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Page MM, Hardikar W, Alex G, Bates S, Srinivasan S, Stormon M, Hall K, Evans HM, Johnston P, Chen J, Wigg A, John L, Ekinci EI, O'Brien RC, Jones R, Watts GF. Long-term outcomes of liver transplantation for homozygous familial hypercholesterolaemia in Australia and New Zealand. Atherosclerosis 2023; 387:117305. [PMID: 37863699 DOI: 10.1016/j.atherosclerosis.2023.117305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/14/2023] [Accepted: 09/20/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND AND AIMS Homozygous familial hypercholesterolaemia (FH) causes severe cardiovascular disease from childhood. Conventional drug therapy is usually ineffective; lipoprotein apheresis (LA) is often required. Liver transplantation (LT) can correct the metabolic defect but is considered a treatment of last resort. Newer drugs including lomitapide and evinacumab might reduce the need for apheresis and LT. We sought to determine the long-term outcomes following LT in Australia and New Zealand. METHODS We analysed demographic, biochemical and clinical data from all patients in Australia and New Zealand who have received LT for homozygous FH, identified from the Australia and New Zealand Liver and Intestinal Transplant Registry. RESULTS Nine patients (five female; one deceased; seven aged between 3 and 6 years at the time of LT and two aged 22 and 26 years) were identified. Mean follow-up was 14.1 years (range 4-27). Baseline LDL-cholesterol off all treatment was 23 ± 4.1 mmol/L. Mean LDL-cholesterol on medical therapy (including maximal statin therapy in all patients, ezetimibe in three and LA in five) was 11 ± 5.7 mmol/L (p < 0.001). After LT, mean LDL-cholesterol was 2.6 ± 0.9 mmol/L (p = 0.004) with three patients remaining on statin therapy and none on LA. One patient died from acute myocardial infarction (AMI) three years after LT. Two patients required aortic valve replacement, more than 10 years after LT. The remaining six patients were asymptomatic after eight to 21 years of follow-up. No significant adverse events associated with immunosuppression were reported. CONCLUSIONS LT for homozygous FH was highly effective in achieving substantial long-term reduction in LDL-cholesterol concentrations in all nine patients. LT remains an option for severe cases of homozygous FH where drug therapy combined with apheresis is ineffective or unfeasible.
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Affiliation(s)
- Michael M Page
- Medical School, The University of Western Australia, Perth, Australia; Western Diagnostic Pathology, Perth, Australia
| | - Winita Hardikar
- Gastroenterology and Clinical Nutrition, The Royal Children's Hospital Melbourne, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - George Alex
- Gastroenterology and Clinical Nutrition, The Royal Children's Hospital Melbourne, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Sue Bates
- Gastroenterology and Clinical Nutrition, The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Shubha Srinivasan
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Michael Stormon
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Gastroenterology and Hepatology, The Children's Hospital at Westmead, Sydney, Australia
| | - Kat Hall
- Hepatobiliary and Liver Transplant Surgery Unit, Austin Health, Melbourne, Australia
| | - Helen M Evans
- Paediatric Gastroenterology and Hepatology, Starship Child Health, Auckland, New Zealand; Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Peter Johnston
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
| | - John Chen
- South Australia Liver Transplant Unit, Flinders Medical Centre, Adelaide, Australia; College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Alan Wigg
- South Australia Liver Transplant Unit, Flinders Medical Centre, Adelaide, Australia; College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Libby John
- South Australia Liver Transplant Unit, Flinders Medical Centre, Adelaide, Australia
| | - Elif I Ekinci
- Department of Endocrinology, Austin Health, Melbourne, Australia; The Australian Centre for Accelerating Diabetes Innovation, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia; Department of Medicine, Austin Health, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Richard C O'Brien
- Department of Endocrinology, Austin Health, Melbourne, Australia; Department of Medicine, Austin Health, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Robert Jones
- Hepatobiliary and Liver Transplant Surgery Unit, Austin Health, Melbourne, Australia; Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Gerald F Watts
- Medical School, The University of Western Australia, Perth, Australia; Department of Cardiovascular Medicine, Royal Perth Hospital, Perth, Australia.
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2
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Shaik NA, Al-Shehri N, Athar M, Awan A, Khalili M, Al Mahadi HB, Hejazy G, Saadah OI, Al-Harthi SE, Elango R, Banaganapalli B, Alefishat E, Awan Z. Protein structural insights into a rare PCSK9 gain-of-function variant (R496W) causing familial hypercholesterolemia in a Saudi family: whole exome sequencing and computational analysis. Front Physiol 2023; 14:1204018. [PMID: 37469559 PMCID: PMC10353052 DOI: 10.3389/fphys.2023.1204018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/12/2023] [Indexed: 07/21/2023] Open
Abstract
Familial hypercholesterolemia (FH) is a globally underdiagnosed genetic condition associated with premature cardiovascular death. The genetic etiology data on Arab FH patients is scarce. Therefore, this study aimed to identify the genetic basis of FH in a Saudi family using whole exome sequencing (WES) and multidimensional bioinformatic analysis. Our WES findings revealed a rare heterozygous gain-of-function variant (R496W) in the exon 9 of the PCSK9 gene as a causal factor for FH in this family. This variant was absent in healthy relatives of the proband and 200 healthy normolipidemic controls from Saudi Arabia. Furthermore, this variant has not been previously reported in various regional and global population genomic variant databases. Interestingly, this variant is classified as "likely pathogenic" (PP5) based on the variant interpretation guidelines of the American College of Medical Genetics (ACMG). Computational functional characterization suggested that this variant could destabilize the native PCSK9 protein and alter its secondary and tertiary structural features. In addition, this variant was predicted to negatively influence its ligand-binding ability with LDLR and Alirocumab antibody molecules. This rare PCSK9 (R496W) variant is likely to expand our understanding of the genetic basis of FH in Saudi Arabia. This study also provides computational structural insights into the genotype-protein phenotype relationship of PCSK9 pathogenic variants and contributes to the development of personalized medicine for FH patients in the future.
