A flow-cytometric method with fluorescence-labeled monoclonal antibodies (MABs) against the low density lipoprotein (LDL) receptor (C7A MAB) or 3,3'-dioctadecylindocarbocyanin-iodide (Dil) LDL has been developed that allows the quantification of LDL receptors on leukocytes and the identification of patients with familial hypercholesterolemia (FH) within 48 hours. Leukocytes were isolated from 10 mL anticoagulated blood by density gradient centrifugation. To induce maximal expression of LDL receptors, mononuclear cells were preincubated with either phytoheraagglutinine (PHA) or iipoprotein-deflcient serum (LPDS). LPDS-treated raonocytes provided a more homogeneous cell population with regard to LDL receptor activity than did the PHA-treated lymphocytes; they also provided a greater discrimination between the fluorescence of the receptor probes and cellular autofluorescence. The C7A MAB was able to compete for Dil LDL binding by about 40%. In competition with unlabeled LDL, Dil LDL revealed linear binding, indicating an affinity similar to native LDL. The binding characteristics of Dil LDL were also similar to IZ5 I-LDL binding. LDL isolated from familial defective apolipoprotein B-100 was not able to compete for Dil LDL binding on monocytes, whereas native LDL reduced it by about 80%. In monocytes from FH heterozygous patients, the cellular mean fluorescence using either C7A MAB or Dil LDL at 4°C was 30% to 70%; in FH homozygotes, cellular mean fluorescence was less than 20% of that in monocytes from normal individuals. In patients with familial defective apolipoprotein B-100 antibody binding was normal, but one patient's own LDL failed to compete with normal Dil LDL for 4°C binding on U937 test monocytes. Patient monocytes having internalization defects showed normal 4°C Dil LDL binding, but at 20°C cell-associated fluorescence was reduced by about 40%. In our study 384 hypercholesterolemic patients (preselected according to serum cholesterol levels, clinical symptoms, and family history) were analyzed for LDL receptor expression using the C7A MAB-based assay. In 71.8% of the patients with cholesterol levels higher than 300 mg/dL, an LDL receptor deficiency was observed. Apolipoprotein E isofonns and lipoprotein [a] were found to be independent from the LDL receptor status. In some patients with high cholesterol levels but normal LDL receptor expression with the C7A MAB assay, LDL receptor defects could be diagnosed when either reduced binding or internalization of Dil LDL or familial defective apolipoprotein B-100 was detected. We conclude that fluorescence flow cytometry provides an appropriate, easily performed assay system for the differential diagnosis of LDL receptor defects, including LDL receptor deficiencies and internalization defects, and also allows the discovery of ligand defects.