ArticlePDF AvailableLiterature Review

Potential COVID-19 therapeutic approaches targeting angiotensin-converting enzyme 2; An updated review

December 2021
Reviews in Medical Virology 32(2)

December 2021
32(2)

DOI:10.1002/rmv.2321

Authors:

Saba Zanganeh

University of North Carolina at Chapel Hill

Nima Goodarzi

Purdue University

Mohammad Doroudian

Trinity College Dublin

COVID-19 has spread swiftly throughout the world posing a global health emergency. The significant numbers of deaths attributed to this pandemic have researchers battling to understand this new, dangerous virus. Researchers are looking to find possible treatment regimens and develop effective therapies. This study aims to provide an overview of published scientific information on potential treatments, emphasizing angiotensin-converting enzyme II (ACE2) inhibitors as one of the most important drug targets. SARS-CoV-2 receptor-binding domain (RBD); as a viral attachment or entry inhibitor against SARS-CoV-2, human recombinant soluble ACE2; as a genetically modified soluble form of ACE2 to compete with membrane-bound ACE2, and microRNAs (miRNAs); as a negative regulator of the expression of ACE2/TMPRSS2 to inhibit SARS-CoV2 entry into cells, are the potential therapeutic approaches discussed thoroughly in this article. This review provides the groundwork for the ongoing development of therapeutic agents and effective treatments against SARS-COV-2.

Content uploaded by Mohammad Doroudian

Content may be subject to copyright.

Received: 18 October 2021

Revised: 24 November 2021

Accepted: 30 November 2021

DOI: 10.1002/rmv.2321

REVIEW

Potential COVID‐19 therapeutic approaches targeting

angiotensin‐converting enzyme 2; An updated review

Saba Zanganeh

|Nima Goodarzi

|Mohammad Doroudian

|Elaheh Movahed

Department of Cell and Molecular Sciences,

Faculty of Biological Sciences, Kharazmi

University, Tehran, Iran

Wadsworth Center, New York State

Department of Health, Albany, New Year, USA

Correspondence

Mohammad Doroudian, Department of Cell

and Molecular Sciences, Faculty of Biological

Sciences, Kharazmi University, Tehran 14911‐

15719, Iran.

Email: mdoroudi@tcd.ie

Elaheh Movahed, Wadsworth Center, New

York State Department of Health, Albany,

New Year, USA.

Email: elaheh.movahed@health.ny.gov

Summary

COVID‐19 has spread swiftly throughout the world posing a global health emer-

gency. The signiﬁcant numbers of deaths attributed to this pandemic have re-

searchers battling to understand this new, dangerous virus. Researchers are looking

to ﬁnd possible treatment regimens and develop effective therapies. This study aims

to provide an overview of published scientiﬁc information on potential treatments,

emphasizing angiotensin‐converting enzyme II (ACE2) inhibitors as one of the most

important drug targets. SARS‐CoV‐2 receptor‐binding domain (RBD); as a viral

attachment or entry inhibitor against SARS‐CoV‐2, human recombinant soluble

ACE2; as a genetically modiﬁed soluble form of ACE2 to compete with membrane‐

bound ACE2, and microRNAs (miRNAs); as a negative regulator of the expression of

ACE2/TMPRSS2 to inhibit SARS‐CoV2 entry into cells, are the potential therapeutic

approaches discussed thoroughly in this article. This review provides the ground-

work for the ongoing development of therapeutic agents and effective treatments

against SARS‐COV‐2.

KEYWORDS

ACE2, COVID‐19, drug repositioning, SARS‐CoV‐2, small molecule drugs

INTRODUCTION

SARS‐CoV‐2 is a single‐stranded positive‐sense RNA virus

that

causes acute respiratory distress syndrome, which leads to serious

global health issues.

The SARS‐CoV in 2002–3,

the Mers‐CoV in

2012–2013

and the current pandemic of SARS‐CoV‐2 prove that

the diseases distribution is more expansive than previously

recognized.

The glycosylated spike protein (S) is one of several

structural proteins encodes by the COVID‐19 genome.

This glyco-

protein mediates virus entry by two functional subunits responsible

for attachment to host cell receptor (S1 subunit) and viral and cellular

membranes (S2 subunit) fusion. S is further cleaved at the S20site, by

a host transmembrane Serine Protease 2 (TMPRSS2), at immediate

upstream of the fusion peptide.

The resulting cleavage leads to

Abbreviations: ACE 2, angiotensin‐converting enzyme 2; ACEI, angiotensin‐converting enzyme inhibitors; ADAM17, A disintegrin and metalloprotease 17; AGTR1, angiotensin II receptor

type 1; Ang II, angiotensin II; aPKC, atypical protein kinase C; AT1, angiotensin II Type 1; AT2, angiotensin II Type 2; BLI, bio‐layer interferometry; CD13, cluster of differentiation 13

(glycoprotein); CD3, cluster of differentiation 3; CD8, cluster of differentiation 8; Cdc42, cell division control protein 42 homologue; COVID‐19, coronavirus disease 2019; cryo‐EM, cryogenic

electron microscopy; DPP4, dipeptidyl peptidase 4; HCoV‐229E, human coronavirus 229E; HCoV‐HKU1, human coronavirus Hong Kong University 1; HCoV‐NL63, human coronavirus

NetherLand 63; HCoV‐OC43, human coronavirus organ culture 43; HF, heart failure; HIV, human immunodeﬁciency virus; hrsACE2, human recombinant soluble ACE2; IFN, interferon; IL‐1β,

interleukin 1 beta; IL‐6, interleukin 6; ISG, interferon‐stimulated gene; JARID1B, jumonji AT‐rich interactive domain 1B; KDM5B, lysine‐speciﬁc demethylase 5B; MERS‐CoV, Middle East

respiratory syndrome coronavirus; miRNAs, microRNAs; MSA, measurement systems analysis; mTOR, mammalian target of rapamycin; NF‐κB, nuclear factor kappa light chain enhancer of

activated B cells; PAK1, P21‐activated kinase 1; PAK2, P21‐activated kinase 2; Par3, partitioning‐defective protein 3; Par6, partitioning‐defective protein 6; PLpro, papain‐like protease; PPIs,

protein–protein Interactions; RAS, renin–angiotensin system; RBD, receptor‐binding domain; RdRP, RNA‐dependent RNA polymerase; Rho, Ras homologous; SARS‐CoV, severe acute

respiratory syndrome‐related coronavirus; SARS‐CoV‐2, severe acute respiratory syndrome coronavirus 2; SPR, surface plasmon resonance; TGF‐β, transforming growth factor beta;

TMPRSS2, transmembrane serine protease 2; TNF alpha, tumour necrosis factor alpha.

This article has not been published and is not under consideration for publication elsewhere.

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https://doi.org/10.1002/rmv.2321

extensive irreversible conformational changes, in which protein is

activated for membrane fusion.

8,9

Thus far it is unclear if angiotensin‐

converting enzyme 2 (ACE2) and TMPRSS2 are required on the same

cell, or soluble proteases can activate SARS‐CoV‐2 S‐protein to

invade ACE2‐single‐positive cells.

10,11

Furthermore, it is still ambig-

uous whether SARS‐CoV‐2‐S may have a furin cleavage site. This

potential protease on the spike glycoprotein causes a broad set of

host proteases that could mediate S‐protein activation.

10,12,13

active S‐protein has a limited lifetime for ﬁnding a target cell mem-

brane. The S‐protein's activation timing and cellular location are

essential. Effective entries mainly occur in proximity to the plasma

membrane.

14,15

Subfamily coronavirinae is divided into four genera; alpha‐CoV,

beta‐CoV, gamma‐CoV, and delta‐CoV.

16,17

Most SARS‐related

coronaviruses interact directly with the host ACE2 receptor on the

lung and heart cells to enter the target cells.

The infection efﬁ-

ciency depends on the ability of ACE2 to support viral replication in

humans, mice, and rats.

19–21

Mutation(s) have occurred in the

sequence of the SARS‐CoV‐2 spike protein that can lead to sustained

transmission among humans.

Acquisition of polybasic cleavage sites

in CoV‐2 spike is one such example. There are differences between

the S1 subunit of the receptor‐binding domains (RBDs) of spike that

cause a major effect on SARS‐CoV‐2 spike/ACE2 interaction and

decrease the binding energy compared to the one of Bat‐CoV to this

receptor.

SARS CoV‐1 has six amino acid RBDs essential for

interaction. Five of the amino acids are different in CoV‐2. Different

viral species use distinct domains within the S1 subunit to recognize

various attachments and entry receptors.

Proteolytic processing of

SARS‐CoV2‐S protein in human cells and several arginine residues at

the S1/S2 cleavage site of SARS‐CoV2‐S protein is efﬁcient as oppose

to SARS‐S protein.

SARS‐S and SARS‐2‐S proteins share approxi-

mately 76% amino acid identity.

Not only the slow rate of vaccination in low‐income countries,

but also non‐adherence/hesitance to vaccination in high‐income

countries equally threaten the effectiveness of vaccines. Even while

attempting to vaccinate the world's population, the newly emerging

variants of COVID19 have negatively affected the efﬁcacy of vac-

cines. ACE 2, as the essential receptor for binding to SARS‐CoV‐2,

plays a signiﬁcant role in the occurrence of this deadly disease.

