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Kwon GE, Son HH, Moon JY, Lee A, Jung MK, Rhie S, Park MJ, Garg A, Yoo EG, Choi MH. Dried blood spot-based free sterol signatures in sitosterolemia diagnostics. Clin Chim Acta 2024; 562:119886. [PMID: 39053727 DOI: 10.1016/j.cca.2024.119886] [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: 08/25/2023] [Revised: 07/19/2024] [Accepted: 07/21/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Sitosterolemia is a rare inherited lipid metabolic disorder characterized by increased levels of plant sterols and accelerated atherosclerosis. Although early detection is beneficial for the prevention of disease progression, it is largely underdiagnosed by routine screening based on conventional lipid profiles. MATERIALS AND METHODS A gas chromatography-mass spectrometry (GC-MS)-based profiling has been developed and validated to measure the levels of biologically active free sterols, including five endogenous sterols and three plant sterols (sitosterol, campesterol, and stigmasterol) in dried blood spot (DBS). RESULTS Within- and between-run precisions were 1.4-11.1 % and 2.2-14.1 %, respectively, while the accuracies were all 86.3 ∼ 121.9 % with the correlation coefficients (r2) > 0.988 for all the sterols. In the patients (four girls and two boys, 6.5 ± 2.8 years), sitosterol levels were significantly increased, with an optimal cut-off value of 2.5 µg/mL distinguishing them from ninety-three age-matched healthy children. A cut-off value of 31.9 µg/mL differentiated the patients from six ABCG5/ABCG8 heterozygous carriers. In addition, the molecular ratios of sitosterol to cholesterol, desmosterol, and 7-dehydrocholesterol provided excellent cut-off values of 26.3, 67.6, and 21.6, respectively, to distinguish patients from both healthy controls and heterozygous carriers. CONCLUSIONS The novel DBS-based GC-MS profiling of free sterols accurately identified patients with sitosterolemia, with a performance comparable to that of a serum assay. The DBS profiling could be more feasible method in clinical practice as well as population screening programs, and it can provide diagnostic cut-off values for individual plant sterols.
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MESH Headings
- Humans
- Lipid Metabolism, Inborn Errors/blood
- Lipid Metabolism, Inborn Errors/diagnosis
- Female
- Male
- Intestinal Diseases/blood
- Intestinal Diseases/diagnosis
- Gas Chromatography-Mass Spectrometry
- Child
- Phytosterols/blood
- Phytosterols/adverse effects
- Dried Blood Spot Testing/methods
- Hypercholesterolemia/blood
- Hypercholesterolemia/diagnosis
- Child, Preschool
- ATP Binding Cassette Transporter, Subfamily G, Member 5/blood
- ATP Binding Cassette Transporter, Subfamily G, Member 5/genetics
- Sterols/blood
- ATP Binding Cassette Transporter, Subfamily G, Member 8/blood
- ATP Binding Cassette Transporter, Subfamily G, Member 8/genetics
- Lipoproteins/blood
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Affiliation(s)
- Go Eun Kwon
- Center for Advanced Biomolecular Recognition, Korea Institute of Science and Technology, Seoul 02792, Republic of Korea
| | - Hyun-Hwa Son
- Center for Advanced Biomolecular Recognition, Korea Institute of Science and Technology, Seoul 02792, Republic of Korea
| | - Ju-Yeon Moon
- Center for Advanced Biomolecular Recognition, Korea Institute of Science and Technology, Seoul 02792, Republic of Korea
| | - Ayoung Lee
- Center for Advanced Biomolecular Recognition, Korea Institute of Science and Technology, Seoul 02792, Republic of Korea
| | - Mo Kyung Jung
- Department of Pediatrics, CHA Bundang Medical Center, Gyeonggi-do 13496, Republic of Korea
| | - Seonkyeong Rhie
- Department of Pediatrics, CHA Bundang Medical Center, Gyeonggi-do 13496, Republic of Korea
| | - Mi Jung Park
- Department of Pediatrics, Inje University Sanggye Paik Hospital, Seoul 01757, Republic of Korea
| | - Abhimanyu Garg
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX 75390, USA
| | - Eun-Gyong Yoo
- Department of Pediatrics, CHA Bundang Medical Center, Gyeonggi-do 13496, Republic of Korea.
| | - Man Ho Choi
- Center for Advanced Biomolecular Recognition, Korea Institute of Science and Technology, Seoul 02792, Republic of Korea.
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2
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Tarugi P, Bertolini S, Calandra S, Arca M, Angelico F, Casula M, Cefalù AB, D'Erasmo L, Fortunato G, Perrone-Filardi P, Rubba P, Suppressa P, Averna M, Catapano AL. Consensus document on diagnosis and management of familial hypercholesterolemia from the Italian Society for the Study of Atherosclerosis (SISA). Nutr Metab Cardiovasc Dis 2024; 34:1819-1836. [PMID: 38871496 DOI: 10.1016/j.numecd.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 04/04/2024] [Accepted: 05/03/2024] [Indexed: 06/15/2024]
Abstract
AIMS Familial Hypercholesterolemia (FH) is a genetic disorder of lipoprotein metabolism that causes an increased risk of premature atherosclerotic cardiovascular disease (ASCVD). Although early diagnosis and treatment of FH can significantly improve the cardiovascular prognosis, this disorder is underdiagnosed and undertreated. For these reasons the Italian Society for the Study of Atherosclerosis (SISA) assembled a Consensus Panel with the task to provide guidelines for FH diagnosis and treatment. DATA SYNTHESIS Our guidelines include: i) an overview of the genetic complexity of FH and the role of candidate genes involved in LDL metabolism; ii) the prevalence of FH in the population; iii) the clinical criteria adopted for the diagnosis of FH; iv) the screening for ASCVD and the role of cardiovascular imaging techniques; v) the role of molecular diagnosis in establishing the genetic bases of the disorder; vi) the current therapeutic options in both heterozygous and homozygous FH. Treatment strategies and targets are currently based on low-density lipoprotein cholesterol (LDL-C) levels, as the prognosis of FH largely depends on the magnitude of LDL-C reduction achieved by lipid-lowering therapies. Statins with or without ezetimibe are the mainstay of treatment. Addition of novel medications like PCSK9 inhibitors, ANGPTL3 inhibitors or lomitapide in homozygous FH results in a further reduction of LDL-C levels. LDL apheresis is indicated in FH patients with inadequate response to cholesterol-lowering therapies. CONCLUSION FH is a common, treatable genetic disorder and, although our understanding of this disease has improved, many challenges still remain with regard to its identification and management.
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Affiliation(s)
- Patrizia Tarugi
- Department of Life Sciences, University of Modena and Reggio Emilia, Modena, Italy.
| | | | - Sebastiano Calandra
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Marcello Arca
- Department of Translational and Precision Medicine (DTPM), Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | | | - Manuela Casula
- Department of Pharmacological and Biomolecular Sciences (DisFeB), Epidemiology and Preventive Pharmacology Service (SEFAP), University of Milan, Milan, Italy; IRCCS Multimedica, Sesto San Giovanni (Milan), Italy
| | - Angelo B Cefalù
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Laura D'Erasmo
- Department of Translational and Precision Medicine (DTPM), Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Giuliana Fortunato
- Department of Medicina Molecolare e Biotecnologie Mediche, University of Naples Federico II and CEINGE Biotecnologie avanzate "Franco Salvatore", Naples, Italy
| | | | - Paolo Rubba
- Department of Internal Medicine and Surgery, Federico II University, Naples, Italy
| | - Patrizia Suppressa
- Department of Internal Medicine and Rare Diseases Centre "C. Frugoni", University of Bari A. Moro, Bari, Italy
| | - Maurizio Averna
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy; Biophysical Institute CNR, Palermo, Italy
| | - Alberico L Catapano
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milano, Italy; IRCCS Multimedica, Milano, Italy
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3
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Alquraishi AS, Rayees S. Sitosterolemia With Two Heterozygous Variants Including a Novel Mutation c.1800T>A in the ABCG5 Gene: A Case Report of a Rare Condition in a Young Saudi Girl. Cureus 2024; 16:e63088. [PMID: 39055399 PMCID: PMC11270141 DOI: 10.7759/cureus.63088] [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] [Accepted: 06/25/2024] [Indexed: 07/27/2024] Open
Abstract
Sitosterolemia is a rare autosomal recessively inherited lipid disorder characterized by an accumulation and deposition of phytosterols in various tissues with decreased biliary excretion leading to various complications. We report a case of a three-year-old Saudi girl who exhibited xanthomas and elevated cholesterol levels. Initially, she was misdiagnosed with familial hypercholesterolemia, but subsequent testing of the low-density lipoprotein receptor gene by next-generation sequencing ruled out this condition. Two heterozygous variants were identified in the ABCG5 gene through a whole exome sequencing study. These variants, namely c.1336C>T and c.1800T>A, have been characterized as pathogenic and likely pathogenic, respectively, with the latter being a novel mutation associated with sitosterolemia. The patient responded positively to treatment with ezetimibe, resulting in controlled cholesterol levels and decreased xanthoma size.
