HDL-C Transport and
Atheroprotection
by Jane V. Mulcahy and Jim S. Owen
For years, LDL has riddle: a small drop of blood
dominated research into
cholesterol metabolism.
The lower interest in
A contains over five hundred
thousand trillion particles
of one particular type that serve to
HDL was due to a lack of protect us from a variety of environ-
mental insults. These particles have
knowledge about HDL antioxidant, antiparasitic, and anti-
receptors, but also to the inflammatory actions; they can
fact that clues about neutralise endotoxins and modu-
HDL’s functions did not late our immune response; and
they have diverse beneficial effects
fit the prevailing para-
on vascular tone. What are they?
digm of lipoprotein They can be described as “multi-
receptor activity. The molecular, pseudomicellar, quasi-
recent discovery of two spherical particles,” but this offers
key proteins in HDL little clue to their identity. That
they also transport lipid molecules
metabolism, SR-BI
is a strong pointer. And if this is
and ABCA1, has rekin- refined to “the good cholesterol car-
dled interest in HDL. rier,” then their identity is almost
Today, thinking about certainly revealed. They are HDL,
cholesterol has switched or high-density lipoproteins.
Emerging evidence supports
from controlling raised such protective effects of HDL, un-
LDL levels alone to also related to lipid transport. Yet, one
correcting low HDL biological function of HDL over-
levels. New therapies shadows the others: its role in intra-
acting on HDL transport vascular cholesterol metabolism.
This is not surprising. While
may offer athero- cholesterol is an essential constit-
protection by raising uent of cell surface membranes,
HDL levels, but may also and the precursor of bile acids and
promote regression of steroid hormones, it also has a
existing atherosclerotic dark side and is implicated in the
pathology of several diseases: most
lesions by accelerating commonly, coronary artery disease
cholesterol efflux and gallstones, and most recently,
from lipid-laden cells. Alzheimer’s disease and HIV. This
Janus-faced character of choles-
terol has fascinated scientists and
physicians for over 100 years, and
the molecule has yielded more
than a dozen Nobel laureates.
76
The story is far from exhausted,
as important new facets of choles-
terol’s role in cell biology have
emerged. These include the recog-
nition that some proteins have a
cholesterol-sensing domain that
regulates their activity, while oth-
ers, important for embryonic devel-
opment, are modified by covalent
attachment of cholesterol. Another
discovery concerns the complex-
ities of intracellular cholesterol
trafficking, which are integral to
controlling protein distribution
within organelles and to formation
of membrane microdomains.
In this paper, we focus on an
additional area: the role of HDL in
centripetal cholesterol transport
and its atheroprotective action,
highlighting two newly described
cell-surface proteins — SR-BI (scav-
enger receptor class B, type I) and
ABCA1 (ATP-binding cassette
transporter, class A1).
HDL Consists of
Multiple Subclasses
Lipoproteins comprise a function-
ally and metabolically interlinked
family of spherical, macromolecu-
lar particles that primarily serve to
ferry water-insoluble lipids around
the circulation.
In brief, chylomicrons and very-
low-density lipoproteins (VLDL)
are synthesized in the gut and liver,
respectively, as large particles to
transport energy-rich triglycerides
to muscle or adipose tissue. Low-
density lipoproteins (LDL), the
