Disequilibrium between the classic renin-angiotensin system and its opposing arm in SARS-CoV-2-related lung injury
Open accessAbstract
A dysregulation of the renin-angiotensin system (RAS) has been involved in the genesis of lung injury and acute respiratory distress syndrome from different causes, including several viral infections. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection of pneumocytes, the hallmark of the pandemic coronavirus disease 2019 (COVID-19) involving both alveolar interstitium and capillaries, is linked to angiotensin-converting enzyme 2 (ACE2) binding and its functional downregulation. ACE2 is a key enzyme for the balance between the two main arms of the RAS: the ACE/angiotensin (Ang) II/Ang II type 1 receptor axis ("classic RAS") and the ACE2/Ang(1-7)/Mas receptor (MasR) axis ("anti-RAS"). The ACE2 downregulation, as a result of SARS-coronaviruses binding, enhances the classic RAS, leading to lung damage and inflammation with leaky pulmonary blood vessels and fibrosis, when the attenuation mediated by the anti-RAS arm is reduced. ACE inhibitors (ACE-I) and Ang II type 1 receptor blockers (ARB), effective in cardiovascular diseases, were found to prevent and counteract acute lung injury in several experimental models by restoring the balance between these two opposing arms. The evidence of RAS arm disequilibrium in COVID-19 and the hypothesis of a beneficial role of RAS modulation supported by preclinical and clinical studies are the focus of the present review. Preclinical and clinical studies on drugs balancing RAS arms might be the right way to counter COVID-19.
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Increased angiotensin-II levels and reduced angiotensin-(1-7) production due to lower ACE2 activity could provoke multiple COVID-19 symptoms, including vasoconstriction, thrombosis, inflammation, and potentially fatal respiratory failure.
“Increased levels of Ang-II and reduced production of Ang-1-7 due to the lower ACE2 activity could provoke multiple COVID-19 symptoms, including vasoconstriction, thrombosis, inflammation, and potentially fatal respiratory failure.14,18, 19, 20, 21”
Binding of SARS-CoV-2 spike protein to ACE2 may lead to dysregulation of the renin-angiotensin system.
“Binding of SARS-CoV-2's spike protein to ACE2 may lead to a dysregulation of the RAS.14”
Binding of SARS-CoV-2's spike protein to ACE2 may lead to dysregulation of the RAS.
“we and others have posed the hypothesis that binding of SARS-CoV-2's spike protein to ACE2 may lead to a dysregulation of the RAS.14”
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- Bastos AC, Magalhães GS, Gregório JF, Matos NA, Motta-Santos D, Bezerra FS, Santos RAS, Campagnole Santos MJ, Rodrigues- L332 DISEQUILIBRIUM OF RAS IN SARS-CoV-2-RELATED LUNG INJURY AJP-Lung Cell Mol Physiol • doi:10.1152/ajplung.00189.2020 • www.ajplung.org Downloaded from journals.physiology.org/journal/ajplung (151.019.095.153) on September 19, 2020. · DOI
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Angiotensin-converting enzyme 2 in human plasma and lung tissue
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Mechanisms and Potential Roles of Glucose-Lowering Agents in COVID-19: A Review
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Expression of SARS-CoV-2 Entry Factors in Human Alveolar Type II Cells in Aging and Emphysema
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A Testimony of the Surgent SARS-CoV-2 in the Immunological Panorama of the Human Host
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Reply to: The role of continuous spinal anesthesia in covid-19 pandemic
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ACE2Fc: A Promising Therapy for SARS-Cov2 Infection
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- Authors
- Sarzani, R., Giulietti, F., Di Pentima, C., Giordano, P., & Spannella, F.
- Affiliations
- Marche Polytechnic University (IT)
- Internal Medicine and Geriatrics, “Hypertension Excellence Centre” of the European Society of Hypertension, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Ricovero e Cura per Anziani, Ancona, Italy
- European Society of Hypertension (IT)
- Corresponding author
- Sarzani, Riccardo
- Venue
- American Journal of Physiology-Lung Cellular and Molecular Physiology
- Publisher
- American Physiological Society
- Published
- 2020-08-01
- Volume
- 319
- Issue
- 2
- Pages
- L325-L336
- ISSN
- 1040-0605 (ISSN-L)
- 1522-1504
- PMC
- PMC7414236
- OpenAlex
- W3041583427
- Cited by
- 86
- References
- 114
- Citations by year
- 2026: 1 · 2025: 6 · 2024: 9 · 2023: 7 · 2022: 19 · 2021: 26 · 2020: 18
- FWCI
- 2.96
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- American Journal of Physiology-Lung Cellular and Molecular Physiology (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Università Politecnica delle Marche (Università Politecnica delle Marche) (submittedVersion, other-oa)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Renin-Angiotensin System Studies
- Health Sciences › Medicine › Infectious Diseases › COVID-19 Clinical Research Studies
- Health Sciences › Medicine › Infectious Diseases › SARS-CoV-2 and COVID-19 Research
- Keywords
- renin-angiotensin system, SARS-CoV-2, COVID-19 pandemic, lung injury, acute respiratory distress syndrome, ACE2 downregulation, angiotensin II type 1 receptor, angiotensin-(1-7), Mas receptor, ACE inhibitors, angiotensin receptor blockers, pulmonary fibrosis, lung inflammation
- MeSH terms
- Betacoronavirus, Angiotensin-Converting Enzyme 2, COVID-19, SARS-CoV-2, Proto-Oncogene Mas, Angiotensin-Converting Enzyme Inhibitors, Humans, Peptidyl-Dipeptidase A, Pneumonia, Viral, Pulmonary Alveoli, Receptors, Angiotensin, Renin-Angiotensin System, Respiratory Distress Syndrome, Down-Regulation, Coronavirus Infections, Lung Injury, Alveolar Epithelial Cells, Angiotensin Receptor Antagonists, Pandemics
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