Hypobetalipoproteinemia: Difference between revisions

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|Age of Presentation
|Age of Presentation
|Infancy
|[[Infancy]]
|Asymptomatic
|Asymptomatic
|2months to 1 year
|2 months to 1 year
|Asymptomatic
|Asymptomatic
|-
|-
|History and Symptoms
|History and Symptoms
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*Similar to abetalipoproteinemia.
*Similar to [[abetalipoproteinemia]]
*Steatorrhea, failure to thrive.
*[[Steatorrhea]], [[failure to thrive]]
*Without vitamin E replacement symptoms progress and include reduced visual acuity, ataxia, dysarthria, loss of vibration and proprioception and areflexia as the posterior columns are affected.
*Without [[vitamin E]] replacement symptoms progress and include reduced [[visual acuity]], [[ataxia]], [[dysarthria]], [[loss of vibration]] and [[proprioception]] and [[areflexia]] as the [[posterior columns]] are affected
|
|
*Patients are asymptomatic, malabsorption can occur in patients with short trucated apo B forming mutations.<ref name="pmid11590210">{{cite journal| author=Tarugi P, Lonardo A, Gabelli C, Sala F, Ballarini G, Cortella I et al.| title=Phenotypic expression of familial hypobetalipoproteinemia in three kindreds with mutations of apolipoprotein B gene. | journal=J Lipid Res | year= 2001 | volume= 42 | issue= 10 | pages= 1552-61 | pmid=11590210 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11590210  }} </ref>  
*Patients are asymptomatic, [[malabsorption]] can occur in patients with short trucated [[apolipoprotein B]] forming mutations<ref name="pmid11590210">{{cite journal| author=Tarugi P, Lonardo A, Gabelli C, Sala F, Ballarini G, Cortella I et al.| title=Phenotypic expression of familial hypobetalipoproteinemia in three kindreds with mutations of apolipoprotein B gene. | journal=J Lipid Res | year= 2001 | volume= 42 | issue= 10 | pages= 1552-61 | pmid=11590210 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11590210  }} </ref>  
*Common feature is hepatic steatosis.<ref name="pmid14967820">{{cite journal| author=Tanoli T, Yue P, Yablonskiy D, Schonfeld G| title=Fatty liver in familial hypobetalipoproteinemia: roles of the APOB defects, intra-abdominal adipose tissue, and insulin sensitivity. | journal=J Lipid Res | year= 2004 | volume= 45 | issue= 5 | pages= 941-7 | pmid=14967820 | doi=10.1194/jlr.M300508-JLR200 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14967820  }} </ref>
*Common feature is [[hepatic steatosis]]<ref name="pmid14967820">{{cite journal| author=Tanoli T, Yue P, Yablonskiy D, Schonfeld G| title=Fatty liver in familial hypobetalipoproteinemia: roles of the APOB defects, intra-abdominal adipose tissue, and insulin sensitivity. | journal=J Lipid Res | year= 2004 | volume= 45 | issue= 5 | pages= 941-7 | pmid=14967820 | doi=10.1194/jlr.M300508-JLR200 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14967820  }} </ref>
|
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*Diarrhea, steatorrhea, abdominal distention, and failure to thrive, neurological symptoms manifest if vitamin E supplementation is not initiated.<ref name="pmid19285442">{{cite journal| author=Peretti N, Roy CC, Sassolas A, Deslandres C, Drouin E, Rasquin A et al.| title=Chylomicron retention disease: a long term study of two cohorts. | journal=Mol Genet Metab | year= 2009 | volume= 97 | issue= 2 | pages= 136-42 | pmid=19285442 | doi=10.1016/j.ymgme.2009.02.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19285442  }} </ref><ref name="pmid20920215">{{cite journal| author=Peretti N, Sassolas A, Roy CC, Deslandres C, Charcosset M, Castagnetti J et al.| title=Guidelines for the diagnosis and management of chylomicron retention disease based on a review of the literature and the experience of two centers. | journal=Orphanet J Rare Dis | year= 2010 | volume= 5 | issue=  | pages= 24 | pmid=20920215 | doi=10.1186/1750-1172-5-24 | pmc=2956717 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20920215  }} </ref>
*[[Diarrhea]], [[steatorrhea]], [[abdominal distention]], and [[failure to thrive]], neurological symptoms manifest if [[vitamin E]] supplementation is not initiated.<ref name="pmid19285442">{{cite journal| author=Peretti N, Roy CC, Sassolas A, Deslandres C, Drouin E, Rasquin A et al.| title=Chylomicron retention disease: a long term study of two cohorts. | journal=Mol Genet Metab | year= 2009 | volume= 97 | issue= 2 | pages= 136-42 | pmid=19285442 | doi=10.1016/j.ymgme.2009.02.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19285442  }} </ref><ref name="pmid20920215">{{cite journal| author=Peretti N, Sassolas A, Roy CC, Deslandres C, Charcosset M, Castagnetti J et al.| title=Guidelines for the diagnosis and management of chylomicron retention disease based on a review of the literature and the experience of two centers. | journal=Orphanet J Rare Dis | year= 2010 | volume= 5 | issue=  | pages= 24 | pmid=20920215 | doi=10.1186/1750-1172-5-24 | pmc=2956717 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20920215  }} </ref>
*Essential fatty acid deficiency.
*Essential fatty acid deficiency.
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|
Line 253: Line 253:
|Physical Examination
|Physical Examination
|
|
*Growth Retardation
*[[Growth Retardation]]
*Malnutrition
*[[Malnutrition]]
 
