key: cord-1050117-mkclqzy3
authors: Smadja, David M.; Philippe, Aurélien; Bory, Olivier; Gendron, Nicolas; Beauvais, Agathe; Gruest, Maxime; Peron, Nicolas; Khider, Lina; Guerin, Coralie L.; Goudot, Guillaume; Levavasseur, Françoise; Duchemin, Jérome; Pene, Frédéric; Cheurfa, Cherifa; Szwebel, Tali‐Anne; Sourdeau, Elise; Planquette, Benjamin; Hauw‐Berlemont, Caroline; Hermann, Bertrand; Gaussem, Pascale; Samama, Charles‐Marc; Mirault, Tristan; Terrier, Benjamin; Sanchez, Olivier; Rance, Bastien; Fontenay, Michaela; Diehl, Jean‐Luc; Chocron, Richard
title: Placental growth factor level in plasma predicts COVID‐19 severity and in‐hospital mortality
date: 2021-05-17
journal: J Thromb Haemost
DOI: 10.1111/jth.15339
sha: 82cfb4d51cd273347a1f50bc822c0388f5f90057
doc_id: 1050117
cord_uid: mkclqzy3

BACKGROUND: Coronavirus disease 2019 (COVID‐19) is a respiratory disease associated with vascular inflammation and endothelial injury. OBJECTIVES: To correlate circulating angiogenic markers vascular endothelial growth factor A (VEGF‐A), placental growth factor (PlGF), and fibroblast growth factor 2 (FGF‐2) to in‐hospital mortality in COVID‐19 adult patients. METHODS: Consecutive ambulatory and hospitalized patients with COVID‐19 infection were enrolled. VEGF‐A, PlGF, and FGF‐2 were measured in each patient ≤48 h following admission. RESULTS: The study enrolled 237 patients with suspected COVID‐19: 208 patients had a positive diagnostic for COVID‐19, of whom 23 were mild outpatients and 185 patients hospitalized after admission. Levels of VEGF‐A, PlGF, and FGF‐2 significantly increase with the severity of the disease (P < .001). Using a logistic regression model, we found a significant association between the increase of FGF‐2 or PlGF and mortality (odds ratio [OR] 1.11, 95% confidence interval [CI; 1.07–1.16], P < .001 for FGF‐2 and OR 1.07 95% CI [1.04–1.10], P < .001 for PlGF) while no association were found for VEGF‐A levels. Receiver operating characteristic curve analysis was performed and we identified PlGF above 30 pg/ml as the best predictor of in‐hospital mortality in COVID‐19 patients. Survival analysis for PlGF confirmed its interest for in‐hospital mortality prediction, by using a Kaplan‐Meier survival curve (P = .001) and a Cox proportional hazard model adjusted to age, body mass index, D‐dimer, and C‐reactive protein (3.23 95% CI [1.29–8.11], P = .001). CONCLUSION: Angiogenic factor PlGF is a relevant predictive factor for in‐hospital mortality in COVID‐19 patients. More than a biomarker, we hypothesize that PlGF blocking strategies could be a new interesting therapeutic approach in COVID‐19.

Coronavirus disease 2019 (COVID-19) mortality is related to respiratory failure characterized by interstitial pneumonia progressing into a life-threatening acute respiratory distress syndrome with a potential evolution in fibrosis. 1 The pathogenic pathways involved in the local lung fibrogenesis, in particular in idiopathic pulmonary fibrosis (IPF), are still elusive. However, lung parenchymal lesions are consistently associated with major vascular remodeling processes, 2 microvascular alterations, 3 and changes in endothelial phenotype. [4] [5] [6] Mechanisms underlying this vascular remodeling are yet to be elucidated. We previously proposed a deregulation of circulating angiogenic factors as a potential origin of endothelial dysfunction in IPF. 7 Autopsy findings and circulating markers of endotheliopathy in COVID-19 have accumulated. [8] [9] [10] [11] [12] This endothelial injury is probably mostly the result of cytokine release and complement-system activation. 11 ,13 Moreover, we recently described an association between several biomarkers of endothelial activation and intensive care unit (ICU) referral or in-hospital mortality. 14, 15 Moreover, more than endothelial lesion, increased vessel growth, through a mechanism of intussusceptive angiogenesis has been reported in the lungs of patients who died from COVID-19 16 in contrast to patients who died from influenza virus. This abnormal angiogenesis was associated with a dysregulated expression of numerous angiogenesis-related genes. 16 However, the association of circulating angiogenic marker levels with disease severity and mortality has still not been established in large cohorts.

