Cardiovascular Diabetology (May 2021)

Glycated ACE2 receptor in diabetes: open door for SARS-COV-2 entry in cardiomyocyte

  • Nunzia D’Onofrio,
  • Lucia Scisciola,
  • Celestino Sardu,
  • Maria Consiglia Trotta,
  • Marisa De Feo,
  • Ciro Maiello,
  • Pasquale Mascolo,
  • Francesco De Micco,
  • Fabrizio Turriziani,
  • Emilia Municinò,
  • Pasquale Monetti,
  • Antonio Lombardi,
  • Maria Gaetana Napolitano,
  • Federica Zito Marino,
  • Andrea Ronchi,
  • Vincenzo Grimaldi,
  • Anca Hermenean,
  • Maria Rosaria Rizzo,
  • Michelangela Barbieri,
  • Renato Franco,
  • Carlo Pietro Campobasso,
  • Claudio Napoli,
  • Maurizio Municinò,
  • Giuseppe Paolisso,
  • Maria Luisa Balestrieri,
  • Raffaele Marfella

DOI
https://doi.org/10.1186/s12933-021-01286-7
Journal volume & issue
Vol. 20, no. 1
pp. 1 – 16

Abstract

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Abstract Rationale About 50% of hospitalized coronavirus disease 2019 (COVID-19) patients with diabetes mellitus (DM) developed myocardial damage. The mechanisms of direct SARS-CoV-2 cardiomyocyte infection include viral invasion via ACE2-Spike glycoprotein-binding. In DM patients, the impact of glycation of ACE2 on cardiomyocyte invasion by SARS-CoV-2 can be of high importance. Objective To evaluate the presence of SARS-CoV-2 in cardiomyocytes from heart autopsy of DM cases compared to Non-DM; to investigate the role of DM in SARS-COV-2 entry in cardiomyocytes. Methods and results We evaluated consecutive autopsy cases, deceased for COVID-19, from Italy between Apr 30, 2020 and Jan 18, 2021. We evaluated SARS-CoV-2 in cardiomyocytes, expression of ACE2 (total and glycosylated form), and transmembrane protease serine protease-2 (TMPRSS2) protein. In order to study the role of diabetes on cardiomyocyte alterations, independently of COVID-19, we investigated ACE2, glycosylated ACE2, and TMPRSS2 proteins in cardiomyocytes from DM and Non-DM explanted-hearts. Finally, to investigate the effects of DM on ACE2 protein modification, an in vitro glycation study of recombinant human ACE2 (hACE2) was performed to evaluate the effects on binding to SARS-CoV-2 Spike protein. The authors included cardiac tissue from 97 autopsies. DM was diagnosed in 37 patients (38%). Fourth-seven out of 97 autopsies (48%) had SARS-CoV-2 RNA in cardiomyocytes. Thirty out of 37 DM autopsy cases (81%) and 17 out of 60 Non-DM autopsy cases (28%) had SARS-CoV-2 RNA in cardiomyocytes. Total ACE2, glycosylated ACE2, and TMPRSS2 protein expressions were higher in cardiomyocytes from autopsied and explanted hearts of DM than Non-DM. In vitro exposure of monomeric hACE2 to 120 mM glucose for 12 days led to non-enzymatic glycation of four lysine residues in the neck domain affecting the protein oligomerization. Conclusions The upregulation of ACE2 expression (total and glycosylated forms) in DM cardiomyocytes, along with non-enzymatic glycation, could increase the susceptibility to COVID-19 infection in DM patients by favouring the cellular entry of SARS-CoV2.

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