Human noninsulin-dependent diabetes: identification of a defect in plasma cholesterol transport normalized in vivo by insulin and in vitro by selective immunoadsorption of apolipoprotein E.

Plasma cholesterol metabolism in patients with poorly controlled noninsulin-dependent diabetes was characterized by inhibition of cholesterol net transport between cultured cells (fibroblasts) and plasma, inhibition of cholesterol esterification, and inhibition of cholesteryl ester transfer to low and very low density lipoproteins, relative to a normal control group. Plasma from these patients also contained a 2-fold higher level of apolipoprotein E (apo E). Effective control of hyperglycemia with insulin normalized both the parameters of plasma cholesterol metabolism and plasma levels of apo E. Removal of apo E by immunoaffinity chromatography normalized cell-to-plasma cholesterol transport but was without effect on the rate of cholesterol esterification or of cholesteryl ester transfer. These findings suggest that an inhibition in the chain of reactions by which cellular cholesterol is transferred in esterified form to low and very low density lipoproteins is associated with the appearance of an apo E-dependent "shunt" pathway, returning cholesterol from plasma back to the cells and so nullifying the normal cell-to-plasma transport pathway.