Angiopoietin-like Protein 4 Concentrations Research Articles

Angiopoietin-like protein 4 induces growth hormone variant secretion and aggravates insulin resistance during pregnancy, linking obesity to gestational diabetes mellitus.

Angiopoietin-like protein 4 (ANGPTL4) is a secretory glycoprotein involved in regulating glucose homeostasis in non-pregnant subjects. However, its role in glucose metabolism during pregnancy and the pathophysiology of gestational diabetes mellitus (GDM) remains elusive. Thus, this study aimed to clarify the relationship between ANGPTL4 and GDM and investigate the pathophysiology of placental ANGPTL4 in glucose metabolism. We investigated this issue using blood and placenta samples in 957 pregnant women, the human 3A-sub-E trophoblast cell line, and the L6 skeletal muscle cell line. We found that ANGPTL4 expression in the placenta was higher in obese pregnant women than in lean controls. Palmitic acid significantly induced ANGPTL4 expression in trophoblast cells in a dose-response manner. ANGPTL4 overexpression in trophoblast cells resulted in endoplasmic reticulum (ER) stress, which stimulated the expression and secretion of growth hormone-variant (GH2) but not human placental lactogen. In L6 skeletal muscle cells, soluble ANGPTL4 suppressed insulin-mediated glucose uptake through the epidermal growth factor receptor (EGFR)/extracellular signal-regulated kinases 1/2 (ERK 1/2) pathways. In pregnant women, plasma ANGPTL4 concentrations in the first trimester predicted the incidence of GDM and were positively associated with BMI, plasma triglyceride, and plasma GH2 in the first trimester. However, they were negatively associated with insulin sensitivity index ISI0,120 in the second trimester. Overall, placental ANGPTL4 is induced by obesity and is involved in the pathophysiology of GDM via the induction of ER stress and GH2 secretion. Soluble ANGPTL4 can lead to insulin resistance in skeletal muscle cells and is an early biomarker for predicting GDM.

The association between plasma angiopoietin-like protein 4, glucose and lipid metabolism during pregnancy, placental function, and risk of delivering large-for-gestational-age neonates

BackgroundLarge-for-gestational-age (LGA) neonates have increased risk of adverse pregnancy outcomes and adult metabolic diseases. We aimed to investigate the relationship between plasma angiopoietin-like protein 4 (ANGPTL4), a protein involved in lipid and glucose metabolism during pregnancy, placental function, growth factors, and the risk of LGA. MethodsWe conducted a prospective cohort study and recruited women with singleton pregnancies at the National Taiwan University Hospital between 2013 and 2018. First trimester maternal plasma ANGPTL4 concentrations were measured. ResultsAmong 353 pregnant women recruited, the LGA group had higher first trimester plasma ANGPTL4 concentrations than the appropriate-for-gestational-age group. Plasma ANGPTL4 was associated with hemoglobin A1c, post-load plasma glucose, plasma triglyceride, plasma free fatty acid concentrations, plasma growth hormone variant (GH-V), and birth weight, but was not associated with cord blood growth factors. After adjusting for age, body mass index, hemoglobin A1c, and plasma triglyceride concentrations, plasma ANGPTL4 concentrations were significantly associated with LGA risk, and its predictive performance, as measured by the area under the receiver operating characteristic curve, outperformed traditional risk factors for LGA. ConclusionsPlasma ANGPTL4 is associated with glucose and lipid metabolism during pregnancy, plasma GH-V, and birth weight, and is an early biomarker for predicting the risk of LGA.

Expression of Angiopoetin-Like Protein-4 and Kidney Injury Molecule-1 as Preliminary Diagnostic Markers for Diabetes-Related Kidney Disease: A Single Center-Based Cross-Sectional Study.

