COVID-19 pathophysiology may be driven by an imbalance in the renin-angiotensin-aldosterone system

Susanne Rysz, Jonathan Al-Saadi, Anna Sjöström, Maria Farm, Francesca Campoccia Jalde, Michael Plattén, Helen Eriksson, Margareta Klein, Roberto Vargas-Paris, Sven Nyrén, Goran Abdula, Russell Ouellette, Tobias Granberg, Malin Jonsson Fagerlund and Johan Lundberg ()
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Susanne Rysz: Karolinska Institutet
Jonathan Al-Saadi: Karolinska Institutet
Anna Sjöström: Karolinska Institutet
Maria Farm: Karolinska Institutet
Francesca Campoccia Jalde: Karolinska University Hospital
Michael Plattén: Karolinska Institutet
Helen Eriksson: Stockholm University
Margareta Klein: Karolinska Institutet
Roberto Vargas-Paris: Karolinska Institutet
Sven Nyrén: Karolinska Institutet
Goran Abdula: Karolinska Institutet
Russell Ouellette: Karolinska Institutet
Tobias Granberg: Karolinska Institutet
Malin Jonsson Fagerlund: Karolinska University Hospital
Johan Lundberg: Karolinska Institutet

Nature Communications, 2021, vol. 12, issue 1, 1-12

Abstract: Abstract SARS-CoV-2 uses ACE2, an inhibitor of the Renin-Angiotensin-Aldosterone System (RAAS), for cellular entry. Studies indicate that RAAS imbalance worsens the prognosis in COVID-19. We present a consecutive retrospective COVID-19 cohort with findings of frequent pulmonary thromboembolism (17%), high pulmonary artery pressure (60%) and lung MRI perfusion disturbances. We demonstrate, in swine, that infusing angiotensin II or blocking ACE2 induces increased pulmonary artery pressure, reduces blood oxygenation, increases coagulation, disturbs lung perfusion, induces diffuse alveolar damage, and acute tubular necrosis compared to control animals. We further demonstrate that this imbalanced state can be ameliorated by infusion of an angiotensin receptor blocker and low-molecular-weight heparin. In this work, we show that a pathophysiological state in swine induced by RAAS imbalance shares several features with the clinical COVID-19 presentation. Therefore, we propose that severe COVID-19 could partially be driven by a RAAS imbalance.

Date: 2021
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DOI: 10.1038/s41467-021-22713-z

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