catabolic product of VLDL, deliver
SCIENCE & MEDICINE
 Phospholipid
Free
cholesterol
Polypeptides
(apolipoproteins)
cholesterol to peripheral cells.
while HDL returns it to the liver
for excretion.
These lipoprotein classes share
a common structure: an oily core of
triglycerides and cholesterol esters
surrounded by a surface coat, one
molecule thick, of various amphi-
pathic polypeptides (apolipopro-
teins) and phospholipid and free
cholesterol molecules.
For HDL in particular, this rela-
tively simple organization masks a
considerable heterogeneity, and
the population of particles present
can be fractionated according to
electrophoretic mobility, density,
size, or apolipoprotein content.
Historically, lipoproteins were
first separated by electrophoresis
into lipid-staining fractions with
three different mobilities: α (HDL),
pre-β (VLDL), and β (LDL). Later,
in the 1960s, HDL particles were
recognized as heterogeneous by
their flotation characteristics in
the ultracentrifuge. One form is
relatively cholesterol-poor, HDL3
(approximately 70% of total HDL,
the major subclass), while the other
two forms have acquired extra cho-
lesterol for transport to the liver
March/April 2002
Cholesterol esters
Triglycerides
All lipoprotein classes share a common
structure: a lipid core of triglycerides and
cholesterol esters contained within a sur-
face coat of various apolipoprotein, phos-
pholipid and free cholesterol molecules.
Plasma has 10 to 20 times more HDL
particles than VLDL and LDL particles,
though HDL transports only one-quarter
of the cholesterol. Most HDL are small, 8
to 12 nm diameter and 200 to 400 kDa.
JAMES A. PERKINS
and are larger: HDL2 (25%) and
HDL1 (5%).
However, as new separation
techniques with increased resolu-
tion were introduced, it became
clear that several minor HDL sub-
populations also existed. This het-
erogeneity of serum HDL can be
reconciled with its biological role.
HDL Mediates
Reverse Cholesterol
Transport
Cells obtain cholesterol, a key struc-
tural component of membranes, by
synthesis and from LDL particles,
which they take up via specific cell-
surface receptors. Mutations in the
gene for the LDL receptor were
first identified by Joe Goldstein and
Mike Brown and are the cause of
familial hypercholesterolemia.
Human LDL has a lifespan of
2.5 days and is removed from plas- JANE V. MULCAHY
ma by binding to LDL receptors is a doctoral student supported by
that cluster in clarithrin-coated the British Heart Foundation.
JIM S. OWEN
pits, specialized invaginations in
is Senior Lecturer at the
the cell membrane. The bound LDL Department of Medicine, Royal
is internalized by receptor-mediat- Free and University College
ed endocytosis and degraded in Medical School, London.
lysosomes to release cholesterol.
77
 Heterogeneity of Serum HDL
The major HDL polypeptides are apoAI (28 kDa, ~70% Designation of HDL Subclasses by
of total protein) and apoA-II (17.4 kDa, ~20%), with Separation Technique
smaller amounts of apoE and apoC present.
Paper electrophoresis α
Standard ultracentrifugation distinguishes a bimodal Analytical ultracentrifugation HDL1, HDL2, HDL3
distribution (HDL2, ρ1.063-1.125 g/mL, and HDL3,
Preparative ultracentrifugation HDL2, HDL3
ρ1.125-1.21 g/mL), while electrophoretic separation
2-dimensional agarose preβ1-, preβ2-,
reveals minor HDL subpopulations. These include preβ-
LpAI and γ-LpE, nascent particles that contain apoAI electrophoresis preβ3-LpAI, γ-LpE
and apoE, respectively, which avidly sequester excess
cellular cholesterol.

