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Approches biochimique, épidémiologique et clinique du métabolisme intégré de la Lipoprotéine (a)

Abstract : One in five individuals in the population displays elevated circulating levels of lipoprotein (a) [Lp(a)], a highly atherogenic lipoprotein resembling LDL. Pathophysiological, epidemiological and genetic studies demonstrate that circulating Lp(a) levels above 125 nmol/L are associated with a sharp increase in cardiovascular events rate.The major structural difference between Lp(a) and LDL is that Lp(a) contains a signature protein, apo(a), extremely polymorphic in size as it contains 1 to more than 40 Kringle IV2 (KIV2) domains. The size of apo(a) is inversely correlated with the circulating levels of Lp(a). Besides apo(a), apoE and PCSK9 are the only other plasma proteins known to modulate Lp(a) levels. The aims of my PhD project were to assess how the size of apo(a), the polymorphism of apoE and the pharmacological inhibition of PCSK9 govern Lp(a) plasma concentrations. First, we have developed a robust methodological approach to quantitatively assay apolipoproteins, assess their polymorphisms and evaluate their metabolic fluxes by mass spectrometry. In addition, we have set up a resolutive separation technique allowing the investigation of distinct apo(a) isoforms on agarose gels. We then showed using mass spectrometry that apoE specifically present on VLDL impacts on Lp(a) production, synthesis and/or assembly. In addition, we clearly established that familial hypercholesterolemic patients specifically carrying the apoE2 isoform display reduced Lp(a) plasma levels and are thereby less prone to recurrent cardiovascular events compared with apoE3 or E4 carriers. Finally, we demonstrate that the response to PCSK9 inhibitor treatments of patients at high cardiovascular risk in terms of Lp(a) lowering is proportional to the size of apo(a). We also observed that apheresis procedures performed on a patient with extreme Lp(a) plasma levels reduce his risk of undergoing recurrent myocardial infarction. Taken together, my PhD results allowed us to decipher the physiological modalities by which apo(a) size and apoE polymorphism modulate the circulating levels of this extremely atherogenic lipoprotein species. The therapies currently available (PCSK9 inhibitors, plasmapheresis) remain however clearly insufficient to treat patients with elevated Lp(a).
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Submitted on : Thursday, September 17, 2020 - 1:02:36 AM
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Valentin Blanchard. Approches biochimique, épidémiologique et clinique du métabolisme intégré de la Lipoprotéine (a). Santé. Université de la Réunion; University of Western Australia, 2020. Français. ⟨NNT : 2020LARE0007⟩. ⟨tel-02941333⟩

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