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Paquette M, Trinder M, Guay SP, Brunham LR, Baass A. Prevalence of Dysbetalipoproteinemia in the UK Biobank According to Different Diagnostic Criteria. J Clin Endocrinol Metab 2024:dgae259. [PMID: 38625929 DOI: 10.1210/clinem/dgae259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 03/26/2024] [Accepted: 04/11/2024] [Indexed: 04/18/2024]
Abstract
CONTEXT Dysbetalipoproteinemia (DBL) is a multifactorial disorder that disrupts the normal metabolism of remnant lipoproteins, causing increased risk of cardiovascular disease. However, establishing a proper diagnosis is difficult and the true prevalence of the disease in the general population remains unknown. OBJECTIVE The objectives were to study the prevalence of the disease and to validate the performance of different clinical diagnostic criteria in a large population-based cohort. METHODS This study included 453 437 participants from the UK Biobank. DBL was established in participants having an ε2ε2 genotype with mixed dyslipidemia or lipid-lowering therapy use (n=964). The different diagnostic criteria for DBL were applied in individuals without lipid-lowering medication (n=370 039, n=534 DBL), to compare their performance. RESULTS Overall, 0.6% of participants had an ε2ε2 genotype, of which 36% were classified as DBL, for a disease prevalence of 0.2% (1:469). The prevalence of DBL was similar between the different genetic ancestries (≤0.2%). Several diagnostic criteria showed good sensitivity for the diagnosis of DBL (>90%), but they suffered from a very low positive predictive value (0.6%-15.4%). CONCLUSION This study reported for the first time the prevalence of DBL in the UK Biobank according to genetic ancestry. Furthermore, we provided the first external validation of different diagnostic criteria for DBL in a large population-based cohort and highlighted the fact that these criteria should not be used to diagnose DBL alone but should rather be used as a first screening step to determine which individuals may benefit from genetic testing to confirm the diagnosis.
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Affiliation(s)
- Martine Paquette
- Lipids, Nutrition, and Cardiovascular Prevention Clinic of the Montreal Clinical Research Institute, Montreal Québec, H2W 1R7, Canada
| | - Mark Trinder
- Faculty of Medicine, University of British Columbia, Centre for Heart and Lung Innovation, Department of Medicine, University of British Columbia, Vancouver British Columbia, V6Z 1Y6, Canada
| | - Simon-Pierre Guay
- Lipids, Nutrition, and Cardiovascular Prevention Clinic of the Montreal Clinical Research Institute, Montreal Québec, H2W 1R7, Canada
- Department of Medicine, Division of Endocrinology, Université de Montréal, Montréal Québec, H3T 1J4, Canada
| | - Liam R Brunham
- Faculty of Medicine, University of British Columbia, Centre for Heart and Lung Innovation, Department of Medicine, University of British Columbia, Vancouver British Columbia, V6Z 1Y6, Canada
| | - Alexis Baass
- Lipids, Nutrition, and Cardiovascular Prevention Clinic of the Montreal Clinical Research Institute, Montreal Québec, H2W 1R7, Canada
- Department of Medicine, Divisions of Experimental Medicine and Medical Biochemistry, McGill University, Montreal Québec, H3G 2M1, Canada)
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Affiliation(s)
- Robert A Hegele
- Department of Medicine and Robarts Research Institute, Western University, 4288A-1151 Richmond Street North, London, Ontario, N6A 5B7, Canada.
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Paquette M, Blais C, Fortin A, Bernard S, Baass A. Dietary recommendations for dysbetalipoproteinemia: A need for better evidence. J Clin Lipidol 2023; 17:549-556. [PMID: 37268489 DOI: 10.1016/j.jacl.2023.05.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 05/16/2023] [Accepted: 05/22/2023] [Indexed: 06/04/2023]
Abstract
The increased risk of cardiovascular disease in patients with dysbetalipoproteinemia (DBL) is well documented and is associated with the dysfunctional metabolism of remnant lipoproteins. Although these patients are known to respond well to lipid-lowering medication including statins and fibrates, the best dietary approach to lower remnant lipoprotein accumulation and to prevent cardiovascular outcomes remain unclear. Indeed, current evidence is based on studies published mainly in the 1970s, which comprise small sample sizes and methodological limitations. This review aims to summarize nutritional studies performed in DBL patients to date and to discuss potential avenues in this field and future areas of research.