The purpose of the study was to examine the urinary levels of kidney injury molecule-1 (KIM-1) and angiopoietin-like protein-4 (ANGPTL-4) in individuals with diabetic kidney disease (DKD) and their association with established DKD diagnostic markers such as albuminuria and estimated glomerular filtration rate (eGFR). Levels of ANGPTL-4 and KIM-1 were estimated in urine samples. A total of 135 participants were recruited into three groups: 45 diabetes type 2 patients in the control group and 90 DKD patients in two disease groups. Concentrations of ANGPTL-4 and KIM-1 were conclusively related to the urinary albumin-creatinine ratio (UACR). Also, the levels of both ANGPTL-4 and KIM-1 were negatively associated with the eGFR. Multivariable Poisson regression analysis showed that urinary ANGPTL-4 (PR: 3.40; 95% CI: 2.32 to 4.98; p < 0.001) and KIM-1 (PR: 1.25; 95% CI: 1.14 to 1.38; p < 0.001) were prevalent in DKD patients. Receiver operating characteristic (ROC) analysis of urinary ANGPTL-4 and KIM-1 in the combined form resulted in an area under curve (AUC) of 0.967 (95%CI: 0.932-1.000; p < 0.0001) in the microalbuminuria group and 1 (95%CI: 1.000-1.000; p < 0.0001) in the macroalbuminuria group. The association of urinary levels of ANGPTL-4 and KIM-1 with UACR and eGFR and significant prevalence in the diabetic kidney disease population illustrates the diagnostic potential of these biomarkers.

Angiopoietin-like protein 4 and clinical outcomes in ischemic stroke patients.

AimsAngiopoietin‐like protein 4 (ANGPTL‐4) had been reported to be associated with the risk of ischemic stroke, but its prognostic value remained unclear. The aim of this study was to investigate the association between plasma ANGPTL‐4 concentrations and prognosis of ischemic stroke.MethodsBaseline plasma ANGPTL‐4 concentrations were measured in 3379 acute ischemic stroke patients. The primary outcome was a combination of death or major disability (modified Rankin Scale score, ≥3) at 3 months after ischemic stroke.ResultsAt 3 months after ischemic stroke, 850 (26.16%) participants experienced major disability or died (750 major disabilities and 100 deaths). After adjusting for important covariates, odds ratios for the highest tertile of plasma ANGPTL‐4 concentrations were 1.59 (1.22–2.06) for primary outcome, 1.53 (1.18–1.97) for major disability, and 2.03 (1.03–4.00) for death when compared with the lowest tertile of plasma ANGPTL‐4 concentrations. For 1‐SD increase in log‐ANGPTL‐4 concentrations (0.44 ng/mL), the adjusted odds ratios were 1.24 (1.11–1.38), 1.14 (1.03–1.27), and 1.72 (1.32–2.23), respectively. Adding ANGPTL‐4 to a model containing conventional risk factors improved risk prediction for composite outcome of death and major disability.ConclusionHigher plasma ANGPTL‐4 concentration was associated with poor prognosis in acute ischemic stroke patients, suggesting that ANGPTL‐4 might be a prognostic marker for ischemic stroke.

Angiopoietin-like protein 4 promotes very-low-density lipoprotein assembly and secretion in bovine hepatocytes in vitro.

In dairy cows, fatty liver is one of the most common metabolic diseases that occurs during the periparturient period. Angiopoietin-like protein 4 (ANGPTL4) is a well-known downstream target of peroxisome proliferator-activated receptors (PPARs), which regulate the glucose and fatty acid metabolisms. The inhibition of lipoprotein lipase (LPL) activity interferes with the storage of triglycerides (TG) in adipocytes, which plays an essential role in lipid metabolism in rodents. However, it remains unclear whether ANGPTL4 is involved in the pathological process of fatty liver in dairy cows as a result of the regulation of the hepatocellular lipid transport system. This study intended to investigate the effect of ANGPTL4 on the very-low-density lipoprotein (VLDL) assembly and secretion in bovine hepatocytes. Bovine hepatocytes were isolated using a modified two-step perfusion and collagenase digestion process, and treated with different concentrations of ANGPTL4 (0, 4, 12, and 24 ng/ml) for 24 hr. The results showed that a high concentration of ANGPTL4 could significantly increase the extracellular concentration of VLDL while reducing the intracellular content of TG. Thus, it was confirmed that ANGPTL4 could promote the transport of TG in the form of VLDL by partially regulating the expression of related proteins in hepatocytes, thereby contributing to the partial adaptive regulation of lipid transport in dairy cows.

