Ignite Creation Date:
2024-05-06 @ 3:49 PM
Last Modification Date:
2024-10-26 @ 1:57 PM
Study NCT ID:
NCT04766645
Status:
COMPLETED
Last Update Posted:
2023-07-18
First Post:
2021-02-22
Brief Title:
ACE2 Gender Differences in Stroke With COVID-19
Sponsor:
Fondazione Don Carlo Gnocchi Onlus
Organization:
Fondazione Don Carlo Gnocchi Onlus
Study Overview
Official Title:
Gender Differences in Stroke With COVID-19 Epigenetic and Biochemical Study of ACE2 Receptor and Relationship With Rehabilitative Outcome
Status:
COMPLETED
Status Verified Date:
2023-07
Last Known Status:
None
Delayed Posting:
No
If Stopped, Why?:
Not Stopped
Has Expanded Access:
False
If Expanded Access, NCT#:
N/A
Has Expanded Access, NCT# Status:
N/A
Acronym:
ACEGENDER
Brief Summary:
The new coronavirus SARS-CoV-2 causes the COVID-19 infection which showed a form of neurovirulence involving the Central and peripheral Nervous Systems Baig et al 2020 In a mouse model for human ACE2 expression the virus entered the brain mainly through the olfactory bulb pathway Netland et al 2008 with an encephalic invasion uniformly lethal even with low viral doses and without lung involvement The death of the animal was reasonably related to neuronal dysfunctiondeath in cardiorespiratory bone marrow centers while the absence of ACE2 prevented severe encephalopathy
Men has a highly frequency of severe and lethal COVID-19 and the observed gender difference could be related to the regulation of ACE2 receptor expression
The ACE2 gene is encoded by a region of the X chromosome that escapes inactivation so that women have an increased expression of this protein The process of inactivation of the X chromosome includes DNA methylation with a decrease in the expression of genes that are affected by methylation In This way an epigenetic mechanism could modulate the expression of ACE2 in a gender-specific way determining its levels and consequently its protective role
Also in this regulatory context of ACE2 expression the role of microRNA miRNA could be very important In fact the untranslated 3 region UTR of ACE2 presents a binding sequence for miRNA miR-200c-3p that has been found at high levels of expression in cellular models infected with H5N1 influenza virus Liu et al 2017
In addition high plasma levels of miR-200c-3p were found in patients with severe pneumonia while ACE2 was reduced suggesting a regulatory role of this miRNA in ACE2 receptor expression Liu et al 2017 Deficiency of 25 OHD is common among elderly and obese men during winter and spring highlighting the sex-specific difference observed in COVID-19 infection La Vignera et al 2020 This vitamin envolved in physical recovery Siotto et al 2019 and in the pathway of the renin angiotensin system seems important to be assessed in ex-COVID-19 patients with stroke outcomes in admission and at the end of the rehabilitation process
The study will consist in
Epigenetic study evaluation of methylation of ACE2 promoter and miR-200c-3p levels
Biochemical analysis the evaluation of levels of angiotensin II ACE2 and Vitamin D
Correlation between rehabilitative outcome and biological markers
Men has a highly frequency of severe and lethal COVID-19 and the observed gender difference could be related to the regulation of ACE2 receptor expression
The ACE2 gene is encoded by a region of the X chromosome that escapes inactivation so that women have an increased expression of this protein The process of inactivation of the X chromosome includes DNA methylation with a decrease in the expression of genes that are affected by methylation In This way an epigenetic mechanism could modulate the expression of ACE2 in a gender-specific way determining its levels and consequently its protective role
Also in this regulatory context of ACE2 expression the role of microRNA miRNA could be very important In fact the untranslated 3 region UTR of ACE2 presents a binding sequence for miRNA miR-200c-3p that has been found at high levels of expression in cellular models infected with H5N1 influenza virus Liu et al 2017
In addition high plasma levels of miR-200c-3p were found in patients with severe pneumonia while ACE2 was reduced suggesting a regulatory role of this miRNA in ACE2 receptor expression Liu et al 2017 Deficiency of 25 OHD is common among elderly and obese men during winter and spring highlighting the sex-specific difference observed in COVID-19 infection La Vignera et al 2020 This vitamin envolved in physical recovery Siotto et al 2019 and in the pathway of the renin angiotensin system seems important to be assessed in ex-COVID-19 patients with stroke outcomes in admission and at the end of the rehabilitation process
The study will consist in
Epigenetic study evaluation of methylation of ACE2 promoter and miR-200c-3p levels
Biochemical analysis the evaluation of levels of angiotensin II ACE2 and Vitamin D
Correlation between rehabilitative outcome and biological markers
Detailed Description:
A new coronavirus was identified in December 2019 in Wuhan China as the causative agent of Severe Acute Respiratory Syndrome SARS-CoV-2 a viral lung infection indicated by the acronym COVID-19 coronavirus disease 2019 By the end of January 2020 this rapidly spreading virus had already infected more than 100000 people in several countries leading the World Health Organization to declare a global emergency Wu et al 2020 The clinical manifestations of COVID-19 can vary from the common cold to more serious lung diseases such as those observed in the Severe Acute Respiratory Syndrome SARS of 2002-2003 and the Middle East Respiratory Syndrome MERS of 2011
The Sars-Cov2 virus like other RNA viruses also showed a form of neurovirulence with consequent involvement in some patients of the Central Nervous System CNS and Peripheral Nervous System SNP Baig et al 2020
Neurological symptoms in patients with COVID-19 infection fall into three categories
1 neurological expressions of the symptoms of the underlying disease headache dizziness dysfunction of consciousness ataxia epileptic manifestations and stroke
2 symptoms of neuro-peripheral origin hypo-ageusia hyposmia neuralgia
3 symptoms of skeletal muscle damage often associated with liver and kidney damage
The first data on COVID-19 infection are in favor of neurological involvement in a variable percentage of cases with particular expression in more severe patients Mao et al 2020 According to some authors involvement of the nervous system may be partly responsible for respiratory impairment Yan-Chao et al 2020
It should be noted that in the case of SARS-CoV infection in a mouse model for human ACE2 expression the virus had entered the brain mainly through the olfactory bulb pathway Netland et al 2008 Encephalic invasion was uniformly lethal with further evidence that brain inoculation with low viral doses could be lethal even without lung involvement The death of the animal was reasonably related to neuronal dysfunctiondeath in cardiorespiratory bone marrow centers and the histopathological picture was characterized by a minimal cellular infiltrate in the brain supporting the hypothesis of a transsynaptic viral dissemination The absence of ACE2 prevented severe encephalopathy in the animal model The structures selectively affected by neuronal death were the dorsal vagal complex nucleus of the solitary tract postremactic area dorsal motor nucleus of the vagus
On the other hand trans-nasal invasion selectively interfered with thalamic hypothalamic amygdala nuclei Some affected nuclei had no explanation in the connection eg cochlear nuclei The invoked mechanism of neuronal loss was that of a flock of cytokines IL-6
CNSSNP and muscle involvement is present in COVID-19 patients and a careful interpretation of them is desirable The hyposmia reported suggests a nasal infection route with direct access to the CNS This pathway could be alternative to the respiratory and intestinal pathways and theoretically it could occur as in some cases of SARS-COV with mainly neurological symptoms
Recently it has been reported that symptoms of corticospinal tract impairment have been observed in 67 of patients Helms et al 2020
The epidemiological data collected so far indicate a substantial difference between men and women in clinical manifestations and SARS-CoV-2 infections Specifically a mortality rate among men has been found to be 73 in China Chen et al 2020 59 in South Korea Korean society of infectious disease 2020 and 70 in Italy as reported by the Higher Institute of Health ISS In addition the mortality rate is very dependent on the presence of comorbidities In fact in 45000 Chinese patients positive for COVID-19 the mortality rate went from 09 in those patients without comorbidity to 105 73 and 63 in those with cardiovascular disease diabetes mellitus and hypertension respectively Novel Coronavirus Pneumonia Emergency Response Epidemiology Team 2020
In Italy data provided by the ISS have documented a percentage of deaths around 21 in patients without comorbidity a percentage that increases to 213 259 and 507 in those patients with one two and three comorbidities respectively
Thus the gender and presence of comorbidities have been identified as key factors in the evolution of COVID-19
In addition to pre-existing comorbidities which as already reported are almost always present in patients with severe and lethal COVID-19 with greater frequency in men the biological mechanisms are to be considered the main responsible for the observed gender difference
A hypothesis that attempts to explain all these epidiemological data is based on the regulation of ACE2 receptor expression Angiotensin Converting Enzyme 2
ACE2 is an enzyme that degrades angiontensin II by generating angiotensin 1-7 which plays a protective role against damage caused by infection inflammation and stress Vickers et al 2002 Zisman et al 2003
The SARS-CoV-2 virus penetrates the target cells of the respiratory system through the binding of its surface S protein spike protein to the ACE2 receptor reducing its expression
In this way there is also a decrease in angiotensin levels 1-7 resulting in increased hypertension and lung failure Gurwitz et al 2020
