Abstract: Introduction: Familial hypercholesterolemia (FH) is an autosomal dominant disorder mainly caused by mutations in the coding region of the LDLR gene. However, a variety of mutations within the LDLR promoter have been associated with FH. Genetic screening in persons clinically diagnosed with HF revealed the presence of four new heterozygous mutations within the promoter region. Objective: To study the functionality of the four new LDLR promoter mutations (c.-36T>G, c.-136C>G, c.-140C>G and c.-208A>T) found in Spain, using the LIPOchip® platform in patients with clinically suspected FH. Methods: The functional analysis of mutations was carried out by using electrophoretic mobility shift assays (EMSA) and luciferase reporter gene expression in HepG2 transfected cells with the mutated promoters. Results: Two mutations, c.-136G and c.-140, located within the R3 regulatory element, showed a significant change in the pattern of nuclear binding protein affinity. Moreover, these mutations reduced the residual activity of the LDLR promoter by 88-93%. However, mutations c.-36G and c.-208T, located outside the response elements, produced no significant changes in EMSA experiments or reporter genes. Conclusions: Mutations within the R3 element are associated with FH, while those located outside the regulatory elements of the LDLR promoter are not a direct cause of FH. Our results reveal the importance of functional analysis of the new variants in the LDLR promoter region to identify their role in the FH phenotype.

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