Effect of rosuvastatin on fasting and postprandial endothelial biomarker levels and microvascular reactivity in patients with type 2 diabetes and dyslipidemia: a preliminary report
Kim et al. Cardiovasc Diabetol
Effect of rosuvastatin on fasting and postprandial endothelial biomarker levels and microvascular reactivity in patients with type 2 diabetes and dyslipidemia: a preliminary report
Kyoung Min Kim 0
Kyong Yeun Jung 2
Han Mi Yun 1
Seo Young Lee 0
Tae Jung Oh 0
Hak Chul Jang 0
Soo Lim 0
0 Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital , 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 463-707 , South Korea
1 Physiologic Diagnostic Laboratory, Vascular Laboratory, Seoul National University Bundang Hospital , Seongnam , South Korea
2 Department of Internal Medicine, Eulji General Hospital , Seoul , South Korea
Background: The cardiovascular benefits of statins have been proven, but their effect on circulation in small vessels has not been examined fully. We investigated the effect of 20 mg rosuvastatin on biomarkers, including paraoxonase-1 (PON-1) and asymmetric dimethylarginine (ADMA), and on microvascular reactivity. Method: We enrolled 20 dyslipidemic patients with type 2 diabetes and 20 age- and body mass index (BMI)matched healthy controls. Rosuvastatin (20 mg/day) was given to the patient group for 12 weeks. Biochemical parameters, including PON-1 and ADMA, were compared between the patient and control groups, and before and after rosuvastatin treatment in the patient group. Fasting and 2 h postprandial levels of PON-1 and ADMA after mixedmeal challenge were also compared. Microvascular reactivity in a peripheral artery was examined using laser Doppler flowmetry. Results: The respective mean ± standard deviation of age and BMI were 50.1 ± 3.8 year and 25.8 ± 3.7 kg/m2 in the patients and 50.2 ± 3.2 year and 25.4 ± 3.4 kg/m2 in the controls. The patient group had worse profiles of cardiometabolic biomarkers, including PON-1 and ADMA, than the controls. In the patients treated with 20 mg rosuvastatin, lowdensity lipoprotein (LDL)-cholesterol decreased from 147.2 ± 26.5 to 68.3 ± 24.5 mg/dL and high-density lipoprotein (HDL)-cholesterol increased from 42.4 ± 5.2 to 44.7 ± 6.2 mg/dL (both P < 0.05). Both fasting and 2 h postprandial levels of PON-1 increased and those of ADMA decreased after treatment with rosuvastatin for 12 weeks. The changes in postprandial levels of both biomarkers were greater than those after fasting. Microcirculation assessed as reactive hyperemia in the patients after an ischemic challenge increased significantly from 335.3 ± 123.4 to 402.7 ± 133.4% after rosuvastatin treatment. The postprandial changes in the biomarkers were significantly associated with improvement of microvascular reactivity. Conclusions: Rosuvastatin treatment for 12 weeks improved microvascular reactivity with concomitant beneficial changes in the postprandial levels of PON-1 and ADMA. These results suggest that rosuvastatin improves the postprandial cardiometabolic milieu in type 2 diabetes.
Trial registration ClinicalTrials.gov: NCT02185963 (July 7, 2014)
The cardiovascular benefits of statin treatment have been
proven in patients with type 2 diabetes (T2D) [
]. In the
Collaborative Atorvastatin Diabetes Study,
atorvastatin (10 mg/day) was found to be efficacious in reducing
the risk of cardiovascular events in patients with T2D,
even those without high levels of low-density lipoprotein
]. In the “Justification for the Use of
Statins in Prevention: An Intervention Trial Evaluating
Rosuvastatin” trial, treatment with 20 mg rosuvastatin
reduced major cardiovascular events in 17,802 healthy
individuals with relatively low levels of LDL-cholesterol
for up to 5 years [
However, studies that have investigated the effects of
statins on circulation in small vessels are limited. A recent
study reported that treatment with 20 mg pravastatin for
6 months improved fasting and postprandial endothelial
dysfunction as assessed by forearm blood flow during
post-ischemic reactive hyperemia in patients with angina
]. In a study of patients undergoing primary coronary
intervention, treatment of 40 mg atorvastatin before and
after the procedure reduced circulating levels of
endothelin-1, a marker of endothelial dysfunction [
Several biomarkers are directly related to endothelial
function or microcirculation. Among them, asymmetric
dimethylarginine (ADMA) and paraoxonase-1
(PON1) have drawn attention. ADMA is a dimethylarginine
structurally related to l-arginine. It is considered a key
regulator of vascular tone because it inhibits the
production of nitric oxide (NO). A study using metabolomics
has identified ADMA as a new biomarker of chronic
kidney disease [
]. High ADMA level leads to a decrease in
NO production, indicating its association with
endothelial dysfunction [
]. Cross-sectional studies have found
that ADMA levels are elevated in persons with T2D and
macrovascular disease [
]. Moreover, ADMA is an
independent risk factor for cardiovascular disease and
mortality in a wide spectrum of populations [
PON-1 is an enzyme associated with high-density
lipoprotein (HDL), and several studies have shown that
PON-1 has antioxidant and antiatherosclerotic effects.
