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Individuals with familial hypercholesterolemia FH have a high risk of coronary artery disease, but their risk of peripheral arterial disease PAD and chronic kidney disease CKD is unknown. Heterozygous familial hypercholesterolemia FH is an autosomal dominant disorder of lipoprotein metabolism, estimated to affect one out of individuals in Western populations 1 , 2.

Mutations in genes involved in the recycling pathways of the low-density lipoprotein LDL receptor lead to decreased clearance of LDL cholesterol from plasma and consequently substantially increased total and LDL cholesterol concentrations 3 , 4. Lifelong vascular exposure to elevated concentrations of LDL cholesterol leads to atherosclerosis, the major clinical manifestation of FH.

A similar involvement of the peripheral arteries seems likely but is largely unknown for individuals with FH. Lower extremity peripheral arterial disease PAD and chronic kidney disease CKD are two manifestations of peripheral atherosclerotic disease that significantly contribute to morbidity and mortality 6 , 7.

Furthermore, both diseases constitute independent risk factors for CAD in the general population 6 , 7. Both have been shown to be markers of cardiovascular risk in individuals in the general population 7 , 8 but hitherto not in individuals with FH. Consequently, signs and symptoms of PAD and CKD may not be routinely screened for as part of the FH diagnosis, and the results are not included in the overall cardiovascular risk assessment in FH, thus influencing decisions on treatment, treatment intensity, and clinical follow-up 3 , 9.