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Affiliation(s)
- Noor Ahmad Shaik
- Department of Genetic Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Princess Al-Jawhara Center of Excellence in Research of Hereditary Disorders, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Najla Al-Shehri
- Department of Clinical Biochemistry, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammad Athar
- Department of Medical Genetics, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
- Science and Technology Unit, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Ahmed Awan
- Department of Clinical Biochemistry, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mariam Khalili
- Department of Pharmacology, College of Medicine, Khalifa University, Abu Dhabi, United Arab Emirates
| | | | - Gehan Hejazy
- Department of Clinical Biochemistry, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Omar I. Saadah
- Department of Pediatrics, Pediatric Gastroenterology Unit, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Sameer Eida Al-Harthi
- Department of Clinical Pharmacology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ramu Elango
- Department of Genetic Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Princess Al-Jawhara Center of Excellence in Research of Hereditary Disorders, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Babajan Banaganapalli
- Department of Genetic Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Princess Al-Jawhara Center of Excellence in Research of Hereditary Disorders, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Eman Alefishat
- Department of Pharmacology, College of Medicine, Khalifa University, Abu Dhabi, United Arab Emirates
- Department of Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, The University of Jordan, Amman, Jordan
- Center for Biotechnology, Khalifa University, Abu Dhabi, United Arab Emirates
| | - Zuhier Awan
- Department of Clinical Biochemistry, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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3
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Bassani Borges J, Fernandes Oliveira V, Dagli-Hernandez C, Monteiro Ferreira G, Kristini Almendros Afonso Barbosa T, da Silva Rodrigues Marçal E, Los B, Barbosa Malaquias V, Hernandes Bortolin R, Caroline Costa Freitas R, Akira Mori A, Medeiros Bastos G, Marques Gonçalves R, Branco Araújo D, Zatz H, Bertolami A, Arpad Faludi A, Chiara Bertolami M, Guerra de Moraes Rego Souza A, Ítalo Dias França J, Strelow Thurow H, Dominguez Crespo Hirata T, Takashi Imoto Nakaya H, Elim Jannes C, da Costa Pereira A, Nogueira Silbiger V, Ducati Luchessi A, Nayara Góes Araújo J, Arruda Nakazone M, Silva Carmo T, Rossi Silva Souza D, Moriel P, Yu Ting Wang J, Satya Naslavsky M, Gorjão R, Cristina Pithon-Curi T, Curi R, Moreno Fajardo C, Lin Wang HT, Regina Garófalo A, Cerda A, Ferraz Sampaio M, Dominguez Crespo Hirata R, Hiroyuki Hirata M. Identification of pathogenic variants in the Brazilian cohort with Familial Hypercholesterolemia using exon-targeted gene sequencing. Gene 2023; 875:147501. [PMID: 37217153 DOI: 10.1016/j.gene.2023.147501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 05/16/2023] [Accepted: 05/18/2023] [Indexed: 05/24/2023]
Abstract
Familial hypercholesterolemia (FH) is a monogenic disease characterized by high plasma low-density lipoprotein cholesterol (LDL-c) levels and increased risk of premature atherosclerotic cardiovascular disease. Mutations in FH-related genes account for 40% of FH cases worldwide. In this study, we aimed to assess the pathogenic variants in FH-related genes in the Brazilian FH cohort FHBGEP using exon-targeted gene sequencing (ETGS) strategy. FH patients (n=210) were enrolled at five clinical sites and peripheral blood samples were obtained for laboratory testing and genomic DNA extraction. ETGS was performed using MiSeq platform (Illumina). To identify deleterious variants in LDLR, APOB, PCSK9, and LDLRAP1, the long-reads were subjected to Burrows-Wheeler Aligner (BWA) for alignment and mapping, followed by variant calling using Genome Analysis Toolkit (GATK) and ANNOVAR for variant annotation. The variants were further filtered using in-house custom scripts and classified according to the American College Medical Genetics and Genomics (ACMG) guidelines. A total of 174 variants were identified including 85 missense, 3 stop-gain, 9 splice-site, 6 InDel, and 71 in regulatory regions (3'UTR and 5'UTR). Fifty-two patients (24.7%) had 30 known pathogenic or likely pathogenic variants in FH-related genes according to the American College Medical and Genetics and Genomics guidelines. Fifty-three known variants were classified as benign, or likely benign and 87 known variants have shown uncertain significance. Four novel variants were discovered and classified as such due to their absence in existing databases. In conclusion, ETGS and in silico prediction studies are useful tools for screening deleterious variants and identification of novel variants in FH-related genes, they also contribute to the molecular diagnosis in the FHBGEP cohort.
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Affiliation(s)
- Jéssica Bassani Borges
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo 05508-000 SP, Brazil; Laboratory of Molecular Research in Cardiology, Institute of Cardiology Dante Pazzanese, Sao Paulo 04012-909, Brazil; Department of Teaching and Research, Real and Benemerita Associação Portuguesa de Beneficiencia, Sao Paulo 01323-001, Brazil
| | - Victor Fernandes Oliveira
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo 05508-000 SP, Brazil
| | - Carolina Dagli-Hernandez
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo 05508-000 SP, Brazil
| | - Glaucio Monteiro Ferreira
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo 05508-000 SP, Brazil; Laboratory of Molecular Research in Cardiology, Institute of Cardiology Dante Pazzanese, Sao Paulo 04012-909, Brazil
| | | | - Elisangela da Silva Rodrigues Marçal
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo 05508-000 SP, Brazil; Laboratory of Molecular Research in Cardiology, Institute of Cardiology Dante Pazzanese, Sao Paulo 04012-909, Brazil
| | - Bruna Los
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo 05508-000 SP, Brazil
| | - Vanessa Barbosa Malaquias
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo 05508-000 SP, Brazil
| | - Raul Hernandes Bortolin
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo 05508-000 SP, Brazil; Department of Cardiology, Boston Children's Hospital, Boston, MA 02115, United States
| | - Renata Caroline Costa Freitas
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo 05508-000 SP, Brazil; Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA 02115, United States
| | - Augusto Akira Mori
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo 05508-000 SP, Brazil
| | - Gisele Medeiros Bastos
- Laboratory of Molecular Research in Cardiology, Institute of Cardiology Dante Pazzanese, Sao Paulo 04012-909, Brazil; Department of Teaching and Research, Real and Benemerita Associação Portuguesa de Beneficiencia, Sao Paulo 01323-001, Brazil
| | | | - Daniel Branco Araújo
- Medical Clinic Division, Institute of Cardiology Dante Pazzanese, Sao Paulo 04012-909, Brazil
| | - Henry Zatz
- Medical Clinic Division, Institute of Cardiology Dante Pazzanese, Sao Paulo 04012-909, Brazil
| | - Adriana Bertolami
- Medical Clinic Division, Institute of Cardiology Dante Pazzanese, Sao Paulo 04012-909, Brazil
| | - André Arpad Faludi
- Medical Clinic Division, Institute of Cardiology Dante Pazzanese, Sao Paulo 04012-909, Brazil
| | | | | | - João Ítalo Dias França
- Laboratory of Epidemiology and Statistics, Institute of Cardiology Dante Pazzanese, Sao Paulo 04012-909, Brazil
| | - Helena Strelow Thurow
- Department of Teaching and Research, Real and Benemerita Associação Portuguesa de Beneficiencia, Sao Paulo 01323-001, Brazil
| | - Thiago Dominguez Crespo Hirata
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo 05508-000 SP, Brazil