Angiopoietin-like protein 4 (ANGPTL4) is related to gestational weight gain in pregnant women with obesity

Angiopoietin-like protein 4 (ANGPTL4) is a circulating protein involved in the regulation of adipose tissue metabolism. However, its role in obesity and pregnancy is unknown. To evaluate the relationship between gestational weight gain (GWG) and circulating concentrations of ANGPTL4 in pregnant women with overweight and obesity, weight gain and fasting maternal blood samples of thirty-one pregnant women was drawn at 15, 24 and 32 weeks of gestation. ANGPTL4 concentrations continuously rose throughout gestation, whereas VEGF and leptin did not show the same trend. NEFA and glycerol concentrations remained stable during pregnancy. In contrast, total concentrations of saturated, monounsaturated and n-6 fatty acids, but not n-3 fatty acids, increased with pregnancy. In multiple regression analysis, the increase in plasma ANGPTL4 and decrease in linoleic acid concentrations were the most significant predictors of GWG, although only ANGPTL4 was significantly associated with the weight gain from early pregnancy (area under the ROC curve was 0.80 p < 0.01(95% CI 0.61–0.99)). In conclusion, in pregnant women with overweight and obesity, an increase in plasma ANGPTL4 concentrations throughout pregnancy is positively associated with GWG and could be used as an early marker of increased susceptibility to excess gestational weight gain.

Serum hepatokines in dairy cows: periparturient variation and changes in energy-related metabolic disorders

BackgroundDuring peripartum period, dairy cows are highly susceptible to energy metabolism disorders such as fatty liver and ketosis. Angiopoietin-like protein 4 (ANGPTL4) and fibroblast growth factor 21 (FGF21), known as hepatokines, play important roles in lipid metabolism. The purposes of our study were to evaluate variations of serum ANGPTL4 and FGF21 concentrations in periparturient dairy cows and changes in these serum analyte concentrations of energy-related metabolic disorders in early lactation dairy cows.This study was divided into two experiments. Experiment I: Blood parameters were measured in healthy periparturient Holstein cows from 4 wk antepartum to 4 wk postpartum (n = 219). In this experiment, weekly blood samples were obtained from 4 wk before the expected calving date through 4 wk after calving. Experiment II: Blood parameters were measured in healthy cows (n = 30) and cows with clinical ketosis (n = 29) and fatty liver (n = 25) within the first 4 wk of lactation. In the present study, all blood samples were collected from the coccygeal vein in the early morning before feeding.ResultsSerum ANGPTL4 and FGF21 concentrations peaked at parturition, and declined rapidly over the following 2 wk Serum ANGPTL4 and FGF21 concentrations were positively correlated with serum non-esterified fatty acids (NEFA) concentration (r = 0.856, P = 003; r = 0.848, P = 0.004, respectively). Cows with clinical ketosis and fatty liver had significantly higher serum ANGPTL4 and FGF21 concentrations than healthy cows (P < 0.01).ConclusionSerum ANGPTL4 and FGF21 concentrations were elevated during peripartum period, suggesting that energy balance changes that were associated with parturition contributed significantly to these effects. Although FGF21 and ANGPTL4 could play important roles in the adaptation of energy metabolism, they may be involved in the pathological processes of energy metabolism disorders of dairy cows in the peripartum period.

Effect of diet-induced weight loss on angiopoietin-like protein 4 and adipose tissue lipid metabolism in overweight and obese humans.

Angiopoietin‐like protein 4 (ANGPTL4) plays a role in lipid partitioning by inhibiting lipoprotein lipase (LPL)‐dependent plasma clearance of triacylglycerol in adipose tissue. We investigated the effects of diet‐induced weight loss on plasma ANGPTL4 concentrations in relation to in vivo adipose tissue LPL activity and lipolysis and adipose tissue ANGPTL4 release in overweight/obese participants. Sixteen individuals (BMI: 28–35 kg/m2; 10 women) were randomized to a dietary intervention composed of either a low‐calorie diet (1250 kcal/day) for 12 weeks (n = 9) or a very low‐calorie diet (500 kcal/day) for 5 weeks, followed by a 4‐week weight stable period. Before and after the intervention, we measured arteriovenous concentration differences in combination with adipose tissue blood flow before and after intake of a high‐fat mixed meal with [U‐13C]‐palmitate to assess in vivo adipose tissue LPL activity and lipolysis. The intervention significantly reduced body weight (−8.6 ± 0.6 kg, P < 0.001). Plasma ANGPTL4 concentrations were unaffected. Significant postprandial adipose tissue ANGPTL4 release into the circulation was observed (P < 0.01). No association was observed between plasma ANGPTL4 and in vivo LPL activity. After intervention, fasting and postprandial plasma ANGPTL4 concentrations were positively associated with adipose tissue nonesterified FA (NEFA) and glycerol release, reflecting in vivo adipose tissue lipolysis (fasting NEFA: P = 0.039 and postprandial NEFA: P = 0.003). In conclusion, plasma ANGPTL4 is unaffected by weight loss and is secreted from human adipose tissue after a high‐fat meal in overweight/obese participants. Plasma ANGPTL4 concentrations were not related to in vivo adipose tissue LPL activity, but were positively associated with in vivo adipose tissue lipolysis after weight loss.