Endogenous cholesterol synthe- sterol nucleus cannot be broken

Cholesterol is an essential constituent
of cell membranes and is the building
block for steroid hormones (e.g., proges-
terone) and bile acids (e.g., cholic acid).
It is esterified with fatty acids for storage
as cholesterol esters, either in the core of
lipoproteins or as intracellular lipid
droplets.
sis in cells and the number of
expressed LDL receptors is control-
led by negative-feedback regula-
tion. When the concentration of
cholesterol in the cell rises, tran-
scription of the LDL receptor gene
is suppressed. This delays plasma
LDL clearance and, signficantly,
allows the accumulating particles
to undergo oxidative damage by
cells or metal ions.
By contrast, when cell cholesterol
levels fall, gene transcription is
induced to enhance LDL clearance.
This mechanism explains the LDL-
lowering action of the statin drugs,
which block HMG-CoA reductase,
an enzyme in the cholesterol bio-
synthetic pathway, which functions
to deplete cell cholesterol.
A defining feature of human
cholesterol metabolism is that the
down. Cholesterol losses from the
body, to balance the input from
food and by synthesis, occur pri-
marily by fecal excretion of biliary
cholesterol and bile salts.
Thus, as peripheral cells are
unable to degrade cholesterol, they
must efflux it into the circulation,
for transport to the liver where it
can be catabolized and excreted.
This process of cholesterol removal
is termed reverse cholesterol trans-
port and is the main physiologic
function of HDL.
Imbalances in cellular choles-
terol homeostasis are prevalent in
industrialized societies. In particu-
lar, the hallmark of early athero-
sclerotic lesions is the appearance
of “foam cells,” cholesterol-ester-
engorged macrophages. These cells
arise when blood monocyte-macro-

O
Steroid Bile
OH hormone acid OH O–
synthesis synthesis
OH

Cholesterol
O OH OH
Esterification

Progesterone Cholic acid

O
CH2 O
CH2
7 7
Cholesterol ester
JAMES A. PERKINS

78 SCIENCE & MEDICINE


LDL receptor
LDL particle
Apolipo- Cholesterol
protein ester
Free
cholesterol Ligand
binding
Cell membrane
phages infiltrate damaged endo-
thelium. There, they express unreg-
ulated scavenger receptors that
engulf oxidized LDL so that the
cells inexorably accumulate choles-
terol, stored as intracellular drop-
lets of esterified cholesterol.
Factors that promote LDL oxi-
dation and cholesterol accumula-
tion within the arterial intima are
under intense investigation, wheth-
er due to genetic or environmental
causes or a combination of both.
By contrast, other contributory
factors have been neglected, partic-
ularly the failure of HDL to clear
deposited cholesterol—i.e., the rea-
son for reverse cholesterol trans-
port being ineffective. This is not
a trivial point. About half of all pa-
tients with coronary heart disease
have low HDL levels, the most
common lipoprotein abnormality.
LCAT is Needed to
Produce Mature HDL
Bulk plasma HDL, consisting of
spherical HDL3, HDL2, and HDL1,
are not secreted directly, but are
formed in plasma and the inter-
cellular space from immature or
nascent HDL by mechanisms
involving the cholesterol-esterify-
ing enzyme, lecithin-cholesterol
acyltransferase (LCAT).
March/April 2002
Free cholesterol Membranes or
storage
Receptor
recycling
Endo-
cytosis
Synthesis of
LDL receptor
Lysosome and cholesterol
Cytoplasm Nucleus
JAMES A. PERKINS
Nascent HDL are discoidal par- LDL receptors cluster in coated pits,
ticles, like hockey pucks, composed bind LDL particles, and mediate endocy-
tosis. The LDL is degraded in lysosomes
largely of apoAI and phospholipid
to release free cholesterol, while the
(lecithin) molecules, which can be
receptor recycles. As cellular cholesterol
detected in the plasma of LCAT- accumulates, synthesis of LDL receptors
deficient patients by electron micro- is suppressed. In contrast, when statins
scopy. These immature HDL avid- block endogenous cholesterol synthesis
ly sequester free cholesterol in the to reduce cell cholesterol, gene tran-
surface membrane of cells to be- scription of LDL receptors is induced to
come optimal substrates for LCAT, enhance uptake of plasma LDL.
which esterifies cholesterol using a
fatty acyl chain from lecithin. This
generates mature, spherical HDL3
and then the larger HDL 2 and
HDL1 particles.
By converting diffusible cellular
cholesterol into insoluble lipopro-
tein esters, LCAT helps drive
reverse cholesterol transport. Un-
fortunately, our understanding of
this pathway and its physiologic
and pathophysiologic consequences,
has lagged behind that of LDL,
largely because identifying func-
tional HDL receptors which facili-
tate cholesterol delivery or efflux
has proved difficult.
SR-BI Selectively
Extracts CE from
HDL Particles
In the early 1980s, it was thought
that HDL1, which is relatively rich
in apoE, might deliver its choles-
terol ester (CE) to the liver by
79