Therefore it is important to consider the expression of ACE2 in those patients with hypertension heart disease or diabetes when evaluating the different mortality rate in patients with these comorbidities
In addition gender-specific mortality could be precisely related to modulation of ACE2 expression In fact estrogens induce an increase in ACE2 receptor expression suggesting that at least in women of childbearing age even after infection this enzyme is able to perform its protective function particularly towards the lungs In men it seems that androgenic hormones play a pathogenetic role in modulating the expression of cellular enzymes such as serine protease TMPSSR2 involved in the phases following the attack of the virus on the receptor ie in the viral entry promoting the spread of the infection in lung cells
The ACE2 gene is encoded by a region of the X chromosome that escapes inactivation thus supporting the hypothesis of an increased expression of this protein in women who would have the advantage of being protected from the complications and fatalities of COVID-19 infection
The process of inactivation of the X chromosome includes DNA methylation and as a result there is a decrease in the expression of those genes that are affected by methylation In This way an epigenetic mechanism could modulate the expression of ACE2 in a gender-specific way determining its levels and consequently its protective role
Also in this regulatory context of ACE2 expression the role of microRNA miRNA could be very important In fact the untranslated 3 region UTR of ACE2 presents a binding sequence for miRNA miR-200c-3p that has been found at high levels of expression in cellular models infected with H5N1 influenza virus Liu et al 2017
In addition high plasma levels of miR-200c-3p were found in patients with severe pneumonia while ACE2 was reduced suggesting a regulatory role of this miRNA in ACE2 receptor expression Liu et al 2017
Vitamin D reduces the risk of viral infections especially respiratory infections as described in literature Martineau et al 2016 Gruber-Bzura et al 2018 Gombart et al 2020 Grant et al 2020 In fact Vitamin D increases cellular immunity by reducing circulating cytokines induced by the innate immune system in response to viral infections Huang et al 2020
Vitamin D deficiency or deficiency contributes to acute respiratory syndrome in which mortality increases with age and chronic comorbidities Vásárhelyi et al 2011 This vitamin is a prohormone that has been shown to attenuate acute lipopolysaccharide-induced lung damage in mice by regulating the expression of components of the renin angiotensin system including ACE and ACE2 renin and angiotensin III Xu J 2017 Tsujino et al 2019 In these two months different research groups strongly suggested the need for an analysis on the correlations between vitamin D levels and COVID-19 infections Tian et al 2020 Panarese et al 2020 Marik et al 2020 Serum concentrations of Vitamin D 25 OHD tend to decrease with age which may be determinant in COVID-19 infection due to case fatality rates CFR that increase with age
Reasons include less time spent in the sun and reduced vitamin D production as a result of lower levels of 7-dehydrocholesterol in the skin Siotto et al 2019 In addition it has been pointed out that deficiency of 25 OHD is particularly common among elderly and obese men post-menopausal women tend to control levels through Vitamin D supplements especially during winter and spring highlighting the sex-specific difference observed in COVID-19 infection La Vignera et al 2020
Considering the importance of this vitamin also in physical recovery Siotto et al 2019 in addition to its role in the pathway of the renin angiotensin system it seems important to assess serum levels in ex-COVID-19 patients with stroke outcomes in admission and at the end of the rehabilitation process
In summary epidemiological data collected in recent months in different countries around the world have shown how gender differences and the presence of comorbidities affect the mortality rate due to COVID-19 Our hypothesis is that biological factors could play an important role in determining the severity of the disease in particular the ACE2 receptor could be the key element in the development of the differences in gender-related immune response
Study objectives
Main objectives
To study the molecular mechanism of regulation of ACE2 in relation to gender in patients with NeuroCovid19 outcomes and in particular with stroke outcomes in Covid19 hospitalized in 3 rehabilitation facilities
In particular they will be performed
Epigenetic study evaluation of methylation levels of ACE2 promoter and miR-200c-3p levels
Biochemical analysis the evaluation of serum levels of angiotensin II ACE2 and Vitamin D
Correlation between rehabilitative outcome and biological markers epigenetic and biochemical This project will study the molecular mechanisms underlying the regulation of ACE2 related to gender differences in patients post stroke in NeuroCOVID-19 stroke hospitalized in Rehabilitation facilities and the relationship between these variables and the rehabilitation outcome