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Affiliation(s)
- Ali S Alquraishi
- Pediatric Endocrinology, Armed Forces Hospital Southern Region, Khamis Mushait, SAU
| | - Syed Rayees
- Pediatrics, Armed Forces Hospital Southern Region, Khamis Mushait, SAU
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4
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Tada H, Kawashiri MA, Nohara A, Sekiya T, Watanabe A, Takamura M. Genetic Counseling and Genetic Testing for Familial Hypercholesterolemia. Genes (Basel) 2024; 15:297. [PMID: 38540356 PMCID: PMC10970256 DOI: 10.3390/genes15030297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 02/15/2024] [Accepted: 02/19/2024] [Indexed: 06/14/2024] Open
Abstract
Familial hypercholesterolemia (FH) is one of the most common autosomal codominant Mendelian diseases. The major complications of FH include tendon and cutaneous xanthomas and coronary artery disease (CAD) associated with a substantial elevation of serum low-density lipoprotein levels (LDL). Genetic counseling and genetic testing for FH is useful for its diagnosis, risk stratification, and motivation for further LDL-lowering treatments. In this study, we summarize the epidemiology of FH based on numerous genetic studies, including its pathogenic variants, genotype-phenotype correlation, prognostic factors, screening, and usefulness of genetic counseling and genetic testing. Due to the variety of treatments available for this common Mendelian disease, genetic counseling and genetic testing for FH should be implemented in daily clinical practice.
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Affiliation(s)
- Hayato Tada
- Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medicine, Kanazawa 920-8640, Japan;
| | - Masa-aki Kawashiri
- Department of Internal Medicine, Kaga Medical Center, Kaga 922-8522, Japan;
| | - Atsushi Nohara
- Department of Clinical Genetics, Ishikawa Prefectural Central Hospital, Kanazawa 920-8530, Japan;
| | - Tomoko Sekiya
- Division of Clinical Genetics, Kanazawa University Hospital, Kanazawa 920-8641, Japan; (T.S.); (A.W.)
| | - Atsushi Watanabe
- Division of Clinical Genetics, Kanazawa University Hospital, Kanazawa 920-8641, Japan; (T.S.); (A.W.)
| | - Masayuki Takamura
- Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medicine, Kanazawa 920-8640, Japan;
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5
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Loh WJ, Watts GF. Xenosterolemia in clinical practice: what is in a name? Curr Opin Endocrinol Diabetes Obes 2023; 30:123-127. [PMID: 36597814 DOI: 10.1097/med.0000000000000795] [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] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW The aim of this study was to assess the potential value of the measurement of plasma xenosterols (or phytosterols) concentrations in clinical practice. RECENT FINDINGS Recent genetic studies suggest that individuals with elevated plasma phytosterol concentrations due to monogenic and polygenic variants are at an increased risk of coronary artery disease. This supports early observations that elevated plasma phytosterol concentrations are per se atherogenic. SUMMARY Measurement of plasma phytosterols can identify individuals with xenosterolemia (or phytosterolemia). This may be clinically useful in four ways: Establishing a diagnosis and informing management of patients with homozygous phytosterolemia; Providing a comprehensive differential diagnosis for familial hypercholesterolemia; Providing an index of cholesterol absorption that may inform personalized pharmacotherapy; and Informing more precise assessment of risk of cardiovascular disease.
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Affiliation(s)
- Wann Jia Loh
- School of Medicine, University of Western Australia
- Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
- Department of Endocrinology, Changi General Hospital, Changi
- Duke-NUS Medical School, Singapore, Singapore
| | - Gerald F Watts
- School of Medicine, University of Western Australia
- Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
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6
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Windler E, Beil FU, Berthold HK, Gouni-Berthold I, Kassner U, Klose G, Lorkowski S, März W, Parhofer KG, Plat J, Silbernagel G, Steinhagen-Thiessen E, Weingärtner O, Zyriax BC, Lütjohann D. Phytosterols and Cardiovascular Risk Evaluated against the Background of Phytosterolemia Cases-A German Expert Panel Statement. Nutrients 2023; 15:nu15040828. [PMID: 36839186 PMCID: PMC9963617 DOI: 10.3390/nu15040828] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/23/2023] [Accepted: 01/25/2023] [Indexed: 02/08/2023] Open
Abstract
Phytosterols (PSs) have been proposed as dietary means to lower plasma LDL-C. However, concerns are raised that PSs may exert atherogenic effects, which would offset this benefit. Phytosterolemia was thought to mimic increased plasma PSs observed after the consumption of PS-enriched foods. This expert statement examines the possibility of specific atherogenicity of PSs based on sterol metabolism, experimental, animal, and human data. Observational studies show no evidence that plasma PS concentrations would be associated with an increased risk of atherosclerosis or cardiovascular (CV) events. Since variants of the ABCG5/8 transporter affect the absorption of cholesterol and non-cholesterol sterols, Mendelian randomization studies examining the effects of ABCG5/8 polymorphisms cannot support or refute the potential atherogenic effects of PSs due to pleiotropy. In homozygous patients with phytosterolemia, total PS concentrations are ~4000% higher than under physiological conditions. The prevalence of atherosclerosis in these individuals is variable and may mainly relate to concomitant elevated LDL-C. Consuming PS-enriched foods increases PS concentrations by ~35%. Hence, PSs, on a molar basis, would need to have 20-40 times higher atherogenicity than cholesterol to offset their cholesterol reduction benefit. Based on their LDL-C lowering and absence of adverse safety signals, PSs offer a dietary approach to cholesterol management. However, their clinical benefits have not been established in long-term CV endpoint studies.
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Affiliation(s)
- Eberhard Windler
- Preventive Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg-Eppendorf, Martinistr. 52-Bldg. N26, 20246 Hamburg, Germany
| | - Frank-Ulrich Beil
- Ambulanzzentrum, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Heiner K. Berthold
- Department of Internal Medicine and Geriatrics, Bethel Clinic, 33611 Bielefeld, Germany
| | - Ioanna Gouni-Berthold
- Center for Endocrinology, Diabetes and Preventive Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Ursula Kassner
- Lipid Clinic at the Interdisciplinary Metabolism Center, Charite-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Gerald Klose
- Praxen Dres. T. Beckenbauer & S. Maierhof, Am Markt 11, 28195 Bremen und Dres. I. van de Loo & K. Spieker, Gerold Janssen Straße 2 A, 28359 Bremen, Germany
| | - Stefan Lorkowski
- Institute of Nutritional Science and Competence Cluster for Nutrition and Cardiovascular Health (nutriCARD), Halle-Jena-Leipzig, Friedrich Schiller University Jena, Dornburger Str. 25, 07743 Jena, Germany
| | - Winfried März
- SYNLAB Akademie für Ärztliche Fortbildung, SYNLAB Holding Deutschland GmbH, P5,7, 68161 Mannheim, Germany
- Medical Clinic V, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, 8010 Graz, Austria
- Correspondence:
| | - Klaus G. Parhofer
- Medizinische Klinik IV, Klinikum der Universität München, Grosshadern, Marchioninistr. 15, 81377 München, Germany
| | - Jogchum Plat
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, 6211 LK Maastricht, The Netherlands
| | - Günter Silbernagel
- Division of Vascular Medicine, Department of Internal Medicine, Medical University of Graz, 8010 Graz, Austria
| | - Elisabeth Steinhagen-Thiessen
- Arbeitsbereich Lipidstoffwechsel der Medizinischen Klinik für Endokrinologie und Stoffwechselmedizin, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Oliver Weingärtner
- Klinik für Innere Medizin I, Universitätskliniken Jena, Friedrich-Schiller-Universität Jena, 07743 Jena, Germany
| | - Birgit-Christiane Zyriax
- Midwifery Science—Health Care Research and Prevention, Research Group, Preventive Medicine and Nutrition, Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Dieter Lütjohann
- Institute of Clinical Chemistry and Clinical Pharmacology, University Clinics Bonn, 53127 Bonn, Germany
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7
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Loh WJ, Watts GF. The Inherited Hypercholesterolemias. Endocrinol Metab Clin North Am 2022; 51:511-537. [PMID: 35963626 DOI: 10.1016/j.ecl.2022.02.006] [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] [Indexed: 11/03/2022]
Abstract
Inherited hypercholesterolemias include monogenic and polygenic disorders, which can be very rare (eg, cerebrotendinous xanthomatosis (CTX)) or relatively common (eg, familial combined hyperlipidemia [FCH]). In this review, we discuss familial hypercholesterolemia (FH), FH-mimics (eg, polygenic hypercholesterolemia [PH], FCH, sitosterolemia), and other inherited forms of hypercholesterolemia (eg, hyper-lipoprotein(a) levels [hyper-Lp(a)]). The prevalence, genetics, and management of inherited hypercholesterolemias are described and selected guidelines summarized.
