Serum Dickkopf-1 signaling and calcium deposition in aortic valve are significantly related to the presence of concomitant coronary atherosclerosis in patients with symptomatic calcified aortic stenosis
© Motovska et al.; licensee BioMed Central. 2015
Received: 1 August 2014
Accepted: 29 January 2015
Published: 15 February 2015
The study aimed to assess serum RANKL:OPG ratio, Dkk-1 and deposition of calcium in aortic valve in relation to the presence of concomitant coronary atherosclerosis in patients with symptomatic calcified aortic stenosis (CAS).
OPG, soluble RANKL and Dkk-1 were measured in 218 consecutive patients who were undergoing cardiac catheterization because of symptomatic CAS. Values of studied compounds were compared between patients without (Group A) and with (Group B) coronary atherosclerosis. Computed tomography derived Agatston score was assessed by using 256-slice CT.
Presence of coronary atherosclerosis was related to significantly (p = 0.007) higher OPG and to significantly (p = 0.004) lower Dkk-1. Coronary atherosclerosis was also associated with a trend towards a decrease of RANKL. RANKL/OPG Ratios (mean (95% C.I.)) were: 20.04 (16.58; 24.23) in Group A and 12.69 (9.96; 16.17) in Group B, resp., p = 0.018). After adjustment, the difference in RANKL:OPG ratios was no longer significant. Multivariable regression underscored the significance of difference in Dkk-1 (pafter adjustement = 0.020). Group A patients had significantly higher Dkk-1, significantly higher deposition of calcium in aortic valve and were symptomatic in significantly younger age (p < 0.001) as compared to group B patients: Agatston score (mean (95% C.I.)) 4069.9 (3211.8; 5134.5) and 2413.5 (1821.3; 3198.1), p = 0.007.
Dkk-1 and deposition of calcium in aortic valve differ significantly in relation to the presence/absence of coronary atherosclerosis in patients with symptomatic CAS. A positive association was found between Dkk-1 and calcium load in aortic valve in patients with symptomatic CAS and angiographically normal coronary arteries.
KeywordsCalcified aortic stenosis Dickkopf-1 signaling Calcium deposition in aortic valve
Calcified aortic valve disease, a progressive mineralization of aortic valves, is responsible for the most common valve malfunction in adult population – aortic stenosis. Every 50th of individuals ≥ 65 years old has calcified aortic stenosis (CAS), with 80% progressing to symptoms requiring a surgery to prevent death and to improve quality of life [1,2].
It has been recognized, that the most significant predictor of clinical progression of calcified aortic valve disease is the load of calcium in aortic valve . The process of calcium deposition in aortic valve is a multi-factorial event where several pathways interact and influence disease progression . OPG (Osteoprotegerin)/RANKL (Receptor Activator Of Nuclear Factor Kappa B Ligand)/RANK cytokine axis and Wingless tail (Wnt)/Dickkopf-1 (Dkk-1) signaling have been linked to the development of atherosclerosis and might be along the causal pathway in regulation of valvular calcification in CAS. Published observations suggest that RANKL/RANK interaction stimulates vascular/valvular calcification. Osteoprotegerin acts as a decoy receptor for the pro-osteoclastic RANKL, and therefore OPG may inhibit the process of calcification . The OPG:RANKL ratio determines the net effect on osteoclasts. The effects of Dkk-1 on bone are mediated by inhibition of Wnt signaling, which directly impaired new bone formation and limited OPG expression, thereby shifting the OPG:RANKL ratio to favor bone resorption .
Degenerative aortic valve disease shares many features with atherosclerosis. The initial plaque of aortic stenosis is similar to that seen in coronary artery disease . However, a significant proportion of patients with severe aortic stenosis have no coronary atherosclerosis. Therefore, the study was designed to asses serum RANKL/OPG ratio, Dkk-1 signaling and deposition of calcium in aortic valve in patients with symptomatic CAS in relation to the presence of concomitant coronary atherosclerosis.
The research was carried out according to the principles of the Declaration of Helsinki. Patients gave informed consent and the Ethics committee of University Hospital Kralovske Vinohrady in Prague (Czech Rep.) approved the study.
