Pathogenesis of type III hyperlipoproteinemia (dysbetalipoproteinemia): questions, quandaries, and paradoxes
Open accessAbstract
Type III hyperlipoproteinemia (HLP) is a genetic disorder characterized by accumulation of remnant lipoproteins in the plasma and development of premature atherosclerosis. Although receptor binding-defective forms of apolipoprotein (apo) E are the common denominator in this disorder, a number of apparent paradoxes concerning its pathogenesis still exist. However, studies in transgenic animals are resolving the mechanisms underlying this disorder. PARADOX I: Defective apoE (commonly apoE2) is essential but not sufficient to cause overt type III HLP. In fact, most apoE2 homozygotes are hypolipidemic. Studies in apoE2 transgenic models have demonstrated the impact of other genes or hormones in converting the hypolipidemia to hyperlipidemia. PARADOX II: Among apoE2 homozygotes, men are more susceptible than women to type III HLP. Transgenic studies have shown that estrogen affects both LDL receptor expression and lipolytic processing, explaining the resistance of women to this disorder until after menopause. PARADOX III: ApoE deficiency is associated with hypercholesterolemia, whereas the type III HLP phenotype is characterized by both hypercholesterolemia and hypertriglyceridemia. The hypercholesterolemia is caused by impaired receptor-mediated clearance, whereas the hypertriglyceridemia is caused primarily by impaired lipolytic processing of remnants and increased VLDL production associated with increased levels of apoE. PARADOX IV: ApoE2 is associated with recessive inheritance of this disorder, whereas other defective apoE variants are associated with dominant inheritance. Determinants of the mode of inheritance are the differential binding of apoE variants to the LDL receptor versus the HSPG/LRP complex and the preference of certain apoE variants for specific lipoproteins. Thus, the pathogenesis of this sometimes mysterious disorder has been clarified.
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Compared with ApoE3, ApoE2 and ApoE3ch show 98% and 60% reductions in LDLR binding, respectively.
“Previous reports showed that compared to ApoE3, ApoE2 and ApoE3ch are associate with a 98% and 60% reductions in LDLR binding, respectively11,14.”
From Resistance to autosomal dominant Alzheimer’s disease in an APOE3 Christchurch homozygote: a case report (2019) · cites this paper as [11]
Carriers of APOEch and other rare mutations in APOE's LDLR-binding region commonly have hyperlipoproteinemia type III, similar to 5-10% of APOE2 homozygotes.
“Carriers of APOEch and other rare mutations in APOE’s low density lipoprotein receptor (LDLR) binding region commonly have hyperlipoproteinemia type III (HLP-III), similar to that observed in 5–10% of APOE2 homozygotes11.”
From Resistance to autosomal dominant Alzheimer’s disease in an APOE3 Christchurch homozygote: a case report (2019) · cites this paper as [11]
The R136S mutation lies in an APOE region known to participate in binding to lipoprotein receptors and heparan sulfate proteoglycans.
“The R136S mutation is located in a region of APOE known to play a role in binding to lipoprotein receptors and heparan sulfate proteoglycans (HSPG)11.”
From Resistance to autosomal dominant Alzheimer’s disease in an APOE3 Christchurch homozygote: a case report (2019) · cites this paper as [11]
The APOE3ch homozygote individual had unusually high PET measurements of Aβ plaque burden, relatively limited PET measurements of PHF tau burden, minimal cerebral glucose hypometabolism in AD-affected brain regions, and Type III hyperlipoproteinemia.
“Interestingly, this individual had unusually high PET measurements of Aβ plaque burden, relatively limited PET measurements of PHF tau (neurofibrillary tangle) burden, minimal cerebral glucose hypometabolism in AD-affected brain regions, and like some APOE2 homozygotes, Type III hyperlipoproteinemia5,6.”
From Exceptionally low likelihood of Alzheimer’s dementia in APOE2 homozygotes from a 5,000-person neuropathological study (2020) · cites this paper as [6]
Dysbetalipoproteinemia is caused in part by a mutation in the APOE gene, resulting in impairment in the hepatic uptake of apoE-containing lipoproteins and reduction in the conversion of VLDL and IDL to LDL particles.
“Dysbetalipoproteinemia, also called type III hyperlipoproteinemia or remnant removal disease, is caused in part by a mutation in the APOE gene, resulting in impairment in the hepatic uptake of apoE-containing lipoproteins and reduction in the conversion of VLDL and IDL to LDL particles (121).”
From Evaluation and Treatment of Hypertriglyceridemia: An Endocrine Society Clinical Practice Guideline (2012) · cites this paper as [121]
The cysteine change at position 158 in APOE2, near the LDLR binding region, hinders APOE2 binding to the LDLR.
“This is attributed to the fact that the cysteine change at position 158 in APOE2, near the LDLR binding region, hinders APOE2 binding to the LDLR [30, 40].”
APOE2hAβ rats are characterized as a model for type III HLP.
“This observation, coupled with evident mixed hypercholesterolemia and hypertriglyceridemia, supports the characterization of APOE2hAβ rats as a model for type III HLP”
HSPGs may function as co-receptors to facilitate engagement of ApoE with LDLR and/or LRP1.
“Blocking ApoE-HSPG interaction with heparin also attenuated pHrodo-HDL uptake with more pronounced effects at 6 h than at 1 d (Figure S3A–C), suggesting HSPGs may function as co-receptors to facilitate engagement with LDLR and/or LRP1, as shown for peripheral apolipoproteins32.”
From Decreased lipidated ApoE‐receptor interactions confer protection against pathogenicity of ApoE and its lipid cargoes in lysosomes (2025) · cites this paper as [32]
LDL biology is mostly relevant for peripheral diseases.
