Lecithin-cholesterol acyltransferase (EC 2.3.1.43, LCAT) is the enzyme responsible for the formation of the bulk of cholesteryl ester in human plasma. The LCAT-reaction takes place mainly on high-density lipoproteins and requires an apolipoprotein as activator. Besides apolipoprotein (apo) A-I several other potent activator apolipoproteins (AIV, E and CI) were identified, furthermore apo A-II was shown to be a modulator of the enzyme's reaction in the presence of apo A-I. Serum amyloid A, an apolipoprotein mainly associated with high-density lipoprotein, massively accumulates in plasma upon acute phase reactions. We therefore studied the possible influence of this acute phase reactant on cholesterol esterification in human plasma. There was a significant decrease of esterified cholesterol in plasma during acute phase reaction. We found a highly significant correlation between the unesterified part of plasma cholesterol and serum amyloid A levels (r = 0.694, P = 0.0001). Also, plasma LCAT activity was negatively correlated with serum amyloid A levels. Lipoproteins containing apo A-I and A-II (LpA-I: A-II) and lipoproteins containing apo A-I but no A-II (LpA-I) decreased significantly with the appearance in plasma of serum amyloid A. To study the influence of serum amyloid A on the LCAT reaction, artificial substrates were prepared either by a detergent dialysis procedure or by addition of apolipoprotein to a sonicated aqueous dispersion of lipid. In addition two different molar ratios of apolipoprotein/phospholipid (PC) (1:50 and 1:310) were chosen at a constant molar ratio of total cholesterol/PC of 1:20. The various substrates were incubated with purified LCAT enzyme. DMPC - or egg yolk phosphatidylcholine - cholesterol-[4-14C]cholesterol-serum amyloid A complexes per se did not stimulate LCAT activity significantly. However, apo serum amyloid A incorporated together with apo A-I by a detergent dialysis procedure lead at low concentrations of serum amyloid A to a marked increase in cholesteryl ester formation as compared to apo A-I alone but inhibited the cholesteryl ester formation at high concentrations. Thus, the low levels of esterified cholesterol in acute phase plasma are to some extent due to decreased plasma enzyme activity and in part may be due to interference of apo serum amyloid A with the natural substrate complexes of plasma HDL.