Lecithin cholesterol acyltransferase deficiency

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Lecithin cholesterol acyltransferase deficiency
Classification and external resources
Specialty endocrinology
ICD-10 E78.6
ICD-9-CM 272.5
OMIM 245900 136120
DiseasesDB 7343
eMedicine med/1270
MeSH D007863

Lecithin cholesterol acyltransferase deficiency (LCAT deficiency) is a disorder of lipoprotein metabolism.[1] The disease has two forms:[2] Familial LCAT deficiency, in which there is complete LCAT deficiency, and Fish-eye disease, in which there is a partial deficiency.[3]

Lecithin cholesterol acyltransferase catalyzes the formation of cholesterol esters in lipoproteins.

Types[edit]

Both the familial type and Fish-eye disease are autosomal recessive disorders caused by mutations of the LCAT gene located on chromosome 16q22.1, which is the long (q) arm of chromosome 16 a position 22.1.[4] Both diseases are very rare with ~70 reported cases of familial LCAT deficiency[5] and ~30 cases of fish-eye disease.[6]

Signs and symptoms[edit]

Symptoms of the familial form include visual impairment caused by diffuse corneal opacities, target cell hemolytic anemia, and renal failure. Less common symptoms include atherosclerosis, hepatomegaly (enlarged liver), splenomegaly (enlarged spleen), and lymphadenopathy.[7]

Fish-eye disease is less severe and most commonly presents with impaired vision due to corneal opacification. It rarely presents with other findings, although, atherosclerosis, hepatomegaly, splenomegaly, and lymphadenopathy can occur.[7] Carlson and Philipson found that the disease was named so because the cornea of the eye was so opaque or cloudy with dots of cholesterol that it resembled a boiled fish.[8]

If an individual only carry one copy of the mutated gene, they typically do not show symptoms.[9]

Pathophysiology[edit]

A deficiency of LCAT causes accumulation of unesterified cholesterol in certain body tissues. Cholesterol effluxes from cells as free cholesterol and is transported in HDL as esterified cholesterol. LCAT is the enzyme that esterifies the free cholesterol on HDL to cholesterol ester and allows the maturation of HDL. LCAT deficiency does not allow for HDL maturation resulting in its rapid catabolism of circulating apoA-1 and apoA-2. The remaining form of HDL resembles nascent HDL.

The LCAT glycoprotein produces lysophosphatidylcholine and cholesterol ester and binds to lipoproteins after being secreted by the liver.[8] Usually the enzyme produced is responsible for cholesterol ester formation and high density lipoprotein (HDL) metabolism, but in fish-eye disease the enzyme cannot esterify, or make the acid into an alkyl, cholesterol in HDL particles.[4] However, there is only a partial deficiency because the enzyme remains active on the cholesterol particles in very low density lipoproteins (VLDL) and low density lipoproteins (LDL).[4] The opaqueness of the eye is caused by the deposit of lipids onto the cornea.[4]

Diagnosis[edit]

Definitive diagnosis requires LCAT gene analysis for mutation and functional activity. However, numerous lab tests may help with making a diagnosis such as complete blood count (CBC), urinalysis, blood chemistries, lipid panels, and plasma LCAT activity.[10]

Fish-eye disease is characterized by abnormalities like visual impairment, plaques of fatty material, and dense opacification.[8][4]

Familial LCAT Deficiency Lab Findings[edit]

  • CBC: normochromic normocytic anemia
  • Urinalysis: proteinuria in young adults (suggestive of renal failure)
  • Blood Chemistries: elevated blood urea nitrogen (BUN) and creatinine (suggestive of renal failure)
  • Lipid Panel: low high-density lipoprotein (HDL) < 10 mg/dL, elevated very low-density lipoprotein (VLDL) and triglycerides, high plasma unesterified cholesterol, and low plasma cholesterol ester
  • Plasma LCAT activity: decreased (determined by decreased ability to esterify radioactive cholesterol in exogenous lipoproteins)

Fish-eye Disease Lab Findings[edit]

  • CBC: no anemia
  • Urinalysis: no proteinuria
  • Blood Chemistries: normal blood urea nitrogen (BUN) and creatinine (no signs of renal failure)
  • Lipid Panel: low high-density lipoprotein (HDL) < 10 mg/dL, elevated very low-density lipoprotein (VLDL) and triglycerides, high plasma unesterified cholesterol in HDL particles, and low cholesterol ester in HDL particles but normal levels in low-density lipoprotein (LDL) and VLDL particles
  • Plasma LCAT activity: decreased only in HDL particles but not LDL