This enzyme hydrolyzes aromatic carboxylic acid esters,
organophosphates, and oxidized phospholipids. Thus,
PON-1 protects against lipid oxidation, leading to a
decrease in oxidized lipoprotein production [
Decreased PON-1 activity is associated with
accelerated atherosclerosis . A meta-analysis suggested that
statin therapy is associated with a significant elevation of
PON-1 activity [
Skin microvascular reactivity, as measured
noninvasively by laser Doppler flowmetry, is a parameter that can
be used to assess the responsiveness of microcirculation
to occlusion or temperature [
reactivity is attenuated in insulin-resistant conditions, and is
an independent marker of future cardiovascular events
in patients with T2D. Therefore, it has been recently
adopted to assess endothelial function at an early stage
Postprandial lipid profiles are thought to be important
in vascular health. The cardiovascular milieu around the
vascular endothelium is aggravated particularly after a
high-fat meal. A recent study showed that a high-fat diet
increased NO consumption in the circulation [
that the removal of the lipids from the plasma
decelerates NO consumption, statin treatment might be able
to improve an unfavorable endothelial milieu after food
intake. However, to our knowledge, there is no study that
has investigated the effect of a statin on postprandial
levels of vascular biomarkers such ADMA or PON-1 and
their association with circulation in small vessels. Given
that most people spend about half of each day in
postprandial status, it would be intriguing to know whether
high-intensity statin treatment may influence
microcirculation, and, moreover, differently affect levels of
biomarkers in fasting and postprandial status.
The purpose of this study was to investigate the effect
of rosuvastatin biomarkers related to endothelial
function, focusing on ADMA and PON-1, and microvascular
reactivity in patients with T2D. We also assessed whether
changes in fasting and postprandial levels of ADMA or
PON-1 are associated with microvascular reactivity.
Patients and design
We recruited 20 patients with T2D and dyslipidemia and
20 age- and body-mass index (BMI)-matched healthy
controls. Inclusion criteria for the patients group were
individual with age ≥ 20 year, T2D with HbA1c ≥ 6.5%,
LDL-cholesterol level ≥ 100 mg/dL, and
HDL-cholesterol level < 40 mg/dL in men and < 50 mg/dL in women.
Exclusion criteria were contraindications to statins, a
statin medication history within 12 weeks of study
enrollment, and aspartate or alanine aminotransferase (AST or
ALT) levels > 3 times above the upper normal range. For
the healthy control group, individuals who had normal
glucose and lipid profiles without cardiovascular risk and
were ± 3 years of the age and ± 2 kg/m2 of the BMI of
the patient participants were selected.
First, we compared biochemical parameters and
microcirculation between the patients and healthy controls.
In addition to lipid and glucose metabolism parameters,
vascular biomarkers such as ADMA and PON-1 levels
were measured at fasting and in the 2 h postprandial
condition after the mixed-meal challenge in both patients
and controls. Second, in the patient group, we
investigated changes in microcirculation and fasting and
postprandial levels of ADMA and PON-1 between baseline
and after 12 weeks of treatment with 20 mg rosuvastatin
This study was approved by the Institutional Review
Board of Seoul National University Bundang
Hospital (SNUBH) (IRB no. B-1403-241-008) and complied
with the principles of the Declaration of Helsinki and its
contemporary amendments. This study was registered
at ClinicalTrials.gov: NCT02185963. All participants
provided their written informed consent to participate
before enrollment in this study.
