A Japanese subject with homozygous familial hypercholesterolemia was found to have a 7.8-kilobase deletion in the gene for the low density lipoprotein receptor. The deletion joins intron 15 to the middle of exon 18, which encodes the 3' untranslated region, thereby removing all 3' splice acceptor sites distal to intron 15. By S1 nuclease mapping, we demonstrated that the 5' splice donor site of intron 15 is no longer used. Instead a continuous transcript is produced in which exon 15 is followed by the remaining segments of intron 15 and exon 18. The translational reading frame of exon 15 continues for 165 nucleotides into intron 15 before a termination codon is reached. This mRNA should produce a truncated receptor that lacks the normal membrane-spanning region and cytoplasmic domain and that has 55 novel amino acids at its COOH terminus. A cDNA expression vector containing this sequence produced a receptor that behaved similarly to the truncated protein produced by the Japanese patient, i.e. greater than 90% of the receptor was secreted from the cell, and the receptors remaining on the surface showed defective internalization. The deletion in this subject resulted from a recombination between two repetitive sequences of the Alu family, one in intron 15 and the other in exon 18. To date, Alu sequences have been observed at the deletion joints of all four gross deletions in the low density lipoprotein receptor gene that have been characterized. Within these Alu sequences, six out of the seven breakpoints have occurred in the left arm. These data suggest that recombination between Alu sequences may be a frequent cause of deletions in the human genome.