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Licensed Unlicensed Requires Authentication Published by De Gruyter June 26, 2017

NGAL and MMP-9/NGAL as biomarkers of plaque vulnerability and targets of statins in patients with carotid atherosclerosis

  • Wolf Eilenberg , Stefan Stojkovic , Alexandra Kaider , Nicolas Kozakowski , Christoph M. Domenig , Christopher Burghuber , Josif Nanobachvili , Kurt Huber , Markus Klinger , Christoph Neumayer , Ihor Huk , Johann Wojta and Svitlana Demyanets EMAIL logo



Neutrophil gelatinase associated lipocalin (NGAL) is expressed in atherosclerotic lesions and was recently implicated in the pathogenesis of cardiovascular pathologies. Statins are known to exert stabilizing effects on atherosclerotic plaque. The aims of our study were (1) to investigate the association of serum NGAL and metalloproteinase (MMP)-9/NGAL complex with the vulnerability of the atherosclerotic plaque, and (2) to reveal the effects of statin treatment on circulating NGAL and MMP-9/NGAL levels in patients with carotid artery stenosis.


We examined the levels of NGAL and MMP-9/NGAL in blood samples from 136 patients with carotid artery stenosis by specific enzyme-linked immunosorbent assays.


Patients with vulnerable plaques, as determined by ultrasound (plaques with decreased echogenicity) and histological analysis (type VI according to the classification of American Heart Association [AHA]), displayed the highest levels of NGAL (both p<0.0001) and MMP-9/NGAL complex (p=0.0004 and p=0.004, respectively). Moreover, patients with symptomatic carotid atherosclerosis had significantly higher NGAL levels compared to asymptomatic patients (p=0.0007). The statin-treated group (n=108) demonstrated lower NGAL (73.9 vs. 128.0 μg/L, p<0.0001) and MMP-9/NGAL (28.9 vs. 40.6 μg/L, p=0.046) as compared to the non-statin group (n=28). Furthermore, in multivariate regression analysis NGAL, but not MMP-9/NGAL levels, were independently associated with symptomatic carotid artery stenosis. In addition, statin treatment was independently associated with lower NGAL levels.


Circulating NGAL and MMP-9/NGAL are associated with plaque vulnerability in patients with carotid artery stenosis. Statin treatment could contribute to plaque stabilization by reducing circulating NGAL and MMP-9/NGAL levels.

Corresponding author: Svitlana Demyanets, MD, PhD, Department of Laboratory Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria, Phone: +43 1 40400/53550, Fax: +43 1 40400/73587
Wolf Eilenberg and Stefan Stojkovic contributed equally to this work.


The authors wish to thank Mira Brekalo from the Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna for the excellent technical support.

  1. Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

  2. Financial support: Svitlana Demyanets has received grant support from the Herzfelder’sche Familienstiftung (Vienna, Austria). The other authors have no conflicts to report. Furthermore, this work was supported by the Association for the Promotion of Research in Atherosclerosis, Thrombosis and Vascular Biology.

  3. Employment or leadership: None declared.

  4. Honorarium: None declared.

  5. Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.


1. Kjeldsen L, Johnsen AH, Sengelov H, Borregaard N. Isolation and primary structure of NGAL, a novel protein associated with human neutrophil gelatinase. J Biol Chem 1993;268:10425–32.10.1016/S0021-9258(18)82217-7Search in Google Scholar

2. Liu Q, Nilsen-Hamilton M. Identification of a new acute phase protein. J Biol Chem 1995;270:22565–70.10.1074/jbc.270.38.22565Search in Google Scholar PubMed

3. Kashani K, Cheungpasitporn W, Ronco C. Biomarkers of acute kidney injury: the pathway from discovery to clinical adoption. Clin Chem Lab Med 2017;55:1074–89.10.1515/cclm-2016-0973Search in Google Scholar PubMed

4. Bolignano D, Coppolino G, Lacquaniti A, Buemi M. From kidney to cardiovascular diseases: NGAL as a biomarker beyond the confines of nephrology. Eur J Clin Invest 2010;40:273–6.10.1111/j.1365-2362.2010.02258.xSearch in Google Scholar PubMed

5. Eilenberg W, Stojkovic S, Piechota-Polanczyk A, Kaun C, Rauscher S, Groger M, et al. Neutrophil gelatinase-associated lipocalin (NGAL) is associated with symptomatic carotid atherosclerosis and drives pro-inflammatory state in vitro. Eur J Vasc Endovasc Surg 2016;51:623–31.10.1016/j.ejvs.2016.01.009Search in Google Scholar PubMed

6. Yan L, Borregaard N, Kjeldsen L, Moses MA. The high molecular weight urinary matrix metalloproteinase (MMP) activity is a complex of gelatinase B/MMP-9 and neutrophil gelatinase-associated lipocalin (NGAL). Modulation of MMP-9 activity by NGAL. J Biol Chem 2001;276:37258–65.10.1074/jbc.M106089200Search in Google Scholar PubMed