Height and body weight were measured by standard
methods with the participants in light clothing. BMI was
calculated as body weight (in kg) divided by the square of
the height (in m).
We used a commercialized formula for the standardized
meal test (New Care, Daesang, Seoul, South Korea). A
can of New Care contains 200 kcal, 28 g of carbohydrates,
8 g of protein, 7 g of fat, and 180 mg of sodium. Detailed
information of the individual nutrient content is shown
in Additional file 1: Table S1. Two and a half cans of New
Care (500 kcal in total) were given to each patient
participant who had been in a fasting state for 10 h. Blood
samples were obtained at fasting and 2 h postprandially.
After 10 h of overnight fasting, venous blood
samples were taken for biochemical assays at baseline and
after rosuvastatin treatment. The serum levels of total
cholesterol, triglycerides, HDL-cholesterol, and
LDLcholesterol were measured using a Hitachi 747 Clinical
Chemistry Analyzer (Hitachi, Tokyo, Japan). Aspartate
aminotransferase/alanine aminotransferase (AST/ALT)
and creatinine were measured using an Architect Ci8200
analyzer (Abbott Laboratories, Abbott Park, IL, USA).
Plasma glucose concentration was measured using
a glucose oxidase method (747 Clinical Chemistry
Analyzer; Hitachi). Glycated hemoglobin (HbA1c) levels
were measured using a Bio-Rad Variant II Turbo HPLC
Analyzer (Bio-Rad, Hercules, CA, USA) in the National
Glycohemoglobin Standardization Program level II
certified laboratory at SNUBH. Fasting insulin levels were
measured by radioimmunoassay (Linco, St. Louis, MO,
USA). The homeostasis model assessments of insulin
resistance (HOMA-IR) and β-cell function (HOMA-β)
were calculated [
]. High-sensitivity C-reactive protein
(hsCRP) levels were measured with a high-sensitivity
automated immunoturbidimetric method (CRP II Latex
3; Denka Seiken, Tokyo, Japan).
Measurement of specific biomarkers related to endothelial function
Blood was centrifuged immediately after collection from
each participant, and the plasma was frozen and stored at
− 80 °C. The maximal storage time of the plasma samples
before analysis of biomarkers was 6 months.
PON-1 activity was measured in serum using
commercial enzyme-linked immunosorbent assay kits according
to the manufacturer’s instructions (VersaMax; Molecular
Devices, Sunnyvale, CA, USA) [
]. The intra- and
interassay coefficients of variation for the assays were 4.2 and
Plasma concentrations of ADMA were determined by
high-performance liquid chromatography/mass
spectrometry simultaneously with fluorescence detection
(LC–MS/MS, Agilent Technologies, Santa Clara, CA,
USA) as previously described [
], using modified
chromatographic separation conditions [
]. For ADMA, the
intra- and interassay coefficients of variation were < 2.1
and < 4.2%, respectively.
Assessment of microvascular reactivity in small vessels
Vascular health was assessed by microcirculation using a
laser Doppler system in a fasting state in both controls
and patients, and was repeated after 12 weeks of
rosuvastatin treatment only in the patient group. To measure
microvascular flow, a Laser Doppler perfusion monitor
system (PeriFlux System 5000, Perimed, Stockholm,
Sweden) was used [
]. This system operates with two laser
diodes that emit light with a wavelength of 780 nm. The
Laser Doppler probe was applied at the dorsum of the
hand, avoiding any underlying bony structures or large
vessels. Mean blood flow was measured over 1 min while
patients were resting. Postocclusive reactive hyperemia
was assessed during the examination by a 5-min
occlusion of the upper limb, which was performed using a cuff
placed on the upper arm. The pressure of the cuff was
50 mmHg higher than the systolic pressure measured
on the upper arm. The maximal flow within 5 min after
release of the cuff was recorded.
Data are given as the mean ± standard deviation (SD).
Baseline characteristics were compared between the
patient and control groups using a Student t or Mann–
Whitney U test. A paired t test or Wilcoxon signed-rank
test was used to compare various factors before and after
statin treatment. The Pearson correlation coefficient was
analyzed to evaluate the association between levels of
biomarkers and microcirculation. We considered P < 0.05
to be significant. Statistical analyses were performed
using SPSS Statistics for Windows (version 20.0, IBM
Corp, Armonk, NY, USA).
