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Bettina Ibold, Janina Tiemann, Isabel Faust, Uta Ceglarek, Julia Dittrich, Theo G. M. F. Gorgels, Arthur A. B. Bergen, Olivier Vanakker, Matthias Van Gils, Cornelius Knabbe, Doris Hendig

• Genetic studies link adenosine triphosphate-binding cassette transporter C6 (\(\it {ABCC6}\)) mutations to pseudoxanthoma elasticum (PXE). \(\it {ABCC6}\) sequence variations are correlated with altered HDL cholesterol levels and an elevated risk of coronary artery diseases. However, the role of ABCC6 in cholesterol homeostasis is not widely known. Here, we report reduced serum cholesterol and phytosterol levels in Abcc6-deficient mice, indicating an impaired sterol absorption. Ratios of cholesterol precursors to cholesterol were increased, confirmed by upregulation of hepatic 3-hydroxy-3-methylglutaryl coenzyme A reductase (\(\it {Hmgcr}\)) expression, suggesting activation of cholesterol biosynthesis in \(\it {Abcc6}^{−/−}\) mice. We found that cholesterol depletion was accompanied by a substantial decrease in HDL cholesterol mediated by lowered ApoA-I and ApoA-II protein levels and not by inhibited lecithin-cholesterol transferase activity. Additionally, higher proprotein convertase subtilisin/kexin type 9 (Pcsk9) serum levels in \(\it {Abcc6}^{−/−}\) mice and PXE patients and elevated ApoB level in knockout mice were observed, suggesting a potentially altered very low-density lipoprotein synthesis. Our results underline the role of Abcc6 in cholesterol homeostasis and indicate impaired cholesterol metabolism as an important pathomechanism involved in PXE manifestation.