Cholesterol acquired by extrahepatic tissues (from de novo synthesis or lipoproteins) is returned to the liver for excretion in a process called reverse cholesterol transport (RCT). We undertook studies to determine if RCT could be enhanced by up-regulating individual steps in the RCT pathway. Overexpression of 7␣-hydroxylase, Scavenger receptor B1, lecithin:cholesterol acyltransferase (LCAT), or apoA-I in the liver did not stimulate cholesterol efflux from any extrahepatic tissue. In contrast, infusion of apoA-I⅐phospholipid complexes (rHDL) that resemble nascent HDL markedly stimulated cholesterol efflux from tissues into plasma. Cholesterol effluxed to rHDL was initially unesterified but by 24 h this cholesterol was largely esterified and had shifted to normal HDL (in mice lacking cholesteryl ester transfer protein) or to apoB containing lipoproteins (in cholesteryl ester transfer protein transgenic mice). Most of the cholesterol effluxed into plasma in response to rHDL came from the liver. However, an even greater proportion of effluxed cholesterol was cleared by the liver resulting in a transient increase in liver cholesterol concentrations. Fecal sterol excretion was not increased by rHDL. Thus, although rHDL stimulated cholesterol efflux from most tissues and increased net cholesterol movement from extrahepatic tissues to the liver, cholesterol flux through the entire RCT pathway was not increased.Cholesterol that has been acquired by extrahepatic tissues (from de novo synthesis or lipoproteins) is returned to the liver for excretion in a process called reverse cholesterol transport (RCT) 1 (1-3). The first step in the RCT pathway is efflux of cholesterol from cell membranes to nascent HDL in interstitial fluid (2, 3). Nascent HDL are discoidal pre--migrating complexes of phospholipid and apoA-I (other amphipathic apoproteins such as apoE and apoA-IV may also be present). These particles are secreted by the liver (4, 5) and small intestine (6) and are also formed during the metabolism of triglyceride-rich lipoproteins from excess surface material. In addition, lipid-free apoA-I can mediate the efflux of cholesterol and phospholipid from cells generating pre-migrating nascent HDL (7,8). ATP-binding cassette transporter 1 (ABCA1) appears to play a key role in this process although the exact mechanism is unclear (9 -12). Cholesterol that is transferred to nascent HDL is esterified by lecithin: cholesterol acyltransferase (LCAT) to cholesteryl esters, which by virtue of their hydrophobicity move into the core of the HDL particle resulting in the formation of ␣-migrating spherical HDL. HDL cholesteryl esters are cleared from plasma mainly by the liver (13-16). HDL cholesteryl ester uptake by the liver is mediated by the scavenger receptor BI (SR-BI), which selectively transports HDL cholesteryl esters resulting in an HDL particle of reduced size and cholesteryl ester content (17, 18). In species with cholesteryl ester transfer protein, a portion of HDL cholesteryl ester is transferred to lower density apoB-c...