1. Date-14.02.2014WELCOME1

2. PRESENTED BY:FACILIATED TO:MISS SAYANTI SAUDR. SHIVALINGE GOWDA K.P. H.O.D. DEPT. OF PHARMACOLOGY PESCP, BANGALOREI M. PHARM DEPT. OF PHARMACOLOGY PESCP, BANGALORE2 3. BILIRUBIN Bilirubin (formerly referred to as hematoidin) is the yellow breakdown product of normal heme catabolism. Bilirubin is excreted in bile and urine, and elevated levels may indicate certain diseases. It is responsible for the the background straw-yellow color of urine (via its reduced breakdown product, urobilin the more obvious butvariable bright yellow colour of urine is due to thiochrome, a breakdown product of thiamine), the browncoloroffeces(viaitsconversionto stercobilin), and the yellow discoloration in jaundice. Bilirubin consists of an open chain of four pyrrole-like rings (tetrapyrrole) a porphyrin ring. 3 4. TYPES OF BILIRUBIN Direct bilirubin (conjugated bilirubin-BC) -In the liver, bilirubin is conjugated with glucuronic acid by the enzyme glucuronyl transferase, making it soluble in water. Much of it goes into the bile and thus out into the small intestine. However, 95% of the secreted bilirubin is reabsorbed by the intestines (Terminal Ileum) and reaches the liver by portal circulation and then resecreted by the liver into the small intestine. This process is known as enterohepatic circulation. The remaining 5%-> large intestine->urobilinogen-> stercobilin-> feces.Unconjugated or indirect bilirubin (BU) - Insoluble in water.Total bilirubin ("TBIL") It measures both BC and BU. Total and direct bilirubin levels can be measured from theblood, but indirect bilirubin is calculated from the total and direct bilirubin. TOTAL BILIRUBIN = INDIRECT BILIRUBIN + DIRECT BILIRUBIN4 5. NORMAL LEVELS Direct bilirubin: Less than 0.4 mg/dL or 7 mol/LTotal bilirubin: less than 1.5 mg/dL or less than 26 mol/L5 6. MEASUREMENT METHODS Originally the Van den Bergh reaction was used for a qualitative estimate of bilirubin. Total bilirubin is now often measured by the 2,5-dichlorophenyldiazonium (DPD) method.URINE TESTS Urine bilirubin may also be clinically significant. Bilirubin is not normally detectable in the urine of healthy people. If the blood level of conjugated bilirubin becomes elevated, e.g. due to liver disease, excess conjugated bilirubin is excreted in the urine, indicating a pathological process. Unconjugated bilirubin is not water-soluble and so is not excreted in the urine. Testing urine for both bilirubin and urobilinogen can help differentiate obstructive liver disease from other causes of jaundice.INCREASES Total bilirubin is elevated in obstructive condition of the bile duct, hepatitis, cirrhosis, in hemolytic disorders and several inherited enzyme deficiency. Indirect bilirubin is elevated by prehepatic causes such as hemolytic disorder or liver diseases resulting in impaired entry, transport or conjugation within the liver. Monitoring of indirect bilirubin in neonates is of special importance as it the indirect (or free) bilirubin bound to be albumin that is able to cross the BBB more easily, increasing the danger of cerebral damage. 6 7. HYPERBILIRUBINEMIA Hyperbilirubinemia results from a higher-than-normal level of bilirubin in the blood. 1. Mild rises in bilirubin may be caused by the following: Hemolysis or increased breakdown of red blood cells. Gilbert's syndrome a genetic disorder of bilirubin metabolism that can result in mild jaundice, found in about 5% of the population Rotor syndrome- non-itching jaundice, with rise of bilirubin in the patient's serum, mainly of the conjugated type. 2.Moderaterise in bilirubin may be caused by: Pharmaceutical drugs-(especially antipsychotic, some sex hormones,Sulfonamides are contraindicated in infants less than 2 months old as the increase unconjugated bilirubin leading tokernicterus. Hepatitis (levels may be moderate or high) Chemotherapy Biliary stricture (benign or malignant)3.Very high levels of bilirubin may be caused by: Neonatal hyperbilirubinaemia- where the newborn's liver is not able to properly process the bilirubin causing jaundice unusually large bile duct obstruction, e.g. stone