What organ gets rid of cholesterol?

Cholesterol is a waxy, fat-like substance that is found in all cells of the body. It plays important roles in hormone production, vitamin D synthesis, and bile acid formation. However, high levels of cholesterol in the blood, also known as hypercholesterolemia, can increase the risk for heart disease and stroke. The liver plays a central role in cholesterol homeostasis by regulating cholesterol synthesis, uptake, and excretion. This article will discuss the key functions of the liver related to cholesterol metabolism and removal.

Overview of Cholesterol

Cholesterol is a sterol molecule produced by all animal cells. While cholesterol has important biological functions, elevated levels of cholesterol in the blood are strongly associated with atherosclerosis and increased risk for heart attacks and strokes. The body maintains cholesterol homeostasis through a balance of cholesterol synthesis, dietary cholesterol intake, and cholesterol excretion. The liver serves as the main hub for regulating whole-body cholesterol balance.

Types of Lipoproteins

Cholesterol is transported in the bloodstream by spherical particles called lipoproteins. The major lipoproteins are:

  • Low-density lipoproteins (LDL): Carry cholesterol from liver to peripheral tissues. High LDL levels correlate with increased cardiovascular disease risk.
  • High-density lipoproteins (HDL): Facilitate reverse cholesterol transport back to the liver for excretion. High HDL levels lower cardiovascular disease risk.
  • Very low-density lipoproteins (VLDL): Export triglycerides and cholesterol from liver. Elevated VLDL levels indicate increased risk.


Atherosclerosis is the buildup of plaque in artery walls composed of cholesterol, fat, calcium, and other substances. High LDL cholesterol contributes to atherosclerosis by infiltrating the endothelium and becoming oxidized, triggering inflammation and plaque formation. Rupture of unstable plaques can lead blood clots that block arteries, resulting in heart attacks or strokes. Lowering LDL cholesterol reduces atherosclerotic progression and risk of cardiovascular events.

Liver Synthesis of Cholesterol

While dietary intake contributes to cholesterol levels, the majority of cholesterol is synthesized in the body. The liver is the primary site of cholesterol biosynthesis, producing about 1 gram of cholesterol per day. Cholesterol synthesis in the liver is highly regulated to maintain cholesterol homeostasis.

Regulation of Cholesterol Synthesis

Cholesterol synthesis in the liver occurs through a complex, multi-step process mediated by over 20 enzymes. The rate-limiting step in hepatic cholesterol synthesis is controlled by an enzyme called HMG-CoA reductase. This enzyme is regulated at several levels:

  • Transcriptional regulation of HMGCR gene expression
  • Degradation of HMG-CoA reductase protein
  • Phosphorylation/dephosphorylation affecting HMGCR enzyme activity

When cellular cholesterol levels decline, mechanisms activate to increase HMG-CoA reductase activity and cholesterol synthesis. When cholesterol builds up, pathways inhibit HMG-CoA reductase, slowing synthesis. Several cholesterol-lowering statin drugs target inhibition of HMG-CoA reductase to lower blood cholesterol.

Sources of Cholesterol for Synthesis

The liver synthesizes cholesterol from acetyl-CoA. Three primary sources provide acetyl-CoA for cholesterol synthesis:

  • Fatty acids – Derived from diet or adipose tissues. Fatty acid breakdown generates acetyl-CoA.
  • Glucose – Dietary carbohydrates converted to acetyl-CoA via glycolysis and pyruvate oxidation.
  • Ketone bodies – Acetyl-CoA derived from ketogenesis in the liver provides substrate for cholesterol synthesis.

Increased intake of excess calories from fat, carbohydrates, or protein stimulates cholesterol synthesis by increasing availability of acetyl-CoA.

Absorption of Dietary Cholesterol

In addition to internal synthesis, dietary cholesterol contributes to overall body cholesterol levels. Dietary cholesterol is obtained exclusively from animal foods including meat, dairy, eggs, and shellfish. Intestinal absorption of cholesterol involves:

  1. Incorporation into micelles containing bile acids and phospholipids.
  2. Uptake by enterocytes of the jejunum via Niemann-Pick C1-Like 1 (NPC1L1) protein transporters.
  3. Packaging into chylomicron particles that enter the lymphatic system.
  4. Clearance by the liver and incorporation into VLDL particles.

Dietary cholesterol absorption is an active, regulated process impacted by genetics and dietary factors. Increased cholesterol intake typically leads to downregulation of absorption efficiency to maintain homeostasis.

Factors Affecting Cholesterol Absorption

Multiple factors modulate the intestinal absorption of dietary cholesterol, including:

  • Genetic polymorphisms affecting NPC1L1 activity
  • Presence of dietary fiber and plant sterols that limit uptake
  • Consumption of saturated vs. unsaturated fatty acids
  • Secretion and composition of bile acids

On average, humans absorb 30-60% of dietary cholesterol, but absorption rates vary substantially based on genetics, dietary patterns, age, and health status.

Excretion of Cholesterol

To balance cholesterol input from synthesis and diet, mechanisms exist to eliminate excess cholesterol from the body. The liver facilitates both direct cholesterol excretion into bile as well as conversion into bile acids.