| | - Helder Takashi Imoto Nakaya
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo 05508-000 SP, Brazil
| | - Cinthia Elim Jannes
- Laboratory of Genetics and Molecular Cardiology, Heart Institute, University of Sao Paulo, Sao Paulo 05403-900, Brazil
| | - Alexandre da Costa Pereira
- Laboratory of Genetics and Molecular Cardiology, Heart Institute, University of Sao Paulo, Sao Paulo 05403-900, Brazil
| | - Vivian Nogueira Silbiger
- Department of Clinical and Toxicological Analysis, Federal University of Rio Grande do Norte, Natal 59078-900 Brazil; Northeast Biotechnology Network (RENORBIO), Graduate Program in Biotechnology, Federal University of Rio Grande do Norte, Natal 59078-900, Brazil
| | - André Ducati Luchessi
- Department of Clinical and Toxicological Analysis, Federal University of Rio Grande do Norte, Natal 59078-900 Brazil; Northeast Biotechnology Network (RENORBIO), Graduate Program in Biotechnology, Federal University of Rio Grande do Norte, Natal 59078-900, Brazil
| | - Jéssica Nayara Góes Araújo
- Northeast Biotechnology Network (RENORBIO), Graduate Program in Biotechnology, Federal University of Rio Grande do Norte, Natal 59078-900, Brazil
| | - Marcelo Arruda Nakazone
- Department of Cardiology and Cardiovascular Surgery, Faculdade de Medicina de São José do Rio Preto, Sao Jose do Rio Preto 15090-000, Brazil
| | - Tayanne Silva Carmo
- Department of Cardiology and Cardiovascular Surgery, Faculdade de Medicina de São José do Rio Preto, Sao Jose do Rio Preto 15090-000, Brazil
| | - Dorotéia Rossi Silva Souza
- Department of Biochemistry and Molecular Biology, Sao Jose do Rio Preto Medical School, Sao Jose do Rio Preto 15090-000, Brazil
| | - Patricia Moriel
- Department of Clinical Pathology, Faculty of Pharmaceutical Sciences, State University of Campinas-UNICAMP, Campinas 13083-871, Brazil
| | - Jaqueline Yu Ting Wang
- Human Genome and Stem-Cell Research Center, Biosciences Institute, University of Sao Paulo, Sao Paulo 05508-090, Brazil
| | - Michel Satya Naslavsky
- Human Genome and Stem-Cell Research Center, Biosciences Institute, University of Sao Paulo, Sao Paulo 05508-090, Brazil
| | - Renata Gorjão
- Interdisciplinary Post-graduate Program in Health Sciences, Cruzeiro do Sul University, Sao Paulo 01311-925, Brazil
| | - Tania Cristina Pithon-Curi
- Interdisciplinary Post-graduate Program in Health Sciences, Cruzeiro do Sul University, Sao Paulo 01311-925, Brazil
| | - Rui Curi
- Interdisciplinary Post-graduate Program in Health Sciences, Cruzeiro do Sul University, Sao Paulo 01311-925, Brazil
| | - Cristina Moreno Fajardo
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo 05508-000 SP, Brazil
| | - Hui-Tzu Lin Wang
- Laboratory of Molecular Research in Cardiology, Institute of Cardiology Dante Pazzanese, Sao Paulo 04012-909, Brazil
| | - Adriana Regina Garófalo
- Laboratory of Molecular Research in Cardiology, Institute of Cardiology Dante Pazzanese, Sao Paulo 04012-909, Brazil
| | - Alvaro Cerda
- Department of Basic Sciences, Center of Excellence in Translational Medicine, BIOREN, Universidad de La Frontera, Temuco 4810296, Chile
| | - Marcelo Ferraz Sampaio
- Department of Cardiology, Real and Benemerita Associação Portuguesa de Beneficiencia, Sao Paulo 01323-001, Brazil
| | - Rosario Dominguez Crespo Hirata
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo 05508-000 SP, Brazil
| | - Mario Hiroyuki Hirata
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo 05508-000 SP, Brazil.
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4
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Medeiros AM, Bourbon M. Genetic Testing in Familial Hypercholesterolemia: Is It for Everyone? Curr Atheroscler Rep 2023; 25:127-132. [PMID: 36862327 PMCID: PMC10027780 DOI: 10.1007/s11883-023-01091-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2023] [Indexed: 03/03/2023]
Abstract
PURPOSE OF REVIEW Lipid measurements and genetic testing are the main diagnostic tools for FH screening that are available in many countries. A lipid profile is widely accessible, and genetic testing, although available worldwide, in some countries is only performed in a research context. Still FH is diagnosed late, showing lack of early screening programs worldwide. RECENT FINDINGS Pediatric screening of FH was recently recognized by the European Commission Public Health Best Practice Portal as one on the best practices in non-communicable disease prevention. The early diagnosis of FH and the lowering of LDL-C values over lifespan can reduce the risk of coronary artery disease and offer health and socioeconomic gains. Current knowledge about FH shows that early detection through appropriate screening needs to become a priority in healthcare systems worldwide. Governmental programs for FH identification should be implemented to unify the diagnosis and increase patient identification.
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Affiliation(s)
- A M Medeiros
- Unidade de I&D, Grupo de Investigação Cardiovascular, Departamento de Promoção da Saúde E Prevenção de Doenças Não Transmissíveis, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisbon, Portugal
- BioISI - Biosystems & Integrative Sciences Institute, Faculdade de Ciências, Universidade de Lisboa, Lisbon, Portugal
| | - M Bourbon
- Unidade de I&D, Grupo de Investigação Cardiovascular, Departamento de Promoção da Saúde E Prevenção de Doenças Não Transmissíveis, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisbon, Portugal.
- BioISI - Biosystems & Integrative Sciences Institute, Faculdade de Ciências, Universidade de Lisboa, Lisbon, Portugal.
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5
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Nayara Góes de Araújo J, Fernandes de Oliveira V, Bassani Borges J, Dagli-Hernandez C, da Silva Rodrigues Marçal E, Caroline Costa de Freitas R, Medeiros Bastos G, Marques Gonçalves R, Arpad Faludi A, Elim Jannes C, da Costa Pereira A, Dominguez Crespo Hirata R, Hiroyuki Hirata M, Ducati Luchessi A, Nogueira Silbiger V. In silico analysis of upstream variants in Brazilian patients with Familial Hypercholesterolemia. Gene X 2022; 849:146908. [PMID: 36167182 DOI: 10.1016/j.gene.2022.146908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 08/16/2022] [Accepted: 09/19/2022] [Indexed: 10/14/2022] Open
Abstract
Familial hypercholesterolemia (FH) is a prevalent autosomal genetic disease associated with increased risk of early cardiovascular events and death due to chronic exposure to very high levels of low-density lipoprotein cholesterol (LDL-c). Pathogenic variants in the coding regions of LDLR, APOB and PCSK9 account for most FH cases, and variants in non-coding regions maybe involved in FH as well. Variants in the upstream region of LDLR, APOB and PCSK9 were screened by targeted next-generation sequencing and their effects were explored using in silico tools. Twenty-five patients without pathogenic variants in FH-related genes were selected. 3 kb upstream regions of LDLR, APOB and PCSK9 were sequenced using the AmpliSeq (Illumina) and Miseq Reagent Nano Kit v2 (Illumina). Sequencing data were analyzed using variant discovery and functional annotation tools. Potentially regulatory variants were selected by integrating data from public databases, published data and context-dependent regulatory prediction score. Thirty-four single nucleotide variants (SNVs) in upstream regions were identified (6 in LDLR, 15 in APOB, and 13 in PCSK9). Five SNVs were prioritized as potentially regulatory variants (rs934197, rs9282606, rs36218923, rs538300761, g.55038486A>G). APOB rs934197 was previously associated with increased rate of transcription, which in silico analysis suggests that could be due to reducing binding affinity of a transcriptional repressor. Our findings highlight the importance of variant screening outside of coding regions of all relevant genes. Further functional studies are necessary to confirm that prioritized variants could impact gene regulation and contribute to the FH phenotype.