in common bile duct, tumour obstructing common bile duct etc. Severe liver failure with cirrhosis(e.g. primary biliary cirrhosis) 7 8. DEMO ESTIMATION - by ERBA kit METHODOLOGY-PRINCIPLE Bilirubin reacts with diazotized sulphanilic acid in acidic medium to form pink colored azobilirubin with absorbance directly proportional to bilirubin concentration. Direct bilirubin, being water soluble directly reacts in acidic medium. However indirect or unconjugated bilirubin is solubilized using a surfactant than it reacts similar to direct bilirubin.SAMPLE Unhaemolysed serum or plasma. Avoid hemolysis as it causes falsely low results. Sample should be protected from bright light as bilirubin is photo labile. Samples may be stored refrigerated for 3 days or frozen for 1 month.REAGENT COMPOSITIONSurfactant1.00%HCL100 mmol/LSulphanilic acid5 mmol/LREAGENT 2: DIRECT BILIRUBIN REAGENTSulphanilic acid10 mmol/LHCL100 mmol/LREAGENT 3: SODIUM NITRITE REAGENTSodium nitrite144 mmol/LREAGENT 1: TOTAL BILIRUBIN REAGENT8 9. ASSAY PROCEDURE TOTAL BILIRUBIN / DIRECT BILIRUBIN Pipette into test tubes markedBlankStandardTestWorking reagent500 l500 l500 lDistilled water25 l--Standard/calibrator-25 l-Test--25 l9 10. GLUCOSE Glucose(C6H12O6,alsoknownasD-glucose,dextrose,orgrapesugar)isasimple monosaccharide found in plants. It is one of the three dietary monosaccharides, along with fructose and galactose, that are absorbed directly into the bloodstream during digestion. An important carbohydrate in biology, cells use it as a secondary source of energy and a metabolic intermediate. Glucose is one of the main products of photosynthesis and fuels for cellular respiration. Glucose exists in several different molecular structures, but all of these structures can be divided into two families of mirror-images (stereoisomers). Only one set of these isomers exists in nature, those derived from the "particular chiral form" of glucose, denoted D-glucose. Thechemical D-glucose is sometimes referred to as dextrose. Glucose is a major source of energy for most cells of the body; insulin facilitates glucose entry into the cells.INCREASES Due to diabetes mellitus, in patients receiving glucose containing fluids intravenously, during severe stress and cerebro vascular accidents.DECREASES On insulin administration, as a result of insulinoma, inborn errors of carbohydrate metabolism or on fasting. 10 11. FUNCTION ANALYTE IN MEDICAL BLOOD TEST Glucose is a common medical analyte measured in blood samples. Eating or fasting prior to taking a blood sample has an effect on the result. A high fasting glucose blood sugar level may be a sign of prediabetes or diabetes mellitus. ENERGY SOURCE Glucose is a ubiquitous fuel in biology. Use of glucose may be by either aerobic respiration, anaerobic respiration, or fermentation. Glucose is the human body's key source of energy, through aerobic respiration, providing approximately 3.75 kilocalories (16 kilojoules) of food energy per gram. Breakdown of carbohydrates (e.g. starch) yields mono- and disaccharides, most of which is glucose. Glucose is a primary source of energy for the brain, and hence its availability influences psychological processes. When glucose is low, psychological processes requiring mental effort (e.g., self-control, effortful decisionmaking) are impaired. Use of glucose as an energy source in cells is via aerobic respiration or anaerobic respiration.NORMAL VALUES Fasting ValuePost PrandialCategory of a person Minimum ValueMaximum ValueValue 2 hours after consuming glucoseNormal70100Less than 140Early Diabetes101126140 to 200Established DiabetesMore than 126-More than 200 11 12. ESTIMATION OF GLUCOSE Enzymatic methods for glucose determination are classified into three groups: 1. Methods with glucose oxidase, 2. Methods with hexokinase, 3. Methods with glucose dehydrogenasePRINCIPLE Glucose oxidase (GOD) converts glucose to gluconic acid. Hydrogen peroxide formed in this reaction, in presence of peroxidase (POD) oxidatively couples with 4aminoantipyrine and phenol to produce red quinoneimine dye. This dye has absorbance maximum at 