ACE2 Is Expressed in Immune Cells That Infiltrate the Placenta in Infection-Associated Preterm Birth

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Abstract

COVID-19 is associated with increased incidence of preterm birth (PTB). We assessed pathways by which SARS-CoV-2 could access the placenta. Placentae, from PTB with or without chorioamnionitis (ChA), or from term pregnancies (n = 12/13/group) were collected. Peripheral blood was collected from healthy pregnant women (n = 6). Second trimester placental explants (16–20 weeks, n = 5/group) were treated with lipopolysaccharide (LPS, to mimic bacterial infection) and ACE2, CCL2, IL-6/8 and TNFα mRNA was assessed. ChA-placentae exhibited increased ACE2 and CCL2 mRNA expression (p < 0.05). LPS increased cytokine and ACE2 mRNA in placental explants. Placental ACE2 protein localized to syncytiotrophoblast, fetal endothelium, extravillous trophoblast and in immune cells-subsets (M1/M2 macrophage and neutrophils) within the villous stroma. Significantly increased numbers of M1 macrophage and neutrophils were present in the ChA-placenta (p < 0.001). Subsets of peripheral immune cells from pregnant women express the ACE2 mRNA and protein. A greater fraction of granulocytes was positive for ACE2 protein expression compared to lymphocytes or monocytes. These data suggest that in pregnancies complicated by ChA, ACE2 positive immune cells in the maternal circulation have the potential to traffic SARS-CoV-2 virus to the placenta and increase the risk of vertical transmission to the placenta/fetus.

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  1. SciScore for 10.1101/2020.09.27.20201590: (What is this?)

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

    Table 1: Rigor

    Institutional Review Board StatementConsent: All tissues and peripheral blood were provided by the Research Centre for Women’s and Infants’ Health Bio Bank program at Sinai Health System and are collected following informed written consent (process n# 20-0101-E) and in adherence with the policies of the Sinai Health System and the University of Toronto Research Ethics Board and in accordance with the Helsinki declaration on the use of human tissues.
    IRB: All tissues and peripheral blood were provided by the Research Centre for Women’s and Infants’ Health Bio Bank program at Sinai Health System and are collected following informed written consent (process n# 20-0101-E) and in adherence with the policies of the Sinai Health System and the University of Toronto Research Ethics Board and in accordance with the Helsinki declaration on the use of human tissues.
    RandomizationExplants were cultured for 24 hours and then randomly divided into treatment groups.
    BlindingStatistical Analysis: All analyses were conducted blind to the experimental conditions.
    Power Analysisnot detected.
    Sex as a biological variableEthical Approval: This is a cross-sectional study involving placental tissue collection from pregnancies (25.3-36.0 weeks’ gestation) complicated by preterm birth (PTB; N=12) or preterm birth with chorioamnionitis (ChA; N=12) or from term pregnancies (>37 weeks’ gestation) from healthy women in labour (vaginal delivery, SVD; n=12) or not in labour (elective caesarean section, ELCS; N=12).

