Evolocumab Lowers Low-Density-Lipoprotein Cholesterol and Lipoprotein (A) Levels in Nephrotic Syndrome

ABSTRACT Objectives: To present a patient with nephrotic syndrome and elevated low-density-lipoprotein (LDL) cholesterol (LDL-C) secondary to increased lipoprotein a (Lp[a]) levels and to demonstrate a decrease in Lp(a) levels secondary to evolocumab therapy. Methods: Lp(a) was measured by immunoturbidimetric assay. The elevated Lp(a) level was treated with evolocumab. Results: A 56-year-old man with coronary artery disease and peripheral vascular disease presented with elevated LDL-C. Physical examination revealed grade 4+ pitting pedal edema. A 24-hour urine protein collection revealed proteinuria in the nephrotic range. The fasting LDL-C level on a combination of high-intensity statins, ezetimibe, and lifestyle changes was 156 mg/dL (4.04 mmol/L), and the fasting Lp(a) level was 130 mg/dL (4.641 μmol/L). Treatment with evolocumab resulted in a 73% reduction in Lp(a) and a concomitant 76.9% reduction in LDL-C. Conclusion: Nephrotic syndrome increases the Lp(a) level. Lp(a) contains cholesterol that is not differentiated from LDL-C by current LDL-C measurement methods. Hence, Lp(a)-corrected LDL-C should be used in patients with increased Lp(a). Evolocumab decreased the Lp(a) levels by 73%, thereby providing the correct estimation of LDL-C. Abbreviations: ASCVD = atherosclerotic vascular disease;HDL = high-density lipoprotein;LDL-C = low-density-lipo-protein cholesterol;Lp(a) = lipoprotein (a);PCSK9 = proprotein convertase subtilisin/kexin type 9