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Affiliation(s)
- Jéssica Nayara Góes de Araújo
- Northeast Biotechnology Network (RENORBIO), Graduate Program in Biotechnology, Federal University of Rio Grande do Norte, Natal 59078-900, Brazil
| | - Victor Fernandes de Oliveira
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo 05508-000, Brazil
| | - Jéssica Bassani Borges
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo 05508-000, Brazil; Laboratory of Molecular Research in Cardiology, Institute Dante Pazzanese of Cardiology, Sao Paulo, 04012-909, Brazil
| | - Carolina Dagli-Hernandez
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo 05508-000, Brazil
| | | | - Renata Caroline Costa de Freitas
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo 05508-000, Brazil
| | - Gisele Medeiros Bastos
- Laboratory of Molecular Research in Cardiology, Institute Dante Pazzanese of Cardiology, Sao Paulo, 04012-909, Brazil; Medical Clinic Division, Institute Dante Pazzanese of Cardiology, Sao Paulo 04012-909, Brazil
| | | | - André Arpad Faludi
- Medical Clinic Division, Institute Dante Pazzanese of Cardiology, Sao Paulo 04012-909, Brazil
| | - Cinthia Elim Jannes
- Laboratory of Genetics and Molecular Cardiology, Heart Institute, University of Sao Paulo 05403-900, Brazil
| | - Alexandre da Costa Pereira
- Laboratory of Genetics and Molecular Cardiology, Heart Institute, University of Sao Paulo 05403-900, Brazil
| | - Rosario Dominguez Crespo Hirata
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo 05508-000, Brazil
| | - Mario Hiroyuki Hirata
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Sao Paulo 05508-000, Brazil
| | - André Ducati Luchessi
- Northeast Biotechnology Network (RENORBIO), Graduate Program in Biotechnology, Federal University of Rio Grande do Norte, Natal 59078-900, Brazil; Department of Clinical and Toxicological Analyses, Federal University of Rio Grande do Norte, Natal 59012-570, Brazil
| | - Vivian Nogueira Silbiger
- Northeast Biotechnology Network (RENORBIO), Graduate Program in Biotechnology, Federal University of Rio Grande do Norte, Natal 59078-900, Brazil; Department of Clinical and Toxicological Analyses, Federal University of Rio Grande do Norte, Natal 59012-570, Brazil.
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6
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Horton AE, Martin AC, Srinivasan S, Justo RN, Poplawski NK, Sullivan D, Brett T, Chow CK, Nicholls SJ, Pang J, Watts GF. Integrated guidance to enhance the care of children and adolescents with familial hypercholesterolaemia: Practical advice for the community clinician. J Paediatr Child Health 2022; 58:1297-1312. [PMID: 35837752 PMCID: PMC9545564 DOI: 10.1111/jpc.16096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 05/17/2022] [Accepted: 05/28/2022] [Indexed: 11/28/2022]
Abstract
Familial hypercholesterolaemia (FH) is a highly penetrant monogenic disorder present from birth that markedly elevates plasma low-density lipoprotein (LDL)-cholesterol (LDL-C) concentration and, if untreated, leads to premature atherosclerosis and coronary artery disease (CAD). At a prevalence of 1:250 individuals, with over 90% undiagnosed, recent estimates suggest that there are approximately 22 000 children and adolescents with FH in Australia and New Zealand. However, the overwhelming majority remain undetected and inadequately treated until adulthood or after their first cardiac event. The guidance in this paper aims to increase awareness about paediatric FH and provide practical advice for the diagnosis and management of FH in children and adolescents. Recommendations are given on the detection, diagnosis, assessment and management of FH in children and adolescents. Recommendations are also made on genetic testing, including counselling and the potential for universal screening programmes. Practical guidance on management includes treatment of non-cholesterol risk factors, and safe and appropriate use of LDL-C lowering therapies, including statins, ezetimibe, PCSK9 inhibitors and lipoprotein apheresis. Models of care for FH need to be adapted to local and regional health care needs and available resources. Targeting the detection of FH as a priority in children and young adults has the potential to alter the natural history of atherosclerotic cardiovascular disease and recognise the promise of early detection for improving long-term health outcomes. A comprehensive implementation strategy, informed by further research, including assessments of cost-benefit, will be required to ensure that this new guidance benefits all families with or at risk of FH.
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Affiliation(s)
- Ari E Horton
- Monash Heart and Monash Children's HospitalMonash HealthMelbourneVictoriaAustralia,Monash Cardiovascular Research Centre, Victorian Heart InstituteMonash UniversityMelbourneVictoriaAustralia,Department of PaediatricsMonash UniversityMelbourneVictoriaAustralia
| | - Andrew C Martin
- Department General PaediatricsPerth Children's HospitalPerthWestern AustraliaAustralia,Division of Paediatrics, Faculty of Health and Medical SciencesUniversity of Western AustraliaPerthWestern AustraliaAustralia
| | - Shubha Srinivasan
- Institute of Endocrinology and DiabetesThe Children's Hospital at WestmeadSydneyNew South WalesAustralia,Discipline of Child and Adolescent Health, Faculty of Medicine and HealthUniversity of SydneySydneyNew South WalesAustralia
| | - Robert N Justo
- Department of Paediatric CardiologyQueensland Children's HospitalBrisbaneQueenslandAustralia,School of MedicineUniversity of QueenslandBrisbaneQueenslandAustralia
| | - Nicola K Poplawski
- Adult Genetics UnitRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia,Adelaide Medical SchoolUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - David Sullivan
- Department of Chemical PathologyRoyal Prince Alfred HospitalSydneyNew South WalesAustralia,Sydney Medical School, Faculty of Medicine and HealthUniversity of SydneySydneyNew South WalesAustralia
| | - Tom Brett
- General Practice and Primary Health Care Research, School of MedicineUniversity of Notre Dame AustraliaFremantleWestern AustraliaAustralia
| | - Clara K Chow
- Westmead Applied Research CentreThe University of SydneySydneyNew South WalesAustralia,Department of CardiologyWestmead HospitalSydneyNew South WalesAustralia,Cardiovascular DivisionGeorge Institute for Global HealthSydneyNew South WalesAustralia
| | - Stephen J Nicholls
- Monash Heart and Monash Children's HospitalMonash HealthMelbourneVictoriaAustralia,Monash Cardiovascular Research Centre, Victorian Heart InstituteMonash UniversityMelbourneVictoriaAustralia
| | - Jing Pang
- School of Medicine, Faculty of Health and Medical SciencesUniversity of Western AustraliaPerthWestern AustraliaAustralia
| | - Gerald F Watts
- School of Medicine, Faculty of Health and Medical SciencesUniversity of Western AustraliaPerthWestern AustraliaAustralia,Lipid Disorders Clinic, Cardiometabolic Service, Department of CardiologyRoyal Perth HospitalPerthWestern AustraliaAustralia,Lipid Disorders Clinic, Cardiometabolic Service, Department of Internal MedicineRoyal Perth HospitalPerthWestern AustraliaAustralia
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7
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McIntosh CS, Watts GF, Wilton SD, Aung-Htut MT. Splice correction therapies for familial hypercholesterolemic patients with low-density lipoprotein receptor mutations. Curr Opin Lipidol 2021; 32:355-362. [PMID: 34653074 PMCID: PMC8631153 DOI: 10.1097/mol.0000000000000793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Antisense oligomers (ASOs) have been available for decades: however, only recently have these molecules been applied clinically. This review aims to discuss the possible development of antisense-mediated splice correction therapies as precision medicines for familial hypercholesterolemic patients carrying mutations that compromise normal splicing of the low-density lipoprotein receptor (LDLR) gene transcript. RECENT FINDINGS Three antisense drugs are currently being assessed in ongoing clinical trials for dyslipidemias, aiming to lower the plasma concentrations of lipoproteins that lead to end-organ damage, principally coronary artery disease. Although a handful of drugs may be applicable to many patients with familial hypercholesterolemia (FH), mutation-specific personalised antisense drugs may be even more effective in selected patients. Currently, there is no therapy that effectively addresses mutations in the LDLR, the major cause of FH. Many mutations in the LDLR that disrupt normal pre-mRNA processing could be applicable to splice correction therapy to restore receptor activity. SUMMARY Precision medicine could provide long-term economic and social benefits if they can be implemented effectively and sustainably. Many mutations found in the LDLR gene could be amendable to therapeutic splice correction and we should consider developing a therapeutic ASO platform for these mutations.