*[[Retinal degeneration]] changes
*Retinal degeneration changes
*[[Hepatomegaly]]
 
*[[Truncal Ataxia]]
*Hepatomegaly
*[[Muscle weakness]] and [[atrophy]]
 
*Diminished [[deep tendon reflexes]]
*Truncal Ataxia
*Loss of [[vibration sense]] and [[proprioception]]
 
|[[Hepatomegaly]]
*Muscle weakness and atrophy
 
*Diminished deep tendon reflexes
 
*Loss of vibration sense and proprioception
|Hepatomegaly
|
|
*Growth Retardation
*[[Growth Retardation]]
*Malnutrition
*[[Malnutrition]]
 
*[[Retinal degeneration]] changes
*Retinal degeneration changes
*[[Hepatomegaly]]
 
*[[Truncal Ataxia]]
*Hepatomegaly
*[[Muscle weakness]] and [[atrophy]]
 
*Diminished [[deep tendon reflexes]]
*Truncal Ataxia
*Loss of [[vibration sense]] and [[proprioception]]
 
*Muscle weakness and atrophy
 
*Diminished deep tendon reflexes
 
*Loss of vibration sense and proprioception


|Normal Physical Exam
|Normal Physical Exam

Revision as of 16:48, 29 March 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2]

Synonyms and keywords: Familial hypobetalipoproteinemia, FHBL, normotriglyceridemic hypobetalipoproteinemia

Overview

These are a set of diseases caused my mutations in genes involved in triglyceride(TG), cholesterol transport and metabolism. These diseases primarily cause low plasma LDL C and triglyceride levels less than in the 5th percentile of normal population. Clinical manifestations can vary from being completely asymptomatic to multiple features of vitamin deficiencies, and fat malabsorption. Clinical symptoms of vitamin E are seen early in the course of the disease as the amount of vitamin E is parallel to the total lipid level in the body. Failure to diagnose and to initiate timely vitamin supplementation results in the development of neurological symptoms. The mutations causing low LDL levels are widely studied as newer lipid lowering therapies are based on similar mechanisms of these diseases.

Historical Perspective

Pathophysiology

Pathogenesis

Hypobetalipoproteinemias are caused by mutations in the genes involved in triglyceride transport and metabolism.


 
 
 
APOB gene is responsible for the production of Apo B48 in intestine which is critical for the formation and secretion of chylomicrons[7] , and Apo B100 in the liver which is released into circulation as VLDL
 
Mutation in the APOB gene affects the translation of mRNA of apolipoprotein B causing familial hypobetalipoproteinemia. The severity of clinical phenotype in familial hypobetalipoproteinemia depends on length of trucated Apo B and zygosity.[8].
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
MTP transfers triglycerides from cytsol onto nacent apolipoprotein B in endoplasmic reticulum which is required for assembly and secretion of VLDL and chylomicrons. Mutation in MTP causes abetalipoproteinemia[9].
 