Reverse cholesterol transport is the
collection of excess cholesterol from
peripheral cells by HDL and its transfer
to the liver for excretion. Nascent HDL
sequesters plasma membrane free cho-
lesterol, which is esterified by LCAT to
generate mature HDL. Finally, this HDL
cholesterol ester is removed by the liver.
SR-BI, a scavenger receptor, mediates
the selective uptake of CE to cells with-
out the concomitant uptake and degra-
dation of the whole HDL particle. SR-BI
is a 509-residue glycoprotein, anchored
to the plasma membrane at both the N-
and C-terminals (horseshoe shaped)
with short cytoplasmic tails of 8 and 45
residues, respectively.
HDL
Cholesterol
ester
SR-BI
N
C
80
Cell
plasma
membrane Phospholipid
Free cholesterol
Free
cholesterol
efflux LCAT
ApoAI
Discoidal pre-β-HDL
receptor-mediated endocytosis.
However, by separately labeling
CE and apoAI in HDL, it was
found that CE was delivered with-
out uptake and degradation of the
whole HDL particle, i.e., by selec-
tive lipid uptake. Ligand-blotting
studies revealed a variety of HDL-
binding proteins, but their isola-
tion and characterization were elu-
sive, and several leads could not be
substantiated.
Then, in 1996, a mouse scaveng-
er receptor (class B, type I or SR-BI)
was reported to bind HDL with
high affinity. In fact, the SR-BI
gene had been identified 2 years
earlier by expression cloning using
acetylated-LDL as ligand. It was
placed in the scavenger receptor
family because of its close homology
with CD36, which recognizes and
engulfs apoptotic cells.
Although SR-BI also bound
native LDL, its classification as a
physiologic HDL receptor was sup-
ported by its abundant expression
in liver, adrenals, and testes, all
tissues that selectively take up CE
from mature, spherical HDL in
vivo. Subsequent experiments cor-
roborated this proposal and high-
lighted the crucial role that SR-BI
plays in selectively extracting CE
from circulating HDL particles, for
bile production and steroidogenesis.
Spherical
mature
HDL
Cholesterol
ester
CE uptake
Liver
JAMES A. PERKINS
Unlike LDL receptors, which
concentrate in clathrin-coated pits,
SR-BI localizes to additional invag-
inations in the cell-surface mem-
brane, caveolae. These micro-
domains are composed mainly of
glycosphingolipids, cholesterol, and
caveolins, 21- to 24-kDa proteins
that bind cholesterol and form
oligomeric structures.
Caveolae serve to compartment-
alize and integrate transmem-
brane signaling. They are also
important for cellular cholesterol
homeostasis. As well as being the
acceptor site for cholesterol that is
selectively taken up by SR-BI,
caveolae also receive endogenously
synthesized cholesterol that is
translocated from the endoplasmic
reticulum.
However, the mechanism by
which SR-BI mediates selective
cholesterol uptake from donor
HDL particles remains unclear. An
early view was that “docking” of
HDL to SR-BI allowed CE to flow
down the concentration gradient
into the plasma membrane, from
which it was irreversibly internal-
ized. This concept was consistent
with high levels of hepatic lipase in
tissues expressing SR-BI; this
remodelling enzyme digests HDL
surface phospholipid and so might
facilitate transfer of core CE.
SCIENCE & MEDICINE
 Caveolar SR-BI
binds HDL
CE

SR-BI and
lipid-poor HDL
recycles to
caveolae

CE
FC

When SR-BI, localized in membrane

caveolae, binds HDL, the intact particles
CE hydrolysis are taken up into endosomes. The CE is
in endosome Cholesterol hydrolysed to free cholesterol (FC), while
secretion
in bile the receptor and its lipid-depleted HDL
are recycled to the cell surface.
JAMES A. PERKINS

