Acta Diabetologica

, Volume 54, Issue 4, pp 367–372 | Cite as

Association between microfibrillar-associated protein 4 (MFAP4) and micro- and macrovascular complications in long-term type 1 diabetes mellitus

  • S.L. BlindbækEmail author
  • A. Schlosser
  • A. Green
  • U. Holmskov
  • G.L. Sorensen
  • J. Grauslund
Original Article



To evaluate microfibrillar-associated protein 4 (MFAP4) as a marker of micro- and macrovascular complications in patients with type 1 diabetes.


This cross-sectional study included 203 persons with a long duration of type 1 diabetes from a population-based cohort ascertained in the former Funen County, Denmark. Detection of plasma-MFAP4 (pMFAP4) was performed by the AlphaLISA Technique. Diabetic retinopathy (DR) was graded in accordance with the Early Treatment Diabetic Retinopathy Study adaptation of the modified Airlie House classification. A monofilament test was used to test for neuropathy, and nephropathy was evaluated in a single spot urine sample. Data describing macrovascular disease were obtained from the Danish National Patient Register.


Median age and duration of diabetes were 58.7 and 43 years, respectively, and 61% were males. High levels of pMFAP4 were found in participants of old age, in women and in non-smokers (p < 0.05). In a multiple logistic regression model, patients with high levels of pMFAP4 were more likely to have diabetic neuropathy (OR 2.47 for quartile 4 versus quartile 1, 95% CI 1.01–6.03). No association was found between pMFAP4 and proliferative diabetic retinopathy, nephropathy or macrovascular disease.


No association between pMFAP4 and macrovascular vascular complications was found. However, high levels of pMFAP4 correlated independently with diabetic neuropathy. Further studies on the predictive value of increased circulating MFAP4 in diabetic neuropathy are warranted.


Type 1 diabetes mellitus Complications Pathophysiology Microfibrillar-associated protein 4 (MFAP4) 



This study was supported by Fight for Sight, Denmark. Grant received by Jakob Grauslund (grant number not available). The funder had no involvement in study design, data collection, data analysis, manuscript preparation and/or publication decision.

Compliance with ethical standards

Conflict of interest

Søren Leer Blindbæk, Anders Green, Jakob Grauslund: None. Uffe Holmskov, Anders Schlosser, Grith L Sorensen own two patents P1389DK00 and P1183DK00 regarding MFAP4 binding antibodies blocking the interaction between MFAP4 and integrin receptors.

Ethical standard

This study was carried out in accordance with the Helsinki Declaration and Good Clinical Practice and approved by the Regional Scientific Ethical Committee for Southern Denmark.

Human and animal rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5).

Informed consent

Informed consent was obtained from all patients for being included in the study.