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Affiliation(s)
- Craig S. McIntosh
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia
- Centre for Molecular Medicine and Innovative Therapeutics, Health Futures Institute, Murdoch University, Murdoch, Western Australia, Australia
| | - Gerald F. Watts
- School of Medicine, University of Western Australia
- Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Steve D. Wilton
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia
- Centre for Molecular Medicine and Innovative Therapeutics, Health Futures Institute, Murdoch University, Murdoch, Western Australia, Australia
| | - May T. Aung-Htut
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia
- Centre for Molecular Medicine and Innovative Therapeutics, Health Futures Institute, Murdoch University, Murdoch, Western Australia, Australia
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8
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Watts GF, Sullivan DR, Hare DL, Kostner KM, Horton AE, Bell DA, Brett T, Trent RJ, Poplawski NK, Martin AC, Srinivasan S, Justo RN, Chow CK, Pang J. Essentials of a new clinical practice guidance on familial hypercholesterolaemia for physicians. Intern Med J 2021; 51:769-779. [PMID: 34047032 DOI: 10.1111/imj.15327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/05/2021] [Accepted: 03/16/2021] [Indexed: 11/28/2022]
Abstract
Familial hypercholesterolaemia (FH) is a common, heritable and preventable cause of premature coronary artery disease. New clinical practice recommendations are presented to assist practitioners in enhancing the care of all patients with FH. Core recommendations are made on the detection, diagnosis, assessment and management of adults, children and adolescents with FH. Management is under-pinned by the precepts of risk stratification, adherence to healthy lifestyles, treatment of non-cholesterol risk factors and appropriate use of low-density lipoprotein (LDL)-cholesterol-lowering therapies including statins, ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. The recommendations need to be utilised using judicious clinical judgement and shared decision-making with patients and families. New government-funded schemes for genetic testing and use of PCSK9 inhibitors, as well as the National Health Genomics Policy Framework, will enable adoption of the recommendations. However, a comprehensive implementation science and practice strategy is required to ensure that the guidance translates into benefit for all families with FH.
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Affiliation(s)
- Gerald F Watts
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia.,Lipid Disorders Clinic, Cardiometabolic Service, Departments of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - David R Sullivan
- Department of Chemical Pathology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - David L Hare
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Karam M Kostner
- Department of Cardiology, Mater Hospital, University of Queensland, Brisbane, Queensland, Australia
| | - Ari E Horton
- Monash Heart and Monash Children's Hospital, Monash Health, Melbourne, Victoria, Australia.,Monash Cardiovascular Research Centre, Melbourne, Victoria, Australia.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Damon A Bell
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia.,Lipid Disorders Clinic, Cardiometabolic Service, Departments of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia.,Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Royal Perth Hospital and Fiona Stanley Hospital Network, Perth, Western Australia, Australia.,Department of Clinical Biochemistry, Clinipath Pathology, Perth, Western Australia, Australia.,Sonic Genetics, Sonic Pathology, Sydney, New South Wales, Australia
| | - Tom Brett
- General Practice and Primary Health Care Research, School of Medicine, University of Notre Dame Australia, Perth, Western Australia, Australia
| | - Ronald J Trent
- Department of Medical Genomics, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Nicola K Poplawski
- Adult Genetics Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Andrew C Martin
- Department General Paediatrics, Perth Children's Hospital, Perth, Western Australia, Australia.,Division of Paediatrics, University of Western Australia, Perth, Western Australia, Australia
| | - Shubha Srinivasan
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Discipline of Child and Adolescent Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Robert N Justo
- Department of Paediatric Cardiology, Queensland Children's Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Clara K Chow
- Westmead Applied Research Centre, The University of Sydney, Sydney, New South Wales, Australia.,Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia.,George Institute for Global Health, Sydney, New South Wales, Australia
| | - Jing Pang
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
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9
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Sánchez A, Bustos P, Honorato P, Burgos CF, Barriga N, Jannes CE, Sáez K, Alonso R, Asenjo S, Radojkovic C. Phenotypic characterization and predictive analysis of p.Asp47Asn LDL receptor mutation associated with Familial Hypercholesterolemia in a Chilean population. J Clin Lipidol 2021; 15:366-374.e1. [PMID: 33547002 DOI: 10.1016/j.jacl.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 12/22/2020] [Accepted: 01/11/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Familial hypercholesterolemia (FH) is an inherited disorder mainly caused by mutations in the LDL receptor (LDL-R) and characterized by elevation of low-density lipoprotein cholesterol (LDL-C) levels and premature cardiovascular disease. OBJECTIVE In this study, we evaluated the clinical phenotype of the p.Asp47Asn, described as an uncertain pathogenic variant, and its effect on the structure of LDL-R and ligand interactions with apolipoproteins. METHODS 27 children and adolescents with suspected FH diagnosis were recruited from a pediatric endocrinology outpatient clinic. Blood samples were collected after 12 h fasting for lipid profile analysis. DNA sequencing was performed for six FH-related genes by Ion Torrent PGM platform and copy number variation by MLPA. For index cases, a familial cascade screening was done restricted to the same mutation found in the index case. In silico analysis were developed to evaluate the binding capacity of LDL-R to apolipoproteins B100 and E. RESULTS Lipid profile in children and adolescents demonstrated higher LDL-C levels in p.Asp47Asn carriers compared to the wild type genotype. In silico analysis predicted a reduction in the binding capacity of the ligand-binding modules LA1-2 of p.Asp47Asn LDL-R for ApoB100 and ApoE, which was not produced by local structural changes or folding defects but as a consequence of a decreased apparent affinity for both apolipoproteins. CONCLUSION The clinical phenotype and the structural effects of p.Asp47Asn LDL-R mutation suggest that this variant associates to FH.