Comparison of baseline characteristics of patients with symptomatic calcified aortic stenosis and without (Group A) or with (Group B) concomitant coronary atherosclerosis
N = 112
N = 106
Age years, mean (SD)
Men N (%)
Obesity N (%)
Hyperlipidemia N (%)
Hypertension N (%)
Diabetes mellitus N (%)
Smoking (anytime) N (%)
IACE therapy N (%)
ARB therapy N (%)
Statin therapy N (%)
Pressure gradient across the aortic valve (mmHg);
Mean ± SD
44.4 ± 17.9
40.4 ± 15.5
Median (25th to 75th percentile)
43 (32 to 57)
41 (28 to 50)
Peak aortic valve velocity (m/s)
Mean ± SD
4.1 ± 0.8
4.0 ± 0.8
Median (25th to 75th percentile)
4.2 (3.6 to 4.7)
4.0 (3.4 to 4.4)
Severe aortic stenosis N (%)
Blood samples were collected during cardiac catheterization. After standard processing, serum was stored at −70°C until assayed. Samples were assayed with OPG ELISA kit (Biovendor, Laboratorni Medicina, Brno, Czech Rep.), sRANKL ELISA kit (Biovendor, Laboratorni Medicina, Brno, Czech Rep.) and Dkk-1 ELISA kit (Biovendor, Laboratorni Medicina, Brno, Czech Rep.), respectively, according to the manufacturer’s protocol. Limits of detection were: 0.1 pmol/l of OPG, 0.4 pmol/l of sRANKL, and 0.01 ng/ml of Dkk-1.
Values of circulating OPG, sRANKL, Dkk-1 were compared between patients without (Group A) and with (Group B) concomitant coronary atherosclerosis (coronary artery stenosis ≥ 50%). Patients in group A had angiographically normal coronary arteries and without coronary calcification.
Continuous data are presented as arithmetic and geometric means for normally and log-normally distributed variables, respectively, and 95% confidence intervals are used to describe the amount of uncertainty associated with estimate of a population mean. For the analysis, the asymmetrically distributed dependent variables were log-transformed. The comparison of groups was based on Student’s t-test and multiple linear regressions, which were used to adjust for potential confounders. Categorical data are presented as absolute frequencies and percentages and were analyzed using Fisher’s exact test and the proportional odds model. A statistical analysis was performed by statistical software Stata, release 9.2 (Stata Corp LP, College Station, TX). All statistical tests were evaluated at a significance level of 0.05.
Comparison of studied compounds between patients with calcified aortic stenosis and without (Group A) or with (Group B) concomitant coronary atherosclerosis
A (N = 112)
B (N = 106)
P 1 -value
P 2 -value
P 3 - value
6.06 (5.58; 6.58)
7.27 (6.74; 7.84
gmean (95% C.I.)
121.43 (103.37; 142.64)
92.24 (73.35; 115.99)
gmean (95% C.I.)
1.44 (1.25; 1.66)
1.01 (0.87; 1.17)
gmean (95% C.I.)
After adjustment for variables that significantly influenced levels of OPG (age, diabetes mellitus) and RANKL (age, hypertension), the difference in RANKL:OPG ratio between Group A and Group B was no longer significant (Table 2). Conversely, multivariable regression underscored the significance of difference in Dkk-1 signaling in relation to the presence/absence of concomitant coronary atherosclerosis in patients with CAS (pafter adjustement = 0.020).
Active osteochondrogenic differentiation and signaling were demonstrated in aortic valves in CAS . Load of calcium in valve tissue was recognized as the substantial sign of disease progression. Recent studies have led to an understanding of the roles of cytokine and cell-signaling pathways involving OPG/RANKL/RANK and Wnt in disease pathogenesis. The cross talk between the two systems seems to be of biological relevance [10,11].
Both pathways, RANKL/RANK/OPG and Wnt, appear to be activated by atherogenic factors . There is a hypothesis according to which calcified aortic valve disease represents an atherosclerosis-like process involving the aortic valve [15,16]. Our study, however, which includes consecutive patients, confirmed previous observations that about half of patients with severe CAS had angiographically normal coronary arteries. Therefore we designed a study which aimed to asses serum RANKL/OPG ratio, Dkk-1 signaling and deposition of calcium in aortic valve in patients with symptomatic CAS in relation to the presence of concomitant coronary atherosclerosis. The study documented significant differences in serum Dkk-1 signaling and deposition of calcium in aortic valves in relation to the presence of concomitant coronary atherosclerosis in patients with symptomatic CAS. Our understanding of mechanisms controlling initiation and progression of aortic valve calcification is limited. Calcification of aortic valve is an actively-regulated multifactorial process. Study results evoke suggestions that concomitant coronary atherosclerosis influences progression of calcified aortic valve disease, or that there are at least two distinct pathogenic entities of aortic valve calcification.