Finding treatments that target ACE 2 can be an effective strategy for

the treatment of COVID‐19. SARS‐CoV‐2 RBD protein can be used

as a viral attachment or entry inhibitor against SARS‐CoV‐2 because

of its ability to block S protein‐mediated SARS‐CoV‐2 pseudovirus

entry into its ACE2 receptor‐expressing target cell. Human recom-

binant soluble ACE2 (hrsACE2), as a genetically modiﬁed soluble

form of ACE2, can reduce cell entry of SARS‐CoV‐2 since it competes

with membrane‐bound ACE2. MicroRNAs (miRNAs) can negatively

regulate the expression of ACE2/TMPRSS2 and inhibit SARS‐CoV2

entry into cells by binding to the target mRNA at the 30untrans-

lated regions leading to degradation or translational downregulation

of the target. The therapy strategies provided in this article involve

ACE2 and the results of the recent studies on ACE2‐related potential

treatments to encourage and recommend further required research

in order to accelerate the quest for a universally effective COVID‐19

treatment.

ROLE OF ACE2 IN CORONAVIRUS INFECTIONS

(SARS‐CoV AND SARS‐CoV‐2) INFECTION

Angiotensin‐converting enzyme (ACEI) inhibitors can confront

COVID‐19 infection by increasing the number of CD3 and CD8 T

cells and reducing the viral load and interleukin 6 (IL‐6) levels that

control SARS‐CoV‐2 replication via NF‐κB.

There is hope that

certain drugs, including SARS‐CoV‐2 receptor blockers, anti‐

inﬂammatory agents (against rheumatic diseases), monoclonal anti-

bodies, anti‐IL‐1 and anti‐IL‐6, remdesevir drug (analogue adenosine),

and vaccines can provide promising strategies to combat COVID‐19.

Angiotensin II binds to the angiotensin AT1 receptor to cause

vasoconstriction, and angiotensin (1−7) elicits vasodilation mediated

by AT2.

25–27

Manipulation of the ACE2/Ang 1–7 axis can reduce

SARS‐induced tissue injuries, which can be a potential treatment

strategy.

In vivo studies showed that catalytically active ACE2

mitigates pulmonary damage and vascular damage,

29,30

It also further

reduces lung ﬁbrosis, arterial remodelling, and improves ventricular

performance.

31,32

In a clinical study, administration of ACE2 lessened

systemic inﬂammation and shifted the RAS peptide balance away

from Ang II towards Ang 1–7.

33,34

Ongoing global efforts have

focussed on the potential role of the ACE2/Ang 1–7 axis to curtail

SARS‐CoV‐2 infection while trying to highly protect against lung and

cardiovascular injury in COVID‐19 patients.

ACE2, AT1 receptors, and AT2 receptors are changed during

invasion.

However, according to a hypothesis formed by Sriram &

Insel, ACE2 activity and expression are decreased by SARS viruses,

which results in an imbalance in the signalling by ACE1 and ACE2

products that increases Ang II/AT1 signalling and is also super-

imposed on concurrent pathology. Ang II is a crucial mediator of

injury in the tissues of the lung and heart. The improved effects and

signalling enhancement from co‐morbidities can upsurge the severity

of COVID‐19. The reduction of ACE2 activity duo to SARS viruses

can unleash a cascade of injurious effects through a heightened

imbalance in the actions of the products of ACE1 versus ACE2 in

patients who are more prone to the damaging effects of Ang II

(Figure 1).

Blocking the virus from entering cells is the most direct approach

to combat SARS‐CoV‐2.

Since there is no chance for mutations in

the host ACE2 protein, it can be considered a potential drug devel-

opment strategy.

Exploring receptors and their targets would be a

big step forward to ﬁnd a remedy for the SARS‐CoV‐2 infection.

genetically modiﬁed variant of ACE2, called hrsACE2, can block

COVID‐19 from entering cells by attaching to the copy instead of the

actual cells.

40,41

Drug APN01 is an example of hrsACE2 tested in

Phase II trials for lung disease.

Arbidol 20 is another virus‐host cell

fusion inhibitor against inﬂuenza virus that prevents the virus from

entering the host cells. This broad‐spectrum antiviral has been

considered a clinical trial to treat SARS‐CoV‐2.

Losartan is another

2 of 14

ZANGANEH

ET AL.

FIGURE 1 According to the critical role of ACE2 in SARS‐Cov‐2 cell entry, the Angiotensin‐Renin system is affected by the infection.

(a) Under the typical situation, Renin converts Angiotensin to Angiotensin I, further converted to Angiotensin II (Ang II) by the Angiotensin‐

Converting Enzyme 1 (ACE1). Ang II signalling through Ang II type 1 receptor (At1) can lead to organ damages and inﬂammation. For this

reason, ACE2 converts Ang II into Ang 1‐7 with an opposite effect through MAS receptor signalling. Thus, ACE2 function balances the At1

signalling pathway by reducing Ang II concentration and neutralizing At1 signalling effects through MAS receptor signalling. (b) During

infection, the virus binds to ACE2 through its S Protein, activated earlier by TMPRSS2. This binding causes disfunction in ACE2, leading to an

imbalance in the Renin‐Angiotensin System. Besides, the virus enters the cell through receptor‐intermediated endocytosis and releases its

genome into the cytosol. The viral RNA genome expression using the host cell ribosome synthesized two sets of proteins: viral polymerase and

accessory proteins. The viral polymerase replicates the viral genome; some break into subgenomic transcriptomes and translate into viral

structural proteins, others bind to the nucleocapsid proteins and form the nucleocapsid. Then, the components pack and form the new virus

that exits the cell through exocytosis

ZANGANEH ET AL.

3 of 14

ACE inhibitor for SARS‐CoV‐2 pneumonia infections. There are

ongoing clinical trials on infected patients.

43,44

The other selective

ACE2 inhibitor, DX600, might also be helpful in SARS‐CoV‐2 in-

fections. Nevertheless, its clinical signiﬁcance in COVID19 has not

been assessed.

45,46

The soluble form of ACE2, which lacks the membrane anchor,

can compete with SARS‐CoV receptors by inhibiting viral particle

binding to the surface‐bound, full‐length ACE2.

6,47–50

Camostat

mesylate is one of these nonspeciﬁc TMPRSS2 protease inhibitors

that bears the S protein of SARS‐CoV‐2 in cell culture through

pseudovirus.

Protease inhibitors such as disulﬁram, alpha‐

interferon, lopinavir‐ritonavir, and PLpro proteases, have been pro-

posed as potential agents against SARS and MERS. Chloroquine

blocks the action of heme polymerase and remdesivir, which also

blocks RdRp protease.

6,52

Remdesivir (GS‐5734) is a phosphor-

amidate prodrug of an adenine derivative with a similar chemical

structure to the approved tenofovir alafenamide, an HIV reverse

transcriptase inhibitor. Remdesivir anti MERS and SARS activities

have been reported against RNA viruses in cell cultures and animal

models and clinical thus far.

Another strategy would be using ACE2 inhibitors that inhibit

SARS coronavirus spike protein‐mediated cell fusion. In a recent

study by Huentelman et al., ≈140,000 small molecules were moni-

tored for the highest predicted binding scores for ACE2 enzymatic

inhibitory activity to inhibit SARS coronavirus spike protein‐

mediated cell fusion. Among those small molecules, N‐(2‐amino-

ethyl)‐1 aziridine‐ethanamine has been proposed as a novel ACE2

inhibitor with the highest predicted binding scores.

54–57

There is compelling evidence that the colocalization of ACE2 and

TMPRSS2 is often found in large number of cells, which can vary with

different tissues and in a cell‐speciﬁc manner.

58–61

Speciﬁc progeni-

tor cells in the bronchi, which normally develop into the cilia are

mainly responsible for producing the coronavirus receptors.

62,63

ACE2 receptor is an interferon‐stimulated gene in upper airway

epithelial cells. SARS‐CoV‐2 may increase infection via interferon

(IFN)‐driven upregulation of ACE2, a key tissue‐protective mediator

during lung injury.

Therefore, Antiviral/IFN combination therapy

for SARS‐CoV‐2 infection can assist in balancing host restriction,

tissue tolerance, and viral enhancement mechanisms.

65–67

SARS coronavirus infection correlates with cell differentiation of

airway epithelia and ACE2 expression and localization.

68,69

ACE2

proteins are more abundantly expressed on the apical than the

basolateral surface of polarized airway epithelia.

Among the

numerous molecules at the apical membrane, only a few essential

molecules are responsible for the identity and epithelial polarity of

the apical membrane. These proteins include; Cdc42, atypical protein

kinase C, Par6, Par3/Bazooka/ASIP.

71–74

Cdc42 has been implicated

in numerous functions, including dendritic growth, branching, and

branch stability.

75–77

Membrane localization principally occurs at the

highest concentration of the molecule. When Cdc42 is not present,

apical determinants cannot be maintained at the apical membrane.

Due to this occurrence, apical identity and polarity are lost.

