The mechanism by which heparan sulfate was downregulated in these lesions remained unknown for some time. One theory states that high glucose in circulation could lead to a decrease in GAG chain attachment to perlecan, but not necessarily a change in the synthetic pathway of the GAG chains or that of the core protein. After treatment of human aortic endothelial cells with high glucose medium, secreted perlecan contained less sulfate incorporation accompanied by less overall GAG chain incorporation. Although no signaling pathway is identified leading to this decrease in GAG chain incorporation, it is suggested that the 30% loss in overall glycosylation of the protein could mean loss of one of the three HS chains on perlecan in this model of diabetes-associated hyperglycemia. It is also noted that similar decreases in extracellular HS without a change in staining for the core protein chains occur in diabetic kidneys and in kidney cells in culture treated with high glucose.