In Apo B48 associated chylomicrons, transport of proteins from endoplasmic reticulum to golgi complex is dependent on coat protien complex 2(COP II), secretion-associated, Ras-related GTPase 1B (Sar1b) encoded by the gene SAR1B is a major part of the protein essential for this intra cellular transport[10]. Mutation in Sar1b causes chylomicron retention disease[4].
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
In the periphery by the action of lipoprotein lipase in the endothelium of the capillaries and glycosylphosphatidylinositol-anchored high-density lipoprotein- binding protein 1 (GPIHBP1)[11], a transporter for lipoprotien lipase, triglycerides are hydrolysed to form free fatty acids and glycerol
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
This results in the formation of VLDL remnant(Intermediate density lipoprotein) and chylomicron remnants. The lipases are inhibited by Angiopoietin-like protein 3 (ANGPTL3) thereby decreasing the triglyceride and LDL C[12].[13]
 
Loss of function mutations or complete absence of ANGPTL3 gene cause familial combined hypolipidemia [14][15] .
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IDL on further removal of triglycerides forms a cholesterol ester rich LDL C. The chylomicron and VLDL remnants removal is apolipoprotein E dependent via the LDL receptors and LDL receptor related protiens[16]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
LDL C is removed from the circulation by binding to LDL receptors in the liver. The receptor degradation is enhanced by Proprotein convertase subtilisin kexin 9 (PCSK9)[17].
 
Mutation causing loss of function of the enzyme causes low LDL C levels, and gain of function mutations are associated with familial hypercholesterolemia[18].
 
 

Genetics

The genetic defect, transmission and the result of the mutation in various diseases is described below:

Homozygous familial

hypobetalipoproteinemia(FHBL)

Heterozygous familial

hypobetalipoprotienemia

Chylomicron Retention

Disease

Familial Combined

Hypolipidemia

Inheritance Autosomal codominant Autosomal codominant Autosomal recessive Autosomal codominant
Defective Gene APOB gene on chromosome locus 2p23-24 APOB gene SAR1B gene on chromosome 5q31 ANGPTL3 gene on chromosome 1[19]
Pathophysiology Absence of apolipoprotein B results in absent plasma VLDL, triglyceride and LDL C Intracellular transport of chylomicrons is affected ,resulting in the accumulation of lipids in the cells of the intestine and liver.[20] Loss of function mutation results in the failure of inhibition of Lipoprotien lipase, leading to low LDL, VLDL and HDL levels.

Causes

The following are the list of causes and lipid levels for primary hypobetalipoproteinemia:

  • Abetalipoproteinemia
  • Familial hypobetalipoproteinemia
  • Chylomicron Retention Disease
  • PCSK9 deficiency
  • Familial Combined Hypolipidemia
Abetalipoprotienemia Familial Homozygous

Hypobetalipoproteinemia

Familial Heterozygous

Hypobetalipoproteinemia

PCSK9 deficiency Chylomicron Retention

Disease

Familial Combined

Hypolipidemia

LDL C ↓↓↓ (0) ↓↓↓ ↓↓ ↓↓
Apo B ↓↓↓( 0) ↓↓↓ N ↓↓ N
TG ↓↓↓ ↓↓↓ N
TC ↓↓↓ ↓↓↓ ↓↓
HDL ↓↓ ↓↓ N N ↓↓ ↓↓
VLDL ↓↓ ↓↓ N ↓↓
Apo A1 ↓↓ ↓↓ N ↓↓ N

Epidemiology and Demographics

The prevalence of these diseases is as follows[23]:

