TG was still high(TG 2.26 mmol/L ), non-HDL-C should be assisted in minitoring therapeutic efficiency n In ATP , Patient , TG was in marginal (1.702.25mmol/L ), was suggested to change life style ,and neednt to calculate non-HDL-C . The standard value and target value for hyperlipidimia received treatment (China 1997) AS (-) TC 5.72 mmol/L Other risk （ 220.0mg/dl ） factor(-) Ldl-c 3.64 mmol/L （ 140.0mg/dl ） AS (-) TC 5.2 mmol/L Other risk （ 200.0mg/dl ） factor(+) Ldl-c 3.12 mmol/L （ 120.0mg/dl ） AS (+) TC 4.68 mmol/L （ 180.0mg/dl ） Ldl-c 3.64 mmol/L （ 100.0mg/dl ） Drug therapy Diet Target value TC 6.24 mmol/L（ 240.0mg/dl ） Ldl-c 4.16 mmol/L （ 160.0mg/dl ） TC 5.72 mmol/L（ 220.0mg/dl ） Ldl-c 3.64 mmol/L （ 140.0mg/dl ） TC 5.20 mmol/L（ 200.0mg/dl ） Ldl-c 3.12 mmol/L （ 120.0mg/dl ） TC 20%） 100mg/dl 100.0mg/dl ） 2.59.3.36mmol/Lconsidering if drug treatment needed 2 risk factor 20%） 100mg/dl ， (can select objective： 70mg/dl) especially patient with very high risk ) 100mg/dl 100mg/dl (100mg/dl ;may regard medicine) milddling risk： 2 risk agent （ 10 years risk is 10 20 ） 130mg/dl ( can select objective： 100mg/dl 130mg/dl# 130mg/dl (100-129md/dL; ;may regard medicine) milddling risk ： 2 risk agent （ 10 year risk10%） 130mg/dl 130mg/dl 160mg/dl low risk： 0 1 risk agent 160mg/dl 160mg/dl 190mg/dl (160-190mg/dl； ;may regard medicine decresing LDL) pay attention to several problems Several incorrect concepts n HDL-C HDL n HDL-C is merely a part of HDL， but can reflect the HDL in the blood n nLDL-C LDL n LDL-C is merely a part of LDL， but can reflect the LDL in the blood Reasonable selection and application of lipid items n Clinical routine lipids assay should include at least four items: TC, TG,HDL-C and LDL-C. n Merely measured TC and TG cant reflect basic lipids level n Some cases were not suitable to calculate LDL-C by Friedewald formula CM existed in plasma； TG 4.52mmol/L (400mg/dl)； Abnormal beta-lipoprotein existed type hyperlipidemia (HLP) (1) Reasonable selection and Application of lipid items (2) Cases needed to measure plasma ApoAI and ApoB ： n Unsure if there were any risk factors in the patient with cardiovascular or cerebrovascular disease, but the routine lipids items were normal. n The youth and middle-aged men suffering from cardiovascular or cerebrovascular disease. n Persons have the family histoty of early onset of AS. n Family member with low ApoAI and high ApoB . Reasonable selection and Application of lipid items (3) Cases needed to measure plasma Lp(a) n Unsure if there were any risk factors in the patient with cardiovascular or cerebrovascular disease, but the routine lipids items were normal. n The youth and middle-aged men suffering from cardiovascular or cerebrovascular disease. n Patients with the family histoty of early onset of AS. n Family member with high Lp(a) . n HDL-C represented the metabolism status of cholesterol and transported by HDL. ApoAI can reflect the capacity of HDL, but increasing or decreasing of ApoAI was not in proportion to HDL-C. nTo measure the level of ApoAI and HDL-C at one time was helpful to analyze the pathologic and physical status. ApoAI or HDL-C can not represent HDL , they were all necessary to be measured. HDL-C and ApoAI shoud not replace with each other LDL-C and ApoB shoud not substitute for each other n In general , the level of ApoB can represent LDL,and it was a positive correlation with LDL C. n LDL was a kind of lipoprotein which contained different size of particles and diverse compositions, and it can be divided into LDL1 ( type A) and LDL2 (type B). n In hypertriglycerdemia, the level of the small dense LDL may increase, LDL-C may be normal but apoB elevated obviously, so the two items cant be substitute for each other. Risk factors diagnostic criteria n Lipid index can be served to estimate the risk of CHD, but they wre not diagnostic criteria. n We should avoid to use