Efficient uptake, however, re- ABCA1 Transporter

quires more than simple “docking.”
CD36 also localizes to caveolae and
binds HDL with high affinity, yet
it cannot sequester CE. Moreover,
CD36/SR-BI chimeric constructs
reveal that only the extracellular
binding domain of SR-BI is func-
tionally active, suggesting that
SR-BI might promote lipid uptake
by forming a hydrophobic channel
or by associating with other sur-
face proteins.
A major problem with models
that postulate transfer of CE into
the plasma membrane is that CE,
unlike unesterified cholesterol, has
very low solubility in phospholipid
bilayers.
In a closer examination of this
dilemma, Alan Tall and his col-
leagues in New York have found
that after binding by SR-BI, intact
HDL particles are endocytosed into
the early endosome system. There,
CE is hydrolysed by neutral ester-
ases to release cholesterol to the
endosome membrane, while the
depleted HDL particles and SR-BI
are not degraded but recycled back
to the surface.
Promotes Cholesterol
Efflux
Efflux of cellular cholesterol is a
complex process, and multiple
mechanisms may operate. These
mechanisms vary with the particu-
lar cell type and its metabolic
state, different membrane choles-
terol pools, and the nature of the
acceptor particles.
The simplest mechanism is
aqueous diffusion, in which choles-
terol molecules desorb from the
plasma membrane to be captured
by acceptors such as bulk HDL.
Intriguingly, SR-BI can also medi-
ate cellular cholesterol efflux to
mature HDL particles, although
its physiologic significance is
uncertain.
A third mechanism involves the
release of cholesterol to lipid-free
or lipid-poor apolipoproteins, par-
ticularly apoAI. Circumstantial
evidence implicated a receptor or
other membrane protein(s) in
effluxing cholesterol to lipid-poor
apoAI, but its nature defied identi-
fication for several years.
Evidence for SR-BI as a
Physiologic HDL Receptor
Tissue distribution — Liver, adrenal,
ovaries, testes, i.e. for bile
production and steroidogenesis
Regulation — SR-BI expression is
affected by induction or suppres-
sion of steroid hormone synthesis
Specificity — Binds discoidal HDL
and small HDL3 poorly; high-
affinity for large, CE-rich HDL2
Blocking antibodies — Prevent
HDL-CE uptake by cultured
mouse adrenocortical cells,
causing reduced steroidogenesis
Transgenic (overexpressing) mice —
Have low plasma HDL levels;
increased biliary cholesterol
Knockout mice — Have high
plasma HDL; decreased biliary
cholesterol; adrenal cholesterol
insufficiency