Prevalence
Abetalipoproteinemia <1:1,000,000
Familial

Hypobetalipoproteinemia

1:1000 – 1:3000
Chylomicron Retention

Disease

Very rare
Familial Combined

Hypolipidemia

Very rare
PCSK9 Deficiency Very rare

Natural History, complications and Prognosis

Homozygous Familial Hypobetalipoproteinemia Heterozygous Familial Hypobetalipoproteinemia Chylomicron Retention Disease Familial Combined Hypolipidemia
Disease Course Steatorrhea early in infancy and progression to neurological symptoms which begin in the 1st or 2nd decade. Usually benign, few patients may present with steatorrhea. Early onset of symptoms with diarrhea and failure to thrive. Benign
Complications Neurologic degeneration, Anemia, Blindness None
Prognosis A familial syndrome of longevity has been observed in the benign forms of HBL and many patients live over the age of 85.[27] Poorly documented evidence on prognosis.[28] Good

Diagnosis

History, Symptoms and Physical Examination

Hypobetalipoproteinemias present with varying severity of similar symptoms based on the type of mutation as follows:

Homozygous Familial

Hypobetalipoproteinemia

Heterozygous Familial

Hypobetalipoproteinemia

Chylomicron Retention

Disease

Familial Combined

Hypolipidemia

Age of Presentation Infancy Asymptomatic 2 months to 1 year Asymptomatic
History and Symptoms
Physical Examination Hepatomegaly Normal Physical Exam

Laboratory Results

Laboratory findings consistent with the diagnosis of hypobetalipoproteinemias include as follows:

Homozygous Familial

Hypobetalipoproteinemia

Heterozygous Familial

Hypobetalipoproteinemia

Chylomicron Retention

Disease

Familial Combined

Hypolipidemia

Lipid analysis
  • ApoB <5th percentile
  • LDL-C between 20- 50 mg/dL[33]
  • LDL C is one third of normal value and not 50% of expected for age and sex.
  • Due to decreased production and increased catabolism of VLDL apo B-100.[34] This causes decreased secretion of triglycerides and low LDL C levels.[35]
  • LDL and HDL 50% of normal[36]
  • Normal TG levels is the characteristic laboratory finding.
  • Homozygotes and compound heterozygotes show panhypolipidemia with LDL low TG and reduced HDL C.[37]
  • Heterozygotes  : Normal HDL, with LDL <25th percentile.[21]
Other findings
  • Low liposoluble vitamin level.
  • Mild elevation of LFTs
  • Acanthocytosis
  • Mild elevation of LFTs
  • Failure of chylomicron secretion after a lipid rich meal.
  • Low liposoluble vitamin level.
  • Endoscopy shows a typical white stippling.
  • The enterocytes on biopsy show accumulations of large lipid droplets free in the cytoplasm as well as membrane-bound lipoprotein-sized structures.[38]
  • Mild elevation of liver transaminases.[39]
  • Elevated Creatine Kinase
  • None
  • Definitive gold standard for diagnosis is gene sequencing for APOB, MTTP, SAR1B, ANGPTL3 to see the exact mutation.

Approach to patient with Low LDL C

 
 
 
 
 
Low LDL C <5th percentile
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rule out secondary causes of low LDL
Anemia
Criticial illness
Chronic inflammation
Chronic liver disease
Hyperthyroidism
Infection
Malabsorption
Malignancy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Once secondary causes are ruled out consider primary diseases based on analysis of Lipid panel
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal Triglycerides
 
 
 
 
Low Triglycerides
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chlyomicron retention disease
(Confirm with gene sequencing)
 
 
 
 
Screen the lipid panel of the patient's parents
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal Parental Lipid Panel
 
 
If Parental Lipid Panel <50% of Normal on:
*LDL
*Total Cholesterol
*Triglycerides
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abetalipoproteinemia
(Confirm with gene sequencing)
 
 
Familial Homozygous hypobetalipoproteinemia
(Confirm with gene sequencing)

Treatment

Medical Therapy

  • The mainstay of management of FHBL include early diagnosis and early initiation of low fat diet and fat soluble vitamin supplementation in all symptomatic patients, with yearly follow up to assess the growth and nutritional status, diet compliance, neurological function, lipid panel.
  • FHBL heterozygous patients with elevated liver enzyme, regular ultrasound imaging is recommended to monitor for progression of fatty liver to cirrhosis or hepatocellular carcinoma.[40]