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Affiliation(s)
- Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, 2 Simei Street 3, Singapore 529889.
| | - Gerald F Watts
- School of Medicine, University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia 6009, Australia; Department of Cardiology and Internal Medicine, Royal Perth Hospital, Victoria Square, Perth, Western Australia 6000, Australia
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Shen MF, Hu YN, Chen WX, Liao LS, Wu M, Wu QY, Zhang JH, Zhang YP, Luo JW, Lin XF. Clinical and Genetic Analysis of a Family With Sitosterolemia Caused by a Novel ATP-Binding Cassette Subfamily G Member 5 Compound Heterozygous Mutation. Front Cardiovasc Med 2022; 9:887618. [PMID: 35557526 PMCID: PMC9086554 DOI: 10.3389/fcvm.2022.887618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/05/2022] [Indexed: 11/13/2022] Open
Abstract
Sitosterolemia (OMIM ##210250), also known as phytosterolemia, is a rare autosomal recessive disorder caused by mutations in the ATP-binding cassette subfamily G member 5 (ABCG5) or member 8 (ABCG8) genes. This leads to abnormal functions of the transporter sterolin-1 protein encoded by ABCG5 and sterolin-2 protein encoded by ABCG8, respectively, which can hinder the formation of stable ABCG5/G8 heterodimers, decreasing its ability to transport sterols. As a result, phytosterols in tissue or plasma are significantly increased, leading to early onset atherosclerosis-related diseases and xanthelasma of tendons and skin. In this study, whole exome sequencing was performed on a Chinese Han proband with sitosterolemia to capture the target gene and screen for suspected pathogenic mutations. Sanger sequencing of the family members was performed to verify the relationship between family genetics and phenotypes. The structural and functional changes in the transporter sterolin-1 protein after the responsible mutation were predicted using bioinformatics analysis. A novel compound heterozygous mutation in the ABCG5 gene (NM_022436) was identified in a proband with sitosterolemia, one of which was inherited from the father: c.296T >G (p.M99R), and one from the mother: c.−76 C >T. SIFT, Polyphen2, and Mutation Taster software predicted that p.M99R may be the responsible variant and a novel variant. RNAFold software predicts that c.−76 C >T may affect the transcriptional information or the binding of RNA binding proteins by regulating the structure of RNA, and ultimately affect gene transcription or RNA stability and translation. Swiss model software predicts that the amino acid sequence around p.M99R is highly conserved, and p.M99R leads to instability of the tertiary structure of the ABCG5/ABCG8 heterodimer. GPS 5.0 predicted that M99R affects the phosphorylation of nearby amino acid sequences, and DUET and VarSite software predicted that M99R affects the stability of sterolin-1 and cause disease. The p.M99R and c.−76 C >T mutations led to the formation of unstable heterodimers, which disturbed sterol absorption and excretion in vivo. The compound heterozygous variants c.296 T >G (p.m99r) and C.−76 C >T on exon 3 of ABCG5 in this family may be the molecular genetic basis of sitosterolemia.
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Affiliation(s)
- Ming-fang Shen
- Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Pediatrics Department, Fujian Provincial Hospital, Fuzhou, China
| | - Ya-nan Hu
- Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Wei-xiang Chen
- Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Pediatrics Department, Fujian Provincial Hospital, Fuzhou, China
| | - Li-sheng Liao
- Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Hematology, Fujian Provincial Hospital, Fuzhou, China
| | - Min Wu
- Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Qiu-yan Wu
- Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Jian-hui Zhang
- Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Yan-ping Zhang
- Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Jie-wei Luo
- Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Traditional Chinese Medicine, Fujian Provincial Hospital, Fuzhou, China
- *Correspondence: Jie-wei Luo,
| | - Xin-fu Lin
- Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Pediatrics Department, Fujian Provincial Hospital, Fuzhou, China
- Xin-fu Lin,
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9
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Iyama K, Ikeda S, Koga S, Yoshimuta T, Kawano H, Tsuji S, Ando K, Matsushima K, Tada H, Kawashiri MA, Kawakami A, Maemura K. Acute Coronary Syndrome Developed in a 17-year-old Boy with Sitosterolemia Comorbid with Takayasu Arteritis: A Rare Case Report and Review of the Literature. Intern Med 2022; 61:1169-1177. [PMID: 34615826 PMCID: PMC9107993 DOI: 10.2169/internalmedicine.8288-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 17-year-old boy with acute coronary syndrome was admitted to our hospital. He had xanthomas over his elbow and Achilles tendon and a high level of low-density lipoprotein cholesterol; therefore, his initial diagnosis was familial hypercholesterolemia. However, a genetic analysis revealed a compound heterozygous mutation in the ABCG5 gene with a high serum level of sitosterol, leading to the diagnosis of sitosterolemia. After lipid-lowering treatment, percutaneous coronary intervention was performed. Furthermore, a persistently high C-reactive protein level and images of large arteries led to a diagnosis of Takayasu arteritis. To our knowledge, this is the first case of sitosterolemia complicated by Takayasu arteritis.
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Affiliation(s)
- Keita Iyama
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
- Department of Radiation Disaster Medicine, Fukushima Medical University, Japan
| | - Satoshi Ikeda
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Seiji Koga
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Tsuyoshi Yoshimuta
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Hiroaki Kawano
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Sosuke Tsuji
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Medical Sciences, Japan
| | - Koji Ando
- Department of Hematology, Atomic Bomb Disease and Hibakusha Medicine Unit, Atomic Bomb Disease Institute, Nagasaki University, Japan
| | - Kayoko Matsushima
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Hayato Tada
- Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medicine, Japan
| | - Masa-Aki Kawashiri
- Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medicine, Japan
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Medical Sciences, Japan
| | - Koji Maemura
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
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10
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Tada H, Kojima N, Takamura M, Kawashiri MA. Sitosterolemia. Adv Clin Chem 2022; 110:145-169. [DOI: 10.1016/bs.acc.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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11
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Xia Y, Duan Y, Zheng W, Liang L, Zhang H, Luo X, Gu X, Sun Y, Xiao B, Qiu W. Clinical, genetic profile and therapy evaluation of 55 children and 5 adults with sitosterolemia. J Clin Lipidol 2021; 16:40-51. [PMID: 34969652 DOI: 10.1016/j.jacl.2021.11.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/03/2021] [Accepted: 11/29/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Sitosterolemia is a rare autosomal recessive disease characterized by phytosterol accumulation in the blood and tissues. However, the detailed clinical and genetic spectra are lacking. OBJECTIVE To describe and compare the clinical, biochemical, genetic, therapeutic, and follow-up characteristics of 55 pediatric and five adult sitosterolemia patients. METHODS Clinical, genetic and therapeutic data from 60 patients at Xinhua Hospital from January 2016 to June 2021 were retrospectively collected. RESULTS Pediatric patients' manifestations included xanthomas(93%), hematological disorders(30%), arthralgia(24%), splenomegaly(11%), atherosclerosis(10%). Adult patients had symptoms such as atherosclerosis(5/5), xanthomas(4/5), hematological disorders(3/5), arthralgia(3/5), splenomegaly(3/5). Elevated total cholesterol(TC) and low-density lipoprotein cholesterol(LDL-C) were observed in 96% patients (pediatric 98%, adult 3/4), and phytosterol levels in 100% patients. The age of onset was also negatively correlated with blood TC (P < 0.0001, r = -0.5548) and LDL-C (P = 0.0001, r = -0.4859) levels. Targeted treatments resulted in symptomatic remission(pediatric 96%, adult 4/5), and significantly decreased lipid and phytosterol levels(all P<0.05). In the dietary-therapy cohort(n=34), blood lipid levels decreased(all P<0.05). In the 13 pediatric patients from the dietary-therapy cohort who switched from dietary to combination therapy with ezetimibe, dietary therapy decreased TC and LDL-C levels by 54% and 52%, and ezetimibe further decreased them by 18% and 20%, respectively. Further, we identified 15 novel ABCG5/ABCG8 variants. CONCLUSIONS This study expands the clinical and genetic spectra of sitosterolemia. The low-phytosterol diet is the cornerstone of sitosterolemia treatment. Ezetimibe can further decrease blood lipid levels and increase daily dietary phytosterol tolerance.
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Affiliation(s)
- Yu Xia
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Pediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kong Jiang Road, Shanghai 200092, China
| | - Ying Duan
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Pediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kong Jiang Road, Shanghai 200092, China
| | - Wanqi Zheng
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Pediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kong Jiang Road, Shanghai 200092, China
| | - Lili Liang
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Pediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kong Jiang Road, Shanghai 200092, China
| | - Huiwen Zhang
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Pediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kong Jiang Road, Shanghai 200092, China
| | - Xiaomei Luo
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Pediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kong Jiang Road, Shanghai 200092, China
| | - Xuefan Gu
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Pediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kong Jiang Road, Shanghai 200092, China
| | - Yu Sun
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Pediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kong Jiang Road, Shanghai 200092, China.
| | - Bing Xiao
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Pediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kong Jiang Road, Shanghai 200092, China.
| | - Wenjuan Qiu
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Pediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kong Jiang Road, Shanghai 200092, China.