March/April 2002 81

ABCA1, a membrane-spanning trans-
porter, is essential for efficient choles-
terol efflux. Cholesterol released from
CE stores or synthesized de novo, accu-
mulates in the plasma membrane. It was
suggested that, as levels increased, ATP
bound to ABCA1 was hydrolysed to “flip”
the excess cholesterol to the outer mem-
brane leaflet, where they are sequest-
ered by circulating lipid-poor apoAI.
Current evidence, however, favors a
two-step mechanism.
TAP, an ABC transporter
involved in HLA class I antigen
processing, is diagrammed in the
paper by Hicklin and Ferrone, on
page 91 of this issue.
82
Extracellular
Lipid-poor
apoAI
ATP-binding
site
Highly hydrophobic region
ABCA1
Intracellular
The first clue came in 1995 from
a study of Tangier disease, a rare
recessive disorder in which HDL
and apoAI levels are very low, typi-
cally 2 to 3% of normal. Cells from
these patients were defective in
excreting cholesterol and phospho-
lipids onto lipid-free apoAI. Then,
4 years later, several groups report-
ed that Tangier disease was caused
by mutations in the ATP-binding-
cassette transporter, class A1 gene.
ABCA1 belongs to a large family
of transmembrane transport pro-
teins that use the energy from ATP
hydrolysis to drive diverse sub-
strates across membranes. Muta-
tions in other family members
cause a variety of genetic diseases,
including cystic fibrosis, intrahep-
atic cholestasis, adrenoleukodys-
trophy, and a peroxisomal disorder
Zellweger syndrome. The P-glyco-
protein involved in multidrug
resistance in cancer chemotherapy
is also an ABCA1 transporter.
ABC transporters are typified
by six membrane-spanning do-
mains and a cytosolic ATP-binding
fold, assembled as two functional
units (either in a single molecule,
as in ABCA1, or as a homodimeric
or heterodimeric pair). In ABCA1,
the two units are linked by a long
Mature CE-rich
HDL particle
Discoidal
pre-β-HDL
LCAT
Free Cholesterol
cholesterol ester pool
synthesis
charged region and a highly hydro-
phobic segment, a relatively rare
feature and presumably an essen-
tial element for lipid translocation.
A “flippase” action occurs in the
ABCA1 transporter. In this process,
binding and hydrolysis of ATP are
coupled to the rapid flipping of cho-
lesterol and phospholipid from the
inner to the outer leaflet of the
membrane bilayer. In the extracel-
lular fluid, lipid-poor apoAI (newly
secreted by the liver or intestine or
recycled by dissociation from ma-
ture HDL as core CE is delivered
to cells) efficiently sequesters the
lipid flipped to the surface. This
generates nascent HDL as discoid-
al or small spherical particles that
are then acted on by LCAT, com-
miting them to the HDL matura-
tion cascade.
If ABCA1 is defective, as in
Tangier disease, insufficient cellu-
lar cholesterol is made available to
form normal amounts of nascent
HDL. Also, the unused, lipid-poor
apoAI is rapidly cleared from the
circulation by the proximal tubule
of the kidney cortex, probably via
the cubilin receptor, and degraded.
The stimulation of both choles-
terol and phospholipid efflux by
ABCA1 expression was puzzling,
SCIENCE & MEDICINE
 ABCA1
First step in HDL maturation
apoAI
ABCA1
PL
FC
HDL
Peripheral
tissues
although certain other ABC trans-
porters have relaxed substrate
specificity. However, recent work
suggests that phospholipids, not
cholesterol, are the primary sub-
strates of ABCA1. Rather, choles-
terol is effluxed in an autocrine or
paracrine manner as a second step.
ABCA1 Transports
Phospholipid, but
Not Cholesterol
Thus, ABCA1 flips phospholipid
molecules into the outer membrane
leaflet, where they are extracted by
lipid-poor apoAI to form discoidal
phospholipid-apoAI complexes.
These, in turn, sequester cholesterol
from the same, or perhaps neigh-
boring, cells. Cholesterol, unlike
phospholipids, rapidly equilibrates
across membrane bilayers and is
not dependent on ABCA1 for trans-
location. Indeed, phospholipid-
apoAI discs efficiently efflux choles-
terol from ABCA1-deficient cells.
Transcription of the ABCA1
gene and cell-surface expression of
ABCA1 protein is tightly control-
led, including upregulation by cho-
lesterol loading. This response to
March/April 2002
Defective ABCA1
No HDL maturation
Liver apoAI
Defective
ABCA1
CE
Rapid
catabolism HDL maturation is mediated by the
Peripheral ABCA1 transporter. In the first stage of
tissues
HDL maturation, ABCA1 indirectly efflux-
es cell cholesterol to lipid-poor apoAI. In
Tangier disease, defective ABCA1 fails to
Kidney
load enough cholesterol onto to lipid-poor
apoAI, which is then rapidly cleared by
the kidney rather than entering the HDL
maturation cascade.
cholesterol accumulation, which is
reversed when the cells are deplet-
ed of cholesterol, is mediated by
the nuclear hormone receptor, LXR
(liver X receptor).
Nuclear receptors are intracellu-
lar transcription factors that switch
on target genes when activated by
binding of small hydrophobic lig-
ands, including metabolites gener-
ated within cells themselves. LXR
only stimulates gene promoters as
a heterodimer with RXR (retinoid
X receptor), a “permissive” partner-
ship as ligands for either LXR or
RXR (e.g., the vitamin A derivative
9-cis retinoic acid) switch on tran-
scription.
Oxysterols, such as 24-epoxy-
cholesterol and 22-hydroxycholes-
terol, which are found in the liver
and adrenals, are physiologic lig-
ands for LXR. They allow the LXR-
RXR heterodimer to bind with
high-affinity to a recognition motif
in the ABCA1 promoter that
enhances gene expression. This
recognition motif consists of two
direct repeats of a hexanucleotide
sequence, separated by four nucleo-
tides, and is now termed a DR-4
element.
83