505 nm (500- 550 nm). The intensity of the colour complex is directly proportional to the concentration of glucose in sample. Principle: (Trinders method ) -D-glucoseMutarotase-D-glucose +H2O+O2-D-glucose Glucose oxidaseH2O2+ 4-aminophenazone+phenol The intensity of the color concentration in the sample.formedD-gluconic acid+H2O2 PeroxidaseisQuinonemine +4 H2Oproportionaltotheglucose 12 13. DEMO ESTIMATION - by ERBA kit ASSAY PROCEDURE Pipette into tubes marked Working reagent Distilled water Standard TestBlank 1000ul 10ul ---Standard 1000ul -10ul --Test 1000ul --10ul13 14. SGOT Aspartatetransaminase(AST)alsocalledaspartateaminotransferaseiscommonlyknownasSGOT(AspAT/ASAT/AAT) or serum glutamic oxaloacetic transaminase (SGOT) ,is a pyridoxial phosphate(PLP)dependent transaminase enzyme. AST catalyses the reversible transfer of an - amino group between aspartate andglutamateand,assuch,inanimportantenzymeinaminoacidmetabolism.Transaminase or aminotransferase is an enzyme that catalyses a type of reaction between an amino acid and a keto acid. An amino acid contains an amine (NH2) group. A keto acid contains a keto (=O) group. In transamination, the NH2 group on one molecule is exchanged with the =O group on the other molecule. The amino acid becomes a keto acid, and the keto acid becomes an amino acid. AST is found in liver, heart,skeletal muscle, kidney, brain and red blood cells, and it is commonly measured clinically as a marker for liver health.CLINICAL SIGNIFICANCE SGOT is important in the clinical diagnosis of human disease. AST is associated with liver parenchymalcells, heart, skeletal muscle, kidney, brain, red blood cell are released from cells as a part of cell injury that occurs in myocardial infraction, hepatitis, acute pancreatitis, acute haemolytic anaemia, severe burns, acute renal disease, musculoskeletal disease and trauma . Assay of these enzyme activities in blood serum can be used both in diagnosis and in monitoring the progress of a patient during treatment. AST was defined as biochemical marker for diagnosis of acute myocardial infraction earlier.AST is commonly measured clinically as a part of diagnostic liver function test to determine liver health such as liver cancer, liver cirrhosis.14 15. INCREASES: Increased levels are associated with liver diseases or damage , myocardial infraction, muscular dystrophy.DECREASES: Decreased levels are observed in patients undergoing renal dialysis and those with B6 deficiency. Monitoring the change in the levels over a period of time is beneficial to the physician evaluating myocardial infraction or following chronic or resolving hepatitis.FUNCTIONS Aspartate transaminase catalyses the interconversion of aspartate and -ketoglutarate to oxaloacetate and glutamate. Reaction catalysed by aspartate aminotransferase. Aspartate(Asp) + -ketoglutarate oxaloacetate + glutamateREFERENCE VALUES Female-6-34 IU/L Male-8-40 IU/LESTIMATION OF SGOT LEVEL IN SERUM PRINCIPLE AST (Transaminase enzyme) catalyses the following reaction.L-Aspartate +2- OxaloglutarateOxaloacetate+ L-glutamateIn this present method salts is used which selectively reacts with oxaloacetate to produce a colour complex that is measured photomertically.15 16. DEMO ESTIMATION - by ERBA kit METHOD AST L-Aspartate + 2-OxaloglutarteOxaloacetate + L-Glutamate MDHOxaloacetate + NADHMalate +NAD LDHSample pyruvate + NADHL-Lactate +NADAST:Aspartate aminotransferaseMDH:Malate dehydrogenaseLDH:Lactate dehydrogenaseSAMPLE Unhaemolysed serum or Heparinised plasma. According to the IFCC expert panel onenzymes, AST is stable for 3 days at 4oc.16 17. ASSAY PROCEDURE Allow the working reagent to attain 37oc before performing the test. PipetteVolumesWorking reagent1000ulTest100ul17 18. SGPT Alanine transaminase or ALT is a transaminase enzyme. It is also called serum glutamic-pyruvic transaminase (SGPT), or alanine amino transaminase (ALAT). ALT is found in plasma and in various bodily tissues, but is most commonly associated with the liver. An alanine aminotransferase (ALT) test is often part of an initial screening for liver disease. Normally, ALT is