“While LDL biology is mostly relevant for peripheral diseases32,54,55”
From Decreased lipidated ApoE‐receptor interactions confer protection against pathogenicity of ApoE and its lipid cargoes in lysosomes (2025) · cites this paper as [32]
HSPGs are responsible for neuronal uptake of tau and the R136S mutation causes impaired binding affinity of APOE to HSPGs, leading to reduced tau pathology.
“HSPGs are responsible for neuronal uptake of tau and the R136S mutation causes impaired binding affinity of APOE to HSPGs, leading to reduced tau pathology [15, 41, 76, 84, 85].”
From APOE Christchurch enhances a disease-associated microglial response to plaque but suppresses response to tau pathology (2025) · cites this paper as [84]
ApoE2 (Arg158Cys) and major LPG mutants (apoE Kyoto [Arg25Cys] and Sendai [Arg145Pro]), which are located in the NT, induce dyslipidemia.
“ApoE2 (Arg158Cys) and major LPG mutants (apoE Kyoto [Arg25Cys] and Sendai [Arg145Pro]), which are located in the NT, induce dyslipidemia [7, 11].”
More than 90% of affected individuals with familial type III HLP are APOE2 homozygotes, with the remainder having rare APOE variants, including those causing apoE deficiency or compound heterozygotes of APOE variants and APOE2.
“In fact, more than 90% of affected individuals are APOE2 homozygotes, with the remainder having rare APOE variants, including those causing apoE deficiency or compound heterozygotes of APOE variants and APOE2 23, 25-28).”
From Impact of Apolipoprotein E Variants: A Review of Naturally Occurring Variants and Clinical Features (2025) · cites this paper as [23]
Common polymorphisms of human apoE (apoE2, -E3, and -E4) influence lipid metabolism due to differences in receptor binding activity and lipoprotein association preference.
“Common polymorphisms of human apoE (apoE2, -E3, and -E4) infl uence lipid metabolism due to differences in receptor binding activity and lipoprotein association preference (5)(6)(7)(8)(9).”
From Macrophage-derived apoESendai suppresses atherosclerosis while causing lipoprotein glomerulopathy in hyperlipidemic mice (2014) · cites this paper as [6]
apoE made by macrophages is secreted into the circulation, where it associates with lipoproteins and mediates their hepatic uptake by the liver.
“apoE made by macrophages is secreted into the circulation, where it associates with lipoproteins and mediates their hepatic uptake by the liver ( 3,6 ).”
From Macrophage-derived apoESendai suppresses atherosclerosis while causing lipoprotein glomerulopathy in hyperlipidemic mice (2014) · cites this paper as [6]
Macrophage apoE effects manifest as secretion into the circulation and association with lipoproteins to mediate their hepatic uptake.
“Atherogenesis is infl uenced by macrophage expression of apoE ( 11 ), the effects of which manifest as: 1 ) secretion into the circulation and association with lipoproteins to mediate their hepatic uptake ( 3, 6 ); and 2 ) modulation of the macrophage infl ammatory response in the atheroma ( 16,17 ).”
From Macrophage-derived apoESendai suppresses atherosclerosis while causing lipoprotein glomerulopathy in hyperlipidemic mice (2014) · cites this paper as [6]
Familial type III hyperlipoproteinemia or dysbetalipoproteinemia is due to accumulation of cholesterol-rich VLDL, which results in a higher ratio of core CE to triglyceride (>0.3) than in normal VLDL (0.2).
“Familial type III hyperlipoproteinemia or dysbetalipoproteinemia is due to the accumulation of cholesterol-rich VLDL, 146,147 which results in a higher ratio of core CE to triglyceride (Ͼ0.3) than in normal VLDL (0.2).”
From Triglycerides and Cardiovascular Disease: A Scientific Statement From the American Heart Association (2011) · cites this paper as [147]
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Impact of Apolipoprotein E Variants: A Review of Naturally Occurring Variants and Clinical Features
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- Authors
- Mahley, R. W., Huang, Y., & Rall, S. C.
- Affiliations
- University of California, San Francisco (US)
- Corresponding author
- Mahley, Robert W.
- Venue
- Journal of Lipid Research
- Publisher
- Elsevier BV
- Published
- 1999-11
- Volume
- 40
- Issue
- 11
- Pages
- 1933-1949
- ISSN
- 0022-2275 (ISSN-L)
- OpenAlex
- W2129883875
- Cited by
- 447
- References
- 130
- Citations by year
- 2026: 17 · 2025: 17 · 2024: 16 · 2023: 20 · 2022: 23 · 2021: 17 · 2020: 18 · 2019: 14 · 2018: 14 · 2017: 15 · 2016: 11 · 2015: 12 · 2014: 20 · 2013: 17 · 2012: 14
- FWCI
- 9.45
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Journal of Lipid Research (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- National Institutes of Health (5p01hl047660-10)
- National Heart, Lung, and Blood Institute (HL-47660)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Lipid metabolism and disorders
- Health Sciences › Medicine › Surgery › Lipoproteins and Cardiovascular Health
- Health Sciences › Medicine › Surgery › Cholesterol and Lipid Metabolism
- Keywords
- type III hyperlipoproteinemia, dysbetalipoproteinemia, apolipoprotein E, APOE2, remnant lipoproteins, LDL receptor, hypertriglyceridemia, hypercholesterolemia, estrogen, sex differences, transgenic animal models, mode of inheritance, premature atherosclerosis
- MeSH terms
- Animals, Apolipoproteins E, Arteriosclerosis, Female, Homozygote, Humans, Hyperlipoproteinemia Type III, Lipoproteins, Male, Apolipoprotein E2
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