Effects of Clostridium butyricum on breast muscle lipid metabolism of broilers

To investigate the effects of Clostridium butyricum (C. butyricum) on breast muscle lipid metabolism of broilers, 192 one-day-old male Arbor Acres broilers were randomly allocated into 2 treatments with 6 replicates in a completely randomised design. The broilers were fed corn-soybean meal-based diets and supplemented with 0 or 1 × 109 cfu of C. butyricum/kg of diet for 42 days. The birds in the C. butyricum-supplemented group showed higher (p < .05) average daily gain during the grower phase and throughout the entire period of the experiment and a lower (p = .047) feed conversion rate during the grower phase. Supplementation with C. butyricum increased (p < .05) the intramuscular fat content, lipoprotein lipase activity and mRNA levels in the breast muscle at 42 days of age, increased (p = .032) the serum insulin level at 21 days of age, and enhanced (p = .020) the caecal Firmicutes relative abundance at 42 days of age. Additionally, supplementation with C. butyricum reduced (p < .05) the serum growth hormone levels at both 21 and 42 days of age, decreased (p < .05) the ileum angiopoietin-like protein 4 (ANGPTL4) mRNA levels and serum ANGPTL4 concentrations at 42 days of age, and decreased (p < .05) the hormone-sensitive lipase activity, carnitine palmitoyltransferase 1, carnitine palmitoyltransferase 2, and long-chain acyl-CoA dehydrogenase mRNA levels in the breast muscle at 42 days of age. In conclusion, dietary supplementation with C. butyricum could potentially target caecal microbiota and reduced the breast muscle fatty acid oxidation of broilers.

Negative energy balance up‐regulate the levels of hepatokines in dairy cows during the peripartum period

IntroductionThe periparturient period is vitally important to the health status and the reproductive performance of dairy cows. Negative energy balance (NEB) is considered as the pathological basis of energy metabolic disorders. Serum non‐esterified fatty acids (NEFA) and β‐hydroxybutyrate (BHBA) concentrations are the indicators of energy balance status. Angiopoietin‐like protein 4 (ANGPTL4) and fibroblast growth factor 21 (FGF21), known as hepatokines, play essential roles in lipid metabolism. However, in vivo the kinetics of ANGPTL4 and FGF21 are not entirely clear of dairy cows, particularly in dairy cows with ketosis and fatty liver. The purposes of this project were to evaluate the variations in serum concentrations of ANGPTL4 and FGF21 in periparturient dairy cows, and to examine the correlations between serum NEFA, BHBA concentrations and ANGPTL4, FGF21 concentrations, respectively, in the serum of experimental cows. Moreover, the serum concentrations of hepatokines from cows with spontaneous ketosis and fatty liver, and healthy cows were compared.MethodsExperiment IBlood parameters were measured in healthy periparturient Holstein cows from 4 wk antepartum to 4 wk postpartum (n=219). In this experiment, weekly blood samples were obtained from 4 wk before the expected calving date to 4 wk after calving.Experiment IIBlood parameters were measured in healthy cows (n=30), cows with ketosis (n=29) and fatty liver (n=25) within the first 4 wk of lactation. In this present study, all blood samples were collected from the coccygeal vein in the early morning before feeding.ResultsSerum concentrations of ANGPTL4 and FGF21 peaked at parturition, and declined rapidly over the following 2 wk. Serum ANGPTL4 and FGF21 concentrations were positively correlated with serum NEFA concentration (ANGPTL4 and NEFA: r=0.856, P=003; FGF21 and NEFA: r=0.848, P=0.004). However, the correlations between serum BHBA concentration and the serum concentrations of ANGPTL4 and FGF21 were not observed in experimental cows. Cows with ketosis and fatty liver had significantly higher serum concentrations of ANGPTL4 and FGF21 when compared with healthy cows (P&lt;0.01).ConclusionSerum concentrations of ANGPTL4 and FGF21 were elevated during peripartum period in dairy cows, demonstrating that the energy balance changes that were associated with parturition contributed significantly to these effects. We propose that blood ANGPTL4 and FGF21 concentrations could be used as supplementary biomarkers of “energy balance” status in postpartum dairy cows. Although FGF21 and ANGPTL4 could play important roles in the adaptation of energy metabolism, they may be involved in the pathological processes of energy metabolism disorders of dairy cows in the peripartum period.Support or Funding InformationThis abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Angiopoietin-Like Protein 4 and Postprandial Skeletal Muscle Lipid Metabolism in Overweight and Obese Prediabetics.