found inside liver cells. But if the liver is inflamed or injured, ALT is released into the bloodstream. In a normally healthy individual, the level of SGPT is measurable in the blood. When there is acute liver damage, the level of SGPT tends to rise dramatically. ALT is present in high concentration in the liver and to a lesser extent in kidney , heart, skeletal muscle , pancreas , spleen and lungs. The next stage of the liver test for SGPT is to understand the underlying cause of the liver damage. The liver could be damaged by an infectious disease such as mononucleosis or hepatitis. This damage is generally temporary and heals after the patient has recovered from the condition. The level of SGPT is also elevated in an individual who is suffering from bile related problems. There are many different medications that are likely to cause an elevation in the level of SGPT in the blood. This elevation tends to be temporary and gets reversed as the patients body absorbs the medication or passes it out of the system in the urine. When a drug overdose has occurred, the patient may suffer from liver damage which, apart from causing an elevation in the level of ALT also causes other typical symptoms of liver damage. The liver test for SGPT is diagnostically relevant and can be used with other tests such as the ALT or SGOT test. These tests can confirm whether the elevation in the level of SGPT is related to liver damage or related to bile duct problems. The liver test for SGPT is almost never conducted in isolation.SignificantlyelevatedlevelsofALT(SGPT)oftensuggesttheexistenceofother medicalproblemssuchasviral hepatitis, diabetes, congestive heart failure, liver damage, bile duct problems, infectious mononucleosis, or myopathy. For this reason, ALT is commonly used as a way of screening for liver problems. Elevated ALT may also be caused by dietary choline deficiency. However, elevated levels of ALT do not automatically mean that medical problems exist. Fluctuation of ALT levels is normal over the course of the day, and ALT levels can also increase in response to strenuous physical exercise.18 19. INCREASES Increases levels are generally a result of primary liver diseases such as cirrhosis ,carcinoma,viral or toxic hepatitis and obstructive jaundice.DECREASES Decreased levels may be observed in renal dialysis patients and those with vitamin B6 deficiency.REFFERENCE VALUES Female 34 IU/L Male 45 IU/LFUNCTION It catalyzes the transfer of an amino group from L-alanine to -ketoglutarate, the products of this reversible transamination reaction being pyruvate and L-glutamate. L-glutamate + pyruvate -ketoglutarate + L-alanine ALT (and all transaminases) require the coenzyme pyridoxal phosphate, which is converted into pyridoxamine in the first phase of the reaction, when an amino acid is converted into a keto acid.ESTIMATION OF SGPT PRINCIPLE ALT (GPT) catalyze the transfer of amino groups from specific amino acids to ketoglutaric acid yielding glutamic acid and oxaloacetic or pyruvic acid respectively. These ketoacids are then determined colorimetrically after their reaction with 2,4dinitrophenylhydrazine (DNP).L-Alanine + Ketoglutarate Pyruvate + L-Glutamate Pyruvate + NADH + H+ L Lactate + NAD+19 20. DEMO ESTIMATION - by ERBA kit METHODSALT(Alanine aminotransferase)L-Alanine + 2- OxoglutaratePyruvate + L-GlutamateLDH(Lactate dehydrogenase) L Lactate + NAD+Pyruvate + NADHREAGENT RECONSTITUTION Allow the reagent bottle and Aqua-4 to attain room temperature (15-30oc). Add the amount of Aqua-4 indicated on the label to contents of each vial. Swirl to dissolve ,do not shake vigorously. SAMPLE Unhemolysed serum or heparinised plasma. Anticoagulant such as Heparin or EDTA are suitable. ALT is stable for 3 days at 2-8oc. ASSAY PROCEDURE PipetteVolumesWorking reagent1000ulTest100ul 20 21. 