The objective of the present study was to assess if major angiogenic biomarkers vascular endothelial growth factor (VEGF)-A, fibroblast growth factor (FGF)-2 and placental growth factor (PlGF) measured at admission were predictive of in-hospital mortality in a large cohort of 208 adult COVID-19-positive patients.

We performed a bi-centric cross-sectional study of adult (≥18 years old) COVID- 19 Objectives: To correlate circulating angiogenic markers vascular endothelial growth factor A (VEGF-A), placental growth factor (PlGF), and fibroblast growth factor 2 (FGF-2) to in-hospital mortality in COVID-19 adult patients.

Consecutive ambulatory and hospitalized patients with COVID-19 infection were enrolled. VEGF-A, PlGF, and FGF-2 were measured in each patient ≤48 h following admission.

The study enrolled 237 patients with suspected COVID-19: 208 patients had a positive diagnostic for COVID-19, of whom 23 were mild outpatients and 185 patients hospitalized after admission. Levels of VEGF-A, PlGF, and FGF-2 significantly increase with the severity of the disease (P < .001). Using a logistic regression model, we found a significant association between the increase of FGF-2 or PlGF and mortal- Conclusion: Angiogenic factor PlGF is a relevant predictive factor for in-hospital mortality in COVID-19 patients. More than a biomarker, we hypothesize that PlGF blocking strategies could be a new interesting therapeutic approach in COVID-19.

angiogenesis, COVID-19, FGF-2, mortality, placental growth factor, PlGF all patients included or their trusted relatives at the time of enrollment (SARCODO 2020-A01048-31A, NCT04624997). All included patients, hospitalized or not, presented a confirmed diagnosis of COVID-19, using a reverse transcriptase-polymerase chain reaction (RT-PCR) assay on nasopharyngeal swab samples as previously described. 15 Patients were classified according to World Health Organization guidance (WHO) as non-critical (median oxygen requirement 3 L/min; WHO score range 4-6) or critical (requiring mechanical ventilation, WHO score range 7-9) in the first 48 h following admission for clinically suspected COVID-19. Outpatients were COVID-19 patients who did not meet hospitalization criteria and returned home immediately after RT-PCR testing for COVID-19. None of the outpatients required supplemental oxygen, were later hospitalized, or died in the month following COVID-19 diagnosis. Finally, we also included 29 non-COVID-19 non-hospitalized individuals who served as controls. These patients had suspected COVID-19, but with mild clinical presentation and a negative RT-PCR result. Patient characteristics including age, sex, comorbidities, medical history, and treatment at admission were recorded. The primary outcome was COVID-19 inhospital mortality. 

