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Dr DS Fredrickson Sophia Wong, MD, Ahmad Al-Sarraf, MD, FRCPC, Andrew Ignaszewski, MD, FRCPC, Jiri Frohlich, MD, FRCPC Dr D.S. Fredrickson: Founding father of the field of lipidology The quintessential physician-scientist, Dr Fredrickson contributed to medical breakthroughs that have shaped our understanding of lipid metabolism and pathologies. ABSTRACT: Dr D.S. Fredrickson is n the 21st century, physicians are Bos ton’s Peter Bent Brigham Hospi- considered by many to be the found- well versed in the association be - tal (now the Brigham and Women’s ing father of lipidology. An excep- Itween total cholesterol (TC) and Hospital), Fredrickson completed a tional scientist, Fredrickson discov- coronary heart disease (CHD) risk. residency and fellowship in internal ered Tangier disease and cholesteryl The graded relationship of TC and medicine. He then spent a year in the ester storage disease, two genetic CHD has been meticulously docu- laboratory of Ivan Frantz, a choles- conditions caused by aberrant lipid mented in multiple epidemiological terol biochemist, at the Massachusetts metabolism. His identification of var- studies.1-3 In particular, the causal role General Hospital. ious apolipoprotein components con- of low density lipoprotein cholesterol In 1953 Fredrickson moved to tributed to our current understand- (LDL-C) in atherosclerosis is sup- Bethesda, Maryland, and the National ing of lipid transport and physiology. ported by various clinical trials dem - Heart Institute (a division of the Na - His classification of lipoprotein ab - onstrating concurrent reductions in tional Institutes of Health, which was normalities, established on the basis LDL-C level and CHD morbidity and renamed the National Heart, Lung, of electrophoretic plasma lipopro- mortality.3,4 Lipid-lowering therapies, and Blood Institute in 1976). There he tein patterns, was accepted by the especially statins, are known to be ef - began a tremendously fruitful career World Health Organization as a stan- fective in both primary5-8 and second- dard of clinical practice and pro- ary9-11 prevention of CHD. Certainly Dr Wong is a resident in medical biochem- voked global interest in dyslipidem- our present understanding of lipids istry at the University of British Columbia. ic disorders. Fredrickson was part of exemplifies the leg acy of Dr Donald Dr Al-Sarraf is a clinical fellow in medical a remarkable trio of scientists who Sharp Fredrickson, whose pioneering biochemistry at UBC and a diplomate of devised the formula for estimating work and inspiring endeavors have the American Board of Clinical Lipidology. low density lipoprotein cholesterol been fundamental in lipidology. Dr Ignaszewski is head of the Division of levels, a calculation that continues Cardiology at St. Paul’s Hospital and med- to be used in laboratories worldwide. Early years ical director of the Healthy Heart Program. He was also instrumental in the cre- Donald Sharp Fredrickson was born He is also a clinical professor in the division ation of the Lipid Research Clinics in Canon City, Colorado, in 1924 to an of Cardiology at UBC. Dr Frohlich is direc- Program, which sponsored the land- attorney father. He commenced under- tor of clinical trials at the Healthy Heart Pro- mark Coronary Primary Prevention graduate studies at the University of gram Prevention Clinic at St. Paul’s Hospi- Trial, the first major study to defini- Colorado, and subsequently trans- tal and a professor of pathology and tively demonstrate that lowering ferred to the University of Michigan, laboratory medicine at UBC. He is also a cholesterol reduces coronary heart where he graduated with a bachelor member of the Health Canada Dyslipi- disease risk. of science degree in 1946 and an demia Working Group and the Canadian MD with distinction in 1949. Under Cardiovascular Risk Assessment Working This article has been peer reviewed. the mentorship of George Thorn at Group. 336 BC MEDICAL JOURNAL VOL. 54 NO. 7, SEPTEMBER 2012 www.bcmj.org Dr D.S. Fredrickson: Founding father of the field of lipidology in lipidology. At the institute Fredrick- son furthered his research in lipids and lipoproteins with future Nobel laure- ate Christian B. Anfinsen; dabbled in cholesterol metabolism with Daniel Steinberg; and worked with collabo- rators to isolate and sequence the apo - lipoprotein components A-II, C-I, C-II, and C-III. Together with John Stanbury and James Wyngaarden, Fredrickson also edited The Metabolic Basis of Inherit- ed Disease, a compendium of infor- mation on hereditary disorders first published in 1960. The four-volume work, currently in its eighth edition, has since been renamed The Metabol- ic and Molecular Bases of Inherited Disease, and continues to be recogniz - ed as a classic in molecular medicine. Tangier