It has been shown that the HCoV‐229E receptor, aminopepti-

dase N (CD13), and MERS‐CoV receptor DPP4 (CD26) are different

from ACE2 receptors of SARS‐CoV‐2.

The infectivity of HCoV‐

229E, HCoV‐OC43, HCoV‐NL63, and HCoV‐HKU1 is comparatively

low with slight respiratory symptoms, while SARS‐CoV and MERS‐

CoV, which use ACE2 receptor, cause outbreaks with high mortal-

ity.

80,81

According to Cryo‐EM structure studies, the binding afﬁnity

of SARS‐CoV‐2 S protein to ACE2 is about 10–20 times stronger

than SARS‐CoV S protein.

6,82

Therefore, the transmissibility and

contagiousness of SARS‐CoV‐2 is higher compared to SARS‐CoV.

POTENTIAL INHIBITOR TARGETING ACE2

RECEPTORS

ACE2 is a type I integral membrane carboxypeptidase that cleaves a

single hydrophobic/basic residue from the C‐terminus of its sub-

strates.

The ACE2 open reading frame in humans encodes an 805

amino‐acid polypeptide.

ACE2 protein sequence reveals two

hydrophobic regions. A potential 18‐amino‐acid signal peptide at the

N‐terminus and a 22‐amino‐acid—near the Cterminus.

ACE2 binds

to the cell membrane via the hydrophobic region close to the

C‐terminus of the protein. The active site is positioned on the

N‐terminal region of ACE2—which faces the extracellular space.

ACE2, similar to ACE, is an ectoenzyme located at the cell surface

to hydrolyse circulating peptides. ACE2 has six potential

N‐glycosylation sites in humans, as shown by the presence of the

Asn‐X‐Ser/Thr motif (at positions Asn53, Asn90, Asn103, Asn322,

Asn432, Asn546) in its primary structure.

The ACE2 gene in

humans consists of 18 exons with the Ace2 zinc‐binding motif

(HEXXH) positioned in exon 9.

Human Cdc42 is a small GTPase of the Rho family. Cdc42 reg-

ulates signalling pathways responsible for various cellular functions

such as cell morphology, cell migration, endocytosis, and cell cycle

progression.

Rho GTPases are essential for dynamic actin cyto-

skeletal assembly and rearrangement. These are the basis of cell‐to‐

cell adhesion and migration. Cdc42 activates by conformational

changes.

P21‐activated kinases, PAK1 and PAK2 are responsible

for regulating cell adhesion, migration, and invasion.

91,92

PAK1 is the

major ‘pathogenic’ kinase, whose abnormal activation can lead to

cancers, inﬂammation, malaria, and pandemic viral infection,

including inﬂuenza, HIV, and COVID‐19.

Natural and synthetic

PAK1‐blockers such as propolis, melatonin, ciclesonide, ivermectin,

and ketorolac have been suggested as potential therapeutics against

COVID‐19.

They directly block the replication of this virus in cell

culture. However, the lack of binding surface for small molecule

targeting of Protein–Protein Interactions (PPIs) involving Cdc42 is

yet to be revealed.

The two small molecules, ZCL278, and AZA197

target Cdc42 to inﬂuence PPIs. They can inhibit Cdc42 and suppress

proliferative and pro‐survival signalling pathways through PAK1‐ERK

signalling. This pathway can eliminate migration of ‐colon cancer

cells.

96,97

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ET AL.

ACE2 AND THE RBD

ACE2 is a vital SARS‐CoV‐2 receptor. A transmembrane protein

known for its physiological role and carboxypeptidase activity in the

renin‐angiotensin system, which is involved in the COVID‐19 path-

ogenesis since it permits viral entry into target cells.

ACE2 is also

the host receptor binding to SARS‐CoV's virus S protein. The RBD in

SARS‐CoV‐2 S protein is acknowledged to be a high potential target

for developing neutralizing antibodies, virus attachment inhibitors, as

well as vaccines.

79,99

Tai et al. have characterized the SARS‐CoV‐2

RBD that demonstrates strong binding to its cellular and soluble

ACE2 receptors originated in bats and humans. The RBD of SARS‐

CoV‐2 spike glycoprotein compared to SARS‐CoV RBD presents

10‐to 20‐fold higher binding afﬁnity to ACE2, which underpins the

elevated pathogenesis ability of SARS‐CoV‐2 infections by blocking

the binding, resulting in SARS‐CoV RBD and SARS‐CoV‐2 RBD

attachment to ACE2‐expressing cells, therefore preventing their

infection from hosting cells.

100

As a viral attachment or entry in-

hibitor against SARS‐CoV‐2, SARS‐CoV‐2 RBD protein is suggested

due to its ability in blocking S protein‐mediated SARS‐CoV‐2 pseu-

dovirus entry into its ACE2 receptor‐expressing target cells.

100

ACE2, similar to several other cell‐surface proteins, undergoes

regulated internalization in a clathrin‐dependent manner.

101,102

Hence, triggering internalization using identiﬁed or designed small

molecules that can bind with ACE2 could be a practical approach in

reducing the ACE2 cell surface density to block binding and diminish

viral entry. RBD from SARS‐CoV S protein induces ACE2 internali-

zation by binding to ACE2.

103

SARS‐CoV RBD‐induced antibodies

can also cross‐react with SARS‐CoV‐2 RBD and cross‐neutralize

SARS‐CoV‐2 pseudovirus infection, which demonstrates the poten-

tial application of SARS‐CoV RBD‐speciﬁc antibodies to treat SARS‐

CoV‐2 infection. SARS‐CoV‐2 or SARS‐CoV RBD protein can perform

as a candidate vaccine to induce cross‐neutralizing or cross‐reactive

antibodies to inhibit SARS‐CoV‐2 or SARS‐CoV infection.

104,105

The recombinant RBD protein binds strongly to bat ACE2

(bACE2) and human ACE2 (hACE2) receptors and blocks the entry of

SARS‐CoV and SARS‐CoV‐2 into their respective hACE2‐expressing

cells.

100

Most monoclonal antibodies neutralize the virus through

binding to epitopes in the RBD protein and inhibiting its interaction

with ACE2. The antibodies' ability to bind to RBD with high afﬁnity

and speciﬁcity enables the antagonism of ACE2 binding. Several

methods, including surface plasmon resonance, X‐ray/cryo‐EM, and

bio‐layer interferometry can be applied to perform characteriza-

tion.

106–109

In research conducted by Oany et al., 14 S proteins have been

retrieved and a phylogenetic study has been performed indicating

that they were more closely related.

Moreover, the measurement

systems analysis study on RBD sequences from different strains and

the structural analysis by Wrapp et al. exposes highly conserved

residues in SARS‐SOV‐2 S RBD compared to SARS‐CoV S RBD, that

are vital for the binding of ACE2 receptors. Therefore, preventing

SARS‐COV‐2 S protein from binding to human ACE2 receptors ap-

pears to be the most promising target for developing an innovative

therapeutic drug to come to grips with the current pandemic

situation.

57,82

HUMAN RECOMBINANT SOLUBLE ACE2

ACE2 is involved in the renin‐angiotensin‐aldosterone system, which

regulates ﬂuid balance, blood pressure, and intestinal functions, and

protects organs against inﬂammatory injuries. ADAM17 and

TMPRSS2 are the proteases capable of shedding ACE2. The SARS‐

CoV binding site is the N‐terminal peptidase domain. The cellular

form and circulating form are the two types of ACE2 protein,

membrane‐bound and soluble, respectively. TMPRSS2 and cellular

ACE2 are required for positive SARS‐CoV‐2 infection. ADAM17‐

shedded ACE2 (circulating ACE2) is considered the major shedding

enzyme in protecting the lungs from viral infection. The expression of

TMPRSS2 obstructs ADAM17‐shedding of ACE2.

110–112

TMPRSS2, ADAM17, and cellular ACE2 are expressed on the cell

membrane. Soluble ACE2 is ﬁrst shed by ADAM17 and then released

from its full‐length form to counteract the consequences of Ang II

signalling. Furthermore, cellular ACE2 is shed by TMPRSS2, resulting

in the fusion of SARS‐CoV‐2 cell membrane, releasing SARS‐CoV‐2

RNA into the cytoplasm, and efﬁcient viral processing replication.

The soluble ACE2 has the ability to bind to coronavirus since it

comprises the virus binding site. The virus cannot be duplicated

without an intracellular environment.

(Figure 2).

There is a genetically modiﬁed soluble form of ACE2 known as

hrsACE2. (Also called hrsACE2) This can reduce SARS‐CoV‐2 cell

entry by competing with the membrane‐bound form of ACE2.

APN01, currently in a multi‐centre, double‐blind, randomized,

placebo‐controlled, interventional trial designed by Apeiron Bi-

ologics, is a hrsACE2 that emulates the human ACE2, and reduces

SARS‐CoV‐2 cell entry to decrease lung injury and various organ

dysfunctions. A molecular rationalization for the severe lung failure

and death caused by COVID‐19 was provided by Monteil et al., that

suggested the treatment of COVID‐19 patients using APN01 due to

its prevention abilities in SARS‐CoV‐2 infections.

