Upregulation of cAMP prevents antibody-mediated thrombus formation in COVID-19

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Abstract

Thromboembolic events are frequently reported in patients infected with the SARS-CoV-2 virus. The exact mechanisms of COVID-19-associated hypercoagulopathy, however, remain elusive. Recently, we observed that platelets (PLTs) from patients with severe COVID-19 infection express high levels of procoagulant markers, which were found to be associated with increased risk for thrombosis. In the current study, we investigated the time course as well as the mechanisms leading to procoagulant PLTs in COVID-19. Our study demonstrates the presence of PLT-reactive IgG antibodies that induce marked changes in PLTs in terms of increased inner-mitochondrial transmembrane potential (Δψ) depolarization, phosphatidylserine (PS) externalization, and P-selectin expression. The IgG-induced procoagulant PLTs and increased thrombus formation were mediated by ligation of PLT Fc-γ RIIA (FcγRIIA). In addition, contents of calcium and cyclic-adenosine-monophosphate (cAMP) in PLTs were identified to play a central role in antibody-induced procoagulant PLT formation. Most importantly, antibody-induced procoagulant events, as well as increased thrombus formation in severe COVID-19, were inhibited by Iloprost, a clinically approved therapeutic agent that increases the intracellular cAMP levels in PLTs. Our data indicate that upregulation of cAMP could be a potential therapeutic target to prevent antibody-mediated coagulopathy in COVID-19 disease.

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  1. SciScore for 10.1101/2020.12.15.20247775: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementIRB: : Studies involving human material were approved by the Ethics Committee of the Medical Faculty, Eberhard-Karls University of Tuebingen, Germany, and were conducted in accordance with the declaration of Helsinki.
    RandomizationImmunofluorescence and bright field images were taken from 3-5 randomly chosen microscopic fields (x20, Olympus IX73, Olympus GmbH, Hamburg, Germany)
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Antibodies
    SentencesResources
    Detection of phosphatidylserine exposure: To assess externalization of phosphatidylserine (PS) on the PLT surface after antibody treatment, 10 µL of PLT suspension were transferred into 100 µL of Hank’s balanced salt solution (HBSS), (137 mM NaCl, 1.25 mM CaCl2, 5.5 mM glucose, [Carl-Roth, Karlsruhe, Germany]) and incubated with 1 µL Annexin V-FITC (Immunotools, Friesoythe, Germany) for 30 min at RT in the dark.
    Annexin V-FITC
    suggested: (Thermo Fisher Scientific Cat# BMS500FI/100, RRID:AB_2575598)
    Membranes were then incubated with primary anti-human cleaved-caspase 3 antibody (1:1000, Abcam, Cambridge, UK) and anti-human alpha-tubulin (1:1000, Cell Signaling Technology, Danvers, USA) at 4°C overnight.
    anti-human cleaved-caspase 3
    suggested: None
    anti-human alpha-tubulin
    suggested: None
    After washing with TBS-T buffer, the membranes were incubated with the appropriate secondary anti-rabbit or anti-mouse antibody conjugated with IRDye®680 / IRDye®800 (1:3000, LI-COR®, Lincoln, USA) for 1 h at RT.
    anti-rabbit
    suggested: None
    anti-mouse
    suggested: None
    Assessment of the mechanisms of antibody-mediated effects on PLTs: 75 µL wPLTs were pretreated with the FcγRIIA blocking monoclonal antibody (moAb) anti-CD32 (5 µL moAb IV.3;
    anti-CD32
    suggested: None
    Software and Algorithms
    SentencesResources
    Western blots were analyzed by ImageJ software (NIH, Bethesda,
    ImageJ
    suggested: (ImageJ, RRID:SCR_003070)
    Statistical analysis: Statistical analyses were performed using GraphPad Prism 7 (La Jolla, USA).
    GraphPad Prism
    suggested: (GraphPad Prism, RRID:SCR_002798)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).


    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Our study is subjected to some limitations. First, as an observational, monocentric study, we cannot conclude that the reported associations between IgG antibodies and changes in activation/apoptosis markers in COVID-19 are causal for the thrombosis or specific for the disease. Second, we cannot exclude the possibility of remaining residual confounding or unmeasured potential confounders in our mechanistic studies. Third, the low number of patients does not enable a final and robust statistical analysis to assess clinical outcomes in patients with increased procoagulant PLTs. Nevertheless, data presented in this study may provide a background for future studies to dissect mechanisms related to PLT activation that are involved in the progression of COVID-19. Taken together, our study shows that IgG antibodies from patients with severe COVID-19 are able to stimulate FcγRIIA leading to the induction of procoagulant PLTs with an increased ability of clot formation. These processes are dependent on calcium and can be efficiently inhibited by cAMP inducers suggesting that ADC might represent a potentially promising target to prevent thromboembolic complications in COVID-19 disease.

    Results from TrialIdentifier: No clinical trial numbers were referenced.


    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.


    Results from JetFighter: We did not find any issues relating to colormaps.


    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

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