Genetic findings in Fish eye disease[edit]

Mutations in the LCAT gene, which is localized in the q21–22 region of chromosome 16, cause fish-eye disease.[3] The mutation in the LCAT gene is homozygous for a Thr123→Ile mutation or Pro10→Leu mutation.[11] New mutations have been identified as homozygosity for an A2205→G nucleotide substitution in exon 4 of the LCAT gene which is predicted to be the cause of an Asp131→Asn substitution.[4]


Treatment[edit]

Currently, there is no specific treatment to correct the LCAT deficiency so therapy is focused on symptom relief. Corneal transplant may be considered for patients presenting with severely impaired vision caused by cholesterol corneal opacities. Dialysis may be required for patients presenting with renal failure, and kidney transplant may be considered.

Mortality and morbidity[edit]

Renal failure is the major cause of morbidity and mortality in complete LCAT deficiency, while in partial deficiency (fish eye disease) major cause of morbidity is visual impairment due to corneal opacity. These patients have low HDL cholesterol but surprisingly premature atherosclerosis is not seen. However, there are some reported cases.

References[edit]

  1. ^ Kuivenhoven JA, Pritchard H, Hill J, Frohlich J, Assmann G, Kastelein J (February 1997). "The molecular pathology of lecithin:cholesterol acyltransferase (LCAT) deficiency syndromes". J. Lipid Res. 38 (2): 191–205. PMID 9162740. 
  2. ^ Calabresi L, Pisciotta L, Costantin A, Frigerio I, Eberini I, Alessandrini P, Arca M, Bon GB, Boscutti G, Busnach G, Frasc G, Gesualdo L, Gigante M, Lupattelli G, Montali A, Pizzolitto S, Rabbone I, Rolleri M, Ruotolo G, Sampietro T, Sessa A, Vaudo G, Cantafora A, Veglia F, Calandra S, Bertolini S, Franceschini G (Sep 2005). "The molecular basis of lecithin:cholesterol acyltransferase deficiency syndromes: a comprehensive study of molecular and biochemical findings in 13 unrelated Italian families.". Arteriosclerosis, thrombosis, and vascular biology. 25 (9): 1972–1978. doi:10.1161/01.ATV.0000175751.30616.13. ISSN 1079-5642. PMID 15994445. 
  3. ^ a b Koster, H; Savoldelli, M; Dumon, M. F.; Dubourg, L; Clerc, M; Pouliquen, Y (1992). "A fish-eye disease-like familial condition with massive corneal clouding and dyslipoproteinemia. Report of clinical, histologic, electron microscopic, and biochemical features". Cornea. 11 (5): 452–64. doi:10.1097/00003226-199209000-00016. PMID 1424675. 
  4. ^ a b c d e f Kuivenhoven, J. A.; van Voorst tot Voorst EJ; Wiebusch, H; Marcovina, S. M.; Funke, H; Assmann, G; Pritchard, P. H.; Kastelein, J. J. (1995). "A unique genetic and biochemical presentation of fish-eye disease". Journal of Clinical Investigation. 96 (6): 2783–91. doi:10.1172/JCI118348. PMC 185988Freely accessible. PMID 8675648. 
  5. ^ Reference, Genetics Home. "complete LCAT deficiency". Genetics Home Reference. Retrieved 2016-12-11. 
  6. ^ Reference, Genetics Home. "fish-eye disease". Genetics Home Reference. Retrieved 2016-12-11. 
  7. ^ a b "Lecithin-Cholesterol Acyltransferase Deficiency: Overview, Presentation, Differential Diagnosis". 2016-08-08. 
  8. ^ a b c Kuivenhoven, J. A.; Pritchard, H; Hill, J; Frohlich, J; Assmann, G; Kastelein, J (1997). "The molecular pathology of lecithin:cholesterol acyltransferase (LCAT) deficiency syndromes". Journal of lipid research. 38 (2): 191–205. PMID 9162740. 
  9. ^ Kaneshiro, N.K. (2014). "Autosomal Recessive". National Institutes of Health, Medline Plus. 
  10. ^ "Lecithin-Cholesterol Acyltransferase Deficiency: Overview, Presentation, Differential Diagnosis". 2016-08-08. 
  11. ^ Contacos, C; Sullivan, D. R.; Rye, K. A.; Funke, H; Assmann, G (1996). "A new molecular defect in the lecithin: Cholesterol acyltransferase (LCAT) gene associated with fish eye disease". Journal of lipid research. 37 (1): 35–44. PMID 8820100.