LDLR variant classification through activity-normalized prime editing screening

We show that prime editing-mediated reporter editing correlates with endogenous variant installation frequency, allowing activity normalization to improve imputation of LDLR variant effect. Our optimized prime editing assay identifies a broad, continuous spectrum of variant functional effects. We achieve robust separation of pathogenic vs. benign ClinVar variants and concordance between experimentally derived functional scores and LDL-C levels measured in UK Biobank participants.

Further, we calibrate the strength of this functional evidence to align with the ACMG/AMP variant interpretation guidelines. By integrating additional sources of evidence, a majority of currently unclassified rare LDLR variants appear to meet computational evidence thresholds for reclassification and can be prioritized for expert review. We use the broad coverage of this screen to gain insight into how apolipoproteins bind to LDLR.

In particular, we identify and characterize rare LDLR variants that enhance LDL-C uptake through increased interaction with apolipoprotein B. Finally, we compare prime editing-based functional scores with those derived from recent base editing and cDNA-based LDLR variant screens, and find that all approaches show robust correlation with clinically observed LDL-C levels and computational scores, while prime editing identifies splice-altering coding variants that are not modeled by cDNA screening.

Altogether, our approach demonstrates the power of prime editing to significantly improve understanding of how variants in LDLR impact function and contribute to FH.