Angiopoietin-like protein 4 (ANGPTL4) decreases plasma triacylglycerol (TAG) clearance by inhibiting lipoprotein lipase (LPL) and may contribute to impairments in lipid metabolism under compromised metabolic conditions. To investigate the effects of a high-saturated fatty acid (SFA) mixed meal on plasma ANGPTL4 concentrations in relation to in vivo muscle LPL activity, to study the effects of dietary fat quality, and to examine skeletal muscle ANGPTL4 release. Design, Participants, Setting, and Interventions: We used a dual stable-isotope tracer technique in combination with measurements of arteriovenous concentration differences across forearm muscle to investigate muscle ANGPTL4 secretion and fatty acid handling under fasting conditions and after a high-SFA mixed meal in 73 overweight and obese humans at the Metabolic Research Unit of Maastricht University. The effect of dietary fat quality manipulation on plasma ANGPTL4 was investigated in 10 obese insulin-resistant participants. The high-SFA meal decreased circulating ANGPTL4 concentrations (fasting, 5.2 ng/mL; vs 4 hours postprandial, 4.0 ng/mL; P < .001). Furthermore, skeletal muscle ANGPTL4 secretion into the circulation was observed (AUC0-4 h, P = .048). However, no association was observed between plasma ANGPTL4 and skeletal muscle very low-density lipoprotein or dietary (chylomicron) TAG extraction (AUC0-4 h, P = .372 and P = .139, respectively). In contrast to a high-SFA or high-monounsaturated fat meal, plasma ANGPTL4 remained unchanged after a high-polyunsaturated fat meal. ANGPTL4 is secreted by human forearm muscle in postprandial conditions after a high-SFA meal. Plasma ANGPTL4 concentrations were not associated with in vivo skeletal muscle LPL activity after a high-SFA meal. Dietary fat quality affects plasma ANGPTL4, but it remains to be elucidated whether this influences short-term skeletal muscle lipid handling.

ANGPTL-4 correlates with vascular endothelial growth factor in patients with proliferative diabetic retinopathy.

To investigate the relationship between angiopoietin-like protein 4 (ANGPTL-4) and vascular endothelial growth factor (VEGF) in the serum and vitreous of eyes in patients with proliferative diabetic retinopathy (PDR). Thirty-five eyes of 35 patients with PDR, 20 eyes of 20 patients with non-proliferative diabetic retinopathy, 20 eyes of 20 patients with diabetes but no diabetic retinopathy, and 14 eyes of 14 nondiabetic patients with an idiopathic macular hole (IMH) were recruited from Shanghai First People's Hospital. The ANGPTL-4 and VEGF concentrations were determined using enzyme-linked immunosorbent assays. Group means were compared using one-way analysis of variance with GraphPad Prism 4.0 and SPSS ver. 17.0. The research followed the tenets of the Declaration of Helsinki. The ANGPTL-4 and VEGF levels were significantly higher in the vitreous and serum of patients with PDR compared with patients with IMH. There were significant correlations between the ANGPTL-4 and VEGF levels in the vitreous and serum of patients with PDR. The vitreous and serum ANGPTL-4 levels were also significantly correlated in patients with PDR. The ANGPTL-4 in both the vitreous and serum correlated with the serum triglyceride and high-density lipoprotein cholesterol levels. The ANGPTL-4 levels were markedly elevated and the ANGPTL-4 expression was directly correlated with the VEGF expression in the vitreous and serum of patients with PDR. The vitreous and serum ANGPTL-4 levels were also significantly correlated with serum lipids in patients with PDR. Our results suggest that the ANGPTL-4 may be used as a new therapeutic target for the treatment of PDR.

