ABSTRACT: Mutations of the sigma subunit of the heterotetrameric adaptor-related protein complex 2 (AP2?) impair signalling of the calcium-sensing receptor (CaSR), and cause familial hypocalciuric hypercalcaemia type 3 (FHH3). To date, FHH3-associated AP2? mutations have only been identified at one residue, Arg15. We hypothesized that additional rare AP2? variants may also be associated with altered CaSR function and hypercalcaemia, and sought for these by analysing?>111 995 exomes (>60 706 from ExAc and dbSNP, and 51 289 from the Geisinger Health System-Regeneron DiscovEHR dataset, which also contains clinical data). This identified 11 individuals to have 9 non-synonymous AP2? variants (Arg3His, Arg15His (x3), Ala44Thr, Phe52Tyr, Arg61His, Thr112Met, Met117Ile, Glu122Gly and Glu142Lys) with 3 of the 4 individuals who had Arg15His and Met117Ile AP2? variants having mild hypercalcaemia, thereby indicating a prevalence of FHH3-associated AP2? mutations of ?7.8 per 100 000 individuals. Structural modelling of the novel eight AP2? variants (Arg3His, Ala44Thr, Phe52Tyr, Arg61His, Thr112Met, Met117Ile, Glu122Gly and Glu142Lys) predicted that the Arg3His, Thr112Met, Glu122Gly and Glu142Lys AP2? variants would disrupt polar contacts within the AP2? subunit or affect the interface between the AP2? and AP2? subunits. Functional analyses of all eight AP2? variants in CaSR-expressing cells demonstrated that the Thr112Met, Met117Ile and Glu142Lys variants, located in the AP2? ?4-?5 helical region that forms an interface with AP2?, impaired CaSR-mediated intracellular calcium (Cai2+) signalling, consistent with a loss of function, and this was rectified by treatment with the CaSR positive allosteric modulator cinacalcet. Thus, our studies demonstrate another potential class of FHH3-causing AP2? mutations located at the AP2?-AP2? interface.