113–115

In patients with heart failure, chronic kidney diseases, arterial

hypertension, and type 1 or type 2 diabetes, circulating ACE2 is over‐

expressed as a defensive response to counterbalance the adverse

effect of Ang II. ACE2 may also regulate immune functions via the

Ang‐(1‐7)‐Mas axis since Ang II‐AT

receptor signalling stimulates

autoimmune response.

35,116,117

Therefore, increasing ACE2, mainly

circulating ACE2, is an innovative approach to protect organs by

reducing SARS‐CoV‐2‐induced severe damage. In experiments using

in vitro cell‐culture and engineered human blood vessel organoids, it

was shown that clinical‐grade human soluble ACE2 can reduce SARS‐

CoV‐2 load, thus, lower its infection rate by a factor of 1000–5000 in

human kidney organoids. This indicates that ACE2 can effectively

neutralize SARS‐CoV‐2 and block early stages of SARS‐CoV‐2

infections.

114,118,119

Soluble ACE2 safety is proven in clinical studies on the treatment

of SARS and ARDS.

34,120

The results of the phase‐I study of hrsACE2

ZANGANEH ET AL.

5 of 14

on 89 healthy volunteers show that APN01 can decrease viremia

and viral titres. The phase‐II clinical studies of patients with acute

respiratory distress syndrome indicate that APN01 reduces the risk

of medical complications as well as recovery time. To date, APN01

can be considered as a promising therapeutic drug against

COVID‐19.

119,121,122

More potent soluble ACE2 forms have been

engineered with computational design, afﬁnity maturation, and deep

mutagenesis. Chan et al. discovered sACE22.v2.4 by designing solu-

ble ACE2 utilizing afﬁnity maturation by the mutations of the 117

residues engaged in the binding of S protein. The resilience of

sACE22.v2.4 against mutants is demonstrated via its capability in

potently neutralizing coronaviruses, such as SARS‐CoV‐2, SARS‐CoV

and SARS‐like bat coronaviruses, that utilize ACE2 as entry port.

123

Linsky and Glasgow et al. have worked successfully on a similar

approach.

124,125

CTC‐445.2t and CTC‐445.2d are the two decoys

engineered by Linsky et al., showing SARS viruses' potent neutrali-

zation, which protected Syrian hamsters against SARS‐CoV‐2 with a

single prophylactic dose. However, even smaller versions of decoy

receptors are able to produce potent neutralization effects.

126,127

APN01 has two theoretical mechanisms of action that should be

beneﬁcial in COVID‐19 treatment. The ﬁrst mechanism includes

competitively binding the viral spike protein to neutralize SARS‐CoV‐2

or at least slow viral entry into the host cell, and the second is

rescuing cellular ACE2 activity that reduces injury to multiple organs,

such as the lungs, heart, and kidneys, due to unabated renin‐

angiotensin system hyperactivation and ampliﬁed angiotensin II

concentrations.

128–130

Monteil et al., in a recent study examined an innovative

approach, combining two different modalities of virus control, and

realized by blocking entry using hrsACE2 and preventing intracellular

viral RNA replication through remdesivir. Effects can be improved in

SARS‐CoV‐2‐infected cells and human stem cell‐derived kidney

organoids.

131

Predominantly, utilizing hrsACE2 did not result in a reduction in

the neutralizing antibodies' generation. Abd El‐Aziz et al., observed

similar data in a patient with severe COVID‐19 symptoms treated

with two doses of hrsACE2 for one day. The rapid decline of viral

load in the serum and the antiviral antibodies' generation were

detected in the patient. HrsACE2 diminishes the viral load in the

respiratory system. It takes a noteworthy part in slowing or inhibiting

the systemic spread of SARS‐CoV‐2 from the lungs to other organs to

minimize the virus attacks on the lining of blood vessels. However, it

is unclear if there are any hrsACE2 related side effects that have

been reported. Proper precaution should be taken since reduced

FIGURE 2 Targeting SARS‐CoV‐2 entry for the treatment of Covid‐19

6 of 14

ZANGANEH

ET AL.

angiotensin II formation due to the ACE2 overexpression, might lead

to hypotension and acute kidney injury. Although Initial clinical ob-

servations have been promising, further research is essential to

expose the full capacity of hrsACE2 as a proper therapeutic tool.

121

THERAPEUTIC POTENTIAL OF miRNAs

TARGETING ACE2

MicroRNAs (miRNAs) are small endogenous non‐coding RNAs con-

sisting of nearly 22 nucleotides, capable of regulating one‐third of

human gene expression. They are actively involved in adaptive and

innate immune responses against coronavirus infections. Also, miR-

NAs play an essential role in various biological processes such as

apoptosis, cellular division, growth and development through the

post‐transcriptional mechanism, translational repression or mRNA

degradation, and numerous protein‐coding genes in animals, plants,

and some viruses.

132,133

MiRNAs can inﬂuence a variety of cell sig-

nalling pathways and thus be involved in various pathophysiological

conditions. Some viruses express viral miRNAs associated with

apoptosis regulation, host‐pathogen interplay, and host immune

systems modulation that could assure viral survival within infected

cells and propel viral pathogenesis.

134,135

Viral miRs can regulate

gene expression upon infection.

136

MicroRNAs can be an excellent option to negatively regulate the

expression of ACE2/TMPRSS2 and inhibit SARS‐CoV2 entry into

cells. This is done by binding to the target mRNA at the 30untrans-

lated regions (30‐UTR) that lead to degradation or translational

downregulation of the target. Nersisyan S, et al., Applied the same

approach and realized that KDM5B gene encoding lysine‐speciﬁc

demethylase 5B (JARID1B), can repress transcription of hsa‐mir‐

141/hsa‐miR‐200 and hsa‐let‐7e/hsa‐mir‐125a miRNA families,

hence, indirectly affecting ACE2/TMPRSS2 expression and impeding

virus entry into the host cell.

137,138

MicroRNAs low expression rate allows increased susceptibility to

infection while their speciﬁc, highly expressed immune response

genes can protect the lungs against the viral infection. By investi-

gating miRNAs' role in the host interface with SARS‐CoV‐2, valuable

insights can be provided in detecting promising molecular thera-

peutic targets to control the pathogenesis ability of SARS‐CoV‐2.

139

ACE2, via epigenetic mechanisms and miRNAs, is subjected to

extensive transcriptional and post‐transcriptional modulation, with

supplementary regulation occurring at the mRNA level. Lambert et al.

conducted in vitro research on putative microRNA‐binding sites

revealed that miR‐421 downregulates ACE2, also modulates ACE2

expression through obstructing translation instead of degradation of

mRNA transcripts.

140,141

Most of the investigational miRNA‐based

treatments are directed against the viral S protein‐ACE2 receptor

checkpoint.

142,143

SARS‐CoV‐2, as a respiratory infection, targets the airway and lung

epithelial cells. After cleavage by TMPRSS2, the SARS‐CoV‐2 spike

protein RBD gets activated and binds to ACE2 receptor of the host

cells. Thus, Chauhan et al. suggested that for COVID‐19 prevention and

management, it is highly helpful to identify and deliver certain miRNAs,

as they are responsible for engaging which in blocking the binding or

inhibiting the activation of ACE2 or TMPRSS2.

144

Hosseini Rad SM & McLellan identiﬁed four host miRNAs; hsa‐

mir‐4464, hsa‐mir‐885‐5p, hsa‐mir‐7107‐5p, hsa‐mir‐1234‐3p,

which have entirely complementarity within the RBD region of S

gene and are able to bind to that RBD. These miRNAs might be

related to miRNA‐mediated virus attenuation technology applied on

SARS‐COV‐2, since their target sequences are in the critical ACE‐2

targeting region, however SARS‐CoV‐2 target cells do not express

these miRNAs.

145

Patients with diabetic and cardiac diseases using ACE2

enhancement drugs are more susceptible to infection with SARS‐

CoV‐2. hsa‐miRNA‐27b, which is also correlated with SARS‐CoV‐2

Indian origin variant genome, regulating ACE2. The synthesis and

replication of viral proteins occur in the host cell. The miRNAs can

prevent the target mRNA's translation into the proteins.

146–148

To control coronavirus diseases, particularly COVID‐19, perfect

complementary miRNAs can be utilized. These target the viral gene

and impede its post transcriptional expression. These miRNAs

include miRNA‐7114–5p, miRNA 3154, ID00448.3p‐miRNA,

ID02510.3p‐miRNA, ID02750.3p‐miRNA, miRNA‐5197–3p, and

ID01851.5p‐miRNA that demonstrated a strong binding with the

viral genome of SARS‐CoV‐2.

149

Chauhan et al. performed a TargetScan search (http://www.tar-

getscan.org/vert_72/) for the miRNAs that can directly target ACE2

along with TMPRSS2 in SARS‐CoV‐2 infection and may play a sig-

niﬁcant role in the utilization of effective therapeutic molecules that

are able to regulate key proteins. They are also essential for viral

contraction and SARS‐CoV‐2 entry to the host airway epithelial cells.