Continuous data were expressed as median (interquartile range [IQR]) and categorical data as frequencies and proportions. The association between levels of angiogenic biomarkers and COVID-19 severity was assessed using the Kruskal-Wallis test followed by Dunn's post-test for multiple group comparisons with median reported. Clinical characteristics and outcomes (categorical variables) were compared according to the COVID-19 severity using the Cochran-Armitage trend test. Spearman rank coefficient correlation was used to determine the correlation between angiogenic biomarkers (VEGF-A, PLGF, and FGF-2) and biomarkers of multiorgan dysfunction (creatinine, Hs-TnI, D-dimer, and CRP). In order to estimate the ability of PlGF to predict in-hospital mortality, we used receiver operating characteristic (ROC) analysis. We estimated the area under the curve (AUC) and its 95% confidence interval (CI) and selected the optimal cutoff that illustrated the prognostic ability of PlGF. For the survival analysis among patients hospitalized for COVID-19, the start of the study was triggered by the diagnosis of SARS-CoV-2 infection. The end of the study was defined either by patient's death during their hospitalization or by discharge alive from the hospital. We used the Kaplan-Meier curve to estimate the survival function from diagnosis to in-hospital death according to the optimal cutoff of PlGF. Survival curves were compared using the log-rank test. We used the Cox proportional hazard model adjusted for age, body mass index (BMI), D-dimer, and CRP levels to investigate the relationships between the increase in PlGF (over the calculated cut-off value) and in-hospital mortality. In sensitivity analysis, to adjust for bias due to nonrandom allocation of potential covariates among COVID-19 patients, we applied propensity score-matching methods. For each angiogenic biomarker, we estimated the propensity score by running a logistic regression model in which the outcome variable is a binary variable indicating biomarkers levels status (< or > threshold). We included any covariate that is related to both biomarkers and potential outcomes such as age, sex, and BMI. Then a 1:1 match was performed using Greedy matching techniques. Based on the matched dataset, we compare patients' characteristics and outcomes according to the threshold of angiogenic biomarkers (< or > threshold). All analyses were two-sided and a P-value of <.05 was considered statistically significant. Statistical analysis was performed using R studio software (R Foundation for Statistical Computing).

A total of 208 COVID-19 adult patients comprising 23 outpatients and 185 hospitalized patients were included (Table 1) Figure 1A) . We evaluated the correlation between VEGF-A, PlGF, and FGF-2 and biomarkers of multiorgan dysfunction. Because Hs-TnI, D-dimer, CRP, and creatinine at admission were associated to severity, 9, 17 we analyzed the association of angiogenic factors with these four markers ( Figure 1D-O) . While a significant association was found between CRP, D-dimer, and the three angiogenic biomarkers studied (all with P-value < .001), no association existed with creatinine, Hs-TnI, and VEGF-A (P = .16 for VEGF-A and creatinine; P = .07 for Hs-TnI and VEGF-A). In contrast, FGF-2 and PlGF were both associated to creatinine and Hs-TnI (with P < .001 for FGF-2 and both creatinine and Hs-TnI; P < .01 for PlGF and creatinine, and P < .001 for PlGF and Hs-TnI).

ROC curve analysis was performed to define an optimal cut-off of VEGF-A, FGF-2, and PlGF level to predict in-hospital mortality.

We identified that VEGF-A level above 44.2 pg/ml, FGF-2 level above 18 pg/ml, and a PlGF level above 30 pg/ml could predict inhospital mortality in COVID-19 patients (AUC 51. 8 Moreover, we performed a propensity-matched score for VEGF-A, PlGF, and FGF-2 adjusted on age, sex, and BMI. As demonstrated in Table 2 , clinical characteristics were the same between patients with high and low levels of VEGF-A, PlGF, and Because PlGF provided the best prognostic value (higher AUC, sensitivity, specificity, and negative predictive value), we performed the survival analysis for PlGF confirming its usefulness for in-hospital mortality prediction, using a Kaplan-Meier survival curves (P = .001; Figure 2B (VEGFR-1, aka Flt-1). In animal studies, PlGF was reported to increase angiogenesis in pathological but not physiological angiogenesis. 21 PlGF stimulates angiogenesis through VEGFR-1 direct signaling and/or displacing VEGF from its binding site, and we previously described PlGF involvement in human endothelial progenitor differentiation. 22 In line with these angiogenic functions, increased PlGF plasma levels have been proposed as a biomarker of adverse outcome in patients with acute chest pain, 23 of thrombotic events risk in antiphospholipid syndrome, 24 and of poor prognosis in cancer. 25 In pregnant women, a low soluble Flt-1/PlGF ratio is used to predict the short-term absence of preeclampsia (PE Our results highlight the potential for plasma PlGF to discriminate COVID-19 severity and higher risk of in-hospital mortality, but also may help identify and target patients for new therapeutic approaches.

We thank AP-HP for promotion of the SARCODO Project. We 

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