Lipid-poor
apoAI
ABCA1
ABCA1 effluxes cholesterol by a two-
step mechanism. The true ABCA1 sub-
strates are now identified as phospho-
lipids, which are flipped across the mem-
brane to bind apoAI and form discoidal
phospholipid-apoAI complexes. These
complexes then avidly sequester excess
cholesterol, which unlike phospholipids
rapidly traverses the membrane by diffu-
sion. Although shown on the cell surface,
ABCA1 is also found in intracellular
endocytic compartments, where it may
help direct trafficking of substrate lipids
to the surface membrane.
84
Discoidal
pre-β-HDL
However, ABCA1 gene expres-
sion is more complex than this.
Several other motifs that may reg-
ulate expression have been identi-
fied. Also, a second transcriptional
start site between exons 1 and 2
(exon 1a) was recently reported, with
an alternative promoter that con-
tains its own regulatory elements.
HDL Treatment
May Regress
Atherosclerotic Lesions
For over 20 years, research into
cholesterol metabolism has been
dominated by LDL — initially,
through insights afforded by the
classic studies of its receptor-medi-
ated cellular metabolism, and later
by unravelling the interactions of
modified LDL with macrophage
scavenger receptors.
The importance of HDL in chol-
esterol metabolism was not over-
looked in this period, but progress
toward molecular understandings
was slow, mainly because the func-
tional counterparts of LDL metab-
olism, HDL receptors, were not
characterized. Moreover, pioneering
studies that provided clues to a
larger role for HDL, such as identi-
fication of the selective lipid uptake
pathway, went unheeded. Their
conclusions did not fit the paradigm
of lipoprotein receptors as agents
for endocytosis and degradation.
Mature CE-rich
HDL particle
LCAT
However, with the identification
of two key proteins in HDL metab-
olism, SR-BI and ABCA1, there
has been a remarkable swing of
the pendulum. Today, the interest
in cholesterol is not simply in “high
lows” but also in “low highs,” a
switch from controlling raised LDL
levels alone to also correcting the
risk factor of low HDL levels.
Indeed, recent epidemiologic
studies into HDL have concluded
that (a) low HDL is a marker of
atherosclerotic disease; (b) HDL
and atherosclerosis are causally
related; and (c) HDL-cholesterol
measurements are surrogate mark-
ers for atherosclerotic risk.
Pharmaceutical companies are
now developing drugs that selec-
tively enhance ABCA1 expression
or activity. They do this because
this mechanism offers hope of a
double-whammy effect: to acceler-
ate cholesterol efflux from lipid-
laden macrophages and regress
atherosclerotic lesions, and to raise
HDL levels and hence gain addi-
tional atheroprotection through
their anti-inflammatory and anti-
platelet properties or by their inhi-
bition of LDL oxidation.
Impetus to this work has come
from findings in transgenic mice.
Overexpressing ABCA1 in the liver
and macrophages of mice raised
serum HDL levels and was athero-
protective when the animals were
SCIENCE & MEDICINE
 LXR ligand RXR ligand
e.g., oxysterol e.g., 9-cis-retinoic acid