Chylomicron Retention Disease Management

  • If the patient is diagnosed early in the course of the disease diet modification and oral supplementation of vitamins improved outcomes.[32]
    • Low-fat diet.
    • Vegetable oil enriched in essential fatty acids ± Enriched in medium-chain triglycerides.
    • Vitamin E (hydrosoluble form): 50 IU/kg/d.
    • Vitamin A: 15,000 IU/d (adjust according to plasma levels).
    • Vitamin D: 800-1200 IU/kg/d or 100,000 IU/2 month if < 5 y old, and 600,000 IU/2 month if > 5 y old.
    • Vitamin K: 15 mg/week (adjust according to INR and plasma levels).
  • If patient is diagnosed late and with neurological disease, combined oral and parental supplementation is recommended:
    • Fatty acids-intralipid 20%2g/kg/month
    • Vitamin E 4 to 6 mg/kg/month
    • Vitamin A 500 IU/kg/month once a month is recommended
Follow up
  • Annual follow up to 10years to assess the growth and nutritional status, diet compliance, neurological function, lipid panel.
  • Every 3year follow up to check bone mineral density, liver function with ultrasound, ophthalmologic exam for fundus, color vision, visual evoked potentials and electroretinography after the age of 10years.
  • Echocardiography in adulthood.

Surgical Therapy

  • No surgical options are available.

Prevention

Primary Prevention

  • As the set of the diseases are rare there are no primary preventive measures.

Secondary Prevention

  • Regular follow up to look for complications and strict adherence to therapy has shown to prevent progression of the disease.