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12
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Yellowish nodular changes in infants - juvenile xanthogranuloma and xanthoma. Postepy Dermatol Alergol 2021; 38:159-162. [PMID: 34408584 PMCID: PMC8362781 DOI: 10.5114/ada.2021.104292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 03/03/2020] [Indexed: 11/17/2022] Open
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13
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Frederiksen TC, Mortensen MB, Kanstrup HL. Seventeen years of misdiagnosis in rare dyslipidaemia: a case report of sitosterolaemia in a young female. Eur Heart J Case Rep 2021; 5:ytab188. [PMID: 34268478 PMCID: PMC8276620 DOI: 10.1093/ehjcr/ytab188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/23/2020] [Accepted: 04/16/2021] [Indexed: 01/21/2023]
Abstract
Background Sitosterolaemia is a rare, autosomal recessive dyslipidaemia with increased absorption
of dietary plant sterol and often presents with hypercholesterolaemia, xanthomas, and
haematologic manifestations. If left untreated, sitosterolaemia can lead to high
symptomatic burden and coronary artery disease (CAD). Case summary We describe a case of a young female who initially presented at 4 years of age with
classic manifestations of sitosterolaemia. She was misdiagnosed and treated for both
juvenile arthritis and later familial hypercholesterolaemia until adulthood, when venous
blood samples showed significantly elevated concentrations of plant sterols. DNA
analyses showed that the patient was homozygous for a mutation in the ABCG5 gene,
[c.1336C>T, p.(Arg446*)], which is known to be associated with sitosterolaemia. Discussion Sitosterolaemia presents with multiple manifestations, which can initially be
misinterpreted leading to prolonged misdiagnosis. Early diagnosis is key in order to
relieve symptoms and prevent CAD.
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Affiliation(s)
| | - Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark
| | - Helle Lynge Kanstrup
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark
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14
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Tada H, Nomura A, Ogura M, Ikewaki K, Ishigaki Y, Inagaki K, Tsukamoto K, Dobashi K, Nakamura K, Hori M, Matsuki K, Yamashita S, Yokoyama S, Kawashiri MA, Harada-Shiba M. Diagnosis and Management of Sitosterolemia 2021. J Atheroscler Thromb 2021; 28:791-801. [PMID: 33907061 PMCID: PMC8326170 DOI: 10.5551/jat.rv17052] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Sitosterolemia is an inherited metabolic disorder characterized by increased levels of plant sterols, such as sitosterol. This disease is caused by loss-of-function genetic mutations in ATP-binding cassette (ABC) subfamily G member 5 or member 8 (
ABCG5
or
ABCG8
, respectively), both of which play important roles in selective excretion of plant sterols from the liver and intestine, leading to failure to prevent absorption of food plant sterols. This disorder has been considered to be extremely rare. However, accumulated clinical data as well as genetics suggest the possibility of a much higher prevalence. Its clinical manifestations resemble those observed in patients with familial hypercholesterolemia (FH), including tendon xanthomas, hyper LDL-cholesterolemia, and premature coronary atherosclerosis. We provide an overview of this recessive genetic disease, diagnostic as well as therapeutic tips, and the latest diagnostic criteria in Japan.
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Affiliation(s)
- Hayato Tada
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Akihiro Nomura
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Masatsune Ogura
- Department of Molecular Innovation in Lipidology, National Cerebral and Cardiovascular Center Research Institute
| | - Katsunori Ikewaki
- Division of Neurology, Anti-Aging, and Vascular Medicine, Department of Internal Medicine, National Defense Medical College
| | - Yasushi Ishigaki
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Iwate Medical University
| | - Kyoko Inagaki
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Nippon Medical School
| | | | - Kazushige Dobashi
- Department of Pediatrics, School of Medicine, University of Yamanashi
| | - Kimitoshi Nakamura
- Department of Pediatrics, Kumamoto University Graduate School of Medical Sciences
| | - Mika Hori
- Department of Endocrinology, Research Institute of Environmental Medicine, Nagoya University
| | - Kota Matsuki
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine
| | | | | | - Masa-Aki Kawashiri
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Mariko Harada-Shiba
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center Research Institute
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15
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Nakano Y, Komiya C, Shimizu H, Mishima H, Shiba K, Tsujimoto K, Ikeda K, Kashimada K, Dateki S, Yoshiura KI, Ogawa Y, Yamada T. A case of ezetimibe-effective hypercholesterolemia with a novel heterozygous variant in ABCG5. Endocr J 2020; 67:1099-1105. [PMID: 32641618 DOI: 10.1507/endocrj.ej20-0044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Sitosterolemia is caused by homozygous or compound heterozygous gene mutations in either ATP-binding cassette subfamily G member 5 (ABCG5) or 8 (ABCG8). Since ABCG5 and ABCG8 play pivotal roles in the excretion of neutral sterols into feces and bile, patients with sitosterolemia present elevated levels of serum plant sterols and in some cases also hypercholesterolemia. A 48-year-old woman was referred to our hospital for hypercholesterolemia. She had been misdiagnosed with familial hypercholesterolemia at the age of 20 and her serum low-density lipoprotein cholesterol (LDL-C) levels had remained about 200-300 mg/dL at the former clinic. Although the treatment of hydroxymethylglutaryl-CoA (HMG-CoA) reductase inhibitors was ineffective, her serum LDL-C levels were normalized by ezetimibe, a cholesterol transporter inhibitor. We noticed that her serum sitosterol and campesterol levels were relatively high. Targeted analysis sequencing identified a novel heterozygous ABCG5 variant (c.203A>T; p.Ile68Asn) in the patient, whereas no mutations were found in low-density lipoprotein receptor (LDLR), proprotein convertase subtilisin/kexin type 9 (PCSK9), or Niemann-Pick C1-like intracellular cholesterol transporter 1 (NPC1L1). While sitosterolemia is a rare disease, a recent study has reported that the incidence of loss-of-function mutation in the ABCG5 or ABCG8 gene is higher than we thought at 1 in 220 individuals. The present case suggests that serum plant sterol levels should be examined and ezetimibe treatment should be considered in patients with hypercholesterolemia who are resistant to HMG-CoA reductase inhibitors.
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Affiliation(s)
- Yujiro Nakano
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan
| | - Chikara Komiya
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan
| | - Hitomi Shimizu
- Department of Pediatrics, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaski 852-8501, Japan
- Department of Human Genetics, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki 852-8501, Japan
| | - Hiroyuki Mishima
- Department of Human Genetics, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki 852-8501, Japan
| | - Kumiko Shiba
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan
| | - Kazutaka Tsujimoto
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan
| | - Kenji Ikeda
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan
| | - Kenichi Kashimada
- Department of Pediatrics and Developmental Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan
| | - Sumito Dateki
- Department of Pediatrics, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaski 852-8501, Japan
| | - Koh-Ichiro Yoshiura
- Department of Human Genetics, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki 852-8501, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Tetsuya Yamada
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan
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16
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Sun W, Zhang T, Zhang X, Wang J, Chen Y, Long Y, Zhang G, Wang Y, Chen Y, Fang T, Chen M. Compound heterozygous mutations in ABCG5 or ABCG8 causing Chinese familial Sitosterolemia. J Gene Med 2020; 22:e3185. [PMID: 32166861 DOI: 10.1002/jgm.3185] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/07/2020] [Accepted: 03/09/2020] [Indexed: 02/03/2023] Open
Affiliation(s)
- Weiwei Sun
- Beijing Chigene Translational Medicine Research Center Beijing Yizhuang China
| | - Tian Zhang
- Department of Pediatrics, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of China Hefei Anhui China
| | - Xiaoguang Zhang
- Department of Pediatrics, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of China Hefei Anhui China
| | - Jieyu Wang
- Reproductive Medicine Center, Department of Obstetrics and GynecologyThe First Affiliated Hospital of Anhui Medical University Hefei Anhui China
| | - Yuqing Chen
- Department of Rheumatism ImmunologyAnhui Provincial Children's Hospital Hefei Anhui China
| | - Yun Long
- Department of GastroenterologyAnhui Provincial Children's Hospital Hefei Anhui China
| | - Gong Zhang
- Department of Children's Health PreventionAnhui Provincial Children's Hospital Hefei Anhui China
| | - Yajian Wang
- Beijing Chigene Translational Medicine Research Center Beijing Yizhuang China
| | - Ye Chen
- Department of Pediatrics, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of China Hefei Anhui China
| | - Tao Fang
- Department of Pediatrics, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of China Hefei Anhui China
| | - Mingwu Chen
- Department of Pediatrics, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of China Hefei Anhui China
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17
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Veit L, Allegri Machado G, Bürer C, Speer O, Häberle J. Sitosterolemia-10 years observation in two sisters. JIMD Rep 2019; 48:4-10. [PMID: 31392106 PMCID: PMC6607017 DOI: 10.1002/jmd2.12038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 04/18/2019] [Accepted: 04/24/2019] [Indexed: 12/26/2022] Open
Abstract
Familial hypercholesterolemia due to heterozygous low-density lipoprotein-receptor mutations is a common inborn errors of metabolism. Secondary hypercholesterolemia due to a defect in phytosterol metabolism is far less common and may escape diagnosis during the work-up of patients with dyslipidemias. Here we report on two sisters with the rare, autosomal recessive condition, sitosterolemia. This disease is caused by mutations in a defective adenosine triphosphate-binding cassette sterol excretion transporter, leading to highly elevated plant sterol concentrations in tissues and to a wide range of symptoms. After a delayed diagnosis, treatment with a diet low in plant lipids plus ezetimibe to block the absorption of sterols corrected most of the clinical and biochemical signs of the disease. We followed the two patients for over 10 years and report their initial presentation and long-term response to treatment.