The analysis listed miRNAs such as miRNA 429, hsa‐miRNA 200c‐3p,

hsa‐miRNA 200b‐3p for ACE2, and hsa‐miRNA 98–5p, hsa‐let 7a‐5p,

hsa‐let 7b‐5p, hsa‐let 7c‐5p, hsa‐let 7d‐5p, hsa‐let 7e‐5p, hsa‐let 7f‐

5p, hsa‐let 7g‐5p, hsa‐let 7i‐5p, hsa‐miRNA 4458, and hsa‐miRNA

4500 for TMPRSS2.

144,145

Bozgeyik used miRNA‐target prediction algorithms (including

TargetScan, TarBase v.8 (DIANA Tools),

150

miRDB,

151

and miRTar-

Base

152

and suggests that members of miR‐200 family, specially miR‐

200c‐3p, are strong candidate targets to regulate ACE2.

153

Table 1

demonstrates several promising miRNAs and their roles.

Based on miRNA‐target predictions of Wicik et al., hsa‐miR‐

10b‐5p, and hsa‐miR‐16‐5p, hsa‐miR‐26b‐5p, hsa‐miR‐27a‐3p, hsa‐

miR‐124‐3p, hsa‐miR‐200b‐3p, hsa‐miR‐302c‐5p, hsa‐miR‐587, and

hsa‐miR‐1305 are common regulators of ACE2 networks and SARS‐

COV‐2 proteins identiﬁed in all analysed datasets.

166

An inclusive list

of miRNAs with strong binding potential against human ACE2 along

with their sequences is arranged by Mukhopadhyay and Mussa.

167

Table 1presents the potential application of miRNAs as a diagnostic

and prognostic tool utilized in heart muscle injury during SARS‐

CoV‐2 infection which can be used as promising biomarkers to

assist the detection of COVID‐19 pathological changes or develop

therapeutic targets that are stabilized in the serum in order to form a

basis for personalized therapy.

166

ZANGANEH ET AL.

7 of 14

Barreda‐Manso et al. used computational techniques and con-

ducted a bioinformatics screening to search for endogenous human

miRNAs that target the 30‐UTR of SARS‐CoV‐2 and identiﬁed 10

potential candidates. The capacity to target the SARS‐CoV‐2 30‐UTR

was validated in vitro by gene reporter examinations for hsa‐

miR138‐5p and other 3 of them. hsa‐miR‐138‐5p and hsa‐miR‐

3941 demonstrated efﬁcient SARS‐CoV‐2 genome targeting

through complementary antiviral or protective effects in the host

cells. These miRNAs are promising candidates for the treatment of

most of COVID‐19 variants that are already identiﬁed.

168

MicroRNAs have been remarkable biomarkers and novel targets

for therapeutic approaches. They are well‐known for their signiﬁcant

roles in the latest advances of pneumonia, asthma, cancer, pulmonary

and cardiac disorders, cardiac ﬁbrosis, and other diseases. The

landscape of miRNAs as diagnostic and interventional medicine has

not been extensively explored as of this piece being written. The

main concerns with miRNA‐based viral therapies are transporting

miRNAs to the target cells and tissues, high instability of miRNAs,

poor circulation, and the toxicity of conventional delivery vehicles.

Simple chemical modiﬁcation can be used as a medium to improve

the stability of miRNAs. To enhance miRNAs delivery to the target

cells and tissues, several viral vectors including retroviral, lentiviral,

and adenoviral vectors are broadly used for preclinical and clinical

purposes, there however have been major issues such as poor loading

efﬁcacy of miRNAs, immunogenicity, and off‐target toxicity that lead

to the consideration of developing non‐viral delivery vectors to

TABLE 1The potential role of miRNAs as antiviral modulators of the ACE2 network and a promising biomarker of Covid‐19‐related HF

MicroRNA Role Ref.

miR‐1305 TGF‐β signalling pathway regulators in HF progression

154

miR‐587 TGF‐β signalling pathway regulators in HF progression

155

miR‐302c‐5p Potential antiviral therapeutic and biomarker of HF

156,157

miR‐26b‐5p Anti‐ﬁbrotic agent and AGTR1‐Dependent hypertension modulator

158

miR‐27a‐3p A potential biomarker of acute HF and NF‐κB signalling regulator

159,160

hsa‐miR‐16‐5p Modulates inﬂammatory signalling and cytokines such as IL‐1β, IL‐6,

and TNF‐α, NF‐κB mTOR‐Related pathways

161–163

hsa‐miR‐124‐3p Has a potentially aggravating role in cardiovascular consequences of Covid‐19

164,165

Abbreviations: ACE2, angiotensin‐converting enzyme II; AGTR1, angiotensin II receptor type 1; HF, heart failure; IL‐1β, interleukin 1 beta; IL‐6,

interleukin 6; mTOR, mammalian target of rapamycin; NF‐κB, nuclear factor kappa light chain enhancer of activated B cells; TGF‐β, transforming growth

factor beta.

FIGURE 3 SARS‐Cov‐2 infection can be inhibited by three different strategies targeting virus‐ACE2 binding. (a) Administration of virus

Receptor‐Binding Domain (RBD) can efﬁciently block the ACE2 according to its higher afﬁnity than the virus S‐protein. However, this strategy

may result in ACE2 disfunction. (b) Using Human Recombinant Soluble ACE2 (hrs ACE2) is another potential therapy that can inhibit virus‐

ACE2 binding via blocking virus S Protein, allowing ACE2 to remain activated. (c) In addition, utilizing anti‐ACE2 miRNAs that inhibit ACE2

expression, thus the number available ACE2 on the cell surface, may reduce the infection probability

8 of 14

ZANGANEH

ET AL.

deliver miRNAs effectively.

169

Nanoparticle‐based delivery can

tackle these obstacles, since Nanotherapeutics are a favourable

platform that successfully deliver the miRNAs to the host cells.

170,171

Several nanoparticle carriers have been recommended for the

effective delivery of miRNAs, such as inorganic nanoparticles, lipid

nanoparticles, and polymeric particles.

172–175

Exosomes or endo-

somal vesicles have been recently utilized as successful and prom-

ising delivery vehicles for miRNAs.

176,177

ACE2 and TMPRSS2 assist the binding and activation of SARS‐

CoV‐2 and assist its entry to the host cell. MiRNAs associated with

these two receptors can act as a therapeutic modality for SARS‐CoV‐2.

With the current lack of new COVID‐19 treatments and the rising

number of COVID‐19 cases despite the vaccination, discovering

therapies based on miRNAs can be very effective in preventing the

replication of the virus. Using the predicted host cell miRNAs for tar-

geting SARS‐CoV‐2 viral genes presently requires additional cell lines

and animal models research.

144

Figure 3summarizes the approaches discussed in this article.

CONCLUSION

The COVID‐19 pandemic has resulted in many serious health, per-

sonal, and economic consequences across the globe. Despite the

vaccination of 4.5 billion people, the death rate has begun to climb

again. Effective treatment strategies to combat SARS‐COV‐2 are

urgently needed to be created and improved. Considering the

importance of ACE2 as the key receptor binding to SARS‐COV‐2, this

review has tried to present promising therapies addressing ACE2

inhibitors with the potential for treating and preventing the coro-

navirus infections. The role of ACE2 in coronavirus infections and the

therapeutic approaches that advantage from that role was discussed.

As an essential viral attachment inhibitor against SARS‐CoV‐2, the

recombinant RBD protein binds strongly to ACE2 receptors and

blocks the entry of SARS‐CoV‐2 into its ACE2‐expressing cells.

hrsACE2 is a genetically modiﬁed soluble form of ACE2 that com-

petes with membrane‐bound ACE2, thus reducing cell entry of SARS‐

CoV‐2. MiRNAs bind to the target mRNA and negatively regulate the

expression of ACE2/TMPRSS2 to inhibit SARS‐CoV2 entry into cells.

The potential miRNA targets for the regulation of SARS‐CoV‐2 host

cell receptor ACE2 have been collected. These promising strategies

hopefully will provide assistance in ﬁnding the proper drug or ther-

apies to ﬁght against SARS‐COV‐2; however, more experimental and

clinical studies are required.

ACKNOWLEDGEMENTS

We would like to thank Dr. Mohammad Ali Zahed for his

insightful comments, Mr. Ali Najafyar for his valuable assistance

in creating ﬁgures. We also thank Mr. Peter Koch for his valuable

support with revising the manuscript that greatly improved the

ﬁnal manuscript. This research did not receive any speciﬁc grant

from funding agencies in the public, commercial, or not‐for‐proﬁt

sectors.

CONFLICT OF INTEREST

The authors have no conﬂicts of interest to declare.

ETHICS APPROVAL

Not applicable.

AUTHOR CONTRIBUTIONS

Saba Zanganeh: conceptualization, preparation, writing–original

draft. Nima Goodarzi: preparation, original draft preparation.

Mohammad Doroudian: conceptualization, preparation, reviewing

and editing. Elaheh Movahed: conceptualization, preparation,

reviewing and editing.

DATA AVAILABILITY STATEMENT

Not applicable.

CONSENT TO PARTICIPATE

Not applicable.

CONSENT FOR PUBLICATION

Not applicable.

CODE AVAILABILITY

Not applicable.