If the study showed the presence of molecular mechanisms capable of influencing recovery we could identify rehabilitation pathways more tailored to the characteristics of the patient
The Sars-Cov2 virus like other RNA viruses also showed a form of neurovirulence with consequent involvement in some patients of the Central Nervous System CNS and Peripheral Nervous System SNP Baig et al 2020
Neurological symptoms in patients with COVID-19 infection fall into three categories
1 neurological expressions of the symptoms of the underlying disease headache dizziness dysfunction of consciousness ataxia epileptic manifestations and stroke
2 symptoms of neuro-peripheral origin hypo-ageusia hyposmia neuralgia
3 symptoms of skeletal muscle damage often associated with liver and kidney damage
The first data on COVID-19 infection are in favor of neurological involvement in a variable percentage of cases with particular expression in more severe patients Mao et al 2020 According to some authors involvement of the nervous system may be partly responsible for respiratory impairment Yan-Chao et al 2020
It should be noted that in the case of SARS-CoV infection in a mouse model for human ACE2 expression the virus had entered the brain mainly through the olfactory bulb pathway Netland et al 2008 Encephalic invasion was uniformly lethal with further evidence that brain inoculation with low viral doses could be lethal even without lung involvement The death of the animal was reasonably related to neuronal dysfunctiondeath in cardiorespiratory bone marrow centers and the histopathological picture was characterized by a minimal cellular infiltrate in the brain supporting the hypothesis of a transsynaptic viral dissemination The absence of ACE2 prevented severe encephalopathy in the animal model The structures selectively affected by neuronal death were the dorsal vagal complex nucleus of the solitary tract postremactic area dorsal motor nucleus of the vagus
On the other hand trans-nasal invasion selectively interfered with thalamic hypothalamic amygdala nuclei Some affected nuclei had no explanation in the connection eg cochlear nuclei The invoked mechanism of neuronal loss was that of a flock of cytokines IL-6
CNSSNP and muscle involvement is present in COVID-19 patients and a careful interpretation of them is desirable The hyposmia reported suggests a nasal infection route with direct access to the CNS This pathway could be alternative to the respiratory and intestinal pathways and theoretically it could occur as in some cases of SARS-COV with mainly neurological symptoms
Recently it has been reported that symptoms of corticospinal tract impairment have been observed in 67 of patients Helms et al 2020
The epidemiological data collected so far indicate a substantial difference between men and women in clinical manifestations and SARS-CoV-2 infections Specifically a mortality rate among men has been found to be 73 in China Chen et al 2020 59 in South Korea Korean society of infectious disease 2020 and 70 in Italy as reported by the Higher Institute of Health ISS In addition the mortality rate is very dependent on the presence of comorbidities In fact in 45000 Chinese patients positive for COVID-19 the mortality rate went from 09 in those patients without comorbidity to 105 73 and 63 in those with cardiovascular disease diabetes mellitus and hypertension respectively Novel Coronavirus Pneumonia Emergency Response Epidemiology Team 2020
In Italy data provided by the ISS have documented a percentage of deaths around 21 in patients without comorbidity a percentage that increases to 213 259 and 507 in those patients with one two and three comorbidities respectively
Thus the gender and presence of comorbidities have been identified as key factors in the evolution of COVID-19
In addition to pre-existing comorbidities which as already reported are almost always present in patients with severe and lethal COVID-19 with greater frequency in men the biological mechanisms are to be considered the main responsible for the observed gender difference
A hypothesis that attempts to explain all these epidiemological data is based on the regulation of ACE2 receptor expression Angiotensin Converting Enzyme 2
ACE2 is an enzyme that degrades angiontensin II by generating angiotensin 1-7 which plays a protective role against damage caused by infection inflammation and stress Vickers et al 2002 Zisman et al 2003
The SARS-CoV-2 virus penetrates the target cells of the respiratory system through the binding of its surface S protein spike protein to the ACE2 receptor reducing its expression
In this way there is also a decrease in angiotensin levels 1-7 resulting in increased hypertension and lung failure Gurwitz et al 2020
Therefore it is important to consider the expression of ACE2 in those patients with hypertension heart disease or diabetes when evaluating the different mortality rate in patients with these comorbidities