Biliary Cholesterol Secretion

The liver directly excretes cholesterol into bile at a rate of 400-800 mg/day. Key steps in biliary cholesterol secretion include:

  1. Free cholesterol is esterified by ACAT to form cholesteryl esters
  2. Cholesteryl esters are transferred to apolipoprotein B containing lipoproteins
  3. Lipoproteins are transported across the canalicular membrane of hepatocytes via ABCG5/G8 transporters

Cholesterol secreted in bile is eliminated in feces. Factors that impact bile salt synthesis and secretion affect the rate of cholesterol excretion via this route.

Bile Acid Synthesis

Conversion of cholesterol into bile acids represents the major route for cholesterol catabolism, accounting for 50% or more of cholesterol elimination. Bile acid synthesis involves:

  1. Initiation of the neutral pathway by 7-alpha hydroxylation of cholesterol via CYP7A1.
  2. Production of primary bile acids cholic acid and chenodeoxycholic acid.
  3. Conjugation with glycine or taurine, generating bile salts.
  4. Secretion and storage in the gallbladder.
  5. Enterohepatic circulation and fecal elimination of 3-8 g of bile salts/cholesterol daily.

Increasing bile acid synthesis provides an important mechanism to enhance cholesterol turnover and reverse cholesterol accumulation in conditions of hypercholesterolemia.

Reverse Cholesterol Transport

Reverse cholesterol transport is the process by which excess peripheral cholesterol is returned to the liver for recycling or excretion. It provides an anti-atherogenic function by removing cholesterol from artery walls. Key aspects involve:

  • HDL particles uptake free cholesterol from cells via ABCA1.
  • Cholesterol esterification onto HDL via LCAT enzyme.
  • CETP mediates transfer to apoB-containing lipoproteins.
  • Hepatic clearance via SR-BI receptors.
  • Excretion or recycling.

Factors that raise HDL levels promote RCT and lower cardiovascular disease risk. Cholesterol efflux capacity correlates strongly with reduced atherosclerosis progression.

LDL Receptor-Mediated Clearance

About 70% of circulating LDL is removed by LDL receptors (LDLR) expressed abundantly in liver hepatocytes. Key steps include:

  1. LDL particles bind to LDLRs on hepatic cell surface.
  2. LDL-LDLR complexes undergo endocytosis forming endosomes.
  3. Proprotein convertases cleave LDL from receptors.
  4. LDLRs recycle back to cell surface.
  5. Cholesterol esters in LDL are hydrolyzed in lysosomes.

Reduced LDLR activity due to genetic mutations causes familial hypercholesterolemia. Statin drugs increase LDLR expression to lower LDL levels.

LXR Regulation of Hepatic Cholesterol Metabolism

Liver X receptors (LXRs) are nuclear receptors that act as key transcriptional regulators of cholesterol metabolism in the liver. Activation of LXRs:

  • Induces expression of cholesterol export pumps like ABCA1.
  • Stimulates bile acid synthesis enzymes.
  • Inhibits NPC1L1-mediated cholesterol uptake.
  • Downregulates lipogenesis.

Synthetic LXR agonists lower LDL cholesterol in animal models, but may increase triglycerides. LXRs serve as central modulators that promote cholesterol excretion in the liver.

Cholesterol Metabolism in Disease

Defects in hepatic cholesterol metabolism contribute to cardiovascular and metabolic diseases:


  • Overproduction of LDL and VLDL particles exports cholesterol to arteries.
  • Reduced HDL function impairs reverse cholesterol transport.
  • Excess LDL oxidation and plaque formation.

Nonalcoholic Fatty Liver Disease (NAFLD)

  • Hepatic cholesterol accumulation promotes inflammation and progression to NASH.
  • Dysregulation of SREBP and LXR pathways disrupt cholesterol homeostasis.

Gallstone Disease

  • Increased biliary cholesterol saturation and stone formation.
  • Altered regulation of hepatic bile acid and phospholipid synthesis.

Therapeutic interventions targeting restoration of normal liver cholesterol metabolism pathways hold promise for treating these diseases.


The liver plays an essential role in whole-body cholesterol regulation and homeostasis. Critical functions include endogenous cholesterol synthesis, intake of dietary cholesterol, export and excretion of cholesterol, bile acid production, and orchestration of reverse cholesterol transport. Disruption in these pathways through genetic and environmental factors can lead to cardiovascular diseases, NAFLD, and other conditions. Understanding the molecular regulation of liver cholesterol metabolism provides insights for development of cholesterol-lowering medications and targeted therapies to combat cholesterol-related diseases. Ongoing research continues to unravel new mechanisms by which the liver adapts to maintain cholesterol balance and protect against hypercholesterolemia and atherosclerosis progression.

Liver Function Processes
Cholesterol synthesis HMG-CoA reductase controls rate-limiting step. Regulated by multiple mechanisms.
Dietary cholesterol absorption Micelle formation, uptake by NPC1L1, incorporation into chylomicrons.
Biliary cholesterol excretion Esterification by ACAT, secretion in bile via ABCG5/G8.
Bile acid synthesis CYP7A1 initiates neutral pathway. Synthesized primary bile acids.
Reverse cholesterol transport HDL uptake from tissues, transport to liver, SR-BI clearance.
LDL receptor clearance LDLR endocytosis of LDL particles, recycling to cell surface.
LXR regulation Stimulates cholesterol export and catabolism. Inhibits cholesterol uptake.

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