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Affiliation(s)
- Martine Paquette
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Montreal, Québec, Canada
| | - Chantal Blais
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Montreal, Québec, Canada
| | - Andréanne Fortin
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Montreal, Québec, Canada
| | - Sophie Bernard
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Montreal, Québec, Canada; Department of Medicine, Division of Endocrinology, University of Montreal, Montreal, Québec, Canada; Research Centre of the Centre Hospitalier Universitaire de Montréal (CRCHUM), Montreal, Québec, Canada
| | - Alexis Baass
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Montreal, Québec, Canada; Department of Medicine, Divisions of Experimental Medicine and Medical Biochemistry, McGill University, Montreal, Québec, Canada.
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Chemello K, Blom DJ, Marais AD, Lambert G, Blanchard V. Genetic and Mechanistic Insights into the Modulation of Circulating Lipoprotein (a) Concentration by Apolipoprotein E Isoforms. Curr Atheroscler Rep 2022; 24:399-405. [PMID: 35355214 DOI: 10.1007/s11883-022-01016-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2022] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW Lipoprotein (a) [Lp(a)] is a highly atherogenic lipoprotein species. A unique feature of Lp(a) is the strong genetic determination of its concentration. The LPA gene is responsible for up to 90% of the variance in Lp(a), but other genes also have an impact. RECENT FINDINGS Genome-wide associations studies indicate that the APOE gene, encoding apolipoprotein E (apoE), is the second most important locus modulating Lp(a) concentrations. Population studies clearly show that carriers of the apoE2 variant (ε2) display reduced Lp(a) levels, the lowest concentrations being observed in ε2/ε2 homozygotes. This genotype can lead predisposed adults to develop dysbetalipoproteinemia, a lipid disorder characterized by sharp elevations in cholesterol and triglycerides. However, dysbetalipoproteinemia does not significantly modulate circulating Lp(a). Mechanistically, apoE appears to impair the production but not the catabolism of Lp(a). These observations underline the complexity of Lp(a) metabolism and provide key insights into the pathways governing Lp(a) synthesis and secretion.
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Affiliation(s)
- Kévin Chemello
- Laboratoire Inserm, UMR 1188 DéTROI, Université de La Réunion, 2 Rue Maxime Rivière, 97490, Sainte Clotilde, France
| | - Dirk J Blom
- Division of Lipidology and Cape Heart Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - A David Marais
- Division of Chemical Pathology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Gilles Lambert
- Laboratoire Inserm, UMR 1188 DéTROI, Université de La Réunion, 2 Rue Maxime Rivière, 97490, Sainte Clotilde, France.
| | - Valentin Blanchard
- Laboratoire Inserm, UMR 1188 DéTROI, Université de La Réunion, 2 Rue Maxime Rivière, 97490, Sainte Clotilde, France.,Departments of Medicine, Centre for Heart Lung Innovation, Providence Healthcare Research Institute, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
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Abstract
Apolipoprotein E (apoE) is a major apolipoprotein involved in lipoprotein metabolism. It is a polymorphic protein and different isoforms are associated with variations in lipid and lipoprotein levels and thus cardiovascular risk. The isoform apoE4 is associated with an increase in LDL-cholesterol levels and thus a higher cardiovascular risk compared to apoE3. Whereas, apoE2 is associated with a mild decrease in LDL-cholesterol levels. In the presence of other risk factors, apoE2 homozygotes could develop type III hyperlipoproteinemia (familial dysbetalipoproteinemia or FD), an atherogenic disorder characterized by an accumulation of remnants of triglyceride-rich lipoproteins. Several rare APOE gene variants were reported in different types of dyslipidemias including FD, familial combined hyperlipidemia (FCH), lipoprotein glomerulopathy and bona fide autosomal dominant hypercholesterolemia (ADH). ADH is characterized by elevated LDL-cholesterol levels leading to coronary heart disease, and due to molecular alterations in three main genes: LDLR, APOB and PCSK9. The identification of the APOE-p.Leu167del variant as the causative molecular element in two different ADH families, paved the way to considering APOE as a candidate gene for ADH. Due to non mendelian interacting factors, common genetic and environmental factors and perhaps epigenetics, clinical presentation of lipid disorders associated with APOE variants often strongly overlap. More studies are needed to determine the spectrum of APOE implication in each of the diseases, notably ADH, in order to improve clinical and genetic diagnosis, prognosis and patient management. The purpose of this review is to comment on these APOE variants and on the molecular and clinical overlaps between dyslipidemias.