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Affiliation(s)
- Lara Veit
- Division of Metabolism and Children's Research CenterUniversity Children's Hospital ZurichZurichSwitzerland
| | - Gabriella Allegri Machado
- Division of Metabolism and Children's Research CenterUniversity Children's Hospital ZurichZurichSwitzerland
| | - Céline Bürer
- Division of Metabolism and Children's Research CenterUniversity Children's Hospital ZurichZurichSwitzerland
| | - Oliver Speer
- Division of Haematology and Children's Research CenterUniversity Children's Hospital ZurichZurichSwitzerland
- Institut für LabormedizinSpital Thurgau AGFrauenfeldSwitzerland
| | - Johannes Häberle
- Division of Metabolism and Children's Research CenterUniversity Children's Hospital ZurichZurichSwitzerland
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18
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19
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Lee JH, Lee K, Jun SH, Song SH, Shin CH, Song J. A Multiplex Phytosterol Assay Utilizing Gas Chromatography-Mass Spectrometry for Diagnosis of Inherited Lipid Storage Disorders. Ann Lab Med 2019; 39:411-413. [PMID: 30809990 PMCID: PMC6400724 DOI: 10.3343/alm.2019.39.4.411] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 10/27/2018] [Accepted: 01/15/2019] [Indexed: 11/19/2022] Open
Affiliation(s)
- Joon Hee Lee
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kyunghoon Lee
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sun Hee Jun
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang Hoon Song
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea
| | - Choong Ho Shin
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Junghan Song
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
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20
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Huang D, Zhou Q, Chao YQ, Zou CC. Clinical features and genetic analysis of childhood sitosterolemia: Two case reports and literature review. Medicine (Baltimore) 2019; 98:e15013. [PMID: 30985648 PMCID: PMC6485811 DOI: 10.1097/md.0000000000015013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
RATIONALE Sitosterolemia is a rare autosomal recessive disorder of dyslipidemia due to mutations of genes ABCG5 and ABCG8, leading to highly elevated plasma levels of plant sterols and expanded body pools of cholesterol. PATIENT CONCERNS We present a 9-year-old and a 7-year-old Chinese boy with hypercholesterolemia and xanthomas of sitosterolemia due to ABCG5 gene mutations. We also make a literature review of another 30 sitosterolemic children cases that have been reported with virulence ABCG5 gene mutations. DIAGNOSIS We took peripheral blood samples from 2 patients and their parents to conduct genetic analysis by next-generation sequencing (NGS) technologies. INTERVENTIONS The 2 patients received dietary modifications without pharmaceuticals treatment. OUTCOMES A c.1166G>A (Arg389His) homozygosis mutation in exon 9 was observed in case 1, whereas a c.751C>T (Gln251*) homozygosis mutation in exon 6 was found in case 2. Literature review found another 30 pediatric cases with sitosterolemia due to ABCG5 gene mutation. The lipid profile was normalized and xanthomas got smaller with combined therapy of a combined low-cholesterol and low-phytosterols diet. LESSONS These suggested that in patients (especially Asian patients) with multiple xanthomas, severe hypercholesterolemia, or elevated low-density lipoprotein-cholesterol, sitosterolemia should be considered in the differential diagnosis. Early diagnosis is important, and restriction of both cholesterol and phytosterols diet should suggested for these patients.
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Affiliation(s)
- Dan Huang
- Department of Endocrinology, Children's Hospital, Zhejiang University School of Medicine
| | - Qiong Zhou
- Department of Endocrinology, Children's Hospital, Zhejiang University School of Medicine
- Department of Pediatrics, Hangzhou Children's Hospital, Hangzhou, China
| | - Yun-Qi Chao
- Department of Endocrinology, Children's Hospital, Zhejiang University School of Medicine
| | - Chao-Chun Zou
- Department of Endocrinology, Children's Hospital, Zhejiang University School of Medicine
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21
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Clinical features, molecular characteristics, and treatments of a Chinese girl with sitosterolemia: A case report and literature review. J Clin Lipidol 2019; 13:246-250. [DOI: 10.1016/j.jacl.2019.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 01/14/2019] [Accepted: 01/16/2019] [Indexed: 11/22/2022]
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22
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Tao C, Shkumatov AA, Alexander ST, Ason BL, Zhou M. Stigmasterol accumulation causes cardiac injury and promotes mortality. Commun Biol 2019; 2:20. [PMID: 30675518 PMCID: PMC6335236 DOI: 10.1038/s42003-018-0245-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 12/02/2018] [Indexed: 12/11/2022] Open
Abstract
Cardiovascular disease is expected to remain the leading cause of death worldwide despite the introduction of proprotein convertase subtilisin/kexin type 9 inhibitors that effectively control cholesterol. Identifying residual risk factors for cardiovascular disease remains an important step for preventing and clinically managing the disease. Here we report cardiac injury and increased mortality occurring despite a 50% reduction in plasma cholesterol in a mouse model of phytosterolemia, a disease characterized by elevated levels of dietary plant sterols in the blood. Our studies show accumulation of stigmasterol, one of phytosterol species, leads to left ventricle dysfunction, cardiac interstitial fibrosis and macrophage infiltration without atherosclerosis, and increased mortality. A pharmacological inhibitor of sterol absorption prevents cardiac fibrogenesis. We propose that the pathological mechanism linking clinical sitosterolemia to the cardiovascular outcomes primarily involves phytosterols-induced cardiac fibrosis rather than cholesterol-driven atherosclerosis. Our studies suggest stigmasterol is a potent and independent risk factor for cardiovascular disease.
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Affiliation(s)
- Caroline Tao
- Cardiometabolic Disorders Therapeutic Area, Amgen Research, South San Francisco, CA USA
| | - Artem A. Shkumatov
- Comparative Biology and Safety Sciences, Amgen Research, South San Francisco, CA USA
| | - Shawn T. Alexander
- Cardiometabolic Disorders Therapeutic Area, Amgen Research, South San Francisco, CA USA
| | - Brandon L. Ason
- Cardiometabolic Disorders Therapeutic Area, Amgen Research, South San Francisco, CA USA
| | - Mingyue Zhou
- Cardiometabolic Disorders Therapeutic Area, Amgen Research, South San Francisco, CA USA
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23
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Marais AD. Contrasting effects of sterols on metabolism. J Clin Pathol 2018; 71:863-864. [PMID: 30232215 DOI: 10.1136/jclinpath-2018-205221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 07/03/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Adrian David Marais
- Department of Pathology, University of Cape Town, Cape Town, South Africa .,Department of Pathology, National Health Laboratory Service, Cape Town, South Africa
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24
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Martin JM, Cuesta A, Velasco R, Herrero A, Ramon D, Monteagudo C. Two-year-old girl with tuberous xanthomas. J Clin Pathol 2018; 71:860-862. [DOI: 10.1136/jclinpath-2017-204818] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 04/14/2018] [Accepted: 04/16/2018] [Indexed: 11/03/2022]
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25
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Tada H, Nohara A, Inazu A, Sakuma N, Mabuchi H, Kawashiri MA. Sitosterolemia, Hypercholesterolemia, and Coronary Artery Disease. J Atheroscler Thromb 2018; 25:783-789. [PMID: 30033951 PMCID: PMC6143779 DOI: 10.5551/jat.rv17024] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 05/24/2018] [Indexed: 12/31/2022] Open
Abstract
Sitosterolemia is a rare inherited disease characterized by increased levels of plant sterols, such as sitosterol. The cause of this disease is ATP-binding cassette (ABC) subfamily G member 5 or member 8 (ABCG5 or ABCG8, respectively) gene mutations. Recent advances in genetics have revealed that the prevalence of subjects with deleterious mutations in ABCG5 and/or ABCG8 genes could be more than 1 in ~200,000 individuals among the general population. Furthermore, accumulated evidence, including infantile cases exhibiting progression/regression of systemic xanthomas associated with LDL cholesterol levels, have shown that the elevation of LDL cholesterol seems to be the major cause of development of atherosclerosis and not the elevation of sitosterol. Regarding therapies, LDL apheresis, as well as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, could be useful for sitosterolemia, in addition to ezetimibe and/or colestimide. In this study, we provide the current understanding and future perspectives of sitosterolemia, which is currently considered an extremely rare disorder but is expected to be much more prevalent in clinical settings.