We suggest that the main finding of this study is that elevation of serum Dkk-1 was associated with a significant increase of load of calcium in aortic valve. Rosenhek and colleagues  demonstrated that the presence of aortic valve calcium in patients with asymptomatic mild or moderate aortic stenosis was the single most significant predictor of clinical progression. The studied population consisted of consecutive patients who were being considered for aortic valve replacement because of symptomatic CAS. Patients with CAS and normal coronary angiography, with significantly higher Dkk-1 signaling and significantly higher load of calcium were symptomatic at significantly younger age in comparison to patients with CAS and significant coronary atherosclerosis.
Clinical observational studies showed that aortic valve calcification is inversely correlated with low bone tissue mineral density [17,18]. Direct in vivo measurements confirmed a paradox of simultaneous osteolysis and ectopic calcification in the same animal . This evidence suggests that osteoporosis may contribute to cardiovascular calcification by adding to a pathological microenvironment that promotes osteogenesis of the aortic valve. During bone resorption, biochemical factors are released into the circulation, contributing to vascular calcification . RANKL – RANK interaction induces osteoclast differentiation and activation, stimulates bone resorption, whereas OPG neutralizes the binding of RANKL to RANK and prevents bone loss. Dkk-1-mediated inhibition of Wnt blocks maturation of osteoblasts. Thereby, Dkk-1 enhances RANKL levels, because osteoblast precursors produce relatively large amounts of RANK ligand . It was confirmed by a clinical studies that serum Dkk-1 expression was highly inversely correlated with bone mass density . It was shown that agents that block bone resorption in animal models also block vascular calcification [23,24]. Dkk-1 antisense oligonucleotide treatment affected bone metabolism by increasing osteoblast numbers and also by reducing RANKL expression, ultimately decreasing osteoclastogenesis . Monoclonal neutralizing anti-Dkk-1 antibody reduces osteolytic bone resorption and increases bone formation in multiple myolema . Our results suggest that it might be interesting for further research examining the potential impact of Dkk-1 antagonists on progression of calcified aortic valve disease.
Circulating Dkk-1 and calcium deposition in aortic valve differ significantly in relation to the presence of coronary atherosclerosis in patients with symptomatic CAS. A positive association was found between serum Dkk-1 signaling and calcium load in aortic valve in patients with symptomatic CAS and angiographically normal coronary arteries.
The study was supported by the Internal Grant Agency of the Ministry of Health, Czech Republic, Project No. NT/13711.
- Rajamannan NM, Bonow RO, Rahimtoola SH. Calcific aortic stenosis: an update. Nat Clin Pract Cardiovasc Med. 2007;4:254–62.View ArticlePubMedGoogle Scholar
- Towler D. Vascular calcification: a perspective on an imminent disease epidemic. IBMS BoneKEy. 2008;5:41–58.View ArticleGoogle Scholar
- Rosenhek R, Binder T, Porenta G, Lang I, Christ G, Schemper M, et al. Predictors of outcome in severe, asymptomatic aortic stenosis. N Engl J Med. 2000;343:611–7.View ArticlePubMedGoogle Scholar
- Parolari A, Loardi C, Mussoni L, Cavallotti L, Camera M, Biglioli P, et al. Nonrheumatic calcific aortic stenosis: an overview from basic science to pharmacological prevention. Eur J Cardiothorac Surg. 2009;35:493–504.View ArticlePubMedGoogle Scholar
- Towler DA. Molecular and cellular aspects of calcific aortic valve disease. Circ Res. 2013;113:198–208.View ArticlePubMed CentralPubMedGoogle Scholar
- Pinzone JJ, Hall BM, Thudi NK, Vonau M, Qiang YW, Rosol TJ, et al. The role of Dickkopf-1 in bone development, homeostasis, and disease. Blood. 2009;113:517–25.View ArticlePubMed CentralPubMedGoogle Scholar
- Otto CM, Kuusisto J, Reichenbach DD, Gown AM, O’Brien KD. Characterization of the early lesion of ‘degenerative’ valvular aortic stenosis: histological and immunohistochemical studies. Circulation. 1994;90:844–53.View ArticlePubMedGoogle Scholar
- European Perspectives in Cardiology. Centres of excellence: the cardiocentre prague, czech republic. Circulation. 2008;118:f13–8.View ArticleGoogle Scholar