Comparison of biochemical parameters between patients with diabetes and healthy controls
Clinical and biochemical characteristics in the 20
dyslipidemic patients with T2D and 20 age- and BMI-matched
healthy controls are presented in Table 1. They were
generally middle aged and moderately overweight. Among
the patients with T2D, five were managed with lifestyle
modification alone, eight with metformin alone, and
seven with metformin plus other hypoglycemic agents.
As expected, the patients had higher fasting levels of
glucose, insulin, and HbA1c than the controls.
Accordingly, HOMA-IR was greater and HOMA-β was lower in
the patients than in the controls. Patient participants also
had significantly higher levels of fasting total cholesterol,
triglycerides, LDL-cholesterol, and hsCRP, and lower
levels of HDL-cholesterol. Fasting and 2 h postprandial
levels of ADMA were significantly higher in the patients
than in the controls. By contrast, fasting and 2 h
postprandial levels of PON-1 were significantly lower in the
patients than in the controls. Postocclusive
microvascular reactivity was significantly lower in the patients than
in the controls (P < 0.05), suggesting altered endothelial
Changes in biochemical parameters, including ADMA and PON‑1, and microcirculation after rosuvastatin treatment
All 20 study participants completed 12 weeks of
treatment with rosuvastatin. As shown in Table 2, BMI,
glycemic indices, HOMA-IR, and HOMA-β did not change
after 12 weeks of treatment with 20 mg rosuvastatin. Total
cholesterol, triglycerides, and LDL-cholesterol levels
decreased significantly, while HDL-cholesterol increased
significantly in response to rosuvastatin treatment.
Circulating concentrations of hsCRP also decreased
significantly after rosuvastatin treatment. The degree of
postocclusive reactive hyperemia increased by 20.1%
(from 335.3 ± 123.4 to 402.7 ± 133.4%) after same
duration of treatment (Table 2), suggesting altered
Fasting ADMA levels decreased by 3.87% and fasting
PON-1 levels increased by 5.88% after treatment with
rosuvastatin for 12 weeks (P = 0.040 and P = 0.066,
respectively). Levels of ADMA 2 h postprandially
decreased by 8.58% and those of PON-1 increased by
17.92% (both P < 0.01). Thus, the changes in fasting levels
of both markers were modest compared with the changes
in 2 h postprandial levels.
As shown in Fig. 1, the decrement in postprandial
ADMA levels was significantly greater than the
decrement in fasting ADMA levels (P = 0.025). The increment
in postprandial PON-1 levels was significantly greater
than the increment in fasting PON-1 levels (P = 0.041).
Correlations between changes in ADMA or PON-1
and changes in microvascular reactivity were analyzed
to determine whether they were directly associated. As
shown in Fig. 2b, d, the changes in 2 h postprandial levels
of ADMA and PON-1 after a mixed-meal test were
correlated with changes in microvascular reactivity
significantly. By contrast, there was no significant correlation
between changes in fasting levels of ADMA or PON-1
and changes in microvascular reactivity (Fig. 2a, c).
In the present study, circulating levels of ADMA and
hsCRP were significantly higher and levels of PON-1
were significantly lower in the patients than in the
ageand BMI-matched healthy controls. In the intervention
study, treatment with 20 mg rosuvastatin for 12 weeks
improved postocclusive microvascular reactivity in
the upper extremities, and increased PON-1 levels and
decreased ADMA levels both under fasting conditions
and 2 h postprandially. In particularly, changes in
postprandial levels of PON-1 and ADMA after rosuvastatin
treatment were significantly associated with
improvement in microvascular reactivity.
Endothelial function impairment is considered a
pathophysiological starting point in the initiation and
progression of atherosclerotic vascular diseases [
endothelial dysfunction is caused by endothelial damage
and leads to subsequent events such as vascular stenosis,
platelet aggregation, inflammation, and oxidative stress.
Ultimately, this series of processes leads to the rupture
of atheromatous plaques, resulting in an acute coronary
Unfortunately, it is difficult to assess endothelial
function at an early stage in vivo, despite much effort to do
so. Flow-mediated dilation is used for this purpose, but
it is somewhat examiner-dependent and not always
available. In our study, we assessed postocclusive
microvascular reactivity to detect early endothelial dysfunction
using laser Doppler flowmetry. Microvascular reactivity
was used as an early marker of endothelial dysfunction in
women with gestational diabetes [
circulatory function was assessed using laser Doppler
flowmetry in patients with T2D [
Among the many biomarkers related to vascular health,
ADMA and PON-1 reflect endothelial dysfunction and
are known as early markers for cardiovascular events.
