24Specific mutations in Apolipoprotein A-I (ApoA-I) of high-density lipoprotein (HDL) are 25 responsible for a late-onset systemic amyloidosis. Carriers do not exhibit increased 26 cardiovascular disease risk despite reduced levels of ApoA-I/ HDL-cholesterol. To explain 27 this paradox, we show that the HDL particle profile of L75P and L174S patients presents a 28 higher relative abundance of the 8.4 nm vs 9.6 nm particles, and that serum from patients, as 29 well as reconstituted 8.4 and 9.6 nm HDL particles (rHDL), possess increased capacity to 30 catalyze cholesterol efflux from macrophages. Synchrotron radiation circular dichroism and 31 hydrogen-deuterium exchange revealed that the variants in 8.4 nm rHDL have altered 32 secondary structure composition and display a more flexible binding to lipids compared to 33 their native counterpart. The reduced HDL-cholesterol levels of patients carrying ApoA-I 34 amyloidogenic variants are thus balanced by higher proportion of small, dense HDL particles 35 and better cholesterol efflux due to altered, region-specific protein structure dynamics. 36 37 Keywords 38 Apolipoprotein A-I, amyloidosis, high-density lipoprotein, cholesterol efflux, cardiovascular 39 disease 40 41 Abbreviations 42 ABCA1, ATP binding cassette A1; ABCG1, ATP binding cassette G1, ApoA-I, apolipoprotein 43 A-I; ApoB, apolipoprotein B; CD, circular dichroism; CVD, cardiovascular disease; FC, 44 unesterified free cholesterol; HDL, high-density lipoprotein; HDX, hydrogen-deuterium 45 exchange; LCAT, lecithin-cholesteryl acyl transferase; PBS, phosphate buffer saline; POPC, 46 1-palmitoyl-2-oleoyl-sn-glycero-3-phosphocholine; rHDL, reconstituted HDL; SRCD, 47 Synchrotron Radiation Circular Dichroism; TEV, tobacco etch virus; Tm, transition 48 temperature; WT, wild-type.49 3 Main 50 Amyloidoses are a broad group of diseases caused by protein instability and misfolding that 51 leads to pathological aggregation of proteins as amyloid deposits in tissues and organs 1 .52 These amyloid deposits are either localized, as in Alzheimer's and Parkinson's diseases, or 53 systemic, as is the case of transthyretin and light-chain amyloidoses. The different types of 54 amyloidoses commonly lead to severe and age-related damage of the tissues where 55 aggregation takes place. The understanding of the determinants leading to protein fibril 56 formation and amyloidosis development is thus key for finding ways to develop efficient 57 treatments for the affected individuals.58 Apolipoprotein A-I (ApoA-I), associated with hereditary systemic amyloidosis, has a key role 59 for the transportation of cholesterol and lipids in the circulation between peripheral tissues 60 and the liver 2 . Following its synthesis in the liver and intestines, ApoA-I mediates this 61 transportation by the formation of high-density lipoprotein (HDL) particles. These load 62 cholesterol and lipids from macrophages at the artery wall via a regulated efflux mechanism 63 catalyzed by the cellular ATP-binding cassette (ABC)A1 receptor. HDLs are then c...