ORCID

Mohammad Doroudian

https://orcid.org/0000-0002-2933-9898

Elaheh Movahed https://orcid.org/0000-0001-5040-399X

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Renal function impairment might be worsened by SARS-CoV-2 virus: a triple critical care disease causing hypoxemia

Article

Full-text available

May 2023

Gudisa Bereda

Unlabelled: People who have underlying chronic renal disease may be more susceptible to the catastrophic disease caused by coronavirus disease 2019 (COVID-19), which is characterized by multisystem organ failure, thrombosis, and an aggravated inflammatory response. Case presentation: On 11 July 2022, a middle-aged black African male merchant, 57 was taken to the emergency room. The patient arrived at the emergency room with grade II pitting edema, weight loss, a cold intolerance, stress, a fever, a headache, dehydration, and shortness of breath that had persisted for 2 days. After 28 h, the results of the polymerase chain reaction test on a throat swab confirmed the presence of the severe acute respiratory syndrome coronavirus-2 virus. An auscultation of the chest revealed bilateral wheezing, crepitations in the right infrascapular region, and bilateral airspace consolidations, which were more pronounced on the left side and included practically all zones. He received 1000 ml of fluid resuscitation (0.9% normal saline) and insulin therapy through a drip as soon as he was admitted to an ICU. He received subcutaneous enoxaparin 80 mg once every 12 h as treatment for his confirmed COVID-19 and thromboprophylaxis. Clinical discussion: The COVID-19 infection can cause difficulties in infected individuals that can result in pneumonia, intubation, admission to an ICU, and even death. Common diseases, including diabetes mellitus and chronic renal disease, have a synergistic relationship with early death. Conclusion: The existence of prior chronic renal impairment may possibly be a factor in the increased prevalence of kidney involvement seen in hospitalized COVID-19 patients.

Optimization of Performance Traditional Back-propagation with Cyclical Rule for Forecasting Model

Article

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Nov 2022

The traditional Back-propagation algorithm has several weaknesses, including long training times and significant iterations to achieve convergence. This study aims to optimize traditional Back-propagation using the cyclical rule method to cover these weaknesses. Optimization is done by changing the training function and standard Back-propagation parameters using the training function and cyclical rule parameters. After that, a comparison of the two results will be carried out. This study uses quantitative method of time-series data on coronavirus cases sourced from the Worldometer website, then analyzed using three forecasting models with five input layers, one hidden layer (5, 10, and 15 neurons) and one output layer. The results showed that the 5-10-1 model with the training function and cyclical rule parameters and the tansig and purelin activation functions could perform well in optimization, including faster training time and smaller iterations (epochs), MSE training performance, and better tests. Low and high accuracy (92%) with an error rate of 0.01. So it was concluded that the training function and cyclical rule parameters with the tansig and purelin activation functions were able to optimize the traditional Back-propagation method, and the 5-10-1 model could be used for forecasting active cases of the coronavirus in Asia

Unravelling Insights into the Evolution and Management of SARS-CoV-2

Article

Full-text available

Feb 2024

Worldwide, the COVID-19 pandemic, caused by the brand-new coronavirus SARS-CoV-2, has claimed a sizable number of lives. The virus’ rapid spread and impact on every facet of human existence necessitate a continuous and dynamic examination of its biology and management. Despite this urgency, COVID-19 does not currently have any particular antiviral treatments. As a result, scientists are concentrating on repurposing existing antiviral medications or creating brand-new ones. This comprehensive review seeks to provide an in-depth exploration of our current understanding of SARS-CoV-2, starting with an analysis of its prevalence, pathology, and evolutionary trends. In doing so, the review aims to clarify the complex network of factors that have contributed to the varying case fatality rates observed in different geographic areas. In this work, we explore the complex world of SARS-CoV-2 mutations and their implications for vaccine efficacy and therapeutic interventions. The dynamic viral landscape of the pandemic poses a significant challenge, leading scientists to investigate the genetic foundations of the virus and the mechanisms underlying these genetic alterations. Numerous hypotheses have been proposed as the pandemic has developed, covering various subjects like the selection pressures driving mutation, the possibility of vaccine escape, and the consequences for clinical therapy. Furthermore, this review will shed light on current clinical trials investigating novel medicines and vaccine development, including the promising field of drug repurposing, providing a window into the changing field of treatment approaches. This study provides a comprehensive understanding of the virus by compiling the huge and evolving body of knowledge on SARS-CoV-2, highlighting its complexities and implications for public health, and igniting additional investigation into the control of this unprecedented global health disaster.

Computational Analysis of CD46 Protein Interaction with SARS-CoV-2 Structural Proteins: Elucidating a Putative Viral Entry Mechanism into Human Cells

Article

Full-text available

Nov 2023

This study examines an unexplored aspect of SARS-CoV-2 entry into host cells, which is widely understood to occur via the viral spike (S) protein’s interaction with human ACE2-associated proteins. While vaccines and inhibitors targeting this mechanism are in use, they may not offer complete protection against reinfection. Hence, we investigate putative receptors and their cofactors. Specifically, we propose CD46, a human membrane cofactor protein, as a potential putative receptor and explore its role in cellular invasion, acting possibly as a cofactor with other viral structural proteins. Employing computational techniques, we created full-size 3D models of human CD46 and four key SARS-CoV-2 structural proteins—EP, MP, NP, and SP. We further developed 3D models of CD46 complexes interacting with these proteins. The primary aim is to pinpoint the likely interaction domains between CD46 and these structural proteins to facilitate the identification of molecules that can block these interactions, thus offering a foundation for novel pharmacological treatments for SARS-CoV-2 infection.

Advances in Angiotensin Converting Enzyme-2 and Renin-Angiotensin System Against COVID-19: A Pharmacotherapy and Physicochemical Review

Article

Full-text available

Sep 2023

The renin-angiotensin-aldosterone system (RAAS) is a key regulator of cardiovascular function through components like angiotensin II (Ang II) and angiotensin 1-7 (Ang 1-7). Angiotensin-converting enzyme (ACE) plays a pivotal role, existing as ACE1 and ACE2 isoforms. The COVID-19 pandemic, resulting from coronavirus, exploits ACE2 for cell entry, leading to a global outbreak. The virus's impact on ACE2 and the RAAS system influences disease severity. This review concentrates on the interplay between ACE2, RAAS, and SARS-CoV-2, investigating viral entry, binding patterns, and effects on RAAS balance. The virus binds to ACE2's receptor-binding domain (RBD) and enters cells via endocytosis, involving TMPRSS2 protease. SARS-CoV-2's higher ACE2 affinity contributes to its infectivity. ACE2 expression varies in health and disease, impacting COVID-19 outcomes. The RAAS has two opposing arms-classical and counter-regulating. ACE2 bridges these arms, converting Ang II to Ang 1-7 with vasodilatory and protective effects. The pandemic introduces a "third arm," the RAAS-SARS-CoV-2-axis, impacting ACE2 expressions and RAAS balance. Recombinant ACE2 (hrsACE2) shows promise in inhibiting viral replication and reducing viral load. ACE2-loaded extracellular vesicles (EVs) extend ACE2's effectiveness, inhibiting virus infectivity. Immunological factors such as cytokines, interferons, and cell count influence COVID-19 severity. Understanding ACE2's role and its interactions with RAAS and SARS-CoV-2 is vital for potential therapeutic strategies and disease management.

Unravelling Insights into the Evolution and Management of SARS-CoV-2: A Comprehensive Review

Preprint

Full-text available

Aug 2023

Worldwide, the COVID-19 pandemic, which was brought on by the brand-new coronavirus SARS-CoV-2, has claimed a sizable number of lives. Despite the urgency, COVID-19 does not have any particular antiviral treatments at this time. As a result, scientists are concentrating on repurposing already existing antiviral medications or creating brand-new ones. The SARS-CoV-2 main protease, which is necessary for viral replication, has been identified as a possible target for a family of medicines called main protease inhibitors (MPIs). Studies of the major proteases from SARS-CoV and MERS-CoV, which have remarkably similar structures and functions to SARS-CoV-2, have provided insight for the creation of MPIs. By analyzing the MPI trials for SARS-CoV and MERS-CoV, this review sheds light on the possible therapeutic uses of MPIs for COVID-19. The review talks about how MPIs work, how effective they are against SARS-CoV and MERS-CoV, and how safe they are. The paper also emphasizes current developments in the creation of MPIs for SARS-CoV-2, including as computational studies, in vitro and in vivo research, and clinical trials. According to the review, there is a lot of hope for MPIs in the treatment of COVID-19, and numerous medications are in the works. Although more research is needed to assess their safety and effectiveness in clinical settings, these medications may offer patients with COVID-19 a much-needed therapeutic option. The review also emphasizes the importance of ongoing research into the structure and function of the SARS-CoV-2 main protease, as this information will be critical for the development of effective MPIs and other antiviral drugs in the future.