High ADMA levels are associated with increases in
cardiovascular events such as myocardial infarction,
percutaneous coronary intervention, coronary-artery bypass
graft, stroke, and carotid revascularization in patients
with T2D [
]. Elevated levels of ADMA are
independently associated with an increased risk of poor
cardiovascular outcomes in T2D patients with coronary artery
disease (CAD) [
]. Thus, clinical studies have proven a
significant association between high ADMA levels and
worse cardiovascular outcomes. A recent study reported
that the circulating levels of ADMA were not altered
after 12 weeks of treatment with trelagliptin, a dipeptidyl
peptidase-4 inhibitor [
]. Additional studies are needed
to corroborate the clinical value of ADMA as a
The evidence on the effects of statin treatment on
ADMA levels is inconsistent. A meta-analysis reported
that hydrophilic statins such as rosuvastatin,
pravastatin, and fluvastatin decrease ADMA levels, while
hydrophobic statins such as atorvastatin or simvastatin do not
alter ADMA levels [
]. However, there is no study that
has investigated whether changes in ADMA levels after
statin treatment are associated with an improvement in
In the present study, ADMA levels decreased after
treatment with 20 mg rosuvastatin, and the decrement
in ADMA levels during a mixed-meal test was associated
with improved microvascular reactivity. Two potential
mechanisms underlying this finding can be suggested.
First, statins upregulate both proprotein convertase
subtilisin/kexin type 9 mRNA levels and LDL receptor
protein via activation of sterol-regulatory-element-binding
protein-2, an important activator of dimethylarginine
dimethylaminohydrolase (DDAH) transcription and
]. Second, statins inhibit ADMA-induced
inflammation, which is modulated by a
mitogen-activated protein kinase (MAPK) pathway in endothelial
]. Rosuvastatin preserves endothelial function
through stimulation of vascular endothelial NO [
Taken together, these studies suggest that statin therapy
might decrease ADMA levels through decreasing
inflammation aggravated by MAPK pathways and/or
activation of decreased activity of DDAH, which is linked to
PON-1 has drawn attention because of its
association with cardiovascular and metabolic disorders [
A case–control study suggests that lower PON-1 activity
and higher oxidized LDL levels are independently
associated with CAD [
]. PON-1 activity is associated with
HDL function, such as diminishing malondialdehyde
]. Moreover, PON-1 inactivation leads to
greater activation of protein kinase C-β, which is closely
linked to endothelial dysfunction [
], and decreased
phosphorylation of eNOS-Ser1177. This process blunts
NO production, aggravates monocyte–endothelial
cell adhesion, and impairs the endothelial repair
system. These findings suggest a potential mechanistic link
between decreased PON-1 activity and endothelial
function. Furthermore, HDL fails to stimulate NO
production or to antagonize endothelial inflammatory activation
from Pon1−/− mice [
]. These findings indicate that
PON-1 has an important impact on endothelial function,
which is consistent with the results of our present study
and those of others [
In addition to their lipid-lowering effect, several other
mechanisms could be inferred to explain the
improvement in microvascular function observed after treatment
with statins, particularly rosuvastatin. Improvement in
endothelial function after rosuvastatin treatment has
been demonstrated in studies performed in animals and
patients with heart failure [
]. In an in vitro study,
rosuvastatin treatment also suppressed the expression
of the alkaline phosphatase mRNA, a proposed
mechanism for vascular calcification , leading to impaired
vascular reactivity. Alleviation in inflammatory processes
by statin treatment was proven in cell studies [
Decrease in inflammatory markers by rosuvastatin
treatment was also found in clinical studies [
], and was
associated with mitigation of the progression of
atherosclerosis and reduction of cardiovascular events. In most
cases, these changes were not associated directly with
changes in lipid levels, which indicates that rosuvastatin
has multifactorial effects on vascular function beyond its
direct lipid-lowering action. Along these lines, the serum
levels of ADMA, a novel biomarker reflecting endothelial
dysfunction, and PON-1, a specific enzyme with
antioxidant and antiatherosclerotic properties, were modulated
in a positive direction by rosuvastatin treatment,
especially after fat loading, in the present study (Fig. 2). These
findings support the potential favorable effect of
rosuvastatin on microvascular reactivity beyond its
Postprandial hyperlipidemia triggers the
proatherosclerotic processes of endothelial cells and is more closely
related to early endothelial dysfunction than are
fasting levels [
]. In subjects with T2D, such postprandial
hyperlipidemia is prominent, long lasting, and finally
contributes to increased risks of atherosclerotic disease.