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Affiliation(s)
- Hayato Tada
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Atsushi Nohara
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Akihiro Inazu
- Department of Laboratory Science, Molecular Biochemistry and Molecular Biology, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Nagahiko Sakuma
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hiroshi Mabuchi
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Masa-aki Kawashiri
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
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26
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Tada H, Nomura A, Yamagishi M, Kawashiri MA. First case of sitosterolemia caused by double heterozygous mutations in ABCG5 and ABCG8 genes. J Clin Lipidol 2018; 12:1164-1168.e4. [DOI: 10.1016/j.jacl.2018.06.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/08/2018] [Accepted: 06/14/2018] [Indexed: 12/30/2022]
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Wang W, Jiang L, Chen PP, Wu Y, Su PY, Wang LY. A case of sitosterolemia misdiagnosed as familial hypercholesterolemia: A 4-year follow-up. J Clin Lipidol 2018; 12:236-239. [DOI: 10.1016/j.jacl.2017.10.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 09/26/2017] [Accepted: 10/12/2017] [Indexed: 11/16/2022]
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Yagasaki H, Nakane T, Toda T, Kobayashi K, Aoyama K, Ichikawa T, Sugita K. Carotid intima media thickness in a girl with sitosterolemia carrying a homozygous mutation in the ABCG5 gene. J Pediatr Endocrinol Metab 2017; 30:1007-1011. [PMID: 28771437 DOI: 10.1515/jpem-2017-0093] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 07/03/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Sitosterolemia is a rare lipid metabolism disorder that involves storage of plant sterols. This disease is associated with atherosclerosis, but detailed vascular endothelial assessment is difficult. CASE PRESENTATION We report a 5-year-old girl with sitosterolemia who presented with xanthomas at 23 months of age. Her total cholesterol was 868 mg/dL, and her plasma sitosterol level was 9.48 mg/dL. Direct sequencing detected a homozygous mutation in gene ABCG5 (p.Arg389His). Echocardiographic examination revealed that the carotid artery intima media thickness (cIMT) was 0.4 mm with heterogenous hyperechogenicity inside the arterial wall. She was treated using dietary therapy and ezetimibe, which effectively lowered her sitosterol levels. After 3 years of treatment, her cIMT was stable in diameter and arterial wall echogenicity had improved. CONCLUSIONS Sitosterolemia is a unique disorder in which it is difficult to avoid premature atherosclerosis because of high sitosterol levels. cIMT measurement with arterial wall assessment may improve management.
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Buonuomo PS, Iughetti L, Pisciotta L, Rabacchi C, Papadia F, Bruzzi P, Tummolo A, Bartuli A, Cortese C, Bertolini S, Calandra S. Timely diagnosis of sitosterolemia by next generation sequencing in two children with severe hypercholesterolemia. Atherosclerosis 2017; 262:71-77. [DOI: 10.1016/j.atherosclerosis.2017.05.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 04/14/2017] [Accepted: 05/03/2017] [Indexed: 01/27/2023]
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Othman RA, Myrie SB, Mymin D, Roullet JB, Steiner RD, Jones PJH. Effect of ezetimibe on low- and high-density lipoprotein subclasses in sitosterolemia. Atherosclerosis 2017; 260:27-33. [PMID: 28340366 DOI: 10.1016/j.atherosclerosis.2017.03.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 03/08/2017] [Accepted: 03/09/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND AIMS Sitosterolemia displays high plasma total sterols [high plant sterols (PS) + normal to high total cholesterol (TC)] with normal to moderately elevated low-density lipoprotein (LDL) levels. High LDL, intermediate-density lipoprotein (IDL) and very low-density lipoprotein (VLDL) particles, low high-density lipoprotein (HDL), and increased non-HDL and the ratios of TC and triglycerides (TG) to HDL can increase the risk for atherosclerosis. Ezetimibe (EZE) can reduce plasma PS and TC levels in sitosterolemia, but its effect on lipoprotein subclasses has not been previously reported. METHODS Sitosterolemia patients (n = 8) were taken off EZE for 14 weeks (OFF EZE) and placed on EZE (10 mg/d) for 14 weeks (ON EZE). Serum lipids were measured enzymatically and lipoprotein subclasses were assessed by polyacrylamide gel electrophoresis. RESULTS EZE reduced (p < 0.05) total sterols (-12.5 ± 4.1%) and LDL-sterol (-22.7 ± 5.7%) and its sterol mass of large VLDL (-24.4 ± 4.5%), VLDL remnants (-21.1 ± 7.9%) and large IDL (-22.4 ± 7.2%) compared to OFF EZE. EZE did not affect large LDL subclasses or mean LDL particle size (273.8 ± 0.6 vs. 274.6 ± 0.3 Å). EZE increased HDL-sterol (25.5 ± 8.0%, p = 0.008) including intermediate (34 ± 14%, p = 0.02) and large (33 ± 16%, p = 0.06) HDL. EZE reduced non-HDL-sterol (-21.8± 5.0%), total sterols/HDL (-28.2 ± 5.5%) and TG/HDL (-27.4 ± 6.5%, all p < 0.01). CONCLUSIONS EZE improves VLDL and HDL subfraction distribution, thereby reducing the atherogenic lipid profile, thus providing potential clinical benefit in sitosterolemia beyond TC and PS reduction.
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Affiliation(s)
- Rgia A Othman
- Human Nutritional Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; Richardson Center for Functional Foods and Nutraceuticals, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Semone B Myrie
- Human Nutritional Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; Richardson Center for Functional Foods and Nutraceuticals, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - David Mymin
- Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jean-Baptiste Roullet
- College of Pharmacy, Washington State University, Spokane, WA, United States; Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, United States
| | - Robert D Steiner
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Peter J H Jones
- Human Nutritional Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; Richardson Center for Functional Foods and Nutraceuticals, University of Manitoba, Winnipeg, Manitoba, Canada
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Ono S, Matsuda J, Saito A, Yamamoto T, Fujimoto W, Shimizu H, Dateki S, Ouchi K. A case of sitosterolemia due to compound heterozygous mutations in ABCG5: clinical features and treatment outcomes obtained with colestimide and ezetimibe. Clin Pediatr Endocrinol 2017; 26:17-23. [PMID: 28203044 PMCID: PMC5295247 DOI: 10.1297/cpe.26.17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 11/22/2016] [Indexed: 12/27/2022] Open
Abstract
Sitosterolemia is a rare, autosomal recessively inherited disorder of lipid metabolism
caused by mutations in the “ATP-binding cassette, subfamily G” member 5 and 8 proteins
(encoded by the ABCG5 and ABCG8 genes, respectively),
which play critical roles in the intestinal and biliary excretion of plant sterols. We
report the clinical features and treatment outcomes of an 18-month-old Japanese girl with
sitosterolemia, who presented with multiple linear and intertriginous xanthomas around the
joint areas. Serum lipid analyses revealed elevated levels of total cholesterol (T-Chol:
866 mg/dL), low density lipoprotein-cholesterol (LDL-C: 679 mg/dL), and plant sterols
(sitosterol: 24.6 mg/dL, campesterol: 19.2 mg/dL, stigmasterol: 1.8 mg/dL). Compound
heterozygous mutations (p.R419H and p.R389H) were identified in ABCG5.
The patient was placed on a low cholesterol/low plant sterol diet and treated with
colestimide (a bile acid sequestrant) and ezetimibe (an NPC1L1 inhibitor). Serum T-Chol
and LDL-C levels decreased to normal within 2 mo, and plant sterol levels decreased by 30%
within 4 mo. The xanthomas regressed gradually, and almost completely disappeared after
1.5 yr of treatment. No further reductions of plant sterol levels were observed. Long-term
follow-up is important to verify appropriate therapeutic goals to prevent premature
atherosclerosis and coronary artery disease.