The Current Landscape of Glioblastoma Biomarkers in Body Fluids

Article

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Jul 2023

Simple Summary Glioblastoma is a highly aggressive brain cancer, and early detection and accurate diagnosis are crucial for effective treatment. Traditional diagnostic methods have limitations, and liquid biopsies offer a non-invasive and dynamic approach to detecting and monitoring glioblastoma. This review provides a comprehensive overview of various cancer biomarkers, including circulating tumor cells, cell-free DNA, and RNA, such as microRNA, as well as extracellular vesicles. It highlights their clinical utility in glioblastoma detection, monitoring, and prognosis. In addition, challenges and limitations in implementing liquid biopsy strategies in clinical practice are addressed. Abstract Glioblastoma (GBM) is a highly aggressive and lethal primary brain cancer that necessitates early detection and accurate diagnosis for effective treatment and improved patient outcomes. Traditional diagnostic methods, such as imaging techniques and tissue biopsies, have limitations in providing real-time information and distinguishing treatment-related changes from tumor progression. Liquid biopsies, used to analyze biomarkers in body fluids, offer a non-invasive and dynamic approach to detecting and monitoring GBM. This article provides an overview of GBM biomarkers in body fluids, including circulating tumor cells (CTCs), cell-free DNA (cfDNA), cell-free RNA (cfRNA), microRNA (miRNA), and extracellular vesicles. It explores the clinical utility of these biomarkers for GBM detection, monitoring, and prognosis. Challenges and limitations in implementing liquid biopsy strategies in clinical practice are also discussed. The article highlights the potential of liquid biopsies as valuable tools for personalized GBM management but underscores the need for standardized protocols and further research to optimize their clinical utility.

Functional Foods: A Promising Strategy for Restoring Gut Microbiota Diversity Impacted by SARS-CoV-2 Variants

Article

Full-text available

Jun 2023

Citation: Banerjee, A.; Somasundaram, I.; Das, D.; Jain Manoj, S.; Banu, H.; Mitta Suresh, P.; Paul, S.; Bisgin, A.; Zhang, H.; Sun, X.-F.; et al. Functional Foods: A Promising Strategy for Restoring Gut Microbiota Diversity Impacted by SARS-CoV-2 Variants. Nutrients 2023, 15, 2631. https://doi.org/10.3390/ Abstract: Natural herbs and functional foods contain bioactive molecules capable of augmenting the immune system and mediating anti-viral functions. Functional foods, such as prebiotics, probiotics, and dietary fibers, have been shown to have positive effects on gut microbiota diversity and immune function. The use of functional foods has been linked to enhanced immunity, regeneration, improved cognitive function, maintenance of gut microbiota, and significant improvement in overall health. The gut microbiota plays a critical role in maintaining overall health and immune function, and disruptions to its balance have been linked to various health problems. SARS-CoV-2 infection has been shown to affect gut microbiota diversity, and the emergence of variants poses new challenges to combat the virus. SARS-CoV-2 recognizes and infects human cells through ACE2 receptors prevalent in lung and gut epithelial cells. Humans are prone to SARS-CoV-2 infection because their respiratory and gastrointestinal tracts are rich in microbial diversity and contain high levels of ACE2 and TMPRSS2. This review article explores the potential use of functional foods in mitigating the impact of SARS-CoV-2 variants on gut microbiota diversity, and the potential use of functional foods as a strategy to combat these effects.

Molecular insights to the anti-COVID-19 potential of α-, β- and γ-cyclodextrins

Article

Dec 2023

Viral Nanoparticles‐Mediated Delivery of Therapeutic Cargo

Article

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Jul 2023

The rapid advancement of nanotechnology in recent years has opened new avenues of investigation for biomedical sciences. Viral nanoparticles (VNPs) are formulated from plant viruses, mammalian viruses, or bacteriophages. Based on their structure, viruses, and synthetic carriers have been utilized to design bio‐inspired nanocarriers, which serve as building blocks for innovative therapeutic applications. Scientists can chemically or genetically engineer VNPs to encompass various properties, such as enhancing their functionalization with therapeutic molecules and imaging reagents, enabling targeted delivery to specific ligands. The implementation of these novel nanocarrier platforms can revolutionize treatments for cancer, infectious diseases, and chronic illnesses. The primary goal of drug delivery systems is to localize cargo to the specific target site, increasing therapeutic benefits and minimizing off‐target effects. This review critically evaluates the major virus species used as nanocarriers, their applications in therapeutics, and their advantages and disadvantages.

Human embryonic stem cell-derived cardiomyocyte platform screens inhibitors of SARS-CoV-2 infection

Article

Full-text available

Jul 2021

Patients with cardiovascular comorbidities are more susceptible to severe infection with SARS-CoV-2, known to directly cause pathological damage to cardiovascular tissue. We outline a screening platform using human embryonic stem cell-derived cardiomyocytes, confirmed to express the protein machinery critical for SARS-CoV-2 infection, and a SARS-CoV-2 spike-pseudotyped virus system. The method has allowed us to identify benztropine and DX600 as novel inhibitors of SARS-CoV-2 infection in a clinically relevant stem cell-derived cardiomyocyte line. Discovery of new medicines will be critical for protecting the heart in patients with SARS-CoV-2, and for individuals where vaccination is contraindicated.

Keep out! SARS-CoV-2 entry inhibitors: their role and utility as COVID-19 therapeutics

Article

Full-text available

Jul 2021
VIROL J

The COVID-19 pandemic has put healthcare infrastructures and our social and economic lives under unprecedented strain. Effective solutions are needed to end the pandemic while significantly lessening its further impact on mortality and social and economic life. Effective and widely-available vaccines have appropriately long been seen as the best way to end the pandemic. Indeed, the current availability of several effective vaccines are already making a significant progress towards achieving that goal. Nevertheless, concerns have risen due to new SARS-CoV-2 variants that harbor mutations against which current vaccines are less effective. Furthermore, some individuals are unwilling or unable to take the vaccine. As health officials across the globe scramble to vaccinate their populations to reach herd immunity, the challenges noted above indicate that COVID-19 therapeutics are still needed to work alongside the vaccines. Here we describe the impact that neutralizing antibodies have had on those with early or mild COVID-19, and what their approval for early management of COVID-19 means for other viral entry inhibitors that have a similar mechanism of action. Importantly, we also highlight studies that show that therapeutic strategies involving various viral entry inhibitors such as multivalent antibodies, recombinant ACE2 and miniproteins can be effective not only for pre-exposure prophylaxis, but also in protecting against SARS-CoV-2 antigenic drift and future zoonotic sarbecoviruses.

Secreted Expression of mRNA‐Encoded Truncated ACE2 Variants for SARS‐CoV‐2 via Lipid‐Like Nanoassemblies

Article

Full-text available

Jul 2021
ADV MATER

The transfer of foreign synthetic messenger RNA (mRNA) into cells is essential for mRNA-based protein-replacement therapies. Prophylactic mRNA COVID-19 vaccines commonly utilize nanotechnology to deliver mRNA encoding SARS-CoV-2 vaccine antigens, thereby triggering the body's immune response and preventing infections. In this study, a new combinatorial library of symmetric lipid-like compounds is constructed, and among which a lead compound is selected to prepare lipid-like nanoassemblies (LLNs) for intracellular delivery of mRNA. After multiround optimization, the mRNA formulated into core–shell-structured LLNs exhibits more than three orders of magnitude higher resistance to serum than the unprotected mRNA, and leads to sustained and high-level protein expression in mammalian cells. A single intravenous injection of LLNs into mice achieves over 95% mRNA translation in the spleen, without causing significant hematological and histological changes. Delivery of in-vitro-transcribed mRNA that encodes high-affinity truncated ACE2 variants (tACE2v mRNA) through LLNs induces elevated expression and secretion of tACE2v decoys, which is able to effectively block the binding of the receptor-binding domain of the SARS-CoV-2 to the human ACE2 receptor. The robust neutralization activity in vitro suggests that intracellular delivery of mRNA encoding ACE2 receptor mimics via LLNs may represent a potential intervention strategy for COVID-19.

Evolutionary insights into the furin cleavage sites of SARS-CoV-2 variants from humans and animals

Article

Full-text available

Sep 2021
ARCH VIROL

The SARS-CoV-2 spike protein Q677P/H mutation and furin cleavage site (FCS) have been shown to affect cell tropism and virus transmissibility. Here, we analyzed the frequency of Q677P/H and FCS point mutations in 1,144,793 human and 1042 animal spike protein sequences and from those of the emergent variants B.1.1.7, B.1.351, P.1, B.1.429 + B.1.427, and B.1.525, which were deposited in the database of the GISAID Initiative. Different genetic polymorphisms, particularly P681H and A688V, were detected in the FCS, mainly in human isolates, and otherwise, only pangolin and bat sequences had these mutations. Multiple FCS amino acid deletions such as Δ680SPRRA684 and Δ685RSVA688 were only detected in eight and four human isolates, respectively. Surprisingly, deletion of the entire FCS motif as Δ680SPRRARSVA688 and Δ680SPRRARSVAS689 was detected only in three human isolates. On the other hand, analysis of FCS from emergent variants showed no deletions in the FCS except for spike P681del, which was detected in seven B.1.1.7 isolates from the USA. Spike Q677P was detected only once in variant, B.1.1.7, whereas Q677H was detected in all variants, i.e., B.1.1.7 (n = 1938), B.1.351 (n = 28), P.1 (n = 9), B.1.429 + B.1.427 (n = 132), and B.1.525 (n = 1584). Structural modeling predicted that mutations or deletions at or near the FCS significantly alter the cleavage loop structure and would presumably affect furin binding. Taken together, our results show that Q677H and FCS point mutations are prevalent and may have various biological effects on the circulating variants. Therefore, we recommend urgent monitoring and surveillance of the investigated mutations, as well as laboratory assessment of their pathogenicity and transmissibility.