    Table 2: Resources

    Antibodies
    SentencesResources
    Briefly, slides were deparaffinized, rehydrated, and subjected to heat mediated antigen retrieval with 10mM sodium citrate Ph6.0 for CD206 and neutrophil primary antibodies, or 1mM EDTA Ph9.0 for MHC-II, CD68 and ACE2.
    MHC-II, CD68
    suggested: None
    ACE2
    suggested: None
    After blocking with Dako protein block (Dako, Mississauga, ON, Canada), the slides were incubated overnight at 4°C with primary antibodies: anti-rabbit ACE2 (1:200, ab15348, Abcam, Toronto, ON, Canada
    anti-rabbit ACE2
    suggested: (Abcam Cat# ab15348, RRID:AB_301861)
    , anti-rabbit neutrophil (NE)(1:100, ab21595, abcam) was added instead of the primary antibody.
    anti-rabbit neutrophil ( NE)
    suggested: None
    Negative controls were performed using either isotype Mouse IgG1 or rabbit IgG/IgG1 antibodies.
    IgG1
    suggested: None
    rabbit IgG/IgG1
    suggested: None
    Subsequently, ACE2 + CD68 slides were washed three times and incubated with fluorescent secondary antibodies, using either the anti-mouse Alexa 488 (1:1000) or the anti-rabbit Alexa 594 (1:1000) secondary antibodies (Thermo Fisher Scientific and counterstained with 1 μg/mL of DAPI, for 1 hour).
    anti-mouse
    suggested: None
    anti-rabbit
    suggested: None
    For the localization of ACE2+MHC-II (M1), ACE2+CD206 (M2) and ACE2+Neutrophil elastase (NE) (primary antibodies the same species), immunofluorescence experiments were performed as described previously (Salio et al., 2005; Dunk et al., 2018; Choudhury et al., 2019).
    M1
    suggested: (Fitzgerald Industries International Cat# 10C-CR2005M1, RRID:AB_1282560)
    ACE2+Neutrophil elastase
    suggested: None
    Slides were incubated with primary antibodies anti rabbit-MHC II (M1) (1:100, Abcam), anti-rabbit mannose receptor (CD206, M2,1:100, Abcam) anti-rabbit NE (1:100, Abcam) and anti-rabbit IgG1 (Abcam) added as an isotype control overnight at 4°C.
    anti rabbit-MHC II ( M1 )
    suggested: None
    anti-rabbit mannose receptor
    suggested: None
    CD206
    suggested: None
    anti-rabbit NE
    suggested: None
    anti-rabbit IgG1
    suggested: None
    The primary antibodies used were anti-rabbit ACE2 (dilution 1:1000; Abcam, ab108209, Toronto, ON, Canada) and anti-goat β-actin (dilution 1:2000; Santa Cruz Biotechnology, Dallas, TX, USA).
    anti-goat β-actin
    suggested: None
    The PVDF membranes were subsequently incubated for 1 h with HRP-linked anti-goat secondary antibody (GE Healthcare Bio-Science
    anti-goat
    suggested: None
    To detect the expression of ACE2 protein, surface staining was conducted by Alexa Fluor® 700-conjugated mouse anti-human ACE-2 (R&D Systems) and APC-H7 mouse anti-human CD45 (BD Biosciences) antibodies.
    anti-human ACE-2
    suggested: None
    anti-human CD45
    suggested: None
    Software and Algorithms
    SentencesResources
    The protein band intensity was quantified using Image Lab™ software.
    Image Lab™
    suggested: (Image Lab Software, RRID:SCR_014210)
    Data analyses were performed by FlowJo V10 (TreeStar) or Kaluza 2 (Beckman Coulter) software.
    FlowJo
    suggested: (FlowJo, RRID:SCR_008520)
    Data analyses were performed with Prism version 8 (GraphPad Software Inc.
    Prism
    suggested: (PRISM, RRID:SCR_005375)
    , San Diego, CA, USA) qPCR data were assessed for normal distribution using D’Agostino and Pearson or the Shapiro-Wilk test; outliers were identified using “QuickCalcs” Outlier calculator program (version 7.0; GraphPad Software, Inc.
    GraphPad
    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: An explicit section about the limitations of the techniques employed in this study was not found. We encourage authors to address study limitations.

    Results from TrialIdentifier: No clinical trial numbers were referenced.


    Results from Barzooka: We found bar graphs of continuous data. We recommend replacing bar graphs with more informative graphics, as many different datasets can lead to the same bar graph. The actual data may suggest different conclusions from the summary statistics. For more information, please see Weissgerber et al (2015).


    Results from JetFighter: Please consider improving the rainbow (“jet”) colormap(s) used on page 14. At least one figure is not accessible to readers with colorblindness and/or is not true to the data, i.e. not perceptually uniform.


    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.
    • Thank you for including a protocol registration statement.

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