The therapeutic roles of lipid-lowering agents, including
statins and ezetimibe, which lower lipid levels and inhibit
the inflammatory process, have been proven to be
superior regarding postprandial status [
the effects of rosuvastatin in improving atherosclerotic
biomarkers are stronger in postprandial conditions, and
were closely correlated with the improvement of
microvascular reactivity in the present study.
Our present study has several limitations. First, our
study population comprised only a small number of
relatively healthy patients with T2D and dyslipidemia.
Second, the duration of treatment was short, so long-term
effects could not be evaluated. Third, antidiabetic
treatments in the present study were diverse, including
drugnaïve, treatment with metformin, or a combination of
metformin with sulfonylurea; this may affect ADMA or
PON-1 levels. Nevertheless, these treatments were
maintained throughout the study period.
Our present study also has several advantages. First,
we assessed circulation in small vessels using laser
Doppler flowmetry, which has been validated for assessing
endothelial dysfunction [
]. Second, a
standardized mixed-meal was given to the study participants to
measure postprandial levels of PON-1 and ADMA in a
standardized fashion. The changes in postprandial levels
of PON-1 and ADMA were associated with
microcirculation in small vessels after rosuvastatin treatment.
In the present study, treatment with 20 mg
rosuvastatin decreased hsCRP levels, which is consistent with the
results of other studies [
]. HsCRP reflects low-grade
inflammation and has links to future cardiovascular
events through having a deleterious effect on endothelial
In conclusion, treatment with 20 mg rosuvastatin
improved microvascular reactivity in patients who had
both diabetes and dyslipidemia. The favorable changes
observed in the levels of biomarkers, i.e., increased
PON-1 and decreased ADMA levels, which are related
to endothelial function, were significantly associated with
an improvement in microvascular reactivity. Our present
findings suggest that, in addition to the lipid-lowering
effects of rosuvastatin treatment, improved circulation in
small vessels may contribute to its positive outcomes on
cardiovascular morbidity and mortality.
Additional file 1: Table S1. Amount and percentage* of nutritional
components contained in 100 mL of a can of New Care.
T2D: type 2 diabetes; LDL: low-density lipoprotein; ADMA: asymmetric
dimethylarginine; PON-1: paraoxonase-1; NO: nitric oxide; AST: aspartate
aminotransferase; ALT: alanine aminotransferase; BMI: body mass index; HbA1c: glycated
hemoglobin; HOMA-IR: homeostasis model assessment of insulin resistance;
HOMA-β: homeostasis model assessment of β-cell function; hsCRP: high
sensitivity C-reactive protein; CAD: coronary artery disease; HDL: high-density
lipoprotein; MMT: mixed-meal test; SD: standard deviation; MAPK:
mitogenactivated protein kinase; DDAH: dimethylarginine dimethylaminohydrolase.
KMK, KYJ and SL researched data and contributed to the experimental
design and discussion. KMK, KYJ, HMY, SYL, TJO and HCJ researched data and
contributed to the discussion. KMK, KYJ and SL drafted the manuscript. All
authors edited and revised the manuscript and approved the final version.
SL is responsible for the integrity of the work as a whole. All authors read and
approved the final manuscript.
The authors declare that they have no competing interests.
Availability of data and materials
The datasets used and analyzed during the current study are available from
the corresponding author upon reasonable request.
Consent for publication
Not application with respect to patients, all the authors agreed to submission.
Ethics approval and consent to participate
This study was approved by the Institutional Review Board of Seoul National
University Bundang Hospital (SNUBH) (IRB No. B-1403-241-008) and complied
with the principles of the Declaration of Helsinki and its contemporary
amendments. All participants provided their written informed consent to
participate before enrollment in this study.
This work was supported by research grants from the Korea Diabetes
Association (B-1405/250-005) and Seoul National University Bundang Hospital. The
funding agencies had no role in the study design, data collection or analysis,
decision to publish or preparation of the manuscript. The sole responsibility
for the content of this paper lies with the authors.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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