PCSK9, a target for the treatment of dyslipidemia, enhances the degradation of the LDL receptor (LDLR) in endosomes/ lysosomes, up-regulating LDL-cholesterol levels. Whereas the targeting and degradation of the PCSK9-LDLR complex are under scrutiny, the roles of the N-and C-terminal domains of PCSK9 are unknown. Although autocatalytic zymogen processing of PCSK9 occurs at Gln 152 2, here we show that human PCSK9 can be further cleaved in its N-terminal prosegment at Arg 46 2 by an endogenous enzyme of insect High Five cells and by a cellular mammalian protease, yielding an ϳ4-fold enhanced activity. Removal of the prosegment acidic stretch resulted in ϳ3-fold higher binding to LDLR in vitro, in >4-fold increased activity on cellular LDLR, and faster cellular internalization in endosome/lysosome-like compartments. Finally, swapping the acidic stretch of PCSK9 with a similar one found in the glycosylphosphatidylinositol-anchored heparin-binding protein 1 does not impair PCSK9 autoprocessing, secretion, or activity and confirmed that the acidic stretch acts as an inhibitor of PCSK9 function. We also show that upon short exposure to pH values 6.5 to 5.5, an ϳ2.5-fold increase in PCSK9 activity on total and cell surface LDLR occurs, and PCSK9 undergoes a second cleavage at Arg 248 , generating a two-chain PCSK9-⌬N 248 . At pH values below 5.5, PCSK9 dissociates from its prosegment and loses its activity. This pH-dependent activation of PCSK9 represents a novel pathway to further activate PCSK9 in acidic endosomes. These data enhance our understanding of the functional role of the acidic prosegment and on the effect of pH in the regulation of PCSK9 activity.Complications resulting from cardiovascular disorders are the main cause of death worldwide. High levels of circulating low density lipoprotein-cholesterol represent a major risk factor that leads to coronary heart disease associated with increased death and morbidity worldwide (1). LDL is constantly cleared by internalization into cells by the LDL receptor (LDLR), 4 which binds and internalizes LDL via its unique apolipoprotein B (apoB) protein. Mutations in LDLR or APOB genes are major causes for the frequent autosomal dominant genetic disorder known as familial hypercholesterolemia (2, 3). More recently, the PCSK9 gene (4), which is highly expressed in liver and small intestine (5), was identified as the third locus associated with familial hypercholesterolemia (6). PCSK9 binds the LDLR and triggers its intracellular degradation in acidic endosomes/lysosomes, resulting in increased circulating LDL-cholesterol (7-10).Following its autocatalytic cleavage, PCSK9 is secreted as a stable noncovalent complex with its 122-amino acid (aa 31-152) N-terminal prosegment (5, 7). This cleavage results in a conformational change (11), which favors the binding of PCSK9 to the EGFA domain of the LDLR (12), with much increased affinity at acidic pH values (11).Overexpression studies in liver suggested that PCSK9 targets the LDLR (9, 13, 14) toward degradation in late endosomes/l...