ABCAI

Transcription
ABCAI
LXR RXR of ABCAI
mRNA
sequence

N N N N
T T T T
G C G C
A C A C

DR-4 site in ABCAI promoter

fed a high-cholesterol diet. In con-
trast, ABCA1 knockout mice had
low HDL levels and accumulated
lipid-laden macrophages.
Importantly, indirect evidence
also suggests that increased
ABCA1 activity is atheroprotective
in humans. A single nucleotide
polymorphism (SNP) in ABCA1,
the Arg219Lys variant, which has
a carrier frequency of over 40%,
slows atherogenesis. Conversely,
individuals heterozygous for
ABCA1 mutations that reduce cho-
lesterol efflux are at increased risk,
whether judged by insensitive end-
point markers or by the surrogate
marker of intima-media thickness
of peripheral arteries.
However, the simple notion that
high HDL equates with atheropro-
tection, as implied by epidemiologic
data, must be refined. In mice,
hepatic overexpression of SR-BI
reduces HDL levels but prevents
atherosclerosis from developing.
Its absence markedly hastens the
onset of atherosclerosis even
though HDL rises.
Such considerations support the The nuclear hormone receptor, LXR,
emerging concept that cholesterol forms an obligate heterodimer with RXR
flux is the key factor, and that this to switch on ABCA1 gene transcription.
does not have a simple relationship It does this by binding to a motif, the DR-
4 element, in its promoter. LXR is acti-
to concentrations of plasma HDL.
vated by oxysterols, which increase as
For example, though resulting in
cellular cholesterol levels rise; ligands
an HDL deficit, an increase in SR- for RXR, such as 9-cis retinoic acid, can
BI activity enhances reverse cho- also switch on ABCA1 gene expression.
lesterol transport and atheropro-
tection because it accelerates selec-
tive lipid uptake by the liver.
he recent discoveries of SR-BI
T and ABCA1 have revolution-
ised our understanding of HDL
metabolism. Molecular details of
their functioning and regulation
are now emerging that have pro-
vided important insights into cho-
lesterol metabolism. More will fol-
low, and there undoubtedly will be
significant opportunities to develop
new, rational drugs for therapeutic
use. The aim is clear — not simply
to slow atherogenesis, but to treat
preexisting disease by actively
regressing lesions.

RECENT REVIEWS ORIGINAL PAPERS

Monty Krieger: Scavenger receptor class B type I is a multiligand HDL
receptor that influences diverse physiologic systems. Journal of Clinical
Investigation 108:793-797, September 2001.
Alan D. Attie, John P. Kastelein, and Michael R. Hayden: Pivotal role of
ABCA1 in reverse cholesterol transport influencing HDL levels and
susceptibility to atherosclerosis. Journal of Lipid Research 42:717-726,
November 2001.
David P. Wade and Jim S. Owen: Regulation of the cholesterol efflux gene,
ABCA1. Lancet 357:161-163, January 20, 2001.
Nan Wang, et al. ATP-binding cassette transporter A1 (ABCA1) functions
as a cholesterol efflux regulatory protein. Journal of Biological
Chemistry 276:23742-23747, June 29, 2001.
Karen F. Kozarsky, et al: Gene transfer and hepatic overexpression of the
HDL receptor SR-BI reduces atherosclerosis in the cholesterol-fed LDL
receptor deficient mouse. Arteriosclerosis, Thrombosis, and Vascular
Biology 20:721-727, March 2000.
Susanne M. Clee, et al: Age and residual cholesterol efflux affect HDL
cholesterol levels and coronary artery disease in ABCA1 heterozygotes.
Journal of Clinical Investigation 106:1263-1270, November 2000.

March/April 2002 85