21 22. CHOLESTEROL Cholesterol, from the Ancient Greek chole- (bile) and stereos (solid) followed by the chemical suffix-ol for an alcohol, is an organic molecule. It is a sterol (or modified steroid), and an essential structural component of animal cell membranes that is required to establish proper membrane permeability and fluidity. Cholesterol is thus considered within the class of lipid molecules. In addition to its importance within cells, cholesterol also serves as a precursor for the biosynthesis of steroid hormones, bile acids, and vitamin D. Since cholesterol is essential for all animal life, each cell synthesizes it from simpler molecules, a complex 37step process that starts with the intracellular protein enzyme HMG-CoA reductase. Most ingested cholesterol is esterified, and esterified cholesterol is poorly absorbed. The body also compensates for any absorption of additional cholesterol by reducing cholesterol synthesis. For these reasons, cholesterol intake in food has little, if any, effect on total body cholesterol content or concentrations of cholesterol in the blood. Cholesterol is recycled. The liver excretes it in a non-esterified form (via bile) into the digestive tract. Typically about 50% of the excreted cholesterol is reabsorbed by the small bowel back into the bloodstream. Plants make cholesterol in very small amounts. Plants manufacture phyto sterols (substances chemically similar to cholesterol produced within plants), which can compete with cholesterol for reabsorption in the intestinal tract, thus potentially reducing cholesterol reabsorption. When intestinal lining cells absorb phytosterols, in place of cholesterol, they usually excrete the phytosterol molecules back into the GI tract, an important protective mechanism.22 23. FUNCTION Cholesterol is required to build and maintain membranes; it modulates membrane fluidity over the range of physiological temperatures. cholesterol reduces the permeability of the plasma membrane to neutral solutes, protons, (positive hydrogen ions) and sodium ions. Within the cell membrane, cholesterol also functions in intracellular transport, cell signaling and nerve conduction. Recently, cholesterol has also been implicated in cell signaling processes, assisting in the formation of lipid rafts in the plasma membrane. Within cells, cholesterol is the precursor molecule in several biochemical pathways. In the liver, cholesterol is converted to bile, which is then stored in the gallbladder. Bile contains bile salts, which solubilize fats in the digestive tract and aid in the intestinal absorption of fat molecules as well as the fat-soluble vitamins, A, D, E, and K. Cholesterol is an important precursor molecule for the synthesis of vitamin D and the steroid hormones, including the adrenalgland hormones cortisol and aldosterone, as well as the sex hormones progesterone, estrogens, andtestosterone. Some research indicates cholesterol may act as an antioxidant. 23 24. BIOSYNTHESIS24 25. METABOLISM, RECYCLING AND EXCRETION Cholesterol is susceptible to oxidation and easily forms oxygenated derivatives known as oxysterols.Cholesterol is oxidized by the liver into a variety of bile acids. These, in turn, are conjugated with glycine, taurine, glucuronic acid, or sulfate. A mixture of conjugated and non conjugated bile acids, along with cholesterol itself, is excreted from the liver into the bile. Approximately 95% of the bile acids are reabsorbed from the intestines, and the remainder are lost in the feces. The excretion and reabsorption of bile acids forms the basis of the enterohepatic circulation, which is essential for the digestion and absorption of dietary fats. Under certain circumstances, when more concentrated, as in the gallbladder, cholesterol crystallises and is the major constituent of most gallstones. Cholesterol is converted mainly into coprostanol, a nonabsorbable sterol that is excreted in the feces.DIETARY SOURCES Animal fats are complex mixtures of triglycerides, with lesser amounts of phospholipids and cholesterol. As a consequence, all foods containing animal fat contain cholesterol to varying extents. Major dietary sources of cholesterol include cheese, egg yolks, beef, pork, poultry, fish. From a dietary perspective, cholesterol is not found in significant amounts in plant sources. Inaddition, plant products such as flax seeds and peanuts contain