  1. 1.
    Terry T, Raravikar K, Chokrungvaranon N, Reaven PD (2012) Does aggressive glycemic control benefit macrovascular and microvascular disease in type 2 diabetes? Insights from ACCORD, ADVANCE, and VADT. Curr Cardiol Rep 14(1):79–88CrossRefPubMedGoogle Scholar
  2. 2.
    Selvin E, Parrinello CM, Sacks DB, Coresh J (2014) Trends in prevalence and control of diabetes in the United States, 1988–1994 and 1999–2010. Ann Intern Med 160(8):517–525CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Green A, Sortso C, Jensen PB, Emneus M (2015) Incidence, morbidity, mortality, and prevalence of diabetes in Denmark, 2000–2011: results from the diabetes impact study 2013. Clin Epidemiol 7:421–430CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Pambianco G, Costacou T, Ellis D, Becker DJ, Klein R, Orchard TJ (2006) The 30-year natural history of type 1 diabetes complications: the Pittsburgh epidemiology of diabetes complications study experience. Diabetes 55(5):1463–1469CrossRefPubMedGoogle Scholar
  5. 5.
    Grauslund J, Green A, Sjolie AK (2009) Blindness in a 25-year follow-up of a population-based cohort of Danish type 1 diabetic patients. Ophthalmology 116(11):2170–2174CrossRefPubMedGoogle Scholar
  6. 6.
    Grauslund J, Green A, Sjolie AK (2009) Prevalence and 25 year incidence of proliferative retinopathy among Danish type 1 diabetic patients. Diabetologia 52(9):1829–1835CrossRefPubMedGoogle Scholar
  7. 7.
    Anjana RM, Shanthirani CS, Unnikrishnan R, Mugilan P, Amutha A, Nair HD et al (2015) Regularity of follow-up, glycemic burden, and risk of microvascular complications in patients with type 2 diabetes: a 9-year follow-up study. Acta Diabetol 52(3):601–609CrossRefPubMedGoogle Scholar
  8. 8.
    Stone MA, Charpentier G, Doggen K, Kuss O, Lindblad U, Kellner C et al (2013) Quality of care of people with type 2 diabetes in eight European countries: findings from the guideline adherence to enhance care (GUIDANCE) study. Diabetes Care 36(9):2628–2638CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Ali MK, Bullard KM, Saaddine JB, Cowie CC, Imperatore G, Gregg EW (2013) Achievement of goals in US diabetes care, 1999–2010. N Engl J Med 368(17):1613–1624CrossRefPubMedGoogle Scholar
  10. 10.
    Marzona I, Avanzini F, Lucisano G, Tettamanti M, Baviera M, Nicolucci A et al (2016) Are all people with diabetes and cardiovascular risk factors or microvascular complications at very high risk? Findings from the risk and prevention study. Acta Diabetol. doi: 10.1007/s00592-016-0899-0 PubMedGoogle Scholar
  11. 11.
    Lausen M, Lynch N, Schlosser A, Tornoe I, Saekmose SG, Teisner B et al (1999) Microfibril-associated protein 4 is present in lung washings and binds to the collagen region of lung surfactant protein D. J Biol Chem 274(45):32234–32240CrossRefPubMedGoogle Scholar
  12. 12.
    Schlosser A, Thomsen T, Shipley JM, Hein PW, Brasch F, Tornoe I et al (2006) Microfibril-associated protein 4 binds to surfactant protein A (SP-A) and colocalizes with SP-A in the extracellular matrix of the lung. Scand J Immunol 64(2):104–116CrossRefPubMedGoogle Scholar
  13. 13.
    Kasamatsu S, Hachiya A, Fujimura T, Sriwiriyanont P, Haketa K, Visscher MO et al (2011) Essential role of microfibrillar-associated protein 4 in human cutaneous homeostasis and in its photoprotection. Sci Rep 1:164CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Pilecki B, Schlosser A, Wulf-Johansson H, Trian T, Moeller JB, Marcussen N et al (2015) Microfibrillar-associated protein 4 modulates airway smooth muscle cell phenotype in experimental asthma. Thorax 70(9):862–872CrossRefPubMedGoogle Scholar
  15. 15.
    Schlosser A, Pilecki B, Hemstra LE, Kejling K, Kristmannsdottir GB, Wulf-Johansson H et al (2016) MFAP4 promotes vascular smooth muscle migration, proliferation and accelerates neointima formation. Arterioscler Thromb Vasc Biol 36(1):122–133PubMedGoogle Scholar
  16. 16.
    Pilop C, Aregger F, Gorman RC, Brunisholz R, Gerrits B, Schaffner T et al (2009) Proteomic analysis in aortic media of patients with Marfan syndrome reveals increased activity of calpain 2 in aortic aneurysms. Circulation 120(11):983–991CrossRefPubMedGoogle Scholar
  17. 17.
    Modrego J, Lopez-Farre AJ, Martinez-Lopez I, Muela M, Macaya C, Serrano J et al (2012) Expression of cytoskeleton and energetic metabolism-related proteins at human abdominal aortic aneurysm sites. J Vasc Surg 55(4):1124–1133CrossRefPubMedGoogle Scholar
  18. 18.