In addition gender-specific mortality could be precisely related to modulation of ACE2 expression In fact estrogens induce an increase in ACE2 receptor expression suggesting that at least in women of childbearing age even after infection this enzyme is able to perform its protective function particularly towards the lungs In men it seems that androgenic hormones play a pathogenetic role in modulating the expression of cellular enzymes such as serine protease TMPSSR2 involved in the phases following the attack of the virus on the receptor ie in the viral entry promoting the spread of the infection in lung cells
The ACE2 gene is encoded by a region of the X chromosome that escapes inactivation thus supporting the hypothesis of an increased expression of this protein in women who would have the advantage of being protected from the complications and fatalities of COVID-19 infection
The process of inactivation of the X chromosome includes DNA methylation and as a result there is a decrease in the expression of those genes that are affected by methylation In This way an epigenetic mechanism could modulate the expression of ACE2 in a gender-specific way determining its levels and consequently its protective role
Also in this regulatory context of ACE2 expression the role of microRNA miRNA could be very important In fact the untranslated 3 region UTR of ACE2 presents a binding sequence for miRNA miR-200c-3p that has been found at high levels of expression in cellular models infected with H5N1 influenza virus Liu et al 2017
In addition high plasma levels of miR-200c-3p were found in patients with severe pneumonia while ACE2 was reduced suggesting a regulatory role of this miRNA in ACE2 receptor expression Liu et al 2017
Vitamin D reduces the risk of viral infections especially respiratory infections as described in literature Martineau et al 2016 Gruber-Bzura et al 2018 Gombart et al 2020 Grant et al 2020 In fact Vitamin D increases cellular immunity by reducing circulating cytokines induced by the innate immune system in response to viral infections Huang et al 2020
Vitamin D deficiency or deficiency contributes to acute respiratory syndrome in which mortality increases with age and chronic comorbidities Vásárhelyi et al 2011 This vitamin is a prohormone that has been shown to attenuate acute lipopolysaccharide-induced lung damage in mice by regulating the expression of components of the renin angiotensin system including ACE and ACE2 renin and angiotensin III Xu J 2017 Tsujino et al 2019 In these two months different research groups strongly suggested the need for an analysis on the correlations between vitamin D levels and COVID-19 infections Tian et al 2020 Panarese et al 2020 Marik et al 2020 Serum concentrations of Vitamin D 25 OHD tend to decrease with age which may be determinant in COVID-19 infection due to case fatality rates CFR that increase with age
Reasons include less time spent in the sun and reduced vitamin D production as a result of lower levels of 7-dehydrocholesterol in the skin Siotto et al 2019 In addition it has been pointed out that deficiency of 25 OHD is particularly common among elderly and obese men post-menopausal women tend to control levels through Vitamin D supplements especially during winter and spring highlighting the sex-specific difference observed in COVID-19 infection La Vignera et al 2020
Considering the importance of this vitamin also in physical recovery Siotto et al 2019 in addition to its role in the pathway of the renin angiotensin system it seems important to assess serum levels in ex-COVID-19 patients with stroke outcomes in admission and at the end of the rehabilitation process
In summary epidemiological data collected in recent months in different countries around the world have shown how gender differences and the presence of comorbidities affect the mortality rate due to COVID-19 Our hypothesis is that biological factors could play an important role in determining the severity of the disease in particular the ACE2 receptor could be the key element in the development of the differences in gender-related immune response
Study objectives
Main objectives
To study the molecular mechanism of regulation of ACE2 in relation to gender in patients with NeuroCovid19 outcomes and in particular with stroke outcomes in Covid19 hospitalized in 3 rehabilitation facilities
In particular they will be performed
Epigenetic study evaluation of methylation levels of ACE2 promoter and miR-200c-3p levels
Biochemical analysis the evaluation of serum levels of angiotensin II ACE2 and Vitamin D
Correlation between rehabilitative outcome and biological markers epigenetic and biochemical This project will study the molecular mechanisms underlying the regulation of ACE2 related to gender differences in patients post stroke in NeuroCOVID-19 stroke hospitalized in Rehabilitation facilities and the relationship between these variables and the rehabilitation outcome
If the study showed the presence of molecular mechanisms capable of influencing recovery we could identify rehabilitation pathways more tailored to the characteristics of the patient
Study Oversight
Has Oversight DMC:
None
Is a FDA Regulated Drug?:
False
Is a FDA Regulated Device?:
False
Is an Unapproved Device?:
None
Is a PPSD?:
None
Is a US Export?:
None
Is an FDA AA801 Violation?:
None