7. Kafkas N, Demponeras C, Zoubouloglou F, Spanou L, Babalis D, Makris K. Serum levels of gelatinase associated lipocalin as indicator of the inflammatory status in coronary artery disease. Int J Inflam 2012;2012:189–797.10.1155/2012/189797Search in Google Scholar PubMed PubMed Central

8. Lindberg S, Pedersen SH, Mogelvang R, Jensen JS, Flyvbjerg A, Galatius S, et al. Prognostic utility of neutrophil gelatinase-associated lipocalin in predicting mortality and cardiovascular events in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. J Am Coll Cardiol 2012;60:339–45.10.1016/j.jacc.2012.04.017Search in Google Scholar PubMed

9. Artom N, Montecucco F, Dallegri F, Pende A. Carotid atherosclerotic plaque stenosis: the stabilizing role of statins. Eur J Clin Invest 2014;44:1122–34.10.1111/eci.12340Search in Google Scholar PubMed

10. Biasucci LM, Biasillo G, Stefanelli A. Inflammatory markers, cholesterol and statins: pathophysiological role and clinical importance. Clin Chem Lab Med 2010;48:1685–91.10.1515/CCLM.2010.277Search in Google Scholar PubMed

11. Demyanets S, Kaun C, Maurer G, Huber K, Wojta J. Statins modulate expression of components of the plasminogen activator/plasmin system in human cardiac myocytes in vitro. J Thromb Haemost 2006;4:476–9.10.1111/j.1538-7836.2006.01747.xSearch in Google Scholar PubMed

12. Piechota-Polanczyk A, Demyanets S, Nykonenko O, Huk I, Mittlboeck M, Domenig CM, et al. Decreased tissue levels of cyclophilin A, a cyclosporine a target and phospho-ERK1/2 in simvastatin patients with abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2013;45:682–8.10.1016/j.ejvs.2013.02.015Search in Google Scholar PubMed

13. Piechota-Polanczyk A, Goraca A, Demyanets S, Mittlboeck M, Domenig C, Neumayer C, et al. Simvastatin decreases free radicals formation in the human abdominal aortic aneurysm wall via NF-kappaB. Eur J Vasc Endovasc Surg 2012;44:133–7.10.1016/j.ejvs.2012.04.020Search in Google Scholar PubMed

14. Stojkovic S, Kaun C, Heinz M, Krychtiuk KA, Rauscher S, Lemberger CE, et al. Interleukin-33 induces urokinase in human endothelial cells–possible impact on angiogenesis. J Thromb Haemost 2014;12:948–57.10.1111/jth.12581Search in Google Scholar PubMed

15. Park SJ, Kang SJ, Ahn JM, Chang M, Yun SC, Roh JH, et al. Effect of statin treatment on modifying plaque composition: a double-blind, randomized study. J Am Coll Cardiol 2016;67:1772–83.10.1016/j.jacc.2016.02.014Search in Google Scholar PubMed

16. Ammirati E, Moroni F, Norata GD, Magnoni M, Camici PG. Markers of inflammation associated with plaque progression and instability in patients with carotid atherosclerosis. Mediators Inflamm 2015;2015:718329.10.1155/2015/718329Search in Google Scholar PubMed PubMed Central

17. Gokaldas R, Singh M, Lal S, Benenstein RJ, Sahni R. Carotid stenosis: from diagnosis to management, where do we stand? Curr Atheroscler Rep 2015;17:480.10.1007/s11883-014-0480-7Search in Google Scholar PubMed

18. Hansson GK, Libby P, Tabas I. Inflammation and plaque vulnerability. J Intern Med 2015;278:483–93.10.1111/joim.12406Search in Google Scholar PubMed PubMed Central

19. Demyanets S, Konya V, Kastl SP, Kaun C, Rauscher S, Niessner A, et al. Interleukin-33 induces expression of adhesion molecules and inflammatory activation in human endothelial cells and in human atherosclerotic plaques. Arterioscler Thromb Vasc Biol 2011;31:2080–9.10.1161/ATVBAHA.111.231431Search in Google Scholar PubMed

20. Demyanets S, Huber K, Wojta J. Inflammation and the cardiovascular system. Eur Surg 2011;43:78–89.10.1007/s10353-011-0607-9Search in Google Scholar

21. Stojkovic S, Kaun C, Basilio J, Rauscher S, Hell L, Krychtiuk KA, et al. Tissue factor is induced by interleukin-33 in human endothelial cells: a new link between coagulation and inflammation. Sci Rep 2016;6:25171.10.1038/srep25171Search in Google Scholar PubMed PubMed Central

22. Montanari E, Stojkovic S, Kaun C, Lemberger CE, de Martin R, Rauscher S, et al. Interleukin-33 stimulates GM-CSF and M-CSF production by human endothelial cells. Thromb Haemost 2016;116:317–27.10.1160/TH15-12-0917Search in Google Scholar PubMed

