Relationship Between Endothelial and Angiogenesis Biomarkers Envisage Mortality in a Prospective Cohort of COVID-19 Patients Requiring Respiratory Support

Felipe Maldonado, Diego Morales, Catalina Díaz-Papapietro, Catalina Valdés, Christian Fernandez, Nicolas Valls, Marioli Lazo, Carolina Espinoza, Roberto González, Rodrigo Gutiérrez, Álvaro Jara, Carlos Romero, Oscar Cerda, Mónica Cáceres, Felipe Maldonado, Diego Morales, Catalina Díaz-Papapietro, Catalina Valdés, Christian Fernandez, Nicolas Valls, Marioli Lazo, Carolina Espinoza, Roberto González, Rodrigo Gutiérrez, Álvaro Jara, Carlos Romero, Oscar Cerda, Mónica Cáceres

Abstract

Purpose: Endothelial damage and angiogenesis are fundamental elements of neovascularisation and fibrosis observed in patients with coronavirus disease 2019 (COVID-19). Here, we aimed to evaluate whether early endothelial and angiogenic biomarkers detection predicts mortality and major cardiovascular events in patients with COVID-19 requiring respiratory support.

Methods: Changes in serum syndecan-1, thrombomodulin, and angiogenic factor concentrations were analysed during the first 24 h and 10 days after COVID-19 hospitalisation in patients with high-flow nasal oxygen or mechanical ventilation. Also, we performed an exploratory evaluation of the endothelial migration process induced by COVID-19 in the patients' serum using an endothelial cell culture model.

Results: In 43 patients, mean syndecan-1 concentration was 40.96 ± 106.9 ng/mL with a 33.9% increase (49.96 ± 58.1 ng/mL) at day 10. Both increases were significant compared to healthy controls (Kruskal-Wallis p < 0.0001). We observed an increase in thrombomodulin, Angiopoietin-2, human vascular endothelial growth factor (VEGF), and human hepatocyte growth factor (HGF) concentrations during the first 24 h, with a decrease in human tissue inhibitor of metalloproteinases-2 (TIMP-2) that remained after 10 days. An increase in human Interleukin-8 (IL-8) on the 10th day accompanied by high HGF was also noted. The incidence of myocardial injury and pulmonary thromboembolism was 55.8 and 20%, respectively. The incidence of in-hospital deaths was 16.3%. Biomarkers showed differences in severity of COVID-19. Syndecan-1, human platelet-derived growth factor (PDGF), VEGF, and Ang-2 predicted mortality. A multiple logistic regression model with TIMP-2 and PDGF had positive and negative predictive powers of 80.9 and 70%, respectively, for mortality. None of the biomarkers predicted myocardial injury or pulmonary thromboembolism. A proteome profiler array found changes in concentration in a large number of biomarkers of angiogenesis and chemoattractants. Finally, the serum samples from COVID-19 patients increased cell migration compared to that from healthy individuals.

Conclusion: We observed that early endothelial and angiogenic biomarkers predicted mortality in patients with COVID-19. Chemoattractants from patients with COVID-19 increase the migration of endothelial cells. Trials are needed for confirmation, as this poses a therapeutic target for SARS-CoV-2.

Keywords: COVID-19; VEGF; angiogenesis; angiopoietin-2; syndecan-1.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 Maldonado, Morales, Díaz-Papapietro, Valdés, Fernandez, Valls, Lazo, Espinoza, González, Gutiérrez, Jara, Romero, Cerda and Cáceres.

Figures

Figure 1
Figure 1
Serum levels of endothelial damage and angiogenesis-related proteins. (A) Summary of key molecules involved in angiogenesis and endothelial damage. (B) Graph representing the mean serum of syndecan-1 and thrombomodulin during the first 24 h of hospitalisation (n = 43), after 10 days (n = 28) and in healthy individuals (n = 9). (C) Graph representing the mean serum of angiopoietin-2, TIMP-2. VEGF, PDGF-BB, HGF, and IL-8. Statistical significance (P-values) is obtained using two-sided Kruskal–Wallis with Dunn's multiple comparison test, *P < 0.05; **P < 0.01; ***P < 0.001. ****P < 0.0001.
Figure 2
Figure 2
Receiver operating characteristic (ROC) curve for mortality: (A) Endothelial biomarkers (B) Angiogenic biomarkers. ROC curves with area under the curve for mortality.
Figure 3
Figure 3
Serum levels comparison according to coronavirus disease 2019 severity during the first 24 h of hospitalisation. (A) Levels of syndecan-1 and thrombomodulin. (B) Graph representing the mean serum of angiopoietin-2, vascular endothelial growth factor (VEGF), human platelet-derived growth factor (PDGF), human tissue inhibitor of metalloproteinases-2 (TIMP-2), human hepatocyte growth factor (HGF), and human Interleukin-8 (IL-8). Statistical significance (P-values) is obtained using two-sided Kruskal–Wallis test, *P < 0.05; **P < 0.01; ***P < 0.001; ****P < 0.0001. (C) Multivariate model logistic regression receiver operating characteristic curve using TIMP-2 and PDGF for predicting mortality (n = 11 severe, n = 25 critical, n = 7 non-survivors).
Figure 4
Figure 4
Proteome profiler array and cell migration induced by coronavirus disease 2019 blood serum. (A) Representative image of the angiogenic proteome profiler array using blood serum samples from healthy participants and from those with severe COVID-19. (B) Quantification of pixel mean density of each angiogenesis-related protein. (C) Schematics of Transwell Boyden chamber assay using blood serum samples from COVID-19-infected and healthy participants in the lower compartment as chemoattractants. (D) Representative images of migrated endothelial EA.hy926 cells induced by blood serum samples of COVID-19-infected and healthy participants. (E) Quantification of migrated cells by field (n = 5 healthy individuals, n = 3 severe, n = 1 critical, and n = 1 non-surviving COVID-19 patient) using both samples in first 24 h and on the 10th day of hospitalisation. Statistical significance (P-values) is obtained using Mann–Whitney *P < 0.05.

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