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Affiliation(s)
- Sahoko Ono
- Department of Pediatrics, Kawasaki Medical School, Okayama, Japan
| | - Junko Matsuda
- Department of Pediatrics, Kawasaki Medical School, Okayama, Japan; Department of Pathophysiology and Metabolism, Kawasaki Medical School, Okayama, Japan
| | - Aki Saito
- Department of Pediatrics, Kawasaki Medical School, Okayama, Japan
| | | | - Wataru Fujimoto
- Department of Dermatology, Kawasaki Medical School, Okayama, Japan
| | - Hitomi Shimizu
- Department of Pediatrics, Nagasaki University, Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Sumito Dateki
- Department of Pediatrics, Nagasaki University, Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazunobu Ouchi
- Department of Pediatrics, Kawasaki Medical School, Okayama, Japan
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Clinical utility gene card for: Sitosterolaemia. Eur J Hum Genet 2016; 25:ejhg2016187. [PMID: 28029149 DOI: 10.1038/ejhg.2016.187] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 10/04/2016] [Accepted: 11/22/2016] [Indexed: 12/17/2022] Open
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France M, Rees A, Datta D, Thompson G, Capps N, Ferns G, Ramaswami U, Seed M, Neely D, Cramb R, Shoulders C, Barbir M, Pottle A, Eatough R, Martin S, Bayly G, Simpson B, Halcox J, Edwards R, Main L, Payne J, Soran H. HEART UK statement on the management of homozygous familial hypercholesterolaemia in the United Kingdom. Atherosclerosis 2016; 255:128-139. [DOI: 10.1016/j.atherosclerosis.2016.10.017] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 08/03/2016] [Accepted: 10/07/2016] [Indexed: 12/16/2022]
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Abstract
Homozygous familial hypercholesterolaemia (HoFH) is an inherited disease causing an approximately fourfold increase in blood low-density lipoprotein cholesterol (LDLC) from birth compared with the age-matched normal population owing to reduced low-density lipoprotein receptor (LDLR) activity. Such elevated cholesterol is associated with accelerated atheromatous disease, particularly of the aortic root and coronary arteries. However, HoFH is clinically heterogeneous, reflecting residual low-density lipoprotein receptor (LDLR) activity. The main objective in treating children may be stated to be the avoidance of irreversible cardiac damage requiring heart transplantation by sufficient lowering of blood cholesterol. Lipoprotein apheresis or plasmapheresis are safe means of lowering cholesterol but may be insufficient on their own. Statin drugs, PCSK9 inhibitors ezetimibe and bile acid sequestrants are relatively ineffective if LDLR activity is lacking, but should be used if effective. Two new drugs, lomitapide and mipomersen, have been licensed specifically for HoFH by some regulatory authorities. They work by reducing LDL production rate. They have been associated with fatty liver in adults. Evidence of safety in children is lacking. An alternative is liver transplantation, which replaces the missing LDLR and normalises cholesterol. Clinicians are faced with a dilemma in choosing between these options or deferring such treatment associated with potential harm. Individual case descriptions are an important means of informing clinical judgement. Management of the two cases described in this issue is discussed in the light of modern developments in transplantation and pharmacotherapy.
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Key Words
- ADH, autosomal dominant hypercholesterolaemia, refers to hypercholesterolaemia owing to a single mutation of an allele of a gene affecting LDLR activity
- APOB, apolipoprotein B, is the main protein component of LDL and is the ligand for LDL receptors in the liver
- ARH, autosomal recessive hypercholesterolaemia, refers to hypercholesterolaemia owing to a mutation of both alleles of a single gene affecting LDLR activity
- Evolucomab
- FH, familial hypercholesterolaemia, is an inherited condition causing reduced LDLR activity with consequent hypercholesterolaemia
- HeFH, heterozygous familial hypercholesterolaemia, is caused by one mutant allele of genes affecting LDLR activity
- HoFH, homozygous familial hypercholesterolaemia is caused by two mutant alleles of genes affecting LDLR activity
- Homozygous familial hypercholesterolaemia
- LDL, low-density lipoprotein, is a complex of cholesterol attached to a lipoprotein particle which is removed from blood mainly by the liver
- LDLC, LDL cholesterol, refers to the cholesterol component of LDL
- LDLR, LDL receptors, mediate LDL uptake by the liver
- LDLRAP1, a protein called LDLR adaptor protein 1, facilitates LDLR function
- Lipoprotein apheresis
- Liver transplantation
- Lomitapide
- Microsomal triglyceride transfer protein is an enzyme involved in the hepatic assembly of triglyceride, cholesterol and APOB into triglyceride-rich particles which are secreted by the liver. These particles are metabolised to LDL
- PCSK9
- PCSK9, a protein called proprotein convertase subtilisin/kexin type 9, increases the rate of degradation of LDLR
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Affiliation(s)
- Michael France
- a Cardiovascular Trials Unit , Central Manchester University Hospitals Foundation Trust and Cardiovascular Research Group, University of Manchester , Manchester , UK
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Yamamoto T, Matsuda J, Dateki S, Ouchi K, Fujimoto W. Numerous intertriginous xanthomas in infant: A diagnostic clue for sitosterolemia. J Dermatol 2016; 43:1340-1344. [PMID: 27401767 DOI: 10.1111/1346-8138.13511] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 05/30/2016] [Indexed: 11/29/2022]
Abstract
Sitosterolemia is a very rare autosomal recessive lipoprotein metabolic disorder caused by homozygous or compound heterozygous mutations in one of the two adenosine triphosphate-binding cassette transporter genes, ABCG5 and ABCG8. Sitosterolemia is clinically characterized by xanthomas and atherosclerosis, arthritis, fever, hemolysis and macrothrombocytopenia even in early childhood. We described a 16-month-old girl, who had numerous yellowish-brown intertriginous xanthomas along the skin creases on the extremities with severe hypercholesterolemia and elevated plant sterol levels. Histopathologically, xanthoma showed aggregation of foam cells in the dermis with a zone of mucin deposits in the dermal papilla. Electron microscopy showed numerous membrane-bound lipid droplets and multivesicular lipid bodies in the foam cells, a round cell containing lipid droplets in the basal cell layer and abundant mucin deposits just beneath the basal lamina. Diagnosis of sitosterolemia was confirmed by DNA sequencing showing compound heterozygosity for previously reported missense mutations in exon 9 of ABCG5. Infants presenting with multiple xanthomas should be investigated for sitosterolemia, if there is no family history of dyslipidemia.
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Affiliation(s)
- Takenobu Yamamoto
- Department of Dermatology, Kawasaki Medical School, Kurashiki, Japan.
| | - Junko Matsuda
- Department of Pediatrics, Kawasaki Medical School, Kurashiki, Japan
| | - Sumito Dateki
- Department of Pediatrics, Nagasaki University School of Medicine, Nagasaki, Japan
| | - Kazunobu Ouchi
- Department of Pediatrics, Kawasaki Medical School, Kurashiki, Japan
| | - Wataru Fujimoto
- Department of Dermatology, Kawasaki Medical School, Kurashiki, Japan
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Yoo EG. Sitosterolemia: a review and update of pathophysiology, clinical spectrum, diagnosis, and management. Ann Pediatr Endocrinol Metab 2016; 21:7-14. [PMID: 27104173 PMCID: PMC4835564 DOI: 10.6065/apem.2016.21.1.7] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 03/15/2016] [Indexed: 12/28/2022] Open
Abstract
Sitosterolemia is an autosomal recessive disorder characterized by increased plant sterol levels, xanthomas, and accelerated atherosclerosis. Although it was originally reported in patients with normolipemic xanthomas, severe hypercholesterolemia have been reported in patients with sitosterolemia, especially in children. Sitosterolemia is caused by increased intestinal absorption and decreased biliary excretion of sterols resulting from biallelic mutations in either ABCG5 or ABCG8, which encode the sterol efflux transporter ABCG5 and ABCG8. Patients with sitosterolemia show extreme phenotypic heterogeneity, ranging from almost asymptomatic individuals to those with severe hypercholesterolemia leading to accelerated atherosclerosis and premature cardiac death. Hematologic manifestations include hemolytic anemia with stomatocytosis, macrothrombocytopenia, splenomegaly, and abnormal bleeding. The mainstay of therapy includes dietary restriction of both cholesterol and plant sterols and the sterol absorption inhibitor, ezetimibe. Foods rich in plant sterols include vegetable oils, wheat germs, nuts, seeds, avocado, shortening, margarine and chocolate. Hypercholesterolemia in patients with sitosterolemia is dramatically responsive to low cholesterol diet and bile acid sequestrants. Plant sterol assay should be performed in patients with normocholesterolemic xanthomas, hypercholesterolemia with unexpectedly good response to dietary modifications or to cholesterol absorption inhibitors, or hypercholesterolemia with poor response to statins, or those with unexplained hemolytic anemia and macrothrombocytopenia. Because prognosis can be improved by proper management, it is important to find these patients out and diagnose correctly. This review article aimed to summarize recent publications on sitosterolemia, and to suggest clinical indications for plant sterol assay.
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Affiliation(s)
- Eun-Gyong Yoo
- Department of Pediatrics, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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Two novel mutations in the ABCG5 gene, c.144 -1G>A and c.1523 delC, in a Mexican family with sitosterolemia. J Clin Lipidol 2016; 10:204-8. [DOI: 10.1016/j.jacl.2015.09.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Revised: 08/27/2015] [Accepted: 09/23/2015] [Indexed: 11/19/2022]
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Seo HS, Choi MH. Cholesterol homeostasis in cardiovascular disease and recent advances in measuring cholesterol signatures. J Steroid Biochem Mol Biol 2015; 153:72-9. [PMID: 25910582 DOI: 10.1016/j.jsbmb.2015.04.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 04/17/2015] [Accepted: 04/20/2015] [Indexed: 01/08/2023]
Abstract
Despite the biochemical importance of cholesterol, its abnormal metabolism has serious cellular consequences that lead to endocrine disorders such as cardiovascular disease (CVD). Nevertheless, the impact of blood cholesterol as a CVD risk factor is still debated, and treatment with cholesterol-lowering drugs remains controversial, particularly in older patients. Although, the prevalence of CVD increases with age, the underlying mechanisms for this phenomenon are not well understood, and metabolic changes have not been confirmed as predisposing factors of atherogenesis. The quantification of circulating biomarkers for cholesterol homeostasis is therefore warranted, and reference values for cholesterol absorption and synthesis should be determined in order to establish CVD risk factors. The traditional lipid profile is often derived rather than directly measured and lacks a universal standard to interpret the results. In contrast, mass spectrometry-based cholesterol profiling can accurately measure free cholesterol as a biologically active component. This approach allows to detect alterations in various metabolic pathways that control cholesterol homeostasis, by quantitative analysis of cholesterol and its precursors/metabolites as well as dietary sterols. An overview of the mechanism of cholesterol homeostasis under different physiological conditions may help to identify predictive biomarkers of concomitant atherosclerosis and conventional CVD risk factors.
