If mitochondrial acetyl-CoA metabolism is impaired, carnitine-fatty acid cycling is impaired and carnitine usage is shifted to acetyl-carnitine from palmitoyl-carnitine (Figure 3).This results in a build-up of palmitate in the cytosol.Normally, peroxisomes only oxidize 20-30% of cellular palmitate [125,126].Fatty acid transport into peroxisomes occurs via their CoA esters, not carnitine.Peroxisomes are designed to consume excess cytosolic fatty acids.However, unlike mitochondria fatty acid -oxidation, which is a catabolic, energy generating process [127], peroxisomal -oxidation plays primarily an anabolic role where imported fatty acid-CoA is partially -oxidized to acetyl-CoA and medium-chain fatty acids [128].Within the peroxisome, this acetyl-CoA is used for the synthesis of the fatty alcohol that ultimately becomes the sn-1 ether in plasmalogens [129-132].In addition to the synthesis of the 1-O-alkyl bond of plasmalogens, the synthesis of docosahexaenoic acid (DHA)also involves a peroxisomal component.Following the synthesis of24:6 (tetracosahexaenoic acid) via fatty acid elongation and desaturation of 18:3 (-linolenic acid) in the endoplasmic reticulum, 24:6 is transported to the peroxisome where it is -oxidized to 22:6 (DHA) [133]

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Lancet 5-12-1979;1(8124):1041-1042