Hans Meinertz

Spectrum of LDL receptor gene mutations in Denmark: implications for molecular diagnostic strategy in heterozygous familial hypercholesterolemia

Heterozygous familial hypercholesterolemia (FH) is one of the most common potentially fatal single-gene diseases leading to premature coronary artery disease, but the majority of heterozygous FH patients have not been diagnosed. FH is due to mutations in the gene coding for the low-density lipoprotein (LDL) receptor, and molecular genetic diagnosis may facilitate identification of more FH subjects. The Danish spectrum of 29 different mutations, five of which account for almost half of heterozygous FH, is intermediate between that of countries such as South Africa, where three mutations cause 95% of heterozygous FH in the Afrikaners, and Germany or England, where there are many more mutations. In clinical practice, a strategy for the genetic diagnosis of heterozygous FH, tailored to the mutational spectrum of patients likely to be seen at the particular hospital/region of the country, will be more efficient than screening of the whole LDL receptor gene by techniques such as single-strand conformation polymorphism (SSCP) analysis in every heterozygous FH candidate. In Aarhus, Denmark, we have chosen to examine all heterozygous FH candidates for the five most common LDL receptor gene mutations (W23X, W66G, W556S, 313 + 1G --> A, 1846 - 1G --> A) and the apoB-3500 mutation by rapid restriction fragment analysis. Negative samples are examined for other mutations by SSCP analysis followed by DNA sequencing of the exon indicated by SSCP to contain a mutation. If no point mutation or small insertion/deletion is detected, Southern blot or Long PCR analysis is performed to look for the presence of large gene rearrangements. In conclusion, our data suggest that an efficient molecular diagnostic strategy depends on the composition of common and rare mutations in a population.

Effects of soy protein and casein in low cholesterol diets on plasma lipoproteins in normolipidemic subjects

Dietary plant proteins may lower plasma cholesterol and LDL concentrations in hypercholesterolemic patients when substituted for animal proteins, particularly in diets with low cholesterol and saturated fat content. Plant protein diets appear, however, to be without effect on plasma lipoprotein levels in normal subjects. In the present study, we have examined whether the origin of the dietary protein, i.e. plant (soy) or animal (casein), affects the plasma lipoproteins in normolipidemic subjects when these proteins are presented as components of diets low in cholesterol and saturated fat. The study followed a crossover design. Five men and 5 women consumed liquid formula diets containing 20% of calories as casein or soy protein, 28% as fat (mainly monounsaturated), and 52% as carbohydrate; the intake of cholesterol was less than 100 mg per day. The two dietary periods, each of 1 month duration, were separated by an interim period of 1 month on self-chosen food. Following an initial 30% reduction of cholesterol and LDL plasma levels on both diets, the concentrations of each of the major lipoprotein classes (VLDL, IDL, LDL, HDL2 and HDL3) were similar during the two experimental dietary periods. Body weights were essentially constant. Dietary soy protein and casein could not be distinguished in their effects on the plasma concentrations and chemical composition of the major lipoprotein classes in normolipidemic subjects.

Excessive hypertriglyceridemia and pancreatitis in pregnancy: Association with deficiency of lipoprotein lipase

Acute pancreatitis verified at laparotomy occurred in the 37th week in 1 of 4 women who developed excessive hypertriglyceridemia (type V hyperlipoproteinemia) during pregnancy. The hypertriglyceridemia was associated with and possibly caused by deficiency of lipoprotein lipase, measured as the NaCl sensitive component of post‐heparin lipase activity. A severely fat‐restricted diet controlled the hypertriglyceridemia in 1 of the patients, followed during a second pregnancy.

High-density lipoprotein cholesterol assay by magnesium dextransulphate precipitation

A method for determination of high-density lipoprotein cholesterol (HDL-C) is evaluated: after precipitation of low and very low lipoprotein cholesterol in serum by magnesium dextransulphate, HDL-C is determined by an enzymatic method. The precision of the method was good: coefficient of variation 4%. The accuracy was good, evaluated by correlating HDL-C results from the present assay to the results obtained from three other HDL-C assays (n = 17): ultracentrifugation r = 0.91, phosphotungstate/MgCl2 r = 0.98, and alpha-lipoprotein determination by electrophoresis r = 0.91 (p less than 0.01). Repeated analysis showed that serum may be kept at 4 degrees C for 1 month, at -20 degrees C for 2 months, and requires -80 degrees C for longer storage. Ten patients with acute myocardial infarction showed significantly lower HDL-C from day 4 in the acute phase and during the first 3 months follow up (p less than 0.05). Eighty patients with peripheral vascular disease, who were compared to a group of matched controls, also showed significantly decreased serum HDL-C (p less than 0.01). The present HDL-C assay is easy, fast and reliable and is considered a valuable clinical test.

Phenotypic characterization of a patient homozygous for the D558N LDL receptor gene mutation

We describe the clinical, biochemical, and genetic features of a patient with true homozygous familial hypercholesterolemia due to the D558N low‐density lipoprotein receptor gene mutation, previously designated FH Cincinnati‐4. Functional flow‐cytometric analysis of the LDL receptorR protein on upregulated EB V‐transformed lymphocytes indicated reduction of the number of receptors on the cell surface by 87% and reduction of receptor activity by 89% compared to control cells. With drugs and a portacaval shunt operation, performed when the patient was 15 years old, serum cholesterol was reduced from about 28 to about 15 mmol/l. He died at the age of 32 of a myocardial infarction. The autopsy showed generalized atherosclerosis, especially in the coronary arteries, which were severely stenosed proximally. A rare finding was a large intracranial xanthoma that apparently had been asymptomatic.

The magnitude of metabolically induced changes in the density of human low-density lipoproteins

Radiolabelled low-density lipoproteins (LDL), obtained from a patient with heterozygous, familial hypercholesterolaemia and from a normal subject, were injected into the patient and two normal subjects. Two approaches were made to evaluate the kinetics of metabolism of these LDL: (1) by serial measurements of radioactivity in serum, urine and the whole body; (2) by observing the density of the labelled LDL from serum using density-gradient ultracentrifugation. No significant change was seen in the model density of the LDL in either the patient or the normal subjects, but there were changes in the skewness of the radioactivity peaks. This contrasts with previously published findings in the guinea pig, in which LDL radioactivity gradually accumulated in the densest particles. The guinea pig findings suggested that lipoproteins in the LDL region are structurally modified during their intravascular circulation. The present study indicates that modification leading to changes in density does not occur to any significant degree in the human, whose LDL represent the end product of intravascular metabolism of apolipoprotein B-containing lipoproteins.

Drugs affecting lipid metabolism

Publisher Summary This chapter provides an overview of drugs affecting lipid metabolism. Hypolipidemic drug treatment is generally undertaken to prevent or postpone development of atherosclerosis and its complications. However, the use of lipid-lowering drugs should not be considered until secondary hyperlipidemia has been excluded and it has been determined that the level of atherogenic lipoproteins cannot be adequately controlled by dietary modifications, weight reduction, and restricted alcohol consumption. The benefits to be derived from hypolipidemic drug therapy may be expected to vary both with the cardiovascular condition of the patient and with the initial level of plasma lipoproteins and their response to the treatment. Clofibrate treatment of patients with manifest ischemic heart disease has so far been without convincing benefits in terms of lower mortality or morbidity. On the contrary, evidence has been obtained that clofibrate in these patients may be the cause of serious cardiovascular complications as well as gallstone formation. Whether substantial benefits may be obtained in patients with severe hyperlipidemia who respond well to the drug with pronounced lowering of elevated lipoprotein levels is possible but as yet unproven.