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Affiliation(s)
- Andrea Sánchez
- Departamento de Bioquímica Clínica e Inmunología, Facultad de Farmacia, Universidad de Concepción, Concepción, Chile
| | - Paulina Bustos
- Departamento de Bioquímica Clínica e Inmunología, Facultad de Farmacia, Universidad de Concepción, Concepción, Chile
| | - Paula Honorato
- Departamento de Bioquímica Clínica e Inmunología, Facultad de Farmacia, Universidad de Concepción, Concepción, Chile
| | - Carlos F Burgos
- Departamento de Fisiología, Facultad de Ciencias Biológicas, Universidad de Concepción, Concepción, Chile
| | - Natalia Barriga
- Departamento de Bioquímica Clínica e Inmunología, Facultad de Farmacia, Universidad de Concepción, Concepción, Chile
| | - Cinthia E Jannes
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), University of São Paulo Medical School Hospital, São Paulo, Brazil
| | - Katia Sáez
- Departamento de Estadística, Facultad de Ciencias Físicas y Matemáticas, Universidad de Concepción, Concepción, Chile
| | - Rodrigo Alonso
- Center for Advanced Metabolic Medicine and Nutrition, Santiago de Chile. Fundación Hipercolesterolemia Familiar, Madrid, Spain
| | - Sylvia Asenjo
- Departamento de Pediatría, Facultad de Medicina, Universidad de Concepción, Concepción, Chile
| | - Claudia Radojkovic
- Departamento de Bioquímica Clínica e Inmunología, Facultad de Farmacia, Universidad de Concepción, Concepción, Chile.
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10
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Watts GF, Sullivan DR, Hare DL, Kostner KM, Horton AE, Bell DA, Brett T, Trent RJ, Poplawski NK, Martin AC, Srinivasan S, Justo RN, Chow CK, Pang J. Synopsis of an integrated guidance for enhancing the care of familial hypercholesterolaemia: an Australian perspective. Am J Prev Cardiol 2021; 6:100151. [PMID: 34327493 PMCID: PMC8315409 DOI: 10.1016/j.ajpc.2021.100151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/15/2021] [Accepted: 01/28/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction Familial hypercholesterolaemia (FH) is a common, heritable and preventable cause of premature coronary artery disease, with significant potential for positive impact on public health and healthcare savings. New clinical practice recommendations are presented in an abridged guidance to assist practitioners in enhancing the care of all patients with FH. Main recommendations Core recommendations are made on the detection, diagnosis, assessment and management of adults, children and adolescents with FH. There is a key role for general practitioners (GPs) working in collaboration with specialists with expertise in lipidology. Advice is given on genetic and cholesterol testing and risk notification of biological relatives undergoing cascade testing for FH; all healthcare professionals should develop skills in genomic medicine. Management is under-pinned by the precepts of risk stratification, adherence to healthy lifestyles, treatment of non-cholesterol risk factors, and appropriate use of low-density lipoprotein (LDL)-cholesterol lowering therapies, including statins, ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. Recommendations on service design are provided in the full guidance. Potential impact on care of FH These recommendations need to be utilised using judicious clinical judgement and shared decision making with patients and families. Models of care need to be adapted to both local and regional needs and resources. In Australia new government funded schemes for genetic testing and use of PCSK9 inhibitors, as well as the National Health Genomics Policy Framework, will enable adoption of these recommendations. A broad implementation science strategy is, however, required to ensure that the guidance translates into benefit for all families with FH.
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Affiliation(s)
- Gerald F Watts
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia.,Lipid Disorders Clinic, Cardiometabolic Service, Departments of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - David R Sullivan
- Department of Chemical Pathology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - David L Hare
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.,Department of Cardiology, Austin Health, Melbourne, Australia
| | - Karam M Kostner
- Department of Cardiology, Mater Hospital, University of Queensland, Brisbane, Australia
| | - Ari E Horton
- Monash Heart and Monash Children's Hospital, Monash Health, Melbourne, Victoria, Australia.,Monash Cardiovascular Research Centre, Melbourne, Victoria, Australia.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Damon A Bell
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia.,Lipid Disorders Clinic, Cardiometabolic Service, Departments of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia.,Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Royal Perth Hospital and Fiona Stanley Hospital Network, Perth, Western Australia, Australia.,Department of Clinical Biochemistry, Clinipath Pathology, Perth, Western Australia, Australia.,Sonic Genetics, Sonic Pathology, Australia
| | - Tom Brett
- General Practice and Primary Health Care Research, School of Medicine, University of Notre Dame Australia, Fremantle, Australia
| | - Ronald J Trent
- Department of Medical Genomics, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Central Clinical School, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Nicola K Poplawski
- Adult Genetics Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Andrew C Martin
- Department General Paediatrics, Perth Children's Hospital, Perth, Western Australia, Australia.,Division of Paediatrics, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Shubha Srinivasan
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, Australia.,Discipline of Child and Adolescent Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Robert N Justo
- Department of Paediatric Cardiology, Queensland Children's Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Clara K Chow
- Westmead Applied Research Centre, The University of Sydney, Sydney, New South Wales, Australia.,Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia.,George Institute for Global Health, Sydney, New South Wales, Australia
| | - Jing Pang
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
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11
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Marusic T, Sustar U, Sadiq F, Kotori V, Mlinaric M, Kovac J, Shafi S, Khan I, Cevc M, Trebusak Podkrajsek K, Battelino T, Groselj U. Genetic and Clinical Characteristics of Patients With Homozygous and Compound Heterozygous Familial Hypercholesterolemia From Three Different Populations: Case Series. Front Genet 2020; 11:572176. [PMID: 33093846 PMCID: PMC7528874 DOI: 10.3389/fgene.2020.572176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/20/2020] [Indexed: 11/17/2022] Open
Abstract
Homozygous familial hypercholesterolemia (HoFH) and compound heterozygous familial hypercholesterolemia (cHeFH) are rare disorders generated by disease-causing variants in both alleles of the LDLR or other familial hypercholesterolemia (FH)-related genes. HoFH and cHeFH are characterized by severely elevated low-density lipoprotein-cholesterol (LDL-C), frequently leading to early cardiovascular disease. We investigated the genetic and clinical characteristics of HoFH and cHeFH patients from the Slovenian FH registry and/or those who were previously diagnosed or managed at our institution (Slovenian, Pakhtun and Albanian ethnicity), where genetic testing is not available. Our study includes seven patients. Their median age at the time of clinical diagnosis was 6.3 years (2.9-12.9 years); 2/7 were females. Two patients were diagnosed through the universal FH screening and five patients were diagnosed due to the presence of xanthomas. All the mutations are present in LDLR gene: 7 different genotypes for HoFH (p.Cys167Leu, p.Asp178Asn, p.Cys243Tyr, p.Gly549Asp, p.Cys27Trp, p.Ile585Thr and p.Val797Met) and p.Gly549Asp/p.Gln384Pro genotype for cHeFH patient. The median initial level of LDL-C was 17.0 mmol/L [655 mg/dL] (range 7.6-21.6 mmol/L). The HoFH/cHeFH patients are clinically and genetically very diverse. The clinical criteria (as Simon Broome criteria) might be applicable already in children to raise suspicion of FH but in some cases fail to distinguish heterozygous FH and HoFH/cHeFH patients. However, genetic testing is helpful in confirming the diagnosis, also for a prompt awareness, better compliance to treatment and family screening.