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Affiliation(s)
- Hong Seog Seo
- Cardiovascular Center, Korea University Guro Hospital, Seoul 152-703, South Korea; Korea University-Korea Institute of Science and Technology Graduated School of Converging Science and Technology, Seoul 152-703, South Korea
| | - Man Ho Choi
- Materials and Life Science Research Division, Korea Institute of Science and Technology, Seoul 136-791, South Korea.
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Abstract
Phytosterolemia (sitosterolemia) is a rare autosomal recessive sterol storage disease caused by mutations in either of the adenosine triphosphate (ATP) binding cassette transporter genes; (ABC) G5 or ABCG8, leading to impaired elimination of plant sterols and stanols, with their increased accumulation in the blood and tissues. Thus the disease is characterized by substantially elevated serum plant sterols and stanols, with moderate to high plasma cholesterol levels, and increased risk of premature atherosclerosis. Hematologic abnormalities including macrothrombocytopenia, stomatocytosis and hemolysis are frequently observed in sitosterolemia patients. Currently, ezetimibe, a sterol absorption inhibitor, is used as the routine treatment for sitosterolemia, with reported improvement in plant sterol levels and hemolytic parameters. This review summarizes the research related to the health impact of plant sterols and stanols on sitosterolemia.
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Affiliation(s)
- Bridget O. Ajagbe
- University of Manitoba, Department of Human Nutritional Sciences, Winnipeg, MB, Canada, R3T 2N2, and University of Manitoba, Richardson Centre for Functional Foods and Nutraceuticals, Winnipeg, MB, Canada, R3T 6C5
| | - Rgia A. Othman
- University of Manitoba, Department of Human Nutritional Sciences, Winnipeg, MB, Canada, R3T 2N2, and University of Manitoba, Richardson Centre for Functional Foods and Nutraceuticals, Winnipeg, MB, Canada, R3T 6C5
| | - Semone B. Myrie
- University of Manitoba, Department of Human Nutritional Sciences, Winnipeg, MB, Canada, R3T 2N2, and University of Manitoba, Richardson Centre for Functional Foods and Nutraceuticals, Winnipeg, MB, Canada, R3T 6C5
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Tada H, Kawashiri MA, Takata M, Matsunami K, Imamura A, Matsuyama M, Sawada H, Nunoi H, Konno T, Hayashi K, Nohara A, Inazu A, Kobayashi J, Mabuchi H, Yamagishi M. Infantile Cases of Sitosterolaemia with Novel Mutations in the ABCG5 Gene: Extreme Hypercholesterolaemia is Exacerbated by Breastfeeding. JIMD Rep 2015; 21:115-22. [PMID: 25665839 DOI: 10.1007/8904_2014_404] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 11/25/2014] [Accepted: 12/23/2014] [Indexed: 12/13/2022] Open
Abstract
Few data exists regarding the clinical impact of breastfeeding in infantile sitosterolaemic cases. We report four Japanese infantile cases of sitosterolaemia, an extremely rare inherited disease characterised by increased serum levels of plant sitosterol, presenting with severe hypercholesterolaemia and systemic xanthomas exacerbated by breastfeeding. In these four cases, genetic analyses were performed for low-density lipoprotein (LDL) receptor, proprotein convertase subtilisin/kexin type 9 (PCSK9), LDL receptor adaptor protein 1 and ATP-binding cassette (ABC) subfamily G member 5 and 8 (ABCG5 and ABCG8) genes. We assessed their clinical manifestations, including responsiveness to a variety of treatments, especially to weaning from breastfeeding and use of ezetimibe. Two pairs of mutations in the ABCG5 gene in each case, including two novel mutations (c.130C>T or p.Ser44Ala and c.1813_1817delCTTTT or p.Pro558GlufsX14) and two known mutations (c.1306G>A or p.Arg389His and c.1336C>T or p.Arg446X), were identified. Significant reductions in cholesterol levels were obtained by means of weaning from breastfeeding alone. Substantial reductions in sitosterol levels, without any apparent side effects, were observed with ezetimibe. In conclusion, we have identified infantile Japanese sitosterolaemic subjects with extreme hypercholesterolaemia exacerbated by breastfeeding. Their unique response to weaning from breastfeeding, as well as to use of ezetimibe, could provide insights into the metabolic basis of sterols in humans.
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Affiliation(s)
- Hayato Tada
- Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan,
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Othman RA, Myrie SB, Mymin D, Merkens LS, Roullet JB, Steiner RD, Jones PJ. Ezetimibe reduces plant sterol accumulation and favorably increases platelet count in sitosterolemia. J Pediatr 2015; 166:125-31. [PMID: 25444527 PMCID: PMC4274192 DOI: 10.1016/j.jpeds.2014.08.069] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 08/04/2014] [Accepted: 08/28/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess if ezetimibe (EZE), a sterol-absorption inhibitor, improves platelet (PLT) count and size relative to its effect on plasma plant sterol (PS) in patients with sitosterolemia (STSL). STUDY DESIGN Patients with STSL (5 males, 3 females, 16-56 years of age) receiving EZE intervention as part of their routine care participated in this study. EZE was discontinued for 14 weeks (off) and then resumed for another 14 weeks (on). Hematology variables along with plasma and red blood cells (RBC) PS and total cholesterol (TC) levels were measured at the end of each phase. RESULTS EZE increased PLT count (23% ± 9%) and decreased mean PLT volume (MPV; 10% ± 3%, all P < .05). In patients off EZE, PLT counts inversely correlated (r = -0.96 and r = -0.91, all P < .01) with plasma and RBC PS to TC ratio (PS/TC), and MPV positively correlated (r = 0.91, P = .03 and r = 0.93, P = .02) with plasma and RBC PS/TC. EZE reduced plasma and RBC sitosterol (-35% ± 4% and -28% ± 3%), total PS (-37% ± 4% and -28% ± 3%, all P < .0001) levels, and PS/TC (-27% ± 4% and -28% ± 4%, P < .01). CONCLUSIONS EZE reduces plasma and RBC PS levels, while increasing PLT count and decreasing MPV, and thereby may reduce the risk for bleeding in STSL. Plasma PS levels and ABCG5/ABCG8 genes should be analyzed in patients with unexplained hematologic abnormalities.
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Affiliation(s)
- Rgia A. Othman
- Human Nutritional Sciences, University of Manitoba, Winnipeg, MB, Canada, R3T 6C5,Richardson Centre for Functional Foods and Nutraceuticals, University of Manitoba, Winnipeg, MB, Canada, R3T 6C5
| | - Semone B. Myrie
- Human Nutritional Sciences, University of Manitoba, Winnipeg, MB, Canada, R3T 6C5,Richardson Centre for Functional Foods and Nutraceuticals, University of Manitoba, Winnipeg, MB, Canada, R3T 6C5
| | - David Mymin
- Internal Medicine, University of Manitoba, Winnipeg, MB, Canada, R3T 6C5
| | - Louise S. Merkens
- Pediatrics, Institute on Development and Disability/Doernbecher Children’s Hospital, Oregon Health & Science University, 3181 SW Jackson Park Road, Portland, OR 97239
| | - Jean-Baptiste Roullet
- Pediatrics, Institute on Development and Disability/Doernbecher Children’s Hospital, Oregon Health & Science University, 3181 SW Jackson Park Road, Portland, OR 97239
| | - Robert D. Steiner
- Pediatrics, Institute on Development and Disability/Doernbecher Children’s Hospital, Oregon Health & Science University, 3181 SW Jackson Park Road, Portland, OR 97239,Molecular and Medical Genetics, Institute on Development and Disability/Doernbecher Children’s Hospital, Oregon Health & Science University, 3181 SW Jackson Park Road, Portland, OR 97239,Marshfield Clinic Research Foundation, Marshfield, WI and the University of Wisconsin, Madison, WI
| | - Peter J.H. Jones
- Human Nutritional Sciences, University of Manitoba, Winnipeg, MB, Canada, R3T 6C5,Richardson Centre for Functional Foods and Nutraceuticals, University of Manitoba, Winnipeg, MB, Canada, R3T 6C5
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