    Abdul-Salam VB, Wharton J, Cupitt J, Berryman M, Edwards RJ, Wilkins MR (2010) Proteomic analysis of lung tissues from patients with pulmonary arterial hypertension. Circulation 122(20):2058–2067CrossRefPubMedGoogle Scholar
  19. 19.
    Molleken C, Sitek B, Henkel C, Poschmann G, Sipos B, Wiese S et al (2009) Detection of novel biomarkers of liver cirrhosis by proteomic analysis. Hepatology 49(4):1257–1266CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Wulf-Johansson H, Lock Johansson S, Schlosser A, Trommelholt Holm A, Rasmussen LM, Mickley H et al (2013) Localization of microfibrillar-associated protein 4 (MFAP4) in human tissues: clinical evaluation of serum MFAP4 and its association with various cardiovascular conditions. PLoS ONE 8(12):e82243CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Saekmose SG, Mossner B, Christensen PB, Lindvig K, Schlosser A, Holst R et al (2015) Microfibrillar-associated protein 4: a potential biomarker for screening for liver fibrosis in a mixed patient cohort. PLoS ONE 10(10):e0140418CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Johansson SL, Roberts NB, Schlosser A, Andersen CB, Carlsen J, Wulf-Johansson H et al (2014) Microfibrillar-associated protein 4: a potential biomarker of chronic obstructive pulmonary disease. Respir Med 108(9):1336–1344CrossRefPubMedGoogle Scholar
  23. 23.
    Green A, Hauge M, Holm NV, Rasch LL (1981) Epidemiological studies of diabetes mellitus in Denmark. II. A prevalence study based on insulin prescriptions. Diabetologia 20(4):468–470CrossRefPubMedGoogle Scholar
  24. 24.
    Grauslund J, Jørgensen TMM, Nybo M, Green A, Rasmussen LM, Sjølie AK (2010) Risk factors for mortality and ischemic heart disease in patients with long-term type 1 diabetes. J Diabetes Complicat 24(4):223–228CrossRefPubMedGoogle Scholar
  25. 25.
    Grauslund J (2011) Eye complications and markers of morbidity and mortality in long-term type 1 diabetes. Acta Ophthalmol 89(THESIS 1):1–19CrossRefPubMedGoogle Scholar
  26. 26.
    Sjolie AK (1985) Ocular complications in insulin treated diabetes mellitus. An epidemiological study. Acta Ophthalmol Suppl 172:1–77PubMedGoogle Scholar
  27. 27.
    Early Treatment Diabetic Retinopathy Study Research Group (1991) Grading diabetic retinopathy from stereoscopic color fundus photographs—an extension of the modified Airlie House classification. ETDRS report number 10. Ophthalmology 98(5 Suppl):786–806Google Scholar
  28. 28.
    Early Treatment Diabetic Retinopathy Study Research Group (1991) Fundus photographic risk factors for progression of diabetic retinopathy. ETDRS report number 12. Ophthalmology 98(5 Suppl):823–833Google Scholar
  29. 29.
    Saekmose SG, Schlosser A, Holst R, Johansson SL, Wulf-Johansson H, Tornoe I et al (2013) Enzyme-linked immunosorbent assay characterization of basal variation and heritability of systemic microfibrillar-associated protein 4. PLoS ONE 8(12):e82383CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Holm AT, Wulf-Johansson H, Hvidsten S, Jorgensen PT, Schlosser A, Pilecki B et al (2015) Characterization of spontaneous air space enlargement in mice lacking microfibrillar-associated protein 4. Am J Physiol Lung Cell Mol Physiol 308(11):L1114–L1124CrossRefPubMedGoogle Scholar
  31. 31.
    Barrette B, Calvo E, Vallieres N, Lacroix S (2010) Transcriptional profiling of the injured sciatic nerve of mice carrying the Wld(S) mutant gene: identification of genes involved in neuroprotection, neuroinflammation, and nerve regeneration. Brain Behav Immun 24(8):1254–1267CrossRefPubMedGoogle Scholar
  32. 32.
  33. 33.
    Klein BE, Knudtson MD, Tsai MY, Klein R (2009) The relation of markers of inflammation and endothelial dysfunction to the prevalence and progression of diabetic retinopathy: Wisconsin epidemiologic study of diabetic retinopathy. Arch Ophthalmol 127(9):1175–1182CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Roy S, Amin S, Roy S (2016) Retinal fibrosis in diabetic retinopathy. Exp Eye Res 142:71–75CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.

Copyright information

© Springer-Verlag Italia 2016

Authors and Affiliations

  1. 1.Department of OphthalmologyOdense University HospitalOdense CDenmark
  2. 2.Department of Cancer and Inflammation, Institute of Molecular MedicineUniversity of Southern DenmarkOdense CDenmark
  3. 3.OPEN, Odense Patient data Exploratory NetworkOdense University HospitalOdense CDenmark
  4. 4.OPEN, Odense Patient data Exploratory Network, Department of Clinical ResearchUniversity of Southern DenmarkOdense CDenmark

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