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Affiliation(s)
- Tatiana Marusic
- University Children’s Hospital, University Medical Center, Ljubljana, Slovenia
| | - Ursa Sustar
- University Children’s Hospital, University Medical Center, Ljubljana, Slovenia
| | - Fouzia Sadiq
- Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Vjosa Kotori
- Department of Endocrinology, Pediatric Clinic, University Clinical Center of Kosovo, Pristina, Kosovo
| | - Matej Mlinaric
- University Children’s Hospital, University Medical Center, Ljubljana, Slovenia
| | - Jernej Kovac
- University Children’s Hospital, University Medical Center, Ljubljana, Slovenia
| | - Saeed Shafi
- Department of Anatomy, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Iqbal Khan
- Shifa Tameer-e-Millat University, Islamabad, Pakistan
- Department of Vascular Surgery, Shifa International Hospital, Islamabad, Pakistan
| | - Matija Cevc
- Division of Medicine, Centre for Preventive Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Katarina Trebusak Podkrajsek
- University Children’s Hospital, University Medical Center, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tadej Battelino
- University Children’s Hospital, University Medical Center, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Urh Groselj
- University Children’s Hospital, University Medical Center, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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12
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Rieck L, Bardey F, Grenkowitz T, Bertram L, Helmuth J, Mischung C, Spranger J, Steinhagen-Thiessen E, Bobbert T, Kassner U, Demuth I. Mutation spectrum and polygenic score in German patients with familial hypercholesterolemia. Clin Genet 2020; 98:457-467. [PMID: 32770674 DOI: 10.1111/cge.13826] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 12/17/2022]
Abstract
Autosomal-dominant familial hypercholesterolemia (FH) is characterized by increased plasma concentrations of low-density lipoprotein cholesterol (LDL-C) and a substantial risk to develop cardiovascular disease. Causative mutations in three major genes are known: the LDL receptor gene (LDLR), the apolipoprotein B gene (APOB) and the proprotein convertase subtilisin/kexin 9 gene (PCSK9). We clinically characterized 336 patients suspected to have FH and screened them for disease causing mutations in LDLR, APOB, and PCSK9. We genotyped six single nucleotide polymorphisms (SNPs) to calculate a polygenic risk score for the patients and 1985 controls. The 117 patients had a causative variant in one of the analyzed genes. Most variants were found in the LDLR gene (84.9%) with 11 novel mutations. The mean polygenic risk score was significantly higher in FH mutation negative subjects than in FH mutation positive patients (P < .05) and healthy controls (P < .001), whereas the score of the two latter groups did not differ significantly. However, the score explained only about 3% of the baseline LDL-C variance. We verified the previously described clinical and genetic variability of FH for German hypercholesterolemic patients. Evaluation of a six-SNP polygenic score recently proposed for clinical use suggests that it is not a reliable tool to classify hypercholesterolemic patients.
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Affiliation(s)
- Lorenz Rieck
- Department of Endocrinology and Metabolism, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Frieda Bardey
- Department of Endocrinology and Metabolism, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Thomas Grenkowitz
- Department of Cardiology, Charité - University Medicine Berlin (Campus Benjamin Franklin), Berlin, Germany
| | - Lars Bertram
- Lübeck Interdisciplinary Platform for Genome Analytics, Institutes of Neurogenetics and Cardiogenetics, University of Lübeck, Lübeck, Germany.,Center for Lifespan Changes in Brain and Cognition (LCBC), Dept of Psychology, University of Oslo, Oslo, Norway
| | - Johannes Helmuth
- Department Molecular Diagnostics, Labor Berlin - Charité Vivantes GmbH, Berlin, Germany
| | - Claudia Mischung
- Department Molecular Diagnostics, Labor Berlin - Charité Vivantes GmbH, Berlin, Germany
| | - Joachim Spranger
- Department of Endocrinology and Metabolism, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Elisabeth Steinhagen-Thiessen
- Department of Endocrinology and Metabolism, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Thomas Bobbert
- Department of Endocrinology and Metabolism, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ursula Kassner
- Department of Endocrinology and Metabolism, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ilja Demuth
- Department of Endocrinology and Metabolism, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Charité - Universitätsmedizin Berlin, BCRT - Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany
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13
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Familial hypercholesterolaemia: evolving knowledge for designing adaptive models of care. Nat Rev Cardiol 2020; 17:360-377. [DOI: 10.1038/s41569-019-0325-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2019] [Indexed: 01/05/2023]
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14
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Page MM, Bell DA, Watts GF. Widening the spectrum of genetic testing in familial hypercholesterolaemia: Will it translate into better patient and population outcomes? Clin Genet 2019; 97:543-555. [PMID: 31833051 DOI: 10.1111/cge.13685] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/25/2019] [Accepted: 12/03/2019] [Indexed: 12/14/2022]
Abstract
Familial hypercholesterolaemia (FH) is caused by pathogenic variants in LDLR, APOB or PCSK9. Impaired low-density lipoprotein (LDL) receptor function leads to decreased LDL catabolism and premature atherosclerotic cardiovascular disease (ASCVD). Thousands of LDLR variants are known, but assignation of pathogenicity requires accurate phenotyping, family studies and assessment of LDL receptor function. Precise, genetic diagnosis of FH using targeted next generation sequencing allows for optimal treatment, distinguishing FH from pathogenically distinct disorders requiring different treatment. Polygenic hypercholesterolaemia resulting from an accumulation of LDL cholesterol-raising single nucleotide polymorphisms (SNPs) could also be suspected by this approach. Similarly, ASCVD risk could be estimated by broader sequencing of cholesterol and non-cholesterol-related genes. Both of these areas require further research. The clinical management of FH, focusing on the primary or secondary prevention of ASCVD, has been boosted by PCSK9 inhibitor therapy. The efficacy of PCSK9 inhibitors in homozygous FH may be partly predicted by the LDLR variants. While expanded genetic testing in FH is clinically useful in providing an accurate diagnosis and enabling cost-effective testing of relatives, further research is needed to establish its value in improving clinical outcomes.
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Affiliation(s)
- Michael M Page
- School of Medicine, Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Australia.,Department of Clinical Biochemistry, Western Diagnostic Pathology, Perth, Australia
| | - Damon A Bell
- School of Medicine, Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Australia.,Department of Clinical Biochemistry, PathWest Fiona Stanley Hospital and Royal Perth Hospital, Perth, Australia.,Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth, Australia.,Department of Clinical Biochemistry, Clinipath Pathology, Perth, Australia
| | - Gerald F Watts
- School of Medicine, Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Australia.,Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth, Australia
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15
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Familial Hypercholesterolaemia in 2020: A Leading Tier 1 Genomic Application. Heart Lung Circ 2019; 29:619-633. [PMID: 31974028 DOI: 10.1016/j.hlc.2019.12.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 11/26/2019] [Accepted: 12/03/2019] [Indexed: 12/15/2022]
Abstract
Familial hypercholesterolaemia (FH) is caused by a major genetic defect in the low-density lipoprotein (LDL) clearance pathway. Characterised by LDL-cholesterol elevation from birth, FH confers a significant risk for premature coronary artery disease (CAD) if overlooked and untreated. With risk exposure beginning at birth, early detection and intervention is crucial for the prevention of CAD. Lowering LDL-cholesterol with lifestyle and statin therapy can reduce the risk of CAD. However, most individuals with FH will not reach guideline recommended LDL-cholesterol targets. FH has an estimated prevalence of approximately 1:250 in the community. Multiple strategies are required for screening, diagnosing and treating FH. Recent publications on FH provide new data for developing models of care, including new therapies. This review provides an overview of FH and outlines some recent advances in the care of FH for the prevention of CAD in affected families. The future care of FH in Australia should be developed within the context of the National Health Genomics Policy Framework.