Decreased Concentrations of the Lipoprotein Lipase Inhibitor Angiopoietin-Like Protein 4 and Increased Serum Triacylglycerol Are Associated With Increased Neonatal Fat Mass in Pregnant Women With Gestational Diabetes Mellitus

Angiopoietin-like protein 4 (ANGPTL4) is an extracellular inhibitor of lipoprotein lipase (LPL) activity. No studies have been done in pregnancy in which hypertriglyceridemia and tissue-specific changes in LPL activity are present. The objective of the study was to determine the relationship between neonatal fat mass (FM) and concentrations of ANGPTL4 and triacylglycerols (TAG) in maternal and cord serum of pregnant women with gestational diabetes mellitus (GDM) compared with controls. Maternal blood samples (control, n = 90, and GDM, n= 80) and umbilical cord blood were drawn before and after vaginal delivery, respectively. Control and GDM subjects were grouped separately into 3 subgroups, according to neonatal FM: 0-25th percentiles, 25th-75th percentiles, and 75th-100th percentiles. Glucose, insulin, TAG, nonesterified fatty acids (NEFAs), and ANGPTL4 were determined in maternal and neonatal serum. Age and pregestational body mass index did not differ between GDM and control women in any subgroups. Maternal serum of GDM pregnant women who delivered the newborn with the highest FM showed the highest concentrations of TAG and NEFAs and lowest concentration of ANGPTL4, despite glucose and insulin concentrations being independent of changes in neonatal FM. However, cord serum of neonates of GDM patients with the highest FM showed higher concentrations of insulin and lower concentrations of TAG than those with lower neonatal FM but no significant differences in NEFAs or ANGPTL4 concentrations. In well-controlled GDM pregnancies, decreased maternal ANGPTL4 concentrations and a gradient of TAG toward the fetus are related with higher neonatal FM. However, in GDM fetuses with the highest FM, the potential effect of ANGPTL4 inhibiting adipose tissue LPL activity could be overcome by their hyperinsulinemia.

Dietary modulation of plasma angiopoietin-like protein 4 concentrations in healthy volunteers and in patients with type 2 diabetes

Angiopoietin-like protein 4 (ANGPTL4) has been identified as an inhibitor of lipoprotein lipase. Preliminary data suggest that plasma nonesterified fatty acids (NEFAs) raise plasma ANGPTL4 concentrations in humans. The objective was to assess plasma ANGPTL4 concentrations after various nutritional interventions that increase NEFA concentrations in healthy subjects and in patients with type 2 diabetes mellitus. We studied 4 groups, both at baseline and after 3 d of either fasting (n = 22 healthy men), a very-low-calorie diet (VLCD; n = 10 healthy men and n = 10 patients with diabetes), or a high-fat, high-energy diet (HFED; n = 15 healthy men). Plasma ANGPTL4, NEFA, and triglyceride concentrations were measured. In healthy men, a VLCD increased ANGPTL4 from 13.2 (IQR: 8.1-24.2) at baseline to 18.2 (16.7-33.4) ng/mL (P < 0.05), fasting increased ANGPTL4 from 10.6 (7.6-17.6) to 28.0 (23.1-35.0) ng/mL (P < 0.05), and an HFED increased ANGPTL4 from 13.9 (8.2-22.0) to 17.2 (11.2-23.6) ng/mL (P < 0.05). In men with diabetes, a VLCD also increased ANGPTL4, from 10.9 ± 2.4 to 19.2 ± 3.2 ng/mL (P < 0.05). All interventions significantly increased plasma NEFAs in both healthy men and patients with diabetes. The change in ANGPTL4 positively correlated with the change in NEFA concentrations (β = 0.048, P < 0.001) and negatively correlated with the change in plasma triglycerides (β = -0.051, P = 0.01). Three days of either fasting, a VLCD, or an HFED increased plasma ANGPTL4 concentrations in healthy men, concomitantly with increased plasma NEFA concentrations. Similarly, a VLCD in patients with diabetes increased ANGPTL4 concentrations, concomitantly with increased NEFA concentrations.