Publication date: Jan 30, 2025

SARS-CoV-2 targets angiotensin converting enzyme-2 (ACE2), a key peptidase of the renin-angiotensin system (RAS), which regulates the balance of the vasoconstrictor/inflammatory peptide Ang II and the vasodilator/anti-inflammatory peptide Ang-(1-7). Few studies have quantified the circulating elements of the RAS longitudinally in SARS-CoV-2 infection and their association with COVID-19 outcomes. Thus, we evaluated the association of circulating RAS enzymes and peptides with mortality among patients with COVID-19. Blood samples were collected from 111 patients with COVID-19 and new-onset hypoxemia during the delta and omicron waves at 19 hospitals in the United States. Circulating RAS components were quantified via radioimmunoassay or ELISA at 0 (baseline), 1, 3, and 5 days after randomization. We used multivariable Cox regression to estimate the association of baseline and longitudinal RAS concentrations with 90-day mortality. Participants were aged 18-90 (mean [SD]: 55 [14]) years and 62% were male. There were 22 (20%) deaths over 90 days of follow-up. ACE2 levels above the sample median (≥4. 9 pM; adjusted HR [95% CI]: 0. 10 [0. 02, 0. 43]) and ACE2/ACE ratio (≥6. 0cD710; adjusted HR: 0. 08 [0. 02, 0. 39]) were associated with significantly lower mortality. Similarly, when analyzed as continuous, log2-normalized, time-varying predictors from Day 0 to Day 5, two-fold increments of ACE2 and ACE2/ACE ratio over this period were associated with lower mortality (adjusted HR: 0. 79 [0. 65, 0. 97] and 0. 78 [0. 63, 0. 97], respectively). Circulating Ang II, Ang-(1-7), and ACE levels were not associated with mortality. These results suggest higher circulating ACE2 protein in hospitalized patients with COVID-19 is associated with reduced mortality.

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