cholesterol-like compounds calledphytosterols.containingfunctionalPhytosterols foodsorcanbesupplementednutraceuticalsproven LDL cholesterol-lowering efficacy.thatarethrough widelytheuserecognizedof asphytosterolhaving 25a 26. CLINICAL SIGNIFICANCE HYPERCHOLESTEROLEMIA According to the lipid hypothesis, abnormal cholesterol levels (hypercholesterolemia) actually higher concentrations of LDL particles and lower concentrations of functional HDL particles are strongly associated with cardiovascular disease because these promote atheroma development in arteries (atherosclerosis). This disease process leads to myocardial infarction(heart attack), stroke, and peripheral vascular disease. LDL particles are often termed "bad cholesterol" because they have been linked to atheroma formation. On the other hand, high concentrations of functional HDL, which can remove cholesterol from cells and atheroma, offer protection and are sometimes referred to as "good cholesterol". Conditions with elevated concentrations of oxidized LDL particles, especially "small dense LDL" (sd LDL) particles, are associated with atheroma formation in the walls of arteries, a condition known as atherosclerosis, which is the principal cause of coronary heart disease and other forms of cardiovascular disease. In contrast, HDL particles (especially large HDL) have been identified as a mechanism by which cholesterol and inflammatory mediators can be removed from atheroma. Increased concentrations of HDL correlate with lower rates of atheroma progressions and even regression. Elevated levels of the lipoprotein fractions, LDL, IDL and VLDL are regarded as atherogenic (prone to cause atherosclerosis).Level mg/dLLevel mmol/LInterpretation< 200< 5.2Desirable level corresponding to lower risk for heart disease2002405.26.2Borderline high risk> 240> 6.2High risk26 27. Adult Treatment Panels suggests the total blood cholesterol level should be: < 200 mg/dL normalblood cholesterol, 200239 mg/dL borderline-high, > 240 mg/dL high cholesterol. Total cholesterol is defined as the sum of HDL, LDL, and VLDL. Usually, only the total, HDL, and triglycerides are measured. For cost reasons, the VLDL is usually estimated as one-fifth of the triglycerides and the LDL isestimated using the Friedewald formula (or a variant): estimated LDL = [total cholesterol] [total HDL] [estimated VLDL].HYPOCHOLESTEROLEMIA Abnormally low levels of cholesterol are termed hypocholesterolemia. Research into the causes of this state is relatively limited, but some studies suggest a link with depression, cancer, and cerebral hemorrhage. In general, the low cholesterol levels seem to be a consequence, rather than a cause, of an underlying illness. A genetic defect in cholesterol synthesis causes Smith-Lemli-Opitz syndrome, which is often associated with low plasma cholesterol levels.27 28. INCREASES Increased levels are found most characteristically in primaryhyperlipoproteinaemias,innephroticsyndrome , jaundice and in diabetis mellitus.DECREASES Low values are frequently obtained in anaemias , in hemolyticjaundiceinmalabsorptionsyndrome, severe malnutrition , acute infections and in terminal state. Very low values occur in betalipoproteinaemias and to a lesser degree in familial hypobetalipoproteinaemias.NORMAL VALUES The normal range of cholesterol depends on age, sex, diet, race and geographical location. Reference values for guidelines are : 140-250 mg/dl28 29. DEMO ESTIMATION by ERBA kit METHOD The estimation of cholesterol involves the following enzyme catalyzed reactions. CE 1.Cholesterol estercholesterol + Fatty acid CHOD2.Cholesterol + O2cholest-4-en-3-one + H2O2 POD3.2H2O2 + 4AAP +phenol CECECHOD CHOD 4AAP : 4AAP: :4H2O + QuinoneimineCholesterol esterase: Cholesterol esterase Cholesterol oxidase : Cholesterol oxidase 4-Aminoantipyrine : 4-AminoantipyrineAbsorbance of Quinoneimine so formed is directly propotional to cholesterol in the specimen.29 30. SAMPLE Unhemolyzed serum separated from the cells as soon as possible. Plasma may be used with heparin or EDTA as the anticoagulant. Fluoride or oxalate will interfere with the