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Affiliation(s)
- Yara Abou Khalil
- Laboratory for Vascular Translational Science (LVTS), INSERM U1148, Centre Hospitalo-Universitaire Xavier Bichat, Paris, France; Université de Paris, Paris, France; Laboratory of Biochemistry and Molecular Therapeutics (LBTM), Faculty of Pharmacy, Pôle Technologie- Santé (PTS), Saint-Joseph University, Beirut, Lebanon
| | - Jean-Pierre Rabès
- Laboratory for Vascular Translational Science (LVTS), INSERM U1148, Centre Hospitalo-Universitaire Xavier Bichat, Paris, France; Laboratory of Biochemistry and Molecular Genetics, Centre Hospitalo-Universitaire Ambroise Paré, HUPIFO, AP-HP. Paris-Saclay, Boulogne-Billancourt, France; UFR Simone Veil-Santé, UVSQ, Montigny-Le-Bretonneux, France
| | - Catherine Boileau
- Laboratory for Vascular Translational Science (LVTS), INSERM U1148, Centre Hospitalo-Universitaire Xavier Bichat, Paris, France; Université de Paris, Paris, France; Genetics Department, AP-HP, CHU Xavier Bichat, Paris, France
| | - Mathilde Varret
- Laboratory for Vascular Translational Science (LVTS), INSERM U1148, Centre Hospitalo-Universitaire Xavier Bichat, Paris, France; Université de Paris, Paris, France.
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Seedat F, Patel M, Phillip V, Mohamed F, Marais AD, Blackhurst DM, Solomon G, Currin S, Raal FJ. Hyperlipidemic myeloma, a rare form of acquired dysbetalipoproteinemia, in an HIV seropositive African female. Clin Chim Acta 2021; 520:71-75. [PMID: 34052205 DOI: 10.1016/j.cca.2021.05.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 11/16/2022]
Abstract
Dysbetalipoproteinemia (DBL) is an uncommon condition characterized by a mixed hyperlipidemia due to accumulation of remnant lipoproteins and is highly atherogenic. Typically, DBL is an autosomal recessive condition requiring an additional metabolic stress with reduced apolipoprotein E (apoE) function. However, DBL is also described in patients with multiple myeloma without the characteristic apoE2/E2 mutation seen in familial DBL. Although the underlying pathogenesis in these cases is not fully characterized, it is thought to occur due to interference with apoE function by antibodies produced from clonal plasma cells. Such cases are referred to as hyperlipidemic myeloma (HLM) and have rarely been described in the literature. To our knowledge there is no prior description of HLM in HIV positive patients in Africa. We describe a case of HLM in an African woman with underlying HIV infection who presented with phenotypic and biochemical features of DBL that responded poorly to lipid lowering therapy.
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Affiliation(s)
- Faheem Seedat
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Moosa Patel
- Division of Clinical Hematology, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Vinitha Phillip
- Division of Clinical Hematology, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Farzahna Mohamed
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - A David Marais
- Division of Chemical Pathology, University of Cape Town Health Science Faculty, Cape Town, South Africa
| | - Dee M Blackhurst
- Division of Chemical Pathology, University of Cape Town Health Science Faculty, Cape Town, South Africa
| | - Gabriele Solomon
- Division of Chemical Pathology, University of Cape Town Health Science Faculty, Cape Town, South Africa
| | - Sean Currin
- Department of Chemical Pathology, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | - Frederick J Raal
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Abstract
PURPOSE OF REVIEW The functions, genetic variations and impact of apolipoprotein E on lipoprotein metabolism in general are placed in the context of clinical practice dealing with moderate dyslipidaemia as well as dysbetalipoproteinemia, a highly atherogenic disorder and lipoprotein glomerulopathy. RECENT FINDINGS Additional variants of apolipoprotein E and participation of apolipoprotein E in inflammation are of interest. The mostly favourable effects of apolipoprotein E2 as well as the atherogenic nature of apolipoproteinE4, which has an association with cognitive impairment, are confirmed. The contribution of remnant lipoproteins of triglyceride-rich lipoproteins, of which dysbetalipoproteinemia represents an extreme, is explored in atherosclerosis. Mimetic peptides may present new therapeutic approaches. Apolipoprotein E is an important determinant of the lipid profile and cardiovascular health in the population at large and can precipitate dysbetalipoproteinemia and glomerulopathy. Awareness of apolipoprotein E polymorphisms should improve medical care.