Molecular PET/CT Profiling of ACE2 Expression In Vivo: Implications for Infection and Outcome from SARS‐CoV‐2

Article

Full-text available

Jun 2021

Rapid progress has been made to identify and study the causative agent leading to coronavirus disease 2019 (COVID‐19) but many questions including who is most susceptible and what determines severity remain unanswered. Angiotensin‐converting enzyme 2 (ACE2) is a key factor in the infection process of severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2). In this study, molecularly specific positron emission tomography imaging agents for targeting ACE2 are first developed, and these novel agents are evaluated in vitro, in preclinical model systems, and in a first‐in‐human translational ACE2 imaging of healthy volunteers and a SARS‐CoV‐2 recovered patient (NCT04422457). ACE2 expression levels in different organs in live subjects are quantitatively delineated and observable differences are measured in the patient recovered from COVID‐19. Surprising sites of uptake in the breast, reproductive system and very low uptake in pulmonary tissues are reported. This novel method can add a unique tool to facilitate SARS‐CoV‐2 related research and improve understanding of this enigmatic disease. Molecular imaging provides quantitative annotation of ACE2, the SARS‐CoV‐2 entry receptor, to noninvasively monitor organs impacted by the COVID‐19. Severe acute respiratory syndrome coronavirus‐2 gains infect cells through binding to the angiotensin‐converting enzyme 2 (ACE2) receptor. Using a high affinity radiolabeled peptide to the receptor, the whole body and quantitative determination of ACE2 expression can be imaged. This molecular imaging approach enables animal model and clinical evaluation of this critical receptor, noninvasively.

The Fight against COVID-19 on the Multi-Protease Front and Surroundings: Could an Early Therapeutic Approach with Repositioning Drugs Prevent the Disease Severity?

Article

Full-text available

Jun 2021

The interaction between the membrane spike (S) protein of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the transmembrane angiotensin-converting enzyme 2 (ACE2) receptor of the human epithelial host cell is the first step of infection, which has a critical role for viral pathogenesis of the current coronavirus disease-2019 (COVID-19) pandemic. Following the binding between S1 subunit and ACE2 receptor, different serine proteases, including TMPRSS2 and furin, trigger and participate in the fusion of the viral envelope with the host cell membrane. On the basis of the high virulence and pathogenicity of SARS-CoV-2, other receptors have been found involved for viral binding and invasiveness of host cells. This review comprehensively discusses the mechanisms underlying the binding of SARS-CoV2 to ACE2 and putative alternative receptors, and the role of potential co-receptors and proteases in the early stages of SARS-CoV-2 infection. Given the short therapeutic time window within which to act to avoid the devastating evolution of the disease, we focused on potential therapeutic treatments—selected mainly among repurposing drugs—able to counteract the invasive front of proteases and mild inflammatory conditions, in order to prevent severe infection. Using existing approved drugs has the advantage of rapidly proceeding to clinical trials, low cost and, consequently, immediate and worldwide availability.

Multilevel Systems Biology Analysis of Lung Transcriptomics Data Identifies key miRNAs and Potential miRNA Target Genes for SARS-CoV-2 Infection

Article

Full-text available

Jun 2021
COMPUT BIOL MED

Background The spread of a novel severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) has affected both the public health and the global economy. The current study was aimed at analysing the genetic sequence of this highly contagious corona virus from an evolutionary perspective, comparing the genetic variation features of different geographic strains, and identifying the key miRNAs as well as their gene targets from the transcriptome data of viral infected lung tissues. Methods A multilevel robust computational analysis was undertaken for viral genetic sequence alignment, phylogram construction, genome-wide transcriptome data interpretation of virus-infected lung tissues, miRNA mapping, and functional biology networking. Results Our findings show both genetic similarities as well as notable differences in the S protein length among SARS-CoV-1, SARS-CoV-2 and MERS viruses. All SARS-CoV-2 strains showed a high genetic similarity with the parent Wuhan strain, but Saudi Arabian, South African, USA, Russia and New Zealand strains carry 3 additional genetic variations like P333L (RNA -dependant RNA polymerase), D614G (spike), and P4715L (ORF1ab). The infected lung tissues demonstrated the upregulation of 282 (56.51%) antiviral defensive response pathway genes and downregulation of 217 (43.48%) genes involved in autophagy and lung repair pathways. By miRNA mapping, 4 key miRNAs (hsa-miR-342-5p, hsa-miR-432-5p, hsa-miR-98-5p and hsa-miR-17-5p), targeting multiple host genes (MYC, IL6, ICAM1 and VEGFA) as well as SARS-CoV2 gene (ORF1ab) were identified. Conclusion Systems biology methods offer a new perspective in understanding the molecular reasons underlying the faster spread of SARS-CoV-2 infection. The antiviral miRNAs identified in this study may aid in the ongoing search for novel personalized therapeutic avenues for COVID patients.

Decrypting the role of predicted SARS-CoV-2 miRNAs in COVID-19 pathogenesis: A bioinformatics approach

Article

Sep 2021
COMPUT BIOL MED

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), is a highly transmissible virus causing the ongoing global pandemic, COVID-19. Evidence suggests that viral and host microRNAs play pivotal roles in progression of such infections. The decisive impact of viral miRNAs and their putative targets in modulating the transcriptomic profile of its host, however remains unexplored. We hypothesized that the SARS-CoV-2 derived miRNAs can potentially play a contributory role in its pathogenicity and aid in its survival. A series of computational tools predicted 34 SARS-CoV-2 encoded miRNAs and their putative targets in the host. Immune and apoptotic pathways were identified as most enriched pathways. Further investigation using a dataset of SARS-CoV-2 infected cells (available from public repository- GSE150392) revealed that 46 genes related to immune and apoptosis-related functions were deregulated. Of these 46 genes, 42 genes were identified to be significantly up-regulated and 4 genes were down-regulated. In silico analysis revealed all of the these significantly down-regulated genes to be putative targets of 9 out of 34 of our predicted viral miRNAs. Overall, 123 out of 324 genes that are differentially regulated in SARS-CoV2 infected cells, and also identified as putative targets of viral miRNAs, were found to be significantly down-regulated. KEGG pathway analysis using these genes revealed p53 signaling as the most enriched pathway – a pathway that is known to influence immune responses. This study thus provides the theoretical foundation for the underlying molecular mechanisms involved in progression of viral pathogenesis.

Underpinning the Rudimentary/Underlying Mechanisms Involved in the Pathogenesis of SARS-CoV-2 (COVID-19) in Human Lung Cells

Chapter

Jul 2021

The COVID-19 pandemic is presently the major threat to human society and health due to its high infectivity and mortality rates. To date, this pandemic has resulted in more than 1.5 million deaths globally, affecting more than 200 countries. Phylogenetic analysis of the SARS-CoV-2 genome revealed its striking homology with the bat-derived coronavirus strains, thus confirming the zoonotic origin of the virus. SARS-CoV-2 binds to the angiotensin-converting enzyme 2 (ACE2) receptors expressed on the surface of the host cells, leading to endocytosis of the receptor, followed by the replication of the viral RNA, packaging, assembly, and release of the progeny viruses. This leads to the systemic infection in the host body and the shredding of the virus, causing its transmission to a new host. The extent of infection in the host cells depends on the expression of ACE2 expression and hyperactivation of the immune system to generate a cocktail of inflammatory cytokines, also referred to as the cytokine storm. This inflammatory response can cause severe damage to the lung tissues.

The lethal internal face of the coronaviruses: Kidney tropism of the SARS, MERS, and COVID‐19 viruses

Article

Jun 2021

The kidney is one of the main targets attacked by viruses in patients with a coronavirus infection. Until now, SARS‐CoV‐2 has been identified as the seventh member of the coronavirus family capable of infecting humans. In the past two decades, humankind has experienced outbreaks triggered by two other extremely infective members of the coronavirus family; the MERS‐CoV and the SARS‐CoV. According to several investigations, SARS‐CoV causes proteinuria and renal impairment or failure. The SARS‐CoV was identified in the distal convoluted tubules of the kidney of infected patients. Also, renal dysfunction was observed in numerous cases of MERS‐CoV infection. And recently, during the 2019‐nCoV pandemic, it was found that the novel coronavirus not only induces acute respiratory distress syndrome (ARDS) but also can induce damages in various organs including the liver, heart, and kidney. The kidney tissue and its cells are targeted massively by the coronaviruses due to the abundant presence of ACE2 and Dpp4 receptors on kidney cells. These receptors are characterized as the main route of coronavirus entry to the victim cells. Renal failure due to massive viral invasion can lead to undesirable complications and enhanced mortality rate, thus more attention should be paid to the pathology of coronaviruses in the kidney. Here, we have provided the most recent knowledge on the coronaviruses (SARS, MERS, and COVID19) pathology and the mechanisms of their impact on the kidney tissue and functions. This article is protected by copyright. All rights reserved.

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Abstract

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