disease and cholesteryl ester storage disease During the 1960s and 1970s Fredrick- son and his colleagues were revered for their discovery of two familial Photo from the U.S. National Library of Medicine. lipid disorders. The first, Tangier dis- Dr Fredrickson, shown here in 1969, changed our understanding of lipid metabolism and pathologies. ease (TD), was named after the island in Chesapeake Bay where the original kindred was identified. TD manifest- ticles, which are quickly catabolized.16 teryl ester aggregation, upregulation ed clinically with hepatosplenomeg - The second discovery made by of LDL receptor and HMG-CoA re - aly, peripheral neuropathy, and tonsils Fredrickson and his colleagues, cho- duc tase, and further accumulation of “of unusual size and coloration.”12 lesteryl ester storage disease (CESD), lysosomal lipids. Complete absence Biochemically, a significant decrease is an autosomal recessive condition at- of LAL activity is seen in Wolman dis- in high-density-lipoprotein choles- tributed to mutation of the gene for en - ease, and affected patients rarely sur- terol (HDL-C) was evident. The here - coding for lysosomal acid lipase (LAL) vive beyond 6 months of age.19 In con- ditary defect responsible would be on chromosome 10q23.2-q23.3.17,18 trast, partial LAL deficiency accounts identified simultaneously in Europe Normally, when LDL binds to its re - for CESD, with a patient life expec - and in Vancouver, Canada, 40 years ceptor and undergoes endocytosis, the tancy of less than 30 years.20 CESD later—mutation of the ATP-binding enzyme LAL hydrolyzes and releases can present in childhood or adulthood cassette transporter A1 (ABCA1) gene, cholesterol from the lysosomes.18 The with liver abnormalities ranging from encoding for the cholesterol efflux subsequent rise in intracellular cho- elevated transaminases to hepatom - regulatory protein, on chromosome lesterol acts by way of negative feed- egaly, jaundice, fibrosis, and liver 9q31.13-15 Impaired cholesterol efflux back and reduces expression of both failure.18 Hypercholesterolemia (and from macrophages gives rise to foam LDL receptor and hydroxymethyl - oftentimes hypertriglyceridemia), cells, and may potentially explain the glutaryl-CoA reductase (HMG-CoA decreased HDL-C, and premature ath- premature CHD frequently noted in TD reduc tase), thereby maintaining cho- erosclerosis are also features of this patients.15 Diminished efflux may also lesterol homeostasis.18 Not surprising- disease.18 lead to lipid-depleted nascent HDL par- ly, LAL deficiency leads to choles- www.bcmj.org VOL. 54 NO. 7, SEPTEMBER 2012 BC MEDICAL JOURNAL 337 Dr D.S. Fredrickson: Founding father of the field of lipidology Fredrickson classification that organizes lipoprotein abnormali- 3806 asymptomatic middle-aged males of hyperlipidemias ties on the basis of their genetic etiol- with primary hypercholesterolemia Fredrickson’s best-known contribu- ogy and pathophysiology. for a mean period of 7.4 years. The tion to lipidology is his classification study subjects were divided into two of lipoprotein disorders (Table ), de - The Lipid Research Clinics groups: the treatment group received veloped with Robert Levy and Robert Coronary Primary 24 g of the bile acid sequestrant cho - Lees. The five phenotypes were des - Prevention Trial lestyramine daily, while the control cribed according to their clinical fea- Fredrickson was pivotal in the estab- group received a placebo. Subjects in tures and plasma lipoprotein patterns lishment of the nationwide Lipid Re - the cholestyramine arm demonstrated on paper electrophoresis.21 This clas- search Clinics Program at the Nation- a 19% decrease (P < .05) in the com- sification system was the first to rec- al Heart Institute.26 The group was bined primary endpoint of definite ognize phenotype III (now known as responsible for the landmark Coronary CHD death and/or definite nonfatal familial dysbetalipoproteinemia) as a Primary Prevention Trial (CPPT),27,28 myocardial infarction when compared unique clinical and biochemical enti- the first major study to conclusively with subjects in the control arm. Sep- ty distinct from the heterogeneous demonstrate the efficacy of choles- arate analysis of the resin-treated group con ditions formerly referred to as terol lowering in reducing CHD.29,30 revealed that a 19% decline in CHD familial hypercholesterolemia.22-24 When study enrolment began in 1973, risk was associated with each decre- It is important to note that Fred - observational epidemiological studies ment of 8% in total cholesterol level rickson’s classification is based sim- had shown an association between or 11% in LDL-C level (P < .001). ply on biochemical parameters, and raised TC/LDL-C and increased CHD. Equipped with CPPT’s definitive
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