key: cord-0775723-xor2j7c9
authors: Liu, Nan; Long, Hui; Sun, Jianhua; Li, Huan; He, Yunting; Wang, Qiang; Pan, Kai; Tong, Yongliang; Wang, Bingshun; Wu, Qingming; Gong, Likun
title: New laboratory evidence for the association between endothelial dysfunction and COVID‐19 disease progression
date: 2022-03-17
journal: J Med Virol
DOI: 10.1002/jmv.27693
sha: 4cfa866a2ab14efa6e0b5c99a3f44097c48ea959
doc_id: 775723
cord_uid: xor2j7c9

There is growing evidence that angiotensin‐converting enzyme 2 is highly expressed on endothelial cells, endothelial dysfunction plays a critical role in coronavirus disease 2019 (COVID‐19) progression, but laboratory evidence is still lacking. This study established a multicenter retrospective cohort of 966 COVID‐19 patients from three hospitals in Wuhan, China. We found that male (62.8% vs. 46.5%), old age [72 (17) vs. 60.5 (21)], and coexisting chronic diseases (88.5% vs. 60.0%) were associated with poor clinical prognosis in COVID‐19. Furthermore, the deteriorated patients exhibited more severe multiorgan damage, coagulation dysfunction, and extensive inflammation. Additionally, a cross‐sectional study including 41 non‐COVID‐19 controls and 39 COVID‐19 patients assayed endothelial function parameters in plasma and showed that COVID‐19 patients exhibited elevated vascular cell adhesion molecule‐1 (VCAM‐1) (median [IQR]: 0.32 [0.27] vs. 0.17 [0.11] μg/ml, p < 0.001), E‐selectin (21.06 [12.60] vs. 11.01 [4.63] ng/ml, p < 0.001), tissue‐type plasminogen activator (tPA) (0.22 [0.12] vs. 0.09 [0.04] ng/ml, p < 0.001), and decreased plasminogen activator inhibitor‐1 (0.75 [1.31] vs 6.20 [5.34] ng/ml, p < 0.001), as compared to normal controls. Moreover, VCAM‐1 was positively correlated with d‐dimer (R = 0.544, p < 0.001); tPA was positively correlated with d‐dimer (R = 0.800, p < 0.001) and blood urea nitrogen (R = 0.638, p < 0.001). Our findings further confirm the strong association between endothelial dysfunction and poor prognosis of COVID‐19, which offers a rationale for targeting endothelial dysfunction as a therapeutic strategy for COVID‐19.

poor prognosis of COVID-19, which offers a rationale for targeting endothelial dysfunction as a therapeutic strategy for COVID-19.

COVID-19, endothelial dysfunction, laboratory evidence, prognosis

The coronavirus disease 2019 (COVID-19) pneumonia epidemic has spread rapidly around the world since its occurrence. It poses an even more severe threat to global public health with the emergence of "super variants." [1] [2] [3] [4] [5] [6] A proportion of patients experience rapid disease exacerbation and even death during hospitalization for reasons that have not been fully elucidated. Angiotensin-converting enzyme 2 (ACE2) is a primary host target of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is widely expressed on the vascular endothelial cells of the lung, kidney, heart, and intestine. 7 A growing body of research has proposed that endothelial dysfunction may be an essential factor in the rapid progression of COVID-19, but laboratory evidence is still lacking. [8] [9] [10] The endothelium plays a crucial role in maintaining the dynamic balance between procoagulants and fibrinolytic factors in the vascular system. Resting endothelial cells maintain vascular homeostasis by expressing antiplatelet and anticoagulant agents to inhibit platelet aggregation and fibrin formation. Events such as SARS-CoV-2 infection could activate the endothelium, which releases more procoagulant factors, triggering fibrin formation, as well as platelet adhesion and aggregation, promoting and exacerbating diffuse microvascular and macrovascular thrombosis. 9, 11 Klok et al. 12 reported a 31% incidence of thrombotic complications in the intensive care unit patients with COVID-19. Autopsy findings from many locations reported the formation of deep vein thrombosis and pulmonary thromboembolism in COVID-19 decedents. [13] [14] [15] [16] Activated endothelial cells also release leukocyte adhesion molecules, pro-inflammatory cytokines, and chemokines which induce COVID-19-associated endotheliitis. 8 Varga et al. 17 To investigate the relationship between endothelial disorders and disease progression in patients with COVID-19, we first compared the demographic characteristics of COVID-19 patients with different outcomes. We then analyzed their multiple laboratory indicators, including organ function (liver, kidney, and heart), coagulation function, inflammatory status, and hematological indicators. Finally, we examined endothelial function parameters in plasma of COVID-19 patients versus non-COVID-19 controls by enzyme-linked immunosorbent assay (ELISA) and explored the correlation of these parameters with disease severity. This study is expected to provide further laboratory evidence for the connection between endothelial dysfunction and disease progression in COVID-19. Table 1 . Laboratory findings were tested within the first 3 days following admission ( Table 2 ).