- Rajamannan NM, Subramaniam M, Rickard D, Stock SR, Donovan J, Springett M, et al. Human aortic valve calcification is associated with an osteoblast phenotype. Circulation. 2003;107:2181–4.View ArticlePubMed CentralPubMedGoogle Scholar
- Diarra D, Stolina M, Polzer K, Zwerina J, Ominsky MS, Dwyer D, et al. Dickkopf-1 is a master regulator of joint remodeling. Nat Med. 2007;13:156–63.View ArticlePubMedGoogle Scholar
- Rajamannan NM. Oxidative-mechanical stress signals stem cell niche mediated Lrp5 osteogenesis in eNOS(−/−) null mice. J Cell Biochem. 2012;113:1623–34.PubMed CentralPubMedGoogle Scholar
- Yasuda H, Shima N, Nakagawa N, Yamaguchi K, Kinosaki M, Mochizuki S, et al. Osteoclast differentiation factor is a ligand for osteoprotegerin/osteoclastogenesis-inhibitory factor and is identical to TRANCE/RANKL. Proc Natl Acad Sci U S A. 1998;95:3597–602.View ArticlePubMed CentralPubMedGoogle Scholar
- Shao JS, Cheng SL, Pingsterhaus JM, Charlton-Kachigian N, Loewy AP, Towler DA. Msx2 promotes cardiovascular calcification by activating paracrine Wnt signals. J Clin Invest. 2005;115:1210–20.View ArticlePubMed CentralPubMedGoogle Scholar
- O’Brien KD. Pathogenesis of calcific aortic valve disease: a disease process comes of age (and a good deal more). Arterioscler Thromb Vasc Biol. 2006;26:1721–8.View ArticlePubMedGoogle Scholar
- Wierzbicki A, Shetty C. Aortic stenosis: an atherosclerotic disease? J Heart Valve Dis. 1999;8:416–23.PubMedGoogle Scholar
- Agmon Y, Khandheria BK, Meissner I, Sicks JR, O’Fallon WM, Wiebers DO, et al. Aortic valve sclerosis and aortic atherosclerosis: different manifestations of the same disease? Insights from a population-based study. J Am Coll Cardiol. 2001;38:827–34.View ArticlePubMedGoogle Scholar
- Banks LM, Lees B, MacSweeney JE, Stevenson JC. Effect of degenerative spinal and aortic calcification on bone density measurements in post-menopausal women: links between osteoporosis and cardiovascular disease? Eur J Clin Invest. 1994;24:813–7.View ArticlePubMedGoogle Scholar
- Hak AE, Pols HA, van Hemert AM, Hofman A, Witteman JC. Progression of aortic calcification is associated with metacarpal bone loss during menopause: a population-based longitudinal study. Arterioscler Thromb Vasc Biol. 2000;20:1926–31.View ArticlePubMedGoogle Scholar
- Hjortnaes J, Butcher J, Figueiredo JL, Riccio M, Kohler RH, Kozloff KM, et al. Arterial and aortic valve calcification inversely correlates with osteoporotic bone remodelling: a role for inflammation. Eur Heart J. 2010;31:1975–84.View ArticlePubMed CentralPubMedGoogle Scholar
- Aicher A, Kollet O, Heeschen C, Liebner S, Urbich C, Ihling C, et al. The Wnt antagonist Dickkopf-1 mobilizes vasculogenic progenitor cells via activation of the bone marrow endosteal stem cell niche. Circ Res. 2008;103:796–803.View ArticlePubMedGoogle Scholar
- Tian E, Zhan F, Walker R, Rasmussen E, Ma Y, Barlogie B, et al. The role of the Wnt-signaling antagonist DKK1 in the development of osteolytic lesions in multiple myeloma. N Engl J Med. 2003;349:2483–94.View ArticlePubMedGoogle Scholar
- Butler JS, Murray DW, Hurson CJ, O’Brien J, Doran PP, O’Byrne JM. The role of Dkk1 in bone mass regulation: correlating serum Dkk1 expression with bone mineral density. J Orthop Res. 2011;29:414–8.View ArticlePubMedGoogle Scholar
- Price PA, June HH, Buckley JR, Williamson MK. Osteoprotegerin inhibits artery calcification induced by warfarin and by vitamin D. Arterioscler Thromb Vasc Biol. 2001;21:1610–6.View ArticlePubMedGoogle Scholar
- Shao JS, Cheng SL, Charlton-Kachigian N, Loewy AP, Towler DA. Teriparatide (human parathyroid hormone (1–34)) inhibits osteogenic vascular calcification in diabetic low density lipoprotein receptor-deficient mice. J Biol Chem. 2003;278:50195–202.View ArticlePubMedGoogle Scholar
- Baron R, Rawadi G. Targeting the Wnt/beta-catenin pathway to regulate bone formation in the adult skeleton. Endocrinology. 2007;148:2635–43.View ArticlePubMedGoogle Scholar
- Yaccoby S, Ling W, Zhan F, Walker R, Barlogie B, Shaughnessy JD. Antibody-based inhibition of DKK1 suppresses tumor-induced bone resorption and multiple myeloma growth in-vivo. Blood. 2006;109:2906–11.Google Scholar
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