References

  1. SALT HB, WOLFF OH, LLOYD JK, FOSBROOKE AS, CAMERON AH, HUBBLE DV (1960). "On having no beta-lipoprotein. A syndrome comprising a-beta-lipoproteinaemia, acanthocytosis, and steatorrhoea". Lancet. 2 (7146): 325–9. PMID 13745738.
  2. ANDERSON CM, TOWNLEY RR, JOHANSEN P (1961). "Unusual causes of steatorrhoea in infancy and childhood". Med J Aust. 48(2): 617–22. PMID 13861205.
  3. Roy CC, Levy E, Green PH, Sniderman A, Letarte J, Buts JP; et al. (1987). "Malabsorption, hypocholesterolemia, and fat-filled enterocytes with increased intestinal apoprotein B. Chylomicron retention disease". Gastroenterology. 92 (2): 390–9. PMID 3792776.
  4. 4.0 4.1 Jones B, Jones EL, Bonney SA, Patel HN, Mensenkamp AR, Eichenbaum-Voline S; et al. (2003). "Mutations in a Sar1 GTPase of COPII vesicles are associated with lipid absorption disorders". Nat Genet. 34 (1): 29–31. doi:10.1038/ng1145. PMID 12692552.
  5. Conklin D, Gilbertson D, Taft DW, Maurer MF, Whitmore TE, Smith DL; et al. (1999). "Identification of a mammalian angiopoietin-related protein expressed specifically in liver". Genomics. 62 (3): 477–82. doi:10.1006/geno.1999.6041. PMID 10644446.
  6. Arca M, Minicocci I, Maranghi M (2013). "The angiopoietin-like protein 3: a hepatokine with expanding role in metabolism". Curr Opin Lipidol. 24 (4): 313–20. doi:10.1097/MOL.0b013e3283630cf0. PMID 23839332.
  7. Dash S, Xiao C, Morgantini C, Lewis GF (2015). "New Insights into the Regulation of Chylomicron Production". Annu Rev Nutr. 35: 265–94. doi:10.1146/annurev-nutr-071714-034338. PMID 25974693.
  8. Di Leo E, Eminoglu T, Magnolo L, Bolkent MG, Tümer L, Okur I; et al. (2015). "The Janus-faced manifestations of homozygous familial hypobetalipoproteinemia due to apolipoprotein B truncations". J Clin Lipidol. 9 (3): 400–5. doi:10.1016/j.jacl.2015.01.005. PMID 26073401.
  9. Berriot-Varoqueaux N, Aggerbeck LP, Samson-Bouma M, Wetterau JR (2000). "The role of the microsomal triglygeride transfer protein in abetalipoproteinemia". Annu Rev Nutr. 20: 663–97. doi:10.1146/annurev.nutr.20.1.663. PMID 10940349.
  10. Shoulders CC, Stephens DJ, Jones B (2004). "The intracellular transport of chylomicrons requires the small GTPase, Sar1b". Curr Opin Lipidol. 15 (2): 191–7. PMID 15017362.
  11. Young SG, Davies BS, Voss CV, Gin P, Weinstein MM, Tontonoz P; et al. (2011). "GPIHBP1, an endothelial cell transporter for lipoprotein lipase". J Lipid Res. 52 (11): 1869–84. doi:10.1194/jlr.R018689. PMC 3196223. PMID 21844202.
  12. Shan L, Yu XC, Liu Z, Hu Y, Sturgis LT, Miranda ML; et al. (2009). "The angiopoietin-like proteins ANGPTL3 and ANGPTL4 inhibit lipoprotein lipase activity through distinct mechanisms". J Biol Chem. 284 (3): 1419–24. doi:10.1074/jbc.M808477200. PMC 3769808. PMID 19028676.
  13. Yoshida K, Shimizugawa T, Ono M, Furukawa H (2002). "Angiopoietin-like protein 4 is a potent hyperlipidemia-inducing factor in mice and inhibitor of lipoprotein lipase". J Lipid Res. 43 (11): 1770–2. PMID 12401877.
  14. Romeo S, Yin W, Kozlitina J, Pennacchio LA, Boerwinkle E, Hobbs HH; et al. (2009). "Rare loss-of-function mutations in ANGPTL family members contribute to plasma triglyceride levels in humans". J Clin Invest. 119 (1): 70–9. doi:10.1172/JCI37118. PMC 2613476. PMID 19075393.
  15. 15.0 15.1 Robciuc MR, Maranghi M, Lahikainen A, Rader D, Bensadoun A, Öörni K; et al. (2013). "Angptl3 deficiency is associated with increased insulin sensitivity, lipoprotein lipase activity, and decreased serum free fatty acids". Arterioscler Thromb Vasc Biol. 33 (7): 1706–13. doi:10.1161/ATVBAHA.113.301397. PMID 23661675.
  16. Lillis AP, Van Duyn LB, Murphy-Ullrich JE, Strickland DK (2008). "LDL receptor-related protein 1: unique tissue-specific functions revealed by selective gene knockout studies". Physiol Rev. 88 (3): 887–918. doi:10.1152/physrev.00033.2007. PMC 2744109. PMID 18626063.
  17. Garvie CW, Fraley CV, Elowe NH, Culyba EK, Lemke CT, Hubbard BK; et al. (2016). "Point mutations at the catalytic site of PCSK9 inhibit folding, autoprocessing, and interaction with the LDL receptor". Protein Sci. 25 (11): 2018–2027. doi:10.1002/pro.3019. PMC 5079255. PMID 27534510.
  18. Marais AD, Kim JB, Wasserman SM, Lambert G (2015). "PCSK9 inhibition in LDL cholesterol reduction: genetics and therapeutic implications of very low plasma lipoprotein levels". Pharmacol Ther. 145: 58–66. doi:10.1016/j.pharmthera.2014.07.004. PMID 25046268.
  19. Fazio S, Sidoli A, Vivenzio A, Maietta A, Giampaoli S, Menotti A; et al. (1991). "A form of familial hypobetalipoproteinaemia not due to a mutation in the apolipoprotein B gene". J Intern Med. 229 (1): 41–7. PMID 1995762.
  20. Charcosset M, Sassolas A, Peretti N, Roy CC, Deslandres C, Sinnett D; et al. (2008). "Anderson or chylomicron retention disease: molecular impact of five mutations in the SAR1B gene on the structure and the functionality of Sar1b protein". Mol Genet Metab. 93 (1): 74–84. doi:10.1016/j.ymgme.2007.08.120. PMID 17945526.
  21. 21.0 21.1 21.2 Minicocci I, Montali A, Robciuc MR, Quagliarini F, Censi V, Labbadia G; et al. (2012). "Mutations in the ANGPTL3 gene and familial combined hypolipidemia: a clinical and biochemical characterization". J Clin Endocrinol Metab. 97 (7): E1266–75. doi:10.1210/jc.2012-1298. PMID 22659251.
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