The endpoint of this study was 14 days after access (including patients who were discharged or died during this period).

The cross-sectional study including 39 COVID-19 patients and 41 age-and sex-matched non-COVID-19 subjects was established in Tianyou Hospital. Blood specimens were collected at the time of the patient's initial diagnosis of COVID-19 or physical examination. The clinical characteristics of these participants are described in Table 3 . The flow chart of this study is shown in 

Contemporaneous blood specimens were obtained from age-and sex-matched patients with COVID-19 (n = 39) and non-COVID-19 subjects (n = 41) to investigate endothelial function. In all cases, a fasting blood sample was collected into test tubes containing EDTA in the morning and centrifuged at 3000g and 4°C for 10 min. Then, the blood plasma was collected and inactivated, portioned into 0.5 ml aliquots, and stored at −80°C until the assays were performed. 

Patients' clinical characteristics and laboratory findings were given the median (interquartile range) for continuous variables and the number (%) for categorical variables. The Wilcoxon rank-sum test was used for quantitative data not conforming to a normal distribution.

For categorical data, the χ 2 test was used. Pearson correlations examined relationships between variables, and false discovery rate was used to correct multiple comparisons. Graphical abstract was created using graphics from www.Biorender.com.

Missing data were omitted in the analysis of clinical indicators for different groups, and all statistical analyses were performed using SAS statistical software (version 9.4). We set the level of statistical significance at 5%, and all statistical tests were two-tailed.

Between January 13 and March 9, 2020, a total of 966 patients with laboratory-confirmed COVID-19 were enrolled, 888 (91.93%) of these patients were recovered/improved, and 78 (8.07%) were deteriorated/died. The clinical characteristics of the study cohort at baseline are described in Table 1 . As previously reported, males (62.82% vs. 46.51%) predominated in the deteriorated/died group compared with the recovered/improved group, and the patients in the deteriorated/died group were significantly older than those in the recovered/improved group [72 (17) vs. 60.5 (21) ]. Coexisting chronic diseases had higher frequencies in the deteriorated/died group (88.46%) than in the recovered/improved group (59.95%). There was no significant difference in common COVID-19 symptoms reported cough and fever between the groups.

On admission, compared with the recovered/improved group, the deteriorated/died group had significantly higher white blood cell (WBC) and neutrophil counts and more pronounced lymphopenia. In addition, they also exhibited more severe multiorgan impairment, mainly manifested by significantly elevated serum transaminases 

In this retrospective study, we found that the poor prognosis of infection. 22 Some individual factors, such as age and coexisting chronic diseases, also affect vascular endothelial function. 23, 24 Previous studies have reported that ACE2-mediated SARS-CoV-2 entry into the body may activate endothelial cells. [24] [25] [26] Endothelial cell activation leads to increased cytokines and adhesion molecules that trigger leukocyte homing, adhesion, and migration to the vascular endothelium. 27 Especially, E-selectin is probably the most specific for endothelial activation, 28 and we found here that plasma E-selectin concentrations were significantly higher in COVID-19 patients than non-COVID-19 controls. Endothelial cell activation is also involved in procoagulation, The renin-angiotensin-aldosterone system (RAAS) inhibitors, including ACE inhibitors and angiotensin receptor blockers, have been proven to improve endothelial dysfunction. 36 variables (e.g., markers of cardiac function) in our cohort may cause a bias in the results. However, the differences we found between the two groups were highly significant, making our results still convincing.

In summary, our study provides new laboratory evidence for the theory that endothelial dysfunction relates to multiorgan damage, extensive inflammation and coagulation disturbances, and eventual exacerbation/death in COVID-19 patients. Our findings provide new insights into how to advance the understanding of the pathogenesis of this disease and provide a basis for targeting endothelial dysfunction as a therapeutic strategy for COVID-19.

We thank the patients and their families or legal representatives for providing consent and assisting with the present study. Additionally, we want to express our gratitude to the hospital boards for their support. We are also very grateful to all the heads of the clinical departments and all the staff in the clinical biochemistry departments from the three hospitals mentioned in the article, without whose assistance this study could not have been completed. There was no funding source for this study.

The authors declare no conflicts of interest. 

The data that support the findings of this study are available on request from the corresponding author.

Qiang Wang https://orcid.org/0000-0001-7420-8646

Qingming Wu http://orcid.org/0000-0002-8009-1867

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New laboratory evidence for the association between endothelial dysfunction and COVID-19 disease progression