Familial hypercholesterolemia (FH, OMIM no. 143890) is a common autosomal dominant condition with a prevalence of 1 in 500. Patients with FH have raised serum cholesterol levels and increased arterial deposition of low-density lipoprotein (LDL) cholesterol, leading to premature coronary heart disease. Despite the fact that early-onset coronary heart disease can be prevented by cholesterol-lowering drugs such as statins, less than a quarter of FH patients have currently been identified in the United Kingdom.1 Several diagnostic criteria have been developed to identify individuals with FH, including the Dutch Lipid Clinic 2 criteria and the MedPed 3 criteria. In the United Kingdom, the clinical diagnosis of FH is based on the Simon Broome criteria of cholesterol levels, presence of tendon xanthomata, family history, and genetic testing. 4 The UK National Institute for Health and Clinical Excellence guidelines recommend initial mutation screening of index cases fulfilling Simon Broome criteria followed by cascade screening in at least firstand second-degree relatives.
5Most cases of FH are caused by mutations in the LDLR gene that encodes the LDL receptor protein, which binds LDL particles at the hepatic cell membrane and internalizes them for processing and excretion. FH-causing mutations in LDLR are found throughout the gene and include missense, truncating, and splice site mutations; small insertion/deletion mutations; and large insertions/deletions that can encompass multiple exons. Some mutations have been found in many unrelated individuals with FH, whereas others are found rarely. 6 Mutations in two other genes, PCSK9 and APOB, can also cause the FH phenotype but in <20% of cases.7 Rare autosomal-recessive hypercholesterolemia is caused by mutations in the LDLRAP1 gene.
8Conventional DNA testing of FH disease-causing genes is mostly based on direct capillary sequencing, with multiplex ligation-dependent probe amplification (MLPA) used for the detection of large insertions or deletions.9 These molecular techniques are sensitive and specific, but because of the cost and time involved, they are impractical for screening large numbers of patients. To overcome some of these limitations, assays such as the Amplification Refractory Mutation System (Elucigene FH20; Tepnel Molecular Diagnostics, Abingdon, UK) or arraybased sequencing methods (LIPOchip; Progenika Biopharma, Derio, Spain) have been developed. These assays are tailored to Purpose: Familial hypercholesterolemia is a common Mendelian disorder associated with early-onset coronary heart disease that can be treated by cholesterol-lowering drugs. The majority of cases in the United Kingdom are currently without a molecular diagnosis, which is partly due to the cost and time associated with standard screening techniques. The main purpose of this study was to test the sensitivity and specificity of two next-generation sequencing protocols for genetic diagnosis of familial hypercholesterolemia.
Methods:Libraries were prepared for next-generation sequencing by tw...