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16
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Ward NC, Page MM, Watts GF. Clinical guidance on the contemporary use of proprotein convertase subtilisin/kexin type 9 monoclonal antibodies. Diabetes Obes Metab 2019; 21 Suppl 1:52-62. [PMID: 31002454 DOI: 10.1111/dom.13637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/09/2019] [Accepted: 01/10/2019] [Indexed: 12/01/2022]
Abstract
There is now significant evidence for the benefits of lowering low-density lipoprotein cholesterol (LDL-c) to reduce the risk of atherosclerotic cardiovascular disease (ASCVD). Although statins are the most widely prescribed lipid-lowering therapy that effectively lower LDL-c, especially in combination with ezetimibe, some patients require adjunctive therapy to further lower LDL-c and mitigate attendant risk of ASCVD. The gap can be filled by proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibodies whose use is currently supported by two recent cardiovascular outcome studies and new treatment guidelines. We provide an overview of extant studies investigating PCSK9 monoclonal antibodies in various patient populations, an update of the guidelines regarding their use and a case-based discussion.
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Affiliation(s)
- Natalie C Ward
- School of Public Health, Curtin University, Perth, Australia
- School of Medicine, University of Western Australia, Perth, Australia
| | - Michael M Page
- School of Medicine, University of Western Australia, Perth, Australia
- PathWest Laboratory Medicine, Fiona Stanley Hospital, Perth, Australia
| | - Gerald F Watts
- School of Medicine, University of Western Australia, Perth, Australia
- Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth, Australia
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Sarraju A, Knowles JW. Genetic Testing and Risk Scores: Impact on Familial Hypercholesterolemia. Front Cardiovasc Med 2019; 6:5. [PMID: 30761309 PMCID: PMC6361766 DOI: 10.3389/fcvm.2019.00005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 01/11/2019] [Indexed: 12/11/2022] Open
Abstract
Familial Hypercholesterolemia (FH) is an inherited lipid disorder affecting 1 in 220 individuals resulting in highly elevated low-density lipoprotein levels and risk of premature coronary disease. Pathogenic variants causing FH typically involve the LDL receptor (LDLR), apolipoprotein B-100 (APOB), and proprotein convertase subtulisin/kexin type 9 genes (PCSK9) and if identified convey a risk of early onset coronary artery disease (ASCVD) of 3- to 10-fold vs. the general population depending on the severity of the mutation. Identification of monogenic FH within a family has implications for family-based testing (cascade screening), risk stratification, and potentially management, and it has now been recommended that such testing be offered to all potential FH patients. Recently, robust genome wide association studies (GWAS) have led to the recognition that the accumulation of common, small effect alleles affecting many LDL-c raising genes can result in a clinical phenotype largely indistinguishable from monogenic FH (i.e., a risk of early onset ASCVD of ~3-fold) in those at the extreme tail of the distribution for these alleles (i.e., the top 8% of the population for a polygenic risk score). The incorporation of these genetic risk scores into clinical practice for non-FH patients may improve risk stratification but is not yet widely performed due to a less robust evidence base for utility. Here, we review the current status of FH genetic testing, potential future applications as well as challenges and pitfalls.
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Affiliation(s)
- Ashish Sarraju
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, CA, United States
| | - Joshua W Knowles
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, CA, United States.,The FH Foundation, Pasadena, CA, United States.,Stanford Diabetes Research Center, Stanford University, Stanford, CA, United States
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18
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Lan NSR, Martin AC, Brett T, Watts GF, Bell DA. Improving the detection of familial hypercholesterolaemia. Pathology 2018; 51:213-221. [PMID: 30579649 DOI: 10.1016/j.pathol.2018.10.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 10/15/2018] [Accepted: 10/15/2018] [Indexed: 02/03/2023]
Abstract
Familial hypercholesterolaemia (FH) is a dominantly inherited disorder of low-density lipoprotein (LDL) catabolism, which if untreated causes lifelong elevated LDL-cholesterol (LDL-c), accelerated atherosclerosis and premature cardiovascular disease. Recent evidence suggests the prevalence of heterozygous FH is ∼1:220, making FH the most common autosomal dominant condition. Lowering LDL-c with statin and lifestyle therapy reduces the risk of cardiovascular events. Furthermore, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors significantly lower LDL-c in addition to statin therapy, and early outcome data suggest improved vascular outcomes with these agents in FH patients in addition to statins. However, the vast majority of people with FH still remain undiagnosed. The onus is on clinicians to identify kindreds with FH, as PCSK9 inhibitors, although expensive, are funded for patients with FH in Australia. Multiple strategies for detecting FH have been proposed. The detection of index cases can be achieved through applying electronic screening tools to general practice databases, universal screening of children during immunisation, and targeted screening of patients with premature cardiovascular disease. Advances in genomic technology have decreased costs of genetic testing, improved the understanding of the pathogenesis of FH and facilitated cascade screening. However, awareness of FH amongst clinicians and the general public still requires optimisation. This review outlines recent advances in FH detection, including emerging strategies and challenges for the next decade.
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Affiliation(s)
- Nick S R Lan
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Andrew C Martin
- Department of General Paediatrics, Perth Children's Hospital, Nedlands, WA, Australia
| | - Tom Brett
- Department of General Practice and Primary Health Care Research, School of Medicine, The University of Notre Dame Australia, Fremantle, WA, Australia
| | - Gerald F Watts
- Faculty of Health and Medical Sciences, School of Medicine, The University of Western Australia, Crawley, WA, Australia; Department of Cardiology, Lipid Disorders Clinic, Cardiometabolic Service, Royal Perth Hospital, Perth, WA, Australia
| | - Damon A Bell
- Faculty of Health and Medical Sciences, School of Medicine, The University of Western Australia, Crawley, WA, Australia; Department of Cardiology, Lipid Disorders Clinic, Cardiometabolic Service, Royal Perth Hospital, Perth, WA, Australia; Department of Clinical Biochemistry, PathWest Laboratory Medicine, Royal Perth Hospital, Perth, WA, Australia; Department of Clinical Biochemistry, Australian Clinical Laboratories, Perth, WA, Australia.
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Abstract
PURPOSE OF REVIEW Precision medicine is the concept of disease treatment and prevention using an individual's genomic profile in addition to personal and environmental factors. This review outlines examples of new biomarker strategies that enable the practice of precision cardiovascular medicine. RECENT FINDINGS Although commonly attributed to identifying causative genetic variants, mono-genetic causes of cardiovascular diseases (CVD) are not common and largely focused on lipoprotein analyses. Nevertheless, rare clinical presentations in families with extreme phenotypes can sometimes identify novel pathways that can serve as therapeutic targets, such as the discovery of PCSK9 inhibitors for familial hypercholesterolemia or small molecular inhibitors of myosin ATPase activities for hypertrophic cardiomyopathy. Polygenetic risks scores can also identify high-risk cohorts before their clinical manifestations. Novel metabolomic insights can also lead to unexpected modulators of CVD susceptibility, such as nutrient-induced gut microbiota-derived metabolic pathways. SUMMARY Adequate knowledge systems and data infrastructure are necessary for clinicians to take into account both genetic and environmental factors to operationalize precision medicine and to prevent CVD.
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