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Goldberg IJ, Ibrahim N, Bredefeld C, Foo S, Lim V, Gutman D, Huggins LA, Hegele RA. Ketogenic diets, not for everyone. J Clin Lipidol 2021; 15:61-67. [PMID: 33191194 PMCID: PMC7887024 DOI: 10.1016/j.jacl.2020.10.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND The adoption of low-carbohydrate diets can lead to weight loss in many patients. However, these now widespread diets also have the potential to exacerbate hypercholesterolemia. OBJECTIVE The objective of this study is to display the potentially harmful effects of the ketogenic diet on cholesterol levels in patients with or without underlying hyperlipidemia. METHODS We describe 5 patients who developed marked increases in plasma cholesterol on ketogenic diets and assessed whether they had a well-described underlying genetic hyperlipidemia. RESULTS Three out of 5 patients had extraordinary increases of blood cholesterol levels to over 500 mg/dL. The other 2 patients more than doubled their low-density lipoprotein cholesterol levels on a ketogenic diet. One patient had an APOE E2/E2 genotype. A higher burden of common genetic polymorphisms was found in 2 patients, with no major mutations found. No potential genetic cause was seen in a fourth patient, and the fifth patient had no genetic testing. Three patients, including the one who was most hypercholesterolemic, had a marked reduction in cholesterol after reverting to a more liberal diet. One refused to change his diet but had a satisfactory low-density lipoprotein cholesterol reduction on ezetimibe. CONCLUSION These cases should serve as a caution that high-fat low-carbohydrate diets have the potential to exacerbate or cause hypercholesterolemia in patients with or without underlying genetic hyperlipidemia.
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Affiliation(s)
- Ira J Goldberg
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Medical Center, New York, NY, USA.
| | - Nouran Ibrahim
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Medical Center, New York, NY, USA
| | - Cindy Bredefeld
- Winthrop Endocrinology, Diabetes and Metabolism, NYU Long Island School of Medicine, Mineola, NY, USA
| | - Sandra Foo
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Medical Center, New York, NY, USA
| | - Vivien Lim
- Queens Cardiovascular and Division of Cardiology, Long Island Jewish Hospital, Flushing, NY, USA
| | - Deborah Gutman
- Department of Emergency Medicine, Warren Alpert School of Medicine, Providence, RI, USA
| | - Lesley-Ann Huggins
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Medical Center, New York, NY, USA
| | - Robert A Hegele
- Departments of Medicine and Biochemistry, Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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Paquette M, Bernard S, Paré G, Baass A. Triglycerides, hypertension, and smoking predict cardiovascular disease in dysbetalipoproteinemia. J Clin Lipidol 2019; 14:46-52. [PMID: 31959563 DOI: 10.1016/j.jacl.2019.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 12/18/2019] [Accepted: 12/18/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND Dysbetalipoproteinemia (DBL) is an autosomal recessive lipid disorder associated with a reduced clearance of remnant lipoproteins and is associated with an increased cardiovascular disease (CVD) risk. The genetic cause of DBL is apoE2 homozygosity in 90% of cases. However, a second metabolic hit must be present to precipitate the disease. However, no study has investigated the predictors of CVD, peripheral artery disease and coronary artery disease in a large cohort of patients with DBL. OBJECTIVE The objectives of this study were to describe the clinical characteristics of a DBL cohort and to identify the predictors of CVD, peripheral artery disease, and coronary artery disease in this population. METHODS The inclusion criteria included age ≥ 18 years, apoE2/E2, triglycerides (TG) > 135 mg/dL and VLDL-C/plasma TG ratio > 0.30. RESULTS We studied 221 adult DBL patients, of which 51 (23%) had a history of CVD. We identified 3 independent predictors of CVD, namely hypertension (OR 5.68, 95% CI 2.13-15.16, P = .001), pack year of smoking (OR 1.03, 95% CI 1.01-1.05, P = .01) and TG tertile (OR 1.82, 95% CI 1.09-3.05, P = .02). The CVD prevalence was 51% in patients with hypertension and 18% in those without hypertension (P = .00001), and 30% in the highest TG tertile vs 15% in the lowest tertile (P = .04). Similarly, the CVD prevalence was higher in heavy smokers compared with nonsmokers (36% vs 13%, P = .006). CONCLUSION Hypertension, smoking, and TG are independently associated with CVD risk in patients with DBL. Aggressive treatment should be initiated in patients with DBL because of the increased risk of CVD.