23. Abella V, Scotece M, Conde J, Gomez R, Lois A, Pino J, et al. The potential of lipocalin-2/NGAL as biomarker for inflammatory and metabolic diseases. Biomarkers 2015;20:565–71.10.3109/1354750X.2015.1123354Search in Google Scholar PubMed PubMed Central

24. De Berardinis B, Gaggin HK, Magrini L, Belcher A, Zancla B, Femia A, et al. Comparison between admission natriuretic peptides, NGAL and sST2 testing for the prediction of worsening renal function in patients with acutely decompensated heart failure. Clin Chem Lab Med 2015;53:613–21.10.1515/cclm-2014-0191Search in Google Scholar PubMed

25. Anwaar I, Gottsater A, Hedblad B, Palmqvist B, Mattiasson I, Lindgarde F. Endothelial derived vasoactive factors and leukocyte derived inflammatory mediators in subjects with asymptomatic atherosclerosis. Angiology 1998;49:957–66.10.1177/000331979804901201Search in Google Scholar PubMed

26. Elneihoum AM, Falke P, Hedblad B, Lindgarde F, Ohlsson K. Leukocyte activation in atherosclerosis: correlation with risk factors. Atherosclerosis 1997;131:79–84.10.1016/S0021-9150(96)06077-7Search in Google Scholar

27. Giaginis C, Zira A, Katsargyris A, Klonaris C, Theocharis S. Clinical implication of plasma neutrophil gelatinase-associated lipocalin (NGAL) concentrations in patients with advanced carotid atherosclerosis. Clin Chem Lab Med 2010;48:1035–41.10.1515/CCLM.2010.211Search in Google Scholar PubMed

28. Hemdahl AL, Gabrielsen A, Zhu C, Eriksson P, Hedin U, Kastrup J, et al. Expression of neutrophil gelatinase-associated lipocalin in atherosclerosis and myocardial infarction. Arterioscler Thromb Vasc Biol 2006;26:136–42.10.1161/01.ATV.0000193567.88685.f4Search in Google Scholar PubMed

29. Leclercq A, Houard X, Philippe M, Ollivier V, Sebbag U, Meilhac O, et al. Involvement of intraplaque hemorrhage in atherothrombosis evolution via neutrophil protease enrichment. J Leukoc Biol 2007;82:1420–9.10.1189/jlb.1106671Search in Google Scholar PubMed

30. te Boekhorst BC, Bovens SM, Hellings WE, van der Kraak PH, van de Kolk KW, Vink A, et al. Molecular MRI of murine atherosclerotic plaque targeting NGAL: a protein associated with unstable human plaque characteristics. Cardiovasc Res 2011;89:680–8.10.1093/cvr/cvq340Search in Google Scholar PubMed

31. Amarenco P, Labreuche J. Lipid management in the prevention of stroke: review and updated meta-analysis of statins for stroke prevention. Lancet Neurol 2009;8:453–63.10.1016/S1474-4422(09)70058-4Search in Google Scholar PubMed

32. Merwick A, Albers GW, Arsava EM, Ay H, Calvet D, Coutts SB, et al. Reduction in early stroke risk in carotid stenosis with transient ischemic attack associated with statin treatment. Stroke 2013;44:2814–20.10.1161/STROKEAHA.113.001576Search in Google Scholar PubMed PubMed Central

33. Albert MA, Danielson E, Rifai N, Ridker PM. Effect of statin therapy on C-reactive protein levels: the pravastatin inflammation/CRP evaluation (PRINCE): a randomized trial and cohort study. JAMA 2001;286:64–70.10.1001/jama.286.1.64Search in Google Scholar PubMed

34. Liu T, Meng XY, Li T, Zhang DY, Zhou YH, Han QF, et al. Rosuvastatin may stabilize vulnerable carotid plaques and reduce carotid intima media thickness in patients with hyperlipidemia. Int J Cardiol 2016;212:20–1.10.1016/j.ijcard.2016.03.029Search in Google Scholar PubMed

35. Kadoglou NP, Kottas G, Lampropoulos S, Vitta I, Liapis CD. Serum levels of fetuin-A, osteoprotegerin and osteopontin in patients with coronary artery disease: effects of statin (HMGCoA-reductase inhibitor) therapy. Clin Drug Investig 2014;34:165–71.10.1007/s40261-013-0157-ySearch in Google Scholar PubMed

36. Kadoglou NP, Gerasimidis T, Moumtzouoglou A, Kapelouzou A, Sailer N, Fotiadis G, et al. Intensive lipid-lowering therapy ameliorates novel calcification markers and GSM score in patients with carotid stenosis. Eur J Vasc Endovasc Surg 2008;35:661–8.10.1016/j.ejvs.2007.12.011Search in Google Scholar PubMed

Received: 2017-2-23
Accepted: 2017-5-13
Published Online: 2017-6-26
Published in Print: 2017-11-27

©2018 Walter de Gruyter GmbH, Berlin/Boston

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