assay. Samples arestable for 7 days at 2-8Oc.ASSAY PROCEDURE PIPETTE INTO TUBES MARKEDBLANKSTANDARDTESTWorking reagent1000 ul1000ul1000 ulDistilled water20 ul----Standard--20 ul--Test----20 ul30 31. HDL High-density lipoprotein (HDL) is one of the five major groups of lipoproteins. High density lipoproteins (HDL) contains particles of different density including lipid and highest concentration of proteins amongst the different lipoproteins. It includes free and esterified cholesterol ,triglycerides ,phospholipids and apoproteins A, C and E. HDL cholesterol values are about 1/5th of the total cholesterol values and can be expressed as percentage of total cholesterol.Because of the high cost of directly measuring HDL and LDL protein particles, blood tests are commonly performed for the surrogate value, HDL-C, i.e. the cholesterol associated with ApoA-1/HDL particles. HDL particles remove fats and cholesterol from cells including within artery wall atheroma and transport it back to the liver for excretion or re-utilization, the reason why the cholesterol carried within HDL particles (HDL-C) is sometimes called "good cholesterol" .Those with higher levels of HDL-C tend to have fewer problems with cardiovascular diseases, while those with low HDL-C cholesterol levels (especially less than 40 mg/dL or about 1 mmol/L) have increased rates for heart disease. Higher native HDL levels are correlated with better cardiovascular health; however, it does not appear that further increasing one's HDL improves cardiovascular outcomes.Several steps in the metabolism of HDL can participate in the transport of cholesterol from lipidladen macrophages of atherosclerotic arteries, termed foam cells, to the liver for secretion into the bile. This pathway has been termed reverse cholesterol transport and is considered as the classical protective function of HDL toward atherosclerosis.31 32. However, HDL carries many lipid and protein species, several of which have very low concentrations but are biologically very active. For example, HDL and its protein and lipid constituents help to inhibit oxidation, inflammation, activation of the endothelium, coagulation, and platelet aggregation. All these properties may contribute to the ability of HDL to protect from atherosclerosis, and it is not yet known which are the most important.SUBFRACTIONS Five subfractions of HDL have been identified. From largest (and most effective in cholesterol removal) to smallest (and least effective), the types are 2a, 2b, 3a, 3b, and 3c.DECREASES There exists an inverse relationship between HDL cholesterol and coronary heart disease. Low concentration that is below 30 mg/ml is one of the risk factors for cardiac ailments.MEMORY Fasting serum lipids have been associated with short term verbal memory. In a large sample of middle aged adults, low HDL cholesterol was associated with poor memoryand decreasing levels over a five year follow-up period were associated with decline in memory.32 33. INCREASING HDL LEVELS DIET AND LIFESTYLE Certain changes in lifestyle may have a positive impact on raising HDL levels: Aerobic exercise Weight loss niacin (vitamin B3, aka nicotinic acid) supplementation Smoking cessation Removal of trans fatty acids from the diet Mild to moderate alcohol intake Addition of soluble fiber to diet Consumption of omega-3 fatty acids such as fish oil or flax oil Decreased intake of simple carbohydrates. Consumption of cannabis (or marijuana) has been wrongly speculated to have a positive impact on the HDL-C level. 33 34. DRUGS While higher HDL levels are correlated with cardiovascular health, no increase in HDL has been proven to improve health. In other words, while high HDL levels might correlate with better cardiovascular health, specifically increasing one's HDL might not increase cardiovascular health. Pharmacological therapy to increase the level of HDL cholesterol includes use of fibrates and niacin. Lovaza has been shown to increase HDL-C. Magnesium supplements raise HDL-C. Apo-A1 Milano, the most effective proven HDL agent.RECOMMENDED RANGES Level mg /dLLevel mmol/LInterpretation