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Affiliation(s)
- Martine Paquette
- Lipids, Nutrition and Cardiovascular Prevention Clinic of the Montreal Clinical Research Institute, Québec, Canada
| | - Sophie Bernard
- Lipids, Nutrition and Cardiovascular Prevention Clinic of the Montreal Clinical Research Institute, Québec, Canada; Division of Endocrinology, Department of Medicine, Université de Montreal, Québec, Canada
| | - Guillaume Paré
- Genetic Molecular Epidemiology Lab, Population Health Research Institute, Ontario, Canada
| | - Alexis Baass
- Lipids, Nutrition and Cardiovascular Prevention Clinic of the Montreal Clinical Research Institute, Québec, Canada; Divisions of Experimental Medicine and Medical Biochemistry, Department of Medicine, McGill University, Québec, Canada.
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Abstract
Familial type III hyperlipoproteinemia (HLP) was first recognized as a distinct entity over 60 years ago. Since then, it has proven to be instructive in identifying the key role of apolipoprotein E (apoE) in removal of the remnants of very low density lipoproteins and chylomicrons produced by the action of lipoprotein lipase on these triglyceride-transporting lipoproteins. It has additionally shed light on the potent atherogenicity of the remnant lipoproteins. This review describes the history of development of our understanding of type III HLP, discusses the several genetic variants of apoE that play roles in the genesis of type III HLP, and describes the remarkable responsiveness of this fascinating disorder to lifestyle modification, especially carbohydrate restriction and calorie restriction, and, when required, the addition of pharmacotherapy.
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Affiliation(s)
- Conrad B Blum
- Columbia University College of Physicians and Surgeons, New York, NY 10019, USA.
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Kei A, Miltiadous G, Bairaktari E, Hadjivassiliou M, Cariolou M, Elisaf M. Dysbetalipoproteinemia: Two cases report and a diagnostic algorithm. World J Clin Cases 2015; 3:371-376. [PMID: 25879010 PMCID: PMC4391008 DOI: 10.12998/wjcc.v3.i4.371] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 12/14/2014] [Accepted: 01/20/2015] [Indexed: 02/05/2023] Open
Abstract
Dysbetalipoproteinemia is a rare familial dyslipidemia characterized by approximately equally elevated serum cholesterol and triglyceride levels due to accumulated remnant lipoproteins in apolipoprotein E2/E2 homozygotes. It is associated with an increased risk for premature cardiovascular disease. Thus, making a diagnosis of dysbetalipoproteinemia aids in assessing cardiovascular risk correctly and allows for genetic counseling. However, the diagnostic work-up can be challenging. Diagnosis of dysbetalipoproteinemia should be considered in patients mixed dyslipidemia when the apolipoprotein B concentration is relatively low in relation to the total cholesterol concentration or when there is significant disparity between the calculated low density lipoprotein (LDL) and directly measured LDL cholesterol concentrations. Other indices are also informative in the diagnostic process. We present herein two phenotypically different cases (a 44-year-old man with severe hypertriglyceridemia and a 49-year-old woman with mixed dyslipidemia) of genotypically proven familial dysbetalipoproteinemia and a diagnostic algorithm of the disease.
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